[Ethical conflicts in pediatric surgery: high-performance medicine and the economical environment]

A scoping review of empirical evidence on the impacts of the DRG introduction in Germany and Switzerland

CONTEXT

Germany and Switzerland have introduced diagnosis-related groups (DRGs) for hospital reimbursement. This scoping review aims to evaluate if empirical evidence exists on the effect of the DRG introduction.

METHODS

Medline via PubMed, Embase (Elsevier), CINAHL, PsychINFO, and Psyndex were systematically screened for studies from 2003 onwards using keywords-DRG, prospective payment system, and lump sum-in English, German, and French. Abstracts were screened for alignment with our inclusion criteria and classified as editorial/commentary, review, or empirical study. The full-text extraction included data on country, study design, collected data, study population, specialty, comparison group, and outcome measures.

RESULTS

Our literature search yielded 1944 references, of which 1405 references were included in the abstract screening after removal of duplicates. 135 articles were relevant to DRG, including 94 editorials/comments/reviews and 41 empirical articles from 36 different samples. The most frequently used outcome parameters were length of stay (12), reimbursement/cost (9), and case numbers (9).

CONCLUSIONS

Only a minority of identified articles (30.4%; 41 of 135) presented empirical data. This indicates that discussion on the topic is not totally evidence-based. The only common trend was a decrease in length of stay.

White paper: statement on conflicts of interest

INTRODUCTION

Conflicts of interest are a normal part of human social intercourse. They become problematic when there is a power differential between participants in the setting of relationships requiring a high degree of trust, as in healthcare. In this white paper we consider how these conflicts may be detected and mitigated.

METHODS

Following Medline search and reference chaining, we undertook a narrative review of the literature with iterative discussion.

RESULTS

Conflicts of interest may be financial, professional or personal, and may operate at the level of the individual or the organisation. Unmanaged, they become a source of bias which places the interests of the professional or the organisation before those of the patient. Reported with increasing frequency, conflicts damage trust, harm patients, and defraud the health system. We make 15 recommendations for minimising conflicts of interest.

CONCLUSIONS

Nationally funded open-access registries should be established to permit complete disclosure of financial, professional, and personal relationships with the potential for driving bias in research, clinical practice, or health management. Governance of disclosure should be the responsibility of employing organisations through annual staff appraisals, audited by national research integrity committees. Research fraud should incur suspension of the license to practice. Organisations should monitor staff perceptions of ethical climate to enhance awareness of staff behaviours and the potential for misconduct driven by academic pressures. Clear separation of advisory and voting roles is needed in best practice guideline panels. Professional societies and scientific journals should display conflict of interest policies for their own staff and officers as well as for speakers and authors. Undergraduates should not be exposed to pharmaceutical promotions masquerading as education. Undergraduate and postgraduate training programmes should include teaching about managing conflicts of interest and identifying research misconduct.

[Indication: scientific and ethical basis of medical practice]

The medical indication provides a rational foundation for treatment decisions. An indication can be defined as the reasonable professional judgement that a medical procedure is suitable and useful to reach a specific therapeutic goal with a certain probability. An indication includes empirical, causal and purposive considerations and justifications, and a scrutiny of the individual case. This ensures that medical aspects of the patient, therapeutic goals and evidence-based knowledge are integrated and represented in the indication. An indication justifies a treatment proposal to the patient, which may only be carried out after a procedure of informed consent. Indications can be considered as the ethical basis of treatment decisions and as the heart of professionalism: indications should be used as a professional tool to protect against irrational therapeutic expectations, while ensuring the patient's right for reasonable treatment. In health care that is increasingly shaped by economic constraints, conscientious indications ensure the professional and ethical basis of medical treatment decisions.