Transcript Titel Presentatie Lorem ipsum dolorem Mei 2013

Acute pain:
View of an administrator
Peter Fontaine
COO AZ Delta / CEO Stedelijk Ziekenhuis Roeselare
Importance of acute pain control in
hospitals
• Growing awareness and importance
•
•
•
•
Patient rights
Patient satisfaction
Accreditation
Pain measurement and guidelines
• Acute pain management practices in the Belgian
hospitals
• Financing: Legal initiatives – hospital budget
• Hospital budget: Financing of algological function
• Forfeit pharmacy
• Doctors fee for acute pain treatment
•
Reference amounts
• Impact of acute pain treatment for the hospital –
literature review
Patient rights
• Law on patient rights in Belgium – 22
augustus 2002
• Not directly referred to pain treatment
• Art. 5: “The patient has … the right on a high quality
service …”
• KB 24 November 2004 (BS 17-10-2005)
• New article 11 bis:
Art. 11bis. –Everyone should receive from the healthcare
professional the most appropriate care to prevent, have
attention to, evaluate, take into account, treat and heal
pain.
Acute pain control and patient satisfaction
• Flemish patient platform developed a patient satisfaction survey
• Flemish Agency for care and health – Flemish Quality indicator
project
• 2013 measurement: June and October
• At least 150 patients
• http://www.zorg-en-gezondheid.be/Beleid/Kwaliteit/vpp.html
• 2 questions regarding pain control – total 28
• Healthcare professionals regularly asked if I had pain
• My pain was kept well under control
Answer categories: never, sometimes, mostly and always
• Data delivered to TTP (trusted third party)
• Feedback
• Comparison between hospitals
Hospital Accreditation
• Broad movement in Flanders
• Flemish agency ends general audit (visitation) of hospitals
• Engagement to acquire a hospital accreditation within the next years
• Most hospitals opted for an accreditation by an
international agency: ISQua accredited
• NIAZ (Dutch agency for accreditation in Care)
• JCI: Join Commission international
• The accreditation standards stress the importance of
acute pain management in hospitals
• Directly referred to pain management (3)
• Indirectly referred to pain management (5)
Hospital Accreditation (JCI)
Standard PFR.2.4.
The organization supports the patient’s right to
appropriate assessment and management of pain
Intent of PFR.2.4.
Pain is a common part of the patient experience, and unrelieved pain has adverse physical
and psychological effects. A patient’s response to pain is frequently within the context of
societal norms and cultural and religious traditions. Thus, patients are encouraged and
supported in their reporting of pain. The organization’s care processes recognize and reflect
the right of all patients to appropriate assessment and management of pain. (Also see COP.6)
Measurable Elements of PFR.2.4.
❏ 1. The organization respects and supports the patient’s right to appropriate assessment
and management of pain. (Also see COP.7.1, ME 1)
❏ 2. The organization’s staff understand the personal, cultural, and societal influences on the
patient’s right to report pain and accurately assess and manage pain
Hospital Accreditation (JCI)
Standard AOP.1.7.
All inpatients and outpatients are screened for pain and
assessed when pain is present
Intent of AOP.1.7.
During the initial assessment and during any reassessments, a screening procedure is used to identify
patients with pain. When pain is identified, the patient can be treated in the organization or referred for
treatment. The scope of treatment is based on the care setting and services provided.
When the patient is treated in the organization, a more comprehensive assessment is performed. This
assessment is appropriate to the patient’s age and measures pain intensity and quality, such as pain
character, frequency, location, and duration. This assessment is recorded in a way that facilitates regular
reassessment and follow-up according to criteria developed by the organization and the patient’s needs.
Measurable Elements of AOP. 1.7.
❏ 1. Patients are screened for pain. (Also see COP.6, ME 1)
❏ 2. When pain is identified from the initial screening exam, the patient is referred or the organization
performs a comprehensive assessment, appropriate to the patient’s age and measuring pain intensity
and quality, such as pain character, frequency, location, and duration.
❏ 3. The assessment is recorded in a way that facilitates regular reassessment and follow-up according
to criteria developed by the organization and the patient’s needs.
Hospital Accreditation (JCI)
Standard COP.6.
