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 A L A C NZ a UK li a Z da an TA di M DR M M ra na iw n- In SA TO st Ta no Ca Au SA 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 A CT an m l o ta R th oe rb BA To so Bl Du B/ Le H + /J et FS Pr 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 RA FS A CT an S rb A tal /B Du To B /JH ria eto Pr 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 FS po C ZN W P al C G N W m N po K pu m M Li 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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