Transcript TB record systems models for ART care - Dan Bleed (WHO) ppt, 731kb

TB R&R System's strong points
• Standardized system implemented widely
• Collection of follow-up information on each patient
over long course of treatment
• Data sources succinct, cleverly designed for
tabulation, cross-referencing
• Definitions that are clear, serve both epi and clinical
purposes
• Outcomes based on mutually exclusive irrevocable
categories that are assessed by cohort
• Works as a completely paper-based system up to
central level in developing countries
• Known benchmarks (e.g. proportion cases smear +)
TB records: treatment card
TB records: patient register
Tool of DHO (not all of the data in TC)
1 row = 1 course of treatment
Does not "track" a change in
Ordered by date of reg.
regimen (re-reg)
Handy use of multiple col.
(probably ART pgm cannot
afford this luxury)
“Transfer-out” outcome is really a
•“Default” outcome does not exactly say
subset of unknowns (transfer-out
whatcases
happened to the patient and his
with outcome unknown). It is episode of TB. Defaulters may or may
not be lost patients. Or they may be
responsibility of the initial registration
(only) to report the outcome. known
The to be dead. Still, the default
outcome is irrevocable. It is a point of
receiving unit registers for
closure on the current regimen.
mgmt/monitoring, but record is
disregarded when making cohort
reports.
TB records: lab register
TB quarterly reports
TB quarterly reports
Implementation of district TB register:
2 scenarios
Centralized registration
Patient presents centrally (1), is examined
and diagnosed (2), registered (3) and
takes observed treatment at same site or
(preferrable) at peripheral facility near his
home where treatment card is kept (4).
De-centralized registration
Patient presents to peripheral facility and
is examined (1), sputum is sent to one of
several labs (2), patient begins treatment
with treatment card (3); at a later date,
district supervisor visits facility and
registers case (4), transcribing from
treatment card.
Some notes about TB system
Drug planning is relatively simple (few deviations from defined
regimen) Can estimate monthly/quarterly needs from the casefinding report.
Duration of follow-up relatively limited (6-9 mo), and limited pieces
of follow-up info (follow-up smears). Patients may travel to
higher level registration/diagnostic center for follow-up smears.
Outcomes are mutually exclusive and irrevocable events (e.g.,
once defaulted, end of story for that "case" because end of the
road for the use of that regimen.)
Some notes about TB system (2)
Each arrow
represents
a patient's
treatment
across time,
with some
outcome
reached
Q1
Q2
Q3
Q4
• Cohort analysis: common time period of initiating treatment
(versus a common period when outcome is reached – highly variable).
• Useful to monitoring trends in programme performance.
• Involves a long delay in assessment (to allow everyone to have
a chance to finish their regimen), but works nicely in context of
SCC (std duration).
• Cohort exclusions are few, so cohort N is stable
Issues for ART monitoring
Substitutions and switches in ARV regimens are not
uncommon.
Implications (probably):
• Default (interruption) outcome may not have same
significance / usefulness.
• Definition and significance of "failure"?
• Need frequent reports for drug planning (monthly)
– So register (and reporting) must be facility based.
Issues for ART monitoring (2)
Treatment duration is forever: only irrevocable “outcome” for the
patient is death.
Implication/Issues:
• Might not make sense to monitor only outcome of the
original regimen course (where 2nd regimen entails reregistration on new line in the register book). Rather, it
might make sense to monitor outcomes of patients (up to a
certain point … 2 yrs?), and keep all info on one line in the
register (no re-registration).
• Probably cannot expect initial registration unit to follow
transferred patient’s outcomes quarterly for 2 yrs, so…
–
–
transferring could be a legitimate and final outcome, but then
cohort N will become fuzzy due to transfer-in cases; this would be a
sacrifice in transparency at lower level; OK at higher levels)
Issues for ART monitoring (3)
Substitutions/switches are important status/events to
monitor.
Implication:
• Substitution/switch (1st/2nd-line) events could be
viewed as part of the outcome definition, e.g.,
– those alive and still on original regimen
– those alive and on substituted regimen
– those alive and on switched [2nd line] regimen.
ART outcome analyses are tricky…
Possibilities: "How many patients stopped treatment…"
–
–
–
–
In the most recent month?
From Jan-Mar of this year?
Ever (since beginning of pgm)?
As of their 6 month of treatment?
[Cross-Sectional *]
[Cross-Sectional *]
[Cumulative *]
[Survival analysis]
Example of cohort analysis:
"How many patients entering ART during a given time period
had a "stopped treatment" outcome one year after the close of that time
period."
Hand-outs suggest a minimum way to get cross-sectional and cohort data of
interest to programmes using a paper-based system. (More data
available in the register for computerized analyses).
* This is a "transient" (not irrevocable) status / event / outcome.