Increasing Health Care Provider Awareness on Cardiovascular

Disease by Malang Cardiovascular Networking System

Astrid Pramudya

1,2

, Mohammad Saifur Rohman

1,2

, Muhamad Rizki Fadlan

1,2

Liemena Harold Adrian

1,2

, Faris Wahyu Nugroho

1,2

, Monika Sitio

1,2

Diah Ivanasari

1,2

and Ardani Galih Prakosa

1,2

Department of Cardiology and Vascular Medicine, Faculty of Medicine,

Brawijaya University - Dr. Saiful Anwar General Hospital, Malang East Java, Indonesia

Brawijaya Cardiovascular Research Center, Brawijaya University, Malang East Java, Indonesia

Keywords: Malang Cardiovascular Networking System, Health Care Provider Awareness, Referral System.

Abstract: The state of being great value of interacting and linking health care unit for the management of acute

coronary syndrome (ACS) and other cardiovascular diseases (CVD) have been highlighted in the 2012

guidelines by the European Society of Cardiology (ESC) on ST-segment elevation myocardial infarction

(STEMI). Our past study in Malang showed that lack of health care provider awareness contributes to high

mortality due to cardiovascular disease. Malang Cardiovascular Networking System in Malang, established

since 2015 facilitates referral for further management on a daily basis. A retrospective cohort study was

conducted on analysing chat consultation and advocacy through Malang Cardiovascular Networking System

using Whatsapp Messaging Application in Malang Raya Region for the period 2015–2019. Also,

electrocardiogram machine suggested local public policy to strengthen the networking system. ECG report

was sent to enhance the consultation. The increasing number of consultation was the primary end-point.

The proportion of consultation in patients with cardiovascular disease (CVD) increased significantly after

Malang Cardiovascular Networking System began. Daily consultation accepted on Malang Cardiovascular

Networking System was 5-10 consultation, 150-200 monthly consultation, and more than 2000 (n= 2.114)

consultation annually, with a total of consultation 8.456 consultations. Within 4 years, 2283 (27%) patients

were referred to RSSA with CVD problem, 1040 (12.3%) patients were ACS, and the rest was non ACS

(14.7%, n = 1243). The number of consultation was increased annually since 2015 with increase rate about

2.3%, 3.4%, and 5.6%, respectively. The number of ACS patients undergoing reperfusion strategy was

found increase after 4-years of updating knowledge and advocacy with rate 12.1 % compared to the first

year (P=0.046). Malang Cardiovascular Networking System significantly increased health care provider

awareness on cardiovascular disease by increasing the number of consultations and provider’s knowledge.

1 BACKGROUND

The state of being great value of interacting and

linking health care units for the management of

acute coronary syndrome (ACS) and other

cardiovascular diseases (CVD) have been

highlighted in the 2012 guidelines by the European

Society of Cardiology (ESC) on ST-segment

elevation myocardial infarction (STEMI) (Steg,

2012). The networking is aimed at providing optimal

care by minimizing delays and, thereby, improving

clinical outcomes. In the management of patients

with STEMI, primary percutaneous coronary

intervention (PPCI) is a preferred reperfusion

strategy and a better choice than pre- hospital

fibrinolysis or in-hospital fibrinolysis (Wallentin,

2014).

Malang Raya is a region in East Java, Indonesia,

encompassing the municipality of Malang. Malang

has a mountainous area, also southern coast

bordering Indian ocean. Malang and its suburb,

Batu, had total of population 3.465.004 (2017

census) with total area of 3.882,44 km

(Pemerintah

Kota Malang, 2019). In Malang, Saiful Anwar

General Hospital (RSSA) is the main center and top

referral hospital and the biggest percutaneous

coronary intervention (PCI) and cardiovascular

center, established at 2015 with more than 50 other

Pramudya, A., Rohman, M., Fadlan, M., Adrian, L., Nugroho, F., Sitio, M., Ivanasari, D. and Prakosa, A.

Increasing Health Care Provider Awareness on Cardiovascular Disease by Malang Cardiovascular Networking System.

DOI: 10.5220/0009388500480052

In Proceedings of the 4th Annual International Conference and Exhibition on Indonesian Medical Education and Research Institute (The 4th ICE on IMERI 2019), pages 48-52

ISBN: 978-989-758-433-6

hospitals and primary health care referring their

cardiovascular patients for PCI or further

management to RSSA.

Our past study in Malang showed that lack of

health care provider awareness contributes to high

mortality due to cardiovascular disease. Malang

Cardiovascular Networking System in Malang,

established since 2015 facilitates referral for further

management on a daily basis.

