Analysis of European policy towards generic medicines

Abstract:
In this paper, we provide an overview of a PhD project we undertook on European policy on generic medicines. In the course of our research, we identified various causes for delayed market access of generic medicines and the need for policies to accelerate market access. These should work in conjunction with policies designed to influence demand, as these can significantly affect use of generic medicines. Ideally, demand-side policies should focus on promoting the use of generic medicines to physicians, pharmacists and patients, with or without financial incentives. Lastly, we present our recommendations for increasing the use of generic medicines.

Submitted: 29 October 2013; Revised: 13 November 2013; Accepted: 14 November 2013; Published online first: 27 November 2013

Generic drugs are cheaper than originator drugs but of comparable quality to their branded counterparts, and can therefore yield substantial savings. We conducted a comparative analysis of policies on generic medicines in retail markets in Europe, and proposed tools to continue developing them. Here we provide an overview of our research.

European governments have implemented a variety of generic medicine policies, encompassing supply-side policies, i.e. market access, pricing and reimbursement; and demand-side policies, i.e. incentives for physicians, pharmacists and patients. On the supply-side, we analysed market access to generic medicines [1], and identified factors that might delay entry. These included defensive patenting strategies, patent litigations, patent linkage, third-party interventions during the process of obtaining marketing authorization, pricing and reimbursement decisions, and backlogs in national approval systems.

First, we examined the status and effect of generic medicine pricing policies in Europe [2]. Competition from Indian generic medicine manufacturers, European variation in generic medicine prices, and competition between generic medicine manufacturers by discount indicated that the potential savings from generic medicines to healthcare payers and patients were not fully realized in Europe. The European experience also suggests a fragmented approach towards developing generic medicine pricing policies in Europe. We identified a relationship between the market share of generic medicines and the change of their price level [3]. The average price level of generic medicines decreased more in countries with a high generics market share than in those with a low generics market share. In addition, we assessed the experience of tendering programmes for outpatient prescription pharmaceuticals in Europe [4]. Only seven countries had applied this policy for pharmaceuticals in ambulatory care in 2011. Tendering led to drastic reductions of the price level of medicines and generated significant short-term savings in some countries. Several negative long-term consequences were associated with this policy, including drug shortages, closure of domestic manufacturing plants, and closure of pharmacies.

We also analysed reference pricing systems in Europe [5, 6]. We found that reference pricing reduced medicines prices, usually only to the level of the reference price, and increased the use of medicines priced at or below the reference price. No negative effects on health outcomes of patients were reported in the literature. The effect on pharmaceutical expenditures was limited, as no, or only marginal, savings were attained, which also tended to be short term. Reference pricing, however, caused a once only setback of expenditure, whereupon the growth rate returned to its former levels. Although long-term growth of pharmaceutical expenditures was not affected, the setback of expenditures created headroom to finance innovative, expensive medicines.

On the demand side, we conducted a literature review of policies implemented by European governments to encourage the use of generic medicines [7]. We found that positive knowledge and perceptions of generic medicines by all stakeholders are necessary prerequisites to increasing the use of generic medicines. Therefore, governments must initiate appropriate policies to achieve this, e.g. independent academic detailing programmes, continuous medical education events for healthcare professionals, and information campaigns for all stakeholders. These policies should be combined with those designed to facilitate prescribing and dispensing of generic medicines and to increase all stakeholders’ financial responsibility within the healthcare system.

We then analysed the effect of prescribing quota for cheap medicines in Belgium [8]. A cheap medicine was defined in this case as a generic medicine, an original medicine whose price has dropped to the reference price level, or a prescription by International Nonproprietary Name (INN). The policy was successful, as most groups of physicians reached their minimum annual percentages between 2006 and 2009. The percentage of cheap medicines (in defined daily doses) increased from 22.9% in January 2005 to 44.2% of all prescribed medicines in ambulatory care in December 2009. The percentage of generic medicines increased from 12.10% in 2004 to 24.03% of all prescribed medicines in ambulatory care in 2008. Despite the success of this policy, it could be even more successful. The definition of cheap medicines in Belgium currently also includes any prescription by INN, whether or not this actually leads to the dispensing of a lower priced medicine.

