Continuity of care refers to the ability of the system to ensure that the care for any given patient is organised smoothly and properly coordinated over time and across providers, institutions and regions, and covers the entire disease trajectory. Poorly coordinated care or a lack of communication can cause a whole range of issues, like examinations being performed multiple times, treatments interacting in a negative way or even counteracting each other, a lack of follow-up (particularly after a hospital stay), etc. It is therefore crucial that all healthcare providers working around a patient know what the others are doing and make sure their interventions complete each other.
Continuity of care can cover a whole range of aspects, like the ability to keep relying on the same provider(s) over time, the availability of a medical record to store and share medical information, a smooth transition between hospital and ambulatory care, good communication and coordination between different healthcare providers, etc.
This section covers four major aspects of continuity, assessed through seven indicators:
- Informational continuity, i.e. the availability and use of data from prior events during current patient encounters, assessed through the number of people who have a global medical record with their GP (QC-1);
- Relational continuity, i.e. an ongoing relationship between patients and one or more providers, assessed through the share of healthcare contacts that involve the “usual” provider (QC-2);
- Management continuity, i.e. a coherent delivery of care by different providers across different care settings, assessed through the percentage of (older) patients who have seen their GP within a week after being discharged from hospital (QC-3);
- Coordination of care, i.e. the connection between different healthcare providers over time to achieve a common objective, assessed through the follow-up of people living with diabetes (QC-4, QC-5) and the percentage of eligible people who have a reference pharmacist (QC-7) in ambulatory care and through the percentage of cancer patients who have been discussed during a multidisciplinary team meeting (QC-6) in hospital care.
Initiatives on integrated, people-centred care across various settings also relate to the continuity and coordination of care, but are described in the section on person-centredness of care.
Coverage of the global medical record (QC-1)
Since 2001, Belgian patients have the possibility to open a global medical record (GMR) with a GP of their choice, who will record and centralise their medical information and history over time. Entrusting the coordination of the care for a specific patient to one single provider is expected to improve the quality of care, e.g. by ensuring more efficient referrals and communication with other providers, by preventing the same medical exam from happening twice when once would have been enough, by avoiding treatments which might counteract each other, etc. An official electronic GMR system was launched in 2016; its use has become compulsory as of 2021.
Results
- The percentage of patients who have a GMR with their GP is increasing over time, from 52.1% in 2010 to 83.3% in 2021.
- Coverage is better for older people than for their younger counterparts: in 2021, over 90% of people aged 65 years or more had a GMR vs less than 80% of people less than 45 years old. Coverage is also somewhat higher in women than in men.
- There are major differences between regions (as well as between districts within regions), with particularly low coverage in Brussels (67.8% in 2021) compared to Flanders (87.8%) and Wallonia (79.6%).
Link to technical sheet and detailed results
Data source: IMA - AIM
Usual Provider Continuity index ≥ 0.75 (in % of patients with 3 or more contacts with GP in last two years) (QC-2)
A long-term relationship between physician and patient has been shown to improve communication, satisfaction and overall quality of care; patients will for instance be more likely to receive the treatment that suits them best, take their medication regularly, be properly vaccinated or take part in relevant screenings, and less likely to be admitted to hospital or to the ER because a long-term issue got out of hand.
To assess this long-term care relationship, we have used the Usual Provider Continuity (UPC) index, which refers, for any given patient, to the share of all GP contacts involving the usual GP (i.e. the one the patient sees most frequently) over a period of two years. If, for instance, a patient has had ten contacts with a GP over the past two years, seven with his usual GP and three with one or more other GPs (e.g. during on-call hours, because he was staying far from home, because his usual GP shares a group practice with others and a colleague took over while he was unavailable, etc.), the UPC will be 0.70.
Results
- In 2021, 60.3% of patients had a high UPC index (≥ 0.75), meaning that at least three out of four GP contacts over the last two years were with their usual GP. This share has decreased since 2011. Only 30.9% of patients had an exclusive relationship with their GP (encounters with the same GP every time).
- Wallonia had the highest percentage of patients with a high UPC index (68%), followed by Brussels (60.3%) and Flanders (56.4%); the same was observed for exclusivity (37% in Wallonia, 33% in Brussels and 27.6% in Flanders). There was also considerable variation between districts.
- The percentage of patients with a high UPC index increased with the total number of GP contacts during the last two years. On the other hand, the likelihood of seeing the same GP every single time (exclusivity) was lower for patients with a higher number of contacts.
- The proportion of patients with a high UPC index increases gradually with age from 20 years old. Among older people (aged 65 years or more), those receiving nursing care at home were most likely to have a high UPC index (77%, of which a little under 34% had an exclusive relationship with one single GP).
