Pattern of Referral of Obstetric Patients at a Tertiary Care Hospital in Southern Nigeria

Background: Health challenges that are difficult to manage at primary health centres should be referred to secondary health facilities, and if untreated, to the tertiary hospitals. A good referral should include the patient’s biography, such as age, gender, tribe, religion, occupation, medical history, the reason for the referral, treatments received, and clinical diagnosis. Objectives: To evaluate the referral patterns, indications for referrals, and feto-maternal outcomes for obstetric patients who were referred to the University of Port Harcourt Teaching Hospital. Materials and Methods: A prospective study of patients admitted to the Obstetric unit from January 1, 2021, to December 31, 2022. Data was collected from patients while on admission or clinic visits and recorded in an excel spread sheet. Data was analyzed with the Statistical Package for Social Sciences (SPSS) version 25. Results: Of the 3469 patients were admitted to the obstetric unit, 1476 and 1993 were admitted in 2021 and 2022, respectively. Most (70.35%) of the patients were in the 20-34 years age group, parity 1-4 was the most frequent (66.49%), while 85.39% of patients were booked. 10.46% of the booked patients were referred from other facilities, whereas 89.54% of patients were booked at our facility from the onset. Most common indications of referrals were previous caesarean section (CS) at term (40.09%) and hypertensive disorders of pregnancy (17.59%). The outcome for 2021 indicated 17 maternal deaths, 132 fetal deaths and 1010 live births, giving maternal mortality ratio (MMR) as 1810.44 per 100,000 live births and perinatal mortality ratio (PMR) of 130.7 per 1000 births respectively. In 2022, there were 17 maternal deaths, 130 fetal deaths and 1297 deliveries, giving a MMR of 1399 per 100,000 live births and a PMR of 100.2 per 1000 births. Conclusion: The pattern of referral among obstetric patients in this study shows that a lot of the patients do not get adequate care at the lower cadre of the referral system, hence adequate facilities should be made available in primary and secondary health centres to tackle obstetric emergencies.

Acceptability of Phone-Based Communication Intervention by Healthcare Workers as an Adjunct to Routine Referral Form: A Qualitative Study in South Western Uganda

Introduction: A functional maternal referral system should encompass a feasible communication system between health facilities. In Uganda, the current paper-based patient referral form is associated with inadequate patient-information and low feedback rates. A recent quasi-experimental study demonstrated that a phone-based communication intervention is feasible for iterative communication between health facilities, and there were improved maternal-fetal outcomes and high rates of feedback. However, the acceptability of the intervention was not assessed. Objective: The study assessed the acceptability of a phone-based communication intervention by the health care workers (HCWs) for iterative communication between the referring and receiving health facilities. Methods: This was a qualitative study conducted in South Western Uganda, in April 2021. The study employed a theoretical framework of acceptability of medical interventions. We conducted in-depth interviews with HCWs and used deductive-inductive analysis. Results: We enrolled a total of 23 HCWs, of whom 69.6% (n = 16) were females while 30.4% (n = 7) were males. Majority (65.2%, n = 15), were midwives and the rest were: doctors (30.4%, n = 7) and a nurse (4.3%). The HCWs were positive towards the intervention: they believed that the intervention reduced delays, promoted professional escort, encouraged sharing of supplies, enabled exchange of relatively more patient details, feedback and improved case management. They believed it was culturally acceptable and had enough skills and experience of operating phones. All participants recommended scale out of the intervention, but advised on the need for dedicated human-resource to coordinate phone calls, ensure availability of airtime and charged battery. Conclusion: This study demonstrates that the phone-based communication intervention was highly accepted by the healthcare workers, and that hospitals can successfully give feedback to lower health centres through iterative phone calls. This provides a possible solution to the long-standing challenge of poor feedback rates and a vicious cycle of poor maternal-fetal outcomes in resource limited settings.

