Rosenberg (right photo)
Institute of Diagnostic Radiology and Neuroradiology, University Medicine,
Ernst Moritz Arndt University, Greifswald, Germany
Kristin Kroos (left photo)
Prof. Dr. Steffen Fleßa (right photo)
Department of General Business
Administration and Health Care Management,
Faculty of Law and Economics,
Ernst Moritz Arndt University, Greifswald, Germany
Prof. Dr. Norbert Hosten (photo above)
Telemedicine Pomerania e.V., Institute of Diagnostic Radiology and Neuroradiology,
University Medicine, Ernst Moritz Arndt University, Greifswald,
Due to a lack of medical personnel, ensuring excellent medical care in regions with a low population density is a challenge that requires innovative solutions. The Telemedizin Pomerania project is a European Union-promoted international project initiated to address this problem by applying telemedical solutions. The adjacent areas of north-eastern Germany, north-western Poland and southern Sweden belong to the Euroregion Pomerania, and cooperate in the fields of telepathology, teleradiology, telestroke, teleotolaryngology, telemonitoring and teleconferences.
Teleconferences especially provide a tool to secure high standards in patient care by making interdisciplinary tumour boards available to smaller community hospitals that cannot afford their own specialists such as oncologists, radiologists, nuclear medicine specialists and pathologists.
A tumour teleconference project has been set up in the north-eastern German federal state of Brandenburg (see Image 1), an area consisting of three administrative districts (Barnim, Märkisch-Oderland and Uckermark), which have between one-third and one-tenth of the population density compared to urban areas such as Berlin (see Table 1).
Such rural areas lack medical personnel, not especially in relation to the number of inhabitants, but in relation to the area they cover. Berlin has roughly 690 physicians per 1000 square kilometres whereas the northeastern Brandenburg districts of Barnim, Märkisch-Oderland and Uckermark vary between 4.6 and 1.2 physicians per 1000 square kilometres (see Table 1).
The central stage of the weekly tumour board is the community hospital in Eberswalde (see image page 16), a small city of about 40,000 inhabitants in northeastern Brandenburg. Eberswalde provides oncologists, internal medicine specialists, general surgeons, gynaecologists, urologists, paediatricians, otolaryngologists, oral and maxillofacial surgeons, neurosurgeons, radiologists and radiotherapists. A thoracic surgery specialist from Berlin is present as well. The conference takes place in a room with a telemedical setup consisting of cameras, microphones and numerous large screens for broadcasting video, audio and remote presentations (see Image 2).
The five smaller community hospitals in Angermünde, Prenzlau, Schwedt, Strausberg and Wriezen participate through videoconference access as well as pathologists from either Neubrandenburg or the University Medicine in Greifswald, situated at 131 and 182 kilometres distance respectively in the northern German federal state of Mecklenburg-Vorpommern (Image 1).
Apart from acquisition costs for telemedical equipment, the consequences for personnel resources and therefore on the operating costs need to be taken into account when being asked to decide on implementation or participation in a teleconference setup. Making use of the teleconference example mentioned above, the authors’ primary aim is a comparative cost analysis for scenario 1 – teleconference implementation – and scenario 2 – physicians travelling to personally take part in a tumour board distant to their own facility. The analysis is intended to identify the least cost-intensive scenario and conditions from the perspective of a small external hospital. As a secondary objective it is aimed at determining the lower price limit for the conducting facility to perform cost-effective practice when charging for the consultation service.
To compare the two scenarios, the authors performed an original cost analysis for both settings. The total costs in each scenario comprised relevant variable and fixed costs and therefore also depend on the number of cases that need to be presented to the specialists.
Scenario 1: Remote Tumour Conference
The fixed costs mainly consist of the depreciation costs of the teleconference equipment. Each of the five external hospitals is responsible for one-fifth of the total acquisition costs of the technical equipment, which is used in the external sites, the teleconference conducting hospital in Eberswalde as well as by integrated external specialists. As it holds the tumour conference anyway, the Eberswalde site implements techniques to transfer the relevant data and to audio-visually connect with the external hospitals only for the purpose of having the external hospitals taking part in the conference. The expected depreciation period of five years finally determines the depreciation costs.
The variable costs primarily consist of the personnel costs of the physicians. In order to calculate the personnel costs, information about the personnel cost per minute (net factor cost) and the working time that can be allocated to the presentation and discussion of one case is needed for all physicians participating. The calculation of the personnel cost per minute is based on TV-Ärzte/VKA valid for 2012. The annual gross salary for a specialist doctor (group II level 2) is extended by indirect labour costs of 26.85%. Additionally, the productive labour time per year has been calculated by deducting 30 days leave, ten days time off for sickness, five days off for training and 10% for unproductive times from the annual gross working time based on 42 hours a week. As for the working time a medical case conference consumes and the number of physicians involved, an analysis was conducted measuring and calculating mean times for preparation, presentation and discussion of all cases dealt with in a conference as well as the number of cases (from external hospitals) and physicians per conference on average. These data were collected in 13 tumour conferences held in Eberswalde. The authors assumed that, after having discussed his/her relevant cases, the physician from the external hospital disconnects from the teleconference. Furthermore, the time for one case conference has to be multiplied by the number of physicians involved (those present at the tumour conference in Eberswalde and the specialists from external hospitals) to receive the lowest price limit for compensation of the teleconference service. The annual number of cases an external hospital might come up with at the teleconference was extrapolated on the basis of the collected data.
