Implementation science to improve the quality of tuberculosis diagnostic services in Uganda
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Date
2020
Journal Title
Journal ISSN
Volume Title
Publisher
Journal of clinical tuberculosis and other mycobacterial diseases
Abstract
Nucleic acid amplification tests such as Xpert MTB/RIF (Xpert) have the potential to revolutionize tuberculosis
(TB) diagnostics and improve case finding in resource-poor settings. However, since its introduction over a
decade ago in Uganda, there remain significant gaps along the cascade of care for patients undergoing TB
diagnostic evaluation at peripheral health centers. We utilized a systematic, implementation science-based approach
to identify key reasons at multiple levels for attrition along the TB diagnostic evaluation cascade of care.
Provider- and health system-level barriers fit into four key thematic areas: human resources, material resources,
service implementation, and service coordination. Patient-level barriers included the considerable costs and time
required to complete health center visits. We developed a theory-informed strategy using the PRECEDE framework
to target key barriers by streamlining TB diagnostic evaluation and facilitating continuous quality
improvement. The resulting SIMPLE TB strategy involve four key components: 1) Single-sample LED fluorescence
microscopy; 2) Daily sputum transport to Xpert testing sites; 3) Text message communication of Xpert
results to health centers and patients; and 4) Performance feedback to health centers using a quality improvement
framework. This combination of interventions was feasible to implement and significantly improved the
provision of high-quality care for patients undergoing TB diagnostic evaluation. We conclude that achieving high
coverage of Xpert testing services is not enough. Xpert scale-up should be accompanied by health system cointerventions
to facilitate effective implementation and ensure that high quality care is delivered to patients.
Description
Keywords
Tuberculosis, Quality improvement, Implementation science, Nucleic acid amplification tests such as Xpert MTB/RIF (Xpert) have the potential to revolutionize tuberculosis (TB) diagnostics and improve case finding in resource-poor settings. However, since its introduction over a decade ago in Uganda, there remain significant gaps along the cascade of care for patients undergoing TB diagnostic evaluation at peripheral health centers. We utilized a systematic, implementation science-based approach to identify key reasons at multiple levels for attrition along the TB diagnostic evaluation cascade of care. Provider- and health system-level barriers fit into four key thematic areas: human resources, material resources, service implementation, and service coordination. Patient-level barriers included the considerable costs and time required to complete health center visits. We developed a theory-informed strategy using the PRECEDE framework to target key barriers by streamlining TB diagnostic evaluation and facilitating continuous quality improvement. The resulting SIMPLE TB strategy involve four key components: 1) Single-sample LED fluorescence microscopy; 2) Daily sputum transport to Xpert testing sites; 3) Text message communication of Xpert results to health centers and patients; and 4) Performance feedback to health centers using a quality improvement framework. This combination of interventions was feasible to implement and significantly improved the provision of high-quality care for patients undergoing TB diagnostic evaluation. We conclude that achieving high coverage of Xpert testing services is not enough. Xpert scale-up should be accompanied by health system cointerventions to facilitate effective implementation and ensure that high quality care is delivered to patients.
Citation
Cattamanchi, A., Berger, C. A., Shete, P. B., Turyahabwe, S., Joloba, M., Moore, D. A., ... & Katamba, A. (2020). Implementation science to improve the quality of tuberculosis diagnostic services in Uganda. Journal of clinical tuberculosis and other mycobacterial diseases, 18, 100136. https://doi.org/10.1016/j.jctube.2019.100136