Problems in continuity of medication management upon transition between primary and secondary care: patients' and professionals' experiences.

BACKGROUND AND OBJECTIVES: Patients often experience drug-related problems at admission or after discharge from hospital. The objective of this study was to identify the main problems in medication management at transition between settings of care, as experienced by health care professionals (HCPs) and patients. METHODS: Focus group discussions were organised between December 2009 and February 2010; nine focus groups with primary and secondary care HCPs and patients and two with stakeholders. Focus group discussions were audiotaped and observation files were constructed. For the analysis, a thematic framework approach was used. Between November 2015 and April 2016, 19 additional interviews and 1 focus group were performed with general practitioners (GP) and community pharmacists (CP). RESULTS: This qualitative study provided a long list of problems that could be summarised in five clusters: (1) problems at admission, e.g. incomplete list of medication, absence of information in case of emergency admission; (2) problems at discharge, e.g. lack of communication with GP, insufficient supplies of medication for the weekend; (3) problems as to professions, e.g. GP's opinion different to that of the medical specialist; (4) problems as to patients and family, e.g. failure to understand treatment; (5) problems as to processes, e.g. medication substitutions. CONCLUSION: HCPs and patients experience many problems in medication management at transition between settings of care. The fact that these problems occur at different stages and persist over time stresses the necessity for multilevel solutions.

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.

The view of severely burned patients and healthcare professionals on the blind spots in the aftercare process: a qualitative study.

BACKGROUND: In most Western countries burn centres have been developed to provide acute and critical care for patients with severe burn injuries. Nowadays, those patients have a realistic chance of survival. However severe burn injuries do have a devastating effect on all aspects of a person's life. Therefore a well-organized and specialized aftercare system is needed to enable burn patients to live with a major bodily change. The aim of this study is to identify the problems and unmet care needs of patients with severe burn injuries throughout the aftercare process, both from patient and health care professional perspectives in Belgium. METHODS: By means of face-to-face interviews (n = 40) with individual patients, responsible physicians and patient organizations, current experiences with the aftercare process were explored. Additionally, allied healthcare professionals (n = 17) were interviewed in focus groups. RESULTS: Belgian burn patients indicate they would benefit from a more integrated aftercare process. Quality of care is often not structurally embedded, but depends on the good intentions of local health professionals. Most burn centres do not have a written discharge protocol including an individual patient-centred care plan, accessible to all caregivers involved. Patients reported discontinuity of care: nurses working at general wards or rehabilitation units are not specifically trained for burn injuries, which sometimes leads to mistakes or contradictory information transmission. Also professionals providing home care are often not trained for the care of burn injuries. Some have to be instructed by the patient, others go to the burn centre to learn the right skills. Finally, patients themselves underestimate the chronic character of burn injuries, especially at the beginning of the care process. CONCLUSIONS: The variability in aftercare processes and structures, as well as the failure to implement locally developed best-practices on a wider scale emphasize the need for a comprehensive network, which can initiate transversal activities such as the development of discharge protocols, common guidelines, and quality criteria.

Stakeholders' perception on the organization of chronic care: a SWOT analysis to draft avenues for health care reforms.

BACKGROUND: Adequate care for individuals living with chronic illnesses calls for a healthcare system redesign, moving from acute, disease-centered to patient-centered models. The aim of this study was to identify Belgian stakeholders' perceptions on the strengths, weaknesses, opportunities and threats of the healthcare system for people with chronic diseases in Belgium. METHODS: Four focus groups were held with stakeholders from the micro and meso level, in addition to two interviews with stakeholders who could not attend the focus group sessions. Data collection and the discussion were based on the Chronic Care model. Thematic analysis of the transcripts allowed for the identification of the strengths, weaknesses, opportunities and threats of the current health care system with focus on chronic care. RESULTS: Informants stressed the overall good quality of the acute health care system and the level of reimbursement of care as an important strength of the current system. In contrast, the lack of integration of care was identified as one of the biggest weaknesses of today's health care system, along with the unclear definitions of the roles and functions of health professionals involved in care processes. Patient education to support self-management exists for patients with diabetes and/or terminal kidney failure but not for those living with other or multiple chronic conditions. The current overall fee-for-service system is a barrier to integrated care, as are the lack of incentives for integrated care. Attending multidisciplinary meetings, for example, is underfinanced to date. Finally, clinical information systems lack interoperability, which further impedes the information flow across settings and disciplines. CONCLUSION: Our study's methods allowed for the identification of problematic domains in the health system for people living with chronic conditions. These findings provided useful insights surrounding perceived priorities. This methodology may inspire other countries faced with the challenge of drafting reforms to tackle the issue of chronic care.

