Cécile Knai

Ageing in the European Union

The ageing of European populations presents health, long-term care, and welfare systems with new challenges. Although reports of ageing as a fundamental threat to the welfare state seem exaggerated, societies have to embrace various policy options to improve the robustness of health, long-term care, and welfare systems in Europe and to help people to stay healthy and active in old age. These policy options include prevention and health promotion, better self-care, increased coordination of care, improved management of hospital admissions and discharges, improved systems of long-term care, and new work and pension arrangements. Ageing of the health workforce is another challenge, and policies will need to be pursued that meet the particular needs of older workers (ie, those aged 50 years or older) while recruiting young practitioners.

The burden of disease attributable to nutrition in Europe.

OBJECTIVE This review examines the extent to which differences in nutrition could explain the diversity of health in Europe and how dietary patterns might contribute to the overall burden of disease in the region. SETTING Europe. DESIGN Between-country variations and time trends in dietary and health patterns in Europe are described, taking into account recent evidence on east-west mortality differentials. Existing information on the contribution of dietary factors to the overall burden of disease in Europe and to the burden of cardiovascular diseases and cancer is then reviewed, including a discussion of the methodological challenges that face those seeking to quantify this burden accurately. RESULTS While evidence from ecological data have long suggested that variations in health patterns in Europe may be at least partly attributed to differences in dietary intake, recent research into the major risks to disease, disability and death is confirming the importance of poor nutrition to major health problems and overall disease burden in Europe. Findings from the Global Burden of Disease 2000 study suggest that 4.4% of the overall burden of disease in the region could be attributed to low fruit and vegetable intake, and 7.8% to overweight and obesity. CONCLUSIONS The burden of disease attributed to poor nutrition in Europe appears to be substantial and probably underestimated. However, better quantification of the contribution of nutrition to the regions burden of disease awaits further research to assess the dietary intake of Europeans and to explore the relationship between nutritional factors and health outcomes in diverse parts of Europe.

Is Europe putting theory into practice? A qualitative study of the level of self-management support in chronic care management approaches

BackgroundSelf-management support is a key component of effective chronic care management, yet in practice appears to be the least implemented and most challenging. This study explores whether and how self-management support is integrated into chronic care approaches in 13 European countries. In addition, it investigates the level of and barriers to implementation of support strategies in health care practice.MethodsWe conducted a review among the 13 participating countries, based on a common data template informed by the Chronic Care Model. Key informants presented a sample of representative chronic care approaches and related self-management support strategies. The cross-country review was complemented by a Dutch case study of health professionals’ views on the implementation of self-management support in practice.ResultsSelf-management support for chronically ill patients remains relatively underdeveloped in Europe. Similarities between countries exist mostly in involved providers (nurses) and settings (primary care). Differences prevail in mode and format of support, and materials used. Support activities focus primarily on patients’ medical and behavioral management, and less on emotional management. According to Dutch providers, self-management support is not (yet) an integral part of daily practice; implementation is hampered by barriers related to, among others, funding, IT and medical culture.ConclusionsAlthough collaborative care for chronic conditions is becoming more important in European health systems, adequate self-management support for patients with chronic disease is far from accomplished in most countries. There is a need for better understanding of how we can encourage both patients and health care providers to engage in productive interactions in daily chronic care practice, which can improve health and social outcomes.

Socioeconomic Patterning of Childhood Overweight Status in Europe

There is growing evidence of social disparities in overweight among European children. This paper examines whether there is an association between socioeconomic inequality and prevalence of child overweight in European countries, and if socioeconomic disparities in child overweight are increasing. We analyse cross-country comparisons of household inequality and child overweight prevalence in Europe and review within-country variations over time of childhood overweight by social grouping, drawn from a review of the literature. Data from 22 European countries suggest that greater inequality in household income is positively associated with both self-reported and measured child overweight prevalence. Moreover, seven studies from four countries reported on the influence of socioeconomic factors on the distribution of child overweight over time. Four out of seven reported widening social disparities in childhood overweight, a fifth found statistically significant disparities only in a small sub-group, one found non-statistically significant disparities, and a lack of social gradient was reported in the last study. Where there is evidence of a widening social gradient in child overweight, it is likely that the changes in lifestyles and dietary habits involved in the increase in the prevalence of overweight have had a less favourable impact in low socio-economic status groups than in the rest of the population. More profound structural changes, based on population-wide social and environmental interventions are needed to halt the increasing social gradient in child overweight in current and future generations.

