Yoğun Bakım / Bakım Kalitesi ( Ekonomik Verimlilik )
Transkript
Yoğun Bakım / Bakım Kalitesi ( Ekonomik Verimlilik )
YOĞUN BAKIM, BAKIM KALİTESİ, (EKONOMİK VERİMLİLİK) Yar. Doç. Dr. Kadir Doğruer Anesteziyoloji ve Reanimasyon Avrasya Hastanesi GER İ AR ÖDEM TIK ED E T KRİ EK TER MALİYETETKİLİLİK COSTEFFECTIVENESS ? MEDİKAL ETKİLİLİK GÜVEN KALİTE DÜNYA GENELİNDE; HÜKÜMETLER, SAĞLIK HİZMETİ SUNUM SİSTEMLERİ, SİGORTACILAR VE TÜKETİCİLER ARASINDA BİR SAVAŞ VAR: BİR YANDAN ARTAN SAĞLIK TALEBİNİ KARŞILAMAK VE DİĞER YANDAN MALİYETLERİ OLABİLDİĞİNCE DÜŞÜRMEK. HİZMET KALİTESİ…? TASARRUF YASAL DÜZENLEMELER VE UYUM SEKTÖR HEDEFLERİ MARKETLERE ADAPTASYON DEĞİŞİM VE DİJİTAL İNOVASYON Deloitte Touche Tohmatsu Limited, 2014 SAĞLIK HARCAMALARI ÜZERİNDEKİ BASKILAR SAĞLIK HARCAMALARI ÜZERİNDEKİ BASKILAR ➤ ➤ ➤ Yaşlı nüfusta artış Giderek büyüyen marketler Yeni tedavi teknikleri < ➤ ➤ ➤ Yaşlı nüfusta artış Giderek büyüyen marketler Yeni tedavi teknikleri Deloitte Touche Tohmatsu Limited, 2014 ➤ Sağlık harcamalarını azaltma BASKISI SAĞLIKTA PARADİGMA DEĞİŞİMİ HASTALIK ODAKLI SAĞLIK, FONKSİYONELLİK VE İYİLİK HALİ ODAKLI TIBBİ BAKIM ODAKLI SAĞLIK BAKIM ODAKLI HEKİM HASTALIĞIN İYİLEŞTİRİCİSİ HEKİM İYİLEŞTİRİCİLİĞİN YANISIRA SAĞLIĞIN GELİŞTİRİCİSİ HASTALIK PATOLOJİK VE FİZYOLOJİK ÖZELLİKLERE GÖRE ÖLÇÜLÜR YAŞAM KALİTESİ, FONKSİYONELLİK VE İYİLİK HALİ KAVRAMLARI SAĞLIKTA İLGİ ALANLARI MI DEĞİŞİYOR…? ➤ AMAÇ SAĞLIK MI, YOKSA..? ➤ TIBBİ BAKIM MI, YOKSA BAŞKA PROGRAMLAR MI..? ➤ DOKTOR MU, YOKSA DİĞER SAĞLIK SUNUCULARI MI..? ➤ BUGÜN MÜ, YARIN MI SAĞLIK..? ➤ KİMİN HAYATI ÖNEMLİ PEKİ..? R A IK I Ç R AR E L L İ P B U LO UR G L SA R UM LE PL İH TO RC TE L A S ER M İL U T L N P E O T KL BE İNANÇLAR VE DİĞER YARGILAR BİL KAN Gİ VE ITL AR SİYASET Ekonomik Değerlendirme Tanımlama Maliyet-Etkililik Analizi Bir ürün ya da hizmetin veya müdahalenin maliyetinin ölçülmesi. Karar vermede sıklıkla kullanılan bir tekniktir. Projenin beklenen faydaları toplam bütçeden çıkarılır. Sonuç başına harcanan Maliyet-Etkililik Oranı Toplam maliyetin toplam faydaya oranı Maliyet Analizi Maliyet-Fayda Analizi Maliyet-Yarar Analizi Maliyet-Yarar Oranı Maliyet-fayda analizi yöntemlerinden biridir. Farklı prosedürler ve sonuçlar karşılaştırılır. 1 QALY elde etmek için yapılan girişimlerin karşılaştırılması MALİYET MİNİMİZASYON ANALİZİ COST-MINIZATION ANALYSIS MALİYET FAYDA ANALİZİ COST-BENEFIT ANALYSIS MALİYET ETKİLİLİK ANALİZİ COST-EFFECTIVENESS ANALYSIS MALİYET YARARLANIM ANALİZİ COST-UTILITY ANALYSIS Düşük maliyet Yüksek maliyet MALİYET B A C Daha az etkili Daha çok etkili ETKİNLİK Maliyet-Etkinlik Model’inin Duyarlılık Analizi Burada, bir maliyet-etkinlik alanı tanımlanmaya çalışılmaktadır: Standart veya uygulanmakta olan tedavilerden daha etkin veya daha az etkin, daha ucuz veya daha pahalı tedavi yöntemlerinin karşılaştırılabildiği bir diyagram oluşturulmaya çalışılmaktadır. Understanding Costs and Cost-Effectiveness in Critical Care. Report from the Second American Thoracic Society Workshop on Outcomes Research THIS OFFICIAL WORKSHOP REPORT OF THE AMERICAN THORACIC SOCIETY WAS APPROVED BY THE ATS BOARD OF DIRECTORS JUNE 2001 MALİYET YÜKSEK MALİYET DÜŞÜK ETKİLİLİK (HAKİM) YÜKSEK MALİYET YÜKSEK ETKİLİLİK QALY DÜŞÜK MALİYET DÜŞÜK ETKİLİLİK DÜŞÜK MALİYET YÜKSEK ETKİLİLİK (BASKIN) Eşik Değer (Threshold) ➤ 1973 yılında Weinstein ve Zeckhauser’in sağlık maliyetleri ve etkilerinin bir sağlık sistemi için kabul edilebilir bir ölçüde olması gerektiğini savunmalarıyla ortaya atılmış bir kavramdır ➤ Eşik değer; karar vericinin bir birim sağlık çıktısına verdiği değeri gösteren bir kuraldır. Weinstein MC, Zeckhauser R. Critical ratios and efficient allocation. J. Public Econ. 1973;2:147–157. Sağlık Harcamalarının Gelişimi on TL ılı a, TL 9 0 1 7 7 3 7 5 6 6 8 0 KAYNAK: TUİK Sağlık Harcamala Milyon TL Türkiye’de 2002-2013 döneminde sağlık harcamaları nominal olarak 3,5 kat civarında, reel olarak ise 0,6 kat artmıştır. Yıllar TL 2013 Yılı Fiyatlarıyla, TL 2002 18.774 52.289 2003 24.279 53.980 2004 30.021 61.461 2005 35.359 66.917 2006 44.069 76.097 2007 50.904 80.823 2008 57.740 83.007 2009 57.911 78.355 2010 61.678 76.866 2011 68.607 80.306 2012 74.189 79.748 2013 84.390 84.390 2002-2013 Artış (Kat) 3,5 0,6 KAYNAK: TUİK Türkiye’de 2002-2013 döneminde sağlık harcamala B- Sağlık Harcamalarının Gelişimi (2002-2013 Dönemi) Yıllar İtibariyle Sağlık Harcamaları ve GSYH İçindeki Payı Milyon TL % 90.000 7,0 80.000 70.000 5,8 5,4 5,3 5,4 6,0 6,1 6,1 5,6 5,4 5,3 6,0 5,4 5,2 5,0 60.000 4,0 84.390 74.189 61.678 57.911 57.740 44.069 35.359 24.279 10.000 18.774 20.000 30.021 30.000 50.904 40.000 68.607 50.000 3,0 2,0 1,0 0 0,0 2002 2003 2004 2005 Sağlık Harcamaları, Milyon TL 2006 2007 2008 2009 2010 2011 2012 2013 Sağlık Harcamalarının GSYİH İçindeki Payı (%) 2002-2013 yıllarındaki sağlık hizmetlerinde yaşanan gelişmelere rağmen sağlık harcamalarının Gayri Safi Yurt İçi Hasıla içindeki payı (%5,4) değişmemiştir 6 i Başı Sağlık Harcamasının Gelişimi KAYNAK: TUİK PMC full text: Int J Environ Res Public Health. 2010 Apr; 7(4): 1835–1840. Published online 2010 Apr 20. doi: 10.3390/ijerph7041835 Copyright/License ► Request permission to reuse Table 1. Use of economic evaluation in decision making around the world. Country Organisation Implementation date Australia Pharmaceutical Benefits Advisory Committee 1993 Belgium Medicine Reimbursement Committee 2002 England/Wales National Institute for Health and Clinical Excellence 1999 France High Health Authority 2008 Institute for Quality and Efficiency in Health Care 2007 Netherlands Health Care Insurance Board 1999 New Zealand Pharmaceutical Management Agency 1993 Scotland Scottish Medicines Consortium 2002 Sweden Dental and Pharmaceutical Benefits Agency 2002 Taiwan Centre for Medicine Evaluation 2008 Germany Int J Environ Res Public Health. 