Evaluating point-of-care testing for glycosylated haemoglobin in public sector primary care facilities in the Western Cape, South Africa.

BACKGROUND: Diabetes mellitus contributes significantly to the burden of disease in South Africa (SA). Monitoring of glycaemic control with glycosylated haemoglobin (HbA1c) is recommended, even though current laboratory-based testing does not support immediate clinical decision-making. OBJECTIVES: To evaluate the costs and consequences for quality of care by introducing point-of-care (POC) testing for HbA1c for patients with type 2 diabetes at community health centres in Cape Town, SA. METHODS: A quasi-experimental study was conducted at two control and two intervention sites in the same sub-district. The DCA Vantage Analyzer (Siemens, Germany) for POC testing was introduced at the intervention sites for 12 months. Patients were randomly selected from the diabetes register at the intervention (n=300) and control (n=300) sites, respectively, and data were collected from patient records at baseline and 12 months. Focus group interviews were performed at the intervention sites. Technical quality and cost implications were evaluated. RESULTS: POC testing was feasible, easy to integrate into the organisation of care, resulted in more immediate feedback to patients (p<0.001) and patients appeared more satisfied. POC testing did not improve test coverage, treatment intensification, counselling or glycaemic control. There was an incremental cost of ZAR2 110 per 100 tests. Compliance with quality control was poor, although control tests showed good reliability. CONCLUSION: This study does not support the introduction of POC testing for HbA1c in public sector primary care practice in the current context. POC testing should be evaluated further in combination with interventions to overcome clinical inertia and strengthen primary healthcare.

Physician and patient perceptions of cultural competency and medical compliance.

To examine the relationship between the different perceptions of medical teams and their patients of the cultural competence of physicians, and the influence of this relationship on the conflict between them. Physicians' cultural competence (Noble A. Linguistic and cultural mediation of social services. Cultural competence of health care. Echo New Studio 2007; 91:18-28) might reduce this phenomenon. Structured questionnaires were distributed to 90 physicians working in outpatient clinics in a central hospital in Israel, and to 417 of their patients. Each physician had four to six sampled patients.The findings showed a significant negative correlation (r = -0.50, P < 0.05) between the physicians' perception of their cultural competence and the patients' perception of physician competence. The more patients perceive the physician as culturally competent, the more they comply with their medical recommendations. In addition, the findings show that ethnicity significantly affects patients' perception of the cultural competence of physicians, and their satisfaction with the medical care they receive.

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.

Guideline for the management of acute asthma in adults: 2013 update.

Acute asthma attacks (asthma exacerbations) are increasing episodes of shortness of breath, cough, wheezing or chest tightness associated with a decrease in airflow that can be quantified and monitored by measurement of lung function (peak expiratory flow (PEF) or forced expiratory volume in the 1st second) and requiring emergency room treatment or admission to hospital for acute asthma and/or systemic glucocorticosteroids for management. The goals of treatment are to relieve hypoxaemia and airflow obstruction as quickly as possible, restore lung function, and provide a suitable plan to avoid relapse. Severe exacerbations are potentially life-threatening and their treatment requires baseline assessment of severity, close monitoring, and frequent reassessment using objective measures of lung function (PEF) and oxygen saturation. Patients at high risk of asthma-related death require particular attention. First-line therapy consists of oxygen supplementation, repeated administration of inhaled short-acting bronchodilators (beta-2-agonists and ipratropium bromide), and early systemic glucocorticosteroids. Intravenous magnesium sulphate and aminophylline are second- and third-line treatment strategies, respectively, for poorly responding patients. Intensive care is indicated for severe asthma that is not responsive to first-line treatment. Antibiotics are only indicated when there are definite features of bacterial infection. Factors that precipitated the acute asthma episode should be identified and preventive measures implemented. Acute asthma is preventable with optimal control of chronic asthma.

The development and psychometric evaluation of a safety climate measure for primary care.

