Palestinian Ministry of Health

PALESTINIAN MINISTRY OF HEALTH

SERVICE PURCHASE UNIT PROTOCOL MEDICAL PROCEDURES AND OTHER TESTS REFERRAL PROTOCOL 7: Based MEDICAL PROCEDURES AND OTHER TESTS

SELECT CARDIAC CONDITIONS 2018

TABLE OF CONTENTS

ACRONYMS ...... 3 PART ONE – GENERAL INFORMATION ...... 4 INTRODUCTION ...... 4 PURPOSE ...... 4 PROTOCOL DEVELOPMENT PROCESS...... 6 OVERVIEW OF CURRENT REFERRAL VOLUME AND STATUS ...... 7 SUMMARY OF HEALTH SECTOR CAPACITY ...... 8 SERVICES COVERED AS DERIVED FROM THE LAW ...... 8 PART TWO – REFERRAL POLICIES...... 9 GENERAL POLICIES ...... 9 SPECIFIC POLICIES FOR MEDICAL IMAGING ...... 10 CT SCAN ...... 10 CT ANGIOGRAPHY (CTA) ...... 11 MRI SCANS WITH OR WITHOUT CONTRAST...... 12 PET-CT SCAN ...... 13 BONE SCAN ...... 14 HEPATOBILIARY (HIDA) SCAN ...... 15 THALLIUM SCAN ...... 15 TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) ...... 16 HOLTER MONITOR...... 16 SPECIFIC POLICIES FOR ENDOSCOPY ...... 17 ENDOSCOPIES ...... 17 PILLCAM CAPSULE ENDOSCOPY ...... 18 ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPH (ERCP) ...... 18 SLEEVE SURGERY/OBESITY TREATMENT SURGERY ...... 20

ACRONYMS

BMT Bone Marrow Transplant

CTA Computed Tomography Angiography

CT Computed Tomography

ERCP Endoscopic Retrograde Cholangio-Pancreatography

EUS Endoscopic Ultrasound

GIST Gastrointestinal Stromal Tumor

HIDA Hepatobiliary

MRA Magnetic Resonance Angiogram

MRI Magnetic Resonance Imaging

PET Positron Emission Tomography

PHCP Palestinian Health Capacity Project

PMC Palestine Medical Complex

PMOH Palestinian Ministry of Health

SPU Service Purchase Unit

TEE Transesophageal echocardiography

PART ONE – GENERAL INFORMATION

INTRODUCTION The defining characteristics of the provision of health services in the Palestinian Territories and its governing power are the Public Health Law (2004) and the Health Insurance and Treatment Abroad Law (2004). Both laws ensure coverage for basic health services to every resident of the West Bank and Gaza and define the government's responsibility to provide a defined set of health services to every insured person without discrimination. The Service Purchase Unit (SPU) of the Palestinian Ministry of Health (PMOH) strives to ensure access to quality healthcare services that are not available through public PMOH facilities but are included in the set of services guaranteed to all insured people. The PMOH strives to make those services available without difficulty and in an equitable manner to all categories of the population regardless of geographical distribution, socio-economic status, or gender.

The PMOH promotes internationally accepted guidelines, recommendations, and evidence- based medicine in the treatment and management of Palestinian patients, while taking into consideration the utilization of existing local resources to provide optimal therapy and improve health outcomes.

PURPOSE As outlined in the health insurance law, there are sets of services not available within the service delivery system of PMOH facilities. Those services will be subject to referral to facilities outside the PMOH public health system based on clinical guidelines established by the PMOH and through referral processes managed by the SPU.

Clinical protocols for referrals are deemed necessary to outline the medical eligibility criteria to guide any referral decision taken at the level of the Regional Referral Committees (RRCs) and the SPU. These guidelines will provide a road map for all conditions and diseases that require referral outside the services of the PMOH.

The clinical referral protocols present the general outline and criteria for selecting patients to be referred outside public health services for specific medical conditions. The protocols do not represent a treatment plan for practitioners, but rather provide information on the most common conditions for referrals, where to refer patients, and approved drugs to be prescribed to patients and made available by the PMOH.

