United Hospital Fund

IntroductionSoil-transmitted helminth (STH) and schistosomiasis (SCH) infections remain some of the most prevalent neglected tropical diseases (NTDs), causing significant morbidity in most of sub-Saharan Africa (SSA), including Rwanda. With dwindling international funding for NTD services and recent commitments focused on other diseases considered easier to eliminate as a public health problem, it is essential to assess domestic financing sources’ scale, efficiency, and effectiveness. The study aims to strengthen domestic efforts towards sustainable financing for neglected tropical disease programs in Africa, particularly in Rwanda.MethodUp to 235 patients from 24 health centers in four districts of Rwanda were sampled for this survey. The districts selected had the highest number of STH and SCH based on routine data from June 2021 to December 2022, which is the window period of the study. We estimated affordability using the lowest-paid government worker (LPGW) and then compared this with household income and expenditure obtained from patients participating in the survey. Data was collected from August to September 2023. Limited secondary data were collected to complement primary data. Descriptive statistical analysis was used to present the findings.Results and ConclusionsThe most available drugs were mebendazole, with 100% of facilities reporting no stockout. Praziquantel (PZQ) was the most unavailable drug, reporting 92% stockout at the time of the survey, mainly due to delays in getting supplies from MDA-implementing health facilities. Diagnostics for SCH are the most inaccessible lab services. On average, the total cost (both direct and opportunity cost) to access and utilize STH and SCH services was USD 0.72 (RWF 861.92) and USD 0.96 (RWF 1136.41) for male and female patients, respectively. Although the assessment revealed that treatment for STH and SCH was affordable for the LPGW, women pay a 33% higher cost than men to access NTD services. While services are generally satisfactory, the reimbursement processes are slow, hindering timely access and utilization of SCH and STH services at the health facilities in Rwanda.While the access and utilization of STH and SCH services in health centers are generally promising, the findings underscore the potential for improvement. By addressing the efficiency in the supply of praziquantel drugs and enhancing reimbursement timelines, we can ensure the continuity and effectiveness of these services, offering hope for a brighter future in the fight against neglected tropical diseases.

Objetivos: Mapear e caracterizar os tipos de alimentos aceitos por crianças com dificuldades alimentares (DA), a partir do registro dos alimentos no inventário alimentar (IA). Métodos: Estudo observacional retrospectivo realizado a partir da análise do IA de 67 pacientes com DA atendidos no Centro de Dificuldades Alimentares localizado em São Paulo – SP. Os alimentos descritos foram classificados segundo cor, sabor, consistência e textura, e segundo a classificação da Agência Nacional de Vigilância Sanitária, adaptada para este estudo. Utilizou-se análise descritiva com distribuição por frequência para obtenção dos resultados. Resultados: Identificou-se 359 variedades de alimentos/preparações presentes no IA. Houve predomínio das categorias “Doces, guloseimas e sobremesas” (15,8%, n=57 itens) e “Produtos de panificação e biscoitos” (14,4%, n=52 itens), e baixo predomínio das categorias “Frutas” e “Hortaliças” 29 (8%) e 32 (8,8%) itens, respectivamente. Observou-se que os mais consumidos possuem sabor doce (45,6%, n=163) seguido do sabor umami (30,9%, n=111), coloração clara – amarelo/branco/alaranjado (57,1%, n=205), consistência sólida (43,1%, n=155) e textura sólida dura solúvel (40%, n=144). Conclusão: O consumo de crianças acompanhadas em um centro de DA baseou-se em alimentos de sabor doce, cor clara, consistência sólida e textura dura solúvel. Esses alimentos se traduzem em doces, guloseimas, sobremesas, produtos de panificação e biscoitos. Palavras-chave: Nutrição infantil. Crianças. Alimentação.

Despite concerted actions to streamline care transitions, the journey from hospital to home remains hazardous for patients and caregivers. Remarkably little is known about the patient and caregiver experience during care transitions, the services they need, or the outcomes they value. The aims of this study were to (1) describe patient and caregiver experiences during care transitions and (2) characterize patient and caregiver desired outcomes of care transitions and the health services associated with them. We interviewed 138 patients and 110 family caregivers recruited from 6 health networks across the United States. We conducted 34 homogenous focus groups (103 patients, 65 caregivers) and 80 key informant interviews (35 patients, 45 caregivers). Audio recordings were transcribed and analyzed using principles of grounded theory to identify themes and the relationship between them. Patients and caregivers identified 3 desired outcomes of care transition services: (1) to feel cared for and cared about by medical providers, (2) to have unambiguous accountability from the health care system, and (3) to feel prepared and capable of implementing care plans. Five care transition services or provider behaviors were linked to achieving these outcomes: (1) using empathic language and gestures, (2) anticipating the patient's needs to support self-care at home, (3) collaborative discharge planning, (4) providing actionable information, and (5) providing uninterrupted care with minimal handoffs. Clear accountability, care continuity, and caring attitudes across the care continuum are important outcomes for patients and caregivers. When these outcomes are achieved, care is perceived as excellent and trustworthy. Otherwise, the care transition is experienced as transactional and unsafe, and leaves patients and caregivers feeling abandoned by the health care system.

