SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
October, 2016 - SUPPORT Summary of a systematic review | print this article | download PDF
The overall number of people living with HIV has steadily increased, as HIV treatments extend life. As HIV infection is shifting mostly to a chronic disease managed primarily in the ambulatory setting, chronic disease management interventions such as decision support and clinical information systems might be useful to this population.
Pasricha A, Deinstadt RT, Moher D, et al. Chronic care model decision support and clinical information systems interventions for people living with HIV: a systematic review. J Gen Intern Med 2013; 28:127-35.
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
As HIV infection becomes a chronic disease, it is important to understand how the principles of chronic disease management could be applied to this population. Strategies for improving management of chronic diseases (within the Chronic Care Model) include: decision support interventions (such as the distribution of educational materials, use of clinical practice guidelines, and case discussions) and clinical information system interventions (based on establishing information systems to organize patient data in order to improve the delivery of care, such as by developing schedules of patients with certain conditions, audit and feedback, change in medical records systems, and providing reminders).
| Review objectives: To assess the effectiveness of decision support (DS) and clinical information system (CIS) interventions for people living with HIV | ||
| Type of | What the review authors searched for | What the review authors found |
|---|---|---|
| Study designs & interventions | Comparative studies that examined the impact of DS and CIS interventions compared to usual care, another (non Chronic Care Model) intervention, or both |
16 studies were included in the review: 2 randomized trials, 1 non randomized trial, 4 prospective and 5 retrospective cohorts, 1 cross sectional study, 2 time series, and 1 prospective timemotion study. |
| Participants | Healthcare providers caring for individuals known to be living with HIV |
Ambulatory patients. Participants in 1 study were children and the rest were adults (mostly men under 50 years). |
| Settings | Ambulatory setting |
USA (10 studies), UK (1), France (1), Switzerland (1), South Africa (1), Zambia (1) and Uganda (1) |
| Outcomes | 1) Immunologic or virologic outcomes such as CD4 count or viral load; 2) medical outcomes such as mortality, progression to AIDS, opportunistic infections, adherence to medication, and risk behaviours; 3) psychosocial outcomes such as quality of life or psychological health and wellbeing; 5) economic outcomes such as healthcare utilization (length of stay, visits), costs; and 6) healthcare process/provider performance outcomes |
Process and health outcome measures |
| Date of most recent search: February 2011 | ||
| Limitations: This is a well conducted systematic review with only minor limitations. | ||
Pasricha A, Deinstadt RT, Moher D, et al. Chronic care model decision support and clinical information systems interventions for people living with HIV: a systematic review. J Gen Intern Med 2013; 28:127-35.
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
Sixteen studies were included in the review.
Four studies reported nine process measures and 12 health outcome measures.
Decision support |
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| People: Healthcare providers caring for individuals known to be living with HIV. Settings: Ambulatory. Intervention: Decision support. Comparison: Usual care, another (non Chronic Care Model) intervention, or both. |
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| Outcomes | Impact | Certainty of the evidence (GRADE) |
|
| Health outcomes |
The proportion of patients with <HIV 75 copies/ml increased 33% in one study. Remission (6 months follow-up): odds ratio 2.40 (95% CI 1.10-5.22) and at 12 months 1.36 (0.66-2.88) |
Very Low | |
| Healthcare utilization |
Mean reductions for the total visit time (11.5 minutes, p<0.001), the time spent in direct patient care (2.9 vs. 2.3 min/visit, p<0.001), and the time spent in indirect patient care (3.2 vs. 2.9 min/visit, p=0.7) |
Very Low | |
| Process outcomes | The median increase in adherence to recommended practice or adherence to treatment was 13% (ranging from 0% to 43%). | Low | |
| GRADE: GRADE Working Group grades of evidence (see above and last page) |
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Nine studies evaluated clinical infromation systems: two examined reminders, two audit and feedback, two examined presence of quality monitoring, and three studies examined both reminders and changes in medical records systems. Eight studies assessed 41 process measures. Three studies (two randomized trials) assessed nine health outcomes.
