achieving program targets: a n hiv care cascade approach

Achieving Program Targets: An HIV Care Cascade Approach

Molly McNairy and Bill Reidy, ICAP-NYMarch 28, 2013

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

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

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)

URS Targets Dashboardhttps://urs2.icap.columbia.edu/#dashboard

Filter by country and time period

https://urs2.icap.columbia.edu/#dashboard

URS Targets Dashboard

Export data to Excel sheet

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

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

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

*

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

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

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

Webinar Overview


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

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

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).

ART EligibleLink

McNairy, El-Sadr AIDS 2012

Adult Care & Treatment

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

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

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

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

3. Determining & Prioritizing Interventions

• Root cause Analysis/Driver Diagram

• Focusing Matrix

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…

Primary Drivers

Secondary Drivers Interventions

Aim

Driver Diagram

• Step 1: Aim– Target– Numerical goal for improvement– Time frame– Location (place or # of clinics)

Increase ART initiations by at least 30% in 3 months at 15 priority

clinics

Primary Drivers


Aim

• 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

Increase ART initiations by at

least 30% in 3 months at 15 priority

clinics

Provider/Patient

Supplies (CD4/Lab)

Drugs

Primary Drivers


Aim

• 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

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


Aim

Continue to fill in and complete boxes for all secondary drivers and interventions

Focusing Matrix

• Tool to aid in prioritizing interventions• Uses both importance and ease of

implementation to rank priority

An example…

Focusing MatrixIMPORTANCE

1(Least) 2 3 4 5

(Most)

1(Hardest)

2

3

4

5(Easiest)

Ease

of I

mpl

emen

tatio

n

Focusing MatrixIMPORTANCE

1(Least) 2 3 4 5

(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

Item # Proposed Intervention Importance Ease 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 I

MP

LEM

EN

TATI

ON

Prioritizing InterventionsExample: Low ART Initiations (adult)

Interventions B and A should be first priority

4. Choosing Priority SitesHighest Volume Lowest Performance

65% 80% 42%

55% 30% 75%

20% 85% 66%

40% 35% 80%

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)

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

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

Cohort 1 Cohort 2 Cohort 3 Cohort 4 Cohort 50

10

20

30

40

50

60

70

80

90

100

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%


10

20

30

40

50

60

70

80

90

100


umbe

r of p

atien

ts


Intervention begins

58%

36%36%

73%

58%


10

20

30

40

50

60

70

80

90

100


umbe

r of p

atien

ts


Intervention begins

58%

36%

73%

58%

79%

70%


10

20

30

40

50

60

70

80

90

100


umbe

r of p

atien

ts


Intervention begins

58%

36%

73%

58%

79%

70%

95%

88%


10

20

30

40

50

60

70

80

90

100


umbe

r of p

atien

ts


Interventionbegins

58%

73%

58%

79%

70%

95%

88%

99%

91%

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 improvement3. 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

Webinar Overview


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

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

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

Lomahash

a Clin

ic

Vuvulan

e Clin

icSP

HU

Gilgal C

linic

Simunye

Lubuli Clin

ic

Ubombo

Sincen

i Clin

ic

Nkonjwa C

linic

Sitsat

sawen

i Clin

ic

Manyev

eni 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

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

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

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

Jun-Aug cohort Sep cohort Oct cohort Nov cohort Dec cohort0

500

1000

1500

2000

2500

3000

3500


umbe

r of p

atien

ts

Additional post-intervention cohort data to-be collected

1356

66%

Intervention roll-out begins

80%

90%

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)

Re-count of ART initiation data

Q1 Q2 Q3 -

500

1,000

1,500

2,000

2,500

3,000

FY12 Quarterly ART initiations: ICAP supported sites

ICAP verified dataMOH routine M&E data

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

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 MOH2. 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

Webinar Overview


Toolkit

1. Cascade Approach Overview 2. Cohort Methodology3. Driver Diagram4. Focusing Matrix5. URS Reports 6. DQA SOP

Acknowledgements

• Country team staff who are conducting cascade approach

• Especially ICAP in Swaziland who have seen much success

Thank you!

achieving program targets: a n hiv care cascade approach

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