Laurence Kohn

Trends in cannabis use and its determinants among teenagers in the French-speaking community of Belgium.

BACKGROUND Cannabis consumption among teenagers has undergone dramatic changes in Europe since the beginning of the 1990s. A number of behaviors associated with cannabis consumption, such as tobacco smoking, excessive drinking and truancy are developing too, each in their own way. METHODS To assess the evolution over time of the various types of cannabis consumption (both ever and weekly consumption) in relation to these determinants (age, sex, studies chosen, truancy, tobacco smoking and recurrent intoxication), we have analyzed the cross-sectional study on Health Behaviour in School-Aged Children in the French-speaking Belgian Community (12-17 years) since 1994. We used logistic models to analyze the evolution of the various types of cannabis consumption and to identify the associated factors. Finally, in order to demonstrate time trends, we tested for each type of consumption in the interactions between the significant predictive variables in each model and the survey year (1994-1998-2000). RESULTS Rates of ever use, past 30-day use and weekly use among the ever users have been increasing from 1994 to 2002 and reached, respectively, 22.0%, 11.6%, 6.8% and 32.9%. Cannabis ever use rose more noticeably among the general education students (adjusted OR (95%CI)): 3.08 (2.66-3.57) and among the truants: 4.57 (3.39-6.14). Weekly cannabis smoking rose most especially among the truants: 1.92 (1.34-2.78). CONCLUSION Truants should constitute a priority target for the prevention of cannabis consumption, while the phenomenon of truancy must be moreover examined in depth in order to more thoroughly identify the appropriate prevention programs organized both in and outside of the school environment.

Acceptability and Perceived Benefits and Risks of Public and Patient Involvement in Health Care Policy: A Delphi Survey in Belgian Stakeholders

BACKGROUND In systems with public health insurance, coverage decisions should reflect social values. Deliberation among stakeholders could achieve this goal, but rarely involves patients and citizens directly. OBJECTIVES This study aimed at evaluating the acceptability, and the perceived benefits and risks, of public and patient involvement (PPI) in coverage decision making to Belgian stakeholders. METHODS A two-round Delphi survey was conducted among all stakeholder groups. The survey was constructed on the basis of interviews with 10 key stakeholders and a review of the literature on participation models. Consensus was defined as 65% or more of the respondents agreeing with a statement and less than 15% disagreeing. Eighty stakeholders participated in both rounds. They were defined as the Delphi panel. RESULTS Belgian stakeholders are open toward PPI in coverage decision processes. Benefits are expected to exceed risks. The preferred model for involvement is to consult citizens or patients, within the existing decision-making structures and at specific milestones in the process. Consulting citizens and patients is a higher level of involvement than merely informing them and a lower level than letting them participate actively. Consultation involves asking nonbinding advice on (parts of) the decision problem. According to the Delphi panel, the benefits of PPI could be increasing awareness among members of the general public and patients about the challenges and costs of health care, and enriched decision processes with expertise by experience from patients. Potential risks include subjectivity, insufficient resources to participate and weigh on the process, difficulties in finding effective ways to express a collective opinion, the risk of manipulation, and lobbying or power games of other stakeholders. CONCLUSIONS PPI in coverage decision-making processes is acceptable to Belgian stakeholders, be it in different ways for different types of decisions. Benefits are expected to outweigh risks.

The Belgian geriatric day hospitals as part of a care program for the geriatric patient: first results of the implementation at the national level.

Abstract Purpose: In order to deliver individual, specialized and multidisciplinary care for older people, the Belgian national health authorities developed the care program for the geriatric patient. In that context, 48 geriatric day hospitals (GDHs) have been financed by the government since January 1st 2006. The main objective of this study is to describe the patient characteristics, facility features and activities related to the Belgian GDHs. Methods: A prospective, multicenter study was performed from October 1st till December 31st 2006 in all 48 GDHs. For each GDH a transversal data collection was carried out. In the same period all patients scheduled for the GDHs were registered and followed for 3 months. Therefore two questionnaires were developed using Filemaker® software: one for each GDH and one for each patient . There were no exclusion criteria. Results: Six GDHs did not complete one or both questionnaires. Consequently, the results of 42 GDHs were included. GDHs with more years of activity had significantly more new patient contacts per day. Activities in the Belgian GDHs were mainly diagnostic with emphasis on geriatric syndromes and specific medical problems. The reason for admission to the GDH was often multifactorial. The syndromes that motivated patients 75 or older to visit the GDH were clearly geriatric (mainly cognitive disorders) and represent the principle public health problems in this age category. Despite the legal provision preserving GDHs for patients 75 years or older a quarter of all patients was younger than 75, presenting with a geriatric syndrome. The contribution of the general practitioners was limited. Conclusions: Activities in the Belgian GDHs are mainly diagnostic with emphasis on geriatric syndromes (particularly cognitive disorders) and specific medical problems. More information is needed on the knowledge and expectations of general practitioners in order to establish a closer collaboration.

