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DeWyer A, Scheel A, Kamarembo J, Akech R, Asiimwe A, Beaton A, Bobson B, Canales L, DeStigter K, Kazi DS, Kwan GF, Longenecker CT, Lwabi P, Murali M, Ndagire E, Namuyonga J, Sarnacki R, Ssinabulya I, Okello E, Aliku T, Sable C. Establishment of a cardiac telehealth program to support cardiovascular diagnosis and care in a remote, resource-poor setting in Uganda. PLoS One 2021; 16:e0255918. [PMID: 34358281 PMCID: PMC8345851 DOI: 10.1371/journal.pone.0255918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 07/26/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION To address workforce shortages and expand access to care, we developed a telemedicine program incorporating existing infrastructure for delivery of cardiovascular care in Gulu, Northern Uganda. Our study had three objectives: 1) assess feasibility and clinical impact 2) evaluate patient/parent satisfaction and 3) estimate costs. METHODS All cardiology clinic visits during a two-year study period were included. All patients received an electrocardiogram and echocardiogram performed by a local nurse in Gulu which were stored and transmitted to the Uganda Heart Institute in the capital of Kampala for remote consultation by a cardiologist. Results were relayed to patients/families following cardiologist interpretation. The following telemedicine process was utilized: 1) clinical intake by nurse in Gulu; 2) ECG and echocardiography acquisition in Gulu; 3) echocardiography transmission to the Uganda Heart Institute in Kampala, Uganda; 4) remote telemedicine consultation by cardiologists in Kampala; and 5) communication of results to patients/families in Gulu. Clinical care and technical aspects were tracked. Diagnoses and recommendations were analyzed by age groups (0-5 years, 6-21 years, 22-50 years and > 50 years). A mixed methods approach involving interviews and surveys was used to assess patient satisfaction. Healthcare sector costs of telemedicine-based cardiovascular care were estimated using time-driven activity-based costing. RESULTS Normal studies made up 47%, 55%, 76% and 45% of 1,324 patients in the four age groups from youngest to oldest. Valvular heart disease (predominantly rheumatic heart disease) was the most common diagnosis in the older three age groups. Medications were prescribed to 31%, 31%, 24%, and 48% of patients in the four age groups. The median time for consultation was 7 days. A thematic analysis of focus group transcripts displayed an overall acceptance and appreciation for telemedicine, citing cost- and time-saving benefits. The cost of telemedicine was $29.48/visit. CONCLUSIONS Our data show that transmission and interpretation of echocardiograms from a remote clinic in northern Uganda is feasible, serves a population with a high burden of heart disease, has a significant impact on patient care, is favorably received by patients, and can be delivered at low cost. Further study is needed to better assess the impact relative to existing standards of care and cost effectiveness.
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Affiliation(s)
- Alyssa DeWyer
- Virginia Tech Carilion School of Medicine, Roanoke, VA, United States of America
| | - Amy Scheel
- Emory University School of Medicine, Atlanta, GA, United States of America
| | | | - Rose Akech
- Gulu Regional Referral Hospital, Gulu, Uganda
| | | | - Andrea Beaton
- The Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, United States of America
- The University of Cincinnati School of Medicine, Cincinnati, OH, United States of America
| | | | - Lesley Canales
- Children’s National Hospital, Washington, DC, United States of America
| | - Kristen DeStigter
- University of Vermont Medical Center, Burlington, VT, United States of America
| | - Dhruv S. Kazi
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
- Cardiovascular Medicine Section, Department of Medicine, Harvard Medical School, Boston, MA, United States of America
| | - Gene F. Kwan
- Boston University School of Medicine, Boston, MA, United States of America
| | - Chris T. Longenecker
- Case Western Reserve University School of Medicine, Cleveland, OH, United States of America
- University Hospitals Harrington Heart & Vascular Institute, Cleveland, OH, United States of America
| | | | - Meghna Murali
- Children’s National Hospital, Washington, DC, United States of America
| | | | | | - Rachel Sarnacki
- Children’s National Hospital, Washington, DC, United States of America
| | | | | | | | - Craig Sable
- Children’s National Hospital, Washington, DC, United States of America
- George Washington School of Medicine, Washington, DC, United States of America
