Right ventricular mechanical pattern in patients undergoing mitral valve surgery: a predictor of post-operative dysfunction?

AIMS: The PREPARE-MVR study (PRediction of Early PostoperAtive Right vEntricular failure in Mitral Valve Replacement/Repair patients) sought to investigate the alterations of right ventricular (RV) contraction pattern in patients undergoing mitral valve replacement/repair (MVR) and to explore the associations between pre-operative RV mechanics and early post-operative RV dysfunction (RVD). METHODS AND RESULTS: We prospectively enrolled 42 patients (63 ± 11 years, 69% men) undergoing open-heart MVR. Transthoracic three-dimensional (3D) echocardiography was performed pre-operatively, at intensive care unit discharge, and 6 months after surgery. The 3D model of the RV was reconstructed, and RV ejection fraction (RVEF) was calculated. We decomposed the motion of the ventricle to compute longitudinal ejection fraction (LEF) and radial ejection fraction (REF). Pulmonary artery catheterization was performed to monitor RV stroke work index (RVSWi). RVEF was slightly decreased after MVR [52 (50-55) vs. 51 (46-54)%; P = 0.001], whereas RV contraction pattern changed notably. Before MVR, the longitudinal shortening was the main contributor to global systolic RV function [LEF/RVEF vs. REF/RVEF; 0.53 (0.47-0.58) vs. 0.33 (0.22-0.42); P < 0.001]. Post-operatively, the radial motion became dominant [0.33 (0.28-0.43) vs. 0.46 (0.37-0.51); P = 0.004]. However, this shift was temporary as 6 months later the two components contributed equally to global RV function [0.44 (0.38-0.50) vs. 0.41 (0.36-0.49); P = 0.775]. Pre-operative LEF was an independent predictor of post-operative RVD defined as RVSWi < 300 mmHg⋅mL/m2 [OR = 1.33 (95% CI: 1.08-1.77), P < 0.05]. CONCLUSIONS: MVR induces a significant shift in the RV mechanical pattern. Advanced indices of RV mechanics are associated with invasively measured parameters of RV contractility and may predict post-operative RVD.

Tax-funded social health insurance: an analysis of revenue sources, Hungary.

Health financing is a complex health system function, which cannot be analysed accurately without tracking each step of the flow of funds separately. We analysed the revenue mix of the Hungarian health insurance fund from 1994 to 2015 and discuss the policy implications of our findings. We used the System of Health Accounts published in 2000 and the revised version of 2011, which introduced separate classifications for the sources of health expenditure. Based on the 2000 version, health insurance contributions were the main source of public funding in Hungary. According to the 2011 version, nearly 70% of health insurance fund revenues came from government tax transfers in 2015, illustrating the striking difference in how revenues and expenditures are reported using this version. Use of the 2011 version will better inform national policy-making and international comparisons and facilitate documentation and analysis of how countries have adapted their revenue mix to changing macroeconomic circumstances. The finding that Hungary has a predominantly tax-funded social health insurance system suggests that traditional understanding and description of health-financing models are no longer adequate and may limit consideration of potential resource-generation options. Hungary is also a good example of how separating revenue generation and pooling broadens policy options to tackle gaps in social health insurance coverage, although the government did not act on these due to the lack of a consistent health-financing strategy. The findings may be particularly relevant for low- and middle-income countries that are trying to expand social health insurance coverage despite limited formal employment.

Le financement de la santé est une fonction complexe du système de santé, qui ne peut pas être précisément analysée sans étudier séparément chaque étape du flux de fonds. Dans cet article, nous analysons le mix de recettes du fonds d'assurance maladie hongrois de 1994 à 2015 et nous évoquons les implications de nos constatations sur la définition des politiques. Nous avons utilisé le Système des Comptes de la Santé publié en 2000 ainsi que sa version révisée de 2011, qui a introduit des classifications différentes pour les sources des dépenses de santé. En se fondant sur la version de 2000, ce sont les cotisations d'assurance maladie qui ont constitué la principale source de financement public en Hongrie. Mais d'après la version de 2011, près de 70% des recettes constitutives des fonds de l'assurance maladie sont provenues de transferts fiscaux gouvernementaux en 2015, ce qui illustre la différence flagrante dans la manière d'enregistrer les recettes et les dépenses proposée par cette version révisée. L'utilisation de la version de 2011 permettra de mieux informer le processus d'élaboration des politiques nationales, de faciliter les comparaisons internationales ainsi que de mieux documenter et analyser la manière dont les pays adaptent leur mix de recettes face à l'évolution des circonstances macroéconomiques. Le fait que le système d'assurance maladie sociale de Hongrie s'avère principalement financé par l'impôt montre que la compréhension et la description habituelles des modèles de financement de la santé ne sont plus adaptées et que cela peut même entraver la considération d'autres options envisageables pour générer des recettes. La Hongrie est également un bon exemple illustrant comment le fait de séparer la génération des recettes et la mise en commun des fonds élargit les options politiques pour réduire les déficiences dans la couverture de l'assurance maladie sociale, même si le gouvernement n'a pas agi sur ce point, faute de stratégie de financement de la santé cohérente en la matière. Ces constatations peuvent être particulièrement utiles pour les pays à revenu faible et intermédiaire qui essayent d'étendre la couverture de leur assurance maladie sociale malgré un niveau d'emploi limité dans le secteur formel.

