Assessing healthcare quality using routine data: evaluating the performance of the national tuberculosis programme in South Africa

ObjectiveTo assess the performance of healthcare facilities by means of indicators based on guidelines for clinical care of TB, which is likely a good measure of overall facility quality.MethodsWe assessed quality of care in all public health facilities in South Africa using graphical, correlation and locally weighted kernel regression analysis of routine TB test data.ResultsFacility performance falls short of national standards of care. Only 74% of patients with TB provided a second specimen for testing, 18% received follow‐up testing and 14% received drug resistance testing. Only resistance testing rates improved over time, tripling between 2004 and 2011. National awareness campaigns and changes in clinical guidelines had only a transient impact on testing rates. The poorest performing facilities remained at the bottom of the rankings over the period of study.ConclusionThe optimal policy strategy requires both broad‐based policies and targeted resources to poor performers. This approach to assessing facility quality of care can be adapted to other contexts and also provides a low‐cost method for evaluating the effectiveness of proposed interventions. Devising targeted policies based on routine data is a cost‐effective way to improve the quality of public health care provided.ObjectifEvaluer la performance des établissements de santé au moyen d’indicateurs basés sur des directives pour les soins cliniques de la tuberculose (TB), qui sont probablement une bonne mesure de la qualité globale des établissements.MéthodesNous avons évalué la qualité des soins dans tous les établissements de santé publique en Afrique du Sud à l’aide d’une analyse de régression graphique, de corrélation et localement pondérée des données de dépistage de routine de la TB.RésultatsLa performance des établissements ne respecte pas les normes nationales de soins. Seuls 74% des patients TB ont fourni un deuxième échantillon pour les tests, 18% ont reçu des tests de suivi et 14% ont reçu des tests de résistance aux médicaments. Seuls les taux de dépistage de la résistance se sont améliorés au cours du temps, en triplant entre 2004 et 2011. Les campagnes de sensibilisation nationales et les changements apportés aux directives cliniques n’ont eu qu’un impact transitoire sur les taux de dépistage. Les établissements avec la plus mauvaise performance sont restés au bas du classement au cours de la période étudiée.ConclusionLa stratégie politique optimale requiert à la fois des politiques générales et des ressources ciblées pour la mauvaise performance. Cette méthode d’évaluation de la qualité des soins peut être adaptée à d’autres contextes et procure également une méthode peu coûteuse pour évaluer l’efficacité des interventions proposées. L’élaboration de politiques ciblées basées sur des données de routine est un moyen rentable pour améliorer la qualité des soins de santé publique fournis.Mots‐clésqualité des soins, mesure de la qualité, prestation des soins de santé, politique de santé, tuberculose, résistance aux antibiotiques, Afrique du SudObjetivoEvaluar el desempeño de los centros sanitarios por medio de indicadores basados en guías para la atención clínica de la TB, lo cual podría ser una buena medida de la calidad general de las instalaciones.MétodosHemos evaluado la calidad de la atención en centros sanitarios públicos de Sudáfrica mediante análisis gráficos, correlaciones y regresiones ponderadas de Kernel utilizando datos rutinarios de TB.ResultadosEl desempeño de los centros está por debajo de los estándares nacionales de cuidado. Solo un 74% de los pacientes con TB proveyeron un segundo espécimen para pruebas, un 18% recibió pruebas de seguimiento, y un 14% pruebas de resistencia a medicamentos. Solo mejoraron a lo largo del tiempo las tasas de las pruebas de resistencia, triplicándose entre el 2004‐2011. Las campañas de concienciación nacionales y los cambios en las guías clínicas solo tenían un impacto transitorio sobre las tasas de las pruebas. Los centros con los peores resultados continuaron en lo más bajo de la clasificación a lo largo del periodo de estudio.ConclusiónLa estrategia óptima requiere tanto el uso de políticas de base amplia como de recursos dirigidos a quienes tienen un peor desempeño. Esta aproximación para evaluar la calidad de la atención de los centros puede adaptarse a otros contextos, y también provee un método de bajo coste para evaluar la efectividad de las intervenciones propuestas. La elaboración de políticas orientadas, basadas en datos rutinarios, es una forma coste‐efectiva de mejorar la calidad de la atención sanitaria pública.Palabras clavecalidad de la atención, calidad de medidas, entrega de atención sanitaria, política sanitaria, tuberculosis, resistencia a antibióticos, SudáfricaPeer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/135966/1/tmi12819.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/135966/2/tmi12819_am.pd

