Multicomponent Intervention to Improve Acute Myocardial Infarction Care in Tanzania: Protocol for a Pilot Implementation Trial.
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2024-09
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Abstract
Background
Although the incidence of acute myocardial infarction (AMI) is rising in sub-Saharan Africa, the uptake of evidence-based care for the diagnosis and treatment of AMI is limited throughout the region. In Tanzania, studies have revealed common misdiagnosis of AMI, infrequent administration of aspirin, and high short-term mortality rates following AMI.Objective
This study aims to evaluate the implementation and efficacy outcomes of an intervention, the Multicomponent Intervention to Improve Acute Myocardial Infarction Care (MIMIC), which was developed to improve the delivery of evidence-based AMI care in Tanzania.Methods
This single-arm pilot trial will be conducted in the emergency department (ED) at a referral hospital in northern Tanzania. The MIMIC intervention will be implemented by the ED staff for 1 year. Approximately 400 adults presenting to the ED with possible AMI symptoms will be enrolled, and research assistants will observe their care. Thirty days later, a follow-up survey will be administered to assess mortality and medication use. The primary outcome will be the acceptability of the MIMIC intervention, which will be measured by the Acceptability of Intervention Measurement (AIM) instrument. Acceptability will further be assessed via in-depth interviews with key stakeholders. Secondary implementation outcomes will include feasibility and fidelity. Secondary efficacy outcomes will include the following: the proportion of participants who receive electrocardiogram and cardiac biomarker testing, the proportion of participants with AMI who receive aspirin, 30-day mortality among participants with AMI, and the proportion of participants with AMI taking aspirin 30 days following enrollment.Results
Implementation of MIMIC began on September 1, 2023. Enrollment is expected to be completed by September 1, 2024, and the first results are expected to be published by December 31, 2024.Conclusions
This study will be the first to evaluate an intervention for improving AMI care in sub-Saharan Africa. If MIMIC is found to be acceptable, the findings from this study will inform a future cluster-randomized trial to assess effectiveness and scalability.Trial registration
ClinicalTrials.gov NCT04563546; https://clinicaltrials.gov/study/NCT04563546.International registered report identifier (irrid)
DERR1-10.2196/59917.Type
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Hertz, Julian T, Francis M Sakita, Faraan O Rahim, Blandina T Mmbaga, Frida Shayo, Vivian Kaboigora, Julius Mtui, Gerald S Bloomfield, et al. (2024). Multicomponent Intervention to Improve Acute Myocardial Infarction Care in Tanzania: Protocol for a Pilot Implementation Trial. JMIR research protocols, 13. p. e59917. 10.2196/59917 Retrieved from https://hdl.handle.net/10161/34658.
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Scholars@Duke
Julian T Hertz
Julian Hertz, MD, MSc, is an Associate Professor of Emergency Medicine & Global Health. He graduated summa cum laude from Princeton University and attended medical school at Duke University, where he received the Dean's Merit Scholarship and the Thomas Jefferson Award for leadership. He completed his residency training in emergency medicine at Vanderbilt University Medical Center and his fellowship in Global Health at Duke.
Dr. Hertz's primary interests include global health, implementation science, and undergraduate and graduate medical education. Dr. Hertz's research focuses on using implementation science methods to improve cardiovascular care both locally and globally. His current projects involve developing interventions to improve acute myocardial infarction care in Tanzania, to improve management of hypertension among Tanzanians with HIV, and to improve post-hospital care among patients with multimorbidity in East Africa.
Dr. Hertz has received numerous awards for clinical, educational, and research excellence, including the Duke Emergency Medicine Faculty Teacher of the Year Award, the Duke Emergency Medicine Faculty Clinician of the Year Award, and the Duke Emergency Medicine Faculty Researcher of the Year Award. He has also received the Golden Apple Teaching Award from the Duke medical student body, the Duke Master Clinician/Teacher Award, and the Global Academic Achievement Award from the Society of Academic Emergency Medicine.
Gerald Bloomfield
Gerald Bloomfield, MD, MPH, joined the faculty in Medicine and Global Health after completing his Cardiovascular Medicine fellowship training at Duke University Medical Center and Duke Clinical Research Institute. Bloomfield also completed the Duke Global Health Residency/Fellowship Pathway and a Fogarty International Clinical Research Fellowship. He received his medical education, internal medicine residency and Master of Public Health degree from Johns Hopkins University. Bloomfield leads a longstanding research and capacity building program on cardiovascular global health which includes work in under-resourced communities in the US and a number of low- and middle-income country settings.
Hayden Barry Bosworth
Dr. Bosworth is a health services researcher and Deputy Director of the Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT) at the Durham VA Medical Center. He is also Vice Chair of Education and Professor of Population Health Sciences. He is also a Professor of Medicine, Psychiatry, and Nursing at Duke University Medical Center and Adjunct Professor in Health Policy and Administration at the School of Public Health at the University of North Carolina at Chapel Hill. His research interests comprise three overarching areas of research: 1) clinical research that provides knowledge for improving patients’ treatment adherence and self-management in chronic care; 2) translation research to improve access to quality of care; and 3) eliminate health care disparities.