We investigated pharmacist remuneration systems, as it is important that pharmacists are not financially penalized for dispensing generic medicines, which has been the case in some European countries [9]. Pharmacist remuneration should move towards a fee-for-performance model instead of a price-dependent model; the latter has been the model of choice in many European countries.

We also reviewed the Spanish generic medicines market, and identified hurdles that impede its development. We found that the market share of generic medicines varied among autonomous communities, demonstrating the importance of demand-side policies. Limited use of generic medicines, drastic reductions of the price level of both innovator and generic medicines, and the erosion of price differences between originator and generic medicines have undermined the economic viability of the Spanish generic medicines market. We make recommendations for increasing the sustainability of the Spanish generic medicines market and the efficiency of the pharmaceutical use within the healthcare system. These include accelerating market entrance of generic medicines, creating a price difference between originator and generic medicines, differentiating between patient co-payment rates between originator and generic medicines, improving physicians’ and patients’ trust in generic medicines, increasing prescribing by INN, deploying electronic prescribing systems, making physicians financially responsible for their prescribing behaviour, and making pharmacists’ remuneration independent of the prices of medicines.

On the basis of our research, we propose recommendations to enhance market access of generic medicines in the European Union. These include establishing a unitary EU patent and a unified and specialized litigation system at European level; faster approval of pricing and reimbursement decisions upon marketing authorization; and a reduction of backlogs in national approval systems.

We make recommendations for governments so that they can continue developing their generic medicine retail markets. These proposed policies have been shown to increase the use of generic medicines effectively, independent of any country-specific characteristics. The recommendations concentrate mainly on demand-side issues, such as increasing prescribing by INN, improving physicians’ training and education in drug selection, implementing electronic prescribing systems for physicians, introducing fee-for-performance systems for pharmacists, and improving patients’ perception of generic medicines. The effect of hospital policies on generic medicines is discussed, as this may affect future medication schemes in ambulatory care.

We conclude by forecasting the future of the generic medicines industry. The industrial landscape for pharmaceutical companies is changing, with a tendency for pharmaceutical companies to combine both originator and generics divisions, and the development of biopharmaceuticals and biosimilars [10]. Future research should focus on the development of generic medicines in emerging markets and country-specific analyses of other European countries with limited use of generic medicines.

Competing interests: Professor Steven Simoens holds the EGA Chair ‘European policy towards generic medicines’. The authors have no conflicts of interest that are directly relevant to the content of this manuscript. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Provenance and peer review: Commissioned; internally peer reviewed.

Co-authors

Professor Arnold G Vulto, PharmD, PhD, Deputy Head Hospital Pharmacy, Professor of Hospital Pharmacy and Practical Therapeutics, Erasmus University Medical Center, PO Box 2040, 230 Gravendijkwal, NL-3015 CE Rotterdam, The Netherlands.

Professor Steven Simoens, MSc, PhD, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Onderwijs en Navorsing 2, PO Box 521, 49 Herestraat, BE-3000 Leuven, Belgium.

References
1. Dylst P, Vulto A, Simoens S. Overcoming challenges in market access of generic medicines in the European Union. J Generic Med. 2012;9(1):21-8.
2. Dylst P, Simoens S. Generic medicine pricing policies in Europe: current status and impact. Pharmaceuticals. 2010;3(3):471-81.
3. Dylst P, Simoens S. Does the market share of generic medicines influence the price level?: a European analysis. Pharmacoeconomics. 2011;29(10):875-82.
4. Dylst P, Vulto A, Simoens S. Tendering for outpatient prescription pharmaceuticals: what can be learned from current practices in Europe? Health Policy. 2011;101(2):146-52.
5. Dylst P, Vulto A, Simoens S. The impact of reference-pricing systems in Europe: a literature review and case studies. Expert Rev Pharmacoecon Outcomes Res. 2011;11(6):729-37.
6. Dylst P, Vulto A, Simoens S. Reference pricing systems in Europe: characteristics and consequences. Generics and Biosimilars Initiative Journal (GaBI Journal). 2012;1(3-4):127-31. doi:10.5639/gabij.2012.0103-4.028
7. Dylst P, Vulto A, Simoens S. Demand-side policies to encourage the use of generic medicines: an overview. Expert Rev Pharmacoecon Outcomes Res. 2013;13(1):59-72.
8. Dylst P, Vulto A, Simoens S. Where a cheap medicine is not the same as a generic medicine: the Belgian case. Journal of Pharmaceutical Health Services Research. 2011;2:185-89.
9. Dylst P, Vulto A, Simoens S. How can pharmacist remuneration systems in Europe contribute to generic medicine dispensing? Pharmacy Pract. 2012;10(1):3-8.
10. Dylst P, Vulto A, Godman B, Simoens S. Generic medicines: solutions for a sustainable drug market? Applied Health Economics and Health Policy 2013; doi:10.1007/s40258-013-0043-z

