Chris Barnard Division of Cardiothoracic Surgery - Self assessment of the the decade ending December 2014
The Chris Barnard Division is a small Division within the UCT Department of Surgery, comparable to other highly specialised disciplines such as Neurosurgery; it almost exclusively treats indigent patients who have no medical aid and as such are dependent on public hospitals. When the government shifted tertiary resources to primary health care in the mid 1990s Cardiothoracic surgery suffered significantly more drastic cuts in its staff and operating capacity than other disciplines. Viewed as an archetypical tertiary specialty that benefits few patients at significant cost, adult cardiothoracic operating lists at Groote Schuur Hospital were reduced to one third of the Division’s pre-1994 level in the course of the second half of the 1990s. Fearing a public backlash, authorities left the Division’s paediatric operating capacity as it was. However, with no growth through the ensuing 20 years a progressively severe under-delivery of services to children developed as the population grew rapidly, such that today we have a critical backlog of children awaiting surgery.
The reduction in adult cardiac surgical case-load by almost 70% inevitably had a dramatic impact on our ability to train registrars. Moreover it had, and increasingly has, a profound effect on service delivery to the 85% of the population which depends on public hospitals. A typical first-world cardiac centre caters for an adult population of one million, offering them 800-1000 open heart operations per year. Together with Tygerberg Hospital we have a drainage area of more than 6 million people and yet together we operate on only 700 adult cardiac patients per year; a conservative estimate indicates that this is an 8-fold under-delivery of services related to population needs, whilst also having a significant damaging affect on the academic and registrar needs of a teaching hospital. Petitions, pleas, demographic analyses and cost-effective proposals for capacity increases have fallen on deaf ears with the Government and remained unsupported by the Faculty for over 15 years.
Against this sobering background, we have a proud track record and reputation within UCT as being:
The only surgical discipline with a world-class dedicated research laboratory at the Medical School with an average staff of 20-30. The Cardiovascular Research Unit (CVRU) complex has a highly sophisticated infrastructure including three electron microscopes, confocal microscopy, cell culture facilities, polymer laboratories, histology labs, etc., and a high-impact research output that compares well with leading institutions overseas.
A review of the CVR Unit in 2003 by a combined panel consisting of members of UCT and the University of Stellenbosch concluded that:
“The CVRU has an impressive list of national and international collaborators. Prof. Zilla is the coordinator of a large multi-centre trial which includes 14 international researchers. In our view, the research conducted in this unit has enormous potential for future development. The group grew out of earlier work of Professor Zilla and he provides a strong directive and cohesive force. The team leaders have the capacity to continue their respective lines of research independently.”
The only Division or Department at UCT with self-financed, modern large-animal research operating theatres boasting state-of-the-art x-ray and echocardiography equipment.
The initiators of the UCT Private Academic Hospital (UCTPAH) (together with Professors Bateman and Forder of Respiratory Medicine and Microbiology respectively), and the Division which brought Rhön Klinikum on board to build the 120-bed hospital and establish the platform for the eventual take-over by Netcare, which has now put the hospital on a firm footing.
The initiators – together with Prof. Lionel Opie and supported by the then-Dean, Prof. JP van Niekerk – of the “Cape Heart Centre” after relocating the non-cardiovascular tenants from the Chris Barnard Building to other premises while uniting key players like Lipidology, the Hatter Institute and the CB Division under one roof.
The Division that organised private funding for the renovation of the wards, ICUs and Transplant Clinic for indigent patients at GSH to an aesthetic level surpassing that of private hospitals, thereby becoming the ‘show case’ for the hospital administration. The same was later done for the extensive research laboratories complex in the Chris Barnard Building.
The Division that attracted funding of nearly R100 million in the past 10 years and well over R140 million over the past 15 years.
A small Division within Surgery which nevertheless published a total of 158 peer-reviewed papers, almost exclusively in international journals, with an h-index of 46. Of these, 120 were published since Prof. Zilla took over (the head of the division has been cited more than 5,000 times and has an overall h-index of 36).
The only surgical discipline that has a laboratory-based higher degree program with 14 Ph.D. students (in Cardiothoracic Surgery, Biomaterials, and Biomedical Engineering) of which eight have graduated, and 19 M.Sc. students, with 13 having graduated within this Review period, and an additional 3 Ph.D. and 7 M.Sc. students funded by Medtronic fellowships, graduating in the time leading up to current Review period (a total of 11 Ph.D. and 20 M.Sc. graduates).
