The Integrated Tracking, Referral, and Electronic Decision Support, and Care Coordination (I-TREC) program: scalable strategies for the management of hypertension and diabetes within the government healthcare system of India

Shivani A Patel, Hanspria Sharma, Sailesh Mohan, Mary Beth Weber, Devraj Jindal, Prashant Jarhyan, Priti Gupta, Rakshit Sharma, Mumtaj Ali, Mohammed K Ali, K M Venkat Narayan, Dorairaj Prabhakaran, Yashdeep Gupta, Ambuj Roy, Nikhil Tandon, Shivani A Patel, Hanspria Sharma, Sailesh Mohan, Mary Beth Weber, Devraj Jindal, Prashant Jarhyan, Priti Gupta, Rakshit Sharma, Mumtaj Ali, Mohammed K Ali, K M Venkat Narayan, Dorairaj Prabhakaran, Yashdeep Gupta, Ambuj Roy, Nikhil Tandon

Abstract

Background: Hypertension and diabetes are among the most common and deadly chronic conditions globally. In India, most adults with these conditions remain undiagnosed, untreated, or poorly treated and uncontrolled. Innovative and scalable approaches to deliver proven-effective strategies for medical and lifestyle management of these conditions are needed.

Methods: The overall goal of this implementation science study is to evaluate the Integrated Tracking, Referral, Electronic decision support, and Care coordination (I-TREC) program. I-TREC leverages information technology (IT) to manage hypertension and diabetes in adults aged ≥30 years across the hierarchy of Indian public healthcare facilities. The I-TREC program combines multiple evidence-based interventions: an electronic case record form (eCRF) to consolidate and track patient information and referrals across the publicly-funded healthcare system; an electronic clinical decision support system (CDSS) to assist clinicians to provide tailored guideline-based care to patients; a revised workflow to ensure coordinated care within and across facilities; and enhanced training for physicians and nurses regarding non-communicable disease (NCD) medical content and lifestyle management. The program will be implemented and evaluated in a predominantly rural district of Punjab, India. The evaluation will employ a quasi-experimental design with mixed methods data collection. Evaluation indicators assess changes in the continuum of care for hypertension and diabetes and are grounded in the Reach, Effectiveness, Adoption Implementation, and Maintenance (RE-AIM) framework. Data will be triangulated from multiple sources, including community surveys, health facility assessments, stakeholder interviews, and patient-level data from the I-TREC program's electronic database.

Discussion: I-TREC consolidates previously proven strategies for improved management of hypertension and diabetes at single-levels of the healthcare system into a scalable model for coordinated care delivery across all levels of the healthcare system hierarchy. Findings have the potential to inform best practices to ultimately deliver quality public-sector hypertension and diabetes care across India.

Trial registration: The study is registered with Clinical Trials Registry of India (registration number CTRI/2020/01/022723 ). The study was registered prior to the launch of the intervention on 13 January 2020. The current version of protocol is version 2 dated 6 June 2018.

Keywords: Continuum of care; Diabetes; Health system; Hypertension; Implementation science; Information technology; Quality improvement; mHealth.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Geographical location of the study setting. Figure 1 was created by the authors using a map taken from Map Data© 2020 Google
Fig. 2
Fig. 2
Patient flow under the I-TREC program. Panel a shows patient flow across facilities and Panel b shows patient flow within facilities. Figure 2 was developed by the authors

