Impact of health technology assessment on preventive screening in Belgium: case studies of mammography in breast cancer, PSA screening in prostate cancer, and ultrasound in normal pregnancy.

OBJECTIVE: To describe how scientific evidence has influenced healthcare policy making in Belgium in the field of sickness prevention for mammography, PSA testing in prostate cancer screening, and use of ultrasound in pregnancy. METHODS: Review of published and gray literature and interviews with stakeholders and experts. RESULTS: At the end of 1999, a systematic national/regional screening program had not yet been implemented for any of the three screening strategies. A systematic breast cancer screening program is being prepared for implementation only in Flanders. This limited impact can be attributed to the fragmentation in healthcare policy, the different options among the different regions, fragmentation in healthcare practice, the strong impact of healthcare stakeholders (provider groups and sickness funds) on decision making, and limited attention to scientific evidence in health policy and technology assessment. CONCLUSIONS: Health technology assessment has had very little impact on policy and practice in use of mammography, PSA testing, and ultrasound in pregnancy in Belgium.

Cost analysis of ERCP in a university hospital.

BACKGROUND: A detailed analysis of the costs of ERCP is needed to provide medical staff, hospital administrators, and health care insurers with a solid basis for decision making. METHODS: An incremental cost analysis was performed from the hospital perspective. Cost calculations were based on a prospective registration of materials, labor time, and equipment needed to perform 204 ERCPs in a tertiary care center. RESULTS: Annual fixed cost related to the organization of the ERCP-unit amounted to $136,213. Variable costs per procedure, including labor and material costs, amounted to $344 and $961 for diagnostic and therapeutic procedures, respectively. Average reimbursement was $221. For the actual situation in our unit, with about 900 procedures yearly and a ratio diagnostic versus therapeutic procedures of 35 to 65, a net yearly loss because of the performance of ERCP activities amounts to $608,038. Theoretical measures to decrease costs could reduce this loss to $394,798, with an average loss of $439 per procedure. CONCLUSIONS: This analysis of costs related to performance of ERCPs clearly shows that ERCP is not sufficiently reimbursed. From our model, it appears that increasing the reimbursement rate for therapeutic procedures to $600 per procedure would generate a net positive balance.

Psychosocial and behavioral selection criteria for solid organ transplantation.

An evidence-based selection process for organ transplantation may be a valuable approach to improve posttransplant outcomes. This paper reviews state-of-the-art psychosocial and behavioral selection criteria and assesses their validity in view of predicting outcomes after transplantation. Psychosocial factors addressed are psychiatric disorders, mental retardation, irreversible cognitive dysfunction, and lack of social support. Behavioral selection criteria discussed are alcoholism, smoking, drug abuse, and obesity. This review reveals that the evidence concerning these selection criteria in scarce. There is a definite need for more longitudinal research to strengthen the scientific basis of the psychosocial and behavioral dimension of transplantation.

Palliative radiotherapy practice within Western European countries: impact of the radiotherapy financing system?

PURPOSE: To analyze the reimbursement modalities for radiotherapy in the different Western European countries, as well as to investigate if these differences have an impact on the palliative radiotherapy practice for bone metastases. MATERIALS AND METHODS: A questionnaire was sent to 565 radiotherapy centres included in the 1997 ESTRO directory. In this questionnaire the reimbursement strategy applied in the different centres was assessed, with respect to the use of a budget (departmental or hospital budget), case payment and/or fee-for-service reimbursement. The differences were analyzed according to country and to type and size of the radiotherapy centre. RESULTS: A total of 170 centres (86% of the responders) returned the questionnaire. Most frequent is budget reimbursement: some form of budget reimbursement is found in 69% of the centres, whereas 46% of the centres are partly reimbursed through fee-for-service and 35% through case payment. The larger the department, the more frequent the reimbursement through a budget or a case payment system and the less the importance of fee-for-service reimbursement (chi(2): P=0.0012; logit: P=0.0055). Whereas private centres are almost equally reimbursed by fee-for-service financing as by budget or case payment, radiotherapy departments in university hospitals receive the largest part of their financial resources through a budget or by case payment (83%) (chi(2): P=0.002; logit: P=0.0073). A correlation between the country and the radiotherapy reimbursement system was also demonstrated (P=0.002), radiotherapy centres in Spain, the Netherlands and the United Kingdom being almost entirely reimbursed through a budget and/or case payment and centres in Germany and Switzerland mostly through a fee-for-service system. In budget and case payment financing lower total number of fractions and lower total dose (chi(2): P=0.003; logit: P=0.0120) as well as less shielding blocks (chi(2): P=0.003; logit: P=0.0066) are used. A same tendency is found for the use of isodose calculations and field set-up, but without being statistically significant (P=0.264 and P=0.061 res.). The type of the centre and the reimbursement modality influence the fractionation regimen independently (P=0.0274). This is not the case for the centre size and the reimbursement, which were found to exert correlated effects on the fractionation schedule (P=0.1042). CONCLUSION: Reimbursement systems seem to influence radiotherapy practice. One should therefore aim to develop reimbursement criteria that pursue to deliver, not only the best qualitative, but also the most cost-effective treatments to the patients.

