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Whitaker J, Edem I, Amoah AS, Dube A, D'Ambruoso L, Rickard RF, Leather AJM, Davies J. Understanding the health system utilisation and reasons for avoidable mortality after fatal injury within a Three-Delays framework in Karonga, Northern Malawi: a retrospective analysis of verbal autopsy data. BMJ Open 2024; 14:e081652. [PMID: 38684258 PMCID: PMC11086451 DOI: 10.1136/bmjopen-2023-081652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 04/10/2024] [Indexed: 05/02/2024] Open
Abstract
OBJECTIVES To use verbal autopsy (VA) data to understand health system utilisation and the potential avoidability associated with fatal injury. Then to categorise any evident barriers driving avoidable delays to care within a Three-Delays framework that considers delays to seeking (Delay 1), reaching (Delay 2) or receiving (Delay 3) quality injury care. DESIGN Retrospective analysis of existing VA data routinely collected by a demographic surveillance site. SETTING Karonga Health and Demographic Surveillance Site (HDSS) population, Northern Malawi. PARTICIPANTS Fatally injured members of the HDSS. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was the proportion of fatal injury deaths that were potentially avoidable. Secondary outcomes were the delay stage and corresponding barriers associated with avoidable deaths and the health system utilisation for fatal injuries within the health system. RESULTS Of the 252 deaths due to external causes, 185 injury-related deaths were analysed. Deaths were predominantly among young males (median age 30, IQR 11-48), 71.9% (133/185). 35.1% (65/185) were assessed as potentially avoidable. Delay 1 was implicated in 30.8% (20/65) of potentially avoidable deaths, Delay 2 in 61.5% (40/65) and Delay 3 in 75.4% (49/65). Within Delay 1, 'healthcare literacy' was most commonly implicated barrier in 75% (15/20). Within Delay 2, 'communication' and 'prehospital care' were the most commonly implicated in 92.5% (37/40). Within Delay 3, 'physical resources' were most commonly implicated, 85.7% (42/49). CONCLUSIONS VA is feasible for studying pathways to care and health system responsiveness in avoidable deaths following injury and ascertaining the delays that contribute to deaths. A large proportion of injury deaths were avoidable, and we have identified several barriers as potential targets for intervention. Refining and integrating VA with other health system assessment methods is likely necessary to holistically understand an injury care health system.
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Affiliation(s)
- John Whitaker
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Idara Edem
- Insight Institute of Neurosurgery & Neuroscience, Flint, Michigan, USA
- Michigan State University, East Lansing, Michigan, USA
| | - Abena S Amoah
- Department of Parasitology, Leiden University Medical Center, Leiden, The Netherlands
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
- Malawi Epidemiological and Intervention Research Unit, Chilumba, Malawi
| | - Albert Dube
- Malawi Epidemiological and Intervention Research Unit, Chilumba, Malawi
| | - Lucia D'Ambruoso
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Surgery, Stellenbosch University, Stellenbosch, South Africa
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
- Public Health, National Health Service (NHS) Grampian, Grampian, Scotland
| | - Rory F Rickard
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Andy J M Leather
- School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Surgery, Stellenbosch University, Stellenbosch, South Africa
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Agarwal N, DiGiorgio A, Michalopoulos GD, Letchuman V, Chan AK, Shabani S, Lavadi RS, Lu DC, Wang MY, Haid RW, Knightly JJ, Sherrod BA, Gottfried ON, Shaffrey CI, Goldberg JL, Virk MS, Hussain I, Glassman SD, Shaffrey ME, Park P, Foley KT, Pennicooke B, Coric D, Upadhyaya C, Potts EA, Tumialán LM, Fu KMG, Asher AL, Bisson EF, Chou D, Bydon M, Mummaneni PV. Impact of Educational Background on Preoperative Disease Severity and Postoperative Outcomes Among Patients With Cervical Spondylotic Myelopathy. Clin Spine Surg 2024; 37:E137-E146. [PMID: 38102749 DOI: 10.1097/bsd.0000000000001557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 10/03/2023] [Indexed: 12/17/2023]
Abstract
STUDY DESIGN Retrospective review of a prospectively maintained database. OBJECTIVE Assess differences in preoperative status and postoperative outcomes among patients of different educational backgrounds undergoing surgical management of cervical spondylotic myelopathy (CSM). SUMMARY OF BACKGROUND DATA Patient education level (EL) has been suggested to correlate with health literacy, disease perception, socioeconomic status (SES), and access to health care. METHODS The CSM data set of the Quality Outcomes Database (QOD) was queried for patients undergoing surgical management of CSM. EL was grouped as high school or below, graduate-level, and postgraduate level. The association of EL with baseline disease severity (per patient-reported outcome measures), symptoms >3 or ≤3 months, and 24-month patient-reported outcome measures were evaluated. RESULTS Among 1141 patients with CSM, 509 (44.6%) had an EL of high school or below, 471 (41.3%) had a graduate degree, and 161 (14.1%) had obtained postgraduate education. Lower EL was statistically significantly associated with symptom duration of >3 months (odds ratio=1.68), higher arm pain numeric rating scale (NRS) (coefficient=0.5), and higher neck pain NRS (coefficient=0.79). Patients with postgraduate education had statistically significantly lower Neck Disability Index (NDI) scores (coefficient=-7.17), lower arm pain scores (coefficient=-1), and higher quality-adjusted life-years (QALY) scores (coefficient=0.06). Twenty-four months after surgery, patients of lower EL had higher NDI scores, higher pain NRS scores, and lower QALY scores ( P <0.05 in all analyses). CONCLUSIONS Among patients undergoing surgical management for CSM, those reporting a lower educational level tended to present with longer symptom duration, more disease-inflicted disability and pain, and lower QALY scores. As such, patients of a lower EL are a potentially vulnerable subpopulation, and their health literacy and access to care should be prioritized.
