Impact of new guidelines for arterial hypertension care on costs in Tula Oblast, Russia
A quality assurance project in Tula Oblast, Russia introduced new guidelines for the management of arterial hypertension (AH) in 1999 that emphasized screening, patient education and control of blood pressure. This OR study tested the hypothesis that the new guidelines would shift resources from expensive inpatient care to less expensive outpatient care, thereby resulting in a net reduction in the cost of AH care. An analysis of inpatient and outpatient costs associated with AH before and after the new guidelines in a population of about 10,000 adults supported the hypothesis. AH inpatient admissions dropped 17%, patients under outpatient AH care increased 47%, the cost per 1000 adults of inpatient AH care dropped 32%, and the cost of outpatient AH care per 1000 adults rose 61%. Because inpatient care is far more expensive than outpatient care, overall cost of AH care per 1000 adults dropped 11%. Most of the reduction in inpatient admissions and cost was due to a sharp reduction in the number and cost of emergency admissions for AH care by patients not previously under outpatient care for AH. After reviewing limitations of the study methodology and possible alternative causes, the study concluded that the drop in AH cost was almost certainly due to the new guidelines.
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Assessing the Economic Impact of the New System of Care for Arterial Hypertension in Tula Oblast, Russia
Improved quality of care reduces pregnancy-induced hypertension costs in Tver Oblast, Russia
QAP helped Tver Oblast redesign its system of care for
pregnancy-induced hypertension (PIH) in three hospitals,
including the introduction of new, evidence-based guidelines.
Under the new guidelines, fewer women were admitted for
PIH care, and those admitted received more aggressive
care to prevent progression to eclampsia, including mono-drug
therapy (magnesium sulfate) and early induced delivery
if the drug therapy did not work. The new system resulted
in no progressions to eclampsia, no PIH deaths, and a
60% drop in newborn complications to PIH mothers in the
19 months following the introduction of the new guidelines.
This study focused on measuring the cost of the new and
old systems in two of the hospitals. The direct cost
of drugs, laboratory tests and hospitalization (nurse
and clinician time, food) for PIH inpatient and outpatient
care was estimated for PIH patients in similar 6-month
periods before and after the new guidelines. Total costs
dropped by 87% following the introduction of the new
guidelines. Four factors contributed most to this reduction:
a 76% drop in the number of cases admitted, a 13% reduction
in the length of hospitalization, an 81% reduction in
the number of women given additional PIH outpatient care
over and above normal antenatal care, and more rational
use of drugs, resulting in a 63% reduction in the drug
cost per inpatient.
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Improving the Quality of Care for Women with Pregnancy-Induced Hypertension Reduces Costs in Tver, Russia
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Rwanda
Adherence to antiretroviral therapy among HIV+ patients in the private sector, Rwanda
This study will document and identify barriers to adherence to ARV therapy among HIV+ patients who come for medical care to King Faisal Hospital.
Analysis of workforce needs for the scaling up of HIV care in Rwanda
This study will apply the methodology used in Zambia to assess Rwanda's workforce needs for scaling up HIV care to the entire country. It is anticipated that this analysis would be the first part of a larger study to test interventions to meet these workforce needs.
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Antiretroviral therapy outcomes in Rwanda
This study will apply the methodology used in Zambia to assess Rwanda's workforce needs for scaling up HIV care to the entire country. It is anticipated that this analysis would be the first part of a larger study to test interventions to meet these workforce needs.
Assessing stigma in health providers and its impact on quality of care in Rwanda
This ongoing study examines provider and patient attitudes toward the stigma associated with HIV+ status. Six focus groups are being conducted with providers and 6 focus groups with people living with HIV/AIDS (PLWHA). Provider interviews are being conducted in 13 sites throughout Rwanda.
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Enabling factors affecting the performance of skilled birth attendants
A wide variety of factors might affect the performance of skilled birth attendants, including provider competence and motivation, various patient characteristics, hospital leadership and supervision, availability of equipment, drugs and supplies, policies, time of day and week, and support team. This study examined the relationships between such factors and performance during labor, delivery and immediate postpartum maternal and newborn care. Data were obtained from 5 referral hospitals, 12 smaller hospitals, and 4 health centers in four countries (Benin, Ecuador, Jamaica, Rwanda). Performance was defined as compliance according to international standards and measured by direct observation of all births and retrospective record review of obstetric emergencies. The enabling factors were measured by a variety of instruments, measurements of the competency of birth attendants obtained from a related study.
