Using Network and Complexity Theories to Understand the Functionality of Referral Systems for Surgical Patients in Resource-Limited Settings, the Case of Malawi

Background: A functionally effective referral system that links district level hospitals (DLHs) with referral hospitals (RHs) facilitates surgical patients getting timely access to specialist surgical expertise not available locally. Most published studies from low- and middle-income countries have examined only selected aspects of such referral systems, which are often fragmented. Inadequate understanding of their functionality leads to missed opportunities for improvements. This research aimed to investigate the functionality of the referral system for surgical patients in Malawi, a low-income country. Methods: This study, conducted in 2017-2019, integrated principles from two theories. We used network theory to explore interprofessional relationships between DLHs and RHs at referral network, member (hospital) and community levels; and used principles from complex adaptive systems theory to unpack the mechanisms of network dynamics. The study employed mixed-methods, specifically surveys (n=22 DLHs), interviews with clinicians (n=20), and a database of incoming referrals at two sentinel RHs over a six-month period. Results: Obstacles to referral system functionality in Malawi included weaknesses in formal coordination structures, notably: unclear scope of practice of district surgical teams; lack of referral protocols; lack of referral communication standards; and misaligned organisational practices. Deficiencies in informal relationships included mistrust and uncollaborative operating environments, undermining coordination between DLHs and RHs. Poor system functionality adversely impacted the quality, efficiency and safety of patient referral-related care. Respondents identified aspects of the district-referral hospital relationships, which could be leveraged to build more collaborative and productive inter-professional relationships in the future. Conclusion: Multi-level interventions are needed to address failures at both ends of the referral pathway. This study captured new insights into longstanding problems in referral systems in resource-limited settings, contributing to a better understanding of how to build more functional systems to optimise the continuum and quality of surgical care for rural populations in similar settings.

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The effectiveness of different patient referral systems to shorten waiting times for elective surgeries: systematic review

BMC Health Services Research ◽

10.1186/s12913-021-06140-w ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Dimuthu Rathnayake ◽

Mike Clarke

Keyword(s):

Primary Care ◽

Health Systems ◽

Elective Surgery ◽

Waiting Times ◽

Surgical Care ◽

High Income ◽

Surgical Patients ◽

Timely Access ◽

Referral Systems

Abstract Background Long waiting times for elective surgery are common to many publicly funded health systems. Inefficiencies in referral systems in high-income countries are more pronounced than lower and middle-income countries. Primary care practitioners play a major role in determining which patients are referred to surgeon and might represent an opportunity to improve this situation. With conventional methods of referrals, surgery clinics are often overcrowded with non-surgical referrals and surgical patients experience longer waiting times as a consequence. Improving the quality of referral communications should lead to more timely access and better cost-effectiveness for elective surgical care. This review summarises the research evidence for effective interventions within the scope of primary-care referral methods in the surgical care pathway that might shorten waiting time for elective surgeries. Methods We searched PubMed, EMBASE, SCOPUS, Web of Science and Cochrane Library databases in December-2019 to January-2020, for articles published after 2013. Eligibility criteria included major elective surgery lists of adult patients, excluding cancer related surgeries. Both randomised and non-randomised controlled studies were eligible. The quality of evidence was assessed using ROBINS-I, AMSTAR 2 and CASP, as appropriate to the study method used. The review presentation was limited to a narrative synthesis because of heterogeneity. The PROSPERO registration number is CRD42019158455. Results The electronic search yielded 7543 records. Finally, nine articles were considered as eligible after deduplication and full article screening. The eligible research varied widely in design, scope, reported outcomes and overall quality, with one randomised trial, two quasi-experimental studies, two longitudinal follow up studies, three systematic reviews and one observational study. All the six original articles were based on referral methods in high-income countries. The included research showed that patient triage and prioritisation at the referral stage improved timely access and increased the number of consultations of surgical patients in clinics. Conclusions The available studies included a variety of interventions and were of medium to high quality researches. Managing patient referrals with proper triaging and prioritisation using structured referral formats is likely to be effective in health systems to shorten the waiting times for elective surgeries, specifically in high-income countries.

