Self-rated health as a comprehensive indicator of lifestyle-related health status

Objectives

To evaluate the usefulness of self-rated health (SRH) as a comprehensive indicator of lifestyle-related health status by examining the relationships between SRH and: (1) history of cancer and cardiovascular disease; (2) treatment of hypertension, diabetes, and dyslipidemia; (3) abnormalities in clinical parameters including blood pressure, fasting glucose, and lipids; and (4) lifestyle habits.

Methods

3744 health-check examinees at Tokai University Hachioji Hospital seen between April 2009 and March 2010 were enrolled. SRH was graded as “good,” “relatively good,” “relatively poor,” or “poor.” For statistical comparison, the differences among “healthy” (=good), “relatively healthy” (=relatively good), and “unhealthy” (=relatively poor plus poor) groups were examined. Mantel–Haenszel odds ratios were calculated to remove the confounding effect of age, using the healthy group as the reference. The Mantel-extension method was used as a trend test.

Results

1049 subjects rated their health as good, 2194 as relatively good, 428 as relatively poor, and 73 as poor. The prevalence of all diseases showed significant odds ratios and trends as SRH deteriorated. Obesity, blood pressure, glucose metabolism, and lipids deteriorated significantly as SRH became poorer, and a trend was observed in all parameters. Weight change, exercise, smoking, and rest showed significant odds ratios and trends as SRH deteriorated.

Conclusion

SRH appears useful as a comprehensive indicator of lifestyle-related health status.

Electronic supplementary material

The online version of this article (doi:10.1007/s12199-012-0274-x) contains supplementary material, which is available to authorized users.     

Surgical Quality Is More Than Volume: The Association between Changing Urologists and Complications for Patients with Localized Prostate Cancer

Objectives

To examine the association of changing urologists on surgical complications in men with prostate cancer.

Data Sources/Study Setting

Registry and administrative claims data from the Surveillance, Epidemiology, and End Results-Medicare database from 1995 to 2005.

Study Design

A cross-sectional observational study of men with prostate cancer who underwent radical prostatectomy.

Methods

Subjects were classified as having “changed urologists” if they had a different urologist who diagnosed their cancer from the one who performed their surgery. “Doubly robust” propensity score weighted multivariable logistic regression models were used to investigate the effect of changing urologists on 30-day surgical complications, late urinary complications, and long-term incontinence.

Principal Findings

Men who changed urologists between diagnosis and treatment had significantly lower odds of 30-day surgical complications compared with men who did not change urologists (odds ratio: 0.82; 95 percent confidence interval: 0.76–0.89), after adjustment. Changing urologists was associated with lower risks of 30-day complications for both black and white men compared with staying with the same urologist for their diagnosis and surgical treatment.

Conclusions

Urologist changing is associated with the observed variation in complications following radical prostatectomy. This may suggest that patients are responding to aspects of surgical quality not captured in surgical volume.     

Widely used pesticides with previously unknown endocrine activity revealed as in vitro antiandrogens

Background

Evidence suggests that there is widespread decline in male reproductive health and that antiandrogenic pollutants may play a significant role. There is also a clear disparity between pesticide exposure and data on endocrine disruption, with most of the published literature focused on pesticides that are no longer registered for use in developed countries.

Objective

We used estimated human exposure data to select pesticides to test for antiandrogenic activity, focusing on highest use pesticides.

Methods

We used European databases to select 134 candidate pesticides based on highest exposure, followed by a filtering step according to known or predicted receptor-mediated antiandrogenic potency, based on a previously published quantitative structure–activity relationship (QSAR) model. In total, 37 pesticides were tested for in vitro androgen receptor (AR) antagonism. Of these, 14 were previously reported to be AR antagonists (“active”), 4 were predicted AR antagonists using the QSAR, 6 were predicted to not be AR antagonists (“inactive”), and 13 had unknown activity, which were “out of domain” and therefore could not be classified with the QSAR (“unknown”).

