DE PERFORMANTIE VAN HET BELGISCHE GEZONDHEIDSSYSTEEM RAPPORT 2012

KCE REPORT 196 A

DE PERFORMANTIE VAN HET BELGISCHE GEZONDHEIDSSYSTEEM RAPPORT 2012

2013

www.kce.fgov.be

Het Federaal Kenniscentrum voor de Gezondheidszorg Het Federaal Kenniscentrum voor de Gezondheidszorg is een parastatale, opgericht door de programmawet (1) van 24 december 2002 (artikelen 259 tot 281) die onder de bevoegdheid valt van de Minister van Volksgezondheid en Sociale Zaken. Het Centrum is belast met het realiseren van beleidsondersteunende studies binnen de sector van de gezondheidszorg en de ziekteverzekering.

Raad van Bestuur Voorzitter Leidend ambtenaar RIZIV (vice-voorzitter) Voorzitter FOD Volksgezondheid (vice-voorzitter) Voorzitter FOD Sociale Zekerheid (vice-voorzitter) Administrateur-generaal FAGG Vertegenwoordigers Minister van Volksgezondheid Vertegenwoordigers Minister van Sociale Zaken Vertegenwoordigers Ministerraad Intermutualistisch Agentschap

Beroepsverenigingen van de artsen Beroepsverenigingen van de verpleegkundigen Ziekenhuisfederaties Sociale partners Kamer van Volksvertegenwoordigers

Effectieve Leden

Plaatsvervangende Leden

Pierre Gillet Jo De Cock Dirk Cuypers Frank Van Massenhove

Benoît Collin Chris Decoster Jan Bertels

Xavier De Cuyper Bernard Lange Marco Schetgen Olivier de Stexhe Ri De Ridder Jean-Noël Godin Daniel Devos Michiel Callens Patrick Verertbruggen Xavier Brenez Marc Moens Jean-Pierre Baeyens Michel Foulon Myriam Hubinon Johan Pauwels Jean-Claude Praet Rita Thys Paul Palsterman Lieve Wierinck

Greet Musch François Perl Annick Poncé Karel Vermeyen Lambert Stamatakis Frédéric Lernoux Bart Ooghe Frank De Smet Yolande Husden Geert Messiaen Roland Lemye Rita Cuypers Ludo Meyers Olivier Thonon Katrien Kesteloot Pierre Smiets Leo Neels Celien Van Moerkerke

Controle

Regeringscommissaris

Yves Roger

Directie

Algemeen Directeur

Raf Mertens

Programmadirectie

Christian Léonard Kristel De Gauquier

Contact

Federaal Kenniscentrum voor de Gezondheidszorg (KCE) Doorbuilding (10e verdieping) Kruidtuinlaan 55 B-1000 Brussel Belgium T +32 [0]2 287 33 88 F +32 [0]2 287 33 85 [email protected] http://www.kce.fgov.be

KCE REPORT 196 A HEALTH SERVICES RESEARCH

DE PERFORMANTIE VAN HET BELGISCHE GEZONDHEIDSSYSTEEM RAPPORT 2012

FRANCE VRIJENS, FRANÇOISE RENARD, PASCALE JONCKHEER, KOEN VAN DEN HEEDE, ANJA DESOMER, CARINE VAN DE VOORDE, DENISE WALCKIERS, CÉCILE DUBOIS, CÉCILE CAMBERLIN, JOAN VLAYEN, HERMAN VAN OYEN, CHRISTIAN LÉONARD, PASCAL MEEUS

2013

www.kce.fgov.be

COLOFON Titel:

De performantie van het Belgische gezondheidssysteem. Rapport 2012

Auteurs:

France Vrijens (KCE), Françoise Renard (ISP – WIV), Pascale Jonckheer (KCE), Koen Van den Heede (KCE), Anja Desomer (KCE), Carine Van de Voorde (KCE), Denise Walckiers (ISP – WIV), Cécile Dubois (KCE), Cécile Camberlin (KCE), Joan Vlayen (KCE), Herman Van Oyen (WIV - ISP), Christian Léonard (KCE), Pascal Meeus (INAMI – RIZIV) Health Promotion Group : Luc Berghmans (Observatoire de la santé du Hainaut), Lien Braeckevelt (WVG Vlaanderen), Christian De Bock (CM), Léa Maes (UGent), Myriam De Spiegelaere (ULB – Observatoire de la santé Bruxelles), Stephan Van Den Broucke (UCL), Chantal Vandoorne (ULg), Alexander Witpas (WVG Vlaanderen) Mental Healthcare Group: Joël Boydens (CM), Robert Cools (CGG - De Pont), Raf De Rycke (Broeders van Liefde), Pol Gerits (FOD Volksgezondheid – SPF Santé Publique), Jean-Pierre Gorissen (FOD Volksgezondheid – SPF Santé Publique), Bernard Jacob (SPF Santé publique – FOD Volksgezondheid), Gert Peeters (UZ Leuven), Jean-Paul Roussaux (Cliniques Universitaires St-Luc) Continuity of Care and Patient Centeredness Group: Corinne Boüüaert (Maison Médicale Bautista Van Schowen), Xavier de Béthune (CM), Veerle Foulon (KU Leuven), Mirco Petrovic (UZ Gent), Luc Seuntjens (het Artsenhuis), Anne Spinewine (UCL de Mont-Godinne), Johan Van der Heyden (WIV - ISP), Annelies Van Linden (Domus Medica), Johan Wens (UA) Long term care Group: Daniel Crabbe (RIZIV – INAMI), Jan Delepeleire (KU Leuven), Johan Flaming (UZ Leuven), Margareta Lambert (UZ Brussel), Jean Macq (UCL), Alex Peltier (MC), Luc Van Gorp (Katholieke Hogeschool Limburg), Isabelle Vanderbrempt (SPF Santé publique – FOD Volksgezondheid ) End of Life Group: Joachim Cohen (VUB), Marianne Desmedt (UCL), Rita Goetschalckx (RIZIV – INAMI), Johan Menten (UZ Leuven), Kathleen Kleemans (VUB), Birgit Gielen (CM) Greet Haelterman (FOD Volksgezondheid - SPF Santé publique), Willem Alvoet (FOD Volksgezondheid - SPF Santé publique), Marie-Noëlle Verhaegen (FOD Volksgezondheid - SPF Santé publique ), Hans Verrept (FOD Volksgezondheid - SPF Santé publique ), Isabelle Coune (SPF Santé publique - FOD Volksgezondheid), Luc Nicolas (SPF Santé publique – FOD Volksgezondheid), Dirk Moens (FOD Sociale Zekerheid – SPF Sécurité Sociale), Elke Van Hoof (Kankercentrum – Centre Cancer), Elisabeth Van Eycken (Stichting Kankerregister – Fondation Registre du Cancer), Xavier Ledent (INAMI – RIZIV), Pierre Bonte (INAMI – RIZIV), Olaf Moens (VIGeZ), Sadja Steenhuizen (VIGeZ), Stefaan Demarest (WIV – ISP), Béatrice Jans (ISP – WIV), Natacha Viseur (ISP – WIV), Viviane Van Casteren (WIV – ISP), Nathalie Bossuyt (WIV – ISP), Xavier de Béthune (MC), Johan Hellings (ICURO) Ann-Lise Guisset (WHO), Irene Papanicolas (London School of Economics and Political Science), Niek Klazinga (Academisch Medisch Centrum – Universiteit van Amsterdam)

Externe experten:

Acknowledgements:

Externe Validatoren:

Stakeholders:

Belangenconflict:

Layout: Disclaimer:

De volgende administratieve overheden en organisaties zijn gedurende het project geconsulteerd tijdens interadministratieve vergaderingen: op federaal niveau (FOD Volksgezondheid, FOD Sociale Zaken, RIZIV, WIV) en op niveau van de deelstaten: de Vlaamse Gemeenschap en het Vlaamse Gewest (Vlaams Agentschap Zorg en Gezondheid), de Federatie Wallonië-Brussel (Direction générale de la Santé), de Duitstalige Gemeenschap (DGOV Ministerium der Deutschsprachigen Gemeinschaft), het Waalse Gewest (Direction générale opérationelle des Pouvoirs locaux, de l’Action sociale et de la Santé et observatoire wallon de la santé), het Brussels Hoofdstedelijk Gewest (Observatorium voor de Gezondheid) Elke andere directe of indirecte relatie met een producent, verdeler of zorginstelling die zou kunnen opgevat worden als een belangenconflict: Gert Peeters (UZ Leuven – UPC) (Administratief manager van het UPC - UZ Leuven), Joël Boydens (MC; Groep Emmaüs vzw – lid bestuurscomité) Ine Verhulst, Sophie Vaes • De externe experten werden geraadpleegd over een (preliminaire) versie van het wetenschappelijke rapport. Hun opmerkingen werden tijdens vergaderingen besproken. Zij zijn geen coauteur van het wetenschappelijke rapport en gingen niet noodzakelijk akkoord met de inhoud ervan. • Vervolgens werd een (finale) versie aan de validatoren voorgelegd. De validatie van het rapport volgt uit een consensus of een meerderheidsstem tussen de validatoren. Zij zijn geen coauteur van het wetenschappelijke rapport en gingen niet noodzakelijk alle drie akkoord met de inhoud ervan. • Tot slot werd dit rapport unaniem goedgekeurd door de Raad van Bestuur. • Alleen het KCE is verantwoordelijk voor de eventuele resterende vergissingen of onvolledigheden alsook voor de aanbevelingen aan de overheid.

