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1.  Exploring sources of variability in adherence to guidelines across hospitals in low-income settings: a multi-level analysis of a cross-sectional survey of 22 hospitals 
Background
Variability in processes of care and outcomes has been reported widely in high-income settings (at geographic, hospital, physician group and individual physician levels); however, such variability and the factors driving it are rarely examined in low-income settings.
Methods
Using data from a cross-sectional survey undertaken in 22 hospitals (60 case records from each hospital) across Kenya that aimed at evaluating the quality of routine hospital services, we sought to explore variability in four binary inpatient paediatric process indicators. These included three prescribing tasks and use of one diagnostic. To examine for sources of variability, we examined intra-class correlation coefficients (ICC) and their changes using multi-level mixed models with random intercepts for hospital and clinician levels and adjusting for patient and clinician level covariates.
Results
Levels of performance varied substantially across indicators and hospitals. The absolute values for ICCs also varied markedly ranging from a maximum of 0.48 to a minimum of 0.09 across the models for HIV testing and prescription of zinc, respectively. More variation was attributable at the hospital level than clinician level after allowing for nesting of clinicians within hospitals for prescription of quinine loading dose for malaria (ICC = 0.30), prescription of zinc for diarrhoea patients (ICC = 0.11) and HIV testing for all children (ICC = 0.43). However, for prescription of correct dose of crystalline penicillin, more of the variability was explained by the clinician level (ICC = 0.21). Adjusting for clinician and patient level covariates only altered, marginally, the ICCs observed in models for the zinc prescription indicator.
Conclusions
Performance varied greatly across place and indicator. The variability that could be explained suggests interventions to improve performance might be best targeted at hospital level factors for three indicators and clinician factors for one. Our data suggest that better understanding of performance and sources of variation might help tailor improvement interventions although further data across a larger set of indicators and sites would help substantiate these findings.
doi:10.1186/s13012-015-0245-x
PMCID: PMC4416316  PMID: 25928803
Intra-class correlation; Variability; Paediatrics; Hospitals; Clinicians; Low-income settings; Multi-level models; Pneumonia; Malaria; Diarrhoea/dehydration
2.  Oral Amoxicillin versus Benzyl Penicillin for Severe Pneumonia among Kenyan Children: A Pragmatic Randomized Controlled Non-inferiority Trial 
Background
There are concerns that the evidence from studies showing non-inferiority of oral amoxicillin to benzyl penicillin for severe pneumonia may not be generalizable to high mortality settings.
Methods
An open-label multicenter randomized controlled non-inferiority trial was conducted at six Kenyan hospitals. Eligible children aged 2 – 59 months were randomized to receive amoxicillin or benzyl penicillin and followed up for the primary outcome of treatment failure at 48 hours. A non-inferiority margin of risk difference between amoxicillin and benzyl penicillin groups was pre-specified at 7%.
Results
We recruited 527 children including 302 (57.3%) with co-morbidity. Treatment failure was observed in 20/260 (7.7%)and 21/261 (8.0%) of patients in the amoxicillin and benzyl penicillin arms respectively (risk difference −0.3%, 95% confidence interval (CI) −5.0 to 4.3) in per protocol analyses. These findings were supported by the results of intention to treat analyses. Treatment failure by day 5 post-enrolment was 11.4% and 11.0% and rising to 13.5% and 16.8% by day 14 in the amoxicillin versus benzyl penicillin groups respectively. The most frequent cause of cumulative treatment failure at day 14 was clinical deterioration within 48 hours of enrolment (33/59; 55.9%). Four patients died (overall mortality 0.8%) during the study, three of whom were allocated to the benzyl penicillin group. The presence of wheeze was independently associated with less frequent treatment failure.
