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Cited by 26Mobile Health and mHealth ApplicationsHealth Promotion and Cardiovascular PreventionTelemedicine and Telehealth Implementation

Using mHealth Tools to Improve Access and Coverage of People With Public Health Insurance and High Cardiovascular Disease Risk in Argentina: A Pragmatic Cluster Randomized Trial

Open access
Beratarrechea, Andrea, Abrahams‐Gessel, Shafika, Irazola, Vilma, Gutierrez, Laura, Moyano, Daniela, Gaziano, Thomas A.·2019·Journal of the American Heart Association
DOI 10.1161/jaha.118.011799PMC PMC6507203
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Abstract

Background: Control of cardiovascular disease ( CVD ) risk factors is suboptimal in Argentina, despite the government's provision of free blood pressure and cholesterol‐lowering medications for people without private insurance. We assessed whether community health workers’ use of an integrated mH ealth tool encourages patients to attend visits at primary care clinics to improve CVD risk management in 2 provinces of Argentina. Methods and Results: We conducted a pragmatic cluster randomized trial, with primary care clinics randomly assigned to intervention or control. Eligible people were aged 40 to 79 years, lived in the catchment area of primary care clinics, possessed a mobile phone for personal use, had public health coverage, and a 10‐year CVD risk ≥10%. In the control arm, community health workers screened for CVD risk using a paper‐based tool and encouraged high‐risk people to present to the primary care clinics for care. In the intervention arm, community health workers used the mH ealth tool to calculate CVD risk and confirm a scheduled physician appointment. Primary outcomes were the proportion of participants who attended a baseline visit and completed at least 1 follow‐up, respectively. We enrolled 755 people (376 interventions; 379 controls). Intervention participants were significantly more likely to complete baseline visits (49.4% versus 13.5%, P value 0.0008) and follow‐up visits (31.9% versus 7.7%; P value 0.0041). The use of chronic medication and current smoking were significant predictors of primary outcomes. Conclusions: Use of mH ealth tools identifies patients at high CVD risk in their home, increases the likelihood of participating in chronic CVD risk factor management, and strengthens referrals. Clinical Trial Registration: URL : http://www.clinicaltrials.gov . Unique identifier: NCT 02913339.

AI snapshot

Written from the paper’s full text.

TL;DR

In a pragmatic cluster randomized trial in Argentina, community health workers using an integrated mHealth tool increased primary care clinic attendance among public-insurance adults at high cardiovascular disease risk. The intervention improved baseline and follow-up visit completion but did not significantly improve appropriate chronic medication use overall.

Key findings

  • Baseline visit completion within 6 weeks was 49.4% in the intervention arm versus 13.5% in control (net difference 35.9, 95% CI 18.3–53.5; P=0.0008; adjusted net difference 34.1, 95% CI 16.1–52.1; P=0.0006).
  • Follow-up visit completion within 4 months was 31.9% versus 7.7% (net difference 24.2, 95% CI 11.6–36.8; P=0.0041; adjusted net difference 20.9, 95% CI 9.2–32.6; P=0.0036).
  • At least 1 follow-up visit during the study was completed by 59.8% versus 22.4% (net difference 37.4, 95% CI 18.9–55.9; P=0.0004), and mean visits were 1.1 versus 0.4 (net difference 0.7, 95% CI 0.3–1.1; P=0.0077).
  • Appropriate chronic medication use at 6–12 months was 50.6% versus 28.7% (net difference 21.9, 95% CI −6.5–50.2; P=0.1487), not statistically significant overall; intervention group was a predictor of baseline attendance (OR 6.1, 95% CI 2.0–18.3) and follow-up attendance (OR 4.8, 95% CI 1.5–14.8).

