Clinical Cardiology in South East Asia: Indonesian Lessons from the Present towards Improvement

- Low access to care

- Healthcare facilities: inequality and distance (problems with transportation)

- Unavailable or unaffordable CVD services in primary care

- Lack of collaboration between hospitals and primary care doctors

- Utilization of ambulance is underused, especially in rural areas

- Immature health insurance coverage, or unaffordable health insurance

- Lack of surveillance and disease monitoring in the population

- Primary care has insufficient capacity to diagnose, monitor, and manage CVD burden, including hypertension and diabetes

- Limited availability of health personnel, especially in remote areas

- Lack of standardization among healthcare providers and experts in cardiology practice

- Authority in decision-making, ignoring the guideline standards

- Poor management of after-discharge care

- Low awareness of CVD symptoms and risk factors

- Financial problems: high out-of-pocket expenditure or expensive cost of essential treatments, such as medicines for hypertension, diabetes, and cholesterol

- Low adherence to medications for primary and secondary prevention

- Low level of education of the patients and family, in the context of adherence to guideline recommendations

- Reduce delay in hospital admission, especially for patients with acute CVD

- Reduce administrative and insurance barriers in the hospital

- Accessible and affordable cardiovascular care at Puskesmas (primary care centers), such as ambulatory ECG, standardized laboratory checks

- Improve access to revascularization services

- Implementing telemedicine or mobile-health program through SMS/phone calls to improve lifestyle and adherence to after-discharge medications

- Tele-ECG monitoring and consulting at the primary care level

- Reliable patient registries should be available in a computerized format

- Improve data collection for healthcare utilization (i.e. population surveillance, CVD registry, death registry, etc)

- Preventive strategies: optimizing health and nutrition in pregnant women (including vaccination prior to or during pregnancy and adequate treatment for maternal high blood pressure)

• ▪ Lifestyle improvement: reduce consumption of fatty or deep-fried food, sugar, salty or MSG-contained, and fast food; promote active lifestyle; smoking cessation

• ▪ Adequate treatment for hypertension and diabetes: accessible care and diagnostic tools and essential medicines at primary level

- Timely and standardized initial management for acute CVD

- Implement clinical practice guidelines and improve adherence to the guideline recommendations

- Improve hospital discharge planning and transition to chronic care

- Update knowledge and skills

- Improve awareness of acute CVD symptoms

- Improve home monitoring and awareness of CVD risk factors

- Optimizing patients’ adherence and engagement with long-term medications

- Improve lifestyle

- Lack or unavailable patient registries/computerized database

- Limited and unreliable paper-based medical records

- Limited or unavailable population surveillance

- Unavailable/limited death registry

- Inadequate research infrastructures: research devices/tools should be shared with routine services in the hospital

- Less support from the hospital environment (e.g. administrative barriers)

- Lack of supportive facilities: poor internet connection, limited access to knowledge resources (e.g. international journals)

- Limited dedicated time for research, particularly if the investigators are clinicians

- Lack of peer supports

- High-cost expenditures (e.g. hiring research assistant, laboratory expenses, rewards to patients/participants, high publication costs)

- Research community is less familiar with the scientific language of English

- Low ‘research and writing’ culture

- Negative attitude towards research: low participation rate, patients/family members’ mistrust, and negative prejudice, rejection for follow-up

- High rate of lost-to-follow-up, in particular for those from rural areas

- Informed consent issues: difficulty in getting approval from patients and family members (especially if intervention is needed), verbal informed consent for illiterates

- Low education and social values are strong influencers (more comprehensive communications are needed for illiterates/low-educated participants)

- Language barriers: some patients/participants only use their local/traditional language, not Bahasa Indonesia