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Secor AM, Célestin K, Jasmin M, Honoré JG, Wagner AD, Beima-Sofie K, Pintye J, Puttkammer N. Electronic Medical Record Data Missingness and Interruption in Antiretroviral Therapy Among Adults and Children Living With HIV in Haiti: Retrospective Longitudinal Study. JMIR Pediatr Parent 2024; 7:e51574. [PMID: 38488632 PMCID: PMC10986334 DOI: 10.2196/51574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 01/18/2024] [Accepted: 01/19/2024] [Indexed: 04/04/2024] Open
Abstract
Background Children (aged 0-14 years) living with HIV often experience lower rates of HIV diagnosis, treatment, and viral load suppression. In Haiti, only 63% of children living with HIV know their HIV status (compared to 85% overall), 63% are on treatment (compared to 85% overall), and 48% are virally suppressed (compared to 73% overall). Electronic medical records (EMRs) can improve HIV care and patient outcomes, but these benefits are largely dependent on providers having access to quality and nonmissing data. Objective We sought to understand the associations between EMR data missingness and interruption in antiretroviral therapy treatment by age group (pediatric vs adult). Methods We assessed associations between patient intake record data missingness and interruption in treatment (IIT) status at 6 and 12 months post antiretroviral therapy initiation using patient-level data drawn from iSanté, the most widely used EMR in Haiti. Missingness was assessed for tuberculosis diagnosis, World Health Organization HIV stage, and weight using a composite score indicator (ie, the number of indicators of interest missing). Risk ratios were estimated using marginal parameters from multilevel modified Poisson models with robust error variances and random intercepts for the facility to account for clustering. Results Data were drawn from 50 facilities and comprised 31,457 patient records from people living with HIV, of which 1306 (4.2%) were pediatric cases. Pediatric patients were more likely than adult patients to experience IIT (n=431, 33% vs n=7477, 23.4% at 6 months; P<.001). Additionally, pediatric patient records had higher data missingness, with 581 (44.5%) pediatric records missing at least 1 indicator of interest, compared to 7812 (25.9%) adult records (P<.001). Among pediatric patients, each additional indicator missing was associated with a 1.34 times greater likelihood of experiencing IIT at 6 months (95% CI 1.08-1.66; P=.008) and 1.24 times greater likelihood of experiencing IIT at 12 months (95% CI 1.05-1.46; P=.01). These relationships were not statistically significant for adult patients. Compared to pediatric patients with 0 missing indicators, pediatric patients with 1, 2, or 3 missing indicators were 1.59 (95% CI 1.26-2.01; P<.001), 1.74 (95% CI 1.02-2.97; P=.04), and 2.25 (95% CI 1.43-3.56; P=.001) times more likely to experience IIT at 6 months, respectively. Among adult patients, compared to patients with 0 indicators missing, having all 3 indicators missing was associated with being 1.32 times more likely to experience IIT at 6 months (95% CI 1.03-1.70; P=.03), while there was no association with IIT status for other levels of missingness. Conclusions These findings suggest that both EMR data quality and quality of care are lower for children living with HIV in Haiti. This underscores the need for further research into the mechanisms by which EMR data quality impacts the quality of care and patient outcomes among this population. Efforts to improve both EMR data quality and quality of care should consider prioritizing pediatric patients.
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Affiliation(s)
- Andrew M Secor
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Kemar Célestin
- Centre Haïtien pour le Renforcement du Système de Santé, Port-au-Prince, Haiti
| | - Margareth Jasmin
- Centre Haïtien pour le Renforcement du Système de Santé, Port-au-Prince, Haiti
| | - Jean Guy Honoré
- Centre Haïtien pour le Renforcement du Système de Santé, Port-au-Prince, Haiti
| | - Anjuli D Wagner
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Kristin Beima-Sofie
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Jillian Pintye
- Department of Global Health, University of Washington, Seattle, WA, United States
| | - Nancy Puttkammer
- International Training and Education Center for Health, Seattle, WA, United States
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Puttkammer N, Demes JAE, Dervis W, Chéry JM, Elusdort J, Haight E, Honoré JG, Simoni JM. Patient and health worker perspectives on quality of HIV care and treatment services in Haiti. BMC Health Serv Res 2023; 23:66. [PMID: 36683038 PMCID: PMC9869625 DOI: 10.1186/s12913-023-09041-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 01/05/2023] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Poor quality of care is a barrier to engagement in HIV care and treatment in low- and middle-income country settings. This study involved focus group discussions (FGD) with patients and health workers in two large urban hospitals to describe quality of patient education and psychosocial support services within Haiti's national HIV antiretroviral therapy (ART) program. The purpose of this qualitative study was to illuminate key gaps and salient "ingredients" for improving quality of care. METHODS The study included 8 FGDs with a total of 26 male patients and 32 female patients and 15 smaller FGDs with 57 health workers. The analysis used a directed content analysis method, with the goal of extending existing conceptual frameworks on quality of care through rich description. RESULTS Dimension of safety, patient-centeredness, accessibility, and equity were most salient. Patients noted risks to privacy with both clinic and community-based services as well as concerns with ART side effects, while health workers described risks to their own safety in providing community-based services. While patients cited examples of positive interactions with health workers that centered their needs and perspectives, they also noted concerns that inhibited trust and satisfaction with services. Health workers described difficult working conditions that challenged their ability to provide patient-centered services. Patients sought favored relationships with health workers to help them navigate the health care system, but this undermined the sense of fairness. Both patients and health workers described frustration with lack of resources to assist patients in dire poverty, and health workers described great pressure to help patients from their "own pockets." CONCLUSIONS These concerns reflected the embeddedness of patient - provider interactions within a health system marked by scarcity, power dynamics between patients and health workers, and social stigma related to HIV. Reinforcing a respectful and welcoming atmosphere, timely service, privacy protection, and building patient perception of fairness in access to support could help to build patient satisfaction and care engagement in Haiti. Improving working conditions for health workers is also critical to achieving quality.
