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Better adherence to pre-antiretroviral therapy guidelines after implementing an electronic medical record system in rural Kenyan HIV clinics: a multicenter pre-post study.

ABSTRACT: The monitoring of pre-antiretroviral therapy (pre-ART) is a key indicator of HIV quality of care. This study investigated the association of an electronic medical record system (EMR) with adherence to pre-ART guidelines in rural HIV clinics in Kenya.A retrospective study was carried out to assess the quality of pre-ART care using three indicators: (1) the performance of a baseline CD4 test, (2) time from enrollment in care to first CD4 test, and (3) time from baseline CD4 to second CD4 test. A comparison of these indicators was made pre and post the introduction of an EMR system in 17 rural HIV clinics.A total of 18523 patients were receiving pre-ART care, of whom 38.8% in the paper group had had at least one CD4 test compared to 53.4% in the EMR group (p<0.001). The adjusted odds of performing a CD4 test in clinics using an EMR was 1.59 (95% confidence interval 1.49-1.69). The median time from enrolment into HIV care to first CD4 test was 1.40 months (interquartile range (IQR) 0.47-4.87) for paper vs. 0.93 months (IQR 0.43-3.37) for EMR. The median time from baseline to first CD4 follow-up was 7.5 months (IQR 5.97-10.73) for paper and 6.53 months (IQR 5.57-7.87) for EMR.The use of the EMR system was associated with better compliance to HIV guidelines for pre-ART care. EMRs have a potential positive impact on quality of care for HIV patients in resource-constrained settings.

SUBMITTER: Oluoch T

PROVIDER: S-EPMC4987124 | biostudies-literature | 2015 Apr

REPOSITORIES: biostudies-literature

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Better adherence to pre-antiretroviral therapy guidelines after implementing an electronic medical record system in rural Kenyan HIV clinics: a multicenter pre-post study.

Oluoch Tom T Kwaro Daniel D Ssempijja Victor V Katana Abraham A Langat Patrick P Okeyo Nicky N Abu-Hanna Ameen A de Keizer Nicolette N

International journal of infectious diseases : IJID : official publication of the International Society for Infectious Diseases 20141002

<h4>Introduction</h4>The monitoring of pre-antiretroviral therapy (pre-ART) is a key indicator of HIV quality of care. This study investigated the association of an electronic medical record system (EMR) with adherence to pre-ART guidelines in rural HIV clinics in Kenya.<h4>Methods</h4>A retrospective study was carried out to assess the quality of pre-ART care using three indicators: (1) the performance of a baseline CD4 test, (2) time from enrollment in care to first CD4 test, and (3) time from ...[more]

PMID: 25281905

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Project description:INTRODUCTION:Differentiated models of care that include referral of antiretroviral treatment (ART) clients to adherence clubs are an important strategy to help clinics manage increased number of clients living with HIV in resource-constrained settings. This study reported on (i) clinical outcomes among ART clients attending community-based adherence clubs and (ii) experiences of adherence clubs and perceptions of factors key to successful adherence club implementation among clients and healthcare workers. METHODS:A retrospective cohort analysis of routine data and a descriptive analysis of data collected through self-administered surveys completed by clients and healthcare workers were completed. Clients starting ART at the study clinic, between January 2014 and December 2015, were included in the cohort analysis and followed up until December 2016. The survey data were collected from August to September 2017. The primary outcome for the cohort analysis was a comparison of loss to follow-up (LTFU) between clients staying in clinic care and those referred to adherence clubs. Survey data reported on client experiences of and healthcare worker perceptions of adherence club care. RESULTS:Cohort analysis reported on 465 participants, median baseline CD4 count 374 (IQR: 234 to 532) cells/μl and median follow-up time 20.7 (IQR 14.1 to 27.7) months. Overall, 202 (43.4%) participants were referred to an adherence club. LTFU was lower in those attending an adherence club (aHR =0.25, 95% CI: 0.11 to 0.56). This finding was confirmed on analysis restricted to those eligible for adherence club referral (aHR =0.28, 95% CI: 0.12 to 0.65). Factors highlighted as associated with successful adherence club implementation included: (i) referral of stable clients to the club, (ii) an ideal club size of ≥20 members, (iii) club services led by a counsellor (iv) using churches or community halls as venues (v) effective communication between all parties, and (vi) timely delivery of prepacked medication. CONCLUSIONS:This study showed good clinical outcomes, positive patient experiences and healthcare worker perceptions of the adherence club model. Factors associated with successful adherence club implementation, highlighted in this study, can be used to guide implementers in the scale-up of adherence club services across varied high-burden settings.

