Publications by authors named "Koen Van den Heede"

55 Publications

Trends in the utilisation rates and acute hospital capacity needs for total hip replacements: results of an analysis of administrative data.

Acta Orthop Belg 2020 Jun;86(2):253-261

Total hip replacement surgery is the mainstay of treatment for end-stage hip arthritis. In 2014, there were 28227 procedures (incidence rate 252/100000 population). Using administrative data, we projected the future volume of total hip replacement procedures and incidence rates using two models. The constant rate model fixes utilisation rates at 2014 levels and adjusts for demographic changes. Projections indicate 32248 admissions by 2025 or an annual growth of 1.22% (incidence rate 273). The time trend model additionally projects the evolution in age-specific utilisation rates. 34895 admissions are projected by 2025 or an annual growth of 1.95% (incidence rate 296). The projections show a shift in performing procedures at younger age. Forecasts of length of stay indicate a substantial shortening. By 2025, the required number of hospital beds will be halved. Despite more procedures, capacity can be reduced, leading to organisational change (e.g. elective orthopaedic clinics) and more labour intensive stays.
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June 2020

Safe nurse staffing policies for hospitals in England, Ireland, California, Victoria and Queensland: A discussion paper.

Health Policy 2020 10 27;124(10):1064-1073. Epub 2020 Aug 27.

KU Leuven-University of Leuven, Institute for Healthcare Policy, 3000, Leuven, Belgium. Electronic address:

Objective: The association between higher registered nurses (RN) staffing (educational level and number) and better patient and nurse outcomes is well-documented. This discussion paper aims to provide an overview of safe staffing policies in various high-income countries to identify reform trends in response to recurring nurse workforce challenges.

Methods: Based on a scan of the literature five cases were selected: England (UK), Ireland, California (USA), Victoria and Queensland (Australia). Information was gathered via a review of the grey and peer-reviewed literature. Country experts were consulted for additional information and to review country reports.

Results: The focus of safe staffing policies varies: increasing transparency about staffing decisions (England), matching actual and required staffing levels based on patient acuity measurement (Ireland), mandated patient-to-nurse ratios at the level of the nurse (California) or the ward (Victoria, Queensland). Calibration of the number of patients by the number of nurses varies across cases. Nevertheless, positive effects on the nursing workforce (increased bedside staffing) and staff well-being (increased job satisfaction) have been consistently documented. The impact on patient outcomes is promising but less well evidenced.

Conclusion: Countries will have to set safe staffing policies to tackle challenges such as the ageing population and workforce shortages. Various approaches may prove effective, but need to be accompanied by a comprehensive policy that enhances bedside nurse staffing in an evidence-based, objective and transparent way.
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http://dx.doi.org/10.1016/j.healthpol.2020.08.003DOI Listing
October 2020

Nutrition Support Teams: A Systematic Review.

JPEN J Parenter Enteral Nutr 2020 08 17;44(6):1004-1020. Epub 2020 Mar 17.

KCE Belgian Health Care Knowledge Centre, Brussels, Belgium.

Background: The concept of a nutrition support team (NST) was first introduced at the end of the 20th century in the US and Europe. Expected benefits include reduced (inappropriate) prescription of (par)enteral nutrition; however, to the authors' knowledge, no recent review has assessed the effectiveness of NSTs. Therefore, this systematic review evaluated the effectiveness of NSTs with respect to the prevalence of adult patients receiving (par)enteral nutrition.

Methods: Five literature databases were searched and completed by citing searches. Studies on NSTs that were published between 2000 and 2018 in Western countries, applied a comparative design, and contained at least outcome data on the prevalence of (par)enteral nutrition were included. Analyses were mainly descriptive because of high heterogeneity that prevented meta-analyses.

Results: The 27 included studies mainly originated from the UK and US. Only 1 of the included studies was a randomized trial; the other studies had a pre-post design (n = 17) or compared groups in a nonrandomized way. All but 2 studies were performed in acute care hospitals, and 5 studies focused only on intensive care patients. There was conflicting evidence of whether NSTs lead to reduction or increase in patients starting parenteral nutrition (PN); however, weak evidence suggested that NSTs might lead to an increase in the ratio of enteral nutrition to PN use and might decrease inappropriate PN use.

Conclusion: Although almost all studies concluded in favor of NSTs, the evidence base is weak and insufficient because of a lack of well-designed studies and successful outcomes.
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http://dx.doi.org/10.1002/jpen.1811DOI Listing
August 2020

Impact of shortened length of stay for delivery on the required bed capacity in maternity services: results from forecast analysis on administrative data.

BMC Health Serv Res 2019 Sep 5;19(1):637. Epub 2019 Sep 5.

Belgian Health Care Knowledge Centre (KCE), Doorbuilding, Boulevard du Jardin Botanique 55, 1000, Bruxelles, Belgium.

Background: We examine the implications of reducing the average length of stay (ALOS) for a delivery on the required capacity in terms of service volume and maternity beds in Belgium, using administrative data covering all inpatient stays in Belgian general hospitals over the period 2003-2014.

Methods: A projection model generates forecasts of all inpatient and day-care services with a time horizon of 2025. It adjusts the observed hospital use in 2014 to the combined effect of three evolutions: the change in population size and composition, the time trend evolution of ALOS, and the time trend evolution of the admission rates. In addition, we develop an alternative scenario to evaluate the impact of an accelerated reduction of ALOS.

Results: Between 2014 and 2025, we expect the number of deliveries to increase by 4.41%, and the number of stays in maternity services by 3.38%. At the same time, a reduction in ALOS is projected for all types of deliveries. The required capacity for maternity beds will decrease by 17%. In case of an accelerated reduction of the ALOS to reach international standards, this required capacity for maternity beds will decrease by more than 30%.

Conclusions: Despite an expected increase in the number of deliveries, future hospital capacity in terms of maternity beds can be considerably reduced in Belgium, due to the continuing reduction of ALOS.
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http://dx.doi.org/10.1186/s12913-019-4500-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6729074PMC
September 2019

The introduction of hospital networks in Belgium: The path from policy statements to the 2019 legislation.

