Developing an agency's position with respect to patient involvement in health technology assessment: the importance of the organizational culture.

OBJECTIVES: The objective of this study was to map the PI culture at KCE in the context of the development of organization-wide supported position statements about PI. METHODS: A nominal group technique was used to measure the PI culture at KCE. Arguments for and against PI and conditions for PI in different phases of the HTA process were collected. A literature review and interviews fed the draft position statements, for which support was assessed by means of a two-round Delphi process. RESULTS: Arguments in favor of PI in HTA related to the relevance of the scope, expertise with data collection, bringing in fresh ideas for study design, access to survey participants, validation of data analyses, adherence to recommendations. Disadvantages and risks included the lack of scientific knowledge of involved patients, resources requirements, conflicts of interest, and heterogeneity within patient populations. Conditions for meaningful PI referred to measures mitigating the identified disadvantages. Eighteen position statements supported by KCE could be formulated. CONCLUSION: The KCE culture seems predominantly positive toward PI, although attitudes vary between HTA researchers. KCE recognizes the potential value of PI in HTA, but considers the level of involvement to be contingent on the topic and phase in the HTA process.

PRIORITIES FOR HEALTH ECONOMIC METHODOLOGICAL RESEARCH: RESULTS OF AN EXPERT CONSULTATION.

BACKGROUND: The importance of economic evaluation in decision making is growing with increasing budgetary pressures on health systems. Diverse economic evidence is available for a range of interventions across national contexts within Europe, but little attention has been given to identifying evidence gaps that, if filled, could contribute to more efficient allocation of resources. One objective of the Research Agenda for Health Economic Evaluation project is to determine the most important methodological evidence gaps for the ten highest burden conditions in the European Union (EU), and to suggest ways of filling these gaps. METHODS: The highest burden conditions in the EU by Disability Adjusted Life Years were determined using the Global Burden of Disease study. Clinical interventions were identified for each condition based on published guidelines, and economic evaluations indexed in MEDLINE were mapped to each intervention. A panel of public health and health economics experts discussed the evidence during a workshop and identified evidence gaps. RESULTS: The literature analysis contributed to identifying cross-cutting methodological and technical issues, which were considered by the expert panel to derive methodological research priorities. CONCLUSIONS: The panel suggests a research agenda for health economics which incorporates the use of real-world evidence in the assessment of new and existing interventions; increased understanding of cost-effectiveness according to patient characteristics beyond the "-omics" approach to inform both investment and disinvestment decisions; methods for assessment of complex interventions; improved cross-talk between economic evaluations from health and other sectors; early health technology assessment; and standardized, transferable approaches to economic modeling.

CARDIOVASCULAR SCREENING OF YOUNG ATHLETES: A REVIEW OF ECONOMIC EVALUATIONS.

OBJECTIVES: Some experts have promoted preparticipative cardiovascular screening programs for young athletes and have claimed that such programs were cost-effective without performing a critical analysis of studies supporting this statement. In this systematic review, a critical assessment of economic evaluations on these programs is performed to determine if they really provide value for money. METHODS: A systematic review of economic evaluations was performed on December 24, 2014. Web sites of health technology assessment agencies, the Cochrane database of systematic review, the National Health Service Economic Evaluation Database of the Cochrane Library, EMBASE, Medline, Psychinfo, and EconLit were searched to retrieve (reviews of) economic evaluations. No language or time restrictions were imposed and predefined selection criteria were used. Selected studies were critically assessed applying a structured data extraction sheet. RESULTS: Five relevant economic evaluations were critically assessed. Results of these studies were mixed. However, those in favor of screening made (methodological) incorrect choices, of which the most important one was not taking into account a no-screening alternative as comparator. Compared with no screening, other strategies (history and physical examination or history and physical examination plus electrocardiogram) were not considered cost-effective. CONCLUSIONS: Results of primary economic evaluations should not be blindly copied without critical assessment. Economic evaluations in this field lack the support of robust evidence. Negative consequences of screening (false positive findings, overtreatment) should also be taken into account and may cause more harm than good. A mass screening of young athletes for cardiovascular diseases does not provide value for money and should be discouraged.

[Chapter 3. Concretely enhancing the role of elderly through capacitating health care]. / Chapitre 3. Favoriser concrètement le rôle actif et citoyen de la personne âgée : une application du care capacitant.

This paper questions the signification of reinforcing the active role of elderly between societal injunction to feel responsible of the costs to the collectivity and the freedom to choose one's way of life and having the means to realize it. It describes two experiences in two Brussels communes of a model of co-construction with the elderly of a project to live in one's own home, to reinforce the active roles of persons. We want to illustrate the difficulty of such an approach in Belgium, separating the organization and the financing of medical and social care, that does not foster the accompanying and the active role of elderly. The conflict of interest between the different actors is not allowing the proper multidisciplinary approach to empower and allow the maintenance of elderly capability of choice and well being.

