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