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Background/aims: Dementia is one of the main reasons for institutionalization among the elderly. Few studies have explored factors associated with the caregivers' (CG) desire to institutionalize (DTI) a person with dementia (PWD). The objective of this study is to identify modifiable and non-modifiable psychosocial and sociodemographic factors associated with a caregiver's DTI., Methods: Cross-sectional data of 355 informal CG of community-dwelling PWD were analyzed. Several characteristics were identified in CG and PWD to be included in a multivariable regression model based on the purposeful selection method., Results: Positively modifiable associated factors were: higher CG burden, being affected by behavioral problems, and respite care use. Positively associated non-modifiable factors were: CG older age, being professionally active, and CG higher educational level. Cohabitation and change of professional situation were negatively associated., Conclusion: Although no causality can be assumed, several practical recommendations can be suggested. First of all, these results reconfirm the importance of multicomponent strategies, especially support aimed at decreasing burden and in learning coping strategies. Also, CG might benefit from information about support options, such as respite care services. Finally, special attention should be given to older and working CG. In the latter, flexible and adaptive working conditions might alleviate burden and therefore reduce the DTI of the PWD., (© 2018 S. Karger AG, Basel.)

Background: Alcohol is associated with adverse health effects causing a considerable economic impact to society. A reliable estimate of this economic impact for Belgium is lacking. This is the aim of the study., Methods: A prevalence-based approach estimating the direct, indirect and intangible costs for the year 2012 was used. Attributional fractions for a series of health effects were derived from literature. The human capital approach was used to estimate indirect costs, while the concept of disability-adjusted life years was used to estimate intangible costs. Sensitivity and scenario analyses were conducted to assess the uncertainty around cost estimates and to evaluate the impact of alternative modelling assumptions., Results: In 2012, total alcohol-attributable direct costs were estimated at €906.1 million, of which the majority were due to hospitalization (€743.7 million, 82%). The indirect costs amounted to €642.6 million, of which 62% was caused by premature mortality. Alcohol was responsible for 157,500 disability-adjusted life years representing €6.3 billion intangible costs., Conclusions: Despite a number of limitations intrinsic to this kind of research, the study can be considered as the most comprehensive analysis thus far of the health-related social costs of alcohol in Belgium.

Background: Stroke is a very time-sensitive pathology, and many new solutions target the optimization of prehospital stroke care to improve the stroke management process. In-ambulance telemedicine, defined by live bidirectional audio-video between a patient and a neurologist in a moving ambulance and the automated transfer of vital parameters, is a promising new approach to speed up and improve the quality of acute stroke care. Currently, no evidence exists on the cost effectiveness of in-ambulance telemedicine., Objective: We aim to develop a first cost effectiveness model for in-ambulance telemedicine and use this model to estimate the time savings needed before in-ambulance telemedicine becomes cost effective., Methods: Current standard stroke care is compared with current standard stroke care supplemented with in-ambulance telemedicine using a cost-utility model measuring costs and quality-adjusted life-years (QALYs) from a health care perspective. We combine a decision tree with a Markov model. Data from the UZ Brussel Stroke Registry (2282 stroke patients) and linked hospital claims data at individual level are combined with literature data to populate the model. A 2-way sensitivity analysis varying both implementation costs and time gain is performed to map the different cost-effective combinations and identify the time gain needed for cost effectiveness and dominance. For several modeled time gains, the cost-effectiveness acceptability curve is calculated and mapped in 1 figure., Results: Under the base-case scenario (implementation cost of US $159,425) and taking a lifetime horizon into account, in-ambulance telemedicine is a cost-effective strategy compared to standard stroke care alone starting from a time gain of 6 minutes. After 12 minutes, in-ambulance telemedicine becomes dominant, and this results in a mean decrease of costs by US -$30 (95% CI -$32 to -$29) per patient with 0.00456 (95% CI 0.00448 to 0.00463) QALYs on average gained per patient. In over 82% of all probabilistic simulations, in-ambulance telemedicine remains under the cost-effectiveness threshold of US $47,747., Conclusions: Our model suggests that in-ambulance telemedicine can be cost effective starting from a time gain of 6 minutes and becomes a dominant strategy after approximately 15 minutes. This indicates that in-ambulance telemedicine has the potential to become a cost-effective intervention assuming time gains in clinical implementations are realized in the future., (©Alexis Valenzuela Espinoza, Stefanie Devos, Robbert-Jan van Hooff, Maaike Fobelets, Alain Dupont, Maarten Moens, Ives Hubloue, Door Lauwaert, Pieter Cornu, Raf Brouns, Koen Putman. Originally published in JMIR Mhealth and Uhealth (http://mhealth.jmir.org), 24.11.2017.)

Objective: The impact of sociodemographic aspects and comorbidities on the inpatient hospital care costs of traffic victims are not clear. The main goal of this study is to provide insights into the sociodemographic characteristics and clinical conditions (including comorbidities) of the victims that result in higher hospital costs., Participants: For the period 2009-2011, people admitted to a hospital as a result of a road traffic crash (N=64,304) were identified in the national Minimal Hospital Dataset, after which they were linked to their respective claims data from the sickness funds., Methods: A generalized linear model was used to analyse hospital costs controlling for roadway user categories, demographics (gender, age, individual socioeconomic status (SES)), and clinical factors (the nature, location, and severity of injury, and comorbidities)., Results: The median hospital cost was € 2801 (IQR € 1510-€ 7175, 2015 Euros). There was no significant difference between gender. Low SES inpatients incurred 16% (95% CI: 14%-18%) higher hospital costs than inpatients of high SES. The presence of comorbidities was associated with an increased hospital cost, however with varying magnitude. For example traffic victims suffering from dementia incur significantly higher hospital costs than those who were not (49% higher, 95% CI: 44%-53%), whereas diabetes was associated with a smaller increase in costs compared to non-diabetics (13%, 95% CI: 10%-16%)., Conclusion: Comorbidities and low SES are associated with higher hospital costs for traffic victims, notwithstanding their age, and the nature and the severity of their injury. The broad variability of hospital costs among trauma inpatients should be accounted for when reconsidering financing models. Furthermore, the strong predictive value of some comorbidities and SES on hospital costs should be considered when projections of future health care utilisation in traffic safety scenarios are prepared., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: The Michigan Legislature mandated that all public schools stock epinephrine auto-injectors (EAIs). A minimal amount is known regarding the incremental value of EAIs in schools. Our primary objective was to describe the frequency of administration of epinephrine for EMS patients with acute allergic reactions in public schools. Our secondary objective was to estimate the cost of mandating public schools to stock EAIs., Methods: We performed a retrospective cohort study of EMS cases with an impression of allergic reaction and who received epinephrine recorded in the 2014 Michigan EMS Information System (MI-EMSIS). We abstracted patient demographics, incident location by address to identify public schools, source of epinephrine given, and suspected allergen if known. We calculated advanced life support (ALS) response times to assess temporal impact of school EAIs in communities with ALS systems. We estimated the unsubsidized annual procurement cost of this mandate for Michigan public schools (N = 4,039), using range of costs for the required 2 EAIs (adult and pediatric) as estimated by the legislature ($140/each) and recently reported costs for commercial sources ($1,200). Training costs were not included. Descriptive statistics are reported., Results: During this period, there were 1,550,009 EMS cases in the state with 631 receiving non-cardiac arrest epinephrine for presumed anaphylaxis, of which 23 cases were in public schools. Reported allergens were most often food 12 (51.2%), insect stings 4(22.2%) or unknown 7(30.4%). Among these patients, the source for epinephrine used was from the student, 7 (30.4%), EMS 7 (30.4%), school 7(30.4%), and unknown 2(8.7%). A majority (21, 91.3%) of the public school cases occurred in communities with ALS systems and ALS response was relatively rapid (median response 6 minutes, 90 percentile, 13 minutes). The unsubsidized annual cost of Michigan public schools to stock EAIs ranges from $565,460 to $4,846,800., Conclusion: In this study, few public school patients received epinephrine for anaphylaxis and the vast majority occurred in communities with rapid ALS response. The direct annual supply cost of the school EAI mandate is substantial.

Purpose: This international study aims to examine the size and determinants of the impact of stroke on five-year survivors' health-related quality of life (HRQoL) in four different European countries., Method: Patients were recruited consecutively in four European rehabilitation centers. Five years after stroke, the EuroQol-visual analog scale (EQ-VAS) was administered in 226 first-ever stroke patients. Impact of stroke was determined by calculating EQ-VAS z-norm scores (= deviation - expressed in SD - of patients' EQ-VAS level relative to their age-and gender-matched national population norms). Determinants of EQ-VAS z-norm scores were identified using multivariate linear regression analysis., Results: Five years post-stroke, patients' mean EQ-VAS was 63.74 (SD = 19.33). Mean EQ-VAS z-norm score was -0.57 [95%CI: (-0.70)-(-0.42)]. Forty percent of the patients had an EQ-VAS z-norm score <-0.75 SD; 52% had an EQ-VAS z-norm score between -0.75 and +0.75 SD, only 8% scored >+0.75 SD. Higher patients' levels of depression, anxiety and disability were associated with increasingly negative EQ-VAS z-norm scores (adjusted R 2   =   0.392)., Conclusions: Five years after stroke, mean HRQoL of stroke survivors showed large variability and was more than ½ SD below population norm. Forty percent had a HRQoL level below, 52% on, and 8% above population norm. The variability could only partially be explained by the variables considered in this study. Longitudinal studies are needed to increase our understanding of the size and determinants of the impact of stroke on the HRQoL of long-term stroke survivors. Implications for rehabilitation The current European concept of stroke rehabilitation is focused on the acute and sub-acute rehabilitation phase, i.e., in the first months after stroke. The results of this study show that at five years after stroke, the mean level of HRQoL of stroke survivors remains below the healthy population level. This finding shows the need for continuation of rehabilitation in the chronic phase. At five years after stroke, higher patients' levels of depression, anxiety and disability were associated with lower scores for HRQoL. This finding implicates that chronic rehabilitation programs should be multi-faceted in order to increase long-term survivors' psychosocial outcomes.

