I NTRODUCTION THE EVALUATION OF HOSPITAL SERVICES USING AFTER IMPLEMENTATION OF RESTRUCTURING MEASURES IN ROMANIA, MAY 2011 HOSPITAL MANAGEMENT

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1 THE EVALUATION OF HOSPITAL SERVICES USING AFTER IMPLEMENTATION OF RESTRUCTURING MEASURES IN ROMANIA, MAY 2011 Marius CIUTAN 1 MD Alin PREDA 1 - MD Nona Delia CHIRIAC 1 - MD, researcher Mihnea DOSIUS 1 - MD Prof. Cristian VLĂDESCU 1- MD 1 National School of Public Health, Management and Professional Development, Bucharest Hospital system in Romania is one of the most burdened hospital system in Europe. At least in theory, the restructuration decision of the hospital sector, which affected 13% of hospitals in Romania (66 hospitals) was conducted according to best practices (as contained in the reform plan, guidance and grounding decision by contributing experts: specialist committees, expert consultation etc. list of recommendations, objective, etc.). Currently, there are no signs that draw attention to imbalances caused by this implementation. One year after application of Governmental Decision, hospital activity decreased significantly (by 10%, both in terms of hospitalization days and number of hospitalization episodes) and the assumption that the remaining hospitals in the counties will be overloaded with patients is invalidated for this first year of evaluation. Time will determine if there is any negative impact, and that other political and strategic measures to be supported by other consistent measures [1] (Development of National, Regional and Local hospitals plans, reduction of hospital overcapacity for admission, classification and accreditation of hospitals, review of hospital financing and so on). Reconfiguration of the health system had been applied to smaller scale, and this decision proves to be necessary and also politically brave considering that is anti-popular. Weaknesses points are plenty and one of them would be the time to apply so radical measures, due to the gap in reforming other medical sectors, beside poor alignment of measures to reform the healthcare system as a whole. Keywords: assessment, hospitals, restructuring, Romania, access. I NTRODUCTION Hospital system in Romania is one of the most burdened hospital system in Europe, requiring coverage of a large number of hospitalizations episodes compared with other European countries (one of the highest rates of hospitalization: discharges/1000 inhabitans) and also having scarce resources, inefficiently allocated within the hospital system (about 200 Euro / capita for health, around 50% of National Health Indurance Fund is alocated for hospitals) [1]. On one hand the system bears the mark of historical heritage when public hospitals in Romania were placed in the center of administrative territory (territorial organization of medical units under the communist regime), and were organized and operated by Semashko model of health system organisation and by other hand, can be considered the central pawn of sacrifice for health reform in Romania after the `90. In this last period, although it was unanimously appreciated as the engine of medical field, hospital care was rather sacrificed at the expense of other sectors. Even though, in recent years, health reform included attempts to reform the hospital system, they either were represented only by changes in the functioning of hospital activity (no changes made to the needs of a correlation between structure and organization of the hospital), or were standby measures (cosmetic, replacements, reappointment to office, 3-year management contracts, managerial decentralization by which hospital management is carried out by local authorities) that proved absolutely mandatory and accompanied action reform of other levels of care (health reform focusing on reconfiguration and development of primary health care - especially in the early stages of health reform, privatization of medical offices for specialist and family doctors etc). One of the main reasons for the high number of admissions to hospitals in Romania can be attributed to the imbalance, outdated & uneven development levels of care. Thus, solving a small share of cases in the pre-hospital sector (family physicians, outpatient specialty clinics) led, inevitably, to a abnormal overuse of hospital beds, with negative financial implications and also in terms of accessibility to medical services. In turn, high consumption of hospital resources initiated a new cycle of unused resource throughout the entire healthcare system, this cycle determined the changing priorities of action due to lack of resources, a factor that was added to other barriers, including political instability that can be considered the main obstacle of health reform in Romania. 13

