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Song J, Wang X, Wang B, Ge Y, Bi L, Jing F, Jin H, Li T, Gu B, Wang L, Hao J, Zhao Y, Liu J, Zhang H, Li X, Li J, Ma W, Wang J, Normand SLT, Herrin J, Armitage J, Krumholz HM, Zheng X. Learning implementation of a guideline based decision support system to improve hypertension treatment in primary care in China: pragmatic cluster randomised controlled trial. BMJ 2024; 386:e079143. [PMID: 39043397 DOI: 10.1136/bmj-2023-079143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]
Abstract
OBJECTIVE To evaluate the effectiveness of a clinical decision support system (CDSS) in improving the use of guideline accordant antihypertensive treatment in primary care settings in China. DESIGN Pragmatic, open label, cluster randomised trial. SETTING 94 primary care practices in four urban regions of China between August 2019 and July 2022: Luoyang (central China), Jining (east China), and Shenzhen (south China, including two regions). PARTICIPANTS 94 practices were randomised (46 to CDSS, 48 to usual care). 12 137 participants with hypertension who used up to two classes of antihypertensives and had a systolic blood pressure <180 mm Hg and diastolic blood pressure <110 mm Hg were included. INTERVENTIONS Primary care practices were randomised to use an electronic health record based CDSS, which recommended a specific guideline accordant regimen for initiation, titration, or switching of antihypertensive (the intervention), or to use the same electronic health record without CDSS and provide treatment as usual (control). MAIN OUTCOME MEASURES The primary outcome was the proportion of hypertension related visits during which an appropriate (guideline accordant) treatment was provided. Secondary outcomes were the average reduction in systolic blood pressure and proportion of participants with controlled blood pressure (<140/90 mm Hg) at the last scheduled follow-up. Safety outcomes were patient reported antihypertensive treatment related events, including syncope, injurious fall, symptomatic hypotension or systolic blood pressure <90 mm Hg, and bradycardia. RESULTS 5755 participants with 23 113 visits in the intervention group and 6382 participants with 27 868 visits in the control group were included. Mean age was 61 (standard deviation 13) years and 42.5% were women. During a median 11.6 months of follow-up, the proportion of visits at which appropriate treatment was given was higher in the intervention group than in the control group (77.8% (17 975/23 113) v 62.2% (17 328/27 868); absolute difference 15.2 percentage points (95% confidence interval (CI) 10.7 to 19.8); P<0.001; odds ratio 2.17 (95% CI 1.75 to 2.69); P<0.001). Compared with participants in the control group, those in the intervention group had a 1.6 mm Hg (95% CI -2.7 to -0.5) greater reduction in systolic blood pressure (-1.5 mm Hg v 0.3 mm Hg; P=0.006) and a 4.4 percentage point (95% CI -0.7 to 9.5) improvement in blood pressure control rate (69.0% (3415/4952) v 64.6% (3778/5845); P=0.07). Patient reported antihypertensive treatment related adverse effects were rare in both groups. CONCLUSIONS Use of a CDSS in primary care in China improved the provision of guideline accordant antihypertensive treatment and led to a modest reduction in blood pressure. The CDSS offers a promising approach to delivering better care for hypertension, both safely and efficiently. TRIAL REGISTRATION ClinicalTrials.gov NCT03636334.
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Affiliation(s)
- Jiali Song
- National Clinical Research Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Centre for Cardiovascular Diseases, Beijing, China
| | - Xiuling Wang
- National Clinical Research Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Centre for Cardiovascular Diseases, Beijing, China
| | - Bin Wang
- National Clinical Research Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Centre for Cardiovascular Diseases, Beijing, China
| | - Yilan Ge
- National Clinical Research Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Centre for Cardiovascular Diseases, Beijing, China
| | - Lei Bi
- National Clinical Research Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Centre for Cardiovascular Diseases, Beijing, China
| | - Fuyu Jing
- National Clinical Research Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Centre for Cardiovascular Diseases, Beijing, China
| | - Huijun Jin
- National Clinical Research Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Centre for Cardiovascular Diseases, Beijing, China
| | - Teng Li
- National Clinical Research Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Centre for Cardiovascular Diseases, Beijing, China
| | - Bo Gu
- National Clinical Research Centre for Cardiovascular Diseases, Shenzhen, Fuwai Shenzhen Hospital, Chinese Academy of Medical Sciences, Shenzhen, China
| | - Lili Wang
- National Clinical Research Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Centre for Cardiovascular Diseases, Beijing, China
| | - Jun Hao
- Medical Research and Biometrics Centre, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yanyan Zhao
- Medical Research and Biometrics Centre, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Centre for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiamin Liu
- National Clinical Research Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Centre for Cardiovascular Diseases, Beijing, China
| | - Haibo Zhang
- National Clinical Research Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Centre for Cardiovascular Diseases, Beijing, China
| | - Xi Li
- National Clinical Research Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Centre for Cardiovascular Diseases, Beijing, China
- National Clinical Research Centre for Cardiovascular Diseases, Shenzhen, Fuwai Shenzhen Hospital, Chinese Academy of Medical Sciences, Shenzhen, China
| | - Jing Li
- National Clinical Research Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Centre for Cardiovascular Diseases, Beijing, China
| | - Wenjun Ma
- Hypertension Centre, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Jiguang Wang
- The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Sharon-Lise T Normand
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Jeph Herrin
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jane Armitage
- Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
- Centre for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
| | - Xin Zheng
- National Clinical Research Centre for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Centre for Cardiovascular Diseases, Beijing, China
- National Clinical Research Centre for Cardiovascular Diseases, Shenzhen, Fuwai Shenzhen Hospital, Chinese Academy of Medical Sciences, Shenzhen, China
- Coronary Artery Disease Ward 2, Fuwai Shenzhen Hospital, Chinese Academy of Medical Sciences, Shenzhen, China
- Clinical Trial Centre, Fuwai Shenzhen Hospital, Chinese Academy of Medical Sciences, Shenzhen, China
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2
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Dorr DA, Montgomery E, Ghumman AJ, Michaels L, Rolbiecki A, Canfield S, Shaffer V, Johnson B, Lockwood M, Ghosh P, Martinez W, Koopman R. Study protocol: Collaboration Oriented Approach to Controlling High blood pressure (COACH) in adults - a randomised controlled trial. BMJ Open 2024; 14:e085898. [PMID: 38977368 PMCID: PMC11256044 DOI: 10.1136/bmjopen-2024-085898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 06/10/2024] [Indexed: 07/10/2024] Open
Abstract
INTRODUCTION Hypertension, the clinical condition of persistent high blood pressure (BP), is preventable yet remains a significant contributor to poor cardiovascular outcomes. Digital self-management support tools can increase patient self-care behaviours to improve BP. We created a patient-facing and provider-facing clinical decision support (CDS) application, called the Collaboration Oriented Approach to Controlling High BP (COACH), to integrate home BP data, guideline recommendations and patient-centred goals with primary care workflows. We leverage social cognitive theory principles to support enhanced engagement, shared decision-making and self-management support. This study aims to measure the effectiveness of the COACH intervention and evaluate its adoption as part of BP management. METHODS AND ANALYSIS The study design is a multisite, two-arm hybrid type III implementation randomised controlled trial set within primary care practices across three health systems. Randomised participants are adults with high BP for whom home BP monitoring is indicated. The intervention arm will receive COACH, a digital web-based intervention with effectively enhanced alerts and displays intended to drive engagement with BP lowering; the control arm will receive COACH without the alerts and a simple display. Outcome measures include BP lowering (primary) and self-efficacy (secondary). Implementation preplanning and postevaluation use the Consolidated Framework for Implementation Research and Reach-Effectiveness-Adoption-Implementation-Maintenance metrics with iterative cycles for qualitative integration into the trial and its quantitative evaluation. The trial analysis includes logistic regression and constrained longitudinal data analysis. ETHICS AND DISSEMINATION The trial is approved under a single IRB through the University of Missouri-Columbia, #2091483. Dissemination of the intervention specifications and results will be through open-source mechanisms. TRIAL REGISTRATION NUMBER NCT06124716.
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Affiliation(s)
- David Andrew Dorr
- Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon, USA
| | | | - Aisha J Ghumman
- Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon, USA
| | - LeAnn Michaels
- Oregon Health & Science University, Portland, Oregon, USA
| | - Abigail Rolbiecki
- University of Missouri System, Columbia, Missouri, USA
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | | | | | - Blake Johnson
- Oregon Health & Science University, Portland, Oregon, USA
| | | | - Parijat Ghosh
- University of Missouri System, Columbia, Missouri, USA
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3
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Mortier P, Amigo F, Bhargav M, Conde S, Ferrer M, Flygare O, Kizilaslan B, Latorre Moreno L, Leis A, Mayer MA, Pérez-Sola V, Portillo-Van Diest A, Ramírez-Anguita JM, Sanz F, Vilagut G, Alonso J, Mehlum L, Arensman E, Bjureberg J, Pastor M, Qin P. Developing a clinical decision support system software prototype that assists in the management of patients with self-harm in the emergency department: protocol of the PERMANENS project. BMC Psychiatry 2024; 24:220. [PMID: 38509500 PMCID: PMC10956300 DOI: 10.1186/s12888-024-05659-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 03/05/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Self-harm presents a significant public health challenge. Emergency departments (EDs) are crucial healthcare settings in managing self-harm, but clinician uncertainty in risk assessment may contribute to ineffective care. Clinical Decision Support Systems (CDSSs) show promise in enhancing care processes, but their effective implementation in self-harm management remains unexplored. METHODS PERMANENS comprises a combination of methodologies and study designs aimed at developing a CDSS prototype that assists clinicians in the personalized assessment and management of ED patients presenting with self-harm. Ensemble prediction models will be constructed by applying machine learning techniques on electronic registry data from four sites, i.e., Catalonia (Spain), Ireland, Norway, and Sweden. These models will predict key adverse outcomes including self-harm repetition, suicide, premature death, and lack of post-discharge care. Available registry data include routinely collected electronic health record data, mortality data, and administrative data, and will be harmonized using the OMOP Common Data Model, ensuring consistency in terminologies, vocabularies and coding schemes. A clinical knowledge base of effective suicide prevention interventions will be developed rooted in a systematic review of clinical practice guidelines, including quality assessment of guidelines using the AGREE II tool. The CDSS software prototype will include a backend that integrates the prediction models and the clinical knowledge base to enable accurate patient risk stratification and subsequent intervention allocation. The CDSS frontend will enable personalized risk assessment and will provide tailored treatment plans, following a tiered evidence-based approach. Implementation research will ensure the CDSS' practical functionality and feasibility, and will include periodic meetings with user-advisory groups, mixed-methods research to identify currently unmet needs in self-harm risk assessment, and small-scale usability testing of the CDSS prototype software. DISCUSSION Through the development of the proposed CDSS software prototype, PERMANENS aims to standardize care, enhance clinician confidence, improve patient satisfaction, and increase treatment compliance. The routine integration of CDSS for self-harm risk assessment within healthcare systems holds significant potential in effectively reducing suicide mortality rates by facilitating personalized and timely delivery of effective interventions on a large scale for individuals at risk of suicide.
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Grants
- AC22/00006; AC22/00045 Instituto de Salud Carlos III (ISCIII) and by the European Union NextGenerationEU, Mecanismo para la Recuperación y la Resiliencia
- AC22/00006; AC22/00045 Instituto de Salud Carlos III (ISCIII) and by the European Union NextGenerationEU, Mecanismo para la Recuperación y la Resiliencia
- AC22/00006; AC22/00045 Instituto de Salud Carlos III (ISCIII) and by the European Union NextGenerationEU, Mecanismo para la Recuperación y la Resiliencia
- AC22/00006; AC22/00045 Instituto de Salud Carlos III (ISCIII) and by the European Union NextGenerationEU, Mecanismo para la Recuperación y la Resiliencia
- AC22/00006; AC22/00045 Instituto de Salud Carlos III (ISCIII) and by the European Union NextGenerationEU, Mecanismo para la Recuperación y la Resiliencia
- AC22/00006; AC22/00045 Instituto de Salud Carlos III (ISCIII) and by the European Union NextGenerationEU, Mecanismo para la Recuperación y la Resiliencia
- AC22/00006; AC22/00045 Instituto de Salud Carlos III (ISCIII) and by the European Union NextGenerationEU, Mecanismo para la Recuperación y la Resiliencia
- AC22/00006; AC22/00045 Instituto de Salud Carlos III (ISCIII) and by the European Union NextGenerationEU, Mecanismo para la Recuperación y la Resiliencia
- AC22/00006; AC22/00045 Instituto de Salud Carlos III (ISCIII) and by the European Union NextGenerationEU, Mecanismo para la Recuperación y la Resiliencia
- AC22/00006; AC22/00045 Instituto de Salud Carlos III (ISCIII) and by the European Union NextGenerationEU, Mecanismo para la Recuperación y la Resiliencia
- AC22/00006; AC22/00045 Instituto de Salud Carlos III (ISCIII) and by the European Union NextGenerationEU, Mecanismo para la Recuperación y la Resiliencia
- ESF+; CP21/00078 ISCIII-FSE Miguel Servet co-funded by the European Social Fund Plus
- PI22/00107 ISCIII and co-funded by the European Union
- PI22/00107 ISCIII and co-funded by the European Union
- PI22/00107 ISCIII and co-funded by the European Union
- 202220-30-31 Fundación la Marató de TV3
- 202220-30-31 Fundación la Marató de TV3
- 202220-30-31 Fundación la Marató de TV3
- 202220-30-31 Fundación la Marató de TV3
- 202220-30-31 Fundación la Marató de TV3
- 202220-30-31 Fundación la Marató de TV3
- 202220-30-31 Fundación la Marató de TV3
- 202220-30-31 Fundación la Marató de TV3
- FI23/00004 PFIS ISCIII
- FI23/00004 PFIS ISCIII
- SGR 00624 the Secretaria d'Universitats i Recerca del Departament d'Economia i Coneixement of the Generalitat de Catalunya AGAUR 2021
- SGR 00624 the Secretaria d'Universitats i Recerca del Departament d'Economia i Coneixement of the Generalitat de Catalunya AGAUR 2021
- SGR 00624 the Secretaria d'Universitats i Recerca del Departament d'Economia i Coneixement of the Generalitat de Catalunya AGAUR 2021
- SGR 00624 the Secretaria d'Universitats i Recerca del Departament d'Economia i Coneixement of the Generalitat de Catalunya AGAUR 2021
- SGR 00624 the Secretaria d'Universitats i Recerca del Departament d'Economia i Coneixement of the Generalitat de Catalunya AGAUR 2021
- SGR 00624 the Secretaria d'Universitats i Recerca del Departament d'Economia i Coneixement of the Generalitat de Catalunya AGAUR 2021
- SGR 00624 the Secretaria d'Universitats i Recerca del Departament d'Economia i Coneixement of the Generalitat de Catalunya AGAUR 2021
- SGR 00624 the Secretaria d'Universitats i Recerca del Departament d'Economia i Coneixement of the Generalitat de Catalunya AGAUR 2021
- CIBERESP; CB06/02/0046 CIBER of Epidemiology & Public Health
- CIBERESP; CB06/02/0046 CIBER of Epidemiology & Public Health
- CIBERESP; CB06/02/0046 CIBER of Epidemiology & Public Health
- CIBERESP; CB06/02/0046 CIBER of Epidemiology & Public Health
- CIBERESP; CB06/02/0046 CIBER of Epidemiology & Public Health
- CIBERESP; CB06/02/0046 CIBER of Epidemiology & Public Health
- ERAPERMED2022 the Health Research Board Ireland
- ERAPERMED2022 the Health Research Board Ireland
- no. 2022-00549 the Swedish Innovation Agency
- no. 2022-00549 the Swedish Innovation Agency
- project no. 342386 the Research Council of Norway
- project no. 342386 the Research Council of Norway
- project no. 342386 the Research Council of Norway
- the Secretaria d’Universitats i Recerca del Departament d’Economia i Coneixement of the Generalitat de Catalunya AGAUR 2021
- CIBER of Epidemiology & Public Health
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Affiliation(s)
- Philippe Mortier
- Hospital del Mar Research Institute, Barcelona Biomedical Research Park (PRBB), Carrer Doctor Aiguader, 88, 08003, Barcelona, Spain.
