Yoğun Bakım / Bakım Kalitesi ( Ekonomik Verimlilik )

Transkript

YOĞUN BAKIM,
BAKIM KALİTESİ,
(EKONOMİK
VERİMLİLİK)
Yar. Doç. Dr. Kadir Doğruer
Anesteziyoloji ve Reanimasyon
Avrasya Hastanesi
GER
İ
AR ÖDEM
TIK ED
E
T
KRİ
EK
TER
MALİYETETKİLİLİK
COSTEFFECTIVENESS
?
MEDİKAL ETKİLİLİK
GÜVEN
KALİTE
DÜNYA GENELİNDE;
HÜKÜMETLER, SAĞLIK
HİZMETİ SUNUM
SİSTEMLERİ, SİGORTACILAR
VE TÜKETİCİLER ARASINDA
BİR SAVAŞ VAR:
BİR YANDAN ARTAN SAĞLIK
TALEBİNİ KARŞILAMAK VE
DİĞER YANDAN MALİYETLERİ
OLABİLDİĞİNCE DÜŞÜRMEK.
HİZMET KALİTESİ…?
TASARRUF
YASAL
DÜZENLEMELER
VE UYUM
SEKTÖR
HEDEFLERİ
MARKETLERE
ADAPTASYON
DEĞİŞİM VE
DİJİTAL
İNOVASYON
Deloitte Touche Tohmatsu Limited, 2014
SAĞLIK HARCAMALARI ÜZERİNDEKİ BASKILAR
SAĞLIK HARCAMALARI ÜZERİNDEKİ BASKILAR
➤
➤
➤
Yaşlı nüfusta artış
Giderek büyüyen marketler
Yeni tedavi teknikleri
<
➤
➤
➤
Yaşlı nüfusta artış
Giderek büyüyen marketler
Yeni tedavi teknikleri
Deloitte Touche Tohmatsu Limited, 2014
➤
Sağlık
harcamalarını
azaltma
BASKISI
SAĞLIKTA PARADİGMA DEĞİŞİMİ
HASTALIK ODAKLI
SAĞLIK, FONKSİYONELLİK VE
İYİLİK HALİ ODAKLI
TIBBİ BAKIM ODAKLI
SAĞLIK BAKIM ODAKLI
HEKİM HASTALIĞIN
İYİLEŞTİRİCİSİ
HEKİM İYİLEŞTİRİCİLİĞİN
YANISIRA SAĞLIĞIN
GELİŞTİRİCİSİ
HASTALIK PATOLOJİK VE
FİZYOLOJİK ÖZELLİKLERE GÖRE
ÖLÇÜLÜR
YAŞAM KALİTESİ,
FONKSİYONELLİK VE İYİLİK
HALİ KAVRAMLARI
SAĞLIKTA
İLGİ
ALANLARI MI
DEĞİŞİYOR…?
➤
AMAÇ SAĞLIK MI, YOKSA..?
➤
TIBBİ BAKIM MI, YOKSA
BAŞKA PROGRAMLAR MI..?
➤
DOKTOR MU, YOKSA
DİĞER SAĞLIK
SUNUCULARI MI..?
➤
BUGÜN MÜ, YARIN MI
SAĞLIK..?
➤
KİMİN HAYATI ÖNEMLİ
PEKİ..?
R
A
IK I
Ç
R AR
E
L
L
İ
P
B
U
LO UR
G
L
SA R
UM LE
PL İH
TO RC
TE
L
A
S ER
M İL
U
T
L
N
P E
O
T KL
BE
İNANÇLAR
VE DİĞER
YARGILAR
BİL
KAN Gİ VE
ITL
AR
SİYASET
Ekonomik Değerlendirme
Tanımlama
Maliyet-Etkililik Analizi
Bir ürün ya da hizmetin veya müdahalenin
maliyetinin ölçülmesi.
Karar vermede sıklıkla kullanılan bir tekniktir.
Projenin beklenen faydaları toplam bütçeden
çıkarılır.
Sonuç başına harcanan
Maliyet-Etkililik Oranı
Toplam maliyetin toplam faydaya oranı
Maliyet Analizi
Maliyet-Fayda Analizi
Maliyet-Yarar Analizi
Maliyet-Yarar Oranı
Maliyet-fayda analizi yöntemlerinden biridir.
Farklı prosedürler ve sonuçlar karşılaştırılır.
1 QALY elde etmek için yapılan girişimlerin
karşılaştırılması
MALİYET MİNİMİZASYON ANALİZİ
COST-MINIZATION ANALYSIS
MALİYET FAYDA ANALİZİ
COST-BENEFIT ANALYSIS
MALİYET ETKİLİLİK ANALİZİ
COST-EFFECTIVENESS ANALYSIS
MALİYET YARARLANIM ANALİZİ
COST-UTILITY ANALYSIS
Düşük maliyet Yüksek maliyet
MALİYET
B
A
C
Daha az etkili
Daha çok etkili
ETKİNLİK
Maliyet-Etkinlik Model’inin Duyarlılık Analizi
Burada, bir maliyet-etkinlik alanı tanımlanmaya çalışılmaktadır: Standart veya uygulanmakta olan tedavilerden daha
etkin veya daha az etkin, daha ucuz veya daha pahalı tedavi yöntemlerinin karşılaştırılabildiği bir diyagram
oluşturulmaya çalışılmaktadır.
Understanding Costs and Cost-Effectiveness in Critical Care. Report from the Second American Thoracic Society Workshop on Outcomes Research
THIS OFFICIAL WORKSHOP REPORT OF THE AMERICAN THORACIC SOCIETY WAS APPROVED BY THE ATS BOARD OF DIRECTORS JUNE 2001
MALİYET
YÜKSEK MALİYET
DÜŞÜK
ETKİLİLİK
(HAKİM)
YÜKSEK MALİYET
YÜKSEK
ETKİLİLİK
QALY
DÜŞÜK MALİYET
DÜŞÜK
ETKİLİLİK
DÜŞÜK MALİYET
YÜKSEK
ETKİLİLİK
(BASKIN)
Eşik Değer (Threshold)
➤
1973 yılında Weinstein ve
Zeckhauser’in sağlık maliyetleri
ve etkilerinin bir sağlık sistemi
için kabul edilebilir bir ölçüde
olması gerektiğini
savunmalarıyla ortaya atılmış bir
kavramdır
➤
Eşik değer; karar vericinin bir birim
sağlık çıktısına verdiği değeri gösteren
bir kuraldır.
Weinstein MC, Zeckhauser R. Critical ratios and efficient
allocation. J. Public Econ. 1973;2:147–157.
Sağlık Harcamalarının Gelişimi
on TL
ılı
a, TL
9
0
1
7
7
3
7
5
6
6
8
0
KAYNAK: TUİK
Sağlık Harcamala
Milyon TL
Türkiye’de 2002-2013
döneminde sağlık
harcamaları nominal
olarak 3,5 kat
civarında, reel olarak
ise 0,6 kat artmıştır.
Yıllar
TL
2013 Yılı
Fiyatlarıyla, TL
2002
18.774
52.289
2003
24.279
53.980
2004
30.021
61.461
2005
35.359
66.917
2006
44.069
76.097
2007
50.904
80.823
2008
57.740
83.007
2009
57.911
78.355
2010
61.678
76.866
2011
68.607
80.306
2012
74.189
79.748
2013
84.390
84.390
2002-2013
Artış (Kat)
3,5
0,6
KAYNAK: TUİK
Türkiye’de 2002-2013 döneminde sağlık harcamala
B- Sağlık Harcamalarının Gelişimi (2002-2013 Dönemi)
Yıllar İtibariyle Sağlık Harcamaları ve GSYH İçindeki Payı
Milyon TL
%
90.000
7,0
80.000
70.000
5,8
5,4
5,3
5,4
6,0
6,1
6,1
5,6
5,4
5,3
6,0
5,4
5,2
5,0
60.000
4,0
84.390
74.189
61.678
57.911
57.740
44.069
35.359
24.279
10.000
18.774
20.000
30.021
30.000
50.904
40.000
68.607
50.000
3,0
2,0
1,0
0
0,0
2002
2003
2004
2005
Sağlık Harcamaları, Milyon TL
2006
2007
2008
2009
2010
2011
2012
2013
Sağlık Harcamalarının GSYİH İçindeki Payı (%)
2002-2013 yıllarındaki sağlık hizmetlerinde yaşanan gelişmelere rağmen sağlık
harcamalarının Gayri Safi Yurt İçi Hasıla içindeki payı (%5,4) değişmemiştir
6
i Başı Sağlık Harcamasının Gelişimi
KAYNAK: TUİK
PMC full text: Int J Environ Res Public Health. 2010 Apr; 7(4): 1835–1840.