The only clinical discipline to successfully found a spin-off company, that is housed within the Chris Barnard Building and that not only attracted over 60 million rand in funding but serves as a platform for students and research papers.
In spite of the government-implemented cuts in clinical capacity, we remain the leading Cardiothoracic Surgery unit on the African continent. We continue to pioneer cardiac solutions for Africa rather than depend on solutions tailored to patients in the developed world. This is demonstrated by the “home-grown” trans-catheter initiatives being driven in our research laboratory by the SAT section of our Division.
We are at present the only SA academic unit with an established trans-catheter valve program, a minimally invasive surgery program, and a comprehensive rheumatic mitral repair program. We are also the only public sector heart transplant unit on the continent, and have national government support.
Our Paediatric Cardiothoracic Surgery component is based in the only dedicated public children’s hospital on the continent; Red Cross Children’s Hospital is internationally regarded as a cornerstone for excellence in child healthcare and treatment, and well known for excellent ICU and operating theatre facilities offering the full spectrum of congenital cardiac surgery.
In spite of being a small division we had a total income of 98 million rand over the 2005-2014 period, which equates to R120m when adjusted to present value. Of this total, the largest amount of R64 million came over the period 2012-2015 towards our start-up company (SAT) for the development for ‘home grown’ heart valve therapies. SAT has been structured to allow for a strong academic research presence and offer students an exciting project that has the potential to benefit millions of African patients. Another large amount of 30 million rand funding for research, building and equipment, was obtained from as conditional research grants from industry. Funding for two large equipment acquisitions, namely a C-arm fluoroscope and a high-end portable echocardiographic machine, amounted to another 2.5 million rand, funded by the National Research Foundation.
In accordance with our mission statement, we see our ourselves in ten years time as an African cardiac care centre of excellence, having extended the operating capacity of a world-class service and training institution back to international levels allowing us to train more world-class surgeons for Africa who are proficient in all aspects of Cardiothoracic Surgery with an understanding of the special needs of the indigent populations of Africa. By then, we expect to have well-established “satellite” self-sustaining cardiac units in many other African countries with an e!ven broader access to the peculiarly African burden of disease for trainees and research.
The restrictions imposed on us have already been highlighted. However, our sophisticated cross-platform database introduced in 2003, which covers all clinical services as well as the Division’s Cardiovascular Research Unit, has allowed us to decisively show that the Government strategy of cutting tertiary funding in favour of primary health care in the cardiac field has failed and urgently needs to be significantly amended. Referral maps linking our patients to their geographic origins, and ‘normalising’ these patient numbers to population density in those regions, clearly show that practically no patients outside the two large urban conglomerates of George and Cape Town find their way to tertiary centres. Thus the urban indigent population with life-style diseases have disproportional access to cardiothoracic surgery, whilst there is almost zero-access for rural areas, except for those close to the Cape Town and George metropoles. Self-referral to tertiary centres is no longer possible under the current system, so these patients who are not referred from the primary health care level are doomed to endure their heart disease without appropriate treatment, typically eventually dying without access to proper cardiac care.
This inability of the primary health care system outside the two big cities to identify cardiac patients (most of them with rheumatic heart disease) in need of surgery is further aggravated by the fact that the population has almost doubled since 1994, the year when the cuts commenced. As such, even the 70% higher level of services we could provide in 1994 would be far below the actual needs of today’s population. The number of cardiac operations offered to the indigent population country-wide was 142 per million population in 1992. By 2001 it had decreased to 66 per million while the need was then estimated at 356 per million, an under-delivery by a factor of 5.4. Taking into account the additional population growth of the 13 years since 2001, together with the simultaneous further decrease in operative capacity in most of the public cardiac centres of the country, it is evident that only every 8th to 10th indigent patient in this country who needs cardiac surgery will receive it at present. Rectifying this detrimental policy is a sine qua non for getting us back to an operating capacity appropriate to the role the Division plays nationally and internationally.
Apart from the need to address the shortcomings of the referral system, and for a concomitant dramatic increase in cardiothoracic operating capacity, we believe the way forward for us as the leading cardiothoracic surgery institution on the continent is to be pioneers in Africa by introducing modern, affordable and widely accessible cardiothoracic surgery techniques and technology.