Acceptability and Perceived Benefits and Risks of Public and Patient Involvement in Health Care Policy: A Delphi Survey in Belgian Stakeholders.

BACKGROUND: In systems with public health insurance, coverage decisions should reflect social values. Deliberation among stakeholders could achieve this goal, but rarely involves patients and citizens directly. OBJECTIVES: This study aimed at evaluating the acceptability, and the perceived benefits and risks, of public and patient involvement (PPI) in coverage decision making to Belgian stakeholders. METHODS: A two-round Delphi survey was conducted among all stakeholder groups. The survey was constructed on the basis of interviews with 10 key stakeholders and a review of the literature on participation models. Consensus was defined as 65% or more of the respondents agreeing with a statement and less than 15% disagreeing. Eighty stakeholders participated in both rounds. They were defined as the Delphi panel. RESULTS: Belgian stakeholders are open toward PPI in coverage decision processes. Benefits are expected to exceed risks. The preferred model for involvement is to consult citizens or patients, within the existing decision-making structures and at specific milestones in the process. Consulting citizens and patients is a higher level of involvement than merely informing them and a lower level than letting them participate actively. Consultation involves asking nonbinding advice on (parts of) the decision problem. According to the Delphi panel, the benefits of PPI could be increasing awareness among members of the general public and patients about the challenges and costs of health care, and enriched decision processes with expertise by experience from patients. Potential risks include subjectivity, insufficient resources to participate and weigh on the process, difficulties in finding effective ways to express a collective opinion, the risk of manipulation, and lobbying or power games of other stakeholders. CONCLUSIONS: PPI in coverage decision-making processes is acceptable to Belgian stakeholders, be it in different ways for different types of decisions. Benefits are expected to outweigh risks.

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.

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.

The French airbridge for circulatory support in the Carribean.

OBJECTIVES: We report the assessment and the activities for the first year of our airborne circulatory support mobile unit (CSMU) in the French Caribbean. METHODS: From January 2010 to June 2011, 12 patients (mean age = 35.7 years; range: 15-62 years; sex ratio = 1:1) were attended outside Martinique by our CSMU and transferred to our unit by air. RESULTS: Eight patients had acute respiratory distress syndrome and were assisted by veno-venous extra corporeal membrane oxygenation (ECMO) four had refractory cardiogenic shock, assisted by extra corporeal life support (ECLS). The average air transfer distance for patients was 912 km (range: 198-1585 km). The average flying time was 124 min (range: 45-255 min). The aircraft used were helicopter, military transport or private jet. The setting-up of assistance devices and transfer of patients was uneventful. One patient subsequently benefited from heart transplantation after long-term circulatory support. One patient died under ECMO support after 51 days of assistance and another died on the 60th day after withdrawal of ECLS. CONCLUSIONS: CSMUs can be very efficient in providing support to patients in refractory shock, when remote from a cardiac surgery centre. The airborne transfer of patients on ECMO/ECLS can be achieved safely, even over long distances.

Challenges in physician supply planning: the case of Belgium.

INTRODUCTION: Planning human resources for health (HRH) is a complex process for policy-makers and, as a result, many countries worldwide swing from surplus to shortage. In-depth case studies can help appraising the challenges encountered and the solutions implemented. This paper has two objectives: to identify the key challenges in HRH planning in Belgium and to formulate recommendations for an effective HRH planning, on the basis of the Belgian case study and lessons drawn from an international benchmarking. CASE DESCRIPTION: In Belgium, a numerus clausus set up in 1997 and effective in 2004, aims to limit the total number of physicians working in the curative sector. The assumption of a positive relationship between physician densities and health care utilization was a major argument in favor of medical supply restrictions. This new regulation did not improve recurrent challenges such as specialty imbalances, with uncovered needs particularly among general practitioners, and geographical maldistribution. New difficulties also emerged. In particular, limiting national training of HRH turned out to be ineffective within the open European workforce market. The lack of integration of policies affecting HRH was noteworthy. We described in the paper what strategies were developed to address those challenges in Belgium and in neighboring countries. DISCUSSION AND EVALUATION: Planning the medical workforce involves determining the numbers, mix, and distribution of health providers that will be required at some identified future point in time. To succeed in their task, health policy planners have to take a broader perspective on the healthcare system. Focusing on numbers is too restrictive and adopting innovative policies learned from benchmarking without integration and coordination is unfruitful. Evolving towards a strategic planning is essential to control the effects of the complex factors impacting on human resources. This evolution requires an effective monitoring of all key factors affecting supply and demand, a dynamic approach, and a system-level perspective, considering all healthcare professionals, and integrating manpower planning with workforce development. CONCLUSION: To engage in an evidence-based action, policy-makers need a global manpower picture, from their own country and abroad, as well as reliable and comparable manpower databases allowing proper analysis and planning of the workforce.

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.

Physician supply forecast: better than peering in a crystal ball?

