Effectiveness of a group diabetes education programme in under-served communities in South Africa: a pragmatic cluster randomized controlled trial.

AIM: To evaluate the effectiveness of group education, led by health promoters using a guiding style, for people with type 2 diabetes in public sector community health centres in Cape Town. METHODS: This was a pragmatic clustered randomized controlled trial with 17 randomly selected intervention and 17 control sites. A total of 860 patients with type 2 diabetes, regardless of therapy used, were recruited from the control sites and 710 were recruited from the intervention sites. The control sites offered usual care, while the intervention sites offered a total of four monthly sessions of group diabetes education led by a health promoter. Participants were measured at baseline and 12 months later. Primary outcomes were diabetes self-care activities, 5% weight loss and a 1% reduction in HbA(1c) levels. Secondary outcomes were self-efficacy, locus of control, mean blood pressure, mean weight loss, mean waist circumference, mean HbA1c and mean total cholesterol levels and quality of life. RESULTS: A total of 422 (59.4%) participants in the intervention group did not attend any education sessions. No significant improvement was found in any of the primary or secondary outcomes, apart from a significant reduction in mean systolic (-4.65 mmHg, 95% CI 9.18 to -0.12; P = 0.04) and diastolic blood pressure (-3.30 mmHg, 95% CI -5.35 to -1.26; P = 0.002). Process evaluation suggested that there were problems with finding suitable space for group education in these under-resourced settings, with patient attendance and with full adoption of a guiding style by the health promoters. CONCLUSION: The reported effectiveness of group diabetes education offered by more highly trained professionals, in well-resourced settings, was not replicated in the present study, although the reduction in participants' mean blood pressure is likely to be of clinical significance.

Impact of a centralized osteoporosis coordinator on post-fracture osteoporosis management: a cluster randomized trial.

UNLABELLED: We conducted a cluster randomized trial evaluating the effect of a centralized coordinator who identifies and follows up with fracture patients and their primary care physicians about osteoporosis. Compared with controls, intervention patients were five times more likely to receive BMD testing and two times more likely to receive appropriate management. INTRODUCTION: To determine if a centralized coordinator who follows up with fracture patients and their primary care physicians by telephone and mail (intervention) will increase the proportion of patients who receive appropriate post-fracture osteoporosis management, compared to simple fall prevention advice (attention control). METHODS: A cluster randomized controlled trial was conducted in small community hospitals in the province of Ontario, Canada. Hospitals that treated between 60 and 340 fracture patients per year were eligible. Patients 40 years and older presenting with a low trauma fracture were identified from Emergency Department records and enrolled in the trial. The primary outcome was 'appropriate' management, defined as a normal bone mineral density (BMD) test or taking osteoporosis medications. RESULTS: Thirty-six hospitals were randomized to either intervention or control and 130 intervention and 137 control subjects completed the study. The mean age of participants was 65 ± 12 years and 69% were female. The intervention increased the proportion of patients who received appropriate management within 6 months of fracture; 45% in the intervention group compared with 26% in the control group (absolute difference of 19%; adjusted OR, 2.3; 95% CI, 1.3-4.1). The proportion who had a BMD test scheduled or performed was much higher with 57% of intervention patients compared with 21% of controls (absolute difference of 36%; adjusted OR, 4.8; 95% CI, 3.0-7.0). CONCLUSIONS: A centralized osteoporosis coordinator is effective in improving the quality of osteoporosis care in smaller communities that do not have on-site coordinators or direct access to osteoporosis specialists.

Multimorbidity and mortality in Ontario, Canada: A population-based retrospective cohort study.

