AASCIT Journal of Medicine

2015; 1(3): 37-42

Published online July 20, 2015 (http://www.aascit.org/journal/medicine)

Keywords Heart Failure,

Cardiology,

Compliance,

Cost of Treatment,

Bamako

Received: May 30, 2015

Revised: July 8, 2015

Accepted: July 9, 2015

Management and Treatment Compliance of Heart Failure (HF) at Mother-Child Hospital "Le Luxembourg" (MCHL) in Bamako

Bâ Hamidou Oumar1, Touré Mamadou

2, Maiga Asmaou Kéita

2,

Menta Ichaka1, Daou Adama

3, Sidibé Noumou

1, Sangaré Ibrahima

1,

Landouré Guida4, Doumbia Coumba Thiam

5, Diallo Souleymane

2,

Sidibé Salimata2, Diarra Mamadou Bocary

2

1University Hospital Gabriel Touré, Cardiology, Bamako, Mali 2University Hospital “Le Luxembourg”, Cardiology, Bamako, Mali 3National Support Center for Fight the Disease, Training Division, Bamako, Mali 4University Hospital Point G, Cardiology, Bamako, Mali 5University Hospital Kati, Cardiology, Kati, Mali

Email address bhamiba@gmail.com (B. H. Oumar)

Citation Bâ Hamidou Oumar, Touré Mamadou, Maiga Asmaou Kéita, Menta Ichaka, Daou Adama, Sidibé

Noumou, Sangaré Ibrahima, Landouré Guida, Doumbia Coumba Thiam, Diallo Souleymane,

Sidibé Salimata, Diarra Mamadou Bocary. Management and Treatment Compliance of Heart

Failure (HF) at Mother-Child Hospital "Le Luxembourg" (MCHL) in Bamako. AASCIT Journal of

Medicine. Vol. 1, No. 3, 2015, pp. 37-42.

Abstract Objective: To describe management of HF. and compliance associated factors with

treatment in MCHL Methodology: The study was cross-sectional, descriptive, realized

from August to December 2014 in MCH among all outpatients and those hospitalized with

echocardiographically confirmed HF. After collecting socio-demographic, clinical and

laboratory findings in an Access 2007 database, the data were verified and analyzed using

Microsoft Excel 2007 and SPSS software. Results: HF prevalence was 2.6%, and the mean

of the sample was 49.06 ± 20.782 years. Loop diuretics and Angiotensin converting

enzyme inhibitors were prescribed respectively in 91.3 and 82.6% of patients. The main

reasons for discontinuation of treatment were economic reasons and the lack of

information in 42.31 and 23.08% of patients respectively. The regularity and duration of

treatment were significantly associated with good compliance. The average monthly cost

of outpatient treatment was 63% of the minimum wage and that of hospitalization

exceeded the minimum wage (3.55, 2.31 and 10.16 times resp. for medicines,

complementary exams and hospital beds) Conclusion: HF management is based on

international guidelines with financial reasons as main cause for non-compliance. The cost

of treatment is relatively high and its lowering could be from great benefit for patients

through improving of adherence.

1. Introduction

Heart failure is a public health problem due to its prevalence and implications in terms

of costs related to the management [1-4]. The latter is relatively well codified in recent

years thanks to the many conducted clinical trials [5, 6]

The difficulties and approach to the management of the IC were discussed by many

authors [7-10].

38 Bâ Hamidou Oumar et al.: Management and Treatment Compliance of Heart Failure (HF) at Mother-Child Hospital

"Le Luxembourg" (MCHL) in Bamako

Most class of recommended drugs for the management of

HF are available in Bamako. Except first generation

ACE-Inhibitors, loop diuretics, digitalis and anti-platelet

agent acetyl salicylic acid which are available in generic forms,

the others for HF indicated medicaments are very expensive.

HF patients are frequently hospitalized [4] and this situation

contributes to the high cost of this disease. In some countries

patients have to pay just a little part of the costs for treatment.

