In recent years there has been a breakthrough in healthcare related to state-of-the-art technologies, especially in diagnostics. Computed tomography, ultrasonography and magnetic resonance are some of the most advanced imaging diagnostic techniques. Imaging examinations are used to detect diseases, e.g. cancers but also to evaluate treatment effectiveness or monitor medical procedures. Currently up to 80% of diagnoses are made or confirmed based on imaging examinations. In case of X-ray examinations in trauma medicine or neurosurgery it is up to 100%.
Robotics is more and more broadly applied in medicine. It allows performing complicated operations with high precision, while being minimally invasive at the same time. The skills of robots are used among others in surgery, gynaecology, urology or transplantology. Until present, about 900 thousand surgeries by means of robotic systems have been performed worldwide. About 60 procedures of this type were carried out in Poland in 2018, whereas in 2019 it was nearly 900. The robotic surgery market in our country is still fledging. In line with the data of the Ministry of Health of December 2021, only 12 medical facilities used the da Vinci surgical system in the public healthcare system.
Growing popularity of modern technologies is linked to increasing demand for specialised medical staff, trained to use such devices. This situation generates high costs related to the purchase and maintenance of specialist medical equipment. The NIK audit was to show, first of all, if the medical facilities optimally use high-tech medical equipment to diagnose and treat patients; in other words if the equipment is used to the highest benefit of patients and in line with the economy principle.
In the audited period, the medical facilities’ level of high-tech medical equipment went up by 26%. In 2017-2021, those entities purchased the total of 119 specialist devices for over PLN 434 million. The purchases were made first of all to replace obsolete and worn-out medical equipment.
But the main reason why the medical facilities decided to buy high-tech medical equipment was to finance the purchase from external sources. The purchase decisions were often taken on an ad hoc basis, without proper identification of patients’ needs and despite the lack of interest on part of the National Health Fund to contract an extended scope of services. This is in breach of the principle set out in the Public Finance Act which says that public funds should be used in an adequate and economic way.
In 10 medical facilities (almost 60% covered by the audit) high-tech medical equipment was not used in an optimal way.
Four hospitals bought medical equipment for over PLN 9.5 million (including machines for angiography, mammography, magnetic resonance and intraoperative radiotherapy). However, the machines were not fully used due to the limited scope of services provided under the contract with the National Health Fund.
Frequent breakdowns of medical devices and related costs were a significant issue. In the audited period, in 13 facilities covered by the audit the costs of repairs exceeded PLN 10 million. Because of breakdowns three entities stopped using medical equipment to diagnose or treat patients.
Only five in 17 audited medical facilities (less than 30%) had da Vinci surgical systems at their disposal. Four of them bought the da Vinci equipment for nearly PLN 50 million in the audited period. Until the end of 2020, the total of 696 procedures were performed using those systems. In two entities the da Vinci surgical systems were used to a little extent because of high costs of procedures. In 2017, the Minister of Health started legislation works to add robotic surgery treatment in three cancer types to the list of guaranteed medical services. The works were not finalised by the end of the audit, though. Only on 25 January 2022, under the ordinance of the Minister of Health, the robotic system treatment of prostate cancers was added to that list.
The devices used most in the audited period were accelerators. They were used by six in 17 audited entities. The procedures using accelerators made up as much 36% of all examinations and procedures performed by means of the audited equipment. Interestingly enough, the number of those devices went up slightly in the audited period. NIK has pointed out that buying subsequent accelerators without a thorough analysis of patients’ needs may result in ineffective use of funds in the entire healthcare system.
At the same time, the number of procedures using accelerators per one device is declining. The downward trend in this area could be observed even before the COVID-19 epidemic. In 2020, the number of such procedures went down by the average of 10 per day, which is a nearly 30% decrease.
The majority of the audited medical facilities (10 in 17) made sure the high-tech medical equipment was used in a safe manner. In six entities, technical inspections were too rare, though. The inspections were delayed for 11 devices, by one month on average. That situation posed a risk of errors in examination results, improper course of treatment or failure to provide safety to patients. In a longer-term perspective, the provision of services using defective equipment may be the basis for patients’ claims due to medical malpractices.
Despite an increase in the total number of radiologists, there was a shortage of those specialists in nearly ⅓ of the audited entities. The situation was particularly difficult in small hospitals. There were no doctors on duty, which extended the time of waiting for the diagnosis. The access to X-ray examinations depended on the region and on the equipment deployment as well as on the number of doctors providing healthcare services. Doctors were unwilling to work during the night and on holidays. The problem was solved by enabling doctors to interpret X-ray images on a remote basis, as part of the so-called teleradiology.
A smaller increase was reported in case of the so-called difficult specialisations, including oncological radiotherapy and nuclear medicine (by 10% in both cases in 2017-2021). In 2021 in Poland, there were 835 doctors specialised in oncological radiotherapy and only 322 nuclear medicine specialists.
Because of staff shortages in two entities the minimum staffing was not guaranteed to provide services in the computed tomography unit. In one hospital it happened that cardiologists were on duty for several days in turn, without any break. In extreme cases doctors were on duty for 120 hours, i.e. 5 days. NIK has emphasised that this situation created a risk of low-quality services which, consequently, posed a threat to the health of patients and doctors.
In the audited facilities, 65% of interpretations of examination results (including computed tomography, magnetic resonance or mammography) were prepared within 3 days. NIK highlighted the alarmingly high percentage of image interpretations which took longer than two weeks (16%). It happened that examination results were interpreted even longer: over two months in an emergency and over 6 months in a stable case.
In three entities (18%), in case of 41 imaging diagnostics and nuclear medicine examinations, interpretations were made after the deadlines defined in civil law contracts signed with radiologists. Sometimes the delays reached 1.5 months.
In 13 medical facilities (76%), breaches of the Medical Activity Act were reported. In particular it was about awarding contracts for services worth more than the equivalent of EUR 30 thousand, without the required tender procedure. The total value of illegally awarded contracts was nearly PLN 11.5 million.
NIK’s recommendations
To the Minister of Health
- to speed up the process of adding the robotic surgery treatment of selected medical conditions to the list of guaranteed medical services, which is also supposed to accelerate the development of robotic medicine in Poland;
- to prepare solutions within the whole healthcare system, to ensure effective use of medical equipment purchased from public funds, also to introduce a requirement to include planned examination or procedure performance indicators in all requests and contracts to subsidise high-tech medical equipment, as a point of reference to monitor the use of those devices;
- to use data gathered in the system called healthcare statistics and maps of healthcare needs, to ensure effective public spending.
To provincial governments
- to introduce a requirement to include planned examination or procedure performance indicators in all requests and contracts to subsidise high-tech medical equipment, as a point of reference to monitor the use of those devices.
To medical facilities
- to specify maximum deadlines to interpret X-ray imaging examinations in internal procedures and civil law contracts signed with doctors.
