Extensively drug-resistant (XDR) tuberculosis (TB) is a type of multidrug-resistant (MDR) TB that is resistant to isoniazid, rifampicin, fluoroquinolones and at least one injectable second-line drug. There are insufficient antibiotics for effective combination therapy and mortality exceeds 70% [1]. Following successful phase IIb trials [2] in 2013, the novel mycobacterial ATP-synthase inhibitor bedaquiline was approved in Europe and the USA for the first 24 weeks of MDR/XDR-TB treatment alongside a World Health Organization (WHO)-approved optimised background regimen. Phase III trials are ongoing but cohort data describe good early bacteriological outcomes in France [3, 4], Italy [5], the UK [6], the USA [7], India [8] and South Africa [9].
ObjectivesTuberculosis cohort audit (TBCA) was introduced across the North West (NW) of England in 2012 as an ongoing, multidisciplinary, systematic case review process, designed to improve clinical and public health practice. TBCA has not previously been introduced across such a large and socioeconomically diverse area in England, nor has it undergone formal, qualitative evaluation. This study explored health professionals’ experiences of the process after 1515 cases had been reviewed.DesignQualitative study using semistructured interviews. Respondents were purposively sampled from 3 groups involved in the NW TBCA: (1) TB nurse specialists, (2) consultant physicians and (3) public health practitioners. Data from the 26 respondents were triangulated with further interviews with key informants from the TBCA Steering Group and through observation of TBCA meetings.AnalysisInterview transcripts were analysed thematically using the framework approach.ResultsParticipants described the evolution of a valuable ‘community of practice’ where interprofessional exchange of experience and ideas has led to enhanced mutual respect between different roles and a shared sense of purpose. This multidisciplinary, regional approach to TB cohort audit has promoted local and regional team working, exchange of good practices and local initiatives to improve care. There is strong ownership of the process from public health professionals, nurses and clinicians; all groups want it to continue. TBCA is regarded as a tool for quality improvement that improves patient safety.ConclusionsTBCA provides peer support and learning for management of a relatively rare, but important infectious disease through discussion in a no-blame atmosphere. It is seen as an effective quality improvement strategy which enhances TB care, control and patient safety. Continuing success will require increased engagement of consultant physicians and public health practitioners, a secure and ongoing funding stream and establishment of clear reporting mechanisms within the public health system.
Measurement of children's height and weight at regular intervals is important for identifying growth problems as well as for planning health promotion interventions for those at risk from under or over nutrition. Opportunistic measurement is recommended when children are seen by healthcare professionals for other reasons. Identification of variations in practice around measurement of height and weight in a children's unit led to the development of guidelines, purchase of new equipment, implementation of educational strategies and introduction of a growth link nurse role. Repeat audit revealed that these approaches did not bring about the desired changes in practice. Growth assessment is a quick, non invasive procedure that can provide valuable information about the general health and well being of the child but is perceived as a low priority by some healthcare professionals. Different approaches are needed to improve this important aspect of health care for children.
SUMMARYBACKGROUND: In the United Kingdom, tuberculosis (TB) predominantly affects the most deprived populations, yet the extent to which deprivation affects TB care outcomes is unknown.METHODS: Since 2011, the North West TB Cohort Audit collaboration has undertaken quarterly reviews of outcomes against consensus-defined care standard indicators for all individuals notified with TB. We investigated associations between adverse TB care outcomes and Index of Multiple Deprivation (IMD) 2010 scores measured at lower super output area of residence using logistic regression models.RESULTS: Of 1831 individuals notified with TB between 2011 and 2014, 62% (1131/1831) came from the most deprived national quintile areas. In single variable analysis, greater deprivation was significantly associated with increased likelihood of the completion of a standardised risk assessment (OR 2.99, 95%CI 5.27–19.65) and offer of a human immunodeficiency virus test (OR 1.72, 95%CI 1.10–2.62). In multivariable analysis, there were no significant associations.CONCLUSIONS: TB patients in the most deprived areas had similar care indicators across a range of standards to those of individuals living in the more affluent areas, suggesting that the delivery of TB care in the North West of England is equitable. The extent to which the cohort review process contributes to, and sustains, this standard of care deserves further study.
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