Background: Legal and illegal drugs impose a considerable burden to the individual and to society. The misuse of addictive substances results in healthcare and law enforcement costs, loss of productivity and reduced quality of life., Methods: A social cost study was conducted to estimate the substance-attributable costs of alcohol, tobacco, illegal drugs and psychoactive medication to Belgian society in 2012. The cost-of-illness framework with prevalence-based and human capital approach was applied. Three cost components were considered: direct, indirect and intangible costs related to substance misuse., Results: The direct and indirect cost of addictive substances was estimated at 4.6 billion euros in Belgium (419 euros per capita or 1.19% of the GDP) and more than 515,000 healthy years are lost due to substance misuse. The Belgian social cost study reaffirms that alcohol and tobacco impose the highest cost to society compared to illegal drugs. Health problems are the main driver of the social cost of legal drugs. Law enforcement expenditure exceed the healthcare costs but only in the case of illegal drugs., Conclusion: Estimating social costs of addictive substances is complex because it is difficult to determine to what extent the societal harm is caused by substances. It can be argued that social cost studies take only a 'snapshot' of the monetary consequences of substance misuse. Nevertheless, the current study offers the most comprehensive analysis thus far of the social costs of substance misuse in Belgium., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Alcohol, tobacco, illicit drugs, and psychoactive pharmaceuticals' use is associated with a higher likelihood of developing several diseases and injuries and, as a consequence, considerable health-care expenditures. There is yet a lack of consistent methodologies to estimate the economic impact of addictive substances to society. The aim was to assess the methodological approaches applied in social cost studies estimating the economic impact of alcohol, tobacco, illicit drugs, and psychoactive pharmaceuticals., Methods: A systematic literature review through the electronic databases, Medline (PubMed) and Web of Science, was performed. Studies in English published from 1997 examining the social costs of the addictive substances alcohol, tobacco, illicit drugs, and psychoactive pharmaceuticals were eligible for inclusion., Results: Twelve social cost studies met the inclusion criteria. In all studies, the direct and indirect costs were measured, but the intangible costs were seldom taken into account. A wide variety in cost items included across studies was observed. Sensitivity analyses to address the uncertainty around certain cost estimates were conducted in eight studies considered in the review., Conclusion: Differences in cost items included in cost-of-illness studies limit the comparison across studies. It is clear that it is difficult to deal with all consequences of substance use in cost-of-illness studies. Future social cost studies should be based on sound methodological principles in order to result in more reliable cost estimates of the economic burden of substance use.

Background: Frequent hospitalization and permanent nursing home placement not only affect the well-being of persons with dementia, but also place great financial strain on society. Therefore, it is important to create effective strategies to support informal caregivers so that they can continue to perform their demanding role. Preliminary qualitative evidence suggests that community-based respite services can actually be important for caregivers, and that the level of evidence should be further established in terms of effectiveness. Therefore, a comparative study to assess the effectiveness and cost-effectiveness of an in-home respite care program will be initiated., Methods: This manuscript described a quasi-experimental study to assess (cost)-effectiveness of an in-home respite care program to support informal caregivers of persons with dementia., Study Population: 124 informal caregivers and persons with dementia will be included in the intervention group and will receive an in-home respite care program by an organization called Baluchon Alzheimer. 248 dyads will be included in the control group and will receive standard dementia care. The primary outcome is caregiver burden. Secondary outcomes are: quality of life of caregivers, frequency of behavioral problems of persons with dementia and the reactions of caregivers to those problems, intention to institutionalize the care-recipient, time to nursing home placement, resource use of the care-recipient, and willingness to pay for in-home respite care. When the trial demonstrates a difference in outcomes between both groups, within-trial and modeled cost-effectiveness analyses will be conducted in a separate economic evaluation plan to evaluate possible cost-effectiveness of the in-home respite care program compared to the control group receiving standard dementia care. Finally, the model based cost-effectiveness analyses will allow to extrapolate effects over a longer time horizon than the duration of the trial., Discussion: This study will have great added value because to date no studies measured effectiveness and cost-effectiveness of an in-home respite care program of the Baluchon type. Results of this trial can thus give much more insight in potential benefits and disadvantages of community-based respite care. Conclusions based on this trial can help policy-makers in elaborating future directions of dementia care., Trial Registration: Clinicaltrials.gov Identifier NCT02630446 .

Objective: Supporting informal caregivers of persons with dementia is considered to be an effective strategy for improving the well-being of caregivers and care recipients and for delaying nursing home placement. Although considerable research has been conducted to investigate the effectiveness of psychoeducational interventions, cognitive behavioral therapy, and occupational therapy, research into the effectiveness of respite care is rare. This systematic review aims to investigate the effectiveness of different types of respite care in supporting informal caregivers of persons with dementia., Methods: A systematic literature search was conducted using Web of Science and PubMed, and the Quality Assessment Tool for Quantitative Studies was used to assess the methodological quality. Randomized controlled trials, quasi-experimental studies, pretest-posttest studies without a control group, and cohort studies were included., Results: Seventeen papers met the inclusion criteria. Day care services are effective in decreasing caregiver burden and behavioral problems in persons with dementia, but they also accelerate time to nursing home admission. The results of temporary residential admission are rather mixed and show unexpected adverse effects on both caregivers and care recipients. High-quality comparable evidence on community-based respite care is still lacking, although earlier qualitative evidence indicated promising results., Conclusion: Unlike in previous reviews, we were able to draw some conclusions about the effectiveness of some types of respite care. There is nonetheless still a need for new intervention studies measuring the impact of respite care, especially in-home respite care programs, on the caregiver, the care recipient, and health care resource utilization. Copyright © 2016 John Wiley & Sons, Ltd., (Copyright © 2016 John Wiley & Sons, Ltd.)

Objective: We used log-linear and log-log exposure-response (E-R) functions to model the association between PM2.5 exposure and non-elective hospitalizations for pneumonia, and estimated the attributable hospital costs by using the effect estimates obtained from both functions., Methods: We used hospital discharge data on 3519 non-elective pneumonia admissions from UZ Brussels between 2007 and 2012 and we combined a case-crossover design with distributed lag models. The annual averted pneumonia hospitalization costs for a reduction in PM2.5 exposure from the mean (21.4μg/m(3)) to the WHO guideline for annual mean PM2.5 (10μg/m(3)) were estimated and extrapolated for Belgium., Results: Non-elective hospitalizations for pneumonia were significantly associated with PM2.5 exposure in both models. Using a log-linear E-R function, the estimated risk reduction for pneumonia hospitalization associated with a decrease in mean PM2.5 exposure to 10μg/m(3) was 4.9%. The corresponding estimate for the log-log model was 10.7%. These estimates translate to an annual pneumonia hospital cost saving in Belgium of €15.5 million and almost €34 million for the log-linear and log-log E-R function, respectively., Discussion: Although further research is required to assess the shape of the association between PM2.5 exposure and pneumonia hospitalizations, we demonstrated that estimates for health effects and associated costs heavily depend on the assumed E-R function. These results are important for policy making, as supra-linear E-R associations imply that significant health benefits may still be obtained from additional pollution control measures in areas where PM levels have already been reduced., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objectives: The use of medication plays an important role in secondary stroke prevention and treatment of post-stroke comorbidities. The Collaborative Evaluation of Rehabilitation in Stroke across Europe (CERISE) was set up to investigate the inpatient stroke rehabilitation process in four centres, each in a different European country: Belgium, Germany, United Kingdom and Switzerland., Patients and Methods: Patients' medication use 5 years post-stroke was compared between countries. Focus was put on cerebrovascular secondary prevention, including (a) adequate antithrombotic treatment, (b) treatment of cardiovascular comorbidities and diabetes, and (c) the use of lipid-lowering drugs; as well as on the treatment of stroke-related disorders such as depression, anxiety and pain., Results: Medication data were available for 247 patients. Data about depression and anxiety were available for 233., Conclusion: There were no significant differences between the four centres in antithrombotic treatment and in the treatment of cardiovascular comorbidities and diabetes. However, significantly more patients from the UK were treated with lipid-lowering drugs compared to Belgian patients. Significant differences were also observed between the centres in the prevalence and treatment of depression. More Belgian patients suffered from depression compared to German patients and significantly more Belgian patients took antidepressants than patients in Germany. This was in contrast to the prevalence and treatment of anxiety and pain, for which no significant differences between the centres were seen. Related to pain treatment, it was observed that almost 40% of all patients suffering from pain, used no specific medication., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Introduction: The adverse health effects of exposure to air pollution have been well-established and include mortality, hospital admissions, emergency department visits, etc, but also less severe outcomes such as medication use and purchase. The economic impact, an additional motivator for policy, has been studied primarily for the more severe outcomes., Methods: Purchase data of reimbursed medications typically prescribed for asthma and chronic obstructive pulmonary disease, were obtained through the mandatory Belgian health insurance system. A time series analyses approach was used to model daily sales on daily air pollution concentrations (NO2, PM10 and PM2.5) for residents of the Brussels Capital Region as a whole. In addition, a higher geographical resolution of both sales and pollutant concentrations allowed for a multi-sector approach. Annual savings were estimated for the scenario of a 10% reduction in each of the pollutants., Results: Medication purchase was significantly associated with NO2 concentrations, leading to an annual cost saving potential of € 107,845 [95%CI: € 71,483-€ 143,823] in R03 sales (WHO classification for drugs of obstructive airway diseases). Saving potentials of PM10 and PM2.5 were not significant. Estimates were not sensitive to the geographical resolution, however, higher precision can be obtained with higher resolution data, subject to the condition that the number of sales is sufficiently large., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Background: Examining determinants of antenatal care (ANC) is important to stimulate equitable distribution of ANC across Europe. This study (1) compares ANC utilisation in Belgium and the Netherlands and (2) identifies predisposing, enabling and pregnancy-related determinants., Methods: Secondary data analysis is performed using data from Belgium, and the Netherlands. The content and timing of care during pregnancy (CTP) tool measured ANC use. Non-parametric tests and ordinal logistic regression are performed to gain insight in the determinants of health care use., Results: Dutch women receive appropriate ANC more often than Belgian women. Multivariate analysis showed that lower education, unemployment, lower continuity of care and non-attendance of antenatal classes are associated with a lower likelihood of having more appropriate ANC., Conclusions: Predisposing and pregnancy related variables are most important to influence the content and timing of ANC, irrespective of the country women live in. Lower health literacy in socially vulnerable women might explain the predisposing determinants of health care use in both countries. Stimulating accessibility to antenatal courses or organising public education are recommendations for practice. Regarding pregnancy-related determinants, improving continuity of care can optimise ANC use in both countries.