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Affiliation(s)
- Nancy Puttkammer
- International Training and Education Center for Health (I-TECH), Department of Global Health, University of Washington, 325 Ninth Ave, Box # 359932, Seattle, WA 98104 USA
| | - Joseph Adrien Emmanuel Demes
- Faculté de Médecine et de Pharmacie, Université d’Etat d’Haïti (National University of Haiti), 89, Rue Oswald DURAND, Port-Au-Prince, HT6110 Haïti
| | - Witson Dervis
- Centre Haïtien de Renforcement du Système Sanitaire (CHARESS), 14, Route de Jacquet, Delmas 95, Port-Au-Prince, Haïti
| | - Jean Marcxime Chéry
- Centre Haïtien de Renforcement du Système Sanitaire (CHARESS), 14, Route de Jacquet, Delmas 95, Port-Au-Prince, Haïti
| | - Josette Elusdort
- Centre Haïtien de Renforcement du Système Sanitaire (CHARESS), 14, Route de Jacquet, Delmas 95, Port-Au-Prince, Haïti
| | - Elizabeth Haight
- International Training and Education Center for Health (I-TECH), Department of Global Health, University of Washington, 325 Ninth Ave, Box # 359932, Seattle, WA 98104 USA
| | - Jean Guy Honoré
- Centre Haïtien de Renforcement du Système Sanitaire (CHARESS), 14, Route de Jacquet, Delmas 95, Port-Au-Prince, Haïti
| | - Jane M. Simoni
- Department of Psychology, University of Washington, 3921 W Stevens Way NE, Box #351525, Seattle, WA 98195-0000 USA
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Parrish C, Basu A, Fishman P, Koama JB, Robin E, Francois K, Honoré JG, Van Onacker JD, Puttkammer N. Correction to: A sub-group evaluation of the multi-month dispensing strategy for differentiated HIV care: is personalization of care guidelines warranted in Haiti? BMC Health Serv Res 2022; 22:124. [PMID: 35093059 PMCID: PMC8800270 DOI: 10.1186/s12913-022-07534-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Canada Parrish
- University of Washington, Magnuson Health Sciences Building, 1705 NE Pacifc Street, Seattle, WA, 98195, USA.
| | - Anirban Basu
- University of Washington, Magnuson Health Sciences Building, 1705 NE Pacifc Street, Seattle, WA, 98195, USA
| | - Paul Fishman
- University of Washington, Magnuson Health Sciences Building, 1705 NE Pacifc Street, Seattle, WA, 98195, USA
| | | | - Ermane Robin
- Programme National de Lutte contre le VIH/ SIDA (PNLS), Ministère de la Santé Publique et de la Population (MSPP), Port-au-Prince, Haiti
| | - Kesner Francois
- Programme National de Lutte contre le VIH/ SIDA (PNLS), Ministère de la Santé Publique et de la Population (MSPP), Port-au-Prince, Haiti
| | - Jean Guy Honoré
- Centre Haïtien pour le Renforcement du Système de Santé (CHARESS), Port-au-Prince, Haiti
| | - Joëlle Deas Van Onacker
- Programme National de Lutte contre le VIH/ SIDA (PNLS), Ministère de la Santé Publique et de la Population (MSPP), Port-au-Prince, Haiti
| | - Nancy Puttkammer
- University of Washington, Magnuson Health Sciences Building, 1705 NE Pacifc Street, Seattle, WA, 98195, USA
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Parrish C, Basu A, Fishman P, Koama JB, Robin E, Francois K, Honoré JG, Van Onacker JD, Puttkamme N. A sub-group evaluation of the multi-month dispensing strategy for differentiated HIV care: is personalization of care guidelines warranted in Haiti? BMC Health Serv Res 2022; 22:80. [PMID: 35034656 PMCID: PMC8761104 DOI: 10.1186/s12913-022-07475-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 01/06/2022] [Indexed: 11/30/2022] Open
Abstract
Background Differentiated care strategies are rapidly becoming the norm for HIV care delivery globally. Building upon an interest in tailoring antiretroviral therapy (ART) delivery for client-centered needs, the Ministry of Health and Population in Haiti formally endorsed multiple-month dispenses (MMD) in the 2016 national ART guidelines This study explores heterogeneity in retention in care with MMD for specific Haitian populations living with HIV and evaluates if a targeted algorithm for optimal ART prescription intervals is warranted in Haiti. Methods This study included ART-naïve individuals who started ART on or after January 1st, 2017 in Haiti. To identify subgroups in which to explore heterogeneity of retention, we implemented a double-lasso regression method to determine which individual characteristics would define the subgroups. Characteristics evaluated for potential subgroup definition included: sex, age category, WHO clinical stage, and body mass index category. We employed instrumental variable models to estimate the causal effect of increasing ART dispensing length on ART retention, by client subgroup. The outcome of interest was retention in care after one year in treatment. We then estimated the marginal effect of a 30-day increase to ART dispensing length to retention in care for each of these subgroups. Results There was evidence for heterogeneity in the effect of extending ART dispensing intervals on retention by WHO clinical stage. We observed significant improvements to retention in care at one year with a 30-day increase in ART dispense length for all subgroups defined by WHO clinical stages 1-4. The effects ranged from a 14.7% increase (95% CI: 12.4-17.0) to the likelihood of retention for people with HIV in WHO stage 1 to a 21.6% increase (95% CI: 18.7-24.5) to the likelihood of retention for those in WHO stage 3. Conclusions All the subgroups defined by WHO clinical stage experienced a benefit of extending ART intervals to retention in care at one year. Though the effect did differ slightly by WHO stage, the effects went in the same direction and were of similar magnitude. Therefore, a standardized recommendation for MMD among those living with HIV and new on ART is appropriate for Haiti treatment guidelines.