Results

All 14 pesticides with previous evidence of AR antagonism were confirmed as antiandrogenic in our assay, and 9 previously untested pesticides were identified as antiandrogenic (dimethomorph, fenhexamid, quinoxyfen, cyprodinil, λ-cyhalothrin, pyrimethanil, fludioxonil, azinphos-methyl, pirimiphos-methyl). In addition, we classified 7 compounds as androgenic.

Conclusions

Due to estimated antiandrogenic potency, current use, estimated exposure, and lack of previous data, we strongly recommend that dimethomorph, fludioxonil, fenhexamid, imazalil, ortho-phenylphenol, and pirimiphos-methyl be tested for antiandrogenic effects in vivo. The lack of human biomonitoring data for environmentally relevant pesticides presents a barrier to current risk assessment of pesticides on humans.     

A Bayesian network approach to the study of historical epidemiological databases: modelling meningitis outbreaks in the Niger

Objective

To develop a tool for evaluating the risk that an outbreak of meningitis will occur in a particular district of the Niger after outbreaks have been reported in other, specified districts of the country.

Methods

A Bayesian network was represented by a graph composed of 38 nodes (one for each district in the Niger) connected by arrows. In the graph, each node directly influenced each of the “child” nodes that lay at the ends of the arrows arising from that node, according to conditional probabilities. The probabilities between “influencing” and “influenced” districts were estimated by analysis of databases that held weekly records of meningitis outbreaks in the Niger between 1986 and 2005. For each week of interest, each district was given a Boolean-variable score of 1 (if meningitis incidence in the district reached an epidemic threshold in that week) or 0.

Findings

The Bayesian network approach provided important and original information, allowing the identification of the districts that influence meningitis risk in other districts (and the districts that are influenced by any particular district) and the evaluation of the level of influence between each pair of districts.

Conclusion

Bayesian networks offer a promising approach to understanding the dynamics of epidemics, estimating the risk of outbreaks in particular areas and allowing control interventions to be targeted at high-risk areas.     

Why first-level health workers fail to follow guidelines for managing severe disease in children in the Coast Region, the United Republic of Tanzania

Objective

To determine why health workers fail to follow integrated management of childhood illness (IMCI) guidelines for severely ill children at first-level outpatient health facilities in rural areas of the United Republic of Tanzania.

Methods

Retrospective and prospective case reviews of severely ill children aged < 5 years were conducted at health facilities in four districts. We ascertained treatment and examined the characteristics associated with referral, conducted follow-up interviews with parents of severely ill children, and gave health workers questionnaires and interviews.

Findings

In total, 502 cases were reviewed at 62 facilities. Treatment with antimalarials and antibiotics was consistent with the diagnosis given by health workers. However, of 240 children classified as having “very severe febrile disease”, none received all IMCI-recommended therapies, and only 25% of severely ill children were referred. Lethargy and anaemia diagnoses were independently associated with referral. Most (91%) health workers indicated that certain severe conditions can be managed without referral.

Conclusion

The health workers surveyed rarely adhered to IMCI treatment and referral guidelines for children with severe illness. They administered therapy based on narrow diagnoses rather than IMCI classifications, disagreed with referral guidelines and often considered referral unnecessary. To improve implementation of IMCI, attention should focus on the reasons for health worker non-adherence.     

Characterization of Adverse Events Detected in a Large Health Care Delivery System Using an Enhanced Global Trigger Tool over a Five‐Year Interval

Objective

To report 5 years of adverse events (AEs) identified using an enhanced Global Trigger Tool (GTT) in a large health care system.

Study Setting

Records from monthly random samples of adults admitted to eight acute care hospitals from 2007 to 2011 with lengths of stay ≥3 days were reviewed.

Study Design

We examined AE incidence overall and by presence on admission, severity, stemming from care provided versus omitted, preventability, and category; and the overlap with commonly used AE-detection systems.

Data Collection

Professional nurse reviewers abstracted 9,017 records using the enhanced GTT, recording triggers and AEs. Medical record/account numbers were matched to identify overlapping voluntary reports or AHRQ Patient Safety Indicators (PSIs).

