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Research Article | DOI: https://doi.org/10.31579/2642-973X/129
Department of Child Health and Paediatrics, School of Medicine – Moi University, Kenya.
*Corresponding Author: Paul Jairus Njanwe. Department of Child Health and Paediatrics, School of Medicine – Moi University, Kenya.
Citation: Paul J. Njanwe, Irene Marete, Samuel Ayaya, (2024), Adherence to National Healthcare Referral Guidelines and Its Effect on The Management Outcomes Among Children Seen at A Teaching Hospital in Western Kenya, J. Brain and Neurological Disorders, 7(5): DOI:10.31579/2642-973X/129
Copyright: © 2024, Paul Jairus Njanwe. This is an open-access article distributed under the terms of The Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 14 November 2024 | Accepted: 20 December 2024 | Published: 02 December 2024
Keywords: PALM-COEIN; abnormal uterine bleeding; AUB; women; reproductive age; Western Kenya
Introduction: Referral guidelines are meant to ensure coordination and continuity across all levels of healthcare. Poor adherence to these guidelines could result in increased morbidity and mortality among the patients who are denied access; especially in the resource constrained healthcare settings in developing economies.
Aim:To determine adherence to the national healthcare referral guidelines and immediate outcomes of children seen at a tertiary teaching hospital in Western Kenya. Materials and methods: A Cross-sectional study conducted at the Pediatric emergency department of Moi Teaching and Referral Hospital in Western Kenya between February to June 2016. A total of 422 children aged below 15 years were recruited systematically. Sociodemographic and clinical data were collected using interviewer administered questionnaires and clinical chart reviews respectively. Checklists were used to collect information from ambulances. Pearson chi-square tests and odds ratios were used to test for association between predictor and outcome variables using statistical package for social science (SPSS) version-24.
Results: More than half (55.5%) of the 422 children enrolled were male while 51.4% were aged between 5 to 14 years. Hospital referrals accounted for 15.9% (n=67) with the rest being self- referrals and no counter referrals seen. Adherence to all the four transfer guideline requirements was observed in 46.3% (n=31) of the 67 hospital referrals. Less than half (46.3%) of the hospital referrals had their referring facilities calling the receiving facility prior to initiating the referral; 83.6% had a referral document; 64.2% were transferred in ambulances while 68.7% (n=46) were accompanied by health care workers. Most (88.1%) of the hospital referrals were admitted. Lower level of parental education (p= 0.025), residing outside the host county (p<0.001) and a child being older than five years (p = 0.015) were significantly associated with hospital referrals. Hospital referrals were nearly three times (AOR = 2.932; 95% CI: 2.422 – 3.550; p<0.001) more likely to be admitted compared to children who were self-referred.
Conclusion: There is low adherence to national healthcare referral guidelines among children seen at the second largest national hospital in Kenya; with less than half of hospital referrals transferred as per the transfer process guidelines.
The process of transferring patients from lower-level healthcare systems to those with advanced infrastructural and human resources is a key element of the health care system globally. In low and middle-income countries such as Kenya, this is necessitated by lack of adequate technological and infrastructural resources as well as professional skills to handle some debilitating health conditions. Patient referrals especially between various hospitals by healthcare providers acts as a building elevator to facilitate forward and backward management of clients’ needs. A functional patient referral system ensures optimal use of healthcare facilitpersonnel by improving communication among all healthcare providers involved in the patient’s management [1]. The healthcare system in Kenya is hierarchical from the community health care services, primary health care, county referral services to the national teaching and referral facilities [2]. The higher the level of the facility, the more sophisticated it is in providing diagnostic, therapeutic and rehabilitative services (Tom Kizito et al, 2005). To ensure proper coordination of the patient referral system, Kenya’s Ministry of Health developed National Healthcare Referral Guidelines [3]. Both patients and healthcare providers are expected to adhere to these referral guidelines and ensure safe and proper patient transfer across healthcare facilities. Optimal adherence to these guidelines further ensures that patientsreceive the full spectrum of care provided by the health system, regardless of the level at which they physically access health care. The referral guidelines recommend that patients should first seek medical care at primary healthcare facilities except in emergency situations where referral facilities can be accessed directly. In the event of hospital-to-hospital referral, the attending healthcare provider is required to call the receiving facility in advance to ensure availability of the required medical service, legibly fill-out a client referral form in English, indicate previous medical care offered including attaching all the relevant diagnostic test results, especially in emergency referrals. Adherence to transfer process guidelines especially among pediatric patients requires that the patient is transferred in an ambulance with a functional oxygen supply, first-aid kit, essential medicines and a transfer couch. The patient in the ambulance must also be accompanied by a competent healthcare provider. Despite all these guidelines in place, adherence to referral and transfer process guidelines by both patients and healthcare providers has been a challenge in many national referral hospitals. This has been exemplified by long queues of patients with medical conditions that could be easily managed at primary healthcare facilities. Parents of paediatric patients living in urban centers near these national referral hospitals often opt to bypass the healthcare hierarchy by self-referring their children. This study therefore aimed to determine the adherence to National Healthcare Referral Guidelines and document immediate outcomes among children seen at Moi Teaching and Referral Hospital (MTRH) in Eldoret-Kenya. Specifically, it determined the proportion of children seen at MTRH who were referred from other health facilities; described the patterns of referrals; determined the level of adherence to the transfer process guidelines and the immediate management outcomes of children seen.
