Evaluation of health system readiness and coverage of intermittent preventive treatment of malaria in infants (IPTi) in Kambia district to inform national scale-up in Sierra Leone.

BACKGROUND: Intermittent preventive treatment of malaria in infants (IPTi) with sulfadoxine-pyrimethamine (SP) is a proven strategy to protect infants against malaria. Sierra Leone is the first country to implement IPTi nationwide. IPTi implementation was evaluated in Kambia, one of two initial pilot districts, to assess quality and coverage of IPTi services. METHODS: This mixed-methods evaluation had two phases, conducted 3 (phase 1) and 15-17 months (phase 2) after IPTi implementation. Methods included: assessments of 18 health facilities (HF), including register data abstraction (phases 1 and 2); a knowledge, attitudes and practices survey with 20 health workers (HWs) in phase 1; second-generation sequencing of SP resistance markers (pre-IPTi and phase 2); and a cluster-sample household survey among caregivers of children aged 3-15 months (phase 2). IPTi and vaccination coverage from the household survey were calculated from child health cards and maternal recall and weighted for the complex sampling design. Interrupted time series analysis using a Poisson regression model was used to assess changes in malaria cases at HF before and after IPTi implementation. RESULTS: Most HWs (19/20) interviewed had been trained on IPTi; 16/19 reported feeling well prepared to administer it. Nearly all HFs (17/18 in phase 1; 18/18 in phase 2) had SP for IPTi in stock. The proportion of parasite alleles with dhps K540E mutations increased but remained below the 50% WHO-recommended threshold for IPTi (4.1% pre-IPTi [95%CI 2-7%]; 11% post-IPTi [95%CI 8-15%], p < 0.01). From the household survey, 299/459 (67.4%) children ≥ 10 weeks old received the first dose of IPTi (versus 80.4% for second pentavalent vaccine, given simultaneously); 274/444 (62.5%) children ≥ 14 weeks old received the second IPTi dose (versus 65.4% for third pentavalent vaccine); and 83/217 (36.4%) children ≥ 9 months old received the third IPTi dose (versus 52.2% for first measles vaccine dose). HF register data indicated no change in confirmed malaria cases among infants after IPTi implementation. CONCLUSIONS: Kambia district was able to scale up IPTi swiftly and provide necessary health systems support. The gaps between IPTi and childhood vaccine coverage need to be further investigated and addressed to optimize the success of the national IPTi programme.

Decision-making and health system strengthening: bringing time frames into perspective.

In many low-and middle-income countries, health systems decision-makers are facing a host of new challenges and competing priorities. They must not only plan and implement as they used to do but also deal with discontented citizens and health staff, be responsive and accountable. This contributes to create new political hazards susceptible to disrupt the whole execution of health plans. The starting point of this article is the observation by the first author of the limitations of the building-blocks framework to structure decision-making as for strengthening of the Moroccan health system. The management of a health system is affected by different temporalities, the recognition of which allows a more realistic analysis of the obstacles and successes of health system strengthening approaches. Inspired by practice and enriched thanks a consultation of the literature, our analytical framework revolves around five dynamics: the services dynamic, the programming dynamic, the political dynamic, the reform dynamic and the capacity-building dynamic. These five dynamics are differentiated by their temporalities, their profile, the role of their actors and the nature of their activities. The Moroccan experience suggests that it is possible to strengthen health systems by opening up the analysis of temporalities, which affects both decision-making processes and the dynamics of functioning of health systems.

Inequalities in health by regime of affiliation to the health system in events of obligatory notification, Colombia, 2015 / Desigualdades en salud según régimen de afiliación y eventos notificados al Sistema de Vigilancia (Sivigila) en Colombia, 2015

Introduction: Inequalities in the health field are caused by the differences in the social and economic conditions, that influence the disease risk and the measures taken to treat the disease. Objective: We aimed to estimate the social inequalities in health in Colombia, according to the type of affiliation to the health system as a proxy of socioeconomic status. Materials and methods: We conducted a retrospective descriptive analysis calculating incidence rates age and sex adjusted for all mandatory reporting events using the affiliation regime (subsidized and contributory) as a socioeconomic proxy. Estimates were made at departmental level for 2015. Social inequalities were calculated in terms of absolute and relative gaps. Results: We found social inequalities in the occurrence of mandatory reporting events in population affiliated to the Colombian subsidized regime (poor population). In this population, 82.31 cases of Plasmodium falciparum malaria per 100,000 affiliates were reported more than those reported in the contributory regime. Regarding the relative gap, belonging to the subsidized regime increased by 31.74 times the risk of dying from malnutrition in children under 5 years of age. Other events such as those related to sexual and reproductive health (maternal mortality, gestational syphilis and congenital syphilis); neglected diseases and communicable diseases related to poverty (leprosy and tuberculosis), also showed profound inequalities. Conclusion: In Colombia there are inequalities by regime of affiliation to the health system. Measured socioeconomic status was a predictor of increased morbidity and premature mortality.

