Angeni Bheekie

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

Abstract Objectives 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. Design Pragmatic cluster randomised controlled trial, with clinics as the unit of randomisation. Setting 40 primary care clinics, staffed by nurse practitioners, in the Free State province, South Africa. Participants 1999 patients aged 15 or over with cough or difficult breathing (1000 in intervention clinics, 999 in control clinics). Intervention 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. Main outcome measures Sputum screening for tuberculosis, tuberculosis case detection, inhaled corticosteroid prescriptions for obstructive lung disease, and antibiotic prescriptions for respiratory tract infections. Results 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). Conclusions 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. Trial registration Current controlled trials ISRCTN13438073.

Outreach education for integration of HIV/AIDS care, antiretroviral treatment, and tuberculosis care in primary care clinics in South Africa: PALSA PLUS pragmatic cluster randomised trial

Objective To investigate whether PALSA PLUS, an on-site educational outreach programme of non-didactic, case based, iterative clinical education of staff, led by a trainer, can increase access to and comprehensiveness of care for patients with HIV/AIDS. Design Cluster randomised trial. Setting Public primary care clinics offering HIV/AIDS care, antiretroviral treatment (ART), tuberculosis care, and ambulatory primary care in Free State province, South Africa. Participants Fifteen clinics all implementing decentralisation and task shifting were randomised. The clinics cared for 400 000 general primary care patients and 10 136 patients in an HIV/AIDS/ART programme. There were 150 nurses. Intervention On-site outreach education in eight clinics; no such education in seven (control). Main outcome measures Provision of co-trimoxazole prophylaxis among patients referred to the HIV/AIDS/ART programme, and detection of cases of tuberculosis among those in the programme. Proportion of patients in the programme enrolled through general primary care consultations. Results Patients referred to the HIV/AIDS programme through general primary care at intervention clinics were more likely than those at control clinics to receive co-trimoxazole prophylaxis (41%, (2253/5523) v 32% (1340/4210); odds ratio 1.95, 95% confidence interval 1.11 to 3.40), and tuberculosis was more likely to be diagnosed among patients with HIV/AIDS/ART (7% (417/5793) v 6% (245/4343); 1.25, 1.01 to 1.55). Enrolment in the HIV/AIDS and ART programme through HIV testing in general primary care was not significantly increased (53% v 50%; 1.19, 0.51 to 2.77). Secondary outcomes were similar, except for weight gain, which was higher in the intervention group (2.3 kg v 1.9 kg, P<0.001). Conclusion Though outreach education is an effective and feasible strategy for improving comprehensiveness of care and wellbeing of patients with HIV/AIDS, there is no evidence that it increases access to the ART programme. It is now being widely implemented in South Africa. Trial registration Current Controlled Trials ISRCTN 24820584.

Inhaled versus oral steroids for adults with chronic asthma

Objectives To determine therapeutically equivalent doses of inhaled versus oral steroids for adults with chronic asthma. Search strategy The Cochrane Airways Group trials register was searched using the terms: (drug delivery systems OR ((nebuli* OR inhal* OR MDI) AND oral*)) AND ( steroid* OR corticosteroid* OR glucocorticoid* OR beclomethasone OR betamethasone OR fluticasone OR cortisone OR dexamethasone OR hydrocortisone OR prednisolone OR prednisone OR triamcinolone). Selection criteria Randomised controlled trials were selected of at least 4 weeks duration and included patients over the age of 15 years with chronic asthma. Trials compared inhaled steroids and oral prednisolone or prednisone; where the maximum dose for inhaled steroids was 2000 mcg/day and prednisolone 60 mg (on alternate days). Data collection and analysis Two independent reviewers screened 1285 titles and abstracts from the electronic search, bibliography searches and other contacts. Of these, 10 trials met previously defined inclusion criteria. Two reviewers independently extracted study characteristics, and outcome measures. Main results All trials were small and no data could be pooled. Carry-over effects were present in at least one cross-over trial. Data from six trials produced the same pattern, in which prednisolone 7.5-12 mg/day appeared to be as effective as inhaled steroid 300-2000 mcg/day. In two trials, inhaled steroid 300-400 mcg/day was more effective than prednisolone 5 mg/day. All doses of inhaled steroid appeared to be more effective than alternate day doses of prednisolone up to 60 mg on alternate days. Side-effect data were reported too variably to permit comparisons. A 30% incidence was reported in one study in patients receiving prednisolone 5 mg/day, none were reported in patients on inhaled steroids. Reviewers conclusions A daily dose of prednisolone 7.5-10 mg/day appears to be equivalent to moderate-high dose inhaled corticosteroids. Side-effects may be present on low doses, so if there is no alternative to oral steroids, the lowest effective dose should be prescribed.

Development of a South African integrated syndromic respiratory disease guideline for primary care.

AIMS The Practical Approach to Lung Health in South Africa (PALSA) initiative aimed to develop an integrated symptom- and sign-based (syndromic) respiratory disease guideline for nurse care practitioners working in primary care in a developing country. METHODS A multidisciplinary team developed the guideline after reviewing local barriers to respiratory health care provision, relevant health care policies, existing respiratory guidelines, and literature. Guideline drafts were evaluated by means of focus group discussions. Existing evidence-based guideline development methodologies were tailored for development of the guideline. RESULTS A locally-applicable guideline based on syndromic diagnostic algorithms was developed for the management of patients 15 years and older who presented to primary care facilities with cough or difficulty breathing. CONCLUSIONS PALSA has developed a guideline that integrates and presents diagnostic and management recommendations for priority respiratory diseases in adults using a symptom- and sign-based algorithmic guideline for nurses in developing countries.

Cost-effectiveness of educational outreach to primary care nurses to increase tuberculosis case detection and improve respiratory care: economic evaluation alongside a randomised trial.

