Bias and discrimination by healthcare professionals threaten quality of care and disproportionately affect minorities and vulnerable individuals, thereby contradicting ethical standards of equal treatment. During professional socialisation, health profession students acquire clinical skills and internalise norms and behaviours by observing healthcare professionals. This study explored biased and discriminatory behaviour towards patients in clinical training environments, as observed by health profession students. Within a cross-sectional online study (N = 2176 students) on discrimination in healthcare at ZHAW Zurich University of Applied Sciences, School of Health Sciences, Switzerland, in June and September 2024, students’ experiences of witnessing biased and discriminatory patient care were assessed. Free-text responses were analysed qualitatively using deductive and inductive coding according to Kuckartz. Out of 2176 eligible BSc and MSc healthcare students, 422 answered the question whether they had observed biased or discriminatory care of patients by healthcare staff during clinical training (response rate 19.4

BACKGROUND:Unconscious bias refers to automatic, implicit attitudes or stereotypes that influence our understanding, decisions, and actions without our conscious awareness. It is recognised as a significant problem in healthcare contributing to disparities in treatment. To date it remains unclear how unconscious bias towards patients develops among health professionals. One hypothesis is that such bias is acquired during education, either through teaching content or by observing other health professionals interacting with patients and adopting their behaviour. We investigated whether health care students show an unconscious bias and whether there are indications that it develops during their professional education. METHODS:We conducted a factorial survey experiment with bachelor's and master's students enrolled in various health professions' programmes. Unconscious bias was assessed using three written vignettes describing clinical situations involving patients. Participants were asked to evaluate their likelihood of helping immediately, expected patient adherence, and expected quality of the patient relationship. Vignette dimensions contained common sources of bias that were experimentally manipulated: gender, age, socio-economic status, migration status, diagnosis (physical or mental illness), and sexual orientation. Multivariable regression models were used to estimate the causal effects of patient characteristics on vignettes on students' responses. Additionally, an Implicit Association Test (IAT) on unconscious bias regarding homosexuality was used to measure implicit bias. Explicit attitudes were assessed via self-report. RESULTS:A total of 470 students (response rate 21.5%) participated. Vignette analysis showed no differences in stated helping intention, adherence expectations, or relationship assessments with regard to patient characteristics such as gender, age, socio-economic status, foreign name, sexual orientation or diagnosis. No systematic differences were observed for subgroups of participants such as year of study, programme type, prior work experience, or reported exposure to bias behaviour by health care staff. Similarly, IAT results indicated no overall bias towards homosexuality. CONCLUSIONS:We found no evidence of systematic unconscious bias among students' helping intentions, expected patient adherence, and expected patient relations across various patient characteristics. Comparisons across study years and programs provided no indication that such biases emerge or intensify during training. If replicated, these results would be encouraging, as it indicates an absence of unconscious bias in health care students.

The relationship between nurses and patients is particularly important, as nursing activities often require a high degree of intimacy. To promote an open, honest, reciprocal and equal relationship, nurses disclose personal information and experiences about themselves. Nurses belonging to the LGBTIQ + community, however, may fear stigmatisation or rejection from their patients if they disclose their sexual orientation or gender identity. This study aims to explore how nurses belonging to the LGBTIQ + community navigate their relationship with patients under these circumstances. A qualitative descriptive approach with semi-structured interviews was applied. Interviews with eight nurses who identified themselves as members of the LGBTIQ + community, were conducted. When building relationships, nurses belonging to the LGBTIQ + community often experience a dilemma as to whether they want to come out to a patient in a care situation/encounter. When patient-carer relationships are being built, there is often a heightened focus on striking a balance between not revealing too much or too little information about themselves. In everyday life, nurses belonging to the LGBTIQ + community often face the dilemma of a desire for authenticity and the fear of rejection. Disclosing personal information and experiences, (to the right degree), can help build relationships.

