Improving access to quality medicines in East Africa: An independent perspective on the East African Community Medicines Regulatory Harmonization initiative

Alexander Giaquinto and co-authors discuss the East African Community's Medicines Regulatory Harmonization initiative.

Coming together to improve access to medicines: The genesis of the East African Community's Medicines Regulatory Harmonization initiative

Hiiti Sillo and colleagues reveal how the East African Community's Medicines Regulatory Harmonization initiative improves access to important medicines in Africa.

Optimizing the East African Community's Medicines Regulatory Harmonization initiative in 2020-2022: A Roadmap for the Future

Margareth Ndomondo-Sigonda outlines future challenges for the East African Medicines Regulatory Harmonization initiative.

Urban general practice and medical education: Academic outcomes from a unique urban, longitudinal integrated community-based program

BACKGROUND

In 2009, Flinders University established an urban, community-based, longitudinal integrated program providing medical students extended placements that offered continuities of patient care, clinical supervision and peer group.

OBJECTIVE

The aim of this research was to analyse academic outcomes of the new placement program.

METHODS

The results of all students undertaking Year 3 exams from 2011 to 2014 were collected and analysed. The Years 1 and 2 exam results for students in the new program were also analysed.

RESULTS

Students in the new placement program achieved significantly higher grades than those who undertook the traditional rotations program, with aver-age scores of 69.05, compared with 66.45 (P = 0.03). Analysis of average class ranking for students who undertook the new program showed a statistically significant improvement from 59th in class to 48th in class (P = 0.03).

DISCUSSION

This evaluation shows that an urban, community-based, longitudinal integrated clerkship centred in general practice provides at least academically equivalent outcomes to traditional rotations-based programs.

[General medicine in the 21st century]

General medicine is the main pivot of our healthcare system. General practitioners' tasks are numerous: front line responsibility, networking coordination, long-term patient care, community medicine and also primary care research. In the framework of general medicine that has been undergoing profound change for many years, we have chosen to develop three of these facets: general practitioners' knowledge of family, psychological, social or environmental factors and their capacity to coordinate with other health workers will help them in their primary and secondary prevention and also quaternary work by sparing patients unnecessary treatment and examinations. General medicine will increasingly become a discipline, one of which specific expertise will be to manage bio-psycho-societal complexity. Multidisciplinary action will be the rule: general practitioners will no longer be able to claim they can deal with all the curative, preventive and health education tasks. And the research in general medicine is essential because general practitioners can deal with over 80% of the health problems identified by patients and because the symptoms leading to the treatment cannot only be studied by laboratory or hospital research.

Development and implementation of a quality assurance infrastructure in a multisite home visitation program in Ohio and Kentucky

As home visitation programs go to scale, numerous challenges are faced in implementation and quality assurance. This article describes the origins and implementation of Every Child Succeeds, a multisite home visitation program in southwestern Ohio and Northern Kentucky. In order to optimize quality assurance and generate new learning for the field, a Web-based system (eECS) was designed to systematically collect and use data. Continuous quality assurance procedures derived from business and industry have been established. Findings from data collection have documented outcomes, and have identified clinical needs that potentially undermine the impact of home visitation. An augmented module approach has been used to address these needs, and a program to treat maternal depression is described as an example of this approach. Challenges encountered are also discussed.

The development and evaluation of community health competencies for family medicine

BACKGROUND

There is an increasing emphasis on teaching community-responsive care and population health in medical education. This focus requires a multidimensional perspective on community health that examines the determinants, ranges, and variations of health status and disease in the community as a whole.

DESCRIPTION

The Department of Family and Community Medicine at the Medical College of Wisconsin sought to strengthen the community health curriculum in its residency programs by developing a core set of competencies in community health as well as a service-learning model to teach residents about community needs and strengths.

EVALUATION

A common core curriculum was developed and evaluated based on these competencies.

CONCLUSION

Residents who have mastered these competencies will be capable of functioning more effectively as community-responsive physicians.