Principal Findings

Estimated AE rates were as follows: 61.4 AEs/1,000 patient-days, 38.1 AEs/100 discharges, and 32.1 percent of patients with ≥1 AE. Of 1,300 present-on-admission AEs (37.9 percent of total), 78.5 percent showed NCC-MERP level F harm and 87.6 percent were “preventable/possibly preventable.” Of 2,129 hospital-acquired AEs, 63.3 percent had level E harm, 70.8 percent were “preventable/possibly preventable”; the most common category was “surgical/procedural” (40.5 percent). Voluntary reports and PSIs captured <5 percent of encounters with hospital-acquired AEs.

Conclusions

AEs are common and potentially amenable to prevention. GTT-identified AEs are seldom caught by commonly used AE-detection systems.     

Wheezing, asthma, hay fever, and atopic eczema in relation to maternal occupations in pregnancy

Objectives

To examine whether prenatal occupational exposures, especially to organic solvents, are associated with atopic diseases in childhood.

Methods

The study comprised children born in Odense or Aalborg, Denmark between 1984 and 1987. Occupational job titles were derived from questionnaires filled out by the mothers when attending midwife centres. Assessment of organic solvent exposures was based on job titles selected by occupational specialists. A follow up questionnaire to the parents provided data on medical diagnoses as well as wheezing symptoms for 7844 children aged 14–18. Multivariate logistic regression analyses were performed to estimate the cumulative risk for wheezing (early wheezing not diagnosed as asthma), asthma, hay fever, and atopic eczema during childhood by means of odds ratios (OR) and 95% confidence intervals (CI).

Results

Explorative analyses by maternal job titles in pregnancy showed elevated odds ratios concerning different atopic diseases for occupational groups such as “bakers, pastry cooks, and confectionary makers”, “dental assistants”, “electrical and electronic assemblers”, “sewers and embroiders”, and “bookbinders and related workers”. An excess risk ratio for hay fever (OR 2.8, CI 1.1 to 7.5) was found following maternal gestational exposure to organic solvents. Furthermore, a slightly raised odds ratio for asthma was observed in children of shift workers (OR 1.2, CI 1.0 to 1.5).

Conclusion

The data suggest links between certain maternal occupations during pregnancy and atopic diseases, which merits further scrutiny. However, no consistent pattern was seen across the different atopic diseases.     

The role of matched controls in building an evidence base for hospital-avoidance schemes: a retrospective evaluation

Objective

To test whether two hospital-avoidance interventions altered rates of hospital use: “intermediate care” and “integrated care teams.”

Data Sources/Study Setting

Linked administrative data for England covering the period 2004 to 2009.

Study Design

This study was commissioned after the interventions had been in place for several years. We developed a method based on retrospective analysis of person-level data comparing health care use of participants with that of prognostically matched controls.

Data Collection/Extraction Methods

Individuals were linked to administrative datasets through a trusted intermediary and a unique patient identifier.

Principal Findings

Participants who received the intermediate care intervention showed higher rates of unscheduled hospital admission than matched controls, whereas recipients of the integrated care team intervention showed no difference. Both intervention groups showed higher rates of mortality than did their matched controls.

Conclusions

These are potentially powerful techniques for assessing impacts on hospital activity. Neither intervention reduced admission rates. Although our analysis of hospital utilization controlled for a wide range of observable characteristics, the difference in mortality rates suggests that some residual confounding is likely. Evaluation is constrained when performed retrospectively, and careful interpretation is needed.     

Assessing the effects of non-steroidal anti-inflammatory drugs on antihypertensive drug therapy using post-marketing surveillance database

Background

Antihypertensive and non-steroidal anti-inflammatory drugs (NSAIDs) are used to treat many common diseases. However, it has been suspected that interactions between these drugs exist. Here, we assessed the interactions between non-selective NSAIDs and several classes of antihypertensive drugs.

