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Lievens Y.,Ghent University | Obyn C.,Belgian Health Care Knowledge Center | Mertens A.-S.,Mobius NV SA | Halewyck D.V.,Mobius NV SA | Hulstaert F.,Belgian Health Care Knowledge Center
Journal of Thoracic Oncology | Year: 2015

Introduction: Despite the lack of randomized evidence, stereotactic body radiotherapy (SBRT) is being accepted as superior to conventional radiotherapy for patients with T1-2N0 non-small-cell lung cancer in the periphery of the lung and unfit or unwilling to undergo surgery. To introduce SBRT in a system of coverage with evidence development, a correct financing had to be determined. Methods: A time-driven activity-based costing model for radiotherapy was developed. Resource cost calculation of all radiotherapy treatments, standard and innovative, was conducted in 10 Belgian radiotherapy centers in the second half of 2012. Results: The average cost of lung SBRT across the 10 centers (6221€) is in the range of the average costs of standard fractionated 3D-conformal radiotherapy (5919€) and intensity-modulated radiotherapy (7379€) for lung cancer. Hypofractionated 3D-conformal radiotherapy and intensity-modulated radiotherapy schemes are less costly (3993€ respectively 4730€). The SBRT cost increases with the number of fractions and is highly dependent of personnel and equipment use. SBRT cost varies more by centre than conventional radiotherapy cost, reflecting different technologies, stages in the learning curve and a lack of clear guidance in this field. Conclusions: Time-driven activity-based costing of radiotherapy is feasible in a multicentre setup, resulting in real-life resource costs that can form the basis for correct reimbursement schemes, supporting an early yet controlled introduction of innovative radiotherapy techniques in clinical practice. © 2014 by the International Association for the Study of Lung Cancer.

Neyt M.,Belgian Health Care Knowledge Center | Van Brabandt H.,Belgian Health Care Knowledge Center | Devriese S.,Belgian Health Care Knowledge Center | Van De Sande S.,Belgian Health Care Knowledge Center
BMJ Open | Year: 2012

Background: Patients with severe aortic stenosis and coexisting non-cardiac conditions may be at high risk for surgical replacement of the aortic valve or even be no candidates for surgery. In these patients, transcatheter aortic valve implantation (TAVI) is suggested as an alternative. Results of the PARTNER (Placement of AoRTic TraNscathetER Valve) trial comparing the clinical effectiveness of TAVI with surgical valve replacement and standard therapy were published. The authors assessed the cost-effectiveness of TAVI in Belgium. Methods: A Markov model of incremental costs, effects (survival and quality of life) and incremental cost-effectiveness of TAVI was developed. The impact on survival, number of events and quality of life was based on the PARTNER trial. Costs per event were context specific. Results: In high-risk operable patients, even if the minor differences in 30-day and 1-year mortality are taken into account, the incremental cost-effectiveness ratio (ICER) remains on average above €750 000 per quality-adjusted life-year (QALY) gained (incremental cost: €20 400; incremental effect: 0.03 QALYs). In inoperable patients, an ICER of €44 900 per QALY (incremental cost: €33 200; incremental effect: 0.74 QALYs) is calculated, including a life-long extrapolation of the mortality benefit. This result was sensitive to the assumed time horizon. The subgroup of anatomically inoperable patients had better outcomes than medically inoperable patients, with ICERs decreasing more than €10 000/QALY. Conclusions: It is inappropriate to consider reimbursement of TAVI for high-risk operable patients. Reimbursing TAVI in inoperable patients in essence is a political decision. From an economic perspective, it would be prudent to first target patients that are inoperable because of anatomical prohibitive conditions. In the search for evidence, the authors identified non-published negative results from a randomised controlled TAVI trial. The study sponsor should be more willing to share this information to allow balanced evaluations and policy recommendations. Payers should require these data before taking reimbursement decisions.

