Practice list size, workforce composition and performance in English general practice: a latent profile analysis.

BACKGROUND: Following government calls for General Practices in England to work at scale, some practices have grown in size from traditionally small, General Practitioner (GP)-led organisations to large multidisciplinary enterprises. We assessed the effect of practice list size and workforce composition on practice performance in clinical outcomes and patient experience. METHODS: We linked five practice-level datasets in England to obtain a single dataset of practice workforce, list size, proportion of registered patients ≥ 65 years of age, female-male sex ratio, deprivation, rurality, GP contract type, patient experience of care, and Quality and Outcomes Framework (QOF) and non-QOF clinical processes and outcomes. Latent Profile Analysis (LPA) was used to cluster general practices into groups based on practice list size and workforce composition. Bayesian Information Criterion, Akaike Information Criterion and deliberation within the research team were used to determine the most informative number of groups. One-way ANOVA was used to assess how groups differed on indicator variables and other variables of interest. Linear regression was used to assess the association between practice group and practice performance. RESULTS: A total of 6024 practices were available for class assignment. We determined that a 3-class grouping provided the most meaningful interpretation; 4494 (74.6%) were classified as 'Small GP-reliant practices', 1400 (23.2%) were labelled 'Medium-size GP-led practices with a multidisciplinary team (MDT) input' and 131 (2.2%) practices were named 'Large multidisciplinary practices'. Small GP-reliant practices outperformed larger multidisciplinary practices on all patient-reported indicators except on confidence and trust where medium-size GP-led practices with MDT input appeared to do better. There was no difference in performance between small GP-reliant practices and larger multidisciplinary practices on QOF incentivised indicators except on asthma reviews where medium-size GP-led practices with MDT input performed worse than smaller GP-reliant practices and immunisation coverage where the same group performed better than smaller GP-reliant practices. For non-incentivised indicators, larger multidisciplinary practices had higher cancer detection rates than small GP-reliant practices. CONCLUSION: Small GP-reliant practices were found to provide better patient reported access, continuity of care, experience and satisfaction with care. Larger multidisciplinary practices appeared to have better cancer detection rates but had no effect on other clinical processes and outcomes. As England moves towards larger multidisciplinary practices efforts should be made to preserve good patient experience.

Coronavirus Disease 2019 (COVID-19) Reinfection Rates in Malawi: A Possible Tool to Guide Vaccine Prioritisation and Immunisation Policies.

As the fight against the COVID-19 pandemic continues, reports indicate that the global vaccination rate is still far below the target. Understanding the levels of reinfection may help refocus and inform policymakers on vaccination. This retrospective study in Malawi included individuals and patients who tested for COVID-19 infections via reverse transcriptase polymerase chain reaction (rt-PCR) from the data at the Public Health Institute of Malawi (PHIM). We included all data in the national line list from April 2020 to March 2022. Upon review of 47,032 records, 45,486 were included with a reported 82 (0.18) reinfection representing a rate of 0.55 (95% CI: 0.44-0.68) per 100,000 person-days of follow-up. Most reinfections occurred in the first 90 to 200 days following the initial infection, and the median time to reinfection was 175 days (IQR: 150-314), with a range of 90-563 days. The risk of reinfection was highest in the immediate 3 to 6 months following the initial infection and declined substantially after that, and age demonstrated a significant association with reinfection. Estimating the burden of SARS-CoV-2 reinfections, a specific endurance of the immunity naturally gained, and the role played by risk factors in reinfections is relevant for identifying strategies to prioritise vaccination.

Patient satisfaction with health care at a tertiary hospital in Northern Malawi: results from a triangulated cross-sectional study.

