The indirect impact of COVID-19 pandemic on inpatient admissions in 204 Kenyan hospitals: An interrupted time series analysis

The first case of severe acute respiratory coronavirus 2 (SARS-CoV-2) was identified in March 2020 in Kenya resulting in the implementation of public health measures (PHM) to prevent large-scale epidemics. We aimed to quantify the impact of COVID-19 confinement measures on access to inpatient services using data from 204 Kenyan hospitals. Data on monthly admissions and deliveries from the District Health Information Software version 2 (DHIS 2) were extracted for the period January 2018 to March 2021 stratified by hospital ownership (public or private) and adjusting for missing data using multiple imputation (MI). We used the COVID-19 event as a natural experiment to examine the impact of COVID-19 and associated PHM on use of health services by hospital ownership. We estimated the impact of COVID-19 using two approaches;Statistical process control (SPC) charts to visualize and detect changes and Interrupted time series (ITS) analysis using negative-binomial segmented regression models to quantify the changes after March 2020. Sensitivity analysis was undertaken to test robustness of estimates using Generalised Estimating Equations (GEE) and impact of national health workers strike on observed trends. SPC charts showed reductions in most inpatient services starting April 2020. ITS modelling showed significant drops in April 2020 in monthly volumes of live-births (11%), over-fives admissions for medical (29%) and surgical care (25%) with the greatest declines in the under-five's admissions (59%) in public hospitals. Similar declines were apparent in private hospitals. Health worker strikes had a significant impact on post-COVID-19 trends for total deliveries, live-births and caesarean section rate in private hospitals. COVID-19 has disrupted utilization of inpatient services in Kenyan hospitals. This might have increased avoidable morbidity and mortality due to non-COVID-19-related illnesses. The declines have been sustained. Recent data suggests a reversal in trends with services appearing to be going back to pre- COVID levels.

The indirect impact of COVID-19 pandemic on inpatient admissions in 204 Kenyan hospitals: An interrupted time series analysis.

The first case of severe acute respiratory coronavirus 2 (SARS-CoV-2) was identified in March 2020 in Kenya resulting in the implementation of public health measures (PHM) to prevent large-scale epidemics. We aimed to quantify the impact of COVID-19 confinement measures on access to inpatient services using data from 204 Kenyan hospitals. Data on monthly admissions and deliveries from the District Health Information Software version 2 (DHIS 2) were extracted for the period January 2018 to March 2021 stratified by hospital ownership (public or private) and adjusting for missing data using multiple imputation (MI). We used the COVID-19 event as a natural experiment to examine the impact of COVID-19 and associated PHM on use of health services by hospital ownership. We estimated the impact of COVID-19 using two approaches; Statistical process control (SPC) charts to visualize and detect changes and Interrupted time series (ITS) analysis using negative-binomial segmented regression models to quantify the changes after March 2020. Sensitivity analysis was undertaken to test robustness of estimates using Generalised Estimating Equations (GEE) and impact of national health workers strike on observed trends. SPC charts showed reductions in most inpatient services starting April 2020. ITS modelling showed significant drops in April 2020 in monthly volumes of live-births (11%), over-fives admissions for medical (29%) and surgical care (25%) with the greatest declines in the under-five's admissions (59%) in public hospitals. Similar declines were apparent in private hospitals. Health worker strikes had a significant impact on post-COVID-19 trends for total deliveries, live-births and caesarean section rate in private hospitals. COVID-19 has disrupted utilization of inpatient services in Kenyan hospitals. This might have increased avoidable morbidity and mortality due to non-COVID-19-related illnesses. The declines have been sustained. Recent data suggests a reversal in trends with services appearing to be going back to pre- COVID levels.

Quantifying the indirect impact of COVID-19 pandemic on utilisation of outpatient and immunisation services in Kenya: a longitudinal study using interrupted time series analysis.

