Strengthening cardiac services in Faridabad District: A facility mapping exercise to explore implementation of a hub-and-spoke model

Material & Methods

This cross-sectional study was carried out in Faridabad district of North Indian State of Haryana in 2019-2020. Ethical clearance was obtained from the Institutional Ethics Committee of the All India Institute of Medical Sciences (AIIMS), New Delhi.

Results

Out of the total 236 health facilities identified in the district, 96 were excluded for various reasons (Fig. 1). Four hospitals were identified during the survey totalling to 144 eligible health facilities for mapping of services. We covered 109 health facilities (37 public including 2 Employees State Insurance Corporation hospitals and 72 private) with five refusals and 30 facilities had either closed or could not be located (Fig. 1).

Close

Fig. 1.

Flow chart of recruitment of hospitals and the mapping exercise. CMO, chief medical officer; NHM, national health mission; ENT, ear, nose & throat.

Export to PPT

The availability and distribution of different resources needed for the provision of cardiac care services in the district are shown in Table II. There were a total of 34 cardiologists and 13 cardiothoracic surgeons in the district, and except two cardiologists, all were in private sector. There were 529 and 114 intensive and coronary care unit beds, respectively in the district with less than 10 per cent being in the public sector. This came to 1.6 cardiologist and 5.4 coronary care unit beds per 100,000 population in the district. The district hospital was providing angioplasty facility in the public sector, while eight hospitals were doing so in the private sector. Even in the existing medical college, L5 facility was not being provided. The single public and six private facilities were providing this service round-the-clock.

Diagnostic facilities including ECG (9 facilities) and point-of-care tests were poorly available in the public sector, but available in most of private sector facilities. Thrombolytic agents, the first line of therapy for STEMI, were available in none of the public sector facilities and only in 10 out of 72 private facilities. Only 13 (18%) private facilities were covered under the government’s Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) scheme of health insurance. The ambulances in most of these facilities also lacked basic requirements for cardiac resuscitation such as oxygen cylinder (46%) or defibrillators (14.7%).

Results of the assessment of the current service provision is shown in Table III. Only one public facility at the district level (in a public-private partnership mode) was providing L5 STEMI-related services. Private facilities were providing a range of services with a substantial number functional at L5. Figure 2 depicts the geographical distribution of facilities, which were currently providing any kind of cardiac services as envisaged under the government guidelines. It shows heavier concentration in the central part of the district, which was urban with very poor rural penetration.

Close

Fig. 2.

Health facilities currently providing different levels of care as envisaged under the ministry guidelines. Map generated using QGIS software version 3.20 (Free Software Foundation Inc., Boston, USA).

Export to PPT

To develop a cardiac care plan for the district, we assessed the potential for each site to provide cardiac care by training or provision of additional medicines without addition of human resources or equipment. For example, all PHCs and HWCs could serve as potential L1 facilities as they do not need any ECG or MBBS doctor. The sub-district hospital at Ballabgarh could serve as L3 facility and the CHCs as L2 facility with the necessary strengthening. This is also applicable to the private sector, and we could potentially expand the network of facilities providing STEMI services. This would alter the geographical distribution of facilities as shown in Figure 3 and could greatly enhance the access to STEMI services, especially if arranged in a hub-and-spoke model. However, the centrally concentrated facilities are a challenge for this to ensure that cases from rural areas can access optimum and timely therapy.

Close

Fig. 3.

Distribution of all public and private health facilities in Faridabad district with potential for cardiac services. Map generated using QGIS software version 3.20 (Free Software Foundation Inc., Boston, USA).

Export to PPT

Discussion

This study describes the availability of health facilities to provide care for STEMI in the public as well as private sector in the district of Faridabad. Our study shows major private–public and rural-urban differentials in the provision and availability of STEMI care. Establishment of a hub-and-spoke model of care will need that these issues are addressed adequately. Most public health facilities can be strengthened to perform to their potential as there is availability of human resources and equipment, and can be used to develop a hub-and-spoke model of STEMI care. Only the district hospital had facilities for angiography, angioplasty and Coronary Care Unit (CCU) beds, that too outsourced to a private provider.

Unlike our study, the study from Kerala showed that 69.84 per cent of the population resided within half-an-hour travel distance from a percutaneous coronary intervention (PCI)-capable hospital¹⁶. The estimated travel time were derived using historical traffic data from Google navigation systems¹⁶. Of the 432 acute care hospitals in Kerala, 258 hospitals were offering thrombolytic services for STEMI and 104 had cardiac catheterization facility. Only 10 PCI-capable hospitals were in the public sector and 93 PCI-capable hospitals in the private sector with one being non-functional¹⁶. In Madhya Pradesh, 85 (75%) of ICUs were in private for-profit sector with an average availability of 2.5 beds per 100,000 population⁶. In South Africa, it was found that districts with preponderance of rural settings had among the lowest densities of health facilities providing cardiac care¹⁷. This predominant role of the private sector and lack of access in rural areas have been documented in earlier studies as well.

