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

差异化服务提供(DSD)增加了撒哈拉以南非洲(SSA)的抗逆转录病毒治疗(ART)机会 通过将患者从拥挤的ART诊所转移到社区接受护理。DSD和传统型患者的预后 以诊所为基础的护理看起来类似，但成本更低。减少捐赠者资金、卫生系统限制、医疗保健 工人(HCW)短缺，以及与COVID相关的呼吁减少诊所就诊，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(EMRS)确保有效患者 符合复杂指南的医疗和急救，改善患者预后并减少工作量。然而，尽管 几十年来对SSA EMRS的投资，EMRS的好处不会延伸到低资源/低基础设施环境 大多数DSD都会发生。如何为DSD患者护理优化收集和使用高质量的M&E是一个关键 优先实施研究。灯塔信托基金(LT)在利隆圭经营着两家卫生部诊所， 马拉维，有35,000名抗逆转录病毒治疗患者。它的实时、护理点(POC)EMR收集复杂的M&E 数据和提供决策支持，确保遵守综合艾滋病毒/结核病指南，优化 患者和计划结果。它的急诊室扩展到了所有大型的MoH艺术诊所。它实行由护士主导的 基于社区的ART计划(NCAP)，为2400个稳定的LT提供ART和快速评估的DSD模型 社区中的病人。它的EMRS需要一致的电源和服务器访问权限。没有EMR，NCAP 供应商缺乏嵌入式提示和警报，降低了综合MoH ART指南的合规性。NCAP M&E是 不完整和繁重，留下了数据缺口，从而降低了监控和护理的连续性。糟糕的M&E限制 NCAP扩展。因此，华盛顿大学国际卫生培训和教育中心， IT和Medc寻求利用经过验证的开源数字医疗框架来设计、部署和评估 线下--以用户为中心、电池供电的App，《社区型艺术保留与抑制》(CARE)。 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 电。CARE为NCAP带来了类似于PoC EMRS的应用程序，为最佳、集成的患者提供实时好处 关心。CARE捕获完整的患者M&E数据并同步到设施EMR，从而提高数据质量，同时 减少工作负荷。在实施科学的指导下，我们使用了一个准实验的、间断的时间序列 设计以评估NCAP患者护理、护理前和护理后。用混合方法评价CARE对NCAP的影响 患者结果、数据质量、工作负载和成本。目标：1)评估CARE如何确保高质量的NCAP 使用RE-AIM衡量覆盖范围、有效性、采用、实施和维护的患者结果；以及 2)从系统的角度估算维护成本，以改善维护和环境。我们假设关心会增加 NCAP准时，年度VS测试从65%降低到80%，成本更低。COVID19将此应用程序的潜在影响提升到 加强综合DSD护理服务，并提供有关DSD患者和计划结果的监测和评估证据。

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.