Relationship between characteristics of volunteer community health workers and antiretroviral treatment outcomes in a community-based treatment programme in Uganda.

Community health workers (CHWs) can help to redress the shortages of health human resources needed to scale up antiretroviral treatment (ART). However, the selection of CHWs could influence the effectiveness of a CHW programme. The purpose of this observational study was to assess whether sociodemographic characteristics and geographic proximity to patients of volunteer CHWs were predictors of clinical outcomes in a community-based ART (CBART) programme in Kabarole, Uganda. Data from CHW surveys for 41 CHWs and clinic charts for 185 patients in the CBART programme were analysed using multivariable logistic and Cox regression models. Time to travel to patients was the only statistically significant characteristic of CHWs associated with ART outcomes. Patients whose CHWs had to travel one or more hours had a 71% lower odds of virologic suppression (adjusted OR = 0.29, 95% CI = 0.13-0.65, p = .002) and a 4.52 times higher mortality hazard rate (adjusted HR = 4.52, 95% CI = 1.20-17.09, p = .026) compared to patients whose CHWs had to travel less than one hour. The findings show that the sociodemographic characteristics of CHWs were not as important as the geographic distance they had to travel to patients.

Tuberculosis and human immunodeficiency virus: exploring stigma in a community in western Uganda.

The threat of tuberculosis (TB) in Uganda cannot be considered in isolation from the HIV/AIDS epidemic. Stigma contributes to delays in seeking treatment and poor adherence for both TB and HIV patients. This study aims to assess and describe stigma and predictors of stigma related to TB and HIV in the population of western Uganda. This was a cross-sectional mixed methods study. A survey was administered to 360 individuals, randomly selected from one district in western Uganda. Participants were classified as low/high stigma based on weighted scores built from survey questions. Logistic regression was used to determine significant predictors for high stigma. Six focus groups were conducted to inform survey findings; themes were developed using content analysis. Twenty-six per cent of respondents were found to have stigmatising attitudes towards HIV and 47% towards TB. Multivariate logistic regression models included age, sex, marital status, education, residence and having a friend with HIV/TB. Those who had an HIV-positive friend were less likely to have high HIV stigma (OR: 0.41, 95% CI: 0.23-0.72). Those with secondary education or more were half as likely to have high TB stigma (OR: 0.50, 95% CI: 0.27-0.91). Focus group participants felt that "normalisation" of HIV has contributed to reduced HIV stigma, but there is still a fear of being recognised at the HIV clinic. TB stigma causes patients to remain silent instead of seeking care. Fear of TB is driven by the assumption that "TB means HIV". Declining HIV stigma is encouraging but more effort needs to be made to improve confidentiality. TB stigma is high and is likely affecting care seeking behaviour; TB awareness campaigns should be a priority and emphasise the treatability and curability of TB, regardless of HIV status.

Impact of community-based HIV/AIDS treatment on household incomes in Uganda.

Though health benefits to households in developing countries from antiretroviral treatment (ART) programs are widely reported in the literature, specific estimates regarding impacts of treatments on household incomes are rare. This type of information is important to governments and donors, as it is an indication of returns to their ART investments, and to better understand the role of HIV/AIDS in development. The objective of this study is to estimate the impact of a community-based ART program on household incomes in a previously underserved rural region of Uganda. A community-based ART program, based largely on labor contributions from community volunteers, was implemented and evaluated. All households with HIV/AIDS patients enrolled in the treatment programme (n = 134 households) were surveyed five times; once at the beginning of the treatment and every three months thereafter for a period of one year. Data were collected on household income from cash earnings and value of own production. The analysis, using ordinary least squares and quantile regressions, identifies the impact of the ART program on household incomes over the first year of the treatment, while controlling for heterogeneity in household characteristics and temporal changes. As a result of the treatment, health conditions of virtually all patients improved, and household incomes increased by approximately 30% to 40%, regardless of household income quantile. These increases in income, however, varied significantly depending on socio-demographic and socio-economic control variables. Overall, results show large and significant impacts of the ART program on household incomes, suggesting large returns to public investments in ART, and that treating HIV/AIDS is an important precondition for development. Moreover, development programs that invest in human capital and build wealth are important complements that can increase the returns to ART programs.

