Introducing the H2020 AQUACROSS project: Knowledge, Assessment, and Management for AQUAtic Biodiversity and Ecosystem Services aCROSS EU policies.

The AQUACROSS project was an unprecedented effort to unify policy concepts, knowledge, and management of freshwater, coastal, and marine ecosystems to support the cost-effective achievement of the targets set by the EU Biodiversity Strategy to 2020. AQUACROSS aimed to support EU efforts to enhance the resilience and stop the loss of biodiversity of aquatic ecosystems as well as to ensure the ongoing and future provision of aquatic ecosystem services. The project focused on advancing the knowledge base and application of Ecosystem-Based Management. Through elaboration of eight diverse case studies in freshwater and marine and estuarine aquatic ecosystem across Europe covering a range of environmental management problems including, eutrophication, sustainable fisheries as well as invasive alien species AQUACROSS demonstrated the application of a common framework to establish cost-effective measures and integrated Ecosystem-Based Management practices. AQUACROSS analysed the EU policy framework (i.e. goals, concepts, time frames) for aquatic ecosystems and built on knowledge stemming from different sources (i.e. WISE, BISE, Member State reporting within different policy processes, modelling) to develop innovative management tools, concepts, and business models (i.e. indicators, maps, ecosystem assessments, participatory approaches, mechanisms for promoting the delivery of ecosystem services) for aquatic ecosystems at various scales of space and time and relevant to different ecosystem types.

[Medical human resources planning in Europe: A literature review of the forecasting models]. / La planification des médecins en Europe : une revue de la littérature des modèles de projection.

BACKGROUND: Healthcare is a labor-intensive sector in which half of the expenses are dedicated to human resources. Therefore, policy makers, at national and internal levels, attend to the number of practicing professionals and the skill mix. This paper aims to analyze the European forecasting model for supply and demand of physicians. METHODS: To describe the forecasting tools used for physician planning in Europe, a grey literature search was done in the OECD, WHO, and European Union libraries. Electronic databases such as Pubmed, Medine, Embase and Econlit were also searched. RESULTS: Quantitative methods for forecasting medical supply rely mainly on stock-and-flow simulations and less often on systemic dynamics. Parameters included in forecasting models exhibit wide variability for data availability and quality. The forecasting of physician needs is limited to healthcare consumption and rarely considers overall needs and service targets. Besides quantitative methods, horizon scanning enables an evaluation of the changes in supply and demand in an uncertain future based on qualitative techniques such as semi-structured interviews, Delphi Panels, or focus groups. Finally, supply and demand forecasting models should be regularly updated. Moreover, post-hoc analyze is also needed but too rarely implemented. CONCLUSION: Medical human resource planning in Europe is inconsistent. Political implementation of the results of forecasting projections is essential to insure efficient planning. However, crucial elements such as mobility data between Member States are poorly understood, impairing medical supply regulation policies. These policies are commonly limited to training regulations, while horizontal and vertical substitution is less frequently taken into consideration.

Evaluation of cost and length of stay, linked to complications associated with major surgical procedures.

INTRODUCTION: A lot of studies have demonstrated the possibility of reducing the number of post-operative complications in the domain of major surgical procedures with the use of medical preventive techniques. However, complications following surgical procedures are unfortunately frequent and are a major problem, not only because of the impact for the patient, but also because of economic consequences that they provoke. The aim of the present study is to evaluate the extra length of stay and the extra cost, born by the hospital and the social security, linked to complications, incurring after major surgical procedures. MATERIAL AND METHODS: Study based on the data from 13 Belgian hospitals for the year 2012. Complications were extracted through medical discharge summaries. The cost born by the social security was assessed on the basis of the billing data, hospital cost are taken from cost accounting studies. RESULTS: The rate of complication for all the hospitals is 6.6%. About 30.3% of inpatient stays having a major or extreme severity of index had a complication during the stay, 1.8% of stays with a minor or moderate severity of index had a complication. The extra length of stay is 19.38 days when the stay has had a complication (p < 0.001). The additional mean cost borne from the hospital perspective is €21 353.07 and €8 026.65 for the social security. This additional mean cost varies greatly from one hospital to another. DISCUSSION/CONCLUSION: The present study has shown that the actual financing do not cover real hospital costs in the field of major surgical procedures having caused complications. Results should encourage Belgian authorities to propose and finance preventive measures in order to reduce these complications, which represent major economic impacts, not only for authorities but also for hospitals.