Introducción. Las desigualdades en salud se generan por diferencias en las condiciones sociales y económicas, lo cual influye en el riesgo de enfermar y la forma de enfrentar la enfermedad. Objetivo. Evaluar las desigualdades sociales en salud en Colombia, utilizando el tipo de afiliación al sistema de salud como un parámetro representativo (proxy) de la condición socioeconómica. Materiales y métodos. Se trata de un análisis descriptivo y retrospectivo en el que se calcularon las tasas específicas de incidencia, ajustadas por edad y sexo, para eventos de notificación obligatoria, utilizando el régimen de afiliación (subsidiado o contributivo) como variable representativa del nivel socioeconómico. Las estimaciones se hicieron a nivel departamental para el 2015. Las desigualdades sociales se calcularon en términos de brechas absolutas y relativas. Resultados. Se evidencian desigualdades sociales en la ocurrencia de eventos de notificación obligatoria, las cuales desfavorecen a la población afiliada al régimen subsidiado. En esta población, se reportaron 82,31 casos más de malaria Plasmodium falciparum por 100.000 afiliados, que los notificados en el régimen contributivo. Respecto a la brecha relativa, el pertenecer al régimen subsidiado se asocia con un aumento de 31,74 veces del riesgo de morir por desnutrición en menores de cinco años. Otros eventos también presentaron profundas desigualdades, como los relacionados con la salud sexual y reproductiva (mortalidad materna, sífilis gestacional y sífilis congénita), las enfermedades infecciosas y las enfermedades transmisibles relacionadas con la pobreza (lepra y tuberculosis). Conclusión. El tipo de afiliación al Sistema General de Seguridad Social en Salud en Colombia es un buen indicador del nivel socioeconómico, y es un factor predictor de mayor morbilidad y mortalidad prematura asociada con los factores determinantes sociales de la salud.

Variation in health system performance for managing diabetes among states in India: a cross-sectional study of individuals aged 15 to 49 years.

BACKGROUND: Understanding where adults with diabetes in India are lost in the diabetes care cascade is essential for the design of targeted health interventions and to monitor progress in health system performance for managing diabetes over time. This study aimed to determine (i) the proportion of adults with diabetes in India who have reached each step of the care cascade and (ii) the variation of these cascade indicators among states and socio-demographic groups. METHODS: We used data from a population-based household survey carried out in 2015 and 2016 among women and men aged 15-49 years in all states of India. Diabetes was defined as a random blood glucose (RBG) ≥ 200 mg/dL or reporting to have diabetes. The care cascade-constructed among those with diabetes-consisted of the proportion who (i) reported having diabetes ("aware"), (ii) had sought treatment ("treated"), and (iii) had sought treatment and had a RBG < 200 mg/dL ("controlled"). The care cascade was disaggregated by state, rural-urban location, age, sex, household wealth quintile, education, and marital status. RESULTS: This analysis included 729,829 participants. Among those with diabetes (19,453 participants), 52.5% (95% CI, 50.6-54.4%) were "aware", 40.5% (95% CI, 38.6-42.3%) "treated", and 24.8% (95% CI, 23.1-26.4%) "controlled". Living in a rural area, male sex, less household wealth, and lower education were associated with worse care cascade indicators. Adults with untreated diabetes constituted the highest percentage of the adult population (irrespective of diabetes status) aged 15 to 49 years in Goa (4.2%; 95% CI, 3.2-5.2%) and Tamil Nadu (3.8%; 95% CI, 3.4-4.1%). The highest absolute number of adults with untreated diabetes lived in Tamil Nadu (1,670,035; 95% CI, 1,519,130-1,812,278) and Uttar Pradesh (1,506,638; 95% CI, 1,419,466-1,589,832). CONCLUSIONS: There are large losses to diabetes care at each step of the care cascade in India, with the greatest loss occurring at the awareness stage. While health system performance for managing diabetes varies greatly among India's states, improvements are particularly needed for rural areas, those with less household wealth and education, and men. Although such improvements will likely have the greatest benefits for population health in Goa and Tamil Nadu, large states with a low diabetes prevalence but a high absolute number of adults with untreated diabetes, such as Uttar Pradesh, should not be neglected.