- CIBER of Epidemiology and Public Health, Carlos III Health Institute (CIBERESP, ISCIII), Madrid, Spain.
| | - Franco Amigo
- Hospital del Mar Research Institute, Barcelona Biomedical Research Park (PRBB), Carrer Doctor Aiguader, 88, 08003, Barcelona, Spain
- CIBER of Epidemiology and Public Health, Carlos III Health Institute (CIBERESP, ISCIII), Madrid, Spain
| | - Madhav Bhargav
- School of Public Health & National Suicide Research Foundation, University College Cork, Cork, Ireland
| | - Susana Conde
- Hospital del Mar Research Institute, Barcelona Biomedical Research Park (PRBB), Carrer Doctor Aiguader, 88, 08003, Barcelona, Spain
| | - Montse Ferrer
- Hospital del Mar Research Institute, Barcelona Biomedical Research Park (PRBB), Carrer Doctor Aiguader, 88, 08003, Barcelona, Spain
- CIBER of Epidemiology and Public Health, Carlos III Health Institute (CIBERESP, ISCIII), Madrid, Spain
- Department of Medicine and Life Sciences, Universitat Pompeu Fabra, Barcelona, Spain
| | - Oskar Flygare
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Sweden
| | - Busenur Kizilaslan
- National Centre for Suicide Research and Prevention, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Laura Latorre Moreno
- Hospital del Mar Research Institute, Barcelona Biomedical Research Park (PRBB), Carrer Doctor Aiguader, 88, 08003, Barcelona, Spain
| | - Angela Leis
- Research Programme on Biomedical Informatics (GRIB), Hospital del Mar Research Institute, Barcelona, Spain
- Department of Medicine and Life Sciences, Universitat Pompeu Fabra, Barcelona, Spain
| | - Miguel Angel Mayer
- Research Programme on Biomedical Informatics (GRIB), Hospital del Mar Research Institute, Barcelona, Spain
- Department of Medicine and Life Sciences, Universitat Pompeu Fabra, Barcelona, Spain
| | - Víctor Pérez-Sola
- Neuropsychiatry and Drug Addiction Institute, Barcelona MAR Health Park Consortium PSMAR, Barcelona, Spain
- CIBER of Mental Health and Carlos III Health Institute (CIBERSAM, ISCIII), Madrid, Spain
- Department of Paediatrics, Obstetrics and Gynaecology and Preventive Medicine and Public Health Department, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Ana Portillo-Van Diest
- Hospital del Mar Research Institute, Barcelona Biomedical Research Park (PRBB), Carrer Doctor Aiguader, 88, 08003, Barcelona, Spain
- CIBER of Epidemiology and Public Health, Carlos III Health Institute (CIBERESP, ISCIII), Madrid, Spain
| | - Juan Manuel Ramírez-Anguita
- Research Programme on Biomedical Informatics (GRIB), Hospital del Mar Research Institute, Barcelona, Spain
- Department of Medicine and Life Sciences, Universitat Pompeu Fabra, Barcelona, Spain
| | - Ferran Sanz
- Research Programme on Biomedical Informatics (GRIB), Hospital del Mar Research Institute, Barcelona, Spain
- Department of Medicine and Life Sciences, Universitat Pompeu Fabra, Barcelona, Spain
- National Bioinformatics Institute - ELIXIR-ES (IMPaCT-Data-ISCIII), Barcelona, Spain
| | - Gemma Vilagut
- Hospital del Mar Research Institute, Barcelona Biomedical Research Park (PRBB), Carrer Doctor Aiguader, 88, 08003, Barcelona, Spain
- CIBER of Epidemiology and Public Health, Carlos III Health Institute (CIBERESP, ISCIII), Madrid, Spain
| | - Jordi Alonso
- Hospital del Mar Research Institute, Barcelona Biomedical Research Park (PRBB), Carrer Doctor Aiguader, 88, 08003, Barcelona, Spain
- CIBER of Epidemiology and Public Health, Carlos III Health Institute (CIBERESP, ISCIII), Madrid, Spain
- Department of Medicine and Life Sciences, Universitat Pompeu Fabra, Barcelona, Spain
| | - Lars Mehlum
- National Centre for Suicide Research and Prevention, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ella Arensman
- School of Public Health & National Suicide Research Foundation, University College Cork, Cork, Ireland
| | - Johan Bjureberg
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services, Region Stockholm, Sweden
| | - Manuel Pastor
- Research Programme on Biomedical Informatics (GRIB), Hospital del Mar Research Institute, Barcelona, Spain
- Department of Medicine and Life Sciences, Universitat Pompeu Fabra, Barcelona, Spain
| | - Ping Qin
- National Centre for Suicide Research and Prevention, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Xie W, Paul RR, Goon IY, Anan A, Rahim A, Hossain MM, Hersch F, Oldenburg B, Chambers J, Mridha MK. Enhancing care quality and accessibility through digital technology-supported decentralisation of hypertension and diabetes management: a proof-of-concept study in rural Bangladesh. BMJ Open 2023; 13:e073743. [PMID: 37984955 PMCID: PMC10660961 DOI: 10.1136/bmjopen-2023-073743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 10/04/2023] [Indexed: 11/22/2023] Open
Abstract
OBJECTIVE The critical shortage of healthcare workers, particularly in rural areas, is a major barrier to quality care for non-communicable diseases (NCD) in low-income and middle-income countries. In this proof-of-concept study, we aimed to test a decentralised model for integrated diabetes and hypertension management in rural Bangladesh to improve accessibility and quality of care. DESIGN AND SETTING The study is a single-cohort proof-of-concept study. The key interventions comprised shifting screening, routine monitoring and dispensing of medication refills from a doctor-managed subdistrict NCD clinic to non-physician health worker-managed village-level community clinics; a digital care coordination platform was developed for electronic health records, point-of-care support, referral and routine patient follow-up. The study was conducted in the Parbatipur subdistrict, Rangpur Division, Bangladesh. PARTICIPANTS A total of 624 participants were enrolled in the study (mean (SD) age, 59.5 (12.0); 65.1% female). OUTCOMES Changes in blood pressure and blood glucose control, patient retention and patient-visit volume at the NCD clinic and community clinics. RESULTS The proportion of patients with uncontrolled blood pressure reduced from 60% at baseline to 26% at the third month of follow-up, a 56% (incidence rate ratio 0.44; 95% CI 0.33 to 0.57) reduction after adjustment for covariates. The proportion of patients with uncontrolled blood glucose decreased from 74% to 43% at the third month of follow-up. Attrition rates immediately after baseline and during the entire study period were 29.1% and 36.2%, respectively. CONCLUSION The proof-of-concept study highlights the potential for involving lower-level primary care facilities and non-physician health workers to rapidly expand much-needed services to patients with hypertension and diabetes in Bangladesh and in similar global settings. Further investigations are needed to evaluate the effectiveness of decentralised hypertension and diabetes care.
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Affiliation(s)
- Wubin Xie
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Rina Rani Paul
- Centre for Non-communicable Diseases and Nutrition, BRAC University James P Grant School of Public Health, Dhaka, Bangladesh
| | - Ian Y Goon
- Tyree Foundation Institute of Health Engineering, UNSW, Sydney, New South Wales, Australia
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- Sprightly Pte Ltd, Singapore
| | - Aysha Anan
- Centre for Non-communicable Diseases and Nutrition, BRAC University James P Grant School of Public Health, Dhaka, Bangladesh
| | | | - Md Mokbul Hossain
- Centre for Non-communicable Diseases and Nutrition, BRAC University James P Grant School of Public Health, Dhaka, Bangladesh
| | | | - Brian Oldenburg
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- School of Psychology and Public Health, La Trobe University, Melbourne, Victoria, Australia
| | - John Chambers
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
- Department of Epidemiology and Biostatistics, Imperial College London, London, UK
| | - Malay Kanti Mridha
- Centre for Non-communicable Diseases and Nutrition, BRAC University James P Grant School of Public Health, Dhaka, Bangladesh
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5
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Wang ST, Lin TY, Chen THH, Chen SLS, Fann JCY. Cost-Effectiveness Analysis of Personalized Hypertension Prevention. J Pers Med 2023; 13:1001. [PMID: 37373989 DOI: 10.3390/jpm13061001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Revised: 06/09/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND While a population-wide strategy involving lifestyle changes and a high-risk strategy involving pharmacological interventions have been described, the recently proposed personalized medicine approach combining both strategies for the prevention of hypertension has increasingly gained attention. However, a cost-effectiveness analysis has been hardly addressed. This study was set out to build a Markov analytical decision model with a variety of prevention strategies in order to conduct an economic analysis for tailored preventative methods. METHODS The Markov decision model was used to perform an economic analysis of four preventative strategies: usual care, a population-based universal approach, a population-based high-risk approach, and a personalized strategy. In all decisions, the cohort in each prevention method was tracked throughout time to clarify the four-state model-based natural history of hypertension. Utilizing the Monte Carlo simulation, a probabilistic cost-effectiveness analysis was carried out. The incremental cost-effectiveness ratio was calculated to estimate the additional cost to save an additional life year. RESULTS The incremental cost-effectiveness ratios (ICER) for the personalized preventive strategy versus those for standard care were -USD 3317 per QALY gained, whereas they were, respectively, USD 120,781 and USD 53,223 per Quality-Adjusted Life Year (QALY) gained for the population-wide universal approach and the population-based high-risk approach. When the ceiling ratio of willingness to pay was USD 300,000, the probability of being cost-effective reached 74% for the universal approach and was almost certain for the personalized preventive strategy. The equivalent analysis for the personalized strategy against a general plan showed that the former was still cost-effective. CONCLUSIONS To support a health economic decision model for the financial evaluation of hypertension preventative measures, a personalized four-state natural history of hypertension model was created. The personalized preventive treatment appeared more cost-effective than population-based conventional care. These findings are extremely valuable for making hypertension-based health decisions based on precise preventive medication.
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Affiliation(s)
- Sen-Te Wang
- Department of Family Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
- Department of Family Medicine, Taipei Medical University Hospital, Taipei 10301, Taiwan
| | - Ting-Yu Lin
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei 10663, Taiwan
| | - Tony Hsiu-Hsi Chen
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei 10663, Taiwan
| | - Sam Li-Sheng Chen
- School of Oral Hygiene, College of Oral Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Jean Ching-Yuan Fann
- Department of Health Industry Management, School of Healthcare Management, Kainan University, Tao-Yuan 33857, Taiwan
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Leach MJ. Development and validation of the global assessment of the evidence implementation environment [GENIE] tool. Complement Ther Clin Pract 2023; 52:101764. [PMID: 37137208 DOI: 10.1016/j.ctcp.2023.101764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/27/2023] [Accepted: 04/28/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND Overcoming the various barriers to evidence implementation is critical to delivering evidence-based health care. Identifying and managing these obstacles is somewhat challenging however, due to interprofessional and interjurisdictional variations in reported barriers. An efficient, systematic, comprehensive and innovative approach to isolating the barriers to evidence implementation is therefore needed. MATERIALS AND METHODS Using a mixed methods design, the study aimed to develop, refine and validate a tool to assess the evidence implementation environment for complementary medicine (CM) professions. The tool was developed using a five-stage process, and refined and validated using a two-round e-Delphi technique. RESULTS Informed by reviews examining the barriers and enablers to evidence implementation in CM, and shaped by the Behaviour Change Wheel Framework, a preliminary 33-item tool was created (i.e. the Global Assessment of the Evidence Implementation Environment [GENIE] tool). A two-round Delphi technique was used to refine the criteria, with a panel of 23 experts agreeing to the removal of two criteria, and the addition of two items. In the end, the Delphi panel reached consensus on 33 criteria, which were sorted into nine stakeholder groups. CONCLUSION This study has for the first time, created an innovative tool to assess the capacity and capability of CM professions to engage in evidence-based practice at an optimal level. By assessing the evidence implementation environment of CM professions, the GENIE tool is able to determine where resources, infrastructure and personnel should be directed in order to optimise the uptake of evidence-based practices within CM professions.
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Affiliation(s)
- Matthew J Leach
- National Centre for Naturopathic Medicine, Southern Cross University, Military Road, Lismore, NSW, 2480, Australia.
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Mikhael EM, Ong SC, Hussain SA. Cost-Effectiveness Analysis of the Culturally Developed Diabetes Self-Management Education and Support Program among Type 2 Diabetes Mellitus Patients in Iraq. JOURNAL OF PHARMACY AND BIOALLIED SCIENCES 2023; 15:49-56. [PMID: 37313544 PMCID: PMC10259737 DOI: 10.4103/jpbs.jpbs_767_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 06/22/2022] [Accepted: 01/17/2023] [Indexed: 06/15/2023] Open
Abstract
Background Diabetes mellitus (DM) is a chronic disease associated with a major economic burden on persons, health care systems, and countries. Diabetes self-management education and support (DSME(S)) programs are highly effective method in the management of T2DM patients. Therefore, this study aimed to determine the cost-effectiveness of the developed culturally-specific DSME(S) program regarding glycemic control, lipid profile, and body weight for Iraqi type 2 DM patients. Methods A randomized controlled clinical trial design was used to assess the cost-effectiveness of the culturally-specific DSME(S) program from the perspective of health care providers. In the cost-effectiveness analysis (CEA), cost per patient and clinical outcomes over 6 months were compared between the intervention and control group. Incremental cost-effectiveness ratios (ICERs) were expressed as cost per unit improvement in glycosylated hemoglobin (HbA1c), fasting blood glucose (FBG), total cholesterol (TC), low-density lipoprotein-cholesterol (LDL-C), high density lipoprotein- cholesterol (HDL-C), systolic blood pressure (SBP), diastolic blood pressure (DBP), and body weight. Results The effectiveness of most outcomes was better in the intervention group compared with the control group. The ICER per unit improvement in HbA1c, SBP, DBP, serum TC, and TG levels was <1 of the minimum CET compared with the control group, thus meeting the definition of being highly cost-effective. Conclusion The currently developed DSME(S) was cost effective method to improve glycemic control, blood pressure, TC, and TG for T2DM patients in Iraq.
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Affiliation(s)
- Ehab Mudher Mikhael
- Clinical Pharmacy Department – College of Pharmacy – University of Baghdad, Baghdad, Iraq
| | - Siew Chin Ong
- School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
| | - Saad Abdulrahman Hussain
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Al-Rafidain University College, Baghdad, Iraq
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Dorr DA, Richardson JE, Bobo M, D'Autremont C, Rope R, Dunne MJ, Kassakian SZ, Samal L. Provider Perspectives on Patient- and Provider-Facing High Blood Pressure Clinical Decision Support. Appl Clin Inform 2022; 13:1131-1140. [PMID: 35977714 PMCID: PMC9713301 DOI: 10.1055/a-1926-0199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 08/11/2022] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Hypertension, persistent high blood pressures (HBP) leading to chronic physiologic changes, is a common condition that is a major predictor of heart attacks, strokes, and other conditions. Despite strong evidence, care teams and patients are inconsistently adherent to HBP guideline recommendations. Patient-facing clinical decision support (CDS) could help improve recommendation adherence but must also be acceptable to clinicians and patients. OBJECTIVE This study aimed to partly address the challenge of developing a patient-facing CDS application, we sought to understand provider variations and rationales related to HBP guideline recommendations and perceptions regarding patient role and use of digital tools. METHODS We engaged hypertension experts and primary care respondents to iteratively develop and implement a pilot survey and a final survey which presented five clinical cases that queried clinicians' attitudes related to actions; variations; prioritization; patient input; importance; and barriers for HBP diagnosis, monitoring, and treatment. Analysis of Likert's scale scores was descriptive with content analysis for free-text answers. RESULTS Fifteen hypertension experts and 14 providers took the pilot and final version of the surveys, respectively. The majority (>80%) of providers felt the recommendations were important, yet found them difficult to follow-up to 90% of the time. Perceptions of relative amounts of patient input and patient work for effective HBP management ranged from 22 to 100%. Stated reasons for variation included adverse effects of treatment, patient comorbidities, shared decision-making, and health care cost and access issues. Providers were generally positive toward patient use of electronic CDS applications but worried about access to health care, nuance of recommendations, and patient understanding of the tools. CONCLUSION At baseline, provider management of HBP is heterogeneous. Providers were accepting of patient-facing CDS but reported preferences for that CDS to capture the complexity and nuance of guideline recommendations.
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Affiliation(s)
- David A. Dorr
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, United States
| | - Joshua E. Richardson
- Center for Health Informatics and Evidence Synthesis, RTI International, Chicago, Illinois, United States
| | - Michelle Bobo
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, United States
| | - Christopher D'Autremont
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, United States
| | - Robert Rope
- Department of Medicine, Oregon Health and Science University, Portland, Oregon, United States
| | - MJ Dunne
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, United States
| | - Steven Z. Kassakian
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, United States
- Department of Medicine, Oregon Health and Science University, Portland, Oregon, United States
| | - Lipika Samal
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States
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9
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Chen W, Howard K, Gorham G, O'Bryan CM, Coffey P, Balasubramanya B, Abeyaratne A, Cass A. Design, effectiveness, and economic outcomes of contemporary chronic disease clinical decision support systems: a systematic review and meta-analysis. J Am Med Inform Assoc 2022; 29:1757-1772. [PMID: 35818299 PMCID: PMC9471723 DOI: 10.1093/jamia/ocac110] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/21/2022] [Accepted: 06/25/2022] [Indexed: 01/10/2023] Open
Abstract
Objectives Electronic health record-based clinical decision support (CDS) has the potential to improve health outcomes. This systematic review investigates the design, effectiveness, and economic outcomes of CDS targeting several common chronic diseases. Material and Methods We conducted a search in PubMed (Medline), EBSCOHOST (CINAHL, APA PsychInfo, EconLit), and Web of Science. We limited the search to studies from 2011 to 2021. Studies were included if the CDS was electronic health record-based and targeted one or more of the following chronic diseases: cardiovascular disease, diabetes, chronic kidney disease, hypertension, and hypercholesterolemia. Studies with effectiveness or economic outcomes were considered for inclusion, and a meta-analysis was conducted. Results The review included 76 studies with effectiveness outcomes and 9 with economic outcomes. Of the effectiveness studies, 63% described a positive outcome that favored the CDS intervention group. However, meta-analysis demonstrated that effect sizes were heterogenous and small, with limited clinical and statistical significance. Of the economic studies, most full economic evaluations (n = 5) used a modeled analysis approach. Cost-effectiveness of CDS varied widely between studies, with an estimated incremental cost-effectiveness ratio ranging between USD$2192 to USD$151 955 per QALY. Conclusion We summarize contemporary chronic disease CDS designs and evaluation results. The effectiveness and cost-effectiveness results for CDS interventions are highly heterogeneous, likely due to differences in implementation context and evaluation methodology. Improved quality of reporting, particularly from modeled economic evaluations, would assist decision makers to better interpret and utilize results from these primary research studies. Registration PROSPERO (CRD42020203716)
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Affiliation(s)
- Winnie Chen
- Menzies School of Health Research, Charles Darwin University, Casuarina, Northern Territory, Australia
| | - Kirsten Howard
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Gillian Gorham
- Menzies School of Health Research, Charles Darwin University, Casuarina, Northern Territory, Australia
| | - Claire Maree O'Bryan
- Menzies School of Health Research, Charles Darwin University, Casuarina, Northern Territory, Australia
| | - Patrick Coffey
- Menzies School of Health Research, Charles Darwin University, Casuarina, Northern Territory, Australia
| | - Bhavya Balasubramanya
- Menzies School of Health Research, Charles Darwin University, Casuarina, Northern Territory, Australia
| | - Asanga Abeyaratne
- Menzies School of Health Research, Charles Darwin University, Casuarina, Northern Territory, Australia
| | - Alan Cass
- Menzies School of Health Research, Charles Darwin University, Casuarina, Northern Territory, Australia
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10
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Conducting a representative national randomized control trial of tailored clinical decision support for nurses remotely: Methods and implications. Contemp Clin Trials 2022; 118:106712. [PMID: 35235823 PMCID: PMC9851662 DOI: 10.1016/j.cct.2022.106712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 01/12/2022] [Accepted: 02/16/2022] [Indexed: 01/22/2023]
Abstract
Clinical Decision Support (CDS) systems, patient specific evidence delivered to clinicians via the electronic health record (EHR) at the right time and in the right format, has the potential to improve patient outcomes. Unfortunately, outcomes of CDS research are mixed. A potential cause lies in its testing. Many CDS are implemented in practice without sufficient testing, potentially leading to patient harm. When testing is conducted, most research has focused on "what" evidence to provide with little attention to the impact of the CDS display format (e.g., textual, graphical) on the user. In an adequately powered randomized control trial with 220 hospital based registered nurses, we will compare 4 randomly assigned CDS format groups (text, text table, text graphs, tailored to subject's graph literacy score) for effects on decision time and simulated patient outcomes. We recruit using state based professional registries, which allows access to participants from multiple institutions across the nation. We use online survey software (REDCap) for efficient study workflow including screening, informed consent documentation, pre-experiment demographic data collection including a graph literacy questionnaire used in randomization. The CDS prototype is accessed via a web app and the simulation-based experiment is conducted remotely at a subject's local computer using video-conferencing software. Also included are 6 post intervention surveys to assess cognitive workload, usability, numeracy, format preference, CDS utilization rationale, and CDS interpretation. Our methods are replicable and scalable for testing of health information technologies and have the potential to improve the safety and effectiveness of these technologies across disciplines.
