Evaluation of the effectiveness of implemention of the practical approach to lung health (PALSA) in the Free State
Abstract
English: Currently, respiratory diseases constitute about one third of patients that present
to primary care clinics in under-resourced countries of the world. Communicable
respiratory diseases such as tuberculosis, acute respiratory infections in adults
and non-communicable respiratory diseases such as asthma, chronic obstructive
pulmonary disease, lung cancer represent about one-fifth of the global burden of
disease measured in disability adjusted life years (DALY). Opportunistic
infections, other respiratory complications, and the widespread use of tobacco
further increase the respiratory disease burden in high HIV prevalence settings.
In developing countries clinic nurses with limited training and basic skills are
entrusted to properly diagnose and treat respiratory patients from overloaded
clinics. We developed an educational outreach intervention, Practical Approach
to Lung Health in South Africa (PALSA) on integrated respiratory case
management aimed at improving the quality of respiratory care in South African
primary care clinics.
The intervention comprised 3 to 4 academic detailing training sessions of primary
care nursing practitioners; dissemination of locally adapted PALSA guidelines
and support materials; changes in prescribing provisions for primary care nurses,
and doctors' sensitization about PALSA.
The impact of PALSA on the processes and outcomes of respiratory care was
evaluated through a pragmatic cluster randomized controlled trial in the Free
State province in 2003.
A total of 1000 patients in the intervention arm and 999 patients in the control
arm presenting with respiratory conditions to the 40 largest primary care clinics of
the Free State province were interviewed at the first post-intervention survey. The
number of patients recruited ranged from 47 to 52 patients per clinic. The follow
up rate was 92.9% for the intervention arm and 92.7% for the control arm.
Twenty two patients died in the intervention clinics and twenty six died in the
control clinics. During data analysis, four patients in each arm were deleted due
to unavailability of the first post-intervention survey data and/or because they did
not meet the inclusion criteria. Professional nurses in intervention clinics received
a median of 2 training sessions while nurses in the control clinic received nothing.
First post-intervention survey characteristics of the intervention and control arms
balanced as a result of randomization. Almost two thirds of the patients were
females with the most frequent age group being 25-54 years. About 50% of
patients had a smoking history, about 50% had primary education, close to 50%
were unemployed, above 80% walked to get to the nearest clinic and 70% spent
between 2 and 12 hours to travel to and from the clinic.
The inclusion criteria to the study were adults 15 years and older presenting with
a cough or difficulty breathing on the day of the interview, recurrent cough or
difficulty breathing in the last 6 months or cough for less than two weeks with any
of the four severity markers. Rates of cough and difficulty breathing ranged
between 70% and 90%. About 70% of the patients complained about chest
symptoms interfering with their usual activities while around 36% had gone to the
clinic for a check-up on recurrent respiratory problem.
Compared to control clinics, intervention clinics had a significant improvement in
inhaled steroid prescription of 16.1% versus 10.3% (odds ratio 1.70; 95%CI 1.13
to 2.56), and an improvement in sending of sputa for tuberculosis testing of
16.7% versus 11.2% (odds ratio 1.60; 95%CI 1.00 to 2.54). There were also
significant improvements seen on appropriate referral of patients that had one of
the four severity makers of 10.6% versus 4.9% (odds ratio 2.56; 95%CI 1.06 to
6.17), and close to significant improvement of the tuberculosis detection rate of
3.0% versus 1.8% (odds ratio 1.67; 95%CI 0.92 to 3.02). There was a significant
increase in interference with usual activities due to chest symptoms of 68.0%
versus 60.1% (odds ratio 1.44; 95%CI1.13 to 1.85). There was no improvement
on antibiotic prescription of 36.1% versus 38.0% (odds ratio 0.92; 95%CI 0.62 to
1.36) as well as cotrimoxazole prophylaxis of 12.6% versus 9.9% (odds ratio
1.52; 95%CI 0.60 to 3.89). Results of this study suggest that inhaled steroid
prescription, tuberculosis case detection rate, and appropriate referral of patients
with severe respiratory diseases can be improved in nurse staffed primary care
clinics in developing countries and under-resourced settings.
This study exemplifies an evaluation of the effectiveness of an educational
intervention in South African primary care. It shows how a carefully developed
intervention, using a syndromic approach to diagnosis and treatment, can
improve several aspects of clinical care after brief training of primary care nurses.
It also illustrates opportunities for, and difficulties in, implementing such an
intervention, and conducting a large scale trial in this setting. This study suggests
that other international interventions based on dissemination of clinical
guidelines, such as, for IMCI, STls and HIV/AIDS should be developed and
rigorously evaluated locally, given their potential impact on public health and on
services. Afrikaans: Respiratoriese siektes is tans verantwoordelik vir ongeveer 'n derde van die
pasiënte wat aanmeld by primêre sorg klinieke in hulpbron-arm lande van die
wêreld. Oordraagbare respiratoriese siektes soos tuberkulose, akute
respiratoriese infeksies in volwassenes en nie-oordraagbare respiratoriese
siektes soos asma, chroniese obstruktiewe pulmonêre siekte, longkanker
verteenwoordig een vyfde van die globale siektelas gemeet aan gestremdheidsaangepaste
lewensjare. Opportunistiese infeksies, ander respiratoriese
komplikasies, en die algemene gebruik van tabak vehoog die respiratoriese
seiktelas verder in omgewings met 'n hoë MIV voorkoms. In ontwikkelende lande
word van kliniekverpleegkundiges met beperkte opleiding en basiese
vaardighede verwag om respiratoriese pasiënte korrek te diagnoseer en te
behandel in oorlaaide klinieke. Ons het 'n opvoedkundige uitreik intervensie,
Practical Approach to Lung Health in South Africa (PALSA) ontwikkel, gemik op
geïntegreerde respiratoriese gevalshantering om die kwaliteit van respiratoriese
sorg in Suid-Afrikaanse primêre sorg klinieke te verbeter.
