Upload
nyayahealth
View
441
Download
3
Embed Size (px)
DESCRIPTION
Citation preview
Nyaya Health 2010
PROSPECTIVE STUDY OF SURGICAL CARE SCALE-UP IN A RURAL, RESOURCE-LIMITED
SETTING
Duncan Maru, MD, PHDMed-Peds Noon Conference, February
3, 2011
Nyaya Health 2010
Didactic Objectives
1) Think critically about the design of implementation research studies in resource-limited settings
2) Think about the process of applying to NIH during residency
3) Give Duncan feedback without making him cry
2
(*ANSWER KEY: KEEP IT SIMPLE*)
Nyaya Health 2010
The Need: Implementation Gap in Surgical Care
Two billlion people, a third of the global population live in areas with less than one operating room per 100,000 people
Approximately 11% of death and disability are attributable to surgical diseases
3
Nyaya Health 2010
The Problem: Deploying Surgical Care
WHO has produced Integrated Management for Emergency and Essential Surgical Care, and this has been utilized in several sites
But: no studies have yet prospectively studied the implementation process
4
Nyaya Health 2010
Our Proposal: A Prospective, Implementation Research Study
Prospectively study the implementation of an IMEESC-plus protocol at a district hospital in rural Nepal.
IMEESC: WHO’s current model
IMEESC-plus: includes community-based follow-up and hospital-based quality improvement methods
Study the process using mixed quantitative and qualitative methodologies at the hospital-, staff-, and patient levels
5
Nyaya Health 2010
Study Objectives
1) Rigorously study an innovative model for surgical care (IMEESC-plus)
2) Pilot an implementation research methodology that can be used in a larger multi-site study
3) Generate data for larger scale-up of surgical care worldwide
6
Nyaya Health 2010
Setting: Bayalpata Hospital
Infrastructure development and capacity building, not care provision alone Government collaboration: Government partnership contract for 5 years signed June 2009
– June 2014 Currently one of the highest levels of clinical care in the Far West (2 million people) Over 50,000 patients seen to date
Nyaya Health 2010
Setting: Bayalpata Hospital
25%
35%
19%
21%
Distance walked by patients for X-Ray services (each way)
0-3 hrs
3-6 hrs
6-10 hrs
>10 hrs
Nyaya Health 2010
Setting: Bayalpata Hospital
Nyaya Health 2010
Setting: Bayalpata Hospital
Nyaya Health 2010
Setting: Bayalpata Hospital
Nyaya Health 2010
Setting: Bayalpata Hospital
Nyaya Health 2010
Setting: Bayalpata Hospital
Nyaya Health 2010
Setting: Bayalpata Hospital
Nyaya Health 2010
Setting: Bayalpata Hospital
Nyaya Health 2010
Setting: Bayalpata Hospital
Nyaya Health 2010
Setting: Community Health Outreach Program
Nyaya Health 2010
Setting: Community Health Outreach Program
Builds off of government’s existing female community health volunteer program
Pays incentives for their work; not salary as per government mandate
Focuses on follow-up and referral
SIMPLE referral system from the hospital
Catchment of 1,357 households covered by 35 FCHVs
Managed by salaried community health advocate (approximately 9-14 FCHVs per community health advocate)
18
Nyaya Health 2010
Setting: Quality Improvement Programming
Mortality and morbidity conferences
Checklists
Data-driven plan-do- study-act strategies
19
Nyaya Health 2010
Translating Idea to Action…
20
Nyaya Health 2010
Funding Mechanisms for a career in Global Health
Organizational: serviceSocial entrepreneurship grants, foundation development
grants, individual donors
Academic: researchNIH, though only a few of its 27 centers really applySome (few) foundations like Doris Duke
Clinical work in the States
For-profit entrepreneurship
Ultimately, the bottom line is the bottom line
21
Nyaya Health 2010
NIH: A core academic funding mechanism
22
Picture from: Janet Hall, MD. “Grantwriting: Who Reviews Grants?”
Nyaya Health 2010
R21: PA10-040 Implementation Research
This Funding Opportunity Announcement (FOA) encourages investigators to submit research grant applications that will identify, develop, and refine effective and efficient methods, structures, and strategies to disseminate and implement research-tested health behavior change interventions and evidence-based prevention, early detection, diagnostic, treatment, and quality of life improvement services into public health and clinical practice settings.