Transitional care (TC) has received widespread attention from researchers, health system leaders, clinicians, and policy makers as they attempt to improve health outcomes and reduce preventable hospital readmissions, yet little is known about the critical elements of effective TC and how they relate to patients' and caregivers' needs and experiences. To address this gap, the Patient-Centered Outcomes Research Institute (PCORI) funded a national study, Achieving patient-centered Care and optimized Health In care transitions by Evaluating the Value of Evidence (Project ACHIEVE). A primary aim of the study is the identification of TC components that yield desired patient and caregiver outcomes. Project ACHIEVE established a multistakeholder workgroup to recommend essential TC components for vulnerable Medicare beneficiaries. Guided by a review of published evidence, the workgroup identified and defined a preliminary set of components and then analyzed how well the set aligned with real-world patients' and caregivers' experiences. Through this process, the workgroup identified eight TC components: patient engagement, caregiver engagement, complexity and medication management, patient education, caregiver education, patients' and caregivers' well-being, care continuity, and accountability. Although the degree of attention given to each component will vary based on the specific needs of patients and caregivers, workgroup members agree that health systems need to address all components to ensure optimal TC for all Medicare beneficiaries.

The use of metformin in chronic kidney disease (CKD) population has been intensely debated with conflicting evidence. Large population studies are needed to inform risk assessment and therapeutic decision-making. We evaluated the associations among metformin, metabolic acidosis, and CKD in a 10-year nationally representative noninstitutionalized civilian population in the United States.In this cross-sectional study, a total of 2279 diabetic adults aged 20 years or older in the National Health and Nutrition Examination Survey (NHANES) from 2003 to 2012 were included and had measurements of serum bicarbonate, sodium, potassium, and chloride. The exposure was metformin use. The outcome was subclinical and severe metabolic acidosis defined by serum bicarbonate <23 mEq/L and anion gap > 16mEq/L and by serum bicarbonate < 20 mEq/L, respectively.The prevalence of metformin use decreased from 67.2% among CKD-1 and -2, 40.6% among CKD-3, to 1.3% among advanced CKD-4 and -5. Across CKD stages up to CKD-3b, we observed a tendency of lower levels of serum bicarbonate that was significant in metformin users with CKD-2 and CKD-3a and marginally significant with CKD-3b compared to nonmetformin users. The corresponding tendency of higher anion gap in metformin users with the estimated glomerular filtration rate >60 mL/min/1.73 m was also observed. In multiple linear regression analysis, metformin was significantly associated with decreased serum bicarbonate levels (β = -0.45, 95% CI: -0.73, -0.17) and increased serum anion gap levels (β = 0.40, 95% CI: 0.19, 0.61). The adjusted odds ratio of subclinical high anion gap and severe metabolic acidosis for metformin users was 1.68 (95% CI: 1.11, 2.55) and 1.31 (0.49, 3.47), respectively. The association between metformin and serum bicarbonate was significantly modified by CKD status. No interaction was found between metformin and CKD stages for serum anion gap and acidosis.Metformin is associated with subclinical metabolic acidosis but not with severe metabolic acidosis. The propensity of serum bicarbonate-lowering effect was intensified in advanced CKD; however, such tendency was not associated with the risk of clinically defined acidosis. Our findings highlight a potential of cautious expansion of metformin use among CKD-3b patients with diabetes meriting further investigations.

It has been 29 years since the first professionally staffed Naturally Occurring Retirement Community-Supportive Service Program (NORC-SSP) opened its doors in New York City. Much has occurred since November 1986 to establish and develop the NORC-SSP model, create public policy, and influence not only how we think about aging but also what is necessary to help older adults “age in place” in their communities. As the “mothers” of the NORC-SSP model, we are proud of how far we have come. As the 30th anniversary of the model approaches, it is a good time to reflect on what has been accomplished and what needs to be done to secure its place in the field of aging. The terms NORC and NORC-SSP are often used interchangeably, but they are not interchangeable. A NORC is a demographic term to describe an age-integrated housing development or neighborhood that was originally built for families and that, over time, becomes home to large concentrations of older adults, 60 years of age and older.

