The Community-based ART REtention and Suppression (CARES) App: an innovation to improve patient monitoring and evaluation data in community-based antiretroviral therapy programs in Lilongwe, Malawi

基于社区的 ART 保留和抑制 (CARES) 应用程序：一项创新，旨在改善马拉维利隆圭社区抗逆转录病毒治疗项目中的患者监测和评估数据

• 批准号: 10543832
• 负责人: Caryl Feldacker
• 金额: $ 19.91万
• 依托单位: UNIVERSITY OF WASHINGTON
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-01-01 至 2024-12-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10543832
• 关键词: Acquired Immunodeficiency Syndrome; Adherence; Adoption; Africa South of the Sahara; COVID-19; Caring; Clinic; Clinic Visits; Collection; Communities; Community Healthcare; Complement; Complex; Continuity of Patient Care; Cost Analysis; Cost Effectiveness Analysis; Data; Database Management Systems; Decision Making; Development; Effectiveness; Electricity; Emergency Situation; Ensure; Evaluation; Face; Funding; Future; Government; Guideline Adherence; Guidelines; HIV; HIV/TB; Health; Health Personnel; Health system; Individual; Inequity; Infrastructure; Intensive Care; International; Interruption; Intervention; Interview; Investments; Maintenance; Malawi; Manuals; Measures; Methods; Monitor; Nurses; Nursing Assessment; Outcome; Patient Care; Patient Monitoring; Patient-Focused Outcomes; Patients; Persons; Phase; Population; Printing; Program Evaluation; Provider; Quality of Care; Quasi-experiment; Reach, Effectiveness, Adoption, Implementation, and Maintenance; Research Priority; Resources; Risk; Rural; Series; Service delivery model; Site; System; Tablets; Technology; Testing; Time; Time and Motion Studies; Training and Education; Treatment Failure; Trust; Universities; Viral; Washington; Workload; antiretroviral therapy; assessment application; care delivery; clinical decision-making; coronavirus disease; cost; cost estimate; data quality; data reduction; design; digital; digital health; electronic medical record system; epidemic response; falls; implementation research; implementation science; improved; informant; innovation; integrated care; literacy; low income country; mHealth; open source; point of care; pressure; program costs; programs; scale up; secondary outcome; service delivery; therapy outcome; usability; user centered design

Differentiated service delivery (DSD) increases antiretroviral therapy (ART) access in sub-Saharan Africa (SSA) by moving patients out of congested ART clinics to communities for care. Patient outcomes in DSD and traditional clinic-based care appear similar at lower cost. Decreased donor funding, health system constraints, healthcare worker (HCW) shortages, and COVID-related calls to reduce clinic visits, push DSD expansion. But, DSD settings challenge routine patient monitoring and evaluation (M&E) required to ensure quality care, risking viral suppression (VS), scarce resources, and epidemic control. Electronic medical record systems (EMRs) ensure effective patient M&E in compliance with complex guidelines, improving patient outcomes and reducing workload. Yet, despite decades of SSA EMRs investment, EMRs benefits do not extend to low resource/low infrastructure settings where the majority of DSD occurs. How to optimize collection and use of high quality M&E for DSD patient care is a critical implementation research priority. Lighthouse Trust (LT) operates two Ministry of Health (MoH) clinics in Lilongwe, Malawi, with combined >35,000 ART patients. LT’s real-time, point-of-care (POC) EMRs collects complex M&E data and provides decision-making support, ensuring adherence to integrated HIV/TB guidelines that optimize patient and program outcomes. LT’s EMRs scaled to all large MoH ART clinics. LT implements a nurse-led community-based ART program (NCAP), a DSD model to provide ART and rapid assessment to 2400 stable LT patients in the community. LT’s EMRs requires consistent power and server access. Without EMRs, NCAP providers lack embedded prompts and alerts, reducing integrated MoH ART guideline compliance. NCAP M&E is incomplete and burdensome, leaving data gaps that lessen VS monitoring and care continuity. Poor M&E limits NCAP expansion. Therefore, University of Washington’s International Training and Education Center for Health, LT, and Medic seek to leverage a proven, open-source digital health framework to design, deploy, and assess an offline-first, user-centered, battery-operated App, “Community-based ART REtention and Suppression” (CARES). Apps are faster to design, simpler to deploy, cheaper to maintain, and operate without constant connectivity or electricity. CARES brings a POC EMRs-like App to NCAP with real-time benefits for optimal, integrated patient care. CARES captures complete patient M&E data and syncs to facility EMRs, improving data quality while reducing workload. Guided by implementation science, we use a quasi-experimental, interrupted time-series design to assess NCAP patient care, pre- and post-CARES. Mixed-methods evaluate CARES effect on NCAP patient outcomes, data quality, workload, and cost. Aims: 1) Assess how CARES ensures high quality NCAP patient outcomes using RE-AIM to gauge reach, effectiveness, adoption, implementation, and maintenance; and 2) Estimate CARES cost to improve M&E using a systems perspective. We hypothesize that CARES increases NCAP on-time, annual VS testing from 65% to 80% at lower cost. COVID19 raises potential impact of this App to strengthen integrated DSD care provision and to provide M&E evidence on DSD patient and program outcomes.

