Dataset Information

Effect of Educational Outreach Timing and Duration on Facility Performance for Infectious Disease Care in Uganda: A Trial with Pre-Post and Cluster Randomized Controlled Components.

ABSTRACT:

Background

Classroom-based learning is often insufficient to ensure high quality care and application of health care guidelines. Educational outreach is garnering attention as a supplemental method to enhance health care worker capacity, yet there is little information about the timing and duration required to improve facility performance. We sought to evaluate the effects of an infectious disease training program followed by either immediate or delayed on-site support (OSS), an educational outreach approach, on nine facility performance indicators for emergency triage, assessment, and treatment; malaria; and pneumonia. We also compared the effects of nine monthly OSS visits to extended OSS, with three additional visits over six months.

Methods

This study was conducted at 36 health facilities in Uganda, covering 1,275,960 outpatient visits over 23 months. From April 2010 to December 2010, 36 sites received infectious disease training; 18 randomly selected sites in arm A received nine monthly OSS visits (immediate OSS) and 18 sites in arm B did not. From March 2011 to September 2011, arm A sites received three additional visits every two months (extended OSS), while the arm B sites received eight monthly OSS visits (delayed OSS). We compared the combined effect of training and delayed OSS to training followed by immediate OSS to determine the effect of delaying OSS implementation by nine months. We also compared facility performance in arm A during the extended OSS to immediate OSS to examine the effect of additional, less frequent OSS.

Results

Delayed OSS, when combined with training, was associated with significant pre/post improvements in four indicators: outpatients triaged (44% vs. 87%, aRR = 1.54, 99% CI = 1.11, 2.15); emergency and priority patients admitted, detained, or referred (16% vs. 31%, aRR = 1.74, 99% CI = 1.10, 2.75); patients with a negative malaria test result prescribed an antimalarial (53% vs. 34%, aRR = 0.67, 99% CI = 0.55, 0.82); and pneumonia suspects assessed for pneumonia (6% vs. 27%, aRR = 2.97, 99% CI = 1.44, 6.17). Differences between the delayed OSS and immediate OSS arms were not statistically significant for any of the nine indicators (all adjusted relative RR (aRRR) between 0.76-1.44, all p>0.06). Extended OSS was associated with significant improvement in two indicators (outpatients triaged: aRR = 1.09, 99% CI = 1.01; emergency and priority patients admitted, detained, or referred: aRR = 1.22, 99% CI = 1.01, 1.38) and decline in one (pneumonia suspects assessed for pneumonia: aRR: 0.93; 99% CI = 0.88, 0.98).

Conclusions

Educational outreach held up to nine months after training had similar effects on facility performance as educational outreach started within one month post-training. Six months of bi-monthly educational outreach maintained facility performance gains, but incremental improvements were heterogeneous.

SUBMITTER: Burnett SM

PROVIDER: S-EPMC4564214 | biostudies-literature | 2015

REPOSITORIES: biostudies-literature

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Publications

Effect of Educational Outreach Timing and Duration on Facility Performance for Infectious Disease Care in Uganda: A Trial with Pre-Post and Cluster Randomized Controlled Components.

Burnett Sarah M SM Mbonye Martin K MK Naikoba Sarah S Zawedde-Muyanja Stella S Kinoti Stephen N SN Ronald Allan A Rubashembusya Timothy T Willis Kelly S KS Colebunders Robert R Manabe Yukari C YC Weaver Marcia R MR

PloS one 20150909 9

<h4>Background</h4>Classroom-based learning is often insufficient to ensure high quality care and application of health care guidelines. Educational outreach is garnering attention as a supplemental method to enhance health care worker capacity, yet there is little information about the timing and duration required to improve facility performance. We sought to evaluate the effects of an infectious disease training program followed by either immediate or delayed on-site support (OSS), an educatio ...[more]