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Affiliation(s)
- Canada Parrish
- University of Washington, Magnuson Health Sciences Building, 1705 NE Pacific Street, Seattle, WA, 98195, USA.
| | - Anirban Basu
- University of Washington, Magnuson Health Sciences Building, 1705 NE Pacific Street, Seattle, WA, 98195, USA
| | - Paul Fishman
- University of Washington, Magnuson Health Sciences Building, 1705 NE Pacific Street, Seattle, WA, 98195, USA
| | | | - Ermane Robin
- Programme National de Lutte contre le VIH/SIDA (PNLS), Ministère de la Santé Publique et de la Population (MSPP), Port-au-Prince, Haiti
| | - Kesner Francois
- Programme National de Lutte contre le VIH/SIDA (PNLS), Ministère de la Santé Publique et de la Population (MSPP), Port-au-Prince, Haiti
| | - Jean Guy Honoré
- Centre Haïtien pour le Renforcement du Système de Santé (CHARESS), Port-au-Prince, Haiti
| | - Joëlle Deas Van Onacker
- Programme National de Lutte contre le VIH/SIDA (PNLS), Ministère de la Santé Publique et de la Population (MSPP), Port-au-Prince, Haiti
| | - Nancy Puttkamme
- University of Washington, Magnuson Health Sciences Building, 1705 NE Pacific Street, Seattle, WA, 98195, USA
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Puttkammer N, Parrish C, Desir Y, Hyppolite N, Joseph N, Hall L, Honoré JG, Robin E, Perrin G, François K. Timely initiation of HIV antiretroviral therapy in Haiti 2004-2018: a retrospective cohort study. Rev Panam Salud Publica 2021; 45:e139. [PMID: 34815736 PMCID: PMC8603999 DOI: 10.26633/rpsp.2021.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 06/07/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To describe trends in timing of ART initiation for newly diagnosed people living with HIV before and after Haiti adopted its Test and Start policy for universal HIV antiretroviral therapy (ART) in July 2016, and to explore predictors of timely ART initiation for both newly and previously diagnosed people living with HIV following Test and Start adoption. METHODS This retrospective cohort study explored timing of ART initiation among 147 900 patients diagnosed with HIV at 94 ART clinics in 2004-2018 using secondary electronic medical record data. The study used survival analysis methods to assess time trends and risk factors for ART initiation. RESULTS Timely uptake of ART expanded with Test and Start, such that same-day ART initiation rates increased from 3.7% to 45.0%. However, only 11.0% of previously diagnosed patients initiated ART after Test and Start. In adjusted analyses among newly diagnosed people living with HIV, factors negatively associated with timely ART initiation included being a pediatric patient aged 0-14 years (HR = 0.23, p < 0.001), being male (HR = 0.92, p = 0.03), being 50+ years (HR = 0.87, p = 0.03), being underweight (HR = 0.79, p < 0.001), and having WHO stage 3 (HR = 0.73, p < 0.001) or stage 4 disease (HR = 0.49, p < 0.001). Variation in timely ART initiation by geographic department and health facility was observed. CONCLUSIONS Haiti has made substantial progress in scaling up Test and Start, but further work is needed to enroll previously diagnosed patients and to ensure rapid ART in key patient subgroups. Further research is needed on facility and geographic factors and on strategies for improving timely ART initiation among vulnerable subgroups.
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Affiliation(s)
- Nancy Puttkammer
- University of WashingtonWashingtonUnited States of AmericaUniversity of Washington, Washington, United States of America
| | - Canada Parrish
- University of WashingtonWashingtonUnited States of AmericaUniversity of Washington, Washington, United States of America
| | - Yrvel Desir
- National Association of State and Territorial AIDS DirectorsPort-au-PrinceHaitiNational Association of State and Territorial AIDS Directors, Port-au-Prince, Haiti
| | - Nathaelf Hyppolite
- Centre Haitien pour le Renforcement du Système de SantéPort-au-PrinceHaitiCentre Haitien pour le Renforcement du Système de Santé, Port-au-Prince, Haiti
| | - Nadjy Joseph
- National Association of State and Territorial AIDS DirectorsPort-au-PrinceHaitiNational Association of State and Territorial AIDS Directors, Port-au-Prince, Haiti
| | - Lara Hall
- United States Centers for Disease Control and PreventionPort-au-PrinceHaitiUnited States Centers for Disease Control and Prevention, Port-au-Prince, Haiti
| | - Jean Guy Honoré
- Centre Haitien pour le Renforcement du Système de SantéPort-au-PrinceHaitiCentre Haitien pour le Renforcement du Système de Santé, Port-au-Prince, Haiti
| | - Ermane Robin
- Ministère de Santé Publique et de la PopulationPort-au-PrinceHaitiMinistère de Santé Publique et de la Population, Port-au-Prince, Haiti
| | - Georges Perrin
- United States Centers for Disease Control and PreventionPort-au-PrinceHaitiUnited States Centers for Disease Control and Prevention, Port-au-Prince, Haiti
| | - Kesner François
- Ministère de Santé Publique et de la PopulationPort-au-PrinceHaitiMinistère de Santé Publique et de la Population, Port-au-Prince, Haiti
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Parrish C, Basu A, Fishman P, Koama JB, Robin E, Francois K, Honoré JG, Van Onacker JD, Puttkammer N. Estimating the effect of increasing dispensing intervals on retention in care for people with HIV in Haiti. EClinicalMedicine 2021; 38:101039. [PMID: 34368659 PMCID: PMC8326717 DOI: 10.1016/j.eclinm.2021.101039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 07/01/2021] [Accepted: 07/05/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Multi-month dispensing (MMD) for antiretroviral therapy (ART) is a promising care strategy to improve HIV treatment adherence. The effectiveness of MMD in routine settings has not yet been evaluated within a causal inference framework. We analyzed data from a robust clinical data system to evaluate MMD in Haiti. METHODS We assessed 1-year retention in care among 21,880 ART-naïve HIV-positive persons who started ART on or after January 1, 2017, up until November 1, 2018. We used an instrumental variable analysis to estimate the causal impact of MMD. This approach was used to address potential selection into specific dispensing intervals because MMD is not randomly applied to individuals. FINDINGS We found that extending ART dispensing intervals increased the probability of retention at 12 months after ART initiation, with up to a 24·2%-point increase (95%CI: 21·9, 26·5) in the likelihood of retention with extending dispenses by 30 days for those receiving one-month dispenses. We observed statistically significant gains to retention with MMD with up to an approximately 4-month supply of ART; +5·1%-points (95%CI: 2·4,7·8). Increasing dispensing lengths for those already receiving ≥5-month supply of ART had a potentially negative effect on retention. INTERPRETATION MMD for ART is an effective service delivery strategy that improves care retention for new ART recipients. There is a potentially negative effect of increasing prescription lengths for those new ART recipients already receiving longer ART supplies, though more research is needed to characterize this effect given medication supplies of this length are not common for newer ART recipients.
