Application of the Deming PDSA Cycle as a Patient Experience Management Tool to Improve HIV Care. An Action Research in Under-Resourced Settings of Jinja-Uganda
Abstract:
The
study to determine the effect of patient experience management using the Deming
PDSA cycle on the quality of HIV care was conducted in under-resourced settings
of Uganda. The interventional study had 437 files studied, and 224 adult HIV clients
with poor HIV care outcomes of; missed appointments for more than two weeks, poor
adherence to treatment of < 85%, and unsuppressed viral load of > 1000 viral
copies per milliliter were interviewed at baseline and end line. The
study revealed a 13.6% prevalence of the study HIV care outcomes among all the client
files, the majority of which were for patients in care for more than four years.
11.8%, 65.2%, and 46.5% were due to poor adherence
to treatment, two weeks missed appointments, and unsuppressed viral load at baseline,
which reduced to 4.7%, 25.1%, and 31.5% at
end-line assessment, respectively. 80% of the studied clients were retention in
care between the baseline and end-line assessments. 7.7% of the study files had
never had a viral load done to the clients at baseline, which reduced to 1.4% at
the end line. 34.5% of the study client files were overdue for a viral load at baseline
but only 16.8% at end-line assessment.
The study also showed a general improvement on the patient experience before and
after interventions. In conclusion, Patient Experience Management
using the Deming PDSA cycles improves the quality of HIV care in under-resourced
settings.
References:
[1] Moen D. Ronald and Clifford L. Norman, (2010). Circling back. Clearing
up myths about Deming cycle and seeing how it keeps evolving. https://deming.org/wp-content/uploads/2020/06/circling-back.pdf.
[2] Bita Kash1* and Molly McKahan (2017). The Evolution of Measuring Patient
Satisfaction. Journal of Primary Health Care and General Practice.
[3] Wolf, Jason A., Niederhauser, V. Marshburn,
Dianne and LaVela, Sherri L. (2014). “Defining Patient Experience,” Patient Experience
Journal: Vol. 1: Iss. 1, Article 3.
[4] Jackson,
J. L., Chamberlin, J., &Kroenke, K. (2001). Predictors of patient satisfaction.
Social Science and Medicine, 52(4), 609-620. Doi:10.1016/S0277-9536(00)00164-7.
[5] Sophie
Barton-Knott, (2017). The GENEVA/PARIS,
2017—UNAIDS new report. https://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2017/july/20170720_PR_Global_AIDS_Update_2017.
[6]
Musinguzi Joshua Ministry of Health, Uganda.
(2019) Uganda Population-based HIV Impact Assessment (UPHIA) 2016-2017: Final Report.
Kampala: Ministry of Health; July 2019. http://www.afro.who.int/sites/default/files/2017-08/UPHIA%20Uganda%20factsheet.pdf.
[7]
Musinguzi Joshua. MoH
(2012), Uganda AIDS Indicator Survey 2011. http://health.go.ug/docs/UAIS_2011_REPORT.pdf.
[8] Kambugu A.D (2016). Test and treat in Uganda:
Perspectives from An Implementing/Academic Partner, Infectious Diseases Institute
Makerere University College of Health Sciences. Southern African HIV clinicians’
society, 3rd biannual conference April 2016.
[9] Mobye K Anthony, and MoH (2016). Consolidated
guidelines for HIV prevention, and treatment in Uganda 2016. https://differentiatedservicedelivery.org/portals/0/adam/content/hvpzrp5yuusdpce2m0kmdq/file/consolidated%20guidelines%20for%20prevention%20and%20treatment%20of%20hiv%20in%20uganda.pdf.
[10] UNFPA (2017). Uganda, the status of HIV prevention
in 2017. Where are we in the fight against HIV. UNFPA Technical Division SRHB May
2017. https://uganda.unfpa.org/sites/default/files/pub-pdf/Uganda_Status%20of%20HIV%20Prevention.pdf.
[11] Fonsah JY, Njamnshi AK, Kouanfack C, Qiu F,
Njamnshi DM, Tagny CT, et al. (2017) Adherence to Antiretroviral Therapy (ART) in
YaoundeÂ-Cameroon: Association with Opportunistic Infections, Depression, ART Regimen
and Side Effects. Plos One 12(1): e0170893. DOI: 10.1371/journal.pone.0170893.