Van Brabandt H.,Belgian Health Care Knowledge Center | Neyt M.,Belgian Health Care Knowledge Center | Devos C.,Belgian Health Care Knowledge Center
Europace | Year: 2013

Aim To assess the outcome and cost of catheter ablation of atrial fibrillation (AF) in Belgium. Methods and results From a nationwide health insurers' database, we retrieved claims data of all patients that underwent a catheter ablation of AF from November 2007 through December 2008. Based on data on reimbursed procedures and drugs, we assessed AF recurrence using different models. Costs related to the index hospitalization were calculated. During the observation period, 830 patients underwent a first catheter ablation of AF. Two-year follow-up data were available for all patients, with an average follow-up of 30.2 months. Seventy-seven percent of patients were treated for paroxysmal AF. Recurrence of AF was defined as the occurrence of one of the following events: A repeat catheter ablation, an electric cardioversion or an antiarrhythmic drug (AAD) prescription, the latter two taking into account a blanking period of 3 months. Atrial fibrillation recurred in 59.8% of patients after 1 year and in 65.9% of them after 2 years. If AAD prescription was considered as an indicator for ablation failure only if it occurred after a 1 month AAD-free period, recurrence of AF occurred in 37.3% of patients after 1 year and in 49.9% after 2 years. Based on the prescription of rate and rhythm control drugs before the ablation, we conclude that up to 15.8% of patients underwent catheter ablation as first-line therapy. Catheter ablation of AF in Belgium on average costs about €9600 for the initial intervention. Conclusion Since the effectiveness of catheter ablation of AF appears to be less favourable in real-world practice as compared with results reported in clinical trials, and given the high initial cost of the procedure, we suggest to strictly limiting the intervention to patients in whom it is currently believed to be most beneficial, i.e. those with severely symptomatic and drug-refractory paroxysmal AF with no or minimal structural heart disease. © 2013 Published on behalf of the European Society of Cardiology. All rights reserved.

Neyt M.,Belgian Health Care Knowledge Center | Hulstaert F.,Belgian Health Care Knowledge Center | Gyselaers W.,Hospital Oost Limburg | Gyselaers W.,Hasselt University
BMJ Open | Year: 2014

Background: The first- and second-trimester screening for trisomy 21 (T21) are reimbursed for all pregnant women in Belgium. Using a cut-off risk of 1:300 for T21, about 5% of all pregnant women are referred for definitive prenatal diagnosis using an invasive test, at a sensitivity of (only) 72.5%. The sensitivity and specificity of the non-invasive prenatal test (NIPT) are over 99% but come at a cost of €460 (£373) per test. The objective is to estimate the consequences of introducing NIPT for the detection of T21.Methods: A cost-consequences analysis was performed presenting the impact on benefits, harms and costs. Context-specific real-world information was available to set up a model reflecting the current screening situation in Belgium. This model was used to construct the second and first line NIPT screening scenarios applying information from the literature on NIPT's test accuracy.Results: Introducing NIPT in the first or second line reduces harm by decreasing the number of procedurerelated miscarriages after invasive testing. In contrast with NIPT in the second line, offering NIPT in the first line additionally will miss fewer cases of T21 due to less false-negative test results. The introduction of NIPT in the second line results in cost savings, which is not true for NIPT at the current price in the first line. If NIPT is offered to all pregnant women, the price should be lowered to about €150 to keep the screening cost per T21 diagnosis constant.Conclusions: In Belgium, the introduction and reimbursement of NIPT as a second line triage test significantly reduces procedure-related miscarriages without increasing the short-term screening costs. Offering and reimbursing NIPT in the first line to all pregnant women is preferred in the long term, as it would, in addition, miss fewer cases of T21. However, taking into account the government's limited resources for universal reimbursement, the price of NIPT should first be lowered substantially before this can be realised.

Stordeur S.,Belgian Health Care Knowledge Center | Leonard C.,Belgian Health Care Knowledge Center
Human Resources for Health | Year: 2010

Introduction: Planning human resources for health (HRH) is a complex process for policy-makers and, as a result, many countries worldwide swing from surplus to shortage. In-depth case studies can help appraising the challenges encountered and the solutions implemented. This paper has two objectives: to identify the key challenges in HRH planning in Belgium and to formulate recommendations for an effective HRH planning, on the basis of the Belgian case study and lessons drawn from an international benchmarking.Case description: In Belgium, a numerus clausus set up in 1997 and effective in 2004, aims to limit the total number of physicians working in the curative sector. The assumption of a positive relationship between physician densities and health care utilization was a major argument in favor of medical supply restrictions. This new regulation did not improve recurrent challenges such as specialty imbalances, with uncovered needs particularly among general practitioners, and geographical maldistribution. New difficulties also emerged. In particular, limiting national training of HRH turned out to be ineffective within the open European workforce market. The lack of integration of policies affecting HRH was noteworthy. We described in the paper what strategies were developed to address those challenges in Belgium and in neighboring countries.Discussion and evaluation: Planning the medical workforce involves determining the numbers, mix, and distribution of health providers that will be required at some identified future point in time. To succeed in their task, health policy planners have to take a broader perspective on the healthcare system. Focusing on numbers is too restrictive and adopting innovative policies learned from benchmarking without integration and coordination is unfruitful. Evolving towards a strategic planning is essential to control the effects of the complex factors impacting on human resources. This evolution requires an effective monitoring of all key factors affecting supply and demand, a dynamic approach, and a system-level perspective, considering all healthcare professionals, and integrating manpower planning with workforce development.Conclusion: To engage in an evidence-based action, policy-makers need a global manpower picture, from their own country and abroad, as well as reliable and comparable manpower databases allowing proper analysis and planning of the workforce. © 2010 Stordeur and Léonard; licensee BioMed Central Ltd.

