scholarly journals TB case fatality and recurrence in a private sector cohort in Mumbai, India

2021 ◽  
Vol 25 (9) ◽  
pp. 738-746
Author(s):  
S. Huddart ◽  
P. Ingawale ◽  
J. Edwin ◽  
V. Jondhale ◽  
M. Pai ◽  
...  
Keyword(s):  
Quality Of Care ◽  
Private Sector ◽  
Treatment Duration ◽  
Proportional Hazards ◽  
Case Fatality ◽  
Cox Proportional Hazards ◽  
Post Treatment ◽  
Private Provider ◽  
Recurrence Rates

BACKGROUND: Half of India´s three million TB patients are treated in the largely unregulated private sector, where quality of care is often poor. Private provider interface agencies (PPIAs) seek to improve private sector quality of care, which can be measured in terms of case fatality and recurrence rates.METHODS: We conducted a retrospective cohort survey of 4,000 private sector patients managed by the PATH PPIA between 2014 and 2017. We estimated treatment and post-treatment case-fatality ratios (CFRs) and recurrence rates. We used Cox proportional hazards models to identify predictors of fatality and recurrence. Patient loss to follow-up was adjusted for using selection weighting.RESULTS: The treatment CFR was 7.1% (95% CI 6.0–8.2). At 24 months post-treatment, the CFR was 2.4% (95% CI 1.7–3.0) and the recurrence rate was 1.9% (95% CI 1.3–2.5). Treatment fatality was associated with age (HR 1.02, 95% CI 1.02–1.03), clinical diagnosis (HR 0.61, 95% CI 0.45–0.84), treatment duration (HR 0.09, 95% CI 0.06–0.10) and adherence. Post-treatment fatality was associated with treatment duration (HR 0.87, 95% CI 0.79–0.91) and adherence.CONCLUSIONS: We found a moderate treatment phase CFR among PPIA-managed private sector patient with low rates of post-treatment fatality and recurrence. Routine monitoring of patient outcomes after treatment would strengthen PPIAs and inform future post TB interventions.

scholarly journals Case fatality and recurrent tuberculosis among patients managed in the private sector: A cohort study in Patna, India

PLoS ONE ◽  
2021 ◽  
Vol 16 (3) ◽  
pp. e0249225
Author(s):  
Sophie Huddart ◽  
Mugdha Singh ◽  
Nita Jha ◽  
Andrea Benedetti ◽  
Madhukar Pai
Keyword(s):  
Cohort Study ◽  
Private Sector ◽  
Case Fatality ◽  
Weighted Average ◽  
Treatment Phase ◽  
Cox Proportional Hazards ◽  
Post Treatment ◽  
Private Provider ◽  
World Health ◽  
Healthcare Sector

Background A key component of the WHO End TB Strategy is quality of care, for which case fatality is a critical marker. Half of India’s nearly 3 million TB patients are treated in the highly unregulated private sector, yet little is known about the outcomes of these patients. Using a retrospective cohort design, we estimated the case fatality ratio (CFR) and rate of recurrent TB among patients managed in the private healthcare sector in Patna, India. Methods World Health Partners’ Private Provider Interface Agencies (PPIA) pilot project in Patna has treated 89,906 private sector TB patients since 2013. A random sample of 4,000 patients treated from 2014 to 2016 were surveyed in 2018 for case fatality and recurrent TB. CFR is defined as the proportion of patients who die during the period of interest. Treatment CFRs, post-treatment CFRs and rates of recurrent TB were estimated. Predictors for fatality and recurrence were identified using Cox proportional hazards modelling. Survey non-response was adjusted for using inverse probability selection weighting. Results The survey response rate was 56.0%. The weighted average follow-up times were 8.7 months in the treatment phase and 26.4 months in the post-treatment phase. Unobserved patients were more likely to have less than one month of treatment adherence (32.0% vs. 13.5%) and were more likely to live in rural Patna (21.9% vs. 15.0%). The adjusted treatment phase CFR was 7.27% (5.97%, 8.49%) and at 24 months post-treatment was 3.32% (2.36%, 4.42%). The adjusted 24 month post-treatment phase recurrent TB rate was 3.56% (2.54%, 4.79%). Conclusions Our cohort study provides critical estimates of TB patient outcomes in the Indian private sector, and accounts for selection bias. Patients in the private sector in Patna experienced a moderate treatment CFR but rates of recurrent TB and post-treatment fatality were low.

