title: Tuberculosis screening in patients with HIV: use of audit and feedback to improve quality of care in Ghana.
abstract: BACKGROUND
  Tuberculosis screening of people living with HIV (PLHIV) can contribute to early tuberculosis diagnosis and improved patient outcomes. Evidence-based guidelines for tuberculosis screening are available, but literature assessing their implementation and the quality of clinical practice is scarce.
  
  
  OBJECTIVE
  To assess tuberculosis screening practices and the effectiveness of audit and performance feedback to improve quality of tuberculosis screening at HIV care clinics in Ghana.
  
  
  METHODS
  Healthcare providers at 10 large HIV care clinics prospectively registered patient consultations during May and October 2014, before and after a performance feedback intervention in August 2014. The outcomes of interest were overall tuberculosis suspicion rate during consultations and provider adherence to the International Standards for Tuberculosis Care and the World Health Organizations' guidelines for symptom-based tuberculosis screening among PLHIV.
  
  
  RESULTS
  Twenty-one healthcare providers registered a total of 2,666 consultations; 1,368 consultations before and 1,298 consultations after the feedback intervention. Tuberculosis suspicion rate during consultation increased from 12.6 to 20.9% after feedback (odds ratio, OR 1.83; 95% confidence interval, CI: 1.09-3.09). Before feedback, sputum smear microscopy was requested for 58.7% of patients with suspected tuberculosis, for 47.2% of patients with cough ≥2 weeks, and for 27.5% of patients with a positive World Health Organization (WHO) symptom screen (any of current cough, fever, weight loss or night sweats). After feedback, patients with a positive WHO symptom screen were more likely to be suspected of tuberculosis (OR 2.21; 95% CI: 1.19-4.09) and referred for microscopy (OR 2.71; 95% CI: 1.25-5.86).
  
  
  CONCLUSIONS
  A simple prospective audit tool identified flaws in clinical practices for tuberculosis screening of PLHIV. There was no systematic identification of people with suspected active tuberculosis. We found low initial tuberculosis suspicion rate compounded by low referral rates of relevant patients for sputum smear microscopy. Adherence to recommended standards and guidelines for tuberculosis screening improved after performance feedback.
authors: Department of Infectious Diseases, Odense University Hospital, Odense, Denmark.|Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark; steph@medicinsk.dk.
authors: Stephanie
authors: S
authors: Bjerrum
authors: National Tuberculosis Control Programme, Disease Control and Prevention Department, Ghana Health Services, Korle-Bu Teaching Hospital, Accra, Ghana.
authors: Frank
authors: F
authors: Bonsu
authors: National Tuberculosis Control Programme, Disease Control and Prevention Department, Ghana Health Services, Korle-Bu Teaching Hospital, Accra, Ghana.
authors: Nii Nortey
authors: NN
authors: Hanson-Nortey
authors: Department of Medicine-Fevers Unit, Korle-Bu Teaching Hospital, Accra, Ghana.|School of Public Health, University of Ghana, Legon, Accra, Ghana.
authors: Ernest
authors: E
authors: Kenu
authors: Department of Infectious Diseases, Odense University Hospital, Odense, Denmark.
authors: Isik Somuncu
authors: IS
authors: Johansen
authors: Institute of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.|Department of Infectious Diseases, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
authors: Aase Bengaard
authors: AB
authors: Andersen
authors: Department of Public Health, University of Copenhagen, Copenhagen, Denmark.
authors: Lars
authors: L
authors: Bjerrum
authors: Department of Public Health, University of Southern Denmark, Odense, Denmark.
authors: Dorte
authors: D
authors: Jarbøl
authors: Department of Public Health, University of Southern Denmark, Odense, Denmark.
authors: Anders
authors: A
authors: Munck
keywords: HIV; audit; clinical practice; feedback; quality of healthcare; screening; tuberculosis