Department of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
University of North Carolina Project, Lilongwe, Malawi.
PLoS One. 2022 Jun 8;17(6):e0269062. doi: 10.1371/journal.pone.0269062. eCollection 2022.
Viral load (VL) testing coverage remains low particularly in resource limited countries despite recommendation by World Health Organization, and Malawi is no exception. A quality improvement (QI) approach was used to improve VL testing coverage from 27% to a target of 80% at an urban health facility in Malawi.
A QI study employing a time-series quasi-experimental design with no comparison group was conducted at Chilomoni health centre in Blantyre from April 2020 to July 2020. A retrospective record review of all patient records (257) from 8 weeks before the study was conducted to determine baseline VL testing coverage. Root cause analysis of low VL testing coverage was done using fish-bone tool and factors prioritized using a Pareto-chart. Priority factors included inadequate capacity to update electronic medical records and competing tasks. Change ideas were identified and prioritized using an effort-impact matrix. Two change ideas; re-orienting ART providers on VL test order in EMR and dedicated ART provider to serve VL tested patients were implemented and tested in 5 Plan-Do-Study-Act (PDSA) cycles from the Model for Improvement (MFI), each lasting one week. The latter was tested, and adapted in 3 cycles, and eventually adopted for monitoring for another 5 weeks. VL testing coverage was tracked throughout the study using run charts and p-charts.
VL testing coverage increased from 27% to 71% by the end of the study, with children aged 0 to 14 years having the lowest coverage throughout the study.
The MFI as a QI approach improved VL testing coverage through implementation of contextualized change ideas. A reliable data system, leadership buy-in and commitment are important for sustained improvement. Future research should focus on evaluating sustainability of improved VL testing coverage at the health facility and assessing barriers to VL testing among the paediatric population.
尽管世界卫生组织建议，但病毒载量 (VL) 检测覆盖率仍然很低，特别是在资源有限的国家，马拉维也不例外。采用质量改进 (QI) 方法，将马拉维一个城市卫生机构的 VL 检测覆盖率从 27%提高到 80%的目标。
2020 年 4 月至 7 月，在布兰太尔的奇洛莫尼卫生中心开展了一项 QI 研究，采用时间序列准实验设计，无对照组。在研究开展前的 8 周内，对所有患者记录（257 份）进行回顾性记录审查，以确定 VL 检测覆盖率的基线。使用鱼骨图工具对 VL 检测覆盖率低的原因进行根本原因分析，并使用帕累托图对因素进行优先级排序。优先级因素包括更新电子病历的能力不足和竞争任务。使用努力影响矩阵确定和优先考虑变更思路。使用改进模型 (MFI) 中的 5 个计划-执行-研究-行动 (PDSA) 循环实施和测试了两个变更思路，即重新定向电子病历中 ART 提供者的 VL 检测顺序和专门的 ART 提供者为接受 VL 检测的患者提供服务，每个循环持续一周。后者经过测试并在 3 个循环中进行了调整，最终被采用并监测了另外 5 周。在整个研究过程中，使用运行图和 p 图跟踪 VL 检测覆盖率。
到研究结束时，VL 检测覆盖率从 27%提高到 71%，0 至 14 岁的儿童在整个研究过程中的覆盖率最低。
作为 QI 方法，MFI 通过实施基于情境的变更思路提高了 VL 检测覆盖率。可靠的数据系统、领导层的认可和承诺对于持续改进很重要。未来的研究应侧重于评估卫生机构改进后的 VL 检测覆盖率的可持续性，并评估儿科人群中 VL 检测的障碍。
