Improving the Quality of Voluntary Medical Male Circumcision through Use of the Continuous Quality Improvement Approach: A Pilot in 30 PEPFAR-Supported Sites in Uganda.

BACKGROUND: Uganda adopted voluntary medical male circumcision (VMMC) (also called Safe Male Circumcision in Uganda), as part of its HIV prevention strategy in 2010. Since then, the Ministry of Health (MOH) has implemented VMMC mostly with support from the United States President's Emergency Plan for AIDS Relief (PEPFAR) through its partners. In 2012, two PEPFAR-led external quality assessments evaluated compliance of service delivery sites with minimum quality standards. Quality gaps were identified, including lack of standardized forms or registers, lack of documentation of client consent, poor preparedness for emergencies and use of untrained service providers. In response, PEPFAR, through a USAID-supported technical assistance project, provided support in quality improvement to the MOH and implementing partners to improve quality and safety in VMMC services and build capacity of MOH staff to continuously improve VMMC service quality. METHODS AND FINDINGS: Sites were supported to identify barriers in achieving national standards, identify possible solutions to overcome the barriers and carry out improvement plans to test these changes, while collecting performance data to objectively measure whether they had bridged gaps. A 53-indicator quality assessment tool was used by teams as a management tool to measure progress; teams also measured client-level indicators through self-assessment of client records. At baseline (February-March 2013), less than 20 percent of sites scored in the "good" range (>80%) for supplies and equipment, patient counseling and surgical procedure; by November 2013, the proportion of sites scoring "good" rose to 67 percent, 93 percent and 90 percent, respectively. Significant improvement was noted in post-operative follow-up at 48 hours, sexually transmitted infection assessment, informed consent and use of local anesthesia but not rate of adverse events. CONCLUSION: Public sector providers can be engaged to address the quality of VMMC using a continuous quality improvement approach.

Improving care for patients on antiretroviral therapy through a gap analysis framework.

OBJECTIVE: To improve quality of care through decreasing existing gaps in the areas of coverage, retention, and wellness of patients receiving HIV care and treatment. DESIGN: The antiretroviral therapy (ART) Framework utilizes improvement methods and the Chronic Care Model to address the coverage, retention, and wellness gaps in HIV care and treatment. This is a time-series study. SETTING: The ART Framework was applied in five health centers in Buikwe District, Uganda. PARTICIPANTS: Quality improvement teams, consisting of healthcare workers and expert patients, were established in each of the five healthcare facilities. INTERVENTION: The intervention period was October 2010 to September 2012. It consisted of quality improvement teams analyzing their facility and systems of care from the perspective of the Chronic Care Model to identify areas of improvement. They implemented the ART Framework, collected data and assessed outcomes, focused on self-management support for patients, to improve coverage, retention, and wellness gaps in HIV care and treatment. MAIN OUTCOME MEASURE(S): Coverage was defined as every patient who needs ART in the catchment area, receives it. Retention was defined as every patient who receives ART stays on ART, and wellness defined as having a positive clinical, immunological, and/or virological response to treatment without intolerable or unmanageable side-effects. RESULTS: Results from Buikwe show the gaps in coverage, retention, and wellness greatly decreased a gap in coverage of 44-19%, gap in retention of 49-24%, and gap in wellness of 53-14% during a 2-year intervention period. CONCLUSION: The ART Framework is an innovative and practical tool for HIV program managers to improve HIV care and treatment.

Body composition and energy metabolism following Roux-en-Y gastric bypass surgery.

Roux-en-Y gastric bypass (RYGB) surgery has become an accepted treatment for excessive obesity. We conducted a longitudinal study to assess regional body composition, muscle proteolysis, and energy expenditure before RYGB, and 6 and 12 months after RYGB. Whole-body and regional fat mass (FM) and lean mass (LM) were assessed via dual energy X-ray absorptiometry (DXA), and myofibrillar protein degradation was estimated by urinary 3-methylhistidine (3-MeH) in 29 subjects. Energy expenditure and substrate oxidation were also determined using a whole-room, indirect calorimeter in 12 of these subjects. LM loss constituted 27.8 +/- 10.2% of total weight loss achieved 12 months postoperatively, with the majority of LM loss (18 +/- 6% of initial LM) occurring in the first 6 months following RYGB. During this period, the trunk region contributed 66% of whole-body LM loss. LM loss occurred in the first 6 months after RYGB despite decreased muscle protein breakdown, as indicated by a decrease in 3-MeH concentrations and muscle fractional breakdown rates. Sleep energy expenditure (SEE) decreased from 2,092 +/- 342 kcal/d at baseline to 1,495 +/- 190 kcal/day at 6 months after RYGB (P < 0.0001). Changes in both LM and FM had an effect on the reduction in SEE (P < 0.001 and P = 0.005, respectively). These studies suggest that loss of LM after RYGB is significant and strategies to maintain LM after surgery should be explored.