title: Scheduled Follow-Up Referrals and Simple Prevention Kits Including Counseling to Improve Post-Discharge Outcomes Among Children in Uganda: A Proof-of-Concept Study.
abstract: Recurrent illness following hospital discharge is a major contributor to childhood mortality in resource-poor countries. Yet post-discharge care is largely ignored by health care workers and policy makers due to a lack of resources to identify children with recurrent illness and a lack of cohesive systems to provide care. The purpose of this proof-of-concept study was to evaluate the effectiveness of a bundle of interventions at discharge to improve health outcomes during the vulnerable post-discharge period.
  
  
  
  The study was conducted between December 2014 and April 2015. Eligible children were between ages 6 months and 5 years who were admitted with a suspected or proven infectious disease to one of two hospitals in Mbarara, Uganda. A bundle of interventions was provided at the time of discharge. This bundle included post-discharge referrals for follow-up visits and a discharge kit. The post-discharge referral was to ensure follow-up with a nearby health care provider on days 2, 7, and 14 following discharge. The discharge kit included brief educational counseling along with simple preventive items as incentives (soap, a mosquito net, and oral rehydration salts) to reinforce the education. The primary study outcome was the number of post-discharge referral visits completed. Secondary study outcomes included satisfaction with the intervention, rates of readmission after 60 days, and post-discharge mortality rates. In addition, outcomes were compared with a historical control group, enrolled using the same inclusion criteria and outcome-ascertainment methods.
  
  
  
  During the study, 216 children were admitted, of whom 14 died during hospitalization. Of the 202 children discharged, 85% completed at least 1 of the 3 follow-up referral visits, with 48% completing all 3 visits. Within 60 days after discharge, 22 children were readmitted at least once and 5 children (2.5%) died. Twelve (43%) readmissions occurred during a scheduled follow-up visit. Compared with prospectively enrolled historical controls, the post-discharge referral for follow-up increased the odds of readmission (odds ratio [OR], 1.92; 95% confidence interval [CI], 1.14 to 3.23) and care sought after discharge (OR, 14.61; 95% CI, 9.41 to 22.67). Overall satisfaction with the bundle of interventions was high, with most caregivers strongly agreeing that the discharge kit and post-discharge referrals improved their ability to care for their child.
  
  
  
  Interventions initiated at the time of discharge have the potential to profoundly affect the landscape of care during illness recovery and lead to significantly improved outcomes among children under 5 years of age.
authors.affiliation: University of British Columbia, Vancouver, Canada mowiens@outlook.com.
authors.forename: Matthew O
authors.initials: MO
authors.lastname: Wiens
authors.affiliation: University of British Columbia, Vancouver, Canada.
authors.forename: Elias
authors.initials: E
authors.lastname: Kumbakumba
authors.affiliation: University of British Columbia, Vancouver, Canada.
authors.forename: Charles P
authors.initials: CP
authors.lastname: Larson
authors.affiliation: Massachusetts General Hospital, Boston, MA.
authors.forename: Peter P
authors.initials: PP
authors.lastname: Moschovis
authors.affiliation: Mbarara University of Science and Technology, Mbarara, Uganda.
authors.forename: Celestine
authors.initials: C
authors.lastname: Barigye
authors.affiliation: Mbarara University of Science and Technology, Mbarara, Uganda.
authors.forename: Jerome
authors.initials: J
authors.lastname: Kabakyenga
authors.affiliation: Mbarara University of Science and Technology, Mbarara, Uganda.
authors.forename: Andrew
authors.initials: A
authors.lastname: Ndamira
authors.affiliation: University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
authors.forename: Lacey
authors.initials: L
authors.lastname: English
authors.affiliation: University of British Columbia, Vancouver, Canada.
authors.forename: Niranjan
authors.initials: N
authors.lastname: Kissoon
authors.affiliation: University of British Columbia, Vancouver, Canada.
authors.forename: Guohai
authors.initials: G
authors.lastname: Zhou
authors.affiliation: University of British Columbia, Vancouver, Canada.
authors.forename: J Mark
authors.initials: JM
authors.lastname: Ansermino
mesh_terms: D000359:Aftercare / Q000379:methods*; D000067576:Child Health; D002675:Child, Preschool; D003376:Counseling; D005260:Female; D005500:Follow-Up Studies; D006761:Hospitals; D006801:Humans; D007223:Infant; D008297:Male; D016017:Odds Ratio; D010349:Patient Compliance; D010351:Patient Discharge; D010353:Patient Education as Topic; D010359:Patient Readmission; D017060:Patient Satisfaction; D012008:Recurrence; D012017:Referral and Consultation; D055502:Secondary Prevention / Q000379:methods*; D014454:Uganda