Steven Simoens

Impact, regulation and health policy implications of physician migration in OECD countries

BackgroundIn the face of rising demand for medical services due to ageing populations, physician migration flows are increasingly affecting the supply of physicians in Organisation for Economic Co-operation and development (OECD) countries. This paper offers an integrated perspective on the impact of physician migration on home and host countries and discusses international regulation and policy approaches governing physician migration.MethodsInformation about migration flows, international regulation and policies governing physician migration were derived from two questionnaires sent to OECD countries, a secondary analysis of EUROSTAT Labour Force Surveys, a literature review and official policy documents of OECD countries.ResultsOECD countries increasingly perceive immigration of foreign physicians as a way of sustaining their physician workforce. As a result, countries have entered into international agreements regulating physician migration, although their success has been limited due to the imposition of licensing requirements and the protection of vested interests by domestic physicians. OECD countries have therefore adopted specific policies designed to stimulate the immigration of foreign physicians, whilst minimising its negative impact on the home country. Measures promoting immigration have included international recruitment campaigns, less strict immigration requirements and arrangements that foster shared learning between health care systems. Policies restricting the societal costs of physician emigration from developing countries such as good practice guidelines and taxes on host countries have not yet produced their expected effect or in some cases have not been established at all.ConclusionsAlthough OECD countries generally favour long-term policies of national self-sufficiency to sustain their physician workforce, such policies usually co-exist with short-term or medium-term policies to attract foreign physicians. As this is likely to continue, there is a need to create a global framework that enforces physician migration policies that confer benefits on home and host countries. In the long term, OECD countries need to put in place appropriate education and training policies rather than rely on physician migration to address their future needs.

Job satisfaction and quitting intentions: A structural model of British general practitioners

A structural model of job satisfaction and quitting intentions is estimated using data from a survey of general practitioners in the UK. Previous research has used reduced form models, making the interpretation of coefficients problematic. The use of a structural recursive model helps to clarify the relationships between intentions to quit, overall job satisfaction, domains of job satisfaction and personal and job characteristics. Job and personal characteristics have a direct effect on job satisfaction in addition to their indirect impact through job satisfaction domains. Job satisfaction domains have a direct effect on intentions to quit, in addition to their effect via overall job satisfaction. The structural approach provides a richer interpretation of the role and effect of job characteristics on job satisfaction and intentions to quit than is found in previous research. This is particularly relevant in some public sector labour markets, where the opportunity to alter wages to compensate for the relative advantages and disadvantages of jobs is limited because of national wage bargaining.

Job Satisfaction, Work-Related Stress and Intentions to Quit of Scottish GPS:

Job satisfaction and work-related stress influence physician retention, turnover, and patient satisfaction. This study purports to elicit the views of Scottish GPs on job satisfaction, stress, intentions to quit, and to examine any patterns by demographic, job, and practice characteristics. A descriptive, cross-sectional study was undertaken by postal questionnaire on a random sample of 1,000 GP principals, 359 GP non-principals, and 62 PMS GPs. The response rate was 56%. GPs were most satisfied with their colleagues, variety in the job, and amount of responsibility given. The most frequently mentioned sources of job stress were increasing workloads, paperwork, insufficient time to do justice to the job, increased and inappropriate demands from patients. White, female, young (under 40 years) and old (55 years and over) GP non-principals and PMS GPs who work less than 50 hours per week as a GP were more likely to be satisfied with their job and reported lower levels of stress. Conclusions: GP participation in the workforce could be promoted by introducing more flexible working patterns (e.g. part-time work), by expanding the scope of contractual arrangements, and by making patient expectations more realistic by clearly communicating what the role of a GP actually encompasses.