Patients are supported in managing pain effectively
Intent of COP.6.
Pain can be a common part of the patient experience; unrelieved pain has adverse physical and
psychological effects. The patient’s right to appropriate assessment and management of pain is
respected and supported (also see PFR.2.5, intent statement). Based on the scope of services provided,
the organization has processes to assess and to manage pain appropriately, including
a) identifying patients with pain during initial assessment and reassessments;
b) providing management of pain according to guidelines or protocols;
c) communicating with and educating patients and families about pain and symptom management in the
context of their personal, cultural, and religious beliefs (also see PFR.1.1, ME 1); and
d) educating health care practitioners about pain assessment and management. (Also see PFR.2.4)
Measurable Elements of COP.6.
o 1. Based on the scope of services provided, the organization has processes to identify patients in pain.
(Also see AOP.1.7, ME 1)
o 2. Patients in pain receive care according to pain management guidelines.
o 3. Based on the scope of services provided, the organization has processes to communicate with and
to educate patients and families about pain. (Also see PFE.4, ME 4)
o 4. Based on the scope of services provided, the organization has processes to educate staff about pain.
(Also see SQE.3, ME 1)
Hospital Accreditation (JCI)
Standard PFR.2.5.
The organization supports the patient’s right to respectful and compassionate care at the
end of life
To accomplish this, all staff members are made aware of patients’ unique needs at the end of life. These
needs include treatment of primary and secondary symptoms; pain management….
Standard AOP.1.2.
Each patient’s initial assessment(s) includes an evaluation of physical, psychological, social
and economic factors, including a physical examination of health history
The most important factors are that the assessments are complete and available (also see MCI.7, ME 2)
to those caring for the patient. (Also see AOP.1.7, ME 1, regarding pain assessments)
Standard AOP.1.8.
The organization conducts individualized initial assessment for special populations cared
for by the organization
Intent of AOP.1.8.
Patients with intense or chronic pain
Hospital Accreditation (JCI)
Standard COP.7.1.
Care of the dying patient optimizes his or her comfort and dignity
The organization ensures appropriate care of those in pain or dying by taking interventions to manage
pain and primary or secondary symptoms;
Standard PFE.4.
Patient and family education includes the following topics, related to the patient’s care: the
safe use of medications, the safe use of medical equipment, potential interactions between
medications and food, nutritional guidance, pain management and rehabilitation
techniques
The organization routinely provides education in areas that carry high risk to patients. Education
supports the return to previous functional levels and maintenance of optimal health.
The organization uses standardized materials and processes in educating patients on at least the
following topics:
…
• Pain management
Growing attention to pain management
• Starting systematic measurements
• Increasing attention by nurses (temporary)
Stedelijk ziekenhuis Roeselare
jan/11
okt/11
Review nursing record
Nursing records reviewed
?
51
Pain registration
44%
53%
No VAS Score
70%
53%
VAS Score
30%
47%
1X / 24 Hours
16%
20%
+1X / 24 hours
14%
27%
Patient satisfaction with pain
Interviewd patients
48
Satisfied with paintreatment
84%
96%
Enough attention to pain
83%
Changes in pain management
15%
Source: Kris Verbeke – Painnurse SZR
okt/12
61
36%
64%
36%
8%
28%
44
100%
84%
7%
Growing attention to pain management:
conclusions
• Right on pain management is part of the patients rights.
• Effective pain management and appropriate procedures
become essential to acquire an accreditation.
• Increasing attention by the hospital for measuring
performance on pain management.
• Pain management measures become part of broad
patient satisfaction questionnaires.
Actual practices acute pain management in
hospitals
• Get insight in actual pain management practices
in hospitals.