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Abstract
Despite considerable progress in tackling cardiovascular disease over the past 50 years, many gaps in the quality of care for cardiovascular disease remain. Multiple missed opportunities have been identified at every step in the prevention and treatment of cardiovascular disease, such as failure to make risk factor modifications, failure to diagnose cardiovascular disease, and failure to use proper evidence based treatments. With the digital transformation of medicine and advances in health information technology, clinical decision support (CDS) tools offer promise to enhance the efficiency and effectiveness of delivery of cardiovascular care. However, to date, the promise of CDS delivering scalable and sustained value for patient care in clinical practice has not been realized. This article reviews the evidence on key emerging questions around the development, implementation, and regulation of CDS with a focus on cardiovascular disease. It first reviews evidence on the effectiveness of CDS on healthcare process and clinical outcomes related to cardiovascular disease and design features associated with CDS effectiveness. It then reviews the barriers encountered during implementation of CDS in cardiovascular care, with a focus on unintended consequences and strategies to promote successful implementation. Finally, it reviews the legal and regulatory environment of CDS with specific examples for cardiovascular disease.
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Affiliation(s)
- Yuan Lu
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Edward R Melnick
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Biostatistics (Health Informatics), Yale School of Public Health, New Haven, CT, USA
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
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12
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Song J, Wang X, Wang B, Gao Y, Liu J, Zhang H, Li X, Li J, Wang JG, Cai J, Herrin J, Armitage J, Krumholz HM, Zheng X. Effectiveness of a clinical decision support system for hypertension management in primary care: study protocol for a pragmatic cluster-randomized controlled trial. Trials 2022; 23:412. [PMID: 35578345 PMCID: PMC9109449 DOI: 10.1186/s13063-022-06374-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 04/29/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Clinical decision support systems (CDSS) are low-cost, scalable tools with the potential to improve guideline-based antihypertensive treatment in primary care, but their effectiveness needs to be tested, especially in low- and middle-income countries such as China. METHODS The Learning Implementation of Guideline-based decision support system for Hypertension Treatment (LIGHT) trial is a pragmatic, four-stage, cluster-randomized trial conducted in 94 primary care sites in China. For each city-based stage, sites are randomly assigned to either implementation of the CDSS for hypertension management (which guides doctors' treatment recommendations based on measured blood pressure and patient characteristics), or usual care. Patients are enrolled during the first 3 months after site randomization and followed for 9 months. The primary outcome is the proportion of hypertension management visits at which guideline-based treatment is provided. In a nested trial conducted within the CDSS, with the patient as the unit of randomization, the LIGHT-ACD trial, patients are randomized to receive different initial mono- or dual-antihypertensive therapy. The primary outcome of the LIGHT-ACD trial is the changes in blood pressure. DISCUSSION The LIGHT trial will provide evidence on the effectiveness of a CDSS for improving guideline adherence for hypertension management in primary care in China. The nested trial, the LIGHT-ACD trial, will provide data on the effect of different initial antihypertensive regimens for blood pressure management in this setting. TRIAL REGISTRATION ClinicalTrials.gov, identifier: LIGHT (NCT03636334) and LIGHT-ACD (NCT03587103). Registered on 3 July 2018.
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Affiliation(s)
- Jiali Song
- grid.415105.40000 0004 9430 5605National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Center for Cardiovascular Diseases, 167 Beilishi Road, Beijing, 100037 China
| | - Xiuling Wang
- grid.415105.40000 0004 9430 5605National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Center for Cardiovascular Diseases, 167 Beilishi Road, Beijing, 100037 China
| | - Bin Wang
- grid.415105.40000 0004 9430 5605National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Center for Cardiovascular Diseases, 167 Beilishi Road, Beijing, 100037 China
| | - Yan Gao
- grid.415105.40000 0004 9430 5605National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Center for Cardiovascular Diseases, 167 Beilishi Road, Beijing, 100037 China
| | - Jiamin Liu
- grid.415105.40000 0004 9430 5605National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Center for Cardiovascular Diseases, 167 Beilishi Road, Beijing, 100037 China
| | - Haibo Zhang
- grid.415105.40000 0004 9430 5605National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Center for Cardiovascular Diseases, 167 Beilishi Road, Beijing, 100037 China
| | - Xi Li
- grid.415105.40000 0004 9430 5605National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Center for Cardiovascular Diseases, 167 Beilishi Road, Beijing, 100037 China
| | - Jing Li
- grid.415105.40000 0004 9430 5605National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Center for Cardiovascular Diseases, 167 Beilishi Road, Beijing, 100037 China
| | - Ji-Guang Wang
- grid.16821.3c0000 0004 0368 8293The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jun Cai
- grid.415105.40000 0004 9430 5605Hypertension Center, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Jeph Herrin
- grid.47100.320000000419368710Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut USA
| | - Jane Armitage
- grid.4991.50000 0004 1936 8948Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford, OX3 7LF UK ,grid.4991.50000 0004 1936 8948MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Harlan M. Krumholz
- grid.16821.3c0000 0004 0368 8293The Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China ,grid.417307.6Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut USA ,grid.47100.320000000419368710Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut USA
| | - Xin Zheng
- National Clinical Research Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, National Center for Cardiovascular Diseases, 167 Beilishi Road, Beijing, 100037, China. .,National Clinical Research Center for Cardiovascular Diseases, Shenzhen, Coronary Artery Disease Center, Fuwai Hospital Chinese Academy of Medical Sciences, Shenzhen, China.
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Garbern SC, Nelson EJ, Nasrin S, Keita AM, Brintz BJ, Gainey M, Badji H, Nasrin D, Howard J, Taniuchi M, Platts-Mills JA, Kotloff KL, Haque R, Levine AC, Sow SO, Alam NH, Leung DT. External validation of a mobile clinical decision support system for diarrhea etiology prediction in children: a multicenter study in Bangladesh and Mali. eLife 2022; 11:72294. [PMID: 35137684 PMCID: PMC8903833 DOI: 10.7554/elife.72294] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 02/05/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Diarrheal illness is a leading cause of antibiotic use for children in low- and middle-income countries. Determination of diarrhea etiology at the point-of-care without reliance on laboratory testing has the potential to reduce inappropriate antibiotic use. Methods: This prospective observational study aimed to develop and externally validate the accuracy of a mobile software application ('App') for the prediction of viral-only etiology of acute diarrhea in children 0-59 months in Bangladesh and Mali. The App used a previously derived and internally validated model consisting of patient-specific ('present patient') clinical variables (age, blood in stool, vomiting, breastfeeding status, and mid-upper arm circumference) as well as location-specific viral diarrhea seasonality curves. The performance of additional models using the 'present patient' data combined with other external data sources including location-specific climate, data, recent patient data, and historical population-based prevalence were also evaluated in secondary analysis. Diarrhea etiology was determined with TaqMan Array Card using episode-specific attributable fraction (AFe) >0.5. Results: Of 302 children with acute diarrhea enrolled, 199 had etiologies above the AFe threshold. Viral-only pathogens were detected in 22% of patients in Mali and 63% in Bangladesh. Rotavirus was the most common pathogen detected (16% Mali; 60% Bangladesh). The present patient + viral seasonality model had an AUC of 0.754 (0.665-0.843) for the sites combined, with calibration-in-the-large α=-0.393 (-0.455 - -0.331) and calibration slope β=1.287 (1.207 - 1.367). By site, the present patient + recent patient model performed best in Mali with an AUC of 0.783 (0.705 - 0.86); the present patient + viral seasonality model performed best in Bangladesh with AUC 0.710 (0.595 - 0.825). Conclusion: The App accurately identified children with high likelihood of viral-only diarrhea etiology. Further studies to evaluate the App's potential use in diagnostic and antimicrobial stewardship are underway. Funding: Funding for this study was provided through grants from the Bill and Melinda Gates Foundation (OPP1198876) and the National Institute of Allergy and Infectious Diseases (R01AI135114). Several investigators were also partially supported by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases (R01DK116163). This investigation was also supported by the University of Utah Population Health Research (PHR) Foundation, with funding in part from the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR002538. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The funders had no role in the study design, data collection, data analysis, interpretation of data, or in the writing or decision to submit the manuscript for publication.
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Affiliation(s)
| | - Eric J Nelson
- Department of Pediatrics, University of Florida, Gainesville, United States
| | - Sabiha Nasrin
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | | | - Ben J Brintz
- Department of Internal Medicine, University of Utah, Salt Lake City, United States
| | - Monique Gainey
- Department of Emergency Medicine, Rhode Island Hospital, Providence, United States
| | - Henry Badji
- Center for Vaccine Development, Bamako, Mali
| | - Dilruba Nasrin
- Center for Vaccine Development and Global Healt, University of Maryland School of Medicine, Baltimore, United States
| | - Joel Howard
- Department of Pediatrics, University of Kentucky, Lexington, United States
| | - Mami Taniuchi
- Department of Medicine, University of Virginia, Charlottesville, United States
| | | | - Karen L Kotloff
- Department of Pediatrics, University of Maryland, Baltimore, United States
| | - Rashidul Haque
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Adam C Levine
- Department of Emergency Medicine, Brown University, Providence, United States
| | - Samba O Sow
- Center for Vaccine Development, Bamako, Mali
| | - Nur Haque Alam
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Daniel T Leung
- Internal Medicine (Infectious Diseases), University of Utah, Salt Lake City, United States
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Teufel A, Binder H. Clinical Decision Support Systems. Visc Med 2021; 37:491-498. [PMID: 35087899 PMCID: PMC8738909 DOI: 10.1159/000519420] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 09/03/2021] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND By combining up-to-date medical knowledge and steadily increasing patient data, a new level of medical care can emerge. SUMMARY AND KEY MESSAGES Clinical decision support systems (CDSSs) are an arising solution to handling rich data and providing them to health care providers in order to improve diagnosis and treatment. However, despite promising examples in many areas, substantial evidence for a thorough benefit of these support solutions is lacking. This may be due to a lack of general frameworks and diverse health systems around the globe. We therefore summarize the current status of CDSSs in medicine but also discuss potential limitations that need to be overcome in order to further foster future development and acceptance.
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Affiliation(s)
- Andreas Teufel
- Department of Medicine II, Section of Hepatology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Clinical Cooperation Unit Healthy Metabolism, Center for Preventive Medicine and Digital Health Baden-Württemberg (CPDBW), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Harald Binder
- Institute of Medical Biometry and Statistics (IMBI), Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
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15
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Vijayakumar VK, Mustafa T, Nore BK, Garatun-Tjeldstø KY, Næss Ø, Johansen OE, Aarli BB. Role of a Digital Clinical Decision-Support System in General Practitioners' Management of COPD in Norway. Int J Chron Obstruct Pulmon Dis 2021; 16:2327-2336. [PMID: 34413641 PMCID: PMC8370595 DOI: 10.2147/copd.s319753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 07/19/2021] [Indexed: 11/23/2022] Open
Abstract
Background The study investigated if a web-based clinical decision–support system (CDSS) tool would improve general practitioners’ (GPs) accuracy of diagnosis and classification of patients with chronic obstructive pulmonary disease (COPD), and whether nonpharmacological and pharmacological treatment would be better aligned with the COPD guidelines. Methods GPs were randomized to either a single use of the CDSS or continuing standard of care. The clinical recommendations of the CDSS were based on the GOLD guidelines and provided suggestions for treatment and management of COPD. Data were collected digitally from GPs and patients in both groups using a tablet computer. A follow-up questionnaire was sent to the GPs 1 year after the conclusion of the study. Results A total of 25 GPs (31% women, mean age 41 years) participated, 12 randomized to using the CDSS tool and 13 followed standard of care when assessing their next five to ten COPD patients. In sum, 149 patients with presumed COPD were included (88 CDSS group, 61 standard-of-care group). In the CDSS group, no COPD misdiagnoses occurred, 98% received vaccine recommendations, and all smokers (n=39) received smoking-cessation advice. The standard-of-care group had 23% misdiagnosis (P<0.001), only 67% received vaccine recommendations (P<0.001), and 87% smoking-cessation advice (P=0.022. All told, 31% of patients did not receive medication as recommended according to guidelines, with no significant differences between the groups. GPs rated the CDSS as very useful. Mean usage time was 3 minutes, 26 seconds. A majority (13 of 19, 68%) of the GPs continued using the CDSS after the conclusion of the study. CAT score identified twice as many patients as having more symptoms than the mMRC, indicating the added value of the multi-item questionnaire. Conclusion Use of the CDSS was associated with preventing misdiagnosis of COPD and improved adherence to recommended nonpharmacological measures, but a single use did not improve pharmacological treatment considerations. ![]()
Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use: https://youtu.be/6_qLDwt1JSc
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Affiliation(s)
- Varun Kumar Vijayakumar
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Tehmina Mustafa
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway
| | | | | | | | - Odd Erik Johansen
- Department of Medical Research, Bærum Hospital, Vestre Viken Hospital Trust, Gjettum, Norway
| | - Bernt Bøgvald Aarli
- Department of Thoracic Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
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16
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Dorr DA, D'Autremont C, Pizzimenti C, Weiskopf N, Rope R, Kassakian S, Richardson JE, McClure R, Eisenberg F. Assessing Data Adequacy for High Blood Pressure Clinical Decision Support: A Quantitative Analysis. Appl Clin Inform 2021; 12:710-720. [PMID: 34348408 DOI: 10.1055/s-0041-1732401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE This study examines guideline-based high blood pressure (HBP) and hypertension recommendations and evaluates the suitability and adequacy of the data and logic required for a Fast Healthcare Interoperable Resources (FHIR)-based, patient-facing clinical decision support (CDS) HBP application. HBP is a major predictor of adverse health events, including stroke, myocardial infarction, and kidney disease. Multiple guidelines recommend interventions to lower blood pressure, but implementation requires patient-centered approaches, including patient-facing CDS tools. METHODS We defined concept sets needed to measure adherence to 71 recommendations drawn from eight HBP guidelines. We measured data quality for these concepts for two cohorts (HBP screening and HBP diagnosed) from electronic health record (EHR) data, including four use cases (screening, nonpharmacologic interventions, pharmacologic interventions, and adverse events) for CDS. RESULTS We identified 102,443 people with diagnosed and 58,990 with undiagnosed HBP. We found that 21/35 (60%) of required concept sets were unused or inaccurate, with only 259 (25.3%) of 1,101 codes used. Use cases showed high inclusion (0.9-11.2%), low exclusion (0-0.1%), and missing patient-specific context (up to 65.6%), leading to data in 2/4 use cases being insufficient for accurate alerting. DISCUSSION Data quality from the EHR required to implement recommendations for HBP is highly inconsistent, reflecting a fragmented health care system and incomplete implementation of standard terminologies and workflows. Although imperfect, data were deemed adequate for two test use cases. CONCLUSION Current data quality allows for further development of patient-facing FHIR HBP tools, but extensive validation and testing is required to assure precision and avoid unintended consequences.
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Affiliation(s)
- David A Dorr
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, United States
| | - Christopher D'Autremont
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, United States
| | - Christie Pizzimenti
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, United States
| | - Nicole Weiskopf
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, United States
| | - Robert Rope
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, United States
| | - Steven Kassakian
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, United States
| | | | - Rob McClure
- MD Partners, Lafayette, Colorado, United States
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17
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Usmanova G, Lalchandani K, Srivastava A, Joshi CS, Bhatt DC, Bairagi AK, Jain Y, Afzal M, Dhoundiyal R, Benawri J, Chaudhary T, Mishra A, Wadhwa R, Sridhar P, Bahl N, Gaikwad P, Sood B. The role of digital clinical decision support tool in improving quality of intrapartum and postpartum care: experiences from two states of India. BMC Pregnancy Childbirth 2021; 21:278. [PMID: 33827459 PMCID: PMC8028806 DOI: 10.1186/s12884-021-03710-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 03/09/2021] [Indexed: 11/10/2022] Open
Abstract
Background Computerized clinical decision support (CDSS) –digital information systems designed to improve clinical decision making by providers – is a promising tool for improving quality of care. This study aims to understand the uptake of ASMAN application (defined as completeness of electronic case sheets), the role of CDSS in improving adherence to key clinical practices and delivery outcomes. Methods We have conducted secondary analysis of program data (government data) collected from 81 public facilities across four districts each in two sates of Madhya Pradesh and Rajasthan. The data collected between August –October 2017 (baseline) and the data collected between December 2019 – March 2020 (latest) was analysed. The data sources included: digitized labour room registers, case sheets, referral and discharge summary forms, observation checklist and complication format. Descriptive, univariate and multivariate and interrupted time series regression analyses were conducted. Results The completeness of electronic case sheets was low at postpartum period (40.5%), and in facilities with more than 300 deliveries a month (20.9%). In multivariate logistic regression analysis, the introduction of technology yielded significant improvement in adherence to key clinical practices. We have observed reduction in fresh still births rates and asphyxia, but these results were not statistically significant in interrupted time series analysis. However, our analysis showed that identification of maternal complications has increased over the period of program implementation and at the same time referral outs decreased. Conclusions Our study indicates CDSS has a potential to improve quality of intrapartum care and delivery outcome. Future studies with rigorous study design is required to understand the impact of technology in improving quality of maternity care. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-03710-y.
