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Pilot Audit of Trichiasis Surgery Outcomes Using a Mobile App in the Republic of
Chad

Article  in  Middle East African journal of ophthalmology · April 2020

DOI: 10.4103/meajo.MEAJO_75_19

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Original Article

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Pilot Audit of Trichiasis Surgery
Outcomes Using a Mobile App in the
Republic of Chad
Dézoumbé Djore1, Djada Djibrine2,3, Abdelkerim Bouka Ali1, Harba Tyau‑Tyau4,
Website: Doniphan Hiron5, Barka Kali6, Jean‑Eudes Biao6, Jerôme Bernasconi5,
www.meajo.org Karim Bengraïne5, Serge Resnikoff5
DOI:
10.4103/meajo.
MEAJO_75_19 Abstract:
PURPOSE: The purpose of the study was to assess the feasibility of a mobile data collection app
for use in trichiasis surgical audits in the Melfi and Mangalme districts of the Guera region of the
Republic of Chad and to perform a cost analysis to determine if the auditing mechanism could be
implemented nationally.
MATERIALS AND METHODS: Patients who underwent trichiasis surgery 6 months prior and who
had follow‑up 7–14 days after surgery were included in the study. Each surgeon had a sample of 20%
of operated eyelids; nine surgeons with data for ≥20 eyelids were included. A trichiasis recurrence
rate of ≥25% suggested that the surgeon needed retraining. Smartphones captured data using the
data collection app, which transmitted data to an online server. Direct costs and supervision costs
were collated and summed.
RESULTS: There were 916 eyelids operated on; 170 patients (269 eyelids, 29% follow‑up rate)
participated in the audit. Twenty participants (11.8%) had recurrence. The mean recurrence
rate among surgeons was 8.3%  (standard deviation: 0.07%; range: 0%–17.9%). None had a
recurrence rate of  ≥25%; thus, no retraining was necessary. The total cost of the audit was
1
National Program to US$15,111.25 ($12,882.28 in direct costs and $2,228.97 in supervision costs).
Prevent Blindness,
N’Djamena, Chad,
CONCLUSIONS: The simple, easy‑to‑use, and low‑cost mobile auditing mechanism is a practical
2
Faculty of Medicine of
solution for conducting surgical audits in remote and resource‑limited settings and is undergoing
N’Djamena, N’Djamena,
national scale‑up by the Chadian trachoma elimination program.
Chad, 3Department of Keywords:
Ophtalmology, National Mobile data collection, pilot, Republic of Chad, surgical audit, trachoma, trichiasis surgeries
Referral Hospital,
N’Djamena, Chad,
4
Faculty of Medicine
of Abéché, Abéché,
Introduction range from 18% to 66%.[2] Fear of surgery
has been identified as a principal barrier
Chad, 5Organization
for the Prevention of
Blindness, Paris, France, T rachoma causes 3% of global blindness.[1]
Approximately 200 million people need
treatment for trachoma, 7.2 million of
to trichiasis surgery, which can stem from
negative outcomes experienced by patients
who were operated on for TT.[3‑5] The TT
6
Organization for the
Prevention of Blindness, whom have trachomatous trichiasis (TT), recurrence rate is the qualitative outcome
N’Djamena, Chad which – without proper surgical measure for trichiasis surgery.[5] Although
intervention – may result in vision loss.[1] the Surgery for Trichiasis, Antibiotics
Address for
to Prevent Recurrence (STAR) trial in
correspondence:
Mr. Doniphan Hiron,
The tremendous backlog of unoperated Ethiopia reported low recurrence rates of
17, Villa d'Alesia 75014, TT is exacerbated by suboptimal rates of 10%–13% at 3 years,[6,7] high recurrence rates
Organization for the patient uptake of surgical services, which have been a concern of trachoma control
Prevention of Blindness,
This is an open access journal, and articles are
programming.[4,5,8‑11] Recurrence rates have
Paris, France.
E‑mail: d.hiron@opc. distributed under the terms of the Creative Commons been reported as high as 32% at 6 months
asso.fr Attribution‑NonCommercial‑ShareAlike 4.0 License, which
allows others to remix, tweak, and build upon the work How to cite this article: Djore D, Djibrine D, Ali AB,
Received: 13‑03‑2019 non‑commercially, as long as appropriate credit is given and Tyau‑Tyau H, Hiron D, Kali B, et al. Pilot audit of
Revised: 06‑10‑2019 the new creations are licensed under the identical terms. trichiasis surgery outcomes using a mobile app in
Accepted: 18‑02‑2020 the Republic of Chad. Middle East Afr J Ophthalmol
Published Online: 2020;27:14-21.
