Does the Belgian diabetes type 2 care trajectory improve quality of care for diabetes patients?

Lipid-lowering therapy and risk-based LDL-C goal attainment in Belgium: DA VINCI observational study

BACKGROUND

Cardiovascular disease (CVD) is one of the leading causes of death in Belgium. Current strategies for the prevention and management of CVD focus on reducing low-density lipoprotein cholesterol (LDL-C) levels. This analysis assessed whether LDL-C goals, recommended by the European Society of Cardiology (ESC)/European Atherosclerosis Society (EAS) guidelines, were being achieved in a Belgian study population.

METHODS

The cross-sectional, observational, DA VINCI study enrolled patients prescribed lipid-lowering therapy (LLT) between 21 June 2017 and 20 November 2018. Data for patients from Belgium were extracted for this country-specific analysis. Primary endpoint was the proportion of patients who achieved 2016 ESC/EAS risk-based LDL-C goals; attainment of 2019 risk-based LDL-C goals was evaluated post hoc.

RESULTS

Of 497 enrolled patients, 41% were female and mean age was 68 years. Among subjects with an LDL-C measurement on stabilised LLT, moderate-intensity statin monotherapy was the most prescribed LLT regimen (59%). Overall, 63% of patients achieved their risk-based LDL-C goals according to the 2016 ESC/EAS guidelines. Among patients with established ASCVD, risk-based LDL-C goal attainment was higher in patients with peripheral arterial disease (53%) than patients with coronary (37%) and cerebrovascular disease (42%). According to the updated 2019 ESC/EAS guidelines, less than half (41%) of patients achieved their risk-based LDL-C goal. The proportion of primary and secondary prevention patients who achieved 2019 risk-based LDL-C goals was 59% and 18%, respectively.

CONCLUSION

These findings reveal a large gap between the LDL-C goals advocated by the ESC/EAS and the levels achieved in routine clinical practice in Belgium.

Scale-up of a chronic care model-based programme for type 2 diabetes in Belgium: a mixed-methods study

BACKGROUND

Type 2 diabetes (T2D) is an increasingly dominant disease. Interventions are more effective when carried out by a prepared and proactive team within an organised system - the integrated care (IC) model. The Chronic Care Model (CCM) provides guidance for its implementation, but scale-up of IC is challenging, and this hampers outcomes for T2D care. In this paper, we used the CCM to investigate the current implementation of IC in primary care in Flanders (Belgium) and its variability in different practice types.

METHODS

Belgium contains three different primary-care practice types: monodisciplinary fee-for-service practices, multidisciplinary fee-for-service practices and multidisciplinary capitation-based practices. Disproportional sampling was used to select a maximum of 10 practices for each type in three Flemish regions, leading to a total of 66 practices. The study employed a mixed methods design whereby the Assessment of Chronic Illness Care (ACIC) was complemented with interviews with general practitioners, nurses and dieticians linked to the 66 practices.

RESULTS

The ACIC scores of the fee-for-service practices - containing 97% of Belgian patients - only corresponded to basic support for chronic illness care for T2D. Multidisciplinary and capitation-based practices scored considerably higher than traditional monodisciplinary fee-for-service practices. The region had no significant impact on the ACIC scores. Having a nurse, being a capitation practice and having a secretary had a significant effect in the regression analysis, which explained 75% of the variance in ACIC scores. Better-performing practices were successful due to clear role-defining, task delegation to the nurse, coordination, structured use of the electronic medical record, planning of consultations and integration of self-management support, and behaviour-change intervention (internally or using community initiatives). The longer nurses work in primary care practices, the higher the chance that they perform more advanced tasks.

CONCLUSIONS

Besides the presence of a nurse or secretary, also working multidisciplinary under one roof and a capitation-based financing system are important features of a system wherein IC for T2D can be scaled-up successfully. Belgian policymakers should rethink the role of paramedics in primary care and make the financing system more integrated. As the scale-up of the IC varied highly in different contexts, uniform roll-out across a health system containing multiple types of practices may not be successful.

Development and operationalization of a data framework to assess quality of integrated diabetes care in the fragmented data landscape of Belgium

Background

To assess the quality of integrated diabetes care, we should be able to follow the patient throughout the care path, monitor his/her care process and link them to his/her health outcomes, while simultaneously link this information to the primary care system and its performance on the structure and organization related quality indicators. However the development process of such a data framework is challenging, even in period of increasing and improving health data storage and management. This study aims to develop an integrated multi-level data framework for quality of diabetes care and to operationalize this framework in the fragmented Belgium health care and data landscape.

