Assessing and coping with the financial burden of computed tomography utilization in Limbe, Cameroon: a sequential explanatory mixed-methods study.

BACKGROUND: There has been a significant increase in computed tomography (CT) utilization over the past two decades with the major challenges being a high exposure to ionizing radiation and rising cost. In this study we assess the risk of financial hardship after CT utilization and elaborate on how users adapt and cope in a sub-Saharan context with user fee for services and no national health insurance policy. METHODS: We carried out a sequential explanatory mixed methods study with a quantitative hospital-based survey of CT users followed by in-depth interviews of some purposively selected participants who reported risk of financial hardship after CT utilization. Data was summarized using frequencies, percentages and 95% confidence intervals. Logistic regression was used in multivariable analysis to determine predictors of risk of financial hardship. Identified themes from in-depth interviews were categorized. Quantitative and qualitative findings were integrated. RESULTS: A total of 372 participants were surveyed with a male to female sex ratio of 1:1.2. The mean age (standard deviation) was 52(17) years. CT scans of the head and facial bones accounted for 63% (95%CI: 59-68%) and the top three indications were suspected stroke (27% [95%CI: 22-32%]), trauma (14% [95%CI: 10-18%]) and persistent headaches (14% [95%CI: 10-18%]). Seventy-two percent (95%CI: 67-76%) of the respondents reported being at risk of financial hardship after CT utilization and predictors in the multivariable analysis were a low socioeconomic status (aOR: 0.19 [95%CI: 0.10-0.38]; p < 0.001), being unemployed or retired (aOR: 11.75 [95%CI: 2.59-53.18]; p = 0.001) and not having any form of health insurance (aOR: 3.59 [95%CI: 1.31-9.85]; p = 0.013). Coping strategies included getting financial support from family and friends, borrowing money and obtaining discounts from the hospital administration and staff. CONCLUSION: No health insurance ownership, being unemployed or retired and a low socioeconomic status are associated with financial hardship after CT utilization. Diverse coping strategies are utilized to lessen the financial burden, some with negative consequences. Minimizing out-of-pocket payments and/or the direct cost of CT can reduce this financial burden and improve CT access.

Antiretroviral resistance testing in HIV-positive people.

BACKGROUND: Resistance to antiretroviral therapy (ART) among people living with human immunodeficiency virus (HIV) compromises treatment effectiveness, often leading to virological failure and mortality. Antiretroviral drug resistance tests may be used at the time of initiation of therapy, or when treatment failure occurs, to inform the choice of ART regimen. Resistance tests (genotypic or phenotypic) are widely used in high-income countries, but not in resource-limited settings. This systematic review summarizes the relative merits of resistance testing in treatment-naive and treatment-exposed people living with HIV. OBJECTIVES: To evaluate the effectiveness of antiretroviral resistance testing (genotypic or phenotypic) in reducing mortality and morbidity in HIV-positive people. SEARCH METHODS: We attempted to identify all relevant studies, regardless of language or publication status, through searches of electronic databases and conference proceedings up to 26 January 2018. We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP), and ClinicalTrials.gov to 26 January 2018. We searched Latin American and Caribbean Health Sciences Literature (LILACS) and the Web of Science for publications from 1996 to 26 January 2018. SELECTION CRITERIA: We included all randomized controlled trials (RCTs) and observational studies that compared resistance testing to no resistance testing in people with HIV irrespective of their exposure to ART.Primary outcomes of interest were mortality and virological failure. Secondary outcomes were change in mean CD4-T-lymphocyte count, clinical progression to AIDS, development of a second or new opportunistic infection, change in viral load, and quality of life. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed each reference for prespecified inclusion criteria. Two review authors then independently extracted data from each included study using a standardized data extraction form. We analysed data on an intention-to-treat basis using a random-effects model. We performed subgroup analyses for the type of resistance test used (phenotypic or genotypic), use of expert advice to interpret resistance tests, and age (children and adolescents versus adults). We followed standard Cochrane methodological procedures. MAIN RESULTS: Eleven RCTs (published between 1999 and 2006), which included 2531 participants, met our inclusion criteria. All of these trials exclusively enrolled patients who had previous exposure to ART. We found no observational studies. Length of follow-up time, study settings, and types of resistance testing varied greatly. Follow-up ranged from 12 to 150 weeks. All studies were conducted in Europe, USA, or South America. Seven studies used genotypic testing, two used phenotypic testing, and two used both phenotypic and genotypic testing. Only one study was funded by a manufacturer of resistance tests.Resistance testing made little or no difference in mortality (odds ratio (OR) 0.89, 95% confidence interval (CI) 0.36 to 2.22; 5 trials, 1140 participants; moderate-certainty evidence), and may have slightly reduced the number of people with virological failure (OR 0.70, 95% CI 0.56 to 0.87; 10 trials, 1728 participants; low-certainty evidence); and probably made little or no difference in change in CD4 cell count (mean difference (MD) -1.00 cells/mm³, 95% CI -12.49 to 10.50; 7 trials, 1349 participants; moderate-certainty evidence) or progression to AIDS (OR 0.64, 95% CI 0.31 to 1.29; 3 trials, 809 participants; moderate-certainty evidence). Resistance testing made little or no difference in adverse events (OR 0.89, 95% CI 0.51 to 1.55; 4 trials, 808 participants; low-certainty evidence) and probably reduced viral load (MD -0.23, 95% CI -0.35 to -0.11; 10 trials, 1837 participants; moderate-certainty evidence). No studies reported on development of new opportunistic infections or quality of life. We found no statistically significant heterogeneity for any outcomes, and the I² statistic value ranged from 0 to 25%. We found no subgroup effects for types of resistance testing (genotypic versus phenotypic), the addition of expert advice to interpretation of resistance tests, or age. Results for mortality were consistent when we compared studies at high or unclear risk of bias versus studies at low risk of bias. AUTHORS' CONCLUSIONS: Resistance testing probably improved virological outcomes in people who have had virological failure in trials conducted 12 or more years ago. We found no evidence in treatment-naive people. Resistance testing did not demonstrate important patient benefits in terms of risk of death or progression to AIDS. The trials included very few participants from low- and middle-income countries.