This was a cross-sectional study conducted among paediatric patients attending MTRH’s sick child clinic February to June 2016. The hospital is the second largest national governmentteaching and referral hospital in Kenya with a bed capacity for 800 patients and attends to patients in the greater Western Kenya. The study design was adopted because the researcher only came into contact with the children and their parents at enrollment, while all other information were obtained from medical records. The eligible children were those below 15 years who were not revisiting the sick child clinic for review or follow-up due to the same condition during the study period. Referred children who died on arrival at the sick-child clinic were excluded. The children were further sampled and enrolled systematically with a sampling interval of 28 until the desired sample size of 422 was achieved. Patient data was collected using an interviewer administered questionnaire that was divided into six sections: demographic data, referral status, referral process, status of the transferring vehicle or ambulance, referral documents, and care given at MTRH. If the patient was self-referred, information such as the nearest health facility, and distance from MTRH was collected. Primarydata source was the parents or guardians of the sick children; while secondary data obtained from referral notes, referral forms, patient transfer forms and medical charts. All the patients received standard pediatric care as is required by the ethical guidelines and approvals obtained from the Institutional Research and Ethics Committee (IREC) of MTRH and Moi University School of Medicine (Approval # 1516). Other ethical considerations such as parental consent and pediatric assents were obtained prior to data collection as well as participants privacy and confidentiality were ensured by deidentifying patient data and storing their information in password protected databases. Descriptive (frequency, mean and median with correspondingproportions, standard deviations and interquartile ranges) and Inferential (Pearson chi-square and odds ratios at 95% confidence interval) statistical analysis were conducted using Statistical Package for Social Sciences (SPSS) version 24.
This study enrolled 422 children with more than half (51.4%; n=217) of them older than 5 years of age. The male to female ratio was 1.2:1 and majority (88.9%; n=375) of the children lived in the hospital’s host county of Uasin Gishu in Western Kenya (Table/Fig 1). More than one-tenth (15.9%; n=67) of the children enrolled were hospital referrals to MTRH, while the rest were self-referrals with no counter-referrals reported. Among the hospital referrals, majority (86.6%; n=58) were from government facilities, followed by those from private hospitals (11.9%; n=8), with the least representation from private clinics at 1.5% (n=1). The main reason for referral was to seek specialized care. The main referral patterns studies were the proportion of hospital referrals living near a public hospital, the distance they covered to reach MTRH, their chief complaints, tests done prior to referral (Table/Fig. 2). When a test of association was conducted, it was determined that children whose parents or guardians had secondary education or less, lived outside Usain Gishu County were more than five (5) years of age were more likely to be referred from healthcare facilities (Table/Fig. 3).