This specific protocol has been prepared to:

• Describe current capacity and volume of medical imaging and other select procedures in PMOH facilities and through referrals • Outline overall clinical guidelines for use of imaging and other selected medical procedures to be covered as derived from the law • Clarify the referral process and criteria for when imaging and other medical procedures may require referral to a non-PMOH facility • Guide medical staff and health referral section coordinators to process referrals

The following medical imaging and other procedures are covered in this guideline:

Medical Imaging CT Scan CT Angiography MRI (with and without contrast) PET Scan Bone Scan Hepatobiliary (HIDA) Scan Thallium Scan Endoscopy (see page 17 for complete list of procedures) Obesity Treatment Surgery/Sleeve Surgery

In most cases the medical procedures outlined above are available within the PMOH. Referrals for the procedures outlined in this guideline are justified if:

• The service is required and indicated as part of the management of the medical condition, but is not possible to perform at a PMOH hospital • The presence of a clear justification and medical indication for the procedure, as well as information regarding when and where to refer the case exist

PROTOCOL DEVELOPMENT PROCESS The PMOH SPU, supported by the USAID-funded Palestinian Health Capacity Project (PHCP), developed a special referral protocol focusing on the most common medical diagnostic procedures and other tests which are often subject to referral, such as MRIs and different types of CT scans and endoscopies.

Development of this protocol involved consultations with a number of Palestinian clinical practitioners in the field of internal medicine, gastroenterology, radiology, and a review of data on service utilization, referrals, and the capacity of the medical cadre in the Palestinian health sector. As a result, the experts offered recommendations on policies and indications related to referrals for a select number of diagnostic medical procedures. The content of this protocol has been endorsed by the Minister and the Deputy Minister of Health.

The development of this protocol and collaboration with specialists was led by:

Dr. Abd Al-Naser Daraghmeh, General Director, SPU, PMOH

Dr. Amira Al-Hindi, Advisor to the Minister of Health for Referrals, SPU, PMOH

Dr. Ammar Rashed, Internist and Medical Director, Al-Wattani Hospital, PMOH

OVERVIEW OF CURRENT REFERRAL VOLUME AND STATUS While PMOH facilities provide many medical procedures and diagnostic tests as described in the next section, under certain circumstances patients are referred to outside providers for these services. The volume of referrals for MRIs, CT scans, PET-CT scans, and endoscopies for the period of January - September 2017 is shown below. The total number of referrals for medical imaging services was 4,608, or an average of 512 referrals a month. Referrals for MRI are most numerous, followed by PET-CT scans and CT scans. Endoscopy procedures provided through referral to other facilities was 2,478, or an average of 275 per month for a variety of procedures.

MEDICAL PROCEDURE REFERRALS # OF REFERRALS, Jan-Sept 2017 Medical Imaging Referrals 4,608 Computed Tomography Scan ( CT Scan) 944 CT Brain 425 CT Abdomen 142 CT Chest 119 CT Guided Biopsy 101 CT Spine (Cervical, Dorsal, and Lumbar) 65 CT Other Body Parts 92 Magnetic Resonance Imaging (MRI) 2,303 MRI Brain 1,144 MRI Cervical Spine 589 MRI Lower Extremities (Pelvis, Knee, Foot) 228 MRI Spinal Cord 64 MRI Head, Face, Neck 62 MRI Abdomen and Liver 58 MRI 56 MRI Pituitary Gland 41 MRI Hand, Arm, Forearm, Elbow 24 MRI Angiography 17 MRI Chest 15 MRI Heart 5 PET-CT Scan 1,361 Endoscopy Referrals 2,478 Gastroscopy 940 Colonoscopy 753

ERCP 467

Cystoscopy and Ureteroscopy 202 Endoscopy 116

SUMMARY OF HEALTH SECTOR CAPACITY PMOH HOSPITAL CAPACITY Services for diagnostic and medical imaging (CT scans and MRIs) are provided by radiology departments located at select PMOH hospitals.

