PROJECT SUMMARY. Heart failure (HF) is a lethal, yet treatable, cardiovascular disease that is common in rural areas of Haiti and other low-income countries (LICs). In rural Haiti, where I have worked since 2012, ~46% of medical ward admissions are due to HF and inpatient fatality is 11%. Part of the problem is that evidence-based medicines for HF are used only 21% of the time. However, suboptimal treatment cannot be addressed unless we first confront the problem of diagnosis. The lack of access to (1) echocardiography, and (2) clinicians with skills to interpret them are major barriers to HF treatment. Haiti has only 17 cardiologists for a population of 11 million. The advent of low-cost, portable handheld ultrasound devices has the potential to address both of these barriers. Our attention is focused on affordable and sustainable ways to train clinicians to both acquire images and interpret the findings. Since 2008, we have developed, implemented, and evaluated the training of mid-level clinicians using a simplified focused cardiac ultrasound (sFoCUS) protocol. We successfully implemented this training in Rwanda, Liberia, and Malawi. However, the training model is resource-intense requiring a 1-on-1 apprentice approach with cardiologist expert trainers. Limited availability and cost of cardiologists are principal barriers to dissemination. To address this barrier, we propose employing simulators to train mid-level clinicians in rural Haiti in our sFoCUS protocol. Our Seattle team has developed novel training tools including visual guidance and image matching in a self-administered training simulator. This novel simulator has been successfully tested among students and general physicians in the US. However, incorporating simulation into sFoCUS training is unstudied in LICs. Because our simulator displays real patient images, the curriculum can be adjusted to be consistent with the HF epidemiology in Haiti. We hypothesize that a self-administered, simulation-based training intervention is feasible, acceptable, high-fidelity, and promotes effective learning of echocardiography skills and interpretation in low-resourced settings. We will test this hypothesis through the following specific aims. AIM 1 : Adapt a simulator-based self-administered training curriculum for the Haitian context. Using the ADAPT-ITT framework, we will first examine the current use of echocardiography by informally trained Haitian staff, then assess the simulator’s usability and appropriateness. We will obtain new cases from patients with pathology consistent with Haitian HF epidemiology. AIM 2 : Determine the effectiveness and study the implementation & cost of the adapted simulator-based FoCUS training. We will train 50 clinicians using the simulator. Guided by the RE-AIM framework, we will investigate reach, effectiveness, adoption, implementation, and maintenance. Our primary effectiveness outcome will be improvement in diagnostic accuracy: proper HF category assignment of standardized simulation cases. If successful, our study will lead to a feasible and scalable sFoCUS training platform to improve access to HF diagnostics ready for dissemination throughout Haiti and to other LICs.

PROJECT NARRATIVE This project focuses on a problem of significant public health need: diagnosis of heart failure in low-income countries, which is essential for prescribing evidence-based therapies. an adapted, self-administered simulator to train non-expert clinicians in simplified Focused Cardiac Ultrasound (sFoCUS) is an innovative strategy to address the gap in cardiologist availability. We will determine the effectiveness and study the implementation & cost of an adapted simulator-based sFoCUS training curriculum in rural Haiti.