Introduction: Despite scientific progress with regard to pain neuroscience, perioperative education tends to stick to the biomedical model. This may involve, for example, explaining the surgical procedure or 'back school' (education that focuses on biomechanics of the lumbar spine and ergonomics). Current perioperative education strategies that are based on the biomedical model are not only ineffective, they can even increase anxiety and fear in patients undergoing spinal surgery. Therefore, perioperative pain neuroscience education is proposed as a dramatic shift in educating patients prior to and following surgery for lumbar radiculopathy. Rather than focusing on the surgical procedure, ergonomics or lumbar biomechanics, perioperative pain neuroscience education teaches people about the underlying mechanisms of pain, including the pain they will feel following surgery., Research Objectives: The primary objective of the study is to examine whether perioperative pain neuroscience education ('brain school') is more effective than classic back school in reducing pain and improving pain inhibition in patients undergoing surgery for spinal radiculopathy. A secondary objective is to examine whether perioperative pain neuroscience education is more effective than classic back school in: reducing postoperative healthcare expenditure, improving functioning in daily life, increasing return to work, and improving surgical experience (ie, being better prepared for surgery, reducing incongruence between the expected and actual experience) in patients undergoing surgery for spinal radiculopathy., Design: A multi-centre, two-arm (1:1) randomised, controlled trial with 2-year follow-up., Participants and Setting: People undergoing surgery for lumbar radiculopathy (n=86) in two Flemish hospitals (one tertiary care, university-based hospital and one regional, secondary care hospital) will be recruited for the study., Intervention: All participants will receive usual preoperative and postoperative care related to the surgery for lumbar radiculopathy. The experimental group will also receive perioperative pain neuroscience education comprising one preoperative and one postoperative individual educational session plus an educational booklet., Control: Participants in the control group will receive perioperative back school on top of usual preoperative and postoperative care, comprising one preoperative and one postoperative individual educational session plus an educational booklet., Measurements: Self-reported pain and endogenous pain modulation (including measurements of simultaneous cortical activation via electroencephalography) will be the primary outcome measures. Secondary outcome measures will include daily functioning, return to work, postoperative healthcare utilisation and surgical experience/satisfaction. Psychological factors will be measured as possible treatment mediators., Procedure: All assessments will take place in the week preceding surgery (baseline), and at 3 days and 6 weeks after surgery. Intermediate and long-term follow-up assessments will take place at 6, 12 and 24 months after surgery., Analysis: All data analyses will be based on the intention-to-treat principle. Repeated measures AN(C)OVA analyses will be used to evaluate and compare treatment effects. Baseline data, treatment centre, age and gender will be included as covariates. Statistical, as well as clinically, significant differences will be evaluated and effect sizes will be determined. In addition, the numbers needed to treat will be calculated., Discussion: This study will determine whether pain neuroscience education is worthwhile for patients undergoing surgery for lumbar radiculopathy. It is expected that participants who receive perioperative pain neuroscience education will report less pain and have improved endogenous pain modulation, lower postoperative healthcare costs and improved surgical experience. Lower pain and improved endogenous pain modulation after surgery may reduce the risk of developing postoperative chronic pain., (Copyright © 2016 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.)

Background: Dementia is known as a major public health problem affecting both patients and caregivers, and placing a high financial strain upon society. In community-dwelling patients, it is important to support informal caregivers in order to help them sustain their demanding role. Previous reviews about effectiveness of such supporting strategies often included a small number of studies, focused only on particular supportive types, particular outcomes, or solely on caregivers., Objective: A general systematic review was conducted investigating effectiveness of different supportive strategies on at least the well-being of the caregiver or the care-recipient., Methods: A systematic literature search was conducted in Web of Science and PubMed. An adapted version of the Downs and Black (1998) checklist was used to assess methodological quality. A new classification was developed to group different types of caregiver support., Results: Fifty-three papers met the inclusion criteria. Although 87% of the interventions were to some extent effective, methods and findings were rather inconsistent. Psychoeducational interventions generally lead to positive outcomes for caregivers, and delay permanent institutionalization of care-recipients. Cognitive behavioral therapy decreases dysfunctional thoughts among caregivers. Occupational therapy decreases behavioral problems among patients and improves self-efficacy of caregivers. In general, those interventions tailored on individual level generate better outcomes. Comparative research on respite care was very rare., Conclusions: Despite methodological inconsistency, supporting caregivers appears to be an effective strategy often improving well-being of caregiver or care-recipient and resulting in additional benefits for society. However, there is a need for more research on the (cost)-effectiveness of respite care.

Background and Aim: Injury severity scores are important in the context of developing European and national goals on traffic safety, health-care benchmarking and improving patient communication. Various severity scores are available and are mostly based on Abbreviated Injury Scale (AIS) or International Classification of Diseases (ICD). The aim of this paper is to compare the predictive value for in-hospital mortality between the various severity scores if only International Classification of Diseases, 9th revision, Clinical Modification ICD-9-CM is reported., Methodology: To estimate severity scores based on the AIS lexicon, ICD-9-CM codes were converted with ICD Programmes for Injury Categorization (ICDPIC) and four AIS-based severity scores were derived: Maximum AIS (MaxAIS), Injury Severity Score (ISS), New Injury Severity Score (NISS) and Exponential Injury Severity Score (EISS). Based on ICD-9-CM, six severity scores were calculated. Determined by the number of injuries taken into account and the means by which survival risk ratios (SRRs) were calculated, four different approaches were used to calculate the ICD-9-based Injury Severity Scores (ICISS). The Trauma Mortality Prediction Model (TMPM) was calculated with the ICD-9-CM-based model averaged regression coefficients (MARC) for both the single worst injury and multiple injuries. Severity scores were compared via model discrimination and calibration. Model comparisons were performed separately for the severity scores based on the single worst injury and multiple injuries., Results: For ICD-9-based scales, estimation of area under the receiver operating characteristic curve (AUROC) ranges between 0.94 and 0.96, while AIS-based scales range between 0.72 and 0.76, respectively. The intercept in the calibration plots is not significantly different from 0 for MaxAIS, ICISS and TMPM., Discussion: When only ICD-9-CM codes are reported, ICD-9-CM-based severity scores perform better than severity scores based on the conversion to AIS., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: In-ambulance telemedicine is a recently developed and a promising approach to improve emergency care. We implemented the first ever 24/7 in-ambulance telemedicine service for acute stroke. We report on our experiences with the development and pilot testing of the Prehospital Stroke Study at the Universitair Ziekenhuis Brussel (PreSSUB) to facilitate a wider spread of the knowledge regarding this technique., Methods: Successful execution of the project involved the development and validation of a novel stroke scale, design and creation of specific hardware and software solutions, execution of field tests for mobile internet connectivity, design of new care processes and information flows, recurrent training of all professional caregivers involved in acute stroke management, extensive testing on healthy volunteers, organisation of a 24/7 teleconsultation service by trained stroke experts and 24/7 technical support, and resolution of several legal issues., Results: In all, it took 41 months of research and development to confirm the safety, technical feasibility, reliability, and user acceptance of the PreSSUB approach. Stroke-specific key information can be collected safely and reliably before and during ambulance transportation and can adequately be communicated with the inhospital team awaiting the patient., Conclusion: This paper portrays the key steps required and the lessons learned for successful implementation of a 24/7 expert telemedicine service supporting patients with acute stroke during ambulance transportation to the hospital., (© 2016 S. Karger AG, Basel.)

