Effectiveness of care

Effectiveness of care is 'the degree of achieving desirable outcomes, given the correct provision of evidence-based healthcare services to all who could benefit but not those who would not benefit’.

 Effectiveness can be measured in all areas of care and from different angles. In this report, we have defined different categories of effectiveness of care indicators:

  • Two overall indicators to assess mortality which is amenable through the healthcare system (QE-8) and mortality that is preventable through health policies (QE-9)
  • Effectiveness of first-line care is measured by the number of preventable hospitalisations for two chronic pathologies, asthma (QE-1) and diabetes (QE-2).
  • Effectiveness of hospital care is measured according to result indicators such as: 5-year survival rates following breast cancer (QE-3) and colorectal cancer (QE-4) as well as mortality rates within 30 days following an admission for acute myocardial infarction (QE-5), following ischaemic stroke (QE-6) and after colorectal surgery (QE-7).
Summary of the indicators of effectiveness of care​​
(ID) indicatorScoreBELYearFlaWalBRUSource

EU-15 mean [Belgium]

Effectiveness primary care – avoidable hospital admissions
QE-1 Asthma hospital admissions
in adults (/100 000 pop)
orange stable 30 2014 29 29 39 MZG-RHM

39(1)
[BE:37]

QE-2 Complication of diabetes hospital admissions in adults (/100 000 pop) orange improving 130 2014 130 132 128 MZG-RHM

122(1)
[BE:143]

Effectiveness hospital care – health outcomes
QE-3 Breast cancer 5-year relative survival rate (%) orange stable 89.9 2012 89.8 90.2 89.6 BE cancer registry 86.2(1,2)
[BE:86.4]
QE-4 Colorectal cancer 5-year
relative survival rate (%)
green improving 67.5 2012 69.0 64.3 67.7 BE cancer registry 63.3,62.9(1,2,3)
[BE: 67.8,66.6]
QE-5 Case fatality within 30 days after admission for AMI (pop. aged 45+, admission-based, %) orange improving 7.0 2016 6.7 7.7 7.7 MZG-RHM

6.3(1)
[BE:7.0]

QE-6 Case fatality within 30 days after admission for ischaemic stroke (pop aged 45+,admission-based, %) orange stable 9.0 2016 8.6 9.9 8.9 MZG-RHM

7.1(1)
[BE:8.4]

QE-7
NEW 2019
Case fatality within 30 days after surgery for colon (c) or rectal (r) cancer

 orange improvingorange stable

3.9(c)
2.1(r)
2011-2015 3.3(c)
1.7(r)
4.9(c)
3.0(r)
5.4(c)
3.2(r)
BE cancer registry -
QE-7
NEW 2019
Case fatality within 90 days after surgery for colon (c) or rectal (r) cancer

 orange improvingorange stable

6.7(c)
4.2(r)
2011-2015 5.7(c)
3.6(r)
8.3(c)
5.3(r)
9.5(c)
4.8(r)
BE cancer registry -
QE-8 Amenable mortality, men   green improving 110.6 2013-2015 95.7 118.7 137.6 Statbel 127.8(4)
[BE:113.8]
Amenable mortality, women   orange improving 81.0 2013-2015 75.4 84.3 90.7 Statbel 81.5(4)
[BE:82.7]
QE-9 Preventable mortality, men    red improving 281.4

2013-2015

246.3 288.5 349.6 Statbel 236.6(4)
[BE:288.8]
Preventable mortality, women   red empty  152.4 2013-2015 132.7 161.3 186.7 Statbel 133.4(4)
[BE:157.2]

(1)OECD Health Statistics 2018,(2) 2009-2014 data,(3)Results for colon/rectum cancer are presented separately in OECD Health Statistic,(4)Eurostats

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

  • Among safety of care indicators: incidence of hospital-acquired MRSA infections (QS-2), incidence of post-operative sepsis after abdominal surgery (QS-4), prevalence of hospital-acquired cat II-IV pressure ulcers (QS-5);
  • Among preventive care indicators: incidence of measles (P-5);
  • Among mental healthcare indicators: deaths due to suicide (MH-1); rate of involuntary committals in psychiatric hospital wards;
  • Among mother and newborn care indicators: neonatal mortality (MN-1), Apgar score at 5 minutes (MN-2), and proportion of neonatal screening tests done within the required deadlines (sub-indicator of MN-9). 

