Task shifting the management of non-communicable diseases to nurses in Kibera, Kenya: Does it work?

Background: In sub-Saharan Africa there is an increasing need to leverage available health care workers to provide care for non-communicable diseases (NCDs). This study was conducted to evaluate adherence to Médecins Sans Frontières clinical protocols when the care of five stable NCDs (hypertension, diabetes mellitus type 2, epilepsy, asthma, and sickle cell) was shifted from clinical officers to nurses. Methods: Descriptive, retrospective review of routinely collected clinic data from two integrated primary health care facilities within an urban informal settlement, Kibera, Nairobi, Kenya (May to August 2014). Results: There were 3,554 consultations (2025 patients); 733 (21%) were by nurses out of which 725 met the inclusion criteria among 616 patients. Hypertension (64%, 397/616) was the most frequent NCD followed by asthma (17%, 106/616) and diabetes mellitus (15%, 95/616). Adherence to screening questions ranged from 65%to 86%, with an average of 69%. Weight and blood pressure measurements were completed in 89%and 96%of those required. Laboratory results were reviewed in 91% of indicated visits. Laboratory testing per NCD protocols was higher in those with hypertension (88%) than diabetesmellitus (67%) upon review. Only 17 (2%) consultations were referred back to clinical officers. Conclusion: Nurses are able to adhere to protocols for managing stable NCD patients based on clear and standardized protocols and guidelines, thus paving the way towards task shifting of NCD care to nurses to help relieve the significant healthcare gap in developing countries. This was a retrospective review of routinely collected clinic data. Kenya is an east African country with a population of over 40 million.[12] It is experiencing an increasing burden of NCDs, including within informal settlements, putting a strain on the health care work force.[13] Kibera is an urban, informal settlement in the capital, Nairobi, with a population of about 240,000 people.[14] Kibera is characterized by poverty, and a lack of potable water, housing and access to health care, resulting in a large disease burden and poor health outcomes.[15] MSF, in collaboration with the MoH, offers free comprehensive PHC service, including NCD management. The MSF Kibera NCD programme started in 2009 in two PHC facilities, in response to an increasing number of NCD cases; there is an active cohort of 2,200 NCD and 5,500 HIV patients, leading to approximately 8,000 consultations per month. In these MSF facilities, integrated care includes acute and chronic services for HIV, TB, maternal-child health, NCDs, mental health, and sexual-gender based violence, all provided by the same clinical staff, who routinely rotate positions. The healthcare team consists of a supervising physician, clinical officers, nurses, counselors, social workers, health promoters and laboratory staff, as described previously.[16] All routine NCD labs are run at the larger PHC facility. All services, including medication, are provided free of charge. Referrals are made to either Mbagathi District Hospital or Kenyatta National Hospital. The volume of care translates into 45 to 50 consultations per clinical officer per day. Until early 2014, clinical officers managed all NCD cases. This resulted in an overwhelming NCD patient volume load. To overcome this challenge, management of some stable NCD cases was shifted to three nurses from March, 2014. The patient inclusion criteria for nurse task shifting are in Fig 1. The same nurses were already task shifting for stable patients with HIV, TB and general outpatient consultations. Five conditions were task shifted to nurses: HT, DM, epilepsy, SCD and asthma. Within the NCD programme, the diagnostic criteria for HT were: two or more high BP measurements (>140/90) recorded during two or more clinic visits and for DM, fasting plasma glucose ≥7.0 mmol/l (126 mg/dl). A positive sickle cell test confirmed SCD. For asthma, the criteria included shortness of breath, presence of an identified asthma trigger and reversal of symptoms with an inhaled beta-agonist medication. Epilepsy was diagnosed through detailed medical history with confirmed witness account of repeated seizures (at least two, greater than 24 hours apart) that were not fever related. Routine follow up laboratory testing for hypertension included creatinine clearance and fasting total cholesterol yearly, while diabetes also included HbA1c every 6 months. During clinical visits nurses were required to document whether they reviewed previous labs and ordered required laboratory tests per NCD protocol based upon date of last test. All nurses selected for the NCD program were four-year academically trained in Kenya before joining MSF. Individually they had at least five years clinical nursing experience with MSF and were allowed to prescribe medications under Kenya regulations. Each nurse underwent standardized training on the five NCDs for one week with didactics and clinical case scenarios. In addition, they were trained using structured clinical decision support protocols, provided by the NCD supervising physician and included follow up field mentorship. The NCD clinical decision support protocols and training were aligned with available MSF, Kenyan MoH and international guidelines as of 2013, for each of the five NCD diagnoses. The nurses worked within the PHC setting with continuous on-site clinical officer supervision and had NCD protocols available in both paper-bound form and electronically. The NCD trained nurses had no additional salary increase or incentives compared with other MSF/MOH nurses. There was no turnover of these nurses during the study period. The study included all NCD patients (adults and children), who had consultations performed by the three trained nurses in the Kibera project between May and August 2014 based on the criteria defined for task shifting. Patients and consultations where a diagnosis was not recorded were excluded from the analysis. Data were collected to determine the number and proportion of NCD consultations where patients were screened for medication adherence, side effects and complications; blood tests requested and medications prescribed as per protocol; and referred back to clinical officers as needed. NCD consultations by nurse task shifters were recorded in a standardized paper format (available online). Clinical and laboratory data were retrieved from patient files using a structured data capture form, double entered into an Epi Data software and de-identified for confidentiality (version 3.1, EpiData Association, Odense, Denmark). All consultations done by the three nurses were compared against the variables in the protocols. Descriptive and summary statistics were used; analysis was done using Epi Info 7 Analysis software package (Centers for Disease Control, Atlanta, GA, USA).a Statistical significance was evaluated using chi-square and Fisher exact testing and utilized a two tailed p-value < 0.05. For this study, routinely collected MSF data was retrospectively reviewed and de-identified. Hence, informed consent from patients or their families was not obtained. Ethics approval was obtained from the Kenya Medical Research Institute (Nairobi, Kenya) and the study met the Médecins Sans Frontières Ethics Review Board (Geneva, Switzerland) 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).