Objective: We describe a methodological framework to estimate potential cost savings in Belgium for a decrease in cardiovascular emergency admissions (ischemic heart disease (IHD), heart rhythm disturbances (HRD), and heart failure) due to a reduction in air pollution., Methods: Hospital discharge data on emergency admissions from an academic hospital were used to identify cases, derive risk functions, and estimate hospital costs. Risk functions were derived with case-crossover analyses with weekly average PM10, PM2.5, and NO2 exposures. The risk functions were subsequently used in a micro-costing analysis approach. Annual hospital cost savings for Belgium were estimated for two scenarios on the decrease of air pollution: 1) 10% reduction in each of the pollutants and 2) reduction towards annual WHO guidelines., Results: Emergency admissions for IHD and HRD were significantly associated with PM10, PM2.5, and NO2 exposures the week before admission. The estimated risk reduction for IHD admissions was 2.44% [95% confidence interval (CI): 0.33%-4.50%], 2.34% [95% CI: 0.62%-4.03%], and 3.93% [95% CI: 1.14%-6.65%] for a 10% reduction in PM10, PM2.5, and NO2 respectively. For Belgium, the associated annual cost savings were estimated at € 5.2 million, € 5.0 million, and € 8.4 million respectively. For HRD, admission risk could be reduced by 2.16% [95% CI: 0.14%-4.15%], 2.08% [95% CI: 0.42%-3.70%], and 3.46% [95% CI: 0.84%-6.01%] for a 10% reduction in PM10, PM2.5, and NO2 respectively. This corresponds with a potential annual hospital cost saving in Belgium of € 3.7 million, € 3.6 million, and € 5.9 million respectively. If WHO annual guidelines for PM10 and PM2.5 are met, more than triple these amounts would be saved., Discussion: This study demonstrates that a model chain of case-crossover and micro-costing analyses can be applied in order to obtain estimates on the impact of air pollution on hospital costs., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Background and Purpose: Recovery of patients within the first 6 months after stroke is well documented, but there has been little research on long-term recovery. The aim of this study was to analyze functional and motor recovery between admission to rehabilitation centres and 5 years after stroke., Methods: This follow-up of the Collaborative Evaluation of Rehabilitation in Stroke Across Europe study, included patients from 4 European rehabilitation centres. Patients were assessed on admission, at 2 and 6 months, and 5 years after stroke, using the Barthel Index, Rivermead Motor Assessment Gross Function, Leg and Trunk function, and Arm function. Linear mixed models were used, corrected for baseline characteristics. To account for the drop-out during follow-up, the analysis is likelihood-based (assumption of missingness at random)., Results: A total of 532 patients were included in this study, of which 238 were followed up at 5 years post stroke. Mean age at stroke onset was 69 (±10 SD) years, 53% were men, 84% had ischemic strokes, and 53% had left-sided motor impairment. Linear mixed model analysis revealed a significant deterioration for all 4 outcomes between 6 months and 5 years (P<0.0001). Scores at 2 months were not statistically significant different from scores at 5 years after stroke. Higher age (P<0.0001) and increasing stroke severity on admission (P<0.0001) negatively affected long-term functional and motor recovery., Conclusions: Five-year follow-up revealed deterioration in functional and motor outcome, with a return to the level measured at 2 months. Increasing age and increasing stroke severity negatively affected recovery up to 5 years after stroke., (© 2015 American Heart Association, Inc.)

Rationale: Stroke is a time-critical medical emergency requiring specialized treatment. Prehospital delay contributes significantly to delayed or missed treatment opportunities. In-ambulance telemedicine can bring stroke expertise to the prehospital arena and facilitate this complex diagnostic and therapeutic process., Aims: This study evaluates the efficacy, safety, feasibility, reliability and cost-effectiveness of in-ambulance telemedicine for patients with suspicion of acute stroke. We hypothesize that this approach will reduce the delay to in-hospital treatment by streamlining the diagnostic process and that prehospital stroke care will be improved by expert stroke support via telemedicine during the ambulance transportation., Design: PreSSUB II is an interventional, prospective, randomized, open-blinded, end-point, single-center trial comparing standard emergency care by the Paramedic Intervention Team of the Universitair Ziekenhuis Brussel (control) with standard emergency care complemented with in-ambulance teleconsultation service by stroke experts (PreSSUB)., Study Outcomes: The primary efficacy endpoint is the call-to-brain imaging time. Secondary endpoints for the efficacy analysis include the prevalence of medical events diagnosed and corrected during in-ambulance teleconsultation, the proportion of patients with ischemic stroke receiving recanalization therapy, the assessment of disability, functional status, quality of life and overall well-being. Mortality at 90 days after stroke is the primary safety endpoint. Secondary safety analysis will involve the registration of any adverse event. Other analyses include assessment of feasibility and reliability and a health economic evaluation.

Abstract Introduction. Early CPR and use of automated external defibrillators (AEDs) have been shown to improve cardiac arrest (CA) outcomes. Placement of AEDs on golf courses has been advocated for more than a decade, with many trade golf publications calling for their use. Objective. To describe the incidence and treatment of CAs at Michigan golf courses and assess the response readiness of their staff. Methods. We performed a retrospective study of CA on Michigan golf courses from 2010 to 2012. Cases were identified from the Michigan EMS Information (MI-EMSIS) database. Cases with "golf" or "country club" were manually reviewed and location type was confirmed using Google Maps. We conducted a structured telephone survey capturing demographics, course preparedness, including CPR training and AED placement, and a description of events, including whether CPR was performed and if an AED was used. Our primary area of interest was the process of care. We also recorded return of spontaneous circulation (ROSC) as an outcome measure. EMS Utstein data were collected from MI-EMSIS. Descriptive data are presented. Results. During the study period, there were 14,666 CAs, of which 40 (0.18%) occurred on 39 golf courses (1 arrest/64 courses/year). Of these, 38 occurred between May and October, yielding a rate of 1 arrest/33.5 courses/golf season. Almost all (96.2%) patients were male, mean age 66.3 (range 45-85), 68% had VT/VF, and 7 arrested after EMS arrival. Mean interval from 9-1-1 call to EMS arrival at the patient was 9:45 minutes (range 3-20). Of all cases, 24 (72.3%) patients received CPR with 2 patients having CPR performed by course staff. Although AEDs were available at 9 (22.5%) courses, they were only placed on 2 patients prior to EMS arrival. Sustained ROSC was obtained in 12 (30.0%) patients. Only 7, (17.9%) courses required CPR/AED training of staff. Conclusion. When seasonally adjusted, the rate of cardiac arrest on Michigan golf courses is similar to that of other public locations. AED use was rare even when available. Preparedness for and response during a CA is suboptimal. Despite more than a decade of advocacy, response to golf course cardiac arrest is still not up to par.

Pharmacists' roles are shifting away from medicines supply and the provision of patient education involving acute medications towards consultation-type services for chronic medications. Determining the cost effectiveness of pharmacist interventions has been complicated by methodological challenges. A critique of 31 economic evaluations carried out alongside comparative studies of pharmacist interventions published between 2003 and 2013 (12 from the UK, six from the USA) found a range of disease-specific and cross-therapeutic interventions targeting both patients and prescribers in a range of settings evaluated through a variety of study designs. Only ten were full economic evaluations, five of which were based on randomized controlled trials (RCTs). The intervention was usually quite well described, but the comparator was not always clearly described, and some interventions are very context specific due to the variability in pharmacist services available in different countries and practice settings. Complex multidirectional aims of most pharmacist interventions have led to many process, intermediate and longer-term outcomes being included in any one study. Quality of resource use and cost data varied. Most incremental cost-effectiveness ratios (ICERs) were generated from process indicators such as errors and adherence, with only four studies reporting cost per quality-adjusted life-year (QALY). Very few studies examined the effect of uncertainty, and methods used were not very clear in some cases. The principal finding from our critique is that poor RCT study design or analysis precludes many studies from finding pharmacist interventions effective or cost effective. We conclude with a set of recommendations for future study design.