1.1 Aim

To obtain the relationship between health care

provider awareness on cardiovascular disease by

Malang Cardiovascular Networking System.

2 METHOD

A retrospective cohort study was conducted on

analyzing chat consultation and advocacy through

Malang Cardiovascular Networking System using

Whatsapp Messaging Application in Malang Raya

Region for the period 2015–2019. Whatsapp

messaging group consisted of three groups, Malang

regency, Batu City and Malang City. The group

member is general practitioners in primary health

care, clinics, Type D, C and B Hospital.

Besides, the Malang government policy and

task to complete all the public health care with one

electrocardiogram machine and routinely ECG

training to support and strengthen Malang ACS

networking existence (Dinas Kesehatan Kota

Malang, 2016). Whatsapp group received the data

transmitted from a previous health care center that

would refer the patient to RSSA. A pre-hospital data

included name, age, type of insurance, patient’s

general examination line subjective, objective (vital

sign, physical examination), supporting observation,

especially 12-lead ECG; chest X-Ray and laboratory

examination results. All the data is directly

transmitted from the group consultation centered in

RSSA cardiology unit, and skilled operators with

direct access to RSSA received and analyzing the

consultation. This method possibly decreasing the

delay between referral time and increasing response

and fast patient management tracks to bypass the

ER, or Catheterization laboratory (cath lab), or

Intensive Cardiovascular Care Unit (iCVCU).

Each consultation attached with

electrocardiogram patient’s result, and/or CXR of

the patient. was sent to the group. The increasing

number of consultation was the primary end-point.

This networking system also had annual training to

the GP all around Malang greater area. The big data

also conducted using hospital medical records. All

patients referred to RSSA included ACS and non

ACS patients who were admitted to RSSA from any

public health care, primary clinic, and hospital

operating under the area of Malang Cardiovascular

Networking System between the 3 May 2015 to 30

September 2019. We record and observe the

consultation data including age, genders, type of

cardiovascular disease (acute coronary syndrome

versus non acute coronary syndrome), date of

consultation, date of admission in RSSA, date of

discharge, managements and intervention types,

status of discharge.

We observed two primary indicators describing

the performance of the main targeted network, one

for care processes and one for outcomes, using as

dependent variables: The clinical characteristics and

proportion of patients with ACS and non ACS

admitted to RSSA, ACS treated with reperfusion

strategy, the recommended and standard treatment

choice of STEMI according to the guideline;

increasing number of consultation and referral cases.

To evaluate the relationships between the

performance indicators and awareness of health care

providers and to take the systematical structure of

the data into account, we performed multilevel

logistic regression with random intercepts for

hospitals, controlling for potential intra-hospital

correlations. Next, to investigate the gap in

outcomes and

the introduction of the network. We

performed data analyses using SPSS 22. All p-

values reported are two sided with significance

threshold of p < 0.05.

3 RESULTS

From the final analysis we found 8.456 consultations

within 4 years we accepted on Malang

Cardiovascular Networking System, with the

number of daily consultation was 5-10 consultation,

150-200 monthly consultation, and average annual

consultation was 2.114. At first year of its existence

there are 2017 consultation (2015-2016), 2060

(2016-2017), 2129 (2017-2018) and 2250

consultations in 2018-2019 (Figure 1). We noted it

increased significantly over time for 4 years, with

increase rate about 2.3%, 3.4%, and 5.6%,

respectively.

Increasing Health Care Provider Awareness on Cardiovascular Disease by Malang Cardiovascular Networking System

Figure 1: Number of consultation.

Table 1: Clinical Characteristics and Cases.

Variable 2015-2016

proportion (%)

2016-2017

proportion (%)

2017-2018

proportion (%)

2018-2019

proportion (%)

Total proportion

(%)

Number of

consultations

2.017 2.060 2.129 2.250 8.456

Referred to RSSA 474 (20.7) 515 (22.5) 635 (27.8) 659 (28.8) 2.283 (27)

Patient’s diagnosis

ACS

196 (41.3)

228 (44.3)

275 (43.3)

341 (51.8)

1040 (45.5)

Non ACS 278 (48.7) 287 (45.7) 360 (46.7) 318 (48.2) 1243 (54.5)

Management strategy

of ACS

Reperfusion

91 (46.2)

121 (53)

152 (55.2)

199 (58.3)

563 (44.1)

Non reperfusion 105 (43.8) 107 (47) 123 (54.8) 142 (41.7) 477 (45.9)

3.1 Clinical Characteristics

The total number of consultations has been increased

significantly, as we saw in Table 1. At its year of

launched, 2015-1016 there 2017 consultation, and in

the end of 4-years existence there were 2250

consultation (increased 11.5 %) at average the

number of patient referred to RSSA for further

treatment was 27% (2.283 cases) among 4 years.