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International Radiotherapy Referrals From Rural Rwanda: Implementation Processes and Early Clinical Outcomes

Journal of Global Oncology ◽

10.1200/jgo.18.00089 ◽

2018 ◽

pp. 1-12

Author(s):

Maud Hanappe ◽

Lowell T. Nicholson ◽

Shekinah N.C. Elmore ◽

Alexandra E. Fehr ◽

Jean Bosco Bigirimana ◽

...

Keyword(s):

Rectal Cancer ◽

Head And Neck ◽

Low Income ◽

Cancer Care ◽

Sub Saharan Africa ◽

Resource Limited Settings ◽

Cancer Centre ◽

Resource Limited ◽

Centre Of Excellence ◽

Sub Saharan

Purpose Low- and middle-income countries disproportionately comprise 65% of cancer deaths. Cancer care delivery in resource-limited settings, especially low-income countries in sub-Saharan Africa, is exceedingly complex, requiring multiple modalities of diagnosis and treatment. Given the vast human, technical, and financial resources required, access to radiotherapy remains limited in sub-Saharan Africa. Through 2017, Rwanda has not had in-country radiotherapy services. The aim of this study was to describe the implementation and early outcomes of the radiotherapy referral program at the Butaro Cancer Centre of Excellence and to identify both successful pathways and barriers to care. Methods Butaro District Hospital is located in a rural area of the Northern Province and is home to the Butaro Cancer Centre of Excellence. We performed a retrospective study from routinely collected data of all patients with a diagnosis of cervical, head and neck, or rectal cancer between July 2012 and June 2015. Results Between 2012 and 2015, 580 patients were identified with these diagnoses and were potential candidates for radiation. Two hundred eight (36%) were referred for radiotherapy treatment in Uganda. Of those referred, 160 (77%) had cervical cancer, 31 (15%) had head and neck cancer, and 17 (8%) had rectal cancer. At the time of data collection, 101 radiotherapy patients (49%) were alive and had completed treatment with no evidence of recurrence, 11 (5%) were alive and continuing treatment, and 12 (6%) were alive and had completed treatment with evidence of recurrence. Conclusion This study demonstrates the feasibility of a rural cancer facility to successfully conduct out-of-country radiotherapy referrals with promising early outcomes. The results of this study also highlight the many challenges and lessons learned in providing comprehensive cancer care in resource-limited settings.

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Providing Anesthesia Care in Resource-limited Settings

Anesthesiology ◽

10.1097/aln.0000000000000985 ◽

2016 ◽

Vol 124 (3) ◽

pp. 561-569 ◽

Cited By ~ 19

Author(s):

Promise Ariyo ◽

Miguel Trelles ◽

Rahmatullah Helmand ◽

Yama Amir ◽

Ghulam Haidar Hassani ◽

...

Keyword(s):

General Anesthesia ◽

Spinal Anesthesia ◽

Surgical Care ◽

Resource Limited Settings ◽

Perioperative Mortality ◽

Patient Demographics ◽

Resource Limited ◽

Anesthesia Providers ◽

Wide Range ◽

Surgical Duration

Abstract Background Anesthesia is integral to improving surgical care in low-resource settings. Anesthesia providers who work in these areas should be familiar with the particularities associated with providing care in these settings, including the types and outcomes of commonly performed anesthetic procedures. Methods The authors conducted a retrospective analysis of anesthetic procedures performed at Médecins Sans Frontières facilities from July 2008 to June 2014. The authors collected data on patient demographics, procedural characteristics, and patient outcome. The factors associated with perioperative mortality were analyzed. Results Over the 6-yr period, 75,536 anesthetics were provided to adult patients. The most common anesthesia techniques were spinal anesthesia (45.56%) and general anesthesia without intubation (33.85%). Overall perioperative mortality was 0.25%. Emergent procedures (0.41%; adjusted odds ratio [AOR], 15.86; 95% CI, 2.14 to 115.58), specialized surgeries (2.74%; AOR, 3.82; 95% CI, 1.27 to 11.47), and surgical duration more than 6 h (9.76%; AOR, 4.02; 95% CI, 1.09 to 14.88) were associated with higher odds of mortality than elective surgeries, minor surgeries, and surgical duration less than 1 h, respectively. Compared with general anesthesia with intubation, spinal anesthesia, regional anesthesia, and general anesthesia without intubation were associated with lower perioperative mortality rates of 0.04% (AOR, 0.10; 95% CI, 0.05 to 0.18), 0.06% (AOR, 0.26; 95% CI, 0.08 to 0.92), and 0.14% (AOR, 0.29; 95% CI, 0.18 to 0.45), respectively. Conclusions A wide range of anesthetics can be carried out safely in resource-limited settings. Providers need to be aware of the potential risks and the outcomes associated with anesthesia administration in these settings.

