AHAFIT

In my last post, I discussed the need for physicians to engage in discussions of meaningful health systems reform in order to help realize the ideal of a healthier society for all Americans. However, innovative solutions addressing the shortcomings of our current care-delivery model designed and tested within the United States are few and far between. Instead, over the next two posts, I describe some of the strategies developed in and for resource-limited settings that may have applicability to the U.S. context.

The current post details two categories of interventions with the potential to provide expanded access to healthcare providers that may be particularly valuable for the provision of preventive cardiac services. Task-shifting interventions, which comprise the first category of this discussion, are defined by the Centers for Disease Control and Prevention as “the process of delegation” of health responsibilities and duties from skilled to less specialized healthcare workers and operate by means of rapid expansion of the healthcare workforce with the inclusion of a new cadre of providers.¹ The second category includes mobile health interventions, which range from low-tech appointment reminders to more technologically advanced home cardiac rehabilitation programs and medical counseling curricula. The combined anticipated effect of both groups of interventions is to simultaneously grow the workforce able to provide high-value cardiac care, while also redefining the clinical setting in order to enhance the accessibility of health services. Below, we briefly explore potential applications of both categories of interventions to cardiac care in the U.S., highlighting existing experience with each.

Task-shifting interventions for cardiovascular care:

Although the COVID-19 pandemic exacerbated shortages in the healthcare workforce globally, the problem can be traced back long before the current crisis, with devastating consequences in rural and low-income communities. Assuming no expansion of health services beyond current levels, the American Association of Medical Colleges (AAMC) projects that by 2033 the United States will face a shortage of between 55 and 139 thousand physicians, up from prior years and including both primary care providers and specialists.² Should universal health coverage become a reality in the coming decade, this gap in providers is likely to balloon as individuals previously excluded from health services attempt to gain access to the system. The solutions proposed to this problem have long focused on increasing the training capacity of the current medical education system and aggressive recruitment of skilled providers from outside the U.S., however, both strategies are costly and may take years—if not longer—to realize gains.

Developed in low- and middle-income countries (LMIC), task-shifting—which incorporates greater numbers of non-physician healthcare workers (NPHW) and minimally trained community healthcare workers into the medical workforce—may provide a pragmatic and low-cost solution to shortages in the U.S, just as it has done in LMIC. Demonstrating potential applications to cardiac care, a 2019 Lancet meta-analysis including task-shifting interventions where community healthcare workers, dietitians, nurses, and pharmacists delivered versions of algorithm-driven hypertension care and lifestyle counseling found that the strategy led to a statistically significant 5-point reduction in systolic blood pressure. Moreover, recent randomized trials in low-income settings have employed non-physician health workers to achieve both blood pressure improvements and reductions in mortality.^3-5 Such interventions have effectively implemented short training periods (ranging from 3-7 days in many cases with periodic ‘refresher’ training) combined with clinical decision support tools to guide algorithm-driven care for screening, counseling, and treatment of basic cardiac conditions, all at low cost to the system.⁶

Yet uptake of such interventions in resource-limited settings within high-income countries such as the U.S. has been minimal. A 2019 JAMA Surgery editorial highlights this contradiction: commending the innovative use of NPHWs and non-surgically trained physicians in performing low-complexity surgeries such as hernia repairs in low-income countries, while acknowledging the failure to translate such benefits to communities in need in the U.S.⁷ One notable example within cardiovascular prevention in the U.S. bears remembering, however. The barbershop-based blood pressure study, led by Dr. Ronald Victor and published in the New England Journal of Medicine in 2018, evaluated the effect of a pharmacist-led hypertension treatment based in community barbershops in improving blood pressure among Black men when compared to counseling in the barbershops alone.⁸ The study demonstrated a whopping mean systolic blood pressure reduction of 27 points among those receiving the pharmacist-led intervention, with more than two-thirds of intervention participants achieving blood pressure control by the end of the study. The takeaway? With innovative adaptation of task-shifting approaches to local contexts in the U.S., such strategies have the potential to transform the model for care-delivery, reduce gaps in access to care and drive meaningful reductions in cardiovascular disease.

Mobile & virtual health interventions:

Over the past year, virtual and telehealth medical services have rapidly expanded, propelled by the desire to protect patients and providers alike during the height of pandemic lockdowns. The shift is likely to be one of the longest-lasting impacts of the pandemic on the way we practice medicine, but calls to incorporate mobile and virtual health services are not new within the pandemic era. Prior studies have demonstrated potential applications of mobile health or mHealth interventions to provide patient-centered education, communicate clinical reminders and advice, and perform complex health training, including cardiac rehabilitation, though mHealth tools can be more broadly categorized as patient-facing, provider-facing, and communication oriented.^9-11 Additional applications in the treatment and counseling of high-risk conditions, including heart failure, hypertension, hyperlipidemia and coronary artery disease  have additionally been proposed, though implementation in these instances has lagged. Nonetheless, such interventions have demonstrated potentially dramatic results in LMIC with significant and sustained reductions in blood pressure, LDL levels, and improvements in metrics such as 6-minute walk distance with physical activity training, at little cost to the health system.^12-14

