Abstract
BackgroundHypertension and diabetes are among the most common and deadly chronic conditions globally. In India, most adults with these conditions remain undiagnosed, untreated, or poorly treated and uncontrolled. Innovative and scalable approaches to deliver proven-effective strategies for medical and lifestyle management of these conditions are needed.MethodsThe overall goal of this implementation science study is to evaluate the Integrated Tracking, Referral, Electronic decision support, and Care coordination (I-TREC) program. I-TREC leverages information technology (IT) to manage hypertension and diabetes in adults aged ≥30 years across the hierarchy of Indian public healthcare facilities. The I-TREC program combines multiple evidence-based interventions: an electronic case record form (eCRF) to consolidate and track patient information and referrals across the publicly-funded healthcare system; an electronic clinical decision support system (CDSS) to assist clinicians to provide tailored guideline-based care to patients; a revised workflow to ensure coordinated care within and across facilities; and enhanced training for physicians and nurses regarding non-communicable disease (NCD) medical content and lifestyle management. The program will be implemented and evaluated in a predominantly rural district of Punjab, India. The evaluation will employ a quasi-experimental design with mixed methods data collection. Evaluation indicators assess changes in the continuum of care for hypertension and diabetes and are grounded in the Reach, Effectiveness, Adoption Implementation, and Maintenance (RE-AIM) framework. Data will be triangulated from multiple sources, including community surveys, health facility assessments, stakeholder interviews, and patient-level data from the I-TREC program’s electronic database.DiscussionI-TREC consolidates previously proven strategies for improved management of hypertension and diabetes at single-levels of the healthcare system into a scalable model for coordinated care delivery across all levels of the healthcare system hierarchy. Findings have the potential to inform best practices to ultimately deliver quality public-sector hypertension and diabetes care across India.Trial registrationThe study is registered with Clinical Trials Registry of India (registration number CTRI/2020/01/022723). The study was registered prior to the launch of the intervention on 13 January 2020. The current version of protocol is version 2 dated 6 June 2018.
Highlights
Hypertension and diabetes are among the most common and deadly chronic conditions globally
We describe the evaluation protocol for the I-TREC multi-component strategy to improve diabetes and hypertensions care at all levels of the four-tier healthcare system in India
While the I-TREC program is implemented within the health system by clinicians, we will assess indicators at the levels of facilities, clinicians, patients, and communities
Summary
Hypertension and diabetes are among the most common and deadly chronic conditions globally. Hypertension and diabetes together affect over 275 million Indians and their families [1]. These conditions are rising rapidly in all regions of India, commonly co-occur [2,3,4], and are associated with several adverse health outcomes—such as higher rates of death, myocardial infarction, stroke, blindness, kidney failure. Both hypertension and diabetes are treatable such that timely and appropriate therapy mitigates associated morbidity due to complications and premature mortality. Under-diagnosis, under-treatment, and poor control for both hypertension and diabetes are disproportionately high in rural settings [11, 12], where the majority of the Indian population resides
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