BACKGROUND: Anticipating physician supply to tackle future health challenges is a crucial but complex task for policy planners. A number of forecasting tools are available, but the methods, advantages and shortcomings of such tools are not straightforward and not always well appraised. Therefore this paper had two objectives: to present a typology of existing forecasting approaches and to analyse the methodology-related issues. METHODS: A literature review was carried out in electronic databases Medline-Ovid, Embase and ERIC. Concrete examples of planning experiences in various countries were analysed. RESULTS: Four main forecasting approaches were identified. The supply projection approach defines the necessary inflow to maintain or to reach in the future an arbitrary predefined level of service offer. The demand-based approach estimates the quantity of health care services used by the population in the future to project physician requirements. The needs-based approach involves defining and predicting health care deficits so that they can be addressed by an adequate workforce. Benchmarking health systems with similar populations and health profiles is the last approach. These different methods can be combined to perform a gap analysis. The methodological challenges of such projections are numerous: most often static models are used and their uncertainty is not assessed; valid and comprehensive data to feed into the models are often lacking; and a rapidly evolving environment affects the likelihood of projection scenarios. As a result, the internal and external validity of the projections included in our review appeared limited. CONCLUSION: There is no single accepted approach to forecasting physician requirements. The value of projections lies in their utility in identifying the current and emerging trends to which policy-makers need to respond. A genuine gap analysis, an effective monitoring of key parameters and comprehensive workforce planning are key elements to improving the usefulness of physician supply projections.

Association between physician density and health care consumption: a systematic review of the evidence.

BACKGROUND: Supplier-induced demand (SID) for health care could be a crucial factor of rising health expenditures. However, there is thus far no consensus on the topic. OBJECTIVE: To assess how physician density (physician-to-population ratio) and health care consumption correlate. METHODS: A systematic review of studies retrieved through electronic databases: Medline, Econlit, PsychINFO and Embase. Search, inclusion and quality appraisal were based on standard procedures and applied independently by two researchers. RESULTS: Twenty-five studies, generally of moderate quality, were included. Despite a substantial heterogeneity in study design and data modelling, a significant association between physician density and health care consumption was consistently observed. However, estimates varied according to a number of method parameters such as the definition of the dependent variable (physician volume or care intensity), the geographical entity or the medical specialty under consideration, and the adjustment for confounding factors. CONCLUSIONS: The exact importance of SID and the underlying motivations remain poorly understood. We discuss technical issues for better SID assessment. In the absence of more accurate information, limiting physician supply as a measure of cost containment should also be considered cautiously.

Alkali ocular burns in Martinique (French West Indies) Evaluation of the use of an amphoteric solution as the rinsing product.

PRECIS: During the 4 years of this study, we noted 66 cases of alkali ocular burns, or approximately 16 cases per year, nearly half (45.5%) of which are due to an assault. For grade 1 and 2 burns the time elapsed to reepithelialization appears to be shorter when rinsed with Diphoterine* versus physiological solution. PURPOSE: Comparison of the effectiveness of two rinsing solutions for emergency use: a physiological solution and an amphoteric solution (Diphoterine*, Laboratories Prevor, Valmondois, France). Description of the clinical and progressive characteristics of alkali burns treated at the University Hospital Center of Fort de France in Martinique (French West Indies). DESIGN: Prospective consecutive observational case series and nonrandomized comparative study. PARTICIPANTS: Sixty-six patients were included. The total number of burned eyes is 104. Forty-eight eyes (46%) were rinsed with physiological solution and 56 eyes (54%) with Diphoterine*. METHODS: All patients benefited from an ocular rinse with 500ml of physiological solution or Diphoterine*, followed by a complete ophthalmologic exam. The ocular injuries were classified according to the Roper-Hall modification of the Hughes classification system. The same standardized therapeutic protocol was applied and adapted to the seriousness of the burn. MAIN OUTCOME MEASURES: Demographic data, time to corneal reepithelialization, final best corrected visual acuity and complications were analysed. RESULTS: Twenty-eight (42.4%) patients have a unilateral burn and 38 (57.6%) patients have bilateral burns. In decreasing order of frequency, the circumstances surrounding the injury are: assaults in 45.5% of cases (n=30), work-related accidents in 32% of cases (n=31), and domestic accidents in 23% of cases (n=15). For grade 1 and 2 burns the time elapsed to reepithelialization appears to be shorter when rinsed with Diphoterine* versus physiological solution (respectively): 1.9+/-1 days versus 11.1+/-1.4 days (p=10(-7)) and 5.6+/-4.9 days versus 10+/-9.2 days (p=0.02). For grade 3 and 4 burns, there are complications in 11 cases (11.6%): 8 corneal opacities and 3 perforations. CONCLUSIONS: This study is the first conducted in humans that takes into account the type of ocular rinse product used in the progressive follow-up study of injuries. The time elapsed to reepithelialization is shorter with Diphoterine* for grade 1 and 2 burns. There are not enough cases of grade 3 and 4 burns to make a conclusion. Diphoterine* seems very effective in terms of its mechanism of action and the experimental and clinical results.