2010 Apr; 7(4): 1835–1840. Published online 2010 Apr 20. Health Economic Assessment: Cost-Effectiveness Thresholds and Other Decision Criteria Steven Simoens* QALY Quality-Adjusted Life Year QALY ➤ QALY sağlık hizmetlerinin sunumunun kalitesi ve kantitesini dikkate alır. ➤ Beklenen veya geri kalan yaşam süresi içindeki yaşam kalitesinin yıla göre değerlendirildiği sayısal bir veridir. ➤ QALY konsepti karar bilimi ve beklenen yarar teorimine dayanmaktadır. EQ-5D EQ-5D ilk defa EuroQol Grup tarafından tanımlanmıştır. Bu gurup 1987 yılında Hollanda, Birleşik Kırallık, İsveç, Finlandiya ve Norveç’ten araştırmacıların multidisipliner katılımıyla kurulmuştur. Bu gurubun amacı hastalığa özel olmayan, genel bir sağlık/yaşam kalitesi süreçlerini değerlendirmek için bir araç geliştirmektir. EQ-5D3 SKORLAMASI SORUN YOK BAZI SORUNLAR BÜYÜK SORUN VAR Mobilite Sorunsuz yürüyebiliyor Yürürken problem Yatağa bağımlı Ağrı/Rahatsız Rahatsızlık veya ağrı yok Orta derecede rahatsızlık veya ağrı Şiddetli derecede rahatsızlık veya ağrı Ankisiyete/ Depresyon Ankisiyete veya depresyon yok Şiddetli Ankisiyete veya depresyon Kişisel Bakım Kişisel bakımında sorun yok Orta derecede ankisiyete veya depresyon Kişisel bakımda bazı sorunlar Genel aktiviteleri gerçekleştirmede bazı sorunlar var Genel aktiviteleri gerçekleştiremiyor Genel Aktiviteler/Ev Genel aktiviteleri işi yapmak, çalışmak, amaçsız gerçekleştirmede sorun yok aktiviteler Kendi kendine bakımı ÖRNEK EQ-5D5 SETLERİ 5L profile 11111 11112 11113 11114 11115 11121 11122 11123 11124 11125 11131 11132 11133 11134 11135 11141 11142 11143 Denmark 1,000 0,856 0,818 0,671 0,519 0,859 0,787 0,768 0,622 0,469 0,824 0,770 0,756 0,609 0,457 0,691 0,637 0,623 France Germany Japan 1,000 1,000 1,000 0,929 0,999 0,829 0,910 0,999 0,785 0,769 0,809 0,761 0,622 0,611 0,736 0,910 0,910 0,814 0,839 0,909 0,740 0,820 0,909 0,721 0,679 0,719 0,697 0,532 0,521 0,672 0,888 0,887 0,768 0,817 0,887 0,718 0,798 0,887 0,705 0,657 0,697 0,681 0,510 0,499 0,656 0,757 0,677 0,723 0,686 0,677 0,673 0,667 0,677 0,660 Netherlands 1,000 0,845 0,805 0,592 0,370 0,874 0,765 0,736 0,523 0,301 0,843 0,745 0,719 0,506 0,284 0,652 0,554 0,528 Spain Thailand UK US 1,000 1,000 1,000 1,000 0,932 0,814 0,879 0,876 0,914 0,766 0,848 0,844 0,731 0,660 0,635 0,700 0,541 0,549 0,414 0,550 0,910 0,780 0,837 0,861 0,857 0,723 0,768 0,820 0,843 0,708 0,750 0,809 0,660 0,602 0,537 0,669 0,470 0,491 0,316 0,524 0,887 0,726 0,796 0,827 0,838 0,701 0,740 0,806 0,825 0,694 0,725 0,800 0,642 0,588 0,512 0,661 0,452 0,477 0,291 0,517 0,702 0,616 0,584 0,682 0,653 0,590 0,527 0,663 0,640 0,584 0,513 0,659 Zimbabwe 0,900 0,864 0,854 0,792 0,727 0,846 0,810 0,800 0,738 0,673 0,833 0,797 0,787 0,725 0,660 0,739 0,703 0,693 Türkiye’de EQ-5D3’ün 2. Versiyonu ve EQ-5D5’in 1. Versiyonu implante edilmiştir. -Ceri Phillips BSc(Econ) MSc(Econ) PhD Professor of Health Economi Hayward Medical Communications, a division of Hayward Group Ltd. Copyright © 2009 Hayward Group Ltd. 1 0 Olası EN İYİ yaşam kalitesi + - ÖLÜM Mükemmel sağlık durumu ’1’olarak değerlendirilirken, sağlık durumundaki her kalite azalması 1’in altında değerlendirilir. Ölüm ‘0’ değerini alır. Bazı sağlık durumunları ölümden dahi kötü olabilir. Bu nedenle bu durumlar ‘negatif’ QALY değeri olarak değerlendirilir. Olası EN KÖTÜ yaşam kalitesi utilities of some of the health states are shown in Table 1. KEY FORMULA 1 EQ-5D3 Calculating QALYs: an example at 0.75 will generate one more QALY than an intervention that generates four additional years in a health state valued at 0.5 (Key formula 1). Effect of interventions When data relating to both health-related EQ-5D3 kullanımı talebi giderek artmaktadır. EQ-5D’nin hizmetlerinin quality ofsağlık life and survival are available, it is klinik Intervention B: four years in health state 0.5 2 QALYs then possible to chart the impact of a ve ekonomik değerlendirilmesinde kullanılması Washington Panel on Cost healthcare intervention on an individual Additional number of QALYs generated by A 1 QALY patient. For example, it is possible to compare Effectiveness in Health & Medicine tarafından önerilmektedir. Intervention A: four years in health state 0.75 3 QALYs Table 1. EQ-5D health state valuations Health state Description Valuation 11111 No problems 1.000 11221 No problems walking about; no problems with self-care; some problems with performing usual activities; some pain or discomfort; not anxious or depressed 0.760 22222 Some problems walking about; some problems washing or dressing self; some problems with performing usual activities; moderate pain or discomfort; moderately anxious or depressed 0.516 12321 No problems walking about; some problems washing or dressing self; unable to perform usual activities; some pain or discomfort; not anxious or depressed 0.329 21123 Some problems walking about; no problems with self-care; no problems with performing usual activities; moderate pain or discomfort; extremely anxious or depressed 0.222 23322 Some problems walking about, unable to wash or dress self, unable to perform usual activities, moderate pain or discomfort, moderately anxious or depressed 0.079 33332 Confined to bed; unable to wash or dress self; unable to perform usual activities; extreme pain or discomfort; moderately anxious or depressed –0.429 Ceri Phillips BSc(Econ) MSc(Econ) PhD Professor of Health Economi Hayward Medical Communications, a division of Hayward Group Ltd. Copyright3© 2009 Hayward Group Ltd. Date of preparation: April 2009 NPR09/1265 UK, using a choice-based method of valuation QALY. Thus, an intervention that gener a condition with a poor prognosis. As shown, years in a health state va (the time trade-off method). Examples of the four additional Using QALY theutilities treatment has an initial improvement on of some of the health states are at 0.75 will generate one more QALY th health-related quality of life, but, as adverse QALYs provide a com shown in Table 1. intervention that generates four additio years in a health valued 0.5 be effects associated with the treatment become thestate extent ofatthe (Key formula 1). KEY FORMULA 1 is lost and quality of apparent, this benefit life variety of interventi falls below that for a non-treated related quality of lif Calculating QALYs: anexpected example Effect ofpatient. interventions patient. This quality of life deficit associated They are us to both health-relat health state 0.75generates3 ‘QALYs QALYs lost’When data relating Intervention A: four years withinthe treatment effectiveness of inte quality of life and survival are available compared non-treated2 QALYs patient. At athen possiblecombined withofthe Intervention B: four years in healthwith statea0.5 to chart the impact a onthe an individu