2 Box 1. Methodology for selection of units with beds that cannot sign contracts with the health insurance funds in 2012 Selection methodology According to Art. 2, of the Health Ministry Order establishing the selection of health units with beds that cannot contract with health insurance funds and for the approval of their selection criteria, objective criteria on which the selection committee (commission) proposes the list of health units with beds that cannot enter into contracts with health insurance funds for failure in one of these are: a) providing appropriate hospital services for the organizational structure approved by law, including their complexity; b) ensuring continuity of care with specialized persona, including on call doctors for all approved specialties; c) modeling criteria for the classification of hospitals according to their competence; d) distance to hospitals with a higher level of competence; e) Specialized medical staffing, according to law; f) accessibility of the population served in pre-hospital emergency medical services and medical transportation; g) accessibility of the population served by specialized health services at the county level; h) the uniqueness of the health unit at county / regional level; i) legal and physical state of the properties operating in the health unit; j) other criteria identified by the Commission. During discussions and analyzes in the panel showed that for most hospitals with over 130 beds these criteria are met. Accordingly, the Commission examined, in particular, health care facilities with fewer than 130 beds. To this provision was further discussed Caritas Hospital, where there is a specific proposal from the Bucharest General City Hall, because the property is given back to the owner in title. Were considered primarily: organizational structure approved by the Minister of Health, the latest data on human resources, especially time coverage, functionality and number of on- line doctors, complexity of the cases treated by the units financed through DRG system, revealed by the Case Mix Index (CMI). Also was analyzed the capacity of solving more complex cases, evaluating in parallel the qualitative indicators " Percent of sick discharged patients, readmitted to another hospital, with the same pathology, within 48 hours of discharge "; Percentage of transferred patients to another hospital for the same pathology type, within 48 hours of admission" and "Percentage of discharged patients, readmitted to the same hospital, with the same pathology type within 48 hours of hospital discharge". Another important point to consider was a possible alternative mode for reorganization of the unit by organizing other types of care, mainly emergency care and medical transportation, distance to the nearest higher rank hospital for complicated cases and for specialized personnel. The aspects mentioned above have been analyzed based on the map location in each county, as well as direct experience that members of the Commission have had over time through on-site inspection of establishments. Data were summarized in a table, for better and easy presentation. For the units that were selected were prepared fact sheets with more complete information to motivate the proposal: location, population served property situation, organizational structure, staffing, and number of lines on call, based on self reporting of health units and data held by specialized departments of the MoH and NHIH. The table, mentioned materials, lists of quality indicators and maps for positioning health units are additional material of the working committee and represent the underlying criteria for this proposal. The committee also used existing or specially created data, information and analysis put together by specialists from the MoH, and are presented in the analysis made by Romanian and international experts such as: - "National Strategy for rationalization of hospital services", 2003, Ray Blight (World Bank); - "Project planning and regulatory GVG health care system", 2004, edited by GVG consulting company (Gesellschaft für und-gestaltung Versicherungswissenschaft ev); - "National Strategy for rationalization of health services of the Ministry of Health" officially approved by Government Decision no /2004 for approving the National Strategy on health and Action Plan for Health Sector Reform; - "Elaboration a strategy for the development of hospital infrastructure in Romania", PHARE project written in 2007 by an international team of experts composed of Elisabeth Antunes (Portugal), Patrick Mordelet (France) and Tony Groote (Belgium); - "A health system focused on the needs of citizens", 2008, report of the Presidential Commission for review and public health policy in Romania, under the supervision of Prof. Dr. Cristian Vladescu; - "Romania - technical assistance to support hospital strategy update", 2009, World Bank expert report Jaanus Pikani and Dan Ioan Sava. Information in Government Decision No. 345 from 31 march 2011 [1]. 14

