I work in Salta city, in a third-level hospital, a reference centre for infectious diseases and autoimmune diseases in the province. One year ago, we implemented an office specific for the care of adult Chagas disease patients, with a focus on women of childbearing age. This office is open once a week, in the afternoon, and appointments are booked on the same day, directly by the patient or through a referral from another health professional of the same hospital or other institutions. The objective is to evaluate each case to determine the indication of trypanocidal treatment, following the national recommendations and in a shared decision-making process.
Engaging patients
At first, the greatest challenge was to engage patients to visit the doctor’s consultation room. I asked for the collaboration of the hospital communications department, the ministry of health and the assistance of the nurse department (who deliver health education to the population). Short videos were made for the social networks, as well as posters and brochures, so that would people come to the hospital spontaneously. I also established contact with other institutions and professionals to ask them to refer patients: blood banks from the province, the mother and child hospital, health professionals from different specialties and laboratories.
Barriers to access to diagnosis
An obstacle that we came across was access to diagnosis. With the implementation of the doctor’s office, the demand for serological tests increased due not only to its own activities but also to a change in the recommendations for the control of other diseases. At present, a test to detect Chagas disease is indicated to all patients with diagnosis of Tuberculosis and patients treated for rheumatic diseases, in addition to patients recently diagnosed with HIV. Today, there are not enough reagents available in the laboratory to perform all the requested tests and we still have not found a solution to that situation.
Challenges in the health care circuit
When patients started to come, other difficulties emerged. We had established an internal circuit to evaluate each patient, with a first visit to the Chagas office, when the patient is asked some questions and is subjected to a physical examination. Then, we ask for tests and consultations to other specialties (laboratory and cardiology). Then there is a second visit with the results of those tests in which, if the patient is candidate for trypanocidal treatment and is willing to receive it, a medication request form is filled in and is handed in at the epidemiology department.
This circuit was previously agreed with the Cardiologists, appointment system and Epidemiology, and it works fairly well. On average, in general, patients return with the tests two weeks later. The first difficulty arose when we sent the first case report forms; there was a delay in the delivery of the medication by central level to the hospital, and unattended requests for treatments started to accumulate.
The epidemiology department of the hospital made a special request to the ministry of health of the province to have a stock of benznidazole available at the hospital pharmacy, and the ministry sent it. Since then, the circuit has become more efficient because, on the second visit to the doctor’s office, the patient receives the medication to start treatment, along with a form for self-report medication intake and indicating the date of appointment for the first control.
Adverse effects and patient follow-up
Finally, another important challenge was the management of adverse drug reactions since, while they are mostly mild, they do occur and require immediate response. Since the doctor’s office is open once a week, the patients have the personal phone number of the assistant physician to communicate in case of the appearance of adverse effects and receive immediate instructions. Anyway, in some cases, the patients did not communicate and went to emergency rooms, where they did not receive an appropriate treatment nor were they indicated to stop taking the drug, with the consequent progression of the reaction to more severe forms. For this reason, a brief specific protocol for action was provided to the hospital emergency department for cases of adverse reactions of trypanocidal drugs. In addition, the patients are instructed to communicate by phone, if needed, as well as to go to the emergency room of the hospital instead of going to other institutions.
Although I am aware that the strategy of a consultation centralized in a hospital is not ideal for the care of Chagas disease, I think that, since the start of the activities, the doctor’s office has improved. We have learnt and overcome difficulties, giving response to at least a small portion of the population that goes to the hospital. In addition, I think that the existence of the doctor’s office can be a driver for the community and other health professionals to think more of Chagas disease and ask about its treatment.