Definition of a core set of quality indicators for the assessment of HIV/AIDS clinical care: a systematic review

Quality performance or quality of clinical care is the main subject in the health care system and it can be precisely defined. Many studies have been made on this subject [1‐3]. The Institute of Medicine defined Quality of care as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge [3, 4]. This assessment can be made by measures that can give us the degree of quality of care. Indicators are defined as a measurement tool that can be used to monitor and evaluate the quality of important governance, management, clinical, and supported functions [5]. They provide a quantitative basis for clinicians, organizations, and planners aiming to achieve improvement in care and in the processes by which patient care is provided [6]. Donabedian and Fleming related indicators to structure, process and outcome [7]. Process indicators assess what the provider did to the patient and if it was well done; it measures the activities and tasks in patient episodes of care. Outcome indicators measure the state of health or events that follow care and that may be affected by health care. In general, either process or outcome may be valid measures of quality. For an outcome to be considered a valid measure of quality, it must be closely related to processes of care that can be manipulated to affect the outcome. Likewise, for a process to be a valid measure of quality, it must be closely related to an outcome that people care about [4]. In many cases, there are multiple factors that contribute to a patient’s survival and health outcome. In those cases, it is useful that outcome measures are adjusted for factors like psychosocial characteristics, lifestyle factors and severity of the illness, if we want to make fair comparisons. Risk adjustment is useful to control confounding factors that might contribute to the outcome indicator [8].

In this review we wanted to find out what HIV/AIDS quality indicators are used to assess clinical care, their development and validation methods. We found few studies. Most of them are process or outcome indicators and, as Mainz defined, “process denotes what is actually done in giving and receiving care and outcomes measures attempt to describe the effects of care on the patients’ health status and populations” [10]. So, through this review, we have an overview of the most relevant aspects that we have to look at when assessing HIV clinical care. The methods used (guidelines and expert panels) to select them are according to what is described in the literature [8, 9, 33], nevertheless, little information has been given about their validation methods.

We found 50 process indicators that assess different aspects of HIV/AIDS hospital care. Wollersheim et al. [9] say that there is some conflict between the number of indicators selected and the amount of work which must be spent on recording data. They argue that to achieve a good balance, it is recommended to select about 12 clinical indicators for care process.

Attempting to establish the core set of indicators useful to assess HIV/AIDS clinical care, we compared the quality indicators we got with the American and European guidelines. For some indicators, there is no doubt about their relevance, they are in both guidelines and in more than one study, for instance, CD4 count cell, viral load; for others, the difference is that they are only in one guideline, but this doesn’t make them less important. Indicators like syphilis or gonorrhea screening are also very important even though they are not endorsed by the American guideline. The fact of the matter is that there are specific guidelines for each aspect of HIV care. Another important aspect in this comparison between indicators studies and guidelines is that there are some indicators that are in both guidelines, but are only mentioned by one study. For instance, knowing the “Proportion of patients eligible for ART who are currently on ART” is as important as knowing if they have prescribed appropriate ART. Defining a core set of indicators is a hard task.

In Table 4, we have the core set of indicators we think that can be used to approach HIV/AIDS clinical care. Some specific HIV clinical care indicators used are: CD4 cell count, viral load test, non-detectable HIV viral load at 48 treatment weeks, Hepatitis C screening, Hepatitis B testing, Tuberculosis screening, Hepatitis B vaccination, PCP (pneumocystis jiroveci pneumonia) prophylaxis, adherence to ART, appropriately prescribed ART, and HIV-TB co-treatment. All these measures are considered to be critical elements in the clinical care of individuals with HIV/AIDS [25], and they have clinical utility because they are endorsed by guidelines [17, 18]. In the core of indicators that we propose, only 3 of the 23 are outcome indicators. Although it is desirable to obtain outcome indicators it is not always possible, due to: firstly, there are many processes that compete for the same outcome [34]; secondly, due to the time needed to obtain the desired result, surrogate measures are used; thirdly, data limits often dictate the extent of the measures that can be established or are not suitable to every HIV-infected patient. Unless a measure addresses potential pitfalls adequately, the results produced from the measure may be misleading rather than helpful [35].

Some indicators are obtained from a set of steps which includes more than one data element, or are influenced by many factors, such as age or gender (adjustment measures). One of the challenges hospitals face nowadays is the quality of the data they collect [36‐38]. Some variables can have missing values, can be biased (for instance, because of their main purpose), or may not be possible to collect, and so adjustments can be difficult. Nevertheless the dissemination of indicators throughout regions and hospitals should help them to understand the key elements of HIV/AIDS care that will be under scrutiny, and thereby encourage hospitals to implement data management systems that facilitate measurement of their HIV/AIDS care process and patient outcomes.

When we analyze the validity of the quality indicators, a common characteristic is that most of the studies assess the quality of care, only one is about the validity of the quality indicator itself. So for each indicator, it is necessary to analyze it in order to find out its reliability, relevance and applicability.

Indicators included in the WHO Indicator and Measurement Registry are set up “on a national basis”; some of them can be applied at a local level, but few of them are to assess the quality of HIV clinical care. These indicators are well defined and are ready to be used by everyone as they are valid and reliable.

We wanted to identify a core set of indicators that represent optimal care and that will facilitate uniform measurement and benchmarking of the quality of HIV/AIDS clinical care at a local level, and can lead to the establishment of comparative reporting between developed and developing countries.

The main findings of this systematic review are that there are efforts from the USA and Spain to establish a national core set of indicators useful to assess the HIV/AIDS clinical care; the assessment of HIV/AIDS clinical care must take into account the main aspects of baseline assessment, screening, immunization, prophylaxis, HIV monitoring, and therapy. Most of the indicators are process-related, are intended to guide (the good practice) and to evaluate the clinical care provided to HIV/AIDS patients.