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Quality of hospital care for children in Kazakhstan, Republic of Moldova, and Russia: systematic observational assessment
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Quality of hospital care for children in Kazakhstan, Republic of Moldova, and Russia: systematic observational assessment Trevor Duke, Elena Keshishiyan, Aigul Kuttumuratova, Mikael Ostergren, Irina Ryumina, Ekaterina Stasii, Martin W Weber, Giorgio Tamburlini
Summary Background Major concerns about the quality of basic hospital care for children have been raised in developing countries, but no formal assessment applying international standards has been done in the Commonwealth of Independent States. Methods We assessed 17 hospitals in Kazakhstan, the Republic of Moldova, and the Russian Federation with a generic WHO hospital assessment framework adapted for use in the WHO European region. WHO management guidelines for paediatric care in peripheral hospitals were used as standards. Findings Hospital access for children was generally good. Good health networks existed, and skilled and committed doctors cared for children. Case-fatality rates were low. However, unnecessary and lengthy hospital stays were common, and most children received excessive and ineffective treatment (in one country median number of drugs prescribed concurrently was 5, IQR 2–6). Several conditions were systematically overdiagnosed, especially neurological disease, or overinvestigated, such as acute diarrhoea. Reasons for these practices included absence of clear evidence-based clinical guidelines, regulations tying duration of admission to financial reimbursement, generalisation of disease-control methods from rare problems to common illnesses, and regulations maintaining financial and professional status of some subspecialties. Many disincentives to efficient practice existed. Interpretation To improve quality of hospital care for children in the Commonwealth of Independent States, several issues must be addressed, including: adoption of international guidelines for inpatient management; complementary guidelines for outpatient management; reforms to health regulations governing admission and discharge criteria; improvement of quality of training, availability of medical information, and systems to promote and certify quality of care.
Introduction The Millennium Development Goals call for a reduction in child mortality by two thirds between 1990 and 2015, along with other targets that would result in a better environment for healthy development of children. The quality of care provided in health facilities, and the nature of interactions between health systems, families, and communities have major consequences for child health, human rights, poverty alleviation, and development.1 In the Commonwealth of Independent States (CIS), the former Soviet Union, the economic and social consequences of transition have placed large and complex burdens on the health sector.2 This problem has been partly due to reduced health budgets, increased disease burdens, obsolete infrastructure and equipment, and persistent exclusion from sources of evidence-based medical practice and training. Between 1990 and 2004, some countries in the CIS, including the Russian Federation and the Republic of Moldova, have seen overall reductions in child mortality rates, but other countries, such as Kazakhstan, have experienced a worsening of child survival, according to global estimates.3 During the 1990s, attempts to improve hospital care for children in the CIS predominantly focused on perinatal care, with little attention being paid to hospital www.thelancet.com Vol 367 March 18, 2006
care for children outside the newborn period. In many countries throughout the world over recent years, data on hospital care have been collected, but none was available from the European region. In February, 2002, at a technical consultation held at the WHO Regional Office for Europe in Copenhagen, representatives of CIS recommended that a regionwide assessment be undertaken to identify the major problems related to paediatric hospital care, to make recommendations for improvement, and to ensure that health reforms appropriately addressed key issues in child health.4 We describe a study that was done in three CIS countries in response to this recommendation.
Lancet 2006; 367: 919–25 Centre for International Child Health, Department of Paediatrics, University of Melbourne, Royal Children’s Hospital, Parkville, Victoria, 3052, Australia (T Duke MD); Moscow Scientific Research Institute of Paediatrics and Paediatric Surgery, Moscow, Russian Federation (E Keshishiyan MD); WHO, Country Sub-Office, Almaty, Kazakhstan (A Kuttumuratova PhD); WHO, Regional Office for Europe, Copenhagen, Denmark (M Ostergren MD); WHO, Office for the Russian Federation, Moscow, Russian Federation (I Ryumina MD); State Medical and Pharmaceutical University of Republic of Moldova, Kishinau, Republic of Moldova (E Stasii MD); WHO, Geneva, Switzerland (M W Weber MD); and Institute for Child Health, IRCCS Burlo Garafolo, Trieste, Italy (G Tamburlini MD) Correspondence to: Dr Trevor Duke [email protected]
Methods Study population The WHO Regional Office for Europe selected Kazakhstan, Republic of Moldova, and the Russian Federation as countries for the assessment of hospital quality of care. Health authorities were approached for their agreement, and to jointly identify suitable oblasts (provinces) to participate. In Kazakhstan and the Russian Federation, the Almaty and Ryazan oblasts, respectively, were selected. The whole of the Republic of Moldova was included, because of the smaller size of this country compared with the other two. 919
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Procedures We used a questionnaire and direct assessment framework, originally developed at WHO Headquarters in Geneva and modified by the WHO European Regional Office.5 Clinical and management standards used in the assessment framework were from the Russian translation of the WHO guidelines for care of children in first-level referral hospitals, and criteria for referral based on the WHO/UNICEF Integrated Management of Childhood Illness (IMCI) strategy.6 IMCI has been adopted in the CIS, but implementation has been largely confined to pilot regions. In April, 2002, questionnaires were distributed to all hospitals offering paediatric care in the three assessment areas: to 20 hospitals in the Almaty Oblast in Kazakhstan, 32 hospitals in the Ryazan Oblast in Russia, and to all 25 hospitals in Moldova. This questionnaire requested data relating to bed numbers, staff resources, equipment, number of admissions per year, outpatients and deliveries, common causes of admission and number, causes of deaths, availability of drugs and equipment, and procedures commonly done. In May and June, 2002, direct assessment was undertaken by three international consultants (TD, GT, MW) in collaboration with senior professionals from the CIS countries. 17 hospitals were assessed; seven in Almaty Oblast, five in the Republic of Moldova, and five in Ryazan Oblast. Hospitals were chosen as being representative of the three countries: a combination of rayon (district) hospitals, remote rural hospitals, and oblast children’s hospitals. Hospitals were selected to be representative of all levels of hospital care, from the most peripheral facilities to those closer to or within major centres. The direct assessment questionnaire was based on a generic tool developed by WHO headquarters, and adapted to fit the needs of the region by WHO Regional Office for Europe.5 We recorded information on key areas of care, via the gathering of demographic data, visits to all relevant wards and services where children were managed (maternity, neonatal ward, admission department, paediatric ward, surgical ward, intensive care); interviews with staff and mothers; and direct observation of patients. Attention was paid to all phases of care, from triage and admission, including initial assessment, laboratory investigations, monitoring and treatment, to the time of discharge and follow-up. Further information was gathered from case records, hospital admission books and mortality registers, laboratories, and emergency transport services. We sought opinions from clinical and administrative staff as to the major problems in paediatric care. We also collected information about local treatment protocols, investigations undertaken, regulations governing treatment, length-of-stay, available resources, funding, equipment, and drug supplies. Treatment protocols were translated and assessed for their internal 920
consistency and consistency with international standards, including the WHO clinical guidelines. Using the assessment questionnaire, key areas of health-service structure and health-care delivery were assessed as being satisfactory, needing some improvement, or needing substantial improvement. Consent for hospitals to take part in the assessment was obtained from the national and provincial health authorities, and a provincial health officer took part in the visit. Hospital administrators had received previous communication about the assessment from the health authorities. At the beginning of each site visit, the hospital staff were informed of the project and their agreement was obtained. A debriefing occurred with the hospital director and some of the health staff at the end of the visit in each health facility, with presentation and discussion of the main findings. Meetings were also held with national authorities, professionals involved in paediatric education and training, and international agencies active in the health sector at the completion of the assessment, which took 2 weeks in each country.
Role of the funding source WHO staff participated in study design, data collection, data analysis, and writing of the report. The corresponding author had full access to the data in the study and had final responsibility for the decision to submit for publication after approval from WHO.
