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Missed opportunities in TB diagnosis: a TB process-based performance review tool to evaluate and improve clinical care.

ABSTRACT: Traditional tuberculosis (TB) treatment outcome measures, such as cure rate, do not provide insight into the underlying reasons for missing clinical targets. We evaluated a TB Process-Based Performance Review (TB-PBPR) tool, developed to identify "missed opportunities" for timely and accurate diagnosis of TB. The tool enables performance assessment at the level of process and quality of care.The TB-PBPR tool is a single-page structured flow-sheet that identifies 14 clinical actions (grouped into elicited symptoms, clinical examination and investigations). Medical records from selected deceased patients were reviewed at two South African mine hospitals (A = 56 cases; B = 26 cases), a South African teaching hospital (C = 20 cases) and a UK teaching hospital (D = 13 cases).In hospital A, where autopsy was routine, TB was missed in life in 52% (23/44) of cases and was wrongly attributed as the cause of death in 16% (18/110). Clinical omissions were identified at each hospital and at every stage of clinical management. For example, recording of chest symptoms was omitted in up to 39% of cases, sputum smear examination in up to 85% and chest radiograph in up to 38% of cases respectively.This study introduces the TB-PBPR tool as a novel method to review and evaluate clinical performance in TB management. We found that simple clinical actions were omitted in many cases. The tool, in conjunction with a manual describing best practice, is adaptable to a range of settings, is educational and enables detailed feedback within a TB programme. The TB-PBPR tool and manual are both freely available for general use.

SUBMITTER: Field N

PROVIDER: S-EPMC3051909 | biostudies-other | 2011 Feb

REPOSITORIES: biostudies-other

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Missed opportunities in TB diagnosis: a TB process-based performance review tool to evaluate and improve clinical care.

Field Nigel N Murray Jill J Wong Michelle L ML Dowdeswell Rob R Dudumayo Ntomboxolo N Rametsi Lesego L Martinson Neil N Lipman Marc M Glynn Judith R JR Sonnenberg Pam P

BMC public health 20110222

<h4>Background</h4>Traditional tuberculosis (TB) treatment outcome measures, such as cure rate, do not provide insight into the underlying reasons for missing clinical targets. We evaluated a TB Process-Based Performance Review (TB-PBPR) tool, developed to identify "missed opportunities" for timely and accurate diagnosis of TB. The tool enables performance assessment at the level of process and quality of care.<h4>Methods</h4>The TB-PBPR tool is a single-page structured flow-sheet that identifie ...[more]

PMID: 21342493

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Project description:Setting40 primary health clinics (PHCs) in four provinces in South Africa, June 2012 -February 2013.ObjectiveTo determine whether health care worker (HCW) practice in investigating people with TB symptoms was altered when the initial test for TB was changed from smear microscopy to Xpert MTB/RIF.DesignCross-sectional substudy at clinics participating in a pragmatic cluster randomised trial, Xpert for TB: Evaluating a New Diagnostic "XTEND", which evaluated the effect of Xpert MTB/RIF implementation in South Africa.MethodsConsecutive adults exiting PHCs reporting at least one TB symptom (defined as any of cough, weight loss, night sweats and fever) were enrolled. The main outcome was the proportion who self-reported having sputum requested by HCW during the clinic encounter just completed.Results3604 adults exiting PHCs (1676 in Xpert arm, 1928 in microscopy arm) were enrolled (median age 38 years, 71.4% female, 38.8% reported being HIV-positive, 70% reported cough). For 1267 participants (35.2%) the main reason for attending the clinic was TB symptom(s). Overall 2130/3604 (59.1%) said they reported their symptom(s) to HCW. 22.7% (818/3604) reported having been asked to give sputum for TB investigation. Though participants in the Xpert vs. microscopy arm were more likely to have sputum requested by HCW, this was not significantly different: overall (26.0% [436/1676] vs 19.8% [382/1928]; adjusted prevalence ratio [aPR] 1.31, [95% CI 0.78-2.20]) and when restricted to those presenting at clinics due to symptoms (49.1% [260/530] vs 29.9% [220/737]; aPR 1.38 [0.89-2.13]) and those reporting being HIV-positive (29.4% [190/647] vs 20.8% [156/749]; aPR 1.38[0.88-2.16]). Those attending clinic due to TB symptoms, were more likely to have sputum requested if they had increasing number of symptoms; longer duration of cough, unintentional weight loss and night sweats and if they reported symptoms to HCW.ConclusionsA large proportion of people exiting PHCs reporting TB symptoms did not get tested. Implementation of Xpert MTB/RIF did not substantially change the probability of testing for TB. Better systems are needed to ensure that opportunities to identify active TB among PHC attendees are not missed.

