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105-109 The management of chronic diseases is a prime challenge of most 21st century health care systems. Many Western countries have invested heavily in care plans oriented towards specific conditions and diseases, such as dementia and cancer. The major downside of this narrowly focused approach is that treatment of multimorbidity is ignored. This paper describes the development and main stance of a national position that proposes streamlined reforms of the Belgian health care system to improve care for patients with multiple chronic diseases. We used a combination of methods to develop this stance: literature review and stakeholders’ consultation. The latter identified areas for improvement: efficiency of the health care system, coordination of care, investments in human care resources, informal caregivers’ support, better accessibility, and changes in the financial payment system. The position paper list 20 recommendations that are translated into about 50 action points to reform the health care system. Chronic care tailored to the patient's needs, including implementation of multidisciplinary teamwork, new functions, task delegation in primary care, and empowerment of the patient and informal caregivers are some major areas discussed. In addition, improved support, revised payment mechanisms, and setting up a quality system, along with the tailoring of patient care, can all facilitate delivery of high quality care in patients with chronic comorbidities.

The management of chronic diseases is a prime challenge of most 21st century health care systems. Many Western countries have invested heavily in care plans oriented towards specific conditions and diseases, such as dementia and cancer. The major downside of this narrowly focused approach is that treatment of multimorbidity is ignored. This paper describes the development and main stance of a national position that proposes streamlined reforms of the Belgian health care system to improve care for patients with multiple chronic diseases. We used a combination of methods to develop this stance: literature review and stakeholders’ consultation. The latter identified areas for improvement: efficiency of the health care system, coordination of care, investments in human care resources, informal caregivers’ support, better accessibility, and changes in the financial payment system. The position paper list 20 recommendations that are translated into about 50 action points to reform the health care system. Chronic care tailored to the patient's needs, including implementation of multidisciplinary teamwork, new functions, task delegation in primary care, and empowerment of the patient and informal caregivers are some major areas discussed. In addition, improved support, revised payment mechanisms, and setting up a quality system, along with the tailoring of patient care, can all facilitate delivery of high quality care in patients with chronic comorbidities.

In addition to keeping an eye on the quality of our clinical services, making small changes in how we deliver services can have a big impact on how patients feel about their experience – which will in turn motivate them and others to come for the eye care they need. Here are a few things to you may be able to try.

Managing a successful eye clinic can be very challenging. We may have many questions.

The best systems create little extra work for staff and can be implemented almost without thinking in the course of a busy day. The system used in the stock room of our eye clinic in Ivory Coast illustrates this well.

Good practice procedures for purchasing surgical instruments and consumables.

VI, 166 p. Ill. SCIENTIFIC REPORT 11 -- 1. THE CHALLENGE OF CHRONIC CARE 11 -- 1.1. CHRONIC CARE: A GROWING BURDEN FOR THE HEALTH CARE SYSTEMS. 11 -- 1.2. OBJECTIVE: DEVELOPMENT OF A POSITION PAPER FOR CHRONIC CARE IN BELGIUM 11 -- 1.3. SCOPE: FROM “CHRONIC DISEASE” TO “CHRONIC CARE BASED ON THE PATIENT’S NEEDS” 13 -- 1.3.1. Chronic disease: official definitions based on a listing of diseases 13 -- 1.3.2. The patient with “chronic disease”: frequently in the plural 13 -- 1.3.3. Chronic care as an answer to the patient’s needs 13 -- 1.3.4. on care (versus primary prevention and “health in all policies”) 15 -- 1.4. EPIDEMIOLOGY AND COSTS OF CHRONIC DISEASES 15 -- 1.4.1. Epidemiology 15 -- 1.4.2. Costs 16 -- 2. HIGHLIGHTS FROM THE INTERNATIONAL PERSPECTIVE 18 -- 2.1. VIEWPOINTS OF THE EUROPEAN UNION, THE UNITED NATIONS AND THE WORLD HEALTH ORGANIZATION 18 -- 2.1.1. Data sources 18 -- 2.1.2. International frameworks: calls for integrated care 18 -- 2.1.3. Shift towards integrated care: advocacy for organizational changes 21 -- 2.1.4. Role of primary care: hub of coordination 22 -- 2.1.5. Summary and conclusions 24 -- 2.2. CHRONIC CARE MODEL 26 -- 2.2.1. Elements of the chronic care model 26 -- 2.2.2. Evidence underlying the chronic care model 27 -- 2.3. HIGHLIGHTS FROM 4 COUNTRIES 28 -- 2.3.1. Methods 28 -- 2.3.2. Stakeholder collaboration: shared vision and leadership 29 -- 2.3.3. Information technologies and performance measurement. 31 -- 2.3.4. Engaging consumers 31 -- 2.3.5. Improving Health Care delivery: translation of the national/regional strategy at local level 32 -- 2.3.6. Aligning finance /insurance: incentives 32 -- 2.3.7. Outcomes 33 -- 2.3.8. Barriers in redesigning chronic care management 33 -- 2.3.9. Key points: lessons learned 33 -- 3. REASONING FRAMEWORK FOR A HEALTH SYSTEM ORIENTED TOWARDS CHRONIC CARE 34 -- 3.1. OBJECTIVE OF THIS CHAPTER 34 -- 3.2. DEVELOPMENT OF A VISION FOR A REFORM OF CHRONIC CARE IN BELGIUM 35 -- 3.2.1. General shape of the vision or root definition 35 -- 3.2.2. Core purpose 36 -- 3.2.3. Additional qualifications 36 -- 3.2.4. Expanded vision/root definition 38 -- 3.3. CONCEPTUAL MODEL: FUNCTIONAL ACTIVITIES REQUIRED FOR A CHRONIC CARE SYSTEM 39 -- 3.3.1. Plan, provide and co-ordinate routine care 40 -- 3.3.2. Provide acute episode response and specialized services 41 -- 3.3.3. Conduct early identification 42 -- 3.3.4. Support patient/informal caregiver empowerment (including self-management) 43 -- 3.3.5. Conduct health promotion and prevention activities 44 -- 3.3.6. Implement and follow-up a dynamic care model 45 -- 3.3.7. Six requirements for each activity 45 -- 3.4. CONCLUDING REMARKS 47 -- 4. CHRONIC CARE INITIATIVES IN BELGIUM 48 -- 4.1. OBJECTIVE OF THIS CHAPTER 48 -- 4.2. METHODS 48 -- 4.2.1. Data sources 48 -- 4.2.2. Data collection 48 -- 4.2.3. Inclusion and exclusion criteria 48 -- 4.3. NATIONAL PLAN: “PRIORITY TO CHRONIC PATIENTS!” 49 -- 4.4. DESCRIPTION OF THE INITIATIVES FROM THE FEDERAL PUBLIC SERVICE HEALTH, FOOD CHAIN SAFETY AND ENVIRONMENT AND FROM THE SICKNESS FUNDS 49 -- 4.4.1. Inventory of initiatives that target patients with a chronic illness 49 -- 4.4.2. Discussion: initiatives from the Federal Public Service Health, Food Chain Safety and environment and from the Sickness Funds 55 -- 4.5. DESCRIPTION OF INITIATIVES FROM THE NATIONAL INSTITUTE FOR HEALTH AND DISABILITY INSURANCE 56 -- 4.5.1. Health care system level 56 -- 4.5.2. Plan, provide and coordinate care in the primary care setting 57 -- 4.5.3. Self-empowerment of the patients 63 -- 4.6. KEY POINTS: CHRONIC CARE INITIATIVES IN BELGIUM 64 -- 5. RECOMMENDATIONS IN RELATION TO CHRONIC CARE: ANALYSIS OF KCE REPORTS 65 -- 5.1. OBJECTIVE OF THIS CHAPTER 65 -- 5.2. METHODS 65 -- 5.3. TAILORED DELIVERY SYSTEM DESIGN 65 -- 5.3.1. Strengthening primary care: illustration of type 2 diabetes care 66 -- 5.3.2. Organizational models that streamline transition between primary, secondary and tertiary care 67 -- 5.3.3. Organization of services for the older persons 67 -- 5.3.4. Organization of Palliative care services 69 -- 5.3.5. Organization of Mental Health Care Services 70 -- 5.3.6. Organization of rehabilitation services 70 -- 5.4. APPROPRIATE WORKFORCE 71 -- 5.4.1. Physician workforce planning 71 -- 5.4.2. Attractiveness, recruitment and retention of the GP profession 71 -- 5.4.3. Differentiated Nursing Practice 72 -- 5.4.4. The right function for the right health professional: physiotherapists and pharmacists 72 -- 5.4.5. Important role for the occupational physician and the advisory physician from the sickness funds 73 -- 5.4.6. Role for informal caregivers 73 -- 5.4.7. Curricula and continuous education based on needs 73 -- 5.5. APPROPRIATE FINANCING 74 -- 5.5.1. Financial accessibility 74 -- 5.5.2. Financing system for home care nursing 75 -- 5.5.3. Comparison of two financing systems for primary health care 76 -- 5.5.4. Financial initiatives for quality 76 -- 5.6. QUALITY PROCESSES 77 -- 5.7. DECISION SUPPORT 78 -- 5.7.1. Seamless care with regard to medications 79 -- 5.7.2. Self-empowerment in chronic dialysis 79 -- 5.8. CLINICAL INFORMATION SYSTEMS 79 -- 5.9. KEY POINTS: EVIDENCE AND RECOMMENDATIONS FROM KCE REPORTS 80 -- 6. FOCUS ON PATIENT EMPOWERMENT AND NEW PROFILES/ FUNCTIONS IN THE FIRST LINE OF CARE 82 -- 6.1. OBJECTIVE OF THIS CHAPTER 82 -- 6.2. METHODS 82 -- 6.3. HOW TO FOSTER THE PATIENT SELF-EMPOWERMENT ? INSIGHTS FROM A SYSTEMATIC REVIEW OF THE LITERATURE 82 -- 6.3.1. Scope of the literature review 83 -- 6.3.2. Methods 84 -- 6.3.3. Results of the search strategy 84 -- 6.3.4. Effectiveness of the interventions: results by disease 88 -- 6.3.5. Summary of the findings: analysis by type of intervention 94 -- 6.3.6. Conclusion: what elements make up successful interventions? 97 -- 6.3.7. Strengths of this review 98 -- 6.3.8. Caveats in the interpretation of results 98 -- 6.3.9. Key points: interventions to foster patient empowerment 99 -- 6.4. NEW PROFILES AND FUNCTIONS IN THE HEALTH CARE SYSTEM 99 -- 6.4.1. Objective: analysis of the possible changes within the workforce to tackle the future challenges of chronic care 99 -- 6.4.2. Methods 100 -- 6.4.3. New roles in health care: examples from the UK, Canada and The Netherlands 100 -- 6.4.4. Situation in Belgium 110 -- 6.4.5. Discussion: implementation of new functions and professions in the Belgian health care system 114 -- 6.4.6. Key points: new functions and roles in primary health care 115 -- 7. ORGANIZATION OF CHRONIC CARE IN BELGIUM: STAKEHOLDERS’ ANALYSIS 116 -- 7.1. OBJECTIVE OF THIS CHAPTER 116 -- 7.2. METHODS: CONSULTATION OF STAKEHOLDERS FROM DIFFERENT LEVELS 116 -- 7.2.1. Micro and meso levels: four brainstorming sessions and semi-structured interviews 116 -- 7.2.2. Macro level: two meetings with stakeholders 117 -- 7.3. RESULTS: STAKEHOLDERS’ VIEWS ON THE ORGANIZATION OF CHRONIC CARE IN BELGIUM 118 -- 7.3.1. Theme 1: continuum of care within lines of care and between lines of care calls for coordination 118 -- 7.3.2. Theme 2: Redefining the roles of health professionals and training 121 -- 7.3.3. Theme 3: Empowerment and support of the patient and his/her informal caregiver 124 -- 7.3.4. Theme 4: Payment system influences care 125 -- 7.3.5. Theme 5: Clinical information systems and e-Data 127 -- 7.3.6. Theme 6: Accessibility of care 129 -- 7.3.7. Strengths and limitations of this SWOT analysis 130 -- 7.4. KEY POINTS: HIGHLIGHTS FROM THE SWOT ANALYSIS WITH STAKEHOLDERS 131 -- 7.4.1. Lack of efficiency 131 -- 7.4.2. Coordination at micro level: a multidisciplinary primary care team is at the centre of a system designed for people with chronic care needs 131 -- 7.4.3. Coordination at the meso level: mid-level scale initiatives to improve seamless care between hospital and home care 131 -- 7.4.4. Task delegation and new functions in the health care system: the added value of medical assistants and qualified nurses 131 -- 7.4.5. Preventing institutionalization: importance of respite care and coaching the informal caregivers 132 -- 7.4.6. Patients and Informal care givers. Roles of their organizations 132 -- 7.4.7. Balancing payment systems 132 -- 7.4.8. Information systems 132 -- 7.4.9. Accessible care 133 -- 8. ANALYSIS OF COORDINATION STRUCTURES AND PROGRAMMES IN BELGIUM 134 -- 8.1. OBJECTIVE OF THIS CHAPTER 134 -- 8.2. BACKGROUND: HEALTH CARE SYSTEM, A COMPLEX ADAPTIVE SYSTEM 135 -- 8.3. COORDINATION STRUCTURES AND PROGRAMMES IN HEALTH CARE 135 -- 8.3.1. Coordination structures 135 -- 8.3.2. Coordination programmes 136 -- 8.4. KEY FEATURES OF COORDINATION STRUCTURES AND PROGRAMMES 136 -- 8.4.1. Coordination structures at micro level 136 -- 8.4.2. Need for a geographically integrated system at meso level 138 -- 8.4.3. Towards a uniform vision at macro level 138 -- 8.5. EVOLUTION OF COORDINATION STRUCTURES IN BELGIUM 139 -- 8.5.1. Micro level: from single-handed practices towards more collaboration 139 -- 8.5.2. Meso level: from home care coordinating centres (SIT/CCSSD) to Integrated Primary Care Systems (GDT/SISD) 140 -- 8.6. CARE PROGRAMMES: FIT WITHIN “MICRO” OR “MESO” HORIZONTAL STRUCTURES 142 -- 8.6.1. Local multidisciplinary Networks 143 -- 8.6.2. Alternative forms of care for older persons 143 -- 8.6.3. Palliative care platforms and teams 143 -- 8.7. FROM LESSONS LEARNED TO FUTURE PERSPECTIVES 144 -- REFERENCES 146

