Value in acute care surgery, Part 1: Methods of quantifying cost.

BACKGROUND: With health care expenditures continuing to increase rapidly, the need to understand and provide value has become more important than ever. In order to determine the value of care, the ability to accurately measure cost is essential. The acute care surgeon leader is an integral part of driving improvement by engaging in value increasing discussions. Different approaches to quantifying cost exist depending on the purpose of the analysis and available resources. Cost analysis methods range from detailed microcosting and time-driven activity-based costing to less complex gross and expenditure-based approaches. An overview of these methods and a practical approach to costing based on the needs of the acute care surgeon leader is presented.

The Factors Associated With Direct Medical Costs in Patients With Gastric Cancer: Quantile Regression Approach Compared With Gamma Regression.

OBJECTIVES: Evaluating the costs of illness can provide evidence to improve performance at all levels of health organizations. This study aimed to identify the relationship between the costs of diagnosing and treating patients with gastric cancer and their explanatory variables, using quantile and gamma regressions and comparing the results of the two models. METHODS: This was a cross-sectional and descriptive-analytic study carried out in 2016. In total, 449 patients with gastric cancer were selected at a hospital affiliated with Mashhad University of Medical Sciences. Direct costs and other variables were collected from medical documents. Data were analyzed using the STATA 12 software, using quantile and gamma regression analysis, and the results were compared. RESULTS: The highest average cost per patient was related to hospitalization costs in both metastatic (20 911 034 Iranian Rials) and nonmetastatic patients (20 738 062 Iranian Rials). The lowest average cost was related to biopsy services in nonmetastatic patients. The results of the study also showed that quantile regression is an appropriate substitute for gamma regression and, in some cases, can provide more information for the analysis of disease costs. Based on the results of the quantile regression, being a male and having a shorter stay had a positive effect on cost and the age of the patient had a significantly negative effect. CONCLUSIONS: Examining the cost of a common illness, such as gastric cancer, is an important economic tool for policy makers and decision makers. It provides evidence-based decision making about resource allocation that they can use for future planning and cost control.

A physician-led initiative to improve clinical documentation results in improved health care documentation, case mix index, and increased contribution margin.

INTRODUCTION: Clinical documentation is the key determinant of inpatient acuity of illness and payer reimbursement. Every inpatient hospitalization is placed into a diagnosis related group with a relative value based on documented procedures, conditions, comorbidities and complications. The Case Mix Index (CMI) is an average of these diagnosis related groups and directly impacts physician profiling, medical center profiling, reimbursement, and quality reporting. We hypothesize that a focused, physician-led initiative to improve clinical documentation of vascular surgery inpatients results in increased CMI and contribution margin. METHODS: A physician-led coding initiative to educate physicians on the documentation of comorbidities and conditions was initiated with concurrent chart review sessions with coding specialists for 3 months, and then as needed, after the creation of a vascular surgery documentation guide. Clinical documentation and billing for all carotid endarterectomy (CEA) and open infrainguinal procedures (OIPs) performed between January 2013 and July 2016 were stratified into precoding and postcoding initiative groups. Age, duration of stay, direct costs, actual reimbursements, contribution margin (CM), CMI, rate of complication or comorbidity, major complication or comorbidity, severity of illness, and risk of mortality assigned to each discharge were abstracted. Data were compared over time by standardizing Centers for Medicare and Medicaid Services (CMS) values for each diagnosis related group and using a CMS base rate reimbursement. RESULTS: Among 458 CEA admissions, postcoding initiative CEA patients (n = 253) had a significantly higher CMI (1.36 vs 1.25; P = .03), CM ($7859 vs $6650; P = .048), and CMS base rate reimbursement ($8955 vs $8258; P = .03) than precoding initiative CEA patients (n = 205). The proportion of admissions with a documented major complication or comorbidity and complication or comorbidity was significantly higher after the coding initiative (43% vs 27%; P < .01). Among 504 OIPs, postcoding initiative patients (n = 227) had a significantly higher CMI (2.23 vs 2.05; P < .01), actual reimbursement ($23,203 vs $19,909; P < .01), CM ($12,165 vs $8840; P < .01), and CMS base rate reimbursement ($14,649 vs $13,496; P < .01) than precoding initiative patients (n = 277). The proportion of admissions with a documented major complication or comorbidity and complication or comorbidity was significantly higher after the coding initiative (61% vs 43%; P < .01). For both CEA and OIPs, there were no differences in age, duration of stay, total direct costs, or primary insurance status between the precoding and postcoding patient groups. CONCLUSIONS: Accurate and detailed clinical documentation is required for key stakeholders to characterize the acuity of inpatient admissions and ensure appropriate reimbursement; it is also a key component of risk-adjustment methods for assessing quality of care. A physician-led documentation initiative significantly increased CMI and CM.

