RESUMO
The discussion of adequate compliance in health care often refers to a lack of information between patients and physicians. In our setting, we show that contract arrangements as well as the distribution of information are important for an adequate alignment of the interest of patients and physicians. The analysis emphasises the benefit of organised pharmaco-therapy enhancing the concomitant compliance. Therefore, the results can work as a proxy for the need of good economic-based approaches discussing compliance in chronic diseases.
Assuntos
Conservadores da Densidade Óssea/economia , Cálcio da Dieta/economia , Difosfonatos/economia , Osteoporose , Cooperação do Paciente , Cloridrato de Raloxifeno/economia , Conservadores da Densidade Óssea/uso terapêutico , Cálcio da Dieta/uso terapêutico , Doença Crônica , Análise Custo-Benefício , Suplementos Nutricionais/economia , Difosfonatos/uso terapêutico , Combinação de Medicamentos , Embalagem de Medicamentos , Feminino , Alemanha , Humanos , Masculino , Modelos Econométricos , Osteoporose/dietoterapia , Osteoporose/tratamento farmacológico , Osteoporose/economia , Osteoporose/psicologia , Relações Médico-Paciente , Cloridrato de Raloxifeno/uso terapêuticoRESUMO
BACKGROUND: More than 70 % of critically ill patients die in intensive care units (ICUs) after treatment is reduced. End-of-life decision making in the ICU is a grey area that varies in practice, and there are potential economic consequences of over- and under-treatment. The aim of this study was to describe the end-of-life decisions of critically ill patients in a surgical ICU in Germany and to identify how financial incentives may influence decision making. METHODS: Data on the admission diagnosis, end-of-life decision making and cause of death were obtained for 69 critically ill patients who died in the ICU (Hospital of Bayreuth, Germany) in 2009. A cost-revenue analysis was conducted on the 46 patients who did not die within 3 days of ICU admission. Because we lacked real data on costs, our analysis was based on the average cost for each diagnosis-related group (DRG) from the Institute for the Hospital Remuneration System (InEK). Hospital revenues based on the DRG were considered. Subsequently, we compared the estimated financial impact of earlier and later decisions to withdraw or withhold futile therapy. RESULTS: In this study, we found that end-of-life decision making was poorly documented. Only 11 % of patients had a valid power of attorney and advanced directives, and therapy with presumed consent was performed in 43 % of all cases. From long-stay patients, therapy was withdrawn for 37 % of patients and withheld from 26 % of patients, and 37 % of the patients died receiving maximal therapy. Almost 72 % of DRG-related reimbursements were dependent on ventilation hours. The average total cost estimate (according to InEK) for the 46 long-stay patients was 1,201,000
Assuntos
Tomada de Decisão Clínica , Cuidados Críticos/economia , Estado Terminal/economia , Estado Terminal/mortalidade , Grupos Diagnósticos Relacionados/economia , Assistência Terminal/economia , Diretivas Antecipadas/economia , Diretivas Antecipadas/estatística & dados numéricos , Idoso , Cuidados Críticos/estatística & dados numéricos , Grupos Diagnósticos Relacionados/estatística & dados numéricos , Feminino , Alemanha , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Masculino , Modelos Econômicos , Mortalidade , Ordens quanto à Conduta (Ética Médica) , Assistência Terminal/estatística & dados numéricosRESUMO
The introduction of disease management programs for chronic diseases aims to achieve a permanent improvement of care. Such an improvement cannot be reached without effective incentives. However, the incentives set in the German Health Care System may cause reactions on the micro level that do not correspond to the aims on the macro level. In the long term, patient empowerment will be needed in order to enable a shared-decision-making of patients and physicians. A market-oriented solution consists of quality competition allowing for various delivery systems and the search for new models that lead to an improvement of care. However, quality competition will have to respect the traditional principle of solidarity underlying the German health care system. Disease management will contribute to an integrated, incentive-oriented delivery system but only if it allows for a variety of care.