VII, 60 p. Ill. Plus d'un quart des Belges déclarent souffrir d'une maladie chronique et cette proportion augmentera encore, vu le vieillissement de notre population. En 2008, le programme national «Priorité aux malades chroniques !" mettait surtout l'accent sur l’information du patient et sur l'accessibilité des soins. Dans une seconde étape, la ministre de la Santé Publique a demandé au Centre fédéral d’expertise des soins de santé (KCE) de développer, en concertation avec l’administration de la Santé Publique et l'INAMI, une vision relative à l’organisation future des soins chroniques. Le KCE a analysé la littérature scientifique internationale et les initiatives actuellement en cours, en Belgique et à l’étranger, pour la prise en charge des maladies chroniques. Les experts du terrain et les décideurs ainsi que les représentants des organisations de patients ont également été impliqués dans cette étude. Le résultat : un "Position Paper" qui propose plus de 50 actions concrètes afin de réformer en profondeur l'organisation des soins chroniques. PRÉFACE 1 -- POSITION PAPER2 -- 1. LES MALADIES CHRONIQUES: UN DÉFI POUR LE SYSTÈME DES SOINS DE SANTÉ 5 -- 1.1. LES MALADIES CHRONIQUES RESTENT UNE PRIORITÉ POUR LES AUTORITÉS BELGES DE LA SANTÉ 5 -- 1.2. LES MALADIES CHRONIQUES: UN DÉFI POUR TOUS LES SYSTÈMES DE SOINS DE SANTÉ 6 -- 1.2.1. Stratégies proposées à l’échelon international 6 -- 1.2.2. Prévalence des maladies chroniques en Europe 6 -- 1.3. PRÉVALENCE DES MALADIES CHRONIQUES EN BELGIQUE 7 -- 1.4. IMPORTANCE DE LA MULTIMORBIDITÉ7 -- 1.5. UN FARDEAU POUR LES PERSONNES LES PLUS FRAGILES7 -- 1.6. DES COÛTS CROISSANTS 7 -- 2. QU'EST-CE QU'UNE MALADIE CHRONIQUE? DE L'APPROCHE ORIENTÉE 'MALADIE' À L'APPROCHE ORIENTÉE 'BESOINS DU PATIENT' 8 -- 2.1. LE LARGE ÉVENTAIL DES BESOINS DU PATIENT 9 -- 2.2. OPTER POUR UNE APPROCHE ORIENTÉE “BESOINS” 9 -- 3. IMPORTANCE DE L’ “EMPOWERMENT” DU PATIENT 10 -- 4. SUJET DU POSITION PAPER ET MÉTHODES 11 -- 4.1. SOUS LA LOUPE : LES SOINS CHRONIQUES ET LE SYSTÈME DES SOINS DE SANTÉ 11 -- 4.1.1. Importance de “la santé dans toutes les politiques” (“Health in all policies”) 11 -- 4.1.2. Sujet du position paper: soins et support offerts dans le cadre du système de santé11 -- 4.2. MÉTHODES 12 -- 5. VISION DE L’ORGANISATION FUTURE DES SOINS CHRONIQUES EN BELGIQUE 12 -- 5.1. UNE VISION DE L’OFFRE DE SOINS CHRONIQUES DANS LE SYSTÈME BELGE DES SOINS DE SANTÉ 12 -- 5.1.1. Sources 12 -- 5.1.2. Vision générale13 -- 5.1.3. Qualificatifs additionnels13 -- 5.1.4. Vision étendue de l’offre de soins chroniques au sein du système de soins de santé 15 -- 5.2. MODÈLE CONCEPTUEL: ACTIVITÉS POUR METTRE EN OEUVRE LA VISION DE SOINS -- CHRONIQUES 15 -- 5.2.1. Module n°1: planifier, prodiguer et coordonner les soins de routine15 -- 5.2.2. Module n°2: offrir des services spécialisés et une réponse lors d’épisodes aigus 16 -- 5.2.3. Module n°3: réaliser des activités de dépistage précoce 16 -- 5.2.4. Module n°4: soutenir l'empowerment des patients et des aidants informels 16 -- 5.2.5. Module n°5: organiser des activités de promotion de la santé et de prévention primaire16 -- 5.2.6. Module n°6: mettre en place et suivre un modèle de soins dynamique16 -- 5.2.7. Conditions pour la réalisation des activités mentionnées ci-dessus17 -- 5.2.8. Présentation du modèle conceptuel proposé pour un système de santé orienté vers des soins chroniques 17 -- 5.3. D'UN MODÈLE D'ACTIVITÉ À DES RECOMMANDATIONS EN MATIÈRE DE POLITIQUE DE SANTÉ 18 -- 6. RECOMMANDATIONS EN MATIÈRE DE POLITIQUE DE SANTÉ 18 -- 6.1. PLANIFIER, PRODIGUER ET COORDONNER LES SOINS DE ROUTINE 18 -- 6.1.1. Plan de soins individualisé18 -- 6.1.2. Offrir un support et des soins de routine au malade chronique 21 -- 6.1.3. Suivre et évaluer la qualité des soins 27 -- 6.1.4. Assurer la coordination des soins 29 -- 6.2. OFFRIR UNE RÉPONSE AUX ÉPISODES AIGUS ET DES SERVICES SPÉCIALISÉS 32 -- 6.3. RÉALISER DES ACTIVITÉS DE DÉPISTAGE PRÉCOCE35 -- 6.4. SOUTENIR L’« EMPOWERMENT » DU PATIENT ET DE SES AIDANTS INFORMELS 35 -- 6.4.1. Développer des outils et des aptitudes chez les soignants pour soutenir l’empowerment des -- patients 35 -- 6.4.2. Proposer des services et un soutien pour l'empowerment des patients37 -- 6.5. ORGANISER DES ACTIVITÉS DE PROMOTION DE LA SANTÉ ET DE PRÉVENTION PRIMAIRE38 -- 6.6. MISE EN OEUVRE ET SUIVI D'UN MODÈLE DE SOINS DYNAMIQUE 38 -- 7. REFERENCES 45 -- ANNEXE DU POSITION PAPER 54

54 p. Ill. POSITION PAPER 2 -- TABLE OF CONTENTS 2 -- 1. CHRONIC DISEASES: A CHALLENGE FOR THE HEALTH CARE SYSTEM 5 -- 1.1. CHRONIC DISEASES REMAIN A PRIORITY FOR THE BELGIAN HEALTH AUTHORITIES 5 -- 1.2. CHRONIC DISEASES: A CHALLENGE FOR ALL HEALTH CARE SYSTEMS 5 -- 1.2.1. Strategies proposed by international organisations 5 -- 1.2.2. Prevalence of chronic diseases in Europe 6 -- 1.3. PREVALENCE OF CHRONIC DISEASES IN BELGIUM. 6 -- 1.4. IMPORTANCE OF MULTIMORBIDITY 6 -- 1.5. A BURDEN FOR THE FRAILEST PATIENTS 6 -- 1.6. ESCALATING COSTS OF CHRONIC DISEASES 7 -- 2. WHAT IS A CHRONIC DISEASE? FROM A DISEASE-ORIENTED TO A NEEDS-BASED -- CONCEPT 8 -- 2.1. MULTIPLICITY OF PATIENTS’ NEEDS 8 -- 2.2. NEEDS-BASED APPROACH FOR CHRONIC CARE 8 -- 3. IMPORTANCE OF PATIENT EMPOWERMENT 9 -- 4. SCOPE AND METHODS 10 -- 4.1. SCOPE OF THE POSITION PAPER: FOCUS ON CHRONIC CARE AND SUPPORT -- DELIVERED BY THE HEALTHCARE SYSTEM 10 -- 4.1.1. Importance of “health in all policies” 10 -- 4.1.2. Scope of the position paper: focus on care and support delivered by the healthcare -- system 10 -- 4.2. COMBINATION OF METHODS 11 -- 5. A VISION ON THE FUTURE ORGANISATION OF CHRONIC CARE IN BELGIUM 11 -- 5.1. VISION OF THE PROVISION OF CHRONIC CARE IN THE BELGIAN HEALTH CARE SYSTEM 11 -- 5.1.1. Sources 11 -- 5.1.2. Core vision 12 -- 5.1.3. Additional qualifications 12 -- 5.1.4. Expanded vision of the provision of chronic care within the health care system 13 -- 5.2. CONCEPTUAL MODEL: ACTIVITIES TO IMPLEMENT THE VISION OF CHRONIC CARE 13 -- 5.2.1. Module 1: plan, provide and coordinate routine care 14 -- 5.2.2. Module 2: provide acute episode response and specialized services 14 -- 5.2.3. Module 3: conduct early identification 14 -- 5.2.4. Module 4: support patient/informal caregiver empowerment (including self-management) 14 -- 5.2.5. Module 5: conduct health promotion and prevention activities 14 -- 5.2.6. Module 6: implement and follow-up a dynamic care model 15 -- 5.2.7. Requirements for the above mentioned activities 15 -- 5.2.8. Overview of the conceptual model proposed for a health care system oriented -- towards chronic care 15 -- 5.3. FROM ACTIVITY MODEL TO POLICY RECOMMENDATIONS 16 -- 6. POLICY RECOMMENDATIONS 16 -- 6.1. PLAN, PROVIDE AND COORDINATE ROUTINE CARE IN THE PRIMARY CARE SETTING 16 -- 6.1.1. Individualized care plan 16 -- 6.1.2. Provide routine care and support for the chronic patient 19 -- 6.1.3. Monitor and evaluate progress and quality of care 23 -- 6.1.4. Provide care coordination 26 -- 6.2. PROVIDE ACUTE EPISODE RESPONSE AND SPECIALISED SERVICES 28 -- 6.3. CONDUCT EARLY IDENTIFICATION 30 -- 6.4. SUPPORT PATIENT AND INFORMAL CAREGIVER EMPOWERMENT 31 -- 6.4.1. Develop provider skills and tools for patient empowerment 31 -- 6.4.2. Provide patient empowerment services and support 33 -- 6.5. CONDUCT HEALTH PROMOTION AND PRIMARY PREVENTION ACTIVITIES 34 -- 6.6. IMPLEMENTATION AND FOLLOW-UP OF A DYNAMIC CARE MODEL 34 -- 7. REFERENCES OF THE POSITION PAPER 39 -- APPENDIX OF THE POSITION PAPER 49 -- APPENDIX 1. RECAPITULATIVE INVENTORY OF THE MAIN ACTION FIELDS AND OF THE -- ACTORS INVOLVED 49 -- APPENDIX 1.1. EDUCATION 49 -- APPENDIX 1.2. DEVELOPMENT OF PROTOCOLS AND TOOLS FOR COMMUNICATION 50 -- APPENDIX 1.3. DEVELOPMENT OF INFORMATION AND COMMUNICATION TECHNOLOGY -- APPLICATIONS 50 -- APPENDIX 1.4. QUALITY IMPROVEMENT INITIATIVES 50 -- APPENDIX 1.5. EMPOWERMENT 51 -- APPENDIX 1.6. MANPOWER 51 -- APPENDIX 1.7. ORGANIZATIONAL REFORMS 52

