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.

Evaluation of Computer-assisted Image Enhancement in Minimal Invasive Endoscopic Surgery

Objectives: This paper focusses on the evaluation of the usage of computer-aided image processing methods for minimal invasive surgery. During video endoscopy of visceral cavities the images are displayed directly on the monitor without further processing. In the course of the operation the former good quality of the images decreases due to typical disturbances like bleeding, smoke or flying particles. These disturbances can be reduced by using image processing methods like color normalization, temporal filtering or equalization.

Methods: In this double-blinded analysis, 14 surgeons with different levels of experience evaluated 120 image pairs and 5 image sequences, directly comparing original and processed images or movies.

Results: Color normalization and equalization proved to significantly enhance video endoscopic images. With regard to temporal filtering, an improvement could be seen in the image sequences with filter size 5 being a greater enhancement than filter size 3. Comparing the state of experience and its influence on the results, it occurred that the experienced surgeons preferred the original color while altogether agreeing that the color-normalized images were better.

Conclusions: The results obtained in the present evaluation show that the image processing methods which were used can significantly improve the quality of video endoscopic images. As a result of this, necessary lavages of the operated area are reduced and a better overview and orientation for the surgeon can be reached.

Light Fields for Minimal Invasive Surgery Using an Endoscope Positioning Robot

Objectives: To generate a fast and robust 3-D visualization of the operation site during minimal invasive surgery.

Methods: Light fields are used to model and visualize the 3-D operation site during minimal invasive surgery. An endoscope positioning robot provides the position and orientation of the endoscope. The a priori unknown transformation from the endoscope plug to the endoscope tip (hand-eye transformation) can either be determined by a three-step algorithm, which includes measuring the endoscope length by hand or by using an automatic hand-eye calibration algorithm. Both methods are described in this paper and their respective computation times and accuracies are compared.

Results: Light fields were generated during real operations and in the laboratory. The comparison of the two methods to determine the unknown hand-eye transformation was done in the laboratory. The results which are being presented in this paper are: rendered images from the generated light fields, the calculated extrinsic camera parameters and their accuracies with respect to the applied hand-eye calibration method, and computation times.

Conclusion: Using an endoscope positioning robot and knowing the hand-eye transformation, the fast and robust generation of light fields for minimal invasive surgery is possible.

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.

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.

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.

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.

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.

[How to improve the continuity of pharmacotherapy at hospital admission and discharge]

The continuity of pharmacotherapy is of vital importance when patients move from one health care setting to another. Unfortunately, this continuity is not always guaranteed. The aim of this study is to propose solutions to enhance the continuity of pharmacotherapy at hospital admission and discharge. The study consists of a systematic review of the international literature and an analysis of seamless care initiatives in seven selected countries; a summary of Belgian data on problems as well as solutions with regard to continuity of care; a quantification of the extent of medication changes as a result of a hospital stay in Belgium; and a qualitative analysis of the perception of Belgian health care professionals (HCPs) on approaches to improve seamless care. The literature review yielded 15 papers of sufficient quality. However, this review did not generate definitive conclusions on the clinical impact and the cost-effectiveness of interventions aiming to enhance the continuity of pharmacotherapy. The most important initiatives that have been put in practice in foreign countries include the development and implementation of guidelines for HCPs; national information campaigns; education of HCPs; and the development of information technologies as to share patient and prescription data between settings of care. For Belgium, 66 seamless care initiatives were identified. The high number and variety of projects show the interest for this topic as well as the involvement of various HCPs from diverse settings in the development of solutions. Based on this research, and the solutions discussed in the focus groups, the following elements are proposed to enhance the continuity of pharmacotherapy: a national guideline governing the continuity of pharmacotherapy; a national campaign to sensitize HCPs and patients in this area; the availability of a comprehensive and up to date medication list for each patient; and electronic healthcare infrastructure that facilitates sharing of information.

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.

