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Half of Poles die of heart disease, cancer kills one in four. And the government is proposing to cut spending on cardiology by as much as 60 percent. Doctors are outraged. Why should we save on Zawałówka? – we ask prof. Paweł Buszman, an outstanding cardiologist, president of the Board of the Polish-American Heart Clinics.
Ela Dziob-Radziszewska / Onet .: Professor, is it true that cardiovascular diseases have been the main killers of Poles for over half a century?
Prof. Paweł Buszman: That’s true. Almost 50% of people in our country die of cardiovascular disease. all Poles. Another killer on the list, cancer diseases, will kill every fourth Pole. Cancer and diseases of the heart and vessels are civilization diseases that take a huge toll. In the case of cardiovascular diseases, we observe the greatest inequalities in health: people from small towns and villages, people with lower incomes and lower education suffer more often and die.
Why are there so many morbidity and deaths due to cardiovascular disease?
First, there are standard risk factors. Poles suffer from hypertension more often than inhabitants of rich EU countries, and the same applies to smoking and being overweight. On the other hand, the remaining risk factors are already comparable. However, when it comes to Poland and Central Europe in the context of rich EU countries, one thing is clearly different – air pollution. For about 15 years, many studies have been published on the effects of fine particulate air pollution on the formation of cardiovascular disease, coronary artery disease, disseminated atherosclerosis, heart attack and strokes. It turned out that the higher the dust, the greater the risk of an acute cardiovascular event. Unfortunately, Poland is the leader in Europe in terms of pollination. As recently presented by the WHO report and the EU report, out of the 50 cities with the highest dustiness in Europe, 33 are Polish cities, mainly in the south of our country. Our standards are exceeded, above all, when it comes to PM2,5 dust below 2,5 μm. It is them that damage the vascular endothelium by stimulating leukocytes circulating in the blood, accelerate atherosclerosis and increase the readiness for the formation of wall clots, and thus it is just one step to a heart attack or stroke. Unfortunately, this also applies to relatively young, healthy people.
So air pollution itself can be an argument for not reducing spending on cardiology?
Cardiologists are literally flooded by a tsunami of human misfortune, such as disseminated atherosclerosis, heart attack or stroke. There are really a lot of sick people. I do not know where this hatred of cardiologists and Polish cardiology and the desire to hide the facts that we have so many patients with cardiovascular diseases comes from. Often, these patients wait years in lines to see a cardiologist to get an appointment and then qualify for hospital treatment. Unfortunately, a Pole must suffer a heart attack to be admitted to a cardiology department. It is unbelivable.
How can this be changed?
First of all, you need to increase funds for cardiology. In our country, we have PLN 3 billion for hospital treatment in cardiology. It is only 10 percent. the entire NHF budget allocated to hospital treatment in Poland. For comparison, in the Czech Republic, the hospital budget for cardiology is 22%, and in Germany it is 18%. If someone in Poland says that cardiology takes money from the NHF budget, this is clearly not true. First of all, Poles must be given a chance to have equal access to treatment for all diseases, especially cardiovascular diseases. The mortality rate due to cardiovascular diseases in Poland is still 1,5-2 times higher than in Europe. This high mortality, although reduced by 25% over the past 15 years, persists despite the tremendous success that cardiology has achieved during this period. This shows the huge scale of the problem and the need for coordinated actions, especially in the field of outpatient specialist care in the field of cardiology, early diagnosis and treatment of cardiovascular diseases.
What is the success of cardiology?
First of all, the reduction of mortality due to coronary heart disease by 27% and mortality due to heart attack by 50% in our country. This translated into an extension of life in Poland in general. It is also important to reduce the so-called indirect costs achieved thanks to interventional cardiology. Reducing cardiovascular mortality means reducing social costs. Treatment with the use of very effective invasive techniques allows a patient after a heart attack to return home even within 2-3 days, and to full professional and life activity within 4-8 weeks. In this way, he becomes a productive citizen of this country again. Hence, it is often said that reducing cardiovascular mortality, and thus extending life, has a direct impact on the GDP and prosperity of a country. Therefore, rich, highly developed countries do not save money on cardiology, especially in the case of procedures that guarantee high effectiveness of treatment. In Poland, the annual mortality in MI has been reduced from 25-30% (with conservative treatment) to 10% (thanks to interventional treatment). They are tens of thousands of lives. For example, in the last 5 years in Poland, invasive cardiologists treated about half a million heart attacks and saved 70 from death. patients.
What it comes from?
I think it is a success of both modern medical technology and the success of an innovative organizational solution. We have exceptional know-how in inpatient HTA (Health Technology Assessment) and cardiac HTA. We have created a network of invasive cardiology centers, one of the most modern of this type in Europe. Despite the lowest prices for this type of treatment in the European Union, we have obtained excellent clinical results: mortality from myocardial infarction, both early and late, is one of the lowest in OECD countries. All this was achieved thanks to the exceptional commitment of the cardiologist community, their passion, enormous competences and outstanding scientific achievements. On the other hand, the myths about the salaries of cardiologists obscure the real values that society has gained thanks to this activity. I would like to remind you that currently a cardiologist earns less per hour of work in a hospital than a doctor in primary care.