Drug substitution associated with a hospital stay in Belgium: a retrospective analysis of a claims database.

OBJECTIVES: This study measures the extent of drug substitution associated with a hospital stay in Belgium. METHODS: Data were extracted from the 2006-2007 dataset of the Belgian Agency of Health Insurance Funds on drug use of patients hospitalized in acute hospitals. Reimbursed drugs received in ambulatory care during the 3 months prior to hospitalization were compared with drugs received during the 3 months following hospital discharge. Both a narrow definition and a broad definition were used for drug substitution. Narrow substitution (switches between generic and originator drugs) was computed for 14 drug classes for chronic conditions with the highest public expenditure. Broad substitution (changes between chemical substances within the drug class at ATC level 4, changes in brand name) was calculated for statins and proton-pump inhibitors only. KEY FINDINGS: The database included 17 764 patients (mean age 66 ± 17 years; 60% female). In 71% of cases an originator drug was received prior to and following hospitalization. A generic drug was received prior to and following hospitalization in 25% of cases. Some form of narrow substitution occurred in 4% of cases: a generic drug was replaced by an originator drug in 2% of cases and an originator drug was replaced by a generic drug in 2% of cases. Some form of broad substitution occurred in 25% of cases for proton-pump inhibitors and 13% of cases for statins. CONCLUSIONS: Hospitalization was not a trigger for changes between originator and generic versions of a drug. Broad substitution associated with a hospital stay was relatively limited for statins and proton-pump inhibitors.

A systematic review and meta-analysis of acute stroke unit care: what's beyond the statistical significance?

BACKGROUND: The benefits of stroke unit care in terms of reducing death, dependency and institutional care were demonstrated in a 2009 Cochrane review carried out by the Stroke Unit Trialists' Collaboration. METHODS: As requested by the Belgian health authorities, a systematic review and meta-analysis of the effect of acute stroke units was performed. Clinical trials mentioned in the original Cochrane review were included. In addition, an electronic database search on Medline, Embase, the Cochrane Central Register of Controlled Trials, and Physiotherapy Evidence Database (PEDro) was conducted to identify trials published since 2006. Trials investigating acute stroke units compared to alternative care were eligible for inclusion. Study quality was appraised according to the criteria recommended by Scottish Intercollegiate Guidelines Network (SIGN) and the GRADE system. In the meta-analysis, dichotomous outcomes were estimated by calculating odds ratios (OR) and continuous outcomes were estimated by calculating standardized mean differences. The weight of a study was calculated based on inverse variance. RESULTS: Evidence from eight trials comparing acute stroke unit and conventional care (general medical ward) were retained for the main synthesis and analysis. The findings from this study were broadly in line with the original Cochrane review: acute stroke units can improve survival and independency, as well as reduce the chance of hospitalization and the length of inpatient stay. The improvement with stroke unit care on mortality was less conclusive and only reached borderline level of significance (OR 0.84, 95% CI 0.70 to 1.00, P = 0.05). This improvement became statistically non-significant (OR 0.87, 95% CI 0.74 to 1.03, P = 0.12) when data from two unpublished trials (Goteborg-Ostra and Svendborg) were added to the analysis. After further also adding two additional trials (Beijing, Stockholm) with very short observation periods (until discharge), the difference between acute stroke units and general medical wards on death remained statistically non-significant (OR 0.86, 95% CI 0.74 to 1.01, P = 0.06). Furthermore, based on figures reported by the clinical trials included in this study, a slightly higher proportion of patients became dependent after receiving care in stroke units than those treated in general medical wards - although the difference was not statistically significant. This result could have an impact on the future demand for healthcare services for individuals that survive a stroke but became dependent on their care-givers. CONCLUSIONS: These findings demonstrate that a well-conducted meta-analysis can produce results that can be of value to policymakers but the choice of inclusion/exclusion criteria and outcomes in this context needs careful consideration. The financing of interventions such as stroke units that increase independency and reduce inpatient stays are worthwhile in a context of an ageing population with increasing care needs. One limitation of this study was the selection of trials published in only four languages: English, French, Dutch and German. This choice was pragmatic in the context of this study, where the objective was to support health authorities in their decision processes.

