Model Answers 1


Administrative problem TB control

The medical officer in charge of a hospital was writing the 1998 annual report. She compared the data of 1998 with previous years and saw that the total number of patients admitted and treated at the OPD for TB had clearly increased in the last few years:

 
1994
1995
1996
1997
1998
No. Of TB cases
112
158
201
244
279

How had the hospital coped with this increase? She was interested in finding out how many of the TB patients who had started their treatment at the hospital, were cured. She wondered how to go about it.

Step 1. Clarification
Maybe a student likes to know whether only new TB cases are meant or all TB cases. As no more information is available, one must assume that it concerns all cases.

Step 2. Analysis
The underlying problems in this case could be defined as:

  • an apparent steady increase in TB patients treated at the hospital, cases have more than doubled in four years time
  • there is a lack of knowledge about how to analyze TB treatment results of a hospital

Step 3. Explanations / hypotheses

Problem Hypotheses
Why increase in TB cases? real increase of TB in community
increase in HIV infection
overdiagnosis (functioning of the laboratory
How to collect and analyze TB data? hospital admission book
OPD register
TB register
TB Patient Record Cards
TB laboratory register
different categories of TB patients
How to calculate cure rate? follow-up sputum examinations patients' treatment outcome grouped according to treatment regimens

Step 4. Formulation of learning objectives

The following learning questions may be formulated:

  1. what is the relationship between HIV and TB?
  2. which forms of TB are the most important in TB control?
  3. what is the role of the laboratory in TB control?
  4. what information can be found in the hospital admission book?
  5. how does a TB register look like?
  6. what information is recorded on the TB patient record card (PRC)?
  7. what information is needed to assess whether a patient is treated properly?
  8. what is the role of sputum examination in assessing cure rate?

After discussion between the tutor / facilitator and the group, the list of learning questions is limited - in line with the course objective "Treatment outcome of TB" - to just the questions 5 to 8.

Step 5. Individual self-directed learning

Using the table: Proces of formulation of self guided learning objectives, a student may decide to approach the problems as follows:

Questions 5 and 6 "how does a TB register and TB PRC look like?"

These questions concern understanding of factual information, but also of the process of treatment, recording and reporting and thus the structure of the recording system.

The resources for this study would include:

  • TB PRC and register
  • National TB (L) Control Programme manual
  • Books of WHO / IUATLD
  • Articles (e.g., from Tubercle and Lung Disease)
  • Own investigation in the hospital ward/OPD

The product of the study may be:

  • a copy of the TB PRC and TB register
  • a short presentation on the logical sequence of items to be entered in the PRC and of the columns in the TB register
  • a literature review (list of references)

The assessment of this part of the study would focus on the understanding of the structure and use of the PRC and register. This assessment could be through the use of simulation data (case study) or by observation during a field visit to hospital or clinic.

Question 7 "what information is needed to assess the treatment outcome of TB?"
Concerns again factual information and understanding of the process.

The resources are similar to those for questions 5 and 6.

The product of the study could be a presentation to the other students which data from the register (or PRC) to collect and how to analyze.

The assessment could be done by requesting students to make a cohort report during a field visit to a TB clinic or by using a (simulated) register at the training centre.

For question 8, "what is the role of sputum examination in assessing cure rate?"
Most learning will be facts and steps in the process of the TB treatment routine.
The resources are similar to those for questions 5 and 6; with perhaps in addition to the TB register the lab. Register.
The product of the study: presentation to the others of the routine sputum checks.
The assessment: also the cohort report.

Step 6. Synthesis and application

The study of these questions will result in all students of the group to know and understand the TB PRC, TB register, perhaps lab register as well. The procedure for analyzing treatment results for quarterly or annual cohorts of TB patients should be understood.
Armed with this new knowledge, students could now undertake to solve a similar problem by studying real data from a hospital nearby, a clinic or even a whole district. Trainer could also prepare a case study based on above used problem (as indicated under assessment in step 5.).

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