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Journal of Evaluation in Clinical Practice ISSN 1365-2753
The effect of an integrated syndromic respiratory disease guideline in primary health care settings Maher Abouda MD,1 Agnes Hamzaoui MD,2 Ekram Drira MD,2 Ridha Djebeniani MD,3 Salah Othmani MD, PhD4 and Ali Ben Kheder MD2 1
Assistant Professor, Respiratory Diseases Department, FSI Hospital, La Marsa, Tunisia Professor, Abderrahmen Mami Hospital, d’Ariana, Tunisia 3 TB Officer, WHO, Djibouti, Djibouti 4 Professor, STOP TB, WHO, Geneva, Switzerland 2
Keywords clinical guidelines, health care, health economics Correspondence Mrs Maher Abouda Department of Pulmonary Medicine FSI Hospital Rue Taher Ben Achour La Marsa 2070 Tunisia E-mail: [email protected] Accepted for publication: 9 June 2015 doi:10.1111/jep.12420
Abstract Rationale, aims and objectives The use of integrated syndromic guidelines (ISG) aims to improve the quality of care for patients with respiratory diseases. The impact of such ISG in clinical practice can be potentially significant in primary health care (PHC) settings. We report the impact of the use by general practitioners (GPs) of a Tunisian ISG for respiratory diseases in management of respiratory patients in PHC. Methods The short-term impact was assessed through the results of the feasibility study. This study included a baseline survey, before training on ISG, and an impact survey, after training on ISG. The same 73 GPs practicing within 28 PHCs were involved in the two surveys at an interval of 6 weeks. Information on each patient mentioned gender, age, underlying conditions, symptoms, referral, diagnosis and drug prescription details. Results During the periods of the baseline and impact surveys, 36.0 and 31.1% of PHC attendees, respectively, sought care for respiratory symptoms. Acute respiratory infection (ARI) cases accounted for more than 85% of patients with respiratory disease. In the impact survey, chronic respiratory disease (CRD) diagnosis increased by approximately 50%. In the same way, the proportion of tuberculosis suspects increased 5.5 times. The number of drugs prescribed per patient decreased by 18.8%, and the proportion of patients who were prescribed antibiotics decreased by 19.0%. The prescription of steroids also significantly decreased while inhaled β-agonist prescription increased. The average cost of drug prescription was reduced by 19%. Conclusion Training on ISG for respiratory diseases improved the diagnosis of CRD and tuberculosis, and lead to a more rational use of drugs for ARIs in PHCs.
Introduction The use of standardized guidelines for clinical conditions has been widely developed in clinical care. In the United States, some 20 000 health care standards and clinical practice guidelines have been issued by over 500 organizations [1]. The impact of such guidelines in clinical practice can be potentially significant. However, these guidelines can be difficult for clinicians to apply in a given system, particularly in a poor country. This depends on clinicians’ knowledge of the guidelines and health resources availability. Integrated syndromic guidelines (ISG) are integrated symptom- and sign-based algorithms for the detection and management of disease conditions in primary care. For example, the use of ISG for the detection and management of tuberculosis (TB) 976
is widely used. It helps to stop dissemination of TB in many parts of the world, especially in poor countries [2]. In contrast, in such countries there was no development of clinical pathways and guidelines for important conditions such as respiratory diseases. Although, these diseases account for 15–20% of health care demand in primary health care (PHC) settings [3,4]. In Tunisia, a middle-income country, the national TB programme supervised by the World Health Organization (WHO) has successfully implemented the directly observed treatment supervision in PHC network, resulting in a TB case detection of 70% and cure rate of 85% [5]. Nevertheless, the burden of many chronic diseases, including chronic respiratory diseases (CRD), is growing [3,4,6,7]. This can be explained by the high prevalence of smoking estimated to 30%
Journal of Evaluation in Clinical Practice 21 (2015) 976–981 © 2015 John Wiley & Sons, Ltd.
