Enhancing care quality and accessibility through digital technology-supported decentralisation of hypertension and diabetes management: a proof-of-concept study in rural Bangladesh

• Published in: BMJ open Vol. 13; no. 11; p. e073743
• Main Authors: Xie, Wubin, Paul, Rina Rani, Goon, Ian Y, Anan, Aysha, Rahim, Aminur, Hossain, Md Mokbul, Hersch, Fred, Oldenburg, Brian, Chambers, John, Mridha, Malay Kanti
• Format: Journal Article
• Language: English
• Published: London British Medical Journal Publishing Group 19.11.2023; BMJ Publishing Group LTD; BMJ Publishing Group
• Subjects: Acquired immune deficiency syndrome; AIDS; Blood pressure; Childrens health; Clinics; Community health care; Decentralization; Diabetes; diabetes & endocrinology; Digital technology; Global health; health services accessibility; Hypertension; Indigent care; Infectious diseases; Low income groups; Maternal & child health; Paramedics; Patients; Primary care; Rural areas; Workers; Bangladesh; South Asia
• ISSN: 2044-6055; 2044-6055
• DOI: 10.1136/bmjopen-2023-073743

ObjectiveThe critical shortage of healthcare workers, particularly in rural areas, is a major barrier to quality care for non-communicable diseases (NCD) in low-income and middle-income countries. In this proof-of-concept study, we aimed to test a decentralised model for integrated diabetes and hypertension management in rural Bangladesh to improve accessibility and quality of care.Design and settingThe study is a single-cohort proof-of-concept study. The key interventions comprised shifting screening, routine monitoring and dispensing of medication refills from a doctor-managed subdistrict NCD clinic to non-physician health worker-managed village-level community clinics; a digital care coordination platform was developed for electronic health records, point-of-care support, referral and routine patient follow-up. The study was conducted in the Parbatipur subdistrict, Rangpur Division, Bangladesh.ParticipantsA total of 624 participants were enrolled in the study (mean (SD) age, 59.5 (12.0); 65.1% female).OutcomesChanges in blood pressure and blood glucose control, patient retention and patient-visit volume at the NCD clinic and community clinics.ResultsThe proportion of patients with uncontrolled blood pressure reduced from 60% at baseline to 26% at the third month of follow-up, a 56% (incidence rate ratio 0.44; 95% CI 0.33 to 0.57) reduction after adjustment for covariates. The proportion of patients with uncontrolled blood glucose decreased from 74% to 43% at the third month of follow-up. Attrition rates immediately after baseline and during the entire study period were 29.1% and 36.2%, respectively.ConclusionThe proof-of-concept study highlights the potential for involving lower-level primary care facilities and non-physician health workers to rapidly expand much-needed services to patients with hypertension and diabetes in Bangladesh and in similar global settings. Further investigations are needed to evaluate the effectiveness of decentralised hypertension and diabetes care.