Continuing Professional Development at Two Rural Hospitals in Ecuador.

Background: E-learning Continuing Professional Development (CPD) is an activity demonstrated to improve the quality of healthcare delivery. The CPD of medical and nursing staff in high income countries (HICs) is commonplace. CPD of administrative staff is less common, but increasingly frequent. In low- and middle-income countries (LMICs), CPD of any kind is infrequent, particularly in rural and remote areas. Objective: The aim of this study was to describe a hospital-based e-learning CPD program for clinical and non-clinical personnel as a unique example of a successful, ongoing educational pilot, quality improvement program involving a broad cohort of employees, in a country that does not require such activities. Methods: Using the online educational platform Chamilo, e-learning modules were created for eight groups including clinical and non-clinical employees. Upon completion of each module, one to two paragraph discussions were provided for each incorrect answer submitted. Two additional chances were offered for the employee to achieve a passing score of 70%. This study reports on the first 10-month period of the program. Findings: All participants achieved the 70% passing threshold after the first or second attempt. There was 100% participation by the employees required to complete the e-learning modules. Employee feedback suggested the modules were good for continuing education, but some felt the CPD was imposed on them. Conclusion: E-learning CPD is an important and emerging element for CPD and may provide opportunities for healthcare service quality improvement as part of broader pedagogical modalities, such as conferences and directed readings, in rural and remote areas of LMICs. These pilot programs could provide important information to develop Spanish-language e-learning CPD programs across a broader region, promote collaboration with regional professional societies, and possibly contribute to the establishment of national health program CPD standards.

Seasonal patterns of dengue fever in rural Ecuador: 2009-2016.

Season is a major determinant of infectious disease rates, including arboviruses spread by mosquitoes, such as dengue, chikungunya, and Zika. Seasonal patterns of disease are driven by a combination of climatic or environmental factors, such as temperature or rainfall, and human behavioral time trends, such as school year schedules, holidays, and weekday-weekend patterns. These factors affect both disease rates and healthcare-seeking behavior. Seasonality of dengue fever has been studied in the context of climatic factors, but short- and long-term time trends are less well-understood. With 2009-2016 medical record data from patients diagnosed with dengue fever at two hospitals in rural Ecuador, we used Poisson generalized linear modeling to determine short- and long-term seasonal patterns of dengue fever, as well as the effect of day of the week and public holidays. In a subset analysis, we determined the impact of school schedules on school-aged children. With a separate model, we examined the effect of climate on diagnosis patterns. In the first model, the most important predictors of dengue fever were annual sinusoidal fluctuations in disease, long-term trends (as represented by a spline for the full study duration), day of the week, and hospital. Seasonal trends showed single peaks in case diagnoses, during mid-March. Compared to the average of all days, cases were more likely to be diagnosed on Tuesdays (risk ratio (RR): 1.26, 95% confidence interval (CI) 1.05-1.51) and Thursdays (RR: 1.25, 95% CI 1.02-1.53), and less likely to be diagnosed on Saturdays (RR: 0.81, 95% CI 0.65-1.01) and Sundays (RR: 0.74, 95% CI 0.58-0.95). Public holidays were not significant predictors of dengue fever diagnoses, except for an increase in diagnoses on the day after Christmas (RR: 2.77, 95% CI 1.46-5.24). School schedules did not impact dengue diagnoses in school-aged children. In the climate model, important climate variables included the monthly total precipitation, an interaction between total precipitation and monthly absolute minimum temperature, an interaction between total precipitation and monthly precipitation days, and a three-way interaction between minimum temperature, total precipitation, and precipitation days. This is the first report of long-term dengue fever seasonality in Ecuador, one of few reports from rural patients, and one of very few studies utilizing daily disease reports. These results can inform local disease prevention efforts, public health planning, as well as global and regional models of dengue fever trends.

Intercultural health in Ecuador: an asymmetrical and incomplete project.

Intimate connections between culture and health are complicated by various understandings of the human body, divergent beliefs about reality and place-bound theories about healing. Health care systems in various countries are modified with a goal of creating 'hybrid' structures that make room for traditional practices within a dominant Western model. But genuine intercultural health care is elusive. In Ecuador, a country with great cultural and geographic diversity, the culture-health spectrum is broad and bumpy. This is especially evident in health care politics, education and administration. A constitution adopted in 2008 aims for inclusivity and equality by incorporating indigenous concepts of the 'good life' and ideals of an intercultural society. These new values and perspectives should be reflected in economics, law, education and health care. But these concepts confront a racial, political and economic history that has delegitimized indigenous systems of knowledge and belief. This paper contrasts 'ideal' and 'real' intercultural health care using case studies of the Tsáchila, an indigenous group in coastal Ecuador. The conclusion is that 'ideal' intercultural health care, as reflected in medical school education and clinical practice, is a superficial attempt at dialogue and understanding between indigenous and western medicine. 'Real' intercultural health care involves a more profound level of mutual respect and cross-cultural understanding that aims for symmetry in patient-doctor relationships. Insights from medical anthropology guide the authors through a critical analysis that addresses interculturality as a political issue and a political struggle that the Tsáchilas - like other indigenous groups - are losing.

