Compliance and appropriateness of referral for curative care in rural Burkina Faso

• Main Authors: Tegawendé Pierre Ilboudo, 伊畢天
• Other Authors: Nicole Huang
• Format: Others
• Language: en_US
• Published: 2009
• Online Access: http://ndltd.ncl.edu.tw/handle/51302779936374714870

碩士 === 國立陽明大學 === 公共衛生研究所 === 97 === Background: The goal of this study was to contribute to improving the functioning of the referral system in rural Burkina Faso. The main objectives were to ascertain the compliance rate of referral and to identify factors associated with, and to ascertain appropriateness of provider’s referral decision from health center (HC) to first level referral hospital for two indicator conditions (severe malaria in children and pneumonia in adults). Methods: A record review of twelve months curative consultations in eight randomly selected HCs was conducted to identify referral cases, severe malaria (SM) in children under five and pneumonia in adults. To assess referral compliance, all patient documents at referral hospitals from the day the referral was made up to seven days later were checked to verify whether the referred case arrived or not. The correctness of diagnosis and the appropriateness of provider’s referral decision were determined using national clinical guidebook as the ‘gold standard’. Descriptive statistics were performed to compute the compliance rate and the appropriateness rate. Simple and multiple logistic regressions were performed to identify factors associated with referral compliance. Chi-square test and Fisher’s exact test were performed to explore difference between referred and non-referred cases with regard to appropriateness of provider’s decision. SPSS 15.0 package was used for the analysis. Results: The number of HC visits per patient per year was 0.6 and the referral rate was 2.0%. Of those who were referred the compliance rate was 41.5% (364/878). After adjustment, children between 5 and 14 years old (OR= 0.5; 95% CI=0.3-0.9), females (OR=0.7; 95% CI=0.5-0.95), patients referred during the rainy seasons (OR=0.6; 95% CI=0.4-0.8), non-emergency referrals (OR=0.5; 95% CI=0.4-0.7), referrals without a referral slip (OR=0.3, 95%; CI=0.2-0.4), patients referred directly to a regional hospital (OR=0.3; 95% CI=0.2-0.6) and referrals from HCs located 10 km or more from the District Hospital (OR=0.5; 95% CI=0.3-0.7) were significantly less likely to comply. Patients referred by a provider of above 30 years (OR=2.1; 95% CI=1.4-3.3) were more likely to comply with the referral. For SM cases in children under five, 14.4% (66/457) of diagnoses were correct according to the guidebook. The appropriateness rate of the provider’s referral decision was 60.6% (40/66). Of those who were actually referred (31 cases), 74.2% should not be referred (over-referral). Of those who were actually not referred (35 cases), 8.6% should be referred (under-referral). For pneumonia cases in adults, 5.9% (79/1331) of diagnoses were correct according to the guidebook. The appropriateness rate of the provider’s referral decision was 98.7% (78/79). There was only one case which should not be referred but referred (over-referral). Conclusions: In a rural district of Burkina Faso, we found a relatively low compliance with referral and that multiple factors were associated with a failure to comply. The adherence to the National guideline among health center providers in making diagnosis was low for severe malaria or pneumonia. The appropriateness of referral decision varied by condition. Interventions to improving compliance with referral should target cost concerns, potential geographical barriers, seasonal/climate factors, reinforcement of the District Hospital (DH) and improvement in the providers’ communication skills. Providers should be better trained in the diagnostic process and the management of SM cases. Evaluation of the validity and the reliability of the clinical guidelines and further qualitative studies regarding poor compliance of staff with clinical guidelines may contribute to improving the performance of referral system.