Brief hospital quality improvement program: preventing venous thromboembolism

Venous thromboembolism (VTE) is a frequent but potentially preventable complication in the hospitalized patient. Solid medical evidence exists about pharmacological and other techniques of effective prevention. As part of a University Hospital quality improvement (QI) program, the Department of Familyand Community Medicine (FCM) increased the rate of prevention from 25 percent to more than 90 percent of eligible patients in just eight months. This overview describes the steps taken in this project to achieve rapid results using accepted QI methodology to reduce VTE.

Empirical evidence for symbiotic medical education: a comparative analysis of community and tertiary-based programmes

BACKGROUND

Flinders University has developed the Parallel Rural Community Curriculum (PRCC), a full year clinical curriculum based in rural general practice in South Australia. The examination performance of students on this course has been shown to be higher than that of their tertiary hospital-based peers.

AIM

To compare the learning experiences of students in the community-based programme with those of students in the tertiary hospital in order to explain these improved academic outcomes.

METHOD

A case study was undertaken, using an interpretivist perspective, with 3 structured interviews carried out over 2 academic years with each of 6 students from the community-based programme and 16 students from the tertiary hospital. The taped interviews were transcribed and analysed thematically using NUD*IST software.

RESULTS

The community-based programme was successful in immersing the students in the clinical environment in a meaningful way. Four key themes were found in the data. These represented clear differences between the experiences of the community-based and hospital-based students. These differences involved: the value that students perceived they were given by supervising doctors and their patients; the extent to which the student's presence realised a synergy between the work of the university and the health service; opportunities for students to meet the aspirations of both the community and government policy, and opportunities for students to learn how professional expectations can mesh with their own personal values.

CONCLUSION

This study has provided empirical evidence for the importance of the concept of symbiosis in understanding quality in medical education.

Assessing the effects of training on knowledge and skills of health personnel: a case study from the family health project in Sindh, Pakistan

BACKGROUND

The Family Health Project (FHP) was implemented in the province of Sindh during 1992-99 with the assistance of the World Bank. The project was designed to bring substantial changes in health care system for achieving improvement in the health status by strengthening the quality and integration of primary health care services. One of the major components of the project was to develop the institutional capacity of Ministry of Health in Sindh. This is a comparative analysis to assess the knowledge and skills of health care providers in Area Focus Approach (AFA) health facilities with the ones in non-AFA health care facilities.

METHODS

In order to obtain a representative sample, 8 districts were selected which included, Larkana, Khairpur, Nawabshah, Dadu, Tharparkar, Thatta, Karachi South, and Karachi West. A structured questionnaire was designed with various sections to assess the knowledge and skills of various cadres of health facility staff.

RESULTS

This comparative assessment has come up with some interesting results; there is a difference between the scores of knowledge and skills between AFA and non-AFA health care providers. This assessment identified some important methodological issues such as the use of base-line information for comparing the results and the selection of a comparable study population for controlling the confounding factors.

CONCLUSIONS

These findings can be used as important lessons learned for producing better results of any post training assessment intervention.

Recognizing the value of community involvement by AHC faculty: a case study

Physicians seek connections to their communities. Some health care and academic leaders believe that facilitating the creation of more such community connections is one way to reverse the trend of waning social and political legitimacy for the U.S. medical profession. For academic health centers (AHCs), such connections can maintain local and state support crucial to their long-term success. Multiple barriers exist to such involvement, especially for physicians in AHCs, where work done beyond direct patient care, administration, and research rarely contributes to the tenure and promotion process. The authors present a case study to show how one department in an AHC, beginning in the late 1990s, has been overcoming these barriers to incorporate the scholarship of community engagement into its mission and structure. The case study incorporates theoretical underpinnings to crystallize the following lessons that the department has learned so far: (1) If academic departments wish community service to be a central part of their mission, they need ways to institutionalize community engagement within organizational structures. (2) Community engagement can be scholarly. (3) If faculty members are to be recognized for their service activities, measures are necessary to determine what constitutes "excellence" and "scholarship" in community service. (4) Scholarship of community engagement goes beyond performing service activities in the community.