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Affiliation(s)
- Gulnoza Usmanova
- Jhpiego-An Affiliate of Johns Hopkins University, New Delhi, 110020, India
| | | | - Ashish Srivastava
- Jhpiego-An Affiliate of Johns Hopkins University, New Delhi, 110020, India
| | | | | | | | - Yashpal Jain
- Jhpiego-An Affiliate of Johns Hopkins University, New Delhi, 110020, India
| | - Mohammed Afzal
- Jhpiego-An Affiliate of Johns Hopkins University, New Delhi, 110020, India
| | - Rashmi Dhoundiyal
- Jhpiego-An Affiliate of Johns Hopkins University, New Delhi, 110020, India
| | - Jyoti Benawri
- Jhpiego-An Affiliate of Johns Hopkins University, New Delhi, 110020, India
| | - Tarun Chaudhary
- Department of Health and Family Welfare, NHM, Jaipur, Rajasthan, 302001, India
| | - Archana Mishra
- Maternal Health, NHM, Bhopal, Madhya Pradesh, 462011, India
| | - Rajni Wadhwa
- Project Management Unit, ASMAN: Alliance for Saving Mothers and Newborns, Mumbai, 400021, India
| | | | - Nupur Bahl
- Reliance Foundation, Mumbai, 400021, India
| | | | - Bulbul Sood
- Jhpiego-An Affiliate of Johns Hopkins University, New Delhi, 110020, India
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18
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Schutte AE, Srinivasapura Venkateshmurthy N, Mohan S, Prabhakaran D. Hypertension in Low- and Middle-Income Countries. Circ Res 2021; 128:808-826. [PMID: 33793340 DOI: 10.1161/circresaha.120.318729] [Citation(s) in RCA: 96] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In recent decades low- and middle-income countries (LMICs) have been witnessing a significant shift toward raised blood pressure; yet in LMICs, only 1 in 3 are aware of their hypertension status, and ≈8% have their blood pressure controlled. This rising burden widens the inequality gap, contributes to massive economic hardships of patients and carers, and increases costs to the health system, facing challenges such as low physician-to-patient ratios and lack of access to medicines. Established risk factors include unhealthy diet (high salt and low fruit and vegetable intake), physical inactivity, tobacco and alcohol use, and obesity. Emerging risk factors include pollution (air, water, noise, and light), urbanization, and a loss of green space. Risk factors that require further in-depth research are low birth weight and social and commercial determinants of health. Global actions include the HEARTS technical package and the push for universal health care. Promising research efforts highlight that successful interventions are feasible in LMICs. These include creation of health-promoting environments by introducing salt-reduction policies and sugar and alcohol tax; implementing cost-effective screening and simplified treatment protocols to mitigate treatment inertia; pooled procurement of low-cost single-pill combination therapy to improve adherence; increasing access to telehealth and mHealth (mobile health); and training health care staff, including community health workers, to strengthen team-based care. As the blood pressure trajectory continues creeping upward in LMICs, contextual research on effective, safe, and cost-effective interventions is urgent. New emergent risk factors require novel solutions. Lowering blood pressure in LMICs requires urgent global political and scientific priority and action.
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Affiliation(s)
- Aletta E Schutte
- School of Population Health, University of New South Wales, Sydney, Australia (A.E.S.).,George Institute for Global Health, Sydney, NSW, Australia (A.E.S.).,Hypertension in Africa Research Team, MRC Unit for Hypertension and Cardiovascular Disease, North-West University, Potchefstroom, South Africa (A.E.S.)
| | - Nikhil Srinivasapura Venkateshmurthy
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurgaon (N.S.V., S.M., D.P.).,Centre for Chronic Disease Control, New Delhi, India (N.S.V., S.M., D.P.).,School of Exercise and Nutrition Sciences (N.S.V.), Deakin University, Burwood, VIC, Australia
| | - Sailesh Mohan
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurgaon (N.S.V., S.M., D.P.).,Centre for Chronic Disease Control, New Delhi, India (N.S.V., S.M., D.P.).,Faculty of Health (S.M.), Deakin University, Burwood, VIC, Australia
| | - Dorairaj Prabhakaran
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurgaon (N.S.V., S.M., D.P.).,Centre for Chronic Disease Control, New Delhi, India (N.S.V., S.M., D.P.).,Department of Epidemiology, London School of Hygiene and Tropical Medicine, United Kingdom (D.P.)
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19
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Venkateshmurthy NS, Mohan S, Singh K, Prabhakran D, Huffman MD. Implementation Research to Improve Cardiovascular Disease Management in India's Heterogeneous Primary Healthcare System. NATIONAL MEDICAL JOURNAL OF INDIA 2021; 33:65-68. [PMID: 33753632 DOI: 10.4103/0970-258x.310986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
| | - Sailesh Mohan
- Centre for Chronic Disease Control, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Deakin University, Burwood, Victoria, Australia
| | - Kavita Singh
- Centre for Chronic Disease Control, New Delhi, India
| | - Dorairaj Prabhakran
- Centre for Chronic Disease Control, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Department of Epidemiology London School of Hygiene and Tropical Medicine, UK
| | - Mark D Huffman
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, USA; Food Policy Division, The George Institute for Global Health, University of New South Wales, Sydney, Australia
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20
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Acceptability and Barriers to Use of the ASMAN Provider-Facing Electronic Platform for Peripartum Care in Public Facilities in Madhya Pradesh and Rajasthan, India: A Qualitative Study Using the Technology Acceptance Model-3. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17228333. [PMID: 33187163 PMCID: PMC7696182 DOI: 10.3390/ijerph17228333] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 10/09/2020] [Indexed: 12/15/2022]
Abstract
The evolving field of mobile health (mHealth) is revolutionizing collection, management, and quality of clinical data in health systems. Particularly in low- and middle-income countries (LMICs), mHealth approaches for clinical decision support and record-keeping offer numerous potential advantages over paper records and in-person training and supervision. We conducted a content analysis of qualitative in-depth interviews using the Technology Acceptance Model 3 (TAM-3) to explore perspectives of providers and health managers in Madhya Pradesh and Rajasthan, India who were using the ASMAN (Alliance for Saving Mothers and Newborns) platform, a package of mHealth technologies to support management during the peripartum period. Respondents uniformly found ASMAN easy to use and felt it improved quality of care, reduced referral rates, ensured timely referral when needed, and aided reporting requirements. The TAM-3 model captured many determinants of reported respondent use behavior, including shifting workflow and job performance. However, some barriers to ASMAN digital platform use were structural and reported more often in facilities where ASMAN use was less consistent; these affect long-term impact, sustainability, and scalability of ASMAN and similar mHealth interventions. The transitioning of the program to the government, ensuring availability of dedicated funds, human resource support, and training and integration with government health information systems will ensure the sustainability of ASMAN.
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21
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Michalakeas C, Katsi V, Soulaidopoulos S, Dilaveris P, Vrachatis D, Lekakis I, Vlachopoulos C, Tsioufis K, Tousoulis D. Mobile phones and applications in the management of patients with arterial hypertension. AMERICAN JOURNAL OF CARDIOVASCULAR DISEASE 2020; 10:419-431. [PMID: 33224593 PMCID: PMC7675159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 09/06/2020] [Indexed: 06/11/2023]
Abstract
The use of mobile health (mHealth) in the field of medicine is constantly evolving and advancing. Arterial hypertension, a major modifiable cardiovascular risk factor with a high prevalence in the general population, frequently remains underdiagnosed and thus untreated. Furthermore, the majority of hypertensive patients fail to achieve blood pressure target levels. The purpose of this review is to identify and evaluate current use of mHealth strategies, with focus on mobile phones, smartphones and applications, in the management of patients with arterial hypertension. Current mobile technology has the capacity to inform and motivate the general public for timely diagnosis of hypertension, to facilitate communication between physicians and patients, to aid in the monitoring of blood pressure levels and the optimization of treatment and to promote, in general, a healthy lifestyle and assist in the management of other cardiovascular risk factors. There is potential for positive impact of mHealth technology in the management of arterial hypertension, as well as probable detrimental effects that warrant caution. The research in this field is ongoing and future well-conducted studies are needed in order to establish the use of mobile technology in arterial hypertension management.
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Affiliation(s)
- Christos Michalakeas
- Second Department of Cardiology, Attikon Hospital, Athens Medical School, National and Kapodistrian University of AthensAthens, Greece
| | - Vasiliki Katsi
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, National and Kapodistrian University of AthensGreece
| | - Stergios Soulaidopoulos
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, National and Kapodistrian University of AthensGreece
| | - Polychronis Dilaveris
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, National and Kapodistrian University of AthensGreece
| | - Dimitrios Vrachatis
- Department of Cardiology, General Hospital of Athens “G. Gennimatas”Athens, Greece
| | - Ioannis Lekakis
- Second Department of Cardiology, Attikon Hospital, Athens Medical School, National and Kapodistrian University of AthensAthens, Greece
| | - Charalambos Vlachopoulos
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, National and Kapodistrian University of AthensGreece
| | - Konstantinos Tsioufis
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, National and Kapodistrian University of AthensGreece
| | - Dimitrios Tousoulis
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, National and Kapodistrian University of AthensGreece
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22
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Kostova D, Spencer G, Moran AE, Cobb LK, Husain MJ, Datta BK, Matsushita K, Nugent R. The cost-effectiveness of hypertension management in low-income and middle-income countries: a review. BMJ Glob Health 2020; 5:e002213. [PMID: 32912853 PMCID: PMC7484861 DOI: 10.1136/bmjgh-2019-002213] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 05/31/2020] [Accepted: 06/15/2020] [Indexed: 01/11/2023] Open
Abstract
Hypertension in low-income and middle-income countries (LMICs) is largely undiagnosed and uncontrolled, representing an untapped opportunity for public health improvement. Implementation of hypertension control strategies in low-resource settings depends in large part on cost considerations. However, evidence on the cost-effectiveness of hypertension interventions in LMICs is varied across geographical, clinical and evaluation contexts. We conducted a comprehensive search for published economic evaluations of hypertension treatment programmes in LMICs. The search identified 71 articles assessing a wide range of hypertension intervention designs and cost components, of which 42 studies across 15 countries reported estimates of cost-effectiveness. Although comparability of results was limited due to heterogeneity in the interventions assessed, populations studied, costs and study quality score, most interventions that reported cost per averted disability-adjusted life-year (DALY) were cost-effective, with costs per averted DALY not exceeding national income thresholds. Programme elements that may reduce cost-effectiveness included screening for hypertension at younger ages, addressing prehypertension, or treating patients at lower cardiovascular disease risk. Cost-effectiveness analysis could provide the evidence base to guide the initiation and development of hypertension programmes.
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Affiliation(s)
- Deliana Kostova
- Division of Global Health Protection, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Garrison Spencer
- Center for Global Noncommunicable Diseases, RTI International, Seattle, Washington, USA
| | - Andrew E Moran
- Resolve to Save Lives, an initiative of Vital Strategies, New York, New York, United States
- Columbia University Irving Medical Center, New York, New York, United States
| | - Laura K Cobb
- Resolve to Save Lives, an initiative of Vital Strategies, New York, New York, United States
| | - Muhammad Jami Husain
- Division of Global Health Protection, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Biplab Kumar Datta
- Division of Global Health Protection, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Rachel Nugent
- Center for Global Noncommunicable Diseases, RTI International, Seattle, Washington, USA
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23
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Akkawi ME, Nik Mohamed MH, Md Aris MA. The impact of a multifaceted intervention to reduce potentially inappropriate prescribing among discharged older adults: a before-and-after study. J Pharm Policy Pract 2020; 13:39. [PMID: 32695426 PMCID: PMC7367269 DOI: 10.1186/s40545-020-00236-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 05/31/2020] [Indexed: 01/02/2023] Open
Abstract
Background Potentially inappropriate prescribing (PIP) is associated with the incidence of adverse drug reactions, drug-related hospitalization and other negative outcomes in older adults. After hospitalization, older adults might be discharged with several types of PIPs. Studies have found that the lack of healthcare professionals' (HCPs) knowledge regarding PIP is one of the major contributing factors in this issue. The purpose of this study is to investigate the impact of a multifaceted intervention on physicians' and clinical pharmacists' behavior regarding potentially inappropriate medication (PIM) and potential prescribing omission (PPO) among hospitalized older adults. Methods This is a before-and-after study that took place in a tertiary Malaysian hospital. Discharge medications of patients ≥65 years old were reviewed to identify PIMs/PPOs using version 2 of the STOPP/START criteria. The prevalence and pattern of PIM/PPO before and after the intervention were compared. The intervention targeted the physicians and clinical pharmacists and it consisted of academic detailing and a newly developed smartphone application (app). Results The study involved 240 patients before (control group) and 240 patients after the intervention. The prevalence of PIM was 22% and 27% before and after the intervention, respectively (P = 0.213). The prevalence of PPO in the intervention group was significantly lower than that in the control group (42% Vs. 53.3%); P = 0.014. This difference remained statistically significant after controlling for other variables (P = 0.015). The intervention was effective in reducing the two most common PPOs; the omission of vitamin D supplements in patients with a history of falls (P = 0.001) and the omission of angiotensin converting enzyme inhibitor in patients with coronary artery disease (P = 0.03). Conclusions The smartphone app coupled with academic detailing was effective in reducing the prevalence of PPO at discharge. However, it did not significantly affect the prevalence or pattern of PIM.
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Affiliation(s)
- Muhammad Eid Akkawi
- Department of Pharmacy Practice, Faculty of Pharmacy, International Islamic University Malaysia, Kuantan, Malaysia
| | - Mohamad Haniki Nik Mohamed
- Department of Pharmacy Practice, Faculty of Pharmacy, International Islamic University Malaysia, Kuantan, Malaysia
| | - Mohd Aznan Md Aris
- Department of Family Medicine & Non-Communicable Disease Research Unit, Faculty of Medicine, International Islamic University Malaysia, Kuantan, Malaysia
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24
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Ye X, Zeng QT, Facelli JC, Brixner DI, Conway M, Bray BE. Predicting Optimal Hypertension Treatment Pathways Using Recurrent Neural Networks. Int J Med Inform 2020; 139:104122. [PMID: 32339929 PMCID: PMC10490557 DOI: 10.1016/j.ijmedinf.2020.104122] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 03/13/2020] [Accepted: 03/18/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND In ambulatory care settings, physicians largely rely on clinical guidelines and guideline-based clinical decision support (CDS) systems to make decisions on hypertension treatment. However, current clinical evidence, which is the knowledge base of clinical guidelines, is insufficient to support definitive optimal treatment. OBJECTIVE The goal of this study is to test the feasibility of using deep learning predictive models to identify optimal hypertension treatment pathways for individual patients, based on empirical data available from an electronic health record database. MATERIALS AND METHODS This study used data on 245,499 unique patients who were initially diagnosed with essential hypertension and received anti-hypertensive treatment from January 1, 2001 to December 31, 2010 in ambulatory care settings. We used recurrent neural networks (RNN), including long short-term memory (LSTM) and bi-directional LSTM, to create risk-adapted models to predict the probability of reaching the BP control targets associated with different BP treatment regimens. The ratios for the training set, the validation set, and the test set were 6:2:2. The samples for each set were independently randomly drawn from individual years with corresponding proportions. RESULTS The LSTM models achieved high accuracy when predicting individual probability of reaching BP goals on different treatments: for systolic BP (<140 mmHg), diastolic BP (<90 mmHg), and both systolic BP and diastolic BP (<140/90 mmHg), F1-scores were 0.928, 0.960, and 0.913, respectively. CONCLUSIONS The results demonstrated the potential of using predictive models to select optimal hypertension treatment pathways. Along with clinical guidelines and guideline-based CDS systems, the LSTM models could be used as a powerful decision-support tool to form risk-adapted, personalized strategies for hypertension treatment plans, especially for difficult-to-treat patients.
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Affiliation(s)
- Xiangyang Ye
- Department of Biomedical Informatics, The University of Utah, 421 Wakara Way, Suite 140, Salt Lake City, UT, 84108, USA.
| | - Qing T Zeng
- Department of Biomedical Informatics, The University of Utah, 421 Wakara Way, Suite 140, Salt Lake City, UT, 84108, USA; Department of Clinical Research and Leadership, The George Washington University, 2600 Virginia Ave., NW, First Floor, Washington DC, 20037, USA
| | - Julio C Facelli
- Department of Biomedical Informatics, The University of Utah, 421 Wakara Way, Suite 140, Salt Lake City, UT, 84108, USA
| | - Diana I Brixner
- Department of Pharmacotherapy, The University of Utah, 30 South 2000 East, Salt Lake City, UT, 84108, USA
| | - Mike Conway
- Department of Biomedical Informatics, The University of Utah, 421 Wakara Way, Suite 140, Salt Lake City, UT, 84108, USA
| | - Bruce E Bray
- Department of Biomedical Informatics, The University of Utah, 421 Wakara Way, Suite 140, Salt Lake City, UT, 84108, USA
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Satish P, Khetan A, Barbhaya D, Agarwal M, Madan Mohan SK, Josephson R, Webel AR. A qualitative study of facilitators and barriers to cardiovascular risk factor control in a semiurban population in India. J Family Med Prim Care 2019; 8:3773-3778. [PMID: 31879612 PMCID: PMC6924214 DOI: 10.4103/jfmpc.jfmpc_492_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Revised: 08/22/2019] [Accepted: 09/05/2019] [Indexed: 12/13/2022] Open
Abstract
Cardiovascular (CV) risk factors like diabetes and hypertension are poorly controlled in both rural and urban India. This study was designed to identify the reasons for suboptimal control in a semiurban population in India. A total of 70 participants from the Study to Expand Heart Associated Treatments (SEHAT) trial, conducted in West Bengal, India. We qualitatively examined perspectives regarding CV risk factor control using focus group discussions based on the theory of reasoned action. Qualitative content analysis was used to analyze prevailing themes. Participants demonstrated a generalized knowledge of healthy lifestyle practices but lacked insight into disease-specific prevention methods. We further noticed significant gaps in the translation of existing knowledge into behavior. While personal and systemic barriers exist, factors like high patient motivation and a deep sense of trust in providers can potentially be harnessed to improve risk factor control in the community. We identified key facilitators and barriers to CV risk factor control in the community using a knowledge attitude behavior approach. Our findings provide direction for the development of community-based CV risk reduction models.