| Variable | Category | Frequency | Percent |
| Gender of the child | Male | 234 | 55.5 |
| Female | 188 | 44.5 | |
| Age of the child | <1year> | 51 | 12.1 |
| 1 – 5years | 154 | 36.5 | |
| 6 -14years | 217 | 51.4 | |
| Occupation of parent/guardian | Formally Employed | 105 | 24.9 |
| Informally Employed | 199 | 47.2 | |
| Unemployed | 118 | 27.9 | |
| Monthly Family/household Income (in KSh) | <10000> | 126 | 29.9 |
| 10000 – 20000 | 211 | 50.0 | |
| 21000 – 50000 | 71 | 16.8 | |
| 51000 - 100000 | 12 | 2.8 | |
| >100000 | 2 | 0.5 | |
| Residence | Uasin Gishu county | 375 | 88.9 |
| Other counties | 47 | 11.1 | |
| Parent/Guardian level of Education | None | 4 | 0.9 |
| Primary | 65 | 15.4 | |
| Secondary | 274 | 64.9 | |
| Tertiary | 79 | 18.7 |
Table 1: Sociodemographic characteristics of Study Participants
| Referral Patterns (N=67) | Frequency (n) | Percentages (%) | ||
Living neara public hospital County Hospital Health Centers | 18 18 | 31% 31% | 287
288 | |
| Distance to MTRH | ||||
| >10km | 59 | 88.1% | 289 | |
| <10km> | 8 | 11.9% | ||
Chief Complaint Fever Trauma Abdominal Mass Swelling Cough Others | 32 4 3 3 22 | 47.7% 6% 4.5% 4.5% 32.8% 1.5% | 290
291
292
293 | |
| Tests done: | CBC OtherTests | 40 27 | 68.8% 31.2% |
294 |
Reason for Referral Specialized care | 53 | 79.1% | 295 | |
| Lack of Equipment Investigations | 5 2 | 7.5% 3% | 296 | |
| Further management | 7 | 10.4% | 297 | |
| Referral Diagnosis | 9 6 3 3 | 13.4% 8.9% 4.5 4.5 |
298
299 | |
| Pneumonia | ||||
| Anemia | ||||
| Malaria | ||||
| Meningitis | ||||
Table 2: Summary of Patient Characteristics of Children Referred to MTRH
| Characteristic | AOR (95% CI) | p-value |
| Level of Education (Parent/Guardian): | ||
| ≤ Secondary | 1.146 (1.046 – 1.256) | 0.025 |
| Tertiary | 0.435 (0.198 – 0.960) | |
| County of Residence | ||
| Uasin Gishu | 0.461 (0.353 – 0.601) | <0> |
| Other Counties | 19.604 (10.256 -37.476) | |
| Pediatric Age Group | ||
| ≤ 5 years | 0.713 (0.526 – 0.968) | 0.015 |
| > 5 years | 1.372 (1.091 – 1.727) |
Table 3: Association between Sociodemographic Characteristics and Facility Referral
When adherence to transfer guidelines was assessed, four aspects (Calling prior to referral, having a Referral Document, being transferred by an ambulance and the patient being accompanied by a healthcare worker) were scored. Lack of adherence to any of the steps was scored as zero while partial adherence was defined as compliance to one of the four transfer guidelines. Total adherence was when the child’s transfer adhered to all the four aspects. When this technique was adopted, 14.9% (10) of the children referred were transferred without adhering to any of the four transfer guidelines, while nearly half (46.3%; n=31) of all hospital referrals had total adherence. More than four-fifths of the children referred from other health facilities came to MTRH with a referral document, all the ambulances had oxygen supply that was intact (Table. 4).
| REFERRAL GUIDELINE | YES n (%) | NO n (%) | |
| Calling priorto Referral | 32 (47.8%) | 35 (52.2%) | |
| Referral Document | 56 (83.6%) | 11 (16.4%) | |
| Referral form: | 31 (55.4%) | ||
| Referral note: | 25 (44.6%) | ||
| Transfer by an Ambulance | 43 (64.2%) | 24 (35.8%) | |
| Oxygen supply: | 43 (100%) | ||
| Oxygen supply intact: | 43 (100%) | ||
| Equipment functional: | 40 (93%) | 3 (7%) | |
| Essential Medicines: | 38 (88.4%) | 5 (11.6%) | |
| First Aid Kit: | 40 (93%) | 3 (7%) | |
| Transfer Couch: | 42 (97.7%) | 1 (2.3%) | |
| Patient Accompanied | 46 (68.7%) | 21 (31.3%) | |
| Clinical officer: | 6 (13%) | ||
| Enrolled Community Nursing: | 11 (23.9%) | ||
| Registered Nurse: | 28 (60.9%) | ||
| Nursing student: | 1 (2.2%) | ||
Table 4: Adherence to Transfer Guidelines among Facility Referrals (N=67)
Majority of the hospital referrals were admitted while nearly two-thirds of the self-referrals were treated and discharged (Table/Fig. 5). Pediatric patients who were referred from hospitals were nearly three times (AOR = 2.932; 95% CI: 2.422, 3.550) more likely to be admitted to the wards than those who were not (Table/Fig. 6).
