Abstract Aims Atherosclerotic cardiovascular disease (ASCVD) continues to pose a growing burden driven by aging, comorbidities, and socioeconomic vulnerability. Yet, the regional distribution of these disparities remains poorly characterized, partly because no single dataset provides comprehensive ASCVD surveillance data. To address this gap, we combined insights from small-area health insurance claims and individual-level primary care data to assess how socioeconomic vulnerability relates to ASCVD indicators across regional contexts in Belgium. Methods We conducted a cross-sectional study using two complementary data sources: (i) small-area ASCVD indicators from a nationwide health insurance organization and (ii) individual-level clinical diagnoses from a general practice (GP) registry in Flanders. A multidimensional small-area socioeconomic vulnerability index was constructed using established methodology. Associations were examined using Spearman correlation, Mann-Whitney U tests, bootstrapping, and hierarchical logistic regression models. Results Both small-area health insurance claims data and small-area predictions derived from individual-level GP registry data revealed regional disparities in ASCVD prevalence that overlapped with patterns of socioeconomic vulnerability. Socioeconomic vulnerability was positively correlated with ASCVD prevalence at both small-area and individual levels. In the claims dataset, the median ASCVD prevalence was 1.57 times higher (95% CI: 1.46–1.65) in high-vulnerability areas compared with low-vulnerability areas. In the GP registry, overall ASCVD prevalence was 6.46%, with marked disparities by age, sex, socioeconomic status, and lipid-lowering medication. Increased compensation, a proxy for individual-level socioeconomic vulnerability, was associated with higher ASCVD prevalence, particularly among individuals not receiving lipid-lowering therapy. Small-area risk estimates of increased compensation derived from the GP registry showed moderate agreement with the multidimensional vulnerability index. An accompanying geoportal visualizes small-area data, enabling stakeholders to identify high-vulnerability areas and support targeted public health interventions. Conclusion Combining small-area health insurance claims with individual-level primary care data provides a more comprehensive framework for cardiovascular health surveillance, revealing socioeconomic disparities that are not fully captured by either dataset alone. The agreement between the findings from these data sources strengthens confidence in the observed spatial patterns and highlights regional inequalities in indicators of ASCVD prevalence across Belgium, underscoring the value of integrated data approaches for public health monitoring and the need for localized public health interventions addressing both area-level and individual-level social determinants of health.

Introduction Inappropriate antibiotic prescribing in primary care remains a major driver of antimicrobial resistance, despite national guidelines and audit-and-feedback systems. Digital antimicrobial stewardship tools may support clinicians in making evidence-based prescribing decisions. The Prescription Search Support (PSS) tool translates guideline recommendations into an interactive decision tree integrated into electronic health records (EHR). This project aims to evaluate the impact of implementing the tool on antibiotic prescribing behaviour in Belgian general practice and to understand the contextual factors influencing its adoption.Methods and analysis This stepped-wedge cluster randomised trial includes four steps over 12 months. Belgian general practices were randomised in a 1:3:3:3 ratio using stratified block randomisation. All practices start in the control condition, where physicians are expected to provide usual care. At each step, one cluster transitions to the intervention, where PSS becomes accessible through the EHR. The primary objective is to assess whether the implementation of the tool reduces practice-level antibiotic prescribing rates. The primary analysis will use generalised linear mixed models with a logit link, accounting for clustering, time effects and relevant covariates. Secondary analyses include subgroup analyses by region, EHR vendor and intensity of tool use. A nested process evaluation, combining user log file analysis and semistructured interviews, will assess usability, acceptability, fidelity and mechanisms of impact. Sample size calculations indicate that at least 36–48 practices are required to detect a 5% absolute reduction in prescribing with 80% power. All quantitative analyses will be performed in R, and qualitative data will be analysed using reflexive thematic analysis.Ethics and dissemination The study will be conducted in compliance with the principles of the Declaration of Helsinki (current version) and the principles of Good Clinical Practice and in accordance with all applicable regulatory requirements. Ethics approval for this study was obtained on 10 October 2025 from the Ethical Committee Research UZ/KU Leuven under reference MP037810. We will ensure that the findings of the study will be disseminated to relevant stakeholders beyond the scientific world including the public, healthcare providers and policy makers. The process evaluation that is part of this trial will inform the further implementation strategy. It will be essential to educate physicians on using this new PSS tool in daily practice.Trial registration number NCT07347015.

