Victoria Hardy

Exploring the barriers and facilitators to use of point of care tests in family medicine clinics in the United States.

BackgroundPoint-of-care tests (POCTs) are increasingly used in family medicine clinics in the United States. While the diagnostics industry predicts significant growth in the number and scope of POCTs deployed, little is known about clinic-level attitudes towards implementation of these tests. We aimed to explore attitudes of primary care providers, laboratory and clinic administrative/support staff to identify barriers and facilitators to use of POCTs in family medicine.MethodsSeven focus groups and four semi-structured interviews were conducted with a total of 52 clinic staff from three family medicine clinics in two US states. Qualitative data from this exploratory study was analyzed using the constant comparison method.ResultsFive themes were identified which included the impact of POCTs on clinical decision-making; perceived inaccuracy of POCTs; impact of POCTs on staff and workflow; perceived patient experience and patient-provider relationship, and issues related to cost, regulation and quality control. Overall, there were mixed attitudes towards use of POCTs. Participants believed the added data provided by POCT may facilitate prompt clinical management, diagnostic certainty and patient-provider communication.Perceived barriers included inaccuracy of POCT, shortage of clinic staff to support more testing, and uncertainty about their cost-effectiveness.ConclusionsThe potential benefits of using POCTs in family medicine clinics are countered by several barriers. Clinical utility of many POCTs will depend on the extent to which these barriers are addressed. Engagement between clinical researchers, industry, health insurers and the primary care community is important to ensure that POCTs align with clinic and patient needs.

Qualitative study of primary care clinicians’ views on point-of-care testing for C-reactive protein for acute respiratory tract infections in family medicine

Objective To explore clinicians views of the barriers and facilitators to use of C-reactive protein (CRP) point-of-care tests (POCT) in US family medicine clinics for the management of acute respiratory tract infections (ARTIs) in adults. Setting Five family medicine clinics across two US states. Participants 30 clinicians including 18 physicians, 9 physician residents, 2 physician assistants and 1 nurse practitioner, took part in the study. Design A qualitative study using a grounded theory approach to thematically analyse focus group interviews. Results These clinicians had limited access to diagnostic tests for patients with ARTI, and very little knowledge of CRP POCT. Three major themes were identified and included the potential clinical role of CRP POCT, concerns related to implementing CRP POCT and evidence needed prior to wider adoption in family medicine. Clinicians believed CRP POCT could support decision-making for some presentations of ARTIs and patient populations when used in conjunction with clinical criteria. Clinicians had concerns about possible overuse and inaccuracy of CRP POCT which they believed might increase antibiotic prescribing rates. Other concerns identified included integration of the test with clinic workflows and cost-effectiveness. Conclusions Clinicians stand at the forefront of antibiotic stewardship efforts, but have few diagnostic tests to help them confidently manage ARTIs. CRP POCT may facilitate some aspects of clinical practice. Incorporating CRP POCT with clinical guidelines may strengthen utility of this test, when there is diagnostic uncertainty.

Supporting LIFE: Mobile Health Application for Classifying, Treating and Monitoring Disease Outbreaks of Sick Children in Developing Countries

This paper presents the Supporting LIFE L ow cost I ntervention F or dis E ase control project. Supporting LIFE applies a novel combination of Android based smartphone technology, patient vital sign sensors and expert decision support systems to assist Community Health Workers in resource-poor settings in their assessment, classification and treatment of seriously ill children, more specifically children from 2 months to 5 years of age. The application digitises widely accepted WHO/UNICEF paper based guidelines known as Community Case Management. The project also facilitates for disease monitoring and surveillance via a reporting website.

A mobile health technology intervention for addressing the critical public health issue of child mortality

Evaluations of development initiatives in resource‐poor settings dominate Health Information Technology/Systems research. Yet a dearth of research exists, which documents the design and development of these technological artefacts. Through the lens of Transition Management Framework, this research attempts to address this gap in literature, to describe a particular technology (ie, Supporting LIFE—SL eCCM App) and the way in which its hardware, software, and system configurations interact with the sociocultural and economic context in one rural region of the Malawian community. This study uses a design science perspective to ensure the design and development of a health technology intervention that is relevant and has utility in the context for which it has been built, ie, Malawi Africa. This paper addresses the manner in which the configurations of a mobile Health intervention (known as Supporting LIFE eCCM App) interact within a developing world context. Supporting LIFE eCCM aims to leverage the critical societal issue of reducing child mortality in Malawi, Africa. The design science approach supports the design and build of a health intervention that is a good fit for the “real‐world” health scenario considered. Coupled with Geels Transition Management Framework, we emphasise the need for a balanced sociotechnical approach to mHealth, placing individuals at the centre of the IT development project while also considering social, economic, and cultural factors. These are key environmental aspects of a development project such as this one.

