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Improving clinic visit efficiency to support retention of Adolescent Girls and Young Women in the MTN-034 study at Kampala site, Uganda

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BACKGROUND:

Maximizing study clinic visit efficiency for a prospective cohort of adolescent girls and young women (AGYW) is critical in avoiding long waiting times and enhancing participant retention. A persistent and multi-disciplinary approach can help improve recruitment, sustain participation, and help participants adhere to study visits which motivates a participant to continue with study participation resulting in better protocol implementation. MTN-034 is implemented at the MU-JHU site from February 2019 and the study team realized that study visits were very long with long wait times which resulted in agitated and anxious participants. We describe the strategies that have been instituted in the MTN-034 clinic at the Kampala site to improve visit efficiency.


METHODS:

Visit flow assessments are done at different time points for the screening, enrollment, monthly, quarterly, and crossover visits, with a mixture of adolescents and adults. Visit length is calculated using a tool provided by FHI 360 and a visit efficiency report created. The clinic has a flow manager who ensures smooth clinic operations and is charged with resolving any issues in real time. Challenges are also discussed during weekly study meeting or impromptu meetings with the clinic team to obtain appropriate strategies.


RESULTS:

Summary of visit efficiency reports overtime in the REACH study clinic at MU-JHU; Visit Type August 2019 December 2019 Challenges/ Bottle necks Screening Visit Average Total Visit Length(hrs) (Normal Range) 5.00 (3.00 – 3.45) 3.45 (3.00 – 3.45) Longest wait time was for lab results which has improved by having 2 lab technicians in the stat lab Longest single procedure was the Informed Consent Process, which improved after counsellors gained experience in engaging parents/guardians of minors Overall Improvement in December attributed to staff being familiar with study procedures. Average Total Procedure Time(hrs) (Normal Range) 4.00 (2.30– 3.00) 3.00 (2.30– 3.00) Average Total Wait Time hrs) (Normal Range) 1.00 (0.30 – 0.45) 0.45 (0.30 – 0.45) Longest Single ProcedureTime (hrs) 2.50 1.50 Longest Wait Time (hrs) 0.45 0.30 Enrolment Visit Average Total Visit Length (hrs) (Normal Range) 5.50 (4.00 – 4.30) 4.30 (4.00 – 4.30) Longest single procedure was product counselling (involves audio recording and watching the REACH video) markedly improved after counsellors were more familiar with procedure Standard Lab test time is about 30 minutes To optimize visit efficiency, participants have lunch as they wait for lab results or some other procedures are done during this time Average Total Procedure Time(hrs) (Normal Range) 4.5 (3,00– 4.00) 3.45 (3,00– 4.00) Average Total Wait Time (hrs) (Normal Range) 1.00 (0.30 – 0.50) 0.45 (0.30 – 0.50) Longest Single ProcedureTime (hrs) 0.40 0.30 Longest Wait Time(hrs) 0.45 0.30 Monthly Visits Average Total Visit Length(hrs) (Normal Range) 3.30 (1.50– 3.00) 2.00 (1.50– 3.00) Longest single procedure was lab testing which improved after another lab technician was brought on board in the stat lab. Standard Lab test time is about 30 minutes To optimize visit efficiency, participants have lunch as they wait for lab results or some other procedures are done during this time Overall Improvement in December attributed to staff being familiar with study procedures Average Total Procedure Time(hrs) (Normal Range) 2.30 (1.20 – 2.15) 1.30 (1.20 – 2.15) Average Total Wait Time(hrs) (Normal Range) 1.00 (0.30 – 0.45) 0.30 (0.30 – 0.45) Longest Single ProcedureTime (hrs) 0.50 0.30 Longest Wait Time (hrs) 0.45 0.30 Other Visits: Quarterly Visits visit length was on average 4hrs in August which improved to 3hrs in December due to the study team being more familiar with the procedures. They are longer than monthly visits due to more procedures like ACASI and pelvic exams Crossover and Choice visit length were on average 4hrs. More procedures than the quarterly visit are done which include behavioral assessments, new product counselling, instructions for new product and additional Case Reports Forms Note: When participants come in early (at about 9:00hrs) they are seen quickly however those that come after 11:00hrs usually face some delays as the study team are already engaged with the earlier participants. Participants are always reminded to come in as early as possible for their visits. Average participants scheduled per day is about 5, however some days may have about 7– 8 participants when delays may occur in case most come in at the same time. Participants have also reported great satisfaction with the more efficient visits. Some of the impediments occurred when participants arrived on dates that were not their scheduled appointments or came in late after 11:00hrs, however, they are seen as fast as possible


CONCLUSIONS:

Conclusion: More efficient visits have resulted in great participant satisfaction. Visit efficiency therefore continues to be a priority and conducting regular visit flow assessments is key in identifying “bottle necks” and develop strategies to overcoming them.