Department of Global Health and Population, Harvard School of Public Health, Boston, MA 02115, USA.
Int J Med Inform. 2012 Mar;81(3):166-72. doi: 10.1016/j.ijmedinf.2011.11.003. Epub 2011 Dec 16.
The shortage of doctors and nurses, along with future expansion into rural clinics, will require that the majority of clinic visits by HIV infected patients on antiretroviral therapy (ART) are managed by non-doctors. The goal of this study was to develop and evaluate a screening protocol to determine which patients needed a full clinical assessment and which patients were stable enough to receive their medications without a doctor's consultation. For this study, we developed an electronic, handheld tool to guide non-physician counselors through screening questions.
Patients visiting two ART clinics in South Africa for routine follow-up visits between March 2007 and April 2008 were included in our study. Each patient was screened by non-physician counselors using the handheld device and then received a full clinical assessment. Clinicians' report on whether full clinical assessment had been necessary was used as the gold standard for determining "required referral". Observations were randomly divided into two datasets--989 for developing a referral protocol and 200 for validating protocol performance.
A third of patients had at least one physical complaint, and 16% had five or more physical complaints. 38% of patients required referral for full clinical assessment. We identify a subset of questions which are 87% sensitive and 47% specific for recommended patient referral.
The final screening protocol is highly sensitive and could reduce burden on ART clinicians by 30%. The uptake and acceptance of the handheld tool to support implementation of the protocol was high. Further examination of the data reveals several important questions to include in future referral algorithms to improve sensitivity and specificity. Based on these results, we identify a refined algorithm to explore in future evaluations.
医生和护士的短缺，以及未来向农村诊所的扩展，将要求大多数接受抗逆转录病毒疗法（ART）的艾滋病毒感染者的门诊就诊由非医生管理。本研究的目的是制定和评估一种筛选方案，以确定哪些患者需要全面的临床评估，哪些患者足够稳定，可以在没有医生咨询的情况下接受药物治疗。为此，我们开发了一种电子手持工具，以指导非医师顾问通过筛选问题。
我们将 2007 年 3 月至 2008 年 4 月期间在南非两家 ART 诊所进行常规随访就诊的患者纳入我们的研究。每位患者均由非医师顾问使用手持设备进行筛查，然后接受全面的临床评估。临床医生报告是否需要进行全面临床评估作为确定“需要转介”的金标准。观察结果随机分为两个数据集 - 989 个用于制定转介方案，200 个用于验证方案性能。
三分之一的患者有至少一种身体投诉，16%的患者有五种或更多身体投诉。38%的患者需要进行全面临床评估。我们确定了一组问题，这些问题对推荐的患者转介具有 87%的敏感性和 47%的特异性。
最终的筛选方案具有很高的敏感性，可以将 ART 临床医生的负担减少 30%。对手持工具的接受度和接受度很高，支持了该方案的实施。对数据的进一步检查揭示了一些在未来转介算法中需要包含的重要问题，以提高敏感性和特异性。基于这些结果，我们确定了一个经过改进的算法，以在未来的评估中进行探索。
