achieving program targets: an hiv care cascade approach molly mcnairy and bill reidy, icap-ny march...
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Achieving Program Targets: An HIV Care Cascade Approach
Molly McNairy and Bill Reidy, ICAP-NYMarch 28, 2013
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Webinar Overview
1. Background2. Examples of low target performance3. Dimensions of the problem: M&E & Clinical4. Introduce a cascade approach 5. A case study6. Toolkit inventory
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Webinar Overview
1. Background2. Examples of low target performance3. Dimensions of the problem: M&E & Clinical4. Introduce a cascade approach 5. A case example6. Toolkit inventory
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Background
• There are many reasons why a program may face challenges reaching key targets
• Even the highest-functioning program can have low target performance
• It is important that we address these challenges on an ongoing basis
• Country teams have various methods for monitoring progress to targets (e.g., ongoing DQA, reports to funders, slide sets, URS)
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URS Targets Dashboardhttps://urs2.icap.columbia.edu/#dashboard
Filter by country and time period
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URS Targets Dashboard
Export data to Excel sheet
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Webinar Overview
1. Background2. Examples of low target performance3. Dimensions of the problem: M&E & Clinical4. Introduce a Cascade approach 5. A case example6. Toolkit inventory
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ART Initiation: Swaziland
Oct-Dec 2011 Jan-Mar 2012 Apr-Jun 20120
2,000
4,000
6,000
8,000
10,000
12,000
New and cumulative patients on ARTCDC Rapid Scale-up Year 3
New on ART Cumulative on ART
Quarter
Num
ber o
f pati
ents
Target = 11,296 by Oct 2012
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APR 2012 report to CDC Re-counted numbers0
5000
10000
15000
20000
25000
30000
35000
# ART patients# ART patients retained
Retention on ART: Mozambique
50%
59%
Target = 85% retained
*Excludes patients who transferred out
*
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Pediatric TB screeningOne OPD facility: Tanzania
week 3 jan week 4 jan week 1 feb0
20
40
60
80
100
120
140
160
180
200
attendedscreened
8%
25%
32%
Target = 100% screened
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Webinar Overview
1. Background2. Examples of low target performance3. Dimensions of the problem: M&E & Clinical4. Introduce a Cascade approach 5. A case example6. Toolkit inventory
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Low performance may have multiple and overlapping M&E-Clinical components
M&E Clinical• Data quality• Data availability• M&E system issues
• Structural barriers• Staffing issues• Health system issues
Solution = must include both components
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Webinar Overview
1. Background2. Examples of low target performance3. Dimensions of the problem: M&E & Clinical4. Introduce a cascade approach 5. A case study6. Toolkit inventory
![Page 14: Achieving Program Targets: An HIV Care Cascade Approach Molly McNairy and Bill Reidy, ICAP-NY March 28, 2013](https://reader030.vdocument.in/reader030/viewer/2022032707/56649e215503460f94b0dd63/html5/thumbnails/14.jpg)
A Cascade Approach: Why?
• A care cascade outlines the multiple steps in a clinical pathway needed to achieve optimal health outcomes.
• The target of interest is part of a larger cascade of care in which the previous steps affect the target
• Improving the entire cascade will lead to improvements in the target as well as other targets simultaneously
• Improving the entire cascade will lead to more sustainable improvements
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Steps in the Cascade Approach
1. Identify steps in the cascade that relate to target
2. Identify baseline data to operationalize the cascade
3. Choose priority sites4. Choose interventions and prioritize them5. Use a cohort methodology to monitor
progress
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1. Identify steps in the cascade that relate to target
• The cascade’s steps are specific to the disease (i.e. HIV, TB) and the patient population (i.e. adults, children, pregnant women/infants).
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ART Eligible
Link
McNairy, El-Sadr AIDS 2012
Adult Care & Treatment
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TB Suspect
Tuberculosis
TB Disease TB Treatment
Retain, counsel monitor and
support
Prevent recurrence,
ongoing screening
Evaluate for TB disease
Screen
TB Treatment Success
Fayorsey, Howard 2013
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2. Identify Baseline Data to Operationalize Cascade
• Where to get baseline data for a cascade?• Routinely-reported M&E data, e.g.:
– Country aggregate databases – URS
• Original data collection from clinics
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What source to use for baseline data?
