Listening to older voices: results of a cross-sectional survey of older patient-reported experiences of facility-based healthcare in Nouna, Burkina Faso

Background: Ensuring responsive healthcare which meets patient expectations and generates trust is important to increase rates of access and retention. This need is important for aging populations where non-communicable diseases (NCDs) are a growing cause of morbidity and mortality. Methods: We performed a cross-sectional household survey including socio-demographic, morbidities, and health system utilization, responsiveness, and quality outcomes in individuals over age 40 in northwestern Burkina Faso. We describe results and use exploratory factor analysis to derive a contextually appropriate grouping of health system responsiveness (HSR) variables. We used linear or logistic regression to explore associations between socio-demographics, morbidities, and the grouped-variable, then between these variables and health system quality outcomes. Results: Of 2,639 eligible respondents, 26.8% had least one NCD, 56.3% were frail or pre-frail and 23.9% had a recent visit, including only 1/3 of those with an NCD. Highest ratings of care experience (excellent/very good) included ease of following instructions (86.1%) and trust in provider skills (81.1%). The HSR grouping with the greatest factor loading included involvement in decision-making, clarity in communication, trust in the provider, and confidence in provider skills, termed as Shared Understanding and Decision Making (SUDM). In multivariable analysis, higher quality of life (OR 1.02,95%CI 1.01-1.04), frailty (OR 1.47,95%CI 1.00-2.16), and SUDM (OR 1.06,95%CI 1.05-1.09) were associated with greater health system trust and confidence. SUDM was associated with overall positive assessment of the healthcare system (OR 1.02,95%CI 1.01-1.03) and met healthcare needs (OR 1.09,95%CI 1.08-1.11). Younger age and highest wealth quintile were also associated with higher met needs. Conclusions: Recent healthcare access was low for people with existing NCDs, and SUDM was the most consistent factor associated with higher health system quality outcomes. Results highlight the need to increase continuity of care for aging populations with NCDs and explore strengthening SUDM to achieve this goal.

Use of interrupted time series methods in the evaluation of health system quality improvement interventions: a methodological systematic review

BackgroundWhen randomisation is not possible, interrupted time series (ITS) design has increasingly been advocated as a more robust design to evaluating health system quality improvement (QI) interventions given its ability to control for common biases in healthcare QI. However, there is a potential risk of producing misleading results when this rather robust design is not used appropriately. We performed a methodological systematic review of the literature to investigate the extent to which the use of ITS has followed best practice standards and recommendations in the evaluation of QI interventions.MethodsWe searched multiple databases from inception to June 2018 to identify QI intervention studies that were evaluated using ITS. There was no restriction on date, language and participants. Data were synthesised narratively using appropriate descriptive statistics. The risk of bias for ITS studies was assessed using the Cochrane Effective Practice and Organisation of Care standard criteria. The systematic review protocol was registered in PROSPERO (registration number: CRD42018094427).ResultsOf 4061 potential studies and 2028 unique records screened for inclusion, 120 eligible studies assessed eight QI strategies and were from 25 countries. Most studies were published since 2010 (86.7%), reported data using monthly interval (71.4%), used ITS without a control (81%) and modelled data using segmented regression (62.5%). Autocorrelation was considered in 55% of studies, seasonality in 20.8% and non-stationarity in 8.3%. Only 49.2% of studies specified the ITS impact model. The risk of bias was high or very high in 72.5% of included studies and did not change significantly over time.ConclusionsThe use of ITS in the evaluation of health system QI interventions has increased considerably over the past decade. However, variations in methodological considerations and reporting of ITS in QI remain a concern, warranting a need to develop and reinforce formal reporting guidelines to improve its application in the evaluation of health system QI interventions.