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SMARTHealth India: Development and Field Evaluation of a Mobile Clinical Decision Support System for Cardiovascular Diseases in Rural India

BACKGROUND: Cardiovascular disease (CVD) is the major cause of premature death and disability in India and yet few people at risk of CVD are able to access best practice health care. Mobile health (mHealth) is a promising solution, but very few mHealth interventions have been subjected to robust eva...

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Autores principales: Praveen, Devarsetty, Patel, Anushka, Raghu, Arvind, Clifford, Gari D, Maulik, Pallab K, Mohammad Abdul, Ameer, Mogulluru, Kishor, Tarassenko, Lionel, MacMahon, Stephen, Peiris, David
Formato: Online Artículo Texto
Lenguaje:English
Publicado: JMIR Publications Inc. 2014
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4275493/
https://www.ncbi.nlm.nih.gov/pubmed/25487047
http://dx.doi.org/10.2196/mhealth.3568
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author Praveen, Devarsetty
Patel, Anushka
Raghu, Arvind
Clifford, Gari D
Maulik, Pallab K
Mohammad Abdul, Ameer
Mogulluru, Kishor
Tarassenko, Lionel
MacMahon, Stephen
Peiris, David
author_facet Praveen, Devarsetty
Patel, Anushka
Raghu, Arvind
Clifford, Gari D
Maulik, Pallab K
Mohammad Abdul, Ameer
Mogulluru, Kishor
Tarassenko, Lionel
MacMahon, Stephen
Peiris, David
author_sort Praveen, Devarsetty
collection PubMed
description BACKGROUND: Cardiovascular disease (CVD) is the major cause of premature death and disability in India and yet few people at risk of CVD are able to access best practice health care. Mobile health (mHealth) is a promising solution, but very few mHealth interventions have been subjected to robust evaluation in India. OBJECTIVE: The objectives were to develop a multifaceted, mobile clinical decision support system (CDSS) for CVD management and evaluate it for use by public nonphysician health care workers (NPHWs) and physicians in a rural Indian setting. METHODS: Plain language clinical rules were developed based on standard guidelines and programmed into a computer tablet app. The algorithm was validated and field-tested in 11 villages in Andhra Pradesh, involving 11 NPHWs and 3 primary health center (PHC) physicians. A mixed method evaluation was conducted comprising clinical and survey data and in-depth patient and staff interviews to understand barriers and enablers to the use of the system. Then this was thematically analyzed using NVivo 10. RESULTS: During validation of the algorithm, there was an initial agreement for 70% of the 42 calculated variables between the CDSS and SPSS software outputs. Discrepancies were identified and amendments were made until perfect agreement was achieved. During field testing, NPHWs and PHC physicians used the CDSS to screen 227 and 65 adults, respectively. The NPHWs identified 39% (88/227) of patients for referral with 78% (69/88) of these having a definite indication for blood pressure (BP)-lowering medication. However, only 35% (24/69) attended a clinic within 1 month of referral, with 42% (10/24) of these reporting continuing medications at 3-month follow-up. Physicians identified and recommended 17% (11/65) of patients for BP-lowering medications. Qualitative interviews identified 3 interrelated interview themes: (1) the CDSS had potential to change prevailing health care models, (2) task-shifting to NPHWs was the central driver of change, and (3) despite high acceptability by end users, actual transformation was substantially limited by system-level barriers such as patient access to doctors and medicines. CONCLUSIONS: A tablet-based CDSS implemented within primary health care systems has the potential to help improve CVD outcomes in India. However, system-level barriers to accessing medical care limit its full impact. These barriers need to be actively addressed for clinical innovations to be successful. TRIAL REGISTRATION: Clinical Trials Registry of India: CTRI/2013/06/003753; http://ctri.nic.in/Clinicaltrials/showallp.php?mid1=6259&EncHid=51761.70513&userName=CTRI/2013/06/003753 (Archived by WebCite at http://www.webcitation.org/6UBDlrEuq).
