Measuring Quality Gaps in TB Screening in South Africa Using Standardised Patient Analysis

Abstract

This is the first multi-district Standardised Patient (SP) study in South Africa. It measures the quality of TB screening at primary healthcare (PHC) facilities. We hypothesise that TB screening protocols and best practices are poorly adhered to at the PHC level. The SP method allows researchers to observe how healthcare providers identify, test and advise presumptive TB patients, and whether this aligns with clinical protocols and best practice. The study was conducted at PHC facilities in two provinces and 143 interactions at 39 facilities were analysed. Only 43% of interactions resulted in SPs receiving a TB sputum test and being offered an HIV test. TB sputum tests were conducted routinely (84%) while HIV tests were offered less frequently (47%). Nurses frequently neglected to ask SPs whether their household contacts had confirmed TB (54%). Antibiotics were prescribed without taking temperatures in 8% of cases. The importance of returning to the facility to receive TB test results was only explained in 28%. The SP method has highlighted gaps in clinical practice, signalling missed opportunities. Early detection of sub-optimal TB care is instrumental in decreasing TB-related morbidity and mortality. The findings provide the rationale for further quality improvement work in TB management.

‘They are inconveniencing us’ - exploring how gaps in patient education and patient centred approaches interfere with TB treatment adherence: perspectives from patients and clinicians in the Free State Province, South Africa

“…Christian et al explored the quality of HIV and TB health care provision in the Western Cape and its alignment to the national protocols. They cited that only 43% of cases met the minimum threshold for adequate case management and protocol deviations could be attributed to poor training and knowledge, deficiencies in monitoring and the lack of clinical governance [37]. They reported consistently poor information sharing by the staff; and the importance of returning for TB results was only discussed in a third of interactions.…”

“…Consequently, there was no objective measure of whether the patients had been adequately informed about the disease or its management. The overall findings from the Western Cape study suggested low effort in communicating invaluable information regarding untreated TB and the need for treatment and acknowledged that the poor adherence to the protocols were possibly resulting in the disappointing TB outcomes [37].…”

Evaluation of the Adherence Guidelines for Chronic Diseases in South Africa Using Routinely Collected Data

“…Ensure universal TB screening -Clinics should screen everybody coming into the clinic who is not currently on tuberculosis treatment. Yet, currently our data suggest that either this is not happening or it is being poorly recorded 52 .…”

‘They are inconveniencing us’ - Exploring how gaps in patient education and patient centred approaches interfere with TB treatment adherence: Perspectives from patients and clinicians in the Free State Province, South Africa.

“…Christian et al explored the quality of HIV and TB health care provision in the Western Cape and its alignment to the national protocols. They cited that only 43% of cases met the minimum threshold for adequate case management and protocol deviations could be attributed to poor training and knowledge, deficiencies in monitoring and the lack of clinical governance (38). They reported consistently poor information sharing by the staff; and the importance of returning for TB results was only discussed in a third of interactions.…”

“…Consequently, there was no objective measure of whether the patients had been adequately informed about the disease or its management. The overall findings from the Western Cape study suggested low effort in communicating invaluable information regarding untreated TB and the need for treatment and acknowledged that the poor adherence to the protocols were possibly resulting in the disappointing TB outcomes (38).…”