Anesthetic Services in Serbia A

Explanation the topic: Due to the development of knowledge and technology our world is becoming a global city where rapidly occur changes in political and economic milieu, such as the introduction of corporate capitalism in the economic crisis, contemporary migrations etc. Health care as a public good on one hand and as the highest individual value of each individual on the other hand, changes and suff ers changes. Health care system policy insists on partnership relation of the individual with medical service providers. This refers to the a secure and accessible modern treatment of each individual and to the state as to rationalize and reduce medical costs with eff ective methods of treatment. Topic position in scientifi c/professional public: Anesthesiology is evolving along with the surgical disciplines. Highly sophisticated with organized service,anesthesiology is equally important because of the multiplicity of anesthetic services in the surgical treatment of the disease in terms of teamwork and multidisciplinary treatment of the disease. The intention is to provide a description of work, education and our results in the economic, geopolitical and cultural context of the Serbian health system policy as well as to improve safe performance, availability and cost rationalization in anesthesia. The health care system is territorially organized in Serbia. In hospitals, Serbia employs 940 anesthesiologists (1:7,575 inhabitants). According to data from the Regional Medical Chamber of Belgrade,382 anesthesiologists were registered in Belgrade out of total. Anesthesia department network is well organized in all surgical hospitals. Anesthesia services are available depending on the place of residence, type of surgical illness or injury, and the distance to the nearest clinic. Sub-specializations in the fi eld of anesthesiology have not been introduced although pediatric, neurosurgery and cardiosurgical anesthesia have spontaniously singled, as well as other areas of anesthesia. Previously mentioned areas of anesthesiology have been defi ned by National and international certifi cates, courses of University and professional anesthetic associations. Our results showed that the direct costs of anesthesia services combine 40% of the costs for salaries, 32% for medicines and supplies and 28% for other expenses. Further action: Future activities in anesthesia include continuing medical education, standardization of equipment, diagnostic and therapeutic protocols. This paper shows anesthesiology work in Serbia with a special emphasis on results.


Explanation the topic
Safety anesthesia -Th e strategy of surgical treatment of diseases could not be implemented without the participation of the anesthesiologist in the preoperative, operative and postoperative period.
Anesthesia services include various types of general anesthesia and local anesthesia techniques.Anesthesia procedures are skills used during hospitalization: analgesia, anesthesia and other procedures.Other anesthetic procedures include controlled hypotension, a cannulation of a.radialis,v.jugularisinterne, preparation and connection monitoring for the direct measurement of blood pressure etc.Only doctors specializing in anesthesiology with reanimation are permitted to provide anesthesia services in hospitals and in cooperation with the anesthesiology technicians, who are specially trained.
In the world, 230 million patients receive anesthesia for surgery every year.Of that number, 7 million patients develop complications of surgical procedures, with 1 million fatalities (200,000 in Europe) [1,2].
American Association of Anesthesiologists (ASA) made a Relative Value Guide system which determines anesthetic risk for surgical intervention, according to the general condition of the patient, the duration of anesthesia and type of surgery.Relative Value Guide increases depending on the number of organ systems that are pathological condition of the patient, such as age, malnutrition and urgency of surgical intervention or reintervention, which is used in most countries in the World [3,4,5].
Th e risk of death during anesthesia in otherwise healthy patients (ASA I) is about 1: 250 000.Mistakes during application of drugs in anesthesia occur in about 1 in 1,000 anesthesia services.Th e risk of the presence of consciousness during general anesthesia is 1: 650.Neurological complications occur rarely during epidural and spinal anesthesia.Allergy and anaphylaxis were recorded, most commonly to muscle relaxants.Pulmonary aspiration are expected in about 1: 7,000 anesthesia, with low morbidity in healthy patients.Th e incidence of anesthetic complications is higher in infants compared to the adult population anesthetized patients.Serious complications of anesthesia are related to cardiovascular and respiratory systems.Anesthesia complications result in combination of diff erent factors whereas human errors and organizational failures contribute to complications in 50-70% cases [6].
World Federation and the European Society of Anesthesiologists have made an effort to formulate the minimum international standards and to defi ne the available resources for the safe anesthetic practice.Anesthesia services need to be available to every patient.As a fi nal result, we have adopted Th e Helsinki Declaration for Patient Safety in Anaesthesiology [7], signed by our Serbian Association of Anesthesiologists.Considering the above facts, in order to improve the health and quality of life of surgically treated patients, the European Committee of Anesthesiologists has defi ned goals.All institutions that provide anesthesia services in Europe have to to comply with the minimum standards laid down in the operating room, and postoperative care.Standard protocols relate to preoperative preparation and verifi cation of anesthesia equipment and drugs [8,9] evaluate the possibilities of diffi cult intubation, malignant hyperthermia, allergies, toxicity local anesthesia, the possibility of bleeding more than 500 ml and infection control.