23
Nyaya Health 2010
Collaborators
Center for Surgery and Public Health(R21 PI: Selwyn Rogers)Experience in surgical researchLarge network of surgeons and researchers
Nyaya Health (R21 PI: Duncan Maru) Experience in clinical epidemiologyGrassroots implementation in rural Nepal
24
Nyaya Health 2010
Challenges with NIH Mechanism for Global Health Work
BudgetingOriginal (R03) Budget: $95K over two years, primarily for local
staff salaries and co-PI travelUpon Reviewing: $241K over two years, with large sums
for indirect costs and consultant fees; switched to R21
Institutional bureaucracy to navigate
Balancing competing needs for service and research
Mentorship
25
Nyaya Health 2010
Study Objectives
1) Rigorously study an innovative model for Surgical Care (IMEESC-plus)
2) Pilot an implementation research methodology that can be used in a larger multi-site study
3) Generate data for larger scale-up of Surgical Care worldwide
26
Nyaya Health 2010
Levels of Analysis Important to Implementation Science
1) Hospital Operations
2) Human Resources
3) Patients
27
Nyaya Health 2010
Hospital-Level Outcomes
Deliverable: micro-costing for use in larger implementations and studies
Specific Aim 1: We will quantify the raw financial inputs into the system, including total costs and broken down by pharmaceutical, capital equipment, consumables, and facilities construction and maintenance. We hypothesize that the overall construction and two-year operating costs of implementing the WHO surgical model will be $0.50 per capita in the district.
28
Nyaya Health 2010
Hospital-Level Outcomes
Deliverable: supply chain utilization data for use in larger implementations and studies
Specific Aim 2: We will tabulate the pharmaceutical and consumable items utilized during the roll-out process. We will assess institutional adherence to supply chain protocols for appropriate stocking of emergency and surgical equipment and consummable goods. This will be based on the WHO Monitoring and Evaluation Tool. We hypothesize there will be a steady compliance to stocking protocols, with approximately 5-10% missing stock items on a monthly basis throughout the study period.
29
Nyaya Health 2010
Staff-level Outcomes
Deliverable: rich, qualitative descriptions of human resource management
Specific Aim 3: We will document the scale-up process qualitatively from the staff’s perspectives. This will be done through three modalities: open-ended, semi-structured interviews of staff at three-monthly periods; non-participant observation of planning meetings; and focus groups with staff at three-monthly periods. The primary domains of analysis will include: human resource management, supply chains, in-hospital work flows, and patient-level interactions.
30
Nyaya Health 2010
Staff-level Outcomes
Deliverable: evaluation during the roll-out phase with the well-tested surgical safety checklist
Specific Aim 4: We will assess staff adherence to the Surgical Safety Checklist. We hypothesize that adherence rates will improve rapidly over the first six months of implementation to achieve 95% adherence and then stabilize subsequently.
31
Nyaya Health 2010
Staff-level Outcomes
Deliverable: evaluation during the roll-out phase with the well-tested surgical safety checklist
Specific Aim 5: We will assess how rapidly hospital staff achieve 95% compliance with resuscitation protocols, as determined by a post-resuscitation evaluation form. We hypothesize that this will occur within six months of implementation.
32
Nyaya Health 2010
Patient-Level Outcomes
Deliverable: data on surgical type and volume during the roll-out process
Specific Aim 6: We will quantify the type of surgical diseases and their treatment using a simple data recording instrument. We hypothesize there that there will be a gradual expansion over time of more complex diagnoses and surgical procedures, and that this expansion will be steep over the first 6 months and hit a plateau by 18 months, and by 18 months the annual number of surgeries will approach 20 per 10,000 citizens.
33
Nyaya Health 2010
Patient-level Outcomes
Deliverable: evaluation of post-surgical discharge processes
Specific Aim 7: We will assess how rapidly improvements occur in patient follow-up one week following discharge from the hospital. Based on existing experience at the hospital, we hypothesize that 50% of patients will be brought back for a one-week follow-up visit by three months, 65% by six months, and 80% by one year.
34
Nyaya Health 2010
Patient-level Outcomes
Deliverable: describe complications data during the surgical roll-out process
Specific Aim 8: We will assess the speed by which newly implemented essential Surgical Care are able to achieve target major complication rates (<5%). We hypothesize that the time to achieve this will be within one year.
