Effect of educoutreach to nurses on tuberculosis case detection and primary care of respiratory illness: pragmatic cluster randomised controlled trial

Knowledge Translation Unit, University of Cape Town Lung Institute, University of Cape Town, Groote Schuur, South Africa.
BMJ (online) (Impact Factor: 17.45). 11/2005; 331(7519):750-4. DOI: 10.1136/bmj.331.7519.750
Source: PubMed


To develop and implement an educational outreach programme for the integrated case management of priority respiratory diseases (practical approach to lung health in South Africa; PALSA) and to evaluate its effects on respiratory care and detection of tuberculosis among adults attending primary care clinics.
Pragmatic cluster randomised controlled trial, with clinics as the unit of randomisation.
40 primary care clinics, staffed by nurse practitioners, in the Free State province, South Africa.
1999 patients aged 15 or over with cough or difficult breathing (1000 in intervention clinics, 999 in control clinics).
Between two and six educational outreach sessions delivered to nurse practitioners by usual trainers from the health department. The emphasis was on key messages drawn from the customised clinical practice guideline for the outreach programme, with illustrative support materials.
Sputum screening for tuberculosis, tuberculosis case detection, inhaled corticosteroid prescriptions for obstructive lung disease, and antibiotic prescriptions for respiratory tract infections.
All clinics and almost all patients (92.8%, 1856/1999) completed the trial. Although sputum testing for tuberculosis was similar between the groups (22.6% in outreach group v 19.3% in control group; odds ratio 1.22, 95% confidence interval 0.83 to 1.80), the case detection of tuberculosis was higher in the outreach group (6.4% v 3.8%; 1.72, 1.04 to 2.85). Prescriptions for inhaled corticosteroids were also higher (13.7% v 7.7%; 1.90, 1.14 to 3.18) but the number of antibiotic prescriptions was similar (39.7% v 39.4%; 1.01, 0.74 to 1.38).
Combining educational outreach with integrated case management provides a promising model for improving quality of care and control of priority respiratory diseases, without extra staff, in resource poor settings.
Current controlled trials ISRCTN13438073.

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    • "Despite considerable advocacy for increased collaboration and integration of TB and HIV care, few models of integration have been implemented, evaluated and reported [11,17,20,28,29]. However, existing evidence favors integrating TB and HIV care for improving active case finding and early diagnosis of TB, which in turn, reduces the risk of TB transmission [28]. "
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    ABSTRACT: In 2012, an estimated 8.6 million people developed tuberculosis (TB) and 1.3 million died from the disease. With its recent resurgence with the human immunodeficiency virus (HIV); TB prevention and management has become further challenging. We systematically evaluated the effectiveness of community based interventions (CBI) for the prevention and treatment of TB and a total of 41 studies were identified for inclusion. Findings suggest that CBI for TB prevention and case detection showed significant increase in TB detection rates (RR: 3.1, 95% CI: 2.92, 3.28) with non-significant impact on TB incidence. CBI for treating patients with active TB showed an overall improvement in treatment success rates (RR: 1.09, 95% CI: 1.07, 1.11) and evidence from a single study suggests significant reduction in relapse rate (RR: 0.26, 95% CI: 0.18, 0.39). The results were consistent for various study design and delivery mechanism. Qualitative synthesis suggests that community based TB treatment delivery through community health workers (CHW) not only improved access and service utilization but also contributed to capacity building and improving the routine TB recording and reporting systems. CBI coupled with the DOTS strategy seem to be an effective approach, however there is a need to evaluate various community-based integrated delivery models for relative effectiveness.
    Infectious Diseases of Poverty 08/2014; 3(1):27. DOI:10.1186/2049-9957-3-27 · 4.11 Impact Factor
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    • "Table 1 shows the key differences between the PALM PLUS training approach compared to the standard approach in Malawi. The PALM PLUS package was adapted from a similar intervention from South Africa called Practical Approach to Lung Health in South Africa (PALSA), which has been shown to have achieved clinically important and statistically significant improvements in quality of care and health outcomes [6]. "
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    ABSTRACT: Background The government of Malawi is committed to the broad rollout of antiretroviral treatment in Malawi in the public health sector; however one of the primary challenges has been the shortage of trained health care workers. The Practical Approach to Lung Health Plus HIV/AIDS in Malawi (PALM PLUS) package is an innovative guideline and training intervention that supports primary care middle-cadre health care workers to provide front-line integrated primary care. The purpose of this paper is to describe the lessons learned in implementing the PALM PLUS package. Methods A clinical tool, based on algorithm- and symptom-based guidelines was adapted to the Malawian context. An accompanying training program based on educational outreach principles was developed and a cascade training approach was used for implementation of the PALM PLUS package in 30 health centres, targeting clinical officers, medical assistants, and nurses. Lessons learned were identified during program implementation through engagement with collaborating partners and program participants and review of program evaluation findings. Results Key lessons learned for successful program implementation of the PALM PLUS package include the importance of building networks for peer-based support, ensuring adequate training capacity, making linkages with continuing professional development accreditation and providing modest in-service training budgets. The main limiting factors to implementation were turnover of staff and desire for financial training allowances. Conclusions The PALM PLUS approach is a potential model for supporting mid-level health care workers to provide front-line integrated primary care in low and middle income countries, and may be useful for future task-shifting initiatives.
    BMC Health Services Research 05/2014; 14(Suppl 1):S8. DOI:10.1186/1472-6963-14-S1-S8 · 1.71 Impact Factor
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    • "Given that the sites are scattered throughout a large province, different models for providing ongoing training, such as electronic or in-service, need to be explored. [40], [41] In addition, regular, careful support and supervision improves quality of services significantly. [42] If staff feel supported and confident, they are less likely to seek alternative employment. "
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    ABSTRACT: To improve the treatment of MDR-TB and HIV co-infected patients, we investigated the relationship between health system performance and patient treatment outcomes at 4 decentralised MDR-TB sites. In this mixed methods case study which included prospective comparative data, we measured health system performance using a framework of domains comprising key health service components. Using Pearson Product Moment Correlation coefficients we quantified the direction and magnitude of the association between health system performance and MDR-TB treatment outcomes. Qualitative data from participant observation and interviews analysed using systematic text condensation (STC) complemented our quantitative findings. We found significant differences in treatment outcomes across the sites with successful outcomes varying from 72% at Site 1 to 52% at Site 4 (p<0.01). Health systems performance scores also varied considerably across the sites. Our findings suggest there is a correlation between treatment outcomes and overall health system performance which is significant (r = 0.99, p<0.01), with Site 1 having the highest number of successful treatment outcomes and the highest health system performance. Although the 'integration' domain, which measured integration of MDR-TB services into existing services appeared to have the strongest association with successful treatment outcomes (r = 0.99, p<0.01), qualitative data indicated that the 'context' domain influenced the other domains. We suggest that there is an association between treatment outcomes and health system performance. The chance of treatment success is greater if decentralised MDR-TB services are integrated into existing services. To optimise successful treatment outcomes, regular monitoring and support are needed at a district, facility and individual level to ensure the local context is supportive of new programmes and implementation is according to guidelines.
    PLoS ONE 04/2014; 9(4):e94016. DOI:10.1371/journal.pone.0094016 · 3.23 Impact Factor
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