Four sexually transmitted infections (STIs) in Belgian general practice: first results (2013-2014) of a nationwide continuing surveillance study

OBJECTIVES

To describe and explore data from the surveillance of chlamydia, syphilis, gonorrhoea and genital warts by the Belgian Network of Sentinel General Practices (SGP) over the first 2 years (2013 and 2014) and to estimate the incidence of these 4 sexually transmitted infections (STIs). A special focus is put on data quality.

DESIGN

Retrospective observational study.

SETTING

General practices from the nationwide representative SGP network.

OUTCOME MEASURES

Agreement between data distributions by year, agreement between SGP-based incidence and incidence based on mandatory notification, missingness of patient age or gender and incompleteness of sexual risk history of patients.

RESULTS

306 new STI episodes were reported from 298 patients, corresponding with an episode-based incidence of 91.9/100 000 (95% CI 81.9 to 102.8) general practice patients, with almost half of it due to chlamydia. The incidence of chlamydia in men was significantly higher in 2014 than in 2013. Population characteristics were similarly distributed in 2013 and 2014. The SGP-based incidence of gonorrhoea and syphilis in Flanders were in agreement with the incidence based on mandatory notification of cases. Patient age or gender was missing from 35 episodes (11.4%). Independent determinants of missingness of patient age or gender were the Flemish region (OR 3.46; 95% CI 1.02 to 11.73) and genital warts infection (OR 2.23; 95% CI 1.07 to 4.63). An incomplete sexual risk history was reported for 54.6% STI episodes. The odds for an incomplete sexual history were higher for older patients (OR 1.72; 95% CI 1.06 to 2.76) and for patients infected with syphilis, gonorrhoea or co-infection(s) (OR 1.71; 95% CI 1.03 to 2.83).

CONCLUSIONS

Incompleteness of reports about patients with STI sexual risk histories is important from the perspective of quality of data and of quality of care. Together with the low rates of both HIV testing and discussion of partner notification, this suggests that a general practice guideline is needed.

Public Health Triangulation to inform decision-making in Belgium

We assessed the impact of a nation-wide ambulatory care complex intervention (the "care trajectory program") on quality of care in Belgium. We used the three-step public health triangulation method described in this paper and data from four different data sources: a national reimbursement database, an electronic patient record-based general practitioner network, the Belgian general practitioner sentinel network, and a new national registry for care trajectory patients. By applying our method and using the available evidence, we identified key findings that have been accepted by experts and stakeholders. We also produced timely recommendations for the decision-making process, four years after the start of the care trajectory program.

EPR-based, quality-related process parameters: a nationwide assessment

The aim of the study was to determine whether or not primary care EPR-based data can be used to measure specific process parameters that can then, in turn, be used to assess the quality of care provided to chronic patients. We analysed data from a large research network that collects data from all Belgian GP practices through both manual and automatic extraction procedures. We built a number of quality-related process parameters and observed the concordance of our results with two external databases: a nationwide reimbursement database and a regional EPR-based network. We found that only the automatic data extraction method was suitable for building process parameters. The current research network may lead to an underestimation of the quality of care processes. We suggested ways to improve this network.

The incidence and first-year mortality of heart failure in Belgium: a 2-year nationwide prospective registration

AIMS

The aim of this study is to determine the incidence and mortality of heart failure (HF) in Belgium.

METHODS

Data were prospectively collected during a 2-year period by a nationwide network of sentinel practices. All adult patients for whom, for the first time the diagnosis of HF was clinically suspected were registered. Patients were finally included if the diagnosis of HF was confirmed after 1 month.

RESULTS

The yearly incidence of confirmed HF in the Belgian adult population was estimated to be 194 patients per 100,000 inhabitants (95% CI: 172-218). At diagnosis, the median age of the patients with confirmed HF was 79 years: 82 years for women and 76 years for men (p < 0.0001). For the population aged 55 years or more, the yearly incidence of HF was 502 (95% CI: 444-565) with no significant difference between men and women. At diagnosis, most of the patients were classified as NYHA III (50%), 27% as NYHA IV and 20% as NYHA II. Six months after the initial diagnosis, the mortality was 19% and after 12 months it was 26%.