Conclusions
Our findings confirm non-inferiority of amoxicillin to benzyl penicillin, provide estimates of risk of treatment failure in Kenya and offer important additional evidence for policy making in sub-Saharan Africa
doi:10.1093/cid/ciu1166
PMCID: PMC4370168  PMID: 25550349
3.  Moving towards Routine Evaluation of Quality of Inpatient Pediatric Care in Kenya 
PLoS ONE  2015;10(3):e0117048.
Background
Regular assessment of quality of care allows monitoring of progress towards system goals and identifies gaps that need to be addressed to promote better outcomes. We report efforts to initiate routine assessments in a low-income country in partnership with government.
Methods
A cross-sectional survey undertaken in 22 ‘internship training’ hospitals across Kenya that examined availability of essential resources and process of care based on review of 60 case-records per site focusing on the common childhood illnesses (pneumonia, malaria, diarrhea/dehydration, malnutrition and meningitis).
Results
Availability of essential resources was 75% (45/61 items) or more in 8/22 hospitals. A total of 1298 (range 54–61) case records were reviewed. HIV testing remained suboptimal at 12% (95% CI 7–19). A routinely introduced structured pediatric admission record form improved documentation of core admission symptoms and signs (median score for signs 22/22 and 8/22 when form used and not used respectively). Correctness of penicillin and gentamicin dosing was above 85% but correctness of prescribed intravenous fluid or oral feed volumes for severe dehydration and malnutrition were 54% and 25% respectively. Introduction of Zinc for diarrhea has been relatively successful (66% cases) but use of artesunate for malaria remained rare. Exploratory analysis suggests considerable variability of the quality of care across hospitals.
Conclusion
Quality of pediatric care in Kenya has improved but can improve further. The approach to monitoring described in this survey seems feasible and provides an opportunity for routine assessments across a large number of hospitals as part of national efforts to sustain improvement. Understanding variability across hospitals may help target improvement efforts.
doi:10.1371/journal.pone.0117048
PMCID: PMC4378956  PMID: 25822492
4.  Assessment of neonatal care in clinical training facilities in Kenya 
Archives of Disease in Childhood  2014;100(1):42-47.
Objective
An audit of neonatal care services provided by clinical training centres was undertaken to identify areas requiring improvement as part of wider efforts to improve newborn survival in Kenya.
Design
Cross-sectional study using indicators based on prior work in Kenya. Statistical analyses were descriptive with adjustment for clustering of data.
Setting
Neonatal units of 22 public hospitals.
Patients
Neonates aged <7 days.
Main outcome measures
Quality of care was assessed in terms of availability of basic resources (principally equipment and drugs) and audit of case records for documentation of patient assessment and treatment at admission.
Results
All hospitals had oxygen, 19/22 had resuscitation and phototherapy equipment, but some key resources were missing—for example kangaroo care was available in 14/22. Out of 1249 records, 56.9% (95% CI 36.2% to 77.6%) had a standard neonatal admission form. A median score of 0 out of 3 for symptoms of severe illness (IQR 0–3) and a median score of 6 out of 8 for signs of severe illness (IQR 4–7) were documented. Maternal HIV status was documented in 674/1249 (54%, 95% CI 41.9% to 66.1%) cases. Drug doses exceeded recommendations by >20% in prescriptions for penicillin (11.6%, 95% CI 3.4% to 32.8%) and gentamicin (18.5%, 95% CI 13.4% to 25%), respectively.
Conclusions
Basic resources are generally available, but there are deficiencies in key areas. Poor documentation limits the use of routine data for quality improvement. Significant opportunities exist for improvement in service delivery and adherence to guidelines in hospitals providing professional training.
doi:10.1136/archdischild-2014-306423
PMCID: PMC4283661  PMID: 25138104
Neonatology; Health services research; Measurement; Evidence Based Medicine; Data Collection
5.  Oral Amoxicillin Versus Benzyl Penicillin for Severe Pneumonia Among Kenyan Children: A Pragmatic Randomized Controlled Noninferiority Trial 
Evidence demonstrating noninferiority of oral amoxicillin vs benzyl penicillin for severe childhood pneumonia is largely drawn from Asian populations where mortality is low. This study confirms noninferiority and is expected to inform policy on treatment of pneumonia in sub-Saharan Africa.
