[Quality parameters in the treatment of acute stroke: comparison of various regional treatment concepts]. / Qualitätsparameter der akuten Schlaganfallversorgung: Gegenüberstellung unterschiedlicher regionaler Versorgungskonzepte.

BACKGROUND: The long-term prognosis of stroke patients is still dependent in particular on the timing of a correct diagnosis, immediate initiation of a suitable specific therapy and competent treatment in a stroke unit. Therefore, nationwide attempts are being made to establish a comprehensive coverage of the necessary specific competence and infrastructural requirements. Divergent regional circumstances and economic viewpoints determine the characteristics of the various healthcare concepts and the interplay between participating cooperation partners. This article compares the development with respect to three qualitative treatment parameters exemplified by four regional healthcare models during the time period 2008-2011. METHODS: The hospitalization rates for patients with transitory ischemic attacks, ischemic and hemorrhagic stroke, the case numbers for stoke unit treatment and the rates of systemic thrombolysis and mechanical thrombectomy in the regions of Berlin, the Ruhr Area, Ostwestfalen-Lippe and southeast Bayern (TEMPiS) are presented based on the data from the DRG statistical reports for the years 2008 and 2011. RESULTS: The average hospitalization rates for ischemic stroke patients (brain infarct ICD 163) in the time period from 2008 to 2011 were 294 per 100,000 inhabitants for the Ruhr Area, 257 per 100,000 inhabitants for Ostwestfalen-Lippe and 265 per 100,000 inhabitants each for Berlin and southeast Bayern. The complex stroke treatment quota for southeast Bayern in 2008 was 31 % and 47 % in 2011 and the respective quotas for the other regions studied were 42-44 % and 58-59 %. The rate of systemic thrombolysis in 2008 ranged between 4.2 % and 7.4 % and in 2011 the increase in the range for the 4 regions studied was between 41 % and 145 %. In 2011 the thrombectomy quota of 2 % in the Ruhr Area was the only one which was above the national average of 1.3 % of all brain infarcts. DISCUSSION: Stroke is a common disease in the four regions studied. For the established forms of therapy, complex treatment of stroke and systemic thrombolysis, the positive effect of structurally improved approaches in the four different regional treatment concepts could be confirmed during the course of the observational time period selected. Mechanical thrombectomy which is currently still considered to be an individual healing attempt, was used significantly more often in the Ruhr Area in 2011 than in the other three regions studied. A standardized referral procedure had previously been established in the metropolitan regions.

Quasi-market and cost-containment in Beveridge systems: the Lombardy model of Italy.

In the very recent past, the Lombardy health care system - established in 1997 on the quasi market model - has caught the interest of researchers and politicians in different OECD countries(1). Its merits, compared to other Italian regional systems, are the control of health care spending and the balanced budget, in a frame of good quality of services and patient choice. From the theoretical point of view, an appealing aspect of the Lombardy model is its gradual shift from a quasi market (QM) to a "quasi administered" system, which maintains all the typical features of the QM orientation - separation between purchasers and providers, the co-presence of public, not for profit and public providers, and patient free choice - but has deliberately sacrificed competition in order to control health expenditure. Another aspect of the Lombardy model is the sharp presence of private providers: the evidence that private sector is mainly concentrated in the long term care, where risks of complications are lower and financial remuneration is higher, suggests that a closer control should be exerted on hospital activity. Furthermore, possible distortions such as cream skimming and cherry picking by the private providers need more consideration. Another concern is linked to health spending control: equity issues could arise when observing a still relatively high share of private (out of pocket) health care expenditure. The paper stems from a literature review and tries to analyse the evolution of this regional system, the institutional path that brought to the implementation of the model, its theoretical basis, its merits and criticism. The period considered ranges from 1997, when the reform was enacted, to 2010.

Pharmaceuticals and the strategic national stockpile program.

