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BACKGROUND: Hypertension is a major risk factor for cardiovascular disease and all-cause mortality worldwide. Despite the widespread availability of effective antihypertensives, blood pressure (BP) control rates remain suboptimal, even in high-income countries such as Belgium. In this study, we used a cascade of care approach to identify where most patients are lost along the continuum of hypertension care in Belgium, and to assess the main risk factors for attrition at various stages of hypertension management. METHODS: Using cross-sectional data from the 2018 Belgian Health Interview Survey and the Belgian Health Examination Survey, we estimated hypertension prevalence among the Belgian population aged 40-79 years, and the proportion that was (1) screened, (2) diagnosed, (3) linked to care, (4) in treatment, (5) followed up and (6) well-controlled. Cox regression models were estimated to identify individual risk factors for being unlinked to hypertension care, untreated and not followed up appropriately. RESULTS: The prevalence of hypertension based on self-reported and measured high BP was 43.3%. While 98% of the hypertensive population had their BP measured in the past 5 years, only 56.7% were diagnosed. Furthermore, 53.4% were linked to care, 49.8% were in treatment and 43.4% received adequate follow-up. Less than a quarter (23.5%) achieved BP control. Among those diagnosed with hypertension, males, those of younger age, without comorbidities, and smokers, were more likely to be unlinked to care. Once in care, younger age, lower BMI, financial hardship, and psychological distress were associated with a higher risk of being untreated. Finally, among those treated for hypertension, females, those of younger age, and without comorbidities were more likely to receive no adequate follow-up. CONCLUSION: Our results show that undiagnosed hypertension is the most significant barrier to BP control in Belgium. Health interventions are thus needed to improve the accurate and timely diagnosis of hypertension. Once diagnosed, the Belgian health system retains patients fairly well along the continuum of hypertension care, yet targeted health interventions to improve hypertension management for high-risk groups remain necessary, especially with regard to improving treatment rates.
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Hipertensión , Humanos , Persona de Mediana Edad , Bélgica/epidemiología , Hipertensión/epidemiología , Estudios Transversales , Masculino , Femenino , Adulto , Anciano , Factores de Riesgo , Prevalencia , Encuestas Epidemiológicas , Antihipertensivos/uso terapéutico , Continuidad de la Atención al Paciente/estadística & datos numéricosRESUMEN
BACKGROUND: Type 2 diabetes (T2D) is an increasingly dominant disease. Interventions are more effective when carried out by a prepared and proactive team within an organised system - the integrated care (IC) model. The Chronic Care Model (CCM) provides guidance for its implementation, but scale-up of IC is challenging, and this hampers outcomes for T2D care. In this paper, we used the CCM to investigate the current implementation of IC in primary care in Flanders (Belgium) and its variability in different practice types. METHODS: Belgium contains three different primary-care practice types: monodisciplinary fee-for-service practices, multidisciplinary fee-for-service practices and multidisciplinary capitation-based practices. Disproportional sampling was used to select a maximum of 10 practices for each type in three Flemish regions, leading to a total of 66 practices. The study employed a mixed methods design whereby the Assessment of Chronic Illness Care (ACIC) was complemented with interviews with general practitioners, nurses and dieticians linked to the 66 practices. RESULTS: The ACIC scores of the fee-for-service practices - containing 97% of Belgian patients - only corresponded to basic support for chronic illness care for T2D. Multidisciplinary and capitation-based practices scored considerably higher than traditional monodisciplinary fee-for-service practices. The region had no significant impact on the ACIC scores. Having a nurse, being a capitation practice and having a secretary had a significant effect in the regression analysis, which explained 75% of the variance in ACIC scores. Better-performing practices were successful due to clear role-defining, task delegation to the nurse, coordination, structured use of the electronic medical record, planning of consultations and integration of self-management support, and behaviour-change intervention (internally or using community initiatives). The longer nurses work in primary care practices, the higher the chance that they perform more advanced tasks. CONCLUSIONS: Besides the presence of a nurse or secretary, also working multidisciplinary under one roof and a capitation-based financing system are important features of a system wherein IC for T2D can be scaled-up successfully. Belgian policymakers should rethink the role of paramedics in primary care and make the financing system more integrated. As the scale-up of the IC varied highly in different contexts, uniform roll-out across a health system containing multiple types of practices may not be successful.