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Affiliation(s)
- Canada Parrish
- University of Washington, 12054 42nd Ave S. Tukwila, Seattle, WA 98169, USA
| | - Anirban Basu
- University of Washington, 12054 42nd Ave S. Tukwila, Seattle, WA 98169, USA
| | - Paul Fishman
- University of Washington, 12054 42nd Ave S. Tukwila, Seattle, WA 98169, USA
| | | | - Ermane Robin
- Ministère de la Santé Publique et de la Population (MSPP), Programme National de Lutte contre le VIH/SIDA (PNLS), Port-au-Prince, Haiti
| | - Kesner Francois
- Ministère de la Santé Publique et de la Population (MSPP), Programme National de Lutte contre le VIH/SIDA (PNLS), Port-au-Prince, Haiti
| | - Jean Guy Honoré
- Center Haïtien de Renforcement du Système Sanitaire (CHARESS), Port-au-Prince, Haiti
| | - Joëlle Deas Van Onacker
- Ministère de la Santé Publique et de la Population (MSPP), Programme National de Lutte contre le VIH/SIDA (PNLS), Port-au-Prince, Haiti
| | - Nancy Puttkammer
- University of Washington, 12054 42nd Ave S. Tukwila, Seattle, WA 98169, USA
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Ramaiya MK, Haight E, Simoni JM, Chéry JM, Dervis W, Genna W, Dubé JG, Calixte G, Balan JG, Honoré JG, Puttkammer N. Patient-Provider Communication and Information, Motivation, and Behavioral Skills in HIV-Positive Adults Initiating Antiretroviral Therapy in Haiti. J Int Assoc Provid AIDS Care 2021; 19:2325958220952631. [PMID: 32924764 PMCID: PMC7493277 DOI: 10.1177/2325958220952631] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
While Haiti has scaled up use of antiretroviral therapy (ART), current studies suggest sub-optimal adherence threatens long-term viral suppression in this understudied setting. Patient-provider communication (PPC) and information, motivation, and behavioral skills (IMB) have been implicated in ART adherence globally. However, no studies have examined their relevance in Haiti. The present mixed-methods study utilized cross-sectional survey data from 128 ART-initiating patients at 2 large HIV treatment sites in Haiti, as well as observational data from 12 clinic visits, to document associations between adherence-related PPC and IMB. Multivariate regression analyses suggested that PPC is associated with IMB constructs. At the bivariate level, more effective PPC was associated with higher levels of adherence-related information and motivation, but not behavioral skills. Observational findings indicate infrequent and non-collaborative adherence support. Taken together, findings lay the groundwork for additional research in the area of PPC, IMB, and ART adherence in Haiti.
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Affiliation(s)
- Megan K Ramaiya
- Department of Psychology, 7284University of Washington, Seattle, WA, USA
| | - Elizabeth Haight
- Department of Global Health, 7284University of Washington, Seattle, WA, USA
| | - Jane M Simoni
- Department of Psychology, 7284University of Washington, Seattle, WA, USA
| | - Jean Marcxime Chéry
- Centre Haïtien pour le Renforcement du Système de Santé (CHARESS), Port-au-Prince, Haiti
| | - Witson Dervis
- Centre Haïtien pour le Renforcement du Système de Santé (CHARESS), Port-au-Prince, Haiti
| | - Wilner Genna
- Justinien University Hospital, Cape Haitian, Haiti
| | | | | | - Jean Gabriel Balan
- Centre Haïtien pour le Renforcement du Système de Santé (CHARESS), Port-au-Prince, Haiti
| | - Jean Guy Honoré
- Centre Haïtien pour le Renforcement du Système de Santé (CHARESS), Port-au-Prince, Haiti
| | - Nancy Puttkammer
- Department of Global Health, 7284University of Washington, Seattle, WA, USA.,International Training & Education Center for Health (I-TECH), Seattle, WA, USA
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Celestin K, Allorant A, Virgin M, Marinho E, Francois K, Honoré JG, White C, Valles JS, Perrin G, De Kerorguen N, Flowers J, Balan JG, Koama JBT, Barnhart S, Puttkammer N. Short-Term Effects of the COVID-19 Pandemic on HIV Care Utilization, Service Delivery, and Continuity of HIV Antiretroviral Treatment (ART) in Haiti. AIDS Behav 2021; 25:1366-1372. [PMID: 33738698 PMCID: PMC7971405 DOI: 10.1007/s10461-021-03218-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2021] [Indexed: 11/30/2022]
Abstract
Introduction Our study describes changes in HIV care service delivery and continuity of HIV antiretroviral therapy (ART) for people living with HIV (PLHIV) during the 8 weeks before and after diagnosis of the first coronavirus disease 2019 (COVID-19) cases in Haiti on March 19, 2020. Methods Using data from 96 out of 167 health facilities offering ART services, we compared four ART program indicators: (1) count of HIV visits; (2) proportion of ART dispenses in community-based settings (DAC); (3) proportion of multi-month dispensing of ART medications > 6 months (> 6 m MMD); and (4) proportion of timely ART refills. We used uncontrolled interrupted time series (ITS) models to estimate slope and level changes in each indicator with the arrival of COVID-19. Results and Discussion From week 1 to week 16, the average number of HIV visits fell from 121.5 to 92.5 visits, the proportion of DAC rose from 22.7% to 36.7%, the proportion of > 6 m MMD rose from 29.4% to 48.4%, and the proportion of timely ART refills fell from 51.9% to 43.8%. The ITS models estimated abrupt increases of 36% in > 6 m MMD (p < 0.001) and 37% in DAC (p < 0.001) at the time of COVID-19 arrival, and no change after arrival of COVID-19. The was an abrupt decline of 18% in timely ART refills with the arrival of COVID-19 and a decline of 1% per week thereafter, both non-statistically significant changes. Conclusions The sudden changes in HIV service utilization represent dramatic adaptations needed to mitigate primary and secondary effects of the COVID-19 pandemic on PLHIV. This study underscores the urgency of optimizing ART delivery models in Haiti and beyond, in order to maintain progress toward HIV epidemic control.
