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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 University of Alabama at Birmingham Ministry of Health Zambia
Transcript of The CIDRZ Experience: use of data to understand patient .../media/Files/Activity Files/Global... ·...
The CIDRZ Experience: use of data
to understand patient outcomes and
guide program implementation07 January 2010
Dr C Bolton Moore
Deputy Medical Director
CIDRZ
University of Alabama at Birmingham
Ministry of Health
Zambia
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)
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
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
Rapid Scale Up
0
50000
100000
150000
200000
250000
Ma
y-04
Jun
-04
Jul-0
4
Au
g-0
4
Se
p-0
4
Oct-0
4
No
v-0
4
De
c-0
4
Jan
-05
Fe
b-0
5
Ma
r-05
Ap
r-05
Ma
y-05
Jun
-05
Jul-0
5
Au
g-0
5
Se
p-0
5
Oct-0
5
No
v-0
5
De
c-0
5
Jan
-06
Fe
b-0
6
Ma
r-06
Ap
r-06
Ma
y-06
Jun
-06
Jul-0
6
Au
g-0
6
Se
p-0
6
Oct-0
6
No
v-0
6
De
c-0
6
Jan
-07
Fe
b-0
7
Ma
r-07
Ap
r-07
Ma
y-07
Jun
-07
Jul-0
7
Au
g-0
7
Se
p-0
7
Oct-0
7
No
v-0
7
De
c-0
7
Jan
-08
Fe
b-0
8
Ma
r-08
Ap
r-08
Ma
y-08
Jun
-08
Jul-0
8
Au
g-0
8
Se
p-0
8
Oct-0
8
No
v-0
8
De
c-0
8
Jan
-09
Fe
b-0
9
Ma
r-09
Ap
r-09
Ma
y-09
Jun
-09
Jul-0
9
Au
g-0
9
Se
p-0
9
Oct-0
9
No
v-0
9
Enrolled in HIV Care On ART
May 04 Nov 09
16, 460
children
enrolled
PMTCT Services at 312 sites Oct 2001 - Sep
2009
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
900,000
Counseled
Tested
Positive
Maternal NVP
Infant NVP
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
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
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
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
0
10
20
30
40
50
60
70
80
90
100
Base CD4 Base Ht/Wt Cd4 in 9/12 eligible on art pcp proph Base Alt Base Creat 3/12 visit
Lusaka Clinic performance indicators Q1- Q3 2009
Children enrolled May 04-Dec 09
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
Ma
y-0
4
Ju
n-0
4
Ju
l-04
Au
g-0
4
Se
p-0
4
Oct-0
4
No
v-0
4
De
c-0
4
Ja
n-0
5
Fe
b-0
5
Ma
r-05
Ap
r-05
Ma
y-0
5
Ju
n-0
5
Ju
l-05
Au
g-0
5
Se
p-0
5
Oct-0
5
No
v-0
5
De
c-0
5
Ja
n-0
6
Fe
b-0
6
Ma
r-06
Ap
r-06
Ma
y-0
6
Ju
n-0
6
Ju
l-06
Au
g-0
6
Se
p-0
6
Oct-0
6
No
v-0
6
De
c-0
6
Ja
n-0
7
Fe
b-0
7
Ma
r-07
Ap
r-07
Ma
y-0
7
Ju
n-0
7
Ju
l-07
Au
g-0
7
Se
p-0
7
Oct-0
7
No
v-0
7
De
c-0
7
Ja
n-0
8
Fe
b-0
8
Ma
r-08
Ap
r-08
Ma
y-0
8
Ju
n-0
8
Ju
l-08
Au
g-0
8
Se
p-0
8
Oct-0
8
No
v-0
8
De
c-0
8
Ja
n-0
9
Fe
b-0
9
Ma
r-09
Ap
r-09
Ma
y-0
9
Ju
n-0
9
Ju
l-09
Au
g-0
9
Se
p-0
9
Oct-0
9
No
v-0
9
NO
. E
NR
OL
LE
D
MONTHS
AGE 0 - 1 AGE 2 - 4 AGE 5 - 14
May 04 Nov 09
Early mortality
Stringer et al Rapid Scale up of ART in Zambia JAMA 2006
Mortality in Paediatrics
Bolton Moore et al Clinical Outcomes and CD4 Response in Children in Zambia JAMA 2007
Wt for age Z score
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
Mortality by adherence
Chi et al. Adherence to first-line antiretroviral therapy Int J Epidemiol. 2009
Post 90-Day mortality in adults initiating generic
and proprietary formulations of ZDV -based ART
Manuscript under development
Single Drug Substitution: TDF,
AZT,D4T
Chi, Early Clinical and Programmatic Outcomes with Tenofovir in Zambia: manuscript under review
2004
2005
2006
2007
Overall
Mis
cla
ssific
ation, %
0
2
4
6
8
10
12
14
16
18
20
Lost to Follow-up Threshold, days
0 30 60 90 120 150 180
56 days
5.1% misclassified
Defining Lost to follow up
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
