Improvement in rheumatic fever and rheumatic heart disease management and prevention using a health centre-based continuous quality improvement approach

Abstract

BackgroundRheumatic heart disease (RHD) remains a major health concern for Aboriginal Australians. A key component of RHD control is prevention of recurrent acute rheumatic fever (ARF) using long-term secondary prophylaxis with intramuscular benzathine penicillin (BPG). This is the most important and cost-effective step in RHD control. However, there are significant challenges to effective implementation of secondary prophylaxis programs. This project aimed to increase understanding and improve quality of RHD care through development and implementation of a continuous quality improvement (CQI) strategy.MethodsWe used a CQI strategy to promote implementation of national best-practice ARF/RHD management guidelines at primary health care level in Indigenous communities of the Northern Territory (NT), Australia, 2008–2010. Participatory action research methods were employed to identify system barriers to delivery of high quality care. This entailed facilitated discussion with primary care staff aided by a system assessment tool (SAT). Participants were encouraged to develop and implement strategies to overcome identified barriers, including better record-keeping, triage systems and strategies for patient follow-up. To assess performance, clinical records were audited at baseline, then annually for two years. Key performance indicators included proportion of people receiving adequate secondary prophylaxis (≥80% of scheduled 4-weekly penicillin injections) and quality of documentation.ResultsSix health centres participated, servicing approximately 154 people with ARF/RHD. Improvements occurred in indicators of service delivery including proportion of people receiving ≥40% of their scheduled BPG (increasing from 81/116 [70%] at baseline to 84/103 [82%] in year three, p = 0.04), proportion of people reviewed by a doctor within the past two years (112/154 [73%] and 134/156 [86%], p = 0.003), and proportion of people who received influenza vaccination (57/154 [37%] to 86/156 [55%], p = 0.001). However, the proportion receiving ≥80% of scheduled BPG did not change. Documentation in medical files improved: ARF episode documentation increased from 31/55 (56%) to 50/62 (81%) (p = 0.004), and RHD risk category documentation from 87/154 (56%) to 103/145 (76%) (p < 0.001). Large differences in performance were noted between health centres, reflected to some extent in SAT scores.ConclusionsA CQI process using a systems approach and participatory action research methodology can significantly improve delivery of ARF/RHD care.

Improving Delivery of Secondary Prophylaxis for Rheumatic Heart Disease in a High‐Burden Setting: Outcome of a Stepped‐Wedge, Community, Randomized Trial

“…Challenges to delivery of this regimen in remote Australian settings are similar to those in many resource‐poor populations globally with the highest RHD burdens: high turnover and limited ARF knowledge among healthcare staff; young and mobile patients; pain of injections; and cultural factors leading to different concepts of disease causation and treatment, along with barriers to acceptance of Western medicine 8, 9, 10. The proportion of patients in the NT in 2009 with ARF/RHD achieving ≥80% of scheduled injections—the current Australian benchmark for acceptable adherence7—was only ≈25% 11…”

“…CQI approaches use data proactively to motivate healthcare providers and clinic managers to work toward improved targets. Application of CQI has shown promise previously in the NT, with implementation at 6 remote clinics leading to improvements in some ARF/RHD outcomes 11. Health systems improvements providing a “comprehensive care program” or combining education strategies with development of a register have also been associated with ARF rate reductions in the United States, Cuba, and the Caribbean 15, 16, 17.…”

Approaches to Improving Adherence to Secondary Prophylaxis for Rheumatic Fever and Rheumatic Heart Disease

“…One study from the Northern Territory in Australia suggested that CQI activities did improve some aspects of ARF/RHD care but had no impact on the proportion of patients receiving ≥80% of their scheduled LAB injections. 41 Thus, it remains unclear whether formal CQI initiatives are superior to other organizational strategies to improve service delivery such as those that encourage reflective and responsive health care at an individual provider level.…”

Qualitative Evaluation of a Complex Intervention to Improve Rheumatic Heart Disease Secondary Prophylaxis

“…CQI processes aim to engage staff in understanding and responding to their own data and can be a powerful tool to motivate change in primary care settings 10. We previously showed incremental improvements in clinical care targets achieved in RHD management using CQI 2. Processes included proactive use of adherence data from each participating clinic to motivate healthcare providers and managers to work toward improved penicillin delivery targets, specifically, for more clients to achieve ≥80% of scheduled injections.…”