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Puttkammer N, Simoni JM, Sandifer T, Chéry JM, Dervis W, Balan JG, Dubé JG, Calixte G, Robin E, François K, Casey C, Wilson I, Honoré JG. An EMR-Based Alert with Brief Provider-Led ART Adherence Counseling: Promising Results of the InfoPlus Adherence Pilot Study Among Haitian Adults with HIV Initiating ART. AIDS Behav 2020; 24:3320-3336. [PMID: 32715409 DOI: 10.1007/s10461-020-02945-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
To promote HIV antiretroviral therapy (ART) outcomes in Haiti, we developed a culturally relevant intervention (InfoPlus Adherence) that combines an electronic medical record alert identifying patients at elevated risk of treatment failure and provider-delivered brief problem-solving counseling. We conducted a quasi-experimental mixed-methods study among 146 patients at two large ART clinics in Haiti with 728 historical controls. We conducted quantitative assessments of patients at baseline and intervention completion (6 months) as well as focus groups with health workers and exit interviews with patients. The primary quantitative outcome measures were HIV viral suppression according to medical record and ART adherence in terms of ≥ 90% for "proportion of days covered" (PDC) according to pharmacy dispensing data. Results indicated that the proportion of intervention patients with suppressed VL during the study/historical periods was 80.0%/86.0% and 76.8%/87.4% for controls. In a difference-in-differences (DID) analytic model, the adjusted relative risk for viral suppression with the intervention was 1.15 (95% CI 0.92-1.45, p = 0.21), representing favorable but non-significant association between the intervention and the trajectory of VL outcomes. PDC ≥ 90% during the study/historical periods was 30.9%/11.0% among intervention participants and 16.9%/19.4% among controls. In the adjusted DID model, the relative risk for of PDC ≥ 90% with the intervention was 4.00 (95% CI 1.91-8.38, p < 0.001), representing a highly favorable association between the intervention and the trajectory of PDC outcomes. Qualitative data affirmed acceptability of the intervention, although providers reported some challenges consistently implementing it. Future research is needed to demonstrate efficacy and explore optimal implementation strategies.
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Wang Y, Barnhart S, Francois K, Robin E, Kalou M, Perrin G, Hall L, Koama JB, Marinho E, Balan JG, Honoré JG, Puttkammer N. Expanded access to viral load testing and use of second line regimens in Haiti: time trends from 2010-2017. BMC Infect Dis 2020; 20:283. [PMID: 32299389 PMCID: PMC7160963 DOI: 10.1186/s12879-020-04978-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 03/17/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Haiti initiated the scale-up of HIV viral load (VL) testing in 2015-2016, with plans to achieve 100% coverage for all patients on antiretroviral therapy (ART) for treatment of HIV/AIDS. In the absence of HIV drug susceptibility testing, VL testing is a key tool for monitoring response to ART and optimizing treatment results. This study describes trends in expanded use of VL testing, VL results, and use of second-line ART regimens, and explores the association between VL testing and second-line regimen switching in Haiti from 2010 to 2017. METHODS We conducted a retrospective cohort study with 66,042 patients drawn from 88 of Haiti's 160 national ART clinics. Longitudinal data from the iSanté electronic data system was used to analyze the trends of interest. We described patients' VL testing status in five categories based on up to two most recent VL test results: no test; suppressed; unsuppressed followed by no test; re-suppressed; and confirmed failure. Among those with confirmed failure, we described ART adherence level. Finally, we used Cox proportional hazards regression to estimate the risk of second-line regimen switching by VL testing status, after adjusting for other individual characteristics. RESULTS The number of patients who had tests done increased annually from 11 in 2010 to 18,828 in the first 9 months of 2017, while the number of second-line regimen switches rose from 21 to 279 during this same period. Compared with patients with no VL test, the hazard ratio (HR) for switching to a second-line regimen was 22.2 for patients with confirmed VL failure (95% confidence interval [CI] for HR: 18.8-26.3; p < 0.005) after adjustment for individual characteristics. Among patients with confirmed VL failure, 44.7% had strong adherence, and fewer than 20% of patients switched to a second-line regimen within 365 days of VL failure. CONCLUSIONS Haiti has significantly expanded access to VL testing since 2016. In order to promote optimal patient health outcomes, it is essential for Haiti to continue broadening access to confirmatory VL testing, to expand evidence-based initiatives to promote strong ART adherence, and to embrace timely switching for patients with confirmed ART failure despite strong ART adherence.