Development of a national position paper for chronic care: example of Belgium.

The management of chronic diseases is a prime challenge of most 21st century health care systems. Many Western countries have invested heavily in care plans oriented towards specific conditions and diseases, such as dementia and cancer. The major downside of this narrowly focused approach is that treatment of multimorbidity is ignored. This paper describes the development and main stance of a national position that proposes streamlined reforms of the Belgian health care system to improve care for patients with multiple chronic diseases. We used a combination of methods to develop this stance: literature review and stakeholders' consultation. The latter identified areas for improvement: efficiency of the health care system, coordination of care, investments in human care resources, informal caregivers' support, better accessibility, and changes in the financial payment system. The position paper list 20 recommendations that are translated into about 50 action points to reform the health care system. Chronic care tailored to the patient's needs, including implementation of multidisciplinary teamwork, new functions, task delegation in primary care, and empowerment of the patient and informal caregivers are some major areas discussed. In addition, improved support, revised payment mechanisms, and setting up a quality system, along with the tailoring of patient care, can all facilitate delivery of high quality care in patients with chronic comorbidities.

Participating or not in a cardiac rehabilitation programme: factors influencing a patient's decision.

BACKGROUND: International research indicates that attendance of patients to a proposed cardiac rehabilitation (CR) programme varies between 21% and 75%. Addressing the reasons why cardiac patients are not participating will improve accessibility to CR. The objective of this study was to investigate patient compliance with cardiac rehabilitation and the reasons of refusing or abandoning the programme. METHODS: Twenty hospital centres were recruited to participate. Each centre was asked to recruit patients from three patient groups, namely: percutaneous coronary intervention patients, patients that underwent major cardiac surgery, and patients being admitted because of an acute myocardial infarction and not belonging to the other two groups. Patients were asked to fill out a questionnaire during a follow-up outpatient consultation after the cardiac intervention. RESULTS: In total, 226 patients participated in the survey. Most patients were proposed (86%) and accepted (81% out of proposed) to attend a CR programme. Of those who accepted, 77% completed the programme. The main reasons that led to patients' refusal to participate in a CR programme were distance to the CR centre, patients' belief they could handle their own problems, and lack of time. The main three reasons for not completing an initiated CR programme were other physical problems, patients' belief they could handle their own problems, and the cost of rehabilitation. CONCLUSION: Our findings demonstrate the importance of raising patients' awareness of the benefits of CR. Addressing potential barriers to attend a CR programme should be investigated with patients individually in order to ensure compliance.

Terminal patients in Belgian nursing homes: a cost analysis.

Policy makers and health care payers are concerned about the costs of treating terminal patients. This study was done to measure the costs of treating terminal patients during the final month of life in a sample of Belgian nursing homes from the health care payer perspective. Also, this study compares the costs of palliative care with those of usual care. This multicenter, retrospective cohort study enrolled terminal patients from a representative sample of nursing homes. Health care costs included fixed nursing home costs, medical fees, pharmacy charges, other charges, and eventual hospitalization costs. Data sources consisted of accountancy and invoice data. The analysis calculated costs per patient during the final month of life at 2007/2008 prices. Nineteen nursing homes participated in the study, generating a total of 181 patients. Total mean nursing home costs amounted to 3,243 € per patient during the final month of life. Total mean nursing home costs per patient of 3,822 € for patients receiving usual care were higher than costs of 2,456 € for patients receiving palliative care (p = 0.068). Higher costs of usual care were driven by higher hospitalization costs (p < 0.001). This study suggests that palliative care models in nursing homes need to be supported because such care models appear to be less expensive than usual care and because such care models are likely to better reflect the needs of terminal patients.

Multidisciplinary outpatient rehabilitation following cardiac revascularization or valve surgery: patient-related factors for uptake.