VII, 166 p. Ill. Plus d'un quart des Belges déclarent souffrir d'une maladie chronique et cette proportion augmentera encore, vu le vieillissement de notre population. En 2008, le programme national «Priorité aux malades chroniques !" mettait surtout l'accent sur l’information du patient et sur l'accessibilité des soins. Dans une seconde étape, la ministre de la Santé Publique a demandé au Centre fédéral d’expertise des soins de santé (KCE) de développer, en concertation avec l’administration de la Santé Publique et l'INAMI, une vision relative à l’organisation future des soins chroniques. Le KCE a analysé la littérature scientifique internationale et les initiatives actuellement en cours, en Belgique et à l’étranger, pour la prise en charge des maladies chroniques. Les experts du terrain et les décideurs ainsi que les représentants des organisations de patients ont également été impliqués dans cette étude. Le résultat : un "Position Paper" qui propose plus de 50 actions concrètes afin de réformer en profondeur l'organisation des soins chroniques. SCIENTIFIC REPORT 11 -- 1. THE CHALLENGE OF CHRONIC CARE 11 -- 1.1. CHRONIC CARE: A GROWING BURDEN FOR THE HEALTH CARE SYSTEMS. 11 -- 1.2. OBJECTIVE: DEVELOPMENT OF A POSITION PAPER FOR CHRONIC CARE IN BELGIUM 11 -- 1.3. SCOPE: FROM “CHRONIC DISEASE” TO “CHRONIC CARE BASED ON THE PATIENT’S NEEDS” 13 -- 1.3.1. Chronic disease: official definitions based on a listing of diseases 13 -- 1.3.2. The patient with “chronic disease”: frequently in the plural 13 -- 1.3.3. Chronic care as an answer to the patient’s needs 13 -- 1.3.4. on care (versus primary prevention and “health in all policies”) 15 -- 1.4. EPIDEMIOLOGY AND COSTS OF CHRONIC DISEASES 15 -- 1.4.1. Epidemiology 15 -- 1.4.2. Costs 16 -- 2. HIGHLIGHTS FROM THE INTERNATIONAL PERSPECTIVE 18 -- 2.1. VIEWPOINTS OF THE EUROPEAN UNION, THE UNITED NATIONS AND THE WORLD HEALTH ORGANIZATION 18 -- 2.1.1. Data sources 18 -- 2.1.2. International frameworks: calls for integrated care 18 -- 2.1.3. Shift towards integrated care: advocacy for organizational changes 21 -- 2.1.4. Role of primary care: hub of coordination 22 -- 2.1.5. Summary and conclusions 24 -- 2.2. CHRONIC CARE MODEL 26 -- 2.2.1. Elements of the chronic care model 26 -- 2.2.2. Evidence underlying the chronic care model 27 -- HIGHLIGHTS FROM 4 COUNTRIES 28 -- 2.3.1. Methods 28 -- 2.3.2. Stakeholder collaboration: shared vision and leadership 29 -- 2.3.3. Information technologies and performance measurement. 31 -- 2.3.4. Engaging consumers 31 -- 2.3.5. Improving Health Care delivery: translation of the national/regional strategy at local level 32 -- 2.3.6. Aligning finance /insurance: incentives 32 -- 2.3.7. Outcomes 33 -- 2.3.8. Barriers in redesigning chronic care management 33 -- 2.3.9. Key points: lessons learned 33 -- 3. REASONING FRAMEWORK FOR A HEALTH SYSTEM ORIENTED TOWARDS CHRONIC CARE 34 -- 3.1. OBJECTIVE OF THIS CHAPTER 34 -- 3.2. DEVELOPMENT OF A VISION FOR A REFORM OF CHRONIC CARE IN BELGIUM 35 -- 3.2.1. General shape of the vision or root definition 35 -- 3.2.2. Core purpose 36 -- 3.2.3. Additional qualifications 36 -- 3.2.4. Expanded vision/root definition 38 -- 3.3. CONCEPTUAL MODEL: FUNCTIONAL ACTIVITIES REQUIRED FOR A CHRONIC CARE SYSTEM 39 -- 3.3.1. Plan, provide and co-ordinate routine care 40 -- 3.3.2. Provide acute episode response and specialized services 41 -- 3.3.3. Conduct early identification 42 -- 3.3.4. Support patient/informal caregiver empowerment (including self-management) 43 -- 3.3.5. Conduct health promotion and prevention activities 44 -- 3.3.6. Implement and follow-up a dynamic care model 45 -- 3.3.7. Six requirements for each activity 45 -- 3.4. CONCLUDING REMARKS 47 -- 4. CHRONIC CARE INITIATIVES IN BELGIUM 48 -- 4.1. OBJECTIVE OF THIS CHAPTER 48 -- 4.2. METHODS 48 -- 4.2.1. Data sources 48 -- 4.2.2. Data collection 48 -- 4.2.3. Inclusion and exclusion criteria 48 -- 4.3. NATIONAL PLAN: “PRIORITY TO CHRONIC PATIENTS!” 49 -- 4.4. DESCRIPTION OF THE INITIATIVES FROM THE FEDERAL PUBLIC SERVICE HEALTH, FOOD CHAIN SAFETY AND ENVIRONMENT AND FROM THE SICKNESS FUNDS 49 -- 4.4.1. Inventory of initiatives that target patients with a chronic illness 49 -- 4.4.2. Discussion: initiatives from the Federal Public Service Health, Food Chain Safety and -- environment and from the Sickness Funds 55 -- 4.5. DESCRIPTION OF INITIATIVES FROM THE NATIONAL INSTITUTE FOR HEALTH AND DISABILITY INSURANCE 56 -- 4.5.1. Health care system level 56 -- 4.5.2. Plan, provide and coordinate care in the primary care setting 57 -- 4.5.3. Self-empowerment of the patients 63 -- 4.6. KEY POINTS: CHRONIC CARE INITIATIVES IN BELGIUM 64 -- 5. RECOMMENDATIONS IN RELATION TO CHRONIC CARE: ANALYSIS OF KCE REPORTS 65 -- 5.1. OBJECTIVE OF THIS CHAPTER 65 -- 5.2. METHODS 65 -- 5.3. TAILORED DELIVERY SYSTEM DESIGN 65 -- 5.3.1. Strengthening primary care: illustration of type 2 diabetes care 66 -- 5.3.2. Organizational models that streamline transition between primary, secondary and tertiary care 67 -- 5.3.3. Organization of services for the older persons 67 -- 5.3.4. Organization of Palliative care services 69 -- 5.3.5. Organization of Mental Health Care Services 70 -- 5.3.6. Organization of rehabilitation services 70 -- 5.4. APPROPRIATE WORKFORCE 71 -- 5.4.1. Physician workforce planning 71 -- 5.4.2. Attractiveness, recruitment and retention of the GP profession 71 -- 5.4.3. Differentiated Nursing Practice 72 -- 5.4.4. The right function for the right health professional: physiotherapists and pharmacists 72 -- 5.4.5. Important role for the occupational physician and the advisory physician from the sickness funds 73 -- 5.4.6. Role for informal caregivers 73 -- 5.4.7. Curricula and continuous education based on needs 73 -- 5.5. APPROPRIATE FINANCING 74 -- 5.5.1. Financial accessibility 74 -- 5.5.2. Financing system for home care nursing 75 -- 5.5.3. Comparison of two financing systems for primary health care 76 -- 5.5.4. Financial initiatives for quality 76 -- 5.6. QUALITY PROCESSES 77 -- 5.7. DECISION SUPPORT 78 -- 5.7.1. Seamless care with regard to medications 79 -- 5.7.2. Self-empowerment in chronic dialysis 79 -- 5.8. CLINICAL INFORMATION SYSTEMS 79 -- 5.9. KEY POINTS: EVIDENCE AND RECOMMENDATIONS FROM KCE REPORTS 80 -- 6. FOCUS ON PATIENT EMPOWERMENT AND NEW PROFILES/ FUNCTIONS IN THE FIRST LINE OF CARE 82 -- 6.1. OBJECTIVE OF THIS CHAPTER 82 -- 6.2. METHODS 82 -- 6.3. HOW TO FOSTER THE PATIENT SELF-EMPOWERMENT ? INSIGHTS FROM A SYSTEMATIC REVIEW OF THE LITERATURE 82 -- 6.3.1. Scope of the literature review 83 -- 6.3.2. Methods 84 -- 6.3.3. Results of the search strategy 84 -- 6.3.4. Effectiveness of the interventions: results by disease 88 -- 6.3.5. Summary of the findings: analysis by type of intervention 94 -- 6.3.6. Conclusion: what elements make up successful interventions? 97 -- 6.3.7. Strengths of this review 98 -- 6.3.8. Caveats in the interpretation of results 98 -- 6.3.9. Key points: interventions to foster patient empowerment 99 -- 6.4. NEW PROFILES AND FUNCTIONS IN THE HEALTH CARE SYSTEM 99 -- 6.4.1. Objective: analysis of the possible changes within the workforce to tackle the future challenges of chronic care 99 -- 6.4.2. Methods 100 -- 6.4.3. New roles in health care: examples from the UK, Canada and The Netherlands 100 -- 6.4.4. Situation in Belgium 110 -- 6.4.5. Discussion: implementation of new functions and professions in the Belgian health care system 114 -- 6.4.6. Key points: new functions and roles in primary health care 115 -- 7. ORGANIZATION OF CHRONIC CARE IN BELGIUM: STAKEHOLDERS’ ANALYSIS 116 -- 7.1. OBJECTIVE OF THIS CHAPTER 116 -- 7.2. METHODS: CONSULTATION OF STAKEHOLDERS FROM DIFFERENT LEVELS 116 -- 7.2.1. Micro and meso levels: four brainstorming sessions and semi-structured interviews 116 -- 7.2.2. Macro level: two meetings with stakeholders 117 -- 7.3. RESULTS: STAKEHOLDERS’ VIEWS ON THE ORGANIZATION OF CHRONIC CARE IN BELGIUM 118 -- 7.3.1. Theme 1: continuum of care within lines of care and between lines of care calls for coordination 118 -- 7.3.2. Theme 2: Redefining the roles of health professionals and training 121 -- 7.3.3. Theme 3: Empowerment and support of the patient and his/her informal caregiver 124 -- 7.3.4. Theme 4: Payment system influences care 125 -- 7.3.5. Theme 5: Clinical information systems and e-Data 127 -- 7.3.6. Theme 6: Accessibility of care 129 -- 7.3.7. Strengths and limitations of this SWOT analysis 130 -- 7.4. KEY POINTS: HIGHLIGHTS FROM THE SWOT ANALYSIS WITH STAKEHOLDERS 131 -- 7.4.1. Lack of efficiency 131 -- 7.4.2. Coordination at micro level: a multidisciplinary primary care team is at the centre of a system designed for people with chronic care needs 131 -- 7.4.3. Coordination at the meso level: mid-level scale initiatives to improve seamless care between hospital and home care 131 -- 7.4.4. Task delegation and new functions in the health care system: the added value of medical assistants and qualified nurses 131 -- 7.4.5. Preventing institutionalization: importance of respite care and coaching the informal caregivers 132 -- 7.4.6. Patients and Informal care givers. Roles of their organizations 132 -- 7.4.7. Balancing payment systems 132 -- 7.4.8. Information systems 132 -- 7.4.9. Accessible care 133 -- 8. ANALYSIS OF COORDINATION STRUCTURES AND PROGRAMMES IN BELGIUM 134 -- 8.1. OBJECTIVE OF THIS CHAPTER 134 -- 8.2. BACKGROUND: HEALTH CARE SYSTEM, A COMPLEX ADAPTIVE SYSTEM 135 -- 8.3. COORDINATION STRUCTURES AND PROGRAMMES IN HEALTH CARE 135 -- 8.3.1. Coordination structures 135 -- 8.3.2. Coordination programmes 136 -- 8.4. KEY FEATURES OF COORDINATION STRUCTURES AND PROGRAMMES 136 -- 8.4.1. Coordination structures at micro level 136 -- 8.4.2. Need for a geographically integrated system at meso level 138 -- 8.4.3. Towards a uniform vision at macro level 138 -- 8.5. EVOLUTION OF COORDINATION STRUCTURES IN BELGIUM 139 -- 8.5.1. Micro level: from single-handed practices towards more collaboration 139 -- 8.5.2. Meso level: from home care coordinating centres (SIT/CCSSD) to Integrated Primary Care Systems (GDT/SISD) 140 -- 8.6. CARE PROGRAMMES: FIT WITHIN “MICRO” OR “MESO” HORIZONTAL STRUCTURES 142 -- 8.6.1. Local multidisciplinary Networks 143 -- 8.6.2. Alternative forms of care for older persons 143 -- 8.6.3. Palliative care platforms and teams 143 -- 8.7. FROM LESSONS LEARNED TO FUTURE PERSPECTIVES 144 -- REFERENCES 146

