Cost-effectiveness and Economic Benefit of Continuous Professional Development for Drug Prescribing: A Systematic Review

Importance

The economic impact of continuous professional development (CPD) education is incompletely understood.

Objective

To systematically identify and synthesize published research examining the costs associated with physician CPD for drug prescribing.

Evidence Review

MEDLINE, Embase, PsycInfo, and the Cochrane Database were searched from inception to April 23, 2020, for comparative studies that evaluated the cost of CPD focused on drug prescribing. Two reviewers independently screened all articles for inclusion and reviewed all included articles to extract data on participants, educational interventions, study designs, and outcomes (costs and effectiveness). Results were synthesized for educational costs, health care costs, and cost-effectiveness.

Findings

Of 3338 articles screened, 38 were included in this analysis. These studies included at least 15 659 health care professionals and 1 963 197 patients. Twelve studies reported on educational costs, ranging from $281 to $183 554 (median, $15 664). When economic outcomes were evaluated, 31 of 33 studies (94%) comparing CPD with no intervention found that CPD was associated with reduced health care costs (drug costs), ranging from $4731 to $6 912 000 (median, $79 373). Four studies found reduced drug costs for 1-on-1 outreach compared with other CPD approaches. Regarding cost-effectiveness, among 5 studies that compared CPD with no intervention, the incremental cost-effectiveness ratio for a 10% improvement in prescribing ranged from $15 390 to $437 027 to train all program participants. Four comparisons of alternative CPD approaches found that 1-on-1 educational outreach was more effective but more expensive than group education or mailed materials (incremental cost-effectiveness ratio, $18-$4105 per physician trained).

Conclusions and Relevance

In this systematic review, CPD for drug prescribing was associated with reduced health care (drug) costs. The educational costs and cost-effectiveness of CPD varied widely. Several CPD instructional approaches (including educational outreach) were more effective but more costly than comparators.

Commercial Interests in Continuing Medical Education: Where Do Electronic Health Record Vendors Fit?

The Accreditation Council for Continuing Medical Education (ACCME) will not accredit an organization that it defines as a commercial interest, that is an entity that produces, markets, resells, or distributes health care goods or services consumed by, or used on, patients. Thus, commercial interests are not eligible to be accredited organizations offering continuing medical education (CME) credit to physicians. This decision is based on the concern that commercial interests may use CME events to market their products or services to physicians, who then might inappropriately prescribe or administer those products or services to patients. Studies have shown that CME events supported by pharmaceutical companies, for example, have influenced physicians' prescribing behaviors.Currently, however, the ACCME does not recognize electronic health record (EHR) vendors, which are part of a multi-billion-dollar business, as commercial interests, and it accredits them to provide or directly influence CME events. Like pharmaceutical company-sponsored CME events, EHR vendor activities, which inherently only focus on use of the sponsoring vendor's EHR system despite its potential intrinsic limitations, can lead to physician reciprocity. Such events also may inappropriately influence EHR system purchases, upgrades, and implementation decisions. These actions can negatively influence patient safety and care. Thus, the authors of this Perspective call on the ACCME to recognize EHR vendors as commercial interests and remove them from the list of accredited CME providers.

Comparison of Continuing Medical Education at U.S. Medical Schools and Other Accredited Organizations: A 20-Year Analysis

PURPOSE

To describe a long-term overview of accredited continuing medical education (CME) at M.D.-granting medical schools in the United States.

METHOD

Self-reported data about type, duration, and numbers of learner participants of accredited CME activities and income for CME units from each medical school were compiled annually by the Accreditation Council for Continuing Medical Education (ACCME) between 1998 and 2017. Comparisons were made with data from all other ACCME-accredited organizations.

