Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Private Bag X7 Congella, Durban, 4013, South Africa.
School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa.
Implement Sci. 2021 Sep 17;16(1):88. doi: 10.1186/s13012-021-01155-7.
A quality improvement (QI) collaborative approach to enhancing integrated HIV-Tuberculosis (TB) services may be effective in scaling up and improving the quality of service delivery. Little is known of the role of organizational contextual factors (OCFs) in influencing the success of QI collaboratives. This study aims to determine which OCFs were associated with improvement in a QI collaborative intervention to enhance integrated HIV-TB services delivery.
This is a nested sub-study embedded in a cluster-randomized controlled trial. Sixteen nurse supervisors (clusters) overseeing 40 clinics were randomized (1:1) to receive QI training and mentorship, or standard of care support (SOC). In the QI arm, eight nurse supervisors and 20 clinics formed a "collaborative" which aimed to improve HIV-TB process indicators, namely HIV testing, TB screening, isoniazid preventive therapy (IPT) initiations, viral load testing, and antiretroviral therapy for TB patients. OCFs measured at baseline were physical infrastructure, key staff, flexibility of clinic hours, monitoring data for improvement (MDI), and leadership support. Surveys were administered to clinic staff at baseline and month 12 to assess perceptions of supportiveness of contexts for change, and clinic organization for delivering integrated HIV-TB services. Linear mixed modelling was used to test for associations between OCFs and HIV-TB process indicators.
A total of 209 clinic staff participated in the study; 97 (46.4%) and 112 (53.6%) from QI and SOC arms, respectively. There were no differences between the QI and SOC arms scores achieved for physical infrastructure (78.9% vs 64.7%; p = 0.058), key staff (95.8 vs 92; p = 0.270), clinic hours (66.9 vs 65.5; p = 0.900), MDI (63.3 vs 65; p = 0.875, leadership support (46.0 vs 57.4; p = 0.265), and perceptions of supportiveness of contexts for change (76.2 vs 79.7; p = 0.128 and clinic organization for delivering integrated HIV-TB services (74.1 vs 80.1; p = 0.916). IPT initiation was the only indicator that was significantly improved in the parent study. MDI was a significantly associated with increasing IPT initiation rates [beta coefficient (β) = 0.004; p = 0.004].
MDI is a practice that should be fostered in public health facilities to increase the likelihood of success of future QI collaboratives to improve HIV-TB service delivery.
Clinicaltrials.gov , NCT02654613 . Registered 01 June 2015.
改善医疗服务质量（QI）的合作方法可能有助于扩大和提高服务提供的质量。然而，我们对组织背景因素（OCFs）在影响 QI 合作的成功方面所起的作用知之甚少。本研究旨在确定哪些 OCFs 与改善增强 HIV-TB 服务提供的 QI 合作干预措施有关。
这是一项嵌套的子研究，嵌入在一项集群随机对照试验中。16 名监督护士（集群）监督 40 个诊所，随机（1:1）接受 QI 培训和指导，或接受标准护理支持（SOC）。在 QI 组中，8 名护士监督和 20 个诊所组成了一个“合作”小组，旨在改善 HIV-TB 过程指标，即 HIV 检测、TB 筛查、异烟肼预防治疗（IPT）的启动、病毒载量检测和 TB 患者的抗逆转录病毒治疗。在基线时测量的 OCFs 包括物理基础设施、关键人员、诊所时间的灵活性、改进监测数据（MDI）和领导支持。在基线和第 12 个月向诊所工作人员进行调查，以评估对变革支持性背景的看法，以及诊所组织提供整合的 HIV-TB 服务的情况。线性混合模型用于测试 OCFs 与 HIV-TB 过程指标之间的关联。
共有 209 名诊所工作人员参加了这项研究，QI 组和 SOC 组分别有 97 名（46.4%）和 112 名（53.6%）。QI 组和 SOC 组在物理基础设施（78.9%与 64.7%；p=0.058）、关键人员（95.8%与 92%；p=0.270）、诊所时间（66.9%与 65.5%；p=0.900）、MDI（63.3%与 65%；p=0.875）、领导支持（46.0%与 57.4%；p=0.265）和变革支持性背景的看法（76.2%与 79.7%；p=0.128）以及提供整合的 HIV-TB 服务的诊所组织（74.1%与 80.1%；p=0.916）方面的得分均无差异。在主研究中，IPT 启动是唯一显著改善的指标。MDI 与增加 IPT 启动率显著相关[β系数（β）=0.004；p=0.004]。
MDI 是一种应该在公共卫生机构中培养的实践，以增加未来 QI 合作提高 HIV-TB 服务提供的成功可能性。
Clinicaltrials.gov，NCT02654613。于 2015 年 6 月 1 日注册。