M. Abouda et al.
[8]. In order to ameliorate the management of patients consulting for respiratory conditions, an ISG for respiratory diseases was developed for the first time in 2004 in Tunisia under the supervision of the WHO. This ISG developed by a National Working Group (NWG), composed of pulmonary practitioners, is a patientcentred and symptom-based strategy to manage patients with respiratory disease in a standardized and integrated way. It aims at improving the quality of care services and focuses on priority respiratory diseases: TB, acute respiratory infections (ARIs) and CRD, mainly asthma and chronic obstructive pulmonary disease (COPD). This paper highlights the effect of a homemade ISG carefully developed and implemented on the management of patients with respiratory disease in PHC settings in Tunisia.
Materials and method The effect of ISG on the management of patients with respiratory disease in PHC settings in Tunisia was evaluated by an interventional study. This study included a baseline survey, before training on ISG, and an impact survey, after training on ISG.
Selection of survey sites and process of data collection A total of 28 PHCs in the capital of Tunisia were selected. The selection of the PHC facilities was based on the availability of qualified human resources and mobility means, allowing the appropriate monitoring and supervision of the quality of data to be collected. Seventy-three general practitioners (GPs) practicing within these 28 PHCs were involved in the baseline and impact surveys. Any patient aged 5 years and over who visited any of the 28 PHC centres for respiratory symptoms was eligible. In both surveys, every GP collected information on each patient enrolled mentioning gender, age, underlying conditions, symptoms, referral, drug prescription and diagnosis in a special study register. GPs are recommended to answer in single words or brief phrases. The diagnosis was strictly reported in line with the categories listed in the study protocol. Written comments can be added if desired. If a drug prescription was provided, a copy was made to establish its cost on the basis of the standardized pricing system. The number of patients who visited the study health facility for any reason was collected. Specific information was also collected on another form, from TB laboratory and consultation desk of TB clinic, in order to assess the follow-up of each TB suspect identified.
Baseline survey A three one-day work sessions were organized in order to explain to the 73 GPs the study protocol, the procedures and the way to fill in the study register. They were asked to collect the information about all patients they examine in five consecutive days in the study register. They were asked to manage the patients with respiratory disease as they used to do in their daily practice. Additional information was collected during the following 30 days for the patients with respiratory disease, such as TB suspects who needed a follow-up.
© 2015 John Wiley & Sons, Ltd.
Respiratory disease guideline in primary health care
Training on ISG Four weeks after the baseline survey, the 73 GPs were trained on using the ISG. Training was made by the NWG members. Plenary sessions of management of respiratory diseases using the ISG in different cases were organized. Each GP was trained for 3 days on using the ISG in daily practice. Comments on the ISG were collected by the NWG members.
Impact survey It involved the same GPs and was carried out 2 weeks after the training, following the same procedures. The GPs had to comply with the ISG directives in managing patients with respiratory disease. Similar to the baseline survey, additional information was collected for some study participants during the following 30 days.
Statistics All the data collected in both surveys were entered in a special data entry program using Epi-info package (Epi-6) (CDC, Atlanta, USA). Data analysis involved the distribution study of the variables used in the survey. The analysis of findings was compared between the baseline and impact surveys. The Student’s t-test was used to compare two means, and the chi-square test to compare proportions. The Breslow–Day test was used to assess the heterogeneity between strata. The Fisher’s exact test was used whenever the expected number was below 5 in univariate analysis. A statistical difference was considered significant when P-value was below 5%.
Results Characteristics of patients with respiratory disease In the baseline and impact surveys, 2366 and 1475 patients with respiratory disease aged 5 years and over were, respectively, enrolled. In both study populations, the proportion of females was significantly higher: 61.6% in the baseline survey and 60.7% in the impact survey. The average age of the study participants was 28.0 ± 19.9 and 30.5 ± 20.6 years in the baseline and impact surveys, respectively (P < 0.001). In both surveys, the average age was significantly higher in females (30.7 ± 19.8 and 31.7 ± 20) than in males (23.5 ± 19.8 and 28.4 ± 21.4).
Perception of ISG by GPs All 73 GPs were trained on using the ISG, and comments were collected by the NWG members. All GPs have expressed an improvement in their knowledge after training; however, 23 GPs think that the application of this ISG can be difficult in real situations because translation of complaints in Arabic to symptoms in French language can be confusing.