This article discusses current stockpile practices after exploring a history of the use of biologic agents as weapons, the preventive measures that the federal government has used in the past, and the establishment of a Strategic National Stockpile Program in 2003. The article also describes the additional medical supplies from the managed inventory and the federal medical stations. The issues (financial burden, personnel, and materiel selection) for local asset development are also discussed. Critical is the cost to local communities of the development and maintenance of a therapeutic agent stockpile and the need for personnel to staff clinics and medical stations. Finally, the important role of the dental profession for dispensing medication and providing mass immunization in the event of a disaster is described.

Modeling participation in the NHII: operations research approach.

Regional health information organizations (RHIOs) form the core building blocks of any approach to creating the National Health Information Infrastructure. RHIOs are computer-supported information sharing alliances composed of health care institutions that need to exchange clinical, financial or administrative data. Many uncertainties, including institution conversion costs, price-to-participate, and RHIO governance decisions make estimating the cost consequences difficult to establish. Current approaches to health information technology investment rely on a net-present-value analysis, which is inadequate to capture the dynamic, uncertain course likely to occur in the RHIO environment. Methods from operations research provide decision makers robust tools for exploring the cost and consequences of RHIO structures. We present here an initial modeling approach that allows explicit examination of RHIO structure and pricing options. Once refined, these models will provide the core of a suite of decision support tools for evaluation of RHIO pricing options, discount rates, and optimal organizational structures.

Outcomes of an integrated telehealth network demonstration project.

An integrated telehealth network that linked three hospitals, a federally qualified health care clinic with six sites, a county dental clinic, and patient homes was developed and implemented using both private and federal funding. The goal of the network was to deliver 10 different medical, dental, and behavioral health services to a rural community. The network served patients from nine different counties and two states. Outcomes from the disease management programs for congestive heart failure and diabetes, as well as crisis telehealth and teledental health, were reported. Results for the diabetes disease management program increased the number of diabetics who brought their blood sugar under control. Additionally, based on hospital days per patient per year with and without intervention, and the cost of intervention by telehealth, it was projected that the national cost of care for CHF hospitalizations could be reduced from 8 billion dollars to 4.2 billion dollars. This telehealth network can serve as a model for integrating health services in each county of the state. Once each county had an integrated telehealth network, the county networks could be linked to provide regional services and coordination on a statewide basis.

Economic evaluation of programmes aiming at eradicating infectious diseases.

The subject of this article is to discuss the global and regional economic aspects of programmes for eradicating infectious diseases. The perspective on the issue is that scarce health care resources should be employed in the best possible way. The task is then to examine what the best possible use might be. A starting point is by asking the relevant policy questions attached to eradications: Is there a suitable technique, what are the costs, and what are the benefits? Of particular importance is the opportunity cost of using resources on eradication when other health care problems may require more urgent donation of resources. The paper attempts to set up a generic model for economic evaluation of eradication programmes. But, as there are many different treatment strategies varying from one country to another, such a generic model may need modifications to suit a particular strategy. However, the paper is contextual and should only be viewed as guidance for those wishing to conduct an economic analysis of eradication programmes, or as a initiative to create discussion among health care decision makers.

The changing health care environment: implications for residency training.

Throughout the United States, the growth of managed care is forcing pediatric providers (physicians and hospitals) to reconstruct and integrate the health care delivery system with a focus away from the academic center and toward the community. Managed care also is forcing new financing approaches geared toward the assumption of economic risk for patient management and utilization of services. Radical changes in pediatric training programs will be necessary to accommodate the strategic and operational changes being pursued in response to these evolving market forces. These changes, while disruptive, will strengthen the breadth and diversity of graduate medical education and will better prepare trainees for the new delivery system in which they will practice. In this article, we examine how the evolution of managed care is redefining the basic financial and organizational framework for pediatric care and the implications of this redefinition for children's hospitals and academic medical center-based pediatric programs. We draw on our experience in the greater Philadelphia market to illustrate the impact of these changes and discuss one pediatric system's response. Finally, we review the educational opportunities provided by these changes.

Prevention of blood-borne HIV transmission using a decentralized approach in Shaba, Zaire.