Students' perspectives on research and assessment of a model template designed to guide beginners in research in a medical school in Cameroon.

BACKGROUND: Research activities for medical students and residents (trainees) are expected to serve as a foundation for the acquisition of basic research skills. Some medical schools therefore recommend research work as partial requirement for certification. However medical trainees have many difficulties concerning research, for which reason potential remedial strategies need to be constantly developed and tested. The views of medical trainees are assessed followed by their use and appraisal of a novel "self-help" tool designed for the purposes of this study with potential for improvement and a wider application. METHODS: This study was a cross-sectional survey of volunteering final-year medical students and residents of a medical school in Cameroon. RESULTS: This study surveyed the opinions of a total of 120 volunteers of which 82 (68%) were medical students. Three out of 82 (4%) medical students reported they had participated in research activities with a publication versus 10 out of 38 residents (26%). The reported difficulties in research for these trainees included referencing of material (84%), writing a research proposal (79%), searching for literature (73%) and knowledge of applicable statistical tests (72%) amongst others. All participants declared the "self-help" tool was simple to use, guided them to think and better understand their research focus. CONCLUSION: Medical trainees require much assistance on research and some "self-help" tools such as the template used in this study might be a useful adjunct to didactic lectures.

Acute pulmonary embolism in the era of multi-detector CT: a reality in sub-Saharan Africa.

BACKGROUND: The advantages of multi-detector computed tomography (MDCT) have made it the imaging modality of choice for some patients with suspected cardiothoracic disease, of which pulmonary embolism (PE) is an exponent. The aim of this study was to assess the incidence of PE in patients with clinical suspicion of acute PE using MDCT in a sub-Saharan setting, and to describe the demographic characteristics of these patients. METHODS: Consecutive records of patients who underwent MDCT pulmonary angiography for suspected acute PE over a two-year period at the Radiology Department of a university-affiliated hospital were systematically reviewed. All MDCT pulmonary angiograms were performed with a 16-detector computed tomography (CT) scanner using real-time bolus tracking technique. Authorization for the study was obtained from the institutional authorities. RESULTS: Forty-one MDCT pulmonary angiograms were reviewed of which 37 were retained. Of the 4 excluded studies, 3 were repeat angiograms and 1 study was not technically adequate. Twelve of 37 patients (32.4%) had CT angiograms that were positive for PE, of which 7 were males. The mean age of these patients was 47.6±10.5 years (age range from 33 to 65 years). Twenty five patients out of 37 (67.6%) had CT angiograms that were negative for PE. Eleven PE-positive patients (91.7%) had at least 1 identifiable thromboembolic risk factor whilst 5 PE-negative patients (20%) also had at least a thromboembolic risk factor. The relative risk of the occurrence of PE in patients with at least a thromboembolic risk factor was estimated at 14.4. CONCLUSION: Acute PE is a reality in sub-Saharan Africa, with an increased likelihood of MDCT evidence in patients with clinical suspicion of PE who have at least a thromboembolic risk factor. The increasing availability of MDCT will help provide more information on the occurrence of PE in these settings.

