Implementation of HIV treatment as prevention strategy in 17 Canadian sites: immediate and sustained outcomes from a 35-month Quality Improvement Collaborative

Clarke, Christina M.; Cheng, Tessa; Reims, Kathleen; Steinbock, Clemens; Thumath, Meaghan; Milligan, Robert Sam; Barrios, Rolando

doi:10.1136/bmjqs-2015-004269

Cited by 14 publications

(13 citation statements)

References 30 publications

(27 reference statements)

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“…Beyond scaling up HIV testing and care sites, provincial partners sought to improve the quality of care itself through a provincial collaborative launched in 2011 that brought together 17 teams across the province to engage in continuous quality improvement and adult learning activities(#111). This collaborative later (2013) morphed into the HIV quality improvement network, mandated to address gaps in the provincial cascade of HIV care [85].…”

Section: Communitymentioning

confidence: 99%

A historical review of HIV prevention and care initiatives in British Columbia, Canada: 1996‐2015

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Enns

Panagiotoglou

et al. 2017

Journal of the International AIDS Society

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Introduction: British Columbia has made significant progress in the treatment and prevention of HIV since 1996, when Highly Active Antiretroviral Therapy (HAART) became available. However, we currently lack a historical summary of HIV prevention and care interventions implemented in the province since the introduction of HAART and how they have shaped the HIV epidemic. Guided by a socio-ecological framework, we present a historical review of biomedical and health services, community and structural interventions implemented in British Columbia from 1996–2015 to prevent HIV transmission or otherwise enhance the cascade of HIV care. Methods: We constructed a historical timeline of HIV interventions implemented in BC between 1996 and 2015 by reviewing publicly available reports, guidelines and other documents from provincial health agencies, community organizations and AIDS service organizations, and by conducting searches of peer-reviewed literature through PubMed and Ovid MEDLINE. We collected further programmatic information by administering a data collection form to representatives from BC’s regional health authorities and an umbrella agency representing 45 AIDS Service organizations. Using linked population-level health administrative data, we identified key phases of the HIV epidemic in British Columbia, as characterized by distinct changes in HIV incidence, HAART uptake and the provincial HIV response. Results and Discussion: In total, we identified 175 HIV prevention and care interventions implemented in BC from 1996 to 2015. We identify and describe four phases in BC’s response to HIV/AIDS: the early HAART phase (1996–1999); the harm reduction and health service scale-up phase (2000–2005); the early Treatment as Prevention phase (2006–2009); and the STOP HIV/AIDS phase (2010-present). In doing so, we provide an overview of British Columbia’s universal and centralized HIV treatment system and detail the role of community-based and provincial stakeholders in advancing innovative prevention and harm reduction approaches, as well as “seek, test, treat and retain” strategies. Conclusions: The review provides valuable insight into British Columbia’s HIV response, highlights emerging priorities, and may inform future efforts to evaluate the causal impact of interventions.

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Section: Communitymentioning

confidence: 99%

A historical review of HIV prevention and care initiatives in British Columbia, Canada: 1996‐2015

Olding

Enns

Panagiotoglou

et al. 2017

Journal of the International AIDS Society

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“…At the trial level, without these further analyses, the degree to which each hospital had implemented the care pathway as intended or improved would have remained unclear, as each hospital’s signal was obscured within the results of a large and heterogeneous cohort. The use of run charts to evaluate QI programmes at scale remains rare, with some notable exceptions,37 yet they are ideally suited to this level of granular data analysis. The main strength of this analysis is that we have tested this approach experientially, alongside our main trial analyses, using the same dataset, and found it was largely congruent with, but added value to, our previous understanding of what happened during the EPOCH trial.…”

Section: Discussionmentioning

confidence: 99%

Hospital-level evaluation of the effect of a national quality improvement programme: time-series analysis of registry data

