1. From Aggregate Indicators to Impacting Patients - Data Use to Inform Treatment and Improve Care Ian Wanyeki Track 1.0 Implementers Meeting Dar Es Salaam August 4 th – 6 th 2009 Ian Wanyeki Providing Treatment, Restoring Hope

2. Goals Maximize patient health outcomes Build capacity of service providers for sustainable quality care and treatment Work with Facility and AR Clinical Team Departments to integrate CQI into daily routine Improve overall quality of AIDSRelief supported HIV care and treatment programs

3. Overview What must they collect? Facility based quarterly reports What else do they collect? Information in medical charts, log books How often do they look at it? Graph and trend analysis Present findings to clinical/CQI/SI teams How can they use it? Small Test of Change (STOC – based on PDSA model) Repeat…

4. 2 practical examples 1.Baseline and Repeat CD4 counts 2.Missed ARV (pharmacy) pick up analysis

5. Aggregate Data Trends Baseline and Repeat CD4 counts Facility Based Quarterly Report showed very low numbers of CD4 tests compared to the number of patients eligible for tests Additionally, the median CD4 count among patients receiving the test was low Medical Evidence influencing prioritization of CD4 tests as indicator of focus Higher mortality and LTFU among patients with CD4 <200 at ART start Program Needs Low enrollment of patients onto ART thus not meeting targets

6. Mortality and Starting CD4 (n=5651) p < 0.001

7. A large # of missing CD4s No CD4 and CD4 <50 had lower retention than all other groups.

8. Not all receiving Baseline CD4 count and Low CD4 at enrollment

9. CD4 Indicator Trend to Action: STOC Overarching Goals Increase access to therapy Engage patients earlier in disease progression Below Patient Targets (August 07) Number of eligible patients (estimated 3,000) Number of patients with unknown CD4 (~2000) Lessons from the ground: Community efforts to support patients were not in place Patient monitoring was a major problem e.g. CD4 @ baseline and 6 months

10. CQI Team Plan Improve clinical systems and care Promote communication within and between hospitals Maximize use of CD4 cell counts in initiating & monitoring therapy Improve clinic flow Staff Education & Training Emphasize National Guidelines require CD4 Didactic sessions : IRS /Lab tests/Staging Patient Ownership/empowerment Stimulate patient participation in healthcare Stay healthy longer Be an active partner Public asks for their own care

11. STOC Focal Areas Triaging: Patient sent for CD4 if data not in chart Pharmacy: adequate drugs on site Community: sensitization campaigns Health Talks: What does a CD4 Count mean? Training of PLHIV and community volunteers as CD4 ambassadors VCT/TB centers- referrals Lab: Inventory of lab equipment Coordination meeting @ each hospital then among hospitals

12. Planning for the know your CD4 campaign

13. Know Your CD4 Campaign

14. CD4 at enrollment

15. Patient Adherence - Rwanda STOC: Improving ARV pick up Why: Many patients appeared to be defaulting on their scheduled ARV collection Data verification of our # of active patients on ART Opportunity Coincided with computerization of data and regular feedbackcomputerization Medical Evidence Patients who miss doses are less likely to be suppressed than patients that do not Patients that miss appointments are less likely to be suppressed than patients that do not

16. Self reported doses missed in the last week and viral suppression Missed Doses Not Suppressed Suppressed No 369 (11.36%) 2878 (88.64%) Yes 68 (20.86%) 258 (79.14%) p < 0.001

17. Self reported appointments missed in the last 3 months and viral suppression Missed Appointment Not Suppressed Suppressed No 370 (11.42%) 2871 (88.58%) Yes 60 (16.95%) 294 (83.05%) p < 0.01

18. Building Support and Belief The initial reaction from the site teams was that the numbers of clients reported as missing their ARV pick-ups was too high and not possible! 184 patients in August 2008!!!! Was this a data quality issue, or were in fact many clients going missing? Possible data quality issues included the following: Clinician’s failure to update the medical record at each clinic visit Data entry clerk’s failure to upload the medical records to IQChart Patient transfers to another site but not recorded in the medical record Patient deaths not recorded in the medical record

19. Team approach used for STOC 1.Data validation and routine feedback to clinical team 2.Refresher training 3.Strengthened community support system 4.Strengthened routine patient monitoring and facility-community collaboration

20. Results over time

21. Summary Multidisciplinary Team Approach Mentoring Team & Site Team Just the minimal data sites are aggregating tells us a lot Simple frameworks to support data use are easily integrated into day to day activities (STOC) Facilities are owning the process and improving outcomes for sustainable medically driven programming

22. Thank You