Background: Recovery post stroke is well documented in the field of stroke rehabilitation. The structure and process of rehabilitation are different between developed and developing countries. The aim of the present study was to compare the motor and functional recovery of stroke patients in Germany versus stroke patients receiving rehabilitation in South Africa., Methods: This study used secondary data analysis of patient protocols collected in two independent studies conducted in Germany and South Africa respectively. A total of 73 patients from the two separate studies were matched for age at stroke onset, gender, and initial motor functioning. Motor and functional recovery were assessed at baseline, two and six months post stroke using the Rivermead Motor Assessment Scale and the Barthel Index (BI) respectively. Significant differences in motor and functional recovery were found, using the Wilcoxon rank sum test on admission to the centre, and at two and six months after stroke. A generalized linear mixed-methods model (GLIMMIX) was used to compare the recovery patterns between the participants from the two settings over time., Results: The results of the GLIMMIX revealed a significant difference in favour of the German participants for gross motor (RMA-GF) and upper limb (RMA-A) recovery, while no significant difference was found for lower limb (RMA-LT) and functional (BI) recovery patterns between the participants of the two settings. No significant differences existed in RMA-A and BI-scores on admission to the CHC/SRU. At two and six months after stroke, both the RMA-A and BI-scores were significantly lower in the South African than the German sample., Conclusion: The results of this study provide empirical evidence for differential recovery patterns for patients in developed and developing countries. A detailed exploration of the factors to which this difference in recovery patterns can be attributed was beyond the scope of the present study, and is recommended for future research.

Purpose: To determine the prognostic value of single items of the Barthel Index (BI) at discharge from rehabilitation, in predicting independence in personal activities of daily living (ADL) (BI score ≥ 95/100) at five years after stroke., Method: People with stroke were recruited consecutively from four European rehabilitation centres. BI was assessed on discharge and at five years after stroke. Stepwise multivariate logistic regression analysis was used to determine independent predictors of BI score ≥ 95/100 at five years after stroke. Thereupon, percentage chance of reaching BI ≥ 95/100 at five years after stroke was calculated., Results: Data were available for 153 patients. Independence in dressing (odds ratio (OR)=5.22, 95% confidence interval (CI)=1.85-14.76, p=0.002) and bathing (OR=8.10, 95% CI=3.40-19.32, p<0.0001) were independent predictors. Independence in both items resulted in 74.1% (57.6-85.8) chance of reaching BI ≥ 95/100 at five years after stroke. Dependence in both items resulted in 6.3% (5.1-7.9) chance. Independence in bathing, but dependence in dressing resulted in 35.4% (30.7-40.4) chance whereas the opposite resulted in 26.1% (20.7-32.3) chance., Conclusion: Simple assessment of dressing and bathing on discharge from rehabilitation enables therapeutic staff to predict prognosis for long-term independence in personal ADL. This method can be used for early identification of persons with stroke who need intensive follow-up. Implications for Rehabilitation (In)dependence for dressing and bathing at discharge from a rehabilitation centre are significant factors in the prediction of (in)dependence in personal ADL at five years after stroke. This predictive tool can be used for targeting inpatient stroke rehabilitation and early identification of those patients who need intensive follow-up.

Background: Antenatal care can play an important role in the prevention of preterm birth. Evaluation of antenatal care is usually based on the number of visits rather than the content of care, using tools such as the Adequacy of Prenatal Care Use index. This article presents an analysis of the relation between specific elements of antenatal care and the risk of preterm birth compared with considering the number of visits only., Methods: A prospective cohort study was conducted in the Brussels Metropolitan Region. In all, 333 women were consecutively recruited at the beginning of their antenatal care trajectory and followed until birth. Information on timing and content for every visit was recorded by structured interview. A new tool was developed to measure the antenatal care trajectory, which included Content and Timing of care in Pregnancy (CTP). Odds ratios (OR) (adjusted and unadjusted) for preterm birth were calculated for the Adequacy of Prenatal Care Use and CTP model., Results: The number of visits alone was not associated with preterm birth. In contrast, a significant association was found between the content and timing of care and preterm birth. Compared with the CTP lowest ('inadequate') category, women in the CTP 'sufficient' (OR 0.30; 95% CI 0.09-0.94) and CTP 'appropriate' (OR 0.21; 95% CI 0.06-0.68) category had a lower risk., Conclusions: This study suggests that measurement of the content and timing of care of antenatal care using the new CTP tool is a better assessment of the risk of preterm birth than assessment of the number of antenatal visits alone.

Background: When examining risk factors for inadequate antenatal care, the assessment of antenatal care hardly considers the content and timing of interventions during pregnancy. This study aims to provide information about the importance of predisposing, enabling and pregnancy-related determinants on the received content and timing of antenatal care., Methods: In the Brussels Metropolitan Region, 333 women were consecutively recruited at the beginning of their pregnancies. Antenatal care use was recorded prospectively. A classification system measuring the content and timing of care during pregnancy (CTP) divided the women into four categories. Ordinal regression analyses were applied to define unadjusted and adjusted odds ratios (ORs), measuring the effect of different determinants on being assigned to a higher CTP category., Results: A total of 10.2% of the women had an inadequate, 8.4% an intermediate, 36% a sufficient and 45.3% an appropriate antenatal care trajectory. Adjusted ORs showed a lower likelihood of being assigned to a higher CTP category for lower educated women (OR: 0.58; 95% CI 0.37-0.92), women of Maghreb origin (OR: 0.38; 95% CI 0.22-0.66) and women with a higher discontinuity of care (OR: 0.56; 95% CI 0.34-0.90)., Conclusions: When controlling for confounders, no enabling determinants were found that affect the content and timing of care in pregnancy. Although antenatal care is equally available to all women, predisposing and pregnancy-related factors were related to the likelihood of completing an appropriate antenatal care trajectory. Besides stimulating knowledge about the importance of antenatal care in less-educated and Maghreb women, supporting continuity of care during pregnancy might result in higher levels of received antenatal care.

Transportation policy measures often aim to change travel behaviour towards more efficient transport. While these policy measures do not necessarily target health, these could have an indirect health effect. We evaluate the health impact of a policy resulting in an increase of car fuel prices by 20% on active travel, outdoor air pollution and risk of road traffic injury. An integrated modelling chain is proposed to evaluate the health impact of this policy measure. An activity-based transport model estimated movements of people, providing whereabouts and travelled kilometres. An emission- and dispersion model provided air quality levels (elemental carbon) and a road safety model provided the number of fatal and non-fatal traffic victims. We used kilometres travelled while walking or cycling to estimate the time in active travel. Differences in health effects between the current and fuel price scenario were expressed in Disability Adjusted Life Years (DALY). A 20% fuel price increase leads to an overall gain of 1650 (1010-2330) DALY. Prevented deaths lead to a total of 1450 (890-2040) Years Life Gained (YLG), with better air quality accounting for 530 (180-880) YLG, fewer road traffic injuries for 750 (590-910) YLG and active travel for 170 (120-250) YLG. Concerning morbidity, mostly road safety led to 200 (120-290) fewer Years Lived with Disability (YLD), while air quality improvement only had a minor effect on cardiovascular hospital admissions. Air quality improvement and increased active travel mainly had an impact at older age, while traffic safety mainly affected younger and middle-aged people. This modelling approach illustrates the feasibility of a comprehensive health impact assessment of changes in travel behaviour. Our results suggest that more is needed than a policy rising car fuel prices by 20% to achieve substantial health gains. While the activity-based model gives an answer on what the effect of a proposed policy is, the focus on health may make policy integration more tangible. The model can therefore add to identifying win-win situations for both transport and health., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Statistics on road traffic accidents (RTAs) mainly come from police records. The police reported RTA statistics however are known to have a large degree of under-registration, underestimating the true risk of being injured in traffic accidents. The use of medical based datasets can provide a more accurate estimate of the actual traffic accident health risk. Exposure-based rates of the actual burden from Flanders and Brussels were calculated, comparing differences between road user, age, gender and type of injury sustained. Minimal Clinical Data (MCD) was selected for the years 2003-2007, as well as data from the mortality statistics. Disability Adjusted Life Years (DALY) were calculated and put into perspective with the passenger kilometres travelled. Motorcyclists followed by bicyclists and pedestrians showed a higher DALY per travelled kilometre (6365, 1724 and 1359 DALY per billion kilometres respectively), compared to 113 DALY per billion kilometres for motor vehicles. In bicyclists and to lesser extent in motorcyclists, the majority of the health burden was attributed to disability following injuries and not fatalities. Also in the other road user categories disability added substantially to the total health loss. The use of medical data and more particular the MCD may be a valuable addition of those RTAs that are missed by the police scope. Although the results are still conservative estimations, an injury-based approach can help to better understand the health problem that road traffic accidents cause., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Introduction: The majority of traffic safety policies are limited to preventing mortality. However, non-fatal injuries also impose a significant risk of adverse health. Therefore, both mortality and morbidity outcomes should be included in the evaluation of traffic safety policies. The authors propose a method to evaluate different policy options taking into account both fatalities and serious injuries., Methods: A health impact model was developed and aligned with a transport and road safety model, calculating the health impact of fatalities and seriously injured traffic victims for two transport scenarios in Flanders and Brussels (Belgium): a base scenario and a fuel price increase of 20% as an alternative. Victim counts were expressed as disability adjusted life years, using a combination of police and medical data. Seriously injured victims were assigned an injury, using injury distributions derived from hospital data, to estimate the resulting health impact from each crash. Health impact of fatalities was taken as the remaining life expectancy at the moment of the fatal crash., Results: The fuel price scenario resulted in a decrease of health impact due to fatalities of 5.53%--5.85% and 3.37%--3.88% for severe injuries. This decrease was however not equal among all road users., Conclusions: With this method, the impact of traffic polices can be evaluated on both mortality and morbidity, while taking into account the variability of different injuries following a road crash. This model however still underestimates the impact due to non-fatal injuries.