OBJECTIVE: To examine the relationship between multimorbidity and mortality, and whether relationship varied by material deprivation/rural location and by age. METHODS: Retrospective population-based cohort study conducted using 2013-14 data from previously created cohort of Ontario, Canada residents classified according to whether or not they had multimorbidity, defined as having 3+ of 17 chronic conditions. Adjusted rate ratios were calculated to compare mortality rates for those with and without multimorbidity, comparing rates by material deprivation/rural location, and by age group. RESULTS: There were 13,581,191 people in the cohort ages 0 to 105 years; 15.2% had multimorbidity. Median length of observation was 365 days. Adjusted mortality rate ratios did not vary by material deprivation/rural location; overall adjusted mortality rate ratio was 2.41 (95% CI 2.37-2.45). Adjusted mortality rate ratios varied by age with ratios decreasing as age increased. Overall rate ratio was 14.7 (95% CI 14.48-14.91). Children (0-17 years) had highest ratio, 40.06 (95% CI 26.21-61.22). Youngest adult age group (18-24 years) had rate ratio of 9.96 (95% CI 7.18-13.84); oldest age group (80+ years) had rate ratio of 1.97 (95% CI 1.94-2.04). CONCLUSION: Compared to people without multimorbidity, multimorbidity conferred higher risk of death in this study at all age groups. Risk was greater in early and middle adulthood than in older ages. Results reinforce the fact multimorbidity is not just a problem of aging, and multimorbidity leads not only to poorer health and higher health care utilization, but also to a higher risk of death at a younger age.

A demonstration project of a multi-component educational intervention to improve integrated post-fracture osteoporosis care in five rural communities in Ontario, Canada.

UNLABELLED: This study evaluated a multi-component intervention (educational materials and outreach visits) to increase knowledge and improve post-fracture care management in five rural communities in Canada. One hundred and twenty-five patients pre- intervention and 149 post-intervention were compared. No significant improvement in post-fracture care was documented suggesting that a more targeted intervention is needed. INTRODUCTION: Currently, the majority of patients with a low trauma fracture are under-investigated and under-treated for osteoporosis. We set out to evaluate an educational intervention on increasing knowledge of post-fracture care among health care professionals (HCPs) and fracture patients and on improving post-fracture management. METHODS: We studied five rural communities in Ontario, Canada, using a multi-component intervention ("Behind the Break"), including educational material for HCPs and patients and educational outreach visits to physicians. The study had a historical control, non-equivalent pre/post design. Telephone surveys were carried out with individuals > or =40 years of age who had a low trauma fracture in 2003 (n = 125) or in 2005 (n = 149). Family physicians and emergency department staff were also surveyed. RESULTS: A total of 4,207 educational packages were distributed. Seventy-three percent of family physicians had an outreach visit. Two-thirds indicated that they received enough information about post-fracture follow-up to incorporate it into their practice. Despite this, no significant improvement in post-fracture care was documented (32% in the "pre" group had a bone mineral density test and 25% in the "post" group). Of those diagnosed with osteoporosis, the majority were prescribed a bone-sparing medication (63% "pre" and 80% "post"). CONCLUSION: A more targeted intervention linking fracture patients to their physician needs to be evaluated in rural communities.

Chest radiograph in acute respiratory infections.

BACKGROUND: Chest radiography is widely used during the management of acute lower respiratory infections, but the benefits are unknown. OBJECTIVES: To assess the effects of chest radiography on clinical outcome in acute lower respiratory infections. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 1), MEDLINE (1950 to January 2007) and EMBASE (January 1976 to February 2007). SELECTION CRITERIA: Randomised or quasi-randomised trials of chest radiography in acute respiratory infections. DATA COLLECTION AND ANALYSIS: Both review authors independently applied the inclusion criteria, extracted data and assessed trial quality. MAIN RESULTS: We identified two trials. One, of 522 outpatient children (and performed by the review authors), found that 46% of both radiography and control participants had recovered by seven days (relative risk (RR) 1.01, 95% confidence interval (CI) 0.79 to 1.31). Thirty-three per cent of radiography participants and 32% of control participants made a subsequent hospital visit within four weeks (RR 1.02, 95% CI 0.79 to 1.30) and 3% of both radiography and control participants were subsequently admitted to hospital within four weeks (RR 1.02, 95% CI 0.41 to 2.52). The other trial involving 1502 adults attending an emergency department found no significant difference in length of illness, the single outcome prespecified for this review (mean of 16.9 days in radiograph group versus 17.0 days in control group, P > 0.05). AUTHORS' CONCLUSIONS: There is no evidence that chest radiography improves outcome in outpatients with acute lower respiratory infection. The findings do not exclude a potential effect of radiography, but the potential benefit needs to be balanced against the hazards and expense of chest radiography. The findings apply to outpatients only.

