Effect of Integrated Capacity-Building Interventions on Malaria Case Management by Health Professionals in Uganda: A Mixed Design Study with Pre/Post and Cluster Randomized Trial Components

BackgroundThe Integrated Infectious Diseases Capacity Building Evaluation (IDCAP) designed two interventions: Integrated Management of Infectious Disease (IMID) training program and On-Site Support (OSS). We evaluated their effects on 23 facility performance indicators, including malaria case management.MethodologyIMID, a three-week training with two follow-up booster courses, was for two mid- level practitioners, primarily clinical officers and registered nurses, from 36 primary care facilities. OSS was two days of training and continuous quality improvement activities for nine months at 18 facilities, to which all health workers were invited to participate. Facilities were randomized as clusters 1∶1 to parallel OSS “arm A” or control “arm B”. Outpatient data on four malaria case management indicators were collected for 14 months. Analysis compared changes before and during the interventions within arms (relative risk = RR). The effect of OSS was measured with the difference in changes across arms (ratio of RR = RRR).FindingsThe proportion of patients with suspected malaria for whom a diagnostic test result for malaria was recorded decreased in arm B (adjusted RR (aRR) = 0.97; 99%CI: 0.82,1.14) during IMID, but increased 25% in arm A (aRR = 1.25; 99%CI:0.94, 1.65) during IMID and OSS relative to baseline; (aRRR = 1.28; 99%CI:0.93, 1.78). The estimated proportion of patients that received an appropriate antimalarial among those prescribed any antimalarial increased in arm B (aRR = 1.09; 99%CI: 0.87, 1.36) and arm A (aRR = 1.50; 99%CI: 1.04, 2.17); (aRRR = 1.38; 99%CI: 0.89, 2.13). The proportion of patients with a negative diagnostic test result for malaria prescribed an antimalarial decreased in arm B (aRR = 0.96; 99%CI: 0.84, 1.10) and arm A (aRR = 0.67; 99%CI: 0.46, 0.97); (aRRR = 0.70; 99%CI: 0.48, 1.00). The proportion of patients with a positive diagnostic test result for malaria prescribed an antibiotic did not change significantly in either arm.InterpretationThe combination of IMID and OSS was associated with statistically significant improvements in malaria case management.背景：综合传染病能力建设评估（Integrated Infectious Diseases Capacity Building Evaluation, IDCAP）设计了两项干预措施：综合传染病管理（Integrated Management of Infectious Disease, IMID）培训项目与现场支持（On-Site Support, OSS）。本研究针对23项医疗卫生机构绩效指标（含疟疾病例管理），评估了这两项干预措施的实施效果。 研究方法：IMID为为期三周的培训课程，配套两次跟进强化环节，面向36家基层医疗卫生机构的2名中级医疗卫生从业者（主要为临床医师与注册护士）。OSS则面向18家基层医疗卫生机构的全体医护人员，包含为期两天的专项培训与持续九个月的持续质量改进活动。本次研究以整群1:1随机的方式，将所有医疗机构分配至平行的OSS干预组（A组）与常规对照组（B组）。研究收集了14个月内的四项疟疾病例管理指标门诊诊疗数据。分析采用组内干预前与干预期间的变化对比，以相对风险（Relative Risk, RR）作为评价指标；OSS的干预效果则通过两组间变化幅度的差值进行评估，以相对风险比（Relative Risk Ratio, RRR）作为评价指标。 研究结果：在IMID干预阶段，B组中完成疟疾诊断检测并记录结果的疑似疟疾患者占比有所下降（校正相对风险（adjusted Relative Risk, aRR）=0.97；99%置信区间CI:0.82,1.14）；而A组在IMID联合OSS干预阶段，该占比较基线水平上升25%（aRR=1.25；99%CI:0.94,1.65），组间校正相对风险比aRRR=1.28；99%CI:0.93,1.78。在开具过任意抗疟药物的患者中，接受规范抗疟治疗的患者占比在B组（aRR=1.09；99%CI:0.87,1.36）与A组（aRR=1.50；99%CI:1.04,2.17）中均有所上升，组间aRRR=1.38；99%CI:0.89,2.13。疟疾检测结果为阴性但被开具抗疟药物的患者占比在B组（aRR=0.96；99%CI:0.84,1.10）与A组（aRR=0.67；99%CI:0.46,0.97）中均有所下降，组间aRRR=0.70；99%CI:0.48,1.00。而疟疾检测结果为阳性的患者中被开具抗生素的占比在两组中均无显著统计学变化。 研究结论：IMID与OSS联合干预可显著提升疟疾病例管理质量，该结果具有统计学意义。