Avoidable mortality: amenable mortality (QE-8) and preventable mortality (QE-9)

As part of a report evaluating the performance of a health system, it appears logical to examine the so-called ‘premature’ mortality rate, i.e. deaths occurring before an age when death may be expected. However, an indicator that would show this overall mortality ‘for any reason’ would not be entirely correct, as many factors outside of the health system can affect the mortality rate. It is therefore necessary to have indicators that reflect more specifically the different healthcare procedures and/or health policies.

For this reason, we have selected two complementary indicators, ‘amenable mortality’ and ‘preventable mortality’. These two concepts distinguish deaths which could have been ’avoided’ – or whose number could have been reduced – if either more effective medical procedures, or more effective public health action had been implemented.

  • Amenable mortality (mortality preventable through the healthcare system – QE-8) is referred to if, using current medical knowledge, all or part of the deaths resulting from a given cause could have been avoided through good quality of care. As an example, it must be possible to avoid deaths due to appendicitis, pneumonia, or gastric ulcer if these conditions are correctly treated (although one should, of course, also take into account the patient’s pre-existing health status). This is therefore an indicator of effectiveness of care.
  • Preventable mortality (mortality preventable through health policies – QE-9) is involved if, using what is known about health determining factors, all or part of these deaths could have been be avoided through public health measures related to known health determining factors, such as lifestyle, socio-economic status, or environmental factors. As an example, deaths due to road accidents, tobacco use or alcohol-related diseases are three types of deaths which are referred to as ‘preventable mortality’. This is therefore an indicator of the (long-term) results of promoting health.

These two types of avoidable mortality are not mutually exclusive: some causes of death can be considered as preventable both through the healthcare system and through public health measures, such as for example tuberculosis or breast cancer.

‘Potential Years of Life Lost’ (PYLL) are sub-indicators which help better highlight the deaths occurring in younger people. Their calculation consists in adding the number of deaths at each age and multiplying it by the number of years remaining to live until an arbitrarily selected age limit (here, 75 years). It should be noted that this indicator is heavily influenced by neonatal mortality, which leads many authors to calculate it starting from 1 year of age.

RESULTS
Mortality preventable through the healthcare system (QE-8)
  • Mortality preventable through the healthcare system is higher for men (sex ratio: 1.37)
  • It is higher in Wallonia and in Brussels than in Flanders, and the difference between sexes is most marked in Wallonia (1.52) compared to Brussels (1.41) and particularly Flanders (1.27). (Table 1 and Figure 1)
  • The primary causes of death preventable through the healthcare system in men are cardiac diseases, stroke, and colorectal cancer. In women, breast cancer comes first, followed by cardiac diseases and stroke. (Figure 2)
  • Overall, this mortality rate has been decreasing. (Figure 3)
  • Compared to the EU-15 European average, mortality preventable through the healthcare system is lower for men, but higher for women (Figure 4).
  • According to a report by the OECD and the European Observatory on Health Policies and Health Systems, countries which dedicate less means (per capita) to healthcare have much higher rates of mortality preventable through the healthcare system. This is primarily the case in Eastern European countries. However, comparing the situation in Belgium with countries that have a similar level of preventable mortality (IT, ES, CY), the Belgian per capita health expenditure to reach this level is relatively high. (Figure 5)
Table 1 – Age-standardized amenable mortality rate (average 2013-2015)
Source: Sciensano

