Abstract
BackgroundUniversal health coverage promises equity in access to and quality of health services. However, there is variability in the quality of the care (QoC) delivered at health facilities in low and middle-income countries (LMICs). Detecting gaps in implementation of clinical guidelines is key to prioritizing the efforts to improve quality of care. The aim of this study was to present statistical methods that maximize the use of existing electronic medical records (EMR) to monitor compliance with evidence-based care guidelines in LMICs.MethodsWe used iSanté, Haiti’s largest EMR to assess adherence to treatment guidelines and retention on treatment of HIV patients across Haitian HIV care facilities. We selected three processes of care – (1) implementation of a ‘test and start’ approach to antiretroviral therapy (ART), (2) implementation of HIV viral load testing, and (3) uptake of multi-month scripting for ART, and three continuity of care indicators – (4) timely ART pick-up, (5) 6-month ART retention of pregnant women and (6) 6-month ART retention of non-pregnant adults. We estimated these six indicators using a model-based approach to account for their volatility and measurement error. We added a case-mix adjustment for continuity of care indicators to account for the effect of factors other than medical care (biological, socio-economic). We combined the six indicators in a composite measure of appropriate care based on adherence to treatment guidelines.ResultsWe analyzed data from 65,472 patients seen in 89 health facilities between June 2016 and March 2018. Adoption of treatment guidelines differed greatly between facilities; several facilities displayed 100% compliance failure, suggesting implementation issues. Risk-adjusted continuity of care indicators showed less variability, although several facilities had patient retention rates that deviated significantly from the national average. Based on the composite measure, we identified two facilities with consistently poor performance and two star performers.ConclusionsOur work demonstrates the potential of EMRs to detect gaps in appropriate care processes, and thereby to guide quality improvement efforts. Closing quality gaps will be pivotal in achieving equitable access to quality care in LMICs.
Highlights
Universal health coverage promises equity in access to and quality of health services
Examples of inappropriate care in low and middle-income countries (LMICs) highlighted in the HQSS report encompass the omission of oral rehydration therapy and the unnecessary use of antibiotics to treat children with diarrhea, which can result in child death and antimicrobial resistance, and the low uptake of Human immunodeficiency virus (HIV) antiretroviral therapy, despite the effectiveness of the treatment in reducing deaths and suffering from HIV/AIDS
We argue that national electronic medical records (EMR) have the potential to drive country-led quality measurement and improvement in LMICs
Summary
Universal health coverage promises equity in access to and quality of health services. There is variability in the quality of the care (QoC) delivered at health facilities in low and middle-income countries (LMICs). The fundamental problem of quality assessment resides in the fact that medical care is multifaceted In his seminal work on QoC, Donabedian distinguishes three main approaches to quality assessment: studies focusing on structures, processes, and outcomes [2]. Examples of inappropriate care in LMICs highlighted in the HQSS report encompass the omission of oral rehydration therapy and the unnecessary use of antibiotics to treat children with diarrhea, which can result in child death and antimicrobial resistance, and the low uptake of HIV antiretroviral therapy, despite the effectiveness of the treatment in reducing deaths and suffering from HIV/AIDS. Health providers in LMICs fulfill less than 50% of recommended clinical guidelines, on average [1]
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