time when patient dies,healthcare the intervention providing interv Additional number ofpoint QALYs in generated by A the latter 1 QALY patient. For example, it is possible to co treated patient demonstrates ‘QALYs gained’ cost–utility ratios. A difference between Table 1. EQ-5D health state valuations interventions divide Health state Description Valuation QALYs they produce 11111 No problems A recent1.000 example 11221 No problems walking about; no problems with self-care; some problems with 0.760 by t the assessments performing usual activities; some pain or discomfort; not anxious or depressed Consortium5 and Al 22222 Some walking about; washing or dressing self; 0.5166 Costproblems of Intervention A –some Costproblems of Intervention B Strategy Group of d Cost–utility ratio = some problems with performing usual activities; moderate pain or discomfort; sanofi-aventis) in co moderately depressed by Intervention A No. of anxious QALYsorproduced and 5-fluorouracil ( 12321 No–problems some problems washing or B dressing self; unable 0.329 No. of walking QALYsabout; produced by Intervention to perform usual activities; some pain or discomfort; not anxious or depressed treatment of patient 0.222 Some problems walking about; no problems with self-care; no problemsadvanced squamous 21123 KEY FORMULA 2 Cost–utility ratio – an example with performing usual activities; moderate pain or discomfort; extremely anxious or depressed 2a 23322 Some problems walking about, unable to wash or dress self, unable to perform 2b 1 1 of Ceri Phillips BSc(Econ) MSc(Econ) PhD Professor of Health Economipain Hayward Medical Communications, a division usual activities, moderate or discomfort, moderately anxious orQALYs depressed Hayward Group Ltd. Copyright © 2009 Hayward Group Ltd. gained 33332 Confined to bed; unable to wash or dress self; unable to perform usual 0.079 –0.429 activities; extreme pain or discomfort; moderately anxious or depressed Quality Intervention A Quality No intervention KAZANILAN QALY 1 1 Tedavi 1 Tedavi Yok KAZANILAN QALY KAYBEDİLEN QALY KAZANILAN QALY Tedavi 0 Tedavi 2 0 ÖLÜM 1 ÖLÜM 2 ÖLÜM 1 ÖLÜM 2 ZAMAN YOĞUN BAKIM Yoğun Bakım Maliyetleri Yönetilebilir mi? YOĞUN BAKIM MALİYETİNDE ETKİLİ BAZI FAKTÖRLER: ➤ Yoğun bakımın sabit giderleri yüksektir. ➤ Yoğun bakım hastalarının tedavisinde pahalı ilaçlar kullanıldığı gibi, pahalı tanı yöntemleri de sıklıkla kullanılmaktadır. ➤ Her geçen gün yoğun bakım yatağı gereksinimi artmaktadır. Holcomb BW, Wheeler AP, Ely EW: New ways to reduce unnecessary varia- tion and improve outcomes in the intensive care unit. Curr Opin Crit Care 2001, 7:304–311. MODERN YOĞUN BAKIM ÜNİTELERİNİN TOPLUM ÜZERİNDEKİ EKONOMİK BASKISI ÇOK BÜYÜK… ➤ Yoğun bakım yatak sayısı, toplam yatak sayısının %10’undan daha düşük olmasına karşın, normal yatağın 1$’ına karşılık yoğun bakım yatağında 3$ harcama yapılıyor. 3x1 Halpern NA, Bettes L, Greenstein R: Federal and nationwide intensive care units and health care costs: 1986–1992. Crit Care Med 1994, 22:2001– 2007. Crit Care Med. 2006 Nov;34(11):2738-47. When is critical care medicine cost-effective? A systematic review of the cost-effectiveness literature. Talmor D1, Shapiro N, Greenberg D, Stone PW, Neumann PJ. METHODOLOGY HISTORY CEVR's goals in constructing and maintaining this database are threefold: Identify society's best opportunities for targeting resources to improve health; Assist policymakers in healthcare resource allocation decisions; and Move the field towards the use of standardized methodology. The CEA Registry is a comprehensive database of 5,000 cost-utility analyses on a wide variety of diseases and treatments. The registry has made an impact in several areas: CEVR’in bu veri tabanını oluşturma ve sürdürmesindeki temel amaçlar: Used as a data source for 50 peer-reviewed publications; Used or cited in analyses performed byen USdoğru Environmental Protection Agency, için the Food and Drug Administration, 1. Sağlık hizmetlerini geliştirirken kaynakların şekilde yönetilmesi seçeneklerin oluşturulması the Institute of Medicine, the Medicare Payment Assessment Commission, academia, and industry; Highlighted on the National Library of Medicine's website as an important healthyol economics resource; 2. Sağlık sektöründeki kaynakların kullanımında politikaları düzenleyenlere göstermek 3. Sektörde ölçme Cited in the popular press, including Forbes, The New York Times, The Washington Post and The Boston and ve Globe; değerlendirmede standart bir metodun oluşmasını sağlamak Catalogs information on over 13,400 cost-effectiveness ratios and more than 16,900 utility weights YOĞUN BAKIM MALİYETİ… ABD’de yoğun bakım gideri toplam hastane giderinin % 22’ini Halpern NA, Bettes L, Greenstein R. Federal and nationwide intensive care units and healthcare costs: 1986 –1992. Crit Care Med 1994;22:2001–7. Hollanda’da yoğun bakım gideri toplam hastane giderinin % 20’ini tutmakta… van Dijk FE, van der Werken C. [What are the costs of an intensive care patient? The direct costs of a surgical patient per ICU-admission and per inpatient day.]. Medisch Contact 1998;53:1154–6. Almanya’da yapılan bir çalışmada yoğun bakım maliyeti ortalama 855 € Moerer O, Plock E, Mgbor U, et al. A German national prevalence study on the cost of intensive care: an evaluation from 51 intensive care units. Crit Care 2007;11:R69. ABD’de yapılan bir çalışmada ise yoğun bakım ortalama maliyeti 3221 € bildirilmiştir. Cooper LM, Linde-Zwirble WT. Medicare intensive care unit use: analysis of incidence, cost, and payment. Crit Care Med 2004;32: 2247–53. 