Socio-Demographic Factors, Clinical Characteristics and Maternal Prognosis of Hypertensive Disorders in Pregnancy at Panzi General Referral Hospital

Background: Hypertensive disease in pregnancy is an important cause of morbidity, long-term disability, and maternal and neonatal mortality. The aim is to determine the socio-demographic characteristics and maternal prognosis of these women with Hypertension during pregnancy. Material and Method: We conducted a cross-sectional study, we interview patients and after discussion we transcripts in a database in Excel software before analysis with SPSS version 20.0 and Stata 14.0 The qualitative variables have been summarised by the Percentage and the quantitative variables will be summarised by Means and Standard Deviation. The associations of the variables were calculated by Pearson’s chi-square test with a significance level set at a p-value Result: The average age of the patients was 30.33 ± 7.020 years, 92.1% were married, 79.8% lived in urban areas, most of the patients were overweight (43%), 92.1% of them had monofetal pregnancies, 36% were multiparous, 34.2% had a previous history of preeclampsia in pregnancy and 14% were known to have hypertension. Pre-eclampsia was the most frequent form of hypertension in pregnancy with 73.68% of cases and represents 84.8% of severe forms of hypertension in pregnancy, 53.4% of the patients delivered vaginally. Eclampsia was the most frequent complication in our patients with 31.7% frequency and among the socio-demographic parameters, age and body mass index were significantly associated with maternal complications. Conclusion: Maternal age and body mass index are important socio-demographic factors associated with the occurrence of maternal complications in women with hypertensive disorders in pregnancy.

Delayed referral for liver transplant evaluation worsens outcomes in chronic liver disease patients requiring inpatient transplant evaluation

BACKGROUND Indications to refer patients with cirrhosis for liver transplant evaluation(LTE)include hepatic decompensation or a model for end stage liver disease(MELDNa)score≥15.Few studies have evaluated how delaying referral beyond these criteria affects patient outcomes.AIM To evaluate clinical characteristics of patients undergoing inpatient LTE and to assess the effects of delayed LTE on patient outcomes(death,transplantation).METHODS This is a single center retrospective cohort study assessing all patients undergoing inpatient LTE(n=159)at a large quaternary care and liver transplant center between 10/23/2017-7/31/2021.Delayed referral was defined as having prior indication(decompensation,MELD-Na≥15)for LTE without referral.Early referral was defined as referrals made within 3 mo of having an indication based on practice guidelines.Logistic regression and Cox Hazard Regression were used to evaluate the relationship between delayed referral and patient outcomes.RESULTS Many patients who require expedited inpatient LTE had delayed referrals.Misconceptions regarding transplant candidacy were a leading cause of delayed referral.Ultimately,delayed referrals negatively affected overall patient outcome and an independent predictor of both death and not receiving a transplant.Delayed referral was associated with a 2.5 hazard risk of death.CONCLUSION Beyond initial access to an liver transplant(LT)center,delaying LTE increases risk of death and reduces risk of LT in patients with chronic liver disease.There is substantial opportunity to increase the percentage of patients undergoing LTE when first clinically indicated.It is crucial for providers to remain informed about the latest guidelines on liver transplant candidacy and the transplant referral process.

A Retrodirective Array Enabled by CMOS Chips for Two-Way Wireless Communication with Automatic Beam Tracking

This article proposes and demonstrates a retrodirective array(RDA)for two-way wireless communication with automatic beam tracking.The proposed RDA is enabled by specifically designed chips made using a domestic complementary metal-oxide semiconductor(CMOS)process.The highly integrated CMOS chip includes a receiving(Rx)chain,a transmitting(Tx)chain,and a unique tracking phaselocked loop(PLL)for the crucial conjugated phase recovery in the RDA.This article also proposes a method to reduce the beam pointing error(BPE)in a conventional RDA.To validate the above ideas simply yet without loss of generality,a 2.4 GHz RDA is demonstrated through two-way communication links between the Rx and Tx chains,and an on-chip quadrature coupler is designed to achieve a nonretrodirective signal suppression of 23 dBc.The experimental results demonstrate that the proposed RDA,which incorporates domestically manufactured low-cost 0.18 lm CMOS chips,is capable of automatically tracking beams covering±40with a reduced BPE.Each CMOS chip in the RDA has a compact size of 4.62 mm^(2) and a low power consumption of 0.15 W.To the best of the authors’knowledge,this is the first research to demonstrate an RDA with a fully customized CMOS chip for wireless communication with automatic beam tracking。

