Treatment Outcomes and Cost-Effectiveness of Shifting Management of Stable ART Patients to Nurses in South Africa: An Observational Cohort
Background:
To address human resource and infrastructure shortages, resource-constrained countries are being encouraged to shift HIV care to lesser trained care providers and lower level health care facilities. This study evaluated the cost-effectiveness of down-referring stable antiretroviral therapy (ART) patients from a doctor-managed, hospital-based ART clinic to a nurse-managed primary health care facility in Johannesburg, South Africa.
Methods and Findings:
Criteria for down-referral were stable ART (≥11 mo), undetectable viral load within the previous 10 mo, CD4>200 cells/mm3, <5% weight loss over the last three visits, and no opportunistic infections. All patients down-referred from the treatment-initiation site to the down-referral site between 1 February 2008 and 1 January 2009 were compared to a matched sample of patients eligible for down-referral but not down-referred. Outcomes were assigned based on vital and health status 12 mo after down-referral eligibility and the average cost per outcome estimated from patient medical record data.
The down-referral site (n = 712) experienced less death and loss to follow up than the treatment-initiation site (n = 2,136) (1.7% versus 6.2%, relative risk = 0.27, 95% CI 0.15–0.49). The average cost per patient-year for those in care and responding at 12 mo was US$492 for down-referred patients and US$551 for patients remaining at the treatment-initiation site (p<0.0001), a savings of 11%. Down-referral was the cost-effective strategy for eligible patients.
Conclusions:
Twelve-month outcomes of stable ART patients who are down-referred to a primary health clinic are as good as, or better than, the outcomes of similar patients who are maintained at a hospital-based ART clinic. The cost of treatment with down-referral is lower across all outcomes and would save 11% for patients who remain in care and respond to treatment. These results suggest that this strategy would increase treatment capacity and conserve resources without compromising patient outcomes.
: Please see later in the article for the Editors' Summary
Vyšlo v časopise:
Treatment Outcomes and Cost-Effectiveness of Shifting Management of Stable ART Patients to Nurses in South Africa: An Observational Cohort. PLoS Med 8(7): e32767. doi:10.1371/journal.pmed.1001055
Kategorie:
Research Article
prolekare.web.journal.doi_sk:
https://doi.org/10.1371/journal.pmed.1001055
Souhrn
Background:
To address human resource and infrastructure shortages, resource-constrained countries are being encouraged to shift HIV care to lesser trained care providers and lower level health care facilities. This study evaluated the cost-effectiveness of down-referring stable antiretroviral therapy (ART) patients from a doctor-managed, hospital-based ART clinic to a nurse-managed primary health care facility in Johannesburg, South Africa.
Methods and Findings:
Criteria for down-referral were stable ART (≥11 mo), undetectable viral load within the previous 10 mo, CD4>200 cells/mm3, <5% weight loss over the last three visits, and no opportunistic infections. All patients down-referred from the treatment-initiation site to the down-referral site between 1 February 2008 and 1 January 2009 were compared to a matched sample of patients eligible for down-referral but not down-referred. Outcomes were assigned based on vital and health status 12 mo after down-referral eligibility and the average cost per outcome estimated from patient medical record data.
The down-referral site (n = 712) experienced less death and loss to follow up than the treatment-initiation site (n = 2,136) (1.7% versus 6.2%, relative risk = 0.27, 95% CI 0.15–0.49). The average cost per patient-year for those in care and responding at 12 mo was US$492 for down-referred patients and US$551 for patients remaining at the treatment-initiation site (p<0.0001), a savings of 11%. Down-referral was the cost-effective strategy for eligible patients.
Conclusions:
Twelve-month outcomes of stable ART patients who are down-referred to a primary health clinic are as good as, or better than, the outcomes of similar patients who are maintained at a hospital-based ART clinic. The cost of treatment with down-referral is lower across all outcomes and would save 11% for patients who remain in care and respond to treatment. These results suggest that this strategy would increase treatment capacity and conserve resources without compromising patient outcomes.
