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Down-referral strategy for ART led to lower costs, better outcomes in South Africa

BOSTON – The use of a down-referral strategy from higher- to lower-level health care facilities and staff reduced costs and improved outcomes for patients on antiretroviral therapy in Johannesburg, South Africa.

“One of the more interesting developments in the last couple of years has been a new focus on task-shifting, in an attempt to provide ART, save money, deal with absolute scarcities of doctors and more highly trained clinicians, and expand access to treatment by using lower-level facilities that are more widespread,” Sydney Rosen, MPA, assistant professor at the Boston University School of Public Health, said during a press conference.

Rosen and colleagues evaluated a nurse management pilot program in which stable ART patients were down-referred to a local primary clinic between 2008 and 2009. They assessed the cost and effectiveness of treatment for patients initiated on ART at the hospital-based main clinic (n=1,620) when compared with treatment after down-referral to a primary health clinic. Patients who were down-referred were matched using propensity scores on the basis of age, gender, CD4 cell count, time on ART, and regimen with a comparison group who remained at the main clinic site.

Costs were about 10% lower at the down-referral site when compared with the main clinic. Specifically, the cost per patient was $505 per year at the down-referral site vs. $553 at the initiation site, Rosen said.

“If this model were generalizable to the country as a whole and could be expanded, potential savings in the neighborhood of between $12 and $20 million per year, which isn’t a lot in absolute terms, but it represents probably 25,000 to 40,000 additional patients who could be treated with the same budget,” she said. – by Ashley DeNyse

For more information:

• Rosen S. #43. Presented at: 18th Conference on Retroviruses and Opportunistic Infections; Feb. 27-March 3, 2011; Boston.

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