Korom Robert Ryan, Onguka Stephanie, Halestrap Peter, McAlhaney Maureen, Adam Mary
Penda Health, Nairobi, Kenya.
Department of Medicine, Massachusetts General Hospital, Harvard University, Boston, MA, United States of America.
PLoS One. 2017 Apr 14;12(4):e0174566. doi: 10.1371/journal.pone.0174566. eCollection 2017.
The quality of primary care delivered in resource-limited settings is low. While some progress has been made using educational interventions, it is not yet clear how to sustainably improve care for common acute illnesses in the outpatient setting. Management of urinary tract infection is particularly important in resource-limited settings, where it is commonly diagnosed and associated with high levels of antimicrobial resistance. We describe an educational programme targeting non-physician health care providers and its effects on various clinical quality metrics for urinary tract infection.
We used a series of educational interventions including 1) formal introduction of a clinical practice guideline, 2) peer-to-peer chart review, and 3) peer-reviewed literature describing local antimicrobial resistance patterns. Interventions were conducted for clinical officers (N = 24) at two outpatient centers near Nairobi, Kenya over a one-year period. The medical records of 474 patients with urinary tract infections were scored on five clinical quality metrics, with the primary outcome being the proportion of cases in which the guideline-recommended antibiotic was prescribed. The results at baseline and following each intervention were compared using chi-squared tests and unpaired two-tailed T-tests for significance. Logistic regression analysis was used to assess for possible confounders.
Clinician adherence to the guideline-recommended antibiotic improved significantly during the study period, from 19% at baseline to 68% following all interventions (Χ2 = 150.7, p < 0.001). The secondary outcome of composite quality score also improved significantly from an average of 2.16 to 3.00 on a five-point scale (t = 6.58, p < 0.001). Interventions had different effects at different clinical sites; the primary outcome of appropriate antibiotic prescription was met 83% of the time at Penda Health, and 50% of the time at AICKH, possibly reflecting differences in onboarding and management of clinical officers. Logistic regression analysis showed that intervention stage and clinical site were independent predictors of the primary outcome (p < 0.0001), while all other features, including provider and patient age, were not significant at a conservative threshold of p < 0.05.
This study shows that brief educational interventions can dramatically improve the quality of care for routine acute illnesses in the outpatient setting. Measurement of quality metrics allows for further targeting of educational interventions depending on the needs of the providers and the community. Further study is needed to expand routine measurement of quality metrics and to identify the interventions that are most effective in improving quality of care.
在资源有限的环境中提供的初级保健质量较低。虽然通过教育干预已取得了一些进展，但尚不清楚如何在门诊环境中可持续地改善对常见急性疾病的护理。在资源有限的环境中，尿路感染的管理尤为重要，因为尿路感染在该环境中很常见且与高水平的抗菌药物耐药性相关。我们描述了一项针对非医师医疗保健提供者的教育计划及其对尿路感染各种临床质量指标的影响。
我们采用了一系列教育干预措施，包括1）正式引入临床实践指南，2）同行间病历审查，以及3）描述当地抗菌药物耐药模式的同行评审文献。在肯尼亚内罗毕附近的两个门诊中心，对24名临床干事进行了为期一年的干预。对474例尿路感染患者的病历进行了五项临床质量指标评分，主要结果是开具指南推荐抗生素的病例比例。使用卡方检验和非配对双尾T检验比较基线和每次干预后的结果是否具有显著性。采用逻辑回归分析评估可能的混杂因素。
在研究期间，临床医生对指南推荐抗生素的依从性显著提高，从基线时的19%提高到所有干预后的68%（Χ2 = 150.7，p < 0.001）。综合质量评分的次要结果也显著改善，在五分制量表上从平均2.16提高到3.00（t = 6.58，p < 0.001）。干预在不同临床地点有不同效果；在彭达健康中心，83%的时间达到了适当抗生素处方的主要结果，而在AICKH只有50%的时间达到，这可能反映了临床干事入职和管理方面的差异。逻辑回归分析表明，干预阶段和临床地点是主要结果的独立预测因素（p < 0.0001），而所有其他特征，包括提供者和患者年龄，在保守的p < 0.05阈值下均无显著性。
本研究表明，简短的教育干预可以显著提高门诊环境中常规急性疾病的护理质量。质量指标的测量有助于根据提供者和社区的需求进一步确定教育干预的目标。需要进一步研究以扩大质量指标的常规测量，并确定在改善护理质量方面最有效的干预措施。