Health Policy 2019 07 16;123(7):601-605. Epub 2019 May 16.

Strategic Policy Cell, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Ghent Belgium; Department of Public Health and Primary Care, Faculty of Medicine and Health Science, Ghent University, Corneel Heymanslaan 10, 9000 Ghent, Belgium. Electronic address:

In April 2015, the Belgian Federal Minister for Social Affairs and Public Health launched an Action Plan to reform the hospital landscape. With the creation of "localregional clinical hospital networks" with their own governance structures, the plan follows the international trend towards hospital consolidation and collaboration. The major complicating factors in the Belgian context are (1) that policy instruments for the redesign of the hospital service delivery system are divided between the federal government and the federated authorities, which can result in an asymmetric hospital landscape with a potentially better distribution of clinical services in the Flanders hospital collaborations than in the other federated entities; and (2) the current regulations stipulate that only hospitals (and not networks) are entitled to hospital budgets. Although the reform is the most significant and drastic transformation of the Belgian hospital sector in the last three decades, networks mainly offer a framework in which hospitals can collaborate. More regulation and policy measures are needed to enhance collaboration and distribution of clinical services.
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http://dx.doi.org/10.1016/j.healthpol.2019.05.008DOI Listing
July 2019

The role of governance in different types of interhospital collaborations: A systematic review.

Health Policy 2019 05 5;123(5):472-479. Epub 2019 Mar 5.

Strategic Policy Cell, Ghent University Hospital, De Pintelaan 185 9000 Ghent, Belgium; Department of Public Health, Faculty of Medicine and Health Science, Ghent University, De Pintelaan 185 9000 Ghent, Belgium. Electronic address:

Context: Financial challenges and the need for high-quality care have vastly increased the number of hospital collaborations in recent decades. The governance of these collaborations remains a challenge. The goal of this study is twofold: (1) to investigate the governance characteristics in an interhospital collaboration and (2) explore the impact on the performance of the interhospital collaboration.

Methods: A systematic review was conducted to provide a comprehensive overview of the evidence on governance in interhospital collaborations. Database searches yielded 9304 candidate articles, of which 26 studies fulfilled the inclusion criteria.

Findings: Governance in collaborations differs in collaboration structure, governance characteristics and contextual factors. Although outcome factors are influenced by contextual determinants and the collaboration structure itself, governance characteristics are of great importance.

Conclusions: A critical challenge for managers is to successfully adapt collaborations structures and governance characteristics to rapidly changing conditions. Policy makers should ensure that new legislation and guidelines for internal governance can be adapted to different contextual factors. Research in the future should investigate the impact of governance as a dynamic process. More longitudinal case study research is needed to provide an in-depth view of the relationship between this process and the performance of a collaboration.
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http://dx.doi.org/10.1016/j.healthpol.2019.02.010DOI Listing
May 2019

Varying viewpoints of Belgian stakeholders on models of interhospital collaboration.

BMC Health Serv Res 2018 Dec 4;18(1):942. Epub 2018 Dec 4.

Strategic Policy Cell, Ghent University Hospital, Corneel Heymanslaan 10, B-9000, Ghent, Belgium.

Background: Hospitals are increasingly parts of larger care collaborations, rather than individual entities. Organizing and operating these collaborations is challenging; a significant number do not succeed, as it is difficult to align the goals of the partners. However, little research has focused on stakeholders' views regarding hospital collaboration models or on whether these views are aligned with those of hospital management. This study explores Belgian hospital stakeholders' views on the factors affecting hospital collaborations and their perspectives on different models for Belgian interhospital collaboration.

Methods: Qualitative focus group study on the viewpoints, barriers, and facilitators associated with hospital collaboration models (health system, network, joint venture).

Results: A total of 55 hospital stakeholders (hospital managers, chairs of medical councils, chair of hospital boards and special interest groups) participated in seven focus group sessions. Collaboration in health care is challenging, as the goals of the different stakeholder groups are partly parallel but also sometimes conflicting. Hospital managers and special interest groups favored health systems as the most integrated form. Hospital board members also opted for this model, but believed a coordinated network to be the most pragmatic and feasible model at the moment. Members of physicians' organizations preferred the joint venture, as it creates more flexibility for physicians. Successful collaboration requires trust and commitment. Legislation must provide a supporting framework and governance models.

Conclusions: Involvement of all stakeholder groups in the process of decision-making within the collaboration is perceived as a necessity, which confirms the importance of the stakeholders' theory. The health system is the collaboration structure best suited to enhancing task distribution and improving patient quality. However, the existence of networks and joint ventures is considered necessary in the process of transformation towards more solid hospital collaborations such as health systems.
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http://dx.doi.org/10.1186/s12913-018-3763-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6280430PMC
December 2018

Improving the forecasting of hospital services: A comparison between projections and actual utilization of hospital services.

Health Policy 2018 07 24;122(7):728-736. Epub 2018 May 24.

Belgian Health Care Knowledge Centre (KCE), Kruidtuinlaan 55, 1000 Brussels, Belgium. Electronic address:

Objectives: To compare projected and observed hospital inpatient use in Belgium and to draw lessons from that comparison.

Methods: In 2005, projections for hospital service use were generated up to 2015, based on demographic change, substitution from inpatient to day care, and, the evolution of the average length of stay (LOS). The accuracy of the forecasts was assessed by comparing projected and observed population size, admissions and inpatient days, average LOS and percentage change in case mix.

Results: The demographic growth was underestimated. Overall, the baseline projection for hospital admissions was remarkably close to the observed figures but the underlying case mix diverged importantly. With substitution between inpatient and day care, the number of admissions was underestimated by 15%-40%. The number of days was projected to increase in every scenario, whereas a decreasing trend was observed mainly due to the faster decline in average LOS than projected.