A positive feature of the Faridabad district is the high number of hospitals that are PCI capable, though in the private sector, that can be roped in for STEMI care management. Faridabad district faces limited access to thrombolysis services as public and most private L3 hospitals refrain from thrombolysis due to low confidence and perceived lack of support if something goes wrong. Hub-and-spoke model implementation could enhance confidence and promote service provision in the district.

It is evident in the ICMR STEMI ACT model initiated in eight districts of seven States, with CHCs, Civil hospitals, District hospitals as spoke and tertiary care facilities with cardiac services as a hub that health system-based intervention like capacity building and tele-ECG support had significantly improved the timely thrombolytic therapy rate in STEMI patients in spoke hospitals. The National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases including Stroke (NPCDCS) STEMI guidelines are adapting to include this model^18,19.

The medical college can be strengthened to serve a L5 facility. The challenge, therefore, is in developing the spokes (S1 and S2) and ensuring geographical spread. Another strength is that the road network is good and a national highway goes right through it around which the large hospitals are situated like veins of a leaf. This ensures that at least one L5 facility can be reached within 2 hours.

Evidence suggests that any STEMI care model in India should be able to improve the rate of fibrinolysis and reduce the time from symptom onset to first medical contact (FMC), and treatment. Ensuring the performance of ECGs at the point of FMC, will enable their prompt interpretation followed by initiation of bolus fibrinolytic therapy and subsequent transportation to the hub hospital²⁰. Such hub-and-spoke based implementation plan by the STEMI India for STEMI care²¹ is of critical importance.

In contrast with patients in the urban setting, individuals requiring care in rural areas, with suspected long transportation times to PCI-capable hospitals, should utilize the thrombolysis-first strategy with thrombolysis therapy, followed by catheterization and PCI, if indicated. With the strengthening of the public sector, this type of service delivery is certainly mobilizable through the government sector. Existing public L2 facilities can immediately be made functional by using telemedicine with the district hospital for ECG reading and training on providing thrombolysis. Some L1 facilities can also be easily upgraded to L2 level by making ECG machines available and linking them via tele-medicine for quicker diagnosis along with ensuring availability of essential medicines. Use of tele-electrocardiography support for primary care physicians has also been shown to reduce the treatment time in acute coronary syndromes²².

While public sector strengthening is critical, it should be noted that engagement with the private sector may be needed to bear the burden of treating acute coronary syndromes in a district at least initially. One year data from the National Intervention Council in India showed that “out of 30 lakhs expected STEMI cases in India, 12 lakhs underwent thrombolysis and only 57,512 patients received primary PCI”²³. While the Tamil Nadu (TN) model¹¹ has an extensive involvement of private sector hospitals, the Goa model¹³ is largely public sector based. Guidelines developed by NITI Aayog to provide health services in district hospitals for the provision of prevention and treatment services of non-communicable diseases (NCDs) related to cardiac, oncology and pulmonary services in Tier 2 & 3 cities encourage working through Public Private Partnership (PPP)²⁴. Even under the NPCDCS, many district hospitals are running cardiac care units (as in Faridabad). However, the experience of such efforts has not been fully evaluated. Another issue that comes up with the involvement of the private sector is the financial protection for those with an acute illness. Studies have shown that “uninsured CAD patients in India are younger with more risk factors, more likely to have multivessel disease and coronary stenting compared to those with government or private insurance”²⁵. A study from Kerala found that the mean cost of acute myocardial infarction management was US $480.4 (US $112.5–$1733), largely driven by in-hospital expenditures²⁶. Financial constraints and concerns of overtreatment in the private sector were among the important barriers to timely treatment initiation⁹. This calls for an integration of insurance schemes like Ayushman Bharat, which are an integral part of STEMI care as used in the TN model.

The present study also noted that ambulance services in these facilities were poor. Currently in the district, the free centralized ambulance services are mainly provided for obstetric and neonatal emergencies. There is a dire need to expand such services to include acute cardiac syndromes. Another area requiring attention is the monitoring and oversight of all intervention components under STEMI. Salve et al¹³ have described the implementation of the Government of Goa STEMI programme and found it functioning effectively due to its emphasis on the importance of regular monitoring. Over or under diagnosis and treatment affect quality of care, cost and outcome. Adequate and transparent audit and quality control assessment of all hub-and-spoke facilities, irrespective of their being private or public, should therefore be built into the system. Sufficient generation of awareness to promote judicious care-seeking, strengthening ambulance services and involving peripheral medical practitioners to reduce delays are other requirements for hub-and-spoke models to be successful²⁷.

In conclusion, we believe that adequate access to acute cardiac care is an important goal that district health systems should aim to achieve in near future and it can serve as a template for other acute conditions. This will require strengthening and training of the public health systems, active engagement of private sector as needed and coordination of hospitals, insurance schemes and ambulance services to provide optimum STEMI care.