Current efforts and proposals to reduce healthcare costs in Serbia

Comprehensive Risk Analysis of Emergency Medical Response Systems in Serbian Healthcare: Assessing Systemic Vulnerabilities in Disaster Preparedness and Response

BACKGROUND/OBJECTIVES

Emergency Medical Response Systems (EMRSs) play a vital role in delivering medical aid during natural and man-made disasters. This quantitative research delves into the analysis of risk and effectiveness within Serbia's Emergency Medical Services (EMS), with a special emphasis on how work organization, resource distribution, and preparedness for mass casualty events contribute to overall disaster preparedness.

METHODS

The study was conducted using a questionnaire consisting of 7 sections and a total of 88 variables, distributed to and collected from 172 healthcare institutions (Public Health Centers and Hospitals). Statistical methods, including Pearson's correlation, multivariate regression analysis, and chi-square tests, were rigorously applied to analyze and interpret the data.

RESULTS

The results from the multivariate regression analysis revealed that the organization of working hours (β = 0.035) and shift work (β = 0.042) were significant predictors of EMS organization, explaining 1.9% of the variance (R2 = 0.019). Furthermore, shift work (β = -0.045) and working hours (β = -0.037) accounted for 2.0% of the variance in the number of EMS points performed (R2 = 0.020). Also, the availability of ambulance vehicles (β = 0.075) and financial resources (β = 0.033) explained 4.1% of the variance in mass casualty preparedness (R2 = 0.041). When it comes to service area coverage, the regression results suggest that none of the predictors were statistically significant. Based on Pearson's correlation results, there is a statistically significant correlation between the EMS organization and several key variables such as the number of EMS doctors (p = 0.000), emergency medicine specialists (p = 0.000), etc. Moreover, the Chi-square test results reveal statistically significant correlations between EMS organization and how EMS activities are conducted (p = 0.001), the number of activity locations (p = 0.005), and the structure of working hours (p = 0.001).

CONCLUSIONS

Additionally, the results underscore the necessity for increased financial support, standardized protocols, and enhanced intersectoral collaboration to strengthen Serbia's EMRS and improve overall disaster response effectiveness. Based on these findings, a clear roadmap is provided for policymakers, healthcare administrators, and EMS personnel to prioritize strategic interventions and build a robust emergency medical response system.

Pharmacoeconomic Analysis of the Different Therapeutic Approaches in Control of Bovine Mastitis: Phytotherapy and Antimicrobial Treatment

Mastitis in dairy cows is responsible for major economic losses on dairy farms worldwide as the most expensive and prevalent disease in dairy cattle. In spite of the fact that antibiotic therapy still remains the main treatment strategy for bovine mastitis, concerns about the shortcomings of this treatment approach are continuously raised. Hence, research on alternative treatments with increased effectiveness and reduced costs is needed. Therefore, we conducted a pharmacoeconomic analysis of conventional antibiotic vs. a proposed Phyto-Bomat treatment based on essential oils in bovine mastitis therapy. Treatments were compared from the farmer's perspective in the domain of costs (expressed in total, direct and indirect, cost differences) and effectiveness (expressed in daily milk yield differences). Economic calculations were based on data from a dairy farm in Serbia. The average cost of conventional antibiotic treatment was estimated at EUR 80.32 consisting of therapy costs, veterinary services and milk rejection costs at EUR 16.54, EUR 17.68 and EUR 46.10, respectively. The average cost of Phyto-Bomat treatment was estimated at EUR 76.34 with therapy costs of EUR 34.34, veterinary costs of EUR 32.00 and rejection of milk costs of only EUR 10.00. Therefore, Phyto-Bomat results in cost savings approximating EUR 4 per each mastitis episode with the highest cost reductions obtained in milk rejection costs. This estimation of Phyto-Bomat's economic benefits could be used as a starting point for the inclusion of this formulation as an alternative treatment approach with a focus on subclinical mastitis since it contributes to most of the financial losses.

