International comparative study of low back pain care pathways and analysis of key interventions.

PURPOSE: Low back pain (LBP) is a major public health problem worldwide. Significant practice variation exists despite guidelines, including strong interventionist focus by some practitioners. Translation of guidelines into pathways as integrated treatment plans is a next step to improve implementation. The goal of the present study was to analyze international examples of LBP pathways in order to identify key interventions as building elements for care pathway for LBP and radicular pain. METHODS: International examples of LBP pathways were searched in literature and grey literature. Authors of pathways were invited to fill a questionnaire and to participate in an in-depth telephone interview. Pathways were quantitatively and qualitatively analyzed, to enable the identification of key interventions to serve as pathway building elements. RESULTS: Eleven international LBP care pathways were identified. Regional pathways were strongly organized and included significant training efforts for primary care providers and an intermediate level of caregivers in between general practitioners and hospital specialists. Hospital pathways had a focus on multidisciplinary collaboration and stepwise approach trajectories. Key elements common to all pathways included the consecutive screening for red flags, radicular pain and psychosocial risk factors, the emphasis on patient empowerment and self-management, the development of evidence-based consultable protocols, the focus on a multidisciplinary work mode and the monitoring of patient-reported outcome measures. CONCLUSION: Essential building elements for the construction of LBP care pathways were identified from a transversal analysis of key interventions in a study of 11 international examples of LBP pathways.

The Belgian national guideline on low back pain and radicular pain: key roles for rehabilitation, assessment of rehabilitation potential and the PRM specialist.

Low back pain (LBP) and radicular pain are very common health problems. They are rarely caused by serious underlying pathology and will usually recover spontaneously in time. In about one third of the cases however, the pain and functional impairment will persist one year after onset, being responsible for high health care costs and work absence. The management of LBP and radicular pain should focus therefore on excluding signs and symptoms of serious underlying pathology, on an active approach and on the prevention of chronicity. In 2017 the Belgian Health Care Knowledge Centre (KCE) published a guideline on LBP and radicular pain. This guideline formed the basis for a national pathway on LBP and radicular pain and is the first step to change and optimize our daily clinical practice. In this Belgian guideline the importance is stressed of a comprehensive clinical assessment and a tailored rehabilitation. Pharmacological and invasive treatments have a more doubtful effect or should only be considered under certain conditions. Implementing these recommendations in an interdisciplinary pathway necessitates a central role for Physical and Rehabilitation Medicine (PRM) especially in giving advice on and/or coordinating the tailored rehabilitation to prevent chronicity. To do this, the PRM specialist should perform a medical and functional assessment according to the ICF framework and taking into account the risk for chronicity or persistent impairment and the rehabilitation potential.

The pivotal role for the multidisciplinary approach at all phases and at all levels in the national pathway for the management of low back pain and radicular pain in Belgium.

INTRODUCTION: High level evidence on management of spinal disorders is scarce, which results in guidelines being of limited practical use for practitioners. Care pathways are complex interventions intended for the mutual decision making of organization of care processes for a well-defined group of patients. The goal of this project was to design a pathway for the management of low back pain and radicular pain for national implementation in Belgium. EVIDENCE ACQUISITION: An international and Belgian study on characteristics of low back pain care pathways was performed along with a literature study and focus group interrogation. Based on essential building elements identified and a consensus approach among all relevant stakeholders in primary, hospital and reintegration care, a national pathway was constructed. The process was endorsed by the Belgian Health Care Knowledge Center, Belgian National Institute of Health and Disability Insurance and the Spine Society of Belgium. EVIDENCE SYNTHESIS: Eleven international pathways were identified, varying in implementation width from hospital-based to region/province-based. Seven Belgian pathway initiatives were detected. Notwithstanding differences, consistent building elements were identified. Three groups of caregivers, divided in primary care, hospital care and reintegration and including all relevant medical/paramedical disciplines, worked on integrating the essential building elements into a single concrete patient pathway of direct use to any caregiver and patient and based on a consensus model including reference to the 2017 Belgian adaptation of the 2016 NICE guidelines. The resulting pathways on management of low back pain and radicular pain underpin the importance of multidisciplinary teamwork. CONCLUSIONS: Essential building elements were identified from literature and established pathways and were successfully integrated in a Belgian national low back pain and radicular pain pathway using an integrative consensus approach. The pathways are consultable at www.lowbackpain.kce.be.

The Belgian Evidence-Based Practice Program: network governance to improve efficiency and effectiveness of evidence-based practice uptake.

