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HEART FAILURE MANAGEMENT
INSTITUT JANTUNG NEGARA

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Cardiovascular diseases is the top five causes of hospital admission for the nation. Mortality rate due to Ischemic Heart Disease was the number one cause of death in the country for the past 30 years or so. IJN recognizes that heart disease accounts for approximately 25 percent of total deaths and is the main cause of death in Malaysian hospitals. According to our National Cardiovascular Disease Database (NCVD), those afflicted are younger than the western countries with the average age of those admitted with heart attack being 59 years, seven years younger than the Global Registry, where the average age was 66 years age group. These people are at the peak of their career and have families to support. The impact of disability and death of these young and productive people is to their families, communities as well as to the country. Most of these patients, who has suffered heart attack, will soon be in a heart failure condition. IJN realizes that “Heart Failure” is the future chronic disease and foresees that patients at the end stage of heart failure will increase in number as per what is happening in developed countries. For example in 2008, United States of America has recorded half a million cases of end stage heart failure that cost the country an expense of over USD35billion. 300,000 death were also recorded due to end stage of heart failure. In Malaysia, the prevalence rate is 100:1000 population. This is expected to increase in years to come and involve high cost of treatment to be borne. According to the Clinical Practice Guideline produced by the Ministry of Health Malaysia in 2007, a good 10 percent of patients treated in Malaysian hospitals are at end stage of heart failure. In the past these patients will not have an opportunity to lead a more quality life once diagnosed. In its early stages, heart failure can often be managed with medication and a healthy lifestyle; as the disease progressed, the heart becomes weaker and treatment gets more complex.