A Global Assessment of Sustainable Development: Integrating Socioeconomic, Resource and Environmental Dimensions

Sustainable development and its assessment have increasingly played a key background role in government policymaking across the world. Generally, sustainable development is defined as the coordination of economic, environmental, and social development in order to balance intra-generational welfare and maximize inter-generational overall welfare. Therefore, the purpose of our research is to assess national sustainable development from the perspective of integrating economic, environmental, and social dimensions, and then to better monitor the status of sustainable development. We first adopt and modify the National Sustainable Development Index, which has been proposed as a way to amend the Human Development Index, including 12 indicators (weighted by the Entropy Method) in economic, environmental, and social dimensions. After that, we assess the sustainable development status of 179 countries from 2010 to 2016. The result shows that there is no obvious trend of narrowing the gap in sustainable development levels among countries, or even an expanding trend in this period. We also make a comparison between the original NSDI and our modified NSDI and find that the modified NSDI not only retains the merits but also makes up for the shortcomings of the original one in acceptability, reliability, and continuity.

The Global South political economy of health financing and spending landscape - history and presence

The Global South nations and their statehoods have presented a driving force of economic and social development through most of the written history of humankind. China and India have been traditionally accounted as the economic powerhouses of the past. In recent decades, we have witnessed reestablishment of the traditional world economic structure as per Agnus Maddison Project data. These profound changes have led to accelerated real GDP growth across many LMICs and emerging countries of the Global South. This evolution had a profound impact on an evolving health financing landscape. This review revealed hidden patterns and explained the driving forces behind the political economy of health spending in these vast world regions. The medical device and pharmaceutical industry play a crucial role in addressing the unmet medical needs of rising middle class citizens across Asia, Latin America, and Africa. Domestic manufacturing has only been partially meeting this ever rising demand for medical services and medicines. The rest was complemented by the participation of multinational pharmaceutical industry, whose focus on investment into East Asia and ASEAN nations remains part of long-term market access strategies. Understanding of the past remains essential for the development of successful health strategies for the present. Political economy has been driving the evolution of health financing landscape since the establishment of early modern health systems in these countries. Fiscal gaps these governments face in diverse ways might be partially overcome with the spreading of cost-effectiveness based decision-making and health technology assessment capacities. The considerable remaining challenges ranging from insufficient reimbursement rates, large out-of-pocket spending, and lengthy lag in the introduction of cutting-edge technologies such as monoclonal antibodies, biosimilars, or targeted oncology agents, might be partially resolved only in the long run.

Long-Term Effectiveness and Cost Effectiveness of Multiple Myeloma Treatment Strategies for Elderly Transplant-Ineligible Patients in Serbia

Introduction

Evidence on long-term effectiveness and cost effectiveness of treatment sequences for multiple myeloma (MM) is sparse. We used published data and country-specific data to assess the cost effectiveness of four-line treatment sequences for elderly transplant-ineligible patients with MM in Serbia.

Method

We developed a Markov cohort model to compare long-term effectiveness and cost effectiveness of five sequential MM treatment alternatives from the perspective of the national healthcare provider. Effectiveness parameters on progression, mortality and adverse events were extracted from published clinical trials. Costs were based on price lists of the National Health Insurance Fund. We compared life expectancy, costs, and incremental cost-effectiveness ratios among alternative courses of action. The model was analyzed over a lifelong time horizon applying a 3% annual discount rate for effectiveness outcomes and costs. Robustness of the model was tested in multiple deterministic sensitivity analyses.

Results

The sequences were defined by the frontline treatment: MPT (melphalan-prednisone-thalidomide), MPV (melphalanprednisone-bortezomib), CTD (cyclophosphamide-thalidomide-dexamethasone), VCD (bortezomib-cyclophosphamidedexamethasone) and BP (bendamustine-prednisone). MPV sequence resulted in the highest remaining life expectancy (4.76 life years). Cost-effectiveness analysis resulted in three non-dominated strategies: MPT, VCD, and MPV sequences, with an incremental cost-effectiveness ratio of EUR 35,300 per life-year gained (LYG) for VCD and EUR 47,200/LYG for MPV relative to MPT.

Conclusion

MPV sequence was the most effective in terms of life expectancy for elderly transplant-ineligible MM patients in Serbia. Bortezomib-based strategies would be recommended for the frontline treatment of patients with MM in Serbia if the willingness-to-pay threshold is around EUR 35,000-60,000/LYG.