Objectives: As there is no ranking designed for schools of Public Health, the aim of this project was to create one.Methods: To design the Public Health Academic Ranking (PHAR), we used the InCites Benchmarking and Analytics™ software and the Web Of Science™ Core Collection database. We collected bibliometric data on 26 schools of Public Health from each continent, between August and September 2022. We included 11 research indicators/scores, covering four criteria (productivity, quality, accessibility for readers, international collaboration), for the period 2017–2021. For the Swiss School of Public Health (SSPH+), a network gathering faculties across different universities, a specific methodology was used, with member-specific research queries.Results: The five top schools of the PHAR were: London School of Hygiene and Tropical Medicine, Public Health Foundation of India, Harvard T.H. Chan School of Public Health, SSPH+, Johns Hopkins Bloomberg School of Public Health.Conclusion: The PHAR allows worldwide bibliometric ordering of schools of Public Health. As this is a pilot project, the results must be taken with caution. This article aims to critically discuss its methodology and future improvements.

BACKGROUND:Unconscious biases are one of the causes of health disparities. Health professionals have prejudices against patients due to their race, gender, or other factors without their conscious knowledge. This review aimed to provide an overview of research on unconscious bias among health professionals and to investigate the biases that exist in different regions of the world, the health professions that are considered, and the research gaps that still exist. METHODS:We conducted a scoping review by systematically searching PubMed/MEDLINE, CINAHL, PsycINFO, PsycARTICLES, and AMED. All records were double-screened and included if they were published between 2011 and 2021. RESULTS:A total of 5186 records were found. After removing duplicates (n = 300), screening titles and abstracts (n = 4210), and full-text screening (n = 695), 87 articles from 81 studies remained. Studies originated from North America (n = 60), Europe (n = 13), and the rest of the world (n = 6), and two studies were of global scope. Racial bias was investigated most frequently (n = 46), followed by gender bias (n = 11), weight bias (n = 10), socio-economic status bias (n = 9), and mental illness bias (n = 7). Most of the studies were conducted by physicians (n = 51) and nurses (n = 20). Other health care professionals were rarely included in these studies. CONCLUSIONS:Most studies show that health professionals have an implicit bias. Racial biases among physicians and nurses in the USA are well confirmed. Research is missing on other biases from other regions and other health professions.

Abstract Interprofessionelle Lehre (IPL) bedeutet, dass Studierende verschiedener Professionen mit-, von- und übereinander lernen. 2019 wurde im Kanton Zürich ein interprofessioneller Ausbildungstag (IPE-Tag) mit 68 Studierenden und acht Dozierenden über acht Lektionen durchgeführt mit dem Ziel, interprofessionelle Kompetenzen zu verbessern. Studierende aus sechs Fachbereichen des Gesundheitswesens und PhD-Studierende mit unterschiedlichem fachlichem Hintergrund mussten gemeinsam in Gruppen zwei Fälle mit Simulationspatienten/-innen bearbeiten. Zur Evaluation des IPE Tages wurde eine Prä-Post-Online-Befragung durchgeführt. Sie umfassten unter anderem eine Selbsteinschätzung mittels Items aus dem Kompetenzrahmen der Zürcher InterProfessionellen AusbildungsStation (ZIPAS®) und dem Interprofessional Collaborative Competency Attainment Survey (ICCAS) sowie offene Fragen zum IPE-Tag. Dabei wurden ZIPAS®-Kompetenzrahmen und ICCAS quantitativ, die offenen Fragen qualitativ ausgewertet. Es zeigten sich statistisch signifikante Verbesserungen in den meisten Subskalen des ZIPAS®-Kompetenzrahmens, aber nur in einem Drittel der Subskalen des ICCAS. Außerdem zeigten sich in der qualitativen Analyse der Aussagen insbesondere Verbesserungen in der Kollaboration sowie positive Aussagen zum Austausch mit Studierenden anderer Professionen, wobei viele Studierende dem Thema «Interprofessionalität» eine große Bedeutung zugeschrieben und ihren Blick bereits auf die Zukunft und ihren Alltag gerichtet haben. Der IPE-Tag könnte eine gute Methode sein, um die Zusammenarbeit und Kommunikation mit Studierenden anderer Professionen aus dem Gesundheitsbereich zu verbessern.

