Influenza versus other respiratory viruses - assessing severity among hospitalised children, Belgium, 2011 to 2020.

BackgroundKnowledge on the burden attributed to influenza viruses vs other respiratory viruses in children hospitalised with severe acute respiratory infections (SARI) in Belgium is limited.AimThis observational study aimed at describing the epidemiology and assessing risk factors for severe disease.MethodsWe retrospectively analysed data from routine national sentinel SARI surveillance in Belgium. Respiratory specimens collected during winter seasons 2011 to 2020 were tested by multiplex real-time quantitative PCR (RT-qPCR) for influenza and other respiratory viruses. Demographic data and risk factors were collected through questionnaires. Patients were followed-up for complications or death during hospital stay. Analysis focused on children younger than 15 years. Binomial logistic regression was used to identify risk factors for severe disease in relation to infection status.ResultsDuring the winter seasons 2011 to 2020, 2,944 specimens met the study case definition. Complications were more common in children with underlying risk factors, especially asthma (adjusted risk ratio (aRR): 1.87; 95% confidence interval (CI): 1.46-2.30) and chronic respiratory disease (aRR: 1.88; 95% CI: 1.44-2.32), regardless of infection status and age. Children infected with non-influenza respiratory viruses had a 32% higher risk of complications (aRR: 1.32; 95% CI: 1.06-1.66) compared with children with influenza only.ConclusionMulti-virus testing in children with SARI allows a more accurate assessment of the risk of complications and attribution of burden to respiratory viruses beyond influenza. Children with asthma and respiratory disease should be prioritised for clinical care, regardless of their virological test result and age, and targeted for prevention campaigns.

End-of-life communication in advanced cancer: international trends (2009-2014).

OBJECTIVE: To examine trends in end-of-life communication with people with cancer in general practice. METHODS: Mortality follow-back survey among general practitioners (GPs) in representative epidemiological surveillance networks in Belgium (BE), the Netherlands (NL) and Spain (ES) in 2009-2010 (ES: 2010-2011) and 2013-2014. Using a standardised form, GPs registered all deceased adult patients in their practice and reported for five end-of-life care topics whether they had been discussed with the patient. Non-sudden cancer deaths were included (n=2306; BE: 1233; NL: 729; ES: 344). RESULTS: A statistically significant increase was found between 2009/2010 and 2014 in the prevalence of communication about diagnosis (from 84% to 94%) and options for end-of-life care (from 73% to 90%) in BE, and in GPs' awareness of patients' preferences for medical treatment and a proxy decision-maker in BE (from 41% and 20% up to 53% and 28%) and the NL (from 62% and 32% up to 70% and 52%). Communication about options for end-of-life care and psychosocial problems decreased in the NL (from 88% and 91% down to 73%) and ES (from 76% and 77% down to 26% and 39%). CONCLUSION: Considerable change in GP-patient communication seems possible in a relatively short time span, but communication cannot be assumed to increase over time. Increasing specialisation of care and task differentiation may lead to new roles in communication for healthcare providers in primary and secondary care. Improved information sharing between GPs and other healthcare providers may be necessary to ensure that patients have the chance to discuss important end-of-life topics.

General practice patients starting treatment for substance use problems: observations from two data sources across levels of care.