Tuberculosis in the era of infection with the human immunodeficiency virus: assessment and comparison of community knowledge of both infections in rural Uganda.

BACKGROUND: In Uganda, despite a significant public health burden of tuberculosis (TB) in the context of high human immunodeficiency virus (HIV) prevalence, little is known about community knowledge of TB. The purpose of this study was to assess and compare knowledge about TB and HIV in the general population of western Uganda and to examine common knowledge gaps and misconceptions. METHODS: We implemented a multi-stage survey design to randomly survey 360 participants from one district in western Uganda. Weighted summary knowledge scores for TB and HIV were calculated and multiple linear regression (with knowledge score as the dependant variable) was used to determine significant predictors. Six focus group discussions were conducted to supplement survey findings. RESULTS: Mean (SD) HIV knowledge score was 58 (12) and TB knowledge score was 33 (15), both scores out of 100. The TB knowledge score was statistically significantly (p < 0.001) lower. Multivariate regression models included age, sex, marital status, education, residence, and having a friend with HIV/TB as independent variables. TB knowledge was predicted by rural residence (coefficient = -6.27, 95% CI: -11.7 to -0.8), and age ≥45 years (coefficient = 7.45, 95% CI: 0.3-14.6). HIV knowledge was only predicted by higher education (coefficient = 0.94, 95%CI: 0.3-1.6). Focus group participants mentioned various beliefs in the aetiology of TB including sharing cups, alcohol consumption, smoking, air pollution, and HIV. Some respondents believed that TB was not curable. CONCLUSION: TB knowledge is low and many misconceptions about TB exist: these should be targeted through health education programs. Both TB and HIV-infection knowledge gaps could be better addressed through an integrated health education program on both infections, whereby TB program managers include HIV information and vice versa.

Antiretroviral treatment for HIV in rural Uganda: two-year treatment outcomes of a prospective health centre/community-based and hospital-based cohort.

BACKGROUND: In sub-Saharan Africa, a shortage of trained health professionals and limited geographical access to health facilities present major barriers to the expansion of antiretroviral therapy (ART). We tested the utility of a health centre (HC)/community-based approach in the provision of ART to persons living with HIV in a rural area in western Uganda. METHODS: The HIV treatment outcomes of the HC/community-based ART program were evaluated and compared with those of an ART program at a best-practice regional hospital. The HC/community-based cohort comprised 185 treatment-naïve patients enrolled in 2006. The hospital cohort comprised of 200 patients enrolled in the same time period. The HC/community-based program involved weekly home visits to patients by community volunteers who were trained to deliver antiretroviral drugs to monitor and support adherence to treatment, and to identify and report adverse reactions and other clinical symptoms. Treatment supporters in the homes also had the responsibility to remind patients to take their drugs regularly. ART treatment outcomes were measured by HIV-1 RNA viral load (VL) after two years of treatment. Adherence was determined through weekly pill counts. RESULTS: Successful ART treatment outcomes in the HC/community-based cohort were equivalent to those in the hospital-based cohort after two years of treatment in on-treatment analysis (VL≤400 copies/mL, 93.0% vs. 87.3%, p = 0.12), and in intention-to-treat analysis (VL≤400 copies/mL, 64.9% and 62.0%, p = 0.560). In multivariate analysis patients in the HC/community-based cohort were more likely to have virologic suppression compared to hospital-based patients (adjusted OR = 2.47, 95% CI 1.01-6.04). CONCLUSION: Acceptable rates of virologic suppression were achieved using existing rural clinic and community resources in a HC/community-based ART program run by clinical officers and supported by lay volunteers and treatment supporters. The results were equivalent to those of a hospital-based ART program run primarily by doctors.

Enough children: reproduction, risk and "unmet need" among people receiving antiretroviral treatment in western Uganda.

