Neurological Sciences

, Volume 34, Issue 12, pp 2193–2198

Need for neurology specialists to be dedicated to hospital care in Italy

Authors

    • Neurology Care UnitLoreto Nuovo Hospital
  • Domenico Inzitari
    • Stroke and Neurology UnitCareggi University Hospital
Original Article

DOI: 10.1007/s10072-013-1446-1

Cite this article as:
de Falco, F.A. & Inzitari, D. Neurol Sci (2013) 34: 2193. doi:10.1007/s10072-013-1446-1
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Abstract

Any patients admitted to healthcare facilities with a neurological diseases deserves to be managed by a neurologist. This is particularly important for acute onset neurological disorders, because of their severity and the requirement of early and appropriate diagnostic–therapeutic approach. In addition, this may reduce both unnecessary admissions and length of stay, with a significant saving of resources for the National Health System (NHS). To ensure this, it is important to evaluate predictable needs for hospital neurologists in Italy. The hospital discharges for neurological medical diseases of the Major Disease Category (MDC) 1 were 455,132 in 2009 and 491,836 in 2008, more than 50 % of which were acute neurological disorders. Stroke and transient ischemic attacks (TIA) accounted for about 170,000 per year. Currently available neurologists in Italian healthcare facilities are largely insufficient to assist such a large number of patients. The 270 Neurological Care Units in Italy (of which 243 open to the emergency care) are equipped with an average number of 7.7 neurologists per unit, inadequate to ensure on duty care 24 h a day, 7 days a week. In addition, the mean age of hospital neurologists is quite high, with provision for large retirement. It is therefore required to increase in the next few years the number of neurologists by at least 30 %, with an increase of 562 units. To meet the need for neurology specialists committed to hospital care in Italy is also necessary to increase the number of scholarships for residents in post-graduate schools.

Keywords

Neurology manpowerNeurology educationPostgraduate trainingNeurological acute diseases

Introduction

Most of neurological disorders have an acute onset or present as a medical emergency requiring urgent intervention: conversely, neurological diseases account for a significant proportion of the medical emergencies dealt within any hospital setting [1]. Furthermore, neurological emergencies are often related to severe conditions associated with high mortality and high costs, the latter not only generated by the emergency care provided in the acute phase, but also resulting from their frequent disabling outcomes.

In the past, Neurology was generally considered as a low intensity-of-care discipline, whereas now the greater understanding of the pathophysiology of acute neurological conditions, the advances in the field of diagnostic imaging and the availability of new treatment options [2] have completely changed the diagnostic–therapeutic approach to neurological emergencies. Neurologist is now emerging as an increasingly important figure in emergency departments [36], and Italian neurology units mostly admit patients with acute diseases requiring high-intensity and high quality care. Despite this, in Italy, Neurology continues to be classed even at institutional level as a medium care specialization and neurological care units often do not have sufficient medical staff to provide round-the-clock care.

In Italy, in the year 2012, about 5,000 post-graduate training contracts have been assigned by the Ministry of Health for the first academic year to all specialties, of which only 113 (slightly more than 2 %) have been allocated to neurology training. In a recent Decree of the Minister of Health, in consultation with Education and Economics Ministries (published on May 23, 2012), it was estimated as 24,798 the units needed to be trained in post-graduate schools of medicine for any specialty throughout 2011–2014 years, with 8,438 contracts for 2011–2012, 8,170 for 2012–2013 and 8,190 for 2013–2014. Even if the number will be increased as announced, and the proportion of positions for neurology training will be maintained as the 2 %, 160 new neurology specialists will be available for the whole (including the outpatients care) neurology care each year. This number is largely lower compared with the number of hospital neurologists who annually retire or are unavailable for service each year.

According to data reported by the Italian National Health Plan for 2011–2013, among the 112,000 doctors employed in the NHS, there is a high concentration of aged 60 or more years, so that there is the expectation of retirement of 17,000 physicians within 2015, with a negative balance between retirements and new recruitment already in 2012. Data reported by the National Association of Hospital Doctors (ANAAO-ASSOMED) are even more alarming, with 30,000 expected retirements from 2011 to 2015. The neurologists account for about 2 % (2,240) of doctors in the NHS with an expectation of 340–600 retirements in that period. To this figure must be added the number of neurologists employed in private healthcare facilities and outpatient clinics.

