Asthma affects over 300 million people worldwide and is the sixth highest cause of morbidity and mortality in South Africa. Mitchell’s Plain is a large suburb in Cape Town, with a population of approximately 320 000 people. A previous study in 2006 indicated that 15.7% of patients that presented to Mitchell’s Plain Community Health Care casualty were for an acute exacerbation of asthma and 7.8% of total deaths were from acute asthma. There was generally poor adherence to the national guidelines with respect to the management of an acute asthma exacerbation. Aim and Objectives: This study aimed to assess and improve the quality of management of acute bronchospasm at Mitchell’s Plain CHC. Objectives included assessing the current management, comparing it to the national guidelines and implementing strategies to improve care. Method: The study methodology was that of an audit cycle. Eligible patients were identified from the casualty admissions register. A total of 351 patients’ records were reviewed and compared to criteria based on the national guidelines. The initial findings were presented to the casualty staff that critically reflected; planned and implemented change. Intervention strategies involved raising awareness about the asthma guidelines, the audit tool and the South African Triage Score. A re-audit was performed after 6 months.

Background: The importance of effective team work for improving quality of care has been demonstrated consistently in research. We conducted a baseline measure of team effectiveness and a baseline measure of primary health care performance. Aim: To improve Primary health care team effectiveness and ultimately the quality and user experience of primary care at Du Noon Community Health Centre. (CHC) Setting: Du Noon CHC in the southern/western substructure of the Cape Town Metro district services. Methods: A cross sectional study using a combination of Nominal Group Technique (NGT) method and a questionnaire survey to assess PHC team effectiveness and to obtain baseline measure for Primary Health Care (PHC) organization and performance. Results: Data from 20 providers from the primary health care team, showed that the PHC team members perceived their team as a well functioning team (70% agreement on the 7 items of the PHC team assessment tool, incorporated in the ZA PCAT. The NGT method reveals that communication and leadership are the main challenges to effective team functioning, The NGT also provides ideas on how to deal with these challenges. Data from 110 users and 12 providers using the ZA PCAT: 18.2% of users rated first contact-access as acceptable to good; 47,3% rated ongoing care as acceptable to good. The remaining subdomains of the ZA PCAT were rated as acceptable to good by at least 65% of the users. 33% of the providers (doctors and clinical nurse practitioners) rated first contact-access as acceptable to good; 25% rated ongoing care as acceptable to good, the remaining subdomains of the ZA PCAT were rated as acceptable to good by at least 50% of providers. First contact-access received the lowest acceptable to good score (18.2%) and comprehensiveness (service available) received the highest score (88.2%) from the users. For the providers the lowest acceptable to good score was for ongoing care (25%) and the highest acceptable to good score was for primary health care team (100%). The total primary scores are good (above 60%) for both users and providers but moderately higher for the providers. Conclusions: How teams perceive their effectiveness can motivate them to generate ideas for improvement. There were discrepancies between ZA PCAT (PHC team functioning) results and the NGT method results. The ZA PCAT (8 pre-existing domains) baseline results show a contrast between providers' and users' perceptions of the PHC system at Du Noon consistent with the finding of the Western Cape ZA PCAT study. We encourage Du Noon CHC to use these results to improve the user experience of primary health care services there.

Includes summary. / Includes bibliographical references (leaves 44-48). / In his experience working in the Metro District Health Services Clinics of the Department of Western Cape, the researcher has encountered numerous cases of sub-standard quality of medical care for mental health patients. These encounters, as well as a need to audit the general quality of care of patients with chronic diseases of lifestyle, have been the motivation behind the creation of this research project.The study is a retrospective cohort study using patient folders as a source of data. It compares the standards, processes and outcomes of the management of hypertension in two populations at Crossroads Community Health Clinic in Cape Town. The first cohort consists of hypertensive patients with psychiatric illnesses, and the second are hypertensive patients without psychiatric illnesses. The study attempts to examine the quality of care of established hypertension in patients with psychiatric illnesses.