BACKGROUND: In 2016 the Malawi government embarked on several interrelated health sector reforms aimed at improving the quality of health services at all levels of care and attain Universal Health Coverage by 2030. Patient satisfaction with services is an important proxy measure of quality. We assessed patient satisfaction at a tertiary hospital in Northern Malawi to understand the current state. METHODS: We conducted exit interviews with patients aged ≥ 18 years using a 28 statement interviewer administered questionnaire. Patients were asked to express their level of agreement to each statement on a five-point Likert scale - strongly disagree to strongly agree, corresponding to scores of 1 to 5. Overall patient satisfaction was calculated by summing up the scores and dividing the sum by the number of statements. Mean score > 3 constituted satisfaction while mean score ≤ 3 constituted dissatisfaction. A χ2 test was used to assess the association between overall patient satisfaction and demographic variables, visit type and clinic consulted at alpha 0.05. Patient self-rated satisfaction was determined from a single statement that asked patients to rate their satisfaction with services on a five-point Likert scale. We also asked patients to mention aspects of hospital care that they did not like. Responses were summarized into major issues which are presented according to frequencies. RESULTS: Overall patient satisfaction was 8.4% (95% CI: 5.2 - 12.9%). Self-rated patient satisfaction was 8.9% (95% CI: 5.5 - 13.4%). There was no significant association between overall patient satisfaction and all predictor variables assessed. Patients raised six major issues that dampened their health care seeking experience, including health workers reporting late to work, doctors not listening to patients concerns and neither examining them properly nor explaining the diagnosis, shortage of medicines, diagnostics and medical equipment, unprofessional conduct of health workers, poor sanitation and cleanliness, and health worker behaviour of favouring relatives and friends over other patients. CONCLUSIONS: We found very low levels of patient satisfaction, suggesting that quality of services in the public health sector is still poor. It is, therefore, critical to accelerate and innovate the Ministry of Health's quality improvement initiatives to attain Malawi's health goals.

Paediatric sickle cell disease at a tertiary hospital in Malawi: a retrospective cross-sectional study.

Introduction: Sickle cell disease (SCD) remains a major cause of childhood mortality and morbidity in Malawi. However, literature to comprehensively describe the disease in the paediatric population is lacking. Methods: A retrospective review of clinical files of children with SCD was conducted. Descriptive statistics were performed to summarise the data. χ2 or Fisher's exact test was used to look for significant associations between predictor variables and outcome variables (case fatality and length of hospital stay). Predictor variables that were significantly associated with outcome variables (p≤0.05) in a χ2 or Fisher's exact test were carried forward for analysis in a binary logistic regression. A multivariable binary logistic regression was used to identify covariates that independently predicted length of hospital stay. Results: There were 16 333 paediatric hospitalisations during the study period. Of these, 512 were patients with SCD representing 3.1% (95% CI: 2.9%- 3.4%). Sixty-eight of the 512 children (13.3%; 95% CI: 10.5% - 16.5%) were newly diagnosed cases. Of these, only 13.2% (95% CI: 6.2% - 23.6%) were diagnosed in infancy. Anaemia (94.1%), sepsis (79.5%) and painful crisis (54.3%) were the most recorded clinical features. The mean values of haematological parameters were as follows: haemoglobin (g/dL) 6.4 (SD=1.9), platelets (×109/L) 358.8 (SD=200.9) while median value for white cell count (×109/L) was 23.5 (IQR: 18.0-31.2). Case fatality was 1.4% (95% CI: 0.6% - 2.8%)and 15.2% (95% CI: 12.2% -18.6%) of the children had a prolonged hospital stay (>5 days). Patients with painful crisis were 1.7 (95% CI: 1.02 - 2.86) times more likely to have prolonged hospital stay than those without the complication. Conclusion: Anaemia, sepsis and painful crisis were the most common clinical features paediatric patients with SCD presented with. Patients with painful crisis were more likely to have prolonged hospital stay. Delayed diagnosis of SCD is a problem that needs immediate attention in this setting. Although somewhat encouraging, the relatively low in-hospital mortality among SCD children may under-report the true mortality from the disease considering community deaths and deaths occurring before SCD diagnosis is made.