Author for correspondence: Pieter Dylst, PharmD, PhD, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Onderwijs en Navorsing 2, PO Box 521, 49 Herestraat, BE-3000 Leuven, Belgium

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Reference pricing systems in Europe: characteristics and consequences

Author byline as per print journal: Pieter Dylst, PharmD; Professor Steven Simoens, MSc, PhD; Professor Arnold G Vulto, PharmD, PhD

Introduction: A reference pricing system is a system that establishes a common reimbursement level or reference price for a group of interchangeable medicines, i.e. the reference group. This article provides an overview of the different characteristics of the different reference pricing systems in Europe. Additionally, the impact of reference pricing on price competition, generic medicine use, pharmaceutical expenditure and health outcome will be discussed.
Methods: Studies relevant for this article were found by means of a literature review. A survey was carried out to document the current status of reference pricing systems in Europe. Survey data were collected from member associations of the European Generic medicines Association in the context of their 2011 survey of European drug retail markets.
Results: Many European governments have introduced reference pricing systems. Reference pricing systems reduce medicine prices but not always below the reference price, increase the use of medicines priced at or below the reference price, generate savings in pharmaceutical expenditure that tend to be limited to the short term, and do not seem to adversely affect health outcomes.
Conclusion: Reference pricing is a popular policy for governments to contain pharmaceutical expenditures and seems to be effective in the different European countries.

Submitted: 16 May 2012; Revised: 8 August 2012; Accepted: 15 August 2012; Published online first: 17 August 2012

Introduction

A reference pricing system is a system that establishes a reimbursement level or reference price for a group of interchangeable medicines. If a medicine is priced above the reference price, the patient pays the difference between the price of the medicine and the reference price, in addition to any other co-payments, e.g. prescription fee, percentage co-payment [1].

Unlike its name suggests, a reference pricing system is not a pricing system, but in fact a reimbursement system. A reference pricing system sets a common reimbursement level, i.e. reference price, for a group of medicines, thereby generating savings for the third-party payer. Manufacturers are in principle free to set prices, although medicines priced above the reference price incur an additional patient co-payment and generic medicines in some countries, e.g. Belgium, need to be priced below the reference price in order to be reimbursed.

Reference pricing can help governments to contain public pharmaceutical expenditure as it controls the reimbursement level of medicines. A reference pricing system may also promote generic medicine use because originator medicines priced above the level of the reference price are likely to lose market share as a result of the additional patient co-payment.

Many European countries have already installed a reference pricing system, see Table 1. Sweden had adopted a reference pricing system in 1993 but abandoned this in 2002 [2]. In Norway, reference pricing applied from 1993 until the end of 2000. In 2003, the Norwegian government installed a system called ‘index pricing’ to a set of off-patent medicines, which has many resemblances with a reference pricing system [3, 4]. Reference pricing is in many European countries combined with other policies such as prescribing by international non-proprietary name or generics substitution, as this combination of policies seems to positively influence each other [5].

Table 1: European countries with or without reference pricing system[68]

This article describes the characteristics of the different reference pricing systems in Europe. Also, the impact of reference pricing on price competition, generic medicine use, pharmaceutical expenditure and health outcome will be discussed. To this effect, a literature review and survey were carried out. The survey was used to document the current status of reference pricing systems in Europe. Survey data were collected from member associations of the European Generic medicines Association in the context of their 2011 survey of European drug retail markets [6].

Reference price methods in Europe

Table 2 gives an overview of the different methods used by European countries to set reference prices. A country may employ one or a combination of method(s) to establish reference prices. The reference price is generally calculated as a function of market prices of medicines. The medicines which are taken into account for the calculation of these reference prices can differ between countries, see Table 2.

