ArticlePDF Available

Using Technology and Innovation to Address the Three Delays in Access to Cardiac Surgery

Authors:
Afr. Ann Thorac. Cardiovasc.Surg.2018;13(1) 5-10
Afr. Ann. Thorac. CardiovascSurg.2018;13(1) 5-10
5
INTRODUCTION
CHIRURGIE CARDIAQUE / CARDIAC SURGERY
USING TECHNOLOGY AND INNOVATION TO ADDRESS
THE THREE DELAYS IN ACCESS TO CARDIAC SURGERY
D. VERVOORT, MD1.J. KPODONU, MD2
1. Program in Global Surgery and Social Change, Harvard Medical School
2. Beth Israel Deaconess, Harvard Medical School
Keywords:Technology; Innovation; Cardiac Surgery; Global Health
Correspondence:J. Kpodonu,MD
Beth Israel Deaconess Medical
Center Division of Cardiac Surgery
110 Francis Street, Suite 2A
Boston, MA 02215
Email: jkpodonu@bidmc.harvard.edu
Cardiovascular diseases (CVD) make up the leading cause of mortality in the world with 17.65 million
deaths every year, of which more than 80% occurs in low- and middle-income countries (LMICs)(1) .
With the ongoing shift of the global burden of CVD towards low-resource settings, a mortality rate of
25 million deaths is projected in these regions by 2030(2). Nevertheless, it is estimated that 93% of the
population in LMICs do not have access to safe cardiac surgical care, due to lack of nearby facilities,
limited specialist and allied health workforce, and high risk of catastrophic expenditure. As such, there
is a pressing need to address the barriers in receiving cardiac surgical care.
The Three Delays Framework can be used as a model to examine the barriers underlying access to
cardiac care. The First Delay, the delay in recognizing the disease and seeking care, comprises
health illiteracy, stigma of the condition, misperceptions of or lack of trust in modern medicine, and
economic barriers. The Second Delay, the delay in reaching care, includes the time and difficulty
reaching the nearest facility providing cardiac surgical care, dependent on road infrastructure, cli-
mate conditions, availability of private vehicles, public transport, or ambulatory services, and the
geographical distance to the facility. The Third Delay, the delay in receiving care, includes a four-fold
delay: a delay in receiving appropriate care at the initial facility, delay in timely referral to another
facility to receive definite care, delay in receiving appropriate definite care at a second facility, and a
delay in post-operative care and long-term follow-up in the setting of cardiac diseases.
The availability of workforce, in particular surgical specialist workforce, is a constant and widespread
issue in LMICs. Sub-Saharan Africa, for example, relies on only 1 cardiothoracic surgeon per 4 mil-
lion people. (3). In total, they possess only 1% of the world’s total cardiothoracic surgical workforce. In
addition, lack of surgical and medical infrastructure imposes an additional barrier for receiving care.
Afr. Ann Thorac. Cardiovasc.Surg.2018;13(1) 5-10
Afr. Ann. Thorac. CardiovascSurg.2018;13(1) 5-10
6
For example, in LMICs, dedicated cardiac intensive care units (CICUs) with specialized personnel is
limited, but dramatically improves outcomes in patients following cardiac surgery.(4).
Telemedicine is a useful tool to overcome geographical barriers and lack of workforce in order to
provide quality care and medical education from a distance. Clinicians are able to use mobile
videoconference systems to remotely access a patient’s room and monitor vital signs. This, in turn,
can allow for better care and service for the patient, whilst saving time and reducing costs of clini-
cians, patients, and their families.(5). For heart failure, telecare decreased hospitalization and mor-
tality rates by 20% with corresponding reduction in medical expenses and increase in the quality of
life.(6) .Similarly, the use in follow-up after cardiac surgery has proven effective in reducing readmis-
sion rates and preventing unnecessary visits (and related costs and anxiety), with high levels of sa-
tisfaction by both surgeons and patients.(7). Moreover, the use of “electronic CICUs” (e-CICUs) ser-
viced through telemedicine and adapted to local needs has proven logistically feasible and effective
in reducing CICU and hospital length-of-stay for both adult and paediatric cardiac care compared to
pretelemedicine periods.(4,8).In a day and age of widespread cellular use and expanding internet
connectivity, the use and development of mobile health (mHealth) innovations to scale up access to
healthcare in low-resource settings becomes increasingly important.mHealth devices allow for
reductions in costs, higher ease of use, and portability to help bridge existing gaps in cardiac care
through decentralizing diagnostics and medical management to health professionals and CHWs in
remote locations.(9). In this study, we review existing and potential technological innovations to address
the three delays limiting access to cardiac surgical care in low- and middle-income countries.
METHODS
A focused literature review was done searching the medical database PubMed using the keywords
“technology”, “innovation”, “low-income”, “low-resource”, “developing country”, “rheumatic heart di-
sease”, “congenital heart defect”, and “cardiac surgery” to identify literature on low-cost innovations
and technology to bridge the gap to accessing cardiac surgical care.
