Impact of the medical home model on the quality of primary care: the Belgian experience.

BACKGROUND: The Belgium medical home (MH) model, which has been garnering support of late, resembles its US counterpart in that it aims at improving the quality of health care while containing costs. OBJECTIVES: To compare the quality of care offered by MHs with that offered by traditional individual practices (IPs) in Belgium in terms of the extent of their adherence to clinical practice guidelines in antibiotherapy, cervical-cancer screening, influenza vaccination, and the management of diabetes. RESEARCH DESIGN: This is a retrospective study using public insurance claims data. Data consisted of a random sample of patients using the services of MHs and IPs who were previously matched according to sex, age category, location, disability, and socioeconomic status. We applied the McNemar test, the t test, or the Wilcoxon test, depending on the type of variable being compared. SUBJECTS: The final sample comprised 43,678 patients in the year 2004. MEASURES: On the basis of a review of the literature, we selected 4 themes, corresponding to 25 indicators: antibiotherapy, cervical-cancer screening, influenza vaccination, and the management of diabetes. RESULTS: MHs were more likely than IPs to adhere to evidence-based clinical practice guidelines. They prescribed less and more appropriate antibiotherapy, provided wider influenza-vaccination coverage for target groups, and provided a better follow-up for diabetics than did IPs. In regard to cervical-cancer screening, no significant differences were found. CONCLUSIONS: MHs, as they combine a greater adherence to guidelines and savings in secondary care, are a cost-effective alternative to traditional IPs and therefore should be encouraged.

Forty years of USAID health cooperation in Bolivia. A lose-lose game?

The present article proposes an analysis of the USA-Bolivia relationships in the health sector between 1971 and 2010 based on a grey and scientific literature review and on interviews. We examined United States Agency for International Development (USAID) interventions, objectives, consistency with Bolivian needs, and impact on health system integration. USAID operational objectives--decentralization, fertility and disease control, and maternal and child health--may have worked against each other while competing for limited Ministry of Health resources. They largely contributed to the segmentation and fragmentation of the Bolivian health system. US cooperation in health did not significantly improve health status while the USAID failed to properly tackle anti-drugs, political, and economic US interests in Bolivia.

Medical homes versus individual practice in primary care: impact on health care expenditures.

BACKGROUND: The medical home (MH) model has prompted increasing attention given its potential to improve quality of care while reducing health expenditures. OBJECTIVES: We compare overall and specific health care expenditures in Belgium, from the third-party payer perspective (compulsory social insurance), between patients treated at individual practices (IP) and at MHs. We compare the sociodemographic profile of MH and IP users. RESEARCH DESIGN: This is a retrospective study using public insurance claims data. Generalized linear models estimate the impact on health expenditures of being treated at a MH versus IP, controlling for individual, and area-based sociodemographic characteristics. The choice of primary care setting is modeled using logistic regressions. SUBJECTS: A random sample of 43,678 persons followed during the year 2004. MEASURES: Third-party payer expenditures for primary care, secondary care consultations, pharmaceuticals, laboratory tests, acute and long-term inpatient care. RESULTS: Overall third-party payer expenditures do not differ significantly between MH and IP users (€+27). Third-party payer primary care expenditures are higher for MH than for IP users (€+129), but this difference is offset by lower expenditures for secondary care consultations (€-11), drugs (€-40), laboratory tests (€-5) and acute and long-term inpatient care (€-53). MHs attract younger and more underprivileged populations. CONCLUSIONS: MHs induce a shift in expenditures from secondary care, drugs, and laboratory tests to primary care, while treating a less economically favored population. Combined with positive results regarding quality, MH structures are a promising way to tackle the challenges of primary care.

Inequality in treatment use among elderly patients with acute myocardial infarction: USA, Belgium and Quebec.