Coding algorithms for identifying patients with cirrhosis and hepatitis B or C virus using administrative data.

BACKGROUND AND AIMS: Despite the use of administrative data to perform epidemiological and cost-effectiveness research on patients with hepatitis B or C virus (HBV, HCV), there are no data outside of the Veterans Health Administration validating whether International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes can accurately identify cirrhotic patients with HBV or HCV. The validation of such algorithms is necessary for future epidemiological studies. METHODS: We evaluated the positive predictive value (PPV) of ICD-9-CM codes for identifying chronic HBV or HCV among cirrhotic patients within the University of Pennsylvania Health System, a large network that includes a tertiary care referral center, a community-based hospital, and multiple outpatient practices across southeastern Pennsylvania and southern New Jersey. We reviewed a random sample of 200 cirrhotic patients with ICD-9-CM codes for HCV and 150 cirrhotic patients with ICD-9-CM codes for HBV. RESULTS: The PPV of 1 inpatient or 2 outpatient HCV codes was 88.0% (168/191, 95% CI: 82.5-92.2%), while the PPV of 1 inpatient or 2 outpatient HBV codes was 81.3% (113/139, 95% CI: 73.8-87.4%). Several variations of the primary coding algorithm were evaluated to determine if different combinations of inpatient and/or outpatient ICD-9-CM codes could increase the PPV of the coding algorithm. CONCLUSIONS: ICD-9-CM codes can identify chronic HBV or HCV in cirrhotic patients with a high PPV and can be used in future epidemiologic studies to examine disease burden and the proper allocation of resources.

Presence of food allergy emergency action plans in Mississippi.

BACKGROUND: Multiple national, state, and local organizations recommend that emergency action plans (EAPs) direct therapy of allergic reactions in schoolchildren. OBJECTIVE: To investigate the school nurse's perception of food allergies and the presence of EAPs for food allergic students in Mississippi. METHODS: An investigator-developed food allergy survey was offered to all Mississippi public school nurses in 2008 and 2009. RESULTS: The survey had a combined response rate of 29% (194/659) for the 2 years of the study. In both years, most participating school nurses had at least 1 food allergic student at their school (mean [SD], 11 [10] students per school). In 2008, 30% (28/93) of the school nurses reported that food allergy EAPs were present for all of their food allergic students, whereas 29% (27/93) of school nurses had 0% to 10% of their known food allergic students on EAPs. Similarly, in 2009, 37% (34/93) of school nurses reported all of their food allergic students possessed a food allergy EAP, whereas 26% (24/93) of school nurses had 0% to 10% of their known food allergic students on EAPs. In 2008, students were more likely to have food EAPs if the nurse received information on food allergies from parents or a physician or if the student attended a school in an urban area. However in 2009, only if the nurse received information from a physician were they more likely to have an EAP for their students. CONCLUSION: Although numerous organizations recommend food allergy EAPs for allergic students, our study highlights their inconsistent use in Mississippi.

Risk of venous thromboembolism among hospitalized medically ill patients.

PURPOSE: The 90-day risk of venous thromboembolism (VTE) among medically ill patients admitted to a hospital was estimated and is discussed. SUMMARY: Patients aged > or =40 years who were hospitalized between January 1, 1998, and June 30, 2002, for reasons other than traumatic injury, labor and delivery, mental disorder, or VTE and who did not undergo surgery were identified in a large U.S. healthcare claims database. Patients receiving anticoagulants in the 90-day period preceding hospital admission were excluded. We estimated the percentage of study subjects who developed clinical deep-vein thrombosis (DVT) or pulmonary embolism (PE) within 90 days of hospital admission using Kaplan-Meier methods. We also estimated hazard ratios (HRs) for potential risk factors for VTE using univariate and stepwise multivariate Cox proportional hazards regression models. Among 92,162 study subjects, 1468 (1.59%) developed clinical DVT or PE within 90 days of hospital admission; 18% of these events occurred postdischarge. In multivariate analyses, significant risk factors for clinical VTE included: 1) history of cancer (HR, 1.67; 95% confidence interval [CI], 1.45-1.93); 2) history of VTE within six months of index admission (HR, 6.14; 95% CI, 4.74-7.96); 3) operating room procedure within 30 days of index admission (HR, 1.81; 95% CI, 1.47-2.24); 4) peripheral artery disease during index admission (HR, 1.68; 95% CI, 1.28-2.21); and 5) heart failure during index admission (HR, 1.72; 95% CI, 1.52-1.95). CONCLUSION: The risk of clinical VTE among medically ill patients admitted to a hospital, although less than that of patients undergoing major surgery, is not negligible. Patients with a history of recent VTE or surgery, those who are admitted to the intensive care unit, those with an admitting diagnosis of heart failure, and those with active cancer are at especially high risk of VTE and deserve increased consideration for prophylaxis.