Interprofessional education: effects on professional practice and health care outcomes.

BACKGROUND: Patient care is a complex activity which demands that health and social care professionals work together in an effective manner. The evidence suggests, however, that these professionals do not collaborate well together. Interprofessional education (IPE) offers a possible way to improve collaboration and patient care. OBJECTIVES: To assess the effectiveness of IPE interventions compared to education interventions in which the same health and social care professionals learn separately from one another; and to assess the effectiveness of IPE interventions compared to no education intervention. SEARCH STRATEGY: We searched the Cochrane Effective Practice and Organisation of Care Group specialised register, MEDLINE and CINAHL, for the years 1999 to 2006. We also handsearched the Journal of Interprofessional Care (1999 to 2006), reference lists of the six included studies and leading IPE books, IPE conference proceedings, and websites of IPE organisations. SELECTION CRITERIA: Randomised controlled trials (RCTs), controlled before and after (CBA) studies and interrupted time series (ITS) studies of IPE interventions that reported objectively measured or self reported (validated instrument) patient/client and/or healthcare process outcomes. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed the eligibility of potentially relevant studies, and extracted data from, and assessed study quality of, included studies. A meta-analysis of study outcomes was not possible given the small number of included studies and the heterogeneity in methodological designs and outcome measures. Consequently, the results are presented in a narrative format. MAIN RESULTS: We included six studies (four RCTs and two CBA studies). Four of these studies indicated that IPE produced positive outcomes in the following areas: emergency department culture and patient satisfaction; collaborative team behaviour and reduction of clinical error rates for emergency department teams; management of care delivered to domestic violence victims; and mental health practitioner competencies related to the delivery of patient care. In addition, two of the six studies reported mixed outcomes (positive and neutral) and two studies reported that the IPE interventions had no impact on either professional practice or patient care. AUTHORS' CONCLUSIONS: This updated review found six studies that met the inclusion criteria, in contrast to our first review that found no eligible studies. Although these studies reported some positive outcomes, due to the small number of studies, the heterogeneity of interventions, and the methodological limitations, it is not possible to draw generalisable inferences about the key elements of IPE and its effectiveness. More rigorous IPE studies (i.e. those employing RCTs, CBA or ITS designs with rigorous randomisation procedures, better allocation concealment, larger sample sizes, and more appropriate control groups) are needed to provide better evidence of the impact of IPE on professional practice and healthcare outcomes. These studies should also include data collection strategies that provide insight into how IPE affects changes in health care processes and patient outcomes.

Building capacity for antiretroviral delivery in South Africa: a qualitative evaluation of the PALSA PLUS nurse training programme.