Differences in palliative radiotherapy for bone metastases within Western European countries.

PURPOSE: To evaluate the differences in palliative radiotherapy for painful bone metastases amongst different Western European countries. MATERIALS AND METHODS: A questionnaire was sent to 565 radiotherapy centres in 19 Western European countries, based on the 1997 ESTRO directory. In this questionnaire the current local palliative radiotherapy practice for bone metastases was assessed in terms of total dose, fractionation, treatment complexity (use of shielding blocks, frequency of isodose calculations, field set-up) and type of machine used. The differences were analyzed according to the country and to the type and size of radiotherapy centre. RESULTS: A total of 205 centres (36%) returned the questionnaire, of which 198 could be further analyzed. The most frequently used antalgic fractionation schedule is 30 Gy in ten daily fractions of 3 Gy (50%), single fractions and conventional 2 Gy fractions being used in a minority of the centres (respectively, 11 and 9%). Most antalgic treatments are performed on a linear accelerator (67% of the centres uses linear accelerators) and 64% of the centres predominantly uses a two-field set-up. The majority of the centres uses shielding blocks and performs isodose calculations in less than 50% of the patients, (respectively, 88 and 81%). There is a correlation between the centre size and the palliative irradiation practice, the largest centres using more hypofractionation (chi(2): P=0.001; logit: P=0. 0003) and a less complex treatment set up as expressed by the use of isodose calculations (chi(2): P=0.027; logit: P=0.0161). There is also a tendency to use less shielding blocks (P=0.177). The same goes for university centres as compared with private centres: university centres use shorter fractionation schedules (chi(2): P=0. 008; logit: P=0.0094), less isodoses (chi(2): P=0.010; logit: P=0. 0115) and somewhat less shielding blocks (P=0.151). Amongst the analyzed countries different tendencies in fractionation (P=0.001) and treatment complexity are observed (use of isodoses: P=0.014, use of shielding blocks: P=0.001). CONCLUSION: These data suggest that beside work-load and clinical evidence, country-related factors such as tradition and habits, past teaching, the national organization of health care and reimbursement criteria may influence the local practice.

Health technology assessment in Belgium.

The Belgian healthcare system has a Bismarck-type compulsory health insurance, covering almost the entire population, combined with private provision of care. Providers are public health services, independent pharmacists, independent ambulatory care professionals, and hospitals and geriatric care facilities. Healthcare responsibilities are shared between the national Ministries of Public Health and Social Affairs, and the Dutch-, French-, and German-speaking Community Ministries of Health. The national ministries are responsible for sickness and disability insurance, financing, determination of accreditation criteria for hospitals and heavy medical care units, and construction of new hospitals. The six sickness and disability insurance funds are responsible for reimbursing health service benefits and paying disability benefits. The system's strength is that care is highly accessible and responsive to patients. However, the healthcare system's size remained relatively uncontrolled until recently, there is an excess supply of certain types of care, and there is a large number of small hospitals. The national government created a legal framework to modernize the insurance system to control budgetary deficits. Measures for reducing healthcare expenditures include regulating healthcare supply, healthcare evaluation, medical practice organization, and hospital budgets. The need to control healthcare facilities and quality of care in hospitals led to formal procedures for opening hospitals, acquiring expensive medical equipment, and developing highly specialized services. Reforms in payment and regulation are being considered. Health technology assessment (HTA) has played little part in the reforms so far. Belgium has no formal national program for HTA. The future of HTA in Belgium depends on a changing perception by providers and policy makers that health care needs a stronger scientific base.