From this group there were 1040 cases (45.4%), and

the rest was non ACS (54.5%) ACS.

The group of patients with non ACS cases was

mostly patient with heart failure, atrial fibrillation,

other arrhythmia disturbances, acute limb ischemia,

and any others cardiovascular disease. The patient

referred was 54.5 % (n=1243).

3.2 Management Strategy

The majority of ACS patients were diagnosed with

STEMI. Among those with STEMI, reperfusion was

not done in most patients. On most STEMI patients

referred for reperfusion strategy such as primary

percutaneous coronary intervention (PPCI), over

half of them were given fibrinolysis. The number of

reperfusion strategy was 44.1 % (563 cases) from

1.040 cases of ACS referred to RSSA, and the

remaining were not. It could be

Caused by the patient had been undergone a

PPCI or fibrinolytics from the previous hospital,

patients with autolysis STEMI, patients with onset

more than 3 days, or patients with conservative

treatment.

The 4th ICE on IMERI 2019 - The annual International Conference and Exhibition on Indonesian Medical Education and Research Institute

The number of ACS patients undergoing

reperfusion strategy was found to increase after 4-

years of updating knowledge and advocacy, with

rate 5.6% compared to the first year (P=0.046). The

awareness of health care providers was achieved on

their top level since their knowledge increased too.

Technology based management is significantly

support the successful of cardiovascular networking.

General practitioners and/or other specialists had

been more aware of cardiovascular disease

especially ACS cases.

According to the guideline, we fulfilled the

recommendation for the cardiovascular network,

especially reperfusion network to achieve speed

target time, delivery for cardiovascular disease

therapy. We were tailored network for the

community, and network itself respond to local

conditions and surroundings, easy to access, gain

support and acceptance from all stakeholders, and

adaptability to new knowledge.

Somehow, most parts of the world existed

cardiovascular networks are VIENNA STEMI

network and SAMU system in Europe, The Vital

Heart Network in Canada, and any other STEMI and

cardiovascular alert team in United States, India,

China, Russia, Australia, Latin America, and South

Africa.

Huber et al declared the essential ST-elevation

myocardial infarction system of care consist of

single telephone emergency number, ambulances

(vehicles, helicopters, planes), equipped with 12 lead

ECGs and defibrillators, and staffed with physicians

or well-trained paramedics, capable of basic and

advanced cardiac life support, occasionally

automatic ECG interpretation or ECG telemetry,

direct telephone access to catheterization laboratory,

protocols for standardized care, cardiologist or

intensive care specialist as a network leader,

involvement of healthcare authorities, public

information campaigns, regular meeting of involved

parties, and prospective registry (Abdul, 2019).

As cardiovascular networking system provided

those list above too, we already completed the

essential cardiovascular networking system and care

except the ambulances facility. Thus we relied social

messaging in order to make easier access to bigger

cardiovascular centers and shortening the delay.

More than that, beside its role on behalf to

management pre hospital of cardiovascular disease,

another possible function of cardiovascular network

was monitoring post discharge patients in primary

health care and home. The possible monitoring

checklist we can performed are cardiac symptoms,

physical and cardiac examination, drugs, and simple

cardiac rehabilitation at home. A study reported by

Chiantera et al. in Italy contemplate the use of ACS

networking and usual care, 63% of patients

discharged after ACS was found to exhibit cardiac

symptoms 1-month post discharge. ACS networking

was found to be able to slightly reduce hospital

readmissions (ACS networking 44% versus usual

care 56%) while at the same time better identifying

true from false angina among the patients (ACS

networking 85% true positive for cardiac cause

versus usual care 55%) (Chiantera, 2016).

4 CONCLUSION

Malang Cardiovascular Networking System

significantly increased health care provider

awareness on cardiovascular disease by increasing

number of consultation and provider’s knowledge.

Networking system like Malang Cardiovascular

network including electrocardiogram machine

facilities, and whatsapp group and bigger medical

center with catheterization laboratories facility along

24/7, and within a distance that can achieve

recommended transport are able to raise guideline

adherence and patient outcomes by streamlining the

critical pre- and intra-hospital processes as well as

improving timely access to invasive procedures,

recommended management and best outcome from

the patient.

ACKNOWLEDGEMENT

We would like to thank the Department of

cardiology and vascular medicine, faculty of

medicine Brawijaya University, dr. Saiful Anwar

general hospital Malang and the Malang

cardiovascular networking system for supporting in

the development of this manuscript.

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