In this paper, we use survey (n = 87) and interview (n = 30) data to investigate orientations towards future childbearing among people receiving antiretroviral treatment and their family members in western Uganda. We investigate how reproductive options are perceived, by those receiving treatment and those closest to them, and consider what these perceptions suggest about the existence of an "unmet need" for birth control for women with HIV. While most people say they do not wish to have more children while on treatment, this intention coexists with contradictory desires for the benefits and happiness that more children might bring. We argue that the factors influencing birth desires and outcomes are so complex and contradictory that it is virtually impossible to predict demand or uptake of birth control as more and more people with AIDS in Africa gain the ability to access antiretroviral treatment.

Unmet need for effective family planning in HIV-infected individuals: results from a survey in rural Uganda.

BACKGROUND AND METHODOLOGY: This study determined the unmet need for family planning among HIV-positive and HIV-negative individuals living in western Uganda. Semi-structured interviews were conducted with individuals who were randomly selected from HIV testing lists. Of those individuals, further analysis was conducted on a subset of 206 participants who did not desire more children and were not using a highly effective method of contraception. Descriptive, bivariate and multivariate methods were performed to assess the relationship between HIV status and unmet need for effective family planning. RESULTS: The unmet need for effective family planning was much greater in HIV-infected individuals compared to HIV-negative individuals [75.0% vs 33.8%, adjusted odds ratio (OR) 3.97, 95% confidence interval (CI) 1.97-8.03, p<0.001]. Females were more likely to report an unmet need compared to males (69.0% vs 49.5%; adjusted OR 1.94, 95% CI 0.94-4.00, p=0.071). Other predictors of unmet need for effective family planning were older age (adjusted OR 1.08 for each year of age, 95% CI 1.00-1.16, p=0.018) and single/cohabiting vs being married (OR 2.36, 95% CI 1.16-4.80, p=0.036). Being on antiretroviral therapy was not a predictor of having a lower unmet need for effective family planning methods. DISCUSSION AND CONCLUSIONS: There is high unmet need for effective family planning in HIV-positive study participants in a region of western Uganda, which should be of concern. This suggests that HIV-infected individuals do not want to use family planning or encounter barriers to accessing and utilising family planning services. Family planning programmes and HIV care and prevention services have to work together more effectively to create services conducive to clients from both programmes.

Comparing antiretroviral treatment outcomes between a prospective community-based and hospital-based cohort of HIV patients in rural Uganda.

BACKGROUND: Improved availability of antiretroviral therapy in sub-Saharan Africa is intended to benefit all eligible HIV-infected patients; however in reality antiretroviral services are mainly offered in urban hospitals. Poor rural patients have difficulty accessing the drugs, making the provision of antiretroviral therapy inequitable. Initial tests of community-based treatment programs in Uganda suggest that home-based treatment of HIV/AIDS may equal hospital-based treatment; however the literature reveals limited experiences with such programs. THE RESEARCH: This intervention study aimed to; 1) assess the effectiveness of a rural community-based ART program in a subcounty (Rwimi) of Uganda; and 2) compare treatment outcomes and mortality in a rural community-based antiretroviral therapy program with a well-established hospital-based program. Ethics approvals were obtained in Canada and Uganda. RESULTS AND OUTCOMES: Successful treatment outcomes after two years in both the community and hospital cohorts were high. All-cause mortality was similar in both cohorts. However, community-based patients were more likely to achieve viral suppression and had good adherence to treatment. The community-based program was slightly more cost-effective. Per capita costs in both settings were unsustainable, representing more than Uganda's Primary Health Care Services current expenditures per person per year for all health services. The unpaid community volunteers showed high participation and low attrition rates for the two years that this program was evaluated. CHALLENGES AND SUCCESSES: Key successes of this study include the demonstration that antiretroviral therapy can be provided in a rural setting, the creation of a research infrastructure and culture within Kabarole's health system, and the establishment of a research collaboration capable of enriching the global health graduate program at the University of Alberta. Challenging questions about the long-term feasibility and sustainability of a community-based ARV program in Uganda still remain. THE PARTNERSHIP: This project is a continuation of previous successful collaborations between the School of Public Health of Makerere University, the School of Public Health of University of Alberta, the Kabarole District Administration and the Kabarole Research and Resource Center.

Impact of antiretroviral therapy on fertility desires among HIV-infected persons in rural Uganda.

