Prevention of decubitus pays off
Good and affordable healthcare is possible when medical practitioners look beyond the disorder and also focus on a better quality of life for the patient.
An 88 year old woman who suffered from dementia and atrial fibrillation had a hip fracture and was operated. Given the circumstances, her condition was reasonably good. The hospital where the surgery took place was known as a quality local hospital. Structurally and process-wise, the operation went very well. After a few days, she was able to take short walks using a walker, and she did not develop an infection or thrombosis.
When taking into account the patient experience and looking at effectiveness and safety, however, the assessment is different. Because of a prophylactic antibiotics treatment, the patient suffered from diarrhea and impaired digestion, and deteriorated physically, mentally and emotionally. In addition, she was discharged from the hospital with decubitus. During the two weeks after she was discharged, she was taken to the emergency room of the hospital twice, which significantly increased the amount of care required for this patient after hip surgery.
Could this be improved? An interview with the attending specialist led to the conclusion that the prophylactic use of a pressure sore mattress for all patients who have had hip surgery is too expensive for the hospital.
But what choices would this hospital make if the hospital had outcome-based funding of, for example, zero per cent decubitus ulcers?
Prevention of decubitus leads to less pain and discomfort for patients. Every Euro invested pays itself back three times, and it results in a saving of one fte of nursing staff for every fifty patients. The risk that a person contracts decubitus in Dutch nursing homes and hospitals is eight times than that in a German nursing home or hospital. Since 2011, the reduction of the number of decubitus wounds in the Netherlands has stagnated. The year 2014 showed an increase in chronic wounds.
Studies show that the costs of the treatment of decubitus wounds in the Netherlands is estimated at 300 million Euros annually. The decubitus percentage greatly differs per institute. This can be due to for instance less attention and vigilance. Although some cases of decubitus can perhaps not be prevented, there are nine care institutions in the Netherlands with a decubitus percentage of zero per cent. Does the usual, volume-based management play a role in this respect? In the current funding system, an increase in volume results in more income, regardless of the appropriateness and quality of the care provided. The report Uitkomstbekostiging in de zorg: een (on) begaanbare weg?(“Outcome-based funding in healthcare: option or impossibility?”) (instituut Beleid&Management Gezondheidszorg; Netherlands´ Healthcare Policy & Management institute) concludes that implementation of outcome-based funding will not be possible in 2020, because there are too many formal and practical obstacles and the stakeholders do not feel any urgency. The implementation of outcome-based funding with regard to decubitus is easy. The urgency indeed exists for every patient, and outcome-based funding is also necessary to reduce the costs of healthcare.
Published in Dutch in Healthcare magazine SKIPR may 2015