In Mali Health insurance is newly implemented and most

insured people are employees of the state or from the private

sector. So a very large majority of the population don’t have

yet access to insurance. This situation is a very big concern as

HF is a chronic disease with periods of remission and

exacerbation.

There are few published data on the treatment of IC in Mali,

what motivated this study with the objectives of describing the

management of the IC and the factors associated with

treatment compliance in MCHL.

2. Methodology

We conducted a cross-sectional and descriptive study at the

MCHL in the cardiology department from August to

December 2014. Consent was obtained from all patients.

Sample Subjects of the study were all patients seen in the

study period as outpatients or hospitalized patients

As HF patients were considered:

� HF outpatients, whose diagnosis was established

� Hospitalized patients with a HF record as diagnosis

HF had to be confirmed both clinically and with

echocardiography.

Data Collection and Processing

For each patient socio-demographic, clinical and labor tests

were obtained recorded on the basis of a formulary, specially

tailored for the study. We also evaluate adherence to treatment

among patients with known HF applying a series of questions.

The collection and processing of data has been made with

Microsoft Access 2007 and Microsoft Excel 2007 resp. for

inputting and checking data and SPSS Version 12 for

statistical analysis and we used appropriate statistical tests as

needed. The significance level of the tests was set at 0.05. We

formed 2 groups of patients: newly diagnosed HF called New

HF and patients whose diagnosis was known before the

inclusion in the study called Old HF. These 2 groups were than

compared.

3. Results

The prevalence of HF was 2.6% with a predominance of

males (55.9%), of the age group 60-74 years (30.1%) and

unschooled patients (58.1%) (Table 1).

Table 1. Socio-demographic characteristics of 93 patients diagnosed with HF.

Variables New HF Old HF N (%) p

Age groups (years)

<30 14 06 20 (21.5) 0.009

30-44 10 08 18 ( 19.4)

45-59 08 11 19 (20.4)

60-74 09 19 28 (30.1)

≥75 01 07 08 (08.6)

Sex

Female 18 23 41 (44.1) 0.829

Male 24 28 52 (55.9)

Education level

Unschooled 21 33 54 (58.1) 0.506

Primary 08 07 15 (16.1)

Post-primary 01 00 01 (01.1)

Secondary 10 08 18 (19.4)

University 02 03 05 (05.4)

Insurance

None 28 36 64 (68.8) 0.153

Canam* 07 12 19 (20.4)

Anam** 07 02 09 (09.7)

Private 00 01 01 (01.1)

Environnement

Family*** 31 39 70 (75.3) 0.640

Couple 09 11 20 (21.5)

Others 01 01 2 (02.2)

Alone 01 00 01 (01.1)

Caisse Nationale d’Assurance Maladie (National Health Insurance Fund)

Agence Nationale d’Assurance Maladie (National Health Insurance Agency) ***More than 6 members

AASCIT Journal of Medicine 2015; 1(3): 37-42 39

The mean age of the sample was 49.06 ± 20.782 years, mean HR 96.10 ± 30.497 / min and mean Waist Circumference (WC)

82.59 ± 18.655 cm (Table 2).

Table 2. Anthropometric characteristics of 93 patients admitted for HF.

Variables Old HF New HF Mean ± SD Min. Max.

Age* (years) 42.05 54.84 49.06 ± 20.78 4 86

BP** (NS+) mmHg 86.53 90.76 88.85 ±20.99 36.67 150

PP** (NS) mmHg 46.49 50.40 48.64 ±22.51 10 110

HR (NS) /min. 91.31 100.04 96.10 ±30.50 50 130

Weight (NS) (Kg) 64.57 65.29 64.97 ±20.04 10 137

Height (NS) (cm) 167.90 168.76 168.38 ±15.18 70 198

BMI (NS) (Kg/m2) 24.85 22.49 23.56 ±13.27 5.65 134.69

WC (NS) (cm) 79.50 85.14 82.59 ±18.65 42 140

Age: p = 0.003+ Not significant BP: blood pressure HR: heart rate PP: pulsed pressure BMI: body mass index WC: waist circumference

Among new patients 82.9% were referred, while 38.6% of

patients with known HF (p <0.0001).