La financiación de la salud es una función compleja del sistema sanitario que no puede analizarse con precisión si no se hace un seguimiento independiente de cada paso del flujo de fondos. Se ha analizado la combinación de ingresos de la caja húngara de seguros médicos de 1994 a 2015 y se han discutido las implicaciones políticas de los resultados. Se ha usado el Sistema de Cuentas de Salud publicado en 2000 y la versión revisada de 2011, que introdujo las clasificaciones separadas para las fuentes de gasto en salud. Según la versión de 2000, las cotizaciones al seguro de enfermedad eran la principal fuente de financiación pública en Hungría. Según la versión de 2011, casi el 70 % de los ingresos de la caja de seguros médicos procedían de las transferencias de impuestos del gobierno en 2015, lo que ilustra la sorprendente diferencia en la forma en que se informan los ingresos y los gastos utilizando esta versión. El uso de la versión de 2011 servirá de base para la formulación de políticas nacionales y comparaciones internacionales y facilitará la documentación y el análisis de cómo los países han adaptado su combinación de ingresos a las cambiantes circunstancias macroeconómicas. La conclusión de que Hungría tiene un sistema de seguridad social financiada principalmente por los impuestos sugiere que la comprensión y la descripción tradicionales de los modelos de financiación sanitaria ya no son adecuados y limitan la consideración de las posibles opciones de generación de recursos. Hungría es también un buen ejemplo de cómo la separación entre la generación de ingresos y la puesta en común amplía las opciones políticas para abordar las brechas en la cobertura de la seguridad social, aunque el gobierno no haya actuado al respecto debido a la falta de una estrategia coherente de financiación sanitaria. Las conclusiones pueden ser particularmente pertinentes para los países de ingresos bajos y medianos que estén tratando de ampliar la cobertura de la seguridad social a pesar de la limitación del empleo formal.

Qualitative assessment of opportunities and challenges to improve evidence-informed health policy-making in Hungary - an EVIPNet situation analysis pilot.

BACKGROUND: In evidence-informed policy-making (EIP), major knowledge gaps remain in understanding the context and possibilities for institutionalisation of knowledge translation. In 2014, the WHO Evidence-informed Policy Network (EVIPNet) Europe initiated a number of pilot countries, with Hungary among them, to engage in a 'situation analysis' (SA) in order to fill some of those gaps. This contribution discusses the results of the SA in Hungary on research-policy interactions, facilitating factors and potential barriers to establish a knowledge translation platform (KTP). METHODS: In line with the EVIPNet Europe SA Manual, a document analysis, 13 interviews, 3 focus group discussions with 21 participants, and an online survey with 31 respondents were carried out from April to October, 2015. A SA aims to assess the context in which EIP takes form and seeks opportunities to establish a KTP, so information was gathered on the current practice of EIP and knowledge translation, its relevant actors, enablers and barriers for EIP, and opinions on a future KTP. Methodological and researcher triangulation resulted in a narrative synthesis of data, including a comparison with literature. A stakeholder consultation was organised to validate findings. RESULTS: This study reveals that stakeholders show commitment to produce and use research evidence in Hungarian health policy-making. All stakeholders endorsed the idea of strengthening the systematic use of evidence in decision-making and favoured the idea of establishing a KTP. In line with literature on other countries, some good practices exist on the uptake of evidence in policy-making; however, a systematic approach of developing, translating and using research evidence in health policy processes is lacking. EIP is currently hampered by scattered capacity, coordination problems, high fluctuation in government, an often legalistic and a more 'symbolic' rather than practical support for knowledge translation and EIP. The article summarises recommendations on a Hungarian KTP. CONCLUSIONS: Pragmatic adaptation of the SA Manual to local needs proved to be a useful mechanism to provide insight into the Hungarian EIP field and the establishment of a potential KTP. Despite the success of a KTP pilot, it remains unclear how a KTP in Hungary will be institutionalised in a sustainable way.