RESULTS

Between 1998 and 2017, medical schools represented 18%-19% of all ACCME-accredited organizations. CME activities, hours of instruction, learner participants, and income increased gradually until reaching the highest levels between 2008 and 2011 before remaining constant. In 2017, each school generated a median of 132 activities (interquartile range [IQR]: 66-266), of which 44% were courses and 31% were regularly scheduled series (RSS), and a median of 29,824 learner interactions (IQR: 8,464-46,255). Total income rose gradually until 2010 before declining. In 2017, each school reported a median annual income of $1.0 million (IQR: $0.2 million - $2.9 million) from CME activities, comprising 44% from registration fees, 39% from commercial support, and 14% from advertising and exhibits. Compared with other accredited organization types, medical schools generally developed more RSS activities and proportionally fewer interprofessional and online activities.

CONCLUSIONS

While medical schools represent less than 20% of all ACCME-accredited organizations, their role is pivotal and their influence far-reaching. For medical schools to fulfill their responsibility as education leaders, they need to prioritize support for CME offices and faculty development and implement new approaches to teaching and learning.

Pharmaceutical industry funding of events for healthcare professionals on non-vitamin K oral anticoagulants in Australia: an observational study

OBJECTIVES

To describe the nature, frequency and content of non-vitamin K oral anticoagulant (NOAC)-related events for healthcare professionals sponsored by the manufacturers of the NOACs in Australia. A secondary objective is to compare these data to the rate of dispensing of the NOACs in Australia.

DESIGN AND SETTING

This cross-sectional study examined consolidated data from publicly available Australian pharmaceutical industry transparency reports from October 2011 to September 2015 on NOAC-related educational events. Data from April 2011 to June 2016 on NOAC dispensing, subsidised under Australia's Pharmaceutical Benefits Scheme (PBS), were obtained from the Department of Health and the Department of Human Services.

MAIN OUTCOME MEASURES

Characteristics of NOAC-related educational events including costs (in Australian dollars, $A), numbers of events, information on healthcare professional attendees and content of events; and NOAC dispensing rates.

RESULTS

During the study period, there were 2797 NOAC-related events, costing manufacturers a total of $A10 578 745. Total expenditure for meals and beverages at all events was $A4 238 962. Events were predominantly attended by general practitioners (42%, 1174/2797), cardiologists (35%, 977/2797) and haematologists (23%, 635/2797). About 48% (1347/2797) of events were held in non-clinical settings, mainly restaurants, bars and cafes. Around 55% (1551/2797) of events consisted of either conferences, meetings or seminars. The analysis of the content presented at two events detected promotion of NOACs for unapproved indications, an emphasis on a favourable benefit/harm profile, and that all speakers had close ties with the manufacturers of the NOACs. Following PBS listings relevant to each NOAC, the numbers of events related to that NOAC and the prescribing of that NOAC increased.

CONCLUSIONS

Our findings suggest that the substantial investment in NOAC-related events made by four pharmaceutical companies had a promotional purpose. Healthcare professionals should seek independent information on newly subsidised medicines from, for example, government agencies or drug bulletins.

Cardiothoracic surgery training grants provide protected research time vital to the development of academic surgeons

BACKGROUND

The Ruth L. Kirschstein Institutional National Research Service Award (T32) provides institutions with financial support to prepare trainees for careers in academic medicine. In 1990, the Cardiac Surgery Branch of the National Heart, Lung and Blood Institute (NHLBI) was replaced by T32 training grants, which became crucial sources of funding for cardiothoracic (CT) surgical research. We hypothesized that T32 grants would be valuable for CT surgery training and yield significant publications and subsequent funding.

METHODS

Data on all trainees (past and present) supported by CT T32 grants at two institutions were obtained (T32), along with information on trainees from two similarly sized programs without CT T32 funding (Non-T32). Data collected were publicly available and included publications, funding, degrees, fellowships, and academic rank. Non-surgery residents and residents who did not pursue CT surgery were excluded.

RESULTS

Out of 76 T32 trainees and 294 Non-T32 trainees, data on 62 current trainees or current CT surgeons (T32: 42 vs Control: 20) were included. Trainees who were supported by a CT T32 grant were more likely to pursue CT surgery after residency (T32: 40% [30/76] vs Non-T32: 7% [20/294], P < .0001), publish manuscripts during residency years (P < .0001), obtain subsequent NIH funding (T32: 33% [7/21] vs Non-T32: 5% [1/20], P = .02), and pursue advanced fellowships (T32: 41% [9/22] vs Non-T32: 10% [2/20], P = .02).