Most PMOH hospitals are equipped with CT scans and have physicians and technicians available to do the scans.

MRI services are available in three PMOH hospitals distributed throughout the three West Bank regions as follows:

• North: Jenin Hospital, Jenin • Middle: Palestine Medical Complex (PMC), Ramallah • South: Alia Hospital, Hebron

Other highly specialized procedures such as CT-guided biopsy, magnetic resonance angiogram (MRA), endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS), PillCam capsule endoscopy, and positron emission tomography (PET) are offered through PMOH contracts with select facilities. The only service that is not available at any of the PMOH hospitals or in the Palestinian contracted referral facilities is the PET-CT scan.

Different types of endoscopic procedures (e.g. gastroscopy, colonoscopy) are routinely available at PMOH hospitals, however, due to limited capacity in terms of specialists and equipment, and the urgent nature of certain conditions, these procedures become subject to referral.

In 2016, the total number of diagnostic and medical imaging procedures conducted in PMOH hospitals in the Palestinian Territories was 643,324, including 66,096 CT scans. This is in addition to the 517,854 normal diagnostic imaging procedures and 10,355 magnetic resonance imaging procedures conducted (2016 PMOH Annual Report).

SERVICES COVERED AS DERIVED FROM THE LAW As outlined in the health insurance and treatment abroad regulations (2006) there is a set of services which are part of the PMOH defined package of government essential services that are provided by PMOH hospitals and centers. Medical procedures in particular are available and provided within PMOH facilities. If there is need to seek these services through referral to outside providers, specific reasons and justifications must be provided and a process must be followed for authorization of such referrals.

The health insurance regulations permit referrals outside PMOH facilities if the following conditions apply:

• The requested service is included in the covered services provided by the PMOH and coverage is allowable under government health insurance rules and regulations. Eligibility of coverage is decided by the PMOH referral section. • The requested service is not available in PMOH hospitals due to lack of qualified personnel, equipment, or medical devices, or inability to accommodate the patient within PMOH facilities due to high occupancy rates, after ensuring that the case could not be referred to another governmental hospital. This will be decided by the PMOH referral section. • The waiting time to receive the required service within the PMOH health system is too long and would result in detrimental health consequences for the patient. In the case of non-emergency services (elective cases), if the waiting time for accessing services is estimated to be six months or longer, a referral to outside services will be considered, except in certain conditions where the waiting time could exceed the 6 month period without any urgency. This will be decided at the RRC level. • If PMOH facilities are not able to competently address an emergency situation that poses a threat to human life and requires immediate action, patients are to be referred immediately for services outside the PMOH. Such cases cannot wait to be submitted through appropriate referral channels. This decision will be made at the PMOH hospital referral section level, and retrospectively reviewed by the RRC and approved by the SPU.

PART TWO – REFERRAL POLICIES GENERAL POLICIES The decision to refer a patient for any medical diagnostic procedure must respect and follow the following general policies:

1. All medical procedures that require referral outside PMOH facilities should undergo a primary evaluation at a PMOH hospital by specialists before submission of a referral request to the RRC or specialty committee. 2. The Regional Referral Committee and specialized committees should review all requests submitted to the committee for review and approval, and the SPU will issue the authorization of the referral to one of the contracted hospitals. 3. Cases eligible for referral should only be referred to the PMOH’s contracted referral facilities based on a preferred list of services and providers. 4. SPU staff and Technical and Regional Referral Committees will utilize a preferred list of services and referral facilities based on quality, service availability, geography, and contract price lists. 5. The preferred list will be revised regularly and will take into consideration the availability of the service and the presence of qualified professionals. 6. The contracted treating facility should adhere to the approved procedure indicated on the authorized referral form.

