Cilliers Human Resources by ExQYZ9

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									     Paediatric Cardiology
  Human Resources – targets,
  developing & retaining skills

       Antoinette Cilliers
     Paediatric Cardiology
   C.H. Baragwanath Hospital
University of the Witwatersrand
         Johannesburg
Introduction
   The role of the Paediatric Cardiologist (PC) has
    expanded dramatically in recent times to include care
    of adults with CHD, foetal cardiac medicine, and
    interventional catheterization.
   We face numerous challenges to achieve these goals
    not to mention the national priority to address
    primary health care needs in the country and the HIV
    epidemic.
   Do we have the national human resource capacity to
    deal with the burden of disease in SA ? Are we
    training too many PC to meet the needs of the
    population of South Africa ?
                                                                              Public Service 9
                                                                              Private Practice 13
                                                                              Trainees 8
                                               PC in SA – 22

GT 13                         KZN 2                          WC 5                          FS 2


        PUBLIC 4                      PUBLIC 1                      PUBLIC 3                      Combined 2



              Trainees 5                     Trainees 1                     Trainees 2                    Trainees 0


              Supernumery 0                  Supernumery 0                 Supernumery 1                  Supernumery 0




                                                                                                  Paed/echo 1
        PRIVATE 9                 PRIVATE 1                         PRIVATE 2                       Kimberley


     Paed/echo 3                                                    Paed/echo 3
                                      Paed/echo 0
   NW, Pretoria, NP                                                     EC
       SA Data
1. Census 2001.
Http://www.statssa.gov.za
2. Medical Aid Beneficiaries,
2002 (Health Systems Trust).
Http://new.hst.org.za
Total Population (44.8 m)
Non-Medical Aid Patients (37.8m)
Medical Aid Patients (Total = 15.4%, 6.9m)
                                                       5.2m/4.8m/0.46m


                                                          3.1m/2.7m/0.44m

                                 3.7m/3.2m/0.48   8.8m/6.5m/2.4m




                                    2.7m/2.3m/0.4m 2.2m
                                                          9.4m/8.2m/1.2m
              0.8m/0.7m/0.16m




                                      6.4m/5.8m/0.66

            4.5m/3.2m/1,3m
Referral area population



Total = 20.8m (46%)
Non-Med Aid = 17.2m
Med Aid = 3.78 m



    Total with Lesotho = 5.3 m
    Without Lesotho = 3.1 m (7%)
    Non-MA = 2.65 m
    MA = 0.48 m


                                                 Total = 12.6 (28%)
                                                 Non-MA = 11.1 m
                                                 MA = 1.86 m



                             Total = 8.1 (18%)
                             Non-MA = 6.5 m
                             MA = 1.7 m
Estimate of CHD Burden in SA
    1,380.497 Live Incidence of CHD
    Births (LB) in < 1% LB14
    200513
    Children with   13,805
    CHD/yr
    50% need        6,903
    invasive
    diagnostics12
    40% need open 5,522
    heart
    surgery12
Management of CHD in India 199815
      – Population 1 Billion
   1250 infants & newborns underwent surgery
            = 1-2 % affected population
   Therefore 98 – 99% did not survive !

    REASONS SUGGESTED:
   Lack of awareness.
   Poor training of Paediatricians regarding CHD.
   No. PC in India = ½ at Children’s Hospital in
    Boston.
   Vast areas of India do not have PC surgery.
                 Expenditure

                   USA 199712                        SA 2005
                                                   Total health expenditure
                                                    US 8/ZAR 48 Billion*

Paediatric       US 3.4/                       US 1.5/
cardiovascular   ZAR 20.4 Billion             ZAR 9 billion
care                                          = 19% health budget!
Children born    32,000                       14,000 (est)
with CHD
Cost/pt          US 106,250/                                  ?
                 ZAR 637,500

                 * Mail & Guardian online, 25 Feb 2005
          Paediatric Cardiologists
                required ?
   Each centre providing cardiac services should
    have a minimum of;
   1 PC per ½ million population served (0.5:1)
   (should have expertise in foetal and adult congenital cardiology)



Report of the Paediatric & Congenital Cardiac Services Review Group, UK, 2003   10
                            SA vs Other Countries: Pop (million) vs Pop:PC ratio                                          Pop
                                                                                                                          Ratio


                 2500                                                      2200
Pop (millions)




                 2000
                 1500
                 1000                                                            440
                  500    30
                          0.42 4.2
                                 0.7    600.8      200.8   136.5    1818                 20 1    44.82       384.2      0.5
                                                                                                                      6.9
                    0