scholarly journals The effect of the employment of consultants in the Emergency Department on quality of care and equity – a quasi-experimental retrospective cohort study

2019 ◽  
Author(s):  
Mette Bendtz Lindstroem ◽  
Ove Andersen ◽  
Thomas Kallemose ◽  
Line Jee Hartmann Rasmussen ◽  
Susanne Rosthoej ◽  
...  
Keyword(s):  
Socioeconomic Status ◽  
Quality Of Care ◽  
Length Of Stay ◽  
Hospital Mortality ◽  
Clinical Decision Making ◽  
Proportional Hazards ◽  
Negative Impact ◽  
Cox Proportional Hazards ◽  
Medical Patients

Abstract Background Crowding and bed occupancy are challenging issues in the hospitals with increasing acute admissions, caused by an aging population. Crowding in Emergency Departments (EDs) has a negative impact on length of hospitalisation, in-hospital mortality, patient safety, and flow. Thus, the Danish Health Authorities recommend the presence of specialist doctors in the ED who are dedicated to execute the clinical decision-making process. Thus, in 2016, the model of acute care was changed in the ED at Hvidovre Hospital, Denmark, to include consultant-led triage and continuous presence of consultants, referred to as Acute Medical Consultants. However, there is little evidence concerning the effect of consultants treating patients in the ED, and how it affects care for patients of varying socioeconomic status compared with other models of ED staffing. This study investigated whether the employment of Acute Medical Consultants in a Danish ED affected the quality of care for acutely admitted medical patients in terms of length of stay, readmission, mortality, and secondly how this effect was distributed across socioeconomic status in patients. Methods Admission data for 9,869 adult medical patients admitted for up to 48 hours in the ED was collected in two separate 7-month periods, one prior to and one after the organisational intervention. Linear regression and Cox proportional hazards regression analyses adjusted for age, sex, comorbidities, level of education, and employment status were applied. Results Following the employment of Acute Medical Consultants, an overall 11% increase in index-admissions was observed, and 90% of patients were discharged by an Acute Medical Consultant with a reduced mean length of stay by 1.4 hours (95% CI: 1.0 – 1.9). No significant change was found in in-hospital mortality, readmission, or mortality within 90 days after discharge. No difference was found in quality of care across socioeconomic status. Conclusion The employment of Acute Medical Consultants in the ED was associated with reduced length of admission without a negative effect on the quality of care for ED-admitted medical patients in general, or for patients with lower socioeconomic status. Yet, in order to reduce readmission and mortality among acutely admitted patients, other means must be initiated.

The effect of the employment of consultants in the Emergency Department on quality of care and equity

2020 ◽  
Vol 30 (Supplement_5) ◽  
Author(s):  
M B Lindstroem ◽  
O Andersen ◽  
T Kallemose ◽  
L J H Rasmussen ◽  
S Rosthoej ◽  
...  
Keyword(s):  
Socioeconomic Status ◽  
Quality Of Care ◽  
Hospital Mortality ◽  
Clinical Decision Making ◽  
Proportional Hazards ◽  
Clinical Decision ◽  
Cox Proportional Hazards ◽  
Medical Patients ◽  
Negative Effect

Abstract Background Hospitals struggle with increasing acute admissions and crowding in Emergency Departments (EDs) negatively affect length of hospitalisation, in-hospital mortality, patient safety and flow. In response to this, the Danish Health Authorities have recommended the presence of consultants in the ED to expedite the clinical decision-making process. In 2016, consultant-led triage and continuous presence of consultants was introduced at the ED at Hvidovre Hospital, Denmark. However, little is known on the effect of consultants in the ED, and how it affects care for patients of varying socioeconomic status. This study investigated whether the employment of consultants in a Danish ED affected the quality of care for acutely admitted medical patients in terms of length of admission, readmission, and mortality, and how this effect was distributed across socioeconomic status in patients. Methods Admission data was collected during two 7-month periods, one prior to and one after the organisational intervention, with 9,869 adult medical patients admitted for up to 48 hours in the ED. Linear regression and Cox proportional hazards regression analyses adjusted for age, sex, comorbidities, level of education and employment status were applied. Results Following the employment of consultants, an overall 11% increase in index-admissions was observed, and 90% of patients were discharged by a consultant with a reduced mean length of admission by 1.4 hours (95% CI: 1.0 - 1.9). No significant change was found in in-hospital mortality, readmission, or mortality within 90 days after discharge. No difference was found in quality of care across socioeconomic status. Conclusions Consultants in the ED was found to reduce length of admission without a negative effect on the quality of care for ED admitted medical patients in general, or for patients with lower socioeconomic status. To reduce readmission and mortality among acutely admitted patients, other means must be initiated. Key messages Consultants in the ED may reduce length of admission without a negative effect on the quality of care. To reduce readmission and mortality among acutely admitted patients, other means must be initiated.