The following sections outline the clinical guidelines for use of medical imaging endoscopy procedures and sleeve surgery procedures. These guidelines apply whether or not the service is provided within PMOH facilities or requires referral to an outside provider based on the conditions for referral outlined in the previous section. It is important to note that while sleeve surgery for obesity treatment is not included in the essential health services package of covered services, referral guidelines are nonetheless included for exceptional cases.

SPECIFIC POLICIES FOR MEDICAL IMAGING

CT SCAN Diagnostic Test Description A CT scan of the body uses special X-ray equipment to help detect a variety of diseases and conditions. CT scanning is fast, painless, noninvasive, and accurate. In emergency cases, it can reveal internal injuries and bleeding quickly enough to help save lives.

Indications for CT Scan • A CT scan is appropriate for an acute head injury when there is need to rule out an associated acute cerebral condition. • A CT scan is appropriate for low back injuries with clinical neurological deficits which have not responded to conservative treatment after a period of four to six weeks. • Orbital CT scans may be ordered by an ophthalmologist in the case of eye injury presenting with a foreign body or orbital injury.

• A CT scan may be required in shoulder injuries, but this should be ordered by an orthopedic surgeon. • A CT scan may be ordered in a case where a patient has undergone a second or third surgical procedure and in which a lumbar fusion is being considered.

When Not to Order CT Scans • A repeat CT scan may be ordered if there has been a marked regression or deterioration manifested by signs and symptoms but should not be ordered for routine follow-up purposes. Referrals for follow-up CT scans may only be done with the permission of the SPU medical reviewers and authorization of the SPU director.

Individuals Authorized to Order the Test Most CT scans can be provided in PMOH hospitals. In the event that a referral is required, all CT scan referral requests (emergency or non-emergency) must follow the same path and process of any other referral request. The following specialists are authorized to order referrals for CT scans: • Orthopedic surgeon • Neurologists and neurosurgeon • Ophthalmologist (in case of eye injury)

CT ANGIOGRAPHY (CTA) Diagnostic Test Description Computed tomography angiography (CTA) is available at each PMOH hospital that conducts CT scans or has a CT machine. CTA uses an injection of iodine-rich contrast material and CT scanning to help diagnose and evaluate blood vessel disease or related conditions, such as aneurysms or blockages.

CT coronary angiography requires the new generation of CT scanners, which can take 64 pictures a minute. This service is not available at PMOH facilities and therefore requires a referral.

Indications for CTA Physicians use CTA to diagnose and evaluate many diseases of blood vessels and related conditions such as:

• Injuries

• Aneurysms • Blockages (including those from blood clots or plaques) • Disorganized blood vessels and blood supply to tumors • Congenital (birth related) abnormalities of the heart, blood vessels, or various parts of the body which might be supplied by abnormal blood vessels

Individuals Authorized to Order the Test Referrals for cardiac CTA can only be requested by a cardiologist or internist if a cardiologist is not available.

MRI SCANS WITH OR WITHOUT CONTRAST Diagnostic Test Description A magnetic resonance imaging (MRI) scan is a common procedure that uses a strong magnetic field and radio waves to create detailed images of the organs and tissues within the body. Physicians can use this test to diagnose a patient or to see how well a patient responded to treatment. Unlike X-rays and CT scans, an MRI doesn't use radiation.

Indications for MRI Scan • Cervical injuries, in which a cervical disc is suspected, generally performed without contrast • Acute knee injuries with suspected meniscal injuries or collateral ligament injuries • In lumbar disc injuries, a CT scan may be a reasonable alternative; generally, MRI and CT scans should not both be performed • In metatarsal fractures, an MRI is rarely indicated, and can only be ordered by an orthopedic surgeon, hand surgeon, or rheumatologist • Thoracic spine injuries with any indication of damage within the canal • Waters view is frequently done to determine if there is a suspicion of a metallic foreign body in the orbit; if there is a high level of suspicion of metallic foreign body in the orbit, a CT scan of the orbit can be done • Shoulder injuries • Peripheral nerve disorder; may only be ordered by a specialist (mentioned below)

Indications for Breast MRI scan for patients with breast cancer • Non-conclusive mammography and breast ultrasound • Young female patients <35 years old with diffuse micro-calcifications • Positive axillae for carcinoma with negative breast imaging • Follow-up for patients of young age

Indications for a Repeat MRI Scan • There are clear clinical signs or symptoms, or radiographic signs of significant regression • After surgery if a patient differentiates between further disc material and scar tissue • Any follow-up MRI study may only be done with the permission of the SPU

When Not to Order MRI Scans MRI scans may not be ordered for routine follow-up purposes.