29-04-2020 For reprints contact: reprints@medknow.com

14 © 2020 Middle East African Journal of Ophthalmology | Published by Wolters Kluwer - Medknow
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Djore, et al.: Mobile audit of trichiasis surgery in Chad
in Gambia, 40% at 1 year in Gambia, and 62% at 3 years
in Oman.[5,11] Recurrence can be either early due to
surgical factors or late due to disease progression.[4,5]
Multiple authors have reported that most recurrence
occurred within 6 months of surgery,[4,12] most likely as
a result of poor‑quality surgery. Intersurgeon recurrence
rates vary significantly from 0% to 83% despite the use
of high‑volume, trained surgeons.[4,5,12,13] Even more
alarming is that the number of surgeries with poor
outcomes is increasing as surgical output increases.[14,15]
In the wake of major surgical scale‑up efforts to address
the TT backlog, there is now heightened concern to
improve surgical quality.[5,14] Unfortunately, trachoma
control programming lacks systematic postoperative
follow‑up.[9] Consequently, surgeons (many of whom are
nonphysicians in some countries) are not evaluated for
their performance and surgical outcomes, and surgical
programming lacks quality control. While trachoma
control programs have focused on improving surgical
techniques and on strengthening training via a surgical
certification process, there is no standardized method
to evaluate recurrence. [5,16] There is also a need to
identify surgeons with poor surgical outcomes in need
of retraining.[5,14] A standard mechanism to improve the
quality of care in healthcare systems is an audit.[5] The
use of a surgical audit may improve TT surgery outcomes
and hence improve patient uptake,[5,10,14] which would be
instrumental in reducing the TT backlog.
In 2002, it was estimated that 10%–29.9% of the
population of Mangalme and Melfi districts in the
Guera region of Chad had trachoma.[17] An unpublished
2017 survey found that the sex- and age‑adjusted
TT prevalence was 1.0% in Mangalme and 0.25% in
Melfi. Since 2014, a comprehensive trachoma control
and prevention program has been implemented in
Guera via Surgery, Antibiotics, Facial cleanliness, and
Environmental improvements strategy.[18] With national
trachoma control scale‑up measures underway, the
need to improve surgical programming quality was
urgent, but, until now, no auditing mechanism has
been implemented by the national trachoma elimination
program.
In this study, the Chadian national trachoma elimination
program tested the feasibility of a mobile surgical
auditing method that aims to establish a quality control
and improvement mechanism that can evaluate and
improve TT surgical outcomes. The Organization1 =
United Nations, the Organization 2 = International
Rescue Committee, and the Organization3 = Harvard
Humanitarian Initiative developed the Device = KoBo
Collect app Organization 4 = KoBo Toolbox (Cambridge,
MA, USA), a digital data platform for mobile survey that
is based on the Open Data Kit, the standard for mobile
Middle East African Journal of Ophthalmology ‑ Volume 27, Issue 1, January-March 2020 15
data collection, is open source and can be downloaded
for free on a smartphone using Android technology
for mobile surveying.[19] This pilot study assessed the
feasibility of the implementation of the Device app for
its use in TT surgical audits in the Melfi and Mangalme
health districts of Guera region of Chad and determined
the programmatic cost of the mobile audit for future
budgeting purposes (to determine if the mobile auditing
mechanism could be implemented at the national level,
based on the program’s overall national operational
budget).
Materials and Methods
This prospective, one‑arm, pilot, feasibility study was
carried out in 24 health districts of Mangalme and
Melfi  (population: 256,783 people) in Guera, Chad,
in June 2017.[20] Given that TT surgical audit should
be conducted from three to 6 months after surgery,[21]
these districts were chosen because outreach campaigns
took place in them 6 months before the study, they are
relatively accessible (geographically), and they have
lower violence and crime rates.
