vol45.3 LR.pdf - International Hospital Federation

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Management: Quality and funding The misuse of clinical paths as an instrument for funding inpatient care in Bulgaria TONI Y VEKOV, DMSC CHAIRMAN OF THE DIRECTORS BOARD, UNICARDIO CLINIC PLEVEN, BULGARIA PROFESSOR MLADEN V GRIGOROV EXECUTIVE DIRECTOR, UNICARDIO CLINIC PLEVEN, BULGARIA SLAVEYKO N DJAMBAZOV, MD CHIEF EXECUTIVE OFFICER, BULGARIAN CARDIAC INSTITUTE ABSTRACT: Clinical paths in Bulgaria are used not as a method for quality assessment, but as an instrument to fund hospitals. Their use and incompleteness cause limited access of all Bulgarian citizens to the international treatment guidelines. That way quality of treatment worsens and mortality increases. The Bulgarian system of regulated medical guidelines by all therapeutic and surgical lines still suffers many deficiencies. The National Health Insurance Fund should use the system of clinical paths for quality control as well. One of the most widely spread quality assessment methods in health-care activity is the assessment through medical guidelines. In this case particular health-care services are compared to pre-determined and pre-adopted guidelines, which are a medical algorithm for the treatment of a specific disorder. In the health-care sector guidelines that are methodical guidelines develop consecutively on the basis of gained experience and generalized assessment. Regulation of particular quality guidelines is a general problem of every reform in health care. International medical guidelines have been adopted by many national legislations. In Bulgaria there are still no regulated medical guidelines in all therapeutic and surgical directions. Methods An appropriate specific example for the implementation of the guidelines for assurance of the quality of inpatient medical activity is the clinical path. In its essence it is an organizational, diagnostic and therapeutic algorithm, which through a balance between medical and economical expedience resolves the growing conflict between clinical freedom and health-care management. The multidisciplinary approach is typical for the clinical path, which constitutes a set of instructions, describing the common and necessary way for assurance of medical care for a specific type of patients and allowing deviations with the purpose of improving health-care quality. Therefore, clinical paths require recurrent reassessment and update. The clinical paths of the National Health Insurance Fund (NHIF) are the only approach for quality assurance of medical service in inpatient care, in accordance with the coverage of the available resources. Results What practically happens with the use of clinical paths in Bulgaria and their insufficiency? Table 1 presents the main cardiovascular pathology, which is life-threatening and is missing from the content of clinical paths. All of these insufficiencies make doctors in inpatient care use either of the two possibilities: ✚ not to treat patients in accordance with the algorithm of international medical guidelines, which directly leads to higher mortality rate; ✚ to treat patients in accordance with medical guidelines, but to prepare their documentation based on existing clinical paths, which directly infringes the contract between the inpatient care provider and the NHIF. The lack of clinical paths for extracardiac vascular pathology represents a similar situation. For the NHIF such a thing as the vast field of carotid and vertebral pathology and its interventional treatment is non-existing. As a result Bulgaria heads the list of stroke and mortality rates in the European Union with mortality rates thrice higher than the average European ones (EHJ, 2008). Over 80% of the strokes are ischemic and 30% of them are due to carotid pathology, which can be fought through angioplasty, moreover, without distal protection. Therefore, the use and the insufficiency of clinical paths in Bulgaria directly limit the accessibility of all Bulgarian citizens to successful modern life-saving treatment methods. The situation with incompatibilities with medical guidelines in inpatient care is identical – Table 2. Discussion Obviously, rules and requirements for the applicable examinations of outpatients severely restrict their accessibility to quality health care. The other main fault of the principle and organization of work of the NHIF is that it stimulates health managers to mistakenly 10 World Hospitals and Health Services Vol. 45 No. 3
Management: Quality and funding Table 1. Incompatibilities of clinical paths and medical guidelines Table 1: Incompatibilities of clinical paths and medical guidelines Disease Medical methods missing from clinical paths Cardiogenic shock Neither the life-saving mechanical treatment through counterpulsation, nor the direct haemodynamic treatment through SwanGanz catheter are included in the medical algorithm AMI Discrepancies in the medication – GP IIB/IIA inhibitors are not reimbursed Hypertensive crisis No clinical path Pulmonary hypertension No clinical path CRT implantation No clinical path ICD implantation No clinical path Heart trauma No clinical path NSTEMI No clinical path Table guidelines 2: Incompatibilities of outpatient examinations and examinations by international medical guidelines Condition Missing compulsory examinations in compliance with medical guidelines 50 – Congestive HF Lack of creatinine testing 20 – Angina Pectoris Lack of cholesterol fractions testing, EchoCG and exercise test 25.2 – previous Lack of cholesterol fractions testing, EchoCG and exercise test myocardial infarction 25.3 – cardiac aneurysm Lack of cholesterol fractions testing, EchoCG and INR 15 – secondary hypertension Lack of consultation with an endocrinologist and a nephrologist, no hormonal and creatinine testing 27 – primary pulmonary Lack of pulmonary scintigraphy or pulmonary angiography hypertension 31 – chronic pericarditis Lack of tuberculosis examination 38 – endocarditis Lack of hemoculture examination 171,4 – aneurysm of abdominal aorta Lack of lipid profile and EchoCG consider clinical paths an instrument for funding inpatient care. These mistakes urge doctors to use outdated and inadequate treatment methods, even where modern alternatives are available. A study of AMI treatment in Pleven District by data of the Regional Health Centre and the RHIF in 2008 revealed the facts presented in Figure 1. Pleven District was chosen as the study location, as it has all of the following three possibilities for infarction treatment within 30 minutes: ✚ pPCI – treatment through primary angioplasty - mortality rate up to 5%; ✚ TL - treatment through thrombolysis - mortality rate up to 14%; ✚ Without reperfusion therapy - mortality rate up to 25%; The analysis of this data arise the following question: Why are 75% of patients with AMI treated through methods that cause the highest mortality rates, considering the fact that accessibility is not a restrictive factor? There is a single objective answer – health managers, in order to improve the financial results of the medical establishment they manage, try to treat every patient, no matter Without reperfusion therapy 75% TL – thrombolysis pPCI – primary PCI TL 10% Figure 1: Treatment of 1015 cases of AMI in Pleven region, 2008 pPCI 15% World Hospitals and Health Services Vol. 45 No. 3 11
Page 1: 2009 Volume 45 Number 3 www.ihf-fih
Page 4 and 5: Editorial Editorial DR JOSE CARLOS
Page 6 and 7: Policy: US health insurance reform
Page 8 and 9: Policy: US health insurance reform
Page 10 and 11: Policy: migrant-friendly hospitals
Page 14 and 15: Management: Quality and funding Tab
Page 17 and 18: PROGRAM - 36 th World Hospital Cong
Page 19 and 20: Management: Hospital finances Males
Page 21 and 22: Clinical care: Oncology caregivers
Page 23 and 24: Clinical care: Oncology caregivers
Page 25 and 26: WIPAK SEE-THROUGH PEEL POUCHES AND
Page 27 and 28: Reference beaucoup de soutien socia
Page 29 and 30: Reference IHF Governing Council 200
Page 31 and 32: Sterile Barrier Systems ensure opti

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