Marc Vanmeerbeek

Advantages, disadvantages and feasibility of Pay-for-Quality programs in Belgium

Quality of care, as currently measured, shows unintended and avoidable variability in health care, and the existence of under use, overuse and misuse of health care, as compared to best practice. One possible part of the solution is to introduce Pay- for-Quality (P4Q) by aligning the payment system with quality of care. However, there is a lack of comprehensive conceptual guidance on P4Q use in health care. Reviews of empirical results on P4Q effects concluded that effects are mixed and highly context dependent. The level of acceptance and support by stakeholders in Belgium was unknown. Finally, practical feasibility of P4Q implementation in Belgium was unclear. This study explored the advantages, disadvantages and feasibility of P4Q implementation in Belgium. A consortium of four universities gathered data from literature, international experts and Belgian stakeholders to assess (1) what can be learned from international P4Q models on design, implementation and evaluation; and (2) what conditions are needed to apply international P4Q models in Belgium; i.e., start from scratch, or enlarge the Belgian quality-improvement programs. The focus of this study was restricted to medical care in primary and acute hospital settings.

What factors determine Belgian general practitioners' approaches to detecting and managing substance abuse? A qualitative study based on the I-Change Model.

BackgroundGeneral practitioners (GPs) are considered to play a major role in detecting and managing substance abuse. However, little is known about how or why they decide to manage it. This study investigated the factors that influence GP behaviours with regard to the abuse of alcohol, illegal drugs, hypnotics, and tranquilisers among working Belgians.MethodsTwenty Belgian GPs were interviewed. De Vries’ Integrated Change Model was used to guide the interviews and qualitative data analyses.ResultsGPs perceived higher levels of substance abuse in urban locations and among lower socioeconomic groups. Guidelines, if they existed, were primarily used in Flanders. Specific training was unevenly applied but considered useful. GPs who accepted abuse management cited strong interpersonal skills and available multidisciplinary networks as facilitators.GPs relied on their clinical common sense to detect abuse or initiate management. Specific patients’ situations and their social, psychological, or professional dysfunctions were cited as cues to action.GPs were strongly influenced by their personal representations of abuse, which included the balance between their professional responsibilities toward their patients and the patients’ responsibilities in managing their own health as well the GPs’ abilities to cope with unsatisfying patient outcomes without reaching professional exhaustion. GPs perceived substance abuse along a continuum ranging from a chronic disease (whose management was part of their responsibility) to a moral failing of untrustworthy people. Alcohol and cannabis were more socially acceptable than other drugs. Personal experiences of emotional burdens (including those regarding substance abuse) increased feelings of empathy or rejection toward patients.Multidisciplinary practices and professional experiences were cited as important factors with regard to engaging GPs in substance abuse management. Time constraints and personal investments were cited as important barriers.Satisfaction with treatment was rare.ConclusionsMotivational factors, including subjective beliefs not supported by the literature, were central in deciding whether to manage cases of substance abuse. A lack of theoretical knowledge and training were secondary to personal attitudes and motivation. Personal development, emotional health, self-awareness, and self-care should be taught to and fostered among GPs to help them maintain a patient-centred focus. Health authorities should support collaborative care.

Enfants négligés : ils naissent, ils vivent, mais surtout ils survivent

Child neglect leads to numerous and serious consequences. The physical and neurophysiological development can be altered by the lack of stimulation or via a chronic stress which increases the production of cortisol. Gradually, psychomotor and cognitive deficits can appear. The emotions can be deeply touched and cause dysfunctional social relationship, ranging from withdrawal to aggressiveness. Primary care health practitioners have a role to play in the screening of risk situations and long term follow-up of the families. The interventions should ideally begin early, be participatory and based on an enhancement of the parent-child relationship.