Individuals Authorized to Order the Test The MRIs mentioned above are generally to be ordered by an orthopedic surgeon, neurologist, neurosurgeon, oncologist, or rheumatologist.

PET-CT SCAN Diagnostic Test Description Positron emission tomography, also called PET-CT imaging or a PET-CT scan, is a type of nuclear medicine imaging. PET-CT scans measure the metabolic activity of cells in the human body and are used in patients with certain conditions affecting the brain and the heart. PET-CT is a service available to patients for diagnosis, staging, restaging, and monitoring response to treatment for an increasing number of cancers.

Indications for PET-CT Scan in Lymphoma PET-CT scans are generally indicated in lymphoma and considered as an indication for referral as noted below:

• Baseline at time of diagnosis in Hodgkin's lymphoma • After completing 2-3 cycles of chemotherapy in Hodgkin's lymphoma, if feasible • After 1-2 months of completing treatment for non-Hodgkin’s lymphoma (diffuse large- cell type) • Pre-BMT and post-salvage therapy in Hodgkin's lymphoma and non-Hodgkin’s lymphoma (diffuse large-cell type) • Clinically Stage IA-follicular lymphoma when considering curative treatment by radiotherapy

Indications for PET-CT Scan in Solid Tumors • Esophageal carcinoma before definitive therapy (surgery or chemo-radiation therapy) • Stage IV colorectal carcinoma before metastasectomy

• Carcinoma of cervix for staging • Head and neck carcinoma for staging • Lung carcinoma before and after definitive therapy (surgery or chemo-radiation therapy) • Breast carcinoma with high tumor marker and normal CT scan finding • Melanoma for staging • Seminoma with residual disease more than three centimeters after treatment • Ewing sarcoma for staging and treatment evaluation • GIST • Select cases of suspected liver metastasis in solid tumors • Localized and locally advanced rectal cancer • Cases with multiple lesions to decide on the primary site • Cases that require measurement of response to treatment schedule

Referral Policy for PET-CT Scans Approval for referrals to perform PET-CT scans is subject to the review and recommendation made by the Specialized Oncology and Hematology Referral Committee.

All PET-CT scan referrals should meet the clinical indications specified in the Oncology and Hematology Protocol (and protocols included here) in order to be referred to one of the contracted Israeli hospitals that provide PET-CT scan services.

Individuals Authorized to Order the Test PET-CT scans can only be authorized through the Specialized Oncology and Hematology Referral Committee.

BONE SCAN Diagnostic Test Description Bone CT and MRI scans are used to determine the presence of infections and certain diseases, such as cancer, in bones. Bone CT scans are the most widely recommended method for diagnosing bone diseases, but some benefits of using MRI scans instead of CT scans are emerging as MRI use increases. Several factors are taken into consideration in deciding whether to use a CT scan or MRI for detection of cancer, infection, and other bone disorders.

Indications for Bone Scan A bone scan may be ordered for the following reasons: • Suspected tumor involvement of the bony part injured • Suspected infection of the bony part injured

• Where X-rays have failed to show a fracture (occasionally) • In some cases of acute knee injuries (should be ordered by an orthopedic surgeon)

Individuals Authorized to Order the Test Bone scans can only be authorized through a recommendation submitted by orthopedic or oncology specialists to be reviewed by the RRC or Specialized Oncology and Hematology Referral Committee.

HEPATOBILIARY (HIDA) SCAN Diagnostic Test Description Hepatobiliary (HIDA) scan is an imaging procedure used to diagnose problems of the liver, gallbladder, and bile ducts.

