Increasing Access to Cardiac Care in Africa
Lessons from Kenya (2016 – 2018)
Introduction
In 2016, Agile HMS was commissioned by Kenya’s National Hospital Insurance Fund (NHIF) to coordinate a national cardiac care program. Initially, the program focused on patients with rheumatic heart disease (RHD) in need of open-heart surgery (OHS). However, it became clear that there was a pressing need for care of non-RHD conditions, and that not all cases required OHS. Thus, the program evolved to also support interventional cardiology procedures (IC) and other causes of disease.
Method
Agile identified and vetted hospitals in Kenya equipped, staffed, and willing to handle the patient population. Hospitals and physicians in need of support were brought in contact with foreign specialists and/or hospitals. These partnerships were meant to increase capacity in Kenyan clinicians to handle the cases by mixing teams initially, with less involvement of the foreign teams over time. This seemed necessary because this was the first time that cardiac interventions were covered on a wider scale by the Kenyan NHIF in its roll-out of universal healthcare (UHC). Previously, given this lack of coverage, no surgeon in Kenya could afford to concentrate only on cardiac surgery due to low procedure volume.
Agile staff contacted both patients in need of cardiac care and those registered on waiting lists at major tertiary care centers in the country to inform them of the program. Agile worked with local cardiologists to identify the urgency of a patient’s condition based on a physical exam and echocardiogram. Agile then distributed patients to adequately equipped hospitals across the country depending various factors designed to direct patients to the most appropriate care. Agile managed admission, patient experience, data collection, and patient follow-up.
The following clinical outcomes were measured: overall mortality, perioperative mortality, and mortality on days 30 and 180 post-operatively, respectively; and unscheduled returns to the operating theatre (OT) and intensive care unit (ICU), as well as unscheduled readmissions within 30 days after discharge.
Patient Characteristics
Between October 2016 and December 2017, a total of 506 patients were treated in the program.
In 199 of the patients (39.3%), RHD had been diagnosed, while the remaining 307 patients (60.7%) were treated for non-RHD diseases, with the three most frequent diagnoses being heart block, patent ductus arteriosus, and ventricular septum defect.
There was a distinct difference in patients’ age groups: While nearly 60% of non-RHD patients were below 20 years of age (range: 1 – 98 years), the RHD patients were slightly older: 44% of them were between 20 – 40 years old (1 – 67 years; see graphs below).
Gender-wise, there was also a major difference between the two groups: while nearly 70% of RHD patients were female, genders were nearly equally distributed in the non-RHD group.
Regarding the procedure necessary, the overwhelming majority (93.5%) of the patients with RHD needed OHS.
Clinical Outcomes
Overall mortality on 31 July 2018 was 11.1% for all patients (56/506). Mortality rates at days 30 and 180, respectively, are provided in the table below. Please note that we compared rates for the RHD vs. non-RHD patient populations as well as for patients undergoing OHS vs. IC.
A total of 41 patients (8.1%) were lost to follow-up, which points to various potential reasons, among them relocation, inability to reach the patient on numerous occasions, refusal of the hospital to give out contact information, or of course death.
Other Clinical Indicators: In the OHS group, 17 patients (4.5%) died perioperatively, i.e., within 48 hours after start of surgery. Two patients (0.5%) had to return to the operating theatre unexpectedly, while 19 patients (5.1%) were readmitted within 30 days after discharge. In the IC group, there was one peri-procedural mortality (0.8%), and two patients (1.5%) were readmitted within 30 days after discharge.
Economic Results
Within a few months of the start of the program, the cardiac care sector of Kenyan healthcare underwent considerable changes:
Hospitals started investing in new equipment and qualified staff, since they saw a viable market within which to operate. Hospitals and physicians alike were very enthusiastic about the fact that they did not have to worry over where new patients would come from.
Cardiac surgeons teamed up with local and international colleagues to take on more complex cases and concentrated their surgeries in one or two hospitals, instead of spreading out over many hospitals as before.
Young surgeons considered subspecializing in cardiac surgery, since they felt that they could make a living from it in the future.
By taking over management of the program including identifying and distributing patients, Agile was able to lower procedure price by about half in negotiations with the providers.
Discussion
To our knowledge, this is the first time that a comprehensive effort like this has taken place in Eastern and possibly all of Africa. In transgressing the boundaries among public, charity-based, and private hospitals, Agile was able to organize cardiac care access for over 500 patients.
The study confirmed well-known findings regarding the gender and age distribution of RHD vs. non-RHD cases. We consider the fact that the overall program mortality rate was below 12% a great success, as well as a consequence of the fact that all stakeholders in the project were aware that results were collected on the indicators described. While past efforts to treat cardiac surgery patients in Kenya have resulted in mortality rates of up to 50%, the careful approach of the cardiac surgeons and cardiologists involved in this program – and their willingness to team with local or international colleagues – may have contributed to reduced mortality.
The higher mortality rates in the patient group treated for RHD may be caused by facts such as the higher age of the patients and the increased severity of their diseases at the time of the procedure, as depicted by the higher proportion of patients with ASA class III
Way Forward
This project saved many lives and enabled hundreds of critically ill young Kenyans to become productive members of society; nonetheless, the cost of the procedures remains considerable for a low-income country. While the plan of the Kenyan government to expand UHC is commendable, existing funds could be better spent on secondary prevention by identifying RHD at an earlier stage, at which point patients can be effectively treated with penicillin, or at least sufficiently stabilized to delay surgery (Massell et al. 1988).
In collaboration with an international cardiology team, Agile has therefore proposed to the Kenyan government to screen youth between 7 – 19 years for RHD and other cardiac defects to identify affected patients at an earlier stage when treatment is less cost-intensive. However, since the occurrence of RHD often points to low hygienical standards, there also needs to be a comprehensive effort to address these problems. Ultimately, efforts should be made to eradicate RHD, as has occurred in many other countries.
Acknowledgments
We would like to offer special thanks to the Government of Kenya, the Ministry of Health, the National Hospital Insurance Fund and the many clinicians and administrators from the public and private sectors, who works so hard to deliver meaningful care for all patients, but especially those with heart diseases. The professionalism and dedication of Kenya’s cardiologists and cardio-thoracic surgeons is an example for all. Thank you for allowing us to work in support of your vision for a healthy and thriving Kenya.
Funding
This program was funded by the National Hospital Insurance Fund, Republic of Kenya.
Click below to access Agile’s presentation poster from the 2018 ISQUA Conference in Kuala Lumpur, Malaysia: Abstract No. ISQUA18-1178 (you will be redirected to epostersonline.com/isqua2018).