The Organization 5 = Organization for the Prevention
of Blindness (Paris, France; referred to as OPC based on
its abbreviation in French) implemented this study and
supervised it along with the Organization 6 = National
Program to Prevent Blindness (Chad; referred to as the
PNLC based on its abbreviation in French). This study
adhered to the Declaration of Helsinki and was approved
by the Organization 7 = Global Trachoma Mapping
Project (GTMP) Bioethics National Committee.
A 20% sample of operated eyelids from each surgeon
was required for surgeon inclusion in the audit, which
was decided by the Organization5 = OPC and the
Organization8 = International Coalition for Trachoma
Control to be an adequate and reliable threshold for data
validation, provided that there were at least 20 eyelids
examined per audited surgeon. Any cases of recurrence
were considered as failures. Recurrence was defined as
when at least one lash started to touch the globe, the
patient had to pluck lashes to prevent rubbing, or repeat
surgery was needed.[21] The posterior lamellar tarsal
rotation (PLTR; the Trabut method) technique is used
in surgical campaigns in Chad. The postoperative TT
recurrence threshold rate following PLTR surgery was
estimated at 15%, which was based on data for PLTR
surgery in Ethiopia.[10] To determine the recurrence
rate that would necessitate surgical retraining, the cut-
off recurrence rate was doubled to 30%. However, to
maximize surgical quality improvement, the threshold
was arbitrarily reduced to 25%. Therefore, if a surgeon
had a failure rate of 25% or greater, then retraining was
indicated.
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Djore, et al.: Mobile audit of trichiasis surgery in Chad
The patient population was selected from patients
who participated in TT surgical outreach campaigns in
Melfi in December 2016 and in Mangalme in January
2017, whose medical records indicated that they had
postoperative follow‑up from 7 to 14 days after surgery.
The surveyors met with the heads of each health center to
inform them of the surgical audit and to verify the names
of the patients in each village. Participants provided their
oral informed consent.
On June 10, 2017, an Organization5 = OPC trainer trained
two survey teams of one grader and one recorder per
team. The two recorders previously were recorders
during the Organization7 = GTMP surveys. One grader
was an ophthalmic technician, and the other was an
ophthalmic nurse. The surveyors were trained on the
study protocol, the Device = KoBo Collect and online
survey form, and how to locate patients. Surveyors were
also instructed to take clear, digital photographs with
their smartphones, with one open eye only in each image.
The supervising team comprised one member of the
Organization 6 = PNLC and two members of the
Organization 5 = OPC; they ensured that data collection
using the apps went smoothly and provided assistance
to the survey teams as needed. On June 12, 2017, they
were trained on how to use the Organization4 = KoBo
Toolbox online platform.
In 2014, the Organization7 = GTMP provided study
investigators with smartphones (Smartphone Model
= BLU, Doral, FL, USA), on which the Device = KoBo
Collect app was installed (the app requires Android 4.1
and up, can be installed on any computer or server, and is
used with any modern browser). All data were collected
remotely by surveyors using the Device = KoBo Collect
app on their smartphones. The app captured user/
smartphone device  –  specific data, Global Positioning
System (GPS) location, and the following survey data:
• Region
• Surgeon name
• Patient name
• Patient sex
• Patient age
• Patient phone
• Patient village
• Location of the original surgical campaign
• Date of the original surgical campaign
• Eye operated on (left/right/both)
• Whether or not the patient had TT recurrence in either
eye or both (and if yes, which eye or both)
• Digital photographs of the eyes affected with TT
recurrence.
Mandatory data fields were programmed in the app to
avoid missing data.
16 Middle East African Journal of Ophthalmology ‑ Volume 27, Issue 1, January-March 2020
In case of technical difficulties and program malfunction,
the Organization4 = KoBo Toolbox website offers a
help center support portal at no charge, and the app
itself includes remote, real‑time technical assistance via
messages with the technical support team.
The Device = KoBo Collect app was programmed so
that once a questionnaire was completely filled in, it
was automatically transmitted to the Organization4 =
KoBo Collect server as soon as a network was available.
The Organization4 = KoBo Toolbox online platform
stores a photo library of recurrent cases and generates
data reports and maps showing the distribution of
patients’ sex, surgeries distributed by the surgeon,
operated eyes, recurrence, and the distribution of eyes
with recurrences (right/left/both eyes). Data were
downloaded from the Organization4 platform and
copied and pasted into an Excel database for further
analysis. Descriptive statistics were used for surgeon and
patient characteristics and recurrence rates.