RESULTS
The First Delay - Delay in Seeking Care
Any delay in recognizing existing disease or being aware of the availability of necessary treatment
increases the likelihood of not receiving timely care and thus negatively influences outcomes and
long-term prognosis. Although cost is traditionally mentioned as an important factor in deciding to
seek care, other factors, such as recognizing the disease and the perception of the quality of the
available care, influence this decision more.(10,11).For the former, training community health wor-
kers (CHWs) to timely detect signs of cardiac surgical disease is an effective and low-cost way to
reduce the delay in seeking care. The use of handheld echocardiography, rather than sole auscul-
tation, is an effective and low-cost innovation to detect early cardiac disease, in particular RHD, by
trained non-physicians.(12,13) .This can be strengthened through web-based evaluation of echocar-
diograms using a cloud-based server through specialists from a distance.(14). More broadly, using
mHealth kits able to monitor vital signs (e.g., mobile blood pressure, oxymetry, pocket echocar-
diography, iPhone electrocardiogram, and point-of-care BNP) allows for timely referral for cardiac
interventions and lower probability of hospitalization or death.(15) .
The Second Delay - Delay in Reaching Care
Identifying and reaching the nearest facility able to provide affordable and quality cardiac care re-
lies upon the organization of the prehospital chain to access the clinical setting. Initiating effective
pre-hospital care through training lay first responders has proven to improve survival by reducing
the time to treatment in trauma care. (16).Mobile surgical units for cardiovascular disease further
reduce the time to treatment and can serve as a bridge between immediate life-saving care in the
pre-hospital setting and more complex permanent interventions upon reaching the surgical facility(17)
Afr. Ann Thorac. Cardiovasc.Surg.2018;13(1) 5-10
The Third Delay - Delay in Receiving Care
In order to avoid delays in care and prevent needless suffering, decentralizing diagnosis and ma-
nagement of cardiac with appropriate medical therapy and timely referral to surgical facilities is
possible and necessary.(18) .Conferencing between remote hospitals and cardiac centers allows for
the optimization of and reduction in (unnecessary) patient transfers.(19). After receiving surgical care
for cardiac diseases, immediate and long-term medical care and follow-up screening is essential to
warrant optimal health outcomes. Cardiac rehabilitation, due to the costs and lack of widespread
specialized centers, is traditionally hardly accessible for patients in LMICs. Through telemedicine
using videoconferencing, patients are able to access rehabilitation at distant sites with similar re-
sults as conventional rehabilitation sites.(20).For example, the eRegister system by the World Heart
Federation ensures real-time patient data collection and secondary prophylaxis, whilst keeping pa-
tients reminded of appointments through the use of SMS reminders and CHWs compliant with dia-
gnostic guidelines through electronic forms.(21) .
DISCUSSION
Technological innovation has the ability to reduce all three delays in accessing cardiac surgical care,
in addition to strengthening post-operative and long-term primary health systems to ensure optimal
short- and long-term outcomes. The use of digital health kits including portable echocardiography
and mHealth devices able to monitor oxymetry, blood pressure, ECG, and point-of-care BNP allows
for efficient and cost-effective early diagnosis and follow-up of cardiac conditions ranging from RHD
to heart failure. In addition, the widespread use of smartphones, cellular use, and internet connecti-
vity allows for remote monitoring and conferencing of experienced specialists with less experienced
specialists in rural hospitals or community health workers in community facilities. Moreover, pa-
tients are able to be reminded of medication use, rehabilitation instructions, or screening reminders
through mobile texting. Altogether, mHealth can bridge the gap in accessing cardiac care.
One barrier in receiving care for cardiac surgical disease is the availability of equipment, in particular
to replace valves in patients with severe aortic stenosis or mitral stenosis, the latter commonly due
to rheumatic heart disease (RHD). Every year, over 290,000 valve replacements are done around
the world, the majority taking place in Europe and the United States, accounting for a US$2 billion
market. Due to the high costs, use in LMICs remains scarce in the light of the higher need due to
RHD. The creation of low-cost biomolecularly enhanced polymeric heart valve with hyaluronan, as
opposed to traditional use of tissue valves, allows for high biocompatibility and lifelong durability,
able to be placed using trans-catheter aortic valve replacement (TAVR). In addition, the polymeric
heart valve material does not require anticoagulation therapy, minimizing costs and need for close
monitoring and follow-up of patients.
In addition to potential widespread use of technology to improve patient care, the ability to improve
the skills and opportunities for surgeons arises in a similar manner. Mobile applications have al-
lowed students and health professionals around the world to practice their medical and surgical
knowledge and skills outside the clinical setting. For example, Touch Surgery, a free mobile applica-
tion with over 2 million users worldwide, lets users learn, prepare, and test for surgical procedures
at any given location at any given time through a library of over 150 interactive, cognitive surgical
simulations.(22) .Virtual reality is slowly becoming used to give students, residents, and surgeons
remote access to surgical procedures elsewhere in the world to learn from experts in a virtual real-
time manner. Moreover, a digital health platform can connect cardiac specialists all over the world
through a collaborative platform for training, education, research, and patient care, with the ability to
expedite information sharing and service coordination to create a practical pathway for the delivery
of cardiac care in LMICs. Lastly, such a platform would promote the establishment of a coalition of
stakeholders, including, but not limited to cardiothoracic surgeons, cardiologists, industry, govern-
ments, and funders, to discuss and advance cardiac care around the world.
