Cost-effectiveness of implementing the chronic care model for HIV care in Uganda

Objective: The chronic care model (CCM) is an integrated, population-based approach for treating those with chronic diseases that involves patient self-management, delivery system design and decision support for clinicians to ensure evidence-based care. We sought to determine effectiveness and cost-effectiveness of implementing the CCM for HIV care in Uganda. Design: This controlled, pre/post-intervention study used difference-in-differences analysis to evaluate effectiveness of the CCM to improve patient adherence to antiretroviral therapy (ART) and CD4 counts. Setting: One district hospital and two smaller facilities each in one intervention and one control district in Uganda. Participants: About 46 randomly sampled patients receiving HIV services at three control sites and 56 patients from three intervention sites. Intervention: Two group training sessions and monthly coaching visits from improvement experts over 1 year, implementing the CCM. Main Outcome Measure(s): Patient adherence to ART prescriptions (pill counts) and CD4 counts were measured at baseline and en dline. Results: The odds of increased CD4 in the intervention group was 3.2 times higher than controls (P = 0.022). Clinician-reported ART adherence was 60% (P = 0.001) higher in the intervention group. The intervention cost $ 11 740 and served 7016 patients ($ 1.67 per patient). Incremental cost-effectiveness ratios of the intervention compared to business-as-usual was $ 6.90 per additional patient with improved CD4 and $ 3.40 per additional ART patient with stable or improved adherence. Conclusion: For modest expenditure, it is possible to improve indicators of HIV care quality using the CCM. We recommended implementing the CCM in Uganda; it may be applicable in similar settings in other countries.