The Ukrainian government is carrying out an initiative that aims to improve urgent cardiology quality and develop regional reperfusion networks to provide free stenting in emergency cases of acute myocardial infarction. The co-financing model will provide for the state procurement of the necessary angiography equipment and free-of-charge urgent stenting to patients with symptoms of acute myocardial infarction.
‘SAVING THE HEARTS OF UKRAINE’ INITIATIVE
For years, Ukraine has been 'the leader' among all European countries in terms of mortality rates from cardiovascular diseases. Over 40,000 people in Ukraine suffer from heart attacks each year and about 14% of heart attack patients die. Meanwhile, urgent stenting can prevent 21% of such deaths.
The European Society of Cardiology (ESC) estimated that in 2017 about 16,000 acute myocardial infarction patients in Ukraine needed emergency stenting. To put this in perspective, only 6,800 stent placement procedures were performed in 2016.
For the first time in the country's history, an international organization controlled the centralized procurement of stent systems and medical supplies to ensure that every patient who needs urgent angiography / stenting will receive such services FREE-OF-CHARGE.
The Government approved Resolution of the Cabinet of Ministers of Ukraine No.185 dated February 21, 2017 ‘On Approval of the Procedure and Conditions for the Provision of Subventions from the State Budget to Local Budgets for the Purchase of Angiography Equipment’ that provides for the purchase of stationary angiography equipment under the terms of co-financing from local budgets.
Our aim is to develop a network of regional reperfusion centers, which shall fundamentally change the system of urgent care for patients with acute myocardial infarction symptoms. However, the effective network functioning does not only depend on the availability of angiography equipment, but more importantly on the efficient coordinated work of all units – emergency first aid, reperfusion centers and cardiac care departments that ensure postoperative rehabilitation of patients.
THE REGIONAL REPERFUSION NETWORK IN UKRAINE
Each reperfusion center should ensure 24/7/365 care delivery (i.e. operate 24 hours a day, 7 days a week, 365 days a year). All patients who need urgent stenting should be provided with timely diagnosis, and free-of-charge effective treatment. According to the European clinical practice guidelines, to maximize the effect of the procedure and subsequent effective rehabilitation, urgent stenting should be performed within the first 2 hours from the initial patient contact with medical staff (or within 12 hours after the onset of symptoms).
As of mid-2017, there were 22 reperfusion centers in 18 oblasts of Ukraine. Regional reperfusion centers are located on the territory of the country so that it is possible to deliver a patient in time by an ambulance (or by car) during the first 2 hours. To ensure a full load and timely assistance, each reperfusion center should work for 0.3-1 million people in the 24/7/365 mode.
Reperfusion centers constitute only one component of the entire system. Therefore, it is important to regulate and coordinate work of all urgent care delivery services and ensure that all units have enough ECG systems and defibrillators, permanent telephone connection with reperfusion centers and cardiac care departments, and that healthcare professionals are trained in full compliance with modern clinical practice guidelines and treatment protocols.
The activities of reperfusion centers are aimed at, among other, reducing the mortality rates in patients with acute coronary syndrome. Today, in-hospital mortality rates from myocardial infarction in clinics that are already functioning as reperfusion centers decreased to 3-6%.
HOW TO GET FREE STENTING
Patients with signs and symptoms of acute myocardial infarction (AMI is the initial stage; the sharpest phase of AMI is called acute coronary syndrome with ST-segment elevation or STEMI) should seek treatment by calling 103 emergency number, especially in cases when types of transportation other than an ambulance are unavailable.
If AMI is confirmed in the first hours after the initial onset of symptoms, it is important to provide assistance within the first 12 hours (in some cases 24 hours) after the onset of symptoms – the sooner, the better. To maximize the effect of the procedure and to ensure subsequent effective rehabilitation, a patient has to be delivered to the RC within the first 2 hours from the initial contact with medical staff.
Then, a team of interventional cardiologists shall carry out a stenting procedure.