Background. There are concerns that the evidence from studies showing noninferiority of oral amoxicillin to benzyl penicillin for severe pneumonia may not be generalizable to high-mortality settings.
Methods. An open-label, multicenter, randomized controlled noninferiority trial was conducted at 6 Kenyan hospitals. Eligible children aged 2–59 months were randomized to receive amoxicillin or benzyl penicillin and followed up for the primary outcome of treatment failure at 48 hours. A noninferiority margin of risk difference between amoxicillin and benzyl penicillin groups was prespecified at 7%.
Results. We recruited 527 children, including 302 (57.3%) with comorbidity. Treatment failure was observed in 20 of 260 (7.7%) and 21 of 261 (8.0%) of patients in the amoxicillin and benzyl penicillin arms, respectively (risk difference, −0.3% [95% confidence interval, −5.0% to 4.3%]) in per-protocol analyses. These findings were supported by the results of intention-to-treat analyses. Treatment failure by day 5 postenrollment was 11.4% and 11.0% and rising to 13.5% and 16.8% by day 14 in the amoxicillin vs benzyl penicillin groups, respectively. The most frequent cause of cumulative treatment failure at day 14 was clinical deterioration within 48 hours of enrollment (33/59 [55.9%]). Four patients died (overall mortality 0.8%) during the study, 3 of whom were allocated to the benzyl penicillin group. The presence of wheeze was independently associated with less frequent treatment failure.
Conclusions. Our findings confirm noninferiority of amoxicillin to benzyl penicillin, provide estimates of risk of treatment failure in Kenya, and offer important additional evidence for policy making in sub-Saharan Africa.
Clinical Trial Registration. NCT01399723.
doi:10.1093/cid/ciu1166
PMCID: PMC4370168  PMID: 25550349
childhood pneumonia; sub-Saharan Africa; amoxicillin; treatment failure; World Health Organization
6.  Assessing the ability of health information systems in hospitals to support evidence-informed decisions in Kenya 
Global Health Action  2014;7:10.3402/gha.v7.24859.
Background
Hospital management information systems (HMIS) is a key component of national health information systems (HIS), and actions required of hospital management to support information generation in Kenya are articulated in specific policy documents. We conducted an evaluation of core functions of data generation and reporting within hospitals in Kenya to facilitate interpretation of national reports and to provide guidance on key areas requiring improvement to support data use in decision making.
Design
The survey was a cross-sectional, cluster sample study conducted in 22 hospitals in Kenya. The statistical analysis was descriptive with adjustment for clustering.
Results
Most of the HMIS departments complied with formal guidance to develop departmental plans. However, only a few (3/22) had carried out a data quality audit in the 12 months prior to the survey. On average 3% (range 1–8%) of the total hospital income was allocated to the HMIS departments. About half of the records officer positions were filled and about half (13/22) of hospitals had implemented some form of electronic health record largely focused on improving patient billing and not linked to the district HIS. Completeness of manual patient registers varied, being 90% (95% CI 80.1–99.3%), 75.8% (95% CI 68.7–82.8%), and 58% (95% CI 50.4–65.1%) in maternal child health clinic, maternity, and pediatric wards, respectively. Vital events notification rates were low with 25.7, 42.6, and 71.3% of neonatal deaths, infant deaths, and live births recorded, respectively. Routine hospital reports suggested slight over-reporting of live births and under-reporting of fresh stillbirths and neonatal deaths.
