CAT allows for prompt feedback to HCWs, increases HCW autonomy, and allows managers to allocate resources and time in an equitable manner. CAT is an effective, feasible, and acceptable implementation strategy to prioritize areas most requiring improvement within complex health systems, although adaptations are being currently evaluated.
Cascades have been used to characterize sequential steps within a complex health system and are used in diverse disease areas and across prevention, testing, and treatment. Routine data have great potential to inform prioritization within a system, but are often inaccessible to frontline health care workers (HCWs) who may have the greatest opportunity to innovate health system improvement.
CAT has been adapted 7 times: to a mobile application for prevention of mother-to-child transmission; for hypertension screening and management and for mental health outpatient services in Mozambique; for pediatric and adolescent HIV testing and treatment, HIV testing in family planning, and cervical cancer screening and treatment in Kenya; and for naloxone distribution and opioid overdose reversal in the United States. The main domains of adaptation have been technical-estimating denominators and structuring steps to be binary sequential steps-as well as logistical-identifying acceptable approaches for data abstraction and aggregation, and not overburdening HCW.
The cascade analysis tool (CAT) is an Excel-based, simple simulation model with an optimization function. It identifies the step within a cascade that could most improve the system. The original CAT was developed for HIV treatment and the prevention of mother-to-child transmission of HIV.
Wagner AD, Gimbel S, Ásbjörnsdóttir KH, Cherutich P, Coutinho J, Crocker J, Cruz E, Cuembelo F, Cumbe V, Eastment M, Einberg J, Floriano F, Gaitho D, Guthrie BL, John-Stewart G, Kral AH, Lambdin BH, Liu S, Maina M, Manaca N, Matsuzaki M, Mattox L, Mburu N, McClelland RS, Micek MA, Mocumbi AO, Muanido A, Nduati R, Njuguna IN, Oluoch G, Oyiengo LB, Ronen K, Soi C, Wagenaar BH, Wanje G, Wenger LD, Sherr K. (2019). Cascade Analysis: An Adaptable Implementation Strategy Across HIV and Non-HIV Delivery Platforms. Journal of acquired immune deficiency syndromes (1999), (82 Suppl 3)