3 In the hospital sector priorities have changed from one politically frame to another and have experienced a sudden twist action, from relieving the hospital of all excess use of services and resources, to radical restructuring both functional and structural. In this context of the ongoing reform attempts, but discontinuous and incongruous health system activities, the need to reform the hospital system (not necessarily radical, but consistent with the results achieved so far) has become a imperative priority action from witch, more theoretical notions circulated during the reform like restructuring or reconfiguring hospitals can take shape and can be applied without affecting the effectiveness of measures already implemented. Thus, the most recent major review of the hospital sector, launched in February 2010, which was established three committees, came in the second step of the analytical algorithm, that a total of 67 units with beds were proposed to be dissolved, merged or converted and integrated in to the social network delivering services. In a first step, already implemented before 2012 and before hospitals decentralization, were cut 9200 hospital beds nation wide among departments that can provide outpatient medical services, such as dermatology, ophthalmology, internal medicine, diabetes etc. (main criterion was not to affect medical care). The 67 hospitals proposed to be restructured and not to be aloud to sign a contract to supply medical services NHIH was based on 10 criteria that evaluate aspects of structure and equipment, operational, legal and especially issues related to access and availability of health services (Box 1). IM and OBJECTIVES A The main purpose of this analysis is to provide an overall weighted image regarding the hospital system before and after the restructuring of the 67 hospitals proposed to stop contract with NHIH, in terms of access to hospital services. Research Objectives * 1. Profile description of the restructured hospitals, in terms of geographical layout, and role in providing hospital services to the population; 2. Comparative analysis (ante-post decision) activity and use of hospital services by the population; 3. Comparing the pool of origin of hospitalized patients in the pre-and post-implementation policy decision of restructuring: 4. Identification of population models addressing hospital services; 5. Issues of access to medical services offered in county hospitals (comparative analysis between pre-and postimplementation of restructuring political decision) * Results of objectives 4 and 5 will be presented in future issues of this journal M ETHODOLOGY To highlight the differences in access to hospital services were used analyzes of access both in terms of local availability and geographic access to public hospital services and the analysis of hospital activity before and after the intervention in order to identify patterns of overor under-services in certain areas. In this regard, we started from the assumption that the closed hospitals where not absolutely necessary, in which case their closure would not increase the number of discharges from other hospitals in the area. The comparative analysis was based on benchmarking data on the use of hospital services before (during May 2010 April 2011) and after (period May 2011 Aprill 2012) the measure of hospital restructuring (GD 345/31 March 2011 approving for 2011 The report of selection of health units with beds that can not contract services with health insurance funds, as well as the list with these hospitals). The present study is a comparative cross-sectional research, for cases discharged in the mentioned period (one year pre-and post-intervention year), according to data reported and existing under DRG National data base. The variables used were: hospital code, hospital type, county of the hospital, city of the hospital, county of the patient, hospitalization days, number of hospitalization episodes. Methods: frequency distributions, comparison tests (t-test for averages, chi2 for structures) correlation test, graphic representation (cartograms) etc.. R ESULTS 1. The profile of hospitals proposed for the list of hospitals that will not contract medical services NHIH in 2012 Geographical layout and the role of hospitals in providing the population with hospital services To see in detail how these hospitals are located in territorial profile and to have a topographic image of the closed hospitals, was used cartograms configuration (Figure 1) representing the place where hospitals were closed accordingly to the GD. At an general overview on the cartograms we can highlight a rather scattered image with the closed hospitals, with only 6 counties that do not have closed hospitals. Also in terms of hospital type, we can highlight a rather dispersed image, except the chronic disease hospitals, sanitariums and preventoria, some of which are located in cities with history of chemical and mining industry: Baia Sprie, Petrila, Zlatna Borsa, Victoria etc. 15

4 Figure 1. Cartograme with hospitals affected by Government Decision 16

5 As can be observed (Table 1 and Figure 2) political decision affects a number of 66 hospitals (not including Codlea Municipal Hospital, removed from the list), most of which are municipal hospitals (26 hospitals, representing 38 % of affected hospitals) and health centers (20 centers, 30% of hospitals affected). Moreover, more than two thirds of hospitals affected are among municipal hospital and municipal centers, 14% were community hospitals, other types of hospitals representing less than 10% of the total (Figure 3) county hospital or institutes were not restructured, restructuring measures did not affect private hospitals, military, prison or transportation network hospitals. It is also worth noting that none of the closed hospitals have a emergency profile or Emergency Rooms. Table 1. Frequency of restructured hospitals, Romania, 2011 TYPE of HOSPITAL Restructured accordingly with GD No. of hosp. % No. of hosp. Other hospitals % No. of hosp. Total Institute Speciality hospital 1 0, , County hospitals 0 0, , Municipal hospitals 3 3, , City hospital 26 27, , Community hospitals 9 69,2 4 30, Health centre 20 80,0 5 20, Chronic diseases hospital 6 50,0 6 50, Nursing and preventoria 1 9, , Privat hospital 0 0, , Military hospital 0 0, , Transport system hospital 0 0, , Prison hospital 0 0, , Other 0 0, , Total 66 12, , Figure 2. The number and proportion of restructured hospitals, by type % 17

