Sağlık Politikaları Çalışma Grubu

SGK Tarafından Anestezi Uzmanı Eşliğinde Yapılmasına Hükmedilen Bronkoskopi İşlemleri Konulu TTD SPÇG Görüş Raporu

SGK tarafından 05.09.2012 tarihinde yayımlanan ilgili Mevzuat ve Ek’i ekli dosyalarda yer alan düzenlemede, bronkoskopi işlemlerimizin anestezi uzmanı eşliğinde yapılmadığı takdirde geri ödemesinin gerçekleşmeyeceği bildirilmektedir.

Alanımızla ilgili temel bir tanısal ve terapötik yöntem olan bronkoskopi işlemiyle ilgili uluslar arası uzlaşılarda düzenlenmiş standardize koşullar bulunmaktadır (1,2). Bu koşulları karşılamayan merkezlerde zaten bronkoskopi işlemi gerçekleştirilemez. Hastayı bronkoskopiye hazırlama işleminden, bronkoskopi bitimine kadar, ilgili rehberlerde altı çizilen tüm aşamalarda, hasta sağlığı ve güvenliği işlemi uygulayan hekimin öncelikli amacıdır. Yıllardır uygulanagelen bu koşullar arasında da anestezi uzmanı işbirliğinin zorunlu olduğuna dair bir bilgi bulunmamaktadır.

Düzenlemeyi takiben hızla reaksiyon veren TTD MYK, yetkililerle görüşmeleri sonucunda ‘hekimlerin anestezi uzmanı olmaksızın yapılan işlemlerde gelişen komplikasyonların hukuki davalarında ceza almaları’ nedeniyle bu düzenlemenin yapıldığı bilgisini almıştır. Her girişimsel işlemde olduğu gibi bronkoskopi işleminde de komplikasyon olasılığı, örnekleme işleminin türüne ve süresine gören değişen oranlarda, bulunmaktadır. Literatürde anestezi uzmanı olmaksızın yapılan uygulamalarda bildirilen komplikasyon oranları % 0.08-0.03 gibi çok düşük düzeylerdedir (3). Riskler hasta hazırlama aşamasında bilgilendirilmiş onam formu ile hasta ve hasta yakınına okutulmaktadır, imzaları alınmaktadır.

SGK bilgi notunda dikkati çeken bir unsur, ilk düzenlemeyi takiben Sağlık Bakanlığı’nın itirazı ile bazı işlemlerin bu uygulamanın dışında bırakılarak yeniden düzenleme yapıldığı yönündeki açıklamadır. Bu açıklama da SGK’nın, tarafların görüşlerini almaksızın anlaşılması ve izahı güç olan bir düzenlemeyi hızla yaptığı izlenimini vermektedir. Zira Sağlık Bakanlığı yetkililerinin TTD MYK temsilcilerine, bu uygulamanın yürürlükten kaldırılması için gerekli girişimlerde bulunacakları sözünü vermeleri de bu düşünceyi doğrulamaktadır.

Önerilen düzenlemenin pratik karşılığı olmadığından, mevzuata uyum çabasının ciddi hasta mağduriyetlerine yol açması da kaçınılmazdır. Geri ödemenin yapılabilmesi adına işlemi gerçekleştiren hekimin kağıt üzerinde uyumsallaşma çabalarının da medikolegal, etik pek çok problemi tetikleyeceğini (bulunmayan anestezistin yazılması vb) öngörmek güç değildir.

Özetle, önerilen düzenlemenin gerçek ihtiyaçlar ve tıbbi çerçeve bakımından yeniden değerlendirilmesi ve düzeltilmesi çağrısında bulunuyoruz.

Not: Konu ÇG’muzca prosedür yanlışlığı yönüyle ele alınıp tartışılmıştır. Raporda bronkoskopi işlemlerine yönelik içerik zenginleştirilmesi amacıyla Tanı Yöntemleri ÇG’nun görüş ve önerilerinin alınması da uygun olabilir.

Saygılarımızla bilgilerinize sunarız.

SPÇG Yürütme Kurulu

Kaynaklar:

  1. Bolliger CT, Mathur PN, Beamis IF et al. ERS/ATS statement on interventional pulmonology. European Respiratory Society. Eur Respir J 2002; 19:356-373
  2. British Thoracic Society Bronchoscopy Guidelines Committee. British Thoracic Society guidelines on diagnostic flexible bronchoscopy. Thorax 2001; 56(suppl 1):11-121
  3. Karadağ M. Hasta Hazırlığı, Uygulama, Örnekleme Teknikleri ve Komplikasyonlar. İç: Bronkoskopi (ed Metintaş M). Ankara 2008, Poyraz Yayıncılık, s:135-148

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