Project description:BackgroundSeveral lines of evidence indicate that medical schools have been failing to adequately nurture empathy and the ethical dimension in their graduates, the lack of which may play a central role in the genesis of medical errors, itself a major source of avoidable deaths, incapacity and wasted resources. It has been widely proposed that medical schools should adopt evaluation strategies as a means to promote a culture of respectful relationships. However, it is not clear if evaluation strategies in medical schools have addressed key domains related to that aim, such as ethics, through the perspective of their students. Hence, we conducted a national survey of instruments used by Brazilian medical schools to assess clerkship rotations from the perspective of students, with a main focus on the ethical domain.MethodsThe authors invited 121 randomly selected institutions to participate in the study. Key informants answered a questionnaire about clerkship rotations and sent copies of any instrument used to assess the quality of clerkship rotations according to the students' perspectives.ResultsTwenty-six (53%) of 49 participating schools used an instrument to assess the quality of clerkship rotations according to the perspective of students. Just 13 (27%) schools had instruments containing at least one question encompassing the ethical domain. Only 2 (4%) schools asked students specifically about the occurrence of any negative experience concerning the ethical domain during rotations. Merely 1 (2%) school asked students about having witnessed patient mistreatment and none asked about mistreatment against students themselves.ConclusionsThere are several missed opportunities in the way medical schools assess the quality of clerkship rotations regarding the ethical domain. Closing the gap between usual institutional discourses regarding ethics and how that dimension is assessed within clerkship rotations might represent an important step towards the improvement of medical education and healthcare systems.

Project description:Simple interventions resolve the problem of missed lab appointments. It is essential that patients complete ordered laboratory studies. This maintains clinical quality and, potentially, keeps patients safe from harm. In our academic family medicine practice, baseline data demonstrated patients completed 94.7% of labs as ordered (26850/28348 patients per year) while 1498 (5.3%) did not. Our baseline patient reminder process, a mail or portal based generic letter, resulted in only 449 (30%) of patients ultimately completing them (1049 [70%] did not). Our baseline system was 96.3 % reliable. This process did not allow for provider review or input, and was not personalized for patients. We designed a quality improvement project involving three PDSA (Plan, Do, Study, and Act) cycles of about two months each. Desk staff created weekly reports of unresolved lab orders. A message in the electronic medical record (EMR) solicited provider input. Providers could elect to cancel studies (if already completed, reordered, or no longer clinically indicated) or have the patient receive a personalized reminder, including provider name and associated diagnoses. This reminder was sent by patient portal secure messaging (if an account existed) or with a mailed letter. These interventions resulted in 98.8 % process reliability. The frequency of unresolved lab orders decreased from 70% at baseline to 25%. In the second PDSA cycle, we contacted patients by the portal only if there was evidence of an active account. Otherwise, they were contacted by telephone. Patients without a portal account continued to receive a letter by mail. These modified processes resulted in an overall reliability rate of 99.2%. The frequency of unresolved lab orders decreased to 17%. A final PDSA cycle utilized only telephone contact with patients with unresolved lab orders. Schedulers offered patients a choice of appointment dates if they spoke personally. Otherwise, they were left messages with a future lab appointment date two weeks later.Overall process reliability now increased to 100%. The frequency of unresolved lab orders decreased to 0%. Our interventions resulted in increased system reliability.Provider input was not perceived as burdensome. Desk staff work effort was not increased.Telephone patient contact resulted in more frequent lab order completion than other methods.