Emergency Department of a Rural Hospital in Ecuador.

INTRODUCTION: There is a paucity of data studying patients and complaints presenting to emergency departments (EDs) in low- and middle-income countries. The town of Pedro Vicente Maldonado (PVM) is located in the northwestern highlands of Ecuador. Hospital PVM (HPVM) is a rural teaching hospital providing family medicine residency training. These physicians provide around-the-clock acute medical care in HPVM's ED. This study provides a first look at a functioning ED in rural Latin America by reviewing one year of ED visits to HPVM. METHODS: All ED visits between April 14, 2013, and April 13, 2014, were included and analyzed, totaling 1,239 patient visits. Data were collected from their electronic medical record and exported into a de-identified Excel® database where it was sorted and categorized. Variables included age, gender, mode of arrival, insurance type, month and day of the week of the service, chief complaint, laboratory and imaging requests, and disposition. We performed descriptive statistics, and where possible, comparisons using Student's T or chi-square, as appropriate. RESULTS: Of the 1239 total ED visits, 48% were males and 52% females; 93% of the visits were ambulatory, and 7% came by ambulance. Sixty-three percent of the patients had social security insurance. The top three chief complaints were abdominal pain (25.5%), fever (15.1%) and trauma (10.8%). Healthcare providers requested labs on 71.3% of patients and imaging on 43.2%. The most frequently requested imaging studies were chest radiograph (14.9%), upper extremity radiograph (9.4%), and electrocardiogram (9.0%). There was no seasonal or day-of-week variability to number of ED patients. The chief complaint of human or animal bite made it more likely the patient would be admitted, and the chief complaint of traumatic injury made it more likely the patient would be transferred. CONCLUSION: Analysis of patients presenting to a rural ED in Ecuador contributes to the global study of acute care in the developing world and also provides a self-analysis identifying disease patterns of the area, training topics for residents, areas for introducing protocols, and information to help planning for rural EDs in low- and middle-income countries.

Management of snakebite and systemic envenomation in rural Ecuador using the 20-minute whole blood clotting test.

OBJECTIVES: In low-income countries, snakebites are frequently managed in rural areas in health centers with severely constrained resources. Many healthcare providers in these settings have limited access to the numerous and relatively expensive laboratory studies used to diagnose envenomation. The relatively simple and inexpensive 20-minute whole blood clotting test (WBCT) has been recommended by several international organizations for the diagnosis of certain venomous snakebites. This study proposes to confirm the utility of the WBCT as the sole laboratory diagnostic tool to determine systemic envenomation in hematotoxic snakebite management in severely resource-constrained areas of the world. METHODS: The authors reviewed all 110 cases of snakebite during a 6-year period in a small hospital in rural Ecuador using the WBCT. RESULTS: All cases presented within 24 hours of snakebite. Twenty cases revealed normal coagulation with no clinical evidence of systemic envenomation. Ninety cases had no evidence of clot formation (positive WBCT) at 20 minutes, suggesting systemic envenomation. Of these 90 cases, according to a classification scale, 54 were mild, 26 were moderate, and 10 were severe envenomations requiring transfer to tertiary care. All mild and moderate systemic envenomations were successfully treated at the rural hospital. All severe envenomations were treated initially with antivenom before transfer to tertiary care. One patient with severe envenomation died in tertiary care. CONCLUSIONS: The WBCT was predictive of the presence or absence of systemic envenomation from snakebite in our region. The WBCT guided the successful management of mild and moderate systemic envenomation, and spared patients with no evidence of systemic envenomation from potential side effects of antivenom.

Quantifying the reduction in nonmedical costs after the introduction of a rural county hospital in Ecuador.

OBJECTIVE: This study attempts to quantify the impact of the introduction of local second-level health services on nonmedical costs (NMCs) for residents of the rural Ecuadorian county of La Maná. METHODS: NMCs for patients accessing second-level health care were assessed by using a quasi-experimental pre- and postintervention study design. In 2007, before local second-level health care services existed, and then in 2008, after the introduction of second-level health care services in the form of a county hospital, 508 patients from the county who sought second-level health care were interviewed. RESULTS: Mean NMCs per patient per illness episode were US$ 93.58 before the county hospital opened and US$ 12.62 after it opened. This difference was largely due to reductions in transport costs (US$ 50.01 vs. US$ 4.28) and food costs (US$ 25.38 vs. US$ 7.28) (P < 0.001 for each category). CONCLUSIONS: NMCs can be decreased sevenfold with the introduction of a county hospital in a rural province previously lacking second-level health care. Introduction of rural second-level health care reduces financial barriers and thus may increase access to these health services for poorer patients in rural communities.