BACKGROUND: Little is known about the fertility desires of HIV infected individuals on highly active antiretroviral therapy (HAART). In order to contribute more knowledge to this topic we conducted a study to determine if HIV-infected persons on HAART have different fertility desires compared to persons not on HAART, and if the knowledge about HIV transmission from mother-to-child is different in the two groups. METHODS: The study was a cross-sectional survey comparing two groups of HIV-positive participants: those who were on HAART and those who were not. Semi-structured interviews were conducted with 199 HIV patients living in a rural area of western Uganda. The desire for future children was measured by the question in the questionnaire "Do you want more children in future." The respondents' HAART status was derived from the interviews and verified using health records. Descriptive, bivariate and multivariate methods were used to analyze the relationship between HAART treatment status and the desire for future children. RESULTS: Results from the multivariate logistic regression model indicated an adjusted odds ratio (OR) of 1.08 (95% CI 0.40-2.90) for those on HAART wanting more children (crude OR 1.86, 95% CI 0.82-4.21). Statistically significant predictors for desiring more children were younger age, having a higher number of living children and male sex. Knowledge of the risks for mother-to-child-transmission of HIV was similar in both groups. CONCLUSIONS: The conclusions from this study are that the HAART treatment status of HIV patients did not influence the desire for children. The non-significant association between the desire for more children and the HAART treatment status could be caused by a lack of knowledge in HIV-infected persons/couples about the positive impact of HAART in reducing HIV transmission from mother-to-child. We recommend that the health care system ensures proper training of staff and appropriate communication to those living with HIV as well as to the general community.

Breastfeeding practices of HIV-positive and HIV-negative women in Kabarole district, Uganda.

Ugandan policy regarding infant feeding for HIV-positive mothers is replacement feeding (RF), if feasible; otherwise, exclusive breastfeeding (EBF) for 3 months is advised (or EBF for 6 months, if RF is still not feasible). HIV-negative mothers should practise EBF for 6 months. The study objective was to explore the association between maternal HIV status and breastfeeding practices in Kabarole, Uganda. Data were collected from questionnaires administered at home to 182 women (44 HIV-positive and 138 HIV-negative) 3 months post-partum and from medical charts. The HIV-negative women were matched on delivery date to HIV-positive women at a ratio of 3:1. Interviewers were blinded to HIV status. There was no statistically significant association between adherence to Ugandan national feeding guidelines and maternal HIV status in bivariate analysis [odds ratio (OR) = 1.52; confidence interval (CI): 0.76-3.04]. Multivariate analyses showed a significant association between adherence to feeding guidelines and child illness (OR = 0.40; CI: 0.21-0.79) and between adherence to feeding guidelines and rural residence in Burahya county (OR = 2.43; CI: 1.15-5.13). Many mothers do not follow the feeding guidelines for HIV infection. This region-specific information on breastfeeding practice determinants will be used to inform local Prevention of Mother-to-Child Transmission (PMTCT) programmes. The nature of the association between child illness and EBF should be further explored.

Risk factors and trends in childhood stunting in a district in Western Uganda.

OBJECTIVES: This representative, cross-sectional study conducted in Kabarole District, Western Uganda, determined the nutritional status of children 6-59 months of age and established a trend in the childhood stunting rates. METHODS: A multi-stage random cluster sampling was performed to select 322 children and their principal caregivers. Anthropometric measurements were taken from the children and compared with a reference population and the children's principle caregivers were interviewed. RESULTS: Childhood stunting was high with 43.0% of all children having a z-score of less than or equal to -2. Predictive factors for stunting were a low economic status of the household, poor health of the child's caregiver, residence located at a long distance from a health unit and use of a contaminated water source. The comparison of our study results with an earlier nutritional study in Kabarole District revealed that there is an increasing trend of childhood stunting over the years of 28.0% [95% confidence interval (CI) 22.1-33.1%] in 1989 vs 43% (95% CI 37.6-48.8%) in 2006 and that stunting rates in Kabarole District were much higher compared to national data. CONCLUSION: The high stunting rates in children and the increasing trend in stunting needs further investigations. It should also be determined why stunting rates in children in Kabarole District are much higher than the national average. There is a need for better nutritional interventions as part of the district's public health programs.