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Diabetes Mellitus Tipo 2 , Humanos , Diabetes Mellitus Tipo 2/terapia , Atención Primaria de Salud , Bélgica , Enfermedad Crónica , AciclovirRESUMEN
BACKGROUND: To assess the quality of integrated diabetes care, we should be able to follow the patient throughout the care path, monitor his/her care process and link them to his/her health outcomes, while simultaneously link this information to the primary care system and its performance on the structure and organization related quality indicators. However the development process of such a data framework is challenging, even in period of increasing and improving health data storage and management. This study aims to develop an integrated multi-level data framework for quality of diabetes care and to operationalize this framework in the fragmented Belgium health care and data landscape. METHODS: Based on document reviews, iterative working group discussions and expert consultations, theoretical approaches and quality indicators were identified and assessed. After mapping and assessing the validity of existing health information systems and available data sources through expert consultations, the theoretical framework was translated in a data framework with measurable quality indicators. The construction of the data base included sampling procedures, data-collection, and several technical and privacy-related aspects of linking and accessing Belgian datasets. RESULTS: To address three dimensions of quality of care, we integrated the chronic care model and cascade of care approach, addressing respectively the structure related quality indicators and the process and outcome related indicators. The corresponding data framework is based on self-collected data at the primary care practice level (using the Assessment of quality of integrated care tool), and linked health insurance data with lab data at the patient level. CONCLUSION: In this study, we have described the transition of a theoretical quality of care framework to a unique multilevel database, which allows assessing the quality of diabetes care, by considering the complete care continuum (process and outcomes) as well as organizational characteristics of primary care practices.
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Atención a la Salud , Diabetes Mellitus , Bélgica/epidemiología , Continuidad de la Atención al Paciente , Diabetes Mellitus/epidemiología , Diabetes Mellitus/terapia , Femenino , Instituciones de Salud , Humanos , MasculinoRESUMEN
BACKGROUND: The COVID-19 pandemic affects the processes of routine care for chronic patients. A better understanding helps to increase resilience of the health system and prepare adequately for next waves of the pandemic. METHODS: A qualitative study was conducted in 16 primary care practices: 6 solo working, 4 monodisciplinary and 7 multidisciplinary. Twenty-one people (doctors, nurses, dieticians) were interviewed, using semi-structured video interviews. A thematic analysis was done using the domains of the Chronic Care Model (CCM). RESULTS: Three themes emerged: changes in health care organization, risk stratification and self-management support. All participating practices reported drastic changes in organization with a collective shift towards COVID-19 care, and reduction of chronic care activities, less consultations, and staff responsible for self-management support put on hold. A transition to digital support did not occur. Few practitioners had a systematic approach to identify and contact high-risk patients for early follow-up. A practice with a pre-established structured team collaboration managed to continue most chronic care elements. Generally, practitioners expected no effects of the temporary disruption for patients, although they expressed concern about patients already poorly regulated. CONCLUSION: Our findings show a disruption of the delivery of chronic care in the Belgium prim care context. In such contexts, the establishment of the CCM can facilitate continuity of care in crisis times. Short term actions should be directed to facilitate identifying high-risk patients and to develop a practice organization plan to organize chronic care and use digital channels for support, especially to vulnerable patients, during next waves of the epidemic.
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Actitud del Personal de Salud , COVID-19/terapia , Necesidades y Demandas de Servicios de Salud/organización & administración , Atención Primaria de Salud/organización & administración , Bélgica , COVID-19/prevención & control , Femenino , Humanos , Masculino , Investigación CualitativaRESUMEN
Background: Despite its overall good performance, the Belgium healthcare system scores less well in providing equal access to healthcare compared to other European countries. This increases the risk of people worse off to receive late diagnosis and to get complications of chronic diseases. Methods: This study aims to achieve a deeper understanding of how people with complications of a chronic disease - diabetes type 2 - experience care in the Belgium health system through semi-structured interviews with extreme case study sampling of people with advanced diabetes, and inductive analysis. Results: The results show that most respondents were diagnosed late in the course of their disease. There are variations in treatment and type of provider. People appreciate the personal and long-lasting contact with a medical doctor, while the contact with and role of paramedical providers was less recognized. Disease management has a significant impact on their financial budget and some respondents experienced barriers to obtain additional financial support. Discussion: Non-medical costs are not reimbursed, presenting a high burden to people. Self-management is tedious and hampered by other worries that people may have, such as financial constraints and coping with important life events. To conclude this study highlighted the need to improve diabetes screening. We suggest to enhance the role of paramedical professionals, integrate a social care worker, reduce financial constraints, and increase health literacy through more patient-centered, goal-oriented care.
