Baseline assessment of adult and adolescent primary care delivery in Rwanda: An opportunity for quality improvement

Ashwin Vasan; Manzi Anatole; Catherine Mezzacappa; Bethany L. Hedt-Gauthier; Lisa R. Hirschhorn; Fulgence Nkikabahizi; Marc Hagenimana; Aphrodis Ndayisaba; Felix R. Cyamatare; Bonaventure Nzeyimana; Peter Drobac; Neil Gupta

doi:10.1186/1472-6963-13-518

Baseline assessment of adult and adolescent primary care delivery in Rwanda: An opportunity for quality improvement

Ashwin Vasan^*, Manzi Anatole, Catherine Mezzacappa, Bethany L. Hedt-Gauthier, Lisa R. Hirschhorn, Fulgence Nkikabahizi, Marc Hagenimana, Aphrodis Ndayisaba, Felix R. Cyamatare, Bonaventure Nzeyimana, Peter Drobac, Neil Gupta

^*Corresponding author for this work

Medical Social Sciences

Research output: Contribution to journal › Article › peer-review

5 Scopus citations

Abstract

Background: As resource-limited health systems evolve to address complex diseases, attention must be returned to basic primary care delivery. Limited data exists detailing the quality of general adult and adolescent primary care delivered at front-line facilities in these regions. Here we describe the baseline quality of care for adults and adolescents in rural Rwanda. Methods. Patients aged 13 and older presenting to eight rural health center outpatient departments in one district in southeastern Rwanda between February and March 2011 were included. Routine nurse-delivered care was observed by clinical mentors trained in the WHO Integrated Management of Adolescent & Adult Illness (IMAI) protocol using standardized checklists, and compared to decisions made by the clinical mentor as the gold standard. Results: Four hundred and seventy consultations were observed. Of these, only 1.5% were screened and triaged for emergency conditions. Fewer than 10% of patients were routinely screened for chronic conditions including HIV, tuberculosis, anemia or malnutrition. Nurses correctly diagnosed 50.1% of patient complaints (95% CI: 45.7%-54.5%) and determined the correct treatment 44.9% of the time (95% CI: 40.6%-49.3%). Correct diagnosis and treatment varied significantly across health centers (p = 0.03 and p = 0.04, respectively). Conclusion: Fundamental gaps exist in adult and adolescent primary care delivery in Rwanda, including triage, screening, diagnosis, and treatment, with significant variability across conditions and facilities. Research and innovation toward improving and standardizing primary care delivery in sub-Saharan Africa is required. IMAI, supported by routine mentorship, is one potentially important approach to establishing the standards necessary for high-quality care.

Original language	English (US)
Article number	518
Journal	BMC health services research
Volume	13
Issue number	1
DOIs	https://doi.org/10.1186/1472-6963-13-518
State	Published - Dec 17 2013

Funding

The study was conducted as part of the Rwanda Population Health Implementation & Training (PHIT) Partnership, and funded by the Doris Duke Charitable Foundation’s African Health Initiative. The Rwanda PHIT Partnership is co-led by the Rwanda Ministry of Health and Partners In Health with key involvement from the National University of Rwanda School of Public Health (NURSPH), Rwanda National Institute of Statistics, as well as Harvard Medical School, and Brigham and Women’s Hospital in Boston, USA. BHG received additional support from the Department of Global Health and Social Medicine Research Core at Harvard Medical School. The authors would also like to thank Stephen D. Lawn and David C. Mabey from the London School of Hygiene & Tropical Medicine for their helpful insight and comments.

Keywords

Africa
IMAI
Integration
Nurses
Outpatient department
Primary care
Quality improvement
Resource-limited settings
Training

ASJC Scopus subject areas

Health Policy

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

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10.1186/1472-6963-13-518

Cite this

Vasan, A., Anatole, M., Mezzacappa, C., Hedt-Gauthier, B. L., Hirschhorn, L. R., Nkikabahizi, F., Hagenimana, M., Ndayisaba, A., Cyamatare, F. R., Nzeyimana, B., Drobac, P., & Gupta, N. (2013). Baseline assessment of adult and adolescent primary care delivery in Rwanda: An opportunity for quality improvement. BMC health services research, 13(1), Article 518. https://doi.org/10.1186/1472-6963-13-518

