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Purpose: The present situation of COVID-19 pandemic has put the health-care systems under tremendous stress and stringent tests for their ability to offer expected quality of health-care services, as it decides the sustainability and growth of health-care service providers. This study aims to deliver a quantitative framework for service quality assessment in the health-care industry by classifying the health-care service quality parameters into four balanced scorecard (BSC) perspectives. Design/methodology/approach: To determine the service quality for the Indian health-care system, decision-making trial and evaluation laboratory and analytical network process are integrated in a fuzzy environment to contemplate the interaction among BSC perspectives and respective performance measures. Findings: The results indicate “internal processes” perspective assumes the key role within BSC perspectives, while performance measures “nursing staff turnover” and “staff training” play the key roles. The results also signify that “patient satisfaction” is the most vital issue and can be strongly influenced by measures belonging to the “learning and growth” perspective. In “learning and growth” perspective, “staff training” is the most decisive criteria, very highly influencing “patient satisfaction”, highly influencing “profitability,” “change of cost per patient (both in and out patients)” and “outpatient waiting time” while moderately influencing “staff satisfaction,” “bed occupancy” and “nursing staff turnover”. Moreover, “staff training” criteria have a positive influence on “nursing staff turnover.” Originality/value: The contributions of this study are in two folds in the domain of quantification of service quality for the health-care system. First, it delivers an assessment framework for Indian health-care service quality. Second, it demonstrates an application of the framework for a case situation and validates the proposed framework. © 2022, Emerald Publishing Limited.
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Background: Index testing is a viable strategy to identify HIV cases globally and is a cornerstone of all PEPFAR programs. COVID-19 and associated lockdowns impacted access to health services including HIV testing. The financial impact of these lockdowns on HIV case detection has not been studied in-depth. Methods: Program ACCELERATE implemented Facility-Based Index Testing (FBIT;n=5 districts) and Community-Based Index Testing (CBIT;n=3 districts) in 2 high-burden Indian states. Retrospective costing data were obtained from expenditure records, including cost of labor, supplies/equipment, capital, training, and operational costs. Fixed and recurrent costs at the programmatic level, both overall and per district, were estimated, excluding the cost of HIV testing. On 03/24/2020, India implemented a nationwide lockdown. 10/2019- 03/2020 was classified as pre-COVID and 04/2020-09/2020 as post-COVID. To derive the unit cost per individual, the number of clients offered and accepted index testing, contacts elicited, contacts who accepted and completed HIV testing, contacts who tested positive, and new PLHIV initiated on ART were retrieved for each district. Results: The total programmatic cost to implement FBIT pre-COVID was $265,061, which reduced by 21.5% to $207,333 post-COVID, including startup cost for both periods. The cost to implement CBIT reduced by 63% from $160,851 to $59,605, pre and post pandemic. Pre-COVID, labor accounted for 77% of the overall implementation cost vs. 90.3% post-COVID. The total number of contacts who tested positive over 6 months of FBIT implementation reduced by 65.3% pre- to post-COVID (1048 vs 364) and by 30.6% (399 vs 277) for CBIT. Newly diagnosed PLHIV initiated on ART declined by 65.1% (895 vs 312) for FBIT and by 19.3% (311 vs 251) for CBIT. Across all districts implementing FBIT, the cost per new HIV diagnosis increased from $253 to $728, and for CBIT, from $403 to $581. The per unit cost of PLHIV initiated on ART for FBIT increased from $296 to $850, and for CBIT, from $517 to $641. Conclusion: The average pre-COVID cost per new HIV diagnosis through FBIT among 5 Indian districts is below the estimated cost in most LMICs. Post-COVID, the cost per diagnosis and ART initiation almost tripled for FBIT, primarily driven by a lower volume of cases. Innovative strategies, such as integrating homebased testing and HIV-self testing, may be required to offset travel restrictions imposed by COVID-19 and improve program efficiency, while minimizing exposure to SARS-CoV-2.