CONCLUSIONS

T32 training grants supporting CT surgery research are vital to develop academic surgeons. These results support continued funding by the NHLBI to effectively develop and train the next generation of academic CT surgeons.

[Complications and costs in primary knee replacement surgery in an endoprosthetics centre : Influence of state of training]

BACKGROUND

This work examines the hypothesis that in endoprosthesis implantation there are differences between experienced primary and senior caregivers (S-Op) and less experienced follow-up assistants (T-Op) with respect to process-relevant parameters. The main hypothesis is that compared to S‑Op, T‑Op cause significantly longer surgery times and thus additional operating theatre costs. As sub-hypotheses, differences in various perioperative (p-o) parameters between T‑Op and S‑Op were examined.

MATERIALS AND METHODS

The status of the operator (senior and/or senior main operator [S-Op]) and/or postoperative CRP, perioperative blood loss, the amount of transfused erythrocyte concentrates, patient age, gender, ASA risk classification (American Society of Anesthesiologists), duration of surgery and blood transfusion, duration of inpatient stay, as well as the rates of early revision surgery and complications were recorded. A comparison of patients who had been operated by an S‑Op and those who had been operated by a T‑Op was made for all parameters.

RESULTS

Significant differences were found with respect to the duration of surgery, the duration of the hospital stay, and CRP on the third p‑o day. The T‑Op required an average of 11 min more than the S‑Op. CRP was significantly higher in the T‑Op group only on the third p‑o day, by 18 mg/l. In contrast, in the T‑Op group, a blood loss of 181 ml was lower than in the S‑Op group. This corresponded to a reduction of 0.26 transfused erythrocyte concentrates. There were no significant differences in complication rates between S‑Op and T‑Op.

DISCUSSION

In the setting of a certified endoprosthetics centre, the comparison of T‑Op with S‑Op showed that the use of the former with at a non-increased complication rate led to a significant extension of the operating time. This leads to additional training costs in the amount of an estimated 3% of the current DRG remuneration. These additional costs are not represented adequately in the current remuneration system.

Paediatric cardiopulmonary resuscitation training program in Latin-America: the RIBEPCI experience

BACKGROUND

To describe the design and to present the results of a paediatric and neonatal cardiopulmonary resuscitation (CPR) training program adapted to Latin-America.

METHODS

A paediatric CPR coordinated training project was set up in several Latin-American countries with the instructional and scientific support of the Spanish Group for Paediatric and Neonatal CPR. The program was divided into four phases: CPR training and preparation of instructors; training for instructors; supervised teaching; and independent teaching. Instructors from each country participated in the development of the next group in the following country. Paediatric Basic Life Support (BLS), Paediatric Intermediate (ILS) and Paediatric Advanced (ALS) courses were organized in each country adapted to local characteristics.

RESULTS

Five Paediatric Resuscitation groups were created sequentially in Honduras (2), Guatemala, Dominican Republican and Mexico. During 5 years, 6 instructors courses (94 students), 64 Paediatric BLS Courses (1409 students), 29 Paediatrics ILS courses (626 students) and 89 Paediatric ALS courses (1804 students) were given. At the end of the program all five groups are autonomous and organize their own instructor courses.

CONCLUSIONS

Training of autonomous Paediatric CPR groups with the collaboration and scientific assessment of an expert group is a good model program to develop Paediatric CPR training in low- and middle income countries. Participation of groups of different countries in the educational activities is an important method to establish a cooperation network.

[Conflict of interest in continuing medical education - Studies on certified CME courses]

OBJECTIVES

Although the problem of conflict of interest in medical education is discussed intensively, few valid data have been published on how to deal with the form, content, funding, sponsorship, and the influence of economic interests in continuing medical education (CME). Against this background, we carried out an analysis of data which had been documented for the purpose of certification by a German Medical Association. A central aim of the study was to obtain evidence of possible influences of economic interests on continuing medical education. Furthermore, strategies for quality assurance of CME contents and their implementation were to be examined.

