Labour complications remain the most important risk factors for perinatal mortality in rural Kenya.
(33/323)
OBJECTIVES: To identify and quantify risk factors for perinatal mortality in a Kenyan district hospital and to assess the proportion of perinatal deaths attributable to labour complications, maternal undernutrition, malaria, anaemia and human immunodeficiency virus (HIV). METHODS: A cross-sectional study of 910 births was conducted between January 1996 and July 1997 and risk factors for perinatal mortality were analysed. FINDINGS: The perinatal mortality rate was 118 per 1000 births. Complications of labour such as haemorrhage, premature rupture of membranes/premature labour, and obstructed labour/ malpresentation increased the risk of death between 8- and 62-fold, and 53% of all perinatal deaths were attributable to labour complications. Placental malaria and maternal HIV, on the other hand, were not associated with perinatal mortality. CONCLUSIONS: Greater attention needs to be given to the quality of obstetric care provided in the rural district-hospital setting. (+info)
Teleneurology to improve stroke care in rural areas: The Telemedicine in Stroke in Swabia (TESS) Project.
(34/323)
BACKGROUND AND PURPOSE: Assessing both stroke patients and their CT scans by using a conventional videoconference system offers an interesting opportunity to improve stroke care in rural areas. However, until now there have been no studies to suggest whether this method is feasible in routine stroke management. METHODS: Seven rural hospitals in the southern part of Germany in Swabia were connected to the stroke unit of Gunzburg with the use of a videoconference link (Telemedicine in Stroke in Swabia [TESS] Project). The local physicians are free to present every admitted stroke patient to the Gunzburg stroke expert, who can assess the clinical status and CT images, thereafter giving therapeutic recommendations. All teleconsultations are rated concerning transmission quality and relevance of telemedicine for stroke management. RESULTS: A total of 153 stroke patients were examined by teleconsultation. Mean age was 67.5 years. Eighty-seven patients had suffered an ischemic stroke, 9 had an intracerebral hemorrhage, and 17 suffered a transient ischemic attack. Forty patients were revealed to have a diagnosis other than stroke. Duration of teleconsultation was 15 minutes on average. User satisfaction was good concerning imaging and audio quality, and patient satisfaction was very good or good in all cases. Relevant contributions could be made in >75% of the cases concerning diagnostic workup, CT assessment, and therapeutic recommendations. CONCLUSIONS: Teleconsultation using a videoconference system seems to be a feasible and promising method to improve stroke care in rural areas where management in a stroke unit is hindered by long transportation distances. (+info)
Introducing criteria based audit into Ugandan maternity units.
(35/323)
PROBLEM: Maternal mortality in Uganda has remained unchanged at 500/100 000 over the past 10 years despite concerted efforts to improve the standard of maternity care. It is especially difficult to improve standards in rural areas, where there is little money for improvements. Furthermore, staff may be isolated, poorly paid, disempowered, lacking in morale, and have few skills to bring about change. DESIGN: Training programme to introduce criteria based audit into rural Uganda. SETTING: Makerere University Medical School, Mulago Hospital (large government teaching hospital in Kampala), and Mpigi District (rural area with 10 small health centres around a district hospital). STRATEGIES FOR CHANGE: Didactic teaching about criteria based audit followed by practical work in own units, with ongoing support and follow up workshops. EFFECTS OF CHANGE: Improvements were seen in many standards of care. Staff showed universal enthusiasm for the training; many staff produced simple, cost-free improvements in their standard of care. LESSONS LEARNT: Teaching of criteria based audit to those providing health care in developing countries can produce low cost improvements in the standards of care. Because the method is simple and can be used to provide improvements even without new funding, it has the potential to produce sustainable and cost effective changes in the standard of health care. Follow up is needed to prevent a waning of enthusiasm with time. (+info)
A case report: ethics of a proposed qualitative study of hospital closure in an Australian rural community.
(36/323)
BACKGROUND: The GP and qualitative researcher use similar patient-centred approaches, but their roles are different. Guidelines for conducting GP research in small communities are limited. I planned a qualitative study about hospital closure in a small rural Australian town where I worked. Few studies have researched community reaction to hospital closure and this process of change. METHODS: I used historical analysis to improve external reliability, and purposeful sampling to develop and pre-test a qualitative semi-structured research instrument. Newspaper articles, minutes and tape recordings of public meetings, annual reports from 1991 to 1997, quality assurance data and interviews with two health professionals were analysed in this process. These sources were coded using content and thematic analysis. Ethical issues arose during early stages of planning. Ethical guidelines and bioethics principles were discussed with colleagues and a member of an ethics committee. I validated my findings with three other community members involved in the hospital closure. RESULTS: Themes of a transition, from resistance to change and divisions between key stake holders, to a need to appreciate the benefits of change emerged in coding material from 1991 to 1997. The principle of non-maleficence outweighed the principle of beneficence in this study. Existing health services could be harmed by examining the process of change after spending time and resources to reconcile community differences. Individuals could be harmed as confidentiality in a small community was difficult to maintain, and discussions about sensitive issues could produce adverse public criticism. The autonomy of participants to give informed consent was complicated by the author providing clinical services in the community, raising concerns about patients feeling an obligation to participate. CONCLUSIONS: A justified case for discontinuing this study was made by the researcher on ethical grounds. Use of bioethical principles and community representatives to validate findings was a useful technique to guide decisions in a small rural community. This discussion has application in planning other small community studies. (+info)
Medicare program; hospital outpatient prospective payment system; payment reform for calendar year 2004. Interim final rule with comment period.