[Description of the severely injured in the DRG system: is treatment of the severely injured still affordable?]. / Abbildung von Schwerverletzten im DRG-System : Wird die Schwerverletztenversorgung doch bezahlbar?

BACKGROUND: Due to the heterogeneity of severely injured patients (multiple trauma) it is difficult to assign them to homogeneic diagnosis-related groups (DRG). In recent years this has led to a systematic underfunding in the German reimbursement system (G-DRG) for cases of multiply injured patients. This project aimed to improve the reimbursement by modifying the case allocation algorithms of multiply injured patients within the G-DRG system. METHODS: A retrospective analysis of standardized G-DRG data according to §21 of the Hospital Reimbursement Act (§ 21 KHEntgG) including case-related cost data from 3,362 critically injured patients from 2007 and 2008 from 10 university hospitals and 7 large municipal hospitals was carried out. For 1,241 cases complementary detailed information was available from the trauma registry of the German Trauma Society to monitor the case allocation of multiply injured patients within the G-DRG system. Analysis of coding and grouping, performance of case allocation and the homogeneity of costs in the G-DRG versions 2008-2012 was carried out. RESULTS: The results showed systematic underfunding of trauma patients in the G-DRG version 2008 but adequate cost covering in the majority of cases with the G-DRG versions 2011 and 2012. Cost coverage was foundfor multiply injured patients from the clinical viewpoint who were identified as multiple trauma by the G-DRG system. Some of the overfunded trauma patients had high intensive care costs. Also there was underfunding for multiple injured patients not identified as such in the G-DRG system. CONCLUSIONS: Specific modifications of the G-DRG allocation structures could increase the appropriateness of reimbursement of multiply injured patients. Data-based analysis is an essential prerequisite for a constructive development of the G-DRG system and a necessary tool for the active participation of medical specialist societies.

Physician cost profiling--reliability and risk of misclassification.

BACKGROUND: Insurance products with incentives for patients to choose physicians classified as offering lower-cost care on the basis of cost-profiling tools are increasingly common. However, no rigorous evaluation has been undertaken to determine whether these tools can accurately distinguish higher-cost physicians from lower-cost physicians. METHODS: We aggregated claims data for the years 2004 and 2005 from four health plans in Massachusetts. We used commercial software to construct clinically homogeneous episodes of care (e.g., treatment of diabetes, heart attack, or urinary tract infection), assigned each episode to a physician, and created a summary profile of resource use (i.e., cost) for each physician on the basis of all assigned episodes. We estimated the reliability (signal-to-noise ratio) of each physician's cost-profile score on a scale of 0 to 1, with 0 indicating that all differences in physicians' cost profiles are due to a lack of precision in the measure (noise) and 1 indicating that all differences are due to real variation in costs of services (signal). We used the reliability results to estimate the proportion of physicians in each specialty whose cost performance would be classified inaccurately in a two-tiered insurance product in which the physicians with cost profiles in the lowest quartile were labeled as "lower cost." RESULTS: Median reliabilities ranged from 0.05 for vascular surgery to 0.79 for gastroenterology and otolaryngology. Overall, 59% of physicians had cost-profile scores with reliabilities of less than 0.70, a commonly used marker of suboptimal reliability. Using our reliability results, we estimated that 22% of physicians would be misclassified in a two-tiered system. CONCLUSIONS: Current methods for profiling physicians with respect to costs of services may produce misleading results.

Metastatic non-small cell lung cancer: costs associated with disease progression.