Conclusion: Hospital capacity planning is an important component of evidence informed policymaking. Projection results benefit from a well-designed methodology: choice of forecast groups, estimation models, selection criteria, and a sensitivity analysis of the results. To cope with the dynamic and continuously evolving context in which hospitals operate, regular updates to incorporate new data and to reassess estimated trends should be an integral part of the projection framework.
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http://dx.doi.org/10.1016/j.healthpol.2018.05.010DOI Listing
July 2018

Hospital networks: how to make them work in Belgium? Facilitators and barriers of different governance models.

Acta Clin Belg 2018 Oct 29;73(5):333-340. Epub 2018 Mar 29.

b Strategic Policy Cell , Ghent University Hospital , Ghent , Belgium.

Objectives This study aims to identify the facilitators and barriers to governance models of hospital collaborations. The country-specific characteristics of the Belgian healthcare system and legislation are taken into account. Methods A case study was carried out in six Belgian hospital collaborations. Different types of governance models were selected: two health systems, two participant-governed networks, and two lead-organization-governed networks. Within these collaborations, 43 people were interviewed. Results All structures have both advantages and disadvantages. It is important that the governance model fits the network. However, structural, procedural, and especially contextual factors also affect the collaborations, such as alignment of hospitals' and professionals' goals, competition, distance, level of integrated care, time needed for decision-making, and legal and financial incentives. Conclusion The fit between the governance model and the collaboration can facilitate the functioning of a collaboration. The main barriers we identified are contextual factors. The Belgian government needs to play a major role in facilitating collaboration.
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http://dx.doi.org/10.1080/17843286.2018.1457196DOI Listing
October 2018

Evaluating the need to reform the organisation of care for major trauma patients in Belgium: an analysis of administrative databases.

Eur J Trauma Emerg Surg 2019 Oct 26;45(5):885-892. Epub 2018 Feb 26.

Belgian Healthcare Knowledge Centre, Kruidtuinlaan 55, 1000, Brussels, Belgium.

Purpose: In light of the international evolutions to establish inclusive trauma systems and to concentrate the care for the most severely injured in major trauma centres, we evaluated the degree of dispersion of trauma care in Belgium.

Methods: We used descriptive statistics to illustrate the dispersion of major trauma care in Belgium based on two independent administrative databases: the registry of Mobile Intensive Care Units (2009-2015) and the Belgian Hospital Discharge Dataset (2009-2014).

Results: Patients with a severe trauma (n = 3856 in 2015) were transported towards 145 different hospital sites (on a total of 198 hospital sites) resulting in a median of 17 cases per hospital site (min = 1; P25 = 4; P75 = 30; max = 165). A minority of major trauma patients is after admission transferred to another hospital (8%) with a median of 10 days after admission to the hospital (IQR 3.5-24).

Conclusions: The dispersion of care for major trauma patients in Belgium is so high that a reorganisation of care for severe injured patients in major trauma centres concentrating professional expertise and specialised equipment is recommended to guarantee a high quality of care in a qualitative and sustainable way.
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http://dx.doi.org/10.1007/s00068-018-0932-9DOI Listing
October 2019

Variability in elective day-surgery rates between Belgian hospitals - Analyses of administrative data explained by surgical experts.

Int J Surg 2017 Sep 19;45:118-124. Epub 2017 Jul 19.

Belgian Health Care Knowledge Centre (KCE), Belgium. Electronic address:

Background: In the last decades, day surgery has steadily and significantly grown in many countries, yet the increase has been uneven. There are large variations in day-surgery activity between countries, but also within countries between hospitals and surgeons. This paper explores the variability in day-care activity for elective surgical procedures between Belgian hospitals.

Materials And Methods: The administrative hospital data of all patients formally admitted in a Belgian hospital for inpatient or day-care surgery between 2011 and 2013 were analysed and summarized in graphs. During 11 expert meetings with ad-hoc surgical expert groups the variability in day-surgery share between hospitals was discussed in depth.

Results: The variability in day-care share between Belgian hospitals is considerable. For 37 out of 486 elective surgical procedures, the variability ranged between 0 and 100%. High national day-care rates do not preclude room for improvement for certain hospitals as for the majority of these procedures there are "low performers". According to the consulted clinical experts, the high variability in day-care share may for the greater part be explained by medical team related factors, customs and traditions, the lack of clinical guidelines, financial factors, organisational factors and patient related factors.

Conclusion: If a further expansion of day surgery is envisaged in Belgium the factors that contribute to the current variability in day-surgery rates between hospitals should be addressed. In addition, a feedback system in which hospitals and health care providers have the figures on their percentage of procedures carried out in day surgery compared to other hospitals and care providers (benchmarking) and the monitoring of a number of quality indicators (e.g. unplanned readmission, unplanned inpatient stay, emergency department visit) should be installed.
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http://dx.doi.org/10.1016/j.ijsu.2017.07.075DOI Listing
September 2017

The 2016 proposal for the reorganisation of urgent care provision in Belgium: A political struggle to co-locate primary care providers and emergency departments.

Health Policy 2017 Apr 20;121(4):339-345. Epub 2017 Feb 20.

Belgian Healthcare Knowledge Centre (KCE), Kruidtuinlaan 55, 1000 Brussels, Belgium. Electronic address:

Internationally the number of emergency department (ED) visits is on the rise while evidence suggests that a substantial proportion of these patients do not require emergency care but primary care. This paper presents the Belgian 2016 proposal for the reorganisation of urgent care provision and places it into its political context. The proposal focused on re-designing patient flow aiming to reduce inappropriate ED visits by improving guidance of patients through the system. Initially policymakers envisaged, as cornerstone of the reform, to roll-out as standard model the co-location of primary care centres and EDs. Yet, this was substantially toned down in the final policy decisions mainly because GPs strongly opposed this model (because of increased workload and loss of autonomy, hospital-centrism, etc.). In fact, the final compromise assures a great degree of autonomy for GPs in organising out-of-hours care. Therefore, improvements will depend on future developments in the field and continuous monitoring of (un-)intended effects is certainly indicated. This policy process makes clear how important it is to involve all relevant stakeholders as early as possible in the development of a reform proposal to take into account their concerns, to illustrate the benefits of the reform and ultimately to gain buy-in for the reform.
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http://dx.doi.org/10.1016/j.healthpol.2017.02.006DOI Listing
April 2017

Interventions to reduce emergency department utilisation: A review of reviews.