Loop diuretics, Angiotensin Converting Enzyme and

antiplatelet agents were the most prescribed drugs in

respectively 91.3, 82.61 and 69.57% of cases (Graph 1).

Graph 1. Prescribed Drugs in 93 heart failure patients.

Of 42 with known HF 21 (50%) regularly came to their

appointments, only 32 of them were following medical

treatment and 10 associate traditional to medical treatment

(Table 3).

These traditional treatments have as major characteristic

that they are very cheap. They are also not codified and not

approved and of course not covered by insurance. These

traditional are thought to have no or less side effects. In fact as

they are not tested in laboratories, anybody could talk about

their safe use and more important about their efficacy. Most of

them are in powder form or as mixture

A break in treatment occurred in 26 patients with drugs

including loop diuretics, aldosteron-antagonists, digitalis and

Beta-Blocker respectively in 43.8%, 40.6% and 34.4% and

31.3% cases (Table 3).

The main reasons for the breakdown of the treatment were

dominated by economic reasons, the lack of information and

negligence in resp. 42.31, 23.08 and 19.23% of the cases

(Table 3).

Among various factors duration of HF, regularity and

duration of treatment differed significantly depending on

whether the patient is or is not adherent to the treatment (Table

40 Bâ Hamidou Oumar et al.: Management and Treatment Compliance of Heart Failure (HF) at Mother-Child Hospital

"Le Luxembourg" (MCHL) in Bamako

4).

Table 3. Treatment aspects in 42 heart failure patients known.

Treatment N (%)

Appointment regularity Yes 21 ( 50.0)

No 21 ( 50.0)

Type of treatment Only medical 32 ( 76.2)

Medical + traditional 10 ( 23.8)

Treatment interruption Yes 16 (38.1)

No 26 (61.9)

Interrompted drugs Loop diuretic 14 (43.8)

Anti aldosterone 13 ( 40.6)

Digitalis 11 ( 34.4)

Beta-blocker 10 ( 31.3)

ARA2 09 (28.1)

ACE-Inhibitor 06 ( 18.8)

Thiazide type diuretic 04 (12.5)

Nitrate derivated 03 (09.4)

Calcium-Ca Inhibitor 02 ( 06.3)

Others 13 (40.6)

Reasons of interruption Economic 11 (42.31)

Lack of information 06 (23.08)

Negligence 05 (19.23)

Confusion 01 (03.85)

Drug availability 01 (03.85)

Side effects 01 (03.85)

Number of drugs 01 (03.85)

Table 4. Parameters influencing compliance.

Parameters Treatment adherence

P Yes No

Statut hospitalized not hospitalized 5308 2408 0.96

HF duration new case old case 4516 0.626 0.028

Number of drugs ≤ 3 4 - t6 ≥7 153412 0.62105 0.99

Appointment regularity regular non

regular 1603 0.722 0.0053

Symptom release Not at all or few Full 1249 0.230 0.12

Sex male female 3625 1616 0.98

Education level None or primary

Post-primary, secondary and

University

4516 2408 0.99

Residence Bamako Out of Bamako 4219 2309 0.99

Insurance None Yes 4021 2408 0.97

Environment Family Couple 4515 2505 0.97

Treatment duration < 6 mois ≥ 6 mois 5011 0.824 0.0000

23

A proportion of 64.29% had a prescription containing 4 to 6

tablets

The pre-therapeutic conversation focused on the dosage and

drug treatment modalities (Graph 2).

The average cost of outpatient treatment was about 28 USD,

representing 0.63 times the guaranteed minimum wage

(GMW), the costs of the hospitalization 3.55, 2.31 and 10.16 x

the GMW resp. for medicines, complementary exams and

hospital beds (Table 5).

Table 5. Monthly Cost in USD for the management of HF.

