Quality improvement intervention to increase adherence to ART prescription policy at HIV treatment clinics in Lusaka, Zambia: A cluster randomized trial

Abstract

IntroductionIn urban areas, crowded HIV treatment facilities with long patient wait times can deter patients from attending their clinical appointments and picking up their medications, ultimately disrupting patient care and compromising patient retention and adherence.MethodsFormative research at eight facilities in Lusaka revealed that only 46% of stable HIV treatment patients were receiving a three-month refill supply of antiretroviral drugs, despite it being national policy for stable adult patients. We designed a quality improvement intervention to improve the operationalization of this policy. We conducted a cluster-randomized controlled trial in sixteen facilities in Lusaka with the primary objective of examining the intervention’s impact on the proportion of stable patients receiving three-month refills. The secondary objective was examining whether the quality improvement intervention reduced facility congestion measured through two proxy indicators: daily volume of clinic visits and average clinic wait times for services.ResultsThe mean change in the proportion of three-month refills among control facilities from baseline to endline was 10% (from 38% to 48%), compared to a 25% mean change (an increase from 44% to 69%) among intervention facilities. This represents a significant 15% mean difference (95% CI: 2%-29%; P = 0.03) in the change in proportion of patients receiving three-month refills. On average, control facilities had 15 more visits per day in the endline than in the baseline, while intervention facilities had 20 fewer visits per day in endline than in baseline, a mean difference of 35 fewer visits per day (P = 0.1). The change in the mean facility total wait time for intervention facilities dropped 19 minutes between baseline and endline when compared to control facilities (95% CI: -10.2–48.5; P = 0.2).ConclusionA more patient-centred service delivery schedule of three-month prescription refills for stable patients is viable. We encourage the expansion of this sustainable intervention in Zambia’s urban clinics.

Assessment of facility and health worker readiness to provide quality antenatal, intrapartum and postpartum care in rural Southern Nepal

“…Similar findings of better service readiness in hospitals compared to primary care facilities is evident in other settings as well [33,45]. Studies have shown that healthcare utilization patterns, retention in care and people's decision to bypass facilities is due to the patient's perception of quality [46,47]. In Nepal [48], India [15,49] and some sub-Saharan Africa countries [50,51], bypassing the nearest public health facility for a higher level facility or private facility due to at least one quality concern is evident.…”

Emerging priorities for HIV service delivery

“…In Ethiopia, 6-month refills have been rolled out with initial positive findings [33]. A quality improvement intervention from Zambia increased the number of facilities offering 3-month refills in accordance with national policy, which resulted in 20 fewer patient visits per day in facilities receiving the intervention [34]. Since April 2019, following a Ministry of Health directive, Zambia also has scaled up 6-month refills for stable patients.…”

Building a tuberculosis-free world: The Lancet Commission on tuberculosis

“…By leveraging a four-step continuous cycle of improvement (plan-do-check-act), these programmes have driven substantive change by developing local solutions to improve the quality of HIV care. Improvements have been shown across different facets of care, including treatment adherence, 136 reducing mother-to-child transmission of HIV, 137 paediatric services, 138 enhancing adherence to treatment guidelines, 139 and strengthening the clinical capacity of front-line providers. 140 Similar approaches can be used to improve the quality of care for patients with tuberculosis, while also enabling increased accountability at all levels of national tuberculosis programmes (case studies in the appendix pp 22-24 provide examples from the public and private sector, at facility and regional level, of how quality improvement approaches have been deployed to improve tuberculosis outcomes).…”