Improving Global Health Care Delivery Through Collaboration & - - PowerPoint PPT Presentation

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Improving Global Health Care Delivery Through Collaboration & - - PowerPoint PPT Presentation

Feb 15, 2024 256 likes •902 views

Improving Global Health Care Delivery Through Collaboration & Partnership Michelle Niescierenko MD Global Health Program Director Pediatric Emergency Medicine Attending Boston Childrens Hospital Disclosures No financial disclosures

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SLIDE 1

Improving Global Health Care Delivery Through Collaboration & Partnership

Michelle Niescierenko MD

Global Health Program Director

Pediatric Emergency Medicine Attending Boston Children’s Hospital

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SLIDE 2

Disclosures

  • No financial disclosures
  • No conflicts of interest
  • All photos unless otherwise cited taken for use

in teaching with parental verbal consent

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SLIDE 3

Objectives

  • Country Background: Liberia
  • Program development timeline

– Quality improvement initiatives – Interventional & research projects

  • Challenges
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SLIDE 4

Why Liberia?

  • I was a senior pediatrics resident
  • A new project was starting in Liberia
  • The project lead asked me “you have

experience in Africa – can you work in Liberia?”

With permission, Mapoteng Lesotho

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SLIDE 5

Liberia

  • 150 years of close US

relations

  • Charter member of

United Nations

  • Former tertiary referral &

training center for all of North/West/South Africa

  • 4.1 million people
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SLIDE 6

Liberia

1989-2003: Disastrous Civil War from 2005: Democratic election

  • f the first women

president in Africa 2011: Re-election 2014: Reconstruction

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SLIDE 7
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SLIDE 8

WHO, Global Health Observatory

Effect of Civil War on Child Health

Statistics 2003 2009-2011 Population (Millions) 3.03 3.9 Population < 15y (%) 44 44 Mortality Under 5 (per/1,000) 164 78 Under 1 (per/1,000) 112 58 Malnutrition Stunting (%) 45 38 Underweight (%) 23 20 Immunization Measles 47 64 DPT 39 64 45 38

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SLIDE 9

Health Status

  • 50% of the population is

<15 yrs

  • Under 5 mortality in the

top 5

  • Stunting due to

malnutrition

  • HIV prevalence 6%
  • 224 physicians in the

country

  • 2 Pediatricians
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SLIDE 10

Evolution of an Academic Collaborative

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SLIDE 11

HEARTT Formed

2006

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SLIDE 12
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SLIDE 13

HEARTT Formed

2006 2008

Pediatrics

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SLIDE 14

Roles of Visiting Clinicians

  • US Faculty Responsibilities

– Give didactic lectures – Teach on clinical rounds – Support Liberian Trainees – Orient/Supervise US residents

  • US Resident Responsibilities

– Model good clinical practice – Work alongside Liberian interns and SMO – Clinical teaching – Supplement medical student teaching

*Residents sent in teams with at least one faculty mentor for the first 2 weeks

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SLIDE 15

Frequency of US Trainee Global Health Electives

1980 2012 1996 2012

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Resident Global Health Electives

Perceived Benefits:

  • Improved clinical skills
  • Greater appreciation of public

health

  • Enhanced resident

recruitment

Criticisms/ Ethical Concerns:

  • Premature responsibility given

to trainees

  • Burden imposed on host

countries to provide housing, food, etc.

  • Lack of defined learning
  • bjectives
  • Inadequate supervision

Thompson M et al 2003 & Crump JA 2008

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SLIDE 17

AAP Consensus Guidelines

American Academy of Pediatrics (AAP) develops consensus guidelines for international child health electives during residency training 4 Principles: (1) prerequisite training (2) adequate supervision (3) pre-departure orientation (4) formal evaluation

Torjesen K et al 1999

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Resident Elective

  • 1. Prerequisite training

Only 3rd year pediatrics residents Have completed supervisory, NICU, ED & ICU rotations

  • 2. Adequate Supervision

All US residents supervised by US faculty Residents perform duties alongside US faculty

  • 3. Pre-Departure Orientation

Two day pre-departure meeting Didactic Lectures & Discussion Simulation Cases Orientation Manual

  • 4. Formal Evaluation

Residents are evaluated by US faculty Residents evaluate the rotation

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SLIDE 19

US Pediatric Workforce in Liberia

2008 2009 2010 2011 Total

% Repeating

Resident 4 10 11 16 41 12% Fellow 2 5 5 2 14 50% Faculty 3 5 7 11 26 42%

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SLIDE 20

Liberia Rotation and Impact

  • n Resident’s Career Choices

33% -

Reaffirmed an interest in incoporating GH

42% -Stimulated an Interest in incorporating GH

10% Influenced Fellowship choice 10% unsure 5% None

University of Massachusetts 2011

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SLIDE 21

HEARTT Formed

2006 2008

Pediatrics

2009

Long-term Pediatrician

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Collaborative Medical Education