61 p. Ill. Meer dan een kwart van de Belgische bevolking zegt aan een chronische aandoening te lijden, en door de vergrijzing neemt dit aantal steeds toe. In 2008 werd het nationaal programma “Prioriteit aan de chronisch zieken” gelanceerd, dat sterk de nadruk legde op goede informatie en op de toegankelijkheid van de zorg. In een volgende stap vroeg de minister van Volksgezondheid het Federaal Kenniscentrum voor de Gezondheidszorg (KCE) om samen met de FOD Volksgezondheid en het RIZIV een toekomstvisie voor de chronische zorg te ontwikkelen. Het KCE bestudeerde de internationale, wetenschappelijke literatuur, en keek naar het werk dat in binnen-en buitenland reeds rond chronische zorg gebeurde. Het betrok ook uitgebreid de mensen van het terrein, het beleid en de koepels van patiëntenverenigingen bij het onderzoek. Het resultaat: een ‘Position paper’ die meer dan 50 concrete acties voorstelt om de organisatie van de chronische zorg fundamenteel te hervormen. POSITION PAPER 2 -- 1. CHRONISCHE ZIEKTEN: EEN UITDAGING VOOR DE BELGISCHE GEZONDHEIDSZORG 5 -- 1.1. CHRONISCHE ZIEKTEN BLIJVEN EEN PRIORITEIT VOOR DE BELGISCHE OVERHEDEN 5 -- 1.2. CHRONISCHE ZIEKTEN: EEN UITDAGING VOOR ALLE GEZONDHEIDSZORGSYSTEMEN 6 -- 1.2.1. Internationale consensus over plan van aanpak 6 -- 1.2.2. Prevalentie van chronische ziekten in Europa 6 -- 1.3. PREVALENTIE VAN CHRONISCHE ZIEKTEN IN BELGIË 7 -- 1.4. HET BELANG VAN MULTIMORBIDITEIT 7 -- 1.5. EEN BELASTING VAN DE MEEST KWETSBARE PATIËNTEN 7 -- 1.6. STIJGENDE KOSTEN 7 -- 2. WAT IS EEN CHRONISCHE ZIEKTE? VAN EEN PATHOLOGIEGERICHT NAAR EEN BEHOEFTEN-GESTUURD CONCEPT 8 -- 2.1. EEN BREDE WAAIER VAN PATIËNTENBEHOEFTEN 9 -- 2.2. KIEZEN VOOR EEN BEHOEFTEN GESTUURDE BENADERING 9 -- 3. HET BELANG VAN “PATIENT- EMPOWERMENT” 10 -- 4. SCOPE EN METHODEN 11 -- 4.1. SCOPE: FOCUS OP CHRONISCHE ZORG EN GEZONDHEIDSZORG 11 -- 4.1.1. Belang van ‘Health in all Policies’ 11 -- 4.1.2. Scope: focus op chronische zorg en gezondheidszorg 11 -- 4.2. METHODEN 11 -- 5. EEN VISIE OP DE TOEKOMSTIGE ORGANISATIE VAN CHRONISCHE ZORG IN BELGIË 12 -- 5.1. VISIE OP CHRONISCHE ZORG IN DE BELGISCHE GEZONDHEIDSZORG 12 -- 5.1.1. Bronnen 12 -- 5.1.2. Kernvisie 13 -- 5.1.3. Bijkomende kwalificaties 13 -- 5.1.4. Visie op chronische zorg binnen de gezondheidszorg 14 -- 5.2. CONCEPTUEEL MODEL: ACTIVITEITEN OM DE VISIE OP CHRONISCHE ZORG TE REALISEREN 15 -- 5.2.1. Module 1: routinezorg plannen, verlenen en coördineren 15 -- 5.2.2. Module 2: respons op acute episodes en het verlenen van gespecialiseerde diensten 15 -- 5.2.3. Module 3: uitvoeren van activiteiten rond vroegtijdige opsporing 15 -- 5.2.4. Module 4: ondersteunen van empowerment van patiënt en mantelzorger 16 -- 5.2.5. Module 5: activiteiten voor gezondheidspromotie en acties gericht op primaire preventie 16 -- 5.2.6. Module 6: een dynamisch zorgmodel implementeren en opvolgen 16 -- 5.2.7. Noodzakelijke voorwaarden voor bovenvermelde activiteiten 17 -- 5.2.8. Overzicht van het conceptuele model voorgesteld voor een gezondheidszorgsysteem aangepast aan zorg voor chronisch zieken 17 -- 5.3. VAN ACTIVITEITENMODEL TOT BELEIDSAANBEVELINGEN 18 -- 6. BELEIDSAANBEVELINGEN 18 -- 6.1. ROUTINEZORG PLANNEN, VERLENEN EN COÖRDINEREN 18 -- 6.1.1. Geïndividualiseerd zorgplan 18 -- 6.1.2. Routinezorg en ondersteuning bieden aan de chronisch zieke 21 -- 6.1.3. Het controleren en evalueren van de zorgkwaliteit 27 -- 6.1.4. Instaan voor zorgcoördinatie 29 -- 6.2. RESPONS OP ACUTE EPISODEN EN VERLENEN VAN GESPECIALISEERDE DIENSTEN 32 -- 6.3. HET UITVOEREN VAN ACTIVITEITEN ROND VROEGTIJDIGE OPSPORING 34 -- 6.4. ONDERSTEUNEN VAN EMPOWERMENT VAN PATIËNT EN MANTELZORGER 35 -- 6.4.1. Ontwikkelen van competenties bij zorgverleners en van hulpmiddelen om patient empowerment te ondersteunen 35 -- 6.4.2. Zorgen voor dienstverlening en ondersteuning van patiënt empowerment 37 -- 6.5. HET UITVOEREN VAN GEZONDHEIDSPROMOTIE EN ACTIES GERICHT OP PRIMAIRE PREVENTIE 38 -- 6.6. EEN DYNAMISCH ZORGMODEL IMPLEMENTEREN EN OPVOLGEN 38 -- 7. REFERENTIES 45 -- BIJLAGE VAN DE POSITION PAPER 55 -- OVERZICHT VAN DE BELANGRIJKSTE ACTIEGEBIEDEN EN BETROKKEN ACTOREN 55 -- BIJLAGE 1.1. ONDERWIJS EN OPLEIDING 55 -- BIJLAGE 1.2. ONTWIKKELING VAN PROTOCOLLEN EN COMMUNICATIEHULPMIDDELEN; 56 -- BIJLAGE 1.3. ONTWIKKELING VAN TOEPASSINGEN VOOR INFORMATIE- EN COMMUNICATIETECHNOLOGIE 56 -- BIJLAGE 1.4. INITIATIEVEN VOOR KWALITEITSVERBETERING 57 -- BIJLAGE 1.5. EMPOWERMENT 57 -- BIJLAGE 1.6. PERSONEELSBESTAND 58 -- BIJLAGE 1.7. ORGANISATORISCHE HERVORMINGEN 58

