Quality of Care, a global perspective : The future of quality of care

Transcription

1 Quality of Care, a global perspective : The future of quality of care Kevin De Cock, CDC Kenya

2 Quality of Care, A Global Perspective: The Future of Quality of Care Kevin M. De Cock, MD Country Director, CDC Kenya 2 nd EACS Conference Brussels, November 16-17, 2016 Division of Global HIV/&TB CDC Kenya

3 From Tropical Medicine to Global Health People are beginning to realize that there is nothing in the world so remote that it can t impact you as a person William H. Foege Director, CDC, Ebola, Zaire AIDS IOM Report on EID Investing in Health World AIDS Conference World AIDS Conference MDGs SARS PEPFAR WHO Global Action Plan on NCDs Ebola, West Africa Paris Climate Change Conference

4 Tropical Medicine, International Health, or Global Health? State of the Union Address January 28, 2003 President Bush announces U.S. President s Emergency Plan for AIDS Relief

5 Health Impact: Progress Towards MDGs 4 & 5

6 (WHO, 2016) Malaria Burden by GNP, and Access to Diagnostics and ACTs, 2015

7 Trends in Tuberculosis in the Era of ART

8 WHO ART Guidelines, 2002

9 Tuberculosis standardized therapy, safe therapy, everywhere.

10 HIV Science, Policy and Program Convergence

11 Differentiated Models of Care for ART Client-centred approach that simplifies and adapts HIV services across the cascade to reflect the preferences and expectations of various groups of people living with HIV (PLHIV) while reducing unnecessary burdens on the health system. By providing differentiated care the health system can refocus resources to those most in need.

12 Non-AIDS cancers CVD Osteoporosis Depression Diabetes mellitus Frailty Cognitive disorders Chronic liver disease COPD Chronic renal disease

13 Leapfrogging Cell phones E-banking Informatics, e-health Molecular diagnostics Point of care tests Vaccines Public health approach to ART

14 Global Health Post-Ebola and the MDGs Emerging Issues Universal health coverage Non-communicable diseases Emerging and reemerging infections Antimicrobial resistance Climate change Injuries Source: Emerg Infect Dis 2013;19:

15 Silver Linings and Gathering Clouds Economic growth Security and conflict Migration Corruption Population growth Environment and resources Climate change

16 Population Growth and Urbanization

17 Towards an AIDS-free Generation

18 By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases

19 The First 90

20 Total Homa Bay Siaya Kisumu Migori Nyamira Samburu Kwale Bomet Narok Kakamega Taita Taveta Mombasa Murang'a Turkana Nakuru Kajiado Baringo West Pokot Laikipia Kilifi Nairobi County Elgeyo Marakwet Lamu Tana River Makueni Vihiga Nandi Kisii Mandera Trans Nzoia Bungoma Garissa Nyandarua Machakos Isiolo Wajir Tharaka Nithi Busia Embu Kericho Kiambu Kirinyaga Kitui Marsabit Meru Nyeri Uasin Gishu Identification of PLHIV 16% 15% 14% 13% 12% 11% 10% 9% 8% 7% 6% 5% 4% 3% 2% 1% 0% Comparison of Overall and Remaining Prevalence after accounting for PLHIV already in care prevalence "remaining prevalence" APR15 6.5million tests done 3%HIV+ yield Source: NACC&NASCOP, 2014 HIV Estimates; PEPFAR Kenya APR 2015 Analysis

21 Outpatient Department VCT co-located VCT standalone Inpatient VMMC Mobile Tuberculosis HIV Care and Treatment Clinic Home-based Other Service Delivery Point Sexually Transmitted Infections HIV+ Yield for Different Testing Approaches ,0% ,2% 18,0% 16,0% ,0% 14,0% 12,0% 10,0% ,9% ,5% 4,6% ,6% 2,5% 4,3% 1,6% 2,9% 3,7% ,0% 6,0% 4,0% 2,0% - 0,0% HIV Positive Yield Source: PEPFAR APR 2015 Analysis

22 Maximizing HIV Testing Yield Provider-initiated HIV testing and counseling Assisted Partner Services (partner notification) Family testing Home-based testing Community testing Self-testing

23 The Second 90

24 Superior Outcomes with Same-Day HIV Testing and ART Initiation, Haiti 120% 100% 80% 60% 40% 20% 0% 100% Standard vs. Same-day ART* 100% 100% 92% 71% 80% Completed CD4 count Initiated ART Alive and in Care at 12 months Standard (285) Same Day (Test /Treat) (279) 50% 61% Alive with undetectable VL Same-day ART initiation was associated with ART uptake 100% vs 92%, p<0.001 Improved retention with viral suppression aor 1.76 (95% CI ; p=0.002) Reduced risk of mortality aor 0.35 (95% CI ; p=0.021) *Serena Koenig, et al., GHESKIO, Haiti, AIDS 2016

25 Treatment Adherence: Recommendations Effective interventions Peer counsellors Mobile phone text messages Reminder devices Cognitive behavioural therapy Behavioural skills training /medication adherence training Fixed dose combinations and once daily regimens WHO Guideline Dissemination Workshop, Johannesburg, South Africa, April 25-29, 2016

26 Differentiated Models of Care for ART Client-centred approach that simplifies and adapts HIV services across the cascade to reflect the preferences and expectations of various groups of people living with HIV (PLHIV) while reducing unnecessary burdens on the health system. By providing differentiated care the health system can refocus resources to those most in need.