Project description:BackgroundSamples submitted for HIV PCR testing that fail to yield a positive or negative result represent missed diagnostic opportunities. We describe HIV PCR test rejections and indeterminate results, and the associated delay in diagnosis, within South Africa's early infant diagnosis (EID) program from 2010 to 2015.MethodsHIV PCR test data from January 2010 to December 2015 were extracted from the National Health Laboratory Service Corporate Data Warehouse, a central data repository of all registered test-sets within the public health sector in South Africa, by laboratory number, result, date, facility, and testing laboratory. Samples that failed to yield either a positive or negative result were categorized according to the rejection code on the laboratory information system, and descriptive analysis performed using Microsoft Excel. Delay in diagnosis was calculated for patients who had a missed diagnostic opportunity registered between January 2013 and December 2015 by means of a patient linking-algorithm employing demographic details.ResultsBetween 2010 and 2015, 2 178 582 samples were registered for HIV PCR testing of which 6.2% (n = 134 339) failed to yield either a positive or negative result, decreasing proportionally from 7.0% (n = 20 556) in 2010 to 4.4% (n = 21 388) in 2015 (p<0.001). Amongst 76 972 coded missed diagnostic opportunities, 49 585 (64.4%) were a result of pre-analytical error and 27 387 (35.6%) analytical error. Amongst 49 694 patients searched for follow-up results, 16 895 (34.0%) had at least one subsequent HIV PCR test registered after a median of 29 days (IQR: 13-57), of which 8.4% tested positive compared with 3.6% of all samples submitted for the same period.ConclusionsRoutine laboratory data provides the opportunity for near real-time surveillance and quality improvement within the EID program. Delay in diagnosis and wastage of resources associated with missed diagnostic opportunities must be addressed and infants actively followed-up as South Africa works towards elimination of mother-to-child transmission.

Project description:Newborn mortality and adverse birth outcomes (ABOs) in Sao Tome & Príncipe (STP) are overwhelmingly high, and access to quality-antenatal care (ANC) is one of the strategies to tackle it. This study aimed to fill the gaps in ANC screenings with a focus on how to improve neonatal outcomes. We conducted a retrospective hospital-based study in which ANC pregnancy cards were reviewed. Screenings were described and compared according to the total number of ANC contacts: 1–3 (inadequate), 4–7 (adequate), and ≥8 (complete). The collected data were entered into QuickTapSurvey and exported to SPSS version 25 for analysis. Statistical significance was considered at a p-value ≤0.05. A total of 511 ANC pregnancy cards were reviewed. Mothers’ mean age was 26.6 (SD = 7.1), 51.7% had a first trimester early booking, 14.9% (76) had 1–3 ANC contacts, 46.4% (237) had 4–7 and 38.7% (198) ≥8. Screening absence was found in 24%-41%, lack of money was registered in 36%. Pregnant women had no screening performed for HIV in 4.5%, syphilis in 8.8%, HBV 39.3%, malaria 25.8%, hemoglobin 24.5%, blood glucose 45.4%, urine 29.7%, stool exams 27.8% and 41.1% had no ultrasound. Screening completion for blood group, HIV, malaria, urine, hemoglobin, and coproparasitological exam were found to have a statistically significant difference (p<0.001) for the complete ANC group when compared to other groups. Antenatal problems identified were: 1) bacteriuria (43.2%); 2) maternal anemia (37%); 3) intestinal parasitic infections (59.2%); 4) sickle cell solubility test positive (13%); and 5) a RhD-negative phenotype (5.8%). Missed-ANC treatments were up to 50%. This study reveals a coverage-quality gap in STP since no pregnant woman is left without ANC contact, although most still miss evidence-based screenings with an impact on neonatal outcomes. Strategies such as implementing a total free ANC screening package in STP would enhance maternal diagnosis and prompt treatments.

Project description:Differences in the prevalence of undiagnosed HIV between different types of emergency departments (EDs) are not well understood. We seek to define missed opportunities for HIV diagnosis within 3 geographically proximate EDs serving different patient populations in a single metropolitan area.For an urban academic, an urban community, and a suburban community ED located within 10 miles of one another, we reviewed visit records for a cohort of patients who received a new diagnosis of HIV between July 1999 and June 2003. Missed opportunities for earlier HIV diagnosis were defined as ED visits in the year before diagnosis, during which there was no documented ED HIV testing offer or test. Outcomes were the number of missed opportunity visits and the number of patients with a missed opportunity for each ED. We secondarily reviewed medical records for missed opportunity encounters, using an extensive list of indications that might conceivably trigger testing.Among 276 patients with a new HIV diagnosis, 123 (44.5%) visited an ED in the year before diagnosis or received a diagnosis in the ED. The urban academic ED HIV testing program diagnosed 23 (8.3%) cases and offered testing to 24 (8.7%) patients who declined. Missed opportunities occurred during 187 visits made by 76 (27.5%) patients. These included 70 patients with 157 visits at the urban academic ED, 9 patients with 24 visits at the urban community ED, and 4 patients with 6 visits at the suburban community ED. Medical records were available for 172 of the 187 missed opportunity visits. Visits were characterized by the following potential testing indicators: HIV risk factors (58; 34%), related diagnosis indicating risk (7; 4%), AIDS-defining illness (8; 5%), physician suspicion of HIV (29; 17%), and nonspecific signs or symptoms of illness potentially consistent with HIV (126; 73%).Geographically proximate EDs differ in their opportunities for earlier HIV diagnosis, but all 3 sites had missed opportunities. Many ED patients with undiagnosed HIV have potential indications for testing documented even in the absence of a dedicated risk assessment, although most of these are nonspecific signs or symptoms of illness that may not be clinically useful selection criteria.

