Divisions of Pulmonary and Critical Care Medicine, Department of Medicine, San Francisco General Hospital, California.
Am J Respir Crit Care Med. 2011 Aug 1;184(3):362-7. doi: 10.1164/rccm.201012-1984OC. Epub 2011 Mar 11.
Tuberculosis case-detection rates are below internationally established targets in high-burden countries. Real-time monitoring and evaluation of adherence to widely endorsed standards of tuberculosis care might facilitate improved case finding.
To monitor and evaluate the quality of tuberculosis case-detection and management services in a low-income country with a high incidence of tuberculosis.
We prospectively evaluated tuberculosis diagnostic services at five primary health-care facilities in Uganda for 1 year, after introducing a real-time, electronic performance-monitoring system. We collected data on every clinical encounter, and measured quality using indicators derived from the International Standards of Tuberculosis Care.
In 2009, there were 62,909 adult primary-care visits. During the first quarter of 2009, clinicians referred only 21% of patients with cough greater than or equal to 2 weeks for sputum smear microscopy and only 71% of patients with a positive sputum examination for tuberculosis treatment. These proportions increased to 53% and 84%, respectively, in the fourth quarter of 2009. The cumulative probability that a smear-positive patient with cough greater than or equal to 2 weeks would be appropriately evaluated and referred for treatment rose from 11% to 34% (P = 0.005). The quarterly number of tuberculosis cases identified and prescribed treatment also increased four-fold, from 5 to 21.
Poor adherence to internationally accepted standards of tuberculosis care improved after introduction of real-time performance monitoring and was associated with increased tuberculosis case detection. Real-time monitoring and evaluation can strengthen health systems in low-income countries and facilitate operational research on the effectiveness and sustainability of interventions to improve tuberculosis case detection.
在高负担国家，结核病病例检出率低于国际既定目标。实时监测和评估对广泛认可的结核病护理标准的遵守情况，可能有助于提高病例检出率。
在一个结核病发病率高的低收入国家，监测和评估结核病病例检出和管理服务的质量。
我们在乌干达的 5 个初级保健机构前瞻性地评估了结核病诊断服务，在引入实时电子绩效监测系统后进行了为期 1 年的评估。我们收集了每一次临床接触的数据，并使用源自国际结核病护理标准的指标来衡量质量。
2009 年，有 62909 例成人初级保健就诊。在 2009 年第一季度，临床医生仅将 21%的咳嗽大于或等于 2 周的患者转诊进行痰涂片显微镜检查，仅将 71%的痰检阳性的患者转诊进行结核病治疗。到 2009 年第四季度，这两个比例分别增加到 53%和 84%。咳嗽大于或等于 2 周且痰涂片阳性的患者得到适当评估和转诊进行治疗的累积概率从 11%上升到 34%（P=0.005）。每季度发现和开具治疗方案的结核病病例数也从 5 例增加到 21 例，增加了四倍。
在引入实时绩效监测后，对国际公认的结核病护理标准的遵守情况较差得到了改善，并且与结核病病例检出率的提高相关。实时监测和评估可以加强低收入国家的卫生系统，并促进关于提高结核病病例检出率的干预措施的有效性和可持续性的运营研究。