BRICs Nations Growing Impact on the Global Health Sector

The most notable feature of the past five centuries of global economic history dating back from Colonial Age until the present accelerated globalization is the persistence of «North–South» division between the global rich and poor. This ground pattern has been falling apart over the last three decades with the rise of BRICs emerging economies (Brazil, Russia, India, China). The Chinese Belt and Road Initiative fosters further rapid growth and synergy among these large nations. This ambitious and historically unprecedented infrastructural project if successful can lead to a formation by 2049 of a huge common economic zone bringing opportunities for multilateral development to the BRICs. These profound changes have deep implications for the global health care sector. Previous research on health and pharmaceutical spending has clearly documented that low- and middle-income economies (LMICs), led by these emerging markets, have doubled their share in global health spending from roughly 20% up to approximately 40% in purchasing power parity terms. Alongside with these global developments, a decade ago, some of the leading Western academic centers, confirm new era of rising world’s geo-economic and geopolitical multipolarity. The world witnesses this process being accelerated today and seek deeper understanding how it will reflect on long term health and pharmaceutical expenditure trends, particularly in the leading BRICs emerging markets being a front runner of such evolution.

The authors declare absence of conflict of interests.

Dynamics of Health Care Financing and Spending in Serbia in the XXI Century

Serbia is an upper-middle income Eastern European economy. It has inherited system of health provision and financing, which is a mixture of Soviet Semashko and German Bismarck models. So far, literature evidence on long-term trends in health spending remains scarce on this region. Observational descriptive approach was utilized relying on nationwide aggregate data reported by the Republic Health Insurance Fund (RHIF) and the Government of Serbia to the WHO office. Consecutively, the WHO Global Health Expenditure Database was used. Long-term trends were extrapolated on existing data and underlying differences were analyzed and explained. The insight was provided across two distinctively different periods within 2000-2016. The first period lasted from 2000 till 2008 (the beginning of global recession triggered by Lehman Brothers' bankruptcy). This was a period of strong upward growth in ability to invest in health care. Spending grew significantly in terms of GDP share, national and per capita reported expenditures. During the second period (2009-2016), after the beginning of worldwide economic crisis, Serbia was affected in a way that its health expenditure growth in PPP terms slowed down effectively fluctuating around plateau values from 2014 to 2016. Serbia health spending showed promising signs of steady growth in its ability to invest in health care. Consolidation marked most of the past decade with certain growth rates in recent years (2017-2019), which were not captured in these official records. The future national strategy should be devised to take into account accelerated population aging as major driver of health spending.

The Amount of Weight Loss Six Months after Bariatric Surgery: It Makes a Difference

BACKGROUND

Bariatric surgery, especially Roux-en-Y gastric bypass (RYGB), has become the most frequently used therapy for morbid obesity.

OBJECTIVES

The aim of this study was to examine the effects of surgically induced weight loss on cardiopulmonary function 6 months after the procedure, as well as the effect of such an intervention on well-known risk factors for cardiovascular diseases.

METHODS

This is a cross-sectional study on 66 morbidly obese patients (BMI ≥40 or ≥35 kg/m2 with present comorbidities), comparing their cardiopulmonary function prior to and 6 months after RYGB surgery.

RESULTS

The substantial amount of weight loss (29.80 ± 13.27 kg) after RYGB surgery was associated with significant reduction of comorbidities, especially diabetes and sedentary lifestyle (p = 0.005 and p = 0.002, respectively). Regarding functional capacity, there was significant increase in peak oxygen uptake (VO2 peak, p = 0.003), duration of exercise testing, metabolic equivalents (exercise time and METs, p < 0.001), and in peak O2 pulse. These findings were particularly pronounced in a group of patients who had lost more than 18% of initial weight.

CONCLUSIONS

Reduction of body weight after RYGB surgery is associated with significantly improved cardiorespiratory function 6 months after surgery, especially in patients who lost more than 18% of their initial body weight. In addition, substantial decreases in body weight were also associated with a reduction of cardiovascular risk factors such as diabetes, smoking, hypertriglyceridemia, and sedentary lifestyle.