It is expected that the distribution of training contracts across the different specialties will be object of a next further decree by the Ministry of Education, and it is therefore urgent to demonstrate the real predictable needs for hospital neurologists in Italy on the basis of the real neurologic hospital care requirements, apart from the necessity to replace the retirements. Adjusting the number of available specialist to real needs would address among others the problem of inequality of services among different Italian Regions, besides promoting more appropriate care at any hospital level, reduce unnecessary admissions and clinic attendances, shorten hospital stays, an investment that would surely prove to be cost-effective in the long term.

Need for neurologists in Italy

To evaluate the need of neurologists engaged in the hospital care activity for the treatment of neurological diseases and especially of neurological acute diseases, the following issues should be considered:
  1. 1.

    number of hospital discharges for neurological non-surgical diseases of the MDC 1 (ICD-9-CM, International Classification of Diseases––Clinical Modification), assessing the absolute number per year, days of hospitalization consumed and the number of hospital beds that have been committed;

     
  2. 2.

    (a) number of hospital discharges for acute neurological diseases, primarily cerebrovascular [stroke but also transient ischemic attack (TIA)], length-of-stay in hospital and beds requirement, and (b) assessment of the needs of neurologists, based on the number of Stroke Units required in Italy, according to the guidelines of the Ministry of Health, considering that the second and third level SU are defined as neurological care units with 24 h a day/7 days specialist.

     

Neurological medical diseases

Over the last years, the total number of patients with neurological diseases (MDC 1) discharged from Italian health facilities were substantially stable, with a slight reduction reflecting a general reduction in hospital admissions.
  • In 2008, N. 577,850 (7.5 % of all hospital discharges)

  • In 2009, N. 540,895 (7.1 % of all hospital discharges)

  • In 2010, N. 523,287 (7.1 % of all hospital discharges)

If we detract discharges for surgical DRGs of MDC 1, the neurological medical cases treated in Italian facilities have been:
  • In 2008, N. 491,836 consuming 3,827,987 days of hospitalization (mean length of stay 7.8 days).

  • In 2009, N. 455,132 consuming 3,624,330 days of hospitalization (mean length of stay 7.9 days).

  • In 2010 available data were not complete, but the cerebrovascular acute diseases alone were 182,408 (DRGs 14, 15, 524).

The above data, obtained from Health Informatics System of Italian Ministry of Health [7], shows that neurological medical diseases of the MDC 1, in years 2008 and 2009, consumed a number of days of hospitalization corresponding to 10,488 beds in 2008 and 9,930 beds in 2009 (assuming a theoretical occupation of the bed of 100 %).

The neurological beds in Italy are about 5,000 and in the Neurological Care Units are engaged approximately 2,080 neurologists, as results from the Italian epidemiological survey “NEU project” [8] and from the NEU-2 data presented in 2011 by the Italian Neurological Society to the Italian Senate. If all neurological disorders should be managed in neurology units, it would take just another 5,000 beds and 2,000 neurologists.

This goal is not easily accomplished, but these data confirm that a large proportion of neurological patients have no access to specialist care (probably with some implications for diagnostic and therapeutic protocols).

The proportion of neurological diseases that are not treated by a specialist neurologist (lost market share), was very high and has been well highlighted by the SINERGIA Study (CERGAS), which was attended by the President of Italian Neurological Society along with other senior colleagues, although with some limitations: to be referred to Lombardy (a large Italian region where Neurological Cure Units are strongly represented, compared to many other Regions) and to be referred only to healthcare facilities where a neurology care unit was present.

Acute neurological diseases, cerebrovascular diseases, and stroke units requirement

With regard to acute neurological diseases, particularly to stroke which is the most frequent and requires competence and high quality care, the Italian Ministry of Health in agreement with the Italian and international guidelines and the scientific evidences has already given clear indications. These indications provide that stroke patients should be managed in dedicated facilities with qualified medical and nursing staff (Stroke Units) and indicate that the second and third level SU must be specialist neurological care units (The Stroke Unit, Quaderni del Ministero della Salute n. 2, 2010 [9]).

In 2008, the number of patients treated for stroke (DRG 14) in Italian health facilities was 113,042 cases. In 2009 and 2010 there were some changes in the coding system (ICD-9-CM) and number of cases of DRG 14 were 90,194 in 2009 and 91,307 in 2010. It should be noted that in these 2 years it appears a new DRG 15 (which previously codified the TIA, now coded as DRG 524) defined as “non-specific acute cerebrovascular disease and precerebral occlusion without infarction”, equal to 34,277 discharges in 2009 and 31,841 in 2010, in which a considerable number of acute cerebrovascular diseases fall.

