Developing a Digital Health-enabled Intervention to tackle Multimorbidity in Primary care in India

One in four people seeking primary healthcare facilities in India is estimated to have multimorbidity, which is characterised by the co-occurrence of two or more medical conditions. People with multimorbidity are less likely to receive appropriate care for the individual diseases they have, primarily because clinical care systems are designed around single conditions or body systems. The overarching aim of this research proposal is to develop a digital health-enabled intervention for multimorbidity management in the primary care setting, test its feasibility, and pilot it for deriving inputs for planning a larger evaluation in future. The proposed research work will be carried out in the north-Indian state of Tripura in India. As part of India's National Programme on Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS), Tripura has established 40 Non-communicable Disease (NCD) clinics in the state. Over the past 29 months, the healthcare team in these NCD clinics has been using a digital health system namely the mPower Heart Digital Health System to compute the clinical management plan and maintain patient health record electronically. This digital health system is unique because the healthcare team used to capture information on presence/absence of 14 medical conditions that are frequently seen among people with chronic conditions such as hypertension, diabetes, dyslipidemia, chronic obstructive pulmonary diseases, alcoholism and tobacco use.

In the proposed research work, we will attempt discovering the most frequent multimorbidity patterns seen among patients who sought care for the past 29 months from 40 NCD clinics in Tripura. Using these inputs, along with advice from experts, we will develop a package of intervention, that involves modifying the mPower Heart digital health system for addressing most frequent and severe multimorbidity patterns. The development of the intervention package will be carried out involving experts, health administrators, members of the healthcare team and patients. The intervention development will consider the key components of the health system - such as service delivery, workforce, supply of essential medicines/diagnostics, health information system, financing, and governance/leadership - and other contextual factors that have a role in the successful implementation of the package in the health facilities. The intervention package will be piloted in two health facilities to assess its feasibility and acceptability in the real world helps design an evaluation that will work and be implemented in real-world health systems, rather than just an intervention that it is possible to evaluate in a research setting. We will be then developing a research proposal to evaluate the intervention in a large scale to know the impact of such an intervention in improving quality of care and patient outcomes. This work will have high scalability and national significance in reorienting the NPCDCS from a vertical, disease-oriented model into a holistic, patient-oriented care delivery model. The NPCDCS is providing access to millions of people with chronic diseases in India in primary care. Thus this proposal aligns with the UN sustainable development Goals (No -2: Good Health and Wellbeing) explicitly addressing the UNSDG Target 3.3 (fight communicable diseases) and Target 3.4 (Reduce mortality from non-communicable diseases and promote mental health).

More than a quarter of adult patients attending primary care facilities in India have multimorbidity. However, national health programmes are disease-centric, including the ongoing National Programme for Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS), which caters to large population groups in primary care for a range of chronic conditions. The specific objectives of the proposed research work in the Indian state of Tripura are: a) To discover major multimorbidity patterns relevant for NPCDCS in primary care; and b) To develop a digital health-enabled intervention, targeting major multimorbidity patterns, relevant for NPCDCS, to improve targeting and delivery of clinical services in primary care. A digital tool- comprising clinical decision support and electronic health record- is deployed in 40 primary care facilities in Tripura to aid the healthcare team in managing six chronic conditions - hypertension, diabetes, dyslipidaemia, chronic obstructive pulmonary diseases, alcoholism and tobacco use- for the past 29 months. In such patient's record, information on the presence of eight additional chronic conditions is also routinely recorded. This dataset will be used for discovering multimorbidity patterns. Using these inputs, and expert consultations, we will develop a digital health-enabled intervention for the management of multimorbidity following the MRC framework for developing complex interventions. To guide intervention development, a theory of change will be constructed, covering the building blocks of the health system and other contextual factors. Using mixed methods, we will develop a prototype intervention and pilot it in two health facilities for assessing feasibility, developing mitigation strategies for barriers, identifying potential indicators for the process of care and patient-level outcomes, sample size and recruitment feasibility for planning an application for controlled evaluation of the intervention developed in a future trial.

Multimorbidity has emerged as a significant public health problem for India and other LMICs. Our proposed study aims to develop a feasible, scalable intervention to address multimorbidity in primary care in India. Our proposal is around India's National Program for the Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS), leveraging our ongoing digital health-enabled interventions for several of these individual chronic conditions in the north-eastern Indian state Tripura. Our research will enhance the capability of the Indian health system through various means but not limited to: enhancing the skills/knowledge of the healthcare team, introducing clinical management protocols for multimorbidity, introducing digital clinical decision support tools, adapting/re-organising the support system, etc. Our work will also generate much-needed evidence for implementing better approaches to enhance NPCDCS services for addressing multimorbidity at the national level.

We have been working closely with the Indian health system and translating research-driven digital health-enabled interventions for chronic conditions in two states in India (Tripura and Mizoram). Our success has led the Government of India to integrate the clinical decision support module into an Electronic Health Record platform which will be rolled out throughout India in the next 2-3 years. Our experience in creating successful digital health-enabled intervention and our long-standing engagement with health administrators and healthcare team ensures that we come up with a feasible, acceptable, cost-efficient intervention comprising strategies improve the integration of services for patients with multimorbidity in primary care. Our proposal is timely in the context of several interventional bodies advocate for efficient delivery of effective care for chronic conditions, particularly in primary care, to prevent the associated premature deaths and disability.