Pak Armed Forces Med J 2016, 6oSapp}SI750 IMPACT OF INTERNATIONAL COLLABORATION ON IMPROVING PEDIATRIC ‘CARDIAC SERVICES AT AFIC/NIHD, RAWALPINDI ‘Kamal Saleem, Willam M Novick, Syed Afzal Ahmed, Azhar Rashi, Shahab Naqvi, Itikhar Ahmed, Maad Ullah, == "Taig Rao, Dawood Kamal Metsoed, ltsar UT Hag roves of Canty Naor ose of Her Die, Ravan Past, “Unversy of Tense Heth ‘Seocer Coney orga TN USK ‘ABSTRACT Objective: ‘This study assessed the program by measuring Improvement in the surgical result of the instation ‘Stuy Design: Retrospective analytical stud. Place and Duration of Study: International Children’s heart Foundation (ICHF) in 2005 to 2008. Material and Methods: During 04 years (2005 to 2009), ICHE team mace 15 educational trips working tlongpide local team. The study compared surgical results of 03 years prior to the program (Era A) with Of Seats during the program (Era B) and 03 years (Era ©) after the program. Risk Adjasiment for Congenital Heart Surgery (RACIIS-1) scheme was used for risk adjustment. Mixed and risk adjusted in-hospital mortality along with standardized mortality ratio was calculated for each era. Chi square statistics were used aa teat of significance. Results: total of 4709 cases were assigned toa risk adjustment for congenital heart surgery (RACHS-1) risk Category. Cave numbers increased significantly across the thee tins periods (p < 0.001). RACHS-1 complexity increased from 176 to 216 by the end of “Era B” and to 207 in “Era C". Mixed mortality decreased ‘ienficantly trom 1203% in “Eta A” to 976%during “Era B” to7.01% in “Era C” (p-0.09) Mortality decreased. Significantly in each RACHS1 category. Standardized mortality ratio improved from 3.65 in ‘Era A" to 1.81 in “EraB” to131 during “Era C” (p< 0001), amounting to 127 deaths avoided among 3637 patients in7 yeas. Conclusion: Reduction in mixed and risk adjusted morality with improvement in standardized mortality ‘allo validated the usefulness ofthe program. Keywords: Pediatric cardiac services, Risk adjustment, Mortality. ares Ra a a Ga Coe A ESTHET INTRODUCTION There is a substantial number of children provide assistance in underdeveloped countries to achieve this target. With the help of these suffering from congenital heart diseases who belong to less privileged areas of the world and have no or limited access to good quality pediatric cardiac care facilites. This has led to increased concerned among individuals and organization to address the issue. Different approaches have been employed to address this problem but now it is emerging, that the best ‘way to tackle this problem is by identifying and training the local personals in their own circumstances and environments so that they ‘could work as a team and provide sustained ‘services based on local conditions, customs and availability of resources, Various organizations fand foundations from all over the world ‘organizations various pediatric cardiac centers in the developing countries have come up and shown significant improvement over a period of time! Armed Forces Institute of Cardiology / National Institute of Heart Diseases (AFIC / NIHD) is a tertiary care dedicated cardiac facility in Pakistan with a pediatric cardiac surgery program that needed improvement to meet the international standards, In this background AFIC / NID collaborated with International Children’s Heart Foundation (ICH) in 2005 to upgrade its pediatric cardiac services. The purpose of the program was to educate and train the local staff to eventually become independent with a view to provide sustained quality care to local pediatric ‘population with congenital heart diseases. This si76study was conducted to assess the efficacy of the program measured in terms of reduction in risk-adjusted in-hospital mortality based on RiskAdjustment for Congenital Heart Surgery (RACHS-1) risk stratification scheme’ MATERIAL AND METHODS Cardiac Program: AFIC / NIHD is a 250 bed tertiary care cardiac facility in Pakistan that caters for a huge population of pediatric cardiac patients, Professor William Micheal Novick who is the founder and medical director of ICHF visited AFIC / NIHD in June 2005 10 gather firsthand ‘knowledge about the Infrastructure and existing. facilities. He identified areas of strength and weaknesses and spelled out in detail how ICHF could provide help. After deliberation among the concemed authorities a plan for future interactions was formulated. The program was launched on 5th December 2005 with the first