Implementing Innovative Approaches to Improve Health Care Delivery Systems for Integrating Communicable and Non-Communicable Diseases Using Tuberculosis and Diabetes as a Model in Tanzania.
Implementing Innovative Approaches to Improve Health Care Delivery Systems for Integrating Communicable and Non-Communicable Diseases Using Tuberculosis and Diabetes as a Model in Tanzania.
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实施创新方法，以坦桑尼亚的结核病和糖尿病为模式，改善卫生保健提供系统，将传染性和非传染性疾病结合起来。
DOI：
10.3390/ijerph20176670
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发表时间：
2023-08-29
影响因子：
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通讯作者：
Ramaiya KL
中科院分区：
文献类型：
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作者：
Mpagama SG;Byashalira KC;Chamba NG;Heysell SK;Alimohamed MZ;Shayo PJ;Kalolo A;Chongolo AM;Gitige CG;Mmbaga BT;Ntinginya NE;Alffenaar JC;Bygbjerg IC;Lillebaek T;Christensen DL;Ramaiya KL
背景：许多基于证据的卫生干预措施，特别是在低收入环境中，未能产生预期的影响。我们设计了一个适应性疾病控制专家计划在坦桑尼亚（ADEPT），以解决医疗服务的系统性挑战，并检查了可行性，可接受性和有效性的模式使用结核病（TB）和糖尿病（DM）作为原型。方法：这是在达累斯萨拉姆、伊林加和基利曼哈罗地区实施的有效性-实施混合3型设计。该战略包括一个逐步的培训方法，基于网络的平台适应吉布斯的反思周期。提供结核病服务的卫生设施补充了糖尿病诊断，包括糖化血红蛋白A1 c（HbA 1c）。临床稽查作为一项忠诚度措施。采用回顾性和横断面设计评价模型的逼真度、可接受性和可行性。结果如下：从2019年到2021年，临床审计显示，ADEPT干预卫生设施更经常识别出中位8（IQR 6-19）个患有结核病和糖尿病的双重患者，而对照卫生设施的中位数为1（IQR 0-3）（p = 0.02）。同样，在TB/DM个体中，HbA 1c在干预部位的临床效用为63%（IQR：35-75%），而在所有水平的对照部位中均无，而双重TB和DM患者临床管理标准的其他组成部分无显著差异。卫生机构在筛查其他合并症（如高血压和营养不良）方面没有差异。共有46名护士和医生/专家参加了分阶段培训，其中40人（87%）参加了讲习班。31人（67%），即18名护士和13名医生/专家，执行了培训其他人的第二步，总共培训了519名前线保健工作者：371名护士和148名临床医生。总体而言，ADEPT模型被评为可行的指标适用于一线医疗保健提供者和卫生设施。结论：采用逐步培训和临床审核的方法支持结核病和糖尿病管理的整合是可行的，在坦桑尼亚不同地区基本上是可以接受和有效的。如果在坦桑尼亚卫生系统中加以调整，该模式将有可能提高服务质量。
Background: Many evidence-based health interventions, particularly in low-income settings, have failed to deliver the expected impact. We designed an Adaptive Diseases Control Expert Programme in Tanzania (ADEPT) to address systemic challenges in health care delivery and examined the feasibility, acceptability and effectiveness of the model using tuberculosis (TB) and diabetes mellitus (DM) as a prototype. Methods: This was an effectiveness-implementation hybrid type-3 design that was implemented in Dar es Salaam, Iringa and Kilimanjaro regions. The strategy included a stepwise training approach with web-based platforms adapting the Gibbs’ reflective cycle. Health facilities with TB services were supplemented with DM diagnostics, including glycated haemoglobin A1c (HbA1c). The clinical audit was deployed as a measure of fidelity. Retrospective and cross-sectional designs were used to assess the fidelity, acceptability and feasibility of the model. Results: From 2019–2021, the clinical audit showed that ADEPT intervention health facilities more often identified median 8 (IQR 6–19) individuals with dual TB and DM, compared with control health facilities, median of 1 (IQR 0–3) (p = 0.02). Likewise, the clinical utility of HbA1c on intervention sites was 63% (IQR:35–75%) in TB/DM individuals compared to none in the control sites at all levels, whereas other components of the standard of clinical management of patients with dual TB and DM did not significantly differ. The health facilities showed no difference in screening for additional comorbidities such as hypertension and malnutrition. The stepwise training enrolled a total of 46 nurse officers and medical doctors/specialists for web-based training and 40 (87%) attended the workshop. Thirty-one (67%), 18 nurse officers and 13 medical doctors/specialists, implemented the second step of training others and yielded a total of 519 additional front-line health care workers trained: 371 nurses and 148 clinicians. Overall, the ADEPT model was scored as feasible by metrics applied to both front-line health care providers and health facilities. Conclusions: It was feasible to use a stepwise training and clinical audit to support the integration of TB and DM management and it was largely acceptable and effective in differing regions within Tanzania. When adapted in the Tanzania health system context, the model will likely improve quality of services.