Methods

  • Pragmatic cluster randomized trial in 8 public primary care centers in Corrientes and Almirante Brown, Argentina; clusters were assigned 1:1 with stratified restricted randomization by province. Participants were aged 40–79 years, lived in the catchment area, owned a mobile phone, had public health coverage, and had 10-year CVD risk ≥10%; 755 were enrolled (376 intervention, 379 control).
  • Intervention CHWs used an mHealth app to calculate CVD risk and schedule a physician appointment via an electronic scheduling system, with SMS reminders and educational messages; control CHWs used paper-based WHO charts and encouraged participants to schedule appointments.
  • Outcomes were assessed from case report forms and medical records; intention-to-treat analyses used generalized estimating equations for primary and secondary outcomes.

Limitations

  • The paper states it could not assess health-system factors that may have affected implementation and patient response, or identify who is most likely to benefit; it also notes little evidence on optimal text-message dosing, frequency, and content.
  • The paper notes the overall medication outcome was not significant while site-specific medication results were significant, which may be a chance finding; it explains this partly by intracluster correlation differences (Almirante Brown 0.0760; Corrientes 0.1490; global 0.2420) and limited power for the global secondary outcome.
  • The paper states further study is needed to assess whether increased visits reduce actual risk factors such as blood pressure and dyslipidemia, and CVD events. Evident from the text: participants and staff were not blinded, medication use was self-reported, and follow-up was 6 months.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1161/jaha.118.011799

Cites

24 of 24 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 31 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    No differences were observed between female and male participants in primary outcomes.

    “No differences were observed between female and male participants in primary outcomes, but males were more likely to be under chronic medication in the intervention group compared with males in control group, showing a statistically significant difference (54.9% versus 24.6%, P=0.0342) (Table 4).”
    Quote in the paperNot a substantial claim
  • Findingown data

    Overall, the clinical attendance rate was significantly higher in the intervention group (59.8%) compared with the control group (22.4%).

    “Overall, the clinical attendance rate was significantly higher in the intervention group, 59.8%, compared with the control group, 22.4% (Table 2).”
    Quote in the paperSubstantial claim
  • Findingown data

    These effects were similar across most subgroups including sex and region of country.

    “These effects were similar across most subgroups including sex and region of country, but having a higher educational level or using other chronic medications increased the likelihood of responding to the intervention.”
    Quote in the paperNot a substantial claim
  • Findingown data

    Overall, the number of clinic visits was nearly 3 times as high in the intervention arm compared with control.

    “Overall, the number of clinic visits was nearly 3 times as high in the intervention arm compared with control.”
    Quote in the paperSubstantial claim
  • Findingreasoning

    There is much more variability in the proportion of appropriate prescriptions among the 4 clinics analyzed together than between the 2 clinics in each site.

    “This is because there is much more variability in the proportion of appropriate prescriptions among the 4 clinics analyzed together than between the 2 clinics in each site.”
    Quote in the paperSubstantial claim
  • The quote only partly states this claim. 2
  • May combine two claims. 24
  • Classified as probably not a substantial claim. 29

  • The quote only partly states this claim.

    Findingown data

    Intervention participants were significantly more likely to complete follow-up visits (31.9% vs 7.7%, P=0.0041).

    “For follow‐up visits, 31.9% of participants in the intervention group completed a visit within the 4 months of the first visit at the clinic compared with 7.7% in the control group.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    From August 2016 to July 2017, 990 people were screened, and 755 met eligibility criteria and were enrolled.

    “From August 2016 to July 2017, 990 people living in the catchment area within the selected PCCs were screened, and 755 met eligibility criteria and were enrolled (Figure 2).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The use of chronic medication and current smoking were significant predictors of primary outcomes.

    “The use of chronic medication and current smoking were significant predictors of primary outcomes.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    A significant and positive effect was observed in each region for the proportion of participants who were under chronic medication, and within both sites there was a significantly increased rate of appropriate prescriptions in the intervention arm compared with usual care.

    “A significant and positive effect was observed in each region when we analyze the effect of the intervention in the proportion of participants who were under chronic medication (Table 3).”
    • Also stated in: § Summary of Findings · hedged
      “While we did not find a statistically significant greater difference in the rate of appropriate medications in the intervention arm compared with the usual‐care arm in the overall study, when we evaluated it by site, we found that within both sites, there was a significantly increased rate of appropriate prescriptions in the intervention arm compared with usual care.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    The mean age of participants with a 10-year CVD risk ≥10% was 54±8 years and 68.6% (518) were women.