Where do these myths about the earnings of cardiologists come from?
It’s hard to say… In general, the salaries of doctors in Poland, especially of specialists, have increased significantly recently. This is due to a large deficit on the labor market, unnecessarily excessive requirements of the National Health Fund and the need to keep specialists in our country (large emigration to EU countries). At the moment, POZs receive constant increases from time to time, therefore they offer wages that can be attracted, among others, by internists. We do not envy our colleagues, but I would like to refute this myth that there is a lot of money in cardiology. Over the last 5 years, we have had a number of significant reductions in procedures and, in fact, the next cut means that many centers will have to be closed, which may contribute to the departure of our specialists to work abroad. When it comes to cardiology, for example, Great Britain is behind us. There is a great need to open new centers. I know from experience that every interventional cardiologist from Poland will easily get a job there, despite the UK leaving the EU. And the basic salary for invasive cardiology consultants is between £ 10 and £ 12 a month.
In the times of Zbigniew Religa, Polish cardiology enjoyed success. What has changed since then?
Mr. prof. Zbigniew Religa has released limits for the treatment of heart attacks. It was enormous progress. With prof. I had the opportunity to work as a religa in Zabrze, when he was opening a cardiac surgery department and starting a transplantation program. At that time, I was working in the hemodynamics laboratory and co-creating with my older colleagues a program for treating myocardial infarction. The undoubted success of prof. Zbigniew Religa was that this method was made available to every Pole. At the moment, the average travel time of the patient to the nearest interventional cardiology center is approx. 30 minutes, which means that we are able to shorten the pre-hospital delay and quickly bring the patient to the center on duty 24 hours a day, which allows to save the heart muscle. This means that, despite the symptoms of an early infarction, this infarction often does not occur. An example may be Dąbrowa Górnicza, where our center is located next to a municipal hospital in the middle of a large agglomeration. A patient with a heart attack comes directly to our facility in the so-called the golden hour, where we observe a “stopped infarction”, that is, a state in which, despite clinical symptoms, an infarction does not occur. The infarction artery is mechanically opened immediately and blood flow to the ischemic heart muscle is restored. Recently, NIK auditors have questioned the validity of short hospitalizations. Unfortunately, they did not notice that many patients, for example in Dąbrowa Górnicza, were patients with a stopped heart attack who came to us at the “golden hour” and could already be discharged on the second or third day after the heart attack. On the other hand, NIK encourages to increase the conservative treatment of acute coronary syndromes, which is against the European guidelines. Keeping a patient in a general internal medicine or cardiology ward, conservative treatment is asking for disaster both for the patient – because it worsens the prognosis, and for the hospital – because it increases costs unnecessarily. This is the reason for the increasing number of patients with heart failure in Poland.
So conservative treatment is not really recommended?
It is absolutely contraindicated when it comes to acute coronary syndrome as well as chronic heart diseases caused by advanced changes in the coronary arteries or a heart defect. This is a medical malpractice. One cannot criticize the expensive invasive treatment, although in Poland it is the cheapest of all EU countries, if the socioeconomic effects are not assessed in the long term. This is another error of the Supreme Audit Office’s analysis, which did not take into account such important elements as the impact of these procedures and the network of invasive cardiology centers on the demography in Poland, epidemiology, mortality due to coronary heart disease, heart attack and reduction of social costs. In this respect, interventional cardiology and cardiosurgery are extremely cost-effective, extending life and the period of professional activity.
What is the main problem of Polish cardiology at present? The thing we are talking about now – lowering the cost of cardiovascular treatment, or something else?
The main problem is, first of all, the insufficient budget for cardiology, vascular surgery (dealing with the treatment of atherosclerosis) and too low pricing in cardiac surgery, which means that the mortality rate in many centers in Poland is too high. In the case of cardiology, there is not enough money to complete the treatment of a heart attack, for specialist cardiology care and for rehabilitation. Today, in order to improve and further reduce the mortality rate of myocardial infarction in acute coronary syndrome, it is necessary to start using modern methods available in cardiology. And the Ministry of Health wants to fill the current financial shortages by taking money from hospital cardiology. It shouldn’t be that way.
Our analyzes and calculations, which we conducted in 60 centers, show that in fact the valuation of these procedures should be increased, because in the last 10 years many innovations have been introduced that improve the results of coronary artery disease treatment. At that time, the requirements of the National Health Fund increased significantly, which forced additional expenditure and personnel costs (often unnecessary from the point of view of the treatment effect). After 2005, labor costs increased significantly, especially of doctors and nurses. The costs of energy, water, sewage and waste disposal have also increased. We equalize the costs of minimum wages and we have eliminated the so-called junk contracts. It all adds up to the cost of cardiological procedures, and their valuations have only been decreasing for 5 years. Theories that tariffs are overestimated because stent prices have fallen prove the lack of knowledge about the operation and costs of providing services in a hospital ward.