Methods

Based on document reviews, iterative working group discussions and expert consultations, theoretical approaches and quality indicators were identified and assessed. After mapping and assessing the validity of existing health information systems and available data sources through expert consultations, the theoretical framework was translated in a data framework with measurable quality indicators. The construction of the data base included sampling procedures, data-collection, and several technical and privacy-related aspects of linking and accessing Belgian datasets.

Results

To address three dimensions of quality of care, we integrated the chronic care model and cascade of care approach, addressing respectively the structure related quality indicators and the process and outcome related indicators. The corresponding data framework is based on self-collected data at the primary care practice level (using the Assessment of quality of integrated care tool), and linked health insurance data with lab data at the patient level.

Conclusion

In this study, we have described the transition of a theoretical quality of care framework to a unique multilevel database, which allows assessing the quality of diabetes care, by considering the complete care continuum (process and outcomes) as well as organizational characteristics of primary care practices.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08625-8.

The state of health in Belgium, 1990-2019: a benchmarking analysis based on the Global Burden of Disease 2019 study

BACKGROUND

In a context of decreasing resources and growing health needs, evidence-based health and care policies are essential. This study aims to assess the health trends in Belgium between 1990 and 2019, to compare the Belgian health status to that of the EU-15 countries, and to identify the main drivers in trends over time and country differences within the EU-15.

METHODS

We extracted estimates from the GBD 2019 study via the GBD results tool and visualization tools. We compared the Belgian health status with 14 European Union comparator countries between 1990 and 2019, and decomposed the time trends and country differences into the unique contributions of the different underlying causes of death and disability.

RESULTS

Life expectancy (LE) in Belgium improved significantly between 1990 and 2019 for both men and women. Belgium age-standardised mortality rates dropped significantly for men (-40%) and women (-33%) between 1990 and 2019. Overall, Belgium age-standardised disability-adjusted life year (DALY) rates dropped by 23%. This decrease is mainly due to decreasing trends in age-standardised years of life lost (YLL) rates while age-standardised years lived with disability (YLD) rates remained stable. Compared to EU-15, Belgium's ranking in terms of age-standardised DALY rates worsened for both men and women in 2019. Self-harm and falls are major causes of disease burden, with DALY rates that are higher than in many other EU-15 countries, indicating a realistic potential for improvement. Lung cancer DALY rates remain worrisome for men, and even show an increasing trend for women. Increasing trends of headache disorders, drug use disorders, and diabetes, require further attention.

CONCLUSION

Non-communicable diseases remain the main contributors for health burden in Belgium, with disability accounting for an increasingly larger share of the disease burden. Despite considerable improvements, Belgium's ranking for DALYs decreased between 1990 and 2019 compared to the EU-15. This study identified priority causes of disease burden based on their contributions to current evolutions and EU-15 differences. Since many of these causes are considered to be avoidable, primary and secondary prevention are crucial elements for reducing the burden of disease on the healthcare system.

Assessing related factors to fasting blood sugar and glycosylated hemoglobin in patients with type 2 diabetes simultaneously by a multivariate longitudinal marginal model

The multivariate marginal model can be used to simultaneously examine the factors affecting both FBS and HbA1c using longitudinal data. The model fitted to multivariate longitudinal data should prevent redundant parameter estimation in order to have greater efficiency. In this study, a multivariate marginal model is used to simultaneously investigate the factors affecting both FBS and HbA1c with longitudinal data for patients with type 2 diabetes in Northern Iran. The present research is a retrospective cohort study. Overall, 500 medical records with complete information were reviewed. The multivariate marginal model is used to determine the factors associated with FBS and HbA1c using longitudinal data. Data have been analyzed in R-3.4.0 using ‘mmm2’ package. Given that the coefficients for the interactions of rtype with the intercept, time, family history of diabetes, history of hypertension, history of smoking, insulin therapy, systolic/diastolic blood pressure and duration of disease at first visit are significantly different from zero (P < 0.05), the effect of the independent variables on the two response variables is different and different coefficients should be used for each. Therefore, the interactions of these variables with rtype are kept in the final model. The coefficients for the interactions of rtype with sex, age at first visit, history of high cholesterol, and weight are not significantly different from zero (P > 0.05), indicating that their effect on the two response variables is similar and only one coefficient should be used for each. We examined the similarity of coefficients when fitting the longitudinal multivariate model for the relationship between FBS/HbA1c and sex, age, history of high blood cholesterol, and body weight. If an independent variable has similar effects on both responses, only one coefficient should be estimated, which will increase the efficiency of the model and the reliability of the results.

What Makes Integration of Chronic Care so Difficult? A Macro-Level Analysis of Barriers and Facilitators in Belgium

Introduction

Although many countries have been implementing integrated care, the scale-up remains difficult. Macro-level system barriers play an important role. By selecting three key policies, which have implemented integrated care in Belgium over the last 10 years, we aim to go beyond the identification of their specific barriers and facilitators to obtain an overarching generic view.