    “The mean age of participants with a 10‐year CVD risk ≥10% was 54±8 years and 68.6% (518) were women.”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingown data

    Participants who were screened in their home by CHWs using a mobile phone app with digital integration to the clinic schedule were significantly more likely to attend a recommended first and follow-up visit with a primary care physician at the PCC compared with CHWs using the standard of care of a paper-based screening tool with verbal referral.

    “In conclusion, in this cluster randomized study of patients at moderate to high risk of CVD, the rates of clinic attendance and follow‐up appointments at primary health centers were higher among those screened in community by CHWs using an mHealth app integrated with a digital clinical scheduling system compared with those using a paper system.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The relative increase was similar but the absolute differences were different across the regions.

    “The relative increase was similar but the absolute differences were different across the regions.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Argentina's challenges to improve detection and management of CVD include low rates of awareness, shortages of trained healthcare workers for noncommunicable diseases, overcrowded primary care centers, and overall lack of resources in the healthcare system.

    “However, like other low‐ and middle‐income countries, Argentina's challenges to improve the detection and management of CVD include low rates of awareness, shortages of trained healthcare workers for noncommunicable diseases, overcrowded primary care centers (PCCs), and overall lack of resources in the healthcare system.5”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [5] Tsolekile LP, Abrahams‐Gessel S, Puoane T. Healthcare professional shortage and task‐shifting to prevent cardiovascular disease: implications for low‐ and middle‐income countries. Curr Cardiol Rep. 2015; 17: 115. 26482758

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Cluster randomization was conducted at the data coordinating center at Harvard, and the 8 PCCs were randomly assigned using the RAND function in Excel Pro Plus 2010.

    “Cluster randomization was conducted at the data coordinating center at the Center for Health Decision Science at the Harvard T.H. Chan School of Public Health. The 8 PCCs were randomly assigned to the intervention or control (usual care) arm using the RAND function in Excel Pro Plus 2010 (Microsoft, Redmond, WA).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Using a mobile phone app version of the CVD screening reduces the time required and improves the cost-effectiveness of the intervention.

    “Using a mobile phone app version of this screening reduces the time required and improves the cost‐effectiveness of the intervention.10, 11”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [10] Surka S, Edirippulige S, Steyn K, Gaziano T, Puoane T, Levitt N. Evaluating the use of mobile phone technology to enhance cardiovascular disease screening by community health workers. Int J Med Inform. 2014; 83: 648– 654. 25002305 PMC4108525 source

      Not checked in the free run.

    • cites [11] Gaziano T, Abrahams‐Gessel S, Surka S, Sy S, Pandya A, Denman CA, Mendoza C, Puoane T, Levitt NS. Cardiovascular disease screening by community health workers can be cost‐effective in low‐resource countries. Health Aff (Millwood). 2015; 34: 1538– 1545. 26355056 PMC4795815

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    The trial was designed to provide 80% statistical power to detect a 40% or more relative increase in the proportion of participants with CVD risk ≥10% who completed a first visit at PCCs and a 60% relative increase in follow-up visit, with α=0.05 for a 2-tailed test.

    “The trial was designed to provide 80% of statistical power to detect a 40% or more relative increase in the proportion of participants with CVD risk ≥10% who completed a first visit at the PCCs and a 60% relative increase in the proportion of these participants who completed a follow‐up visit at the clinic within 4 months of the baseline (α=0.05 for a 2‐tailed test).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    CHWs were trained and certified based on proficiency using the mobile app to classify people with moderate and high CVD risk and to schedule appointments.

    “CHWs were certified based on their proficiency using the mobile app to classify people with moderate and high CVD risk and to schedule appointments.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Study administrative staff, healthcare professionals, CHWs, and participants were not blinded to intervention assignment.