@article{aac9b00264c74194b040c74651706655,

title = "Baseline assessment of adult and adolescent primary care delivery in Rwanda: An opportunity for quality improvement",

abstract = "Background: As resource-limited health systems evolve to address complex diseases, attention must be returned to basic primary care delivery. Limited data exists detailing the quality of general adult and adolescent primary care delivered at front-line facilities in these regions. Here we describe the baseline quality of care for adults and adolescents in rural Rwanda. Methods. Patients aged 13 and older presenting to eight rural health center outpatient departments in one district in southeastern Rwanda between February and March 2011 were included. Routine nurse-delivered care was observed by clinical mentors trained in the WHO Integrated Management of Adolescent & Adult Illness (IMAI) protocol using standardized checklists, and compared to decisions made by the clinical mentor as the gold standard. Results: Four hundred and seventy consultations were observed. Of these, only 1.5% were screened and triaged for emergency conditions. Fewer than 10% of patients were routinely screened for chronic conditions including HIV, tuberculosis, anemia or malnutrition. Nurses correctly diagnosed 50.1% of patient complaints (95% CI: 45.7%-54.5%) and determined the correct treatment 44.9% of the time (95% CI: 40.6%-49.3%). Correct diagnosis and treatment varied significantly across health centers (p = 0.03 and p = 0.04, respectively). Conclusion: Fundamental gaps exist in adult and adolescent primary care delivery in Rwanda, including triage, screening, diagnosis, and treatment, with significant variability across conditions and facilities. Research and innovation toward improving and standardizing primary care delivery in sub-Saharan Africa is required. IMAI, supported by routine mentorship, is one potentially important approach to establishing the standards necessary for high-quality care.",

keywords = "Africa, IMAI, Integration, Nurses, Outpatient department, Primary care, Quality improvement, Resource-limited settings, Training",

author = "Ashwin Vasan and Manzi Anatole and Catherine Mezzacappa and Hedt-Gauthier, {Bethany L.} and Hirschhorn, {Lisa R.} and Fulgence Nkikabahizi and Marc Hagenimana and Aphrodis Ndayisaba and Cyamatare, {Felix R.} and Bonaventure Nzeyimana and Peter Drobac and Neil Gupta",

note = "Funding Information: The study was conducted as part of the Rwanda Population Health Implementation & Training (PHIT) Partnership, and funded by the Doris Duke Charitable Foundation{\textquoteright}s African Health Initiative. The Rwanda PHIT Partnership is co-led by the Rwanda Ministry of Health and Partners In Health with key involvement from the National University of Rwanda School of Public Health (NURSPH), Rwanda National Institute of Statistics, as well as Harvard Medical School, and Brigham and Women{\textquoteright}s Hospital in Boston, USA. BHG received additional support from the Department of Global Health and Social Medicine Research Core at Harvard Medical School. The authors would also like to thank Stephen D. Lawn and David C. Mabey from the London School of Hygiene & Tropical Medicine for their helpful insight and comments.",

year = "2013",

month = dec,

day = "17",

doi = "10.1186/1472-6963-13-518",

language = "English (US)",

volume = "13",

journal = "BMC health services research",

issn = "1472-6963",

publisher = "BioMed Central",

number = "1",

}

Vasan, A, Anatole, M, Mezzacappa, C, Hedt-Gauthier, BL, Hirschhorn, LR, Nkikabahizi, F, Hagenimana, M, Ndayisaba, A, Cyamatare, FR, Nzeyimana, B, Drobac, P & Gupta, N 2013, 'Baseline assessment of adult and adolescent primary care delivery in Rwanda: An opportunity for quality improvement', BMC health services research, vol. 13, no. 1, 518. https://doi.org/10.1186/1472-6963-13-518

TY - JOUR

T1 - Baseline assessment of adult and adolescent primary care delivery in Rwanda

T2 - An opportunity for quality improvement

AU - Vasan, Ashwin

AU - Anatole, Manzi

AU - Mezzacappa, Catherine

AU - Hedt-Gauthier, Bethany L.

AU - Hirschhorn, Lisa R.

AU - Nkikabahizi, Fulgence

AU - Hagenimana, Marc

AU - Ndayisaba, Aphrodis

AU - Cyamatare, Felix R.