Results The key results of the questionnaire are presented in table 1. Case fatality rates were low. Electricity was available in all hospitals; however, in several there was no back-up power supply and electricity supplies were intermittent. Cold running water was also generally available, but there were frequent interruptions to water supply in a few, mostly rural hospitals. Heating was reported to be a problem in some small hospitals during winter. The most peripheral hospitals had between four and 25 beds for children. Most rayon (district) hospitals had 40–80 beds. Several small rural hospitals did not have a children’s ward but nursed children in adults’ wards. Table 2 summarises the assessment of key areas of health service structure and health-care delivery in the three countries. The networks of health facilities, primary care, emergency transport, record keeping, and communication in each region were of an adequate standard. Immunisation services were well organised and achieved high levels of coverage, although opportunistic immunisation in hospitals rarely occurred because this task is seen to be the responsibility of the primary health system. IMCI has been introduced into a few pilot areas, but had not been undertaken on a national scale in any of the three countries. Hospital buildings were large and spacious, but yearly admission numbers showed that they would rarely be www.thelancet.com Vol 367 March 18, 2006
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Kazakhstan Number of hospitals Number of rayon (district) hospitals Number of oblast paediatric hospitals Other hospital types
Republic of Moldova
20 16 2 2 infectious diseases
Beds (median [IQR]) 22 (20–30) Admissions (total number in hospitals surveyed in 2002) 17 291 Yearly admissions per hospital (median [IQR]) 735 (403–1061) Case fatality rate (median [range]) 1·2% (0–5·6) Neonatal case fatality rate (median [range]) 2·5% (0–50) Electricity reliably available* 19† Running water available* 20 (100%)§ Oxygen available (always or often)* 19 (95%) Suction equipment available (always or often)* 18 (90%) Nebulisers or spacer devices for asthma treatment available (always or often)* 11 (55%) Neonatal resuscitation equipment available (always or often)* 11 (55%) Phototherapy available (always or often)* 7 (35%)
Russian Federation
25 18 6 1 university paediatric 24 (12–60) 56 260 604 (460–1468) 0·4% (0–2·6) 2·2% (0–8) 25 25 (100%) 24 (96%) 20 (80%) 10 (40%) 21 (84%) 20 (80%)
32 25 3 2 neurological rehabilitation 2 infectious diseases 15 (10–30) 30 370 454 (287–876) 0·25% (0–0·69) 2·3% (0–12) 30‡ 32 (100%) 23 (72%) 21 (66%) 6 (19%) 19 (59%) 9 (28%)
*Values are number of hospitals with this characteristic. †1 hospital reported having unreliable supply and no back-up generator. ‡2 hospitals reported occasional problems with electricity supplies. §frequent interruptions to water supply in rural hospitals.
Table 1: Characteristics of hospitals
close to capacity. Most buildings and basic infrastructure (water supply and toilet facilities, sterilisation, oxygen supply systems, kitchens and refrigeration, etc) had not received any maintenance over the past one or two decades, and many were in need of repairs. Paediatric doctors had a high level of commitment and dedication to their patients, and had a great deal of pride in their work and their profession. The number of doctors and nurses in children’s wards was usually sufficient, varying from one to two in the smallest rural hospitals to four to ten in larger rayon or oblast hospitals. Most doctors were specialised in paediatrics, which, in Soviet times required a 4-year undergraduate course. This requirement has now changed in many CIS countries, such that paediatrics is now a postgraduate specialty. Paediatricians were technically skilled in commonly needed practical procedures, although understanding of appropriate indications for procedures was often deficient. In almost all hospitals, most diagnostic equipment was outdated. A lot of equipment was poorly functioning, inefficient (especially oxygen delivery equipment), or unsafe (particularly radiograph equipment). Other equipment that is unknown or rarely used in western medicine, such as “electrotherapy” (generating warmth through a car battery and electrodes directly applied to the body) and “fluorescent light” therapy for tonsillitis, was used regularly in some hospitals. Several welllooking children were staying in hospital for longer than a week to receive fluorescent light therapy for tonsillitis. For some modern equipment that had been supplied by external donors, hospitals could not afford the cost of consumables, such as reagents for electrolyte analysers, so the machines were dormant. Basic laboratory investigations (haemoglobin, blood film, and microscopy of urine, cerebrospinal fluid, and www.thelancet.com Vol 367 March 18, 2006
other biological fluids) were available in most hospitals. Tertiary care centres had a higher laboratory capacity, where HIV testing was also available. Stool culture was frequently done in all hospitals, with negative results (from both the child with diarrhoea and his or her mother) a pre-requisite for hospital discharge. Blood or cerebrospinal fluid culture was done at infectious disease hospitals, but not at rayon hospitals. In general, intramuscular or intravenous administration of drugs was the predominant route of administration, even if oral preparations were available (such as penicillins) and even for mild cases, such as mild pneumonia or bronchitis. Few hospitals had an antibiotic against staphylococcal disease. Vitamin A and vitamin K were not always available to treat measles or as prophylaxis against haemorrhagic disease of the newborn baby, while group B vitamins were always available and frequently No significant deficiencies Hospital network Availability of beds Physical facilities Financial accessibility Health personnel Equipment Drugs and supplies Triage and emergency care Diagnosis Treatment Supportive and intensive care Monitoring Clinical guidelines Mother-and-child-friendly services
K, RM, RF K, RM, RF RF RF
RF
RM, RF
Need for some improvement
K, RM K, RM K, RM, RF K, RM, RF K, RM, RF K, RM K, RM, RF*
Need for substantial improvement
K, RM, RF† K, RM, RF
K, RM, RF K K, RM, RF K, RM, RF
K=Kazakhstan. RM=Republic of Moldova. RF=Russian Federation. *General. †Neurological and some other specific
conditions.
Table 2: Results of observational assessment
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used for a wide variety of illnesses. With the exception of BCG and hepatitis B vaccines, which are administered at birth, vaccines were usually not available in hospitals, since immunisation was seen as a service provided by primary health-care facilities. Therefore, despite very large numbers of relatively well children filling the hospitals, examples of opportunistic immunisation were uncommon. Respiratory infections, perinatal conditions, trauma, other infectious diseases, and neurological disorders were the most common reasons for hospital admissions and deaths in all three countries. Pneumonia and other acute respiratory infection were the most important causes of death among infants outside the neonatal period, and trauma was the most common cause of death in children older than 1 year. Children were referred to hospital by family doctors, the emergency services, or specialists from the polyclinics, or were brought directly to hospital by carers. No hospital had systems for triage, but in view of small case numbers this was not seen as a problem. Up to 90% of children presenting or referred to hospitals were admitted; admission thresholds or criteria were rarely specified.
