Suchergebnisse

A holistic theoretical model is presented which attempts to integrate various perspectives and findings in order to research questions related to the provision of high-quality, patient-sensitive, primary care. The model is divided into three broad components: the patient world, the provider world, and their interaction. "World" refers to the background, attitudes, and social support systems of each group. Following a detailed description of the paradigm and its underlying rationale, specific methodologies to better understand patient and provider satisfaction, patient compliance, and medical outcome are described. Hypotheses are proposed which are currently under investigation at a university-based municipal hospital. Initial findings and proposed strategies for later investigation are discussed, along with broader, nonmedical implications of this research.

BackgroundIn resource‐poor settings, mortality is at its highest during the first 3 months after combination antiretroviral treatment (cART) initiation. A clear predictor of mortality during this period is having a low CD4 count at the time of treatment initiation. The objective of this study was to evaluate the effect on survival and clinic retention of a nurse‐based rapid assessment clinic for high‐risk individuals initiating cART in a resource‐constrained setting.MethodsThe USAID‐AMPATH Partnership has enrolled more than 140,000 patients at 25 clinics throughout western Kenya. High Risk Express Care (HREC) provides weekly or bi‐weekly rapid contacts with nurses for individuals initiating cART with CD4 counts of ≤100 cells/mm3. All HIV‐infected individuals aged 14 years or older initiating cART with CD4 counts of ≤100 cells/mm3 were eligible for enrolment into HREC and for analysis. Adjusted hazard ratios (AHRs) control for potential confounding using propensity score methods.ResultsBetween March 2007 and March 2009, 4,958 patients initiated cART with CD4 counts of ≤100 cells/mm3. After adjusting for age, sex, CD4 count, use of cotrimoxazole, treatment for tuberculosis, travel time to clinic and type of clinic, individuals in HREC had reduced mortality (AHR: 0.59; 95% confidence interval: 0.45‐0.77), and reduced loss to follow up (AHR: 0.62; 95% CI: 0.55‐0.70) compared with individuals in routine care. Overall, patients in HREC were much more likely to be alive and in care after a median of nearly 11 months of follow up (AHR: 0.62; 95% CI: 0.57‐0.67).ConclusionsFrequent monitoring by dedicated nurses in the early months of cART can significantly reduce mortality and loss to follow up among high‐risk patients initiating treatment in resource‐constrained settings.