Reference-frame-independent quantum key distribution with two-way classical communication

The data post-processing scheme based on two-way classical communication(TWCC)can improve the tolerable bit error rate and extend the maximal transmission distance when used in a quantum key distribution(QKD)system.In this study,we apply the TWCC method to improve the performance of reference-frame-independent quantum key distribution(RFI-QKD),and analyze the influence of the TWCC method on the performance of decoy-state RFI-QKD in both asymptotic and non-asymptotic cases.Our numerical simulation results show that the TWCC method is able to extend the maximal transmission distance from 175 km to 198 km and improve the tolerable bit error rate from 10.48%to 16.75%.At the same time,the performance of RFI-QKD in terms of the secret key rate and maximum transmission distance are still greatly improved when statistical fluctuations are considered.We conclude that RFI-QKD with the TWCC method is of practical interest.

Beamforming Design for IRS-and-UAV-Aided Two-Way Amplify-and-Forward Relay Networks in Maritime IoT

In this paper,an intelligent reflecting surface(IRS)-and-unmanned aerial vehicle(UAV)-assisted two-way amplify-and-forward(AF)relay network in maritime Internet of Things(IoT)is proposed,where ship1(S1)and ship2(S2)can be viewed as data collecting centers.To enhance the message exchange rate between S1 and S2,a problem of maximizing minimum rate is cast,where the variables,namely AF relay beamforming matrix and IRS phase shifts of two time slots,need to be optimized.To achieve a maximum rate,a low-complexity alternately iterative(AI)scheme based on zero forcing and successive convex approximation(LC-ZF-SCA)algorithm is presented.To obtain a significant rate enhancement,a high-performance AI method based on one step,semidefinite programming and penalty SCA(ONSSDP-PSCA)is proposed.Simulation results show that by the proposed LC-ZF-SCA and ONS-SDP-PSCA methods,the rate of the IRS-and-UAV-assisted AF relay network surpass those of with random phase and only AF relay networks.Moreover,ONS-SDP-PSCA perform better than LC-ZF-SCA in aspect of rate.

Frequency of and reasons behind non-listing in adult patients referred for liver transplantation: Results from a retrospective study

BACKGROUND Few studies have evaluated the frequency of and the reasons behind the refusal of listing liver transplantation candidates.AIM To assess the ineligibility rate for liver transplantation and its motivations.METHODS A single-center retrospective study was conducted on adult patients which entailed a formal multidisciplinary assessment for liver transplantation eligibility.The predictors for listing were evaluated using multivariable logistic regression.RESULTS In our center,314 patients underwent multidisciplinary work-up before liver transplantation enlisting over a three-year period.The most frequent reasons for transplant evaluation were decompensated cirrhosis(51.6%)and hepatocellular carcinoma(35.7%).The non-listing rate was 53.8%and the transplant rate was 34.4%for the whole cohort.Two hundred and five motivations for ineligibility were collected.The most common contraindications were psychological(9.3%),cardiovascular(6.8%),and surgical(5.9%).Inappropriate or premature referral accounted for 76(37.1%)cases.On multivariable analysis,a referral from another hospital(OR:2.113;95%CI:1.259–3.548)served as an independent predictor of non-listing.CONCLUSION A non-listing decision occurred in half of our cohort and was based on an inappropriate or premature referral in one case out of three.The referral from another hospital was taken as a strong predictor of non-listing.

