cost effectiveness procedures in cathlab: tips and tricks
TRANSCRIPT
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
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
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
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