Published online 2010 Apr 20. doi: 10.3390/ijerph7041835
Copyright/License ►
Request permission to reuse
Table 1.
Use of economic evaluation in decision making around the world.
Country
Organisation
Implementation date
Australia
Pharmaceutical Benefits Advisory Committee
1993
Belgium
Medicine Reimbursement Committee
2002
England/Wales National Institute for Health and Clinical Excellence
1999
France
High Health Authority
2008
Institute for Quality and Efficiency in Health Care
2007
Netherlands
Health Care Insurance Board
1999
New Zealand
Pharmaceutical Management Agency
1993
Scotland
Scottish Medicines Consortium
2002
Sweden
Dental and Pharmaceutical Benefits Agency
2002
Taiwan
Centre for Medicine Evaluation
2008
Germany
Int J Environ Res Public Health. 2010 Apr; 7(4): 1835–1840.
Published online 2010 Apr 20. Health Economic Assessment: Cost-Effectiveness Thresholds and Other Decision Criteria Steven Simoens*
QALY
Quality-Adjusted Life Year
QALY
➤
QALY sağlık hizmetlerinin
sunumunun kalitesi ve
kantitesini dikkate alır.
➤
Beklenen veya geri kalan
yaşam süresi içindeki yaşam
kalitesinin yıla göre
değerlendirildiği sayısal bir
veridir.
➤
QALY konsepti karar bilimi ve
beklenen yarar teorimine
dayanmaktadır.
EQ-5D
EQ-5D ilk defa EuroQol Grup
tarafından tanımlanmıştır. Bu
gurup 1987 yılında Hollanda,
Birleşik Kırallık, İsveç,
Finlandiya ve Norveç’ten
araştırmacıların multidisipliner
katılımıyla kurulmuştur. Bu
gurubun amacı hastalığa özel
olmayan, genel bir sağlık/yaşam
kalitesi süreçlerini
değerlendirmek için bir araç
geliştirmektir.
EQ-5D3 SKORLAMASI
SORUN YOK
BAZI SORUNLAR BÜYÜK SORUN VAR
Mobilite
Sorunsuz
yürüyebiliyor
Yürürken problem
Yatağa bağımlı
Ağrı/Rahatsız
Rahatsızlık veya
ağrı yok
Orta derecede
rahatsızlık veya
ağrı
Şiddetli derecede
rahatsızlık veya
ağrı
Ankisiyete/
Depresyon
Ankisiyete veya
depresyon yok
Şiddetli Ankisiyete
veya depresyon
Kişisel Bakım
Kişisel bakımında
sorun yok
Orta derecede
ankisiyete veya
depresyon
Kişisel bakımda
bazı sorunlar
Genel aktiviteleri
gerçekleştirmede
bazı sorunlar var
Genel aktiviteleri
gerçekleştiremiyor
Genel Aktiviteler/Ev Genel aktiviteleri
işi yapmak,
çalışmak, amaçsız gerçekleştirmede
sorun yok
aktiviteler
Kendi kendine
bakımı
ÖRNEK EQ-5D5 SETLERİ
5L profile
11111
11112
11113
11114
11115
11121
11122
11123
11124
11125
11131
11132
11133
11134
11135
11141
11142
11143
Denmark
1,000
0,856
0,818
0,671
0,519
0,859
0,787
0,768
0,622
0,469
0,824
0,770
0,756
0,609
0,457
0,691
0,637
0,623
France Germany Japan
1,000
1,000
1,000
0,929
0,999
0,829
0,910
0,999
0,785
0,769
0,809
0,761
0,622
0,611
0,736
0,910
0,910
0,814
0,839
0,909
0,740
0,820
0,909
0,721
0,679
0,719
0,697
0,532
0,521
0,672
0,888
0,887
0,768
0,817
0,887
0,718
0,798
0,887
0,705
0,657
0,697
0,681
0,510
0,499
0,656
0,757
0,677
0,723
0,686
0,677
0,673
0,667
0,677
0,660
Netherlands
1,000
0,845
0,805
0,592
0,370
0,874
0,765
0,736
0,523
0,301
0,843
0,745
0,719
0,506
0,284
0,652
0,554
0,528
Spain Thailand UK
US
1,000
1,000
1,000 1,000
0,932
0,814
0,879 0,876
0,914
0,766
0,848 0,844
0,731
0,660
0,635 0,700
0,541
0,549
0,414 0,550
0,910
0,780
0,837 0,861
0,857
0,723
0,768 0,820
0,843
0,708
0,750 0,809
0,660
0,602
0,537 0,669
0,470
0,491
0,316 0,524
0,887
0,726
0,796 0,827
0,838
0,701
0,740 0,806
0,825
0,694
0,725 0,800
0,642
0,588
0,512 0,661
0,452
0,477
0,291 0,517
0,702
0,616
0,584 0,682
0,653
0,590
0,527 0,663
0,640
0,584
0,513 0,659
Zimbabwe
0,900
0,864
0,854
0,792
0,727
0,846
0,810
0,800
0,738
0,673
0,833
0,797
0,787
0,725
0,660
0,739
0,703
0,693
Türkiye’de EQ-5D3’ün 2. Versiyonu ve EQ-5D5’in 1. Versiyonu implante edilmiştir.
-Ceri Phillips BSc(Econ) MSc(Econ) PhD Professor of Health Economi Hayward Medical Communications, a division of
Hayward Group Ltd. Copyright © 2009 Hayward Group Ltd.
1
0
Olası EN İYİ yaşam kalitesi
+
-
ÖLÜM
Mükemmel sağlık
durumu ’1’olarak
değerlendirilirken,
sağlık durumundaki
her kalite azalması
1’in altında
değerlendirilir. Ölüm
‘0’ değerini alır. Bazı
sağlık durumunları
ölümden dahi kötü
olabilir. Bu nedenle
bu durumlar
‘negatif’ QALY değeri
olarak
değerlendirilir.
Olası EN KÖTÜ yaşam kalitesi
utilities of some of the health states are
shown in Table 1.
KEY FORMULA 1
EQ-5D3 Calculating QALYs: an example
at 0.75 will generate one more QALY than an
intervention that generates four additional
years in a health state valued at 0.5
(Key formula 1).
Effect of interventions
When data relating to both health-related
EQ-5D3 kullanımı talebi giderek artmaktadır. EQ-5D’nin
hizmetlerinin
quality ofsağlık
life and survival
are available, it is klinik
Intervention B: four years in health state 0.5
2 QALYs
then possible to chart the impact of a
ve ekonomik değerlendirilmesinde kullanılması Washington
Panel on Cost
healthcare intervention on an individual
Additional number of QALYs generated by A
1 QALY
patient. For example, it is possible to compare
Effectiveness in Health & Medicine tarafından önerilmektedir.