An example of a way forward within the current clinical setting is to begin to reverse the trend of the past years by re- commencing operating in parallel theatres. Until the cuts of the mid-1990s, cardiothoracic surgery was being performed in parallel operating theatres, allowing four cardiac operations per day with the staff for just three, because floor nurses, anaesthetists and support staff could be partially shared while working parallel. We have started again some parallel theatre work, and intelligent patient clustering on a target day may allow sufficient staff sharing to double the day’s case numbers without doubling the costs.
An example of an area needing an urgent solution in the clinical service is how to address the unmanageable waiting list at Red Cross Children’s Hospital (RCCH). Staff increases in Paediatric Cardiology which were promised when all Western Cape cases were centralised at RCCH never materialised. As such, the current cardiologist service trying to cover both UCT’s Red Cross hospital and the University of Stellenbosch’s Tygerberg Hospital is stretched to the limit and is wasting valuable hours travelling between the hospitals. If there were a dedicated cardiologist service at each hospital, as was promised, it would free up the overstretched cardiologists and also allow for the restarting of a paediatric cardiac surgery service at Tygerberg Hospital, as the current ‘cross- platform’ approach with centralisation at RCCH has clearly failed. As we have trained one of the Tygerberg surgeons in paediatrics over the past few years, they have the surgical capacity to do approximately 50-70 less-complex cases annually, thereby reducing the untenable waiting list. This would also have a benefit in reducing the number of late- p!resenting patients, as waiting times would be significantly shortened.
A total of 17 South African cardiothoracic surgery registrars were and are being trained in the Division in the course of this Review period, of which eight have obtained their Fellowship of the College of Cardiothoracic Surgeons of South Africa (FC Cardio(SA)) qualification within 4-5 years. Three of the registrars additionally obtained M.Med. degrees, and another a concomitant Ph.D. In this Review period, the Division also trained six supernumerary registrars (5 of which completed the full training and graduated with FC Cardio(SA)) from Nigeria, Zambia and Namibia.
Apart from continuous involvement with undergraduate students (e.g. cardiovascular physiology for first year medical (MBChB) students and more than 150 5th year medical students who rotate annually through cardiothoracic surgery), the Division registered 14 Ph.D. students in the last ten years (in Cardiothoracic Surgery, Biomaterials, and Biomedical Engineering) with eight graduating after 3-4 years of study. A further 19 M.Sc. students in the same disciplines have joined the postgraduate program, with 13 graduating within 2-3 years. The Division has strived to achieve transformative demographics in the last decade and with an average 48% enrolment of female postgraduate students over the past eight years and 40% black students over the last five years, this drive towards transformation is starting to show success. In the clinical training program, more than 65% of the registrars have come from previously disadvantaged backgrounds, and our demographic distribution of registrars is approaching the demographics of the Western Cape.
Regarding the quality of the clinical training offered by the CB Division, we have continued successfully training cardiothoracic surgeons over the years in spite of being seriously limited in our operating capacity. Registrars have had to accept that a caseload of ca. 120 cases over the training period, which in the past took under four years, can now only be reached with significantly longer training periods. Adequate numbers of operations performed by each registrar were sometimes achieved only after the final college exams, sometimes before. Thus the question of whether we can justify training cardiothoracic surgeons in view of the restricted operating capacity can still be answered in the affirmative. Although the training time is longer, we have shown it is still possible to train surgeons well under these conditions.
However, South Africa has an over-saturated cardiothoracic ‘market’ in the private sector, while the government has so dramatically curtailed the discipline in the state sector all over the country that minimal career opportunities are available for many of surgeons being trained. While engaging government to change its view of cardiothoracic surgery as a cost factor rather than as an important service and career path, we have risen to the challenge of helping the rest of Africa build cardiothoracic surgery capacity for the almost one billion population without any access to proper cardiac care. In light of this lack of access, the very high incidence of rheumatic heart disease in Africa, and the increasing support by African governments to establish local cardiothoracic capacities, this is a cause worth pursuing.
We are committed to providing services which are not only world-class in terms of quality, but also appropriate to the context both of South Africa and further in Africa. We are similarly committed to research and teaching which is relevant to the population we serve. But with the WHO predictions that heart disease will become the number one killer in developing countries by 2020, it is essential that Government’s belated acknowledgement of this fact also urgently leads to an adjustment of the cardiothoracic operating capacity to meet population needs.
