[Reprinted: Jamaica Observer, 9-27-2020]
Health care opportunities for Jamaica in the post-COVID-19 world
So far in this series the authors drs. Edwards and Madu, have been outlining the issues and problems facing health care in Jamaica while proffering general, paradigmatic solutions. In part 6, they plan to start discussing specific opportunities and strategies for transformation in the health care sector, with a focus on centres of excellence.
We will attempt to make specific, predictive recommendations on critical areas that not only provide much-needed answers and will thus solve health care challenges, but which will also have immediate and long-term impact on economic growth for Jamaica and will improve the quality of life for citizens. Some of our prescriptions may have been briefly discussed in our earlier articles but we will now discuss them with some level of granularity.
Centres of excellence (COE) in health care
The development of hospitals and institutes that focus care on a particular area or specialty is certainly not a new idea. Women’s health and paediatrics are areas within medicine which have for a long time been recognised as benefiting from specialised focus. Over the past decades, within individual hospitals, specialty services have been developed. This has been a result of the explosion in breadth and depth of specialised medical knowledge so much so that it is no longer possible to be a “Jack of all trades”, and a recognition that true mastery and excellence in patient care requires deep and focused knowledge in a smaller area than was possible 50 years ago or even 10 years ago.
This is not to discount the need for the general surgeon, general internist or family practitioner who needs a wide breath of general knowledge and experience. In areas in which manpower or specialist services are not readily available, generalist physicians and surgeons still have a wide breadth of practice. However, in 2020 we realise that heart attacks, for example, are much better managed by cardiologists than internists, obstetricians should achieve better outcomes delivering babies as opposed to family practitioners, and if your child needs surgery a paediatric surgeon may be a better choice than a general surgeon.
This idea of focus can be expanded beyond the practitioner level to an institutional or system level. The mechanism of delivery and resource needs of different areas of medicine are not the same, and in fact may conflict with each other.
A general hospital must often balance competing priorities which can result in suboptimal or inefficient delivery of services, particularly in environments of scarcity and manpower shortage. An example of this compromise is the intensive care unit (ICU). In our context, intensive care beds are limited and shared by all services in a general hospital. When the ICU in a general hospital is full, surgical services that require post-operative intensive care such as neurosurgical and cardiac operations must be postponed or cancelled. During our training overseas, a common finding was academic hospitals with multi-floor ICU towers in which various sub-specialities had their own floors with dedicated ICU beds.
Having specialty focus at the hospital level results in the ability to target the resources of a facility in as cost-effective/efficient method as possible. It allows for specialised pathways, lowers the need for resources and human capital, and usually results in high- value focused care.
Physicians and nurses are more easily able to gain experience and improve skills in a high-volume, single-specialty environment. The centre of excellence concept simply extends these benefits to an institutional level. These institutions have as their core mission, delivering high-value care in a particular area of medicine. Examples worldwide would include MD Anderson Cancer Center or Memorial Sloan Kettering Cancer Center in the United States, specifically focused on cancer care; and the National Hospital for Neurology and Neurosurgery in England. These centres can function at a national or regional level.
In the United States for example, the treatment of stroke, heart attack or trauma at a city level is usually performed at a few hospitals that have demonstrated the ability to manage these conditions quickly, efficiently and effectively. The idea that every hospital is equally capable of dealing with the complexities of every ailment is antiquated, wrong and misguided and often leads to suboptimal care with less than desirable outcomes.
Centre of excellence for cardiovascular care in Jamaica
There are areas of medicine that are probably better suited to the centre of excellence approach, especially in Jamaica. Cardiovascular disease is one such area. Cardiovascular diseases are a major cause of death and disability in Jamaica.
The Jamaican population is getting older and thus more predisposed to cardiovascular diseases. About 20 to 30 per cent of the Jamaican adult population is hypertensive, about 30 per cent of men and 60 per cent of women are overweight or obese, and as many as one in six adults are thought to be afflicted with diabetes. These risk factors promote cardiovascular diseases. While risk factor modifications can help in staving off cardiovascular diseases, risk factor modification will not lead to eradication of cardiovascular diseases.
Cardiovascular diseases are largely treatable when the appropriate infrastructure and expertise exist. Sudden events like heart attacks and cardiac arrests are unpredictable and require immediate and appropriate attention in the right setting, otherwise, the likely outcome is death or major disability.
While there are a good number of cardiologists currently in practice in Jamaica, there is very little cohesion in the management of acute cardiac emergencies. Currently, reliable, and appropriate 24/7 coverage for cardiovascular emergencies is not readily available to many. Ideally, there should be an established mechanism for prompt intervention in cardiac emergencies islandwide by facilitating movement of acute and critical cardiac emergencies to a centre of excellence equipped with the resources, expertise, and personnel to attend to those cases.
The Heart Institute of the Caribbean (HIC) is a leader in focused and a centre of excellence for cardiovascular care. Patients with heart attacks can expect physician attention within 10 to 15 minutes, and rapid opening of the blocked heart vessels usually within 90 minutes of arrival at HIC.