Health Policy 2016 Dec 13;120(12):1337-1349. Epub 2016 Oct 13.

Belgian Healthcare Knowledge Centre (KCE), Kruidtuinlaan 55, 1000 Brussels, Belgium. Electronic address:

Objective: To describe policy interventions that have the objective to reduce ED use and to estimate their effectiveness.

Methods: Narrative review by searching three electronic databases for scientific literature review papers published between 2010 and October 2015. The quality of the included studies was assessed with AMSTAR, and a narrative synthesis of the retrieved papers was applied.

Results: Twenty-three included publications described six types of interventions: (1) cost sharing; (2) strengthening primary care; (3) pre-hospital diversion (including telephone triage); (4) coordination; (5) education and self-management support; (6) barriers to access emergency departments. The high number of interventions, the divergent methods used to measure outcomes and the different populations complicate their evaluation. Although approximately two-thirds of the primary studies showed reductions in ED use for most interventions the evidence showed contradictory results.

Conclusion: Despite numerous publications, evidence about the effectiveness of interventions that aim to reduce ED use remains insufficient. Studies on more homogeneous patient groups with a clearly described intervention and control group are needed to determine for which specific target group what type of intervention is most successful and how the intervention should be designed. The effective use of ED services in general is a complex and multi-factorial problem that requires integrated interventions that will have to be adapted to the specific context of a country with a feedback system to monitor its (un-)intended consequences. Yet, the co-location of GP posts and emergency departments seems together with the introduction of telephone triage systems the preferred interventions to reduce inappropriate ED visits while case-management might reduce the number of ED attendances by frequent ED users.
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http://dx.doi.org/10.1016/j.healthpol.2016.10.002DOI Listing
December 2016

Structure and processes of interdisciplinary geriatric consultation teams in acute care hospitals: A scoping review.

Int J Nurs Stud 2016 Mar 9;55:98-114. Epub 2015 Oct 9.

Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Kapucijnenvoer 35/4, Leuven B-3000, Belgium; Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, Leuven B-3000, Belgium. Electronic address:

Background And Objectives: Interdisciplinary geriatric consultation teams are implemented in the acute hospital setting in several high-income countries to provide comprehensive geriatric assessment for the increasing numbers of older patients with a geriatric profile hospitalized on non-geriatric units. Given the inconclusive evidence on this care model's effectiveness to improve patient outcomes, health care policy and practice oriented recommendations to redesign the structure and process of care provided by interdisciplinary geriatric consultation teams are needed. A scoping review was conducted to explore the structure and processes of interdisciplinary geriatric consultation teams in an international context. As nurses are considered key members of these teams, their roles and responsibilities were specifically explored.

Design: The revised scoping methodology framework of Arksey and O'Malley was applied.

Data Sources: An electronic database search in Ovid MEDLINE, CINAHL and EMBASE and a hand search were performed for the identification of descriptive and experimental studies published in English, French or Dutch until April 2014.

Review Methods: Thematic reporting with descriptive statistics was performed and study findings were validated through interdisciplinary expert meetings.

Results: Forty-six papers reporting on 25 distinct interdisciplinary geriatric consultation teams in eight countries across three continents were included. Eight of the 12 teams (67%) reporting on their composition, stated that nurses and physicians were the main core members with head counts varying from 1 to 4 members per profession. In 80% of these teams nurses were required to have completed training in geriatrics. Advanced practice nurses were integrated in eleven out of fourteen interdisciplinary geriatric consultation teams from the USA. Only 32% of teams used formal screening to identify patients most likely to benefit from their intervention, using heterogeneous screening methods, and scarcely providing information on the responsibilities of nurses. Nurses were involved in the medical, functional, psychological and social assessment of patients in 68% of teams, either in a leading role or in collaboration with other professions. Responsibilities of interdisciplinary geriatric consultation teams' nurses regarding in-hospital follow-up or transitional care at hospital discharge were infrequently specified (16% of teams).

Conclusions: This scoping review identified that the structure and processes of care provided to geriatric patients by interdisciplinary geriatric consultation teams are highly heterogeneous. Despite nurses being key team members, only limited information on their specific roles and responsibilities was identified. More research in this area is required in order to inform health care policy and to formulate practice oriented recommendations to redesign the interdisciplinary geriatric consultation team care model aiming to improve its effectiveness.
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http://dx.doi.org/10.1016/j.ijnurstu.2015.09.015DOI Listing
March 2016

The view of severely burned patients and healthcare professionals on the blind spots in the aftercare process: a qualitative study.

BMC Health Serv Res 2015 Aug 1;15:302. Epub 2015 Aug 1.

Belgian Healthcare Knowledge Centre (KCE), Kruidtuinlaan 55, 1000, Brussels, Belgium.

Background: In most Western countries burn centres have been developed to provide acute and critical care for patients with severe burn injuries. Nowadays, those patients have a realistic chance of survival. However severe burn injuries do have a devastating effect on all aspects of a person's life. Therefore a well-organized and specialized aftercare system is needed to enable burn patients to live with a major bodily change. The aim of this study is to identify the problems and unmet care needs of patients with severe burn injuries throughout the aftercare process, both from patient and health care professional perspectives in Belgium.

Methods: By means of face-to-face interviews (n = 40) with individual patients, responsible physicians and patient organizations, current experiences with the aftercare process were explored. Additionally, allied healthcare professionals (n = 17) were interviewed in focus groups.

Results: Belgian burn patients indicate they would benefit from a more integrated aftercare process. Quality of care is often not structurally embedded, but depends on the good intentions of local health professionals. Most burn centres do not have a written discharge protocol including an individual patient-centred care plan, accessible to all caregivers involved. Patients reported discontinuity of care: nurses working at general wards or rehabilitation units are not specifically trained for burn injuries, which sometimes leads to mistakes or contradictory information transmission. Also professionals providing home care are often not trained for the care of burn injuries. Some have to be instructed by the patient, others go to the burn centre to learn the right skills. Finally, patients themselves underestimate the chronic character of burn injuries, especially at the beginning of the care process.

