Medication Adherence Clubs: A potential solution to managing large numbers of stable patients with multiple chronic diseases in informal settlements

Objectives: To assess the care of hypertension, diabetes mellitus and/or HIV patients enrolled into Medication Adherence Clubs (MACs). Methods: Retrospective descriptive study was carried out using routinely collected programme data from a primary healthcare clinic at informal settlement in Nairobi, Kenya. All patients enrolled into MACs were selected for the study. MACs are nurse-facilitated mixed groups of 25-35 stable hypertension, diabetes mellitus and/or HIV patients who met quarterly to confirm their clinical stability, have brief health discussions and receive medication. Clinical officer reviewed MACs yearly, when a patient developed complications or no longer met stable criteria. Results: A total of 1432 patients were enrolled into 47 clubs with 109 sessions conducted between August 2013 and August 2014. There were 1020 (71%) HIV and 412 (29%) non-communicable disease patients. Among those with NCD, 352 (85%) had hypertension and 60 (15%) had DM, while 12 had HIV concurrent with hypertension. A total of 2208 consultations were offloaded from regular clinic. During MAC attendance, blood pressure, weight and laboratory testing were completed correctly in 98-99% of consultations. Only 43 (2%) consultations required referral for clinical officer review before their routine yearly appointment. Loss to follow-up from the MACs was 3.5%. Conclusions: This study demonstrates the feasibility and early efficacy of MACs for mixed chronic disease in a resource-limited setting. It supports burden reduction and flexibility of regular clinical review for stable patients. Further assessment regarding long-term outcomes of this model should be completed to increase confidence for deployment in similar contexts. This was a retrospective, descriptive study using routinely collected programme data in Kenya, an East African country with an approximate population of 39 million (Kenya population and housing census 2009 12. Nairobi, where Kibera is located, has an estimated population of three million (Kenya population and housing census 2009 12. The country is experiencing a rapidly growing burden of non‐communicable diseases (UNAIDS report‐2011 (13). The prevalence of diabetes mellitus in urban areas is almost twice the national average of 3.3% (First Kenya National forum on non‐communicable disease 2011 13. Overall, non‐communicable diseases cause over 50% of all hospital deaths and admissions (First Kenya National forum on NCD 2011 14. Of these deaths, 13% are due to cardiovascular diseases and 4% are due to complications of diabetes mellitus (First Kenya National Forum on NCD 2011 14. Of the 600 000 HIV‐infected people on ART, 75.4% have achieved viral suppression (Kenya AIDS indicator survey 2012 6), adding to the pool of chronic, stable patients. Currently, Kenya Ministry of Health facilities offer hypertension and diabetes mellitus treatment only at the subcounty and county referral hospital levels and not at health centres or dispensaries. Most patients have to pay user fees to access non‐communicable disease services and medications. Despite decentralisation of HIV treatment where antiretroviral drugs are free, the majority of patients still pay out of pocket for treatment of opportunistic infections and laboratory tests other than those for routine HIV monitoring. The study site was Kibera South Health Centre with an estimated catchment population of 88 000 (MSF Belgium Kibera; Annual report 2013 15). MSF, in collaboration with the Ministry of Health, is providing a comprehensive integrated primary health package that includes HIV, TB, non‐communicable disease, general outpatient department, nutrition, maternal child health and sexual‐ and gender‐based violence care at no cost to the client. There are 5500 active HIV patients (4700 on antiretroviral drugs, 80% with suppressed viral loads), 2200 hypertension and diabetes mellitus patients and approximately 200 patients who are comorbid with HIV and hypertension or diabetes mellitus (MSF Belgium Kibera; Annual report 2013 15). The clinics are currently grappling with the challenge of large patient numbers requiring follow‐up, the majority of whom are stable. On average, there are approximately 3000 HIV and 1000 hypertension and diabetes mellitus combined consultations per month. There are approximately 100 new HIV and 70 new hypertension and diabetes mellitus patients per month. The same clinical officers and nurses who care for both HIV and non‐communicable disease patients also carry out outpatient department consultations averaging a total of 8000 consultations per month (MSF Belgium Kibera; Annual report 2013 15). This translates to approximately 45–50 consultations per day per clinician. The effect of this workload is an unacceptably long waiting time for patients at the clinics, averaging four to six hours (MSF Belgium Kibera; patient satisfaction survey 2012 16. The current loss to follow‐up rate for hypertension, diabetes mellitus and HIV cohorts, which is between 30 and 40% 7, (MSF Belgium Kibera; Annual report 2013 15), is possibly related to the long wait times and no available care on weekends. HIV and non‐communicable disease patients were informed about the option of joining MACs through daily health talks in waiting bays, patient empowerment meetings and posters in the clinic. Patients were screened by clinicians during routine follow–up and if they met the inclusion criteria (see below) were offered the option of attending a MAC. Some patients proposed to join a MAC independently of clinician inquiry after sensitisation. Patients were provided signed informed consent before enrolment into the groups, acknowledging that there would be hypertension, diabetes mellitus and HIV patients in the MACs, but that diagnosis disclosure was voluntary. Those declining to join MACs, yet met entrance criteria, were informed that they would continue to be seen as usual through spaced clinic appointments. The MACs were conducted on Wednesday, Thursday and Saturday afternoons between 3 p.m. and 5 p.m. Timing was structured to provide maximum flexibility for patients to attend. All patients who were enrolled into MACs between August 2013 and 31 August 2014 were included in the study. Inclusion criteria for the MACs for hypertension and diabetes mellitus patients were as follows: ≥25 years old, >6 months on medications, having blood pressure < 150/100 and/or HBA1c <8%; for HIV patients, the inclusion criteria were as follows: ≥25 years old, >1 year on ARVs, CD4 > 200, previous viral load was undetectable and not in WHO Stage 3 or 4 active disease. Outcome measures included the number and proportion of: (i) non‐communicable disease consultations where the patients’ blood pressure and/or blood sugar were below MACs threshold, (BP <150/100 mmHg, Hba1c <8.0%, respectively) whose weight was recorded and routine blood workup was requested as per the non‐communicable diseases protocol; (ii) HIV consultations where patients’ weight and blood pressure were recorded and routine blood workup was requested as per the HIV protocol; (iii) non‐communicable disease and HIV consultations where the patients were referred from MACs for clinical consultation for NCD, HIV or non‐NCD/HIV‐related problems (annual review by the clinical officer was not included as a referral back to clinic); and (iv) retention at months three, six and twelve. Lost to follow‐up was determined 3 months after a patient failed to attend a MAC session, pick up their medication and was not reported in any of the following outcomes: referred to regular clinic, transferred out or died. Patients’ demographic and baseline clinical characteristics were collected from the MACs register. Double data entry and validation was performed using EpiData Entry software (version 3.1, EpiData Association, Odense, Denmark). HIV variables were extracted from a FUCHIA database (version 1.7.1 Epicentre, Paris, France) and were merged with those from an EpiData database, which served as the non‐communicable diseases database. File reviews were performed for patients whose variables were missing on the electronic databases. Descriptive analysis was performed using EpiData Analysis software (version 2.2.2.182, EpiData Association, Odense, Denmark). Ethics approval was received from Kenya AMREF Ethics and Scientific Review Committee. The study met the Médecins Sans Frontières (MSF) Ethics Review Board (Geneva, Switzerland) approved criteria for studies of routinely collected data and was also approved by the Ethics Advisory Group of the International Union Against Tuberculosis and Lung Disease, Paris, France.