There are six Cardiac Surgeons in Kenya, two in Tanzania and one in Uganda-Dr. Raj Jutley

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Clinical Proceedings of PSCTS’s 9th Annual Conference
There are six Cardiac Surgeons in Kenya, two
in Tanzania and one in Uganda-Dr. Raj Jutley
Affordability is a problem and almost 70% of the patients
die waiting as we are quite expensive

KARACHI: The first scientific session of PSCTS 9th annual conference held at Aga Khan University on the second day March 30th was devoted to Quality Assurance and Databases. It was chaired by Prof., Riaz Anwar along with Prof. M. Rehman. Dr.Faisal Cheema from Columbia was the first speaker who discussed at length about quality, research and patient safety. He was of the view that improved clinical outcome and efficiency are the ultimate goal in quality assurance. Data, he opined, should be useable, information must be useful for day to day. Patient care has limited access for clinicians and researchers. Database, he further stated, is actually owned by the patient, it does not belong to any individual or institution. Every system is designed to achieve exactly the results it achieves. We should budget our resources and go for this national task of having a database. He concluded his presentation by quoting that God we Trust and all others must bring data.

Dr. Raj Jutley

This was followed by an excellent presentation by Dr. Raj Jutley Cardiac Surgeon and Director Research at AKU Nairobi Heart Cancer Centre, from Nairobi Kenya. Since he spoke nothing but the whole truth, it made his talk extremely interesting. He talked about cardiac surgery in East Africa. East African Community, he said, consists of Kenya, Tanzania and Uganda. Cardiac Surgery started in 1980 but there is no Registry, no common forum but isolated hospitals and no one is interested in publishing his data. 
Kenya, he said, has six cardiac centers, Tanzania two and Uganda one and all of them are mostly dependent on visiting teams of cardiac surgeons and Missions who come and perform surgeries here. We have only one cardiothoracic center at AKU Heart Cancer Center. Here cardiac surgery started in 2011 and we have our own staff. We performed twenty six operations in 2011, fifty six in 2012 and eleven in 2013 so far. Mean age in these ninety three patients was forty nine years. Two third of our patients were male and 75% of the cardiac surgery procedures were elective. Fifty percent cases were of CABG with overall mortality of 6.7%. Internal benchmark is a must for local database. During the first year we had 15% renal failure, total CVA were 3%. We are under capacity, have RHVD hotspots. We have a big waiting list. Affordability is the problem and almost 70% of the patients die waiting. Charges at our Heart and Cancer Centre are even much more than National Health Service which is unacceptable. We cannot afford that. There are very few accredited cardiac surgeons and since cardiac surgery is very expensive in East Africa, over a thousand patients have been taken away to India for treatment because there it is comparatively economical.
Continuing Dr. Raj Jutley said that we have unique population, have ethnic differences and young and unique physiology. Most patients come with late presentation as they waste lot of time collecting money for surgery. Many of them are suffering from ARF, pulmonary hypertension and have very low EF. Hence, we have to very carefully select our patients for cardiac surgery.HIV, he said, was not an issue as only four out of ninety three of our patients were HIV positive. Overall prevalence of HIV in Kenya is about 7%. He then talked about capacity building and pointed out that he wishes to bring the cost of cardiac surgery down. It is my wish to go to the base of the pyramid. We should have Registry. He emphasized the importance of having collaboration between East African Community and Pakistan. We should learn from those people who have made mistakes. There is no use in collaborating with the West. We are expecting some CIDA grant which will help us improve the service based on quality. He also emphasized the importance of transparency in results.
Dr. Tariq Azam from NICVD was the next speaker who gave details of their Database. The institution started collecting its data in 1992 and we established our database in 2004. Previous record is being entered into the database. It shows that coronary surgery has been going up every year except in 2009. He then described in detail and also showed a video how the data is collected, relevant details are filled in by different people in various sections and then it goes to the IT department for recording. Data is collected on hard copy and the surgeon looks at the details filled in by others before making his own entries to ensure that no one has failed to make entries related to their department.
Dr. Khalid Rasheed gave details of the database established at Tabba Heart Institute at Karachi. He first talked about reports of hospitals with abnormal mortality rates in USA which was highlighted in the media which prompted the authorities to take necessary measures. He was of the view that inappropriate use of raw data should be discouraged and we must talk about risk adjusted mortality figures. Cardiac surgery at THI started in 2005 and I joined there in 2009. We started the database in July-August 2010. We have started retrospective entry of data. We have our own internal validation protocol, have weekly audit meetings and we hope to start external validation soon. Giving details of the 918 CABG cases, he said 50% of the patients were diabetic, 53% had history of MI, 80% had triple vessel disease, and 17% had left main involvement. LIMA graft was used in 90% of the cases. We had in-hospital complications in 15%. We had one hospital death and nineteen total deaths with a mortality of 2.1%. He was of the view that we need National Cardiothoracic surgery registry.
Dr. Afsheen Iqbal from AFIC in his brief presentation talked about risk adjusted outcome. He pointed out that since 2005, they do about twelve hundred cases every year. He also referred to the neurological and renal complications and said that patient has a right to take data from the institution. High mortality, he opined, is relative and not absolute. He then referred to changing trend in IABP insertion. We found out that if dobutamine was added, the outcome was much better. We did 375 endartrectomies this year. He also talked about stuck valve and added that data base helps us in changing our practices. We must differentiate between common practices to best practices.

Dr. Anjum Jelal

Dr. Anjum Jelal Cardiac Surgeon from Institute of Cardiology at Multan was the next speaker. He pointed out that cardiac surgery at their center started in 2007 and they have compiled the last five years record. Last year we performed about thirteen hundred operations. He discussed in detail the pre-requisites for maintaining a database like powerful hardware, appropriate software, protocol for entry, manpower and motivation. We have been doing lot of good work with limited resources. There have been improvements in software during the last five years. Low salary of staff, long working hours, motivation is lacking are some of the problems but one has to reassure the staff and remain in contact with the team. He also talked about the limitations of manpower, limitations of hardware, lack of proper anti viruses, lack of understanding at administrative level, lack of motivation at user level besides lack of collaboration at national level. He was of the view that if we pool our resources and establish proper database, national results can be published. Since 2009 we have done 4245 total cases and information is available in the database. Once we have these figures, it is helpful for research as well as publications, he added.
Dr. Imran gave details of the Punjab Institute of Cardiology database. PIC, he said, is a three hundred bed tertiary cardiac care facility which was established on October 9th 1990 and we do eight to ten open heart cases daily. We perform over two thousand surgeries annually. We use KARDAS database for collecting the data. We have an ICU and a step down ICU before the patients are discharged. We maintain death register and also have a Death Review committee.
Dr. Hasnat Shareef gave details of the AKU database and said that cardiac surgery at AKU started in 1994. Data programme was developed in 2006 though hard copy data collection started in 1994. We have a dedicated individual who is involved in manual data extraction and then put it in the computer base. We do internal validation of cardiothoracic database before its publication. From 1995-2007, we have data of 4152 patients. From January 2006 to December 2012, we did 2,943 cases. Almost 97% of our cases were triple vessel disease as double vessel diseases cases are taken away by the interventional cardiologists. Our AKU mortality was 2.8% while mortality in reoperation cases was 3.8%. We had 0.5% CVA and total fourteen cases of renal failure. Rheumatic Fever is the main problem as well. Hospital stay at AKU was 5.1 days. We used IMA graft in 93% of our cases. We need national guidelines for stuck valves, he added.

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