Quality of Care at a Multi-site PEPFAR-funded ART Program: From Measuring to Improvement
Partner
Project HEART Background• Rapid growth of clinical programs and patient
load
• Initial emphasis on maximizing number of clients enrolled and started on ART and ensuring minimum quality of systems and care
• Expansion of work to ensuring high levels of quality of care and building capacity for ongoing quality improvement
Project HEART and Quality2004-2006
• Integrated quality management program to measure and provide support
• Focused on baseline assessments and identifying urgent TA needs
• Standardized approach including system assessments and chart review
• Immediate feedback to sites
Chart Review • Sites chosen by country staff
• Charts randomly selected at site level
• Baseline and care in prior 6 months data extracted
• Data sources included the medical chart and pharmacy logs
Quality of Care Indicators• Indicators reflect international standards and
critical care and treatment areas• Included:
– On cotrimoxazole if eligible– On ART if eligibility– TB screening– Adherence
• Identified problems and adherence support
– Missed visits and outreach– Disclosure and risk reduction discussions
Population• Adults receiving HIV care at Project-
HEART-supported sites between 2005 and 2006
• 935 randomly chosen patients at 22 sites, with 708 patients (85%) alive and active in the program at the start of the review period.
Population CharacteristicsWomen 62%
Age - >35 60%
Median CD4 137 (114 – 178)
On ART at program entry
4 – 26%
CI Tanzania South Africa Zambia
Last seen > 6 months ago (all pts)
12% 2% 2% 7%
ART patients
Seen in review period
100% 98% 98% 96%
Missed visit 13% 16% 8% 26%
Outreach if missed visit*
0% 0% 22% 10%
Adherence to care and missed visits
*documented in chart
ART and Response
CI Tanzania South Africa Zambia
Started on ART if eligible
57% 87% 93% 93%
Interruption 7% 10% 8% 24%Response if on ART >6 months* 96% 90% 95% 89%CD4 change (median)** 124 124 117 153Last CD4 >200 100% 100% 100% 93%
*Response: clinical stability or improvement, no new OIs > 3months since ART start, gained weight or CD4 count improvement**If on >6 mos. Difference not significant
ART and Adherence
39%
65%
100%96%
11% 11%
96%94%
23%
6%
20%21%
77%
94%
80%79%
0%10%20%
30%40%50%60%
70%80%90%
100%
Adherenceassessed/ever
Adherenceassess/always
Problem intervention ifproblem
CI Tanzania South Africa Zambia
86% 81%90%
47% 44%
65%59%
100%
0%
10%20%
30%40%
50%60%70%
80%90%
100%
CTX if eligible TB screen
CI Tanzania South Africa Zambia
OI Prevention
0%4%
88%93%
35%
17%
99% 98%
0%
10%20%
30%40%
50%60%70%
80%90%
100%
Risk reduction Disclosure discussion
CI Tanzania South Africa Zambia
Risk Reduction and Disclosure Discussion
Cross-country analysis
• No disparities in care received seen by gender
• Each country had strengths and areas of potential challenges– Some represented differences in quality– Others, differences in documentation or
policies
Inter-site variability
• Significant variability across sites – Disclosure discussions– Risk reduction counseling– TB screening– Cotrimoxazole use
• Provides opportunities for cross-site and inter-country sharing of best practices and lessons learned
QI Case Study: Cote d’Ivoire
• February 2007 QI visit at CAT Adjamé showed lower than expected adherence to follow-up visits.
• Issue– Actual missed visits– Documentation of visits
Site response• Reorganized medical record filing system to
allow for easier chart access• Training regarding documenting visits in
patient medical record• Enhanced pre-ART adherence counseling• Strengthened pharmacy counseling efforts• Follow up visit found extensive improvements
in documentation • Next steps – focusing on outreach for missed
visits
QI Case Study: Tanzania
• Issue: CD4 testing not done according to the national guidelines at Mawenzi District Hospital (MDH)– Of 45 patients reviewed, 38 (84%) had an
enrollment CD4, and 19 (42%) had a CD4 during the last 6 months
– Tests run only 2 days/week– Only 2 staff trained to run FACS
Site Response
• Tests run more routinely (4 days/week)
• Refresher training about – Utilization of CD4– The need to document CD4 test results
Chart review pending
Limitations of initial approach
• Limited ability to revisit sites for change over time
• Initial efforts to build capacity in-country overwhelmed by basic M & E demands
• Different country level priorities for specific areas of concern vs measurement of overall quality.
Challenges of Developing a Sustainable QM Program
• How to expand to meet rapid growth of number of sites and geographic distance
• How to build local capacity at the country program level
• Heterogeneity of capacity at country and site level– IMPORTANCE OF TAILORING THE APPROACH
• Need to harmonize with national or provincial programs (ex. South Africa, Mozambique)
Quality Measurement and Improvement Expansion Phase
• QM integrated into the overall program at central and country programs
• Develop and Implement individualized Quality Management Program to support initiatives to improve care
• Tailor approaches to meet needs and reflect existing capacity
• Focus on capacity building– country level and then sites
Implementation
• Develop Project-wide core indicators
• Develop country QM plans– Leadership, country-specific indicators
• Training and capacity building at country level and pilot at site level– Didactic and practical training
Conclusions
• Despite rapid expansion, Project HEART-supported programs have delivered high quality of care in a number of areas
• Varied challenges within and across countries
• Fostering local ownership, capacity and sustainability is a challenge