Quantifying the reduction in nonmedical costs after the introduction of a rural county hospital in Ecuador / Cuantificación de la reducción de los costos no médicos mediante la apertura de un hospital en un cantón rural del Ecuador

OBJECTIVE: This study attempts to quantify the impact of the introduction of local second-level health services on nonmedical costs (NMCs) for residents of the rural Ecuadorian county of La Maná. METHODS: NMCs for patients accessing second-level health care were assessed by using a quasi-experimental pre- and postintervention study design. In 2007, before local second-level health care services existed, and then in 2008, after the introduction of second-level health care services in the form of a county hospital, 508 patients from the county who sought second-level health care were interviewed. RESULTS: Mean NMCs per patient per illness episode were US$ 93.58 before the county hospital opened and US$ 12.62 after it opened. This difference was largely due to reductions in transport costs (US$ 50.01 vs. US$ 4.28) and food costs (US$ 25.38 vs. US$ 7.28) (P < 0.001 for each category). CONCLUSIONS: NMCs can be decreased sevenfold with the introduction of a county hospital in a rural province previously lacking second-level health care. Introduction of rural second-level health care reduces financial barriers and thus may increase access to these health services for poorer patients in rural communities.

OBJETIVO: Este estudio tiene por objeto cuantificar la repercusión de la introducción de servicios de salud locales de segundo nivel sobre los costos no médicos para los residentes del cantón rural ecuatoriano de La Maná. MÉTODOS: Se evaluaron los costos no médicos de los pacientes que tuvieron acceso a atención médica de segundo nivel mediante un estudio cuasiexperimental de análisis previo y posterior a la intervención. En el 2007 (antes de que existieran servicios locales de este tipo) y en el 2008 (después de la introducción de atención médica de segundo nivel representada por el hospital del cantón) se entrevistaron a 508 pacientes del cantón que requirieron atención médica de segundo nivel. RESULTADOS: Los costos no médicos medios por paciente y por episodio de enfermedad fueron de US$ 93,58 antes de la apertura del hospital local y de US$ 12,62 después de la inauguración del establecimiento. Esta diferencia se debió en gran parte a la reducción de los costos de transporte (US$ 50,01 frente a US$ 4,28) y de los costos de alimentación (US$ 25,38 frente a US$ 7,28) (P < 0,001 para cada categoría). CONCLUSIONES: Es posible reducir los costos no médicos a una séptima parte mediante la apertura de un hospital local en una zona rural que anteriormente carecía de atención médica de segundo nivel. La introducción de atención médica de segundo nivel en una zona rural reduce los obstáculos financieros y, por lo tanto, podría aumentar el acceso a estos servicios de salud para los pacientes más pobres en las comunidades rurales.

The rural hospital in Ecuador.

Over a period of twelve years, the author's vision of improving the health of rural Ecuadorians has evolved from an initial emphasis on primary health care to secondary care. The local community convinced him of the critical need for an efficiently managed, high-quality, and affordable rural secondary care hospital. Exploring a variety of funding options, the hospital ultimately achieved financial sustainability, principally through Ecuadorian public sources. Now, in partnership with the Ministry of Public Health (MOH), the rural hospital model that evolved in Pedro Vicente Maldonado is being adapted as a pilot project in an existing MOH rural hospital.

Making secondary care a primary concern: the rural hospital in Ecuador

En Ecuador, el acceso de la población rural a servicios adecuados de atención secundaria de salud se ha hecho cada vez más difícil. A pesar de que los sectores público y privado han acertado en dedicar esfuerzos a la atención primaria y a la salud pública, la mayoría de las poblaciones rurales no tienen acceso a una adecuada atención secundaria. Por lo general, los modelos tradicionales de atención médica secundaria en zonas rurales no se han adaptado a las nuevas situaciones, como la tendencia general a la descentralización, el énfasis en el desarrollo de capacidades locales, el antagonismo entre el acceso universal y la autonomía financiera, las alternativas financieras innovadoras y los recién llegados médicos de familia. En 2001, la organización no gubernamental con sede en los Estados Unidos de América Andean Health & Development (Saludesa en Ecuador) inauguró un hospital rural de 17 camas, construido conjuntamente con el municipio local y el Ministerio de Salud de Ecuador. El hospital atiende a una comunidad rural de 50000 personas que antes no tenían acceso local a servicios secundarios de salud. Los esfuerzos de AHD/Saludesa para desarrollar una red autosostenible pública/privada de atención primaria/secundaria de salud y de alta calidad han generado una considerable experiencia en la administración de un hospital rural. El proyecto piloto de AHD se concentró en un hospital rural y logró su autosostenibilidad total en 2007. Esto se logró mediante una combinación de mecanismos financieros, entre ellos la venta de paquetes prepagados de atención sanitaria, un contrato con el Instituto Ecuatoriano de Seguridad Social, contribuciones municipales y el pago tradicional por los servicios.