Routinely collected EHR data are increasingly repurposed for secondary use. As data move through multi-stage pipelines, data quality losses can be introduced at each transformation step. Yet most assessment approaches treat data quality as a static, post-hoc property of a final dataset, making transformation induced losses invisible. Emerging regulatory frameworks demand transparency and traceability across the full data lifecycle but provide limited operational guidance on how to achieve this. To introduce a lifecycle framework for assessing data quality across sequential ETL transformations and validate it using the Intego-II database. The framework comprised two components: information loss and selection bias. It was applied to Intego-II database by comparing three dataset representations within ETL Stage 2: pseudonymised source data, transformed data, and standardised data. Four indicators were evaluated across the condition, procedure, and drug exposure domains: patient coverage, domain coverage, temporal coverage, and mapping coverage. TPQAs evaluated selection bias using Cohen’s d and standardised mean differences. Patient attrition of 31,6% (1,421,150 to 971,762) arose from SSN-based deduplication of legacy EHR records and eligibility-driven exclusion. ICD-10 to SNOMED CT mapping achieved 58,3% coverage, attributable to a decimal separator inconsistency affecting 3,871 codes and approximately 326,800 condition records (1,7%). Drug concept granularity was compressed by 99,9% due to three co-occurring failures: non-standard source codes, incomplete national mapping coverage, and structural ATC-to-RxNorm vocabulary gaps. TPQA-1 showed eligibility-driven attrition was demographically neutral (Cohen’s d = -0,003; SMD = 0,031). TPQA-2 identified vocabulary-driven drug domain loss disproportionately affecting older patients (Cohen’s d = -0,49). Sequential ETL processing introduces heterogeneous, mechanism-specific data quality losses invisible to post-hoc assessment. The framework is reproducible, generalisable, and supports the transparency and traceability requirements of the European Health Data Space and EU AI Act.

Background The perceptions of general practitioners (GP), cardiologists and pharmacists on multidisciplinary heart failure (HF) care were studied before. However, geriatricians are often overlooked in HF research, despite the high prevalence of HF in the elderly. Therefore, we investigated how geriatricians perceive their role in multidisciplinary HF care. Methods This study is a qualitative semi-structured interview study with geriatricians, working in Flanders, Belgium. Purposive sampling was performed, and interviews were conducted until data saturation was reached. The QUAGOL method was used for data analysis. Results Thirteen geriatricians were interviewed. They reported to feel confident about HF management and see themselves as the guardians of the patient during hospitalization. Regarding care organization during the hospitalization phase, striking differences were reported in triage at the emergency department (ED). Geriatricians were satisfied with the collaboration with the cardiologists and valued their role, although they reported differences in vision about dealing with geriatric HF patients. Regarding transmural care organization, follow-up after hospitalization was valued highly to prevent rehospitalization but most geriatricians did not see this as their responsibility. They mostly passed on the follow-up to the GP and the cardiologist. Some did take this follow-up into their own hands in various forms because of the high rehospitalization rate and many suggested ways to improve the organization of multidisciplinary HF care. Advance care planning was seen as an important aspect of geriatrics, yet they expected more involvement from both the cardiologist and the GP in this matter. Conclusions Based on these results, our study highlights three recommendations for optimizing the care of geriatric HF patients. First, the development of standardized methods to triage patients at the ED, in combination with geriatric-cardiologist co-management to ensure that each patient receives appropriate in-hospital care. Secondly, structured and closer transitional follow-up to limit readmission rates. Lastly, inclusion of advance care planning as a mandatory component in every HF program.