For this reason, it is more reliable to refer to data of 2008, with 113,042 stroke patients treated in Italian health facilities. These patients had a mean hospital stay of 10.4 days, corresponding to the use of 3,221 beds. With a mean hospital stay of 8.5 days (considered optimal for stroke hospital management in Stroke Unit), the same number of patients configures the need for 960,500 hospital days and 2,630 beds dedicated in SU, saving 591 beds.

This number is absolutely in accordance with the provisions of the guidelines of the Ministry of Health.

Excerpta from “Quaderni del Ministero della Salute n. 2, 2010” [9]

The need for dedicated beds in SU is generally provided in eight beds for 100/200,000 inhabitants. A more detailed analysis of the requirements can be made on the basis of incident cases (cases expected in a given population, taking into account its composition by age) or that of the treated cases (the number of discharged patients with a diagnosis of stroke for region or province). In the latter case, based on real numbers, for 129,200 cases of stroke discharged each year in our country and considering a mean hospital stay of 8.4 days, it would take 2,970 beds. The requirement for a population of 57.5 million, corresponds to approximately 50 beds per million population, in line with what is generally required in the Guidelines. The long-term goal is then of six second and third level SU with eight beds per million inhabitants. The medium-term objective is achieving at least 50 % of second and third level SU, with the transient permanence of first level SU that will gradually acquire the higher level. This can be achieved through the reorganization of health care resources already involved in managing acute stroke, firstly the neurological care units, and through the implementation of integrated care and rehabilitation pathways.

Thus, also considering the expected minimum of six SU of eight beds per million inhabitants, compared to the current population of 60,000,000 inhabitants, this translates into a requirement of 360 SU with a total of 2,880 beds. The reduction of the mean hospital stay to 8.4 days represents a considerable savings for the NHS and a greater efficiency in the management of patients.

In Italian health facilities, there are currently about 130 SU, with variable number of beds. The planned 360 SU (structured as simple, departmental or complex care units, depending on the complexity and size of the structure) should be implemented mainly in the context of Neurological Care Units and, in any case, a SU must have a specialist staffing which provides a neurologist on duty 24 h a day.

Currently, the 270 Neurological Care Units in Italy (of which 243 open to the emergency urgency) are equipped with an average number of 7.7 neurologists, inadequate to ensure patient care and specialist on duty 24 h a day, 7 days a week (which in fact is present in <50 % of them) [8]. In addition, the mean age of hospital neurologists is quite high, with provision for progressive retirement. Is therefore required to increase the number of neurologists by 30 %, from the current 1,874 employees in 243 Italian neurological care units open to emergency to the number of 2,436 with an increase of 562 units.

This number is only required to treat stroke patients, limiting to the minimum the number of planned SU and using for the most part neurologists already employed in the actual neurological care units. It should also be stressed that an additional number of acute cerebrovascular events that often require hospitalization for clinical observation and an appropriate diagnostic path, is represented by TIAs. TIA patients discharged from Italian hospitals were:
  • 58,673 cases in 2008 (DRG 15), with a mean length of stay 6.8 days, consuming 400,091 days of hospitalization;

  • 62,314 cases in 2009 (DRG 524), with a mean length of stay 7.3 days, consuming 454,055 days of hospitalization;

  • 59,260 cases in 2010 (DRG 524), with a mean length of stay 7.0 days, consuming 414,820 days of hospitalization.

Urgent specialist assessment and treatment of these patients reduces disability, days in hospital, and costs [10]. To provide a neurological management to this additional relevant number of acute cerebrovascular patients, using specific skills and diagnostic technologies already present in the SU, it would be necessary to increase the number of beds in SU. However, a competent specialized approach may lead to a reduction in the duration of hospitalization, so that with a mean hospital stay of 4 days, 60,000 TIA cases can be managed with 657 beds, instead of 1,136 as currently done, with a significant saving of resources by the NHS. According to the SINERGIA Study, the percentage of TIA that is not currently managed by neurologists is 55 %. The study was carried out in hospitals equipped with a Neurological Cure Unit so that if we consider all Italian facilities, with or without Neurological Care Unit, the percentage is to be assumed even higher. Assuming that the percentage was 70 %, additional 460 neurological beds are required, with 115 neurologists, one every four beds (the indication of one for four beds is questionable and depends on the characteristics of the healthcare facility).

Discussion

All patients admitted to healthcare facilities with neurological diseases should be managed by a specialist neurologist. This is particularly important for acute onset neurological disorders, because of their severity and the requirement of early diagnostic–therapeutic approach, in order to achieve a better clinical outcome. The admission of these patients to a Neurological Care Unit could also reduce the mean hospital stay and therefore the number of hospital beds required, with a significant saving of resources to the NHS [9, 10].

