Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK.
Warwick Medical School, University of Warwick, Coventry, UK; Centre for Health Policy, University of the Witwatersrand, Johannesburg, South Africa.
Lancet Glob Health. 2023 Nov;11(11):e1753-e1764. doi: 10.1016/S2214-109X(23)00411-4.
In-person health care poses risks to health workers and patients during pandemics. Remote consultations can mitigate these risks. The REaCH intervention comprised training and mobile data allowance provision for mobile phones to support remotely delivered primary care in Africa compared with no training and mobile data allowance. The aim of this study was to estimate the effects of REaCH among adults with non-communicable diseases on remote and face-to-face consultation rates, patient safety, and trustworthiness of consultations.
In these two independent stepped-wedge cluster randomised controlled trials, we enrolled 20 primary care clusters in each of two settings (Oyo State, Nigeria, and Morogoro Region, Tanzania). Eligible clusters had 100 or more patients with diabetes, hypertension, and cardiovascular or pulmonary disease employing five health workers. Clusters were computer-randomised to one of ten (Nigeria) or one of seven (Tanzania) sequences to receive the REaCH intervention. Only outcome assessors were masked. Primary outcomes were consultation, prescription, and investigation rates, and trustworthiness collected monthly for 12 months (Nigeria) and 9 months (Tanzania) from open cohorts. Ten randomly sampled consulting patients per cluster-month completed patient reported outcome measures. This trial was registered with ISRCTN, ISRCTN17941313.
Overall, 40 clusters comprising 8776 (Nigeria) and 3246 (Tanzania) patients' open cohort data were analysed (6377 [72·7%] of 8776 females in Nigeria, and 2235 [68·9%] of 3246 females in Tanzania). The mean age of the participants was 55·3 years (SD 13·9) in Nigeria and 59·2 years (14·2) in Tanzania. In Nigeria, no evidence of change in face-to-face consulting rate was observed (rate ratio [RR] 1·06, 95% CI 0·98 to 1·09; p=0·16); however, remote consultations increased four-fold (4·44, 1·34 to >10; p=0·01). In Tanzania, face-to-face (0·94, 0·61 to 1·67; p=0·99) and remote consulting rates (1·17, 0·56 to 5·57; p=0·39) were unchanged. There was no evidence of difference in prescribing rates (Nigeria: 1·05, 0·60 to 1·14; p=0·23; Tanzania: 0·92, 0·60 to 1·67; p=0·97), investigation rates (Nigeria: 1·06, 0·23 to 2·12; p=0·49; Tanzania: 1·15, 0·35 to 1·64; 0·58) or trustworthiness scores (Nigeria: mean difference 0·05, 95% CI -0·45 to 0·42; p=0·89; Tanzania: 0·07, -0·15 to 0·76; p=0·70).
REaCH can be implemented and could improve intervention versus control health-care access. Remote consultations appear safe and trustworthy, supporting universal health coverage.
The UK Research and Innovation Collective Fund.
For the Swahili and Yoruba translations of the abstract see Supplementary Materials section.
在大流行期间，面对面的医疗服务会给卫生工作者和患者带来风险。远程咨询可以降低这些风险。REaCH 干预措施包括为手机提供培训和移动数据津贴，以支持非洲远程提供初级保健，而对照组则没有培训和移动数据津贴。本研究的目的是评估 REaCH 对非洲患有非传染性疾病的成年人的远程和面对面咨询率、患者安全和咨询可信度的影响。
在这两项独立的逐步楔形集群随机对照试验中，我们在两个环境（尼日利亚奥约州和坦桑尼亚莫罗戈罗地区）中的每个环境中招募了 20 个初级保健集群。符合条件的集群拥有 100 名或以上患有糖尿病、高血压、心血管或肺部疾病的患者，由五名卫生工作者提供服务。集群被计算机随机分配到十个（尼日利亚）或七个（坦桑尼亚）序列之一，以接受 REaCH 干预。只有结局评估者被蒙蔽。主要结局是每月收集 12 个月（尼日利亚）和 9 个月（坦桑尼亚）的咨询、处方和调查率，以及可信度，来自开放队列。每个集群月随机抽取 10 名就诊患者完成患者报告的结果测量。这项试验在 ISRCTN、ISRCTN17941313 注册。
总的来说，分析了来自 40 个集群的 8776 名（尼日利亚）和 3246 名（坦桑尼亚）患者的开放队列数据（尼日利亚女性 6377 名[72.7%]，坦桑尼亚女性 2235 名[68.9%]）。参与者的平均年龄为 55.3 岁（SD 13.9）在尼日利亚和 59.2 岁（14.2）在坦桑尼亚。在尼日利亚，面对面咨询率没有观察到变化（比率比[RR] 1.06，95%置信区间 0.98 至 1.09；p=0.16）；然而，远程咨询增加了四倍（4.44，1.34 至 >10；p=0.01）。在坦桑尼亚，面对面（0.94，0.61 至 1.67；p=0.99）和远程咨询率（1.17，0.56 至 5.57；p=0.39）保持不变。在处方率方面没有证据表明差异（尼日利亚：1.05，0.60 至 1.14；p=0.23；坦桑尼亚：0.92，0.60 至 1.67；p=0.97）、调查率（尼日利亚：1.06，0.23 至 2.12；p=0.49；坦桑尼亚：1.15，0.35 至 1.64；p=0.58）或可信度评分（尼日利亚：平均差值 0.05，95%置信区间-0.45 至 0.42；p=0.89；坦桑尼亚：0.07，-0.15 至 0.76；p=0.70）。
REaCH 可以实施，并可以改善干预与对照的医疗保健获取。远程咨询似乎是安全和值得信赖的，支持全民健康覆盖。
英国研究与创新集体基金。
