Table 2 Clinical monitoring standard examined and performance
Clinical Monitoring requirement audited | Specified target in guidelines | Proportion of cases with documentation of meeting audit standard % (n/N) |
|---|---|---|
Whether a baseline HIV resistance test had been done or sample stored for later testing | Patients with a genotypic resistance test performed within 3 months of first diagnosis (or with a stored sample available for later testing) (90%). | 80.8% (6636/8258 tested, 40/8258 sample stored) |
Whether HIV viral load measured within past 6 months | Patients on ART with HIV viral load measured within the last 6 months (80%). | 90.1% (6660/7395) |
Whether adherence assessed within past 425 days | Adherence documented within the first 3 months of starting ART (90%) and at least annually thereafter (70%). | 93.4% (6908/7395) |
Whether all medication recorded within past 425 days | All medication taken by patients on ART should be reviewed annually (100%). | 89.0% (6584/7395) |
Whether vaccinated/immune to hepatitis A | No target specified but serology recommended followed by vaccination for all non-immune at risk and/or co-infected with hepatitis B or C. | 61.2% (5053/8258) |
Whether hepatitis B serology recorded; whether anti-surface antibody measured within past 425 days for individuals with serology consistent with vaccination | No target specified but surface antigen (HBsAg), anti-core total antibody (anti-HBc) and anti-surface antibody (anti-HBs) testing recommended. Vaccination recommended if non-immune. Annual surface antibody titre measurement recommended in vaccine responders. | 82.1% (6781/8258) |
Whether hepatitis C antibody status known | No target specified but antibody testing recommended, followed by RNA testing if antibody positive. Annual re-testing recommended for antibody negative men who have sex with men (MSM) or injecting drug users (IDU). | 96.6% (7979/8258) |
Whether CVD risk assessed, within past 3 years if on ART, ever if not on ART | 10-year cardiovascular disease (CVD) risk calculated within 1 year of first presentation (70%), and within the last 3 years if taking ART (70%). | 44.9% (3318/7395) on ART 32.3% (279/863) |
Whether smoking status recorded within past two years; if a smoker, whether offered a cessation service. | Smoking history documented in the last 2 years (90%) and if a smoker offered referral to a cessation service (90%). | 65.9% (5445/8258) 45.2% (862/1905) offered cessation |
Whether blood pressure recorded within past 425 days | Blood pressure (BP) recorded in the last year (90%). | 85.5% (7058/8258) |
Whether glucose measurement recorded within past 425 days | No target specified but recommended yearly or 3–6-monthly if on ART. | 77% (6359/8258) |
Whether lipid profile recorded within past 425 days | No target specified but recommended yearly or 6–12-monthly if on ART. | 83.2% (6869/8258) |
Whether liver function test (LFT) assessed within past 425 days | No target specified but recommended yearly or 3–6 monthly if on ART. | 97% (8013/8258) |
Whether estimated glomerular filtration rate (eGFR) assessed within past 425 days | No target specified but recommended yearly or 3–6 monthly if on ART. | 95.5% (7887/8258) |
Whether urinalysis or urine protein/creatinine (uP/C) checked within past 425 days, or 243 if receiving tenofovir | No target specified but urinalysis and uP/C recommended annually, with 3–6-monthly urinalysis if receiving tenofovir. | 73.7% (2050/2781) 74.8% (4098/5477) receiving tenofovir |
Whether flu vaccination had been done or record made of advice to obtain this from general practitioner (GP) within past year: as audit was conducted in summer this fully covered the preceding season | No target specified in monitoring guidelines but vaccination history recommended as part of regular clinical review. Vaccination guidelines specify: offer annual influenza vaccination to all HIV-infected persons (target 95%) [14]. | 21.1% (1744/8258) vaccination given 36.2% (2993/8258) advice given |
Whether sexual health screen offered within past 425 days | No target specified but recommended to offer sexual health screen 12-monthly, or more frequently if identified risks. | 65.7% (5424/8258) |
Whether syphilis serology had been done within past 243 days | No target specified but recommended 3–6-monthly at each routine visit for MSM and 12-monthly for others | 63.0% (5201/8258) |
Whether cervical cytology had been done or record made of advice to obtain elsewhere within past 425 days, females only | No target specified but recommended 12-monthly. | 53.2% (1471/2763) |
Whether bone mineral density measured, individuals aged >70 and on ART only | No target specified but recommended in all men aged 70 years and all women aged 65 years. | 17.4% (29/167) |
Whether fracture risk assessed within past 3 years, individuals aged >50 only | No target specified but recommended 3-yearly if aged over 50 years. | 16.7% (430/2568) |
Outcome: whether vaccinated against pneumococcus, CD4 > 200 only | No target specified in monitoring guidelines but vaccination history recommended as part of regular clinical review. Vaccination guidelines recommend pneumococcus vaccination if CD4 > 200, and consideration of vaccination at lower CD4. | 26.4% (2082/7877) |