Public Health and the New Law of Public Health in Republic of Serbia

The new Law on Public Health was published in the Official Gazette of the Republic of Serbia No. 15 dated 25 February 2016. Comparing to the previous Law, the biggest changes have been made in the domain of monitoring the indicators of the environment and population health. The responsibility of controlling the quality and safety of food was given back to the Ministry of Health. This paper presents the principal regulations regarding the main functions, principals and organizational features of the public health system in Serbia.

Cold War Legacy in Public and Private Health Spending in Europe

Cold War Era (1946-1991) was marked by the presence of two distinctively different economic systems, namely the free-market (The Western ones) and central-planned (The Eastern ones) economies. The main goal of this study refers to the exploration of development pathways of Public and Private Health Expenditure in all of the countries of the European WHO Region. Based on the availability of fully comparable data from the National Health Accounts system, we adopted the 1995-2014 time horizon. All countries were divided into two groups: those defined in 1989 as free market economies and those defined as centrally-planned economies. We observed six major health expenditures: Total Health Expenditure (% of GDP), Total Health Expenditure (PPP unit), General government expenditure on health (PPP), Private expenditure on health (PPP), Social security funds (PPP) and Out-of-pocket expenditure (PPP). All of the numerical values used refer exclusively to per capita health spending. In a time-window from the middle of the 1990s towards recent years, total health expenditure was rising fast in both groups of countries. Expenditure on health % of GDP in both group of countries increased over time with the increase in the Free-market economies seen to be more rapid. The steeper level of total expenditure on health for the Free-market as of 1989 market economies, is due mainly to a steep increase in both the government and private expenditure on health relative to spending by centrally-planned economies as of the same date, with the out-of-pocket expenditure and the social security funds in the same market economies category following the same steepness. Variety of governments were leading Eastern European countries into their transitional health care reforms. We may confirm clear presence of obvious divergent upward trends in total governmental and private health expenditures between these two groups of countries over the past two decades. The degree of challenge to the fiscal sustainability of these health systems will have to be judged for each single nation, in line with its own local circumstances and perspectives.

Prescribing practices in Southeastern Europe - focus on benzodiazepine prescription at discharge from nine university psychiatric hospitals

There is much concern about the widespread long-term use of benzodiazepines. Our manuscript addressed its use in the region of Southeastern Europe, which seems extensive, but insufficiently explored. At nine university psychiatric hospitals (Croatia, Macedonia and Serbia), we retrospectively analyzed discharge summary documents to find the prevalence of discharge benzodiazepine prescriptions and the prescribed benzodiazepine doses. This study included 1047 adult subjects and showed that 81.9% of them had benzodiazepines prescribed in the discharge summary document, with high mean daily dose of around 5mg lorazepam equivalents. Factors associated with the prescriptions were exclusively clinical factors (diagnosis of schizophrenia spectrum disorders, more lifetime hospitalizations, psychiatric comorbidity, co-prescription of antidepressant or mood stabilizer, shorter duration of the hospitalization), while socio-demographic factors were not found to influence benzodiazepine discharge prescriptions. Similarly, factors which influenced the prescription of higher daily benzodiazepine dose were more lifetime psychiatric hospitalizations and co-prescription of antidepressant or mood stabilizer, as well as the diagnosis of mental/behavioral disorders due to substance use and co-prescribed antipsychotic. Our data are emphasizing an urgent need for guidelines and improved education of both health care professionals and patients, in order to prevent long term benzodiazepine (mis)use and related side-effects.

Within the triangle of healthcare legacies: comparing the performance of South-Eastern European health systems

OBJECTIVE

Inter-regional comparison of health-reform outcomes in south-eastern Europe (SEE).

METHODS

Macro-indicators were obtained from the WHO Health for All Database. Inter-regional comparison among post-Semashko, former Yugoslavia, and prior-1989-free-market SEE economies was conducted.

