Research Archives - Page 2 of 4 - Center for Integration Science

Implementation of self-monitoring of blood glucose for patients with insulin-dependent diabetes at a rural non-communicable disease clinic in Neno, Malawi

T Ruderman, G Ferrari, F Valeta, M Boti, K Kumwenda, P H Park, G Ngoga, E Ndarama, E Connolly, G Bukhman, A Adler

Self-monitoring of blood glucose (SMBG) is a widely accepted standard of practice for management of insulin-dependent diabetes, yet is largely unavailable in rural sub-Saharan Africa (SSA). This prospective cohort study is the first known report of implementation of SMBG in a rural, low-income country setting.

Forty-eight patients with type 1 and insulin-dependent type 2 diabetes were trained to use glucometers and logbooks. Participants monitored preprandial glucose daily at rotating times and overnight glucose once a week. Healthcare providers were trained to evaluate glucose trends, and adjusted insulin regimens based on results. Adherence was measured as the frequency with which patients checked and documented blood glucose at prescribed times, while clinical changes were measured by change in glycated haemoglobin (HbA1c) over a 6-month period.

SMBG is feasible for patients with insulin-dependent diabetes in a rural SSA population, and may be associated with improved HbA1c levels. Despite common misconceptions, all patients, regardless of education level, can benefit from SMBG. Further research on long-term retention of SMBG activities and the benefits of increasing frequency of monitoring is warranted.

Protocol for an evaluation of the initiation of an integrated longitudinal outpatient care model for severe chronic non-communicable diseases (PEN-Plus) at secondary care facilities (district hospitals) in 10 lower-income countries

Alma J Adler, Emily B Wroe, Andrea Atzori, Neusa Bay, Wondu Bekele, Victoria M Bhambhani, Remy Bitwayiki Nkwiro, Chantelle Boudreaux, Dawson Calixte, Jonathan Chiwanda Banda, Matthew M Coates, Wubaye Walelgne Dagnaw, Katia Domingues, Laura Drown, Symaque Dusabeyezu, Darius Fenelon, Neil Gupta, Isaac Ssinabulya, Yogesh Jain, Yogeshwar Kalkonde, Innocent Kamali, Catherine Karekezi, Biraj Man Karmacharya, Bhagawan Koirala, Julie Makani, Fabio Manenti, Alexio Mangwiro, Beatriz Manuel, Jones K Masiye, Fastone Mathew Goma, Mary Theodory Mayige, Amy McLaughlin, Emmanuel Mensah, Nicole Mocumbi Salipa, Reuben Mutagaywa, Alvern Mutengerere, Gedeon Ngoga, Marta Patiño, Giovanni Putoto, Todd Ruderman, Devashri Salvi, Santigie Sesay, Fameti Taero, Emílio Tostão, Sterman Toussaint, Gene Bukhman, Ana Olga Mocumbi, for the PEN-Plus Partnership study group.

The Package of Essential Noncommunicable Disease Interventions—Plus (PEN-Plus) is a strategy decentralising care for severe non-communicable diseases (NCDs) including type 1 diabetes, rheumatic heart disease and sickle cell disease, to increase access to care. Inthe PEN-Plus model, mid-level clinicians in intermediary facilities in low and lower middle income countries are trained to provide integrated care for conditions where services traditionally were only available at tertiary referral facilities. For the upcoming phase of activities, 18 first-level hospitals in 9 countries and 1 state in India were selected for PEN-Plus expansion and will treat a variety of severe NCDs. Over 3 years, the countries and state are expected to: (1) establish PEN-Plus clinics in one or two district hospitals, (2) support these clinics to mature into training sites in preparation for national or state-level scale-up, and (3) work with the national or state-level stakeholders to describe, measure and advocate for PEN-Plus to support development of a national operational plan for scale-up.

Models of care for sickle cell disease in low-income and lower-middle-income countries: a scoping review

Laura Drown, Miriam Osei, Ada Thapa, Chantelle Boudreaux, Natasha Archer, Gene Bukhman, Alma J Adler

As part of the Centre for Integration Science’s ongoing efforts to define, systematise, and implement integrated care delivery models for non-communicable diseases (NCDs), this Review explores models of care for sickle cell disease in LICs and LMICs. We identified 99 models from 136 studies, primarily done in tertiary, urban facilities in LMICs. Except for two models of integrated care for concurrent treatment of other conditions, sickle cell disease care was mostly provided in specialised clinics, which are low in number and accessibility. The scarcity of published evidence of models of care for sickle cell disease and integrated care in rural settings of LICs and LMICs shows a need to implement more integrated models to improve access, particularly in rural areas. PEN-Plus, a model of decentralised, integrated care for severe chronic non-communicable diseases, provides an approach to service integration that could fill gaps in access to comprehensive sickle cell disease care in LICs and LMICs.

