Use of Patient-Level HIV Care and Treatment Reports for Focused Site Support, Evidence-Based Decision Making, and More!

Matthew LambICAP-NYmrl2013@columbia.edu

Outline

• Brief overview: where the data comes from and how the feedback reports are generated

• How is patient-level data useful for clinical, programmatic, and SI purposes?

• How to read and use the patient-level feedback reports• Examples of use of patient-level data for epidemiologic

research

KY MZ TZ

Import and de-identification tool

Report Creator

ET RWUnique databases used in-country by ICAP

ICAP’s patient-level database

SA

Analysis File(one per country)

Analyses for abstracts and manuscripts

Country-level reports

AdultPediatricStandards of Care (SOC)

Site-level reports

Cohort ReportsStandards of Care (SOC)

Today’s focus

Patient-level feedback reports

Country-level Reports Site-level Reports

Adult Country Report Site Report

Pediatric Country Report

Standards of Care (SOC) Reports

Standards of Care (SOC) Reports

Patient-level information is available for 60% of patients ever attending ICAP-supported care and treatment clinics in 4 countries

URS reporting, Q1 2013 Patient-level data reporting, Q1 2013

Country Sites reporting Enrolling in HIV Care

Initiating ART Sites reporting (% of URS total)

Enrolling in HIV Care (% of URS total)

Initiating ART (% of URS total)

Ethiopia 276 197,756 127,799 48 (17%) 108,793 (55%) 65,579 (51%)

Kenya 260 240,172 124,858 46 (18%) 99,492 (41%) 50,064 (40%)

Mozambique 71 189,852 72,381 32 (45%) 147,341 (78%) 56,996 (79%)

Tanzania 208 125,852 67,968 74 (36%) 102,412 (81%) 58,100 (85%)

Total 815 753,632 393,006 200 (25%) 458,038 (61%) 230,739 (59%)

Countries no longer providing patient-level dataRwanda1 48 57,263 33,309 41 (85%) 43,427 (76%) 27,130 (81%)

South Africa2 66 113,549 71,608 3 (5%) 6,973 (6%) 4,597 (6%)

1 Rwanda totals are through March 2011 2South Africa totals are through March 2010

ICAP’s patient-level reports provide one tool to critically evaluate program performance

Country-level reports• Regular data dissemination meetings• Identification of problematic areas and/or sites• Identification of high-performing sites• Tracking trends in program achievement over time

Site-level reports• Preparation for site visits by M&E, clinical, and

program staff• Data Quality Assurance• Trends in enrollment and active patient population

Patient-level reports are complementary to other information collected for reporting

• What proportion of patients are initiating ART at advanced disease stage? Does this differ between sites?

• Does most LTF occur before or after ART initiation?

• Does the proportion of total program attrition attributable to LTF or recorded death differ substantially between sites?

• What proportion of patients are missing records of both CD4+ cell count and WHO staging at enrollment and ART initiation? Does this differ between sites?

Country-level reports

• Adult Country Report

• Pediatric Country Report

• Country-level SOC Report

Country-level Adult and Pediatric reports: Layout

• Summary paragraph

• Listing of sites (name and URS ID) contributing to the report

• Key characteristics of active patients, by gender

• Trends in number of active patients over time and % on ART

• Age and gender distribution at enrollment

• Between-site comparisons of enrollment characteristics

• CD4, WHO Stage, ART eligibility, cotrimoxazole provision, tuberculosis treatment

• Between-site comparisons of ART initiation characteristics

• CD4, WHO Stage, advanced disease at initiation, regimen characteristics

• Patient outcomes after enrollment into HIV care and ART initiation

• Recorded Death, LTF, attrition, combined and between-site comparisons

Cumulative enrollment in HIV care and on ART

Active adult patients this

quarter

Active patients this quarter

Follow-up characteristics

of those no longer active (LTF, death,

transfer)

Country Reports: Summary

Country Reports: Site listing

SiteID used for the rest of the report

Country Reports: Characteristics of Active patients at enrollment into HIV care and ART initiation

Patients not returning for a follow-up visit

may not have their CD4+

counts recorded

Overall and separate by gender

Country Reports: Trends in active enrollment over time

36.8%

74.1%

Between-site comparisons from Country Reports

Country Reports: Advanced HIV infection at ART initiation

SiteID

Per

cent

Country Reports: Between-site comparison of Death, LTF, and Attrition (LTP)

Country Reports: Summary

• Provides a useful snapshot summarizing key characteristics of the patient population enrolling into HIV care and initiating ART

• Enables a quick means of comparing key characteristics across sites within the same country

• Regional reports can also be generated

• Very useful for ICAP-NY and in-country clinical, SI, and programmatic staff to assess overall characteristics and differences between sites

• More detail on specific sites can be found in the site-level reports…

Site Reports

• Provide in-depth, site-specific summaries

• Useful in preparation for site visits, and to delve deeper into issues identified from the country reports

Site Reports: Layout similar to Country Report

• Summary paragraph• Trends in new patient enrollment over time

and % on ART• Key characteristics of active patients, total

and separated by adult/pediatric• Enrollment characteristics

• Point of entry, age and gender distribution, CD4, WHO Stage, ART eligibility, cotrimoxazole provision, tuberculosis treatment, anthropometric measures

• ART initiation characteristics• CD4, WHO Stage, advanced disease

at initiation, regimen characteristics• Patient outcomes after enrollment into HIV

care and ART initiation• Outcomes before and after ART

initiation• Survival curves

Site Reports: new patient enrollment over time shows impact of decentralization

Site Reports: Immunologic characteristics at enrollment

Site Reports: Patient retention

Site Reports: Summary

• Gives in-depth detail on characteristics of patients attending a given site, focusing on characteristics at enrollment into HIV care, ART initiation, and retention after these benchmarks

• Useful for site visit preparation to identify issues for focused supportive supervision

ICAP Standards of Care (SOC) Reports

• Calculates ICAP Priority Indicators of HIV care and other Standards of Care from the electronic patient-level databases

• Intended to provide information on the quality of HIV care and changes over time

• Available as an overall country SOC report and for each site reporting data

Most recent quarter

ICAP Standards of Care (SOC) Reports: Priority Indicators

ICAP Standards of Care (SOC) Reports: Pre-ART Standards of Care

ICAP Standards of Care (SOC) Reports: ART Standards of Care

ICAP Standards of Care (SOC) Reports: Notes on the Indicators

SOC Reports: Summary

• Allows us to track progress towards achievement of ICAP Standards of Care over time, and to look more deeply into issues affecting the quality of HIV care

• Many SOCs are calculated, such as:• Proportion with CD4 within 1 month of enrollment• Proportion eligible receiving CTX• Proportion initiating ART within 1 month of eligibility• Proportion with CD4 in the last 6 months• And more

• Useful in combination with Standards of Care calculated through sampling of clinical records• Comparing results between these will allow us to assess

the quality of the electronic patient-level database

We welcome suggestions for corrections, edits, and additions!

• These reports have evolved over time based on feedback from users

• If you see something that doesn’t seem right, please let us know and we can investigate

• Also, future ideas for enhancements are in the works• HIV care cascade• Changes to ART eligibility as countries adopt new

guidelines• Others?

The Automated Reports are available on the URShttp://urs2.icap.columbia.edu

The Automated Reports are available on the URShttp://urs2.icap.columbia.edu

Beyond the automated reports

… and many more in the pipeline

Questions?

http://urs2.icap.columbia.edu