    “Study administrative staff, healthcare professionals, CHWs, and participants were not blinded to the intervention assignment.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductreasoning

    The required sample size was calculated as 740 people (92 per clinic), assuming 8 clinics with average cluster size 84, 10% loss to follow-up, and ICC 0.01.

    “Eight clinics (4 in each arm) with an average cluster size of 84 participants with CVD risk ≥10%, a 10% loss to follow‐up or poor data quality, and an intracluster correlation coefficient (ICC) of 0.01 were assumed. The required sample size calculated was 740 people (92 per clinic).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductreasoning

    Clusters were assigned 1:1 to intervention or control using stratified, restricted randomization, with strata defined by province.

    “Clusters were assigned (1:1) to either the intervention or control groups. To ensure reasonable balance between the 2 arms in both provinces, we used stratified, restricted randomization to allocate clusters. The strata were defined on the basis of the province where PCCs were located.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductown data

    Outcomes were determined from two data sources: case report forms and medical records at PCCs, with trained researchers reviewing medical records and chronic prescription refills using a structured record review checklist.

    “We used data from 2 sources to determine outcomes: case report forms and medical records at PCCs.”
    • Also stated in: § Data Collection · plain
      “Trained researchers reviewed medical records and chronic prescription refills of study participants and primary data were collected by using a structured record review checklist to assess the study outcomes.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    All statistical analyses were based on the intention-to-treat principle.

    “All statistical analyses were based on the intention‐to‐treat principle.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    In the control arm, CHWs were trained and certified based on proficiency using the World Health Organization chart to classify participants with high cardiovascular risk in the community.

    “CHWs were certified based on their proficiency using the World Health Organization chart to classify participants with high cardiovascular risk in the community.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The REMEDIAR and REDES Programs, now under the Plan for Universal Health Care, were funded by the Argentina Ministry of Health to provide free medications and health care to low-income, uninsured patients.

    “In response to the 2001 economic depression, the REMEDIAR and REDES Programs, now under the Plan for Universal Health Care (Cobertura Universal de la Salud) were funded by the Argentina Ministry of Health to provide free medications and health care to low‐income, uninsured patients.6, 7”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [6] Ministerio de Salud de la Nacion. Cus medicamentos CUS Medicamentos. 2018.

      Not checked in the free run.

    • cites [7] Ministerio de Salud de la Nacion. Programa redes. 2018.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Cardiovascular diseases are one of the leading causes of morbidity, mortality, and disability in low- and middle-income countries, including Argentina where the CVD burden and risk factors continue to rise.

    “Cardiovascular diseases (CVDs) are one of the leading causes of morbidity, mortality, and disability in low‐ and middle‐income countries, including Argentina where the CVD burden and risk factors continues to rise.1, 2”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [1] Beaglehole R, Bonita R, Horton R, Adams C, Alleyne G, Asaria P, Baugh V, Bekedam H, Billo N, Casswell S, Cecchini M, Colagiuri R, Colagiuri S, Collins T, Ebrahim S, Engelgau M, Galea G, Gaziano T, Geneau R, Haines A, Hospedales J, Jha P, Keeling A, Leeder S, Lincoln P, McKee M, Mackay J, Magnusson R, Moodie R, Mwatsama M, Nishtar S, Norrving B, Patterson D, Piot P, Ralston J, Rani M, Reddy KS, Sassi F, Sheron N, Stuckler D, Suh I, Torode J, Varghese C, Watt J; Lancet NCDAG, Alliance NCD. Priority actions for the non‐communicable disease crisis. Lancet. 2011; 377: 1438– 1447. 21474174 source

      Not checked in the free run.

    • cites [2] Rubinstein A, Colantonio L, Bardach A, Caporale J, Garcia Marti S, Kopitowski K, Alcaraz A, Gibbons L, Augustovski F, Pichon‐Riviere A. Estimate of the cardiovascular disease burden attributable to modifiable risk factors in Argentina. Rev Panam Salud Publica. 2010; 27: 237– 245. 20512225

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductcitation

    Three blood pressure measurements were obtained by CHWs at baseline according to a standard American Heart Association protocol, and the mean of all measurements was used to calculate CVD risk.

