Patient satisfaction with the Nigerian National Health Insurance Scheme two decades since establishment: A systematic review and recommendations for improvement

Background: To improve healthcare access and mitigate healthcare costs for its population, Nigeria established a National Health Insurance Scheme (NHIS) in 1999. The NHIS remains Nigeria’s leading vehicle for achieving universal health coverage; nonetheless, questions remain regarding its quality and effectiveness. Studies on patient satisfaction have served as a useful strategy to further understand the patient experience and the efficacy of health systems.Aim: To synthesise current knowledge on patient satisfaction with the NHIS.Methods: The authors performed a systematic review of primary literature from 1999 to 2020 reporting on NHIS patient satisfaction in eight databases (including PubMed, Embase, and Africa-wide Information).Results: This search returned 764 unique records of which 21 met criteria for full data extraction. The 21 qualifying studies representing 11 of the 36 Nigerian states, were published from 2011 to 2020, and found moderate overall satisfaction with the NHIS (64%). Further, when disaggregated into specific domains, NHIS enrolees were most satisfied with provider attitudes (77%) and healthcare environments (70%), but less satisfied with laboratories (62%), billings (62%), pharmaceutical services (56%), wait times (55%), and referrals (51%). Importantly, time trends indicate satisfaction with the NHIS is increasing – although to differing degrees depending on the domain.Conclusion: The beneficiaries of the NHIS are moderately satisfied with the scheme. They consider it an improvement from being uninsured, but believe that the scheme can be considerably improved. The authors present two main recommendations: (1) shorter wait times may increase patient satisfaction and can be a central focus in improving the overall scheme, and (2) more research is needed across all 36 states to comprehensively understand patient satisfaction towards NHIS in anticipation of potential scheme expansion.

A systematic literature review exploring the psychosocial aspects of palliative care provision for incarcerated persons: a human rights perspective

Purpose The purpose of this study is to explore the psychosocial aspects of palliative care provision for incarcerated persons drawing on a human rights perspective. Design/methodology/approach Seven databases were searched to identify empirical studies published from 2010 to 2020. Articles included were qualitative, quantitative, mixed methods, written in English and with westernised health/prison settings, with a key focus on the psychosocial aspects of palliative care provision and human rights. The quality of the articles was appraised using the Mixed Methods Assessment Tool (2018). Findings The results from 26 articles revealed multiple models of care, with the US prison hospice program depicted as optimal, because of the use of trained incarcerated caregivers, working as aides to the interprofessional team. The bereavement needs of caregivers were highlighted. The barriers to adequate psychosocial care were negative public discourse, prison processes and resources, provider attitudes and the incarcerated person’s level of knowledge and trust. Identified facilitators were related to incarcerated persons’ caregiving programs, a sense of purpose and visitation leniency. Human rights principles were identified in studies that featured compassionate release and advance care planning. Research limitations/implications There is inconsistency in the literature regarding what constitutes psychosocial care, which meant that the authors needed to draw on multiple literature sources to formulate a definition. Additionally, the review only included studies written in English, meaning some high-quality studies could have been missed. The articles that conducted interviews with incarcerated individuals were undertaken in male prisons only and not female prisons. Practical implications Understanding the importance of psychosocial care for incarcerated persons with a life-limiting illness requires a shift in negative public discourse and the need for a stronger human rights focus. Some countries, such as the USA and UK, are achieving effective outcomes; however, countries such as Australia are yet to contribute to this knowledge base. Originality/value If palliative care is a human right, then its philosophy should be considered in its entirety, with the inclusion of psychosocial care.

First and second trimester ultrasound in pregnancy: A systematic review and metasynthesis of the views and experiences of pregnant women, partners, and health workers

Background The World Health Organization (WHO) recommends one ultrasound scan before 24 weeks gestation as part of routine antenatal care (WHO 2016). We explored influences on provision and uptake through views and experiences of pregnant women, partners, and health workers. Methods We undertook a systematic review (PROSPERO CRD42021230926). We derived summaries of findings and overarching themes using metasynthesis methods. We searched MEDLINE, CINAHL, PsycINFO, SocIndex, LILACS, and AIM (Nov 25th 2020) for qualitative studies reporting views and experiences of routine ultrasound provision to 24 weeks gestation, with no language or date restriction. After quality assessment, data were logged and analysed in Excel. We assessed confidence in the findings using Grade-CERQual. Findings From 7076 hits, we included 80 papers (1994–2020, 23 countries, 16 LICs/MICs, over 1500 participants). We identified 17 review findings, (moderate or high confidence: 14/17), and four themes: sociocultural influences and expectations; the power of visual technology; joy and devastation: consequences of ultrasound findings; the significance of relationship in the ultrasound encounter. Providing or receiving ultrasound was positive for most, reportedly increasing parental-fetal engagement. However, abnormal findings were often shocking. Some reported changing future reproductive decisions after equivocal results, even when the eventual diagnosis was positive. Attitudes and behaviours of sonographers influenced service user experience. Ultrasound providers expressed concern about making mistakes, recognising their need for education, training, and adequate time with women. Ultrasound sex determination influenced female feticide in some contexts, in others, termination was not socially acceptable. Overuse was noted to reduce clinical antenatal skills as well as the use and uptake of other forms of antenatal care. These factors influenced utility and equity of ultrasound in some settings. Conclusion Though antenatal ultrasound was largely seen as positive, long-term adverse psychological and reproductive consequences were reported for some. Gender inequity may be reinforced by female feticide following ultrasound in some contexts. Provider attitudes and behaviours, time to engage fully with service users, social norms, access to follow up, and the potential for overuse all need to be considered.