Table 2: Methods for setting reference prices in European countries 2011[6, 8]

The different methods of setting reference prices need to be considered in the context of price competition and the volume of generic medicine use. Some European countries set the reference price at the average price level of (generic) medicines in the reference group. If accompanied by incentives to stimulate demand for generic medicines, generic medicine companies have an incentive to compete, thereby driving down (reference) prices of medicines.

Once the generic medicines market reaches a minimum level of development—for instance, a generic drug market share by volume of 40%—the reference price can be further reduced and set at the level of the lowest priced (generic) medicine. For instance, the high generic medicines market share in combination with reference prices based on the lowest priced medicines in Poland support price competition between companies and maximize savings from generic medicines use. However, other countries such as Italy and Spain have set the reference price based on the lowest priced medicine in the absence of strong incentives to stimulate demand for generic medicines, thereby undermining the development of the generic medicines market [9].

Conversely, in countries with developing generic medicines markets, setting the reference price at a higher level to encourage generic medicines market entry can be introduced as a temporary measure to boost the generic medicines market until it reaches a more mature level of development [9]. For instance, when the reference pricing system was first introduced in Portugal in 2003, the reference price was established at the level of the most expensive generic medicine. This approach increased the number of generics competitors and competition in the generic medicines market [10].

This recommendation reflects the approach used in Germany, where the reference price is calculated as a function of medicine prices and the number of generics competitors. Higher reference prices are awarded in reference groups with fewer generics competitors, thereby stimulating market entry of generic medicines companies. Conversely, reference prices are reduced and price competition is stimulated in established markets, but not to the extent that it becomes economically unviable for generic medicines companies to remain on the market [11].

In Belgium, the reference price is set at 69% (imposed by the government) of the price of the originator medicine on the day that the patent expires. This method has the benefit of guaranteeing savings to health insurance funds, but has in general not generated price reductions of generic medicines below the reference price [12].

Reference group

In a reference pricing system, equivalent medicines are put together in a reference group as defined by:

  1. active substance, i.e. medicines with the same active substance (ATC-level 5)
  2. pharmacological class, i.e. medicines with chemically-related active substances that are pharmacologically equivalent (ATC-level 4) or
  3. therapeutic class, i.e. medicines that have a comparable therapeutic effect (ATC-level 3).

The term ‘generic reference pricing’ refers to a level 1 reference group, whereas ‘therapeutic reference pricing’ relates to level 2 and 3 reference groups [13].

The methods for establishing reference groups in European countries are outlined in Table 3. Countries can implement a combination of these methods to group medicines in reference groups.

Table 3: Methods for establishing reference groups in European countries 2011[6]

The majority of countries group medicines by active substance, see Table 2. Such a method may lead to ‘re-allocation of demand’ away from off-patent medicines included in the reference pricing system towards patented medicines with a similar therapeutic indication that do not fall under the reference pricing system [9].

Re-allocation of demand occurred in Italy in the case of ranitidine: the falling market share of originator ranitidine following the advent of generic medicines was offset by increasing sales of patented medicines with the same therapeutic indication, e.g. omeprazole and its derivatives. Estimates suggest that re-allocation of demand was responsible for an increase in public pharmaceutical expenditure by 3.1% in 2003 [14].

Following the patent expiry of omeprazole in The Netherlands, a higher percentage of patients switched to another proton pump inhibitor (such as pantoprazole and esomeprazole, which are not included in the reference pricing system) than before the patent expiry of omeprazole [15].

In the Valencian region of Spain, the inclusion of fluoxetine in the reference pricing system and the market entry of generics competitors resulted in a shift away from fluoxetine to other antidepressants, e.g. escitalopram, venlafaxine, which were not included in the reference pricing system [16].

In countries that define reference groups by pharmacological class or by therapeutic class, see Table 3, the heterogeneity of medicines within the reference group increases. As a result, physicians may be incited to prescribe a specific medicine for financial reasons, i.e. avoidance of patient co-payment, rather than for clinical reasons, i.e. effectiveness, safety, drug–drug interaction profile [9].

