Recommendations for starting a grown up congenital heart disease (GUCH) unit / Recomendações para a implantação de uma Unidade de Cardiopatias Congênitas no Adulto

AbstractDuring the last decades, advances in diagnosis and treatment of congenital heart disease have allowed many individuals to reach adulthood. Due mainly to the great diagnostic diversity and to the co-morbidities usually present in this age group, these patients demand assistance in a multidisciplinary facility if an adequate attention is aimed. In this paper we reviewed, based in the international literature and also on the authors’ experience, the structural conditions that should be available for these patients. We highlighted aspects like the facility characteristics, the criteria usually adopted for patient transfer from the paediatric setting, the composition of the medical and para- medical staff taking into account the specific problems, and also the model of outpatient and in-hospital assistance. We also emphasized the importance of patient data storage, the fundamental necessity of institutional support and also the compromise to offer professional training. The crucial relevance of clinical research is also approached, particularly the development of multicenter studies as an appropriate methodology for this heterogeneous patient population.

ResumoDurante as últimas décadas, os avanços verificados no diagnóstico e tratamento das cardiopatias congênitas têm permitido que muitos indivíduos cheguem à idade adulta. Devido principalmente à grande diversidade diagnóstica e também às comorbidades habitualmente presentes nesse grupo etário, esses pacientes necessitam ser atendidos numa unidade multidisciplinar, se o objetivo for proporcionar uma assistência adequada. Neste trabalho revisamos, com base na experiência dos autores e na literatura internacional, as condições estruturais que devem estar disponíveis para esses pacientes. Procuramos ressaltar aspectos como as características da unidade, o critério usualmente adotado para transferência desses pacientes da unidade pediátrica, a composição das equipes médica e paramédica levando em consideração os problemas específicos dos pacientes e também o modelo de assistência ambulatorial e hospitalar. Enfatizamos, ainda, a importância do armazenamento dos dados dos pacientes, a necessidade fundamental de apoio institucional e a importância de oferecer treinamento profissional. A relevância da pesquisa clínica é também abordada, particularmente a importância da confecção de estudos multicêntricos, como uma metodologia apropriada para essa heterogênea população de pacientes.

Recommendations for starting a grown up congenital heart disease (GUCH) unit.

During the last decades, advances in diagnosis and treatment of congenital heart disease have allowed many individuals to reach adulthood. Due mainly to the great diagnostic diversity and to the co-morbidities usually present in this age group, these patients demand assistance in a multidisciplinary facility if an adequate attention is aimed. In this paper we reviewed, based in the international literature and also on the authors' experience, the structural conditions that should be available for these patients. We highlighted aspects like the facility characteristics, the criteria usually adopted for patient transfer from the paediatric setting, the composition of the medical and para- medical staff taking into account the specific problems, and also the model of outpatient and in-hospital assistance. We also emphasized the importance of patient data storage, the fundamental necessity of institutional support and also the compromise to offer professional training. The crucial relevance of clinical research is also approached, particularly the development of multicenter studies as an appropriate methodology for this heterogeneous patient population.

Partnered care in the Bahamas: A model of advanced healthcare delivery for developing countries.

OBJECTIVE: To assess the delivery of advanced specialized medical care using The Partnered Care Model as a means of providing affordable access to all, irrespective of ability to pay. DESIGN AND METHODS: A retrospective analysis of all persons presenting to a specialized, private, cardiac unit, The Bahamas Interventional Cardiology Center (BICC), over an 8.5-year period from March 1996 to September 2004 was conducted. The Bahamas Heart Center's Discounted Service System had been applied since inception to all patients in three groups including insured patients billed at 100% of the fee schedule of The Medical Association of the Bahamas for the procedures performed, private self-pay and government patients billed at 75% and 50% respectively. Their respective distribution and contributions to total revenue was analyzed. A series of financial models were constructed taking into consideration variables that could influence the percentages of revenues collected from each sector and the number of individuals served RESULTS: One thousand five-hundred and forty-two patients received services in BICC over the 8.5 year period (56% males and 44% females age range: 0.25 - 96 years, with mean age of 55.7 years). One thousand eight-hundred and eighty-eight patient-procedures were performed, with 51% insured generating 69% total revenue, 18% Private producing 16% Revenue, and 31% Government patients generating 15%. Financial models were created to predict revenue behaviour in various scenarios. CONCLUSION: Partnered Care is a viable alternative for Governments (Ministries of Health) of developing countries to provide costly specialized healthcare to their populations at minimal expense and capital outlay. Partnered Care reduces the otherwise overwhelming burden of healthcare cost to governments, particularly in developing countries, by sharing the burden of care between the private, user and government sectors.