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Affiliation(s)
- Yu Wang
- Department of Global Health, University of Washington, Seattle, USA
| | - Scott Barnhart
- Departments of Medicine and Global Health, University of Washington, Seattle, USA
| | - Kesner Francois
- National AIDS Control Program, Haiti Ministry of Public Health and Population (PNLS/MSPP), Port-au-Prince, Haiti
| | - Ermane Robin
- National AIDS Control Program, Haiti Ministry of Public Health and Population (PNLS/MSPP), Port-au-Prince, Haiti
| | - Mireille Kalou
- Division of Global HIV and Tuberculosis Haiti, US Centers for Disease Control and Prevention, Atlanta, USA
| | - Georges Perrin
- Division of Global HIV and Tuberculosis Haiti, US Centers for Disease Control and Prevention, Atlanta, USA
| | - Lara Hall
- Division of Global HIV and Tuberculosis Haiti, US Centers for Disease Control and Prevention, Atlanta, USA
| | - Jean Baptiste Koama
- Division of Global HIV and Tuberculosis Haiti, US Centers for Disease Control and Prevention, Atlanta, USA
| | - Elisma Marinho
- Centre Haïtien pour le Renforcement du Système de Santé, Port-au-Prince, Haiti
| | - Jean Gabriel Balan
- Centre Haïtien pour le Renforcement du Système de Santé, Port-au-Prince, Haiti
| | - Jean Guy Honoré
- Centre Haïtien pour le Renforcement du Système de Santé, Port-au-Prince, Haiti
| | - Nancy Puttkammer
- Department of Global Health, University of Washington, Seattle, USA
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11
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Myrtil MP, Puttkammer N, Gloyd S, Robinson J, Yuhas K, Domercant JW, Honoré JG, Francois K. ART Attrition across Health Facilities Implementing Option B+ in Haiti. J Int Assoc Provid AIDS Care 2019; 17:2325958218774037. [PMID: 29781378 PMCID: PMC6748512 DOI: 10.1177/2325958218774037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Describing factors related to high attrition is important in order to improve the implementation of the Option B+ strategy in Haiti. Methods: We conducted a retrospective cohort study to describe the variability of antiretroviral therapy (ART) retention across health facilities among pregnant and lactating women and assess for differences in ART retention between Option B+ clients and other ART patients. Results: There were 1989 Option B+ clients who initiated ART in 45 health facilities. The percentage of attrition varied from 9% to 81% across the facilities. The largest health facilities had 38% higher risk of attrition (relative risk [RR]: 1.38, 95% confidence interval [CI]: 1.08-1.77, P = .009). Private institutions had 18% less risk of attrition (RR: 0.82, 95% CI: 0.70-0.96, P = .020). Health facilities located in the West department and the South region had lower risk of attrition. Conclusion: Being on treatment in a large or public health facility or a facility located in the North region was a significant risk factor associated with high attrition among Option B+ clients. The implementation of the Option B+ strategy must be reevaluated in order to effectively eliminate mother-to-child HIV transmission.
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Affiliation(s)
| | - Nancy Puttkammer
- 1 Department of Global Health, University of Washington, Seattle, WA, USA.,2 International Training and Education Center for Health (I-TECH), Seattle, WA, USA
| | - Stephen Gloyd
- 1 Department of Global Health, University of Washington, Seattle, WA, USA.,3 Health Alliance International (HAI), Seattle, WA, USA
| | - Julia Robinson
- 1 Department of Global Health, University of Washington, Seattle, WA, USA.,3 Health Alliance International (HAI), Seattle, WA, USA
| | - Krista Yuhas
- 4 University of Washington Center for AIDS Research, Seattle, WA, USA
| | | | - Jean Guy Honoré
- 6 International Training and Education Center for Health (I-TECH), Port au Prince, Haiti
| | - Kesner Francois
- 7 Ministry of Health of the Government of Haiti, Port au Prince, Haiti
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12
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Lipira L, Kemp C, Domercant JW, Honoré JG, Francois K, Puttkammer N. The role of service readiness and health care facility factors in attrition from Option B+ in Haiti: a joint examination of electronic medical records and service provision assessment survey data. Int Health 2018; 10:54-62. [PMID: 29329386 DOI: 10.1093/inthealth/ihx060] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 11/22/2017] [Indexed: 11/14/2022] Open
Abstract
Background Option B+ is a strategy wherein pregnant or breastfeeding women with HIV are enrolled in lifelong antiretroviral therapy (ART) for prevention of mother-to-child transmission (PMTCT) of HIV. In Haiti, attrition from Option B+ is problematic and variable across health care facilities. This study explores service readiness and other facility factors as predictors of Option B+ attrition in Haiti. Methods This analysis used longitudinal data from 2012 to 2014 from the iSanté electronic medical record system and cross-sectional data from Haiti's 2013 Service Provision Assessment. Predictors included Service Availability and Readiness Assessment (SARA) measures for antenatal care (ANC), PMTCT, HIV care services and ART services; general facility characteristics and patient-level factors. Multivariable Cox proportional hazards models modelled the time to first attrition. Results Analysis of data from 3147 women at 63 health care facilities showed no significant relationships between SARA measures and attrition. Having integrated ANC/PMTCT care and HIV-related training were significant protective factors. Being a public-sector facility, having a greater number of quality improvement activities and training in ANC were significant risk factors. Conclusion Several facility-level factors were associated with Option B+ attrition. Future research is needed to explore unmeasured facility factors, clarify causal relationships, and incorporate community-level factors into the analysis of Option B+ attrition.