Gerkens S.,Belgian Health Care Knowledge Center
Health systems in transition | Year: 2010

The Health Systems in Transition (HiT) profiles are country-based reports that provide a detailed description of a health system and of policy initiatives in progress or under development. HiTs examine different approaches to the organization, financing and delivery of health services and the role of the main actors in health systems; describe the institutional framework, process, content and implementation of health and health care policies; and highlight challenges and areas that require more in-depth analysis. The Belgian population continues to enjoy good health and long life expectancy. This is partly due to good access to health services of high quality. Financing is based mostly on proportional social security contributions and progressive direct taxation. The compulsory health insurance is combined with a mostly private system of health care delivery, based on independent medical practice, free choice of physician and predominantly fee-for-service payment. This Belgian HiT profile (2010) presents the evolution of the health system since 2007, including detailed information on new policies. While no drastic reforms were undertaken during this period, policy-makers have pursued the goals of improving access to good quality of care while making the system sustainable. Reforms to increase the accessibility of the health system include measures to reduce the out-of-pocket payments of more vulnerable populations (low-income families and individuals as well as the chronically ill). Quality of care related reforms have included incentives to better integrate different levels of care and the establishment of information systems, among others. Additionally, several measures on pharmaceutical products have aimed to reduce costs for both the National Institute for Health and Disability Insurance (NIHDI) and patients, while maintaining the quality of care. World Health Organization 2010, on behalf of the European Observatory on health systems and Policies.

Schwierz C.,Belgian Health Care Knowledge Center
Health Economics | Year: 2011

Over the last 20 years, acute-care hospitals in most OECD countries have built up costly overcapacities. From the perspective of economic policy, it is desirable to know how hospitals of different ownership forms respond to changes in demand and are probably best suited to deal with existing overcapacities. This article examines ownership-specific differences in the responsiveness to changes in demand for hospital services in Germany between 1996 and 2006. With respect to the speed of adaptation to increasing demand, the study finds for-profit ownership to be superior to public and nonprofit ownership. However, contrary to other ownership types, for-profits also tend to expand in markets with decreasing demand - mainly through conversions of publicly owned hospitals. Thus, in short term, the privatization of the hospital sector may slow down the reduction of excess capacities and be therefore socially wasteful. Copyright © 2010 John Wiley & Sons, Ltd.

Neyt M.,Belgian Health Care Knowledge Center | Van Brabandt H.,Belgian Health Care Knowledge Center | Devos C.,Belgian Health Care Knowledge Center
BMC Cardiovascular Disorders | Year: 2013

