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Eberly LA, Rusingiza E, Park PH, Ngoga G, Dusabeyezu S, Mutabazi F, Gahamanyi C, Ntaganda E, Kwan GF, Bukhman G. 10-Year Heart Failure Outcomes From Nurse-Driven Clinics in Rural Sub-Saharan Africa. J Am Coll Cardiol 2020; 73:977-980. [PMID: 30819366 DOI: 10.1016/j.jacc.2018.12.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 12/11/2018] [Accepted: 12/11/2018] [Indexed: 11/17/2022]
Abstract
Nurse-led delivery care models have the potential to address the significant burden of heart failure in sub-Saharan Africa. Starting in 2006, the Rwandan Ministry of Health, supported by Inshuti Mu Buzima (Partners In Health-Rwanda), decentralized heart failure diagnosis and care delivery in the context of advanced nurse-led integrated noncommunicable clinics at rural district hospitals. Here, the authors describe the first medium-term survival outcomes from the district level in rural sub-Saharan Africa based on their 10-year experience providing care in rural Rwanda. Kaplan-Meier methods were used to determine median time to event for: 1) composite event of known death from any cause, lost to follow-up, or transfer to estimate worst-case mortality; and 2) known death only. Five-year event-free rates were 41.7% for the composite outcome and 64.3% for known death. While death rates are encouraging, efforts to reduce loss to follow-up are needed.
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Affiliation(s)
- Lauren A Eberly
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Emmanuel Rusingiza
- Department of Pediatrics, Pediatric Cardiology Unit, Centre Hospitalier Universitaire de Kigali, Kigali, Rwanda
| | - Paul H Park
- Partners in Health, Boston, Massachusetts; Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | | | - Gene F Kwan
- Partners in Health, Boston, Massachusetts; Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; Section of Cardiology, Department of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Gene Bukhman
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Partners in Health, Boston, Massachusetts; Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
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Eberly LA, Rusingiza E, Park PH, Ngoga G, Dusabeyezu S, Mutabazi F, Harerimana E, Mucumbitsi J, Nyembo PF, Borg R, Gahamanyi C, Mutumbira C, Ntaganda E, Rusangwa C, Kwan GF, Bukhman G. Nurse-Driven Echocardiography and Management of Heart Failure at District Hospitals in Rural Rwanda. Circ Cardiovasc Qual Outcomes 2019; 11:e004881. [PMID: 30562070 DOI: 10.1161/circoutcomes.118.004881] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Lauren A Eberly
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA (L.A.E., G.B.)
| | - Emmanuel Rusingiza
- Department of Pediatrics, Pediatric Cardiology Unit, Centre Hospitalier Universitaire de Kigali, Rwanda (E.R.).,Inshuti Mu Buzima, Rwinkwavu, Rwanda (E.R., G.N., S.D., F.M., E.H., R.B., C.G., C.M., C.R.)
| | - Paul H Park
- Partners in Health, Boston, MA (P.H.P., G.F.K., G.B.).,Program in Global NCDs and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA (P.H.P., G.F.K., G.B.)
| | - Gedeon Ngoga
- Inshuti Mu Buzima, Rwinkwavu, Rwanda (E.R., G.N., S.D., F.M., E.H., R.B., C.G., C.M., C.R.)
| | - Symaque Dusabeyezu
- Inshuti Mu Buzima, Rwinkwavu, Rwanda (E.R., G.N., S.D., F.M., E.H., R.B., C.G., C.M., C.R.)
| | - Francis Mutabazi
- Inshuti Mu Buzima, Rwinkwavu, Rwanda (E.R., G.N., S.D., F.M., E.H., R.B., C.G., C.M., C.R.)
| | - Emmanuel Harerimana
- Inshuti Mu Buzima, Rwinkwavu, Rwanda (E.R., G.N., S.D., F.M., E.H., R.B., C.G., C.M., C.R.)
| | - Joseph Mucumbitsi
- Department of Paediatrics, King Faisal Hospital, Kigali, Rwanda (J.M.)
| | | | - Ryan Borg
- Inshuti Mu Buzima, Rwinkwavu, Rwanda (E.R., G.N., S.D., F.M., E.H., R.B., C.G., C.M., C.R.)
| | - Cyprien Gahamanyi
- Inshuti Mu Buzima, Rwinkwavu, Rwanda (E.R., G.N., S.D., F.M., E.H., R.B., C.G., C.M., C.R.)