Outclinic a

Hospitalisation

Drugs b Labor

tests c Bed d

Min. 2,21 32 0 113

Max. 55 323 263 876

Mean (x GMW) 23 (0.63) 128 (3.55) 83 (2.31) 366 (10.16)

a Monthly cost of treatment for 90 patients, Total drug costs for 41 inpatients, c

Labor tests of 77 patientsd Total cost for 43 hospitalized patients

4. Discussion

Our study focused on the analysis of the management of

heart failure in MCHL with a sample of 93 patients of which

42 old and 51 new without significant difference for

socio-demographic and anthropometric data except for age.

The great proportion of unschooled and not insured patients

could be explained by the development level of the country.

Possible explanations for age differences (Tables 1, 2) could

be the increase with age of HF prevalence [5,6,11-12] but also

by the fact that patients were seen too late in hospital, at

advanced stages of the disease.

All essential drugs of medical HF treatment [5,6] are

prescribed. Drug prescriptions were dominated by loop

diuretics and ACE inhibitors. The availability in generic forms

could explain the high proportion in prescription of these 2

medications classes. The low prescription of other drugs

including new beta blockers (bisoprolol and carvedilol) and

antagonists of mineralocorticoid could be explained primarily

by their high cost, especially since 68.8% of patients in the

study did not have medical insurance to support the costs. A

lower prescription of beta-blockers was also noted by

Saudubray et al. [10] 24%, Kingue et al. [13] 19% while Ruf et

al. [8] found higher percentages of 84% and 64% resp. for

beta-blockers and spironolactone. In a multicenter study

Damasceno et al. [14] found 81.4%, 79.6%, 30.8% and 72.4%

resp. for IEC / ARA-2, diuretics, beta-blockers and

anti-aldosterone. It should be noted in this study that at six

months treatment prescriptions of anti-aldostérones dropped

to 63.1% while that of IEC / ARA-2 and beta-blockers resp.

increased to 83.6 and 48.9%. We have not had enough period

of observation to describe a trend in our sample.

Unlike studies in western countries, our patients used

frequently traditional medications alone or in substitution to

“modern treatment”. It should be noted that sometimes these

medications are not from “Medecine-Man”, but are taken

because another patients took it and recommands them. Main

raison are the low cost and the supposed absence of

side-effect.

Several studies on adherence were conducted [15-19], all

noted the complexity of observance concept. One of the first

AASCIT Journal of Medicine 2015; 1(3): 37-42 41

causes of noncompliance in our study was financial reasons in

42.31% of patients (Table 3), which is not a problem in most

studies [14,16,18,19]. Only the study of Brand [17] mentions

this aspect.

In our study among the factors that could be related to

compliance [20], only HF duration, regularity of appointments

and duration of the disease (Table 4) were significantly

associated with good adherence. This should be related to

informations provided in the appointments and the early

detection of signs of decompensation. Some can understand

that the chronic disease has a learning effect for patient, which

then earlier looked up for medical assistance.

Particular pharmaceutical class does not seem to be the

cause of the treatment disruption/interruption, since all

therapeutic combinations are represented as shown in Graph

2.

Graph 2. Contents of the pre-therapeutic counselling.

The breaking of the treatment in addition to the financial

reason could be related to a lack of information since the

pre-therapeutic interview (Table 3), focused on dosage and

care arrangements.

The management of HF is expensive [22] and relatively

more in developing countries [3, 21]. We preferred to focus on

the financial burden by giving the amounts and their

proportion of the Guaranteed Minimum Wage).

Good adherence results in higher costs for the regular

purchase of drugs [23] rapidly balanced with a decrease in

other non-drug-related costs. In our study cost was the first

barrier to a good management including drug prescription.

5. Conclusion

HF is a relatively frequent disease needing for its

management high costs, so that financial difficulties the main

cause for non-adherence to the treatment. Besides that most

relevant medications are available even expensive. , treatment

through traditional medications is another part of the

non-adherence to treatment. The extension of insurance

underwriting as now in progress and making new

medicaments such aldosterone antagonists and new

Bêta-blocker available in generic forms could greatly reduce

the cost of management and therefore improve the adherence

to treatment.

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