Translating and Advocating New Evidence-Based Research into Hungarian Health Care
- Dr Peter Pal Varga Shares His Experience
Dr Peter Pal Varga, MD, is a recognized world leader in the field of spine surgery and spine tumor management. He has been involved with AOSpine since 2005, and is currently a steering committee member of the Knowledge Forum Tumor, a pathology-focused study group that produces evidence-based research on primary and metastatic tumors of the spine. Varga has been practicing as an orthopedic spine surgeon for almost 40 years. During his medical career, he has made a profound impact on the Hungarian and Eastern European countries, by significantly increasing the quality of spine care in Hungary, and by translating research findings into policy-making.
In this article, Varga shares his experience as the founder of the Buda Health Center and Director of the National Center for Spinal Disorders in Budapest, Hungary. He also shares highlights from his role as president of the Hungarian Spine Society, which uses evidence-based knowledge to drive policy-making, and as Chairperson of BBBSpine, one of the most important spine tumor conferences in Europe.
Health and spine care in Hungary
Hungary, which has a population of approximately ten million, has a centrally-organized health system.
Expenditure on healthcare is financed mainly through a combination of contributions and general tax revenue transfers to the health insurance scheme. The benefits provided are comprehensive but not exhaustive. The National Health Insurance Fund Országos Egészségbiztosítási Pénztár (OEP), a central agency, is responsible for the reimbursement policy.
"The biggest key challenge has been how to implement the results of the latest research into the everyday clinical practice of individual clinicians and hospitals."
According to Varga, Hungary has a good healthcare system, but as in any country, there is always a need for improvement. One has to bear in mind the country’s history: 40 years under communist rule eroded the economy although a benefit was the provision of social healthcare. Since the transition to a Western-style democracy, Hungary has both a national healthcare system and a private sector. There is only one government-owned health insurance company. Apart from that, there's no other significant health insurance activity in the country. Patients who are insured with a private health care provider pay for services out of their own pockets. The public health plan, which provides a clear vision of the government’s plans for the development of healthcare provision based on public needs, includes evidence-based standards.
The provision of spine surgery in Hungary has massively improved in recent years. For example, about five years ago, the waiting time for elective spine surgery was more than three years. Today, it is only six months across the country.
The Buda Health Center and the National Center for Spinal Disorders
The Buda Health Center was established in 2000 by Varga, who also acts as director general. It is a private health clinic. More than 100 physicians in 47 specialties see their private patients in the facility, and more than 230 national and multinational companies have contracts with them for their employees’ health care.
Varga states: "My significant income from the industry after my medical device and implant innovations between 1994-2006 enabled me to provide the economic background to establish Buda Health Center (eg, purchase of the building and equipment). Later, the company itself grew comprehensively, and the positive business processes provided satisfactory capital for continuous re-investment."
"The insurance companies understand the benefits that the latest treatments and techniques provide for both patients and the healthcare system."
The National Center for Spinal Disorders (NCSD) in Budapest is the affiliate hospital to the Buda Health Center. Currently, about 90% of the spine tumors treated in Hungary are treated at the NCSD. It is the only hospital in Hungary that covers virtually the entire spectrum of spinal disorders, from diagnosis and non-surgical and surgical treatments, right through to rehabilitation. The high level of professional know-how, state-of-the-art equipment, and preparedness has made it the country’s foremost spine care institution. The center is a large organization, carrying out over 2,000 surgeries a year. The hospital also offers publicly-financed outpatient care in the areas of musculoskeletal disorders (spine care, orthopedics, and traumatology) and anesthesiology, as well as inpatient spine care and spine surgery for national and international private patients, and patients who are covered by Hungarian Health Insurance. The center was a part of the Department of Spinal Surgery and Rehabilitation of the Orthopedic Clinic at Semmelweis University of Medicine until 1995, when it was integrated into the Medical Center of the Hungarian Defense Forces. In 2005, it became independent. It is currently operated by the Buda Health Center, under the direction of Varga.
Over the years, the NCSD has collected a vast amount of data of the highest quality in its registry. Varga constantly works with oncologists in order to evolve and develop the database. The NCSD has a staff of approximately 170. Of these, 20 are directly involved in spine surgery. The center is financed by the National Health Insurance Fund.
The clinic has become known worldwide, gaining international recognition for its complex method of reasoning behind the treatment of spinal disorders, and the orthopedic and philosophical innovations that have come out of the center have gone on to become universally-accepted methods of treatment of the spine.
Implementing the latest research results into everyday practice and funding spine care
Today, it is often the case that the insurance companies in Hungary are waiting for the latest evidence in order to fund new treatments or procedures. Therefore, once research has been published, a proposal can be made to the insurance companies. Although the cost of the procedure may potentially be high, the insurance companies understand the benefits it has for patients.
"The biggest key challenge has been how to implement the results of the latest research into the everyday clinical practice of individual clinicians and hospitals," shares Varga. "The main issue was how to achieve reimbursement for a new treatment or procedure, which is recommended based on the latest evidence, and could lead to changes in the treatment paradigm," he adds.
In the case of spine care, the Hungarian Spine Society proposed the Hungarian government to create the so-called Spine Committee, an official structure for reviewing the clinical evidence and implementing new treatments or procedures into the reimbursement system. This committee is composed of three doctors, including Varga (the chairman), and three people from the OEP. Through this new structure, when a new medical treatment or procedure becomes available, a rapid response to a proposal for its reimbursement can be obtained from the OEP. The Spine Committee makes a proposal, which is then discussed with representatives of the OEP, who usually accept the proposal. The treatment or procedure is then accepted by the government as the best evidence-based current practice and is immediately implemented in the Hungarian healthcare system. The OEP creates the standard, proposes the reimbursement, and then reimburses and finances the treatment or procedure.