Intervention A: four years in health state 0.75
3 QALYs
Table 1. EQ-5D health state valuations
Health state
Description
Valuation
11111
No problems
1.000
11221
No problems walking about; no problems with self-care; some problems with
performing usual activities; some pain or discomfort; not anxious or depressed
0.760
22222
Some problems walking about; some problems washing or dressing self;
some problems with performing usual activities; moderate pain or discomfort;
moderately anxious or depressed
0.516
12321
No problems walking about; some problems washing or dressing self; unable
to perform usual activities; some pain or discomfort; not anxious or depressed
0.329
21123
Some problems walking about; no problems with self-care; no problems
with performing usual activities; moderate pain or discomfort; extremely
anxious or depressed
0.222
23322
Some problems walking about, unable to wash or dress self, unable to perform
usual activities, moderate pain or discomfort, moderately anxious or depressed
0.079
33332
Confined to bed; unable to wash or dress self; unable to perform usual
activities; extreme pain or discomfort; moderately anxious or depressed
–0.429
Ceri Phillips BSc(Econ) MSc(Econ) PhD Professor of Health Economi Hayward Medical Communications, a division of
Hayward Group Ltd. Copyright3© 2009 Hayward Group Ltd.
Date of preparation: April 2009
NPR09/1265
UK, using a choice-based
method
of valuation
QALY. Thus, an intervention that gener
a condition
with a poor
prognosis.
As shown,
years in a health
state va
(the time trade-off method). Examples of the
four additional
Using
QALY
theutilities
treatment
has
an
initial
improvement
on
of some of the health states are
at 0.75 will generate one more QALY th
health-related
quality of life, but, as adverse
QALYs
provide
a com
shown in Table 1.
intervention that
generates
four additio
years in a health
valued
0.5 be
effects associated with the treatment become
thestate
extent
ofatthe
(Key formula 1).
KEY
FORMULA
1 is lost and quality of
apparent,
this benefit
life
variety of interventi
falls
below that
for a non-treated
related quality of lif
Calculating
QALYs:
anexpected
example
Effect ofpatient.
interventions
patient. This quality of life deficit associated
They are us
to both health-relat
health
state 0.75generates3 ‘QALYs
QALYs lost’When data relating
Intervention A: four years
withinthe
treatment
effectiveness
of inte
quality of life and survival are available
compared
non-treated2 QALYs
patient. At athen possiblecombined
withofthe
Intervention B: four years
in healthwith
statea0.5
to chart the impact
a
onthe
an individu
time when
patient dies,healthcare
the intervention
providing
interv
Additional number ofpoint
QALYs in
generated
by A the latter
1 QALY
patient. For example, it is possible to co
treated patient demonstrates ‘QALYs gained’
cost–utility ratios. A
difference between
Table 1. EQ-5D health state valuations
interventions divide
Health state
Description
Valuation
QALYs they
produce
11111
No problems
A recent1.000
example
11221
No problems walking about; no problems with self-care; some problems
with
0.760 by t
the
assessments
performing usual activities; some pain or discomfort; not anxious or depressed
Consortium5 and Al
22222
Some
walking about;
washing or dressing
self;
0.5166
Costproblems
of Intervention
A –some
Costproblems
of Intervention
B
Strategy
Group
of d
Cost–utility ratio = some problems with performing usual activities; moderate pain or discomfort;
sanofi-aventis) in co
moderately
depressed by Intervention A
No. of anxious
QALYsorproduced
and 5-fluorouracil
(
12321
No–problems
some problems
washing or B
dressing self; unable
0.329
No. of walking
QALYsabout;
produced
by Intervention
to perform usual activities; some pain or discomfort; not anxious or depressed
treatment of patient
0.222
Some problems walking about; no problems with self-care; no problemsadvanced squamous
21123
KEY FORMULA 2
Cost–utility ratio – an example
with performing usual activities; moderate pain or discomfort; extremely
anxious or depressed
2a
23322
Some problems walking about, unable to wash or dress self, unable to perform
2b
1
1 of
Ceri Phillips BSc(Econ) MSc(Econ) PhD
Professor
of Health
Economipain
Hayward
Medical Communications,
a division
usual
activities,
moderate
or discomfort,
moderately anxious
orQALYs
depressed
Hayward Group Ltd. Copyright © 2009 Hayward Group Ltd.
gained
33332
Confined to bed; unable to wash or dress self; unable to perform usual
0.079
–0.429
activities; extreme pain or discomfort; moderately anxious or depressed
Quality
Intervention A
Quality
No intervention
KAZANILAN QALY
1
1
Tedavi 1
Tedavi Yok
KAZANILAN QALY
KAYBEDİLEN
QALY
KAZANILAN QALY
Tedavi
0
Tedavi 2
0
ÖLÜM 1 ÖLÜM 2
ÖLÜM 1 ÖLÜM 2
ZAMAN
YOĞUN
BAKIM
Yoğun Bakım Maliyetleri
Yönetilebilir mi?
YOĞUN BAKIM MALİYETİNDE ETKİLİ BAZI FAKTÖRLER:
➤
Yoğun bakımın sabit giderleri yüksektir.
➤
Yoğun bakım hastalarının tedavisinde pahalı ilaçlar
kullanıldığı gibi, pahalı tanı yöntemleri de sıklıkla
kullanılmaktadır.
➤
Her geçen gün yoğun bakım yatağı gereksinimi artmaktadır.
Holcomb BW, Wheeler AP, Ely EW: New ways to reduce unnecessary varia- tion and improve outcomes in the
intensive care unit. Curr Opin Crit Care 2001, 7:304–311.
MODERN YOĞUN BAKIM ÜNİTELERİNİN TOPLUM ÜZERİNDEKİ
EKONOMİK BASKISI ÇOK BÜYÜK…
➤
Yoğun bakım yatak sayısı, toplam yatak sayısının %10’undan
daha düşük olmasına karşın, normal yatağın 1$’ına karşılık
yoğun bakım yatağında 3$ harcama yapılıyor.
3x1
Halpern NA, Bettes L, Greenstein R: Federal and nationwide intensive care units and health care costs: 1986–1992. Crit Care Med 1994, 22:2001– 2007.
Crit Care Med. 2006 Nov;34(11):2738-47.
When is critical care medicine cost-effective? A systematic review of the cost-effectiveness literature.
Talmor D1, Shapiro N, Greenberg D, Stone PW, Neumann PJ.
METHODOLOGY
HISTORY
CEVR's goals in constructing and maintaining this database are threefold:
Identify society's best opportunities for targeting resources to improve health;
Assist policymakers in healthcare resource allocation decisions; and
Move the field towards the use of standardized methodology.
The CEA Registry is a comprehensive database of 5,000 cost-utility analyses on a wide variety of diseases and
treatments. The registry has made an impact in several areas:
CEVR’in bu veri tabanını oluşturma ve sürdürmesindeki temel amaçlar:
Used as a data source for 50 peer-reviewed publications;
Used
or cited in analyses
performed byen
USdoğru
Environmental
Protection
Agency, için
the Food
and Drug Administration,
1. Sağlık hizmetlerini
geliştirirken
kaynakların
şekilde
yönetilmesi
seçeneklerin
oluşturulması
the Institute of Medicine, the Medicare Payment Assessment Commission, academia, and industry;
Highlighted
on the National
Library of Medicine's
website as
an important healthyol
economics
resource;
2. Sağlık sektöründeki
kaynakların
kullanımında
politikaları
düzenleyenlere
göstermek
3. Sektörde ölçme
Cited in the popular press, including Forbes, The New York Times, The Washington Post and The Boston
and
ve Globe;
değerlendirmede
standart bir metodun oluşmasını sağlamak
Catalogs information on over 13,400 cost-effectiveness ratios and more than 16,900 utility weights
YOĞUN BAKIM MALİYETİ…
ABD’de yoğun bakım gideri toplam
hastane giderinin % 22’ini
Halpern NA, Bettes L, Greenstein R. Federal and nationwide intensive care units
and healthcare costs: 1986 –1992. Crit Care Med 1994;22:2001–7.
Hollanda’da yoğun bakım gideri
toplam hastane giderinin % 20’ini
tutmakta…
van Dijk FE, van der Werken C. [What are the costs of an intensive care patient? The
direct costs of a surgical patient per ICU-admission and per inpatient day.]. Medisch
Contact 1998;53:1154–6.