Publicatiedatum: Domein: MeSH: NLM classificatie: Taal: Formaat: Wettelijk depot: Copyright:

25 januari 2013 Health Services Research (HSR) Delivery of Health Care; Health Promotion; Health Services Accessibility; Quality of Health Care; Efficiency, Organizational; Healthcare Disparities; Social Justice; Benchmarking; Belgium W84 Nederlands, Engels Adobe® PDF™ (A4) D/2012/10.273/110 De KCE-rapporten worden gepubliceerd onder de Licentie Creative Commons « by/nc/nd » http://kce.fgov.be/nl/content/de-copyrights-van-de-kce-rapporten

Hoe refereren naar dit document?

Vrijens F, Renard F, Jonckheer P, Van den Heede K, Desomer A, Van de Voorde C, Walckiers D, Dubois C, Camberlin C, Vlayen J, Van Oyen H, Léonard C, Meeus P. De performantie van het Belgische gezondheidssysteem Rapport 2012. Health Services Research (HSR). Brussel: Federaal Kenniscentrum voor de Gezondheidszorg (KCE). 2012. KCE Report 196A. D/2012/10.273/110. Dit document is beschikbaar op de website van het Federaal Kenniscentrum voor de Gezondheidszorg.

KCE Report 196A

VOORWOORD

De performantie van het gezondheidssysteem

i

Ons tijdvak wordt vaak enigszins pejoratief geassocieerd met een performantie-cultus. Maar binnen het domein van de gezondheid en de gezondheidszorg staat het onderzoek naar de performantie wel hoog aangeschreven, en biedt het een soort van geruststelling. Wie zou er immers klagen over een kwaliteitsvol, doeltreffend, efficiënt, toegankelijk en billijk zorgsysteem? Wat zou men kunnen verwijten aan gezondheidspromotie die actief de ongelijkheden in gezondheid doeltreffend aanpakt en bijdraagt aan een gestage verbetering van dat gezondheidsniveau? Voorliggend rapport biedt u een snapshot van deze performantie aan de hand van 74 indicatoren, die op een nauwgezette manier werden samengebracht door de onderzoekers van het KCE, van het Wetenschappelijk Instituut Volksgezondheid en van het RIZIV. Hun werk werd ondersteund en verrijkt door de inbreng van tientallen experten uit de academische wereld en het middenveld. De leden van de administratie en de politieke overheid hebben actief alle productiestappen van dit rapport gevolgd. Wij willen ieder van hen hartelijk danken voor deze betrokkenheid die de geloofwaardigheid van het resultaat ten goede komt en de toe-eigening door alle betrokken partijen zal vergemakkelijken. We laten u de sterke punten van ons systeem ontdekken, zoals de perceptie van de eigen gezondheidstoestand door onze medeburgers of de vaccinatiegraad bij kinderen. Toch mag men de inspanningen waar men nu tevreden over is niet laten verslappen. Ook mag dit de aandacht niet afleiden van domeinen waarin nog ruimte voor verbetering is, zoals de opsporing van bepaalde kankers of het uitstellen van gezondheidszorgen om financiële redenen. Men moet ook waakzaam blijven voor de vele ongelijkheden tussen socio-economische groepen of regio’s. De rigoureuze manier waarop elke indicator is ontwikkeld, ontslaat de lezer niet van enige voorzichtigheid bij de interpretatie. De meest recent beschikbare data zijn soms meerdere jaren oud, zeker de data op basis van enquêtes. Men moet er ook rekening mee houden dat de effecten van een interventie op het vlak van de volksgezondheid vaak pas na geruime tijd zichtbaar worden in de cijfers. Denken we maar aan de maatregelen van de administratie en politieke overheid op het vlak van het medische zorgaanbod, de gelijkheid en billijkheid van de zorg. Om dus te kunnen besluiten dat we op koers zitten op de weg naar een optimale performantie, zullen we deze evaluatie regelmatig moeten herhalen. Zeer waarschijnlijk zullen in volgende versies nieuwe data geregistreerd moeten worden en zullen bepaalde indicatoren moeten worden aangepast of vervangen. Op vlak van gezondheid en gezondheidszorg, zoals in de andere domeinen van het menselijk streven, is weinig of niets eens en voor altijd verworven. Efficiëntie en billijkheid zullen dus altijd werkpunten blijven.