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                                                                                                  SA
                        US – 300 million with pop:PC ratio of 0.25million:1PC ?
                              Public Service - Population served & Pop:PC ratio

                 40                                                                                  37.8
                 35
Pop (millions)




                 30
                 25
                                                                                       17.2                       Pop
                 20
                                                                                                                  Ratio
                 15                                                   11.111.1
                 10                     4.9         6.45
                        2.651.33                                                              4.3           4.2
                  5                           2.5          2.2
                  0




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                                       Bloem – FS,½ NC
                                       Pretoria/JHB – GT, NP, Mpumalanga, NW
                                       CT – WC, ½ NC, ½ EC
                                       Durban – KZN, ½ EC
                   Ideal no. Paediatric Cardiologists Required in Public Hospital
                                               Service

         70        63
         60
         50
Number




         40                                31                                       PC req
         30                                              20                         PC
         20             9                                         8
                                                4             1        3   4    2
         10
          0
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                                  Cardiac Physicians & Surgeons - SA (2006)

                                      156
                         160
                         140
                                                                                 108
                         120
                         100
       No.                80
                          60
                                                          24
                          40
                          20
                           0
                               Adult Card           Paed Card            C-T Surg

2006
                                  Population to Practitioner ratio - SA (2006)

                                                           2

                          2


                         1.5
        Pop (millions)




                          1
                                                                                 0.4
                                      0.3
                         0.5


                          0
                               Adult Card          Paed Card             C-T Surg
                  Children per PC & Training resources: USA vs SA

                                                         877
       900
       800
       700
       600
       500
       400                                                                    USA
       300                                                                    SA
       200
       100    72.3                       45                       43
               *               19.3                                    5
         0
              < 18yrs     < 19yrs     < 18yrs/PC   < 19yrs/PC   Training
             (million)   (million)      (thou)       (thou)     Centers


USA census data 2000 *; Am Board of Cardiology > 1609 board certified PC in USA.   12
Solutions ???
   Problem of the need for more trained PC needs to
    be recognized. With that we need proper
    structured training programme with recognized
    training posts.
   Skills should be retained if working environment
    improved e.g. proper diagnostic and interventional
    modalities and adequate surgical facilities
    (Current expectation is that we deliver essential
    health care in the public service with limited
    resources).
   Better infrastructure for uninsured patients
    which are the majority.
                             References
1) American Academy of Paediatrics. Section on cardiology: Pediatrics1991;87:576-80.
2) Task Force 6: Pediatric cardiology. J Am Coll Cardiol.1994 Aug;24(2):322-8.
3) Guidelines for Pediatric Cardiology Diagnostic and Treatment centers.
    Pediatrics.1978;62:258-61.
4) Excert from Conference Program. Gunnar RM et al. 1994;24:275-328.
5) Task force 1: The Underserved. Haywood LJ et al. 1994;24:275-328.
6) Census 2001. Http://www.statssa.gov.za
7) Medical Aid Beneficiaries, 2002 (Health Systems Trust). Http://new.hst.org.za
8) Management of Grown Up Congenital Heart Disease. Deanfield et al. European Heart
    Journal. 2003;24:1035-1084.
9) Background to the Study Area: Soweto. Ramchander O. 2004. University of Pretoria.
10) Report of the Paediatric and Congenital Cardiac Services Review Group (UK). Dec 2003.
    Http://www.advisorybodies.doh.gov.uk.
11) Johannesburg’s Population. State of the Cities Report 2004. Http://www.joburg.org.za.
12) Chang R-K R et al. Resources, use, and regionalization of pediatric cardiac services. Curr
    Opin Cardiol 2003;18:1898-101.
13) Statistics South Africa. Live births 2005.
14) Abdulla R. What is the prevalence of CHD? Pediatr Cardiol 1997;18:268.
15) Kumar R. CHD Management in developing countries. Pediatr Cardiol 24:311,2003.
16)Task force 2: Academic Health Centers. King SB et al. JACC 1994;24:275-328.
                                     Medical Aid Pop & Pop:PC ratios

                 8
                                                                         6.9
                 7
                 6
Pop (millions)




                 5
                                  3.78                                                pop
                 4
                                                                                      Ratio
                 3
                                                1.71         1.53 1.53
                 2
                                                       0.9
                 1   0.48 0.24           0.42                                  0.53

                 0
                      Bloem      Pretoria/JHB      CT         Durban      Total


                                 Bloem – FS, ½ NC
                                 Pretoria/JHB – GT, NP, Mpumalanga, NW
                                 CT – WC, ½ NC, ½ EC
                                 Durban – KZN, ½ EC
                             No Adult Card per 100,000 Pop