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spelling pubmed-42754932014-12-26 SMARTHealth India: Development and Field Evaluation of a Mobile Clinical Decision Support System for Cardiovascular Diseases in Rural India Praveen, Devarsetty Patel, Anushka Raghu, Arvind Clifford, Gari D Maulik, Pallab K Mohammad Abdul, Ameer Mogulluru, Kishor Tarassenko, Lionel MacMahon, Stephen Peiris, David JMIR Mhealth Uhealth Original Paper BACKGROUND: Cardiovascular disease (CVD) is the major cause of premature death and disability in India and yet few people at risk of CVD are able to access best practice health care. Mobile health (mHealth) is a promising solution, but very few mHealth interventions have been subjected to robust evaluation in India. OBJECTIVE: The objectives were to develop a multifaceted, mobile clinical decision support system (CDSS) for CVD management and evaluate it for use by public nonphysician health care workers (NPHWs) and physicians in a rural Indian setting. METHODS: Plain language clinical rules were developed based on standard guidelines and programmed into a computer tablet app. The algorithm was validated and field-tested in 11 villages in Andhra Pradesh, involving 11 NPHWs and 3 primary health center (PHC) physicians. A mixed method evaluation was conducted comprising clinical and survey data and in-depth patient and staff interviews to understand barriers and enablers to the use of the system. Then this was thematically analyzed using NVivo 10. RESULTS: During validation of the algorithm, there was an initial agreement for 70% of the 42 calculated variables between the CDSS and SPSS software outputs. Discrepancies were identified and amendments were made until perfect agreement was achieved. During field testing, NPHWs and PHC physicians used the CDSS to screen 227 and 65 adults, respectively. The NPHWs identified 39% (88/227) of patients for referral with 78% (69/88) of these having a definite indication for blood pressure (BP)-lowering medication. However, only 35% (24/69) attended a clinic within 1 month of referral, with 42% (10/24) of these reporting continuing medications at 3-month follow-up. Physicians identified and recommended 17% (11/65) of patients for BP-lowering medications. Qualitative interviews identified 3 interrelated interview themes: (1) the CDSS had potential to change prevailing health care models, (2) task-shifting to NPHWs was the central driver of change, and (3) despite high acceptability by end users, actual transformation was substantially limited by system-level barriers such as patient access to doctors and medicines. CONCLUSIONS: A tablet-based CDSS implemented within primary health care systems has the potential to help improve CVD outcomes in India. However, system-level barriers to accessing medical care limit its full impact. These barriers need to be actively addressed for clinical innovations to be successful. TRIAL REGISTRATION: Clinical Trials Registry of India: CTRI/2013/06/003753; http://ctri.nic.in/Clinicaltrials/showallp.php?mid1=6259&EncHid=51761.70513&userName=CTRI/2013/06/003753 (Archived by WebCite at http://www.webcitation.org/6UBDlrEuq). JMIR Publications Inc. 2014-12-08 /pmc/articles/PMC4275493/ /pubmed/25487047 http://dx.doi.org/10.2196/mhealth.3568 Text en ©Devarsetty Praveen, Anushka Patel, Arvind Raghu, Gari D Clifford, Pallab K Maulik, Ameer Mohammad Abdul, Kishor Mogulluru, Lionel Tarassenko, Stephen MacMahon, David Peiris. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 08.12.2014. http://creativecommons.org/licenses/by/2.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR mhealth and uhealth, is properly cited. The complete bibliographic information, a link to the original publication on http://mhealth.jmir.org/, as well as this copyright and license information must be included.
spellingShingle Original Paper
Praveen, Devarsetty
Patel, Anushka
Raghu, Arvind
Clifford, Gari D
Maulik, Pallab K
Mohammad Abdul, Ameer
Mogulluru, Kishor
Tarassenko, Lionel
MacMahon, Stephen
Peiris, David
SMARTHealth India: Development and Field Evaluation of a Mobile Clinical Decision Support System for Cardiovascular Diseases in Rural India
title SMARTHealth India: Development and Field Evaluation of a Mobile Clinical Decision Support System for Cardiovascular Diseases in Rural India
title_full SMARTHealth India: Development and Field Evaluation of a Mobile Clinical Decision Support System for Cardiovascular Diseases in Rural India
title_fullStr SMARTHealth India: Development and Field Evaluation of a Mobile Clinical Decision Support System for Cardiovascular Diseases in Rural India
title_full_unstemmed SMARTHealth India: Development and Field Evaluation of a Mobile Clinical Decision Support System for Cardiovascular Diseases in Rural India
title_short SMARTHealth India: Development and Field Evaluation of a Mobile Clinical Decision Support System for Cardiovascular Diseases in Rural India
title_sort smarthealth india: development and field evaluation of a mobile clinical decision support system for cardiovascular diseases in rural india
topic Original Paper
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4275493/
https://www.ncbi.nlm.nih.gov/pubmed/25487047
http://dx.doi.org/10.2196/mhealth.3568
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