Clinical information systems |
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| People: Healthcare providers caring for individuals known to be living with HIV. Settings: Ambulatory. Intervention: Clinical information systems. Comparison: Usual care, another (non Chronic Care Model) intervention, or both. |
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| Outcomes | Impact | Certainty of the evidence (GRADE) |
|
| Health outcomes. | The median proportion of patients with a suppressed HIV load increased by 9% (ranging from 6% to 13%). |
Moderate |
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| Process outcomes |
The median increase in adherence to recommended practice or adherence to treatment was 9% (ranging from a reduction of 3% to an increase of 71%) |
Low |
|
| GRADE: GRADE Working Group grades of evidence (see above and last page) |
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Combinations of decision support and clinical information systems were evaluated in three studies.
Decision support and clinical information systems. |
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People: Healthcare providers caring for individuals known to be living with HIV. Settings: Ambulatory. |
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| Outcomes | Impact | Certainty of the evidence (GRADE) |
|
| Change in atrisk behaviors. |
Occurrence of anal or vaginal intercourse without a condom in the past 3 months decreased from 42% to 23% during follow up (p<0.0001). |
Very Low | |
| Process outcomes |
The median increase in adherence to recommended practice or adherence to treatment was 9% (ranging from 1% to 50%) |
Low | |
| GRADE: GRADE Working Group grades of evidence (see above and last page) |
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| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
| 13 studies included in the systematic review were conducted in high income countries, 1 in a middle income country and 2 in low income countries. |
When assessing the transferability of these findings to low income countries the following factors should be considered: -The availability of human and technical resources -The acceptability and costs of the interventions |
| EQUITY | |
| Equity indicators were poorly reported overall. When reported, these indicators did not provide any significant insights into populations for which the interventions were more or less effective compared to others. |
Resources needed for decision support and clinical information systems may be less available in disadvantaged settings. Decision support and clinical information systems may increase inequity if they are not available to these populations. |
| ECONOMIC CONSIDERATIONS | |
| The systematic review found scarce data about resource utilization. |
Scaling up many of the interventions may require substantial resources, which should to be considered. -Local costings should be undertaken, in settings differing from the original investigations. |
| MONITORING & EVALUATION | |
| The certainty of the evidence is low or very low, or no evidence was found for all of the comparisons and outcomes. |
More rigorous studies are required to determine the effects and the cost effectiveness of decision support and clinical information systems, particularly in resource poor settings. |
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*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low income countries. For additional details about how these judgements were made see: www.supportsummaries.org/methods |
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Oluoch T, Santas X, Kwaro D, et al. The effect of electronic medical record based clinical decision support on HIV care in resource constrained settings: a systematic review. International Journal of Medical Informatics 2012; 81(10):e83-92.
Main C, Moxham T, Wyatt JC, et al. Computerised decision support systems in order communication for diagnostic, screening or monitoring test ordering: systematic reviews of the effects and cost effectiveness of systems. Health Technology Assessment 2010; 14(48):1-227.
Rackal JM, Tynan AM, Handford CD, et al. Provider training and experience for people living with HIV/AIDS. The Cochrane Database of Systematic Reviews 2011; (6):CD003938.
Brinkhof MW, Pujades Rodriguez M, Egger M. Mortality of patients lost to follow up in antiretroviral treatment programmes in resource limited settings: systematic review and meta analysis. PloS One 2009; 4(6):e5790.
Agustín Ciapponi, Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina
None declared. For details, see: www.supportsummaries.org/coi
This summary has been peer reviewed by: Heiner C. Bucher and Claire Kendall.
Pasricha A, Deinstadt RT, Moher D, et al. Chronic care model decision support and clinical information systems interventions for people living with HIV: a systematic review. J Gen Intern Med 2013; 28:127-35.
Ciapponi A. Do decision support and clinical information systems improve the healthcare process and health outcomes of people living with HIV? A SUPPORT Summary of a systematic review. October 2016. www.supportsummaries.org
evidence informed health policy, evidence based, systematic review, health systems research, health care, low and middle income countries, developing countries, primary health care, HIV/AIDS; chronic disease management; Chronic Care Model; decision support; clinical information systems.
