Using quality improvement to accelerate highly active antiretroviral treatment coverage in South Africa
- Patty D Webster1,
- Maria Sibanyoni2,
- Dinah Malekutu2,
- Kedar S Mate1,3,
- W D Francois Venter2,4,
- Pierre M Barker1,5,
- Winnie Moleko2
- 1Institute for Healthcare Improvement, Cambridge, Massachusetts, USA
- 2Wits Reproductive Health and HIV Institute Johannesburg, South Africa
- 3Weill Cornell Medical School, New York City, New York, USA
- 4South African HIV Clinicians Society, Johannesburg, South Africa
- 5University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Correspondence to Patty D Webster, Institute for Healthcare Improvement, 20 University Road, 7th Floor, Cambridge, MA 02138, USA;
Contributors All authors have made a substantial, direct, intellectual contribution to this study. All authors had full access to all of the data in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis. All authors meet the following criteria for authorship: made substantial contributions to conception and design (PB, FV, WM) or acquisition of data (MS, DM), or analysis and interpretation of data (PW, MS, DM, KM, PB, WM); drafting the article (PW, PB, FV) or revising it critically for important intellectual content (PW, MS, DM, KM, WM); and final approval of the version to be published (all).
- Accepted 28 December 2011
Introduction The authors report on a health systems strengthening intervention using quality improvement (QI) methods at the subdistrict level to accelerate highly active antiretroviral treatment (HAART) initiation in South Africa.
Methods Using a phased scale-up design between August 2006 and November 2009, 14 primary healthcare clinics, one community health centre, one district hospital and one tertiary hospital in a subdistrict were recruited into a ‘learning network’ using QI methods to facilitate cross-facility learning/mentorship/support. Clinic teams consisting of nurses, counsellors, clerks and/or doctors set collective and individual performance targets, analysed their care systems using ‘real-time’ data feedback, and designed/implemented a set of simple changes to improve HIV testing and HAART initiation rates across the region.
Data analysis Primary clinic data were used to measure HAART initiation rates (primary outcome) and HIV testing (secondary outcome). We analysed data variation/trends using an interrupted time series design. Logistic regression analysis was applied to examine trends in HAART initiation during the intervention phases.
Results Clinics in the learning network increased HIV testing by 301.8% from 891/month (SD=94.2) to 3580/month (SD=327.7) (p<0.0001). Monthly HAART initiations increased by 185.5% from 179/month (SD=17.22) to 511/month (SD=44.93) (p<0.0001). During the pilot (phase I), the monthly rate of HAART initiations increased by 3.6 patients. In the prototype collaborative (phase II), there was no acceleration in the rate of increase (3.3/month, p=0.92). Significant acceleration was observed in the rate of increase during the QI scale up (phase III) (10.1/month, p<0.001). The proportion of estimated need for HAART met in the region increased from 35.8% to 72.4% at a time of rapid population growth.
Conclusion A QI approach, using learning networks to teach simple data-driven methods for addressing system failures, with increased training and resource inputs, can assist districts to quickly reach universal coverage targets.
- Quality improvement
- quality improvement methodologies
- continuous quality improvement
- breakthrough groups
- healthcare quality improvement
- patient-centred care
- primary care
- comparative effectiveness research
- implementation science
Funding This project (Wits Reproductive Health and HIV Institute (WRHI)) was made possible by the generous support of the American people through the US Agency for International Development (USAID). The contents do not necessarily reflect the views of USAID or the US government. USAID/President's Emergency Plan for AIDS Relief (PEPFAR) funded WRHI's overall work, not the Institute for Healthcare Improvement (IHI).
Competing interests None.
Patient consent The Institutional Review Board (IRB) at the University of North Carolina at Chapel Hill determined that this study did not require full IRB approval. An exemption was provided on the basis that this was a quality improvement project of an existing standard government protocol using aggregate, de-identified data that were routinely collected in the public health system.
Ethics approval The Human Research Ethics Committee (HREC) of the University of the Witwatersrand, Johannesburg, South Africa.
Provenance and peer review Not commissioned; externally peer reviewed.
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