European hospital reforms in times of crisis: aligning cost containment needs with plans for structural redesign?

Analysis for health system resilience against the economic crisis: a best-fit framework synthesis

INTRODUCTION

Countries, especially developing countries, are prone to economic crises, which are the consequences of various crises, including pandemics, climate crises, armed conflicts and migration. Therefore, policy-makers need a guiding framework for policy-making against the economic crisis that contributes to health system resilience. This study aimed to provide a holistic framework that guides health system policies before or during an economic crisis.

METHOD

The study utilized the best-fit framework synthesis to enhance and adapt the Resilience Analysis Meta-Framework (RAMF) in the context of an economic crisis. The study analysed and compared the experiences of three high-income countries and three low-middle-income countries with the greatest diversity in terms of their context, shocks that caused the economic crises and their responses to them. The framework was expanded and adjusted on the basis of the adopted policies in the context of the economic crisis.

RESULTS

The adapted RAMF provides a holistic framework which shows the priority and relationships of various policy alternatives in each health system building block. This framework can be used as a guide to analyse any policy solution against the economic crisis by considering its necessary antecedent policies and consequence policies in other health system building blocks.

CONCLUSIONS

Awareness in a health system via adapting appropriate cost control policies and governance structure can contribute to evidence-based cost control in all health system building blocks and need-based financing, drug and medical equipment procurement, human resource planning and service provision.

The cost of readmissions in hospitals: the case of the Spanish public hospitals

BACKGROUND

In this paper, we propose a novel model that allows us to understand the effect of hospital readmissions on technology and costs. To do this, we consider that hospitals may experience heterogeneous discharges: on the one hand, discharges corresponding to patients who have completed their healing process in hospital and, on the other hand, discharges resulting from patients who have been discharged too early and are therefore required to be readmitted to hospital. In the first case, discharges involve more resources; in the second case, the patient returns implying an additional use of resources. In tandem, two new issues arise which need to be addressed: a) Does a trade-off exist between the decision to discharge at the finalisation of fully completed treatment or the decision to discharge taken at an earlier stage; b) Readmissions may prove endogenous and if so, their econometric treatment must be considered in order to obtain unbiased results. Our study contributes to the literature by proposing a novel model which estimates the marginal cost of readmissions, thus allowing us to understand the effect of readmission on technology and hospital costs.

METHODS

To resolve the foregoing concerns, this paper proposes a theoretical and empirical model based on the dual theory, which combines cost and input-oriented distance functions to obtain the marginal cost of readmissions. Our empirical application uses a panel of Spanish public hospitals observed over the period 2002-2016.

RESULTS

Results indicate that the treatment required by a patient who is readmitted proves more expensive than keeping the patient under observation for a few extra days in order to achieve a definitive discharge. Moreover, this additional cost follows an increasing temporal trend, especially in times of expansion when the availability of resources is greater.

CONCLUSIONS

Given that the results indicate that readmissions imply an additional cost for the hospital system, they must be contained. In fact, readmission rates are a significant component of current hospital sector activity improvement strategies. Therefore, knowing the cost which readmission implies is relevant for the design of policies that seek to penalize those hospitals with high readmission rates.

Country-level effects of diagnosis-related groups: evidence from Germany's comprehensive reform of hospital payments

Hospitals account for about 40% of all healthcare expenditure in high-income countries and play a central role in healthcare provision. The ways in which they are paid, therefore, has major implications for the care they provide. However, our knowledge about reforms that have been made to the various payment schemes and their country-level effects is surprisingly thin. This study examined the uniquely comprehensive introduction of diagnosis-related groups (DRGs) in Germany, where DRGs function as the sole pricing, billing, and budgeting system for hospitals and almost exclusively determine hospital revenue. The introduction of DRGs, therefore, completely overhauled the previous system based on per diem rates, offering a unique opportunity for analysis. Using aggregate data from the Organisation for Economic Co-operation and Development and recent advances in econometrics, we analyzed how hospital activity and efficiency changed in response to the reform. We found that DRGs in Germany significantly increased hospital activity by around 20%. In contrast to earlier studies, we found that DRGs have not necessarily shortened the average length of stay.

