This is one of the first studies to look at management of NCDs in an LMIC setting. In Kigali, Rwanda, the SAMU prehospital ambulance service routinely manages NCD-related cases, although at a smaller proportion than obstetric and traumatic cases. However, these NCD patients tended to be older and more critically ill and have higher odds of dying than the rest of SAMU patients based on Proportional Mortality Ratio.
SAMU patients with NCDs had more vital sign derangements than other emergency patients. This may be because of delays in recognition of illness, delays in accessing care, and/or delays in availability of quality services. In obstetrics and gynecology, the three delay model describes delays: deciding to seek appropriate medical help for an obstetric emergency, reaching an appropriate obstetric facility, and receiving adequate care when a facility is reached.10 This model can be translated to delays for NCDs. Patients in many LMICs experience delays in care-seeking generally due to sociocultural factors.11,12 Lack of awareness of NCDs by the public or by medical staff, cultural practices contributing to delays in accessing care, cost of accessing care, shortages of staff or complexities of the current healthcare system may contribute to challenges for patients with NCDs. The general public may not be aware of the signs and symptoms of NCDs to seek help. The symptoms may be vague; for example, nausea and heartburn are known to be atypical symptoms of myocardial infarction in HIC settings.13 The medical staff may not be familiar with signs and symptoms of acute NCDs since these are still fairly underrecognized. Lack of training and lack of nurses were previously described as barriers to adequate ICU care in LMICs.14
Cultural practices may lead to delays in seeking care. Patients may seek care from traditional healers, for example.15,16,17 These barriers to care have been noted across a variety of settings, in both HICs and LMICs.18,19
The infrastructure of the health care system may also be a barrier. The referral system acts as a gatekeeping mechanism and may limit getting care for emergent conditions since patients need to progress to higher levels through the system. Furthermore, the healthcare system does not currently have advanced capabilities such as a cardiac catheterization lab, neurointerventional operating room, or cardiac surgical care currently -- which would be necessary to manage conditions such as myocardial infarction and stroke. These resources are being discussed at this time but would require time to deploy and only be available in Kigali. The AFRICARDIO2015 team has developed a consensus statement highlighting the need for equipping first line healthcare facilities with electrocardiograms, emergency rooms in large towns to have fibrinolytic therapy and large cities to have percutaneous cardiology intervention facilities.20 These factors will need to be addressed to decrease the acuity of patients with NCDs and offer them the best chances for good outcomes in Rwanda. Prehospital care is one area of investment that may be low-hanging fruit since these staff can address all causes of emergencies, including NCDs. The Ministry of Health’s investment in SAMU since 2007 is noteworthy and likely to increase in necessity over time.
SAMU patients with NCDs were much older than patients without NCDs. However, deaths between the ages of 30 and 69 years old are considered premature and therefore potentially preventable. Globally, 15 million deaths are attributed to NCDs in this age group.1 SAMUs largest cohort of NCD patients was over 60 years old suggesting that the increase in life-expectancy over the last two decades in Rwanda may have resulted in a population that is aging and therefore at risk for developing NCDs. Another possible explanation may be that younger patients with NCDs may access care differently compared to this older cohort -- whether that means taking private transport to the hospital instead of calling the ambulance service or seeking care outside the country. Economy recovery in the last 25 years may have contributed to a well-to-do portion of the population that does not use the public emergency system. These are all areas that require further research in Rwanda.
Lastly, public education on NCDs and their risk factors will be increasingly important as NCDs displace communicable diseases. In 2017, NCDs had the largest risk-attributable burden of any disease globally.21 As primary health care in Rwanda improves, a health-literate population may be more likely to incorporate risk reduction strategies to decrease the incidence of NCDs. Risk factors of NCDs such as tobacco use, physical inactivity, excessive use of alcohol, and unhealthy diet are becoming more common as countries urbanize.5,21 The Ministry of Health of Rwanda is working towards a national goal to reduce 80% of premature deaths caused by NCDs or by injury in people under 40 years of age by the year 2020 through two initiatives: car-free day and “80 × 40 × 20”.22,23 Car-free day occurs twice a month, where parts of the city of Kigali close their roads and hold physical activities for the public to encourage a healthy lifestyle. 80 × 40 × 20 is These are valuable long-term strategies to decrease the incidence of NCDs and their attendant emergencies.
Our study has several limitations. This study was limited to the prehospital setting. Patients were not followed through the emergency department or hospital stays because no infrastructure exists yet to connect data across these settings. This study, therefore, did not aim to study patient outcomes or whether patients received the correct treatment for their complaint. The data collection and entry process may have limitations from entry errors as well as omission and transcription errors. SAMU holds daily morning meetings to discuss patients seen during the last 24 hours which provides an internal check on the information logged into the run sheets, but no formal audit has been conducted of this data set. Finally, the patients with NCDs represented a small subset of the overall population therefore subgroup analyses are limited due to insufficient sample size to make valid statistical comparisons. Nevertheless, it is valuable to understand the care provided by SAMU for NCDs in Kigali using the best available data. Future directions may include creating data infrastructure to study patient outcomes and intervention studies to determine if prehospital interventions may reduce the mortality and morbidity from NCDs in LMIC settings.