Clinical Pediatric Teaching Curriculum Design Clinical Practice Guideline Revision of Pediatric Clerkship Curriculum Case Conferences Pediatric Graduate Medical Education Journal Clubs Board Review Course – WACP* Grand Rounds Didactic Teaching Administration of Pediatric Exams 3rd year Medical Student Curriculum Preparation of written exams 4th year Medical Student Curriculum Oral exams

*WACP: West African College of Physicians

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SLIDE 23

4 8 16 41 38 50 50

10 20 30 40 50 60 2008 2009 2010 2011 2012 2013 2014* 2015* 2016*

Number of Medical Students Years

Dogliotti College of Medicine Graduates

Liberian Physician Pipeline

* Expected graduates based upon current class size

A.M. Dogliotti School of Medicine

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SLIDE 24

Quality Improvement

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Clinical Practice Guidelines

  • Anemia
  • Burkitt’s Lymphoma
  • DKA
  • Malaria
  • Malnutrition
  • Neonatal Sepsis
  • Seizure management
  • Tuberculosis
  • Tetanus
  • HIV
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SLIDE 26
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SLIDE 27

5 10 15 20 25 30 35 2008 2010 2013 (Rainy Season) 2013 (Dry Season) Mortality Rate (%) Year

Overall Pediatric Ward Mortality Rate

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SLIDE 28

HEARTT Formed

2006 2008

Pediatrics

2009

World Bank Pediatrician

2010

ACSMEL NCD Clinic

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SLIDE 29

Academic Collaborative to Support Medical Education in Liberia

Harborview Medical

Seattle, WA

University of Massachusetts Medical Center

Worcester, MA

University of Massachusetts Baystate Medical Center

Springfield, MA

Boston Children’s Hospital

Boston, MA Seattle, WA Boston, MA

Mount Sinai Medical Center

New York, NY

SUNY Upstate Medical Center

Syracuse ,NY

A.M. Dogliotti College of Medicine

Monrovia, Liberia

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SLIDE 30

Chronic Care Clinic

  • Over a million children world wide

suffer from non-communicable diseases (NCDs)

  • 29 million people die annually due to

NCD

  • Low/middle-income countries – 80%
  • f deaths
  • ½ million children with diabetes
  • 1/120 born with congenital heart

disease

  • 15 million DALYs lost to asthma

annually

A focus on children and NCDs, United Nations Summit 2011

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SLIDE 31

Clinic Operations

  • Funded by a three year I-CATCH grant from the AAP
  • Patients with NCD enrolled from the ward
  • Charts are pulled the day before, eliminates waiting

in line

  • Patients receive a reminder phone call
  • Patients seen by local pediatrician or visiting

pediatric faculty or residents

  • Management guided by disease-specific protocols
  • Future appointments are scheduled and entered

into log book

SOIC H International Community Access to Child Health SOIC H Community Access to Child Health

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CCC Outcomes

  • 338 total patients
  • 73% under age 5 years
  • 25% had more than one admission prior to

enrollment

  • 48 unique diagnoses

62% 38%

One Diagnosis Two Diagnoses Three/+ Diagnoses 61% 26%

12%

Diagnoses per Patient

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SLIDE 33

CCC Outcomes

0% 5% 10% 15% 20% 25% 30% Percent of Clinic Population

Burden of Types of NCDs Among Clinic Population

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CCC Outcomes

0% 20% 40% 60% 80% 100% 120% Enrollment Visit 1st 2nd 3rd 4th 5 or More Percent of Follow Up Visits Attended

Follow Up Visit Attendance* *Mean follow up 60 days, std 70 days, range 1 - 553 days

Visit Number

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CCC Outcomes

50 100 150 200 250 Asthma Cerebral Palsey Congenital Heart Disease Developmental Delay Seizure Disorder Sickle Cell Disease

46* 89* 27* 28* 61* 72*

Follow Up Time (Days)

Follow Up Visit Compliance by Disease

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SLIDE 36

Post clinic enrollment admission rate:

  • 11% (22/196 patients),
  • mean 130 days
  • range 2-445 days
  • Standard deviation 137 days
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SLIDE 37

HEARTT Formed

2006 2008

Pediatrics

2009

World Bank Pediatrician

2010

NCD Clinic ACSMEL

2011

Liberian Pediatricians

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SLIDE 38

HEARTT Formed

2006 2008

Pediatrics

2009

World Bank Pediatrician

2010

NCD Clinic ACSMEL

2011

Liberian Pediatricians

2012

NICU Clinic Malaria, GME

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SLIDE 39

Civil War and Physician Work Force

2003 2012 Total Physicians 100 200 Practicing Physicians 50 150 Pediatricians* 2 General Surgeons 2 3 Anesthesiologists

*44% population 0-14 years of age

Liberian Medical and Dental Board

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SLIDE 40

Global Physician Workforce

Physicians/ 1,000 people (Generalist & Subspecialist)