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BACKGROUND: Hypertension, a chronic medical condition affecting millions of people worldwide, is a leading cause of cardiovascular diseases. A multidisciplinary approach is needed to reduce the burden of the disease, with general practitioners playing a vital role. Therefore, it is crucial that GPs provide high-quality care that is standardized and based on the most recent European guidelines. Quality indicators (QIs) can be used to assess the performance, outcomes, or processes of healthcare delivery and are critical in helping healthcare professionals identify areas of improvement and measure progress towards achieving desired health outcomes. However, QIs to evaluate the care of patients with hypertension in general practice have been studied to a limited extent. The aim of our study is to define quality indicators for hypertension in general practice that are extractable from the electronic health record (EHR) and can be used to evaluate and improve the quality of care for hypertensive patients in the general practice setting. METHODS: We used a Rand-modified Delphi procedure. We extracted recommendations from European guidelines and assembled them into an online questionnaire. An initial scoring based on the SMART principle and extractability from the EHR was performed by panel members, these results were analyzed using a Median Likert score, prioritization and degree of consensus. A consensus meeting was set up in which all the recommendations were discussed, followed by a final validation round. RESULTS: Our study extracted 115 recommendations. After analysis of the online questionnaire round and a consensus meeting round, 37 recommendations were accepted and 75 were excluded. Of these 37 recommendations, 9 were slightly modified and 4 were combined into 2 recommendations, resulting in a list of 35 recommendations. All recommendations of the final set were translated to QIs, made up of 7 QIs on screening, 6 QIs on diagnosis, 11 QIs on treatment, 5 QIs on outcome and 6 QIs on follow-up. CONCLUSIONS: Our study resulted in a set of 35 QIs for hypertension in general practice. These QIs, tailored to the Belgian EHR, provide a robust foundation for automated audit and feedback and could substantially benefit other countries if adapted to their systems.
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Técnica Delphi , Registros Electrónicos de Salud , Hipertensión , Indicadores de Calidad de la Atención de Salud , Humanos , Registros Electrónicos de Salud/normas , Hipertensión/diagnóstico , Médicos Generales , Medicina General/normas , Consenso , Encuestas y Cuestionarios , Guías de Práctica Clínica como Asunto/normasRESUMEN
Introduction: Integrated care of chronic patients improves quality of their management, but there is scarce evidence of its implementation in different healthcare settings. With this article, we wanted to determine the level of integrated care implementation in the management of T2D (diabetes) and HT (hypertension) in three different settings: Belgium, Slovenia, and Cambodia. Methods: This was an observational study with integrated approach. It was conducted in primary health care organisations in three countries. In each primary health care organisation, we aimed to include primary care workers that worked with Type 2 Diabetes (T2D) and hypertension (HT) patients. Data was collected with the Integrated Care Package (ICP) grid (consisting of six elements: identification, treatment, health education, self-management, caregiver collaboration, and care organisation). Results: ICP is almost completely implemented without major differences within Slovenia. There is a considerable variability across practice types in Belgium. Implementation is constrained by health system resources in Cambodia. Some elements, especially identification, are better implemented then others, across health systems. Conclusion: Countries can enhance integrated care for chronic diseases by implementing central policies, standardized protocols, and local adaptation, addressing resource constraints, promoting systematic screening and health education, and providing training for healthcare workers, tailored to community needs, to improve patient outcomes and healthcare delivery.
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Introduction: Non-communicable diseases, such as arterial hypertension (HTN) and type-2 diabetes (T2D), pose a global public health problem. Integrated care with focus on person-centred principles aims to enhance healthcare quality and access. Previous qualitative research has identified facilitators and barriers for scaling-up integrated care, however the lack of standardized terms and measures hinder cross-country comparisons. This paper addresses these gaps by presenting a generic codebook for qualitative research on integrated care implementation for HTN and T2D. Description: The codebook serves as a tool for deductive or deductive-inductive qualitative analysis, organizing concepts and themes from qualitative data. It consists of nine first level and 39 second level themes. First level codes cover core issues; and second level codes provide detailed insights into facilitators and barriers. Discussion: This codebook is more widely applicable than previously developed tools because it includes a broader scope of stakeholders across micro, meso, and macro levels, and the themes being derived from highly diverse health systems across high- and low-income countries. Conclusion: The codebook is a useful tool for implementation research on integrated care for HTN and T2D at global scale. It facilitates cross-country learning, contributing to improved implementation, scale-up and outcomes.
