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Aims This process evaluation aims at identifying the facilitators and inhibitors that influenced the successful uptake of a nurse-led triage system streaming low-risk patients from an emergency department (ED) to the general practitioner (GP). Design & Methods Semi-structured interviews with ED nurses (n = 12), ED doctors (n = 6) from the ED of a Belgian general hospital and GPs (n = 5) affiliated with the adjacent GP cooperative (GPC). The process evaluation ran in parallel with the TRIAGE trial that started in March 2019 and ended 31st of December 2019. The first set of interviews was conducted in June 2019 and the second set in January 2020. Data were analysed based on grounded theory. Results Through a deductive framework, facilitators and inhibitors could be identified on three levels: the organisational, group and individual level. Main inhibitors are the degree of risk aversion of individual nurses, possible language barriers during delivery of the triage advice and the non-adapted ED infrastructure. Training on both the use of the triage protocol and effective delivery of the triage advice, in combination with periodical feedback from the GPC were the most important facilitators. Conclusion Based on the process evaluation we can conclude that a consensus exists among stakeholders that the ED Nurses are considered ideally positioned to perform the triage of walk-in patients, although a certain degree of experience is necessary. Although the extended triage protocol and GPC referral increases the complexity and duration of triage and entails a higher workload for the triage nurses, ED nurses found it did lead to a lower (perceived) workload for the ED in general.

Background During the TRIAGE trial, emergency nurses diverted 13.3% of patients with low-risk complaints from a Belgian emergency department (ED) to the adjacent general practitioner cooperative (GPC). We examined the effects of this diversion on the total cost, insurance costs and patient costs, as charged on the invoice. Changes in the cost composition and the direct impact on revenues of both locations were examined as a secondary objective. Methods The differences in costs between intervention and control weekends were tested with two-sample t-tests and Kolmogorov-Smirnov (KS) tests. For the main outcomes an additional generalised linear model was created. Proportions of patients charged with certain costs were examined using Pearson's chi-square tests. Average revenues per weekend were compared using pooled t-tests. Results During intervention weekends, total costs increased by 3% (€3.3). The costs decreased by 8% (€2.2) for patients and increased by 6% (€5.5) for insurance, mainly driven by differences in physician fees. More patients were charged a consultation fee only (25% vs. 19%, p-value

ObjectivesTo determine the effectiveness and safety of a tool diverting low urgency patients eligible for primary care from an emergency department (ED) to the adjacent general practitioner cooperative (GPC).MethodsUnblinded, randomised controlled trial with weekends serving as clusters (three intervention clusters for each control). The intervention was nurse-led triage using a new tool assigning patients to either ED or GPC. During intervention weekends, patients were encouraged to follow this assignment while it was not communicated to the patients during control weekends (they remained at the ED). The primary outcome was the proportion of patients assigned to and handled by the GPC during intervention weekends. The trial was randomised for the secondary outcome: the proportion of patients assigned to the GPC during intervention and control weekends. Additional outcomes were association of these outcomes with possible confounders (study tool parameters, nurse, and patient characteristics), proportion of patients referred back to the ED by the GPC, hospitalisations, and performance of the study tool to detect primary care eligible patients (with the opinion of the treating physician as the gold standard).ResultsIn the intervention group, 838/6374 patients (13.3%, 95% CI 12.5 to 14.2) were assigned to the GPC (secondary outcome), in the control group 431/1744 (24.7%, 95% CI 22.7 to 26.8). In the intervention group, 599/6374 patients (9.5%, 95% CI 8.8 to 10.3) experienced the primary outcome which was influenced by the chosen MTS presentational flowchart, patient’s age, and the nurse. 24/599 patients (4.0%, 95% CI 2.7 to 5.9) patients were referred back to the ED of which three were hospitalised. Positive and negative predictive values of the studied tool during intervention weekends were 0.96 (95%CI 0.94 to 0.97) and 0.60 (95% CI 0.58 to 0.62). Out of the patients assigned to the GPC, 2.4% (95% CI 1.7 to 3.4) were hospitalised.ConclusionsED nurses using a new tool safely diverted 9.5% of the included patients to primary care.ClinicalTrials.gov IdentifierNCT03793972FundingResearch Foundation – Flanders (FWO)