: Please see later in the article for the Editors' Summary
Zdroje
1. World Health Organization 2008 Task shifting: rational redistribution of tasks among health workforce teams: global recommendations and guidelines Geneva World Health Organization Available: http://www.who.int/healthsystems/TTR-TaskShifting.pdf. Accessed 2 November 2010
2. CallaghanMFordNSchneiderH 2010 A systematic review of task- shifting for HIV treatment and care in Africa. Hum Resour Health 8 8 doi:10.1186/1478-4491-8-8
3. BedeluMFordNHilderbrandKReuterH 2007 Implementing antiretroviral therapy in rural communities: the Lusikisiki model of decentralized HIV/AIDS care. J Infect Dis 196 Suppl S464 S468
4. FattiGGrimwoodABockP 2010 Better antiretroviral therapy outcomes at primary healthcare facilities: an evaluation of three tiers of ART services in four South African provinces. PLoS ONE 5 e12888 doi:10.1371/journal.pone.0012888
5. HumphreysCPWrightJWalleyJMamvuraCTBaileyKA 2010 Nurse led, primary care based antiretroviral treatment versus hospital care: a controlled prospective study in Swaziland. BMC Health Serv Res 10 229
6. BemelmansMVan Den AkkerTFordNPhilipsMZachariahR 2010 Providing universal access to antiretroviral therapy in Thyolo, Malawi through task shifting and decentralization of HIV/AIDS care. Trop Med Int Health 15 1413 1420 doi:10.1111/j.1365-3156.2010.02649.x
7. SelkeHMKimaiyoSSidleJEVedanthanRTierneyWM 2010 Task-shifting of antiretroviral delivery from health care workers to persons living with HIV/AIDS: clinical outcomes of a community-based program in Kenya. J Acquir Immune Defic Syndr 55 483 490 doi:10.1097/QAI.0b013e3181eb5edb
8. SanneIMOrrellCFoxMPConradieFIveP 2010 Nurse versus doctor management of HIV-infected patients receiving antiretroviral therapy (CIPRA-SA): a randomised non-inferiority trial. Lancet 376 33 40
9. SanneIMWestreichDMacphailAPRubelDMajubaP 2009 Long term outcomes of antiretroviral therapy in a large HIV/AIDS care clinic in urban South Africa: a prospective cohort study. J Int AIDS Soc 12 38 doi:10.1186/1758-2652-12-38
10. RosenbaumPRRubinDB 1983 The central role of the propensity score in observational studies for causal effects. Biometrika 70 41 55 doi:10.1093/biomet/70.1.41
11. KosankeJLBergstralhEJ 2010 Dist [SAS macro] Rochester (Minnesota) Division of Biomedical Statistics and Informatics, Mayo Clinic, 2010 Available: http://mayoresearch.mayo.edu/biostat/sasmacros.cfm. Accessed 9 June 2011
12. RosenSLongLSanneIM 2008 The outcomes and outpatient costs of different models of antiretroviral treatment delivery in South Africa. Trop Med Int Health 13 1005 1015 doi:10.1111/j.1365-3156.2008.02114.x
13. EfronBTibshiraniRJ 1993 An introduction to the bootstrap Boca Raton (Florida) Chapman and Hall/CRC 436
14. Joint United Nations Programme on HIV/AIDS 2010 Outlook report 2010 Geneva Joint United Nations Programme on HIV/AIDS Available: http://data.unaids.org/pub/Outlook/2010/20100713_outlook_report_web_en.pdf. Accessed 3 October 2010
15. South African National AIDS Council 2010 National strategic plan 2007–2011: mid term review 2010 Pretoria South African National AIDS Council Available: http://www.irinnews.org/pdf/Mid_Term_Review_of_the_NSP_(preliminary_report).pdf. Accessed 7 April 2011
16. DrummondMSculpherMTorranceGO'BrienBStoddartG 2005 Methods for the economic evaluation of health care programmes, 3rd edition Oxford Oxford University Press 396
17. GengEHNashDKambuguAZhangYBraitsteinP 2010 Retention in care among HIV-infected patients in resource-limited settings: emerging insights and new directions. Curr HIV/AIDS Rep 7 234 244 doi:10.1007/s11904-010-0061-5
18. World Health Organization 2007 Task shifting to tackle health worker shortages Geneva World Health Organization Available: http://www.who.int/healthsystems/task_shifting_booklet.pdf. Accessed 12 January 2011
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