Security-Reliability Analysis and Optimization for Cognitive Two-Way Relay Network with Energy Harvesting

This paper investigates the security and reliability of information transmission within an underlay wiretap energy harvesting cognitive two-way relay network.In the network,energy-constrained secondary network(SN)nodes harvest energy from radio frequency signals of a multi-antenna power beacon.Two SN sources exchange their messages via a SN decode-and-forward relay in the presence of a multiantenna eavesdropper by using a four-phase time division broadcast protocol,and the hardware impairments of SN nodes and eavesdropper are modeled.To alleviate eavesdropping attacks,the artificial noise is applied by SN nodes.The physical layer security performance of SN is analyzed and evaluated by the exact closed-form expressions of outage probability(OP),intercept probability(IP),and OP+IP over quasistatic Rayleigh fading channel.Additionally,due to the complexity of OP+IP expression,a self-adaptive chaotic quantum particle swarm optimization-based resource allocation algorithm is proposed to jointly optimize energy harvesting ratio and power allocation factor,which can achieve security-reliability tradeoff for SN.Extensive simulations demonstrate the correctness of theoretical analysis and the effectiveness of the proposed optimization algorithm.

Description and Factors Affecting the Referral of Presumptive Tuberculosis Patients in China

To describe and analyze the factors affecting the referral of presumptive tuberculosis patients between health-care facilities that are not affiliated with the National TB Control Program （NTP） and NTP-designated medical facilities in China, we carried out a retrospective study based on data collected in the Tuberculosis Information Management System in 2015. Out of 324,221 presumptive pulmonary tuberculosis （PTB） cases reported by non-NTP health-care facilities, 302,006 （93.1%） reported cases successfully arrived at designated medical facilities and 22,215 cases （6.9%） were lost to follow-up. The arrival rate of presumptive cases among male patients （92.9%） was slightly lower than that among female ones （93.7%）, and this difference is statistically significant. The majority （73.3%） of reported cases were local permanent residents. Migrants have a higher risk of being lost to follow-up compared with local residents （adjusted odds ratios 4.126 and 5.003, respectively）. Compared with farmers and herdsmen, pre-school children, unemployed laborers, retirees, and people with other occupations （adjusted odds ratios 2.361, 1.274, 1.068, and 1.993, respectively） had higher rates of loss to follow-up during the referral and tracing processes. In conclusion, this study demonstrates that the high referral rate of presumptive TB cases from non-NTP health-care facilities to designated medical facilities in China is due to implementation of effective active case identification strategies. In addition, migrant populations, pre-school children, unemployed laborers, and retirees were identified as high-risk groups that contribute to the loss to follow-up.

Failed biliary cannulation: Clinical and technical outcomes after tertiary referral endoscopic retrograde cholangiopancreatography

AIM: Prospective evaluation of repeat endoscopic retrograde cholangiopancreatography (ERCP) for failed Schutz grade 1 biliary cannulation in a high-volume center. METHODS: Prospective intention-to-treat analysis of patients referred for biliary cannulation following recent unsuccessful ERCP. RESULTS: Fifty-one patients (35 female; mean age: 62.5 years; age range: 40-87 years) with previous failed biliary cannulation were referred for repeat ERCP. The indication for ERCP was primarily choledocholithiasis (45%) or pancreatic malignancy (18%). Successful biliary can- nulation was 100%. The precut needle knife sphincterotomy (NKS) rate was 27.4%. Complications occurred in 3.9% (post-ERCP pancreatitis). An identif iable reason for initial unsuccessful biliary cannulation was present in 55% of cases. Compared to a cohort of 940 nave pa-pilla patients (female 61%; mean age: 59.9 years; age range: 18-94 years) who required sphincterotomy over the same time period, there was no statistical difference in the cannulation success rate (100% vs 98%) or postERCP pancreatitis (3.1% vs 3.9%). Precut NKS use was more frequent (27.4% vs 12.7%) (P = 0.017). CONCLUSION: Referral to a high-volume center following unsuccessful ERCP is associated with high technical success, with a favorable complication rate, compared to routine ERCP procedures.