差异化服务提供 (DSD) 增加了撒哈拉以南非洲 (SSA) 地区抗逆转录病毒治疗 (ART) 的可及性 将患者从拥挤的 ART 诊所转移到社区接受 DSD 和传统治疗。 基于诊所的护理看起来相似，但成本较低。 工作人员（HCW）短缺，以及与新冠疫情相关的减少就诊次数的呼吁，推动了 DSD 的扩张。 确保高质量护理所需的常规患者监测和评估 (M&E) 面临挑战，冒着病毒抑制的风险 （VS）稀缺资源和疫情控制确保有效的患者。 尽管如此，监测和评估仍遵循复杂的指南，改善了患者的治疗效果并减少了工作量。 尽管 SSA EMR 投资数十年，但 EMR 的优势并未延伸到资源匮乏/基础设施不足的环境中 大多数 DSD 都会发生，如何优化 DSD 患者护理的高质量 M&E 的收集和使用至关重要。 灯塔信托基金 (LT) 在利隆圭运营着两家卫生部 (MoH) 诊所。 马拉维总共有超过 35,000 名 ART 患者，其实时护理点 (POC) EMR 收集复杂的 M&E。 数据并提供决策支持，确保遵守综合艾滋病毒/结核病指南，优化 LT 的 EMR 扩展到所有大型 MoH ART 诊所，并实施由护士主导的服务。 基于社区的 ART 计划 (NCAP)，一种为 2400 名稳定 LT 提供 ART 和快速评估的 DSD 模型 LT 的 EMR 需要持续的电源和服务器访问。 提供商缺乏嵌入式提示和警报，从而降低了 MoH ART 指南的综合合规性。 不完整且繁琐，留下的数据空白会减少 VS 监测和护理连续性。 因此，华盛顿大学国际健康培训和教育中心， LT 和 Medic 寻求利用经过验证的开源数字健康框架来设计、部署和评估 离线优先、以用户为中心、电池供电的应用程序，“基于社区的艺术保留和抑制”（CARES）。 应用程序设计更快、部署更简单、维护成本更低，并且无需持续连接或运行 power. CARES 为 NCAP 带来了类似 POC EMR 的应用程序，可为患者提供最佳、综合的实时益处。 CARES 捕获完整的患者 M&E 数据并同步到设施 EMR，同时提高数据质量。 在实施科学的指导下，我们使用准实验性的、中断的时间序列。 设计评估 NCAP 患者护理、CARES 前后的混合方法评估 CARES 对 NCAP 的影响。 患者治疗结果、数据质量、工作量和成本 目标： 1) 评估 CARES 如何确保高质量的 NCAP。 使用 RE-AIM 来衡量覆盖范围、有效性、采用、实施和维护的患者结果； 2) 从系统角度估计改进 M&E 的 CARES 成本。 NCAP 年度 VS 测试按时率从 65% 提高到 80%，而 COVID19 提高了该应用程序的潜在影响。 加强综合 DSD 护理服务，并提供有关 DSD 患者和项目结果的 M&E 证据。