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Background: In rural sub-Saharan Africa, access to care for severe non-communicable diseases (NCDs) is limited due to myriad delivery challenges. We describe the implementation, patient characteristics, and retention rate of an integrated NCD clinic inclusive of cancer services at a district hospital in rural Rwanda. Methods: 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. We report descriptive statistics of patient characteristics and retention. Results: Three hundred forty-seven patients enrolled during the study period: oncology – 71.8%, hypertension – 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%. Conclusions: 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.
This study was conducted at RDH, a hospital located in Southern Kayonza District in the Eastern Province of Rwanda (see Figure Figure1).1). The hospital’s catchment area covers a population of approximately 179,000 and encompasses eight health centers. The population of Southern Kayonza is predominantly rural (90%), female (51.6%) and young, with 49.4% of the population less than 18 years of age in the 2012 census [11]. In addition to the NCD clinic, RDH houses neonatal, pediatric, maternal, internal medicine, surgical, laboratory, radiology, pharmacy and general outpatient departments. Map of Rwanda with catchment area of Rwinkwavu District Hospital (Southern Kayonza District) highlighted along with the location of the Butaro Cancer Center of Excellence, the primary referral hospital for cancer service. The initial step in the integrated NCD clinic’s implementation focused on governance [12]. PIH’s strong partnership with the RMoH at both the central and district levels allowed for collective strategic planning and commitment. Subsequent steps included drafting and approving national NCD clinical and operational protocols for heart failure, hypertension, type 1 and 2 diabetes, chronic kidney disease, and palliative care. Based on the protocols, training curricula for nurses and physicians helped establish a new cadre of Rwandan health care delivery pioneers for management of severe chronic NCDs. Using a combination of practical and didactic training, in the first year (2007–2008) four nurses from outpatient services and six general practitioners from inpatient services were trained in multiple areas of NCD care delivery, such as diagnostics and monitoring, which included the following specialized tools: echocardiography, International Normalized Ratio (INR), hemoglobin A1c (HbA1c), and peak flow meter. The duration of the combined didactic and practical training was two months. Trainers included US-based internal medicine, cardiology, and pulmonology specialists. Additionally, gaps in the availability of essential medicines and equipment were identified and addressed. Initial procurement operations were heavily supported and subsidized by PIH/IMB; these supports and subsidies have since been substantially reduced. The integrated NCD clinic was housed in a single room with a desk, filing cabinet for patient medical records, a laptop computer, one exam table, and one of each of the following pieces of medical equipment: ultrasound with cardiac probe, stethoscope, sphygmomanometer, peak flow meter, HbA1c point-of-care machine, INR point-of-care machine, monofilament, glucometer, and a weight scale. Disease-specific clinical forms were developed with input from both clinicians and monitoring and evaluation (M&E) specialists; training on completion of forms was also provided. These forms were later programmed into PIH/IMB’s electronic medical record (EMR) system, OpenMRS (OpenMRS Inc., Indianapolis, USA), to allow for continuity of care and more robust M&E and research. To support continuity and comprehensive care, criteria were developed to guide social workers in identifying vulnerable patients who required social assistance in the form of subsidizing transportation fees and distributing food packages. Essential human resources within the integrated NCD clinic included three nurses, a general practitioner, a data officer and a clerk. NCD-trained nurses led the majority of patient encounters. The general practitioner attended to more complex cases such as patients not responding to standardized treatment regimens or those at especially high risk for clinical exacerbation. The data officer managed patient data and files, transcribed data from the paper forms into the EMR, and monitored form completeness. The clerk facilitated administrative workflow within the clinic and its interactions with the rest of the hospital. In addition, a cardiologist and an endocrinologist visited the clinic on a monthly basis to evaluate complex patients as well as newly diagnosed patients. These specialists also provided direct mentorship and education to the clinic staff. The integrated NCD clinic operated on a weekly schedule with each day of the week exclusively dedicated to a particular disease unless the patient had multiple NCD diagnoses, in which case s/he would receive treatment for all illnesses during one clinic visit. Patients were referred to the NCD clinic from health centers, the RDH’s general outpatient department, inpatient departments, self-referral, or other district hospitals without such specialized services. Ultimately, the clinic was able to establish and communicate clear referral criteria for complex cases requiring a higher level of care. The addition of oncology services to the integrated NCD clinic provided an opportunity to establish a model integrated district-level approach that provided decentralized cancer care with referrals to higher levels of care as needed. Given the unique intricacies of cancer care delivery, program leadership developed and implemented new training and referral pathways for both diagnosis and treatment. A two-month national oncology training inclusive of both didactic and practical components was organized at RDH in 2013 and covered both inpatient and outpatient content. Training of physicians and subsequent care delivery at RDH was focused on initial evaluation, including peripheral mass and bone marrow biopsy, staging, and initial treatment plan for select cancers, including lymphoma, leukemia, breast, and cervical cancers. For treatment, RDH provided a limited selection of intravenous chemotherapy and oral hormonal treatment regimens as well as palliative care, however the intravenous chemotherapy would later be phased out. Referral facilities were routinely used for more invasive biopsy, pathology diagnosis, advanced radiography, advanced intravenous chemotherapy, surgery, and radiotherapy. The primary referral facility was Butaro Cancer Center of Excellence (BCCOE), in Butaro Hospital, Northern Province. Central University Hospital in Kigali (CHUK), Rwanda Military Hospital, also in the capital city, Kigali, and Central University Hospital in Butare (CHUB) of the Southern Province provided key support as referral hospitals, especially with respect to treatment plan, follow-up, surgeries, CT scans, and biopsies [13]. Radiotherapy required transfer to cancer centers in Uganda and Kenya [14]. Regarding training and mentorship, US-based oncologists and nurses from Dana-Farber/Brigham & Women’s Cancer Center supported the RMoH in clinical protocol writing, on-site training, routine conference calls and email communication surrounding specific patient cases and programmatic challenges. Drug procurement was also subsidized by external partners. Advanced medications, including chemotherapy and warfarin, were not readily available through the public supply chain, so PIH procured these medications as to support the RMoH until the public sector was able to procure independently. The RMoH and partners also established an oncology platform within the OpenMRS EMR. This was a retrospective cohort study of new patients who enrolled in the RDH integrated NCD clinic with the addition of oncology services, between 1 July 2012 to 30 June 2014. All qualifying patients were then assessed for 12 months as described below. Patients of all ages diagnosed with heart failure, diabetes, CRD, hypertension or a type of cancer were included in the analysis. De-identified data on demographic, clinical and outcome variables were extracted from the EMR. As some diseases did not have representative electronic forms, EMR records were not available for patients with chronic kidney and liver disease and, thus, those patients were not included in this study. If a patient was enrolled in more than one disease program, each enrollment was treated as a separate record. Data were reported by disease group to better describe the clinical profile of patients, and the most relevant characteristics of each disease group (e.g. diabetes type, cancer type, heart failure diagnosis) were reported if those data was available. The primary outcome was patient status at 12 months after his/her enrollment date. A patient was considered to be “alive and in care” if s/he had a recorded follow-up visit within ±3 months of the 12-month milestone; “lost to follow-up” (LTFU) if s/he did not have a recorded visit within ±3 months of the 12-month milestone; and “dead” if s/he had a date of death recorded in the EMR during the study window. Extracted data were cleaned and analyzed using Stata v14 (College Park, TX). Descriptive statistics were calculated and number and percentages presented for categorical data. The research protocol was approved by the Rwanda National Ethics Committee, National Health Research Committee, and by the Brigham and Women’s Hospital Institutional Review Board in Boston, Massachusetts, USA, prior to the initiation of the study.
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