Evaluation of the effectiveness of implemention of the practical approach to lung health (PALSA) in the Free State

[摘要] English: Currently, respiratory diseases constitute about one third of patients that presentto primary care clinics in under-resourced countries of the world. Communicablerespiratory diseases such as tuberculosis, acute respiratory infections in adultsand non-communicable respiratory diseases such as asthma, chronic obstructivepulmonary disease, lung cancer represent about one-fifth of the global burden ofdisease measured in disability adjusted life years (DALY). Opportunisticinfections, other respiratory complications, and the widespread use of tobaccofurther increase the respiratory disease burden in high HIV prevalence settings.In developing countries clinic nurses with limited training and basic skills areentrusted to properly diagnose and treat respiratory patients from overloadedclinics. We developed an educational outreach intervention, Practical Approachto Lung Health in South Africa (PALSA) on integrated respiratory casemanagement aimed at improving the quality of respiratory care in South Africanprimary care clinics.The intervention comprised 3 to 4 academic detailing training sessions of primarycare nursing practitioners; dissemination of locally adapted PALSA guidelinesand 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 wasevaluated through a pragmatic cluster randomized controlled trial in the FreeState province in 2003.A total of 1000 patients in the intervention arm and 999 patients in the controlarm presenting with respiratory conditions to the 40 largest primary care clinics ofthe Free State province were interviewed at the first post-intervention survey. Thenumber of patients recruited ranged from 47 to 52 patients per clinic. The followup 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 thecontrol clinics. During data analysis, four patients in each arm were deleted dueto unavailability of the first post-intervention survey data and/or because they didnot meet the inclusion criteria. Professional nurses in intervention clinics receiveda median of 2 training sessions while nurses in the control clinic received nothing.First post-intervention survey characteristics of the intervention and control armsbalanced as a result of randomization. Almost two thirds of the patients werefemales with the most frequent age group being 25-54 years. About 50% ofpatients 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% spentbetween 2 and 12 hours to travel to and from the clinic.The inclusion criteria to the study were adults 15 years and older presenting witha cough or difficulty breathing on the day of the interview, recurrent cough ordifficulty breathing in the last 6 months or cough for less than two weeks with anyof the four severity markers. Rates of cough and difficulty breathing rangedbetween 70% and 90%. About 70% of the patients complained about chestsymptoms interfering with their usual activities while around 36% had gone to theclinic for a check-up on recurrent respiratory problem.Compared to control clinics, intervention clinics had a significant improvement ininhaled steroid prescription of 16.1% versus 10.3% (odds ratio 1.70; 95%CI 1.13to 2.56), and an improvement in sending of sputa for tuberculosis testing of16.7% versus 11.2% (odds ratio 1.60; 95%CI 1.00 to 2.54). There were alsosignificant improvements seen on appropriate referral of patients that had one ofthe four severity makers of 10.6% versus 4.9% (odds ratio 2.56; 95%CI 1.06 to6.17), and close to significant improvement of the tuberculosis detection rate of3.0% versus 1.8% (odds ratio 1.67; 95%CI 0.92 to 3.02). There was a significantincrease 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 improvementon antibiotic prescription of 36.1% versus 38.0% (odds ratio 0.92; 95%CI 0.62 to1.36) as well as cotrimoxazole prophylaxis of 12.6% versus 9.9% (odds ratio1.52; 95%CI 0.60 to 3.89). Results of this study suggest that inhaled steroidprescription, tuberculosis case detection rate, and appropriate referral of patientswith severe respiratory diseases can be improved in nurse staffed primary careclinics in developing countries and under-resourced settings.This study exemplifies an evaluation of the effectiveness of an educationalintervention in South African primary care. It shows how a carefully developedintervention, using a syndromic approach to diagnosis and treatment, canimprove several aspects of clinical care after brief training of primary care nurses.It also illustrates opportunities for, and difficulties in, implementing such anintervention, and conducting a large scale trial in this setting. This study suggeststhat other international interventions based on dissemination of clinicalguidelines, such as, for IMCI, STls and HIV/AIDS should be developed andrigorously evaluated locally, given their potential impact on public health and onservices.

[发布机构] University of the Free State