India

Integrated tracking, referral, and electronic decision support, and care coordination (I-TREC)

Hy-TREC
A training session with leader and students at the study field site.

The I-TREC program entirely aligns with the policy of the government in the space of NCDs.
What we intend to do for this project is to provide workable solutions for managing chronic disease not only in India but across low and middle-income countries.

Project summary

In rural India, roughly three-quarters of adults with high blood pressure never receive treatment, and 90% of individuals receiving treatment for high blood pressure fail to achieve blood pressure control.

We will work with the state Department of Health in India to use information technology to address this issue; by creating and testing an Integrated Tracking, Referral, Electronic Decision Support, and Care Coordination (I-TREC) package focused on high blood pressure and diabetes, a condition that commonly occurs among people with high blood pressure in India.

Findings will have the potential to revolutionize care for deadly chronic diseases across India, in the most vulnerable and hard-to-reach patients, who rely mostly on the government healthcare system and generate a scalable model that can be applied to other similar settings.

Members of the I-TREC team sitting in a semi-circle discussing
Members of the team share feedback and experiences during a meeting to discuss progress and status of the project

Project goals

  1. To adapt our prior suite of quality of care improvement interventions into the comprehensive Integrated Tracking, Referral, and Electronic Decision Support, and Care Coordination (I-TREC) package.
  2. To provide technical training and assistance to the Government of Punjab, India to implement I-TREC in all healthcare facilities of a single block.
  3. To evaluate I-TREC using a quasi-experimental design by comparing outcomes in separate patient panels and community-based samples of adults served by the I-TREC facilities and adults served in a neighboring comparison block.
Dr. Tandon, the Principal investigator of the India project, introduces I-TREC's aims and activities.

Current status

The integration between the government’s electronic case record form for patients and our clinical decision support system for providers is nearly complete. Beta testing is scheduled for January 2019, and we anticipate that the software applications will be finalized by February 2019.

Simultaneously, the baseline community survey for intervention evaluation is underway and will be completed by March 2019. I-TREC will be launched in April 2019.

Location

The study will take place in a rural region of Punjab, a state in northern India. Based on consultation with the Department of Health and Family Welfare (DHFW), Government of Punjab, the I-TREC package will be implemented in Mukandpur block (22 health facilities).

For comparison, we will monitor health care indicators in the neighboring Sujjon block (29 health facilities). Both Mukandpur and Sujjon block fall within Shaheed Bhagat Singh Nagar district and are thus governed by the same administrative structure.

Strategy

Our primary research objective is to assess whether the I-TREC package improves hypertension and diabetes processes of care in patients and the community at large.

The project will be conducted in three phases: intervention development, implementation, and evaluation phases.

During Phase-1 we will:

  1. develop an Advisory Committee to provide expert opinion for the development of I-TREC.
  2. conduct a pre-intervention quantitative survey.
  3. conduct qualitative interviews in community and health facilities to understand the status of hypertension and diabetes care in the community and modifiable barriers to achieve optimal outcomes.

A pre-intervention health facility survey will also be conducted to assess the current facilities for hypertension and diabetes management.

Phase-2 will include implementation of I-TREC system, training of all health professionals and observations (direct and indirect) in intervention block of Nawanshahr district Punjab.

Phase-3 will involve evaluating health endpoints and identifying facilitators and barriers of scaling up the intervention to all of Punjab and all of India using the RE-AIM framework and qualitative evaluation.

Dr Tandon at lecture giving a talk to a room of seated listeners
Dr Tandon addresses the AIIMS faculty about NIH collaboration.

Dissemination

We will disseminate our findings widely with the aim of sharing lessons from this project to inform the development and scale-up of similar platforms in India and elsewhere.

Our National and State Advisory Boards are well positioned to disseminate findings among networks of health policy makers, administrators, and professionals engaged in programming to improve care for hypertension in India in the context of the public health care system.

Our International Advisory Board and Investigator team members from 5 continents, who are well placed to disseminate results among scientific networks. We will prepare reports and scientific manuscripts targeting policy makers and academics, and present these findings at meetings of relevant national and local committees as well as professional societies.

Team Members

Our project has the support of 1 Principal Investigator, 13 Research Team members and 2 trainees.

Members of the India project team standing in a group.
  • Nikhil Tandon

    Nikhil Tandon

    Principal Investigator India project

    Dr.Tandon is the Principal Investigator for the Indian project and an endocrinologist by training, with interest in chronic disease epidemiology across the life course; genetics of complex disorders; and intervention studies to address cardio-metabolic risk.