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Met pare ac costing e Nethe ix. the the dire t to com alysis, ethodolo case-m Italy, th om re m en an y, nt fr pa g m an tie st m in ed co cost in pa y, co Germ rform es in ud ed pe iz st nc ts de and rd as re e s en as w ic da s diffe parativ logy w conom departm of a stan of ICU patient ds: com rtmethodo armacoe . means Keywor costing alysis ICU depa y for Ph ive care dom by Inc. e seven l Societ dardized , intens el e cost an er th na ot an pe iv vi io at st ct “h ro se e at r ta pe El Eu fo rn by retros ctive. Th lity of da proach 12, Inte blished sumht © 20 l’s perspe s of the availabi m– up ap POR). Pu s,” “con Copyrig hospita si the botto arch (IS gnostic es Rese €1168 on the ba e application of for “dia Outcom veloped th proach nged from pod ra ap ile y n sources ta w da It en p– do -care re per ICU cost com ments. d the to yct costs of health ried by ition” an spital pa lts: Dire lability costs va and nutr r.” Resu t), the ho the avai ution of bo ni , U ent), rib “la n) y st d tio di denc e paym ntila en nc ve ables,” an en though the ep l ra D ca su h has Hig d in 5. Ev mechani ce of a [2,6]. It -mix an to €202 untries e presen /private s 1 Table 2 – Characteristics of the patient samples. Department A (n # 400) Department B (n # 448) Department C (n # 756) Department D (n # 242) Department E (n # 304) Department F (n # 30) Department G (n # 549) 66 " 16 214/186 (54/46) 7.8 " 12.6 (2–98) 28 " 15 155 (39) 61 " 19 267/181 (60/40) 5.2 " 7.4 (1–117) 41 " 22 366 (82) 65 " 21 489/267 (65/35) 7.0 " 5.8 (1–158) 27 " 15 248 (33) 54 " 15 133/109 (55/45) 6.0 " 5.6 (1–30) * 180 (74) 64 " 18 176/128 (58/42) 5.9 " 12.2 (1–148) 34 " 16 177 (58) 58 " 16 16/14 (53/47) 3.8 " 5.7 (1–8) * 19 (63) 55 " 20 341/208 (62/38) 5.0 " 5.1 (1–40) 42 " 20 384 (70) 21 (5) 125 (31) 12 (3) 20 (5) 38 (10) 27 (7) 157 (39) 69 (15) 40 (9) 31 (7) 73 (16) 20 (5) 164 (37) 51 (11) 225 (30) 150 (20) 5 (1) 39 (5) 97 (13) 114 (15) 126 (17) 27 (18) 26 (18) 1 (1) 33 (22) 2 (1) 27 (18) 32 (22) 146 (47) 54 (17) 8 (3) 22 (7) 8 (3) 67 (22) 5 (1) 10 (33) 6 (20) 0 (0) 4 (13) 1 (3) 9 (30) 0 (0) 83 (15) 58 (11) 10 (2) 40 (7) 28 (5) 132 (24) 198 (36) co ic erence (e.g., th tween .g., publ cost diff ices be stem (e costs observed solute pr ment sy ate the and ab e of the e m tim so tiv es la of at to re th 10% and es used wever, ]. ss than l gued, ho ces [7,8 hodologi prise le n et ita ar en enm io m sp er en co e gy ff ct ho be u lo di th beds tual total Introd methodo result of it (ICU) in n 22% of sult of ac costing are as a e care un rtments nsume s betwee g as a re dardized intensiv ents co an bein fference ICU depa an y m gh di th st el of rt ibs ou st at a er pa tr st co th lth im at A ra tual prox n be ion of the co ICU de ac , at ca o, ap of s ic t ls ds n A pl ce en be ]. n l en es [1 pariso repres than The ap betwee hospita st differ ted Stat ful com ated to n, rather per day is way co the Uni meaning en estim ideratio rde costs ,10]. Th general costs in ables a have be der cons t, standa , with th rvices [9 than in herlands rvices un 1,12]. Ye s of l budget -care se ments [1 st se th rt ita e bility co al gy pa sp the Net la ar e lo he de ai ho e av hodo alth-c ICU ssed th th et he e total in se m e a by r th g as th te ed in of rict 20% y. From nts are d grea uted to ies have the cost ten rest al patie tensivel d fivefol ral stud ences in es are of vary ex en l costs r individu three- an Therefore, seve to differ hodologi the tota ICU stay ision, ev tities fo et of ec ed an ]. m rt pr ns ,3 g e qu po [2 io in of re at wards treme, th e level Resource em and ized cost et al. [4] st estim ing syst other ex of data. the sam Moerer ices. Co e e st y, rv ity er th co ith al w t se ud w al A U st qu es ic IC at in an and lable 2008). s [13]. nited St ider’s cl ter Germ not avai flated to provider ain the U are prov multicen €855 (in generally th-care e applic rtments health-c day to be een heal erns on th U depa a single for per ICU endatio cost diff dly betw within ) [5]. day at IC m ke al r 08 ial bias m ar tu pe 20 co m ac s st vary ix is d potent ted to plain ade re t s an m fla -m ex en em total co se es (in er ve to st 1 gi ff ca ha sy lo di tient be €322 ve tried studies ices at methodo The pa of ICU 5] udies ha found to Several costing are serv [2,6,7]. al costs et al. [1 ber of st dardized health-c rtments woller ces the actu an tz n pa en A num st Ri on ee de er of e, ff ct tw U di effe tion exampl lity be tween IC tual cost portant , den15]. For mparabi ences be cing ac ve an im the co ers [13– ncy rate influen ed to ha e provid d occupa medfactors consider alth-car ions in tential g (e.g., be he x at po in ri tt er va se , th , P.O. Bo udy use of days. O position) tterdam ns in st n, and aff com variatio rsiteit Ro al patter , and st include us Unive ls, referr re beds m ca va as e ie Er tr ut t, re report. essmen sity of ac ergency terest to . logy Ass tice (em (ISPOR) icts of in edical Techno ical prac search no confl M mes Re ors have n, Institute for th d Outco au e mics an st: Th an Ta re no Sw te co in ok oe of : Si . Pharmac Conflicts rrespondence to ety for herlands co nal Soci The Net * Address ternatio erdam, 2012, In DR Rott © 00 t l. 30 gh r.n , ri g.eu 1738 ter Copy tan@bm ont mat E-mail: – see fr 5/$36.00 1098-301 er Inc. vi se El d by .007 Publishe .2011.09 16/j.jval doi:10.10 Age (y), mean " SD Gender, male/female, n (%) ICU stay (d), mean " SD (min-max) SAPS II, mean " SD Mechanical ventilation, n (%) Admission diagnosis, n (%) Cardiovascular Gastrointestinal Metabolic Neurological Renal Respiratory Unknown/Other VALUE IN HEALTH 15 (2012) 81– 86 ropean Four Eu in y ta it S , odology Care Un PhD, MD tensive d Costing Meth PhD, MD , Joerg Martin, In f o is ila, ize lys , Atul Kap elte, PhD ost Ana tandard , MSc , Direct C : Applying a S , Marga E. Hoogendrooonkrn, PhD, MD , Robert W iversity us MC Un ire s re, Erasm sh r E. Sp D, MD yal Berk tensive Ca D , Pete kker, Ph Countrie Care, Ro M ent of In e Ba , Care, siv n D rtm e Ja ten pa Ph siv In *, journa g systems in place; application of the bottom– up apd require the information from each of the systems to ched. Where resource quantities of “hotel and nutriructurally available at the patient level, those of “laot available at the patient level at any of the departdition, wide variability existed in terms of training of cialists and ICU nurses. Therefore, the standardized hodology entailed the application of the bottom– up “hotel and nutrition” and the top– down approach for ” “consumables,” and “labor.” quantities and unit costs of the cost components ed by using uniform reporting templates, which are readers on request. Resource quantities of “diagnosmables,” and “hotel and nutrition” were derived from d Patient Data Management Systems. Labor time specialists, ICU nurses, and consulted specialists per determined by dividing the number of workable days en from collective labor agreements) by the number of year (taken from computerized Patient Data Managems). Unit costs represented the costs to the hospital wholesale prices. The unit costs of “diagnostics,” “conand “hotel and nutrition” were primarily obtained al administrative databases. The unit costs of labor on normative incomes (taken from hospital financial nd allocated to patients according to the time spent Normative incomes included wages, social premir irregular working hours, and the costs of replaceillness. were based on Euro 2008 cost data. All costs were 008 using the Eurostat harmonized indices of con[23]. Mean exchange rates for 2008 were used. Statiss were conducted with the statistical software proor Windows version 17.0. In all cases, P ! 