BACKGROUND:Evidence regarding thyroid function changes with ageing remains inconsistent and the implications of potential changes are unclear. We aimed to investigate ageing-related thyroid function changes and their associations with mortality. METHODS:In this individual participant data (IPD) analysis, prospective population-based cohorts were eligible for inclusion when data on thyroid function measurements and mortality were available in individuals aged 18 years and older. Eligible datasets were identified through a systematic search of PubMed. We excluded cohorts of participants with only thyroid disease or thyroid-altering medications, or pregnant individuals. We requested data from all eligible cohorts that agreed to participate in the study. Linear mixed models were used to investigate associations between age and thyroid function, stratified for sex and regional iodine status. Annual changes in thyroid-stimulating hormone (TSH) and free thyroxine (FT4) were estimated per individual and categorised into quintiles, with the highest and lowest quintiles defined as increasing and decreasing, respectively, and the rest as stable. Patterns of thyroid function change were identified based on combined TSH and FT4 evolution. We used cohort-stratified Cox models to assess associations between changing patterns and all-cause mortality. This study is registered with PROSPERO, CRD42023408086. FINDINGS:In this IPD analysis, we analysed data collected between Jan 1, 2011, and Oct 13, 2022, from 31 cohorts across Europe (n=19), the USA (n=5), Asia (n=3), Brazil (n=2), and Australia (n=2; 137 488 participants; 68 322 [49·7%] were female and 69 166 [50·3%] were male; median age 60 years [range 18-106]). Cross-sectionally, older age was associated with higher TSH in iodine-sufficient regions and with lower TSH in iodine-insufficient regions. Longitudinal analyses showed that TSH increased with increasing age regardless of iodine status. The overall increase in TSH from age 18 years to 100 years was 0·61 mIU/L (0·52 SD) for female participants and 0·99 mIU/L (0·76) for male participants from iodine-sufficient regions. Greater variability in population distribution and longitudinal TSH changes was observed in adults aged 65 years or older. Higher FT4 with older age was suggested cross-sectionally, but longitudinally FT4 increased in iodine-sufficient regions and decreased in iodine-insufficient regions. Compared with stable thyroid function, all changing patterns were associated with increased all-cause mortality: hazard ratios of 1·80 (95% CI 1·57-2·06) for increasing TSH with stable or decreasing FT4; 2·45 (2·01-2·97) for increasing TSH and increasing FT4; 2·45 (1·99-3·01) for decreasing TSH with decreasing FT4; and 1·94 (1·68-2·24) for decreasing TSH with stable or increasing FT4. INTERPRETATION:Ageing-related changes in thyroid function varied by sex and iodine status. Most individuals had stable thyroid function during ageing with a slight increase in TSH, although older adults displayed greater variability. Patterns of changing thyroid function were associated with an increased all-cause mortality risk, warranting further exploration of the underlying mechanisms and clinical management. FUNDING:None.

Background Electronic health records (EHRs) can potentially revolutionize primary care by enhancing data storage, communication, and quality measure reporting. The COVID-19 pandemic accelerated the adoption of digital tools in Belgium, highlighting the potential of EHR data in audit and feedback (A&F) strategies. This study aims to outline the design and national implementation process of automated A&F monitoring instruments (locally known as barometers), in Belgian primary care.Methods Using Clinical Performance Feedback Intervention Theory, we developed three monitoring instruments for primary care: COVID-19 vaccination coverage, type 2 diabetes management, and appropriate antibiotic use. Quality indicators were selected at the national level using a Rand-modified Delphi method and validated by the Flemish Institute for Quality of Health Care (VIKZ). Data were collected from general practitioners' EHR systems, aggregated at the practice level, and analyzed using the Healthdata.be platform. Feedback was provided through the Healthstat.be interface, incorporating local and regional benchmarks and evidence-based recommendations.Results The COVID-19 vaccination monitoring instrument included 5223 GPs from 2269 practices, the type 2 diabetes monitoring instrument involved 9373 GPs from 3596 practices, and the antibiotics monitoring instrument covered 10 486 GPs from 3724 practices. These monitoring instruments collectively covered approximately eight million patients. Feedback reports were designed to be low in cognitive load, frequent, and benchmarked against the best-performing decile of practices. Integration of active, in-EHR delivery and formal evaluation of use are planned for future phases.Conclusion The implementation of automated A&F instruments in Belgian primary care demonstrated the feasibility and scalability of such systems. These monitoring instruments can provide valuable insights for quality improvement and support the transition toward a Learning Health System. Future work will focus on expanding the range of monitoring instruments and integrating active feedback mechanisms within EHR systems.