Voluntary medical male circumcision (VMMC) programs have been implemented in fourteen countries in sub Saharan Africa since 2007. The uptake of services has been suboptimal in some of the countries partly due to the widespread use of surgical methods. Circumcision using device methods was postulated to increase the uptake of VMMC services by making the procedure quicker and more appealing to men. We conducted a systematic review to establish the uptake and acceptability of the Prepex and Shang ring male circumcision devices in VMMC program countries. A metaanalysis was also performed. Methods: A comprehensive literature search from several databases was carried out to identify studies reporting VMCC coverage, uptake or acceptability of either the Prepex or Shang ring device methods. Search terms included, “non-surgical methods, male circumcision instrumentation as well as the individual device names such as Prepex, Shang ring, Gomco, Mogen, Plastibell, Accucirc, Alisklamp, Ismail Clamp, Tara Klamp, Unicirc, Smartclamp”. Electronic searches were complemented by going through the reference lists of the included studies. All searches were carried out on 12th May, 2017. Included studies must have been conducted between 1st April, 2007 and 28th February, 2017.The search was limited to studies among adolescents and adults in VMMC implementing countries. Two reviewers independently reviewed, rated, and abstracted data from each article. Uptake estimates were pooled in a meta-analysis and stratified according to the device method and participant age using Stata. Acceptability of device methods among recipients was summarized using four criteria and presented as proportions. Results: Of the 391 total articles retrieved, 25 studies incorporating observational and interventional study designs met the inclusion criteria. Of these 25 studies, 7 articles reported uptake of device method, 5 and 2 being on the Prepex and Shang ring devices respectively. The pooled uptake estimate was 75% (95% confidence interval 62% to 89%). Prepex uptake was estimated to be 73% while the Shang ring estimates were 82%. On stratification by population group, uptake of device methods among adolescents was 82% compared to 72% by adults. Majority (21) of the studies reported at least one of the criteria used to assess device acceptability. Acceptability of the two device methods was high: 95% of participants reported satisfaction with a device procedure. The devices were not associated with lengthy periods out of work, with 87% of participants reported to have resumed normal activities within two days after the procedure. Almost all (97%) participants circumcised with the device methods indicated they would recommend a device procedure to a friend or relative. Conclusion: Our findings showed a high uptake and acceptability of the two circumcision devices methods that have been prequalified by WHO for use among adolescents and adults. There is a dearth of evidence on the extent of utilization of devices for adolescent or adult circumcision and whether this has improved the overall uptake of VMMC services, thus emphasizing the need for more studies on this topic.

Includes bibliographical references / The group studied were elderly people who had recently experienced an unexpected deterioration in their functioning, and who seemed to be coping well. It has been noted in the literature that many elderly continue to "age well" despite a setback to their health. The aim of this study was to understand and describe factors that participants had found useful in adapting to deterioration in health, so as to inform others going through a similar process, and health care workers who work with the elderly. This was a qualitative study conducted in a General Practice setting in Southern Suburbs of Cape Town. Nine semi-structured interviews were conducted. These were recorded and transcribed. Transcriptions were analyzed using Thematic Analysis. Analysis revealed a Core Theme, "In search of a new normal life", which described a process of transformation of aspects of themselves which participants needed to undergo in order to successfully deal with their new circumstances. Additionally, four Themes were identified that facilitated this transformation. These were "Groundwork" (preparation for old age), "Support" (family, friends and accepting help) , "Spirituality" (religious as well as existential wellbeing) and "Character" (key traits and attitudes). Overall, this study suggested that in order to continue to "successfully age" when health fails, a process of transformation of self seems to be necessary. Furthermore, it identified facilitating factors that may be able to be taught and learned. Importantly, the study also highlighted the shortcomings of the prevalent "Pathological Model" of health with respect to care of the elderly. The following implications for practice in caring for the elderly emerged from this study. One: Health care practitioners need to look beyond the biomedical model and remember the importance of spiritual, social and psychological dimensions that contribute towards living a meaningful life in older age. Two: Health care practitioners need to be aware of a transformative process that the elderly undergo in dealing with deteriorating function, and to assist in this process. Further research in this area to develop practical interventions, is recommended. Three: Based on the factors identified that facilitate transformation, health care practitioners need to educate their younger patients about what measures they can put in place to prepare for older age.