Partnered care in the Bahamas: A model of advanced healthcare delivery for developing countries / Cuidados mediante asociación en las bahamas: un modelo avanzado de prestación de servicios de salud Para los países en vías de desarrollo

OBJECTIVE: To assess the delivery of advanced specialized medical care using The Partnered Care Model as a means of providing affordable access to all, irrespective of ability to pay. DESIGN AND METHODS: A retrospective analysis of all persons presenting to a specialized, private, cardiac unit, The Bahamas Interventional Cardiology Center (BICC), over an 8.5-year period from March 1996 to September 2004 was conducted. The Bahamas Heart Center's Discounted Service System had been applied since inception to all patients in three groups including insured patients billed at 100of the fee schedule of The Medical Association of the Bahamas for the procedures performed, private self-pay and government patients billed at 75and 50respectively. Their respective distribution and contributions to total revenue was analyzed. A series of financial models were constructed taking into consideration variables that could influence the percentages of revenues collected from each sector and the number of individuals served RESULTS: One thousand five-hundred and forty-two patients received services in BICC over the 8.5 year period (56males and 44females age range: 0.25 - 96 years, with mean age of 55.7 years). One thousand eight-hundred and eighty-eight patient-procedures were performed, with 51insured generating 69total revenue, 18Private producing 16Revenue, and 31Government patients generating 15. Financial models were created to predict revenue behaviour in various scenarios. CONCLUSION: Partnered Care is a viable alternative for Governments (Ministries of Health) of developing countries to provide costly specialized healthcare to their populations at minimal expense and capital outlay. Partnered Care reduces the otherwise overwhelming burden of healthcare cost to governments, particularly in developing countries, by sharing the burden of care between the private, user and government sectors.

OBJETIVO: Evaluar la prestación de servicios médicos especializados avanzados, usando el modelo de cuidados mediante asociación, como medio de proporcionar acceso económico a todos, con independencia de su capacidad de pago. DISEÑO Y MÉTODOS: Se llevó a cabo un análisis retrospectivo de todas las personas que acudieron a una unidad privada de cardiología – The Bahamas Interventional Cardiology Center (BICC) – por un periodo del 8.5 años, a saber, de marzo de 1996 a septiembre de 2004. El sistema de servicio de descuentos del Centro Cardiológico de Bahamas, había sido aplicado desde el principio a todos los pacientes en tres grupos. Los mismos comprendían: los pacientes con seguro – quienes pagaban el 100% de la suma estipulada por la Asociación Médica de Bahamas para los procedimientos realizados, los pacientes privados auto-financiados, y los pacientes con asistencia gubernamental, que abonaban 75% y 50% respectivamente. Se analizó su distribución respectiva y sus contribuciones al ingreso total. Se construyó una serie de modelos financieros tomando en consideración las variables que podrían influir en los porcentajes de ingresos percibidos por cada sector así como el número de individuos atendidos. RESULTADOS: Mil quinientos cuarenta y dos pacientes recibieron servicios en el BICC por espacio de 8.5 años (56% hombres y 44% mujeres). El rango de edad: 0.25–96 años, con una edad media de 55.7 años). Se realizaron mil ochocientos ochenta y ocho procedimientos por los cuales el 51% constituido por los asegurados generó un ingreso total del 69%; el 18% formado por los privados produjo un ingreso del 17%; y el 31% representado por los pacientes gubernamentales generó una entrada del 15%. Se crearon modelos financieros a fin de predecir el comportamiento de los ingresos en diversos escenarios. CONCLUSIÓN: El cuidado mediante asociación es una alternativa viable, mediante la cual los gobiernos (los ministerios de salud) de los países en vías de desarrollo pueden brindar a sus respectivas poblaciones, servicios de salud especializados – que de otra forma serían costosos – con costos y desembolso de capital mínimos. Los cuidados mediante asociación reducen la carga del costo de la atención a la salud para los gobiernos – carga que de otra forma resultaría realmente abrumadora, especialmente en los países en vías de desarrollo. Esto se logra mediante el procedimiento de compartir la carga de los cuidados médicos entre los tres sectores referidos – el de los usuarios, el privado, y el gubernamental.