Use of office spirometers in Flemish general practice: results of a telephone survey

BACKGROUND

While office spirometry is seen as potentially useful and feasible in general practice, little is known about its use in Flemish general practice. Our aim was to describe the use of spirometers by Flemish GPs, characteristics of their spirometry practice, training needs and preferences, and attitudes towards office spirometry.

METHODS

A telephone survey was set up in a random sample of Flemish GPs. Interviews were carried out by a GP researcher using a structured piloted questionnaire.

RESULTS

197 out of 243 eligible GPs (81%) were interviewed. Most GPs (66%) had never used an office spirometer, 17.3% were using one and 16.7% stopped using one. Time constraints (54%) and insufficient knowledge and skills (27%) were the main reasons for not using an office spirometer (any longer). GPs particularly used their spirometer to diagnose COPD and asthma, and less frequently in follow-up. GPs (67.9%), especially current users (91.2%), considered spirometry as a GP task. Spirometry training should be provided (86%) and spirometry by GPs should be reimbursed (79.5%). More information on spirometry would be very useful (62.3%), with a marked preference for training in small groups (86.8%).

CONCLUSION

Although office spirometry is not widespread in Flemish general practice, GPs show an undoubted interest in it. They need educational and financial support to overcome prevailing barriers in establishing office spirometry on a routine basis.

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.

[Evaluation of the vaccine coverage of the general practitioners in the French Community]

The present inter-University study aims to analyze the vaccine statute of the Belgian French-speaking general practionners and the reasons of their possible non-vaccination. A questionnaire with an exhaustive list of vaccines was sent by postal way to a random sample of thousand two hundred and twenty general practitioners. The results were analyzed via SPSS 13. The rate of answer is 60.83%. Two thirds of the doctors (67%) considered themselves in order of vaccination anti-influenza. A majority of doctors (59.7%) is vaccinated systematically each year. The majority of the doctors (83%) considered themselves in antitetanus order of vaccination. Two thirds (67%) think that the vaccine protects from 5 to 10 years. Nearly 73% of the doctors considered themselves in order of vaccination against hepatitis B. More than 50% of the doctors received a vaccine HBV since less than 10 years. The majority of the doctors (79.2%) made a blood control of their protection after vaccination HBV Almost half of the doctors thinks that the vaccine protect for life, 23% from 10 to 20 years and 14% from 5 to 10 years. Two thirds (67%) of the doctors did not make a vaccine against rubella. In 80% of the cases vaccination dated from more than 20 years. In nearly two thirds of the cases the doctors did not make blood control of their protection. Nearly 60% of the questioned doctors think that vaccination offers a protection to life. About half of the doctors did not consider themselves in order of vaccination against the whooping-cough. In three quarter of the cases last vaccination dated from more than 20 years. The two principal durations of protection of the vaccine are with life and between 10 and 20 years. Three quarters of the questioned doctors are considered in order of vaccination against the poliomyelitis. However in 62% of the cases the last vaccine goes up with more than 20 years. More two thirds of the doctors think than the vaccine protects with life or from 10 to 20 years. Two thirds of doctors considered themselves in order of vaccination against the diphteria. For a third of the doctors the vaccine dated from less than 5 years, in more than one quarter of the cases to more than 20 years like between 5 and 10 years. About half of the doctors said they were vaccinated against other pathologies: hepatitis A (34.5%), the yellow fever (21.1%), the thyphoid fever (12.5%), the BCG (8.9%), the pneumococcus (6.6%), meningitis and variola (5%). In the French Community, the vaccine coverage of the general practitioners against the influenza (67%), tetanus (83%) and hepatitis B (73%) is, in this study, higher or equal to the other Belgian and international studies but remains insufficient. A bad vaccine coverage is observed concerning rubella, the whooping-cough, the poliomyelitis. The answers over the durations of protection of the vaccines are rather disparate and show a bad knowledge of these durations and diagrams of vaccination. An update of this knowledge could be carried out during the continuous medical trainings.

