Tracking of Inter-Facility Patient Transfers and Retention on Antiretroviral Treatment in Namibia Presenter Naita Nashilongo Ministry of Health and Social Services Authors: Pereko, Dawn (1) ; Sumbi, Victor (1) ; Mazibuko, Greatjoy (2) ; Mabirizi, David (1) ; Wellwood, Sandya (3) ; Brandt, Laura (3) ; Lates, Jennie (2) ; Naita Nashilongo (2) ; Kangudie, Mbayi (4) Affiliations: (1) Management Sciences for Health/ Strengthening Pharmaceutical Systems; (2) Ministry of Health and Social Services; (3) International Training and Education Center for Health; (4) United States Agency for International Development

Background The population of Namibia is highly mobile. This presents some challenges in the management of clients with chronic diseases such as those with HIV on Antiretroviral Treatment (ART). The public sector of Namibia started provision of ART services in 2003 and by June 2011, more than patients were recorded by the public sector pharmacies as receiving ARV therapy Patient retention on treatment is critical to the success of any ART program The Electronic Dispensing Tool (EDT) enables pharmacy staff at the facility level to manage their patients, monitor patient adherence, monitor stock movements and quantify ARV needs for their facility. It is a real time tool that is updated upon dispensing medicines to a patient

Background (2) By July 2011 the EDT was installed in 42 main ART sites. The tool also flags patients who miss appointments making it easier to identify clients who may not be adherent. Some outreach sites that have been upgraded to full ART sites used manual records initially when first established until they acquire EDT computers EDT data is aggregated into a National Database (NDB) that is based in Windhoek. Data from the NDB is used to monitor various aspects of the ART program and to inform policy and decision making. NDB data was used for this study

Background (3) Provision has been made in the EDT reporting system to record when patients transfer-in and transfer-out of different facilities in Namibia. Monthly facility EDT reports identified patients who transferred out of facilities. However the EDT systems in different facilities are not linked, therefore it was not clear whether these patients reported at another facility or were lost to follow up. Furthermore, the referral procedure in use was unidirectional resulting in the referring facility not knowing if the referred patient had reached and been enrolled in the ART program at the receiving facility. 4

Objectives & Assessment Questions Aim of study The aim of the assessment was to determine the level of patient retention in therapy in Namibia for patients who were transferred out of one facility to another. Specific objectives Determine number of patients enrolled in treatment in 2008 in any public health facility who transferred out before the end of Dec Determine the number and percentage of patients who were re- admitted into care at any facility after having been transferred out from any public health facility in Namibia. Determine the status of all re-admitted patients (as at Sept 2009) Determine if there was a treatment gap between transfer out and re- admission, and if so, how many days. 5

Methods (1) All patients started on ART in 2008 and who were flagged as “transferred out” on the EDT’s National Database (NDB) by 31 December 2008 were identified. The NDB was then used to identify patients who appeared again, (after the date of their transfer out), under a different status. The status of identified patients as of 30 September 2009 was determined as follows: The date of previous pharmacy appointment for each patient was checked. If this was on, or after, 29 th June 2009, the patients were classified as active. If it was 3 months before 30 Sep 2009, the patients were classified as lost to follow up (“LTFU”). The status of “LTFU” patients was further clarified and the “LTFU” status corrected for those identified as deceased or as having stopped treatment. The remainder remained classified as LTFU. 6

Methods (2) The time interval between transfer out from one facility and re- admission into the next facility was computed thus: The date of transfer out from the first facility (D 1 ) was compared with the date of arrival at new facility (D 2 ). The time difference in days between D 1 and D 2 was computed. For patients who appeared in more than 2 facilities: The status on 30 September 2009 was calculated using data from the last facility at which the patient had received medicines. 7

Methods (3) The treatment gap was calculated as follows: [Time interval in days between transfer out and re-admission (as calculated above)] minus [Number of days of ARV medicines dispensed at the last visit before patient was transferred out was recorded (D d )] Treatment gap (D int ) = [D 2 - D 1 ] – D d If D int was ≤0, then there was no treatment gap For patients not found after transfer out, patient files at their original facility were used to: determine the clinical state of the patient at time of transfer out determine the appointment keeping pattern of the patient prior to transfer out try to identify which facility they were transferred out to 8

Results (1) *Of all 202 patients re-admitted, 77% were still active on treatment, 1.5% had died, and 12% were lost to follow up. 9.5% were either stopped by physician or had missing data DescriptionNumber (%) Patients initiated on ART in 2008 (January to December) Patients transferred out by 31 December (100%) Tracing of transferred out patients -Transferred into other facilities (from NDB records) -Transferred into other facilities (from manual records) -Not found after transfer out 125 (27.4%) 77 (16.9%) *202 (44.3%) 254 (55.7%) 9

Results (3) Treatment gap (days)% patients (Number) (N=65) 0 (no treatment gap)62% (40) % (6) % (5) % (1) % (4) % (2) Unknown10% (7) 10 Treatment gap observed for transferred out patients Electronic dispensing data were available for only 65 of the 202 patients found to have been re-absorbed after being transferred out

Discussion During the study period the referral system in use for ART patients was uni-directional; the patients were issued with a transfer-out letter from the referring facility to the new facility. There was no direct communication between the two facilities, therefore if the patient did not arrive at the new facility then there was no mechanism to follow them up. Due to the loss of patients who were being transferred out, a bi-directional referral system is now being developed and will be piloted in four of the 13 regions from December

Recommendations Transferred out patients should be carefully monitored to ensure that they arrive at the facility they have been referred to. With improved monitoring of transferred out clients the proportion of patients who are either lost or LTFU after transfer should be significantly reduced. The bi-directional transfer system will ensure that clients are carefully monitored and those that do not arrive are reminded to report for treatment A unique identifier must be developed for each patient in order to ease the process of tracking patients country wide 12

Conclusions A facility-based electronic patient record system in conjunction with a national data repository is useful in tracking patients between ART sites in a country with high patient mobility. The transfer of patients between facilities without adequate and appropriate monitoring may contribute to patients being lost from HIV care and treatment. Appropriate patient tracking and referral measures must be put in place to ensure that receiving facilities expect the transferring patient and referring facilities are given feedback on their arrival. A successful feedback loop will allow facilities to follow-up non- arrival of patients in their new sites in a timely manner, promoting a decrease in the interval between transfer out and re-uptake, and thereby increasing patient retention on treatment. 13

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