    “In addition, 3 blood pressure measurements were obtained by CHWs at the baseline data collection visit according to a standard protocol recommended by the American Heart Association, and the mean of all the measurements was used to calculate CVD risk.21”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [21] Pickering GT, Hall EJ, Appel JL, Falkner EB, Graves NJ, Hill WM, Jones GD, Kurtz JT, Sheps JS, Roccella JE. Recommendations for blood pressure measurement in humans and experimental animals: part 1: blood pressure measurement in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Circulation. 2005; 111: 697– 716. 15699287 source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductown data

    The trial was a pragmatic cluster randomized trial involving 8 primary care centers within a national public health system in Argentina.

    “This was a pragmatic cluster randomized trial involving 8 PCCs within a national public health system (REMEDIAR and REDES Program) in Argentina.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [17] Abrahams‐Gessel S, Beratarrechea A, Irazola V, Gutierrez L, Moyano D, Fernandez A, Ciganda A, Celis LA, Winkler E, Rubinstein A, Gaziano TA. Using mHealth tools to improve access, coverage and treatment of uninsured people with high cardiovascular disease risk in Argentina: a study protocol for a pragmatic cluster randomised trial. BMJ Innov. 2018; 4: 135– 141.

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Web-based scheduling appointment systems serve purposes critical to managing chronic disease patients, including managing clinic workload, rapidly identifying missed appointments, improving patient satisfaction, and monitoring timely attendance.

    “The adoption of web‐based scheduling appointment systems serve many purposes critical to managing chronic disease patients: managing clinic workload; rapidly identifying those who miss appointments in order to initiate patient follow‐up; improving patient satisfaction because of reduced waiting time; and monitoring the percentage of patients who attend the clinics in a timely manner.12”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [12] Chalker JC, Wagner AK, Tomson G, Johnson K, Wahlstrom R, Ross‐Degnan D; International Network for the Rational Use of Drugs Initiative on Adherence to Antiretroviral T. Appointment systems are essential for improving chronic disease care in resource‐poor settings: learning from experiences with HIV patients in Africa. Int Health. 2013; 5: 163– 165. 24030266

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    The institutional review boards of Partners Human Research Committee/Brigham and Women's Hospital and Hospital Italiano de Buenos Aires approved the study, and written informed consent was obtained from all eligible participants who accepted participation.

    “The institutional review boards of Partners Human Research Committee/Brigham and Women's Hospital and Hospital Italiano de Buenos Aires in Argentina approved the study. Written informed consent was obtained by all eligible participants who accepted participating in the study during screening activities conducted by CHWs.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Evidence-based clinical practice guidelines recommend identifying and managing individuals at high CVD risk using a combined strategy of lifestyle modification and appropriate medication for CVD prevention and control.

    “Evidence‐based clinical practice guidelines recommend identifying and managing individuals at high CVD risk by using a combined strategy of lifestyle modification and appropriate medication for CVD prevention and control.4”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [4] Gaziano TA, Opie LH, Weinstein MC. Cardiovascular disease prevention with a multidrug regimen in the developing world: a cost‐effectiveness analysis. Lancet. 2006; 368: 679– 686. 16920473 PMC2365896

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The CHW-led, home-based intervention has also been successful in addressing other related chronic conditions and settings.

    “The CHW–led, home‐based intervention has also been successful in addressing other related chronic conditions and settings.24, 25”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [24] Brownstein JN, Chowdhury FM, Norris SL, Horsley T, Jack L Jr, Zhang X, Satterfield D. Effectiveness of community health workers in the care of people with hypertension. Am J Prev Med. 2007; 32: 435– 447. 17478270

      Not checked in the free run.

