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214 Musculoskeletal & Neurological Rehabilitation KCE reports 57 9.2.3 Planning of rehabilitation services 9.2.3.1 General rehabilitation (mono-disciplinary and simple multidisciplinary): bottomup To ensure accessibility at this level, no restrictions should be set on the number of organisations. General rehabilitation services should be provided geographically widespread (bottom-up approach). It could be considered to allow these organisations to admit patients with complex needs in the chronic phase, as these people do not always have easy access to adapted temporary intensive rehabilitation (e.g. in nursing homes). These services can be delivered by the departments of Physical Medicine and Rehabilitation, present in most of the acute hospitals. 9.2.3.2 Complex multidisciplinary rehabilitation: top-down Decision-makers should define the number of organisations needed based on epidemiological data and evidence about intensity, content and duration of rehabilitation therapy. As this information is not yet available in Belgium, it is currently not possible to plan in such a way. An epidemiological monitoring of musculoskeletal and neurological disorders and a follow up of the developments in rehabilitation sciences is necessary. For this last purpose, an international research collaboration is recommended. Planning of rehabilitation services requires a central database in which data of delivered services and activities as well as patients’ profiles are registered, in order to dispose of relevant information concerning musculoskeletal and neurological rehabilitation in Belgium. Besides musculoskeletal and neurological rehabilitation, other types of rehabilitation (e.g. cardiac and pulmonary rehabilitation) should be considered while planning rehabilitation services in order to increase efficiency. These types of rehabilitation might be offered in a comparable administrative framework with similar infrastructure and equipment. 9.2.3.3 Estimation of the number of needed rehabilitation services for the five selected pathologies As mentioned earlier, in Belgium there is no central registration of rehabilitation activities or patient profiles. In order to estimate the need for rehabilitation services an attempt is made to define the number of patients needed to be treated within these facilities, at least for the five selected pathologies in this study. These data need to be interpreted with very great caution as they are based on incidence and prevalence figures obtained by extrapolation of other countries (Chapter 2), completed by Belgian expert opinion and some RIZIV/INAMI data. There are some specific aspects in the Belgian context making that a model of services supply cannot be merely copied in Belgium. Here is referred to Belgium as a federal state with different regions and communities. Distances are small but the population density is very high as compared to other European countries. The aim of this estimation is merely to give an idea on how to start, and the services supply should be corrected where necessary in the future, based on exact data once they are available. This estimation is based on the incidence/prevalence as developed in Chapter 10, Figure 10.5. The report of the Ministerial subgroup for locomotor and neurological rehabilitation 131 is also taken into account as this is the result of a reflection process and dialogue between different Belgian stakeholders, during more than a year of discussion and dialogue.
KCE reports 57 Musculoskeletal & Neurological Rehabilitation 215 TOTAL HIP REPLACEMENT The assumption is that 85% of the patients with THR have only temporary and simple rehabilitation needs, wich can usually be covered by monodisciplinary treatment. About 15 % of the patients are considered as fragile (mostly after traumatic hip fracture) or present with polypathology (e.g. rheumatoid arthritis, stroke or polyneuropathy). These patients may need a simple multidisciplinary approach. The required rehabilitation activities in patients with THR can be provided by general rehabilitation services, present in most of the acute hospitals. The overall incidence of patients with THR in Belgium was 16.599 in 2004 46 . In the Study of prof. Closon of the Sp facilities they account for 26% of the hospital stays 24 . LOWER EXTREMITY AMPUTATION The incidence of LEA is difficult to estimate in Belgium as in literature it is not always specified which amputation levels are included. In the Sp-study by prof. Closon LEA accounts for only 3 % of the hospital stays 24 . The majority of LEA is due to vascular disease (82%), mostly in diabetic patients. A minority are traumatic (9%) or oncological (9%) 237 . In other studies the percentages of vascular causes are often even higher. About half of the patients with LEA are fitted with a prosthesis 66 . Patients who are not fitted with a prosthesis can usually be treated in general rehabilitation services (except e.g. for bilateral above knee amputation). Based on literature, expert opinion and RIZIV/INAMI data the assumption is that in Belgium there are about 600 new prosthesis patients each year. Of these prostheses, the proportion above knee/below knee is approximately 50/50%. The majority of the LEA needing a prosthesis can be treated in specific services. In order to admit 30 new LEA patients per centre per year maximum 20 specific centres are needed. The patients with above knee amputation, associated problems (traumatic or oncological etiology) and younger age, with broader rehabilitation goals, can even need highly specific services. Technology has become very specialised and the indication for expensive knee mechanisms such as microprocessor knees should depend on the decision of a highly specialised multidisciplinary team. For the small number of patients (maximum 10 %) with highly specific needs (associated problems, high technology needs, pelvic level of amputation for traumatic or oncological reasons), 2 to 3 centres are sufficient which need to collaborate with the specific centres in the network. For reasons of efficiency the highly specific centres could combine the specific function for the own region. SPINAL CORD INJURY The incidence of spinal cord injury in Belgium is estimated between 1 and 3/ 100.000 / year. Nearly all present with complex rehabilitation needs. These patients need treatment in highly specific services. This means that there are about 200 new SCI patients per year in Belgium (100-300). Considering, as is defined in the report of “the Ministerial subgroup for locomotor and neurological rehabilitation”, that a total critical mass of minimum 30 patients/day and 30 new patients per year is needed this brings us to a total of three or four centres for Belgium. This still means 1 centre for 2.500.000 inhabitants whereas abroad there usually is one centre for 4 to 6.000.000 inhabitants (e.g. UK and France 12 centres, Denmark 2 centres). These highly specific centres need to work in collaboration with a network of specific centres, for instance if the distance to the highly specific centre would be to important for ambulatory treatment.
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Dépôt légal : D/2007/10.273/19
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35. Etude relative aux coûts poten
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