Differences exist between European countries with respect to the consideration of dosage equivalence when establishing reference groups [13]. If there is no differentiation between dosages, e.g. 10 mg, 20 mg and 40 mg of the same active substance are included in the same reference group; 1 mg of active substance will be the cheapest in the highest dosage formulation. Thus, patients have an incentive to switch to the highest dosage of the medicine with the lowest co-payment. Alternatively, reference groups may be defined based on the defined daily dose of medicines. However, one defined daily dose of a specific medicine may not be therapeutically equivalent with one defined daily dose of another medicine in the same reference group. Defined daily doses of medicines also might change over time. World Health Organization therefore stresses that the defined daily dose methodology should not be misused for pricing and reimbursement decisions [17].

Hungary already applied a reference pricing system by active substance since 1997 and introduced a reference pricing system by therapeutic class for, amongst other medicine classes, statins in 2003. Statins were put together in one reference group based on their mechanism of action, without taking into account differences in pharmacologic profile, safety and effectiveness between individual products. As the reference price was determined based on the price per mg, the reference pricing system financially promoted the use of higher-dosed statins such as atorvastatin 40 mg and fluvastatin 80 mg. As a result, the majority of patients switched to higher-dosed statins and the anticipated reduction in the average price of prescribed statins did not materialize [18].

Reference pricing and price competition in Europe

What is the impact of a reference pricing system on price competition? The literature suggests that the introduction of a reference pricing system reduces prices of all medicines that are included in the system [19, 20]. Obviously, price reductions tend to be larger for originator medicines than for generic medicines. Also, greater price reductions have been witnessed in markets where generic medicine competition already occurred prior to the introduction of a reference pricing system [19].

The European experience with respect to price reductions below the reference price is mixed: such price competition has occurred in some countries, e.g. Lithuania [20], but not in others, e.g. Slovenia, Spain [21]. Conversely, some medicines that were originally priced below the reference price actually increased their prices to the level of the reference price following the implementation of a reference pricing system in The Netherlands [22] and in Spain [23]. Therefore, in addition to setting reference prices as a function of the prices of existing medicines, some countries have established a fixed minimum price difference between generic and originator medicines, e.g. Finland, Portugal, Spain [6].

The number of generic medicine competitors within a reference pricing system appears to be associated with the extent of competition, although this impact occurs mainly through discounting to the distribution chain rather than through price competition. Larger discounts have been observed when there are more generic medicine competitors [20, 24].

Finally, as compared with other mechanisms to regulate prices such as price caps i.e. a system where the regulator sets a maximum price that can be charged for a medicine, a Norwegian study reports that a reference pricing system stimulates generics competition to a greater extent and leads to lower prices than price cap regulation [3].

In Germany, medicine prices dropped by 10–26% in the first years following the introduction of the reference pricing system in 1989. This price reduction was greater for originator medicines that faced more generic medicines competition. However, price reductions were counterbalanced by an increase in prices of medicines that were not included in the reference pricing system [25, 26]. In Norway, the implementation of a system called ‘index pricing’ to a set of off-patent medicines in 2003, which has many resemblances with reference pricing, reduced prices of originator medicines by 18% and prices of generic medicines by 8% [3]. In Sweden, medicines covered by the reference pricing system saw a drop in prices by 19% following the introduction of the system [27].

Reference pricing and generic medicine use

In general, the implementation of a reference pricing system has been accompanied by an increase in the use of medicines priced at or below the reference price [13]. However, a literature review indicated that a reference pricing system does not aid generic medicines use if:

  1. prices of originator medicines fall to the level of the reference price
  2. the originator company launches new dosages and/or new formulations
  3. physicians switch to patented medicines with a similar therapeutic indication that do not fall under the reference pricing system (re-allocation of demand) [19].

In Germany, therapeutic reference pricing applies to the group of statins since 2005. As the manufacturer of atorvastatin claimed that atorvastatin was superior to other statins in terms of side effects and drug interaction profile, the manufacturer kept the price of atorvastatin above the reference price. As a result, the market share of atorvastatin declined from 33.3% prior to the reference pricing system to 4.8% in 2006. This volume shifted mainly towards simvastatin to which no additional patient co-payment was applicable as its price was below the reference price [28].

Reference pricing and pharmaceutical expenditure in Europe

A literature review has indicated that reference pricing systems generate savings in the short term, but that savings are probably limited to the one-off impact of the introduction of the reference pricing system and that savings may be substantial at the level of individual medicines, but not necessarily at the level of total pharmaceutical expenditure [19]. Figure 1 shows how the introduction of a reference pricing system may impact long-term pharmaceutical expenditure [29].