District authorities collected detailed costs of the
study [Table 1], which were collated and summed by
the Organization5 = OPC to determine budgeting for
future audits, based on the global budget of the national
trachoma elimination program.
Results
This study was conducted from June 13, 2017 to June 28,
2017. Fourteen senior ophthalmic technicians or senior
ophthalmic nurses were screened for inclusion in the
audit. Four surgeons were excluded, because their patient
sample size was lower than 20%. One surgeon had only
2.4% of eyelids examined (1/41), one surgeon had 10.6%
examined (5/47), one had 5.6% examined (2/36), and one
surgeon had no eyelids examined in the audit  (0/17).
A fifth surgeon was excluded because his sample only
included 10 eyelids. Therefore, patient data from nine
surgeons were ultimately audited. Their demographic
and clinical characteristics, as well as their surgical
outcomes, are summarized in Table 2. The mean age of
the surgeons was 36.7 years (standard deviation [SD]:
4.9; median; 37). The mean experience was 2.2 years (SD:
0.4; median: 2).
During the surgical outreach campaigns, there were
450 eyelids operated on in Melfi (298 patients) and 466
in Mangalme (289 patients) for a total of 916 eyelids.
There were 170 patients surveyed in this study, 102 (60%)
from Mangalme and 68 (40%) from Melfi. Twenty‑three
patients (3.9%) were lost to follow‑up on days 7–14 and
ineligible. Some patients were followed up, but their data
were not accurately recorded, which made it impossible
to locate them. Others were unable to participate, because
the rainy season had already begun, making some roads
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Djore, et al.: Mobile audit of trichiasis surgery in Chad

Table 1: Total costs of pilot phase of surgical audit, including supervision costs
Expense Items Cost Per Unit/Per Diem, US$ Number of units Total cost, US$
Survey expenses
Per diem of local community guides, 1 per survey team, 10 days each $17.62 20 $352.40
Rental of 2 vehicle for 18 days, including drivers and insurance N/A 2 $4,758.23
Fuel for 31 days (10 days for 1 survey team and 21 days for other) N/A N/A $3,425.19
Driver’s accidental insurance $93.97 1 $93.97
Per diem of trainer $17.62 7 $123.34
Per diem of 2 graders for 18 days $52.87 36 $1,903.32
Per diem of recorders for 18 days $44.06 36 $1,586.16
Camping gear for surveyors (bed, sheets, and two blankets) N/A 3 $62.56
Internet subscription N/A 1 $281.53
Tetracycline ointments for recurrent cases $0.35 1,000 $350.00
Total survey expenses $12,936.70
Supervision expenses
Accommodations and meals for 3 people for 10 nights $37.01 30 $1,110.30
Driver’s per diem for 10 days $24.67 10 $246.72
Per diem of local community guide for 1 day $14.10 1 $14.10
Motorbike rental for 1 day $26.44 1 $26.44
Fuel for 6 days N/A N/A $770.30
Inner tubes and workforce N/A N/A $61.67
Total supervision expenses $2,229.53
Total project expenses $15,166.23
N/A: Not available

Table 2: Demographic and clinical characteristics and surgical outcomes of surgeons who completed the audit
Surgeon Age Experience, Number of Number of surveyed eyelids Successful Recurrence, n
number (years) years operated eyelids (percentage of operated eyelids) outcomes, n (rate, percentage)
1 39 2 112 23 (20.5) 20 3 (13)
2 36 2 89 21 (23.6) 19 2 (9.5)
3 46 2 84 50 (59.5) 47 3 (6.0)
4 40 2 62 20 (32.3) 20 0 (0.0)
5 33 2 86 25 (29.1) 25 0 (0.0)
6 38 2 80 28 (35.0) 23 5 (17.9)
7 37 2 146 29 (19.9) 24 5 (17.2)
8 29 3 44 26 (59.1) 25 1 (3.8)
9 33 3 34 28 (82.4) 26 2 (7.1)

and paths inaccessible. Other patients were unavailable,
because they were working in the field no longer in the
area.