Health care reform and financial crisis in the Netherlands: consequences for the financial arena of health care organizations

Over the past decade, many health care systems across the Global North have implemented elements of market mechanisms while also dealing with the consequences of the financial crisis. Although effects of these two developments have been researched separately, their combined impact on the governance of health care organizations has received less attention. The aim of this study is to understand how health care reforms and the financial crisis together shaped new roles and interactions within health care. The Netherlands - where dynamics between health care organizations and their financial stakeholders (i.e., banks and health insurers) were particularly impacted - provides an illustrative case. Through semi-structured interviews, additional document analysis and insights from institutional change theory, we show how banks intensified relationship management, increased demands on loan applications and shifted financial risks onto health care organizations, while health insurers tightened up their monitoring and accountability practices towards health care organizations. In return, health care organizations were urged to rearrange their operations and become more risk-minded. They became increasingly dependent on banks and health insurers for their existence. Moreover, with this study, we show how institutional arenas come about through both the long-term efforts of institutional agents and unpredictable implications of economic and societal crises.

Measuring the efficiency of public hospitals: A multistage data envelopment analysis in Fujian Province, China

Objective

The present study aimed to evaluate the operational efficiency of public hospitals in Fujian Province and the factors responsible for the inefficiency of these hospitals and provide relevant suggestions for health policymakers in allocating service resources.

Method

In the first stage of the research, the variables affecting the efficiency of hospitals were extracted by qualitative and quantitative methods, including literature optimization, gray related analysis and gray clustering evaluation. In the second stage, the data envelopment analysis (DEA) method was used to evaluate the operational efficiency of 49 hospitals of different levels and types selected by sampling in 2020. Finally, a Tobit regression model with introduced institutional factors and background factors was established to study the main influencing factors of hospital inefficiency.

Results

In the first stage, 10 input variables and 10 output variables necessary from the mangers' point of view were identified to test efficiency. In the second stage, the average comprehensive TE, PTE, and SE of 49 sample hospitals was 0.802, 0.888, and 0.902, respectively. 22.45% of these hospitals met the effective criteria, i.e., the overall effective rate was 22.45%. The low SE value of the hospital was the main reason hindering the improvement of the comprehensive efficiency value. The overall effective rate of secondary public hospitals (30.77%) was higher than that of tertiary public hospitals (19.44%), and the overall effective rate of public specialized hospitals (30%) was higher than that of general public hospitals (18.92%). Based on the third stage results, the bed occupancy rate (BOR) and the proportion of beds (POB) were major factors affecting the operation efficiency of grade III hospitals (p < 0.01). However, the operating efficiency of grade II hospitals was significantly affected by POB and regional per capita GDP(GDPPC) (p < 0.05). Moreover, the impact of BOR and GDPPC was positive, and POB was negatively correlated with hospital operation efficiency.

Conclusions

The study results indicated that the overall operation efficiency of public hospitals in Fujian Province is low. This study revealed that intervention should be strengthened from a policy and management perspective to improve the operation efficiency of public hospitals.

An impact of economic slowdown on health. New evidence from 21 European countries

Background

The economic slowdown affects the population's health. Based on a social gradient concept, we usually assume that this detrimental impact results from a lower social status, joblessness, or other related factors. Although many researchers dealt with the relationship between economy and health, the findings are still inconsistent, primarily related to unemployment. This study reinvestigates a relationship between the economy's condition and health by decomposing it into macroeconomic indicators.

Methods

We use data for 21 European countries to estimate the panel models, covering the years 1995–2019. Dependent variables describe population health (objective measures – life expectancy for a newborn and 65 years old, healthy life expectancy, separately for male and female). The explanatory variables primarily represent GDP and other variables describing the public finance and health sectors.

Results

(1) the level of economic activity affects the population’s health – GDP stimulates the life expectancies positively; this finding is strongly statistically significant; (2) the unemployment rate also positively affects health; hence, increasing the unemployment rate is linked to better health – this effect is relatively short-term.

Conclusions

Social benefits or budgetary imbalance may play a protective role during an economic downturn.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13740-6.

Hospitals during economic crisis: a systematic review based on resilience system capacities framework

Background

Hospitals are the biggest users of the health system budgets. Policymakers are interested in improving hospital efficiency while maintaining their performance during the economic crisis. This study aims at analysing the hospitals’ policy solutions during the economic crisis using the resilience system capacities framework.