Does directly observed therapy improve tuberculosis treatment? More evidence is needed to guide tuberculosis policy

Abstract Background Tuberculosis (TB) now ranks alongside HIV as the leading infectious disease cause of death worldwide and incurs a global economic burden of over $12 billion annually. Directly observed therapy (DOT) recommends that TB patients complete the course of treatment under direct observation of a treatment supporter who is trained and overseen by health services to ensure that patients take their drugs as scheduled. Though the current WHO End TB Strategy does not mention DOT, only “supportive treatment supervision by treatment partners”, many TB programs still use it despite the fact that the has not been demonstrated to be statistically significantly superior to self-administered treatment in ensuring treatment success or cure. Discussion DOT is designed to promote proper adherence to the full course of drug therapy in order to improve patient outcomes and prevent the development of drug resistance. Yet over 8 billion dollars is spent on TB treatment each year and thousands undergo DOT for all or part of their course of treatment, despite the absence of rigorous evidence supporting the superior effectiveness of DOT over self-administration for achieving drug susceptible TB (DS-TB) cure. Moreover, the DOT component burdens patients with financial and opportunity costs, and the potential for intensified stigma. To rigorously evaluate the effectiveness of DOT and identify the essential contributors to both successful treatment and minimized patient burden, we call for a pragmatic experimental trial conducted in real-world program settings, the gold standard for evidence-based health policy decisions. It is time to invest in the rigorous evaluation of DOT and reevaluate the DOT requirement for TB treatment worldwide. Summary Rigorously evaluating the choice of treatment supporter, the frequency of health care worker contact and the development of new educational materials in a real-world setting would build the evidence base to inform the optimal design of TB treatment protocol. Implementing a more patient-centered approach may be a wise reallocation of resources to raise TB cure rates, prevent relapse, and minimize the emergence of drug resistance. Maintaining the status quo in the absence of rigorous supportive evidence may diminish the effectiveness of TB control policies in the long run.http://deepblue.lib.umich.edu/bitstream/2027.42/134652/1/12879_2016_Article_1862.pd

First non-destructive internal imaging of Rangea, an icon of complex Ediacaran life

The origins of multicellular life have remained enigmatic due to the paucity of high-quality, three-dimensionally preserved fossils. Rangea was a centimetre- to decimetre-scale frond characterised by a repetitive pattern of self-similar branches and a sessile benthic lifestyle. Fossils are typically preserved as moulds and casts exposing only a leafy petalodium, and the rarity and incompleteness of specimens has made it difficult to reconstruct the three-dimensional (3D) morphology of the entire organism. This, in turn, has led to many differing interpretations of its morphology and phylogenetic affinities. Here we use high resolution X-ray micro-computed tomography (microCT) to investigate the 3D internal morphology of rare, exceptionally preserved ironstone fossils of Rangea from the Nama Group in southern Namibia. Our investigation reveals a series of structures that represent boundaries between individual fronds or structural elements that divide into smaller secondary and tertiary elements, leading to a repetitive pattern of branches. These elements surround an internal core of a distinctly different texture and internal appearance. There is no distortion of the walls of the primary elements, thus we conclude that Rangea likely had a rigid or semi-rigid skeleton-like structure that prevented buckling or compression and maintained integrity during life. We compare these findings with previous interpretations of Rangea morphology and present new insights on the architecture of internal structures, such as the central core, and the overall appearance of this complex Ediacaran life form. Our insights based on microCT scans of these rare, uniquely-preserved specimens provide a more accurate interpretation of the 3D morphology essential for determining the true affinities and modes of life of the Ediacaran biota during this early stage in the evolution of complex macroscopic life

Lessons learned and study results from HIVCore, an HIV implementation science initiative

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/138261/1/jia21261.pd

Association between alcohol and cardiovascular disease: Mendelian randomisation analysis based on individual participant data.

