Abstract
Trial DesignBest 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.MethodsThirty-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.ResultsScores 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.ConclusionsClinical 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.Trial RegistrationClinicalTrials.gov NCT01190540
Highlights
Efforts to reduce the global burden of infectious disease are significantly constrained by shortages of trained health professionals and by deficits in quality of available care. [1,2,3,4,5,6,7,8] There is scant available evidence supporting different approaches to addressing these human-resource gaps. [9,10]Systematic reviews of capacity-building interventions report modest and significant improvements in clinical practice
Focusing on low and middle income countries, Rowe et al summarized ‘‘that the simple dissemination of written guidelines is often ineffective, that supervision and audit with feedback is generally effective, and that multifaceted interventions might be more effective than single interventions.’’ [10] Focusing on fever case management in Africa, Zurovac and Rowe reported that continuous quality improvement interventions were associated with better quality of care
This paper addresses the effect of the Infectious Disease Capacity-Building Evaluation (IDCAP) interventions on individual competence
Summary
Efforts to reduce the global burden of infectious disease are significantly constrained by shortages of trained health professionals and by deficits in quality of available care. [1,2,3,4,5,6,7,8] There is scant available evidence supporting different approaches to addressing these human-resource gaps. [9,10]Systematic reviews of capacity-building interventions report modest and significant improvements in clinical practice. A review of continuing medical education, [11] which included four studies in Africa, reported median improvements ranging from 6.9 to 13.6 percent. For systematic reviews of educational outreach visits [12] and audit and feedback, [13] which respectively included no studies and one study in Africa, the median improvements respectively ranged from 5.6 to 21 percent, and 5.0 to 16 percent. Focusing on low and middle income countries, Rowe et al summarized ‘‘that the simple dissemination of written guidelines is often ineffective, that supervision and audit with feedback is generally effective, and that multifaceted interventions might be more effective than single interventions.’’ [10] Focusing on fever case management in Africa, Zurovac and Rowe reported that continuous quality improvement interventions were associated with better quality of care. [18] In this context, the Integrated Infectious Disease Capacity-Building Evaluation (IDCAP) undertook a prospective study of two different approaches to MLP training in infectious-disease care. On-site support (OSS) was an educational outreach package of four activities over the course of two days per month at each health facility for nine months
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