cross-sectional assessment of patient outcomes using a systematic file review process
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Cross-sectional assessment of patient outcomes using a systematic file review process. Ambereen Jaffer, Gesine Meyer-Rath, Malebo Maponyane, Aimee Malingan, Ebrahim Variava, Francois Venter. Background. - PowerPoint PPT PresentationTRANSCRIPT
Cross-sectional assessment of patient outcomes using a systematic file review process
Ambereen Jaffer, Gesine Meyer-Rath, Malebo Maponyane, Aimee Malingan,
Ebrahim Variava, Francois Venter
2005
Background
RHRU provides technical assistance with HIV related clinical services and capacity building via training and mentorship to Department of Health antiretroviral (ARV) clinic in Gauteng, KZN and North-West provinces.
Wellness clinic at Klerksdorp Hospital is one of the largest partnering treatment sites, providing services to close to 6000 patients requiring HIV related care.
One of the first sites in South Africa to establish a down/up referral model. Referral model is enabling the clinic to continue to initiate large number of patients on ARVs.
2005
Background
With the increasing number of clients, management of data and defaulters has become an area of concern for the clinic.
In June 2006, the clinic leadership asked RHRU for assistance. A retrospective review of all patient files since the ARV roll out initiated in April 2004 was deemed necessary.
2005
Background
Developed & piloted a one page data collection tool.
Over 70 (clinical & non-clinical) individuals from DoH, RHRU & Aurum participated in the file review activity in July 2006.
Two additional file reviews have been conducted at: ARV Clinic at Johannesburg Hospital: Completed Jan 2007 Wellness Clinic at Taung Hospital, NW: Completed Mar 2007
2005
Background
Interested in finding out :How many patients are currently on treatment?How many patients have been down-referred?How many patients are lost to follow-up?What regimens are the patients on?Side effects, treatment changes, other illnesses informationCD4 & viral load information on the patients
2005
Results - Klerksdorp
Total of 5750 files were reviewed.
Approx 63% of patients accessing service at this clinic are females & 36% are males.
Mean age of patients is 38 yrs
Patients files were classified as follows: Active Patients Pre-ART Defaulters (never started on ARVs & did not return after initial visit
which was >6 weeks ago) Down Referred Post Treatment Defaulters (Started on ARVs but have not returned to clinic
in > 6 weeks since the last clinic or pharmacy visit). Deceased
2005
Results: Klerksdorp
Current Status of all patients (n=5750)
41%
23%
19%
14%
2%
1%
Actively accessing care
Pre-ART Defaulters
Down referred
Post ART Defaulters
Died
Unknown
2005
Results: Klerksdorp
68% of all patients have been initiated on ART
Current Status of patients initiated on ART (n=3900)
51%
27%
20%
2%
Actively accessing care
Down referred
Post ART Defaulters
Died
2005
Results: Klerksdorp
31% of the total patients have not been initiated on ARVs
Current status of patients NEVER initiated on ARVs (n=1754)
22%75%
2%
1% Actively accessing care
Pre-ART Defaulters
Down referred
Died
2005
Results: ART Regimen
ARV Regimens
1% 2%2%
96%91%
3% 5%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1A 1B 2 Other
Regimens
% o
f p
ati
en
ts
Initial Regimen
Last Regimen
Only 5% of patients had a change in regimen. The top few reasons for changes in regimen were Pregnancy, Toxicity:
Lactic Acidosis, Toxicity: Peripheral Neuropathy, and Viralogical Failure.
2005
Result: Co-morbidities
Occurrence of TB in the full cohort: 34% Co-morbidities not mutually exclusive Crypto underreported
Most prevalent co-morbidities(n= 2640)
73.3%
11.1% 8.4%1.1% 0.9% 0.9% 0.5% 0.5% 3.2%
0%10%20%30%40%50%60%70%80%
TB
Hyp
ert
en
sio
n
*Cry
pto
co
cca
l
Me
nin
gitis
Ep
ilep
sy
Ka
po
si
Sa
rco
ma
Ch
ron
ic lu
ng
dis
ea
se
Ca
rdia
c
dis
ea
se
Dia
be
tes
Oth
er
Co-morbidities
% o
f a
ll c
o-m
orb
idit
ies
2005
Down Referral
Percentage of patients on treatment downreferred to partnering sites (n=1065)
32%
16%12%
8% 7% 5% 3% 3% 2% 2% 1% 1%
10%
0%5%
10%15%20%25%30%35%
% of patients down referred
Dow
n re
ferr
al s
ites
2005
Results: CD4 Counts
The mean and median baseline CD4 count for all patients were 103 cells/mm3 and 95 cells/mm3 respectively.
The mean & median baseline CD4 counts for patients Initiated on ART were 101 cells/mm3 and 96 cells/mm3 respectively.
The mean & median baseline CD4 counts for patients NOT initiated on ART were 109 cells/mm3 and 94 cells/mm3 respectively.