| | - Cadet Mutumbira
- Inshuti Mu Buzima, Rwinkwavu, Rwanda (E.R., G.N., S.D., F.M., E.H., R.B., C.G., C.M., C.R.)
| | | | - Christian Rusangwa
- Inshuti Mu Buzima, Rwinkwavu, Rwanda (E.R., G.N., S.D., F.M., E.H., R.B., C.G., C.M., C.R.)
| | - Gene F Kwan
- Partners in Health, Boston, MA (P.H.P., G.F.K., G.B.).,Program in Global NCDs and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA (P.H.P., G.F.K., G.B.).,Section of Cardiology, Department of Medicine, Boston Medical Center, MA (G.F.K.)
| | - Gene Bukhman
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, MA (L.A.E., G.B.).,Partners in Health, Boston, MA (P.H.P., G.F.K., G.B.).,Program in Global NCDs and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA (P.H.P., G.F.K., G.B.).,Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA (G.B.)
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Eberly LA, Rusangwa C, Ng'ang'a L, Neal CC, Mukundiyukuri JP, Mpanusingo E, Mungunga JC, Habineza H, Anderson T, Ngoga G, Dusabeyezu S, Kwan G, Bavuma C, Rusingiza E, Mutabazi F, Mucumbitsi J, Gahamanyi C, Mutumbira C, Park PH, Mpunga T, Bukhman G. Cost of integrated chronic care for severe non-communicable diseases at district hospitals in rural Rwanda. BMJ Glob Health 2019; 4:e001449. [PMID: 31321086 PMCID: PMC6597643 DOI: 10.1136/bmjgh-2019-001449] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 04/29/2019] [Accepted: 05/04/2019] [Indexed: 11/17/2022] Open
Abstract
Background Integrated clinical strategies to address non-communicable disease (NCDs) in sub-Saharan Africa have largely been directed to prevention and treatment of common conditions at primary health centres. This study examines the cost of organising integrated nurse-driven, physician-supervised chronic care for more severe NCDs at an outpatient specialty clinic associated with a district hospital in rural Rwanda. Conditions addressed included type 1 and type 2 diabetes, chronic respiratory disease, heart failure and rheumatic heart disease. Methods A retrospective costing analysis was conducted from the facility perspective using data from administrative sources and the electronic medical record systems of Butaro District Hospital in rural Rwanda. We determined initial start-up and annual operating financial cost of the Butaro district advanced NCD clinic for the fiscal year 2013–2014. Per-patient annual cost by disease category was determined. Results A total of US$47 976 in fixed start-up costs was necessary to establish a new advanced NCD clinic serving a population of approximately 300 000 people (US$0.16 per capita). The additional annual operating cost for this clinic was US$68 975 (US$0.23 per capita) to manage a 632-patient cohort and provide training, supervision and mentorship to primary health centres. Labour comprised 54% of total cost, followed by medications at 17%. Diabetes mellitus had the highest annual cost per patient (US$151), followed by heart failure (US$104), driven primarily by medication therapy and laboratory testing. Conclusions This is the first study to evaluate the costs of integrated, decentralised chronic care for some severe NCDs in rural sub-Saharan Africa. The findings show that these services may be affordable to governments even in the most constrained health systems.