What Does the Public Want? Structural Consideration of Citizen Preferences in Health Care Coverage Decisions

Background. Multi-criteria decision analysis can improve the legitimacy of health care reimbursement decisions by taking societal preferences into account when weighting decision criteria. This study measures the relative importance of health care coverage criteria according to the Belgian general public and policy makers. Criteria are structured into three domains: therapeutic need, societal need, and new treatments’ added value. Methods. A sample of 4,288 citizens and 161 policy makers performed a discrete choice experiment. Data were analyzed using multinomial logistic regression analysis. Level-independent criteria weights were determined using the log-likelihood method. Results. Both the general public and policy makers gave the highest weight to quality of life in the appraisal of therapeutic need (0.43 and 0.53, respectively). The general public judged life expectancy (0.14) as less important than inconvenience of current treatment (0.43), unlike decision makers (0.32 and 0.15). The general public gave more weight to “impact of a disease on public expenditures” (0.65) than to “prevalence of the disease” (0.56) when appraising societal need, whereas decision makers’ weights were 0.44 and 0.56, respectively. When appraising added value, the general public gave similar weights to “impact on quality of life” and “impact on prevalence” (0.37 and 0.36), whereas decision makers judged “impact on quality of life” (0.39) more important than “impact on prevalence” (0.29). Both gave the lowest weight to impact on life expectancy (0.14 and 0.21). Limitations. Comparisons between the general public and policy makers should be treated with caution because the policy makers’ sample size was small. Conclusion. Societal preferences can be measured and used as decision criteria weights in multi-criteria decision analysis. This cannot replace deliberation but can improve the transparency of health care coverage decision processes.

A multi-criteria decision approach for ranking unmet needs in healthcare

Early temporary reimbursement (ETR) schemes for new interventions targeting high unmet needs are increasingly applied in pharmaceutical policy. Crucial for these schemes is the assessment of unmet healthcare needs of patients and society. This study develops and tests a multi-criteria decision approach (MCDA) for assessing therapeutic and societal needs. The Belgian unmet needs commission, responsible for creating a list of unmet needs for the ETR programme, has tested this methodology to assess the needs in eight health conditions. For therapeutic need, three criteria were included (impact of the condition on quality of life and on life expectancy and inconvenience of current treatment); for societal need two criteria (condition-related healthcare expenditures per patient, prevalence). The results show that the proposed MCDA is feasible and acceptable for the unmet needs commission. Clear definitions of the criteria and regular repetition of these is needed to avoid variable interpretation of the criteria by the commission members. Quality assessment of the evidence is desired. Rankings resulting from the application have face validity. Considering therapeutic need separately from societal need is considered appropriate. Policy makers should consider the use of MCDA in assessing healthcare needs. MCDA improves the transparency and accountability of the decision making processes and is practical and feasible.

Reflections on Outsourcing and Applying for Funding

In agencies aiming at formulating recommendations to policymakers, such as the Belgian Health Care Knowledge Centre (KCE), data collection – especially in qualitative methods – is often outsourced to academic teams or private companies, consultants, commercial agencies or research consultancies. This chapter focuses on comparing the approach to using focus groups taken by academic and non-academic research teams. More specifically it assesses: (i) the kind of expertise they bring to bear in responding to tenders; (ii) their skills with regard to working in several languages (important in a multi-lingual country such as Belgium); (iii) the proposed cost; (iv) their scientific approach; (v) their capacity to recruit participants; and (vi) their analysis and reporting skills. They were found to differ with regard to their specific strengths. Such collaboration takes time and requires a pragmatic focus (i.e. developing policy recommendations) rather than a theoretical focus. Thus, academic teams should not seek funding to pursue their own fundamental research, while non-academic teams would be well-advised to include a topic expert in their team.