www.ias2013.org kuala lumpur, malaysia, 30 june - 3 july 2013 sombat thanprasertsuk md, mph...

www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013

Rethinking care as part of the treatment cascade: what and how to measure quality of

care?

Sombat Thanprasertsuk MD, MPHDepartment of Disease Control, MOPH Thailand

2 July 2013


National ART Program, Thailand

• ART is provided by government and private hospitals• ART for all citizen is fully subsidized under 3 health

care benefit schemes– Universal Coverage by National Health Security Office

(NHSO) (case load share 60-70%)– Social Security Fund (10-20%)– Civil Servant Health and Medical Benefit (around 10%)


2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 -

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

Coverage 70%

Total need

Total received (current)

239,090

<2000


Gap 30%


Death21,116(10.8%) Loss to FU

17,015(8.7%)

Retain156,725(80.3%)

ART casesData from NHSO, up to end 2012 FY

Death322 (5.0%)

Loss to FU396(6.1%)

Retain5,730

(88.7%)


N=195,104 N=6,461

Stop med.248 (0.1%)

Stop med.248 (3.8%)

Adult Pediatrics


• Reduce disease burdens: – magnitude, mortality & morbidity – transmission– complication, etc.

• Standardized and harmonized treatment and care services

• Self monitoring and benchmarking at facility• Streamlining quality of care in HIV/AIDS with others

Why Quality Monitoring on HIV Care is needed?

Maintain retention, minimize drop out, improve coverage

Healthy PHA


• HIVQUAL: an approach developed by NYSDOH since 1992,

• Initiative for performance measurement (PM) and quality improvement (QI) in Thai HIV clinic

• HIVQUAL-T based upon 3 conceptual pillars1) HIVQUAL-T software for performance

measurement2) Quality improvement projects 3) Infrastructure building

• Integrated as cyclical process of repeated measurement and improvement

Introduction of HIVQUAL to Thai ART Program

Thailand MOPH, with technical collaboration from USCDC and NYSDOH, applied HIVQUAL-T since 2002


Development of HIVQUAL-T

12 hospitals 762 hospitals (84.7%) of all 77 provinces

HIVQUAL-T Pediatrics HIVQUAL-T

2005


QI Technical Committee

HIVQUAL-T Administration

Steering Committee

Monitoring and Evaluation Committee

8

Advisory committee

Local QI CommitteeRegional/Provincial

Regional QI Committee: Regional Offices of Health Security, Provincial Health, Disease Control, NGO, PHA hospitals

Provincial QI Committee: Provincial Health Office, NGO, PHA, hospitals


Activity to support Performance Measurement and Quality improvement activities

•Develop and revise HIVQUAL-T indicators according to national guideline for HIV/AIDS care and treatment

•Develop and revise guideline; and software to be friendly used, with automatic report printout at facility level

•Capacity building for personnel at all levels

•Develop website (www.cqihiv.com) to disseminate information on HIVQUAL-T: software, publication, educational slides, results of indicators, and stories


HIVQUAL-T Indicators• Group of indicators– CD4 Monitoring (5)– ART Monitoring (19)– OI Prophylaxis (10)– Disease Screening (17)– Health Promotion (12)

• Core indicators (12)• Optional indicators

(other)

Pediatrics HIVQUAL-T Indicators14 Indicators


Role of Hospital

• Measure performance – Collecting data from samples of cases– Key in HIVQUAL-T software and calculate results (data can

then be analyzed at provincial, regional and national level)– Compare overtime, analyze quality gap and causes;

benchmarking with target or with others

• Develop quality improvement (QI) projects – Analysis and formulate project/activity to fill in the gap– Monitor and evaluate the results

• Re-do performance measurement


Results of HIVQUAL-T, 2006-2010*by selected indicators

Year No. of hosp. participated

Case-list Sample

2006 233 48,879 10,9162007 651 93,639 35,4482008 658 118,775 41,6732009 701 138,844 48,6242010 107 16,071 8,069

Note * most hospitals participated in 2010 using a more advance version of software