BACKGROUND: Previous research has provided evidence that socioeconomic status has an impact on invasive treatments use after acute myocardial infarction. In this paper, we compare the socioeconomic inequality in the use of high-technology diagnosis and treatment after acute myocardial infarction between the US, Quebec and Belgium paying special attention to financial incentives and regulations as explanatory factors. METHODS: We examined hospital-discharge abstracts for all patients older than 65 who were admitted to hospitals during the 1993-1998 period in the US, Quebec and Belgium with a primary diagnosis of acute myocardial infarction. Patients' income data were imputed from the median incomes of their residential area. For each country, we compared the risk-adjusted probability of undergoing each procedure between socioeconomic categories measured by the patient's area median income. RESULTS: Our findings indicate that income-related inequality exists in the use of high-technology treatment and diagnosis techniques that is not justified by differences in patients' health characteristics. Those inequalities are largely explained, in the US and Quebec, by inequalities in distances to hospitals with on-site cardiac facilities. However, in both Belgium and the US, inequalities persist among patients admitted to hospitals with on-site cardiac facilities, rejecting the hospital location effect as the single explanation for inequalities. Meanwhile, inequality levels diverge across countries (higher in the US and in Belgium, extremely low in Quebec). CONCLUSION: The findings support the hypothesis that income-related inequality in treatment for AMI exists and is likely to be affected by a country's system of health care.

Deriving a risk-adjustment formula for hospital financing: integrating the impact of socio-economic status on length of stay.

The imperfect risk adjustment of prospective payment for hospitals may have dramatic consequences on equity. If the hospital is able to distinguish subgroups of patients with different expected costs within a group for which the risk-adjusted payment per admission is the same, it is likely to select the most profitable cases and deny care to the others. Meanwhile, hospitals refusing to practice patients' selection may experience solvency problems. In the long term, either those hospitals fail and access to care is at risk, or they decrease the quality of treatments and access to quality is at risk. In Belgium, since 1995, a prospective payment per case has replaced the traditional per diem payments for non-medical expenditures. A fixed number of days are paid to each admission, based on the patient's characteristics, namely diagnosis, age and geriatric profile. In this paper, we examine the imperfect risk adjustment related to the non-inclusion of socio-economic factors in the hospital financing formula. Using data from 61 Belgian hospitals from 1995, we observe that socio-economic status, which is currently not accounted for as risk adjuster, has a significant impact on length of stay (LOS). We estimate that patients in the upper-income categories, patients with a self-employed status and patients with an employee status are beneficial for hospitals' financial results, due to their shorter stays. On the contrary, the non-active, the low-income patients and patients benefiting from an insurance preferential regime represent, on average, a financial loss for hospitals. Finally, we find that financial results under the current financing scheme are biased due to the non-inclusion of SES risk-adjustors. Hospitals with the most beneficial social case-mix are shown to experience a shift from a positive to a negative financial outcome when SES risk adjustors are included, while the reverse is observed for hospitals with the worst social case-mix.

Health networks: actors, professional relationships, and controversies.

In recent years international policies have aimed to stimulate the use of information and communication technologies (ICT) in the field of health care. Belgium has also been affected by these developments and, for example, health electronic regional networks ("HNs") are established. Thanks to a qualitative case study we have explored the implementation of such innovations (HN) to better understand how health professionals collaborate through the HN and how the HN affect their relationships. Within the HNs studied a common good unites the actors: the continuity of care for a better quality of care. However behind this objective of continuity of care other individual motivations emerge. Some controversies need also to be resolved in order to achieve cooperative relationships. HNs have notably to take national developments into account. These developments raise the question of the control of medical knowledge and medical practice. Professional issues, and not only practical changes, are involved in these innovations.

Hospital response to prospective financing of in-patient days: the Belgian case.