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Affiliation(s)
- Lauren Lipira
- Department of Health Services, University of Washington, Seattle, WA, USA
| | - Christopher Kemp
- Department of Global Health, University of Washington, Seattle, WA, USA
| | | | - Jean Guy Honoré
- International Training and Education Center for Health, Port-au-Prince, Haiti and Seattle, WAUSA
| | - Kesner Francois
- Ministry of Public Health and Population (MSPP), Port-au-Prince, Haiti
| | - Nancy Puttkammer
- Department of Global Health, University of Washington, Seattle, WA, USA
- International Training and Education Center for Health, Port-au-Prince, Haiti and Seattle, WA USA
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13
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Kemp CG, Sorensen R, Puttkammer N, Grand'Pierre R, Honoré JG, Lipira L, Adolph C. Health facility readiness and facility-based birth in Haiti: a maximum likelihood approach to linking household and facility data. J Glob Health Rep 2018; 2:e2018023. [PMID: 31406933 PMCID: PMC6690361 DOI: 10.29392/joghr.2.e2018023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Haiti has one of the world's highest maternal mortality ratios. Comprehensive obstetric services could prevent many of these deaths, though most births in Haiti occur outside health facilities. Demand-side factors like a mother's socioeconomic status are understood to affect her access or choice to deliver in a health facility. However, analyses of the role of supply-side factors like health facility readiness have been constrained by limited data and methodological challenges. We sought to address these challenges and determine whether Haiti could increase rates of facility-based birth by improving facility readiness to provide delivery services. METHODS Our task was to characterize facility delivery readiness and link it to nearby births. We used birth data from the 2012 Haiti DHS and facility data from the 2013 Haiti SPA. Our outcome of interest was facility-based birth. Our predictor of interest was delivery readiness at the DHS sampling cluster level. We derived a novel likelihood function that used Kernel Density Estimation to estimate cluster-level readiness alongside the coefficients of a logistic regression. RESULTS We analyzed data from 389 facilities and 1,991 births. Rural facilities were less ready than urban facilities to provide delivery services. Women delivering in health facilities were younger, more educated, wealthier, less likely to live in rural areas, and had fewer previous children. Our model estimated that rural facilities (σ = 12.28, standard error [SE] = 0.16) spread their readiness over larger areas than urban facilities (σ = 7.14, SE = 0.016). Cluster-level readiness was strongly associated with facility-based birth (adjusted log-odds = 0.031; p = 0.005), as was socioeconomic status (adjusted log-odds = 0.78; p < 0.001). CONCLUSIONS Health system policymakers in Haiti could increase rates of facility-based birth by supporting targeted interventions to improve facility readiness to provide delivery-related services, alongside efforts to reduce poverty and increase educational attainment among women.
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Affiliation(s)
- Christopher G Kemp
- Department of Global Health, University of Washington, Ninth and Jefferson Building, 13th Floor, Box 359932, 908 Jefferson Street, Seattle, WA 98104, USA
| | - Reed Sorensen
- Department of Global Health, University of Washington, Ninth and Jefferson Building, 13th Floor, Box 359932, 908 Jefferson Street, Seattle, WA 98104, USA
| | - Nancy Puttkammer
- Department of Global Health, University of Washington, Ninth and Jefferson Building, 13th Floor, Box 359932, 908 Jefferson Street, Seattle, WA 98104, USA
| | - Reynold Grand'Pierre
- Family Health Unit, Ministère de la Santé Publique et de la Population, Port-au-Prince, Haiti
| | - Jean Guy Honoré
- I-TECH Haiti, Delmas 95, Route de Jacquet #14, Pétion Ville, Haïti
| | - Lauren Lipira
- Department of Health Services, University of Washington, 1959 NE Pacific St, Box 357660 Seattle, WA 98195, USA
| | - Christopher Adolph
- Department of Political Science, University of Washington, 101 Gowen Hall, Box 353530. Seattle, WA 98195, USA
- Center for Statistics and the Social Sciences, University of Washington, Padelford Hall, Box 354320, Seattle, WA 98195, USA
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14
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deRiel E, Puttkammer N, Hyppolite N, Diallo J, Wagner S, Honoré JG, Balan JG, Celestin N, Vallès JS, Duval N, Thimothé G, Boncy J, Coq NRL, Barnhart S. Success factors for implementing and sustaining a mature electronic medical record in a low-resource setting: a case study of iSanté in Haiti. Health Policy Plan 2018; 33:237-246. [PMID: 29253138 DOI: 10.1093/heapol/czx171] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2017] [Indexed: 11/13/2022] Open
Abstract
Electronic health information systems, including electronic medical records (EMRs), have the potential to improve access to information and quality of care, among other things. Success factors and challenges for novel EMR implementations in low-resource settings have increasingly been studied, although less is known about maturing systems and sustainability. One systematic review identified seven categories of implementation success factors: ethical, financial, functionality, organizational, political, technical and training. This case study applies this framework to iSanté, Haiti's national EMR in use in more than 100 sites and housing records for more than 750 000 patients. The author group, consisting of representatives of different agencies within the Haitian Ministry of Health (MSPP), funding partner the Centers for Disease Control and Prevention (CDC) Haiti, and implementing partner the International Training and Education Center for Health (I-TECH), identify successes and lessons learned according to the seven identified categories, and propose an additional cross-cutting category, sustainability. Factors important for long-term implementation success of complex information systems are balancing investments in hardware and software infrastructure upkeep, user capacity and data quality control; designing and building a system within the context of the greater eHealth ecosystem with a plan for interoperability and data exchange; establishing system governance and strong leadership to support local system ownership and planning for system financing to ensure sustainability. Lessons learned from 10 years of implementation of the iSanté EMR system are relevant to sustainability of a full range of increasingly interrelated information systems (e.g. for laboratory, supply chain, pharmacy and human resources) in the health sector in low-resource settings.
