title: Electronic decision protocols for ART patient triaging to expand access to HIV treatment in South Africa: a cross sectional study for development and validation.
abstract: BACKGROUND
  The shortage of doctors and nurses, along with future expansion into rural clinics, will require that the majority of clinic visits by HIV infected patients on antiretroviral therapy (ART) are managed by non-doctors. The goal of this study was to develop and evaluate a screening protocol to determine which patients needed a full clinical assessment and which patients were stable enough to receive their medications without a doctor's consultation. For this study, we developed an electronic, handheld tool to guide non-physician counselors through screening questions.
  
  
  METHODS
  Patients visiting two ART clinics in South Africa for routine follow-up visits between March 2007 and April 2008 were included in our study. Each patient was screened by non-physician counselors using the handheld device and then received a full clinical assessment. Clinicians' report on whether full clinical assessment had been necessary was used as the gold standard for determining "required referral". Observations were randomly divided into two datasets--989 for developing a referral protocol and 200 for validating protocol performance.
  
  
  RESULTS
  A third of patients had at least one physical complaint, and 16% had five or more physical complaints. 38% of patients required referral for full clinical assessment. We identify a subset of questions which are 87% sensitive and 47% specific for recommended patient referral.
  
  
  CONCLUSIONS
  The final screening protocol is highly sensitive and could reduce burden on ART clinicians by 30%. The uptake and acceptance of the handheld tool to support implementation of the protocol was high. Further examination of the data reveals several important questions to include in future referral algorithms to improve sensitivity and specificity. Based on these results, we identify a refined algorithm to explore in future evaluations.
authors.affiliation: Department of Global Health and Population, Harvard School of Public Health, Boston, MA 02115, USA. mmitchel@hsph.harvard.edu
authors.forename: Marc
authors.initials: M
authors.lastname: Mitchell
authors.forename: Bethany L
authors.initials: BL
authors.lastname: Hedt
authors.forename: Ingrid
authors.initials: I
authors.lastname: Eshun-Wilson
authors.forename: Hamish
authors.initials: H
authors.lastname: Fraser
authors.forename: Melanie-Anne
authors.initials: MA
authors.lastname: John
authors.forename: Colin
authors.initials: C
authors.lastname: Menezes
authors.forename: Martin P
authors.initials: MP
authors.lastname: Grobusch
authors.forename: Jonathan
authors.initials: J
authors.lastname: Jackson
authors.forename: Jantjie
authors.initials: J
authors.lastname: Taljaard
authors.forename: Neal
authors.initials: N
authors.lastname: Lesh
mesh_terms: D000465:Algorithms; D003430:Cross-Sectional Studies; D020000:Decision Support Systems, Clinical / Q000458:organization & administration*; D005260:Female; D005500:Follow-Up Studies; D006678:HIV / Q000187:drug effects; D015658:HIV Infections / Q000145:classification / Q000188:drug therapy* / Q000451:nursing*; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D016347:Medical Records Systems, Computerized / Q000458:organization & administration*; D011320:Primary Health Care; D012372:ROC Curve; D012017:Referral and Consultation; D012680:Sensitivity and Specificity; D013019:South Africa; D014218:Triage