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.