Background/Objectives: The Belgian healthcare system is currently organised from a single-disease point of view, which poses a unique challenge for patients suffering from two or more long-term physical and/or mental conditions (multimorbidity) and their healthcare providers. To search for strategies that respond to the constantly changing medical landscape and the complexity of multimorbid care. Patient-centred care programmes for multimorbid patients in primary care were investigated and their intervention elements were assessed as to whether or not they have a positive effect on the Triple Aim. Methods: A scoping review was performed and reported following the PRISMA-ScR guidelines. Online databases (PubMed, Cochrane, Embase) were used to identify papers published between January 2000 and August 2023, supplemented by reference tracking and a manual search in the grey literature. Studies were included if they assessed the efficacy of patient-centred intervention in primary care for multimorbid adult patients. Results: From the 7020 papers identified, 39 were selected and included in the review. Interventions took place at three levels (patient, professional and organisational). The efficacy of the studies included was heterogeneous. The different intervention elements had a more frequent positive effect on healthcare experience than on health status and behaviour. The only intervention that appeared to score partially positive results across all Triple Aim domains was a care coordinator. Conclusions: This scoping review provides an overview of existing patient-centred interventions for multimorbidity. Findings could be used to assist in the development of a framework for multimorbid patient care. Future studies should recognise the importance of patient experience and formulate and evaluate sufficient outcomes within this domain.

There is a lack of knowledge on the registration of body mass index (BMI) and prevalence of obesity-related complications in the Belgian healthcare system. We therefore evaluated these in Belgians living with overweight or obesity. BMI registration and obesity-related complication prevalences were determined using cross-sectional data from a Belgian general practitioners' morbidity registry (Intego) with 208 891 personal records and from 3605 visitors to an obesity clinic. Two Intego data subsets were used: 53 555 individuals with and 84 017 individuals without registered BMI. Groups were compared using chi-square tests (p-value of < 0.05). For Intego data, BMI was registered in 25.6% of cases. Individuals with registered BMI (mean BMI 27.1 ± 5.5 kg/m2) had a higher prevalence of hypertension (30.1% vs. 17.0%), dyslipidemia (26.9% vs. 14.7%), prediabetes (17.0% vs. 7.9%), type 2 diabetes (12.7% vs. 4.4%) and sleep apnea (3.8% vs. 1.5%) compared to people without registered BMI. People assessed at the obesity clinic (mean BMI 39.0 ± 6.5 kg/m2) had higher prevalences of hypertension (43.1% vs. 37.5%), dyslipidemia (44.4% vs. 32.9%) and sleep apnea (37.9% vs. 5.5%) compared to Intego individuals with BMI ≥ 25 kg/m2(mean BMI 30.3 ± 4.3 kg/m2). BMI is registered only in 25% of patient files in general practice, and people with a registered BMI in general practice have a substantially higher prevalence of the five obesity-related complications than people without registered BMI. When registered, mean BMI is substantially lower than in the obesity clinic, but the prevalence of complications is already substantial, though lower than in the obesity clinic.

OBJECTIVES:Unplanned hospital revisits (UHR) among older adults are common and contribute to adverse clinical outcomes, caregiver burden and increased healthcare costs. We aimed to develop and validate a risk prediction model for UHR in older adults to support early identification. METHODS:We conducted a retrospective cohort study, following the TRIPOD statement, using a Flemish linked database combining primary care and national health insurance data. Adults aged ≥75 years with an all-cause hospital admission in 2014 were included. The primary outcome was UHR, defined as emergency department visits or unplanned hospital admissions within 6 months post-discharge. We used multivariable logistic regression to identify predictors for UHR and develop a risk prediction model. Model performance was assessed using balanced accuracy. Missing data were handled using multiple imputation by chained equations. The model was validated on a held-out test set and a k-nearest neighbour classifier was used to cross-validate risk categories. RESULTS:Among 3133 patients, 309 (10%) experienced UHR. The best-performing model had a balanced accuracy of 0.56, with a sensitivity of 58% and a specificity of 54%. Predictors were polypharmacy, male sex, haemoglobin level, number of general practitioner contacts and multimorbidity. Excessive polypharmacy (>9 medications) was associated with a 55% increase in UHR odds. Three UHR risk groups were identified: low-risk (5.1%), medium-risk (8.8%) and high-risk (11.6%). CONCLUSIONS:UHR are common in older adults, with excessive polypharmacy emerging as a key predictor. The pragmatic model described here provides a valuable tool to stratify older adults into distinct risk groups, identifying a high-risk group that may benefit from targeted interventions.