Methods

The study design was a cohort study using “The Antihypertensive Drug Database,” which is a collection of data accumulated from Drug Use Investigations. Subjects newly starting antihypertensive drug therapy were identified in the database. We compared the “User” group, who were co-administered NSAIDs, with the “Non-user” group, who were not. The outcome measure was the change in systolic blood pressure from the baseline after 2 months of treatment. We estimated the non-adjusted and adjusted differences in the change in systolic blood pressure between the “User” and “Non-user” groups.

Results

Data were collected for a total of 1,204 subjects, of whom 364 were prescribed beta blockers, 60 were prescribed diuretics, 628 were prescribed angiotensin-converting enzyme inhibitors, and 152 were prescribed calcium channel blockers. The adjusted difference in the change in systolic blood pressure between the User (n = 301) and Non-user (n = 903) groups was 2.88 mmHg (95% confidence interval: 0.89, 4.87); thus, systolic blood pressure in the Non-User group decreased further from the baseline than that in the User group. In subjects administered beta blockers, diuretics, angiotensin-converting enzyme inhibitors, and calcium channel blockers, the corresponding differences were 0.37 mmHg (-3.24, 3.98), 6.11 mmHg (-3.16, 15.37), 3.85 mmHg (1.16, 6.66), and 3.50 mmHg (-2.03, 9.02).

Conclusion

The effectiveness of antihypertensive drugs was attenuated by the co-administration of NSAIDs. The differences in the effects of NSAIDs varied with different classes of antihypertensive drugs.Key words: Drug Interactions, Antihypertensive Agents, NSAIDs, Database     

Road injuries and relaxed licensing requirements for driving light motorcycles in Spain: a time-series analysis

Objective

To assess differences between the risk of injury for motorcycle riders before and after the passing of a law allowing licenced car drivers to drive light motorcycles without having to take a special motorcycle driving test.

Methods

We carried out a quasi-experimental study involving comparison groups, and a time-series analysis from 1 January 2002 to 30 April 2008. The study group was composed of people injured while driving or riding a light motorcycle (engine capacity 51–125 cubic centimetres), while the comparison groups consisted of riders of heavy motorcycles (engine capacity > 125 cc), mopeds (engine capacity ≤ 50 cc) or cars who were injured in a collision within the city limits. The “intervention” was a law passed in October 2004 allowing car drivers to drive light motorcycles without taking a special driving test. To detect and quantify changes over time we used Poisson regression, with adjustments for trend and seasonality in road injuries and the existence of a driver’s licence penalty point system.

Findings

The risk of injury among light motorcycle riders was greater after the law than before (relative risk, RR = 1.46; 95% confidence interval, CI: 1.34–1.60). Although less markedly, after the law the risk of injury also increased among heavy motorcycle drivers (RR = 1.15; 95% CI: 1.02–1.29) but remained unchanged among riders of mopeds (RR = 0.92; 95% CI: 0.83–1.01) and cars (RR = 1.06; 95% CI: 0.97–1.16).

Conclusion

Allowing car drivers to drive motorcycles without passing a special test increases the number of road injuries from motorcycle accidents.     

Barriers to Use of Workers' Compensation for Patient Care at Massachusetts Community Health Centers

Objectives

To examine barriers community health centers (CHCs) face in using workers'' compensation insurance (WC).

Data Sources/Study Setting

Leadership of CHCs in Massachusetts.

Study Design

We used purposeful snowball sampling of CHC leaders for in-depth exploration of reimbursement policies and practices, experiences with WC, and decisions about using WC. We quantified the prevalence of perceived barriers to using WC through a mail survey of all CHCs in Massachusetts.

Data Collection/Extraction Methods

Emergent coding was used to elaborate themes and processes related to use of WC. Numbers and percentages of survey responses were calculated.

Principal Findings

Few CHCs formally discourage use of WC, but underutilization emerged as a major issue: “We see an awful lot of work-related injury, and I would say that most of it doesn''t go through workers'' comp.” Barriers include lack of familiarity with WC, uncertainty about work-relatedness, and reliance on patients to identify work-relatedness of their conditions. Reimbursement delays and denials lead patients and CHCs to absorb costs of services.

