Continuity of care

Continuity of care addresses  ’the extent to which healthcare for specified users, over time, is smoothly organised within and across providers, institutions and regions, and to which extent the entire disease trajectory is covered’.

We have distinguished four different aspects of continuity:

• continuity of information: measured by the degree of Global Medical Record (GMR) use among the population (QC-1)
• relational continuity: measured by the Usual Provider Continuity index (QC-2)
• management continuity: measured by the proportion of hospital discharges of elderly people (aged 65+ years) which are followed by a contact with a general practitioner within one week (QC-3)
• coordination of care: the connection between different health providers over time to achieve a common objective, such as for example in outpatient care, care trajectories for diabetes (QC-4 and QC-5) or, in hospital care, multidisciplinary oncology consultations (MOCs) (QC-6)

Indicators on continuity of care

(ID) indicator		Score	BEL	Year	Fla	Wal	Bru	Source	EU-15 (mean)
Informational continuity in general practice
QC-1	Coverage of global medical record (% of persons who have a global medical record (GMR) with a general practitioner)		67.5	2016	76.4	57.1	49.3	AIM-IMA	-
Relational continuity in general practice
QC-2	Usual Provider Continuity index sup. or equal 0.75 (%)		67.6	2015-2016	65.8	71.9	64.7	AIM-IMA	-
Management continuity between hospital and GP
QC-3	GP encounter within 7 days after hospital discharge (% patients 65+)		56.6	2016	58.1	55.7	45.7*	AIM-IMA	-
Coordination in ambulatory care
QC-4	Proportion of adult diabetics (under insulin) with a convention, a pass/pre-care trajectory or a care trajectory (% of patients, 18+)		89.9	2016	91.3	88.6	86.1	AIM-IMA	-
QC-5	Proportion of adult diabetics (receiving only glucose-lowering drugs, excluding insulin) with a convention, a pass/pre-care trajectory or a care trajectory (% of patients, 50+)		20.2	2016	26.0	12.3	17.5	AIM-IMA	-
Coordination in hospital care
QC-6	Patients with cancer discussed at the multidisciplinary team meeting (%)		87.5	2015	88.7	85.1	87.8	Cancer registry, AIM-IMA	-

*Underestimated (see the technical sheet)

Some of the indicators analysed in other sections of this report may also be interpreted in terms of continuity of care:

• Among mental healthcare indicators: Proportion of readmissions within 30 days in psychiatric hospitals (MH-11).

Coverage of global medical record (GMR) (QC-1)

Since 2001, in Belgium, each person can request a general practitioner to create a Global Medical Record (GMR) for them, where all their medical information can be centralised and managed. This allows the physician to have a better overview about everything that affects the person’s health, their medical history, treatments, allergies, vaccinations, hospitalisations, etc. Each examination or visit made with another healthcare provider is also recorded, which avoids unnecessary examinations and promotes communication between the different caregivers. A Global Medical Record is therefore a guarantee of optimal health management for every person.

Since 2016, GMRs have become electronic: they are now named eGMRs, and general practitioners have an obligation to acquire approved software in order to be able to manage these computerised medical records by 2020 at the latest. The computerisation of medical records is analysed in the Sustainability of care section. This indicator measures the proportion of the population who have a Global Medical Record.

RESULTS

• The number of GMRs has been increasing consistently. 67.5% of the population had a GMR in 2016, which represents more than twice the figure for 2013 (32.1%). (Figure 1)
• Major geographical differences persist: in Flanders, 76.4% of the population are covered, versus 57.1% in Wallonia and 49.3% in the Brussels region (Figure 1). Significant differences can also be observed between provinces within the same region: for example, in Flanders, coverage in Limburg is better (84.5%) than in Flemish Brabant (69.3%). The same is true in the Walloon Region: The Liège province has better coverage (59.4%) than Walloon-Brabant (52.6%). (Figure 2)
• Women more often have a GMR (70.7%) than men (64.2%).
• Elderly people more often have a GMR (>80%) than young people (less than 62%). However, coverage has been increasing at the same rate in each age group over time. (Figure 3)
• People entitled to increased reimbursement more often have a GMR (73.7%) than others (66.5%).

