NCD’s: PHFI study findings can help national policy makers

This study has key lessons for health systems of India in terms of the management of Non-communicable Diseases (NCDs) at primary care settings

Image Source: Google
Image Source: Google

India is facing a burden of Non-Communicable Diseases. A large study on the Effectiveness of a mHealth-Based Electronic Decision Support System for Integrated Management of Chronic Conditions in Primary Care in India conducted by the Public Health Foundation of India (PHFI), the London School of Hygiene and Tropical Medicine, UK (LSHTM) and the Centre for Chronic Disease Control (CCDC) was presented at the prestigious American Heart Association annual meeting at Chicago on Saturday.

The results of the study were published in the American Heart Association Journal Circulation and released simultaneously at the meeting on Saturday which is a rare honour.

In this prospective, multicentre, open-label, cluster-randomized controlled trial involving 40 community health centers in Haryana and Karnataka using hypertension and diabetes mellitus as entry points, the trial evaluated the effectiveness of mWellcare, a 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 the trial end (12-month follow-up), using intention to- treat analysis, the researchers examined the mean difference between the two arms in change in systolic blood pressure and glycated haemoglobin (HBA1c) 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 using a robust statistical modelling approach.

Key Lessons from the Study

  • Importance of providing a clinic nurse to support the physician in the management of hypertension and diabetes mellitus
  • Ensuring continuous availability of essential drugs
  • Periodic training of healthcare professionals on guideline- directed care
  • Maintaining Electronic patient registry
  • Monitoring quality of care
  • Centrally updating clinical protocols for all users through the mHealth application
  • Generating useful information from the registry for planning (e.g., forecasting requirement of drugs, diagnostics, manpower)

Clinical Implications of the Study

  • This trial demonstrates the feasibility of an ambitious multifactorial electronic health record– and electronic decision support–based mHealth intervention across multiple sites at the primary car level using available trained staff.
  • The overall null result, likely resulting from benefits achieved in the enhanced usual care arm, emphasizes the potential value of leveraging non physician providers and improving access to needed medications.
  • National health policymakers in low- and middle-income countries, including India, can use this information to inform decisions surrounding the rollout of widespread public health interventions

Professor Dorairaj Prabhakaran, Vice President – Research and Policy, PHFI and the principal investigator of the study said, “The mWellcare study is an innovative trial evaluating the role of a nurse led electronic clinical decision support systems supported chronic disease care at the primary healthcare level.”

He added, Training of health care professionals and ensuring continuous drug supply in the health system was an important component of the study. The trial demonstrates the importance of trained non-physician health care providers and allied health professionals.”

Professor Nikhil Tandon, Professor and Head of the Department of Endocrinology and Metabolism, AIIMS, a key collaborator on the study said “The number of people with diabetes has shown a staggering rise from 26 million in 1990 to 65 million in 2016. The electronic clinical decision support system combined with the systematic patient assessment and guideline-based management system which ensures follow-up of patients suffering from chronic conditions has demonstrated how an integrated mHealth system can deliver better quality of care to patients.”

Tandon added, “Key findings from this study can be adopted and integrated into chronic conditions management programmes designed and implemented by State Health Departments.”