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      The Association between Quality of HIV Care, Loss to Follow-Up and Mortality in Pediatric and Adolescent Patients Receiving Antiretroviral Therapy in Nigeria

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          Abstract

          Access to pediatric HIV treatment in resource-limited settings has risen significantly. However, little is known about the quality of care that pediatric or adolescent patients receive. The objective of this study is to explore quality of HIV care and treatment in Nigeria and to determine the association between quality of care, loss-to-follow-up and mortality. A retrospective cohort study was conducted including patients ≤18 years of age who initiated ART between November 2002 and December 2011 at 23 sites across 10 states. 1,516 patients were included. A quality score comprised of 6 process indicators was calculated for each patient. More than half of patients (55.5%) were found to have a high quality score, using the median score as the cut-off. Most patients were screened for tuberculosis at entry into care (81.3%), had adherence measurement and counseling at their last visit (88.7% and 89.7% respectively), and were prescribed co-trimoxazole at some point during enrollment in care (98.8%). Thirty-seven percent received a CD4 count in the six months prior to chart review. Mortality within 90 days of ART initiation was 1.9%. A total of 4.2% of patients died during the period of follow-up (mean: 27 months) with 19.0% lost to follow-up. In multivariate regression analyses, weight for age z-score (Adjusted Hazard Ratio (AHR): 0.90; 95% CI: 0.85, 0.95) and high quality indicator score (compared a low score, AHR: 0.43; 95% CI: 0.26, 0.73) had a protective effect on mortality. Patients with a high quality score were less likely to be lost to follow-up (Adjusted Odds Ratio (AOR): 0.42; 95% CI: 0.32, 0.56), compared to those with low score. These findings indicate that providing high quality care to children and adolescents living with HIV is important to improve outcomes, including lowering loss to follow-up and decreasing mortality in this age group.

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          Most cited references23

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          Defining and classifying clinical indicators for quality improvement.

          J Mainz (2003)
          This paper provides a brief review of definitions, characteristics, and categories of clinical indicators for quality improvement in health care. Clinical indicators assess particular health structures, processes, and outcomes. They can be rate- or mean-based, providing a quantitative basis for quality improvement, or sentinel, identifying incidents of care that trigger further investigation. They can assess aspects of the structure, process, or outcome of health care. Furthermore, indicators can be generic measures that are relevant for most patients or disease-specific, expressing the quality of care for patients with specific diagnoses. Monitoring health care quality is impossible without the use of clinical indicators. They create the basis for quality improvement and prioritization in the health care system. To ensure that reliable and valid clinical indicators are used, they must be designed, defined, and implemented with scientific rigour.
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            Defining quality of care.

            This paper defines quality of health care. We suggest that there are two principal dimensions of quality of care for individual patients; access and effectiveness. In essence, do users get the care they need, and is the care effective when they get it? Within effectiveness, we define two key components--effectiveness of clinical care and effectiveness of inter-personal care. These elements are discussed in terms of the structure of the health care system, processes of care, and outcomes resulting from care. The framework relates quality of care to individual patients and we suggest that quality of care is a concept that is at its most meaningful when applied to the individual user of health care. However, care for individuals must placed in the context of providing health care for populations which introduces additional notions of equity and efficiency. We show how this framework can be of practical value by applying the concepts to a set of quality indicators contained within the UK National Performance Assessment Framework and to a set of widely used indicators in the US (HEDIS). In so doing we emphasise the differences between US and UK measures of quality. Using a conceptual framework to describe the totality of quality of care shows which aspects of care any set of quality indicators actually includes and measures and, and which are not included.
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              High attrition before and after ART initiation among youth (15-24 years of age) enrolled in HIV care.