- A high UPC index (≥ 0.75) is found more often in patients entitled to increased reimbursement (denoting a lower socio-economic status) than in those without.
Link to technical sheet and detailed results
Data source: IMA – AIM
Data source: IMA – AIM
GP encounter within 7 days after hospital discharge (% of patients aged ≥65 years) (QC-3)
Continuity of care is important at all times, but even more so when a patient leaves hospital to go back home after an inpatient stay. Indeed, follow-up treatments, monitoring and (medical, physical or emotional) support might – and often will – still be necessary after discharge, especially in a context where hospital stays have become increasingly short. Typically, this is the stage where ambulatory care should take over. A lack of coordination or communication during this transition increases the risk of complications or adverse events, which might even cause the patient to have to go back to hospital.
A follow-up contact with a GP approximately a week after leaving hospital is particularly important and highly recommended for older people (and certainly for those with multiple and complex chronic conditions), e.g. to check whether care arrangements put in place at the time of discharge are still appropriate and more generally to keep an eye on any issues that might arise.
This indicator assesses the percentage of older patients (aged 65 years or more) who have seen their GP within 7 days of leaving hospital.
Results
- In 2021, only 43.5% of older patients saw a GP within a week after leaving the hospital. A little over half (52%) of these contacts took place remotely.
- Figures were very similar in Flanders (44.6%) and Wallonia (41.2%), but lower in Brussels (29.8%). Within regions, there were also substantial differences between districts.
- The percentage of patients seeing a GP within a week of leaving hospital was considerably lower in 2021 than in 2013 (55.6%). This decreasing trend might reflect a reduction in early follow-up, but possibly also a switch to other modes of follow-up which might involve other healthcare providers (home nurse, medical specialist, etc.).
- Women were slightly more likely to see a GP within a week of discharge (45.7%, vs 41% for men), as were people receiving long-term care (over 50%, vs 34.6% for those without long-term care) and people entitled to increased reimbursement, which reflects a lower socio-economic level (just over 50%, vs 40% for those without). The probability also increased with age (from 32.5% among 65-69 years old vs 58% among those aged 90 years or more), which is likely to be linked at least in part to the increase in long-term care.
Link to technical sheet and detailed results
Data source: IMA – AIM
Data source: IMA – AIM
Percentage of adults living with diabetes (receiving insulin or receiving glucose-lowering drugs other than insulin) enrolled in an official follow-up initiative (QC-4, QC-5)
Diabetes is a common chronic (long-term) disease that occurs when the body is unable to regulate excessive levels of glucose (sugar); in Belgium, about 6.8% of the population have received this diagnosis. The actual number of patients is likely to be much higher, as one in three patients is thought to be undiagnosed. If left untreated or poorly controlled, the disease can result in serious complications.
In Belgium, several reimbursed initiatives have been set up by RIZIV – INAMI to optimize the care provided to people living with this condition:
- The diabetes pre-care trajectory (modèle de soins “suivi d’un patient diabétique de type 2” or prétrajet diabète/zorgmodel “opvolging van een patiënt met diabetes type 2” or voortraject diabetes) was launched in early 2016, to replace the “diabetes pass” (passeport diabète/diabetespas). It aims to improve patient education and involvement in their care, and to support communication with health care providers.
- The care trajectory for people living with type 2 diabetes (trajet de soins diabète de type 2/zorgtraject diabetes type 2) was launched in September 2009. It aims to improve follow-up and collaboration between patients, GP and medical specialist.
- Conventions with specialised centres for diabetes self-management (conventions INAMI/RIZIV overeenkomsten) and other specific support programmes were set up in 1986. Their aim is to better organise the multidisciplinary management of people living with diabetes in specialised hospital centres, in order to support patient education and involvement in their care, as well as communication with their healthcare providers.
Participation in these initiatives is voluntary and subject to a number of conditions, both medical (e.g. type of diabetes, type of treatment…) and practical (e.g. having a global medical record with a GP, having a certain number of yearly contacts with a GP and medical specialist…). It gives patients access to a number of advantages, like better or full insurance coverage for certain healthcare services (e.g. dietician, podiatrist…) and self-management devices, and ensures a better follow-up, coordination and continuity of care.
The indicators for this section measure participation in two groups of patients: those who receive an insulin treatment (QC-4) and those who receive glucose-lowering drugs other than insulin (QC-5). More detailed information on diabetes and its treatments can be found in the section on appropriateness of care (QA-1 and QA-2).
Results
- In 2021, the percentage of adult patients with diabetes treated with insulin who are registered for at least one of the abovementioned initiatives was relatively high (86%). Most of them had signed a convention. Participation has decreased between 2020 and 2021.