CONCLUSION

In Belgium, yearly 15,643 new patients of HF are diagnosed (95% CI: 13,861-17,590). HF is fatal for more than one quarter of the patients in the first year after the diagnosis.

Organization of a quality-assurance project in all Belgian multidisciplinary diabetes centres treating insulin-treated diabetes patients: 5 years' experience

AIMS

To describe the IQED, a quality-assurance system started in 2001 in Belgian hospital-based multidisciplinary diabetes centres, and its effects on the quality of care.

METHODS

The study was conducted through four data collections (in 2001, 2002, 2004 and 2006). Approximately 120 diabetes centres provided data on a systematic random sample of 10% of their adult diabetic patients on at least two daily insulin injections. Data on patient characteristics, glycaemic control, cardiovascular risk, diabetes complications, follow-up procedures and treatment were obtained. Local quality promotion was encouraged by returning comprehensive feedback (benchmarks) and during information meetings.

RESULTS

Nearly all diabetes centres (98-100%) participated. The pooled sample consisted of 9194 (32%) Type 1 and 19 828 (68%) Type 2 diabetes patients, with mean diabetes duration of 17 years and 14 years, prevalence of microvascular complications of 23% and 38% and prevalence of macrovascular complications of 9% and 26%, respectively. At the start, the quality of care was good in terms of risk-factor testing rates and moderate in terms of patients meeting goals for risk-factor management. At least 50% of the centres initiated quality-promoting initiatives. After 5 years, significant improvements were seen in risk-factor testing rates, apart from renal screening. Improvements in intermediate outcomes were less obvious, apart from an increase in patients reaching the targets for blood pressure and LDL cholesterol.

CONCLUSIONS

It is feasible to implement a continuous quality-improvement project on a nationwide scale, with improvements particularly in process indicators.

The use of a compliant EHR when providing clinical pathway driven care to a subset of diabetic patients: recommendation from a Working Group

The Belgian National Health Insurance Institute (NHII) and other Healthcare Authorities intend to improve the quality of care through promoting clinical pathway driven care and by optimising cooperation between the responsible primary care physician and the diabetologist. Patients and healthcare professionals are granted some (financial) benefits when meeting the conditions defined in a mutual agreement.This article describes the conditions and the functional requirements to be met by an EHR to enable and to maximise the benefits of a clinical pathway driven patient care to a specific group of diabetic type 2 patients, based on a mandate issued by the NHII.The generic and specific functional requirements are then translated in test criteria for certification and prioritised in an implementation plan.

The incidence of home accidents is going down in Belgium

The objective of the present study was to estimate the incidence of home accidents in Belgium in 2002 and to compare them with the results of 1996. The Belgian network of general practitioners (GPs) is a national network of GPs who collect and report data on selected conditions, including home accidents. The data about home accidents were recorded by 181 GPs in 1996 and by 150 GPs in 2002. The standardized incidence of home accidents decreased from 2935 per 100,000 inhabitants in 1996 (95% CI 2846 - 3026) to 2669 in 2002 (95% CI 2588 - 2751). This corresponds to a decrease of 9% (p < 0.001). A decrease of 14% was observed in the Flemish Community (p < 0.001). The reduction was very important (36%) among women aged between 75 and 89 years (p < 0.001). In the French community the decrease was not significant. The incidence of home accidents observed in general practice decreased in Belgium, especially in the Flemish Community.

Lower stroke death rates in patients receiving blood pressure lowering therapy before the onset of a stroke

The objective of this study was to compare stroke death rates among patients with and without blood pressure lowering treatment before the onset of the stroke. During two consecutive years all patients with acute stroke were recorded by 178 Belgian general practitioners of the sentinel network. In total 511 patients with acute stroke were recorded. The death rate after one month was found significantly higher among the untreated patients (33%; n = 84) compared to those receiving blood pressure lowering treatment (23%; n = 61) (p = 0.007). Blood pressure lowering treatment before the onset of stroke had a beneficial effect on survival in a backward stepwise logistic regression (OR 0.38; 95% CI 0.20-0.72). In conclusion, stroke mortality is significantly lower among patients receiving blood pressure lowering treatment before the onset of stroke compared to those without blood pressure lowering treatment.