Palliative care provider attitudes toward existential distress and treatment with psychedelic-assisted therapies

Background Existential distress is a significant source of suffering for patients facing life-threatening illness. Psychedelic-Assisted Therapies (PAT) are novel treatments that have shown promise in treating existential distress, but openness to providing PAT may be limited by stigma surrounding psychedelics and the paucity of education regarding their medical use. How PAT might be integrated into existing treatments for existential distress within palliative care remains underexplored. Methods The present study aimed to elucidate the attitudes of palliative care clinicians regarding treatments for existential distress, including PAT. We recruited palliative care physicians, advanced practice nurses, and spiritual and psychological care providers from multiple US sites using purposive and snowball sampling methods. Attitudes toward PAT were unknown prior to study involvement. Semi-structured interviews targeted at current approaches to existential distress and attitudes toward PAT were analyzed for thematic content. Results Nineteen respondents (seven physicians, four advanced practice nurses, four chaplains, three social workers, and one psychologist) were interviewed. Identified themes were 1) Existential distress is a common experience that is frequently insufficiently treated within the current treatment framework; 2) Palliative care providers ultimately see existential distress as a psychosocial-spiritual problem that evades medicalized approaches; 3) Palliative care providers believe PAT hold promise for treating existential distress but that a stronger evidence base is needed; 4) Because PAT do not currently fit existing models of existential distress treatment, barriers remain. Conclusions PAT is seen as a potentially powerful tool to treat refractory existential distress. Larger clinical trials and educational outreach are needed to clarify treatment targets and address safety concerns. Further work to adapt PAT to palliative care settings should emphasize collaboration with spiritual care as well as mental health providers and seek to address unresolved concerns about equitable access.

Barriers in Access to Healthcare for Kenyan Queer Womxn and Trans Men: Findings of a Cross-Sectional Online Survey and Interviews

BackgroundIn many African countries, including Kenya, sexual behaviour between consenting adults of the same sex/ gender is illegal, which results in limited availability and access to health services and information for sexual and gender minorities. This results in unmet health issues for sexual and gender minorities who have a higher burden of STD/STI and HIV, STI-related cancers, and mental ill-health and trauma.MethodsWe conducted an online survey among 335 Kenyan queer womxn and trans men over the age of 18 who had at least one self-identified female sexual partner, collecting data on health service utilisation and barriers to accessing healthcare. ResultsWe identified gaps in all four areas that comprise standard of health – availability, accessibility, acceptability, and quality of care, exacerbated by the restrictive law and policy landscape in Kenya. Queer womxn and trans men face multiple service-access barriers, many related to stigma and discrimination, as well as concerns around provider attitudes and knowledge. Violations of human rights and privacy are a concern for queer womxn and trans men patients. There are insufficient numbers of facilities, programmes, and information to meet the needs of queer womxn and trans men, which leads to a lack of holistic care or patients delaying care and preventative interventions. ConclusionMental health and trans health are areas that are particularly poorly equipped to serve the informants’ needs, highlighting the need to address the exclusion of sexual and gender minorities in the vulnerable groups of the National Mental Health Policy. Resources regarding the use of services need to be made available, and service providers need to be educated to provide non-judgmental, inclusive care for queer womxn and trans men in Kenya.

Use of inhalational anaesthetic agents in paediatric and adult patients for status asthmaticus, status epilepticus and difficult sedation scenarios: a protocol for a systematic review

IntroductionInhaled volatile anaesthetics have a long tradition of use as hypnotic agents in operating rooms and are gaining traction as sedatives in intensive care units (ICUs). However, uptake is impeded by low familiarity with volatiles, unique equipment and education needs. Inhaled anaesthetics are often reserved in ICUs as therapies for refractory and life threatening status asthmaticus, status epilepticus, high and difficult sedation need scenarios given they possess unique pharmacological properties to manage these medical conditions while providing sedation to acutely ill patients. The objective of this systematic review is to collate evidence regarding the efficacy, safety and feasibility of volatile anaesthetics in adult and paediatric ICU patients for these three emergency conditions.Methods and analysisWe will conduct a systematic review of the primary studies in adult and paediatric ICU patients with status asthmaticus, status epilepticus and high/difficult sedation needs. We will include observational and interventional studies published from 1970 to 2021 in English or French investigating patients who have received a volatile inhalational agent for the above indications. We will evaluate the efficacy, safety, feasibility and implementation barriers for the volatile anaesthetics for each of three specified indications. Included studies will not be limited by necessity of a comparator arm. We will also evaluate clinical characteristics, patient demographics and provider attitudes towards volatile anaesthetic administration in defined critical care scenarios. Data will be extracted and analysed across these domains. The databases MEDLINE, EMBASE, the Science Citation Index as well as the Cochrane Central Controlled Trials Register will be queried with our search strategy.Descriptive and statistical analysis will be employed where appropriate. Data extraction and quality assessment will be performed in duplicate using a standardised tool. A narrative approach and statistical analyses will be used to describe patient characteristics, volatile efficacy, safety concerns, technical administration, attitudes towards administration and other implementation barriers.Ethics and disseminationNo ethics board approval will be necessary for this systematic review. This research is independently funded. Results will be disseminated in a peer-reviewed journal and conference presentation.PROSPERO numberCRD42021233083.