Background Out-of-pocket payments have a diverse impact on the burden of those with a higher morbidity or the chronically ill. As the prevalence of chronic diseases increases with age, older adults are a vulnerable group. The paper aims to evaluate the impact of chronic diseases on the out-of-pocket payments burden of the 50+ populations in Belgium, the Czech Republic and Germany. Methods Data from the sixth wave of the Survey of Health, Ageing and Retirement in Europe is used. A two-part model with a logit model in the first part and a generalised linear model in the second part is applied. Results The diseases increasing the burden in the observed countries are heart attacks, high blood pressure, cancer, emotional disorders, rheumatoid arthritis and osteoarthritis. Reflecting country differences Parkinson’s disease and its drug burden is relevant in Belgium, the drugs burden related to heart attack and outpatient care burden to chronic kidney disease in the Czech Republic and the outpatient care burden of cancer and chronic lung disease in Germany. In addition, we confirm the regressive character of out-of-pocket payments. Conclusions We conclude that the burden is not equitably distributed among older adults with chronic diseases. Identification of chronic diseases with a high burden can serve as a supplementary protective feature.

Background Eswatini is facing a critical shortage of human resources for health (HRH) and limited access to multidrug-resistant tuberculosis (MDR-TB) treatment in rural areas. This study assessed multiple stakeholders’ perceptions of task-shifting directly observed treatment (DOT) supervision and administration of intramuscular MDR-TB injections to lay health workers (LHWs). Methods A mixed methods study comprising a cross-sectional survey using a semi-structured questionnaire with community treatment supporters (CTSs) and a focus group discussion with key stakeholders including representatives from the Eswatini Ministry of Health (MOH), donor organisations, professional regulatory institutions, nursing academia, civil society and healthcare providers was conducted in May 2017. Descriptive statistics, thematic content analysis and data triangulation aided in the interpretation of results. Results A large majority of CTSs (n = 78; 95.1%) were female and 33 (40.2%) were older than 50 years. Most (n = 7; 70.0%) key stakeholders had over 10 years of work experience in policy-making, advocacy in the fields of HRH or day-to-day practice in MDR-TB management. Task-shifting of MDR-TB injection administration was implemented without national policy guidance and regulation. Stakeholders viewed the strategy to be driven by the prevailing shortage of professional frontline HRH and limited access to MDR-TB treatment. Task-shifting was perceived to improve medication adherence, and reduce stigma and transport-related MDR-TB treatment access barriers. Frontline healthcare workers and implementing donor partners fully supported task-shifting. Policy-makers and other stakeholders accepted task-shifting conditionally due to fears of poor standards of care related to perceived incompetence of CTSs. Appropriate compensation, adequate training and supervision, and non-financial incentives were suggested to retain CTSs. A holistic task-shifting policy and collaboration between the MOH, academia and nursing council in regulating the practice were recommended. Conclusions Stakeholders generally accepted the delegation of DOT supervision and administration of intramuscular MDR-TB injections to LHWs as a strategy to increase access to treatment, albeit with some apprehension. Findings from this study stress that task-shifting is not a panacea for HRH shortages, but a short-term solution that must form part of an overall simultaneous strategy to train, attract and retain adequate numbers of professional healthcare workers in Eswatini. To address some of the apprehension and ambivalence about expanding access to MDR-TB services through task-shifting, attention should be paid to important aspects such as competence-based training, certification and accreditation, adequate supportive on-the-job supervision, recognition, compensation, and expediting policy and regulatory support for LHWs.

Background Breast cancer accounts for 10 to 20 percent of the total cancer cost. The direct cost of cancer care are the health care expenses directly related to prevention and cancer treatment. The indirect cost, 2-3 times the direct cost include presenteeism, disability to work, absenteism and workers compensation. The aim of this study is to achieve a better understanding of the direct cost and the importance of the variables. Methods This retrospective descriptive study used the administrative data of AZ KLINA linked to the Cancer Registry of Belgium. The study comprised women diagnosed with breast cancer between July 2015 and December 2015. The direct health care costs were calculated for the diagnostic and treatment phase up to 365 days after diagnosis. The costs were grouped according to the different kinds of medical interventions. Regression analyses were performed for 3 dependent variables i.e. the patient contribution, the health insurance cost and the total cost. The type of room, age, chemotherapy, radiation therapy, antibody therapy, disease stage, number of hospital visits and right for increased reimbursement were independent variables. Results The study population included 107 patients. The total mean cost of the diagnostic phase was 817 €, divided into the personal contribution of 80 € and the health insurance cost of 737 €. The mean patient cost of the treatment phase was 1.712 €, for the health insurance 17.282 €. The regression analyses revealed the number of hospital visits was significantly associated with total cost, patient cost and health insurance cost. The patient cost was highly predictive by the choice of the room. The total cost of the diagnostic phase for 107 patients was 87.377 €. Imaging 32.742 € and pathology 32.895 € were most important, followed by pharmacy 9.641 € and consultation 6.598 €. In the treatment phase radiotherapy 436.247 €, antibody treatment with trastuzumab 326.961 € were most important, followed by chemotherapy 189.729 €, hospitalisation cost 153.026 €, pathology cost 144.239 €, and surgery cost 134.251 €. Conclusions In our study an estimation was given of all direct medical costs of breast cancer of the diagnostic and treatment phase. The results can inform hospital executives and policy makers to determine further strategic decisions for financing breast cancer care. Legal entity responsible for the study University of Antwerp. Funding Has not received any funding. Disclosure All authors have declared no conflicts of interest.