Community-engaged scholarship: is faculty work in communities a true academic enterprise?

Since Ernest Boyer's landmark 1990 report, Scholarship Reconsidered: Priorities of the Professoriate, leaders in higher education, including academic medicine, have advocated that faculty members apply their expertise in new and creative ways in partnership with communities. Such community engagement can take many forms, including community-based teaching, research, clinical care, and service. There continues to be a gap, however, between the rhetoric of this idea and the reality of how promotion and tenure actually work in health professions schools. The Commission on Community-Engaged Scholarship in the Health Professions was established in October 2003 with funding from the W.K. Kellogg Foundation to take a leadership role in creating a more supportive culture and reward system for community-engaged faculty in the nation's health professions schools. The authors prepared this article to inform the commission's deliberations and to stimulate discussion among educators in the health professions. The authors define the work that faculty engage in with communities, consider whether all work by faculty in community-based settings is actually scholarship, and propose a framework for documenting and assessing community-engaged scholarship for promotion and tenure decisions. They conclude with recommendations for change in academic health centers and health professions schools.

Detection and management of falls and instability in vulnerable elders by community physicians

OBJECTIVES

To investigate quality of care for falls and instability provided to vulnerable elders.

DESIGN

Six process of care quality indicators (QIs) for falls and instability were developed and applied to community-living persons aged 65 and older who were at increased risk of death or decline. QIs were implemented using medical records and patient interviews.

SETTING

Northeastern and southwestern United States.

PARTICIPANTS

Three hundred seventy-two vulnerable elders enrolled in two senior managed care plans.

MEASUREMENTS

Percentage of QIs satisfied concerning falls or mobility disorders.

RESULTS

Of the 372 consenting vulnerable elders with complete medical records, 57 had documentation of 69 episodes of two or more falls or fall with injury during the 13-month study period (14% of patients fell per year, 18% incidence). Double this frequency was reported at interview. An additional 22 patients had documented mobility problems. Clinical history of fall circumstances, comorbidity, medications, and mobility was documented from 47% of fallers and two or more of these four elements from 85%. Documented physical examination was less complete, with only 6% of fallers examined for orthostatic blood pressure, 7% for gait or balance, 25% for vision, and 28% for neurological findings. The evaluation led to specific recommendations in only 26% of cases, but when present they usually led to appropriate treatment modalities. Mobility problems without falls were evaluated with gait or balance examination in 23% of cases and neurological examination in 55%.

CONCLUSION

Community physicians appear to underdetect falls and gait disorders. Detected falls often receive inadequate evaluation, leading to a paucity of recommendations and treatments. Adhering to guidelines may improve outcomes in community-dwelling older adults.

Can randomized trial outcomes for carotid endarterectomy be achieved in community-wide practice?

The benefit of carotid endarterectomy (CEA) is dependent upon achieving procedural outcomes comparable to those observed in randomized trials. We have extensively examined outcomes of the procedure in the community with a complete medical record (hospital chart) review of over 20,000 Medicare patients undergoing CEA in 10 states. In patients with comparable indications, overall risk of stroke or death of 6.9% in our Medicare studies was comparable to the 6.5% combined event rate in the North American Symptomatic Carotid Endarterectomy Trial. In asymptomatic patients, however, the overall Medicare study result of 3.8% was inferior to the benchmark perioperative combined event rate of 1.5% achieved in the Asymptomatic Carotid Atherosclerosis Study. Our data demonstrated that the randomized trial benchmarks could be achieved or even exceeded at a statewide level. Our studies also documented that evidence-based processes that can reduce perioperative stroke and death (eg, perioperative antiplatelet therapy, patching) are underutilized in the community. Overall process and outcomes assessment show considerable room for improvement. All surgeons performing CEA should use a system-based approach to ensure that all evidence-based processes are employed for patients undergoing CEA and should use indication stratification to document their own outcomes for the procedure.