The Chris Barnard Division of Cardiothoracic Surgery has published a total of 158 peer-reviewed papers since the arrival of Prof. Zilla, almost exclusively in international journals, with an h-index of 46. Of these, 75 papers have been published during this Review period. The head of the division has been cited more than 5,000 times and has an overall h-index of 36. The 75 papers published in the period of this Review were in some of the highest impact journals in the fields of cardiothoracic surgery and biomaterials, e.g. Circulation, European Heart Journal, Acta Biomaterialia, Annals of Thoracic Surgery, with no fewer than 12 papers in “Biomaterials” (impact factor IF=8.3, ranked first out of 27 journals in the category of Materials Science).
Four investigators have B1 (HOD) or C ratings by the National Research Foundation with the related incentive and rated-researcher funding. We are also part of the highly successful and well-funded MRC Inter-University Cape Heart Research Grouping, with the head of the Division, Prof. Zilla, as Director for the past 10 years.
The Division’s CVR Unit received glowing reviews from the MRC during the 2003 and 2009 reviews. The Division has a worldwide network of collaborators at leading medical device companies and Universities. Examples of collaborations include those with Medtronic Inc., University of Zurich and ETH; Carolinska Institute Stockholm, Wake Forest Institute N.C., Centre for Stem Cell Research (India) etc..
Realising that our 20 years of collaboration with a first world corporation (Medtronic) had produced a plethora of patents which, while they could have improved the lives of many patients in threshold countries, were mostly never used, a decision was made to pursue local solutions. With the help of new leadership at UCT’s Innovation Centre, a UCT spin-off company was founded, Strait Access Technologies with the goal of developing affordable, easy-to-implant trans-catheter heart valves for the vast majority of rheumatic heart disease patients who have no access to open heart surgery. From 2011 to date, 18 million rand was raised from the Dept. of Science and Technology and 41 million rand from private investors.
Since the HOD is responsible for both the Clinical Services and the Laboratory-Based Research, encouragement to cross-boundary projects is guaranteed and has included the freeing up of registrars during their work week for l!aboratory-based Ph.D., M.Sc., and M.Med. programs.
Critically examining leadership in the Division shows that it has had a very structured collective decision making system in place since the appointment of the current management team in 2000. The Division spans three geographical locations (the laboratory complex occupying two and a half floors of the Chris Barnard Building at the Medical School Campus; Groote Schuur Hospital for adult patients; and Red Cross Children’s Hospitals for paediatric patients) and five structural entities (Adult Cardiac, Adult Thoracic, and Paediatric Cardiothoracic Surgery, the Cardiovascular Research Unit and SAT). Communication lines from the HOD to the section leaders on the clinical side and the senior lecturers on the research side go via the Director of Clinical Services and the Research Director.
Transformation of staff is believed by the Division’s collective management to be preferentially on the grounds of mentoring “home grown” candidates from graduate students or registrars. Although half of our residents are from historically disadvantaged population groups, it will take another two to three years until the first one will be ready to take up a staff-surgeon position – partially due to the almost doubled training time resulting from the imposed cuts in clinical services. This will coincide with the three most senior surgeons retiring within a two year period, freeing u!p staff positions that were continuously occupied by the same three senior surgeons for the past quarter of a century.
The Division believes that it has a high engagement level regarding social responsiveness. In pursuit of a more just healthcare system, we have repeatedly and intensely engaged and challenged health authorities to improve access to Cardiothoracic Surgery in the public sector, to improve the quality of service, to improve referral channels, and to seek the capacity to expand. In addition we have been engaged in high quality biomedical research which is targeted at cost-effective solutions to cardiothoracic issues facing the poor. Moreover, featured articles and interviews on rheumatic heart disease, heart valve therapies and biomechanics, etc. have appeared in numerous local popular magazines and newspapers. An example of relevant research is the pursuit for the past two decades of an affordable, durable prosthetic heart valve for developing nations. A more recent focus has been on a ‘home-grown’ catheter-based delivery system with the goal that valve replacements could be easily and cheaply done through a transapical cardiac puncture without the need for cardiopulmonary bypass, eventually even in the second-tier hospitals of Africa. On a continent that has fewer hospitals providing cardiothoracic surgery outside South Africa than there are in Cape Town, such solutions will open access to therapies for rheumatic heart disease dramatically. Several outreach programs both locally and further into Africa have been undertaken, and several are in the planning stages. These include successfully accomplished outreach programs like Namibia as well as partnerships that will persist long-term, e.g. George Provincial Hospital, Zambia and Nigeria.