Development and Implementation of a Decision Support System to Improve Control of Hypertension and Diabetes in a Resource-Constrained Area in Brazil: Mixed Methods Study

Abstract

Background The low levels of control of hypertension and diabetes mellitus are a challenge that requires innovative strategies to surpass barriers of low sources, distance, and quality of health care. Objective The aim of this study is to develop a clinical decision support system (CDSS) for diabetes and hypertension management in primary care, to implement it in a resource-constrained region, and to evaluate its usability and health care practitioner satisfaction. Methods This mixed methods study is a substudy of HealthRise Brazil Project, a multinational study designed to implement pilot programs to improve screening, diagnosis, management, and control of hypertension and diabetes among underserved communities. Following the identification of gaps in usual care, a team of clinicians established the software functional requirements. Recommendations from evidence-based guidelines were reviewed and organized into a decision algorithm, which bases the CDSS reminders and suggestions. Following pretesting and expert panel assessment, pilot testing was conducted in a quasi-experimental study, which included 34 primary care units of 10 municipalities in a resource-constrained area in Brazil. A Likert-scale questionnaire evaluating perceived feasibility, usability, and utility of the application and professionals’ satisfaction was applied after 6 months. In the end-line assessment, 2 focus groups with primary care physicians and nurses were performed. Results A total of 159 reminders and suggestions were created and implemented for the CDSS. At the 6-month assessment, there were 1939 patients registered in the application database and 2160 consultations were performed by primary care teams. Of the 96 health care professionals who were invited for the usability assessment, 26% (25/96) were physicians, 46% (44/96) were nurses, and 28% (27/96) were other health professionals. The questionnaire included 24 items on impressions of feasibility, usability, utility, and satisfaction, and presented global Cronbach α of .93. As for feasibility, all professionals agreed (median scores of 4 or 5) that the application could be used in primary care settings and it could be easily incorporated in work routines, but physicians claimed that the application might have caused significant delays in daily routines. As for usability, overall evaluation was good and it was claimed that the application was easy to understand and use. All professionals agreed that the application was useful (score 4 or 5) to promote prevention, assist treatment, and might improve patient care, and they were overall satisfied with the application (median scores between 4 and 5). In the end-line assessment, there were 4211 patients (94.82% [3993/4211] with hypertension and 24.41% [1028/4211] with diabetes) registered in the application’s database and 7960 consultations were performed by primary health care teams. The 17 participants of the focus groups were co...

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“…This mixed methods study was a substudy of the Charming Project that took place in 34 primary health care centers (PHCCs) in 10 municipalities of Mucuri Valley: Ataléia, Catuji, Crisólita, Frei Gaspar, Itaipé, Ladainha, Novo Oriente de Minas, Ouro Verde de Minas, Setubinha, and Teófilo Otoni [ 13 ]. Mucuri Valley is part of the Northeast Macro-Region of Minas Gerais, Brazil, with a territorial extension of 24,781.5 km 2 and a population of 516,073 inhabitants, marked by drastic socioeconomic contrasts, high rates of illiteracy and poverty, and low rates of control of hypertension and DM [ 14 ].…”

“…Data were obtained through the usual medical and nursing consultation procedures, recorded in the software developed in the study [ 13 ]. Variables of interest were sociodemographic data (age, sex, education, income), clinical data (hypertension, DM, stroke, peripheral arterial disease, coronary artery disease, heart failure, alcoholism, physical inactivity, smoking), laboratory data (glycated hemoglobin [HbA 1c ]), physical examination measures (systolic BP [SBP] and diastolic BP [DBP]), and follow-up data (number of consultations performed).…”

“…Community health workers (CHWs) received tablets to enroll patients in the screening phase. These devices were also useful to improve CHWs’ work routines, facilitating the entry of data into the Ministry of Health's information system [ 13 ].…”

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“…CDSSs should not be an extension of their work, rather they should serve as a support for the development of more advanced CDSS frameworks. Indeed, according to the results of the systematic literature on controlling diabetes and hypertension with CDSSs, 63 a variety of sources agreed that such systems were useful in promoting prevention, supporting treatment, and improving patient care. However, doctors claim that they have caused significant delays in everyday practice.…”

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