Postpartum hemorrhage (PPH) is the leading cause of maternal mortality in Kenya. The aim of this study was to measure quality and timeliness of care for PPH in a sample of deliveries in referral hospitals in Kenya. We conducted direct observations of 907 vaginal deliveries in three Kenyan hospitals from October 2018 through February 2019, observing the care women received from admission for labor and delivery through hospital discharge. We identified cases of “suspected PPH”, defined as cases in which providers indicated suspicion of and/or took an action to manage abnormal bleeding. We measured adherence to World Health Organization and Kenyan guidelines for PPH risk assessment, prevention, identification, and management and the timeliness of care in each domain. The rate of suspected PPH among the observed vaginal deliveries was 9% (95% Confidence Interval: 7% - 11%). Health care providers followed all guidelines for PPH risk assessment in 7% (5% - 10%) of observed deliveries and all guidelines for PPH prevention in 4% (3% - 6%) of observed deliveries. Lowest adherence was observed for taking vital signs and for timely administration of a prophylactic uterotonic. Providers did not follow guidelines for postpartum monitoring in any of the observed deliveries. When suspected PPH occurred, providers performed all recommended actions in 23% (6% - 40%) of cases. Many of the critical actions for suspected PPH were performed in a timely manner, but, in some cases, substantial delays were observed. In conclusion, we found significant gaps in the quality of risk assessment, prevention, identification, and management of PPH after vaginal deliveries in referral hospitals in Kenya. Efforts to reduce maternal morbidity and mortality from PPH should emphasize improvements in the quality of care, with a particular focus on postpartum monitoring and timely emergency response.

Improving the quality of primary care is essential for achieving universal health coverage in low- and middle-income countries. This study examined the level and variation in primary care provider knowledge and effort in Cambodia, using cross-sectional data collected in 2014-2015 from public sector health centers in nine provinces. The data included clinical vignettes and direct observations of processes of antenatal care, postnatal care, and well-child visits and covered between 290-495 health centers and 370-847 individual providers for each service and type of data. The results indicate that provider knowledge and observed effort were generally low and varied across health centers and across individual providers. In addition, providers' effort scores were generally lower than their knowledge scores, indicating the presence of a "know-do gap." Although higher provider knowledge was correlated with higher levels of effort during patient encounters, knowledge only explained a limited fraction of the provider-level variation in effort. Due to low baseline performance and the know-do gap, improving provider adherence to clinical guidelines through training and practice standardization alone may have limited impact. Overall, the findings suggest that raising the low quality of care provided by Cambodia's public sector will require multidimensional interventions that involve training, strategies that increase provider motivation, and improved health center management. The authors reported there is no funding associated with the work presented in this article.

BACKGROUND:Gout is a common type of inflammatory arthritis in patients seen by primary care physicians.PURPOSE:To review evidence about treatment of acute gout attacks, management of hyperuricemia to prevent attacks, and discontinuation of medications for chronic gout in adults.DATA SOURCES:Multiple electronic databases from January 2010 to March 2016, reference mining, and pharmaceutical manufacturers.STUDY SELECTION:Studies of drugs approved by the U.S. Food and Drug Administration and commonly prescribed by primary care physicians, randomized trials for effectiveness, and trials and observational studies for adverse events.DATA EXTRACTION:Data extraction was performed by one reviewer and checked by a second reviewer. Study quality was assessed by 2 independent reviewers. Strength-of-evidence assessment was done by group discussion.DATA SYNTHESIS:High-strength evidence from 28 trials (only 3 of which were placebo-controlled) shows that colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroids reduce pain in patients with acute gout. Moderate-strength evidence suggests that low-dose colchicine is as effective as high-dose colchicine and causes fewer gastrointestinal adverse events. Moderate-strength evidence suggests that urate-lowering therapy (allopurinol or febuxostat) reduces long-term risk for acute gout attacks after 1 year or more. High-strength evidence shows that prophylaxis with daily colchicine or NSAIDs reduces the risk for acute gout attacks by at least half in patients starting urate-lowering therapy, and moderate-strength evidence indicates that duration of prophylaxis should be longer than 8 weeks. Although lower urate levels reduce risk for recurrent acute attacks, treatment to a specific target level has not been tested.LIMITATION:Few studies of acute gout treatments, no placebo-controlled trials of management of hyperuricemia lasting longer than 6 months, and few studies in primary care populations.CONCLUSION:Colchicine, NSAIDs, and corticosteroids relieve pain in adults with acute gout. Urate-lowering therapy decreases serum urate levels and reduces risk for acute gout attacks.PRIMARY FUNDING SOURCE:Agency for Healthcare Research and Quality. (Protocol registration: http://effectivehealth-care.ahrq.gov/ehc/products/564/1992/Gout-managment-protocol-141103.pdf).

