Impact of the COVID-19 pandemic on acute mental health admissions in Croatia.

Background: The pandemic of COVID-19 had a profound impact on our community and healthcare system. This study aims to assess the impact of COVID-19 on psychiatric care in Croatia by comparing the number of acute psychiatric cases before coronavirus disease (2017-2019) and during the pandemic (2020-2022). Materials and methods: The paper is a retrospective, comparative analyzes of the hospital admission rate in Diagnosis Related Group (DRG) classes related to mental diseases, and organic mental disorders caused by alcohol and drug use. This study used DRG data from all acute hospitals in Croatia accredited to provide mental health care services and relevant publicly available data from the Croatian Institute of Public Health (CIPH) and the Croatian Health Insurance Fund (CHIF). All hospital admissions for acute psychiatric patients in Croatia were tracked during both periods under study. Results: During the pandemic, the average number of all such cases decreased by 28% in secondary and tertiary hospitals, and by 11% in specialist psychiatric hospitals. It was also found that during COVID-19, there was a decrease in case numbers in DRG classes related to major affective disorders and anxiety, alcohol, and drug intoxication (31, 48, 34 and 45%, respectively). However, the same period saw an increase in hospital activity for eating disorders and for involuntary admissions related to schizophrenia and paranoia (30, 34 and 39% respectively). There were no changes in the admission rate for cases related to opioid use. Conclusion: The COVID-19 pandemic resulted in both a steep decrease in the overall number of psychiatric cases inpatient treatment at mental health facilities and their DRG casemix. Increasing our understanding of how pandemics and isolation affect demand for psychiatric care will help us better plan for future crises and provide more targeted care to this vulnerable group.

The importance of good governance in hospital payment reform - A case study from Ukraine.

In 2005, Ukraine embarked on hospital financing reforms that included the introduction of a Diagnosis Related Group (DRG) based payment system for acute inpatient care. The primary purpose of introducing activity-based funding was to provide incentives for hospitals to use their limited resources more efficiently. Following an extended period of preparation and planning during which technical assistance was provided by various development agencies, Ukraine took action to implement the DRG system at a national level in April 2018, through a World Bank project. While some progress was made, the execution of the reform faced challenges with the organisation and administration of the implementation process, and duplication of effort. The consequence of these shortcomings was that the newly introduced system was not capable of measuring inpatient DRG activity at a level of accuracy necessary for the determination of hospital performance and the subsequent calculation of payments. If the expected outcomes of DRG implementation in Ukraine are to be realised, stakeholders including both beneficiary agencies and development organisations, will need to improve program governance through better coordination of their activities towards a common goal.

Impact of COVID-19 on inpatient care related to skin conditions.

Background: The COVID-19 pandemic significantly affected our society and healthcare system. This study aims to evaluate the effects of COVID-19 on the number of hospitalized patients with dermatological diseases in Croatia, as well as the number of these patients treated surgically and conservatively, before (2017-2019) and during the pandemic (2020-2021). Materials and methods: This is a retrospective, comparative study of the hospital admission rate for patients with skin, subcutaneous tissue, and breast disorders both before and during the pandemic. This study used data from the Croatian Institute of Public Health (CIPH) and the Croatian Health Insurance Fund (CHIF). Inpatient data for the CHIF data collection were categorized using the Australian Refined Diagnosis Related Groups (AR-DRGs). All hospital admissions for dermatology patients at all non-specialized hospitals in Croatia were tracked during two periods, before (2017-2019) and during the pandemic (2020-2021). Results: The average number of dermatology patients in all hospitals fell by 29% during the pandemic. The overall number of dermatological patients admitted to hospitals fell by 32% in 2020 and by 26% in 2021 when compared to the number of patients admitted each year on average over the preceding 3 years. Additionally, there was an average 22% fall in surgical procedures performed during the pandemic. The only exception for surgical procedures is Major Breast Reconstruction for which is noted an increase, as also for Malignant Breast Disorders, Minor Complexity and Major Skin Disorders, Minor Complexity in a group of non-surgically treated patients. Conclusion: Examining the all consequences of the Croatian dermatological patient care interruption will require more investigation. Reduced access to medical care during the pandemic is anticipated to lead to later illness diagnosis, a later start to treatment, a poorer disease prognosis, as well as higher medical expenditures.

The Impact of COVID-19 on Hospital Admissions in Croatia.

Background: The COVID-19 pandemic disrupted hospital care, as hospitals had to deal with a highly infectious virus, while at the same time continuing to fulfill the ongoing health service needs of their communities. This study examines the direct effects of COVID-19 on the delivery of inpatient care in Croatia. Materials and Methods: The research is a retrospective, comparative analysis of the hospital admission rate across all Diagnosis Related Group (DRG) classes before and during the pandemic. It is based on DRG data from all non-specialized acute hospitals in Croatia, which account for 96% of national inpatient activity. The study also used COVID-19 data from the Croatian Institute of Public Health (CIPH). Results: The results show a 21% decrease in the total number of admissions [incident rate ratio (IRR) 0.8, p < 0.0001] across the hospital network during the pandemic in 2020, with the greatest drop occurring in April, when admissions plunged by 51%. The decrease in activity occurred in non-elective DRG classes such as cancers, stroke, major chest procedures, heart failure, and renal failure. Coinciding with this reduction however, there was a 37% increase (IRR 1.39, p < 0.0001) in case activity across six COVID-19 related DRG classes. Conclusions: The reduction in hospital inpatient activity during 2020, can be attributed to a number of factors such as lock-downs and quarantining, reorganization of hospital operations, the rationing of the medical workforce, and the reluctance of people to seek hospital care. Further research is needed to examine the consequences of disruption to hospital care in Croatia. Our recommendation is to invest multidisciplinary effort in reviewing response procedures to emergencies such as COVID-19 with the aim of minimizing their impact on other, and equally important community health care needs.