Three recent developments and trends do bode well for the future of mobile and virtual health expansion in cardiovascular care. First, smartphones and wearable mobile health devices have become increasingly common in the U.S., with more than three-quarters of the U.S. population reporting use of a smartphone and wearable technology rapidly advancing to gain FDA-approval for detection of atrial fibrillation and in the near future likely continuous blood pressure and glucose monitoring.^11,15 As such technology becomes more ubiquitous, moreover, the potential for such interventions to be used to reach under-resourced populations, including low-income and elderly individuals, is far more likely, expanding the potential reach of the healthcare system. Second, although high-quality evidence for mHealth interventions is lacking currently, the ability for mHealth applications to rapidly enroll large numbers of participants at low cost suggests an opportunity to grow the evidence base rapidly.¹⁶ Recent partnerships between academia and tech companies, including an ongoing study led by Yale University and Boehringer Ingelheim evaluating multiple mHealth based interventions for the management of heart failure, demonstrate the potential to generate new, high-quality evidence to guide future interventions.¹⁷ Finally, the past decade has been a time of tremendous investment in digital health, with venture capital investment exceeding $4 billion in 2014 alone and new startups emerging monthly.¹¹

The result of this innovation and investment could be ground-shifting for low-income populations. What mobile and virtual technology ultimately offer is a means for redefining the clinic and hospital to bring healthcare directly into homes within underserved communities. Done well, mHealth interventions could address numerous barriers to care in under-resourced communities, improving health literacy, removing the financial and time cost of transportation to brick and mortar health institutions, and guiding care via simple and easy-to-access applications. This will require thoughtful application of technology to the goal of expanded care, however, as residual high costs of such services could ultimately undermine efforts at equity.

The bottom line: innovative approaches to care delivery that focus on both the who and where of healthcare have the potential to meaningfully alter care for low-income populations in the United States. Many such interventions have demonstrated efficacy already on a small-scale, but incorporation of such strategies into a new national approach to healthcare could go beyond these efforts in pairing an expanded vision of healthcare with universal health coverage. The potential for change is there, we just need the creativity and willpower to utilize it.

REFERENCE

1. Sharing and Shifting Tasks to Maintain Essential Healthcare During COVID-19 in Low Resource, Non-US Settings. Centers for DIsease Control and Prevention;2020.
2. Boyle P. U.S. physician shortage growing. In: Colleges AAoM, ed2020:https://www.aamc.org/news-insights/us-physician-shortage-growing.
3. Jeemon P, Joseph LM, Anand TN. Task sharing with non-physician health-care workers for management of blood pressure – Authors’ reply. Lancet Glob Health. 2019;7(10):e1327.
4. He J, Irazola V, Mills KT, et al. Effect of a Community Health Worker-Led Multicomponent Intervention on Blood Pressure Control in Low-Income Patients in Argentina: A Randomized Clinical Trial. JAMA. 2017;318(11):1016-1025.
5. Jafar TH, Gandhi M, de Silva HA, et al. A Community-Based Intervention for Managing Hypertension in Rural South Asia. N Engl J Med. 2020;382(8):717-726.
6. Joshi R, Thrift AG, Smith C, et al. Task-shifting for cardiovascular risk factor management: lessons from the Global Alliance for Chronic Diseases. BMJ Glob Health. 2018;3(Suppl 3):e001092.
7. Wren SM, Kushner AL. Task Shifting in Surgery-What US Health Care Can Learn From Ghana. JAMA Surg. 2019;154(9):860.
8. Victor RG, Lynch K, Li N, et al. A Cluster-Randomized Trial of Blood-Pressure Reduction in Black Barbershops. N Engl J Med. 2018;378(14):1291-1301.
9. Piette JD, List J, Rana GK, Townsend W, Striplin D, Heisler M. Mobile Health Devices as Tools for Worldwide Cardiovascular Risk Reduction and Disease Management. Circulation. 2015;132(21):2012-2027.
10. Dorn SD. Digital Health: Hope, Hype, and Amara’s Law. Gastroenterology. 2015;149(3):516-520.
11. Eapen ZJ, Turakhia MP, McConnell MV, et al. Defining a Mobile Health Roadmap for Cardiovascular Health and Disease. J Am Heart Assoc. 2016;5(7).
12. Srinivasapura Venkateshmurthy N, Ajay VS, Mohan S, et al. m-Power Heart Project – a nurse care coordinator led, mHealth enabled intervention to improve the management of hypertension in India: study protocol for a cluster randomized trial. Trials. 2018;19(1):429.
13. Prabhakaran D, Jha D, Prieto-Merino D, et al. Effectiveness of an mHealth-Based Electronic Decision Support System for Integrated Management of Chronic Conditions in Primary Care: The mWellcare Cluster-Randomized Controlled Trial. Circulation. 2018.
14. Beratarrechea A, Abrahams-Gessel S, Irazola V, Gutierrez L, Moyano D, Gaziano TA. Using mH ealth Tools to Improve Access and Coverage of People With Public Health Insurance and High Cardiovascular Disease Risk in Argentina: A Pragmatic Cluster Randomized Trial. J Am Heart Assoc. 2019;8(8):e011799.
15. Jia X, Kohli P. Telehelath and Cardiovascular Disease Prevention: A Discussion of the Why and How. American College of Cardiology2020.
16. Rowland SP, Fitzgerald JE, Holme T, Powell J, McGregor A. What is the clinical value of mHealth for patients? NPJ Digit Med. 2020;3:4.
17. Wicklund E. Yale Studies 3 Different Telehealth, mHealth Tools for Cardiac Care. mHealth Intelligence. 2020. https://mhealthintelligence.com/news/yale-studies-3-different-telehealth-mhealth-tools-for-cardiac-care.

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