In emergency departments across Malawi and Tanzania, doctors are missing the full picture when patients arrive with multiple chronic conditions like HIV, high blood pressure, and diabetes all at once. These patients often delay seeking help until they are critically ill, and hospitals focus only on the most obvious problem, sending people home without treating their other conditions. This leads to repeated emergency visits, spiralling costs, and preventable deaths. The research team will test a “screen and link” strategy: using simple point-of-care tests during emergency assessment to identify undiagnosed or poorly controlled multimorbidity, then immediately connecting patients to long-term care. The trial will involve roughly 2,800 patients across twenty hospitals, measuring whether this approach keeps people alive and out of hospital three months after discharge. If it works, the strategy could reshape how emergency care is delivered across sub-Saharan Africa—not by adding expensive technology, but by rethinking the clinical pathway itself. The project also trains African PhD researchers in health systems, economics, and social science, building the local expertise needed to sustain these changes beyond the study period.
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RESEARCH QUESTION What is the optimal structure for healthcare systems to effectively recognise and treat adults admitted to hospital with multimorbidity in sub-Saharan Africa? BACKGROUND Sub-Saharan Africa suffers from an interplay of high rates of infectious disease and rising prevalence of non-communicable diseases, resulting in multimorbidity. Importantly, HIV (and anti-retroviral treatment) can accelerate non-communicable disease. Patients frequently delay seeking treatment until they are severely ill and require emergency management. Hospital care then predominantly focusses on the primary presenting problem, overlooking multimorbidity. This oversight precipitates frequent hospital admissions, increases health system and out-of-pocket expenses, and leads to disability and death. AIM To design and test a system which identifies patients suffering from multimorbidity during emergency assessment in sub-Saharan African hospitals, optimises immediate treatment, and ensures post-discharge linkage to appropriate care. OBJECTIVES To confirm the prevalence of multimorbidity in patients attending acute hospital services in Malawi and Tanzania. To create a strategy to recognise and treat multimorbidity using point-of-care tests incorporated into the emergency care pathways in Malawi and Tanzania, maximising acceptability to patients and healthcare workers, and optimising the impact of available resources. To test the optimised emergency care pathway intervention with a primary outcome of hospital admission-free survival three months after hospital admission. METHODS In Malawi and Tanzania, we will research the most efficient pathway to improve the early diagnosis of common medical presentations (including hypertension, diabetes, HIV treatment failure) using point-of-care tests in emergency departments. We will develop a rich understanding by studying patient experience, diagnostic performance, and implementation costs. We will build capacity amongst future African research leaders through PhD training in health systems, social science, health economics and clinical research. Stage one will confirm multimorbidity prevalence in patients attending hospital, and observe how additional tests add or change management. Working with patients, community groups, and healthcare professionals, we will investigate how treatment pathways could be more efficient and responsive [Year1]. Stage two incorporates this multi-source evidence into a theoretical model of the hospital system to investigate the value of enhanced testing in emergency care. For example, we will compare alternative approaches using applicability, cost and efficiency trade-offs. With key stakeholders, we will select, pilot and refine the intervention. [Year2]. Stage three evaluates this intervention in a cluster randomised trial of approximately 2800 patients in twenty hospitals, determining rates of survival, hospital readmission, and disease control. This will provide us, and national policymaker-colleagues, rigorous evidence of intervention effectiveness [Year3 + Year4]. IMPACT Through identifying common, poorly controlled and undiagnosed multimorbidity, we aim to improve patient outcomes and optimise resource use through early and appropriate treatment (reducing death), and effective linkage to long-term care (preventing complications, disability, and hospital readmission). By enhancing capacity to lead and conduct research (students, clinicians, patient advisors, and support staff), the project builds skills and partnerships to sustainably transform the treatment of acute multimorbidity in sub-Saharan Africa. Incorporating policymakers and economic analysis into our project from the outset will ensure relevance, assess value and provide a pathway for evidence uptake.
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