Nominated From: University of Washington
Research Site: Ghana
Research Area: Surgery/Emergency Medicine/Trauma
Primary Mentor: Charles Mock
Assessing Referral Patterns for Newly Diagnosed HIV-Infected Trauma Patients in Ghana
The Human Immunodeficiency Virus (HIV) epidemic has brought new frontiers to medicine and surgery. While strides are made in developed nations, care of HIV patients lags behind in many LMICs. HIV-related mortality 5 of 9 remains the highest cause of death in Sub-Saharan Africa(1), but with widespread antiretroviral medication implementation, the WHO is working towards reducing HIV-related mortality by 25% by this year(2). Recently, the WHO has recommended initiating treatment for all patients infected with HIV(3), regardless of CD4 count.
However, more than 50% of currently infected patients in Africa remain undiagnosed(4). As these patients are diagnosed, the already stressed medical systems in LMICs will need to develop new and efficient means to address the increasing need for patient care and treatment.
Surveys of medical systems and referral practices across Africa have noted widespread deficits in accessing specialized care(5-8). Within this, HIV care is particularly difficult not only with respect to identifying infected patients, but also ensuring they begin proper treatment in a timely fashion(9). Initially described in the United States(10), recent studies in East and Central African countries revealed that trauma and surgical patients had tenfold the prevalence of HIV over national rates(11,12). Similar findings(13) have been demonstrated in a large hospital in Ghana, and suggest an opportunity to direct a relatively large number of undiagnosed patients with HIV to appropriate care.
By analyzing the referral practices of newly diagnosed patients from the Accident and Emergence (AE) ward, we will gain insight into the referral pathway that HIV-infected patients follow to treatment, providing an opportunity to identify deficits, and eventually targets, for strategic improvement aimed at strengthening and streamlining the referral process and maximizing patient retention.
- Describe current practices and perceptions of referrals for injured patients after discharge (e.g. referral to postoperative clinics, rehab, HIV clinics)
- Identification and timed analysis (i.e. “Time-and-Motion” methods) of key steps (i.e. “work elements”) along referral pathway to HIV care
- Recommend targeted interventions to improve efficiency of referrals to HIV clinics and retention in patient care based on the findings
The recommended interventions will be introduced to study facilities with the help of hospital officials. Data collection will continue during this period. Additional major points of data aggregation and analysis will take place every two months thereafter for continual evaluation and adjustment of the improvement efforts. These interventions will be aimed at the systems level to ensure low-cost, sustainable solutions that will not only improve care for HIV-infected patients, but promote continued growth of system capacities (e.g. referral system, patient retention for follow-up care, provider communication).
While this will immediately benefit the newly diagnosed HIV-infected patients, it also has the potential for system-wide improvements by creating a roadmap for other referrals from trauma wards, including to physical therapy, rehab, establishing primary care, and specialized clinics. Further, an efficient referral processes to specialized care will improve HIV-infected patient satisfaction and clinical outcomes(18).
Outside of the intended effects of this study’s undertaking, there is also a potential for aggregating the collected data into a future HIV trauma database. The creation of this resource could be immensely valuable as we look towards the future of HIV and trauma research in LMIC, as well as serve as a model for system and outcome evaluation extending beyond Ghana into other HIV endemic developing countries.