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Quantification of physician-time saved in a task shifting pilot program in Rwanda
By: J. Chung1, M. O'Brien1, J. Price2, F. Shumbusho2

Background: Equipping nurses to initiate treatment and provide follow-up care may alleviate strain on limited human resources. Using data from a pilot in three health centers where nurses provided HIV treatment under the supervision of physicians, a simulation model was created to estimate the number and length of provider consultations, vary the assignment of provider, and incorporate physician time spent supporting nurses, thus providing an estimate of physician time saved when nurses were primary providers.
Methods: WHO stage and CD4 count distribution, visit schedules and length, and rates of enrollment, death, attrition, and CD4 decline were used to create a simulation of the HIV care for 946 patients. The model estimated dates of entry into the program, utilization of ART, frequency and length of provider consultations, and attrition. Validation confirmed that the model accurately reflected the pilot population. Provider consultation times were aggregated to calculate human resource requirements. Results were extrapolated to quantify the potential impact of task shifting on a national level.
Results: Task shifting from 9/2005-12/2007 in the pilot saved 656 physician-hours. During the last quarter, the savings was 56 hours/month. One hour worked by a prescribing nurse saved approximately 45 minutes of physician time when physician supervision of prescribing nurses and consultation for complicated cases was included. By end-2008, approximately 59,000 people will be on ART in Rwanda; provision of care according to national guidelines will require about 12,400 hours of direct patient consultation/month. In a physician-centered model, this requires 103 physicians working 30 hours/week, or 69% of the physician capacity. Implementing task shifting nationally reduces the demand to 25 physicians, or 17% of the available physicians.
Conclusions: Implementation of task shifting can reduce the demand on physician time by 76%, allowing the government of Rwanda to scale-up HIV treatment while limiting strain on the healthcare system.

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