Programme no. 233-OP
Quality Improvement
Stephanie Bjerrum*1, Nii Nortey Hanson-Nortey2, Anders Munck3, Frank Bonsu4, Isik Somuncu Johansen5, Åse Bengård Andersen6, Lars Bjerrum7, Dorte Jarbøl8
1Institute of Clinical Research, Infectious Diseases,University of Southern Denmark,Odense,Denmark, 2National Tuberculosis Control Programme,Ghana Health Service,Accra,Ghana, 3Research unit of General Practice,University of Southern Denmark,Odense,Denmark, 4National Tuberculosis Control Programme,Ghana Health Service,Accra,Ghana, 5Infectious Diseases,Odense University Hospital,Odense,Denmark, 6Infectious Diseases,Odense University Hospital,Odense,Denmark, 7Department of Public Health, Section of General Practice,University of Copenhagen,Copenhagen,Denmark, 8Research Unit of General Practice ,University of Southern Denmark,Odense,Denmark
* = Presenting author
Objectives: To assess TB screening practices among clinicians providing care for HIV positive individuals and evaluate effectiveness of clinical audit and feedback in improving quality of performance.
Background: Audit and feedback are well-described methods to improve quality of clinical practice and performance, especially in settings where baseline adherence to recommended guidelines is low. Guidelines for regular screening for tuberculosis (TB) among HIV positive individuals are available to promote early TB diagnosis and reduced mortality, but implementation is challenging. In collaboration with the National TB Control Programme in Ghana, we used Audit Project Odense (APO) methodology innovatively to evaluate TB screening practices at HIV out-patient clinics in Ghana.
Results: The APO methodology was feasible and easily adopted by the clinicians. A total of 19 doctors and nurses registered 1,368 patient consultations during the first registration. TB was suspected in 172 patients (12.6%, 95% CI; 10.9-14.4). Nurses suspected TB more often than doctors (15.5% vs. 9.5%, p=0.0008). The proportions of TB suspects reported amongst patients meeting the WHO and National criteria for being a TB suspect were 37.3% and 59.1% respectively. Routine TB diagnostic investigations like chest x-ray and sputum smear microscopy was requested for respectively 74.4% and 58.7% of patients registered as TB suspects.
Material/Methods: Medical doctors and nurses from 10 purposively selected HIV out-patient clinics in Ghana were invited to participate in the study. Participants registered their consultations with HIV positive clients over a 2-week period before and after a multifaceted feedback and training intervention. A second round of registration was completed in December 2014, but data is yet to be analysed. To determine impact on quality, selected indicators will be compared between the two registrations.
Conclusion: A simple audit and feedback method was successfully introduced in an African setting to evaluate clinical performance of TB screening among HIV out-patients. The suspicion of TB was significantly lower among doctors than nurses and compliance to TB screening guidelines was suboptimal, representing a missed opportunity for TB case detection.
Points for discussion: TB is globally the leading cause of morbidity and mortality in people living with HIV. Autopsy studies in Africa have found TB present in as many as 32%>67% of HIV related deaths, often undiagnosed by current standard of care. This calls for strict adherence to evidence based TB screening guidelines.