Integrated care pathways for airway diseases (AIRWAYS-ICPs)

The objective of Integrated Care Pathways for Airway Diseases (AIRWAYS-ICPs) is to launch a collaboration to develop multi-sectoral care pathways for chronic respiratory diseases in European countries and regions. AIRWAYS-ICPs has strategic relevance to the European Union Health Strategy and will add value to existing public health knowledge by: 1) proposing a common framework of care pathways for chronic respiratory diseases, which will facilitate comparability and trans-national initiatives; 2) informing cost-effective policy development, strengthening in particular those on smoking and environmental exposure; 3) aiding risk stratification in chronic disease patients, using a common strategy; 4) having a significant impact on the health of citizens in the short term (reduction of morbidity, improvement of education in children and of work in adults) and in the long-term (healthy ageing); 5) proposing a common simulation tool to assist physicians; and 6) ultimately reducing the healthcare burden (emergency visits, avoidable hospitalisations, disability and costs) while improving quality of life. In the longer term, the incidence of disease may be reduced by innovative prevention strategies. AIRWAYSICPs was initiated by Area 5 of the Action Plan B3 of the European Innovation Partnership on Active and Healthy Ageing. All stakeholders are involved (health and social care, patients, and policy makers).

Health-related quality of life and cost of ambulatory care in osteoporosis: how may such outcome measures be valuable information to health decision makers and payers?

The objective was to quantify the outcome of osteoporosis (OP) in terms of health-related quality of life (HR-QOL) and cost of ambulatory care and to look at the association between these two outcomes variables. A cross-sectional health survey of 4800 Belgian individuals over the age of 45 years was used. Individuals having reported OP were retrieved and for each of them, at least two matched individuals for age, sex, residency location, and health insurance status were identified. All individuals were assessed with the SF-36. The two major health insurance providers furnished cost value for ambulatory care. HR-QOL and cost data were compared between the OP group and control group. Beta-coefficients from linear regression were calculated to give information on the relative importance of the association between each SF-36 dimensions and cost of ambulatory care. Of 4796 individuals appropriately surveyed, 221 (4.8%) reported OP. The control group included 651 individuals. The OP group experienced impaired HR-QOL compared to their matched counterparts, all the difference in mean or median SF-36 scores being significant at the level of P < 0.001. Osteoporotic respondents averaged 816 in cost of ambulatory care whereas controls averaged 579 (P < 0.001). When looking at detailed comparisons between categories of cost, costs in the OP group far exceeded those in the control group, all the differences being significant at the level of P < 0.001 except for home health nurse (P = 0.012). In the OP group, vitality dimensions played the most important role in the determination of cost (beta = -0.28, P < 0.001), followed by physical functioning (beta = -0.26, P < 0.01), general health, and social functioning (beta = -0.23, P < 0.01). This study evidences the burden of OP in terms of HR-QOL and cost of ambulatory care. Exploring the association between HR-QOL and cost show that mental dimension such as vitality can play an important role in the determination of cost. Conclusively, they should not be neglected in future management of OP.

[Intracranial hemorrhages associated with oral anticoagulant therapy. Analysis of 38 cases]

The major risk of oral anticoagulant therapy is haemorrhage potentially affecting all organs. Bleeding in the central nervous system is a rare but severe complication of anticoagulant therapy. This study aimed to analyse a series of intracranial haemorrhages. This series from the Regional Pharmacovigilance Center of Amiens included spontaneously reported and retrospectively collected cases from January 1999 to December 2000. During this period, 38 cases of intracranial bleeding possibly related to oral anticoagulant administration were reported; 19 women and 19 men, median age 69.5 (29 to 87) years. In 34% of the cases, patients died and in 18% neurologic sequelae were still present at the time of the evaluation. In 21 cases (62%), the INR (International Normalized Ratio) was higher than the therapeutic range recommended for the indication. Among the most frequent risk factors, hypertension and recent minor trauma are highlighted in this series. In 17 cases, oral anticoagulants were associated with potentially potentiating drugs. Mental status changes or headache were prominent early symptoms which had often been present for days. Our data confirm that anticoagulant-associated intracranial haemorrhages are not rare, can be severe, potentially fatal and are probably underestimated by physicians. The fact that more than 50% of patients in this series were overanticoagulated at the time of bleeding suggests that many cases of intracranial haemorrhage could be prevented by improved anticoagulation control. Epidemiological studies are needed in order to prospectively evaluate the incidence of this type of complication and its avoidance. The value of anticoagulation clinics can be discussed.

Intensive and prolonged health promotion strategy may increase awareness of osteoporosis among postmenopausal women

The aim of the study was to measure the results of a 15-year health promotion strategy towards osteoporosis, in an urban community of subjects over 45 years old, in terms of osteoporosis awareness and handling. To this end an ancillary study to a large survey of the Belgian population's self-perceived health status was carried out. A rectangular sample of 4800 individuals over 45 years old was randomly selected in two Belgian cities, among the affiliates of the two main health insurance providers. One of the cities (Liège) had been, since the early 1980s, the target of a constant health promotion strategy, directed to both the medical community and the general population, aimed at increasing osteoporosis awareness in women after the menopause. During the same period, no particular steps were taken in the other city (Aalst) to increase osteoporosis awareness in the community. In our study, the participants were asked to spontaneously report any chronic, serious and/or severe disorders that they had been suffering from, for at least 6 months, during the previous 12 months. They also provided a list of drugs they were taking at the time of the survey. Osteoporosis was reported to be a disease affecting 1.5% of men in Aalst and 1.3% of men in Liege (p = 0.61). For women, osteoporosis was reported to be present in 4.8% in Aalst and 10.8% in Liege (p<0.001). Self-reporting of osteoporosis prevalence in Liege was statistically significantly higher in women aged 45-64 years, 65-74 years or over 75 years (p<0.001). Obesity, alcohol consumption or physical activity were equally distributed between women from Liège and Aalst. Prescription drugs used for osteoporosis had been delivered to a similar proportion of men in Aalst and Liège. In women, a statistically significant difference in these prescription drugs was observed between Liège and Aalst, both for the overall population (p<0.001) and in each of the age classes (p<0.001 for 45-64 years and 65-74 years; p<0.009 for over 75 years). A continuous long-term health promotion strategy, directed toward both physicians and the general population, thus appears to increase awareness about osteoporosis in women over 45 years and/or in the medical community. This is reflected by an increase in self-reported prevalence of osteoporosis and in the prescription of drugs aimed at prevention and treatment of this disorder. Whether these observations reflect an appropriate diagnosis and a proper handling of the disease remains to be evaluated by objective diagnostic tools such as bone densitometry and by an evaluation of the effectiveness of prescription practices in postmenopausal women.