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Affiliation(s)
- Priyanka Satish
- Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Aditya Khetan
- Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
- Department of Cardiovascular Medicine, Case Western Reserve University School of Medicine, Cleveland, OH 44122, USA
| | - Dweep Barbhaya
- Department of Pharmacology, Seth G S Medical College, Mumbai, Maharashtra, India
| | - Manyoo Agarwal
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Sri Krishna Madan Mohan
- Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
- Department of Cardiovascular Medicine, Case Western Reserve University School of Medicine, Cleveland, OH 44122, USA
| | - Richard Josephson
- Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA
- Department of Cardiovascular Medicine, Case Western Reserve University School of Medicine, Cleveland, OH 44122, USA
| | - Allison R. Webel
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH 44122, USA
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Dodd R, Palagyi A, Jan S, Abdel-All M, Nambiar D, Madhira P, Balane C, Tian M, Joshi R, Abimbola S, Peiris D. Organisation of primary health care systems in low- and middle-income countries: review of evidence on what works and why in the Asia-Pacific region. BMJ Glob Health 2019; 4:e001487. [PMID: 31478026 PMCID: PMC6703302 DOI: 10.1136/bmjgh-2019-001487] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 06/15/2019] [Accepted: 06/23/2019] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION This paper synthesises evidence on the organisation of primary health care (PHC) service delivery in low-income and middle-income countries (LMICs) in the Asia Pacific and identifies evidence of effective approaches and pathways of impact in this region. METHODS We developed a conceptual framework describing key inputs and outcomes of PHC as the basis of a systematic review. We searched exclusively for intervention studies from LMICs of the Asia-Pacific region in an effort to identify 'what works' to improve the coverage, quality, efficiency, equity and responsiveness of PHC. We conducted a narrative synthesis to identify key characteristics of successful interventions. RESULTS From an initial list of 3001 articles, we selected 153 for full-text review and included 111. We found evidence on the impact of non-physician health workers (NPHWs) on coverage and quality of care, though better integration with other PHC services is needed. Community-based services are most effective when well integrated through functional referral systems and supportive supervision arrangements, and have a reliable supply of medicines. Many studies point to the importance of community engagement in improving service demand. Few studies adopted a 'systems' lens or adequately considered long-term costs or implementation challenges. CONCLUSION Based on our findings, we suggest five areas where more practical knowledge and guidance is needed to support PHC systems strengthening: (1) NPHW workforce development; (2) integrating non-communicable disease prevention and control into the basic package of care; (3) building managerial capacity; (4) institutionalising community engagement; (5) modernising PHC information systems.
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Affiliation(s)
- Rebecca Dodd
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Anna Palagyi
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- The University of Sydney School of Public Health, Faculty of Medicine and Health, Sydney, NSW, Australia
| | - Marwa Abdel-All
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Devaki Nambiar
- The George Institute for Global Health, New Delhi, India
| | | | - Christine Balane
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Maoyi Tian
- The George Institute for Global Health, Beijing, China
| | - Rohina Joshi
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- The University of Sydney School of Public Health, Faculty of Medicine and Health, Sydney, NSW, Australia
- The George Institute for Global Health, New Delhi, India
| | - Seye Abimbola
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- The University of Sydney School of Public Health, Faculty of Medicine and Health, Sydney, NSW, Australia
| | - David Peiris
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
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Groenhof TKJ, Asselbergs FW, Groenwold RHH, Grobbee DE, Visseren FLJ, Bots ML. The effect of computerized decision support systems on cardiovascular risk factors: a systematic review and meta-analysis. BMC Med Inform Decis Mak 2019; 19:108. [PMID: 31182084 PMCID: PMC6558725 DOI: 10.1186/s12911-019-0824-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 05/20/2019] [Indexed: 12/21/2022] Open
Abstract
Background Cardiovascular risk management (CVRM) is notoriously difficult because of multi-morbidity and the different phenotypes and severities of cardiovascular disease. Computerized decision support systems (CDSS) enable the clinician to integrate the latest scientific evidence and patient information into tailored strategies. The effect on cardiovascular risk factor management is yet to be confirmed. Methods We performed a systematic review and meta-analysis evaluating the effects of CDSS on CVRM, defined as the change in absolute values and attainment of treatment goals of systolic blood pressure (SBP), low density lipoprotein cholesterol (LDL-c) and HbA1c. Also, CDSS characteristics related to more effective CVRM were identified. Eligible articles were methodologically appraised using the Cochrane risk of bias tool. We calculated mean differences, relative risks, and if appropriate (I2 < 70%), pooled the results using a random-effects model. Results Of the 14,335 studies identified, 22 were included. Four studies reported on SBP, 3 on LDL-c, 10 on CVRM in patients with type II diabetes and 5 on guideline adherence. The CDSSs varied considerably in technical performance and content. Heterogeneity of results was such that quantitative pooling was often not appropriate. Among CVRM patients, the results tended towards a beneficial effect of CDSS, but only LDL-c target attainment in diabetes patients reached statistical significance. Prompting, integration into the electronical health record, patient empowerment, and medication support were related to more effective CVRM. Conclusion We did not find a clear clinical benefit from CDSS in cardiovascular risk factor levels and target attainment. Some features of CDSS seem more promising than others. However, the variability in CDSS characteristics and heterogeneity of the results – emphasizing the immaturity of this research area - limit stronger conclusions. Clinical relevance of CDSS in CVRM might additionally be sought in the improvement of shared decision making and patient empowerment. Electronic supplementary material The online version of this article (10.1186/s12911-019-0824-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- T Katrien J Groenhof
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University of Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands.
| | - Folkert W Asselbergs
- Department of Cardiology, Division Heart & Lungs, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands.,Institute of Cardiovascular Science, Faculty of Population Health Sciences, University College London, London, UK.,Health Data Research UK and Institute of Health Informatics, University College London, London, UK
| | - Rolf H H Groenwold
- Farr Institute of Health Informatics Research and Institute of Health Informatics, University College London, London, UK.,Department of Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Diederick E Grobbee
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University of Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - Michiel L Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, University of Utrecht, Heidelberglaan 100, 3584, CX, Utrecht, the Netherlands
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Srinivasapura Venkateshmurthy N, Mc Namara K, Koorts H, Mohan S, S Ajay V, Jindal D, Malipeddi BR, Roy A, Tandon N, Prabhakaran D, Worsley T, Maddison R, O’Reilly S. Process evaluation protocol for a cluster randomised trial of a complex, nurse-led intervention to improve hypertension management in India. BMJ Open 2019; 9:e027841. [PMID: 31110103 PMCID: PMC6530308 DOI: 10.1136/bmjopen-2018-027841] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION India has high prevalence of hypertension but low awareness, treatment and control rate. A cluster randomised trial entitled 'm-Power Heart Project' is being implemented to test the effectiveness of a nurse care coordinator (NCC) led complex intervention to address uncontrolled hypertension in the community health centres (CHCs). The trial's process evaluation will assess the fidelity and quality of implementation, clarify the causal mechanisms and identify the contextual factors associated with variation in the outcomes. The trial will use a theory-based mixed-methods process evaluation, guided by the Consolidated Framework for Implementation Research. METHODS AND ANALYSIS The process evaluation will be conducted in the CHCs of Visakhapatnam (southern India). The key stakeholders involved in the intervention development and implementation will be included as participants. In-depth interviews will be conducted with intervention developers, doctors, NCCs and health department officials and focus groups with patients and their caregivers. NCC training will be evaluated using Kirkpatrick's model for training evaluation. Key process evaluation indicators (number of patients recruited and retained; concordance between the treatment plans generated by the electronic decision support system and treatment prescribed by the doctor and so on) will be assessed. Fidelity will be assessed using Borrelli et al's framework. Qualitative data will be analysed using the template analysis technique. Quantitative data will be summarised as medians (IQR), means (SD) and proportions as appropriate. Mixed-methods analysis will be conducted to assess if the variation in the mean reduction of systolic blood pressure between the intervention CHCs is influenced by patient satisfaction, training outcome, attitude of doctors, patients and NCCs about the intervention, process indicators etc. ETHICS AND DISSEMINATION: Ethical approval for this study was obtained from the ethics committees at Public Health Foundation of India and Deakin University. Findings will be disseminated via peer-reviewed publications, national and international conference presentations. TRIAL REGISTRATION NUMBER NCT03164317; Pre-results.
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Affiliation(s)
- Nikhil Srinivasapura Venkateshmurthy
- School of Exercise and Nutrition Sciences, Deakin University, Burwood, Victoria, Australia
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurgaon, Haryana, India
| | - Kevin Mc Namara
- School of Medicine, Deakin University, Burwood, Victoria, Australia
| | - Harriet Koorts
- School of Exercise and Nutrition Sciences, Deakin University, Burwood, Victoria, Australia
| | - Sailesh Mohan
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurgaon, Haryana, India
| | | | - Devraj Jindal
- Centre for Chronic Disease Control, New Delhi, Delhi, India
| | | | - Ambuj Roy
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Nikhil Tandon
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Dorairaj Prabhakaran
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, Gurgaon, Haryana, India
| | - Tony Worsley
- School of Exercise and Nutrition Sciences, Deakin University, Burwood, Victoria, Australia
| | - Ralph Maddison
- School of Exercise and Nutrition Sciences, Deakin University, Burwood, Victoria, Australia
| | - Sharleen O’Reilly
- School of Exercise and Nutrition Sciences, Deakin University, Burwood, Victoria, Australia
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Silveira DV, Marcolino MS, Machado EL, Ferreira CG, Alkmim MBM, Resende ES, Carvalho BC, Antunes AP, Ribeiro ALP. Development and Evaluation of a Mobile Decision Support System for Hypertension Management in the Primary Care Setting in Brazil: Mixed-Methods Field Study on Usability, Feasibility, and Utility. JMIR Mhealth Uhealth 2019; 7:e9869. [PMID: 30907740 PMCID: PMC6452279 DOI: 10.2196/mhealth.9869] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 11/05/2018] [Accepted: 12/10/2018] [Indexed: 12/12/2022] Open
Abstract
Background Despite being an important cardiovascular risk factor, hypertension has low control levels worldwide. Computerized clinical decision support systems (CDSSs) might be effective in reducing blood pressure with a potential impact in reducing cardiovascular risk. Objective The goal of the research was to evaluate the feasibility, usability, and utility of a CDSS, TeleHAS (tele–hipertensão arterial sistêmica, or arterial hypertension system), in the care of patients with hypertension in the context of a primary care setting in a middle-income country. Methods The TeleHAS app consists of a platform integrating clinical and laboratory data on a particular patient, from which it performs cardiovascular risk calculation and provides evidence-based recommendations derived from Brazilian and international guidelines for the management of hypertension and cardiovascular risk. Ten family physicians from different primary care units in the city of Montes Claros, Brazil, were randomly selected to use the CDSS for the care of hypertensive patients for 6 months. After 3 and 6 months, the feasibility, usability, and utility of the CDSS in the routine care of the health team was evaluated through a standardized questionnaire and semistructured interviews. Results Throughout the study, clinicians registered 535 patients with hypertension, at an average of 1.24 consultations per patient. Women accounted for 80% (8/10) of participant doctors, median age was 31.5 years (interquartile range 27 to 59 years). As for feasibility, 100% of medical users claimed it was possible to use the app in the primary care setting, and for 80% (8/10) of them it was easy to incorporate its use into the daily routine and home visits. Nevertheless, 70% (7/10) of physicians claimed that the time taken to fill out the CDSS causes significant delays in service. Clinicians evaluated TeleHAS as good (8/10, 80% of users), with easy completion and friendly interface (10/10, 100%) and the potential to improve patients’ treatment (10/10, 100%). A total of 90% (9/10) of physicians had access to new knowledge about cardiovascular risk and hypertension through the app recommendations and found it useful to promote prevention and optimize treatment. Conclusions In this study, a CDSS developed to assist the management of patients with hypertension was feasible in the context of a primary health care setting in a middle-income country, with good user satisfaction and the potential to improve adherence to evidence-based practices.
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Affiliation(s)
- Daniel Vitório Silveira
- Telehealth Center, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,Post-Graduate Program in Infectious Diseases and Tropical Medicine, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,Telehealth Network of Minas Gerais, Belo Horizonte, Brazil
| | - Milena Soriano Marcolino
- Telehealth Center, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,Post-Graduate Program in Infectious Diseases and Tropical Medicine, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,Telehealth Network of Minas Gerais, Belo Horizonte, Brazil
| | - Elaine Leandro Machado
- Post-Graduate Program in Infectious Diseases and Tropical Medicine, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Camila Gonçalves Ferreira
- Post-Graduate Program in Infectious Diseases and Tropical Medicine, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Maria Beatriz Moreira Alkmim
- Telehealth Center, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,Post-Graduate Program in Infectious Diseases and Tropical Medicine, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,Telehealth Network of Minas Gerais, Belo Horizonte, Brazil
| | - Elmiro Santos Resende
- Post-Graduate Program in Infectious Diseases and Tropical Medicine, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,Medical School, Universidade Federal de Uberlândia, Uberlândia, Brazil
| | - Bárbara Couto Carvalho
- Post-Graduate Program in Infectious Diseases and Tropical Medicine, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - André Pires Antunes
- Post-Graduate Program in Infectious Diseases and Tropical Medicine, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,Medical School, Universidade Estadual de Montes Claros, Montes Claros, Brazil
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Donohoe K, Ahuja S. Society of Nuclear Medicine and Molecular Imaging Efforts Toward Standardization: From Procedure Standards to Appropriate Use Criteria. Semin Nucl Med 2019; 49:153-160. [DOI: 10.1053/j.semnuclmed.2018.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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31
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Willcox M, Moorthy A, Mohan D, Romano K, Hutchful D, Mehl G, Labrique A, LeFevre A. Mobile Technology for Community Health in Ghana: Is Maternal Messaging and Provider Use of Technology Cost-Effective in Improving Maternal and Child Health Outcomes at Scale? J Med Internet Res 2019; 21:e11268. [PMID: 30758296 PMCID: PMC6391645 DOI: 10.2196/11268] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 09/12/2018] [Accepted: 09/12/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Mobile technologies are emerging as tools to enhance health service delivery systems and empower clients to improve maternal, newborn, and child health. Limited evidence exists on the value for money of mobile health (mHealth) programs in low- and middle-income countries. OBJECTIVE This study aims to forecast the incremental cost-effectiveness of the Mobile Technology for Community Health (MOTECH) initiative at scale across 170 districts in Ghana. METHODS MOTECH's "Client Data Application" allows frontline health workers to digitize service delivery information and track the care of patients. MOTECH's other main component, the "Mobile Midwife," sends automated educational voice messages to mobile phones of pregnant and postpartum women. We measured program costs and consequences of scaling up MOTECH over a 10-year analytic time horizon. Economic costs were estimated from informant interviews and financial records. Health effects were modeled using the Lives Saved Tool with data from an independent evaluation of changes in key services coverage observed in Gomoa West District. Incremental cost-effectiveness ratios were presented overall and for each year of implementation. Uncertainty analyses assessed the robustness of results to changes in key parameters. RESULTS MOTECH was scaled in clusters over a 3-year period to reach 78.7% (170/216) of Ghana's districts. Sustaining the program would cost US $17,618 on average annually per district. Over 10 years, MOTECH could potentially save an estimated 59,906 lives at a total cost of US $32 million. The incremental cost per disability-adjusted life year averted ranged from US $174 in the first year to US $6.54 in the tenth year of implementation and US $20.94 (95% CI US $20.34-$21.55) over 10 years. Uncertainty analyses suggested that the incremental cost-effectiveness ratio was most sensitive to changes in health effects, followed by personnel time. Probabilistic sensitivity analyses suggested that MOTECH had a 100% probability of being cost-effective above a willingness-to-pay threshold of US $50. CONCLUSIONS This is the first study to estimate the value for money of the supply- and demand-side of an mHealth initiative. The adoption of MOTECH to improve MNCH service delivery and uptake represents good value for money in Ghana and should be considered for expansion. Integration with other mHealth solutions, including e-Tracker, may provide opportunities to continue or combine beneficial components of MOTECH to achieve a greater impact on health.
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Affiliation(s)
- Michelle Willcox
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | | | - Diwakar Mohan
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | | | | | | | - Alain Labrique
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Amnesty LeFevre
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States.,Health Intelligence Initiative, Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
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Chu L, Kannan V, Basit MA, Schaeflein DJ, Ortuzar AR, Glorioso JF, Buchanan JR, Willett DL. SNOMED CT Concept Hierarchies for Computable Clinical Phenotypes From Electronic Health Record Data: Comparison of Intensional Versus Extensional Value Sets. JMIR Med Inform 2019; 7:e11487. [PMID: 30664458 PMCID: PMC6351992 DOI: 10.2196/11487] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 11/23/2018] [Accepted: 12/09/2018] [Indexed: 01/19/2023] Open
Abstract
Background Defining clinical phenotypes from electronic health record (EHR)–derived data proves crucial for clinical decision support, population health endeavors, and translational research. EHR diagnoses now commonly draw from a finely grained clinical terminology—either native SNOMED CT or a vendor-supplied terminology mapped to SNOMED CT concepts as the standard for EHR interoperability. Accordingly, electronic clinical quality measures (eCQMs) increasingly define clinical phenotypes with SNOMED CT value sets. The work of creating and maintaining list-based value sets proves daunting, as does insuring that their contents accurately represent the clinically intended condition. Objective The goal of the research was to compare an intensional (concept hierarchy-based) versus extensional (list-based) value set approach to defining clinical phenotypes using SNOMED CT–encoded data from EHRs by evaluating value set conciseness, time to create, and completeness. Methods Starting from published Centers for Medicare and Medicaid Services (CMS) high-priority eCQMs, we selected 10 clinical conditions referenced by those eCQMs. For each, the published SNOMED CT list-based (extensional) value set was downloaded from the Value Set Authority Center (VSAC). Ten corresponding SNOMED CT hierarchy-based intensional value sets for the same conditions were identified within our EHR. From each hierarchy-based intensional value set, an exactly equivalent full extensional value set was derived enumerating all included descendant SNOMED CT concepts. Comparisons were then made between (1) VSAC-downloaded list-based (extensional) value sets, (2) corresponding hierarchy-based intensional value sets for the same conditions, and (3) derived list-based (extensional) value sets exactly equivalent to the hierarchy-based intensional value sets. Value set conciseness was assessed by the number of SNOMED CT concepts needed for definition. Time to construct the value sets for local use was measured. Value set completeness was assessed by comparing contents of the downloaded extensional versus intensional value sets. Two measures of content completeness were made: for individual SNOMED CT concepts and for the mapped diagnosis clinical terms available for selection within the EHR by clinicians. Results The 10 hierarchy-based intensional value sets proved far simpler and faster to construct than exactly equivalent derived extensional value set lists, requiring a median 3 versus 78 concepts to define and 5 versus 37 minutes to build. The hierarchy-based intensional value sets also proved more complete: in comparison, the 10 downloaded 2018 extensional value sets contained a median of just 35% of the intensional value sets’ SNOMED CT concepts and 65% of mapped EHR clinical terms. Conclusions In the EHR era, defining conditions preferentially should employ SNOMED CT concept hierarchy-based (intensional) value sets rather than extensional lists. By doing so, clinical guideline and eCQM authors can more readily engage specialists in vetting condition subtypes to include and exclude, and streamline broad EHR implementation of condition-specific decision support promoting guideline adherence for patient benefit.