Almanya’da yapılan bir çalışmada
yoğun bakım maliyeti ortalama 855 €
Moerer O, Plock E, Mgbor U, et al. A German national prevalence study on the cost
of intensive care: an evaluation from 51 intensive care units. Crit Care 2007;11:R69.
ABD’de yapılan bir çalışmada ise
yoğun bakım ortalama maliyeti 3221
€ bildirilmiştir.
Cooper LM, Linde-Zwirble WT. Medicare intensive care unit use: analysis of
incidence, cost, and payment. Crit Care Med 2004;32: 2247–53.
Av
HEAL
E IN
online
ailable
(2012
TH 15
w.s
at ww
.e
: www
epage
86
) 81–
cience
lsevier
direct.
.com/l
com
ocate/
jval
l hom
5
4
9
3
8
2
7
1,
2
PhD 6
lands; De 4 Department of 6 partment of Inten
i Pittoni,
ne,
e Nether
s;
an Tan,
De
re Medici
Giovann1
rdam, Th
therland
Siok Sw
Germany; ent of Intensive Ca
D, MD ,
am, Rotte
e, The Ne
Ph
rd
oll
D
i,
ppingen,
tte
zz
Zw
Ph
,
Ro
Pe
ijen,
Clinics
GmbH, Gö va, Italy; 8 Departm
ersiteit
Ro
la
n
iv
n
Angelo
ge
Isa
Un
,
in
va
re
us
sive Ca
y
t, Erasm
ità, Pado
eises Göpp
akkaart, German
sessmen 3 partment of Inten
-Univers
s Landkr
Leona H
pedaliera
iniken de
nology As
De
es, Munich
Os
, Kl
m
l Tech
lands;
th Outco
sive Care
, Azienda
for Medica am, The Nether
ts & Heal
t of Inten
sive Care
Institute
5
tterd
partmen7
w Produc
t of Inten
Center, Ro
partmen9
Kline, Ne
g, UK; De
De
ith
in
m
ad
ly;
oS
Re
Medical
l,
ilan, Ita
s; Glax
t Hospita
ts. The
ilano, M
therland
NHS Trus
partmen
udi di M
, The Ne
at all de
fairly
à degli St
Apeldoorn
t were
Universit
st driver
as Site),
ent G bu
rtant co
m
spital (Luk
Direct
po
rt
Ho
s:
im
pa
t
lre
Ge
lusion
e mos
9 at de
nc
th
62
Co
as
€1
.
w
. Our
5)
to
bor
ed
! 11
rtments
nent, la
amount
ts (€711
n depa
d
r “labor”
le instru
partmen
the seve
sure an
costs fo
tween
a valuab
other de
to mea
A C T
be
e
as
R
y
as
from
th
e
U
el
w
T
rv
IC
ng
at
id
y
ry w
A B S
uld se
seven
milar
resulti
t stud
va
co
si
e
at
en
ys
os
gy
ys
es
th
da
lo
pr
as
U) da
ICU
ethodo
Kinge of the
unit (IC
es, such
costs of
United
sting m
objectiv
ive care
logy,
differenc
ized co
and the
es: The
of intens
hods: A
methodo
tual cost
rlands,
standard
Objectiv
ct costs
gy. Met
pare ac
costing
e Nethe
ix.
the
the dire
t to com
alysis,
ethodolo
case-m
Italy, th
om
re
m
en
an
y,
nt
fr
pa
g
m
an
tie
st
m
in
ed
co
cost
in pa
y, co
Germ
rform
es
in
ud
ed
pe
iz
st
nc
ts
de
and
rd
as
re
e
s
en
as
w
ic
da
s
diffe
parativ
logy w
conom
departm
of a stan of ICU patient
ds: com
rtmethodo
armacoe
.
means
Keywor
costing
alysis
ICU depa
y for Ph
ive care
dom by
Inc.
e seven
l Societ
dardized
, intens
el
e cost an
er
th
na
ot
an
pe
iv
vi
io
at
st
ct
“h
ro
se
e
at
r
ta
pe
El
Eu
fo
rn
by
retros
ctive. Th
lity of da
proach
12, Inte
blished
sumht © 20
l’s perspe s of the availabi
m– up ap
POR). Pu
s,” “con
Copyrig
hospita
si
the botto
arch (IS
gnostic
es Rese
€1168
on the ba e application of
for “dia
Outcom
veloped
th
proach
nged from pod
ra
ap
ile
y
n
sources
ta
w
da
It en
p– do
-care re
per ICU
cost com
ments.
d the to
yct costs
of health
ried by
ition” an
spital pa
lts: Dire
lability
costs va
and nutr
r.” Resu
t), the ho
the avai
ution of
bo
ni
,
U
ent),
rib
“la
n)
y
st
d
tio
di
denc
e paym
ntila
en
nc
ve
ables,” an en though the
ep
l
ra
D
ca
su
h
has
Hig
d in
5. Ev
mechani
ce of a
[2,6]. It
-mix an
to €202
untries
e presen
/private
s
1
Table 2 – Characteristics of the patient samples.
Department A
(n # 400)
Department B
(n # 448)
Department C
(n # 756)
Department D
(n # 242)
Department E
(n # 304)
Department F
(n # 30)
Department G
(n # 549)
66 " 16
214/186 (54/46)
7.8 " 12.6 (2–98)
28 " 15
155 (39)
61 " 19
267/181 (60/40)
5.2 " 7.4 (1–117)
41 " 22
366 (82)
65 " 21
489/267 (65/35)
7.0 " 5.8 (1–158)
27 " 15
248 (33)
54 " 15
133/109 (55/45)
6.0 " 5.6 (1–30)
*
180 (74)
64 " 18
176/128 (58/42)
5.9 " 12.2 (1–148)
34 " 16
177 (58)
58 " 16
16/14 (53/47)
3.8 " 5.7 (1–8)
*
19 (63)
55 " 20
341/208 (62/38)
5.0 " 5.1 (1–40)
42 " 20
384 (70)
21 (5)
125 (31)
12 (3)
20 (5)
38 (10)
27 (7)
157 (39)
69 (15)
40 (9)
31 (7)
73 (16)
20 (5)
164 (37)
51 (11)
225 (30)
150 (20)
5 (1)
39 (5)
97 (13)
114 (15)
126 (17)
27 (18)
26 (18)
1 (1)
33 (22)
2 (1)
27 (18)
32 (22)
146 (47)
54 (17)
8 (3)
22 (7)
8 (3)
67 (22)
5 (1)
10 (33)
6 (20)
0 (0)
4 (13)
1 (3)
9 (30)
0 (0)
83 (15)
58 (11)
10 (2)
40 (7)
28 (5)
132 (24)
198 (36)
co
ic
erence
(e.g., th
tween
.g., publ
cost diff
ices be
stem (e
costs
observed
solute pr
ment sy
ate the
and ab
e of the
e
m
tim
so
tiv
es
la
of
at
to
re
th
10%
and
es used
wever,
].
ss than
l
gued, ho
ces [7,8
hodologi
prise le
n
et
ita
ar
en
enm
io
m
sp
er
en
co
e
gy
ff
ct
ho
be
u
lo
di
th
beds
tual
total
Introd
methodo
result of
it (ICU)
in
n
22% of
sult of ac
costing
are as a
e care un
rtments
nsume
s betwee
g as a re
dardized
intensiv
ents co
an bein
fference
ICU depa
an
y
m
gh
di
th
st
el
of
rt
ibs
ou
st
at
a
er
pa
tr
st
co
th
lth
im
at
A
ra
tual
prox
n be
ion of
the co
ICU de
ac
,
at
ca
o,
ap
of
s
ic
t
ls
ds
n
A
pl
ce
en
be
].