ICHF team visit and continued for 04 years. ICHF team visited AFIC / NIHD every third month, However, 6th tip, scheduled for September 2007 was cancelled due to unavoidable circumstances. ICHF gradually reduced the number of visiting team members from 12-15 initially to 48 in the last year to give more confidence and ‘opportunity to the local team members. ICHF team worked alongside local specialist with progressive delegation of responsibilities leading to eventual independence of local team in the last year of the program. The program ‘ended on 19th December 2009 after the 15th and. the last visit The program resulted in the development of all aspects of pediatric cardiac services including pediatric cardiology, pediatric cardiac surgery, pediatric anesthesia, intensive care, resource management and research development, Data: AFIC / NIHD data were obtained from the hospital database. All the patients operated for congenital heart disease from 5th December 2003 to 31 December 2012 who were less than 18 years were included. Study period was divided into 3 time periods: “Era A” was from st January 2003 to 4th December 2005 and corresponds to 03 years status prior to the initiation of the program. “Era B” was from 5th December 2005 to 19 December 2009 and Pak Armed Forces Med } 2016; 66(Suppl)S17680 represented 04 years of the program. “Era C” extends fom 20th December 2009 to Sst December 2012 and depicted 03 years status after the completion of the program. RACHS-1 {@) scheme was used to assign operations to 1 of 6 risk categories to adjust for case mix. When more than one procedure was peeiormed, cases ‘wore placed in the risk category corresponding to the highest risk procedure. Cases that could rot be placed in any RACHS4 category were excluded from the study. Any RACHS4 category with less than 10 cases in that category ‘was excluded from the analysis. For each time period and for each year within each time period, overall and risk adjusted in-hospital mortality was caleulated. Standardized mortality ratio (SMR) was calculated on the basis of predicted mortalities derived from Pediatric Cardiac Care Consortium (PCCC) data obtained from the original publication by Jenkins et al. Chi square test was used as a test of significance and a p value of less than 0105 ‘was considered significant. RESULTS During period from 5th December 2002 to 31st December 2012 a total of 4864 congenital heart surgeries were performed Out of these A715 could be assigned a RACHS1 category: Number of cases in category 5 and 6 were only 6 s0 as per protocol these cases were excliced from the study, leaving, 4709 cases for analysis. 712 (511%) out of these were combinedprocedures. The total number of cases in each Era along with mortality and standardized mortality ratio (SMR) is given in Table 1-Total number of cases increased from 357 2301 cases per year in “Era A” to 499 2 13.78 cases per year during “Era B” and this improvement was maintained in “Era C” with 491 £ 845 cases per year. This overall increase in work load was statistically highly significant ( < 0001) Distribution of cases according to RACHSH categories is given in table-2. Most of the procedures were performed in risk categories 1 and 2, representing, 68.72 % (0 = 3283) of the total, Category 1 cases decreased from 44.86% in “Era A” to 21.02 % in “Era C, ‘whereas category 3 cases increased from 18.47% to 2821%(table-2}. Category 2 and category 3 17cases that constitute 53.45% of the work load prior to program increased to 70.64% and 70.62% during and after the program respectively. The cases in category 2 remained fairly constant during the whole study period at around 35-50% The overall RACHS-1 score increased from 1.76 to 2.16 by the end of the Program in 2009 and 2.07 in 2012. The overall mixed mortality in “Era A” ‘was 12.03 + 3.29% per year that came down to 8.8% by the end of the program in 2009 with a ‘mean of 9.76 + 1.0 % per year for the whole “Era BY”. This improvement in mixed mortality was statistically significant (p< 0.03), The improving trend continued after the program when the ‘Table: Comparison of morality across each time period Pak Armed Forces Med J 2016; 66(Suppl)S176-80 shown in table-3. Combined mortality for category 2 and category 3 that constitute the bulk of workload dropped from 19.02% in “Era A’ to 10.9% in “Era B” and decreased further to 7.8% in Era C”, DISCUSSION Recently various strategies have been devised to improve pediatric cardiac services in