OBJECTIVE: To use the rs1229984 variant in the alcohol dehydrogenase 1B gene (ADH1B) as an instrument to investigate the causal role of alcohol in cardiovascular disease. DESIGN: Mendelian randomisation meta-analysis of 56 epidemiological studies. PARTICIPANTS: 261 991 individuals of European descent, including 20 259 coronary heart disease cases and 10 164 stroke events. Data were available on ADH1B rs1229984 variant, alcohol phenotypes, and cardiovascular biomarkers. MAIN OUTCOME MEASURES: Odds ratio for coronary heart disease and stroke associated with the ADH1B variant in all individuals and by categories of alcohol consumption. RESULTS: Carriers of the A-allele of ADH1B rs1229984 consumed 17.2% fewer units of alcohol per week (95% confidence interval 15.6% to 18.9%), had a lower prevalence of binge drinking (odds ratio 0.78 (95% CI 0.73 to 0.84)), and had higher abstention (odds ratio 1.27 (1.21 to 1.34)) than non-carriers. Rs1229984 A-allele carriers had lower systolic blood pressure (-0.88 (-1.19 to -0.56) mm Hg), interleukin-6 levels (-5.2% (-7.8 to -2.4%)), waist circumference (-0.3 (-0.6 to -0.1) cm), and body mass index (-0.17 (-0.24 to -0.10) kg/m(2)). Rs1229984 A-allele carriers had lower odds of coronary heart disease (odds ratio 0.90 (0.84 to 0.96)). The protective association of the ADH1B rs1229984 A-allele variant remained the same across all categories of alcohol consumption (P=0.83 for heterogeneity). Although no association of rs1229984 was identified with the combined subtypes of stroke, carriers of the A-allele had lower odds of ischaemic stroke (odds ratio 0.83 (0.72 to 0.95)). CONCLUSIONS: Individuals with a genetic variant associated with non-drinking and lower alcohol consumption had a more favourable cardiovascular profile and a reduced risk of coronary heart disease than those without the genetic variant. This suggests that reduction of alcohol consumption, even for light to moderate drinkers, is beneficial for cardiovascular health

Anomalous plantar intrinsic foot muscle attaching to the medial longitudinal arch: possible mechanism for medial nerve entrapment: a case report.

BackgroundMuscular variations are potentially symptomatic and may complicate imaging interpretation. Intrinsic foot musculature and extrinsic tendon insertion variations are common. Distinct supernumerary muscles are rare. We report a novel anomalous intrinsic foot muscle on the medial longitudinal arch.Case presentationAn accessory muscle was encountered on the medial arch of the right foot of a 78-year-old white male cadaver, between layers two and three of the foot intrinsics. It did not appear to be a slip or variant of a known foot muscle. This muscle consisted of two slips that ran transversely on the plantar aspect of the medial arch, crossing the medial transverse tarsal joint and attaching to the tuberosity of the navicular, the short and long plantar ligaments, and spring ligament.ConclusionsThe medial plantar vessels and nerve passed from deep to superficial between the two slips, and this suggests a possible location for medial nerve entrapment

Early Postnatal B Cell Ontogeny and Antibody Repertoire Maturation in the Opossum, <em>Monodelphis domestica</em>

<div><p>Marsupials are a lineage of mammals noted for giving birth to highly altricial young, which complete much of their “fetal” development externally attached to a teat. Postnatal B cell ontogeny and diversity was investigated in a model marsupial species, the gray short-tailed opossum, <em>Monodelphis domestica.</em> The results support the initiation of B cell development late in gestation and progressing into the first two weeks of postnatal life. Transcription of CD79a and CD79b was detected in embryonic tissue prior to birth, while immunoglobulin heavy chain locus transcription was not detected until the first postnatal 24 hours. Transcription of the Ig light chains was not detected until postnatal day 7 at the earliest. The predicted timing of the earliest appearance of mature B cells and completion of gene rearrangements is consistent with previous analyses on the timing of endogenous antibody responses in newborn marsupials. The diversity of early B cell IgH chains is limited, as has been seen in fetal humans and mice, but lacks bias in the gene segments used to encode the variable domains. Newborn light chain diversity is, from the start, comparable to that of the adult, consistent with an earlier hypothesis that light chains contribute extensively to antibody diversity in this species.</p> </div

Representative IgH VDJ junctions, showing only the end of the VH through the start of the JH for P4 through adult animals.

<p>The age of the animals is indicated on the left and individual opossums in each age group are numbered in the first column, followed by the clone number in the second column. Nucleotides identified as P, N or DH, as determined using the SoDA website are indicated at the top. The specific V, D, and J germ-line gene segments used in each clone are indicated in the third column. Putative micro-homology at the VD and DJ junctions is underlined.</p