Geo-political, demographic and economic aspects of Serbia
Serbia is an upper -middle income economy with an average monthly salary of $ 542, and the overall unemployment rate of 22%, with the trend of falling wages and rising unemployment.
Serbia is divided into fi ve regions with 29 counties and the city of Belgrade, with a total of 193 municipalities.Serbia has two autonomous provinces in the north of Vojvodina (7 districts, 46 municipalities) and the south, Kosovo and Metohija (5 districts, 30 municipalities).From 2006, Kosovo and Metohija is under an international protectorate and in 2008, Kosovo and Metohija had declared independence [10].
According to the recent Census in 2011, Serbia extends over 88,407 km 2 with a population of 7,120,666 inhabitants excepting Kosovo and Metohija [11].Th e average population density is 125 people per km 2 .
Th e average age of populatin is 40.4 years (men 39.1 years, women 41.7 years).Life expectancy of residents is 74 years of age (men 71 years, women 76 years) [12].In European countries, costs for health care related to the gross national product (Gross Domestic Product-GDP) have increased, from 7% in 1990 to 8.9% in 2004.By 2008, the cost of GDP increased to 10.9% in Switzerland; 9.5% in France; 9.7% in Canada and 17% in USA [13].According to the World Health Care Organization (WHO), in 2004, total health care cost per capita were $ 917.According to the World Bank (WB), in 2005, total health care costs were 8% GDP.
In Serbia, health care costs per capita in 2011 were less than 300 euros. .Th e costs per capita increased from 131 euros in 2003 to 230 euros in 2007 and the costs per capita in 2008 were 255 euros [14,15,16].Movement of GDP, per capita GDP and the rate of growth of GDP in Serbia is shown in Table 1.
Currently, the economic crisis is expected to decrease the expected GDP growth and the funds available for health care.Results of GDP are taken with caution, for now, it is a universal indicator for comparison of the health economy in countries.the expected GDP growth and thus the funds available for health care.Results of GDP are taken with caution, for now, it is a universal indicator for comparison of the health economy in countries.GDP does not indicate diff erences in the cost of living in diff erent countries therefore considerable variations of the exchange rate in relation to the national currency mostly aff ect the fi nal value of the funds.Financial organizations such as: World Bank, International Monetary Fund etc. publish variations of exchange rate annually.
Data can diff er, depending on the interest of organizations that publish them.
A large part of health care resources is used for hospital costs.In Europe, during 2005 and 2006, 38% of the funds were spent on hospital costs.In Southeastern Europe, for example in Serbia, the percentage of funds for hospital costs was 47% and 50% in Bosnia and Hercegovina [17].Th erewithal, a lower quality of service is recorded, based on the length of hospitalization.In Serbia,the average length of hospitalization ranged from 9.5 to 11 days, unlike the countries of the European Union, where the average length of hospitalization ranges from 4 to 8 days.In the European Union, the target value for the length of hospitalization is 4 days [18].In Southeastern Europe, number of ccupied hospital beds is 5 to 10% lower than in the EU countries, where that number is 76%.In the the European Union countries national bank accounts for health care have been established during 2000 and in Serbia national bank accounts for health care have been established in 2010 in order to improve control of the distribution of private and public funds for health care.Serbia's economy is based on the service industry and agricultural activities.Serbia is faced with problems of the high unemployment rate of 21.6% in the population of 15-64 years of age, national budget defi cits and high level of imports compared to exports.Serbia faces a number of reforms, including health care reform on the road to the European Union.In January 2011,the average value of gross income was 47,383 RSD (EU 460) [19].