AU - Nzeyimana, Bonaventure

AU - Drobac, Peter

AU - Gupta, Neil

N1 - Funding Information: The study was conducted as part of the Rwanda Population Health Implementation & Training (PHIT) Partnership, and funded by the Doris Duke Charitable Foundation’s African Health Initiative. The Rwanda PHIT Partnership is co-led by the Rwanda Ministry of Health and Partners In Health with key involvement from the National University of Rwanda School of Public Health (NURSPH), Rwanda National Institute of Statistics, as well as Harvard Medical School, and Brigham and Women’s Hospital in Boston, USA. BHG received additional support from the Department of Global Health and Social Medicine Research Core at Harvard Medical School. The authors would also like to thank Stephen D. Lawn and David C. Mabey from the London School of Hygiene & Tropical Medicine for their helpful insight and comments.

PY - 2013/12/17

Y1 - 2013/12/17

N2 - Background: As resource-limited health systems evolve to address complex diseases, attention must be returned to basic primary care delivery. Limited data exists detailing the quality of general adult and adolescent primary care delivered at front-line facilities in these regions. Here we describe the baseline quality of care for adults and adolescents in rural Rwanda. Methods. Patients aged 13 and older presenting to eight rural health center outpatient departments in one district in southeastern Rwanda between February and March 2011 were included. Routine nurse-delivered care was observed by clinical mentors trained in the WHO Integrated Management of Adolescent & Adult Illness (IMAI) protocol using standardized checklists, and compared to decisions made by the clinical mentor as the gold standard. Results: Four hundred and seventy consultations were observed. Of these, only 1.5% were screened and triaged for emergency conditions. Fewer than 10% of patients were routinely screened for chronic conditions including HIV, tuberculosis, anemia or malnutrition. Nurses correctly diagnosed 50.1% of patient complaints (95% CI: 45.7%-54.5%) and determined the correct treatment 44.9% of the time (95% CI: 40.6%-49.3%). Correct diagnosis and treatment varied significantly across health centers (p = 0.03 and p = 0.04, respectively). Conclusion: Fundamental gaps exist in adult and adolescent primary care delivery in Rwanda, including triage, screening, diagnosis, and treatment, with significant variability across conditions and facilities. Research and innovation toward improving and standardizing primary care delivery in sub-Saharan Africa is required. IMAI, supported by routine mentorship, is one potentially important approach to establishing the standards necessary for high-quality care.

AB - Background: As resource-limited health systems evolve to address complex diseases, attention must be returned to basic primary care delivery. Limited data exists detailing the quality of general adult and adolescent primary care delivered at front-line facilities in these regions. Here we describe the baseline quality of care for adults and adolescents in rural Rwanda. Methods. Patients aged 13 and older presenting to eight rural health center outpatient departments in one district in southeastern Rwanda between February and March 2011 were included. Routine nurse-delivered care was observed by clinical mentors trained in the WHO Integrated Management of Adolescent & Adult Illness (IMAI) protocol using standardized checklists, and compared to decisions made by the clinical mentor as the gold standard. Results: Four hundred and seventy consultations were observed. Of these, only 1.5% were screened and triaged for emergency conditions. Fewer than 10% of patients were routinely screened for chronic conditions including HIV, tuberculosis, anemia or malnutrition. Nurses correctly diagnosed 50.1% of patient complaints (95% CI: 45.7%-54.5%) and determined the correct treatment 44.9% of the time (95% CI: 40.6%-49.3%). Correct diagnosis and treatment varied significantly across health centers (p = 0.03 and p = 0.04, respectively). Conclusion: Fundamental gaps exist in adult and adolescent primary care delivery in Rwanda, including triage, screening, diagnosis, and treatment, with significant variability across conditions and facilities. Research and innovation toward improving and standardizing primary care delivery in sub-Saharan Africa is required. IMAI, supported by routine mentorship, is one potentially important approach to establishing the standards necessary for high-quality care.

KW - Africa

KW - IMAI

KW - Integration

KW - Nurses

KW - Outpatient department

KW - Primary care

KW - Quality improvement

KW - Resource-limited settings

KW - Training

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U2 - 10.1186/1472-6963-13-518

DO - 10.1186/1472-6963-13-518

M3 - Article

C2 - 24344805

AN - SCOPUS:84890298221

SN - 1472-6963

VL - 13

JO - BMC health services research

JF - BMC health services research

IS - 1

M1 - 518

ER -

Baseline assessment of adult and adolescent primary care delivery in Rwanda: An opportunity for quality improvement

Abstract

Funding

Keywords

ASJC Scopus subject areas

UN SDGs

Access to Document

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