The mean age of the participants was 56.2  years  (SD:
18.7 years; range: 10–90 years), and 77% (n = 131) were
women. Ninety‑nine participants  (58.2%) underwent
bilateral trichiasis surgery, 39 (22.9%) had the right eye
only operated on, and 32 (18.8%) had the left eye only
operated on [Figure 1].
were 11  cases of recurrence  (11.1%), of which five
were bilateral and six were unilateral. Among the
unilateral cases of trichiasis, there were 9 cases of
recurrence  (12.7%). Table 2 summarizes surgical
outcome data for the nine audited surgeons. The mean
number of eyelids operated on per surgeon was 82 (SD:
34; range: 34–146). The mean sample was 40.2% (SD:
21.8%; range 20.5%–82.4%). The mean recurrence rate
was 8.3%  (SD: 0.07%; range: 0%–17.9%). None of the
surgeons had a failure rate of 25% or greater.

Among the 170 participants surveyed, 269 operated
eyelids were assessed [Table 2], which is a follow‑up rate
of 29%. Recurrence occurred in 20 participants (11.8%),
of whom eight cases (4.7%) were in the right eye, seven
cases (4.1%) were in the left eye, and five cases (2.9%)
were in both eyes [Figure 2]. The recurrence rate
was very similar among bilateral and unilateral
cases. Among the bilateral cases of trichiasis, there
The only patient data not captured by the audit were
the participants’ phone numbers, as many did not own
any type of telephone, given the poverty level of the
participants’ communities in a country where 40% live
below the poverty line[22] and in a region where 86.1% are
rural.[23] The surgical audit cost US$15,166.23, including
$12,936.70 in survey costs and $2,229.53 in supervision
costs, with detailed expenses provided in Table 1. The

Middle East African Journal of Ophthalmology ‑ Volume 27, Issue 1, January-March 2020 17

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Djore, et al.: Mobile audit of trichiasis surgery in Chad
Figure 1: Distribution of operated eyes. When accessing the map via the
Organization4 = KoBo Toolbox online, one can click on each colored dot to access
complete participant data
global budget was $7.6 million for 2014–2019, so the audit
only cost 0.2% of the global budget.
Discussion
Multiple auditing methodologies for trichiasis surgery
have been suggested.[5,21] These include performing
an audit as a part of supportive supervision by an
experienced surgeon supervisor,[21] which is often not
possible in remote areas with limited workforce. Lot
quality assurance sampling can be conducted where
there are no supervisors and uses a simpler method to
classify surgeons as having either high or low recurrence
rates, [5,21] rather than estimating actual recurrence.
Outreach sampling for audit is used when surgeries are
audited at the end of a surgical outreach campaign.[21]
This third method has its limitations, as it is performed
much closer to the date of surgery, limiting the timeframe
for recurrence to occur.
This pilot study tested a simplified auditing mechanism
that used a mobile data collection app to audit trichiasis
surgeons in remote communities with limited human
resources 6  months after surgery, based on a 20%
sample of operated eyelids per surgeon (with at least 20
operated eyelids per surgeon included). Buchan et al.
recommend that 40 consecutive cases be audited to
minimize the potential of bias;[5] however, surgeons in
our study performed a mean number of surgeries of 82;
thus, the required 20‑eyelid minimum is a reasonable
sample of 24.4%. Part of the challenge of surgical
18 Middle East African Journal of Ophthalmology ‑ Volume 27, Issue 1, January-March 2020
Figure 2: Distribution of eyes with recurrence. When accessing the map via the
Organization4 = KoBo Toolbox online, one can click on each colored dot to access
complete participant data
TT audit sampling is that there is no recommended,
standard surgical productivity rate benchmark to
evaluate surgeons. Low surgical volume and attrition
is a common issue among trachoma control programs.
Only 16.1% of surgeons working in trachoma‑endemic
areas are high volume (defined as performing more than
50 annual operations).[24] Highly productive surgeons
are thought to have better outcomes. However, the
two surgeons  (22.2%) in this study, who operated
on  <50  cases, had recurrence rates of 3.8% and 7.1%
that were much lower than the two most productive
surgeons, who operated on 112 and 146 eyelids and
had respective recurrence rates of 13% and 17.2%. This
finding is likely due to bias as a result of a small sample
size (<50 cases).
Recurrence rates vary widely across time points,
although they are generally higher than 25%, making it
difficult to ascertain between an acceptable, standard,
recurrence rate versus a cutoff for surgical retraining.