              To compare pre and post-ART attrition between youth (15-24 years) and other patients in HIV care, and to investigate factors associated with attrition among youth. Cohort study utilizing routinely collected patient-level data from 160 HIV clinics in Kenya, Mozambique, Tanzania, and Rwanda. Patients at least 10 years of age enrolling in HIV care between 01/05 and 09/10 were included. Attrition (loss to follow-up or death 1 year after enrollment or ART initiation) was compared between youth and other patients using multivariate competing risk (pre-ART) and traditional (post-ART) Cox proportional hazards methods accounting for within-clinic correlation. Among youth, patient-level and clinic-level factors associated with attrition were similarly assessed. A total of 312,335 patients at least 10 years of age enrolled in HIV care; 147,936 (47%) initiated ART, 17% enrolling in care and 10% initiating ART were youth. Attrition before and after ART initiation was substantially higher among youth compared with other age groups. Among youth, nonpregnant women experienced lower pre-ART attrition than men [sub-division hazard ratio = 0.90, 95% confidence interval (CI): 0.86-0.94], while both pregnant [adjusted hazard ratio (AHR) = 0.85, 95% CI: 0.74-0.97] and nonpregnant (AHR = 0.79, 95% CI: 0.73-0.86) female youth experienced lower post-ART attrition than men. Youth attending clinics providing sexual and reproductive health services including condoms (AHR = 0.47, 95% CI: 0.32-0.70) and clinics offering adolescent support groups (AHR = 0.73, 95% CI: 0.52-1.0) experienced significantly lower attrition after ART initiation. Youth experienced substantially higher attrition before and after ART initiation compared with younger adolescents and older adults. Adolescent-friendly services were associated with reduced attrition among youth, particularly after ART initiation.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, USA )
                1932-6203
                2014
                30 July 2014
                : 9
                : 7
                : e100039
                Affiliations
                [1 ]John Snow Inc., Boston, Massachusetts, United States of America
                [2 ]Massachusetts General Hospital, Infectious Disease Division, Boston, Massachusetts, United States of America
                [3 ]Columbia University, Department of Epidemiology, New York, New York, United States of America
                [4 ]United States Agency for International Development (USAID), Washington, D. C., United States of America
                [5 ]United States Agency for International Development (USAID), Abuja, Nigeria
                [6 ]Indepth Precision, Abuja, Nigeria
                [7 ]Boston University School of Public Health, Department of Biostatistics, Boston, Massachusetts, United States of America
                [8 ]Boston University School of Medicine, Boston, Massachusetts, United States of America
                [9 ]Harvard Medical School, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
                University of São Paulo School of Medicine, Brazil
                Author notes

                Competing Interests: Bisola Ojikutu and Molly-Higgins Biddle are employed by John Snow Inc. Usman Kolapo is employed by Indepth Precision. Benjamin R. Phelps and Anouk Amzel, are employed by the U.S. Agency for International Development. There are no patents, products in development or marketed products to declare. This does not alter the authors' adherence to all PLOS ONE policies on sharing data and materials.

                Conceived and designed the experiments: BO MHB DG BRP AA EO UK HC EC LH. Performed the experiments: BO MHB DG UK EC HC. Analyzed the data: BO MHB DG HC LH. Contributed reagents/materials/analysis tools: BO MHB DG EO UK HC EC LH. Wrote the paper: BO MHB DG EO UK HC LH.

                Article
                PONE-D-14-04128
                10.1371/journal.pone.0100039
                4116117
                25075742
                1024e83c-c000-4be3-ab2e-15f33f2e58d7
                Copyright @ 2014

                This is an open-access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.

                History
                : 30 January 2014
                : 22 May 2014
                Page count
                Pages: 9
                Funding
                This research has been supported by the President's Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Agency for International Development under the terms of contract no. GHH-I-00–07–00059–00. Bisola Ojikutu and Molly-Higgins Biddle are employed by John Snow Inc. Usman Kolapo is employed by Indepth Precision. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Biology and Life Sciences
                Microbiology
                Medical Microbiology
                Microbial Pathogens
                Viral Pathogens
                Immunodeficiency Viruses
                HIV
                Medicine and health sciences
                Diagnostic medicine
                HIV clinical manifestations
                HIV diagnosis and management
                Infectious Diseases
                Viral Diseases

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                Uncategorized

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