8-month-old boy had three episodes of fever and convulsions over 5 months, diagnosed as “intracranial hypertension syndrome”, “epilepsy”, and “chronic neurological condition”.Treated with sodium valproate. Seizures were under good control with this treatment. Acutely, he represented with fever and seizures, which were difficult to control. On examination he could fix and follow appropriately, and smiled when engaged. The boy was restrained with tapes to the hands to prevent him pulling out the central venous and oxygen catheters. He had tachypnoea and chest wheezes with some crepitations, suggesting viral bronchiolitis as a cause of fever 4-year-old boy presented with pneumonia and a large pleural effusion. The effusion was aspirated with a needle but not drained. He remained febrile and the effusion filled his right hemithorax on radiograph after 5 days of antibiotic treatment 6-month-old boy had been in hospital for 1 week with a diagnosis of intracranial hypertension syndrome. He had presented with an episode of jerking movements and eye-rolling, which had lasted an estimated 3 s and had not recurred at any time during the week of admission. Diagnosis of intracranial hypertension based on cranial ultrasound showing “dilated third ventricle”. Normal head circumference and fontanelle, and normal neurological and developmental examination 2·5-month-old boy admitted with cough and fever. Diagnosis lobar pneumonia. Despite normal psychomotor development he was given phenobarbitone because at the time of birth a diagnosis of perinatal encephalopathy was made 10-month-old boy admitted with fever, diarrhoea, vomiting, and irritability. A diagnosis of intracranial hypertension, hypoxic ischaemic encephalopathy grade 1 was made 6-week-old girl with cough and “diarrhoea” (green stool twice daily), temperature 37·5 ºC. Diagnosis of “dysbacteriosis” 2-year old, post-term birth at 42 weeks, Apgar score 6 at 1 min and 8 at 5 min. Neurological diagnosis: perinatal encephalopathy, intracranial hypertension, hydrocephalus (normal ultrasound), muscular dystonia
25 of 53 children admitted to hospital whose care was systematically reviewed in Kazakhstan and 18 of 45 in the Republic of Moldova could have been adequately and safely managed at home, according to IMCI criteria.7 Examples of IMCI guidelines that were often not followed were that pneumonia without lower chestwall indrawing or danger signs should be treated on an outpatient basis with oral antibiotics, and that watery diarrhoea without severe dehydration should be treated with oral rehydration, without further investigations. Overdiagnosis was common, especially of neurological illnesses. Illustrative cases are presented in table 3. Many infants and children with normal variations in behaviour or mild symptoms such as a single febrile convulsion had been referred to neuropathologists who made diagnoses of “perinatal encephalopathy”, various grades of “encephalopathy”, “neurological disorder”, “intracranial hypertension”, or “myotonic syndrome”. These diagnoses often led to prolonged admission, years of follow-up, and excessive repetitive inpatient treatments that had no basis in evidence. Some of these treatments were potentially dangerous: diazepam, phenobarbital, diuretics to reduce intracranial pressure, and vasodilators designed to “improve brain blood flow”.
Treatment
Comments
Lazoban (a benzodiazepine), nystatin, gentamicin, Cephabid (a cephalosporin), Linex (to prevent diarrhoea), prednisolone, intravenous potassium chloride, acetozolamide, nitrazepam, phenytoin, thiopentone, heparin, insulin and glucose, novocaine (as a “vasodilator”), and oxygen
Probably epilepsy with exacerbation during febrile illness. No evidence of serious neurological dysfunction or intracranial hypertension. Polypharmacy and use of dangerous medications without adequate monitoring
Analgine (a non-narcotic analgesic), Benadryl (antihistamine), thiamine pyrophospate, Roboxinum (purine nucleoside), aminophyline, vitamin C, gentamicin, cefazolin, insulin plus glucose, prednisolone, potassium chloride, colloid solution intravenously 250 mL daily, and “cough mixture” “Electropheresis”, head massage, multivitamins, furosemide, acetazolamide, and intravenous electrolyte solution
Needed drainage of effusion. Polypharmacy: use of many ineffective and unnecessary agents
Overdiagnosis of neurological disease. Polypharmacy, inappropriate use of diuretics
Treated for lobar pneumonia with amoxycillin and multivitamins
Adequate pneumonia treatment. Overdiagnosis of neurological disease and unnecessary use of phenobarbitone
Metoclopramide, dexamethasone, diazepam, gentamicin, intravenous glucose solution, and papaverine (a vasodilator). Many of these drugs had to be bought by the family Erythromycin, theophyllin, Mesin (gastric enzymes), cough syrup, nasal drops, stop breast feeding, changed to formula and water
Overdiagnosis of neurological disease. Polypharmacy
Vitamins, dehydration with acetazolamide, cavinton to increase cerebral blood flow, intramuscular adenosine triphosphate, cerebrolysin, midazolam to decrease muscle tone
Mild upper respiratory tract infection, no real diarrhoea leading to drastic change in feeding away from breastfeeding. Overtreatment of viral illness Several poorly substantiated neurological diagnoses labelling a healthy child as sick, leading to many treatments, none with established efficacy and some of which might be harmful
Table 3: Clinical examples of overdiagnosis and overtreatment
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Multiple intramuscular injections, physiotherapy, and electrotherapy were given. Most children that we saw who had been diagnosed with such syndromes had no evidence of developmental delay. Several other conditions were systematically overdiagnosed and overtreated. These included congenital syphilis and various neurological diseases. Many newborn babies were diagnosed with suspected congenital syphilis on the basis of maternal serology or social circumstances (eg, all abandoned babies). These babies typically received 3 weeks of intramuscular penicillin. Such practices led to excessive hospitalisation, prolonged separation from mothers, exposure to formula feeding, and risk of nosocomial infection. Although diagnostic criteria based on national classifications exist for several conditions, treatment is mainly based on the doctor’s opinion. For example, four cases of community-acquired pneumonia were observed in the same paediatric ward, each being treated with different antibiotics. For many conditions, guidelines have been written in numerous pricazes (Ministry of Health order or notification), but most of these do not accord with international standards, and many recommend a large range of treatments now no longer recommended in international guidelines; many of which were not available in hospital pharmacies. Other pricazes mandate investigations for common diseases, such as repeated culture of stool from children and from mothers of children with acute watery diarrhoea. Children with diarrhoea were hospitalised until they had had three stool cultures free of bacterial pathogens. In Kazakhstan there were more than 200 pricazes relating to child health; which contributed to enormous variation in practice rather than standardising care. Many children received large numbers of ineffective or dubiously effective treatments. In Kazakhstan, the median number of drugs prescribed concurrently at the time of review was 5 (IQR 2–6). Up to 15 drugs were prescribed concurrently to children with acute respiratory infections or perceived neurological problems. There was cumulative potential for serious harm and unnecessary costs to the health service and to families. Although inpatient treatment was theoretically free, parents of children admitted often needed to purchase expensive drugs from privately owned pharmacies within or adjacent to the hospitals. Outpatient drugs need to be bought by parents at the pharmacy, and this arrangement encouraged admission of children who could have been managed at home. Many drugs were given for indications outside those constituting internationally accepted practice. Several drugs from the same class were given to the same patient (for example, use of up to three antihistamines), with potential for cumulative side-effects. Some medications prescribed were potentially dangerous in severely ill children, particularly when biochemical and www.thelancet.com Vol 367 March 18, 2006
blood-pressure monitoring was absent (intravenous insulin, diuretics, and vasodilators for children with respiratory tract infections or sepsis). Many doctors seriously questioned the importance of these therapies, but felt they needed to adhere to protocol recommendations. The protocol for management of perinatal asphyxia and neonatal encephalopathy in Kazakhstan, for example, contained 18 treatment options, including diuretics, intravenous vasodilators, herbal remedies, vitamins, and sedatives. Several other treatments were commonly given with little basis in evidence, including “electrotherapy” (mostly generating warmth, directly applied to the head) for a range of neurological diagnoses, “fluorescent light” therapy for tonsillitis, and broad-spectrum antibiotics for diarrhoea and upper respiratory tract infections. Oxygen was available in most hospitals but often only in intensive care units, and was administered without flow metres in many hospitals. Thus an unknown flow of oxygen was delivered to children directly or through water humidifiers, requiring the use of head-boxes or face masks. In delivery rooms in the Russian Federation, oxygen was given by a mattress containing oxygen at low pressure and delivered through a hosepipe and shower-head close to the newborn baby. Many children with non-severe illnesses received intravenous fluids. Intravenous “infusion therapy” was considered necessary for all neonates with infection. Because of the loose diagnostic criteria for neonatal infection, this policy resulted in the unnecessary separation of many babies from their mothers and disruption to breastfeeding. Nasogastric nutrition was rarely given to seriously ill children. Mothers were permitted to stay with their children 24 h a day in hospital wards, except in intensive care units, where overnight stay was not allowed. Mothers were usually not provided with food and needed to bring it from home. Little attention is paid to the psychological needs of many hospitalised children. Most staff recognised the need for a child-friendly environment, but rarely provided more than some pictures appropriate to children on the walls. Children who had been abandoned were often hospitalised for several weeks or months because of a lack of alternative social services. In most hospitals these children were alone for most of the day with very low levels of stimulation. One hospital in the Republic of Moldova had a specific ward for abandoned children with educational materials, toys, support from volunteer staff, and a child-friendly environment, services that were supported by a non-governmental organisation.