0.05 was istically significant. samples of the seven ICU departments showed some nces at baseline, which are summarized in Table 2. A admissions of age 61 " 19 years with 60% male were th an average of 390 " 232 per department. These elated to 16,791 ICU days (2407 " 1607 on average per . The patient case-mix differed somewhat from dedepartment. The Simplified Acute Physiology Score ged from 27 " 15 in department C to 42 " 20 in departshare of mechanically ventilated patients varied bet department C and 82% at department B. There were portion of patients with gastrointestinal diseases at A (31%), of cardiovascular diseases at department C tment E (47%), and department F (33%), and of respies at department B (37%) and department F (30%). ew of descriptive statistics at the department level is le 3. Direct costs per ICU day varied between €1168 B) and €2025 (department G). Labor was the key cost ntirely explained the increased costs at department G ared with an average €711 at the other departments). for “diagnostics” were responsible for about 14% of sts and ranged from €99 at department G to €255 at D. Absolute costs of “laboratory services” were much artment G (€56 compared with an average €145 at the ments; P # 0.030). for “consumables” were responsible for about 22% of sts and ranged from €241 at department B to €357 at F. The absolute costs of “fluids” predominantly repred (derived) products at departments A, B, C, and G, departments D, E, and F they in addition comprised ere administered to the patient intravenously. ThereVALU ICU, intensive care unit; SAPS Simplified Acute Physiology Score. * Not available. 83 VALUE IN HEALTH 15 (2012) 81– 86 Available online at www.sciencedirect.com journal homepage: www.elsevier.com/locate/jval 84 Direct Cost Analysis of Intensive Care Unit Stay in Four European Countries: Applying a Standardized Costing Methodology Siok Swan Tan, PhD1,*, Jan Bakker, PhD, MD2, Marga E. Hoogendoorn, MSc3, Atul Kapila, PhD, MD4, Joerg Martin, PhD, MD5, Angelo Pezzi, PhD, MD6, Giovanni Pittoni, PhD, MD7, Peter E. Spronk, PhD, MD8, Robert Welte, PhD9, Leona Hakkaart-van Roijen, PhD1 1 Institute for Medical Technology Assessment, Erasmus Universiteit Rotterdam, Rotterdam, The Netherlands; 2Department of Intensive Care, Erasmus MC University Medical Center, Rotterdam, The Netherlands; 3Department of Intensive Care, Isala Clinics, Zwolle, The Netherlands; 4Department of Intensive Care, Royal Berkshire NHS Trust Hospital, Reading, UK; 5Department of Intensive Care, Kliniken des Landkreises Göppingen GmbH, Göppingen, Germany; 6Department of Intensive Care, Università degli Studi di Milano, Milan, Italy; 7Department of Intensive Care, Azienda Ospedaliera-Università, Padova, Italy; 8Department of Intensive Care Medicine, Gelre Hospital (Lukas Site), Apeldoorn, The Netherlands; 9GlaxoSmithKline, New Products & Health Outcomes, Munich, Germany A B S T R A C T Objectives: The objective of the present study was to measure and compare the direct costs of intensive care unit (ICU) days at seven ICU departments in Germany, Italy, the Netherlands, and the United Kingdom by means of a standardized costing methodology. Methods: A retrospective cost analysis of ICU patients was performed from the hospital’s perspective. The standardized costing methodology was developed on the basis of the availability of data at the seven ICU departments. It entailed the application of the bottom– up approach for “hotel and nutrition” and the top– down approach for “diagnostics,” “consumables,” and “labor.” Results: Direct costs per ICU day ranged from €1168 to €2025. Even though the distribution of costs varied by cost compo- nent, labor was the most important cost driver at all departments. The costs for “labor” amounted to €1629 at department G but were fairly similar at the other departments (€711 ! 115). Conclusions: Direct costs of ICU days vary widely between the seven departments. Our standardized costing methodology could serve as a valuable instrument to compare actual cost differences, such as those resulting from differences in patient case-mix. Keywords: comparative study, cost analysis, costing methodology, Europe, intensive care. Table 3 – The direct costs for an ICU day as determined by the standardized costing methodology23. Copyright © 2012, International Society for Pharmacoeconomics and Introduction ment system (e.g., public/private-mix and insurance payment), and relative and absolute prices between countries [2,6]. It has been argued, however, that some of the observed cost differences are as a result of the methodologies used to estimate the costs rather than being as a result of actual differences [7,8]. The application of a standardized costing methodology enables a meaningful comparison of actual cost differences between health-care services [9,10]. This way cost differences can be attributed to the health-care services under consideration, rather than to differences in the costing methodology [11,12]. Yet, standardized costing methodologies are often restricted by the availability and quality of data. Resource quantities for individual patients are generally not available with the same level of precision, even within a single health-care provider’s clinical costing system and systems vary markedly between health-care providers [13]. Several studies have made recommendations on the application of standardized costing methodologies and potential bias for the comparability between health-care services at different health-care