Author + information
- Received February 26, 2013
- Revision received March 28, 2013
- Accepted March 28, 2013
- Published online June 1, 2013.
- Gene F. Kwan, MD∗,†,
- Alice K. Bukhman, MD, MPH∗,
- Ann C. Miller, PhD, MPH‡,
- Gedeon Ngoga, BS, RN§,
- Joseph Mucumbitsi, MD||,
- Charlotte Bavuma, MD, MMed§,¶,#,
- Symaque Dusabeyezu, RN#,
- Michael L. Rich, MD, MPH∗∗∗,
- Francis Mutabazi, BCM#,
- Cadet Mutumbira, BS, RN#,
- Jean Paul Ngiruwera#,
- Cheryl Amoroso, MPH§∗∗,
- Ellen Ball, MS∗∗,
- Hamish S. Fraser, MBChB, MSc∗,‡∗∗,
- Lisa R. Hirschhorn, MD, MPH∗,‡∗∗,
- Paul Farmer, MD, PhD∗,‡∗∗,
- Emmanuel Rusingiza, MD§,#,†† and
- Gene Bukhman, MD, PhD∗,‡,#∗∗,‡‡∗ ()
- ↵∗Reprint requests and correspondence:
Dr. Gene Bukhman, Harvard Medical School, Department of Global Health and Social Medicine, 641 Huntington Avenue, Boston, Massachusetts 02115.
Objectives This study sought to describe a decentralized strategy for heart failure diagnosis and management and report the clinical epidemiology at district hospitals in rural Rwanda.
Background Heart failure contributes significantly to noncommunicable disease burden in sub-Saharan Africa. Specialized care is provided primarily at referral hospitals by physicians, limiting patients' access. Simplifying clinical strategies can facilitate decentralization of quality care to the district hospital level and improve care delivery.
Methods Heart failure services were established within integrated advanced noncommunicable disease clinics in 2 rural district hospitals in Rwanda. Nurses, supervised by physicians, were trained to use simplified diagnostic and treatment algorithms including echocardiography with diagnoses confirmed by a cardiologist. Data on 192 heart failure patients treated between November 2006 and March 2011 were reviewed from an electronic medical record.
Results In our study population, the median age was 35 years, 70% were women, 63% were subsistence farmers, and 6% smoked tobacco. At entry, 47% had New York Heart Association class III or IV functional status. Of children age <18 years (n = 54), rheumatic heart disease (48%), congenital heart disease (39%), and dilated cardiomyopathy (9%) were the leading diagnoses. Among adults (n = 138), dilated cardiomyopathy (54%), rheumatic heart disease (25%), and hypertensive heart disease (8%) were most common. During follow-up, 62% were retained in care, whereas 9% died and 29% were lost to follow-up.
Conclusions In rural Rwanda, the causes of heart failure are almost exclusively nonischemic even though patients often present with advanced symptoms. Training nurses, supervised by physicians, in simplified protocols and basic echocardiography is 1 approach to integrated, decentralized care for this vulnerable population.
- global health
- health policy
- hypertensive heart disease
- noncommunicable disease
- rheumatic heart disease
This study was supported by a National Scientist Development Award (to Dr. G. Bukhman) by the American Heart Association. All authors have reported that they have no relationships relevant to the contents of this paper to disclose. Drs. Kwan and A. K. Bukhman contributed equally to this work.
- Received February 26, 2013.
- Revision received March 28, 2013.
- Accepted March 28, 2013.
- American College of Cardiology Foundation