VIII, 166 p. Ill. Meer dan een kwart van de Belgische bevolking zegt aan een chronische aandoening te lijden, en door de vergrijzing neemt dit aantal steeds toe. In 2008 werd het nationaal programma “Prioriteit aan de chronisch zieken” gelanceerd, dat sterk de nadruk legde op goede informatie en op de toegankelijkheid van de zorg. In een volgende stap vroeg de minister van Volksgezondheid het Federaal Kenniscentrum voor de Gezondheidszorg (KCE) om samen met de FOD Volksgezondheid en het RIZIV een toekomstvisie voor de chronische zorg te ontwikkelen. Het KCE bestudeerde de internationale, wetenschappelijke literatuur, en keek naar het werk dat in binnen-en buitenland reeds rond chronische zorg gebeurde. Het betrok ook uitgebreid de mensen van het terrein, het beleid en de koepels van patiëntenverenigingen bij het onderzoek. Het resultaat: een ‘Position paper’ die meer dan 50 concrete acties voorstelt om de organisatie van de chronische zorg fundamenteel te hervormen. SCIENTIFIC REPORT 11 -- 1. THE CHALLENGE OF CHRONIC CARE 11 -- 1.1. CHRONIC CARE: A GROWING BURDEN FOR THE HEALTH CARE SYSTEMS. 11 -- 1.2. OBJECTIVE: DEVELOPMENT OF A POSITION PAPER FOR CHRONIC CARE IN BELGIUM 11 -- 1.3. SCOPE: FROM “CHRONIC DISEASE” TO “CHRONIC CARE BASED ON THE PATIENT’S NEEDS” 13 -- 1.3.1. Chronic disease: official definitions based on a listing of diseases 13 -- 1.3.2. The patient with “chronic disease”: frequently in the plural 13 -- 1.3.3. Chronic care as an answer to the patient’s needs 13 -- 1.3.4. on care (versus primary prevention and “health in all policies”) 15 -- 1.4. EPIDEMIOLOGY AND COSTS OF CHRONIC DISEASES 15 -- 1.4.1. Epidemiology 15 -- 1.4.2. Costs 16 -- 2. HIGHLIGHTS FROM THE INTERNATIONAL PERSPECTIVE 18 -- 2.1. VIEWPOINTS OF THE EUROPEAN UNION, THE UNITED NATIONS AND THE WORLD HEALTH -- ORGANIZATION 18 -- 2.1.1. Data sources 18 -- 2.1.2. International frameworks: calls for integrated care 18 -- 2.1.3. Shift towards integrated care: advocacy for organizational changes 21 -- 2.1.4. Role of primary care: hub of coordination 22 -- 2.1.5. Summary and conclusions 24 -- 2.2. CHRONIC CARE MODEL 26 -- 2.2.1. Elements of the chronic care model 26 -- 2.2.2. Evidence underlying the chronic care model 27 -- 2.3. HIGHLIGHTS FROM 4 COUNTRIES 28 -- 2.3.1. Methods 28 -- 2.3.2. Stakeholder collaboration: shared vision and leadership 29 -- 2.3.3. Information technologies and performance measurement. 31 -- 2.3.4. Engaging consumers 31 -- 2.3.5. Improving Health Care delivery: translation of the national/regional strategy at local level 32 -- 2.3.6. Aligning finance /insurance: incentives 32 -- 2.3.7. Outcomes 33 -- 2.3.8. Barriers in redesigning chronic care management 33 -- 2.3.9. Key points: lessons learned 33 -- 3. REASONING FRAMEWORK FOR A HEALTH SYSTEM ORIENTED TOWARDS CHRONIC CARE 34 -- 3.1. OBJECTIVE OF THIS CHAPTER 34 -- 3.2. DEVELOPMENT OF A VISION FOR A REFORM OF CHRONIC CARE IN BELGIUM 35 -- 3.2.1. General shape of the vision or root definition 35 -- 3.2.2. Core purpose 36 -- 3.2.3. Additional qualifications 36 -- 3.2.4. Expanded vision/root definition 38 -- 3.3. CONCEPTUAL MODEL: FUNCTIONAL ACTIVITIES REQUIRED FOR A CHRONIC CARE SYSTEM 39 -- 3.3.1. Plan, provide and co-ordinate routine care 40 -- 3.3.2. Provide acute episode response and specialized services 41 -- 3.3.3. Conduct early identification 42 -- 3.3.4. Support patient/informal caregiver empowerment (including self-management) 43 -- 3.3.5. Conduct health promotion and prevention activities 44 -- 3.3.6. Implement and follow-up a dynamic care model 45 -- 3.3.7. Six requirements for each activity 45 -- 3.4. CONCLUDING REMARKS 47 -- 4. CHRONIC CARE INITIATIVES IN BELGIUM 48 -- 4.1. OBJECTIVE OF THIS CHAPTER 48 -- 4.2. METHODS 48 -- 4.2.1. Data sources 48 -- 4.2.2. Data collection 48 -- 4.2.3. Inclusion and exclusion criteria 48 -- 4.3. NATIONAL PLAN: “PRIORITY TO CHRONIC PATIENTS!” 49 -- 4.4. DESCRIPTION OF THE INITIATIVES FROM THE FEDERAL PUBLIC SERVICE HEALTH, FOOD CHAIN SAFETY AND ENVIRONMENT AND FROM THE SICKNESS FUNDS 49 -- 4.4.1. Inventory of initiatives that target patients with a chronic illness 49 -- 4.4.2. Discussion: initiatives from the Federal Public Service Health, Food Chain Safety and environment and from the Sickness Funds 55 -- 4.5. DESCRIPTION OF INITIATIVES FROM THE NATIONAL INSTITUTE FOR HEALTH AND DISABILITY INSURANCE 56 -- 4.5.1. Health care system level 56 -- 4.5.2. Plan, provide and coordinate care in the primary care setting 57 -- 4.5.3. Self-empowerment of the patients 63 -- 4.6. KEY POINTS: CHRONIC CARE INITIATIVES IN BELGIUM 64 -- 5. RECOMMENDATIONS IN RELATION TO CHRONIC CARE: ANALYSIS OF KCE REPORTS 65 -- 5.1. OBJECTIVE OF THIS CHAPTER 65 -- 5.2. METHODS 65 -- 5.3. TAILORED DELIVERY SYSTEM DESIGN 65 -- 5.3.1. Strengthening primary care: illustration of type 2 diabetes care 66 -- 5.3.2. Organizational models that streamline transition between primary, secondary and tertiary care 67 -- 5.3.3. Organization of services for the older persons 67 -- 5.3.4. Organization of Palliative care services 69 -- 5.3.5. Organization of Mental Health Care Services 70 -- 5.3.6. Organization of rehabilitation services 70 -- 5.4. APPROPRIATE WORKFORCE 71 -- 5.4.1. Physician workforce planning 71 -- 5.4.2. Attractiveness, recruitment and retention of the GP profession 71 -- 5.4.3. Differentiated Nursing Practice 72 -- 5.4.4. The right function for the right health professional: physiotherapists and pharmacists 72 -- 5.4.5. Important role for the occupational physician and the advisory physician from the sickness funds 73 -- 5.4.6. Role for informal caregivers 73 -- 5.4.7. Curricula and continuous education based on needs 73 -- 5.5. APPROPRIATE FINANCING 74 -- 5.5.1. Financial accessibility 74 -- 5.5.2. Financing system for home care nursing 75 -- 5.5.3. Comparison of two financing systems for primary health care 76 -- 5.5.4. Financial initiatives for quality 76 -- 5.6. QUALITY PROCESSES 77 -- 5.7. DECISION SUPPORT 78 -- 5.7.1. Seamless care with regard to medications 79 -- 5.7.2. Self-empowerment in chronic dialysis 79 -- 5.8. CLINICAL INFORMATION SYSTEMS 79 -- 5.9. KEY POINTS: EVIDENCE AND RECOMMENDATIONS FROM KCE REPORTS 80 -- 6. FOCUS ON PATIENT EMPOWERMENT AND NEW PROFILES/ FUNCTIONS IN THE FIRST LINE OF CARE 82 -- 6.1. OBJECTIVE OF THIS CHAPTER 82 -- 6.2. METHODS 82 -- 6.3. HOW TO FOSTER THE PATIENT SELF-EMPOWERMENT ? INSIGHTS FROM A SYSTEMATIC REVIEW OF THE LITERATURE 82 -- 6.3.1. Scope of the literature review 83 -- 6.3.2. Methods 84 -- 6.3.3. Results of the search strategy 84 -- 6.3.4. Effectiveness of the interventions: results by disease 88 -- 6.3.5. Summary of the findings: analysis by type of intervention 94 -- 6.3.6. Conclusion: what elements make up successful interventions? 97 -- 6.3.7. Strengths of this review 98 -- 6.3.8. Caveats in the interpretation of results 98 -- 6.3.9. Key points: interventions to foster patient empowerment 99 -- 6.4. NEW PROFILES AND FUNCTIONS IN THE HEALTH CARE SYSTEM 99 -- 6.4.1. Objective: analysis of the possible changes within the workforce to tackle the future challenges of chronic care 99 -- 6.4.2. Methods 100 -- 6.4.3. New roles in health care: examples from the UK, Canada and The Netherlands 100 -- 6.4.4. Situation in Belgium 110 -- 6.4.5. Discussion: implementation of new functions and professions in the Belgian health care system 114 -- 6.4.6. Key points: new functions and roles in primary health care 115 -- 7. ORGANIZATION OF CHRONIC CARE IN BELGIUM: STAKEHOLDERS’ ANALYSIS 116 -- 7.1. OBJECTIVE OF THIS CHAPTER 116 -- 7.2. METHODS: CONSULTATION OF STAKEHOLDERS FROM DIFFERENT LEVELS 116 -- 7.2.1. Micro and meso levels: four brainstorming sessions and semi-structured interviews 116 -- 7.2.2. Macro level: two meetings with stakeholders 117 -- 7.3. RESULTS: STAKEHOLDERS’ VIEWS ON THE ORGANIZATION OF CHRONIC CARE IN BELGIUM 118 -- 7.3.1. Theme 1: continuum of care within lines of care and between lines of care calls for coordination 118 -- 7.3.2. Theme 2: Redefining the roles of health professionals and training 121 -- 7.3.3. Theme 3: Empowerment and support of the patient and his/her informal caregiver 124 -- 7.3.4. Theme 4: Payment system influences care 125 -- 7.3.5. Theme 5: Clinical information systems and e-Data 127 -- 7.3.6. Theme 6: Accessibility of care 129 -- 7.3.7. Strengths and limitations of this SWOT analysis 130 -- 7.4. KEY POINTS: HIGHLIGHTS FROM THE SWOT ANALYSIS WITH STAKEHOLDERS 131 -- 7.4.1. Lack of efficiency 131 -- 7.4.2. Coordination at micro level: a multidisciplinary primary care team is at the centre of a system designed for people with chronic care needs 131 -- 7.4.3. Coordination at the meso level: mid-level scale initiatives to improve seamless care between hospital and home care 131 -- 7.4.4. Task delegation and new functions in the health care system: the added value of medical assistants and qualified nurses 131 -- 7.4.5. Preventing institutionalization: importance of respite care and coaching the informal caregivers 132 -- 7.4.6. Patients and Informal care givers. Roles of their organizations 132 -- 7.4.7. Balancing payment systems 132 -- 7.4.8. Information systems 132 -- 7.4.9. Accessible care 133 -- 8. ANALYSIS OF COORDINATION STRUCTURES AND PROGRAMMES IN BELGIUM 134 -- 8.1. OBJECTIVE OF THIS CHAPTER 134 -- 8.2. BACKGROUND: HEALTH CARE SYSTEM, A COMPLEX ADAPTIVE SYSTEM 135 -- 8.3. COORDINATION STRUCTURES AND PROGRAMMES IN HEALTH CARE 135 -- 8.3.1. Coordination structures 135 -- 8.3.2. Coordination programmes 136 -- 8.4. KEY FEATURES OF COORDINATION STRUCTURES AND PROGRAMMES 136 -- 8.4.1. Coordination structures at micro level 136 -- 8.4.2. Need for a geographically integrated system at meso level 138 -- 8.4.3. Towards a uniform vision at macro level 138 -- 8.5. EVOLUTION OF COORDINATION STRUCTURES IN BELGIUM 139 -- 8.5.1. Micro level: from single-handed practices towards more collaboration 139 -- 8.5.2. Meso level: from home care coordinating centres (SIT/CCSSD) to Integrated Primary Care Systems (GDT/SISD) 140 -- 8.6. CARE PROGRAMMES: FIT WITHIN “MICRO” OR “MESO” HORIZONTAL STRUCTURES 142 -- 8.6.1. Local multidisciplinary Networks 143 -- 8.6.2. Alternative forms of care for older persons 143 -- 8.6.3. Palliative care platforms and teams 143 -- 8.7. FROM LESSONS LEARNED TO FUTURE PERSPECTIVES 144 -- REFERENCES 146

219 p. Ill.

The importance of surgical instruments and consumables in the delivery of eye care and covered maintenance, repair, training, purchasing, and donations.

186-90 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.

