Table 3.
Arraying qualitative quotes with quantitative findings to better understand the Determine LAM test role in tuberculosis management among inpatients living with HIV in Ghana—a joint display.
| Quantitative findings | Illustrative qualitative quotes | Themes with explanations of how the qualitative data contributed to a better understanding of the quantitative data |
|---|---|---|
| In the standard-of-care population of the TBPOC study, less than half (45.2%) of severely ill inpatients with HIV and high risk of TB obtained a routine test for TB (sputum Xpert). | “For those who come in who are ill, who are admitted onto our wards we virtually would do a chest X-ray minimum for each of the patients and irrespective of what we are managing them for, because we know of the prevalence of HIV/TB co-infection, virtually everybody unless those who cannot produce sputum, everybody gets the opportunity to be investigated for TB.” Infectious diseases doctor | Barriers to routine sputum Xpert testing Patient not being able to produce a sputum sample; Lack of relatives to assist in sample logistics; Negative beliefs about the disease |
| “So then for a LAM test, it can be performed right at the ward by the patient bedside, with immediate result so that I would not have to wait for relatives to first go and get me a sputum bottle, patients always produce urine, so getting a sample is far easier than in a patient who is not coughing and you would have to wait for them to get you a sputum sample.” Junior medical doctor | ||
| “There are certain patients, because of the stigma. I want to ask do you cough, and she see this red bottle, she would say no.” TB diagnostic HCW | ||
| In the HCW survey, almost all, 68/69 (98.6%), HCWs experienced the Determine LAM test procedure as easy or very easy. In the TBPOC study, 12/174 patients (6.8%) were not tested with the Determine LAM test despite being eligible. Reasons included disrupted communication between HCW (33.3%), the clinician wanting the infectious disease team to decide on testing (8.3%), the clinician not suspecting TB (8.3%), the patient being discharged before the test was requested (8.3%), the patient was dying (33.3%) or not willing to get tested (8.3%). | “Because sometimes patients will be on the ward for perhaps a week or more before we think to do a retro screen [HIV test].” Junior medical doctor | Barriers and facilitators to Determine LAM testing Barriers: Patients being unwilling to get tested (out of fear, or more trust in herbal medicine or believing the disease was spiritual); Delayed HIV screening Facilitators: Instant test, any trained HCW can test |
| “The challenges that we tend to have with the LAM test is that, we need to want it. The doctors need to embrace it, and it has to be prescribed for almost all of our patients who come on admission who we think have [HIV-associated] TB.” Senior medical nurse | ||
| “…for instance with the sputum testing, they have to go and come back in 24 h for their result, and then a lot of people get frustrated. Some people will not even come back because they are like, why do I have to take transportation, go and come. But with the LAM, if it’s an instant thing, you cut down the costs for the patients, you cut down the chances of losing them to follow up…” Senior medical nurse | ||
| “I think that as a point-of-care test it can be done by any clinical staff with appropriate training, so the key word is training.” TB diagnostic staff | ||
| In the TBPOC study it took a median of 4 days from hospital admission to have an Xpert result, and the Determine LAM intervention reduced the time from enrolment to TB diagnosis from a median of 2 days to a median of 0 days. More than 80% in the HCW survey estimated that urine could be obtained within 60 min, and that the overall Determine LAM activity per patient took a median of 30 min. | “So those emergency cases that comes [in the weekend] and they are then suspected [of having TB], they find it difficult to take samples [for Xpert] until Monday.” TB diagnostic HCW | Timely TB diagnosis when assisted by Determine LAM compared to using Xpert only Logistics with sputum sample transportation and pick up of results from the Xpert laboratory; Limited Xpert laboratory opening hours; Xpert cartridge stock-out; Technical issue with the Xpert machine |
| “…GeneXpert, the sputum, it takes like 100 min to a maximum two hours, but sometimes it takes days! We have to follow up to get the results, but this one it’s right by the bedside. You can do it and know the result. I think, it’s not to say that those [Xpert] are not important, but the point is, this [Determine LAM] will be a very helpful addition.” Infectious diseases doctor | ||
| There has been quite a number of instances where you send a patient from the consulting room to the X-ray room, and the machine is down or” dumsor,” power, there is no power. So, and even with the GeneXpert, the AFB, the DST, sometimes they do not have…ehh…materials [Xpert cartridges etc.] or sometimes their machine needs to be worked on. So then the 24 h I’m talking about extends to further notice, which is also an issue.” Senior medical nurse | ||
| “So I’m thinking that there is a lot of times where you tell somebody to produce sputum for testing, and they would tell you, ohh I cannot get it. But urine is something that everybody, as long as you are drinking water, you will pee. So it will be easier to get urine samples than other samples for testing.” Senior medical nurse | ||
| The majority, 142/162 (87.7%) of the Determine LAM tests in the TBPOC study were performed at the bedside. HCW in the HCW survey also reported that bedside was the routinely used place for testing in 87% of cases, but among respondents, more than half thought that a dedicated room at the ward or the laboratory would be the optimal place for testing. More doctors, 15/26 (57.7%), than nurses, 17/40 (42.5%), thought bedside was the optimal place for testing. | “Even if you screen [use physical screens between beds]. At first you explain the procedure to the patient. The patient laying on the next bed can actually hear. And then they hear that…eei, you are about to perform tuberculosis test, then they get alarmed (laugh). So I still do not see it to be private enough.” Senior medical nurse | The place of Determine LAM testing in clinical practice was at the bedside The observed difference between clinical practice and what HCW thought was the best place for Determine LAM testing was better understood in the qualitative data. Nurses were concerned about patient confidentiality, and to ensure patient confidentiality, they used physical screens between patient beds. Nurses thought that the optimal place for testing and disclosure of the result would be in a dedicated room in the ward, while one doctor explained that the Determine LAM test would lose its value as a point-of-care test if performed away from the patient. |