                                                                 12
           12

           10

            8                                       6.5
                  (2006)
        No. 6

            4          2.8

            2                            1

            0
                  SA                UK           USA         Italy


Task Force 2: Academic Centres. JACC 1994;24:275-328; PC/100000, SA = 0.05
                 Cardiac Surgery10

    Significant lower mortality risk at institution if
     performing more than 300 cases/yr.
    Any centre providing open-heart surgery on young
     children should have 2 surgeons each performing
     40-50 open-heart procedures/yr.
    UK – 24 surgeons/60 million


    Report of the Paediatric & Congenital Cardiac Services Review Group, UK, 2003
Resource usage12

   Children with heart disease in the USA
    account for only 0.3% of all hospital
    admissions.
   They incur 3% all hospital costs in
    children !
Conclusions
   If the Report of the Paediatric &
    Congenital Cardiac Services Review Group
    (UK, 2003) where the ideal ratio of Pop:PC
    of 0.5:1 is accepted then the “Non-Med
    Aid Paying Population” of SA is grossly
    underserved.
   There is an urgent need to train or employ
    more Paediatric Cardiologists to meet
    these demands !
Interventional Cardiologists10

   To ensure competence Interventional
    Cardiologists should undertake a minimum
    of 40 procedures per year.
   Lead interventionalist should participate in
    at least 80 procedures per year.
   “Dual operator” concept should be
    encouraged to cement teamworking and
    continuing professional development.
    GUCH (grown-ups with CH)
            centres8
   The number of grown-up congenital heart diseas
    patients with individual lesions depends on the
    incidence at birth, early mortality in childhood as
    well as the rate of late death.
   A specialist unit should be located in an adult
    medical environment with multi-disciplinary
    specialist provision & should be associated with a
    strong paediatric cardiology groups. Each
    specialist centre should serve 5-10 m people !!!
  Management of transitions as
       the child grows10

  ??

                            Young            ADULT
Foetus   Neonate   Infant   person



                                16 yrs ?



                                           ???????
                                            GUCH
                                    Children per Province

                10
                 9
                 8
Pop (million)




                 7
                 6                                                   < 19 yrs
                 5                                                   < 15 yrs
                 4                                                   Total pop
                 3
                 2
                 1
                 0
                     EC


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Population of Gauteng11




SOWETO 3.5
 million ? 9                          1.9 m
                 0.224 m                                       0.1m



                                  3.2m ?
               0.13

                                              2.5 m
     0.18 m
                           0.1                         0.07m



                                                      Greater CT = 2.9 m
                           0.6m               0.6m    Greater Durban = 3.0 m
Introduction
   Children with heart disease have special needs that
    can only be met by doctors trained and who have
    experience in the management of paediatric
    cardiovascular disease.
   Training of subspecialists should be related to
    thoughtful assessment of future needs rather than
    programmatic or other considerations (4).
   We should be involved in helping society design the
    infrastructure and health care reform needed to
    expand care for our currently underserved
    population while maintaining appropriate services for
    patients requiring tertiary care (4).
Introduction
   1-3% children have congenital or acquired
    heart disease, the impact is large because of
    the length of anticipated life & the great
    differences in outcome related to the success
    of treatment (4).
                   A PC Centre
   A centre is an institution or closely affiliated group of
    facilities providing PC care (diagnosis, medical & surgical
    treatment) to a population with at least 30,000 live births
    per year (3)
   Staff needs are:
    - 1 PC per 75 catheterizations per year
           (TOTAL OF 150 caths per year)
      1 PC per 1000 patient visits per year
      Centers with large OPD, teaching, & research
      responsibilities need additional manpower
     - 2 PC surgeons per center (100 operations per year)
     - Nursing staff – surgical, ICU, ward nurses
     - Medical social workers – to deal with anxiety, fear &
       concerns of families.
                      SUMMARY
   Medical progress means that there are more patients for whom a
    medical or surgical intervention will be appropriate – this creates
    demands for the specialist.
   In SA we are in need of > 50 PC to keep up with the range of needs
    which include foetal medicine through to adults with congenital
    heart disease which are providing a growing caseload.
   To achieve 1 PC /1/2 million population we need a further 51 PC (UK
    suggestion)
   We need an initiative to improve the recruitment and retention of
    PC.
   A national training programme is needed for the future. In order to
    address the shortage by 2010 we need an intake of approx. 12
    trainees/year or 4 per recognised training centre per year (JHB,
    CT, Durban) !! As of June 2006 we have 9 in training country-wide.
Our Underserved Populations
   There is a maldistribution of health resources
    which are allocated along economic lines (5)
   Approximately ……million do not have
    medical aid cover.

								
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