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

Haneuse S, Hedt-Gauthier B, Chimbwandira F, Makombe S, Tenthani L, Jahn A - BMC Med Res Methodol (2015)

Bottom Line: 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.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.

View Article: PubMed Central - PubMed

Affiliation: Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA. shaneuse@hsph.harvard.edu.

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.

No MeSH data available.


Related in: MedlinePlus

Results on the association between age and negative outcome status based on the complete patient data (N = 82,877 patient records) and the quarterly-clinic cohort data (N* = 1,518 records). Shown are odds ratio estimates and 95% confidence intervals; the referent age level for the odds ratio associations is 45 years.
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Fig1: Results on the association between age and negative outcome status based on the complete patient data (N = 82,877 patient records) and the quarterly-clinic cohort data (N* = 1,518 records). Shown are odds ratio estimates and 95% confidence intervals; the referent age level for the odds ratio associations is 45 years.

Mentions: The second column of Table 4 provides results based on the group-level analysis of the quarterly-clinic cohort data. Comparing with the first column, we see discrepant results between the patient- and group-level analyses for the effects of age, gender and WHO stage. For gender and WHO stage, the point estimates based on the aggregated data analysis are substantially attenuated, although remain statistically significant. Analyses based on patient-level data indicate a statistically significant U-shaped relationship between age and six-month outcomes (see Figure 1). Analyses based on group-level data fail to identify a statistically significant quadratic term and erroneously suggest a linear effect for age. This is a classic manifestation of ecological bias.Figure 1


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

Haneuse S, Hedt-Gauthier B, Chimbwandira F, Makombe S, Tenthani L, Jahn A - BMC Med Res Methodol (2015)

Results on the association between age and negative outcome status based on the complete patient data (N = 82,877 patient records) and the quarterly-clinic cohort data (N* = 1,518 records). Shown are odds ratio estimates and 95% confidence intervals; the referent age level for the odds ratio associations is 45 years.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4404107&req=5

Fig1: Results on the association between age and negative outcome status based on the complete patient data (N = 82,877 patient records) and the quarterly-clinic cohort data (N* = 1,518 records). Shown are odds ratio estimates and 95% confidence intervals; the referent age level for the odds ratio associations is 45 years.
Mentions: The second column of Table 4 provides results based on the group-level analysis of the quarterly-clinic cohort data. Comparing with the first column, we see discrepant results between the patient- and group-level analyses for the effects of age, gender and WHO stage. For gender and WHO stage, the point estimates based on the aggregated data analysis are substantially attenuated, although remain statistically significant. Analyses based on patient-level data indicate a statistically significant U-shaped relationship between age and six-month outcomes (see Figure 1). Analyses based on group-level data fail to identify a statistically significant quadratic term and erroneously suggest a linear effect for age. This is a classic manifestation of ecological bias.Figure 1

Bottom Line: 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.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.

View Article: PubMed Central - PubMed

Affiliation: Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA. shaneuse@hsph.harvard.edu.

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.

No MeSH data available.


Related in: MedlinePlus