Gender-related mortality for HIV-infected patients on highly active antiretroviral therapy (HAART) in rural Uganda.

The purpose of this study was to examine gender differences in mortality for human immunodeficiency virus (HIV) patients in rural Western Uganda after six months of highly active antiretroviral therapy (HAART). Three hundred eighty five patients were followed up for six months after initiating HAART. Statistical analysis included descriptive, univariate and multivariate methods, using Kaplan-Meier estimates of survival distribution and Cox proportional hazards regression. Mortality in female patients (9.0%) was lower than mortality in males (13.5%), with the difference being almost statistically significant (adjusted hazard ratio for females 0.55; 95% confidence interval [CI]: 0.28-1.07; P = 0.08). At baseline, female patients had a significantly higher CD4+ cell count than male patients (median 147 cells/µL vs 120 cells/µL; P < 0.01). A higher CD4+ cell count and primary level education were strongly associated with better survival. The higher CD4+ cell count in females may indicate that they accessed HAART services at an earlier stage of their disease progression than males. A borderline statistically significant lower mortality rate in females shows that females fare better on treatment in this context than males. The association between lower mortality and higher CD4+ levels suggest that males are not accessing treatment early enough and that more concerted efforts need to be made by HAART programs to reach male HIV patients.

Gender differences in antiretroviral treatment outcomes of HIV patients in rural Uganda.

Gender differences in treatment outcomes of 305 persons living with HIV receiving antiretroviral treatment (ART) in Kabarole district, western Uganda, were evaluated. The primary treatment outcome was virological suppression defined as HIV-1 RNA viral load (VL) <400 copies/ml and the secondary outcome measure was the increase in the CD4 cell count after six months on ART. Statistical analysis included descriptive, univariate, and multivariate methods. Proportionally, more females chose to seek treatment compared to males. After six months of treatment, females were more likely to have viral suppression (VL > 400 copies/ml) as compared to males (odds ratio 2.14, 95% confidence interval 0.99-4.63, p=0.05). While females had a significantly higher baseline CD4 cell count at initiation of treatment compared to males, the increase in CD4 cell count after six months on ART was similar in males and females. The reasons for better ART outcomes for females should be further investigated. Ideally, ART programs should work toward equitable treatment outcomes for men and women, if the cause of the gender differential lies in patient behavior and the way ART services are delivered.

Quality of life of HIV patients in a rural area of western Uganda: impact of a community-based antiretroviral treatment program.

OBJECTIVE: Community-based antiretroviral treatment (CBART) programs should aim to achieve positive quality of life outcomes. The purpose of this study was to investigate changes in the health related quality of life (HRQOL) outcomes of patients in a CBART program supported by community volunteers in one sub-county in western Uganda located 50 km from the nearest urban centre. METHODS: We administered a translated version of the MOS-HIV survey and collected clinical data at baseline and after one year from 130 patients. Inclusion criteria included residency in the sub-county, eighteen years of age or, treatment-naïve, eligible for ART based on CD4 cell count <200 cells/mm3 or WHO clinical stage 3 or 4, and willing to accept daily treatment support by family/friends and to be visited by a community volunteer weekly. We assessed changes in physical health (PHS) and mental health (MHS) summary scores and examined associations between patient characteristics and changes in HRQOL. RESULTS: After one year, we observed significant increases in mean PHS (42.7 to 50.1; p<0.01) and MHS (43.5 to 49.5; p<0.01) scores. Lower age (p<0.01) and lower baseline PHS scores (p<0.01) were associated with increases in PHS scores and lower age (p=0.03) and lower baseline MHS scores (p<0.01) were associated with increases in MHS scores. Fifteen patients (12%) had reductions in their HRQOL after one year which were not associated with patient or clinical characteristics, including virological suppression. CONCLUSIONS: The observed improvements in HRQOL demonstrate that positive treatment outcomes can be achieved in CBART programs in rural Uganda. However, some patients appear to experience declines in their overall well-being, despite achieving virological suppression. HRQOL surveys can be useful in identifying these patients, who may require additional attention and support to achieve the full benefits of ART.

