Digital tracking, provider decision support systems, and targeted client communication via mobile devices to improve primary health care.

backgroundDigital tracking on mobile devices, combined with clinical decision support systems and targeted client communication, can facilitate service delivery and potentially improve outcomes.

objectivesTo assess the effects of using a mobile device to track service use when combined with clinical decision support (Tracking + CDSS), with targeted client communications (Tracking + TCC), or both (Tracking + CDSS + TCC). SEARCH

methodsCochrane CENTRAL, MEDLINE, Embase, Ovid Population Information Online (POPLINE), K4Health and WHO Global Health Library (2000 to November 2022). SELECTION CRITERIA: Randomised and non-randomised trials in community/primary care settings.

participantsprimary care providers and clients Interventions: 1. Tracking + CDSS 2. Tracking + TCC 3. Tracking + CDSS + TCC Comparators: usual care (without digital tracking) DATA COLLECTION AND ANALYSIS: Two authors independently screened trials, extracted data and assessed risk of bias using the RoB 1 tool. We used a random-effects model to meta-analyse data producing risk differences (RD), risk ratios (RR), or odds ratios (OR) for dichotomous outcomes and mean differences (MD) for continuous outcomes. Evidence certainty was assessed using GRADE. MAIN

resultsWe identified 18 eligible studies (11 randomised, seven non-randomised) conducted in Bangladesh, China, Ethiopia, India, Kenya, Palestine, Uganda, and the USA. All non-randomised studies had a high risk of bias. These results are from randomised studies. 'Probably/may/uncertain' indicates 'moderate/low/very low' certainty evidence. Tracking + CDSS Relating to antenatal/ postnatal care: Providers' adherence to recommendations May slightly increase home visits in the week following delivery (2 studies, 4531 participants; RD 0.10 [0.07, 0.14]) May slightly increase counselling for initiating complementary feeding (2 studies, 4397 participants; RD 0.12 [0.08, 0.15]) May slightly increase the mean number of home visits in the month following delivery (1 study, 3023 participants; MD 0.75 [0.47, 1.03]) Uncertain effect on home visits within 24 hours of delivery Clients' health behaviours May slightly increase skin-to-skin care (1 study, 1544 participants; RD 0.05 [0.00, 0.10]) May slightly increase early breastfeeding (2 studies, 4540 participants; RD 0.08 [0.05, 0.12]) Uncertain effects on applying nothing to the umbilical cord, taking ≥ 90 iron-folate tablets during pregnancy, exclusively breastfeeding for six months, delaying the newborn's bath at least two days and Kangaroo Mother Care. Clients' health status May reduce low birthweight babies (1 study, 3023 participants; RR 0.53 [0.38, 0.73]) May increase infants with pneumonia or fever seeking care (1 study, 3470 participants; RR 1.13 [1.03, 1.24]) Uncertain effects on stillbirths, neonatal and infant deaths, or testing positive for HIV during antenatal testing Tracking + TCC Clients' health status In stroke patients over 12 months: May slightly increase blood pressure (BP) medication adherence (1 study, 1226 participants; RR 1.10 [1.00, 1.21]) May reduce deaths (1 study, 1226 participants; RR 0.52 [0.28, 0.96]) May slightly reduce systolic BP (1 study, 1226 participants; MD -2.80 mmHg [-4.90, -0.70]) May slightly improve EQ-5D scores (1 study, 1226 participants; MD 0.04 [0.02, 0.06]) May reduce stroke hospitalisations (1 study, 1226 participants; RR 0.45 [0.32, 0.64]). Tracking + CDSS + TCC Providers' adherence to recommendations Probably increases guideline adherence for antenatal screening and management of anaemia (1 study, 10,502 participants; OR 1.88 [1.52, 2.32]), diabetes (1 study, 8669 participants; OR 1.45 [1.14, 1.84}), hypertension (1 study, 15,555 participants; OR 1.62 [1.29, 2.04]) and probably leads to lower adherence for abnormal foetal growth (1 study, 1165 participants; OR 0.59 [0.37, 0.95]). May slightly increase nevirapine prophylaxis in infants of HIV+ve mothers (1 study, 609 participants; OR 1.75 [0.73, 4.19]) Data quality In pregnant women (1 study, 6367 participants), tracking + CDSS + TCC: Probably slightly reduces missing data for haemoglobin (RR 0.77 [0.71, 0.84]) but slightly more for BP at delivery (RR 1.16 [1.08, 1.24]) May have little or no effect on missing data on gestational age (RR 0.96 [0.81, 1.14]) or birthweight (RR 0.90 [0.77, 1.04]) Clients' health behaviour May have little or no effect on being on anti-retroviral therapy at delivery (1 study, 438 participants; OR 1.41 [0.81, 2.45]) or exclusive breastfeeding for six months (1 study, 695 participants; OR 1.74 [0.95, 3.17]) in HIV+ve mothers Uncertain effects on physical activity in high cardiovascular-risk adults Clients' health status May reduce the number of deaths in patients with hypertension and diabetes (1 study, 3698 participants; OR 0.61 [0.35, 1.06]) May reduce new cardiovascular events in high-cardiovascular risk adults over 6-18 months (1 study, 8642 participants; OR 0.58 [0.42, 0.80}) May slightly decrease in antenatal women severe hypertension, but the confidence interval includes both a decrease and increase (1 study, 6367 participants; OR 0.61 [0.27, 1.37]) In women receiving antenatal care (1 study, 6367 participants), tracking + CDSS + TCC maymake little or no difference to adverse pregnancy outcomes (OR 0.99 [0.87, 1.12]), moderate or severe anaemia (OR 0.82 [0.51, 1.31]), or large-for-gestational-age babies (OR 1.06 [0.90, 1.25]). In adults with hypertension or diabetes (1 study, 3324 participants), tracking + CDSS + TCC maymake little or no difference to HbA1c (MD 0.08 [-0.27, 0.43]), total cholesterol (MD -2.50 [-7.10, 2.10]), 10-year cardiovascular risk (MD -0.40 [-2.30, 1.50]), tobacco use (MD-0.05 [-0.47, 0.37]), alcohol use (MD 0.70 [-3.70, 5.10]), or PHQ-9 (MD -1.60 [-4.40, 1.20]). Uncertain effects on maternal or infant mortality before the baby reaches 18 months in HIV-positive mothers, patients who achieve optimal BP, BP controlled at five years, diastolic or systolic BP, body mass index, fasting glucose and quality of life in adults with hypertension or diabetes Client service utilisation May have little or no effect on missed early infant diagnosis visits (1 study, 1183 participants; OR 0.92 [0.63, 1.35]). Uncertain effects on linkage to care Client satisfaction Probably increases slightly the number of adults with hypertension or diabetes reporting "slightly/much better" change in the quality of care (1 study, 3324 participants; RR 1.02 [1.00, 1.03]). No studies evaluated time between presentation and appropriate management, timeliness of receiving/accessing care, provider acceptability/satisfaction, resource use, or unintended consequences. AUTHORS'

conclusionsDigital tracking may improve primary care workers' ability to follow recommended antenatal and chronic disease practices, quality of patient records, patient health outcomes and service use. However, these interventions led to small or no outcome differences in most studies.