Raf MERTENS Algemeen Directeur

ii

SAMENVATTING


KCE Reports 196A

INLEIDING Health system performance assessment (HSPA - Beoordeling van de performantie van het gezondheidssysteem) is een landgebonden proces om het gezondheidssysteem holistisch te beoordelen, een "check-up" te doen van het hele gezondheidssysteem. Deze beoordeling maakt gebruik van statistische indicatoren om het systeem te monitoren en koppelt gezondheidsuitkomstmaten aan de strategieën en functies van het gezondheidssysteem. Elke HSPA wordt ontwikkeld volgens de lijnen van een strategisch kader dat specifiek is voor het land. HSPA wordt ook specifiek genoemd in het Handvest van Tallinn dat werd ondertekend door alle landen uit de Europese regio van de Wereldgezondheidsorganisatie (WGO). De eerste Belgische beoordeling van de performantie van het gezondheidssysteem werd gepubliceerd in juni 2010. Het HSPA-rapport van 2012 tracht de toegankelijkheid, kwaliteit, efficiëntie, duurzaamheid en billijkheid van het Belgische gezondheidssysteem te monitoren, om zodoende te dienen als een bron van informatie voor beleidsmakers die bevoegd zijn voor de gezondheid en gezondheidspromotie in België.

KCE Report 196A


iii

DOELSTELLINGEN

METHODES

Strategische doelstellingen van het lopende Performantie beoordelingsproces

In de geïndexeerde literatuur en grijze literatuur werd uitgebreid gezocht naar nieuwe indicatoren in de hierboven vermelde domeinen/dimensies. Selectie van de meest relevante indicatoren gebeurde in samenwerking met externe experts van elk domein. In totaal werden er 74 indicatoren geselecteerd en gemeten. Voor elke indicator werden analyses gemaakt op nationaal niveau, op regionaal niveau (wanneer er gegevens beschikbaar waren), per sociodemografische status (indien van toepassing). De resultaten werden ook gebenchmarkt aan 15 EU-landen, en tot slot werd er een algemene evaluatie gemaakt. Bron van de gegevens Er werd zoveel mogelijk gebruik gemaakt van routinematig beschikbare gegevens (bijv. administratieve databanken, nationale registers of herhaalde enquêtes): de administratieve ontslaggegevens van ziekenhuizen (RHM - MZG), de EPS (échantillon permanent - permanente steekproef), databases van het RIZIV - INAMI (doc N, Pharmanet), het Belgische Kankerregister, het register van ziekenhuisinfecties, de Health Interview Survey (HIS) en vaccinatie-enquêtes.

1. 2.

3.

De gezondheidsautoriteiten informeren over de performantie van het gezondheidssysteem en een draagvlak bieden voor beleidsplanning; Een transparant en controleerbaar beeld schetsen van de performantie van het Belgische gezondheidssysteem, in overeenstemming met het engagement in het Handvest van Tallinn; Op lange termijn de performantie van het gezondheidssysteem in de loop der tijd volgen.

Algemene doelstelling van het rapport van 2012 Een reeks indicatoren voorstellen en meten voor alle domeinen en gekozen dimensies van het Belgische gezondheidssysteem, waarbij het aantal indicatoren beheersbaar blijft (in dit rapport zijn dat er 74).

Operationele doelstellingen van het rapport van 2012 1.

2.

3. 4.