Abstract T P142: Mortality and Stroke Recurrence in Obese Stroke Patients: The Obesity Paradox in a London-Based Population

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Filomena Gomes ◽  
Peter W Emery ◽  
Christine E Weekes
Keyword(s):  
Waist Circumference ◽  
Proportional Hazards ◽  
Hospital Admissions ◽  
Recurrent Stroke ◽  
Normal Weight ◽  
Cox Proportional Hazards ◽  
National Database ◽  
Stroke Recurrence ◽  
Recurrence Rates ◽  
Post Stroke

INTRODUCTION Several studies have shown a paradoxical association between body mass index (BMI) and mortality after stroke. However, the association between BMI, waist circumference (WC) and mortality and stroke recurrence is unclear. This study aimed to determine the associations between BMI, WC and mortality and stroke recurrence at 6 months post stroke. METHODS Patients were recruited from consecutive admissions at 2 hyper-acute stroke units in London and were classified into 4 categories of BMI (underweight, normal weight, overweight and obese) and quartiles of WC. Outcomes were obtained for each patient through a national database that contains details of all hospital admissions. Chi-square tests were used to compare mortality and stroke recurrence rates. Cox Proportional Hazards Models were used to compare mortality risk and survival curves between different BMI categories and WC quartiles. RESULTS Of 543 recruited patients, 51% were males and 87% had an ischaemic stroke, with a mean age of 74.7 years (range 22-99). There were significant inverse associations between BMI and WC and risk of mortality at 6-months post-stroke (see table) ( p=0.001 and p=0.04, respectively). After adjusting for possible confounders (age, ethnicity, gender, severity and type of stroke, stroke risk factors), these associations were attenuated ( p=0.06 for BMI and p=0. 11 for WC). No significant differences were found in stroke recurrence rates between BMI groups (underweight 3.7%, normal weight 3.8%, overweight 4.5%, obese 2.8%; p=0.91) or WC quartiles (Q1 2.8%, Q2 5.1%, Q3 3.5%, Q4 3.6%; p=0.83). CONCLUSION After a stroke, being obese and having a larger waist circumference was associated with reduced mortality but did not affect the risk of a recurrent stroke.

scholarly journals Tuberculosis practices among private medical practitioners in Kaski district, Nepal

2013 ◽  
Vol 1 (2) ◽  
pp. 68-75
Author(s):  
AK Nepal ◽  
A Shrestha ◽  
SC Baral ◽  
R Bhattarai ◽  
Y Aryal
Keyword(s):  
Quality Of Care ◽  
Private Sector ◽  
Structured Interview ◽  
Cross Sectional Study ◽  
Cross Sectional ◽  
Public And Private ◽  
Medical Practitioners ◽  
Sputum Microscopy ◽  
Public And Private Sector

INTRODUCTION: Although the evidences suggest that more than one third tuberculosis (TB) cases are being managed in private sector, the quality of care in private sector is major concern. However, the information regarding the private practices were lacking. Therefore the study was conducted to gain insights on current practices of TB management at private sectors. MATERIALS AND METHODS: A descriptive cross sectional study, applying quantitative method, was conducted at two cities of Kaski among all private practitioners, private pharmacies and private laboratories through self administered questionnaire and structured interview schedule. RESULTS: Nearly one fourth of the TB suspects in the district were found to have consulted private providers with about 20.0% of the total smear positive cases diagnosed in private laboratories. Beside sputum microscopy, Private Medical Practitioners (PMPs) were also found to prefer other tests like X-ray, culture for TB diagnosis. Similarly, PMPs’ varying prescription of anti TB drugs beyond National TB Programme (NTP) recommendation along with their weak recording and case holding were noteworthy, and the cost of TB treatment seemed higher in private sector. Only one third of private institution had their staff trained in TB. Except some informal linkage, no collaboration between public and private sector was noted. CONCLUSIONS: Private sector was managing many TB cases in the district. However, their practice of TB management was not much satisfactory. Therefore NTP should take effective measures for Public Private Mix and to make them aware of the standards through training and orientation in order to improve the quality of care. DOI: http://dx.doi.org/10.3126/ijim.v1i2.7085 Int J Infect Microbiol 2012;1(1):68-75