Critical Assessment of Belgian Reimbursement Dossiers of Orphan Drugs

AbstractBackground: Orphan medicinal products are designed to diagnose or treat rare diseases that are serious, life threatening or chronically debilitating and that affect 50 or fewer people in every 100 000 in the EU. In Belgium, the Drug Reimbursement Committee (DRC) evaluates reimbursement requests for orphan drugs based on multiple criteria: the therapeutic value, price and proposed reimbursement tariff; the importance of the drug in clinical practice; and the budget impact of the drug. Objectives: This study aimed to assess reimbursement dossiers of orphan drugs in Belgium and to compare them with the clinical evidence submitted to the European Medicines Agency (EMA). Methods: A qualitative analysis examined all reimbursement dossiers of orphan drugs that were submitted in Belgium between January 2002 and June 2008. The following information was extracted from each dossier: description of the orphan drug; indication; reimbursement status; therapeutic value and needs; budget impact; and number of registered indications. For selected orphan drugs, an in-depth analysis extracted and compared information about the clinical trials, their primary endpoints and results from EMA documents (i.e. the marketing authorization application file, European public assessment report and summary of product characteristics) and the Belgian reimbursement dossiers. Results: Reimbursement was awarded to the majority of orphan drugs. In addition to the official criteria, other negotiable factors, such as price adjustments, employment incentives, patient population restrictions and funding of diagnostic tests by the company, seemed to play a role in the reimbursement decision. Despite the low number of patients, randomized controlled trials were conducted for many orphan drugs. Budget-impact analyses were simplistic and did not consider the impact across multiple indications. Some differences were also observed between the clinical evidence submitted to the EMA and that submitted to the Belgian DRC.Conclusions: In addition to the official criteria, other negotiable factors, such as price adjustments and employment incentives, may play a role in Belgian reimbursement decisions of orphan drugs. Some differences have also been noted between the clinical evidence reported in EMA documents and the evidence included in Belgian reimbursement dossiers of orphan drugs. There appears to be a need for further standardization of Belgian reimbursement applications and for European cooperation in sharing clinical evidence of orphan drugs.

What does GP out of hours care cost? An analysis of different models of out of hours care in Scotland.

Background: The changes to out of hours care provided by General Practitioners have led to wide variation in the types and costs of out of hours care across the country. Aim: To examine the costs of different models of service delivery for GP out of hours organisations. Methods: This was a prospective cross-sectional survey of eight GP out of hours organisations and samples of their patients. A deputising service, rotas, and various types of GP co-operative across Scotland were surveyed. Information on the quantities of resources used by each organisation was combined with unit costs. Costs incurred by patients and other NHS costs subsequent to the out of hours contact were also calculated. Results: Annual costs incurred by the GP out of hours organisation per 1,000 population ranged from £2,916 to £12,120. There was no relationship between costs and type and size of organisation. There was a three-fold variation in total costs per out of hours contact (£15 to £51). Costs per phone contact were lowest (£6 to £11), followed by cost per centre contact (£10 to £16) and cost per home contact (£21 to £60). Total costs per episode ranged from £78 to £136 for centre contacts, from £130 to £303 for home contacts, and from £70 to £553 for telephone contacts. Home contacts had the highest average cost per episode (£212), followed by telephone contacts (£117) and centre contacts (£85). Conclusions: There are wide variations in the costs of operating GP out of hours services. It is likely that the context in which organisations were set up and local geography influence variations in costs, as well as the level of GP cover.

Empirical management of community-acquired pneumonia: impact of concurrent A/H1N1 influenza pandemic on guideline implementation

BACKGROUND Guideline-concordant therapies have been proven to be associated with improved health and economic outcomes in the treatment of community-acquired pneumonia (CAP). However, actual use of CAP guidelines remains poor, but using tailored interventions looks promising. Based on local observations, we assessed the impact of low-intensity interventions to improve guideline use. METHODS Pre-and post-intervention study with segmented regression analysis in a large tertiary care centre [University Hospitals Leuven (UZL)] and a smaller secondary care control hospital [Ziekenhuis Oost-Limburg (ZOL)] from October 2007 through to June 2010 in Belgium. RESULTS A total of 477 patients were included in UZL, with 58.5% of the patients treated according to local guidelines. Guideline adherence remained stable, but a decrease (-28.6%; P = 0.021) was observed during guideline re-introduction in October 2009. Further analysis showed a high correlation with the concurrent A/H1N1 influenza pandemic (r(point-biserial) = 0.683; P = 0.045) and with suspected influenza infection (odds ratio = 2.70; P = 0.038). In ZOL, 326 patients were enrolled, with 69.3% being treated concordantly. A similar, non-significant decrease in guideline adherence was observed after October 2009. CONCLUSIONS Our interventions did not lead to a higher proportion of CAP patients receiving guideline-compliant therapy. Instead, a compliance decrease was observed, coinciding with the peak in the A/H1N1 pandemic in the population. Similar observations could be made in ZOL. The widespread attention for this pandemic may have altered the perception of needed antibiotic therapy for pulmonary infections, bypassing our interventions and decreasing actual guideline compliance. Increased vigilance and follow-up is needed when epidemics with similar impact occur in the future.