BACKGROUND: South Africa recently launched a national antiretroviral treatment programme. This has created an urgent need for nurse-training in antiretroviral treatment (ART) delivery. The PALSA PLUS programme provides guidelines and training for primary health care (PHC) nurses in the management of adult lung diseases and HIV/AIDS, including ART. A process evaluation was undertaken to document the training, explore perceptions regarding the value of the training, and compare the PALSA PLUS training approach (used at intervention sites) with the provincial training model. The evaluation was conducted alongside a randomized controlled trial measuring the effects of the PALSA PLUS nurse-training (Trial reference number ISRCTN24820584). METHODS: Qualitative methods were utilized, including participant observation of training sessions, focus group discussions and interviews. Data were analyzed thematically. RESULTS: Nurse uptake of PALSA PLUS training, with regard not only to ART specific components but also lung health, was high. The ongoing on-site training of all PHC nurses, as opposed to the once-off centralized training provided for ART nurses only at non-intervention clinics, enhanced nurses' experience of support for their work by allowing, not only for ongoing experiential learning, supervision and emotional support, but also for the ongoing managerial review of all those infrastructural and system-level changes required to facilitate health provider behaviour change and guideline implementation. The training of all PHC nurses in PALSA PLUS guideline use, as opposed to ART nurses only, was also perceived to better facilitate the integration of AIDS care within the clinic context. CONCLUSION: PALSA PLUS training successfully engaged all PHC nurses in a comprehensive approach to a range of illnesses affecting both HIV positive and negative patients. PHC nurse-training for integrated systems-based interventions should be prioritized on the ART funding agenda. Training for individual provider behaviour change is nonetheless only one aspect of the ongoing system-wide interventions required to effect lasting improvements in patient care in the context of an over-burdened and under-resourced PHC system.

Lay health worker intervention with choice of DOT superior to standard TB care for farm dwellers in South Africa: a cluster randomised control trial.

SETTING: Farms in the Boland health district, Western Cape Province, South Africa. OBJECTIVE: To evaluate the effect of lay health workers (LHWs) on tuberculosis (TB) control among permanent farm workers and farm dwellers in an area with particularly high TB prevalence. DESIGN: Pragmatic, unblinded cluster randomised control trial. METHODS: This trial measured successful treatment completion rates among new smear-positive (NSP) adult TB patients on 106 intervention farms, and compared them with outcomes in patients on 105 control farms. Farms were the unit of randomisation, and analysis was by intention to treat. RESULTS: A total of 164 adult TB patients were recruited into the study, 89 of whom were NSP. The successful treatment completion rate in NSP adult TB patients was 18.7% higher (P = 0.042, 95%CI 0.9-36.4) on farms in the intervention group than on farms in the control group. Case finding for adult NSP TB cases was 8% higher (P = 0.2671) on farms in the intervention group compared to the control group. CONCLUSION: Trained LHWs were able to improve the successful TB treatment rate among adult NSP TB patients in a well-established health service, despite reduction of services.

Chest radiograph in acute respiratory infections in children.

BACKGROUND: Chest radiography is widely used in children with acute lower respiratory infections, but the benefits are unknown. OBJECTIVES: To assess the effects of chest radiography for children with acute lower respiratory infections. SEARCH STRATEGY: The searches were updated in November 2004. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2005), MEDLINE (1966 to February, Week 1 2005) and EMBASE (January 1990 to September 2004). We contacted experts in the fields of acute respiratory infections and paediatric radiology to locate additional studies. SELECTION CRITERIA: Randomised or quasi-randomised trials of chest radiography in children with acute respiratory infections. DATA COLLECTION AND ANALYSIS: One reviewer extracted data and assessed trial quality. MAIN RESULTS: We identified only one trial of 522 participants, which was performed by the review authors. The participants were ambulatory children aged two months to five years. Forty-six per cent of both radiography and control participants had recovered by seven days (odds ratio (OR) 1.03, 95% confidence interval (CI) 0.64 to 1.64). Thirty-three per cent of radiography participants and 32% of control participants made a subsequent hospital visit within four weeks (OR 1.02, 95% CI 0.71 to 1.48). Three per cent of both radiography and control participants were subsequently admitted to hospital within four weeks (OR 1.02, 95% CI 0.40 to 2.60). There were no deaths in either group. AUTHORS' CONCLUSIONS: There is no evidence that chest radiography improves outcome in ambulatory children with acute lower respiratory infection. The findings do not exclude a potential effect of radiography, but the potential benefit needs to be balanced against the hazards and expense of chest radiography. The findings apply to ambulatory children only.