Methods

27 participants were purposefully selected, to include all important stakeholders involved on the macro-level in chronic care in Belgium. Semi-structured interviews were guided by a timeline of policies and an inductive thematic analysis was performed.

Results

Barriers and facilitators were identified on both health care and policy level. The major factors restraining the scale-up of integrated care are the fee-for-service reimbursement system, limited data sharing and the fragmentation of responsibilities between different levels of government. Remarkably, these factors strongly interact.

Discussion

This paper highlights the importance of homogenization of responsibilities of governments regarding integrated care and the interdependency of policy and health care system factors. A whole system change is needed instead of the current Belgian model of prolonged search for common ground between conflicting opinions. Political commitment and citizen participation will be crucial.

Cardiologists' perceptions on multidisciplinary collaboration in heart failure care - a qualitative study

BACKGROUND

Cardiologists play a key role in multidisciplinary care by guiding heart failure (HF) management in the hospital and in the community. Regional implementation of multidisciplinary health care interventions depends on how they perceive collaboration with other health care disciplines, yet research on this topic is limited. This study aimed to explore the views and opinions of cardiologists on multidisciplinary collaboration in HF care.

METHODS

We conducted a qualitative study based on face-to-face semi-structured interviews with 11 Belgian cardiologists between September 2019 and February 2020. We used the Qualitative Analysis Guide of Leuven (QUAGOL) method as guidance for data analysis until data saturation was reached.

RESULTS

Cardiologists consider the general practitioner (GP) and HF nurse as the most important partners in HF management. Cardiologists identified four problems in current multidisciplinary collaboration: the communication of a HF diagnosis to the patient, advanced care planning, titration of HF medication by the GP and electronic data exchange and communication. Three themes emerged as ideas for improvement of HF care: 1) expansion of the role of the HF nurse, 2) implementation of a structured, patient-centered, and flexible model of disease management program and 3) integrated data approaches.

CONCLUSION

Cardiologists value close cooperation with GPs in HF management. They advocate an expanded future role for the HF nurse, increased eHealth, and structured disease management to optimize current HF care.

Longitudinal Trend of Fasting Blood Glucose and Related Factors in Patients with Type 2 Diabetes

BACKGROUND

Control of diabetes plays an important role in improving complications and disabilities and quality of life. This study aimed to evaluate the 3-year changes in fasting blood glucose (FBG) values and its related factors in patients with type 2 diabetes.

METHODS

In this retrospective cohort study, 500 patients with type 2 diabetes covered by the National Diabetic Prevention and Care Plan during 2013-2016 were selected based on random cluster systematic sampling. A linear mixed model was used to study changes in FBG levels and their related factors. The data were analyzed using the R3.2.0 software.

RESULTS

The patients' mean age was 47.7 years. Among these patients, 58.6% were female, 19.8% had a history of smoking. High FBG was associated with high disease duration, high body mass index (BMI), low age, normal BMI at baseline, insulin therapy, smoking, and family history of diabetes. Trend of FBG in follow-up was decreasing.

CONCLUSIONS

Given that patients who received insulin therapy had higher mean FBG, it is recommended to examine their insulin dose and modifications should be made in terms of the patients' needs during their continuous follow-up. Weight loss during follow-up and cessation of smoking indicate a favorable prognosis of disease. More attention should be paid to younger patients in care. Patients are encouraged to start treatment and care at the same time diagnose.

Ten-Year Trends in the Morbidity of Diabetes Mellitus and Antidiabetic Drug Utilization in Croatia: A Study Based on Routinely Collected Data

Objectives. To investigate trends of diabetes mellitus (DM) morbidity and antidiabetic drug utilization in Croatian primary health care (PHC) from 2005 to 2014. Method. Routinely collected morbidity data from all PHC units, presented in Croatian health-statistics yearbooks, were retrieved. Data on drug utilization were retrieved from the Annual Reports of the Croatian Agency for Medicinal Products and Medical Devices (ATC/DDD, antidiabetic, A10). Results. Total morbidity increased by 33.3% and DM increased by 65.6%, mostly in patients over age 65 (from 50% to 57%). Estimated DM prevalence in adults increased from 3.9% to 6.4%. Increased morbidity was followed by an even higher increase in drug utilization (120%). Metformin was first, with a constant increase (from 18% to 39%), followed by glimepiride, while glibenclamide use decreased. Total utilization of insulin increased even more, mostly for aspart (600%) and newly introduced glargine and detemir, while human insulin usage sharply decreased. Spending also increased, mostly for aspart (from 21% to 61% of total). Conclusions. Increased DM is followed by a higher increase in antidiabetic drug utilization; this trend will continue in the future. In Croatian PHC, metformin has primacy along with insulin analogues.