Discussion Although in many less developed countries the quality of paediatric care is characterised by poorly structured health networks, and by unavailability of drugs and other 923
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resources,8–10 the three countries we assessed in the CIS had good health networks and adequate numbers of staff. The problems of paediatric care that we identified in Kazakhstan, the Russian Federation, and the Republic of Moldova related more to excesses of treatment, overdiagnosis, and overhospitalisation. The reasons for these difficulties are complex. That most problems were found in all three countries was indicative of the similar systems of health organisation, legislation, medical education, and sub-specialisation. Our findings are probably generalisable to other countries in the region, an assumption supported by our informal meetings with medical personnel from the CIS. The practice of giving too many drugs at once relates to numerous and cumbersome treatment protocols, some written as early as the 1960s. These protocols recommend many drugs that are now known to be ineffective or dangerous for general use in children. Doctors in CIS found these protocols confusing; many questioned the value of recommendations, and wanted clearer guidelines. Although the doses prescribed were often low, a risk of dose errors and interactions exists when several drugs are given together. While some treatments were enshrined in local disease-specific protocols (recorded in pricazes), others, such as antihistamines, were generally given to almost all inpatients. Further reasons for polypharmacy were financial incentives and parental expectations, often fuelled by sub-specialists prescribing drugs to treat trivial conditions or symptoms due to normal behaviour in infants; if prescribed by one doctor, why not another? For some unconventional treatments, such as electrical therapies for neurological disorders and fluorescent light therapy for tonsillitis, there was genuine belief in their value among some treating nurses and doctors, and a pricaz prescribed the treatments. Absence of regulation of pharmacies contributed to unnecessary use of multiple drugs, and passed the costs for these treatments onto patients and their families. Some antidiarrhoeal drugs were strongly promoted by drug companies, and some of the clinical guidelines were brochures sponsored by drug companies. Having multiple privately run pharmacies that practiced shared price-fixing within an individual hospital resulted in inflated rather than competitive drug costs. Drugs were much more expensive in the rural areas than in the cities. A few hospitals had maintained their own non-privatised pharmacies: these seemed to have the least problems with availability of essential drugs. Several oblasts had official audit systems that examined whether local pricazes have been followed. Some hospitals were required to send case-records of all deaths to government officials on a regular basis. Lengthy and unnecessary hospitalisation is a complex issue with many underlying causes. In Kazakhstan, most primary health-care workers follow a former pricaz that any infant with any illness needs to be admitted. 924
Although this practice is at variance with IMCI guidelines, which have also been adopted by official pricazes, the former pricaz has not been repealed. Insurance regulations in the Russian Federation govern duration of hospital stay—eg, 45 days for septicaemia, 9 days for upper respiratory tract infection, and 15 days for asthma. If the child is discharged before this period of time the hospital may not be reimbursed. The traditional need for prolonged isolation of patients with tuberculosis, leprosy, and other infections to protect the rest of the community is generalised in pricazes to the management of trivial viral illnesses and readily treatable bacterial infections. Fear of the punitive consequences by authorities for medical mistakes or not having full hospitals was a driving force for prolonged and unneccessary hospitalisations. The statutory requirement for excessive investigation leads to lengthy hospital stays for many children. For diarrhoeal disease, a pricaz requires three stool samples to be clear of communicable pathogens, including Salmonella typhi. This requirement is one reason for under-reporting and excessive admissions for children with viral gastroenteritis. Stringent regulations about laboratory specimens also applied to other conditions: a teenage girl with Guillain-Barré syndrome was hospitalised for 5 months while waiting for exclusion of poliomyelitis, 1 month after all symptoms had resolved; children with hepatitis in the Russian Federation must remain in hospital until hepatic transaminase levels become normal. Some otherwise well children were admitted because other effective social services were unavailable. Admission was often a kind act of goodwill by health workers in an effort to provide a safe environment for abandoned or orphaned children. However, the hospital stay often lasted weeks or months, and these children were frequently left alone for most parts of the day in a poorly stimulating environment. In CIS, strategies to improve the quality of care need to simultaneously address several issues, including the absence of evidence-based approaches to clinical decision-making, the shortage of access to international standards and simple medical information, the organisation of hospital care, and disincentives for more efficient practices. Strategies need to be consistent with the processes of health reform taking place in the three countries, but could include: adaptation and implementation of WHO hospital guidelines for paediatric care; incorporation of standardised approaches to clinical practice and essential drugs into broader strategies of health-education reform and training;11 reforms to health regulations governing admission and discharge criteria and investigations; pharmacy regulation; and incentives for hospitals complying with good practice standards. Reforms should address the greater problems in delivering child health services in rural areas,12 and should take the opportunity to www.thelancet.com Vol 367 March 18, 2006
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redevelop hospitals as core social institutions that not only provide high quality care, but also reduce the effects of poverty and social disadvantage on health and development.1 The commitment from paediatricians and other key professionals in CIS to public child-health services and reform suggests substantial opportunities for success. Contributors T Duke, M Weber, and G Tamburlini planned the study, did the hospital assessments, and analysed the data. E Keshishiyan, A Kuttumuratova, I Ryumina, and E Stasii were part of the hospital assessment teams. M Ostergren helped to plan and organise the study. T Duke, G Tamburlini, and M Weber wrote early drafts of the paper, and all authors contributed to the final version. Conflict of interest statement We declare that we have no conflict of interest. Acknowledgments We thank the paediatricians, nurses, and administrators who participated in this study. Their involvement was essential to the whole process, and they enthusiastically gave their time to provide information and discuss the issues being addressed. We thank the countries and the provincial health authorities for allowing the assessment. WHO/EURO provided financial support. References 1 Freedman LP. Achieving the MDGs: health systems as core social institutions. Development 2005; 48: 19–24. 2 Balabanova D, McKee M, Pomerleau J, Rose R, Haerpfer C. Health service utilization in the former Soviet Union: evidence from eight countries. Health Serv Res 2004; 39: 1927–50.
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UNICEF. State of the world’s children: statistical tables. http:// www.unicef.org/sowc06/pdfs/sowc06_table10.pdf (accessed Feb 6, 2005). WHO European Office. Technical consultation on improving quality of care for children at first-referral level in European Region. 1, 1-18. 2002. http://www.euro.who.int/Document/CHD/ mmetingrep110601.pdf (accessed Feb 6, 2006). WHO. Improving quality of paediatric care in small hospitals in developing countries. WHO/FCH/CAH/01.25. Geneva: World Health Organization, 2001. http://www.who.int/child-adolescenthealth/New_Publications/CHILD_HEALTH/WHO_FCH_CAH_ 01.25.pdf (accessed Feb 6, 2006). WHO. Management of the child with a serious infection or severe malnutrition: guidelines for care at the first-referral level in developing countries. WHO/FCH/CAH/00.1. Geneva: World Health Organization; 2000. http://www.who.int/child-adolescenthealth/publications/CHILD_HEALTH/WHO_FCH_CAH_00.1.htm (accessed Feb 6, 2006). WHO. IMCI guidelines: chart booklet. Geneva: World Health Organization. http://www.who.int/child-adolescent-health/New_ Publications/IMCI/Chartbooklet.pdf (accessed Feb 6, 2006). English M, Esamai F, Wasunna A, et al. Assessment of inpatient paediatric care in first referral level hospitals in 13 districts in Kenya. Lancet 2004; 363: 1948–53. Nolan T, Angos P, Cunha AJLA, et al. Quality of hospital care for seriously ill children in less-developed countries. Lancet 2001; 357: 106–10. Parfitt T. The health of Russia’s children. Lancet 2005; 366: 357–58. Conaboy KA, Nugmanova Z, Yeguebaeva S, Jaeger F, Daugherty RM. Central Asian republics: a case study for medical education reform. J Contin Educ Health Prof 2005; 25: 52–64. Ensor T, Rittmann J. Reforming health care in the Republic of Kazakstan. Int J Health Plann Manage 2005; 12: 219–34.
