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研究生:伊畢天
研究生(外文):Tegawendé Pierre Ilboudo
論文名稱:布吉納法索偏遠地區醫療照護轉院之遵從性及適當性
論文名稱(外文):Compliance and appropriateness of referral for curative care in rural Burkina Faso
指導教授:黃心苑黃心苑引用關係
指導教授(外文):Nicole Huang
學位類別:碩士
校院名稱:國立陽明大學
系所名稱:公共衛生研究所
學門:醫藥衛生學門
學類:公共衛生學類
論文種類:學術論文
論文出版年:2009
畢業學年度:97
語文別:英文
論文頁數:79
中文關鍵詞:轉院遵從性適當性布吉納法索
外文關鍵詞:ReferralComplianceAppropriatenessBurkina Faso
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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.
CHAPTER ONE: INTRODUCTION 1
1.1 The country profile 1
1.2 Background and significance 4
1.3 Specific aims 6
CHAPTER TWO: LITERATURE REVIEW OF REFERRAL SYSTEM IN DEVELOPING COUNTRIES 7
2.1 Low referral rate 7
2.2 Poor compliance with referral 9
2.3 Inappropriate hospital admission and referrals 11
2.4 Summary 14
CHAPTER THREE: METHODOLOGY 15
3.1 The study setting 15
3.2 Sample and Data 16
3.2.1 Compliance assessment 17
3.2.2 Appropriateness assessment 18
3.3 Statistical Analysis 21
CHAPTER FOUR: RESULTS 23
4.1 Referral compliance assessment 23
4.2 Referral appropriateness assessment 27
4.2.1 Severe Malaria in children under five 27
4.2.2 Pneumonia in adults 28
CHAPTER FIVE: DISCUSSION 30
5.1 Compliance with referral 30
5.1.1 The low compliance rate 30
51.2 Factors associated with low compliance 33
5.2 Appropriateness of referral 37
5.2.1 High proportion of incorrect diagnoses 37
5.2.2 Appropriateness of provider’s decision 39
5.3 Limitations of the study 41
CHAPTER SIX: CONCLUSIONS AND POLICY IMPLICATIONS 45
REFERENCES 47
TABLES 54
FIGURES 61
APPENDICES 65
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