Table 2 Effectiveness indicator results

 % ≥ 0.5 mmol/L reduction in total cholesterol from enrolment to last visit (those enrolled > = 90 days)

Among those with a cholesterol test who were in the cohort for at least 90 days (2585), 651 had ≥ reduction of 0.5 mmol/L in total cholesterol = 25.1%

 % patients with asthma free from exacerbations/ admissions in previous 6 months

Among 382 patients with asthma, only 25 recorded exacerbations in total during the 3-year study period.

 % patients who report decreased/quitting smoking

Not available as self-reported smoking category (stopped, decreased, increased, resumed, unchanged) was reported relative to the last appointment.

 % patients who report increased levels of exercise from baseline

At each visit the category (active, inactive, moderately active, and moderately inactive) for recent activity behaviour was recorded. 3347 patients enrolled in the project at least 90 days had a first and last measurement. 610 (18.2%) had improved activity. 593 (17.7%) had worse activity. 2144 (64.1%) stayed the same. There was no significant improvement (chi sq. =0.284, p = 0.594).

 Trend in referrals to another facility for acute complications/specialist care (% of active cohort)

Trend in referral by type of referral service and volume of referrals were analysed

 % recommended referrals to other services that are appropriate as per guideline

Not tested

 % of active patients with CVD^a prescribed a statin

N = 369 (25.8%)

 % of patients with CVD^a prescribed aspirin

N = 717 (50.1%)

 % of patients with CVD^a prescribed at least one anti-hypertensive^b drug

N = 1007 (70.4%)

 % of patients with asthma^c with inhaler technique check documented

N = 48 (94%)

 No./% of times when appropriate clinical action taken based on clinical or laboratory findings

Among 130 randomly audited diabetic patient files, 100% had cholesterol checked; 73.8% (n = 82) had a CVD risk score subsequently calculated. Of these, 65.9% had a statin correctly prescribed (or not prescribed) according to MSF guidelines^d.

 Description of cohort deaths

2.6% (n = 139) of enrolled patients died by end of study period. Deaths were determined by word of mouth and a defaulter survey. Among all exited^e patients deaths accounted for 9.3% (139 of 1489 exits).