Epidemiologic Profile of Maternal Deaths in Two Referral Hospitals in Cameroon

Introduction: Our objective was to compare the epidemiologic profile of maternal mortality in two structures serving as referral levels of care in Cameroon. Methodology: This cross-sectional, comparative study took place at the maternities of the Yaoundé Central Hospital (YCH) and the Bamenda Regional Hospital (BRH) from December 1st 2014 to May 31st 2015, a 6 months’ period. The medical records of deceased women over 5 years, from January 2010 to December 2014, were collected. We calculated the MMR (Maternal mortality rate) and studied the causes and risk factors associated with maternal death. The Epi info software 3.5.4 was used to analyze data with a significance level of P < 0.05. Results: The maternal mortality ratio (MMR) was 964 and 247 per 100,000 live births for YCH and BRH, respectively. More deaths occurred within the aged group range 20 to 34 years, 76.8% at YCH and 64.7% at BRH. At YCH, 70.7% of these patients were referrals versus 32.4% at BRH. Complication from abortion was often implicated at BRH (P = 0.007;OR = 0.31;CI = 0.13 - 0.74). Others causes were hemorrhage (YCH = 43.4%;BRH = 35.5%), hypertensive diseases (YCH = 17.2%;BRH = 14.7%) and infections (YCH = 8.1%;BRH = 17.6%). At YCH time elapsed from admission to death was <3 h (P = 0.005;OR = 6.63;CI = 1.49 - 29.5). Conclusion: Both hospitals have similar causes of maternal deaths, differing only in the context within which the deaths occurred. Improving access to good quality health care, satisfying unmet needs for family planning, availability of blood products and the establishment of health insurance could decrease the maternal mortality rate.

The Epidemiological Characteristics of Beijing Lineage Mycobacterium tuberculosis from a National Referral Center in China

Our study was to investigate the epidemiological characteristics of M.tuberculosis from a national tuberculosis referral center in China. All strains isolated from TB patients, were genotyped by the RD105 deletion, 8 and 51 SNP loci and VNTR. The high differentiation SNPs of modern Beijing strains were analyzed for protein function and structure. 413 M. tuberculosis were included. Of 379 Beijing lineage M. tuberculosis, ＇modern＇ and ＇ancient＇ strains respectively represented 85.5% （324/379） and 14.5% （55/379）. Rv2494 （V48A） and Rv0245 （Sl03F） were confirmed as high differentiation SNPs associated with modern strains. In a word, Modern Beijing lineage M.tuberculosis was dominant and the structural models suggested that modern sub-lineage may more easily survive in ＇extreme＇ host condition.

Hard exudates referral system in eye fundus utilizing speeded up robust features

In the paper a referral system to assist the medical experts in the screening/referral of diabetic retinopathy is suggested. The system has been developed by a sequential use of different existing mathematical techniques. These techniques involve speeded up robust features（SURF）, K-means clustering and visual dictionaries（VD）. Three databases are mixed to test the working of the system when the sources are dissimilar. When experiments were performed an area under the curve（AUC） of 0.9343 was attained. The results acquired from the system are promising.

Age-determined referral criteria of myopia for large-scale vision screening

Background: This study aimed to explore the best screening measure of myopia and its associated optimal referral criteria for children aged between 6 and 16.Methods: After informed consent of cycloplegia was obtained, a total of 6,321 children aged between 6 and 16 from 53 primary or junior middle schools in Jiading District of Shanghai were included in our populationbased study. Receiver operating characteristic(ROC) curve was performed to determine the best cutoff points, sensitivities and specii cities of different screening tests, including uncorrected visual acuity(UCVA), noncycloplegic autorefraction(NCAR) and the combination of these two tests.Results: There was significant difference in prevalence of myopia between boys and girls(χ~2=6.358, P=0.012). Compared with children of low age, the prevalence of older children was significantly higher(χ~2=1,386.404, P<0.001). For the combination of UCVA and NCAR, the best cutoff point was UCVA less than or equal to 0.2 logarithm of minimum angle of resolution(MAR)(20/30) and NCAR spherical equivalent refraction(SER) less than or equal to -0.75 diopters(D), with associated sensitivity and specificity of 75.0% and 85.0%, respectively, which were higher than those of UCVA and NCAR alone. After stratified by age, the best cutof points were varied among children. The accuracy for children aged between 9 and 12 was higher than that for other ages.Conclusions: The best screening measure of myopia was the combination of UCVA and NCAR. The optimal referral criteria of myopia for children should be age-determined.

