Reduction in hormone replacement therapy use and declining breast cancer incidence in the Belgian province of Limburg.

Breast cancer is the most common female cancer in Europe, but its incidence and mortality are rapidly changing across Europe. The early termination of the women's health initiative (WHI) trial, after the detection of an increased breast cancer risk in hormone replacement therapy (HRT) users, was followed by strong declines of HRT use worldwide. We investigated whether the reduction of HRT sales affected breast cancer incidence in the Belgian province Limburg. All women registered in the Limburg Cancer Registry with a diagnosis of invasive breast cancer diagnosed between 1/1/1996 and 31/12/2005 were included in the study. Data on the use of HRT in the population were obtained from the vendors and the social security system. For age-standardization using the direct method, the European standard population was taken. In 2003 and 2004, the breast cancer incidence rate decreased significantly as compared to 2002 for women aged between 50 and 69 years. This sudden drop in the incidence intercepted a markedly increasing trend until 2002, but was followed again by an increase in 2005. Between 2002 and 2006, the sales of HRT (about 75% to women aged 50-69 years) were reduced by 41%. Breast cancer incidence was maximally related to HRT use in the previous year (R(2) = 77%). The decrease of breast cancer incidence in the Belgian province of Limburg may largely be related to the fall of HRT use following the early termination of the WHI trial. This suggests that HRT stimulates the growth of pre-existing, clinically latent tumours that may not otherwise become clinically apparent.

Development of a national position paper for chronic care: example of Belgium.

The management of chronic diseases is a prime challenge of most 21st century health care systems. Many Western countries have invested heavily in care plans oriented towards specific conditions and diseases, such as dementia and cancer. The major downside of this narrowly focused approach is that treatment of multimorbidity is ignored. This paper describes the development and main stance of a national position that proposes streamlined reforms of the Belgian health care system to improve care for patients with multiple chronic diseases. We used a combination of methods to develop this stance: literature review and stakeholders' consultation. The latter identified areas for improvement: efficiency of the health care system, coordination of care, investments in human care resources, informal caregivers' support, better accessibility, and changes in the financial payment system. The position paper list 20 recommendations that are translated into about 50 action points to reform the health care system. Chronic care tailored to the patient's needs, including implementation of multidisciplinary teamwork, new functions, task delegation in primary care, and empowerment of the patient and informal caregivers are some major areas discussed. In addition, improved support, revised payment mechanisms, and setting up a quality system, along with the tailoring of patient care, can all facilitate delivery of high quality care in patients with chronic comorbidities.

The costs of breast cancer prior to and following diagnosis.

This retrospective incidence-based cost-of-illness analysis aims to quantify the costs associated with female breast cancer in Flanders for the year prior to diagnosis and for each of the 5 years following diagnosis. A bottom-up analysis from the societal perspective included direct health care costs and indirect costs of productivity loss due to morbidity and premature mortality. A case-control study design compared total costs of breast cancer patients with costs of an equivalent standardised population with a view to calculating the additional costs that can be attributed to breast cancer. Total average costs of breast cancer amounted to 107,456 per patient over 6 years. Total costs consisted of productivity loss costs (89% of costs) and health care costs (11% of costs). Health care costs did not vary with age at diagnosis. Health care costs of breast cancer patients converged with those of the general population at 5 years following diagnosis. Patients with advanced breast cancer stadia had higher health care costs. Cost estimates provided by this analysis can be used to determine priorities for, and inform, future research on breast cancer. In particular, attention needs to be focussed on decreasing productivity loss from breast cancer.

Patterns of health care use and expenditure during the last 6 months of life in Belgium: differences between age categories in cancer and non-cancer patients.

OBJECTIVES: We analysed end-of-life care in Belgium to examine potential age variation in place of death, transitions between care settings, health care utilisation and public expenditure in the last 6 months of life. METHODS: Administrative data of one sickness fund were used, and analysed through regression analysis and analysis of variance. The study population comprised 40,794 individuals (age>40 years). RESULTS: Several indicators showed that the end-of-life of older people, especially of those aged >or=90 years, differs from that of younger individuals. Older persons more likely died in a care home, were less transferred between care settings, and stayed less days in hospital. On the other hand, older persons used more home care services, and had more contacts with the general practitioner. Differences between age categories were equally observed for last week's end-of-life care. Opposite to the trend for cancer patients, the odds of having a palliative home care allowance increased with age for non-cancer patients. Public expenditure for the oldest old was lower as compared to the younger decedents, but dependent on place of death. CONCLUSION: Several aspects of end-of-life care in Belgium appear to be influenced by age. In view of ageing of the population, these findings can be of interest to decision makers.