OBJECTIVE: To compare direct costs of care among patients having advanced non-small cell lung cancer (NSCLC) with versus without disease progression following first-line chemotherapy. STUDY DESIGN: A retrospective study was conducted among patients with stage IIIB or IV metastatic NSCLC diagnosed between January 1, 2001, and May 30, 2005. METHODS: Progression was defined as a change in chemotherapy regimen and radiologic confirmation of tumor growth. Total direct costs after diagnosis were computed monthly and were aligned chronologically between patients with and without progression to determine the mean costs for the 3 months after progression. Multivariate linear regression analysis estimated predictors of progression costs. RESULTS: Among 306 patients with NSCLC who received chemotherapy, 108 patients experienced documented progression. Total cost of care from progression to death or end of study was $42,066. The mean direct 3-month postprogression cost of care was $31,129 for patients with progression compared with $18,802 for patients with stable disease, yielding an incremental cost of $12,327. CONCLUSION: Patients with metastatic NSCLC who experience progression have significantly greater costs than similar patients with stable disease.

A study on the economic impact of bariatric surgery.

OBJECTIVE: To evaluate the private third-party payer return on investment for bariatric surgery the United States. STUDY DESIGN: Morbidly obese patients aged 18 years or older were identified in an employer claims database of more than 5 million beneficiaries (1999-2005) using International Classification of Diseases, Ninth Revision, Clinical Modification code 278.01. Each of 3651 patients who underwent bariatric surgery during this period was matched to a control subject who was morbidly obese and never underwent bariatric surgery. Bariatric surgery patients and controls were matched based on patient demographics, selected comorbidities, and costs. METHODS: Total healthcare costs for bariatric surgery patients and their controls were recorded for 6 months before surgery through the end their continuous enrollment. To account for potential differences in patient characteristics, we calculated the cost differential by estimating a Tobit model. A return on investment was estimated from the resulting coefficients. Costs were inflation adjusted to 2005 US dollars using the Consumer Price Index for Medical Care, and the cost savings were discounted by 3.07%, the month Treasury bill rate during the same period. RESULTS: The mean bariatric surgery investment ranged from approximately $17,000 to $26,000. After controlling for observable patient characteristics, we estimated all costs to have been recouped within 2 years for laparoscopic surgery patients and within 4 years for open surgery patients. CONCLUSIONS: Downstream savings associated with bariatric surgery are estimated to offset the initial costs in 2 to 4 years. Randomized or quasiexperimental studies would be useful to confirm this conclusion, as unobserved characteristics may influence the decision to undergo surgery and cannot be controlled for in this analysis.

Economic evaluations of medical care interventions for cancer patients: how, why, and what does it mean?

While the past decade has seen the development of multiple new interventions to diagnose and treat cancer, as well as to improve the quality of life for cancer patients, many of these interventions have substantial costs. This has resulted in increased scrutiny of the costs of care for cancer, as well as the costs relative to the benefits for cancer treatments. It is important for oncologists and other members of the cancer community to consider and understand how economic evaluations of cancer interventions are performed and to be able to use and critique these evaluations. This review discusses the components, main types, and analytic issues of health economic evaluations using studies of cancer interventions as examples. We also highlight limitations of these economic evaluations and discuss why members of the cancer community should care about economic analyses.

Costos directos de atención de pacientes con cáncer cerviño uterino en el Hospital Bertha Calderon Roque de la ciudad de Managua en el periodo de abril – junio del año 2007 / Costs direct care of patients with uterine cancer cerviño in the Bertha Calderon Hospital Roque of the city of Managua in the period from April to June of 2007

El presente estudio refleja la descripción de Costos Directos de Atención de una serie de casos de pacientes con Cáncer cérvico uterino capatadas en consulta externa de Oncología del Hospital Bertha Calderón durante el período abril- junio del 2007 y manejadas en el transcurso del mismo año. Se evalauaron los costos en radioterapia, medicmentos, examenes de laboratorio y de diagnóstico, cirugía, recursos humanos, entre otros, los cuales permitieron establecer los resultados a través de tablas de frecuencia simple para cada grupo específico de pacientes. Del total de la muestra en estudio, 27 pacientes con cáncer cervico uterino el grupo étareo más frecuente fue el de 35 - 49 años con un 55. 55 por ciento seguido por mayor o igual a 50 años 37.04 por ciento; las patologías crónicas fueron hipertensión arterial (15 por ciento) y diabetes mellitus tipo 2 (4 por ciento). El 56 por ciento de los casos se encontraban en estadio III b de la enfermedad seguido por 33 por ciento en estadio II b, 7 por ciento es estadio I b1 y 4 por ciento en estadio IVa...

