The Future of Neurocritical Care in Germany W.F. Haupt
The Future of Neurocritical Care in Germany W.F. Haupt
The Future of Neurocritical Care in Germany W.F. Haupt
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Comparison <strong>of</strong> hospital bedsHospital beds per 100,000 population<strong>Germany</strong> 640USA 390ICU beds per 100,000 population<strong>Germany</strong> 28France 38Italy 9Great Brita<strong>in</strong> 9USA 30
Structure <strong>of</strong> Health <strong>Care</strong> <strong>in</strong> <strong>Germany</strong>Ambulatory sector:Ambulatory care provided by physicians <strong>in</strong> private practiceIn general, no hospital privileges for private physiciansBill<strong>in</strong>g between organization <strong>of</strong> private physicians and health <strong>in</strong>suranceNo direct bill<strong>in</strong>g <strong>of</strong> patients <strong>in</strong> state health <strong>in</strong>surance systemHospital sector:Hospital care provided by salaried hospital physiciansIn general, no ambulatory treatment by hospital physiciansReferral <strong>of</strong> ambulatory patients to hospitals and vice versa
Age distribution <strong>Germany</strong> 2001
Structural problems <strong>of</strong> Germanmedical systemPoor f<strong>in</strong>ancial situation <strong>of</strong> state health system90% <strong>of</strong> population covered by state health <strong>in</strong>surance, 10% privately coveredPrivate <strong>in</strong>surance only for <strong>in</strong>comes >$ 3000 or self-employedHealth <strong>in</strong>surance based on wage <strong>in</strong>come only (50% employer, 50% employee)Current health <strong>in</strong>surance rate 14% <strong>of</strong> gross wage <strong>in</strong>comeFamily members <strong>of</strong> wage earners covered cost- freeUnfavorable demographics, low birth rateRapid <strong>in</strong>crease <strong>of</strong> cost <strong>of</strong> comprehensive medical treatment
Structural problems <strong>of</strong> German hospitalmedic<strong>in</strong>ePoor f<strong>in</strong>ancial situation <strong>of</strong> state health system: low <strong>in</strong>vestment level <strong>in</strong> hospitalsRestrictions <strong>of</strong> work<strong>in</strong>g time and shift work (EU court rul<strong>in</strong>g and other labor laws)Poor situation <strong>of</strong> federal research fund<strong>in</strong>gResearch fund<strong>in</strong>g by pharmaceutical <strong>in</strong>dustry ma<strong>in</strong>ly <strong>in</strong> English-speak<strong>in</strong>gcountriesPrivatizaton <strong>of</strong> hospitals <strong>in</strong>clud<strong>in</strong>g university medical centersMassive adm<strong>in</strong>istrative workload for physicians (> 50% <strong>of</strong> work<strong>in</strong>g time)DRG cod<strong>in</strong>g etc. perfomed by physiciansLow wages <strong>of</strong> residents and junior pr<strong>of</strong>essors (lowest <strong>in</strong> Europe)All these adverse conditions also affect Neurological Critical <strong>Care</strong>
Structure <strong>of</strong> Neuro ICUs <strong>in</strong><strong>Germany</strong>75 Neuro ICUs with between 4 and 15 beds eachUniversity hospitals: 23 Non-university hospitals: 52<strong>The</strong> majority <strong>of</strong> university neurological departments have Neuro ICUsSmaller (municipal) hospitals usally have comb<strong>in</strong>ed ICUsComb<strong>in</strong>ed ICUs usually are Internal Medic<strong>in</strong>e/Neurology orNeurosurgery/Neurology units
