Chris T Longenecker1, Stephen R Morris2, Twalib O Aliku2, Andrea Beaton2, Marco A Costa2, Moses R Kamya2, Cissy Kityo2, Peter Lwabi2, Grace Mirembe2, Dorah Nampijja2, Joselyn Rwebembera2, Craig Sable2, Robert A Salata2, Amy Scheel2, Daniel I Simon2, Isaac Ssinabulya2, Emmy Okello2. 1. From the Case Western Reserve University School of Medicine, Cleveland, OH (C.T.L., S.R.M., M.A.C., R.A.S., D.I.S.); Division of Cardiovascular Medicine (C.T.L., M.A.C., D.I.S.) and Department of Medicine, University Hospitals Cleveland Medical Center, OH (S.R.M., R.A.S.); Uganda Heart Institute, Kampala, Uganda (T.O.A., P.L., J.R., I.S., E.O.); Department of Pediatric Cardiology, Children's National Health System, Washington, DC (A.B., C.S., A.S.); Department of Medicine, Makerere University School of Medicine, Kampala, Uganda (M.R.K.); Joint Clinical Research Centre, Kampala, Uganda (C.K., G.M.); and Mbarara University of Science and Technology, Mbarara, Uganda (D.N.) cxl473@case.edu. 2. From the Case Western Reserve University School of Medicine, Cleveland, OH (C.T.L., S.R.M., M.A.C., R.A.S., D.I.S.); Division of Cardiovascular Medicine (C.T.L., M.A.C., D.I.S.) and Department of Medicine, University Hospitals Cleveland Medical Center, OH (S.R.M., R.A.S.); Uganda Heart Institute, Kampala, Uganda (T.O.A., P.L., J.R., I.S., E.O.); Department of Pediatric Cardiology, Children's National Health System, Washington, DC (A.B., C.S., A.S.); Department of Medicine, Makerere University School of Medicine, Kampala, Uganda (M.R.K.); Joint Clinical Research Centre, Kampala, Uganda (C.K., G.M.); and Mbarara University of Science and Technology, Mbarara, Uganda (D.N.).
Abstract
BACKGROUND: Rheumatic heart disease (RHD) is a leading cause of premature death and disability in low-income countries; however, few receive optimal benzathine penicillin G (BPG) therapy to prevent disease progression. We aimed to comprehensively describe the treatment cascade for RHD in Uganda to identify appropriate targets for intervention. METHODS AND RESULTS: Using data from the Uganda RHD Registry (n=1504), we identified the proportion of patients in the following care categories: (1) diagnosed and alive as of June 1, 2016; (2) retained in care; (3) appropriately prescribed BPG; and (4) optimally adherent to BPG (>80% of prescribed doses). We used logistic regression to investigate factors associated with retention and optimal adherence. Overall, median (interquartile range) age was 23 (15-38) years, 69% were women, and 82% had clinical RHD. Median follow-up time was 2.4 (0.9-4.0) years. Retention in care was the most significant barrier to achieving optimal BPG adherence with only 56.9% (95% confidence interval, 54.1%-59.7%) of living subjects having attended clinic in the prior 56 weeks. Among those retained in care, however, we observed high rates of BPG prescription (91.6%; 95% confidence interval, 89.1%-93.5%) and optimal adherence (91.4%; 95% confidence interval, 88.7-93.5). Younger age, latent disease status, and access to care at a regional center were the strongest independent predictors of retention and optimal adherence. CONCLUSIONS: Our study suggests that improving retention in care-possibly by decentralizing RHD services-would have the greatest impact on uptake of antibiotic prophylaxis among patients with RHD in Uganda.
BACKGROUND:Rheumatic heart disease (RHD) is a leading cause of premature death and disability in low-income countries; however, few receive optimal benzathine penicillin G (BPG) therapy to prevent disease progression. We aimed to comprehensively describe the treatment cascade for RHD in Uganda to identify appropriate targets for intervention. METHODS AND RESULTS: Using data from the Uganda RHD Registry (n=1504), we identified the proportion of patients in the following care categories: (1) diagnosed and alive as of June 1, 2016; (2) retained in care; (3) appropriately prescribed BPG; and (4) optimally adherent to BPG (>80% of prescribed doses). We used logistic regression to investigate factors associated with retention and optimal adherence. Overall, median (interquartile range) age was 23 (15-38) years, 69% were women, and 82% had clinical RHD. Median follow-up time was 2.4 (0.9-4.0) years. Retention in care was the most significant barrier to achieving optimal BPG adherence with only 56.9% (95% confidence interval, 54.1%-59.7%) of living subjects having attended clinic in the prior 56 weeks. Among those retained in care, however, we observed high rates of BPG prescription (91.6%; 95% confidence interval, 89.1%-93.5%) and optimal adherence (91.4%; 95% confidence interval, 88.7-93.5). Younger age, latent disease status, and access to care at a regional center were the strongest independent predictors of retention and optimal adherence. CONCLUSIONS: Our study suggests that improving retention in care-possibly by decentralizing RHD services-would have the greatest impact on uptake of antibiotic prophylaxis among patients with RHD in Uganda.
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