Figure 1: Impact of reference pricing system on long-term pharmaceutical expenditure[29]

The limited scope for savings is to be expected for at least two reasons [29]. First, the coverage of reference pricing systems tends to be limited to off-patent medicines. Patented medicines are included in the reference pricing system by therapeutic class in some countries only. Second, although a reference pricing system may reduce medicine prices and may affect the substitution of new more expensive medicines for older less expensive medicines, it does not affect other drivers of increasing pharmaceutical expenditure such as medicines use by ageing populations, the introduction of expensive biotechnology medicines and orphan medicines, and the transformation from acute to chronic diseases.

Reference pricing and health outcome

A potential concern of therapeutic reference pricing is that switches in medicine use in response to the reference pricing system may adversely affect patient health outcomes and thereby increase the use (and costs) of other healthcare services. There are few studies that explore the impact of reference pricing systems on health and they suffer from methodological limitations. Nonetheless, the available evidence suggests that there is no association between reference pricing systems and health outcomes [13, 19].

A related issue is whether a reference pricing system influences access to health (care) of patient groups with a different socio-economic status. For instance, are patients with a lower socio-economic status more likely to buy costly originator medicines (incurring an additional patient co-payment) in a reference pricing system, thereby placing a financial burden on patient groups with a lower ability to pay? Very few studies have investigated this issue, but a recent Belgian study showed that patients with a lower socio-economic status tended to buy the cheapest (generic) medicines within a reference group and incurred lower medication costs than patients with a higher socio-economic status, thereby laying to rest potential socio-economic equity concerns related to reference pricing systems [8].

Conclusion

Reference pricing is used by many European countries as one element of governments’ strategies to contain public healthcare expenditure. It puts pressure on pharmaceutical companies to compete with the reference priced product but also reduces competition beyond this reference price. It also makes patients sensitive of drug prices, as an increased use of drugs priced at or below the reference price level was observed. The introduction of reference pricing generates a once-only setback of expenditures but does not affect the overall growth rate of health expenditure in the long term. No association between reference pricing and health outcome has been observed.

For patients

Over the last decades, European healthcare budgets have been increasing. Therefore, governments have implemented reference pricing, amongst other measures, in order to contain the pharmaceutical budget. In the reference pricing system, a common reimbursement level is set for a group of comparable and interchangeable medicines. The difference between this reimbursement level and the actual price of the medicine is paid by the patient, a so-called co-payment. This provides patients with a financial incentive to opt for the least expensive medicine. Reference pricing seems to reduce prices of medicines, increases the use of cheaper medicines, i.e. without co-payment, generates savings for healthcare budgets in the short term and does not seem to have a negative influence on the health of patients.

Competing interests: Professor Steven Simoens holds the EGA Chair ‘European policy towards generic medicines’. The authors have no conflicts of interest that are directly relevant to the content of this manuscript. This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Provenance and peer review: Commissioned; externally peer reviewed.

The paper is abstracted based on the presentation at the 24th Annual EuroMeeting, Drug Information Association, 28 March 2012, Copenhagen, Denmark.

Co-authors

Professor Steven Simoens, MSc, PhD, Research Centre for Pharmaceutical Care and Pharmacoeconomics, Katholieke Universiteit Leuven, Onderwijs en Navorsing 2, PO Box 521, 49 Herestraat, BE-3000 Leuven, Belgium

Professor Arnold G Vulto, PharmD, PhD, Deputy Head Hospital Pharmacy, Professor of Hospital Pharmacy and Practical Therapeutics, Erasmus University Medical Center, PO Box 2040, NL-3000 CA Rotterdam, The Netherlands

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Author for correspondence: Pieter Dylst, PharmD, Research Centre for Pharmaceutical Care and Pharmacoeconomics, Katholieke Universiteit Leuven, Onderwijs en Navorsing 2, PO Box 521, 49 Herestraat, BE-3000 Leuven, Belgium

Disclosure of Conflict of Interest Statement is available upon request.

Permission granted to reproduce for personal and non-commercial use only. All other reproduction, copy or reprinting of all or part of any ‘Content’ found on this website is strictly prohibited without the prior consent of the publisher. Contact the publisher to obtain permission before redistributing.

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