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Free Content Cost-effectiveness of educational outreach to primary care nurses to increase tuberculosis case detection and improve respiratory care: economic evaluation alongside a randomised trial

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Abstract:

Summary Objective  To evaluate the cost-effectiveness of an educational outreach intervention to improve primary respiratory care by South African nurses. Methods  Cost-effectiveness analysis alongside a pragmatic cluster randomised controlled trial, with individual patient data. The intervention, the Practical Approach to Lung Health in South Africa (PALSA), comprised educational outreach based on syndromic clinical practice guidelines for tuberculosis, asthma, chronic obstructive pulmonary disease, pneumonia and other respiratory diseases. The study included 1999 patients aged 15 or over with cough or difficult breathing, attending 40 primary care clinics staffed by nurses in the Free State province. They were interviewed at first presentation, and 1856 (93%) were interviewed 3 months later. Results  The intervention increased the tuberculosis case detection rate by 2.2% and increased the proportion of patients appropriately managed (that is, diagnosed with tuberculosis or prescribed an inhaled corticosteroid for asthma or referred with indicators of severe disease) by 10%. It costs the health service $68 more for each extra patient diagnosed with tuberculosis and $15 more for every extra patient appropriately managed. Analyses were most sensitive to assumptions about how long training was effective for and to inclusion of household and tuberculosis treatment costs. Conclusion  This educational outreach method was more effective and more costly than usual training in improving tuberculosis, asthma and urgent respiratory care. The extra cost of increasing tuberculosis case detection was comparable to current costs of passive case detection. The syndromic approach increased cost-effectiveness by also improving care of other conditions. This educational intervention was sustainable, reaching thousands of health workers and hundreds of clinics since the trial.

French
Objectif: 

Evaluer le rapport coût-efficacité d’une intervention d’assistance éducative visant à améliorer les soins primaires respiratoires par les infirmier(e)s sud-africaines. Méthodes: 

Analyse coût-efficacité au cours d’un essai pragmatique randomisé contrôlé en grappe, avec des données individuelles de patients. L’intervention - ‘Approche Pratique de la Santé Pulmonaire en Afrique du Sud (PALSA)’- comprenait l’assistance éducative basée sur les directives de pratique clinique syndromique pour la tuberculose, l’asthme, la broncho-pneumopathie chronique obstructive, la pneumonie et autres maladies respiratoires. L’étude a inclus 1999 patients âgés de 15 ans ou plus avec une toux ou une difficulté respiratoire, visitant 40 cliniques de soins primaires dotées d’infirmier(e)s dans la Province du Free State. Ils ont été interviewés lors de la première présentation et 1856 (93%) d’entre eux ont été interviewés trois mois plus tard. Résultats: 

L’intervention a augmenté de 2,2% le taux de détection des cas de tuberculose et de 10% la proportion de patients pris en charge de façon appropriée (i.e. diagnostic de la tuberculose, prescription d’un corticostéroïde inhalé pour l’asthme ou référé avec des indicateurs de maladie grave). Cela a coûté au service de santé 68 $ de plus pour chaque patient supplémentaire diagnostiqué avec la tuberculose, et 15 $ de plus pour chaque patient supplémentaire convenablement pris en charge. Les analyses ont été plus sensibles pour les hypothèses sur la durée au cours de laquelle la formation était efficace et sur l’inclusion des coûts des ménages et du traitement de la tuberculose. Conclusion: 

Cette méthode d’assistance éducative a été plus efficace et plus coûteuse que la formation habituelle sur l’amélioration des soins pour la tuberculose, l’asthme et les affections respiratoires urgentes. Le coût supplémentaire pour l’augmentation de la détection des cas de tuberculose était comparable aux coûts actuels de détection passive de cas. L’approche syndromique a augmenté la rentabilité en améliorant également les soins pour les autres conditions. Cette intervention éducative était durable, atteignant des milliers d’agents de la santé et des centaines de cliniques depuis l’étude.

Keywords: Tuberculosis; education; essai randomisé; health economics; lung disease; maladies pulmonaires; primary care; randomised trial; soins primaires; tuberculose; tuberculosis; économie de la santé; éducation

Document Type: Research Article

DOI: http://dx.doi.org/10.1111/j.1365-3156.2009.02455.x

Affiliations: 1:  Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa 2:  School of Medicine, Health Policy and Practice, University of East Anglia, Norwich, UK 3:  Centre for Health Services Sciences, Sunnybrook Research Institute, Toronto, Canada 4:  Department of Medicine, University of Cape Town, Cape Town, South Africa 5:  Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA 6:  Biostatistics Unit, Medical Research Council, Cape Town, South Africa 7:  Department of Community Health, University of the Free State, Bloemfontein, South Africa 8:  School of Pharmacy, University of the Western Cape, Cape Town, South Africa 9:  Centre for Health Systems Research and Development, University of the Free State, Bloemfontein, South Africa 10:  Division of Nursing and Midwifery, School of Health and Rehabilitation Sciences, University of Cape Town, Cape Town, South Africa 11:  Free State Department of Health, Bloemfontein, South Africa

Publication date: March 1, 2010

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