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EDITORIAL |
Austria
In the Art of War, Sun Tzu accented on knowing the terrain. To set up an open heart surgical program in the developing world, one has to start with the same principles.
THE PLACE
The type of hospital will influence the funding and priorities, and thus the mechanics and planning of setting up. The required facilities and amount of investment will also differ according to the nature of the open heart surgical (OHS) center (stand-alone, part of a heart center, unit of a franchise, or department in a general hospital). The geography and economics of the region, size of the population, state of the infrastructure, and communications facilities may be critical in the initial phase. If a new building is planned, it is better to be involved from the beginning and avoid the mistakes of many famous centers in the West, whose current incarnation is the result of local compromises. Try to have operating room (OR) space of at least 8 x 10 m plus anterooms for pump and patient preparation. If initial financial outlay is restricted, plan in a modular manner so that additional features can be added at a later time. If an old OR is refurbished for cardiac surgery, ensure enhanced power supply.1 Similarly, the intensive care unit (ICU) should be next to the OR to minimize transit time and avoid too much interaction with visitors or attendants, who are perpetually present in developing countries, another cultural difference from the West. Avoid Western hospital architecture of bygone eras, such as ICU towers. Try to have each ICU segment of 6 beds with adequate space around the bed (approximately 18 m2), including one isolation bed.2 It is advisable to acquire information on contemporary ergonomics of OR and ICU planning.
THE TEAM
A skeleton team requires 1 surgeon, 2 assistants, 2 nurses (1 scrub, 1 circulating), an anesthetist, and a perfusionist; but more people would soon be required to run a viable OHS program. A common trend is to acquire a large number of doctors. Often, more people means less work per person, which in turn affects expertise. A rule of thumb would be: up to 150 cases/year for 1 operator + 2 associates, 150–240 cases/year for 2 operators + 4 associates, 300–400 cases/year for 3 operators + 5 associates. More important is the quality of the staff and cohesion of the team, with hierarchal responsibilities allocated and accepted by all. The motivation of all personnel, their advancement prospects, and personal ambitions have to be considered. Even if the center grows into a prosperous practice, it might not be enough just to share profit; it may be expedient to share credit from the beginning. In a developing country, it is easier to get young doctors to join a new team, but at some stage, turnover of staff vs. long-term stability will have to be considered. It may be necessary to train more people than needed as some will leave and others will not come up to expectation. Former trainees, residents, and patients are the best public-relations assets. It is better to forge long-term loyalties from the beginning.
Physician’s assistants, nurse assistants, and medical students have been used to overcome manpower shortages and lower costs. Such substitutes work better when a program is up and running. In a general hospital setup, there may not be the scope for committed residents to assist, and one may have to carry on the program with residents on rotation from other departments. One might poach trained anesthetists, perfusionists, respiratory therapists, OR and ICU nurses from nearby established centers to start a program. Even then, to ensure a smooth first case, it is better to organize a dummy run in OR and ICU. One model has been to import an entire team to break-in local recruits. Availability of other specialists should be considered. When the OHS center is in a general hospital, that is usually not a problem; otherwise, collaboration of local specialists must be incorporated.
THE FIRST CASE
In primitive conditions, one could start with a small bedside 2-channel (electrocardiograph and invasive pressure) monitor that can also be used in the ICU. In 1977 in Kerala and in 1984 in New Delhi, the only respirator available to me was old Bird Mark IV. In Kerala, the heart-lung machine was fabricated by the local ironsmith. The pharmaceutical input of today’s fast-tracking was not available, but all other principles were utilized. Professor Victor in Madras in the 1970s adopted an even more bare-bones approach and refined the principles.3 Such extreme improvisations may not be necessary in the 21st century. Even with financial constraints, insist on acquiring a pump with at least 3 roller heads and provision for add-ons. Initially, the surgeon might be the only fully trained member of the team and may have to be in the ICU round the clock for bedside monitoring. This is the time to train other members of the team.4 What is lacked in gadgetry, can be partially offset by quality of manpower and care.
SUPPORT SERVICES AND SUPPLY CHAIN
Bulk purchase lowered the cost of imported disposables and devices in India, but it required enormous efforts to get import licenses and customs clearance, and created storage problems. As international manufacturers now have distributors in most major cities, it is easier today to acquire these products on an as-needed basis. However, many small towns in developing countries face delays in ordering or transport, which affect the supply chain and may lead to cancellation of cases. Initial minimum support services include access to 24-hour laboratory facilities, a blood bank, and sterilization facilities. Three-phase electrical supply linkage is critical, and a committed generator hooked to the cardiac OR is a must. Uninterrupted power supply is preferable but often prohibitively expensive for smaller units.
Setting up in the 21st century, one has to address the changed priorities, new technologies, easily available products and devices. Try to invest in low-maintenance-cost viable technologies of tomorrow with broad-based applications, rather than in high-end gizmos. At times, it is cheaper and more expedient to make a quantum leap at a later date than to proceed through the whole process of technology evolution. An appropriate and high-utilization rate of expensive equipment needs to be established. Lessons from the evolution and current shrinkage of cardiac surgical centers in the West will soon lead to more cautious expansion of surgical facilities in developing countries, while the investment may be directed to interventional facilities.
