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Project: Evaluation & Impact Assessment

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

Emmanuel K Rusingiza, Ziad El-Khatib, Bethany Hedt-Gauthier, Gedeon Ngoga, Symaque Dusabeyezu, Neo Tapela, Cadet Mutumbira, Francis Mutabazi,2 Emmanuel Harelimana, Joseph Mucumbitsi, Gene F Kwan, Gene Bukhman

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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.

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.

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.

Integration of Chronic Oncology Services in Noncommunicable Disease Clinic in Rural Rwanda

Robert Rutayisire, Francis Mutabazi, Alice Bayingana, Ann C. Miller, Neil Gupta, Gedeon Ngoga, Eric Ngabireyimana, Ryan Borg, Emmanuel Rusingiza, Charlotte Bavuma, Bosco Bigirimana, Fulgence Nkikabahiz, Marie Aimee Muhimpundu, Gene Bukhman, and Paul H. Park

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In 2006, the Rwandan Ministry of Health at Rwinkwavu District Hospital (RDH) and Partners In Health established an integrated NCD clinic focused on nurse-led care of severe NCDs, within a single delivery platform. Implementation modifications were made in 2011 to include cancer services. For this descriptive study, we abstracted medical record data for 15 months after first clinic visit for all patients who enrolled in the NCD clinic between 1 July 2012 and 30 June 2014.

Three hundred forty-seven patients enrolled during the study period: oncology – 71.8%, hyper- tension – 10.4%, heart failure – 11.0%, diabetes – 5.5%, and chronic respiratory disease (CRD) – 1.4%. Twelve-month retention rates were: oncology – 81.6%, CRD – 60.0%, hypertension – 75.0%, diabetes – 73.7%, and heart failure – 47.4%.

The integrated NCD clinic filled a gap in accessible care for severe NCDs, including cancer, at rural district hospitals. This novel approach has illustrated good retention rates.

Training Mid-Level Providers to Treat Severe Non-Communicable Diseases in Neno, Malawi through PEN-Plus Strategies

Ruderman, T., Chibwe, E., Boudreaux, C., Ndarama, E., Wroe, E. B., Connolly, E. & Bukhman, G.

The primary objective of this study was to evaluate the impact of training mid-level providers to treat severe and chronic NCDs in newly established PEN-Plus clinics in Neno, Malawi.

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Didactic trainings improved provider test scores immediately following training (25-point improvement; p < 0.01), with demonstrated retention of knowledge after 6 months (21-point improvement, p < 0.01). Over 350 patients were enrolled in the first 18 months of program initiation. The PEN-Plus clinic led to significant improvement in the provision of medications and testing across a range of services.

Mid-level providers can be successfully trained to treat severe NCDs with physician-guided education, mentorship, and supervision. The PEN-Plus clinic improved patient enrollment, the quality of clinical care and access to essential medications and laboratory supplies. These lessons learned can guide decentralization of NCD care to district hospitals in Malawi and expansion of PEN-Plus services in the African region.

Feasibility and effectiveness of self-monitoring of blood glucose among insulin-dependent patients with type 2 diabetes: open randomized control trial in three rural districts in Rwanda

Loise Ng’ang’a, Gedeon Ngoga, Symaque Dusabeyezu, Bethany L. Hedt‐Gauthier, Emmanuel Harerimana, Simon Pierre Niyonsenga, Charlotte M. Bavuma, Gene Bukhman, Alma J. Adler, Fredrick Kateera and Paul H. Park

This study explores the feasibility and effectiveness of implementing self-monitoring of blood glucose among patients diagnosed with insulin‐dependent type 2 diabetes in rural Rwanda.

Our study showed that among patients with insulin‐dependent type 2 diabetes residing in rural Rwanda, SMBG was feasible and demonstrated positive outcomes in improving blood glucose control. However, there is need for strategies to enhance accuracy in recording blood glucose test results in the log‐book.

Feasibility and effectiveness of self-monitoring of blood glucose among insulin-dependent patients with type 2 diabetes: open randomized control trial in three rural districts in Rwanda