In 2016, the Belgian Minister for Social Affairs and Public Health decided to set up a central governance structure for evidence-based practice (EBP). The underlying model, consisting of six EBP life cycle cells (prioritization, development, validation, dissemination, implementation and evaluation) and a bipolar governance layer was developed in 2017. Based on the characteristics of the Belgian EBP landscape, a network administrative organization was chosen to coordinate and facilitate the operational processes in the EBP life cycle and act as intermediate between the two forces: stakeholders and funders/policy makers. Scientific processes remain the responsibility of the EBP experts in the cells. As organizational change can result in resistance, building trust and consensus is a very important success factor for the setup of the network. The process is now in an advanced stage and in 2019 the EBP governance structure will be operationalized.

Evaluating fracture risk in acute ankle sprains: Any news since the Ottawa Ankle Rules? A systematic review.

BACKGROUND: Ankle sprain is frequently encountered, both in primary care and in emergency departments. Since 1992, the Ottawa ankle rules (OAR) can assist clinicians in determining whether an X-ray should be performed to exclude a fracture. Several guidelines recommend the use of OAR based on a systematic review from 2003. Ten years later, one can wonder if this recommendation should be changed. OBJECTIVE: To review systematically the current evidence on the most accurate method to assess the fracture risk after an ankle sprain in adults. METHODS: A methodical search for systematic reviews, meta-analyses and primary studies was carried out in Medline, Cochrane Database of systematic reviews, Embase, Pedro, CINAHL, Medion and specific guideline search engines. At least two independent researchers performed selection, quality appraisal (with validated checklists) and data extraction. RESULTS: One systematic review and 21 primary studies were selected. Sensitivity and specificity of the OAR range from 92-100% and from 16-51%, respectively. To improve the OAR specificity, other tools are proposed such as the Bernese ankle rules. Vibrating tuning fork test and ultrasound could be useful in patient with OAR positive to decrease the need for radiographs. No evidence was found in favour of the use of magnetic resonance imaging (MRI) or computed tomography (CT) in the acute phase of ankle sprain. CONCLUSION: The findings confirm the value of the OAR at ruling out fractures after an ankle sprain and propose other or additional tools to decrease the need for X-rays.

Systematic Review of the Efficacy and Safety of High-intensity Focussed Ultrasound for Localised Prostate Cancer.

CONTEXT: High-intensity focussed ultrasound (HIFU) has been used for 10 yr to treat localised prostate cancer (PCa). OBJECTIVE: To evaluate systematically the evidence on the efficacy and side effects of HIFU in the primary treatment of localised PCa. EVIDENCE ACQUISITION: We performed a critical review and appraisal of Medline (Ovid), PreMedline, Embase, and Cochrane Database of Systematic Reviews publications on HIFU up to May 2013. One systematic review and 18 primary studies, all case series, were eligible. EVIDENCE SYNTHESIS: Outcomes were summarised and evidence was evaluated using Grading of Recommendations, Assessment, Development and Evaluation methodology. Low-quality evidence suggests an overall survival rate after Ablatherm HIFU ranging from 80% to 89% for >5 yr. The PCa survival rate ranges from 97% to 99% for >5 yr. Effect of HIFU on quality of life remains undetermined. Erectile dysfunction was the most frequent adverse event reported from zero but up to 74% of patients. Adverse events affecting the urinary tract occurred in 0.7-31% of patients, bladder outlet obstruction in 4-51.5%, and they were more frequent in patients who had transurethral resection of the prostate the same day or within 2 d of HIFU. Outcomes vary for low- and high-risk categories. CONCLUSIONS: Good quality evidence on the efficacy of HIFU treatment for localised PCa is lacking. PATIENT SUMMARY: We reviewed all the data on treatment with high-intensity focussed ultrasound (HIFU) for localised prostate cancer (PCa). The quality of the evidence is very low because the information is based on a series of patients who received HIFU treatment with no comparison with active surveillance or radical treatment. Case series suggest an overall survival rate up to 89% and a PCa survival rate up to 99% after 5 yr, but these numbers vary according to the patient's risk category. Longer term and effects on quality of life are unknown.

The Belgian Health System Performance Report 2012: snapshot of results and recommendations to policy makers.

