To cite this article: Manji I, Pastakia SD, Do AN, Ouma MN, Schellhase E, Karwa R, Miller ML, Saina C, Akwanalo C. Performance outcomes of a pharmacist-managed anticoagulation clinic in the rural, resource-constrained setting of Eldoret, Kenya. J Thromb Haemost 2011; 9: 2215-20.Summary. Background: It is recommended that warfarin therapy should be managed through an anticoagulation monitoring service to minimize the risk of bleeding and subsequent thromboembolic events. There are few studies in Sub-Saharan Africa that describe warfarin management in spite of the high incidence of venous thromboembolism (VTE) and rheumatic heart disease. Objective: To examine the feasibility of the Moi Teaching and Referral Hospital anticoagulation monitoring service and compare its performance with clinics in resource-rich settings. Methods: A retrospective chart review compared the percentage time in the therapeutic range (TTR) and rates of bleeding and thromboembolic events to published performance targets using the inference on proportions test. WilcoxonÕs rank sum analyses were used to establish predictors of TTR. Results: For the 178 patients enrolled, the mean TTR was 64.6% whereas the rates of major bleeds and thromboembolic events per year were 1.25% and 5%, respectively. In the primary analysis, no statistically significant differences were found between the results of TTR, major bleeds and thromboembolic events for the clinic and published performance rates. In the secondary analysis, having an artificial heart valve and a duration of follow-up of > 120 days were positively associated with a higher TTR (P < 0.05) whereas venous thromboembolism, history of tuberculosis, HIV and a duration of followup of < 120 days were associated with having a lower TTR (P < 0.05). Conclusions: The performance of the MTRH anticoagulation clinic is non-inferior to published metrics on the performance of clinics in resource-rich settings.

With proper oversight and stakeholder involvement, this model is a potential solution to improve availability of essential medicines in LMICs. These pilots exemplify the feasibility of implementing and scaling up this model in other locations.

Cardiovascular disease (CVD) is the leading cause of death in the world, with a substantial health and economic burden confronted by low- and middle-income countries. In low-income countries such as Kenya, there exists a double burden of communicable and noncommunicable diseases, and the CVD profile includes many nonatherosclerotic entities. Socio-politico-economic realities present challenges to CVD prevention in Kenya, including poverty, low national spending on health, significant out-of-pocket health expenditures, and limited outpatient health insurance. In addition, the health infrastructure is characterized by insufficient human resources for health, medication stock-outs, and lack of facilities and equipment. Within this socio-politico-economic reality, contextually appropriate programs for CVD prevention need to be developed. We describe our experience from western Kenya, where we have engaged the entire care cascade across all levels of the health system, in order to improve access to high-quality, comprehensive, coordinated, and sustainable care for CVD and CVD risk factors. We report on several initiatives: 1) population-wide screening for hypertension and diabetes; 2) engagement of community resources and governance structures; 3) geographic decentralization of care services; 4) task redistribution to more efficiently use of available human resources for health; 5) ensuring a consistent supply of essential medicines; 6) improving physical infrastructure of rural health facilities; 7) developing an integrated health record; and 8) mobile health (mHealth) initiatives to provide clinical decision support and record-keeping functions. Although several challenges remain, there currently exists a critical window of opportunity to establish systems of care and prevention that can alter the trajectory of CVD in low-resource settings.

BackgroundAtrial fibrillation (AF) is a major contributor to the global cardiovascular disease burden. The clinical profile and outcomes of AF patients with valvular heart diseases in sub-Saharan Africa (SSA) have not been adequately described. We assessed clinical features and 12-month outcomes of patients with valvular AF (vAF) in comparison to AF patients without valvular heart disease (nvAF) in western Kenya.MethodsWe performed a cohort study with retrospective data gathering to characterize risk factors and prospective data collection to characterize their hospitalization, stroke and mortality rates.ResultsThe AF patients included 77 with vAF and 69 with nvAF. The mean (SD) age of vAF and nvAF patients were 37.9(14.5) and 69.4(12.3) years, respectively. There were significant differences (p<0.001) between vAF and nvAF patients with respect to female sex (78% vs. 55%), rates of hypertension (29% vs. 73%) and heart failure (10% vs. 49%). vAF patients were more likely to be taking anticoagulation therapy compared to those with nvAF (97% vs. 76%; p<0.01). After 12-months of follow-up, the overall mortality, hospitalization and stroke rates for vAF patients were high, at 10%, 34% and 5% respectively, and were similar to the rates in the nvAF patients (15%, 36%, and 5%, respectively).ConclusionDespite younger age and few comorbid conditions, patients with vAF in this developing country setting are at high risk for nonfatal and fatal outcomes, and are in need of interventions to improve short and long-term outcomes.

Availability of medicines for treatment of cardiovascular disease (CVD) is low in low-income and middle-income countries (LMIC). Supply chain models to improve the availability of quality CVD medicines in LMIC communities are urgently required. Our team established contextualised revolving fund pharmacies (RFPs) in rural western Kenya, whereby an initial stock of essential medicines was obtained through donations or purchase and then sold at a small mark-up price sufficient to replenish drug stock and ensure sustainability. In response to different contexts and levels of the public health system in Kenya (eg, primary versus tertiary), we developed and implemented three contextualised models of RFPs over the past decade, creating a network of 72 RFPs across western Kenya, that supplied 22 categories of CVD medicines and increased availability of essential CVD medications from <30% to 90% or higher. In one representative year, we were able to successfully supply 5 793 981 units of CVD and diabetes medicines to patients in western Kenya. The estimated programme running cost was US$6.5–25 per patient, serving as a useful benchmark for public governments to invest in medication supply chain systems in LMICs going forward. One important lesson that we have learnt from implementing three different RFP models over the past 10 years has been that each model has its own advantages and disadvantages, and we must continue to stay nimble and modify as needed to determine the optimal supply chain model while ensuring consistent access to essential CVD medications for patients living in these settings.