Exploring sources of variability in adherence to guidelines across hospitals in low-income settings: a multi-level analysis of a cross-sectional survey of 22 hospitalsReportar como inadecuado

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Implementation Science

, 10:60

First Online: 28 April 2015Received: 11 November 2014Accepted: 11 April 2015DOI: 10.1186-s13012-015-0245-x

Cite this article as: Gathara, D., English, M., van Hensbroek, M.B. et al. Implementation Sci 2015 10: 60. doi:10.1186-s13012-015-0245-x


BackgroundVariability in processes of care and outcomes has been reported widely in high-income settings at geographic, hospital, physician group and individual physician levels; however, such variability and the factors driving it are rarely examined in low-income settings.

MethodsUsing data from a cross-sectional survey undertaken in 22 hospitals 60 case records from each hospital across Kenya that aimed at evaluating the quality of routine hospital services, we sought to explore variability in four binary inpatient paediatric process indicators. These included three prescribing tasks and use of one diagnostic. To examine for sources of variability, we examined intra-class correlation coefficients ICC and their changes using multi-level mixed models with random intercepts for hospital and clinician levels and adjusting for patient and clinician level covariates.

ResultsLevels of performance varied substantially across indicators and hospitals. The absolute values for ICCs also varied markedly ranging from a maximum of 0.48 to a minimum of 0.09 across the models for HIV testing and prescription of zinc, respectively. More variation was attributable at the hospital level than clinician level after allowing for nesting of clinicians within hospitals for prescription of quinine loading dose for malaria ICC = 0.30, prescription of zinc for diarrhoea patients ICC = 0.11 and HIV testing for all children ICC = 0.43. However, for prescription of correct dose of crystalline penicillin, more of the variability was explained by the clinician level ICC = 0.21. Adjusting for clinician and patient level covariates only altered, marginally, the ICCs observed in models for the zinc prescription indicator.

ConclusionsPerformance varied greatly across place and indicator. The variability that could be explained suggests interventions to improve performance might be best targeted at hospital level factors for three indicators and clinician factors for one. Our data suggest that better understanding of performance and sources of variation might help tailor improvement interventions although further data across a larger set of indicators and sites would help substantiate these findings.

KeywordsIntra-class correlation Variability Paediatrics Hospitals Clinicians Low-income settings Multi-level models Pneumonia Malaria Diarrhoea-dehydration  Download fulltext PDF

Autor: David Gathara - Mike English - Michael Boele van Hensbroek - Jim Todd - Elizabeth Allen

Fuente: https://link.springer.com/

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