Data Synthesis: Recently developed algorithms including clinical, laboratory, and imaging criteria demonstrated good sensitivity (up to 88%) and fair to good specificity (up to 96%) for diagnosing gout (moderate SOE). Three studies of dual-energy computed tomography (DECT) showed sensitivities of 85% to 100% and specificities of 83% to 92% for diagnosing gout (low SOE). Six studies of ultrasonography showed sensitivities of 37% to 100% and specificities of 68% to 97%, depending on the ultrasonography signs assessed (pooled sensitivity and specificity for the double contour sign: 74% [95% CI, 52% to 88%] and 88% [CI, 68% to 96%], respectively [low SOE]).

Objectives The aim of this review is to assess the evidence for the accuracy and safety of tests to diagnose gout in patients with no prior diagnosis of gout. The review also assesses factors that affect accuracy of diagnostic tests. Tests include algorithms that combine clinical signs and symptoms, dual-energy computed tomography (DECT), ultrasound, and plain x ray, with particular emphasis on tests that can be conducted in primary and acute (urgent and emergent) care settings. Data sources We searched Medline® (from 1946), Embase® (from 1972), the Cochrane Library (from 1945), and the Web of Science™ (from 1980) to November 7, 2014, for published studies. We also searched ClinicalTrials.gov and the Web of Science and contacted manufacturers of imaging equipment and test kits for unpublished data on gout diagnosis. Review methods We reviewed published and unpublished prospective cohort, cross-sectional, and case-control studies, as well as prior systematic reviews on the accuracy (sensitivity and specificity) of diagnostic tests for gout compared with a validated reference standard in patients without a prior gout diagnosis. We also reviewed studies and prior reviews of factors affecting the accuracy of monosodium urate crystal assessment in synovial fluid. We reviewed prospective cohort, cross-sectional, and case-control studies; case reports of any size; and systematic reviews that reported adverse events associated with diagnostic tests for gout and outcomes of gout misdiagnosis. A standardized protocol with predefined criteria was used to extract details on study design, interventions, outcomes, and study quality, and to assess the strength of evidence for each conclusion. Results Six clinical algorithms comprising clinical signs and symptoms have been tested for diagnostic accuracy against the presence of monosodium urate crystals in synovial fluid aspirated from affected joints. Most studies were conducted with small groups of patients in academic rheumatology departments. Two recently developed clinical algorithms, the Diagnostic Rule, which is the only one developed and validated with primary care physicians and patients, and the Clinical Gout Diagnosis (CGD), demonstrated sensitivities of 88 percent and 97 percent, respectively, and specificities of 75 percent and 96 percent, respectively, in patients with shorter (2 years or less) and longer durations of symptoms, and they are simple to administer. However, the strength of evidence supporting their use is low, as validation of these tools remains limited. Three studies of DECT that enrolled patients without a previous gout diagnosis revealed sensitivities ranging from 85 percent to 100 percent and specificities ranging from 83 percent to 92 percent in diagnosing gout; the strength of evidence regarding the use of DECT for gout diagnosis is low. Four studies of ultrasound that enrolled patients without a previous diagnosis showed sensitivities ranging from 37 percent to 100 percent and specificities ranging from 68 percent to 97 percent, depending on the ultrasound signs assessed; the strength of evidence is low for the utility of ultrasound in diagnosing gout. A small number of studies examined factors that affected the accuracy of tests for the diagnosis of gout. The accuracy of monosodium urate analysis in synovial fluid varies widely among practitioners, but evidence on the effects of skill and experience is insufficient. No studies examined differences among practitioners in the rate of successful joint aspiration. No studies reported adverse events directly associated with techniques used to diagnose gout. However in one small study, missed gout diagnosis resulted in unnecessary surgery, longer hospital stays, and delay in appropriate treatment. Conclusions Promising diagnostic clinical algorithms such as the Diagnostic Rule and CGD need to be validated more broadly in primary and urgent care settings. A clinical algorithm with high diagnostic accuracy ideally can form part of a diagnostic decision tree, with referral of more clinically challenging cases to rheumatologists for more invasive tests or imaging. Research is needed to assess the incremental value of synovial fluid monosodium urate crystal analysis and imaging over that of a diagnostic clinical algorithm.