Voluntary agreements between government and business - a scoping review of the literature with specific reference to the Public Health Responsibility Deal.

OBJECTIVES A scoping review was conducted to synthesise the findings of evaluations of voluntary agreements between business and government. It aimed to summarise the types of agreements that exist, how they work in practice, the conditions for their success and how they had been evaluated. METHODS Voluntary agreements were included if they involved a transparent signing-up process and where businesses agreed to carry out specific actions or to achieve specific outcomes. Studies of any design published in English were included. RESULTS 47 studies were identified. Voluntary agreements may help to improve relationships between government and business, and can help both parties agree on target-setting and data-sharing. Governments may also use the experience to help develop subsequent legislation. For voluntary agreements to be successful, targets should be ambitious and clearly defined, with robust independent monitoring. Public knowledge of agreements can help encourage participation and ensure compliance. CONCLUSIONS If properly implemented and monitored, voluntary agreements can be an effective policy approach, though there is little evidence on whether they are more effective than compulsory approaches. Some of the most effective voluntary agreements include substantial disincentives for non-participation and sanctions for non-compliance. Many countries are moving towards these more formal approaches to voluntary agreements.

Are the Public Health Responsibility Deal alcohol pledges likely to improve public health? An evidence synthesis

AIMS The English Public Health Responsibility Deal (RD) is a public-private partnership involving voluntary pledges between industry, government and other actors in various areas including alcohol, and designed to improve public health. This paper reviews systematically the evidence underpinning four RD alcohol pledges. METHODS We conducted a systematic review of reviews of the evidence underpinning interventions proposed in four RD alcohol pledges, namely alcohol labelling, tackling underage alcohol sales, advertising and marketing alcohol, and alcohol unit reduction. In addition, we included relevant studies of interventions where these had not been covered by a recent review. RESULTS We synthesized the evidence from 14 reviews published between 2002 and 2013. Overall, alcohol labelling is likely to be of limited effect on consumption: alcohol unit content labels can help consumers assess the alcohol content of drinks; however, labels promoting drinking guidelines and pregnancy warning labels are unlikely to influence drinking behaviour. Responsible drinking messages are found to be ambiguous, and industry-funded alcohol prevention campaigns can promote drinking instead of dissuading consumption. Removing advertising near schools can contribute to reducing underage drinking; however, community mobilization and law enforcement are most effective. Finally, reducing alcohol consumption is more likely to occur if there are incentives such as making lower-strength alcohol products cheaper. CONCLUSIONS The most effective evidence-based strategies to reduce alcohol-related harm are not reflected consistently in the RD alcohol pledges. The evidence is clear that an alcohol control strategy should support effective interventions to make alcohol less available and more expensive.

Review of current guidelines on adolescent bariatric surgery

A variety of European, North American and, recently, Middle East and Australasian guidelines are now available for clinicians treating obese children and adolescents. This review aims to synthesize recommendations from recent guidance to provide direction to clinicians on the appropriate use of bariatric surgery in adolescents. A literature search for English‐language guidelines endorsed by national governments or professional health associations or societies was conducted, and subject experts were consulted to identify the most recently released guidance. Fifteen sets of guidelines were found, released in the past 6 years, of which nearly all suggested that bariatric surgery is indicated for obese paediatric patients after previous failed attempts at weight loss. Guidance was broadly similar in terms of the categories addressed (patient selection criteria, requirements of the surgical team and institution, and suggested preoperative and postoperative protocols), although relatively little consensus was evident among the criteria specified within these categories. Recommendations differed regarding the appropriate age and degree of obesity at which to intervene. Fewer guidelines addressed preoperative and postoperative care requirements, and of those that did the emphasis varied between familial care and involvement, psychological state and patient motivation, and the importance of long term care. There is a lack of uniformity in the guidance in this area, indicative of the complex nature of obesity management for younger patients. While guidance is necessary to inform and update clinicians, obese paediatric patients require individualized assessment and care.

