In this study, we found high rates of NCDs among inpatients in a district hospital in rural Malawi. We show significant numbers of NCDs outside the traditional set of cardiovascular disease, diabetes, respiratory diseases, and cancers. In particular, we found especially high rates of trauma, mental health, and neurological disease. Inpatients with an NCD diagnosis in our cohort had significantly longer lengths of stay, readmission rates, referrals to higher levels of care and mortality rates. While we did see a difference in patient populations between rainy and dry seasons, this was primarily driven by patients with malaria and tuberculosis. In addition to the seasonal impact of malaria, seasonal differences are likely impacted by difficulties in accessing health facilities during the rainy season as most patients travel on foot.
The mean age for all NCD visits was under age 40, and we found two distinct populations of patients. The first population were patients over 40 years of age, predominantly affected by chronic medical conditions featured in the ‘4x4’ set of NCDs put forward by the WHO. The second population were patients under age 40, who primarily suffered from trauma, burns, and mental health disorders, as well as other chronic conditions such as asthma and epilepsy. We also found a significant number of complex medical NCDs among the pediatric population, including sickle cell disease, rheumatic heart disease, and type 1 diabetes. The high rates of burns and trauma are higher than those found previously [9], but show the need for ongoing research into this area of need.
This study highlights that NCDs are an important part of the inpatient population in rural areas in Sub-Saharan Africa. While the rates of NCDs in our population were high, these rates are likely an underestimation. The diagnosis of many NCDs remains elusive in hospitals throughout Sub-Saharan Africa due to a lack of resources like consistent laboratory testing, spirometry, and reliable imaging in addition to a lack of training for staff. As an example, while the prevalence of RHD in Malawi is estimated at 1% [37], active screening diagnosed latent RHD in 3.4% of school-aged children [38].
A major part of the UHC effort is to match resources with burden of disease. Currently, public resources are often concentrated in urban areas, further exacerbating urban-rural health inequities [39]. The high rates of disease we found at Neno District Hospital highlight that rural hospitals must also be equipped to diagnose and care for a broad range of NCDs, especially those in young people. These diseases in young people are often not covered by the traditional 4x4 set. The significant numbers of neurological disease, mental health disorders, severe chronic conditions, as well as trauma and burns, show the importance of broadening our definitions of NCD to better address the true disease burden.
Our study also found that patients with an NCD diagnosis potentially had significantly higher costs both to the patients and their families as well as to the healthcare system in comparison to patients without an NCD diagnosis. These increased costs included longer lengths of stay, higher readmission rates, and more frequent referrals to higher levels of care. This supports prior studies that demonstrate the significant costs that NCDs have to the health system in addition to their toll on patients and families [40][41]. To improve outcomes and reduce readmissions, we must take an approach that links high-quality acute care with improved longitudinal care in the outpatient setting. Given the high proportion of NCD patients on inpatient wards, there is a real opportunity for programs that screen inpatients for NCDs and then subsequently link them to high-quality outpatient care.
The mortality in our cohort (4%) was lower than a similar cohort at Queens Hospital in Blantyre, Malawi, who had a mortality rate of 22.7% [21]. This is not necessarily surprising, as Queens is a referral hospital with an Intensive Care Unit (ICU) and larger catchment area, likely resulting in a sicker patient population. However, the mortality difference may also be in part to patients presenting to Neno Hospital, a rural hospital closer to their home, earlier in their disease course, though we did not have enough data to evaluate this hypothesis. Additionally, there may be some positive effect from the integrated chronic care clinic (IC3) in Neno District, which provides longitudinal services free of charge to patients with HIV and chronic NCDs [26].
The major strength of this study is that it is the first to look at the burden of NCDs among inpatients at a rural hospital in Malawi. Additionally, we took a broad look at NCDs, not only focusing on diseases outside of the traditional 4x4 set as defined by WHO PEN, but also included the pediatric inpatient population.
A major weakness of this study was that it is a retrospective study with relatively small sample size, only evaluating 16 months of hospital admissions. There are also limitations to the ability to diagnosis all NCDs consistently in our hospital. Given a lack of resources and training, we had difficulty arriving at specific diagnoses for some pulmonary, cardiac, and other complex medical conditions. This is not unique to our study, and despite significant efforts in training and diagnostics, there remains progress to be made. This study highlights the importance of ongoing research into true burdens of non-communicable disease.