2013-2015

Belgium

Flanders

Brussels

Wallonia

ratio Brusselsl/Fla

ratio Wal/Fla

Men

110,6

95,7

118,7

137,6

1,24

1,44

Women

81,0

75,4

84,3

90,7

1,12

1,20

Sex ratio 

1,37 1,27 1,41 1,52    
Figure 1 - Amenable mortality rates by sex by region
Data source: Statbel causes of deaths database
Figure 2 - Leading causes of amenable mortality by sex (2013-2015)
Data source: Statbel causes of deaths database
Figure 3 - Amenable mortality rates by sex and region (2010-2015)
Data source: Statbel causes of deaths database
Figure 4 - Amenable mortality rates by sex: international comparison
Data source: OECD health statistics 2018
Amenable mortality rates by sex: international comparison
Figure 5 - Amenable mortality rates vs health expenditure per capita: international comparison
Data source: OECD health statistics 2018
Amenable mortality rates vs health expenditure per capita: international comparison
Preventable mortality (QE-9)  
  • Preventable mortality is much higher for men than for women (sex ratio: 1.8).
  • It is higher by 40% in Wallonia compared to Flanders, and by 20% in Brussels compared to Flanders, but the sex ratio is similar in all three regions (Table 2 and Figure 6).
  • In men (before 75 years of age), the primary causes of death potentially preventable through health policies are lung cancer, cardiac diseases, and suicide. If we examine the number of potential years of life lost (PYLL), then suicide ranks first since, as it often occurs at an earlier age than lung cancer or cardiac diseases, it causes the ‘loss’ of more life years. In women (under 75 years of age), the primary causes of death potentially preventable through health policies are lung cancer, breast cancer and cardiac diseases. The greatest number of potential years of life lost (PYLL) in women is attributable to breast cancer, lung cancer and suicide. (Figure 7)
  • Mortality preventable through health policies has been slowly decreasing in men, but has remained fairly stable in women; this stagnation may be attributed to the increased lung cancer mortality in women (who smoke more than in the past). (Figure 8)
  • For preventable mortality , Belgium ranks poorly at the European level (13th out of 15), for both men and women. (Figure 9)
Tableau 2: Age-standardized preventable mortality rate (average 2013-2015)
Source: Sciensano
 

Belgium

Flanders

Brussels

Wallonia

ratio Brussels/Fla

ratio Wal/Fla

Men

281,4

246,3

288,5

349,6

1,17

1,42

Women

152,4

132,7

161,3

186,7

1,21

1,41

Sex ratio

1,8

1,9

1,8

1,9

   
Figure 6 - Preventable mortality rates by sex by region
Data source: Statbel causes of deaths database
Figure 7 - Leading causes of preventable mortality by sex (2013-2015)
Data source: Statbel causes of deaths database
Figure 8 - Preventable mortality rates by sex and region (2010-2015)
Data source: Statbel causes of deaths database
Figure 9 - Preventable mortality rates by sex: international comparison
Data source: OECD health statistics 2018
Preventable mortality rates by sex: international comparison

Link to technical datasheet and detailed results

Preventable hospitalisations (QE-1 and QE-2)

Asthma and diabetes are widespread chronic diseases. For both these diseases, there are effective treatments based on strong scientific evidence (evidence-based). These treatments can largely be delivered as first-line care (= by general practitioners). A well-performing first line of care should therefore help avoid hospital admissions for asthma or diabetes complications to a large extent.
High hospitalisation rates for these two diseases can therefore be considered as indicators of poor first-line care effectiveness. They may also be seen as a sign of poor continuity of care coordination.

RESULTS
  • For asthma, the number of preventable hospitalisations has changed from 57/100,000 population in 2000 to 30/100,000 in 2014. The figures are similar for Wallonia (28.8/100,000 in 2014) and Flanders (29.4/100,000), but are higher in Brussels (38.6/100,000) (Figure 10).
  • For diabetes, the number of preventable hospitalisations shows a more recent decrease, changing from 153/100,000 population in 2008 to 130/100,000 in 2014 (Figure 13).
  • For asthma as for diabetes complications, the overall trend is therefore showing a decrease in preventable hospitalisations over the past few years, which is a sign of improvement in the quality of first-line care. This decrease can also be observed in other European countries.
  • Belgium is close to the EU-15 average for both indicators, but this is not very informative as differences between countries can be due to other factors than quality of care.
Figure 10 - Hospital admissions for asthma rate by patient region per 100 000 population aged 15 years and older
Data source: FPS Public Health, hospital administrative discharge data
Figure 11 - Hospital admissions for asthma rate by district per 100 000 population aged 15 years and older
Data source: FPS Public Health, hospital administrative discharge data
Hospital admissions for asthma rate by district per 100 000 population aged 15 years and older
Figure 12 - Age-sex standardized hospital admissions for asthma (for population aged 15 years and older): international comparison (2000-2015)
Data source: OECD health statistics 2018
Age-sex standardized hospital admissions for asthma (for population aged 15 years and older): international comparison (2000-2015)
Figure 13 - Hospital admissions for diabetes rate by patient region per 100 000 population aged 15 years and older
Data source: FPS Public Health, hospital administrative discharge data
Figure 14 - Hospital admissions for diabetes rate by district per 100 000 population aged 15 years and older
Data source: FPS Public Health, hospital administrative discharge data
Hospital admissions for diabetes rate by district per 100 000 population aged 15 years and older
Figure 15 - Age-sex standardized hospital admissions for diabetes (for population aged 15 years and older): international comparison (2000-2015)
Data source: OECD health statistics 2018
Age-sex standardized hospital admissions for diabetes (for population aged 15 years and older): international comparison (2000-2015)