[12] Bach Xuan
Tran1*, Long Thanh Nguyen2, Nga Hoang Nguyen3, Quynh Van Hoang1 and Jongnam Hwang.
Determinants of antiretroviral treatment adherence among HIV/AIDS patients: a multisite
study.
[13] Bharatesh D. Basti,1 Venkatesha Mahesh,2
Dattatreya D. Bant,3 and Geeta V. Bathija (2017). Factors affecting antiretroviral treatment adherence
among people living with human immunodeficiency virus/acquired immunodeficiency
syndrome: A prospective study. Journal of family medicine and primary care.
[14] Oku O. Afiong, Eme T. Owoaje, Oboko O. Oku and
Emmanuel Monjok (2014). Prevalence and Determinants of Adherence to Highly Active
Anti-Retroviral Therapy Amongst People Living with HIV/AIDS in a Rural Setting in
South-South Nigeria. African Journal of Reproductive Health March
2014; 18(1): 134.
[15] Nyakato P, Kiragga AN, Kambugu A, et al.
Correction of estimates of retention in care among a cohort of HIV-positive patients
in Uganda in the period before starting ART: a sampling-based approach. BMJ Open
2018;8: e017487. doi:10.1136/ bmjopen-2017-017487.
[16] Mugisha Kenneth, Andrew Ocero, Edward Semafumu,
Luigi Ciccio, Roland F. Muwanika, James Otim, Med Makumbi, (2009). Retention of
HIV Positive Persons in Antiretroviral Therapy Programs in Post-Conflict Northern
Uganda-Baseline Survey of 17 Health Units.
[17] Musomba R, Frank Mubiru, Shadia Nakalema, Hope
Mackline, Ivan Kalule, Agnes N. Kiragga,1 Rosalind Parkes Ratanshi,1,2, and Barbara
Castelnuovo. Describing Point of Entry into Care and Being Lost to Program in a
Cohort of HIV Positive Pregnant Women in a Large Urban Centre in Uganda. Hindawi
AIDS Research and Treatment, Volume 2017, Article ID 3527563, 6 pages https://doi.org/10.1155/2017/3527563.
[18] Elizabeth Horstmann, Jillian Brown, Fareesa Islam, Johanna Buck, and
Bruce D. Agins, (2010). Retaining HIV-Infected Patients in Care: Where Are We? Where
Do We Go from Here? Clinical Infectious Diseases 2010; 50:752–761.
[19] Park WB, Choe PG, Kim SH, Jo JH, Bang JH, Kim
HB, Kim NJ, Oh M, Choe KW: One-year adherence to clinic visits after highly active
antiretroviral therapy: a predictor of clinical progress in HIV patients. J Intern
Med 2007, 261(3):268–275.
[20] Smith E. O., J. D. Curb, and R. J. Hardy, “Clinic
attendance in the hypertension detection and follow-up program,” Hypertension, vol.
4, no. 5, pp. 710–715, 1982. View at Google Scholar View at Scopus.
[21] Nemes MI, Carvalho HB, Souza MF, (2004). Antiretroviral
therapy adherence in Brazil. AIDS. https://www.ncbi.nlm.nih.gov/pubmed/15322479.
[22] Lucas GM, Chaisson RE, Moore RD, (1999). Highly active antiretroviral
therapy in a large urban clinic: risk factors for virologic failure and adverse
drug reactions. Ann Intern Med; 131(2):81–87.
[23]
TenoRes Study Group (2016).
Global epidemiology of drug resistance after failure of WHO recommended first-line
regimens for adult HIV-1 infection: a multicentre retrospective cohort study. Lancet
Infect Dis. 2016 May;16(5):565-575.
[24] Sethi A, Celentano D, Gange S, Moore R, Gallant
J. Association between adherence to antiretroviral therapy and human immunodeficiency
virus drug resistance. Clin Infect Dis 2003; 37(8):1112–1118.