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Quality of hospital care for children in Kazakhstan, Republic of Moldova, and Russia: systematic observational assessment Trevor Duke, Elena Keshishiyan, Aigul Kuttumuratova, Mikael Ostergren, Irina Ryumina, Ekaterina Stasii, Martin W Weber, Giorgio Tamburlini
Summary Background Major concerns about the quality of basic hospital care for children have been raised in developing countries, but no formal assessment applying international standards has been done in the Commonwealth of Independent States. Methods We assessed 17 hospitals in Kazakhstan, the Republic of Moldova, and the Russian Federation with a generic WHO hospital assessment framework adapted for use in the WHO European region. WHO management guidelines for paediatric care in peripheral hospitals were used as standards. Findings Hospital access for children was generally good. Good health networks existed, and skilled and committed doctors cared for children. Case-fatality rates were low. However, unnecessary and lengthy hospital stays were common, and most children received excessive and ineffective treatment (in one country median number of drugs prescribed concurrently was 5, IQR 2–6). Several conditions were systematically overdiagnosed, especially neurological disease, or overinvestigated, such as acute diarrhoea. Reasons for these practices included absence of clear evidence-based clinical guidelines, regulations tying duration of admission to financial reimbursement, generalisation of disease-control methods from rare problems to common illnesses, and regulations maintaining financial and professional status of some subspecialties. Many disincentives to efficient practice existed. Interpretation To improve quality of hospital care for children in the Commonwealth of Independent States, several issues must be addressed, including: adoption of international guidelines for inpatient management; complementary guidelines for outpatient management; reforms to health regulations governing admission and discharge criteria; improvement of quality of training, availability of medical information, and systems to promote and certify quality of care.
Introduction The Millennium Development Goals call for a reduction in child mortality by two thirds between 1990 and 2015, along with other targets that would result in a better environment for healthy development of children. The quality of care provided in health facilities, and the nature of interactions between health systems, families, and communities have major consequences for child health, human rights, poverty alleviation, and development.1 In the Commonwealth of Independent States (CIS), the former Soviet Union, the economic and social consequences of transition have placed large and complex burdens on the health sector.2 This problem has been partly due to reduced health budgets, increased disease burdens, obsolete infrastructure and equipment, and persistent exclusion from sources of evidence-based medical practice and training. Between 1990 and 2004, some countries in the CIS, including the Russian Federation and the Republic of Moldova, have seen overall reductions in child mortality rates, but other countries, such as Kazakhstan, have experienced a worsening of child survival, according to global estimates.3 During the 1990s, attempts to improve hospital care for children in the CIS predominantly focused on perinatal care, with little attention being paid to hospital www.thelancet.com Vol 367 March 18, 2006
care for children outside the newborn period. In many countries throughout the world over recent years, data on hospital care have been collected, but none was available from the European region. In February, 2002, at a technical consultation held at the WHO Regional Office for Europe in Copenhagen, representatives of CIS recommended that a regionwide assessment be undertaken to identify the major problems related to paediatric hospital care, to make recommendations for improvement, and to ensure that health reforms appropriately addressed key issues in child health.4 We describe a study that was done in three CIS countries in response to this recommendation.
Lancet 2006; 367: 919–25 Centre for International Child Health, Department of Paediatrics, University of Melbourne, Royal Children’s Hospital, Parkville, Victoria, 3052, Australia (T Duke MD); Moscow Scientific Research Institute of Paediatrics and Paediatric Surgery, Moscow, Russian Federation (E Keshishiyan MD); WHO, Country Sub-Office, Almaty, Kazakhstan (A Kuttumuratova PhD); WHO, Regional Office for Europe, Copenhagen, Denmark (M Ostergren MD); WHO, Office for the Russian Federation, Moscow, Russian Federation (I Ryumina MD); State Medical and Pharmaceutical University of Republic of Moldova, Kishinau, Republic of Moldova (E Stasii MD); WHO, Geneva, Switzerland (M W Weber MD); and Institute for Child Health, IRCCS Burlo Garafolo, Trieste, Italy (G Tamburlini MD) Correspondence to: Dr Trevor Duke [email protected]
Methods Study population The WHO Regional Office for Europe selected Kazakhstan, Republic of Moldova, and the Russian Federation as countries for the assessment of hospital quality of care. Health authorities were approached for their agreement, and to jointly identify suitable oblasts (provinces) to participate. In Kazakhstan and the Russian Federation, the Almaty and Ryazan oblasts, respectively, were selected. The whole of the Republic of Moldova was included, because of the smaller size of this country compared with the other two. 919
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Procedures We used a questionnaire and direct assessment framework, originally developed at WHO Headquarters in Geneva and modified by the WHO European Regional Office.5 Clinical and management standards used in the assessment framework were from the Russian translation of the WHO guidelines for care of children in first-level referral hospitals, and criteria for referral based on the WHO/UNICEF Integrated Management of Childhood Illness (IMCI) strategy.6 IMCI has been adopted in the CIS, but implementation has been largely confined to pilot regions. In April, 2002, questionnaires were distributed to all hospitals offering paediatric care in the three assessment areas: to 20 hospitals in the Almaty Oblast in Kazakhstan, 32 hospitals in the Ryazan Oblast in Russia, and to all 25 hospitals in Moldova. This questionnaire requested data relating to bed numbers, staff resources, equipment, number of admissions per year, outpatients and deliveries, common causes of admission and number, causes of deaths, availability of drugs and equipment, and procedures commonly done. In May and June, 2002, direct assessment was undertaken by three international consultants (TD, GT, MW) in collaboration with senior professionals from the CIS countries. 17 hospitals were assessed; seven in Almaty Oblast, five in the Republic of Moldova, and five in Ryazan Oblast. Hospitals were chosen as being representative of the three countries: a combination of rayon (district) hospitals, remote rural hospitals, and oblast children’s hospitals. Hospitals were selected to be representative of all levels of hospital care, from the most peripheral facilities to those closer to or within major centres. The direct assessment questionnaire was based on a generic tool developed by WHO headquarters, and adapted to fit the needs of the region by WHO Regional Office for Europe.5 We recorded information on key areas of care, via the gathering of demographic data, visits to all relevant wards and services where children were managed (maternity, neonatal ward, admission department, paediatric ward, surgical ward, intensive care); interviews with staff and mothers; and direct observation of patients. Attention was paid to all phases of care, from triage and admission, including initial assessment, laboratory investigations, monitoring and treatment, to the time of discharge and follow-up. Further information was gathered from case records, hospital admission books and mortality registers, laboratories, and emergency transport services. We sought opinions from clinical and administrative staff as to the major problems in paediatric care. We also collected information about local treatment protocols, investigations undertaken, regulations governing treatment, length-of-stay, available resources, funding, equipment, and drug supplies. Treatment protocols were translated and assessed for their internal 920
consistency and consistency with international standards, including the WHO clinical guidelines. Using the assessment questionnaire, key areas of health-service structure and health-care delivery were assessed as being satisfactory, needing some improvement, or needing substantial improvement. Consent for hospitals to take part in the assessment was obtained from the national and provincial health authorities, and a provincial health officer took part in the visit. Hospital administrators had received previous communication about the assessment from the health authorities. At the beginning of each site visit, the hospital staff were informed of the project and their agreement was obtained. A debriefing occurred with the hospital director and some of the health staff at the end of the visit in each health facility, with presentation and discussion of the main findings. Meetings were also held with national authorities, professionals involved in paediatric education and training, and international agencies active in the health sector at the completion of the assessment, which took 2 weeks in each country.
Role of the funding source WHO staff participated in study design, data collection, data analysis, and writing of the report. The corresponding author had full access to the data in the study and had final responsibility for the decision to submit for publication after approval from WHO.