Burden of respiratory conditions in PHC services Among patients, aged 5 years and over, who visited the study health facilities for any reason during the periods of the baseline 977
Respiratory disease guideline in primary health care
M. Abouda et al.
Table 1 Characteristics and symptoms of patients with respiratory disease at the study facilities
Symptoms
Baseline study Number (%) 2366 (100.0)
Impact study Number (%) 1475 (100.0)
P-value
Cough Fever Nasal discharge Sore throat Sputum Chest pain Dyspnoea Wheezing Nasal obstruction Haemoptysis
1772 (75.0) 928 (39.3) 795 (33.6) 645 (27.3) 664 (28.1) 270 (11.4) 169 (7.1) 138 (5.8) 76 (3.2) 6 (0.3)
986 (67.0) 563 (38.2) 400 (27.1) 398 (27.0) 244 (23.4) 154 (10.5) 108 (7.3) 63 (4.3) 63 (4.3) 2 (0.1)
0.05 0.05 0.05 >0.05 0.05 >0.05
and impact surveys, 36.0 and 31.1%, respectively, sought care for respiratory symptoms (P < 0.001). The proportion of patients with respiratory disease decreased with age in both genders and in both surveys; this proportion was between 41 and 53% in the 5–14 years age group, 34 and 39% in the 15–49 years age group and 18 and 23% in the 50 years and over age group.
Presentation of patients with respiratory symptoms Patients with at least one concomitant disease accounted for 19.5% in the baseline survey and 20.1% in the impact survey (P > 0.05). Cough, fever, nasal discharge, sore throat and sputum production were the most frequently reported symptoms in both surveys (Table 1).
Table 2 Distribution of respiratory conditions in the baseline and impact studies
Respiratory conditions
Baseline study Number (%) 2366 (100.0)
Impact study Number (%) 1475 (100.0)
P-value
AURI ALRI –Pneumonia CRD –Asthma –COPD TB suspect Others
1022 (43.2) 1187 (50.2) 47 (2.0) 145 (6.1) 51 (2.2) 25 (1.1) 4 (0.2) 8 (0.3)
676 (45.8) 625 (42.4) 20 (1.4) 136 (9.2) 64 (4.3) 27 (1.8) 16 (1.1) 22 (1.5)
>0.05 0.05
Journal of Evaluation in Clinical Practice ISSN 1365-2753
The effect of an integrated syndromic respiratory disease guideline in primary health care settings Maher Abouda MD,1 Agnes Hamzaoui MD,2 Ekram Drira MD,2 Ridha Djebeniani MD,3 Salah Othmani MD, PhD4 and Ali Ben Kheder MD2 1
Assistant Professor, Respiratory Diseases Department, FSI Hospital, La Marsa, Tunisia Professor, Abderrahmen Mami Hospital, d’Ariana, Tunisia 3 TB Officer, WHO, Djibouti, Djibouti 4 Professor, STOP TB, WHO, Geneva, Switzerland 2
Keywords clinical guidelines, health care, health economics Correspondence Mrs Maher Abouda Department of Pulmonary Medicine FSI Hospital Rue Taher Ben Achour La Marsa 2070 Tunisia E-mail: [email protected] Accepted for publication: 9 June 2015 doi:10.1111/jep.12420
Abstract Rationale, aims and objectives The use of integrated syndromic guidelines (ISG) aims to improve the quality of care for patients with respiratory diseases. The impact of such ISG in clinical practice can be potentially significant in primary health care (PHC) settings. We report the impact of the use by general practitioners (GPs) of a Tunisian ISG for respiratory diseases in management of respiratory patients in PHC. Methods The short-term impact was assessed through the results of the feasibility study. This study included a baseline survey, before training on ISG, and an impact survey, after training on ISG. The same 73 GPs practicing within 28 PHCs were involved in the two surveys at an interval of 6 weeks. Information on each patient mentioned gender, age, underlying conditions, symptoms, referral, diagnosis and drug prescription details. Results During the periods of the baseline and impact surveys, 36.0 and 31.1% of PHC attendees, respectively, sought care for respiratory symptoms. Acute respiratory infection (ARI) cases accounted for more than 85% of patients with respiratory disease. In the impact survey, chronic respiratory disease (CRD) diagnosis increased by approximately 50%. In the same way, the proportion of tuberculosis suspects increased 5.5 times. The number of drugs prescribed per patient decreased by 18.8%, and the proportion of patients who were prescribed antibiotics decreased by 19.0%. The prescription of steroids also significantly decreased while inhaled β-agonist prescription increased. The average cost of drug prescription was reduced by 19%. Conclusion Training on ISG for respiratory diseases improved the diagnosis of CRD and tuberculosis, and lead to a more rational use of drugs for ARIs in PHCs.