BACKGROUND: In Belgium, the incidence of treatment episodes for substance use problems is monitored by the Network of Sentinel General Practices (SGP), and at higher, specialist care levels by the Treatment Demand Indicator (TDI) surveillance. Using both data sources, we examine 1) how patients starting specialist treatment for substance use problems on referral by their GP compare to those that were referred by non-GP caregivers; 2) how patients starting GP treatment for substance use problems without receiving concurrent specialist treatment compare to those who did. METHODS: Both surveillances are based on the TDI protocol for reporting data to the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) on individuals starting treatment as a result of their substance use. Data from 2016 and 2017 were examined using 95% confidence intervals and multivariate logistic regression. RESULTS: According to TDI-data (n = 16,543), determinants of being referred by a GP (versus by a non-GP caregiver) for specialist treatment were age ≥ median (OR 1.25; 95% CI 1.13-1.38), education ≥ secondary level (OR 1.27; 95% CI 1.15-1.41), recent employment (OR 1.71; 1.56-1.88), recent stable accommodation (3.62; 95% CI 3.08-4.26), first treatment episode (OR 1.72; 95% CI 1.57-1.87), recent daily primary substance use (OR 1.46; 95% CI 1.33-1.59) and mono substance use (OR 1.23; 95% CI 1.04-1.48). Type of substance use was a significant determinant with higher odds of using pharmaceuticals (and alcohol) (OR 1.24; 95% CI 1.04-1.48), and lower odds of using cannabis only/primarily (OR 0.73; 95% CI 0.62-0.86), with reference to street drugs minus cannabis only/primarily. According to SGP data (n = 314), determinants of starting GP treatment without concurrent specialist treatment were recent employment (OR 2.58; 95% CI 1.36-4.91), first treatment episode (OR 2.78; 95% CI 1.39-5.55) and living in the Brussels or Walloon region (OR 1.97; 95% CI 1.06-3.66). CONCLUSIONS: This study provides a useful insight into the general practice population treated for substance use problems. It shows that both surveillances consistently found a relatively favourable profile of general practice patients with substance use problems.

Primary palliative care for older people in three European countries: a mortality follow-back quality study.

BACKGROUND: Many older people with serious chronic illnesses experience complex health problems for which palliative care is indicated. We aimed to examine the quality of primary palliative care for people aged 65-84 years and those 85 years and older who died non-suddenly in three European countries. METHODS: This is a nationwide representative mortality follow-back study. General practitioners (GPs) belonging to epidemiological surveillance networks in Belgium (BE), Italy (IT) and Spain (ES) (2013-2015) registered weekly all deaths in their practices. We included deaths of people aged 65 and excluded sudden deaths judged by GPs. We applied a validated set of quality indicators. RESULTS: GPs registered 3496 deaths, of which 2329 were non-sudden (1126 aged 65-84, 1203 aged 85+). GPs in BE (reference category) reported higher scores than IT across almost all indicators. Differences with ES were not consistent. The score in BE particularly differed from IT on GP-patient communication (aged 65-84: 61% in BE vs 20% in IT (OR=0.12, 95% CI 0.07 to 0.20) aged 85+: 47% in BE vs 9% in IT (OR=0.09, 95% CI 0.05 to 0.16)). Between BE and ES, we identified a large difference in involvement of palliative care services (aged 65-84: 62% in BE vs 89% in ES (OR=4.81, 95% CI 2.41 to 9.61) aged 85+: 61% in BE vs 77% in ES (OR=3.1, 95% CI 1.71 to 5.53)). CONCLUSIONS: Considerable country differences were identified in the quality of primary palliative care for older people. The data suggest room for improvement across all countries, particularly regarding pain measurement, GP-patient communication and multidisciplinary meetings.

Combining primary care surveillance and a meta-analysis to estimate the incidence of the clinical manifestations of Lyme borreliosis in Belgium, 2015-2017.

Lyme borreliosis (LB) is an important tick-borne disease which can cause a broad range of symptoms mainly affecting the skin, the nervous system and the joints. This study aims to estimate the incidence of the different clinical manifestations of LB in Belgium. The incidence of erythema migrans (EM) was estimated through the network of sentinel general practices at 97.6/100,000 inhabitants (uncertainty interval [UI] 82.0-113.0) for the period 2015-2017. This result was used to estimate the incidence of other LB manifestations based on their proportional distribution (ratios) to EM reported in the neighboring countries of Belgium. To estimate these ratios, we performed a systematic review of studies published between February 1, 2008 and January 31, 2018 and pooled the results using a random effects meta-analysis. Six studies were retained in the systematic review, and the meta-analysis estimated the occurrence ratios for Lyme neuroborreliosis/EM, Lyme arthritis/EM and other manifestations/EM at 0.024 (95% confidence interval [CI] 0.016-0.037), 0.022 (95% CI 0.020-0.024) and 0.014 (95% CI 0.012-0.016) respectively. Applying these ratios to the EM incidence in Belgium resulted in an incidence estimation of 2.4/100,000 inhabitants (95% UI 1.5-3.7) for Lyme neuroborreliosis, 2.1/100,000 (95% UI 1.7-2.6) for Lyme arthritis and 1.4/100,000 (95% UI 1.1-1.7) for other less frequent manifestations. Some of these LB manifestations, other than EM, are more severe, hence these estimates are essential to assess the health burden and economic cost of LB which would be highly relevant for patients, healthcare providers and policymakers. As both over- and underestimation of different clinical LB manifestations remain possible due to characteristics of the primary surveillance systems and the disease itself, future studies to validate these estimates would be of great value.