RESULTS

United Nations Development Program Human Development Index growth was strongest among prior-free-market SEE, followed by former Yugoslavia and post-Semashko. Policy cuts to hospital beds and nursing-staff capacities were highest in post-Semashko. Physician density increased the most in prior-free-market SEE. Length of hospital stay was reduced in most countries; frequency of outpatient visits and inpatient discharges doubled in prior-free-market SEE. Fertility rates fell for one third in Post-Semashko and prior-free-market SEE. Crude death rates slightly decreased in prior-free-market-SEE and post-Semashko, while growing in the former Yugoslavia region. Life expectancy increased by 4 years on average in all regions; prior-free-market SEE achieving the highest longevity. Childhood and maternal mortality rates decreased throughout SEE, while post-Semashko countries recorded the most progress.

CONCLUSIONS

Significant differences in healthcare resources and outcomes were observed among three historical health-policy legacies in south-eastern Europe. These different routes towards common goals created a golden opportunity for these economies to learn from each other.

The New and Old Europe: East-West Split in Pharmaceutical Spending

HIGHLIGHTS Since the geopolitical developments of 1989, former centrally planned economies of Eastern Europe followed distinctively different pathways in national pharmaceutical expenditure evolution as compared to their free market Western European counterparts.Long term spending on pharmaceuticals expressed as percentage of total health expenditure was falling in free market economies as of 1989. Back in early 1990s it was at higher levels in transitional Eastern European countries and actually continued to grow further.Public financing share of total pharmaceutical expenditure was steadily falling in most Central and Eastern European countries over the recent few decades. Opposed scenario were EU-15 countries which successfully increased their public funding of prescription medicines for the sake of their citizens.Pace of annual increase in per capita spending on medicines in PPP terms, was at least 20% faster in Eastern Europe compared to their Western counterparts. During the same years, CEE region was expanding their pharmaceuticals share of health spending in eight fold faster annual rate compared to the EU 15.Private and out-of-pocket expenditure became dominant in former socialist countries. Affordability issues coupled with growing income inequality in transitional economies will present a serious challenge to equitable provision and sustainable financing of pharmaceuticals in the long run.

Can didactic continuing education improve clinical decision making and reduce cost of quality? Evidence from a case study

INTRODUCTION

Administration of human serum albumin (HSA) solutions for the resuscitation of critically ill patients remains controversial. The objective of this study was to assess the effect of continuing medical education (CME) on health care professionals' clinical decision making with regard to HSA administration and the costs of quality (COQ). A quasi-experimental study of time series association of CME intervention with COQ and use of HSA solution was conducted at the Surgery Department of the Hospital Valjevo, Serbia. The CME contained evidence-based criteria for HSA solution administration in surgical patients. The preintervention period was defined as January 2009 to May 2011. CME was provided in June 2011, with the postintervention period June 2011 to May 2012.

METHODS

Total mortality rate, the rate of nonsurgical mortality, the rate of surgical mortality, the rate of sepsis patient mortality, index of irrational use of HSA solutions, and number of hospital days per hospitalized patient were collected for each month as quality indicators. Statistical analysis was performed by multivariate autoregressive integrated moving average (MARIMA) modeling. The specification of the COQ was performed according to a traditional COQ model.

RESULTS

The CME intervention resulted in an average monthly reduction of the hospital days per hospitalized patient, the rate of sepsis patient mortality, index of irrational use of HSA solutions, and COQ for $593,890.77 per year.

DISCUSSION

Didactic CME presenting evidence-based criteria for HSA administration was associated with improvements in clinical decisions and COQ. In addition, this study demonstrates that models combining MARIMA and traditional COQ models can be useful in the evaluation of CME interventions aimed at reducing COQ.

Community-acquired pneumonia: economics of inpatient medical care vis-à-vis clinical severity

OBJECTIVE

To assess the direct and indirect costs of diagnosing and treating community-acquired pneumonia (CAP), correlating those costs with CAP severity at diagnosis and identifying the major cost drivers.

METHODS

This was a prospective cost analysis study using bottom-up costing. Clinical severity and mortality risk were assessed with the pneumonia severity index (PSI) and the mental Confusion-Urea-Respiratory rate-Blood pressure-age ≥ 65 years (CURB-65) scale, respectively. The sample comprised 95 inpatients hospitalized for newly diagnosed CAP. The analysis was run from a societal perspective with a time horizon of one year.