Conclusions: The variability in aftercare processes and structures, as well as the failure to implement locally developed best-practices on a wider scale emphasize the need for a comprehensive network, which can initiate transversal activities such as the development of discharge protocols, common guidelines, and quality criteria.
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http://dx.doi.org/10.1186/s12913-015-0973-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4521491PMC
August 2015

Stakeholders' perception on the organization of chronic care: a SWOT analysis to draft avenues for health care reforms.

BMC Health Serv Res 2014 Apr 18;14:179. Epub 2014 Apr 18.

Institute of Health and Society, Université catholique de Louvain, Clos Chapelle-aux-Champs, Brussels, Belgium.

Background: Adequate care for individuals living with chronic illnesses calls for a healthcare system redesign, moving from acute, disease-centered to patient-centered models. The aim of this study was to identify Belgian stakeholders' perceptions on the strengths, weaknesses, opportunities and threats of the healthcare system for people with chronic diseases in Belgium.

Methods: Four focus groups were held with stakeholders from the micro and meso level, in addition to two interviews with stakeholders who could not attend the focus group sessions. Data collection and the discussion were based on the Chronic Care model. Thematic analysis of the transcripts allowed for the identification of the strengths, weaknesses, opportunities and threats of the current health care system with focus on chronic care.

Results: Informants stressed the overall good quality of the acute health care system and the level of reimbursement of care as an important strength of the current system. In contrast, the lack of integration of care was identified as one of the biggest weaknesses of today's health care system, along with the unclear definitions of the roles and functions of health professionals involved in care processes. Patient education to support self-management exists for patients with diabetes and/or terminal kidney failure but not for those living with other or multiple chronic conditions. The current overall fee-for-service system is a barrier to integrated care, as are the lack of incentives for integrated care. Attending multidisciplinary meetings, for example, is underfinanced to date. Finally, clinical information systems lack interoperability, which further impedes the information flow across settings and disciplines.

Conclusion: Our study's methods allowed for the identification of problematic domains in the health system for people living with chronic conditions. These findings provided useful insights surrounding perceived priorities. This methodology may inspire other countries faced with the challenge of drafting reforms to tackle the issue of chronic care.
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http://dx.doi.org/10.1186/1472-6963-14-179DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4022440PMC
April 2014

Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study.

Lancet 2014 May 26;383(9931):1824-30. Epub 2014 Feb 26.

Centre for Health Services and Nursing Research, Catholic University Leuven, Leuven, Belgium.

Background: Austerity measures and health-system redesign to minimise hospital expenditures risk adversely affecting patient outcomes. The RN4CAST study was designed to inform decision making about nursing, one of the largest components of hospital operating expenses. We aimed to assess whether differences in patient to nurse ratios and nurses' educational qualifications in nine of the 12 RN4CAST countries with similar patient discharge data were associated with variation in hospital mortality after common surgical procedures.

Methods: For this observational study, we obtained discharge data for 422,730 patients aged 50 years or older who underwent common surgeries in 300 hospitals in nine European countries. Administrative data were coded with a standard protocol (variants of the ninth or tenth versions of the International Classification of Diseases) to estimate 30 day in-hospital mortality by use of risk adjustment measures including age, sex, admission type, 43 dummy variables suggesting surgery type, and 17 dummy variables suggesting comorbidities present at admission. Surveys of 26,516 nurses practising in study hospitals were used to measure nurse staffing and nurse education. We used generalised estimating equations to assess the effects of nursing factors on the likelihood of surgical patients dying within 30 days of admission, before and after adjusting for other hospital and patient characteristics.

Findings: An increase in a nurses' workload by one patient increased the likelihood of an inpatient dying within 30 days of admission by 7% (odds ratio 1·068, 95% CI 1·031-1·106), and every 10% increase in bachelor's degree nurses was associated with a decrease in this likelihood by 7% (0·929, 0·886-0·973). These associations imply that patients in hospitals in which 60% of nurses had bachelor's degrees and nurses cared for an average of six patients would have almost 30% lower mortality than patients in hospitals in which only 30% of nurses had bachelor's degrees and nurses cared for an average of eight patients.

Interpretation: Nurse staffing cuts to save money might adversely affect patient outcomes. An increased emphasis on bachelor's education for nurses could reduce preventable hospital deaths.

Funding: European Union's Seventh Framework Programme, National Institute of Nursing Research, National Institutes of Health, the Norwegian Nurses Organisation and the Norwegian Knowledge Centre for the Health Services, Swedish Association of Health Professionals, the regional agreement on medical training and clinical research between Stockholm County Council and Karolinska Institutet, Committee for Health and Caring Sciences and Strategic Research Program in Care Sciences at Karolinska Institutet, Spanish Ministry of Science and Innovation.
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http://dx.doi.org/10.1016/S0140-6736(13)62631-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4035380PMC
May 2014

Soliciting stakeholders' views on the organization of child and adolescent mental health services: a system in trouble.

Child Adolesc Psychiatry Ment Health 2013 Dec 23;7(1):42. Epub 2013 Dec 23.

Belgian Health Care Knowledge Centre (KCE), 55 Boulevard du Jardin Botanique, Brussels 1000, Belgium.

Background: Despite a high prevalence of mental health problems among children and adolescents Belgium, like many other Western countries, does not have a clear strategy for the organization of child and adolescent mental healthcare services (CAMHS).

Methods: This paper describes stakeholders' views on the organization of CAMHS based on a qualitative study. Ten in-depth interviews with high profile stakeholders were complemented by roundtable discussions (n = 30).

Results: This diagnostic analysis illustrated that the system is in serious trouble characterized by fragmentation and compartmentalization.

Conclusion: The findings create a sense of urgency that should be used to initiate a system reform of the Belgian CAMHS system.
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http://dx.doi.org/10.1186/1753-2000-7-42DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3942294PMC
December 2013

Recommendations for the organization of mental health services for children and adolescents in Belgium: use of the soft systems methodology.

