After acute hospital therapy of myocardial infarction or bypass surgery the patient in Germany will be treated using an inpatient rehabilitation programme for 3-4 weeks. One year later only 10% of them are still active in outpatients groups. In our study 61 cardiac patients performed an one-year outpatient rehabilitation (instead of 4 weeks inpatient) programme with intense supervised exercise and behaviour therapy. The money input per patient was the same for the usual care 4 weeks inpatient (6000 DM) as for 1 year outpatient rehabilitation (5800 DM). The exercise capacity per heart rate-blood pressure-product was increased by 43% (p > 0.01) after 12 months. The maximum exercise capacity was reached in the 57th week. Without increased medical treatment, cholesterol and LDL-cholesterol were reduced after 12 months by 3.9% down to 195 +/- 25 mg/dl or by 6.6% down to 122 +/- 21 mg/dl, respectively (n.s.). HDL-cholesterol increased by 2.8% to 48 +/- 8 mg/dl (n.s.). This study shows results similar to outpatient rehabilitation programmes in the United States or in Sweden. The long intervention time and the intensity are main factors for the success of cardiac rehabilitation and patient health. Financial resources should primarily be concentrated on long-term outpatient rehabilitation programmes.
The problems concerning chronic heart failure can be summarized in 4 paradoxes which concern epidemiology, diagnosis, therapy, and financing respectively. Paradox I: The mortality due to chronic heart failure continues to increase worldwide despite a slow but significant decrease in mortality due to acute coronary syndromes. Paradox II: The clinical manifestations of chronic heart failure correlate poorly with the underlying pathophysiological progression. Paradox III: There is a striking discordance between the perception of evidence-based guidelines by the primary care physician and the actual reality in his/her private medical practice. Paradox IV: The inevitable increase in financial cost contrasts sharply with the many desperate attempts for cost reduction by the government. Solution: Heart Failure Clinic. Since the introduction of the first heart failure clinics in Sweden in 1990, numerous studies in various countries have emphasized the medical-cardiological and economical benefit of such organizations, mainly as a result of a substantial reduction of more than 40% in hospitalization. Moreover, a more central role is attributed to the primary care general practicioner.
The postnatal treatment with anti-D immunoglobulin to prevent rhesus sensitization is successful in about 90% of all rhesus-negative mothers at risk. Failures derive mostly from large fetomaternal hemorrhages during the last months of pregnancy. Studies from Canada, Great Britain and Sweden have shown that the injection of an additional dosage of anti-D during the 28th to 34th week of pregnancy results in a further 90% reduction of the failure rate. Although there is only a limited number of cases of hemolytic diseases in the newborn, the cost-effect ratio of this prophylactic treatment calculated for the Federal Republic of Germany shows not only a medical but also an economic benefit.
[Effect of medicamentous cholesterol control on resources utilization in public health--significance of the Scandinavian Simvastatin Survival Study (4-S Study) for cost control in Swiss health management conditions].
Upward spiralling health care expenditures have triggered the need to assess the cost-effectiveness of medical interventions. Specifically, interventions in primary and secondary prevention represent an important field of research. A resource utilization analysis was performed on the basis of the recently published Scandinavian Simvastatin Survival Study. It could be shown that treatment with simvastatin compared to placebo leads to a reduction in patient costs of CHF 8.4 million. This represents a reduction of CHF 3770.- per patient. The effective daily treatment costs can thus be calculated at CHF 1.11, which is equivalent to 36% of the actual acquisition cost per day. These results support the notion that secondary coronary prevention is not only justified from a clinical but also from an economic point of view.
Comment In: Schweiz Med Wochenschr. 1998 Jul 21;128(29-30):1150-19715503
Increase in the cost of medical care force us to adopt "medical rationalisation" instead of as previously "hospital rationalisation". This medical rationalisation constitutes a new, well-thought out way of putting questions about diagnosis, therapy and after-care. We must abandon the opinion that the prestige of a surgical department rests in the number of beds. Instead we must use other yardsticks such as the greater use of ambulant care, the shortest hospital stay for routine operations, the shortest preoperative waiting times and an increased operation frequency. Moreover, we need a diagnosis fixed from the start, a large enough operation capacity and sufficient possibilities for postoperative care, stringency in keeping agreed admittances and discharges as regards elective routine surgery and intimate co-operation between doctors, hospital economists, nursing staff and other experts.
Prioritisation of medical services in Sweden takes place on two different levels. On the national level, the Swedish priority guidelines ascribe priority values ranging from 1 (high priority) to 10 (low priority) to measures (in terms of condition-treatment pairs) of prevention, diagnosis, treatment and rehabilitation of cardiovascular diseases. In addition, this list contains interventions that should be avoided and those that should only be provided as part of clinical research projects. The government then commissions a multi-professional team under the supervision of the National Board of Health and Welfare "Socialstyelsen" with the development of corresponding guidelines. In addition to the scientific evidence, the priority lists incorporate ethical and economical aspects and are based on the so-called ethics platform consisting of human dignity, needs, solidarity and cost-effectiveness. At the other level of prioritisation there are regional projects aiming at the in- and exclusion of medical measures. The Swedish prioritisation process will be described using the example of priority lists in cardiology. (As supplied by publisher).