[Medical supply planning : dynamic registry of physicians, sixth reform of the State and numerus clausus]. / Planification de l'offre médicale : cadastre dynamique des médecins, sixième réforme de l'Etat et numerus clausus.

INTRODUCTION: The last few years have seen major changes in the Belgian medical planning. The paper aims to describe them and to assess how they will affect the medical demography. METHOD: Grey literature review and federal and federated entities legislation summary. RESULTS: A new dynamic register allows a better knowledge of medical workforce in all sectors of labour market. Recent legislation evolutions induce fragmentation of competences related to human resource for health planning : federal authorities are responsive for the fixation of number of GP and specialists and community authorities for registration of health professionals and fixation of sub-quotas in different branches of specialised medicine. Finally, the French Community has setting up a multiple selection system of medical students that have to past an 'orientation test', a possible reorientation after January examinations and then a numerus fixus at the end of the first academic year. CONCLUSIONS: Dynamic register improves the knowledge of medical workforce repartition. However, the assessment of its volume shows methodological limitations. From an operational viewpoint, the fragmentation of competences will ask coordination effort from all authority levels to avoid impairment in planning process. Finally, French Community has to consider evaluation and ambitious revision of medical workforce planning in their region.

INTRODUCTION: Ces dernières années, la planification de l'offre médicale belge a connu des bouleversements majeurs. Cet article propose de les décrire et d'en apprécier l'impact pour le futur de la démographie médicale. METHODE: Revue de la littérature grise et des textes législatifs nationaux et de la Communauté française. RESULTATS: La mise en place d'un cadastre dynamique a permis de mieux connaître la force de travail des médecins au sein des différents secteurs d'activité sur le marché de travail. Les récentes évolutions législatives montrent un morcellement accru des compétences en termes de planification : le Fédéral étant compétent pour la fixation des quotas de généralistes et de spécialistes, et les Communautés pour l'enregistrement des professionnels de santé et des sousquotas par disciplines. Enfin, la Communauté française a mis en place un système d'hyper-sélection des candidats aux études de médecine soumis successivement au test d'orientation, à la session de janvier suivi d'une éventuelle réorientation, et à la session de juin accompagnée de l'épreuve de classement du numerus fixus. CONCLUSIONS: La mise en place du cadastre dynamique améliore grandement la connaissance de la répartition de la force de travail médicale. Cependant, l'évaluation de son volume pose d'importantes questions méthodologiques. D'un point de vue opérationnel, le morcellement des compétences demandera des efforts de coordination entre les différents niveaux de pouvoir pour ne pas porter préjudice au processus de planification. Enfin, la Communauté française ne pourra faire l'économie d'une évaluation et d'une révision ambitieuse de la planification des médecins sur son territoire.

[Focus on planning the supply of physicians in Belgium]. / Focus sur la planification de l'offre médicale en Belgique.