While the 6‑month recurrence rates in the STAR trial in
Ethiopia ranged from 2.5% to 4.3%, it must be clarified
that this trial was done in a controlled environment.[6,7] All
surgeons were certified on the WHO guidelines, which
could have improved outcomes; sutures were removed
after 2 weeks, which could have improved healing
rates; and the most difficult cases were excluded from
participating (patients who had previously undergone
trichiasis surgery, which made up 64% of ineligible
patients). A “real‑world” recurrence rate threshold of
25% or higher was used in this study to indicate that a
surgeon needed retraining. Buchan et al. suggest a more
conservative threshold of below 20% at 1 year instead
of 6 months to determine the need for retraining, but
they explain that given the multiple factors affecting
recurrence (ongoing disease exposure, surgical quality,
surgical technique, etc.), each individual trachoma
control program should determine their own threshold
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Djore, et al.: Mobile audit of trichiasis surgery in Chad
using data from similar settings or previous studies.[5]
Given the fact that no surgeons need re‑training in our
pilot study, we will consider using a more conservative
threshold in future studies.
Six months was used as the audit timeframe rather than
1 year because the WHO recommends surgical follow‑up
up to 6 months,[21] the majority of recurring cases in some
studies have been found to occur within 6 months,[4,12]
and early recurrence is associated with surgical factors/
quality.[4] We aimed to capture recurrence that was more
likely to be related to the surgeons’ performance.
Nine surgeons and 170  patients  (with 269 eyelids, a
29% follow‑up rate) participated in this audit. Twenty
patients  (11.8%) had recurrence; the mean recurrence
rate among surgeons was 8.3%, which is below rates
reported in the literature at 6 months.[4,8,10] The highest
recurrence rate was 17.9%; thus, none of the surgeons
needed retraining.
We implemented a simplified, efficient, mobile surgical
TT audit using a smartphone to collect data remotely,
which in workforce‑limited settings requires a minimum
amount of surveyors and supervision. Timestamped
data entry and GPS positioning functionality help to
prevent the manual error from double data entry, thereby
saving on time. Another advantage of the auditing tool
is that trained operators can delete or modify the survey
questions, which may require revision to improve survey
efficiency and the local context of the audit after they are
transmitted to the server. The app additionally offers
excellent technical support.
A major strength of the auditing mechanism is its low
cost. The audit costs only $15,166.23, or 0.2% of the
global budget; thus, this auditing mechanism is feasible
to scale‑up nationally. Among the audited surgeons, the
per‑surgeon cost was only $1,685.13. Had the surgeons
required retraining, the cost of training would have
been $2,051 per surgeon or a potential total of $18,459.
For less than the cost of retraining the nine surgeons,
we audited them and determined that retraining was
not needed. Therefore, rather than schedule periodic
refresher surgical training, there is a potential saving in
training when implementing quality control measures
in trichiasis surgical programming. Other trachoma
control programs with limited resources could greatly
benefit from the use of this auditing mechanism at
6‑month follow‑up, and as explained above, the survey
questionnaires can easily be adapted to the local context.
Disadvantages of the mobile auditing mechanism
are that Internet access is required to upload and
access data (which can be a challenge in remote, rural
communities), and a trained survey manager is needed
Middle East African Journal of Ophthalmology ‑ Volume 27, Issue 1, January-March 2020 19
to be able to manage and update the on‑line survey form,
as necessary. Many of the health centers in the survey
area have poor infrastructure and do not have access to a
computer, Internet, or reliable electricity for that matter.
Given that the audit took place in communities lacking
an Internet network, most data were not transmitted
by the app until 3 days after the study began, when the
surveyors arrived at the health center of Chinguil, which
had network access. However, the Internet connection
was too weak to access the server and download the
study data. Hard copy audit reports are therefore needed
and will be provided to heads of health centers in future.
The majority of surgeons  (9/14; 64.3%) were audited.