Method

This study is a systematic review. The search strategy was implemented on the Web of Science, PubMed, Embase, Scopus databases, and Econbiz search portal. Data were extracted and analysed through the comparative table of resilience system capacities framework and the World Health Organization (WHO) health system’s six building blocks (i.e., leadership and governance, service delivery, health workforce, health systems financing, health information systems, and medicines and equipment).

Findings

After the screening, 78 studies across 36 countries were reviewed. The economic crisis and adopted policies had a destructive effect on hospital contribution in achieving Universal Health Coverage (UHC). The short-term absorptive capacity policies were the most frequent policies against the economic crisis. Moreover, the least frequent and most effective policies were adaptive policies. Transformative policies mainly focused on moving from hospital-based to integrated and community-based services. The strength of primary care and community-based services, types and combination of hospital financing systems, hospital performance before the crisis, hospital managers’ competencies, and regional, specialties, and ownership differences between hospitals can affect the nature and success of adopted policies.

Conclusion

The focus of countries on short-term policies and undermining necessary contextual factors, prioritizing efficiency over quality, and ignoring the interrelation of policies compromised hospital contribution in UHC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08316-4.

Has China's Healthcare Reform Reduced the Number of Patients in Large General Hospitals?

Many studies have shown that the new round of healthcare reform launched by the Chinese government in 2009 has not effectively solved the problem in which patients more readily choose large general hospitals. We aimed to find out if this situation exists in every department of a large general hospital. This study collected the outpatient data of 24 departments for a large general hospital in Beijing. By calculating the average growth rate of outpatients in each department from 2014 to 2019, and the utilization rate of outpatient appointments in different departments in 2020, we found that the average growth rate of outpatients in 4 departments (16.6%) was negative, and the utilization rate of outpatient appointments in 13 departments (54.16%) was less than 80%. This shows that the number of patients in some departments is declining, and that there is an inefficient use of doctor resources. Obviously, this is inconsistent with people's current beliefs. Therefore, it is not entirely true that China's healthcare reform has not reduced the number of patients in large general hospitals. At the same time, the inefficient use of outpatient doctor resources is a phenomenon worthy of attention; if it persists, it will result in significant waste in the healthcare system. We suggest that policy makers and hospital managers in China, and countries similar to China, can attract attention and take measures.

A multi-stakeholder perspective on sustainable healthcare: From 2030 onwards

Over the past years, the interest in sustainable healthcare has been growing globally and the transition toward environmentally, economically and socially viable health systems is perceived as inevitable and necessary. All the approaches to this emerging field are mainly focusing on short-term specific issues and involving a limited number of stakeholders. This study aimed to address the topic of the possible futures of sustainable healthcare from a multi-stakeholder perspective, in order to define a long-term scenario and the key strategies to enhance this transition. A series of workshops have involved a representative selection of stakeholders based in Nordic countries and concerned with sustainable healthcare (health industries, health providers, managing authorities, universities and research centres, clusters, NGOs and healthcare networks, professional consortia) through a collaborative foresight process. A design-based approach has been adopted to investigate the current scenario and deepen foresight outcomes. The results highlighted three different horizons and the drivers to reshape the roles of individual stakeholders, enhancing the socio-technical transition towards a desirable scenario based on collaboration between distributed dynamic networks. The identified transition strategies move from the local to the international level, focusing on innovation, information and collaboration between stakeholders. This study provides the framework for future studies to deepen the transition process towards sustainable healthcare and its implications at Nordics, European and international levels.

Profile of general hospitals in the Unified Health System

OBJECTIVE To characterize the organization of Brazilian general hospitals that provide services to the Unified Health System using indicators that describe the main dimensions of hospital care. METHODS A 2015 cross-sectional observational study, comprising the range of general hospitals that serve the Unified Health System. We constructed the hospital indicators from two national administrative databases: the National Registry of Health Facilities and the Hospital Information System of the Unified Health System. The indicators include the main dimensions associated with hospital care: public-private mix, production, production factors, performance, quality, case-mix and geographic coverage. Latent class analysis of indicators with bootstrapping was used to identify hospital profiles. RESULTS We identified three profiles, with hospital size being the variable with the highest degree of belonging. Small hospitals show low occupancy rates (21.36%) and high participation of hospitalizations that could have been solved with outpatient care, besides attending only medium complexity cases. They receive few non-residents, indicating that they are mainly dedicated to the local population. Medium-sized hospitals are more similar to small-sized ones: about 100% of the visits are of medium complexity, low occupancy rate (45.81%), high rate of hospitalizations for primary care sensitive conditions (17.10%) and relative importance in the healthcare provision of non-residents (26%). Large hospitals provide high complexity care, have an average occupancy rate of 64.73% and show greater geographical coverage. CONCLUSIONS The indicators point to three hospital profiles, characterized mainly by the production scale. Small hospitals show low performance, suggesting the need to reorganize hospital care provision, especially at the municipal level. The set of proposed indicators includes the main dimensions of hospital care, providing a tool that can help to plan and continuously monitor the hospital network of the Unified Health System.