Since opening our doors we have driven and noted remarkable improvement in emergency cardiovascular care delivery in Jamaica with respect to access, timeliness, quality, and outcome. Heart attack treatment can be quite time-sensitive and having a heart hospital with an emergency room focused on cardiac patients has made a large difference in patient management and outcome.
Patients do not have to compete with other critically ill patients who, while quite sick, do not have time-dependent outcomes. We have been able to greatly improve the efficiency of both invasive and non-invasive testing and critical care by using a systems approach. While cardiac patients in other hospitals routinely have to compete for ICU bed spaces with other critical but non-cardiac patients, at HIC we have capacity for 11 ICU beds dedicated solely to heart patients as well as a dedicated cardiac surgery suite and interventional suite, ensuring that heart attack and other cardiac patients are readily accommodated and attended to 24/7.
A full complement of cardiovascular specialists and cardiothoracic surgeons are on full-time staff and complemented by a cadre of professionals in specialised services available round the clock for optimal cardiovascular care of patients. This is the beauty of a centre of excellence concept. Experienced cardiac nurses and technicians perform lower-skilled, non-physician-dependent work that allows physicians to tackle higher-value work more appropriate to their skills and training.
Having cardiac nurses and cardiovascular technicians who are cross-trained in all areas of cardiac treatment means that we can provide reliable, 24-hour availability for diagnostic and treatment needs of cardiovascular patients with consistently excellent outcomes. Our system has also allowed the aggregation of the best infrastructure, equipment and specialists in all areas of cardiovascular disease care in one facility and within immediate access, ensuring the best possible opportunity for recovery and survival for patients with heart attacks and other heart-related ailments. This is more imperative now in the COVID-19 era with heart patients more at risk for COVID-19 or COVID-19-related complications, thus needing even more now to be cared for in a specialty hospital rather than a general purpose hospital where the risk of exposure is increased.
Another area in which a centre of excellence approach may be useful in the Jamaican context would be that of trauma. Jamaica has a high level of trauma which imposes unique stresses on our tertiary care hospitals.
Routine surgical and orthopaedic cases are often cancelled or postponed due to traumatic emergencies. Intensive care unit (ICU) space is often not available for non-emergent high-risk surgery or for medical emergencies. The Kingston Public Hospital (KPH) currently serves as the “unofficial” trauma centre, but at great cost to its routine operations and general patient care. In the current COVID-19 pandemic, several countries have created temporary COVID-19 hospitals which serve to concentrate resources on the care of the COVID-19 patient. This has benefits in terms of focusing scarce resources, lowering the impact on non-COVID-19 care, and potentially lowering the risk of spread of infection to non-COVID-19 patients.
Currently in Jamaica we have seen the beginnings of a centre of excellence approach. Other examples include the Victoria Jubilee Hospital, Bustamante Hospital for Children and the National Chest Hospital, which have been longstanding leaders in health care for women, children, and pulmonary illnesses, respectively.
Radiology is also an area in which there has been expansion of the free-standing centre model, particularly in the private health care market. This has allowed rapid spread, particularly of ultrasound and CT scanning services, to almost all regions of our country.
There is, however, room for consolidation of these services to create more robust centres of excellence that allow for aggregation of most radiology services under one roof, with multiple radiologists participating in the same programmes and bringing a diverse skill set that may not be readily available in solo practices.
This expansion of health care centres has demonstrated benefits in terms of access to care but we also need to think of the quality of care that is being delivered. How do we ensure that appropriate and uniform standards are being maintained with respect to training and experience of providers, quality, and outcome for patients? What is the point at which duplication of services results in such fragmentation that we do not achieve the efficiencies that could be attained from economies of scale? What of necessary high-cost services that do not easily allow a return on investment in the private health care market but which would benefit from a centre of excellence approach, for example, trauma services and infectious diseases? How do we leverage the capacity within the private health care ecosystem to ensure a broader coverage for all Jamaicans, including those with limited financial means? How do we redirect public sector spending on health care to achieve more value for taxpayers rather than dissipating resources in multiple, underfunded and inefficient health care projects incapable of achieving optimal results? How does the health care leadership within the Government recognise and embrace a more progressive role as an enabler of advances that drive measurable quality in the health care space rather than embody the perception as an obstructionist organ? What services have been successful in other countries using a centre of excellence approach, for example, stroke treatment, pain management, renal care, mental health, elder care, oncology, infectious diseases? We will be addressing some of these in subsequent articles.
To fully recognise the benefits of this approach will require collaboration of all stakeholders in our health care ecosystem. In the interest of national development and citizen welfare, the health care leadership within the Government must recognise and support advances in health care delivery that will improve outcomes and quality of life for Jamaicans.
Jamaicans deserve the benefit of those advances. We need to identify in the Jamaican context what services are best provided in a general tertiary or secondary hospital and what services would benefit from a more focused approach with regional or national centres of excellence.
About the authors: Dr Ernest Madu, MD, FACC, and Dr Paul Edwards, MD, FACC are Consultant Cardiologists at Heart Institute of the Caribbean (HIC) and HIC Heart Hospital, Kingston, Jamaica