Afr. Ann. Thorac. CardiovascSurg.2018;13(1) 5- 10
7
Afr. Ann Thorac. Cardiovasc.Surg.2018;13(1) 5-10
Afr. Ann. Thorac. CardiovascSurg.2018;13(1) 5-10
CONCLUSION
Access to cardiac surgery in developing countries remains scarce and delays in accessing treat-
ment and follow-up care occur at all levels of the care pathway. Innovative mHealth and technologi-
cal strategies to promote early diagnosis of surgical cardiac conditions, reduce readmission rates,
and ensure proper post discharge management of patients are feasible and affordable in bridging
the current gaps in LMICs. In addition, mobile connectivity allows for remote interaction between
patients and medical specialists, as well as the creation of a web-based community of health pro-
fessionals and stakeholders to improve cardiac care around the world.
Afr. Ann Thorac. Cardiovasc.Surg.2018;13(1) 5-10
Afr. Ann. Thorac. CardiovascSurg.2018;13(1) 5-10
REFERENCES
1-IHME GHDx. GBD Results Tool [Internet]. 2016. Available from: http://ghdx.healthdata.org/ gbd-results-
tool
2-Yusuf S, Rangarajan S, Teo K, Islam S, Li W, Liu L, et al. Cardiovascular Risk and Events in 17
Low-, Middle-, and High-Income Countries. N Engl J Med [Internet]. 2014 Aug 27;371(9):81827.
Available from: https://doi.org/10.1056/NEJMoa1311890
3-Yankah C, Fynn-Thompson F, Antunes M, Edwin F, Yuko-Jowi C, Mendis S, et al. Cardiac surgery
capacity in sub-Saharan Africa: Quo Vadis? Thorac Cardiovasc Surg. 2014;62(5):393401.
4-Otero AV, Lopez-magallon AJ, Jaimes D, Motoa MV, Ruz M, Erdmenger J, et al. International
Telemedicine in Pediatric Cardiac Critical Care: A Multicenter Experience. 2014;20(7):61925.
5-Lopez-Magallon AJ, Otero AV, Welchering N, Bermon A, Castillo V, Duran Á, et al. Patient Out- comes
of an International Telepediatric Cardiac Critical Care Program. Telemed J e-Health [Internet]. 2015 Aug
1;21(8):60110. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4523040/
6-Paré G, Jaana M, Sicotte C. Systematic Review of Home Telemonitoring for Chronic Diseases: The
Evidence Base. J Am Med Inform Assoc [Internet]. 2007 Sep 8;14(3):26977. Available from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2244878/
7-Park DK, Jung E-Y, Park RW, Lee YH, Hwang HJ, Son IA, et al. Telecare System for Cardiac Surgery
Patients: Implementation and Effectiveness. Healthc Inform Res [Internet]. 2011 Jun 30;17(2):93100. Available
from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3155172/
8-Gupta S, Dewan S, Kaushal A, Seth A, Narula J,et al. CU Reduces Mortality in STEMI Patients in
Resource-Limited Areas. Glob Heart [Internet]. 2014;9(4):4257. Available from: http://
www.sciencedirect.com/science/article/pii/S2211816014026040
9-Agarwal S, Perry HB, Long L-A, Labrique AB. Evidence on feasibility and effective use of mHealth
strategies by frontline health workers in developing countries: systematic review. Trop Med Int Heal [Internet].
2015 Apr 16;20(8):100314. Available from: https://doi.org/10.1111/tmi.12525
10-Leigh B, Kandeh HB., Kanu M., Kuteh M, Palmer I., Daoh K., et al. Improving emergency obstetric
care at a district hospital, Makeni, Sierra Leone. Int J Gynecol Obstet [Internet]. 1998 Feb 5;59(S2):S5565.
Available from: https://doi.org/10.1016/S0020-7292(97)00148-3
11-Thaddeus S, Maine D. Too far to walk: Maternal mortality in context. Soc Sci Med [In- ternet].
1994;38(8):1091110. Available from: http://www.sciencedirect.com/science/article/ pii/0277953694902267
12-Godown J, Lu JC, Beaton A, Sable C, Mirembe G, Sanya R, et al. Handheld Echocardiography Versus
Auscultation for Detection of Rheumatic Heart Disease. Pediatrics [Internet]. 2015 Apr 1;135(4):e939 LP-e944.
