BMJ  2005;331:750-754 (1 October), doi:10.1136/bmj.331.7519.750

Primary care

Effect of educational outreach to nurses on tuberculosis case detection and primary care of respiratory illness: pragmatic cluster randomised controlled trial

¹ Knowledge Translation Unit, University of Cape Town Lung Institute, University of Cape Town, Groote Schuur, South Africa, ² Division of Nursing and Midwifery, School of Health and Rehabilitation Sciences, University of Cape Town, ³ School of Medicine, Health Policy and Practice, University of East Anglia, Norwich, ⁴ Department of Community Health, University of the Free State, Bloemfontein, South Africa, ⁵ Department of Biostatistics, University of the Free State, ⁶ Centre for Health Services Research and Development, University of the Free State, ⁷ Biostatistics Unit, Medical Research Council, Tygerberg, South Africa, ⁸ School of Pharmacy, University of the Western Cape, Cape Town, South Africa, ⁹ TB Alliance DOTS Support Association, Pretoria, South Africa, ¹⁰ Free State Department of Health, Bloemfontein, South Africa

Objectives To develop and implement an educational outreach programme for the integrated case management of priority respiratory diseases (practical approach to lung health in South Africa; PALSA) and to evaluate its effects on respiratory care and detection of tuberculosis among adults attending primary care clinics.

Design Pragmatic cluster randomised controlled trial, with clinics as the unit of randomisation.

Setting 40 primary care clinics, staffed by nurse practitioners, in the Free State province, South Africa.

Participants 1999 patients aged 15 or over with cough or difficult breathing (1000 in intervention clinics, 999 in control clinics).

Intervention Between two and six educational outreach sessions delivered to nurse practitioners by usual trainers from the health department. The emphasis was on key messages drawn from the customised clinical practice guideline for the outreach programme, with illustrative support materials.

Main outcome measures Sputum screening for tuberculosis, tuberculosis case detection, inhaled corticosteroid prescriptions for obstructive lung disease, and antibiotic prescriptions for respiratory tract infections.

Results All clinics and almost all patients (92.8%, 1856/1999) completed the trial. Although sputum testing for tuberculosis was similar between the groups (22.6% in outreach group v 19.3% in control group; odds ratio 1.22, 95% confidence interval 0.83 to 1.80), the case detection of tuberculosis was higher in the outreach group (6.4% v 3.8%; 1.72, 1.04 to 2.85). Prescriptions for inhaled corticosteroids were also higher (13.7% v 7.7%; 1.90, 1.14 to 3.18) but the number of antibiotic prescriptions was similar (39.7% v 39.4%; 1.01, 0.74 to 1.38).

Conclusions Combining educational outreach with integrated case management provides a promising model for improving quality of care and control of priority respiratory diseases, without extra staff, in resource poor settings.

Trial registration Current controlled trials ISRCTN13438073.

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