OBJECTIVES: In Belgium, a prospective payment system (PPS) has been implemented for in-patient non-medical costs since 1995, aimed at improving efficiency in the management of in-patient stays. We analyze the hospital's response in terms of in-patient length of stay (LOS) and medical and surgical expenditures. METHODS: We use data for all Belgian in-patient discharges over the 1991-1998 period. In-patient stays are aggregated according to pathology, age, year and hospital. Estimates are obtained using panel data regressions with fixed effects. RESULTS: The in-patient length of stay is significantly reduced after the reform. However, the impact is low in magnitude. In addition, medical and surgical expenditures increase, probably reflecting a profit-compensation effect, as medical and surgical services are paid by fee-for-service. Finally, hospitals receiving higher percentages of underprivileged cases, for which the financing scheme is not risk-adjusted, experience a larger decrease in length of stay in the years following the reform. This last finding may be the sign of patient's indirect selection. CONCLUSION: The reform towards more hospital financial responsibility did not allow achieve high reductions in resource use. The non-inclusion of medical services in the new financing and the imperfections of risk-adjustment may largely explain this finding.

[Chapter 3. Concretely enhancing the role of elderly through capacitating health care]. / Chapitre 3. Favoriser concrètement le rôle actif et citoyen de la personne âgée : une application du care capacitant.

This paper questions the signification of reinforcing the active role of elderly between societal injunction to feel responsible of the costs to the collectivity and the freedom to choose one's way of life and having the means to realize it. It describes two experiences in two Brussels communes of a model of co-construction with the elderly of a project to live in one's own home, to reinforce the active roles of persons. We want to illustrate the difficulty of such an approach in Belgium, separating the organization and the financing of medical and social care, that does not foster the accompanying and the active role of elderly. The conflict of interest between the different actors is not allowing the proper multidisciplinary approach to empower and allow the maintenance of elderly capability of choice and well being.

Pneumonia and influenza, and respiratory and circulatory hospital admissions in Belgium: a retrospective database study.

BACKGROUND: Influenza infections can lead to viral pneumonia, upper respiratory tract infection or facilitate co-infection by other pathogens. Influenza is associated with the exacerbation of chronic conditions like diabetes and cardiovascular disease and consequently, these result in acute hospitalizations. This study estimated the number, proportions and costs from a payer perspective of hospital admissions related to severe acute respiratory infections. METHODS: We analyzed retrospectively, a database of all acute inpatient stays from a non-random sample of eleven hospitals using the Belgian Minimal Hospital Summary Data. Codes from the International Classification of Diseases, Ninth Revision, Clinical Modification was used to identify and diagnose cases of pneumonia and influenza (PI), respiratory and circulatory (RC), and the related complications. RESULTS: During 2002-2007, we estimated relative hospital admission rates of 1.69% (20960/1237517) and 21.79% (269634/1237517) due to primary PI and RC, respectively. The highest numbers of hospital admissions with primary diagnosis as PI were reported for the elderly patient group (n = 10184) followed by for children below five years of age (n = 3451). Of the total primary PI and RC hospital admissions, 56.14% (11768/20960) and 63.48% (171172/269634) of cases had at least one possible influenza-related complication with the highest incidence of complications reported for the elderly patient group. Overall mortality rate in patients with PI and RC were 9.25% (1938/20960) and 5.51% (14859/269634), respectively. Average lengths of hospital stay for PI was 11.6 ± 12.3 days whereas for RC it was 9.1 ± 12.7 days. Annual average costs were 20.2 and 274.6 million Euros for PI and RC hospitalizations. Average cost per hospitalization for PI and RC were 5779 and 6111 Euros (2007), respectively. These costs increased with the presence of complications (PI: 7159, RC: 7549 Euros). CONCLUSION: The clinical and economic burden of primary influenza hospitalizations in Belgium is substantial. The elderly patient group together with children aged <18 years were attributed with the majority of all primary PI and RC hospitalizations. TRIAL REGISTRATION: Not applicable.

Impact of socioeconomic factors on in-patient length of stay and their consequences in per case hospital payment systems.

