Cost-effectiveness of implementing the chronic care model for HIV care in Uganda

Objective The chronic care model (CCM) is an integrated, population-based approach for treating those with chronic diseases that involves patient self-management, delivery system design and decision support for clinicians to ensure evidence-based care. We sought to determine effectiveness and cost-effectiveness of implementing the CCM for HIV care in Uganda. Design This controlled, pre/post-intervention study used difference-in-differences analysis to evaluate effectiveness of the CCM to improve patient adherence to antiretroviral therapy (ART) and CD4 counts. Setting One district hospital and two smaller facilities each in one intervention and one control district in Uganda. Participants About 46 randomly sampled patients receiving HIV services at three control sites and 56 patients from three intervention sites. Intervention Two group training sessions and monthly coaching visits from improvement experts over 1 year, implementing the CCM. Main Outcome Measure(s) Patient adherence to ART prescriptions (pill counts) and CD4 counts were measured at baseline and en dline. Results The odds of increased CD4 in the intervention group was 3.2 times higher than controls ( P = 0.022). Clinician-reported ART adherence was 60% ( P = 0.001) higher in the intervention group. The intervention cost $11 740 and served 7016 patients ($1.67 per patient). Incremental cost-effectiveness ratios of the intervention compared to business-as-usual was $6.90 per additional patient with improved CD4 and $3.40 per additional ART patient with stable or improved adherence. Conclusion For modest expenditure, it is possible to improve indicators of HIV care quality using the CCM. We recommended implementing the CCM in Uganda; it may be applicable in similar settings in other countries.