Transforming Bulgarian  Acute Coronary Syndrome Strategy in 2 years Bulgarian Cardiac Institute Slaveyko Djambazov, MD Chi...
Bulgaria <ul><li>Total area  – 110, 910 sq km </li></ul><ul><li>Population  – 7.604.687 </li></ul><ul><li>Transportation  ...
Regional Variations in CV Mortality S.Djambazov, P.Widimsky et al.  (pending World Cardiology Congress, China 2010) 1,42% ...
Trends in Cardiovascular Mortality source: NHIF 2007 *assumptions based on Czech registry Result: Extremely high absolute ...
Reasons <ul><li>Infrastructure   </li></ul><ul><ul><li>remarkable insufficiency of tertiary care across BG ( state respons...
The Project <ul><li>CZ  -  ( 10 m ln  of inhabitans )  </li></ul><ul><li>- 22 cathlabs  </li></ul><ul><li>- 20 with non st...
UniCardio Clinic Pleven First STEMI pt The rest of Brno team followed that policy and it became main focus of the Bulgaria...
Ferrari Widimsky Mauri Pezzano Grigorov Pleven Veliko Tarnovo BCI works closely with ESC
Procedures-Pleven-Oct 07-June 09 2008 2009 VT JM open Extension
Improvement of primary and secondary transportation –  compensating the insufficient state system Fleet of 18 own ambulanc...
BCI ambulances strategic positioning: 24/7 Coverage of app.80% of the territory and 65% of the population Next step: real-...
Scientific Activities <ul><li>International courses in invasive cardiology  </li></ul><ul><li>Attendance of courses abroad...
Overall capacity of BCI 5 500 1 121 PCIs 1 300 296 pPCIs 45 14 Cardiologists 5 (36) 1 (4) International teams 23 3 Trainee...
Procedures-BCI-Oct `07-May `09 2008 2009 VT JM VN For that period more than 550(!) lectures were delivered across the coun...
Further expansion 2009 - 2011 <ul><li>+2 Cardiac Clinics – CCU, Cathlab = 29,000 pts annual capacity </li></ul><ul><li>+1 ...
Further Expansion in place
International Cooperation
Difficulties <ul><li>Local expertise  – reasonably lacking (25/15) </li></ul><ul><li>Local opposition </li></ul><ul><ul><l...
Overcoming difficulties Till 09.2007- STEMI- 585 1st year of work- STEMI- 764 ACS in-hospital mortality rate reduction in ...
Stent for life Percentage of STEMI patients not treated by reperfusion (neither p-PCI, nor thrombolysis).   Mean in-hospit...
Stent for life Bulgaria <ul><li>132 pPCI per 1 mln (app. 17-19%) </li></ul><ul><li>Population per pPCI center – 850,000 </...
Considerations: <ul><li>PUBLIC INTEREST </li></ul><ul><li>GROUP INTEREST </li></ul><ul><li>PERSONAL INTEREST </li></ul><ul...
Healthcare is never immune to saturation Our goal is to achieve 400 pPCI per 1 mln in 3 years Is BCI for profit organizati...
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Transforming BG ACS strategy (version Sinaia)

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Transforming BG ACS strategy (version Sinaia)

