Strategies for monitoring and evaluation of resource-limited national antiretroviral therapy programs: the two-phase design

BMC Medical Research Methodology

Andreas Jahn⁴  Lyson Tenthani²  Simon Makombe⁵  Frank Chimbwandira⁵  Bethany Hedt-Gauthier³  Sebastien Haneuse¹ 

[1]Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA

[2]International Training and Education Center for Health, Lilongwe, Malawi

[3]Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA

[4]International Training and Education Center for Health, Department for Global Health, University of Washington, Seattle, USA

[5]Department for HIV and AIDS, Ministry of Health, Lilongwe, Malawi

关键词: Efficiency;    Two-phase sampling;    Case–control studies;    Aggregated data;    Ecological bias;   

Others  :  1177560
DOI  :  10.1186/s12874-015-0027-9

 received in 2014-07-09, accepted in 2015-03-27,  发布年份 2015

【 摘 要 】

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.

【 授权许可】

   
2015 Haneuse et al.; licensee BioMed Central.

【 图 表 】

Figure 1.

Figure 2.

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