HOPPS: evolution of a CMS process.

Medicare's hospital outpatient prospective payment system (HOPPS) was initially developed in response to the rapid rise in Medicare's outpatient expenses between 1980 and 1991. The Balanced Budget Act of 1997 mandated HOPPS, with an implementation date of August 1, 2000. Unlike the Medicare Physician Fee Schedule, the Centers for Medicare and Medicaid Services (CMS) used hospital charge data to develop the ambulatory patient classification (APC) payment weights. During its evolution as a payment system, Congress mandated the creation of an advisory panel as well as the removal of diagnostic mammography from the APCs. The Deficit Reduction Act proposes applying HOPPS for paying technical fees in nonhospital settings.

Total and component health care costs in a non-Medicare HMO population of patients with and without type 2 diabetes and with and without macrovascular disease.

BACKGROUND: Type 2 diabetes (T2DM) is one of the most prevalent and costly chronic conditions in the United States. Macrovascular disease (MVD) remains a common and costly comorbidity in T2DM. Understanding the impact of MVD on total health care costs in patients with T2DM is of great importance to managed care organizations (MCOs). OBJECTIVE: To examine from the perspective of an MCO the impact of MVD on health care costs in patients with T2DM and in a matched comparison group of patients without diabetes. METHODS: This study involved retrospective analysis of administrative claims (eligibility, pharmacy, and medical) using data from a commercial health maintenance organization population of approximately 700,000 members in an East Coast health plan. Patients were included in this study if they (a) had 2 or more claims for T2DM ( International Classification of Diseases, Ninth Revision, Clinical Modification[ICD-9-CM] codes 250.X0 or 250.X2), or (b) had a prescription drug claim for insulin and a diagnosis of T2DM, or (c) had at least 1 pharmacy claim for an oral glycemic-modifying agent during the 12-month period from January 1, 2003, through December 31, 2003. Patients with 2 or more medical claims for type 1 diabetes (ICD-9-CM codes 250.X1 or 250.X3) were excluded from the study. A random group of comparison patients without diabetes (ICD-9 code 250.xx) were matched on age group and sex. Study patients in these 2 groups were subdivided into 4 groups based on the presence of medical claims with diagnosis codes for MVD (acute myocardial infarction, other ischemic heart disease, coronary artery bypass surgery, percutaneous transluminal angioplasty, congestive heart failure, cerebrovascular accident, peripheral vascular disease, cerebrovascular disease, and peripheral vascular disease). Direct medical costs were aggregated for 12 months after the index date for patients in all 4 groups. Bootstrapping technique was used to compare the health care costs between patients with T2DM and those without diabetes, stratified by MVD status. RESULTS: A total of 9,059 patients with T2DM were identified and were matched by age group and sex to a random group of patients without diabetes. MVD was present in 26.9% (n=2,441) of patients with T2DM versus 11.3% (n=1,027) of patients without diabetes. Patients with MVD and T2DM were, on average, a year younger than patients with MVD but without diabetes (54.55 vs. 55.55 years, P <0.001). Patients with T2DM but without MVD were nearly the same age as patients with neither diabetes nor MVD (50.44 vs. 50.59 years, P=0.092). The T2DM patients with MVD had average 12-month costs more than 3 times the costs for patients with T2DM but without medical claims with diagnosis codes for MVD--10,450 dollars versus 3,385 dollars, respectively. Pharmacy costs accounted for 29.0% and inpatient hospital costs accounted for 43.9% of total medical costs in T2DM patients with MVD versus 55.0% and 17.3%, respectively, in T2DM patients without MVD. Patients with MVD diagnoses and T2DM had total average medical costs that were 1.7 times the total medical costs for MVD patients without T2DM--10,450 dollars versus 6,090 dollars, respectively. CONCLUSIONS: The results of this analysis suggest that MVD may triple the total medical care costs in patients with T2DM. These economic consequences would appear to support the importance of interventions intended to prevent macrovascular events in patients with T2DM.

The economic value of childhood varicella vaccination in France and Germany.