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Affiliation(s)
- E deRiel
- International Training and Education Center for Health, University of Washington, Box 359932, Seattle, WA 98104-2499, USA
| | - N Puttkammer
- International Training and Education Center for Health, University of Washington, Box 359932, Seattle, WA 98104-2499, USA
| | - N Hyppolite
- International Training and Education Center for Health, Delmas 95, Route de Jacquet 14, Pétion-Ville, Haiti
| | - J Diallo
- International Training and Education Center for Health, University of Washington, Box 359932, Seattle, WA 98104-2499, USA
| | - S Wagner
- International Training and Education Center for Health, University of Washington, Box 359932, Seattle, WA 98104-2499, USA
| | - J G Honoré
- International Training and Education Center for Health, Delmas 95, Route de Jacquet 14, Pétion-Ville, Haiti
| | - J G Balan
- International Training and Education Center for Health, Delmas 95, Route de Jacquet 14, Pétion-Ville, Haiti
| | - N Celestin
- US Centers for Disease Control and Prevention, Tabarre 41, Route de Tabarre, Port-au-Prince, Haiti
| | - J S Vallès
- US Centers for Disease Control and Prevention, Tabarre 41, Route de Tabarre, Port-au-Prince, Haiti
| | - N Duval
- Ministère de la Santé Publique et de la Population (MSPP, Ministry of Public Health and Population), 1, Rue Jaques Roumain, Maïs Gaté, Port-au-Prince, Haiti
| | - G Thimothé
- Programme National Pour la Lutte contre le Sida (National AIDS Control Program), 200, Route de Frères, Pétion-Ville, Haiti
| | - J Boncy
- Laboratoire National de Santé Publique (National Public Health Laboratory), 2, angle Delmas 33 et rue Charbonnière, Delmas, Haiti and
| | - N R L Coq
- Independent consultant, 26, Rue Carmelot, Port-au-Prince, Haiti
| | - S Barnhart
- International Training and Education Center for Health, University of Washington, Box 359932, Seattle, WA 98104-2499, USA
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15
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Puttkammer N, Baseman JG, Devine EB, Valles JS, Hyppolite N, Garilus F, Honoré JG, Matheson AI, Zeliadt S, Yuhas K, Sherr K, Cadet JR, Zamor G, Pierre E, Barnhart S. An assessment of data quality in a multi-site electronic medical record system in Haiti. Int J Med Inform 2015; 86:104-16. [PMID: 26620698 DOI: 10.1016/j.ijmedinf.2015.11.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 10/30/2015] [Accepted: 11/04/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Strong data quality (DQ) is a precursor to strong data use. In resource limited settings, routine DQ assessment (DQA) within electronic medical record (EMR) systems can be resource-intensive using manual methods such as audit and chart review; automated queries offer an efficient alternative. This DQA focused on Haiti's national EMR - iSanté - and included longitudinal data for over 100,000 persons living with HIV (PLHIV) enrolled in HIV care and treatment services at 95 health care facilities (HCF). METHODS This mixed-methods evaluation used a qualitative Delphi process to identify DQ priorities among local stakeholders, followed by a quantitative DQA on these priority areas. The quantitative DQA examined 13 indicators of completeness, accuracy, and timeliness of retrospective data collected from 2005 to 2013. We described levels of DQ for each indicator over time, and examined the consistency of within-HCF performance and associations between DQ and HCF and EMR system characteristics. RESULTS Over all iSanté data, age was incomplete in <1% of cases, while height, pregnancy status, TB status, and ART eligibility were more incomplete (approximately 20-40%). Suspicious data flags were present for <3% of cases of male sex, ART dispenses, CD4 values, and visit dates, but for 26% of cases of age. Discontinuation forms were available for about half of all patients without visits for 180 or more days, and >60% of encounter forms were entered late. For most indicators, DQ tended to improve over time. DQ was highly variable across HCF, and within HCFs DQ was variable across indicators. In adjusted analyses, HCF and system factors with generally favorable and statistically significant associations with DQ were University hospital category, private sector governance, presence of local iSante server, greater HCF experience with the EMR, greater maturity of the EMR itself, and having more system users but fewer new users. In qualitative feedback, local stakeholders emphasized lack of stable power supply as a key challenge to data quality and use of the iSanté EMR. CONCLUSIONS Variable performance on key DQ indicators across HCF suggests that excellent DQ is achievable in Haiti, but further effort is needed to systematize and routinize DQ approaches within HCFs. A dynamic, interactive "DQ dashboard" within iSanté could bring transparency and motivate improvement. While the results of the study are specific to Haiti's iSanté data system, the study's methods and thematic lessons learned holdgeneralized relevance for other large-scale EMR systems in resource-limited countries.
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Affiliation(s)
- N Puttkammer
- International Training and Education Center for Health, University of Washington, United States.
| | - J G Baseman
- Department of Epidemiology, University of Washington, United states.
| | - E B Devine
- Department of Pharmacy, University of Washington, United States.
| | - J S Valles
- Division of Global HIV/AIDS, Centers for Disease Control and Prevention, United States.
| | - N Hyppolite
- International Training and Education Center for Health, Haiti Office, Haiti.
| | - F Garilus
- Population Division, Ministry of Public Health and Population, Government of Haiti, Haiti.
| | - J G Honoré
- International Training and Education Center for Health, Haiti Office, Haiti.
| | - A I Matheson
- Department of Epidemiology, University of Washington, United states.
| | - S Zeliadt
- Department of Health Services, University of Washington, United States.
| | - K Yuhas
- National AIDS Control Program (PNLS), Ministry of Public Health and Population, Government of Haiti, Haiti.
| | - K Sherr
- Department of Global Health, University of Washington, United States.
| | - J R Cadet
- National AIDS Control Program (PNLS), Ministry of Public Health and Population, Government of Haiti, Haiti.
| | - G Zamor
- International Training and Education Center for Health, Haiti Office, Haiti.
| | - E Pierre
- National AIDS Control Program (PNLS), Ministry of Public Health and Population, Government of Haiti, Haiti.
| | - S Barnhart
- International Training and Education Center for Health, University of Washington, United States.
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