Conclusion

Follow-up studies should fully characterize barriers to CHC use of WC and experiences in other states to guide system changes in CHCs and WC agencies. Education should target CHC staff and workers about WC.     

Laboratory work and pregnancy outcomes: a study within the National Birth Cohort in Denmark

Aims

To examine pregnancy outcomes in women doing laboratory work.

Methods

Using data from the Danish National Birth Cohort (1997–2003), the authors conducted a prospective cohort study of 1025 female laboratory technicians and 8037 female teachers (as reference). The laboratory technicians were asked about laboratory work tasks during pregnancy in an interview (at around 16 weeks of gestation). Pregnancy outcomes were obtained by linking the cohort to the national registers. Hazard ratios (HRs) of late fetal loss and diagnosing of congenital malformations were calculated by using Cox regression, and odds ratios (ORs) of preterm birth and small for gestational age were calculated by using logistic regression.

Results

Overall, there were no significant differences in pregnancy outcomes between laboratory technicians and teachers. However, we found that laboratory technicians working with radioimmunoassay or radiolabelling had an increased risk of preterm birth (OR = 2.2, 95% CI 0.8 to 6.2 for radioimmunoassay, and OR = 1.9, 95% CI 0.8 to 4.6 for radiolabelling) and “major” malformations (HR = 2.1, 95% CI 1.0 to 4.7 for radioimmunoassay, and HR = 1.8, 95% CI 0.9 to 3.7 for radiolabelling). The ORs of preterm birth doubled for women working with these tasks every day or several times a week. When an exposure matrix was applied, an increased risk of “major” malformations for exposure to organic solvents was seen.

Conclusions

The results did not indicate any high risk of reproductive failures in laboratory technicians in general. Exposure to radioisotopes may carry a high risk of preterm birth and congenital malformations. This finding deserves further investigation.     

Effect of usual source of care on depression among Medicare beneficiaries: an application of a simultaneous-equations model

Objective

To investigate whether having a usual source of care (USOC) resulted in lower depression prevalence among the elderly.

Data Sources

The 2001–2003 Medicare Current Beneficiaries Survey and 2002 Area Resource File.

Study Design

Twenty thousand four hundred and fifty-five community-dwelling person-years were identified for respondents aged 65+, covered by both Medicare Parts A and B in Medicare fee-for-service for a full year. USOC was defined by the question “Is there a particular medical person or a clinic you usually go to when you are sick or for advice about your health?” Ambulatory care use (ACU) was defined by having at least one physician office visit and/or hospital outpatient visit using Medicare claims. Depression was identified by a two-item screen (sadness and/or anhedonia). All measures were for the past 12 months. A simultaneous-equations (trivariate probit) model was estimated, adjusted for sampling weights and study design effects.

Principal Findings

Based on the simultaneous-equations model, USOC is associated with 3.8 percent lower probability of having depression symptoms (p = .03). Also, it had a positive effect on having any ACU (p<.001). Having any ACU had no statistically significant effect on depression (p = .96).

Conclusions

USOC was associated with lower depression prevalence and higher realized access (ACU) among community-dwelling Medicare beneficiaries.     

Emergency triage assessment for hypoxaemia in neonates and young children in a Kenyan hospital: an observational study

Objective

To describe the prevalence of hypoxaemia in children admitted to a hospital in Kenya for the purpose of identifying clinical signs of hypoxaemia for emergency triage assessment, and to test the hypothesis that such signs lead to correct identification of hypoxaemia in children, irrespective of their diagnosis.

Methods

From 2002 to 2005 we prospectively collected clinical data and pulse oximetry measurements for all paediatric admissions to Kilifi District Hospital, Kenya, irrespective of diagnosis, and assessed the prevalence of hypoxaemia in relation to the WHO clinical syndromes of “pneumonia” on admission and the final diagnoses made at discharge. We used the data collected over the first three years to derive signs predictive of hypoxaemia, and data from the fourth year to validate those signs.

