title: Improving facility performance in infectious disease care in Uganda: a mixed design study with pre/post and cluster randomized trial components.
abstract: BACKGROUND
  The effects of two interventions, Integrated Management of Infectious Disease (IMID) training program and On-Site Support (OSS), were tested on 23 facility performance indicators for emergency triage assessment and treatment (ETAT), malaria, pneumonia, tuberculosis, and HIV.
  
  
  METHODS
  The trial was implemented in 36 primary care facilities in Uganda. From April 2010, two mid-level practitioners per facility participated in IMID training. Eighteen of 36 facilities were randomly assigned to Arm A, and received OSS in 2010 (nine monthly two-day sessions); 18 facilities assigned to Arm B did not receive OSS in 2010. Data were collected from Nov 2009 to Dec 2010 using a revised Ministry of Health outpatient medical form and nine registers. We analyzed the effect of IMID training alone by measuring changes before and during IMID training in Arm B, the combined effect of IMID training and OSS by measuring changes in Arm A, and the incremental effect of OSS by comparing changes across Arms A and B.
  
  
  RESULTS
  IMID training was associated with statistically significant improvement in three indicators: outpatients triaged (adjusted relative risks (aRR) = 1.29, 99%CI = 1.01,1.64), emergency and priority patients admitted, detained, or referred (aRR = 1.59, 99%CI = 1.04,2.44), and pneumonia suspects assessed (aRR = 2.31, 99%CI = 1.50,3.55). IMID training and OSS combined was associated with improvements in six indicators: three ETAT indicators (outpatients triaged (aRR = 2.03, 99%CI = 1.13,3.64), emergency and priority patients admitted, detained or referred (aRR = 3.03, 99%CI = 1.40,6.56), and emergency patients receiving at least one appropriate treatment (aRR = 1.77, 99%CI = 1.10,2.84)); two malaria indicators (malaria cases receiving appropriate antimalarial (aRR = 1.50, 99%CI = 1.04,2.17), and patients with negative malaria test results prescribed antimalarial (aRR = 0.67, 99%CI = 0.46,0.97)); and enrollment in HIV care (aRR = 1.58, 99%CI = 1.32,1.89). OSS was associated with incremental improvement in emergency patients receiving at least one appropriate treatment (adjusted ratio of RR = 1.84,99%CI = 1.09,3.12).
  
  
  CONCLUSIONS
  The trial showed that the OSS intervention significantly improved performance in one of 23 facility indicators.
authors.affiliation: Departments of Global Health and Health Services, University of Washington, Seattle Washington, United States of America.
authors.forename: Marcia R
authors.initials: MR
authors.lastname: Weaver
authors.affiliation: Accordia Global Health Foundation, Washington, District of Columbia, United States of America, and Department of Epidemiology and Social Medicine, University of Antwerp, Antwerp, Belgium.
authors.forename: Sarah M
authors.initials: SM
authors.lastname: Burnett
authors.affiliation: Accordia Global Health Foundation, Washington, District of Columbia, United States of America.
authors.forename: Ian
authors.initials: I
authors.lastname: Crozier
authors.affiliation: Center for Human Services, University Research Co. LLC, Bethesda, Maryland, United States of America, and Fio Corporation, Toronto, Ontario, Canada.
authors.forename: Stephen N
authors.initials: SN
authors.lastname: Kinoti
authors.affiliation: Elizabeth Glaser Pediatric AIDS Foundation, Mbarara, Uganda.
authors.forename: Ibrahim
authors.initials: I
authors.lastname: Kirunda
authors.affiliation: Infectious Diseases Institute, Makerere University, Kampala, Uganda and Department of Epidemiology and Social Medicine, University of Antwerp, Antwerp, Belgium.
authors.forename: Martin K
authors.initials: MK
authors.lastname: Mbonye
authors.affiliation: Infectious Diseases Institute, Makerere University, Kampala, Uganda and Department of Epidemiology and Social Medicine, University of Antwerp, Antwerp, Belgium.
authors.forename: Sarah
authors.initials: S
authors.lastname: Naikoba
authors.affiliation: Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
authors.forename: Allan
authors.initials: A
authors.lastname: Ronald
authors.affiliation: Infectious Diseases Institute, Makerere University, Kampala, Uganda and Institute of Development Policy and Management, University of Manchester, Manchester, England.
authors.forename: Timothy
authors.initials: T
authors.lastname: Rubashembusya
authors.affiliation: Infectious Diseases Institute, Makerere University, Kampala, Uganda.
authors.forename: Stella
authors.initials: S
authors.lastname: Zawedde
authors.affiliation: Accordia Global Health Foundation, Washington, District of Columbia, United States of America.
authors.forename: Kelly S
authors.initials: KS
authors.lastname: Willis
mesh_terms: D016000:Cluster Analysis; D015658:HIV Infections / Q000628:therapy*; D006268:Health Facilities / Q000592:standards*; D006801:Humans; D055552:Infectious Disease Medicine / Q000458:organization & administration / Q000592:standards*; D008288:Malaria / Q000628:therapy*; D058996:Quality Improvement; D019984:Quality Indicators, Health Care; D014376:Tuberculosis / Q000628:therapy*; D014454:Uganda