Continuous cytokine haemoadsorption incorporated into a venoarterial ECMO circuit for the management of postcardiotomy cardiogenic and septic shock - a case report.

INTRODUCTION: The acute surgical treatment of infective endocarditis (IE) carries a high risk of postoperative mortality. Most complications are linked to uncontrolled sepsis and inflammatory processes. Cytokine haemoadsorption is an extracorporeal technique which has benefits reported in haemodynamic stability and inflammatory response. CASE REPORT: A 46-year-old male patient underwent emergency cardiac surgery due to progressive IE. Postcardiotomy cardiogenic shock associated with cardiac surgery required the implantation of venoarterial (VA)-ECMO. Three days later, the patient developed secondary septic shock. The novel application of continuous CytoSorbTM treatment installed in the VA-ECMO circuit is demonstrated in this case during the management of simultaneous shocks. Advanced intensive care led to an improvement in the patient's condition, which facilitated successful weaning from mechanical ventilation. However, the patient died from a new onset fulminant septic shock two months after his initial cardiac surgery. DISCUSSION: VA-ECMO is suitable for installation of the CytoSorbTM cartridge. This modality could be an option for high-volume, continuous cytokine haemoadsorption when VA-ECMO is employed without renal replacement therapy. CONCLUSION: This specific application of CytoSorbTM was safe, feasible and contributed to the optimal management of simultaneous shocks.

Impact of intraoperative cytokine adsorption on outcome of patients undergoing orthotopic heart transplantation-an observational study.

AIM: The aim of this study was to assess the influence of intraoperative cytokine adsorption on the perioperative vasoplegia, inflammatory response and outcome during orthotopic heart transplantation (OHT). METHODS: Eighty-four OHT patients were separated into the cytokine adsorption (CA)-treated group or controls. Vasopressor demand, inflammatory response described by procalcitonin and C-reactive protein, and postoperative outcome were assessed performing propensity score matching. RESULTS: In the 16 matched pairs, the median noradrenaline requirement was significantly less in the CA-treated patients than in the controls on the first and second postoperative days (0.14 vs 0.3 µg*kg-1 *min-1 , P = .039 and 0.06 vs 0.32 µg*kg-1 *min-1 , P = .047). The inflammatory responses were similar in the two groups. There was a trend toward shorter length of mechanical ventilation and intensive care unit (ICU) stay in the CA-treated group compared to the controls. No difference in adverse events was observed between the two groups. The frequency of renal replacement therapy was less in the CA­treated patients than in the controls. CONCLUSIONS: Intraoperative CA treatment was associated with reduced vasopressor demand with a favorable tendency in length of mechanical ventilation, ICU stay and renal replacement therapy. CA treatment was not linked to higher rates of adverse events.

Airway dynamics in COPD patients by within-breath impedance tracking: effects of continuous positive airway pressure.

Tracking of the within-breath changes of respiratory mechanics using the forced oscillation technique may provide outcomes that characterise the dynamic behaviour of the airways during normal breathing.We measured respiratory resistance (Rrs) and reactance (Xrs) at 8 Hz in 55 chronic obstructive pulmonary disease (COPD) patients and 20 healthy controls, and evaluated Rrs and Xrs as functions of gas flow (V') and volume (V) during normal breathing cycles. In 12 COPD patients, additional measurements were made at continuous positive airway pressure (CPAP) levels of 4, 8, 14 and 20 hPa.The Rrs and Xrsversus V' and V relationships displayed a variety of loop patterns, allowing characterisation of physiological and pathological processes. The main outcomes emerging from the within-breath analysis were the Xrsversus V loop area (AXV) quantifying expiratory flow limitation, and the tidal change in Xrs during inspiration (ΔXI) reflecting alteration in lung inhomogeneity in COPD. With increasing CPAP, AXV and ΔXI approached the normal ranges, although with a large variability between individuals, whereas mean Rrs remained unchanged.Within-breath tracking of Rrs and Xrs allows an improved assessment of expiratory flow limitation and functional inhomogeneity in COPD; thereby it may help identify the physiological phenotypes of COPD and determine the optimal level of respiratory support.

Improved effectiveness of generic medicine markets in Hungary: analysis and recommendations

This publication summarizes the findings of a series of technical reports by many experts involved in assessing the effectiveness of pharmaceutical policy on generic essential medicines markets in the context of the Hungarian health system. Within the framework of certain agreements, WHO provided technical advice in collaboration with local experts and with involvement from international consultants. The primary objective of this report is to provide an overview of the development of incentives to use generics in the Hungarian health system up to the end of 2011, focusing in particular on the reference pricing system and assessing what impact these incentives have had in recent years.

