Major Findings and Limitations of Published Studies on Digital Referral Systems and Mobile Clinical Decision Support Systems

Author(s), Year of PublicationMajor FindingsLimitations
Agarwal et al., 20157The authors demonstrated that mobile job aids can help CHWs deliver integrated counseling on family planning and HIV/STI screening and collect relevant programmatic data on service delivery.Study is not able to show whether collected data was of good quality and usable by decision makers.
Agboola et al., 201647This randomized controlled trial examined the effect of personalized text messages on physical activity, as measured by a pedometer, and clinical outcomes in patients with diabetes. Patients who received the SMS messages had significantly higher monthly step counts in the third (RR=4.89; 95% CI, 1.20 to 19.92) and fourth (RR=6.88; 95% CI, 1.21 to 39.00) months of the study compared to the control group. However, over the 6-month follow-up period, monthly step counts did not differ statistically by group. HbA1c levels decreased by 0.07% (95% CI, 0.47 to 0.34) in the intervention group compared to the control group.Operational challenges related to pedometer software installation and Internet access to upload activity data contributed to a high attrition rate in the study. Investigators also noted differential rates of activity tracker adherence across comparison groups. Group differences in baseline HbA1c that could potentially bias comparisons of follow-up changes were also observed. Finally, the study did not evaluate the effectiveness of the different types/themes of messages.
Capozza et al., 201549The authors used a randomized controlled trial design to assess the impact on glycemic control of a 2-way SMS-based intervention that provided daily behavioral coaching, education, and testing reminders to patients with diabetes. The secondary aim of the study was to examine patient interaction and satisfaction with the program. The study was conducted in the context of a 6-month clinic-based quality improvement initiative. A comparison of the intervention group and the controls (who continued their usual care without receiving SMS messages) showed similar decreases in average HbA1c levels after 90 and 180 days of follow up, probably reflecting the success of the broader quality improvement initiative. Almost a third (29%) of program users in the intervention group demonstrated frequent engagement, and survey results indicated very high satisfaction with the program.The primary outcome, change in HbA1c, is difficult to affect in the short time frame (6 months), and sample size was small (58 and 35 in intervention and control groups, respectively). Study also reported wide variation in the timing of baseline HbA1c measures relative to study onset. Authors also reported difficulties recalling patients to the clinic for regular HbA1c testing.
Daviaud et al., 201768The authors conducted an economic analysis of the implementation of ICCM, which includes the integrated diagnosis, treatment, and referral services for malaria, suspected pneumonia, and diarrhea among children by CHWs. The analysis was conducted across 6 African countries and assessed country-level scale-up implications. Their analysis indicated that between 10 and 603 treatments were given per CHW per year. Weighted economic costs per treatment ranged from US$2 to US$13. CHWs spent from 1 to 9 hours a week on ICCM.The paper focused on annual costs to providers (health system and donors) to inform planning and budgeting but did not assess program effectiveness due to the recentness of program implementation. CHW time on the program was based on the same assumptions of length of visit and meetings for all countries rather than on observation. Authors note that even though implementation costs are calculated on an annual basis, recent guidelines recommend using a wider window of time.
den Hollander and Mars, 201767The authors conducted a retrospective review of a referral database of cell phone-generated images to demonstrate that telemedicine can be a reliable method of triaging patients before admission into a burn unit. In 66% of studied cases, telemedicine consultation avoided inappropriate admission or delayed admission in late referrals until the patient was ready for definitive treatment.Study highlighted complex issues related to patient data security and confidentiality.
Dobson et al., 201752The systematic review examined 7 randomized controlled trials that investigated the use of SMS-based self-management interventions for patients with diabetes. No clear relationship between positive outcomes and intervention dose, content, and functionality was observed.The small number of articles reviewed was due, in part, to inclusion criteria restricting studies to randomized controlled trial designs. Because only published full-text papers in English were included, the study results were potentially influenced by publication and language bias.
Kabakyenga et al.,201662Findings from this observational study suggest that using mobile phones to support the implementation of ICCM by CHWs could improve supportive care for acutely ill children.The study's design and limited sample size of only 96 trained CHWs did not allow a full assessment of demonstrable improvement in health outcomes attributable to mobile-phone support.
Lim et al., 201646This clinical trial randomized patients with diabetes into either a group offering routine diabetes care with self-monitored blood glucose or a group employing an Internet-based monitoring device that provided real-time individualized feedback (u-healthcare) system combined with exercise monitoring and dietary feedback. The investigators examined the effect of the u-healthcare combination intervention on glycemic control. After 6 months of follow up, the HbA1c level was significantly decreased in the u-healthcare group (8.0% ± 0.7%) compared with the SMBG group (8.1% ± 0.8 %; P<.01).The study was limited to individuals with access to mobile phones and Internet. Additionally, the 6-month follow-up period may not be long enough to evaluate the long-term effect of this system.
  • Abbreviations: CHWs, community health workers; CI, confidence interval; HbA1c, hemoglobin A1c; ICCM, integrated community case management; RR, risk ratio; SMBG, self-monitored blood glucose; SMS, short message service; STI, sexually transmitted infection; u, ubiquitous.