Figure 2 - Proportion of persons who have a global medical record (GMR) with a general practitioner, by province, 2016
Datasource: IMA-AIM

Link to technical datasheet and detailed results

Usual Provider Continuity Index (QC-2)

This indicator measures the proportion of visits with a general practitioner made with the regular general practitioner (= the most often visited provider). It has indeed been proven that a long-term relationship with the same general practitioner leads to better quality of medical care (better communication, better prevention, better treatment follow-up, less hospitalisations and visits to emergency rooms) for chronic patients. The higher this index is, the better the quality of the general practitioner/patient relationship.

It should be noted that this indicator only includes visits paid on a fee-for-service basis. It therefore does not include data from medical houses operating on a lumpsum basis.

RESULTS

• Nearly 68% of the Belgian population has a high continuity index (> 0.75, which means at least 3 visits out of 4 are made with the same general practitioner). However, only 40% of the people systematically visit the same general practitioner (exclusive relationship).
• The higher the number of visits, the higher the continuity. In other words, the more often people visit a general practitioner, the more loyal they become to that practitioner. However, this relation is reversed in the case of an exclusive relationship.
• The older a person’s age is, the more loyal they tend to be to their general practitioner.
• Continuity is slightly higher in people entitled to increased reimbursement.
• There are few differences between the country’s 3 regions; Wallonia has the highest continuity (72%), followed by Flanders (66%) and Brussels (65%) (Figure 4)
• The continuity index had dropped between 2010 and 2014, but seems to have stabilised today around 68%.

Figure 5 - Proportion of patients with a high Usual Provider Continuity Index (UPC ≥ 0.75), per district, 2006-2016
Datasource: IMA-AIM

Link to technical datasheet and detailed results

GP encounter within 7 days after hospital discharge (QC-3)

This indicator measures the proportion of hospital discharges of elderly people (aged 65+ years) that are followed by a contact with a general practitioner within one week, which helps assess the continuity of the relationship between hospitals and general practitioners (first-line medical care).

Returning to one’s regular living environment after the end of a hospital stay is often a critical moment for elderly people. It is not only about leaving the hospital, but also (re-)organising, without discontinuation, the care and emotional support system that will help them resume the normal course of their lives. For this reason, it is recommended that each elderly person leaving hospital visits a/their general practitioner after approximately one week to check if the arrangements made at discharge are (still) appropriate. This helps reduce the number of re-admissions to hospital and the duration of hospital stays.

This indicator is all the more important as the number of elderly patients has been increasing, while the average duration of hospital stays has been decreasing. In the past few years, many initiatives (e.g. integrated care pathways) have been implemented in order to reinforce continuity of care.

RESULTS

• Only 56.6% of elderly people (aged 65+ years) had at least one contact with a general practitioner within a week following hospital discharge. It is however impossible to know whether this contact with the general practitioner resulted from a discharge plan suggested by the hospital, or from the patient’s own initiative (2016 figures).
• The proportion increases with patient age, varying from 44% in the 65-69-year-old age group to over 60% in the over 80-year-old group.
• The proportion is slightly higher for women (59.1%) than for men (53.5%).
• The proportion is higher for people usually receiving long-term care (over 68%) than for people not receiving long-term care (50.2%).
• The proportion is higher for people with a low socio-economic status (entitled to increased reimbursement) (63.4%) than for others (52.4%).
• The proportion is relatively similar in Flanders (58.1%) and in Wallonia (55.7%). It is significantly lower in Brussels (45.7%), but seems to have increased in the past few years. The lower proportion in Brussels can nevertheless be an under-estimation due to the fact that patients who visit a medical house operating on a lump sum basis (who are more numerous in Brussels) are not identifiable in the calculation of this indicator (which is derived from GP visits paid on a fee-for-service basis).
• After having decreased slightly since 2006, this indicator has started to increase slightly since 2015, with a particularly marked trend in Brussels.

Figure 7 - Percentage of patients 65+ with a GP encounter within 7 days after hospital discharge, per district, 2016
Datasource: IMA-AIM

Link to technical datasheet and detailed results

Proportion of adult diabetics with a convention, a pass/pre-care trajectory or a care trajectory (QC-4 and QC-5)

INAMI – RIZIV has instituted various measures intended to optimise care for diabetes patients: care trajectories, conventions for diabetes self-management, and ’diabetes passports’, (replaced since 2016 by the pre-care trajectories for patients with type 2 diabetes).

The purpose of these different measures is to better inform patients and their close relatives about diabetes treatment, management of complications, etc., to encourage their involvement in the patient’s care, and to support good communication between the patient and the different care providers. This last point can serve as an indicator for continuity of care.