Differences in primary palliative care between people with organ failure and people with cancer: An international mortality follow-back study using quality indicators.

BACKGROUND: Measuring the quality of palliative care in a systematic way using quality indicators can illuminate differences between patient groups. AIM: To investigate differences in the quality of palliative care in primary care between people who died of cancer and people who died of organ failure. DESIGN: Mortality follow-back survey among general practitioners in Belgium, the Netherlands, and Spain (2013-2014), and Italy (2013-2015). A standardized registration form was used to construct quality indicators regarding regular pain measurement, acceptance of the approaching end of life, communication about disease-related topics with patient and next-of-kin; repeated multidisciplinary consultations; involvement of specialized palliative care; place of death; and bereavement counseling. SETTING/PARTICIPANTS: Patients (18+) who died non-suddenly of cancer, cardiovascular disease, or respiratory disease ( n = 2360). RESULTS: In all countries, people who died of cancer scored higher on the quality indicators than people who died of organ failure, particularly with regard to pain measurement (between 17 and 35 percentage-point difference in the different countries), the involvement of specialized palliative care (between 20 and 54 percentage points), and regular multidisciplinary meetings (between 12 and 24 percentage points). The differences between the patient groups varied by country, with Belgium showing most group differences (eight out of nine indicators) and Spain the fewest (two out of nine indicators). CONCLUSION: People who died of organ failure are at risk of receiving lower quality palliative care than people who died of cancer, but the differences vary per country. Initiatives to improve palliative care should have different priorities depending on the healthcare and cultural context.

Quality of primary palliative care for older people with mild and severe dementia: an international mortality follow-back study using quality indicators.

Background: measuring the quality of primary palliative care for older people with dementia in different countries is important to identify areas where improvements can be made. Objective: using quality indicators (QIs), we systematically investigated the overall quality of primary palliative care for older people with dementia in three different countries. Design/setting: a mortality follow-back survey through nation- and region-wide representative Sentinel Networks of General Practitioners (GPs) in Belgium, Italy and Spain. GPs registered all patient deaths in their practice. We applied a set of nine QIs developed through literature review and expert consensus. Subjects: patients aged 65 or older, who died non-suddenly with mild or severe dementia as judged by GPs (n = 874). Results: findings showed significantly different QI scores between Belgium and Italy for regular pain measurement (mild dementia: BE = 44%, IT = 12%, SP = 50% | severe dementia: BE = 41%, IT = 9%, SP = 47%), acceptance of approaching death (mild: BE = 59%, IT = 48%, SP = 33% | severe: BE = 41%, IT = 21%, SP = 20%), patient-GP communication about illness (mild: BE = 42%, IT = 6%, SP = 20%) and involvement of specialised palliative services (mild: BE = 60%, IT = 20%, SP = 77%). The scores in Belgium differed from Italy and Spain for patient-GP communication about medical treatments (mild: BE = 34%, IT = 12%, SP = 4%) and repeated multidisciplinary consultations (mild: BE = 39%, IT = 5%, SP = 8% | severe: BE = 36%, IT = 10%, SP = 8%). The scores for relative-GP communication, patient death outside hospitals and bereavement counselling did not differ between countries. Conclusion: while the countries studied differed considerably in the overall quality of primary palliative care, they have similarities in room for improvement, in particular, pain measurement and prevention of avoidable hospitalisations.

Palliative care service use by older people: Time trends from a mortality follow-back study between 2005 and 2014.