Available from: http://pediatrics.aappublications.org/content/135/4/e939. abstract
13-Ploutz M, Lu JC, Scheel J, Webb C, Ensing GJ, Aliku T, et al. Handheld echocardiographic screening
for rheumatic heart disease by non-experts. Heart [Internet]. 2016 Jan 1;102(1):35 LP-39. Available from:
http://heart.bmj.com/content/102/1/35.abstract
14-Singh S, Bansal M, Maheshwari P, Adams D, Sengupta SP, Price R, et al. American Society of
Echocardiography: Remote Echocardiography with Web-Based Assessments for Referrals at a Distance (ASE-
REWARD) Study. J Am Soc Echocardiogr [Internet]. 2013;26(3):22133. Available from:
http://www.sciencedirect.com/science/article/pii/S0894731712009819
15-Bhavnani SP, Sola S, Adams D, Venkateshvaran A, Dash PK, Sengupta PP, et al. A Randomized
Trial of Pocket-Echocardiography Integrated Mobile Health Device Assessments in Modern Structural Heart
Disease Clinics. JACC Cardiovasc Imaging [Internet]. 2018;11(4):54657. Available from:
http://www.sciencedirect.com/science/article/pii/S1936878X17307210
16-Murad M, Husum H. Trained lay first responders reduce trauma mortality: a controlled study of rural
trauma in Iraq. Prehosp Disaster Med. 2010;Nov-Dec;25.
17-Itrat A, Taqui A, Cerejo R, et al. Telemedicine in prehospital stroke evaluation and thrombolysis: Taking
stroke treatment to the doorstep. JAMA Neurol [Internet]. 2016 Feb 1;73(2):1628. Available from:
http://dx.doi.org/10.1001/jamaneurol.2015.3849
18-Kwan GF, Bukhman AK, Miller AC, Ngoga G, Mucumbitsi J, Bavuma C, et al. A Simplified Echocardiographic
Strategy for Heart Failure Diagnosis and Management Within an Integrated Noncommunicable Disease Clinic at District
Hospital Level for Sub-Saharan Africa. JCHF. 2013;1(3):2306.
19- Nagayoshi Y, Oshima S, Ogawa H. Clinical Impact of Telemedicine Network System at Rural Hospitals
Afr. Ann Thorac. Cardiovasc.Surg.2018;13(1) 5-10
Afr. Ann. Thorac. CardiovascSurg.2018;13(1) 5-10
Without On-Site Cardiac Surgery Backup. Telemed e-Health [Internet]. 2016 May 5;22(11):9604. Available
from: https://doi.org/10.1089/tmj.2015.0225
20-Nagayoshi Y, Oshima S, Ogawa H. Clinical Impact of Telemedicine Network System at Rural Hospitals
Without On-Site Cardiac Surgery Backup. Telemed e-Health [Internet]. 2016 May 5;22(11):9604. Available
from: https://doi.org/10.1089/tmj.2015.0225
21-Dalleck LC, Schmidt LK, Lueker R. Cardiac rehabilitation outcomes in a conventional versus
telemedicine-based programme. J Telemed Telecare [Internet]. 2011 Apr 20;17(5):21721. Available from:
https://doi.org/10.1258/jtt.2010.100407
22-Dam J Van, Musuku J, Zühlke LJ, Engel ME, Nestle N, Tadmor B, et al. Cardiovascular To- pics An
open-access , mobile compatible , electronic patient register for rheumatic heart disease (“ eRegister ”) based
on the World Heart Federation ’ s framework for patient registers. 2015;(Octo- ber):17.
23-Brewer ZE, Ogden WD, Fann JI, Burdon TA, Sheikh AY. Creation and Global Deployment of a Mobile,
Application-Based Cognitive Simulator for Cardiac Surgical Procedures. Semin Thorac Cardiovasc Surg
[Internet]. 2016;28(1):19. Available from: http://www.sciencedirect.com/science/
article/pii/S1043067916000277.
Afr. Ann Thorac. Cardiovasc.Surg.2018;13(1) 5-10
Afr. Ann. Thorac. CardiovascSurg.2018;13(1) 5-10
1.
... Included articles had key information extracted, were summarized, and were categorized into 3 distinct themes according to the Three Delays Framework in access to care. 24 The Three Delays Framework divides delays in care into 3 distinct points in time. First, a delay in seeking care may occur, owing to patients not being aware of the need for care (eg, asymptomatic) or feeling deterred from seeking care (eg, by financial barriers, logistical reasons, distance). ...
