RESUMEN
BACKGROUND: Heart failure management programmes have been shown to reduce re-hospitalizations. We recently investigated a new disease management programme comparing usual care (UC) to home-based nurse care (HNC) and a HNC group in which decision-making was based on NT-proBNP levels (BNC). As re-hospitalization is the main contributing economic factor in heart failure expenditures, we hypothesized that this programme might be able to reduce costs and could be conducted cost effectively compared to UC. METHODS: One hundred and ninety congestive heart failure patients, who were included in a randomized trial to receive UC, HNC or BNC at discharge, were analysed in a cost-effectiveness model. Different models were applied to perform analysis of all medical costs, and the costs per year survived were chosen as an effectiveness parameter. RESULTS: Per patient costs because of heart failure treatment in the UC and the BNC group were 7109 ± 11,687 and 2991 ± 4885 (P=0·027), respectively. Corrected for death as a competing risk, the costs in the UC group were 7893 ± 11,734 and were reduced by BNC to 3148 ± 4949 (P=0·012). Considering costs because of all-cause re-hospitalizations, calculated costs per year survived after discharge were 19,694 ± 26,754 for UC, 14,262 ± 25 330 for HNC (P > 0·05) and 8784 ± 14,728 for BNC (t-test-based contrast P=0·015). In all models calculated, HNC was cost neutral. CONCLUSIONS: NT-BNP-guided heart failure specialist care in addition to home-based nurse care is cost effective and cheaper than standard care, whereas HNC is cost neutral.
Asunto(s)
Insuficiencia Cardíaca/enfermería , Servicios de Atención de Salud a Domicilio/economía , Hospitalización/economía , Nivel de Atención/economía , Anciano , Anciano de 80 o más Años , Análisis de Varianza , Análisis Costo-Beneficio , Femenino , Insuficiencia Cardíaca/economía , Insuficiencia Cardíaca/terapia , Servicios de Atención de Salud a Domicilio/normas , Humanos , Masculino , Persona de Mediana Edad , Péptido Natriurético Encefálico , Atención de Enfermería/métodos , Nivel de Atención/normas , SuizaRESUMEN
High quality elective dental care for foreign patients was not exceptional in Hungary before the collapse of the old regime in 1989. Nevertheless, it became business as usual only in the new era thanks to the open state borders and the international competitive market environment. Unfortunately, no scientific study concerning this phenomenon has been conducted so far, however its professional and economic significance has been indicated by day-to-day experience. Additionally, the term "dental tourism" also used in international scientific papers became a commonplace in Hungary with unfavourable connotations. The present survey was the first to study this phenomenon by scientific standards in the most involved areas, namely in the capital city Budapest and in three counties in the Western Hungarian Region. Data collecting was performed by a self-reported questionnaire sent via conventional mail to all members of the Dental Section of the Hungarian Medical Chamber practicing in those indicated regions. Respond rates were 20.65% in Budapest and 25.34% in Western Hungary. The sample obtained this way, clearly indicated dimensions of cross-border patient migration and its economic significance as well. In Western Hungary 80.81% of foreign patients came from the neighbouring Austria and two out of ten practices realized 40 to 100% of their income out of this business. In Budapest foreign patients' nationality was more diversified. The largest group arrived from the United Kingdom (9.93%). Nevertheless the economic impact of dental tourism in Budapest is not relevant and outbalanced by a considerable domestic demand on the local private market.
Asunto(s)
Capitalismo , Atención Odontológica , Viaje , Austria , Comunismo , Atención Odontológica/economía , Atención Odontológica/estadística & datos numéricos , Humanos , Hungría , Encuestas y Cuestionarios , Reino UnidoRESUMEN
BACKGROUND: Although mental health care has undergone substantial re-structuring processes, little attention has been paid to financing issues during these processes. AIMS OF THE STUDY: In this paper the authors seek to examine distributional effects of systems of mental health care financing in the UK, Germany and Austria against the backdrop of ongoing reforms and broader welfare state transformations. METHOD: The article is based on secondary data on mental health care reform processes and financing arrangements. Distributional issues are studied a) on the macro-level related to the sectors 'state', 'market', 'family' and 'voluntary/community' and b) on the individual level. RESULTS AND DISCUSSION: In all of the three countries, shifts towards community care have resulted in a new division of financing responsibilities with a tendency to rising responsibilities for the 'family' and the 'voluntary/community sector'. In addition, strengthening market principles often increases financial burdens for affected individuals and/or their relatives. The study has been limited by the lack of precise data on resource allocation and expenditure for mental health care. IMPLICATIONS FOR HEALTH POLICIES, HEALTH CARE PROVISION AND USE: An increasing focus on the relationship between financing and service provision is required in order to prevent new forms of social exclusion of people with mental disorders. IMPLICATIONS FOR FURTHER RESEARCH: Further research needs to be carried out to increase transparency concerning the complex relationship between provision and the finance of mental health care. In terms of distributional impacts, it needs to be analysed in more detail which persons are affected in which ways. This particularly includes users as well as carers in the formal and informal sector.
Asunto(s)
Servicios Comunitarios de Salud Mental/economía , Planificación en Salud/economía , Trastornos Mentales/economía , Trastornos Mentales/terapia , Austria , Alemania , Humanos , Reino UnidoRESUMEN
BACKGROUND: In Austria, financing health care -and even more so mental health care- is characterized by a mix of federal and provincial responsibilities, lack of uniformity in service provision and service providers, and diverse funding arrangements. The division between financing structures for health care and social care makes the situation even more complex. This state of affairs results in various, partly counterproductive and sometimes paradoxical financial incentives and disincentives for the providers, recipients and financiers of mental health services. In several provinces of Austria, recent reform plans in mental health care have focused strongly on establishing community-based and patient-oriented mental health care. One of the main challenges in implementing this new policy is the re-allocation of resources. AIMS OF THE STUDY: The authors hypothesize that the existing structure of mental health care financing, with its incentives and disincentives, constitutes an obstacle to patient-oriented community-based mental health care. Analyzing the characteristics of the overall mental health care financing system in one Austrian province, Lower Austria, will provide a better understanding of actor-relationships and inherent incentives and highlight implications for the process of deinstitutionalization. METHOD: The authors used an analytical framework based on the principal-agent theory, empirical evidence, and information on financial, organizational and legal structures to identify the characteristics of actor-relationships and the position of single actors within the system. RESULTS: The article shows how incentives are linked to existing constellations of actors involved in mental health care financing and identifies significant power relations. As a consequence, incentives and disincentives within the financing system result in hospital- centered and supply-oriented mental health care in Lower Austria. DISCUSSION: The current system of financing mental health care provides an obstacle to the provision of patient-oriented and community-based mental care. This is due to existing constellations and power relations among the actors where, most importantly, patients are the weakest party in the patient-payer-provider triangle. Balancing power relations will be a significant prerequisite for alternative financing systems. IMPLICATIONS FOR HEALTH POLICIES AND FURTHER RESEARCH: If a community and needs-based mental health care system is to be established in Austria, the financing structures have to be changed accordingly. Applying a principal-agent framework is useful for identifying key aspects in mental health care financing in relation to the provision of services. Further research is needed to help develop alternative financing mechanisms that support community-based and patient-oriented mental health care systems.