Conclusions
Study findings indicate that the HMIS does not deliver quality data. Significant constraints exist in data quality assurance, supervisory support, data infrastructure in respect to information and communications technology application, human resources, financial resources, and integration.
doi:10.3402/gha.v7.24859
PMCID: PMC4119289  PMID: 25084834
health information system; hospital management information system; data quality
7.  Explaining the uptake of paediatric guidelines in a Kenyan tertiary hospital – mixed methods research 
Background
Evidence-based standards for management of the seriously sick child have existed for decades, yet their translation in clinical practice is a challenge. The context and organization of institutions are known determinants of successful translation, however, research using adequate methodologies to explain the dynamic nature of these determinants in the quality-of-care improvement process is rarely performed.
Methods
We conducted mixed methods research in a tertiary hospital in a low-income country to explore the uptake of locally adapted paediatric guidelines. The quantitative component was an uncontrolled before and after intervention study that included an exploration of the intervention dose-effect relationship. The qualitative component was an ethnographic research based on the theoretical perspective of participatory action research. Interpretive integration was employed to derive meta-inferences that provided a more complete picture of the overall study results that reflect the complexity and the multifaceted ontology of the phenomenon studied.
Results
The improvement in health workers’ performance in relation to the intensity of the intervention was not linear and was characterized by improved and occasionally declining performance. Possible root causes of this performance variability included challenges in keeping knowledge and clinical skills updated, inadequate commitment of the staff to continued improvement, limited exposure to positive professional role models, poor teamwork, failure to maintain professional integrity and mal-adaptation to institutional pressures.
Conclusion
Implementation of best-practices is a complex process that is largely unpredictable, attributed to the complexity of contextual factors operating predominantly at professional and organizational levels. There is no simple solution to implementation of best-practices. Tackling root causes of inadequate knowledge translation in this tertiary care setting will require long-term planning, with emphasis on promotion of professional ethics and values and establishing an organizational framework that enhances positive aspects of professionalism. This study has significant implications for the quality of training in medical institutions and the development of hospital leadership.
doi:10.1186/1472-6963-14-119
PMCID: PMC3975593  PMID: 24613001
ETAT+; Ethnographic; Guidelines; Implementation; Performance; Mixed methods research; Hospital leadership; Complex adaptive system
8.  Factors influencing performance of health workers in the management of seriously sick children at a Kenyan tertiary hospital - participatory action research 
Background
Implementation of World Health Organization case management guidelines for serious childhood illnesses remains a challenge in hospitals in low-income countries. Facilitators of and barriers to implementation of locally adapted clinical practice guidelines (CPGs) have not been explored.
Methods
This ethnographic study based on the theory of participatory action research (PAR) was conducted in Kenyatta National Hospital, Kenya’s largest teaching hospital. The primary intervention consisted of dissemination of locally adapted CPGs. The PRECEDE-PROCEED health education model was used as the conceptual framework to guide and examine further reinforcement activities to improve the uptake of the CPGs. Activities focussed on introduction of routine clinical audits and tailored educational sessions. Data were collected by a participant observer who also facilitated the PAR over an eighteen-month period. Naturalistic inquiry was utilized to obtain information from all hospital staff encountered while theoretical sampling allowed in-depth exploration of emerging issues. Data were analysed using interpretive description.
Results
Relevance of the CPGs to routine work and emergence of a champion of change facilitated uptake of best-practices. Mobilization of basic resources was relatively easily undertaken while activities that required real intellectual and professional engagement of the senior staff were a challenge. Accomplishments of the PAR were largely with the passive rather than active involvement of the hospital management. Barriers to implementation of best-practices included i) mismatch between the hospital’s vision and reality, ii) poor communication, iii) lack of objective mechanisms for monitoring and evaluating quality of clinical care, iv) limited capacity for planning strategic change, v) limited management skills to introduce and manage change, vi) hierarchical relationships, and vii) inadequate adaptation of the interventions to the local context.
