Multidisciplinary sickle cell disease obstetrics care program in Ghana: Non-academic vs.Academic Hospital (Pilot Study)

随着非洲人预期寿命的增加，怀孕已成为一种新的威胁生命的并发症 在SCD女性中。在低收入和中等收入国家，与SCD相关的孕产妇死亡的优势比 是22.81，95%可信区间14.67-35.46.1,2012-2014，科尔勒布教学医院产科 加纳阿克拉(KBTH)建立了一家产科医生领导的SCD产科(OB)诊所。制度母性 在这三年(2012-2014)中，SCD的死亡率约为12%。2015年1月，一个 成立了多学科的SCD OB团队。该团队进行了一次综合的回顾/展望 KBTH医院过去七年(2010-2016)患有SCD的所有产妇死亡的病例系列。 回溯性数据收集突出了提供改善护理的失败和挑战。急诊胸腔 综合症，在急性疼痛发作之前，是近87%的妇女死亡的主要原因。 2015年5月，该团队实施了产科/血液学联合诊所，建立了密切的母婴 监测，并实施临床指南/方案。此外，SCD OB团队还建立了一个 每周沟通系统，以裁决具有挑战性的案件的管理。这些干预措施 孕产妇死亡率风险降低了89.1%(每100,000名活产儿死亡人数从10,791人降至1,176人； P=0.007)超过13个月。3自启动我们的多学科SCD OB计划以来，我们一直 与团队成立之前相比，这一队列中的孕产妇死亡率降低了约90% 已建立。4、5这项由医生指导的应用程序旨在进行有效性实施 将我们降低孕产妇死亡率的成果从一家学术医院推广到非学术医院的可行性研究 加纳阿克拉的学术医院环境，目前孕产妇死亡率为5940人/10万人 SCD妇女的活产情况。在五年内，申请者将获得使用综合 实施研究框架(CFIR)6和RE-AIM框架(REACH、有效性、 采用、实施和维护)7，为研究的各个阶段提供信息。申请者将测试 假设“在一项前后研究设计中，申请者将检验以下假设： 在非学术医院为患有SCD的孕妇提供纪律治疗和任务转移将有 与之前同一家医院的死亡率相比，死亡的相对风险降低了80% 这个辅导奖的具体目标是：1)确定背景 影响循证实践适应性的决定因素(障碍/促进者) 建立一个多学科的SCD OB团队，作为对非学术医院的干预，包括 实施过程(1-2年)；2)建设非专业SCD OB计划的能力 学术医院(3-5年)，以及3)进行混合类型1可行性研究，比较其有效性 在非学术站点(3-5年级)进行任务转移的多学科SCD OB项目。

With increasing life expectancy in Africa, pregnancy has become an emerging life-threatening complication in SCD women. In low and middle-income countries, the odds ratio of maternal death associated with SCD is 22.81, 95% CI 14.67–35.46.1 From 2012-2014, the Obstetrics Department, Korle-Bu Teaching Hospital (KBTH), Accra, Ghana, established an obstetrician-led SCD Obstetrics (OB) clinic. The Institutional maternal mortality for SCD over these three years (2012-2014) was approximately 12%. In January 2015, a multidisciplinary SCD OB team was established. The team conducted a combined retrospective/ prospective case series of all maternal deaths in women with SCD at KBTH over seven years (2010-2016).2 This retrospective data collection highlighted failures and challenges to delivering improved care. Acute chest syndrome, preceded by acute pain episodes, was the leading cause of death in nearly 87% of women.2 In May 2015, the team implemented a joint obstetrics/ hematology clinic, instituted close maternal and fetal monitoring, and implemented clinical guidelines/ protocols. In addition, the SCD OB team established a weekly communication system to adjudicate the management of challenging cases. These interventions resulted in an 89.1% risk reduction in maternal mortality (from 10,791 to 1,176 deaths per 100,000 live births; p=0.007) over 13 months.3 Since initiating our multidisciplinary SCD OB program, we have consistently decreased maternal mortality in this cohort by approximately 90% compared to before the team was established.4,5 This physician-mentored application aims to conduct an Effectiveness-Implementation Feasibility Study to extend our results of decreasing maternal mortality from an academic hospital to a non- academic hospital setting in Accra, Ghana with a current maternal mortality rate of 5,940 deaths/ 100,000 live births in SCD women. Over five years, the applicant will acquire the skills to use the Consolidated Framework for Implementation Research (CFIR)6 and the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance)7 to inform the stages of the study. The applicant will test the hypothesis that " In a before and after study design, the applicant will test the hypothesis that multi- disciplinary care and task-shifting in a non-academic hospital for pregnant women with SCD will have an 80% relative risk reduction in death compared to the mortality rate in the same hospital before the multi-disciplinary medical care." The specific aims for this mentored award are: 1) Identify contextual determinants (barriers/ facilitators) that influence the adaptability of the evidence-based practice for establishing a multidisciplinary SCD OB team as an intervention in the non-academic hospital, including the implementation process (Years 1-2); 2) Build capacity for a multidisciplinary SCD OB program in a non- academic hospital (Years 3-5), and 3) Conduct a Hybrid type 1 feasibility study comparing the effectiveness of a task-shifted multidisciplinary SCD OB program in a non-academic site (Years 3-5).