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Affiliation(s)
- Nitin Agarwal
- Department of Neurological Surgery, University of Pittsburgh School of Medicine
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Anthony DiGiorgio
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA
| | | | - Vijay Letchuman
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA
| | - Andrew K Chan
- Department of Neurosurgery, Columbia University Irving Medical Center, New York City, NY
| | - Saman Shabani
- Department of Neurological Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Raj Swaroop Lavadi
- Department of Neurological Surgery, University of Pittsburgh School of Medicine
| | - Daniel C Lu
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, CA
| | - Michael Y Wang
- Department of Neurological Surgery, University of Miami, Miami, FL
| | | | | | | | | | | | - Jacob L Goldberg
- Department of Neurological Surgery, Weill Cornell Medical Center, New York, NY
| | - Michael S Virk
- Department of Neurological Surgery, Weill Cornell Medical Center, New York, NY
| | - Ibrahim Hussain
- Department of Neurological Surgery, Weill Cornell Medical Center, New York, NY
| | | | - Mark E Shaffrey
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
| | - Paul Park
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, University of Tennessee, Memphis, TN
| | - Kevin T Foley
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, University of Tennessee, Memphis, TN
| | - Brenton Pennicooke
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Domagoj Coric
- Neuroscience Institute, Carolina Neurosurgery & Spine Associates, Carolinas Healthcare System, Charlotte
| | - Cheerag Upadhyaya
- Department of Neurosurgery, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Eric A Potts
- Department of Neurological Surgery, Goodman Campbell Brain and Spine, Indianapolis, IN
| | - Luis M Tumialán
- Department of Neurosurgery, Barrow Neurologic Institute, Phoenix, AZ
| | - Kai-Ming G Fu
- Department of Neurological Surgery, Weill Cornell Medical Center, New York, NY
| | - Anthony L Asher
- Neuroscience Institute, Carolina Neurosurgery & Spine Associates, Carolinas Healthcare System, Charlotte
| | - Erica F Bisson
- Department of Neurosurgery, University of Utah, Salt Lake City, UT
| | - Dean Chou
- Department of Neurosurgery, Columbia University Irving Medical Center, New York City, NY
| | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN
| | - Praveen V Mummaneni
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA
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Whitaker J, Amoah AS, Dube A, Rickard R, Leather AJM, Davies J. Access to quality care after injury in Northern Malawi: results of a household survey. BMC Health Serv Res 2024; 24:131. [PMID: 38268016 PMCID: PMC10809521 DOI: 10.1186/s12913-023-10521-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 12/22/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND Most injury care research in low-income contexts such as Malawi is facility centric. Community-derived data is needed to better understand actual injury incidence, health system utilisation and barriers to seeking care following injury. METHODS We administered a household survey to 2200 households in Karonga, Malawi. The primary outcome was injury incidence, with non-fatal injuries classified as major or minor (> 30 or 1-29 disability days respectively). Those seeking medical treatment were asked about time delays to seeking, reaching and receiving care at a facility, where they sought care, and whether they attended a second facility. We performed analysis for associations between injury severity and whether the patient sought care, stayed overnight in a facility, attended a second facility, or received care within 1 or 2 h. The reason for those not seeking care was asked. RESULTS Most households (82.7%) completed the survey, with 29.2% reporting an injury. Overall, 611 non-fatal and four fatal injuries were reported from 531 households: an incidence of 6900 per 100,000. Major injuries accounted for 26.6%. Three quarters, 76.1% (465/611), sought medical attention. Almost all, 96.3% (448/465), seeking care attended a primary facility first. Only 29.7% (138/465), attended a second place of care. Only 32.0% (142/444), received care within one hour. A further 19.1% (85/444) received care within 2 h. Major injury was associated with being more likely to have; sought care (94.4% vs 69.8% p < 0.001), stayed overnight at a facility (22.9% vs 15.4% P = 0.047), attended a second place of care (50.3% vs 19.9%, P < 0.001). For those not seeking care the most important reason was the injury not being serious enough for 52.1% (74/142), followed by transport difficulties 13.4% (19/142) and financial costs 5.6% (8/142). CONCLUSION Injuries in Northern Malawi are substantial. Community-derived details are necessary to fully understand injury burden and barriers to seeking and reaching care.
