Inconsistent diagnosis of acute malnutrition by weight-for-height and mid-upper arm circumference : contributors in 16 cross-sectional surveys from South Sudan, the Philippines, Chad, and Bangladesh

Background: The two anthropometric indicators of acute malnutrition in children under 5 years, i.e. a Mid-Upper Arm Circumference < 125 mm (MUAC(125)) or a Weight-for-Height Z-score<-2 (WHZ(-2)), correlate poorly. We aimed at assessing the contribution of age, sex, stunting (Height-for-Age HAZ<-2), and low sitting-standing height ratio Z-score (SSRZ in the 1st tertile of the study population, called hereafter 'longer legs') to this diagnosis discrepancy. Methods: Data from 16 cross-sectional nutritional surveys carried out by Action Against Hunger International in South Sudan, the Philippines, Chad, and Bangladesh fed multilevel, multivariate regression models, with either WHZ -2 or MUAC(125) as the dependent variable and age, sex, stunting, and 'longer legs' as the independent ones. We also compared how the performance of MUAC125 and WHZ-2 to detect slim children, i.e. children with a low Weight-for-Age (WAZ=-2), was modified by the contributors. Results: Overall 23.1 % of the 14,409 children were identified as acutely malnourished by either WHZ-2 or MUAC125, but only 28.5 % of those (949/3,328) were identified by both indicators. Being stunted (+17.8 %; 95 % CI: 14.8 %; 22.8 %), being a female (+16.5 %; 95 % CI: 13.5 %; 19.5 %) and being younger than 24 months (+33.6 %; 95 % CI: 30.4 %; 36.7 %) were factors strongly associated with being detected as malnourished by MUAC125 and not by WHZ-2, whereas having 'longer legs' moderately increased the diagnosis by WHZ-2 (+4.2 %; 95 % CI: 0.7 %; 7.6 %). The sensitivity to detect slim children by MUAC125 was 31.0 % (95 % CI: 26.8 %; 35.2 %) whereas it was 70.6 % (95 % CI: 65.4 %; 75.9 %) for WHZ-2. The sensitivity of MUAC125 was particularly affected by age (57.4 % vs. 18.1 % in children aged = 24 months). Specificity was high for both indicators. Conclusions: MUAC125 should not be used as a stand-alone criterion of acute malnutrition given its strong association with age, sex and stunting, and its low sensitivity to detect slim children. Having 'longer legs' moderately increases the diagnosis of acute malnutrition by WHZ-2. Prospective studies are urgently needed to elucidate the clinical and physiological outcomes of the various anthropometric indicators of malnutrition

Patient socioeconomic determinants of the choice of generic versus brand name drugs in the context of a reference price system: evidence from Belgian prescription data

The generic reference price system (RPS) can impose a financial penalty for patients using a brand name drug instead of its generic alternative. Previous studies on the impact of the RPS have not considered the potentially differential effect of using generic alternatives for individuals with a different socioeconomic background. However, patients’ characteristics might determine their overall knowledge of the existence of the system and thus of the financial burden to which they may be confronted. The association between patients’ characteristics and the use of generic drugs versus brand name drugs was analyzed for ten highly prescribed pharmaceutical molecules included in the Belgian generic reference price system. Prescriptions were obtained from a 10% sample of all general practitioners in 2008 (corresponding to 120,670 adult patients and 368,101 prescriptions). For each pharmaceutical molecule, logistic regression models were performed, with independent variables for patient socioeconomic background at the individual level (work status, having a guaranteed income and being entitled to increased reimbursement of co-payments) and at the level of the neighborhood (education). The percentage of generic prescriptions ranged from 24.7 to 76.4%, and the mean reference supplement in 2008 ranged from €4.3 to €37.8. For seven molecules, higher use of a generic alternative was associated with either having a guaranteed income, with receiving increased reimbursement of co-payments or with living in areas with the lowest levels of education. Globally, results provided evidence that the generic RPS in Belgium does not lead to a higher financial burden on individuals from a low socioeconomic background

