point-of-care cd4 testing to improve patient-important outcomes: a health system perspective
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Point-Of-Care CD4 Testing to Improve Patient-Important Outcomes: a Health System Perspective . Ilesh V. Jani, MD PhD Instituto Nacional de Saúde Maputo, Mozambique. After Introduction of POC CD4 LTFU before CD4 staging dropped from 57% to 21% . - PowerPoint PPT PresentationTRANSCRIPT
Point-Of-Care CD4 Testing to Improve Patient-Important Outcomes: a Health System Perspective
Ilesh V. Jani, MD PhDInstituto Nacional de Saúde
Maputo, Mozambique
After Introduction of POC CD4 LTFU before CD4 staging dropped from 57% to 21%
Observational cohort study in 4 primary health care facilities in Mozambique
Comparison of before and after implementation of POC CD4 counting
From: Jani (2011)
After Introduction of POC CD4 ART Initiation Rate Increased from 12% to 22%
From: Jani (2011)
After Introduction of POC CD4 Time to ART Initiation Reduced from 48 to 20 Days
From: Jani (2011)
2009 2010 2011
• Technical protocols• Selection of
technologies• Technical and field
evaluations• Pilot design
• Pilot in 7 health facilities
• Impact evaluation
2012
• National scale-up• 110 health facilities
in 2013• 25% of ART patients
with access to POC CD4
• Implementation in one province
• Strategy for national scale-up
2013 2014 2015
• Evaluation of other technologies
• Implementation research• Planning of
implementation
Timeline for Evaluation and Implementation of POC CD4 in Mozambique
Where and How to Implement POC CD4?
Co-existence of POC and conventional instruments in the same network
Development of a tool that considers 7 objective criteria for CD4 POC deployment
Implementation based on lessons learned during a provincial pilot
Operational issues (training, quality control, supervision) are key
Clinic workflow and health system issues are a significant challenge
Point-Of-Care Testing Is Not Error Proof
From: Plebani (2009)
Implementation of Point-Of-Care Tests Is Not Always Done Efficiently
From: Jani (2011)
National Scale-Up of POC CD4• 2011: Pilot in 1 province
• 2012-2013: 110 health facilities nationally
• 2013: ~25% of patients in care with access to POC CD4, >400,000 POC CD4 tests
• Multiple partner effort and cooperation with COORDINATION AT NATIONAL LEVEL
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2012
2013
Effective Implementation of POC Testing Requires Coordination
Provincial Implementati
on
INS
MOH Prov. Gov.
Prov. Partne
rs
Provincial Coordination
Site Matrix
POC ToT
Train Sites
Site Introduction
Continuous Monitoring
Preliminary site list is generated from matrix tool.
Provincial stakeholder meetings, site list is validated.
Central team trains provincial trainers.
Provincial trainers train and certify POC operators.
Sites are mentored. New patient flow diagrams implemented and sites begin to apply POC.
EQA, site supervision, remote monitoring.
Combined Off-site Regional Training with an On-site Workshop for POC CD4National master trainers from the INS led a regional training-
of-trainers in each province
4-8 regional trainers were trained per province
Regional trainers led several 5-day off-site operator trainings in their respective provinces
Following the operator trainings, trainers conducted a one-day on-site workshop at each site receiving a POC device
POC testing extends laboratory services to non-classical settings - the laboratory perspective is critical!
National Managers Monitor Real-time Utilization Data
Modems transmit data daily on device
utilizationManagers target
facilities for remote and on-site follow-up
Follow-ups help minimize errors and
downtime
Follow-up triggers:
High Error Rates
Low Utilizati
on
Device Not
Operating
User Not
Certified
Not Running Controls
External Quality Assessment Helps to Identify Sites with Potential Problems
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5.0CD4 Absoluto
SDI
Data from Mozambique’s National EQA for CD4 Counting
Final Considerations
•POC tests have an important role in increasing access to health care and improving patient-important outcomes
•Evaluations and implementation should be conducted under a health system perspective (and not a given health facility or specific NGO in mind)
•Smart partnerships and strong coordination are strategic to the success of POC diagnostics
•The final impact of POC assays will be shaped by various factors, especially by weaknesses of health systems
Targeted Improvements Necessary to Address the Challenges for Expanded Testing
Revise policy and normative guidance• Cost and cost-effectiveness of POC testing• Testing guidelines• Clinical algorithms• Decentralization of services
Focus Areas Key Improvements
Improve operational systems• Product regulation• Supply chain• Training• Quality Assurance
Drive streamlined clinic services• New staff cadres and shifts• Patient scheduling• Bundled procedures• Improved medical records
Decentralization and retention Initiatives
• Community-based testing• Linkage to care• Integrated services• Adherence tools
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From: Jani & Peter (2013)
Setting: 20,000 pop. in the shores of Lake Niassa.
Strategy: Each 2 months, 2 community workers, without formal health qualifications, perform a circuit of 220km on foot and/or kayak to serve 8 villages.
The Access to Quality Testing in Hard-To-Reach Areas Is Possible