Lay health workers in primary and community health care.

BACKGROUND: Lay health workers (LHWs) are widely used to provide care for a broad range of health issues. However, little is known about the effectiveness of LHW interventions. OBJECTIVES: To assess the effects of LHW interventions in primary and community health care on health care behaviours, patients' health and wellbeing, and patients' satisfaction with care. SEARCH STRATEGY: We searched the Cochrane Effective Practice and Organisation of Care and Consumers and Communication specialised registers (to August 2001); the Cochrane Central Register of Controlled Trials (to August 2001); MEDLINE (1966- August 2001); EMBASE (1966-August 2001); Science Citations (to August 2001); CINAHL (1966-June 2001); Healthstar (1975-2000); AMED (1966-August 2001); the Leeds Health Education Effectiveness Database and the reference lists of articles. SELECTION CRITERIA: Randomised controlled trials of any intervention delivered by LHWs (paid or voluntary) in primary or community health care and intended to promote health, manage illness or provide support to patients. A 'lay health worker' was defined as any health worker carrying out functions related to health care delivery; trained in some way in the context of the intervention; and having no formal professional or paraprofessional certificated or degreed tertiary education. There were no restrictions on the types of consumers. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data onto a standard form and assessed study quality. Studies that compared broadly similar types of interventions were grouped together. Where feasible, the results of included studies were combined and an estimate of effect obtained. MAIN RESULTS: Forty three studies met the inclusion criteria, involving more than 210,110 consumers. These showed considerable diversity in the targeted health issue and the aims, content and outcomes of interventions. Most were conducted in high income countries (n=35), but nearly half of these focused on low income and minority populations (n=15). Study diversity limited meta-analysis to outcomes for five subgroups (n=15 studies) (LHW interventions to promote the uptake of breast cancer screening, immunisation and breastfeeding promotion [before two weeks and between two weeks and six months post partum] and to improve diagnosis and treatment for selected infectious diseases). Promising benefits in comparison with usual care were shown for LHW interventions to promote immunisation uptake in children and adults (RR=1.30 [95% CI 1.14, 1.48] p=0.0001) and LHW interventions to improve outcomes for selected infectious diseases (RR=0.74 [95% CI 0.58, 0.93) p=0.01). LHWs also appear promising for breastfeeding promotion. They appear to have a small effect in promoting breast cancer screening uptake when compared with usual care. For the remaining subgroups (n=29 studies), the outcomes were too diverse to allow statistical pooling. We can therefore draw no general conclusions on the effectiveness of these subgroups of interventions. AUTHORS' CONCLUSIONS: LHWs show promising benefits in promoting immunisation uptake and improving outcomes for acute respiratory infections and malaria, when compared to usual care. For other health issues, evidence is insufficient to justify recommendations for policy and practice. There is also insufficient evidence to assess which LHW training or intervention strategies are likely to be most effective. Further research is needed in these areas.

Is HIV/AIDS a primary-care disease? Appropriate levels of outpatient care for patients with HIV/AIDS.

