Joseph J. Mamlin

Integrating nutrition support for food-insecure patients and their dependents into an HIV care and treatment program in western Kenya.

The Academic Model Providing Access to Healthcare (AMPATH) is a partnership between Moi Teaching and Referral Hospital, Moi University School of Medicine, and a consortium of universities led by Indiana University. AMPATH has over 50,000 patients in active care in 17 main clinics around western Kenya. Despite antiretroviral therapy, many patients were not recovering their health because of food insecurity. AMPATH therefore established partnerships with the World Food Program and United States Agency for International Development and began high-production farms to complement food support. Today, nutritionists assess all AMPATH patients and dependents for food security and refer those in need to the food program. We describe the implementation, challenges, and successes of this program.

The impact of clinical encounter events on patient and physician satisfaction

Abstract This study explored levels of patient and physician satisfaction as a function of events which occur during the clinical encounter. Data which are directly observable (verbal and nonverbal) and obtainable through interviews were considered. Eighty-eight encounters were observed over a one-week period at an outpatient clinic of a university-affiliated hospital. Participants were interviewed subsequent to each interaction. Multiple discriminant analysis showed encounters viewed by patients as relatively unsatisfactory to be characterized by greater distance between parties during information gathering, increased amounts of feedback, highly active physicians, and physicians who were on call. Satisfied patients had encounters marked by increased physician use of (1) nonverbal encouragement, (2) questions about family and social situations, and (3) expressions of continuity from previous visits. Physicians were less satisfied in encounters in which they were active, felt pressed to other medical commitments, and were on call. The most positive physician assessments occurred when patients were seen as compliant and where humor and nonverbal encouragement were used during the interaction. These data suggest variables which are generally amenable to change if physicians are made aware of their potential impact.

Health beliefs and smoking behavior.

Smoking histories and beliefs about smoking were obtained on 120 ex- and current smokers. Ex-smokers view smoking as a serious health problem, did not report having a physician recommend they stop, and feel personally susceptible to its adverse effects. Moderate smokers (0-10/day) also view smoking as serious, but do not see themselves as vulnerable to its adverse effects. The data suggest that certain attitudes can discriminate between groups of current smokers, as well as smokers from ex-smokers.

Effects of home blood pressure measurement on long-term BP control.

This research reports level of blood pressure control and ability to maintain newly discovered hypertensives in a municipal hospital setting by use of family- and self-monitored home blood pressure units. Three hundred ninety-six patients were randomized into family- and self-monitored blood pressure groups and a control group. Findings indicate that the use of either self- or family-read cuffs is effective in the first six months of treatment in lowering blood pressures. The data are suggestive of a beneficial effect of the use of cuffs for up to 18 months; however, with additional time in the study, no differences in the level of blood pressure control could be demonstrated between groups. The use of family-monitored blood pressure cuffs produces a lower drop-out rate than does the use of no cuff. The effect on drop outs is substantial for the first year of treatment, but beyond 12 months, the family-read cuff is also more effective than no cuff in reducing drop outs.

AMPATH: living proof that no one has to die from HIV.

Background and ObjectiveThe HIV/AIDS epidemic in sub-Saharan Africa is decimating populations, deteriorating economies, deepening poverty, and destabilizing traditional social orders. The advent of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) made significant supplemental resources available to sub-Saharan national programs for the prevention and treatment of HIV/AIDS, but few programs have demonstrated the capacity to use these resources to increase rapidly in size. In this context, AMPATH, a collaboration of Indiana University School of Medicine, the Moi University School of Medicine, and the Moi Teaching and Referral Hospital in Eldoret, Kenya, is a stunning exception. This report summarizes findings from an assessment of AMPATH staff perceptions of how and why this has happened.Participants and ApproachSemistructured, in-depth, individual interviews of 26 AMPATH workers were conducted and recorded. Field notes from these interviews were generated by independent reviewers and subjected to close-reading qualitative analysis for themes.ResultsThe themes identified were as follows: creating effectively, connecting with others, making a difference, serving those in great need, providing comprehensive care to restore healthy lives, and growing as a person and a professional.ConclusionInspired personnel are among the critical assets of an effective program. Among the reasons for success of this HIV/AIDS program are a set of work values and motivations that would be helpful in any setting, but perhaps nowhere more critical than in the grueling work of making a complex program work spectacularly well in the challenging setting of a resource-poor country. Sometimes, even in the face of long odds, the human spirit prevails.