Objective: To determine 5-year mortality and its association with baseline characteristics and functional status 6 months post-stroke for patients who received inpatient rehabilitation., Design: A prospective rehabilitation-based cohort study., Subjects: A total of 532 consecutive stroke patients from 4 European rehabilitation centres., Methods: Predictors were recorded on admission. Barthel Index was assessed at 6 months (BI6mths) and patients were followed for 5 years post-stroke. Survival probability was computed using Kaplan-Meier analysis and compared across 3 BI6mths-classes (0-60, 65-90, 95-100) (log-rank test). Significant independent predictors were determined using multivariate Cox regression analysis (hazard ratio (HR))., Results: Five-year cumulative risk of death was 29.12% (95% confidence interval (CI): 22.86-35.38). Age (HR=1.06, 95% CI: 1.04-1.09), cognitive impairment (HR=1.77, 95% CI: 1.21-2.57), diabetes mellitus (HR=1.68, 95% CI: 1.16-2.41) and atrial fibrillation (HR=1.52, 95% CI: 1.08-2.14) were independent predictors of increased mortality. Hyperlipidaemia (HR=0.66, 95% CI: 0.46-0.94), and higher BI6mths (HR=0.98, 95% CI: 0.97-0.99) were independent predictors of decreased mortality. Five-year survival probability was 0.85 (95% CI: 0.80-0.89) for patients in BI6mths-class: 95-100, 0.72 (95% CI: 0.63-0.79) in BI6mths-class: 65-90 and 0.50 (95% CI: 0.40-0.60) in BI6mths-class: 0-60 (p<0.0001)., Conclusion: Nearly one-third of rehabilitation patients died during the first 5 years following stroke. Functional status at 6 months was a powerful predictor of long-term mortality. Maximum functional independence at 6 months post-stroke should be promoted through medical interventions and rehabilitation. Future studies are recommended to evaluate the direct effect of rehabilitation on long-term survival.

Background: Medication errors are common in primary care and are associated with considerable risk of patient harm. We tested whether a pharmacist-led, information technology-based intervention was more effective than simple feedback in reducing the number of patients at risk of measures related to hazardous prescribing and inadequate blood-test monitoring of medicines 6 months after the intervention., Methods: In this pragmatic, cluster randomised trial general practices in the UK were stratified by research site and list size, and randomly assigned by a web-based randomisation service in block sizes of two or four to one of two groups. The practices were allocated to either computer-generated simple feedback for at-risk patients (control) or a pharmacist-led information technology intervention (PINCER), composed of feedback, educational outreach, and dedicated support. The allocation was masked to researchers and statisticians involved in processing and analysing the data. The allocation was not masked to general practices, pharmacists, patients, or researchers who visited practices to extract data. [corrected]. Primary outcomes were the proportions of patients at 6 months after the intervention who had had any of three clinically important errors: non-selective non-steroidal anti-inflammatory drugs (NSAIDs) prescribed to those with a history of peptic ulcer without co-prescription of a proton-pump inhibitor; β blockers prescribed to those with a history of asthma; long-term prescription of angiotensin converting enzyme (ACE) inhibitor or loop diuretics to those 75 years or older without assessment of urea and electrolytes in the preceding 15 months. The cost per error avoided was estimated by incremental cost-effectiveness analysis. This study is registered with Controlled-Trials.com, number ISRCTN21785299., Findings: 72 general practices with a combined list size of 480,942 patients were randomised. At 6 months' follow-up, patients in the PINCER group were significantly less likely to have been prescribed a non-selective NSAID if they had a history of peptic ulcer without gastroprotection (OR 0·58, 95% CI 0·38-0·89); a β blocker if they had asthma (0·73, 0·58-0·91); or an ACE inhibitor or loop diuretic without appropriate monitoring (0·51, 0·34-0·78). PINCER has a 95% probability of being cost effective if the decision-maker's ceiling willingness to pay reaches £75 per error avoided at 6 months., Interpretation: The PINCER intervention is an effective method for reducing a range of medication errors in general practices with computerised clinical records., Funding: Patient Safety Research Portfolio, Department of Health, England., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

We aim to predict the duration of hospitalization for acute stroke in Belgium by evaluating the external validity of the prolonged length of stay (PLOS) score and by formulating a new prediction score that may be better suited for the Belgian healthcare system. This single-center retrospective study is based on data collected prospectively from the departmental stroke registry. To validate the PLOS score, receiver operating characteristic curves were constructed and Hosmer-Lemeshow tests were implemented. Odds ratios were calculated by models of logistic regression, based on predictors of length of stay (LOS) with significance in univariate analyses, and were translated into a new risk score. C-statistics for prediction of LOS ≥7 days, LOS ≥14 days, and LOS ≥30 days using the PLOS score were in the range of 0.6-0.7. Thrombolytic therapy, mortality, and need for institutionalization had a notable negative influence on the discrimination of the PLOS score. Overall, the PLOS score performed better for prediction of LOS ≥14 days than for LOS ≥7 days and ≥30 days. The Belgian length of stay for stroke (BLOSS) score is proposed as a simplified prediction model based only on the NIHSS score and age. The PLOS score showed moderate value for prediction of hospitalization duration for acute stroke in this Belgian cohort. A prediction model based only on age and stroke severity may be a worthy alternative.

Objective: There has been lengthy debate as to which setting, skilled nursing facility (SNF) or inpatient rehabilitation facility (IRF), is more efficient in treating joint replacement patients. This study aims to determine the efficiency of rehabilitation care provided by SNF and IRF to joint replacement patients with respect to both payment and length of stay (LOS)., Methods: This study used a prospective multisite observational cohort design. Tobit models were used to examine the association between setting of care and efficiency. The study enrolled 948 knee replacement patients and 618 hip replacement patients from 11 IRFs and 7 SNFs between February 2006 and February 2007. Output was measured by motor functional independence measure (FIM) score at discharge. Efficiency was measured in 3 ways: payment efficiency, LOS efficiency, and stochastic frontier analysis efficiency., Results: IRF patients incurred higher expenditures per case but also achieved larger motor FIM gains in shorter LOS than did SNF patients. Setting of care was not a strong predictor of overall efficiency of rehabilitation care. Great variation in characteristics existed within IRFs or SNFs and severity groups. Medium-volume facilities among both SNFs and IRFs were most efficient. Early rehabilitation was consistently predictive of efficient treatment., Conclusions: The advantage of either setting is not clear-cut. Definition of efficiency depends in part on preference between cost and time. SNFs are more payment efficient; IRFs are more LOS efficient. Variation within SNFs and IRFs blurred setting differences; a simple comparison between SNF and IRF may not be appropriate.

Background: The mix of physical therapy services is thought to be different with different impairment groups. However, it is not clear how much variation there is across impairment groups. Furthermore, the extent to which the same physical therapy activities are associated with functional outcomes across different types of patients is unknown., Objective: The purposes of this study were: (1) to examine similarities and differences in the mix of physical therapy activities used in rehabilitation among patients from different impairment groups and (2) to examine whether the same physical therapy activities are associated with functional improvement across impairment groups., Design: This was a prospective observational cohort study., Methods: The study was conducted in inpatient rehabilitation facilities. The participants were 433 patients with stroke, 429 patients with total knee arthroplasty (TKA), and 207 patients with traumatic brain injury (TBI). Measures used in this study included: (1) the Comprehensive Severity Index to measure the severity of each patient's medical condition, (2) the Functional Independence Measure (FIM) to measure function, and (3) point-of-care instruments to measure time spent in specific physical therapy activities., Results: All 3 groups had similar admission motor FIM scores but varying cognitive FIM scores. Patients with TKA spent more time on exercise than the other 2 groups (average=31.7 versus 6.2 minutes per day). Patients with TKA received the most physical therapy (average=65.3 minutes per day), whereas the TBI group received the least physical therapy (average=38.3 minutes per day). Multivariate analysis showed that only 2 physical therapy activities (gait training and community mobility) were both positively associated with discharge motor FIM outcomes across all 3 groups. Three physical therapy activities (assessment time, bed mobility, and transfers) were negatively associated with discharge motor FIM outcome., Limitations: The study focused primarily on physical therapy without concurrently considering other therapies such as occupational therapy, speech-language pathology, nursing care, and case management or the potential interaction of these inputs. This analysis did not consider the interventions that physical therapists used when patients participated in discrete physical therapy activities., Conclusions: All 3 patient groups spent a considerable portion of their physical therapy time in gait training relative to other activities. Both gait training and community mobility are higher-level activities that were positively associated with outcomes, although all 3 groups spent little time in community mobility activities. Further research studies, such as randomized clinical trials and predictive validity studies, are needed to investigate whether higher-level or more-integrated therapy activities are associated with better patient outcomes.