Findings

Hypoxemia was found in 977 of 15 289 (6.4%) of all admissions (5% to 19% depending on age group) and was strongly associated with inpatient mortality (age-adjusted risk ratio: 4.5; 95% confidence interval, CI: 3.8–5.3). Although most hypoxaemic children aged ≥ 60 days met the WHO criteria for a syndrome of “pneumonia” on admission, only 215 of the 693 (31%) such children had a final diagnosis of lower respiratory tract infection (LRTI). The most predictive signs for hypoxaemia included shock, a heart rate < 80 beats per minute, irregular breathing, a respiratory rate > 60 breaths per minute and impaired consciousness. However, 5–15% of the children who had hypoxaemia on admission were missed, and 18% of the children were incorrectly identified as hypoxaemic.

Conclusion

The syndromes of pneumonia make it possible to identify most hypoxaemic children, including those without LRTI. Shock, bradycardia and irregular breathing are important predictive signs, and severe malaria with respiratory distress is a common cause of hypoxaemia. Overall, however, clinical signs are poor predictors of hypoxaemia, and using pulse oximetry in resource-poor health facilities to target oxygen therapy is likely to save costs.     

DDT and malaria prevention: addressing the paradox

Background

The debate regarding dichlorodiphenyltrichloroethane (DDT) in malaria prevention and human health is polarized and can be classified into three positions: anti-DDT, centrist-DDT, pro-DDT.

Objective

We attempted to arrive at a synthesis by matching a series of questions on the use of DDT for indoor residual spraying (IRS) with literature and insights, and to identify options and opportunities.

Discussion

Overall, community health is significantly improved through all available malaria control measures, which include IRS with DDT. Is DDT “good”? Yes, because it has saved many lives. Is DDT safe as used in IRS? Recent publications have increasingly raised concerns about the health implications of DDT. Therefore, an unqualified statement that DDT used in IRS is safe is untenable. Are inhabitants and applicators exposed? Yes, and to high levels. Should DDT be used? The fact that DDT is “good” because it saves lives, and “not safe” because it has health and environmental consequences, raises ethical issues. The evidence of adverse human health effects due to DDT is mounting. However, under certain circumstances, malaria control using DDT cannot yet be halted. Therefore, the continued use of DDT poses a paradox recognized by a centrist-DDT position. At the very least, it is now time to invoke precaution. Precautionary actions could include use and exposure reduction.

Conclusions

There are situations where DDT will provide the best achievable health benefit, but maintaining that DDT is safe ignores the cumulative indications of many studies. In such situations, addressing the paradox from a centrist-DDT position and invoking precaution will help design choices for healthier lives.     

Annals Journal Club: Frequency and Prioritization of Patient Health Risks from a Structured Health Risk Assessment

PURPOSE

To describe the frequency and patient-reported readiness to change, desire to discuss, and perceived importance of 13 health risk factors in a diverse range of primary care practices.

METHODS

Patients (n = 1,707) in 9 primary care practices in the My Own Health Report (MOHR) trial reported general, behavioral, and psychosocial risk factors (body mass index [BMI], health status, diet, physical activity, sleep, drug use, stress, anxiety or worry, and depression). We classified responses as “at risk” or “healthy” for each factor, and patients indicated their readiness to change and/or desire to discuss identified risk factors with providers. Patients also selected 1 of the factors they were ready to change as most important. We then calculated frequencies within and across these factors and examined variation by patient characteristics and across practices.

RESULTS

On average, patients had 5.8 (SD = 2.12; range, 0–13) unhealthy behaviors and mental health risk factors. About 55% of patients had more than 6 risk factors. On average, patients wanted to change 1.2 and discuss 0.7 risks. The most common risks were inadequate fruit/vegetable consumption (84.5%) and overweight/obesity (79.6%). Patients were most ready to change BMI (33.3%) and depression (30.7%), and most wanted to discuss depression (41.9%) and anxiety or worry (35.2%). Overall, patients rated health status as most important.

CONCLUSIONS

Implementing routine comprehensive health risk assessments in primary care will likely identify a high number of behavioral and psychosocial health risks. By soliciting patient priorities, providers and patients can better manage counseling and behavior change.     

