- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT02331082
Integrating Pediatric Care Delivery in Rural Healthcare Systems
Study Overview
Status
Conditions
Detailed Description
Introduction: A central challenge in the delivery of evidence-based interventions to promote under-five child survival is the coordination of care across the multiple tiers of the health system, from frontline health workers, to primary care clinics, to district hospitals, to specialty providers. Additionally, children who survive or avoid once-fatal diseases such as congenital and rheumatic heart diseases, prematurity, neurodevelopmental conditions, and disabilities sustained from traumatic injuries, are increasingly living well into adolescence, young adulthood, and beyond. Healthcare delivery systems in resource-limited settings, however, are ill-equipped to manage such patients' care. Mobile technologies, coupled with effective management strategies, may enhance implementation and coordination of evidence-based interventions, but few controlled trials exist to validate this. Particularly lacking are strategies that incorporate mobile technologies in an integrated manner across the health system.
Intervention: We have developed a mobile health care coordination and quality improvement intervention within two rural district healthcare systems in Nepal, where the child mortality rate is an estimated 82 per 1,000, and coordination of child health care is poor. Firstly, the intervention aims to increase the timely engagement in acute care for children under the age of five to receive evidence-based World Health Organization protocols aimed at reducing child mortality-Integrated Management of Pregnancy and Childbirth, Integrated Management of Childhood Illness, Integrated Management of Emergency and Essential Surgical Care, and Community-based Management of Severe Acute Malnutrition. Secondly, the intervention aims to implement a Chronic Care Model for pediatric patients under the age of twenty suffering from a chronic disease (congenital and rheumatic heart disease, diabetes, depression, epilepsy, asthma, musculoskeletal and neurodevelopmental disabilities, and pre- and post-surgical conditions).
Analysis: We will conduct a quasi-experimental, stepped-wedge, cluster-controlled trial. The primary outcome of this trial will be under-two mortality. We hypothesize a 25% reduction in under-two mortality rate during the intervention periods, relative to the control period. We hypothesize a 50% improvement in follow-up rates, a 30% improvement in global symptoms score, a 20% reduction in disability score, and a 20% reduction in inpatient days in hospital. We will use both quantitative and qualitative methods to assess the scalability of the intervention in terms of logistics, human resources, costs, and utilization.
Impact: Rigorous evaluations of systems-level child healthcare interventions are needed to drive global healthcare policies and their implementation. The trial proposed here will inform the potential impact and scalability of health systems strengthening interventions.
Study Type
Enrollment (Anticipated)
Phase
- Not Applicable
Contacts and Locations
Study Contact
- Name: Duncan Maru, MD, PhD
- Phone Number: 1-617-553-4256
- Email: duncan@possiblehealth.org
Study Contact Backup
- Name: Scott Halliday, MS
- Phone Number: 1-530-219-8807
- Email: scott@possiblehealth.org
Study Locations
-
-
Achham
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Sanfebagar, Achham, Nepal
- Recruiting
- Bayalpata Hospital
-
Contact:
- Aradhana Thapa, MPH
- Email: aradhana@possiblehealth.org
-
Contact:
- Bikash Gauchan, MBBS
- Email: bikash@possiblehealth.org
-
Principal Investigator:
- David Citrin, PhD, MPH
-
-
Dolakha
-
Bhimeshwor, Dolakha, Nepal
- Recruiting
- Charikot Primary Health Center
-
Contact:
- Aradhana Thapa, MPH
- Email: aradhana@possiblehealth.org
-
Principal Investigator:
- David Citrin, PhD, MPH
-
Contact:
- Binod Dangal, MD-GP
- Email: binod@possiblehealth.org
-
-
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion Criteria:
- Female
- Reproductive age, 15-49 years
- Resides within 14 village clusters that comprise experimental/control arms
Exclusion Criteria:
- n/a
Study Plan
How is the study designed?
Design Details
- Primary Purpose: Health Services Research
- Allocation: Non-Randomized
- Interventional Model: Parallel Assignment
- Masking: None (Open Label)
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
Active Comparator: Control
Existing healthcare system
|
This is the current rural, district-level public sector healthcare infrastructure of rural Nepal that is not strengthened during the study.