Improved management of radiotherapy departments through accurate cost data.

BACKGROUND AND PURPOSE: Escalating health care expenses urge governments towards cost containment. More accurate data on the precise costs of health care interventions are needed. We performed an aggregate cost calculation of radiation therapy departments and treatments and discussed the different cost components. MATERIALS AND METHODS: The costs of a radiotherapy department were estimated, based on accreditation norms for radiotherapy departments set forth in the Belgian legislation. RESULTS: The major cost components of radiotherapy are the cost of buildings and facilities, equipment, medical and non-medical staff, materials and overhead. They respectively represent around 3, 30, 50, 4 and 13% of the total costs, irrespective of the department size. The average cost per patient lowers with increasing department size and optimal utilization of resources. Radiotherapy treatment costs vary in a stepwise fashion: minor variations of patient load do not affect the cost picture significantly due to a small impact of variable costs. With larger increases in patient load however, additional equipment and/or staff will become necessary, resulting in additional semi-fixed costs and an important increase in costs. A sensitivity analysis of these two major cost inputs shows that a decrease in total costs of 12-13% can be obtained by assuming a 20% less than full time availability of personnel; that due to evolving seniority levels, the annual increase in wage costs is estimated to be more than 1%; that by changing the clinical life-time of buildings and equipment with unchanged interest rate, a 5% reduction of total costs and cost per patient can be calculated. More sophisticated equipment will not have a very large impact on the cost (+/-4000 BEF/patient), provided that the additional equipment is adapted to the size of the department. That the recommendations we used, based on the Belgian legislation, are not outrageous is shown by replacing them by the USA Blue book recommendations. Depending on the department size, costs in our model would then increase with 14-36%. CONCLUSION: We showed that cost information can be used to analyze the precise financial consequences of changes in routine clinical practice in radiotherapy. Comparing the cost data with the prevailing reimbursement may reveal inconsistencies and stimulate to develop improved financing systems.

Federation of European Cancer Societies. Full report. Economic evaluation in cancer care: questions and answers on how to alleviate conflicts between rising needs and expectations and tightening budgets.

All Western countries have experienced a fast growth in their healthcare expenses over recent decades. It is expected that pressure for such growth will continue in the future. But spending an ever larger share of our nation's resources on healthcare cannot be afforded. As a consequence, making choices will become more and more inevitable, even in cancer care. Economic evaluation is a very supportive tool for such decisions. This position statement concludes with recommendations for providers and healthcare policy-makers, to safeguard and further improve good clinical decision making and healthcare policy in cancer care under tightening budgets.

A comparison of health care financing policies for incontinence products in European countries.

OBJECTIVES: This paper offers an overview of the different health care financing policies for incontinence products in 16 European countries and provides health care decision-makers with a framework for positioning their financing policy for incontinence products versus other European countries. METHODS: A questionnaire was sent to institutions or persons acquainted with the health care financing system towards incontinence products in 19 countries. Further details were collected by additional telephone interviews and information from several informants. Three countries did not provide information. RESULTS: Financing systems for incontinence products differ widely from country to country. In all countries, hospitalized incontinent patients are better covered than patients residing in institutions for geriatric care. It is furthermore a common phenomenon that patients living at home receive even less coverage. Moreover, most countries apply a fairly uniform type of financing system, meaning that, once assessed in need, financial coverage is very similar for all patients (i.e. not very much differentiated with respect to the nature and severity of their incontinence problems). CONCLUSION: Given the serious potential impact of incontinence on citizens' quality of life and given the substantial variations in degree of incontinence, most countries could improve their utilization of (scarce) health care resources devoted to incontinence by developing more 'selective' payment policies, whereby reimbursement is 'tailored' to patients' needs.

The additional hospital costs of the LAURA cochlear implant in the department of otorhinolaryngology, head and neck surgery of the university hospital of Leuven.