BACKGROUND: There are concerns in Europe regarding the service provision and accessibility of multidisciplinary cardiac rehabilitation (MDCR) in general, and particularly in ambulatory settings. This paper analyses the utilization of outpatient MDCR and its determinants after cardiac revascularization or valve surgery in Belgium. METHODS: Claims rehabilitation data for all patients discharged in 2007 after a percutaneous cardiac intervention or cardiac surgery were available from the Belgian Common Sickness Funds Agency. Logistic regressions were performed to identify patients demographic and socioeconomic characteristics associated with the uptake of outpatient MDCR during the year following the hospital discharge. RESULTS: A total of 29,021 patients were included. During the hospitalization for the cardiac procedure, 44% were offered inpatient MDCR. After discharge, only 15.6% followed at least one session of outpatient MDCR. The chance of attending outpatient MDCR was lower for female, disabled, and older patients, as well as unemployed patients. The absence of an authorized MDCR centre in the neighbourhood of the patient's residence decreased the chance of attending outpatient MDCR, while living in a neighbourhood with a high education and income level increased this probability. CONCLUSION: These results confirm the low rates of MDCR attendance found in a previous study performed by the European Association of Cardiovascular Prevention and Rehabilitation. The study shows specific patient groups that should be targeted in priority, i.e. women, elderly, unemployed patients, disabled persons, and patients with a low socioeconomic status.

Higher incidence of common diagnoses in patients with low back pain in primary care.

Most studies on comorbidity in low back pain (LBP) have been conducted in specialized settings with the use of self-reports. This study has an original design using data from family practices: the incidence of the most frequent diseases was compared in patients with and without LBP in 2004. The database includes data from 67 family physicians in 52 family practices in Flanders, Belgium. It contains data from 160,000 different patients with 1,500,000 diagnoses during the period 1994 to 2004. The incidence of the most frequent diagnoses is presented in patients with and without LBP in 2004. The diagnoses were coded according to the ICPC-2-classification. In 2004, the incidence of LBP was 51.4‰ (95% CI: 49.8 to 53.1) in patients aged 18 or older. The incidence was slightly higher in women than in men: 53.0‰ (95% CI: 50.7 to 55.4) vs. 49.9‰ (95% CI: 47.7 to 52.3). The highest incidence was recorded in the age group of 50 to 54 years. The most frequent "other" diagnoses in patients with and without LBP are comparable, but some were more frequent in patients with LBP. Respiratory infections and diseases of the locomotor apparatus (neck syndrome, bursitis) are more frequent in patients with LBP. Low back pain is one of the most frequent diagnoses in general practice. Striking is the relatively higher frequency of common self-limiting diseases in patients with a diagnosis of LBP during the same year. To the authors' knowledge, this is the first time that medical demands for non-LBP reasons in family practice have been reported in patients with LBP.

Review of the cost-effectiveness of interventions to improve seamless care focusing on medication.

AIM OF THE REVIEW: This review of the international literature aims to assess the evidence and its methodological quality relating to the cost-effectiveness of interventions to improve seamless care focusing on medication. METHOD: Studies were identified by searching Medline, EMBASE, Centre for Reviews and Dissemination databases, Cochrane Database of Systematic Reviews, and EconLit up to March 2011 using search terms related to health economics and to seamless care. To be included, economic evaluations had to explore the costs and consequences of an intervention to improve seamless care focusing on medication as compared with usual care. Methodological quality of studies was assessed by considering perspective; design; source of clinical and economic data; cost and consequence measures; allowance for uncertainty; and incremental analysis. Costs were actualized to 2007 values. RESULTS: Eight studies on medication interventions for hospitalized patients in the transition between ambulatory and hospital care were included in the review. A variety of types of medication interventions and target populations have been assessed, but the evidence is limited to one economic evaluation for each particular intervention type and each specific target population. Most studies demonstrated an impact of interventions on compliance and (re)hospitalization rates and costs. The studies did not find an impact on quality of life or symptoms. Economic evaluations suffered from methodological limitations related to the narrow perspective; restriction to health care costs only; exclusion of costs of the intervention; use of intermediate consequence measures; no allowance for uncertainty; and absence of incremental analysis. CONCLUSION: In light of the small number of economic evaluations and their methodological limitations, it is not possible to recommend a specific intervention to improve seamless care focusing on medication on health economic grounds.

