An evaluation of the palliative care-related outcomes of a cohort of TB patients in a district hospital setting: a multiple methods quality improvement study

Although curable, tuberculosis (TB) remains a serious health care problem. During 2011 there were almost 9 million new cases and 1.4 million TB deaths worldwide. The World Health Organisation (WHO) lists South Africa as a country with a high TB, HIV and MDR-TB burden. In this country the dual TB/HIV epidemic which has reached critical proportions is fuelled by the high TB/HIV co-infection rate. By definition the focus of palliative care is on the alleviation of suffering associated with lifelimiting illnesses. TB clearly falls into this category. The palliative care-related outcomes of a cohort of hospitalized TB patients were determined during this prospective longitudinal study and a quality improvement strategy was then generated from the audit data. The APCA POS, a validated outcome measurement tool was used to conduct weekly interviews. The audit sample comprised 57 patients with MDR-TB and 57 with drug responsive TB (n=114). The intensity of the multi-dimensional palliative care-related problems experienced by TB and MDR-TB patients on admission as well as the differences that occurred over time were measured over four consecutive weeks. In order to get staff perspectives on using the audit data to develop a quality improvement strategy, a report on the analyzed audit data formed the basis of a focus group discussion (FGD). The purposive sample of FGD participants included key members of staff from the TB and MDR TB wards. Audit findings indicated that on admission to hospital the predominant problems were pain, symptoms and worry. On a Lickert scale of 0-5 with 0 indicating best and 5 worst, the median score for both pain and other symptoms was 3.0, with an inter-quartile range of 2.00-4.25. Participants' worry about their illness attained the worst median baseline score of 4.0. Neither pain nor symptoms showed any sustained improvement over the four weeks of data collection. A statistically significant improvement in worry which moved from 4.0 to 2.0 occurred after week 1 but then remained static. An unexpected crucial finding was that the collective score for participants with drug responsive TB was worse than for those with MDR-TB for both the physical and psycho-social components, and at each time point. Using the APCA POS audit data as the basis of a FGD with key staff members resulted in the development of an appropriate palliative care-focused quality improvement strategy which they considered to be realistic and achievable within their busy hospital setting. Findings from this study support the recent WHO Declaration on the provision of palliative care for people with drug-resistant TB. Furthermore they clearly show that patients with drug responsive TB should not be excluded from a comprehensive palliative care person-centred approach. Palliative care within the context of TB is still an emerging concept. This study makes a meaningful contribution to the scarce information currently available. The topic is important in that the suffering experienced by vast numbers of TB patients and their families could and should be substantially relieved. It is suggested that it would be valuable to explore the impact of a palliative care approach on TB treatment outcomes.

Grantor dc:publisher.institution

Department of Public Health and Family Medicine

Year dc:date.issued

2013

Author dc:creator

• Defilippi, Kathleen Mary

Advisors dc:contributor.advisor

• Gwyther, Liz
• Harding, Richard

Language dc:language.iso

eng

Handle dc:identifier.uri

http://hdl.handle.net/11427/10381

OAI identifier oai:identifier

oai:open.uct.ac.za:11427/10381