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）抗逆转录病毒疗法（ART）的获得 将患者从拥挤的ART诊所转移到社区接受护理。DSD和传统治疗中的患者结局 基于诊所的护理似乎类似，但成本较低。捐助资金减少，卫生系统制约，医疗保健 工人（HCW）短缺，以及与COVID相关的减少诊所就诊的呼吁，推动了DSD的扩张。但是，DSD设置 挑战确保高质量护理所需的常规患者监测和评估（M&E），冒着病毒抑制的风险 (VS)、稀缺资源和疫情控制。电子病历系统（EMR）确保有效的患者 M&E符合复杂的指南，改善患者的治疗效果并减少工作量。但尽管 虽然SSA EMR投资已有数十年，但EMR的好处并没有扩展到低资源/低基础设施环境， 大多数的DSD都是发生的。如何优化收集和使用高质量的M&E为DSD患者护理是一个关键 实施研究优先。灯塔信托基金会在利隆圭经营着两个卫生部诊所， 马拉维，抗逆转录病毒疗法患者总数超过35，000人。LT的实时即时（POC）EMR收集复杂的M&E 数据并提供决策支持，确保遵守艾滋病毒/结核病综合指南， 患者和项目结果。LT的EMR扩展到卫生部所有大型ART诊所。LT实施护士主导 基于社区的ART计划（NCAP），一种DSD模式，为2400名稳定的LT提供ART和快速评估 社区中的患者。LT的EMR需要一致的电源和服务器访问。没有EMR，NCAP 提供者缺乏嵌入式提示和警报，降低了综合卫生部ART指南的合规性。NCAP M&E是 不完整和繁琐，留下的数据缺口减少了VS监测和护理的连续性。不良M&E限制 NCAP扩展。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 离线第一，以用户为中心，电池供电的应用程序，“基于社区的ART保留和抑制”（CARES）。 应用程序的设计速度更快，部署更简单，维护成本更低，并且无需持续连接或 电CARES为NCAP带来了一个类似POC EMR的应用程序，为最佳的综合患者提供实时优势 在乎CARES捕获完整的患者M&E数据并同步到设施EMR，提高数据质量， 减少工作量。在实现科学的指导下，我们使用了一个准实验的，中断的时间序列 设计用于评估NCAP患者护理、护理前和护理后。混合方法评估CARES对NCAP的影响 患者结果、数据质量、工作量和成本。目的：1）评估CARES如何确保高质量的NCAP 使用RE-AIM评估覆盖范围、有效性、采用、实施和维护的患者结局;以及 2)从系统的角度估算CARES成本以改进M&E。我们假设， NCAP每年的VS测试准时率从65%提高到80%，成本更低。COVID 19提高了此应用程序的潜在影响， 加强综合性DSD护理提供，并提供关于DSD患者和计划结果的M&E证据。