Evidence based post graduate training. A systematic review of reviews based on the WFME quality framework.

BACKGROUND: A framework for high quality in post graduate training has been defined by the World Federation of Medical Education (WFME). The objective of this paper is to perform a systematic review of reviews to find current evidence regarding aspects of quality of post graduate training and to organise the results following the 9 areas of the WFME framework. METHODS: The systematic literature review was conducted in 2009 in Medline Ovid, EMBASE, ERIC and RDRB databases from 1995 onward. The reviews were selected by two independent researchers and a quality appraisal was based on the SIGN tool. RESULTS: 31 reviews met inclusion criteria. The majority of the reviews provided information about the training process (WFME area 2), the assessment of trainees (WFME area 3) and the trainees (WFME area 4). One review covered the area 8 'governance and administration'. No review was found in relation to the mission and outcomes, the evaluation of the training process and the continuous renewal (respectively areas 1, 7 and 9 of the WFME framework). CONCLUSIONS: The majority of the reviews provided information about the training process, the assessment of trainees and the trainees. Indicators used for quality assessment purposes of post graduate training should be based on this evidence but further research is needed for some areas in particular to assess the quality of the training process.

Palliative inpatients in general hospitals: a one day observational study in Belgium.

BACKGROUND: Hospital care plays a major role at the end-of-life. But little is known about the overall size and characteristics of the palliative inpatient population. The aim of our study was to analyse these aspects. METHODS: We conducted a one-day observational study in 14 randomly selected Belgian hospitals. Patients who met the definition of palliative patients were identified as palliative. Then, information about their socio-demographic characteristics, diagnoses, prognosis, and care plan were recorded and analysed. RESULTS: There were 2639 in-patients on the day of the study; 9.4% of them were identified as "palliative". The mean age of the group was 72 years. The primary diagnosis was cancer in 51% of patients and the estimated life expectancy was shorter than 3 months in 33% of patients and longer than 1 year in 28% of patients. The professional caregivers expected for most of the patients (73%), that the treatment would improve patient comfort rather than prolong life. Antibiotics, transfusions, treatments specific to the pathology, and artificial nutrition were administered in 90%, 78%, 57% and 50% of the patients, respectively, but were generally given with a view to controlling the symptoms. CONCLUSIONS: This analysis presents a first national estimate of the palliative inpatient population. Our results confirm that hospitals play a major role at the end-of-life, with one out of ten inpatients identified as a "palliative" patient. These data also demonstrate the complexity of the palliative population and the substantial diversity of care that they can require.

Costs of terminal patients who receive palliative care or usual care in different hospital wards.

BACKGROUND: In addition to the effectiveness of hospital care models for terminal patients, policy makers and health care payers are concerned about their costs. This study aims to measure the hospital costs of treating terminal patients in Belgium from the health care payer perspective. Also, this study compares the costs of palliative and usual care in different types of hospital wards. METHODS: A multicenter, retrospective cohort study compared costs of palliative care with usual care in acute hospital wards and with care in palliative care units. The study enrolled terminal patients from a representative sample of hospitals. Health care costs included fixed hospital costs and charges relating to medical fees, pharmacy and other charges. Data sources consisted of hospital accountancy data and invoice data. RESULTS: Six hospitals participated in the study, generating a total of 146 patients. The findings showed that palliative care in a palliative care unit was more expensive than palliative care in an acute ward due to higher staffing levels in palliative care units. Palliative care in an acute ward is cheaper than usual care in an acute ward. CONCLUSIONS: This study suggests that palliative care models in acute wards need to be supported because such care models appear to be less expensive than usual care and because such care models are likely to better reflect the needs of terminal patients. This finding emphasizes the importance of the timely recognition of the need for palliative care in terminal patients treated in acute wards.

The costs of treating terminal patients.