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DeWyer A, Scheel A, Otim IO, Longenecker CT, Okello E, Ssinabulya I, Morris S, Okwir M, Oyang W, Joyce E, Nabongo B, Sable C, Alencherry B, Tompsett A, Aliku T, Beaton A. Improving the accuracy of heart failure diagnosis in low-resource settings through task sharing and decentralization. Glob Health Action 2020; 12:1684070. [PMID: 31694487 PMCID: PMC6844369 DOI: 10.1080/16549716.2019.1684070] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background: Task sharing of TTE may improve capacity for heart failure diagnosis and management in patients in remote, low-resource settings but the impact on diagnostic accuracy and patient outcomes has not been studied. Objectives: Determine feasibility and impact of non-expert training in transthoracic echocardiography (TTE) to improve the diagnosis and outcomes of patients with suspected heart failure in Uganda. Methods: This two-part study examined an innovative training program to develop TTE competency among non-experts and used a pre-post design to determine the impact of decentralized TTE. Four of 8 non-experts (50%) passed a three-part training course. The training comprised of distance learning through a web-based curriculum, a 2-day hands-on workshop with cardiologists, and independent practice with remote mentorship. Continuous measures were compared (pre- vs. post-TTE) using t-tests or Wilcoxon rank-sum tests as distributionally appropriate and categorical variables assessed through chi-square testing. Sensitivity and specificity were calculated according to standard methodology comparing diagnosis pre- and post-TTE during phase 2. Results: Performance in the post-training phase showed good agreement with expert categorization (κ = 0.80) with diagnostic concordance in 421 of 454 studies (92.7%). TTE changed the preliminary diagnosis in 81% of patients, showing low specificity of clinical decision-making alone (14.2%; 95% CI 10.1–19.2%). Dilated cardiomyopathy, hypertensive heart disease with preserved systolic function, and right heart failure were the most underdiagnosed conditions prior to TTE while hypertensive heart disease with decreased systolic function was the most over-diagnosed condition. Conclusions: In conclusion, non-expert providers can achieve a high level of proficiency for the categorization of heart failure using handheld TTE in low-resource settings and use of telemedicine and remote mentorship may improve performance and feasibility. The addition of TTE resulted in substantial improvement in etiological specificity. Further study is needed to understand implications of this strategy on healthcare utilization, long-term patient outcomes, and cost.
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Affiliation(s)
- Alyssa DeWyer
- Department of Cardiology, Children's National Health System, Washington, DC, USA
| | - Amy Scheel
- Department of Cardiology, Children's National Health System, Washington, DC, USA.,School of Medicine, Emory University, Atlanta, GA, USA
| | - Isaac Omara Otim
- Department of Medicine, Lira Regional Referral Hospital, Cardiac Clinic, Lira, Uganda
| | - Christopher T Longenecker
- Department of Cardiology, University Hospitals Harrington Heart & Vascular Institute, Case Western Reserve University, Cleveland, OH, USA
| | - Emmy Okello
- Department of Cardiology, Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - Isaac Ssinabulya
- Department of Cardiology, Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - Stephen Morris
- Department of Cardiology, University Hospitals Harrington Heart & Vascular Institute, Case Western Reserve University, Cleveland, OH, USA
| | - Mark Okwir
- Department of Medicine, Lira Regional Referral Hospital, Cardiac Clinic, Lira, Uganda
| | - William Oyang
- Department of Medicine, Lira Regional Referral Hospital, Cardiac Clinic, Lira, Uganda
| | - Erine Joyce
- Department of Medicine, Lira Regional Referral Hospital, Cardiac Clinic, Lira, Uganda
| | - Betty Nabongo
- Department of Medicine, Lira Regional Referral Hospital, Cardiac Clinic, Lira, Uganda
| | - Craig Sable
- Department of Cardiology, Children's National Health System, Washington, DC, USA
| | - Ben Alencherry
- Department of Cardiology, University Hospitals Harrington Heart & Vascular Institute, Case Western Reserve University, Cleveland, OH, USA
| | - Alison Tompsett
- Department of Cardiology, University Hospitals Harrington Heart & Vascular Institute, Case Western Reserve University, Cleveland, OH, USA
| | - Twalib Aliku
- Department of Cardiology, Uganda Heart Institute, Mulago Hospital Complex, Kampala, Uganda
| | - Andrea Beaton
- Department of Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Nyaga UF, Bigna JJ, Agbor VN, Essouma M, Ntusi NA, Noubiap JJ. Data on the epidemiology of heart failure in Sub-Saharan Africa. Data Brief 2018; 17:1218-1239. [PMID: 29876481 PMCID: PMC5988512 DOI: 10.1016/j.dib.2018.01.100] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 01/21/2018] [Accepted: 01/30/2018] [Indexed: 12/04/2022] Open
Abstract
In Sub-Saharan Africa (SSA), chronic non-communicable diseases and cardiovascular diseases in particular, are progressively taking over infectious diseases as the leading cause of morbidity and mortality. Heart failure is a major public health problem in the region. We summarize here available data on the prevalence, aetiologies, treatment, rates and predictors of mortality due to heart failure in SSA.