    • cites [25] He J, Irazola V, Mills KT, Poggio R, Beratarrechea A, Dolan J, Chen CS, Gibbons L, Krousel‐Wood M, Bazzano LA, Nejamis A, Gulayin P, Santero M, Augustovski F, Chen J, Rubinstein A; Investigators H. Effect of a community health worker—led multicomponent intervention on blood pressure control in low‐income patients in Argentina: a randomized clinical trial. JAMA. 2017; 318: 1016– 1025. 28975305 PMC5761321 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    In the literature, there is little evidence regarding the optimal dosing, frequency, and content of text messages to address CVD management.

    “Moreover, in the literature, there is little evidence regarding the optimal dosing, frequency, and content of text messages to address CVD management.30, 31”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [30] Cole‐Lewis H, Kershaw T. Text messaging as a tool for behavior change in disease prevention and management. Epidemiol Rev. 2010; 32: 56– 69. 20354039 PMC3082846 source

      Not checked in the free run.

    • cites [31] Piette JD, List J, Rana GK, Townsend W, Striplin D, Heisler M. Mobile health devices as tools for worldwide cardiovascular risk reduction and disease management. Circulation. 2015; 132: 2012– 2027. 26596977 PMC5234768

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    mHealth was used as an aid by CHWs to guide CVD risk assessment at the people's home and to refer high CVD risk people to the clinic using a clinical appointment system integrated to the app, making the CHWs' screening and referral tasks more efficient.

    “In this sense, mHealth was used as an aid by CHWs to guide CVD risk assessment at the people's home and to refer high CVD risk people to the clinic using a clinical appointment system integrated to the app, making the CHWs’ screening and referral tasks more efficient.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Subgroup analyses by region and sex were specified a posteriori to examine differences.

    “Additional subgroup analyses by region and sex were specified a posteriori to examine differences.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    We had enough power to detect a significant difference given the lower ICC per site but not for the global comparison, where the ICC was higher.

    “Since appropriate medication was a secondary outcome in our study, we did have enough power to detect a significant difference given the lower ICC per site but not for the global comparison, where the ICC was higher.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    Educational messages were created using content previously validated in this population for cultural appropriateness.

    “All educational messages were created using content that was previously validated in this population for cultural appropriateness.20”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [20] Diez‐Canseco F, Zavala‐Loayza JA, Beratarrechea A, Kanter R, Ramirez‐Zea M, Rubinstein A, Martinez H, Miranda JJ. Design and multi‐country validation of text messages for an mHealth intervention for primary prevention of progression to hypertension in Latin America. JMIR Mhealth Uhealth. 2015; 3: e19. 25693595 PMC4376187 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Tian et al. showed positive effects when an mHealth app that includes a decision support system was included as an aid to CHWs to guide and standardize the implementation of intervention to manage CVD in India and China.

    “Tian et al also showed positive effects when an mHealth app that includes a decision support system was included as an aid to CHWs to guide and standardize the implementation of intervention to manage CVD in India and China.28”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [28] Tian M, Ajay VS, Dunzhu D, Hameed SS, Li X, Liu Z, Li C, Chen H, Cho K, Li R, Zhao X, Jindal D, Rawal I, Ali MK, Peterson ED, Ji J, Amarchand R, Krishnan A, Tandon N, Xu LQ, Wu Y, Prabhakaran D, Yan LL. A cluster‐randomized, controlled trial of a simplified multifaceted management program for individuals at high cardiovascular risk (SimCard Trial) in rural Tibet, China, and Haryana, India. Circulation. 2015; 132: 815– 824. 26187183 PMC4558306 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    In 2016, the World Health Organization-led HEARTS technical package includes task sharing as a key element for reducing the risk of premature mortality from CVDs.

    “In this sense, in 2016 the World Health Organization–led HEARTS technical package includes task sharing as a key element for reducing the risk of premature mortality from CVDs.23”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [23] World Health Organization. Hearts: technical package for cardiovascular disease management in primary health care. 2016.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based). May combine two claims.