Current trends <strong>in</strong> German Intensive <strong>Care</strong>Structural:Concentration <strong>of</strong> ICUs under the leadership <strong>of</strong> anaesthesiologistsConsolidation <strong>of</strong> ICUs <strong>in</strong> a unified <strong>in</strong>tensive care systemFormation <strong>of</strong> units for "conservative" and "operative" <strong>in</strong>tensive careQualification:Abolishment <strong>of</strong> specialized <strong>in</strong>tensive care (<strong>in</strong>ternal med., surgery, neurology etc)Introduction <strong>of</strong> a unified specialist for <strong>in</strong>tensive care medic<strong>in</strong>e
<strong>Future</strong> trends <strong>in</strong> GermanCritical <strong>Care</strong> Medic<strong>in</strong>eMassive concentration <strong>of</strong> resourcesClos<strong>in</strong>g <strong>of</strong> approximately 30 % <strong>of</strong> mostly smaller hospitalsConcentration <strong>of</strong> ICU facilities <strong>in</strong>to a smaller number <strong>of</strong> unitsManagement <strong>of</strong> "surgical" ICUs by anaesthesiologists/<strong>in</strong>tensivistsManagement <strong>of</strong> "conservative" ICUs by <strong>in</strong>ternists and neurologists
P.G.Batoni: Hercules between virtue and love (1748)
To lump or to split?To lump:Organize all ICU beds <strong>in</strong> a s<strong>in</strong>gle <strong>in</strong>tensive care unitSynergy effects will improve cost situationThis will <strong>in</strong>variably be led by anaesthesiologists or <strong>in</strong>tensivistsTo split:Individual specialty ICUs will only be feasable <strong>in</strong> large centersSpecialty ICU will preserve <strong>in</strong>dependence <strong>of</strong> Neurology <strong>in</strong> patientcare, tra<strong>in</strong><strong>in</strong>g, and reseachCompromise: Surgical ICUs versus Conservative ICUs
Possible comb<strong>in</strong>ations <strong>of</strong>Intensive <strong>Care</strong> UnitsNeurology and Internal Medic<strong>in</strong>eNeurology and CardiologyNeurology and NeurosurgeryNeurology and SurgeryNeurology and Anaesthesiology
Two probable ma<strong>in</strong> pathways for thefuture <strong>of</strong> German <strong>Neurocritical</strong> <strong>Care</strong>Alternative 1Neurology and Internal medic<strong>in</strong>eConcept <strong>of</strong> "conservative" ICUProximity <strong>of</strong> stroke patients (60% <strong>of</strong> Neuro ICU patients) to <strong>in</strong>ternalmedic<strong>in</strong>eIntensive care is a core discipl<strong>in</strong>e <strong>of</strong> <strong>in</strong>ternal medic<strong>in</strong>e and neurology,therefore high <strong>in</strong>terest <strong>in</strong> preserv<strong>in</strong>g <strong>in</strong>dependence
Alternative 2Neurology and NeurosurgeryConcept <strong>of</strong> "bra<strong>in</strong>" <strong>in</strong>tensive careProximity <strong>of</strong> patients to neurosurgery for operative treatment(decl<strong>in</strong><strong>in</strong>g)Neurosurgeons usually not <strong>in</strong>terested <strong>in</strong> neurocritical care,therefore, non-operative care <strong>of</strong> bra<strong>in</strong> trauma patientstransferred to neurology
What might improve the outlook for<strong>Neurocritical</strong> <strong>Care</strong> <strong>in</strong> <strong>Germany</strong>?Established NICUs <strong>in</strong> most university hospitalsEstablished neurocritical care society (GSCCN) s<strong>in</strong>ce 1984 ( 500 members)Annual meet<strong>in</strong>gs with 600 to 800 attendees, 120-150 posters<strong>Neurocritical</strong> <strong>Care</strong> summer schools for residentsLarge proportion <strong>of</strong> Neurology residents tra<strong>in</strong>ed <strong>in</strong> <strong>Neurocritical</strong> <strong>Care</strong>Cont<strong>in</strong>u<strong>in</strong>g <strong>in</strong>terest <strong>in</strong> research <strong>in</strong> <strong>Neurocritical</strong> <strong>Care</strong>
Alexander the Great and the Gordic KnotJ.S. Barthelemy (1743-1811)