Green spaces have a beneficial effect on health, but the perspective from a primary care setting, such as general practice, is often missing. This cross-sectional study investigated the association between residential green space, traffic exposure, and anxiety and depression in a primary care setting, which is often the first point of contact for mental health problems.We conducted this study in the urbanized region of Flanders, Belgium, based on consultations registered in the Intego general practice database from 2014 to 2023. Exposures were visible green, residential green space cover in different buffers (150m, 500m and 1500m), access to green space and traffic exposure. The outcomes were diagnoses of depression and anxiety, and prescriptions for antidepressants and benzodiazepines. Models were adjusted for gender, age, socioeconomic status and living in a city and included a random intercept for the level of the practice clinic, to account for spatial clustering of subjects.We identified 180,569 unique patients in the study period of which 16,659 (9.2%) had a diagnosis of depression or anxiety. Overall, increased residential total and taller green cover within 150m was associated with fewer diagnoses of depression or anxiety (total green: adjusted OR 0.95; 95%CI [0.93,0.98] and taller green: OR 0.97; [0.95,0.99]). Increased visible green was associated with decreased rates of diagnosis of depression and anxiety and psychoactive medication prescriptions (diagnoses: OR 0.89 [0.86,0.91], prescriptions: OR 0.92 [0.91,0.94]). There were no associations with green space accessibility. Associations remained robust when adjusting for air pollution.In conclusion, we found protective effects of visible green and green space cover on mental health consultation outcomes in general practice. These results are important as a basis for non-pharmacological, preventive mental health care interventions, and as a call for urban policy to prioritize green in urban areas.

BackgroundWhen used correctly, electronic medical records (EMRs) can support clinical decision-making, provide information for research, facilitate coordination of care, reduce medical errors, and generate patient health summaries. Studies have reported large differences in the quality of EMR data. ObjectiveOur study aimed to develop an evidence-based set of electronically extractable quality indicators (QIs) approved by expert consensus to assess the good use of EMRs by general practitioners (GPs) from a medical perspective. MethodsThe RAND-modified Delphi method was used in this study. The TRIP and MEDLINE databases were searched, and a selection of recommendations was filtered using the specific, measurable, assignable, realistic, and time-bound principles. The panel comprised 12 GPs and 6 EMR developers. The selected recommendations were transformed into QIs as percentages. ResultsA combined list of 20 indicators and 30 recommendations was created from 9 guidelines and 4 review articles. After the consensus round, 20 (100%) indicators and 20 (67%) recommendations were approved by the panel. All 20 recommendations were transformed into QIs. Most (16, 40%) QIs evaluated the completeness and adequacy of the problem list. ConclusionsThis study provided a set of 40 EMR-extractable QIs for the correct use of EMRs in primary care. These QIs can be used to map the completeness of EMRs by setting up an audit and feedback system, and to develop specific (computer-based) training for GPs.

