Análisis Y Planificación Para El Abordaje De Atención Integral De La Patología Cardiovascular A Nivel Nacional

Objectives

The plan sets out a ten-year, comprehensive cardiovascular-care strategy for the Costa Rican Social Security Fund (CCSS), integrating health promotion, prevention, diagnosis, medical, invasive and surgical treatment, rehabilitation, and timely referral across primary, secondary and tertiary care.[1][2][3]It seeks to reduce cardiovascular morbidity and mortality, particularly from acute coronary syndrome and acute myocardial infarction, while improving equitable access, service quality, safety and resolution capacity throughout the national network.[4][5][6]

• Strengthen primary care for healthy lifestyles, tobacco cessation, risk assessment, and the detection, treatment and control of hypertension, diabetes, dyslipidaemia, overweight and obesity.[7][8][9]
• Reduce demand for high-complexity interventions by improving guideline-based control of cardiovascular risk conditions and linking additional primary-care resources to control targets.[2][10]
• Expand cardiac rehabilitation as a structured, interdisciplinary service combining monitored exercise, education, smoking cessation, nutrition, psychological and social support, and sustained treatment adherence.[11][12]
• Improve acute coronary syndrome care through rapid diagnosis, thrombolysis or angioplasty where indicated, chest-pain units, safe transfers, referral and counter-referral, and post-discharge follow-up.[13][5][14]
• Strengthen regional and national capacity for interventional cardiology, haemodynamics, electrophysiology, cardiac surgery, coronary intensive care, recovery units and cardiac-device implantation.[15][16][17]
• Organise specialised services so that complex procedures are concentrated in appropriately equipped centres while lower-complexity facilities provide intermediate and basic services according to population need, territory and network capacity.[6][18]
• Support health promotion through the Ottawa Charter areas of healthy public policy, supportive environments, personal skills, community action and reoriented health services.[4]

Implementation

Implementation uses a network-based and phased model coordinated by an Inter-Management Commission under CCSS Medical Management, bringing together financial, medical, administrative, infrastructure and technology functions.[1][19]The Commission is responsible for implementation oversight, progress reporting and reporting fulfilment of results, while the Directorate of Institutional Development and Directorate of the Services Network monitor targets.[1][20]Delivery is differentiated by the resolution capacity of each care level and combines workforce development, infrastructure, technology, clinical guidance, information systems and coordinated referral pathways.[2][19]

• Deliver first-level services through health areas and Basic Teams for Comprehensive Health Care, using community, household, school and workplace settings for prevention, self-care, physical activity, healthy eating and risk-factor management.[21][22]
• Provide second-level specialist consultation, emergency care, diagnostic testing, intensive care, rehabilitation and structured transfer arrangements for hypertension, dyslipidaemia, acute coronary syndrome, stroke, heart failure and arrhythmias.[23][24]
• Maintain national hospitals and specialised centres as referral sites for tertiary care, including angiography, catheterisation, interventional haemodynamics, cardiac surgery and complex postoperative care.[25][13][26]
• Develop regional coronary-care modules comprising chest-pain units, coronary intensive-care units and haemodynamics services where feasibility, infrastructure and staffing permit.[27][28][29]
• Coordinate patient allocation through unified waiting lists, real-time information on haemodynamics capacity and a national virtual cardiology network, directing patients to hospitals with available capacity.[15][30][31]
• Standardise clinical care through acute coronary syndrome, diabetes, hypertension, dyslipidaemia and cerebrovascular guidance; use protocols for triage, referral, transport, diagnosis, treatment, follow-up and multidisciplinary case review.[32][33][14]
• Strengthen emergency transport with trained clinical teams, cardiac monitoring, defibrillation and resuscitation equipment, approved transfer protocols and risk-based referral criteria.[34][35][36]
• Develop the workforce through continuing education, domestic postgraduate programmes and overseas specialist training in invasive cardiology, haemodynamics, electrophysiology, cardiac recovery and complex pacemaker implantation.[37][38][17]
• Mobilise prevention stakeholders through CCSS and the national agreement on non-communicable diseases and obesity, involving relevant government sectors, public agencies and the Pan American Health Organization and World Health Organization.[4]
• Resource implementation through regular budgets, infrastructure, equipment, medicines, specialist posts and training; the 2018-2026 costing summary includes US$7,519,920 for infrastructure and US$1,149,920 for training and education, alongside specified salary and employer-contribution costs.[39][40]

Monitoring & Evaluation

Monitoring arrangements combine governance reporting, service information, epidemiological surveillance, clinical records and selected performance measures. The Inter-Management Commission, coordinated through the Medical Management Directorate, is responsible for presenting implementation progress and reporting fulfilment of results.[1][39]The Directorate of Institutional Development and the Directorate of the Services Network are assigned responsibility for following up targets.[20]