The effects of diagnosis-related groups payment on efficiency of the hospital health care in Croatia.

AIM: To assess the impact of Croatian reforms related to the funding of inpatient care on the efficiency of acute hospitals. METHODS: Between 2009 and 2018, the study analyzed resourcing, performance, and financing data for 33 acute hospitals. It used data from the Croatian Health Insurance Fund (CHIF) and the Croatian Institute of Public Health and included hospital activity and diagnosis-related grouping; average length of stay (ALOS); hospital staffing; CHIF revenue streams; and hospital incomes and expenditures. RESULTS: During the study period, the cost-efficiency of Croatian public hospitals did not meaningfully improve. While ALOS decreased by 14% and the number of beds decreased by 12%, bed occupancy rates decreased by 9%, acute inpatient admissions by 5%, and diagnosis-related group (DRG)-weighted output by 16%. Hospitals operated at higher costs, as the average cost per DRG-weighted case increased by 17%, from HRK 11828 in 2016, to HRK 13897 in 2018. CONCLUSIONS: In this period, Croatian reforms failed to improve hospital efficiency. This may be explained by the failure of reformers to heed the experience of other countries, which showed that hospital payment reform of this nature calls for systematic and coordinated actions, inter-agency collaboration, and a strategic approach where the various interventions are in congruence and act to reinforce one another.

New general practitioner payment formula in Croatia: is it consistent with worldwide trends?

We describe the history of general practitioner payment in Croatia, and assess the extent to which recent trends are consistent with developments in other countries. We provide a definition of a classification of payment methods, and summarization of the evidence about their merits as described in international literature and an outline of the history of payment methods in Croatia, with emphasis on the changes proposed for 2004. We conclude that the introduction of performance-based payment, as an adjunct to the capitation payments, is consistent with trends in well-managed health systems in other countries. However, we argue that the changes need to be incorporated into a long-term strategy, and we suggest some elements including refinement of the capitation payment risk adjustment.

Croatian pharmaceutical sector reform project: rational drug use.

The Croatian Pharmaceutical Sector Reform Project was one component of a larger Health Reform Project financed by the World Bank. The Croatian government was concerned that Croatia appeared to spend more money on medicinal drugs than most other countries in the region; that the price of drugs purchased in Croatia was higher than in some other countries, and that the prescribing habits of some Croatian physicians were perceived to be unnecessarily expensive. In addition, the Croatian Institute for Health Insurance (CIHI), which pays for most health care, had come under considerable financial pressure due to increasing health expenditure and a decreasing proportion of the population contributing to insurance. The Australian Health Insurance Commission won the contract for the pharmaceutical reform project. Australian experts were matched with Croatian experts in order to share knowledge, learn from each other, and provide the best advice. The project had two main components. The first addressed supply side issues and provided advice about savings that could be made by incorporating pharmacoeconomic principles into the selection and purchase of drugs on the Croatian positive list. The second component addressed demand side issues and provided advice aimed at evaluating and improving the quality and effectiveness of drug prescribing by Croatian physicians. This paper describes the second project component. We quantitatively and qualitatively evaluated the prescribing practice of Croatian physicians and ascertain how these might be improved. Croatian general practitioners are required to enter an International Classification of Diseases, 10th Revision (ICD10) diagnostic code on their prescription in order to indicate the clinical problem being treated. Quantitative research involved sorting CIHI prescription data for 2002 into ICD10 diagnostic categories and comparing the drugs prescribed for particular conditions with the recommendations in local and international best-practice guidelines. The results showed a number of areas where the prescribing of Croatian general practitioners and specialists could be improved, such as the use of antibiotics in upper respiratory tract infections and the treatment of hypertension. Qualitative research involved a series of workshops with local pharmacological experts and general practitioners during which the collected prescribing data was discussed, local factors which influenced prescribing were explored, and suggestions for improvement were collated. Many general practitioners felt pressured by increasingly assertive consumers, relentless pharmaceutical promotion, and strident government (CIHI) demands to restrain escalating health care costs. In addition, there was a lack of information about what constituted cost-effective treatment appropriate to the Croatian economic situation. There was support for the production of concise Croatian therapeutic guidelines that provided a limited number of best-practice treatment options for common conditions. A pilot set of such guidelines was devised and incorporated into a clinical software trialed in a Primary Health Care Information Technology Project in Koprivnica. This initiative received support from the general practitioners involved. It was recommended that a unit for the quality use of medicines should be set up to sustain the production of therapeutic guidelines and coordinate this activity with related initiatives. In addition, a quality assurance system (including performance indicators linked to financial incentives) was recommended that would encourage general practitioners to practice in accord with guidelines. We understand that the Croatian government has accepted a number of these recommendations and, in particular, performance indicators (and financial incentives) are written into new contracts for Croatian general practitioners in 2004.