Is the Risk Really Shared? A Retrospective Analysis of Healthcare Costs of Patients With Type 2 Diabetes Mellitus on a Capitation Model.

OBJECTIVES: Private managed healthcare organizations in South Africa (SA) use a capitation model of care for patients within their healthcare delivery systems for the optimal management of type 2 diabetes mellitus (T2DM) to reduce healthcare costs. Few studies have categorized healthcare costs at a patient level to determine the actual healthcare costs incurred by private insurers for T2DM in SA. This study estimated the direct medical costs of patients with T2DM registered with a private health insurer over a 5-year period between 2 funding models: a capitated risk-sharing model (CM) versus a traditional fee-for-service (FFS) model. METHODS: This population-based cohort study used retrospective claims data of patients with T2DM from 2012 to 2016 of a private medical scheme in SA. Annual healthcare costs of T2DM were assessed. RESULTS: During the 5-year period, most of the identified patients with T2DM were enrolled in CM-534 (64%) of 828 in 2012, which rose to 789 (81%) of 971 in 2016. The median annual healthcare costs of the treatment and management of the patients with T2DM was significantly higher in CM ($2002 [interquartile range (IQR) 2106] in 2012 to $1095 [IQR 1042] in 2016) than FFS ($582 [IQR 772] to $296 [IQR 507]) (P<.0001). A total of 46 patients with T2DM incurred hospitalization costs of ≥$24 243 for a T2DM or other event; 33 were enrolled on CM. CONCLUSIONS: The patients with T2DM on CM accrue significantly higher annual healthcare costs than patients on FFS. The greatest portion of the overall T2DM healthcare costs was associated with high-cost hospitalization of T2DM complications.

A biostatistical support system in health sciences: is this sustainable in a resource-restricted environment?

BACKGROUND: Training in biostatistics is important for strengthening capacity in health research. This is particularly true for Africa, where research output in the health sciences has been low. Training initiatives for the continent are therefore essential. The aim of the present study was to analyse the quality and financial sustainability of the expanded biostatistical support system at a South African health sciences institution between 2013 and 2017. METHODS: A cross-sectional investigation of the initiatives created between the years 2013 and 2017 in the University of the Witwatersrand, Faculty of Health Sciences Research Office was undertaken. An assessment of the one-on-one consultations carried out by postgraduate students and staff, financial costs of the support system and the number of postgraduate student graduations were analysed. RESULTS: The number of statistical consultations increased over the period examined. The consultations were highly recommended by the postgraduate students and staff (consulters). A clear rise in the number of Masters and PhD student graduates and an increase in research units were observed from 2013 to 2017, although these cannot be solely associated with the biostatistical support system. The finances for maintaining the support system are cost effective as the number of graduates increases. The total cost to the Research Office is US$ 225 per graduate per annum. CONCLUSIONS: The expansion of the biostatistical support system has indirectly contributed to an increased number of graduates and research publication units in the institution. While the current finances support the system, any increases in enrolments or growth in diversification of biostatistical requirements may place a strain on the financial sustainability. This service is of value to developed and developing countries.

Assessment of myocardial fibrosis by late gadolinium enhancement imaging and biomarkers of collagen metabolism in chronic rheumatic mitral regurgitation.

BACKGROUND: In chronic rheumatic mitral regurgitation (CRMR), involvement of the myocardium in the rheumatic process has been controversial. Therefore, we sought to study the presence of fibrosis using late gadolinium enhancement cardiac magnetic resonance imaging (LGE-CMR) and biomarkers of collagen turnover in CRMR. METHODS: Twenty-two patients with CRMR underwent CMR and echocardiography. Serum concentrations of matrix metalloproteinase- 1 (MMP-1), tissue inhibitor of MMP-1 (TIMP- 1), MMP-1-to-TIMP-1 ratio, procollagen III N-terminal pro-peptide (PIIINP) and procollagen type IC peptide (PIP) were measured. RESULTS: Four patients had fibrosis on LGE-CMR. PICP and PIIINP concentrations were similar to those of the controls, however MMP-1 concentration was increased compared to that of the controls (log MMP-1 3.5 ± 0.7 vs 2.7 ± 0.9, p = 0.02). There was increased MMP-1 activity as the MMP-1-to- TIMP-1 ratio was higher in CRMR patients compared to the controls ( -1.2 ± 0.6 vs -2.1 ± 0.89, p = 0.002). CONCLUSIONS: Myocardial fibrosis was rare in CRMR patients. CRMR is likely a disease characterised by the predominance of collagen degradation rather than increased synthesis and myocardial fibrosis.

Writing for publication: institutional support provides an enabling environment.

BACKGROUND: Due to the excessive service delivery loads in public hospitals supported by academic institutions in developing environments, researchers at these institutions have little time to develop scientific writing skills or to write up their research. It is imperative to expand the writing skills of researchers and train the next generation of health sciences academics in order to disseminate research findings. This study reports on the implementation of approaches for writing and publication and the extent of support to staff suffering from the overload of service delivery and of heavy teaching duties. METHODS: Workshops in scientific writing and writing retreats were initiated and were offered to all staff. RESULTS: Feedback from participants of the writing skills workshops indicated that the workshops provided an injection of confidence and proficiency. Protected writing time resulted in 132 papers submitted to journals and 95 in preparation from 230 participants of the writing retreats over a two year period. Staff commended the off-site, collegial environment, which also supported future collaboration with new-found colleagues. CONCLUSION: This enabling environment facilitates not only the development of writing skills per se, but also the dissemination of the generated scientific knowledge. In addition, the training in writing skills of this generation will be of value in the training of future cohorts in countries with similar health care deliverables.