Evaluating mobile solutions of integrated Community Case Management (iCCM): Making the final connection

The current state of iCCM Acknowledging a shortage of clinicians and inequitable access to basic health care for many communities in lowand middle-income countries (LMICs), the World Health Organization and United Nations Children’s Fund developed integrated Community Case Management (iCCM)1. iCCM is a paper-based clinical decision rule that is deployed by frontline community health workers (CHWs) in hard-toreach locations. The components of the decision rule are sufficiently simple for CHWs who are educated to secondary school level (with 6 days statutory iCCM training)2 to be able to manage uncomplicated illnesses in the community, and urgently refer seriously ill children to higher-level facilities for more comprehensive medical attention. Rolled out in the early 2000s3 across Asia and sub-Saharan Africa, iCCM (and its related decision rule, Integrated Management of Childhood Illness (IMCI)) contributed to notable progress towards achieving Millennium Development Goal 44. Despite significant reductions in under-5 morbidity and mortality between 1990 and 20155, the overall impact of iCCM on childhood survival in LMICs is undermined by a variety of factors. These include poor CHW adherence to guidelines6,7, incomplete patient recording, cumbersome monthly aggregation and reporting of cases to district health offices, as well as infrequent training opportunities to retain and develop skills, and irregular supervisory support8. This has prompted innovative strategies in attempts to optimize iCCM delivery.

Training community healthcare workers on the use of information and communication technologies: a randomised controlled trial of traditional versus blended learning in Malawi, Africa

BackgroundDespite the increasing uptake of information and communication technologies (ICT) within healthcare services across developing countries, community healthcare workers (CHWs) have limited knowledge to fully utilise computerised clinical systems and mobile apps. The ‘Introduction to Information and Communication Technology and eHealth’ course was developed with the aim to provide CHWs in Malawi, Africa, with basic knowledge and computer skills to use digital solutions in healthcare delivery. The course was delivered using a traditional and a blended learning approach.MethodsTwo questionnaires were developed and tested for face validity and reliability in a pilot course with 20 CHWs. Those were designed to measure CHWs’ knowledge of and attitudes towards the use of ICT, before and after each course, as well as their satisfaction with each learning approach. Following validation, a randomised controlled trial was conducted to assess the effectiveness of the two learning approaches. A total of 40 CHWs were recruited, stratified by position, gender and computer experience, and allocated to the traditional or blended learning group using block randomisation. Participants completed the baseline and follow-up questionnaires before and after each course to assess the impact of each learning approach on their knowledge, attitudes, and satisfaction. Per-item, pre-post and between-group, mean differences for each approach were calculated using paired and unpaired t-tests, respectively. Per-item, between-group, satisfaction scores were compared using unpaired t-tests.ResultsScores across all scales improved after attending the traditional and blended learning courses. Self-rated ICT knowledge was significantly improved in both groups with significant differences between groups in seven domains. However, actual ICT knowledge scores were similar across groups. There were no significant differences between groups in attitudinal gains. Satisfaction with the course was generally high in both groups. However, participants in the blended learning group found it more difficult to follow the content of the course.ConclusionsThis study shows that there is no difference between blended and traditional learning in the acquisition of actual ICT knowledge among community healthcare workers in developing countries. Given the human resource constraints in remote resource-poor areas, the blended learning approach may present an advantageous alternative to traditional learning.

Which Point-of-Care Tests Would Be Most Beneficial to Add to Clinical Practice?: Findings From a Survey of 3 Family Medicine Clinics in the United States

Background Point-of-care tests (POCTs) are increasingly used in family medicine to facilitate screening, diagnosis, monitoring, treatment, and referral decisions for a variety of conditions. Point-of-care tests that clinicians believe might be beneficial to add to clinical practice and the conditions for which they would be most useful in family medicine remain poorly understood in the United States. Methods Forty-two clinicians at 3 family medicine residency clinics completed a brief survey asking which POCTs they believed would be beneficial to add to their clinical practice and the conditions POCTs would be most useful for. We calculated frequencies of reported POCTs and conditions using descriptive statistics. Results Clinicians identified 34 POCTs that would be beneficial to add to family medicine, of which hemoglobin A1c, chemistry panels, and human immunodeficiency virus and gonococcal and/or chlamydia were most frequently reported and anticipated would be used weekly. Clinicians reported 30 conditions for which they considered POCTs would be useful. Diabetes mellitus, sexually transmitted infections, and respiratory tract infections were the most often reported and were identified as benefiting diagnosis, monitoring, and treatment decisions. Conclusions Clinicians identified a number of POCTs they viewed as being beneficial to add to their routine clinical practice, mostly to inform diagnosis and treatment planning. Some POCTs identified are available in the United States; thus, understanding barriers to implementation of these POCTs in primary care settings is necessary to optimize adoption.

Stakeholders perspectives on paper-based and electronic clinical decision support systems in Malawi Africa

Abstract The objective of this paper is to explore the perceptions of key stakeholders involved and/or affected by existing paper-based decision support guidelines (known as Community Case Management (CCM)) and a proposed digitised mobile clinical decision support system (CDSS) of CCM in rural settings of Malawi, Africa. Data was collected using field notes and semi-structured interviews with 17 key stakeholders (i.e. clinical, technical, development aid support (NGO), government and community health workers both in Malawi, Europe and USA). Stakeholders provide a rich insight into the variety of both perceived benefits and challenges of the existing guidelines and the proposed electronic CDSS. It was found that all stakeholders believe that the CDSS will improve adherence to guidelines and subsequently result in better care for children. It is further envisioned that the time needed for administration with the current paper-based approach could be reduced using electronic, as opposed to manual, collation and sending of records. This paper acts to underpin the rationale and motivation for the development and rollout of an electronic CDSS to support community health workers in their assessment, classification and treatment of young children in rural settings in Malawi, Africa.