[25]
Gupta RK, Gregson J, Parkin
N, Haile-Selassie H, Tanuri A, Andrade Forero L, Kaleebu P, Watera C, Aghokeng A,
Mutenda N, Dzangare J, Hone S, Hang ZZ, Garcia J, Garcia Z, Marchorro P, Beteta
E, Giron A, Hamers R, Inzaule S, Frenkel LM, Chung MH, de Oliveira T, Pillay D,
Naidoo K, Kharsany A, Kugathasan R, Cutino T, Hunt G, Avila Rios S, Doherty M, Jordan
MR, Bertagnolio S. HIV-1 drug resistance before initiation or re-initiation of first-line
antiretroviral therapy in low-income and middle-income countries: a systematic review
and meta-regression analysis. Lancet Infect Dis. 2018 Mar;18(3):346-355.
[26] Moore CG, Wilson-Witherspoon P, Probst JC, (2001).
Time and money: effects of no-shows at a family practice residency clinic. Fam Med
2001; 33(7):522–527.
[27] Shumba c., L. Atuhaire, R. Imakit, R. Atukunda, and P. Memiah. Missed
Doses and Missed Appointments: Adherence to ART among Adult Patients in Uganda.
Hindawi Publishing Corporation, ISRN AIDS, Volume 2013, Article ID 270914, 7 pages,
http://dx.doi.org/10.1155/2013/270914.
[28] Bigna Jean Joel R, Jean Jacques N Noubiap, Claudia
S Plottel, Charles Kouanfack1, and Sinata Koulla-Shiro, (2014). Factors associated
with non-adherence to scheduled medical follow-up appointments among Cameroonian
children requiring HIV care: a case-control analysis of the usual-care group in
the MORE CARE trial.
[29] Setor Kunutsor,1 John Walley,1 Elly Katabira,2
Simon Muchuro,2 Hudson Balidawa,3 Elizabeth Namagala,3, and Eric Ikoona3, (2010).
Clinic Attendance for Medication Refills and Medication Adherence amongst an Antiretroviral
Treatment Cohort in Uganda: A Prospective Study. Hindawi Publishing Corporation
AIDS Research and Treatment Volume 2010, Article ID 872396, 8 pages doi:10.1155/2010/872396.
[30]
Uganda Virus Research Institute
(2018). National HIV Drug Resistance Prevention, Monitoring and Surveillance Activities,
National Status Report 2018.
[31]
ECASA Group of Consultants
LTD, (2018). Uganda AIDS Country Progress Report July 2017-June 2018.
[32] Kolab Chhim1, Gitau Mburu2, Sovannary Tuot1,
Ratana Sopha1, Vohith Khol3, Pheak Chhoun1 and Siyan (2018). Factors associated
with viral non‑suppression among adolescents living with HIV in Cambodia: a cross‑sectional
study. AIDS Research and Therapy. 15:20. https://doi.org/10.1186/s12981-018-0205-z.
[33] Katharina Kranzer, Stephen D. Lawn, Leigh F.
Johnson, Linda-Gail Bekker, and Robin Wood, (2014). Community viral load and CD4
count distribution among people living with HIV in a South African township: implications
for treatment as prevention. Europe PMC Funders Group. J Acquir Immune Defic
Syndr. 2013 August 1; 63(4): 498–505. doi:10.1097/QAI.0b013e318293ae48.
[34] Bonner K, et al. Viral load monitoring as a
tool to reinforce adherence: a systematic review. J Acquir Immune Defic Syndr.
2013;64(1):74–8.
[35] Nasuuna Esther, Joanita Kigozi1, Lillian Babirye,
Alex Muganzi, Nelson K. Sewankambo and Damalie Nakanjako, (2018). Low HIV viral
suppression rates following the intensive adherence counseling (IAC) program for
children and adolescents with viral failure in public health facilities in Uganda.
Nasuuna et al. BMC Public Health (2018) 18:1048. https://doi.org/10.1186/s12889-018-5964-x.
[36] Martin Fischer and Gill Ereaut, (2012), Report:
when doctors and patients talk: making sense of the consultation. The health foundation
inspiring improvement.
[37] Institute
of Medicine (1993). Committee on Monitoring Access to Personal Health Care Services.
Access to health care in America. Washington, DC: National Academy Press; 1993.
[38] Agency for Healthcare Research and Quality (2011). National healthcare
disparities report 2011.AHRQ Publication No. 12-0006 March 2012
[39] Sergei Savin, (n.d), Managing patient appointments in primary care.
Graduate School of Business, 404 Uris Hall, Columbia University, New York,
NY 10027.