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Affiliation(s)
- Ling Chu
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Vaishnavi Kannan
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Mujeeb A Basit
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Diane J Schaeflein
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Adolfo R Ortuzar
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Jimmie F Glorioso
- University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Joel R Buchanan
- University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Duwayne L Willett
- University of Texas Southwestern Medical Center, Dallas, TX, United States
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Prabhakaran D, Jha D, Prieto-Merino D, Roy A, Singh K, Ajay VS, Jindal D, Gupta P, Kondal D, Goenka S, Jacob PD, Singh R, Prakash Kumar BG, Perel P, Tandon N, Patel V. Effectiveness of an mHealth-Based Electronic Decision Support System for Integrated Management of Chronic Conditions in Primary Care: The mWellcare Cluster-Randomized Controlled Trial. Circulation 2018; 139:380-391. [PMID: 30586732 DOI: 10.1161/circulationaha.118.038192] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The burden of noncommunicable diseases and their risk factors has rapidly increased worldwide, including in India. Innovative management strategies with electronic decision support and task sharing have been assessed for hypertension, diabetes mellitus, and depression individually, but an integrated package for multiple chronic condition management in primary care has not been evaluated. METHODS In a prospective, multicenter, open-label, cluster-randomized controlled trial involving 40 community health centers, using hypertension and diabetes mellitus as entry points, we evaluated the effectiveness of mWellcare, an mHealth system consisting of electronic health record storage and an electronic decision support for the integrated management of 5 chronic conditions (hypertension, diabetes mellitus, current tobacco and alcohol use, and depression) versus enhanced usual care among patients with hypertension and diabetes mellitus in India. At trial end (12-month follow-up), using intention-to-treat analysis, we examined the mean difference between arms in change in systolic blood pressure and glycated hemoglobin as primary outcomes and fasting blood glucose, total cholesterol, predicted 10-year risk of cardiovascular disease, depression score, and proportions reporting tobacco and alcohol use as secondary outcomes. Mixed-effects regression models were used to account for clustering and other confounding variables. RESULTS Among 3698 enrolled participants across 40 clusters (mean age, 55.1 years; SD, 11 years; 55.2% men), 3324 completed the trial. There was no evidence of difference between the 2 arms for systolic blood pressure (∆=-0.98; 95% CI, -4.64 to 2.67) and glycated hemoglobin (∆=0.11; 95% CI, -0.24 to 0.45) even after adjustment of several key variables (adjusted differences for systolic blood pressure: - 0.31 [95% CI, -3.91 to 3.29]; for glycated hemoglobin: 0.08 [95% CI, -0.27 to 0.44]). The mean withingroup changes in systolic blood pressure in mWellcare and enhanced usual care were -13.65 mmHg versus -12.66 mmHg, respectively, and for glycated hemoglobin were -0.48% and -0.58%, respectively. Similarly, there were no differences in the changes between the 2 groups for tobacco and alcohol use or other secondary outcomes. CONCLUSIONS We did not find an incremental benefit of mWellcare over enhanced usual care in the management of the chronic conditions studied. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT02480062.
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Affiliation(s)
- Dorairaj Prabhakaran
- Centre for Control of Chronic Conditions, Public Health Foundation of India, India
| | - Dilip Jha
- Clinical Trials, Centre for Chronic Disease Control, India
| | - David Prieto-Merino
- Non Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, United Kingdom
| | - Ambuj Roy
- Cardiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Kavita Singh
- Centre for Control of Chronic Conditions, Public Health Foundation of India, India
| | - Vamadevan S Ajay
- Health Systems Unit, Centre for Chronic Disease Control (CCDC) & Public Health Foundation of India (PHFI), India
| | - Devraj Jindal
- HEALTH SYSTEM, Centre for Chronic Disease Control, India
| | - Priti Gupta
- CCCI, Public Health Foundation of India, India
| | - Dimple Kondal
- Centre for Control of Chronic Conditions, Public Health Foundation of India, India
| | - Shifalika Goenka
- Centre for Control of Chronic Conditions, Public Health Foundation of India, India
| | - Pramod David Jacob
- Centre for Control of Chronic Conditions, Public Health Foundation of India, India
| | - Rekha Singh
- Directorate of Health Services, Government of Haryana, India
| | - B G Prakash Kumar
- Directorate of Health & Family Welfare Services, Government of Karnataka, India
| | - Pablo Perel
- Epidemiology and Public Health, London School of Hygiene & Tropical Medicine, United Kingdom
| | - Nikhil Tandon
- Endocrinology and Metabolism, All India Institute of Medical Sciences, India
| | - Vikram Patel
- Global Health and Social Medicine, Harvard Medical School, Boston, MA
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Srinivasapura Venkateshmurthy N, Ajay VS, Mohan S, Jindal D, Anand S, Kondal D, Tandon N, Rao MB, Prabhakaran D. m-Power Heart Project - a nurse care coordinator led, mHealth enabled intervention to improve the management of hypertension in India: study protocol for a cluster randomized trial. Trials 2018; 19:429. [PMID: 30086778 PMCID: PMC6081824 DOI: 10.1186/s13063-018-2813-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 07/18/2018] [Indexed: 12/21/2022] Open
Abstract
Background The proportion of patients with controlled hypertension (< 140/90 mmHg) is very low in India. Thus, there is a need to improve blood pressure management among patients with uncontrolled hypertension through innovative strategies directed at health system strengthening. Methods We designed an intervention consisting of two important components – an electronic decision support system (EDSS) used by a trained nurse care coordinator (NCC). Based on preliminary data, we hypothesized that this intervention will be able to reduce mean systolic blood pressure by 6.5 mmHg among those with uncontrolled blood pressure in the intervention arm compared to the standard treatment arm (paper-based hypertension treatment guidelines). The study will adopt a cluster randomized trial design with the community health center (CHC) as the unit of randomization. The trial will be conducted in Visakhapatnam district (southern India). A total of 1876 participants aged ≥30 years with high blood pressure – systolic blood pressure (SBP) ≥ 160 mmHg or diastolic blood pressure (DBP) ≥ 90 mmHg will be enrolled from 12 CHCs. The intervention consists of trained NCCs equipped with an evidence-based hypertension treatment algorithm in the form of the EDSS with regular SMSs to patients with hypertension to promote hypertension treatment and blood pressure control for 12 months. The primary outcome will be difference in the mean change of SBP, from baseline to 12 months, between the intervention and the standard treatment arm. The secondary outcomes are the difference in mean change of DBP; difference in the proportion of patients with controlled blood pressure (< 140/90 mmHg); difference in mean change of fasting blood sugar, HbA1C, eGFR, and albumin to creatinine ratio; difference in the proportion of patients visiting the CHC regularly (number of actual visits to the CHC/number of visits suggested by the EDSS > 80%); difference in proportion of patients compliant to anti-hypertensive medication/s; cost-effectiveness of intervention versus enhanced care. All the outcomes will be assessed at 12 months. Discussion The study is expected to provide evidence on the effectiveness of NCC-led, EDSS-based hypertension management in India and can likely offer an exemplar for improving cardiovascular disease (CVD) management in India within the resource-constrained public healthcare system. Trial registration ClinicalTrials.gov, ID: NCT03164317). Registered retrospectively on 23 May 2017 (first patient enrolled on 6 April 2017) because the authors did not receive a response to their original registration submission (5 January 2017) to the Clinical Trial Registry – India (CTRI). Electronic supplementary material The online version of this article (10.1186/s13063-018-2813-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Vamadevan S Ajay
- Center for Chronic Disease Control, C-1/52, 2nd Floor, Safdarjung Development Area, New Delhi, India
| | - Sailesh Mohan
- Public Health Foundation of India, Plot 47, Sector 44, Gurgaon, India
| | - Devraj Jindal
- Center for Chronic Disease Control, C-1/52, 2nd Floor, Safdarjung Development Area, New Delhi, India
| | - Shuchi Anand
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Dimple Kondal
- Public Health Foundation of India, Plot 47, Sector 44, Gurgaon, India
| | - Nikhil Tandon
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
| | | | - Dorairaj Prabhakaran
- Public Health Foundation of India, Plot 47, Sector 44, Gurgaon, India. .,Center for Chronic Disease Control, C-1/52, 2nd Floor, Safdarjung Development Area, New Delhi, India.
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35
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Stergiou GS, Dolan E, Kollias A, Poulter NR, Shennan A, Staessen JA, Zhang Z, Weber MA. Blood pressure measurement in special populations and circumstances. J Clin Hypertens (Greenwich) 2018; 20:1122-1127. [PMID: 30003705 PMCID: PMC8030798 DOI: 10.1111/jch.13296] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 03/28/2018] [Indexed: 08/30/2023]
Abstract
According to the established validation protocols, a typical validation study of a blood pressure (BP) monitor includes general population adults with normal or elevated BP. It is recognized, however, that the automated (oscillometric) BP monitors may have different accuracy or uses in some special populations compared with adults in the general population. Thus, an automated BP monitor with proven accuracy in a general population of adults may not be accurate in a special population, and therefore separate validation is needed. Recognized special populations deserving separate validation are those for which there is theoretical, and also clinical evidence, that the accuracy of BP monitors in these groups differs from that in the general population. Young children, pregnant women (including those with preeclampsia), individuals with arm circumference >42 cm, and patients with atrial fibrillation are regarded as special populations. Adolescents, individuals older than 80 years, and patients with end-stage renal disease or diabetes mellitus have also been considered as possible special groups, but there is still inadequate evidence of altered accuracy of BP monitors in these subjects. Validation studies should be performed in special populations and evaluated separately after the BP-measuring device has successfully undergone a validation study in a general population (unless the test device is intended only for a special population). This article discusses issues relating to the measurement of BP and the diagnosis of hypertension in selected special populations, as well as in low-resource settings, where a simplified yet efficient evaluation strategy is necessary.
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Affiliation(s)
- George S. Stergiou
- Hypertension Center STRIDE‐7School of MedicineThird Department of MedicineSotiria HospitalNational and Kapodistrian University of AthensGreece
| | - Eamon Dolan
- Stroke and Hypertension UnitConnolly HospitalDublinIreland
| | - Anastasios Kollias
- Hypertension Center STRIDE‐7School of MedicineThird Department of MedicineSotiria HospitalNational and Kapodistrian University of AthensGreece
| | - Neil R. Poulter
- Faculty of MedicineNational Heart & Lung InstituteImperial College LondonLondonUK
| | | | - Jan A. Staessen
- Department of Cardiovascular SciencesStudies Coordinating Centre, Research Unit Hypertension and Cardiovascular EpidemiologyUniversity of LeuvenLeuvenBelgium
- Cardiovascular Research Institute Maastricht (CARIM)Maastricht UniversityMaastrichtThe Netherlands
| | - Zhen‐Yu Zhang
- Department of Cardiovascular SciencesStudies Coordinating Centre, Research Unit Hypertension and Cardiovascular EpidemiologyUniversity of LeuvenLeuvenBelgium
| | - Michael A. Weber
- Downstate College of MedicineState University of New YorkNew YorkNYUSA
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Cost-effectiveness of health care service delivery interventions in low and middle income countries: a systematic review. Glob Health Res Policy 2018; 3:17. [PMID: 29930989 PMCID: PMC5992822 DOI: 10.1186/s41256-018-0073-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 05/07/2018] [Indexed: 01/17/2023] Open
Abstract
Background Low and middle income countries (LMICs) face severe resource limitations but the highest burden of disease. There is a growing evidence base on effective and cost-effective interventions for these diseases. However, questions remain about the most cost-effective method of delivery for these interventions. We aimed to review the scope, quality, and findings of economic evaluations of service delivery interventions in LMICs. Methods We searched PUBMED, MEDLINE, EconLit, and NHS EED for studies published between 1st January 2000 and 30th October 2016 with no language restrictions. We included all economic evaluations that reported incremental costs and benefits or summary measures of the two such as an incremental cost effectiveness ratio. Studies were grouped by both disease area and outcome measure and permutation plots were completed for similar interventions. Quality was judged by the Drummond checklist. Results Overall, 3818 potentially relevant abstracts were identified of which 101 studies were selected for full text review. Thirty-seven studies were included in the final review. Twenty-three studies reported on interventions we classed as “changing by whom and where care was provided”, specifically interventions that entailed task-shifting from doctors to nurses or community health workers or from facilities into the community. Evidence suggests this type of intervention is likely to be cost-effective or cost-saving. Nine studies reported on quality improvement initiatives, which were generally found to be cost-effective. Quality and methods differed widely limiting comparability of the studies and findings. Conclusions There is significant heterogeneity in the literature, both methodologically and in quality. This renders further comparisons difficult and limits the utility of the available evidence to decision makers.
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Gupta I, Roy A. Economic Studies on Non-Communicable Diseases and Injuries in India: A Systematic Review. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2018; 16:303-315. [PMID: 29611047 DOI: 10.1007/s40258-018-0370-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND The burden from non-communicable diseases and injuries (NCDI) in India is increasing rapidly. With low public sector investment in the health sector generally, and a high financial burden on households for treatment, it is important that economic evidence is used to set priorities in the context of NCDI. OBJECTIVE Our objective was to understand the extent to which economic analysis has been used in India to (1) analyze the impact of NCDI and (2) evaluate prevention and treatment interventions. Specifically, this analysis focused on the type of economic analysis used, disease categories, funding patterns, authorship, and author characteristics. METHODS We conducted a systematic review based on economic keywords to identify studies on NCDI in India published in English between January 2006 and November 2016. In all, 96 studies were included in the review. The analysis used descriptive statistics, including frequencies and percentages. RESULTS A majority of the studies were economic impact studies, followed by economic evaluation studies, especially cost-effectiveness analysis. In the costing/partial economic evaluation category, most were cost-description and cost-analysis studies. Under the economic impact/economic burden category, most studies investigated out-of-pocket spending. The studies were mostly on cardiovascular disease, diabetes, and neoplasms. Slightly over half of the studies were funded, with funding coming mainly from outside of India. Half of the studies were led by domestic authors. In most of the studies, the lead author was a clinician or a public health professional; however, most of the economist-led studies were by authors from outside India. CONCLUSIONS The results indicate the lack of engagement of economists generally and health economists in particular in research on NCDI in India. Demand from health policy makers for evidence-based decision making appears to be lacking, which in turn solidifies the divergence between economics and health policy, and highlights the need to prioritize scarce resources based on evidence regarding what works. Capacity building in health economics needs focus, and the government's support in this is recommended.
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Affiliation(s)
- Indrani Gupta
- Institute of Economic Growth, University of Delhi Enclave, Delhi, 110007, India.
| | - Arjun Roy
- Institute of Economic Growth, University of Delhi Enclave, Delhi, 110007, India
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Rapoport MJ, Zucchero Sarracini C, Kiss A, Lee L, Byszewski A, Seitz DP, Vrkljan B, Molnar F, Herrmann N, Tang-Wai DF, Frank C, Henry B, Pimlott N, Masellis M, Naglie G. Computer-Based Driving in Dementia Decision Tool With Mail Support: Cluster Randomized Controlled Trial. J Med Internet Res 2018; 20:e194. [PMID: 29802093 PMCID: PMC5993977 DOI: 10.2196/jmir.9126] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 01/10/2018] [Accepted: 03/08/2018] [Indexed: 11/25/2022] Open
Abstract
Background Physicians often find significant challenges in assessing automobile driving in persons with mild cognitive impairment and mild dementia and deciding when to report to transportation administrators. Care must be taken to balance the safety of patients and other road users with potential negative effects of issuing such reports. Objective The aim of this study was to assess whether a computer-based Driving in Dementia Decision Tool (DD-DT) increased appropriate reporting of patients with mild dementia or mild cognitive impairment to transportation administrators. Methods The study used a parallel-group cluster nonblinded randomized controlled trial design to test a multifaceted knowledge translation intervention. The intervention included a computer-based decision support system activated by the physician-user, which provides a recommendation about whether to report patients with mild dementia or mild cognitive impairment to transportation administrators, based on an algorithm derived from earlier work. The intervention also included a mailed educational package and Web-based specialized reporting forms. Specialists and family physicians with expertise in dementia or care of the elderly were stratified by sex and randomized to either use the DD-DT or a control version of the tool that required identical data input as the intervention group, but instead generated a generic reminder about the reporting legislation in Ontario, Canada. The trial ran from September 9, 2014 to January 29, 2016, and the primary outcome was the number of reports made to the transportation administrators concordant with the algorithm. Results A total of 69 participating physicians were randomized, and 36 of these used the DD-DT; 20 of the 35 randomized to the intervention group used DD-DT with 114 patients, and 16 of the 34 randomized to the control group used it with 103 patients. The proportion of all assessed patients reported to the transportation administrators concordant with recommendation did not differ between the intervention and the control groups (50% vs 49%; Z=−0.19, P=.85). Two variables predicted algorithm-based reporting—caregiver concern (odds ratio [OR]=5.8, 95% CI 2.5-13.6, P<.001) and abnormal clock drawing (OR 6.1, 95% CI 3.1-11.8, P<.001). Conclusions On the basis of this quantitative analysis, in-office abnormal clock drawing and expressions of concern about driving from caregivers substantially influenced physicians to report patients with mild dementia or mild cognitive impairment to transportation administrators, but the DD-DT tool itself did not increase such reports among these expert physicians. Trial Registration ClinicalTrials.gov NCT02036099; https://clinicaltrials.gov/ct2/show/NCT02036099 (Archived by WebCite at http://www.webcitation.org/6zGMF1ky8)
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Affiliation(s)
- Mark J Rapoport
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | | | - Alex Kiss
- Department of Research Design and Biostatistics, Sunnybrook Research Institute, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Linda Lee
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Anna Byszewski
- Division of Geriatric Medicine, The Ottawa Hospital, Ottawa, ON, Canada.,Division of Geriatric Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Dallas P Seitz
- Seniors Mental Health Program, Providence Care, Kingston, ON, Canada.,Department of Psychiatry, Queen's University, Kingston, ON, Canada
| | - Brenda Vrkljan
- School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
| | - Frank Molnar
- Division of Geriatric Medicine, The Ottawa Hospital, Ottawa, ON, Canada.,Division of Geriatric Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Nathan Herrmann
- Department of Psychiatry, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - David F Tang-Wai
- Memory Clinic, University Health Network, Toronto, ON, Canada.,Division of Neurology, Division of Geriatric Medicine, University of Toronto, Toronto, ON, Canada
| | - Christopher Frank
- Specialized Geriatric Services, Providence Care, Kingston, ON, Canada.,Division of Geriatric Medicine, Queen's University, Kingston, ON, Canada
| | - Blair Henry
- Clinical Ethics Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Nicholas Pimlott
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Department of Family and Community Medicine, Women's College Hospital, Toronto, ON, Canada
| | - Mario Masellis
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Division of Neurology, University of Toronto, Toronto, ON, Canada
| | - Gary Naglie
- Department of Medicine, Baycrest Health Sciences, Toronto, ON, Canada.,Division of Geriatric Medicine, University of Toronto, Toronto, ON, Canada
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Singh K, Chandrasekaran AM, Bhaumik S, Chattopadhyay K, Gamage AU, Silva PD, Roy A, Prabhakaran D, Tandon N. Cost-effectiveness of interventions to control cardiovascular diseases and diabetes mellitus in South Asia: a systematic review. BMJ Open 2018; 8:e017809. [PMID: 29615442 PMCID: PMC5884366 DOI: 10.1136/bmjopen-2017-017809] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 12/28/2017] [Accepted: 02/16/2018] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES More than 80% of cardiovascular diseases (CVD) and diabetes mellitus (DM) burden now lies in low and middle-income countries. Hence, there is an urgent need to identify and implement the most cost-effective interventions, particularly in the resource-constraint South Asian settings. Thus, we aimed to systematically review the cost-effectiveness of individual-level, group-level and population-level interventions to control CVD and DM in South Asia. METHODS We searched 14 electronic databases up to August 2016. The search strategy consisted of terms related to 'economic evaluation', 'CVD', 'DM' and 'South Asia'. Per protocol two reviewers assessed the eligibility and methodological quality of studies using standard checklists, and extracted incremental cost-effectiveness ratios of interventions. RESULTS Of the 2949 identified studies, 42 met full inclusion criteria. Critical appraisal of studies revealed 15 excellent, 18 good and 9 poor quality studies. Most studies were from India (n=37), followed by Bangladesh (n=3), Pakistan (n=2) and Bhutan (n=1). The economic evaluations were based on observational studies (n=9), randomised trials (n=12) and decision models (n=21). Together, these studies evaluated 301 policy or clinical interventions or combination of both. We found a large number of interventions were cost-effective aimed at primordial prevention (tobacco taxation, salt reduction legislation, food labelling and food advertising regulation), and primary and secondary prevention (multidrug therapy for CVD in high-risk group, lifestyle modification and metformin treatment for diabetes prevention, and screening for diabetes complications every 2-5 years). Significant heterogeneity in analytical framework and outcome measures used in these studies restricted meta-analysis and direct ranking of the interventions by their degree of cost-effectiveness. CONCLUSIONS The cost-effectiveness evidence for CVD and DM interventions in South Asia is growing, but most evidence is from India and limited to decision modelled outcomes. There is an urgent need for formal health technology assessment and policy evaluations in South Asia using local research data. PROSPERO REGISTRATION NUMBER CRD42013006479.