Financial Performance of Public Hospitals: A Cross-Sectional Study among Polish Providers

There is growing evidence of a positive association between health care providers’ financial standing and the quality of care. In Poland, the instable financial situation and growing debt of public hospitals has been a source of concern for more than two decades now. The objectives of this paper were to compare the financial performance of public hospitals in Poland, depending on the ownership and organizational form; and analyze whether there is an association between financial performance and the chosen variables. We conducted a cross sectional study covering the whole population of public hospitals operating in 2018. The total number of included units was 805. The hospitals’ financial outcomes were measured by several variables; Spearman’s rank correlation was calculated, and a multivariable logistic regression model was performed. In 2018, the majority of public hospitals in Poland (52%) generated a gross loss, while 40% hospitals had overdue liabilities. There were statistically significant differences between hospital groups, with university hospitals and those owned by counties (local hospitals) being in the most disadvantageous situation. Additionally, corporatized public hospitals performed worse than those functioning in the classic legal form of independent health care units. Urgent actions are needed to measure and monitor the potential impact of financial performance on the quality of care.

Hospital reforms in 11 Central and Eastern European countries between 2008 and 2019: a comparative analysis

This paper aims to: (1) provide a brief overview of hospital sector characteristics in 11 Central and Eastern European countries (Bulgaria, Czech Republic, Estonia, Croatia, Latvia, Lithuania, Hungary, Poland, Romania, Slovakia, Slovenia); (2) compare recent (2008 - 2019) hospital reforms in these countries; and (3) identify common trends, success factors and challenges for reforms. Methods applied involved five stages: (1) a theoretical framework of hospital sector reforms was developed; (2) basic quantitative data characterizing hospital sectors were compared; (3) a scoping review was performed to identify an initial list of reforms per country; (4) the list was sent to national researchers who described the top three reforms based on a standardized questionnaire; (5) received questionnaires were analysed and validated with available literature. Results indicate that the scope of conducted reforms is very broad. Yet, reforms related to hospital sector governance and changes in purchasing and payment systems are much more frequent than reforms concerning relations with other providers. Most governance reforms aimed at transforming hospital infrastructure, improving financial management and/or improving quality of care, while purchasing and payment reforms focused on limiting hospital activities and/or on incentivising a shift to ambulatory/day care. Three common challenges included the lack of a comprehensive approach; unclear outcomes; and political influence. Given similar reform areas across countries, there is considerable potential for shared learning.

The 2017 reform of the hospital sector in Poland - The challenge of consistent design

Beginning in October 2017 a system of basic hospital service provision, popularly called the 'hospitals network' was implemented in Poland. It covered 594 hospitals out of a total number of approx. 920 operating in 2017. The regulation's official objectives were to: "(1) improve the organization of services delivered by hospitals; (2) improve access to hospital care; (3) optimize the number of specialist wards; (4) improve coordination of in- and out-patient care; (5) facilitate hospital management". The aim of this paper is to describe the background of the reform planning and its formal objectives, content and implementation process, as well as to assess the preliminary results and discuss the possible limitations and implications. Although the official term 'hospitals network' is used to describe the reform, in practice it does not involve an element of cooperation between hospitals. The regulation's main feature was changing the financing methods for a pre-defined scope of services (from per-case to global budget).The reform was planned and implemented on a rather ad-hoc basis while its major controversy is the lack of quality of care, health outcome and population health need measures in the network inclusion criteria. The assessment of the reform's impact on service provision requires long-term analysis and access to detailed quantitative data.