Availability and quality of cause-of-death data for estimating the global burden of injuries

Objective

To assess the availability and quality of global death registration data used for estimating injury mortality.

Methods

The completeness and coverage of recent national death registration data from the World Health Organization mortality database were assessed. The quality of data on a specific cause of injury death was judged high if fewer than 20% of deaths were attributed to any of several partially specified causes of injury, such as “unspecified unintentional injury”.

Findings

Recent death registration data were available for 83 countries, comprising 28% of the global population. They included most high-income countries, most countries in Latin America and several in central Asia and the Caribbean. Categories commonly used for partially specified external causes of injury resulting in death included “undetermined intent,” “unspecified mechanism of unintentional injury,” “unspecified road injury” and “unspecified mechanism of homicide”. Only 20 countries had high-quality data. Nevertheless, because the partially specified categories do contain some information about injury mechanisms, reliable estimates of deaths due to specific external causes of injury, such as road injury, suicide and homicide, could be derived for many more countries.

Conclusion

Only 20 countries had high-quality death registration data that could be used for estimating injury mortality because injury deaths were frequently classified using imprecise partially specified categories. Analytical methods that can derive national estimates of injury mortality from alternative data sources are needed for countries without reliable death registration systems.     

Trends in the quality of health care for children aged less than 5?years in Afghanistan, 2004–2006

Objective

To study trends in the quality of the health care provided to children aged less than 5 years in Afghanistan between 2004 and 2006. In particular, to determine the effect on such quality of a basic package of health services (BPHS), including Integrated Management of Childhood Illness (IMCI), introduced in 2003.

Methods

In each year of the study, 500–600 health facilities providing the BPHS were selected by stratified random sampling in 29 provinces of Afghanistan. We observed consultations for children aged less than 5 years, interviewed their caretakers, interviewed health-care providers and measured adherence to case management standards for assessment and counselling in a random sample.

Findings

The quality of the assessment and counselling provided to sick children aged less than 5 years improved significantly between 2004 and 2006. A 43.4% increase in the assessment index and a 28.7% increase in the counselling index (P < 0.001) were noted. Assessment quality improved significantly every year and was statistically associated with certain characteristics of the provider (being a doctor, having a higher knowledge score, being trained in IMCI, being part of a “contracting-in” mechanism and providing a longer consultation time) and the child (being younger and having a female caretaker). Counselling quality was also significantly associated with these characteristics, except for provider cadre and child age. The presence of clinical guidelines and the frequency of supervision were significantly associated with improved quality scores in 2006 (P < 0.05 and < 0.01, respectively).

Conclusion

Quality of care improved over the study period, but performance remained suboptimal in some areas. Continued investments in Afghanistan’s health system capacity are needed.     

Surge Capacity: Analysis of Census Fluctuations to Estimate the Number of Intensive Care Unit Beds Needed

Objective

To compare methods of characterizing intensive care unit (ICU) bed use and estimate the number of beds needed.

Study Setting

Three geographic regions in the Canadian province of Manitoba.

Study Design

Retrospective analysis of population-based data from April 1, 2000, to March 31, 2007.

Methods

We compared three methods to estimate ICU bed requirements. Method 1 analyzed yearly patient-days. Methods 2 and 3 analyzed day-to-day fluctuations in patient census; these differed by whether each hospital needed to independently fulfill its own demand or this resource was shared across hospitals.

Principal Findings

Three main findings were as follows: (1) estimates based on yearly average usage generally underestimated the number of beds needed compared to analysis of fluctuations in census, especially in the smaller regions where underestimation ranged 25–58 percent; (2) 4–29 percent fewer beds were needed if it was acceptable for demand to exceed supply 18 days/year, versus 4 days/year; and (3) 13–36 percent fewer beds were needed if hospitals within a region could effectively share ICU beds.

Conclusions

Compared to using yearly averages, analyzing day-to-day fluctuations in patient census gives a more accurate picture of ICU bed use. Failing to provide adequate “surge capacity” can lead to demand that frequently and severely exceeds supply.