OBJECTIVE: To estimate the proportion of outpatient visits that could be managed at a primary-care level, by World Health Organization (WHO) clinical staging. DESIGN: Prospective, descriptive study. Six medical doctors in a tertiary hospital HIV ambulatory clinic recorded clinical diagnoses, WHO clinical staging and their recommendation regarding the appropriate level of care for each outpatient seen. SETTING AND STUDY POPULATION: All HIV-infected patients attending a public-sector, urban, South African, referral and teaching hospital HIV outpatient clinic between September and November 1992. PARTICIPANTS: There were 238 visits by 148 patients during the study period. RESULTS: Of 238 visits, 165 (69.3%) were deemed suitable for treatment at the primary-care level. After allowing for contradictory responses, at least 141 visits (59.2%) could be appropriately treated at the primary-care level. Although all six doctors assessed more than half of their visits as suitable for primary care, there were significant differences among them. In total, 83 visits (34.8%) needed a medical specialist, and 45 (18.9%) required tertiary-care facilities. Of all the visits, 58 (24.9%), 51 (21.9%), 60 (25.8%) and 64 (27.4%) were classified as WHO stages 1, 2, 3 and 4, respectively. For these stages, 55 (94.8%), 38 (74.5%), 42 (70.0%) and 26 (40.5%) visits, respectively, were suitable for treatment at a primary-care facility. CONCLUSIONS: Many of the outpatient visits to this outpatient specialist clinic could have been safely cared for at a primary-care level. As the severity of the disease increases, there is a decrease in the proportion of patients that can be treated at a primary-care level.

An effectiveness trial of a diagnostic test in a busy outpatients department in a developing country: issues around allocation concealment and envelope randomization.

Methods to ensure allocation concealment in a randomized controlled trial in a busy outpatients department may disrupt usual clinical behavior, and thereby modify the effect of a diagnostic test. In a clinical trial of chest radiography in ambulatory children, concealment was maintained by means of sealed sequentially numbered manila envelopes. Baseline information was collected on all potential participants before they were presented to a clinician for a decision on inclusion in the trial. Excluded patients were followed up. Of 59 excluded patients, only 16 allocation envelopes had been opened or were not accounted for, although 12 of these had non-radiograph allocations (P = 0.05). There was no difference between patients excluded from radiograph and non-radiograph groups in baseline characteristics or primary outcome measure. Most of the improper exclusions occurred early in the study; improved monitoring and feedback reduced the problem. Sealed opaque sequentially numbered envelopes may be appropriate for trials of diagnostic tests in settings where centralized randomization is not feasible, and given careful monitoring of the enrollment process.

Telephone follow-up in a randomized controlled trial in a less developed country: feasibility, validity and representativeness.

Telephone follow-up would offer considerable advantages over other modes of follow-up in less developed countries, if it were feasible and the findings were valid and generalizable. Telephone follow-up was assessed in the context of a randomized controlled trial of chest radiography in South African children. Hospital-based clinical outcomes were measured from hospital records, and also by telephone, in a subset of the same patients who offered a contact telephone number. Of 398 subjects offering a telephone number 308 (77.4%) were followed to recovery or for 28 days. Kappa statistics for a subsequent hospital visit, hospital admission, and chest radiograph were 0.88, 0.83, and 0.56, respectively. The effect of chest radiography did not differ significantly in participants accessible and not accessible by telephone. Telephone follow-up was feasible and produced valid and generalizable results at low cost.

Evaluation of a village health worker programme: the use of village health worker retained records.

A village health worker (VHW) programme in a rural area in South Africa is evaluated, a year after the introduction of VHW-retained child record cards. The programme's success in promoting immunization and breastfeeding and the coverage of and contact with the community by the VHWs was investigated. A population survey on children under one year was matched to VHW records, showing that VHWs were reaching 70.8% of the target population. VHWs were more likely to visit a child with a Road to Health Card (RTHC) and who was born in the village. VHWs generally visit mothers once a month and make contact with most children in their first month of life. Children born before the start of the new VHW programme were compared with those born after, using survival analysis techniques and data from the RTHC on the first year of life of all children under two. An increase in polio immunization coverage was detected but there was a drop in measles immunization coverage. We conclude that a VHW-retained child record for the first year of life plays a valuable role in ongoing health care evaluation.

Prevalence and reliability of asthma symptoms in primary school children in Cape Town.