35
Nyaya Health 2010
Study Objectives
1) Rigorously study an innovative model for Surgical Care (IMEESC-plus)
2) Pilot an implementation research methodology that can be used in a larger multi-site study
3) Generate data for larger scale-up of Surgical Care worldwide
36
Nyaya Health 2010
Concluding Thoughts
Concluding Thoughts
Unmet research need in surgical service delivery
Bayalpata Hospital well-positioned (sort of) as a research site
NIH is a primary mechanism for funding this kind of research
Huge barriers remain in implementing this research
Simplicity is key
On Planners and Searchers
Nyaya Health 2010
References1. Abdullah F, Choo S, Hesse A, Abantanga F, Sory E, et al. (2010) Assessment of Surgical and Obstetrical Care at 10 District Hospitals in Ghana Using On-Site Interviews. J Surg Res. 2. Choo S, Perry H, Hesse A, Abantanga F, Sory E, et al. (2010) Assessment of capacity for surgery, obstetrics and anaesthesia in 17 Ghanaian hospitals using a WHO assessment tool. Trop Med Int Health. 3. Galukande M, von S, Wladis A, Mbembati N, de M, et al. (2010) Essential surgery at the district hospital: a retrospective descriptive analysis in three African countries. PLoS Med. 74. Kruk M, Wladis A, Mbembati N, Ndao-Brumblay S, Hsia R, et al. (2010) Human resource and funding constraints for essential surgery in district hospitals in Africa: a retrospective cross-sectional survey. PLoS Med. 75. Kushner A, Cherian M, Noel L, Spiegel D, Groth S, et al. (2010) Addressing the Millennium Development Goals from a surgical perspective: essential surgery and anesthesia in 8 low- and middle-income countries. Arch Surg. 145: 154-159.6. Contini S, Taqdeer A, Cherian M, Shokohmand A, Gosselin R, et al. (2010) Emergency and essential Surgical Care in Afghanistan: still a missing challenge. World J Surg. 34: 473-479.7. Bickler S, Spiegel D (2010) Improving surgical care in low- and middle-income countries: a pivotal role for the World Health Organization. World J Surg. 34: 386-390.8. Osen H, Chang D, Choo S, Perry H, Hesse A, et al. (2010) Validation of the World Health Organization Tool for Situational Analysis to Assess Emergency and Essential Surgical Care at District Hospitals in Ghana. World J Surg. 9. (2011/01/28) Integrated Management for Emergency and Essential Surgical Care Tool Kit. Available: http://www.who.int/surgery/publications/imeesc/en/index.html. Accessed 0/28/111.10. (2011/01/28) Monitoring and Evaluation Tool for Emergency and Essential Surgical Care. Available: http://www.who.int/surgery/publications/MonitoringEvaluationtoolwithEEE.pdf. Accessed 0/28/111.11. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AHS, et al. (2009) A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 360: 491-499.12. Luboga S, Macfarlane S, von S, Kruk M, Cherian M, et al. (2009) Increasing access to Surgical Care in sub-saharan Africa: priorities for national and international agencies recommended by the Bellagio Essential Surgery Group. PLoS Med. 613. (2011/01/28) Best Practice Protocols: Clinical Procedures Safety-- WHO Manual. Available: http://www.who.int/surgery/publications/BestPracticeProtocolsCPSafety07.pdf. Accessed 0/28/111.14. (2011/01/28) Surgical Care at the District Hospital - The WHO Manual. Available: http://www.who.int/surgery/publications/scdh_manual/en/index.html. Accessed 0/28/111.15. Schwarz D. Implementing a Hospital-Based Morbidity and Mortality Conference in Remote Rural Nepal (in preparation). 16. Surgical Care Wiki Page. Available: http://wiki.nyayahealth.org/SurgicalServices. Accessed 2/2/2011.17. X-Ray Wiki Page. Available: http:// http://wiki.nyayahealth.org/X-Ray/.18. Dindo D, Demartines N, Clavien P (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 240: 205-213.19. Data Management Wiki Page. Available: http://wiki.nyayahealth.org/DataManagement.
Nyaya Health 2010
Acknowledgements
The staff of Bayalpata Hospital & the people of Achham, Nepal
The volunteers and individual donors of Nyaya Health
Dr. Selwyn Rogers and Tess Panizales of the CSPH
The Nepali Ministry of Health & Achham District Health officials: Dr. Deepak Gaylal, Mr. Sailendra Shrestha, Mr. Jhanak Dhungana
Wizfolio and Dropbox
Institutional Supporters: Abbot Laboratories, AMD and the Open Architecture Network, America Nepal Medical Foundation (ANMF), BWH COE in Quality and Safety, Buddha Air, Cents of Relief, Child Health Foundation, CIWEC Clinic (Menlha Nursing Home), Ella Lyman Cabot Trust, EquityEditors Association, Ford Foundation, Frederick Lovejoy Foundation, Google Grants, Nepal Ministry of Health and Population (MOHP), New Aid Foundation, Partners in Health, QBC Diagnostics, Quidel Corporation, Singapore Internet Research Center, Ten Friends, The Hunger Site, The International Foundation, The Shelley and Donald Rubin Foundation, Until There's a Cure Foundation, UpToDate, William Prusoff Foundation, Yale University