Full-text available
Article
(244/250) Indigenous Peoples in Canada are at an increased risk of cardiovascular disease compared to non-Indigenous people. Contributing factors include historical oppression, racism, health care biases, and disparities in terms of the social determinants of health. Access to and inequity in cardiovascular care for Indigenous Peoples in Canada remain poorly studied and understood. A rapid review of the literature was performed using the PubMed/MEDLINE, Web of Science, and Indigenous Studies Portal (iPortal) databases to identify articles describing access to cardiovascular care for Indigenous Peoples in Canada between 2002 and 2021. Included articles were presented narratively in the context of delays in seeking care, reaching care, or receiving care, or as disparities in cardiovascular outcomes, and assessed for their successful engagement in Indigenous health research using a pre-existing framework. Current research suggests that gaps most prominently present as delays in receiving care and poorer long-term outcomes. The literature is concentrated in Alberta, Manitoba, and Ontario, as well as among First Nations people, and largely rooted in a biomedical worldview. Additional community-driven research is required to better elucidate the gaps in access to holistic cardiovascular care for Indigenous Peoples in Canada. Health care professionals, researchers, and policymakers should further reflect upon their actions and privilege, educate themselves about historical facts and the Truth and Reconciliation Commission, tackle prevailing disparities and systemic barriers in the health care systems, and develop culturally safe and ethically appropriate health care interventions to improve the health of all Indigenous Peoples in Canada.
... Tele-CICUs or e-CICUs have become implemented in both rural areas of high-income countries as low-resource areas in LMICs to provide tele-consultation of cardiac intensivists from elsewhere in the country or world to support understaffed CICUs. Notably, for post-operative CVD patients, e-CICUs have shown to be feasible and able to effectively reduce hospital and ICU length of stay compared to non-e-CICU patients [12]. ...
Full-text available
Article
Purpose of Review Cardiovascular diseases (CVD) are the world’s leading cause of mortality, responsible for 18 million deaths each year. Disease prevention is a critical component to curb the morbidity and mortality due to CVD worldwide, and advances in digital health technologies may facilitate adherence to and effectiveness of preventive measures. In this review, we seek to identify and describe recent developments in the use of digital health for CVD prevention between 2015 and 2019. Recent Findings Promising digital health technologies have emerged in the field of cardiology. In the diagnostics arena, AliveCor has shown to obtain real-time electrocardiograms via smartphones, whereas the Apple Watch proved efficacious to detect atrial fibrillation. In the treatment arena, the Corrie Health Digital Platform may enable myocardial infarction patients to benefit from remote cardiac rehabilitation and secondary prevention. Emerging technologies such as virtual reality, artificial intelligence, and machine learning suggest further potential for the growth and clinical relevance of digital cardiology. Summary Digital health technologies have become increasingly popular in the repertoire to prevent CVD. Although caution is warranted given the concurrent surge of unregulated smartphone applications and other technologies, digital cardiology presents important potential to reduce the global burden of CVD.
Chapter
Cardiovascular diseases are the leading cause of morbidity and mortality worldwide, and rapidly growing with the epidemiological transition of low- and middle-income countries (LMICs) from communicable to non-communicable diseases. Timely detection is paramount to avoid progressive disease with a poorer prognosis, yet screening mechanisms for cardiovascular diseases are limited beyond dedicated clinics and centers in LMICs. Moreover, diagnostic modalities are sparse, limiting conclusive diagnosis for many living with cardiovascular diseases in LMICs. However, opportunities arise to train community health workers and non-clinicians to screen people in their communities, whilst generating knowledge on the true burden in countries and regions to hold policy-makers and decision-makers accountable for the gaps in cardiac care.
Article
Background Six billion people in low- and middle-income countries (LMICs) lack timely or ready access to safe and affordable cardiac surgical care when needed, which remains a low priority on the global public health and global surgery agenda. Here, we perform the first state-of-the-art review of cardiac surgical care in LMICs to highlight the important milestones and current progress, as well as challenges associated with the expansion of sustainable global cardiac surgery for those in need. Methods A literature review was performed searching the PubMed/MEDLINE and Google Scholar databases using a combination of cardiac surgery, global health, and LMIC keywords. The Institute for Health Metrics and Evaluation Global Burden of Disease Results Tool was used to assess the global burden of disease related to cardiovascular surgical diseases. Results High-income countries are estimated to have over hundred times as many cardiac surgeons per million population compared to low-income countries. There are over 4,000 cardiac centers worldwide, but less than one center per ten million population in LMICs. Approximately 1.5 million cardiac operations are performed globally, of which a disproportionally low number in LMICs. Despite the high costs associated with cardiac operations, recent data suggests the favorable cost-effectiveness thereof in LMICs. Opportunities arise to sustainably integrate cardiac surgery in holistic health systems strengthening interventions. Conclusions Skepticism underlying the need, feasibility, and cost-effectiveness of cardiac surgery in LMICs prevail, but recent advances, successful case studies, and existing data illustrate the potential of expanding cardiac care globally.
