Siddiqi Kamran, Volz Anna, Armas L, Otero L, Ugaz R, Ochoa E, Gotuzzo E, Torrico F, Newell James N, Walley J, Robinson Mike, Dieltiens G, Van der Stuyft P
Nuffield Centre for International Health and Development, Institute of Health Sciences and Public Health Research, Faculty of Medicine and Health, University of Leeds, Leeds, UK.
Trop Med Int Health. 2008 Apr;13(4):566-78. doi: 10.1111/j.1365-3156.2008.02035.x. Epub 2008 Mar 3.
To assess the effectiveness of clinical audit in improving the quality of diagnostic care provided to patients suspected of tuberculosis; and to understand the contextual factors which impede or facilitate its success.
Twenty-six health centres in Cuba, Peru and Bolivia were recruited. Clinical audit was introduced to improve the diagnostic care for patients attending with suspected TB. Standards were based on the WHO and TB programme guidelines relating to the appropriate use of microscopy, culture and radiological investigations. At least two audit cycles were completed over 2 years. Improvement was determined by comparing the performance between two six-month periods pre- and post-intervention. Qualitative methods were used to ascertain facilitating and limiting contextual factors influencing change among healthcare professionals' clinical behaviour after the introduction of clinical audit.
We found a significant improvement in 11 of 13 criteria in Cuba, in 2 of 6 criteria in Bolivia and in 2 of 5 criteria in Peru. Twelve out of 24 of the audit criteria in all three countries reached the agreed standards. Barriers to quality improvement included conflicting objectives for clinicians and TB programmes, poor coordination within the health system and patients' attitudes towards illness.
Clinical audit may drive improvements in the quality of clinical care in resource-poor settings. It is likely to be more effective if integrated within and supported by the local TB programmes. We recommend developing and evaluating an integrated model of quality improvement including clinical audit.
评估临床审核在提高疑似结核病患者诊断治疗质量方面的有效性；并了解阻碍或促进其成功的背景因素。
招募了古巴、秘鲁和玻利维亚的26个卫生中心。引入临床审核以改善对疑似结核病患者的诊断治疗。标准基于世界卫生组织和结核病规划指南中有关显微镜检查、培养和放射学检查的适当使用。在两年内至少完成两个审核周期。通过比较干预前后两个六个月期间的表现来确定改善情况。采用定性方法确定引入临床审核后影响医疗专业人员临床行为变化的促进和限制背景因素。
我们发现古巴13项标准中的11项、玻利维亚6项标准中的2项以及秘鲁5项标准中的2项有显著改善。所有三个国家24项审核标准中的12项达到了商定标准。质量改进的障碍包括临床医生和结核病规划的目标冲突、卫生系统内协调不力以及患者对疾病的态度。
临床审核可能推动资源匮乏地区临床护理质量的提高。如果纳入当地结核病规划并得到其支持，可能会更有效。我们建议制定和评估包括临床审核在内的综合质量改进模式。