Background: A health technology assessment (HTA) of catheter ablation for atrial fibrillation (CA-AF) was commissioned by the Belgian government and performed by the Belgian Health Care Knowledge Centre (KCE). In this context, a systematic review of the economic literature was performed to assess the procedure's value for money.Methods: A systematic search for economic literature about the cost-effectiveness of CA-AF was performed by consulting various databases: CRD (Centre for Reviews and Dissemination) HTA and CDSR (Cochrane Database of Systematic Reviews) Technology Assessment, websites of HTA institutes, NHS EED (NHS Economic Evaluation Database), Medline (OVID), EMBASE and EconLit. No time or language restrictions were imposed and pre-defined selection criteria were used. The two-step selection procedure was performed by two persons. References of the selected studies were checked for additional relevant citations. Results: Out of 697 references, seven relevant studies were selected. Based on current evidence and economic considerations, the rationale to support catheter ablation as first-line treatment was lacking.The economic evaluations for second-line catheter ablation included several assumptions that make the results rather optimistic or subject to large uncertainty. First, overall AAD (antiarrhythmic drugs) use after ablation was higher in reality than assumed in the economic evaluations, which had its impact on costs and effects. Second, several models focused on the impact of ablation on preventing stroke. This was questionable because there was no direct hard evidence from RCTs to support this assumption. An indirect impact through stroke on mortality should also be regarded with caution. Furthermore, all models included an impact on quality of life (QoL)/utility and assumed a long-term impact. Unfortunately, none of the RCTs measured QoL with a generic utility instrument and information on the long-term impact on both mortality and QoL was lacking. Conclusions: Catheter ablation is associated with high initial costs and may lead to life-threatening complications. Its cost-effectiveness depends on the belief one places on the impact on utility and/or preventing stroke, and the duration of these effects. Having no hard evidence for these important variables is rather troublesome. Although the technique is widely spread, the scientific evidence is insufficient for drawing conclusions about the intervention's cost-effectiveness. © 2013 Neyt et al.; licensee BioMed Central Ltd.

Franken M.,Erasmus University Rotterdam | Le Polain M.,Belgian Health Care Knowledge Center | Cleemput I.,Hasselt University | Koopmanschap M.,Erasmus University Rotterdam
International Journal of Technology Assessment in Health Care | Year: 2012

Objectives: The aim of our study is to compare five European drug reimbursement systems, describe similarities and differences, and obtain insight into their strengths and weaknesses and formulate policy recommendations. Methods: We used the analytical Hutton Framework to assess in detail drug reimbursement systems in Austria, Belgium, France, the Netherlands, and Sweden. We investigated policy documents, explored literature, and conducted fifty-seven interviews with relevant stakeholders. Results: All systems aim to balance three main objectives: system sustainability, equity and quality of care. System impact, however, is mainly assessed by drug expenditure. A national reimbursement agency evaluates reimbursement requests on a case-by-case basis. The minister has discretionary power to alter the reimbursement advice in Belgium, France, and the Netherlands. All systems make efforts to increase transparency in the decision-making process but none uses formal hierarchical reimbursement criteria nor applies a cost-effectiveness threshold value. Policies to deal with uncertainty vary: financial risk-sharing by price/volume contracts (France, Belgium) versus coverage with evidence development (Sweden, the Netherlands). Although case-by-case revisions are embedded in some systems for specific groups of drugs, systematic (group) revisions are limited. Conclusions: As shared strengths, all systems have clear objectives reflected in reimbursement criteria and all are prepared to pay for drugs with sufficient added value. However, all systems could improve the transparency of the decision-making process; especially appraisal lacks transparency. Systems could increase the use of (systematic) revisions and could make better use of HTA (among others cost-effectiveness) to obtain value for money and ensure system sustainability. © Copyright 2012 Cambridge University Press.

Chalon P.X.,Belgian Health Care Knowledge Center | Kraemer P.,Deutsches Institute For Medizinische Dokumentation Und Information Dimdi
International Journal of Technology Assessment in Health Care | Year: 2015

Objectives: The aim of this study was to describe the techniques used in achieving consensus on common standards to be implemented in the EUnetHTA Information Management System (IMS); and to describe how interoperability between tools was explored. Methods: Three face to face meetings were organized to identify and agree on common standards to the development of online tools. Two tools were created to demonstrate the added value of implementing interoperability standards at local levels. Developers of tools outside EUnetHTA were identified and contacted. Results: Four common standards have been agreed on by consensus; and consequently all EUnetHTA tools have been modified or designed accordingly. RDF Site Summary (RSS) has demonstrated a good potential to support rapid dissemination of HTA information. Contacts outside EUnetHTA resulted in direct collaboration (HTA glossary, HTAi Vortal), evaluation of options for interoperability between tools (CRD HTA database) or a formal framework to prepare cooperation on concrete projects (INAHTA projects database). Conclusions: While being entitled a project on IT infrastructure, the work program was also about people. When having to agree on complex topics, fostering a cohesive group dynamic and hosting face to face meetings brings added value and enhances understanding between partners. The adoption of widespread standards enhanced the homogeneity of the EUnetHTA tools and should thus contribute to their wider use, therefore, to the general objective of EUnetHTA. The initiatives on interoperability of systems need to be developed further to support a general interoperable information system that could benefit the whole HTA community. Copyright © 2015 Cambridge University Press.

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