scholarly journals Prescription for antibiotics at drug shops and strategies to improve quality of care and patient safety: a cross-sectional survey in the private sector in Uganda

BMJ Open ◽  
2016 ◽  
Vol 6 (3) ◽  
pp. e010632 ◽  
Author(s):  
Anthony K Mbonye ◽  
Esther Buregyeya ◽  
Elizeus Rutebemberwa ◽  
Siân E Clarke ◽  
Sham Lal ◽  
...  
Keyword(s):  
Patient Safety ◽  
Quality Of Care ◽  
Private Sector ◽  
Improve Quality ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Drug Shops

Association between warfarin combined with serotonin-modulating antidepressants and increased case fatality in primary intracerebral hemorrhage: a population-based study

2014 ◽  
Vol 120 (6) ◽  
pp. 1358-1363 ◽  
Author(s):  
Pekka Löppönen ◽  
Sami Tetri ◽  
Seppo Juvela ◽  
Juha Huhtakangas ◽  
Pertti Saloheimo ◽  
...  
Keyword(s):  
Intracerebral Hemorrhage ◽  
Selective Serotonin Reuptake Inhibitors ◽  
Proportional Hazards ◽  
Oral Anticoagulants ◽  
Case Fatality ◽  
Population Based ◽  
Cox Proportional Hazards ◽  
Significant Independent Predictor ◽  
Kaplan Meier ◽  
Concurrent Use

Object Patients receiving oral anticoagulants run a higher risk of cerebral hemorrhage with a poor outcome. Serotonin-modulating antidepressants (selective serotonin reuptake inhibitors [SSRIs], serotonin-norepinephrine reuptake inhibitors [SNRIs]) are frequently used in combination with warfarin, but it is unclear whether this combination of drugs influences outcome after primary intracerebral hemorrhage (PICH). The authors investigated case fatality in PICH among patients from a defined population who were receiving warfarin alone, with aspirin, or with serotonin-modulating antidepressants. Methods Nine hundred eighty-two subjects with PICH were derived from the population of Northern Ostrobothnia, Finland, for the years 1993–2008, and those with warfarin-associated PICH were eligible for analysis. Their hospital records were reviewed, and medication data were obtained from the national register of prescribed medicines. Kaplan-Meier survival curves were drawn to illustrate cumulative case fatality, and a Cox proportional-hazards analysis was performed to demonstrate predictors of death. Results Of the 176 patients eligible for analysis, 17 had been taking aspirin and 19 had been taking SSRI/SNRI together with warfarin. The 30-day case fatality rates were 50.7%, 58.8%, and 78.9%, respectively, for those taking warfarin alone, with aspirin, or with SSRI/SNRI (p = 0.033, warfarin plus SSRI/SNRI compared with warfarin alone). Warfarin combined with SSRI/SNRI was a significant independent predictor of case fatality (adjusted HR 2.10, 95% CI 1.13–3.92, p = 0.019). Conclusions Concurrent use of warfarin and a serotonin-modulating antidepressant, relative to warfarin alone, seemed to increase the case fatality rate for PICH. This finding should be taken into account if hematoma evacuation is planned.

scholarly journals A National Survey of Private-Sector Outpatient Care of Sick Infants and Young Children in Nepal

2020 ◽  
Author(s):  
Bharat Ban ◽  
Steve Hodgins ◽  
Pranita Thapa ◽  
Surakschha Thapa ◽  
Deepak Joshi ◽  
...  
Keyword(s):  
Quality Of Care ◽  
Private Sector ◽  
Outpatient Care ◽  
Service Providers ◽  
Infants And Children ◽  
Sub Saharan Africa ◽  
Scope Of Practice ◽  
Urban Centers ◽  
Young Infants