Low incidence of anti-osteoporosis treatment after hip fracture.

BACKGROUND: Following hip fracture, pharmacologic treatment can reduce the rate of subsequent fragility fractures. The objective of the present study was to assess the proportion of patients who are managed with bisphosphonates or selective estrogen-receptor modulators after hip fracture and to evaluate, among those managed with alendronate, the twelve-month compliance and persistence with treatment. METHODS: Data were gathered from health insurance companies and were collected by AIM (Agence Intermutualiste) for the Belgian National Social Security Institute (INAMI). We selected all postmenopausal women who had been hospitalized for a hip fracture between April 2001 and June 2004 and had not been previously managed with bisphosphonates. Patients who had received alendronate treatment after the hip fracture were categorized according to their formulation use during the follow-up study (daily, weekly, daily followed by weekly, or weekly followed by weekly). Compliance at twelve months was quantified with use of the medication possession ratio (i.e., the number of days of alendronate supplied during the first year of treatment, divided by 365). Persistence with prescribed treatment was calculated as the number of days from the initial prescription to a lapse of more than five weeks after completion of the previous prescription refill. The cumulative treatment persistence rate was determined with use of Kaplan-Meier survival curves. RESULTS: A total of 23,146 patients who had sustained a hip fracture were identified. Of these patients, 6% received treatment during the study period: 4.6% received alendronate, 0.7% received risedronate, and 0.7% received raloxifene. Bisphosphonate treatment was dispensed to 2.6% and 3.6% of the patients within six months and one year after the occurrence of the hip fracture, respectively. Among women who received alendronate daily (n = 124) or weekly (n = 182) and were followed for at least one year after the hip fracture, the twelve-month mean medication possession ratio was 67% (65.9% in the daily group and 67.7% in the weekly group). The analysis of persistence with treatment included a total of 726 patients (142 in the daily group, 261 in the weekly group, and 323 in the switch group). At twelve months, the rate of persistence was 41% and the median duration of persistence was 40.3 weeks. CONCLUSIONS: The vast majority of patients who experience a hip fracture do not take anti-osteoporotic therapy after the fracture. Furthermore, among patients who begin alendronate treatment after the fracture, the adherence to treatment decreases over time and remains suboptimal.

The denominator in general practice, a new approach from the Intego database.

BACKGROUND: To determine the denominator or the 'population at risk' is a problem which has long been encountered in general practice-based epidemiological research. It is important for calculating epidemiological figures. OBJECTIVES: The aim of this article is to demonstrate how in the absence of a patient list, a reliable denominator can be calculated, starting from the number of patients who contacted their GP in the period of one year. Therefore a brief overview will be given from known approaches, then the new approach will be illustrated on a database named Intego, with data from 43 general practices in Belgium. METHODS: The Intego database contains information about patient contacts, diagnoses, laboratory results and drug prescriptions, extracted from the participants' structured electronic medical record system. The number of patients who contacted the practice in a year can be calculated from the Intego data. On the other hand, the percentage of the population that consults a GP during a particular period was obtained from the reimbursement claims data available from the sickness funds. By combining these two datasets, stratified by age, gender and district, a correction factor was calculated. An estimate of the real size of the Intego practice populations was obtained by extrapolating the yearly contact group by this factor. RESULTS: In 2003 according the Intego-register, 64,161 patients contacted their family practice and this correlated with an estimated practice population of 80,094 patients. The absence of the socio-economic status in the estimation is irrelevant in our model of estimating the practice population. CONCLUSION: The availability of a denominator in general practice-based research is essential to calculate epidemiological figures. This method using a correction factor makes it possible to calculate a reliable practice population. A similar approach will probably also be applicable in other European countries.