- Among patients who receive other glucose-lowering drugs but no insulin, on the other hand, this percentage was rather low at 26.6%. Care trajectories made up a little over half of the total for this group. After an increasing trend from 2011 to 2019, participation has remained more or less stable over the last three years.
- In 2021, this percentage was higher in Flanders (88.2% and 32.8% respectively for the groups with and without insulin treatment) than in Wallonia (84.2% and 17.7%) and Brussels (81.1% and 24%).
- In both groups, the percentage of adult patients participating in at least one diabetes care initiative decreases with age, but it remains above 80% in all age groups except the very old (85 years or more) for those who receive insulin.
- Among older people (65 years or more), the percentage of people living with diabetes taking part in at least one diabetes care initiative is lower for those who reside in an institution (e.g. nursing home). This holds true both for patients under insulin and for those who receive other glucose-lowering drugs.
- Participation is slightly lower among patients with diabetes who receive insulin and are entitled to increased reimbursement, which reflects a lower socio-economic level. Among patients treated with other glucose-lowering drugs but no insulin, on the other hand, being entitled to increased reimbursement makes participation slightly more likely.
Link to technical sheet and detailed results
Data source: IMA – AIM
Data source: IMA – AIM
People with a reference pharmacist (QC-7)
The concept of a “reference pharmacist” (huisapotheker/pharmacien de référence) was introduced in 2017 for customers of public pharmacies who need multiple treatments (with the exclusion of people in residential care or nursing homes). In theory, everyone is allowed to have a reference pharmacist, but this service is only reimbursed for chronic patients. The reference pharmacist ensures registration of all delivered medicines in an (electronic) pharmacy record, provides the patient with a medication scheme and makes this scheme available to other care providers.
This indicator measures the uptake of the service among chronic patients and non-chronic patients.
Results
- Uptake of this relatively new service by the whole target population has increased from 15% in 2017 to 38.7% in 2021 (of which 56.4% were women). This remains fairly low, and could be improved by actively contacting all eligible patients.
- Though figures are on the rise in all three regions, the percentage of eligible patients with a reference pharmacist remains higher in Flanders (44.6% in 2021) than in Brussels (31.6%) and Wallonia (29.9%).
- In the subgroup of the target population with an official RIZIV-INAMI “chronically ill patient” status, uptake has increased from 19.1% in 2017 to 46.6% in 2021.
- In the subgroup of the target population without this official status, uptake remains much lower (12.8% in 2017 and 32.9% in 2021).
Link to technical sheet and detailed results
Data source: IMA – AIM
Patients with cancer discussed during a multidisciplinary team meeting (QC-6)
The concept of a multidisciplinary team meeting (multidisciplinair oncologisch consult/consultation oncologique multidisciplinaire or MOC-COM) has been implemented in many countries to ensure that all cancer patients receive timely diagnosis and treatment, that the disease is managed in an evidence-based way, and that continuity of care is ensured. It brings together a whole range of medical specialists who are involved in the diagnosis and treatment (e.g. oncologists, surgeons, radiotherapists and potentially others depending on the type of cancer), as well as the patient’s GP, to examine his or her specific case together and decide on the best course of action.
This type of multidisciplinary discussion is highly beneficial for continuity of care, and is recommended by all national and international practice guidelines (but not compulsory, except in very specific cases). In Belgium, it is reimbursed since 2003 and strongly encouraged by the National Cancer Plan.
This indicator measures the proportion of patients diagnosed with cancer whose medical record has been discussed during a multidisciplinary team meeting.
Results
- Since specific nomenclature codes for the MOC-COM have been introduced, in 2003, its use has sharply increased for all cancer types. About 90.4% of cancer patients diagnosed in 2020 were discussed during a multidisciplinary team meeting, vs 52.5% in 2004 and 78.9% in 2010.
- This increasing trend was observed in all three regions and, while MOC-COM uptake was initially much higher in Flanders (59.8%, vs 42.1% in Brussels and 42% in Wallonia in 2004), the gap is now almost closed (91.6% in Flanders, 89.3% in Brussels and 88.2% in Wallonia in 2020).
- The uptake of the MOC-COM varies depending on the type of cancer, from 67.5% for cancers for which the primary site was unknown or which were ill-defined and 75.6% for malignant melanoma of the skin to 95.5% for breast cancer in 2022. This variability is, however, lower than a few years ago.
- Patients in the oldest age group (80 years or more) were less frequently discussed in MOC-COM than their younger counterparts. This was true for all types or cancer. This is regrettable, because this team meeting is extremely useful even for cases where a curative treatment is not possible.
Link to technical sheet and detailed results
Data source: BCR & IMA – AIM