Problem: High rates of cardiovascular disease, particularly in the eastern region; primary and secondary settings ill-equipped to provide cardiovascular care and perceived as lower quality by patients, leaving tertiary settings overburdened.
Solution highlights: The initiative strengthened cardiovascular care in primary and secondary settings, providing new training and equipment to providers to establish infrastructure for improved cardiology care outside of specialist settings; a detailed situational analysis informed the initiative’s design and provided evidence supporting the intervention; strong leadership by senior management at Vilnius University Hospital provided technical expertise and generated stakeholder support, while backing from the Ministry of Health added legitimacy to activities; extensive engagement of providers from the beginning was necessary for overcoming an individualistic culture and building collaborative relationships; distribution of a standardized cardiology equipment package to participating locations established basic quality standards and helped enable providers to implement new training.
Description of practice
High cardiovascular disease rates in Lithuania, particularly in the eastern region, were reported throughout the 1990s and early 2000s. Less urbanized areas in the eastern region were particularly affected. Inequitable distribution of cardiology resources negatively impacted rural areas and contributed to longer waiting times for specialists in tertiary centres, where quality of care was perceived to be higher. Fragmentation across care settings was also reported.
Following a detailed situational analysis to inform activities, senior management at Vilnius University Hospital Santarisku Klinkikos (a tertiary centre in the eastern region) convened stakeholders to build support for the Eastern Lithuanian Cardiology Programme. The initiative proposed strengthening provider competencies through trainings, conferences and introduction of a two-year cardiology curriculum; investing in basic equipment to facilitate provision of cardiology services in primary and secondary settings; issuing concrete guidelines for providers and developing evidence-based decision support tools; and implementing electronic medical records to streamline referral systems and connect both providers and patients. Supported by €20 million in funds allocated by the European Union and Government of Lithuania, activities were rolled out across 40 health care institutions volunteering in the Programme between 2004 and 2008. A specially-designed logo and media campaign helped raise public awareness of the Programme. Cardiology services offered within primary and secondary settings in the eastern region have expanded and health promotion, screening and rehabilitation services are now also available. By strengthening primary care, the Programme has reinforced gatekeeping for cardiology services. Simultaneous strengthening of secondary care has increased local delivery of more specialized services. Patients can now access higher quality cardiovascular care in facilities closer to home and infrastructural improvements have improved public perception of quality. Today, the Programme continues to be passively implemented using infrastructure already in place.
Implementation of practice
What stage is the practice currently in?
Fully implemented and scaled up
Who was/is responsible for the implementation of the practice?
Development of the Programme was led by senior management at Vilnius University Hospital, who displayed creativity and foresight in their ability to leverage the region’s poor epidemiological context and provider dissatisfaction to transform the provision of cardiology services. As a specialist learning centre, the Hospital had the necessary recognition and expertise to advance the initiative. Support from stakeholders was solicited early in the design process, notably including a series of meetings with providers, as well as government advocacy efforts led by the Hospital’s director. Support from the Ministry of Health was critical for increasing legitimacy of the Programme. The Ministry also provided 20% of necessary funding, with the remainder supplied by the European Union.
Reports from a formal review of all 40 participating facilities found that combined mortality from all circulatory diseases decreased from 1.71% to 1.55% and mortality from acute myocardial infarction declined by 5% between 2004 and 2008. All participating facilities received the basic equipment package, which seemed to increase adherence to recommended practices. With primary and secondary facilities better equipped to manage patients with cardiovascular disease, care delivery appeared to shift towards lower-level settings. Provision of outpatient services increased by 26% across secondary-level hospitals and demands on specialized inpatient services at Vilnius University Hospital decreased by 6%. Further, access to care increased by 45% based on the number of providers trained to offer cardiology services.
This case was prepared as part of a larger effort by the WHO Regional Office for Europe and published (2016) in the document, "Lessons from transforming health services delivery: Compendium of initiatives in the WHO European Region".
© Copyright World Health Organization (WHO), 2016
The methodology used for the development of this case is slightly different from the templates used on the IntegratedCare4People web platform, in particular in the analysis of enabling factors and barriers to change.
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- Aleksandras Laucenvicius
- Vilnius University Hospital Santarisku Klinkos
- Health care manager