Andersons pediatric cardiology 2264
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whereinsurancecoverorgovernmentsubsidyisscarce,thecostsincurredin
runningaprogramhavetobemetwithlargelybypaymentsrealizedfromthe
patientsthemselves.Anegativebalancesheetmaybelookedatindulgentlyby
theorganizationatthestart,butsustainedlossesarenotacceptableforlong.
Financialviabilityisthereforeacrucialconsiderationforasurgeonrunninga
pediatricprograminanLMIC,andthisoftengovernsthechoiceofpatientswho
wouldbeconsideredforsurgery.Becauseoftheseconsiderations,reducingcosts
ofcareiscentraltotheviabilityofaprogram.Table88.5presentsstrategiesfor
reductionofcostsofcardiaccatheterizationandTable88.6presentscostcontainmentstrategiesforpediatriccardiacsurgeryandintensivecare.
Table88.6
CostContainmentStrategiesinCardiacSurgeriesandIntensiveCare
Sourceof
Solutions
Expense
Reducingcost Maximizeinformationfrompreproceduralechocardiograms,prudentuseofcardiacmagnetic
of
resonanceimaging,computedtomography,anddiagnosticcatheterizationandangiography
preoperative
investigations
Costof
Greateruseofoff-pumpoperationswheneverfeasible(e.g.,cavopulmonaryshuntand
consumables
Fontan)
Resterilizationandreuseofcannulaeandtubing,meticulouslyavoidingwastageofsuture
material
Costof
Handcraftedconduitsinsteadofcommerciallyavailableconduits;UseofpericardiumofDacron
prosthetic
insteadofpolytetrafluoroethylenepatches;effortstorepairvalvesasfaraspossibleinsteadof
implants
replacingthem;Usinglowcostlocallymanufacturedproducts(e.g.,theTTKChitraheartvalve79)
Blood
Consciouslyminimizingtransfusionduringopenheartoperations
products
Delayed
Pragmaticcaseselectionstrategies,carefulpreoperativeassessmentforcomorbidities,ensuring
postoperative meticulousrepairwithnoresiduallesions,fasttrackingstrategiesinlow-riskcases
recovery
Acriticalelementinestablishinganewpediatricheartprograminvolves
pediatriccardiacintensivecare.InmostLMICs,pediatriccardiacintensivecare
isyettotakerootsasadistinctivediscipline.Asaresult,manymodelsexist.
Pediatricheartprogramsareoftenattachedtowell-establishedadultcardiology,
andcardiacsurgeryprogramsandpostoperativecareissometimesdeliveredina
commonsettingwithsharedspace,infrastructure,andpersonnel.Thismodelhas
severallimitationsbecauseofmajordifferencesincareofadultandpediatric
cardiacsurgicalpatients.68Astheproportionofoperatedinfantsandnewborns
increase,itisimperativetodesignateadedicatedspaceforpediatriccardiac
intensivecare.68
Anumberofspecificchallengesneedtobeovercomeindevelopinga
postoperativeunitinLMICenvironments,andadetailedblueprinthasbeen
publishedpreviously.69
Inadditiontoinfrastructure,equipment,andpersonnel,itisvitaltoestablish
robustsystemsandprotocolsforpatientassessmentandmonitoring,specific
proceduresandemergencies,communications,nursetraining,andinfection
control.
IntegratingPediatricHealthCareIntoUniversal
HealthCareModels
Universalhealthcoveragereferstotheexistenceofalegalmandateforuniversal
accesstohealthservicestogetherwithevidenceindicatingthatthevastmajority
ofthepopulationhasmeaningfulaccess.Theabilityofacountrytoprovide
universalhealthcareforallitscitizensisapowerfulindicatorofits
development.Becausecomprehensivepediatricheartcarethatseekstoaddress
allformsofpediatricheartdiseaseisextremelyresourceintensive,onlyselected
advancedeconomieswithrobusthealthsystemsandhighgrossdomesticproduct
canprovidecareforallcardiacconditionsthataffectchildren.Evenhere,itcan
bequitechallengingtoprovidecomprehensivecareforeverysinglechildwith
heartdiseaseregardlessofcomplexity.70
Thereareanumberofchallengeswhenitcomestodevelopingamodelthat
includespediatricheartdiseaseinuniversalhealthcarepackages.Theyare:
1.Competingpediatrichealthprioritiesthatrequirefewerresources
2.Themassiveburdenofpediatricheartdisease
3.Paucityofcomprehensivepediatricheartprogramsthatcandelivercosteffectivepediatriccareandtheirunfavorablegeographicdistribution
4.Awidespectrumofpossibilitiesresultsfromacombinationofalarge
varietyofindividualcongenitalheartdefectsandadditional
comorbidities.Thismakesitdifficulttodevelopaframeworkfor
prioritizinganddeliveringtreatmentunderuniversalhealthcare
packages.
ForLMICsitisnecessarytodevelopacomprehensivenationalplanfor
pediatricheartdiseasethatintegratesdevelopingnewprogramsthatare
distributedinaccordancewithgeographicneeds,capacitybuildinginall
domainsofpediatricheartcare,andapragmaticcoverageplanthatprioritizes
potentiallyseriousbutcorrectableconditions.70Recognizingthefactthatthis
couldtakesomeyearstoestablish,interimstrategiesthatinvolvemobilizingall
resources,publicandprivatetodelivercareshouldbeimplanted.
TrainingProgramstoSuittheNeedsofPediatric
HeartProgramsinLow-andMiddle-Income
Countries
Oneofthemajorobstaclestodeliveringcareforchildrenwithheartdiseasein
LMICsistheshortfallintrainedpersonnel.71Thereisasubstantialdeficiencyof
trainedpediatriccardiologists,cardiacsurgeons,anesthesiologists,and
intensivists.Thereisalsosevereshortfallofsupportingnursingandtechnical
staffsuchasperfusiontechnologists.Inthecomingyearsthisshortfallislikely
tointensifyfurtherasthedemandsfornewerpediatricheartprogramsgrow.
Untilrecently,mostdoctorsaspiringtobecomepediatriccardiologistsor
pediatriccardiacsurgeonssoughtoverseastraininginNorthAmerica,Europe,
Australia/NewZealand,Egypt,andSouthAfrica.Thisisnowbecoming
increasinglydifficult.Giventhevastdifferencesinthepatientprofileandhealth
careenvironments,trainingprogramsinadvancednationsdonotprepare
traineesforthechallengesinlow-resourceenvironments.Furthermore,a
substantialproportionoftraineesfromtheLMICsdonotreturntotheircountries
oforigin.Forthesereasonsitisimperativetoestablishrobusttrainingprograms
invariousdisciplinesofpediatriccardiaccareinLMICs.Althoughabeginning
hasbeenmadeinselectedinstitutionsinafewcountries(suchasIndia,Sri
Lanka,andMalaysia)toestablishtrainingprogramsinsomeofthedisciplines
(pediatriccardiology),muchneedstobedone.72–74Thesituationwithpediatric
cardiacsurgeryisespeciallyworrisomebecausethetrainingperiodislongand
perceptionsthatemploymentandcareeropportunitiesareunattractive.71There
needstobeaconcertedeffortonthepartofprofessionalbodiesandhealth
policymakerstowardcapacitybuildingtoaddressfuturerequirements.
QualityImprovementInitiativesforProgramsin
Low-andMiddle-IncomeCountries
