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

BMJ 2005; 331 doi: (Published 29 September 2005) Cite this as: BMJ 2005;331:750

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  1. Lara R Fairall, research fellow1,
  2. Merrick Zwarenstein, senior scientist (merrick.zwarenstein{at},
  3. Eric D Bateman, professor1,
  4. Max Bachmann, professor3,
  5. Carl Lombard, director7,
  6. Bosielo P Majara, research fellow4,
  7. Gina Joubert, associate professor5,
  8. Rene G English, research fellow1,
  9. Angeni Bheekie, senior lecturer8,
  10. Dingie van Rensburg, professor6,
  11. Pat Mayers, senior lecturer2,
  12. Annatjie C Peters, technical adviser9,
  13. Ronald D Chapman, executive manager: general health support10
  1. 1Knowledge Translation Unit, University of Cape Town Lung Institute, University of Cape Town, Groote Schuur, South Africa
  2. 2Division of Nursing and Midwifery, School of Health and Rehabilitation Sciences, University of Cape Town
  3. 3 School of Medicine, Health Policy and Practice, University of East Anglia, Norwich
  4. 4 Department of Community Health, University of the Free State, Bloemfontein, South Africa
  5. 5 Department of Biostatistics, University of the Free State
  6. 6 Centre for Health Services Research and Development, University of the Free State
  7. 7 Biostatistics Unit, Medical Research Council, Tygerberg, South Africa
  8. 8 School of Pharmacy, University of the Western Cape, Cape Town, South Africa
  9. 9 TB Alliance DOTS Support Association, Pretoria, South Africa
  10. 10 Free State Department of Health, Bloemfontein, South Africa
  1. Correspondence to: M Zwarenstein, Knowledge Translation Programme, University of Toronto at St Michaels Hospital, 500 University Avenue, Toronto, ON, Canada M5G 1V7


    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.


    • Contributors MZ conceived the project and designed the first protocol. EDB and RGE led development of the guideline. LRF, RGE, AB, ACP, PM, MZ, and RDC contributed to the development and implementation of the intervention. MZ, LRF, MB, and EDB established links with policymakers. LRF, CL, MB, EDB, BPM, MZ, and GJ contributed to the final protocol and design of the questionnaire. DvR, LRF, and BPM oversaw data collection. CL led the analysis with LRF. LRF, CL, MZ, MB, and EDB interpreted the data. LRF, MZ, and BPM prepared the first draft of this paper, and all authors contributed to the final version. MZ and LRF are guarantors.

    • Funding This research was completed with the aid of a research grant from the International Development Research Centre, Canada and the Medical Research Council, South Africa. The research was completed independent of the funders. Additional funding was provided by the Free State Department of Health and the University of Cape Town Lung Institute.

    • Competing interests None declared.

    • Ethical approval The study was approved by the research ethics committee of the Faculty of Health Sciences, University of the Free State. The Free State Department of Health gave permission for the trial.

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