Objective: Interprofessional education (IPE) is when two or more stu-dents from different professions learn with, from, and about each other to improve collaboration and quality of healthcare. In October 2019, a first interprofessional education (IPE) day was held in the canton of Zurich with the aim of teaching interprofessional skills to participating students.Methodology: The IPE day was developed by an interprofessional team of students. After a short introduction, the roles and tasks of the profes-sional groups involved were discussed. This was followed by two case studies with simulation persons and reflection rounds. For the evaluation of the day, 15 semi-structured interviews with students and lecturers were conducted and qualitatively evaluated by means of thematic analysis.Results: The students and lecturers had a very positive experience of the IPE day. Especially the participation of medical and pharmacy stu-dents, the practical case studies with simulation persons and the in-formal exchange during the breaks were appreciated. There was room for improvement in the development of role models. Through an open attitude and good communication, the students learned to know and appreciate the competencies of the other professional groups. All those interviewed wished for more interprofessional teaching opportunities and the students felt encouraged to apply what they had learned in their later professional practice. Conclusion: The IPE day could be carried out successfully and the di-dactic concept worked largely well. The evaluation provided subjective evidence that the students were able to improve the interprofessional competencies of teamwork, communication, openness, appreciation and reflectiveness. In the future, the IPE day should be anchored in the curricula.

Abstract Viele Hoffnungen werden an das Thema «Interprofessionalität» geknüpft. Eine genaue Definition des Begriffs fehlt jedoch, wie in einigen gesundheitswissenschaftlichen Arbeiten bereits festgestellt wurde. Linguistische Analysen, die sich dem Begriff der Interprofessionalität und dessen Verwendung widmen, liegen bisher nicht vor. Diese Lücke geht die vorliegende Analyse an. Konkret wurden die Begriffe «Interprofessionalität», «interprofessionell» und «interprofessionelle Zusammenarbeit» in Texten aus zwei linguistischen Korpora quantitativ erfasst. In einem zweiten Arbeitsschritt wurde die Begriffsverwendung qualitativ analysiert. In einem kurzen Fazit werden die Ergebnisse reflektiert und diskutiert. Die linguistische Analyse zeigte einen erheblichen Anstieg der Verwendung aller drei Begriffe, eine Beschränkung auf fachmedizinische Publikationen, einen Fokus auf die interprofessionelle Zusammenarbeit zwischen Ärzten und Ärztinnen und dem Pflegepersonal, ein Fehlen der Patient/-innenperspektive sowie eine typische Relation mit entwicklungsfokussierten Schlagworten, die darauf hinweisen, dass die Schärfung des Begriffsfeldes «Interprofessionalität» noch nicht abgeschlossen ist.

Der Verein zur Förderung der Wissenschaft in den Gesundheitsberufen VFWG veranstaltete zwei Online-Symposien zum Stand der Akademisierung in Deutschland, wo lediglich die Hebammen dank EU-Vorschriften seit 2020 an Fachhochschulen ausgebildet werden. Für die Pflege- und Therapieberufe gilt nach wie vor die Modellklausel, die bis 2024 verlängert wurde. In Österreich und der Schweiz sind die Ausbildungen für die Therapieberufe vollständig an den Fachhochschulen angesiedelt, für diejenigen für die Pflege und die medizinisch-technischen Berufe teilweise. Das erste Symposium erörterte, ob sog. duale Studiengänge ein Modell sein könnten für die Therapieberufe in Deutschland. Das zweite Symposium fragte, ob der Weg, den Österreich und die Schweiz eingeschlagen haben, Argumente liefern kann für eine Akademisierung der Gesundheitsberufe in Deutschland. Dieser Beitrag führt ins Thema ein; die folgenden Beiträge dokumentieren die Beiträge verschiedener Autoren zu den beiden Symposien.

In a recently published article, Quang et al. evaluate the quality of systematic reviews of health economic evaluations of interventions for hepatitis.1 As the authors of one of the systematic reviews included in the assessment,2 we would like to discuss the methods which were applied and which, in our opinion, seem to be inappropriate.

Introduction: The efficiency-frontier approach (EFA) to health economic evaluation aims to benchmark the relative efficiency of new drugs with the incremental cost-effectiveness ratios (ICERs) of non-dominated comparators. By explicitly considering any differences in health outcomes and costs, it enhances the internal reference pricing (IRP) policy that was officially endorsed by Germany as the first country worldwide in 1989. However, the EFA has been repeatedly criticized since its official endorsement in 2009.Areas covered: This perspective aims to stimulate the debate by discussing whether the main objections to the EFA are technically valid, irrespective of national contextual factors in Germany with reservations towards using cost-per-quality-adjusted life year (QALY) thresholds. Moreover, we comparatively assessed whether the objections are truly unique to the EFA or apply equally to IRP and cost-effectiveness thresholds.Expert commentary: The plethora of objections to the EFA (n=20) has obscured that many objections are neither technically valid nor unique to the EFA. Compared with cost-effectiveness thresholds, only two objections apply uniquely to the EFA and concern intended key properties: (1) no external thresholds are needed and (2) the EFA is sensitive to price changes of comparators. Combining these policies and developing them further are under-utilized research areas.