Enfants à haut potentiel: attitude du médecin traitant

Points essentiels Les enfants a haut potentiel intellectuel representent environ 2 % de la population, mais ne sont pas toujours identifies. Ils peuvent souffrir de dyssynchronie interne et sociale , et leurs relations scolaires et familiales peuvent etre perturbees. Les medecins sont consultes principalement pour des troubles de l’humeur ou du comportement, des somatisations. Si des troubles du comportement ou de l’humeur semblent pouvoir etre rapportes a une inadaptation scolaire , il importe de faire pratiquer un bilan psychologique et psychometrique rapidement. Le diagnostic differentiel avec le trouble de deficit de l’attention avec hyperactivite est essentiel en raison de ses implications therapeutiques. Une partie substantielle de la prise en charge du phenomene releve des pedagogues et du milieu scolaire en general. Le medecin est un acteur privilegie dans le soutien de l’enfan t et de sa famille, dans le traitement des troubles associes: depression, anxiete, troubles du sommeil, somatisations. Le traitement medicamenteux n’a qu’une place tres limitee .

A review of guidelines for collaboration in substance misuse management

BACKGROUND Substance misuse among the working population results in increasing economic costs. General practitioners (GPs) and occupational physicians (OPs) can play a central role in detecting and managing substance misuse in the working population. Their collaboration could be critical in coordinating care, in facilitating rehabilitation and in reducing sickness absence. AIMS To search guidelines for evidence on collaboration between GPs and OPs in substance misuse detection and management in the working population. METHODS International guidelines regarding collaborative care for alcohol, illicit drug, hypnotic and tranquillizer misuse were identified by a systematic search in the Guidelines International Network and US National Guidelines Clearinghouse databases. RESULTS In total, 20 guidelines were considered of sufficient methodological quality, based on the criteria of the Appraisal of Guidelines for Research and Education II instrument. Only two guidelines reported on the OPs role in screening and intervention for alcohol misuse. CONCLUSIONS There is a lack of guidance on the OPs role and on collaboration between GPs and OPs in this field. Further study is required on their respective roles in substance misuse management, the effectiveness of workplace interventions and the benefits of collaboration.

Searching for consensus among physicians involved in the management of sick-listed workers in the Belgian health care sector: a qualitative study among practitioners and stakeholders.

BackgroundIn Belgium, the management of sick leave involves general practitioners (GPs), occupational health physicians (OPs) and social insurance physicians (SIPs). A dysfunctional relationship among these physicians can impede a patient’s ability to return to work. The objective of this study was to identify ways to improve these physicians’ mutual collaboration.MethodsTwo consensus techniques were successively performed among the three professional groups. Eight nominal groups (NGs) gathered 74 field practitioners, and a two-round Delphi process involved 32 stakeholders.ResultsFrom the results, it appears that two areas (reciprocal knowledge and evolution of the legal and regulatory framework) are objects of consensus among the three medical group that were surveyed. Information transfer, particularly electronic transfer, was stressed as an important way to improve. The consensual proposals regarding interdisciplinary collaboration indicate specific and practical changes to be implemented when professionals are managing workers who are on sick leave. The collaboration process appeared to be currently more problematic, but the participants correctly identified the need for common training.ConclusionsThe three physician groups all agree regarding several inter-physician collaboration proposals. The study also revealed a latent conflict situation among the analysed professionals that can arise from a lack of mutual recognition.Practical changes or improvements must be included in an extended framework that involves the different determinants of interdisciplinary collaboration that are shown by theoretical models. Collaboration is a product of the actions and behaviours of various partners, which requires reciprocal knowledge and trust; collaboration also implies political and economic structures that are led by public health authorities.

The approach taken to substance abuse by occupational physicians : a qualitative study on influencing factors

Objective: Aiming to enhance occupational physicians’ (OPs) practice when dealing with employee substance abuse, this study analyzes the experiences of OPs to gain insight into the factors influencing their behavior. Methods: Semi-structured interviews were conducted and analyzed using Interpretative Phenomenological Analysis. Results: OPs act differently depending on the type of drug. Their approach was mainly determined by contextual factors and by their attitudes and skills. Many OPs want to invest in health promotion. Barriers such as lack of time and focus on periodic examinations often hamper both adequate prevention and the management of workers with substance abuse. Conclusions: The approach to substance abuse by OPs could be supported by initiatives both at the individual and the collective level. A facilitating work context seems to be particularly important in their commitment to alcohol- and drug-related issues at work.

