Implementation of Choosing Wisely in Rwanda, Tanzania and Ghana
Dr Sarah Kutika Nyagabona - Muhimbili National Hospital, Dar es Salaam, Tanzania
What was the aim of the study?
We did a cross-sectional picture in these three countries. What we found is that there is great concordance to care; there is a lot of deviation but this depends on the infrastructure within the three countries. An example like in Rwanda the tumour board discussion is done in all cancer patients; in Tanzania it’s around 72% but in Ghana it was lower. But also we found there was very high insurance coverage among the patients that we were seeing which also reflects on the institutions that were selected because they were referral centres and they were tertiary. So maybe that’s why the insurance coverage was very high. But this also again points out that the people that are coming to these tertiary centres to get cancer care are people with insurance. So we have a large number of patients not getting the care they want because they lack insurance.
What were the results?
Other results, I would say, because there were five recommendations that we were looking at. So we were looking at whether there was tumour board discussion; we also looked whether there was histological confirmation of a malignancy before a lump was removed. This occurrence was low, a lot were doing mastectomies or lumpectomies before getting a histology that confirms the malignancy. So this is an area for improvement.
In terms of chemotherapy single agent, or multiagent in the metastatic setting, this was still not a practice in all three countries. Most are still giving combination therapy rather than single agent, except for Rwanda but maybe because they have a bigger tumour board discussion for their patients. In terms of radiation therapy Tanzania was giving shorter courses compared to longer courses in the palliative setting.
So there is room for improvement and I think with more advertising for the CW recommendations the concordance can be improved.
Are there any further results?
The conclusion, I think they support the need for CW aims in the African setting. Even though when the initiative started there was is there overuse in a setting when it’s already limited but there is. There are still multiple combinations, longer time, even though we have limitations in terms of resources. So by employing these CW aims we can actually improve and serve more of our population, providing them with care that has less toxicity in terms of the treatment they are getting, the length of time and also in terms of financial toxicity.
What are the conclusions of all these factors?
I would also like to add that there is a need for collaborations within institutions in Africa in order to capitalise on what has already been done and existing. An example from our group looking at three countries – we came to realise there are a lot of similarities, of course there are differences, but this can be brought about by collaborating. Because an initiative done within one country can sometimes not highlight the bigger picture because we know Africa is big and broad.