Health Policy 2014 Feb 7;114(2-3):263-8. Epub 2013 Aug 7.

Belgian Healthcare Knowledge Centre, Belgium. Electronic address:

The prevalence of mental health problems among children and adolescents in Western countries is high. Belgium, like many other Western countries, struggles with the set-up of a coherent and effective strategy for dealing with this complex societal problem. This paper describes the development of a policy scenario for the organization of child and adolescent mental health care services (CAMHS) in Belgium. The development process relied on Soft Systems Methodology including a participatory process with 66 stakeholders and a review of the existing (inter-)national evidence. A diagnostic analysis illustrated that the Belgian CAMHS is a system in serious trouble characterized by fragmentation and compartmentalization. A set of 10 strategic recommendations was formulated to lay down the contours of a future, more effective CAMHS system. They focus on mastering the demands made on scarce and expensive specialized mental health services; strengthening the range of services - in particular for those with serious, complex and multiple mental health problems - and strengthening the adaptive capacity of and the ethical guidance within the future CAMHS system.
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http://dx.doi.org/10.1016/j.healthpol.2013.07.009DOI Listing
February 2014

The Belgian Health System Performance Report 2012: snapshot of results and recommendations to policy makers.

Health Policy 2013 Sep 5;112(1-2):133-40. Epub 2013 Aug 5.

Belgian Health Care Knowledge Centre (KCE), Belgium. Electronic address:

Following the commitments of the Tallinn Charter, Belgium publishes the second report on the performance of its health system. A set of 74 measurable indicators is analysed, and results are interpreted following the five dimensions of the conceptual framework: accessibility, quality of care, efficiency, sustainability and equity. All domains of care are covered (preventive, curative, long-term and end-of-life care), as well as health status and health promotion. For all indicators, national/regional values are presented with their evolution over time. Benchmarking to results of other EU-15 countries is also systematic. The policy recommendations represent the most important output of the report.
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http://dx.doi.org/10.1016/j.healthpol.2013.06.010DOI Listing
September 2013

Development of a national position paper for chronic care: example of Belgium.

Health Policy 2013 Jul 7;111(2):105-9. Epub 2013 May 7.

Belgian Health Care Knowledge Centre, Brussels, Belgium.

The management of chronic diseases is a prime challenge of most 21st century health care systems. Many Western countries have invested heavily in care plans oriented towards specific conditions and diseases, such as dementia and cancer. The major downside of this narrowly focused approach is that treatment of multimorbidity is ignored. This paper describes the development and main stance of a national position that proposes streamlined reforms of the Belgian health care system to improve care for patients with multiple chronic diseases. We used a combination of methods to develop this stance: literature review and stakeholders' consultation. The latter identified areas for improvement: efficiency of the health care system, coordination of care, investments in human care resources, informal caregivers' support, better accessibility, and changes in the financial payment system. The position paper list 20 recommendations that are translated into about 50 action points to reform the health care system. Chronic care tailored to the patient's needs, including implementation of multidisciplinary teamwork, new functions, task delegation in primary care, and empowerment of the patient and informal caregivers are some major areas discussed. In addition, improved support, revised payment mechanisms, and setting up a quality system, along with the tailoring of patient care, can all facilitate delivery of high quality care in patients with chronic comorbidities.
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http://dx.doi.org/10.1016/j.healthpol.2013.04.010DOI Listing
July 2013

Retrospective medical record evaluation: reliability in assessing causation, preventability, and disability of adverse events.

Int J Health Care Qual Assur 2012 ;25(8):649-62

Center for Health Services and Nursing Research, Leuven, Belgium.

Purpose: The purpose of this article is to assess the reliability of an in-depth analysis on causation, preventability, and disability by two separate review teams on five selected adverse events in acute hospitals: pressure ulcer, postoperative pulmonary embolism or deep vein thrombosis, postoperative sepsis, ventilator-associated pneumonia and postoperative wound infection.

Design/methodology/approach: The analysis uses a retrospective medical record review of 1,515 patient records by two independent teams in eight acute Belgian hospitals for the year 2005. The Mann-Whitney U-test is used to identify significant differences between the two review teams regarding occurrence of adverse events as well as regarding the degree of causation, preventability, and disability of found adverse events.

Findings: Team 1 stated a high probability for health care management causation in 95.5 per cent of adverse events in contrast to 38.9 per cent by Team 2. Likewise, high preventability was considered in 83.1 per cent of cases by Team 1 versus 51.7 per cent by Team 2. Significant differences in degree of disability between the two teams were also found for pressure ulcers, postoperative pulmonary embolism or deep vein thrombosis and postoperative wound infection, but not for postoperative sepsis and ventilator-associated pneumonia.

Originality/value: New insight on the degree of and reasons for the huge differences in adverse event evaluation is provided.
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http://dx.doi.org/10.1108/09526861211270613DOI Listing
January 2013

Nurses' reports of working conditions and hospital quality of care in 12 countries in Europe.

Int J Nurs Stud 2013 Feb 17;50(2):143-53. Epub 2012 Dec 17.

Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, PA, USA.

Background: Cost containment pressures underscore the need to better understand how nursing resources can be optimally configured.

Objectives: To obtain a snapshot of European nurses' assessments of their hospital work environments and quality of care in order to identify promising strategies to retain nurses in hospital practice and to avoid quality of care erosions related to cost containment.

Design: Cross sectional surveys of 33,659 hospital medical-surgical nurses in 12 European countries.

Setting: Surveyed nurses provided care in 488 hospitals in Belgium, England, Finland, Germany, Greece, Ireland, the Netherlands, Norway, Poland, Spain, Sweden, and Switzerland.

Participants: All nurses were surveyed from medical-surgical units 30 or more hospitals from geographically representative samples of hospitals in each country, except for Ireland and Norway, where all hospitals were selected, and Sweden, where nearly all hospitals were included by sampling all medical-surgical nurses who were members of the Swedish Nursing Association.

Methods: Percentages are provided for each of the nurse and hospital characteristics reported.