Prenatal care is important for the health and wellbeing of women and their babies. There is international consensus that prenatal care should begin in the first trimester. This study aims to analyze the effects of predisposing, enabling and pregnancy-related determinants of late prenatal care initiation. In this prospective observational study, 333 women were recruited consecutively at the beginning of their prenatal care trajectory. Data was collected on the timing of the first prenatal visit and on socio-demographic and pregnancy-related characteristics, using a semi-structured interview. A multivariate binominal logistic regression was applied to analyze independent effects on late initiation of prenatal care. Bivariately late initiation of care was associated with being inactive on the labor market, non-European origin, not having lived in Belgium since birth, low income, receiving welfare benefits, not having a regular obstetrician and experiencing difficulties getting a first appointment. When adjusting for all determinants, our multivariate analyses showed that late initiation was associated with non-European origin, low income and not having a regular obstetrician. This study shows that late initiation of prenatal care is associated with predisposing and enabling determinants. In order to ensure timely initiation of care, policy-makers should focus on encouraging women to have a regular prenatal care provider before pregnancy and taking steps in lowering out-of-pocket fees for low-income women. Future research is needed to examine whether these determinants are associated with initiation of care only or whether they play a role in the pregnancy follow-up as well.

Background: There is only scarce information on the incidence and costs of stroke in Belgium. Knowledge of these figures permits targeted allocation of resources and aids cost efficacy estimates., Methods: We analysed a nationwide administrative database used for reimbursement of hospitals in Belgium. This database allows analysis of the rate of all hospital admissions for TIA, acute ischemic stroke, intracranial hemorrhage and carotid surgery or angioplasty. We compared the costs of hospitalization for stroke and related disorders with the costs of hospitalization for coronary artery disease., Results: There were 32970 admissions for stroke related disorders in 2007 at a cost of 191.6 million EUROS. There was a decline of 4.7% of the rate of hospitalization for stroke and associated disorders over the period 2002-2007. Despite this decline the total costs did not diminish substantially. In 2007 stroke and related disorders accounted for 2.0% of all Belgian hospitalizations, whereas coronary artery disease hospitalization accounted for 4.4%. The length of stay was longer for stroke and associated disorders. The average cost of hospitalizations in 2007 for stroke related disorders was 6188 EURO and the average cost of coronary artery related disorders was 5026 EURO., Conclusion: The cost of hospitalization for stroke and related disorders is high. Although coronary artery disease is more frequent and has a larger impact on the health care expenditures, the average cost per hospitalization is higher for stroke and related diseases. This is mainly due to the longer hospitalization duration for stroke.

Objective: To assess black-white differences in functional outcomes, controlling for patient characteristics, use of nontherapy ancillaries (NTAs), and use of physical (PT) and occupational therapy (OT) activities and interventions., Design: Multicenter prospective observational cohort study of poststroke rehabilitation., Setting: Six U.S. inpatient rehabilitation facilities., Participants: Patients (N=732) subdivided into case-mix subgroups (CMGs; CMGs 104-107 for moderate strokes [n=397], CMGs 108-114 for severe strokes [n=335])., Interventions: Not applicable., Main Outcome Measure: Discharge Motor FIM., Results: Taking into account patient characteristics, NTAs, and therapy activities, multivariate regressions explained (R(2)) 54% and 69% of variation in outcomes between patients with moderate and severe stroke, respectively. Black race was associated with lower outcomes than white race in the severe group. However, race was no longer associated with outcomes after including interventions used within PT and OT activities. Including interventions within therapy activities increased R(2) to 64% and 74% for moderate and severe strokes, respectively. Some PT and OT activities were provided more to blacks than whites and vice versa. Greater intensity sometimes was associated with better and sometimes with poorer functional outcomes., Conclusions: After controlling for interventions within activities, no racial differences were found in functional outcomes at discharge despite racial differences in rehabilitation care, possibly because each racial group received a mixture of interventions that were negatively and positively associated with outcome. Clinicians should provide therapies associated with better outcomes with high and similar intensities for black and white patients poststroke., (Copyright © 2010 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To understand the use of therapy extenders in stroke rehabilitation., Design: Descriptive analysis of a prospective observational cohort study., Results: Two hundred ninety-eight patients with moderate stroke and 284 with severe stroke from 5 inpatient rehabilitation facilities with complete physical and occupational therapy data are included in the study. Overall, occupational therapists and assistants contributed ∼70% and 21% of all occupational therapy hours, respectively. For physical therapy, these percentages in moderate group (60% vs. 31%) differ from those in severe group (65% vs. 23%). Some variations in the use of therapy extenders are noted in both disciplines across sites. Physical and occupational therapists spend more time in delivering advanced activities that include ongoing integrated evaluation and treatment planning or modification. Their assistants spend more time in delivering lower-level activities, such as bed mobility, transfers, dressing, or nonfunctional activities. Also, therapists are more likely to assign responsibility to assistants to treat moderate motor impairment among patients with stroke., Conclusions: Characterizing therapy practice in stroke rehabilitation is not straightforward. It is multifactorial and takes into account the (1) type of therapy, (2) therapy activity, (3) therapy provider including extender personnel, (4) specific training in stroke, and (5) years of experience. Future research to examine the association between use of therapy extenders and outcomes is recommended.

Objective: To describe racial differences in patient characteristics, nontherapy ancillaries, physical therapy (PT), occupational therapy (OT), and functional outcomes at discharge in stroke rehabilitation., Design: Multicenter prospective observational cohort study of poststroke rehabilitation., Setting: Six U.S. inpatient rehabilitation facilities., Participants: Black and white patients (n=732), subdivided in case-mix subgroups (CMGs): CMGs 104 to 107 for moderate strokes (n=397), and CMGs 108 to 114 for severe strokes (n= 335)., Interventions: Not applicable., Main Outcome Measure: FIM., Results: Significant black-white differences in multiple patient characteristics and intensity of rehabilitation care were identified. White subjects took longer from stroke onset to rehabilitation admission and were more ambulatory prior to stroke. Black subjects had more diabetes. For patients with moderate stroke, black subjects were younger, were more likely to be women, and had more hypertension and obesity with body mass index greater than or equal to 30. For patients with severe stroke, black subjects were less sick and had higher admission FIM scores. White subjects received more minutes a day of OT, although black subjects had significantly longer median PT and OT session duration. No black-white differences in unadjusted stroke rehabilitation outcomes were found., Conclusions: Reasons for differences in rehabilitation care between black and white subjects should be investigated to understand clinicians' choice of treatments by race. However, we did not find black-white differences in unadjusted stroke rehabilitation outcomes., (Copyright © 2010 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To characterize rehabilitation services in two types of postacute facilities in patients who underwent hip replacement following a hip fracture., Design: Multisite prospective observational cohort from 6 freestanding skilled nursing facilities and 11 inpatient rehabilitation facilities. Patients (n = 218) with hip fracture who had either hemiarthroplasty or total hip arthroplasty followed by rehabilitation at skilled nursing facilities or inpatient rehabilitation facilities were enrolled. Using a point-of-care methodology, we recorded data from actual physical therapy and occupational therapy sessions completed including functional outcomes during the postacute admission., Results: Onset time from surgical repair to rehabilitation admission was not significantly different between sites. Average skilled nursing facilities length of stay was 24.7 +/- 13.6 days, whereas inpatient rehabilitation facilities was 13.0 +/- 5.7 days (P < 0.01). Total hours of physical therapy and occupational therapy services per patient day were 1.2 in skilled nursing facilities and 2.0 in inpatient rehabilitation facilities. For weekdays only, these data changed to 1.6 in skilled nursing facilities and 2.6 hrs per patient in inpatient rehabilitation facilities (P < 0.01). Patients in inpatient rehabilitation facilities accrued more time for gait training and exercise in physical therapy, which was found to be 48% and 40% greater, respectively, through day 8. In occupational therapy, patients of inpatient rehabilitation facilities had more time allocated to lower body dressing and transfers., Conclusions: Significant differences in rehabilitation activities were observed, and intensity was notably different within the first 8 therapy days even though baseline demographics and medical complexity were comparable across facility types. Our data suggest that after more complex hip replacement surgery, hip fracture patients can tolerate more intensive therapy earlier within the rehabilitation program.

Purpose: Analyse racial disparities in clinical outcomes after stroke in inpatient rehabilitation facilities (IRF)., Methods: Analyses based on data from a multi-center prospective observational cohort study on inpatient stroke rehabilitation in six IRFs from across the United States. Multivariate models examined racial disparities in functional outcomes upon discharge, taking into account patient characteristics and detailed information on processes of care., Results: In the moderate stroke group (N = 397), functional scores on admission were not significantly different between African-Americans and whites. In the severe stroke group (N = 335), whites showed significantly lower functional scores at admission [Functional Independence Measurement, (FIM)], mean scores, 44 versus 49 for African-Americans, p < 0.001). Multivariate analyses predicting discharge motor FIM score found no significant differences between African-American and white stroke patients (p = 0.2194 and p = 0.3547 in the moderate and severe stroke group, respectively)., Conclusion: Controlling for patient characteristics, therapy intensity and processes of care results in non-significant differences between African-Americans and whites in motor FIM scores upon discharge. The absence of significant differences in recovery while patients were on the rehabilitation unit suggests that racial disparities in long-term functional recovery after stroke are likely to have originated before or after the inpatient rehabilitation stay.

