Effectiveness of care is the degree to which desirable outcomes are achieved through the provision of adequate evidence-based healthcare interventions to all persons who are likely to benefit from them, but not to those who would not benefit from them.
Effectiveness can be measured from different angles and in any area of the healthcare system. In this report, we have assessed this (sub)dimension through indicators relating to various fields:
- The effectiveness of primary care is measured by the number of preventable hospital admissions for three chronic diseases, asthma (QE-1), chronic obstructive pulmonary disease (COPD) (QE-10) and (complications of) diabetes (QE-2).
- The effectiveness of both primary and specialised care is assessed through the adherence to the long and difficult treatment of pulmonary tuberculosis (QE-11).
- The effectiveness of hospital care is measured through indicators relating to treatment results, such as the 5-year survival rates for breast cancer (QE-3) or colorectal cancer (QE-4), and the 30-day mortality rate following a hospital admission for acute myocardial infarction (QE-5), an ischaemic stroke (QE-6) or a colorectal surgery (QE-7).
- A last indicator, treatable mortality (QE-8), gives us an idea of the effectiveness of curative care as a whole.
Attentive readers might remember the indicator on preventable mortality (deaths that can be prevented through health policies) was also presented in this section in the previous installment of the Belgian health system performance assessment; it has now been moved to the section on prevention (P-13). Additionally, a number of other indicators analysed in other sections of this website may also be interpreted in terms of effectiveness:
- Among safety of care indicators: the incidence of healthcare-associated MRSA infections (QS-2);
- Among preventive care indicators: the incidence of measles (P-5);
- Among mental health care indicators: the rate of involuntary committals in psychiatric hospital wards (MH-4);
- 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).
Indicators on effectiveness of care
a calculated at the Belgian level by FARES/VRGT, the Belgian rate is 82.4%
Asthma, diabetes and COPD are three very common chronic (long-term) diseases: in the EU; roughly 6% of people have asthma, 7% have diabetes and 5 to 10% of adults over 40 have COPD.
Both asthma and diabetes can often be kept under control by available treatments, most of which can be delivered in primary care. This also means an effective (and accessible!) primary care system should mostly be able to prevent complications from happening and symptoms from getting so bad that patients have to go to hospital. Therefore, high hospital admission rates for these two conditions can point to shortcomings in primary care, but also to a lack of coordination or continuity of care.
The situation is slightly different for COPD, a severe lung disease which is much more difficult to keep in check. The mere fact that a lot of patients have to stay in hospital due to worsening of their symptoms does not automatically mean that primary care has failed to fulfil its function; however, an increase in such hospital stays can be a signal that something is amiss in the routine care these people receive.
- For both asthma and diabetes, hospital admission rates have declined over recent years, both in Belgium (and in all three of its regions) and in other European countries. In both cases, there was also a stronger decrease during the COVID-19 pandemic, followed by a slight increase in 2021 for diabetes (in Belgium and in the EU).
- After increasing slowly between 2016 and 2019, COPD admission rates have seen a sharp decline in 2020 and 2021, probably due to the COVID-19 pandemic. A sharp increase between 2014 and 2016 is due at least in part to a change in the way cases are calculated.
- Belgian rates are similar to the EU-14 average for asthma hospital admissions, but higher than EU-14 and EU-27 averages for diabetes and COPD hospital admissions. However, differences between countries can be due to many factors besides quality of care. This makes trends over time more informative than hospitalisation rates as such.
Data source: RHM – MKG
Data source: RHM – MKG
Data source: RHM – MZG
Tuberculosis is a communicable disease caused by bacteria; in most cases, it affects the lungs. It is still very common in some parts of the world but, in Belgium, it is now mostly found in vulnerable population groups. Nonetheless, even in our country, it remains a major public health threat and is subject to compulsory reporting and surveillance.
Pulmonary tuberculosis can be cured, but this requires a long and difficult treatment. Patients need to take multiple medications very consistently over a period of at least 6 months, which comes with many potential side effects. Ensuring compliance to the treatment is crucial for its success, but can also be very challenging.
The percentage of patients with tuberculosis who have been successfully cured is a valuable indicator of the ability of the health system to ensure compliance to a long and difficult treatment, even in populations living in a precarious situation. The European Region of the World Health Organisation (WHO) has set the target for this indicator at 85% of successfully cured cases.
- Based on the latest available data, 82.4% of confirmed cases of pulmonary tuberculosis for 2020 had been successfully treated after one year. This is 1.3% more than in 2017 (81.1%), but 1.8% less than in 2014 (84.2%). Overall, the rate of successful treatments has remained quite stable in recent years.
- Differences between regions remain limited, but success rates are slightly lower in Brussels (77.4% in 2021, vs. 83% in Wallonia and just under 86% in Flanders). This might be explained by differences in population, as large cities often host more people with a higher risk of unsuccessful treatment.
Data source: FARES & VRGT
Breast cancer and colorectal cancer are among the most common types of cancer in Belgium. They can both be lethal when discovered at a late stage, but luckily, they can also be easily detected and treated effectively when they are diagnosed early. Belgium has set up screening programmes for both of them (see the section on preventive care), and evidence-based treatment strategies have been recommended in national guidelines.
An improvement in cancer survival can reflect effective public health interventions such as awareness campaigns and successful screening programmes, but also better treatments.
