title: Could clinical audit improve the diagnosis of pulmonary tuberculosis in Cuba, Peru and Bolivia?
abstract: OBJECTIVE
  To assess the effectiveness of clinical audit in improving the quality of diagnostic care provided to patients suspected of tuberculosis; and to understand the contextual factors which impede or facilitate its success.
  
  
  METHODS
  Twenty-six health centres in Cuba, Peru and Bolivia were recruited. Clinical audit was introduced to improve the diagnostic care for patients attending with suspected TB. Standards were based on the WHO and TB programme guidelines relating to the appropriate use of microscopy, culture and radiological investigations. At least two audit cycles were completed over 2 years. Improvement was determined by comparing the performance between two six-month periods pre- and post-intervention. Qualitative methods were used to ascertain facilitating and limiting contextual factors influencing change among healthcare professionals' clinical behaviour after the introduction of clinical audit.
  
  
  RESULTS
  We found a significant improvement in 11 of 13 criteria in Cuba, in 2 of 6 criteria in Bolivia and in 2 of 5 criteria in Peru. Twelve out of 24 of the audit criteria in all three countries reached the agreed standards. Barriers to quality improvement included conflicting objectives for clinicians and TB programmes, poor coordination within the health system and patients' attitudes towards illness.
  
  
  CONCLUSIONS
  Clinical audit may drive improvements in the quality of clinical care in resource-poor settings. It is likely to be more effective if integrated within and supported by the local TB programmes. We recommend developing and evaluating an integrated model of quality improvement including clinical audit.
authors.affiliation: Nuffield Centre for International Health and Development, Institute of Health Sciences and Public Health Research, Faculty of Medicine and Health, University of Leeds, Leeds, UK.
authors.forename: Kamran
authors.initials: K
authors.lastname: Siddiqi
authors.forename: Anna
authors.initials: A
authors.lastname: Volz
authors.forename: L
authors.initials: L
authors.lastname: Armas
authors.forename: L
authors.initials: L
authors.lastname: Otero
authors.forename: R
authors.initials: R
authors.lastname: Ugaz
authors.forename: E
authors.initials: E
authors.lastname: Ochoa
authors.forename: E
authors.initials: E
authors.lastname: Gotuzzo
authors.forename: F
authors.initials: F
authors.lastname: Torrico
authors.forename: James N
authors.initials: JN
authors.lastname: Newell
authors.forename: J
authors.initials: J
authors.lastname: Walley
authors.forename: Mike
authors.initials: M
authors.lastname: Robinson
authors.forename: G
authors.initials: G
authors.lastname: Dieltiens
authors.forename: P
authors.initials: P
authors.lastname: Van der Stuyft
mesh_terms: D001291:Attitude of Health Personnel; D001294:Attitude to Health; D001838:Bolivia; D054869:Clinical Audit; D003462:Cuba; D003954:Diagnostic Services / Q000458:organization & administration*; D006801:Humans; D010568:Peru; D017064:Process Assessment, Health Care / Q000592:standards*; D012423:Rural Health; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis*; D014504:Urban Health