Using a GIS to support the spatial reorganization of outpatient care services delivery in Italy

BACKGROUND

Studying and measuring accessibility to care services has become a major concern for health care management, particularly since the global financial collapse. This study focuses on Tuscany, an Italian region, which is re-organizing its inpatient and outpatient systems in line with new government regulations. The principal aim of the paper is to illustrate the application of GIS methods with real-world scenarios to provide support to evidence-based planning and resource allocation in healthcare.

METHODS

Spatial statistics and geographical analyses were used to provide health care policy makers with a real scenario of accessibility to outpatient clinics. Measures for a geographical potential spatial accessibility index using the two-step floating catchment area method for outpatient services in 2015 were calculated and used to simulate the rationalization and reorganization of outpatient services. Parameters including the distance to outpatient clinics and volumes of activity were taken into account.

RESULTS

The spatial accessibility index and the simulation of reorganization in outpatient care delivery are presented through three cases, which highlight three different managerial strategies. The results revealed the municipalities where health policy makers could consider a new spatial location, a shutdown or combining selected outpatient clinics while ensuring equitable access to services.

CONCLUSIONS

A GIS-based approach was designed to provide support to healthcare management and policy makers in defining evidence-based actions to guide the reorganization of a regional health care delivery system. The analysis provides an example of how GIS methods can be applied to an integrated framework of administrative health care and geographical data as a valuable instrument to improve the efficiency of healthcare service delivery, in relation to the population's needs.

The data on exploratory factor analysis of factors influencing employees effectiveness for responding to crisis in Iran military hospitals

The article presents the data on the exploratory analysis of factors involved in employees’ effectiveness for responding to crisis in Iran׳s military hospitals. This research was a descriptive exploratory study. The statistical population included the 561 medical and nonmedical staff of three military hospitals. Two researcher-made questionnaires were used to collect data, and reliability and validity of the questionnaires were confirmed. The exploratory factor analysis (EFA) method was used to classify, clarify, and explain study factors and the infrastructural structure. At the end, 473 questionnaires were found appropriate for the final analysis. Based on results of the exploratory factor analysis (EFA), 8 criteria were identified as the main factors involved in employees’ effectiveness for responding to crisis. According to Friedman test results, organizational factors were the most important factors influencing employees’ effectiveness with a mean score of 3.76 of 5. Responding to crisis was the most important variable factor involved response to crisis with a mean score of 3.74 of 5.

Impact of the doctor deficit on hospital management in Poland: A mixed-method study

OBJECTIVES

The primary objective was to assess the scale and consequences of the doctor deficit in Poland with the main focus on hospital care providers. To provide the background for the above, an analysis of the system level responses to the problem was also conducted.

DATA AND METHODS

A mixed-method approach was used. We triangulated data collected using 3 methods: (1) a literature review, (2) an analysis of the national statistical databases, and (3) in-depth interviews with hospital managers.

RESULTS

Poland is characterized by the lowest number of physicians per 1000 population in the European Union (2.3 in 2015). Also, the age structure of the doctor working population constitutes an alarming factor (in 2015, approx. 48% of all practicing doctors and 61% of specialists were above 50). In recent years, numerous hospitals were forced to cease provision of specific services and/or close wards due to the doctor deficit. The high competition in employing doctors and pressure for wage increases puts hospital managers in situations where they must often choose between securing service provision (by offering higher wages for doctors) and maintaining the hospital's positive financial outcome (by containing costs).

CONCLUSION

In Poland, the long-term neglect of health workforce planning at the system level (there is neither a dedicated structure nor a formal strategy) has contributed to the current doctor deficit crisis. From the hospital managers' perspective, who are on the frontline of the problem impact, urgent solutions are needed that would at least alleviate its scale in the short term.

Exploring home care nurses' perceptions regarding their services in economic crisis: A qualitative approach

This article explores the home care nurses' perceptions on the services they provide in Cyprus, which has been hit by a financial crisis. Semistructured interviews were conducted in Greek at the home care nurses' offices. Data were analyzed using qualitative content analysis. The participants' perceptions are described in terms of provision of home care nursing, administration of homecare nursing, job satisfaction, financial issues, and suggesting improvements. The financial crisis influences the home care services with regard to workload increase, staff shortage, and lack of resources. Home care nurses are well engaged in the provision of proper services in order to address the patients' needs. However, the financial crisis has set obstacles in the provision of care.