119. Performance of Infectious Diseases Specialists, Hospitalists, and Generalists in Case-Based Scenarios Illustrating Antimicrobial Stewardship Principles at 16 VA Medical Centers

Background As part of a project to implement and evaluate antimicrobial dashboards at selected VA facilities nationwide, we assessed provider attitudes and knowledge related to antibiotic prescribing among physicians working in inpatient settings at 16 VA facilities. Methods The online survey explored attitudes toward antimicrobial use and assessed respondents’ management of four clinical scenarios: cellulitis, community-acquired pneumonia (CAP), non-catheter-associated asymptomatic bacteriuria (NC-ASB), and catheter-associated asymptomatic bacteriuria (C-ASB). Responses were scored by assigning +1 for an answer most consistent with guidelines, 0 for a less-guideline-concordant but acceptable answer and -1 for an incorrect answer. Scores were normalized to 100% correct to 100% incorrect across all questions within a scenario, and mean scores were calculated across respondents by specialty; differences in mean score per scenario were tested using ANOVA. Results One-hundred-thirty-nine physicians completed the survey (n=19 ID physicians, 62 hospitalists, 58 generalists). Attitudes were similar across the three specialties. There was a significant difference in cellulitis scenario scores (correct responses: ID=67.4%, hospitalists=51.2%, generalists=41.8% correct, p=0.0087). Scores were not significantly different across specialties for CAP (correct responses: ID 76.2%, hospitalists 63%, generalists 56.5%, p=0.0914) and NC-ASB (correct responses; ID 63%, hospitalists 55%, generalists 36.2%, p=0.322), though ID trended higher. Lowest scores were observed for C-ASB (ID 39.5% correct, hospitalists 4% incorrect, generalists 8.5% incorrect, p=0.12). Conclusion Significant differences in performance on management of cellulitis and low overall scores on C-ASB management point to these conditions as being potentially high-yield targets for antimicrobial stewardship interventions. Disclosures Matthew B. Goetz, MD, Nothing to disclose Peter A. Glassman, MBBS, US Pharmacopeia (formerly), PAG; Kaiser Permanente (current employee, spouse) (Advisor or Review Panel member, The above refers to USP (ended in 2020).)

624. Perceptions of Telemedicine among Infectious Disease Outpatient Providers during the COVID-19 Pandemic

Background Access to infectious disease (ID) providers has been heavily impacted by COVID-19. Telemedicine (TM) has been viewed as a promising solution to the challenges in care delivery posed by this pandemic. However, perceptions of TM among ID providers remain unclear. This study investigated the impact of TM on outpatient ID during the COVID-19 pandemic, efficacy of TM in ID clinics, which clinical conditions within ID that TM may be best suited for, and influences on provider attitudes toward TM. Methods We conducted online surveys of outpatient ID providers via the IDSA Idea Exchange and by reaching out to large ID private practices via email. Data was collected October 2020 - April 2021 and recorded through REDCap (Research and Electronic Data Capture). Associations were calculated using Hmisc in R and p-values adjusted using B-H. Missing values were imputed by median. Results 108 respondents completed the survey. 70.4% were attendings, 63% were under age 50, and 65.7% practiced in academic centers. 55.7% somewhat or strongly agreed there was a decline in outpatient visits. A median of 40% of outpatient visits during COVID were reported to be conducted via TM, divided equally between telephone and televideo (TV). 71.9% of providers somewhat or strongly agreed that TV visits were more effective than telephone visits. Reasons cited for TM as less effective than in person visits included lessened ability to examine the patient, diminished rapport, and inability to perform labwork. 85.2% somewhat or strongly agreed that patients responded favorably to TM. 89.8% of providers somewhat or strongly agreed they will continue to conduct TM visits when appropriate after COVID-19. Plans to continue TM after COVID were significantly associated with perceptions of patient response to TM. Respondents mentioned specific problems less suited to TM: new HIV patients, skin, soft tissue, and joint infections, fever, abdominal pain, transplant evaluations, rash, and wounds. Conclusion The majority of providers felt their patients responded favorably to TM. Most providers plan to conduct TM visits after COVID-19. These plans are associated with views of patient response and comparability to other visit types. Specific diagnoses were cited as better suited for TM. Disclosures All Authors: No reported disclosures