OBJECTIVE: To determine the economic impact of childhood varicella vaccination in France and Germany. METHODS: A common methodology based on the use of a varicella transmission model was used for the two countries. Cost data (2002 per thousand) were derived from two previous studies. The analysis focused on a routine vaccination program for which three different coverage rates (CRs) were considered (90%, 70%, and 45%). Catch-up strategies were also analyzed. A societal perspective including both direct and indirect costs and a third-party payer perspective were considered (Social Security in France and Sickness Funds in Germany). RESULTS: A routine vaccination program has a clear positive impact on varicella-related morbidity in both countries. With a 90% CR, the number of varicella-related deaths was reduced by 87% in Germany and by 84% in France. In addition, with a CR of 90%, routine varicella vaccination induces savings in both countries from both societal (Germany 61%, France 60%) and third-party payer perspectives (Germany 51%, France 6.7%). For lower CRs, routine vaccination remains cost saving from a third-party payer perspective in Germany but not in France, where it is nevertheless cost-effective (cost per life-year gained of 6521 per thousand in the base case with a 45% CR). CONCLUSION: Considering the impact of vaccination on varicella morbidity and costs, a routine varicella vaccination program appears to be cost saving in Germany and France from both a societal and a third-party payer perspective. For France, routine varicella vaccination remains cost-effective in worst cases when a third-party payer perspective is adopted. Catch-up programs provide additional savings.

An economic assessment of pre-vaccination screening for hepatitis A and B.

OBJECTIVE: The availability of a single vaccine active against hepatitis A and B may facilitate prevention of both infections, but complicates the question of whether to conduct pre-vaccination screening. The authors examined the cost-effectiveness of pre-vaccination screening for several populations: first-year college students, military recruits, travelers to hepatitis A-endemic areas, patients at sexually transmitted disease clinics, and prison inmates. METHODS: Three prevention protocols were examined: (1) screen and defer vaccination until serology results are known; (2) screen and begin vaccination immediately to avoid a missed vaccination opportunity; and (3) vaccinate without screening. Data describing pre-vaccination immunity, vaccine effectiveness, and prevention costs borne by the health system (i.e., serology, vaccine acquisition, and administration) were derived from published literature and U.S. government websites. Using spreadsheet models, the authors calculated the ratio of prevention costs to the number of vaccine protections conferred. RESULTS: The vaccinate without screening protocol was most cost-effective in nine of 10 analyses conducted under baseline assumptions, and in 69 of 80 sensitivity analyses. In each population considered, vaccinate without screening was less costly than and at least equally as effective as screen and begin vaccination. The screen and defer vaccination protocol would reduce costs in seven populations, but effectiveness would also be lower. CONCLUSIONS: Unless directed at vaccination candidates with the highest probability of immunity, pre-vaccination screening for hepatitis A and B immunity is not cost-effective. Balancing cost reduction with reduced effectiveness, screen and defer may be preferred for older travelers and prison inmates.

Cost comparison of three HIV counseling and testing technologies.

BACKGROUND: In the United States, more than 2 million human immunodeficiency virus (HIV) antibody tests are performed annually at publicly funded HIV counseling and testing (CT) clinics. Clients do not receive results from one third of these tests because of low return rates. New rapid-testing technologies may improve receipt of results, but no study has systematically analyzed the costs of these newer technologies compared with the standard protocol. OBJECTIVE: To estimate and compare the economic costs associated with three HIV CT protocols: the standard protocol and the one-step and two-step rapid protocols. METHODS: A cost analysis model was developed in 2002 to calculate the intervention costs for HIV CT services with the standard CT protocol and the one-step and two-step rapid-test protocols for a hypothetical client in a publicly funded HIV clinic. Sensitivity analyses were performed to ascertain the effects of uncertainty in the model parameters. RESULTS: The one-step rapid protocol was generally the least expensive of the three protocols. The standard protocol cost less than the two-step protocol per HIV-positive client notified of his or her HIV status, but cost more per HIV-negative client. The sensitivity analysis indicated overlap in the cost estimates for HIV-negative clients, reflecting the generally similar costs of the three testing protocols. Taking into account HIV seroprevalence, the two-step rapid protocol would be less expensive than the standard protocol for most publicly funded testing programs in the United States. CONCLUSIONS: Rapid test protocols offer economic advantages as well as convenience, compared to the standard testing protocol. The cost estimates presented here should prove helpful to HIV program managers and other public health decision makers who need information on these counseling and testing technologies.

[Costs, costs and more costs: which one should we use?]. / Notions et mesure des coûts en fonction de la perspective choisie.