Full-text available
Article
Objectives: This study sought to determine whether mobile health (mHealth) device assessments used as clinical decision support tools at the point-of-care can reduce the time to treatment and improve long-term outcomes among patients with rheumatic and structural heart diseases (SHD). Background: Newly developed smartphone-connected mHealth devices represent promising methods to diagnose common diseases in resource-limited areas; however, the impact of technology-based care on long-term outcomes has not been rigorously evaluated. Methods: A total of 253 patients with SHD were randomized to an initial diagnostic assessment with wireless devices in mHealth clinics (n = 139) or to standard-care (n = 114) in India. mHealth clinics were equipped with point-of-care devices including pocket-echocardiography, smartphone-connected-electrocardiogram blood pressure and oxygen measurements, activity monitoring, and portable brain natriuretic peptide laboratory testing. All individuals underwent comprehensive transthoracic echocardiography to assess the severity of SHD. The primary endpoint was the time to referral for therapy with percutaneous valvuloplasty or surgical valve replacement. Secondary endpoints included the probability of a cardiovascular hospitalization and/or death over 1-year. Results: An initial mHealth assessment was associated with a shorter time to referral for valvuloplasty and/or valve replacement (83 ± 79 days vs. 180 ± 101 days, p <0.001) and was associated with an increased probability for valvuloplasty/valve replacement compared to standard-care (34% vs. 32%; adjusted hazard ratio: 1.54; 95% CI: 0.96 to 2.47, p = 0.07). Patients randomized to mHealth were associated with a lower risk of a hospitalization and/or death on follow-up (15% vs. 28%, adjusted hazard ratio: 0.41; 95% CI: 0.21 to 0.83; p = 0.013). Conclusions: An initial mHealth diagnostic strategy was associated with a shorter time to definitive therapy among patients with SHD in a resource-limited area and was associated with improved outcomes. (A Randomized Trial of Pocket-Echocardiography Integrated Mobile Health Device Assessments in Modern Structural Heart Disease Clinics; NCT02881398).
Full-text available
Article
Background: Rheumatic heart disease (RHD) remains a major disease burden in low-resource settings globally. Patient registers have long been recognised to be an essential instrument in RHD control and elimination programmes, yet to date rely heavily on paper-based data collection and non-networked data-management systems, which limit their functionality. Objectives: To assess the feasibility and potential benefits of producing an electronic RHD patient register. Methods: We developed an eRegister based on the World Heart Federation's framework for RHD patient registers using CommCare, an open-source, cloud-based software for health programmes that supports the development of customised data capture using mobile devices. Results: The resulting eRegistry application allows for simultaneous data collection and entry by field workers using mobile devices, and by providers using computer terminals in clinics and hospitals. Data are extracted from CommCare and are securely uploaded into a cloud-based database that matches the criteria established by the WHF framework. The application can easily be tailored to local needs by modifying existing variables or adding new ones. Compared with traditional paper-based data-collection systems, the eRegister reduces the risk of data error, synchronises in real-time, improves clinical operations and supports management of field team operations. Conclusions: The user-friendly eRegister is a low-cost, mobile, compatible platform for RHD treatment and prevention programmes based on materials sanctioned by the World Heart Federation. Readily adaptable to local needs, this paperless RHD patient register program presents many practical benefits.
Full-text available
Article
Given the large scale adoption and deployment of mobile phones by health services and frontline health workers (FHW), we aimed to review and synthesize the evidence on the feasibility and effectiveness of mobile-based services on healthcare delivery. Five databases - Medline, Embase, Global Health, Google Scholar and Scopus - were systematically searched for relevant peer-reviewed articles published between 2000 and 2013. Data were extracted and synthesized across three themes: feasibility of use of mobile tools by FHWs, training required for adoption of mobile tools, and effectiveness of such interventions. 42 studies were included in this review. With adequate training, FHWs were able to use mobile phones to enhance various aspects of their work activities. Training of FHWs to use mobile phones for healthcare delivery ranged from a few hours to about one week. Five key thematic areas for the use of mobile phones by FHWs were identified: Data collection and reporting, training and decision support, emergency referrals, work planning through alerts and reminders, and improved supervision of and communication between healthcare workers. Data collection by mobile seems to improve promptness of data collection, reduce error rates, and improve data completeness. Two methodologically robust studies suggest that regular access to health information via SMS or mobile-based decision-support systems may improve the adherence of the FHWs to treatment algorithms. The evidence on the effectiveness of the other approaches was largely descriptive and inconclusive. Use of mHealth strategies by FHWs might offer some promising approaches to improving health care delivery; however, the evidence on the effectiveness of such strategies on healthcare outcomes is insufficient. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
Full-text available
Article
An optimal model for telemedicine use in the international care setting has not been established. Our objective was to describe variables associated with patient outcome during the implementation of an international pediatric cardiac critical care (PCCC) telemedicine program. A retrospective review was performed of clinical records and a telemedicine database of patients admitted to the cardiac intensive care unit (CICU) at the Fundacion Cardiovascular de Colombia, Bucaramanga, Colombia, during the initial 10 months of our program, compared with patients admitted during a previous period. Information collected included demographic data, cardiac diagnosis and associated factors, Risk Adjustment for Congenital Heart Surgery (RACHS)-1 classification, and perioperative events. Primary outcome was composed of CICU and hospital mortality. Secondary outcomes were CICU and hospital length of stay (LOS). Of the 553 patients who were included, teleconsultation was done for 71 (12.4%), with a total of 156 encounters, including 19 for patients on extracorporeal membrane oxygenation. Three hundred twenty-one recommendations were given, and 42 real-time interventions were documented. RACHS-1 distribution was similar between study periods (p=0.427). Teleconsulted patients were significantly younger (44 versus 24 months; p=0.03) and had higher surgical complexity than nonteleconsulted patients (p=0.01). RACHS-1 adjusted hospital survival was similar between study periods. CICU and hospital LOS intervals were significantly shorter in the telemedicine period (10 versus 17 days [p=0.02] and 22 versus 28 days [p<0.001]). In surgical cases, preoperative CICU LOS was significantly shorter (3 versus 6 days; p<0.001). Variables associated with hospital mortality were higher RACHS-1 categories, lower weight, bypass time longer than 150 min, and use of circulatory arrest, as well as the presence of sepsis or necrotizing enterocolitis. Those associated with increased LOS were lower weight, extracorporeal membrane oxygenation, and cross-clamp time longer than 60 min. An international telemedicine service in PCCC was associated with lower CICU and hospital LOS. Prospective telemedicine interventions aimed to decrease mortality and LOS should focus on patients with higher RACHS-1 categories, lower-weight infants, and those with prolonged operative time and selective perioperative complications.