Indications for HIDA Scan A HIDA scan might help in the diagnosis of several diseases and conditions, such as: • Gallbladder inflammation (cholecystitis) • Bile duct obstruction • Congenital abnormalities in the bile ducts, such as biliary atresia • Postoperative complications, such as bile leaks and fistulas • Assessment of liver transplant

Individuals Authorized to Order the Test HIDA scans can be requested by a gastroenterologist or a surgeon.

THALLIUM SCAN Diagnostic Test Description A thallium scan is a nuclear medicine test that examines the supply of blood to the muscles of the heart (the myocardium). The test is usually done in two parts- the stress scan (while the heart is working hard), and the rest scan (while the heart is resting). The two parts of the scan are both done on the same day. The two scans are compared to look for differences that indicate areas of poor blood flow (which may cause chest pain) or no blood flow (due to a previous heart attack). Sometimes a third part of the scan may be needed on the next day. This can distinguish areas of the heart muscle that are not working but which still have viable blood flow. Indications for Thallium Scan A thallium scan might be requested if causes of chest pain couldn’t be revealed by a normal cardiac catheterization.

Individuals Authorized to Order the Test Thallium scans can only be ordered by a cardiologist.

TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) Diagnostic Test Description Transesophageal echocardiography (TEE) is a test that uses ultrasound to make detailed pictures of the heart and the arteries that lead to and from it. Unlike a standard echocardiogram, the echo transducer that produces the sound waves for TEE is attached to a thin tube that passes through the mouth, down the throat and into the esophagus. Because the esophagus is so close to the upper chambers of the heart, very clear images of the heart structures and valves can be obtained.

Indications for TEE Doctors use TEE to find problems in the heart’s structure and function. TEE can give clearer pictures of the upper chambers of the heart, and the valves between the upper and lower chambers of the heart, than standard echocardiograms. Doctors may also use TEE if the patient has a thick chest wall, is obese, has bandages on the chest, or is using a ventilator to help them breathe.

Individuals Authorized to Order the Test TEE can only be ordered by a cardiologist.

HOLTER MONITOR Diagnostic Test Description A Holter monitor is a small, portable medical device that measures the heart’s rate and rhythm. This test is performed if more information is needed about how the heart functions than a routine (EKG) can deliver.

Holter monitoring is a continuous test to record the heart’s rate and rhythm that will be carried out for 12 to 48 hours as the patient goes about his/her normal daily routine. This device has electrodes and electrical leads like a regular EKG and can pick up the heart’s rate, rhythm, and when the patient feels chest pains or exhibits symptoms of an irregular heartbeat or arrhythmia.

Indications for Holter Monitor This test is usually performed if signs and symptoms of a heart problem exist, such as an irregular heartbeat (arrhythmia) or unexplained fainting. These symptoms may suggest that an

16 irregular heart rhythm may be present, and an ordinary electrocardiogram doesn't detect any irregularities.

Individuals Authorized to Order the Test A Holter monitor can only be ordered by a cardiologist.

SPECIFIC POLICIES FOR ENDOSCOPY

ENDOSCOPIES Despite the fact that most endoscopies are available at PMOH hospitals, these procedures often become eligible for referral due to the lack of qualified specialists, medical devices, or equipment, or due to the limited capacity of the facility to cope with increasing demand on specialists.

Medical Procedure Description An endoscopy is a procedure that uses specialized instruments to view and operate on internal organs and vessels of the body. It allows surgeons to view problems within the body without making large incisions. A surgeon inserts an endoscope through a small cut or opening in the body, such as the mouth. An endoscope is a flexible tube with a camera attached that allows the physician to see inside the patient. The surgeon can use forceps (tongs) and scissors on the endoscope to operate or remove tissue for biopsy.