• Data sources = RIZIV data, DRG (RCM/MKG), 3M
Benchmark
• 2 main treatments options or combination
• Pharmaceuticals: Anesthetics and Analgetica
• Patient controlled pumps (PCEA – PCIA)
Actual practices acute pain management in
hospitals
• Analgesics consumption in hospitals: inpatient – inliers
Analgetics consumption (N02) in Pharmaceutical forfait - inliers hospitalisation
Discharge
Expenses
Average
Total expense in Total
% Analgetics
year
Admissions ATC N02
expense N02 forfeit all ATCs
average (N02)
2007
1 551 309 12 789 872
8,24
258 617 148
166,71
4,9%
2010
1 615 724 13 142 114
8,13
258 699 491
160,11
5,1%
4,2%
2,8%
-1,3%
0,032%
-4,0%
2,7%
• Analgesics consumption by Severity of illness – inliers/hosp
Analgetics consumption (N02) by severity of illness - inliers hospitalisation
Severity of
Expenses
Average
Total expense in Total
% Analgetics
illness
Admissions ATC N02
expense N01 forfeit all ATCs
average (N02)
Minor
695 950
3 981 639
5,72
44 132 666 63,41356
9,0%
Moderate
531 043
3 611 640
6,80
60 360 014 113,6631
6,0%
Major
213 264
2 726 221
12,78
60 704 037 284,6427
4,5%
Extreme
72 666
2 392 001
32,92
89 741 545 1234,99
2,7%
1 512 923 12 711 501
8,40
254 938 261
168,51
5,0%
Actual practices acute pain management in
hospitals
• The use of patient controlled pumps: inpatients
– PCEA: 202311
– PCIA: 202333
PCEA
Year
2003
2004
2005
2006
2007
2008
2009
2010
2011
Count
35 693
129 807
131 413
130 485
136 758
147 556
147 045
142 244
145 079
Expenses
1 718 330
6 321 645
6 415 169
6 487 491
6 915 431
7 588 025
7 764 584
7 709 395
7 926 770
PCIA
Avera
ge
48,1
48,7
48,8
49,7
50,6
51,4
52,8
54,2
54,6
Count
25 494
99 079
104 395
111 766
119 768
135 815
140 407
151 794
163 770
PCIA+PCEA**
Expenses Average Count Expenses
1 226 609
48,1 61 187 2 944 939
4 823 761
48,7 228 886 11 145 406
5 096 159
48,8 235 808 11 511 329
5 553 739
49,7 242 251 12 041 230
6 053 940
50,5 256 526 12 969 371
6 983 462
51,4 283 371 14 571 487
7 409 034
52,8 287 452 15 173 618
8 225 135
54,2 294 038 15 934 531
8 948 458
54,6 308 849 16 875 228
*Source: National MBDS data (MKG/RCM) by MDC selection of procedure DRGs
**Source: Besco database based on National invoice RIZIV data
Belgian surgical patients*
%
PCIA+ divided
Count PCEA by1,85
638 270 9,6%
5,2%
646 770 35,4%
19,1%
642 746 36,7%
19,8%
641 181 37,8%
20,4%
643 729 39,8%
21,5%
653 482 43,4%
23,4%
656 460 43,8%
23,7%
664 887 44,2%
23,9%
Top 30 DRGs with PCIA or PCEA*
DRG No
DRG302
DRG301
DRG540
DRG221
DRG304
DRG315
DRG314
DRG403
DRG313
DRG480
DRG310
DRG513
DRG519
DRG220
DRG120
DRG121
DRG442
DRG260
DRG364
DRG173
DRG321
DRG169
DRG510
DRG441
DRG227
DRG950
DRG308
DRG443
DRG363
DRG317
# visits # visits
Total # w/o PCEA
with
APR DRG 28 description
visits
or PCIA
PCEA
Knee Joint Replacement
6327
1856
2607
Hip Joint Replacement
7809
4606
1190
Cesarean Delivery
6434
3276
2010
Major Small & Large Bowel Procedures
4231
1611
1865
Dorsal & Lumbar Fusion Proc Except for Curvature of Back
3011
1036
428
Shoulder, Upper Arm & Forearm Procedures
11770
10102
857
Foot & Toe Procedures
4408
3171
816
Procedures for Obesity
3565
2748
56
Knee & Lower Leg Procedures Except Foot
7129
6312
381
Major Male Pelvic Procedures
1476
774
435
Intervertebral Disc Excision & Decompression
5065
4386
64
Uterine & Adnexa Procedures for Non-Malignancy Except Leiomyoma
4076
3476
226
Uterine & Adnexa Procedures For Leiomyoma
1391
925
182
Major Stomach, Esophageal & Duodenal Procedures
906
472
232
Major Respiratory & Chest Procedures
511
78
337
