Developing an intervention to improve quality of myocardial infarction care in northern Tanzania

项目摘要 心肌梗死（MI）是全球范围内的主要死亡原因。迫切需要提高对 在资源有限的情况下对MI进行循证护理。该提案提出了一个研究职业发展 一项计划，1）确定坦桑尼亚基于证据的MI护理的障碍，2）制定多组分干预措施 通过调整其他环境中已证实的策略来改善护理，以及3）评估可行性，可接受性， 以及干预的潜在效果。候选人是杜克大学的外科助理教授 大学和急诊医学医生，有在坦桑尼亚进行MI研究的经验。 他作为NIH Fogarty全球健康研究员确定的高MI相关死亡率使他寻求额外的治疗方案。 实施科学、干预开发和临床试验设计方面的培训。与多样化的 实施研究、临床试验和全球心血管疾病专家指导委员会， 以及与他合作了十年的坦桑尼亚同事，他将在他先前的基础上， 坦桑尼亚北方MI研究。拟议的活动将使候选人具备以下综合技能： 全球紧急情况实施研究，并使他成为一名成功的独立调查员 在全球卫生、急救医学和实施科学的交叉点上运作。 越来越多的证据表明，在撒哈拉以南非洲（SSA），MI是常见的，经常误诊，很少 采用循证疗法治疗，并与高死亡率相关。初步研究由 坦桑尼亚的候选人发现，22%的急诊科（艾德）患者患有典型的 有症状的急性心肌梗死，但90%的急性心肌梗死病例被艾德医生漏诊。候选人的研究 发现急性心肌梗死后30天的死亡率为43%--比1999年的死亡率高出6倍多。 美国的这种不良的MI结局可能与基于证据的MI护理的低吸收有关;例如， 候选人的初步数据发现，只有23%的急性心肌梗死患者接受阿司匹林治疗， 降低非传染性疾病死亡率的“最佳购买”。尽管这些数据令人震惊， 在SSA中，基于证据的MI护理在很大程度上仍未得到探索，并且当地定制的干预措施可以改善MI护理 在资源有限的情况下，非常缺乏。迫切需要确定MI护理的障碍， 制定适合当地的干预措施，改善坦桑尼亚等低收入环境中的MI结果。 这项建议将通过采用植根于执行科学的方法来弥合这一知识差距。 具体而言，本研究将1）确定北方MI循证诊断和治疗的障碍 坦桑尼亚，2）开发多组分定制干预措施以改善MI护理，以及3）确定可行性， 可接受性和对MI护理的定制干预的潜在影响。这项研究将是重要的第一步 在资源有限的环境中减少MI相关的过度发病率和死亡率。

PROJECT SUMMARY Myocardial infarction (MI) is a leading cause of death worldwide. There is a critical need to improve uptake of evidence-based care for MI in resource-limited settings. This proposal presents a research career development program to 1) identify barriers to evidence-based MI care in Tanzania, 2) develop a multicomponent intervention to improve care by adapting proven strategies from other settings, and 3) assess the feasibility, acceptability, and potential effectiveness of the intervention. The candidate, an Assistant Professor of Surgery at Duke University and emergency medicine physician, has experience conducting research regarding MI in Tanzania. The high MI-associated mortality he identified as an NIH Fogarty Global Health Fellow led him to seek additional training in implementation science, intervention development, and clinical trial design. Working with a diverse mentoring committee of experts in implementation research, clinical trials, and global cardiovascular disease, as well as Tanzanian colleagues with whom he has collaborated for the past ten years, he will build upon his prior study of MI in northern Tanzania. The proposed activities will equip the candidate with a combination of skills in global emergency implementation research and position him to become a successful independent investigator operating at the intersection of global health, emergency medicine, and implementation science. Growing evidence suggests that in sub-Saharan Africa (SSA), MI is common, frequently misdiagnosed, rarely treated with evidence-based therapies, and associated with high mortality. Preliminary research conducted by the candidate in Tanzania found that 22% of patients presenting to the emergency department (ED) with typical symptoms have an acute MI, but 90% of acute MI cases are missed by ED physicians. The candidate’s research found a 30-day mortality rate following acute MI of 43%--more than sixfold higher than the mortality rate in the United States. Such poor MI outcomes are likely related to low uptake of evidence-based MI care; for example, the candidate’s preliminary data found that only 23% of patients with acute MI were treated with aspirin—a WHO “best buy” for reducing noncommunicable disease mortality. Despite these alarming data, the barriers to evidence-based MI care in SSA remain largely unexplored and locally-tailored interventions to improve MI care in resource limited settings are sorely lacking. There is an urgent need to identify barriers to MI care and to develop locally-appropriate interventions that will improve MI outcomes in low-income settings like Tanzania. This proposal will bridge this knowledge gap by using an approach rooted in implementation science. Specifically, this study will 1) identify barriers to evidence-based diagnosis and treatment of MI in northern Tanzania, 2) develop a multicomponent tailored intervention to improve MI care, and 3) determine feasibility, acceptability, and potential effect of a tailored intervention on MI care. This study will be an important first step towards reducing excess MI-associated morbidity and mortality in resource-limited settings.