Spectrum of cardiac disease in maternity in a low-resource cohort in South Africa.

BACKGROUND: Lack of evidence-based data on the spectrum of cardiovascular disease (CVD) in pregnancy or in the postpartum period, as well as on maternal and fetal outcome, provides challenges for treating physicians, particularly in areas of low resources. The objectives of this study were to investigate the spectrum of disease, mode of presentation and maternal and fetal outcome of patients referred to a dedicated Cardiac Disease and Maternity Clinic (CDM). METHODS: The prospective cohort study was conducted at a single tertiary care centre in South Africa. Two hundred and twenty-five women presenting with CVD in pregnancy, or within 6 months postpartum, were studied over a period of 2 years. Clinical assessment, echocardiography and laboratory tests were performed at baseline and follow-up visits. Prepartum, peripartum and postpartum complications were grouped into cardiac, neonatal and obstetric events. RESULTS: Ethnicity was black African (45%), mixed ethnicity (32%), white (15%), Indian/others (8%) and 12% were HIV positive. Of the 225 consecutive women (mean age 28.8±6.4), 196 (86.7%) presented prepartum and 73 in modified WHO class I. The 152 women presenting in a higher risk group (modified WHO class II-IV) were offered close follow-up at the CDM clinic and were diagnosed with congenital heart disease (32%, 15 operated previously), valvular heart disease (26%, 15 operated previously), cardiomyopathy (27%) and other (15%). Women presenting with symptoms of CVD or heart failure postpartum (n=30) presented in a higher New York Heart Association, had higher heart rates (p<0.001) and NTproBNP levels (p<0.0005). Of the 152 patients, 9 (6%) died within the 6-month follow-up period. Eight of the nine patients died >42 days postpartum. Perinatal death occurred in 1/152 (0.7%)-translating to a perinatal mortality rate of 7/1000 live births. CONCLUSIONS: Disease patterns were markedly different to that seen in the developed world. However, joint obstetric-cardiac care in the low-resource cohort was associated with excellent survival outcome rates of pregnant mothers (even with complex diseases) and their offspring and was similar to that seen in the western world. Mortality typically occurred in the postpartum period, beyond the standard date of recording maternal death.

The clinical consequences and challenges of hypertension in urban-dwelling black Africans: insights from the Heart of Soweto Study.

BACKGROUND: There is a paucity of data to describe advanced forms of cardiovascular disease (CVD) in urban black Africans with hypertension (HT). METHODS: Chris Hani Baragwanath Hospital services the black African community of 1.1 million people in Soweto, South Africa. We prospectively collected detailed demographic and clinical data from all de novo presentations to the hospital's Cardiology Unit in 2006. RESULTS: Overall, 761 black African patients (56% of de novo cases) presented with a diagnosis of HT with more women (63%, aged 58.5±14.9 years) than men (aged 58.0±15.6 years). On presentation, 396 women (82%) versus 187 men (67%) had dizziness, palpitations and/or chest pain (OR 1.23, 95% 1.12-1.34: p<0.0001). HT was the primary diagnosis in 266 cases (35%). In the rest (n=495), non-ischaemic forms of heart failure were common (54% of total) while only 6.2% had coronary artery disease. Concurrent left ventricular hypertrophy, renal dysfunction and anaemia were present in 39%, 24% and 11% of cases, respectively, with a similar age-adjusted pattern of co-morbidity according to sex. However, men were more likely to present with impaired systolic function (OR 2.13, 95% CI 1.50 to 3.00; p<0.0001). CONCLUSIONS: In the absence of effective primary and secondary prevention strategies, these unique data highlight the potentially devastating impact of advanced forms of hypertensive heart disease in urban black African communities with more women than men affected.

Sagittal suture overlap in cephalopelvic disproportion: blinded and non-participant assessment.

OBJECTIVE: To determine the role of assessment of overlap of fetal skull bones (molding) in intrapartum prediction of cephalopelvic disproportion (CPD). DESIGN: Prospective cross-sectional study. SETTING: South African high-risk obstetric unit that receives referrals from other facilities. POPULATION: Women of at least 37 weeks' gestation in the active phase of labor, with singleton vertex presentations and live fetuses, and without previous cesarean sections. METHOD: The researcher was blinded to parity and previous clinical information on the women, and not involved in their obstetric care. The researcher performed clinical assessments, including estimation of level of head, cervical dilatation, head flexion, position, overlap of fetal skull bones, caput succedaneum and asynclitism. A single assessment was done on each woman. MAIN OUTCOME MEASURE: CPD, defined as cesarean section for poor progress in labor. RESULTS: The author examined 504 women, and CPD occurred in 113 (22.4%). In multivariate logistic regression analysis, sagittal suture overlap was independently associated with CPD. Other factors associated were maternal height, duration of labor, birth weight, and the interaction between caput succedaneum and cervical dilatation at the time of examination. Lambdoid suture overlap was not significantly associated with CPD, and could be determined in only 66.5% of examinations because of frequent head deflexion. CONCLUSION: Assessment of sagittal suture overlap, but not lambdoid suture overlap, is useful for prediction of CPD. Knowledge of sagittal suture overlap may assist in decisions on clinical management where there is poor progress in a trial of labor.