Full-text available
Article
Background: More than 80% of deaths from cardiovascular disease are estimated to occur in low-income and middle-income countries, but the reasons are unknown. Methods: We enrolled 156,424 persons from 628 urban and rural communities in 17 countries (3 high-income, 10 middle-income, and 4 low-income countries) and assessed their cardiovascular risk using the INTERHEART Risk Score, a validated score for quantifying risk-factor burden without the use of laboratory testing (with higher scores indicating greater risk-factor burden). Participants were followed for incident cardiovascular disease and death for a mean of 4.1 years. Results: The mean INTERHEART Risk Score was highest in high-income countries, intermediate in middle-income countries, and lowest in low-income countries (P<0.001). However, the rates of major cardiovascular events (death from cardiovascular causes, myocardial infarction, stroke, or heart failure) were lower in high-income countries than in middle- and low-income countries (3.99 events per 1000 person-years vs. 5.38 and 6.43 events per 1000 person-years, respectively; P<0.001). Case fatality rates were also lowest in high-income countries (6.5%, 15.9%, and 17.3% in high-, middle-, and low-income countries, respectively; P=0.01). Urban communities had a higher risk-factor burden than rural communities but lower rates of cardiovascular events (4.83 vs. 6.25 events per 1000 person-years, P<0.001) and case fatality rates (13.52% vs. 17.25%, P<0.001). The use of preventive medications and revascularization procedures was significantly more common in high-income countries than in middle- or low-income countries (P<0.001). Conclusions: Although the risk-factor burden was lowest in low-income countries, the rates of major cardiovascular disease and death were substantially higher in low-income countries than in high-income countries. The high burden of risk factors in high-income countries may have been mitigated by better control of risk factors and more frequent use of proven pharmacologic therapies and revascularization. (Funded by the Population Health Research Institute and others.).
Full-text available
Article
Background: Current data on cardiac surgery capacity on which to base effective concepts for developing sustainable cardiac surgical programs in Africa are lacking or of low quality. Methods: A questionnaire concerning cardiac surgery in Africa was sent to 29 colleagues-26 cardiac surgeons and 3 cardiologists in 16 countries. Further, data on numbers of surgeons practicing in Africa were retrieved from the Cardiothoracic Surgery Network (CTSNet). Results: There were 25 respondents, yielding a response rate of 86.2%. Three models emerged: the Ghanaian/German model with a senior local consultant surgeon (Model 1); surgeons visiting for a short period to perform humanitarian surgery (Model 2); and expatriate surgeons on contract to develop cardiac programs (Model 3). The 933 cardiothoracic surgeons listed by CTSNet translated into one surgeon per 1.3 million people. In North Africa, the figure was three surgeons per 1 million and in sub-Saharan Africa (SSA), one surgeon per 3.3 million people. The identified 156 cardiac surgeons represented a surgeon to population ratio of 1:5.9 million people. In SSA, the ratio was one surgeon per 14.3 million. In North Africa, it was one surgeon per 1.1 million people. Open heart operations were approximately 12 per million in Africa, 2 per million in SSA, and 92 per million people in North Africa. Conclusion: Cardiothoracic health care delivery would worsen in SSA without the support of humanitarian surgery. Although all three models have potential for success, the Ghanaian/German model has proved to be successful in the long term and could inspire health care policy makers and senior colleagues planning to establish cardiac programs in Africa.