PMID: 26352257

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Project description:BackgroundThe effects of two interventions, Integrated Management of Infectious Disease (IMID) training program and On-Site Support (OSS), were tested on 23 facility performance indicators for emergency triage assessment and treatment (ETAT), malaria, pneumonia, tuberculosis, and HIV.MethodsThe trial was implemented in 36 primary care facilities in Uganda. From April 2010, two mid-level practitioners per facility participated in IMID training. Eighteen of 36 facilities were randomly assigned to Arm A, and received OSS in 2010 (nine monthly two-day sessions); 18 facilities assigned to Arm B did not receive OSS in 2010. Data were collected from Nov 2009 to Dec 2010 using a revised Ministry of Health outpatient medical form and nine registers. We analyzed the effect of IMID training alone by measuring changes before and during IMID training in Arm B, the combined effect of IMID training and OSS by measuring changes in Arm A, and the incremental effect of OSS by comparing changes across Arms A and B.ResultsIMID training was associated with statistically significant improvement in three indicators: outpatients triaged (adjusted relative risks (aRR)?=?1.29, 99%CI?=?1.01,1.64), emergency and priority patients admitted, detained, or referred (aRR?=?1.59, 99%CI?=?1.04,2.44), and pneumonia suspects assessed (aRR?=?2.31, 99%CI?=?1.50,3.55). IMID training and OSS combined was associated with improvements in six indicators: three ETAT indicators (outpatients triaged (aRR?=?2.03, 99%CI?=?1.13,3.64), emergency and priority patients admitted, detained or referred (aRR?=?3.03, 99%CI?=?1.40,6.56), and emergency patients receiving at least one appropriate treatment (aRR?=?1.77, 99%CI?=?1.10,2.84)); two malaria indicators (malaria cases receiving appropriate antimalarial (aRR?=?1.50, 99%CI?=?1.04,2.17), and patients with negative malaria test results prescribed antimalarial (aRR?=?0.67, 99%CI?=?0.46,0.97)); and enrollment in HIV care (aRR?=?1.58, 99%CI?=?1.32,1.89). OSS was associated with incremental improvement in emergency patients receiving at least one appropriate treatment (adjusted ratio of RR?=?1.84,99%CI?=?1.09,3.12).ConclusionThe trial showed that the OSS intervention significantly improved performance in one of 23 facility indicators.

Project description:Best practices for training mid-level practitioners (MLPs) to improve global health-services are not well-characterized. Two hypotheses were: 1) Integrated Management of Infectious Disease (IMID) training would improve clinical competence as tested with a single arm, pre-post design, and 2) on-site support (OSS) would yield additional improvements as tested with a cluster-randomized trial.Thirty-six Ugandan health facilities (randomized 1?1 to parallel OSS and control arms) enrolled two MLPs each. All MLPs participated in IMID (3-week core course, two 1-week boost sessions, distance learning). After the 3-week course, OSS-arm trainees participated in monthly OSS. Twelve written case scenarios tested clinical competencies in HIV/AIDS, tuberculosis, malaria, and other infectious diseases. Each participant completed different randomly-assigned blocks of four scenarios before IMID (t0), after 3-week course (t1), and after second boost course (t2, 24 weeks after t1). Scoring guides were harmonized with IMID content and Ugandan national policy. Score analyses used a linear mixed-effects model. The primary outcome measure was longitudinal change in scenario scores.Scores were available for 856 scenarios. Mean correct scores at t0, t1, and t2 were 39.3%, 49.1%, and 49.6%, respectively. Mean score increases (95% CI, p-value) for t0-t1 (pre-post period) and t1-t2 (parallel-arm period) were 12.1 ((9.6, 14.6), p<0.001) and -0.6 ((-3.1, +1.9), p?=?0.647) percent for OSS arm and 7.5 ((5.0, 10.0), p<0.001) and 1.6 ((-1.0, +4.1), p?=?0.225) for control arm. The estimated mean difference in t1 to t2 score change, comparing arm A (participated in OSS) vs. arm B was -2.2 ((-5.8, +1.4), p?=?0.237). From t0-t2, mean scores increased for all 12 scenarios.Clinical competence increased significantly after a 3-week core course; improvement persisted for 24 weeks. No additional impact of OSS was observed. Data on clinical practice, facility-level performance and health outcomes will complete assessment of overall impact of IMID and OSS.ClinicalTrials.gov NCT01190540.

Project description:ObjectivesTo develop and implement an educational outreach programme for the integrated case management of priority respiratory diseases (practical approach to lung health in South Africa; PALSA) and to evaluate its effects on respiratory care and detection of tuberculosis among adults attending primary care clinics.DesignPragmatic cluster randomised controlled trial, with clinics as the unit of randomisation.Setting40 primary care clinics, staffed by nurse practitioners, in the Free State province, South Africa.Participants1999 patients aged 15 or over with cough or difficult breathing (1000 in intervention clinics, 999 in control clinics).InterventionBetween two and six educational outreach sessions delivered to nurse practitioners by usual trainers from the health department. The emphasis was on key messages drawn from the customised clinical practice guideline for the outreach programme, with illustrative support materials.Main outcome measuresSputum screening for tuberculosis, tuberculosis case detection, inhaled corticosteroid prescriptions for obstructive lung disease, and antibiotic prescriptions for respiratory tract infections.ResultsAll clinics and almost all patients (92.8%, 1856/1999) completed the trial. Although sputum testing for tuberculosis was similar between the groups (22.6% in outreach group v 19.3% in control group; odds ratio 1.22, 95% confidence interval 0.83 to 1.80), the case detection of tuberculosis was higher in the outreach group (6.4% v 3.8%; 1.72, 1.04 to 2.85). Prescriptions for inhaled corticosteroids were also higher (13.7% v 7.7%; 1.90, 1.14 to 3.18) but the number of antibiotic prescriptions was similar (39.7% v 39.4%; 1.01, 0.74 to 1.38).ConclusionsCombining educational outreach with integrated case management provides a promising model for improving quality of care and control of priority respiratory diseases, without extra staff, in resource poor settings.Trial registrationCurrent controlled trials ISRCTN13438073.