BACKGROUND: The need for increased use and timely initiation of palliative care for all people, not just those who die with cancer, has been advocated worldwide over the past decade. AIM: To investigate whether there has been a time trend in the use of palliative care services and the timing of their initiation for older people. DESIGN: Mortality follow-back survey among general practitioners in a nationally representative Sentinel Network in 2005-2010, 2013 and 2014 in Belgium. SETTING/PARTICIPANTS: Of all their patients who died non-suddenly aged 65+ years, general practitioners reported sociodemographic and clinical data, use of any of the palliative care services available in Belgium and when the first of these services was initiated. RESULTS: General practitioners identified 5344 deaths. Overall, palliative care service use increased from 39% in 2005 to 63% in 2014 ( p < 0.001). The use of a reference person for palliative care in a care home increased from 12% to 26% ( p < 0.001) and of a palliative homecare team from 14% to 17.5% ( p < 0.01), but hospital-based palliative care services did not increase. Controlling for sociodemographic characteristics, no differences were obtained over time in the proportion of cancer/non-cancer patients for whom they provided care. The timing of initiation of palliative care services remained unchanged at a median of 15 days before death. CONCLUSION: Palliative care service use has increased mostly in care homes, possibly as a result of policy changes, while hospital-based palliative care services lag behind. Contrary to recommendations, access for non-cancer patients may remain difficult and palliative care is often initiated late in the disease trajectory.

End-of-life care for people dying with dementia in general practice in Belgium, Italy and Spain: A cross-sectional, retrospective study.

AIM: To describe and compare end-of-life care for people with mild or severe dementia in general practice in Belgium, Italy and Spain, in terms of place of care, place of death, treatment aims, use of specialized palliative care and communication with general practitioners (GPs). METHODS: Cross-sectional retrospective survey was carried out of nationwide networks of GPs in Belgium, Italy and Spain, including patients who died aged 65 years or older in 2009-2011 and were judged by the GP to have had dementia (n = 1623). RESULTS: GPs reported a higher proportion of older people with severe dementia in Belgium (55%) than in Spain (46 %) and Italy (45 %), and a higher proportion of patients living in care homes (57% vs 18% and 13%, respectively). A palliative treatment aim was common in the last 3 months of life in all three countries. Specialized palliative care services were provided in 14% (Italy, severe dementia) to 38% (Belgium, severe dementia) of cases. Communication between GP and patient about illness-related topics occurred in between 50% (Italy) and 72% (Belgium) of cases of mild dementia, and 10% (Italy) to 32% (Belgium) of cases of severe dementia. Patient preferences for end-of-life care were known in a minority of cases. Few people (13-15 %) were transferred between care settings in the last week of life. CONCLUSIONS: Although overall treatment aims at the end of life are often aligned with a palliative care approach and transfer rates are low, there is room for improvement in end-of-life care for people with dementia in all countries studied, especially regarding early patient-GP communication. Geriatr Gerontol Int 2017; 17: 1667-1676.

Final transitions to place of death: patients and families wishes.

Purpose: This four-country study (Belgium, the Netherlands, Italy and Spain) examines prevalence and types of final transitions between care settings of cancer patients and the extent to which patient/family wishes are cited as a reason for the transition. Methods: Data were collected from the EUROSENTI-MELC study over a 2-year period. General practitioners within existing Sentinel Networks registered weekly all deaths of patients within practices using a standardized questionnaire. This registration included place of care in the final 3 months and wishes for the final transition to place of death. All non-sudden deaths due to cancer (+18 years) were included in the analyses. Results: We included 2048 non-sudden cancer deaths; 63% of patients had at least one transition between care settings in the final 3 months of life. 'Hospital death from home' (25-55%) and 'home death from hospital' (16-30%) were the most frequent types of final transitions in all countries. Patients' or families' wishes were mentioned as a reason for a final transition in 5-27% (P < 0.001) and 10-22% (P = 0.002) across countries. Conclusions: 'Hospital deaths from home' is the most prevalent final transition in three of four countries studied, in a significant minority of cases because of patient/family wishes.

General practice patients treated for substance use problems: a cross-national observational study in Belgium.

