The Future of Neurocritical Care in Germany W.F. Haupt

Comparison of hospital bedsHospital beds per 100,000 populationGermany 640USA 390ICU beds per 100,000 populationGermany 28France 38Italy 9Great Britain 9USA 30

Structure of Health Care in GermanyAmbulatory sector:Ambulatory care provided by physicians in private practiceIn general, no hospital privileges for private physiciansBilling between organization of private physicians and health insuranceNo direct billing of patients in state health insurance systemHospital sector:Hospital care provided by salaried hospital physiciansIn general, no ambulatory treatment by hospital physiciansReferral of ambulatory patients to hospitals and vice versa

Age distribution Germany 2001

Structural problems of Germanmedical systemPoor financial situation of state health system90% of population covered by state health insurance, 10% privately coveredPrivate insurance only for incomes >$ 3000 or self-employedHealth insurance based on wage income only (50% employer, 50% employee)Current health insurance rate 14% of gross wage incomeFamily members of wage earners covered cost- freeUnfavorable demographics, low birth rateRapid increase of cost of comprehensive medical treatment

Structural problems of German hospitalmedicinePoor financial situation of state health system: low investment level in hospitalsRestrictions of working time and shift work (EU court ruling and other labor laws)Poor situation of federal research fundingResearch funding by pharmaceutical industry mainly in English-speakingcountriesPrivatizaton of hospitals including university medical centersMassive administrative workload for physicians (> 50% of working time)DRG coding etc. perfomed by physiciansLow wages of residents and junior professors (lowest in Europe)All these adverse conditions also affect Neurological Critical Care

Structure of Neuro ICUs inGermany75 Neuro ICUs with between 4 and 15 beds eachUniversity hospitals: 23 Non-university hospitals: 52The majority of university neurological departments have Neuro ICUsSmaller (municipal) hospitals usally have combined ICUsCombined ICUs usually are Internal Medicine/Neurology orNeurosurgery/Neurology units

Current trends in German Intensive CareStructural:Concentration of ICUs under the leadership of anaesthesiologistsConsolidation of ICUs in a unified intensive care systemFormation of units for "conservative" and "operative" intensive careQualification:Abolishment of specialized intensive care (internal med., surgery, neurology etc)Introduction of a unified specialist for intensive care medicine

Future trends in GermanCritical Care MedicineMassive concentration of resourcesClosing of approximately 30 % of mostly smaller hospitalsConcentration of ICU facilities into a smaller number of unitsManagement of "surgical" ICUs by anaesthesiologists/intensivistsManagement of "conservative" ICUs by internists and neurologists

P.G.Batoni: Hercules between virtue and love (1748)

To lump or to split?To lump:Organize all ICU beds in a single intensive care unitSynergy effects will improve cost situationThis will invariably be led by anaesthesiologists or intensivistsTo split:Individual specialty ICUs will only be feasable in large centersSpecialty ICU will preserve independence of Neurology in patientcare, training, and reseachCompromise: Surgical ICUs versus Conservative ICUs

Possible combinations ofIntensive Care UnitsNeurology and Internal MedicineNeurology and CardiologyNeurology and NeurosurgeryNeurology and SurgeryNeurology and Anaesthesiology

Two probable main pathways for thefuture of German Neurocritical CareAlternative 1Neurology and Internal medicineConcept of "conservative" ICUProximity of stroke patients (60% of Neuro ICU patients) to internalmedicineIntensive care is a core discipline of internal medicine and neurology,therefore high interest in preserving independence

Alternative 2Neurology and NeurosurgeryConcept of "brain" intensive careProximity of patients to neurosurgery for operative treatment(declining)Neurosurgeons usually not interested in neurocritical care,therefore, non-operative care of brain trauma patientstransferred to neurology

What might improve the outlook forNeurocritical Care in Germany?Established NICUs in most university hospitalsEstablished neurocritical care society (GSCCN) since 1984 ( 500 members)Annual meetings with 600 to 800 attendees, 120-150 postersNeurocritical Care summer schools for residentsLarge proportion of Neurology residents trained in Neurocritical CareContinuing interest in research in Neurocritical Care

Alexander the Great and the Gordic KnotJ.S. Barthelemy (1743-1811)