Objective: The critical shortage of healthcare workers, particularly in rural areas, is a major barrier to quality care for noncommunicable disease (NCD) in low- and middle-income countries. In this proof-of-concept study, we aimed to test a decentralized model for integrated diabetes and hypertension management in rural Bangladesh to improve accessibility and quality of care.
Design and setting: The study is a single cohort proof-of-concept study. The key interventions comprised shifting screening, routine monitoring, and dispensing of medication refill from a doctor-managed subdistrict NCD clinic to non-physician health worker managed village level community clinics; a digital care coordination platform was developed for electronic health record, point-of-care support, referral, and routine patient follow-up. The study was conducted in Parbatipur subdistrict, Rangpur Division, Bangladesh.
Participants: A total of 624 participants were enrolled in the study (mean[sd] age, 59.5 [12.0]; 65.1% female).
Outcomes: Changes in blood pressure and blood glucose control, patient retention, and patient-visit volume at the NCD clinic and community clinics.
Results: The proportion of patients with uncontrolled blood pressure reduced from 60% at baseline to 26% at the third month of follow-up, a 56% (IRR 0.44; 95% CI 0.33, 0.57) reduction after adjustment for covariates. The proportion of patients with uncontrolled blood glucose decreased from 74% to 43% at the third month of follow-up. Attrition rates immediately after baseline and during the entire study period were 29.1% and 36.2%, respectively.
Conclusion: The proof-of-concept study highlights the potential for involving lower-level primary care facilities and non-physician health workers to rapidly expand much needed services to the patients with hypertension and diabetes in Bangladesh, and in similar global settings. Further investigations are needed to evaluate the effectiveness of decentralized hypertension and diabetes care.