Summary Objective  To compare the yield of active tuberculosis (TB) case detection among risk groups during home visits with passive detection among patients at health services. Methods  In April 2004, in a first phase, we introduced, active screening for coughing among all family members of patients that were visited at home by their family doctor or nurse for other reasons. Subsequently, from October 2004 onwards, active screening was restricted to family members belonging to groups at risk of TB. Results  The overall detection rate of TB increased from 6.7/100 000 during passive detection at health services before the intervention to 26.2/100 000 inhabitants when passive detection was complemented by active case finding. Active screening among risk groups yielded 35 TB cases per 1000 persons screened compared to 20 TB cases per 1000 persons passively screened at health services. Active case finding was particularly efficient in those coughing for 3 weeks or more (107/1000 screened). Conclusion  This study demonstrates that active case finding in groups at risk during home visits increases the case detection rate in the population and permits the identification of cases that may not be detected through passive case finding at health facility level.

Summaryobjectives 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.

No abstract

No abstract

No abstract