Infrastructure Availability for the Care of Congenital Heart Disease Patients and Its Influence on Case Volume, Complexity and Access Among Healthcare Institutions in 17 Middle-Income Countries

Abstract

The care for patients with congenital heart disease (CHD) is multi-disciplinary and resource intensive. There is limited information about the infrastructure available among programs that care for CHD patients in low and middle-income countries (LMIC). A survey covering the entire care-pathway for CHD, from initial assessment to inpatient care and outpatient follow-up, was administered to institutions participating in the International Quality Improvement Collaborative for Congenital Heart Disease (IQIC). Surgical case complexity-mix was collected from the IQIC registry and estimated surgical capacity requirement was based on population data. The statistical association of selected infrastructure with case volume, case-complexity and percentage of estimated case-burden actually treated, was analyzed. Thirty-seven healthcare institutions in seventeen countries with median annual surgical volume of 361 (41-3503) operations completed the survey. There was a median of two (1-16) operating room/s (OR), nine (2-80) intensive care unit (ICU) beds, three (1-20) cardiac surgeons, five (3-30) OR nurses, four (2-35) anesthesiologists, four (1-25) perfusionists, 28 (5-194) ICU nurses, six (0-30) cardiologists and three (1-15) interventional cardiologists. Higher surgical volume was associated with higher OR availability (p = 0.007), number of surgeons (p = 0.002), OR nurses (0.008), anesthesiologists (p = 0.04), perfusionists (p = 0.001), ICU nurses (p < 0.001), years of experience of the most senior surgeon (p = 0.03) or cardiologist (p = 0.05), and ICU bed capacity (p = 0.001). Location in an upper-middle income country (P = 0.04), OR availability (p = 0.02), and number of cardiologists (p = 0.004) were associated with performing a higher percentage of complex cases. This study demonstrates an overall deficit in the infrastructure available for the care of CHD patients among the participating institutions. While there is considerable variation across institutions surveyed, deficits in infrastructure that requires long-term investment like operating rooms, intensive care capacity, and availability of trained staff, are associated with reduced surgical capacity and access to CHD care.

Hospital Resources and Practice Patterns for Congenital Cardiac Surgery in Pakistan: A Nationwide Status Report

“…To estimate the CHD burden and new-case burden per center in Pakistan, we utilized the methodology described by Wamala et al 11 where they estimated an annual new-case burden of 7057 cases per center across five centers in 2019, assuming a uniform estimated annual incidence of six per 1,000 live births of moderate or severe CHD. Extrapolating from that, in 2022, Pakistan was estimated to have a total population of 235.824 million with a birth rate of 26.538 per 1000.…”

“…To estimate the new case burden, the methodology previously used by Wamala et al was utilized. 11 The approximate required surgical capacity was calculated using the estimated new case burden for moderate or severe CHD for the year 2022. This was calculated by multiplying the number of live births in 2022 (based on the most recently determined birthrate and the population of that year) by a uniform estimated annual incidence rate of six per 1,000 live births of moderate or severe CHD that will require intervention.…”

“…This was calculated by multiplying the number of live births in 2022 (based on the most recently determined birthrate and the population of that year) by a uniform estimated annual incidence rate of six per 1,000 live births of moderate or severe CHD that will require intervention. 1,11,12 Based on the number of centers known to provide CHD care, and assuming that they shared the surgical burden approximately equally, a calculation was made of how much of the national/regional surgical burden the participating programs would be expected to cover. Fisher exact tests were used to explore associations between categorical variables.…”

Benefit From a Humanitarian Pediatric Congenital Heart Surgery Program Over a 10-Year Period

“…[1][2][3] Due to the lack of trained personnel, equipment, and general health care infrastructure, as well as competing health problems like infectious diseases, low-and middle-income countries (LMIC) often struggle to provide adequate medical care for these patients. [4][5][6][7] In response, humanitarian programs have been established to enable congenital heart surgery for these patients 8,9 in the form of patient transfer from LMIC to high-income countries for treatment in specialized centers, 10,11 short-term visits by cardiovascular surgery teams from high-income countries to LMIC to treat patients with CHD in their home country, 12,13 or long-term projects aiming to establish independent structures in LMIC for local therapy of patients with CHD. 8,11,14,15 Surgical interventions in these programs have proven safe and effective in short-term evaluation, with perioperative mortality rates of 0% to 2% for mild CHD and 5% to 6% for moderate or severe CHD 10,13 and significant improvement in disability-adjusted life years.…”

“…1–3 Due to the lack of trained personnel, equipment, and general health care infrastructure, as well as competing health problems like infectious diseases, low- and middle-income countries (LMIC) often struggle to provide adequate medical care for these patients. 4–7…”