World Development Indicators, World Bank

Time (Years)

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SLIDE 41

4 8 16 41 38 50 50

10 20 30 40 50 60 2008 2009 2010 2011 2012 2013 2014* 2015* 2016*

Number of Medical Students Years

Dogliotti College of Medicine Graduates

Liberian Physician Pipeline

* Expected graduates based upon current class size

A.M. Dogliotti School of Medicine

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SLIDE 42

Liberian Physician Pipeline

  • Internship

– 1 year graduate medical training – Pediatrics, OB/GYN, Surgery, Medicine – 24 spots available per year

  • Rural Service

– Posting in a district hospital – 2 years service required

  • Senior Medical Officer

– Clinical service in area of interest (e.g. pediatrics) – No additional training in that area

  • Residency/Graduate Medical Education

– Not previously available in Liberia

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SLIDE 43

Liberian Pediatric Health Care Work Force Needs

  • Limited generalist faculty

– Pediatrics 2 – Medicine 4 – Surgery 1 – OB/GYN 2

  • No subspecialty faculty

Academic Collaborative to Support Medical Education in Liberia (ACSMEL)

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SLIDE 44

Supporting GME Development

  • Work with the Liberian Post Graduate Medical

Council

  • Serve as support faculty for the Liberian faculty
  • Assist with GME as requested

– Curriculum review & design – Preparation of residency candidates – Examination writing – Faculty staffing

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SLIDE 45

2009

World Bank Pediatrician

2010

NCD Clinic ACSMEL

2011

Liberian Pediatricians

2012

NICU Clinic GME

2013

Teen Moms Residencies

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SLIDE 46

Liberian Residency Training

  • Inaugural class started

September 2013

  • Pediatrics, OB/GYN,

Medicine, Surgery

  • Decentralized training

around Liberia

  • Equipment Procurement
  • First 6 months of generalist time at JFKMC
  • Need for resuscitation training
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SLIDE 47

Pediatric Resuscitation & Life Support

  • PALS administered by the American Heart

Association

  • No AHA training center in West African
  • Appropriateness

– 6 years of experience – Knowledge of the trainees

  • AHA permission to use validated assessment

tools

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SLIDE 48

Methods

  • September 2013

– Setting appropriate simulation cases written – Curriculum adapted into site appropriate delivery format (lecture)

  • October 2013 PALS Pretest given

– Pediatric residents took it – Surgery residents did not – After pretest study guides given out

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Methods

  • November 2013

– 4 lecture series on respiratory cases

  • December 2013

– 4 lecture series on shock cases

  • January 2014

– In person 3 day course – Taught by myself and one assistant

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Course Schedule

Time Day 1 10a-11a Pre-test 11a-11:30a Course Overview/ PALS Approach 11:30-12:30p Primary Assessment & Interventions 12:30-1:30p Lunch 1:30-2:30 Respiratory and Shock Cases 2:30p-3:15p Monitoring 3:15p-5p CPR

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Course Schedule

Time Day 2 10a-12p Cardiac Rhythm Interpretation 12p-1p Lunch 1p-2p Resuscitation Team Concept 2p-3p PALS Algorithm Review 3:30 – 5p Simulation Scenarios Time Day 3 10a-12:30p Practice Scenarios 1:30p-3:30p Testing on Scenarios 3:30p-5p Written Exam

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SLIDE 52

Interactive Lectures

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SLIDE 53

Lectures

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SLIDE 54

Barriers to Simulation

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Simulation

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Performance

10 20 30 40 50 60 70 80 90 100 Pre Test (Untimed Pre Test (Timed) Final Exam (1st Attempt) Final Exam (2nd Attemp)

Performance Measure

50 60

Pediatrics Residents

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SLIDE 57

Performance

Performance Measure

20 40 60 80 100 120 Pre Test (Untimed) Pre Test (Timed) Final Exam (1st Attempt) Final Exam (2nd Attemp)

Surgical Residents

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SLIDE 58

2009

World Bank Pediatrician

2010

NCD Clinic ACSMEL

2011

Liberian Pediatricians

2012

NICU Clinic GME

2013

Teen Moms Residencies

2014

???

  • Residency educational needs
  • Country wide trauma study
  • Large database
  • Public policy
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SLIDE 59

Challenges

  • Meeting the needs

– Staffing – Identified clinical needs – Supply chain

  • Communication

– Monthly phone calls – Frequent emails – Team sign-outs – Skype with Liberian colleagues

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SLIDE 60

Challenges

  • Funding

– Institutions – Project specific – Larger funders

  • Cultural

– Shared decision making – Prioritization – Cultural competency

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SLIDE 61

From the Liberian side…

  • Consistent group of faculty

members

– Longer stays preferred

  • Overwhelmed by resident

numbers

  • Temper enthusiasm of volunteers
  • Transparency
  • Supported decision making

Kraeker C et al, Acad Med 2013

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Questions & Thanks!