Collection and analysis of longitudinal pharmacy refill data

from manual registers: Experiences from Ugandan public

health systems

Joshua KayiwaINRUD-IAA, Uganda

Session Objectives

Narrate the experience of the Uganda INRUD-IAA

team in collecting, cleaning, summarizing and

analyzing manually recorded pharmacy refill data

for longitudinal research

Make recommendations for similar longitudinal

studies in the African health systems context

Brief BackgroundMost public health systems in low and middle

income countries maintain patients’ treatment data in manual registers

Mainly due to constraints in technological, financial and human resource capacity to design and maintain appropriate Electronic Medical Record Systems (EMRs)

Has implications for data security, availability, accessibility, accuracy, completeness, and the ease of using such data to study policy impacts

Background to INRUD-IAA StudyDesigned as a longitudinal staggered entry interventional

study among six public health facilities in Uganda

Aim was to investigate the extent to which low-cost interventions meant to reduce clinic congestion, implemented at health facility level would improve patients’ individual-level adherence to antiretroviral therapy (ART) Results in press and also presented elsewhere in this ICIUM

meeting

Collected pharmacy-refill information for evaluation Appointment dates, actual visit dates, numbers of pills

dispensed 720 ART-experienced and 761 patients newly initiating ART for

six months pre-intervention and nine months post-intervention

Where Were Raw Data Found?

• Longitudinal patient-level data in clinical records, diaries, pharmacy, appointment registers

• Manually filled and kept at facility or with patients

What Were We Trying to Measure? Key study outcomes :

% of experienced patients with >30 days of dispensed medication

% of experienced patients missing any scheduled visit

% of experienced patients with 3 or more days without medication

Time until newly-treated patients experienced a medication gap of >7 or >14 days during first 120 days of treatment

Challenges with Collecting Data from Manual Registers and Diaries

Data availabilityHealth workers only record what they think they need to

administer today’s treatmentData often missing, e.g., # of pills dispensed, patients’ CD4

and viral load history

Data accessibility and securityHard to access, especially for patient diariesDiaries prone to wear and tear due to mishandlingPages may tear out or be destroyed by cockroaches / mould

Data accuracy and reliabilityData not protected against entry errors Cannot be verified against secondary sources.

Managing Longitudinal Data Collected from Manual Registers

Data collected and recorded using a standard tool by trained research assistants

Data entry and validationCustomized double entry data input and validation using MS

ExcelFurther quality checks in Stata before analysis

Summarizing the DataUsing appointment

and visit dates and days of medication dispensed, we computed: % of patients

receiving more than 30 days of medication

Number of days by which patient missed any visit (see graph)

Gaps medication availability between appointments

Key Findings (manuscript in press)Among experienced patients,

interventions led to Significant two-fold increase in

patients receiving >30 days of dispensed medication

Significant 33% reductions of missed appointments

Significant 31% reductions of experiencing a medication gap of 3+ days

Among newly treated patients, interventions associated with Significant 44% reduction in

hazard of experiencing medication gap of >7 days (see graph)

Significant 38% reduction medication gap of >14 days

Aim Achieved?We aimed to

determine whether interventions to reduce clinic congestion, improve patient flow and if this would translate into better ART adherence.

Using routine data from manual clinic records, we were able to measure increases in days of medication dispensed, reductions in missed visits, and fewer medication gaps among ART patients.

Lessons Learnt and RecommendationsIt is possible to collect pharmacy refill records from

manual registers in African health facilitiesMany challenges: especially data completeness,

accuracy, security and reliability

RecommendationsManual pharmacy registers and clinical records safer

when kept at the health facility than with patientsMore attention to staff training in record keepingUnless staff see data used for clinical care, management,

or research, they have no incentive to record accuratelyPharmacy refill records should ideally be kept

electronically, whenever resources (human and financial) allow

Thanks Very Much