From the start of 1994 until 1996 ten patients (eight adults and two children) received cochlear implants after careful preoperative selection in our department. Only the deaf adults implanted with the LAURA cochlear implant were included in this retrospective analysis. In this study, the additional hospital costs associated with cochlear implantations were estimated. In doing this, a differentiation was made between 'fixed' costs and 'variable' costs. In general, the average cost of cochlear implantation was 1,186,741 BF (29,418.54 EUR) per implanted adult and a direct fixed cost of 262,880 BF (6,516.62 EUR) was needed for the computer requisites. In general, the cochlear implant enhance speech-perception scores in the postlingually deafened patients as well as in the prelingually deafened adults. After intensive training, all implanted adults of the University Hospital Leuven could recognize the segmental aspects of speech with scores above the level of significance.

Public financing systems for radiology: experience in 12 European countries.

This paper illustrates the evolution in public health care financing systems in 12 European countries, in terms of the financing of radiology services. The financing systems for radiology used by public health care financing agencies are described in detail. The implications of these new financing conditions for health care delivery are briefly sketched. The paper concludes with some strategies to help radiologists cope with the tightening financing conditions for medical imaging.

Disease management. A new technology in need of critical assessment.

Recently, many disease management programs, especially for patients with chronic diseases, have emerged. This paper discusses the potential benefits and disadvantages of disease management, on the basis of an extensive literature review. Disease management is an innovative technology in health care management, which is diffusing throughout the health care system without critical evaluation. Evidence on its effectiveness and costs is still very scarce, while the legal, ethical, organizational, and social implications of this practice have not been analyzed seriously. Before disease management is implemented on a broader scale in different European settings, first, empirical evidence about its alleged benefits and cost-effectiveness should be collected.

Health care expenditure on schizophrenia patients in Belgium.

Schizophrenia generates a great deal of cost and burden. The aim of this study was to assess the direct costs for schizophrenia patients receiving standard treatment in different settings in Belgium. Costs were calculated for patients and for the Belgian insurance system. Data from Belgium's largest sickness fund were used to estimate health expenditures for all schizophrenia patients in Belgium. The mean direct treatment cost was $12,050 per patient per year, or $304 million for all schizophrenia patients per year. This cost constitutes 1.9 percent of the Belgian Government's total health expenditure. Government expenditure per schizophrenia patient is 10 times that of an average citizen.

The additional hospital costs and outcome of the LAURA Cochlear Implant in the Department of Otorhinolaryngology, Head and Neck Surgery of the University Hospitals, Leuven.

The additional hospital costs and the effects of cochlear implantation are described. From the start in 1994 until 1996 ten patients, 8 adults and 2 children, received a cochlear implant after careful preoperative selection. Only the 8 deaf adults implanted with the LAURA cochlear implant in the department of Otorhinolaryngology, Head and Neck Surgery of the University Hospital Leuven will be included in this retrospective analysis. In this study, the additional hospital costs associated with cochlear implantations are estimated. In estimating the costs, a differentation is made between 'fixed' costs and 'variable' costs. In general the costs of cochlear implantation is high: an average cost of 1,186,741, -Bef per implanted adult and a direct fixed cost of 262,880, -Bef for the computer requisites. To evaluate the effect of cochlear implantation a standard test, the AN-test battery, is used. In general, the cochlear implant enhances the speech perception scores in the postlingually deafened as well as in the prelingually deafened adults. After intensive training, all implanted adults of the University hospital Leuven could recognize the segmental aspects of speech with scores above the level of significance. The cochlear implant has also a positive psychological and social impact.

Incentives for cooperation in quality improvement among hospitals--the impact of the reimbursement system.

Up to now, few analytical models have studied the incentives for cooperation in quality improvements among hospitals. Only those dealing with reimbursement systems have shown that, from the point of view of individual or competing hospitals, retrospective reimbursement is more likely to encourage quality improvements than prospective financing, while the reverse holds for efficiency improvements. This paper studies the incentives to improve the quality of hospital care, in an analytical model, taking into account the possibility of cooperative agreements, price besides non-price (quality) competition and quality improvements that may simultaneously increase demand, increase or reduce costs and spill over to rival hospitals. In this setting quality improvement efforts rise with the rate of prospective reimbursement, while the impact of the rate of retrospective reimbursement is ambiguous, but likely to be negative for quality improvements that are highly cost-reducting and create large spillovers. Cooperation may lead to more or less quality improvement than non-cooperative conduct, depending on the magnitude of spillovers and the degree of product market competition, relative to the net effect of quality on profits and the share of costs that is reimbursed retrospectively. Finally, the stability of cooperative agreements, supported by grim trigger strategies, is shown to depend upon exactly the opposite interaction between these factors.

