Improving the accuracy of heart failure diagnosis in low-resource settings through task sharing and decentralization

Alyssa DeWyer, Amy Scheel, Isaac Omara Otim, Christopher T. Longenecker, Emmy Okello, Isaac Ssinabulya, Stephen Morris, Mark Okwir, William Oyang, Erine Joyce, Betty Nabongo, Craig Sable, Ben Alencherry, Alison Tompsett, Twalib Aliku, Andrea Beaton

Research output: Contribution to journalArticlepeer-review

4 Scopus citations


Background: Task sharing of TTE may improve capacity for heart failure diagnosis and management in patients in remote, low-resource settings but the impact on diagnostic accuracy and patient outcomes has not been studied. Objectives: Determine feasibility and impact of non-expert training in transthoracic echocardiography (TTE) to improve the diagnosis and outcomes of patients with suspected heart failure in Uganda. Methods: This two-part study examined an innovative training program to develop TTE competency among non-experts and used a pre-post design to determine the impact of decentralized TTE. Four of 8 non-experts (50%) passed a three-part training course. The training comprised of distance learning through a web-based curriculum, a 2-day hands-on workshop with cardiologists, and independent practice with remote mentorship. Continuous measures were compared (pre- vs. post-TTE) using t-tests or Wilcoxon rank-sum tests as distributionally appropriate and categorical variables assessed through chi-square testing. Sensitivity and specificity were calculated according to standard methodology comparing diagnosis pre- and post-TTE during phase 2. Results: Performance in the post-training phase showed good agreement with expert categorization (κ = 0.80) with diagnostic concordance in 421 of 454 studies (92.7%). TTE changed the preliminary diagnosis in 81% of patients, showing low specificity of clinical decision-making alone (14.2%; 95% CI 10.1–19.2%). Dilated cardiomyopathy, hypertensive heart disease with preserved systolic function, and right heart failure were the most underdiagnosed conditions prior to TTE while hypertensive heart disease with decreased systolic function was the most over-diagnosed condition. Conclusions: In conclusion, non-expert providers can achieve a high level of proficiency for the categorization of heart failure using handheld TTE in low-resource settings and use of telemedicine and remote mentorship may improve performance and feasibility. The addition of TTE resulted in substantial improvement in etiological specificity. Further study is needed to understand implications of this strategy on healthcare utilization, long-term patient outcomes, and cost.

Original languageEnglish (US)
Article number1684070
JournalGlobal Health Action
Issue number1
StatePublished - Jan 1 2019
Externally publishedYes


  • Echocardiography
  • task-shifting
  • telemedicine
  • training
  • Uganda

ASJC Scopus subject areas

  • Health Policy
  • Public Health, Environmental and Occupational Health


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