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 [email protected] (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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