RESULTS

Expressed as mean ± standard deviation, in Euros, the direct and indirect medical costs per CAP patient were 696 ± 531 and 410 ± 283, respectively, the total per-patient cost therefore being 1,106 ± 657. The combined budget impact of our patient cohort, in Euros, was 105,087 (66,109 and 38,979 in direct and indirect costs, respectively). The major cost drivers, in descending order, were the opportunity cost (lost productivity); diagnosis and treatment of comorbidities; and administration of medications, oxygen, and blood derivatives. The CURB-65 and PSI scores both correlated with the indirect costs of CAP treatment. The PSI score correlated positively with the overall frequency of use of health care services. Neither score showed any clear relationship with the direct costs of CAP treatment.

CONCLUSIONS

Clinical severity at admission appears to be unrelated to the costs of CAP treatment. This is mostly attributable to unwarranted hospital admission (or unnecessarily long hospital stays) in cases of mild pneumonia, as well as to over-prescription of antibiotics. Authorities should strive to improve adherence to guidelines and promote cost-effective prescribing practices among physicians in southeastern Europe.

LAT software induced savings on medical costs of alcohol addicts' care--results from a matched-pairs case-control study

Lesch Alcoholism Typology (LAT) is one of the most widely used clinical typologies of alcohol addiction. Study tested whether introduction of LAT software in clinical practice leaded to improved outcomes and reduced costs. Retrospective matched-pairs case-control cost comparison study was conducted at the Regional Addiction Center of the University Clinic in Serbia involving 250 patients during the four-year period. Mean relapse frequency followed by outpatient detoxification was 0.42 ± 0.90 vs. 0.70 ± 1.66 (LAT/non-LAT; p = 0.267). Adding relapses after inpatient treatment total mean-number of relapses per patient was 0.70 ± 1.74 vs. 0.97 ± 1.89 (LAT/non-LAT; p = 0.201). However, these relapse frequency differentials were not statistically significant. Total hospital costs of Psychiatry clinic based non-LAT addicts' care (€ 54,660) were significantly reduced to € 36,569 after initiation of LAT. Mean total cost per patient was reduced almost by half after initiation of LAT based treatment: € 331 ± 381 vs. € 626 ± 795 (LAT/non-LAT; p = 0.001). Mean cost of single psychiatry clinic admission among non-LAT treatment group was € 320 ± 330 (CI 95% 262-378) and among LAT € 197 ± 165 (CI 95% 168-226) (p = 0.019). Mean LAT software induced net savings on psychiatric care costs were € 144 per patient. Total net savings on hospital care including F10 associated somatic co-morbidities amounted to € 295 per patient. More sensitive diagnostic assessment and sub-type specific pharmacotherapy and psychotherapy following implementation of LAT software lead to significant savings on costs of hospital care.

Resource allocation strategies in Southeastern European health policy

The past 23 years of post-socialist restructuring of health system funding and management patterns has brought many changes to small Balkan markets, putting them under increasing pressure to keep pace with advancing globalization. Socioeconomic inequalities in healthcare access are still growing across the region. This uneven development is marked by the substantial difficulties encountered by local governments in delivering medical services to broad sectors of the population. This paper presents the results of a systematic review of the following evidence: published reports on health system reforms in the region commissioned by WHO, IMF, World Bank, OECD, European Commission; all available published evidence on health economics, funding, reimbursement in world/local languages since 1989 indexed at Medline, Excerpta Medica and Google Scholar; in depth analysis of official website data on medical care financing related legislation among key public institutions such as national Ministries of health, Health Insurance Funds, Professional Associations were applicable, in local languages; correspondence with key opinion leaders in the field in their respective communities. Contributors were asked to answer a particular set of questions related to the issue, thus enlightening fresh legislative developments and hidden patterns of policy maker's behavior. Cost awareness is slowly expanding in regional management, academic and industrial establishment. The study provides an exact and comprehensive description of its current extent and legislative framework. Western Balkans policy makers would profit substantially from health-economics-based decision-making to cope with increasing difficulties in funding and delivering medical care in emerging markets with a rapidly growing demand for health services.