A common mantra is “as little as possible and as much as necessary.” This perception can be applied to all kinds of different projects in everyday life in order to help achieve a good outcome. It also applies to medicine, for example, “as little antibiotics as possible and as much/many antibiotics as necessary.” However, does this “rule” also apply to the pediatric workforce, that is, “as few pediatricians as possible and as many pediatricians as necessary”? How can we develop a sustainable pediatric workforce to meet the healthcare needs of children? We previously offered different equations for calculating the needed numbers of annually trained pediatricians to keep the actual number of pediatricians in a country stable in view of variable working conditions such as full-time or part-time working equivalents1Ehrich J. Pettoello-Mantovani M. Never ending stories: the loop in pediatrics. How many pediatricians need to be trained in European countries to keep the pediatric workforce stable?.J Pediatr. 2018; 196: 332-333Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 2Ehrich J. Fruth J. Jansen D. Gerber-Grote A. Pettoello-Mantovani M. The loop in pediatrics: how to calculate the risk of shortage and surplus of pediatric workforce?.J Pediatr. 2018; 199: 286-287Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar and weekly working hours and night shifts.3Machtey E. Ehrich J. Somekh E. Regulations of night shifts of pediatric residents: review of responses to a European survey.J Pediatr. 2018; 201: 302-303Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar We now describe pediatric workforces in 2013-2018 in 16 European countries, 11 European Union and 5 non-European Union countries. National child healthcare systems are embedded in the underlying political and economic systems such as capitalistic, liberal, monarchic, socialistic, or social market system. National pediatric workforces can be analyzed according to the triangle of need–supply–demand. Our analysis neither intended to compare national pediatric workforces with the underlying political systems nor did it investigate the role of different types of health insurance systems, for example, financed by levies to insurance funds (Bismarck system) or by taxes (Beveridge system). We also tried to avoid a single-sided view of pediatricians whose understandable aim is to defend their own needs and to improve working conditions. Instead, we wanted to look at the child healthcare services through the eyes of families and their children. The priority of families is to have an available, adequate/appropriate, affordable, and easily accessible healthcare service provided by highly qualified personnel on all levels ranging from generalists to specialists. Families wish to have a well-functioning and competent child healthcare system that—if fragmented—should be well-coordinated. Different bodies and institutions involved in the care of children should communicate and cooperate well, reaching a consensus wherever and whenever possible. The factors that must be taken into account in the process of calculating the pediatric workforce include geography, population density, transport links, relationship between child health centers, political readiness for change, and cooperation between different types of clinicians. Critical to the discussion is the number of children requiring community care, hospital care, and public healthcare by pediatricians to adapt the different competences of pediatrics to the needs of young patients and their families. Responses to a questionnaire on national pediatric workforce were received from pediatricians (see author list) of 16 European countries and subsequently analyzed (data on individual countries will be published in an upcoming European Paediatric Association article). Results were also compared for the 3 subgroups of child healthcare systems as described by Katz et al4Katz M. Rubino A. Collier J. Rosen J. Ehrich J.H. Demography of pediatricprimary care in Europe: delivery of care and training.Pediatrics. 2002; 109: 788-796Crossref PubMed Scopus (80) Google Scholar and the World Health Organization5Weber M. Backhaus S. Chukwujana O. Fenski F. Henking G. Schatte L. et al.Pädiatrische Versorgungskonzepte in Europa.Monatsschrift Kinderheilkunde. 2018; 166: 131-140Crossref Scopus (4) Google Scholar: pediatric system = 6 countries (Croatia, Czech Republic, Germany, Israel, Russia, Spain), mixed care system = 6 countries (Armenia, Austria, France, Italy, Switzerland, Turkey), and general practitioner system = 4 countries (Bulgaria, Ireland, The Netherlands, Romania). In the 16 countries there were 95 559 853 children <14 years of age and the total number of pediatricians was 116 840, a ratio of 818:1. The mean percentage of primary care pediatricians was 41%; hospital pediatricians equaled 56%, and other types of pediatricians 3% (eg, working in public healthcare services). The mean proportion of trained and accredited pediatric subspecialists was 27%. The median of lifelong working years was 36 years. The median percentage of pediatricians working part time equivalents was 17%; 71% were female and the mean percentage of female pediatricians currently in training was 76%. Eight countries reported an increase of pediatricians from 2013 to 2018 ranging from 1% to 10%; 5 countries reported no change and 2 a decrease. No data were available for 1 country. In 6 of the 16 countries, the number of pediatricians leaving the national workforce and migrating exceeded the number of immigrating physicians; in 3 countries there was an equal balance of incoming and outgoing pediatricians, and there was a surplus of immigrating physicians in 5 countries; no data were available for 2 countries. Data on the influence of new medical technologies or increasing multidisciplinary care by other caregivers than pediatricians on the numbers of pediatricians were unknown. The annual number of active pediatricians leaving child healthcare services for other professions was negligible in all but 1 of the 16 countries. From 2013 to 2018, the mean number of annually trained pediatricians per country was 319. In 2018, there will be 347 trainees, reflecting the accuracy of the equations used when compared with 339 as predicted by using our previously published equations.1Ehrich J. Pettoello-Mantovani M. Never ending stories: the loop in pediatrics. How many pediatricians need to be trained in European countries to keep the pediatric workforce stable?.J Pediatr. 2018; 196: 332-333Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 2Ehrich J. Fruth J. Jansen D. Gerber-Grote A. Pettoello-Mantovani M. The loop in pediatrics: how to calculate the risk of shortage and surplus of pediatric workforce?.J Pediatr. 2018; 199: 286-287Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar In 2013, the presidents of national pediatric societies had been asked to predict the future numbers of pediatricians in their countries. Eight of the 16 presidents correctly predicted the number of pediatricians. The median ratio of children <14 years per pediatrician in 6 countries with a pediatric system was 722:1. This ratio was 1342:1 for primary care pediatricians and 1446:1 for hospital pediatricians. When comparing the mixed care system with the pediatric system, higher numbers of children were treated by 1 pediatrician working in a mixed system, 860:1 vs 722:1 for all pediatricians, 1625:1 vs 1342:1 for primary care pediatricians, and 2540:1 vs 1446:1 for hospital pediatricians. There were no major differences between these 2 groups concerning lifelong working years of pediatricians and percentages of subspecialists, primary care pediatricians, and hospital pediatricians. Countries with the general practitioner system had the highest percentage of hospital pediatricians (90%) and subspecialists (31%), and the highest mean ratio of children per pediatrician, namely 2250:1. What is the best model for testing how to calculate the ideal number of children in the community who should be cared for by a single pediatrician? We may be naive when using the existing statistics on numbers of pediatricians of 16 European countries as indicators for solving the challenges of a highly complex service system also including other caregivers for children.

