Treatment of non-communicable disease in rural resource-constrained settings: a comprehensive, integrated, nurse-led care model at public facilities in Rwanda

Background: Low-income countries face a dual burden of endemic chronic non-communicable diseases (NCDs) and limited resources to implement control strategies. Access to services is even more challenging for patients in countries like Rwanda, where more than 80% of the population reside in rural areas, and there is fewer than one health care provider per 1000 people. Many studies of NCD care delivery models in low-income countries are limited to simple conditions or focus on a single disease. Since 2007, Partners in Health/Inshuti Mu Buzima (PIH/IMB) has been supporting delivery of NCD services at Ministry of Health facilities. Here we describe the model implemented and baseline characteristics of patients served. Methods: Comprehensive NCD services are provided by nurses to patients with an array of complex conditions including heart failure, chronic cancer pain, hypertension, diabetes, and chronic respiratory diseases on disease-specific clinic days. Nurses receive training and longitudinal mentorship from specialist physicians and use reference-standardised diagnosis and treatment protocols. Point-of-care diagnostics are used, such as haemoglobin A1c for patients with diabetes and coagulation testing for patients on warfarin after cardiac valve surgery. Nurses are also able to perform simplified echocardiography to inform initial management of heart failure. Group education sessions and socioeconomic supports are also offered to patients. District hospital nurses serve as mentors for health centre nurses. Community health workers provide support to high-risk patients. Clinical information is documented in structured forms that are compiled in individual patient charts, and entered in an electronic medical records system. These programmes are integrated within MOH facilities and most clinicians are MOH employees. Findings: At Sept 30, 2014, three district hospitals and seven health centres have implemented PIH/IMB-supported NCD programmes. 3367 patients have been enrolled, of whom 67% are female (mean age 48·1 years [SD 19·8]). Disease categories, in descending order of predominance, are: hypertension (30%), chronic respiratory disease (26%), heart failure (26%), and diabetes (16%). A small proportion (2·5%) of patients are HIV positive and 1% have more than one NCD diagnosis. More than 80% (3014) of patients live in rural districts, and of these more than 60% of those with documented occupation (683 out of total documented 1112) are subsistence farmers. Interpretation: An integrated, nurse-led NCD care model has been effectively implemented in Rwanda, providing comprehensive longitudinal care embedded within the public health system in a rural resource-constrained setting. That so many patients have been treated highlights the NCD needs in rural poor populations. Positive outcomes have been described previously for heart failure, and outcomes assessments for diabetes, post-cardiac surgery, and hypertension are underway. The experience from these facilities has contributed to ongoing scale-up of district level NCD services throughout Rwanda. Funding: Ministry of Health, Rwanda, Partners in Health /Inshuti Mu Buzima (PIH / IMB), Medtronic Foundation

Outcomes for patients with rheumatic heart disease after cardiac surgery followed at rural district hospitals in Rwanda

Background In sub-Saharan Africa, continued clinical follow-up, after cardiac surgery, is only available at urban referral centres. We implemented a decentralised, integrated care model to provide longitudinal care for patients with advanced rheumatic heart disease (RHD) at district hospitals in rural Rwanda before and after heart surgery. Methods We collected data from charts at non-communicable disease (NCD) clinics at three rural district hospitals in Rwanda to describe the outcomes of 54 patients with RHD who received cardiac valve surgery during 2007–2015. Results The majority of patients were adults (46/54; 85%), and 74% were females. The median age at the time of surgery was 22 years in adults and 11 years in children. Advanced symptoms—New York Heart Association class III or IV—were present in 83% before surgery and only 4% afterwards. The mitral valve was the most common valve requiring surgery. Valvular surgery consisted mostly of a single valve (56%) and double valve (41%). Patients were followed for a median of 3 years (range 0.2–7.9) during which 7.4% of them died; all deaths were patients who had undergone bioprosthetic valve replacement. For patients with mechanical valves, anticoagulation was checked at 96% of visits. There were no known bleeding or thrombotic events requiring hospitalisation. Conclusion Outcomes of postoperative patients with RHD tracked in rural Rwanda health facilities were generally good. With appropriate training and supervision, it is feasible to safely decentralise follow-up of patients with RHD to nurse-led specialised NCD clinics after cardiac surgery

Treating persistent asthma in rural Rwanda: characteristics, management and 24-month outcomes

SETTING: In 2007, the Rwandan Ministry of Health, with support from Partners In Health, introduced a district-level non-communicable disease programme that included asthma care. OBJECTIVE: To describe the demographics, management and 24-month outcomes of asthma patients treated at three rural district hospitals in Rwanda. DESIGN: We retrospectively reviewed electronic medical records of asthma patients enrolled from January 2007 to December 2012, and extracted information on demographics, clinical variables and 24-month outcomes. RESULTS: Of the 354 patients, 66.7% were female and 41.5% were aged between 41 and 60 years. Most patients (53.1%) were enrolled with moderate persistent asthma, 40.1% had mild persistent asthma and 6.8% had severe persistent asthma. Nearly all patients (95.7%) received some type of medication, most commonly a bronchodilator. After 24 months, 272 (76.8%) patients were still alive and in care, 21.1% were lost to follow-up, 1.7% had died and 0.3% had transferred out. Of the 121 patients with an updated asthma classification at 24 months, the severity of their asthma had decreased: 17.4% had moderate and 0.8% had severe persistent asthma. CONCLUSION: Our findings show improvements in asthma severity after 24 months and reasonable rates of loss to follow-up, demonstrating that asthma can be managed effectively in rural, resource-limited settings.</p

A Clinical Mentorship and Quality Improvement Program to Support Health Center Nurses Manage Type 2 Diabetes in Rural Rwanda

Introduction: The prevalence of diabetes mellitus is rapidly rising in SSA. Interventions are needed to support the decentralization of services to improve and expand access to care. We describe a clinical mentorship and quality improvement program that connected nurse mentors with nurse mentees to support the decentralization of type 2 diabetes care in rural Rwanda. Methods: This is a descriptive study. Routinely collected data from patients with type 2 diabetes cared for at rural health center NCD clinics between January 1, 2013 and December 31, 2015, were extracted from EMR system. Data collected as part of the clinical mentorship program were extracted from an electronic database. Summary statistics are reported. Results: The patient population reflects the rural settings, with low rates of traditional NCD risk factors: 5.6% of patients were current smokers, 11.0% were current consumers of alcohol, and 11.9% were obese. Of 263 observed nurse mentee-patient encounters, mentor and mentee agreed on diagnosis 94.4% of the time. Similarly, agreement levels were high for medication, laboratory exam, and follow-up plans, at 86.3%, 87.1%, and 92.4%, respectively. Conclusion: Nurses that receive mentorship can adhere to a type 2 diabetes treatment protocol in rural Rwanda primary health care settings