    Interpretationnone given

    The success of the intervention is likely related to the improvement in the healthcare infrastructure, organizational changes required to implement the intervention, and its adoption by healthcare professionals at the affected PCCs.

    “The success of the intervention is likely related to the improvement in the healthcare infrastructure, organizational changes required to implement the intervention, and its adoption by healthcare professionals at the affected PCCs.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Task shifting and sharing has proven to be effective in the control of HIV and tuberculosis.

    “Task shifting and sharing has proven to be effective in the control of HIV and tuberculosis and now is emerging as an effective strategy in the control of CVDs in low‐ and middle‐income countries.22”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [22] Perry HB, Zulliger R, Rogers MM. Community health workers in low‐, middle‐, and high‐income countries: an overview of their history, recent evolution, and current effectiveness. Annu Rev Public Health. 2014; 35: 399– 421. 24387091 source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductown data

    Although the intervention group had a slightly lower proportion of individuals with self-reported history of hypercholesterolemia and a higher proportion reporting use of antihypertensive medication, these differences were not statistically significant.

    “Although the intervention group had a slightly lower proportion of individuals with a self‐reported history of hypercholesterolemia and a higher proportion of patients who reported use of antihypertensive medication, differences observed were not statistically different among the intervention and control groups.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Task shifting and sharing is emerging as an effective strategy in the control of CVDs in low- and middle-income countries.

    “Task shifting and sharing has proven to be effective in the control of HIV and tuberculosis and now is emerging as an effective strategy in the control of CVDs in low‐ and middle‐income countries.22”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [22] Perry HB, Zulliger R, Rogers MM. Community health workers in low‐, middle‐, and high‐income countries: an overview of their history, recent evolution, and current effectiveness. Annu Rev Public Health. 2014; 35: 399– 421. 24387091 source

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationnone given

    Although the results do not aim to be generalizable, they can be transferable to similar settings, where access to health professionals and healthcare infrastructure is limited.

    “Although they do not aim to be generalizable, they can be transferable to similar settings, where access to health professionals and healthcare infrastructure is limited as a valuable first step towards developing future mHealth interventions in poor urban settings to manage CVD risk.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    A systematic review showed that CHWs are empowered by using mobile phone-based tools because these reinforce and improve the services they provide.

    “A systematic review that evaluated the feasibility and effective use of mobile phone strategies by frontline health workers showed that CHWs are empowered by using mobile phone–based tools because these reinforce and improve the services they provide.27”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [27] Agarwal S, Perry HB, Long LA, Labrique AB. Evidence on feasibility and effective use of mHealth strategies by frontline health workers in developing countries: systematic review. Trop Med Int Health. 2015; 20: 1003– 1014. 25881735 PMC4692099 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Strategies using mHealth have been considered a strengthening tool to overcome health system constraints.

    “Strategies using mHealth have been considered a strengthening tool to overcome health system constrains.26”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [26] Labrique AB, Vasudevan L, Kochi E, Fabricant R, Mehl G. mHealth innovations as health system strengthening tools: 12 common applications and a visual framework. Glob Health Sci Pract. 2013; 1: 160– 171. 25276529 PMC4168567 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).

    Interpretationnone given

    In the few cases where electronic health records with scheduling capacity are used in low-income settings, an application with appropriate code can be developed to access those systems remotely.

    “In the few cases where electronic health records with scheduling capacity are used in low‐income settings, an application with appropriate code can be developed to access those systems remotely.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    A text messaging intervention linked to an electronic scheduling system and directed to participants with appointment reminders and tailored educational messages increases awareness and promotes follow-up with chronic care.

    “In addition, a text messaging intervention linked to an electronic scheduling system and directed to participants with appointment reminders and tailored educational messages increases awareness and promotes follow‐up with chronic care.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    The corresponding author had full access to all data, takes responsibility for its integrity and data analysis, and had final responsibility for decision to submit for publication.

    “The corresponding author had full access to all the data in the study, takes responsibility for its integrity and the data analysis, and had final responsibility for the decision to submit for publication.”
    Quote in the paperNot a substantial claim
43 of 43

  • The paper relies on this without support.