References

    1. Mohan S, Jarhyan P, Ghosh S, Venkateshmurthy NS, Gupta R, Rana R, et al. UDAY: a comprehensive diabetes and hypertension prevention and management program in India. BMJ Open. 2018;8 Available from: . Cited 2020 Feb 2.
    1. Cheung BMY, Li C. Diabetes and hypertension: is there a common metabolic pathway? Curr Atheroscler Rep. 2012;14:160–166. doi: 10.1007/s11883-012-0227-2.
    1. Mancia G. The association of hypertension and diabetes: prevalence, cardiovascular risk and protection by blood pressure reduction. Acta Diabetol. 2005;42:s17–s25. doi: 10.1007/s00592-005-0177-z.
    1. Selby JV, Peng T, Karter AJ, Alexander M, Sidney S, Lian J, et al. High rates of co-occurrence of hypertension, elevated low-density lipoprotein cholesterol, and diabetes mellitus in a large managed care population. Am J Manag Care. 2004;10:163–170.
    1. Khatib R, Schwalm J-D, Yusuf S, Haynes RB, McKee M, Khan M, et al. Patient and healthcare provider barriers to hypertension awareness, treatment and follow up: a systematic review and meta-analysis of qualitative and quantitative studies. PLoS One. 2014;9:e84238. doi: 10.1371/journal.pone.0084238.
    1. Chow CK, Teo KK, Rangarajan S, et al. Prevalence, awareness, treatment, and control of hypertension in rural and urban communities in high-, middle-, and low-income countries. JAMA. 2013;310:959–968. doi: 10.1001/jama.2013.184182.
    1. Sathish T, Williams ED, Pasricha N, Absetz P, Lorgelly P, Wolfe R, et al. Cluster randomised controlled trial of a peer-led lifestyle intervention program: study protocol for the Kerala diabetes prevention program. BMC Public Health. 2013;13:1035. doi: 10.1186/1471-2458-13-1035.
    1. Joshi SR, Saboo B, Vadivale M, Dani SI, Mithal A, Kaul U, et al. Prevalence of diagnosed and undiagnosed diabetes and hypertension in India--results from the screening India’s Twin Epidemic (SITE) study. Diabetes Technol Ther. 2012;14:8–15. doi: 10.1089/dia.2011.0243.
    1. Anchala R, Kannuri NK, Pant H, Khan H, Franco OH, Di Angelantonio E, et al. Hypertension in India: a systematic review and meta-analysis of prevalence, awareness, and control of hypertension. J Hypertens. 2014;32:1170–1177. doi: 10.1097/HJH.0000000000000146.
    1. Deepa M, Grace M, Binukumar B, Pradeepa R, Roopa S, Khan HM, et al. High burden of prediabetes and diabetes in three large cities in South Asia: the Center for cArdio-metabolic risk reduction in South Asia (CARRS) study. Diabetes Res Clin Pract. 2015;110(2):172–182. doi: 10.1016/j.diabres.2015.09.005.
    1. Prenissl J, Manne-Goehler J, Jaacks LM, Prabhakaran D, Awasthi A, Bischops AC, et al. Hypertension screening, awareness, treatment, and control in India: a nationally representative cross-sectional study among individuals aged 15 to 49 years. PLoS Med. 2019;16:e1002801. doi: 10.1371/journal.pmed.1002801.
    1. Prenissl J, Jaacks LM, Mohan V, Manne-Goehler J, Davies JI, Awasthi A, et al. Variation in health system performance for managing diabetes among states in India: a cross-sectional study of individuals aged 15 to 49 years. BMC Med. 2019;17:92. doi: 10.1186/s12916-019-1325-6.
    1. Hasan H, Zodpey S, Saraf A. Diabetologist’s perspective on practice of evidence based diabetes management in India. Diabetes Res Clin Pract. 2012;95:189–193. doi: 10.1016/j.diabres.2011.09.021.
    1. Pakhare A, Kumar S, Goyal S, Joshi R. Assessment of primary care facilities for cardiovascular disease preparedness in Madhya Pradesh, India. BMC Health Serv Res. 2015;15:408. doi: 10.1186/s12913-015-1075-x.
    1. Kaveeshwar SA, Cornwall J. The current state of diabetes mellitus in India. Australas Med J. 2014;7:45–48. doi: 10.4066/AMJ.2014.1979.
    1. Shah VN, Kamdar PK, Shah N. Assessing the knowledge, attitudes and practice of type 2 diabetes among patients of Saurashtra region, Gujarat. Int J Diabetes Dev Ctries. 2009;29:118–122. doi: 10.4103/0973-3930.54288.