• Routinely-reported M&E data – Advantages:
• historical data is readily available• data available for many facilities • collection requires no additional efforts
– Disadvantages: • indicators not flexible (may not measure what you need)• data may have quality issues
– Particular danger when target shortfall is in part due to M&E system issues
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What source to use for baseline data?
• Original data collection from clinic– Advantages:
• have access to all data collected• high level of flexibility in defining set of indicators• can use highest-quality data available• may be used to compare to reported M&E data
– Disadvantages: • burden of data collection• lack of a large amount of historical data for comparison
• If at all possible, advisable to collect original data to supplement routine M&E data
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3. Determining & Prioritizing Interventions
• Root cause Analysis/Driver Diagram
• Focusing Matrix
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Driver Diagram
• A tool to facilitate root cause analysis– Articulates the aim of the campaign– Organizes primary categories for reasons
contributing to low performance– Subdivides categories into specific reasons– Facilitates a specific intervention tied to each
reason
An example…
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Primary Drivers
Secondary Drivers Interventions
Aim
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Driver Diagram
• Step 1: Aim– Target– Numerical goal for improvement– Time frame– Location (place or # of clinics)
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Increase ART initiations by at least 30% in 3 months at 15 priority
clinics
Primary Drivers
Secondary Drivers Interventions
Aim
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• Step 1: Aim– Time frame– Location
• Step 2: Primary Drivers – Make a list of broad categories of factors that
must be addressed to achieve aim
Driver Diagram
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Increase ART initiations by at
least 30% in 3 months at 15 priority
clinics
Provider/Patient
Supplies (CD4/Lab)
Drugs
Primary Drivers
Secondary Drivers Interventions
Aim
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• Step 1: Aim– Time frame– Location
• Step 2: Primary Drivers – Make a list of factors that must be addressed to
achieve aim• Step 3: Secondary Drivers
– Specific problems under each category• Step 4: Match specific interventions to each driver
Driver Diagram
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Increase ART initiations by at least 30% in 3 months at 15 priority
clinics
Provider/Patient
Knowledge of WHO staging
Staging posted in clinics, train providers
Eligible patient but not on ART
Outreach, phone calls, home visits
Patient refuses ART Assign peer counselor
CD4/Lab
ART
Primary Drivers
Secondary Drivers Interventions
Aim
Continue to fill in and complete boxes for all secondary drivers and interventions
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Focusing Matrix
• Tool to aid in prioritizing interventions• Uses both importance and ease of
implementation to rank priority
An example…
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Focusing MatrixIMPORTANCE
1(Least)
2 3 45
(Most)
1(Hardest)
2
3
4
5(Easiest)
Ease
of I
mpl
emen
tatio
n
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Focusing MatrixIMPORTANCE
1(Least)
2 3 45
(Most)
1(Hardest)
2
3
4
5(Easiest)
Ease
of I
mpl
emen
tatio
n
most important and easiest to implement – #1 priority
# 2 priority
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Item #
Proposed Intervention ImportanceEase of
Implementation
AWHO staging posted in clinics to be reference for providers 3 5
BIdentify ART eligible patients who have not yet initiated ART and call them to return
5 5
C Fix broken CD4 machines 5 1
DOutreach ART eligible patients at home if no show for appointment
5 3
EAssign peer counselor to patients who refuse ART 3 3
IMPORTANCE
1 2 3 4 5
1 C
2
3 E D
4
5 A B
EA
SE
of
IMP
LE
ME
NTA
TIO
N
Prioritizing InterventionsExample: Low ART Initiations (adult)
Interventions B and A should be first priority
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4. Choosing Priority Sites
Highest Volume Lowest Performance
65% 80% 42%
55% 30% 75%
20% 85% 66%
40% 35% 80%
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5. Cohort Methodology to measure change in performance towards target
• Goal is to assess impact of approach on relevant target and cascade indicators
• Impact must be sustainable• A cohort methodology:
1. Define cohorts of patients 2. Collect cascade data for cohort from source
documents3. Summarize graphically4. Review data and revisit intervention plans5. Repeat process 2-4 periodically (e.g., every month)
