Cascade Analysis: An Adaptable Implementation Strategy Across HIV and Non-HIV Delivery Platforms

Abstract

Background: Cascades have been used to characterize sequential steps within a complex health system and are used in diverse disease areas and across prevention, testing, and treatment. Routine data have great potential to inform prioritization within a system, but are often inaccessible to frontline health care workers (HCWs) who may have the greatest opportunity to innovate health system improvement. Methods: The cascade analysis tool (CAT) is an Excel-based, simple simulation model with an optimization function. It identifies the step within a cascade that could most improve the system. The original CAT was developed for HIV treatment and the prevention of mother-to-child transmission of HIV. Results: CAT has been adapted 7 times: to a mobile application for prevention of mother-to-child transmission; for hypertension screening and management and for mental health outpatient services in Mozambique; for pediatric and adolescent HIV testing and treatment, HIV testing in family planning, and cervical cancer screening and treatment in Kenya; and for naloxone distribution and opioid overdose reversal in the United States. The main domains of adaptation have been technical—estimating denominators and structuring steps to be binary sequential steps—as well as logistical—identifying acceptable approaches for data abstraction and aggregation, and not overburdening HCW. Discussion: CAT allows for prompt feedback to HCWs, increases HCW autonomy, and allows managers to allocate resources and time in an equitable manner. CAT is an effective, feasible, and acceptable implementation strategy to prioritize areas most requiring improvement within complex health systems, although adaptations are being currently evaluated.

Development of a Blended Learning Approach to Delivering HIV-Assisted Contact Tracing in Malawi: Applied Theory and Formative Research

“…Group problem-solving draws on concepts from continuous quality improvement, which is a set of formal and systematic processes to identify and address health systems challenges [ 30 , 31 ]. The purpose is to identify challenges with ACT implementation and coordination, evaluate potential solutions, provide actionable recommendations, and revisit progress through a series of meetings.…”

Results of a cluster randomized trial testing the systems analysis and improvement approach to increase HIV testing in family planning clinics

“…It is important to understand how SAIA fits into the larger Kenya HIV Quality Improvement Framework (KHQIF), which encourages plan-do-study-act (PDSA) cycles for continuous quality improvement. In essence, SAIA utilizes PDSA cycles with micro-interventions as 'Plan and Do', the CAT to 'Study', and then adopting, adapting, or abandoning the intervention to 'Act' [21,24]. Although we have shown SAIA's efficacy when delivered by research staff, the next steps to understanding SAIA's sustainability must focus on measuring its effectiveness when delivered at county-wide scale by County DOH implementers.…”

“…This study evaluated SAIA, an evidenced-based five-step multicomponent implementation strategy, focused on improving care cascades [20][21][22][23]. The first step uses an Excel-based ''cascade analysis'' tool to quantify numbers of individuals who complete each cascade step and identify priority steps for improvement [24]. Step two involves sequential process flow mapping to identify modifiable bottlenecks in the system [21].…”

“…Although studies have highlighted the benefits of integration, there has been concern that integrated service delivery may be less efficient, more work for providers, and that clinics lacked adequate staffing and infrastructure to support integration [18,19]. The Systems Analysis and Improvement Approach (SAIA), a blended implementation strategy grounded in systems engineering, holds potential for addressing these concerns by systematically identifying and addressing implementation barriers [20][21][22][23][24]. The objective of this cluster-randomized trial was to compare SAIA versus usual procedures for increasing HTC in family planning clinics in Mombasa County, Kenya.…”

The Systems Analysis and Improvement Approach: Data-driven Quality Improvement

“…SAIA combines systems engineering tools into an iterative process to guide service delivery staff and managers to visualize treatment cascade drop-offs and prioritize areas for system improvements, identify modi able organization/facility-level bottlenecks, identify and implement modi cations to improve system performance and assess their impact. 6 The core systems tools that the SAIA harnesses are cascade analysis 7 (whereby routine data is used to assess how the client population passes through speci c sequential steps, identify drop off among the clients and prioritize steps for quality improvement efforts), process mapping (where frontline service providers and managers collaboratively outline the steps that clients currently go through to achieve care in their speci c organization/facility) and continuous quality improvement (CQI), to guide service provider-led, data-driven quality improvement. This work is conducted through organization/facility-level learning meetings supported by external facilitators and conducted at set intervals, typically monthly, for a minimum of six months, to allow service providers to gain expertise in implementing SAIA to improve outcomes of their speci c service.…”