Die intervensie het bestaan uit 3 tot 4 opleidingsessies vir pnmere sorg
verpleegkundiges, verspreiding van plaaslik aangepaste PALSA riglyne en
ondersteuningsmateriaal; veranderinge in voorskrifbepalings vir primêre sorg
verpleegkundiges, en sensitisering van dokters aangaande PALSA.
Die impak van PALSA op die prosesse en uitkomste van respiratoriese sorg is
geëvalueer deur 'n pragmatiese bundel gerandomiseerde gekontrolleerde proef
in die Vrystaat provinsie in 2003.
'n Totaal van 1000 pasiënte in die intervensie-arm en 999 pasiënte in die
kontrole-arm wat met respiratoriese toestande presenteer by die 40 grootste
primêre sorg klinieke in die Vrystaat, is tydens die eerste post-intervensie
opname ondervra. Die aantal pasiënte gewerf per kliniek het van 47 tot 52
pasiënte gewissel. Die opvolgkoerse was 92.9% in die intervensie-arm en 92.7%
in die kontrole-arm. Twee-en-twintig pasiënte is in die intervensie-klinieke oorlede
en ses-en-twintig in die kontrole-klinieke. Gedurende data-ontleding, is vier
pasiënte in elke arm uitgesluit weens onbeskikbaarheid van aanvanklike postintervensie
data en/of omdat hulle nie aan die insluitingskriteria voldoen het nie.
Professionele verpleegkundiges in die intervensie-klinieke het In mediaan van 2
opleidingsessies ontvang terwyl verpleegkundiges in die kontrole klinieke geen
intervensie ontvang het nie.
Die aanvanklike post-intervensie eienskappe van die intervensie- en kontrolearms
was soortgelyk as gevolg van die randomisasie. Bykans twee derdes van
die pasiënte was vroulik, met die mees algemene ouderdomsgroep 25-54 jaar.
Ongeveer 50% van pasiënte het In rookgeskiedenis, ongeveer 50% het primêre
skoolopleiding, ongeveer 50% was werkloos, meer as 80% het gestap om by die
naaste kliniek te kom, en 70% bestee tussen 2 en 12 ure om na en van die
kliniek te reis.
Die insluitingskriteria vir die studie was volwassenes 15 jaar en ouer wat
presenteer met 'n hoes of moeilike asemhaling op die dag van die onderhoud,
herhaalde hoes of moeilike asemhaling in die afgelope 6 maande of hoes van
minder as twee weke met enige van die vier ernstige merkers. Koerse vir hoes
en moeilike asemhaling het gevarieer tussen 70% en 90%. Ongeveer 70% van
die pasiënte het gekla oor borssimptome wat inmeng met hulle gewone
aktiwiteite terwylongeveer 36% na die kliniek gegaan het vir 'n ondersoek vir
herhaalde respiratoriese probleme.
Vergeleke met kontrole-klinieke het intervensie-klinieke In betekenisvolle
verbetering in die voorskryf van geïnhaleerde steroïede (16.1% versus 10.3%,
kansverhouding 1.70, 95%VI 1.13 tot 2.56), en In verbetering in die stuur van
sputa vir tuberkulosetoesting (16.7% versus 11.2%, kansverhouding 1.60, 95%VI
1.00 tot 2.54) getoon. Daar was ook betekenisvolle verbeterings in toepaslike
verwysings van pasiënte met een of meer van die vier ernstige merkers (10.6%
versus 4.9%, kansverhouding 2.56, 95%VI1.06 tot 6.17), en na aan betekenisvol
vir die tuberkulose-opsporingskoers (3.0% versus 1.8%, kansverhouding 1.67,
95%VI 0.92 tot 3.02). Daar was 'n betekenisvolle verhoging in die inmenging van
borssimptome met gewone aktiwiteite (68.0% versus 60.1%, kansverhouding
1.44, 95%VI 1.13 tot 1.85). Daar was geen verbetering in antibiotika-voorskrifte
nie (36.1% versus 38.0%, kansverhouding 0.92, 95%VI 0.62 tot 1.36) en ook nie
vir cotrimoxazole profilakse nie (12.6% versus 9.9%, kansverhouding 1.52,
95%VI 0.60 tot 3.89). Resultate van hierdie studie dui daarop dat geïnhaleerde
steroïedvoorskrifte, die tuberkulose gevalsopsporingskoers en die toepaslike
verwysing van pasiënte met ernstige respiratoriese siektes verbeter kan word in
primêre gesondheidsorgklinieke beman deur verpleegkundiges in ontwikkelende
lande en hulpron-arm omgewings.
Hierdie studie dien as voorbeeld van 'n evaluering van die effektiwiteit van 'n
opoedkundige intervensie in Suid-Afrikaanse primêre sorg. Dit wys hoe 'n deeglik
ontwerpte intervensie wat gebruik maak van 'n sindromiese benadering tot
diagnose en behandeling, na kort opleiding van primêre sorg verpleegkundiges
verskeie aspekte van kliniese sorg kan verbeter. Dit toon ook die geleenthede vir
en probleme verbonde aan die implementering van sodanige intervensie en die
uitvoer van 'n grootskaalse proef in hierdie omgewing. Hierdie studie dui daarop
dat ander internasionale intervensies gebaseer op die verspreiding van kliniese
riglyne, soos IMCI, SOS en MIVNIGS plaaslik ontwikkel moet word en noukeurig
plaaslik ge-evalueer moet word gegewe hulle potensiële impak op publieke
gesondheid en op dienste.
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