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Cost and Benefits in Delivery of Neurological Services

The scientific and technological advances in medicine in the last three or four decades reproduced in neurology a series of revolutionary changes, which have completely altered the character and the scope of the discipline of neurology. The rapid growth of neurosciences and the introduction of the sophisticated investigation methods into the diagnostics and treatment of most of the neurological diseases resulted in an enormous expansion of manpower, institutions and expensive facilities in neurological services in developed countries, based on close collaboration between basic neurological research and clinical work. Neurology has become one of the most rapidly progressing medical disciplines, having also growing impacts on social and economic life. From a relatively conservative, mostly expectative and epistemologically oriented clinical discipline, with limited diagnostic and therapeutic capabilities it has changed to the very active medical discipline with many possibilities of early diagnostics and often radical ways of treatment. Modern neurosurgery enabled optimal treatment of many neurological diseases - including functional disturbances - , sparing the surrounding nervous tissue, and achieving the best results with minimal secondary lesions. New ways of successful prevention and rehabilitation of many neurological diseases have been appearing in recent years. Through these advances many individual fates, but also the course of many groups of neurological diseases, have been radically modified. The growing insight into the basic pathophysiological mechanisms of the origins and course of neurological diseases constantly improve our competency and efficiency in early diagnostics and rational management of many neurological disorders. However, like in some neurological disorders there are several or even many responsible risk or etiologic factors, it is likely that such multifactorial diseases cannot be treated efficiently by a single medical principle and their management must be complex: this has to be differed from polypragmasy, not only expensive and inefficient, but also potentially harmful. The broadening of the field of neurological activities has been enabled through the application of new technological advances in practical work of neurologists, leading to the growing number of practicing neurologists in most of the developed countries. New diagnostic techniques have been developed and incorporated into everyday clinical neurological practice, as an indispensable modern additions to the neurologists' classical diagnostic tools: hammer and needle. The field of clinical neurophysiology has been enlarged, new methodologies introduced into the good neurological practice, and its field has been recently differentiated into the methodologies investigating the central and peripheral nervous system: while the classical EEG has been extended by polygraphy and computerized methods, like Brain Mapping and Event Related Responses methodologies, the classical EMC has been enlarged by important specific methodologies enabling better diagnosis and more adequate programming of rehabilitation. The classical neuroscintigraphy evolved to the differentiated highly specific researh and diagnostic methodologies (SPECT and PET), while radiology has been enlarged by neuroimaging methods - CT and MRI, indispensable help for contemporary neurologist. Neurosonology developed new and relatively inexpensive diagnostic methods in the field of angiosonography, which can compete with the classical angiography and have specific diagnostic indications. In a relatively short time within the field of clinical neurology new subspecialties have developed in the industrialized countries, legitimate from educational, scientific and organizational standpoints: neuromuscular diseases, epileptology, cerebrovascular diseases, multiple sclerosis, intensive neurology, developmental and child neurology, neuroinfectology, neuro-epidemiology, neurorehabilitation and restorative neurology, neurotoxicology, geriatric neurology, behavioral neurology. Another development of common efforts of basic neurological sciences and contemporary clinical neurological research led to better understanding of the internal brain organization and its functioning, permitting further under-standing of mental functions in respect of learning, cognitive, emotional and other complex higher nervous functions and their disorders. This aspect of neurology brings it closer not only to some related problems of psychiatry and psychology, but also to problems in education, psychological rehabilitation and prevention of brain aging. Relatively recently a burden of many mass neurological diseases and disorders has been disclosed, as well as their social and economic importance. The described developments of the concept of neurology have been accepted as a natural consequence of the scientific and economic progress, but restrictions of financial resources in many developing countries have appeared as an unsolvable problem in their practical implementation. Even in rich industrial countries questions have been risen on the cost and value of the modern diagnostic and therapeutic methods both from economic and medical points of view. In spite of the uncontroversial efficacy of modern scope of neurological practice both for the individual and for the humane vocation of neurology and medicine in general, such problems must be approached through comparative investigations worldwide, trying to find the best solutions in a certain community at a certain time, respecting specific local economic and social conditions. The specific algorithms may be formed for optimal and rational diagnostics and management in order to find the economical solutions for the existing problems ; hovVever they have to be modified in time and adapted to a regional or local situation. Problems of the cost and benefits in delivery of neurological services have not been largely investigated, specifically not in its entirety. This problem was specifically approached at the XVth World Congress of Neurology (New Delhi, 1989) at the Symposium on neurology in developing countries, and afterwards in the WFN Research group on the Organization and Delivery of Neurological Services. In the Medline-Database, incorporating inputs: cost-benefit analysis, neurology, brain diseases, cerebrovascular disorders, epilepsy, neuromuscular diseases, only 34 papers have been found for the period 1992-1995, related to some specific problems. The recent awareness of the current burden of many neurologic diseases, withstanding their social, economic and human importance, including also its cost and benefits aspects, produced recently in a world neurologic community an intensive interest, recognized in the World Federation of Neurology: in the program of the following World Congress of Neurology in Buenos Aires (September 1997) there will be for the first time a symposium on the topic: "Neurology and Public Health. Economical Consequences of the Cost of Treatments and Diagnostic Tests". This main theme of the Pula Symposium presents a pioneer approach of this kind and certainly is a useful encouragement for the research in the field.

cost benefit; neurological services

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