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Affiliation(s)
- John Whitaker
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.
- King's Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK.
| | - Abena S Amoah
- Malawi Epidemiology and Intervention Research Unit (Formerly Karonga Prevention Study), Chilumba, Malawi
- Department of Population Health, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London, UK
- Department of Parasitology, Leiden University Center for Infectious Diseases, Leiden University Medical Center, Leiden, the Netherlands
| | - Albert Dube
- Malawi Epidemiology and Intervention Research Unit (Formerly Karonga Prevention Study), Chilumba, Malawi
| | - Rory Rickard
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Andrew J M Leather
- King's Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
- Department of Global Surgery, Stellenbosch University, Stellenbosch, South Africa
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Whitaker J, Amoah AS, Dube A, Chirwa L, Munthali B, Rickard RF, Leather AJM, Davies J. Novel application of multi-facility process map analysis for rapid injury care health system assessment in Northern Malawi. BMJ Open 2023; 13:e070900. [PMID: 37263691 DOI: 10.1136/bmjopen-2022-070900] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
Abstract
OBJECTIVES We used the process mapping method and Three Delays framework, to identify and visually represent the relationship between critical actions, decisions and barriers to access to care following injury in the Karonga health system, Northern Malawi. DESIGN Facilitated group process mapping workshops with summary process mapping synthesis. SETTING Process mapping workshops took place in 11 identified health system facilities (one per facility) providing injury care for a population in Karonga, Northern Malawi. PARTICIPANTS Fifty-four healthcare workers from various cadres took part. RESULTS An overall injury health system summary map was created using those categories of action, decision and barrier that were sometimes or frequently reported. This provided a visual summary of the process following injury within the health system. For Delay 1 (seeking care) four barriers were most commonly described (by 8 of 11 facilities) these were 'cultural norms', 'healthcare literacy', 'traditional healers' and 'police processes'. For Delay 2 (reaching care) the barrier most frequently described was 'transport'-a lack of timely affordable emergency transport (formal or informal) described by all 11 facilities. For Delay 3 (receiving quality care) the most commonly reported barrier was that of 'physical resources' (9 of 11 facilities). CONCLUSIONS We found our novel approach combining several process mapping exercises to produce a summary map to be highly suited to rapid health system assessment identifying barriers to injury care, within a Three Delays framework. We commend the approach to others wishing to conduct rapid health system assessments in similar contexts.
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Affiliation(s)
- John Whitaker
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- King's Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Abena S Amoah
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Malawi Epidemiological and Intervention Research Unit, Chilumba, Malawi
- Department of Parasitology, Leiden University Center for Infectious Diseases, Leiden University Medical Center, Leiden, The Netherlands
| | - Albert Dube
- Malawi Epidemiological and Intervention Research Unit, Chilumba, Malawi
| | - Lindani Chirwa
- Karonga District Health Office, Karonga, Malawi
- Department of Pathology, School of Medicine & Oral Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Boston Munthali
- Lilongwe Institute of Orthopaedic and Neurosurgery, Lilongwe, Malawi
- Department of Orthopaedic Surgery, Mzuzu Central Hospital, Mzuzu, Malawi
| | - Rory F Rickard
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
| | - Andrew J M Leather
- King's Centre for Global Health and Health Partnerships, School of Life Course and Population Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand Johannesburg Faculty of Health Sciences, Johannesburg, South Africa
- Department of Global Surgery, Stellenbosch University, Stellenbosch, South Africa
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Inferior Clinical Outcomes for Patients with Medicaid Insurance following Surgery for Degenerative Lumbar Spondylolisthesis: A Prospective Registry Analysis of 608 Patients. World Neurosurg 2022; 164:e1024-e1033. [DOI: 10.1016/j.wneu.2022.05.094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 05/19/2022] [Accepted: 05/20/2022] [Indexed: 11/19/2022]
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