icap quarterly data dissemination meeting
DESCRIPTION
ICAP Quarterly Data Dissemination Meeting. September 25, 2009. Data Dissemination Meeting. Welcome Ideas for future Data Dissemination Meetings Please email Suzue Saito: [email protected] 2 nd quarter data (April-June 2009) available on URS 872 of 904 facilities reporting (96%) - PowerPoint PPT PresentationTRANSCRIPT
ICAP Quarterly Data Dissemination Meeting
September 25, 2009
Data Dissemination MeetingWelcome
Ideas for future Data Dissemination MeetingsPlease email Suzue Saito: [email protected]
2nd quarter data (April-June 2009) available on URS872 of 904 facilities reporting (96%)
Excluding Swaziland sitesCare and treatment: 47,950 newly enrolled patients and 25,353 newly
initiating ART (cumulative 327,092)PFaCTS Round 4 nearly completed
PMTCT: 118,259 women tested and received resultsTB screening: 13,746 new HIV patients screened fpr TB
Counseling and testing: 239,592 clients, plus 10,141 TB patientsMore details in forthcoming eUpdate, URS, data dissemination page
We want your data slides ([email protected])
Data Dissemination MeetingMatthew Lamb, Maria Lahuerta & Denis Nash
ICAP-MER NY Sept 25th, 2009
Patient-level data
Monitoring
EvaluationResearch
An orientation to monitoring, evaluation,
and research using routinely-collected care and treatment patient-
level data
1) Intro to care and treatment patient-level data available at ICAP sites
2) Routine program evaluation and dissemination• Country reports, site reports and SOC reports
3) Operations ResearchTheoretical framework: Identifying Optimal Models of HIV care
• Examples4) Strengths and Limitations
Outline
1) Intro to care and treatment patient-level data available at ICAP sites
2) Routine program evaluation and dissemination• Country reports, site reports and SOC reports
3) Operations ResearchTheoretical framework: Identifying Optimal Models of HIV care
• Examples4) Strengths and Limitations
Outline
Routinely-collected care & treatment data
Program/site-level characteristics
Patient-level data
Aggregate indicators
Routine M&E Operations Research
Common-structure patient-level database for sites with electronic patient-level data
Simplifies the development of automated quarterly feedback reports
Enable comparison across sites and countries
ICAP patient-level data warehouse
ICAP common patient-level data warehouse
Common patient-level data
warehouse
MZ
KY
TZ
RW
SA
CDI MTCT+
Current
Coming soon
Closed
Not sharing
Not available
ET
SW
LT
NI
Patient-level data flow, security, and confidentiality
Site-level electronic data entry intocounty-specific database
Regional/Country Aggregation of site databases
Password protectionRoutine backup
Transfer to ICAP-NY
Conversion to common data warehouse format
Site reports
Country reports
SOC reports
Anonymization & Merge Tool
Password protectionencryption
Routine backupStorage of archival dataRestricted access
Analysis file for research
ICAP patient-level data warehouse elements
Enrollment Table• Basic
demographic information • Age• Sex• enrollment
date• Prior ARV use• Point of entry• Transfer
Visit Table: Visit date, WHO stage, height, weight, Hb, ALT, nextscheduled visit date
CD4 Table: CD4 test date, CD4 count, CD4 percent
ART Table: ART regimen, regimen start & end date,reason(s) for switching ART regimen
Medication Table: TB screening date and result, TB medicationreason (treatment or prophylaxis) and dates, CTX & fluconazole
Status Table: Patient disposition status (dead, transferred, withdrew, LTF, stopped ART, etc) and status date
Pregnancy Table: Visit date, weeks gestation at visit, due date, actual pregnancy end date
Baseline: 1 rowPer patient Follow-up data: 1 row per measure per patient
*measures at key points of interest (e.g., enrollment, ART initiation) calculated based on visit dates
ICAP patient-level database through June 2009
COUNTRYSites w/
electronic DB (% over
total)
Sites submitting
data to ICAP-MER NY
Cum # patients enrolled in Care
(% pediatric)
Cum # patients on ART
(% pediatric)
Kenya 6 (5%) 6 22,826 (11.4%) 12,815 (12.0%)
Ethiopia 44 (94%) 0 - -
Mozambique 27 (51%) 27 135,873 (6.6%) 45,160 (6.5%)
Rwanda 32 (64%) 32 33,228 (10.2%) 18,142 (10.5%)
South Africa 3 (7%) 3 5,726 (0.9%) 3,780 (0.3%)
Tanzania 20 (21%) 16 22,094 (7.2%) 10,751 (7.3%)
Cote d’Ivoire 13 (38%) 0 - -