Objectives To review the evidence base for treating patients with gout, both acute attacks and chronic disease. The review specifically focuses on the management of patients with gout in the primary care setting. Data sources We searched Medline, EMBASE, the Cochrane Collection, and the Web of Science using the search terms “gout,” and “gouty,” and terms for tophi (from January 1, 2010 to April 23, 2015, or at least one year prior to the search dates for the most recent systematic reviews). We also obtained relevant references from 28 recent systematic reviews that cover nearly all of the Key Questions. We searched Clinicaltrials.gov and the Web of Science for recently completed studies and unpublished or non-peer-reviewed study findings. Searches were not limited by language of publication. Review methods We used standard systematic review methods including duplicate screening and data extraction from relevant studies, and existing tools to assess the quality of previously published systematic reviews, the risk of bias of individual studies, and the strength of evidence across studies. Results High-strength evidence supports the use of colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs), and systemic corticosteroids to reduce pain in patients with acute gout. Moderate-strength evidence supports the use of animal-derived ACTH formulation for this condition. Moderate-strength evidence supports the finding that low-dose colchicine is as effective as higher-dose colchicine for treating acute gout attacks, and has fewer side effects. Evidence is insufficient from randomized controlled trials that assess symptomatic outcomes for specific dietary therapies. The evidence is also insufficient to support or refute the effectiveness of particular Traditional Chinese Medicine practices (e.g., herbal mixtures, acupuncture, and moxibustion) for symptomatic outcomes. High-strength evidence supports that urate lowering therapy (ULT, with allopurinol or febuxostat) reduces serum urate level. However low-strength evidence supports the finding that treating to a specific target serum urate level reduces the risk of gout attacks. High-strength evidence supports the finding that ULT does not reduce the risk of acute gout attacks within the first 6 months after initiation. However, moderate-strength evidence supports a role for ULT in reducing the risk of acute gout attacks after about 1 year of treatment. Low-strength evidence supports treating to a specific target serum urate level to reduce the risk of gout attacks. High-strength evidence supports the finding that prophylactic therapy with low-dose colchicine or low dose NSAIDs reduces the risk of acute gout attacks when beginning ULT. No criteria for when to discontinue ULT have been validated. Conclusions Effective treatments for acute gout include colchicine, NSAIDs, and corticosteroids/animal-derived ACTH formulation. Urate lowering therapy achieves its goal of lowering serum urate levels. Urate lowering should lead to a reduction in gout attacks, but the benefits and harms of long term urate lowering therapy have yet to be directly demonstrated. Patient preferences and other clinical circumstances are likely to be important in decisions about treating patients with gout.