developing countries. These strategies include children transfer to centers of excellence for treatment, arrangement of surgical trips to developing countries, and, more recently, the development of local programs. The purpose of developing local programs is to transfer the knowledge and skills to the local health fad Fab Fac ‘Number of Cases (n= 708) 1072 196 1681 ‘Observed Morality 329 12.05%) 155 975%) T.7.0ry Predicted mortlity™ 32% 539% 538% Standardized Mortality Ratio 36 181 131 * Predicted morality is derived from the original publication of Jenkins et al. “Table-2: Distribution of cases according to RACHES.1 categories. RACHS+eategory See ‘Number of eases aA En B Eat T 51 80%) 280 24.05%), 35 GLI) zi 375 HSB) S30(41.58%) 77 TARR) 3 BR TBAT) S80 22055) $68 BT) ts TR (L673) 106 631%) 1 G79) “Table. Comparison of morality related to RACHS-I categories RACHS Ea tra mac Predicted Category [Oba M_| SMR | ~Obs [SMR | Oba | SMR] mortality” 1 228% 57 a 47 3s Tas 04%, A Tae 5.0 3% 237 S1% 17a 35% 3. Fixes 191 T02% Tas 95% Loe 33% at 50% 2a SBE, 1a 262% 136 192% Obs. = Observed Mortal, SMI = Standardized Morality Ratio * Priced moval is derived (rom the orginal pblication of Jenks a" mixed mortality further came down to 701+ (0.11%per year in “Era C” (Table-1). SMR in “Era A” was 3.63 indicating an almost 3.5 fold increased risk for death compared to risk of death in PCCC datat. During “Era B” it came down to 181 and in “Era C” the risk was further reduced to SMR of 1.31 tablet, This amounts to 45 deaths avoided out of 1996 patients in “Era B” and 82 deaths avoided out of 1641 patients in “Era C”. This improvement in risk adjusted mortality was statistically highly significant (p< 0.001),Compared with the preprogram time period mortality decreased significantly in each RACHS-I category as professionals by repeated missions over a period of time so that the local team itself become independent and skilled enough to provide sustained long term quality care to their patients. This approach provides an ‘opportunity for care of children in their surroundings and local environment and is of course cost effective!s, International Children's Heart Foundation (ICHF) founded in 1994 is ‘one of few such organizations that had over a period of time provided assistance to various underdeveloped countries in this. regard. In order to assess and compare such programs, risk stratification of surgical data is necessary si78because evaluation based on only mixed ‘mortality rates can be erroneous®®. Various risk stratification models have been developed but two widely used are the “Aristotle Basic ‘Complexity score’? and the “RiskAdjustment for Congenital Heart Surgery (RACHS-1)" Both the systems were developedby consensus of opinion by experts. RACHS1 system isa classification scheme based on operations performed. 79 different types of operations are ‘grouped into six categories graded in order of increasing risk’, The predicted risk adjusted mortality depicted by these stratification models has been validated by various studies ®, We utilized RACHS-I scheme for the risk stratification and used PCCC data from original publication by Jenkins et al! to obtain predicted ‘mortalities and calculate SMR. Interactive collaboration with ICHF resulted in a significant reduction in mixed and risk adjusted mortality after congenital heart surgery at AFIC / NIHD. Overall mixed mortality prior to the program was high at 12.03%. Mortality decreased to 8.8% by the end of the program in 2009 and decreased further down to 7.12% in 2010, one year after the end of the program. This improvement continued in ‘ensuing years and come down further to 7.0% in 2012. This improvement was statistically significant (p = 0.03). The relatively high mortality before the program and significant improvement due to the impact of the program had previously been documented by our group as welli#¥6, Novick etal! also reported significant decrease in mixed mortality from 154% to 67% after first 10 years of ICHF humanitarian efforts across the world. A decrease in mortality occurred in every RACHS1I category at AFIC/ NIHD as shown table 3. When the overall risk adjusted mortal ‘was compared to the PCC! data a decrease in SMR from 3.56 tol 31in 2012 was noted which was a statistically significant improvement (p < 0.001), This improvement resulted in 127 additional lives saved among 3637 patients during 2006 to 2012. These extra mortalities saved were due to the effect of the