6 Figure 3. Percentrage of structured hospitals, by type sent 12,64% of all hospitals providing services at the time of hospital restructuring decision). 2. Activity analysis and use of hospital services by the population According to the criteria used (hospitals with less than 130 beds, the low CMI - complexity of cases treated, organizational structure approved by the Minister of Health, covered human resource, population coverage, functionality and proper on-call activity) in the selection of hospitals included on the list to restructure, we started out our analysis with the assumption that only the hospitals that have a minor contribution to providing the population with hospital-type care, were selected. Therefore, not contracting services, and their unavailability for the period after implementation of the intervention (May 2011 April 2012) should not influence significantly people's access to hospital services or unaffected hospital activity. Days of hospitalization Restructured hospitals role in ensuring continuity of health care can not be denied, they were providing, during the year preceding the decision to close, about 3.22% of registered hospitalization across the country (3% of days of hospitalization in acute wards, or 4.23% of hospitalization days chronic wards). Regarding the number of discharges, the weight of discharge cases from the closed hospitals in relation to total discharge cases is 3.29% (3.13% for acute 5.33% for chronic). The conclusion that can be drawn from these findings is that remaining hospitals were providing 96-97% of hospitalization days across the country, given that they account for 87% of the hospitals (66 of closed hospitals repre- 18 If we compare the two periods (before and after the GD) in terms of days of hospitalization in the Romanian healthcare sector, we observe a decrease in the use of health services, from a total of 37,187,894 days of hospitalization recorded in the previous year of the political decision at a ,630 hospitalization days in the year that followed the political decision to restructure hospitals, representing 91% of the previous value. The relative percentage decrease represents a gain of almost 10% in terms of hospitalization days. The percentage difference between the two periods is of course an average, which means that in some areas (in this case, counties) gain was higher, while in others lower (Table 2). Thus, the largest percentage decline, in terms of days of hospitalization, is seen in counties such as Mehedinti, Alba, Ialomita and so on, especially in counties containing 2-3 hospitals affected by the GD, while the other pole, we have counties with increased activity above the average of 91% (including university) or even over the previous period (such as county, with growth of 138%). There are many factors that may influence the use of hospital services, but only in terms of hospital activity analysis of hospitalization days we can identify at least three patterns of use (Figure 4) which correspond to regions that deviate significantly (two standard deviations from the mean) from the general pattern (decrease of 91% of hospitalization days), and they correspond to counties that have a completely different characteristics, such as: For example, detailed analysis of hospital activity in Braila county hospital which has no hospital on the list of GD proposals show a seemingly inexplicable differences increase in absolute number of days of hospitalization at one hospital. Between the two periods, the activity increased from 541,289 to 740,367 hospital days, and this is due to changes in one hospital. As shown in Table 3, the difference is the number of days of hospitalization recorded for hospital 1, which in turn is not due to acute cases (ICM discharged almost remains the same), but do to chronic cases registered in chronic psychiatric wards and pediatric psychiatry. In the next year after the political decision have been recorded 3.5 times more hospital days than the previous year, one of the explanations beeing the high average length of stay for chronic wards. * There is a moderate correlation, indirect and significant, between the number of closed hospitals and hospital activity at the county level (corr = , p-value = 0.003)

7 The closure of chronic psychiatric wards led to a discharge of a large number of cases admitted even since 2002 (there were 47 cases admitted in 2002 and discharged in 2011, for example, immediately after the implementation of GD). In the remaining four hospitals in Brăila no significant differences could explain the increased activity at the county level. The second model is the overuse of hospital services in the counties surrounding counties where hospitals were closed, suggesting the orientation model pools of un-served population with hospital services to the nearest referral center in the area, often this reference center can be found in university centers where there are institutes, centers of excellence and county hospitals providing a wide range of high quality hospital services (human resources, clinical experience, proper equipment with high performance medical devices). Choosing population for hospital services provided in the reference centers is evident in Figure 4 and Table 2, we can highlight the fact that for almost all university centers (except Cluj), increased hospital activity after the decision was significantly higher (one or two standard deviations) than the national average increase. The third model is the one were it was a significant decrease in activity after the decision. In this category there are counties in all regions, but our analysis will focus in particular on three counties where the decline was two standard deviations from the national average: Mehedinti, Alba and Ialomita. For Ialomita we can assume that the population of this district apeals to neighboring counties which recorded the highest growth like Braila for example. Figure 4. Percentage of structured hospitals; territorial representation Where: shadowed areas represent the difference in hospital services use between the two analyzed time periods (before and after Government Decisionimplementation); 1 point = 1 hospital affected by Government Decision 19

8 Comparative analysis of the use of hospital services for periods that preceded and followed the decision can be resumed in at least three important conclusions: hospital activity decreased after application of the decision of restructuring of hospitals (which included the closure also), in some counties more then in others, depending on the number of hospitals affected* as well as availability of hospital services surrounding areas and easy access to a reference or university center. There are several local patterns of use for hospital services, extremes situation can focus on the remaining issues to ensure optimum availability and access to hospital services: - Braila County is the only county where inpatient activity increased (by 38%) compared to earlier political decision; - Counties with university hospitals, where it is assumed that there is an overload of work from other county hospitals; - counties like Mehedinti, Alba and Ialomita having at least 2 closed hospitals experinced significant reduction in hospital activity (2 standard deviations from the mean). Table 2. Hospital activity (days of hospitalization) in the two analyzed time periods Where: in blue = districts with medical university Table 3. Situation on hospital activity, before and after Government Decision implementation, Braila district 22