Substantial use of primary health care by prisoners: epidemiological description and possible explanations

OBJECTIVES

To describe the use of primary care services by a prisoner population so as to understand the great number of demands and therefore to plan services oriented to the specific needs of these patients.

DESIGN

Retrospective cohort study of a sample of prisoners' medical records.

SETTING

All Belgian prisons (n = 33).

PATIENTS

513 patients over a total of 182 patient years, 3328 general practitioner (GP) contacts, 3655 reasons for encounter.

MAIN RESULTS

Prisoners consulted the GP 17 times a year on average (95%CI 15 to 19.4). It is 3.8 times more than a demographically equivalent population in the community. The most common reasons for encounter were administrative procedures (22%) followed by psychological (13.1%), respiratory (12.9%), digestive (12.5%), musculoskeletal (12%), and skin problems (7.7%). Psychological reasons for consultations (n = 481) involved mainly (71%) feeling anxious, sleep disturbance, and prescription of psychoactive drugs. Many other visits concerned common problems that in other circumstances would not require any physician intervention.

CONCLUSION

The most probable explanations for the substantial use of primary care in prison are the health status (many similarities noted between health problems at the admission and reasons for consultations during the prison term: mental health problems and health problems related to drug misuse), lack of access to informal health services (many contacts for common problems), prison rules (many consultations for administrative procedures), and mental health problems related to the difficulties of life in prison.

Automated segmentation of the optic nerve head for diagnosis of glaucoma

Glaucoma is the second most common cause of blindness worldwide. Low awareness and high costs connected to glaucoma are reasons to improve methods of screening and therapy. A well-established method for diagnosis of glaucoma is the examination of the optic nerve head using scanning-laser-tomography. This system acquires and analyzes the surface topography of the optic nerve head. The analysis that leads to a diagnosis of the disease depends on prior manual outlining of the optic nerve head by an experienced ophthalmologist. Our contribution presents a method for optic nerve head segmentation and its validation. The method is based on morphological operations, Hough transform, and an anchored active contour model. The results were validated by comparing the performance of different classifiers on data from a case-control study with contours of the optic nerve head manually outlined by an experienced ophthalmologist. We achieved the following results with respect to glaucoma diagnosis: linear discriminant analysis with 27.7% estimated error rate for automated segmentation (aut) and 26.8% estimated error rate for manual segmentation (man), classification trees with 25.2% (aut) and 22.0% (man) and bootstrap aggregation with 22.2% (aut) and 13.4% (man). It could thus be shown that our approach is suitable for automated diagnosis and screening of glaucoma.

Cardiovascular prevention in general practice: development and validation of an algorithm

OBJECTIVE

General practice visits are a unique opportunity to identify and treat individuals with a high cardiovascular (CV) risk. However, a case-finding strategy suited to the daily general practice is not provided in the CV prevention guidelines. We wanted to create, validate and test an algorithm for global CV risk assessment and management.

METHODS

The algorithm was 1) developed based on evidence from epidemiological studies and clinical trials, 2) validated in a population-based cohort and 3) tested by randomly selected general practitioners (GPs) who rated its usefulness and applicability.

RESULTS

1) Screening for seven clinical risk factors (RF) allowed a quick classification of patients in four CV risk typologies: obvious high risk (previous CV event and/or type 2 diabetes) in 17%, obvious low risk (no RF) in 14%, smoking-related risk (single RF) in 6%, or undetermined risk (any other RF) to further evaluate in 63% patients. Inter-physician reproducibility for risk prediction was excellent. Overall, predicted risk was high, moderate and low in 25, 17 and 58% of the patients, respectively. 2) These risk predictions were validated in a cohort of 962 men followed over 10 years. 3) Most GPs reported that the algorithm was applicable and useful, while half of them started using it frequently in their daily practice.