METHODS

We analyzed all registration data for courses certified in the category D ("structured interactive CME via print media, online media and audiovisual media") by the Bavarian Chamber of Physicians in 2012. To measure the effects of conflict of interest, relationships between topics of training and variables relating to the alleged self-interest of the organizer/sponsor (for example, drug sales in a group of physicians) were statistically verified. These data were taken from the Bavarian Medical Statistics 2012 and the GKV-Arzneimittelschnellinformation.

RESULTS

In 2012, a total of 734 CME course offerings have been submitted for 51 medical specialties by 30 course suppliers in the Bavarian Medical Association. To ensure the neutrality of interests of the CME courses the course suppliers signed a cooperation treaty ensuring their compliance with defined behavior towards the Bavarian Medical Association concerning sponsorship. The correlation between course topics and drug data suggests that course suppliers tend to submit topics that are economically attractive to them. There was a significant correlation between the number of CME courses in a specific field and the sales from drug prescriptions issued by physicians in the respective field.

CONCLUSIONS

The results show that neutrality of interests regarding continuing medical education is difficult to achieve under the current framework for the organization, certification, and especially the funding of CME events in Germany. The cooperation agreement between the Bavarian Medical Association and training applicants is taken as an example of how legal certainty can be ensured. Based on the findings described below, suggestions and strategies to strengthen assessment expertise of course participants have been developed and elaborated.

Reducing the Use of H2-Receptor Antagonists in the Long-Term-Care Setting

OBJECTIVES

To examine the patterns of H2 blocker use in the long-term-care setting and to assess the effect of educational interventions designed to improve H2 blocker utilization patterns.

DESIGN

Time-series quasi-experimental study and retrospective chart review.

SETTING

A large academically-oriented long-term-care facility.

PATIENTS

Institutionalized elderly patients with a mean age of 88 years receiving H2 blocker therapy.

INTERVENTIONS

Two interventions involving group discussions with the medical staff, supporting educational materials, and physician-specific listings of patients receiving H2 blockers were employed sequentially over a 32-month period.

RESULTS

Each intervention resulted in substantial reductions in medication use (59.6% and 32.1%, respectively). Indications for H2 blocker use were determined retrospectively for patients identified as receiving therapy prior to the interventions (n = 110). Forty-one percent were found to be receiving therapy for reasons unsubstantiated by the medical literature. These patients were more likely to be discontinued from therapy than those receiving therapy for substantiated indications (P less than 0.01), consistent with the primary focus of the educational interventions.

CONCLUSIONS

These results suggest that the excessive use of H2 blocker therapy in the long-term care setting responds to educational interventions with therapeutically appropriate reductions in utilization. Repeated interventions are necessary to maintain such reductions over time although there may be some reduction in the effectiveness of the intervention with repetition.

The consequences of diminishing industry support on the independent education landscape: an evidence-based analysis of the perceived and realistic impact on professional development and patient care among oncologists

In recent years, commercial funding for continuing medical education (CME) has dropped significantly. Yet, little has been written about how this might affect CME in oncology, a field in which new drugs and advances emerge at a rapid pace. This study examines the role oncologists and oncology fellows say that CME plays in their ongoing professional development and their attitudes about the potential and realistic impact upon both the dissemination of medical information and the impact on patient care if commercial support were removed from CME. The study is based upon a national survey of 368 oncology clinicians (283 oncologists and 85 oncology fellows). Respondents indicated that CME is an important part of their ongoing professional development. The majority of oncologists (90%) and oncology fellows (78%) "agreed" or "strongly agreed" that commercial support may be more necessary for oncology than for other specialties due to the rate at which cancer therapies are introduced. Respondents felt loss of commercial support would impact cost, format, and availability of oncology CME programs. Half of oncologists thought eliminating commercial support for CME would have a negative impact on application of new therapies in oncology. Yet, both oncologists and oncology fellows were reluctant to claim the removal of commercial support would negatively affect the practice of evidence-based medicine, patient outcomes, or patient safety. A possible explanation of this apparent contradiction is found in the social sciences literature.