REFERRAL CHAIN
Referral depends on credibility. The problem is how to get the first 10 cases to show expertise and build a reputation. Neither a Western education and training in well-known centers nor all the relevant certificates will guarantee acceptance by the community. Affluent patients in any community tend to think that the grass is greener elsewhere; that trend is more pronounced in poorer countries. The perception of a care gap is widespread in developing countries. Besides availability and accessibility, affordability is a major determinant of acceptance by the populace in any poorer country. Most patients want continuity of care and they prefer cardiac surgeons who will remain in their community. Expectations from visiting foreign experts are different.
Payments to cardiologists or general practitioners are unfortunate realities in many developing countries. I never paid for referral and suffered slow initial growth in all 3 centers. Payment may initially facilitate referral, specially to private hospitals, but it may be regretted at a later date. Cardiac surgeons of tomorrow need to move into a secondary rather than the traditional tertiary role (general practitioner–cardiologist–cardiac surgeon). Even then, cardiac surgeons cannot emulate urologists who hold a critical stake in the entire value chain from diagnostics to patient work-up, treatment, and follow-up. Emerging new technology may enable even primary care physicians to organize all cardiac investigations and thus become the gatekeepers. Acquiring skill in imaging will give surgeons more control of the referral chain. A franchise relationship offers an initial boost in patient referral, similar to the temporary benefit of a famous foreign expert visiting to operate on a few patients.
CASE SELECTION
Start low key despite your wealth of experience. Inevitably, there will be a plethora of high-risk patients who should be avoided in the first 20 cases. The adequacy of different treatment options must be kept in mind. Thus, the worth of diverse treatments may be similar while vastly differing in approach, technology, cost, and the price to the patient. Many patients come so late that poor results are inevitable. In the initial phase, defer them. Sooner or later you will be compelled to offer in your repertoire something different from local competitors. Choose an area of innovation carefully, considering the weakest link in your chain and not your own extent of competence. Also, stay within the range of comprehension of local peers. Visiting foreign experts have an advantage here; operative outcomes do not affect the standing of visiting celebrities, whereas a single high-profile death or morbidity in the initial phase can ruin a local surgeon’s reputation.
WORKPLACE AMBIENCE
Written extensive protocols for a standardized approach must be developed from the beginning for all aspects of cardiac surgical care. These should include preoperative preparation, operative protocol, and postoperative care, and be available to all concerned. A standardized approach and written protocols tend to eliminate mistakes, particularly in the early training period of the team. An academic atmosphere from the beginning will enhance the quality of service, and it does not require any academic title or rank. Mistakes must be discussed to avoid recurrence. Monthly mortality and morbidity analysis is essential. In the absence of a database program, even entry in a simple Excel chart will help enormously. Patient education should be stressed from the first encounter. The best course lies in honest assessment of the odds, providing all the information that the patient and the family ask for, and avoiding compulsion.5 The range of service options and likely immediate and long-term outcomes should be detailed. After admission, patients need to be informed of their role in the process. Regular follow-up and continuity of care needs to be arranged.
COST OF SERVICE
Affordability is critical for most cardiac surgical patients in developing countries. Notwithstanding the legendary financial successes of a handful private clinics in India, China, Brazil, and Venezuela, most developing countries do not have efficient health insurance systems. Even where insurance systems exist, they operate mostly on a reimbursement basis. The prospective total hospital bill needs to be as close as possible to break-even in depressed economies. Surgeons may have to help in organizing finances for patients from the lower socioeconomic strata.5 Government funds, charities, and trusts may subsidize costs. Any measure in cost-containment is an additional boost to the viability of OHS centers. Despite the violation of advocated sterilization protocols, many surgeons in developing countries use re-sterilized stabilizers for minimally invasive coronary bypass, and pass on the cost-saving to their patients. The cost per operation is related to the number of operations performed per year. Break-even point approaches at 80–100 cases/year on the initial minimal outlay.6 The price to the patient needs to reflect this break-even level. While package deals for different categories of OHS are becoming the norm in many developing countries, provision must be made for those who require prolonged hospitalization and critical care. Thus, if projected early output is less than 100 cases/year, the financial drain will be enormous, and the skill of the team and patient outcome will be suboptimal. Past experience of other local centers may not help as even in developing countries, cardiac surgery is going to shrink in the near future. Financing for OHS centers is available from banks nowadays. However, the maximum repayment period is still relatively short, which puts a tremendous strain on the surgical team to meet the required return on investment.
QUALITY OF CARE
Survival of an OHS center depends on fulfilling the need of the community. It is not enough to deliver good quality care; it is equally important to let it be known. Detailed documentation and building a database with risk adjustment is essential from the very beginning. Periodic analyses and annual reports should be part of the regular interaction with local medical associations and other peers. Public awareness of available facilities may be transmitted through the press and other media. An internet website may facilitate the process. The perception of a care gap should be allayed by focusing on national standards, criteria, and guidelines, rather than Western parameters.
There is no magic recipe for success in setting up an OHS center in a developing country. Each community is unique; one has to address its unique features and needs, while planning the why, where, how, and when of the setup.
REFERENCES
This article has been cited by other articles:
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  A. T. Pezzella Open heart surgery in a developing country. Asian Cardiovasc Thorac Ann, August 1, 2006; 14(4): 355 - 356. [Full Text] [PDF]
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