Better noncommunicable disease outcomes: challenges and opportunities for health systems: Hungary country assessment: focus on diabetes

This report reviews health system challenges and opportunities in Hungary to scale up core services for the prevention, early diagnosis and management of diabetes. Diabetes is used in the report as a lens to assess the effectiveness of the health system in addressing the noncommunicable disease (NCD) burden. Although NCD mortality in general has been decreasing over the past 20 years, the prevalence of diabetes remains high and is growing. The report found good progress implementing innovative intersectorial nutrition policies including the Public Health Product Tax. At the same time, core individual services such as early detection and proactive management of diabetes and its complications require further efforts. The main barrier to better diabetes and NCD control in Hungary was found to be the lack of citizen empowerment; the population generally has a low level of health literacy and lacks the knowledge and skills to manage their own health. Other problems identified include a mismatch between the incentive system and the requirements for effective diabetes management, with current measures focusing on processes rather than outcomes. These challenges need to be addressed within a context of a shortage of human resources and a lack of standardized training in diabetes adapted to different cadres of health personnel. The report ends with six strategic recommendations to address these challenges.

Hungary health system review.

Hungary has achieved a successful transition from an overly centralized, integrated Semashko-style health care system to a purchaser provider split model with output-based payment methods. Although there have been substantial increases in life expectancy in recent years among both men and women, many health outcomes remain poor, placing Hungary among the countries with the worst health status and highest rate of avoidable mortality in the EU (life expectancy at birth trailed the EU27 average by 5.1 years in 2009). Lifestyle factors especially the traditionally unhealthy Hungarian diet, alcohol consumption and smoking play a very important role in shaping the overall health of the population.In the single-payer system, the recurrent expenditure on health services is funded primarily through compulsory, non-risk-related contributions made by eligible individuals or from the state budget. The central government has almost exclusive power to formulate strategic direction and to issue and enforce regulations regarding health care. In 2009 Hungary spent 7.4% of its gross domestic product (GDP) on health, with public expenditure accounting for 69.7% of total health spending, and with health expenditure per capita ranking slightly above the average for the new EU Member States, but considerably below the average for the EU27 in 2008. Health spending has been unstable over the years, with several waves of increases followed by longer periods of cost-containment and budget cuts. The share of total health expenditure attributable to private sources has been increasing, most of it accounted for by out-of-pocket (OOP) expenses. A substantial share of the latter can be attributed to informal payments, which are a deeply rooted characteristic of the Hungarian health system and a source of inefficiency and inequity. Voluntary health insurance, on the other hand, amounted to only 7.4% of private and 2.7% of total health expenditure in 2009. Revenue sources for health have been diversified over the past 15 years, but the current mix has yet to be tested for sustainability. The fit between existing capacities and the health care needs of the population remains less than ideal, but improvements have been made over the past 15 years. In general, the average length of stay and hospital admission rates have decreased since 1990, as have bed occupancy rates. However, capacity for long-term nursing care in both the inpatient and outpatient setting is still considered insufficient. Hungary is currently also facing a health workforce crisis, explained by the fact that it is a net donor country with regard to health care worker migration, and health care professionals on the whole are ageing. Although the overall technical efficiency of the system has increased considerably, mainly due to the introduction of output-based payment systems, allocative efficiency remains a problem. Considerable variations exist in service delivery both geographically and by specialization, and equity of access is far from being realized, a fact which is mirrored in differing health outcomes for different population groups. A key problem is the continuing lack of an overarching, evidence-based strategy for mobilizing resources for health, which leaves the health system vulnerable to broader economic policy objectives and makes good governance hard to achieve. On the other hand, Hungary is a target country for cross-border health care, mainly for dental care but also for rehabilitative services, such as medical spa treatment. The health industry can thus be a potential strategic area for economic development and growth.

Hungary: health system review

The Health Systems in Transition (HiT) country profiles provide an analytical description of each health system and of policy initiatives in progress or under development. They aim to provide relevant comparative information to support policy-makers and analysts in the development of health systems and reforms in the countries of the WHO European Region and beyond. The HiT profiles are building blocks that can be used: to learn in detail about different approaches to the financing, organization and delivery of health services; to describe accurately the process, content and implementation of health reform programmes; to highlight common challenges and areas that require more in-depth analysis; and to provide a tool for the dissemination of information on health systems and the exchange of experiences of reform strategies between policy-makers and analysts in countries of the WHO European Region. This series is an ongoing initiative and material is updated at regular intervals.