    The lack of an automated appointment scheduling system in primary care centers in Argentina leads to high-risk people being lost in the healthcare system, missing appointments, and missing months of care and treatment.

    “The lack of an automated appointment scheduling system in PCCs in Argentina leads to these people being lost in the healthcare system, missing appointments, and even missing several months of care and treatment.”

  • The paper relies on this without support.

    To improve follow-up and management of CVD, people identified as high-risk need to have regular visits with physicians based on clinical treatment guidelines.

    “To improve follow‐up and management of CVD, people identified as high‐risk need to have regular visits with physicians based on clinical treatment guidelines.”

  • The paper relies on this without support.

    Early detection of those at high risk for cardiovascular disease can lead to improved management and outcomes for cardiovascular disease.

    “Early detection of those at high risk for cardiovascular disease can lead to improved management and outcomes for cardiovascular disease.”
3 of 3

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

  • Almirante Brown visit difference has the wrong sign

    Major

    The reported intervention and control means are 0.4 and 0.9 visits, respectively. Their difference is −0.5, not the reported positive difference of 0.6.

    Reported 0.6 · recomputed -0.5

  • Corrientes visit difference has the wrong sign

    Major

    The reported intervention mean is 0.5 visits and the control mean is 1.3. Their difference is −0.8, not the reported positive difference of 0.9.

    Reported 0.9 · recomputed -0.8

2 of 2

Cites

Flagged first, then by citations

1 of the 25 references couldn’t be matched to a known paper.

Cited by

Sorted by citations

Related

Authors
Beratarrechea, A., Abrahams‐Gessel, S., Irazola, V., Gutierrez, L., Moyano, D., & Gaziano, T. A.
Affiliations
  • Instituto de Efectividad Clínica y Sanitaria (AR)
  • Harvard University (US)
  • Department of Chronic Diseases South American Center of Excellence for Cardiovascular Health (CESCAS) Institute for Clinical Effectiveness and Health Policy (IECS) Buenos Aires Argentina
  • Brigham and Women's Hospital (US)
Corresponding author
Gaziano, Thomas A.
ORCID
Venue
Journal of the American Heart Association
Publisher
Ovid Technologies (Wolters Kluwer Health)
Published
2019-04-16
Volume
8
Issue
8
Pages
e011799-e011799
ISSN
2047-9980 (ISSN-L)
DOI
10.1161/jaha.118.011799
PMC
PMC6507203
OpenAlex
W2929437320
Semantic Scholar
3c3563eb47c9ae1ea4bbee08136e4be491586c8b
Cited by
26
References
25
Citations by year
2025: 6 · 2024: 4 · 2023: 6 · 2022: 4 · 2021: 3 · 2020: 1 · 2019: 2
FWCI
3.41
Type
journal article
Language
en
Open access
Licence
cc-by-nc-nd
Locations
  • Journal of the American Heart Association (publishedVersion, cc-by-nc-nd)
  • PubMed Central (publishedVersion, cc-by-nc-nd)
  • PubMed (publishedVersion)
  • Conicet (submittedVersion, cc-by-nc-sa)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
Funders
Fogarty International Center (R21TW010173)
Topics
  • Health Sciences › Health Professions › General Health Professions › Mobile Health and mHealth Applications
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Health Promotion and Cardiovascular Prevention
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Telemedicine and Telehealth Implementation
Keywords
mobile health, cardiovascular risk, community health workers, primary care visits, public health insurance, mobile health technology, primary care referral, Argentina
MeSH terms
Adult, Aged, Appointments and Schedules, Argentina, Cardiovascular Diseases, Community Health Workers, Female, Health Services Accessibility, Humans, Insurance, Health, Male, Mass Screening, Middle Aged, Primary Health Care, Risk, Reminder Systems, Medically Uninsured, Telemedicine, Text Messaging, Mobile Applications

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-09.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-09.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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