Fairness in the finance of health care relates to the distribution of health-care payments across the population and is an important issue for most health-care systems. The focus is on whether payments for health care are in accordance with ability to pay and on whether households are protected against catastrophic expenses. This article describes and discusses the methodologies used in measuring both (in)equity concepts. Further an overview is given of empirical results covering developed as well as developing countries. Finally, some policy concerns about improving equity are highlighted.

ObjectivesThis Schizophrenia Outcome Survey compared medical costs, psychopathology and adverse events in outpatients for 2 years following hospitalisation for an acute schizophrenic episode.MethodsAdults stabilised with haloperidol, olanzapine or risperidone entered this observational study ≤1 month after discharge and were assessed at baseline, 3, 6, 12, 18 and 24 months using Brief Psychiatric Rating Scale (BPRS), Clinical Global Impression (CGI), Global Assessment of Functioning and adverse events reporting.ResultsAmong 323 patients (haloperidol 32, olanzapine 149, risperidone 142), baseline characteristics were similar in the olanzapine and risperidone groups, except for more first episodes in the risperidone group (p = 0.01). Haloperidol patients were more often single and institutionalised, less educated, had more residual schizophrenia, were longer hospitalised in the previous year, took more corrective and psychotropic drugs and had more extrapyramidal symptoms (EPS) and gynaecomastia (all significantly). Sixty-eight percent of patients completed a 2-year follow-up. In all groups, CGI and GAF improved during the first 3 months (both p < 0.0001) while BPRS deteriorated in the first year (all within group changes p < 0.05, between group changes NS) before it stabilised. There were no significant differences in hospitalisations and no change in social profile. At the last visit, 66% of haloperidol (p < 0.01), 35% of olanzapine (NS) and 39% (NS) of risperidone patients had ≥1 EPS; 69% (p < 0.013), 40 and 44%, respectively, had ≥1 sexual problem (NS). Mean weight gain was 0.4 (NS), 2.6 (p < 0.05) and 2.6 kg (p < 0.05), respectively.ConclusionsIn this naturalistic study, treatment allocation might have introduced a bias in the interpretation of efficiency results, but olanzapine and risperidone caused less EPS than haloperidol during 2 years of outpatient follow-up.

Objective: To estimate the cost effectiveness of olanzapine and risperidone for the treatment of schizophrenia in Belgium. Methods: Data were retrieved from a prospective, observational, non-randomized, follow-up survey. Clinical investigators assigned 265 patients with schizophrenia to either olanzapine (n - 136) or risperidone (n - 129). Patients were followed up for 2 years. Total healthcare costs were determined from the public payer perspective and calculated by multiplying resource use with official tariffs; effectiveness of the drugs was measured with the EQ-5D. This study uses a net-benefit regression approach to accommodate for baseline differences between treatment groups and uncertainty. Results: Total 2-year costs were very similar for patients receiving risperidone and olanzapine (€20 915.33 and €20 569.69, respectively; p - 0.925) &lsqb;year 2002 values&rsqb;. The health condition of the patients receiving risperidone was better than that of patients receiving olanzapine but not significantly so (1.46 and 1.41, respectively; p - 0.191). Simple ordinary least squares (OLS) regressions indicated that, for λ - €40 000, we could not reject the null hypothesis that the drugs provide similar net monetary benefits to the patient (risperidone vs olanzapine €2046.95; p - 0.656). When we controlled for several patient characteristics, risperidone moved further away from olanzapine but the difference did not reach statistical significance (risperidone vs olanzapine €3198.07; p - 0.595). Numerous sensitivity analyses confirmed the robustness of the results. Conclusion: Results of this study suggest that it is important to control for baseline patient characteristics when performing a cost-effectiveness analysis. No significant difference in net monetary benefit was found between risperidone and olanzapine.