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Define Cohorts of Patients
• A cohort is a group of people sharing a common trait, usually defined by a point in time (e.g., birth cohort of people born in 1981)
• For this cascade approach, define cohort as any patient who entered the cascade during a specified time period, e.g.:– Patients testing HIV-positive at Kagera Regional
Hospital during January 2013– Patients enrolling in HIV care at RFM Hospital
during 2011
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Collect cascade data for cohort from source documents
• Operationalize the steps in relevant cascade– # enrolling in HIV care– # with ART eligibility assessed via CD4/WHO stage– # ART eligible– # initiating ART– # retained on ART (e.g., at 6 months, 12 months)
• Specify the best source of data for each step• Design simple tools (paper, Excel) for abstracting and
summarizing this data• Plan for periodic data collection
– Measuring retrospective improvements– Measuring improvements moving foward
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Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5
New pre-ART 86 NaN NaN NaN NaN
Assessed for ART eligibility 50 NaN NaN NaN NaN
Eligible for ART 28 NaN NaN NaN NaN
ART initiations 10 NaN NaN NaN NaN
5
15
25
35
45
55
65
75
85
95
Pre-ART enrollment, ART eligibility, and ART initiationsN
umbe
r of p
atien
ts
Summarize cohort in a graph
Intervention begins
58%
36%
20
71%
36%
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Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5
New pre-ART 86 81 NaN NaN NaN
Assessed for ART eligibility 50 59 NaN NaN NaN
Eligible for ART 28 31 NaN NaN NaN
ART initiations 10 18 NaN NaN NaN
5
15
25
35
45
55
65
75
85
95
Pre-ART enrollment, ART eligibility, and ART initiationsN
umbe
r of p
atien
ts
Summarize cohort in a graph
Intervention begins
58%
36%36%
73%
58%
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Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5
New pre-ART 86 81 95 NaN NaN
Assessed for ART eligibility 50 59 75 NaN NaN
Eligible for ART 28 31 40 NaN NaN
ART initiations 10 18 28 NaN NaN
5
15
25
35
45
55
65
75
85
95
Pre-ART enrollment, ART eligibility, and ART initiationsN
umbe
r of p
atien
ts
Summarize cohort in a graph
Intervention begins
58%
36%
73%
58%
79%
70%
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Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5
New pre-ART 86 81 95 79 NaN
Assessed for ART eligibility 50 59 75 75 NaN
Eligible for ART 28 31 40 41 NaN
ART initiations 10 18 28 36 NaN
5
15
25
35
45
55
65
75
85
95
Pre-ART enrollment, ART eligibility, and ART initiationsN
umbe
r of p
atien
ts
Summarize cohort in a graph
Intervention begins
58%
36%
73%
58%
79%
70%
95%
88%
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Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 5
New pre-ART 86 81 95 79 91
Assessed for ART eligibility 50 59 75 75 90
Eligible for ART 28 31 40 41 55
ART initiations 10 18 28 36 50
5
15
25
35
45
55
65
75
85
95
Pre-ART enrollment, ART eligibility, and ART initiationsN
umbe
r of p
atien
ts
Summarize cohort in a graph
Interventionbegins
58%
73%
58%
79%
70%
95%
88%
99%
91%
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Review data and revisit intervention plan1. Review pre- and post-intervention cohort data 2. Identify successes and ongoing challenges
• Take inventory of factors enabling program improvement
• Outline likely barriers to improvement
3. Consider revising intervention plan • Identify activities to keep in place, those to drop, and
any new activities to begin• Keep in mind sustainability of activities and
improvements Repeat this process as new cohort data becomes
available
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Webinar Overview
1. Background2. Examples of low target performance3. Dimensions of the problem: M&E & Clinical4. Introduce a cascade approach 5. A case study6. Toolkit inventory
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Case Study: ART Initiations
• ICAP Swaziland at end of Q3 reported reaching 50% of annual target for ART initiations
• Dimensions: M&E, Clinical • The Cascade approach was implemented with the
following steps and results1. Identify steps in the cascade that relate to target2. Identify baseline data to operationalize cascade3. Choose priority sites4. Choose interventions and prioritize them5. Use a cohort methodology
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1. Identify steps in the Cascade
1. # persons test HIV + (not reliable)2. # persons enroll in HIV care3. # persons assessed for ART eligibility (WHO,
CD4) 4. # persons eligible for ART5. # persons initiated ART
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2. Identify baseline data to operationalize cascade
Siphofan
eni C
linic
Shew