"Living by the hoe" in the age of treatment: perceptions of household well-being after antiretroviral treatment among family members of persons with AIDS.

This paper considers the effects of antiretroviral treatment on the households of person with AIDS in western Uganda. Interviews were carried out with 110 co-resident "treatment partners" of people receiving treatment. We discuss these family members' accounts of the impact of sickness, followed by treatment, on their household's livelihood, defined as the activities needed to obtain and process the resources required to sustain the households. The household's ability to muster labour for subsistence agriculture was of paramount concern when family members considered what treatment meant for the households. While they were very happy with the treatment, they said that households have not yet recovered from the shock of AIDS sicknesses.

Results of a community-based antiretroviral treatment program for HIV-1 infection in Western Uganda.

OBJECTIVE: To compare the treatment outcomes and mortality in a rural community-based ART (CBART) program with a hospital-based ART program in the same district. METHODS: The study design was a non-randomized cohort study consisting of 185 persons living with HIV (PLWHIV) in the CBART cohort and 200 PLWHIV in the hospital cohort. Eligibility for both cohorts was: being HIV-infected and eligible for ART, being treatment naïve, age 18 years or older, and being a resident of Rwimi sub-county. The intervention consisted of a community-based program which included weekly home visits to patients by trained volunteers who delivered antiretroviral drugs (ARVs), monitored and supported adherence to treatment, and identified and reported adverse reactions and other clinical symptoms. Outcome variables were compared to patients in a hospital-based cohort who received the standard care delivered to all other HIV patients in the hospital. The main outcome measures were HIV-1 RNA viral load (VL), CD4 cell count and mortality after six months of treatment. RESULTS: Successful ART treatment outcome as measured by virological suppression (VL<400 copies/ml) in the CBART cohort were similar to those in the hospital-based cohort (90.1% vs 89.3%, p=0.47). The median CD4 cell count increased significantly in both cohorts (community-based cohort 159 cells/microl vs 145 cells/microl in the hospital-based cohort). Mortality was not significantly different in both cohorts (community-based cohort 11.9%, hospital-based cohort 9.0%). CONCLUSION: The findings show that outcomes of a CBART intervention in a rural area compare favorably to outcomes of hospital-based care. If the study results are sustainable over a longer time period, this model could be considered for ART roll-out to impoverished rural/remote populations in Uganda and elsewhere.

Public knowledge and attitudes toward HIV/AIDS and antiretroviral therapy in Kabarole district, western Uganda.

A study on knowledge about HIV/AIDS and antiretroviral therapy (ART) was conducted in the general population of a rural district in western Uganda. Three hundred seventy-two participants were selected by random cluster sampling and interviewed with an interview-administered questionnaire. Data were analyzed quantitatively with descriptive, univariate and linear multivariate statistical analysis with the knowledge score about ART as the dependent variable. The results indicate that the mean knowledge was 7.7 in a scale from 0 to 13. Predictor for better ART knowledge was a higher educational status of the participants. Older participants over 50 years were less ART knowledgeable. Only 19% of the participants have been tested for HIV. The conclusions are that the ART knowledge in this population is remarkably high which is reaffirming and important for achieving a high adherence to ART. Of concern is the low proportion of persons tested for HIV in this general population. Kabarole district seems to be receptive and capable for intensifying HIV testing which is a precondition for the ART roll-out.

Fertility desires and infection with the HIV: results from a survey in rural Uganda.

