© 2002 European Society of Cardiology
Management of heart failure patients in Poland
a II Department of Valvular heart Disease, Stefan Cardinal Wyszynski National Institute of Cardiology, Alpejska str.42, 04-828 Warszawa, Poland
b Department of Epidemiology and Prevention of Cardiovascular Diseases, Stefan Cardinal Wyszynski National Institute of Cardiology, Alpejska str.42, 04-828 Warszawa, Poland
* Corresponding author. Tel.: +48-22-8154216; fax: +48-22-8153298. E-mail address: jkorewicki{at}ikard.waw.pl, plmncwwa{at}ikard.waw.pl
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Abstract |
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 Top Abstract 1. Introduction and...2. Organisation of health...3. Access to diagnostic...4. Diagnosis and treatment...5. ConclusionsReferences |
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Over the next 10 years, heart failure is likely to become a medical and sociological problem as a result of improved treatment of ischaemic heart disease and hypertension. At present, in Poland, there are only 50% of the cardiological or cardiac surgery procedures (coronarography, PTCA, CABG, surgery of congenital or acquired heart disease) performed compared to Western Europe. After being registered on the waiting list, it can take anything between 3 and 12 months before the procedure is done. Patients with heart failure have diagnostic tests such as ECG, chest X-ray, and biochemical evaluation performed regardless of the level of care. When echocardiography, exercise testing or Holter monitoring is required, it is done at specialist or reference specialist facilities with a waiting time of approximately 1–3 months. Pharmaceutical treatment of CHF is also inadequate. ACE inhibitors are prescribed in approximately 68% of patients. The average prescribed dosage is far from that recommended in guidelines. Only 18–29% of patients with HF are on beta blockers. The improvement of cardiological care standards depends mainly on the financial resources of State Health System Agencies.
Key Words: Heart failure • Management • Health care services
Received October 11, 2000; Revised July 20, 2001; Accepted September 10, 2001
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1. Introduction and epidemiological data |
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TopAbstract1. Introduction and...2. Organisation of health...3. Access to diagnostic...4. Diagnosis and treatment...5. ConclusionsReferences |
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In the near future, epidemiologists expect a rise in heart failure incidence rate in Poland. This hypothesis is based on the demographic prognosis, which predicts increased ageing of the Polish population. As heart failure is tightly associated with average population age, it will result in an ascent in the morbidity of heart failure. In Poland, the mean expected survival time differs significantly by approximately 4–5 years from that observed in the other Western European countries and ranges from approximately 68 years for men up to 76 years for women. Nevertheless, ageing is not the only factor influencing morbidity [1]. Simultaneous advances in medicine along with improvement in the management of patients with cardiovascular diseases, namely ischaemic heart disease and hypertension, will result in a further rise in this parameter, and at the same time, a decrease in mortality rates due to these conditions [2].
So far, there is no detailed epidemiological information regarding heart failure in the Polish population. Until now, only one paper has been published describing hospital morbidity and mortality of heart failure. These data were based on information from the Department of Hygiene and Main Statistical Office [3].
According to this publication (Fig. 1), standardised hospital morbidity rates in 1995 showed an age-dependent relation. At the same time, hospital stay was also age-dependent and lasted usually 13–14 days. However, it must stressed that these results are based on a 10% sample from all hospitalisation in Poland.
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Similarly standardised heart failure mortality rates for 1995 also increased with the ageing of the studied patient (Fig. 2).
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Additional information gathered from primary care physicians [4] revealed that coronary heart disease had remained the primary aetiology of heart failure (Fig. 3). More reliable and comparable data will not be available until the results from the Improvement and Euro Heart Failure Survey are released [5].
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2. Organisation of health services in Poland |
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TopAbstract1. Introduction and...2. Organisation of health...3. Access to diagnostic...4. Diagnosis and treatment...5. ConclusionsReferences |
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To understand how the patient with heart failure is managed in a particular country, it is necessary to understand the country's health system organisation. In fact, in Poland, the whole health system has been undergoing fundamental changes since 1998. Nowadays, every resident pays 38% of his salary to the Social Insurance Department (20% paid by the employer while the remaining 18% is paid by the employee), 7.75% comes back to the health system, while the rest covers retirement and sick leave or disability compensations. Money for health care is in the possession of the territorial State Health System Agency, which is responsible for its further redistribution. The representatives from State Health System Agencies are in charge of negotiating and signing contracts with health care providers including primary care as well as specialist level (ambulatory and hospitals). High specialist cardiovascular procedures are contracted by the Ministry of Health and covered by the resources directly from the state budget. These additional procedures include interventional cardiology and cardiac surgery.
The health system is organised into two sectors: a primary care sector of community based services and a secondary care sector based within hospitals. Primary care physicians and general practitioners play a major role in providing ambulatory care for all residents and they are responsible for overall health care within the community. The average physician in the primary care sector is responsible for 3000–5000 residents. All Polish residents are given free choice of their primary care physician who decides about further management strategy including diagnostic investigation and treatment. Therefore, whenever specialist consultations, either ambulatory or in-patient, are necessary, a referral note must be obtained from the primary level physician prior to this service. The next level of care is based on specialist out-patient clinics and hospital out-patient departments which have the ability to provide complex non-invasive cardiological evaluations (Fig. 4).
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The secondary care sector is divided into three levels: primary or basic hospital care, specialist and reference specialist hospital care. It is estimated that hospital at the primary level covers 30 000–60 000 residents. On the other hand, at the specialist level (approx. 50 hospitals in Poland), e.g. cardiology hospital is responsible for 400 000–700 000 inhabitants. The reference speciality level includes cardiological centres which comprise both cardiology and cardiac surgery departments situated at University Hospitals and Research Clinical Institutes (n=10) and take care of approximately 3–7 million residents (Fig. 5).