The Milwaukee General Assistance Medical Program: patient perspectives on primary care in an urban safety net

PURPOSE

The General Assistance Medical Program (GAMP) is a managed care model that provides a network of services through community-based clinics and area hospitals. An evaluation of the program included patient focus groups to determine the effectiveness of this safety net.

METHODS

Focus groups were conducted with patients at various hospital and community-based clinics. Researchers identified patterns and themes that emerged from the data.

RESULTS

The focus groups had the following themes: (1) eligibility and enrollment policies, (2) patient advocacy, (3) primary care access, and (4) patient recommendations for improving GAMP.

DISCUSSION

Patient feedback allowed for several improvements in the GAMP system, including an overview seminar and health education materials for new enrollees. Future research could include studying similar safety nets and public insurance programs to compare to GAMP. GAMP still faces many challenges as the "safety net" providing care to these populations in Milwaukee.

Introducing practice-based learning and improvement ACGME core competencies into a family medicine residency curriculum

BACKGROUND

The Accreditation Council for Graduate Medical Education (ACGME) recommends integrating improvement activities into residency training. A curricular change was designed at the Department of Family and Community Medicine, University of Louisville, to address selected ACGME competencies by incorporating practice-based improvement activities into the routine clinical work of family medicine residents.

METHODS

Teams of residents, faculty, and office staff completed clinical improvement projects at three ambulatory care training sites. Residents were given academic credit for participation in team meetings. After 6 months, residents presented results to faculty, medical students, other residents, and staff from all three training sites. Residents, staff, and faculty were recognized for their participation.

PROGRAM EVALUATION

Resident teams demonstrated ACGME competencies in practice-based improvement: Chart audits indicated improvement in clinical projects; quality improvement tools demonstrated analysis of root causes and understanding of the process; plan-do-study-act cycle worksheets demonstrated the change process.

CONCLUSIONS

Improvement activities that affect patient care and demonstrate selected ACGME competencies can be successfully incorporated into the daily work of family medicine residents.

Public health physicians' knowledge of core skills and current policy: clinical audit by questionnaire

BACKGROUND

The aim of this study was to facilitate the assessment of the knowledge of general public health physicians on a range of topics relating to everyday areas of work and core skills, and to encourage learning in the process, by means of an educational clinical audit exercise.

METHODS

A group of experts in different aspects of public health were asked to contribute multiple-choice questions. These were developed into a questionnaire that could be marked by computer. The questionnaire was circulated to all members of the Faculty registered for Continuing Professional Development (CPD) and to specialist registrar members, but participation was voluntary. The experts marked answers according to a marking scheme against model answers agreed.

RESULTS

A total of 499 public health doctors returned answer sheets. There was no 'pass mark' as this was a learning exercise, not an examination. However, although the negative marking system meant that the possible range of scores was -100 per cent to 100 per cent, no one had a negative score. The median uncorrected result was 44 out of 80. Questions on communicable disease and critical appraisal had the highest scores, and one on Primary Care Trusts the lowest. Participants thought the most interesting questions were those on epidemiology and evidence-based medicine, whereas the most unpopular was on Personal Medical Services pilots. Most comments were favourable to the approach but several commented that the whole exercise was too general and questions outside their current area of specialization were irrelevant.

CONCLUSION

The general public health physicians who took part in this audit appeared to be mainly competent in their knowledge of core skills and up to date with current health policy issues. However, the audit raises a debate about what 'core' knowledge is required in the post-training period. The place of UK-wide CPD initiatives over national or regional, or local approaches needs consideration, as do potential regional or national variations in CPD. This will receive further impetus because of revalidation and the need to demonstrate valid CPD activities in public health medicine.