Dr. Bosworth is the recipient of an American Heart Association established investigator award, the 2013 VA Undersecretary Award for Outstanding Achievement in Health Services Research (The annual award is the highest honor for VA health services researchers), and a VA Senior Career Scientist Award. In terms of self-management, Dr. Bosworth has expertise developing interventions to improve health behaviors related to hypertension, coronary artery disease, and depression, and has been developing and implementing tailored patient interventions to reduce the burden of other chronic diseases. These trials focus on motivating individuals to initiate health behaviors and sustaining them long term and use members of the healthcare team, particularly pharmacists and nurses. He has been the Principal Investigator of over 30 trials resulting in over 400 peer reviewed publications and four books. This work has been or is being implemented in multiple arenas including Medicaid of North Carolina, private payers, The United Kingdom National Health System Direct, Kaiser Health care system, and the Veterans Affairs.
Areas of Expertise: Health Behavior, Health Services Research, Implementation Science, Health Measurement, and Health Policy
Janet Prvu Bettger
Dr. Bettger’s research is dedicated to establishing real world evidence aimed to improve health care quality and policies that reduce the burden of disease and disability. As a health services researcher and implementation scientist, her research extends from observational studies to randomized and pragmatic trials. She was the Founding Director of Duke Roybal Center for Translational Research in the Behavioral and Social Sciences of Aging and the Founding Director of Undergraduate Initiatives for the Duke-Margolis Center for Health Policy. She has examined implementation of several integrated care models to improve the transition home from the hospital (VERITAS with virtual exercise therapy after knee replacement, COMPASS for stroke, RECOVER for stroke in rural China, and coordinated care for trauma patients in Tanzania). She also studies implementation of community-based models of care that can prevent functional decline. These include the CTSA-funded IMPAC RCT of integrating physical therapists into primary care as first line providers to address musculoskeletal pain, the VA-funded Gerofit program of structured and progressive in-person and virtual group exercise for older Veterans, MRC-funded SINEMA RCT of a village-based model supporting stroke recovery in China, and a NIDCD study comparing three primary care protocols for older adult hearing healthcare.
In addition to the evidence translation studies in China (RECOVER and SINEMA) and Tanzania, she has partnered with experts in Singapore on stroke systems research, and worked on large cluster randomized trials to improve evidence-based care in Brazil, Peru, Argentina (BRIDGE-Stroke) and China (CNSR and Golden Bridge). To address health locally, she was the faculty sponsor to launch Exercise is Medicine at Duke and Help Desk, a student volunteer community resource navigator model addressing social determinants of health.
Dr. Bettger received her BA from the University of Western Ontario, Canada and her MS from the University of Wisconsin–LaCrosse where she studied community reintegration for stroke and brain-injured patients transitioning from hospital to home. Her doctoral training in Rehabilitation Sciences, completed at Boston University, concluded with an investigation of patterns of functional recovery and factors affecting outcomes in patients transitioning home following acute rehabilitation. While working on her doctorate, she also worked in state government as the director of the Paul Coverdell National Acute Stroke Registry. Dr. Bettger completed post-doctoral training at the University of Pennsylvania with a NIH NRSA research fellowship in neurorehabilitation, a research fellowship at the NewCourtland Center for Transitions and Health, and a Switzer Fellowship funded by the National Institute on Disability and Rehabilitation Research to study the role of the environment on functional outcomes. She completed additional research training at Duke as a mentored scholar in comparative effectiveness research funded by AHRQ. As of July 2022, she is an Adjunct Associate Professor for Duke's Department of Orthopaedics and has transitioned out of her role as Co-Director of the Duke Clinical and Translational Institute (CTSA) Pilots Accelerator Core working with NCCU. She is affiliate faculty with Duke's Science and Society, Duke-Margolis Center for Health Policy, the Duke Clinical Research Institute (DCRI) and Duke Global Health Institute (DGHI), is a Senior Fellow of the Duke Center for the Study of Aging and Human Development, and is a Fellow of the American Heart Association.
Nathan Maclyn Thielman
Broadly, my research focuses on a range of clinical and social issues that affect persons living with or at risk for HIV infection in resource-poor settings. In Tanzania, our group is applying novel methods to optimize HIV testing uptake among high-risk groups. We recently demonstrated that the Discrete Choice Experiment (DCE), a form of stated preference survey research, is a robust tool for identifying (a) which characteristics of HIV testing options are most preferred by different populations and (b) which tradeoffs individuals make in evaluating testing options. Building on more than a decade of productive HIV testing research in the Kilimanjaro Region, the next phase of our NIMH funded project will test the hypothesis that DCE-derived HIV testing options significantly increases rates of testing among groups at high risk for HIV infection. This work holds promise not only for optimizing HIV testing uptake in the Kilimanjaro Region, but also for applying novel tools in the service of translational epidemiology and implementation research.
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