program. However, Mortality by RACHS-1 level of complexity (table-3) is still somewhat higher Pak Armed Forces Med J 2016; 66(Suppl)S17680 than that seen in comparable studies in better established programs worldwide™?, Larrazabal LLA et alt published the result of another similar program conducted in Guatemala from 1997 to 2003 and reported 10.7% overall mixed mortality for the whole duration of the program. They showed a decreasing trend in each RACHS+ category so that by the end of the program the mortality rate decreased in category 1 to 05%, in category 2 to 7.4%, in category 3 to 23.3%, in category 4 to 25%. The {improvement shown in this program was very similar to what occurred at AFIC / NIHD. Similarly marked improvement was shown in Lithuania using the same principals of Jnowledge transfer. At the end of the program results in children older than 1 year were comparable to other centers in Europe with significant improvement in infants and neonates’, Novick et al” compared the first 05 years of their work with the later five years in Croatia and reported a significant decrease in mixed mortality from 16% to 8.0% in the later half with an overall mixed mortality of 11%. Their results were comparable to PCCC data in any RACHS-1 category. Similarly program in ‘Nicaragua'® showed sustained and meaningful improvement (Gur data show that the over-all work load also increased along with reduction in mortality. The annual number of cases was 357 + 23,01 before the program that increased to 499 + 1378 during the program and remained high at 463 cases in 2010 and improved to 632 cases in 2012. Complexity of the cases increased during the duration of the program and remained almost same after the program (table- 2). With the help of ICHF complex and high risk surgeries were performed with confidence and ever improving results. The increased in overall RACHS- I score from 176 to 219 in 5 year period was a big change. The distribution of Cases according to RACHS1 category (Table-2) revealed similar case mix as reported by various other studies. The local team was introduced to many new operative procedures like Right ventricular to pulmonary artery conduit placement, Off pump Bidirectional Glenn, ‘Extra Cardiac Fontan procedure, double’ flap VSD closure and Narwood 179procedure. Modified ultrafiltration and early extubation with fast track anesthesia were other techniques that helped in improving the result. It is beyond the scope of this study to identify specific factors that might have resulted in obvious improvement. We believe that few important steps made huge difference. One of the key step was the separation of pediatric intensive care unit from the adult intensive care unit in the very start of the program. Interested and keen individuals among doctors and nurses were identified, selected, trained and retained to work only for the pediatric unit. The emphasis was on a team approach rather than individual glory. Every effort was made to improve all the concerned departments and specialties. Improvement in surgical outcomes was consequential to improvement in the preoperative diagnosis, anesthesia, intensive care and perfusion. CONCLUSION It is important to appreciate that institutional support and funding should continue to pour in for this program to mature and provide its fullest benefits in future. In developing countries like Pakistan gradual deterioration in such programs due to lack of funds and institutional support can occur after the initial enthusiasm. Monitory constraints under these circumstances may play a very vital role. This aspect has also been highlighted by Wattenwyl R, when he shared his observations ten years after the initiation of congenital heart surgery in Guatemala”, We therefore conclude that such collaborative programs could be of great help in providing assistance to underdeveloped countries in improving their pediatric cardiac CONFLICT OF INTEREST This study has no conflict of interest to declare. Abstract and results of this study were accepted and presented in an oral presentationat the Intemational conference on Medical Education, organised by Association for Excellence in Medical Education (AEME) and_held on 07809 March 2014 at University ‘of Health Sciences (UHS) Lahore, Pakistan, No Pak Armed Forces Med J 2016; 6(Supp)}:S176-80 funding was received from any agency or institution, ACKNOWLEDGEMENT We are highly indebted to Professor William M. 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