Introduction The use of standardized guidelines for clinical conditions has been widely developed in clinical care. In the United States, some 20 000 health care standards and clinical practice guidelines have been issued by over 500 organizations [1]. The impact of such guidelines in clinical practice can be potentially significant. However, these guidelines can be difficult for clinicians to apply in a given system, particularly in a poor country. This depends on clinicians’ knowledge of the guidelines and health resources availability. Integrated syndromic guidelines (ISG) are integrated symptom- and sign-based algorithms for the detection and management of disease conditions in primary care. For example, the use of ISG for the detection and management of tuberculosis (TB) 976
is widely used. It helps to stop dissemination of TB in many parts of the world, especially in poor countries [2]. In contrast, in such countries there was no development of clinical pathways and guidelines for important conditions such as respiratory diseases. Although, these diseases account for 15–20% of health care demand in primary health care (PHC) settings [3,4]. In Tunisia, a middle-income country, the national TB programme supervised by the World Health Organization (WHO) has successfully implemented the directly observed treatment supervision in PHC network, resulting in a TB case detection of 70% and cure rate of 85% [5]. Nevertheless, the burden of many chronic diseases, including chronic respiratory diseases (CRD), is growing [3,4,6,7]. This can be explained by the high prevalence of smoking estimated to 30%
Journal of Evaluation in Clinical Practice 21 (2015) 976–981 © 2015 John Wiley & Sons, Ltd.
M. Abouda et al.
[8]. In order to ameliorate the management of patients consulting for respiratory conditions, an ISG for respiratory diseases was developed for the first time in 2004 in Tunisia under the supervision of the WHO. This ISG developed by a National Working Group (NWG), composed of pulmonary practitioners, is a patientcentred and symptom-based strategy to manage patients with respiratory disease in a standardized and integrated way. It aims at improving the quality of care services and focuses on priority respiratory diseases: TB, acute respiratory infections (ARIs) and CRD, mainly asthma and chronic obstructive pulmonary disease (COPD). This paper highlights the effect of a homemade ISG carefully developed and implemented on the management of patients with respiratory disease in PHC settings in Tunisia.
Materials and method The effect of ISG on the management of patients with respiratory disease in PHC settings in Tunisia was evaluated by an interventional study. This study included a baseline survey, before training on ISG, and an impact survey, after training on ISG.
Selection of survey sites and process of data collection A total of 28 PHCs in the capital of Tunisia were selected. The selection of the PHC facilities was based on the availability of qualified human resources and mobility means, allowing the appropriate monitoring and supervision of the quality of data to be collected. Seventy-three general practitioners (GPs) practicing within these 28 PHCs were involved in the baseline and impact surveys. Any patient aged 5 years and over who visited any of the 28 PHC centres for respiratory symptoms was eligible. In both surveys, every GP collected information on each patient enrolled mentioning gender, age, underlying conditions, symptoms, referral, drug prescription and diagnosis in a special study register. GPs are recommended to answer in single words or brief phrases. The diagnosis was strictly reported in line with the categories listed in the study protocol. Written comments can be added if desired. If a drug prescription was provided, a copy was made to establish its cost on the basis of the standardized pricing system. The number of patients who visited the study health facility for any reason was collected. Specific information was also collected on another form, from TB laboratory and consultation desk of TB clinic, in order to assess the follow-up of each TB suspect identified.
Baseline survey A three one-day work sessions were organized in order to explain to the 73 GPs the study protocol, the procedures and the way to fill in the study register. They were asked to collect the information about all patients they examine in five consecutive days in the study register. They were asked to manage the patients with respiratory disease as they used to do in their daily practice. Additional information was collected during the following 30 days for the patients with respiratory disease, such as TB suspects who needed a follow-up.
© 2015 John Wiley & Sons, Ltd.