OBJECTIVE: In this study, we assess the indirect impact of COVID-19 on utilisation of immunisation and outpatient services in Kenya. DESIGN: Longitudinal study. SETTING: Data were analysed from all healthcare facilities reporting to Kenya's health information system from January 2018 to March 2021. Multiple imputation was used to address missing data, interrupted time series analysis was used to quantify the changes in utilisation of services and sensitivity analysis was carried out to assess robustness of estimates. EXPOSURE OF INTEREST: COVID-19 outbreak and associated interventions. OUTCOME MEASURES: Monthly attendance to health facilities. We assessed changes in immunisation and various outpatient services nationally. RESULTS: Before the first case of COVID-19 and pursuant intervention measures in March 2020, uptake of health services was consistent with historical levels. There was significant drops in attendance (level changes) in April 2020 for overall outpatient visits for under-fives (rate ratio, RR 0.50, 95% CI 0.44 to 0.57), under-fives with pneumonia (RR 0.43, 95% CI 0.38 to 0.47), overall over-five visits (RR 0.65, 95% CI 0.57 to 0.75), over-fives with pneumonia (RR 0.62, 95% CI 0.55 to 0.70), fourth antenatal care visit (RR 0.86, 95% CI 0.80 to 0.93), total hypertension (RR 0.89, 95% CI 0.82 to 0.96), diabetes cases (RR 0.95 95% CI, 0.93 to 0.97) and HIV testing (RR 0.97, 95% CI 0.94 to 0.99). Immunisation services, first antenatal care visits, new cases of hypertension and diabetes were not affected. The post-COVID-19 trend was increasing, with more recent data suggesting reversal of effects and health services reverting to expected levels as of March 2021. CONCLUSION: COVID-19 pandemic has had varied indirect effects on utilisation of health services in Kenya. There is need for proactive and targeted interventions to reverse these effects as part of the pandemic's response to avert non-COVID-19 indirect mortality.

Pulse oximetry adoption and oxygen orders at paediatric admission over 7 years in Kenya: a multihospital retrospective cohort study.

OBJECTIVES: To characterise adoption and explore specific clinical and patient factors that might influence pulse oximetry and oxygen use in low-income and middle-income countries (LMICs) over time; to highlight useful considerations for entities working on programmes to improve access to pulse oximetry and oxygen. DESIGN: A multihospital retrospective cohort study. SETTINGS: All admissions (n=132 737) to paediatric wards of 18 purposely selected public hospitals in Kenya that joined a Clinical Information Network (CIN) between March 2014 and December 2020. OUTCOMES: Pulse oximetry use and oxygen prescription on admission; we performed growth-curve modelling to investigate the association of patient factors with study outcomes over time while adjusting for hospital factors. RESULTS: Overall, pulse oximetry was used in 48.8% (64 722/132 737) of all admission cases. Use rose on average with each month of participation in the CIN (OR: 1.11, 95% CI 1.05 to 1.18) but patterns of adoption were highly variable across hospitals suggesting important factors at hospital level influence use of pulse oximetry. Of those with pulse oximetry measurement, 7% (4510/64 722) had hypoxaemia (SpO2 <90%). Across the same period, 8.6% (11 428/132 737) had oxygen prescribed but in 87%, pulse oximetry was either not done or the hypoxaemia threshold (SpO2 <90%) was not met. Lower chest-wall indrawing and other respiratory symptoms were associated with pulse oximetry use at admission and were also associated with oxygen prescription in the absence of pulse oximetry or hypoxaemia. CONCLUSION: The adoption of pulse oximetry recommended in international guidelines for assessing children with severe illness has been slow and erratic, reflecting system and organisational weaknesses. Most oxygen orders at admission seem driven by clinical and situational factors other than the presence of hypoxaemia. Programmes aiming to implement pulse oximetry and oxygen systems will likely need a long-term vision to promote adoption, guideline development and adherence and continuously examine impact.

Employing learning health system principles to advance research on severe neonatal and paediatric illness in Kenya.

We have worked to develop a Clinical Information Network (CIN) in Kenya as an early form of learning health systems (LHS) focused on paediatric and neonatal care that now spans 22 hospitals. CIN's aim was to examine important outcomes of hospitalisation at scale, identify and ultimately solve practical problems of service delivery, drive improvements in quality and test interventions. By including multiple routine settings in research, we aimed to promote generalisability of findings and demonstrate potential efficiencies derived from LHS. We illustrate the nature and range of research CIN has supported over the past 7 years as a form of LHS. Clinically, this has largely focused on common, serious paediatric illnesses such as pneumonia, malaria and diarrhoea with dehydration with recent extensions to neonatal illnesses. CIN also enables examination of the quality of care, for example that provided to children with severe malnutrition and the challenges encountered in routine settings in adopting simple technologies (pulse oximetry) and more advanced diagnostics (eg, Xpert MTB/RIF). Although regular feedback to hospitals has been associated with some improvements in quality data continue to highlight system challenges that undermine provision of basic, quality care (eg, poor access to blood glucose testing and routine microbiology). These challenges include those associated with increased mortality risk (eg, delays in blood transfusion). Using the same data the CIN platform has enabled conduct of randomised trials and supports malaria vaccine and most recently COVID-19 surveillance. Employing LHS principles has meant engaging front-line workers, clinical managers and national stakeholders throughout. Our experience suggests LHS can be developed in low and middle-income countries that efficiently enable contextually appropriate research and contribute to strengthening of health services and research systems.