Collecting information on the quality of prescribing in primary care using semi-automatic data extraction from GPs’ electronic medical records

OBJECTIVES

To evaluate a semi-automatic data extraction from the electronic medical record (EMR) of general practitioners (GPs) through a comparison with a paper sheets data collection simultaneously used in a primary care research project on the quality of prescribing for osteoarthritis in the elderly.

SUBJECTS

One hundred and fifty-two GPs using five different EMR-software systems participated with the semi-automatic data extraction from the EMR and 233 GPs collected data with paper registration sheets.

METHODS

The proportion of patients with respectively a drug prescription, paracetamol, a non-steroidal anti-inflammatory drug (NSAID) and ibuprofen were compared between the semi-automatic extraction and the paper data collection and among the EMR-software systems.

RESULTS

Using the semi-automatic data extraction, a significantly lower proportion of patients on drugs was obtained compared to the paper data collection (adjusted OR: 0.31; 95% CI 0.25-0.39). However, the proportion of patients on a specific type of drug was comparable. Within the results from the semi-automatic extraction, the results were heterogeneous among the different EMR-software systems.

CONCLUSIONS

The semi-automatic data extraction with multiple EMR-software systems proposed in this study seems suitable for quality of prescribing assessment in primary care. However, it may be less reliable when only a single EMR-software is used.

The prevalence of known diabetes in eight European countries

BACKGROUND

The prevalence of diabetes has been proposed as a European Community Health Indicator. The prevalence of diabetes known to general practitioners (GPs) in different European countries has been investigated and the usefulness of sentinel practice networks in delivering prevalence data on diabetes has been evaluated.

METHODS

Patients presenting with diabetes in a 12 month period (1999/2000) to GPs in established European sentinel practice surveillance networks in eight European countries were registered. Estimates of prevalence were standardized to the 1998 European population.

RESULTS

All-age prevalence reported in the network populations was lowest in Slovenia (male 16, female 16 per 1000) and highest in Belgium (male 31, female 34). The range of estimates obtained in this study was narrower than that published by the WHO in the Health For All database. The range was further reduced by age standardization. In males aged 45 years and over, age standardized prevalence ranged from 39 (Slovenia) to 76 (Belgium) and in females from 37 (Slovenia) to 75 (Belgium). There were no consistent gender differences in national prevalence rates.

CONCLUSIONS

The study demonstrates the capacity of sentinel practice networks to deliver data on the prevalence of known diabetes in persons over 45 years. National differences in prevalence are less than hitherto reported. Prevalence in Belgium measured in all ages and in 45 years and over males and females was higher than in the seven other countries.

The difficult quest for data on "vanishing" vaccine-preventable infections in Europe: the case of measles in Flanders (Belgium)

We aimed to describe the impact of vaccination on the epidemiology of measles infection in Flanders (Belgium), to document probable vaccination coverage based on this evidence, compare these epidemiological data with those generated by a mathematical model and estimate the costs of morbidity from measles. In contrast to previous analyses, we included the costs of long-term care for sequelae due to encephalitis and subacute sclerosing panencephalitis (SSPE). We estimated the direct health care costs per average measles case at 227, 212, 210, 200 and 194 for the age groups of 0-4, 5-9, 10-14, 15-19 and > or=20 years, respectively. Excluding long-term care lowers these estimates by 22-51%, depending on the age group. By including indirect time costs, we arrive at total costs per measles case of 320, 305, 210, 200 and 625, respectively. In addition to registering vaccination coverage more rigorously in the future, it seems necessary to undertake seroprevalence studies to document the age-specific immunity to measles. By using such information, current vaccination strategies can be adapted to prevent future outbreaks and to help eliminate measles from Europe in an efficient way. We noted throughout that many of the data sources are flawed. Better and accessible data bases are required to improve the reliability of similar studies in the future.

Diagnosis and treatment of type 2 diabetes in three Belgian regions. Registration via a network of sentinel general practices

BACKGROUND

The objective of this descriptive study is to investigate the incidence of type 2 diabetes in sentinel general practices in three regions in Belgium and to describe the patient characteristics and the start of the medical management after diagnosis.