BACKGROUND: General Practitioners (GPs) are well placed to care for patients with (chronic) substance use problems. This pilot was carried out to study the feasibility and usefulness of a continuous surveillance of substance use problems among general practice patients. The objectives were (i) to describe variables with missing values exceeding 1% and whether patients were reported without substance-related problems; (ii) the profile and the magnitude of the patient population that is treated for substance use problems. METHODS: Observational study by the Belgian Network of Sentinel General Practices (SGP) in 2013. Baseline (at the first encounter) and 7-month follow-up data were reported of all patients treated for substance use problems. Two main measurements were type of substance use and patient status at follow-up. Multiple logistic regression analysis was used to examine patient status at follow-up. RESULTS: Of 479 patients, 47.2% had problems with alcohol alone, 20.3% with prescription drugs, 16.7% with illicit drugs other than heroin or methadone and 15.9% with heroin or methadone. Problems with alcohol alone were more prevalent in Flanders (53.0%; 95% confidence interval (CI) 46.8-59.1%) than in Wallonia-Brussels (39.8%; 95% CI 33.1-46.8%), while problems with heroin or methadone were more prevalent in Wallonia-Brussels (27.0%; 95% CI 21.1-33.5%) than in Flanders (7.1%; 95% CI 4.3-10.9%). At follow-up, 32.8% of the patients had dropped out, 29.0% had discontinued GP treatment and 38.2% had continued GP treatment. Overall, 32.4% of 479 patients had continued GP treatment for substance use problems during the study period. In Wallonia-Brussels, this proportion was higher (42.7%; 95% CI 35.9-49.6%) than in Flanders (24.3%; 95% CI 19.2-29.8%). CONCLUSIONS: A continuous surveillance of the general practice population treated for substance use problems seems to be feasible and useful. The latter is suggested by the specific profile and the relative magnitude of the population. Inter-regional health system differences should be taken into account to estimate the epidemiology of substance use problems among general practice patients.

Hospitalisations at the end of life in four European countries: a population-based study via epidemiological surveillance networks.

BACKGROUND: There is a paucity of cross-national population-based research on hospitalisations of people at the end of life. We aimed to compare, in four European countries, the frequency, time, length of and factors associated with hospitalisations in the last 3 months of life. METHODS: Population-based mortality follow-back study via Sentinel Networks of general practitioners (GPs) in Belgium, the Netherlands, Italy and Spain. Using a standardised form, GPs recorded the care in the last 3 months of life of every deceased practice patient (≥18 years; 1 January 2009 to 31 December 2011). Sudden deaths were excluded. RESULTS: We studied 4791 deaths that GPs described as non-sudden (66% of all registered deaths). Between 49% (the Netherlands) and 56% (Belgium) of patients were hospitalised at least once in the last 3 months of life. Readmissions were less frequent in the Netherlands (8%) than in the other countries (15-20%, p<0.001). Chances of being hospitalised increased over the last 10 days of life across countries but remained lowest in the Netherlands (Belgium: 21-37%, the Netherlands: 15-29%, Italy: 16-37%, Spain: 14-31%). Hospitalisations in the last week of life were more likely if patients resided at home rather than in a care home (ORs and 95% CIs Belgium: 1.94 (1.28 to 2.94); the Netherlands: 2.61 (1.10 to 6.18); Spain: 4.72 (1.64 to 13.57); non-significant in Italy) and less likely if the GP knew the patient's preferred place of death (ORs and 95% CIs Belgium: 0.52 (0.36 to 0.74); the Netherlands: 0.48 (0.25 to 0.91); Spain: 0.24 (0.13 to 0.44), non-significant in Italy). CONCLUSIONS: The use of hospitals at the end-of-life increased over the last weeks of life of patients in all countries studied, but remained lowest in the Netherlands, as did the rate of readmissions. This may be due to gatekeeping by GPs who are trained and supported in preventing hospital readmissions at the end of life.

Trends from the surveillance of suicidal behaviour by the Belgian Network of Sentinel General Practices over two decades: a retrospective observational study.