How are Scottish integrated primary care organisations managed

In the absence of central guidance on the development of integrated primary care organisations, a diversity of models is emerging. This paper examines the management arrangements of Scottish local health care co-operatives (LHCCs). A postal questionnaire survey of all 79 LHCCs was conducted. The response rate was 35 per cent. LHCCs set up management bodies and created workgroups. Stakeholder representation was not socially inclusive: attempts to engage patients and local communities were limited and need to be stepped up to increase responsiveness and accountability to local health care users. LHCCs were also vehicles for local ownership and control of health care provision. To facilitate co-operation among participating practices, LHCCs need to focus on issues of leadership, organisation, and involvement in decision making. Finally, management expenditure per capita was comparable with that of other types of integrated primary care organisations.

Do ultra-orphan medicinal products warrant ultra-high prices? A review

Correspondence: Eline Picavet Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Herestraat 49, PO Box 521, 3000 Leuven, Belgium Tel +32 16 330 149 Fax +32 16 323 468 Email eline.picavet@pharm.kuleuven.be Abstract: Ultra-orphan medicinal products (ultra-OMPs) are intended for the treatment, prevention, or diagnosis of ultra-rare diseases, ie, life-threatening or chronically debilitating diseases that affect less than one per 50,000 individuals. Recently, high prices for ultra-OMPs have given rise to debate on the sustainability and justification of these prices. The aim of this article is to review the international scientific literature on the pricing of ultra-OMPs and to provide an overview of the current knowledge on the drivers of ultra-OMP pricing. The pricing process of ultra-OMPs is a complex and nontransparent issue. Evidence in the literature seems to indicate that ultra-OMPs are priced according to rarity and what the manufacturer believes the market will bear. Additionally, there appears to be a trend between the price of an ultra-OMP and the number of available alternatives. Patients, third-party payers, and pharmaceutical companies could benefit from more transparent pricing strategies. With a view to containing health care costs, it is likely that cost-sharing strategies, such as performance-based risk sharing arrangements, will become increasingly more important. However, it is vital that any measures for price control are consistent with the intended goals of the incentives to promote the development of new OMPs. Ideally, a balance must be struck between attaining affordable prices for ultra-OMPs and securing a realistic return on investment for the pharmaceutical industry.

Appropriateness of Acid Suppression Therapy

Background: The inappropriate startup of long-term acid suppressive therapy (AST) can have clinical and pharmacoeconomic impacts on ambulatory care. Objective: To assess the proportion of patients with appropriate initiation of long-term AST in non–critically ill patients. To describe possible risk factors for nonappropriate AST. To calculate the potential savings when eliminating the nonappropriate startup of AST. Method: This observational, retrospective study evaluated the appropriateness of startup of long-term AST in medical records using a broad variety of international criteria and guidelines and using a validated screening instrument. Results: A sample of 597 patients was included in the analysis. In 57% of them, AST was appropriately initiated. No specific risk profile could be defined. There was some indication that the availability of a clinical pharmacist and the use of standing orders were correlated to the outcome. Extrapolation to the total population (ie, 2836 patients) led to a total cost of €8880 during hospital stay plus an extra €40 391 per month after discharge. Avoiding inappropriate initiation of AST could lead to a saving of €3805 plus €17 441 per month. Conclusion: In all, 43% of initiation of long-term AST in the hospital was inappropriate. The potential savings from avoiding this could be substantial from a health care payer perspective. No patient characteristics that could predict for inappropriate initiation of AST were identified. A correlation between inappropriate initiation and medical disciplines using standing orders that include AST was seen.

Evaluating the effect of new hospital specialties on GP prescription costs

The aim of this paper is to examine whether the introduction of new hospital specialties contributed to an increase in GP prescription costs. New specialties were introduced in Dr Grays hospital, Grampian, North-East Scotland in 1994. Data on prescription costs and volume for groups of drugs associated with the new specialties were obtained for all GP practices in Moray (study practices) and Kincardine and Deeside (control practices). Comparing the periods January-April in 1994 with 1995, and 1995 with 1996, an upward trend in GP prescription costs was detected for ulcer healing drugs and anti-depressants. The trend in Kincardine and Deeside also pointed to rising prescription costs, although to a lesser extent. The number of patients referred to the psychiatric and gynaecology specialties expanded after the introduction of these specialties at Dr Grays. In conclusion, there is some evidence to support the proposition that the introduction of new specialties at Dr Grays was associated with an increase in the growth of prescription costs within Moray. Further research should establish more clearly whether this is as a result of increased referrals by GPs or the prescribing of more expensive drugs by consultants. The results have implications for the setting of prescribing budgets.