Conclusions
Educational interventions, often regarded as ‘quick-fixes’ to improve care in low-income countries, may be necessary but are unlikely to be sufficient to deliver improved services. We propose that an understanding of organizational issues that influence the behaviour of individual health professionals should guide and inform the implementation of best-practices.
doi:10.1186/1472-6963-14-59
PMCID: PMC3942276  PMID: 24507629
Clinical audits; Clinical practice guidelines; Continuous medical educational sessions; ETAT+; Ethnographic study; Implementation of best-practices; Interpretive description; Participatory action research; Participant observer; Performance of health workers
9.  Hospital outcomes for paediatric pneumonia and diarrhoea patients admitted in a tertiary hospital on weekdays versus weekends: a retrospective study 
BMC Pediatrics  2013;13:74.
Background
Quality of patient care in hospitals has been shown to be inconsistent during weekends and night-time hours, and is often associated with reduced patient monitoring, poor antibiotic prescription practices and poor patient outcomes. Poorer care and outcomes are commonly attributed to decreased levels of staffing, supervision and expertise and poorer access to diagnostics. However, there are few studies examining this issue in low resource settings where mortality from common childhood illnesses is high and health care systems are weak.
Methods
This study uses data from a retrospective cross-sectional study aimed at “evaluating the uptake of best practice clinical guidelines in a tertiary hospital” with a pre and post intervention approach that spanned the period 2005 to 2009. We evaluated a primary hypothesis that mortality for children with pneumonia and/or dehydration aged 2–59 months admitted on weekends differed from those admitted on weekdays. A secondary hypothesis that poor quality of care could be a mechanism for higher mortality was also explored. Logistic regression was used to examine the association between mortality and the independent predictors of mortality.
Results
Our analysis indicates that there is no difference in mortality on weekends compared to weekdays even after adjusting for the significant predictors of mortality (OR = 1.15; 95% CI 0.90 -1.45; p = 0.27). There were similarly no significant differences between weekends and weekdays for the quality of care indicators, however, there was an overall improvement in mortality and quality of care through the period of study.
Conclusion
Mortality and the quality of care does not differ by the day of admission in a Kenyan tertiary hospital, however mortality remains high suggesting that continued efforts to improve care are warranted.
doi:10.1186/1471-2431-13-74
PMCID: PMC3655904  PMID: 23663546
Children; Pneumonia; Diarrhea; Weekend versus weekday; Quality of health care
10.  Performance of Health Workers in the Management of Seriously Sick Children at a Kenyan Tertiary Hospital: Before and after a Training Intervention 
PLoS ONE  2012;7(7):e39964.
Background
Implementation of WHO case management guidelines for serious common childhood illnesses remains a challenge in hospitals in low-income countries. The impact of locally adapted clinical practice guidelines (CPGs) on the quality-of-care of patients in tertiary hospitals has rarely been evaluated.
Methods and Findings
We conducted, in Kenyatta National Hospital, an uncontrolled before and after study with an attempt to explore intervention dose-effect relationships, as CPGs were disseminated and training was progressively implemented. The emergency triage, assessment and treatment plus admission care (ETAT+) training and locally adapted CPGs targeted common, serious childhood illnesses. We compared performance in the pre-intervention (2005) and post-intervention periods (2009) using quality indicators for three diseases: pneumonia, dehydration and severe malnutrition. The indicators spanned four domains in the continuum of care namely assessment, classification, treatment, and follow-up care in the initial 48 hours of admission. In the pre-intervention period patients' care was largely inconsistent with the guidelines, with nine of the 15 key indicators having performance of below 10%. The intervention produced a marked improvement in guideline adherence with an absolute effect size of over 20% observed in seven of the 15 key indicators; three of which had an effect size of over 50%. However, for all the five indicators that required sustained team effort performance continued to be poor, at less than 10%, in the post-intervention period. Data from the five-year period (2005–09) suggest some dose dependency though the adoption rate of the best-practices varied across diseases and over time.
