Bango Funeka, Ashmore John, Wilkinson Lynne, van Cutsem Gilles, Cleary Susan
Provincial Department of Health, Western Cape Government, Cape Town, South Africa.
Médecins Sans Frontières, Khayelitsha, South Africa.
Trop Med Int Health. 2016 Sep;21(9):1115-23. doi: 10.1111/tmi.12736. Epub 2016 Jul 10.
As the scale of the South African HIV epidemic calls for innovative models of care that improve accessibility for patients while overcoming chronic human resource shortages, we (i) assess the cost-effectiveness of lay health worker-led group adherence clubs, in comparison with a nurse-driven 'standard of care' and (ii) describe and evaluate the associated patient cost and accessibility differences.
Our cost-effectiveness analysis compares an 'adherence club' innovation to conventional nurse-driven care within a busy primary healthcare setting in Khayelitsha, South Africa. In each alternative, we calculate provider costs and estimate rates of retention in care and viral suppression as key measures of programme effectiveness. All results are presented on an annual or per patient-year basis. In the same setting, a smaller sample of patients was interviewed to understand the direct and indirect non-healthcare cost and access implications of the alternatives. Access was measured using McIntyre and colleagues' 2009 framework.
Adherence clubs were the more cost-effective model of care, with a cost per patient-year of $300 vs. $374 and retention in care at 1 year of 98.03% (95% CI 97.67-98.33) for clubs vs. 95.49% (95% CI 95.01-95.94) for standard of care. Viral suppression in clubs was 99.06% (95% CI 98.82-99.27) for clubs vs. 97.20% (95% CI 96.81-97.56) for standard of care. When interviewed, club patients reported fewer missed visits, shorter waiting times and higher acceptability of services compared to standard of care.
Adherence clubs offer the potential to enhance healthcare efficiency and patient accessibility. Their scale-up should be supported.
鉴于南非艾滋病疫情的规模需要创新的护理模式，以提高患者的可及性，同时克服长期的人力资源短缺问题，我们（i）评估由非专业卫生工作者主导的群体依从性俱乐部的成本效益，并与护士主导的“护理标准”进行比较，（ii）描述和评估相关的患者成本及可及性差异。
我们的成本效益分析将一种“依从性俱乐部”创新模式与南非开普敦凯伊利沙繁忙的初级卫生保健机构中传统的护士主导护理进行比较。在每种模式下，我们计算提供者成本，并估计护理留存率和病毒抑制率，将其作为项目效果的关键指标。所有结果均按年度或每位患者每年呈现。在同一机构中，对一小部分患者进行了访谈，以了解这两种模式对直接和间接非医疗成本及可及性的影响。可及性采用麦金太尔及其同事2009年的框架进行衡量。
依从性俱乐部是更具成本效益的护理模式，每位患者每年的成本为300美元，而标准护理为374美元；俱乐部1年的护理留存率为98.03%（95%置信区间97.67 - 98.33），标准护理为95.49%（95%置信区间95.01 - 95.94）。俱乐部的病毒抑制率为99.06%（95%置信区间98.82 - 99.27），标准护理为97.20%（95%置信区间96.81 - 97.56）。在接受访谈时，与标准护理相比，俱乐部患者报告的就诊遗漏次数更少、等待时间更短且服务可接受性更高。
依从性俱乐部有提高医疗效率和患者可及性的潜力。应支持扩大其规模。
