Guidelines and mHealth to Improve Quality of Hypertension and Type 2 Diabetes Care for Vulnerable Populations in Lebanon: Longitudinal Cohort Study

Abstract

BackgroundGiven the protracted nature of the crisis in Syria, the large noncommunicable disease (NCD) caseload of Syrian refugees and host Lebanese, and the high costs of providing NCD care, the implications for Lebanon’s health system are vast.ObjectiveThe aim of this study was to evaluate the effectiveness of treatment guidelines and a mobile health (mHealth) app on quality of care and health outcomes in primary care settings in Lebanon.MethodsA longitudinal cohort study was implemented from January 2015 to August 2016 to evaluate the effectiveness of treatment guidelines and an mHealth app on quality of care and health outcomes for Syrian and Lebanese patients in Lebanese primary health care (PHC) facilities.ResultsCompared with baseline record extraction, recording of blood pressure (BP) readings (−11.4%, P<.001) and blood sugar measurements (−6.9%, P=.03) significantly decreased following the implementation of treatment guidelines. Recording of BP readings also decreased after the mHealth phase as compared with baseline (−8.4%, P=.001); however, recording of body mass index (BMI) reporting increased at the end of the mHealth phase from baseline (8.1%, P<.001) and the guidelines phase (7.7%, P<.001). There were a great proportion of patients for whom blood sugar, BP, weight, height, and BMI were recorded using the tablet compared with in paper records; however, only differences in BMI were statistically significant (31.6% higher in app data as compared with paper records; P<.001). Data extracted from the mHealth app showed that a higher proportion of providers offered lifestyle counseling compared with the counseling reported in patients’ paper records (health diet counseling; 77.3% in app data vs 8.8% in paper records, P<.001 and physical activity counseling and 59.7% in app vs 7.1% in paper records, P<.001). There were statistically significant increases in all four measures of patient-provider interaction across study phases. Provider inquiry of medical history increased by 16.6% from baseline following guideline implementation and by 28.2% from baseline to mHealth implementation (P<.001). From baseline, patient report of provider inquiry regarding medication complications increased in the guidelines and mHealth phases by 12.9% and 59.6%, respectively, (P<.001). The proportion of patients reporting that providers asked other questions relevant to their illness increased from baseline through guidelines implementation by 27.8% and to mHealth implementation by 66.3% (P<.001). Follow-up scheduling increased from baseline to the guidelines phase by 20.6% and the mHealth phase by 39.8% (P<.001).ConclusionsResults from this study of an mHealth app in 10 PHC facilities in Lebanon indicate that the app has potential to improve adherence to guidelines and quality of care. Further studies are necessary to determine the effects of patient-controlled health record apps on provider adherence to treatment guidelines, as well as patients’ long-term medication and treatment adherence and disease control.

Characteristics of Syrian and Lebanese Diabetes and Hypertension Patients in Lebanon

“…The study used a phased introduction of the clinical guidelines and mHealth interventions over a period of 20 months with longitudinal measurement of study outcomes presented elsewhere [37,38]. Participants consisted of patients at ten health care centers in Lebanon supported by International Organization for Migration (IOM) and International Medical Corps (IMC) in the South, Bekaa, Beirut, and Mount Lebanon governorates Fig.…”

Addressing noncommunicable diseases among urban refugees in the Middle East and North Africa - a scoping review

“…An intervention in Lebanon also used electronic health tools to improve the quality of care provided in ten primary health centers, managed by the International Organization for Migration and the International Medical Corps. A longitudinal cohort study was conducted to improve care for Syrian refugees and Lebanese patients through the implementation of clinical guidelines and the adoption of an mHealth application [25]. The guidelines were adapted for the local context, and clinicians were trained on all components of the protocol.…”

“…Changes in clinical measures were not significant, though the authors argued that the implementation period was short and that many clinicians rejected use of the application. All components of patient-provider interactions improved significantly (i.e., the provider took a medical history, the provider asked about medication complications) and there were notable increases in the reporting of medication prescription and use in the EMR [25].…”

MSF experiences of providing multidisciplinary primary level NCD care for Syrian refugees and the host population in Jordan: an implementation study guided by the RE-AIM framework

“…It is therefore essential to provide additional programmatic and clinical guidance around poly-pharmacy (and de-prescribing), multi-morbidity, frailty and palliation in the MSF guideline. Written guidance could potentially be supported by technology, such as telemedicine and/or mHealth decision support tools, as trialled in Lebanon (53).…”

“…through use of wearable technology and home or communitybased disease monitoring. Designing and evaluating novel ways to improve access to diagnosis and management of NCD complications at primary care level is also essential, which could include use of telemedicine, mobile technology or arti cial intelligence-supported diagnosis or clinical decision tools (45,53,63).…”