CONCLUSION

This algorithm is a new, pragmatic and evidence-based strategy for systematic and global CV risk management. It was validated at the population level, and shown to be applicable and useful in the daily general practice.

Obstacles to cardiovascular prevention in general practice

OBJECTIVE

In spite of a wide diffusion of the European guidelines for prevention of cardiovascular (CV) diseases, failures in both primary and secondary CV prevention are currently acknowledged. We wanted to uncover obstacles to CV prevention related to the general practitioner's (GP) knowledge and attitudes.

METHODS AND RESULTS

A postal questionnaire was sent to a random sample of GPs from two Belgian provinces. 282 GPs (32%) answered the questionnaire. The proportion of adequate answers was calculated for each item. The main obstacles related to three domains. Regarding awareness of CV burden, 83% of the GPs underestimated the lethality of myocardial infarction and 41% underestimated the prevalence of high CV risk in the adult population. Regarding CV risk assessment, 80% thought that total cholesterol (TC) adequately reflected the individual CV risk; only 55% systematically registered the patient's CV risk factors in the medical record. A tool for global CV risk assessment was never used by 53% of the GPs. Regarding CV therapeutic attitudes, 66% systematically prescribed a lipid-lowering drug to patients with high TC while 62% did not take into account the evidence-based therapeutic targets in type 2 diabetic patients.

CONCLUSIONS

This survey showed that these GPs underestimated the CV burden, lacked a systematic approach to global risk assessment and used to focus on cholesterol treatment rather than on global CV risk management.

Teenagers and their family practitioner: matching between their reasons for encounter

OBJECTIVES

The aim of this study was to analyse the reasons for encounter of teenagers in family practice and to compare them with the reasons recorded by their family practitioner (FP).

METHODS

This cross-sectional study involved 91 FPs from the Paris area and from the French-speaking part of Belgium. The teenagers (12-17 years old) filled in an auto-administered questionnaire in the waiting room of their FP during a 1-week period. The doctor independently filled in a similar form after the consultation. Both questionnaires were matched afterwards to assess the concordance between the reasons for encounter recorded by the young patient and by his/her FP.

RESULTS

More than 100 reasons for encounter were given by 457 teenagers. The majority of the complaints were respiratory (26%), general health (18.5%), osteoarticular (15%), digestive (11%) and neurological problems (9.5%). Gender did not influence the nature of the complaints, but age played a role. The older teenagers had more respiratory complaints, general and pregnancy/contraception problems. In 80% of the cases, the ailments listed by the teenagers were picked up by the practitioner. In 18% of the consultations, the FP recorded problems that had not been noted by the patient.

CONCLUSION

Many common and a few serious although frequent youth problems were found among the reasons for encounter. Most of them were recorded by the practitioner. Time and communication skills are important to give the opportunity to the teenager to share sensitive topics with his/her FP.

Evaluation of computer-assisted image enhancement in minimal invasive endoscopic surgery

OBJECTIVES

This paper focuses on the evaluation of the usage of computer-aided image processing methods for minimal invasive surgery. During video endoscopy of visceral cavities the images are displayed directly on the monitor without further processing. In the course of the operation the former good quality of the images decreases due to typical disturbances like bleeding, smoke or flying particles. These disturbances can be reduced by using image processing methods like color normalization, temporal filtering or equalization.

METHODS

In this double-blinded analysis, 14 surgeons with different levels of experience evaluated 120 image pairs and 5 image sequences, directly comparing original and processed images or movies.

RESULTS

Color normalization and equalization proved to significantly enhance video endoscopic images. With regard to temporal filtering, an improvement could be seen in the image sequences with filter size 5 being a greater enhancement than filter size 3. Comparing the state of experience and its influence on the results, it occurred that the experienced surgeons preferred the original color while altogether agreeing that the color-normalized images were better.

