Poland remains a country with a high cardiovascular risk. We need comprehensive and systematic solutions in the field of cardiology, and the cardiology network should be an important element of them. Ad hoc and short-term activities do not give the expected result – prof. dr hab. n.med.Tomasz Hryniewiecki, National Consultant in Cardiology, Plenipotentiary Representative of the Minister of Health for the National Cardiovascular Disease Program for 2022-2032.
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The pilot of the cardiology network has been going on for almost a year. How would you complete its first stage?
At the initial stage, organizational and conceptual activities prevailed – it is generally necessary for the pilot to take off. As part of the initial conceptual work, the main task was to determine in detail the patient’s pathways by the family physician, depending on the suspected diagnosis. Please note that the pilot’s goal is to cover patients with four groups of diagnoses: heart failure, supraventricular and ventricular arrhythmias and conduction disorders, heart valve disease, as well as resistant and secondary arterial hypertension. There is no purposeful coronary heart disease in this therapeutic field, as solutions that provide high-quality medical care, such as an extensive network of hemodynamic laboratories or a slowly expanding SLE-infarction program, are already in place.
An important element of the patient’s path, of course, is the treatment, in addition to confirming or excluding the initial diagnosis of the primary care physician: not only pharmacological, but also surgical. Unfortunately, access to the treatment procedure remains limited, so it was important to clarify which center the patient in need of such treatment would eventually go to as part of the pilot program.
Another very important issue we focused on was convincing as many organizations as possible to participate in the pilot project. This has not always been easy, as the offer of pilot programs is now very wide, especially at the primary health care level. Therefore, it would be wise to rethink how to effectively encourage family physicians and other levels of the system to be involved – financial incentives do not always work. We should note only the financial advantages of participating in the pilot program of the cardiology network. In my opinion, these are, first of all, organizational improvements and substantial support received by family doctors. In case of doubt about the correct diagnosis, thanks to the participation of the pilot, they will be able to consult a cardiologist. It is also important for the patient to wait up to a month for a cardiological consultation.
How many institutions have expressed interest in the pilot?
In Mazovia, 89 primary care providers and 41 first-tier facilities, mainly specialized clinics and hospital departments in larger cities, have stated their readiness to participate in the pilot program. Of course, I hope that their number will increase, not only due to the expansion of the pilot program to new voivodships. We also hope that patients will look forward to the participation of their family physicians and their inclusion in the program.
If we want to improve the system and reduce the queues for cardiologists, we need more involvement of family doctors in the long-term care of cardiologists. Today, the waiting period for an appointment with a cardiologist is so long – although we do not differ from other European countries in their number – because cardiologists are mainly engaged in the treatment of patients who may be under the supervision of cardiologists. care of family doctors. A cardiologist should be a specialist who confirms the diagnosis, recommends a treatment regimen, and consults with the patient until the condition stabilizes.
At a time when health debt is rising as a result of the COVID-19 pandemic, more efficient use of the system’s human resources is even more important. We need to offer a solution that will reduce the time required to visit a specialist. It is not only a matter of shortening the queues, but also of identifying as soon as possible patients who are at high risk of cardiovascular disease and deserve specialist treatment, including surgery. We will not eliminate queues overnight, but we can catch patients who cannot or should not wait.
The pilot project also applied to the Pomorskie, Małopolskie, Łódzkie, Wielkopolskie and ąląskie voivodships. Why did you choose these special areas?
Many specialists, including already at the beginning of the pilot cardiology network. Members of the National Cardiology Council pointed out that the program should not only cover Mazovia. I agree with a similar assessment, so from the beginning I persuaded the representatives of the Ministry of Health to extend the program, and in the end they decided to do the same.
The choice fell on voivodships, which are relatively easy to identify as a strong, leading center that will coordinate the implementation of a pilot project in a particular area. In addition, we took into account the declarations of service providers: the highest interest in participating in the pilot test was in the five selected regions.
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What example of the patient’s path was suggested to the pilot of the cardiology network?
The patient’s journey begins in the family doctor’s office and is a first aid specialist who suspects a diagnosis, then checked by a cardiologist. In this context, it should be noted that up to 60 percent of family physicians’ requests for cardiological consultation refer to arterial hypertension, a disease that is relatively easy to diagnose and treat at the primary health level. This confirms the possibility that family doctors need more support from cardiologists. The patient can also be referred to a pilot project by a cardiologist at a clinic or department located far from centers with full diagnostic and therapeutic capabilities.
The next stage of the patient’s journey is a cardiological consultation. The cardiologist will check the diagnosis, decide to change the therapeutic procedure, send the patient for in-depth diagnosis and treatment (as well as higher level centers) and return the patient to the primary care facility. We did not deliberately set a strict schedule for the procedure to best suit the patient’s needs. The main thing is that the family doctor will offer you a cardiological consultation no later than 30 days after the initial diagnosis. Of course, we expect that many people will not need an in-depth diagnosis, but, for example, a modification of existing pharmacotherapy.
Patients with resistant and secondary hypertension are a special group of patients that we want to focus on during the pilot study. This is a population that has been receiving inappropriate pharmacological treatment for years without identifying the true cause of arterial hypertension. This is only a few percent of patients, but it is definitely worth including them in an effective diagnosis, because once the correct diagnosis is made, it is possible to implement such a therapy that will radically improve their health – including treatment.
Does the network plan to use KONS assumptions in any form?
Unfortunately, in the end, it was not possible to implement the CONS, which was developed by experts from the Polish Society of Cardiology. It was a concept that met the needs of a diverse group of patients with heart failure as a whole. It is possible that the Ministry of Health refused to implement the solutions used in KONS due to their complexity.
Heart failure has been included in the pilot program of the cardiology network as one of the four diagnoses, but this does not mean that all CONS solutions are included in the program. The proposals included in the pilot program will in fact be the first systemic measures in the field of heart failure – although, unlike CONS, the cardiology network will focus on THREE newly diagnosed patients. In addition, as part of the network, we focused on relatively simple solutions that, in my opinion, are easier to apply in real clinical practice. However, this does not preclude the inclusion of other elements of KONS in the network or the expansion of the pilot project with additional exploration if the program is not finally implemented.
One of the assumptions of the cardiology network is the integration of activities within it with existing programs, many of which – for example, POZ Plus – are carried out at the primary health level. In addition, the cardiology network is part of a larger project: the National Cardiovascular Disease Program, which is planned to run for 10 years. It should be added that the next edition of the WOBASZ survey will be launched later this year – the Multicenter Public Health Survey, first coordinated by the Institute of Cardiology in Warsaw in 2003. Its results will allow to more accurately determine the distribution of cardiovascular risk factors among the Polish population and thus plan specific steps, for example, in the field of prevention. This will be the first program to be implemented on such a scale, including the financial program, and it is absolutely necessary. Poland remains a country of high cardiovascular risk, we need comprehensive, systematic action in the field of cardiology, and the cardiology network should be an important element of them. Information about the incident clearly shows that immediate and short-term measures do not yield the expected results.
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