| Referral Pattern | Total | ||
| Self-Referral | Hospital-Referral | ||
| Admitted to The Ward | 106 (29.9%) | 59 (88.1%) | 165 (39.1%) |
| Death | 1 (0.3%) | 1 (1.5%) | 2 (0.5%) |
| Referred to Specialized Clinic | 25 (7%) | 2 (3%) | 27 (6.4%) |
| Discharged Home | 223 (62.8%) | 5 (7.4%) | 228 (54%) |
| Total | 355 (100%) | 67 (100%) | 422 (100%) |
Table 5: Management outcomes of pediatric patients referred to MTRH (N=422)
| OUTCOME | Adjusted Odds Ratio | p-value | |
| Referred (95% CI) | NotReferred (95% CI) | ||
| Admission | 2.932(2.422 -3.550) | 0.210 (0.118– 0.374) | <0> |
Table 6: Association between Referral Status and Admission
Proportion of Hospital Referrals
Previous studies have demonstrated that low proportions of children are often referred to tertiary national and teaching hospitals from lower-level medical facilities [4–6]. In this study, 15.9% of the children seen at MTRH were hospital referrals as required by the national healthcare referral guidelines. This reported proportion of hospital referrals in Kenya among pediatric patients is less than a third of that reported in Canada at 45.5% [7]. Studies have also compared the proportion of referrals in the United States of America (USA) and the United Kingdom (UK) among mixed populations of children and adults (0-64 years) with varying proportions. In the USA, 30% to 36.8% of patients were referred from medical facilities [8] compared to only13.9% in the UK [9]. This difference is attributed to the lower proportion of pediatric specialists in the UK in comparison to the United States of America [8,10].
The findings of this study differ from other published studies conducted in East Africa. In a study conducted at Tanzania’s Kilometers District Health Care System [11]; out of 5,030 new pediatric cases from government and second level health facilities, 28 (0.6%) were referred for specialized care. This very low proportion of referrals in Tanzania was attributed to the fact that accurately ill children are not often brought to the health facilities; health facility staff do not identify children who need referral and healthcare workers only refer children with socioeconomic support to travel to the referral health facility. Due to similarity in the socioeconomic status of the parents to pediatric patients from both Kenya and Tanzania, thiscould explain the similarity in low proportions of hospital referrals for pediatric patients in Western Kenya.
Patterns of referrals
This study assessed living near a public hospital, distance to the referral facility, the chief complaint of the pediatric patient, tests done prior to referral, reasons given for referral and the final diagnosis as patterns of pediatric patient referral. Nearly two-thirds (62%) of those referred lived near a public hospital which was four times higher than 15.7% reported in South Africa [12]. Majority of the children referred from other health facilities had to travel more than 10 kilometers to seek care. Living far away from the national referral hospital increased the likelihood of the child being referred from a different medical facility compared to those living near the referral hospital who were self-referred.
The most common symptom in nearly half (47.8%) of the pediatric patients referred from other health facilities presented with a fever, which differs from the 17.2% of those seen in a Hong Kong referral hospital who were wheezing [13]. This difference could be attributed to socioeconomic and environmental differences in Kenya and Hong Kong. Whereas Kenya has more cases of infections reported in children and presenting as fever [14], wheezing could be common in Hong Kong due to a high prevalence of asthma.
Most (79.1%) of the children were referred to MTRH for specialized care while in Hong Kong most of the children were referred due to growth problems. This is because in Kenya, there is an insufficiency of medical infrastructure and specialists in many public hospitals in the counties [3]. This necessitates referral to the national hospitals such as MTRH for specialized care. On arrival at the receiving referral hospital, the children were diagnosed with anemia (15.6%) and pneumonia (10.4%). This proportion of pneumonia diagnosis reported in this study was lower than that reported at an advanced pediatric emergency care in Vietnam [4], where 23.7% of the children were diagnosed with pneumonia.
Adherence to transfer process guidelines
This study reports that nearly half (46.3%; n=31) of the children referred were transferred in total adherence to all the steps in the transfer guidelines. The steps of interest were: the referring facility was required to call the receiving facility prior to referral; having a referral document (either a referral form or a referral note); referral by an ambulance (that has essential medicines, first aid kit, transfer couch and an oxygen supply that is both intact and functional); and the patient should be accompanied (by either a clinical officer or a registered nurse). Majority of the children (83%) either had a referral form or referral note as a referral document. These contrasts findings from Saudi Arabia [15] where all the children referred from primary care to hospitals had a referral document. This disparity could be attributed to poor communication channels between the referring and receiving facilities in Kenya. In Punjab-India [16], pre-referral documentation was also found to be inadequate and lower than those reported here at 3.7%. The proportions of children who were transferred by an ambulance (64.2%) and those who were accompanied (68.7%) was close to those reported in Vietnam [4] at 57.8% and 49.6% respectively. Higher government ambulance transfer rate of 85.5% from public hospitals was reported in India [16]. Furthermore, in this study, 87% of the children transferred in an ambulance were accompanied by a nurse compared to 25.1% in Vietnam [4]. Although no child in the current study was accompanied by a medical officer, 7.6% of those in Vietnam were [4]. This difference could be attributed to the variance in the proportional distribution of human resources for health in the two countries.