  1. 1. Transforming Bulgarian Acute Coronary Syndrome Strategy in 2 years Bulgarian Cardiac Institute Slaveyko Djambazov, MD Chief Executive Officer E: s.djambazov.hq@comleague.com Sinaia, September, 2009
  2. 2. Bulgaria <ul><li>Total area – 110, 910 sq km </li></ul><ul><li>Population – 7.604.687 </li></ul><ul><li>Transportation – 204 airports; 40.231 km roadways (including 331 km expressways, crossing the country) </li></ul>500 km
  3. 3. Regional Variations in CV Mortality S.Djambazov, P.Widimsky et al. (pending World Cardiology Congress, China 2010) 1,42% 1,17% 0,94% 0,96% 0,90% 0,95% The relative risk of cardiovascular death is 27% higher in regions without tertiary cardiac care facilities when compared with regions having those
  4. 4. Trends in Cardiovascular Mortality source: NHIF 2007 *assumptions based on Czech registry Result: Extremely high absolute in-hospital ACS mortality – app. 15% source: NHIF, MoH, NSI 2007 168 TL/1mln 132 pPCI/1mln 700 STEMI/1mln* 3250 ACS/1mln*
  5. 5. Reasons <ul><li>Infrastructure </li></ul><ul><ul><li>remarkable insufficiency of tertiary care across BG ( state responsibility ) </li></ul></ul><ul><li>Reimbursement system </li></ul><ul><ul><li>does not support modern treatment </li></ul></ul><ul><li>Conservative training policy for young physicians </li></ul><ul><ul><li>practically no training and certification program was running ( although the Minister of Health was an int. cardiologist ) </li></ul></ul><ul><li>No incentives for transfer of acute patients </li></ul><ul><ul><li>financial oximoron </li></ul></ul><ul><li>Sofia </li></ul><ul><ul><li>retarded organization, although developed infrastructure </li></ul></ul>
  6. 6. The Project <ul><li>CZ - ( 10 m ln of inhabitans ) </li></ul><ul><li>- 22 cathlabs </li></ul><ul><li>- 20 with non stop service </li></ul><ul><li>7 of th em in Prague </li></ul><ul><li><90 min ECG - pPCI </li></ul><ul><li>Bulgaria (~8 mln inhabitants) </li></ul><ul><li>9 cathlabs; 7 in Sofia </li></ul><ul><li>no such measurement </li></ul>
  7. 7. UniCardio Clinic Pleven First STEMI pt The rest of Brno team followed that policy and it became main focus of the Bulgarian Cardiac Institute
  8. 8. Ferrari Widimsky Mauri Pezzano Grigorov Pleven Veliko Tarnovo BCI works closely with ESC
  9. 9. Procedures-Pleven-Oct 07-June 09 2008 2009 VT JM open Extension
  10. 10. Improvement of primary and secondary transportation – compensating the insufficient state system Fleet of 18 own ambulances for primary and secondary transportation Equipment for transportation of patients in cardiogenic shock, IABP, ventilation
  11. 11. BCI ambulances strategic positioning: 24/7 Coverage of app.80% of the territory and 65% of the population Next step: real-time ECG transfer via GSM network from ALL hospitals to BCI ambulances and BCI centers
  12. 12. Scientific Activities <ul><li>International courses in invasive cardiology </li></ul><ul><li>Attendance of courses abroad – Prague, Milano, Brno, Hamburg, Graz </li></ul><ul><li>Scientific production – more than 130 publications (Circulation, European Journal of Heart Failure), report on The World Cardiology Congress – Buenos Aires’08; Spring Cardiac Days </li></ul><ul><li>Own clinical trials (Heart Failure – 2,400 pts, Diabetes – 32,000 pts) </li></ul><ul><li>Prague 13 trial participation </li></ul><ul><li>Home care programs for patients with Heart Failure </li></ul>With Professor JP Bassand on board and intensive collaboration with Ludwighafen clinic (Germany) BCI established own research network - €1 mln/ year
  13. 13. Overall capacity of BCI 5 500 1 121 PCIs 1 300 296 pPCIs 45 14 Cardiologists 5 (36) 1 (4) International teams 23 3 Trainees in interventional cardiology 32 8 CCU beds 178 adj. 56 Cardiac hospital beds 21 000 6 377 Invasive procedures 140 000 60 000 Patients examned est. 2009 2008
  14. 14. Procedures-BCI-Oct `07-May `09 2008 2009 VT JM VN For that period more than 550(!) lectures were delivered across the country – own private budget
  15. 15. Further expansion 2009 - 2011 <ul><li>+2 Cardiac Clinics – CCU, Cathlab = 29,000 pts annual capacity </li></ul><ul><li>+1 Cardiac Surgery – 4 OT; 2,200 pts annual capacity (IT, CZ) </li></ul><ul><li>+11 Out-patient centers = 300,000 annual capacity </li></ul>Est. 60% 35% 33%
  16. 16. Further Expansion in place
  17. 17. International Cooperation
  18. 18. Difficulties <ul><li>Local expertise – reasonably lacking (25/15) </li></ul><ul><li>Local opposition </li></ul><ul><ul><li>Professional – ‘unorthodox lobbying’ and counter actions </li></ul></ul><ul><ul><li>Administrative – delays and hurdles by MoH – deviated understanding of healthcare and timelines </li></ul></ul><ul><li>Budget restriction – far below patients’ needs </li></ul><ul><li>Organizational failures – transfer across administrative units </li></ul>
  19. 19. Overcoming difficulties Till 09.2007- STEMI- 585 1st year of work- STEMI- 764 ACS in-hospital mortality rate reduction in Pleven for 1 year- 30% Unrivalled network capacity and ACS treatment organization Source: T . Vekov , M . Grigorov , O.Hlinomaz, L.Groch, J.Sitar, M.Rezek, S . Djambazov , B.Kuzmanov, V.Hristov, Journal of Biomedical and Clinical Research , volume 1, number 1; Any secrets? call centres BCI gets same reimbursement as state hospitals
  20. 20. Stent for life Percentage of STEMI patients not treated by reperfusion (neither p-PCI, nor thrombolysis). Mean in-hospital mortality of all STEMI patients (including those not treated by reperfusion) in countries with p-PCI dominance and thrombolysis dominance Source: P.Widimsky et al; Reperfusion therapy for ST-elevation acute myocardial infarction in Europe (not published data)
  21. 21. Stent for life Bulgaria <ul><li>132 pPCI per 1 mln (app. 17-19%) </li></ul><ul><li>Population per pPCI center – 850,000 </li></ul><ul><li>Hospitalized AMI – 1570 / 1 mln </li></ul><ul><li>Patient organizations </li></ul>
  22. 22. Considerations: <ul><li>PUBLIC INTEREST </li></ul><ul><li>GROUP INTEREST </li></ul><ul><li>PERSONAL INTEREST </li></ul><ul><li>Mortality rate </li></ul><ul><li>Complications rate </li></ul><ul><li>Success rate </li></ul><ul><li>Patient satisfaction </li></ul>
  23. 23. Healthcare is never immune to saturation Our goal is to achieve 400 pPCI per 1 mln in 3 years Is BCI for profit organization? Thank you! and also to all my colleagues and friends from Czech Republic and BCI family of hospitals

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