Following the commitments of the Tallinn Charter, Belgium publishes the second report on the performance of its health system. A set of 74 measurable indicators is analysed, and results are interpreted following the five dimensions of the conceptual framework: accessibility, quality of care, efficiency, sustainability and equity. All domains of care are covered (preventive, curative, long-term and end-of-life care), as well as health status and health promotion. For all indicators, national/regional values are presented with their evolution over time. Benchmarking to results of other EU-15 countries is also systematic. The policy recommendations represent the most important output of the report.

[General practitioners mobilize to confront a cancer cluster]. / Mobilisation sanitaire face à un agrégat de cancers: le rôle des médecins généralistes.

With a view to respond to the growing concerns of a neighborhood population where a cluster of cancer was observed in 2002, public health authorities organized monitoring and surveillance activities by mobilizing local general practitioners (GPs). The monitoring activity has been carried out in the form of a free annual prevention consultation available at some local GPs' offices. Five years after the initiation of this monitoring activity, it was deemed interesting and necessary to make a review of the activity to take stock of the procedures established. Various data sources have been analyzed: anonymous records and files completed by GPs, answers to satisfaction enquiries sent out to the beneficiaries of the action in 2008, and the compilation of feedback and reactions of participating GPs during the annual meetings with the team responsible for monitoring. In 5 years, 29% of the population concerned went to one consultation at least. The percentage of participants gradually decreased to 2% at the fifth visit. The follow-up consultation was considered to be satisfactory by the surveyed population, and GP volunteers confirmed their interest in this approach. The positive atmosphere in which the follow-up and the monitoring took place is noteworthy and corroborates the role that health professionals can play in the management of a cancer cluster.

Primary healthcare research network: the Belgian ResoPrim recommendations.

Dedicated primary care research networks aim to gather and analyse data collected from general practioners' (GPs) electronic health records (EHRs). ResoPrim (2003-2008) was a Belgian multidisciplinary research project which was set up to provide recommendations for facilitating the organisation and management of these primary care research networks, assessing and improving opportunities for researchers working with available data from EHRs, and stimulating the involvement of GPs in such networks. This paper provides a short description of Resoprim's global methodology (which included 2 pilot phases involving 64 GPs and 6 different software systems), followed by the project's final recommendations.

Education in environmental health of health care professionals: what needs to be done?

BACKGROUND: Health professionals are key actors in environmental health. Taking on this role requires a certain degree of competence. That is the reason why education in environmental health of health care professionals became a major concern at international level, notably at WHO level. However, in the European Union only the individual Member States are responsible for organizing education and no official body seems to have started outlining recommendations on how to set up this kind of training. OBJECTIVES: We set out to draw up some propositions for training in environmental health on the basis of the practice of educational institutions involved in training health care professionals. METHODS: A survey was conducted in 934 educational institutions involved in training health care professionals in 11 European countries and in Canada. RESULTS: Our data reveal that, whereas there are many establishments - nearly half of those that replied - engaged in educating health care professionals in environmental health, they do so in a great variety of ways, whether in terms of objectives, content, the number of teaching hours, or their target groups. Moreover, there is only limited evaluation of this training, which makes the question of recognition a very difficult one. CONCLUSIONS: Numerous difficulties have been raised in relation to education in environmental health, both by trainers and trainees. Some solutions to these difficulties are suggested but the need of official guidelines keeps going.

Electronic Patient Record data as proxy of GPs' thoughts.

Data currently available in primary care Electronic Patient Records (EPR) can potentially be used to study quality of care. In this paper we investigate to which extend these data can reflect GPs' "thoughts" that are an important issue when considering GPs' practice and quality improvement cycle. Within the Resoprim project, we mainly used the consolidated data of three software systems, 26 practices, 1,554 hypertensive patients and 1,977 contacts. Extracted data from the EPR were: some diagnoses, some drugs, referral events, marital status, some parameters (smoking status, height, weight, blood pressure). As "gold standard" of GPs' thoughts we used an electronic questionnaire at the end of each contact. Measures of missing and incoherent values were used to assess our "gold standard". Sensitivity, positive predictive values, correctness and global completeness were used to measure the quality of the automatic extracted data (our proxy). For the "gold standard", the global percentage of missing values is 1.88% and of incoherent values is 3.92%. For most of the practices, the PPV or the correctness of automatic extracted drugs and automatic extracted parameters is high (>95%). The PPV of automatic extracted diagnoses is variable (42.1% to 94.9%). The sensitivity of automatic extracted diagnoses and drugs is lower than 67%. For most of the practices the sensitivity of automatic extracted parameters (excl. smoking status) is higher than 95%. The global completeness of height and weight is lower than 76%. Referrals are badly recorded or extracted. Currently in Belgium, without additional investigations, databases built on data extracted from EPRs can hardly be considered as good proxies of what is thought or known by the GPs. To use them as proxies, we should at least develop tools such as electronic questionnaires to calibrate them. As priority, we suggest an improvement of the extraction procedure design, of the current software interfaces and of the quality control of the extraction modules in order to improve respectively the extracted drugs sensitivity, the global completeness of extracted parameters and the PPV of extracted diagnoses. Training GPs could also be helpful.