Link to technical datasheet and detailed results

Relative survival rates following breast cancer (QE-3) and colorectal cancer (QE-4)

The 5-year relative survival rate following breast or colorectal cancer are indicators of results which can provide an idea about the overall effectiveness of the health system. Firstly, these two types of cancer can be screened at an early stage and are targeted by screening programmes organised at the regional level. Secondly, treatments for these cancers are effective and scientifically well-established.

The survival rates for these two cancers may therefore reflect good progress in public health procedures (increased population awareness, better screening programmes) as well as high treatment effectiveness. We have nevertheless classified them in this section on effectiveness of care rather than in the preventive care section, as the latter already includes indicators that are related to participation rates in screening tests for certain types of cancer.

RESULTS
Relative survival rates following breast cancer (QE-3)
  • The 5-year relative survival rate after a breast cancer diagnosis was 89.9% for patients diagnosed in 2012. This figure has been stable compared to the amount of patients diagnosed in 2004.
  • This survival rate strongly depends, however, on the stage of the disease at the time of diagnosis: for an early-stage diagnosis (stage I (39% of cases for the 2004-2012 period) or stage II (35% of cases)), the 5-year survival rate is similar to that of the general population. For the group of women diagnosed at stage III (12% of cases), a marked increase in the 5-year survival rate can be observed (from 72.0% in 2004 to 77.3% in 2012). Lastly, for women diagnosed at stage IV (6% of cases), the 5-year survival rate reached 32.5%; an improvement in survival can be observed over time: from 32.2% in 2004 to 34.6% in 2012.
  • No regional differences were observed for breast cancer.
  • Belgium has a five-year breast cancer survival rate that is slightly above the average for European countries.
Figure 16 - Five-year relative survival for breast cancer, by stage and year of incidence and distribution of patients across stages (2004-2012)
Data source: Belgian Cancer Registry
Figure 17 - Five-year relative survival for breast cancer: international comparison (%, 2000-2014)
Data source: OECD health statistics 2018
Five-year relative survival for breast cancer: international comparison (%, 2000-2014)
Relative survival rate following colorectal cancer (QE-4)
  • The 5-year relative survival rate following a colorectal cancer diagnosis is 67.5% for patients whose diagnosis was issued in 2012, which represents an improvement compared to those who were diagnosed in 2004 (63.7%).
  • As with breast cancer, the survival rate following colorectal cancer is strongly influenced by the stage of the disease at the time of diagnosis, but colorectal cancer is often diagnosed at a more advanced stage (II or III), hence the difference in prognosis between these two types of cancer.
  • The 5-year relative survival rate is slightly lower in Brussels and in Wallonia, but these figures require further analysis (taking into account possible differences in patient populations) before any conclusions may be drawn about differences in quality of care.
  • Compared to the average for European countries, Belgium has remarkable five-year relative survival rates for colorectal cancer.
Figure 18 - Five-year relative survival for colorectal cancer, by stage and year of incidence and distribution of patients across stages (2004-2012)
Data source: Belgian Cancer Registry
Figure 19 - Five-year relative survival for colon cancer: international comparison (%, 2000-2014)
Data source: OECD health statistics 2018
Five-year relative survival for colon cancer: international comparison (%, 2000-2014)

Link to technical datasheet and detailed results

Mortality rate following myocardial infarction (QE-5) and following ischaemic stroke (QE-6)

The mortality rate due to cardiovascular diseases has significantly decreased since the 1970s. This reduction may in part be attributed to tobacco reduction policies, but also to faster and more effective treatments, particularly in the acute phase, with clear progress in thrombolytic treatment and the emergence of specialised units (stroke units) for stroke.