Project description:BackgroundThe Integrated Infectious Diseases Capacity Building Evaluation (IDCAP) designed two interventions: Integrated Management of Infectious Disease (IMID) training program and On-Site Support (OSS). We evaluated their effects on 23 facility performance indicators, including malaria case management.MethodologyIMID, a three-week training with two follow-up booster courses, was for two mid- level practitioners, primarily clinical officers and registered nurses, from 36 primary care facilities. OSS was two days of training and continuous quality improvement activities for nine months at 18 facilities, to which all health workers were invited to participate. Facilities were randomized as clusters 1∶1 to parallel OSS "arm A" or control "arm B". Outpatient data on four malaria case management indicators were collected for 14 months. Analysis compared changes before and during the interventions within arms (relative risk = RR). The effect of OSS was measured with the difference in changes across arms (ratio of RR = RRR).FindingsThe proportion of patients with suspected malaria for whom a diagnostic test result for malaria was recorded decreased in arm B (adjusted RR (aRR) = 0.97; 99%CI: 0.82,1.14) during IMID, but increased 25% in arm A (aRR = 1.25; 99%CI:0.94, 1.65) during IMID and OSS relative to baseline; (aRRR = 1.28; 99%CI:0.93, 1.78). The estimated proportion of patients that received an appropriate antimalarial among those prescribed any antimalarial increased in arm B (aRR = 1.09; 99%CI: 0.87, 1.36) and arm A (aRR = 1.50; 99%CI: 1.04, 2.17); (aRRR = 1.38; 99%CI: 0.89, 2.13). The proportion of patients with a negative diagnostic test result for malaria prescribed an antimalarial decreased in arm B (aRR = 0.96; 99%CI: 0.84, 1.10) and arm A (aRR = 0.67; 99%CI: 0.46, 0.97); (aRRR = 0.70; 99%CI: 0.48, 1.00). The proportion of patients with a positive diagnostic test result for malaria prescribed an antibiotic did not change significantly in either arm.InterpretationThe combination of IMID and OSS was associated with statistically significant improvements in malaria case management.

Project description:BACKGROUND:Educational outreach visits are meant to improve the practice of health professionals by promoting face-to-face visits to deliver educational contents. They have been shown to change prescription behavior, but long-term effects are still uncertain. This trial aimed to determine if they improve family physician prescribing compared with passive guideline dissemination. METHODS:Parallel, open, superiority, and cluster-randomized trial. National Health Service primary care practices (clusters) were recruited in the Lisbon region-Portugal between March 2013 and January 2014. They could enter if they had at least four family physicians willing to participate and not planning to retire in the follow-up period. Three national guidelines were chosen for dissemination: acid secretion modifiers, non-steroidal anti-inflammatory drugs, and antiplatelets. Physicians in the intervention group received one 15 to 20 min educational outreach visit at their workplace for each guideline. Physicians in the control group had access to guidelines through the Directorate-General for Health's website (passive dissemination). Primary outcomes were the proportion of COX-2 inhibitors prescribed within the NSAID class and the proportion of omeprazole within the PPI class at 18 months after the intervention. A cost-benefit analysis was performed. Practices were randomized by minimization. Data analyses were done at individual physician level using generalized mixed-effects regression models. Participants could not be blinded. RESULTS:Thirty-eight practices with 239 physicians were randomized (120 to intervention and 119 to control). Of 360 planned visits, 322 were delivered. No differences were found between physicians in the intervention and control groups regarding the proportion of omeprazole prescribed among PPIs 18 months after the visit (46.28 vs 47.15%, p?=?0.971) or the proportion of COX-2 inhibitors among NSAIDs (12.07 vs 13.08%, p?=?0.085). All secondary outcome comparisons showed no effect. There was no difference in cumulative drug costs at 18 months (3223.50€/1000 patients in the intervention group and 3143.92€/1000 patients in the control group, p?=?0.848). CONCLUSIONS:Educational outreach visits were unsuccessful in improving compliance with guideline recommendations among Portuguese family physicians. No effects were observed at 1, 6, and 18 months after the intervention, and there were no associated cost savings. TRIAL REGISTRATION:ClinicalTrials.gov NCT01984034 . Registered 7 November 2013.

Dataset Information

Effect of Educational Outreach Timing and Duration on Facility Performance for Infectious Disease Care in Uganda: A Trial with Pre-Post and Cluster Randomized Controlled Components.

Background

Methods

Results

Conclusions

Publications

Effect of Educational Outreach Timing and Duration on Facility Performance for Infectious Disease Care in Uganda: A Trial with Pre-Post and Cluster Randomized Controlled Components.

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