Other Respiratory & Chest Procedures
1000
630
229
Kidney & Urinary Tract Procedures for Malignancy
509
158
266
Major Pancreas, Liver & Shunt Procedures
411
128
233
Other Skin, Subcutaneous Tissue & Related Procedures
2529
2265
19
Other Vascular Procedures
6456
6192
159
Cervical Spinal Fusion & Other Back/Neck Proc Exc Disc Excis/Decomp
2143
1897
89
Major Thoracic & Abdominal Vascular Procedures
631
390
124
Pelvic Evisceration, Radical Hysterectectomy & Radical GYN Procs
523
291
149
Major Bladder Procedures
278
57
181
Hernia Procedures Except Inguinal, Femoral & Umbilical
1592
1371
76
Extensive Procedure Unrelated To Principal Diagnosis
826
608
80
Hip & Femur Procedures for Trauma Except Joint Replacement3044
2838
54
Kidney & Urinary Tract Procedures for Nonmalignancy
725
523
126
Breast Procedures Except Mastectomy
3614
3445
3
Tendon, Muscle & Other Soft Tissue Procedures
2220
2056
75
TOP 30 DRGs with PCEA or PCIA
94 610
67 678 13 549
# visits
N02 avg N02 avg
% PCIA /
with # PCIA
W/O
W
% (PCIA+PCEA
PCIA or PCEA pump € pump € PCIEA
)
1864
4471
14,3
14,3 70,7%
41,7%
2013
3203
20,5
15,2 41,0%
62,8%
1148
3158
10,7
11,9 49,1%
36,4%
755
2620
48,4
58,4 61,9%
28,8%
1547
1975
18,7
19,3 65,6%
78,3%
811
1668
9,6
13,6 14,2%
48,6%
421
1237
10,4
10,9 28,1%
34,0%
761
817
19,6
23,7 22,9%
93,1%
436
817
11,4
15,1 11,5%
53,4%
267
702
18,4
21,7 47,6%
38,0%
615
679
12,3
14,9 13,4%
90,6%
374
600
12,3
20,5 14,7%
62,3%
284
466
14,2
18,8 33,5%
60,9%
202
434
37,8
68,5 47,9%
46,5%
96
433
47,3
52,2 84,7%
22,2%
141
370
22,4
40,7 37,0%
38,1%
85
351
32,3
37,5 69,0%
24,2%
50
283
28,2
68,9 68,9%
17,7%
245
264
11,8
18,1 10,4%
92,8%
105
264
10,6
39,6 4,1%
39,8%
157
246
11,2
14,1 11,5%
63,8%
117
241
24,0
42,6 38,2%
48,5%
83
232
17,9
37,1 44,4%
35,8%
40
221
56,4
71,2 79,5%
18,1%
145
221
14,9
24,2 13,9%
65,6%
138
218
42,7
57,5 26,4%
63,3%
152
206
26,4
38,3 6,8%
73,8%
76
202
17,0
34,3 27,9%
37,6%
166
169
9,3
16,0 4,7%
98,2%
89
164
9,2
19,4 7,4%
54,3%
13 383 26 932
14,6
24,1 28,5%
49,7%
Source: calculated with cooperation of 3M on the 3M HIS Benchmark 2011 – inpatients - 45 hospitals
Actual practices acute pain management in
hospitals: Conclusions
• Increasing importance of inpatient analgesics
consumption (especially in less severe patients)
• Increasing use of pain pump in inpatients in hospitals –
estimated 25% of surgical patients
• Patients with pain pumps have a higher consumption of
analgesics (+9,5 €). (except DRGs knee and hip joint
replacement)
• Most common DRGs with use of pain pumps are
surgical DRGs with the highest use in joint replacement
Reimbursement of acute pain treatment in
hospital
• Financing
•
•
•
•
•
Measures taken for general funding of hospital pain teams
Global evolution in hospital reimbursement
Fee for service: doctor
Pharmaceutical Forfait (hospital)
Other financial elements
• Pain treatment – indirect impact on hospital
performance
• Scientific articles
Reimbursement acute pain treatment
in hospitals
• Funding of hospital pain teams
• Specific accreditations mostly for chronic pain
• Multidisciplinary reference centre for chronic pain (9 in Belgium:
third line)
• New 2013: Centre for treatment of chronic pain (36 in Belgium)
• Funds: 271.000 €/year
• Few specific measures for funding of acute pain
treatment in hospitals
• Cross funding from the hospital chronic pain centre e.g. pain
nurse
• Funding through nomenclature and pharmaceuticals forfait
Reimbursement acute pain treatment
in hospitals
• Funding of hospitals “structures”
• Acute pain?