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BACKGROUND: Globally, health systems have been struggling to cope with the increasing burden of chronic diseases and respond to associated patient needs. Integrated care (IC) for chronic diseases offers solutions, but implementing these new models requires multi-stakeholder action and integrated policies to address social, organisational, and financial barriers. Policy implementation for IC has been little studied, especially through a political lens. This paper examines how IC policies in Belgium were developed over the last decade and how stakeholders have played a role in these policies. METHODS: We used a case study design. After an exploratory document review, we selected three IC policies. We then interviewed 25 key stakeholders in the field of IC. The stakeholder analysis entailed a detailed mapping of the stakeholders' power, position, and interest related to the three selected policies. Interview participants included policy-makers, civil servants (from ministry of health and health insurance), representatives of health professionals' associations, academics, and patient organisations. Additionally, a processual analysis of IC policy processes (2007-2020) through literature review was used to frame the interviews by means of a chronic care policy timeline. RESULTS: In Belgium, a variety of policy initiatives have been developed in recent years both at central and decentralised levels. The power analysis and policy position maps exposed tensions between federal and federated governments in terms of overlapping competence, as well as the implications of the power shift from federal to federated levels as a consequence of the 2014 state reform. CONCLUSION: The 2014 partial decentralisation of healthcare has created fragmentation of decisive power which undermines efforts towards IC. This political trend towards fragmentation is at odds with the need for IC. Further research is needed on how public health policy competences and reform durability of IC policies will evolve.
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Atención a la Salud , Política de Salud , Humanos , Bélgica , Política , Política PúblicaRESUMEN
Objective: To describe the design, delivery and evaluation of the 3rd Global Alliance for Chronic Diseases (GACD) Implementation Science School (ISS), delivered virtually in 2020 for the first time. Methods: Since 2014, GACD has supported the delivery of more than ten Implementation Science Workshops for more than 500 international participants. It has also been conducting an annual ISS since 2018. In this study, we described the design, delivery and evaluation of the third ISS. Results: Forty-six participants from 23 countries in five WHO regions attended the program. The virtual delivery was well-received and found to be efficient in program delivery, networking and for providing collaborative opportunities for trainees from many different countries. The recently developed GACD Implementation Science e-Hub was found to be an instrumental platform to support the program by providing a stand-alone, comprehensive online learning space for knowledge and skill development in implementation research. Conclusion: The delivery of the virtual GACD ISS proved to be feasible, acceptable and effective and offers greater scalability and sustainability as part of a future strategy for capacity strengthening in implementation research globally.
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COVID-19 , Ciencia de la Implementación , COVID-19/epidemiología , Enfermedad Crónica , Humanos , Pandemias , Instituciones AcadémicasRESUMEN
INTRODUCTION: Integrated care interventions for type 2 diabetes (T2D) and hypertension (HT) are effective, yet challenges exist with regard to their implementation and scale-up. The 'SCale-Up diaBetes and hYpertension care' (SCUBY) Project aims to facilitate the scale-up of integrated care for T2D and HT through the co-creation and implementation of contextualised scale-up roadmaps in Belgium, Cambodia and Slovenia. We hereby describe the plan for the process and scale-up evaluation of the SCUBY Project. The specific goals of the process and scale-up evaluation are to (1) analyse how, and to what extent, the roadmap has been implemented, (2) assess how the differing contexts can influence the implementation process of the scale-up strategies and (3) assess the progress of the scale-up. METHODS AND ANALYSIS: A comprehensive framework was developed to include process and scale-up evaluation embedded in implementation science theory. Key implementation outcomes include acceptability, feasibility, relevance, adaptation, adoption and cost of roadmap activities. A diverse range of predominantly qualitative tools-including a policy dialogue reporting form, a stakeholder follow-up interview and survey, project diaries and policy mapping-were developed to assess how stakeholders perceive the scale-up implementation process and adaptations to the roadmap. The role of context is considered relevant, and barriers and facilitators to scale-up will be continuously assessed. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the Institutional Review Board (ref. 1323/19) at the Institute of Tropical Medicine (Antwerp, Belgium). The SCUBY Project presents a comprehensive framework to guide the process and scale-up evaluation of complex interventions in different health systems. We describe how implementation outcomes, mechanisms of impact and scale-up outcomes can be a basis to monitor adaptations through a co-creation process and to guide other scale-up interventions making use of knowledge translation and co-creation activities.
