Georges Bediang^*1, Yannick Kamga², Chris Nadège Nganou-Gnindjio¹, Olivier Ngoule¹, Serge Ndongo¹, Cheick Oumar Bagayoko³, Samuel Nko 'o¹, Antoine Geissbuhler⁴

¹Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Cameroon

² Department for the Control of Disease, Epidemics and Pandemics, Ministry of Public Health, Cameroon

³Faculté de Médecine, de Pharmacie et d'Odonto-Stomatologie, University of Bamako, Mali

⁴Faculty of Medicine, University of Geneva, Geneva, Switzerland

Corresponding author: Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, PO Box 1364, Yaoundé, Cameroon.

Abstract

Background: Cameroon's health system suffers from several deficiencies related to the burden of disease, infrastructure deficit, inadequate human resources, governance and funding problems. Despite efforts made by state to improve offer, quality and access to care in these countries, many health indicators are still below expectations. Otherwise, there is a strong increase of the prevalence of non-communicable diseases, in particular for cardiovascular diseases. In agreement with the World Health Organization, which recommends exploring the potential of telemedicine to solve certain scourges, a telemedicine project has been set up in two districts hospitals in Cameroon. This study aims at evaluating the effectiveness of tele-expertise (tele-ECG) in primary health care in Cameroon for the management of patients with cardiovascular diseases or risk factors.

Method:It is a controlled multicenter study carried out in two health facilities (intervention centers) of Cameroon where tele-ECG has been implemented and two other health facilities (control centers) where telemedicine is not implemented. Patients recruited in the control centers received the usual primary healthcare (management of cardiovascular diseases by general practitioner alone or sending patients to a cardiologist for a specialized consultation) or in intervention centers received usual primary health care and had the possibility to perform an ECG associated with the remote expertise of cardiologist (tele-ECG). Patients included in this study had to have symptoms or history of cardiovascular diseases. The primary outcome was to evaluate the rate of access of patients to an ECG examination and an expertise of a cardiologist. Data analysis were done by the intention-to-treat method.

Results: 171 participants were recruited, 93 participants (54, 4%) from intervention centers, and 78 participants (45.6%) from control centers. 98.9% of the participants in intervention centers had access to ECG and expertise of the cardiologist compared to 33.3% in control centers (p<0.01). The relative risk (RR) for this primary outcome was 2.96 [95% CI: 2.16 - 4.06]. The delay to perform an ECG exam for a patient was on average 1-3 days in intervention centers versus 7 days in the control centers (p<0.01). The delay for patient to have a cardiologist’s consultation was on average 10.3 days in intervention group versus 11.2 days in the control group (p<0.01). 98.9% participants of the intervention centers were present for follow-up appointments (90 days after) compared to 33.3% in control centers (p<0.01). We observed 47.3% of diagnostic discordance rate in intervention centers compared to 51.3% in control centers (p<0.01). The evolution of cardiovascular symptoms was favorable in intervention centers (66.7%) compared to (23.1%) in control centers (p<0.01), as well as  the improvement of blood pressure,  40.9%  in intervention centers versus 17.9%  in control centers  (p<0.01). The participants satisfaction (rated on a scale of 5) was 5 in the intervention group and 4 in the control group (p<0.01).

Discussion and Conclusion: Telemedicine is increasingly becoming an alternative to usual healthcare. Assessment of telemedicine in developing countries remains a major challenge. For telemedicine to become truly anchored as a credible alternative to usual care, evidence of its added-value in terms of effectiveness and efficiency is essential. This study intends to provide more new evidences on the potential of telemedicine in developing countries in general and in particular in Africa where resources are limited. In this study, we observed that the tele-ECG improves the rate of access of patients to an ECG examination and an expertise of a cardiologist. It improves also several secondary outcomes. We ca can conclude that tele-ECG is effective in primary health care in Cameroon for the management of patients with cardiovascular diseases or risk factors.

Keywords: Telemedicine, Effectiveness, Non-Communicable Diseases, Cardiovascular Diseases, Developing Countries, Low-middle Income Countries, Africa.