Results The key results of the questionnaire are presented in table 1. Case fatality rates were low. Electricity was available in all hospitals; however, in several there was no back-up power supply and electricity supplies were intermittent. Cold running water was also generally available, but there were frequent interruptions to water supply in a few, mostly rural hospitals. Heating was reported to be a problem in some small hospitals during winter. The most peripheral hospitals had between four and 25 beds for children. Most rayon (district) hospitals had 40–80 beds. Several small rural hospitals did not have a children’s ward but nursed children in adults’ wards. Table 2 summarises the assessment of key areas of health service structure and health-care delivery in the three countries. The networks of health facilities, primary care, emergency transport, record keeping, and communication in each region were of an adequate standard. Immunisation services were well organised and achieved high levels of coverage, although opportunistic immunisation in hospitals rarely occurred because this task is seen to be the responsibility of the primary health system. IMCI has been introduced into a few pilot areas, but had not been undertaken on a national scale in any of the three countries. Hospital buildings were large and spacious, but yearly admission numbers showed that they would rarely be www.thelancet.com Vol 367 March 18, 2006
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Kazakhstan Number of hospitals Number of rayon (district) hospitals Number of oblast paediatric hospitals Other hospital types
Republic of Moldova
20 16 2 2 infectious diseases
Beds (median [IQR]) 22 (20–30) Admissions (total number in hospitals surveyed in 2002) 17 291 Yearly admissions per hospital (median [IQR]) 735 (403–1061) Case fatality rate (median [range]) 1·2% (0–5·6) Neonatal case fatality rate (median [range]) 2·5% (0–50) Electricity reliably available* 19† Running water available* 20 (100%)§ Oxygen available (always or often)* 19 (95%) Suction equipment available (always or often)* 18 (90%) Nebulisers or spacer devices for asthma treatment available (always or often)* 11 (55%) Neonatal resuscitation equipment available (always or often)* 11 (55%) Phototherapy available (always or often)* 7 (35%)
Russian Federation
25 18 6 1 university paediatric 24 (12–60) 56 260 604 (460–1468) 0·4% (0–2·6) 2·2% (0–8) 25 25 (100%) 24 (96%) 20 (80%) 10 (40%) 21 (84%) 20 (80%)
32 25 3 2 neurological rehabilitation 2 infectious diseases 15 (10–30) 30 370 454 (287–876) 0·25% (0–0·69) 2·3% (0–12) 30‡ 32 (100%) 23 (72%) 21 (66%) 6 (19%) 19 (59%) 9 (28%)
*Values are number of hospitals with this characteristic. †1 hospital reported having unreliable supply and no back-up generator. ‡2 hospitals reported occasional problems with electricity supplies. §frequent interruptions to water supply in rural hospitals.
Table 1: Characteristics of hospitals
close to capacity. Most buildings and basic infrastructure (water supply and toilet facilities, sterilisation, oxygen supply systems, kitchens and refrigeration, etc) had not received any maintenance over the past one or two decades, and many were in need of repairs. Paediatric doctors had a high level of commitment and dedication to their patients, and had a great deal of pride in their work and their profession. The number of doctors and nurses in children’s wards was usually sufficient, varying from one to two in the smallest rural hospitals to four to ten in larger rayon or oblast hospitals. Most doctors were specialised in paediatrics, which, in Soviet times required a 4-year undergraduate course. This requirement has now changed in many CIS countries, such that paediatrics is now a postgraduate specialty. Paediatricians were technically skilled in commonly needed practical procedures, although understanding of appropriate indications for procedures was often deficient. In almost all hospitals, most diagnostic equipment was outdated. A lot of equipment was poorly functioning, inefficient (especially oxygen delivery equipment), or unsafe (particularly radiograph equipment). Other equipment that is unknown or rarely used in western medicine, such as “electrotherapy” (generating warmth through a car battery and electrodes directly applied to the body) and “fluorescent light” therapy for tonsillitis, was used regularly in some hospitals. Several welllooking children were staying in hospital for longer than a week to receive fluorescent light therapy for tonsillitis. For some modern equipment that had been supplied by external donors, hospitals could not afford the cost of consumables, such as reagents for electrolyte analysers, so the machines were dormant. Basic laboratory investigations (haemoglobin, blood film, and microscopy of urine, cerebrospinal fluid, and www.thelancet.com Vol 367 March 18, 2006
other biological fluids) were available in most hospitals. Tertiary care centres had a higher laboratory capacity, where HIV testing was also available. Stool culture was frequently done in all hospitals, with negative results (from both the child with diarrhoea and his or her mother) a pre-requisite for hospital discharge. Blood or cerebrospinal fluid culture was done at infectious disease hospitals, but not at rayon hospitals. In general, intramuscular or intravenous administration of drugs was the predominant route of administration, even if oral preparations were available (such as penicillins) and even for mild cases, such as mild pneumonia or bronchitis. Few hospitals had an antibiotic against staphylococcal disease. Vitamin A and vitamin K were not always available to treat measles or as prophylaxis against haemorrhagic disease of the newborn baby, while group B vitamins were always available and frequently No significant deficiencies Hospital network Availability of beds Physical facilities Financial accessibility Health personnel Equipment Drugs and supplies Triage and emergency care Diagnosis Treatment Supportive and intensive care Monitoring Clinical guidelines Mother-and-child-friendly services
K, RM, RF K, RM, RF RF RF
RF
RM, RF
Need for some improvement
K, RM K, RM K, RM, RF K, RM, RF K, RM, RF K, RM K, RM, RF*
Need for substantial improvement
K, RM, RF† K, RM, RF
K, RM, RF K K, RM, RF K, RM, RF
K=Kazakhstan. RM=Republic of Moldova. RF=Russian Federation. *General. †Neurological and some other specific
conditions.
Table 2: Results of observational assessment
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used for a wide variety of illnesses. With the exception of BCG and hepatitis B vaccines, which are administered at birth, vaccines were usually not available in hospitals, since immunisation was seen as a service provided by primary health-care facilities. Therefore, despite very large numbers of relatively well children filling the hospitals, examples of opportunistic immunisation were uncommon. Respiratory infections, perinatal conditions, trauma, other infectious diseases, and neurological disorders were the most common reasons for hospital admissions and deaths in all three countries. Pneumonia and other acute respiratory infection were the most important causes of death among infants outside the neonatal period, and trauma was the most common cause of death in children older than 1 year. Children were referred to hospital by family doctors, the emergency services, or specialists from the polyclinics, or were brought directly to hospital by carers. No hospital had systems for triage, but in view of small case numbers this was not seen as a problem. Up to 90% of children presenting or referred to hospitals were admitted; admission thresholds or criteria were rarely specified.