OBJECTIVES: First, we describe trends in characteristics of suicidal events using new (2011-2012) and previous (1993-1995, 2000-2001 and 2007-2008) data reported by the Belgian Network of Sentinel General Practices (SGP); second, we examine patient age-related trends in on-site attendance of sentinel general practitioners (GPs) as first professional caregivers following suicidal behaviour; third, we investigate the accuracy of suicide incidence estimates derived from the SGP data. DESIGN: Retrospective observational study. SETTING: General practices from the nationwide representative Belgian Network of SGP. OUTCOME MEASURES: Patient gender and age, suicide methods, whether the patient was new, whether the GP was the first caregiver on-site, and the outcome of the suicidal behaviour (fatal or not) were recorded on standard registration forms. The accuracy of suicide incidence estimates was tested against suicide mortality data. RESULTS: Over the four time periods, 1671 suicidal events were reported: 275 suicides, 1287 suicide attempts and 109 events of suicidal behaviour of unknown outcome. In 2011-2012, sentinel GPs' on-site attendance following the suicidal behaviour of patients <65 years had continued to decrease (from 71% in 1993-1995 to 58% in 2000-2001, 39% in 2007-2008 and 25% in 2011-2012). In 2011-2012, it had also decreased steeply in the population ≥65 years (from 70% in 1993-1995, 76% in 2000-2001 and 79% in 2007-2008 to 35% in 2011-2012). No significant differences were found between the SGP-based suicide incidence estimates for 2011-2012 and the available suicide mortality rates for people <65 and ≥65 years. CONCLUSIONS: GPs' on-site attendance as first professional caregivers following suicidal behaviour continues to decline since 2011-2012 also in the population ≥65 years. Unawareness of patients' suicidal behaviour endangers both care for surviving patients and the completeness of SGP surveillance data. Yet, the incidence of suicide for 2011-2012 was estimated accurately by the SGP.

Does the Belgian diabetes type 2 care trajectory improve quality of care for diabetes patients?

BACKGROUND: The Belgian care trajectory (CT) for diabetes mellitus type 2 (T2DM), implemented in September 2009, aims at providing integrated, evidence-based, multidisciplinary patient- centred care, based on the chronic care model. The research project ACHIL (Ambulatory Care Health Information Laboratory) studied the adherence of CT patients, in the early phases of CT programme implementation, with CT obligations, their uptake of incentives for self-management, whether the CT programme was targeting the appropriate group of patients, how care processes for these patients evolved over time and whether CT start led to better quality in the processes and outcomes of care. METHODS: This observational study took place in the period 2006-2011 and covered T2DM patients who started a CT between 01/09/2009 and 31/12/2011. Four data sources were used: outcome data, from electronic patient records (EPRs) on all CT patients, provided by general practitioners (GPs); reimbursement process data on all CT patients and clinically comparable patients; and data from a sample of CT patients and clinically comparable patients from an EPR-based regional GP network and a paper-based national GP network, respectively. Through multilevel analysis of cross-sectional and longitudinal data, the effect of CT inclusion on processes and outcome was estimated, controlling for potential confounders. RESULTS: By the end of 2011, data on 18,250 CT patients had been collected. Approximately 50 % of these CT patients had received reimbursement for a glucometer and nearly 60 % had had at least one encounter with a diabetes educator. The CT programme recruited T2DM patients who had been difficult to control in the past. In the years prior to CT start, there had been a gradual improvement in the follow up of these patients. Moreover, compared to non-CT patients, the proportion of CT patients adhering to the recommended frequency for monitoring of parameters, such as HbA1c, increased significantly around CT start. Some data sources, albeit not all, suggested there had been an improvement in certain outcomes, such as HbA1c, after CT inclusion. CONCLUSIONS: According to this study, CT enrolment is associated with better quality of care processes compared to non-CT patients. This improvement was found in several of the data sources used in this study. However, results on outcome parameters remain inconclusive.

Transitions between health care settings in the final three months of life in four EU countries.

BACKGROUND: Transitions between care settings may be related to poor quality in end-of-life care. Yet there is a lack of cross-national population-based data on transitions at the end of life. METHOD: International mortality follow-back study with data collection in Belgium, Netherlands, Italy and Spain (2009-11) via existing representative epidemiological surveillance networks of general practitioners (GPs). All general practitioners reported weekly, on a standardized registration form, every deceased patient (≥18 years) in their practice and identified those who died 'non-suddenly'. RESULTS: Among 4791 non-sudden deaths in Belgium, Netherlands, Italy and Spain, 59%, 55%, 60% and 58%, respectively, were transferred between care settings at least once in the final 3 months of life (10%, 8%, 10% and 13% in final 3 days of life); 10%, 5%, 8% and 12% were transferred three times or more (P < 0.001 in multivariate analyses adjusting for country differences in age, sex, cause of death, presence of dementia). In all countries, transitions were more frequent among patients residing at home (61-73%) than among patients residing in a care home (33-40%). Three months before death 5-7% of patients were in hospital, and this rose to 27-39% on the day of death. Patient wishes were cited as the reason for the last transition before death in 27%, 39%, 9% and 6% of cases in Belgium, Netherlands, Italy and Spain, respectively (P < 0.001). CONCLUSION: End-of-life transitions between health care settings are common across EU countries, in particular late hospitalizations for people residing at home. Frequency, type and reasons for terminal hospitalizations vary between countries.