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Point of Care Diagnostics in Resource-Limited Settings: A Review of the Present and Future of PoC in Its Most Needed Environment

Biosensors ◽

10.3390/bios10100133 ◽

2020 ◽

Vol 10 (10) ◽

pp. 133

Author(s):

Benjamin Heidt ◽

Williane Siqueira ◽

Kasper Eersels ◽

Hanne Diliën ◽

Bart van Grinsven ◽

...

Keyword(s):

Low Income ◽

Value Chain ◽

Point Of Care ◽

Healthcare Providers ◽

Low Income Countries ◽

Patient Treatment ◽

Resource Limited Settings ◽

Widespread Application ◽

Resource Limited ◽

Fundamental Research

Point of care (PoC) diagnostics are at the focus of government initiatives, NGOs and fundamental research alike. In high-income countries, the hope is to streamline the diagnostic procedure, minimize costs and make healthcare processes more efficient and faster, which, in some cases, can be more a matter of convenience than necessity. However, in resource-limited settings such as low-income countries, PoC-diagnostics might be the only viable route, when the next laboratory is hours away. Therefore, it is especially important to focus research into novel diagnostics for these countries in order to alleviate suffering due to infectious disease. In this review, the current research describing the use of PoC diagnostics in resource-limited settings and the potential bottlenecks along the value chain that prevent their widespread application is summarized. To this end, we will look at literature that investigates different parts of the value chain, such as fundamental research and market economics, as well as actual use at healthcare providers. We aim to create an integrated picture of potential PoC barriers, from the first start of research at universities to patient treatment in the field. Results from the literature will be discussed with the aim to bring all important steps and aspects together in order to illustrate how effectively PoC is being used in low-income countries. In addition, we discuss what is needed to improve the situation further, in order to use this technology to its fullest advantage and avoid “leaks in the pipeline”, when a promising device fails to take the next step of the valorization pathway and is abandoned.

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Navigating the Turbulent Waters of School Reform Guided by Complexity Theory

Complicity An International Journal of Complexity and Education ◽

10.29173/cmplct24566 ◽

2016 ◽

Vol 13 (1) ◽

Cited By ~ 1

Author(s):

David G. White ◽

James A. Levin

Keyword(s):

School Reform ◽

Complexity Theory ◽

Low Income ◽

Complex Adaptive Systems ◽

Adaptive Systems ◽

Adaptive System ◽

Complex Adaptive System ◽

Design Experiment ◽

Underrepresented Minority ◽

Complex Adaptive

The goal of this research study has been to develop, implement, and evaluate a school reform design experiment at a continuation high school with low-income, low-performing underrepresented minority students. The complexity sciences served as a theoretical framework for this design experiment. Treating an innovative college preparatory program as a nested complex adaptive system within a larger complex adaptive system, the school, we used features of complex adaptive systems (equilibrium, emergence, self-organization, and feedback loops) as a framework to design a strategy for school reform. The goal was to create an environment for change by pulling the school far from equilibrium using a strategy we call “purposeful perturbations” to disrupt the stable state of the school in a purposeful way. Over the four years of the study, several tipping points were reached, and we developed agent-based simulation models that capture important dynamic properties of the reform at these points. The study draws upon complexity theory in multiple ways that have supported improved education for low-achieving students.

