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

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. National ART Program, Thailand. ART is provided by government and private hospitals

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

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  1. Rethinking care as part of the treatment cascade: what and how to measure quality of care? SombatThanprasertsuk MD, MPH Department of Disease Control, MOPH Thailand 2 July 2013

  2. 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%)

  3. National ART Program, Thailand Gap30% <2000

  4. National ART Program, Thailand ART cases Data from NHSO, up to end 2012 FY Adult Pediatrics Stop med. 248 (0.1%) Stop med. 248 (3.8%) N=195,104 N=6,461

  5. Why Quality Monitoring on HIV Care is needed? • 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 Maintain retention, minimize drop out, improve coverage Healthy PHA

  6. Introduction of HIVQUAL to Thai ART Program • 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 pillars 1) HIVQUAL-T software for performance measurement 2) Quality improvement projects 3) Infrastructure building • Integrated as cyclical process of repeated measurement and improvement Thailand MOPH, with technical collaboration from USCDC and NYSDOH, applied HIVQUAL-T since 2002

  7. Development of HIVQUAL-T HIVQUAL-T Pediatrics HIVQUAL-T 2005 12 hospitals 762 hospitals (84.7%) of all 77 provinces

  8. HIVQUAL-T Administration Advisory committee Steering Committee QI Technical Committee Monitoring and Evaluation Committee Local QI Committee Regional/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 8

  9. 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

  10. 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 Indicators 14 Indicators

  11. 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

  12. Results of HIVQUAL-T, 2006-2010*by selected indicators Note * most hospitals participated in 2010 using a more advance version of software

  13. Results of HIVQUAL-T, 2006-2010by selected indicators Percent of patients receiving a CD4 test at least once during the review period (CD4) %

  14. Results of HIVQUAL-T, 2006-2010by selected indicators Percent of patients receiving safe sex information or counseling (safe sex) %

  15. Results of HIVQUAL-T, 2006-2010by selected indicators Percentage of patients reported sexual activity receiving syphilis screening (Syphilis) %

  16. Results of HIVQUAL-T, 2006-2010by selected indicators Percentage of female patients receiving PAP smear (PAP) %

  17. Results of HIVQUAL-T, 2006-2010by selected indicators Percentage of ARV patients receiving VL test at least once (VL) %

  18. Results of HIVQUAL-T, 2010*-2012by selected indicators Note * some hospitals participating in 2010 used former version of software

  19. 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) Cell/cu.mm

  20. Results of HIVQUAL-T, 2010-2012by selected indicators Percentage of HIV-infected patients with pulmonary TB screening (TB) %

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

  22. Results of Pediatrics HIVQUAL-T, 2006-2011 by selected indicators Proportion of HIV-infected children on ART receiving a VL test during the review period (VL) %

  23. Results of Pediatrics HIVQUAL-T, 2006-2011 by selected indicators Proportion of HIV-infected children on ART receiving adherence assessment in the last 3 visits during the review period (Adh) %

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

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

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

  27. 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

  28. Discussion - Challenge • 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

  29. Acknowledgement • IAS2013 • National Health Security Office Dr SorakijBhakeecheep, Senior Manager, Fund Management of HIV/AIDS and TB • Bureau of AIDS, TB and STIs, DDC Dr SumetOngwandee, Director Dr CheewananLertpiriyasuwat • Thailand MOPH-US CDC Collaboration Dr AcharaTeeraratkul Dr ChitladaUtaipiboon Dr RangsimaLolekha Dr Ake-chittraSukkul • New York State Department of Health Dr Bruce Agins • All hospitals and agencies participating in HIVQUAL-T

  30. Thank you for your kind attention

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