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Background: Routine HIV testing for partners and children of PLHIV (e.g., index testing) is a key component of HIV prevention. Anecdotal information suggests that the COVID-19 pandemic's lockdowns and subsequent economic and mobility restrictions have impacted HIV testing programs;however, there is limited empirical data demonstrating this. Methods: Beginning in Oct 2019, we initiated index testing services in 5 high HIV prevalence districts in two Indian states (Maharashtra and Andhra Pradesh) at 55 sites (48 facility-based/7 community-based) to elicit and test contacts (spouses, sexual/needle-sharing partners, children) of known PLHIV. To assess the pandemic's impact on index testing outcomes among contacts, we compared outcomes in a pre-pandemic period (Jan-Mar 2020) to two post-pandemic periods: 1) a lockdown period (Apr-June 2020), and 2) a postlockdown period when restrictions were eased (July-Sept 2020). Specifically, we compared the index testing cascade: number of contacts tested, number of contacts testing HIV+, proportion testing HIV+, and proportion initiating ART, by period and setting (facility vs. community-based). Results: In the pre-pandemic period, 3,191 contacts of 2,258 PLHIV were tested, among whom 859 tested HIV+ (27% positivity). By comparison, in the lockdown period, the number of contacts tested decreased by 84% (rate ratio [RR], 0.16;p<0.001) but positivity increased to 40%. Increases in the number tested were seen post-lockdown, but remained below pre-pandemic levels (RR, 0.54, p<0.001;Panel A). Overall, the pandemic's impact was more severe in facility vs. community sites (Panel B). By Sept 2020, the number of contacts testing positive returned to near pre-pandemic levels in community sites but remained <50% in facility sites. The proportion of newly diagnosed contacts who initiated treatment increased from 81% pre-pandemic to 88% in the lockdown and post-lockdown periods (p<0.01). The median time from diagnosis to ART initiation was 8 days pre-pandemic and during the lockdown, but reduced to 4 days post-lockdown. Conclusion: The pandemic resulted in significant declines in the testing of contacts of PLHIV and new HIV diagnoses, however linkage to ART among those newly diagnosed remained high. Our findings suggest that expansion of community-based service sites and/or incorporating strategies such as HIV self-testing may be needed to regain and maintain progress towards UNAIDS 95-95-95 goals, given the ongoing impacts of COVID-19.
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INTRODUCTION: Acute kidney injury (AKI) has been reported in patients with COVID-19 pneumonia and is a marker of severe disease and associated with higher mortality. The aim of our study is to describe clinical characteristics, outcomes and 60 day hospital mortality of patients with COVID-19 pneumonia and AKI in the ICU setting. METHODS: We conducted a retrospective observational study where all adult patients with confirmed COVID-19 infection admitted to ICUs of Montefiore Medical Center and developing AKI were included. The study period was from 3/10- 4/11/2020. We did 60 day follow up on all patients till 6/11/2020. RESULTS: Out of 300 adult admissions in the ICUs with COVID-19 pneumonia, 224 patients developed AKI with the incidence of 74.6%. The mean (+- SD) age was 60 (+-11.78) years and 140 (62%) were males. By the end of our follow up period on June 11th, 149 (66.5%) patients expired, 75 (33.5%) survived (67 discharged alive, 8 still in hospital). 218 (97%) patients needed invasive mechanical ventilation for moderate to severe ARDS. 113 (50.45%) patients had AKI on day 1 of ICU admission and rest developed later. Peak AKI stage was 1 in 49 (21.8%) patients, 2 in 35 (15.6%) and 3 in 140 (62.5%) patients. 114 patients (50.8%) required renal replacement therapy, median number of days of RRT was 7 days. Of all patients requiring RRT, 80 (70%) expired. Of the 34 survivors on RRT, 25 (73.5%) were able to be weaned off RRT completely before hospital discharge. Non-survivors had significantly higher admission and peak creatinine levels, admission hemoglobin and peak phosphate levels compared to survivors. Higher median peak levels of inflammatory markers (C-reactive protein (CRP) and procalcitonin) was seen amongst non-survivors compared to survivors but no difference in levels of other inflammatory markers like serum ferritin, LDH. The 60 day hospital mortality was 66.5%. CONCLUSIONS: COVID-19 infection in ICU is associated with extremely high incidence of severe AKI, many needing renal replacement therapy. Majority of COVID-19 patients with severe AKI in ICU have moderate to severe ARDS and need invasive mechanical ventilation. Timing or severity of AKI did not affect outcomes. 60 day hospital mortality is high. AKI patients requiring RRT have high mortality but survivors have good rates of RRT recovery.
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Background: Electrolyte abnormalities have been observed in hospitalized patients with COVID-19. Whether the prevalence of electrolyte disturbances differ between hospitalized patients with and without COVID-19 is unknown. Methods: We performed a retrospective observational study of adult patients hospitalized in a large tertiary healthcare system in the Bronx between March 11-April 26, 2020. We compared the prevalence of the disturbances in sodium, potassium, calcium and magnesium between patients with and without COVID-19 using Chi-square. Electrolyte disturbances were defined as the following: hypernatremia (>145 mEq/L), hyponatremia (<135 mEq/L), hyperkalemia (>5 mmol/L), hypokalemia (<3.5 mmol/L), hypermagnesemia (>2.5 mEq/L), hypomagnesemia (<1.5 mEq/L), hypocalcemia (<8.5 mg/dL) and hypoalbuminemia (<3.5 g/dL). Results: Of 4579 patients, 51.8% were male. Median age was 65 years, IQR (52-76). 3313 (72.3%) were positive for the COVID-19. Hypernatremia, hyponatremia, hyperkalemia, hypermagnesemia, hypocalcemia, and hypoalbuminemia were significantly more common in hospitalized patients with COVID-19 (p<0.0001). Conclusions: Dysnatremias, hyperkalemia, and hypermagnesemia were more common in patients with COVID-19. Hypocalcemia was more common in patients with COVID-19 but this may be due to a higher prevalence of hypoalbuminemia. Further studies are needed looking at adjusted models to describe the association between electrolyte abnormalities and clinical outcomes.