Project description:In developing countries, the most common diagnostic method for tuberculosis (TB) is microscopic examination sputum smears. Current assessment requires time-intensive inspection across the microscope slide area, and this contributes to its poor diagnostic sensitivity of ≈50%. Spatially concentrating TB bacteria in a smaller area is one potential approach to improve visual detection and potentially increase sensitivity. We hypothesized that a combination of magnetic concentration and induced droplet Marangoni flow would spatially concentrate Mycobacterium tuberculosis on the slide surface by preferential deposition of beads and TB-bead complexes in the center of an evaporating droplet. To this end, slide substrate and droplet solvent thermal conductivities and solvent surface tension, variables known to impact microfluidic flow patterns in evaporating droplets, were varied to select the most appropriate slide surface coating. Optimization in a model system used goniometry, optical coherence tomography, and microscope images of the final deposition pattern to observe the droplet flows and maximize central deposition of 1 μm fluorescent polystyrene particles and 200 nm nanoparticles (NPs) in 2 μL droplets. Rain-X® polysiloxane glass coating was identified as the best substrate material, with a PBS-Tween droplet solvent. The use of smaller, 200 nm magnetic NPs instead of larger 1 μm beads allowed for bright field imaging of bacteria. Using these optimized components, we compared standard smear methods to the Marangoni-based spatial concentration system, which was paired with magnetic enrichment using iron oxide NPs, isolating M. bovis BCG (BCG) from samples containing 0 and 103 to 106 bacilli/mL. Compared to standard smear preparation, paired analysis demonstrated a combined volumetric and spatial sample enrichment of 100-fold. With further refinement, this magnetic/Marangoni flow concentration approach is expected to improve whole-pathogen microscopy-based diagnosis of TB and other infectious diseases.

Project description:BackgroundLate HIV diagnosis is associated with increased AIDS-related morbidity and mortality as well as an increased risk of HIV transmission. In this study, we quantified and characterized missed opportunities for earlier HIV diagnosis in British Columbia (BC), Canada.DesignRetrospective cohort.MethodsA missed opportunity was defined as a healthcare encounter due to a clinical manifestation which may be caused by HIV infection, or is frequently present among those with HIV infection, but no HIV diagnosis followed within 30 days. We developed an algorithm to identify missed opportunities within one, three, and five years prior to diagnosis. The algorithm was applied to the BC STOP HIV/AIDS population-based cohort. Eligible individuals were ≥18 years old, and diagnosed from 2001-2014. Multivariable logistic regression identified factors associated with missed opportunities.ResultsOf 2119 individuals, 7%, 12% and 14% had ≥1 missed opportunity during one, three and five years prior to HIV diagnosis, respectively. In all analyses, individuals aged ≥40 years, heterosexuals or people who ever injected drugs, and those residing in Northern health authority had increased odds of experiencing ≥1 missed opportunity. In the three and five-year analysis, individuals with a CD4 count <350 cells/mm3 were at higher odds of experiencing ≥1 missed opportunity. Prominent missed opportunities were related to recurrent pneumonia, herpes zoster/shingles among younger individuals, and anemia related to nutritional deficiencies or unspecified cause.ConclusionsBased on our newly-developed algorithm, this study demonstrated that HIV-diagnosed individuals in BC have experienced several missed opportunities for earlier diagnosis. Specific clinical indicator conditions and population sub-groups at increased risk of experiencing these missed opportunities were identified. Further work is required in order to validate the utility of this proposed algorithm by establishing the sensitivity, specificity, positive and negative predictive values corresponding to the incidence of the clinical indicator conditions among both HIV-diagnosed and HIV-negative populations.

Dataset Information

Missed opportunities in TB diagnosis: a TB process-based performance review tool to evaluate and improve clinical care.

Publications

Missed opportunities in TB diagnosis: a TB process-based performance review tool to evaluate and improve clinical care.

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