OBJECTIVE: To determine how a positive HIV diagnosis influences fertility desires and reproductive decisions for women and men living in western Uganda. DESIGN: : Cross-sectional survey comparing two groups of participants: those who tested HIV-positive and those who tested HIV-negative. METHODS: Semistructured interviews were conducted with 421 individuals living in rural areas. Descriptive, bivariate and multivariate methods were used to analyze the relationship of the HIV status to the desire to stop childbearing, reproductive decision-making and to the use of family planning methods. RESULTS: The multivariate logistic regression model indicated that the odds ratio (OR) of wanting to stop childbearing was found to be 6.25 times greater (P < 0.01) for HIV-positive than for HIV-negative individuals. Additional predictors included older age (OR 1.13, P < 0.01), female sex (OR 2.42, P = 0.03), Mutooro ethnic group (OR 3.20, P < 0.01) and greater number of living children (OR 1.62, P < 0.01). Use of dual protection against HIV/sexually transmitted infection and unwanted pregnancy was rare in both groups with seven HIV-positive participants (3.5%) using two contraceptives compared with only one (0.4%) in the HIV-negative group. The unmet need for a highly effective family planning method was higher in HIV-positive participants compared with HIV-negative ones (90 vs. 78%). CONCLUSION: HIV-positive individuals in the Kabarole region have a much greater desire to stop childbearing than their HIV-negative counterparts. The barriers to utilizing family planning services, as evidenced through the very low use of highly effective contraceptive methods, have to be jointly addressed by HIV/AIDS care/prevention and family planning programs.

Assessing validity of ICD-9-CM and ICD-10 administrative data in recording clinical conditions in a unique dually coded database.

OBJECTIVE: The goal of this study was to assess the validity of the International Classification of Disease, 10th Version (ICD-10) administrative hospital discharge data and to determine whether there were improvements in the validity of coding for clinical conditions compared with ICD-9 Clinical Modification (ICD-9-CM) data. METHODS: We reviewed 4,008 randomly selected charts for patients admitted from January 1 to June 30, 2003 at four teaching hospitals in Alberta, Canada to determine the presence or absence of 32 clinical conditions and to assess the agreement between ICD-10 data and chart data. We then re-coded the same charts using ICD-9-CM and determined the agreement between the ICD-9-CM data and chart data for recording those same conditions. The accuracy of ICD-10 data relative to chart data was compared with the accuracy of ICD-9-CM data relative to chart data. RESULTS: Sensitivity values ranged from 9.3 to 83.1 percent for ICD-9-CM and from 12.7 to 80.8 percent for ICD-10 data. Positive predictive values ranged from 23.1 to 100 percent for ICD-9-CM and from 32.0 to 100 percent for ICD-10 data. Specificity and negative predictive values were consistently high for both ICD-9-CM and ICD-10 databases. Of the 32 conditions assessed, ICD-10 data had significantly higher sensitivity for one condition and lower sensitivity for seven conditions relative to ICD-9-CM data. The two databases had similar sensitivity values for the remaining 24 conditions. CONCLUSIONS: The validity of ICD-9-CM and ICD-10 administrative data in recording clinical conditions was generally similar though validity differed between coding versions for some conditions. The implementation of ICD-10 coding has not significantly improved the quality of administrative data relative to ICD-9-CM. Future assessments like this one are needed because the validity of ICD-10 data may get better as coders gain experience with the new coding system.

Impact of librarians in first-year medical and dental student problem-based learning (PBL) groups: a controlled study.

BACKGROUND: Librarians at the University of Alberta have been involved with teaching undergraduate medical and dental education for several years. After 1 year of increased librarian involvement at the problem-based learning (PBL), small-group level, informal feedback from faculty and students suggested that librarians' participation in PBL groups was beneficial. There was, however, no real evidence to support this claim or justify the high demand on librarians' time. OBJECTIVES: The study aimed to determine whether having a librarian present in the small-group, problem-based learning modules for first-year medical and dental students results in an improved understanding of evidence-based medicine concepts, the nature of medical literature, and information access skills. METHODS: One hundred and sixty-four first-year medical and dental students participated in the study. There were a total of 18 PBL groups, each with approximately nine students and one faculty tutor. Six librarians participated and were assigned randomly to the six intervention groups. Students were given pre- and post-tests at the outset and upon completion of the 6-week course. RESULTS: Post-test scores showed that there was a small positive librarian impact, but final exam scores showed no impact. There was also no difference in attitudes or comfort levels between students who had a librarian in their group and those who did not. CONCLUSIONS: Impact was not sufficient to warrant continued participation of librarians in PBL. In future instruction, librarians at the John W. Scott Health Sciences Library will continue to teach at the larger group level.