CONCLUSIONS

The results obtained in the present evaluation show that the image processing methods which were used can significantly improve the quality of video endoscopic images. As a result of this, necessary lavages of the operated area are reduced and a better overview and orientation for the surgeon can be reached.

Light fields for minimal invasive surgery using an endoscope positioning robot

OBJECTIVES

To generate a fast and robust 3-D visualization of the operation site during minimal invasive surgery.

METHODS

Light fields are used to model and visualize the 3-D operation site during minimal invasive surgery. An endoscope positioning robot provides the position and orientation of the endoscope. The a priori un-known transformation from the endoscope plug to the endoscope tip (hand-eye transformation) can either be determined by a three-step algorithm, which includes measuring the endoscope length by hand or by using an automatic hand-eye calibration algorithm. Both methods are described in this paper and their respective computation times and accuracies are compared.

RESULTS

Light fields were generated during real operations and in the laboratory. The comparison of the two methods to determine the unknown hand-eye transformation was done in the laboratory. The results which are being presented in this paper are: rendered images from the generated light fields, the calculated extrinsic camera parameters and their accuracies with respect to the applied hand-eye calibration method, and computation times.

CONCLUSION

Using an endoscope positioning robot and knowing the hand-eye transformation, the fast and robust generation of light fields for minimal invasive surgery is possible.

GPs working in solo practice: obstacles and motivations for working in a group? A qualitative study

OBJECTIVE

Our aim was to analyse the obstacles and eventual motivations of solo GPs for working in group practice.

METHODS

A qualitative study using 12 focus groups was carried out in primary care in French-speaking Belgium. The subjects comprised four samples of GPs: 20 GP trainers, 18 GP trainees, 25 women GPs and 25 other GPs. The focus groups were taped and transcribed. Two independent researchers carried out the analysis using the QSR NUD.IST software.

RESULTS

The participants (88 GPs) did not share a common definition of group practice-in particular multidisciplinary working-the need for a common pool of patients and shared premises. Their main sources of motivation for eventually setting up a group practice were better quality of life, continuity of care and sharing professional knowledge. The main obstacles were a required agreement between colleagues, the loss of a personal patient-GP relationship, budgetary constraints, and divergent views on group practice and GPs' profession (especially true for the association of GPs from different age groups).

CONCLUSION

The current study shows that GPs working solo have divergent views of group practice. However, they clearly perceive advantages to this type of association (e.g. better quality of life and continuity of care). This study also confirms the high level of stress and tiredness felt by GPs and especially senior practitioners.

Patient satisfaction with availability of general practice: an international comparison

OBJECTIVE

To identify associations between the characteristics of general practitioners and practices, and patients' evaluations of the availability of general practice.

DESIGN

Written surveys completed by patients.

SETTING

General practice care in nine European countries: Denmark, Germany, The Netherlands, Norway, UK, Belgium (Flanders and Wallonia), Switzerland, Slovenia and Spain.

STUDY PARTICIPANTS

15996 adult patients consecutively visiting the general practitioner (response rates per country varied between 47 and 89%).

MAIN MEASURES

The Europep instrument to assess patients' evaluations of five aspects of the availability of general practice care: (1) getting an appointment, (2) getting through on the phone, (3) being able to speak to the practitioner on the telephone, (4) waiting time in the waiting room, and (5) providing quick services for urgent health problems. Each general practitioner recorded age, sex, number of years in the practice, number of practitioners and other care providers in the practice, and urbanization level of the practice.

RESULTS

Patients' more positive evaluations were associated with fewer general practitioners in the practice, except for quick services for urgent health problems (range of conditional overall odds ratios, 1.69-2.02). In addition, a number of significant unconditional overall odds ratios were found, particularly those related to the number of general practitioners' working hours and the number of care providers in the practice. None of the associations was found consistently in all countries.

CONCLUSION

Patients favour small practices and full-time general practitioners, which contradicts developments in general practice in many countries. Policy makers should consider how the tensions between patients' views and organizational developments can be solved.