GP’s engagement in detecting and managing abuse of alcohol, illegal drugs, hypnotics and tranquilizers in the Belgian adult population

European General Practice Research Network (EGPRN) Abstracts from the EGPRN meeting in Kudasi, Turkey, 16th – 19 st May, 2013.s from the EGPRN meeting in Kudasi, Turkey, 16th – 19 st May, 2013. THEME: ‘ RISKY BEHAVIOURS AND HEALTHY OUTCOMES IN PRIMARY HEALTH CARE ’ Risk taking is an important component of development for the human condition; it is how we learn about our environment, relationships and opportunities in life. But risk involves the chance of danger and potential harm, which may impact on the health and wellbeing of patients, their families and their communities. The challenge to clinicians is to be able to recognise challenges and to promote healthier outcomes. The excessive use of substances harmful to health is extensive and varied across Europe and the diff ering characteristics are poorly understood. Substance use and misuse in the community is a multi-factorial problem, which needs to be understood in terms of physical, psychological and social dependency. These issues go beyond the consultation room and require a concerted approach by many diff ering sectors of society. Until recently little has been done in general practice. This presentation is focussed directly at the consulting room and the doctor patient interaction. There has been a steady shift across Europe that recognises the pivotal role of primary care in achieving good health outcomes. This is well documented in Starfield ’ s work, but considerable barriers and challenges remain. The general practitioner ’ s role in society has been largely reactive to the problems presented by its population but there is an increasing emphasis on prevention, multi-morbidity, chronic disease management and enhancing the wellbeing of the individual, families and communities. The numerous factors that affect a patient ’ s wellbeing must be seen in totality and hence a greater understanding of a person ’ s lifestyle is vital to place any risk taking behaviour into context. Initial assessment is important to establish the level of risk and context of the behaviour: ” What does it mean for the individual? ” Young people try substances from curiosity and only once ‘ hooked ’ peer pressure continues to encourage a person ’ s ‘ membership ’ . Others may have tried substances to solve a problem: abuse, deprivation, or pain (psychological and physical). Dependency is then established once an individual life revolves around the use of this substance; this may be socially acceptable (smoking, alcohol), illicit (heroin, cocaine, amphetamine) or iatrogenic (over the counter medicines, opiates, benzodiazepines). Each addiction generates a subculture of language, conduct and behaviour that should be understood to facilitate any challenge. European Journal of General Practice, 2013; 19: 162–184 ISSN 1381-4788 print/ISSN 1751-1402 online

La littératie en santé, un levier pour des systèmes de soins plus équitables ? Des outils pour armer les professionnels et impliquer les institutions

This article briefly recalls why low levels of health literacy should be considered to constitute a public health issue. It then proposes the concept of health literacy as a possible lever to help health care systems to more effectively take social health inequalities into account. Finally, it provides concrete tools for field workers, both clinicians and quality of care managers, and emphasises the importance of an organizational approach to health literacy.

Development, dissemination, and applications of a new terminological resource the Q-Code taxonomy for professional aspects of General Practice / Family Medicine.

Abstract Background: While documentation of clinical aspects of General Practice/Family Medicine (GP/FM) is assured by the International Classification of Primary Care (ICPC), there is no taxonomy for the professional aspects (context and management) of GP/FM. Objectives: To present the development, dissemination, applications, and resulting face validity of the Q-Codes taxonomy specifically designed to describe contextual features of GP/FM, proposed as an extension to the ICPC. Development: The Q-Codes taxonomy was developed from Lamberts’ seminal idea for indexing contextual content (1987) by a multi-disciplinary team of knowledge engineers, linguists and general practitioners, through a qualitative and iterative analysis of 1702 abstracts from six GP/FM conferences using Atlas.ti software. A total of 182 concepts, called Q-Codes, representing professional aspects of GP/FM were identified and organized in a taxonomy. Dissemination: The taxonomy is published as an online terminological resource, using semantic web techniques and web ontology language (OWL) (http://www.hetop.eu/Q). Each Q-Code is identified with a unique resource identifier (URI), and provided with preferred terms, and scope notes in ten languages (Portuguese, Spanish, English, French, Dutch, Korean, Vietnamese, Turkish, Georgian, German) and search filters for MEDLINE and web searches. Applications: This taxonomy has already been used to support queries in bibliographic databases (e.g., MEDLINE), to facilitate indexing of grey literature in GP/FM as congress abstracts, master theses, websites and as an educational tool in vocational teaching, Conclusions: The rapidly growing list of practical applications provides face-validity for the usefulness of this freely available new terminological resource.