Browsing by Author "Von Pressentin, Klaus Botho"

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    Evaluating the impact of family physicians within the district health system of South Africa
    (Stellenbosch : Stellenbosch University, 2017-12) Von Pressentin, Klaus Botho; Mash, Robert J.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Family Medicine and Primary Care.
    ENGLISH SUMMARY: The majority of the South African population are dependent on the public health sector in helping them deal with the quadruple burden of disease, consisting of HIV/AIDS and tuberculosis, maternal and child health problems, non-communicable diseases as well as trauma and violence-related injuries. The post-1994 South African government has embraced the global shift towards primary health care (PHC) as the vehicle for delivering quality health care to all. The health of communities is better in countries with strong PHC-centred health systems. Global evidence supports PHC delivered by primary care teams that include doctors with postgraduate training in family medicine (family physicians). However, the evidence on the contribution of family physicians (FPs) to strengthening health systems is mainly derived from high income countries. African leaders and policy makers are looking for local evidence on the potential role of FPs, as investment in the training and development of a new cadre of specialists in family medicine represents a significant financial commitment within the health system. According to a 2015 national consensus paper, South African FPs have six roles in the PHC team: care provider to patients, consultant to the PHC team (mainly nurses and doctors), champion of community-oriented PHC, clinical governance leader (focus on quality improvement), clinical trainer of students and registrars, and capacity building of the PHC team members. FPs are working in various aspects of the South African district health system (DHS), namely district hospitals, primary care facilities (health centres and clinics) and community based PHC teams (community health workers). The DHS consists of all health services relating to the health and wellbeing of a community within a defined geographic area (the health district). The discipline of family medicine was made a specialty in 2007 by the South African health professions council and resulted in re-structured training of FPs in keeping with the training model of other medical specialities. Graduates from this new training model have entered the DHS since 2011. These graduates are deployed in a heterogeneous manner in the different provinces, which reflect the uncertainty among policy makers and health managers on how best to use FPs in their districts. FPs represent a costly human resource investment in an environment dominated by vertical disease programmes and nurse-driven PHC services. This uncertainty together with the paucity of local evidence paved the way for anational study that was conceptualised in response to a joint funding call of the National Department of Health and EuropeAid in 2013, titled: “Strengthening primary health care through primary care doctors and family physicians”. This PhD research project represents one component of the overall project that aimed to evaluate the contribution of FPs to the DHS in South Africa. The study aimed to evaluate the impact of FPs within the DHS of South Africa. The study objectives are shown below: A. To describe the perceived impact of FPs in terms of their six roles within the DHS. B. To describe co-health workers’ perception of the impact of FPs compared to medical officers who had received no postgraduate training. C. To compare the perceived impact of FPs between metropolitan and rural districts, between facility types (district hospitals vs. primary care facilities), as well as by training programme model (graduation before and after 2011). D. To explore the perceptions of district managers regarding the impact of FPs in the following three domains: health system performance, clinical processes and health outcomes. E. To assess the influence of FPs at primary care facilities and district hospitals. The influence of FPs was evaluated in terms of two domains: health system performance, and quality of clinical processes across the burden of disease. F. To evaluate the impact of an increase in FP supply in each district (number per 10 000 population) on key health system performance indicators, key clinical processes and key health outcomes.
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    A medical audit of the management of Cryptococcal Meningitis in HIV patients in the Cape Winelands (East) District, Western Cape, South Africa
    (Stellenbosch : Stellenbosch University, 2010-12) Von Pressentin, Klaus Botho; Conradie, Hoffie H.; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Interdisciplinary Health Sciences. Family Medicine and Primary Care.
    ENGLISH SUMMARY : Introduction: This thesis summarises the findings of a medical audit on the management of Cryptococcal Meningitis (CM). The study population of HIV positive adults (N = twenty five) were admitted during November 2009 – June 2010 to five hospitals of the Cape Winelands (East) District, Western Cape, South Africa. In the context of the HIV pandemic, CM has become the most common cause of community-acquired meningitis, and has poor outcomes if left untreated. The South African HIV Clinician Society has published treatment guidelines in 2007. These guidelines have been used by the audit team to compile a list of measurable criteria (with set targets) to evaluate the structure, process and outcome of CM management. A pilot audit (2008) at the regional hospital has demonstrated that certain target standards were not met. Aims and Objectives: The aim was to improve the quality of the clinical care of HIV-patients diagnosed with CM in the Cape Winelands (East) district. The objectives included the review of the audit criteria and target standards, demonstrating improvement in quality of CM care at the Level 1 and 2 hospitals, identifying new interventions based on the findings and providing recommendations to the health facilities. Methods: In 2009, the researcher formed a new audit team, reviewed the audit criteria and held teaching interventions based on the national treatment guidelines. An intervention, based on the findings of the pilot audit, aimed at improving the clinical team’s adherence to the treatment guidelines. Results: The audit identified the following areas that did not meet the target standards: the availability of Amphotericin B (Ampho B) and spinal manometers; the use of manometry in all initial lumbar punctures (LPs); completing fourteen days of the required Ampho B treatment; renal monitoring in patients on Ampho B; commencement of antiretroviral treatment (ART) by week four; and, the two-month survival figures post-diagnosis. The re-audit at the Level 2 hospital highlighted the need for improved medical record keeping to aid the audit process. Arrangement of inpatient ART counselling happened more consistently at the Level 1 hospitals. Adherence to the ART target and measures to prevent Ampho B related morbidity is comparable to that of the Level 2 hospital. The audit has also provided insight to the researcher and audit team on the practical challenges of conducting a prospective data collection technique across different care settings. Recommendations Level 1 hospitals should continue to manage CM patients. The availability of spinal manometers and closer adherence to renal monitoring require attention. Formal feedback to the audit team and clinical teams is planned. A multimodal interdisciplinary Quality Improvement approach (such as an integrated care pathway) is recommended and a future re-audit is encouraged to assess improved adherence to the CM management guidelines. The buy-in of stakeholders (management, health care workers and patients), the ongoing support of an audit team and a committed Quality Improvement environment will allow the medical audit process to become ingrained in the South African public healthcare setting.