Improving the accuracy of heart failure diagnosis in low-resource settings through task sharing and decentralization

• Published in: Global health action Vol. 12; no. 1; p. 1684070
• Main Authors: DeWyer, Alyssa, Scheel, Amy, Otim, Isaac Omara, Longenecker, Christopher T., Okello, Emmy, Ssinabulya, Isaac, Morris, Stephen, Okwir, Mark, Oyang, William, Joyce, Erine, Nabongo, Betty, Sable, Craig, Alencherry, Ben, Tompsett, Alison, Aliku, Twalib, Beaton, Andrea
• Format: Journal Article
• Language: English
• Published: United States Taylor & Francis 01-01-2019; Taylor & Francis Ltd; Taylor & Francis Group
• Subjects: Accuracy; Adult; Aged; Cardiologists; Cardiovascular disease; Cardiovascular diseases; Classification; Clinical Competence; Clinical decision making; Clinical outcomes; Competence; Curricula; Decentralization; Diagnostic tests; Distance learning; Echocardiography; Echocardiography - methods; Echocardiography - standards; Experts; Feasibility; Female; Health care; Health Personnel - education; Health services utilization; Heart failure; Heart Failure - diagnosis; Heart Failure - diagnostic imaging; Humans; Hypertension; Inservice Training - organization & administration; Internet; Male; Medical diagnosis; Mentoring; Middle Aged; Original; Patients; Sensitivity and Specificity; task-shifting; Telemedicine; Training; Uganda; Ultrasonic imaging; Uganda; telemedicine; Uganda; training; Echocardiography; task-shifting
• ISSN: 1654-9716; 1654-9880
• DOI: 10.1080/16549716.2019.1684070

Background: Task sharing of TTE may improve capacity for heart failure diagnosis and management in patients in remote, low-resource settings but the impact on diagnostic accuracy and patient outcomes has not been studied.
Objectives: Determine feasibility and impact of non-expert training in transthoracic echocardiography (TTE) to improve the diagnosis and outcomes of patients with suspected heart failure in Uganda.
Methods: This two-part study examined an innovative training program to develop TTE competency among non-experts and used a pre-post design to determine the impact of decentralized TTE. Four of 8 non-experts (50%) passed a three-part training course. The training comprised of distance learning through a web-based curriculum, a 2-day hands-on workshop with cardiologists, and independent practice with remote mentorship. Continuous measures were compared (pre- vs. post-TTE) using t-tests or Wilcoxon rank-sum tests as distributionally appropriate and categorical variables assessed through chi-square testing. Sensitivity and specificity were calculated according to standard methodology comparing diagnosis pre- and post-TTE during phase 2.
Results: Performance in the post-training phase showed good agreement with expert categorization (κ = 0.80) with diagnostic concordance in 421 of 454 studies (92.7%). TTE changed the preliminary diagnosis in 81% of patients, showing low specificity of clinical decision-making alone (14.2%; 95% CI 10.1-19.2%). Dilated cardiomyopathy, hypertensive heart disease with preserved systolic function, and right heart failure were the most underdiagnosed conditions prior to TTE while hypertensive heart disease with decreased systolic function was the most over-diagnosed condition.
Conclusions: In conclusion, non-expert providers can achieve a high level of proficiency for the categorization of heart failure using handheld TTE in low-resource settings and use of telemedicine and remote mentorship may improve performance and feasibility. The addition of TTE resulted in substantial improvement in etiological specificity. Further study is needed to understand implications of this strategy on healthcare utilization, long-term patient outcomes, and cost.