[The behavioral determinants for health centers in health districts of urban Africa: results of a survey of households in Kinshasa, Congo]

This study analyses the choice determinants of the population for health centres through a survey of the behaviour of families in a representative sample of 1,000 households in the health districts of Kinshasa, Congo in 1997. For the most recent episode of illness, the respondents turned to seven types of care: the health centre (37%), private dispensaries (26.5%), self-medication through a pharmacy (23.9%), traditional practitioner (21%), traditional self-medication (16.9%), private outpatients' clinic (16.7%) and a reference hospital (10.4%). Past logistics have shown that patients resort to a health centre rather than another type of care structure (P = 0.05) when looking for quality care, reasonable prices and the availability of varied services. On the other hand, concern about the geographical proximity in relation to the family's residence calls for using the private dispensary. When looking for a doctor or the existence of a 'convention', families are more inclined to choose a private officially recognized outpatients' clinic. Those who had been looking for a solution to a special type of illness opted primarily for a traditional practitioner. In conclusion, the results of this study show that if people choose the care offered by health centres, it is because they judge it to be of good quality. The integrated care offered by the same technician, with a required training, is a major asset in the acceptability of the first line of primary health care in Kinshasa. This study suggests that it would no doubt be beneficial to integrate non-official private care structures into the primary health care system, as far as it is possible for them to achieve a level of quality comparable to that of the health centres. In order that the traditional practitioner might play an important complementary role in the realization of primary health care, even in urban areas, the possibility of promoting sites of communication should be studied. Moreover, considering the weak buying power of the city's inhabitants and the previous existence of tontines out of solidarity, the 'conventions' providing relief of health care costs, under the leadership of the local communities, should be integrated into the organization of the urban health system.

[Misunderstanding of medical resource use by women]

By analysing three different Belgian databases, we could demonstrate that whereas women subjectively declare a higher number of diseases, a worse functional state and a higher trend to use medical resources, they are, from an objective point of view, less frequently hospitalized and cause a lower cost, at certain ages, for the Social Security.

[Ambulatory management of moderately and severely malnourished children in the rural health district of Kapolowe in Shaba (Zaire)]

In Kapalowe rural health district, hospitalisation of malnourished children is restricted to complicated cases; once the complication is under control or eliminated, the child's treatment is continued at home, based on a 13 weeks contract, between parents and health centre. The parents commit themselves to feed their child four times a day (two porridge and two family dish portions), to consult once a week at the health centre and to welcome a weekly home visit. The objective of this visit is to support the parents, to detect possible problems and to reach the roots for this particular child. During the contract period, cost of medical treatment and recommended soya flour, is borne by the parents through a lump sum contribution. In this article, data concerning the first 95 children home rehabilitated (1989-1991) in Kapalowe are analysed. Characteristics of these children are classical regarding malnutrition; for example, age distribution is similar to that of weaning and of defunction of children at the hospital during the same year. Approximately half of them are still breastfed at the beginning of the contract. Most of them are correctly immunized and have been seen at the health centre at least two times in the last six months. Seventy-four children finished the contract; there were 17 abandons and 4 deaths. Weight gain is inferior to that observed in specialized feeding centres which do benefit from external resources, which is not the case here. It was not possible to show a significant catch up for the height for age indicator after the three months contract. These anthropometrical results are less important than the global and subjective improvement in the child's general health status observed at the end of the contract. None of the children reached the target weight after 13 weeks but important changes were observed in their behaviour, in their resistance to infection and in the attitude of their parents. The parents generally followed the instructions quite well. The middle of the contract seems to be a key period when either significative changes happen or when the attention is released. Treatment instructions have been amended to avoid monotony and overload, and to stimulate staff creativity and self-satisfaction. Payment was not a problem for the parents as malnutrition is not linked to extreme poverty. Mother's attitude and confidence and child initial weight for height status are two important contract success determinants. Abandons are more frequent when the mother is pessimistic and in case of kwashiorkor. Despite this, most of these children had gained more than one kilo before the contract was interrupted. Some didn't fulfill the W/H inclusion criteria (-2 standard deviations) and should probably not have been under contract. The four deaths were linked to insufficient treatment instructions for usually banal diseases that have another meaning in case of malnutrition, such as diarrhoea, fever, etc. An evaluation performed three months after the end of the contract in 26 children show 13 further improvements, 8 statu quo, 4 relapses and 2 new deaths. Conclusions are that home nutritional rehabilitation is possible where a health district is fully operational, that anthropometric data are useful to monitor rehabilitation but not to be pursued only as sole and ultimate objectives, and that adequate follow up after the first intensive stage is essential. The paper also shows how such a research result can have direct consequences on the organization of health activities.