Quality assurance of rectal cancer diagnosis and treatment - phase 3 : statistical methods to benchmark centres on a set of quality indicators

In 2004, the Belgian Section for Colorectal Surgery, a section of the Royal Belgian Society for Surgery, decided to start PROCARE (PROject on CAncer of the REctum), a multidisciplinary, profession-driven and decentralized project with as main objectives the reduction of diagnostic and therapeutic variability and improvement of outcome in patients with rectal cancer. All medical specialties involved in the care of rectal cancer established a multidisciplinary steering group in 2005. They agreed to approach the stated goal by means of treatment standardization through guidelines, implementation of these guidelines and quality assurance through registration and feedback. In 2007, the PROCARE guidelines were updated (Procare Phase I, KCE report 69). In 2008, a set of 40 process and outcome quality of care indicators (QCI) was developed and organized into 8 domains of care: general, diagnosis/staging, neoadjuvant treatment, surgery, adjuvant treatment, palliative treatment, follow-up and histopathologic examination. These QCIs were tested on the prospective PROCARE database and on an administrative (claims) database (Procare Phase II, KCE report 81). Afterwards, 4 QCIs were added by the PROCARE group. Centres have been receiving feedback from the PROCARE registry on these QCIs with a description of the distribution of the unadjusted centre-averaged observed measures and the centre’s position therein. To optimize this feedback, centres should ideally be informed of their risk-adjusted outcomes and be given some benchmarks. The PROCARE Phase III study is devoted to developing a methodology to achieve this feedback

Patient socioeconomic determinants for the choice of the cheapest molecule within a cluster: evidence from Belgian prescription data

Reference pricing is a common cost-sharing mechanism, with the financial penalty for the use of costly drugs shifted from the third-party payer to the patient. Unintended distributional consequences might arise, if the weakest socioeconomic groups face a relatively higher financial burden. This study analyzed for a sample of Belgian individual prescription data for 4 clusters of commonly used drugs (proton pump inhibitors, statins and two groups of antihypertensives [drugs acting on renin-angiotensin system and dihydropyridine derivatives]) whether the probability to receive the least expensive molecule within a cluster was linked to the socioeconomic status of the patient. Logistic regression models included individual demographic, working, chronic illness and financial status and small area education data for 906,543 prescriptions from 1,280 prescribing general practitioners and specialists. For the 4 clusters, results show that patients with lower socioeconomic status consistently use slightly more the least expensive drugs than other patients. Larger effects are observed for patients residing in a nursing home for the elderly, patients entitled to increased reimbursement of co-payments, unemployed, patients treated in a primary care center financed per capita (and not fee-for-service) and patients having a chronic illness. Also, patients residing in neighborhoods with low education status use more less expensive drugs. The findings of the study suggest that although equity considerations were not explicitly taken into account in the design of the reference price system, there is no real equity problem, as the costly drugs with supplement are not prescribed more often in patients from lower socioeconomic classes

Le système du prix de référence et les différences socio-économiques dans l’utilisation des médicaments moins onéreux

