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

Objectives

The national plan for comprehensive cardiovascular care seeks to reduce cardiovascular morbidity and mortality through an integrated, phased approach spanning health promotion, prevention, diagnosis, medical and invasive treatment, surgery, rehabilitation and long-term follow-up across Costa Rica’s three-level health system. Completion is envisaged over 10 years, with particular emphasis on preventing avoidable disease and reducing medium-term demand for high-complexity, high-cost interventions.[1][2][3][4]

• Strengthen first-level care to identify, treat and control hypertension, diabetes mellitus, dyslipidaemia, tobacco use, overweight and obesity, while promoting healthy diets, physical activity, weight control and avoidance of alcohol and other drugs.[5][6][7][8]
• Reduce premature cardiovascular mortality, with a 2025 target of 97.7 deaths per 100,000 men and 50.6 per 100,000 women, representing an intended 25% reduction over the following decade.[9]
• Improve comprehensive cardiac rehabilitation through exercise, smoking cessation, nutritional, psychological, social and vocational support, extending access beyond the existing specialised rehabilitation centres.[10][11][12]
• Strengthen second- and third-level capacity for specialist cardiology, invasive cardiology, electrophysiology, cardiac surgery, emergency assessment, coronary intensive care and recovery services.[13][14][15][16]
• Ensure timely acute coronary syndrome care through the 2013 Guide for the Diagnosis and Treatment of People with Acute Coronary Syndrome, including assessment of ischaemic chest pain, electrocardiography, stabilisation, continuous monitoring and intervention within defined response times.[17][18]
• Expand equitable access by targeting geographical areas and population groups with the greatest mortality burden, while directing highly complex care to specialised centres and lower-complexity care to appropriate local services.[9][19]

Implementation

Implementation is led within the Costa Rican Social Security Fund, also known as the Caja Costarricense de Seguro Social, through an inter-management commission coordinated by Medical Management and involving financial, medical, administrative, infrastructure and technology management. The plan uses an integrated network model that links primary, secondary and tertiary services, with national hospitals and specialised centres receiving the most complex referrals.[20][21][22][23]

• Coordinate prevention and promotion with ministries, public institutions, community organisations and international partners through the Comprehensive Agreement on Non-Communicable Diseases and Obesity, while using communication, training, local projects and community action to support healthier lifestyles.[24][25][8]
• Deliver first-level services through health areas, local health-service centres, visiting posts and community settings, combining risk-factor screening, clinical management, self-care support, group education, household and workplace interventions, and organised referral to higher levels.[26][6][7]
• Strengthen workforce capacity through continuing medical education, specialist postgraduate training and emergency cardiac-support training. CENDEISSS supports training in diagnosis, treatment, follow-up, electrocardiography and specialist cardiovascular disciplines.[27][28][29][8]
• Provide at least one cardiologist in each second-level hospital, develop haemodynamics capacity in Liberia, Puntarenas, Limón, San Carlos and San Isidro de El General, and train invasive-cardiology specialists alongside infrastructure and equipment development.[30][15][31]
• Establish or strengthen chest-pain units, coronary intensive-care units, cardiac recovery units, rehabilitation spaces and mixed haemodynamic and coronary services in regional hospitals according to accessibility, local need, available infrastructure and response times.[32][33][34][35]
• Standardise clinical pathways, referral and counter-referral procedures, discharge planning, multidisciplinary decision-making and evidence-based technology use. Complex coronary revascularisation cases should involve a heart team comprising clinical cardiologists, interventional cardiologists and cardiovascular surgeons.[36][19][37]
• Centralise ambulatory and emergency procedure waiting lists and operate a real-time virtual cardiology network, using available invasive diagnostic and therapeutic capacity to direct patients to suitable hospitals.[14][16][31]
• Support interim transfers through equipped ambulances in San Ramón, San Carlos, Guápiles and Liberia, with an intended transfer time of less than two hours while regional invasive-cardiology capacity is developed.[14][16]
• Assign hospital directors responsibility for organising hospital cardiovascular services, while Infrastructure and Technologies Management prioritises infrastructure and equipment and Medical Management supports internal resource redistribution.[38][33]
• Monitor implementation through mortality from acute coronary syndrome, disease-control targets, screening and treatment coverage, survivor proportions, waiting-list information, service records, hospital mortality and length of stay. The source does not specify a consolidated reporting timetable or complete accountability framework.[18][39][8][40]

Monitoring & Evaluation

The plan combines population-health surveillance, service-activity records, clinical documentation, capacity assessment and targeted outcome measures, but does not provide a single consolidated monitoring and evaluation framework, reporting timetable or accountability cycle.[1][18][3]

• Monitor standardised premature cardiovascular mortality, with 2025 targets of 97.7 deaths per 100,000 men and 50.6 per 100,000 women, alongside mortality patterns by sex, disease group and canton.[9]
• Track acute coronary syndrome mortality, survival after acute events, implementation of regional and local care plans, and availability of medicines and laboratory reagents.[18][39]
• Measure hypertension screening and control, diabetes coverage, dyslipidaemia management, nutritional assessment and participation in healthy-lifestyle education.[41][42][7][43]
• Use patient registers, surveillance surveys, management-commitment assessments, clinical records, transfer reports, hospital discharges, mortality data and length-of-stay statistics as information sources.[44][45][43][40]
• Maintain real-time waiting-list and haemodynamics-capacity information to direct referrals according to available invasive diagnostic and therapeutic capacity.[14][38][16]
• Assess infrastructure, equipment, staffing and technical capacity to establish the installed and resolutive capacity of health establishments.[23][46][17]
• Assign monitoring of institutional targets to the Institutional Development Directorate and the Services Network Directorate, while the inter-management commission is responsible for reporting progress and results.[20][1]
• Develop employee-performance instruments and consider production-related payment, although performance measures and governance arrangements are not specified.[47][31]

Costing & Financing

The plan identifies extensive resource requirements for prevention, first-level risk-factor management, specialist training, infrastructure, equipment, rehabilitation, emergency transport and advanced cardiovascular services. It contains selected training, staffing and coronary angiography cost estimates, but does not specify a complete financing strategy, overall budget, funding gap or costed infrastructure programme.[27][48][49][12]

• Allocate regular-budget resources to prevention, screening, chronic-disease control, secondary prevention, outpatient cardiology, diagnostic testing and emergency care, without stated monetary amounts for most activities.[6][7][50][51][52]
• Finance institution-supported cardiovascular training, with reported expenditure of 46,466,404.11 Costa Rican colones for other training activities and planned national specialist-training capacity.[27][28]
• Provide human-resource and consumable-input funding for coronary angiography, for which the reported total human-resource cost including social charges was 190,933,200 and total inputs cost 4,033,800, with no currency specified.[48][53]
• Cost salaries and employer social contributions for nutritionist and health-promoter posts over 2016 to 2025, applying a 4% annual increase and excluding occupational-risk insurance because its amount depends on the National Insurance Institute.[49][54][4]
• Invest in infrastructure, technology, maintenance, spare parts, ambulances, cardiac recovery beds, haemodynamics capacity and specialist workforce development, while considering leasing for technology without stated financial terms.[13][14][31][3]
• Recognise that prevention and first-level care are intended to reduce medium-term demand for high-complexity, high-cost interventions, although no quantified savings or economic model is supplied.[30][4]