BackgroundRheumatic heart disease (RHD) remains a major health concern for Aboriginal Australians. A key component of RHD control is prevention of recurrent acute rheumatic fever (ARF) using long-term secondary prophylaxis with intramuscular benzathine penicillin (BPG). This is the most important and cost-effective step in RHD control. However, there are significant challenges to effective implementation of secondary prophylaxis programs. This project aimed to increase understanding and improve quality of RHD care through development and implementation of a continuous quality improvement (CQI) strategy.MethodsWe used a CQI strategy to promote implementation of national best-practice ARF/RHD management guidelines at primary health care level in Indigenous communities of the Northern Territory (NT), Australia, 2008–2010. Participatory action research methods were employed to identify system barriers to delivery of high quality care. This entailed facilitated discussion with primary care staff aided by a system assessment tool (SAT). Participants were encouraged to develop and implement strategies to overcome identified barriers, including better record-keeping, triage systems and strategies for patient follow-up. To assess performance, clinical records were audited at baseline, then annually for two years. Key performance indicators included proportion of people receiving adequate secondary prophylaxis (≥80% of scheduled 4-weekly penicillin injections) and quality of documentation.ResultsSix health centres participated, servicing approximately 154 people with ARF/RHD. Improvements occurred in indicators of service delivery including proportion of people receiving ≥40% of their scheduled BPG (increasing from 81/116 [70%] at baseline to 84/103 [82%] in year three, p = 0.04), proportion of people reviewed by a doctor within the past two years (112/154 [73%] and 134/156 [86%], p = 0.003), and proportion of people who received influenza vaccination (57/154 [37%] to 86/156 [55%], p = 0.001). However, the proportion receiving ≥80% of scheduled BPG did not change. Documentation in medical files improved: ARF episode documentation increased from 31/55 (56%) to 50/62 (81%) (p = 0.004), and RHD risk category documentation from 87/154 (56%) to 103/145 (76%) (p < 0.001). Large differences in performance were noted between health centres, reflected to some extent in SAT scores.ConclusionsA CQI process using a systems approach and participatory action research methodology can significantly improve delivery of ARF/RHD care.

BackgroundDue to Lesotho's high adult HIV prevalence (23%), considerable resources have been allocated to the HIV/AIDS response, while resources for non-communicable diseases have lagged. Since November 2011, the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) has supported Lesotho Ministry of Health to roll out Family Health Days (FHDs), an innovative strategy to increase community access to integrated health services, with a focus on hard-to-reach areas where immunization coverage, HIV service uptake, and screening and treatment for chronic diseases are low.MethodsServices were provided at mobile service delivery points from 17th October to 25th November 2011. Delivery points located in rural setting were staffed by multi-disciplinary teams of doctors, nurses, community workers, nutritionists, AIDS officers, and pharmacists (30-40 health professionals present).ResultsDuring this campaign, 8,396 adults were tested for HIV (67.3% female; 32.6% male). In all, 588 (7%) tested HIV-positive (6.7% female; 7.1% male). Among those testing HIV-positive, 68.5% (403) received CD4 testing and 36.6% were enrolled into HIV care at their nearest clinics. A total of 324 ART defaulters were identified and linked back to care. Follow-up with referral facilities showed 100% of patients (defaulters and newly enrolled) linked to care were enrolled at a facility. Standard immunizations were administered to 990 children. 4,454 adults (24.7% male; 75.3% female) were screened for hypertension, and of those screened, 24.2% had elevated blood pressure and were linked to care centers. Addtitionally, 3,045 adults had blood sugar tests (27.0% males; 73.0% females); 3.1% had elevated blood sugar and were linked to care facilities.ConclusionOffering integrated services within hard-to-reach communities can increase access to a variety of critical health services, including those for non-communicable diseases, and can link ART clients lost to follow-up back to facilities. This approach will be scaled up throughout Lesotho as a strategy to reach all populations in the country.

Aims Several centres described a ‘lockdown effect’: a reduction in emergency surgical admissions during national lockdown (23/03/20-01/06/20). The extent and reproducibility of this is unclear. We evaluated the impact of the COVID-19 pandemic on emergency general surgical activity in a district general hospital. Methods We conducted a retrospective analysis of patients admitted under general surgery and urology between 01/01/2017-31/12/2020 using coding data. Unpaired t-tests were used to compare the total monthly admissions, admissions by diagnosis and monthly operations performed between the ‘first wave’ (April-May 2020) and ‘average’ (all months 2017-2019), and between the ‘second wave’ (November-December 2020) and average. Results Overall emergency admissions in 2020 were reduced compared to the mean 2017-2019 (4498 vs 5037). Monthly admissions were significantly reduced in the first wave compared to 2017-2019 (mean monthly admissions=284.5 vs 419.8; p &lt; 0.001) with the greatest reduction in patients with non-specific abdominal pain (mean=58 vs 109; p = &lt;0.001). A significant reduction in monthly admissions with pancreatitis (mean=8.0 vs 14.6; p = 0.010) and diverticulitis (mean=10.5 vs 18.8; p = 0.028) were also observed. This effect was less apparent during the second wave (mean total admissions=384.5 vs 419.8; p = 0.249). Monthly emergency operations were reduced in both the first wave compared to average (68 vs 101.9; p = 0.007) and the second wave (74.5 vs 101.9; p = 0.025). Conclusions We found strong evidence of a ‘lockdown effect’ in our centre during the first wave. The cause is unclear and likely to be multifactorial. Further research is needed to evaluate whether surgical patients came to harm as a result.