Serbian health system
Th e health care system of Serbia suff ered four reforms and Bismarch's economic model is in force since World War II.Health care system is fi nanced through compulsory health insurance that covers the largest part of the population (96%) with dominant state control of medical equipment and facilities.91% of funds are raised from salary contributions , 7% from government budget grants and 2% from miscellaneous revenue such as participation, donations, private insurance, local community resources, etc. Th e collection and spending of funds should be internal and public [20,21,22].
From the end of 2012, fi nancing primary health care is realized by capitation method.Th erefore, for example, personal income of general practitioners is calculated according to the number of treated patients, the price of drugs, etc. Th e "Offi cial Gazette" states the name and amount of drug, related to the diagnosis of the disease, which a general practitioner can prescribe to patients.Secondary and tertiary health care per patient treated or diagnosis related groups of diseases (DRG) fi nancing is acceptable for countries with high and middle-income such as the countries of Western Europe [23].Th eoretically, this issue is related to a system that should objectively evaluate the health services provided by physicians in the secondary and tertiary health care.In Serbia, the previous practice of paying health care providers upon treatment was not able to recognize all aspects of the treatment of the disease because such practice does not approve the existence of comorbidity and complications, but only the average cost of treatment.DRG system consists of provided diagnostic and therapeutic procedures along with the diagnosis, comorbidities and complications and coded nomenclature, calculated according to the coeffi cient of already formed DRG for this episode of hospital treatment, on the basis of which the payment is made to hospitals.Th e standard price of the service does not have to be correlated to the actual costs of treatment.
Modern approaches to fi nancing health care are envisaged through contracts between those who pay service and service providers as well as public tender.
Serbian health care system is organized on two levels, for individuals and families, including: 1. primary health care (health centers, home care services, ambulance, diagnostic laboratories, dentistry, pediatrics); 2. secondary (specialist services in hospitals); 3. tertiary (specialized hospitals, clinical centers).
In Serbia, Health Care Institutions Action Plan regulates the number, structure, capacity and special distribution of health care institutions .Th e capacity of tertiary health institutions (6,000 hospital beds, or 0.8 beds per capita) is arranged according to the number and density of inhabitants who need special medical care, taking into account the infrastructure capacitities [25].
In 2006, 20,157 physicians were registered, of which 15,317 have been medical specialists (1 physician per 368 population) [26].Th e hospitals had 6,372 specialist doctors employed, of which there were 940 anesthesiologists.According to data of the Regional Medical Chamber in Belgrade, taking in account the total number of anesthesiologists, 382 were registered anesthesiologists in Belgrade.Th e hospitals had 6,372 specialist doctors employed, of which there were 940 anesthesiologists.According to data of the Regional Medical Chamber in Belgrade, taking in account the total number of anesthesiologists, 382 were registered anesthesiologists in Belgrade.Setting the hospital information system of bookkeeping is in progress and Regional Medical Chambre in Belgrade does not have available accurate data for other regions of Serbia.

Anesthesia and anesthesiological service
Patients in need of anesthesia for surgery or those who have the deteriorated condition and need monitoring, support and/or restitution of vital functions primarely aft er stabilization of circulatory volume are refered to further hospital treatment by doctors in primary care or specialist doctor of emergency medicine.
Anesthesiological services begin from secondary health care in anesthesia and resuscitation ambulance.Emergency health care services and outpatient clinics are also entry points of patients in the hospital health care system.Th e responsibility of the anesthesiologist begins in reanimation ambulance, carefully observing patients in the preoperative, operative and postoperative treatment period to the point when patients get released from the hospital.Necessary biochemical and hematological analysis, radiological and ultrasound diagnostic procedures are performed at secondary level of treatment.Tertiary health care level includes specifi c and highly specialized surgical interventions and treatment of complicated diseases and injuries of vital organs.
Th e anesthesiologist is responsible for safety and quality in anesthesia, intensive care unit, including the preoperative period and many other specifi c situations in the hospital and outside of it, where patients are vitally affected.
Th e studies [27,28] show calculated costs per anesthesia.Anesthesia is administered by standard procedure and calculated by the hour, and the duration of anesthesia for surgery.Anesthesia for surgery includes an introduction,surgical procedure time and awakening from anesthesia.
Retrospective and descriptive study of our authors show that the direct costs make up 40% of the expenses for salaries (personal expenses, 32% for medicines and supplies and 28% for other expenses [29][30][31].Th e direct expenses of anesthesia would enlarge the surgical operating costs for 10% if counted as an element of clinical support to center of consumption, ie.surgical expenses [32].
Th e direct costs are the only costs of anesthetics, drugs and material costs realistic, transparent, subject to check and change and all the other elements are determined by law and the annexes to the agreement with the Republic Institute for Health Insurance.
Further cost reductions of anesthesiological services and consumption of drugs are limited (5.93% of total drug spending in KCS) [33] for endangering the choice of type and technique of anesthesia in terms of the extremely restrictive budget for health care.
Online Documentation of material (direct) costs better correlates with expenses through predefi ned standard methods of anesthesia, 90.3% (Pearsson correlation coeffi cient 0.77) in respect to the distribution of material costs, which is performed retrospectively on the basis of data collected in the electronic system of anesthesia (49.1%) [34].Most fi nancial analysis regarding price of anesthetic responsibilities outside the operating room are debatable.Length (hours per case; h/case) and the type of surgery (ASA base units per case; base/ case) determines the anesthetic service [35].

