Abstract
BackgroundThe 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.MethodsWe 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.FindingsClinician 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.ConclusionThis 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.
Highlights
There is increasing recognition that low- and middle-income countries (LMICs) must improve access to health care services, and the quality of those services in order to meet the needs of their populations [1]
Baseline performance on the primary outcome of appropriate antibiotic prescription was 19%, which had improved to 68% at the end of the study period (Χ2 = 150.7 [1 degree of freedom], p < 0.001) (Fig 1)
At Penda Health, baseline performance on the primary outcome of appropriate antibiotic prescription was 35.7%, which had improved to 83.0% at the end of the study period (Χ2 = 51.8 [1 degree of freedom], p < 0.001)
Summary
There is increasing recognition that low- and middle-income countries (LMICs) must improve access to health care services, and the quality of those services in order to meet the needs of their populations [1]. Lacking even in advanced health care systems are quality metrics that assess performance on diagnosis and management of common acute illnesses in the ambulatory care setting [5]. Most ambulatory care metrics focus on chronic disease management, leaving the performance on routine acute illnesses such as the diagnosis and management of urinary tract infection (UTI) largely unknown. 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 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
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