Are problem-oriented medial records (POMR) suitable for use in GPs' daily practice?

Problem-oriented functions have been implemented in almost all Belgian GPs' software systems since 2003. We therefore investigated whether some of them - especially the explicit linking procedure between treatments or referrals and the relevant problems - can be used by GPs in their current daily practice. In 2005, within the Belgian ResoPrim project, we organized data collection, mainly around the theme of "hypertension and cardiovascular risk factors", by 26 volunteer GPs' practices using three different software systems. Data were collected prospectively over six weeks in early 2005, and retrospectively for 2004. In this paper we report only on the part of the study that aimed to assess the linking procedure. For all patients and hypertensive patients alike, the key indicators used were the percentage of (problem-) linked drugs among the drugs extracted, the percentage of anti-hypertensive (problem-) linked drugs among anti-hypertensive drugs extracted, and the percentage of (problem-) linked referrals among the number of referrals extracted. For all patients, the data collected relate to 10,914 contacts (7,831 patients) in 2005, and to 74,878 contacts (16,813 patients) in 2004. Large variations were observed per software system and GP, and also over time. The percentage of linked drugs rose from 2% (2004, two GPs) to 36% (2005, fourteen GPs). For linked referrals the percentage was 65% in 2004 vs. 75% in 2005. Our study shows that some functions related to the problem-oriented patient record were spontaneously used by GPs in daily practice. This use increased during collaboration with the primary care research network. This increase was not restricted to the theme of data collection (i.e. not restricted to hypertensive patients, to anti-hypertensive drugs or to links with cardiovascular problems).

Research networks: can we use data from GPs' electronic health records?

As widely discussed in the literature, there are many potential scientific usages of data extracted from the primary care Electronic Health Records (EHR), such as quality of care, epidemiological or socio-economical studies. Yet, can we use the current available data in the EHR for such purposes? In this paper, our objective is to report on the preliminary findings of the Belgian ResoPrim project (2003-2005) to answer the question. We set up a semi-anonymous network involving 26 current practices (28 volunteer GPs), 3 different EHR software systems and two Trusted Third Parties. Based on a literature overview we identified 27 research questions to be answered using 50 indicators. The study design includes retrospective (2002-2004) and prospective (6 weeks) data collection processes around the theme of "Hypertension and cardiovascular risk factors". For some data sets, the data extraction was a full automatic procedure, for some others, the data extraction was related to an input from the GPs allowing some comparisons between both procedures. At this stage, we performed an extended descriptive analysis of our data. Retrospectively we collected data related to 42,217 patients and 203,128 contacts. Prospectively we collected data for 9,236 patients and 15,234 contacts. Our main findings are briefly presented and discussed in this paper. The most promising fields seem to be the Health Research Information Systems assessment and the quality of care studies. It is quite too soon to reach the expected theoretical benefits for epidemiologic and socio-economic studies, yet some progresses could be made in relation with the denominator issue. Based on our preliminary findings and hypotheses, further analyses are foreseen during the second phase of the project (2006-2007).

Quality of care assessment using GPs' electronic patient records: do we need data from home visits?

The paper tackles the topic of collecting data from home visits using the electronic patient record (EPR) of general practitioners (GPs), in a context with a high proportion of home visits in primary care. Since data from home visits, representing about 40% of GPs' consultations in Belgium, are rather scarcely recorded in the EPR, we wanted to study the impact of not taking into account home visits for quality assessment in primary care. Five quality indicators, which measured the accordance of the delivered care with guidelines on the management of osteoarthritis, were compared between a pooled database (consultations and home visits) and a restricted database (after removal of home visits). Our findings suggest that removing home visits from a database collected from primary care may provide a slight modification of the estimate of the quality of care, whereas conclusions on quality improvement remain relatively stable. Quality of care assessment with the EPR of GPs seems not to be dramatically hampered by the poor recording rate of home visits in the EPR.