OBJECTIVES: The number of countries adopting per case hospital payment systems has been continuously increasing in recent years. Nonetheless, debates persist regarding their consequences for equity of access to services. This concern relates to the failure of diagnostic classifications properly to take into account patients' care requirements, raising the threat of case selection ('cream skimming'). We examine the heterogeneity of costs within diagnostic categories related to socioeconomic (SE) factors using length of stay (LOS) as a proxy measure of care needs and costs. We evaluate its consequences in terms of fairness in resource allocation between hospitals. METHODS: We employ data on all discharges in 2002-03 from a sample of 60 Belgian hospitals (617,275 observations), measuring the association between LOS and SE factors using generalized linear models. We design a resource allocation formula based on the Belgian financing scheme, where non-medical activity is paid based on a normative number of in-patient days, and measure financial penalties and rewards according to whether payment is adjusted for the SE characteristics of patients or not. RESULTS: Both patients' SE status and hospitals' area SE profile have a significant impact on LOS, which persists after controlling for detailed diagnostic and hospital characteristics. Hospitals treating low income patients are financially penalized as a result. CONCLUSION: SE factors are a predictor of in-patient LOS and should be taken into account in per case resource allocation among hospitals.

Comparing the quality of care across Belgian hospitals from medical basic datasets: the case of thromboembolism prophylaxis after major orthopaedic surgery.

RATIONALE, AIMS AND OBJECTIVES: In the current context, the assessment of the quality of care in daily clinical practice becomes essential. The aim of this study was to use medical basic datasets associated with information on pharmacological treatments to assess the quality of care of a prophylaxis treatment after major orthopaedic surgery and to compare hospitals' clinical practices. METHODS: The study was performed in 20 Belgian hospitals. Patients who underwent total hip replacement (THR), total knee replacement (TKR), or hip fracture surgery (HFS) were selected retrospectively from the hospitals' 2002 and 2003 administrative databases (n = 14,991). Quality indicators assessed were incidence of venous thromboembolism, major bleeding and death. Prophylaxis analysed were enoxaparin, nadroparin and fondaparinux. RESULTS: Venous thromboembolism and major bleeding events were rare (1.9% and 1.1% respectively). Patients who underwent HFS were at greater risk of having pulmonary embolism [OR = 2.01; confidence interval (CI) = 1.38-2.92; P = 0.0002], major bleeding (OR = 4.00; CI = 2.93-5.46; P < 0.0001) or death from any cause (OR = 8.86; CI = 6.85-11.45; P < 0.0001) than patients who underwent THR or TKR. Multivariate analyses showed that the hospital variable had a significant impact on the probability to have adverse events and that patients who received enoxaparin were at greater risk of death than patients who received nadroparin (OR(enoxaparin vs fraxiparin) = 1.59; 95% CI = 1.04-2.44; P = 0.033). CONCLUSION: Results indicate that differences in thromboembolism prophylaxis practices among hospitals have a significant impact on adverse events. This reinforces the need to develop data-processing tools that enable better monitoring of quality of care.

Assessing the quality of pharmacological treatments from administrative databases: the case of low-molecular-weight heparin after major orthopaedic surgery.

RATIONALE, AIMS AND OBJECTIVES: 'Real world data' are needed to assess the quality of pharmacological treatments in clinical practice. The aim of this study was to determine whether administrative databases can be used to assess the quality of prophylaxis with low-molecular-weight heparin after major orthopaedic surgery. METHODS: The study was performed in a Belgian university hospital. Patients undergoing total hip replacement (THR), total knee replacement (TKR) or hip fracture surgery (HFS) were selected retrospectively from the hospital's 2002 and 2003 administrative databases. Readmissions during the same year as the procedure were also analysed. Three quality indicators were assessed: incidence of venous thromboembolism (VTE), major bleeding and death; adherence to guidelines; and the costs of care. RESULTS: Although 70% of data were collected from administrative databases, patients' records also had to be examined. During the period studied, VTE and major bleeding events were rare. Patients undergoing HFS were at greater risk of having a pulmonary embolism [Exact odds ratio (OR)=3.78; 95% confidence interval (CI)=1.13-16.22; P=0.03] or of death from any cause (Exact OR=2.15; 95% CI=1.52-infinity; P<0.01) than patients undergoing THR or TKR. The hospital's prophylaxis protocol was not always followed. Half the patients received higher prophylaxis doses than recommended and 11% received lower doses but no impact on adverse events was demonstrated. CONCLUSION: Results show that administrative databases contain enough information to measure the frequency of adverse events but complementary data on patient weight and on non-reimbursed drugs must be extracted from the patients' records to evaluate adherence to guidelines. Our findings stress the need for better integration of information systems.

