EinführungDie DRG-basierte Vergütung ist vom Gesetzgeber beschlossen worden, um ein wirksames Instrument zur Steigerung der Effizienz im stationären Krankenhausbereich zu erhalten. Wenig Kenntnis herrscht jedoch darüber, welche Langzeitfolgen die Anreize zur Steigerung der betrieblichen Effizienz auf die Versorgung der Bevölkerung haben. Zwei Sorgen werden häufig geäußert: Dies sind zum einen die Absenkung der Qualität, insbesondere die Entlassung der Patienten in einem instabilen Zustand,

ZusammenfassungDie Kosten der Schlaganfallbehandlung in Deutschland sind bisher nicht über prospektiv erhobene und unselektierte Daten untersucht worden. Zudem ist unbekannt, welche Kosten durch unterschiedliche Versorgungskonzepte entstehen. Die vorliegende Studie vergleicht erstmals die innerhalb eines Jahres entstehenden gesellschaftlichen Kosten bei Behandlung in 15 neurologischen Kliniken mit akuter Schlaganfallstation (Stroke Unit), 9 allgemein-neurologischen Kliniken und 6 internistischen Kliniken. Ausgewertet wurden die prospektiv zwischen 1998 und 1999 erhobenen Behandlungsdaten von 5192 Patienten mit akutem Schlaganfall. Durch Nachbefragungen der Patienten nach 3 und 12 Monaten wurden auûerdem weitere stationäre Aufenthalte, ambulante Therapiemaûnahmen und Diagnostik sowie indirekte Kosten durch Arbeitsausfall erhoben. Die Fallkosten (Erlöse) wurden über die Pflegesätze der teilnehmenden Kliniken berechnet. Die Gesamtkosten der stationären Behandlung lagen durchschnittlich bei 16 320 DM (Neurologie mit Stroke Unit), 14 069 DM (Neurologie allgemein) und 14 923 DM (Innere Medizin). Im weiteren Verlauf nach Entlassung waren insbesondere ambulante Pflege und Therapiemaûnahmen kostenrelevant. Einen geringeren Kostenanteil trugen Hausarztbehandlungen, ambulante Diagnostik und Sekundärprophylaxe bei. Die indirekten Kosten des Arbeitsausfalls bei Erwerbstätigen lagen durchschnittlich bei 34 583 DM. Ohne Korrektur für die unterschiedlichen Patientenkollektive lagen die Gesamtkosten der Akutbehandlung in neurologischen Kliniken mit Stroke Unit ± bedingt durch höhere Pflegesätze bei kürzerer Verweildauer ± um 9 ± 16 % über denen der anderen untersuchten Versorgungstypen. Für gesundheitspolitische Entscheidungen sind jedoch auch die AbstractThe cost of stroke in Germany have so far not been investigated in terms of unselected and prospectively collected data. It is furthermore unknown how direct and indirect cost of stroke are affected by different types of stroke care. This study therefore compares the cost of stroke up to the first year in 15 departments of Neurology with an Acute Stroke Unit (ASU), 9 departments of General Neurology (GN) and 6 departments of Internal Medicine (IM). 5192 patients were prospectively documented according to an extensive manual during a one year period between 1998 and 1999 and collected in a common data bank. The patients were centrally followed-up via telephone interview after 3 and 12 months to assess further acute hospital and rehabilitation stays, out-patient resource utilization and indirect cost through loss of work force. The hospital cost were calculated via per-day and ward charges (proceeds) provided by each hospital. Mean overall cost for hospital treatment (including rehabilitation) amounted to 16 320 DEM for ASU, 14 069 DEM for GN and 14 023 DEM for IM. After discharge, especially nursing care and out-patient therapies were cost-relevant, while secondary preventive medication, out-patient physician care and out-patient diagnostic workups were less important. Mean cost ...

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Cost accounting has shown that the volume of tissue to be treated is the decisive factor in determining the cost of radioiodine therapy (RAITh). In the case of large goitres, the costs of excision (5.185 DM) and radioiodine therapy (5.562 DM) are, to a large extent, equivalent. Under the 1993 regulations for radiation protection, RAITh was cost-effective for treatment of toxic multinodular goitres up to volumes of 57 ml. However, new maximum permissible levels of radioactivity on discharge from hospital (250 MBq iodine-131 residual activity) have raised this threshold volume to 90 ml. In Germany, remuneration for a goitre resection is calculated from standard charges for total treatment without any consideration of the size and spectrum of medical services offered by different clinics, while remuneration for RAITh comes from payments for basic and specific, departmental medical services. University clinics with departments of nuclear medicine have relatively high basic costs. In the first quarter of 1998, the length of hospitalisation after RAITh (for all indications combined) was 4.6 days in university hospitals in Germany. Owing to this shorter length of hospitalisation, the payments received in some clinics fell far short of the total costs of this treatment calculated by cost accounting.

Coronary catheter revascularisation is less costly than bypass surgery due to lower direct (medical) and indirect costs (loss of work). Many studies show that the time patients stay out of work following coronary intervention is much longer than necessary. This leads to a considerable increase of indirect costs, which can far exceed the medical costs of the treatment. This prospective randomised study was done to determine whether specific information to patient and family doctor results in an earlier return to work. After catheter revascularisation 100 working patients (mean age 52.4 years) were randomised either to the intervention group (information to patient and family doctor) or to the control group (no specific information about return to work). Four months later 81 patients had returned to their previous jobs (mean sick leave 18.9 +/- 24.8 days) while 19 were still out of work. In the control group, the rate was 79% and the mean sick leave was 16.4 +/- 22.0 days (median 7); in the intervention group 83% had returned to work after a mean of 21.5 +/- 27.4 days (median 10). There was no significant difference between the two groups, neither according to the rate of returned workers nor to the duration of sick leave. In the subgroup of patients with a private insurance (23% of all) 96% started to work again (mean sick leave 5.7 +/- 5.1 days median 3.5), while the rate was 77% in the group of panel patients (mean sick leave 23.7 +/- 27.4 days, median 11). The difference in sick leave between these two groups was highly significant (p = 0.0003). Specific information to the patient and family doctor has no effect on the time patients stay out of work following catheter revascularisation. It seems that the observed delay depends on social and psychological factors that cannot be influenced directly.