Objective To estimate the burden of disease and related direct medical cost of Acute Respiratory Infections (ARI) for the health-care system in a low-income district of Bogota, generated by children under age five and senior population over age sixty. Methods A cross-sectional, retrospective, patient level study was conducted in San Cristobal district from 2008 to 2012 among the subsidized population. All inpatients and outpatients with ARI from three hospitals were reported. The total and average direct medical costs were estimated and are reported in International Dollars (Int$). Results It is estimated that, for children, ambulatory incidence rate for ARI varied between 54.4 % and 66.3 % and hospitalization rate between 9.2 % and 12.3 %. The mortality rate in the district oscillated between 18.1 and 27.7 deaths per 100000. The main medical costs where attributed to hospitalizations, and the total medical hospitalization cost per year estimated ranged between Int$ 1,334,352 and Int$ 2,139,597. In the case of senior population, the ambulatory incidence rate fluctuated between 7.6 % and 10.0 %, and the hospitalization rates between 0.6 % and 2.1 %; the mortality rate ranged between 8.9 and 47.8 deaths per 100.000. Hospitalization cost per year was estimated to be between Int$ 88,957 and Int$ 373,382. Conclusion Direct medical costs due to ARI have an important disease and direct medical cost burden in this low-income district.

Background The Colombian health authorities introduced the pneumococcal conjugated vaccine and the seasonal influenza vaccine into the national immunization schedule for children in 2009 and 2007, respectively. Despite this, the health authorities continue to be concerned about the high economic and disease burden among children from low-income households caused by these vaccine-preventable diseases. Objectives 1) To evaluate the potential health outcomes of four vaccination strategies for subsidized children younger than 5 years in a low-income district in Colombia from a public, direct medical health care perspective. 2) To perform univariate, multivariate, and probabilistic sensitivity analysis to evaluate the robustness of these results. Methods We built a Markov deterministic cohort model to evaluate five consecutive cohorts across four alternative situations: 1) no vaccination; 2) vaccination with the 10-valent pneumococcal conjugate vaccine (PCV10 vaccine); 3) vaccination with the trivalent inactivated vaccine (TIV) annually; and 4) combined vaccination with PCV10 vaccine and TIV. Results The introduction of PCV10 vaccine and TIV and their combined use in particular would be highly cost-effective in comparison to no vaccination. For the combined vaccination with PCV10 vaccine and TIV, the incremental cost-effectiveness ratio would be $1,280 per disability-adjusted life-year (DALY) averted, the total incremental cost of the vaccination program would be $776,800, and it would avert four deaths and 332 DALYs for the five cohorts. Conclusions The introduction of PCV10 vaccine and TIV would be highly cost-effective from a public, direct medical health care perspective. Despite these results, we have not observed decreases in severity or hospitalizations. Our findings highlight the need for further studies of the immunization campaign indicators and socioeconomic indicators for this low-income community.

This study investigated the presence of order bias in contingent valuation studies. We compared the willingness to pay (WTP) for an improved drug for attention-deficit/hyperactivity disorder with that for the standard drug and examined whether the order in which the drugs are presented influences the results obtained. A pretested questionnaire was administered to 114 university students. WTP was elicited using the payment card method. A split sample was used to test order bias. The average WTP per month was euro 57.34 for the standard drug and euro 81.95 for the new drug. The results show that WTP for a new drug varies according to the order in which the drugs are presented. Respondents stated a higher WTP for the new drug if the standard therapy was presented first. This may be due to order bias, evidence of which has also been found in other studies and which is considered to be a limitation of the method. Finally, the use of marginal WTP is suggested as a solution.

In this review, the economic aspects of pneumococcal pneumonia are analysed, including the costs, cost effectiveness and cost benefit of treatment and prevention. We identified eight cost-of-illness studies, 15 analyses comparing the costs of different treatment options and 15 economic evaluations of prevention that met our search criteria. The studies were conducted largely in Europe and the US. Most pertained to community-acquired pneumonia (CAP) in general, without specific analysis of pneumococcus-related illness. Many of the studies were considered to be of poor quality for the following reasons: comparison without randomisation or control variables, disregard of health outcomes, small sample size, restriction of costs to drug costs and vague or disputable sources of cost information. In the US, hospitalisation costs resulting from CAP can be estimated to be between US 7,000 dollars and US 8,000 dollars per admission or US 4 million dollars per 100,000 population. Hospitalisation costs are significant (representing about 90% of total costs), but are much lower in Europe than in the US (one-third to one-ninth of the US estimates in the UK and Spain, respectively). In general, economic studies of treatment for pneumococcal pneumonia are in line with clinical evidence. A drug with proven clinical effectiveness would also appear to be supported from an economic stand point. Furthermore, economic data support an early switch from an intravenous to an oral antibacterial, the use of quinolones for inpatients with CAP, and also the use of guidelines built on clinical evidence. Of all the possible preventive strategies for pneumococcal pneumonia, only vaccination has been subjected to economic evaluation. Pneumococcal polysaccharide vaccine seems relatively cost effective (and potentially cost saving) for those between 65 and 75 years of age, for military recruits and for HIV positive patients with a sufficiently high CD4 cell count. Evaluations of the pneumococcal conjugate vaccine (PCV) indicate the price of the vaccine to be the main determinant of cost effectiveness. As the current price is high (in the order of US 50 dollars per dose), the economic attractiveness of the universal PCV vaccination strategies hinges on the potential for price reductions and the willingness of decision makers to adopt a societal perspective.