[40] Lisa Brandenburg, Patricia Gabow, Glenn
Steele, John Toussaint, and Bernard J. Tyson*(2015) Innovation and Best Practices
in Health Care Scheduling. Institute of Medicine of the National Academies.
[41] Mallinson RK, Relf MV, Dekker D, Dolan K, Darcy A, Ford A, (2005).
Maintaining normalcy: a grounded theory of engaging in HIV-oriented primary medical
care. ANS Adv Nurs Sci 2005; 28(3):265–277.
[42] Sendzik D. (2004) Retaining HIV-positive patients
in care. In: Program and abstracts of the XV International AIDS Conference (Bangkok,
Thailand).
[43] Bradford J, Coleman S, Cunningham W. (2007).
HIV System Navigation: an emerging model to improve HIV care access. AIDS Patient
Care STDS.
[44] Wohler-Torres BA, Valverde EE, Anderson-Mahoney
P, Barragan M, Loughlin A, Metsch LR, (2002). System barriers to HIV medical care
appointment compliance: results of the artas study. In: Program and abstracts of
the XIV International AIDS Conference (Barcelona, Spain).
[45] Calsyn RJ, Klinkenberg WD, Morse GA, Miller
J, Cruthis R, (2004). Recruitment, engagement, and retention of people living with
HIV and cooccurring mental health and substance use disorders. AIDS Care.
[46] Niamat Ullah Ibne Hossain, Hunter Debusk, Md
Mahmudul Hasan, Raed Jaradat, Mahmoud T. Khasawneh, (2017), Reducing Patient Waiting
Time in an Outpatient Clinic: A Discrete Event Simulation (DES) Based Approach,
Abstract ID: 2220. Proceedings of the 2017 Industrial and Systems Engineering Conference
K. Coperich, E. Cudney, H. Nembhard, eds.
[47] Emily Tse Lin Ho (2014), Improving waiting time
and operational clinic flow in a tertiary diabetes center. BMJ Quality Improvement
Reports 2014; u201918.w1006 doi: 10.1136/bmjquality. u201918.w1006.
[48] PHCPI (Primary Health Care Performance Initiative), (2018),
improvement strategies model for access and timeliness. Version 1.0: Updated October
2018.
[49] NHS England, (n.d). Involving people in their
own health and care: Statutory guidance for clinical commissioning groups and NHS
England.
[50] Abdullah Khlofh Tabekhan1, Yahia Mater Alkhaldi,
Abdullah Khalufah Alghamdi, (2018), Patient’s satisfaction with consultation at
primary health care centers in Abha City, Saudi Arabia. King Khalid University,
Abha, Saudi Arabia.
[51] Kennedy, Denise M. MBA; Fasolino, John P. MD;
and Gullen, David J. MD (2014) "Improving the patient experience through provider
communication skills building,"Patient Experience Journal: Vol. 1: Iss. 1,
Article 10. Available at: http://pxjournal.org/journal/vol1/iss1/10.
[52] Agency for Healthcare Research and Quality (2019).
More effort is needed to ensure pateints understand doctor’s instructions. https://www.ahrq.gov data spotlight-health-literacy
[53] Leonard L. Berry, Katie A. Deming, and Tracey
S. Danaher, (2018). Improving Nonclinical and Clinical-Support Services: Lessons
from Oncology. Mayo Foundation for Medical Education and Research. Published by
Elsevier Inc.
[54] Shojania K, McDonald K, Wachter R, et al (n.d).
Closing the quality gap: a critical analysis of quality improvement strategies—
Volume 7.
[55] PSIC (Professional Solutions Insurance Company),
(2011), Why the Patient History Is So Important. issue 4 of 2011.
[56]
Nick Summerton
(2008). The medical history
as a diagnostic technology. British Journal of General Practice. DOI: 10.3399/bjgp08X279779.
[57] Institute of Medicine (2014. Facilitating patient
understanding of discharge instructions: Workshop summary. Washington, DC: The National
Academies Press.
[58]
Tanya Bezreh, M Barton Laws, Tatiana Taubin,
Dena E Rifkin, and Ira B Wilson, (2011). Challenges to physician–patient communication
about medication use: a window into the skeptical patient’s world. Health Services
Policy and Practice, University of California-USA.