Antimicrobial resistance: a plan of action for community practice

Antibiotic resistance was once confined primarily to hospitals but is becoming increasingly prevalent in family practice settings, making daily therapeutic decisions more challenging. Recent reports of pediatric deaths and illnesses in communities in the United States have raised concerns about the implications and future of antibiotic resistance. Because 20 percent to 50 percent of antibiotic prescriptions in community settings are believed to be unnecessary, primary care physicians must adjust their prescribing behaviors to ensure that the crisis does not worsen. Clinicians should not accommodate patient demands for unnecessary antibiotics and should take steps to educate patients about the prudent use of these drugs. Prescriptions for targeted-spectrum antibiotics, when appropriate, can help preserve the normal susceptible flora. Antimicrobials intended for the treatment of bacterial infections should not be used to manage viral illnesses. Local resistance trends may be used to guide prescribing decisions.

[What lines of action should the Valencia Society of Family and Community Medicine adopt over the next 4 years?]

OBJECTIVE

To identify the areas of activity in which the Valencia Society of Family and Community Medicine (SVMFyC) should become involved over the next four years.

DESIGN

Qualitative research.Setting. SVMFyC members.

PATIENTS AND OTHER PARTICIPANTS

27 experts belonging to the SVMFyC took part.

INTERVENTIONS

Qualitative consensus-seeking techniques. Reliability and validity of the technique were ensured through triangulation and the selection of experts from among the different professional groups within the SVMFyC.

MEASUREMENTS AND MAIN RESULTS

To determine the recommended lines of action, productivity, spontaneous representativity, intensity of recommendation and degree of agreement were analysed. The priority lines recommended were: defending the MIR path, proposing reforms in undergraduate study plans, watching over the transparency of job selection procedures and the annual OPE selection, promoting the professional degree course, creation of posts for teachers in family and community medicine, defining the size of the population registered with a doctor, proposing an incentives list and studying alternatives to uniform salaries in the form of target-linked remuneration.

CONCLUSIONS

The lines of action recommended by the experts were established.

Managing the 'fit' of information and communication technology in community health: a framework for decision making

The 'fit' of information and communication technologies (ICT) in community health is important in meeting the needs of patients, carers, staff and organizations in the delivery of services. A good fit leads to greater efficiencies and effectiveness in ICT use. A multi-step research project was conducted to look not only at the role of ICT but at how to manage ICT and make a good ICT fit to enhance community health services. Telehealth was identified as the application of ICT to enhance population health, health promotion and health-service delivery. A participatory process was identified as critical to determining needs and potential uses as well as to the successful design and implementation of ICT in health. There was additional value in ensuring a diversity of desired outcomes which balance costs and benefits while fostering capacity and technical sustainability.

Measuring community-oriented attitudes towards medical practice

BACKGROUND

The measurement of attitude and attitudinal changes regarding community-oriented primary care (COPC) and the community-oriented principles of family medicine from the College of Family Physicians of Canada was a key component of this study involving family medicine residents. The Department of Family and Community Medicine at the Toronto Hospital initiated a new COPC curriculum in July 1997 for its first-year residents which was designed to teach the principles of family medicine which are community oriented.

OBJECTIVE

This study was developed to provide an analysis and summary of the attitude and attitudinal changes of residents exposed to the programme and those of two cohort groups who were not exposed.

METHODS

A quasi-experimental design was used. A 20-item questionnaire was administered pre- and post-intervention. Qualitative data were also collected from focus group sessions with the residents exposed to the programme.

RESULTS

The questionnaire was found to have good reliability, with an alpha coefficient of 0.8. No significant differences were observed between the study and control groups pre- and post-intervention. Within the study group, two items from the questionnaire yielded significant differences (P < 0.05). These items dealt with lack of funding and impracticality issues of applying COPC in medical practice. They were also the prevalent themes generated from the focus group session analysis.

CONCLUSIONS

The qualitative data corroborated the findings of the survey. These findings have helped in the evolution of the curriculum. Longitudinal studies to measure attitudes and the practice of COPC and community-oriented principles of family medicine after residency are recommended.