n
l
en
es [1
pariso
repres
than
The ap
betwee
hospita
st differ
ted Stat
ful com
ated to
n, rather
per day
is way co
the Uni
meaning
en estim
ideratio
rde costs
,10]. Th
general
costs in
ables a
have be
der cons
t, standa
, with th
rvices [9
than in
herlands
rvices un
1,12]. Ye
s of
l budget
-care se
ments
[1
st
se
th
rt
ita
e
bility
co
al
gy
pa
sp
the Net
la
ar
e
lo
he
de
ai
ho
e av
hodo
alth-c
ICU
ssed th
th
et
he
e total
in
se
m
e
a
by
r
th
g
as
th
te
ed
in
of
rict
20%
y. From
nts are
d grea
uted to
ies have
the cost
ten rest
al patie
tensivel
d fivefol
ral stud
ences in
es are of
vary ex
en
l costs
r individu
three- an Therefore, seve
to differ
hodologi
the tota
ICU stay
ision, ev
tities fo
et
of
ec
ed
an
].
m
rt
pr
ns
,3
g
e
qu
po
[2
io
in
of
re
at
wards
treme, th
e level
Resource
em and
ized cost
et al. [4]
st estim
ing syst
other ex
of data.
the sam
Moerer
ices. Co
e
e
st
y,
rv
ity
er
th
co
ith
al
w
t
se
ud
w
al
A
U
st
qu
es
ic
IC
at
in
an
and
lable
2008).
s [13].
nited St
ider’s cl
ter Germ
not avai
flated to
provider
ain the U
are prov
multicen
€855 (in
generally
th-care
e applic
rtments
health-c
day to be
een heal
erns on th
U depa
a single
for
per ICU
endatio
cost diff
dly betw
within
) [5].
day at IC
m
ke
al
r
08
ial bias
m
ar
tu
pe
20
co
m
ac
s
st
vary
ix is
d potent
ted to
plain
ade re
t
s
an
m
fla
-m
ex
en
em
total co
se
es
(in
er
ve
to
st
1
gi
ff
ca
ha
sy
lo
di
tient
be €322
ve tried
studies
ices at
methodo
The pa
of ICU
5]
udies ha
found to
Several
costing
are serv
[2,6,7].
al costs
et al. [1
ber of st
dardized
health-c
rtments
woller
ces
the actu
an
tz
n
pa
en
A num
st
Ri
on
ee
de
er
of
e,
ff
ct
tw
U
di
effe
tion
exampl
lity be
tween IC
tual cost
portant
, den15]. For
mparabi
ences be
cing ac
ve an im
the co
ers [13–
ncy rate
influen
ed to ha
e provid
d occupa
medfactors
consider
alth-car
ions in
tential
g (e.g., be
he
x
at
po
in
ri
tt
er
va
se
,
th
, P.O. Bo
udy
use of
days. O
position)
tterdam
ns in st
n, and
aff com
variatio
rsiteit Ro
al patter
, and st
include
us Unive
ls, referr
re beds
m
ca
va
as
e
ie
Er
tr
ut
t,
re
report.
essmen
sity of ac
ergency
terest to
.
logy Ass
tice (em
(ISPOR)
icts of in edical Techno
ical prac
search
no confl
M
mes Re
ors have n, Institute for
th
d Outco
au
e
mics an
st: Th
an Ta
re
no
Sw
te
co
in
ok
oe
of
: Si
.
Pharmac
Conflicts rrespondence to
ety for
herlands
co
nal Soci
The Net
* Address
ternatio
erdam,
2012, In
DR Rott
©
00
t
l.
30
gh
r.n
,
ri
g.eu
1738
ter Copy
tan@bm
ont mat
E-mail:
– see fr
5/$36.00
1098-301
er Inc.
vi
se
El
d by
.007
Publishe
.2011.09
16/j.jval
doi:10.10
Age (y), mean " SD
Gender, male/female, n (%)
ICU stay (d), mean " SD (min-max)
SAPS II, mean " SD
Mechanical ventilation, n (%)
Admission diagnosis, n (%)
Cardiovascular
Gastrointestinal
Metabolic
Neurological
Renal
Respiratory
Unknown/Other
VALUE IN HEALTH 15 (2012) 81– 86
ropean
Four Eu
in
y
ta
it S
,
odology
Care Un
PhD, MD
tensive d Costing Meth PhD, MD , Joerg Martin,
In
f
o
is
ila,
ize
lys
,
Atul Kap
elte, PhD
ost Ana
tandard
, MSc ,
Direct C : Applying a S , Marga E. Hoogendrooonkrn, PhD, MD , Robert W
iversity
us MC Un ire
s
re, Erasm
sh
r E. Sp
D, MD
yal Berk
tensive Ca
D , Pete
kker, Ph
Countrie
Care, Ro
M
ent of In
e
Ba
,
Care,
siv
n
D
rtm
e
Ja
ten
pa
Ph
siv
In
*,
journa
g systems in place; application of the bottom– up apd require the information from each of the systems to
ched. Where resource quantities of “hotel and nutriructurally available at the patient level, those of “laot available at the patient level at any of the departdition, wide variability existed in terms of training of
cialists and ICU nurses. Therefore, the standardized
hodology entailed the application of the bottom– up
“hotel and nutrition” and the top– down approach for
” “consumables,” and “labor.”
quantities and unit costs of the cost components
ed by using uniform reporting templates, which are
readers on request. Resource quantities of “diagnosmables,” and “hotel and nutrition” were derived from
d Patient Data Management Systems. Labor time
specialists, ICU nurses, and consulted specialists per
determined by dividing the number of workable days
en from collective labor agreements) by the number of
year (taken from computerized Patient Data Managems). Unit costs represented the costs to the hospital
wholesale prices. The unit costs of “diagnostics,” “conand “hotel and nutrition” were primarily obtained
al administrative databases. The unit costs of labor
on normative incomes (taken from hospital financial
nd allocated to patients according to the time spent
Normative incomes included wages, social premir irregular working hours, and the costs of replaceillness.
were based on Euro 2008 cost data. All costs were
008 using the Eurostat harmonized indices of con[23]. Mean exchange rates for 2008 were used. Statiss were conducted with the statistical software proor Windows version 17.0. In all cases, P ! 0.05 was
istically significant.
samples of the seven ICU departments showed some
nces at baseline, which are summarized in Table 2. A
admissions of age 61 " 19 years with 60% male were
th an average of 390 " 232 per department. These
elated to 16,791 ICU days (2407 " 1607 on average per
. The patient case-mix differed somewhat from dedepartment. The Simplified Acute Physiology Score
ged from 27 " 15 in department C to 42 " 20 in departshare of mechanically ventilated patients varied bet department C and 82% at department B. There were
portion of patients with gastrointestinal diseases at
A (31%), of cardiovascular diseases at department C
tment E (47%), and department F (33%), and of respies at department B (37%) and department F (30%).
ew of descriptive statistics at the department level is
le 3. Direct costs per ICU day varied between €1168
B) and €2025 (department G). Labor was the key cost
ntirely explained the increased costs at department G
ared with an average €711 at the other departments).
for “diagnostics” were responsible for about 14% of
sts and ranged from €99 at department G to €255 at
D. Absolute costs of “laboratory services” were much
artment G (€56 compared with an average €145 at the
ments; P # 0.030).
for “consumables” were responsible for about 22% of
sts and ranged from €241 at department B to €357 at
F. The absolute costs of “fluids” predominantly repred (derived) products at departments A, B, C, and G,
departments D, E, and F they in addition comprised
ere administered to the patient intravenously. ThereVALU
ICU, intensive care unit; SAPS Simplified Acute Physiology Score.
* Not available.