One issue that might have affected surgeon participation
is that a reserve list of patients was not used to ensure the
minimum sample per surgeon and to reduce bias. Low
surgical volume was generally the reason that surgeons
were excluded; thus, one question for future audits is if
the low surgical volume (and what threshold) should be
justification for retraining. There will be future attempts
to audit the five surgeons who did not participate in this
study; however, the accessibility of their patients must be
further considered. The follow‑up rate (29%) may have
been lower because many patients were inaccessible
during the rainy season. There may have been significant
bias in the patient sample, as people who have easier
access to the health centers and trachoma information in
general may have been operated on when their infection
was milder,[5] whereas more severe cases of trichiasis are
more difficult to operate on and recurrence can be twice
as high.[4,12] However, a higher follow‑up rate was not the
aim of the audit, as the patient data included were based
on the per‑surgeon sample size, meeting the threshold of
20%. Nonetheless, for future audits, we also recommend
that patients should be notified to return for follow‑up
at 6 months at the time of their trichiasis surgery, radio
messages be used to inform the communities of the
audit, and relay persons work in collaboration with
the supervisors and heads of health centers to improve
coordination.
Another study limitation was that the 20% sample size
was determined arbitrarily, but this was a pilot study
with limited published data available to calculate a
sample size. Furthermore, the size falls within the
reasonable recommendations for sampling for surgical
TT audits.[21] Although no randomized method was used
to select patients, which may incur bias,[5] by attempting
to include all patients who participated in follow‑up
on days 7–14 and who were contacted for this audit
ensured the greatest number of participants from these
difficult‑to‑reach communities. A  larger, prospective
trial could be conducted in future to better validate the
sample size and to compare the efficacy and costs of the
mobile auditing mechanism to other auditing models.
[Downloaded free from http://www.meajo.org on Friday, January 15, 2021, IP: 154.73.167.25]
Djore, et al.: Mobile audit of trichiasis surgery in Chad
Figure 3: An example of a digital photograph of a case of recurrence taken by a
surveyor using a smartphone and captured by the Device App
The audit did not capture key patient data, such as disease
severity, surgical complications, pre/postoperative
visual acuity, and follow‑up data. However, a minimum
dataset was included in determining recurrence rates
per surgeon and in guiding the quality improvement
process. Future audits will also include health district
data and exclude the patients’ phone numbers, given
that most did not have one.
Another limitation of the Device = KoBo Collect app is
the digital photography function. Figure 3 represents a
digital photograph of a case of recurrence taken by one
of the surveyors with their smartphone and stored by
the app. The poor quality of the images prevents them
from being used for remote assessment, and thus, it
would not be an efficient use of time to take pictures of
all patients in the field. Surveyors only took photographs
of eyes affected with recurrence to document their work.
The photograph function, however, is not an essential
component of the auditing mechanism, as it is not used
to remotely adjudicate or confirm cases of recurrence.
While testing the Device = KoBo Collect app, this study
did not evaluate the performance of the surveyors. The
survey was programmed so that the questionnaires
were automatically transmitted to the online server once
they were completed. In the future, the surveyors will
manually hit “send” to transmit each patient’s data so
that data entry operators will be able to count the number
of questionnaires completed and sent per surveyor.
One final disadvantage with the study is the audit
coincided with the six monthly follow‑up, which
hindered resource mobilization. Future audits will be
integrated as part of the follow‑up schedule.
This pilot study tested a simple, easy‑to‑use, and
low‑cost mobile auditing mechanism and found it to
20 Middle East African Journal of Ophthalmology ‑ Volume 27, Issue 1, January-March 2020
be a practical solution for conducting surgical audits
in remote and resource‑limited settings for surgical
quality improvement. As a result of these findings, the
Device = KoBo Collect app is now being used in the
entire national trachoma program in Chad. A second
audit was performed in Ouaddaï, Sila, and Salamat in
October 2017, and a third audit was carried out in the
southern districts of Chad in 2018. The auditing tool can
be easily adapted to the local context of other trachoma
control programs and may result in the more frequent
use of surgical auditing in these programs. The routine
use of surgical auditing in trachoma control programs
could improve the quality of trichiasis surgeries and
potentially increase patient uptake, thereby advancing
the global effort to eliminate blinding trachoma.
Acknowledgments
The authors would like to thank Kristen Eckert and
Dr. Marissa Carter of Strategic Solutions, Inc. (Cody, WY,
USA), for their assistance with the statistical analysis of
the study and writing and editing of the manuscript.
Financial support and sponsorship
Sightsavers (Chippenham, United Kingdom) sponsored
this study, with funding provided to them by the UK
Department of International Development.
Conflicts of interest
There are no conflicts of interest.
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Middle East African Journal of Ophthalmology ‑ Volume 27, Issue 1, January-March 2020 21

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