Osteoporosis is a silent disease that is underdiagnosed and undertreated. The discrepancy between and complexity of management guidelines hinder case-finding and treatment and thus fracture prevention. As a result, society bears high costs for the treatment of osteoporotic fractures and their consequences. To improve cost-effectiveness of osteoporosis management, feasible and practical guidelines are a prerequisite. As guideline adoption is impaired by barriers at different levels, careful considerations should be made in their development and implementation. A literature analysis was conducted to identify frequent barriers in osteoporosis management. Recent international guidelines for primary care osteoporosis management were compared and draft guidelines for practical implementation were produced. This was reviewed by a Scientific Steering Committee (SCC) of medical stakeholders in osteoporosis care and a consensus sought. Experts in clinical osteoporosis management were consulted to provide remarks. The result was again presented to the SCC. This process was repeated until final consensus was reached. The guidelines were then presented to 24 family physicians on paper and during a face-to-face educational session, during which they assessed the feasibility. A one page flowchart for osteoporosis management in postmenopausal women with and without comorbidity, including case-finding strategy, was endorsed. Reimbursement criteria for DXA and anti-resorptive therapy in Belgium were thereby accounted for. Family physicians’ personal barriers in knowledge and attitude were tackled during the personal educational session, resulting in a high willingness for implementation. All family physicians rated the flowchart as ‘highly feasible’ at first encounter. The use of a SCC representing all stakeholders in osteoporosis management can increase guideline feasibility without compromising on scientific evidence. A personalized educational approach in family physicians can lead to a higher implementation willingness and decreased scepticism. Therefore, this might be a useful strategy to improve cost-effectiveness in diseases lacking unambiguous or adequate case-finding and treatment strategies.

OBJECTIVE: A multifaceted quality improvement programme for the care of diabetes was implemented in two different Flemish regions (Aalst and Leuven) and with slightly different modalities. The overall objective of the programmes was to improve adherence to evidence-based guidelines on diabetes in primary care physicians. The aim of this study was to assess the cost-effectiveness of the programmes compared to regular care in both regions.

Quality of care, as currently measured, shows unintended and avoidable variability in health care, and the existence of under use, overuse and misuse of health care, as compared to best practice. One possible part of the solution is to introduce Pay- for-Quality (P4Q) by aligning the payment system with quality of care. However, there is a lack of comprehensive conceptual guidance on P4Q use in health care. Reviews of empirical results on P4Q effects concluded that effects are mixed and highly context dependent. The level of acceptance and support by stakeholders in Belgium was unknown. Finally, practical feasibility of P4Q implementation in Belgium was unclear. This study explored the advantages, disadvantages and feasibility of P4Q implementation in Belgium. A consortium of four universities gathered data from literature, international experts and Belgian stakeholders to assess (1) what can be learned from international P4Q models on design, implementation and evaluation; and (2) what conditions are needed to apply international P4Q models in Belgium; i.e., start from scratch, or enlarge the Belgian quality-improvement programs. The focus of this study was restricted to medical care in primary and acute hospital settings.

OBJECTIVE To picture the profile of type 2 diabetic patients in Belgium and to study the quality of care in the primary care setting, with regard, to multi-factorial approach of the disease. METHODS Observational study of all known DM2-patients registered by 120 volunteer general practitioners. Quality of care was evaluated by the achievement of three major treatment targets: HbA1c<7%; Systolic Blood Pressure </=130 mmHg; LDL-Cholesterol<100 mg/dl (ADA 2003). Multivariate analysis was performed. RESULTS 2495 DM2-patients were included with a mean age of 68+/-12 years and 51% being women. One fifth of the patients had microvascular complications and 27% had macrovascular complications. Sixty-eight percent received oral anti-diabetic drugs and 19% were on insulin. Satisfactory glycaemic control (HbA1c<7%) was achieved in 54% of the patients, with however glucose control deteriorating with disease progression despite more intensive hypoglycaemic treatment. Systolic blood pressure targets were reached in 50%. Statin use was present in 39% and LDL levels<100 mg/dl were reached in 42%. 59% of insulin treated patients were followed up in shared care with specialised diabetes centres. These patients obtained lower values for HbA1c (7.5+/-1.2% vs. 7.8+/-1.5%, p=0.038) and LDL-C (90+/-34 vs. 111+/-37, p<0.001) compared to insulin-treated patients only followed up in primary care. CONCLUSION Overall metabolic control in type 2 diabetic patients in primary care in Belgium was acceptable for glucose control, but major room for improvement exists especially for statin use and blood pressure control. Clinical inertia is present and the presence of more structured care in specialised diabetes centres, focusing on therapeutic guidelines, may explain the better overall metabolic control in patients followed up in shared care with these centres.

In this descriptive cross-sectional study, we investigated the incidence, determinants, and consequences of subclinical noncompliance with immunosuppressive therapy in 150 adult renal transplant recipients with more than one year posttransplant status. Symptom frequency and symptom distress, and self-care agency were measured by the Transplant Symptom Frequency and Symptom Distress Scale, and the Appraisal for Self-Care Agency Scale, respectively. The Long-Term Medication Behavior Self-Efficacy Scale and a renal transplant knowledge questionnaire were developed as part of this study to measure perceived self-efficacy and knowledge of the therapeutic regimen. Demographic variables were also measured.The incidence of subclinical noncompliance with immunosuppressive therapy as assessed by interview was 22.3%. Compliers and noncompliers differed significantly on the variables of marital status (P=0.03), situational-operational knowledge (P=0.02), self-care agency (P=0.03), and perceived self-efficacy related to long-term medication intake (P=0.048). A logistic regression model using gender, marital status, perceived self-efficacy, self-care agency, knowledge about medication administration and signs of infection, and situational operational knowledge as predictor variables, revealed a 78.6% correct classification of compliers versus noncompliers and a sensitivity ratio of 95.9%.There were significantly more acute late rejection episodes (P=0.003) in the noncompliant group. Graft survival at 5 years in this group was also significantly lower (P=0.03) than the compliant patients. No significant difference was found in terms of the occurrence of chronic rejection episodes or in terms of patient survival at 5 years.Because noncompliance is a risk, factor for negative clinical outcome in renal transplant recipients, it is of utmost importance to develop intervention strategies to enhance compliance in this population by using determinants identified in exploratory studies.