Measuring competency of skilled birth attendants
This study developed instruments for measuring knowledge and skills of birth attendants. It was tested in four countries: Benin, Ecuador, Jamaica and Rwanda. The instruments measured competency during labor, delivery, postpartum maternal care, and postpartum newborn care. Knowledge was measured with a 55-item test derived from several well-known sources, such as the WHO IMPAC guidelines. The skills test included two partograph exercises and six skill stations using mannekins and attended by expert clinicians. Locally appropriate standards were added to the tests in each country.
Measuring in-facility delays during emergency obstetric care
This study developed and tested a method for measuring delays in the treatment of selected obstetrical emergencies within facilities in four countries: Benin, Ecuador, Jamaica, and Rwanda. Emergencies addressed included eclampsia/pre-eclampsia, sepsis, obstructed labor, postpartum hemorrhage, and post-abortion complications. The method included observing patient flow in the obstetrical ward and/or the emergency room, and record review of obstretrical emergencies. Patient flow data were obtained on 856 maternal cases, and 329 records of obstetrical cases were reviewed by a physician. The study found that patient flow observation is feasible and necessary to measure delays in initial evaluation. Record reviews by physicians also yielded usable information on delays in obstetrical emergencies.
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South Africa
Functional analysis of PMTCT program in Soweto, South Africa
This study of a "best practice" model has just been started and will identify elements of the Soweto PMTCT program that have a potential for scaling up to other sites in South Africa.
Impact of hospital accreditation in KwaZulu-Natal, South Africa
KwaZulu-Natal (KZN) province of South Africa contracted with the Council for Health Services Accreditation of Southern Africa (COHSASA) to introduce hospital accreditation into their public hospitals in 1998. QAP undertook a study of the impact of the COHSASA program in 20 randomly selected hospitals, stratified for size, in KZN, with ten serving as program hospitals and ten as controls. The study analyzed the effect on the standard COHSASA indicators measured as a normal part of their accreditation process, and on a limited set of quality indicators developed by a consensus process and collected by an independent research team. The quality indicators were: nurse perceptions of quality, client satisfaction, client medication education, accessibility and completeness of medical records, quality of peri-operative notes, hospital sanitation, and labeling of ward stocks. Unfortunately, several indicators more directly related to clinical outcomes were dropped due to lack of data. About two years after initiation of the program, the program hospitals had improved their average compliance with COHSASA accreditation standards from 38% to 76%, while no increase was observed in the control hospitals (from 37% to 38%). This improvement of the program hospitals relative to the controls was statistically significant and seems likely to have been due to the accreditation program. However, little or no effect of the program was observed on the indicators collected by the independent research team, with the exception of nurse perceptions of clinical quality. Limitations of the study design may have influenced the observed results. Practical implications of these results are: (1) the COHSASA facilitated accreditation program appears to be successful in improving hospital performance on COHSASA standards, and (2) additional work is needed to determine whether improvements in COHSASA standards of structure and process result in improved quality of care measures.
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The Impact of Accreditation on the Quality of Hospital Care: KwaZulu-Natal Province, Republic of South Africa
Review of Health Services Accreditation Programs in South Africa
Transporting sputum from clinics to lab facilities in South Africa
This study is assessing the effectiveness of using private agents and cellular telephones to transmit tuberculosis sputum test lab results to clinics. The cellular telephones will also be used for reminders for follow-up visits.
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Tanzania
Impact of stigma on HIV/AIDS care providers' attitudes
This ongoing study examines provider and patient attitudes toward the stigma associated with HIV+ status through focus groups with providers and people living with HIV/AIDS (PLWHA). Provider interviews are being conducted in 13 sites throughout Rwanda. In-depth interviews are also being conducted with service providers, and record review is used to assess quality of care provided. This study is being carried out in Rwanda, Tanzania, and Haiti.
Use of job aids to improve infant feeding counseling in PMTCT in Tanzania
This study is testing the impact of job aids in improving the quality of infant feeding counseling within PMTCT services.
Uganda
Case management maps for pregnancy-induced hypertension and postpartum hemorrhage
This study developed, implemented and measured the impact of a case management map on the management of pregnancy-induced hypertension (PIH) and postpartum hemorrhage (PPH) in Jinja Hospital, Uganda. The maps served as a job aid and a permanent record of the care provided. The map development process within the hospital was an integral part of the intervention, including the steps of team selection, current process description, developing the job aid map, define monitoring indicators, and implementation. The development team also worked to solve barriers to good performance such as missing equipment or drugs. This process was undertaken twice in the same ward, first for PIH and six months later for PPH. A third maternal condition, pelvic inflammatory disease (PID), was used as a control. Impact was measured by quality of care and by health outcome. To measure quality of care, three key tasks (one each for assessment, monitoring and treatment) were measured for six months pre-intervention and six months post intervention for all three conditions. The average of the three quality tasks performed to standard in 86 PIH cases increased from 0.33 to 2.3 (significant), and the average for 30 PPH cases increased from 0.45 to 1.1 (not significant), while the performance in 66 PID cases increased only slightly (0.46 pre, 0.62 post, not significant). Health outcomes improved for PIH cases (stillbirths and women progressing to eclampsia both dropped but not significantly), but did not improve for PPH cases (maternal deaths increased). The study concluded that the case management maps contributed to increased quality of care under ideal conditions.
