Task shifting to midlevel clinical health providers: an evaluation of quality of ART provided by non

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Task shifting to mid-level clinical health
providers an evaluation of quality of ART
provided by non-physician clinicians and
physicians in Mozambique Aug 6, 2008

• Gimbel-Sherr K1,2, Augusto O4, Micek M1,2,
  Gimbel-Sherr S1,2, Tomo MI3, Pfeiffer J1,2, Gloyd
  S1,2
• 1 University of Washington, Seattle
• 2 Health Alliance International
• 3 Ministry of Health, Mozambique
• 4 Eduardo Mondlane University, Mozambique
• ksherr_at_u.washington.edu

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Background (1)

• HRH crisis a well documented impediment for ART
  scale-up
• Mozambique
• MDs 2.5/100,000
• RNs 21/100,000
• Non-physician clinicians (NPCs) identified as a
  partial solution to HR gap
• Provide large part of clinical care in Mozambique
• lt600 tecnicos de medicina in country, but
• More readily deployed permanence in rural areas
• Faster to train
• (2.5-3yrs vs. 6 for MDs)
• More training centers (12 vs. 2)
• Lower salaries, lower cost to train

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Background (2)
Majority of NPC trainings completed
MOH, 2007
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Background (3)

• Evidence from US suggests mid-levels (PA/NP)
  perform as well as or better than MDs (including
  for HIV care)1
• Evidence from resource limited settings mostly
  anecdotal
• Policymakers reticent about allowing
  non-physicians to prescribe ART
• Quality of care
• Gaps in mentoring/ongoing support
• Comparison between quality of mid-level providers
  and other care providers (MDs) needed
• This study aims to evaluate the quality of HIV
  care and treatment provided by MDs and NPCs for
  patients on ART in Mozambique

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Methodology (1)

• Cohort study of patients initiating ART during
  the
• first 3.5 years of the national ART program
• (7/04 11/07)
• 2 HIV clinics in Central Mozambique
• High HIV prevalence (over 20 in ANC surveillance
  for
• the last 10 years)
• ART since 2003
• Vertical HIV care approach designed for high
  patient volume and better supervision
• High caseloads
• Relatively well staffed
• Routine clinical database paper records
• Includes clinical, laboratory (CD4), pharmacy,
  and social worker visit data
• Validated (Kgt0.80 for key variables)

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Methodology (2)

• Primary provider of ART patients categorized as
  NPC or MD based on initial provider at the clinic
• Exclusion criteria to ensure comparability in
  provider assignment
• Children
• Patients in MTCT-Plus
• Patients starting ART before July 2004

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Methodology (3)

• Outcomes primarily process indicators reflecting
  country protocols
• CD4 testing at 6 and 12 months post-ART
• Frequency of clinical visit (at least 3 of 4
  quarters post ART initiation)
• Also looked at
• Adherence
• Lost to follow-up
• Mortality
• Unadjusted RR and adjusted RR/HR via stratified
  analysis and Cox PH models

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Results (1)
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Results (2)
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Results (3)
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Discussion (1)

• NPCs are important drivers for ART expansion in
  the study clinics
• Higher FTE, more present at clinic
• Primary provider for twice as many ART patients
  as MDs in study
• Results suggest measures of service quality are
  equivalent to or slightly better for patients
  seen by NPCs vs. MDs
• But neither optimal

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Discussion (2)

• Limitations
• Switching providers may lead to misclassification
  of provider type (occurred in 20)
• Difficult to account for important patient and
  clinic-level characteristics that may impact
  study outcomes (mortality loss to follow-up)
• Additional indicators of quality not measured
  (i.e. clinical diagnostic and management skills,
  accuracy of staging)
• Results from large centralized sites with more
  supervision may not apply to smaller sites

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Discussion (3)

• Nevertheless
• First study to compare NPCs and MDs for HIV care
  in Mozambique
• NPCs with similar or better service quality
  outcomes compared with MDs for patients on ART
• Gaps in outcomes identify need for better
  training, supervision, support

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Acknowledgements

• Study Patients
• Mozambique
• Ministry of Health
• Doris Duke
• Charitable Foundation
• ORACTA
• USAID/PEPFAR