Despite this, the shortage of neurologists and the inadequate weight of education for neurological emergencies in training programs is a problem shared by many countries in Europe and US, and has the largest effect in emergency rooms and other critical-care settings. In US, despite the expansion of neurocritical care concept, large proportions of US neurology residents have limited exposure to a neuro-intensive care units, and a formal training in this selective field may be highly variable [11, 12]. The American Academy of Neurology is investing time and resources to develop “a body of knowledge” for care of critically ill patients with neurological disorders, and the neurohospitalist model, in which inpatient neurology specialists deliver high-quality and efficient care to neurology patients, is now emerging in US to meet these challenges. Neurohospitalists have emerged as “site-specific specialists” focusing on inpatients with neurologic disease that can provide more timely evaluation of either emergency department or hospitalized patients [1315].

A survey of the World Federation of Neurology showed that many regions of the world, including those with the highest prevalence of disorders of the nervous system, have few or no post-graduate neurology training programs [16]. As shown in Table 1, in European countries the number of neurologists is very different between countries, with an average of 6.6 neurologists per 100,000 inhabitants (range 0.9–17.4/100,000 inhabitants). Duration of training in Europe was on average 4.8 years, ranging from 3 to 6 years and considerable differences exist in training curricula [17]. Lack of neurologists has become an obvious problem recently in Hungary, not only in small hospitals, but in major health care centers and also in university hospitals [18]. The UK has among the lowest number of neurologists for its population size in Europe, with just one neurologist per 115,000 population in 2006––less than a third of the European average. Consequently, neurologists are rarely involved in the acute care of patients with common neurological disorders such as stroke, epilepsy and head injury. In some UK regions, as few as 8 % of patients presenting with acute neurological conditions are seen by a neurologist. As a result, the outcome of their care may be suboptimal [1921].
Table 1

Neurology manpower and training in Europe

Country

Neurologists per 100,000 inhabitants

National training program

Training duration (years)

Georgia

17.4

Yes

4

Slovak Republic

12.5

Yes

5

Latvia

12.0

Yes

5

Bulgaria

11.7

Yes

4

Greece

10.9

Yes

5

Austria

9.6

Yes

6

Estonia

9.4

Yes

5

Lithuania

8.9

Yes

4

Norway

7.7

Yes

5

Moldova

7.2

Yes

3

Belgium

6.5

No

5

Iceland

6.5

No

5

Czech Republic

6.3

Yes

5

Finland

6.3

No

6

Croatia

6.2

Yes

4

Hungary

6.0

Yes

5

Italy

5.9

Yes

5

Germany

5.5

Yes

5

Switzerland

5.2

Yes

6

Israel

4.7

Yes

5

The Netherlands

4.7

Yes

6

Luxembourg

4.6

No

4

Romania

4.4

Yes

5

Spain

4.4

Yes

4

Serbia

4.3

Yes

5

Slovenia

4.2

Yes

6

Sweden

3.8

No

5

Portugal

3.4

Yes

5

Albania

2.9

Yes

4

Turkey

2.0

Yes

5

UK

0.9

Yes

5

Modified from Struhal et al. [17]

In Italy, the current number of neurologists is not adequate to assist all patients with neurological acute diseases and about 677 more specialists are required only for treatment of 113,000 stroke and 60,000 TIA patients. To meet the need for neurology specialists to be committed to hospital care in Italy is therefore necessary to increase the number of neurologists to be trained in post-graduate schools.

The reported data, demonstrating the real predictable needs for hospital neurologists, must be disclosed to the competent Ministries in order to assign to the neurological specialty an adequate number of training contracts in the Italian graduate schools, especially considering the announced increase approved by the Ministry of Health for the years 2011–2014.

Concluding remarks

  • If theoretically all neurological medical diseases discharged from Italian healthcare facilities should be managed by neurologists, this would require 5,000 beds (of course converting General Medicine beds) and 2,000 additional specialists.

  • If we consider only acute neurological disorders (all these patients should be seen quickly by a neurologist and cared for in a neurology unit with neurologically trained staff), the number of neurologists should increase by 30 % (562 units), only for treating stroke patients in SU.

  • For management of TIA in neurological specialized units, additional 460 neurological beds are required, with 115 neurologists.

Acknowledgments

The authors thank Ms. Maria Elena Della Santa (Institute of Neurosciences, Italian National Research Council) for her technical support in preparing the manuscript.

Copyright information

© Springer-Verlag Italia 2013