Cross-sectional assessment of patient outcomes using a systematic file review process

Ambereen Jaffer, Gesine Meyer-Rath, Malebo Maponyane, Aimee Malingan,

Ebrahim Variava, Francois Venter

2005

Background

RHRU provides technical assistance with HIV related clinical services and capacity building via training and mentorship to Department of Health antiretroviral (ARV) clinic in Gauteng, KZN and North-West provinces.

Wellness clinic at Klerksdorp Hospital is one of the largest partnering treatment sites, providing services to close to 6000 patients requiring HIV related care.

One of the first sites in South Africa to establish a down/up referral model. Referral model is enabling the clinic to continue to initiate large number of patients on ARVs.

2005

Background

With the increasing number of clients, management of data and defaulters has become an area of concern for the clinic.

In June 2006, the clinic leadership asked RHRU for assistance. A retrospective review of all patient files since the ARV roll out initiated in April 2004 was deemed necessary.

2005

Background

Developed & piloted a one page data collection tool.

Over 70 (clinical & non-clinical) individuals from DoH, RHRU & Aurum participated in the file review activity in July 2006.

Two additional file reviews have been conducted at: ARV Clinic at Johannesburg Hospital: Completed Jan 2007 Wellness Clinic at Taung Hospital, NW: Completed Mar 2007

2005

Background

Interested in finding out :How many patients are currently on treatment?How many patients have been down-referred?How many patients are lost to follow-up?What regimens are the patients on?Side effects, treatment changes, other illnesses informationCD4 & viral load information on the patients

2005

Results - Klerksdorp

Total of 5750 files were reviewed.

Approx 63% of patients accessing service at this clinic are females & 36% are males.

Mean age of patients is 38 yrs

Patients files were classified as follows: Active Patients Pre-ART Defaulters (never started on ARVs & did not return after initial visit

which was >6 weeks ago) Down Referred Post Treatment Defaulters (Started on ARVs but have not returned to clinic

in > 6 weeks since the last clinic or pharmacy visit). Deceased

2005

Results: Klerksdorp

Current Status of all patients (n=5750)

41%

23%

19%

14%

2%

1%

Actively accessing care

Pre-ART Defaulters

Down referred

Post ART Defaulters

Died

Unknown

2005

Results: Klerksdorp

68% of all patients have been initiated on ART

Current Status of patients initiated on ART (n=3900)

51%

27%

20%

2%

Actively accessing care

Down referred

Post ART Defaulters

Died

2005

Results: Klerksdorp

31% of the total patients have not been initiated on ARVs

Current status of patients NEVER initiated on ARVs (n=1754)

22%75%

2%

1% Actively accessing care

Pre-ART Defaulters

Down referred

Died

2005

Results: ART Regimen

ARV Regimens

1% 2%2%

96%91%

3% 5%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1A 1B 2 Other

Regimens

% o

f p

ati

en

ts

Initial Regimen

Last Regimen

Only 5% of patients had a change in regimen. The top few reasons for changes in regimen were Pregnancy, Toxicity:

Lactic Acidosis, Toxicity: Peripheral Neuropathy, and Viralogical Failure.

2005

Result: Co-morbidities

Occurrence of TB in the full cohort: 34% Co-morbidities not mutually exclusive Crypto underreported

Most prevalent co-morbidities(n= 2640)

73.3%

11.1% 8.4%1.1% 0.9% 0.9% 0.5% 0.5% 3.2%

0%10%20%30%40%50%60%70%80%

TB

Hyp

ert

en

sio

n

*Cry

pto

co

cca

l

Me

nin

gitis

Ep

ilep

sy

Ka

po

si

Sa

rco

ma

Ch

ron

ic lu

ng

dis

ea

se

Ca

rdia

c

dis

ea

se

Dia

be

tes

Oth

er

Co-morbidities

% o

f a

ll c

o-m

orb

idit

ies

2005

Down Referral

Percentage of patients on treatment downreferred to partnering sites (n=1065)

32%

16%12%

8% 7% 5% 3% 3% 2% 2% 1% 1%

10%

0%5%

10%15%20%25%30%35%

% of patients down referred

Dow

n re

ferr

al s

ites

2005

Results: CD4 Counts

The mean and median baseline CD4 count for all patients were 103 cells/mm3 and 95 cells/mm3 respectively.

The mean & median baseline CD4 counts for patients Initiated on ART were 101 cells/mm3 and 96 cells/mm3 respectively.

The mean & median baseline CD4 counts for patients NOT initiated on ART were 109 cells/mm3 and 94 cells/mm3 respectively.