27 5-10yrs 2-5yrs 1-2yrs <1yr EVIDENCE OF DIFFERENTIATED CARE MODELS IN KENYA ART PRESCRIPTION PRACTICES BY DURATION ON TREATMENT* days >90 days days >90 days days >90 days days >90 days 0% 9% 13% 17% 18% 14% 14% 17% 21% 21% 42% 39% 30% 31% 35% 83% 41% 58% 61% Average ART clinic visits, FY15** Adults: 4.9 per year Peds: 5.1 per year 86% 0% 10% 20% 30% 40% 50% 60% 70% *CHAI Kenya. Cross-sectional Assessment of ART prescription practices, 2016; **PEPFAR Kenya Expenditure Analysis, FY15

28 EVIDENCE OF DIFFERENTIATED CARE MODELS IN KENYA Rapid ART Refill for Stable Patients Bomu Hospital, Kenya Clinician assesses for rapid ART refill eligibility If eligible, refill prescription (3-6 months) Triplicate form (pharmacy, file, patient) 3 months maximum dispensed Refill visit: 3 months. Reception and direct to pharmacy Advised to come to the clinic if become ill. If new WHO stage 3/4, rapid refill suspended Clinic visit: Every 6 months, full review, CD4/VL done 3-day return visit for lab review Source: Bomu Medical Center, 2016 Viral suppression: 88%

29 KENYA MODEL OF DIFFERENTIATED CARE APPROACH BASED ON DURATION OF ART Care of patients within First Year of ART Care of patients beyond First Year of ART Advanced HIV Disease Those who present well Unstable Patients Stable Patients WHO Stage 3 or 4 CD4 count 200 cell/μl/ (or 25% for children 5 years old) WHO Stage 1 or 2 CD4 count > 200 cell/μl (or > 25% for children 5 years old) Weekly follow-up until ART initiation, and then at week 2 and 4 after ART initiation, and then monthly for the first 6 months of ART Eligible for Community ART Service delivery as a package of Care

30 CRITERIA FOR A HEALTH FACILITY TO IMPLEMENT A COMMUNITY-BASED ART DISTRIBUTION PROGRAM Health Information Systems Has a functioning system in place to monitor and report patient-level outcomes Leadership Involvement of County Leadership Focal person to oversee distribution Program Finance To implement and monitor communitybased ART distribution Commodity Management Currently has 3 months stock of ARV on site Has capacity (including personnel and supplies) Human Resources Appropriate personnel for distributing ART: Capacity to train and supervise ART distributors Service Delivery Uptake of routine VL monitoring is 90% Has functional system in place for fast-tracked facility-based ART distribution for stable patients

31 OPERATIONAL ISSUES Adherence support Rapid referral Retention Program evaluation Peer educator collecting ARV drugs at AMPATH Clinic. Photo used with permission Supply chain issues increased need for ARV supply Patient related issues with bulky prescription

32 The Third 90

33 Viral Load Testing in Kenya National Viral Load Testing Labs Rapid scale up of VL Testing: 2015 Jan- Dec: 649,366 (83% viral suppression) 2016 Jan Aug: 657,610 (84% viral suppression) Challenges: Prolonged turnaround time Equipment breakdown/downtime Commodity stockouts HR challenges Uneven distribution of workload Sub-optimal lab-clinical interphase Delivery of results to patient files Utilization of results by clinicians

34 Suppression rates (% of total tests) Viral suppression by age, SAPR % 90% 39,0 33,0 35,0 39,0 14,0 80% 70% 60% 50% 40% 86,0 30% 61,0 67,0 65,0 61,0 20% 10% 0% <5 5 to <10 10 to <15 15 to < Age (years) Suppressed Not suppressed

35 Measuring Progress and Impact

36 90:90:90 Impact Program targets, not impact measures Ratios, not rates People can drop out and re-enter Need cohort analysis Need electronic medical records Critical impact indicators are HIV incidence and death, possibly TB trends

37 Nairobi Mortuary Study, 2015 The death rate is a fact, everything else is an inference William Farr,

38 Measuring the Cycle of HIV