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Affiliation(s)
- Ulrich Flore Nyaga
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | - Jean Joel Bigna
- Faculty of Medicine, University of Paris Sud XI, Le Kremlin Bicêtre, Paris, France
| | | | - Mickael Essouma
- Department of Internal Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | - Ntobeko A.B. Ntusi
- Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
- Hatter Institute for Cardiovascular Research in Africa, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Cape Universities Body Imaging Center, University of Cape Town, Cape Town, South Africa
| | - Jean Jacques Noubiap
- Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa
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West C, Ploth D, Fonner V, Mbwambo J, Fredrick F, Sweat M. Developing a Screening Algorithm for Type II Diabetes Mellitus in the Resource-Limited Setting of Rural Tanzania. Am J Med Sci 2016; 351:408-15. [PMID: 27079348 DOI: 10.1016/j.amjms.2016.01.012] [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] [Received: 08/04/2015] [Accepted: 12/12/2015] [Indexed: 01/16/2023]
Abstract
BACKGROUND Noncommunicable diseases are on pace to outnumber infectious disease as the leading cause of death in sub-Saharan Africa, yet many questions remain unanswered with concern toward effective methods of screening for type II diabetes mellitus (DM) in this resource-limited setting. We aim to design a screening algorithm for type II DM that optimizes sensitivity and specificity of identifying individuals with undiagnosed DM, as well as affordability to health systems and individuals. METHODS Baseline demographic and clinical data, including hemoglobin A1c (HbA1c), were collected from 713 participants using probability sampling of the general population. We used these data, along with model parameters obtained from the literature, to mathematically model 8 purposed DM screening algorithms, while optimizing the sensitivity and specificity using Monte Carlo and Latin Hypercube simulation. RESULTS An algorithm that combines risk assessment and measurement of fasting blood glucose was found to be superior for the most resource-limited settings (sensitivity 68%, sensitivity 99% and cost per patient having DM identified as $2.94). Incorporating HbA1c testing improves the sensitivity to 75.62%, but raises the cost per DM case identified to $6.04. The preferred algorithms are heavily biased to diagnose those with more severe cases of DM. CONCLUSIONS Using basic risk assessment tools and fasting blood sugar testing in lieu of HbA1c testing in resource-limited settings could allow for significantly more feasible DM screening programs with reasonable sensitivity and specificity.
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Affiliation(s)
- Caroline West
- College of Medicine, Medical University of South Carolina, Charleston, South Carolina.
| | - David Ploth
- Department of Nephrology, Medical University of South Carolina, Charleston, South Carolina
| | - Virginia Fonner
- Department of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Jessie Mbwambo
- Department of Psychiatry, Muhimbili University of Health and Allied Sciences, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Francis Fredrick
- School of Medicine, Muhimbili University of Health and Allied Sciences, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Michael Sweat
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina
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Mocumbi AO. Lack of focus on cardiovascular disease in sub-Saharan Africa. Cardiovasc Diagn Ther 2013; 2:74-7. [PMID: 24282699 DOI: 10.3978/j.issn.2223-3652.2012.01.03] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Accepted: 01/11/2012] [Indexed: 11/14/2022]
Abstract
Research into cardiovascular disease in Sub-Saharan Africa has been hampered by lack of funding and expertise. However, hospital- and community-based data reveal high economic and social costs of these diseases to the national health services and the communities, with the region facing a mixed burden of diseases related to poverty and infections, emergence of risk factors and diseases of affluence, as well as new cardiovascular problems caused by the HIV/AIDS epidemics. The availability of echocardiography has raised the profile of these conditions in sub-Saharan Africa, stimulating several projects led by local cardiologists under the umbrella of the Pan-African Society of Cardiology. This research may help to overcome the lack of focus on cardiovascular diseases in Sub-Saharan Africa, as well as increase the awareness of the public and policymakers on the burden of cardiovascular diseases.
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Affiliation(s)
- Ana Olga Mocumbi
- Instituto Nacional de Saúde & Universidade Eduardo Mondlane, Maputo-Mozambique
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