CONTEXT: In addition to the effectiveness of terminal care, policy makers and health care payers are concerned about the costs of treating terminal patients in a context of spiraling health care costs and limited resources. OBJECTIVES: This article aims to review the international literature on the costs of treating terminal patients. METHODS: Studies were identified by searching PubMed, Centre for Reviews and Dissemination databases, Cochrane Database, and EconLit, up to April 2009. Studies were included that contrasted costs in different health care settings and that compared palliative care with alternative therapeutic approaches for terminal patients. RESULTS: The few studies that focused on treatment of terminal patients across health care settings showed that hospitalization costs represent the principal component of palliative care costs. In the hospital setting, palliative care tends to be cheaper than usual care or care delivered in units other than the palliative care unit. Palliative care costs depend on patient characteristics, such as diagnosis, status of disease, and age. Also, different care models appear to target different patient groups and offer varied packages of services. Finally, there is some evidence pointing to cost advantages of palliative care at home as compared with alternative care models, although this needs to be corroborated by further research. CONCLUSION: Different approaches to deliver palliative care are not substitutes of each other and, thus, have different costs. From a cost perspective, hospitals need to pay attention to admitting patients to the palliative care unit at the right time.

Can we import quality tools? a feasibility study of European practice assessment in a country with less organised general practice.

BACKGROUND: Quality is on the agenda of European general practice (GP). European researchers have, in collaboration, developed tools to assess quality of GPs. In this feasibility study, we tested the European Practice Assessment (EPA) in a one-off project in Belgium, where general practice has a low level of GP organisation. METHODS: A framework for feasibility analysis included describing the recruiting of participants, a brief telephone study survey among non-responders, organisational and logistic problems. Using field notes and focus groups, we studied the participants' opinions. RESULTS: In this study, only 36 of 1000 invited practices agreed to participate. Co-ordination, administrative work, practice visits and organisational problems required several days per practice. The researchers further encountered technical problems, for instance when entering the data and uploading to the web-based server. In subsequent qualitative analysis using two focus groups, most participant GPs expressed a positive feeling after the EPA procedure. In the short period of follow-up, only a few GPs reported improvements after the visit. The participant GPs suggested that follow-up and coaching would probably facilitate the implementation of changes. CONCLUSION: This feasibility study shows that prior interest in EPA is low in the GP community. We encountered a number of logistic and organisational problems. It proved attractive to participants, but it can be augmented by coaching of participants in more than a one-off project to identify and achieve targets for quality improvement. In the absence of commitment of the government, a network of universities and one scientific organisation will offer EPA as a service to training practices.

Prolonged cough in children: a summary of the Belgian primary care clinical guideline.

Prolonged cough is a frequent problem in the community. Several studies in the school setting have found that as many as 4.8% to 10.4% of children suffer from prolonged cough. There is no consensual definition of prolonged cough. In this guideline, we define prolonged cough as a daily cough lasting for more than three weeks. The literature review did not identify any quality study on the aetiology of prolonged cough in children in primary care. A diagnostic decision-tree based on the systematic literature review and expert opinion is proposed. Doctors should seek signs of any serious underlying condition. Chronic productive purulent cough should always be investigated. A careful evaluation of the impact of cough on the quality of life of the child is necessary. In absence of signs of specific underlying illness, coughing is generally a self-limiting condition. Symptomatic treatments have not yet been proven to be effective, and many of them may cause serious side effects. Their use should therefore be limited.

Quality indicators for type-2 diabetes care in practice guidelines: an example from six European countries.

INTRODUCTION: Diabetes mellitus patients need a multidisciplinary management and rigorous follow up. Quality indicators are important to assess and improve the quality of the health-care delivery. Less straightforward, however, is choosing which indicators to use for the assessment of the disease management. METHODS: Review of guidelines. Process and outcome indicators were extracted out of type-2 diabetes guidelines from Belgium and its neighbouring countries. The "most evidence based" indicators were derived after applying a "best evidence" ratio. RESULTS: Thirty-four indicators were classified in five diabetes management topics: (1) control of glycaemia, (2) early detection of glycaemic complications, (3) treatment of glycaemic complications, (4) cardiovascular disease and, (5) quality of life. Target values to outcome indicators and appropriate specifications to process indicators were not assigned because direct transfer to different countries is not possible without considering contextual information such as typical preconditions of every society and health-care system. CONCLUSION: Although not all aspects of care are described in guidelines, five 'mini' lists of highly valuable indicators for optimal treatment in the field of type-2 diabetes could be drawn up. The target sets for indicators' values and specifications are a matter of ongoing concern because evidence changes over time.