Absolute Median Baseline CD4 counts of patients initiated and not initiated on ARVs distributed by age

(n=5479)

020406080

100120140

15-24 25-34 35-44 45-54 55+

Age range (years)

Med

ian

valu

es

Initiated ontreatment

Not initiated ontreatment

2005

Results: Defaulter Information

Age & Gender distibution of Treatment defaulters (n=793)

13%

35%

7%

43%

3%

15%

2%

32%

48%

4%

0%

20%

40%

60%

15-24 25-34 35-44 45-55 55+

Age Range (years)

% D

efa

ult

ing

Females

Males

2005

Results: Defaulter Information

Patient defaulting time frame(n=765)

26%30%

17%13%

5% 4% 3% 1% 0.3% 0.1%0%5%

10%15%20%25%30%35%

<1 1-3 4-6 7-9 10-12 13-15 16-18 19-21 22-24 >24

Months since treatment initiated

Per

cen

tag

e o

f al

l p

atie

nts

def

ault

ing

2005

DISCUSSION

A large number of patients accessing care at the wellness clinic are women. This is congruent with the patterns seen at other HIV clinics around the country.

Less than half of the patients who have visited the clinic since it opened in 2004, are currently actively seeking services at this facility.

Post Treatment defaulters (21%) are a major concern for clinic. These patients are at high risk of developing drug resistance and earlier onset of AIDS. It is imperative to identify defaulters early and get them back on treatment as soon as possible.

2005

DISCUSSION

The file review identified Pre-Treatment Defaulters as another group equally at risk as the Post-Treatment defaulters.

They were probably tested for HIV and in most cases a CD4 count was also done, and they were clinically staged.

There are multiple areas where these patients could have been lost to follow up. The clinic may have lost them after the first appointment, during or after other treatments such as for opportunistic infections, TB, STIs, etc, or while attending the adherence training session.

From the information collected during this review, it is not possible to identify where and when the clinic has lost these patients. However, a detailed review of the files of these patients may reveal reasons/patterns for defaulting.

2005

DISCUSSION

It is important to find out how well the down referral system is working. One way to ascertain this is by reviewing files of the patients at the respective down referral sites.

If the down referral system is found to be effective, it will considerably ease the pressure on the tertiary health care facilities and improve quality of services through out the referral network.

2005

Recommendations

Development and implementation of appropriate data recording and storing mechanisms, Processes to closely monitor and follow up patients initiating on treatment, Systems to immediately identify pre & post treatment defaulters and have them return to the clinic, Inquire into reasons why patients default on treatment, Appropriate follow up processes for patients who are not eligible to start

on ARVs – either because their CD4 is greater than 200 or they have to complete treatment of other opportunistic infections, Standardizing down referral systems and protocols Inquiry into the low percentage of regimen changes at this site.

2005

Challenges & Benefits of File Reviews

Challenges Resource Intensive

Need HR for audits Need HR for DQA

Buy in from clinic staff & leadership imperative

Need people with minimum understanding of HIV care & treatment

Benefits Get an accurate picture of the

situation

Identify the weak areas and propose appropriate interventions.

Building the clinic staff capacity to understand the importance of the information collected and to assist them to continue with such activities

2005

Future Plans

Continue with file reviews at partnering DoH sites

Create a file review package of services for other agencies & DoH sites

Support clinic staff to conduct periodic file reviews.

Klerksdorp & Jhb Hospital: Have put in place a defaulter tracer program based on the outcomes

of the file reviews. Evaluate this program.

2005

Comparative Analysis-Johannesburg & Klerksdorp Hospitals

Johannesburg Hospital ARV Clinic

Mean age of patients: 36 years

63% Females; 36% Males

Initiated on ART: 79%

Side Effects noted: 33%

Klerksdorp Hospital Wellness Clinic

Mean age of patients: 38 years

64% Females; 36% Males

Initiated on ART: 68%

Side Effects noted: 4%

2005

Johannesburg Hospital File Review

Jhb Hospital: Current Patient Status (n=3488)

59%16%

6%

18% 1%

Actively accessingcare

Pre-ART Defaulters

Down referred

Post ART Defaulters

Died

Klerksdorp Hospital: Current Patient Status (n=5750)

41%

23%

19%

14%

2%

1% Actively accessingcare

Pre-ART Defaulters

Down referred

Post ART Defaulters

Died

Unknown

2005

Comparative Analysis-Johannesburg & Klerksdorp Hospitals

Jhb Hospital: Current Status of patients initiated on ARVs (n=2755)

72%

4%

23%0.7%

Actively accessing care

Down referred

Post ART Defaulters

Died

Klerksdorp Hospital: Current Status of patients initiated on ART (n=3900)

51%

27%

20%

2%

Actively accessing care

Down referred

Post ART Defaulters

Died

2005

Acknowledgements

This project is funded by PEPFAR

AcknowledgementsDepartment of Health – NW ProvinceGauteng Provincial GovernmentKlerksdorp Hospital Wellness Clinic Leadership & Staff Johannesburg Hospital ARV Clinic Leadership & StaffAurum RHRU Team