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Patient-reported experience measures (PREMs) provide assessments of patients' subjective experiences and perceptions regarding their interactions with the healthcare system and its services. We present a cross-sectional study of the patient perception and evolution of COVID-19 cases performed at Ovidius Clinical Hospital in Romania during the COVID-19 pandemic. The study objective is to explore the utility and the utilization of PREMs in monitoring patient perceptions of the supplementary protective actions. During the pandemic, the hospital implemented early supplementary protective actions, like PCR and lung CT, to all surgically admitted patients in the hospital alongside government-recommended actions. At the same time, functional PREMs were used to evaluate patient perceptions regarding these supplementary actions. The research was carried out for 19 months between June 2020 and December 2021. The findings revealed that opinions about the severity of the COVID-19 pandemic, the personal risk of infection, and the perception of protective actions in the hospital were not correlated. Conclusions: The patients' appreciation of the COVID-19 protective actions taken by the hospital is related more to the general perceptions induced by the number of cases presented in the mass media and less by perceptions of the gravity of the problem or the risk of infection. In a hospital, the primary mission of patient safety is essential, and it must be fulfilled even if the patients are not sure or fully convinced that this is for their benefit. For management decisions and monitoring, using PREMs can be essential in a situation when general evidence is not conclusive.

The Romanian health system is mainly public financed (80.45%) through the following sources: Social Health Insurance (65%), State and Local Authorities Budget (15.45%), while the private sources (voluntary health insurance and out of pocket) adds an additional 19.55% to the public funds. The shares of the types of expenditure reflect the importance of each sector in the overall health system, and trends in expenditure show the impact of financing on the health sector's structural changes. We analyzed the 20-year trend of the Social Health Insurance budget, from 1999 to 2019. The influences of the different allocations, subcategories, and new budget categories appearing over time were adjusted to reveal relevant trends. Of the 14 medical service categories and the stand-alone Administrative expenditure category, six expenditure categories including Hospital services, Total drugs , and Primary care showed stationary 20-year trends; five including Medical devices, Dialysis , and Homecare services showed ascendant trends; and four including Dentistry and Emergency services showed descendant trends. Stationary trends imply no structural changes in the health sector of relevant magnitude to impact the financing shares of major categories: hospitals, drugs, or primary care. Emerging trends related to the impact of different reforms were revealed only in the low share of expenditures categories. The allocation methodology and statistical analysis of the trends reveal a new perspective on the evolution of health sector in Romania., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Radu, Pana, Pele and Costea.)

Introduction: Hungry bone syndrome (HBS) refers to the rapid, profound, and prolonged hypocalcaemia associated with hypophosphatemia and hypomagnesaemia, and is exacerbated by suppressed parathyroid hormone (PTH) levels, which follows parathyroidectomy in patients with severe primary hyperparathyroidism (PHPT) and preoperative high bone turnover. [1]., Case Report: This report concerns a dialysed patient who underwent surgical treatment for secondary refractory hyperparathyroidism. Haemodialysis was carried out pre-operatively, and subsequently, a total parathyroidectomy with auto-transplantation of parathyroid tissue in the sternocleidomastoid muscle (SCM) was performed. Rapid and progressive hypocalcaemia symptoms developed during the second day postoperatively. Acute cardiac symptoms with tachyarrhythmia, haemodynamic instability and finally asystole occurred, which required cardiopulmonary resuscitation (CPR). The ionic calcium level was 2.2 mg/dL being consistent with a diagnosis of HBS. A second cardiac arrest unresponsive to CPR followed an initial period of normal sinus rhythm. Death ensued shortly after. Before death, the ionic calcium was 3.1 mg/dL., Conclusion: HBS, after parathyroidectomy in patients with secondary hyperparathyroidism (SHPT), may be severe, prolonged and sometimes fatal. Generally, HBS symptomatology is that of a mild hypocalcaemia. It can, however, include heart rhythm disturbances with haemodynamic alterations requiring intensive care measurements and even cardiopulmonary resuscitation. A close clinical and laboratory post-parathyroidectomy monitoring of dialysed patients is of the utmost importance., Competing Interests: Conflict of interest None to declare., (© 2019 Corina Pop Radu, Valentin Daniealopol, Ario Santini, Ruxandra Darie, Daniela Tatiana Sala, published by Sciendo.)