providers [13–15]. For example, Ritzwoller et al. [15] Diagnostic procedures Medical imaging services 49 (4%) 45 (4%) Laboratory services 132 (11%) 160 (14%) Consumables Drugs 115 (9%) 113 (10%) 59 (5%) 51 (4%) ConflictsFluids of interest: The authors have no conflicts of interest to report. * Address correspondence to: Siok Swan Tan, Institute for Medical Technology Assessment, Erasmus Universiteit Rotterdam, P.O. Box Disposables 74 (6%) 77 (7%) 1738, 3000 DR Rotterdam, The Netherlands. E-mail: tan@bmg.eur.nl. 1098-3015/$36.00 see frontnutrition matter Copyright © 2012, International Society for80 Pharmacoeconomics and Outcomes Research (ISPOR). Hotel– and (7%) 38 (3%) Published by Elsevier Inc. Labor doi:10.1016/j.jval.2011.09.007 ICU specialist 196 (16%) 257 (22%) ICU nurse 445 (36%) 369 (32%) Consulted specialist 80 (7%) 58 (5%) Medical specialist 68 54 Pharmacist 1 0 Physiotherapist 6 4 Laboratory technician 4 0 Nutrition specialist 1 0 Total 1.230 1.168 ICU, intensive care unit. Department C (n ! 756) Department D (n ! 242) Department E (n ! 304) Department F (n ! 30) Department G (n ! 549) Total population Department sample (n ! 7) Mean SD 32 (2%) 129 (9%) 60 (5%) 195 (16%) 70 (5%) 130 (9%) 124 (10%) 125 (10%) 43 (2%) 56 (3%) 60 (4%) 132 (10%) 31 42 210 (15%) 39 (3%) 71 (5%) 25 (2%) 145 (12%) 131 (11%) 3 (0%) 90 (8%) 151 (11%) 146 (10%) 33 (2%) 86 (6%) 142 (11%) 151 (12%) 64 (5%) 44 (3%) 113 (6%) 56 (3%) 117 (6%) 11 (1%) 141 (10%) 90 (7%) 63 (5%) 53 (4%) 34 50 36 32 285 (21%) 561 (41%) 33 (2%) 29 0 4 0 0 1.385 150 (13%) 397 (33%) 19 (2%) 16 1 0 1 0 1.190 216 (15%) 562 (40%) 20 (1%) 15 1 1 3 1 1.414 256 (20%) 343 (27%) 18 (1%) 13 0 1 3 1 1.267 296 (15%) 1,123 (55%) 210 (10%) 126 6 55 18 4 2.025 237 (17%) 543 (39%) 63 (5%) 46 1 10 4 1 1.383 52 270 69 41 2 20 6 2 298 VALUE IN HEALTH 15 (2012) 81– 86 Although intensive care unit (ICU) beds comprise less than 10% of hospital beds, ICU departments consume 22% of total hospital costs in the United States [1]. Also, the costs of ICU departments in the Netherlands have been estimated to represent approximately 20% of the total hospital budget, with the costs per day between three- and fivefold greater in ICU departments than in general wards [2,3]. Therefore, several studies have assessed the costs of ICU services. Cost estimations of ICU stay vary extensively. From a multicenter German study, Moerer et al. [4] reported the total costs per ICU day to be €855 (inflated to 2008). At the other extreme, the total costs per day at ICU departments in the United States were found to be €3221 (inflated to 2008) [5]. A number of studies have tried to explain actual cost differences between ICU departments [2,6,7]. The patient case-mix is considered to have an important effect on the actual costs of ICU days. Other potential factors influencing actual cost differences include variations in study setting (e.g., bed occupancy rate, density of acute care beds, and staff composition), variations in medical practice (emergency retrievals, referral pattern, and use of Outcomes Research (ISPOR). Published by Elsevier Inc. Department A Department B mechanical ventilation), the availability of health-care resources (n ! 400) (n ! 448) (e.g., the presence of a High Dependency Unit), the hospital pay- Yoğun bakım direktörünün yeni cihaz ve ilaçları klinik uygulamalara sokarken ilk sorusu: FAYDA ORANI NEDİR? Duyulan huzursuzluklar; ➤Gereksiz(aynı edilebilir) sonuç çok daha basit yöntemlerle elde ➤Başarısız (klinik olarak etkisiz) ➤Güvensiz (riskler faydanın üzerinde); ➤Fizik hasar (uygulama sonrası oluşacak yaşam kalite sorunu kabul edilemez düzeyde) ➤Aptalca (kaynaklar çok daha faydalı bir şeye yönlendirilebilir) Jennett B. Inappropriate use of intensive care. BMJ. 1984;289:1709-1711. Çoğu sağlık profesyoneli tarafından; takdir edilebilir, ancak bununla birlikte taburcu olamaksızın sürdürülen yoğun bakım girişimlerini çoğunlukla ‘BEYHUDE’ olarak kabul edilmekte… “ Yoğun bakım ünitesinde tedavi edilen 10 hastadan 1’inden daha fazlası iyileşme olasılığına sahip değildir. Buna rağmen, beyhude tedaviler devam eder ve ölüm prosesi geciktirilir, kocaman bir hastane faturası oluşur. Robin Wulffson, M.D. NÜFUSUN YAŞLANMASI/60 YAŞ ÜZERİ NÜFUS Gelişmemiş Ülkeler 1980-2010 Gelişmemiş Ülkeler 2010-2040 Az Gelişmiş Ülkeler 1980-2010 Az Gelişmiş Ülkeler 2010-2040 Gelişmiş Ülkeler 1980-2010 Gelişmiş Ülkeler 2010-2040 Dünya 1980-2010 Dünya 2010-2040 0 United Nations, “World Population Aging 2013” 2,25 4,5 6,75 9 Deutsche Homepage Ressources et utilitaires Scoring systems for ICU and surgical patients: TISS-28 (Therapeutic Intervention Scoring System-28) Basic Activities Points Ventilatory Support Laboratory. Biochemical and microbiological investigations. 1 yes Single medication, any route (IV, PO, IM, etc.). 2 yes Multiple intravenous medications (more than 1 drug, single shots, or continuously) 3 yes 1 yes Mechanical ventilation. Any form of mechanical or assisted ventilation with or no without PEEP; with or without muscle relaxants; spontaneous breathing with PEEP). Supplementary ventilatory support. Breathing spontaneously through endotracheal tube without no PEEP; supplementary oxygen by any method except if mechanical ventilation parameters apply. Care of artificial airways. Endotracheal tube or tracheostoma. no Treatment for improving lung function. Thorax physiotherapy, incentive spirometry, inhalation therapy, intratracheal suctioning. Renal Support no 1 yes no 3 yes no Standard monitoring. Hourly vital signs, regular registration and calculation of fluid balance. Routine dressing changes. Care and prevention of decubitus and daily dressing change. Frequent dressing changes (at least one time per each nursing shift) and/or extensive wound care Care of drains. All (except gastric tube). 5 yes Hemofiltration techniques. Dialytic techniques. Quantitative urine output measurement. Active diuresis (e.g. furosemid > 0.5 mg/kg/day for overload). Neurologic Support Cardiovascular Support Single vasoactive medication. Any vasoactive drug. Multiple vasoactive medications. More than1 vasoactive drug, disregard type and dose. Intravenous replacement of large fluid losses. Fluid replacement > 3 liters per square meter per day, disregard type of fluid administered. Miranda DR et al. Simplified Therapeutic Intervention Scoring System : the TISS-28 items. Results from a multicenter study. Crit Care Med. 1996;24:64-73. 