Tuberculosis screening in patients with HIV: use of audit and feedback to improve quality of care in Ghana

Abstract

BackgroundTuberculosis screening of people living with HIV (PLHIV) can contribute to early tuberculosis diagnosis and improved patient outcomes. Evidence-based guidelines for tuberculosis screening are available, but literature assessing their implementation and the quality of clinical practice is scarce.ObjectivesTo assess tuberculosis screening practices and the effectiveness of audit and performance feedback to improve quality of tuberculosis screening at HIV care clinics in Ghana.DesignHealthcare providers at 10 large HIV care clinics prospectively registered patient consultations during May and October 2014, before and after a performance feedback intervention in August 2014. The outcomes of interest were overall tuberculosis suspicion rate during consultations and provider adherence to the International Standards for Tuberculosis Care and the World Health Organizations’ guidelines for symptom-based tuberculosis screening among PLHIV.ResultsTwenty-one healthcare providers registered a total of 2,666 consultations; 1,368 consultations before and 1,298 consultations after the feedback intervention. Tuberculosis suspicion rate during consultation increased from 12.6 to 20.9% after feedback (odds ratio, OR 1.83; 95% confidence interval, CI: 1.09–3.09). Before feedback, sputum smear microscopy was requested for 58.7% of patients with suspected tuberculosis, for 47.2% of patients with cough ≥2 weeks, and for 27.5% of patients with a positive World Health Organization (WHO) symptom screen (any of current cough, fever, weight loss or night sweats). After feedback, patients with a positive WHO symptom screen were more likely to be suspected of tuberculosis (OR 2.21; 95% CI: 1.19–4.09) and referred for microscopy (OR 2.71; 95% CI: 1.25–5.86).ConclusionsA simple prospective audit tool identified flaws in clinical practices for tuberculosis screening of PLHIV. There was no systematic identification of people with suspected active tuberculosis. We found low initial tuberculosis suspicion rate compounded by low referral rates of relevant patients for sputum smear microscopy. Adherence to recommended standards and guidelines for tuberculosis screening improved after performance feedback.

Determinants of Sputum Ordering for Tuberculosis Diagnosis in People Living with HIV in the Greater Accra Region, Ghana

“…The proportion of patients with at least one TB symptom (positive TB screen test) in this study was 29.5%. This nding is comparable to ndings from other studies where the proportion was found to be 8% [16], 14% [13], 28% [7], 37.4% [11] and 62% [14].…”

“…In South Africa, the prevalence of TB screening was 89.6% [12]. In Kenya TB screening prevalence was 98% [13] while in Uganda the prevalence of TB screening was 93% [14].…”

C-reactive protein as a screening test for HIV-associated pulmonary tuberculosis prior to antiretroviral therapy in South Africa

“…The symptom screen, with theoretical benefits of speed, ease of use, and no laboratory cost or delays, has limitations beyond its poor specificity and positive predictive value[9,20]. It may be inadvertently omitted during a brief visit in a high-volume clinic[21]. Symptom questions are subjective; patients may answer differently depending on how the questions are asked, and clinicians may not act on a positive screen due in part to subjectivity and lack of specificity[22,23].…”

Performance of and Factors Associated With Tuberculosis Screening and Diagnosis Among People Living With HIV: Analysis of 2012–2016 Routine HIV Data in Tanzania

“…In Ethiopia, 72% of PLHIV with positive TB screening were linked to sputum microscopy for TB with the remaining PLHIV diagnosed using other methods (13). A study conducted in Ghana also found that sputum for smear microscopy was requested for 58.7% of those who needed (14).…”