Atherosclerotic cardiovascular diseases (ASCVD) account for 85

The compound occurrence of extreme heat and the COVID-19 pandemic may have increased mortality risk beyond the impact of each factor alone. However, the interaction between these two risk factors and their combined effect on mortality has not been adequately quantified. We conducted a time-stratified case-crossover analysis of daily all-cause mortality, minimum temperature, and COVID-19 case counts in Flanders over the period 2018–2021. We applied a distributed lag nonlinear model (DLNM) with a conditional quasi-Poisson regression to estimate the cumulative effects (lag 0–14 days) of extreme heat. The relative risk (RR) was quantified at the 99th percentile (P99) of minimum temperature compared to 50th percentile (P50). To assess effect modification, we used a binary interaction approach (pre-COVID-19 and during COVID-19) and a linear interaction approach. We used a 15-day moving average of daily confirmed cases and centered it at three reference points representing 25th, 75th and 95th percentiles of the distribution, corresponding to low, mild and high intensity levels, respectively. We observed that during the COVID-19 pandemic, the risk of mortality associated with extreme heat was significantly elevated (RR = 1.55; 95

Context: Subclinical thyroid dysfunction (ScTD) comprising subclinical hypothyroidism (SHypo) and subclinical hyperthyroidism (SHyper) has been associated with increased risk for cardiovascular events. Objective: To assess associations between ScTD and cardiovascular risk factors (cvRFs) according to age and sex. Design and setting: Pooled individual participant data analysis of large prospective cohort studies from the Thyroid Studies Collaboration. Participants: Aged 18 to 103 years with SHypo (TSH >4.50 mU/l, normal fT4) and SHyper (TSH <0.45 mU/l, normal fT4) vs. euthyroid (TSH 0.45-4.50 mU/l). Interventions: None as this is an observational study. Main outcome measures: cvRFs, i.e. blood pressure, lipid levels, hs-CRP. Results: Of 69,006 participants (mean age 62 years, 55% women, 25% current smokers) from 16 international cohorts, 3,748 (5.4%) had SHypo and 3,428 (5.0%) had SHyper. In both women and men, systolic and diastolic BP were similar regardless of thyroid status. Exceptions were lower diastolic BP in women with SHyper compared to euthyroids (adjusted mean difference [aMD] -1.3 mmHg, 95%CI -2.0 to -0.5), and lower systolic BP in men with SHyper compared to euthyroids (aMD -3.1 mmHg, 95%CI -4.8 to-1.4). In both women and men, lipid levels (total, HDL, LDL cholesterol, triglycerides) and hs-CRP were similar regardless of thyroid status. The only exception were women with SHyper who had a lower LDL cholesterol compared to euthyroids (aMD -0.17 mmol/l, 95%CI -0.29 to -0.05). Conclusions: Participants with ScTD and euthyroids have similar cvRFs and differences are arguably too small to explain the increased cardiovascular risk in ScTD observed in previous studies.

Diastolic dysfunction (DD) is a common feature in older adults, but its prognostic value is unclear. This study aims to assess the ability of DD against NT-proBNP and frailty to predict all-cause mortality, cardiovascular mortality, and a first unplanned hospitalization in older adults. Secondary analysis of the observational population-based BELFRAIL cohort of patients aged ≥ 80 years with cardiac echography at inclusion. Patients were included if LVEF ≥ 50

Background: The COVID-19 pandemic has underlined the essential role of primary healthcare (PHC) in epidemiological surveillance and public health decision-making. Across Europe, the integration of electronic health records (EHRs) and the sentinel networks have been pivotal in monitoring COVID-19. However, the lack of standardized PHC indicators for COVID-19 hinders the comparability of data among countries. Objective: To establish a consensus on a set of standardized PHC activity indicators related to the COVID-19 pandemic for 31 countries, enhancing the capability of health authorities to make informed decisions and prepare for future health crises. Methods: A two-round eDelphi study was conducted using a structured web-based survey, following the CREDES guidelines, to achieve consensus among a panel of 164 experts from the Eurodata study. 86 Indicators were selected based on their availability during the current pandemic, with participants rating the relevance and utility of proposed indicators. Results: Of the 22 initial indicators, seven received consensuses for inclusion, while two remained contentious after the second round. The study found significant discrepancies in the awareness of sentinel networks and accessibility to PHC data. The consensus emphasized the necessity for indicators to be standardized, reproducible, and easily extractable from databases, with recommendations for disaggregation by age, sex, and vaccination status. Conclusion: Key COVID-19 indicators for PHC were identified, reflecting a consensus among healthcare professionals. Further cooperation between PHC providers and national public health authorities is warranted both on the national and the international level to harmonized healthcare indicators in response to future health emergencies.