A cost is not an intrinsic feature of a product in the same way as temperature is for water and air. It is a calculation based on theory and convention. Costs may be characterised by their object (an hospital admission, a hospitalization day, a diagnostic related group, a treatment phase), their contents (costs directly attributable to the patient, controllable costs, including not only departmental operating costs but also costs resulting from the department's activity, full costs including administrative and infrastructure overhead costs), the point of reference from where the costs are considered (from the point of view of the family, the health professionals suppliers, the buyers, the health care system, or society) and the time when the costs were calculated. The cost framework which must be considered in any economic evaluation must relate to the budgetary concerns of the party whose involvement is sought in a health care project. There is no all encompassing study in this field; an evaluation performed for one type of contributor must only consider this party's point of view.

Tendencias, costos y desafíos para la atención de las enfermedades crónicas en Costa Rica / Tendences, costs and challenges for the attention of the chronic diseases in Costa Rica

Es objetivo de este trabajo es analizar, en el marco de las transformaciones socioeconómicas, demográficas y epidemiológicas de Costa Rica, el comportamiento de las enfermedades crónicas desde la década de los setenta, y los costos de hospitalización y atención ambulatoria para los servicios de salud del país. Se describen los cambios en el modelo de atención y desarrollo de Costa Rica y las tendencias de la mortalidad proporcional, tasas estandarizadas de mortalidad desde 1970 a 1998, tasas de egreso hospitalario y sus diferencias según sexo. Se estiman los costos de hospitalización y consulta ambulatoria de patologías crónicas y se comparan con enfermedades infecciosas como diarrea y neumonía. Finalmente, se plantean algunos desafíos con respecto a la implementación de estrategias de prevención y atención de este tipo de enfermedades en los servicios de salud.

The personal costs and convenience of screening mammography.

BACKGROUND: Few studies have examined the impact of women's personal costs on obtaining a screening mammogram in the United States. METHODS: All women obtaining screening mammograms at nine Connecticut mammography facilities during a 2-week study period were asked to complete a questionnaire. Facilities included urban and rural fixed sites and mobile sites. The survey included questions about insurance coverage, mammogram payment, and personal costs in terms of transportation, family care, parking, and lost work time from the women's perspective. RESULTS: The response rate was 62% (731 of 1189). Thirty-two percent of respondents incurred some type of personal cost, including lost work time, family care, and parking. Women incurring personal costs were more likely than those without personal costs to attend an urban facility (46% vs. 23%, p < 0.01) and be under the age of 50 (40% vs. 26%, p < 0.01). Overall, 61% of women listed convenience and 17% listed cost as a reason for choosing a mammography facility; 23% reported that cost might prevent them from obtaining a future mammogram. CONCLUSIONS: One third of women obtaining mammograms may be incurring personal costs. These personal costs should be considered in future cost-effectiveness analyses.

[Diagnosis related groups (DRG) in child and adolescent psychiatry: results of a prospective pilot study]. / Diagnosis Related Groups (DRG) in der Kinder- und Jugendpsychiatrie: Ergebnisse einer prospektiven Pilotstudie.

Germany faces one of the biggest 'revolutions' in the health care system. As decided by the government in cooperation with medical boards and insurances, beginning with January 1st, 2003 all inpatient treatments will be paid on the basis of adapted Australian-Refined Diagnosis Related Groups. To date, hospitals are requested to obtain prospective databases in order to cluster homogeneous diagnostic groups and calculate realistic treatment-costs. Both psychiatry and child and adolescent psychiatry are so far excluded from the introduction of DRGs. However, most experts predict extensive shifts of patients into psychiatry (i.e. with comorbid internal diseases) under the pressure of short treatments in all non-psychiatric disciplines. Therefore, changes in the payment of psychiatric treatments are inevitably. As part of the DRG pilot-study, we created a catalogue adapted to child and adolescent psychiatry, which was used for 102 consecutively treated inpatients of a child and adolescent hospital. A total of 17.019 prospectively assessed procedures were obtained. Under clinical aspects, 11 categories of 'typical' disorders were analysed. Worst predictability of treatment costs was found for obsessive-compulsive disorders, personality disorders, and eating disorders. Comorbidity and complexity of the disorder was not related to the length of hospital treatment. Implications on future payment systems in child and adolescent psychiatry are discussed.