Understanding integrated service delivery: a scoping review of models for noncommunicable disease and mental health interventions in low-and-middle income countries

Alma J. Adler, Laura Drown, Chantelle Boudreaux, Matthew M. Coates, Andrew Marx, Oyetayo Akala, Temo Waqanivalu, Hongyi Xu and Gene Bukhman

Noncommunicable diseases (NCDs) and mental health conditions represent a growing proportion of disease burden in low- and middle-income countries (LMICs). While past efforts have identified interventions to be delivered across health system levels to address this burden, the challenge remains of how to deliver heterogenous interventions in resource-constrained settings. One possible solution is the Integration of interventions within exist- ing care delivery models. This study reviews and summarizes published literature on models of integrated NCD and mental health care in LMICs.

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

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

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.

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.

Crohn’s disease in low and lower-middle income countries: A scoping review

Ruma Rajbhandari, Samantha Blakemore, Neil Gupta, Alma J Adler, Christopher Allen Noble, Sara Mannan, Klejda Nikolli, Alison Yih, Sameer Joshi, Gene Bukhman

While Crohn’s disease has been studied extensively in high-income countries, its epidemiology and care in low and lower-middle income countries (LLMICs) is not well established due to a lack of disease registries and diagnostic capacity.

The database search yielded 4486 publications, 216 of which were determined tobe relevant to the research questions. Of all 79 LLMICs, only 21 (26.6%) have publications describing individuals with Crohn’s. Overall, the highest number of studies came from India, followed by Tunisia, and Egypt. The mean number of Crohn’s patients reported per study is 57.84 and the median is 22, with a wide range from one to 980.

This scoping review has shown that, although there is a severe lack of population- based data about Crohn’s in LLMICs, there is a signal of Crohn’s in these settings around the world.

Implementation outcomes of national decentralization of integrated outpatient services for severe non-communicable diseases to district hospitals in Rwanda

Simon Pierre Niyonsenga, Paul H. Park, Gedeon Ngoga, Evariste Ntaganda, Fredrick Kateera, Neil Gupta, Edson Rwagasore, Samuel Rwunganira, Antoine Munyarugo, Cadet Mutumbira, Symaque Dusabayezu, Arielle Eagan, Chantelle Boudreaux, Christopher Noble, Marie Aimee Muhimpundu, F. Gilles Ndayisaba, Sabin Nsanzimana, Gene Bukhman, and Francois Uwinkindi

Effective coverage of non-communicable disease (NCD) care in sub-Saharan Africa remains low, with the majority of services still largely restricted to central referral centres. Between 2015 and 2017, the Rwandan Ministry of Health implemented a strategy to decentralise outpatient care for severe chronic NCDs, including type 1 diabetes, heart failure and severe hypertension, to rural first-level hospitals.

By 2017, all NCD clinics were staffed by at least one NCD-trained nurse. With the exception of warfarin and beta-blockers, national essential medicines were available at more than 70% of facilities. Clinicians adhered to clinical protocols at approximately 70% agreement with evaluators.

The government of Rwanda was able to scale a nurse-led outpatient NCD programme to all first-level hospitals with good fidelity, feasibility and penetration as to expand access to care for severe NCDs.

Implementation of blood glucose self- monitoring among insulin-dependent patients with type 2 diabetes in three rural districts in Rwanda

Loise Ng’ang’a, Gedeon Ngoga, Symaque Dusabeyezu, Bethany L Hedt-Gauthier, Patient Ngamije, Michel Habiyaremye, Emmanuel Harerimana, Gilles Ndayisaba, Christian Rusangwa, Simon Pierre Niyonsenga, Charlotte M Bavuma, Gene Bukhman, Alma J Adler, Fredrick Kateera, Paul H. Park

This study explores the feasibility and impact of implementing self-monitoring of blood glucose (SMBG) in patients with type 2 diabetes in rural Rwandan districts. This is an open randomised controlled trial comprising of two arms: (1) Intervention group— participants will receive a glucose metre, blood test strips, logbook, waste management box and training on how to conduct SMBG in additional to usual care and (2) Control group—participants will receive usual care, comprising of clinical consultations and routine monthly follow-up. We will conduct qualitative interviews at enrolment and at the end of the study to assess knowledge of diabetes. At the end of the study period, we will interview clinicians and participants to assess the perceived usefulness, facilitators and barriers of SMBG.

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