[Image analysis system for detection facial paralysis]

BACKGROUND

Evaluation of facial nerve paresis depends on visual assessment and naturally differs from examiner to examiner. An objective measurement instrument is presented.

PATIENTS AND METHOD

Facial features are automatically localized by a parametric face model in videos of a face during relaxation and exercises. Gray-level information is analyzed by a special steerable filter and used to identify symmetries. The computer system was tested in 19 individuals.

RESULTS

Automatic localization of facial features such as the upper arc of the head and ears was correct in 95%, the eyes in 82%, and the mouth in 73%. Lid paresis was correctly recognized in seven of ten (70%) and oral paresis in 10 of 12 (83%) cases. Unaffected eyelid movements were identified in eight of nine (89%) and healthy oral regions in all seven (100%) cases.

CONCLUSION

The computer system presented is able to automatically localize facial features and to identify facial nerve paresis. It is a considerable step toward automatic and objective grading of facial nerve paresis.

Dietary habits during adolescence--results of the Belgian Adolux Study

OBJECTIVE OF THE PRESENT STUDY: To analyse the usual dietary habits of Belgian adolescents from a high cardiovascular risk population.

METHODS

A food frequency questionnaire (57 items) was administered to the whole sample. Complementary questions specified some types of food (eg fat content). A subgroup of 234 adolescents gave detailed information on portion size (picture book and food samples).

SETTING

Twenty-four secondary schools in the Belgian province of Luxembourg.

SUBJECTS

A total of 1,526 adolescents (12-17y) selected by a multiclustered stage sampling (participation: 83.6%).

RESULTS

Respectively 46% and 60% of the adolescents did not eat fruit and vegetables daily. Most of the adolescents (72%) consumed at least one dairy product daily. The frequent consumption of chocolate and French fries indicated the strong cultural influence on dietary habits while imported foods (like hamburgers) had little success. One-third of the adolescents (33%, n = 509) drank alcohol at least once a week and this proportion rose to 57% in the oldest age group. Boys and girls differed significantly in their diet, with girls choosing healthier foods. Dietary habits, in particular drinking habits, differed also significantly between education levels, assessed by the learning option of the participants. The semi-quantitative questionnaire showed that two-thirds of the adolescents had a lipid intake (mainly saturated fatty acids) which exceeded 35% of the total caloric intake. Complex carbohydrates represented less than half of the total carbohydrates intake.

CONCLUSION

The study of the diet of Belgian adolescents confirmed the strong influence of tradition, in particular on the consumption of high fat content foods. The promotion of healthy diet in adolescents should consider the cultural influence, even for this young age group.

Oral contraception and cardiovascular risk factors during adolescence

The objective of the present study was to analyze the pattern of oral contraceptive (OC) use in teenagers and to examine the relationship between OC use and other cardiovascular risk factors. The study was conducted in 24 Belgian secondary schools. Most students (1526 adolescents aged 12-17 years) agreed to participate (participation rate: 83.6%). Smoking, physical activity habits, menarche, and OC use were assessed by a self-administered questionnaire. Total cholesterol level, blood pressure and anthropometric measurements were also measured. Fourteen per cent of mature girls (14%, n = 92) were OC users. Two-thirds of them (66.3%, n = 61) were taking OC which contained either gestodene or desogestrel. Blood pressure and BMI were similar for OC users and non-users. Total cholesterol level was significantly higher in OC users than in non-users (191 mg/dL versus 172 mg/dL). Logistic regression model confirmed the significant influence of OC use on total cholesterol level (OR = 3.08). OC users were also often smokers (39% versus 20% for non-users). In conclusion, the present study has found significant relationships between OC use and cardiovascular risk factors i.e., high total cholesterol and smoking. The first implication is a need for further research on lipoprotein profile in young OC users. Secondly, the combined use of OC and smoking in teenagers calls for preventive actions.