Clinical guidelines in the European Union: Mapping the regulatory basis, development, quality control, implementation and evaluation across member states

INTRODUCTION Clinical guidelines are advocated to improve the quality of care, especially for chronic diseases. However, the regulatory basis of clinical guidelines, their development, quality control, implementation and use as well as evaluation within countries across the European Union is not systematically known. METHODS Using information collected from key informants in each country by means of a structured questionnaire, this mapping exercise illustrates the varied status of guideline production in European Union countries. RESULTS Most European Union countries have an established national, regional or local clinical guideline programme, and a substantial proportion have developed guidelines on the prevention and management of chronic diseases. Several countries have mechanisms in place to ensure the quality of scientific evidence used for the development of guidelines is high and that the process is consistent and transparent. Others are only now taking an interest in guideline development and are taking the first steps towards establishing ways of implementing them. The majority of countries have no legal basis for the development of guidelines and those that have well established systems mostly implement them on a voluntary basis. The process of guideline development varies in its degrees of decentralisation across countries with many different types of organisations taking on this responsibility. There is general acceptance of the value of the instrument developed by the AGREE collaboration for evaluating the methodological robustness of guidelines. However, the extent to which guidelines are implemented in Europe is unknown, as there is no systematic data collection and, in most countries, no structure to enable it. There are few examples of formal evaluations of the development, quality, implementation and use of guidelines. CONCLUSIONS Our findings call for renewed efforts to respond to the severe lack of standardized guideline terminology and accessibility as well as rigorous studies to evaluate the relationship between different ways to develop guidelines and their methodological quality, between their quality and the actual implementation and usage, and finally between implementation and health outcomes.

Cross-border healthcare in the European Union: clarifying patients’ rights

The adoption of a new directive on cross-border healthcare in Europe could bring clarity for patients, health professionals, and policy makers, as well as raising awareness of how healthcare differs between EU member states, say Helena Legido-Quigley and colleagues

Reported barriers to evaluation in chronic care: Experiences in six European countries.

INTRODUCTION The growing movement of innovative approaches to chronic disease management in Europe has not been matched by a corresponding effort to evaluate them. This paper discusses challenges to evaluation of chronic disease management as reported by experts in six European countries. METHODS We conducted 42 semi-structured interviews with key informants from Austria, Denmark, France, Germany, The Netherlands and Spain involved in decision-making and implementation of chronic disease management approaches. Interviews were complemented by a survey on approaches to chronic disease management in each country. Finally two project teams (France and the Netherlands) conducted in-depth case studies on various aspects of chronic care evaluation. RESULTS We identified three common challenges to evaluation of chronic disease management approaches: (1) a lack of evaluation culture and related shortage of capacity; (2) reluctance of payers or providers to engage in evaluation and (3) practical challenges around data and the heterogeity of IT infrastructure. The ability to evaluate chronic disease management interventions is influenced by contextual and cultural factors. CONCLUSIONS This study contributes to our understanding of some of the most common underlying barriers to chronic care evaluation by highlighting the views and experiences of stakeholders and experts in six European countries. Overcoming the cultural, political and structural barriers to evaluation should be driven by payers and providers, for example by building in incentives such as feedback on performance, aligning financial incentives with programme objectives, collectively participating in designing an appropriate framework for evaluation, and making data use and accessibility consistent with data protection policies.