Antibacterial use in community practice: assessing quantity, indications and appropriateness, and relationship to the development of antibacterial resistance

Most use of antibacterials occurs in community practice; however, despite the widespread belief of inappropriate use and the resultant increase in antibacterial resistance, little data exist describing antibacterial use in this setting. A MEDLINE search of English-language articles was conducted for epidemiological studies assessing quantity, indication and appropriateness of antibacterial use in community practice. A 1983 study of international antibacterial use described considerable disparities in quantity of use between countries. Subsequent longitudinal studies from the US, Canada, Australia and the UK described changing patterns of antibacterial use. No increase in the total rate of antibacterial use was reported by any of the 4 countries; however, all countries reported increased use of newer and/or broad-spectrum agents (e.g. fluoroquinolones, amoxicillin-clavulanic acid, cephalosporins and new macrolides] coupled with decreased use of older and/or narrow-spectrum agents [e.g. phenoxymethylpenicillin (penicillin V), erythromycin, ampicillin and tetracycline). Most (approximately three-quarters) use of antibacterials was in the treatment of respiratory tract infections. Prescribing rates for respiratory tract infections of presumed viral aetiology (e.g. the common cold) ranged from 17 to 60% in the UK and US, respectively. Among indications for which antibacterials were indicated, the appropriateness of antibacterial use received little study. Correspondingly, the rates of antibacterial resistance among common respiratory pathogens (Streptococcus pneumoniae and Haemophilus influenzae) have increased significantly in the past decade, although disparities exist between countries. Antibacterial use is considered a major factor in the development of antibacterial resistance, although the relationship between community antibacterial use and resistance has been poorly described. Further study of antibacterial usage patterns and associated resistance patterns is fundamental to the development of methods to reduce unnecessary and inappropriate use, thereby slowing the development of antibacterial resistance in the community.

Practice guidelines for community-based parenteral anti-infective therapy. ISDA Practice Guidelines Committee

This is the fourth in a series of practice guidelines commissioned by the Infectious Diseases Society of America through its Practice Guidelines Committee. The purpose of this guideline is to provide assistance to clinicians when making decisions on when and how to best administer parenteral antimicrobial therapy. The targeted providers are internists, pediatricians, family practitioners, and other providers of outpatient antiinfective therapy. Criteria for selecting the appropriate patients and settings to deliver therapy in the community are described. Panel members represented experts in adult and pediatric infectious diseases. The guidelines are evidence-based. A standard ranking system is used for the strength of the recommendations and the quality of the evidence cited in the literature reviewed. The document has been subjected to external review by peer reviewers as well as by the Practice Guidelines Committee and was approved by the IDSA Council. An executive summary and tables highlight the major recommendations.

Australian Community Health Association Practice Standards and their application for primary health care in Papua New Guinea

This paper describes the Australian Community Health Association Practice Standards (CHASP) and their application in the CHASP review process as a model that could be emulated to improve the quality of primary health care delivery in Papua New Guinea. The characteristics which could be beneficially emulated in Papua New Guinea are the comprehensive nature of the standards and their wide applicability, the balance contained in their development and application between the inputs of technical expertise and local involvement, and the structured nature of the CHASP review process itself. A model is proposed of how the CHASP standards and review process could be fruitfully used in Papua New Guinea to improve the quality of rural health care delivery.

Quality control and the community physician in England: an American perspective

The quality of health care is becoming an issue of increasing public importance in both England and the United States. As the government role in providing health care grows and citizen demands increase, the effective and efficient use of health care resources and their equitable distribution become crucial. Although government responsibilities, particulary for health care, differ in both countries, as do traditions of quality control, cross-national comparisons are nonetheless useful. An examination of the role of the new English community medicine specialist and his potential for quality control may indicate what tools and powers should be introduced into a health planning and quality control system in the United State. The study concludes that at the district level of the National Health Service, where the basic planning, monitoring, and evaluation of services are to take place, the District Community Physician has very limited tools to carry out his quality control function. Although he has formal position in the unified decision-making structure, it is unlikely that he will be able to effect any substantial reallocation of resource without the voluntary support and copperation of the consultants, general practitioners, and other health providers.