www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 20 Rethinking care as part of the treatment cascade: what and how to measure quality of care? Sombat Thanprasertsuk MD, MPH Department of Disease Control, MOPH Thailand 2 July 2013
Feb 25, 2016
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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
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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%)
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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
National ART Program, Thailand
Gap 30%
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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%)
National ART Program, Thailand
N=195,104 N=6,461
Stop med.248 (0.1%)
Stop med.248 (3.8%)
Adult Pediatrics
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• 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
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• 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
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Development of HIVQUAL-T
12 hospitals 762 hospitals (84.7%) of all 77 provinces
HIVQUAL-T Pediatrics HIVQUAL-T
2005
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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
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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
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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
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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
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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
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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
%
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Results of HIVQUAL-T, 2006-2010by selected indicators
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
%
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Results of HIVQUAL-T, 2006-2010by selected indicators
Percentage of patients reported sexual activity receiving syphilis screening (Syphilis)
2006 2007 2008 2009 20102030405060708090
32.07 25.1847.8
64.5
78.45
%
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Results of HIVQUAL-T, 2006-2010by selected indicators
Percentage of female patients receiving PAP smear (PAP)
2006 2007 2008 2009 201020304050607080
27.25 26.19
47.91
63.772.86
%
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Results of HIVQUAL-T, 2006-2010by selected indicators
Percentage of ARV patients receiving VL test at least once (VL)
2006 2007 2008 2009 20100
102030405060708090
6.64
35.08
61.6676.42
83.33%
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Results of HIVQUAL-T, 2010*-2012by selected indicators
Year No. of hosp. participated
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
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Results of HIVQUAL-T, 2010-2012by selected indicators
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
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Results of HIVQUAL-T, 2010-2012by selected indicators
Percentage of HIV-infected patients with pulmonary TB screening (TB)
2010 2011 201250
60
70
80
90
10096.8 98.02 99.21%
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Results of Pediatrics HIVQUAL-T, 2006-2011 by selected indicators
Year No. of hosp. participated
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
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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%
Results of Pediatrics HIVQUAL-T, 2006-2011 by selected indicators
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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 Pediatrics HIVQUAL-T, 2006-2011 by selected indicators
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Results of selected indicators, HIVQUAL-T, 2006-2010
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Results of selected indicators, HIVQUAL-T, 2010-2012
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Results of selected indicators, Pediatrics HIVQUAL-T, 2005-2011
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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
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• 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
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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
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Thank you for your kind attention