Background: Estimating input costs for Markov models in health economic evaluations requires health state-specific costing. This is a challenge in mental illnesses such as depression, as interventions are not clearly related to health states. We present a hybrid approach to health state-specific cost estimation for a German health economic evaluation of antidepressants. Methods: Costs were determined from the perspective of the community of persons insured by statutory health insurance ("SHI insuree perspective") and included costs for outpatient care, inpatient care, drugs, and psychotherapy. In an additional step, costs for rehabilitation and productivity losses were calculated from the societal perspective. We collected resource use data in a stepwise hierarchical approach using SHI claims data, where available, followed by data from clinical guidelines and expert surveys. Bottom-up and top-down costing approaches were combined. Results: Depending on the drug strategy and health state, the average input costs varied per patient per 8-week Markov cycle. The highest costs occurred for agomelatine in the health state first-line treatment (FT) ("FT relapse") with €506 from the SHI insuree perspective and €724 from the societal perspective. From both perspectives, the lowest costs (excluding placebo) were €55 for selective serotonin reuptake inhibitors in the health state "FT remission." Conclusion: To estimate costs in health economic evaluations of treatments for depression, it can be necessary to link different data sources and costing approaches systematically to meet the requirements of the decision-analytic model. As this can increase complexity, the corresponding calculations should be presented transparently. The approach presented could provide useful input for future models.

