Gene F Kwan1, Alice K Bukhman2, Ann C Miller3, Gedeon Ngoga4, Joseph Mucumbitsi5, Charlotte Bavuma6, Symaque Dusabeyezu7, Michael L Rich8, Francis Mutabazi7, Cadet Mutumbira7, Jean Paul Ngiruwera7, Cheryl Amoroso9, Ellen Ball10, Hamish S Fraser11, Lisa R Hirschhorn11, Paul Farmer11, Emmanuel Rusingiza12, Gene Bukhman13. 1. Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Section of Cardiology, Department of Medicine, Boston Medical Center, Boston, Massachusetts. 2. Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts. 3. Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts. 4. Inshuti Mu Buzima, Rwinkwavu, Rwanda. 5. Department of Paediatrics, King Faisal Hospital, Kigali, Rwanda. 6. Inshuti Mu Buzima, Rwinkwavu, Rwanda; Department of Internal Medicine, Endocrinology Unit, Centre Hospitalier Universitaire de Kigali, Kigali, Rwanda; Ministry of Health, Kigali, Rwanda. 7. Ministry of Health, Kigali, Rwanda. 8. Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Partners In Health, Boston, Massachusetts. 9. Inshuti Mu Buzima, Rwinkwavu, Rwanda; Partners In Health, Boston, Massachusetts. 10. Partners In Health, Boston, Massachusetts. 11. Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; Partners In Health, Boston, Massachusetts. 12. Inshuti Mu Buzima, Rwinkwavu, Rwanda; Ministry of Health, Kigali, Rwanda; Department of Pediatrics, Pediatric Cardiology Unit, Centre Hospitalier Universitaire de Kigali, Kigali, Rwanda. 13. Division of Global Health Equity, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts; Ministry of Health, Kigali, Rwanda; Partners In Health, Boston, Massachusetts; VA Boston Healthcare System, Boston, Massachusetts. Electronic address: gbukhman@pih.org.
Abstract
OBJECTIVES: This study sought to describe a decentralized strategy for heart failure diagnosis and management and report the clinical epidemiology at district hospitals in rural Rwanda. BACKGROUND: Heart failure contributes significantly to noncommunicable disease burden in sub-Saharan Africa. Specialized care is provided primarily at referral hospitals by physicians, limiting patients' access. Simplifying clinical strategies can facilitate decentralization of quality care to the district hospital level and improve care delivery. METHODS: Heart failure services were established within integrated advanced noncommunicable disease clinics in 2 rural district hospitals in Rwanda. Nurses, supervised by physicians, were trained to use simplified diagnostic and treatment algorithms including echocardiography with diagnoses confirmed by a cardiologist. Data on 192 heart failure patients treated between November 2006 and March 2011 were reviewed from an electronic medical record. RESULTS: In our study population, the median age was 35 years, 70% were women, 63% were subsistence farmers, and 6% smoked tobacco. At entry, 47% had New York Heart Association class III or IV functional status. Of children age <18 years (n = 54), rheumatic heart disease (48%), congenital heart disease (39%), and dilated cardiomyopathy (9%) were the leading diagnoses. Among adults (n = 138), dilated cardiomyopathy (54%), rheumatic heart disease (25%), and hypertensive heart disease (8%) were most common. During follow-up, 62% were retained in care, whereas 9% died and 29% were lost to follow-up. CONCLUSIONS: In rural Rwanda, the causes of heart failure are almost exclusively nonischemic even though patients often present with advanced symptoms. Training nurses, supervised by physicians, in simplified protocols and basic echocardiography is 1 approach to integrated, decentralized care for this vulnerable population.
OBJECTIVES: This study sought to describe a decentralized strategy for heart failure diagnosis and management and report the clinical epidemiology at district hospitals in rural Rwanda. BACKGROUND:Heart failure contributes significantly to noncommunicable disease burden in sub-Saharan Africa. Specialized care is provided primarily at referral hospitals by physicians, limiting patients' access. Simplifying clinical strategies can facilitate decentralization of quality care to the district hospital level and improve care delivery. METHODS:Heart failure services were established within integrated advanced noncommunicable disease clinics in 2 rural district hospitals in Rwanda. Nurses, supervised by physicians, were trained to use simplified diagnostic and treatment algorithms including echocardiography with diagnoses confirmed by a cardiologist. Data on 192 heart failurepatients treated between November 2006 and March 2011 were reviewed from an electronic medical record. RESULTS: In our study population, the median age was 35 years, 70% were women, 63% were subsistence farmers, and 6% smoked tobacco. At entry, 47% had New York Heart Association class III or IV functional status. Of children age <18 years (n = 54), rheumatic heart disease (48%), congenital heart disease (39%), and dilated cardiomyopathy (9%) were the leading diagnoses. Among adults (n = 138), dilated cardiomyopathy (54%), rheumatic heart disease (25%), and hypertensive heart disease (8%) were most common. During follow-up, 62% were retained in care, whereas 9% died and 29% were lost to follow-up. CONCLUSIONS: In rural Rwanda, the causes of heart failure are almost exclusively nonischemic even though patients often present with advanced symptoms. Training nurses, supervised by physicians, in simplified protocols and basic echocardiography is 1 approach to integrated, decentralized care for this vulnerable population.
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