Depending on each case, patients registered in any of these models receive better reimbursements for visits to their general practitioner and diabetologist, reimbursement for their blood glucose self-monitoring equipment, and visits with nurses specialised in diabetes management, dieticians, podologists, etc.

We have calculated two indicators in this population to measure continuity of care coordination:

• Proportion of adults with diabetes (aged 18 years and over) treated with insulin who are registered in a care trajectory, a convention or holding a diabetes pass/pre-care trajectory (QC-4)
• Proportion of adults with diabetes (aged 50 years and over) treated with anti-diabetics other than insulin who are registered in a care trajectory, a convention or holding a diabetes pass/pre-care trajectory (QC-5).

RESULTS

• A total of 146 450 insulin-treated diabetes patients (aged ≥18 years) and 208 524 diabetes patients (aged ≥50 years) treated with anti-diabetics other than insulin were identified in 2016 via an analysis of their drug prescriptions. This number does not include diabetes patients who have no drug treatment.
• 89.9% of insulin-treated diabetes patients have at least one registration. Conventions for self-management represent 84.2% of these registrations, care trajectories account for 22.3%, and passports account for 4.5% (some people may have more than one registration).
• 20.2% of diabetes patients treated with medicines other than insulin have at least one registration. Half of these registrations are care trajectories (52.6%), 47.2% are passports, and only 4.3% of these patients have a convention (some people may have more than one registration).
• There are no differences between men and women.
• Starting from 85 years of age, the proportion of registered patients decreases, both for insulin-treated patients and for patients treated with non-insulin anti-diabetics.
• In people aged 65+ years, the proportion of registered patients is lower in residential facilities than for people with nursing care at home or for people who have no long-term care, both for insulin-treated patients and for those treated with other anti-diabetics.
• Diabetes patients whose socio-economical level is low (entitled to increased reimbursement) are slightly less often registered when they are insulin-treated and slightly more often registered when they are treated with other anti-diabetics.
• Both for insulin-treated patients and for other patients, the proportion of patients with at least one registration is higher in Flanders (91.3% and 26.0%) than in Wallonia (88.6% and 12.3%) and Brussels (86.1% and 17.5%).
• A positive trend can be observed over time in patients treated with non-insulin anti-diabetics. In insulin-treated patients, the proportion who are registered has been fairly stable since 2014.

Figure 9 - Proportion of adult (18+) diabetics under insulin with a convention/passport/care trajectory, per district, 2016
Datasource: IMA-AIM

Figure 11 - Proportion of adult (50+) diabetics receiving only glucose-lowering drugs (excluding insulin) with a convention/passport/care trajectory, per district, 2016
Datasource: IMA-AIM

Link to technical datasheet and detailed results

Cancer patients in Multidisciplinary Oncology Consultation (MOC) (QC-6)

Multidisciplinary Oncology Consultations (MOCs) are meetings that bring together different specialists (oncologists, surgeons, radiotherapists, etc.) who are concerned by a given type of cancer (breast, bowel, lung cancer, etc.) in order to examine together each patient’s medical record. In this meeting, the specialists (as well as the patient's general practitioner) discuss the tumour diagnosis (its severity, extent, etc.) and examine the various treatment options that may be suggested, in order to offer the best suited type of management for each individual case and to ensure continuity of care.
An MOC is a step recommended by all Belgian and international clinical practice guidelines. In Belgium, MOCs have been reimbursed since 2003, and strongly encouraged, by the National Plan against Cancer.

This indicator measures the proportion of patients diagnosed with cancer whose medical record is under discussion in a multidisciplinary oncology consultation (MOC).

RESULTS

• Since MOCs were introduced into the healthcare nomenclature in 2003, a rapid increase in the number of cancer diagnoses discussed in such consultations has been observed for all types of cancer: in 2015, 87.5% of cancer cases were in an MOC, compared to 51% in 2004 and 84% in 2012.
• The percentage of MOCs varies according to the type of cancer: from 95.7% for breast cancers to 70.5% for malignant melanomas.
• The increase in the use of MOCs is similar in the country’s three regions; in 2015, the percentage reached 88.7% in Flanders, 87.8% in Brussels and 85.1% in Wallonia.
• The initial gap (2004) between Flanders and the rest of Belgium has clearly become narrower over the past few years.

Link to technical datasheet and detailed results