Die Digitalisierung des Gesundheitswesens schreitet voran und ermöglicht neue Denkweisen in der Kinderheilkunde. In der Vergangenheit haben Kinderärzte in den primären und den sekundären Versorgungsstufen einen geringen aktiven Anteil an pädiatrischer Forschung gehabt. In Deutschland sind Lücken der pädiatrischen Versorgungsforschung unübersehbar. Onlineforschung hat die traditionellen Forschungsmethoden erweitert. Neben neuen methodischen Möglichkeiten zu Datenspeicherung, -sicherheit, -sammlung und -design werden auch neue ethische und rechtliche Fragen aufgeworfen, die sich mit Datenanonymität, -vertraulichkeit und -überflutung befassen. Die digitale Dokumentation des Messbaren fordert v. a. die Klärung der Frage, welche Daten für die Verbesserung der Gesundheitsversorgung sinnvoll sind. Die Digitalisierung erleichtert die Zusammenarbeit aller Pädiater auf dem Gebiet der Forschung. Sie kann dazu beitragen, die Fragmentierung pädiatrischer Forschung zu verringern und komplexe Probleme der Kindergesundheit durch Systemdenken zu lösen.

Background. The National Institute for Quality and Efficiency in Health Care (IQWiG) employs an efficiency frontier (EF) framework to facilitate setting maximum reimbursable prices for new interventions. Probabilistic sensitivity analysis (PSA) is used when yes/no reimbursement decisions are sought based on a fixed threshold. In the IQWiG framework, an additional layer of complexity arises as the EF itself may vary its shape in each PSA iteration, and thus the willingness-to-pay, indicated by the EF segments, may vary. Objectives. To explore the practical problems arising when, within the EF approach, maximum reimbursable prices for new interventions are sought through PSA. Methods. When the EF is varied in a PSA, cost recommendations for new interventions may be determined by the mean or the median of the distances between each intervention’s point estimate and each EF. Implications of using these metrics were explored in a simulation study based on the model used by IQWiG to assess the cost-effectiveness of 4 antidepressants. Results. Depending on the metric used, cost recommendations can be contradictory. Recommendations based on the mean can also be inconsistent. Results (median) suggested that costs of duloxetine, venlafaxine, mirtazapine, and bupropion should be decreased by €131, €29, €12, and €99, respectively. These recommendations were implemented and the analysis repeated. New results suggested keeping the costs as they were. The percentage of acceptable PSA outcomes increased 41% on average, and the uncertainty associated to the net health benefit was significantly reduced. Conclusions. The median of the distances between every intervention outcome and every EF is a good proxy for the cost recommendation that would be given should the EF be fixed. Adjusting costs according to the median increased the probability of acceptance and reduced the uncertainty around the net health benefit distribution, resulting in a reduced uncertainty for decision makers.

Aim Since 2011, an early benefit assessment is required for all new drugs being launched in Germany. Evidence submitted by pharmaceutical companies in dossiers is assessed by the Institute for Quality and Efficiency in Health Care (IQWiG) and subsequently appraised by the German Federal Joint Committee (FJC). The exact determination of the patient target population plays an important role for subsequent price negotiations. In diabetes mellitus type 2 the size of target population varies considerably between dossiers. Our aim was to explore the reasons for these differences.Method We analyzed 20 dossiers with drugs for diabetes mellitus type 2 published between January 2012 and May 2015. Details regarding the estimation of the target population were extracted and compared. Based on the extractions a criteria list was developed to categorize possible reasons for different sizes of the target population.Results The estimations of the target population were mainly based on secondary data analyses of drug prescriptions. The methods and assumptions used to analyze these data varied widely.Important reasons for differences in the estimations are the kind of database, the time frame, the operationalization of diabetes patients, the specification of the target population, the type of contraindications, the consideration of currently undetected patients, the mode of extrapolation to the overall population, and the portion of statutory health insurance patients. We could not identify one reason that could explain most of the deviations in the size of the target population. Several reasons seem to interact and it was not possible to determine the direction or size of the effect.Conclusion There is a strong need for more detailed descriptions of the methods and databases used in the dossiers to estimate the size of the target populations. A harmonization of the methods seems to be helpful to reduce the variation.