Absolute Median Baseline CD4 counts of patients initiated and not initiated on ARVs distributed by age
(n=5479)
020406080
100120140
15-24 25-34 35-44 45-54 55+
Age range (years)
Med
ian
valu
es
Initiated ontreatment
Not initiated ontreatment
2005
Results: Defaulter Information
Age & Gender distibution of Treatment defaulters (n=793)
13%
35%
7%
43%
3%
15%
2%
32%
48%
4%
0%
20%
40%
60%
15-24 25-34 35-44 45-55 55+
Age Range (years)
% D
efa
ult
ing
Females
Males
2005
Results: Defaulter Information
Patient defaulting time frame(n=765)
26%30%
17%13%
5% 4% 3% 1% 0.3% 0.1%0%5%
10%15%20%25%30%35%
<1 1-3 4-6 7-9 10-12 13-15 16-18 19-21 22-24 >24
Months since treatment initiated
Per
cen
tag
e o
f al
l p
atie
nts
def
ault
ing
2005
DISCUSSION
A large number of patients accessing care at the wellness clinic are women. This is congruent with the patterns seen at other HIV clinics around the country.
Less than half of the patients who have visited the clinic since it opened in 2004, are currently actively seeking services at this facility.
Post Treatment defaulters (21%) are a major concern for clinic. These patients are at high risk of developing drug resistance and earlier onset of AIDS. It is imperative to identify defaulters early and get them back on treatment as soon as possible.
2005
DISCUSSION
The file review identified Pre-Treatment Defaulters as another group equally at risk as the Post-Treatment defaulters.
They were probably tested for HIV and in most cases a CD4 count was also done, and they were clinically staged.
There are multiple areas where these patients could have been lost to follow up. The clinic may have lost them after the first appointment, during or after other treatments such as for opportunistic infections, TB, STIs, etc, or while attending the adherence training session.
From the information collected during this review, it is not possible to identify where and when the clinic has lost these patients. However, a detailed review of the files of these patients may reveal reasons/patterns for defaulting.
2005
DISCUSSION
It is important to find out how well the down referral system is working. One way to ascertain this is by reviewing files of the patients at the respective down referral sites.
If the down referral system is found to be effective, it will considerably ease the pressure on the tertiary health care facilities and improve quality of services through out the referral network.
2005
Recommendations
Development and implementation of appropriate data recording and storing mechanisms, Processes to closely monitor and follow up patients initiating on treatment, Systems to immediately identify pre & post treatment defaulters and have them return to the clinic, Inquire into reasons why patients default on treatment, Appropriate follow up processes for patients who are not eligible to start
on ARVs – either because their CD4 is greater than 200 or they have to complete treatment of other opportunistic infections, Standardizing down referral systems and protocols Inquiry into the low percentage of regimen changes at this site.
2005
Challenges & Benefits of File Reviews
Challenges Resource Intensive
Need HR for audits Need HR for DQA
Buy in from clinic staff & leadership imperative
Need people with minimum understanding of HIV care & treatment
Benefits Get an accurate picture of the
situation
Identify the weak areas and propose appropriate interventions.
Building the clinic staff capacity to understand the importance of the information collected and to assist them to continue with such activities
2005
Future Plans
Continue with file reviews at partnering DoH sites
Create a file review package of services for other agencies & DoH sites
Support clinic staff to conduct periodic file reviews.
Klerksdorp & Jhb Hospital: Have put in place a defaulter tracer program based on the outcomes
of the file reviews. Evaluate this program.
2005
Comparative Analysis-Johannesburg & Klerksdorp Hospitals
Johannesburg Hospital ARV Clinic
Mean age of patients: 36 years
63% Females; 36% Males
Initiated on ART: 79%
Side Effects noted: 33%
Klerksdorp Hospital Wellness Clinic
Mean age of patients: 38 years
64% Females; 36% Males
Initiated on ART: 68%
Side Effects noted: 4%
2005
Johannesburg Hospital File Review
Jhb Hospital: Current Patient Status (n=3488)
59%16%
6%
18% 1%
Actively accessingcare
Pre-ART Defaulters
Down referred
Post ART Defaulters
Died
Klerksdorp Hospital: Current Patient Status (n=5750)
41%
23%
19%
14%
2%
1% Actively accessingcare
Pre-ART Defaulters
Down referred
Post ART Defaulters
Died
Unknown
2005
Comparative Analysis-Johannesburg & Klerksdorp Hospitals
Jhb Hospital: Current Status of patients initiated on ARVs (n=2755)
72%
4%
23%0.7%
Actively accessing care
Down referred
Post ART Defaulters
Died
Klerksdorp Hospital: Current Status of patients initiated on ART (n=3900)
51%
27%
20%
2%
Actively accessing care
Down referred
Post ART Defaulters
Died
2005
Acknowledgements
This project is funded by PEPFAR
AcknowledgementsDepartment of Health – NW ProvinceGauteng Provincial GovernmentKlerksdorp Hospital Wellness Clinic Leadership & Staff Johannesburg Hospital ARV Clinic Leadership & StaffAurum RHRU Team