Background and Purpose: This study aimed to unravel the multidimensional profile of stroke outcomes by investigating the global correlation structure of motor, functional, and emotional problems of patients, as well as their caregivers' strain, at 6 months after stroke. Potential differential associations based on patients' level of functioning on admission to the rehabilitation center were analyzed., Methods: Data were collected within the CERISE-study (Collaborative Evaluation of Rehabilitation in Stroke across Europe). Six months after stroke, the Rivermead Motor Assessment (RMA), Extended Activities of Daily Living (EADL), Hospital Anxiety and Depression Scale-Anxiety (HADS-A) and Hospital Anxiety and Depression Scale-Depression (HADS-D), EuroQol-Health State (EQ-HS), EuroQol-Visual Analogue Scale (EQ-VAS), and Caregiver Strain Index (CSI) were administered. Patients were classified into 3 categories according to their Barthel Index (BI) score on admission to the rehabilitation center. Principal component analysis was carried out, and a biplot was constructed., Results: Data were available on 510 patients. One cluster was formed by RMA and EADL, and a second one by HADS-A, HADS-D, and EQ-VAS. EQ-HS was situated between these two. CSI formed a third dimension. Patients with low BI scores on admission to the rehabilitation center had higher HADS-A and HADS-D scores 6 months after stroke. High BI scores were associated with large variations in HADS-A and HADS-D scores., Conclusions: This novel biplot strategy for rehabilitation studies revealed 2 clusters: one of motor/functional problems and one of emotional problems. Patients with mild functional deficit measured on admission to the rehabilitation center can suffer from mild to severe anxiety and depression at 6 months poststroke. Screening for emotional disorders in all patients is recommended.

Objective: To examine functional and health status outcomes of patients with joint replacement discharged from a skilled nursing facility (SNF) or an inpatient rehabilitation facility (IRF)., Design: Postdischarge follow-up interview study at 7.5 months after admission., Setting: Five freestanding SNFs, 1 hospital-based SNF, and 6 IRFs., Participants: Patients (N=856): 561 with knee replacement and 295 with hip replacement., Interventions: None., Main Outcome Measures: FIM and Short-Form 12-Item Health Survey (SF-12)., Results: Among patients with knee and hip replacement, IRF patients made larger motor FIM gains from admission and discharge to follow-up. IRF patients, however, were admitted with lower FIM scores and also had more to gain (especially given the ceiling effects within the FIM at follow-up). When adjusted for case mix, IRF patients made larger motor FIM gains and had higher SF-12-related scores among patients with hip replacement but not among patients with knee replacement. Multivariate regressions found modest setting effects that favored IRFs, and the setting effects explained only a modest portion of the variance in motor FIM outcomes., Conclusions: At follow-up, patients with joint replacement discharged from IRFs had better motor FIM outcomes than those discharged from freestanding SNFs and the hospital-based SNF. Settings did not differ materially in terms of SF-12 outcomes. Findings do not favor one setting decisively over another. A sole focus on initial postacute placement overlooks the larger trajectory of postacute care that needs to be managed to achieve superior outcomes.

Objective: To compare functional outcomes at discharge across postacute settings., Design: Prospective observational cohort study., Setting: Eleven inpatient rehabilitation facilities (IRFs), 8 freestanding skilled nursing facilities (SNFs), and 1 hospital-based SNF from across the United States., Participants: Consecutively enrolled patients (N=2152): patients with knee replacement (n=1401) and patients with hip replacement (n=751)., Interventions: None; examination of existing practice patterns., Main Outcome Measure: FIM discharge motor score., Results: Freestanding SNF patients entered with higher motor FIM scores and left with higher scores than did IRF patients. IRF patients, however, achieved larger motor FIM gains and achieved them in a shorter time. In multivariate models controlling for patient differences and onset days, IRFs were associated with better discharge motor outcomes, but the overall setting effect was not large. The largest motor FIM differences were between medium-volume IRFs and low-volume freestanding SNFs: 4.6 motor FIM points for patients with knee replacement and 7.3 motor FIM points for patients with hip replacement. Other differences between settings were much smaller. Multivariate models explained between a third and a half of the variance in outcome., Conclusions: As a group, IRFs had better motor FIM outcomes than did SNFs, but the size of the IRF advantage was not large. Other important facility and practice characteristics also were associated with discharge outcomes after joint replacement rehabilitation. Earlier and more intensive rehabilitation was associated with better outcomes. The volume of joint replacement patients seen by a facility also plays a part: medium-volume facilities among both SNFs and IRFs had better outcomes.

Objective: To compare use of rehabilitation and other health services among patients with knee and hip replacement after discharge from a skilled nursing facility (SNF) or an inpatient rehabilitation facility (IRF)., Design: Follow-up interview study at 7.5 months after discharge., Setting: Five freestanding SNFs, 1 hospital-based SNF, and 6 IRFs from across the United States., Participants: Patients (N=856): patients with knee replacement (n=561) and patients with hip replacement (n=295)., Interventions: No interventions., Main Outcome Measures: Number of home and outpatient therapy visits, physician visits, emergency room visits, rehospitalizations, and medical complications., Results: After discharge from postacute care, the vast majority of patients received home rehabilitation, outpatient rehabilitation, or both. Patients with knee replacement received an average of 19 home and/or outpatient rehabilitation visits; patients with hip replacement received almost 15 visits. There were no statistically significant differences in rates of emergency room use and rehospitalization except that patients with hip replacement discharged from IRFs had higher rates of rehospitalization than those discharged from freestanding SNFs (15.8% vs 3.1%). Multivariate analyses did not find any SNF/IRF effects., Conclusions: Patients with joint replacement from both SNFs and IRFs receive considerable amounts of follow-up rehabilitation care. Study uncovered no setting effects related to rehospitalization or medical complications. Looking only at care rendered in the initial postacute setting provides an incomplete picture of all care received and how it may affect follow-up outcomes.

Objective: To characterize rehabilitation services for patients with knee and hip replacement in 3 types of postacute facilities in the U.S., Design: Multi-site prospective observational cohort study., Setting: Eight freestanding skilled nursing facilities (SNFs), 1 hospital-based SNF, and 11 inpatient rehabilitation facilities (IRFs)., Participants: Patients (N=2158) with knee or hip replacement., Interventions: No new interventions., Main Outcome Measures: Length of stay (LOS), amount and intensity of physical therapy (PT) and occupational therapy (OT), types of therapy activities., Results: Average LOS was about 15 days for freestanding SNF patients, and 9 to 10 days for hospital-based SNF and IRF patients. Freestanding SNFs and IRFs provide about the same number of hours of PT and OT; the hospital-based SNF provided 27% fewer hours. Freestanding SNFs and the hospital-based SNF provided fewer hours a day than did IRFs. Joint replacement patients across all 3 types of facilities spent, on average, 70% to 75% of their PT time in just 2 activities--exercise and gait and spent 56% to 66% of their OT time in 3 activities--exercise, functional mobility, and dressing lower body., Conclusions: Both freestanding SNFs and IRFs provided similar amounts of PT with a similar emphasis on exercise and gait activities. IRFs, however, provided more OT than freestanding SNFs. IRFs had shorter LOSs and more intensive therapy services than freestanding SNFs. Study freestanding SNFs exhibited greater variation in LOS and intensity of therapy than IRFs.

Background: Care after discharge from inpatient stroke rehabilitation units varies across Europe. The aim of this study was to compare service delivery after discharge., Methods: A total of 532 consecutive patients after stroke were recruited from 4 European rehabilitation centres in Germany, Switzerland, Belgium and the UK. At 2-month intervals, clinical assessments and structured interviews were carried out to document functional status and delivery of services after discharge. Significant factors for receiving follow-up services were analysed using a logistic generalized estimating equation model., Results: After controlling for case-mix, the results showed that Belgian patients were most likely to receive physical therapy but least likely to receive occupational therapy. German patients were least likely to receive nursing care. UK patients were less likely to receive medical care from their general practitioner compared with the other patient groups., Conclusion: Clinical characteristics did not explain the variations in service delivery after discharge from in-patient stroke rehabilitation. The decision-making processes involved in the provision of follow-up services need to be better documented. To improve our understanding of events post-discharge, the influence of non-clinical factors, such as healthcare regulations, should be explored further.

Background: Our understanding of the components of stroke rehabilitation critical to patients' outcomes is limited. Comparing practices and outcomes across countries may give clues to how to improve rehabilitation services., Method: In the CERISE project (Collaborative Evaluation of Rehabilitation in Stroke across Europe), clinical and organisational aspects of stroke rehabilitation were compared among four European rehabilitation centres (United Kingdom, Belgium, Switzerland, and Germany). Main findings were summarised and interpreted., Results: Gross motor and functional recovery were significantly better in the German and Swiss centres compared to the British centre, respectively. Insights in admission criteria, patients' therapy time, content of therapy, and task characteristics of physiotherapists and occupational therapists were in line with the differences in recovery. In Germany, neurorehabilitation is more structured with clearly defined phases, each linked with specific criteria and reimbursement schemes. In Belgium, more variation exists in the rehabilitation trajectories., Conclusion: Stroke rehabilitation services are embedded in health care systems, creating contextual constraints with various (dis)incentives. These constraints vary between countries, resulting in differences in the organisation of stroke rehabilitation. Studies on the effectiveness of stroke rehabilitation should incorporate contextual elements of the organisation of the unit.