Can clinical audit, an intervention to influence medical practice, improve the diagnosis of smear negative tuberculosis in three Latin American countries?

BACKGROUND Clinical audit is an intervention designed to improve the quality of clinical care. Although well established in high income countries, there is little research evidence for its effectiveness in resource poor settings. AIMS AND OBJECTIVES I aimed to evaluate the effectiveness of clinical audit in influencing clinical practice in providing diagnostic care for patients with suspected TB. METHODS A total of 26 health centres were recruited in total in Cuba, Peru and Bolivia. 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 two years. Improvement was determined by comparing performance between two six-month periods pre-and-post intervention. Qualitative methods were used to ascertain facilitating and limiting contextual factors influencing change among health care professionals' clinical behaviour, following the introduction of clinical audit. RESULTS I found a significant improvement in 11 out of 13 standards in Cuba, two out of six in Bolivia and two out of five standards in Peru. Barriers to quality improvement included conflicting objectives for clinicians and TB programmes, poor coordination within the health system, and patients' expectations of illness and health services. 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 local TB programmes. I recommend developing and evaluating an integrated model of quality improvement including clinical audit.