Decentralising highly specialised medicine
Astrakhan Centre for Cardiovascular Surgery has 167 beds, four operation theatres and modern x-ray equipment and laboratories. There are two departments for adult cardiac surgery with 50 beds each, one for congenital cardiac surgery with 17 beds and a department for arrhythmias with 50 beds. There is one intensive ward for adults and one for children. The hospital has 700 employees, including 125 doctors and 250 nurses. Hospital director Dmitry Tarasov informed us that 11 500 therapeutic procedures and 72 000 examinations were performed during the first three years. A total of 6 000 patients are admitted every year.
All examinations and treatment are free of charge. The state authorities cover all the hospital costs. So far the hospital has been paid per treated patient but from next year it will have a fixed budget requiring an agreed number of procedures. The cost for one operated patient is approximately 70 000 NOK regardless of procedure or the length of hospital stay. As pointed out by Dr Tara-sov, this makes simple routine procedures profitable, while complicated operations using implants, or where complications occur, may lead to a deficit. In his opinion the financial costs affect treatment strategy only to a small extent: for example, the fact that only 1.5 PCI is carried out for every aorto-coronary bypass.
Modern surgery of the highest international standard is conducted here on adults and children. We witnessed percutaneous vein harvesting, mini invasive mitral valve surgery and Ross operations for aortic valve replacement. Regarding congenital surgery we observed an arterial switch procedure with transposition of the great vessels and closing of VSD through a right sided thoracotomy.
In the department headed by Igor Chernov there are three consultants and three trainees who together perform in excess of 1 000 open heart operations pr year. In addition they carry out carotid endarterectomies in addition to surgery on both the thoracic- and abdominal aorta, but do not perform lung operations. The department has three full time cardiologists. The anaesthesiologists serve the whole hospital without being allocated to any special department.
The doctors are recruited from all parts of Russia. They are young and concentrated on clinical work with a minimum of administrative burdens. It is obvious that the hospital benefits from being small with a minimum of bureaucracy and a management very close to the daily clinical work. Hospital director Tarasov himself occasionally performs open heart operations.
There appeared to be good teamwork, enthusiasm and great transparency. The theatres are fitted with the latest and most modern equipment, and we got the impression that everything is done to achieve clinical excellence. They seem to lack nothing and in return they work hard. The trainees come straight from medical school and work with-out pay for two years. If they are then accep-ted, they start operating and receive a salary.
What is the situation regarding waiting lists, selection of patients and transport in this enormous area the size of France? How is the follow-up after discharge and rehabilitation? The patients are by and large referred by cardiologists in the area. The head of congenital cardiac surgery does, however, often visit the districts to examine patients and select those in need of operation. It is very rare that cardiologists refer patients above the age of 65 for surgery.
The hospital has a short waiting list and the patients can normally choose themselves when they want to be operated. All transport is by car and rail since there are no airfields apart from the one in Astrakhan in the catchment area. This limits emergency operations with the result that the hospital only had 6 acute aortic dissections, type A last year, and no PCI for acute myocardial infarct. The hospital has no organised rehabilitation programme but is planning to organise one. The doctors did express concern regarding the follow-up of patients, especially those requiring anticoagulation following valve implantation.