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A new software developed by the All India Institute of Medical Sciences (AIIMS), Delhi, can extend specialised diabetes care consultation to the remotest primary healthcare centre (PHC). All that a local-level healthcare professional needs to do is feed in patient data on risk factors like blood pressure, cholesterol and blood sugar into the software, which can then process the information to suggest the kind of treatment and medicines needed.
A nine-year-long randomised control trial, conducted on more than 1,100 patients from 10 private and public hospitals, demonstrated the model’s efficiency as patients were able to reduce their diabetes-related complications when they followed the protocol it recommended.
“The study was conducted in low and middle-income countries, including India and Pakistan. This software is suitable for treating patients with diabetes, blood pressure and high cholesterol. We were able to reduce serious complications of diabetes such as kidney, eye and nervous systems by 32 per cent,” said Dr Nikhil Tandon, Head, Department of Endocrinology and Metabolism at AIIMS, and one of the key investigators who did the randomised controlled trial with the new Clinical Decision Support Software (CDSS).
Besides, patients on the CDSS protocol were nearly twice as likely to achieve and maintain target levels for blood sugar, blood pressure and LDL-cholesterol compared to regular patients.
Given its efficacy, this tool could become a key component of public health management of diabetes which, according to a study by the Indian Council of Medical Research (ICMR), has affected 101 million people. That’s why the team of researchers has also suggested integrating it with the electronic health record of patients in the National Programme for NCDs (non-communicable diseases) run by the Government.
“Integrating the software into the patient portal will significantly benefit the national programme. For this, we have also initiated talks with the officials concerned,” Dr Tandon said.
The software could be an integral part of treatment as there are many shortcomings in the diagnosis, treatment and management of diabetes in the country. “Fifty per cent of people are not aware of their disease, 50 per cent of them do not take treatment. Those on treatment stop taking the medicine midway. At a clinic, the doctor wastes time finding out about patient history, often suggesting more tests. Sometimes patients do not get the right advice in remote parts,” he said.
For the last nine years, Dr Tandon and fellow researchers have been working on CDSS, which follows data prompts and can suggest the kind of treatment a patient requires if their blood sugar, blood pressure or cholesterol levels cross a certain level, the medicines to be taken for their condition and dosage. So in places where a trained diabetologist or an endocrinologist is not available, physicians can take support of CDSS prompts and advise treatment to a patient.
Initially, the study was done for two-and-half years with not just patients of diabetes but also patients who needed to control their blood pressure and cholesterol. “The intervention showed that we could control multiple risk factors by more than 200 per cent using our methodology,” Dr Tandon said.
The AIIMS team developed the software on a rule-based algorithm based on a compilation of 2,000-2,500 patient scenarios, symptoms and treatment options. So these advisories are based on mathematical scenarios, which do not include information about lifestyle changes. “It can provide a recommendation for therapy which is based on evidence-based guidelines. If the variables were restricted to what is fed in the computer, this would perform very well but there are variables which cannot be put into the algorithm such as lifestyle-related changes. Therefore, the doctor may also adapt the advice based on the variables related to a patient’s lifestyle and other conditions,” Dr Tandon said.
“Suppose a patient is taking two pills for diabetes but the sugar level is still above what the doctors want it to be, the CDSS can advise adding or subtracting a dose of medicine. However, it cannot ascertain the emotional and mental stress or changes a patient has been through which can affect their disease. It’s the doctor who will decide how the treatment has to be modified,” he said.
The software can be operated by anyone with computer proficiency, who can upload details of the patient’s test results, the comparative score of blood pressure and blood pressure and previous treatment. “Apart from treatment advisories, it can even assess if the patient needs to increase or decrease dosage of his current medication,” he said.
The only human component in software management is a care coordinator, who can be a simple computer operator. “The other component is powered by technology in the form of an electronic health record system, which will keep all the information of a diabetes patient on their tests, reports, past treatment or lack of it. An integrated clinical decision support system analyses these inputs before suggesting an advisory,” he said.
The CDSS has been developed as part of a study, conducted by the Center for Cardiovascular Risk Reduction in South Asia (CARRS), between January 2011 and September 2019. The researchers in the team included doctors from AIIMS, Centre for Chronic Disease Control and the Public Health Foundation of India (PHFI) among others.