The table below provides a list of common endoscopic procedures. Availability of Location of Type of Endoscopy Body Part Examined Service at Insertion PMOH Upper Gastrointestinal Endoscopy/ Esophagus/upper Mouth Yes Esophagogastroduodenoscopy intestinal tract (EGD) PillCam Capsule Endoscopy Small intestine Mouth/anus No ERCP Bile and pancreatic ducts Mouth No Colonoscopy Colon Anus Yes Laryngoscopy Voice box/larynx Mouth/nostril Yes Bronchoscopy Lungs Nose/mouth Yes Area between lungs Incision above Mediastinoscopy No (mediastinum) breastbone Chest, abdomen, and Endoscopic Ultrasound (EUS) Mouth/anus Yes colon Ureteroscopy Ureter Urethra Yes Cystoscopy Urinary Bladder Urethra Yes Hysteroscopy Inside of uterus Vagina No

Incision near area to Laparoscopy Abdominal/pelvic area Yes be examined Incision near area to Arthroscopy Joints Yes be examined From the list above, some types of endoscopic procedures are not available within PMOH facilities and are subject to referral. The following is a description of services that are more frequently referred: PillCam capsule endoscopy, ERCP, and endoscopic ultrasound (EUS).

PILLCAM CAPSULE ENDOSCOPY Medical Procedure Description PillCam capsule endoscopy allows for the examination of the small intestine. The patient swallows a vitamin-sized capsule that has its own camera lens and light source. While the video capsule travels through the digestive tract, images are sent to a data recorder the patient wears on a waist belt. Afterwards, the doctor views the images on a video monitor.

Indications for a PillCam capsule endoscopy The most common reason for the examination is persistent bleeding from the gastrointestinal tract with negative results on an EGD, colonoscopy, or small bowel follow-through X-ray. Other reasons for the examination include an abnormal X-ray of the small intestine, certain chronic conditions, or in rare cases of persistent abdominal pain.

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPH (ERCP) Medical Procedure Description ERCP is a gastroenterology procedure used to study the ducts (drainage tubes) from the liver, gallbladder, and pancreas. An endoscope is passed through the mouth, esophagus, and stomach and into the duodenum. A small plastic tube or catheter is passed through the endoscope and into the ducts. Contrast material is then injected into the ducts and X-rays are taken.

Indications for ERCP ERCP can be helpful in diagnosing or treating a number of conditions such as: • Gallstones trapped in the main bile duct • Blockage of the bile duct • Jaundice • Pancreatitis • Cancer of the pancreas bile ducts • Abdominal pain

ENDOSCOPIC ULTRASOUND (EUS)

Medical Procedure Description Endoscopic ultrasound (EUS) is a combination of an endoscopy and an ultrasound used to examine the digestive tract and the surrounding tissue and organs. Endoscopy refers to the insertion of a long flexible tube via the mouth or rectum to examine the digestive tract. Ultrasound uses high-frequency sound waves to produce images of the organs and structures inside the body. By placing an ultrasound machine at the tip of an endoscope tube, the doctor can obtain high quality images of the organs inside the body.

Indications for Endoscopic Ultrasound (EUS) EUS is used to provide information about the layers of the intestinal wall, nearby organs, or lymph nodes and blood vessels. EUS can also include obtaining tissue samples or biopsies to help in diagnosing enlarged lymph nodes or masses seen on other imaging studies. EUS is useful in several situations including: • Evaluating chronic pancreatitis, masses, or cysts of the pancreas • Studying bile duct abnormalities including stones in the bile duct or gallbladder, or cancer of the bile ducts • Studying certain submucosal lesions such as nodules or "bumps'" that may be hiding in the intestinal wall covered by normal-looking lining of the intestinal tract • Staging (or determining the extent of) certain cancers

Individuals Authorized to Order the Test Decisions regarding endoscopies for one of the above described specialized procedures are subject to the related specialty. Only specialists in the related field are authorized to order the procedure.

ANNEX: SPECIFIC PROCEDURES OUTSIDE THE PMOH ESSENTIAL SERVICE PACKAGE

SLEEVE SURGERY/OBESTITY TREATMENT SURGERY Sleeve surgery is not part of the PMOH essential services package; it is exceptionally permitted upon discussion of individual cases by the Sleeve Specialized Referral Committee.