Background: There is an increasing amount of blood sample rejection at primary health care facilities (PHCFs) impacting negatively on the staff, facility, patient and laboratory costs. Aim: The primary objective was to determine the rejection rate and reasons for blood sample rejection at four PHCFs pre and post phlebotomy training. The secondary objective was to determine whether phlebotomy training improved knowledge amongst primary health care providers (HCPs) and to develop a tool for blood sample acceptability. Study Setting: Two Community Health Centres (CHCs) and two Community Day Centres (CDCs) in Cape Town. Methods: A quasi-experimental study design. Results: The sample rejection rate was 0.79% (n= 60) at CHC A, 1.13% (n= 45) at CHC B, 1.64% (n= 38) at CDC C and 1.36% (n= 8) at CDC D pre training. The rejection rates remained approximately the same post training (p>0.05). The same phlebotomy questionnaire was administered pre and post training to HCPs. The average score increased from 6 3% (95% CI 6.97 - 17.03) to 96% (95% CI 16.91 - 20.09) at CHC A (p 0.039), 58% (95% CI 9.09 – 14.91) to 93% (95% CI 17.64 – 18.76) at CHC B (p 0.006), 60% (95% CI 8.84 – 13.13) to 97% (95% CI 16.14 – 19.29) at CDC C (p 0.001) and 63% (95% CI 9.81 – 13.33) to 97% (95% CI 18.08 – 19.07) at CDC D (p 0.001). Conclusion: There is no statistically significant improvement in the rejection rate of blood samples (p>0.05) post training despite knowledge improving in all HCPs (p <0.05).

Background: Warfarin is the most frequently used oral anticoagulant worldwide and it is the oral anticoagulant of choice in South Africa for reducing thrombosis - related morbidity and mortality. However, the safety and efficacy of warfarin therapy depends mainly on careful monitoring and maintenance of the international normalized ratio (INR) within an optimal therapeutic range. In the ACTIVE - W trial conducted across nine countries, South Africa had the poorest anticoagulation control with warfarin. This study showed that 86% of patients on warfarin therapy in the country have their mean time in therapeutic range below target. This was an indication of a very poor warfarin control in South Africa .The trial reported centre - specific differences within each country. It was however silent on these differences in South Africa. Aim: The aim of this study was to describe the profiles and the anticoagulation outcomes of patients on warfarin therapy in a major warfarin clinic in Western Cape Province of South Africa. Setting: Victoria Hospital - a district hospital in Cape Town, South Africa, which serves around one million people. Methods: A cross sectional review of clinical records of patients on warfarin therapy who attended the INR clinic from 01 January 2014 to 30 June 2014 was done. Data analysis was done with Stata to generate appropriate descriptive data and groups were compared using non - parametric tests. Results: Age range for male patients was between 29 - 85 years with median age of 62 years, while that of female patients was between 17 - 92 years with a median age of 66 years. Atrial fibrillation (AF) was the commonest indication for warfarin use in this study and hypertension was the commonest co-morbidity amongst these patients. Only 48.5% (66 patients) achieved target therapeutic range as of 01 July 2014, while 51.5% (70/136) of the patients were out of range. Patients who were non - alcohol users (88.9%) had better therapeutic control than those who consumed alcohol (9.6%). There was a significant association between alcohol consumption and poor anticoagulation outcomes (p value <0.022). Unlike alcohol use, there was no statistical relationship between smoking habit and target therapeutic range (P value = 0.198). The study also showed that anticoagulation outcomes were better among the older age groups, male patients and in those with atrial fibrillation. The prevalence of thrombotic events while on warfarin treatment was 2.2%, while prevalence of haemorrhagic events was 14%. Most of the patients with bleeding events were on concurrent use of warfarin and other medications with potential drug interactions. Conclusion: In this study, patients who achieved target therapeutic control were less than the acceptable 60%. Bleeding complications were more common among patients on concurrent use of warfarin with other medications such as NSAIDS and simvastatin. Therefore, it is of utmost importance for health professionals to take note of drug - drug or drug - disease interactions among patients on warfarin and to monitor INR levels more frequently in patients who have to unavoidably be on concurrent use of medications with possible major interactions with warfarin. Keywords: Oral anticoagulant, anticoagulation outcomes, therapeutic control, percentage INR within target therapeutic range (%ITTR).

