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Clinical Perspective on Management of
Pediatric Cardiology & Congenital Heart Disease
in JKN Era
Oktavia Lilyasari National Cardiovascular Center Harapan Kita
Jakarta –Indonesia
Introduction
Congenital Heart Disease is still a major problem. Contributor for infant mortality 22/ 1000 live births
Global Prevalence 6-10 live births. Nearly 30-50% are critical
Indonesia: 9/10000 live births
At least 45,000 children per year
45% Requiring surgical or non surgical intervention in the first year of life. Aproximatelly 25,000 cases/year
Biro Pusat Statistik Indonesia. World Bank
(*) Harimurti GM – ASEAN Congress Cardiology 1997
Background Problems
Low Social-
economy status
Low
education
Lack of health
insurance
Delayed in
referring patient Rural areas
Limited
infrastructure
Limited human
resource Delayed
intervention
CHD Problem
Limited centre for training congenital cardiac care in Indonesia
Lack of awareness and knowledge amongst referring physicians
Congenital cardiac care is more demanding and more expensive
Low educated people seek advice from an unqualified person
Limited access to cardiac centre due to geographical condition of Indonesia archipelago
Increasing number of adult with uncorrected congenital heart disease (underdiagnosed)
PERKI pusat 2016
PERKANI Pusat 2016
PIKI 2016
Djer MM, Kardiologi intervensi pada penyakit jantung bawaan. Pidato Upacara Pengukuhan Guru Besar IKA-FKUI. 2016
Banda Aceh
11 / 6
SumUt
44/ 13
Pekanbaru
13 / 5
SumBar
25/ 3
Jambi
8 / 1
Palembang
10 / 3
Bengkulu
4 / 1 Tangerang
53 /13
Jawa Barat
110 / 24 Jawa Tengah
40 /14 Yogyakarta
25 /6 Bali
30 / 5
Batam
6 / 3
Jakarta
229/ 49
Balikpapan
8 / 3
Samarinda
9 / 3
Manado
12 / 4
Palu
2 / 1 Banjarmasin
5 / 3
Makassar
24 / 6
Jawa Timur
141 /31
Bangka
4 / 0
Bandar Lampung
6/ 3
Palangkaraya
4 / 1
Pontianak
5/ 0 Tarakan
1 / 0
Bontang
1 / 0
Gorontalo
3 / 0
Kendari
4 / 0 Ambon
2 / 0
Mataram
7 / 3
Jayapura
5 / 1
Tembagapura
1 / 0
Distribution of Cardiologist and Cath Lab in Indonesia, 2017
Biak
1/ 0
Kupang
2 / 0
Ternate
1 / 0
4
1
1
5 3+1*
7
2
1
1 25+3*
5
2
2
Distribution of Pediatric Cardiologist in Indonesia, mid
year 2018
1*
TOTAL
Cardiologist: 1150
Pediatric Cardiologist: 55 + 5*
Cath Lab: 203
Cardiac Surgical Center: 10
CHD cases
Pediatric
Cardiologist
Center of CHD care
National Cardiovascular Center Harapan Kita Jakarta
Dr Cipto Mangunkusumo General Hospital Jakarta
Dr Soetomo Hospital Surabaya
Dr Sardjito Hospital Yogyakarta
Jakarta Heart Center
Some other hospitals
Aproximately 85% of total Pediatric cardiac surgery / intervention
performed in JAKARTA
Pediatric and Congenital Heart Disease Services
in National Cardiovascular Center Harapan Kita
Jakarta-Indonesia
Pediatric and Congenital Heart Disease Team
10 Pediatric cardiologist
6 Pediatric cardiac surgeons
6 Pediatric cardiac intensivist
Facilities for Pediatric and CHD services
4 Outpatient Clinic (3 pediatric cardiologist clinics & 1
pediatric surgical clinic)
Emergency Department (sharing with adult cardiac EMG)
3 Operating theater
1 Biplane Cath-Lab
Pediatric and CHD ICU: 20 beds
Intermediate Ward: 18 beds, 36 nurses, BOR 80-85%
Pediatric Ward: 40 beds, 35 nurses (7 nurses per shift), BOR
80-90%
Outpatient Clinic 2016-2018
YEAR 2016 2017 2018
Number of Patients 17366 16460 13675
New
patient
Old
patient
87%
13%
Cardiac Catheterization
DIAGNOSTI
C
MODALITIES
Cardiac CT
SVC
AAO
LV
RUPV
PA
ASD
SVC
AAO
LV
ASD
RA
LA
RA LA
IVC MRI
Echocardiography
Transthorakal Echocardiography
(outpatient)
6178 6825
7474 7879
7514
6527
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
2013 2014 2015 2016 2017 2018
Cardiac CT and MRI for CHD
58
136 185
290
340
277 262
472
570 588 610
610
0
100
200
300
400
500
600
700
2013 2014 2015 2016 2017 2018
MRI MSCT
388 430
453 478
670
535
0
100
200
300
400
500
600
700
800
2013 2014 2015 2016 2017 2018
Invasive Diagnostic
Diagnostic cardiac catheterization
Non Surgical Intervention
142
206 238 223
390
488
0
100
200
300
400
500
600
2013 2014 2015 2016 2017 2018
Non-surgical Intervention
Non surgical intervention
Non surgical Intervetion No. Procedure 2016 2017 2018
1 PDA closure with device 113 117 106
2 ASD closure with device 47 120 170
3 VSD closure with device 10 47 46
4 PFO closure with device 8 3 3
5 BPV 36 38 53
6 BAV 1 3 3
7 BAS 14 3 10
8 Collateral Embolization 12 22 27
9 PDA stenting 3 6 5
10 PAV perforation 2 3 1
11 Temporary Pacemaker 8 8 8
12 Pericardiosentesis 7 11 0
PROBLEMS : LONG QUEUING
O SURGICAL PROCEDURE
- simple cases: up to 6 months
- High risk cases: up to 12 months
O Non SURGICAL PROCEDURE (by CATHETERIZATION )
- Diagnostic Catheterization up to 12 months
- Non surgical Intervention: up to 18 months
- PDA closure with device up to 2.5 years
PROBLEM: INSURANCE COVERAGE
Most of patient use National Universal Coverage
(BPJS),
other charity insurance; Yayasan Jantung
Indonesia, Peduli Kasih, etc
NOT ALL the expenses are covered by
insurance
The Hospital has to subsidize the remaining cost
INACBGs Classification
NON SURGICAL INTERVENTION
PDA DEVICE CLOSURE
No of cases queuing : 134 cases
Billing cost : Rp. 59.487.145
Insurance coverage : Rp.40.699.104
DEFISIT : - Rp. 18.788.041
NON SURGICAL INTERVENTION
VSD DEVICE CLOSURE
No of cases queuing : 156 cases
Billing cost : Rp. 118.301.802
Insurance coverage : Rp. 108.256.228
DEFISIT : - Rp. 10.045.574
NON SURGICAL INTERVENTION
ASD DEVICE CLOSURE
No of cases queuing : 152 cases
Billing cost : Rp. 93.520.221
Insurance coverage : Rp. 115.901.300
SURPLUS : Rp. 23.381.079
Summary
Congenital heart disease is still a major problem in
Indonesia
At least 25.000 patients per year with CHD need to be
intervened, but only 2000 cases can be done
Many obstacles are still exist due higher number of cases,
long queuing and limited coverage of Insurance
Suggestion
O New reclassification has to be implemented as
soon as possible
O Collaboration with other parties involved is still
needed
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