Care trajectories are associated with quality improvement in the treatment of patients with uncontrolled type 2 diabetes: A registry based cohort study.

AIMS: To analyse whether care trajectories (CT) were associated with increased prevalence of parenteral hypoglycemic treatment (PHT=insulin or GLP-1 analogues), statin therapy or RAAS-inhibition. Introduced in 2009 in Belgium, CTs target patients with type 2 diabetes mellitus (T2DM), in need for or with PHT. METHODS: Retrospective study based on a registry with 97 general practitioners. The evolution in treatment since 2006 was compared between patients with vs. without a CT, using longitudinal logistic regression. RESULTS: Comparing patients with (N=271) vs. without a CT (N=4424), we noted significant differences (p<0.05) in diabetes duration (10.1 vs. 7.3 years), HbA1c (7.5 vs. 6.9%), LDL-C (85 vs. 98mg/dl), microvascular complications (26 vs. 16%). Moreover, in 2006, parenteral treatment (OR 52.1), statins (OR 4.1) and RAAS-inhibition (OR 9.6) were significantly more prevalent (p<0.001). Between 2006 and 2011, the prevalence rose in both groups regarding all three treatments, but rose significantly faster (p<0.05) after 2009 in the CT-group. CONCLUSIONS: Patients enrolled in a CT differ from other patients even before the start of this initiative with more intense hypoglycemic and cardiovascular treatment. Yet, they presented higher HbA1c-levels and more complications. Enrolment in a CT is associated with additional treatment intensification.

Care provided and care setting transitions in the last three months of life of cancer patients: a nationwide monitoring study in four European countries.

BACKGROUND: This is an international study across four European countries (Belgium[BE], the Netherlands[NL], Italy[IT] and Spain[ES]) between 2009 and 2011, describing and comparing care and care setting transitions provided in the last three months of life of cancer patients, using representative GP networks. METHODS: General practitioners (GPs) of representative networks in each country reported weekly all non-sudden cancer deaths (+18y) within their practice. GPs reported medical end-of-life care, communication and circumstances of dying on a standardised questionnaire. Multivariate logistic regressions (BE as a reference category) were conducted to compare countries. RESULTS: Of 2,037 identified patients from four countries, four out of five lived at home or with family in their last year of life. Over 50% of patients had at least one transition in care settings in the last three months of life; one third of patients in BE, IT and ES had a last week hospital admission and died there. In the last week of life, a treatment goal was adopted for 80-95% of those having palliation/comfort as their treatment goal. Cross-country differences in end-of-life care provision included GPs in NL being more involved in palliative care (67%) than in other countries (35%-49%) (OR 1.9) and end-of-life topics less often discussed in IT or ES. Preference for place of death was less often expressed in IT and ES (32-34%) than in BE and NL (49-74%). Of all patients, 88-98% were estimated to have distress from at least one physical symptom in the final week of life. CONCLUSION: Although palliative care was the main treatment goal for most cancer patients at the end of life in all four countries, frequent late hospital admissions and the symptom burden experienced in the last week of life indicates that further integration of palliative care into oncology care is required in many countries.

Factors associated with fulfilling the preference for dying at home among cancer patients: the role of general practitioners.