5 yes no 2 yes 1 yes no 1 yes no 3 yes no 2 yes no 3 yes no 4 yes no 3 yes 4 yes 4 yes no Peripheral arterial catheter. 5 yes no Treatment of complicated metabolic acidosis/alkalosis. 4 yes no Left atrium monitoring. Pulmonary artery flotation catheter with or without cardiac output measurement. 8 yes no Intravenous hyperalimentation 3 yes no Central venous line. 2 yes no Enteral feeding. Through gastric tube or other GI route (e.g. jejunostomy). 2 yes no 3 yes no Cardiopulmonary resuscitation after arrest in the past 24 hours (single precordial percussion not included) Specific Interventions Single specific interventions in the ICU. Naso or orotracheal intubation, introduction of a pacemaker, cardioversion, endoscopies, emergency surgery in the past 24 hours, gastric lavage. Routine interventions without consequences to the clinical condition of the patient, such as radiographs, echography, EKG, dressings or introduction of venous or arterial catheters, are not included. Multiple specific interventions in the ICU. More than one, as described above. Specific interventions outside of ICU. Surgery or diagnostic procedures. no Measurement of intracranial pressure. Metabolic Support TISS-28 = 0 TISS-28 = SUM (points for activities performed) Compute 3 yes no TISS-76 correlation = 5 yes 5 yes Clear Time of nurse's care = 0 (One TISS-28 point equals 10.6 minutes of each 8 h nurse's shift) 0 (Correlation beetwen TISS-28 and TISS-76: r = 0.93, r2 = 0.86) (TISS-28) = 3.33 + 0.97* (TISS-76) no Criteria of exclusion are applied in four conditions : Moreno R, Morais P. Validation of the simplified therapeutic intervention scoring system on an independent database. Intensive Care Med. 1997;23:640-644. Points "Multiple intravenous medications" excludes "Single medication"; "Mechanical ventilation" excludes " Supplementary ventilatory support"; "Multiple vasoactive medications" excludes "Single vasoactive medication"; "Multiple specific interventions in the ICU" excludes "Single specific interventions in the ICU " I. Basamak II. Basamak III. Basamak ? Basamak ABD’de yoğun bakım ünitelerine her yıl 4.000.000 hasta kabulü yapılıyor. Akut hastane toplam giderlerinin %30’u yoğun bakım giderlerini oluşturuyor. ICU outcomes (mortality and length of stay) methods, data collection tool and data [Internet]. San Francisco, CA: Philip R Lee Institute for Health Policy Studies, University of California, San Francisco; 2012 [cited 2014 Apr 21]. 4. WenhamT,PittardA.Intensivecareunit environment. Continuing Education in Anaesthesia, Critical Care & Pain 2009 Dec;9(6):178-83. Yoğun bakımda hasta güvenliği ile ilgili endişeler devamlı var. Ciddi ilaç hatalarının %78’ yoğun bakım ünitelerinde gerçekleşiyor. Rothschild JM, Landrigan CP, Cronin JW, et al. The Critical Care Safety Study: the incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med 2005 Aug;33(8):1694-700. Ve, yoğun bakımlardaki mortalite oranları %10-28 arasında değişiyor veya başka bir deyişle her yıl 540.000 hasta ölüyor… AngusDC,BarnatoAE,Linde-ZwirbleWT,etal; Robert Wood Johnson Foundation ICU End-Of- Life Peer Group. Use of intensive care at the end of life in the United States: an epidemiologic study. Crit Care Med 2004 Mar; 32(3):638- 43. ➤ TELE-MEDİCİNE (TELE-SAĞLIK) bir noktadan başka bir noktaya elektronik haberleşme yöntemleriyle medikal bilgilerin aktarılmasıyla hastaların sağlık durumlarını iyileştirmek olarak tanımlanır. Kramer M, Maguire P, Brewer BB. Clinical nurses in Mag- net hospitals confirm productive, healthy unit work environments. J Nurs Manag. 2011;19:5–17. REVIEW A Massachusetss Memorial Medical Center’daki 119 yoğun bakım yatağı Tele-ICU A Business Case for Tele-Intensive Care Units programına alınmıştır. TOPLAM 7.120.000 $ Figure 2. University of Massachusetts Memorial Medical Center: one-time costs for tele-intensive care unit implementation, 2010.36 ICU = intensive unit; MiscCase = miscellaneous. REVIEW ARTICLEcare , A Business for Tele-Intensive Care Units, Alberto Coustasse, DrPH, MD, MBA, MPH; Stacie Deslich, MA, MS; Deanna Bailey, MS; Alesia Hairston, MS; David Paul, DDS, PhD Perm J 2014 Fall;18(4): 76-84 command center extended coverage to 9 adult ICUs covering 116 ICU beds in cine into its 14 ICUs in 2007. The tele-ICU command center in Resurrection’s Holy reported, including $11,200 from a 7% reduction in blood transfusions. The hos- tems vendor, Philips VISICU in Baltimore, MD, tele-ICU implementation costs ranged from about $50,000 to $100,000 per bed, and the cost of equipping 100 beds was approximately $3 to $5 million.28,29 Annual operating costs (eg, overhead, maintenance, staffing) were estimated by Philips Findings from an independent evaluation by Cap Gemini Ernst & Young, London, United Kingdom, suggested a $2 million tele-ICU cost that was offset by $3 million in net savings annually.33 It reported extra revenue, approximately $460,000 per month, because of increased Hastane Mortalitesi Table 1. Tele-intensive care unit cases studied, implementation costs, andazalma outcomes %26,4 Yoğun Bakım kalış süresi %13,6’DAN New England Healthcare University of Massachusetts Memorial Medical %11,8’E Institute and Massachusetts Center, academic hospital with 5 adult ICUs, Institution Sentara Healthcare Setting Sentara Healthcare,a academic tertiary care medical center with 5 ICUs, 103 critical care beds Technology Collaborative The University of Massachusetts Memorial Medical Center in Worcester, MA, installed a tele-ICU command center in 2005 and extended the tele-ICU coverage to 2 Massachusetts community hospitals in 2007 and 2008. Over 3 years, 1 tele-ICU Implementation costs (US dollars) 1 million 7.12 million 130 beds, 7000 ICU patients Mortalite Community hospitals with 14 ICUs, 182 critical care beds 13,3’TEN Pre- and postimplementation design; preimplementation: n = 2034 patients; 9,8’E postimplementation: n = 2134 Resurrection Health Care Memorial Medical Center 7 million Yoğun Bakım kalış süresi %17 azalma Major results/outcomes Decreased ICU LOS by 17%; decreased hospital mortality by 26.4%33,36 Decreased ICU LOS (from 13.3 to 9.8 