• Algological function (2012: 73 hospitals): 25.000 €
• New 2013: Multidisciplinary algological team - every hospital
Goals:
o Preventing sub acute pain becomes chronic.
o Sensitization of healthcare professionals
o Education of healthcare professionals: detection and treatment of pain
o Implementing guidelines for chronic pain treatment on wards
o Contact point, …..
Budget:
o Doctor: 0,1 FTE + 0,01 FTE per additional 100 beds
o Nurse: 0,25 FTE + 0,1 FTE per additional 100 beds
o Psychologist: 025 FTE + 0,02 FTE per additional 100 beds
• 330 beds: 57.371 €
• 1213 beds: 127.830 €
General evolution in hospital
reimbursement
Financing of acute pain treatment
Cat. D. anesthesia
Placement of pain pumps
202322 (PCEA) - 202344 (PCIA)
Pharmaceuticals including
Anesthesia and analgesics
Pharmaceuticals: fixed budget by DRG
• Applicable for most pharmaceuticals in inpatients
– Since 2006
– Except Cat. D pharmaceuticals – at patients expense (some
anesthesia and analgesics)
– Pharmaceuticals outside forfait ATC N – ATC5-level
–
–
–
–
–
–
–
N03AF03 Rufinamide
N03AX03 Sultiame
N03AX17 Stiripentol
N04BA02 Lévodopa et inhibiteur de la decarboxylase
N04BB01 Amantadine
N07XX04 Acide hydroxybutyrique
N07XX06 Tétrabenazine
non-Category D anesthetics and analgesics covered by the
DRG-forfeit
Pharmaceuticals: fixed budget by DRG
• Pharmaceuticals used in pain pumps
 E.g. SZR PCEA
 Ropivacaine / Chirocaine – Cat D – At patients expense – local anesth.
(23,15€/32,27€)
 + Sulfentanyl – Cat A - Covered by forfeit (3,43 €)
 E.g. SZR PCIA
Diacetylmorfine = Heroïne = Raw material = at the pharmacy expense
(1,57€) – no reïmbursement
Dehydrobenzperidol – Cat D = at patients expense (N01AX01) (7,92€)
100 cc. Nacl = covered by forfeit (B05B01) (1,35€)
• Other Analgesics
– Covered by forfeit
– ASAP Per os
• Lower cost
• At patient expense
Evolution national budget pharmaceutical
forfait
25% paid on real cost basis
75% should be covered by forfait
DRG year National budget

Sum hospital
expenses
%
01/07/2006-30/06/2007
2003
258 863 000
341 698 121
75,8%
01/07/2007-30/06/2008
2004
260 845 000
352 963 104
73,9%
01/07/2008-30/06/2009
2005
247 898 000
346 013 602
71,6%
01/07/2009-30/06/2010
2006
228 393 232
321 966 814
70,9%
01/07/2010-30/06/2011
2007
219 026 010
312 669 179
70,1%
01/07/2011-30/06/2012
2008
199 022 556
319 521 169
62,3%
01/07/2012-30/06/2013
2009
180 872 007
336 836 623
53,7%
01/07/2013-30/06/2014
2010
172 865 150
315 387 570
54,8%
Systematic decreasing budget – not sufficient to cover expenses
Evolution national budget pharmaceutical
forfait
Pharmaceutical forfeit DRG 302 Severity 1
2008/2010 by ATC
2010 (fin 13-14)
APR
Patient
DRG Severity count
Expenses
302
1
19.465 2.281.442
302
2
13.901 1.935.453
302
3
2.115
758.644
302
4
261
368.709
35.742 5.344.247
Avg
expenses by
DRG / SI
117,21
139,23
358,70
1.412,68
149,5
2008 (fin 11-12)
25%
invoice
29,3
34,8
89,7
353,2
37,4
75%
corrected
Avg
forfait Patient
expenses by
(54,8%) count
Expenses
DRG / SI
64,2
16.240
1.982.393
122,07
76,3
13.143
1.875.626
142,71
196,6
2.773
773.690
279,01
774,1
313
403.672
1.289,69
81,9
32.469
5.035.382
155,1
25%
invoice
30,5
35,7
69,8
322,4
38,8
75%
corrected
forfait
(62,3%)
76,0
88,9
173,8
803,5
96,6
• Pharmaceutical budget by DRG eg APRDRG 302
 DRG/SI Forfeit increases by severity of illness
 The DRG/SI fixed amount after correction for the national budget is
lower than the real expenses – does not cover 75% of the average
national consumption.