METHODS

For two successive years all patients who were newly diagnosed with type 2 diabetes were registered. Two weeks after inclusion, the registering physician completed an extensive questionnaire. This questionnaire dealt with risk factors, biochemical parameters, existing complications and treatment.

RESULTS

According to this study, the yearly incidence of type 2 diabetes in Belgium is 231 per 100,000 inhabitants. Though the biochemical parameters (BMI, HbA1c, serum cholesterol and triglycerides) do not differ in the three regions of the country being investigated, there are considerable differences in the treatment prescribed for diabetes and its co-morbidity. In Flanders, treatment is usually started with sulphonylurea, in the Walloon provinces with biguanides. Hypolipaemic treatment is also started more frequently in the latter region. In Flanders, hypertension is registered in 51.4% of the newly diagnosed patients with diabetes, which is higher than in the other regions. However, no difference is noted between the different regions in the number of patients with diabetes who are treated for hypertension.

CONCLUSION

A network of sentinel physicians, taking part in voluntary registration, can be helpful in calculating the incidence of a health problem, in particular type 2 diabetes in general practice. The sentinel net can also serve as an instrument for describing patient characteristics and showing how physicians deal with health problems. The regional differences in medical approach that are described require further investigation, mainly with respect to their impact on the patients' outcome.

Placements in psychiatric institutions, nursing homes, and homes for the elderly by Belgian general practitioners

This research is an epidemiological study of long-term care facility admissions to various types of institutions (homes for the elderly, nursing homes, psychiatric institutions) during 1994 in Belgium. Data were obtained from a network of 143 general practitioners, which acts as a reliable surveillance system for health-related data. For every patient who was institutionalized, physicians were asked to record the following information: (1) type of institution in which the patient was placed; (2) medical conditions; (3) current living situation; (4) reason for institutionalization; (5) length of the waiting time for institutionalization, and (6) whether or not the patient was hospitalized prior to the institutionalization. The overall incidence for institutionalization among older patients was 1%. The most common medical conditions upon placement were functional impairments and dementia. Over half the patients lived alone just prior to the placement and family members made the majority of requests for placements. Compared to placements in other types of institutions, those to psychiatric facilities were more likely to be 'urgent' and waiting times for admission to these institutions were shorter. Over half of all placements were preceded by an admission to a medical hospital. Few placements (16%) were made with the consultation of home care services. Finally, in about two thirds of the cases, patients were cared for by their general practitioner while they were institutionalized.

Assessment of a three-year experience with a Belgian Primary Care data Network

The paper describes the experiences with a Belgian Primary Care data Network from 1999 till 2002. Three cycles of data collection have been performed. The network involves about 300 general practitioners (GPs) and up to 8 different software packages. This network is semi-anonymous, semi-automatic and mixed (paper and electronic with various software's). For the coming next years, efforts should be focused on solving some frequently occurring problems with the data collection through the EPR, such as a considerable number of data lacking and the fact that GPs do not always use the problem oriented structure of the EPR (Electronic Patient Record). Afterwards, more promising usage could be considered and developed such as repeated data collection using a same GPs' sample, long-term recording studies, usage of larger GPs' samples, etc.

Revealing regional differences in the institutionalization of adult patients in homes for the elderly and nursing homes: results of the Belgian network of sentinel GPs

OBJECTIVES

The aim of this study was, firstly, to determine the number of institutionalizations in homes for the elderly and nursing homes and, secondly, to learn about regional differences in the placement procedure and the pre-existing problems and diseases.

METHODS

Data were recorded during 1994 by the 143 GPs of the network of sentinel practices, which is representative of Belgian GPs. All placements of adult patients in homes for the elderly and nursing homes were registered.

RESULTS

During 1994, Belgian sentinel GPs placed 297 patients in a nursing home or a home for the elderly. Most of them were women and patients who lived alone. At the time of institutionalization, motor function impairment and dementia were the most common diseases. The institutionalizations were motivated mostly by a need for assistance with daily living activities and nursing assistance. An interim hospitalization was necessary in 60% of all institutionalizations. Two-thirds of all patients were on a waiting list. The average length of these waiting lists was shorter in the southern (Walloon) region than in the northern (Flemish) region. Home care services were consulted in 16% of all institutionalizations. In the southern region, home care services were consulted more often than in the northern region.