Myocardial infarction, however, remains the primary cause of cardiovascular mortality in European countries, followed by stroke. It is estimated that the number of stroke cases will increase by one-third by the year 2035 due to the ageing of the population and the higher incidence of certain risk factors.

The 30-day mortality rate following a myocardial infarction or ischaemic stroke is an indicator that reflects the overall effectiveness of all the care processes used in the emergency situation which follows such accidents: fast and accurate diagnosis, rapid patient transportation, timely and appropriate medical or interventional radiology procedure, and strict post-treatment monitoring.

RESULTS
  • Approximately 19 000 patients are hospitalised each year for acute myocardial infarction. Between 2008 and 2016, their mortality rate has slightly decreased, changing from 7.8% to 7.1%. The trend over a longer period of time shows a stronger decrease, since the mortality rate was halved between 2000 and 2015.
  • The mortality results for post-myocardial infarction are better in Flanders (6.7%) than in Wallonia and in Brussels (7.7% each), but the gap has been narrowing.
  • Approximately 21 000 patients are hospitalised each year for ischaemic stroke. Between 2000 and 2016, their mortality rate has decreased only slightly. Results are similar from one region to another (Flanders 9.1%, Wallonia 8.7%, Brussels 8.9%, see Figure 22), but the situation in Wallonia seems to have been somewhat deteriorating in recent times.
  • In international comparisons, the two Belgian indicators are fairly close to the EU-15 average. The same trend towards stagnation is observed in all European countries.
Figure 20 - Case fatality after admission for AMI by region
Data source: RHM - MZG
Figure 21 - Case fatality after admission for AMI: international comparison (%, 2000-2014)
Data source: OECD health statistics 2018
Case fatality after admission for AMI: international comparison (%, 2000-2014)
Figure 22 - Case fatality after admission for ischaemic stroke by region
Data source: RHM - MZG
Figure 23 a - Case fatality after admission for ischaemic stroke: international comparison (%, 2000-2015)
Data source: OECD health statistics 2018
Case fatality after admission for ischaemic stroke: international comparison (%, 2000-2015)
Figure 23 b - Case fatality after admission for ischaemic stroke: international comparison (%, 2014)
Data source: OECD health statistics 2018
Case fatality after admission for ischaemic stroke: international comparison (%, 2014)

Link to technical datasheet and detailed results

Mortality rate following colorectal surgery (QE-7)

In Belgium, colorectal cancer is the second most common type of cancer in men, and the third in women, with 8,468 cases declared in 2016. The first treatment for this type of cancer is surgery (possibly followed by another form of treatment). The surgical procedure consists in removing the portion of the bowel affected by the tumour and the associated cancer node network (node dissection). Depending on the location and extent of the tumour, the removed portion may be more or less large in size. This is considered as a major procedure, but it is currently well understood. 

We have selected the 30-day and 90-day mortality rates after a colorectal cancer surgical procedure as indicators of quality of care.

RESULTS
  • For the 2011-2015 period, 30 556 patients were diagnosed with colon cancer, 80% of whom underwent a surgical procedure. The average post-operative mortality rate for this period has been slightly decreasing, with 3.9% and 6.7% at 30 and 90 days, respectively.
  • The results in Flanders are overall better (3.3% at 30 days and 5.7% at 90 days) than in Wallonia (4.9% at 30 days and 8.3% at 90 days) and Brussels (5.4% at 30 days and 9.5% at 90 days).
  • For the 2011-2015 period, 12 138 patients were diagnosed with rectal cancer, 70% of whom had a surgical procedure. The average post-operative mortality rate for this period has been relatively stable, with 2.1% and 4.2% at 30 and 90 days, respectively.
  • The results in Flanders are overall better (1.7% at 30 days and 3.6% at 90 days) than in Wallonia (3.0% at 30 days and 5.3% at 90 days) and Brussels (3.2% at 30 days and 4.8% at 90 days), but patient variability should be taken into account before any conclusions are drawn about these figures.
Figure 24 - Postoperative mortality at 90 days in colon cancer by region
Data source: Belgian Cancer Registry
Figure 25 - Postoperative mortality at 90 days in rectal cancer by region
Data source: Belgian Cancer Registry

Link to technical datasheet and detailed results