Improving Outpatient Health Information Systems for Integrated Infectious Diseases Management in Rural Uganda

M. Mbonye1, S. Naikoba1, T. Rubashembusya1 , T. Kendle2, S. Kinoti3, L. Mpanga-Sebuyira1, K. Willis2, M. Weaver4

1. Infectious Diseases Institute, Kampala, Uganda; 2. Accordia Global Health Foundation, Washington, D.C. ; 3. University Research Company – Center for Health Services, Washington D.C.; 4. University of Washington;

• Integrated Infectious Diseases Capacity Building Evaluation (IDCAP) is an Accordia Global Health Foundation 3 year initiative funded by Bill and Melinda Gates Foundation.

• Its goal is to evaluate cost-effectiveness of building capacity of Mid-Level Practitioners (MLP) in care and prevention of infectious diseases in Sub-Saharan Africa

• IDCAP is a novel package of classroom training on Integrated Management of Infectious Diseases (IDT), Distance Learning and On-Site Support (OSS) which includes Multi-disciplinary team Training, Individual Clinical Coaching and Continuous Quality Improvement.

• It is implemented as a partnership in 36 health facilities in rural Uganda.

• To measure the impact of OSS on outpatient care, the Ministry of Health (MoH) Management Information System (HMIS) was strengthened.

• 18 sites were randomly assigned to receive OSS for 9 months before the others.

• Results of outpatient care performance for IDCAP sites at baseline (Nov ’09 – Mar ’10) are reported.

• Outpatient performance data on patient visits are collected using a modified MoH Medical Form 5 (MF5).

• The HMIS is facilitated with a computer, printer, power backup/supply system, internet powered data transmission equipment and a data entry assistant. This facilitates entry, cleaning, analysis and transmission of MF5 data.

• Using the MF5 data, IDCAP tracks 26 indicators.• Total number of patient visits were 238,248• Health professionals involved in outpatient care

routinely complete the MF5.

MF5 before modification by UMSP

MF5 after modification by IDCAP

Results

• Results indicate that site study randomization was effectively implemented.

• Subsequent analysis will compare results of outpatient care performance after 9 months of intervention with those of baseline across each phase.

• The MoH now considers adopting the new MF5 to strengthen data and drug supply systems

Baseline outpatient clinical care performance indicators

• Results at baseline indicate that; – HIV screening at patient visit especially for patients less

than 18 months and TB suspects was very low.– Assessment for pneumonia among patients with a

history of cough and no other TB symptoms was low. – Coverage of TB smear exam among suspects was low. – Microscopy among malaria suspects was also low. – Appropriate treatment of malaria was high. – Treatment of patients with malaria negative results was

relatively high. • Note that: OSS aims at having a positive impact on site

performance on all the indicators.• At 95% Confidence Interval, critical t-value of 2.042

(degrees of freedom = 30), there was no evidence of a statistically significant difference between Phase1 and Phase2 sites in outpatient care performance at baseline.

An IDCAP Laboratory Technologist (Left) conducting individual mentoring to a Site Staff: Photo by Sylvia Munube

Indicator N -Phase1

N- Phase2

Mean - Phase1

Mean - Phase2

t-Value

HIV Screening

% Outpatients >=14 years with known HIV status 18 18 11.0% 6.8% 1.1285

% Outpatients 18 months – 13years with known HIV status 18 18 6.4% 1.7% 1.4245

% Outpatients <18 months with known HIV status 18 18 3.4% 0.6% 1.2443

% Outpatients TB suspects >=14 Years with known HIV Status 18 18 17.2% 11.6% 1.0251

% Outpatients TB suspects <14 Years with known HIV Status 18 18 5.2% 1.6% 1.0249

Case Management of Respiratory Illnesses

% Outpatients <5 years with cough < 2 weeks and no other TB symptoms assessed for pneumonia

18 18 5.8% 3.7% 0.5388

% Outpatients <5 years diagnosed with pneumonia treated with an appropriate antibiotic

18 18 57.6% 51.7% 0.7575

% Outpatient TB suspects >=14 Years with 1st AFB Smear 18 18 13.2% 14.6% -0.3379

% Outpatient TB suspects <14 Years with 1st AFB Smear 18 18 1.9% 2.1% -0.1635

% AFB smear positive who start initial TB treatment or referred 16 15 42.8% 33.1% 0.7872

% Outpatients with AFB smear negative results who are started on empiric treatment

18 18 58.4% 50.1% 1.1688

Case Management of Malaria

% outpatients < 5 years appropriately treated among the treated for malaria 18 18 92.0% 93.7% -0.5702

% outpatients >=5 years appropriately treated among the treated for malaria

18 18 87.2% 88.3% -0.2206

% Malaria suspects >=5 years who get a diagnostic test 18 18 40.9% 39.9% 0.1410

% Malaria suspects < 5 years who get a diagnostic test 18 18 44.9% 44.9% 0.0000

% of patients >=5 years with a negative blood smear treated with any anti-malarials

18 18 42.9% 47.6% -0.6651

% of patients <5 years with a negative blood smear treated with any anti-malarials

18 18 60.1% 64.6% -0.7176

% of patients >=5 years with a positive blood smear treated with any antibiotic

18 18 44.3% 45.2% -0.1631

% of patients <5 years with a positive blood smear treated with any antibiotic

18 18 49.2% 53.2% -0.5925

Emergency Triage and Treatment

% Outpatients Triaged 18 18 27.6% 36.3% -1.0323

% Outpatients with emergency status of the triaged 18 17 3.1% 6.0% -1.1611

% Outpatients with priority status of the triaged 18 17 15.4% 20.7% -0.6366

% of priority patients admitted, detained or referred 17 17 14.4% 20.1% -0.9253

I----------------Year 1 ----------------I---------------- Year 2 ----------------I----------------Year3----------------I

Baseline Data Collection

Develop and Test Curriculum

Phas

1 (1

8 Si

tes)

Ph

ase2

(18

Sit

es)

Collect data and analyze it to evaluate impact of IDCAP on Site Performance and trainees competence

------------------IDCAP Evaluation Design--------------------

IDT Booster 1st and 2nd (At 3 and 6 months respectively)

Document & Disseminate

Analyze Cost-Effectiveness

. Distance Learning facilitated by AIDS Treatment Information Center (ATIC)

On-Site Support

IDT (3 week core course before the intervention)

Distance Learning facilitated by ATIC

IDT Booster 1st and 2nd (At 3 and 6 months respectively)

IDT (3 week core course before the intervention)

On-Site Support

Objectives

Design

Accordia’s IDCAP Partners

Acknowledgments1. Uganda Malaria Surveillance Project

(UMSP)2. IDCAP implementing health facilities

Poster # 169

Conclusions