Swaziland 9 (50%) 0 - -
MTCT-Plus* NA 14 10,161 (6%) 5,203 (8%)
TOTAL 154 (33%) 98 229,908 (9.8%) 95,851 (7.9%)
Enrollment into Care (N = 229,908)
Age and Sex distribution through June 2009, 98 sites
1) Intro to care and treatment patient-level data available at ICAP sites
2) Routine program evaluation and dissemination• Country reports, site reports and SOC reports
3) Operations ResearchTheoretical framework: Identifying Optimal Models of HIV care
• Examples4) Strengths and Limitations
Outline
• Overall picture of country programs• Provides between-site comparisons• Separate for adults and pediatric patients
Country reports
Country reports Adult patientsMozambique
Country reportsFigure 4.2 - Median (25th – 75th percentile) CD4 count at ART initiation:
adult patients initiating ART in the last year
Adult patientsMozambique
Country reports Adult patientsMozambique
The overall percentage is represented by a horizontal line
Figure 4.7 Proportion of patients receiving tuberculosis treatment at ART initiation among adult patients initiating ART in the last year
• Provide in-depth, site-specific feedback for program improvement to ICAP staff, as well as site and district staff
• Describe patient characteristics at enrollment and at ART initiation and patient outcomes
Site reports
Totaln (%)
Adultsn (%)
Childrenn (%)
Total 3075 (100) 2770 (100) 305 (100)Median (IQR) CD4 count at ART initiationa (≥5 years old) 154 (80-210) 151 (78-203) 361 (198-540) <50 cells/µL 252 (8.8) 245 (8.8) 7 (6.7) 50-99 281 (9.8) 272 (9.8) 9 (8.6) 100-199 676 (23.5) 668 (24.1) 8 (7.6) 200-349 375 (13) 356 (12.9) 19 (18.1) 350+ 115 (4) 67 (2.4) 48 (45.7) Missing 1175 (40.9) 1161 (41.9) 14 (13.3)WHO clinical stage at ART initiationa WHO Stage I 473 (15.4) 447 (16.1) 26 (8.5) WHO Stage II 322 (10.5) 251 (9.1) 71 (23.3) WHO Stage III 747 (24.3) 676 (24.4) 71 (23.3) WHO Stage IV 215 (7) 197 (7.1) 18 (5.9) Missing 1318 (42.9) 1199 (43.3) 119 (39)Clinical eligibility for ARTb at enrollment Eligible Ineligible
1465 (47.6) 1329 (48) 136 (44.6)746 (24.3) 659 (23.8) 87 (28.5)
Unknown 864 (28.1) 782 (28.2) 82 (26.9)Clinical eligibility for ARTb at ART initiation Eligible 1569 (51) 1403 (50.6) 166 (54.4) Ineligible 554 (18) 467 (16.9) 87 (28.5) Unknown 952 (31) 900 (32.5) 52 (17)
Table 3.2 Measures of immunodeficiency status at ART initiation: active patients currently on ART
Jose Macamo General Hospital
Mozambique
a: window period three months prior and one month postb: according to WHO guidelines
Site reports
Figure 3.4 Weight-for-age z-score at ART initiation: active children1 < 15 yrs currently on ART (CDC standard)
Weight-for-age missing: 22Weight-for-age out of range (z-score <-10 or >10): 10
Moderately or severely malnourished (z-score < -2): 87 (31.9%)Severely malnourished (z-score < -3): 44 (16.1%)
Jose Macamo General Hospital
MozambiqueSite reports
Figure 4.3 Two-year Kaplan-Meier curves of known death, loss to follow-up, and loss to program among ART patients since ART initiation
Jose Macamo General Hospital
Mozambique
Time (years) since ART initiation
At riskSurvivedNot LTF
Retained
Site reports
• Use patient-level data to calculate SOCs• Useful to identify site-level areas in need of
improvement• All patients as opposed to a sample of patients• Easily assess trends
ICAP Standards of Care (SOC) reports
ICAP Standards of Care (SOC) reports
Activity during the specified quartersCurrent quarter
Jan-Mar 2009
Previous quarter
Oct-Dec 2008
Two quarters ago
Jul-Sep 2008n (%) n (%) n (%)
Patients newly initiating ART 71 57 60On treatment within 1 month of known eligibility 16 (22.5) 13 (22.8) 19 (31.7)CD4 test within one month of ART initiation 37 (52.1) 36 (63.2) 38 (63.3)
WHO stage at ART initiation 3 (4.2) 11 (19.3) 11 (18.3)Weight at ART initiation 70 (98.6) 54 (94.7) 59 (98.3)At least one recorded height measurement 0 (0) 0 (0) 0 (0)Screened for TB at ART initiation 0 (0) 0 (0) 0 (0)Children <15 years newly initiating ART 3 (4.2) 3 (5.3) 2 (3.3)
Where to find the reports
1) Intro to care and treatment patient-level data available at ICAP sites
2) Routine program evaluation and dissemination• Country reports, site reports and SOC reports
3) Operations ResearchTheoretical framework: Identifying Optimal Models of HIV care
• Examples4) Strengths and Limitations
Outline
What is Operations Research?