Patient attitudes toward health care: Expectations of primary care in a clinic setting

Abstract Patient satisfaction, defined as the degree to which patient expectations of health care areperceived as being fulfilled, has received increased emphasis in the evaluation of quality of care. To initiate research in this area, expectations of patients receiving care at an outpatient department of a teaching hospital were assessed. Patient expectations were found to be generally high. A factor analysis identified three dimensions of patient expectations: (1) the role of the provider; (2) mutual patient-physician responsibilities; and (3) the convenience of the services. The patient appeared to be subordinate and passive in his/her relationship with the physician. Patient expectations of non-physician providers were oriented toward personal qualities; for physicians, however, concern was with both competence and personal qualities. Cost of health services was not associated with the dimension of convenience.

After-hours telephone access to physicians with access to computerized medical records: Experience in an inner-city general medicine clinic

The authors examined the effect of after-hours telephone access to physicians and physician access to computerized medical records on hospitalizations and emergency room (ER) visits in an inner-city, adult, general medicine clinic. Patients were randomly assigned to a control (C) and two study groups (S1 and S2). Patients in study groups S1 and S2 had after-hours telephone access to physicians. Computerized medical records were accessible to physicians only for callers in study group S2. During the initial 18 months of study, only 7.6% of eligible patients called the after-hours service, a rate of 6 calls/1,000 patients/ month (200 calls/1,849 patients/18 months). Repeated promotion of the service was subsequently undertaken, and 19.4% of the patients used the service during the final 12 months of study, a rate of 24.1 calls/1,000 patients/month (467 calls/1,616 patients/12 months). There were no significant differences in hospitalizations or ER visits among the control and two study groups.

A clinician-nurse model to reduce early mortality and increase clinic retention among high-risk HIV-infected patients initiating combination antiretroviral treatment

BackgroundIn resource-poor settings, mortality is at its highest during the first 3 months after combination antiretroviral treatment (cART) initiation. A clear predictor of mortality during this period is having a low CD4 count at the time of treatment initiation. The objective of this study was to evaluate the effect on survival and clinic retention of a nurse-based rapid assessment clinic for high-risk individuals initiating cART in a resource-constrained setting.MethodsThe USAID-AMPATH Partnership has enrolled more than 140,000 patients at 25 clinics throughout western Kenya. High Risk Express Care (HREC) provides weekly or bi-weekly rapid contacts with nurses for individuals initiating cART with CD4 counts of ≤100 cells/mm3. All HIV-infected individuals aged 14 years or older initiating cART with CD4 counts of ≤100 cells/mm3 were eligible for enrolment into HREC and for analysis. Adjusted hazard ratios (AHRs) control for potential confounding using propensity score methods.ResultsBetween March 2007 and March 2009, 4,958 patients initiated cART with CD4 counts of ≤100 cells/mm3. After adjusting for age, sex, CD4 count, use of cotrimoxazole, treatment for tuberculosis, travel time to clinic and type of clinic, individuals in HREC had reduced mortality (AHR: 0.59; 95% confidence interval: 0.45-0.77), and reduced loss to follow up (AHR: 0.62; 95% CI: 0.55-0.70) compared with individuals in routine care. Overall, patients in HREC were much more likely to be alive and in care after a median of nearly 11 months of follow up (AHR: 0.62; 95% CI: 0.57-0.67).ConclusionsFrequent monitoring by dedicated nurses in the early months of cART can significantly reduce mortality and loss to follow up among high-risk patients initiating treatment in resource-constrained settings.

General internal medicine and technologically less developed countries

Objective:To assess the international health activities of departments of medicine, divisions of general medicine, and general medicine faculty and the interest among departments of medicine in joint international health ventures.Design:15-item, mailed questionnaire.Participants:100 chiefs of divisions of general medicine associated with training programs in internal medicine.Interventions:None.Measurements and main results:Completed questionnaires were returned by 87 division chiefs representing 1,355 general medicine faculty. 49% of divisions had faculty with six weeks’ experience in less developed countries. 8.5% of general medicine faculty had six weeks’ experience in less developed countries. 7.6% of general medicine faculty were interested in spending extended time in less developed countries. 19% of departments had formal collaborations with schools in less developed countries. 45% of departments were interested in affiliations with U.S. institutions for the purpose of joint international health ventures.Conclusions:The international health interests of current general medicine faculty may not be satisfied. Departmental and divisional encouragement of international interests would increase the number of U.S. general internists participating in less developed countries. The authors discuss the potential for greater involvement of general medicine faculty in international health.

Changing house staff attitudes toward nurse practitioners during their residency training.

This study examines the hypothesis that increased physician contact with nurse practitioners (NPs) during residency training would ecourage positive house staff attitudes. House staff expectations of and attitudes toward NPs were assessed at three points during the residency. Data indicated a more positive evaluation of NPs by house staff later in the residency program, as shown by: 1) physician expectations and valuation of NPs, 2) attitudes concerning future employment of NPs, and 3) the extent and capacity of NP utilization by residents.