Respiratory disease guideline in primary health care
Training on ISG Four weeks after the baseline survey, the 73 GPs were trained on using the ISG. Training was made by the NWG members. Plenary sessions of management of respiratory diseases using the ISG in different cases were organized. Each GP was trained for 3 days on using the ISG in daily practice. Comments on the ISG were collected by the NWG members.
Impact survey It involved the same GPs and was carried out 2 weeks after the training, following the same procedures. The GPs had to comply with the ISG directives in managing patients with respiratory disease. Similar to the baseline survey, additional information was collected for some study participants during the following 30 days.
Statistics All the data collected in both surveys were entered in a special data entry program using Epi-info package (Epi-6) (CDC, Atlanta, USA). Data analysis involved the distribution study of the variables used in the survey. The analysis of findings was compared between the baseline and impact surveys. The Student’s t-test was used to compare two means, and the chi-square test to compare proportions. The Breslow–Day test was used to assess the heterogeneity between strata. The Fisher’s exact test was used whenever the expected number was below 5 in univariate analysis. A statistical difference was considered significant when P-value was below 5%.
Results Characteristics of patients with respiratory disease In the baseline and impact surveys, 2366 and 1475 patients with respiratory disease aged 5 years and over were, respectively, enrolled. In both study populations, the proportion of females was significantly higher: 61.6% in the baseline survey and 60.7% in the impact survey. The average age of the study participants was 28.0 ± 19.9 and 30.5 ± 20.6 years in the baseline and impact surveys, respectively (P < 0.001). In both surveys, the average age was significantly higher in females (30.7 ± 19.8 and 31.7 ± 20) than in males (23.5 ± 19.8 and 28.4 ± 21.4).
Perception of ISG by GPs All 73 GPs were trained on using the ISG, and comments were collected by the NWG members. All GPs have expressed an improvement in their knowledge after training; however, 23 GPs think that the application of this ISG can be difficult in real situations because translation of complaints in Arabic to symptoms in French language can be confusing.
Burden of respiratory conditions in PHC services Among patients, aged 5 years and over, who visited the study health facilities for any reason during the periods of the baseline 977
Respiratory disease guideline in primary health care
M. Abouda et al.
Table 1 Characteristics and symptoms of patients with respiratory disease at the study facilities
Symptoms
Baseline study Number (%) 2366 (100.0)
Impact study Number (%) 1475 (100.0)
P-value
Cough Fever Nasal discharge Sore throat Sputum Chest pain Dyspnoea Wheezing Nasal obstruction Haemoptysis
1772 (75.0) 928 (39.3) 795 (33.6) 645 (27.3) 664 (28.1) 270 (11.4) 169 (7.1) 138 (5.8) 76 (3.2) 6 (0.3)
986 (67.0) 563 (38.2) 400 (27.1) 398 (27.0) 244 (23.4) 154 (10.5) 108 (7.3) 63 (4.3) 63 (4.3) 2 (0.1)
0.05 0.05 0.05 >0.05 0.05 >0.05
and impact surveys, 36.0 and 31.1%, respectively, sought care for respiratory symptoms (P < 0.001). The proportion of patients with respiratory disease decreased with age in both genders and in both surveys; this proportion was between 41 and 53% in the 5–14 years age group, 34 and 39% in the 15–49 years age group and 18 and 23% in the 50 years and over age group.
Presentation of patients with respiratory symptoms Patients with at least one concomitant disease accounted for 19.5% in the baseline survey and 20.1% in the impact survey (P > 0.05). Cough, fever, nasal discharge, sore throat and sputum production were the most frequently reported symptoms in both surveys (Table 1).
Table 2 Distribution of respiratory conditions in the baseline and impact studies
Respiratory conditions
Baseline study Number (%) 2366 (100.0)
Impact study Number (%) 1475 (100.0)
P-value
AURI ALRI –Pneumonia CRD –Asthma –COPD TB suspect Others
1022 (43.2) 1187 (50.2) 47 (2.0) 145 (6.1) 51 (2.2) 25 (1.1) 4 (0.2) 8 (0.3)
676 (45.8) 625 (42.4) 20 (1.4) 136 (9.2) 64 (4.3) 27 (1.8) 16 (1.1) 22 (1.5)
>0.05 0.05
