The effectiveness and efficiency of implementing the chronic care model for HIV care in Uganda
The chronic care model (CCM), is an integrated, population-based approach to providing health care for those with chronic diseases that involves patient self-management support, delivery system design and decision-support for clinicians and patients to ensure evidence-based guidelines are integrated into practice. In Uganda, with PEPFAR funding, the CCM was used as the basis of providing care for patients with HIV on antiretroviral therapy (ART) with technical assistance from the USAID ASSIST Project.
We carried out a controlled pre/post-intervention study in two districts to determine the effectiveness and efficiency of the implementing the CCM in Uganda, collecting data on CD4 and patient adherence from a random sample of clients receiving HIV services at any one of six sites. The intervention included learning sessions and monthly coaching visits from improvement experts over one year. We used a difference-in-differences analysis controlling for potential confounders.
The evaluation found that the odds of an increase in CD4 in the intervention group was 3.2 times higher than in the control group (p=0.022). About 9% of clients had clinician-reported adherence to ART the same or better at end line compared to baseline in the intervention group (p<0.001). A greater proportion of the patients in the intervention group reported being more responsible for their health and feeling in better health. The incremental cost-effectiveness ratios of the intervention compared to business-as-usual was $ 8.88 per additional ART patient with an improved CD4 and $ 2.07 per additional ART patient with the same or better adherence to ART.
Qualitative data were gathered using pre-tested semi-structured interview guides and found that there was a perception of increased efficiency and organization which led to positive impressions of the services provided among workers at those sites. Overall, providers experienced improvements delivering care, and clients experienced improvement in the care they received.
The findings suggest that for a modest expenditure, it is possible to improve process and outcome indicators of the quality of care by implementing the CCM.