days); decreased mortality from 13.6% to 11.8%; recovered costs of implementation; lowered rates of complications36 6 months after implementation: 38% decrease in ICU LOS, approximately $3 million in cost savings37,38 Includes both Sentara Norfolk General Hospital and Sentara Hampton General Hospital. ICU = intensive care unit; LOS = length of stay. a İmplementasyondan 6 Care aytele-intensive sonra:careYoğun bakım kalış Table 2. Sentara Healthcare and Resurrection Health unit implementation savings Cost of implementation süresinde % 38 azalma, 3.000.000 $ Hospital (US dollars) Outcomes Cost saving Sentara Healthcare 1 million Reduction in mortality by 27%; Reduced patient cost of $2150; average case TASARRUF (savings from 2002 to 2010) decreased LOS of 17% contribution margin increased by 55.6% REVIEW ARTICLE , A Business Case for Tele-Intensive Care Units, Alberto Coustasse, DrPH, MD, MBA, MPH; Stacie Deslich, MA, MS; Deanna Bailey, MS; Alesia Hairston, MS; David Paul, DDS, PhD Perm J 2014 Fall;18(4):76-84a Resurrection Health Care (savings from 2007 to 2011) 7 million Decreased LOS of 38% 33,36 7% reduction in blood transfusions ($11,200 in savings); estimated total cost savings of $11.5 million37,38 82 124/66 98 98 BUKASIS A DVA N C E D T E L E M E D I C I N E T E C H N O L O G I E S HBYS LIS BUKASIS A DVA N C E D T E L E M E D I C I N E T E C H N O L O G I E S PACS ECZANE DEPO REVIEW ARTICLE , A Business Case for Tele-Intensive Care Units, Alberto Coustasse, DrPH, MD, MBA, MPH; Stacie Deslich, MA, MS; Deanna Bailey, MS; Alesia Hairston, MS; David Paul, DDS, PhD Perm J 2014 Fall;18(4):76-84 Table 5. Studies addressing tele-ICU implementation and utilization Author, year Aaronson et al, 200640 Badawi et al, 201041 Badawi and Shemmeri, 200642 Berenson et al, 200931 Breslow et al, 200412 Chu-Weininger et al, 201043 Coletti et al, 200844 Dickhaus, 200645 Giessel and Leedom, 200746 Groves et al, 200813 Howell et al, 200747 Howell et al, 200848 Ikeda et al, 200967 Kohl et al, 200749 Kohl et al, 200750 Kohl et al, 201216 Kumar et al, 201351 Khunlertkit and Carayon, 201311 Lilly et al, 201117 Mora et al, 200752 Norman et al, 200953 Patel et al, 200754 Rincon et al, 200755 Study design Literature review Pre/posttest of tele-ICU implementation Pre/posttest of tele-ICU implementation Literature review Pre/posttest of tele-ICU implementation across several hospitals Pre/posttest of tele-ICU implementation and utilization in 3 ICUs Cross-sectional survey of residents in ICU and tele-ICUs Pre/posttest of tele-ICU implementation and utilization in a multistate hospital system Pre/posttest of tele-ICU implementation and utilization Literature review Pre/posttest of tele-ICU implementation and utilization Pre/posttest of tele-ICU implementation and utilization Pre/posttest of tele-ICU implementation and utilization Pre/posttest of tele-ICU implementation and utilization Pre/posttest of tele-ICU implementation and utilization Pre/posttest of tele-ICU implementation and utilization Literature review Qualitative study with semistructured interview of tele-ICU staff Pre/posttest of tele-ICU implementation and utilization Survey of residents practicing in tele-ICUs Literature review and meta-analysis Pre/posttest of tele-ICU implementation and utilization of 6 tele-ICUs Pre/posttest of tele-ICU utilization in prevention of sepsis Scales et al, 201156 Thomas et al, 200757 Vespa et al, 200758 Literature review Pre/posttest of tele-ICU implementation and utilization Pre/posttest of tele-ICU implementation and utilization Wilcox and Adhikari, 201215 Willmitch et al, 201259 Meta-analysis of 11 studies Pre/posttest of tele-ICU implementation and utilization over 3 years Literature review and meta-analysis Meta-analysis of 11 studies Survey of physicians practicing in remote areas using tele-ICU Pre/posttest of tele-ICU implementation and utilization Pre/posttest of tele-ICU implementation and utilization in a rural health care system Pre/posttest of tele-ICU implementation and utilization Pre/posttest of tele-ICU implementation and utilization Youn, 200660 Young et al, 201161 Zawada et al, 200662 Zawada et al, 200763 Zawada et al, 200864 Zawada and Herr, 200865 Zawada et al, 200966 ICU = intensive care unit; LOS = length of stay. Outcome Higher rates of ICU staff adherence to critical care best practices Higher rates of ICU staff adherence to critical care best practices Higher rates of ICU staff adherence to critical care best practices Improved patient care Improved hospital financial performance, improved ICU financial performance, improved patient care Improved teamwork and/or safety climate Improved teamwork and/or safety climate Lower ICU LOS Higher rates of ICU staff adherence to critical care best practices Lower ICU LOS Lower ICU LOS Lower ICU LOS Lower ICU LOS Lower ICU LOS Improved ICU financial performance, lower ICU LOS Lower ICU LOS Improved ICU financial performance Improved ICU staff adherence to evidence-based protocols for sepsis, ventilator-associated pneumonia, and blood transfusion Higher rates of ICU staff adherence to critical care best practices, lower ICU LOS, improved patient care Improved patient care Improved ICU financial performance Higher rates of ICU staff adherence to critical care best practices, lower ICU LOS Higher rates of ICU staff adherence to critical care best practices: • Antibiotic administration increased from 55% to 74% • Serum lactate measurement increased from 50% to 66% • Central line placements increased from 33% to 50% Higher rates of ICU staff adherence to critical care best practices Improved teamwork and/or safety climate Improved ICU financial performance, lower ICU LOS, improved patient care Lower ICU LOS Lower ICU LOS Higher rates of ICU staff adherence to critical care best practices Lower ICU LOS Higher rates of ICU staff adherence to critical care best practices, lower ICU LOS Improved ICU financial performance, lower ICU LOS Higher rates of ICU staff adherence to critical care best practices, improved ICU financial performance Improved patient care Improved hospital financial performance Blake Fenwick & Hugh Stehlik Canberra Hospital, Avustralya 2 Keman, 1 Viyola, 1 Viyolensel https://youtu.be/KKFzy7tEXu4 Sabrınız için teşekkür ederim…