    1. Kotwani A, Ewen M, Dey D, Iyer S, Lakshmi PK, Patel A, et al. Prices & availability of common medicines at six sites in India using a standard methodology. Indian J Med Res. 2007;125:645–654.
    1. Jamison DT, Summers LH, Alleyne G, Arrow KJ, Berkley S, Binagwaho A, et al. Global health 2035: a world converging within a generation. Lancet Lond Engl. 2013;382:1898–1955. doi: 10.1016/S0140-6736(13)62105-4.
    1. Siegel KR, Patel SA, Ali MK. Non-communicable diseases in South Asia: contemporary perspectives. Br Med Bull. 2014;111:31–44. doi: 10.1093/bmb/ldu018.
    1. Murray CJL, Barber RM, Foreman KJ, Ozgoren AA, Abd-Allah F, Abera SF, et al. Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990–2013: quantifying the epidemiological transition. Lancet. 2015; Available from: . Cited 2015 Sep 7.
    1. Patel V, Chatterji S, Chisholm D, Ebrahim S, Gopalakrishna G, Mathers C, et al. Chronic diseases and injuries in India. Lancet Lond Engl. 2011;377:413–428. doi: 10.1016/S0140-6736(10)61188-9.
    1. Ajay VS, Tian M, Chen H, Wu Y, Li X, Dunzhu D, et al. A cluster-randomized controlled trial to evaluate the effects of a simplified cardiovascular management program in Tibet, China and Haryana, India: study design and rationale. BMC Public Health. 2014;14:924. doi: 10.1186/1471-2458-14-924.
    1. Tian M, Ajay VS, Dunzhu D, Hameed SS, Li X, Liu Z, et al. A cluster-randomized, controlled trial of a simplified multifaceted management program for individuals at high cardiovascular risk (SimCard trial) in rural Tibet, China, and Haryana, IndiaCLINICAL PERSPECTIVE. Circulation. 2015;132:815–824. doi: 10.1161/CIRCULATIONAHA.115.015373.
    1. 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(12):e004343. 10.1161/JAHA.116.004343.
    1. Ali MK, Singh K, Kondal D, Devarajan R, Patel SA, Shivashankar R, et al. Effectiveness of a multicomponent quality improvement strategy to improve achievement of diabetes care goals: a randomized, controlled trial. Ann Intern Med. 2016;165:399–408. doi: 10.7326/M15-2807.
    1. Jindal D, Gupta P, Jha D, Ajay VS, Goenka S, Jacob P, et al. Development of mWellcare: an mHealth intervention for integrated management of hypertension and diabetes in low-resource settings. Glob Health Action. 2018;11 Available from: . Cited 2019 Jul 27.
    1. Prabhakaran D, Jha D, Prieto-Merino D, Roy A, Singh K, Ajay VS, et al. 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. 10.1161/CIRCULATIONAHA.118.038192.
    1. Kowalski AJ, Poongothai S, Chwastiak L, Hutcheson M, Tandon N, Khadgawat R, et al. The INtegrating DEPrEssioN and Diabetes treatmENT (INDEPENDENT) study: design and methods to address mental healthcare gaps in India. Contemp Clin Trials. 2017;60:113–124. doi: 10.1016/j.cct.2017.06.013.
    1. Jindal D, Roy A, Ajay VS, Yadav SK, Prabhakaran D, Tandon N. Strategies for stakeholder engagement and uptake of new intervention: experience from state-wide implementation of mHealth technology for NCD care in Tripura, India. Glob Heart. 2019;14:165–172. doi: 10.1016/j.gheart.2019.06.002.
    1. Gupta R, Yusuf S. Towards better hypertension management in India. Indian J Med Res. 2014;139:657–660.
    1. Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. 1999;89:1322–1327. doi: 10.2105/AJPH.89.9.1322.
    1. Jeemon P, Narayanan G, Kondal D, Kahol K, Bharadwaj A, Purty A, et al. Task shifting of frontline community health workers for cardiovascular risk reduction: design and rationale of a cluster randomised controlled trial (DISHA study) in India. BMC Public Health. 2016;16:264. doi: 10.1186/s12889-016-2891-6.
    1. Athey S, Imbens GW. Identification and inference in nonlinear difference-in-differences models. Econometrica. 2006;74:431–497. doi: 10.1111/j.1468-0262.2006.00668.x.
    1. National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular diseases and Stroke (NPCDCS). Ministry of Health and Family Welfare, Government of India. . Accessed 29 Oct 2020.

Source: PubMed

Sponsors and Collaborators

Medical Conditions

Drug Interventions

3
Subscribe