Pharmaceutical forfeit DRG 302 Severity 1
2008/2010 by ATC
Pharmaceutical forfait for APR DRG 302 SI 1: joint and hip replacement. Evolution 2008 - 2010 by ATC.
Forfait Budget 2013-2014 (DRG year 2010)
ATC
A
B
C
D
G
H
J
M
N
R
S
V
Description
ATC 2
level
ATC2
Description
Patient
count
Alimentary tract and metabolism
19.465
Blood and blood forming organs
19.465
Cardiovascular sytem
19.465
Dermatologicals
19.465
Genito-urinary system
19.465
Systemic hormonal preperations
19.465
Antiinfectives for systemic use
19.465
Musulo-skeletal system
19.465
N01 Anesthetics
19.465
N02 Analgesics
19.465
N03 Antiepileptics
19.465
N04 Anti-parkinson drugs19.465
N05 Psycholeptics
19.465
N06 Psychoanaleptics 19.465
N07 Other nervous system
19.465
Nervous system
19.465
Respiratory System
19.465
Sensory System
19.465
Various
19.465
Avg
expenses
by DRG / SI
117,21
117,21
117,21
117,21
117,21
117,21
117,21
117,21
117,21
117,21
117,21
117,21
117,21
117,21
117,21
117,21
117,21
117,21
117,21
75%
Avg
25% corrected
Expenses expense
invoice
forfait
by ATC2
(54,8%)
57.048
1.061.382
41.300
226
986
14.170
281.367
117.421
396.811
273.067
1.804
887
9.156
6.463
428
688.617
11.932
2.272
4.300
2,93
54,53
2,12
0,01
0,05
0,73
14,46
6,03
20,39
14,03
0,09
0,05
0,47
0,33
0,02
35,38
0,61
0,12
0,22
0,73
13,63
0,53
0,00
0,01
0,18
3,61
1,51
5,10
3,51
0,02
0,01
0,12
0,08
0,01
8,84
0,15
0,03
0,06
29,30
1,6
29,9
1,2
0,0
0,0
0,4
7,9
3,3
11,2
7,7
0,1
0,0
0,3
0,2
0,0
19,4
0,3
0,1
0,1
64,22
Forfait Budget 2011-2012 (DRG year 2008)
Avg
75%
Patient expenses
Avg
25% corrected
Expenses
count by DRG /
expense invoice forfait
SI
(62,3%)
17.670
17.670
17.670
17.670
17.670
17.670
17.670
17.670
118,51
118,51
118,51
118,51
118,51
118,51
118,51
118,51
61.314
885.555
34.946
364
564
14.509
268.875
123.452
3,47
50,12
1,98
0,02
0,03
0,82
15,22
6,99
17.670
118,51
417.553
23,63
17.670
118,51
253.507
14,35
17.670
118,51
1.212
0,07
17.670
118,51
309
0,02
17.670
118,51
8.273
0,47
17.670
118,51
6.253
0,35
17.670
118,51
305
0,02
17.670
17.670
17.670
17.670
118,51
118,51
118,51
118,51
687.411
10.036
1.286
4.811
38,90
0,57
0,07
0,27
0,87
12,53
0,49
0,01
0,01
0,21
3,80
1,75
5,91
3,59
0,02
0,00
0,12
0,09
0,00
9,73
0,14
0,02
0,07
29,61
2,2
31,2
1,2
0,0
0,0
0,5
9,5
4,4
14,7
8,9
0,0
0,0
0,3
0,2
0,0
24,2
0,4
0,0
0,2
73,80
Nomenclature: fee for service
• Doctors payment for acute pain treatment:
– Doctors fee for placement and supervision of the pain pumps including the
used materials.