Varga comments: "I am currently the president, for the second term, of the Hungarian Spine Society, which was established 25 years ago and currently has about 300 members. This provides a great platform to implement AOSpine Knowledge Forum Tumor recommendations at both the national and district levels, meaning that the expert knowledge can be immediately distributed, on one hand to all members of the society, but also to other stakeholders, such as insurance companies. The Hungarian Spine Society has a very good cooperative working relationship with the insurance companies in Hungary. The insurance companies understand the benefits that the latest treatments and techniques provide for both patients and the healthcare system. A cost control group in a hospital works with a cost control group in the insurance company to investigate the different costs associated with spine care, providing an overview of the entire process. This set-up is operating smoothly and providing acceptable results, with patients having access to state-of-the-art treatment. There are no limitations on the type of treatment or procedures that can be reimbursed."
With this approach, decisions can be made rapidly, as soon as new evidence or recommendations become available. Also, the Spine Committee is constantly up-to-date with ongoing research, so that when a study is nearing completion, it can make decisions quite quickly. When a proposal is made to the OEP, a decision can usually be made within a few weeks. A diagnosis-related group (DRG) system is used, including all patients grouped according to their diagnosis, so patients with spine tumors constitute one DRG. For inpatients, hospitals are paid a fixed price per case, depending on the patient’s DRG.
"How can we provide education for all of the different professional groups and stakeholders involved, so that all the different specialists continuously have a common knowledge base?"
Distributing knowledge and keeping up with the latest technologies
According to Varga, the second challenge was how to distribute the knowledge to surgeons and institutions in order to guarantee consistency. At the National Center for Spinal Disorders, for example, there are 47 different medical specialties. This created the question: "How can we provide education for all of the different professional groups and stakeholders involved, so that all the different specialists continuously have a common knowledge base?"
"Spine surgery is an endless source of excitement, because it is very fast moving when it comes to the implementation of latest technology," Varga comments. "Spine surgeons work at the cutting edge of technology, using the latest techniques available. Thus, the entire educational process is complex and entails a high level of intellectual involvement and a myriad of factors, including surgical technology, patients, data collection and analysis, and co-operation with different medical and scientific specialists. In addition, the younger generation of surgeons has to be continuously trained," he adds.
Varga describes the education and training provided by AOSpine as key success factors for these activities. "AOSpine does very good work. In my opinion, one of its most significant achievements since its foundation has been the international collaboration that takes place. AOSpine has a very professional administration, so it is the ideal organization to coordinate these kind of activities. I don’t think that any other single spine organization could undertake the range of activities that AOSpine carries out. This enables expert knowledge to be disseminated to all members and helps to raise the standards of spine surgery in Hungary and across the world. The results of the research conducted and the recommendations made by AOSpine Knowledge Forum Tumor have had a significant influence and impact on spine care in Hungary, which is now at a similar level to that of the best international standards."
Chairperson of BBBSpine—Bologna-Basel-Budapest Spine Meeting on tumors and osteoporosis
Two friends, Varga and Dr Stefano Boriani, are the chairmen of what is referred to today as the Bologna-Basel-Budapest Spine Meeting on Tumors and Osteoporosis (BBBSpine). In 2011, they initiated the event, previously known as BBSpine. It is a two-day annual meeting, where the world's experts in the field of spine tumor surgery come together to exchange ideas and gather information regarding the latest surgical practice trends and innovations on tumors and osteoporosis-related diseases of the spine.
"Stefano and I have collaborated for several years," explains Varga. "We wanted to expand our cooperation and knowledge by bringing together our two institutions, the National Center for Spinal Disorders (Budapest, Hungary), and the Rizzoli Institute (Bologna, Italy), which are two major reference centers for these pathologies, with other world-renowned experts from different countries," shares Varga.
For the past four editions, the meeting location has alternated between Bologna and Budapest. Since 2014, the AOSpine Knowledge Forum Tumor has been integrated in the event. They have participated as faculty, representing the international consensus and focusing on national needs. They also hold a special symposium where they disseminate the latest research results from their studies.
"Budapest hosted the event twice—in 2012 and 2014. This has been an incredible opportunity not only for my institution, but also for the Hungarian and European spine surgeon communities. We have successfully created a high-level, focused platform to learn, share, and discuss primary and metastatic spine tumor surgery and the treatment of spinal disorders in the aging population with the world's most renowned spine surgeons," comments Varga.
In 2016, at the fifth meeting, another "B" was added, making it the BBBSpine Meeting, because it took place in Basel, Switzerland, under a third chairperson, Dr Stefan Schaeren. Over 30 global experts from 14 different countries contributed to the meeting, representing Europe, North America, the Middle East, and Asia.
"While this event started between two friends and countries, it is expanding. It is one of the most important conferences in Europe on spine tumors and there is nothing else comparable. We are looking forward to hosting the next event in Budapest later this year," Varga concludes.
The sixth BBBSpine Meeting will take place in Budapest, Hungary from November 10-17, 2017. For more information, please visit: www.bbspine.org/2017.
Forrás: AOSpine Newsletter, April 2017