- For patients diagnosed in 2017, relative survival rates (i.e. survival rates just for cancer, not taking into account deaths from other causes) after 5 years were 92.4% for breast cancer and 71.9% for colorectal cancer.
- As survival is mainly determined by the severity of the disease at the moment of diagnosis, this information must be taken into account when assessing survival rates. Breast cancer is diagnosed at an early stage in 75% of patients, while a little over half colorectal cancer patients are diagnosed at a later stage.
- Survival rates for breast cancer have remained fairly stable between 2004 and 2017, with almost non-existent differences between regions.
- Survival rates for colorectal cancer have increased between 2004 and 2017. They are slightly lower in Brussels and Wallonia than in Flanders. This might be due at least in part to a better uptake of screening or to differences in patient populations.
- International comparisons should be interpreted with caution due to several issues relating to data and methodology. Nonetheless, Belgian survival rates for breast cancer are in line with the EU-14 average. For colon and rectum cancer (measured separately in international data), Belgian survival rates are above both EU-27 and EU-14 averages.
Data source: BCR & IMA – AIM
Data source: BCR & IMA – AIM
Deaths within 30 days after admission for acute myocardial infarction (QE-5) or ischaemic stroke (QE-6)
Mortality due to cardiovascular diseases has significantly decreased over the last 50 years, thanks to preventive measures (like smoking reduction policies) and to faster and more effective treatments. Even so, this group of diseases remains one of the leading causes of death across Europe, which warrants further efforts on both fronts.
In Belgium, approximately 18 000 patients are admitted to hospital every year due to an acute myocardial infarction or AMI (“heart attack”). AMI is currently the main cause of cardiovascular mortality, followed by ischaemic stroke (caused by the blood supply of the brain being suddenly cut off). Ischaemic stroke causes some 17 000 patients to be admitted to hospital in Belgium every year, and this number is expected to increase by one-third by 2035 due to the population getting older and to some risk factors becoming more frequent.
The 30-day mortality rate (i.e. the percentage of people who die within 30 days) after a heart attack or ischaemic stroke reflects the overall effectiveness of the care processes following those medical emergencies : fast and accurate diagnosis, rapid patient transportation, timely and appropriate medical or interventional radiology procedure, and strict post-treatment monitoring.
- In Belgium, the 30-day mortality rate after acute myocardial infraction has decreased from 7.5% in 2010 to 5.8% in 2021, following the trend of other European countries. Mortality is lower in Flanders than in Wallonia and Brussels.
- The 30-day mortality rate after ischaemic stroke decreased slightly in Belgium between 2010 and 2021 (falling from 9.6% to 8.6%), like in other European countries. Again, Flanders has a lower mortality rate than the two other regions.
Data source: RHM – MZG
Data source: RHM – MZG
Colorectal cancer is currently the third most frequently occurring cancer for both men and women in Belgium, with 7881 cases reported in 2021. Treatment generally involves surgery. The mortality rate within 30 days and 90 days following surgery is an indicator of the quality of care delivered to patients with colorectal cancer.
- Between 2011 and 2020, the overall mortality rate 30 days after surgery was 3.7% for colon cancer and 2.0% for rectal cancer. After 90 days, it was 6.4% for colon cancer and 4.0% for rectal cancer. Over the studied period, figures have improved for colon cancer and remained stable (with some ups and downs) for rectal cancer.
- Postoperative mortality rates are similar in Brussels and Wallonia, and lower in Flanders. However, this could be due to differences in patient populations rather than to differences in quality of care and requires further analysis.
The term “treatable mortality” refers to the mortality that can be prevented through the healthcare system –the premature (untimely) deaths that could have been avoided through timely and adequate treatment or through preventive measures aiming to limit the negative consequences of an existing disease, known as “secondary prevention”. This indicator gives us an idea of how effective our health care system is at curing diseases or at keeping them under control when an effective treatment exists.
To assess this, we have examined how many people (per 100 000 population) have died before the age of 75 from an issue that could have been treated (according to a list of treatable death causes defined by Eurostat/OECD).
A closely related indicator on preventable mortality (P-13), i.e. premature mortality that could have been avoided by acting on factors that are known to influence the risk of developing health issues or by taking preventive measures against infectious diseases, can be found in the section on prevention. It is worth noting there can be a certain degree of overlap between those two types of mortality, as some health issues can be effectively prevented as well as effectively treated and the premature deaths they cause can reflect a failure on both counts. However, those deaths will only be counted once, either as “preventable” or “treatable”; if a given cause is considered to fall under both categories, half of the associated deaths will be attributed to each.
- Overall, treatable mortality rates have been gradually decreasing between 2010 and 2019 in both sexes and in all Belgian regions. However, clear regional differences remain, with higher rates in Wallonia and Brussels and substantially lower figures in Flanders.
- In 2019 and 2020, treatable mortality was somewhat higher in men in Brussels and Wallonia, but not in Flanders. As a result, regional differences in treatable mortality were also more striking in men.
- In 2020, leading causes of treatable deaths were ischemic heart diseases, colorectal cancer and cerebrovascular diseases in men, and breast cancer, colorectal cancer and cerebrovascular diseases in women. In 2019, the third cause of treatable deaths was unspecified pneumonia in men and ischaemic heart diseases in women.
- In 2020, the treatable mortality rate in Belgium was substantially lower than the EU-14 average in men, and slightly lower than the EU average in women. It is worth noting, however, that treatable mortality is considerably lower in women in almost all countries.