– Fee for service system: 2013 – 105,35 €
– Limit 2013: once per hospital stay
– Used materials at the expense of the doctors fee
• PCIA material cost 16,2 €
• PCEA material cost 13,7 €
• Reference amounts
• System to prevent overconsumption of physician fees for certain DRGs
• For certain nomenclature categories
• Clinical biology
• Radiology
• Technical supplies
• Art. 3 (except clinical biology), 7 (physiotherapy), 11 (special treatments), 20 (internal
medicine) and 22 (physiotherapy)
 No technical limit on the provision of article 12 : anesthesiology physician fees including
the use of pain pumps (PCIA – PCEA) – except possibility to invoice pain pumps once per
hospital stay
Other costs
• Investment cost pain pumps
– SZR: 265€/pump – 20 pumps
– Covered by the Hospital budget
– Budget for medical investments – loss generating
• E.g. SZR medical forfait – 294.000 € / year against +500.000 depreciation
• Nursing cost
– Follow up of pain, medication distribution, nursing record,..
– Nursing budget based on the number of justified beds (based on the casemix of the
hospital) and independent of pain treatment – based on DRG/SI national average length
of stay.
Financing: conclusions
• Reimbursement of acute pain treatment
– Pharmaceuticals
• At patients expense or
• Covered by hospital fixed amount by DRG
– Doctors: fee for service system – material costs at doctors expense
– Investment costs: covered within the fixed amount for medical investments (most
hospital have deficits on this budget)
– Follow up by ward nurse: budget by justified beds.
– Pain team: cross subsiding with chronic pain center
• Mixed signals
– Growing importance of acute pain treatment
<-> fixed and decreasing budgets for pharmaceuticals (including analgesics)
<-> investment and nursing costs should be covered by the actual
reimbursement
<-> no fixed reimbursement for the financing of an acute pain team
<-> no direct financial incentive for good acute pain management practices
Indirect financial effect for the hospital?
• Other indirect effects which could stimulate hospital
investment in acute pain treatment?
– Literature review
– Very few outcome research which relates acute pain treatment
to possible (financial) effects for the hospital e.g. reduction in
LOS, cost reduction,…
• Research
– Oriented towards the effect of acute pain team in a hospital
– Oriented towards patient outcomes
– Oriented towards (non-)economical hospital effects
Indirect financial effect for the hospital?
• Research oriented towards the effect of acute pain team in a
hospital,
– Mc Donnel A.:
- Acute pain teams in England: current provision and their role in
postoperative pain management. J. Adv. Nurs
“ The presence of an acute pain team was associated (p</= 0.05) with higher
estimates of patient controlled analgesia and epidural use, regular in-service
training, written guidelines and protocols, routine use of postoperative pain
measurement systems.”
- Acute pain teams and the management of postoperative pain. J Adv Nurs
“ There is insufficient robust research to assess the impact of APTs on
postoperative outcomes of adult patients or on the processes of postoperative
pain relief.”
Indirect financial effect for the hospital?
• Research oriented towards the effect of acute pain
management on patient outcomes.
– Liu and Wu. The effect of analgesic technique on postoperative patientreported outcomes including analgesia: a systematic review. Anesthesia and
analgesia. 2007.
• Objective: to investigate the effect of postoperative analgesia on non
conventional clinical outcomes e.g. patient reported outcomes such as quality of
life, postoperative quality of recovery and patient satisfaction.
• Conclusions:
– “Although there are data suggesting that improved postoperative analgesia
leads to better patient outcomes, there is insufficient evidence to support
subsequent improvements for inpatient-centered outcomes such as quality
of life and quality of recovery.”
– Of the 4 RCTs obtained from the literature, none showed any difference in
postoperative quality of recovery
– Modest reductions in pain scores do not necessarily equate to clinically
meaningful improved pain relief for the patient.