Organizational Change, Leadership, and the Transformation of Continuing Professional Development: Lessons Learned From the American College of Cardiology

There is a need for a transformational change in clinical education. In postgraduate medical education we have traditionally had a faculty-centric model. That is, faculty knew what needed to be taught and who were the best teachers to teach it. They built the agenda, and worked with staff to follow Accreditation Council for Continuing Medical Education (ACCME) accreditation criteria and manage logistics. Changes in the health care marketplace now demand a learner-centric model-one that embraces needs assessments, identification of practice gaps relative to competency, development of learning objectives, contemporary adult learning theory, novel delivery systems, and measurable outcomes. This article provides a case study of one medical specialty society's efforts to respond to this demand.

Cost-effectiveness of training rural providers to identify and treat patients at risk for fragility fractures

This is a cost-effectiveness analysis of training rural providers to identify and treat osteoporosis. Results showed a slight cost savings, increase in life years, increase in treatment rates, and decrease in fracture incidence. However, the results were sensitive to small differences in effectiveness, being cost-effective in 70 % of simulations during probabilistic sensitivity analysis.

INTRODUCTION

We evaluated the cost-effectiveness of training rural providers to identify and treat veterans at risk for fragility fractures relative to referring these patients to an urban medical center for specialist care. The model evaluated the impact of training on patient life years, quality-adjusted life years (QALYs), treatment rates, fracture incidence, and costs from the perspective of the Department of Veterans Affairs.

METHODS

We constructed a Markov microsimulation model to compare costs and outcomes of a hypothetical cohort of veterans seen by rural providers. Parameter estimates were derived from previously published studies, and we conducted one-way and probabilistic sensitivity analyses on the parameter inputs.

RESULTS

Base-case analysis showed that training resulted in no additional costs and an extra 0.083 life years (0.054 QALYs). Our model projected that as a result of training, more patients with osteoporosis would receive treatment (81.3 vs. 12.2 %), and all patients would have a lower incidence of fractures per 1,000 patient years (hip, 1.628 vs. 1.913; clinical vertebral, 0.566 vs. 1.037) when seen by a trained provider compared to an untrained provider. Results remained consistent in one-way sensitivity analysis and in probabilistic sensitivity analyses, training rural providers was cost-effective (less than $50,000/QALY) in 70 % of the simulations.

CONCLUSIONS

Training rural providers to identify and treat veterans at risk for fragility fractures has a potential to be cost-effective, but the results are sensitive to small differences in effectiveness. It appears that provider education alone is not enough to make a significant difference in fragility fracture rates among veterans.

Massive open online courses are relevant for postgraduate medical training

INTRODUCTION

The CanMEDS framework describes seven roles in postgraduate training, but training and courses relevant to these roles can be limited. Massive open online courses (MOOCs) - free online courses in which anyone can participate, anywhere - may improve course participation. This study investigates the relevance of MOOCs for postgraduate medical training within the CanMEDS framework.

MATERIAL AND METHODS

We extracted a list of all courses posted by the two largest MOOC providers, Coursera and EdX, and reviewed all course descriptions and categorised each course into one of three categories--"relevant," "possibly relevant" or "not relevant"--reflecting the degree of relevance to each of the seven CanMEDS roles. We also noted course workload, duration and the name of the educational institution.

RESULTS

We agreed the most on the role of health advocate (Cronbach's α = 0.85) and the least on the role of collaborator (Cronbach's α = 0.46). After a consensus-building process, 165 courses were found to be relevant or possibly relevant, mostly to the roles as scholar (n = 75) and medical expert (n = 57). The courses had a median duration of seven weeks and a median weekly workload of 4.5 hours, and were predominantly from North American universities.

CONCLUSION

A large number of MOOCs are relevant for postgraduate medical training. A weekly workload of 4.5 hours may enable course participation even for busy clinicians. Physicians should consider these free and universally available courses as relevant and potentially effective means of education.

FUNDING

not relevant.

TRIAL REGISTRATION

not relevant.

