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BACKGROUND - Routine opt-out provider-initiated HIV testing and counseling (PITC) remains underutilized in sub-Saharan Africa. By selectively targeting clients who either volunteer or have clinical indications of HIV disease, standard approaches to HIV counseling and testing are presumed more cost-efficient than PITC.
METHODS - One thousand two hundred twenty-one patients aged 15– 49 years were seen by 22 practitioners in a mobile clinic in southern Zambia. A random sample of physicians was assigned to administer PITC, whereas the remaining practitioners offered standard non- PITC (ie, voluntary or diagnostic). Questionnaires assessed patient demographics and attitudes toward HIV. HIV detection rates were stratified by referral type, demographics, and HIV-related knowledge and attitudes.
RESULTS - HIV prevalence was 10.6%. Infection rates detected using PITC [11.1%; 95% confidence interval (CI): 8.8% to 13.5%] and standard non-PITC (10.0%; 95% CI: 7.5% to 12.5%) did not significantly differ (odds ratio = 1.01; 95% CI: 0.67 to 1.52; P = 0.95). Patients who did not request testing or demonstrate clinical indicators of HIV did not have significantly higher HIV prevalence than those who did (odds ratio = 0.83; 95% CI: 0.55 to 1.24; P = 0.36). Implementation of PITC was highly acceptable and produced a 3-fold increase in patients tested per practitioner compared with standard non-PITC (114 vs. 34 patients per practitioner, respectively).
CONCLUSIONS - PITC detected a comparable HIV infection rate as a standard non-PITC approach among rural adults seeking primary care services. Widespread implementation of PITC may therefore lead to significantly more cases of HIV detected.
BACKGROUND - This study sought to evaluate the effectiveness of an active survey method for detecting anesthesia nonroutine events (NREs). An NRE is any aspect of clinical care perceived by clinicians or observers as a deviation from optimal care based on the context of the clinical situation.
METHODS - A Comprehensive Open-ended Nonroutine Event Survey (CONES) was developed to elicit NREs. CONES, which consisted of multiple brief open-ended questions, was administered to anesthesia providers in the postanesthesia care unit. CONES data were compared with those from the same hospital's anesthesia quality assurance (QA) process, which relied on self-reporting of predefined adverse events.
RESULTS - CONES interviews were conducted after 183 cases of varying patient, anesthesia, and surgical complexity. Fifty-five cases had at least one NRE (30.4% incidence). During the same 30-month period, the QA process captured 159 cases with 96.8% containing at least one NRE among the 8,303 anesthetic procedures conducted (1.9% overall incidence). The CONES data were more representative of the overall surgical population. There were significant differences in NRE incidence (P < 0.001), patient impact (74.5% vs. 96.2%; P < 0.001), and injury (23.6% vs. 60.3%) between CONES and QA data. Outcomes were more severe in the QA group (P < 0.001). Extrapolation of the CONES data suggested a significantly higher overall incidence of anesthesia-related patient injury (7.7% vs. only 1.0% with the QA method).
CONCLUSIONS - An active surveillance tool using the NRE construct identified a large number of clinical cases with potential patient safety concerns. This approach may be a useful complement to more traditional QA methods of self-reporting.