Medical Procedure Description Sleeve gastrectomy is a surgical procedure for weight loss in which the stomach is reduced to about 15% of its original size by surgically removing a portion of the stomach, permanently reducing its size and resulting in a sleeve or tube-like structure. The procedure is generally performed laparoscopically and is irreversible. This intervention can be performed at specific PMOH surgical departments, but may be subject to referral based on specific conditions and criteria.

Indications and Conditions for Obesity Treatment Surgery to be followed for Referral: • The person is over 18 years of age and has achieved full growth • Lack of specific underlying causes of obesity (e.g. endocrine disorders, adrenal or thyroid diseases, or the treatment of metabolic issues); internist report including required medical tests should be requested before referral • Lack of a life threatening condition that will not improve with surgery (such as cancer or cirrhosis) • Within at least the past two years, active participation for at least 6 months in diet programs under the supervision of the PMOH and dietitian. A report should be included, showing monthly documentation (as well as the date of report and responsible person) of each of the following elements: A. Vital indicators including weight

B. Current diet program

C. Physical activity (i.e. exercise program)

D. Behavioral interventions to promote healthy eating and exercise habits (e.g. likes sugars, chocolates, etc.)

E. Attempting to use medicines or medicinal herbs approved by the PMOH (if appropriate) during the follow-up with a nutrition specialist

• If BMI is then more than 40 without the presence of any disease • If BMI is greater than or equal to 35 with one of the following diseases (documents must be submitted for any of the following clinically verified, related disease conditions and

problems): A. The significant and direct inability to perform daily activities B. Circulatory insufficiency C. Coronary heart disease (CHD) (previously called ischemic heart disease (IHD)) D. Secondary physical trauma due to complications of obesity (fractures, dislocation, etc.) E. Respiratory deficiencies F. Medically resistant hypertension (documented with drugs) G. Osteoporosis (documented with tests) H. Type 2 diabetes (documented with tests)

• If BMI is more than 50, there is no need for any of the previous procedures according to medical protocols

Exclusion Criteria for Surgery to Treat Obesity • BMI <35 kg/m2 • Age <18 or >65 years • A medical condition that makes surgery very dangerous (high-risk patients) • Mental and psychological disorders • Pregnant or lactating women, or those planning to conceive within two years of operation • Smokers (all smokers, regardless of their weight, should quit smoking for at least three months before surgery)

Referral Policy for Obesity Treatment Surgery Based on the conditions and criteria outlined above, all cases subject to be referred for this specific procedure should respect the following:

1. All cases should undergo a primary evaluation at a PMOH hospital by specialists before submission to the Sleeve Specialized Referral Committee. 2. All cases should follow the clinical indications decided and included in this protocol. 3. The Sleeve Specialized Referral Committee will review all requests submitted for technical decision, and the SPU will issue the authorization of the referral to one of the contracted hospitals once approved by the committee. 4. Cases eligible for referral should be referred only to the PMOH’s contracted referral facilities based on a preferred list of services and providers. 5. Sleeve surgery is only eligible for referral once. Should a patient wish to undergo sleeve surgery more than once, all costs associated with the procedure will be the responsibility of the patient.

Individuals Authorized to Order Sleeve Surgery Sleeve gastrectomy is a surgical procedure for weight loss. If it is not medically advised, it is considered a cosmetic procedure and therefore not included in the health insurance benefit package. Obtaining a referral for this procedure requires exceptional decision by the specialized committee based on the above mentioned criteria.

Palestinian Health Capacity Project (PHCP) AID-294-LA-13-00001 USAID West Bank/Gaza Office of Human Capital and Social Impact

This document is made possible by the generous support of the American people through the United States Agency for International Development (USAID).

The contents are the responsibility of IntraHealth – PHCP and do not necessarily reflect the views of USAID or the United States Government.

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