This article summarises, extends and updates previous empirical work on the distributional implications of alternative health care financing arrangements in a selection of European countries and the US. On the one hand, total health care payments are almost proportional to ability to pay in most countries. This is predominantly driven by a high reliance on public financing. On the other hand, private payments – out-of-pocket payments as well as private insurance premiums – are highly regressive. More extended reliance on private financing may therefore endanger the equitable nature of financing systems. In addition, private payments put a heavy burden on unfortunate households.

Pneumococcal vaccination of older persons is thought to be cost-effective in preventing pneumococcal pneumonia, but evidence of clinical protection is uncertain. Because there is better evidence of vaccination effectiveness against invasive pneumococcal disease, we determined the cost-effectiveness of pneumococcal vaccination of persons agedor =65 years in preventing hospital admission for both invasive pneumococcal disease and pneumococcal pneumonia in 5 western European countries. In the base case analyses, the cost-effectiveness ratios for preventing invasive disease varied from approximately 11,000 to approximately 33,000 European currency units (ecu) per quality-adjusted life year (QALY). Assuming a common incidence (50 cases per 100,000) and mortality rate (20%-40%) for invasive disease, the cost-effectiveness ratios were12,000 ecu per QALY in all 5 countries. For preventing pneumococcal pneumonia, vaccinating all elderly persons would be highly cost-effective to cost saving. Public health authorities should consider policies for encouraging pneumococcal vaccination for all persons agedor =65 years.

This paper presents a comparison of horizontal equity in health care utilization in 10 European countries and the US. It does not only extend previous work by using more recent data from a larger set of countries, but also uses new methods and presents disaggregated results by various types of care. In all countries, the lower-income groups are more intensive users of the health care system. But after indirect standardization for need differences, there is little or no evidence of significant inequity in the delivery of health care overall, though in half of the countries, significant pro-rich inequity emerges for physician contacts. This seems to be due mainly to a higher use of medical specialist services by higher-income groups and a higher use of GP care among lower-income groups. These findings appear to be fairly general and emerge in countries with very diverse characteristics regarding access and provider incentives.

Background Increasing cost pressure and changing patients’ needs in the healthcare sector have led to new delivery models for primary care. Researchers and practitioners need to establish innovative methods to obtain insights into patients’ preferences and effectiveness of healthcare services. Aim This study reveals the crucial decision criteria of patients in choosing out-of-hours services and provides a projection of a future market share of the newly established central out-of-hours service, called General Practitioner Cooperative. Design A computer-aided discrete choice experiment. Method Respondents were 350 patients in a European city who decided for a service when confronted with a medical emergency in an out-of-hours case; two scenarios called ‘adult’ and ‘child’, describing the persons requiring medical assistance, were used to increase generalizability. Results The two most important attributes were ‘explanation by the doctor’ and ‘waiting time’ while the others – ‘availability of technical equipment’, ‘ease of access’, ‘type of consultation’ and ‘payment method’ – were of less importance. The market share projections predict that the new General Practitioner Cooperative will capture about one third of the market (‘adult’: 39.1%, ‘child’: 31.3%), ahead of the emergency department, the second most preferred service (‘adult’: 32.7%, ‘child’: 30.7%). Conclusions This study quantifies the adoption of a new medical service. As a result, it extends current research approaches on eliciting and matching patient's needs and assists policy makers in establishing adequate service capacities.