Objectives: The objectives of this article were to describe the characteristics of the drug policy in Romania in the last 10 years and to present the consequences in terms of patient accessibility to drugs., Methods: The Romanian health care system with pricing and reimbursement legislation was studied while considering the evolution of pricing and reimbursement processes, the key stakeholders, and the reasons behind changes. A critical appraisal was done covering published materials on the effects of pricing and reimbursement decisions., Results: Romania uses an external reference pricing model considering the lowest price from 12 European Union countries. The result is the visible list price, which is used by the payer as the basis for the reimbursement prices. The reimbursed price depends on the type of drug and the therapeutic area. The claw-back taxation reduces the reimbursement prices by another 12% to 75%, depending on the type of reimbursement for each drug: unconditional (more than 4000 drugs) or conditional (19 drugs) reimbursement. As a consequence, the Romanian prices are one of the cheapest in the European Union, some drugs are leaving the country subject to intracommunity trade and more than 2000 drugs have disappeared from the market in the last 5 years., Conclusions: The drug policy in Romania is centered on price reduction using different techniques and no value-based criteria are used. The pricing is not included in the health technology assessment system, managed entry agreements are not used, and the main effect visible at the patient level is the lack of drugs for some therapeutic areas., (Copyright © 2018 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.)

Objectives: To present the characteristics of the scorecard health technology assessment (HTA) implemented since 2014 and to show the results of this HTA process by the end of 2015., Methods: The health care context and the Romanian HTA legislation were studied while considering the reasons behind HTA introduction, the key stakeholders, and the HTA process as a whole. A critical appraisal was done covering public HTA reports and the decisions made by the Ministry of Health., Results: The scorecard HTA model is in place from 2014 and is based on six criteria: France HTA decision, UK HTA decision, Germany HTA decision, the number of European Union countries with reimbursement, the development of a local real-world data study, and a budget impact assessment. By December 2015, more than 200 HTA dossiers were evaluated and the scorecard HTA results were reflected in three processes of the drug reimbursement list update. Consequently, 25 new drugs, 11 fixed-dose combinations, 2 new indications, and 4 orphan drugs received unconditional inclusion, and 5 drugs received conditional inclusion via commercial arrangements. Moreover, the scorecard system was used for delisting drugs: 16 were delisted and another 21 were moved to a lower level of reimbursement (20%)., Conclusions: The implementation of the scorecard HTA started in 2014 using combined information from Romania and other countries. Although the scorecard HTA system makes no direct evaluation of the value of drugs, authorities consider it to be effective, being designed only to favor cost-saving drugs and to promote high discounts., (Copyright © 2016 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.)

Introduction: The need for parathyroidectomy remains high in the group of patients on long-term dialysis with medically refractory secondary hyperparathyroidism (sHPT). We aim to compare the results after subtotal parathyroidectomies (sPtx) and total parathyroidectomies with autotransplant (tPtx + AT) performed for sHPT at a single referral centre., Material and Methods: This prospective study comparatively analysed sPtx and tPtx + AT performed in our department between February 2010 and December 2014. We followed-up both surgical techniques, with respect to the main clinical symptoms, laboratory data, mortality, and recurrent disease., Results: Forty-three patients on whom we performed 26 sPtx and 19 tPtx + AT were entered in the study. There were no statistically significant differences between groups as far as demographic and preoperative clinical data are concerned. We did not encounter postoperative mortality in either of the groups. The follow-up period was significantly longer for the sPtx group (p = 0.04). The immediate postoperative serum calcium levels were significantly lower in the tPtx + AT group (p = 0.009). Definitive hypoparathyroidism was encountered in two patients in the sPtx group (8.3%) and in one from the tPtx + AT group (5.26%). Four patients from the sPtx group (16.6%) and three from the tPtx + AT group (15.78%) died during the follow-up due to causes unrelated to parathyroidectomy. Overall we had two recurrences in the sPtx group and none in the tPtx + AT group (p = 0.57)., Conclusions: In our opinion both techniques have comparable results concerning the clinical and laboratory outcomes and rates of postoperative hypoparathyroidism, at least in short- and medium-term follow-up.

Aim: To evaluate the effects of the change in the diagnosis-related group (DRG) system on patient morbidity and hospital financial performance in the Romanian public health care system., Methods: Three variables were assessed before and after the classification switch in July 2007: clinical outcomes, the case mix index, and hospital budgets, using the database of the National School of Public Health and Health Services Management, which contains data regularly received from hospitals reimbursed through the Romanian DRG scheme (291 in 2009)., Results: The lack of a Romanian system for the calculation of cost-weights imposed the necessity to use an imported system, which was criticized by some clinicians for not accurately reflecting resource consumption in Romanian hospitals. The new DRG classification system allowed a more accurate clinical classification. However, it also exposed a lack of physicians' knowledge on diagnosing and coding procedures, which led to incorrect coding. Consequently, the reported hospital morbidity changed after the DRG switch, reflecting an increase in the national case-mix index of 25% in 2009 (compared with 2007). Since hospitals received the same reimbursement over the first two years after the classification switch, the new DRG system led them sometimes to change patients' diagnoses in order to receive more funding., Conclusion: Lack of oversight of hospital coding and reporting to the national reimbursement scheme allowed the increase in the case-mix index. The complexity of the new classification system requires more resources (human and financial), better monitoring and evaluation, and improved legislation in order to achieve better hospital resource allocation and more efficient patient care.