AIM: This study aimed to explore clinical and care-related factors associated with fulfilling cancer patients' preference for home death across four countries: Belgium (BE), The Netherlands (NL), Italy (IT), and Spain (ES). METHODS: A mortality follow-back study was undertaken from 2009 to 2011 via representative networks of general practitioners (GPs). The study included all patients aged 18 and over who had died of cancer and whose home death preference and place of death were known by the GP. Factors associated with meeting home death preference were tested using multivariable logistic regressions. RESULTS: Among 2,048 deceased patients, preferred and actual place of death was known in 42.6 percent of cases. Home death preference met ranged from 65.5 to 90.9 percent. Country-specific factors included older age in BE, and decision-making capacity and being female in the NL. GPs' provision of palliative care was positively associated with meeting home death preference. Odds ratios (ORs) were: BE: 9.9 (95 percent confidence interval [CI] 3.7-26.6); NL: 9.7 (2.4-39.9); and IT: 2.6 (1.2-5.5). ORs for Spain are not shown because a multivariate model was not performed. CONCLUSION: Those who develop policy to facilitate home death need to examine available resources for primary end-of-life care.

What determines inclusion in the early phase of the type 2 diabetes care trajectory in Belgium?

BACKGROUND: In 2009, the Belgian National Institute of Health and Disability Insurance established a care trajectory (CT) for a subgroup of type 2 diabetes mellitus patients (T2DM) based on Wagner's chronic care model. The goal of this CT is to optimise the quality of care using an integrated multidisciplinary approach. This study aims to identify patient-related factors associated with inclusion in a CT and to determine the most frequent reasons for non-inclusion. METHODS: In 2010, the Belgian Sentinel Network of General Practices conducted a prevalence study of type 2 diabetes. The surveillance study carried out by this nationwide, representative network collected unique information about eligibility for the CT, inclusion in the CT and reasons for non-inclusion. Based on the official inclusion and exclusion criteria, we first identified a group of eligible patients. Within this group, we then calculated the proportion of patients included in a CT as well as the prevalence of reasons for non-inclusion as reported by GPs. Furthermore, bivariate associations between patient-level parameters and inclusion were analysed. Finally, any patient-level parameters found to be statistically significant were included in a multivariate logistic regression model. RESULTS: The 2010 study recorded 4600 Belgian type 2 diabetes patients. According to the official criteria, 589 patients were eligible for inclusion in a CT T2DM. By the end of August 2011, 95 patients had been included in a CT T2DM. Our findings reveal that the younger the eligible patient was, the more likely he or she was to be included in a CT. Patients living in Flanders were more likely to be included in the CT than were patients living in Wallonia. Motivated patients with specific plans to change their diets were also more likely to be included in a CT. The two most frequently reported reasons for non-inclusion were participation in another diabetes care programme and the timing of this surveillance study (inclusion will take place in the near future). CONCLUSIONS: Eligible diabetes patients who were admitted to a CT T2DM during the early phases of CT implementation were mainly found to be those who are able to make progress in their disease trajectories. In the future, more attention could be paid to also include more high-risk patients.

Actual and preferred place of death of home-dwelling patients in four European countries: making sense of quality indicators.

BACKGROUND: Dying at home and dying at the preferred place of death are advocated to be desirable outcomes of palliative care. More insight is needed in their usefulness as quality indicators. Our objective is to describe whether "the percentage of patients dying at home" and "the percentage of patients who died in their place of preference" are feasible and informative quality indicators. METHODS AND FINDINGS: A mortality follow-back study was conducted, based on data recorded by representative GP networks regarding home-dwelling patients who died non-suddenly in Belgium (n = 1036), The Netherlands (n = 512), Italy (n = 1639) or Spain (n = 565). "The percentage of patients dying at home" ranged between 35.3% (Belgium) and 50.6% (The Netherlands) in the four countries, while "the percentage of patients dying at their preferred place of death" ranged between 67.8% (Italy) and 86.0% (Spain). Both indicators were strongly associated with palliative care provision by the GP (odds ratios of 1.55-13.23 and 2.30-6.63, respectively). The quality indicator concerning the preferred place of death offers a broader view than the indicator concerning home deaths, as it takes into account all preferences met in all locations. However, GPs did not know the preferences for place of death in 39.6% (The Netherlands) to 70.3% (Italy), whereas the actual place of death was known in almost all cases. CONCLUSION: GPs know their patients' actual place of death, making the percentage of home deaths a feasible indicator for collection by GPs. However, patients' preferred place of death was often unknown to the GP. We therefore recommend using information from relatives as long as information from GPs on the preferred place of death is lacking. Timely communication about the place where patients want to be cared for at the end of life remains a challenge for GPs.