Indirect financial effect for the hospital?
• Research oriented towards the effect of acute pain
management on patient outcomes
– Wu and Fleisher. Outcomes research in regional anesthesia and analgesia.
Anesthesia and analgesia. 2000.
• Compares the effect of general anesthesia with regional anesthesia on patient
outcomes
• Specific findings for postoperative pain management
– “it is difficult to determine the effect of postoperative regional analgesia
per se on outcomes. In addition many studies do not measure pain both at
rest and with activity.”
– “regional anesthesia-analgesia may also provide economic benefits by
decreasing length of stay through control of postoperative pain…”
» Although postoperative pain per se is not an independent predictor of
inpatient length of stay, inadequate control of postoperative pain in
one of the leading reasons for readmission after ambulatory surgery.
– The quality of analgesia is an important outcome per se.
Indirect financial effect for the hospital?
• Research oriented - (non-)economical hospital effects.
– Sun, Dexter, Marcia. Can an acute pain service be cost effective? Anesthesia
and analgesia. 2010.
• Given the expense of an acute pain service: what are the incentives for hospitals
and anesthesiologists to participate?
• Findings
– Patient satisfaction with pain control is an important factor of many
measures of hospital quality. How well your pain was controlled was the
second most important variable correlated to whether a patient
recommended the hospital to someone.
– Research on the measures of costs for the hospital are incomplete
» E.g. total knee arthroplasty patients discharged home with a
continuous femoral nerve block had reduced hospital LOS and
associated costs end charges.
» Because stakeholders are likely to be interested in the net costs of
running an acute pain service, future studies should investigate how
pain manamgent affects total hospitalization and downstream costs.
Indirect financial effect for the hospital?
• Research oriented - (non-)economical hospital effects.
– Brooks et al. Effect of evidence-based acute pain management practices on
inpatient cost. Health Services Research. 2009.
• Randomized trial with control groups to estimate the effect of acute pain
management for patients hospitalized with hip fracture. 1.378 patients – 14
hospitals - United States.
• Total inpatient cost = dependent variable. Summative pain treatment index
score = independent variable.
• Findings
– The implementation of acute pain management practices cost on average
17,714 dollars to implement within a hospital but led to cost savings per
inpatient stay of more than 1.500 dollars. (p < 0.001)
– Increased nursing and treatment costs were offset by other cost reductions.
– Impact on length of stay: LOS in control group was 0.5 days longer (ns p =
0.055)
Indirect financial effect for the hospital?
• Research conclusions
– The presence of an acute pain team improves the acute pain
management in a hospital. The cost of such a team can be a
barrier.
– It is difficult to determine the effect of postoperative regional
analgesia per se on outcomes.
– Very few outcome research which relates acute pain treatment
to possible (financial) effects for the hospital e.g. reduction in
LOS, cost reduction,…
– Because of the lack of research on this topic: there is hardly no
evidence that acute pain management in a hospital is costeffective.
– There is evidence about the link between acute pain
management and patient satisfaction.
Overall conclusions
• As a hospital administrator we receive conflicting signals
– Growing importance of acute pain Management: Patient rights Accreditation – importance in patient satisfaction measures
– Growing use of acute pain treatment in hospitals (analgesia, pain pumps,..)
– Prevention and treatment of acute pain increases hospital costs.
• Doctors get a fee covering the treatment in the case of pain pumps
• The hospital gets paid for some but not all costs
– Pharmaceuticals in the forfeit: Forfeit decreases inclusive analgesics
– Additional treatment costs for hospital personnel e.g. nurses
(pharmaceuticals, pain registration, development of protocols,…)
– Financing multidisciplinary algological function (low budget – chronic
pain)
– No scientific evidence for indirect hospital savings because of the lack of
research
Overall conclusions
• Feels like pushing the accelerator AND the brake pedal.
• Pay for performance (P4P) as a solution instead of
structural reimbursement.
–
–
–
–
Little research found on this topic
Define outcome measures for good acute pain management in hospitals
Reward hospitals with good performance
This could mean that there is a future ROI for investment in acute pain
management in your hospital.