Improving the detection of infectious diseases in at-risk migrants with an innovative integrated multi-infection screening digital decision support tool (IS-MiHealth) in primary care: A pilot cluster-randomized controlled trial

Abstract

Background: There are major shortfalls in the identification and screening of at-risk migrant groups. This study aims to evaluate the effectiveness of a new digital tool (IS-MiHealth) integrated into the electronic patient record system of primary care centres in detecting prevalent migrant infections. IS-MiHealth provides targeted recommendations to health professionals for screening multiple infections, including HIV, hepatitis B and C, active tuberculosis, Chagas disease, strongyloidiasis, and schistosomiasis, based on patient characteristics (including variables of country of origin, age, sex). Methods: A pragmatic pilot cluster-randomised controlled trial was deployed from March to December 2018. Eight primary care centres in Catalonia, Spain, were randomly allocated 1:1 to use of the digital tool for screening, or to routine care. The primary outcome was the monthly diagnostic yield of all aggregated infections. Intervention and control sites were compared before and after implementation with respect to their monthly diagnostic yield using regression models. This study is registered on ISRCTN (ISRCTN14795012). Results: 15780 migrants registered across the 8 centres had at least one visit during the intervention period (March to December 2018), of which 14 598 (92.51%) fulfilled the criteria to be screened for at least one infection. There were 210 (2.57%) individuals from the intervention group with new diagnoses compared with 113 (1.49%) from the control group (OR:2.08 95%CI 1.63–2.64, p < 0.001). The intervention centres raised their overall monthly diagnosis rate to 5.80 (95%CI 1.23–10.38, p = 0.013) extra diagnoses compared to the control centres. This monthly increase in diagnosis in intervention centres was also observed if we consider all cases together of HIV, hepatitis B and C, and active TB cases (2.72,[95%CI 0.43–5.00]; p = 0.02) and was observed as well for the parasitic infections´ group (Chagas disease, strongyloidiasis, and schistosomiasis) 2.58 (95%CI 1.60–3.57; p < 0.001). Conclusions: The IS-MiHealth increased screening rate and diagnostic yield for key infections in migrants in a population-based primary care setting. Further testing and development of this new tool is warranted in larger trials and in other countries.

Usefulness and practicality of a multidisease screening programme targeting migrant patients in primary care in Spain: a qualitative study of general practitioners

“… 22 To attempt to address some of the current shortfalls in the provision of screening to migrant patients as part of PHC, we successfully piloted the implementation of an innovative clinical decision-support system, called the ISMiHealth tool, that guides general practitioners (GPs) through computer prompts about screening recommendations for migrants. 23 During the pilot, the tool was integrated within the primary care electronic patient record (EPR) in Catalonia and displayed prompts about screening recommendations based on an individualised approach that uses three variables: sex, age and country of origin. These variables are routinely registered in the EPR system of health centres, thereby providing a passive yet practical tool for health professionals, who receive a prompt with screening recommendations based on a migrant person’s background characteristics when they attend the centre for any reason.…”

“…In our study, we defined migrants as foreign-born people, irrespectively of when they arrived in Spain. 23 No exclusion criteria were stipulated concerning the year of arrival to provide the screening recommendation, except for TB. This criterion was established because all other infections are chronic and because, for several infections, the risk remains even after migration.…”

“…Our pilot study highlighted an increasing yield of infections in the centres where the tool was implemented compared with centres that followed the routine care procedures. 23 …”

“…The tool can easily be adapted to accommodate epidemiological changes of the disease under consideration and to cover other at-risk populations (eg, travellers), settings and conditions, such as rare infections in migrants, and other relatively neglected topics, such as mental health, which is not included systematically in migrants’ health assessments. 23 …”

Initial health assessments for newly arrived migrants, refugees, and asylum seekers

“…Digital tools that offer GPs immediate tailored advice on screening and catch up vaccines, based on country of origin (currently being explored 6 38 )…”