BACKGROUND: Childhood asthma is believed to be a serious problem in Cape Town, South Africa. This study aimed to measure the prevalence and reliability of asthma symptoms and reported asthma in Cape Town schoolchildren aged mainly 7 and 8 years, and to assess underdiagnosis. METHOD: A questionnaire was completed by parents of 1955 children, followed by 620 personal interviews repeating the questions. RESULTS: The prevalence of recent wheeze (previous 12 months) (26.8%) was high by international comparison, but not that of reported asthma (10.8%). Among children with more than 12 recent attacks of wheeze, only 60% were reported as asthmatic and 55% as receiving regular treatment. Symptom prevalences varied with the respondent's familial relationship to the child. On some questions the interview produced higher wheeze prevalences than the self-administered questionnaire. Repeatability of questions varied: asthma over (kappa = 0.69), recent wheeze (kappa = 0.59), and recent sleep disturbance by wheeze (kappa = 0.56) were the most reliable. CONCLUSIONS: Prevalence based on symptom reports may vary with the respondent and between self- and interviewer-administered questionnaires. Also, certain questions currently proposed for childhood asthma questionnaires may be unreliable. Nevertheless, it can be concluded that the prevalence of wheeze is high in this population, and that underdiagnosis and undertreatment of asthma are a problem.

Duration of illness in ambulatory children diagnosed with bronchiolitis.

OBJECTIVES: To measure the duration of illness in ambulatory children diagnosed with bronchiolitis and to examine clinical predictors of duration of illness. DESIGN: Validation inception cohort study. Duration of follow up was 28 days. SETTING: A primary-level ambulatory department of a public sector children's hospital in Cape Town, South Africa. PATIENTS: One hundred eighty-one children aged 2 to 23 months who went to the hospital as their first contact for that episode of illness, and had a clinical diagnosis of bronchiolitis were enrolled consecutively on weekday mornings if their guardian stated that they were contactable by telephone. MAIN OUTCOME MEASURE: Resolution of symptoms, as judged by the guardian, measured by twice-weekly telephone interviews. RESULTS: Median duration of illness (calculated as the reported duration of symptoms before initial hospital visit plus the time from first consultation to recovery) was 12 days (95% confidence interval, 11-14 days). After 21 days, 18% were still ill and after 28 days, 9% were still ill. Sixty-two patients (34.2%) had unscheduled consultations within 28 days, a median of 13 days after the first consultation. There was no association of duration of illness with age, sex, z score for weight for age, or respiratory rate. CONCLUSIONS: Ambulatory children diagnosed with bronchiolitis recover with few complications, but the resolution of symptoms may take several weeks. Providing parents with this information could help reduce the high rate of unscheduled return visits as observed in this cohort.

Gender disparity amongst TB suspects and new TB patients according to data recorded at the South African Institute of Medical Research laboratory for the Western Cape Region of South Africa.

OBJECTIVE: To describe the sex and age distribution of sputum submission and smear positivity in the Western Cape Province of South Africa. METHOD: Laboratory registers of the South African Institute of Medical Research were examined retrospectively for the year 1999. RESULTS: Male tuberculosis (TB) suspects outnumbered females by 1.45:1, whereas amongst confirmed TB cases the ratio was 2.08:1. The odds ratio (OR) for smear positivity amongst males and females was 1.544. The proportion of male sputum positives significantly exceeded the proportion of males in the general population, as measured by the 1996 census. Not only did the number of male TB suspects and confirmed cases exceed that of females in absolute terms, but the proportion of male suspects proving smear-positive exceeded that of females. The age by sex distribution of new smear-positive patients followed the trend reported in recent literature. CONCLUSION: The gendered incidence of tuberculosis identified from this census is consistent with that of other developing countries. However, the smaller proportion of female TB suspects proving smear-positive suggests a higher index of suspicion in females and/or longer delays prior to care seeking amongst males.

A randomised controlled trial of lay health workers as direct observers for treatment of tuberculosis.

