Effects of Patient Tracking Systems and Providers Incentives on Patient Appointment Keeping Rwanda Pilot Study Report Nyamusore Jose 1 *, Hinda Ruton 1, Mutabazi Vincent 1, Karema Corine 1, Nsanzimana Sabin 1, Gaparayi Patrick 2, John Chalker 2, Anita K. Wagner 3, Degnan Dennis-Ross 3, Joseph Ntaganira 4, and Binagwaho Agnes 5 1 RBC/IHDPC, 2 Management Sciences for Health, 3 Harvard Medical School and Harvard Pilgrim Health Care Institute, 4 INRUD, 5 Ministry of Health

Background  HIV infected Patients on Antiretroviral Therapy (ART) need to remain on their medication for life.  Some patients may interrupt their treatment or become lost to follow up for various reasons.  Adverse consequences of non adherence are not only limited to individual patients, but also affect the health care system.  More emphasis should be put on the benefit of both adherence and efficacious ARV combinations on viral load complete suppression

Rationale  Most published research in Africa and Rwanda in particular has focused more on addressing patient- related factors. Little is known regarding system-level interventions to improve adherence to antiretroviral therapy (ART).  There was a need for strengthening ART facility delivery- systems to enable better tracking of patients who missed their appointments and for implementing systems at health facilities to promote and sustain high levels of adherence while ensuring good retention of patients on ART.

Objectives  Assess the effects of a pharmacy-based patient tracking system on patient adherence  Assess the effects of payment for adherence-based performance on patient adherence

Methods  Study Design: A 26 month longitudinal cohort study to assess the effects of an intervention that combined systems changes and financial incentives on appointment keeping and patient retention among patients receiving ART.  Study sites: The study was conducted in 18 health facilities randomly selected and located in 12 administrative districts in the 4 out of 5 provinces of Rwanda  Inclusion criteria: : Having between 150 and 500 adult patients on antiretroviral treatment (as of June 2008), and situated within a radius of 100 km from the capital city Kigali  Categorization: The 18 facilities were randomly assigned in 3 groups: Group 1 (Incentives, tools and training), Group 2 (Tools and training) and Group 3 as controls.  Study population: Adult patients on antiretroviral treatment aged 15 years and above grouped into two cohorts.  Cohort 1: Experienced patients  Cohort 2: Rolling cohort of newly treated adult patients. Only visits that occurred in their first 90 days of treatment were considered

Interventions Health systems strengthening in all 12 intervention facilities (Groups 1 & 2) : –Longitudinal patient tracking register to capture routine medicine refills in pharmacy –Links between the facility and the community to track and bring back patients who missed refill appointments by >3 days –Tailored training for staff from HIV services on basic adherence concepts –Training in extraction and use of clinic data to measure attendance- based indicators to improve appointment keeping and retention. The 6 facilities of Group 1 also received financial incentives for staff working in the ART service based on facility performance with respect to quarterly calculation of the study indicators. –Within the facility, amount earned was equally paid to participating staff regardless of position or qualification Bi-monthly monitoring visits in 12 intervention facilities and quarterly evaluations in Group 1 facilities by the study team.

Results

Percentage of visits for medication refills occurred after 3 days of the scheduled dates by cohort Cohort 1: EXPERIENCED PATIENTSCohort 2: NEWLY TREATED PATIENTS (THEIR FIRST 90 DAYS OF TREATMENT) 3 month Intervention

Probability of occurrence of missed appointments by 3 days

% of patients remaining in care with no gap of >90 days Group 1 Group 2 Controls

Discussions  Quantitative data analysis suggests that the intervention improved adherence in regard to all indicators in both cohorts in the Group 1 (Incentives, Tools and Training)  In the Group 2 (Tools and Training), adherence levels have stayed the same despite the intervention in regard to all indicators in both cohorts  Data from the controls suggests that there were improved levels of adherence in our period of intervention. o Qualitative data in controls showed that some control facilities used patient appointment tools that captured similar information like diaries and other registers in addition to possible spreading of information between study facilities and controls. o During the study period, there was also an increased emphasis and support of home visits through IPs in all ART facilities independent of whether they were in study or controls.

Discussions  For the probability of the occurrence of missed appointments in the first 90 days of treatment, the study shows no apparent differences in the 3 groups for missing appointments up to 3 days  This may be attributed to different factors including insufficient time to contact the missing patients and taking into account the non working days including week-ends.  There is a constant higher probability to retain patients on treatment in both intervention groups even after 90 days of treatment compared to controls.

Conclusion  The study showed the positive impact of combined good patient appointment tracking system, continuous formative supervision and financial incentives on appointment keeping by patients and on their retention at facility level  The intervention also improved the organization of daily activities as well as communication between healthcare team and clients resulting in enhanced mutual trust.  In ART facilities that received financial incentives, the health care providers were much more motivated and innovative to ensure that patients kept their appointment dates.  Some IPs facilitated home visits through provision of transportation and per diem costs, creation of supporting groups among patients and provided nutritional support in both study and control facilities contributing to improved patient appointment keeping.

Recommendations 1.Consider integrating adherence HIV indicators that have worked successfully in the existing PBF evaluations 2.Consider involvement of CHWs in outreach programs of HIV patients with a focus on adherence on ART 3.Harmonize and standardize the patient appointment tracking tools by avoiding duplication and reducing the number of books to be filled by the healthcare providers 4.Work with the decentralized entities to increase number of formative supervisions aimed at improving patient follow up and their adherence 5.If national changes are made in response to this pilot study, assess the process and the outcomes of scale-up of the intervention

Acknowledgement  Rwanda Ministry of Health  RBC/TRAC Plus  USAID  SIDA  MSH  INRUD-IAA  Harvard University team  Participating health facilities