Dermatology-Driven Quality Improvement Interventions to Decrease Diagnostic Delays for Kaposi Sarcoma in Botswana

Abstract

PURPOSEKaposi sarcoma (KS) is an HIV-associated skin cancer that is highly prevalent in Botswana and associated with significant morbidity and mortality. Histopathology-confirmed diagnosis is required for chemotherapeutic interventions in Botswana, which creates barriers to care because of limited biopsy and pathology services. We sought to understand the role a dermatology specialist can play in improving KS care through quality improvement (QI) initiatives to reduce histologic turnaround times (TATs) for KS.METHODSEmployment of a dermatology specialist within a public health care system that previously lacked a local dermatologist generated quality improvements in KS care. Retrospective review identified patients diagnosed with KS by skin biopsy in the predermatology QI interval (January 1, 2015, to December 31, 2015) versus the postdermatology QI interval (January 1, 2016, to November 31, 2017). Histology TATs and clinical characteristics were recorded. A t test compared the median histology TATs in the pre- and post-QI intervals.RESULTSA total of 192 cases of KS were diagnosed by skin biopsy. Nearly all (98.4%) were HIV-positive; and 52.8% of patients were male with a median age of 39 years. Median TAT in the postdermatology QI interval was 11 days (interquartile range, 12-23 days) compared with 32 days in the predermatology QI interval (interquartile range, 24-56 days; P < .00).CONCLUSIONDermatology-led QI initiatives to improve multispecialty care coordination can significantly decrease histology TATs for KS. The reduction of diagnostic delays is a key first step to decreasing the morbidity and mortality associated with this cancer in resource-limited settings.

Evaluating Feasibility and Acceptance of a Mobile Clinical Decision Support System in Botswana

“…At the beginning of the study, the modal response for frequency of referrals was 1-3 times per week (51.9%), while at the end of the study after using VisualDx the modal response to the same question was less than 1 time per week (42.1%). This is of particular signi cance in Botswana, where the healthcare system is experiencing a shortage of medical specialists and especially dermatologists [8,9].…”

“…A low doctor to patient ratio (3.8/10,000) as well as a shortage of medical specialists is also reported [7]. Access to dermatological services continues to be one of the major challenges across the public and private sectors in Botswana, with most available services clustered in the capital city of Gaborone [8,9]. The number of dermatology specialist providers in Botswana's public healthcare system has varied from none to most recently 2 full time Ministry of Health and Wellness (MOHW) employees and three contract specialists from Cuba.…”

“…The number of dermatology specialist providers in Botswana's public healthcare system has varied from none to most recently 2 full time Ministry of Health and Wellness (MOHW) employees and three contract specialists from Cuba. However, the demand for dermatology care in Botswana continues to be much higher than can be provided by the current dermatology specialists and waiting times for appointments can be six or more months [9]. Consequently, the MOHW has provided care to patients with skin diseases through a combination of providers who lack su cient training and reference materials at the point of care to help with the diagnosis and management of skin conditions seen in this environment.…”

Interventions to improve early cancer diagnosis of symptomatic individuals: a scoping review

“…10 17 24 52 53 64 75 77 78 80 83 94 These articles were focused on varied cancer types; four on multiple cancers, two on lung cancer, two on skin cancer and one each on breast, gastrointestinal, haematological and prostate cancers. Four articles were from the UK, 17 52 53 78 two articles each from Canada 24 64 and Sweden, 10 80 and one article each from Botswana, 94 Columbia, 75 Indonesia 77 and the USA. 83 The focus and metrics for assessment of the effectiveness of the interventions varied across the publications, and while most were effective, one intervention for lung cancer and one intervention for skin cancer in the UK 53 and Sweden, 10 respectively, were ineffective.…”

“…The effective interventions were reducing diagnosis through emergency presentation by improving general practice referral in England, UK, 52 the guided personal quality of life (QoL) feedback intervention during the Cancer Research UK's North West regional summer roadshow in Manchester, UK, aimed at offering guided feedback about personal QoL to adults with Open access potential cancer symptoms, living in deprived communities to promote help seeking in primary care among the communities, 78 the mandatory primary care access to faecal immunochemical testing in Nottingham, UK, integrated with the 2-week wait pathway, aimed at improving gastrointestinal cancer diagnosis rather than relying on age and symptoms alone, 17 the Stronach Regional Cancer Centre lung diagnostic assessment programme at Southlake Regional Health Centre, Ontario, Canada, aimed at using learnings from a Lean improvement event to provide coordinated, expedited care for all patients undergoing a possible lung cancer diagnosis and to achieve/improve on the provincial wait time target from consultation to diagnosis for patients with lung cancer, 24 the nurse practitioner-led lymphoma rapid diagnosis clinic in a tertiary care cancer centre (Princess Margaret Cancer Centre, part of University Health Network) in Ontario, Canada, aimed at reducing wait times for a definitive diagnosis of lymphoma, 64 the expedited one-stop prostate cancer diagnosis using advanced imaging and biopsy techniques in a health institution (name not reported) in the USA, aimed at expediting prostate cancer diagnosis. 83 There was also the Swedish Diagnostic Center at the Central Hospital of Kristianstad, Sweden, introduced as a separate outpatient unit within the Department of Internal Medicine to expedite diagnostics, 80 the Partners for Cancer Care and Prevention action plan in Cali, Columbia, aimed at improving access to a coordinated programme of screening and early diagnosis of breast and cervical cancers in three healthcare centres that serve subsidised populations, 75 the dermatology-led quality improvement initiatives in Gaborone, Botswana, aimed at improving multispecialty care coordination, 94 and the culturally sensitive, narrative self-help intervention named PERAN-TARA (PEngantar peRAwataN kesehaTAn payudaRA (translated as introduction to breast health treatment)) across four hospitals in Bandung, West Java, Indonesia, aimed at reducing time to diagnosis in women with breast cancer symptoms. 77 In addition to the above, one unpublished article on the Accelerate, Coordinate, Evaluate programme in the UK was identified.…”