Hochspezialisierte Medizin (HSM)

als Wettbewerbsvorteil

Pierre-Alain Clavien

UniversitätsSpital Zürich

DefinitionBegriffe (Terms):

� Spitzenmedizin

� Hochspezialisierte Medizin (HSM)

� Specialist Medical Care (SMC)

� Interkantonale Vereinbarung über die

Koordination und Konzentration der

hochspezialisierten Medizin (IVKKM)

� Interkantonale Vereinbarung zur

hochspezialisierten Medizin (IVHSM)

� �

Worüber sprechen wir?

GDK ��Spitzenmedizin�

1. Hämatopoïetische Stammzellen-Tx

2. Hypophysenchirurgie

3. Interventionelle Neuroradiologie

4. Kinderherzchirurgie und �

kardiologie

5. Teile der Ophthalmologie

6. Organtransplantationen

7. Positronen-Emissions-Tomographie

8. Protonen-Strahlentherapie

9. Schwerstverbrennungen

Liste HSM (2004)

Hochspezialisierte Medizin (HSM) - 2005

� Selten

� Hohes Innovationspotential

� Hoher personeller oder technischer Aufwand

� Komplexe Behandlungsverfahren

Umschreibung gemäss Gutachten ZH, BE/BS (2005)

Interkantonale Vereinbarung zur

hochspezialisierten Medizin

1. Jan. 2009 in Kraft gesetzt

alle 26 Kantone: OK

� Definition der HSM-Leistung

� Koordination der Konzentration der HSM

� Einbezug der Erkenntnisse der Gutachten ZH + BE/BS

� Allokationsentscheide gemäss Expertenvorschläge

� Kriterien für Evaluation

Aufgaben

�Interkantonale Vereinbarung HSM�

Interkantonale Vereinbarung HSM

Politik

Ärzte

GDK

Interkantonale Vereinbarung HSM

Politik

Ärzte

GDK

Interkantonale Vereinbarung HSM

Politik

Ärzte

GDK

= Multidisziplinär

Unterstützende

Disziplinen

spez. bildgebende Verfahren

Intensivmedizin

Anästhesie

Unterstützende

Disziplinen

Speziallabor

HSM Leistung oderHSM Leistungsbereich

Anforderungen

Liste Interkantonale Vereinbarung HSM

Liste Interkantonale Vereinbarung HSM

Hernienchirurgie, Entfernung der Gallenblase

Asthma

Herzinsuffizienz

TransplantationSpeiseröhrenchirurgiePankreaschirurgie HSM

Check-up

Grippe

Herpes

Primärversorgung

Sekundärversorgung

TertiärversorgungHSM?

� Selten

� Hohes Innovationspotential

� Hoher personeller oder technischer Aufwand

� Komplexe Behandlungsverfahren

Hochspezialisierte Medizin (HSM)

Patientenzahl + Multidisplinäre lokale Expertise

Qualität der Behandlung

Structure Process Outcome

� Patient volume

� Surgical experience

� Specialized

interdisciplinary

center

� Specialized intensive

care units

� �

� Use of special drug

� Use of special devices

� �

� Mortality

� Complications

� Costs

� Patient satisfaction

� Functional health

status

� Return work

� �

Quality parameters

Birkmeyer J. et al: J Am Coll Surg, Vol. 198, No. 4, April 2004

Esophageal surgery

Birkmeyer et al: N Engl J Med 2003; 349: 2117-27

Pancreatic surgery

Birkmeyer et al: N Engl J Med 2003; 349: 2117-27

Liver surgery

Variable Hepatic resections (n) Mortality

Surgeon training

HPB Surgeon

General surgeon

691

72

4.6%

15.3%

McKay et al: 2008; 15: 1348-55

Cancer

Impact of specialized centeron �long term survival�

Esophagus cancer +++

Liver cancer +++

Pancreas cancer +++

Peritoneal cancer +++

Birkmeyer et al: N Engl J Med 2003; 349: 2117-27

Fong Y. et al: Ann Surg 2005; 242: 540-547

� Colorectal surgery

� Bariatric surgery

� Neurosurgery

� Thoracic surgery

� Cardiac surgery

� �

Similar data �

And other medical fields,

like CARDIOLOGY�

Volume Business in Liver Surgery (Pittsburgh)

Quantity Quality

�It depends all on volume and experience�

Concentration of HSM = mandatory

(patient, medical, ethic & cost perspectives)

At least 50-100 procedures per year

Area: 2 to 4 Mio. inhabitants

Population served by University Hospitals

�It depends all on volume and experience�

Concentrate many fields of HSM

at most 2 centers

Concentration NOT in 1 center

�It depends all on volume and experience�

� Change in personnel or resources No longer available in CH

� Competition = better quality

� Competition = better research

� Competition = better innovation

� Multi-cultural

Why?

Concentrate many fields of HSM

Quality Control

�It depends all on volume and experience�

Including

� Outcome data

� Resources needed

� International ranking (Benchmark)

What does Zurich offer?

� Economic Metropolis => outstanding resources

� Know how in many areas (University, ETH, Industry,�)

� National / international collaboration

� Easy access

Airport, excellent transportation services, �

� High standard of living

� Brand name Zurich / Switzerland

� Too many hospitals (>25 hospitals / clinics)

� No coordination among these hospitals

� Several community hospital do 1-2 HSM procedures/year

� Bureaucracy (2001) (2009)

Gesundheitsdirektion, Spitalrat, Spitalleitung, Bereichsleiter,

Controlling + controlling Dr. Patient

� Dramatic cut in Budget (e.g. USZ: 20-30Mio for 2010)

What are the obstacles?

What are the obstacles?

Contradictory signs?

Residents

50hr working time disaster50hr working time disaster

Now same for Oberärzte

Working hard

is illegal

50hrs/week !!!

50hr working time disaster50hr working time disaster

Obstacles

No overtime paid

Obstacles

Cost pressure � Cost-benefit analysis?

Obstacles

Cost pressure � HSM or palliative care?

National & Intern.

recognition

Obstacles � Conflict of interstObstacles � Conflict of interstResearch

= Personal + Space

$$$

Promote: Individuals + Team

HOSPITAL = No benefit

Patients +++

Professionals +++

= $$$$$

Similar clinical focus

Swiss Hepato-Pancreato-Biliary (HPB)

� Transplant Centers

+

Does HSM bring something to Zurich ?

� Economical and political

strengthening of the area of Zurich

� 1st class quality care (fullfilling

WZW* criteria)

� Interaction in research & Innovation

� Promotion of young academics

� Critical mass and flexibility for

sophisticated technology

University Hospital

University

Industry ETH

*Wirksamkeit, Zweckmässigkeit, Wirtschaftlichkeit

� but impossible to quantify

Does HSM bring something to Zurich ?

ConclusionsRequirements for competitiveness in HSM

� Quality => Patient volume & local interdisciplinary experience

� Long term secured financial resources

� Location (infrastructure, center, etc.)

� Human resources and qualified personnel

� Concentration (to get volume and reduce costs)

� Benchmarking (for appropriation of funds)

� Cooperation (national and international)

The region to chose - Zurich

Valais

Thanks

René Magritte � L�harmonie

Picture grouo to thank all

René

Vonlanthen

Master of Health Administration

Thanks