Results of HIVQUAL-T, 2006-2010by selected indicators

Percent of patients receiving a CD4 test at least once during the review period (CD4)

2006 2007 2008 2009 201050

60

70

80

90

100

89.4 88.5193.09 96.06 97.63

%



Percent of patients receiving safe sex information or counseling (safe sex)

2006 2007 2008 2009 201050

60

70

80

90

100

89.29 87.6493.82 95.59 96.55

%



Percentage of patients reported sexual activity receiving syphilis screening (Syphilis)

2006 2007 2008 2009 20102030405060708090

32.07 25.1847.8

64.5

78.45

%



Percentage of female patients receiving PAP smear (PAP)

2006 2007 2008 2009 201020

30

40

50

60

70

80

27.25 26.19

47.91

63.772.86

%



Percentage of ARV patients receiving VL test at least once (VL)

2006 2007 2008 2009 20100

102030405060708090

6.64

35.08

61.66

76.4283.33

%


Results of HIVQUAL-T, 2010*-2012by selected indicators


Current cases

Sample of current

cases

New cases

Sample of new cases

2010 692 142,559 49,866 18,027 9,6302011 759 142,552 53,318 19,034 9,5912012 663 120,254 43,115 14,818 7,762

Note * some hospitals participating in 2010 used former version of software



Median of CD4 levels in HIV-infected patients who started ART in the assessment year at baseline (CD4_MD)

2010 2011 201220

40

60

80

100

120116 113

82.9

Cell/cu.mm



Percentage of HIV-infected patients with pulmonary TB screening (TB)

2010 2011 201250

60

70

80

90

10096.8 98.02 99.21%


Results of Pediatrics HIVQUAL-T, 2006-2011 by selected indicators


Case-list Sample

2005 10 2,070 9202007 26 3,496 1,9662008 78 5,454 3,2602009 48 5,080 2,8962010 324 9,878 6,9082011 366 10,286 7,772


Proportion of HIV-infected children on ART receiving a VL test during the review period (VL)

2005 2007 2008 2009 2010 201130405060708090

100

51.36 36.02

74.36

92.05 89.52 92.5%



Proportion of HIV-infected children on ART receiving adherence assessment in the last 3 visits during the review

period (Adh)

2005 2007 2008 2009 2010 20110

20

40

60

80

10095

60

8997 95 95

%



Results of selected indicators, HIVQUAL-T, 2006-2010


Results of selected indicators, HIVQUAL-T, 2010-2012


Results of selected indicators, Pediatrics HIVQUAL-T, 2005-2011


Discussion – Usefulness of HIVQUAL-T

• HIVQUAL-T, model proven to be a powerful tool to monitor and improve quality of HIV care– Hospitals not in HIVQUAL, found to have less performance level in

several indicators, using the same measurement tool– Move on to other QI program such as STIQUAL, or if possible

HEALTHQUAL

• Approach in HIVQUAL-T – Hospital or facility based, voluntary– Less workload, sampling to measure, meaningful data, according

to indicators developed– QI intervention, its formulation and implementation, based on

local analysis and context, exchange of stories among hospitals– Continuous process in measurement and quality improvement,

including human capacity development


• Sustainability issue– Linkage to Hospital Accreditation system– Advocate to move towards humanized approach

• Holistic care• Empowerment of patients, becoming partner in service• Engaging more stakeholders/counterparts

– Other tools to strengthen QI process• Clinical tracer in HIV care• Composite indicators

Discussion - Challenge


Acknowledgement

• IAS2013• National Health Security Office

Dr Sorakij Bhakeecheep, Senior Manager, Fund Management of HIV/AIDS and TB

• Bureau of AIDS, TB and STIs, DDCDr Sumet Ongwandee, DirectorDr Cheewanan Lertpiriyasuwat

• Thailand MOPH-US CDC CollaborationDr Achara TeeraratkulDr Chitlada UtaipiboonDr Rangsima Lolekha Dr Ake-chittra Sukkul

• New York State Department of HealthDr Bruce Agins

• All hospitals and agencies participating in HIVQUAL-T


Thank you for your kind attention

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