Shavkat Husanbayev, Head of Ferghana city health department
Manzura Usmanova, Chief therapist of Ferghana city
Habibullo Rahmatov, Regional quality coordinator of primary health care facilities
Muhtor Meliboyev, General practitioner (QM team leader)
Odina Sotvoldiyeba, Chief nurse of rayon
Nilufar Rakhmanova, ZdravPlus quality improvement specialist
Shuhrat Kuramatov, ZdravPlus quality improvement specialist
Peter Campbell, ZdravPlus regional director of quality improvement

To improve the quality of care for patients with anemia through implementation of clinical practice guidelines and application of continuous quality improvement techniques in Ferghana Valley, Uzbekistan.

There were several measures used for the project; we have selected the ones that we were able to change:

• Incidence rate of anemia: Out of all patients who received the test how many had their hemoglobin level below the norms
• Treatment rate: Out of all patients with hemoglobin below 120 mg/l (or 110 mg/l for pregnant women) how many were prescribed an appropriate treatment according to guideline
• Effectiveness rate: Out of all patients with anemia how many had their hemoglobin level normalized after three months of treatment

In addition to anemia, we have tracked other measures effecting population health and show that the anemia intervention has indirect positive impacts:

• Maternal death rate: Measured with information from Demographic Uzbekistan Health Examination Survey (DUHES, 1996) and Uzbekistan Health Examination Survey (UHES, 2003)
• Infant mortality: Also measured using data from DUHES (1996) and UHES (2003)
• Patient knowledge on prevention of anemia in children and proper food intake: Measured using information from population surveys conducted in 2002, 2003, 2004, 2005, etc.

Changes were introduced to increase the rate of compliancy to evidence-based standards for iron deficiency anemia and to enhance knowledge and proper behavior in regard to anemia among the population.

System-Level Changes:

• Set up a suitably competent multilevel team representing all structures of the health care system: QM team (supervision and support) and quality improvement teams (facility-level improvement)
• Developed clinical practice guidelines (CPGs) on anemia were developed by a newly established evidence-based medicine center and introduced at the primary care level
• Developed standards and indicators for clinical service (from screening to follow up)
• Introduced a system of self-monitoring of standards based on audit of documents
• Institutionalized the system of inputting the results of the indicators into a Microsoft Access database system that allowed to us to create run charts for analysis and identification of issues

Clinical Changes in Anemia Management:

• Small-scale studies showed that Sahli hemoglobin (Hb) measuring devices underestimated the Hb levels and therefore overstated the prevalence of anemia in patients — the introduction of regular calibration at the regional level helped improve the accurate diagnosis of anemia
• Every Tuesday, known to the population as Anemia Day, patronage nurses delivered iron supplements to reproductive aged women and children at home [NOTE: A patronage nurse works in a primary care facility and is responsible for visiting households to counsel them on issues of health protection and prevention of diseases, as well as for making appointments with the doctor or to get vaccination.]
• Trained providers in interpersonal communication which enabled them to more effectively counsel patients with anemia

Population Targeted Changes:

• Developed booklets on anemia to educate patients with anemia
• Developed short movies to educate the population and broadcasted on regional television during “No Place for Anemia” regional campaign
• Conducted trainings for leaders of mahallya (community) to promote proper nutrition
• Conducted trainings for school teachers to promote proper nutrition and knowledge about anemia
• Conducted survey on population knowledge and behavior about anemia

Explanation of Results (see figures below)