SETTING: Study conducted in a suburb of Cape Town, South Africa. OBJECTIVE: Comparison of successful tuberculosis treatment outcome rates between self supervision, supervision by lay health worker (LHW), and supervision by clinic nurse. METHODS: Open, randomised, controlled trial with intention-to-treat analysis. RESULTS: All groups (n = 156) achieved similar outcomes (LHW vs. clinic nurse: risk difference 17.2%, 95% confidence interval [CI] -0.1-34.5; LHW vs. self supervision 15%, 95%CI -3.7-33.6). New patients benefit from LHW supervision (LHW vs clinic nurse: risk difference 24.2%, 95%CI 6-42.5, LHW vs. self supervision 39.1%, 95%CI 17.8-60.3) as do female patients (LHW vs. clinic nurse 48.3%, 95%CI 22.8-73.8, LHW vs. self supervision 32.6%, 95%CI 6.4-58.7). CONCLUSIONS: LHW supervision approaches statistically significant superiority, but fails to reach it most likely due to the study's limitation, the small sample size. It is possible that subgroups (new and female patients) do well under LHW supervision. LHW supervision could be offered as one of several supervision options within TB control programmes.

Systematic reviews of the effectiveness of quality improvement strategies and programmes.

Systematic reviews provide the best evidence on the effectiveness of healthcare interventions including quality improvement strategies. The methods of systematic review of individual patient randomised trials of healthcare interventions are well developed. We discuss methodological and practice issues that need to be considered when undertaking systematic reviews of quality improvement strategies including developing a review protocol, identifying and screening evidence sources, quality assessment and data abstraction, analytical methods, reporting systematic reviews, and appraising systematic reviews. This paper builds on our experiences within the Cochrane Effective Practice and Organisation of Care (EPOC) review group.

Interventions to promote collaboration between nurses and doctors.

BACKGROUND: Lack of nurse-doctor collaboration contributes to problems in quality and efficiency of patient care. OBJECTIVES: To assess the effects of interventions designed to improve nurse-doctor collaboration. SEARCH STRATEGY: We searched the Cochrane Effective Practice and Organisation of Care Group specialised register and database of studies awaiting assessment, the Cochrane Database of Systematic Reviews, the Cochrane Controlled Trials Register, the Database of Abstracts of Reviews of Effectiveness, MEDLINE, and reference lists of articles up to the end of October 1999. SELECTION CRITERIA: Randomised trials, controlled before-and-after studies and interrupted time series of interventions to improve collaboration between nursing and medical professionals sharing patient care in primary or hospital care settings. DATA COLLECTION AND ANALYSIS: One reviewer assessed the eligibility of potentially relevant studies, extracted data and assessed the quality of included studies; a second reviewer undertook duplicate assessments on the eligibility of some articles and data abstraction on all included studies. MAIN RESULTS: Two trials involving 1945 people were included. One six month trial involving 1102 admissions evaluated daily, structured, team ward rounds, in which nurses, doctors and other professionals made care decisions jointly. There was shortened average length of hospital stay (LOS) from 6.06 to 5.46 days, and reduced hospital charges from US$ 8090 to 6681. There were no differences in mortality rates or the type of care to which patients were discharged. Another three month trial involving 843 admissions compared two female wards and evaluated a four times per week round. There were no significant differences between the intervention and control wards in total average length of stay for all patients (11.7 days in intervention ward versus 11.6 in the control ward). Excluding patients who died in hospital revealed shortened length of stay in the intervention ward (intervention ward 10.5 days, control ward 11.9). Mortality rates were not significantly different. REVIEWER'S CONCLUSIONS: Increasing collaboration improved outcomes of importance to patients and to health care managers. These gains were moderate and affected health care processes rather than outcomes. Further research is needed to confirm these findings. The logistic challenge presented by the complexity of the interventions and the need for large sample sizes due to the likely modest impact and rarity of outcome events may best be met by multi-centre studies. Before launching such studies qualitative research is needed to identify barriers to collaboration. Interventions other than nurse-doctor ward rounds and team meetings should also be tested.