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3. Access to diagnostic procedures at different levels of health system with regard to cardiology |
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TopAbstract1. Introduction and...2. Organisation of health...3. Access to diagnostic...4. Diagnosis and treatment...5. ConclusionsReferences |
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Commonly primary ambulatory settings, with the exception for a few very well equipped practices of primary care physician, do not provide facilities for specialist investigations. These procedures are offered by specialist out-patient settings, which are equipped to give ECG examinations and chest X-rays. Some of the cardiology out-patient departments also provide facilities for 24 h Holter monitoring, exercise ECG test and echocardiographic studies. Additional complementary diagnostic opportunities are offered at specialist and reference specialist out-patient clinics, thus allowing access to complex non-invasive cardiological assessment.
In the secondary sector, primary care hospitals are equipped to provide the opportunity of performing ECGs, chest X-rays, exercise tests, often also Holter monitoring and complex biochemical evaluations. All hospitals at this level have Intensive Care Units.
Cardiology Departments at specialist hospitals also include Intensive Cardiology Care Units or subunits. Generally, these wards share equipment with specialist out-patient departments and allow full cardiological non-invasive evaluation. These in-patient and out-patient departments usually have approximately 3–5 cardiologists on the staff team and co-operate with reference specialist departments.
Reference specialist hospitals provide services for complex invasive and non-invasive cardiological evaluation and possess in-patient cardiology departments.
In Poland in 1999, there were 34 106 coronaro-angiopraphic studies, 10 843 PTCA and 3638 stent procedures, 3052 surgeries of acquired heart disease, 7697 coronary by-pass surgeries and 130 heart transplant operations. (Inhabitants, approx. 36 million.)
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4. Diagnosis and treatment of heart failure patients |
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TopAbstract1. Introduction and...2. Organisation of health...3. Access to diagnostic...4. Diagnosis and treatment...5. ConclusionsReferences |
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There is only limited data concerning management of HF patients in Poland [6]. It was presented in a cross-country epidemiological study concerning heart failure in primary care practice. There were 417 primary care physicians participating in this program which included 10 579 patients with HF, diagnosed mainly according to clinical criteria.
4.1. Chest X-ray
Overall, approximately 50% of patients with HF had documented X-rays. Cardiomegaly was stated in approximately 68% of patients.
4.2. ECG
Resting ECG was performed in 90% of patients. Cardiac arrhythmia was recorded 21% of tracings with atrial fibrillation constituting approximately one-fifth of all abnormalities. Old myocardial infarction or cardiac ischaemia was observed in 70% of patients.
4.3. Echocardiography
Because of the difficulties with the availability of echocardiographic examination (practically, they were only performed at the specialist care level), only 40% of patients records included copies of echocardiographic evaluation (IMPROVEMENT) [5]. According to our own data, which are not representative samples, among subjects with HF in whom an echo was performed, there were 29% of males and 10.2% of females with ejection fraction <45%. With regard to the LV dimension, the results were even worse. There were only 11% of patients with HF with LVESD
50 mm and 8.3% of HF patients with LVEDD65 mm. Observed results might be due to the problems with differentiation between systolic and diastolic heart failure. Information gained from ambulatory care physicians revealed differences in treatment strategies in heart failure patients with regard to level of care (Fig. 6).
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ACE inhibitors were prescribed in 64–72% of patients with HF, however, the average prescribed dosage is far from that recommended in guidelines [1,8,9]. Among ACEI (angiotensin converting enzyme inhibitors), enalapril and captopril (22.7%) were the most often prescribed (30.5% vs. 22.7%, respectively). It must be stressed that there is a big price variation between preparations manufactured in Poland and in Western Europe. Thus, these discrepancies may be responsible for the observed dissimilarities in frequency of administration between enalapril with captopril and other II or III generation ACEI taken once a day. The cost of treatment might also account for the dosing schedule, i.e. captopril given b.i.d instead of t.i.d. and enalapril q.d. instead of b.i.d. Therefore, despite a relatively high percentage of patients receiving ACEI, there is discrepancy between guideline recommendations regarding dosing regimen and the real life situation [7–10] (Fig. 7).
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Beta blockers are rarely given to HF patients (18–29%) [7]; this is particularly surprising when one takes into account that, in the majority of patients, HF is diagnosed with ischaemic aetiology.
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5. Conclusions |
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TopAbstract1. Introduction and...2. Organisation of health...3. Access to diagnostic...4. Diagnosis and treatment...5. ConclusionsReferences |
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The limited resources of the National Health System significantly influence the diagnosis and treatment of heart failure. This financial restriction results in performing too few diagnostic tests (mainly echocardiographic studies) in this group of patients. The high cost of the medicines is another disadvantageous aspect of health care in Poland. Some patients, primarily elderly subjects, do not comply with their physicians recommendations, taking approximately half of the prescribed doses of ACEI and β-blockers. Thus, drawing conclusions without looking into the real doses taken by patients may be misleading. Poor, imprecise diagnostic procedures reduce the percentage of heart failure patients receiving causative treatment.
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References |
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TopAbstract1. Introduction and...2. Organisation of health...3. Access to diagnostic...4. Diagnosis and treatment...5. ConclusionsReferences |
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- Tavazzi L. Epidemiological burden of heart failure. Heart (1998) 79(suppl_2):56–59.
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