Stent placement (stenting) is a procedure for the placement of a small wire mesh tube (stent) within the blood vessel to help keep it open (mechanical removal of thrombus or atherosclerotic plaque) and restore blood flow.
A timely and effective reperfusion procedure usually ensures quick patient recovery, and, depending on the severity of one's condition, patients can be discharged from the RC in a few days and continue rehabilitation on an outpatient basis.
Why is stenting one of the current priorities for the Ukrainian government?
Acute myocardial infarction is the leading cause of death among all groups of cardiovascular diseases. According to statistics, cardiovascular diseases account for 65% of all disease-related deaths in Ukraine and almost 9 million adults develop symptoms of coronary heart disease, which means that at least 25% of the adult population suffers from coronary atherosclerosis. This causes about 50,000 myocardial infarction cases registered on an annual basis.
It is therefore logical that this issue is one of the key focuses of the professional community and at the very heart of public concerns. Clinical and public health efforts can significantly reduce mortality from CVD (by more than 50%!) in a short time through the use of advanced technology and implementation of the new health care system.
Who provides financing for the reperfusion network development in Ukraine?
Reperfusion Network Development in Ukraine is regulated by Resolution of the Cabinet of Ministers of Ukraine dated May 27, 2016 No. 418-p ‘On Establishment of ‘Regional Reperfusion Networks’. The document defines development of regional reperfusion networks as the high-priority task for the Government in line with the healthcare reforms and infrastructure development.
The Ministry of Health of Ukraine elaborates and approves all norms and regulations, as well as criteria for the development of regional reperfusion networks. The Ministry is also responsible for state procurement of necessary equipment and medical supplies.
Crown Agents – a reliable partner of the Ministry of Health of Ukraine – is an international development company that helps countries grow their economies, strengthen their health systems and improve financial management. In Ukraine, the company ensures transparency in the use of budget funds, as well as procurement quality control and supply chain management.
In July 2017, the Government approved Resolution of the Cabinet of Ministers of Ukraine ‘On Approval of the Procedure and Conditions for the Provision of Subventions from the State Budget to Local Budgets for the Purchase of Angiography Equipment’ that provides UAH 150 million for the purchase of stationary angiography equipment for 13 healthcare facilities to contribute to the expansion of regional reperfusion networks in Ukraine.
Are there any specialized courses in stenting for healthcare professionals?
The 6 week Specialized Training Courses in Stent Placement (stenting) are held five times a year at the National Scientific Center ‘M.D. Strazhesko Institute of Cardiology’ of the National Academy of Medical Sciences of Ukraine and Shupyk National Medical Academy of Postgraduate Education (NMAPE). Over the past decade, about 150 healthcare professionals have completed these courses and became qualified to to carry stenting.
What are the estimates for further Regional Reperfusion Network development?
In July 2017, the Cabinet of Ministers of Ukraine adopted Resolution ‘On Approval of the Procedure and Conditions for the Provision of Subventions from the State Budget to Local Budgets for the Purchase of Angiography Equipment’ that provides for development of regional reperfusion networks, which should fundamentally change the system of care for acute myocardial infarction patients. A total of UAH 150 million was allocated for this project. As many as 13 new reperfusion centers were planned to be opened by the end of 2018.
Are all reperfusion centers provided with stents?
In 2017, state procurement of 10,354 stents was funded by the 2016 national budget (compared to 7,179 stents in 2009). This year, stents were distributed under the new model – equitably in proportion to the number of urgent stenting procedures and based on full compliance of reperfusion centers with the criteria set out in Resolution of the Cabinet of Ministers of Ukraine No. 185 dated February 21, 2017 ‘On Approval of the Procedure and Conditions for the Provision of Subventions from the State Budget to Local Budgets for the Purchase of Angiography Equipment’.
According to estimates of the Ukrainian Association of Interventional Cardiology, about 25,000 patients out of over 40,000 people hospitalized with symptoms and signs of acute myocardial infarction required urgent stenting in 2017.