OBJECTIVE: To prevent blood transfusion-acquired HIV infection with a decentralized approach to HIV screening of blood donors, using an instrument-free rapid test. SETTING: Shaba province, Zaire (496,877 km2). METHODS: The programme consisted of training health-care workers, distribution of a rapid HIV-antibody test (DuPont's HIVCHEK) for screening of all blood donations, and quality control of testing by a regional reference centre. RESULTS: Over a 2-year period, 11,940 rapid tests were distributed to 37 hospitals, covering 75% of all hospital beds outside the copper mine's health system in Shaba. Eighty-five per cent of the tests were used to screen blood donors (5.4% positive test rate) and 13% to test patients (39.7% positive test rate). At least 265 cases of HIV-positive blood donation were prevented, at an estimated cost of 137-279 ECU per case. Only 26% of initially positive specimens reached the central laboratory for supplemental testing, and sterile transfusion equipment and blood-grouping reagents were frequently unavailable. The lack of transport and communications and a deteriorating health system were major constraints. CONCLUSIONS: District hospitals in Africa are often long distances from major cities, difficult to reach for most of the year, and perform a small number of transfusions. In this context a classical centralized regional blood bank may not be a feasible option to ensure safe blood transfusions. However, safe blood transfusion can be achieved with a decentralized approach using a rapid test, provided that minimum standards of health-care services are available.

PIP: This program aimed at preventing blood transfusion-acquired HIV infection with a decentralized approach to HIV screening of blood donors using an instrument free raid test was initiated in Shaba province in Zaire (496,877 sq. km and included training of health care workers, distribution of a rapid HIV-antibody test (DuPont's HIVCHEK) for screening of all blood donations, and quality control of testing by a regional reference center. Over a 2-year period, 11,940 rapid tests were distributed to 37 hospitals, covering 75% of all hospital beds outside the copper mine's health system in Shaba. 85% of the tests were used to screen blood donors (5.4% positive test rate) and 13% to test patients (39.7% positive test rate). At least 265 cases of HIV-positive blood donation were prevented at an estimated cost of 137-279 ECU per case. Only 26% of initially positive specimens reached the central laboratory for supplemental testing, and sterile transfusion equipment and blood-grouping reagents were frequently unavailable. The lack of transport and communications and a deteriorating health system were major constraints. District hospitals in Africa are often long distances from major cities, difficult to reach for most of the year, and perform a small number of transfusions. In this context, a classical centralized regional blood bank may not be a feasible option to ensure safe blood transfusions. However, safe blood transfusion can be achieved with a decentralized approach using a rapid test, provided that minimum standards of health care services, are available.

[Financing regional health services. Problems and possible solutions]. / La finaciación de los servicios regionales de salud. Problemas y posibles soluciones.

The purpose of this paper is to highlight the fact that the present financial system of the Health Regional Services is constraining their management and development possibilities and thus, the System designed in the General Law of Health (Ley General de Salud); moreover, it is, hindering the development of the Autonomous Communities themselves, as the financing of these services is a hard weight to carry, within the own financing process of the Autonomous Communities. We just try to demonstrate there is no reason whatsoever that may justify the present financing procedure of the Health Services already Transferred to Government of the Autonomous Communities. We deem it is necessary to change such model, in order that principles of sufficiency, autonomy and interterritorial solidarity become effective. We are also of the opinion that we are now living the adequate moment to overcome these problems, as it is our must to renegotiate the application, for the five-year period 1992-1995, of the principles under the Organic Law for the financing of the Autonomous Communities. (Spanish, LOFCA).

Development and organization of a multiple organ transplantation program.

Multiple organ transplantation has come of age. Indications are that it will continue to grow, if not flourish. The complexity of modern surgical care, its multiperson dependency, and the need for the surgeon to retain knowledge and involvement with his patient's care and problems are nowhere more evident than in multiple organ transplantation. Each organ presents its own associated challenges, the prime solution of which lies with a skillful and dedicated surgeon; but with all organs there are challenges of expectantly waiting patients, housing during the wait and for postoperative observation, procurement, erratic scheduling of the operating room, nursing, social service, immunosuppression, immunopathology, interest of hospital public relations and of the news media, and perennial care. This report concerns the growth and development of the multiple organ transplant program at the University Health Center of Pittsburgh and describes some answers to the challenges presented.