Objective: In this article we investigate the possibility to account for selection bias in observational data by using econometric techniques. Objective: In this article we investigate the possibility to account for selection bias in observational data by using econometric techniques. Methods: One-year costs of 15,237 patients who received a drug-eluting stent (DES) or a bare metal stent (BMS) in Belgium in 2004 were compared. The treatment choice between DES and BMS could be influenced by patient characteristics; therefore, cost estimates could be biased by overt and/or hidden selection bias. Overt bias was addressed by regression adjustment and propensity score matching. Hidden selection bias was dealt with by using an instrumental variable (IV) approach. Results: Due to the higher purchase price DES patients incur higher (unadjusted) costs in the short-term; these costs are, however, compensated in the long-term due to less in-stent restenosis and hospitalizations. Analyses indicated that, for the diabetic population, the null hypothesis of similar average 1-year costs of patients receiving a BMS or DES cannot be rejected. For the non-diabetic patients a significant cost difference between BMS and DES patients was found. It cannot be ruled out that the treatment-effect model does not correct for all observable or unobservable characteristics and that the estimated treatment effect is biased, possibly due to weak instruments. Conclusion: It is interesting and necessary to explore the use of econometric tools in cost and cost effectiveness analysis to investigate the effect of a technology in everyday practice and to take into account patient and disease characteristicsanduncertainty. Further research ishowever necessary to investigate how we can fully correct for selection bias when using observational data.between DES and BMS could be influenced by patient characteristics; therefore, cost estimates could be biased by overt and/or hidden selection bias. Overt bias was addressed by regression adjustment and propensity score matching. Hidden selection bias was dealt with by using an instrumental variable (IV) approach. Results: Due to the higher purchase price DES patients incur higher (unadjusted) costs in the short-term; these costs are, however, compensated in the long-term due to less in-stent restenosis and hospitalizations. Analyses indicated that, for the diabetic population, the null hypothesis of similar average 1-year costs of patients receiving a BMS or DES cannot be rejected. For the non-diabetic patients a significant cost difference between BMS and DES patients was found. It cannot be ruled out that the treatment-effect model does not correct for all observable or unobservable characteristics and that the estimated treatment effect is biased, possibly due to weak instruments. Conclusion: It is interesting and necessary to explore the use of econometric tools in cost and cost effectiveness analysis to investigate the effect of a technology in everyday practice and to take into account patient and disease characteristicsanduncertainty. Further research ishowever necessary to investigate how we can fully correct for selection bias when using observational data.

The effects of immunisation programmes that have existed for several decades in developed countries are demonstrated by the decrease and even eradication of smallpox, poliomyelitis, measles, mumps and hepatitis B. Cost, health policy and spontaneous evolution in the incidence of communicable diseases have a decisive influence on the use of a vaccine. Investment in vaccination policy has to be encouraged to maintain this progress made in the control of infectious diseases and to meet new challenges. Studies re-evaluating ongoing immunisation programmes are scarce. Nevertheless, it can be concluded that for vaccination against hepatitis B in professionally exposed at-risk populations, arguments for positive returns are consistent. The same holds for vaccination against S. pneumoniae and for influenza virus in the elderly. The results of the economic evaluation of revaccination against measles, when insufficient coverage exists, are inconclusive. Universal vaccination of children against Haemophilus influenzae type b (Hib) and of children of hepatitis B-positive mothers against hepatitis may require costs to be paid in order to gain extra health benefits.

Introduction In many countries, a reassessment of after-hours primary care has become necessary. In particular, centralised general practitioner deputizing services (GPDS) have emerged. In this study, consumers' preferences for after-hours medical care were obtained and the use of the new GPDS was predicted.Method On the basis of the Theory of Reasoned Action, a survey was developed that was used at the Free Newborn and Child health care services in Antwerp. Consumers were asked about their knowledge, experience and perceptions concerning the performance of different medical services.Results 350 questionnaires were used for analysis. 98.6% of the respondents knew about the existence of the emergency department, whereas the GPDS was known by 81.7% of the respondents. The main reasons for preferring emergency department over the other services were an easy access, good explanation by the doctor and a late due time of the payment. Respondents preferred the GPDS mainly because of an expected shorter waiting time. Experience had a strong positive influence on choosing a particular after-hours medical service.Conclusion In our study, the consumers' preferences concerning after-hours medical care were assessed. The following items are crucial for choosing after-hours care: experience with the services, easy access to the service, explanation by the doctor about the illness and the treatment and waiting time.

The effects of supplemental health insurance on health-care consumption crucially depend on specific institutional features of the health-care system. We analyse the situation in Belgium, a country with a very broad coverage in compulsory social health insurance and where supplemental insurance mainly refers to extra-billing in hospitals. Within this institutional background, we find only weak evidence of adverse selection in the coverage of supplemental health insurance. We find much stronger effects of socio-economic background. We estimate a bivariate probit model and cannot reject the assumption of exogeneity of insurance availability for the explanation of health-care use. A count model for hospital care shows that supplemental insurance has no significant effect on the number of spells, but a negative effect on the number of nights per spell. We comment on the implications of our findings for equality of access to health care in Belgium.