VI, 110 p. ill. ABREVIATIONS 3 -- 1 INTRODUCTION 5 -- 1.1 BACKGROUND 5 -- 1.2 OBJECTIVES AND METHODS 6 -- 1.3 HISTORICAL BACKGROUND 6 -- 1.3.1 Definition of acupuncture 6 -- 1.3.2 The Chinese origins of acupuncture 6 -- 1.3.3 Importing acupuncture into Europe 8 -- 1.3.4 Acupuncture between tradition and modernity 8 -- 1.3.5 The origins of acupuncture in Belgium 9 -- 2 EFFICACY AND ADVERSE EVENTS 10 -- 2.1 INTRODUCTION 10 -- 2.2 METHODS 10 -- 2.2.1 Databases and search terms 10 -- 2.2.2 Selection criteria 11 -- 2.2.3 Quality assessment 11 -- 2.2.4 Clinical relevance 11 -- 2.3 RESULTS 12 -- 2.3.1 Selected reports and papers 12 -- 2.3.2 Main findings on published effects 13 -- 2.3.3 Discussion and conclusions 19 -- 3 USE OF ACUPUNCTURE IN BELGIUM 21 -- 3.1 SURVEY AMONG THE POPULATION 21 -- 3.1.1 Objective 21 -- 3.1.2 Methods 21 -- 3.1.3 The use of alternative medicines in general 22 -- 3.1.4 Use of acupuncture 23 -- 3.2 INSURANCE COVERAGE 24 -- 3.2.1 Objective 24 -- 3.2.2 Methods 24 -- 3.2.3 Results 24 -- 3.2.4 Discussion 25 -- 3.2.5 Conclusions 26 -- 3.3 SOCIOLOGICAL ASPECTS: USAGE AND PRACTICE OF ACUPUNCTURE IN BELGIUM -- TODAY 26 -- 3.3.1 Scope of this section 26 -- 3.3.2 Material and methods 26 -- 3.3.3 The experience of users 28 -- 3.3.4 The practitioners 38 -- 4 THE PRACTICE 46 -- 4.1 OBJECTIVE 46 -- 4.2 METHODS 46 -- 4.3 RESULTS 46 -- 4.3.1 Response rate 46 -- 4.3.2 Baseline characteristics 47 -- 4.3.3 Training 47 -- 4.3.4 Practice 48 -- 4.3.5 Provider delay 50 -- 4.3.6 Workload and profile of patients 50 -- 4.3.7 Patient referral: 53 -- 4.3.8 Complaints for use of acupuncture 54 -- 4.3.9 Techniques used 55 -- 4.4 DISCUSSION 56 -- 5 ORGANISATIONAL AND LEGAL ASPECTS 57 -- 5.1 BELGIAN AND EUROPEAN LEGAL FRAMEWORK 57 -- 5.1.1 Introduction 57 -- 5.1.2 Methodology 57 -- 5.1.3 The exercise of conventional healthcare in Belgium under the terms of Royal Decree -- no. 78 57 -- 5.1.4 The exercise of non-conventional medicine in Belgium 59 -- 5.1.5 The relationship between the Colla law and Royal Decree no. 78 66 -- 5.1.6 The consequences of the (non-)conventional exercise of healthcare 68 -- 5.1.7 The exercise of non-conventional medicine in the European context 73 -- 5.1.8 Conclusion concerning the Belgian and European legal framework 74 -- 5.2 THE SITUATION IN THE NETHERLANDS, FRANCE AND THE UNITED KINGDOM 75 -- 5.2.1 Structure of the chapter 75 -- 5.2.2 Netherlands 75 -- 5.2.3 France 77 -- 5.2.4 United Kingdom 79 -- 5.2.5 Conclusion on the situation in the Netherlands, France and the United Kingdom 81 -- 5.3 ACUPUNCTURE TRAINING 81 -- 5.3.1 Objectives 81 -- 5.3.2 Methods 82 -- 5.3.3 Results 82 -- 5.3.4 Discussion 84 -- 5.3.5 Conclusion 86 -- 5.4 PROFESSIONAL ORGANISATIONS 87 -- 5.4.1 Objective 87 -- 5.4.2 Methods 87 -- 5.4.3 Results 87 -- 5.4.4 Discussion 89 -- 5.4.5 Conclusion 90 -- 6 GENERAL SYNTHESIS AND DISCUSSION 91 -- 6.1 INTRODUCTION 91 -- 6.1.1 Context 91 -- 6.1.2 Objectives and methods 91 -- 6.1.3 Limitations 92 -- 6.2 ACUPUNCTURE IN BELGIUM: USERS, PRACTITIONERS AND PRACTICES 92 -- 6.2.1 Non-conventional medicines: an increasingly frequent use 92 -- 6.2.2 Acupuncture in Belgium: general background 92 -- 6.2.3 Who are the patients? 93 -- 6.2.4 Who are the practitioners? 94 -- 6.2.5 The pathway of the Patient 95 -- 6.3 IS ACUPUNCTURE CLINICALLY EFFECTIVE? 99 -- 6.3.1 Evidence in the scientific literature 99 -- 6.3.2 Patient point of view 100 -- 6.3.3 Which risks? 100 -- 6.4 TRAINING 100 -- 6.5 LEGAL FRAMEWORK 101 -- 6.5.1 Background 101 -- 6.5.2 The Colla law 101 -- 6.5.3 Consequences of partial execution of the Colla law 103 -- 7 CONCLUSION 104 -- 8 REFERENCES 106

57 p. ill. APPENDICES 1 -- 1 LITERATURE REVIEW 2 -- 1.1 EVIDENCE TABLES 2 -- 1.1.1 Insomnia. 2 -- 1.1.2 Low back pain 2 -- 1.1.3 Induction of labour 3 -- 1.1.4 Chronic fatigue 3 -- 1.1.5 Dementia 3 -- 1.1.6 Wandering in dementia 4 -- 1.1.7 Chronic asthma 4 -- 1.1.8 Enuresis 4 -- 1.1.9 Depression 5 -- 1.1.10 Anxiety 5 -- 1.1.11 Cancer related symptoms 6 -- 1.1.12 Cancer related symptoms 6 -- 1.1.13 Flushes after breast cancer therapy 7 -- 1.1.14 Childhood ailments 7 -- 1.1.15 ADHD 8 -- 1.1.16 Fybromyalgia 9 -- 1.1.17 HIV 10 -- 1.1.18 Chronic venous insufficiency 10 -- 1.1.19 Premenstrual syndrome 10 -- 1.1.20 Allergic rhinitis 11 -- 1.1.21 Adverse effects 12 -- 1.1.22 Adverse effects (homeopathic aggravations) 12 -- 2 SURVEY AMONG THE POPULATION 13 -- 2.1 STRUCTURE OF THE QUESTIONNAIRE 13 -- 2.2 SAMPLE 13 -- 2.3 QUESTIONNAIRE 17 -- 2.4 RESULTS 38 -- 3 THE PRACTICE : QUESTIONNAIRE 45 -- 3.1.1 Rémunération / Betaling 53 -- 4 INSURANCE COVERAGE 55 -- 5 REFERENCES 56

VII, 110 p. ill. Il n’y a pas la moindre preuve scientifique que l’homéopathie soit efficace et pourtant elle est fort utilisée pour toutes sortes de maux. Les expériences positives des utilisateurs pourraient avoir à faire avec l’effet placebo, c'est-à-dire l’obtention d’un résultat en raison de l’attente de ce résultat par le patient et par le thérapeute. Mais dans cette approche de la maladie, on court le risque de ne pas instaurer un traitement médical classique indispensable ou de le démarrer trop tard parce qu’ un diagnostic aura été raté ou posé trop tard. C’est la raison pour laquelle il vaut mieux réserver la pratique de l’homéopathie aux médecins qui forment d’ailleurs déjà actuellement la majeure partie des homéopathes. C’est la conclusion à laquelle arrive le Centre fédéral d’expertise des soins de santé (KCE) dans son troisième rapport sur la situation des médecines non conventionnelles en Belgique. Les rapports précédents concernaient pour l’un l’ostéopathie et la chiropraxie et pour l’autre, l’acupuncture. ABREVIATIONS 4 -- 1 INTRODUCTION 6 -- 1.1 BACKGROUND 6 -- 1.2 OBJECTIVES AND METHODS 7 -- 1.3 HISTORICAL BACKGROUND 7 -- 1.3.1 Definition of homeopathy 7 -- 1.3.2 Homeopathy’s origins 7 -- 1.3.3 Three key principles 7 -- 1.3.4 19th century: the critique of heroic medicine 9 -- 1.3.5 Migrations 9 -- 1.3.6 From master to masters9 9 -- 1.3.7 Self-organization 9 -- 1.3.8 Popularity history 11 -- 1.3.9 The quest of scientific credibility 11 -- 2 EFFICACY AND ADVERSE EVENTS 13 -- 2.1 INTRODUCTION 13 -- 2.2 METHODS 13 -- 2.2.1 Databases and search terms 13 -- 2.2.2 Selection criteria 14 -- 2.2.3 Quality assessment 14 -- 2.3 RESULTS 14 -- 2.3.1 Reports and papers found 14 -- 2.3.2 Main findings on effects 16 -- 2.3.3 Adverse effects 18 -- 2.3.4 Discussion and conclusions 19 -- 3 USE OF HOMEOPATHY IN BELGIUM 21 -- 3.1 SURVEY AMONG THE POPULATION 21 -- 3.1.1 Objective 21 -- 3.1.2 Methods 21 -- 3.1.3 The use of alternative medicines in general 22 -- 3.1.4 Use of homeopathy 23 -- 3.2 CONSUMPTION OF HOMEOPATIC PRODUCTS 23 -- 3.2.1 Research question 23 -- 3.2.2 Availability of data 24 -- 3.2.3 Conclusion 24 -- 3.3 SOCIOLOGICAL ASPECTS: USAGE AND PRACTICE OF HOMEOPATHY IN BELGIUM -- TODAY 24 -- 3.3.1 Introduction 24 -- 3.3.2 Objectives 24 -- 3.3.3 Methodology 24 -- 3.3.4 Views of homeopaths 25 -- 3.3.5 The experience of users 36 -- 4 THE PRACTICE 46 -- 4.1 OBJECTIVE 46 -- 4.2 METHODS 46 -- 4.3 RESULTS 46 -- 4.3.1 Response rate 46 -- 4.3.2 Baseline characteristics 46 -- 4.3.3 Training 47 -- 4.3.4 Practice. 48 -- 4.3.5 Workload and profile of patients 50 -- 4.3.6 Age 51 -- 4.3.7 Provider delay 52 -- 4.3.8 Patient referral: 53 -- 4.3.9 Claims for which homeopathy is used. 55 -- 4.3.10 Type of medicines used and type of homeopathy practiced. 56 -- 4.4 DISCUSSION 56 -- 5 ORGANISATIONAL AND LEGAL ASPECTS 57 -- 5.1 BELGIAN AND EUROPEAN LEGAL FRAMEWORK 57 -- 5.1.1 Introduction 57 -- 5.1.2 Methodology 57 -- 5.1.3 The exercise of conventional healthcare in Belgium under the terms of Royal Decree -- no. 78 57 -- 5.1.4 The exercise of non-conventional medicine in Belgium 59 -- 5.1.5 The relationship between the Colla law and Royal Decree no. 78 65 -- 5.1.6 The consequences of the (non-)conventional exercise of healthcare 67 -- 5.1.7 The exercise of non-conventional medicine in the European context 73 -- 5.1.8 Conclusion concerning the Belgian and European legal framework 74 -- 5.2 THE SITUATION IN THE NETHERLANDS, FRANCE AND THE UNITED KINGDOM 75 -- 5.2.1 Structure of the chapter 75 -- 5.2.2 Netherlands 75 -- 5.2.3 France 77 -- 5.2.4 United Kingdom 79 -- 5.2.5 Conclusion on the situation in the Netherlands, France and the United Kingdom 81 -- 5.3 TRAINING IN HOMEOPATHY 81 -- 5.3.1 Introduction 81 -- 5.3.2 Methods 81 -- 5.3.3 Results 82 -- 5.3.4 Discussion 85 -- 5.3.5 Conclusion 85 -- 5.4 PROFESSIONAL ORGANISATIONS 85 -- 5.4.1 Objectives 85 -- 5.4.2 Methods 86 -- 5.4.3 Results 86 -- 5.4.4 Conclusion 89 -- 5.5 PATIENTS’ ASSOCIATION 90 -- 5.5.1 Objectives 90 -- 5.5.2 Methods 90 -- 5.5.3 Results 90 -- 5.5.4 Conclusion 91 -- 5.6 REIMBURSEMENT POLICY CONCERNING HOMEOPATHY 91 -- 5.6.1 Introduction 91 -- 5.6.2 Methods 91 -- 5.6.3 Results 91 -- 5.6.4 Discussion 92 -- 5.6.5 Conclusion 93 -- 6 OVERVIEW AND DISCUSSION 94 -- 6.1 BACKGROUND 94 -- 6.1.1 Objectives and methods 94 -- 6.2 LIMITATIONS 95 -- 6.3 HOMEOPATHY IN BELGIUM: USERS, PRACTITIONERS AND PRACTICES 96 -- 6.3.1 Increasing use of non-conventional forms of medicine 96 -- 6.3.2 Who are the patients? 96 -- 6.3.3 Who are the practitioners? 97 -- 6.3.4 Typical patient route 98 -- 6.3.5 Financial aspects 99 -- 6.3.6 Patient rating 99 -- 6.4 IS THERE EVIDENCE OF EFFICACY? 100 -- 6.4.1 Scientific literature: no evidence of efficacy 100 -- 6.4.2 Patients’ views 100 -- 6.4.3 What are the risks? 100 -- 6.5 HOW DOES ONE BECOME A HOMEOPATH? 101 -- 6.6 LEGAL FRAMEWORK 101 -- 6.6.1 Background 101 -- 6.6.2 The Colla law 102 -- 6.6.3 Consequences of partial execution of the Colla law 103 -- 6.6.4 Homeopathic remedies 103 -- 7 IN CONCLUSION, WHAT ARE THE FUTURE IMPLICATIONS? 104 -- 7.1 NO SCIENTIFIC EVIDENCE OF CLINICAL EFFICACY EXISTS 104 -- 7.2 ENFORCING COLLA’S LAW? 104 -- 7.3 GUARANTEEING PATIENT SAFETY 104 -- 8 REFERENCES 106