83
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/jval
84
Direct Cost Analysis of Intensive Care Unit Stay in Four European
Countries: Applying a Standardized Costing Methodology
Siok Swan Tan, PhD1,*, Jan Bakker, PhD, MD2, Marga E. Hoogendoorn, MSc3, Atul Kapila, PhD, MD4, Joerg Martin, PhD, MD5,
Angelo Pezzi, PhD, MD6, Giovanni Pittoni, PhD, MD7, Peter E. Spronk, PhD, MD8, Robert Welte, PhD9,
Leona Hakkaart-van Roijen, PhD1
1
Institute for Medical Technology Assessment, Erasmus Universiteit Rotterdam, Rotterdam, The Netherlands; 2Department of Intensive Care, Erasmus MC University
Medical Center, Rotterdam, The Netherlands; 3Department of Intensive Care, Isala Clinics, Zwolle, The Netherlands; 4Department of Intensive Care, Royal Berkshire
NHS Trust Hospital, Reading, UK; 5Department of Intensive Care, Kliniken des Landkreises Göppingen GmbH, Göppingen, Germany; 6Department of Intensive Care,
Università degli Studi di Milano, Milan, Italy; 7Department of Intensive Care, Azienda Ospedaliera-Università, Padova, Italy; 8Department of Intensive Care Medicine,
Gelre Hospital (Lukas Site), Apeldoorn, The Netherlands; 9GlaxoSmithKline, New Products & Health Outcomes, Munich, Germany
A B S T R A C T
Objectives: The objective of the present study was to measure and
compare the direct costs of intensive care unit (ICU) days at seven ICU
departments in Germany, Italy, the Netherlands, and the United Kingdom by means of a standardized costing methodology. Methods: A
retrospective cost analysis of ICU patients was performed from the
hospital’s perspective. The standardized costing methodology was developed on the basis of the availability of data at the seven ICU departments. It entailed the application of the bottom– up approach for “hotel
and nutrition” and the top– down approach for “diagnostics,” “consumables,” and “labor.” Results: Direct costs per ICU day ranged from €1168
to €2025. Even though the distribution of costs varied by cost compo-
nent, labor was the most important cost driver at all departments. The
costs for “labor” amounted to €1629 at department G but were fairly
similar at the other departments (€711 ! 115). Conclusions: Direct
costs of ICU days vary widely between the seven departments. Our
standardized costing methodology could serve as a valuable instrument to compare actual cost differences, such as those resulting from
differences in patient case-mix.
Keywords: comparative study, cost analysis, costing methodology,
Europe, intensive care.
Table 3 – The direct costs for
an ICU day as determined by the standardized costing methodology23.
Copyright © 2012, International Society for Pharmacoeconomics and
Introduction
ment system (e.g., public/private-mix and insurance payment),
and relative and absolute prices between countries [2,6]. It has
been argued, however, that some of the observed cost differences
are as a result of the methodologies used to estimate the costs
rather than being as a result of actual differences [7,8].
The application of a standardized costing methodology enables a meaningful comparison of actual cost differences between
health-care services [9,10]. This way cost differences can be attributed to the health-care services under consideration, rather than
to differences in the costing methodology [11,12]. Yet, standardized costing methodologies are often restricted by the availability
and quality of data. Resource quantities for individual patients are
generally not available with the same level of precision, even
within a single health-care provider’s clinical costing system and
systems vary markedly between health-care providers [13].
Several studies have made recommendations on the application of standardized costing methodologies and potential bias for
the comparability between health-care services at different
health-care providers [13–15]. For example, Ritzwoller et al. [15]
Diagnostic procedures
Medical imaging services
49 (4%)
45 (4%)
Laboratory services
132 (11%)
160 (14%)
Consumables
Drugs
115 (9%)
113 (10%)
59 (5%)
51 (4%)
ConflictsFluids
of interest: The authors have no conflicts of interest to report.
* Address correspondence to: Siok Swan Tan, Institute for Medical Technology Assessment, Erasmus Universiteit Rotterdam, P.O. Box
Disposables
74 (6%)
77 (7%)
1738, 3000 DR
Rotterdam, The Netherlands.
E-mail: [email protected].
1098-3015/$36.00
see frontnutrition
matter Copyright © 2012, International Society for80
Pharmacoeconomics
and Outcomes Research
(ISPOR).
Hotel– and
(7%)
38 (3%)
Published by Elsevier Inc.
Labor
doi:10.1016/j.jval.2011.09.007
ICU specialist
196 (16%)
257 (22%)
ICU nurse
445 (36%)
369 (32%)
Consulted specialist
80 (7%)
58 (5%)
Medical specialist
68
54
Pharmacist
1
0
Physiotherapist
6
4
Laboratory technician
4
0
Nutrition specialist
1
0
Total
1.230
1.168
ICU, intensive care unit.
Department C
(n ! 756)
Department D
(n ! 242)
Department E
(n ! 304)
Department F
(n ! 30)
Department G
(n ! 549)
Total
population
Department
sample (n ! 7)
Mean
SD
32 (2%)
129 (9%)
60 (5%)
195 (16%)
70 (5%)
130 (9%)
124 (10%)
125 (10%)
43 (2%)
56 (3%)
60 (4%)
132 (10%)
31
42
210 (15%)
39 (3%)
71 (5%)
25 (2%)
145 (12%)
131 (11%)
3 (0%)
90 (8%)
151 (11%)
146 (10%)
33 (2%)
86 (6%)
142 (11%)
151 (12%)
64 (5%)
44 (3%)
113 (6%)
56 (3%)
117 (6%)
11 (1%)
141 (10%)
90 (7%)
63 (5%)
53 (4%)
34
50
36
32
285 (21%)
561 (41%)
33 (2%)
29
0
4
0
0
1.385
150 (13%)
397 (33%)
19 (2%)
16
1
0
1
0
1.190
216 (15%)
562 (40%)
20 (1%)
15
1
1
3
1
1.414
256 (20%)
343 (27%)
18 (1%)
13
0
1
3
1
1.267
296 (15%)
1,123 (55%)
210 (10%)
126
6
55
18
4
2.025
237 (17%)
543 (39%)
63 (5%)
46
1
10
4
1
1.383
52
270
69
41
2
20
6
2
298
Although intensive care unit (ICU) beds comprise less than 10% of
hospital beds, ICU departments consume 22% of total hospital
costs in the United States [1]. Also, the costs of ICU departments in
the Netherlands have been estimated to represent approximately
20% of the total hospital budget, with the costs per day between
three- and fivefold greater in ICU departments than in general
wards [2,3]. Therefore, several studies have assessed the costs of
ICU services. Cost estimations of ICU stay vary extensively. From a
multicenter German study, Moerer et al. [4] reported the total costs
per ICU day to be €855 (inflated to 2008). At the other extreme, the
total costs per day at ICU departments in the United States were
found to be €3221 (inflated to 2008) [5].
A number of studies have tried to explain actual cost differences between ICU departments [2,6,7]. The patient case-mix is
considered to have an important effect on the actual costs of ICU
days. Other potential factors influencing actual cost differences
include variations in study setting (e.g., bed occupancy rate, density of acute care beds, and staff composition), variations in medical practice (emergency retrievals, referral pattern, and use of
Outcomes Research (ISPOR). Published by Elsevier Inc.
Department A
Department B
mechanical
ventilation),
the availability of health-care
resources
(n
!
400)
(n ! 448)
(e.g., the presence of a High Dependency Unit), the hospital pay-
Yoğun bakım direktörünün yeni cihaz ve ilaçları klinik
uygulamalara sokarken ilk sorusu: FAYDA ORANI NEDİR?
Duyulan huzursuzluklar;
➤Gereksiz(aynı
edilebilir)
sonuç çok daha basit yöntemlerle elde
➤Başarısız
(klinik olarak etkisiz)
➤Güvensiz
(riskler faydanın üzerinde);
➤Fizik
hasar (uygulama sonrası oluşacak yaşam kalite
sorunu kabul edilemez düzeyde)
➤Aptalca
(kaynaklar çok daha faydalı bir şeye
yönlendirilebilir)
Jennett B. Inappropriate use of intensive care. BMJ. 1984;289:1709-1711. Çoğu sağlık profesyoneli tarafından; takdir edilebilir, ancak bununla
birlikte taburcu olamaksızın sürdürülen yoğun bakım girişimlerini
çoğunlukla ‘BEYHUDE’ olarak kabul edilmekte…
“
Yoğun bakım ünitesinde tedavi
edilen 10 hastadan 1’inden daha
fazlası iyileşme olasılığına sahip
değildir. Buna rağmen, beyhude
tedaviler devam eder ve ölüm
prosesi geciktirilir, kocaman bir
hastane faturası oluşur.