Magnetic sphincter augmentation: Optimal patient selection and referral care pathways

Outcomes associated with magnetic sphincter augmentation (MSA) in patients with gastroesophageal reflux disease (GERD) have been reported,however the optimal population for MSA and the related patient care pathways have not been summarized.This Minireview presents evidence that describes the optimal patient population for MSA,delineates diagnostics to identify these patients,and outlines opportunities for improving GERD patient care pathways.Relevant publications from MEDLINE/EMBASE and guidelines were identified from 2000-2018.Clinical experts contextualized the evidence based on clinical experience.The optimal MSA population may be the 2.2-2.4% of GERD patients who,despite optimal medical management,continue experiencing symptoms of heartburn and/or uncontrolled regurgitation,have abnormal pH,and have intact esophageal function as determined by high resolution manometry.Diagnostic work-ups include ambulatory pH monitoring,high-resolution manometry,barium swallow,and esophagogastroduodenoscopy.GERD patients may present with a range of typical or atypical symptoms.In addition to primary care providers (PCPs) and gastroenterologists (GIs),other specialties involved may include otolaryngologists,allergists,pulmonologists,among others.Objective diagnostic testing is required to ascertain surgical necessity for GERD.Current referral pathways for GERD management are suboptimal.Opportunities exist for enabling patients,PCPs,GIs,and surgeons to act as a team in developing evidence-based optimal care plans.

Knowledge and practices of primary care physicians on the current referral system of diabetic retinopathy in Islamabad and Rawal-Pindi, Pakistan

AIM: To assess the current knowledge and practices in diabetic eye care and referral system regarding diabetic retinopathy(DR) in health centers of Islamabad and RawalPindi. METHODS: A cross-sectional study was carried out in 4 government and private health centers in RawalpindiIslamabad from May 2018 to Oct. 2018. A total of 38 Primary Care Physicians(general practitioners, family physicians, and internists) were recruited out of which data for 2 were either not returned, or were missing partially. Data were collected through a 27-item consented & validated, multiple-choice questionnaire based on physician characteristics, knowledge and practice of diabetic eye care and challenges faced due current DR referral system. Descriptive analyses for all variables were performed including, mean and standard deviation. Analytical analyses were also conducted to study association between different study variables. RESULTS: Mean scores of knowledge for general practitioners, family physicians, and internists were 41.7%, 42.0% and 46.6% respectively. A lack of knowledge, and suboptimal practices were observed regarding signs, symptoms, screening, testing, evaluation and referral of DR regardless of physicians’ specialty, or years in practice. Lack of expertise regarding direct ophthalmoscopy, interpretation of findings, and referral to an ophthalmologist were noted. Physicians who performed consultation and counselling according to patients’ needs referred more patients to an ophthalmologist than those who restricted their consultationto a fixed amount of time and had more patients per unit time(P=0.01). Physicians who had taken care of less than 5 number of patients with DR marked less incorrect answers with no significantly greater number or correct answers compared to physicians who had taken care of more than 5 number of patients with DR(P=0.044). An association of more than 5 patients with DR taken care of with more need based patient consultation and counselling was also noted(P=0.017). An evaluation of the current referral system for DR revealed major loopholes in the health care infrastructure, proper guidelines, properly functioning equipment, check and balances, and lack of guidance to physicians regarding acquiring and updating knowledge regarding DR. CONCLUSION: Lack of updated and adequate knowledge, practices among primary care physicians, and suboptimal diabetic eye care and referral system have contributed to late presentation of DR. Interventions are needed to improve current diabetic eye care, and knowledge and practices of primary care physicians.

