This study shows that tele-ECG consulting in a low-to-middle income Indonesian population was helpful to support primary care GPs in making a quick pre-hospital triage. Of 505 ECG screenings transmitted to the analysis center, all recordings were qualified for analysis. Within 30 days, tele-ECG is associated with a higher rate of early hospitalization when needed. We found no significant differences between the normal and abnormal ECG groups in terms of mid-term cardiovascular death and hospitalization.
From our analyses, we found that patients with normal ECG were predominantly female, younger, showed better clinical profiles, and had fewer CVD risk factors when compared to those with an abnormal ECG. Men were significantly more prone to have an ischemic ECG than women, and participants of older age (>55 years) were more susceptible towards an ischemic or arrhythmic ECG compared with those of younger age groups.
Half of the participants in this study suffered from hypertension; 22% were unaware of this and 33% were untreated. The National Survey 2013 reported that 62% of hypertension cases in the Indonesian general population were undiagnosed (6). A previous review also reported that >50% of the study participants with hypertension in Indonesia were unaware and untreated (4). This recent study showed lower number of unaware and untreated cases, as majority of our study population turned up to primary care center with a cardiovascular symptom and risk factor. However, these numbers are still higher compared with the 16% unaware and 7% untreated hypertension cases in stroke patients recently studied in China (7,8).
A large proportion of the population in Indonesia is estimated to have undiagnosed diabetes, and diabetes is often detected only once patients present with secondary complications (4). Nevertheless, standard screening and detection for diabetes mellitus and dyslipidemia (i.e. fasting plasma glucose and lipid profiles) are usually unavailable at primary care services in this country. In our study, ~9% of participants had known diabetes. We inferred that considering the moderate-to-high risk profile there must be more undetected or undiagnosed diabetes cases in this study population.
From the present study, we observed a higher number of female patients that present with chest pain despite a normal ECG. There is abundant evidence to indicate that women are more likely to present with chest pain – and often with recurrence and re-admissions – compared to men (9). However, CAD occurs more frequently in men (9). Another study also indicated that women scored the intensity of their chest pain significantly higher than men (10). Non-CAD-related angina is commonly associated with persistent chest pain, causing poor function and quality of life, and re-admission (9). Therefore, in women with a normal ECG, it should be kept in mind that if the symptom is moderate and recurring, the angina should not be underestimated. Microvascular dysfunction, coronary artery spasm, coronary artery dissection, and myocardial bridging are the most common causes of chest pain in women who present at the Emergency Department (9). These underlying patho-mechanisms may be undetectable on a one-time point resting ECG assessment. Women are more vulnerable to longer admission to hospital, slower diagnosis, and inadequate treatment (11). Previous studies have suggested that coronary angiography is used less often in women, largely because their risk is underestimated (11). Women describe an atypical clinical feature of chest pain, which significantly differs from men. Often, women complain of concomitant atypical symptoms (e.g. heartburn to epigastric pain, unusual fatigue, dizziness, feeling of doom, and generalized weakness) (9), and make the indication for CVD even more difficult to establish.
Symptomatic patients with normal ECG findings are often reassured by their diagnosis and favorable prognosis, but receive no specific prevention management, despite the presence of a higher risk of CVD events. Despite the moderate-to-high risk profiles, ~52% of our study population received no medications, while ~31% received adequate medications and planned for long-term primary or secondary prevention.
In this study, we focused on evaluating qualitative interpretation of the tele-ECG performance, quantifying patient profiles and management, and conducting an in-depth case analysis of all deaths and hospitalizations observed at the first 30 days and >30 days after tele-ECG advice. Based on patient risk profile and clinical history, we obtained a reasonable picture regarding the quality of care and the impact of the tele-ECG consulting. In non-referral group with abnormal ECG, six (3.7%) patients had been hospitalized for CVD within 30 days, three (1.8%) patients died and 6 (3.7%) were admitted to hospital after 30 days. While in the normal ECG group, two (0.8%) patients died due to uncontrolled diabetes and heart failure, while 7 (2.8%) were admitted to hospital due to CVD during the follow-up period. This indicates that the criteria for referral should be revised, and patients with recurrent and marked cardiovascular symptoms should be treated with caution despite their normal ECG presentation. In the future, GPs decision should be supported by reliable and standardized scores and algorithms, which are currently not available in primary care services.