Robin Wulffson, M.D.
NÜFUSUN YAŞLANMASI/60 YAŞ ÜZERİ NÜFUS
Gelişmemiş Ülkeler 1980-2010
Gelişmemiş Ülkeler 2010-2040
Az Gelişmiş Ülkeler 1980-2010
Az Gelişmiş Ülkeler 2010-2040
Gelişmiş Ülkeler 1980-2010
Gelişmiş Ülkeler 2010-2040
Dünya 1980-2010
Dünya 2010-2040
0
United Nations, “World Population Aging 2013”
2,25
4,5
6,75
9
Deutsche Homepage
Ressources et utilitaires
Scoring systems for ICU and surgical patients:
TISS-28 (Therapeutic Intervention Scoring System-28)
Basic Activities
Points
Ventilatory Support
Laboratory. Biochemical and microbiological
investigations.
1
yes
Single medication, any route (IV, PO, IM,
etc.).
2
yes
Multiple intravenous medications (more than
1 drug, single shots, or continuously)
3
yes
1
yes
Mechanical ventilation. Any
form of mechanical or
assisted ventilation with or
no
without PEEP; with or without
muscle relaxants;
spontaneous breathing with
PEEP).
Supplementary ventilatory
support. Breathing
spontaneously through
endotracheal tube without
no
PEEP; supplementary
oxygen by any method
except if mechanical
ventilation parameters apply.
Care of artificial airways.
Endotracheal tube or
tracheostoma.
no Treatment for improving lung
function. Thorax
physiotherapy, incentive
spirometry, inhalation therapy,
intratracheal suctioning.
Renal Support
no
1
yes
no
3
yes
no
Standard monitoring. Hourly vital signs,
regular registration and calculation of fluid
balance.
Routine dressing changes. Care and
prevention of decubitus and daily dressing
change.
Frequent dressing changes (at least one time
per each nursing shift) and/or extensive
wound care
Care of drains. All (except gastric tube).
5
yes
Hemofiltration techniques.
Dialytic techniques.
Quantitative urine output
measurement.
Active diuresis (e.g.
furosemid > 0.5 mg/kg/day
for overload).
Neurologic Support
Cardiovascular Support
Single vasoactive medication. Any
vasoactive drug.
Multiple vasoactive medications. More than1
vasoactive drug, disregard type and dose.
Intravenous replacement of large fluid losses.
Fluid replacement > 3 liters per square meter
per day, disregard type of fluid administered.
Miranda DR et al. Simplified Therapeutic Intervention Scoring System : the
TISS-28 items. Results from a multicenter study. Crit Care Med. 1996;24:64-73.
5
yes
no
2
yes
1
yes
no
1
yes
no
3
yes
no
2
yes
no
3
yes
no
4
yes
no
3
yes
4
yes
4
yes
no
Peripheral arterial catheter.
5
yes
no
Treatment of complicated
metabolic acidosis/alkalosis.
4
yes
no
Left atrium monitoring. Pulmonary artery
flotation catheter with or without cardiac
output measurement.
8
yes
no
Intravenous
hyperalimentation
3
yes
no
Central venous line.
2
yes
no
Enteral feeding. Through
gastric tube or other GI route
(e.g. jejunostomy).
2
yes
no
3
yes
no
Cardiopulmonary resuscitation after arrest in
the past 24 hours (single precordial
percussion not included)
Specific Interventions
Single specific interventions in the ICU. Naso
or orotracheal intubation, introduction of a
pacemaker, cardioversion, endoscopies,
emergency surgery in the past 24 hours,
gastric lavage. Routine interventions without
consequences to the clinical condition of the
patient, such as radiographs, echography,
EKG, dressings or introduction of venous or
arterial catheters, are not included.
Multiple specific interventions in the ICU.
More than one, as described above.
Specific interventions outside of ICU. Surgery
or diagnostic procedures.
no
Measurement of intracranial
pressure.
Metabolic Support
TISS-28 = 0
TISS-28 = SUM (points for activities performed)
Compute
3
yes
no
TISS-76 correlation =
5
yes
5
yes
Clear
Time of nurse's care = 0
(One TISS-28 point equals 10.6 minutes of each 8 h
nurse's shift)
0
(Correlation beetwen TISS-28 and TISS-76: r = 0.93, r2 =
0.86)
(TISS-28) = 3.33 + 0.97* (TISS-76)
no
Criteria of exclusion are applied in four conditions :
Moreno R, Morais P. Validation of the simplified therapeutic intervention scoring
system on an independent database. Intensive Care Med. 1997;23:640-644.
Points
"Multiple intravenous medications" excludes "Single medication";
"Mechanical ventilation" excludes " Supplementary ventilatory support";
"Multiple vasoactive medications" excludes "Single vasoactive medication";
"Multiple specific interventions in the ICU" excludes "Single specific interventions in the ICU "
I. Basamak
II. Basamak
III. Basamak
? Basamak
ABD’de yoğun bakım ünitelerine her yıl 4.000.000
hasta kabulü yapılıyor. Akut hastane toplam
giderlerinin %30’u yoğun bakım giderlerini
oluşturuyor.
ICU outcomes (mortality and length of stay) methods, data collection tool and data
[Internet]. San Francisco, CA: Philip R Lee Institute for Health Policy Studies,
University of California, San Francisco; 2012 [cited 2014 Apr 21].
4. WenhamT,PittardA.Intensivecareunit environment. Continuing Education in
Anaesthesia, Critical Care & Pain 2009 Dec;9(6):178-83.
Yoğun bakımda hasta güvenliği ile ilgili endişeler
devamlı var. Ciddi ilaç hatalarının %78’ yoğun
bakım ünitelerinde gerçekleşiyor.
Rothschild JM, Landrigan CP, Cronin JW, et al. The Critical Care Safety Study:
the incidence and nature of adverse events and serious medical errors in
intensive care. Crit Care Med 2005 Aug;33(8):1694-700.
Ve, yoğun bakımlardaki mortalite oranları %10-28 arasında
değişiyor veya başka bir deyişle her yıl 540.000 hasta
ölüyor…
AngusDC,BarnatoAE,Linde-ZwirbleWT,etal; Robert Wood Johnson Foundation ICU End-Of- Life Peer Group.
Use of intensive care at the end of life in the United States: an epidemiologic study. Crit Care Med 2004 Mar;
32(3):638- 43.
➤
TELE-MEDİCİNE (TELE-SAĞLIK) bir noktadan başka bir
noktaya elektronik haberleşme yöntemleriyle medikal
bilgilerin aktarılmasıyla hastaların sağlık durumlarını
iyileştirmek olarak tanımlanır.
Kramer M, Maguire P, Brewer BB. Clinical nurses in Mag- net hospitals confirm productive, healthy unit work
environments. J Nurs Manag. 2011;19:5–17. REVIEW A
Massachusetss Memorial Medical Center’daki 119 yoğun bakım yatağı Tele-ICU
A Business Case for Tele-Intensive Care Units
programına alınmıştır.
TOPLAM
7.120.000 $
Figure 2. University of Massachusetts Memorial Medical Center: one-time costs for tele-intensive care unit implementation, 2010.36
ICU = intensive
unit; MiscCase
= miscellaneous.