CONCLUSIONS

Motor function impairment and dementia were the most common pre-existing impairments. Placements were often hampered by long waiting lists and interim hospitalization. In the southern region, waiting lists were shorter and home care services consulted more often. Some placements could be avoided or delayed by a better organization and promotion of the possibilities of professional home care services.

Changing patterns in acute clinical viral hepatitis encountered by Belgian general practitioners

The sentinel network of general practitioners in Belgium was set up in 1979 and monitors a wide range of infectious and non-infectious diseases. Such surveillance systems have been tested and found to be effective and are currently applied in several coun

Use of blood tests in general practice: a collaborative study in eight European countries. Eurosentinel Study Group

BACKGROUND

Laboratory tests are routine examinations in general practice and are associated with increasing costs in industrialized countries.

AIM

The objective of this collaborative study was to determine the differences in general practitioners' use of blood tests in different European countries and to evaluate the relationship between these differences and organizational aspects of the health care system and also characteristics of the participating general practices.

METHOD

A descriptive study was conducted by eight European sentinel networks. Voluntary participating general practitioners registered all blood tests requested for four weeks, specifying the type of test, and age group and sex of patients. Details of all face-to-face encounters with patients by age group and sex were collected for the same period. Information on the participating practices and general practitioners was collected by questionnaire.

RESULTS

The request rate for blood tests varied considerably between countries. The characteristics of general practitioners and practice were only slightly or were not associated with the use of blood tests while dummy 'country' variables were strongly associated. The number of general practitioners per 1000 inhabitants was the most positively associated variable partly explaining the intercountry variation.

CONCLUSION

This European study suggests that some national characteristics of the health system could determine the use of blood tests in general practice and underlines the need for further investigation in order to develop successful strategies for promoting the optimal use of diagnostic technology.

Suicide and attempted suicide reported by general practitioners in Belgium, 1990-1991

In 1990-1991 the Belgian sentinel network of general practitioners recorded suicide and suicide attempts within their practices. The annual attempted suicide rate is estimated at 13.0 cases per 10,000 inhabitants. The highest incidence rates are found among women and young people. The annual suicide rate is estimated at 2.3 cases per 10,000 inhabitants, with the highest rates in men and in elderly people. The highest incidence rates of suicide attempts as well as of suicide are found among divorced people. About 30% of the attempters and committers made at least one earlier attempt. Drug overdose and hanging are the most frequently used methods, respectively when attempting and committing suicide. About 60% of both committers and attempters contacted their general practitioner within a period of 1 month preceding the attempt. Nearly half of the attempters and of the committers were treated for a mental disorder in the year preceding the attempt.

Pharmacoeconomics of immunisation: a review

The effects of immunisation programmes that have existed for several decades in developed countries are demonstrated by the decrease and even eradication of smallpox, poliomyelitis, measles, mumps and hepatitis B. Cost, health policy and spontaneous evolution in the incidence of communicable diseases have a decisive influence on the use of a vaccine. Investment in vaccination policy has to be encouraged to maintain this progress made in the control of infectious diseases and to meet new challenges. Studies re-evaluating ongoing immunisation programmes are scarce. Nevertheless, it can be concluded that for vaccination against hepatitis B in professionally exposed at-risk populations, arguments for positive returns are consistent. The same holds for vaccination against S. pneumoniae and for influenza virus in the elderly. The results of the economic evaluation of revaccination against measles, when insufficient coverage exists, are inconclusive. Universal vaccination of children against Haemophilus influenzae type b (Hib) and of children of hepatitis B-positive mothers against hepatitis may require costs to be paid in order to gain extra health benefits.

