Economic consequences of an increased number of patients on outgoing dialysis.

OBJECTIVE: During the past 10 years the number of prevalent patients on dialysis treatment has doubled in Denmark and the number is expected to increase further. The majority of Danish patients on dialysis receive haemodialysis at a hospital-based centre, and increasing patient numbers will put pressure on these dialysis centres. In order to reduce this pressure, more patients will need to be offered dialysis as outgoing treatment. The aim of this study was to analyse the economic consequences of an increased number of patients on outgoing dialysis in a Danish setting. MATERIAL AND METHODS: A Markov model using Danish cost estimates and clinical parameters from the Danish National Registry was developed and used to simulate changes of dialysis modalities, exits to transplantation or death as well as entry of new incident patients over a period of 10 years. RESULTS: The development in total annual costs over a 10-year period showed that an increased number of patients on outgoing dialysis will lead to total savings of approximately €9.6 million. CONCLUSIONS: The estimated savings of approximately €9.6 million only constitute 0.6% of the total cost of dialysis. In terms of cost over time, therefore, an increased number of patients on outgoing treatment will not lead to an increase in costs; the total cost of treatment will probably be unchanged or slightly reduced. The results were sensitive to inclusion of capital costs and exclusion of costs associated with complications or comorbidity.

Patients' views regarding choice of dialysis modality.

BACKGROUND: Increasing patient numbers have resulted in pressure on dialysis centres and a need to reorganize dialysis treatment. This study explored patients' experiences with different dialysis modalities and investigated issues related to the patient's choice of modality, especially 'out-of-centre' dialysis (i.e. modalities other than CHD). METHODS: Six focus group interviews were conducted with 24 dialysis patients, 3 pre-dialysis patients and 18 relatives. Each focus group comprised patients on one type of dialysis, i.e. CHD, self-care CHD, HHD, CAPD/APD, aAPD or pre-dialysis patients. Based on a semi-structured interview guide, the group discussions centred on advantages and disadvantages of dialysis modalities, problems experienced and their (possible) solutions and patient involvement in choice of modality. RESULTS: The focus groups participants considered that each dialysis modality has its advantages and disadvantages. Flexibility, independence and feelings of security were key factors in determining choice of modality, with maintenance of a normal life being a major goal. Patients and their relatives want to participate in choice of modality, but a genuine offer of out-of-centre dialysis including professional support and appropriate and timely education is needed to encourage a greater use of modalities other than CHD. CONCLUSIONS: No single dialysis modality emerged as offering the best solution for patients with end-stage renal disease. In the absence of absolute clinical contraindications, the treatment of choice should be the modality that best accommodates the patients' preferences for their daily activities and lifestyle. A move towards more patients on out-of-centre dialysis requires a greater focus on pre-dialysis patients and closer consideration of patients' preferences and current lifestyle.

Doing mini-health technology assessments in hospitals: a new concept of decision support in health care?

OBJECTIVES: The purpose of this project was to evaluate local decision support tools used in the Danish hospital sector from a theoretical and an empirical point of view. METHODS: The use of local decision support was evaluated through questionnaires sent to all county health directors, all hospital managers, and all heads of clinical departments in cardiology, orthopedic surgery, and intensive care. In addition, respondents were asked to submit whatever decision support tools they were using (including mini-HTAs, other forms or checklists, and special procedures for decision making concerning new health technologies). A theoretical analysis of the decision support tools (decision theory) was performed as well as a comparison with the business case method used in private companies. Finally, the Danish mini-HTA was compared with foreign production and use of HTA and HTA-like assessments as local decision support. RESULTS: The response rate was high (87 percent, 94 percent, 85 percent, respectively). We collected sixty different forms (of which forty-nine were mini-HTAs) and twenty variants of written procedures. We found theoretical and empirical evidence that local involvement in the process of making the HTA could be important for the use of the results from the HTA and for the process of implementing the new technology. CONCLUSIONS: Doing mini-HTA in hospitals seems to balance the need for quality and depth with the limited time and resources for assessment.

Repeated measurements of generic indicators: a Danish national program to benchmark and improve quality of care.

OBJECTIVE: To measure performance on the basis of generic (non-diagnoses related) standards of care developed in a national Danish quality improvement programme in departments of internal medicine, and to determine the power of repetitive national audits to increase levels of performance. DESIGN: Multifaceted intervention: national audits in 2001 and 2002 based on the standards of the program, combined with direct contact with heads of departments and a national conference to discuss audit results. SETTING: Seventy-nine and 82 wards in 2001 and 2002, respectively, covering 71% of Danish hospitals receiving medical emergencies. The wards participated on a voluntary basis. PARTICIPANTS: In the first audit round, 3950 patients were admitted as emergencies, while 4068 patients were admitted as emergencies in the second audit. Patients were included without reference to diagnoses. MAIN OUTCOME MEASURES: Correct initial diagnostic assessment, early interdisciplinary action plans, correct drug prescriptions, waiting times for examinations, documented patient information, readmissions, and content and processing time for discharge letters. RESULTS: For the 70 wards participating in both rounds, the general level of performance improved significantly between the two audits: the proportion of patients with correct initial diagnostic assessment increased from 75.9% to 79.4%, the proportion of patients with correct drug prescriptions increased from 83.8% to 85.9%, and the proportion of sufficiently informed patients increased from 32.4% to 36.2% (P < 0.05). The proportion of medical records containing action plans for selected clinical problems (nutritional and functional problems, fever, and treatment of pain) increased from 72.8% to 75.9% (P < 0.05). Length of stay in hospital was significantly related to a correct initial assessment and to waiting time for examinations. Wards with a common medication chart for physicians and nurses had significantly more correct drug prescriptions than wards that did not use a medication chart. Fifty-four (75%) of the participating departments indicated that the result of the first audit round had led to organizational changes in the department. CONCLUSION: Professional self-regulation guided by a multidisciplinary audit tool developed in cooperation with professionals can improve quality of care. It is possible to conduct and repeat a national audit on a voluntary basis.

[Prescribing and dispensing drugs in Denmark. Frequency of and intervention against errors in documentation and dispensing of drugs]. / Medicinordinationssystemer og medicindispensering i Danmark. Hyppighed af og intervention mod medicindokumentationsfejl og medicindispenseringsfejl.

Foreign studies mainly describe errors in medicine prescriptions in context with adverse drug events unlike most Danish studies and projects, which focus on documentation. Current methods of prescribing medicines in Denmark only partially follow the guidelines given by the National Board of Health. About two thirds of the prescriptions are unambiguous. Errors of potential clinical significance are estimated to occur in 4.5% of prescriptions. Transcription errors occur mainly from patients' records to the medication forms and are found in 23% to 83% of transcribed prescriptions. Several departments have intervened by using only one prescription form, a paper or electronic version, which reduced the number of ambiguous prescriptions and eliminated transcription errors. Dispensing errors are common and demonstrate the importance of further quality improvement.