21 p. ill. 1 INTRODUCTION . 2 -- 1.1 CONTEXTE 2 -- 1.2 OBJECTIFS ET MÉTHODES . 2 -- 1.3 LIMITES 3 -- 2 L’ACUPUNCTURE EN BELGIQUE: UTILISATEURS, PRATICIENS ET -- PRATIQUES 4 -- 2.1 MÉDECINES NON-CONVENTIONELLES : DE PLUS EN PLUS FRÉQUEMMENT UTILISÉES .. 4 -- 2.2 L’ACUPUNCTURE EN BELGIQUE: CONTEXTE GÉNÉRAL . 4 -- 2.3 QUI SONT LES PATIENTS? . 4 -- 2.4 QUI SONT LES PRATICIENS? 5 -- 2.5 LE PARCOURS DU PATIENT . 7 -- 2.5.1 Premier accès à la médecine non conventionnelle . 7 -- 2.5.2 La consultation . 7 -- 2.5.3 Aspects financiers . 9 -- 2.5.4 Satisfaction des patients 9 -- 3 L’ACUPUNCTURE EST-ELLE CLINIQUEMENT EFFICACE ? 11 -- 3.1 PREUVES DANS LA LITTÉRATURE SCIENTIFIQUE 11 -- 3.2 POINT DE VUE DU PATIENT . 13 -- 3.3 QUELS SONT LES RISQUES ? 13 -- 4 FORMATION 14 -- 5 CADRE JURIDIQUE . 15 -- 5.1 HISTORIQUE 15 -- 5.2 LA « LOI COLLA » 15 -- 5.3 CONSÉQUENCES DE L’EXÉCUTION PARTIELLE DE LA LOI COLLA . 17 -- 6 CONCLUSION . 18 -- 7 REFERENCES 21

21 p. ill. 1 INLEIDING 2 -- 1.1 CONTEXT 2 -- 1.2 DOELSTELLINGEN EN METHODEN 2 -- 1.3 BEPERKINGEN 3 -- 2 ACUPUNCTUUR IN BELGIË: GEBRUIKERS, BEOEFENAARS EN PRAKTIJKEN 4 -- 2.1 NIET-CONVENTIONELE GENEESWIJZEN: STEEDS TOENEMEND GEBRUIK 4 -- 2.2 ACUPUNCTUUR IN BELGIË: ALGEMENE ACHTERGROND 4 -- 2.3 WIE ZIJN DE PATIËNTEN? 4 -- 2.4 WIE ZIJN DE BEOEFENAARS? 5 -- 2.5 HET PAD VAN DE PATIËNT 7 -- 2.5.1 Initiële toegang tot niet-conventionele geneeskunde 7 -- 2.5.2 De consultatie 7 -- 2.5.3 Financiële aspecten 8 -- 2.5.4 Patiëntentevredenheid 9 -- 3 IS ACUPUNCTUUR KLINISCH DOELTREFFEND? 11 -- 3.1 EVIDENTIE IN DE WETENSCHAPPELIJKE LITERATUUR 11 -- 3.2 STANDPUNT VAN DE PATIËNT 13 -- 3.3 WELKE RISICO'S? 13 -- 4 OPLEIDING 14 -- 5 WETTELIJK KADER 15 -- 5.1 ACHTERGROND 15 -- 5.2 DE WET “COLLA” 15 -- 5.3 GEVOLGEN VAN DE GEDEELTELIJKE UITVOERING VAN DE “WET COLLA” 17 -- 6 CONCLUSIE 18 -- 7 REFERENTIES 21

VII, 110 p. ill. Meer dan 1 op 3 Belgen raadpleegt minstens 1 keer in zijn leven een osteopaat, chiropractor, homeopaat of acupuncturist. In het kader van de verdere uitvoering van de wet Colla vroeg de minister van Volksgezondheid het Federaal Kenniscentrum voor de Gezondheidszorg (KCE) een stand van zaken op te maken van deze 4 populaire niet-conventionele geneeswijzen. In een eerste rapport (december 2010) bestudeerde het KCE osteopathie en chiropraxie. Deze keer is acupunctuur aan de beurt. De therapie werd tegelijkertijd vanuit een wetenschappelijke, sociologische, juridische en organisatorische invalshoek bekeken, een Belgische primeur! ABREVIATIONS 3 -- 1 INTRODUCTION 5 -- 1.1 BACKGROUND 5 -- 1.2 OBJECTIVES AND METHODS 6 -- 1.3 HISTORICAL BACKGROUND 6 -- 1.3.1 Definition of acupuncture 6 -- 1.3.2 The Chinese origins of acupuncture 6 -- 1.3.3 Importing acupuncture into Europe 8 -- 1.3.4 Acupuncture between tradition and modernity 8 -- 1.3.5 The origins of acupuncture in Belgium 9 -- 2 EFFICACY AND ADVERSE EVENTS 10 -- 2.1 INTRODUCTION 10 -- 2.2 METHODS 10 -- 2.2.1 Databases and search terms 10 -- 2.2.2 Selection criteria 11 -- 2.2.3 Quality assessment 11 -- 2.2.4 Clinical relevance 11 -- 2.3 RESULTS 12 -- 2.3.1 Selected reports and papers 12 -- 2.3.2 Main findings on published effects 13 -- 2.3.3 Discussion and conclusions 19 -- 3 USE OF ACUPUNCTURE IN BELGIUM 21 -- 3.1 SURVEY AMONG THE POPULATION 21 -- 3.1.1 Objective 21 -- 3.1.2 Methods 21 -- 3.1.3 The use of alternative medicines in general 22 -- 3.1.4 Use of acupuncture 23 -- 3.2 INSURANCE COVERAGE 24 -- 3.2.1 Objective 24 -- 3.2.2 Methods 24 -- 3.2.3 Results 24 -- 3.2.4 Discussion 25 -- 3.2.5 Conclusions 26 -- 3.3 SOCIOLOGICAL ASPECTS: USAGE AND PRACTICE OF ACUPUNCTURE IN BELGIUM -- TODAY 26 -- 3.3.1 Scope of this section 26 -- 3.3.2 Material and methods 26 -- 3.3.3 The experience of users 28 -- 3.3.4 The practitioners 38 -- 4 THE PRACTICE 46 -- 4.1 OBJECTIVE 46 -- 4.2 METHODS 46 -- 4.3 RESULTS 46 -- 4.3.1 Response rate 46 -- 4.3.2 Baseline characteristics 47 -- 4.3.3 Training 47 -- 4.3.4 Practice 48 -- 4.3.5 Provider delay 50 -- 4.3.6 Workload and profile of patients 50 -- 4.3.7 Patient referral: 53 -- 4.3.8 Complaints for use of acupuncture 54 -- 4.3.9 Techniques used 55 -- 4.4 DISCUSSION 56 -- 5 ORGANISATIONAL AND LEGAL ASPECTS 57 -- 5.1 BELGIAN AND EUROPEAN LEGAL FRAMEWORK 57 -- 5.1.1 Introduction 57 -- 5.1.2 Methodology 57 -- 5.1.3 The exercise of conventional healthcare in Belgium under the terms of Royal Decree -- no. 78 57 -- 5.1.4 The exercise of non-conventional medicine in Belgium 59 -- 5.1.5 The relationship between the Colla law and Royal Decree no. 78 66 -- 5.1.6 The consequences of the (non-)conventional exercise of healthcare 68 -- 5.1.7 The exercise of non-conventional medicine in the European context 73 -- 5.1.8 Conclusion concerning the Belgian and European legal framework 74 -- 5.2 THE SITUATION IN THE NETHERLANDS, FRANCE AND THE UNITED KINGDOM 75 -- 5.2.1 Structure of the chapter 75 -- 5.2.2 Netherlands 75 -- 5.2.3 France 77 -- 5.2.4 United Kingdom 79 -- 5.2.5 Conclusion on the situation in the Netherlands, France and the United Kingdom 81 -- 5.3 ACUPUNCTURE TRAINING 81 -- 5.3.1 Objectives 81 -- 5.3.2 Methods 82 -- 5.3.3 Results 82 -- 5.3.4 Discussion 84 -- 5.3.5 Conclusion 86 -- 5.4 PROFESSIONAL ORGANISATIONS 87 -- 5.4.1 Objective 87 -- 5.4.2 Methods 87 -- 5.4.3 Results 87 -- 5.4.4 Discussion 89 -- 5.4.5 Conclusion 90 -- 6 GENERAL SYNTHESIS AND DISCUSSION 91 -- 6.1 INTRODUCTION 91 -- 6.1.1 Context 91 -- 6.1.2 Objectives and methods 91 -- 6.1.3 Limitations 92 -- 6.2 ACUPUNCTURE IN BELGIUM: USERS, PRACTITIONERS AND PRACTICES 92 -- 6.2.1 Non-conventional medicines: an increasingly frequent use 92 -- 6.2.2 Acupuncture in Belgium: general background 92 -- 6.2.3 Who are the patients? 93 -- 6.2.4 Who are the practitioners? 94 -- 6.2.5 The pathway of the Patient 95 -- 6.3 IS ACUPUNCTURE CLINICALLY EFFECTIVE? 99 -- 6.3.1 Evidence in the scientific literature 99 -- 6.3.2 Patient point of view 100 -- 6.3.3 Which risks? 100 -- 6.4 TRAINING 100 -- 6.5 LEGAL FRAMEWORK 101 -- 6.5.1 Background 101 -- 6.5.2 The Colla law 101 -- 6.5.3 Consequences of partial execution of the Colla law 103 -- 7 CONCLUSION 104 -- 8 REFERENCES 106