Estimating health care cost savings from an educational intervention to prevent bleeding-related complications: the outcomes impact analysis model

INTRODUCTION

Investments in continuing medical education (CME) exceed $2 billion annually, but few studies report the economic impact of CME activities. Analysis of patient-level economic outcomes data is often not feasible. Accordingly, we developed a model to illustrate estimation of the potential economic impact associated with CME activity outcomes.

METHODS

Outcomes impact analysis demonstrated how costs averted from a CME symposium that promoted prevention of bleeding-related complications (BRC) and reoperation for bleeding (RFB) in cardiac and thoracic operations could be estimated. Model parameter estimates were from published studies of costs associated with BRC and RFB. Operative volume estimates came from the Society of Thoracic Surgeons workforce data. The base case predicted 3 in 10 participants preventing one BRC or RFB in 2% or 1.5% of annual operations, respectively. Probabilistic sensitivity analysis (PSA) evaluated the effect of parameter uncertainty.

RESULTS

92% of participants (n = 133) self-reported commitment to change, a validated measure of behavior change. For BRC, estimates for costs averted were $1,502,769 (95% confidence interval [CI], $869,860-$2,359,068) for cardiac operations and $2,715,246 (95% CI, $1,590,308-$4,217,092) for thoracic operations. For RFB, the savings estimates were $2,233,988 (95% CI, $1,223,901-$3,648,719).

DISCUSSION

Our economic model demonstrates that application of CME-related learning to prevent bleeding complications may yield substantial cost savings. Model prediction of averted costs associated with CME allows estimation of the economic impact on outcomes in the absence of patient-level outcomes data related to CME activities.

Medical communication companies and industry grants

IMPORTANCE

Medical communication companies (MCCs) are among the most significant health care stakeholders, supported mainly by drug and device companies. How MCCs share or protect physicians' personal data requires greater transparency.

OBJECTIVE

To explore the financial relationships between MCCs and drug and device companies, to describe the characteristics of the large MCCs, and to explore whether they accurately represent themselves to physicians.

DESIGN

We combined data from the 2010 grant registries of 14 pharmaceutical and device companies; grouped recipients into categories such as MCCs, academic medical centers, disease-targeted advocacy organizations, and professional associations; and created a master list of 19,272 grants.

MAIN OUTCOMES AND MEASURES

Determine the distribution of funds from drug and device companies to various entities and assess the characteristics of large MCCs.

RESULTS

Of the 6493 recipients of more than $657 million grant awards from drug and device companies, 18 of 363 MCCs received 26%, academic medical centers received 21%, and disease-targeted organizations received 15%. For-profit MCCs received 77% of funds (208 of 363). Among the top 5% of MCCs, 14 of 18 were for-profit. All 18 offered continuing medical education: 14 offered live and 17 offered online CME courses. All required physicians to provide personal data. Ten stated that they shared information with unnamed third parties. Eight stated they did not share information, but almost all added exceptions. None required explicit physician consent to their sharing policies.

CONCLUSIONS AND RELEVANCE

Medical communication companies receive substantial support from drug and device companies. Physicians who interact with MCCs should be aware that all require personal data from the physician and some share these data with unnamed third parties.

Clinical, metabolic and psychological outcomes and treatment costs of a prospective randomized trial based on different educational strategies to improve diabetes care (PRODIACOR)

AIM

To evaluate the effect of system interventions (formalized data collection and 100% coverage of medications and supplies) combined with physician and/or patient education on therapeutic indicators and costs in Type 2 diabetes.

METHODS

This was a randomized 2 × 2 design in public health, social security or private prepaid primary care clinics in Corrientes, Argentina. Thirty-six general practitioners and 468 adults with Type 2 diabetes participated. Patients of nine participating physicians were selected randomly and assigned to one of four structured group education programmes (117 patients each): control (group 1), physician education (group 2), patient education (group 3), and both physician education and patient education (group 4), with identical system interventions in all four groups. Outcome measures included HbA(1c), BMI, blood pressure, fasting glucose, lipid profile, drug consumption, resource use and patient well-being at baseline and every 6 months up to 42 months.