8-month-old boy had three episodes of fever and convulsions over 5 months, diagnosed as “intracranial hypertension syndrome”, “epilepsy”, and “chronic neurological condition”.Treated with sodium valproate. Seizures were under good control with this treatment. Acutely, he represented with fever and seizures, which were difficult to control. On examination he could fix and follow appropriately, and smiled when engaged. The boy was restrained with tapes to the hands to prevent him pulling out the central venous and oxygen catheters. He had tachypnoea and chest wheezes with some crepitations, suggesting viral bronchiolitis as a cause of fever 4-year-old boy presented with pneumonia and a large pleural effusion. The effusion was aspirated with a needle but not drained. He remained febrile and the effusion filled his right hemithorax on radiograph after 5 days of antibiotic treatment 6-month-old boy had been in hospital for 1 week with a diagnosis of intracranial hypertension syndrome. He had presented with an episode of jerking movements and eye-rolling, which had lasted an estimated 3 s and had not recurred at any time during the week of admission. Diagnosis of intracranial hypertension based on cranial ultrasound showing “dilated third ventricle”. Normal head circumference and fontanelle, and normal neurological and developmental examination 2·5-month-old boy admitted with cough and fever. Diagnosis lobar pneumonia. Despite normal psychomotor development he was given phenobarbitone because at the time of birth a diagnosis of perinatal encephalopathy was made 10-month-old boy admitted with fever, diarrhoea, vomiting, and irritability. A diagnosis of intracranial hypertension, hypoxic ischaemic encephalopathy grade 1 was made 6-week-old girl with cough and “diarrhoea” (green stool twice daily), temperature 37·5 ºC. Diagnosis of “dysbacteriosis” 2-year old, post-term birth at 42 weeks, Apgar score 6 at 1 min and 8 at 5 min. Neurological diagnosis: perinatal encephalopathy, intracranial hypertension, hydrocephalus (normal ultrasound), muscular dystonia
25 of 53 children admitted to hospital whose care was systematically reviewed in Kazakhstan and 18 of 45 in the Republic of Moldova could have been adequately and safely managed at home, according to IMCI criteria.7 Examples of IMCI guidelines that were often not followed were that pneumonia without lower chestwall indrawing or danger signs should be treated on an outpatient basis with oral antibiotics, and that watery diarrhoea without severe dehydration should be treated with oral rehydration, without further investigations. Overdiagnosis was common, especially of neurological illnesses. Illustrative cases are presented in table 3. Many infants and children with normal variations in behaviour or mild symptoms such as a single febrile convulsion had been referred to neuropathologists who made diagnoses of “perinatal encephalopathy”, various grades of “encephalopathy”, “neurological disorder”, “intracranial hypertension”, or “myotonic syndrome”. These diagnoses often led to prolonged admission, years of follow-up, and excessive repetitive inpatient treatments that had no basis in evidence. Some of these treatments were potentially dangerous: diazepam, phenobarbital, diuretics to reduce intracranial pressure, and vasodilators designed to “improve brain blood flow”.
Treatment
Comments
Lazoban (a benzodiazepine), nystatin, gentamicin, Cephabid (a cephalosporin), Linex (to prevent diarrhoea), prednisolone, intravenous potassium chloride, acetozolamide, nitrazepam, phenytoin, thiopentone, heparin, insulin and glucose, novocaine (as a “vasodilator”), and oxygen
Probably epilepsy with exacerbation during febrile illness. No evidence of serious neurological dysfunction or intracranial hypertension. Polypharmacy and use of dangerous medications without adequate monitoring
Analgine (a non-narcotic analgesic), Benadryl (antihistamine), thiamine pyrophospate, Roboxinum (purine nucleoside), aminophyline, vitamin C, gentamicin, cefazolin, insulin plus glucose, prednisolone, potassium chloride, colloid solution intravenously 250 mL daily, and “cough mixture” “Electropheresis”, head massage, multivitamins, furosemide, acetazolamide, and intravenous electrolyte solution
Needed drainage of effusion. Polypharmacy: use of many ineffective and unnecessary agents
Overdiagnosis of neurological disease. Polypharmacy, inappropriate use of diuretics
Treated for lobar pneumonia with amoxycillin and multivitamins
Adequate pneumonia treatment. Overdiagnosis of neurological disease and unnecessary use of phenobarbitone
Metoclopramide, dexamethasone, diazepam, gentamicin, intravenous glucose solution, and papaverine (a vasodilator). Many of these drugs had to be bought by the family Erythromycin, theophyllin, Mesin (gastric enzymes), cough syrup, nasal drops, stop breast feeding, changed to formula and water
Overdiagnosis of neurological disease. Polypharmacy
Vitamins, dehydration with acetazolamide, cavinton to increase cerebral blood flow, intramuscular adenosine triphosphate, cerebrolysin, midazolam to decrease muscle tone
Mild upper respiratory tract infection, no real diarrhoea leading to drastic change in feeding away from breastfeeding. Overtreatment of viral illness Several poorly substantiated neurological diagnoses labelling a healthy child as sick, leading to many treatments, none with established efficacy and some of which might be harmful
Table 3: Clinical examples of overdiagnosis and overtreatment
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Multiple intramuscular injections, physiotherapy, and electrotherapy were given. Most children that we saw who had been diagnosed with such syndromes had no evidence of developmental delay. Several other conditions were systematically overdiagnosed and overtreated. These included congenital syphilis and various neurological diseases. Many newborn babies were diagnosed with suspected congenital syphilis on the basis of maternal serology or social circumstances (eg, all abandoned babies). These babies typically received 3 weeks of intramuscular penicillin. Such practices led to excessive hospitalisation, prolonged separation from mothers, exposure to formula feeding, and risk of nosocomial infection. Although diagnostic criteria based on national classifications exist for several conditions, treatment is mainly based on the doctor’s opinion. For example, four cases of community-acquired pneumonia were observed in the same paediatric ward, each being treated with different antibiotics. For many conditions, guidelines have been written in numerous pricazes (Ministry of Health order or notification), but most of these do not accord with international standards, and many recommend a large range of treatments now no longer recommended in international guidelines; many of which were not available in hospital pharmacies. Other pricazes mandate investigations for common diseases, such as repeated culture of stool from children and from mothers of children with acute watery diarrhoea. Children with diarrhoea were hospitalised until they had had three stool cultures free of bacterial pathogens. In Kazakhstan there were more than 200 pricazes relating to child health; which contributed to enormous variation in practice rather than standardising care. Many children received large numbers of ineffective or dubiously effective treatments. In Kazakhstan, the median number of drugs prescribed concurrently at the time of review was 5 (IQR 2–6). Up to 15 drugs were prescribed concurrently to children with acute respiratory infections or perceived neurological problems. There was cumulative potential for serious harm and unnecessary costs to the health service and to families. Although inpatient treatment was theoretically free, parents of children admitted often needed to purchase expensive drugs from privately owned pharmacies within or adjacent to the hospitals. Outpatient drugs need to be bought by parents at the pharmacy, and this arrangement encouraged admission of children who could have been managed at home. Many drugs were given for indications outside those constituting internationally accepted practice. Several drugs from the same class were given to the same patient (for example, use of up to three antihistamines), with potential for cumulative side-effects. Some medications prescribed were potentially dangerous in severely ill children, particularly when biochemical and www.thelancet.com Vol 367 March 18, 2006
blood-pressure monitoring was absent (intravenous insulin, diuretics, and vasodilators for children with respiratory tract infections or sepsis). Many doctors seriously questioned the importance of these therapies, but felt they needed to adhere to protocol recommendations. The protocol for management of perinatal asphyxia and neonatal encephalopathy in Kazakhstan, for example, contained 18 treatment options, including diuretics, intravenous vasodilators, herbal remedies, vitamins, and sedatives. Several other treatments were commonly given with little basis in evidence, including “electrotherapy” (mostly generating warmth, directly applied to the head) for a range of neurological diagnoses, “fluorescent light” therapy for tonsillitis, and broad-spectrum antibiotics for diarrhoea and upper respiratory tract infections. Oxygen was available in most hospitals but often only in intensive care units, and was administered without flow metres in many hospitals. Thus an unknown flow of oxygen was delivered to children directly or through water humidifiers, requiring the use of head-boxes or face masks. In delivery rooms in the Russian Federation, oxygen was given by a mattress containing oxygen at low pressure and delivered through a hosepipe and shower-head close to the newborn baby. Many children with non-severe illnesses received intravenous fluids. Intravenous “infusion therapy” was considered necessary for all neonates with infection. Because of the loose diagnostic criteria for neonatal infection, this policy resulted in the unnecessary separation of many babies from their mothers and disruption to breastfeeding. Nasogastric nutrition was rarely given to seriously ill children. Mothers were permitted to stay with their children 24 h a day in hospital wards, except in intensive care units, where overnight stay was not allowed. Mothers were usually not provided with food and needed to bring it from home. Little attention is paid to the psychological needs of many hospitalised children. Most staff recognised the need for a child-friendly environment, but rarely provided more than some pictures appropriate to children on the walls. Children who had been abandoned were often hospitalised for several weeks or months because of a lack of alternative social services. In most hospitals these children were alone for most of the day with very low levels of stimulation. One hospital in the Republic of Moldova had a specific ward for abandoned children with educational materials, toys, support from volunteer staff, and a child-friendly environment, services that were supported by a non-governmental organisation.