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Affiliation(s)
- Kavita Singh
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, Delhi, India
- Clinical Trials Unit, Centre for Chronic Disease Control, New Delhi, Delhi, India
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, Delhi, India
| | | | - Soumyadeep Bhaumik
- Health Promotion Division, Public Health Foundation of India, New Delhi, Delhi, India
| | - Kaushik Chattopadhyay
- Division of Epidemiology and Public Health, School of Medicine, The University of Nottingham, Nottingham, UK
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Anuji Upekshika Gamage
- Management Development and Planning Unit, Ministry of Health, Colombo, Western, Sri Lanka
| | - Padmal De Silva
- WHO Collaborating Centre for Public Health Workforce Development, National Institute of Health Sciences, Kalutara, Sri Lanka
| | - Ambuj Roy
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | - Dorairaj Prabhakaran
- Clinical Trials Unit, Centre for Chronic Disease Control, New Delhi, Delhi, India
- Centre for Chronic Conditions and Injuries, Public Health Foundation of India, New Delhi, Delhi, India
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Nikhil Tandon
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, Delhi, India
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Mills KT, Obst KM, Shen W, Molina S, Zhang HJ, He H, Cooper LA, He J. Comparative Effectiveness of Implementation Strategies for Blood Pressure Control in Hypertensive Patients: A Systematic Review and Meta-analysis. Ann Intern Med 2018; 168:110-120. [PMID: 29277852 PMCID: PMC5788021 DOI: 10.7326/m17-1805] [Citation(s) in RCA: 162] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The prevalence of hypertension is high and is increasing worldwide, whereas the proportion of controlled hypertension is low. PURPOSE To assess the comparative effectiveness of 8 implementation strategies for blood pressure (BP) control in adults with hypertension. DATA SOURCES Systematic searches of MEDLINE and Embase from inception to September 2017 with no language restrictions, supplemented with manual reference searches. STUDY SELECTION Randomized controlled trials lasting at least 6 months comparing the effect of implementation strategies versus usual care on BP reduction in adults with hypertension. DATA EXTRACTION Two investigators independently extracted data and assessed study quality. DATA SYNTHESIS A total of 121 comparisons from 100 articles with 55 920 hypertensive patients were included. Multilevel, multicomponent strategies were most effective for systolic BP reduction, including team-based care with medication titration by a nonphysician (-7.1 mm Hg [95% CI, -8.9 to -5.2 mm Hg]), team-based care with medication titration by a physician (-6.2 mm Hg [CI, -8.1 to -4.2 mm Hg]), and multilevel strategies without team-based care (-5.0 mm Hg [CI, -8.0 to -2.0 mm Hg]). Patient-level strategies resulted in systolic BP changes of -3.9 mm Hg (CI, -5.4 to -2.3 mm Hg) for health coaching and -2.7 mm Hg (CI, -3.6 to -1.7 mm Hg) for home BP monitoring. Similar trends were seen for diastolic BP reduction. LIMITATION Sparse data from low- and middle-income countries; few trials of some implementation strategies, such as provider training; and possible publication bias. CONCLUSION Multilevel, multicomponent strategies, followed by patient-level strategies, are most effective for BP control in patients with hypertension and should be used to improve hypertension control. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
- Katherine T Mills
- From Tulane University School of Public Health and Tropical Medicine and Tulane University Translational Science Institute, New Orleans, Louisiana; Nanjing Medical University School of Public Health, Nanjing, China; The First Affiliated Hospital of Xiamen University, Xiamen, China; and Johns Hopkins University School of Medicine and Bloomberg School of Public Health, Baltimore, Maryland
| | - Katherine M Obst
- From Tulane University School of Public Health and Tropical Medicine and Tulane University Translational Science Institute, New Orleans, Louisiana; Nanjing Medical University School of Public Health, Nanjing, China; The First Affiliated Hospital of Xiamen University, Xiamen, China; and Johns Hopkins University School of Medicine and Bloomberg School of Public Health, Baltimore, Maryland
| | - Wei Shen
- From Tulane University School of Public Health and Tropical Medicine and Tulane University Translational Science Institute, New Orleans, Louisiana; Nanjing Medical University School of Public Health, Nanjing, China; The First Affiliated Hospital of Xiamen University, Xiamen, China; and Johns Hopkins University School of Medicine and Bloomberg School of Public Health, Baltimore, Maryland
| | - Sandra Molina
- From Tulane University School of Public Health and Tropical Medicine and Tulane University Translational Science Institute, New Orleans, Louisiana; Nanjing Medical University School of Public Health, Nanjing, China; The First Affiliated Hospital of Xiamen University, Xiamen, China; and Johns Hopkins University School of Medicine and Bloomberg School of Public Health, Baltimore, Maryland
| | - Hui-Jie Zhang
- From Tulane University School of Public Health and Tropical Medicine and Tulane University Translational Science Institute, New Orleans, Louisiana; Nanjing Medical University School of Public Health, Nanjing, China; The First Affiliated Hospital of Xiamen University, Xiamen, China; and Johns Hopkins University School of Medicine and Bloomberg School of Public Health, Baltimore, Maryland
| | - Hua He
- From Tulane University School of Public Health and Tropical Medicine and Tulane University Translational Science Institute, New Orleans, Louisiana; Nanjing Medical University School of Public Health, Nanjing, China; The First Affiliated Hospital of Xiamen University, Xiamen, China; and Johns Hopkins University School of Medicine and Bloomberg School of Public Health, Baltimore, Maryland
| | - Lisa A Cooper
- From Tulane University School of Public Health and Tropical Medicine and Tulane University Translational Science Institute, New Orleans, Louisiana; Nanjing Medical University School of Public Health, Nanjing, China; The First Affiliated Hospital of Xiamen University, Xiamen, China; and Johns Hopkins University School of Medicine and Bloomberg School of Public Health, Baltimore, Maryland
| | - Jiang He
- From Tulane University School of Public Health and Tropical Medicine and Tulane University Translational Science Institute, New Orleans, Louisiana; Nanjing Medical University School of Public Health, Nanjing, China; The First Affiliated Hospital of Xiamen University, Xiamen, China; and Johns Hopkins University School of Medicine and Bloomberg School of Public Health, Baltimore, Maryland
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Jha D, Gupta P, Ajay VS, Jindal D, Perel P, Prieto-Merino D, Jacob P, Nyong J, Venugopal V, Singh K, Goenka S, Roy A, Tandon N, Patel V, Prabhakaran D. Protocol for the mWellcare trial: a multicentre, cluster randomised, 12-month, controlled trial to compare the effectiveness of mWellcare, an mHealth system for an integrated management of patients with hypertension and diabetes, versus enhanced usual care in India. BMJ Open 2017; 7:e014851. [PMID: 28801393 PMCID: PMC5724108 DOI: 10.1136/bmjopen-2016-014851] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Rising burden of cardiovascular disease (CVD) and diabetes is a major challenge to the health system in India. Innovative approaches such as mobile phone technology (mHealth) for electronic decision support in delivering evidence-based and integrated care for hypertension, diabetes and comorbid depression have potential to transform the primary healthcare system. METHODS AND ANALYSIS: mWellcare trial is a multicentre, cluster randomised controlled trial evaluating the clinical and cost-effectiveness of a mHealth system and nurse managed care for people with hypertension and diabetes in rural India. mWellcare system is an Android-based mobile application designed to generate algorithm-based clinical management prompts for treating hypertension and diabetes and also capable of storing health records, sending alerts and reminders for follow-up and adherence to medication. We recruited a total of 3702 participants from 40 Community Health Centres (CHCs), with ≥90 at each of the CHCs in the intervention and control (enhanced care) arms. The primary outcome is the difference in mean change (from baseline to 1 year) in systolic blood pressure and glycated haemoglobin (HbA1c) between the two treatment arms. The secondary outcomes are difference in mean change from baseline to 1 year in fasting plasma glucose, total cholesterol, predicted 10-year risk of CVD, depression, smoking behaviour, body mass index and alcohol use between the two treatment arms and cost-effectiveness. ETHICS AND DISSEMINATION The study has been approved by the institutional Ethics Committees at Public Health Foundation of India and the London School of Hygiene and Tropical Medicine. Findings will be disseminated widely through peer-reviewed publications, conference presentations and other mechanisms. TRIAL REGISTRATION mWellcare trial is registered with Clinicaltrial.gov (Registration number NCT02480062; Pre-results) and Clinical Trial Registry of India (Registration number CTRI/2016/02/006641). The current version of the protocol is Version 2 dated 19 October 2015 and the study sponsor is Public Health Foundation of India, Gurgaon, India (www.phfi.org).
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Affiliation(s)
- Dilip Jha
- Centre for Control of Chronic Conditions, Public Health Foundation of India, Gurgaon, India
| | - Priti Gupta
- Centre for Control of Chronic Conditions, Public Health Foundation of India, Gurgaon, India
| | - Vamadevan S Ajay
- Centre for Control of Chronic Conditions, Public Health Foundation of India, Gurgaon, India
| | - Devraj Jindal
- Centre for Control of Chronic Conditions, Public Health Foundation of India, Gurgaon, India
| | - Pablo Perel
- Centre for Control of Chronic Conditions, London School of Hygiene and Tropical Medicine, London, UK
| | - David Prieto-Merino
- Centre for Control of Chronic Conditions, London School of Hygiene and Tropical Medicine, London, UK
- Applied Statistical Methods in Medical Research Group, Universidad Catolica San Antonio de Murcia, Murcia, Spain
| | - Pramod Jacob
- Centre for Control of Chronic Conditions, Public Health Foundation of India, Gurgaon, India
| | - Jonathan Nyong
- Centre for Control of Chronic Conditions, London School of Hygiene and Tropical Medicine, London, UK
| | - Vidya Venugopal
- Centre for Control of Chronic Conditions, Public Health Foundation of India, Gurgaon, India
- Department of Epidemiology, University of Pittsburgh, Graduate School of Public Health, Pittsburgh, USA
| | - Kavita Singh
- Centre for Control of Chronic Conditions, Public Health Foundation of India, Gurgaon, India
- Department of Endocrinology and Metabolism, Centre for Control of Chronic Conditions, All India Institute of Medical Sciences, New Delhi, India
| | - Shifalika Goenka
- Centre for Control of Chronic Conditions, Public Health Foundation of India, Gurgaon, India
| | - Ambuj Roy
- Department of Cardiology, Centre for Control of Chronic Conditions, All India Institute of Medical Sciences, New Delhi, India
| | - Nikhil Tandon
- Department of Endocrinology and Metabolism, Centre for Control of Chronic Conditions, All India Institute of Medical Sciences, New Delhi, India
| | - Vikram Patel
- Centre for Control of Chronic Conditions, London School of Hygiene and Tropical Medicine, London, UK
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
| | - Dorairaj Prabhakaran
- Centre for Control of Chronic Conditions, Public Health Foundation of India, Gurgaon, India
- Centre for Control of Chronic Conditions, London School of Hygiene and Tropical Medicine, London, UK
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Saronga HP, Duysburgh E, Massawe S, Dalaba MA, Wangwe P, Sukums F, Leshabari M, Blank A, Sauerborn R, Loukanova S. Cost-effectiveness of an electronic clinical decision support system for improving quality of antenatal and childbirth care in rural Tanzania: an intervention study. BMC Health Serv Res 2017; 17:537. [PMID: 28784130 PMCID: PMC5547541 DOI: 10.1186/s12913-017-2457-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 07/17/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND QUALMAT project aimed at improving quality of maternal and newborn care in selected health care facilities in three African countries. An electronic clinical decision support system was implemented to support providers comply with established standards in antenatal and childbirth care. Given that health care resources are limited and interventions differ in their potential impact on health and costs (efficiency), this study aimed at assessing cost-effectiveness of the system in Tanzania. METHODS This was a quantitative pre- and post- intervention study involving 6 health centres in rural Tanzania. Cost information was collected from health provider's perspective. Outcome information was collected through observation of the process of maternal care. Incremental cost-effectiveness ratios for antenatal and childbirth care were calculated with testing of four models where the system was compared to the conventional paper-based approach to care. One-way sensitivity analysis was conducted to determine whether changes in process quality score and cost would impact on cost-effectiveness ratios. RESULTS Economic cost of implementation was 167,318 USD, equivalent to 27,886 USD per health center and 43 USD per contact. The system improved antenatal process quality by 4.5% and childbirth care process quality by 23.3% however these improvements were not statistically significant. Base-case incremental cost-effectiveness ratios of the system were 2469 USD and 338 USD per 1% change in process quality for antenatal and childbirth care respectively. Cost-effectiveness of the system was sensitive to assumptions made on costs and outcomes. CONCLUSIONS Although the system managed to marginally improve individual process quality variables, it did not have significant improvement effect on the overall process quality of care in the short-term. A longer duration of usage of the electronic clinical decision support system and retention of staff are critical to the efficiency of the system and can reduce the invested resources. Realization of gains from the system requires effective implementation and an enabling healthcare system. TRIAL REGISTRATION Registered clinical trial at www.clinicaltrials.gov ( NCT01409824 ). Registered May 2009.
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Affiliation(s)
- Happiness Pius Saronga
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany
| | - Els Duysburgh
- International Centre for Reproductive Health (ICRH), Ghent University, Ghent, Belgium
| | - Siriel Massawe
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Maxwell Ayindenaba Dalaba
- Navrongo Health Research Centre, Navrongo, Ghana
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany
| | - Peter Wangwe
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Felix Sukums
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | | | - Antje Blank
- Department of Clinical Pharmacology and Pharmacoepidemiology, University of Heidelberg, Heidelberg, Germany
| | - Rainer Sauerborn
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany
| | - Svetla Loukanova
- Department of General Medicine and Implementation Research, University of Heidelberg, Heidelberg, Germany
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Lee JT, Lawson KD, Wan Y, Majeed A, Morris S, Soljak M, Millett C. Are cardiovascular disease risk assessment and management programmes cost effective? A systematic review of the evidence. Prev Med 2017; 99:49-57. [PMID: 28087465 DOI: 10.1016/j.ypmed.2017.01.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 12/15/2016] [Accepted: 01/09/2017] [Indexed: 11/25/2022]
Abstract
The World Health Organization recommends that countries implement population-wide cardiovascular disease (CVD) risk assessment and management programmes. The aim of this study was to conduct a systematic review to evaluate whether this recommendation is supported by cost-effectiveness evidence. Published economic evaluations were identified via electronic medical and social science databases (including Medline, Web of Science, and the NHS Economic Evaluation Database) from inception to March 2016. Study quality was evaluated using a modified version of the Consolidated Health Economic Evaluation Reporting Standards. Fourteen economic evaluations were included: five studies based on randomised controlled trials, seven studies based on observational studies and two studies using hypothetical modelling synthesizing secondary data. Trial based studies measured CVD risk factor changes over 1 to 3years, with modelled projections of longer term events. Programmes were either not, or only, cost-effective under non-verified assumptions such as sustained risk factor changes. Most observational and hypothetical studies suggested programmes were likely to be cost-effective; however, study deigns are subject to bias and subsequent empirical evidence has contradicted key assumptions. No studies assessed impacts on inequalities. In conclusion, recommendations for population-wide risk assessment and management programmes lack a robust, real world, evidence basis. Given implementation is resource intensive there is a need for robust economic evaluation, ideally conducted alongside trials, to assess cost effectiveness. Further, the efficiency and equity impact of different delivery models should be investigated, and also the combination of targeted screening with whole population interventions recognising that there multiple approaches to prevention.
