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
November, 2016 - SUPPORT Summary of a systematic review | print this article | download PDF
There are substantial challenges to the provision of care for those living with HIV/AIDS. Several of the key issues involved relate to where care should be provided and how it should be organized.
Setting of care:
Organisation of care:
All the studies reviewed were conducted in high-income coun-tries.
People making decisions concerning setting and organisation of care for people living with HIV/AIDS
Handford C, Tynan AM, Rackal JM, Glazier R. Setting and organization of care for persons living with HIV/AIDS. Cochrane Database of Systematic Re-views 2006, Issue 3. Art.No.: CD004348.
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.
| Review objectives: To determine the effects of the setting of care and the organisation of care on medical,immunological/virological, psychosocial and/or economic outcomes for persons living with HIV/AIDS | ||
| Type of | What the review authors searched for | What the review authors found |
|---|---|---|
| Study designs & interventions | Randomised trials, non-randomised trials, cohort studies, case control studies, cross-sectional studies, and controlled before-after studies that evaluated the settings and organisation of care | 1 randomised trial, 1 non-randomised trial, 5 prospective cohort studies, and 21 retrospective cohort studies were included. |
| Participants | Persons (men, women and children) known to be infected with HIV/AIDS | 39,776 HIV-positive participants were included |
| Settings | All settings | Clinical trial settings; hospitals and clinics in high-income country settings |
| Outcomes | Medical outcomes, immunological or virological outcomes, psychosocial outcomes, economic outcomes | Mortality (12 studies), receipt of antiretrovirals or indicated prophylaxis as an outcome (10 studies), hospitalisation (5 studies), functional status (1 study), healthcare utilisation outcomes (16 studies) |
| Date of most recent search: December 2002 | ||
| Limitations: This is a well conducted systematic review with only minor limitations. However, it has not been updated since the last search in December 2002. | ||
To determine the effects of the setting of care and the organisation of care on medical, immunological/virological, psychosocial and/or economic outcomes for persons living with HIV/AIDS
Handford C, Tynan AM, Rackal JM, Glazier R. Setting and organization of care for persons living with HIV/AIDS. Cochrane Database of Systematic Re-views 2006, Issue 3. Art.No.: CD004348.
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.
Twenty-eight studies, all conducted in high-income countries, evaluating the setting and organisation of care were included. Interventions included the concentration of HIV/AIDS patients (1 study); clinic, hospital or hospital ward volumes (13); the conducting of clinical trials (4), the incorporation of trainees (3), and hours of service (3). Case management interventions were described in 3 studies, multidisciplinary or multi faceted treatment interventions in 6 studies, and health information systems in three. No studies evaluated outreach or travel time to providers as an intervention.
Among people living with HIV/AIDS:
High volume institutions |
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| People: People with HIV/AIDS Intervention: High volume institutions Comparison: Lower volume institutions |
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| Outcomes | Impact | Certainty of the evidence (GRADE) |
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| 30-day mortality | Five studies reported reduced 30-day mortality in high volume institutions compared to lower volume institutions; 4 other studies were inconclusive. |
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| Length of hospital stays |
Two studies demonstrated longer hospital stays in facilities with higher HIV-volumes compared to low volume facilities and reported differences of 5.0 and 2.7 days respectively. Three studies reported differences of 2.0 days or less when comparing high volume with low volume facilities. |
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| Healthcare utilisation | One study found fewer emergency department visits (ED) (31 vs. 43 visits, p=0.01) for patients randomised to a high-volume HIV infectious diseases practice (1,100 HIV-infected patients) compared to a low-volume general medicine practice (<50 HIV‑infected patients). There was no difference reported between the groups in terms of the number of patient visits to the home clinic. Another study found that higher-volume institutions had fewer patients with 2 or more ED visits (aOR 0.56, CI 0.44 to 0.71) compared to patients from lower-volume institutions. |
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| P: p-value; aOR: adjusted odds ratio; CI: confidence interval; GRADE: GRADE Working Group grades of evidence (see above and last page) |
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Among people living with HIV/AIDS:
Case management |
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| People: People with HIV/AIDS Intervention: Case management Comparison: No case management |
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| Outcomes | Impact | Certainty of the evidence (GRADE) |
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| 30-day mortality | Improved two-year survival period (86% vs. 64%, p<.001) for patients who were actively involved in an Early Intervention Program which included case management as compared to patients who were not actively involved in the Program. | ||
| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
| None of the studies in this review were conducted in low-income countries. | It may be difficult for policymakers to replicate the study settings or organisation of care in low income countries. |
| EQUITY | |
| The included studies provided little data regarding the differential effects of the interventions on disadvantaged groups within the included populations. | The effects of changes in the setting or organisation of care may vary in disadvantaged communities. |
| ECONOMIC CONSIDERATIONS | |
| Economic evaluations were not reported on in the review. | Changes to the organisation of care may require training, human resources, the provision of necessary drugs and supplies, and have other associated costs. The cost-effectiveness and sustainability of such measures are uncertain. |
| MONITORING & EVALUATION | |
| Some interventions included in this review appeared promising, but the certainty of the evidence was mostly low or very low. |
Consideration should be given to evaluating the impact of the interventions described using robust methods before attempts are made to implement large‑scale changes. Both intended outcomes and potential adverse effects should be evaluated and monitored. |
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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: http://www.support-collaboration.org/summaries/methods.htm |
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Ofman JJ, Badamgarav E, Henning JM, et al. Does disease management improve clinical and economic outcomes in patients with chronic diseases? A systematic review. American Journal of Medicine 2004; 117:182–92.
Oxman AD, Bjorndal A, Flottorp S, Lewin S, Lindahl AK: Integrated Health Care for People with Chronic Condi-tions. Oslo, Norwegian Knowledge Centre for the Health Services; 2008. http://www.kunnskapssenteret.no/en/publications/integrated-health-care-for-people-with-chronic-conditions.a-policy-brief
Bemelmans M, Van Den Akker T, Ford N, et al. Providing universal access to antiretroviral therapy in Thyolo, Ma-lawi through task shifting and decentralization of HIV/AIDS care. Trop Med Int Health 2010; 15(12):1413-20.
Taryn Young, South African Cochrane Centre, South African Medical Research Council, Cape Town, South Africa
None declared. For details, see: www.supportsummaries.org/coi
This summary has been peer reviewed by: Edward Mills, Anne-Marie Tynan, Simon Goudie, and Hanna
Bergman.
Handford C, Tynan AM, Rackal JM, Glazier R. Setting and organization of care for persons living with HIV/AIDS. Cochrane Database of Systematic Reviews 2006, Issue 3. Art.No.: CD004348.
Young T. What are the impacts of healthcare settings and organisation on the provisions of care for those living with HIV/AIDS? A SUPPORT Summary of a sys-tematic review. November 2016. www.supportsummaries.org
evidence-informed health policy, evidence-based, systematic review, health sys-tems research, health care, low and middle-income countries, developing coun-tries, primary health care, organisation of care, setting of care, HIV/AIDS
The South African Medical Research Council aims to improve South Africa’s health and quality of life through promoting and conducting rele-vant and responsive health research. www.mrc.ac.za/
Cochrane South Africa, the only centre of the global, independent Cochrane network in Africa, aims to ensure that health care decision mak-ing within Africa is informed by high-quality, timely and relevant research evidence. www.mrc.ac.za/cochrane/cochrane.htm