Demand patterns for HIV-tests in general practice: information collected by sentinel networks in 5 European countries

This study describes a 1 year international data collection on the demand pattern for HIV-antibody tests in general practice recorded by 6 sentinel networks in 5 European countries. The purpose of the recording was to evaluate the use of HIV-antibody testing by general practitioners and the demand for testing among the general population. Sentinel networks of general practitioners are a possible and available instrument for monitoring the perception of the HIV-test, and indirectly of the threat of the HIV-epidemic by the public and by the general practitioners (GPs). Differences were found between the countries in the frequency of testing, the person asking the test and the reason for testing. Possible explanatory factors, such as differences in the routine testing of specific groups, differences in the training and in the role of the GP, differences in the characteristics of prevention policy, are discussed. The European comparison also offers the opportunity to reflect on common medical practice in dealing with demands for HIV-tests.

Five years of sentinel surveillance of acute respiratory infections (1985-1990): the benefits of an influenza early warning system

For the last five years, the Brussels Institute of Hygiene and Epidemiology has been involved in the surveillance of acute respiratory infections (ARI). The four indicators used (number of encounters of ARI by GP's/100 encounters, virus isolations, absenteeism and mortality) are discussed. A regression procedure is applied to the data collected by a sentinel network of general practitioners (GP's). This procedure permits the baseline to be visualized and an epidemic threshold to be determined in order to recognize early an influenza outbreak. The traditional use of flu-like illnesses as an indicator might be improved by the addition of non-specific ARI which are more precocious, especially in children. The criteria for an accurate definition of an influenza epidemic are discussed. The same mathematical model can be used for the analysis of mortality linked with an outbreak. It shows that the last epidemic in the winter 1989-1990 was responsible for about 4900 deaths directly or indirectly related to influenza.

[Epidemiological aspects of Campylobacter infections in Belgium]

In the context of a surveillance programme for infectious diseases in Belgium, a network of microbiological laboratories, since February 1983, weekly registers the isolation of a number of pathogenic agents, among which Campylobacter. Some epidemiological characteristics of Campylobacter in Belgium are discussed. Between 54 and 58% of the isolations are reported from males. About 50% of the cases are observed in children under 5 years of age. The mean weekly number of isolations per laboratory is rising in May and remains high until October-November.

Tool for validation of the network of sentinel general practitioners in the Belgian health care system

Morbidity registration by a network of sentinel general practitioners (SGPs) in Belgium raises a number of problems related to possible biases in the network procedure, such as unequal geographical distribution, non-participation of a segment of the target population of practitioners and difficulties in the estimation of the denominator population at risk for the health problems under study. Through the application of two hierarchical clustering procedures, the initial number of 43 districts in the country has been reduced to 15 homogeneous district clusters. These represent the new geographical framework from which the geographical spread of the network is checked. This network is subsequently corrected for such socio-demographic parameters as age, sex and occupation in order to match more closely the total population of Belgian general practitioners (GPs). The population covered by the network is estimated on the basis of the annual number of patient contacts. Application of the described procedures should result in a network allowing valid estimations for a number of health issues as seen by Belgian GPs.

The national prevalence survey of nosocomial infections in Belgium, 1984

A national one-day prevalence survey of nosocomial infections was carried out in March 1984 in 106 Belgian acute-care hospitals involving 8723 patients of whom 6130 had undergone surgery. Three infections were studied: surgical wound infection, bacteraemia and urinary-tract infection. One or more of these three infections was recorded in 9.3% of all patients and in 11.8% of surgical patients. Prevalences increased with increasing duration of hospital stay and with higher ages, but the association of HAI with age was no longer significant after correction for duration of hospital stay. Prevalences varied considerably in different specialties. After adjustment for age and duration of stay, there was no association between perioperative antibiotic prophylaxis and the prevalence of the infections studied, but bias due to selection of higher risk patients in the antibiotic group was probable. Larger hospitals had a higher overall prevalence, but populations differed according to the size of the hospital. Bacteraemia was strongly associated with the presence of an intravenous catheter, and urinary-tract infection with a urinary catheter.

Epidemiological surveillance of measles through a network of sentinel general practitioners in Belgium

Measles morbidity data were collected during 1982-1983 through a network of sentinel general practitioners. The annual incidence rate of the disease in the country was 80.3 per 1000 population with most of the cases seen between 2 and 6 years of age. Complications were encountered in 13.8% of all cases. Emphasis is put on developing a strategy for immunization against measles on a nationwide scale.