• Monitor cardiovascular burden through mortality, hospital discharge, outpatient consultation, emergency-care and in-hospital death data. Circulatory-system discharges rose from 18,712 in 2005 to 22,854 in 2014.[41][42]Hospital discharges increased from 18,304 to 21,190 between 2007 and 2014, while in-hospital cardiovascular deaths increased from 1,811 in 2007 to 2,158 in 2013.[43]
• Track premature cardiovascular mortality by sex. The standardised rate fell from 163.4 to 130.2 among men and from 89.3 to 67.5 among women between 2000 and 2010; the 2025 targets were 97.7 and 50.6 respectively.[44]
• Use risk-factor surveillance indicators covering hypertension, cholesterol, diabetes, overweight and obesity, disability-adjusted life years, and cardiovascular deaths by age and cause.[45]A biennial cardiovascular risk-factor surveillance survey was identified for 2014.[46]
• Measure prevention and primary-care performance through participation in healthy-lifestyle education, screening coverage, service coverage and control of hypertension, diabetes and dyslipidaemia.[47][48][49]In 2014, institutional hypertension coverage was 34.3% and optimal blood-pressure control was 62%; the 2018 target was 65% optimal control among treated people with hypertension in health areas.[47][48]
• Assess acute-care quality through the proportion of eligible patients with ST-segment-elevation myocardial infarction who receive intravenous thrombolysis within a door-to-needle time of 30 minutes or less.[49]Acute coronary syndrome monitoring also includes mortality, post-event survival, implementation of regional and local plans, medicine, reagent and electrocardiography availability, and laboratory response times.[14][50]
• Record referrals, transfers, complications during transport, outpatient consultations, diagnostic procedures, acute coronary syndrome classification, mortality and length of stay through service information systems, medical records and procedure registers.[9][51][52][13][53]
• Use real-time central information on haemodynamics capacity and procedural waiting lists to direct patients to facilities with available invasive-care services.[15][30][31]
• Review infrastructure, equipment, staffing and service capacity through hospital baseline assessments and site visits, including the October 2015 regional-hospital cardiology assessment undertaken by the Directorate of Special Projects Administration.[54][55][56]
• Apply quality and safety mechanisms including clinical protocols, multidisciplinary review, demand management, referral and counter-referral systems, and standardised processes from admission to follow-up.[6][18]International reference benchmarks include at least 500 coronary angiographies and 200 percutaneous coronary interventions per hospital annually, and at least 400 coronary bypass operations annually with at least three trained surgeons.[18][57]
• Track training investments, beneficiaries, study centres, periods and employment status through Centre for Strategic Development and Information in Health and Social Security records.[37][58]

The material does not provide a single consolidated indicator framework, routine reporting calendar, independent evaluation design, surveillance protocol or comprehensive accountability mechanism for the full cardiovascular plan.[1][20][31]

Costing & Financing

The plan identifies substantial resource requirements for comprehensive cardiovascular care, including infrastructure, diagnostic and treatment technology, medicines, specialist staffing, ambulances, rehabilitation facilities, emergency capacity and domestic and overseas professional training.[2][59][15][38]Costing is presented for selected components, principally infrastructure, specialist education and salary-related expenditure, but most service-expansion proposals do not have quantified allocations.[39][60][40]

• Allocate US dollars 7,519,920 for infrastructure and US dollars 1,149,920 for training and professional development during 2018-2026.[39][40]Training allocations comprise US dollars 95,400 for Argentina and US dollars 1,054,520 for Spain.[39][40]
• Provide Costa Rican-colon budget lines of 8,398,204,048 as a subtotal, 496,818,906 for paid study leave, and 8,469,103,773 for salaries and employer contributions over the stated periods.[39]A separate programme total of 17,364,126,727 Costa Rican colones is reported for 2018-2026.[40]
• Cost nutritionist and health-promoter salary and employer social contributions at 4,320,104,918 Costa Rican colones over 2016-2025.[60]The costing assumes a 4% annual salary increase, uses current colones and excludes occupational-risk insurance because its value depends on the National Insurance Institute.[61]
• Estimate the monthly salary-plus-employer-contributions cost for a health promoter at 1,534,571 Costa Rican colones and the annual cost at 19,949,420 Costa Rican colones.[61]
• Report a total investment of 331,894,024.80, with no currency specified, for professional training in cardiovascular care; this includes a reported total of 285,427,620.69 for overseas cardiology sub-specialist training and 46,466,404.11 for other cardiovascular training activities.[37][58]
• Use the regular budget as the stated financing source for prevention, screening, treatment, secondary prevention, emergency care and several outpatient and diagnostic interventions.[22][9][51][52][24][62][53]
• Link additional primary-care resource allocation to achievement of targets for controlling cardiovascular risk conditions, while recognising that high-complexity care requires substantial financial resources.[2][10][63]

No overall financing source, resource-mobilisation strategy, quantified funding gap or comprehensive economic evaluation is specified.[39][60][40]