Abstract Background: Previous research has documented that across South Asia, as well as in some countries in Sub-Saharan Africa, the private sector is the primary source of outpatient care for sick infants and children and, in many settings, informal providers play a bigger role than credentialed health professionals (particularly for the poorer segments of the population). This is the case in Nepal. This study sought to characterize medicine shop-based service providers in rural areas and small urban centers in Nepal, their role in the care and treatment of sick infants and children (with a particular focus on infants aged <2 months), and the quality of the care provided. A secondary objective was to characterize availability and quality of such care provided by physicians in these settings.Methods: A nationally representative sample of medicine shops was drawn, in rural settings and small urban centers in Nepal, from 25 of the 75 districts in Nepal, using multi-stage cluster methodology, with a final sample of 501 shops and 82 physician-run clinics. Face-to-face interviews were conducted.Results: Most medicine shops outside urban areas were not registered with the Department of Drug Administration (DDA). Most functioned as de facto clinics, with credentialed paramedical workers (having 2-3 years of training) diagnosing patients and making treatment decisions. Such a role falls outside their formally sanctioned scope of practice. Quality of care problems were identified among medicine shop-based providers and physicians, including over-use of antibiotics for treating diarrhea, inaccurate weighing technique to determine antibiotic dose, and inappropriate use of injectable steroids for treating potentially severe infections in young infants.Conclusions: Medicine shop-based practitioners in Nepal represent a particular type of informal provider; although most have recognized paramedical credentials, they offer services falling outside their formal scope of practice. Nevertheless, given the large proportion of the population served by these practitioners, engagement to strengthen quality of care by these providers and referral to the formal health sector is warranted.

scholarly journals Docetaxel vs. Novel Hormonal Agent for Upfront Management of De Novo Metastatic Hormone-Sensitive Prostate Cancer: A Comprehensive Report of a Single-Center Experience

2021 ◽  
Author(s):  
Sunny Guin ◽  
Bobby K. Liaw ◽  
Tomi Jun ◽  
Kristin Ayers ◽  
Bonny Patel ◽  
...  
Keyword(s):  
Prostate Cancer ◽  
Prognostic Value ◽  
Proportional Hazards ◽  
De Novo ◽  
Standard Of Care ◽  
Cox Proportional Hazards ◽  
Post Treatment ◽  
Real World Data ◽  
Significant Difference ◽  
Hormone Sensitive

Abstract Background: Upfront docetaxel or novel hormonal agents (NHA) such as abiraterone and enzalutamide have become the standard of care for metastatic hormone sensitive prostate cancer (mHSPC). However, data comparing the efficacy of docetaxel and NHAs in this setting are limited.Patients and Methods: This was a retrospective cohort study of patients with de novo mHSPC treated with upfront docetaxel or an NHA between January 1, 2014 and April 30, 2019 within the Mount Sinai Health System. Clinical data were extracted from the medical record. The primary outcome was failure-free survival (FFS), defined as the time to next treatment. The primary predictor was treatment with docetaxel or NHA. FFS was compared between the two groups using the Kaplan Meier method and multivariable Cox proportional hazards models. We additionally assessed the prognostic value of post-treatment PSA.Results: We identified 94 de novo mHSPC patients; 52 and 42 treated with upfront docetaxel and NHAs, respectively. NHAs were associated with significantly longer FFS compared to docetaxel (20.7 vs. 10.1 months, p=0.023). In a multivariable model adjusting for demographics and clinical factors, docetaxel was independently associated with worse FFS compared to NHAs (HR 1.96, 95% CI 1.12−3.45, p=0.019). High metastasis burden patients had a significantly longer FFS with NHAs than docetaxel (25.12 vs. 9.63 months, p=0.014), while there was no significant difference in FFS among low metastasis burden patients (NHA 20.71 vs. Docetaxel 26.5 months, p=0.9). Regardless of treatment, lower post-treatment PSA levels were associated with improved FFS (58.95 vs. 11.57 vs. 9.4 months for PSA ≤0.2, 0.2-0.4, >0.4ng/ml, respectively; p<0.001) Conclusion: Comparative analysis of real-world data demonstrated longer FFS in de novo mHSPC treated with NHA compared to docetaxel. In addition, the depth of PSA response following combination treatment may hold prognostic value for mHSPC outcomes.

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