ula Clin
ic
Tikhuba C
linic
Mpolonjeni C
linic
Ndzevan
e Clin
ic
Lomah
asha C
linic
Vuvulan
e Clin
icSP
HU
Gilgal
Clinic
Simunye
Lubuli C
linic
Ubombo
Sincen
i Clin
ic
Nkonjw
a Clin
ic
Sitsat
sawen
i Clin
ic
Manye
veni C
linic
Sigcaw
eni
0
20
40
60
80
100
120
140
160
180
200
ART cascade, Lubombo Region facilities, Oct 2011 - Mar 2012
Enrolled in pre-ART Had WHO stage/CD4 at baseline ART eligible Started ART
Num
ber p
atien
ts
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3. Choose priority sites
• 10 largest volume clinics in 3 regions = 30 sites
• Volume was defined as # of patients enrolling in HIV care in the past quarter
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Choose interventions and prioritize them
1. Identify patients with known ART eligibility but no ART initiation and put them in a “expectant” patient box for expert clients to call to return to care
2. Introduce WHO Staging job aid to assist providers to assess patients for ART eligibility given reports of CD4 stock outs
3. Transfer reported CD4 results from lab registers to patient charts
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5. Introduce Cohort Methodology
• Identify steps in relevant cascade• Specify the best source of data for each step
– Pre-ART register, patient HIV medical care file• Design simple tools (paper, Excel) for abstracting and
summarizing this data– Excel sheet for data collection/management– Graph to display cascade data over time
• Identify cohort members– Cohorts will be defined by month of pre-ART enrollment
• For this presentation, initial baseline cohort will include 3 months combined• Expect to see changes prospectively and retrospectively
• Plan for periodic data collection
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Jun-Aug cohort Sep cohort Oct cohort Nov cohort Dec cohort
New pre-ART 3217 NaN NaN NaN NaN
Assessed for ART eligibil-ity
2892 NaN NaN NaN NaN
Eligible for ART 1703 NaN NaN NaN NaN
ART initiations 1124 NaN NaN NaN NaN
250
750
1250
1750
2250
2750
3250
Pre-ART enrollment, ART eligibility, and ART initiationsN
umbe
r of p
atien
ts
Additional post-intervention cohort data to-be collected
1356
66%
Intervention roll-out begins
80%
90%
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Supplemental M&E Component: Verifying national M&E data
• Collection of cascade data from sites allowed us to re-count national reported M&E data
• Recount of site-level ART initiations showed a substantial, systematic undercount in the national M&E data (generated by MOH database)
• Have since implemented a system for identifying patients not counted in M&E system, and having their information entered into MOH database
• Also working towards improving routine M&E processes so all patients are entered into database
• Discrepancy highlights need for routine conduct of in-depth data quality assessments (DQA)
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Re-count of ART initiation data
Q1 Q2 Q3
ICAP verified data
1882.7350594077
2364.36495832594
2425.89998226636
MOH rou-tine M&E data
1591 1998 2050
250
750
1,250
1,750
2,250
2,750
FY12 Quarterly ART initiations: ICAP supported sites
ICAP verified dataMOH routine M&E data
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Summary 1: Results after 3 Months
• Recall that ICAP Swaziland had reached only 50% of annual ART initiations target by the end of Q3
• Combined M&E and clinical efforts during Q4 allowed team to report reaching 81% of the target by project year end
• Findings from efforts informed target-setting for current year
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Summary 2: work is an ongoing process
1. Identify successes and ongoing challenges – Lack of SOP for expert clients calling back ART-eligible
patients develop SOP– Providers not listing f/u appt in chart or register
investigate frequency and cause in 10 clinics (3 per region)– Data still not systematically getting from primary clinics to
central clinics task team with MOH
2. Revisit intervention plan • Identify activities to keep in place, those to drop, and any
new activities to begin• Keep in mind sustainability of activities and improvements
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Webinar Overview
1. Background2. Examples of low target performance3. Dimensions of the problem: M&E & Clinical4. Introduce a cascade approach 5. A case study6. Toolkit inventory
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Toolkit
1. Cascade Approach Overview 2. Cohort Methodology3. Driver Diagram4. Focusing Matrix5. URS Reports 6. DQA SOP
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Acknowledgements
• Country team staff who are conducting cascade approach
• Especially ICAP in Swaziland who have seen much success
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Thank you!