| “Most times we do it at the patient’s bedside but I think that we should have, not the lab per say, because we, nurses and doctors, can easily do it at the ward. We should have a special room for example the treatment room or procedure room, so when the sample is taken it is sent there for it to be done. So that patient privacy and disclosure of patient information will be maintained. Cause we talk about the patients’ rights. They have the right to privacy. When you do it, it should be done in an excluded environment so that when the result is positive, you will know the best way to disclose it to patient, not letting everybody know that the patient is positive. “Senior medical nurse | ||
| “It’s just that the aim of the test is to reduce the patient time, and get fast results. So if we take it to the lab., it means that it defeats the purpose of the test…” “…but it’s not a bad idea, it’s just not the best idea.” Infectious diseases doctor | ||
| In the HCW survey, around 10% of respondents did not use the reference scale card when Determine LAM testing, and more than 10% of respondents thought it was difficult to interpret the Determine LAM test results with discrimination between the four intensity bands | “For the taking of the sample it is not anything difficult and then taking your test kit, dropping it onto it is not so much difficult. But I think where we need to dwell much is the interpretation of the result. The interpretation of the result is where I think we need to dwell much upon.” Senior medical nurse | Determine LAM test interpretation Specifically, it was difficult to discriminate between grade 1 positive and negative. The risk of losing the small reference scale card was an experienced barrier to interpretation and may explain why some HCWs in the HCW did not use the card. Nurses and doctors explained that they took help from a colleague when they were in doubt about the test result. |
| “I think we did one, the line was very faint. I was finding it difficult to read whether it was positive or it was negative.” Senior medical nurse | ||
| “…at a point when I was explaining to one of the nurses at (ward name), the reference card that was given to them was nowhere to be found. So they did not like, I think they had put it somewhere, so they did not know where it was. Because it was in a folder somewhere on the desk.” Junior medical doctor | ||
| “…she wasn’t able to interpret on the numbers, the grading on the card, that was a challenge. She was not able to do it so well so I had to come in and explain to her how it is done.” Senior medical nurse | ||
| In the TBPOC study, 22/41 (53.7%) patients did not initiate TB treatment despite having a positive Determine LAM test with reasons including disrupted communication of result between HCW (13.6%), awaiting sputum Xpert (13.6%), being discharged without having a referral for treatment (9.1%), being referred to Chest clinic to initiate treatment but was not initiated (9.1%), another main diagnosis was more likely (18.2%), patient had comorbidities or was unstable (18.2%), the patient died before treatment was requested or the first dose was taken (9.1%) or nor reason registered (9.1%) | “Ours [the nurses’ digital medical notes] is different and theirs [the doctors] is also different. So we cannot go into their notes. So with this one [the registration of the Determine LAM result], I think we will have a small sheet which is designed as maybe positive or negative, and we document it and then we will take it to the doctor to input it into their notes. I think that will be better.” Senior medical nurse | Barriers to Determine LAM guided TB treatment initiation The new digital medical record was a potential weak link for bedside test result reporting. The dilemma with the initiation of TB treatment is knowing that the specificity is sub-optimal |
| “The LAM test is said not to be, so specific for mycobacterium tuberculosis right. And it may be positive with other mycobacterial species as well like with the mycobacterium avium complex and others. So it’s an issue with the specificity of the test as to whether it is really TB or something else.” Junior medical doctor | ||
| “Yes, so the issue of the [Determine LAM test] false positives makes it a little bit uncomfortable. Because, yeah like, did I make the right choice?” Infectious diseases doctor | ||
| The TBPOC study was not able to show any intervention impact on time to TB treatment initiation that remained at a median 3 days from enrolment. It was registered in the study that a few cases that were Determine LAM positive were not initiated on TB treatment as the clinical team wanted to await a sputum Xpert result. | “…waiting a whole three days and not knowing what to do, is not the best, you know. I mean even giving anti-Kochs, policy wise, Saturday, Sunday, I mean, they are not there, and it can be annoying.” Infectious diseases doctor | Routine healthcare practices compromised timely TB treatment initiation Awaiting needed investigation, e.g., liver function tests that were challenging to obtain due to cost; Limited access to TB treatment and patient registration in the chest clinic in the weekends; Limited access to public health nurses in the weekend to perform pre-counseling and supply the TB medication; TB medications are only given early mornings |
| “So some of them when they come in, you may have some challenges with even doing their labs. Because they are very sick and economically they have lost all their sustenance, okay. So it takes a while for us to get all their investigations to be able to take the final decision to start them on the TB medications.” Infectious Diseases doctor | ||
| “In fact, the duration is a bit long. Ideally I think the doctors should even negotiate with themselves. Now we have instituted that when a patient need DOTs [daily observed TB treatment], we [the public health nurses] go to the chest [clinic] with the doctors. So they [the doctors] will be able to speed up the treatment [initiation] for us. Initially we were going there alone but we have realised that NO, it takes a long time. So why do not we go there with the doctors, so that they will be able to champion the course for us…I mean for the patient.”… “Sometimes if you are lucky too, you will be given the medications. The moment the medication is being given to us, we can educate the patient to take it. As early as possible so every other morning they take it, before they take their meal.” Public health nurse |
QT, Qualitative theme; HCW, healthcare worker; TB, Tuberculosis; LAM, lateral flow urine lipoarabinomannan assay, Determine™ TB LAM Ag test (Abbott Laboratories, Chicago, IL, USA, previously Alere); Xpert, Xpert = sputum Cepheid Xpert MTB/RIF assay or Xpert Ultra (Sunnyvale, California, United States).