Other Names:
|
Experimental: Health System Improvement
Structured Quality Improvement Chronic Care Model Integrated Electronic Medical Record Solar-powered electrical supply Performance-based financing
|
For structured quality improvement, trained healthcare providers (primarily doctors from referral hospital) will serve as mentors to mid-level providers.
The mentors will facilitate on-site trainings of primary care with mid-level providers at the district hospital.
Mentors will also travel monthly to the healthcare facilities themselves to provide training both in the direct context of clinical care and to provide feedback based upon surveillance and monitoring data.
The focus will be on the techniques from the Institute for Healthcare Improvement's Model for Improvement, including Plan-Do-Study-Act cycles, run charts, and root cause analyses.
Finally, they will work with the clinical healthcare staff to identify resource needs from the local government for maintenance, water, electricity, and supplies.
These resource needs will be addressed through an integrated supply chain management system across the tiers of the healthcare system.
Other Names:
Senior physicians trained in mentorship of non-physician mid-level providers will provide decision support for mid-level providers in the current district healthcare system with specific protocols for target conditions.
We will add the following elements: focus on mid-level, non-physician providers as the primary clinicians within the intervention; intensive Community Health Worker (CHW) outreach for detection, screening, follow-up of patients, and encouragement of patient self-care and behavior change; and focused effort on the seamless care coordination of patients across the tiers of the system.
Through trainings of CHWs, much of patient self-management comes in the form of home visits that reinforce clinic and hospital counseling, including risk management and prevention.
CHWs will be trained in the counseling of each target condition, with counseling largely occurring in the patients' homes, where much of the challenges of chronic disease management and behavior change lie.
Other Names:
Clinical information systems.
We are developing a system for tracking patients that integrates across each of the tiers using an electronic medical record.
This is a key technology in supporting each of the above delivery system design elements.
Other Names:
As a component of our comprehensive healthcare systems strengthening intervention, we are installing solar panels at community-level clinics to ensure continuous electrical supply for medical devices and technology.
Other Names:
As part of our healthcare systems strengthening intervention, we have established a performance-based financing agreement with the Government of Nepal that conditionally funds healthcare delivery based on population-level health outcomes and quality healthcare service delivery.
In this arrangement, the Government serves as a regulator of healthcare delivery rather than a primary provider of healthcare services.
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What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Under-two mortality rate
Time Frame: Five years
|
We expect the intervention will lead to a 25% decrease in under-two mortality in the experimental arm.
|
Five years
|
Infant mortality rate
Time Frame: Five years
|
We expect the intervention will lead to a 25% decrease in the infant mortality rate in the experimental arm.
|
Five years
|
Neonatal mortality rate
Time Frame: Five years
|
We expect the intervention will lead to a 25% decrease in the neonatal mortality rate in the experimental arm.
|
Five years
|
Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Institutional Birth Rate
Time Frame: Five years
|
We expect the intervention will lead to a 25% increase in Institutional Birth Rate among reproductive-age women in the experimental arm.
|
Five years
|
Antenatal Care Completion Percentage
Time Frame: Five years
|
We expect the intervention will lead to a 25% increase in number of pregnant women completing all 4 antenatal care visits in the experimental arm.
|
Five years
|
Postpartum contraceptive prevalence rate
Time Frame: Five years
|
We expect the intervention will lead to a 20% increase in postpartum contraceptive prevalence rate among reproductive age women who have delivered in the past 2 years in the experimental arm.
|
Five years
|
Preterm delivery rate
Time Frame: Five years
|
We expect the intervention will lead to 25% fewer preterm births in the experimental arm.
|
Five years
|
Low birthweight delivery rates
Time Frame: Five years
|
We expect the intervention will lead to a 25% reduction in babies born with low birthweights in the experimental arm
|
Five years
|
Percentage of stillbirths
Time Frame: Five years
|
We expect the intervention will lead to 25% fewer stillbirths in the experimental arm.
|
Five years
|
Collaborators and Investigators
Sponsor
Investigators
- Study Director: David Citrin, PhD, MPH, Possible
- Study Chair: Biraj Karmacharya, MBBS, Msc, University of Washington
Publications and helpful links
Helpful Links
Study record dates
Study Major Dates
Study Start (Actual)
Primary Completion (Anticipated)
Study Completion (Anticipated)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Estimate)
Study Record Updates
Last Update Posted (Actual)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Keywords
Additional Relevant MeSH Terms
Other Study ID Numbers
- hssnyaya
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