Examination of patient flow in a rural health center in Malawi.

BACKGROUND: Malawi, like many low-income countries, is facing a severe health worker shortage. A potential stop-gap solution to this crisis is improving the efficiency of health center operations. Given the lack of research on center efficiency in rural health centers in Malawi, we conducted a study to identify deficiencies in center organization and barriers to patient flow. METHODS: We performed a time-motion survey at a rural health center in Ntaja, Malawi over a period of 1 week. We used a standardized questionnaire to collect information on the amount of time a patient spent with each health worker, the number of center staff that attended to each patient, and the total time spent at the center. Additionally, at the end of the visit, we conducted an exit survey to collect demographic information and data on perception of quality of care with the center visit for all patients. RESULTS: A total of 1018 patients were seen over the five-day study. The average total time spent at the center by the patients was 123 min (2-366 min). Adults had an average total time spent at the center of 111 min (2-366 min) and children 134 min (7-365 min). Patient waiting time (PWT) was higher in the early morning hours ranging from 157 min (between 06:00 and 08:00) to 53 min (between 14:00 and 16:00). Health worker contact time (HCT) was higher for adults (2.3 min) than children (1.7 min). Shorter wait times were associated with higher perceptions of quality of service. CONCLUSION: Despite shortages in health workers and funds, opportunities are available to increase efficiency in rural health centers. By removing bottlenecks to increase the productivity of health workers, centers in low-income countries can treat more patients and improve service quality.

Mortality rates among patients with schizophrenia and tardive dyskinesia.

Tardive dyskinesia (TD) is a severe and potentially irreversible movement, and previous studies have suggested increased mortality among patients with TD, but most of these studies are limited by small sample sizes and short periods of follow-up. This study examined the mortality rate of a cohort of 608 Asian patients with schizophrenia during a 6-year period and used survival analyses on time from case ascertainment to outcome (death). Data on the survival status were collected and compared between those with and without TD, and cross-tabulation was performed to show the correlation between survival and mortality rates among patients with and without TD.Seventy-two patients died, 39 (54.2%) of whom had TD previously. Of the 536 surviving cases, 239 (44.6%) have TD. The mortality rates between those with TD and those without TD were statistically significant (hazard ratio, 2.62; 95% confidence interval, 1.58-4.33; P = 0.0006).The mortality rate was dependent on age; nevertheless, the adverse effect of TD on survival rate, although reduced, remains after controlling for age (hazard ratio, 1.90; 95% confidence interval, 1.12-3.20; P = 0.017). Our finding showed a robust association with increased mortality rate and TD, but we failed to find any significant association with any specific cause of death and TD.

The association between community context and mortality among Mexican-American infants.

Mexican-American infants have surprisingly low mortality rates, given their high-risk demographic characteristics. One explanation for this well-known paradox is the beneficial influence of a traditional Mexican cultural orientation. However, many studies have focused on individual, rather than contextual, markers of acculturation to explain the reasons for this paradox. This study incorporated community-level data into the analysis to further elucidate the Mexican paradox. Data from the National Linked Birth and Infant Death files for 1995-1997 were used to stratify infants born in counties of Arizona, California, New Mexico, and Texas into tertiles based on the proportion of Mexican births in each county. We calculated mortality rates for infants in each tertile. Logistic regression, with generalized estimating equations, was used to calculate odds ratios comparing infant mortality in low and medium concentration counties to high concentration counties. Odds ratios were adjusted for maternal age, education, parity, marital status, and maternal nativity status. Among Mexican-American infants, mortality rates ranged from 4.3 in counties with high proportions of Mexican births to 5.5 in counties with low proportions of Mexican births. However, this association was limited to US-born mothers, whose rates ranged from 4.4 in high concentration counties to 7.0 in low concentration counties (adjusted OR, 1.56 [1.35-1.81]); a substantial proportion of that difference was due to lower birth-weight specific mortality among normal birth-weight infants (1.9 vs. 3.1 deaths/1,000 live births). Among infants with Mexico-born mothers, there was no association between community context and mortality (OR, 1.01). Residence in counties with high proportions of Mexican births had a positive influence on birth outcomes among women of Mexican origin born in the United States. Exposure to the Mexican culture may reinforce healthy behaviors that Mexican-American women may lose through acculturation.