title: Strategies for monitoring and evaluation of resource-limited national antiretroviral therapy programs: the two-phase design.
abstract: BACKGROUND
  In resource-limited settings, monitoring and evaluation (M&E) of antiretroviral treatment (ART) programs often relies on aggregated facility-level data. Such data are limited, however, because of the potential for ecological bias, although collecting detailed patient-level data is often prohibitively expensive. To resolve this dilemma, we propose the use of the two-phase design. Specifically, when the outcome of interest is binary, the two-phase design provides a framework within which researchers can resolve ecological bias through the collection of patient-level data on a sub-sample of individuals while making use of the routinely collected aggregated data to obtain potentially substantial efficiency gains.
  
  
  METHODS
  Between 2005-2007, the Malawian Ministry of Health conducted a one-time cross-sectional survey of 82,887 patients registered at 189 ART clinics. Using these patient data, an aggregated dataset is constructed to mimic the type of data that it routinely available. A hypothetical study of risk factors for patient outcomes at 6 months post-registration is considered. Analyses are conducted based on: (i) complete patient-level data; (ii) aggregated data; (iii) a hypothetical case-control study; (iv) a hypothetical two-phase study stratified on clinic type; and, (v) a hypothetical two-phase study stratified on clinic type and registration year. A simulation study is conducted to compare statistical power to detect an interaction between clinic type and year of registration across the designs.
  
  
  RESULTS
  Analyses and conclusions based solely on aggregated data may suffer from ecological bias. Collecting and analyzing patient data using either a case-control or two-phase design resolves ecological bias to provide valid conclusions. To detect the interaction between clinic type and year of registration, the case-control design would require a prohibitively large sample size. In contrast, a two-phase design that stratifies on clinic and year of registration achieves greater than 85% power with as few as 1,000 patient samples.
  
  
  CONCLUSIONS
  Two-phase designs have the potential to augment current M&E efforts in resource-limited settings by providing a framework for the collection and analysis of patient data. The design is cost-efficient in the sense that it often requires far fewer patients to be sampled when compared to standard designs.
authors.affiliation: Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA. shaneuse@hsph.harvard.edu.
authors.forename: Sebastien
authors.initials: S
authors.lastname: Haneuse
authors.affiliation: Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA. bethhedt@gmail.com.
authors.forename: Bethany
authors.initials: B
authors.lastname: Hedt-Gauthier
authors.affiliation: Department for HIV and AIDS, Ministry of Health, Lilongwe, Malawi. frankchimbwandira@gmail.com.
authors.forename: Frank
authors.initials: F
authors.lastname: Chimbwandira
authors.affiliation: Department for HIV and AIDS, Ministry of Health, Lilongwe, Malawi. simond.makombe@yahoo.com.
authors.forename: Simon
authors.initials: S
authors.lastname: Makombe
authors.affiliation: Department for HIV and AIDS, Ministry of Health, Lilongwe, Malawi. ltenthani@gmail.com.|International Training and Education Center for Health, Lilongwe, Malawi. ltenthani@gmail.com.
authors.forename: Lyson
authors.initials: L
authors.lastname: Tenthani
authors.affiliation: Department for HIV and AIDS, Ministry of Health, Lilongwe, Malawi. drandreasjahn@gmail.com.|International Training and Education Center for Health, Department for Global Health, University of Washington, Seattle, USA. drandreasjahn@gmail.com.
authors.forename: Andreas
authors.initials: A
authors.lastname: Jahn
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D003362:Cost-Benefit Analysis; D003695:Delivery of Health Care / Q000191:economics / Q000379:methods; D004196:Disease Outbreaks / Q000517:prevention & control*; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology; D006295:Health Resources / Q000191:economics / Q000600:supply & distribution; D006801:Humans; D016015:Logistic Models; D008295:Malawi / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care / Q000191:economics / Q000379:methods / Q000706:statistics & numerical data; D015397:Program Evaluation / Q000379:methods*; D055815:Young Adult
chemical_list: D044966:Anti-Retroviral Agents