Improving the forecasting of hospital services: A comparison between projections and actual utilization of hospital services

OBJECTIVES

To compare projected and observed hospital inpatient use in Belgium and to draw lessons from that comparison.

METHODS

In 2005, projections for hospital service use were generated up to 2015, based on demographic change, substitution from inpatient to day care, and, the evolution of the average length of stay (LOS). The accuracy of the forecasts was assessed by comparing projected and observed population size, admissions and inpatient days, average LOS and percentage change in case mix.

RESULTS

The demographic growth was underestimated. Overall, the baseline projection for hospital admissions was remarkably close to the observed figures but the underlying case mix diverged importantly. With substitution between inpatient and day care, the number of admissions was underestimated by 15%-40%. The number of days was projected to increase in every scenario, whereas a decreasing trend was observed mainly due to the faster decline in average LOS than projected.

CONCLUSION

Hospital capacity planning is an important component of evidence informed policymaking. Projection results benefit from a well-designed methodology: choice of forecast groups, estimation models, selection criteria, and a sensitivity analysis of the results. To cope with the dynamic and continuously evolving context in which hospitals operate, regular updates to incorporate new data and to reassess estimated trends should be an integral part of the projection framework.

Implementing health care reform: implications for performance of public hospitals in central Ethiopia

Background

Understanding the way health care reforms have succeeded or failed thus far would help policy makers cater continued reform efforts in the future and provides insight into possible levels of improvement in the health care system. This work aims to assess and describe the implications of health care reform on the performance of public hospitals in central Ethiopia.

Methods

A facility-based, cross-sectional study was carried out in five public hospitals with different operational characteristics that have been implementing health care reform in central Ethiopia. The reform documents were reviewed to assess the nature and targets of the reform for interpretive analysis. Adopting dimensions of health system performance as the theoretical framework, a self-administered questionnaire was developed. Consenting health care professionals who have been involved in the reform from inception to implementation filled the questionnaire. Cronbach’s alpha was measured to ensure internal consistency of the instrument. Descriptive statistics, weighted median score, χ², and Mann-Whitney U and Kruskal-Wallis tests were used for data analysis.

Result

s Despite implementation of the reform, the health care system in public hospitals was still fragmented as confirmed by 50% of respondents. Limited effects were reported in favour of quality (48%), access (50%), efficiency (51%), sustainability (53%), and equity (61%) of care, while poor effects were reported in patient-provider (41%) and provider-management (32%) interactions. Though there was substantial gain in infrastructure and workspace, stewardship of health care resources was less benefited. The predominant hindrances of the reform were the working environment (adjusted Odds Ratio (aOR) = 2.27, 95% confidence interval (CI): 1.15-4.47), financial resources (aOR = 3.54, 95%CI = 1.97-6.33), management (aOR = 2.27, 95% CI = 1.15-4.47), and information technology system (aOR = 3.15, 95% CI = 1.57-6.32).

Conclusion

s The Ethiopian health care reform has laid the groundwork for health system improvement, but progress was slow and the health care delivery system was still fragile. Healthcare reform efforts in such settings are feasible, but with regular mapping of programmatic outcomes and bringing a common understanding of the reform among stakeholders.

Building hospital capacity planning mechanisms in Poland: The impact of 2016/2017 regulatory changes

Capacity planning is a crucial component of modern health care governance. The aim of this paper is to analyze the requirements that need to be met to build effective hospital capacity planning mechanisms in Poland. In this context, the recent regulatory changes strongly influencing hospital sector functioning, including introduction of health care needs maps, capital investment assessment, and hospital network regulations, are analyzed. Some possible ways forward, based on review of international experiences in hospital capacity planning, are discussed. Applied methods include literature review and analysis of statistical data as well as desk analysis of key national regulations related to hospital sector. Results indicate that at the system level, the process of capacity planning involves 4 elements: capital investment in facilities, equipment, and technology; service delivery; allocation of staff; and financial resources. For hospital capacity planning to be effective, the strategic decision at the macrolevel must be complemented by appropriate management of individual hospitals. The major challenge of building hospital capacity planning mechanism in Poland is imbedding it into the overall health system strategy. Because of the lack of such a strategy, the practical implementation of the ad hoc changes, which have been introduced, shows some inconsistencies. The regulations implemented between 2016 and 2017 provided a basis for hospital capacity planning, yet still need evaluation and adjustments. Also, including a mechanism for human resources planning is of crucial importance. The regulations should provide incentives for reducing oversized hospital infrastructure with simultaneous development of the long-term and coordinated care models.