ESTABLISHMENT OF LOCAL DIAGNOSTIC REFERENCE LEVEL FOR ROUTINE PAEDIATRIC COMPUTED TOMOGRAPHY EXAMINATIONS IN BAFOUSSAM WEST CAMEROON.

The main purpose of this study was to determine local diagnostic reference level (LDRL) for routine computed tomography (CT) examination in Bafoussam, western Cameroon. The exposure parameters and dose quantities were collected manually. This retrospective, evaluative and comparative study was conducted to determine LDRLs for routine head CT examination in Bafoussam, to optimize these procedures in the region. The 75th percentile values of the calculated volume CT dose index (CTDIvol) and dose length product (DLP) were proposed as LDRL. The sample was classified in four age groups: < 1, 1-5, 5-10 and 10-15 y. The LDRLs obtained for the four age groups were: 24 mGy and 381.32 mGy.cm, 42.5 mGy and 875.55 mGy.cm, 45.85 mGy and 939.62 mGy.cm, 57.12 mGy and 1222.3 mGy.cm, respectively. The 75th percentile CTDIvol and DLP dose values for this study are higher than international values. We propose a coordinating discussions and collaboration about patient's and specific equipment's change information's, between radiologists, medical imaging technicians and medical physicist, which can reduce absorbed doses and improved medical practice in hospitals.

Health Insurance Ownership and Quality of Computed Tomography Requests: Experience from a Peripheral Referral Hospital in Cameroon.

BACKGROUND: Health insurance ownership facilitates access and minimizes financial hardship after utilization of healthcare services such as computed tomography (CT). Understanding the rational utilization of CT by people with health insurance can help optimize the scheme and provide baseline information for a national universal health coverage program. OBJECTIVE: To assess the relationship between health insurance ownership and the appropriateness of requests for CT in a peripheral referral hospital in Cameroon. METHODS: A survey of CT users was conducted during which information on health insurance ownership was collected and the request forms for CT assessed for appropriateness using the American College of Radiologists (ACR) Appropriateness Criteria®. RESULTS: We consecutively enrolled 372 participants of which 167 (45%) were females. The median age (range) was 52 (18-92) years. Thirty-eight out of 370 participants reported having health insurance (10.3%; 95% confidence interval (CI): 7.2%-13.4%). Twenty-nine out of 352 CT scan requests (8.2%; 95% CI: 5.3-11.0) were judged to be "inappropriate." The proportion of inappropriate scan requests was higher amongst people with health insurance compared to those without health insurance (18.4% vs. 7.0%; χ 2 = 5.8; p=0.02). In the logistic regression analysis, health insurance ownership was associated to the appropriateness of CT requests in the univariate analysis only (OR = 0.33; 95% CI: 0.13-0.84; p=0.020). CONCLUSIONS: Inappropriate requests for CT were low but nevertheless associated to health insurance ownership. The continuous sensitization and training of physicians would help minimize potential wasteful utilization of resources.

Multidetector computed tomography utilization in an urban sub-Saharan Africa setting: user characteristics, indications and appropriateness.

INTRODUCTION: multidetector computed tomography (MDCT) is a widely used cross-sectional imaging modality despite increasing concerns about radiation exposure and overuse. The aim of this study was to describe the socio-demographic characteristics of MDCT users in an urban city in Cameroon and to assess the clinical indications for appropriateness. METHODS: we conducted a survey of MDCT users and collected data on demographic attributes and socialization patterns, clinical indications for MDCT and time to obtain MDCT. MDCT appropriateness was assessed using the American College of Radiologists Appropriateness Criteria®. Frequencies, percentages, odds ratios and 95% confidence intervals were used to summarize the data. RESULTS: with a response rate of 79%, 511 MDCT users were surveyed. The mean (standard deviation) age was 45(19) years and male to female sex ratio 1:1. Seventy-eight percent (95% confidence interval [CI]: 74-83%) of respondents reported not having any health insurance. Head scans accounted for 52% (95%CI: 47-56%) of all scans with trauma (19% [95%CI: 15-22%]), low back pain (18% [95%CI: 14-21%]) and suspected stroke (10% [95%CI: 7-13%]) being the most frequent indications. Sixteen percent (95%CI: 13-20%) of the scans were judged to be inappropriate. Predictors of MDCT appropriateness after multivariable logistic regression modeling were age (aOR=0.97; P=0.009; 95%CI=0.94-0.99), health insurance ownership (aOR=0.40; P=0.034; 95%CI=0.18-0.94) and being referred by non-specialist physicians (aOR=0.20; P<0.001; 95%CI=0.09-0.47). CONCLUSION: people from all social strata use MDCT, mostly appropriately and especially for head scans after trauma in this urban setting. However, the proportion of inappropriate studies was considerable suggesting the need for control measures.