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: 10402110
• 负责人: Caryl Feldacker
• 金额: $ 18.33万
• 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 2023-12-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10402110
• 关键词: Acquired Immunodeficiency Syndrome; Adherence; Adoption; Africa South of the Sahara; COVID-19; Caring; Clinic; Clinic Visits; Collection; Communities; Complement; Complex; Computerized Medical Record; Continuity of Patient Care; Cost Analysis; Cost Effectiveness Analysis; Data; Database Management Systems; Decision Making; Development; Effectiveness; Electricity; Emergency Situation; Ensure; Epidemic; Evaluation; Face; Funding; Future; Gold; Government; Guideline Adherence; Guidelines; HIV; HIV/TB; Health; Health Personnel; Health system; Individual; Infrastructure; Intensive Care; International; Interruption; Intervention; Interview; Investments; Maintenance; Malawi; Manuals; Measures; Methods; Monitor; Nurses; Outcome; Outpatients; Patient Care; Patient Monitoring; Patient-Focused Outcomes; Patients; Persons; Population; Program Evaluation; Provider; Quality of Care; 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; base; care delivery; clinical decision-making; coronavirus disease; cost; cost estimate; data quality; design; digital; digital health; falls; implementation research; implementation science; improved; informant; innovation; 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）的抗逆转录病毒疗法（ART） 通过将患者从拥挤的艺术诊所转移到社区进行护理。 DSD和传统的患者结果 基于诊所的护理似乎相似，成本较低。减少捐助者资金，卫生系统限制，医疗保健 工人（HCW）短缺以及与COVID相关的电话，以减少诊所就诊，推动DSD扩展。但是，DSD设置 挑战常规的患者监测和评估（M＆E），以确保高质量护理，风险抑制病毒 （VS），稀缺资源和流行控制。电子病历系统（EMRS）确保有效的患者 M＆E符合复杂的指南，改善患者的结果并减少工作量。但是，目的地 SSA EMRS投资数十年，EMRS的福利不会扩展到低资源/低基础架构设置 大多数DSD发生。如何在DSD患者护理中优化和使用高质量的M＆E是一个关键 实施研究优先。 Lighthouse Trust（LT）在Lilongwe经营两家卫生部（MOH）诊所 马拉维，组合> 35,000名艺术患者。 LT的实时保健点（POC）EMR收集复杂的M＆E 数据并提供决策支持，确保遵守优化的综合艾滋病毒/TB指南 病人和计划结果。 LT的EMR缩放到所有大型MOH艺术诊所。上演护士领导的 基于社区的艺术计划（NCAP），一种DSD模型，可为2400稳定LT提供艺术和快速评估 社区中的患者。 LT的EMR需要一致的功率和服务器访问。没有EMR，NCAP 提供者缺乏嵌入式提示和警报，从而降低了综合的MOH艺术指南合规性。 NCAP M＆E是 不完整且燃烧，留下数据差距，从而减少了监视和护理连续性。 M＆E限制差 NCAP扩展。因此，华盛顿大学的国际培训与教育中心， LT和Medic寻求利用一个经过验证的开源数字健康框架来设计，部署和评估 脱机，以用户为中心的电池操作应用程序，“基于社区的艺术保留和压制”（Cares）。 应用程序的设计速度更快，更易于部署，便宜地维护和操作，而无需持续连接或 电。 CARES将类似POC EMRS的应用程序带到NCAP，具有实时益处的最佳，综合患者 关心。关心捕获完整的患者M＆E数据，并同步设施EMR，从而提高数据质量 减少工作量。在实施科学的指导下，我们使用了准实验，中断的时间序列 设计用于评估NCAP患者护理，前后的护理。混合方法评估护理对NCAP的影响 患者结果，数据质量，工作量和成本。目的：1）评估如何确保高质量的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；和 2）估计使用系统观点来改善M＆E的成本。我们假设关怀会增加 NCAP按时以较低的成本从65％到80％的年度测试。 COVID19将该应用程序的潜在影响引起 强大的综合DSD护理提供，并提供有关DSD患者和计划成果的M＆E证据。