New hospital structure in the twenty-first century: the position of level III (tertiary) neurological and stroke care in a changing healthcare system

AIM

The determination of the necessary capacity and number of neurology wards of level III progressivity that can be defined in the system of criteria detailed in this article and which possess optimal operating conditions in Hungarian terms.

METHODS

We used the National Health Insurance Company's database to calculate case numbers and capacity for different levels of neurological and stroke care. We also revised the allocation of advanced diagnostic and therapeutic technologies, and proposed changes, based on health insurance data. We also discussed these propositions with clinical experts to test their viability.

RESULTS

We determined the adequate number of organisational units capable of providing special neurological healthcare services on the basis of the basic data of the Hungarian healthcare system, specifying this number as 6 instead of the current 11.

CONCLUSIONS

In our study, we have identified significant bias in the nationwide level of neurological and stroke care organisation, which needs revised allocation of healthcare resources. Naturally, this can only be carried out through the restructuring of the emergency care system and the expansion of pre-hospital care.

The changing trends and outcomes in renal replacement therapy: data from the ERA-EDTA Registry

BACKGROUND

This study examines the time trends in incidence, prevalence, patient and kidney allograft survival and causes of death (COD) in patients receiving renal replacement therapy (RRT) in Europe.

METHODS

Eighteen national or regional renal registries providing data to the European Renal Association-European Dialysis and Transplant Association Registry between 1998 and 2011 were included. Incidence and prevalence time trends between 2001 and 2011 were studied with Joinpoint and Poisson regression. Patient and kidney allograft survival and COD between 1998 and 2011 were analysed using Kaplan-Meier and competing risk methods and Cox regression.

RESULTS

From 2001 to 2008, the adjusted incidence of RRT rose by 1.1% (95% CI: 0.6, 1.7) annually to 131 per million population (pmp). During 2008-2011, the adjusted incidence fell by 2.2% (95% CI: -4.2, -0.2) annually to 125 pmp. This decline occurred predominantly in patients aged 45-64 years, 65-74 years and in the primary renal diseases diabetes mellitus type 1 and 2, renovascular disease and glomerulonephritis. Between 2001 and 2011, the overall adjusted prevalence increased from 724 to 1032 pmp (+3.3% annually, 95% CI: 2.8, 3.8). The adjusted 5-year patient survival on RRT improved between 1998-2002 and 2003-2007 [adjusted hazard ratio (HRa) 0.85, 95% CI: 0.84, 0.86]. Comparing these time periods, the risk of cardiovascular deaths fell by 25% (HRa 0.75, 95% CI: 0.74, 0.77). However the risk of malignant death rose by 9% (HRa 1.09, 95% CI: 1.03, 1.16) in patients ≥65 years.

CONCLUSION

This European study shows a declining RRT incidence, particularly in patients aged 45-64 years, 65-74 years and secondary to diabetic nephropathy. Encouragingly, the adjusted RRT patient survival continues to improve. The risk of cardiovascular death has decreased, though the risk of death from malignancy has increased in the older population.

Dysmorphology services: a snapshot of current practices and a vision for the future

Dysmorphology concerns the recognition and management of rare, multiple anomaly syndromes. Genomic technologies and software for gestalt recognition will re-shape dysmorphology services. In order to reflect on a model of the service in the post-genomic era, we compared the utility of dysmorphology consultations in two Mediterranean cities, Athens, Greece and Afula, Israel (MDS), the Manchester Centre for Genomic Medicine, a UK service with dysmorphology expertise (UKDS) and the DYSCERNE, digital service (DDS). We show that it is more likely that chromosome microarray analysis will be performed if suggested in the UKDS rather than in the MDS; this, most probably reflects the difference of access to genetic testing following funding limitations in the MDS. We also show that in terms of achieved diagnosis, the first visit to a dysmorphology clinic is more significant than a follow-up. We show that a confirmed syndrome diagnosis significantly decreases the requests for other, non-genetic, laboratory investigations. Conversely, it increases the requests for reviews by other specialists and, most significantly (t-test: 8.244), it increases further requests for screening for possible associated complications. This is the first demonstration of the demands, on a health service, following the diagnosis of a dysmorphic condition.