Introduction: Severe sepsis and septic shock are associated with a high mortality rate but are under recognized and undertreated. Early antibiotic administration and fluid resuscitation are associated with improved survival. In 2010, the Critical Care Leadership Network of the Greater New York Hospital Association and the United Hospital Fund developed the STOP (Strengthening Treatment and Outcomes for Patients) Sepsis Collaborative—a quality improvement initiative that supports hospitals in the early recognition and treatment of severe sepsis and septic shock using a protocol-based approach in the emergency department and the intensive care unit. Hypothesis: A quality improvement collaborative focused on the implementation of standardized protocols for early identification and treatment of patients with severe sepsis and septic shock in the emergency department can improve treatment process measures and reduce mortality. Methods: Fifty-seven hospitals in the greater New York region participating in a quality improvement collaborative were provided with comprehensive education and tools to recognize patients with severe sepsis and septic shock in the emergency department and implement an evidence-based resuscitation protocol. The intervention period began in January 2011, and included a comprehensive educational program for an interdisciplinary group of clinicians, nurses, and administrators. Data were collected on all sepsis process measures and time stamps were recorded. Participating hospitals also submitted summary patient outcomes. Results: Participating hospitals submitted information on 7,470 patients with severe sepsis admitted between January 2011 and March 2012. Within six months, 91% of participating hospitals had adopted a sepsis identification protocol in the emergency department and sepsis resuscitation protocols were implemented in the emergency department by 93% of the participating hospitals. Between January 2011 and March 2012, inpatient mortality declined from 41% to 26% (absolute mortality reduction of 15%). Conclusions: Hospitals that participated in a quality improvement collaborative designed to assist hospitals in using protocols for early diagnosis and treatment of severe sepsis and septic shock in their emergency departments saw an overall 15% reduction in hospital mortality in patients with these conditions.

Neurological patients have lower mortality and better outcomes when cared for in specialized neurointensive care units than in general ICUs. However, little is known about how the process of care differs between these types of units. The Greater New York Hospital Association conducted a city-wide 24-h ICU prevalence survey on March 15th, 2007. Data was collected on all patients admitted to 143 ICUs in 69 different hospitals. Of 1,906 ICU patients surveyed, 231 had a primary neurological diagnosis. Of these, 52 (22%) were admitted to one of 9 neuro-ICU's in NY and 179 (78%) to a medical or surgical ICU. Neurological patients in neuro-ICUs were more likely to have been transferred from an outside hospital (37% vs. 11%, P<0.0001). Hemorrhagic stroke was more frequent in neuro-ICUs (46% vs. 16%, P<0.0001), whereas traumatic brain injury (2% vs. 24%, P<0.0001) and ischemic stroke (0% vs. 19%, P=0.001) were less common. Despite a lower rate of mechanical ventilation (39% vs. 50%, P=0.15), ICU length of stay was longer in neuro-ICU patients (≥10days, 40% vs. 17%, P<0.0001). More neuro-ICU patients had undergone tracheostomy (35% vs. 15%, P=0.04), invasive hemodynamic monitoring (40% vs. 20%, P=0.002), and invasive intracranial pressure monitoring (29% vs. 9%, P<0.001) than patients cared for in general ICUs. Intravenous sedation was less prevalent in neuro-ICUs (12% vs. 30%, P=0.009) and more patients were receiving nutritional support compared to general ICUs (67% vs. 39%, P<0.001). Neurological patients cared for in specialty neuro-ICUs underwent more invasive intracranial and hemodynamic monitoring, tracheostomy, and nutritional support, and received less IV sedation than patients in general ICUs. These differences in care may explain previously observed disparities in outcome between neurocritical care and general ICUs.

The immune reconstitution inflammatory syndrome (IRIS) associated with highly active antiretroviral therapy (HAART) was studied in rural Ethiopian HIV-infected patients. Review of 1002 charts in an outpatient clinic was conducted. The median CD4 count was 89 cells/mm(3). Ninety-eight patients were hospitalized after initiation of HAART, of whom 74 were hospitalized for manifestations of IRIS (ie, 7% of patients on HAART). Of the 74 patients hospitalized with IRIS, 27 patients had tuberculosis; 12 patients, cryptococcal meningitis; 7 patients, toxoplasmosis; 6 patients, pneumonia and/or effusion; and 5 patients, Pneumocystis jiroveci pneumonia (PCP). Ten adult patients were admitted with gastroenteritis, heretofore not recognized as a manifestation of IRIS. Eighty-one percent of IRIS patients were hospitalized within 3 months of beginning HAART and 99% by 6 months. Of those hospitalized with IRIS, 4 patients (5%) died while in the hospital (3 with cryptococcal meningitis). Thirty-seven or 50% of those hospitalized with IRIS were lost to medical follow up, thus the mortality rate is likely a gross underestimate of the severity of IRIS. In resource-poor settings where the primary goal is to initiate HAART, IRIS may go unrecognized and have fatal consequences.