Is it true that changes in the NHF valuation regarding cardiological procedures will reverse Polish cardiology by 20 years, or is it just a media campaign?
Yes, changes can reverse cardiology by 15-20 years. This could mean an increase in mortality due to cardiovascular diseases by as much as 25-30%, i.e. an additional 30-50 thousand. deaths annually. This must not be allowed to happen! Taking 1/3 of the cardiology budget means a huge tragedy for Polish patients. This person, who takes even 1 zloty, will have thousands of lives on their conscience. After all, money is not taken from cardiologists, but from those suffering from heart disease!
Cardiology needs to develop.
Absolutely … Modern cardiology means full recovery and a quick return to social activity: at work and in the family. According to the prevailing standards in the EU and OECD countries, the cardiology budget should be twice as large.
What is the novelty of creating and implanting a professional, fully biodegradable stent compared to these traditional stents?
A biodegradable stent exists in two forms. Expanded on a balloon catheter, just like a regular steel stent, but it can also expand on its own under the influence of human body temperature, just like a nitinol stent. We conduct such research as Polish-American Heart Clinics in our Research and Development Center (CBR) together with the Institute of Polymers of the Polish Academy of Sciences. We have already produced and implanted the first prototypes. Our young staff from the CBR successfully carried out such procedures, now we are waiting for the results.
The experiment was successful on animals. When will the tests be performed on humans and how long will we have to wait for the official confirmation of their effects?
First, we need to have the product perfectly tested on animals, which may take up to the end of the year. Then, if all goes well, we may be tempted to start clinical trials, even in the second half of next year.
Cardiovascular diseases: stroke, lower limb artery disease – are still the most dangerous for Poles. Will research be conducted here too?
The stents we produce will be good for both the coronary vessels and the peripheral arteries. Particularly in peripheral arteries, biodegradable stents, self-compressing stents, are of great importance. Because traditional steel stents, i.e. nitinol stents – unfortunately due to the fact that the artery of the lower limbs (especially the femoral artery) is subjected to various types of deformation during movement – are exposed to damage. Therefore, it is very important to manufacture a stent that will dissolve within a few months. The vessel supplying the organ with blood and oxygen will be open and no foreign body will remain. This is the main idea behind our new research, to get a stent that will dissolve after 6 or 12 months.
The project is called Apollo, does that mean it is comparable to the American moon landing in 1969?
(smile) You would have to ask our young scientists, because this is their idea, but I think that in this case we are definitely talking about space technology.
Why did the government consider changes to the reimbursement of cardiac treatments necessary?
The government is looking for money for various purposes, but money for life-saving treatments cannot be taken. I understand the needs of cancer patients, but unfortunately we do not have a well-developed cancer treatment network similar to a cardiology network. Certainly, if such a network existed and cooperated with large oncology centers, these results would be visible faster and the expenditure would be lower. However, we have large centers here that monopolize this treatment, therefore it is expensive, mainly focused on the late stages of the disease, i.e. in the incurable phase, when this treatment is the most expensive and the least effective. There is a tendency to return to the same structure in the treatment of heart disease: it will mean the same treatment effectiveness as in the cancer care system.
Should patients blame the government or someone else?
I think that the government, and above all the Ministry of Health, must revise its views on cardiology. Such a long-term belief that cardiology is overestimated is due to ignorance. Dialogue is important to us. We are able to show the costs very accurately, but they must be introduced into the model of a real, not a virtual hospital, created by the Ministry and AOTMiT. This virtual hospital will not work. Different costs are in smaller centers and different in large ones. But it should be remembered that the most important thing is that the patient has equal access to treatment, and the public funds allocated to treatment give specific results.
What does Polish cardiology and cardiac surgery look like compared to the rest of the world? What can we wish for?
Very good! We can wish for an increase in funds that will translate into a specific demographic and economic effect. We prove that it is possible. Cardiological / cardiac surgery treatment is extremely cost-effective – it prevents deaths, heart failure, extends life by 20-30 years and thus patients can return to full social and professional activity.
At the end of our conversation. How was it for your son – Piotr Buszman – wanted to become a cardiologist himself? Are you proud of your son for being so devoted to your passion and medicine?
I never persuaded Piotr to become a doctor. But I am very proud of him. He is not only a talented doctor, but also a scientist. He devotes a lot of attention to scientific research, he is the head of the experimental laboratory, and at the same time he is completing his specialization in cardiology. I must boast that he is the youngest habilitated doctor in the history of the Medical University of Silesia.
Prof. dr hab. n. med. Paweł Buszman is a cardiologist, president of the Board of the Polish-American Heart Clinics. He started working in Zabrze in the 80s, where an intensive heart attack treatment program was being developed. He was a pioneer in setting up coronary stents and was the first in Poland to implant a stent into the carotid artery. Creator of the Polish-American Heart Clinics and winner of the EY 2015 Polish Entrepreneur of the Year award.