BACKGROUND: The planning of human medical resources has been in progress since 1996. The aim of this paper is to describe the process which occurred in Belgium and to point out its assets and limits. METHODS: Literature review, analysis of the Belgian legislation at national and community (Flemish and French-speaking) level and analysis of the projection model. RESULTS: In Belgium, planniing is performed at two different levels of power. Firstly, the federal State determines the number of physicians who will access to the professional titles enabling them to obtain reimbursement of care by Health Funds. It is sustained by a supply projection type " stock and flows", an assessment of the number of required physicians (including healthcare expenditures by age and sex) and the purpose of equalizing Dutch-speaking and French-speaking medical densities. Secondly, Communities, are responsible for training and, as such, are organizing the selection at this level : entrance examination in the North and various selection procedures (now repealed) in the South. CONCLUSION: Worldwide, the managers of medical planning are faced with decisions related to appropriate numbers for human resources, given population needs, use of services and professional productivity. They have to address concerns from medical surplus to shortage. The case study of Belgium provides insight of various parameters which should be taken into account for national planning of physicians. It also shows the difficulty to assess a complex future and the factors which often hinder the implementation of evidence-based decisions.

Determinants of nonurgent use of the emergency department for pediatric patients in 12 hospitals in Belgium.

INTRODUCTION: The nonurgent use of the emergency department (ED) for pediatric patients is an increasing problem facing healthcare systems worldwide. To evaluate the magnitude of the phenomenon and to identify associated factors, an observational prospective survey was performed including all patients (<15 years) attending the ED in 12 Belgian hospitals during 2 weeks in autumn 2010. Use of ED was considered appropriate if at least one of the following criteria was met: child referred by doctor or police, brought by ambulance, in need for short stay, technical examination or orthopedic treatment, in-patient admission, or death. Among the 3,117 children, attending ED, 39.9 % (1,244) of visits were considered inappropriate. Five factors were significantly associated with inappropriate use: age of child, distance to ED, having a registered family doctor, out-of-hours visit, and geographic region. The adjusted odds ratio and 95 % confidence intervals are respectively-1.7 (1.3-2.0), 1.7 (1.3-2.2), 1.5 (1.1-2.2), 1.5 (1.2-1.9), and 0.6 (0.5-0.8). CONCLUSIONS: Almost 40 % of all paediatric ED attendances did not require hospital expertise. The risk of an inappropriate use of ED by pediatrician patients is predominantly associated with organizational and cultural factors. Access, equity, quality of care, and medical human resources availability have to be taken into account to design financially sustainable model of care for those patients. Furthermore, future research is needed to explain reasons why parents visit ED rather than using of primary-care services.

[How to manage the cost-efficacy ratio?]. / Comment gérer les rapports coût-efficacité?

The economical science will gradually introduce the health economy of which the definition urges to seek for a better distribution between public and private means to do more and better for the public health. The health market is principally conducted by the supply and demand law. The needs, the supply and demand and the consumer's behaviour are different in this particular market which evolves continuously and progressively goes closer to the market economy. The health status of each human represents the health demand and the medical goods and services are the supply. The role of the valuation studies in health economy is to favour a better use of the limited resources to the unlimited needs. The basic principles of a cost efficacy analysis are relatively simple. They compare the incremental costs with the increase of efficacy. The QALY is built with a combination between life quality and quantity in a unique concept: the measurement of the quality of life of a human at a given moment. The 100th report of the KCE established the restrictions of this method and its absolute use as in England. Indeed we have to take into account other factors as the added value in terms of clinical efficacy, accessibility, the seriousness of pathological cases and the emotional situation. The ICER (Incremental Cost Efficacy Ration) has a lot of weaknesses and may give the illusion that the reimbursement decision is easy. Nevertheless to neglect the economic approach is not ethical. ICER is first of all a balance factor.

[Is long-term use of clopidogrel cost-effective in high-risk atherothrombotic patients?]. / L'utilisation prolongée du clopidogrel est-elle rentable chez les patients athérothrombotiques a haut risque?