Project description:ImportanceThe 2017 Clinical Practice Guideline (CPG) for the diagnosis and management of pediatric hypertension (PHTN) categorizes a greater proportion of children with elevated blood pressure and PHTN, yet several barriers to CPG adherence have been noted.ObjectiveTo assess adherence to the 2017 CPG for the diagnosis and management of PHTN and use of a clinical decision support (CDS) tool to calculate blood pressure percentiles.Design, setting, and participantsThis cross-sectional study used electronic health record-extracted data from January 1, 2018, to December 31, 2019, among patients visiting 1 of 74 federally qualified health centers in AllianceChicago, a national Health Center Controlled Network. Children and adolescents (aged 3-17 years; hereinafter referred to as children) who attended at least 1 visit and had at least 1 blood pressure reading at or above the 90th percentile or diagnosis of elevated blood pressure or PHTN were eligible for data to be included in the analysis. Data were analyzed from September 1, 2020, to February 21, 2023.ExposuresBlood pressure at or above the 90th or 95th percentile.Main outcomes and measuresDiagnosis of PHTN (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision [ICD-10], code I10) or elevated blood pressure (ICD-10 code R03.0) and CDS tool use; blood pressure management (antihypertensive medication, lifestyle counseling, referral); and follow-up visit attendance. Descriptive statistics described the sample and rates of guideline adherence. Logistic regression analyses identified patient- and clinic-level associations with guideline adherence.ResultsThe sample consisted of 23 334 children (54.9% boys; 58.6% White race; median age, 8 [IQR, 4-12] years). Guideline-adherent diagnosis was observed in 8810 children (37.8%) with blood pressure at or above the 90th percentile and 146 of 2542 (5.7%) with blood pressure at or above the 95th percentile at 3 or more visits. The CDS tool was used to calculate blood pressure percentiles in 10 524 cases (45.1%) and was associated with significantly greater odds of PHTN diagnosis (odds ratio, 2.14 [95% CI, 1.10-4.15]). Among 15 422 children with blood pressure at or above the 95th percentile, antihypertensive medication was prescribed to 831 (5.4%), lifestyle counseling was provided to 14 841 (96.2%), and blood pressure-related referrals were given to 848 (5.5%). Guideline-adherent follow-up was observed in 8651 of 19 049 children (45.4%) with blood pressure at or above the 90th percentile and 2598 of 15 164 (17.1%) with blood pressure at or above the 95th percentile. Differences in guideline adherence by patient- and clinic-level factors were observed.Conclusions and relevanceIn this study, fewer than 50% of children with elevated blood pressure had a guideline-adherent diagnosis code or attended guideline-adherent follow-up. Using a CDS tool was associated with guideline-adherent diagnosis, but the tool was underused. Further work is needed to understand how to best support implementation of tools promoting PHTN diagnosis, management, and follow-up.

Project description:ObjectiveEfficient, effective health care requires rapid availability of patient information. We designed, implemented, and assessed the impact of a primary care electronic medical record (EMR) in three rural Kenyan health centers.MethodLocal clinicians identified data required for primary care and public health reporting. We designed paper encounter forms to capture these data in adult medicine, pediatric, and antenatal clinics. Encounter form data were hand-entered into a new primary care module in an existing EMR serving onsite clinics serving patients infected with the human immunodeficiency virus (HIV). Before subsequent visits, Summary Reports were printed containing selected patient data with reminders for needed HIV care. We assessed effects on patient flow and provider work with time-motion studies before implementation and two years later, and we surveyed providers' satisfaction with the EMR.ResultsBetween September 2008 and December 2011, 72 635 primary care patients were registered and 114 480 encounter forms were completed. During 2011, 32 193 unique patients visited primary care clinics, and encounter forms were completed for all visits. Of 1031 (3.2%) who were HIV-infected, 85% received HIV care. Patient clinic time increased from 37 to 81 min/visit after EMR implementation in one health center and 56 to 106 min/visit in the other. However, outpatient visits to both health centers increased by 85%. Three-quarters of increased time was spent waiting. Despite nearly doubling visits, there was no change in clinical officers' work patterns, but the nurses' and the clerks' patient care time decreased after EMR implementation. Providers were generally satisfied with the EMR but desired additional training.ConclusionsWe successfully implemented a primary care EMR in three rural Kenyan health centers. Patient waiting time was dramatically lengthened while the nurses' and the clerks' patient care time decreased. Long-term use of EMRs in such settings will require changes in culture and workflow.

Dataset Information

Better adherence to pre-antiretroviral therapy guidelines after implementing an electronic medical record system in rural Kenyan HIV clinics: a multicenter pre-post study.

Publications

Better adherence to pre-antiretroviral therapy guidelines after implementing an electronic medical record system in rural Kenyan HIV clinics: a multicenter pre-post study.

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