Results: There was wide variation across countries in the percentages of hospital nurses that were bachelor's prepared (range 0-100%), in patient to nurse average workloads (3.7-10.2) and skill mix (54-82% nurses). More than one in five nurses (11-56%) were dissatisfied with their jobs in most countries, and dissatisfaction was pronounced with respect to wages, educational opportunities and opportunities for advancement. Sizable percentages (19-49%) of nurses intended to leave their jobs, though the percentage that thought it would be easy to find another job varied greatly across countries (16-77%). Nurse concerns with workforce management and adequate resources were widespread. While most nurses did not give their hospitals poor grades on patient safety, many doubted that safety was a management priority. Nurses reported that important nursing tasks were often left undone because of lack of time, and indicated that adverse events were not uncommon.

Conclusions: Nurse shortages can be expected when national economies improve unless hospital work environments improve. Wide variation in nurse staffing and skill mix suggests a lack of evidence-based decision making. Additional research is warranted on the impact of these variations in nurse resources on patient outcomes.
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http://dx.doi.org/10.1016/j.ijnurstu.2012.11.009DOI Listing
February 2013

The Leuven questionnaire on patient knowledge of chemotherapy (L-PaKC): instrument development and psychometric evaluation.

Eur J Oncol Nurs 2013 Aug 1;17(4):465-73. Epub 2012 Dec 1.

Department of Oncology, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.

Purpose: Evidence suggests that patients who gain knowledge perform better self-care, cope better and are more satisfied. Today, up-to-date and valid instruments for evaluating patient knowledge on chemotherapy are unavailable. Hence, our aim was to develop a valid instrument to assess patients' knowledge on chemotherapy.

Method: We performed a literature review to develop a topic list for the construct. Using a triple Delphi procedure, an expert panel of nine oncologists and oncology nurses evaluated the face and content validity of the topic list and the generated items. A preliminary psychometric evaluation of 144 patients allowed to identify and remediate items having limited applicability and item validity. A convenience sample of 440 patients was used to evaluate item statistics (item difficulty), reliability (Cronbach alpha) and construct validity (exploratory factor analysis) of the final instrument.

Results: We developed a 20-item instrument reflecting 14 relevant themes of patient knowledge on chemotherapy in 13 questions. Twelve items cover general chemotherapy aspects, eight items cover treatment-specific knowledge. Three questions are facultative and address oral chemotherapy. Content validity was excellent (CVI = 0.78-1.00). Item difficulty ranged from 0.25 to 0.95. Internal consistency was acceptable (Cronbach's alpha = 0.67). Exploratory factor analysis defined four underlying factors: general aspects of chemotherapy treatment, negative treatment-related events, information resources and intake of oral chemotherapy.

Conclusions: The Leuven Questionnaire on Patient Knowledge of Chemotherapy (L-PaKC) demonstrated good content validity and psychometric properties, permitting application in both research and practice for evaluating patient knowledge on chemotherapy.
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http://dx.doi.org/10.1016/j.ejon.2012.10.012DOI Listing
August 2013

The Leuven questionnaire for Patient Self-care during Chemotherapy (L-PaSC): instrument development and psychometric evaluation.

Eur J Oncol Nurs 2013 Jun 14;17(3):275-83. Epub 2012 Aug 14.

Department of Oncology, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.

Purpose: Since chemotherapy has largely become an outpatient treatment, adequate self-management is of great importance. Available instruments focus exclusively on dealing with side effects. However, self-care during chemotherapy not only concerns symptom self-management. The aim of this study was to develop a valid instrument to assess patient self-care during chemotherapy.

Method: First, we developed a topic list for our construct by performing a theory and literature review. Second, an expert panel of nine oncologists and oncology nurses evaluated content validity of the developing construct and its items using a triple Delphi procedure. A preliminary psychometric evaluation in 144 patients allowed identification and correction of items with poor psychometric properties. A convenience sample of 448 patients was used to evaluate item statistics (item difficulty), reliability (Cronbach alpha) and construct validity (exploratory factor analysis) of the final instrument.

Results: We developed a 22-item instrument with 7 themes expressing the most relevant aspects of patient self-care during chemotherapy. Seven items cover symptom self-management, while 15 items reflect other aspects of self-care during chemotherapy. Content validity was excellent (CVI = 0.78-1.00). Item difficulty index of the questions ranged from 0.17 to 0.89. Internal consistency is acceptable (Cronbach alpha = 0.76). Exploratory factor analysis defines two underlying factors: adhering to treatment recommendations and managing treatment-related negative events on the one hand, and relieving symptoms on the other hand.

Conclusions: The L-PaSC demonstrated good content validity and psychometric properties. The L-PaSC can be applied in research and clinical practice for evaluating patient self-care during chemotherapy.
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http://dx.doi.org/10.1016/j.ejon.2012.07.008DOI Listing
June 2013

Group-level impact of work environment dimensions on burnout experiences among nurses: a multivariate multilevel probit model.

Int J Nurs Stud 2013 Feb 24;50(2):281-91. Epub 2012 Jul 24.

Department of Biostatistics, Erasmus Medical Centre, Erasmus University Rotterdam, The Netherlands.

Background: Nurses' work environments are associated with burnout experiences among nurses. The RN4CAST project provides data on these constructs within a four-level structure (nurse, nursing unit, hospital, and country), implying more complicated multilevel analysis strategies than have been used in previous efforts studying this relationship.

Objectives: First, to explore and investigate the effect of the nursing unit, hospital, and country level variability on the relationship between dimensions of nurses' work environment and dimensions of burnout. Second, to explore the significance of the nursing unit, hospital, and country level variability among the burnout dimensions.

Design: Data from the RN4CAST project were available from a cross-sectional survey among 23,446 nurses in 2087 nursing units in 352 hospitals in 11 countries.

Methods: Nurse-reported information on their work environment (managerial support for nursing, doctor-nurse collegial relations, and promotion of care quality) and burnout experiences (emotional exhaustion, depersonalization and personal accomplishment) were available. We specified ecological measures of the nurse work environment dimensions at the three organizational levels and combined these with individual-level outcomes within a series of multilevel statistical models. The final model was a multivariate multilevel probit model in which we modeled the work environment and burnout dimensions jointly.

