Abstract
Three district hospitals (DHs) and seven health centers (HCs) in rural Rwanda. To describe follow-up and treatment outcomes in stage 1 and 2 hypertension patients receiving care at HCs closer to home in comparison to patients receiving care at DHs further from home. A retrospective descriptive cohort study using routinely collected data involving adult patients aged ⩾18 years in care at chronic non-communicable disease clinics and receiving treatment for hypertension at DH and HC between 1 January 2013 and 30 June 2014. Of 162 patients included in the analysis, 36.4% were from HCs. Patients at DHs travelled significantly further to receive care (10.4 km vs. 2.9 km for HCs, P < 0.01). Odds of being retained were significantly lower among DH patients when not adjusting for distance (OR 0.11, P = 0.01). The retention effect was consistent but no longer significant when adjusting for distance (OR 0.18, P = 0.10). For those retained, there was no significant difference in achieving blood pressure targets between the DHs and HCs. By removing the distance barrier, decentralizing hypertension management to HCs may improve long-term patient retention and could provide similar hypertension outcomes as DHs.
Highlights
Hypertension is a significant cause of death and disability worldwide.[1,2,3] It is the leading risk factor for cardiovascular diseases (CVDs), which are a major cause of death in sub-Saharan Africa
In 2006, the Rwandan Ministry of Health (MOH), with support from Partners In Health (PIH), established the first nurse-led integrated non-communicable diseases (NCDs) clinics at three rural district hospitals (DHs), which were expanded to health centers (HCs) in 2013.15 Expert NCD nurses from the DH serve as onsite mentors for the HC NCD nurses
The HCs were staffed by two nurses who participated in a 1-week training course in NCD diagnosis and management of asthma, stage 1 and 2 hypertension and non-insulin dependent diabetes
Summary
Hypertension is a significant cause of death and disability worldwide.[1,2,3] It is the leading risk factor for cardiovascular diseases (CVDs), which are a major cause of death in sub-Saharan Africa. Delivering health care in the rural environment presents unique challenges such as limited trained personnel, management protocols, diagnostic equipment and medications.[5,6,7] To overcome these inherent barriers of rural settings, evidence has shown that task-shifting care to nurses can lead to cost-effective care for more patients compared to a physician-centered model.[8,9,10] This approach can be valuable for decentralized models based in district hospitals (DHs) and health centers (HCs). Another critical innovation component for resource-limited settings is integration. By comparing hypertension care in DHs to HCs, we aimed to provide evidence that can inform further decentralization of NCD treatment models in Rwanda and similar settings
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