Scenario 2: Physician Travelling to Take Part in Tumour Conference in Person
The calculation of the costs incurring in scenario 2 does not include any variable costs. The authors applied the same methods as in scenario 1 when calculating the personnel costs per minute, the working time for preparation, presentation and discussion for each case and participant. The compensation for the specialists attending the tumour conference in Eberswalde was the same as in scenario 1. In contrast to scenario 1, the external physician attends the tumour conference for the full length. The average time and money spent on travelling was considered by calculating the mean distance between the five external hospitals and the place where the tumour conference is held. The average distance determines the travel time of the external physician and the fuel consumption. The latter is assessed by a mileage allowance of €0.3 per kilometre. The travel costs (personnel and fuel) for one journey (bi-directional) are d ivided b y t he m ean n umber o f cases t he e xternal p hysician p resents at the tumour conference at a time to receive the travel costs per case. Material costs were estimated assuming that the external physician makes use of a CD as a data carrier for each case. The number of cases presented at the tumour conference were the same as in scenario 1.
The calculation of the critical mass that represents the number of cases at which one scenario becomes advantageous over the other (due to lower total costs) completes the cost comparison.
The network uses telemedical hardand software, either installed in conference rooms or in the specialists’ offices. The acquisition costs of the telemedical equipment amount to €367,435 for all eight facilities. This leads to annual depreciation costs of €14,697 in an external hospital. Based on annual labour costs of €83,710 for a specialist doctor and €97,524 underlying productive working minutes, the net factor costs for a p hysician minute come to €0.86. The distance between an external hospital and the teleconference site averages 41.4 kilometres resulting in an average travel time of 41 minutes and a travel allowance of €9.94.
The teleconference takes place three times a week with an average of 7.9 specialist doctors present at the tumour conference in Eberswalde, 1.4 external specialists and 1.7 physicians from external hospitals attending via videoconference. They cover an average of 16.4 cases in 59 minutes, which results in a mean duration of 3.58 minutes per case. 12.9 cases per conference are presented making use of radiological imaging. An external physician presents 2.5 cases per conference on average. Considering the external physician’s probability of taking part in a conference of 0.42 and a total of 156 conferences a year held in Eberswalde leads to 163.61 cases a year, which an external hospital presents at the tumour conference.
Consuming almost 4 minutes per case of the working time of 9.3 specialists on average produces costs of approximately €28 in both scenarios. These costs represent the lower price limit for a compensation fee the tumour conference holding hospital might charge for every case conference.
Table 2 (see p.18) shows the results of the cost comparison between the two scenarios. At 163.61 cases a year, having the physicians travel to the tumour conference implicates lower total costs since its variable costs are below the variable costs that are caused by the teleconference scenario. Furthermore, having no fixed costs privileges scenario 2, at least with such a relatively low number of cases. Figure 1 therefore presents the cost functions revealing the critical mass at the intersection of 272 cases. At this point the total annual costs are €26,758.31.
Since interdisciplinarity means quality, the cooperation of multiple disciplines within a tumour board increasingly is a baseline quality measure in the treatment of cancer patients. Large hospitals are generally able to organise such therapeutic conferences without any problems, as the clinical representatives from all involved disciplines are on site. This is clearly more difficult to attain in areas with low population and hospital density. With the help of telemedicine, conferences can easily bridge distances, bringing medicine at university level to the peripheries. Not only is the quality of care improved, but also continuous training of the physicians in rural areas is achieved. In times of information and communication technologies, teleconferences appear to be the method of choice in comparison with having the physicians travel to the conference. Small hospitals in particular have to carefully consider the consequences for personnel and costs that are caused by taking part in such teleconferences.
Under the assumptions made in this study and with 164 cases annually, the result of the cost comparison clearly favours the scenario with the physicians travelling to the conference. The result shifts towards the teleconference at an annual number of cases of 272, which is not an unrealistic figure due to increasing standardisation of tumour therapy procedures with the necessity of tumour board presentation.
Nevertheless, the results presented have to be regarded as a preliminary attempt to compare the costs of the two scenarios. Further costs have to be included, and the assumptions made have to be expanded. The total costs of scenario 1, for example, have to consider maintenance costs for the technical equipment as well as costs for data transfer and telephone costs. Furthermore, the price for the case conference service might be raised by the proportional depreciation costs of the technical equipment in Eberswalde that is needed for the teleconference. At the same time the depreciation costs for the technical equipment decrease as a result of the extraction of the equipment of Eberswalde from these costs, which leads to lower fixed costs for scenario 1.
Finally, to realise the training aspect of teleconferences, the time an external physician spends on taking part in the tumour conference has to be broadened. He does not disconnect after the presentation of his hospital’s cases, but attends the whole conference, and the benefit of qualification and advanced training within the tumour conference has to be taken into account too.
As for the costs of scenario 2, it has to be revised whether a mileage allowance adequately represents the actual consumption of resources produced by driving by car. Beyond that, the number of external hospitals participating in the teleconference, the distance between the hospitals, the depreciation period of the telemedical equipment and the number of cases presented by an external hospital have an influence on the total costs of both scenarios and therefore on the advantageousness of one scenario over the other. Future calculations need to consider these aspects.