(37/323)
This interim final rule with comment period implements provisions of the Medicare Prescription Drug, Improvement, and Modernization Act (DIMA) of 2003 that affect the Medicare outpatient prospective payment system (OPPS) that become effective January 1, 2004. Sections 303 and 621 of the DIMA include provisions that alter the methods for drug payment in hospital outpatient departments, some of which become effective January 1, 2004. These provisions affect the methodology for paying for pass-through and non-pass-through drugs under the OPPS. Further, the new law includes a requirement that all brachytherapy sources be paid separately. Section 411 of the DIMA reinstates the hold-harmless protection for small rural hospitals with fewer than 100 beds and extends that protection to sole community hospitals in rural areas. (+info)
Rural health care support mechanism. Final rule; denial of petition for reconsideration.
(38/323)
In this document, the Commission modifies its rules to improve the effectiveness of the rural health care support mechanism, which provides discounts to rural health care providers to access modern telecommunications for medical and health maintenance purposes. Because participation in the rural health care support mechanism has not met the Commission's initial projections, the Commission amends its rules to improve the program, increase participation by rural health care providers, and ensure that the benefits of the program continue to be distributed in a fair and equitable manner. In addition, the Commission denies Mobile Satellite Ventures Subsidiary's petition for reconsideration of the 1997 Universal Service Order. (+info)
Medicare program; rural health clinics: amendments to participation requirements and payment provisions; and establishment of a quality assessment and performance improvement program. Final rule.
(39/323)
This final rule amends Medicare certification and payment requirements for rural health clinics (RHCs) as required by the Balanced Budget Act of 1997 (BBA). It changes the definition of a qualifying rural shortage area in which a Medicare RHC must be located; establishes criteria for identifying RHCs essential to delivery of primary care services that we can continue to approve as Medicare RHCs in areas no longer designated as medically underserved; and limits waivers of certain nonphysician practitioner staffing requirements. This final rule imposes payment limits on provider-based RHCs and prohibits "commingling" (the use of the space, professional staff, equipment, and other resources) of an RHC with another entity. The rule also requires RHCs to establish a quality assessment and performance improvement program that goes beyond current regulations. Finally, this final rule addresses public comments received on the February 28, 2002 proposed rule and makes other revisions for clarity and uniformity and to improve program administration. (+info)
Improving the hospital management of malnourished children by participatory research.
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OBJECTIVE: To improve the clinical management of severely malnourished children in rural hospitals in South Africa. STUDY DESIGN: A pre- and post-intervention descriptive study in three stages: assessment of the clinical management of severely malnourished children, planning and implementing an action plan to improve quality of care, and monitoring and evaluating targeted activities. A participatory approach was used to involve district and hospital nutrition teams in all stages of the research. SETTING: Two rural first-referral level hospitals (Mary Theresa and Sipetu) in Mount Frere District, Eastern Cape Province. MAIN MEASURE: A retrospective record review of all admissions for severe malnutrition to obtain patient characteristics and case fatality rates, a detailed review of randomly selected cases to illustrate general case management, structured observations in the paediatric wards to assess adequacy of resources for care of malnourished children, and in-depth interviews and focus group discussions with nursing and medical staff to identify barriers to improved quality of care. RESULTS: Before the study, case fatality rates were 50% and 28% in Mary Theresa and Sipetu hospitals, respectively. Information from case studies, observations, interviews, and focus group discussions revealed many inadequacies in knowledge, resources, and practices. The hospital nutrition team developed and implemented an action plan to improve the quality of care and developed tools for monitoring its implementation and evaluating its impact. In the 12-month period immediately after implementation, case fatality rates fell by approximately 25% in both hospitals. CONCLUSION: Participatory research led to the formation of a hospital nutrition team, which identified shortcomings in the clinical management of severely malnourished children and took action to improve quality of care. These actions were associated with a reduction in case fatality rates. (+info)