The CIDRZ Experience: use of data to understand patient outcomes and guide program implementation 07 January 2010

Transcription

1 The CIDRZ Experience: use of data to understand patient outcomes and guide program implementation 07 January 2010 Dr C Bolton Moore Deputy Medical Director CIDRZ Ministry of Health Zambia University of Alabama at Birmingham

2 HIV in Zambia Population: 12 million HIV prevalence: 14.3% (down by 1.3%) New adult HIV infections rate is 1.6% per year (NAC 2009)

3 CIDRZ Zambian non-profit company, est 2000 Zambian Ministry of Health UAB, other US institutions 3 Part Mission Research Training Service Delivery Funding CDC, NIH, EGPAF, Doris Duke, Gates, GFATM, Fisher Found, UAB, Elton John, Oprah

4 CIDRZ/ EGPAF Comprehensive Support Model Personnel Training Overtime Recruitment and retention Clinical Quality Assurance Protocols and Forms Development Mentoring Laboratory Community Support groups counseling Physical Infrastructure Data / Patient Tracking Logistics and forecasting

5 Rapid Scale Up , 460 children enrolled 0 Nov-09 Oct-09 Sep-09 Aug-09 Jul-09 Jun-09 May-09 Apr-09 Mar-09 Feb-09 Jan-09 Dec-08 Nov-08 Oct-08 Sep-08 Aug-08 Jul-08 Jun-08 May-08 Apr-08 Mar-08 Feb-08 Jan-08 Dec-07 Nov-07 Oct-07 Sep-07 Aug-07 Jul-07 Jun-07 May-07 Apr-07 Mar-07 Feb-07 Jan-07 Dec-06 Nov-06 Oct-06 Sep-06 Aug-06 Jul-06 Jun-06 May-06 Apr-06 Mar-06 Feb-06 Jan-06 Dec-05 Nov-05 Oct-05 Sep-05 Aug-05 Jul-05 Jun-05 May-05 Apr-05 Mar-05 Feb-05 Jan-05 Dec-04 Nov-04 Oct-04 Sep-04 Aug-04 Jul-04 Jun-04 May-04 May 04 Nov 09 Enrolled in HIV Care On ART

6 PMTCT Services at 312 sites Oct Sep , , , , ,000 Counseled Tested 400,000 Positive 300, ,000 Maternal NVP Infant NVP 100,000 0

7 CIDRZ Data Collection National standardized forms and electronic medical record system Paper based clinical records Easier reporting: MoH, EGPAF, CDC, PEPFAR Assess patient level and facility level care Large data base: over 2,500,000 data fields entered per month

8 Using data: QA/QI team: monthly/ quarterly reports Targeted interventions/ training Improving patient care Assessing patient outcomes Cost effectiveness & sustainability Allocation of resources Assessing program impact Late/ LTFU Forecasting: pharmacy, laboratory, staff

9 Patient level reports Monthly/ quarterly reports from database Treatment failure Abnormal labs Viral load results PCR reports Paper files reviewed Corrective action ordered/ targeted interventions

10 Facility Performance indicators Monthly/ quarterly reports from database % Base line CD4, ALT, Creatinine, HB % Baseline Ht/Wt % CD4 repeated according to protocols % Eligible and on ART % Eligible & CTX Prophylaxis Reviewed by clinic staff Corrective actions

11 Lusaka Clinic performance indicators Q1- Q Base CD4 Base Ht/Wt Cd4 in 9/12 eligible on art pcp proph Base Alt Base Creat 3/12 visit

12 NO. ENROLLED Children enrolled May 04-Dec 09 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 Nov-09 Oct-09 Sep-09 Aug-09 Jul-09 Jun-09 May-09 Apr-09 Mar-09 Feb-09 Jan-09 Dec-08 Nov-08 Oct-08 Sep-08 Aug-08 Jul-08 Jun-08 May-08 Apr-08 Mar-08 Feb-08 Jan-08 Dec-07 Nov-07 Oct-07 Sep-07 Aug-07 Jul-07 Jun-07 May-07 Apr-07 Mar-07 Feb-07 Jan-07 Dec-06 Nov-06 Oct-06 Sep-06 Aug-06 Jul-06 Jun-06 May-06 Apr-06 Mar-06 Feb-06 Jan-06 Dec-05 Nov-05 Oct-05 Sep-05 Aug-05 Jul-05 Jun-05 May-05 Apr-05 Mar-05 Feb-05 Jan-05 Dec-04 Nov-04 Oct-04 Sep-04 Aug-04 Jul-04 Jun-04 May-04 May 04 Nov 09 MONTHS AGE 0-1 AGE 2-4 AGE 5-14

13 Early mortality Stringer et al Rapid Scale up of ART in Zambia JAMA 2006

14 Mortality in Paediatrics Bolton Moore et al Clinical Outcomes and CD4 Response in Children in Zambia JAMA 2007

15 Wt for age Z score

16 Distribution of adherence to ART over the first 12 months of treatment Chi et al. Adherence to first-line antiretroviral therapy in Lusaka, Zambia. Int J Epidemiol. 2009

17 Mortality by adherence Chi et al. Adherence to first-line antiretroviral therapy Int J Epidemiol. 2009

18 Post 90-Day mortality in adults initiating generic and proprietary formulations of ZDV -based ART Manuscript under development

19 Single Drug Substitution: TDF, AZT,D4T Chi, Early Clinical and Programmatic Outcomes with Tenofovir in Zambia: manuscript under review

20 Misclassification, % Defining Lost to follow up days 5.1% misclassified Overall Lost to Follow-up Threshold, days

21 What have we learned Scale up is possible while maintaining quality Good data collection and analysis can strengthen quality of care Data can be used in decision making at patient, facility and program level Ongoing quality assessment and improvement is critical to process at every level