REVIEW
ARTICLEcare
, A Business
for Tele-Intensive Care Units, Alberto Coustasse, DrPH, MD, MBA, MPH;
Stacie Deslich, MA, MS; Deanna Bailey, MS; Alesia Hairston, MS; David Paul, DDS, PhD Perm J 2014 Fall;18(4):
76-84
command center extended coverage to
9 adult ICUs covering 116 ICU beds in
cine into its 14 ICUs in 2007. The tele-ICU
command center in Resurrection’s Holy
reported, including $11,200 from a 7%
reduction in blood transfusions. The hos-
tems vendor, Philips VISICU in Baltimore,
MD, tele-ICU implementation costs ranged
from about $50,000 to $100,000 per bed,
and the cost of equipping 100 beds was
approximately $3 to $5 million.28,29 Annual
operating costs (eg, overhead, maintenance, staffing) were estimated by Philips
Findings from an independent evaluation by Cap Gemini Ernst & Young,
London, United Kingdom, suggested a
$2 million tele-ICU cost that was offset
by $3 million in net savings annually.33
It reported extra revenue, approximately
$460,000 per month, because of increased
Hastane
Mortalitesi
Table 1. Tele-intensive care unit cases studied, implementation
costs, andazalma
outcomes
%26,4
Yoğun
Bakım kalış
süresi %13,6’DAN
New England Healthcare
University of Massachusetts Memorial Medical
%11,8’E
Institute and Massachusetts Center,
academic hospital with 5 adult ICUs,
Institution
Sentara Healthcare
Setting
Sentara Healthcare,a academic tertiary care
medical center with 5 ICUs, 103 critical care beds
Technology Collaborative
The University of Massachusetts Memorial Medical Center in Worcester, MA,
installed a tele-ICU command center in
2005 and extended the tele-ICU coverage
to 2 Massachusetts community hospitals in
2007 and 2008. Over 3 years, 1 tele-ICU
Implementation costs
(US dollars)
1 million
7.12 million
130 beds, 7000 ICU patients
Mortalite
Community hospitals with 14 ICUs, 182 critical
care beds
13,3’TEN
Pre- and postimplementation design;
preimplementation: n = 2034 patients; 9,8’E
postimplementation: n = 2134
Resurrection Health Care
Memorial Medical Center
7 million
Yoğun
Bakım kalış
süresi %17
azalma
Major results/outcomes
Decreased ICU LOS by 17%; decreased
hospital mortality by 26.4%33,36
Decreased ICU LOS (from 13.3 to 9.8
days); decreased mortality from 13.6% to
11.8%; recovered costs of implementation;
lowered rates of complications36
6 months after implementation: 38%
decrease in ICU LOS, approximately
$3 million in cost savings37,38
Includes both Sentara Norfolk General Hospital and Sentara Hampton General Hospital.
ICU = intensive care unit; LOS = length of stay.
a
İmplementasyondan
6 Care
aytele-intensive
sonra:careYoğun
bakım
kalış
Table 2. Sentara Healthcare and Resurrection Health
unit implementation
savings
Cost of implementation
süresinde
% 38 azalma, 3.000.000
$
Hospital
(US dollars)
Outcomes
Cost saving
Sentara Healthcare
1 million
Reduction in mortality by 27%; Reduced patient cost of $2150; average case
TASARRUF
(savings from 2002 to 2010)
decreased LOS of 17%
contribution margin increased by 55.6%
REVIEW ARTICLE , A Business Case for Tele-Intensive Care Units, Alberto Coustasse, DrPH, MD, MBA, MPH; Stacie Deslich,
MA, MS; Deanna Bailey, MS; Alesia Hairston, MS; David Paul, DDS, PhD Perm J 2014 Fall;18(4):76-84a
Resurrection Health Care
(savings from 2007 to 2011)
7 million
Decreased LOS of 38%
33,36
7% reduction in blood transfusions ($11,200 in savings);
estimated total cost savings of $11.5 million37,38
82
124/66
98
98
BUKASIS
A DVA N C E D T E L E M E D I C I N E T E C H N O L O G I E S
HBYS
LIS
BUKASIS
A DVA N C E D T E L E M E D I C I N E T E C H N O L O G I E S
PACS
ECZANE
DEPO
REVIEW ARTICLE , A Business Case for Tele-Intensive Care Units, Alberto Coustasse, DrPH, MD, MBA, MPH; Stacie Deslich,
MA, MS; Deanna Bailey, MS; Alesia Hairston, MS; David Paul, DDS, PhD Perm J 2014 Fall;18(4):76-84
Table 5. Studies addressing tele-ICU implementation and utilization
Author, year
Aaronson et al, 200640
Badawi et al, 201041
Badawi and Shemmeri, 200642
Berenson et al, 200931
Breslow et al, 200412
Chu-Weininger et al, 201043
Coletti et al, 200844
Dickhaus, 200645
Giessel and Leedom, 200746
Groves et al, 200813
Howell et al, 200747
Howell et al, 200848
Ikeda et al, 200967
Kohl et al, 200749
Kohl et al, 200750
Kohl et al, 201216
Kumar et al, 201351
Khunlertkit and Carayon, 201311
Lilly et al, 201117
Mora et al, 200752
Norman et al, 200953
Patel et al, 200754
Rincon et al, 200755
Study design
Literature review
Pre/posttest of tele-ICU implementation
Pre/posttest of tele-ICU implementation
Literature review
Pre/posttest of tele-ICU implementation across several
hospitals
Pre/posttest of tele-ICU implementation and utilization
in 3 ICUs
Cross-sectional survey of residents in ICU
and tele-ICUs
in a multistate hospital system
Literature review
Literature review
Qualitative study with semistructured interview
of tele-ICU staff
Survey of residents practicing in tele-ICUs
Literature review and meta-analysis
of 6 tele-ICUs
Pre/posttest of tele-ICU utilization in prevention
of sepsis
Scales et al, 201156
Thomas et al, 200757
Vespa et al, 200758
Literature review
Wilcox and Adhikari, 201215
Willmitch et al, 201259
Meta-analysis of 11 studies
over 3 years
Literature review and meta-analysis
Meta-analysis of 11 studies
Survey of physicians practicing in remote areas using
tele-ICU
Pre/posttest of tele-ICU implementation and utilization in
a rural health care system
Youn, 200660
Young et al, 201161
Zawada et al, 200662
Zawada and Herr, 200865
ICU = intensive care unit; LOS = length of stay.
Outcome
Higher rates of ICU staff adherence to critical care best practices
Improved patient care
Improved hospital financial performance, improved ICU financial
performance, improved patient care
Improved teamwork and/or safety climate
Lower ICU LOS
Lower ICU LOS
Lower ICU LOS
Lower ICU LOS
Lower ICU LOS
Lower ICU LOS
Improved ICU financial performance, lower ICU LOS
Lower ICU LOS
Improved ICU financial performance
Improved ICU staff adherence to evidence-based protocols for
sepsis, ventilator-associated pneumonia, and blood transfusion
Higher rates of ICU staff adherence to critical care best practices,
lower ICU LOS, improved patient care
Improved ICU financial performance
lower ICU LOS
Higher rates of ICU staff adherence to critical care best practices:
• Antibiotic administration increased from 55% to 74%
• Serum lactate measurement increased from 50% to 66%
• Central line placements increased from 33% to 50%
Improved ICU financial performance, lower ICU LOS, improved
patient care
Lower ICU LOS
Lower ICU LOS
Lower ICU LOS
lower ICU LOS
Improved ICU financial performance, lower ICU LOS
improved ICU financial performance
Improved hospital financial performance
Blake Fenwick & Hugh Stehlik
Canberra Hospital, Avustralya
2 Keman, 1 Viyola, 1 Viyolensel
https://youtu.be/KKFzy7tEXu4
Sabrınız için
teşekkür ederim…

Yoğun Bakım / Bakım Kalitesi ( Ekonomik Verimlilik )

Transkript

Benzer belgeler

p. 3 Financial Bid Cuts May Be Severe

theory teori

Ana Okula Gidenlerin Basarili Olmalari Icin

useful words and phrases module 5

i̇tü proficiency writing topics

theory teori - Distributive Justice

GRAMMAR SUBJECTS VOCABULARY Body Parts

grammar subjects vocabulary

sponjel - Selam Medikal