COST EFFECTIVENESS PROCEDURES IN CATHLAB

Isman Firdaus, MDFIHA, FAPSIC, FAsCC, FESC, FSCAI

Pusat Jantung NasionalHarapan kita Hospital, Jakarta

Case Number Cost (USD) Disease

UNIVERSAL HEALTH COVERAGE IN

INDONESIAJanuary-June 2014 (6 months)

Catastrophic Inpatient

735,827 case

232,010 134,821,667

172,303 55,600,810

138,779 55,600,810

70,584 23,232,524

56,033 23,192,193

53,948 12,951,916

12,170 5,277,811

2

Cardiac

Stroke

Kidney

Diabetes

Cancer

Thalassemia

HemophiliaMain NCD

6 billion USD/year

Cardiac Catheterization Lab in Indonesia (2016)

Batam

2210

7

1022 3

1

2

11

3

2

13

3

3

51

1

32

1

3

4

Number of Cardiac Catheterization LabTotal: 168 Cath Lab in 144 hospital

REFERRALSYSTEM

Primary Health Care

Primary Hospital

Regional Referral

1 District/City Hospital

Province Referral Hospital

Regional Referral Hospital

District/City Hospital

Primary Health Center

ClinicPhysicians

Private Practice

Midwives Private PracticeTertiary referral

(not available in all area)

Secondary referral

Primary referral

Primary Health Care

Primary Health Care

Regional Referral

2

Regional Referral

3

Regional Referral

4

Regional Referral

5

Taher, A. Regionalization Concept of Referral System and the Need of Specialist

Doctors. Dirjen BUK Ministry of Health Republic of Indonesia 2014

National Health Coverage Reimbursement Reimbursement depend on case severity and hospital level of services

PCI Tertiary Care

(Type A)Type B

Hospital

Minimum Reimbursement

3,414 USD 2,555 USD

Maximum Reimbursement

7,343 USD 3,476 USD

Permenkes 59/2014 on the Healthcare Standard Tariff, Universal Health Coverage/National Health Insurance (JKN)

Indonesia Case Based Groups (INA-CBGs), Social Security Management Agency (BPJS)

PCI: Percutaneous Coronary Intervention

PCI Reimbursement

National Cardiovascular Center Harapan Kita, Hospital

Six Cathlab in NCC Harapan Kita Hospital:3 Cathlab : Coronary and Emergency1 Cathlab : Vascular and Coronary1 Cathlab : Arrhythmia1 Cathlab : Congenital

7,750

8,060

8,854

9,1628,998

7,000

7,500

8,000

8,500

9,000

9,500

Non surgical Procedure

2011 2012 2013 2014 2015

Number of Cathlab Proceduresin NCC Harapan Kita Hospital

Top 10 Procedure in 2015 in NCC HK

No ICD-9 Description N

1 36.06.1 Insertion of coronary PTCA 1 sten 1.123

2 88.56 Coronary arteriography using two cath 1.091

3 36.06.2 Insertion of coronary PTCA 2 sten 717

4 36.12 Aortocoronary bypass of two coronary arteries 352

5 35.23 Replace/repair mv w/tissue 295

6 37.34 Ablasi chateter lesi 248

7 88.54 Combined R&L heart angiocardiography 209

8 35.53 Repair of ventricular septal defect with prosthesis 187

9 37.23 Combined R&L cardiac catheterization 175

10 36.06.3 Insertion of coronary PTCA 3 sten 166

Procedures in Cathlab is full and highly dependent on devices or implant

Cost effectiveness to follow the budget

In the past : The Budget will Follow the treatment or technique

Today in UHC:Every treatment or technique should follow the budget

Device or Implant

Rp….

Drugs and

Hospitalization

Rp……

Salary or

Remuneration

Rp….

3 Component

• Device/implant selection

• Medication

• Remuneration

No Strategy

Hospital Colaps

Device or Implant

Rp….

Drugs and

Hospitalization

Rp…..

Fee or Salary, Rp…

Cost Effectiveness

in Cathlab

Device or Implant

Rp….

Drugs and

Hospitalization

Rp…..

Fee or Salary, Rp…

Device or Implant

Rp….

Drugs and

Hospitalization

Rp…..

Fee or Salary, Rp…

STRATEGYProgram Policy

Physician - Remunerasi VS fee for service- Physician Champion- Teamwork

Implant and Device for UHCStandarization / e-Katalog

LoS Standarization in pts Hospitalization CP

Hospital Guidelines and Clinical Pathways

Every physician should follow CP

Drugs/Formularium for UHC Using National Formularium for UHC pts

Resume of hospitalization Complete and systematic resume list

Identifikasi program Unggulan /Income generating/ High Cost Exp

Identifikasi program unggulan yang di inginkan

Managerial Always use data for improvement program

Ex/ Sign in every pts for operator Alarm

Kelas 3 Kelas 2 Kelas 1

Ringan1 BMS, 1 balon, 1 wire 1 BMS, 1 balon, 1 wire 2 DES, 1 balon, 1 wire

Sedang2 DES, 1 balon, 1 wire 2 DES, 2 wire, 1 balon 2-3 DES, 2 wire, 2 balon

Berat1 BMS/1DES 1 BMS/1DES 1 BMS/1 DES

Ischemic Time

System Delay

Patient Delay

Hospital Performance

STEMI Standard of Care: Targeting Improvements in STEMI Care Continuum

Process Steps to Achieve Optimal Door to Balloon Times

Symptom awareness

and action

Fast EMR response

• Patient awareness

of MI risk factors and

symptoms

• Rapid <5 min

ambulance

response

Accessibility to 24hr PCI centers

Hospital Triage and Procedure

• 24 hr access

• Documented

transfer

• Early activation

• 15 min to return

to LV Function

EMR ECG interpretation

EMR Thrombolytics

infusion

• Remote ECG

• Interpretation

and diagnosis

by EMT or MD

consult

• Infusion started

in ambulance to

hospital

Patient Awareness/EMS Response

DiagnosticsHospital Triaging

Rapid Reperfusion

STEMI: ST – Elevation Myocardial Infarction

BUDGET

INNOVATION: Cathlab in Emergency

Definisi

Door to balloon time / door-to-device time is the time from the patient entered the

emergency room doors with Acute Coronary Syndrome until Coronary angioplasty is

done for the first time, or thrombus suction first attempt. Door to Balloon Time

targeted by the hospital is <90 minutes.

Numerator The number of ACS patients with Door to Balloon Time < 90 minutes

Denominator The number of ACS patients

86.11%82.76% 81.25%

85.71%

80%

60.00%

70.00%

80.00%

90.00%

100.00%

Januari Februari Maret April

Door to Balloon Time < 90 Menit

Capaian Target

Buying A New Car

Tips and Strategy in UHC

• Schedule engineering in cathlab

• Case load and targetting for every interventionist

• Implant and device standarization for UHC pts

• All cardiologist should support cathlab director who endorse by hospital management to succeed the business process in cathlab.

• Cardiologists’ willingness to move on from individual to team work.

• Team approach: Remember the famous quote, “There is no ‘I’ in team?” To harness the best of each individual, team members need to understand each other’s strengths, roles, responsibilities, and the scope of the task

• Re-used is not prohibited

Tips and Strategy in UHC