Objectives: Although there is a comprehensive public health insurance system in Belgium, out-of-pocket expenditures can be very high, mainly for inpatients. While a large part of the official price is reimbursed, patients are confronted with increased extra billing (supplements). Therefore, the government imposed various restrictions on the amount of supplements to be charged, related to the type of room and the patient's insurance status. We investigate how prices are set and whether the restrictions have been effective. Methods: We use an administrative dataset of the Belgian sickness funds for the year 2003 with billing data per hospitalisation and hospital characteristics. Boxplots describe the distribution of several categories of supplements. OLS is used to explore the relationship between hospital characteristics and extra billing. Results: There is a large and intransparent variation in extra billing practices among different hospitals. Given the room type, supplements per day are smaller for patients qualifying for protection, confirming that the regulation is applied quite well. However, because of their longer length of stay this does not result in lower supplements per stay for these patients. Conclusions: Currently the price setting behavior of providers lacks transparency. Protective regulation could be refined by taking into account the longer length of stay of vulnerable groups. (C) 2009 Elsevier Ireland Ltd. All rights reserved.

Fairness in the finance of health care relates to the distribution of health-care payments across the population and is an important issue for most health-care systems. The focus is on whether payments for health care are in accordance with ability to pay and on whether households are protected against catastrophic expenses. This article describes and discusses the methodologies used in measuring both (in)equity concepts. Furthermore, an overview is given of empirical results covering developed as well as developing countries. Finally, some policy concerns about improving equity are highlighted.

Objective - Recent evidence shows that drug-eluting stent devices (DES) substantially reduce the risk of in-stent restenosis compared with classic bare metal stent devices (BMS). In Belgium, however, the use of BMS is still standard procedure due to the higher prices of the newer DES. Although the use of DES is more expensive in the short term it might be beneficial in the long term due to the avoidance of revascularization costs. The primary objective of this study is to compare the net cost of DES and BMS from the perspective of Belgian health care. Methods and results - Cost differences between DES and BMS are determined by the difference in stent price and the difference in the rate of re-intervention.The cost of revascularization of patients with in-stent restenosis was estimated based on data gathered at the Antwerp University hospital (UZA). Data on effectiveness were obtained from a literature meta-analysis. Because of some important study limitations, a sensitivity analysis was included in this study. In general, the use of DES was cost saving as compared with BMS, with savings amounting to ? 165 for Cypher stent devices and ? 128 for Taxus stent devices in the base case scenario. For patients with a high risk of restenosis net savings persist in almost all sensitivity analyses. Conclusion - The use of DES in patients with a high in-stent restenosis risk is cost saving. Price evolutions in the stent device market predict that the use of DES, if not yet cost saving, will become cost saving in the near future for all types of patients. Recent evidence, however, casts some doubt on the long-term effectiveness of DES.

It has been suggested that the unequal coverage of different socio-economic groups by supplemental insurance could be a partial explanation for the inequality in access to health care in many countries. We analyse the situation in Belgium, a country with a very broad coverage in compulsory social health insurance and where supplemental insurance mainly refers to extra-billing in hospitals. We find that this institutional background is crucial for the explanation of the effects of supplemental insurance. We find no evidence of adverse selection in the coverage of supplemental health insurance, but strong effects of socio-economic background. A count model for hospital care shows that supplemental insurance has no significant effect on the number of spells, but a negative effect on the number of nights. This is in line with patterns of socio-economic stratification that have been well documented for Belgium. It is also in line with the regulation on extra-billing protecting patients in common rooms. For ambulatory care, we find a positive effect of supplemental insurance on visits to a dentist and on number of spells at a day centre but no effect on visits to a GP, on drugs consumption and on visits to a specialist.

OBJECTIVES: This study determines the cost-effectiveness of 3 antipsychotics for the treatment of schizophrenia in Belgium. METHODS: Data were retrieved from a prospective observational non randomized follow-up survey. Clinical investigators included 293 schizophrenic patients; 136 of those patients were assigned to Olanzapine, 129 to Risperidone and 28 to Haloperidol. Patients were followed for 2 years. Total health care costs were determined from the perspective of the public payer and calculated by multiplying resource use with official tariffs; effectiveness of the drugs was measured with EQ-5D. Several studies have already compared the cost-effectiveness of different antipsychiotics for the treatment of schizophrenia, most of them are however flawed by methodological issues. This study therefore uses a new method that was developed to address these limitations but is not widely used yet: the net-benefit regression approach (NBRA). We show its merits by performing a cost-effectiveness analysis of Olanzapine, Risperidone and Haloperidol. RESULTS: Models were checked for selection bias but drug choice was not endogenous; we therefore proceeded with simple OLS regressions. The results indicate that the drugs provide similar net monetary benefits to the patient (H vs O -4452.53 (p=0.645), R vs O 4439.54 (p=0.425), R vs H 8892.07 (p=0.366)). When we control for several patient characteristics R moves away further from H and O but the difference does not reach statistical significance (R vs O 5857.73 (p=0.332), R vs H 15233.53 (p=0.178)). Several important patient subgroups were also identified; they indicate that a drug performs better in a specific patient group. Numerous sensitivity analyses confirm the robustness of the results. CONCLUSION: We conclude by confirming that the NBRA is an important enrichment to the CEA methodology. As was demonstrated in this paper, it is often important to correct cost-effectiveness results for patient characteristics and to identify significant patient subgroups.