Background: Hospital discharge letters are an essential part of good patient record keeping that ensures transmission of the healthcare information of a patient from the hospital of admission to the primary care practitioner. These letters were traditionally handwritten, but the medical ward in Victoria hospital Wynberg in adapting to current progress in clinical record keeping has transited from paper to the use of electronic discharge letters. Objectives: To audit the structure and contents of the electronic discharge summaries and find out to what extent they meet universally accepted criteria. Methodology: A retrospective clinical record audit of 60 patient records was conducted, spanning a period of 12 months (January-December) of 2018. Sequential sampling was used to select five folders from each months’ discharge records, making a total study sample of 60 patient records. A checklist of prescribed criteria was developed and used to collect data which was analysed descriptively. Ethical approval was obtained from University of Cape Towns’(UCT) Human Research Ethics Committee (HREC) and the Western Cape Government Provincial Research Committee. Electronic discharge letters compiled in the period 1 January- 31 December 2018 with corresponding folders found properly indexed in the medical records department were included in the sample, while discharge letters where the folders could not be found were excluded, as were the folders of patients who died during the hospital admission. Results: Nearly all clinical records contained biodata (100%), contact details (93%) and clinical details (93%). Only two-thirds of the folders contained information on other diagnoses(67%) and investigations matched clinical issues 63%.). The least compliant category was medication changes(53%), with just under half the folders containing this information. Conclusion: This study found that clinical records met 67% of the standards that define clinical and medico-legal compliance in the internal medicine ward in Victoria Hospital Wynberg. Several areas for future intervention were identified. A useful audit tool was also developed for ongoing quality improvement cycle.

Includes bibliographical references / The use and demand of echocardiography has increased worldwide. In developed countries, this has not been translated into improved access outside tertiary centres. Previous studies have favoured the appropriate use of echocardiography over its clinical impact, limiting generalisability to resource constrained settings. Objectives: To assess the impact of an echocardiographic service at district hospital level in Cape Town, South Africa. Methods: A prospective, cross-sectional study was performed. A total of 210consecutive patients, referred to the echocardiography clinic over a five-month period, were recruited. Transthoracic echocardiography was evaluated by its indication, new information provided, correlation with referring doctor's diagnosis and subsequent management plan. Impact included the escalation and de-escalation in treatment, as well as usefulness without a change in management. Results: The results show that 84% of the patients' management was impacted by echocardiography. Valvular lesions were the main indication. The most frequent contribution was information provided towards the diagnosis of heart failure and assessment post-myocardial infarction. Fifty-six per cent of the echocardiograms confirming the referring doctor's diagnosis still had a significant impact. The rational prescription of medication had the major impetus, followed by de-escalation of therapy and screening patients for referral to tertiary facilities. Conclusion: Echocardiography has a positive impact on patient management outside tertiary settings, where the definition of impact appears to be different. The value of a normal study, screening prior to upstream referral and usefulness irrespective of change has been established. This should alert policy makers towards the risk of restricted access and promote training.

Introduction: Tenofovir-Emtricitabine-Efavirenz (TEE) fixed-dose-combination (FDC) has been recommended since 2013 as the first-line antiretroviral therapy (ART) for treating HIV for people living with the virus (PLWH) in South Africa. More evidence has emerged to show long term adverse effects of Efavirenz(EFV). This study assesses the adverse effect profile of TEE by determining the event rate of switching from co-formulation and the reason for such switch. Method: This retrospective cohort study involved the review of the records of HIV infected adults receiving the TEE fixed dose combination ART over a 5-year period. All adult patients 18 years age or above, non-pregnant, previous ART treatment naïve that started TEE during 1 September 2014 and 31 August 2019 were included. Follow-up was censored at first drug change, transfer-out, loss-of-follow-upon deaths. Results: Two-thousand-and-ninety subjects were newly initiated on ART and 1961 met the inclusion criteria. Ninety-four patients (4.8%) had drug-changes prior censor date whereas 1867 remained on TEE. Forty-seven (50%) were single drug changes due to adverse effects and the other 50% were regimen changes as result of virological failure. The median time to change for TDF and EFV were 0,24 and 1,26 person years respectively. The median time to change for virological failure was 1,02 years. Patients with baseline CD4 count less than 200 cells/uL has higher risk of switch event. The proportion of poor outcome (death or loss to follow up) in patients with no drug switches (8,78%) was similar to those of patients with drug changes(8,5%). Conclusion: Tenofovir-Emtricitabine-Efavirenz combination treatment remains an excellent first-line ART option for people living with HIV, with a low rate of substitutions due to toxicity and high virological suppression. With the advent of Tenofovir-Lamivudine-Dolutegravir combination regimen as the preferred first-line, clinicians should remain cognisant of Tenofovir adverse drug effects.