9 Table 4. Percentage of hospitalizations, at district level, by district where patient lives, May2010 Apr2011 Table 5. Perc hospitalizatio level, by distr lives, May20 21

10 Table 5. Percentage of hospitalizations, at district level, by district where patient lives, May2011 Apr2012 entage of ns, at district ict where patient 11 Apr2012

11 3. Share of extraterritoriality for all patients (inpatient basin of origin) - see Table 4 and 5. Number of discharges (inpatient episodes) A relevant aspect for assessing the population's access to health services is the pool of origin of the patients, measured by the share of extraterritoriality from all discharged patients. By definition, extraterritorial patient is admitted to a hospital that have a different county then home address. The working hypothesis from which we started was that people in underserved areas (as a result of the GD) will go to a hospital in another county, outside of this alternative, it is possible that some of the less complex cases to be resolved at the primary or secondary care (GP or specialist ambulatory), proving that before the decision there was a inefficient overuse of hospital services by the population and the restructuring measures had the effect of reallocation and supply redistribution of hospital services more appropriate to the needs of the population. The indicator used in this analysis was "extraterritoriality weight" calculated as: % Extraterritorial = number of discharged patients residing in another county / number of total discharged patients. According to Table 4 and 5, where we give the percentages of patients discharged according to home residence, comparative analysis of the number of discharges for the two periods highlights the following: The number of discharges decreased after the decision to restructure the hospital with about 10% (the difference is statistically significant, given that the annual change in the number of discharges has not exceeded 5%); The model of the population demand for hospital services is confirmed in counties with university hospitals. In both periods, we find that for counties having university hospitals, hospitals share of extraterritoriality patient is between 50% (Bucharest) and 13% (Dolj). For other counties, the proportion of patients residing in another county than the treating hospital is 5% - 1.5% (Teleorman); exception to the above rule is given by Covasna (26% extrateritorial), and the explanation is the fact that Covasna is one of national reference centers in cardiology, Ilfov County (51% extraterritorial, mostly represented by patients with residence in Bucharest 33%). Percentage structure of the pool of origin of the patients did not change significantly (except hospitals in Ilfov, the percentage differences are less than 1%) for Ilfov county hospitals, the proportion of patients with residence in Bucharest increased (but there is a numerical growth) from 33% to 39%, while the share of those living in Dâmboviţa County dropped from 7.7% to 1.7%. ISCUSSIONS. CONCLUSIONS D The data presented in this article are part of a detailed analysis of hospital activity in Romania, we selected to be presented only results related to hospital activity (measured by hospitalization days and number of hospital episodes) and access to hospital services for the two compared periods (have not been evaluated aspects of patient and health care human resources satisfaction, ethical, social or economic). The purpose of this paper is to provide an overview with a county level of detail, to identify actual specific problems to local access for health services, it is necessary to deepen the analysis and identify three models of usage and a detailed analysis at local, hospital type, and even hospital (as highlighted in the conclusions of this analysis). Conclusions At least declarative, in theory, the decision process to restructure the hospital sector, which affected 13% of hospitals in Romania (66 hospitals) was conducted according to best practices (as planned in reform plan, counseling and fundamentation of the decision by contributing experts: specialist committees, expert consultation etc. list of recommendations, objective, etc.). At the present moment, even after the overall analysis of the impact of radical measures on access to medical services, there are signs that draw attention to imbalances caused by their implementation. Reconfiguration of the system have been applied to smaller scale before, and the decision is a decision that proves necessary and brave, specially as a anti-popular decisions. Weaknesses are plenty and one of them would be the time of application of such radical measures due to the gap in reforming other medical sectors, and also because of poor alignment of measures to reform the healthcare system as a whole. Apparently, a year after applying GD, hospital activity decreased significantly (by 10%, both in terms of hospitalization and number of hospital episodes) and the assumption that counties without closed hospitals will be overloaded with extraterritorial patients is invalidated for this first year of evaluation. Time will determine if there is any negative impact, and in the political-strategic point of view, the measures that had been taken must be supported by other consistent measures [1] (Development of national, regional and local plan regarding hospitals, reduction of hospital overcapacity, classification and accreditation of hospitals, review of hospital financing and so on). References: 1. Government Decision No. 345 from 31 March 2011 on the 2011 approval of the report of the selection commission of the health units with beds that can not contract with health insurance funds, as well as of the list with these hospitals, Official Monitor No. 226/