XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

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).

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

Apresentacao Em boa hora, decidiu a Sociedade Brasileira de Cardiologia (SBC) fazer uma diretriz em telemedicina aplicada a cardiologia, tambem designada telecardiologia. A Organizacao Pan-americana de Saude (OPAS) e a Organizacao Mundial de Saude (OMS) definem Telemedicina como “a prestacao de servicos de saude remotos na promocao, prevencao, diagnostico, tratamento e reabilitacao pelos profissionais de saude que utilizam as tecnologias de informacao e comunicacao, que lhes permitem trocar dados, com o objetivo de facilitar o acesso e a oportunidade na [...]

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Guideline of the Brazilian Society of Cardiology on Telemedicine in Cardiology - 2019

Brazil’s Family Health Strategy (FHS) leads public health policies and actions regarding community health, addressing arterial hypertension (AH) in primary care settings. In this scenario, the use of communication technologies becomes appropriate for the monitoring of patients with AH. To preliminary verify the intervention approach and the effects of using an m-Health application on the health conditions of patients with AH for a future study, we conducted a non-randomized, controlled, non-blind trial (N = 39), comparing the use of a mobile health app (m-Health) with conventional AH monitoring over 3 months. During the study, we promoted health information workshops to engage patients from both intervention and control groups. Pre and post-intervention, we compared measurements of systolic and diastolic blood pressure; food frequency questionnaire; Appraisal of Self-Care Agency Scale; blood tests of hemogram, creatinine, uric acid, sodium, potassium, lipid profile, and glycemia. Improvements were identified in both groups due to the workshops, including the reduction in total and non-HDL cholesterol, healthier consumption of salads and sugary drinks, and increased self-care scores. Exclusively in the intervention group, which used the m-Health app, there was a change in systolic and diastolic pressure towards more adequate levels. In addition, the intervention group had improved levels of glucose and HDL cholesterol and reduced consumption of ultra-processed foods. In conclusion, the use of an m-Health app had positive effects on the health conditions of patients with AH under treatment within FHS, especially when combined with health information. On the context of FHS, the use of technology is encouraging supporting better health conditions.

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Effects of using a mobile health application on the health conditions of patients with arterial hypertension: A pilot trial in the context of Brazil's Family Health Strategy.

Clinical Decision Support Systems (CDSSs) are used in a clinical setting to help physicians make decisions to improve clinical performance and patient care. There are many benefits to the implementation and adoption of CDSSs, such as reducing the rate of misdiagnosis, improving efficiency and patient care, and reducing the risk of medication errors. On the other hand, CDSSs can have several disadvantages. For example, physicians can see CDSSs as a threat to their clinical autonomy. CDSSs can also be very costly to adopt, maintain, and support. These advantages and disadvantages can have both positive and negative impacts on physicians. We conducted a scoping review to explore the impact of CDSSs on physicians. We searched the following electronic databases: CINAHL, PubMed, and Google Scholar. Two reviewers independently selected the retrieved studies and extracted data from the included studies. A narrative approach was used to synthesize the extracted data. We included 14 studies of the 300 retrieved studies. We identified the following positive impacts: work efficiency, providing more personalized care, improving care and knowledge, increasing confidence in making decisions, improving prescribing behavior, and reducing the number of ordered laboratory and medical imaging tests. Several negative impacts were also reported by the studies, namely: inefficient documentation, interruption in the patient-physician communication, and an increase in unnecessary referrals.

The Impact of Clinical Decision Support Systems (CDSS) on Physicians: A Scoping Review

Background: Despite being an important cardiovascular risk factor, hypertension has low control levels worldwide. Computerized clinical decision support systems (CDSSs) might be effective in reducing blood pressure with a potential impact in reducing cardiovascular risk. Objective: The goal of the research was to evaluate the feasibility, usability, and utility of a CDSS, TeleHAS (tele–hipertensao arterial sistemica, or arterial hypertension system), in the care of patients with hypertension in the context of a primary care setting in a middle-income country. Methods: The TeleHAS app consists of a platform integrating clinical and laboratory data on a particular patient, from which it performs cardiovascular risk calculation and provides evidence-based recommendations derived from Brazilian and international guidelines for the management of hypertension and cardiovascular risk. Ten family physicians from different primary care units in the city of Montes Claros, Brazil, were randomly selected to use the CDSS for the care of hypertensive patients for 6 months. After 3 and 6 months, the feasibility, usability, and utility of the CDSS in the routine care of the health team was evaluated through a standardized questionnaire and semistructured interviews. Results: Throughout the study, clinicians registered 535 patients with hypertension, at an average of 1.24 consultations per patient. Women accounted for 80% (8/10) of participant doctors, median age was 31.5 years (interquartile range 27 to 59 years). As for feasibility, 100% of medical users claimed it was possible to use the app in the primary care setting, and for 80% (8/10) of them it was easy to incorporate its use into the daily routine and home visits. Nevertheless, 70% (7/10) of physicians claimed that the time taken to fill out the CDSS causes significant delays in service. Clinicians evaluated TeleHAS as good (8/10, 80% of users), with easy completion and friendly interface (10/10, 100%) and the potential to improve patients’ treatment (10/10, 100%). A total of 90% (9/10) of physicians had access to new knowledge about cardiovascular risk and hypertension through the app recommendations and found it useful to promote prevention and optimize treatment. Conclusions: In this study, a CDSS developed to assist the management of patients with hypertension was feasible in the context of a primary health care setting in a middle-income country, with good user satisfaction and the potential to improve adherence to evidence-based practices.

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Development and Evaluation of a Mobile Decision Support System for Hypertension Management in the Primary Care Setting in Brazil: Mixed-Methods Field Study on Usability, Feasibility, and Utility.

Background: Although cardiovascular diseases are the main cause of morbimortality in Brazil, the access of small-town populations to electrocardiography and cardiology assessment is limited. The use of telecardiology to assist the access of distant towns to electrocardiography and a second opinion in cardiology is promising; however, it has not been formally assessed.

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Implantação de um Sistema de Telecardiologia em Minas Gerais: Projeto Minas Telecardio Implementation of a Telecardiology System in the state of Minas Gerais: the Minas Telecardio Project

Elmiro Santos Resende

Papers

Development and Evaluation of a Mobile Decision Support System for Hypertension Management in the Primary Care Setting in Brazil: Mixed-Methods Field Study on Usability, Feasibility, and Utility.

Implantação de um Sistema de Telecardiologia em Minas Gerais: Projeto Minas Telecardio Implementation of a Telecardiology System in the state of Minas Gerais: the Minas Telecardio Project