title: Evaluating tuberculosis case detection via real-time monitoring of tuberculosis diagnostic services.
abstract: BACKGROUND
  Tuberculosis case-detection rates are below internationally established targets in high-burden countries. Real-time monitoring and evaluation of adherence to widely endorsed standards of tuberculosis care might facilitate improved case finding.
  
  
  OBJECTIVE
  To monitor and evaluate the quality of tuberculosis case-detection and management services in a low-income country with a high incidence of tuberculosis.
  
  
  METHODS
  We prospectively evaluated tuberculosis diagnostic services at five primary health-care facilities in Uganda for 1 year, after introducing a real-time, electronic performance-monitoring system. We collected data on every clinical encounter, and measured quality using indicators derived from the International Standards of Tuberculosis Care.
  
  
  RESULTS
  In 2009, there were 62,909 adult primary-care visits. During the first quarter of 2009, clinicians referred only 21% of patients with cough greater than or equal to 2 weeks for sputum smear microscopy and only 71% of patients with a positive sputum examination for tuberculosis treatment. These proportions increased to 53% and 84%, respectively, in the fourth quarter of 2009. The cumulative probability that a smear-positive patient with cough greater than or equal to 2 weeks would be appropriately evaluated and referred for treatment rose from 11% to 34% (P = 0.005). The quarterly number of tuberculosis cases identified and prescribed treatment also increased four-fold, from 5 to 21.
  
  
  CONCLUSIONS
  Poor adherence to internationally accepted standards of tuberculosis care improved after introduction of real-time performance monitoring and was associated with increased tuberculosis case detection. Real-time monitoring and evaluation can strengthen health systems in low-income countries and facilitate operational research on the effectiveness and sustainability of interventions to improve tuberculosis case detection.
authors.affiliation: Divisions of Pulmonary and Critical Care Medicine, Department of Medicine, San Francisco General Hospital, California. lucian.davis@ucsf.edu
authors.forename: Jlucian
authors.initials: J
authors.lastname: Davis
authors.forename: Achilles
authors.initials: A
authors.lastname: Katamba
authors.forename: Josh
authors.initials: J
authors.lastname: Vasquez
authors.forename: Erin
authors.initials: E
authors.lastname: Crawford
authors.forename: Asadu
authors.initials: A
authors.lastname: Sserwanga
authors.forename: Stella
authors.initials: S
authors.lastname: Kakeeto
authors.forename: Fred
authors.initials: F
authors.lastname: Kizito
authors.forename: Grant
authors.initials: G
authors.lastname: Dorsey
authors.forename: Saskia
authors.initials: S
authors.lastname: den Boon
authors.forename: Eric
authors.initials: E
authors.lastname: Vittinghoff
authors.forename: Laurence
authors.initials: L
authors.lastname: Huang
authors.forename: Francis
authors.initials: F
authors.lastname: Adatu
authors.forename: Moses R
authors.initials: MR
authors.lastname: Kamya
authors.forename: Philip C
authors.initials: PC
authors.lastname: Hopewell
authors.forename: Adithya
authors.initials: A
authors.lastname: Cattamanchi
mesh_terms: D000328:Adult; D003954:Diagnostic Services / Q000592:standards / Q000706:statistics & numerical data*; D014943:Global Health; D019983:Guideline Adherence / Q000706:statistics & numerical data; D006801:Humans; D015994:Incidence; D011159:Population Surveillance / Q000379:methods; D017410:Practice Guidelines as Topic; D011320:Primary Health Care / Q000379:methods / Q000592:standards / Q000706:statistics & numerical data*; D011446:Prospective Studies; D013183:Sputum / Q000382:microbiology; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis* / Q000453:epidemiology; D014454:Uganda / Q000453:epidemiology