  • Sailesh Mohan

    Deputy Director Centre for Chronic Disease Control, New Delhi
  • Shivani Patel

    Rollins Assistant Professor Emory University
  • Marybeth Weber

    Assistant Professor Emory University
  • Dorairaj Prabhakaran

    Executive Director Centre for Chronic Disease Control, New Delhi
  • Mohammed K Ali

    Associate Director, Georgia Center for Diabetes Translation Research Emory University
  • KM Venkat Narayan

    Ruth and OC Hubert Chair Emory University
  • Ambuj Roy

    Co-Investigator. All India Institute of Medical Sciences
  • Yashdeep Gupta

    Co-Investigator All India Institute of Medical Sciences
  • Hanspria Sharma

    Project Manager All India Institute of Medical Sciences
  • Ajay Vamadevan

    Deputy Director Center for Chronic Disease Control, New Delhi
  • Priti Gupta

    Senior Research Associate and Fogarty Fellow Centre for Chronic Disease Control, New Delhi
  • Rakshit Sharma

    Project Coordinator All India Institute of Medical Sciences
  • Tegveer Singh Research Intern Emory University
  • Shireen Saxena Research Intern University of Rochester

Partner Organisations

We are pleased to partner with the following organisations:

Publications and References

These references document the history of research studies by this team

  • Shah S, Singh K, Ali MK, Mohan V, Kadir MM, Unnikrishnan AG, Sahay RK, Varthakavi P, Dharmalingam M, Viswanathan V, Masood Q, Bantwal G, Khadgawat R, Desai A, Sethi BK, Shivashankar R, Ajay VS, Reddy KS, Narayan KMV, Prabhakaran D, Tandon N. Improving diabetes care: Multi-component CArdiovascular Disease Risk Reduction Strategies for People with Diabetes in South Asia -The CARRS Multi-center Translation Trial. Diabetes Res Clin Pract. 2012 Nov;98(2):285–294. PMCID: PMC3544938

  • Ali MK, Singh K, Kondal D, Devarajan R, Patel SA, Shivashankar R, Ajay VS, Unnikrishnan AG, Menon VU, Varthakavi PK, Viswanathan V, Dharmalingam M, Bantwal G, Sahay RK, Masood MQ, Khadgawat R, Desai A, Sethi B, Prabhakaran D, Narayan KMV, Tandon N, CARRS Trial Group. Effectiveness of a Multicomponent Quality Improvement Strategy to Improve Achievement of Diabetes Care Goals: A Randomized, Controlled Trial. Ann Intern Med. 2016 Sep;165(6):399–408. PMCID: In Process.

  • Vamadevan A, Jindal D, Roy A, Venugopal V, Sharma R, Pawar A, Kinra S, Tandon N, Prabhakaran D. Development of a Smartphone-enabled hypertension and diabetes management package to facilitate evidence-based care delivery in primary healthcare facilities in India: The mPower Heart Project. JAHA J Am Heart Assoc.

  • Ali MK, Shah S, Tandon N. Review of electronic decision-support tools for diabetes care: a viable option for low-and middle-income countries? J Diabetes Sci Technol. 2011 May;5(3):553–70. PMID: 21722571

  • Ajay VS, Tian M, Chen H, Wu Y, Li X, Dunzhu D, Ali MK, Tandon N, Krishnan A, Prabhakaran D, Yan LL. A cluster-randomized controlled trial to evaluate the effects of a simplified cardiovascular management program in Tibet, China and Haryana, India: study design and rationale. BMC Public Health. 2014 Jan;14(1):924. PMID: 25194850

  • Tian M, Ajay VS, Dunzhu D, Hameed SS, Li X, Liu Z, Li C, Chen H, Cho K, Li R, Zhao X, Jindal D, Rawal I, Ali MK, Peterson ED, Ji J, Amarchand R, Krishnan A, Tandon N, Xu L-Q, Wu Y, Prabhakaran D, Yan LL. A Cluster-Randomized, Controlled Trial of a Simplified Multifaceted Management Program for Individuals at High Cardiovascular Risk (SimCard Trial) in Rural Tibet, China, and Haryana, IndiaCLINICAL PERSPECTIVE. Circulation. 2015 Sep 1;132(9):815–824. PMID: 26187183

  • Jindal D, Gupta P, Jha D, Ajay VS, Goenka S, Jacob P, Mehrotra K, Perel P, Nyong J, Roy A, Tandon N, Prabhakaran D, Patel V. Development of mWellcare: an mHealth intervention for integrated management of hypertension and diabetes in low-resource settings. Glob Health Action. 2018;11(1):1517930. doi: 10.1080/16549716.2018.1517930.

  • D Prabhakaran 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.