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Affiliation(s)
- John Tayu Lee
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK; Saw Swee Hock School of Public Health, National University of Singapore, Singapore.
| | - Kenny D Lawson
- Centre for Health Research, School of Medicine, Western Sydney University, Sydney, Australia; Centre for Research Excellence in Chronic Disease Prevention, Public Health and Tropical Medicine, James Cook University, Cairns, Australia
| | - Yizhou Wan
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Stephen Morris
- Department of Applied Health Research, University College London, London, UK
| | - Michael Soljak
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Christopher Millett
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
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Abstract
Cardiovascular diseases (CVDs) have now become the leading cause of mortality in India. A quarter of all mortality is attributable to CVD. Ischemic heart disease and stroke are the predominant causes and are responsible for >80% of CVD deaths. The Global Burden of Disease study estimate of age-standardized CVD death rate of 272 per 100 000 population in India is higher than the global average of 235 per 100 000 population. Some aspects of the CVD epidemic in India are particular causes of concern, including its accelerated buildup, the early age of disease onset in the population, and the high case fatality rate. In India, the epidemiological transition from predominantly infectious disease conditions to noncommunicable diseases has occurred over a rather brief period of time. Premature mortality in terms of years of life lost because of CVD in India increased by 59%, from 23.2 million (1990) to 37 million (2010). Despite wide heterogeneity in the prevalence of cardiovascular risk factors across different regions, CVD has emerged as the leading cause of death in all parts of India, including poorer states and rural areas. The progression of the epidemic is characterized by the reversal of socioeconomic gradients; tobacco use and low fruit and vegetable intake have become more prevalent among those from lower socioeconomic backgrounds. In addition, individuals from lower socioeconomic backgrounds frequently do not receive optimal therapy, leading to poorer outcomes. Countering the epidemic requires the development of strategies such as the formulation and effective implementation of evidence-based policy, reinforcement of health systems, and emphasis on prevention, early detection, and treatment with the use of both conventional and innovative techniques. Several ongoing community-based studies are testing these strategies.
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Affiliation(s)
- Dorairaj Prabhakaran
- From Centre for Chronic Disease Control, Gurgaon, India (D.P., P.J.); Centre for Control of Chronic Conditions, Public Health Foundation of India, Gurgaon, India (D.P., P.J.); and All India Institute of Medical Sciences, New Delhi, India (A.R.).
| | - Panniyammakal Jeemon
- From Centre for Chronic Disease Control, Gurgaon, India (D.P., P.J.); Centre for Control of Chronic Conditions, Public Health Foundation of India, Gurgaon, India (D.P., P.J.); and All India Institute of Medical Sciences, New Delhi, India (A.R.)
| | - Ambuj Roy
- From Centre for Chronic Disease Control, Gurgaon, India (D.P., P.J.); Centre for Control of Chronic Conditions, Public Health Foundation of India, Gurgaon, India (D.P., P.J.); and All India Institute of Medical Sciences, New Delhi, India (A.R.)
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45
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Svensson CM, Hoffmann B, Irmler IM, Straßburger M, Figge MT, Saluz HP. Quantification of arthritic bone degradation by analysis of 3D micro-computed tomography data. Sci Rep 2017; 7:44434. [PMID: 28290525 PMCID: PMC5349516 DOI: 10.1038/srep44434] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 02/07/2017] [Indexed: 12/19/2022] Open
Abstract
The use of animal models of arthritis is a key component in the evaluation of therapeutic strategies against the human disease rheumatoid arthritis (RA). Here we present quantitative measurements of bone degradation characterised by the cortical bone profile using glucose-6-phosphate isomerase (G6PI) induced arthritis. We applied micro-computed tomography (μCT) during three arthritis experiments and one control experiment to image the metatarsals of the hind paws and to investigate the effect of experimental arthritis on their cortical bone profile. For measurements of the cortical profile we automatically identified slices that are orthogonal to individual metatarsals, thereby making the measurements independent of animal placement in the scanner. We measured the average cortical thickness index (CTI) of the metatarsals, as well as the thickness changes along the metatarsal. In this study we introduced the cortical thickness gradient (CTG) as a new measure and we investigated how arthritis affects this measure. We found that in general both CTI and CTG are able to quantify arthritic progression, whilst CTG was found to be the more sensitive measure.
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Affiliation(s)
- Carl-Magnus Svensson
- Applied Systems Biology, Leibniz Institute for Natural Product Research and Infection Biology - Hans-Knöll-Institute, Beutenbergstrasse 11a, 07745 Jena, Germany
| | - Bianca Hoffmann
- Applied Systems Biology, Leibniz Institute for Natural Product Research and Infection Biology - Hans-Knöll-Institute, Beutenbergstrasse 11a, 07745 Jena, Germany.,Cell and Molecular Biology, Leibniz Institute for Natural Product Research and Infection Biology - Hans-Knöll-Institute, Beutenbergstrasse 11a, 07745 Jena, Germany.,Friedrich Schiller University Jena, Germany
| | - Ingo M Irmler
- Institute of Immunology, University Hospital Jena, Leutragraben 3, 07743 Jena, Germany
| | - Maria Straßburger
- Transfer Group Anti-infectives, Leibniz Institute for Natural Product Research and Infection Biology - Hans-Knöll-Institute, Beutenbergstrasse 11a, 07745 Jena, Germany
| | - Marc Thilo Figge
- Applied Systems Biology, Leibniz Institute for Natural Product Research and Infection Biology - Hans-Knöll-Institute, Beutenbergstrasse 11a, 07745 Jena, Germany.,Friedrich Schiller University Jena, Germany
| | - Hans Peter Saluz
- Applied Systems Biology, Leibniz Institute for Natural Product Research and Infection Biology - Hans-Knöll-Institute, Beutenbergstrasse 11a, 07745 Jena, Germany.,Cell and Molecular Biology, Leibniz Institute for Natural Product Research and Infection Biology - Hans-Knöll-Institute, Beutenbergstrasse 11a, 07745 Jena, Germany
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46
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Ajay VS, Jindal D, Roy A, Venugopal V, Sharma R, Pawar A, Kinra S, Tandon N, Prabhakaran D. Development of a Smartphone-Enabled Hypertension and Diabetes Mellitus Management Package to Facilitate Evidence-Based Care Delivery in Primary Healthcare Facilities in India: The mPower Heart Project. J Am Heart Assoc 2016; 5:JAHA.116.004343. [PMID: 28003248 PMCID: PMC5210443 DOI: 10.1161/jaha.116.004343] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background The high burden of undetected and undertreated hypertension and diabetes mellitus is a major health challenge worldwide. The mPower Heart Project aimed to develop and test a feasible and scalable intervention for hypertension and diabetes mellitus by task‐sharing with the use of a mobile phone–based clinical decision support system at Community Health Centers in Himachal Pradesh, India. Methods and Results The development of the intervention and mobile phone–based clinical decision support system was carried out using mixed methods in five Community Health Centers. The intervention was subsequently evaluated using pre–post evaluation design. During intervention, a nurse care coordinator screened, examined, and entered patient parameters into mobile phone–based clinical decision support system to generate a prescription, which was vetted by a physician. The change in systolic blood pressure, diastolic blood pressure, and fasting plasma glucose (FPG) over 18 months of intervention was quantified using generalized estimating equations models. During intervention, 6797 participants were enrolled. Six thousand sixteen participants had hypertension (mean systolic blood pressure: 146.1 mm Hg, 95% CI: 145.7, 146.5; diastolic blood pressure: 89.52 mm Hg, 95% CI: 89.33, 89.72), of which 3152 (52%) subjects were newly detected. Similarly, 1516 participants had diabetes mellitus (mean FPG: 177.9 mg/dL, 95% CI: 175.8, 180.0), of which 450 (30%) subjects were newly detected. The changes in systolic blood pressure, diastolic blood pressure, and FPG observed at 18 months of follow‐up were −14.6 mm Hg (95% CI: −15.3, −13.8), −7.6 mm Hg (CI: −8.0, −7.2), and −50.0 mg/dL (95% CI: −54.6, −45.5), respectively, and were statistically significant even after adjusting for age, sex, and Community Health Center. Conclusions A nurse‐facilitated, mobile phone–based clinical decision support system‐enabled intervention in primary care was associated with improvements in blood pressure and blood glucose control and has the potential to scale‐up in resource poor settings. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifiers: NCT01794052. Clinical Trial Registry—India: CTRI/2013/02/003412.
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Affiliation(s)
- Vamadevan S Ajay
- Centre for Chronic Disease Control (CCDC), New Delhi, India.,Centre for Control of Chronic Conditions (CCCC), Public Health Foundation of India (PHFI), Gurgaon, India
| | - Devraj Jindal
- Centre for Chronic Disease Control (CCDC), New Delhi, India.,Centre for Control of Chronic Conditions (CCCC), Public Health Foundation of India (PHFI), Gurgaon, India
| | - Ambuj Roy
- Department of Cardiology, Centre for Control of Chronic Conditions (CCCC), All India Institute of Medical Sciences, New Delhi, India
| | | | - Rakshit Sharma
- Department of Endocrinology & Metabolism, Centre for Control of Chronic Conditions (CCCC), All India Institute of Medical Sciences, New Delhi, India
| | - Abha Pawar
- Centre for Chronic Disease Control (CCDC), New Delhi, India
| | - Sanjay Kinra
- Department of Non-Communicable Disease Epidemiology, Centre for Control of Chronic Conditions (CCCC), London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Nikhil Tandon
- Department of Endocrinology & Metabolism, Centre for Control of Chronic Conditions (CCCC), All India Institute of Medical Sciences, New Delhi, India
| | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control (CCDC), New Delhi, India .,Centre for Control of Chronic Conditions (CCCC), Public Health Foundation of India (PHFI), Gurgaon, India
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47
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Lee ES, Vedanthan R, Jeemon P, Kamano JH, Kudesia P, Rajan V, Engelgau M, Moran AE. Quality Improvement for Cardiovascular Disease Care in Low- and Middle-Income Countries: A Systematic Review. PLoS One 2016; 11:e0157036. [PMID: 27299563 PMCID: PMC4907518 DOI: 10.1371/journal.pone.0157036] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 05/24/2016] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The majority of global cardiovascular disease (CVD) burden falls on people living in low- and middle-income countries (LMICs). In order to reduce preventable CVD mortality and morbidity, LMIC health systems and health care providers need to improve the delivery and quality of CVD care. OBJECTIVES As part of the Disease Control Priorities Three (DCP3) Study efforts addressing quality improvement, we reviewed and summarized currently available evidence on interventions to improve quality of clinic-based CVD prevention and management in LMICs. METHODS We conducted a narrative review of published comparative clinical trials that evaluated efficacy or effectiveness of clinic-based CVD prevention and management quality improvement interventions in LMICs. Conditions selected a priori included hypertension, diabetes, hyperlipidemia, coronary artery disease, stroke, rheumatic heart disease, and congestive heart failure. MEDLINE and EMBASE electronic databases were systematically searched. Studies were categorized as occurring at the system or patient/provider level and as treating the acute or chronic phase of CVD. RESULTS From 847 articles identified in the electronic search, 49 met full inclusion criteria and were selected for review. Selected studies were performed in 19 different LMICs. There were 10 studies of system level quality improvement interventions, 38 studies of patient/provider interventions, and one study that fit both criteria. At the patient/provider level, regardless of the specific intervention, intensified, team-based care generally led to improved medication adherence and hypertension control. At the system level, studies provided evidence that introduction of universal health insurance coverage improved hypertension and diabetes control. Studies of system and patient/provider level acute coronary syndrome quality improvement interventions yielded inconclusive results. The duration of most studies was less than 12 months. CONCLUSIONS The results of this review suggest that CVD care quality improvement can be successfully implemented in LMICs. Most studies focused on chronic CVD conditions; more acute CVD care quality improvement studies are needed. Longer term interventions and follow-up will be needed in order to assess the sustainability of quality improvement efforts in LMICs.
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Affiliation(s)
- Edward S. Lee
- Department of Medicine, Division of Geriatric, Hospital, Palliative and General Internal Medicine, Keck School of Medicine of University of Southern California, Los Angeles, California, United States of America
| | - Rajesh Vedanthan
- Department of Medicine, Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Panniyammakal Jeemon
- Centre for Control of Chronic Conditions, Public Health Foundation of India, Kerala, India
| | - Jemima H. Kamano
- Moi University College of Health Sciences, Eldoret, Kenya
- Academic Model Providing Access to Healthcare, Eldoret, Kenya
| | - Preeti Kudesia
- Health, Nutrition and Population Global Practice, The World Bank, Kathmandu, Nepal
| | | | - Michael Engelgau
- Center for Translation Research and Implementation Science, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Andrew E. Moran
- Department of Medicine, Division of General Medicine, Columbia University Medical Center, New York, New York, United States of America
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48
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Piot P, Aerts A, Wood DA, Lamptey P, Oti S, Connell K, Dorairaj P, Boufford JI, Caldwell A, Perel P. Innovating healthcare delivery to address noncommunicable diseases in low-income settings: the example of hypertension. Future Cardiol 2016; 12:401-3. [PMID: 27291058 DOI: 10.2217/fca-2016-0032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
London Dialogue event, The Hospital Club, 24 Endell St, London, WC2H 9HQ, London, UK, 1 December 2015 Hypertension is a global health issue causing almost 10 million deaths annually, with a disproportionate number occurring in low- and middle-income countries. The condition can be managed effectively, but there is a need for innovation in healthcare delivery to alleviate its burden. This paper presents a number of innovative delivery models from a number of different countries, including Kenya, Ghana, Barbados and India. These models were presented at the London Dialogue event, which was cohosted by the Novartis Foundation and the London School of Hygiene & Tropical Medicine Centre for Global Noncommunicable Diseases on 1 December 2015. It is argued that these models are applicable not only to hypertension, but provide valuable lessons to address other noncommunicable diseases.
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Affiliation(s)
- Peter Piot
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Ann Aerts
- Novartis Foundation, Novartis Campus Forum 1 - 3.93, CH-4056 Basel, Switzerland
| | - David A Wood
- Imperial College London, The Hammersmith Hospital, Du Cane Road, London, W12 0NN, UK
| | - Peter Lamptey
- FHI360, 359 Blackwell Street, Suite 200, Durham, NC 27701, USA
| | - Samuel Oti
- International Development Research Centre (IDRC), 150 Kent Street, Ottawa, Ontario K1P 0B2, Canada
| | - Kenneth Connell
- The University of the West Indies, Cave Hill Campus, Bridgetown BB11000, Barbados
| | - Prabhakaran Dorairaj
- Centre for Chronic Conditions & Injuries & Public Health Foundation of India, Delhi NCR Plot No. 47, Sector 44, Institutional Area Gurgaon - 122002, India
| | - Jo I Boufford
- The New York Academy of Medicine, 1216 Fifth Avenue, New York, NY 10029, USA
| | - Aya Caldwell
- Novartis Foundation, Novartis Campus Forum 1 - 3.93, CH-4056 Basel, Switzerland
| | - Pablo Perel
- London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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Adler AJ, Prabhakaran D, Bovet P, Kazi DS, Mancia G, Mungal-Singh V, Poulter N. Reducing Cardiovascular Mortality Through Prevention and Management of Raised Blood Pressure: A World Heart Federation Roadmap. Glob Heart 2016. [PMID: 26213298 DOI: 10.1016/j.gheart.2015.04.006] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Affiliation(s)
- Alma J Adler
- World Heart Federation, Geneva, Switzerland, and the London School of Hygiene & Tropical Medicine, London, United Kingdom.
| | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control and Public Health Foundation of India, New Delhi, India
| | - Pascal Bovet
- Institute of Social and Preventive Medicine, Lausanne University Hospital, CHUV, Lausanne, Switzerland
| | - Dhruv S Kazi
- Department of Medicine (Cardiology), University of California, San Francisco, CA, USA
| | - Giuseppe Mancia
- University of Milano-Bicocca and IRCCS Istituto Auxologico Italiano, Milan, Italy
| | | | - Neil Poulter
- School of Public Health, Imperial College London, London, United Kingdom
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50
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Shojania KG, Jennings A, Mayhew A, Ramsay CR, Eccles MP, Grimshaw J. The effects of on-screen, point of care computer reminders on processes and outcomes of care. Cochrane Database Syst Rev 2009; 2009:CD001096. [PMID: 19588323 PMCID: PMC4171964 DOI: 10.1002/14651858.cd001096.pub2] [Citation(s) in RCA: 271] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The opportunity to improve care by delivering decision support to clinicians at the point of care represents one of the main incentives for implementing sophisticated clinical information systems. Previous reviews of computer reminder and decision support systems have reported mixed effects, possibly because they did not distinguish point of care computer reminders from e-mail alerts, computer-generated paper reminders, and other modes of delivering 'computer reminders'. OBJECTIVES To evaluate the effects on processes and outcomes of care attributable to on-screen computer reminders delivered to clinicians at the point of care. SEARCH STRATEGY We searched the Cochrane EPOC Group Trials register, MEDLINE, EMBASE and CINAHL and CENTRAL to July 2008, and scanned bibliographies from key articles. SELECTION CRITERIA Studies of a reminder delivered via a computer system routinely used by clinicians, with a randomised or quasi-randomised design and reporting at least one outcome involving a clinical endpoint or adherence to a recommended process of care. DATA COLLECTION AND ANALYSIS Two authors independently screened studies for eligibility and abstracted data. For each study, we calculated the median improvement in adherence to target processes of care and also identified the outcome with the largest such improvement. We then calculated the median absolute improvement in process adherence across all studies using both the median outcome from each study and the best outcome. MAIN RESULTS Twenty-eight studies (reporting a total of thirty-two comparisons) were included. Computer reminders achieved a median improvement in process adherence of 4.2% (interquartile range (IQR): 0.8% to 18.8%) across all reported process outcomes, 3.3% (IQR: 0.5% to 10.6%) for medication ordering, 3.8% (IQR: 0.5% to 6.6%) for vaccinations, and 3.8% (IQR: 0.4% to 16.3%) for test ordering. In a sensitivity analysis using the best outcome from each study, the median improvement was 5.6% (IQR: 2.0% to 19.2%) across all process measures and 6.2% (IQR: 3.0% to 28.0%) across measures of medication ordering. In the eight comparisons that reported dichotomous clinical endpoints, intervention patients experienced a median absolute improvement of 2.5% (IQR: 1.3% to 4.2%). Blood pressure was the most commonly reported clinical endpoint, with intervention patients experiencing a median reduction in their systolic blood pressure of 1.0 mmHg (IQR: 2.3 mmHg reduction to 2.0 mmHg increase). AUTHORS' CONCLUSIONS Point of care computer reminders generally achieve small to modest improvements in provider behaviour. A minority of interventions showed larger effects, but no specific reminder or contextual features were significantly associated with effect magnitude. Further research must identify design features and contextual factors consistently associated with larger improvements in provider behaviour if computer reminders are to succeed on more than a trial and error basis.
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Affiliation(s)
- Kaveh G Shojania
- Director, University of Toronto Centre for Patient Safety, Sunnybrook Health Sciences Centre, Room D474, 2075 Bayview Avenue, Toronto, Ontario, Canada, M4N 3M5
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