Evaluation of computer-based training for IMCI in Uganda
This study compared the cost-effectiveness of a 9-day IMCI computer-based training course and an 11-day standard classroom IMCI training course on the knowledge, skills and performance of providers. The standard course was given to 55 providers, and 59 took the computer-based course. Tests of IMCI knowledge were given to all course participants before the training, immediately after the training, and 3-4 months after the training. Skill and performance in case management were observed by trained observers immediately after the training and again after 3-4 months. Both types of training led to led to significant and sustained improvements in participants' knowledge of IMCI, but there was no difference between the two training methods. No differences in skills were noted between the two types of training at the end of the course or after 3-4 months, although there was a substantial decay in skills over the 3-4 month period between observations. Because the computer course took less time and required fewer facilitators to administer, it cost 29% less than the standard course per trainee—$335 per trainee for the computer course versus $472 per trainee for the standard course.
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A Comparison of Computer-Based and Standard Training in the Integrated Management of Childhood Illness in Uganda
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Zambia
Development of the national hospital accreditation program
This study describes the development of the Zambian national hospital accreditation program from 1997 to 2000. Data were collected through a review of written documents, interviews with major stakeholders, hospital visits, and discussions with implementers. Zambia successfully developed hospital standards that are relevant and potentially achievable by its hospitals. Half of Zambia's 79 hospitals have received educational surveys, and twelve have also received the full accreditation survey. Significant improvement in compliance with standards occurred in overall scores and in 7 of 13 functional areas. However, the program has stalled due to lack of sufficient funds, lack of legal standing for the Zambia Hospital Accreditation Council, difficulties in retaining qualified surveyors, and indecision on how to handle accreditation results. In addition, hospitals' serious resource constraints and need for ongoing facilitation have hindered their full participation in the program. It is estimated that the program costs about US$ 10,000 per hospital to complete the cycle.
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Setting Up a National Hospital Accreditation Program: The Zambian Experience
Evaluation of the Zambia Quality Assurance Program
In 1998, the Central Board of Health (CBoH) asked QAP to review the performance of the Zambia Quality Assurance Program and provide recommendations to help design its next phase. QAP staff led an international team of six experts from the United States, Norway, Denmark, and Zambia to conduct the quality assurance program evaluation, which focused on: (a) development and communication of standards of care and measurement of compliance with those standards, (b) productivity of quality improvement teams using a problem-solving method, and (c) the existence and effectiveness of the support systems for QA activities. Topics for evaluation were identified from a systems analysis of what an "ideal" quality assurance (QA) program might look like. The evaluation team selected nine districts for the field interviews, purposely choosing districts with health centers that had active QA teams or staff who had received some degree of QA training. In these nine districts, representing all four regions of Zambia, 24 health facilities were visited, and a total of 140 persons were interviewed.
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The Zambia Quality Assurance Program Final Evaluation
Zambia Accreditation Program Evaluation
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Impact of the hospital accreditation program in Zambia
This study assessed the impact of Zambia's nascent hospital accreditation program on the quality of care. Twenty hospitals just starting in the accreditation program formed the study program group, and six non-participating hospitals formed the control group. Data were obtained from the accreditation surveys on hospital performance against the accreditation standards, and from additional research surveys on process and outcome indicators. The study found that hospitals exposed to the accreditation program seemed to have achieved higher performance on standards than the unexposed. The accreditation program has had the greatest impact on general hospitals, followed by district and lastly, mission hospitals. Compliance with accreditation standards appeared linked to improvement in some, but not all, indicators of quality. Management support and good information sharing seemed to lead to higher compliance with accreditation standards.