15 p. ill. Er is geen enkel wetenschappelijk bewijs dat homeopathie werkt. Toch wordt het veel gebruikt voor allerlei kwalen. De positieve ervaringen van de gebruikers kunnen te maken hebben met het ‘placebo-effect’, dus omdat patiënt en therapeut een effect verwachten. Tegelijk is er wel een risico dat men een noodzakelijke klassieke medische behandeling niet of te laat opstart, door een gemiste of verkeerde diagnose. Daarom wordt de uitoefening van homeopathie best beperkt tot artsen, die nu al de meerderheid van de homeopaten uitmaken. Dit concludeert het Federaal Kenniscentrum voor de gezondheidszorg (KCE) in zijn derde studie over de situatie van niet-conventionele therapieën in België. Eerder waren osteopathie en chiropraxie aan de beurt, en vervolgens acupunctuur. 1 CONTEXT 2 -- 2 DOELSTELLINGEN 2 -- 3 BEPERKINGEN 3 -- 4 HOMEOPATHIE IN BELGIË: DE GEBRUIKERS, DE BEOEFENAARS, DE -- METHODEN 4 -- 4.1 TOENEMEND BEROEP OP NIET-CONVENTIONELE GENEESWIJZEN 4 -- 4.2 WIE ZIJN DE PATIËNTEN? 4 -- 4.3 WIE ZIJN DE BEOEFENAARS? 5 -- 4.4 TYPISCH ZORGTRAJECT VAN EEN PATIËNT 6 -- 4.4.1 De sprong wagen naar alternatieve geneeswijzen 6 -- 4.4.2 De consultatie 7 -- 4.5 FINANCIËLE ASPECTEN 7 -- 4.6 WAARDERING DOOR DE PATIËNTEN 8 -- 5 IS DE WERKZAAMHEID BEWEZEN? 9 -- 5.1 DE WETENSCHAPPELIJKE LITERATUUR: GEEN ENKEL BEWIJS VAN WERKZAAMHEID 9 -- 5.2 HET STANDPUNT VAN DE PATIËNTEN 9 -- 5.3 WAT ZIJN DE RISICO’S? 10 -- 6 HOE WORDT MEN HOMEOPAAT? 10 -- 7 WETTELIJK KADER 11 -- 7.1 ACHTERGROND 11 -- 7.2 DE WET “COLLA” 11 -- 7.3 GEVOLGEN VAN DE GEDEELTELIJKE UITVOERING VAN DE “WET COLLA” 13 -- 7.4 DE HOMEOPATHISCHE MIDDELEN 13 -- 8 CONCLUSIE: WAT ZIJN DE TOEKOMSTIGE UITDAGINGEN? 13 -- 9 ER IS GEEN WETENSCHAPPELIJK BEWIJS VAN KLINISCHE -- WERKZAAMHEID 14 -- 10 DE WET COLLA TOEPASSEN? 14 -- 11 DE VEILIGHEID VAN DE PATIËNTEN GARANDEREN 14 -- 12 AANBEVELINGEN 15 -- 13 REFERENTIES 15

88 p. ill. 1 LITERATURE REVIEW 2 -- 2 SURVEY AMONG THE POPULATION 43 -- 2.1 STRUCTURE OF THE QUESTIONNAIRE 43 -- 2.2 SAMPLE 43 -- 2.3 QUESTIONNAIRE 47 -- 2.4 RESULTS 68 -- 3 THE PRACTICE: QUESTIONNAIRE 75 -- 4 INSURANCE COVER 83 -- 5 OVERVIEW OF TRAININGS 83 -- 6 OVERVIEW OF PROFESSIONAL UNIONS 86 -- 7 REFERENCES 87

VII, 110 p. ill. Er is geen enkel wetenschappelijk bewijs dat homeopathie werkt. Toch wordt het veel gebruikt voor allerlei kwalen. De positieve ervaringen van de gebruikers kunnen te maken hebben met het ‘placebo-effect’, dus omdat patiënt en therapeut een effect verwachten. Tegelijk is er wel een risico dat men een noodzakelijke klassieke medische behandeling niet of te laat opstart, door een gemiste of verkeerde diagnose. Daarom wordt de uitoefening van homeopathie best beperkt tot artsen, die nu al de meerderheid van de homeopaten uitmaken. Dit concludeert het Federaal Kenniscentrum voor de gezondheidszorg (KCE) in zijn derde studie over de situatie van niet-conventionele therapieën in België. Eerder waren osteopathie en chiropraxie aan de beurt, en vervolgens acupunctuur. ABREVIATIONS 4 -- 1 INTRODUCTION 6 -- 1.1 BACKGROUND 6 -- 1.2 OBJECTIVES AND METHODS 7 -- 1.3 HISTORICAL BACKGROUND 7 -- 1.3.1 Definition of homeopathy 7 -- 1.3.2 Homeopathy’s origins 7 -- 1.3.3 Three key principles 7 -- 1.3.4 19th century: the critique of heroic medicine 9 -- 1.3.5 Migrations 9 -- 1.3.6 From master to masters9 9 -- 1.3.7 Self-organization 9 -- 1.3.8 Popularity history 11 -- 1.3.9 The quest of scientific credibility 11 -- 2 EFFICACY AND ADVERSE EVENTS 13 -- 2.1 INTRODUCTION 13 -- 2.2 METHODS 13 -- 2.2.1 Databases and search terms 13 -- 2.2.2 Selection criteria 14 -- 2.2.3 Quality assessment 14 -- 2.3 RESULTS 14 -- 2.3.1 Reports and papers found 14 -- 2.3.2 Main findings on effects 16 -- 2.3.3 Adverse effects 18 -- 2.3.4 Discussion and conclusions 19 -- 3 USE OF HOMEOPATHY IN BELGIUM 21 -- 3.1 SURVEY AMONG THE POPULATION 21 -- 3.1.1 Objective 21 -- 3.1.2 Methods 21 -- 3.1.3 The use of alternative medicines in general 22 -- 3.1.4 Use of homeopathy 23 -- 3.2 CONSUMPTION OF HOMEOPATIC PRODUCTS 23 -- 3.2.1 Research question 23 -- 3.2.2 Availability of data 24 -- 3.2.3 Conclusion 24 -- 3.3 SOCIOLOGICAL ASPECTS: USAGE AND PRACTICE OF HOMEOPATHY IN BELGIUM -- TODAY 24 -- 3.3.1 Introduction 24 -- 3.3.2 Objectives 24 -- 3.3.3 Methodology 24 -- 3.3.4 Views of homeopaths 25 -- 3.3.5 The experience of users 36 -- 4 THE PRACTICE 46 -- 4.1 OBJECTIVE 46 -- 4.2 METHODS 46 -- 4.3 RESULTS 46 -- 4.3.1 Response rate 46 -- 4.3.2 Baseline characteristics 46 -- 4.3.3 Training 47 -- 4.3.4 Practice. 48 -- 4.3.5 Workload and profile of patients 50 -- 4.3.6 Age 51 -- 4.3.7 Provider delay 52 -- 4.3.8 Patient referral: 53 -- 4.3.9 Claims for which homeopathy is used. 55 -- 4.3.10 Type of medicines used and type of homeopathy practiced. 56 -- 4.4 DISCUSSION 56 -- 5 ORGANISATIONAL AND LEGAL ASPECTS 57 -- 5.1 BELGIAN AND EUROPEAN LEGAL FRAMEWORK 57 -- 5.1.1 Introduction 57 -- 5.1.2 Methodology 57 -- 5.1.3 The exercise of conventional healthcare in Belgium under the terms of Royal Decree -- no. 78 57 -- 5.1.4 The exercise of non-conventional medicine in Belgium 59 -- 5.1.5 The relationship between the Colla law and Royal Decree no. 78 65 -- 5.1.6 The consequences of the (non-)conventional exercise of healthcare 67 -- 5.1.7 The exercise of non-conventional medicine in the European context 73 -- 5.1.8 Conclusion concerning the Belgian and European legal framework 74 -- 5.2 THE SITUATION IN THE NETHERLANDS, FRANCE AND THE UNITED KINGDOM 75 -- 5.2.1 Structure of the chapter 75 -- 5.2.2 Netherlands 75 -- 5.2.3 France 77 -- 5.2.4 United Kingdom 79 -- 5.2.5 Conclusion on the situation in the Netherlands, France and the United Kingdom 81 -- 5.3 TRAINING IN HOMEOPATHY 81 -- 5.3.1 Introduction 81 -- 5.3.2 Methods 81 -- 5.3.3 Results 82 -- 5.3.4 Discussion 85 -- 5.3.5 Conclusion 85 -- 5.4 PROFESSIONAL ORGANISATIONS 85 -- 5.4.1 Objectives 85 -- 5.4.2 Methods 86 -- 5.4.3 Results 86 -- 5.4.4 Conclusion 89 -- 5.5 PATIENTS’ ASSOCIATION 90 -- 5.5.1 Objectives 90 -- 5.5.2 Methods 90 -- 5.5.3 Results 90 -- 5.5.4 Conclusion 91 -- 5.6 REIMBURSEMENT POLICY CONCERNING HOMEOPATHY 91 -- 5.6.1 Introduction 91 -- 5.6.2 Methods 91 -- 5.6.3 Results 91 -- 5.6.4 Discussion 92 -- 5.6.5 Conclusion 93 -- 6 OVERVIEW AND DISCUSSION 94 -- 6.1 BACKGROUND 94 -- 6.1.1 Objectives and methods 94 -- 6.2 LIMITATIONS 95 -- 6.3 HOMEOPATHY IN BELGIUM: USERS, PRACTITIONERS AND PRACTICES 96 -- 6.3.1 Increasing use of non-conventional forms of medicine 96 -- 6.3.2 Who are the patients? 96 -- 6.3.3 Who are the practitioners? 97 -- 6.3.4 Typical patient route 98 -- 6.3.5 Financial aspects 99 -- 6.3.6 Patient rating 99 -- 6.4 IS THERE EVIDENCE OF EFFICACY? 100 -- 6.4.1 Scientific literature: no evidence of efficacy 100 -- 6.4.2 Patients’ views 100 -- 6.4.3 What are the risks? 100 -- 6.5 HOW DOES ONE BECOME A HOMEOPATH? 101 -- 6.6 LEGAL FRAMEWORK 101 -- 6.6.1 Background 101 -- 6.6.2 The Colla law 102 -- 6.6.3 Consequences of partial execution of the Colla law 103 -- 6.6.4 Homeopathic remedies 103 -- 7 IN CONCLUSION, WHAT ARE THE FUTURE IMPLICATIONS? 104 -- 7.1 NO SCIENTIFIC EVIDENCE OF CLINICAL EFFICACY EXISTS 104 -- 7.2 ENFORCING COLLA’S LAW? 104 -- 7.3 GUARANTEEING PATIENT SAFETY 104 -- 8 REFERENCES 106

Este documento formula algunas reflexiones sobre la cartera de servicios de salud pública del Sistema Nacional de Salud, elaborando un inventario de la aportación de la Administración General del Estado a la misma, en el contexto descentralizado actualmente vigente en España. Se aprecia la existencia de una importante actividad en salud pública, con cierta dispersión entre diversas dependencias. Buena parte de las actuales actividades de la Administración General del Estado se centran en la monitorización del estado de salud y sus determinantes, gestionando diversos sistemas de información y de alerta, pero con un importante papel en el desarrollo de políticas, como interlocutora de la Unión Europea y como catalizadora con las comunidades autónomas y otras organizaciones que influyen en la salud pública. Además, este nivel de la administración garantiza una serie de servicios esenciales que pueden ser poco visibles para la ciudadanía por prestarse la mayoría a otras administraciones o a grupos profesionales. This paper concentrates on the port folio of public health services in the National Health System, with an inventory of those provided by the central level of government in the currently decentralized context of Spain. There is an important activity in public health, with some dispersion among different bodies and organisations. Most of the current activities of the central level of government concentrate in monitoring health levels and their determinants, managing information systems and health alerts and warnings, but with an involvement in policy development, both as a counterpart of the European Union and as an active agent with both regional levels of government and other organisations influencing public health. Besides, this level of government assures some essential services with little visibility for the general population as they are mostly delivered to other public administrations or to professional groups.

xii, 128 p. ill.

xiii, 128 p. ill.