Results: Doctor-nurse collegial relations affected all burnout dimensions, but at the unit level only. For the dimension of promotion of care quality, the effect of the ecological exposure on burnout was pronounced at both the nursing unit and the hospital level for all three burnout dimensions. Findings for the dimensions of managerial support for nursing were ambiguous.

Conclusion: Nurse work environment dynamics are related to nurses' burnout experiences at both the nursing unit and the hospital level. This implies that both hospital-wide and unit-specific interventions should be considered to achieve excellent work environments. The correlation structure among the three burnout outcomes varies across countries, but is stable between hospitals within countries and between nursing units within hospitals.
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http://dx.doi.org/10.1016/j.ijnurstu.2012.07.001DOI Listing
February 2013

A multi-country perspective on nurses' tasks below their skill level: reports from domestically trained nurses and foreign trained nurses from developing countries.

Int J Nurs Stud 2013 Feb 21;50(2):202-9. Epub 2012 Jul 21.

Centre for Health Services and Nursing Research, University of Leuven, Belgium.

Background: Several studies have concluded that the use of nurses' time and energy is often not optimized. Given widespread migration of nurses from developing to developed countries, it is important for human resource planning to know whether nursing education in developing countries is associated with more exaggerated patterns of inefficiency.

Objectives: First, to describe nurses' reports on tasks below their skill level. Second, to examine the association between nurses' migratory status (domestically trained nurse or foreign trained nurse from a developing country) and reports on these tasks.

Design: The Registered Nurse Forecasting Study used a cross-sectional quantitative research design to gather data from 33,731 nurses (62% response rate) in 486 hospitals in Belgium, England, Finland, Germany, Greece, Ireland, the Netherlands, Norway, Poland, Spain, Sweden and Switzerland.

Methods: For this analysis, nurse-reported information on migratory status and tasks below their skill level performed during their last shift was used. Random effects models estimated the effect of nurses' migratory status on reports of these tasks.

Results: 832 nurses were trained in a developing country (2.5% of total sample). Across countries, a high proportion of both domestically trained and foreign trained nurses from developing countries reported having performed tasks below their skill level during their last shift. After adjusting for nurses' type of last shift worked, years of experience, and level of education, there remained a pronounced overall effect of being a foreign trained nurse from a developing country and an increase in reports of tasks below skill level performed during the last shift.

Conclusion: The findings suggest that there remains much room for improvement to optimize the use of nurses' time and energy. Special attention should be given to raising the professional level of practice of foreign trained nurses from developing countries. Further research is needed to understand the influence of professional practice standards, skill levels of foreign trained nurses from developing countries and values attached to these tasks resulting from previous work experiences in their home countries. This will allow us to better understand the conditions under which foreign trained nurses from developing countries can optimally contribute to professional nursing practice in developed country contexts.
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http://dx.doi.org/10.1016/j.ijnurstu.2012.06.013DOI Listing
February 2013

Cross-cultural evaluation of the relevance of the HCAHPS survey in five European countries.

Int J Qual Health Care 2012 Oct 17;24(5):470-5. Epub 2012 Jul 17.

New York University College of Nursing, New York, NY 10003, USA.

Objective: To describe the systematic language translation and cross-cultural evaluation process that assessed the relevance of the Hospital Consumer Assessment of Healthcare Providers and Systems survey in five European countries prior to national data collection efforts.

Design: An approach involving a systematic translation process, expert review by experienced researchers and a review by 'patient' experts involving the use of content validity indexing techniques with chance correction.

Setting: Five European countries where Dutch, Finnish, French, German, Greek, Italian and Polish are spoken.

Participants: 'Patient' experts who had recently experienced a hospitalization in the participating country. Main OutcomeMeasure(s) Content validity indexing with chance correction adjustment providing a quantifiable measure that evaluates the conceptual, contextual, content, semantic and technical equivalence of the instrument in relationship to the patient care experience.

Results: All translations except two received 'excellent' ratings and no significant differences existed between scores for languages spoken in more than one country. Patient raters across all countries expressed different concerns about some of the demographic questions and their relevance for evaluating patient satisfaction. Removing demographic questions from the evaluation produced a significant improvement in the scale-level scores (P= .018). The cross-cultural evaluation process suggested that translations and content of the patient satisfaction survey were relevant across countries and languages.

Conclusions: The Hospital Consumer Assessment of Healthcare Providers and Systems survey is relevant to some European hospital systems and has the potential to produce internationally comparable patient satisfaction scores.
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http://dx.doi.org/10.1093/intqhc/mzs040DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3441096PMC
October 2012

The impact of a high-grade glioma on everyday life: a systematic review from the patient's and caregiver's perspective.

Eur J Oncol Nurs 2013 Feb 31;17(1):107-17. Epub 2012 May 31.

Department of Oncology, University Hospitals Leuven, Leuven, Belgium.

Background: With poor prognosis and disabling symptomatology high-grade gliomas affect not only the patient but also the family.

Purpose: The aim of this systematic review is to explore the experiences and needs of patients with a high-grade glioma and their family caregivers.

Method: Based on literature search in six databases, sixteen qualitative studies, published between 2000 and 2010 and with mixed methodological quality, were included.

Results: For both patients and their caregivers the diagnosis is marked by shock and recognition of death. For patients, coping with restriction seems to be most difficult to deal with. Especially loss of autonomy is hard. For caregivers, neurocognitive symptoms and personality changes irreversibly change the relationship with the patient leading to caregivers expressing a sense of total responsibility. The experience of being a caregiver is described by positive as well as negative feelings. Both patients and caregivers describe the need for hope, support and information.

Conclusion: The review provides some relevant insight in the experiences and needs of patients with a high-grade glioma and their caregivers. The methodological limitations of the included studies, however, urge for more research to refine our understanding of patients' and caregivers' experiences and needs to better tune care to their needs.
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http://dx.doi.org/10.1016/j.ejon.2012.04.006DOI Listing
February 2013
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