At mid-term follow-up, there were no significant differences between the referral and non-referral groups pertaining the cardiovascular death and hospitalization. We can assume that: (1) the low cardiovascular mortality rate in the abnormal ECG group indicated that early hospitalization based on tele-ECG advice had a favorable impact; (2) the higher rate of CVD hospitalization in normal ECG group indicated that those patients could have undetectable and uncontrolled cardiovascular risk factors, particularly because standard screening for diabetes and dyslipidemia is generally not available in primary care centers in Indonesia; and (3) the lower rate of mid-term CVD hospitalization implied well-controlled or prevention of CVD risk factors in the referral group.
A prior study in western population showed that mortality rates in patients with acute myocardial infarction (AMI) were not statistically different between those screened with pre-hospital tele-ECG compared with the controls, both at 30 days and 6 months (12). However, in higher risk AMI patients, pre-hospital tele-ECG triage has been associated with a lower 6-month mortality (12). In our study, we did not use a control group to compare the performance of pre-hospital tele-ECG since we used the general population in primary care settings as our study population.
While low- and middle-income countries are more likely to consider resource barriers such as high costs, underdeveloped infrastructure, and lack of technical expertise to tackle telemedicine, high-income countries are more likely to consider legal issues surrounding patient privacy and confidentiality, competing health priorities, and perceived lack of demand to be barriers in telemedicine implementation (1). However, the success of the Makassar Telemedicine Program has shown that implementation of telemedicine (i.e. tele-ECG) in a low resource setting is feasible and beneficial in the context of early disease detection and selection of patients for referral.
A previous study has suggested that tele-ECG is a practical and cost-effective tool for diagnosis and monitoring of CVD, and accordingly, improves the accessibility and quality of care in a rural low-to-middle income population in India (13). Singh et al. reported the patient satisfaction was ~95% (13), while in our study we accounted the similar 95% for GPs satisfaction in primary care facilities. Another study concluded that pre-hospital tele-ECG is highly appreciated and utilized by the emergency department staff with 86% indicated excellence for the satisfaction rate (14). In developed countries, both pre- and in-hospital tele-ECG triage significantly shorten door-to-balloon time in patients with acute myocardial infarction and result in higher rates of timely primary percutaneous coronary intervention (PCI) (<90 minutes), compared to the control group (12,15,16). Tele-ECG has been relevantly proved to reduce unnecessary hospitalization and wrong diagnosis in the case of suspected acute CVD (14).
To our knowledge, the present study is among the first to explore the implementation of telemedicine programs in South-East Asia and couples the program performance to patient outcomes. During follow-up, we had to cope with the unorganized and incomplete patient data at primary care centers (Puskesmas). Follow-up would be far easier if all Puskesmas kept standardized and reliable medical records. In the future, we hope that firstly, primary care records should be available in the form of an electronic database to ease the integration and communication with the hospitals. Secondly, patient and doctor engagement and long-term planning for primary or secondary prevention should be managed better. Each patient should have a solitary permanent record for all check-ups and consultations. Thirdly, patients who are eligible and willing to participate in a research study should provide a copy of an official ID card (e.g. residence permit or kartu tanda penduduk; or driver’s license or surat ijin mengemudi), to ensure that follow-up and data acquisition from hospital or primary care centers could be performed efficiently.
During the entire follow-up (14 ± 6.6 months), seven (1.4%) patients died and 96 (19.0%) were hospitalized for CVD. However, due to poor medical records in Puskesmas in Indonesia, particularly in Makassar, there is no primary care database available. Therefore, any comparison in terms of cardiovascular mortality or hospitalization is not possible. This study has other potential limitations. Firstly, before this tele-ECG program, the ECG assessment did not exist in most primary care centers in Makassar, and hence comparison regarding the waiting time, performance, or other evaluation tasks before and after the implementation of tele-ECG was also unfeasible.
Secondly, we assumed that there were more undiagnosed and undetected patients with diabetes in our study population, meaning that we might have underestimated the rate of CVD risk factors. The CVD risk profiles could be even worse than we observed. However, this limitation is unlikely to have biased our main results. We suggest that the Indonesian Government should be more serious about combating CVD risk factor burden in this country.
Considering that atherosclerotic CVD and diabetes are the leading causes of mortality and morbidity in Indonesia, detection and screening of diabetes and dyslipidemia should be available and affordable at primary care level (2,4). Thirdly, the effectiveness of the tele-ECG program can only be estimated, as data collection did not allow for reliable calculation of false-negative and false-positive ratios. Lastly, one has to be aware of the fact that the study design required the GPs to send all ECG assessments to the database center, and thus, we possibly overestimated the report of GPs reasoning on making the consultation.