Paediatric Cardiology Human Resources

1
Paediatric Cardiology Human Resources targets,
developing retaining skills

• Antoinette Cilliers
• Paediatric Cardiology
• C.H. Baragwanath Hospital
• University of the WitwatersrandJohannesburg

2
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 ?

3
Public Service 9 Private Practice 13 Trainees 8
4
SA Data

• 1. Census 2001. Http//www.statssa.gov.za
• 2. Medical Aid Beneficiaries, 2002 (Health
  Systems Trust). Http//new.hst.org.za

5
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
8.8m/6.5m/2.4m
3.7m/3.2m/0.48
2.2m
2.7m/2.3m/0.4m
9.4m/8.2m/1.2m
0.8m/0.7m/0.16m
6.4m/5.8m/0.66
4.5m/3.2m/1,3m
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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
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Estimate of CHD Burden in SA
1,380.497 Live Births (LB) in 200513 Incidence of CHD lt 1 LB14
Children with CHD/yr 13,805
50 need invasive diagnostics12 6,903
40 need open heart surgery12 5,522
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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 Childrens Hospital in
  Boston.
• Vast areas of India do not have PC surgery.

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Expenditure
USA 199712 SA 2005 Total health expenditure US 8/ZAR 48 Billion
Paediatric cardiovascular care US 3.4/ ZAR 20.4 Billion US 1.5/ ZAR 9 billion 19 health budget!
Children born with CHD 32,000 14,000 (est)
Cost/pt US 106,250/ ZAR 637,500 ?
Mail Guardian online, 25 Feb 2005
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Paediatric Cardiologists required ?

• Each centre providing cardiac services should
  have a minimum of
• 1 PC per ½ million population served (0.51)
• (should have expertise in foetal and adult
  congenital cardiology)

Report of the Paediatric Congenital Cardiac
Services Review Group, UK, 2003 10
11
US 300 million with popPC ratio of
0.25million1PC ?
12
Bloem FS,½ NC Pretoria/JHB GT, NP,
Mpumalanga, NW CT WC, ½ NC, ½ EC Durban KZN,
½ EC
13
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14
2006
15

USA census data 2000 Am Board of Cardiology gt
1609 board certified PC in USA. 12
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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.

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References

• 1) American Academy of Paediatrics. Section on
  cardiology Pediatrics199187576-80.
• 2) Task Force 6 Pediatric cardiology. J Am Coll
  Cardiol.1994 Aug24(2)322-8.
• 3) Guidelines for Pediatric Cardiology Diagnostic
  and Treatment centers. Pediatrics.197862258-61.
• 4) Excert from Conference Program. Gunnar RM et
  al. 199424275-328.
• 5) Task force 1 The Underserved. Haywood LJ et
  al. 199424275-328.
• 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.
  2003241035-1084.
• 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) Johannesburgs 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 2003181898-101.
• 13) Statistics South Africa. Live births 2005.
• 14) Abdulla R. What is the prevalence of CHD?
  Pediatr Cardiol 199718268.
• 15) Kumar R. CHD Management in developing
  countries. Pediatr Cardiol 24311,2003.
• 16)Task force 2 Academic Health Centers. King SB
  et al. JACC 199424275-328.

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Bloem FS, ½ NC Pretoria/JHB GT, NP,
Mpumalanga, NW CT WC, ½ NC, ½ EC Durban KZN,
½ EC
19
(2006)
Task Force 2 Academic Centres. JACC
199424275-328 PC/100000, SA 0.05
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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
21
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 !

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Conclusions

• If the Report of the Paediatric Congenital
  Cardiac Services Review Group (UK, 2003) where
  the ideal ratio of PopPC of 0.51 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 !

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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.

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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 !!!

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Management of transitions as the child grows10
ADULT
Young person
??
Infant
Neonate
Foetus
16 yrs ?
???????
GUCH
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Population of Gauteng11
SOWETO 3.5 million ? 9
1.9 m
0.1m
0.224 m
3.2m ?
0.13
2.5 m
0.18 m
0.1
0.07m
Greater CT 2.9 m Greater Durban 3.0 m
0.6m
0.6m
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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).

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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).

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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.

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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 gt 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.

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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.