et al. 2019

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Background and objectivesA clinical trial in 93 NHS hospitals evaluated a quality improvement programme for emergency abdominal surgery, designed to improve mortality by improving the patient care pathway. Large variation was observed in implementation approaches and the main trial result showed no mortality reduction. Our objective therefore was to evaluate whether trial participation led to care-pathway implementation and to study the relationship between care-pathway implementation and use of six recommended implementation strategies. MethodsWe performed a hospital-level time-series analysis using data from the Enhanced Peri-Operative Care for High-risk patients (EPOCH) trial. Care-pathway implementation was defined as achievement of >80% median reliability in ten measured care-processes. Mean monthly process performance was plotted on run-charts. Process improvement was defined as an observed run-chart signal, using probability-based 'shift' and 'runs' rules. A new median performance level was calculated after an observed signal. ResultsOf 93 participating hospitals, 80 provided sufficient data for analysis, generating 800 process measure charts from 20,305 patient admissions over 27 months. No hospital reliably implemented all ten processes. Overall, only 279 of the 800 processes were improved (3 [2-5] per hospital) and 14/80 hospitals improved more than six processes. Mortality-risk documented (57/80 [71%]), lactate measurement (42/80 [53%]) and cardiac-output guided fluid therapy (32/80 [40%]) were most frequently improved. Consultant-led decision making (14/80 [18%]), consultant review before surgery (17/80 [21%]) and time to surgery (14/80 [18%]) were least frequently improved. In hospitals using ≥5implementation strategies, 9/30 (30%) hospitals improved 6 care processes compared with 0/11 hospitals using ≤2 implementation strategies. ConclusionOnly a small number of hospitals improved more than half of the measured care-processes, more often when at least 5 of 6 implementation strategies were used. In a longer-term project this understanding may have allowed us to adapt the intervention to be effective in more hospitals. BACKGROUNDAs the volume of surgical procedures performed worldwide continues to increase [1,2] the need for improvement in the quality and safety of surgical care has become a global healthcare priority [3][4][5]. This is of particular importance considering both the increasing age and complexity of the surgical population and the global mortality burden associated with surgery [6,7]. Emergency abdominal surgery is a commonly performed procedure worldwide, with high mortality rates, and wide variations in the standards of care [8][9][10][11]. The Enhanced Peri-Operative Care for High-risk patients (EPOCH) trial was performed to test whether a national quality improvement (QI) programme to implement a carepathway could reduce 90-day mortality following emergency abdominal surgery [12].The EPOCH trial intervention consisted of an evidence based care-pathway designed to improve patient o...

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“…Evidence in support of QI interventions to improve HIV treatment services comes from places such as Canada and Ethiopia where systems-level approaches have been taken to improve health service delivery [16, 17]. …”

Section: Methodsmentioning

confidence: 99%

Quality improvement intervention to increase adherence to ART prescription policy at HIV treatment clinics in Lusaka, Zambia: A cluster randomized trial

et al. 2017

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IntroductionIn urban areas, crowded HIV treatment facilities with long patient wait times can deter patients from attending their clinical appointments and picking up their medications, ultimately disrupting patient care and compromising patient retention and adherence.MethodsFormative research at eight facilities in Lusaka revealed that only 46% of stable HIV treatment patients were receiving a three-month refill supply of antiretroviral drugs, despite it being national policy for stable adult patients. We designed a quality improvement intervention to improve the operationalization of this policy. We conducted a cluster-randomized controlled trial in sixteen facilities in Lusaka with the primary objective of examining the intervention’s impact on the proportion of stable patients receiving three-month refills. The secondary objective was examining whether the quality improvement intervention reduced facility congestion measured through two proxy indicators: daily volume of clinic visits and average clinic wait times for services.ResultsThe mean change in the proportion of three-month refills among control facilities from baseline to endline was 10% (from 38% to 48%), compared to a 25% mean change (an increase from 44% to 69%) among intervention facilities. This represents a significant 15% mean difference (95% CI: 2%-29%; P = 0.03) in the change in proportion of patients receiving three-month refills. On average, control facilities had 15 more visits per day in the endline than in the baseline, while intervention facilities had 20 fewer visits per day in endline than in baseline, a mean difference of 35 fewer visits per day (P = 0.1). The change in the mean facility total wait time for intervention facilities dropped 19 minutes between baseline and endline when compared to control facilities (95% CI: -10.2–48.5; P = 0.2).ConclusionA more patient-centred service delivery schedule of three-month prescription refills for stable patients is viable. We encourage the expansion of this sustainable intervention in Zambia’s urban clinics.

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Implementation of HIV treatment as prevention strategy in 17 Canadian sites: immediate and sustained outcomes from a 35-month Quality Improvement Collaborative

Abstract: This study shows evidence of sustained improvements in HIV care processes and treatment outcomes for an estimated population of 2296 HIV patients in 17 BC sites. Overall success points to opportunities for other high-income countries seeking to improve HIV health outcomes.

Cited by 14 publications

References 30 publications

A historical review of HIV prevention and care initiatives in British Columbia, Canada: 1996‐2015

A historical review of HIV prevention and care initiatives in British Columbia, Canada: 1996‐2015

Hospital-level evaluation of the effect of a national quality improvement programme: time-series analysis of registry data

Quality improvement intervention to increase adherence to ART prescription policy at HIV treatment clinics in Lusaka, Zambia: A cluster randomized trial

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