Management outcomes
More than one third (39.1%) of this study’s participants who were hospital referrals ended up being admitted. This finding was consistent with that of Habib et al (2017) which reported admission outcomes at 39.3%. However, this was four-times higher than that in Vietnam [4]. A low proportion (0.5%) of the referred children in this study died comparable to that in Afghanistan at 3% [17]. Furthermore, nearly all (88%) of the children referred from facilities were admitted in contrast with a study in Saudi Arabia [15] where less than half of the referrals were treated and discharged. This may be because most of the referred patient at MTRH sick child clinic were sicker and more required emergency inpatient management.
This study determined that less than a quarter of pediatric patients at a national referral hospital in Western Kenya were hospital referrals with the majority being self-referrals. There was less than 50
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Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.
My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.
My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.
I would like to offer my testimony in the support. I have received through the peer review process and support the editorial office where they are to support young authors like me, encourage them to publish their work in your esteemed journals, and globalize and share knowledge globally. I really appreciate your journal, peer review, and editorial office.
Dear Agrippa Hilda- Editorial Coordinator of Journal of Neuroscience and Neurological Surgery, "The peer review process was very quick and of high quality, which can also be seen in the articles in the journal. The collaboration with the editorial office was very good."
I would like to express my sincere gratitude for the support and efficiency provided by the editorial office throughout the publication process of my article, “Delayed Vulvar Metastases from Rectal Carcinoma: A Case Report.” I greatly appreciate the assistance and guidance I received from your team, which made the entire process smooth and efficient. The peer review process was thorough and constructive, contributing to the overall quality of the final article. I am very grateful for the high level of professionalism and commitment shown by the editorial staff, and I look forward to maintaining a long-term collaboration with the International Journal of Clinical Case Reports and Reviews.
To Dear Erin Aust, I would like to express my heartfelt appreciation for the opportunity to have my work published in this esteemed journal. The entire publication process was smooth and well-organized, and I am extremely satisfied with the final result. The Editorial Team demonstrated the utmost professionalism, providing prompt and insightful feedback throughout the review process. Their clear communication and constructive suggestions were invaluable in enhancing my manuscript, and their meticulous attention to detail and dedication to quality are truly commendable. Additionally, the support from the Editorial Office was exceptional. From the initial submission to the final publication, I was guided through every step of the process with great care and professionalism. The team's responsiveness and assistance made the entire experience both easy and stress-free. I am also deeply impressed by the quality and reputation of the journal. It is an honor to have my research featured in such a respected publication, and I am confident that it will make a meaningful contribution to the field.
"I am grateful for the opportunity of contributing to [International Journal of Clinical Case Reports and Reviews] and for the rigorous review process that enhances the quality of research published in your esteemed journal. I sincerely appreciate the time and effort of your team who have dedicatedly helped me in improvising changes and modifying my manuscript. The insightful comments and constructive feedback provided have been invaluable in refining and strengthening my work".
I thank the ‘Journal of Clinical Research and Reports’ for accepting this article for publication. This is a rigorously peer reviewed journal which is on all major global scientific data bases. I note the review process was prompt, thorough and professionally critical. It gave us an insight into a number of important scientific/statistical issues. The review prompted us to review the relevant literature again and look at the limitations of the study. The peer reviewers were open, clear in the instructions and the editorial team was very prompt in their communication. This journal certainly publishes quality research articles. I would recommend the journal for any future publications.
Dear Jessica Magne, with gratitude for the joint work. Fast process of receiving and processing the submitted scientific materials in “Clinical Cardiology and Cardiovascular Interventions”. High level of competence of the editors with clear and correct recommendations and ideas for enriching the article.
We found the peer review process quick and positive in its input. The support from the editorial officer has been very agile, always with the intention of improving the article and taking into account our subsequent corrections.