Objective  To evaluate the cost‐effectiveness of an educational outreach intervention to improve primary respiratory care by South African nurses.

Educational outreach to general practitioners reduces children's asthma symptoms: a cluster randomised controlled trial.

BackgroundChildhood asthma is common in Cape Town, a province of South Africa, but is underdiagnosed by general practitioners. Medications are often prescribed inappropriately, and care is episodic. The objective of this study is to assess the impact of educational outreach to general practitioners on asthma symptoms of children in their practice.MethodsThis is a cluster randomised trial with general practices as the unit of intervention, randomisation, and analysis. The setting is Mitchells Plain (population 300,000), a dormitory town near Cape Town. Solo general practitioners, without nurse support, operate from storefront practices. Caregiver-reported symptom data were collected for 318 eligible children (2 to 17 years) with moderate to severe asthma, who were attending general practitioners in Mitchells Plain. One year post-intervention follow-up data were collected for 271 (85%) of these children in all 43 practices.Practices randomised to intervention (21) received two 30-minute educational outreach visits by a trained pharmacist who left materials describing key interventions to improve asthma care. Intervention and control practices received the national childhood asthma guideline. Asthma severity was measured in a parent-completed survey administered through schools using a symptom frequency and severity scale. We compared intervention and control group children on the change in score from pre-to one-year post-intervention.ResultsSymptom scores declined an additional 0.84 points in the intervention vs. control group (on a nine-point scale. p = 0.03). For every 12 children with asthma exposed to a doctor allocated to the intervention, one extra child will have substantially reduced symptoms.ConclusionEducational outreach was accepted by general practitioners and was effective. It could be applied to other health care quality problems in this setting.

Quality of asthma care: Western Cape Province, South Africa

BACKGROUND Asthma is the eighth leading contributor to the burden of disease in South Africa, but has received less attention than other chronic diseases. The Asthma Guidelines Implementation Project (AGIP) was established to improve the impact of the South African guidelines for chronic asthma in adults and adolescents in the Western Cape. One strategy was an audit tool to assist with assessing and improving the quality of care. METHODS The audit of asthma care targeted all primary care facilities that managed adult patients with chronic asthma within all six districts of the Western Cape province. The usual steps in the quality improvement cycle were followed. RESULTS Data were obtained from 957 patients from 46 primary care facilities. Only 80% of patients had a consistent diagnosis of asthma, 11.5% of visits assessed control and 23.2% recorded a peak expiratory flow (PEF), 14% of patients had their inhaler technique assessed and 11.2% were given a self-management plan; 81% of medication was in stock, and the controller/reliever dispensing ratio was 0.6. Only 31.5% of patients were well controlled, 16.3% of all visits were for exacerbations, and 17.6% of all patients had been hospitalised in the previous year. CONCLUSION The availability of medication and prescription of inhaled steroids is reasonable, yet control is poor. Health workers do not adequately distinguish asthma from chronic obstructive pulmonary disease, do not assess control by questions or PEF, do not adequately demonstrate or assess the inhaler technique, and have no systematic approach to or resources for patient education. Ten recommendations are made to improve asthma care.

The dissemination and implementation of national asthma guidelines in South Africa: The use of outcome mapping

Abstract Asthma is an important chronic inflammatory disorder with significant morbidity and mortality in South Africa. The development of national asthma guidelines by the South African Thoracic Society and National Asthma Education Programme has been one approach to try and improve the quality of care. The effectiveness of previous guidelines has been limited by the lack of an effective approach to dissemination, implementation and evaluation. The newly revised guidelines will be completed in 2007 and this paper outlines how Outcome Mapping has been used to create a detailed and comprehensive approach to bridging the gap between the guidelines and clinical practice.

Contextualising undergraduate pharmacy training in service-learning at the University of the Western Cape

The pharmacy profession necessitates continual revision of undergraduate training to meet both changing and challenging health needs. Service-learning is a teaching methodology that assists health professions and academic training institutions in facilitating curriculum changes to improve the competence of pharmacy graduates. This method addresses the core requirements as stipulated by the South African Pharmacy Council for entry-level pharmacists. The aim of service-learning was to introduce an educational intervention for students that would enable them to rotate between the classroom and the workplace with the goal to provide them with the opportunity to accumulate learning experiences in both contexts. This article presents the development of the pharmacotherapy service-learning module as a case study which can be used as an exemplar for other service-learning modules. Fourth year students participating in the service-learning module were the focus of this study. Data was collected in various ways thr...

Re-engineering of South Africa’s primary health care system: where is the pharmacist?

Abstract South Africa’s transition towards a district-based health system (DHS) aims to offer health promotion and prevention services at community level, through re-engineered primary health care (PHC) services. Along with pharmacy workforce shortages and service delivery challenges, health reform is a clarion call to strategically re-position the pharmacist’s role in DHS strengthening. The pharmacist’s involvement in the three DHS streams, namely the clinical specialist support teams, school health services and municipal ward-based PHC outreach teams, is pertinent. This paper contextualises pharmacists’ current peripheral role in the health system, discusses a team-based approach and identifies opportunities to integrate pharmacy students into the re-vitalised PHC framework. Re-positioning of pharmacists within district clinical specialist support and school health teams could create opportunities for community-based and population-based services whereby a range of clinical and pharmaceutical services could materialise. Pharmacy training institutions could strengthen the DHS through established partnerships with the community and health services. Academic service learning programmes could integrate pharmacy students as part of the PHC outreach teams to promote community health. Interdependence between the health services, pharmacy schools and the community would create a platform to contextualise learning and dismantle existing silos between them. Multi-sectoral engagement could enable pharmacy schools to design strategies to optimise pharmaceutical service delivery and align their activities towards social accountability.