Job aids for IMCI in Zambia
This study investigated how a job aid could be used to increase compliance with IMCI guidelines in Zambia. Prior to the study, Zambia had trained many providers in IMCI, and several IMCI job aids were in use. The study included surveys of job aid usage and IMCI compliance in 1999 and in 2000, and the design and introduction of a new IMCI job aid between the two surveys. The 1999 survey observed 385 IMCI cases by 57 providers in 33 health centers. The 2000 survey observed 263 IMCI cases by 56 providers in 16 health centers, and reviewed a random sample of 157 completed IMCI records in the new job aid format. The surveys also interviewed providers and caretakers. Both surveys found high correlation between the use of job aids for IMCI case management and compliance with IMCI standards. This result does not demonstrate that job aids cause improved compliance, perhaps because the study methodology did not address whether individual providers who previously did not use a job aid improved their compliance when they started using job aids. There was no significant difference in compliance between users of the new job aid and the existing IMCI chartbook in 2000. Most providers (82%) said the new job aid was useful because it saves time, reduces errors, helps them remember the IMCI algorithm, and is easy to use, although they also used the existing IMCI chartbook frequently and for the same reasons. Nearly all caretakers said they preferred providers to refer to written material such as a job aid during the IMCI session, thus challenging the contention by some providers that using a job aid would make them look bad in the eyes of patients.
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Assessing the Functionality of Job Aids in Supporting the Performance of IMCI Providers in Zambia
Testing a staff incentive scheme to promote improved health center performance
One component of health reforms in Zambia has been the introduction of cost sharing, which requires that 90% of all revenues accrued by a health center from user fees must be used by that health center to improve health services, and that the remaining 10% of the total fees collected may be used to pay a "bonus" to the staff of the health center to promote improved performance. In reality, the 10% bonus, when divided equally between all the staff working at that health center, is negligible and has done little to either motivate staff or to improve performance. Three District Health Management Teams want to explore the potential for reconfiguring the use of the 10% so as to have more impact on staff performance. The study proposes to answer three questions: Can financial bonuses influence health center performance in priority areas (e.g., promotion of a higher proportion of pregnant women attending antenatal care)? How do performance-based financial rewards influence staff motivation for those who receive them and those who do not? Is a performance-based bonus system perceived as more satisfying (fair and rewarding) than the current "everyone gets an equal share" system?
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Zambia Performance-based Incentives Pilot Study
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Workload and staff to scale-up PMTCT and ARV programs in Zambia
This recently completed study, carried out by QAP subcontractor Initiatives Inc., examined the human resource requirements for HIV/AIDS services in Zambia. The study was conducted to assist the Government of Zambia to determine whether it will have the staff to scale up voluntary counseling and testing (VCT), prevention of mother-to-child transmission of HIV (PMTCT), and antiretroviral (ARV) therapy as planned. Using direct observation, facility record review, and interviews with providers, data were obtained over a 2-4 day period per site for VCT and PMTCT at 3 government hospitals, 5 government clinics, and 3 NGO facilities (VCT only), and for ARV at demonstration sites in 2 government hospitals, 2 private facilities, and one NGO facility. The data included interviews with 102 providers (including doctors, nurses, and volunteers), 320 direct client observations, 42 observations of laboratory services, and 25 observations of ARV dispensing sites (largely pharmacies). Cost figures were calculated for alternative assumptions about scale-up. One such alternative assumes that all residents of Zambia are tested and counseled appropriately once per year at an efficiency equal to the best observed site and the current mix of types of providers, and that 20% of HIV persons will require ARV therapy. These assumptions imply that to accomplish this, Zambia would require a minimum of 958 additional counselors, 302 additional doctors, and 119 additional pharmacy technicians at an annual salary cost of $11.6 million (USD), not counting training or other costs.
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The Zambia HIV/AIDS Workforce Study: Preparing for Scale-up
Zimbabwe
Assessment and improvement of family planning supervision
To assess the quality of supervision at the district level, data were collected from various sources: structured observations of supervisors, audiotaping of supervisor-provider interactions, recording of all supervisory activities, and interviews with supervisors and supervisees. A team composed of current and past supervisors, along with researchers, determined the supervisory practices that would be measured. Relying on supervision standards developed by Zimbabwean stakeholders, the study found zero percent of supervisors performed "high," 56% performed "medium," and 44 percent performed "low." Supervisors devoted less than 5 percent of their time to patient care issues. The supervisors' main strengths were in giving feedback on technical standards, discussing and analyzing data, and developing rapport with the providers. They were most deficient in making suggestions, seeking client input, problem solving with the providers, and building on previous (and future) supervisory visits. The supervisors' weakest areas were continuity of supervisory visits, being proactive, and engaging in joint problem solving with front-line providers. Building on this formative study, QAP designed an intervention to enhance supervisory skills and improve patient care using supervisor led, on-job training of providers, and included a detailed course curriculum. The course was implemented in Zimbabwe's Mashonaland East Province, and the curriculum revised and published.
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The Quality of Supervisor-Provider Interactions in Zimbabwe
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