• Figure 1: Percent of women diagnosed with anemia at primary health care facilities in nine districts of Ferghana, Uzbekistan (2003-2006 data collected quarterly based on a sample of not less than 30 cards): The incidence of women diagnosed with anemia reduced from a mean of 80 percent to 50 percent as a result of calibrating the measuring equipment
• Figure 2: Percent of women prescribed correct treatment for anemia at primary health care facilities in nine districts of Ferghana, Uzbekistan (2003-2006 data collected quarterly based on a sample of not less than 30 cards): The rate of correct prescription for anemia increased from a mean of 60 percent to 90 percent as a result of staff following clinical practice guidelines
• Figure 3: Percent of women with a normalized hemoglobin level 3 months after being diagnosed with anemia at primary health care facilities in nine districts of Ferghana, Uzbekistan (2003-2006 data collected quarterly based on a sample of not less than 30 cards): The rate of women whose hemoglobin level returned to normal increased from a mean of 35 percent to 60 percent as a result of different interventions, including improved consultation, use of booklets and short movies for patients
• Results of the population survey conducted in a sample of 187 people (2002-2005): Survey of knowledge, attitudes, and practices related to anemia of Ferghana province (2002-2005 data based on a sample of 210 women of reproductive age)
  • Figure 4: Anemia prevention in children less than one year of age: Women are listing these as measures to prevent anemia in child less than one year of age. The rate of exclusive breastfeeding has slightly improved from 35 percent up to 40 percent; green tea drinking has decreased from 7 percent to 2 percent; and giving iron supplements has started from 0 percent, then went up to 15 percent and by 2005 it decreased to 7 percent. These changes are the result of patient targeted interventions.
  • Figure 5: Proper food intake: Women are listing these foods as necessary to take to prevent anemia. Taking meat and fish is slightly increased from about 69 percent to 89 percent, and taking legumes and grains has increased from 0 percent to 70 percent. These changes are the result of patient targeted interventions.

Other Related Results:

• According to state statistics, infant mortality decreased from 27.2 percent (in the period from 1993-1997) to 19.1 percent (2002-2005) in the Ferghana region. Data collected on a yearly basis based on reports from the health facilities. Interventions directed to combat anemia could have an indirect effect and explain this decrease.
• The number of children registered as underweight decreased from 17 percent (DUHES, 1996) to 8 percent (UHES, 2003). Data collected on a scientifically determined sample. Proper nutrition interventions could have an impact and explain this decrease.

With the technical support from the USAID-funded ZdravPlus Project (Uzbekistan), the multidisciplinary team of doctors, nurses and health managers in Ferghana, Uzbekistan, has improved health care for patients with anemia through the introduction of quality improvement process using evidence-based guidelines on anemia and the following results were achieved:

• Improved rate of correct prescription for anemia (from mean of 60 percent to 90 percent)
• Decreased the incidence rate of women diagnosed with anemia (from mean of 80 percent to 50 percent) 
• Improved the rate of effective treatment of anemia (from mean of 35 percent to 60 percent)

Lessons Learned:

Overall performance of providers in pilot facilities improved, valuable lessons were learned, and barriers to quality improvement were revealed through the monitoring system. Improved knowledge and proper practices among women have been positive indirect impacts. The value of pilot improvement projects lies not only in the achievement of health objectives, but also in the discovery of system issues that prevent patients benefiting from correct care practices and the mentality shift that comes from a structured approach to implementing changes in a system. The establishment of QI and QM teams, which are new concepts for the health care system in Uzbekistan, and the provision of trainings in QI concepts and methods has been a fundamental component for reforming and improving the quality of care.

Next Steps:

• Integrate all changes that were proven to be effective in the system to make them sustainable.
• We have learned that it requires time and commitment and it should be done as easily and simply as possible, since the workload is in addition to the normal work of the providers.
• Make quality efforts the responsibility of single or multiple quality improvement teams.
• Provide frequent just-in-time trainings in QI and on relevant clinical topics using evidence-based materials. To ensure dynamic improvement, provide continuous feedback to teams.
• Communicate expectations, objectives, and progress on performance to all stakeholders through existing channels of communication without creating non-sustainable new channels.
• Involve local providers to spread QI initiatives through peer-to-peer transfer of knowledge.
• Provide legal support to ensure the stability of the project. It also helps to communicate and take further actions with more confidence.
• Involve opinion leaders such as chief district specialists to promote monitoring and improvement.
• Develop or use existing up-to-date clinical guidelines (based on evidence-based medicine) that provide a framework for individual doctor’s practices; standards and indicators can then be developed to monitor and address issues in implementation.

In conclusion, it should be said that the QI project has been expanded into the whole Ferghana Province and now it is scaling up to three more provinces of Uzbekistan. Health authorities are recognizing that it is possible to improve quality of care with available resources using modern management techniques. That is why the QI training has now been institutionalized in the Tashkent Institute of Advanced Medical Education as part of the continuous medical education to train general practitioners and mid-level managers in new QI approaches.

Nilufar Rakhmanova, Quality Improvement Specialist
Tashkent, Uzbekistan
nilufar@zdravplus.uz