The objective of the analysis is to estimate the long-term costs and effects of clopidogrel versus aspirin in the secondary prevention of ischemic events in patients with a history of more than one atherothrombotic event in Belgium. The following high-risk subpopulations within the CAPRIE trial were analysed: patients with a history of myocardial infarction (MI) or ischemic stroke (IS) prior to the event qualifying for enrolment and patients with prior multiple vascular territory involvement. A Markov model that combined clinical, epidemiological and cost data was used. The base case scenario was based on a treatment duration of 5 years reflecting the long-term use of clopidogrel. A lifelong time horizon was taken, by applying life expectancy data based on the Saskatchewan database. Belgian cost estimates were derived from publicly available sources and literature. Long-term clopidogrel treatment compared to aspirin in patients with a history of MI or IS prior to the event qualifying for enrolment is associated with an incremental cost-effectiveness ratio (ICER) ranging between 2.730 Euro per life year gained (LYG) for the first year of treatment and 8.000 Euro/LYG for a treatment duration of 5 years. In patients with prior multiple vascular territory involvement the ICER of clopidogrel compared to aspirin lays between 3.110 Euro and 5.750 Euro/LYG for the respective treatment durations. Use of clopidogrel for the prevention of subsequent cardiovascular events in patients with a history of more than one ischemic event is associated with favourable ICERs, independently of the presumed treatment duration. Sensitivity analyses varying life expectancy, efficacy of clopidogrel, costs of events and cost of adverse events and discount rates demonstrated the robustness of the results.

[A medical reduced practice reimbursed by the sickness insurance is not synonymous with medical plethora in the French community of Belgium]. / Une pratique médicale réduite à charge de i'assurance maladie n'est pas synonyme de pléthore médicale en communaute française de Belgique.

OBJECTIVE: To determine if a reduced medical practice reimbursed by the sickness insurance is a proof of medical plethora. Enquiry design : Descriptive observation transverse design. POPULATION: The French-speaking general practitioners and specialists questioned in 2003 about their reduced activity volume recorded in 2000 by the National Institute of the Sickness - Disability insurance (INAMI) on the French Community territory. METHOD: All French-speaking general practitioners and specialists, not reaching the accreditation activity level in 2000, were selected starting from databank of the INAMI. A questionnaire was transmitted to the physicians by mailing via the INAMI services. The answer rate was 44,0 % for the specialists and 40,5 % for the general practitioners. RESULTS: In 2000, 47,7 % of the French-speaking general practitioners and 23,3 % of the French-speaking specialists did not reach the activity level given the right to be accredited by the INAMI. After the enquiry, only 5,5 % of the general practitioners and 5,7 % of the specialists had really a reduced activity. It was explained for a great part by the choice of career guidance out of the INAMI system and under-declaration of foreign working and retirement. CONCLUSIONS: The data bases of the INAMI are the only sources of individual medical activity recording. Their uses, in term of medical manpower planning, must be done with corrective factors issued from this study. The accreditation activity level is a good indicator to underline the activity out of the sickness insurance sector.

[Market economy, health economy?]. / Economie de marché, économie de santé?

After the definition of the economy and its different types, we have to stress the political economy which integrates pure economy and society. The economical science will gradually introduce the health economy of which the definition urges to seek for a better distribution between public and private means to do more and better for the public health. The market economy is different from the state economy. She is principally conducted by the supply and demand law. The consumer's behaviour in a competitive market has some characteristics which favour the balance of this market. The healthcare market put also a health supply and demand forward but not with the same values. The needs, the supply, the consumption and the consumer's behaviour are different in this particular market which quickly evolves and progressively goes closer to the market economy. Is the healthcare an economical good or duty? The choices' criteria and the priorities are changeable. The role of the valuation studies in health economy is to try to clarify them and to favour a better use of the limited resources to the unlimited needs.

[The value of pharmaco-economics: the point of view of the drug industry]. / Intérêt de la pharmaco-économie: le point de vue de l'industrie pharmaceutique.

This article describes the causes of the progressive increase of health costs and some of the methods used to contain them. The author addresses the question of assessment of efficacy, both in the area of diagnosis and treatment: what is its definition; which studies are currently under way to improve it; how is it measured today; what are its limitations; which fears does all this generate? The author finally points to the need of avoiding to restrain from an approach strictly limited to pharmaco-economics: the more global problem of health economics is much wider.