“Operations research is being defined broadly and includes the use of analytical techniques to achieve better health outcomes, define optimal
processes of service delivery, and develop more cost-effective systems. It encompasses a wide range of studies, including observational and
outcomes studies, epidemiological modeling, and cost-effectiveness studies.”
From the Doris Duke Charitable Foundation, ORACTA program
Identifying Optimal Models of HIV Care
Contextual
Program/site-level
Patient-level
•Background HIV+ prevalence•Urban/peri-urban/rural
•National guidelines•Social norms, stigma, etc
•Facility type & size•Services offered
•Staffing characteristics•Monitoring frequency
•CD4/WHO stage•Baseline comorbidity
•Demographics•Point of entry
DHS data,Census data, etc
PFaCTS
Patient-level data
Identifying Optimal Models of HIV Care
Goals: 1. Assess the variation in key HIV care and
treatment outcomes within & across sites and countries• CD4/WHO stage at enrollment & ART initiation• Non-retention, loss to follow-up, and death• Treatment failure and regimen switching
2. Identify factors at multiple levels associated with patient & program outcomes, with a particular focus on program-level factors
Factors associated with Late ART initiationExample 1
No ad-vanced HIV
disease48%WHO Stage
IV36%
CD4 < 100
cells/µL64%
Definition of advanced HIV disease at ART initiation (late ART initiation)
•CD4 count <100 cells/µL or
•WHO Stage IV
A B C D E F G H I J K L M N O P Q R S T0%
10%
20%
30%
40%
50%
60%
70%Overall
proportion52%
Fig 1. Distribution of HIV disease status at ART initiation for the 24,273 eligible patients
Fig 2. Variability of the proportion late ART initiators by site
Example 2 Retention of ART patients
Two year LTF and known deaths among ART patients
Overall LTF 29%
A B C D E f G H I J K L M N O P Q R S0%
10%
20%
30%
40%
50% 47%
42%39% 39%
35% 35%
28%26% 26% 26% 25% 24% 24% 23%
19% 19% 18%
13%12%
0%
7%10%
6% 4%
12%
8%
2%5%
2%
10%7%
2% 3%
8%5%
7%4%
10%
% LTF at 24 months % Reported deaths at 24 months
Sites
Perc
enta
ge
Overall death
5%
1) Intro to care and treatment patient-level data available at ICAP sites
2) Routine program evaluation and dissemination• Country reports, site reports and SOC reports
3) Operations ResearchTheoretical framework: Identifying Optimal Models of HIV care
• Examples4) Strengths and Limitations
Outline
Uses of common patient-level data warehouse
M&E
Quality of CareResearch
Data Quality
Strengths
• Service delivery data from scale-up programs• Multiple countries and contexts• Adults and pediatrics• Longitudinal
– Retrospective to program start• Data from pre-ART phase of care• Variety of exposures and outcomes• Ability to examine impact of interventions,
changes in guidelines, etc.• Large sample size
Limitations
• Missing data (completeness)– Incomplete data entry– Incomplete documentation– Incomplete care
• Inaccurate data– Single data entry
• High rates of loss to follow-up– A mixed bag of unascertained deaths, transfers, and
drop outs– Precludes meaningful examination of survival as an
outcome
Figure 4.3 Two-year Kaplan-Meier curves of known death, loss to follow-up, and loss to program among ART patients since ART initiation
Jose Macamo General Hospital
Mozambique
Time (years) since ART initiation
At riskSurvivedNot LTF
Retained
Gatundu District HospitalKenya (intensive defaulter tracing)
Conclusions
• Over 154 of 510 (30%) ICAP-supported care and treatment sites have patient-level databases– 84 sites in 5 countries (17%) are submitting data to ICAP-NY on
a quarterly basis. Warehouse includes:• 229,908 of 754,086 pre-ART patients represented: 30%• 95,851 of 367,179 ART patients: 26%
– Data quality and completeness will be an ongoing challenge• Timely routine feedback/dissemination process in place
– Program evaluation– Program improvement
• SOC report
– Will help shed light on and address data quality issues• Platform for multi-country operations research in place
(Optimal Models protocols)
Future directions
• Feedback and dissemination, utilization, analysis• Need to understand more about reasons for
missing data for key variables, and how to impact it– Improving with time for some variables (e.g. CD4 at
ART initiation) and not others (e.g. height)• Improve ability to examine survival as an
outcome
Acknowledgements• Ashraf Fawzy, Caroline Korves• Senior M&E Advisors and teams
– Muhsin Sheriff– Veronicah Mugisha, Emmanuel Manzi– Maria Fernanda-Alvim, Matt Rosenthal, Carla Xavier– Molly Strachan, Harriet Nuwagaba-Biribonwoha– Kanchan Reed
• Ruby Fayorsey, Stephen Arpadi and Rosalind Carter (peds reports)
• ICAP NY M&E team (MER Liaisons)• ICAP Clinical Unit• ICAP Clinical Advisers