A model for calculating the hospital costs for pediatric endoscopy.

BACKGROUND: Hospitals increasingly need, besides effectiveness data, accurate and reliable cost data to allocate their resources as efficiently as possible. In this article, a framework to calculate the hospital costs of setting up a new activity is presented and applied to pediatric endoscopy. METHODS: The cost calculations were based on a detailed registration of labor time, materials, space, and equipment needed to perform endoscopy in pediatric patients in a tertiary care hospital, the University Hospital in Leuven, Belgium. RESULTS: The initial investment expenses amount to 70,000 ECU ($91,000 in U.S. money), assuming that the facilities of the adult endoscopy unit can be shared. The additional variable cost for each procedure, including labor time and materials, varies between 100 and about 170 ECU ($130 and $221 U.S.), depending on the type of endoscopy (upper or lower, diagnostic or therapeutic). These basic data can be used to calculate the total costs for pediatric endoscopy under alternative scenarios (e.g., varying total number of procedures). CONCLUSIONS: The costing exercise has given the hospital better insights into the working procedures (and hence costs) of pediatric endoscopy. Other organizations will be able to apply this framework in their setting, since all included cost components, as well as volumes and unit prices, are reported separately.

Costing methodology in laparoscopic surgery.

This paper provides some basic insights in economic evaluation and costing methodology by means of illustrations in the field of laparoscopic surgery. Some general methodological aspects are discussed, as well as their impact on the calculation of both societal and hospital costs of medical interventions. First, Health Care Technology Assessment is described, and several techniques of economic evaluation in health care are situated in this area. Two fundamental concepts in costing analysis are discussed : opportunity costs and marginal (or incremental) analysis. Furthermore, it is argued that in designing an economic analysis, sufficient attention should be given to delineating the alternative treatment options and to determining the perspective from which the study is performed (patient, hospital, insurer, society,...). Subsequently, it is argued that all price and wage data for activities performed within a certain period should apply to the same time period. Finally, in order to facilitate overview, re-calculation and interpretation of cost data, it is advised to distinguish fixed from variable costs. Different categories of societal costs are described, as well as a number of methodologies for their evaluation. In calculating hospital costs, the costs of all different resources used (e.g. buildings, equipment, staff, materials) must be identified precisely. The issues of annuitising initial investment expenses, calculating operating and maintenance costs, and allocating labour and overhead costs are discussed. Finally, it is argued that, in all studies, it should be investigated whether the results of the economic analysis are robust to the models' assumptions, by means of sensitivity analysis. This paper provides a practical toolkit for medical doctors, to allow a correct understanding and critical analysis of economic literature in the field of laparoscopic surgery.

A cost comparison of disposable vs reusable instruments in laparoscopic cholecystectomy.

BACKGROUND: This paper compares the costs of disposable and reusable instruments in laparoscopic cholecystectomy. METHODS: The instrument set considered includes those instruments that are available in both a reusable and disposable form. A market study within the Belgian market was performed in order to compare purchase prices. In addition, costs of cleaning, sterilization, wrapping, maintenance, repair, and disposal of waste were calculated. The effects of reusables and disposables were examined by means of a literature overview. RESULTS: It was calculated that the instrument cost per procedure of a full disposable set is 7.4-27.7 times higher than the cost per procedure with reusables. In comparison with disposables, modular systems ("semidisposable") and mixed use of disposables and reusables reduce costs, but still the cost per procedure remains higher than with reusables. A sensitivity analysis confirmed that these conclusions are robust to the model assumptions. In addition, the available evidence in the literature suggests that reusables do not compromise patient or staff safety. CONCLUSIONS: If reusables are used instead of disposables when performing a laparoscopic cholecystectomy, considerable savings can be achieved without compromising patient and staff safety.