Background: The purpose of this study was to provide quantitative information on the economic, social and emotional burden borne by families of children with attention-deficit hyperactivity disorder (ADHD) and on the public healthcare costs of a child with ADHD in Flanders, Belgium, and to compare costs of ADHD children with those of siblings without the disorder. Methods: A pilot-tested questionnaire was sent to all members of the Flemish ADHD society in February 2003. Parents were asked to record utilisation of healthcare, social care and other non-medical resources for their ADHD child and his/her sibling. In addition, data were collected on ADHD severity (IOWA-Conners Rating Scale) and on the sociodemographic and economic characteristics of the parents. Parents’ out-of-pocket and public annual costs were calculated using tariffs. These costs were corrected for several confounding variables using general linear model (GLM) estimates. Results: ADHD affects school results and parents’ productivity and places a psychological and emotional burden on the family. Childhood ADHD also results in a significantly higher use of healthcare: ADHD children have a significantly higher probability of visiting a general practitioner (60.3% vs 37.4%) and a specialist (50.9% vs 12.9%); they also visit the emergency department significantly more often (26% vs 12.1%), and they are hospitalised significantly more often (14% vs 8.4%). Consequently, Flemish children with ADHD incur significantly higher medical costs than their siblings without the disorder. Even after correction for several covariates, these cost differences are still striking. In fact, compared with their sibling, the annual cost for an ADHD child is more than six times higher for the parent (€588.3 vs €91.5), and public costs are twice as high (€779 vs €371.3) [year of costing 2002]. Conclusions: Childhood ADHD results in significantly higher use of healthcare and adversely affects academic achievements and parents’ productivity.

Patients with schizophrenia suffer numerous relapses and rehospitalizations that are associated with high direct and indirect medical expense. Suboptimal therapeutic efficacy and, in particular, problems with compliance are major factors leading to relapse. Atypical antipsychotic agents offer improved efficacy and a lower rate of extrapyramidal adverse effects compared with conventional antipsychotic drugs. Long-acting intramuscular risperidone combines these benefits with improvements in compliance associated with depot injections. To assist decision making regarding the place of long-acting risperidone in therapy, a cost-effectiveness analysis of strategies involving first-line treatment with long-acting risperidone, oral olanzapine or depot haloperidol was performed from the perspective of the Belgian healthcare system. A decision tree model was created to compare the cost effectiveness of three first-line treatment strategies in a sample of young schizophrenic patients who had been treated for 1 year and whose disease had not been diagnosed for longer than 5 years. The model used a time horizon of 2 years, with health state transition probabilities, resource use and cost estimates derived from clinical trials, expert opinion and published prices. The four health states in the model were derived from an analysis of the literature. The principal efficacy measure was the proportion of patients successfully treated, defined as those who responded to initial treatment and who had none to two episodes of clinical deterioration without needing a change of treatment over the 2-year period. Comprehensive sensitivity analysis was carried out to test the robustness of the model. A greater proportion of patients were successfully treated with long-acting risperidone (82.7%) for 2 years, compared with those treated with olanzapine (74.8%) or haloperidol (57.3%). Total mean costs per patient over 2 years were 16,406 Euro with long-acting risperidone, 17,074 Euro with olanzapine and 21,779 Euro with haloperidol (year of costing 2003). The mean cost-effectiveness ratios were 19,839 Euro, 22,826 Euro and 38,008 Euro per successfully treated patient for long-acting risperidone, olanzapine and haloperidol, respectively. Results of the sensitivity analysis confirmed that the results were robust to a wide variation of different input variables (effectiveness, dosing distribution, patient status according to healthcare system). Long-acting risperidone was the dominant strategy, being both more effective and less costly than either oral olanzapine or depot haloperidol. Long-acting risperidone appears to represent a favourable first-line strategy for patients with schizophrenia requiring long-term maintenance treatment.