Comparison of three instruments assessing the quality of economic evaluations: a practical exercise on economic evaluations of the surgical treatment of obesity.

OBJECTIVES: The increasing use of full economic evaluations has led to the development of various instruments to assess their quality. The purpose of this study was to compare the frequently used British Medical Journal (BMJ) check-list and two new instruments: the Consensus Health Economic Criteria (CHEC) list and the Quality of Health Economic Studies (QHES) instrument. The analysis was based on a practical exercise on economic evaluations of the surgical treatment of obesity. METHODS: The quality of nine selected studies was assessed independently by two health economists. To compare instruments, the Spearman rank correlation coefficient was calculated for each assessor. Moreover, the test-retest reliability for each instrument was assessed with the intraclass correlation coefficient (ICC) (3,1). Finally, the inter-rater agreement for each instrument was estimated at two levels: comparison of the total score of each article by the ICC(2,1) and comparison of results per item by kappa values. RESULTS: The Spearman's rank correlation coefficient between instruments was usually high (rho > 0.70). Furthermore, test-retest reliability was good for every instruments, that is, 0.98 (95 percent CI, 0.86-0.99) for the BMJ check-list, 0.97 (95 percent CI, 0.73-0.98) for the CHEC list, and 0.95 (95 percent CI, 0.75-0.99) for the QHES instrument. However, inter-rater agreement was poor (kappa < 0.40 for most items and ICC(2,1) < or = 0.5). CONCLUSIONS: The study shows that the results of the quality assessment of economic evaluations are not so much influenced by the instrument used but more by the assessor. Therefore, quality assessments should be performed by at least two independent experts and final scoring based on consensus.

Concentration of transfusion resources on a few pathologies and a few patients: analysis of the comprehensive in-hospital patient database.

BACKGROUND: Blood is a sparse commodity. Transfusion needs increase while the number of donors decreases. These constraints incite Belgian authorities to pay more attention to transfusion financing. This implies pathologic knowledge of the epidemiology of in-hospital transfusion and the consumption of blood products. STUDY DESIGN AND METHODS: This study is a retrospective analysis of in-hospital stays from the year 2000 and includes data from all 124 Belgian hospitals. The database contains information on diagnoses, procedures, and all-patients refined diagnosis-related groups (APRDRGs) but also on expenses linked to blood products transfused and to transfusion-related pharmaceutical products. RESULTS: Three percent of surgical patients used 55.7 percent of transfusion resources and 75.4 percent of transfusion costs were associated with 24 APRDRGs. In the medical group, 3 percent of the patients accounted for 80.2 percent of transfusion costs and 20 APRDRGs consumed 71.9 percent of transfusion resources. The variables with the highest impact on the proportion of patients transfused were severity, pathology, and age. The effect of hospitals remained significant but had less impact. No substitution of blood products by transfusion-related pharmaceutical products was observed in our analysis. CONCLUSION: Our study confirms that transfusion now centers on a limited number of pathologic entities and, within those, in small subsets of patients. This implies that the costs linked to setting up and running the transfusion system can no longer be shared by a large number of patients who receive transfusions but rely increasingly on patients at higher risks of more unpredictable needs. The system must nevertheless be able to cope with them at any time.