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Pain and Symptoms in Surgical Patients in Resource-Limited Settings: Can We Identify High Symptom Burden?

Journal of the American College of Surgeons ◽

10.1016/j.jamcollsurg.2020.07.244 ◽

2020 ◽

Vol 231 (4) ◽

pp. S127

Author(s):

Helen Wu Li ◽

Connie H. Keung ◽

Ivan Seno Saruni ◽

Kyle Carpenter ◽

Peter S. Kussin

Keyword(s):

Symptom Burden ◽

Surgical Patients ◽

Resource Limited Settings ◽

Resource Limited

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Simple Paper-Based Test for Measuring Blood Hemoglobin Concentration in Resource-Limited Settings

Clinical Chemistry ◽

10.1373/clinchem.2013.204701 ◽

2013 ◽

Vol 59 (10) ◽

pp. 1506-1513 ◽

Cited By ~ 43

Author(s):

Xiaoxi Yang ◽

Nathaniel Z Piety ◽

Seth M Vignes ◽

Melody S Benton ◽

Julie Kanter ◽

...

Keyword(s):

Low Income ◽

Low Cost ◽

Hemoglobin Concentration ◽

Comparison Method ◽

Sub Saharan Africa ◽

Small Samples ◽

Diagnostic Tools ◽

Resource Limited Settings ◽

Resource Limited ◽

Oxygen Carrying Capacity

BACKGROUND The measurement of hemoglobin concentration ([Hb]) is performed routinely as a part of a complete blood cell count to evaluate the oxygen-carrying capacity of blood. Devices currently available to physicians and clinical laboratories for measuring [Hb] are accurate, operate on small samples, and provide results rapidly, but may be prohibitively expensive for resource-limited settings. The unavailability of accurate but inexpensive diagnostic tools often precludes proper diagnosis of anemia in low-income developing countries. Therefore, we developed a simple paper-based assay for measuring [Hb]. METHODS A 20-μL droplet of a mixture of blood and Drabkin reagent was deposited onto patterned chromatography paper. The resulting blood stain was digitized with a portable scanner and analyzed. The mean color intensity of the blood stain was used to quantify [Hb]. We compared the performance of the paper-based Hb assay with a hematology analyzer (comparison method) using blood samples from 54 subjects. RESULTS The values of [Hb] measured by the paper-based assay and the comparison method were highly correlated (R2 = 0.9598); the standard deviation of the difference between the two measurements was 0.62 g/dL. The assay was accurate within 1 g/dL 90.7% of the time, overestimating [Hb] by ≥1 g/dL in 1.9% and underestimating [Hb] by ≥1 g/dL in 7.4% of the subjects. CONCLUSIONS This study demonstrates the feasibility of the paper-based Hb assay. This simple, low-cost test should be useful for diagnosing anemia in resource-limited settings, particularly in the context of care for malaria, HIV, and sickle cell disease patients in sub-Saharan Africa.

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External stoma diversion: a palliative measure for peristomal wound healing in resource-limited settings

Journal of Surgical Case Reports ◽

10.1093/jscr/rjaa502 ◽

2020 ◽

Vol 2020 (12) ◽

Author(s):

Rachel W Davis ◽

Youmna A Sherif ◽

Catherine Anne Morrison

Keyword(s):

Wound Healing ◽

Surgical Procedure ◽

Wound Care ◽

Cost Effective ◽

Surgical Patients ◽

Resource Limited Settings ◽

Care Access ◽

Resource Limited ◽

Intestinal Stoma ◽

Stoma Care

Abstract The provision of intestinal stoma care is challenging in austere settings due to limitations in surgical and wound care access as well as the high cost and sparsity of ostomy supplies. As a result, many surgical patients suffer from ostomy-related complications such as peristomal wounds and are unable to find relief for these complications from standard treatments and measures. This article describes the external stoma diversion, a cost-effective palliative surgical procedure that assists in the healing of peristomal wounds in resource-limited settings.