Conclusion
Active dissemination of locally adapted clinical guidelines for common serious childhood illnesses can achieve a significant impact on documented clinical practices, particularly for tasks that rely on competence of individual clinicians. However, more attention must be given to broader implementation strategies that also target institutional and organisational aspects of service delivery to further enhance quality-of-care.
doi:10.1371/journal.pone.0039964
PMCID: PMC3409218  PMID: 22859945
11.  Quality of hospital care for sick newborns and severely malnourished children in Kenya: A two-year descriptive study in 8 hospitals 
Background
Given the high mortality associated with neonatal illnesses and severe malnutrition and the development of packages of interventions that provide similar challenges for service delivery mechanisms we set out to explore how well such services are provided in Kenya.
Methods
As a sub-component of a larger study we evaluated care during surveys conducted in 8 rural district hospitals using convenience samples of case records. After baseline hospitals received either a full multifaceted intervention (intervention hospitals) or a partial intervention (control hospitals) aimed largely at improving inpatient paediatric care for malaria, pneumonia and diarrhea/dehydration. Additional data were collected to: i) examine the availability of routine information at baseline and their value for morbidity, mortality and quality of care reporting, and ii) compare the care received against national guidelines disseminated to all hospitals.
Results
Clinical documentation for neonatal and malnutrition admissions was often very poor at baseline with case records often entirely missing. Introducing a standard newborn admission record (NAR) form was associated with an increase in median assessment (IQR) score to 25/28 (22-27) from 2/28 (1-4) at baseline. Inadequate and incorrect prescribing of penicillin and gentamicin were common at baseline. For newborns considerable improvements in prescribing in the post baseline period were seen for penicillin but potentially serious errors persisted when prescribing gentamicin, particularly to low-birth weight newborns in the first week of life. Prescribing essential feeds appeared almost universally inadequate at baseline and showed limited improvement after guideline dissemination.
Conclusion
Routine records are inadequate to assess newborn care and thus for monitoring newborn survival interventions. Quality of documented inpatient care for neonates and severely malnourished children is poor with limited improvement after the dissemination of clinical practice guidelines. Further research evaluating approaches to improving care for these vulnerable groups is urgently needed. We also suggest pre-service training curricula should be better aligned to help improve newborn survival particularly.
doi:10.1186/1472-6963-11-307
PMCID: PMC3236590  PMID: 22078071
newborns; child malnutrition; quality of health care
12.  Adoption of recommended practices and basic technologies in a low-income setting 
Archives of Disease in Childhood  2014;99(5):452-456.
Objective
In global health considerable attention is focused on the search for innovations; however, reports tracking their adoption in routine hospital settings from low-income countries are absent.
Design and setting
We used data collected on a consistent panel of indicators during four separate cross-sectional, hospital surveys in Kenya to track changes over a period of 11 years (2002–2012).
Main outcome measures
Basic resource availability, use of diagnostics and uptake of recommended practices.
Results
There appeared little change in availability of a panel of 28 basic resources (median 71% in 2002 to 82% in 2012) although availability of specific feeds for severe malnutrition and vitamin K improved. Use of blood glucose and HIV testing increased but remained inappropriately low throughout. Commonly (malaria) and uncommonly (lumbar puncture) performed diagnostic tests frequently failed to inform practice while pulse oximetry, a simple and cheap technology, was rarely available even in 2012. However, increasing adherence to prescribing guidance occurred during a period from 2006 to 2012 in which efforts were made to disseminate guidelines.
Conclusions
Findings suggest changes in clinical practices possibly linked to dissemination of guidelines at reasonable scale. However, full availability of basic resources was not attained and major gaps likely exist between the potential and actual impacts of simple diagnostics and technologies representing problems with availability, adoption and successful utilisation. These findings are relevant to debates on scaling up in low-income settings and to those developing novel therapeutic or diagnostic interventions.
doi:10.1136/archdischild-2013-305561
PMCID: PMC3995214  PMID: 24482351
Health services research; Tropical Paediatrics

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