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Diabetes Mellitus Tipo 2 , Hipertensión , Humanos , Bélgica , Eslovenia , Diabetes Mellitus Tipo 2/epidemiología , Diabetes Mellitus Tipo 2/terapia , Cambodia , Hipertensión/epidemiología , Hipertensión/terapiaRESUMEN
INTRODUCTION: Although many countries have been implementing integrated care, the scale-up remains difficult. Macro-level system barriers play an important role. By selecting three key policies, which have implemented integrated care in Belgium over the last 10 years, we aim to go beyond the identification of their specific barriers and facilitators to obtain an overarching generic view. METHODS: 27 participants were purposefully selected, to include all important stakeholders involved on the macro-level in chronic care in Belgium. Semi-structured interviews were guided by a timeline of policies and an inductive thematic analysis was performed. RESULTS: Barriers and facilitators were identified on both health care and policy level. The major factors restraining the scale-up of integrated care are the fee-for-service reimbursement system, limited data sharing and the fragmentation of responsibilities between different levels of government. Remarkably, these factors strongly interact. DISCUSSION: This paper highlights the importance of homogenization of responsibilities of governments regarding integrated care and the interdependency of policy and health care system factors. A whole system change is needed instead of the current Belgian model of prolonged search for common ground between conflicting opinions. Political commitment and citizen participation will be crucial.
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INTRODUCTION: Research on models of integrated health care for hypertension and diabetes is one of the priority issues in the world. There is a lack of knowledge about how integrated care is implemented in practice. Our study assessed its implementation in six areas: identification of patients, treatment, health education, self-management support, structured collaboration and organisation of care. METHODS: This was a mixed methods study based on a triangulation method using quantitative and qualitative data. It took place in different types of primary health care organisations, in one urban and two rural regions of Slovenia. The main instrument for data collection was the Integrated Care Package (ICP) Grid, assessed through four methods: 1) a document analysis (of a current health policy and available protocols; 2) observation of the infrastructure of health centres, organisation of work, patient flow, interaction of patients with health professionals; 3) interview with key informants and 4) review of medical documentation of selected patients. RESULTS: The implementation of the integrated care in Slovenia was assessed with the overall ICP score of 3.7 points (out of 5 possible points). The element Identification was almost fully implemented, while the element Self-management support was weakly implemented. DISCUSSION: The implementation of the integrated care of patients with diabetes and/or hypertension in Slovenian primary health care organisations achieved high levels of implementation. However, some week points were identified. CONCLUSION: Integrated care of the chronic patients in Slovenia is already provided at high levels, but the area of self-management support could be improved.
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INTRODUCTION: Although the concept of integrated care for non-communicable diseases was introduced at the primary level to move from disease-centered to patient-centered care, it has only been partially implemented in European countries. The aim of this study was to identify and compare identified facilitators and barriers to scale-up this concept between Slovenia and Belgium. METHODS: This was a qualitative study. Fifteen focus groups and fifty-one semi-structured interviews were conducted with stakeholders at the micro, meso and macro levels. In addition, data from two previously published studies were used for the analysis. Data collection and analysis was initially conducted at country level. Finally, the data was evaluated by a cross-country team to assess similarities and differences between countries. RESULTS: Four topics were identified in the study: patient-centered care, teamwork, coordination of care and task delegation. Despite the different contexts, true teamwork and patient-centered care are limited in both countries by hierarchies and a very heavily skewed medical approach. The organization of primary healthcare in Slovenia probably facilitates the coordination of care, which is not the case in Belgium. The financing and organization of primary practices in Belgium was identified as a barrier to the implementation of task delegation between health professionals. CONCLUSIONS: This study allowed formulating some important concepts for future healthcare for non-communicable diseases at the level of primary healthcare. The results could provide useful insights for other countries with similar health systems.
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Health systems worldwide struggle to manage the growing burden of type 2 diabetes and hypertension. Many patients receive suboptimal care, especially those most vulnerable. An evidence-based Integrated Care Package (ICP) with primary care-based diagnosis, treatment, education and self-management support and collaboration, leads to better health outcomes, but there is little knowledge of how to scale-up. The Scale-up integrated care for diabetes and hypertension project (SCUBY) aims to address this problem by roadmaps for scaling-up ICP in different types of health systems: a developing health system in a lower middle-income country (Cambodia); a centrally steered health system in a high-income country (Slovenia); and a publicly funded highly privatised health-care health system in a high-income country (Belgium). In a quasi-experimental multi-case design, country-specific scale-up strategies are developed, implemented and evaluated. A three-dimensional framework assesses scale-up along three axes: (1) increase in population coverage; (2) expansion of the ICP package; and (3) integration into the health system. The study includes a formative, intervention and evaluation phase. The intervention entails the development and implementation of an improved scale-up strategy through a roadmap with a minimum dataset to monitor proximal and distal outcomes. The SCUBY project is expected to result in three different roadmaps, tailored to the specific health system and country context, to progress scale-up of the ICP along three dimensions. These roadmaps can be adapted to other health systems with similar typology. Implementation is expected to increase the number of well-controlled patients with type 2 diabetes and hypertension in Cambodia, to reduce inequities in care and increase patient empowerment in Belgium and Slovenia.