B. Strategic Approach

 2. What was the solution?
problem. When heart failure progresses to end stage heart failure, aggressive treatment is required to ensure quality of life and living as long as possible. Treatment options for these patients are limited to heart transplantation then. In 1996, IJN formed its Heart Transplant Team on its own in ensuring patients received the best treatment possible. This was the first team in the country. The team was send overseas to receive training from renowned centres around the world that have the capability in treating heart failure and to acquire knowledge on heart and lung transplantation and mechanical heart assist device implantation. The team also introduces the Homograft Bank – the only bank in the country. Previously grafts are acquired from overseas that are highly cost. With the introduction of our own Homograft Bank, many more patients would be able to benefit from it. With the rise in number of patients with end stage heart failure, IJN has also dedicated clinic and ward specially tailored to suits the needs of these patients.
 3. How did the initiative solve the problem and improve people’s lives?
In 2005, IJN introduced the “Thoractec LVAD” a mechanical heart assist device to help increase the survival rate of patients awaiting donor organ. IJN was the first heart centre in Asia Pacific. The initial version was too big and heavy for patients to carry around as such patients are restricted to be in the hospital all the time. In 2010, IJN acquired a new technology for the mechanical assist device by introducing a much smaller and lighter version called the Heart Mate II, which then evolved in 2011 as HeartWare. These devices have a better mobility thus giving the opportunity for the patients to go back to a more normal lifestyle. These innovation offers heart failure patients to have their treatment done in country. Offering a more affordable treatment option for citizens of Malaysia. Ever since the formation of IJN’s Transplant Team, 100 patients were listed on the heart transplant waiting lists, 39 died while waiting and 28 were taken out of the list due to deteriorating condition, refused for transplant and some because the condition has improved with medication and healthy life style. 25 patients underwent successful heart transplantation with the youngest being 12 years old and the longest surviving and still alive has passed 18 years 7 months. The first heart transplant was done in 1997. From 2005 – 2016, 24 patients underwent the implantation of the mechanical heart assist device of which 6 were as bridge to transplantation. The youngest patient being a 13 years old heart failure patient. Due to lack of donor organ and the high cost of mechanical assist devices, some patients are treated using Bi-ventricular Pacemaker and Bi-ventricular ICD (Implantable Cardioverter Device). To date more than 1,000 heart failure patients has benefited from these devices. Over the years, we have seen a rise in number of heart failure patients. In 2015 we have recorded 961 patients as compared to 349 five years before ie 2010 with an average age of 60 years old. The youngest being 13 years old. In order to manage the rising number of heart failure patients, we feel that an integrated management is required to ensure these patients are able to lead a quality life. Treatment of heart failure patients mostly are funded by our very own IJN Foundation especially for the underprivileged.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
The innovative management of heart failure services has evolved ever since the successful heart transplantation in 1997. IJN has introduces more holistic approach to address problems in new and different ways of managing these patients. Homograft bank was established to save coronary grafts should the heart harvested from donor is not suitable for implantation. These saved grafts are for used in heart surgeries for certain category of heart failure patients As the organ donor became scarce, IJN look for innovative ways and introduces the mechanical assist device as a bridge to transplantation in 2005. This has helped those in the waiting list of transplantation to survive longer while waiting for donor organ. The high cost of the mechanical assist device limits the number of patients that would benefit from it. IJN then acquires latest innovative technology in pacing and device implantation. Dedicated clinic and ward were introduced to manage the rising number of heart failure patients. Apart from this, IJN continues to acquire more innovative treatments that are available ( see clinical milestones on www.ijn.com.my)
 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The heart failure services in IJN was funded by the government through the National Economic Action Council, the Malaysia Ministry of Health and IJN Foundation. IJN Foundation acts as IJN’s CSR arm. IJN as a caring corporate citizen also allocates every one sen of every ringgit earned to IJN Foundation to help it funds underprivileged patients as well as sponsoring our personnel for training and skill development in managing these patients.
 6. How was the strategy implemented and what resources were mobilized?
In general, the cost of managing heart failure patients is very high and would only be affordable to certain group of people. The high cost to do a heart transplantation limits the number of patients that can afford this treatment especially so for those suffering from end stage heart failure. With the successful heart transplantation done in 1997 and the innovativeness of this initiative, the Malaysian government has agreed to finance this initiative through: 2002: disbursement of RM5 million through National Economic Action Council (NEAC) 2008: disbursement of RM27.8 million by Ministry of Health Malaysia The above funding from the government of Malaysia has helped IJN to continue to provide the best care and innovative treatment to Malaysians especially those suffering from heart failure. After the introduction of the innovative services on managing heart failure, patients are managed more efficiently through the following programmes: 1. Dedicate Heart Failure Clinic 2. Counseling services for Heart Failure patients 3. Dedicated Ward 4. Pacing and device implantation 5. Homograft Bank 6. Heart Transplantation 7. Mechanical Assist Device – bridge to transplant programme IJN works hand in hand with the National Transplant Resource Centre (NTRC) in promoting the importance of creating awareness among the public on organ donation. The heart failure clinic also aggressively involve in research project related to heart failure. Ten research projects completed between the year 1999 to 2010. In addition, another 6 ongoing projects. Patients on ICDs and Pacing devices all funded through IJN Foundation.
 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
The initiative receives strong backing from the highest level of government ie the Prime Minister and the Minister of Health. IJN itself was first conceived and triggered by the admission of our former prime minister Tun Dr Mohathir Mohamad following a heart attack in 1989. Following his successful heart bypass surgery, he then mooted and singularly pushed for the establishment of a heart specific hospital to spearhead the development of cardiology in the country.
 8. What were the most successful outputs and why was the initiative effective?
1. Many heart failure patients are now able to lead a more quality life with the advancement of our management in heart failure services. More and more heart failure patients are able to get treatment. This can be seen from the number of cases seen that has increased over the years. 2. Reduces morbidity rate that is interrelated to patient condition and better management 3. Increases the survival rate of end stage heart failure patients 4. More patients are benefiting from this service through the funding from IJN Foundation. Treatment is more accessible. 5. Homografts bank has managed to reduce the cost. Prior to having this bank, coronary grafts are imported from overseas that cost around six thousand pounds sterling. Unsuitable hearts for transplantation harvested would have gone to waste.
 9. What were the main obstacles encountered and how were they overcome?
Cost of heart transplantation and devices are too expensive. Lack of funding. The last funding from the government was in 2008. From then, funding is solely from IJN Foundation and with the economic downturn; many corporate companies are not able to donate to IJN Foundation. IJN also faces lack of funding to send personnel for training as part of capability development to acquire skills. Lack of donor. In Malaysia, the country law is Opt In as such many shy away from pledging and donating organs.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
IJN’s workload speak volume to the impact of the initiative to the public. Over the years, since its inception in 1992, IJN has recorded more than 3 million outpatient attendances and over three hundred thousand of inpatient admission. The heart failure initiatives has benefitted those suffering from end stage heart failure. The poor and vulnerable now has an option for treatment here in IJN. Before this is beyond their means.
 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
na
 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
na

Contact Information

Institution Name:   INSTITUT JANTUNG NEGARA
Institution Type:   Other  
Contact Person:   AINALIDA MOHAMAD
Title:   SENIOR MANAGER  
Telephone/ Fax:   603 26006316
Institution's / Project's Website:  
E-mail:   ainajamil@ijn.com.my  
Address:   145 JALAN TUN RAZAK
Postal Code:   50400
City:   KUALA LUMPUR
State/Province:  
Country:  

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