Discussion Although in many less developed countries the quality of paediatric care is characterised by poorly structured health networks, and by unavailability of drugs and other 923
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resources,8–10 the three countries we assessed in the CIS had good health networks and adequate numbers of staff. The problems of paediatric care that we identified in Kazakhstan, the Russian Federation, and the Republic of Moldova related more to excesses of treatment, overdiagnosis, and overhospitalisation. The reasons for these difficulties are complex. That most problems were found in all three countries was indicative of the similar systems of health organisation, legislation, medical education, and sub-specialisation. Our findings are probably generalisable to other countries in the region, an assumption supported by our informal meetings with medical personnel from the CIS. The practice of giving too many drugs at once relates to numerous and cumbersome treatment protocols, some written as early as the 1960s. These protocols recommend many drugs that are now known to be ineffective or dangerous for general use in children. Doctors in CIS found these protocols confusing; many questioned the value of recommendations, and wanted clearer guidelines. Although the doses prescribed were often low, a risk of dose errors and interactions exists when several drugs are given together. While some treatments were enshrined in local disease-specific protocols (recorded in pricazes), others, such as antihistamines, were generally given to almost all inpatients. Further reasons for polypharmacy were financial incentives and parental expectations, often fuelled by sub-specialists prescribing drugs to treat trivial conditions or symptoms due to normal behaviour in infants; if prescribed by one doctor, why not another? For some unconventional treatments, such as electrical therapies for neurological disorders and fluorescent light therapy for tonsillitis, there was genuine belief in their value among some treating nurses and doctors, and a pricaz prescribed the treatments. Absence of regulation of pharmacies contributed to unnecessary use of multiple drugs, and passed the costs for these treatments onto patients and their families. Some antidiarrhoeal drugs were strongly promoted by drug companies, and some of the clinical guidelines were brochures sponsored by drug companies. Having multiple privately run pharmacies that practiced shared price-fixing within an individual hospital resulted in inflated rather than competitive drug costs. Drugs were much more expensive in the rural areas than in the cities. A few hospitals had maintained their own non-privatised pharmacies: these seemed to have the least problems with availability of essential drugs. Several oblasts had official audit systems that examined whether local pricazes have been followed. Some hospitals were required to send case-records of all deaths to government officials on a regular basis. Lengthy and unnecessary hospitalisation is a complex issue with many underlying causes. In Kazakhstan, most primary health-care workers follow a former pricaz that any infant with any illness needs to be admitted. 924
Although this practice is at variance with IMCI guidelines, which have also been adopted by official pricazes, the former pricaz has not been repealed. Insurance regulations in the Russian Federation govern duration of hospital stay—eg, 45 days for septicaemia, 9 days for upper respiratory tract infection, and 15 days for asthma. If the child is discharged before this period of time the hospital may not be reimbursed. The traditional need for prolonged isolation of patients with tuberculosis, leprosy, and other infections to protect the rest of the community is generalised in pricazes to the management of trivial viral illnesses and readily treatable bacterial infections. Fear of the punitive consequences by authorities for medical mistakes or not having full hospitals was a driving force for prolonged and unneccessary hospitalisations. The statutory requirement for excessive investigation leads to lengthy hospital stays for many children. For diarrhoeal disease, a pricaz requires three stool samples to be clear of communicable pathogens, including Salmonella typhi. This requirement is one reason for under-reporting and excessive admissions for children with viral gastroenteritis. Stringent regulations about laboratory specimens also applied to other conditions: a teenage girl with Guillain-Barré syndrome was hospitalised for 5 months while waiting for exclusion of poliomyelitis, 1 month after all symptoms had resolved; children with hepatitis in the Russian Federation must remain in hospital until hepatic transaminase levels become normal. Some otherwise well children were admitted because other effective social services were unavailable. Admission was often a kind act of goodwill by health workers in an effort to provide a safe environment for abandoned or orphaned children. However, the hospital stay often lasted weeks or months, and these children were frequently left alone for most parts of the day in a poorly stimulating environment. In CIS, strategies to improve the quality of care need to simultaneously address several issues, including the absence of evidence-based approaches to clinical decision-making, the shortage of access to international standards and simple medical information, the organisation of hospital care, and disincentives for more efficient practices. Strategies need to be consistent with the processes of health reform taking place in the three countries, but could include: adaptation and implementation of WHO hospital guidelines for paediatric care; incorporation of standardised approaches to clinical practice and essential drugs into broader strategies of health-education reform and training;11 reforms to health regulations governing admission and discharge criteria and investigations; pharmacy regulation; and incentives for hospitals complying with good practice standards. Reforms should address the greater problems in delivering child health services in rural areas,12 and should take the opportunity to www.thelancet.com Vol 367 March 18, 2006
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redevelop hospitals as core social institutions that not only provide high quality care, but also reduce the effects of poverty and social disadvantage on health and development.1 The commitment from paediatricians and other key professionals in CIS to public child-health services and reform suggests substantial opportunities for success. Contributors T Duke, M Weber, and G Tamburlini planned the study, did the hospital assessments, and analysed the data. E Keshishiyan, A Kuttumuratova, I Ryumina, and E Stasii were part of the hospital assessment teams. M Ostergren helped to plan and organise the study. T Duke, G Tamburlini, and M Weber wrote early drafts of the paper, and all authors contributed to the final version. Conflict of interest statement We declare that we have no conflict of interest. Acknowledgments We thank the paediatricians, nurses, and administrators who participated in this study. Their involvement was essential to the whole process, and they enthusiastically gave their time to provide information and discuss the issues being addressed. We thank the countries and the provincial health authorities for allowing the assessment. WHO/EURO provided financial support. References 1 Freedman LP. Achieving the MDGs: health systems as core social institutions. Development 2005; 48: 19–24. 2 Balabanova D, McKee M, Pomerleau J, Rose R, Haerpfer C. Health service utilization in the former Soviet Union: evidence from eight countries. Health Serv Res 2004; 39: 1927–50.
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UNICEF. State of the world’s children: statistical tables. http:// www.unicef.org/sowc06/pdfs/sowc06_table10.pdf (accessed Feb 6, 2005). WHO European Office. Technical consultation on improving quality of care for children at first-referral level in European Region. 1, 1-18. 2002. http://www.euro.who.int/Document/CHD/ mmetingrep110601.pdf (accessed Feb 6, 2006). WHO. Improving quality of paediatric care in small hospitals in developing countries. WHO/FCH/CAH/01.25. Geneva: World Health Organization, 2001. http://www.who.int/child-adolescenthealth/New_Publications/CHILD_HEALTH/WHO_FCH_CAH_ 01.25.pdf (accessed Feb 6, 2006). WHO. Management of the child with a serious infection or severe malnutrition: guidelines for care at the first-referral level in developing countries. WHO/FCH/CAH/00.1. Geneva: World Health Organization; 2000. http://www.who.int/child-adolescenthealth/publications/CHILD_HEALTH/WHO_FCH_CAH_00.1.htm (accessed Feb 6, 2006). WHO. IMCI guidelines: chart booklet. Geneva: World Health Organization. http://www.who.int/child-adolescent-health/New_ Publications/IMCI/Chartbooklet.pdf (accessed Feb 6, 2006). English M, Esamai F, Wasunna A, et al. Assessment of inpatient paediatric care in first referral level hospitals in 13 districts in Kenya. Lancet 2004; 363: 1948–53. Nolan T, Angos P, Cunha AJLA, et al. Quality of hospital care for seriously ill children in less-developed countries. Lancet 2001; 357: 106–10. Parfitt T. The health of Russia’s children. Lancet 2005; 366: 357–58. Conaboy KA, Nugmanova Z, Yeguebaeva S, Jaeger F, Daugherty RM. Central Asian republics: a case study for medical education reform. J Contin Educ Health Prof 2005; 25: 52–64. Ensor T, Rittmann J. Reforming health care in the Republic of Kazakstan. Int J Health Plann Manage 2005; 12: 219–34.
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