Education and continuous medical education of anesthesiologists
Basic medical knowledge is acquired at the Medical Faculty in Belgrade, Novi Sad, Kragujevac, Nis and Pristina.Th e fi rst private School of Medicine was accredited in 2005.License for doctors was introduced in 2008 and on an annual basis, in 2010 were specifi ed criteria and procedures of Continuing Medical Education for license renewal .
Since 2010, specialization of anesthesia and resuscitation takes fi ve years, although there are requirements to return to the previous duration of four years.
In the departments of anesthesia, Emergency Center and Intensive Care Unit, mastering practical clinical skills and various surgical disciplines such as pediatrics, general surgery, neurosurgery, cardiac surgery, ophthalmology, Otorhinolaryngology (ENT), etc. is enabled under the supervision of a mentor.Colloquiums in certain fi elds take place at the end of certain period of practice spent in anesthesiology departments dealing with anesthesia, which is the subject of tests.
Th e fi nal examination is composed of practical and oral part.Practical part is done by administering anesthesia for surgery.Oral part consists of assessment tests taken in the presence of anesthesiology committee.Required literature is written by our and foreign authors (mostly English speaking).
Continuing Medical Education was organized and introduced few years ago by the Faculty of Medicine, Serbian Medical Society, Regional Medical Chambre and professional organization of anesthesiologists.Knowledge and results of the work are compared with those in the region and developed countries and presented by local and international courses, seminars and congresses.
Doctors improve personal medical knowledge by participating in national and international conferences and scientifi c literature in written and in electronic form.

Where do we stand now?
In Serbia, concept of the health care system is composite.Concept of health care system is based on contributions and mandatory health insurance funds and is part of the so-called non-profi t health insurance.Th e positive aspects of this model are: general availability, a high level of solidarity and cost control.Negative aspects are: sluggishness off er, rationalization, waiting lists and bureaucratic legacy.Th is model is popular not only in countries of former Yugoslavia but also in countries with expressed social tradition such as: Austria, Switzerland, France, etc. Th e European models show more solidarity and are cheaper and more attractive than the US model.Hence, voluntary health insurance shall not reach the level of dominance over public health insurence [36].
Education and training of anesthesiologists in Serbia is satisfactory.Anesthesia departments provide services to the surgical departments and clinics.Number of anesthesiwww.hophonline.orgologists, regional distribution and equipment in anesthesiology department such as anesthesia machines, anesthetics and drugs shall be improved in future.
Anesthesia clinics that provide ambulance for preoperative preparation of surgical patients could be organized for the planned surgical procedure and daily hospital could be rendered for a shorter surgical interventions.Th is results in providing a better service, planning, equipment, medical personnel and other resources for operating rooms.
Better preoperative strategy and direct communication of users and health care providers with the founders of health institutions and other government organizations could help to improve the quality of provided services.Th e founders of health institutions are required to provide adequate resources for the service of anesthesia department and on the other hand anesthesiologists are required to safely carry patients through surgical intervention and treatment.
Interview with the patient, medical records and laboratory analysis necessary for anesthesia and physical examination provide information about patient's health.Th e patient is given information about anesthesia and the written consent from a patient is required for the anesthetic service.
In economic terms, anesthesia is clinical support to surgical activities due to performing diagnostic and/or surgical intervention and treatment of patients.Th erefore, good cooperation between anesthesiologists and surgeons is particularly important.Reliable clinical team and, if necessary, consultants of various fi elds of medicine are available to the anesthesiologist in operating room and beyond.
Cooperation as team work with Clinical pharmacologists trained through specialization of Clinical Pharmacology is especially benefi cial for pharmacotherapy, clinical studies and pharmacoeconomics.Furthermore, anesthesiologists may take the subspecialization in Anesthesia Clinical Pharmacology.
Industrial partners, anesthesia equipment, production and supply of anesthetics and drugs play a signifi cant role in the development of anesthesia.
Anesthesiologists are very active in education due to performing the vital functions, especially of the heart, lungs, and the other vital organs.Anesthesiologists are active members of the fallowing international professional associations: World federation of Societies of Anesthesiologists, European members of Anesthesiologists, European and international associations for pain therapy, nutritional support, intensive therapy and regional anesthesia.
Anesthesia faces nowadays challenges of the new knowledge, research and technical innovation.

Further action
Continuous reforms of the health care system are performed in order to change the system of payment for services in conditions of economic crisis No matter how small the cost of anesthesia, because of the multiplicity of services, small savings may reduce direct costs.
Health policy measures of rationalization and cost reduction include: 1. cost management (reduction of supply in the form of insuffi cient budget, standardization, control); 2. the opening of the market (free choice of doctors, method of payment, the privatization of institutions and insurance); 3. changes of the structure and organization i.e. management (decentralization and the introduction of management in health care); 4. self-protection, and 5. the primary protection (selective and preventive).
In addition to these general measures for improving the work of anesthesiologists, we believe that we should take direct measures to improve the quality and safety of anesthesiology services.Direct measures to improve the quality and safety of anesthesiology services shall include: 1. introducing standards for equipment and work in the operating room, hall premedication and the intensive care units; 2. checklist for equipment and labor for certain anesthesia apparatus and procedure; 3 of the Universal lists and algorithms for preoperative preparation and anesthesia; 4. for a better evaluation and monitoring of service, individual data input and payment of all provided anesthesia services.