INTRODUCTION: Building a safety culture is an important part of improving patient care. Measuring perceptions of safety climate among healthcare teams and organisations is a key element of this process. Existing measurement instruments are largely developed for secondary care settings in North America and many lack adequate psychometric testing. Our aim was to develop and test an instrument to measure perceptions of safety climate among primary care teams in National Health Service for Scotland. METHOD: Questionnaire development was facilitated through a steering group, literature review, semistructured interviews with primary care team members, a modified Delphi and completion of a content validity index by experts. A cross-sectional postal survey utilising the questionnaire was undertaken in a random sample of west of Scotland general practices to facilitate psychometric evaluation. Statistical methods, including exploratory and confirmatory factor analysis, and Cronbach and Raykov reliability coefficients were conducted. RESULTS: Of the 667 primary care team members based in 49 general practices surveyed, 563 returned completed questionnaires (84.4%). Psychometric evaluation resulted in the development of a 30-item questionnaire with five safety climate factors: leadership, teamwork, communication, workload and safety systems. Retained items have strong factor loadings to only one factor. Reliability coefficients was satisfactory (α = 0.94 and ρ = 0.93). DISCUSSION: This study is the first stage in the development of an appropriately valid and reliable safety climate measure for primary care. Measuring safety climate perceptions has the potential to help primary care organisations and teams focus attention on safety-related issues and target improvement through educational interventions. Further research is required to explore acceptability and feasibility issues for primary care teams and the potential for organisational benchmarking.

What are the Reasons for Patients not Adhering to their Anti-TB Treatment in a South African District Hospital?

Introduction :TB is a major health problem in South Africa; with increasing numbers of patients notified; inadequate successful treatment rates and an emerging problem with resistant strains. This study was conducted at a District Hospital in KwaZulu-Natal where the successful treatment rate was as low as 23. The aim of this study was to identify key factors at the hospital that may affect adherence to TB treatment and to recommend interventions that could improve adherence. Methods:The study design was a case control study using prospectively collected data. Information was collected over an 8-month period; when the patients started their anti-TB treatment; according to the known factors that influence TB adherence. The patients were then followed up to determine those who did not adhere to their treatment; and those who successfully completed treatment. The two groups involved; therefore; were the controls (those who did adhere) and the cases (those who did not adhere). The data previously collected were then compared for significant associations with the controls and cases. Results :Data were obtained from 159 TB patients; 105 (66) were adherent and 54 (34) non-adherent. The following variables showed a significant association (p 0.05) with non-adherence: higher level of education; distance from the hospital; time taken to travel; the method of transport; satisfaction with the hospital; food security; income; the smoking of tobacco and/or marijuana; the patients' perspective and beliefs; HIV testing and status; functional status; social support; the relationship with the TB nurse; depression score; and self-rating of confidence. A stepwise logistic regression was performed; and only two variables remained significantly associated: travel time (OR7.9; 95CI 1.4-44.1) and the relationship with the TB nurse (OR2.6; 95CI 1.3-5.1). Conclusions: The most important recommendation is to improve the relationship between patients and TB nurses through training in communication skills. A more holistic assessment of patients would help identify issues such as depression; and a more patient-centred approach would help to understand and address patient's concerns; beliefs and expectations. It may also be important to ensure that management and administrative systems support a more patient-centred approach. It may be important to encourage the recruitment of family physicians who are trained in communication skills and a patient-centred approach; to work in the rural areas; where they can mentor and teach other colleagues and staff. More needs to be done in terms of helping patients to access facilities through transport; or in making services more available at the community level through DOTS (Directly Observed Treatment) supporters and adequate home-based carer support

Assessment of the quality of interaction in distance learning programmes utilising the Internet (WebCT) or interactive television (ITV).

INTRODUCTION: This study focuses on the quality of interaction in interactive TV (ITV), WebCT bulletin boards (BBs) and chat rooms (CRs) and addresses the question of how effectively new collaborative electronic technologies have been married with new pedagogical ideas to create effective learning for distance education students. METHODS: Fifteen (out of 68) BB, 14 (out of 32) CR and 13 (out of 25) ITV conversations were randomly selected for coding using a modified exchange structure analysis. The roles that students and lecturers took in the conversations were determined from this. RESULTS: The percentage of turns made by lecturers as opposed to students was 51% in CRs, 14% in BBs and 68% in ITV. The percentage of turns spent on actual coursework was 73% in CRs, 89% in BBs and 82% in ITV. Comparisons between tutors' and students' roles within as well as between ITV, BBs and CRs were all statistically significant with P < 0.05. In CRs the main roles of both students and lecturers were those of elaborators, inquirers and explainers. In BBs the main roles of students and lecturers were those of explainers and evaluators. In ITV sessions students' main roles were those of elaborators and explainers, whereas lecturers' main roles were those of lecturers, elaborators, inquirers and evaluators. CONCLUSION: In terms of creating a constructivist and active learning community that can operate within a distance learning paradigm, WebCT appears superior to ITV.