Analysis of Referrals for Mandibular Advancement Appliances for Sleep Apnoea

Aim: This article investigates the increasing awareness of Obstructive Sleep Apnoea (OSA) as a potentially serious health risk and highlights the role of the dentist in managing mild to moderate OSA cases which can be improved with an intra-oral mandibular advancement appliance. Methods: Data from referrals to a Prosthodontic Unit from 01-01-2019 to 18-8-2022 were analysed. Results: A total of 240 consecutive referrals to an NHS hospital where a patient was fitted with a mandibular advancement appliance (MAA) were analysed and 160 (67%) were male and 80 (33%) were female. The mean age in years was 52 (2019), 50 (2020), 52 (2021) and 51 (2022). Mean age of male referrals was 51 and female referrals was 53. Conclusion: There are a large number of patients with OSA seeking a dental device and practitioners should be aware of this treatment modality to help the medical team manage OSA. Clinical relevance: Dentists may need to have a greater understanding of OSA and be able to provide MAAs.

A Study Protocol on the Evaluation of Referral Strategies for Inflammatory Arthritis in Primary Care Patients at the Level of Healthcare Organization, Patient Relevant Outcomes and Costs

Background: Considering the importance of getting the right patient at the right location to maintain and optimize quality of life of inflammatory arthritis patients, appropriate referral by general practitioners is essential. This study aims to assess the effect and cost effectiveness of different referral strategies for inflammatory arthritis in primary care patients. Methods: This study follows a cluster randomized controlled trial design. General practitioners from primary care centers in Southwest-The Netherlands are randomly assigned to either one of the two strategic interventions for referring adult patients who are in the opinion of the general practitioner suspected of inflammatory arthritis: 1) Standardized digital referral algorithm based on existing referral models PEST, CaFaSpA and CARE;2) Triage by a rheumatologist in the local primary care center. These interventions will be compared to a control group, e.g. usual care. The primary outcome is the percentage of patients diagnosed with inflammatory arthritis by the rheumatologist. Secondary outcomes are quality of life as a patient reported outcome, work participation and healthcare costs. These data, including demographic and clinical parameters, are prospectively collected at baseline, three, six, and twelve months. Discussion: If this study can demonstrate improvements in appropriate referrals to the rheumatologist, thereby improving cost-effectiveness, there is sufficient supporting evidence to implement one of the referral strategies as a standard of care. Finally, with these optimization strategies a higher quality of care can be achieved, that might be of value for all patients with arthralgia. Trial Registration: NCT03454438, date of registration: March 5, 2018. Retrospectively registered: https://clinicaltrials.gov/ct2/show/NCT03454438?term=NCT03454438&draw=1&rank=1.

Service Delivery Factors That Influence Utilization of HIV Integrated Primary Health Care Programme in Embu Referral Hospital, Kenya

Globally, there are approximately 36.7 million people living with HIV. Integration of HIV treatment with primary care services improves effectiveness, efficiency and equity in service delivery. The study sought to establish service delivery factors that influenced utilization of integrated HIV and primary health care services in Embu Teaching and Referral hospital. A descriptive cross-sectional survey design was used to collect data at a specific period and point of time from a sample of 302 seropositive clients who were selected using simple random method. Data collection tool was structured and semi-structured questionnaire. The tool was reliable at Cronbach’s alpha of 0.817. SPSS version 23 was used to analyze the data. A binary logistic regression model was used to predict the relationship between service delivery and utilization of integrated services. Results: Majority of the respondents (59.6%) were aged over 35 years with majority being female (58.9%) and the married were 57.6% of the total sample. On service delivery factors, majority (94.7%) felt that their health status had improved. Action taken when clients developed side effects, 78.8% reported that the drugs were changed. Action taken following drug side effects significantly affected utilization, χ2 = 1.305, p = 0.001, df = 1. The findings showed that waiting time significantly influenced utilization, χ2 = 9.284, df = 1, p = 0.002. Source of information on self care also significantly influenced utilization, χ2 = 10.689, df = 1, p = 0.001. Kind of treatment at the facility also significantly influenced utilization, χ2 = 5.713, p = 0.048. Conclusion: significant factors that influenced utilization of integrated services were source of health care information, secondly waiting time was another factor which influenced utilization. Majority of the respondents were satisfied with duration of time they take before they were served;they reported to take utmost 1 hour to be attended to and action taken by health care provider following side effects was another factor that influenced the utilization.