RESULTS

HbA(1c) decreased significantly from 4 mmol/mol to 10 mmol/mol by 42 months (P < 0.05); the largest and more consistent decrease was in the groups where patients and physicians were educated. Blood pressure and triglycerides decreased significantly in all groups; the largest changes were recorded in the combined education group. The World Health Organization-5 Lowe score showed significant improvements, without differences among groups. The lowest treatment cost was seen in the combined education group.

CONCLUSIONS

In a primary care setting, educational interventions combined with comprehensive care coverage resulted in long-term improvement in clinical, metabolic and psychological outcomes at the best cost-effectiveness ratio.

Five un-easy pieces of pharmaceutical policy reform

Improper dependencies slant policy over a drug's life span, biasing the development of new drugs, the testing and marketing approval for new drugs, and the monitoring of patient safety after drugs are marketed. This article examines five ways in which the public improperly depends on pharmaceutical firms that compromise the integrity of pharmaceutical policy. Today the public relies on pharmaceutical firms: (1) to set priorities on drug research and development; (2) to conduct clinical trials to test whether drugs are safe and effective; (3) to decide what clinical trial data to disclose to the public; (4) to monitor post marketing drug safety; (5) to supply product information to physicians and to finance continuing medical education and other professional activities. The article suggests options to overcome each of these dependencies.

Strategy for the treatment of chronic leg wounds: a new model in Poland

AIM

The aim of the present study was to implement and evaluate a system of care for patients with chronic leg ulceration (CLU) in Poland.

METHODS

All patients within two defined geographical areas in Poland were identified for inclusion in the study. A model of care was developed based on guidelines, including the appropriate education of health professionals treating patients, access to non-invasive methods to determine the ulcer aetiology, compression therapy in those with proven venous ulceration.

RESULTS

In total 309 patients were identified with CLU at the start of the study (120 men, 189 women). Both regions had a similar profile of patients having a median (IQR) duration of ulceration of 96 (30-168) months. Most (75.7%) patients were assessed using clinical signs and symptoms alone, with a mean (SD) number of treatments per week at 1.8 (1.9) visits. Two years after implementation, the numbers of patients had reduced to 205 (86 men, 119 women) a reduction of 33%. Post implementation more patients were treated at home (49.3% versus 19.5%) with a corresponding reduction in those seen at health centres (35.6% versus 63.3%). The mean (SD) number of visits was reduced to 1.3 (0.7). During implementation the healing rate at 30 weeks improved from 73.3% to 82.9%, with a corresponding reduction in amputations from 6.3% to 2.1%. While the cost per patient was higher post-implementation, the overall cost of treating patients within the service reduced from €3847 to €2913 per week.

CONCLUSION

The development and implementation of an evidence based system of care for patients with CLU in Poland is both clinically and cost effective. This may be used as a model for other regions of Poland.

[Hospital cooperation models. Safeguarding optimized patient care, medical training and resource utilization]

INTRODUCTION

In the face of continuous medical progress on the one hand and the increasing cost pressure through the diagnosis-related groups (DRG) system with concomitant hospital privatization on the other, pioneering and economical models for modern and competent patient care are required.

METHODS

The cooperation model of the surgical department of the Heidelberg University Hospital is based on patient selection according to the grade of disease complexity and has been successfully developed in Heidelberg since 2005. The long-term results on the basis of actual proceeds are presented.

RESULTS

Cooperation with the Salem Hospital chaired by the director of the University surgical department has been ongoing for 6 years. General visceral surgery cases with low complexity are treated at the secondary cooperation hospitals whereas complex oncological operations of the esophagus, liver, pancreas, rectum or multivisceral resections and transplantations are performed at the University hospital. Optimal utilization of the operative and infrastructural resources of both cooperation partners lead to an improvement in surgical training and proceeds. Likewise, another cooperation with the secondary hospital in Sinsheim, which started 2 years ago, has shown similar positive results. Clinical rotation for surgical residents and attending surgeons guarantee a complete and competent surgical training in the field of general surgery.

CONCLUSIONS

The long-term results indicate that the cooperation model functions to achieve an optimized treatment of patients and an economical win-win situation for all cooperation partners by differential utilization of the available resources in the hospital network.