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Affiliation(s)
- Lauren Anne Eberly
- Department of Medicine, Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Loise Ng'ang'a
- Inshuti Mu Buzima, Partners In Health - Rwanda, Rwinkwavu, Rwanda
| | - Claire C Neal
- Organizational Transformational Initiatives, Greenville, South Carolina, USA
| | | | - Egide Mpanusingo
- Inshuti Mu Buzima, Partners In Health - Rwanda, Rwinkwavu, Rwanda
| | | | - Hamissy Habineza
- Inshuti Mu Buzima, Partners In Health - Rwanda, Rwinkwavu, Rwanda
| | - Todd Anderson
- Inshuti Mu Buzima, Partners In Health - Rwanda, Rwinkwavu, Rwanda
| | - Gedeon Ngoga
- Inshuti Mu Buzima, Partners In Health - Rwanda, Rwinkwavu, Rwanda
| | | | - Gene Kwan
- Department of Medicine, Section of Cardiology, Boston University, Boston, Massachusetts, USA.,Department of Global Health and Social Medicine, Program in Global NCDs and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Charlotte Bavuma
- Inshuti Mu Buzima, Partners In Health - Rwanda, Rwinkwavu, Rwanda.,Department of Internal Medicine, Endocrinology Unit, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Emmanual Rusingiza
- Inshuti Mu Buzima, Partners In Health - Rwanda, Rwinkwavu, Rwanda.,Department of Pediatrics, Pediatric Cardiology Unit, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Francis Mutabazi
- Inshuti Mu Buzima, Partners In Health - Rwanda, Rwinkwavu, Rwanda
| | | | | | - Cadet Mutumbira
- Inshuti Mu Buzima, Partners In Health - Rwanda, Rwinkwavu, Rwanda
| | - Paul H Park
- Partners In Health, Boston, Massachusetts, USA.,Department of Global Health and Social Medicine, Program in Global NCDs and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Gene Bukhman
- Department of Medicine, Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Partners In Health, Boston, Massachusetts, USA.,Department of Global Health and Social Medicine, Program in Global NCDs and Social Change, Harvard Medical School, Boston, Massachusetts, USA
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Eberly LA, Rusingiza E, Park PH, Ngoga G, Dusabeyezu S, Mutabazi F, Harerimana E, Mucumbitsi J, Nyembo PF, Borg R, Gahamanyi C, Mutumbira C, Ntaganda E, Rusangwa C, Kwan GF, Bukhman G. Understanding the Etiology of Heart Failure Among the Rural Poor in Sub-Saharan Africa: A 10-Year Experience From District Hospitals in Rwanda. J Card Fail 2018; 24:849-853. [PMID: 30312764 DOI: 10.1016/j.cardfail.2018.10.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 10/01/2018] [Accepted: 10/02/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Heart failure is a significant cause of morbidity and mortality in sub-Saharan Africa. Our understanding of the heart failure burden in this region has been limited mainly to registries from urban referral centers. Starting in 2006, a nurse-driven strategy was initiated to provide echocardiography and decentralized heart failure care within noncommunicable disease (NCD) clinics in rural district hospitals in Rwanda. METHODS AND RESULTS We conducted a retrospective review of patients with cardiologist-confirmed heart failure treated at 3 district hospital NCD clinics in Rwanda from 2006 to 2017 to determine patient clinical characteristics and disease distribution. Over 10 years, 719 patients with confirmed heart failure were identified. Median age was 27 years overall, and 42 years in adults. Thirty-six percent were children (age <18 years), 68% were female, and 78% of adults were farmers. At entry, 39% were in New York Heart Association functional class III-IV. Among children, congenital heart disease (52%) and rheumatic heart disease (36%) were most common. In adults, cardiomyopathy (40%), rheumatic heart disease (27%), and hypertensive heart disease (13%) were most common. No patients were diagnosed with ischemic cardiomyopathy. CONCLUSIONS The results of the largest single-country heart failure cohort from rural sub-Saharan Africa demonstrate a persistent burden of rheumatic disease and nonischemic cardiomyopathies.
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Affiliation(s)
- Lauren A Eberly
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Emmanuel Rusingiza
- Department of Pediatrics, Pediatric Cardiology Unit, Centre Hospitalier Universitaire de Kigali, Kigali, Rwanda; Inshuti Mu Buzima, Rwinkwavu, Rwanda
| | - Paul H Park
- Partners in Health, Boston, Massachusetts; Program in Global Noncommunicable Diseases and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | | | | | - Ryan Borg
- Inshuti Mu Buzima, Rwinkwavu, Rwanda
| | | | | | | | | | - Gene F Kwan
- Partners in Health, Boston, Massachusetts; Program in Global Noncommunicable Diseases and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; Section of Cardiology, Department of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Gene Bukhman
- Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Partners in Health, Boston, Massachusetts; Program in Global Noncommunicable Diseases and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
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Eberly L, Rusingiza E, Park P, Ngoga G, Dusabeyezu S, Mutabazi F, Harerimana E, Mucumbitsi J, Nyembo PF, Borg R, Gahamanyi C, Mutumbira C, Ntaganda E, Kwan GF, Bukhman G. HEART FAILURE AS AN ENTRY POINT FOR SEVERE CARDIOVASCULAR DISEASE IN SUB-SAHARAN AFRICA: 10-YEAR EXPERIENCE WITH NURSE-LED DIAGNOSIS AND TREATMENT AT DISTRICT HOSPITALS IN RURAL RWANDA. J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)31197-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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