X, 69 p.ill.Le Centre fédéral d’expertise des soins de santé (KCE) a vérifié si tous les Belges, quel que soit leur statut socio-économique, profitent des avantages financiers que procure l’utilisation de médicaments génériques ou de certains médicaments originaux qui ont baissé leur prix. Le résultat de l’étude est encourageant car ce sont justement les Belges les moins favorisés qui s’avèrent utiliser un peu plus de tels médicaments. Il y aurait tout de même encore moyen de faire mieux, en appliquant des mesures qui encouragent les médecins et les pharmaciens à plus prescrire et délivrer des médicaments moins onéreux. Les patients aussi pourraient recevoir plus d’information sur les suppléments qu’ils paient à l’achat de médicaments pour lesquels une alternative meilleur marché existe.Table of contents -- LIST OF ABRREVIATIONS 3 -- GLOSSARY 4 -- 1 INTRODUCTION AND RESEARCH QUESTIONS 7 -- 1.1 BACKGROUND 7 -- 1.2 RESEARCH QUESTIONS AND SCOPE 8 -- 1.3 CONTENT OF THIS REPORT 8 -- 2 INTERNATIONAL COMPARISON OF REFERENCE PRICING 9 -- 2.1 INTRODUCTION 9 -- 2.2 GENERAL DESCRIPTION OF THE REFERENCE PRICE SYSTEM 10 -- 2.2.1 Definition 10 -- 2.2.2 General characteristics of a reference price system 11 -- 2.3 OVERVIEW OF THE REFERENCE PRICE SYSTEM IN A SELECTION OF 11 OECD -- COUNTRIES 13 -- 2.3.1 Methods 13 -- 2.3.2 Definition and scope of the cluster 14 -- 2.3.3 The reference price level 16 -- 2.3.4 Measures for physicians, pharmacists and patients 16 -- 2.4 DESCRIPTION OF THE BELGIAN REFERENCE PRICE SYSTEM 18 -- 2.4.1 Evolution of the legal basis of the RPS 19 -- 2.4.2 Definition and scope of the cluster 21 -- 2.4.3 The reference price level 21 -- 2.4.4 The security margin 23 -- 2.4.5 Exemptions 23 -- 2.4.6 Measures for physicians, pharmacists and patients 23 -- 3 IMPACT OF THE REFERENCE PRICE SYSTEM: A LITERATURE REVIEW 28 -- 3.1 INTRODUCTION 28 -- 3.2 METHODS 28 -- 3.3 RESULTS 29 -- 3.3.1 Search strategy and study selection of the review studies on the impact of a RPS 29 -- 3.3.2 Association of the RPS with drug use 30 -- 3.3.3 Association of the RPS with drug prices 30 -- 3.3.4 Association of the RPS with drug expenditures 30 -- 3.3.5 Association of the RPS with health services use and health 31 -- 4 RESULTS FROM THE ANALYSIS OF BELGIAN PRESCRIPTION DATA IN 2008 32 -- 4.1 INTRODUCTION 32 -- 4.2 THE BELGIAN PHARMACEUTICAL MARKET: EVOLUTION OF MARKET SHARES AND -- OUT-OF-POCKET PAYMENTS 33 -- 4.2.1 Evolution of market shares 33 -- 4.2.2 The reference supplement in 2008 36 -- 4.3 IMPACT OF THE REFERENCE PRICE SYSTEM IN BELGIUM: LITERATURE REVIEW 39 -- 4.3.1 Market share of low cost drugs 39 -- 4.3.2 Expenditures for the NIHDI and for patients 39 -- 4.3.3 Potential gains from the increasing use of low cost drugs 39 -- 4.3.4 Strategies by pharmaceutical firms 40 -- 4.4 METHODS 40 -- 4.4.1 Data sources 40 -- 4.4.2 Time period 41 -- 4.4.3 Selection of data (sampling procedure) 41 -- 4.4.4 Coupling procedure and authorisation from the Privacy Commission 41 -- 4.4.5 Selection and construction of socioeconomic variables 41 -- 4.4.6 Selection of patients and of pharmaceutical products 43 -- 4.4.7 Statistical analyses 45 -- 4.5 RESULTS 46 -- 4.5.1 Selection of prescribers and patients 46 -- 4.5.2 Choice between high price/low cost drugs 46 -- 4.5.3 Socioeconomic characteristics of patients or physicians and therapeutic reference -- pricing: evidence in the literature 57 -- 4.5.4 Choice of a less costly active ingredient within a class 58 -- 4.5.5 Appraisal of results: barriers to low cost drugs 62 -- 5 SUMMARY, CONCLUSION AND DISCUSSION 63 -- 6 BIBLIOGRAPHY 6