Article
Several modern learning frameworks (eg, cognitive apprenticeship, anchored instruction, and situated cognition) posit the utility of nontraditional methods for effective experiential learning. Thus, development of novel educational tools emphasizing the cognitive framework of operative sequences may be of benefit to surgical trainees. We propose the development and global deployment of an effective, mobile cognitive cardiac surgical simulator. In methods, 16 preclinical medical students were assessed. Overall, 4 separate surgical modules (sternotomy, cannulation, decannulation, and sternal closure) were created utilizing the Touch Surgery (London, UK) platform. Modules were made available to download free of charge for use on mobile devices. Usage data were collected over a 6-month period. Educational efficacy of the modules was evaluated by randomizing a cohort of medical students to either module usage or traditional, reading-based self-study, followed by a multiple-choice learning assessment tool. In results, downloads of the simulator achieved global penetrance, with highest usage in the USA, Brazil, Italy, UK, and India. Overall, 5368 unique users conducted a total of 1971 hours of simulation. Evaluation of the medical student cohort revealed significantly higher assessment scores in those randomized to module use versus traditional reading (75% ± 9% vs 61% ± 7%, respectively; . P < 0.05). In conclusion, this study represents the first effort to create a mobile, interactive cognitive simulator for cardiac surgery. Simulators of this type may be effective for the training and assessment of surgical students. We investigated whether an interactive, mobile-computing-based cognitive task simulator for cardiac surgery could be developed, deployed, and validated. Our findings suggest that such simulators may be a useful learning tool.
Article
Importance Mobile stroke treatment units (MSTUs) with on-site treatment teams that include a vascular neurologist can provide thrombolysis in the prehospital setting faster than treatment in the hospital. These units can be made more resource efficient if the need for an on-site neurologist can be eliminated by relying solely on telemedicine for physician presence.Objective To test whether telemedicine is reliable and remote physician presence is adequate for acute stroke treatment using an MSTU.Design, Setting, and Participants Prospective observational study conducted between July 18 and November 1, 2014. The dates of the study analysis were November 1, 2014, to March 30, 2015. The setting was a community-based study assessing telemedicine success of the MSTU in Cleveland, Ohio. Participants were the first 100 residents of Cleveland who had an acute onset of stroke-like symptoms between 8 am and 8 pm and were evaluated by the MSTU after the implementation of the MSTU program at the Cleveland Clinic. A vascular neurologist evaluated the first 100 patients via telemedicine, and a neuroradiologist remotely assessed images obtained by mobile computed tomography (CT). Data were entered into the medical record and a prospective registry.Main Outcomes and Measures The study compared the evaluation and treatment of patients on the MSTU with a control group of patients brought to the emergency department via ambulance during the same year. Process times were measured from the time the patient entered the door of the MSTU or emergency department, and any problems encountered during his or her evaluation were recorded.Results Ninety-nine of 100 patients were evaluated successfully. The median duration of telemedicine evaluation was 20 minutes (interquartile range [IQR], 14-27 minutes). One connection failure was due to crew error, and the patient was transported to the nearest emergency department. There were 6 telemedicine disconnections, none of which lasted longer than 60 seconds or affected clinical care. Times from the door to CT completion (13 minutes [IQR, 9-21 minutes]) and from the door to intravenous thrombolysis (32 minutes [IQR, 24-47 minutes]) were significantly shorter in the MSTU group compared with the control group (18 minutes [IQR, 12-26 minutes] and 58 minutes [IQR, 53-68 minutes], respectively). Times to CT interpretation did not differ significantly between the groups.Conclusions and Relevance An MSTU using telemedicine is feasible, with a low rate of technical failure, and may provide an avenue for reducing the high cost of such systems.
Article
Timely healthcare access poses a formidable challenge in the semiurban and rural areas of the developing world. This is particularly noticeable in emergency situations such as ST-segment elevation myocardial infarction (STEMI).
Article
Objective: To describe our multicenter experience in telemedicine-assisted pediatric cardiac critical care (PCCC) with four hospitals in Latin America from July 2011 to June 2013. Materials and methods: This was a descriptive study based on telemedicine encounters related to quality of communication, assessed information, activities, and recommendations. Comparison among centers was performed. A postimplementation survey was conducted through a 5-point Likert scale questionnaire investigating acceptance among professionals involved with the telemedicine service through the assessment of general satisfaction, perception about the work system, usefulness, and impact on medical practice. Results: One thousand forty consultations were conducted for 476 patients. Postoperatively, patients were distributed into Risk Adjustment Classification for Congenital Heart Surgery (RACHS-1) categories as follows: 2%, 26%, 36%, 26%, and 10% in categories 1, 2, 3, 4, and 6, respectively. A real-time intervention took place in 23% of encounters. Of the 2,173 recommendations given, 70 were related to extracorporeal membrane oxygenation management. There was a different RACHS-1 distribution and encounter characteristics among centers. From a total of 51 surveys sent, 27 responses were received, and among responders, overall satisfaction was very high (4.27 ± 0.18), as well as work system quality (4.4 ± 0.37). Telemedicine was considered useful in the cardiac intensive care unit (3.86 ± 0.60), for patient outcomes (3.8 ± 0.51), and for education (3.7 ± 0.71). There was a difference in overall satisfaction, perception about telemedicine usefulness in education, and impact on medical practice among centers. Conclusions: An international, multicenter telemedicine program in PCCC is technologically and logistically feasible. Prospective interventions in our international multicenter telemedicine program should consider differences in staff composition, perception of needs, and patient population among centers.