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Burden of Chemotherapy Induced Febrile Neutropenia in Paediatric Oncology in a Low-Income Country: The Children's Hospital Lahore Pakistan Experience

Journal of Global Oncology ◽

10.1200/jgo.18.23700 ◽

2018 ◽

Vol 4 (Supplement 2) ◽

pp. 82s-82s

Author(s):

A. Ahmad

Keyword(s):

Public Sector ◽

Febrile Neutropenia ◽

Childhood Cancer ◽

Low Income ◽

Resource Limited Settings ◽

Children's Hospital ◽

Resource Limited ◽

Public Sector Hospital ◽

Free Treatment ◽

Children’S Hospital

Background: Febrile neutropenia (FN) is one of most common and potentially lethal complications in patients with cancer during chemotherapy. The Oncology Department of the Children's Hospital Lahore Pakistan is a 60 bedded unit providing free treatment to over 1300 new childhood cancer cases each year and over 200 admissions per month with bed occupancy rate around 200%. The department receives childhood cancer cases not only from Pakistan but also from Afghanistan. Therefore it's very challenging to treat cancer and infection parallel with increased burden on the public sector hospital providing free treatment as well as on health professionals managing these patients with advanced stages and frequent infection episodes. Aim: The objective of this study is to evaluate the burden of FN in resource limited settings like a public sector hospital in Pakistan. A prospective review of data of patients treated for febrile neutropenia from October to December 2017 in the Haematology/Oncology Department of The Children's Hospital Lahore after IRB approval. The data were analyzed by using SPSS 20. Results: 250 patients were treated for FN during these three months 59% of them male and mean age 6.27 years. Among diagnoses, 58% had acute lymphoblastic leukaemia, 16% sarcomas, 10% lymphoma and 16% other solid malignancies on different chemotherapy regimens. 53% received their chemo during last 3 days and 35% in the last week prior to FN admission. 84% of them were receiving either induction or intensive phase protocols. 48% had respiratory tract infection followed by AGE 25%, fever alone in 20%, 82% cases had mucositis. 52% cases had symptoms of more than 24 hours before seek treatment of FN. ANC (absolute neutrophil count) was < 100 in 60% and platelets < 50,000 in 56% cases on arrival. 57% cases stayed 1-3 hours drive from the Children´s hospital and only 44% parents had adequate awareness of FN management. Regarding the outcome 81% discharged home, 16% expired (mainly FN and progressive disease) and 3% abandoned treatment. G-CSF (granulocyte-colony stimulating factor) was used in 30% (0.026 for RX cost and 0.043 hospital stay) and blood products in 75%, inotropes used in 16% with mean estimated cost of 15,000 RS/patient (total 3.8 million RS) with 95% staying > 48 hrs. 61 cultures were positive mainly urine, blood, ENT, wound, CSF. 92% were Gram negative with majority Klebsiella followed by Pseudomonas, E. coli and Citrobacter species. There were no central lines used. Conclusion: This study described that FN has been a profound burden in childhood cancer care in public sector hospital in resource limited settings like Pakistan. There is immense need to health educate the parents, nurses and doctors for standard care of febrile neutropenia along with sustainable social support and shared care oncology as being provided in developed countries to share the load of primary treatment centers aiming for decreased morbidity and mortality.

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Introduction to Telemental Health and Its Use in Resource-Limited Settings

10.1093/med/9780190622725.003.0001 ◽

2017 ◽

Author(s):

Hussam Jefee-Bahloul

Keyword(s):

Mental Health ◽

Health Services ◽

Low Income ◽

The Other ◽

Evidence Based ◽

Telemental Health ◽

Resource Limited Settings ◽

Resource Limited ◽

The World ◽

Evidence Based Healthcare

This chapter provides an introduction to telemental health and its applicability in global resource-limited settings. The chapter presents two case studies of applicable technology-based provision of mental health services in the world. Using two examples from low income settings, one marked by poverty and lack of access and the other by war and violence, the projects highlight how telemental health is addressing the gap between knowledge and delivery of evidence-based healthcare in the field of mental health. The discussion serves to introduce the rest of the book with a highlight of the main concepts to be discussed in later chapters.

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