"Choice" in health care: what do people really want?

Proposals to expand the individual health insurance market and promote health savings accounts are intended to provide consumers with more "choice." The types of choices people prefer, however, are not well understood. This analysis of survey data finds that having a choice of health care providers matters more to people than having a choice of health plans. Dissatisfaction among adults with no choice of providers was more than twice as high as among those with no choice of plan. Moreover, a large majority of Americans who have had experience with employer-based health insurance believe that employers do a good job of selecting quality plans. Two of three preferred an employer-selected set of plans over an employer-funded account that they would use to find coverage on their own. Thus, policymakers should be cautious about embracing the individual market and health savings accounts as a way to improve satisfaction in the system.

Revisión de un Plan Gerontológico. El caso de Navarra / A Gerontologycal Plan review. The case of Navarra

Introducción: Se presenta una valoración del grado de cumplimiento del I Plan Gerontológico de Navarra (1997-2000). A propuesta del Departamento de Bienestar Social del Gobierno de Navarra se procedió en consecuencia incorporando, además, algunas líneas de actuación para el nuevo Plan. Material y métodos: Se ha procedido a recoger y elaborar cuanta información aporte datos estadísticos de interés sobre las personas mayores en Navarra. Hay que destacar la información facilitada por el Instituto Navarro de Bienestar Social, el Departamento de Salud del Gobierno de Navarra y el Instituto de Estadística de Navarra. A ello se suma el análisis pormenorizado del I Plan Gerontológico de Navarra. Resultados: Se constata que la población mayor de Navarra tiende a corto plazo hacia el sobreenvejecimiento y, por tanto, se detecta una necesidad objetiva de adecuación de los objetivos de las políticas sociales vigentes en Navarra. Igualmente, se pone de manifiesto el importante esfuerzo social y de los órganos responsables de las políticas sociosanitarias por cumplir las medidas de actuación propuestas en el I Plan Gerontológico de Navarra. No obstante, se han producido ciertos desfases en la distribución de los recursos económicos previstos. Discusión: Los resultados apuntan a la conveniencia de adaptar el I Plan Gerontológico de Navarra al nuevo contexto social, marcado por un significativo sobreenvejecimiento. Obviamente, ello demanda la elaboración a medio plazo de un nuevo Plan que cubra líneas estratégicas como las preventivas, la mejora de la calidad en los servicios, centros y programas (AU)

Plan médico de cabecera: primer semestre 2002

Informe sobre diferentes aspectos del plan en el período analizado: área, especialidad y médico; y diagnóstico

Plan médico de cabecera: primer semestre 2002

Informe sobre diferentes aspectos del plan en el período analizado: área, especialidad y médico; y diagnóstico

The use of breast conserving surgery: linking insurance claims with tumor registry data.

BACKGROUND: The purpose of this study was to use insurance claims and tumor registry data to examine determinants of breast conserving surgery (BCS) in women with early stage breast cancer. METHODS: Breast cancer cases registered in the Hawaii Tumor Registry (HTR) from 1995 to 1998 were linked with insurance claims from a local health plan. We identified 722 breast cancer cases with stage I and II disease. Surgical treatment patterns and comorbidities were identified using diagnostic and procedural codes in the claims data. The HTR database provided information on demographics and disease characteristics. We used logistic regression to assess determinants of BCS vs. mastectomy. RESULTS: The linked data set represented 32.8% of all early stage breast cancer cases recorded in the HTR during the study period. Due to the nature of the health plan, 79% of the cases were younger than 65 years. Women with early stage breast cancer living on Oahu were 70% more likely to receive BCS than women living on the outer islands. In the univariate analysis, older age at diagnosis, lower tumor stage, smaller tumor size, and well-differentiated tumor grade were related to receiving BCS. Ethnicity, comorbidity count, menopausal and marital status were not associated with treatment type. CONCLUSIONS: In addition to developing solutions that facilitate access to radiation facilities for breast cancer patients residing in remote locations, future qualitative research may help to elucidate how women and oncologists choose between BCS and mastectomy.