title: Electronic medical record systems, data quality and loss to follow-up: survey of antiretroviral therapy programmes in resource-limited settings.
abstract: OBJECTIVE
  To describe the electronic medical databases used in antiretroviral therapy (ART) programmes in lower-income countries and assess the measures such programmes employ to maintain and improve data quality and reduce the loss of patients to follow-up.
  
  
  METHODS
  In 15 countries of Africa, South America and Asia, a survey was conducted from December 2006 to February 2007 on the use of electronic medical record systems in ART programmes. Patients enrolled in the sites at the time of the survey but not seen during the previous 12 months were considered lost to follow-up. The quality of the data was assessed by computing the percentage of missing key variables (age, sex, clinical stage of HIV infection, CD4+ lymphocyte count and year of ART initiation). Associations between site characteristics (such as number of staff members dedicated to data management), measures to reduce loss to follow-up (such as the presence of staff dedicated to tracing patients) and data quality and loss to follow-up were analysed using multivariate logit models.
  
  
  RESULTS
  Twenty-one sites that together provided ART to 50 060 patients were included (median number of patients per site: 1000; interquartile range, IQR: 72-19 320). Eighteen sites (86%) used an electronic database for medical record-keeping; 15 (83%) such sites relied on software intended for personal or small business use. The median percentage of missing data for key variables per site was 10.9% (IQR: 2.0-18.9%) and declined with training in data management (odds ratio, OR: 0.58; 95% confidence interval, CI: 0.37-0.90) and weekly hours spent by a clerk on the database per 100 patients on ART (OR: 0.95; 95% CI: 0.90-0.99). About 10 weekly hours per 100 patients on ART were required to reduce missing data for key variables to below 10%. The median percentage of patients lost to follow-up 1 year after starting ART was 8.5% (IQR: 4.2-19.7%). Strategies to reduce loss to follow-up included outreach teams, community-based organizations and checking death registry data. Implementation of all three strategies substantially reduced losses to follow-up (OR: 0.17; 95% CI: 0.15-0.20).
  
  
  CONCLUSIONS
  The quality of the data collected and the retention of patients in ART treatment programmes are unsatisfactory for many sites involved in the scale-up of ART in resource-limited settings, mainly because of insufficient staff trained to manage data and trace patients lost to follow-up.
authors.affiliation: Institute of Social and Preventive Medicine, University of Bern, Switzerland.
authors.forename: Mathieu
authors.initials: M
authors.lastname: Forster
authors.forename: Christopher
authors.initials: C
authors.lastname: Bailey
authors.forename: Martin W G
authors.initials: MW
authors.lastname: Brinkhof
authors.forename: Claire
authors.initials: C
authors.lastname: Graber
authors.forename: Andrew
authors.initials: A
authors.lastname: Boulle
authors.forename: Mark
authors.initials: M
authors.lastname: Spohr
authors.forename: Eric
authors.initials: E
authors.lastname: Balestre
authors.forename: Margaret
authors.initials: M
authors.lastname: May
authors.forename: Olivia
authors.initials: O
authors.lastname: Keiser
authors.forename: Andreas
authors.initials: A
authors.lastname: Jahn
authors.forename: Matthias
authors.initials: M
authors.lastname: Egger
mesh_terms: D019380:Anti-HIV Agents; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D016001:Confidence Intervals; D019992:Databases as Topic; D003906:Developing Countries; D015658:HIV Infections / Q000188:drug therapy*; D019538:Health Care Surveys; D006801:Humans; D016347:Medical Records Systems, Computerized / Q000706:statistics & numerical data*; D015233:Models, Statistical; D015999:Multivariate Analysis; D016017:Odds Ratio; D011203:Poverty; D015397:Program Evaluation; D012107:Research Design; D012959:Socioeconomic Factors
chemical_list: D019380:Anti-HIV Agents; D044966:Anti-Retroviral Agents