De kernset van 55 indicatoren van het vorige rapport herzien, met een speciale focus op de 11 indicatoren waarvoor er geen gegevens waren in 2010; De kernset verrijken met indicatoren uit de volgende domeinen: huisartsgeneeskunde, geestelijke gezondheidszorg, zorg op lange termijn, palliatieve zorg, gezondheidspromotie; indicatoren toevoegen inzake patiëntgerichtheid en zorgcontinuïteit (twee subdimensies inzake kwaliteit); en tot slot indicatoren voorstellen inzake billijkheid in het gezondheidssysteem; De geselecteerde indicatoren waar mogelijk meten, of hiaten in de beschikbaarheid van gegevens identificeren; De resultaten interpreteren met het oog op een globale evaluatie van de performantie van het Belgische gezondheidssysteem door middel van verschillende criteria, waaronder een internationale benchmarking, indien nodig.

iv


RESULTATEN Gezondheidstoestand (4 indicatoren) De vier indicatoren betreffende de gezondheidstoestand laten een positieve evolutie in de tijd zien. Het resultaat van de levensverwachting is iets lager in vergelijking met het EU-15 gemiddelde, terwijl de gezonde levensverwachting (dit zijn de resterende geleefde jaren vanaf een bepaalde leeftijd zonder activiteitbeperking op lange termijn) en de zuigelingensterfte op een middelmatige plaats staan. Het percentage van mensen die hun gezondheid als (minstens) goed beschouwen, is hoger dan het EU-15 gemiddelde.

Toegankelijkheid van de zorg (13 indicatoren) Met betrekking tot de financiële toegankelijkheid, ondanks een universele verzekeringsdekking en het bestaan van sociale zorgnetten (maximumfactuur, Omnio, Bijzonder Solidariteitsfonds), is er sprake van enige bezorgdheid (hoge mate van persoonlijke uitgaven van de patiënt, en in zekere mate uitgestelde contacten met de gezondheidsdiensten om financiële redenen). De toegankelijkheid van preventieve maatregelen toont uiteenlopende resultaten. De cijfers voor vaccinatiegraad tegen griep bij ouderen en kankerscreening (met sociale en enkele regionale verschillen) zijn middelmatig, terwijl de vaccinatiegraad bij kinderen goed is. Een ander aspect van de toegankelijkheid is de beschikbaarheid van het aanbod aan gezondheidszorgpersoneel met betrekking tot de behoeften. Er werden aanzienlijke inspanningen geleverd om gegevens over de aanbodzijde beschikbaar te maken, maar er is nog te weinig informatie over de behoeften aan personeel.

KCE Reports 196A

Zorgkwaliteit: Doeltreffendheid (7 indicatoren), Aangepastheid (8), Veiligheid (6), Continuïteit (7), Patiëntgerichtheid (3) De kwaliteit werd onderverdeeld in 5 subdimensies. De doeltreffendheid liet een gemengd beeld zien. Ze scoorde erg goed qua overlevingskansen bij kanker, maar er is wel bezorgdheid op het vlak van de geestelijke gezondheid, want België telt het op een na hoogste aantal zelfdodingen in Europa (met zeer grote regionale verschillen), en kent een toenemend niveau van onvrijwillige ziekenhuisopnames. Er zijn meer indicatoren en gegevens nodig om de doeltreffendheid in de geestelijke gezondheidszorg te beschrijven. De aangepastheid van de zorg is vrij teleurstellend, met hoge en stijgende cijfers voor borstkankerscreening buiten de doelgroepen, een matige opvolging van de richtlijnen (antibiotica, diabetespatiënten), een stijgend aantal keizersneden met grote variabiliteit tussen de ziekenhuizen. De veiligheid van de zorg toont bemoedigende resultaten, met afnemende trends wat betreft de blootstelling aan medische straling, de ziekenhuisbacterie MRSA, ziekenhuismortaliteit na een heupfractuur, en stabiele incidentie van postoperatieve sepsis en het voorschrijven van anticholinerge antidepressiva aan bejaarden. De incidentie van doorligwonden neemt echter toe. De continuïteit en coördinatie van de zorg geeft gemengde resultaten, met een goede relationele continuïteit met dezelfde arts, een gemiddeld en toenemend cijfer voor multidisciplinaire raadpleging voor kankergevallen, maar een lage dekking van het globaal medisch dossier en een hoge heropname in psychiatrische ziekenhuizen. De patiëntgerichtheid kon slechts deels worden beoordeeld. Er werd een hoge tevredenheidsgraad over de gezondheidszorg vastgesteld, maar ook een toenemende trend om thuis te sterven. Er moeten meer gegevens worden verzameld over dit onderwerp.

KCE Report 196A


v

Efficiëntie van het gezondheidssysteem (3 indicatoren)

Gezondheidspromotie (15 indicatoren)

De efficiëntie van het gezondheidssysteem toont gemiddelde tot goede resultaten met een stijging in het voorschrijven van goedkope medicijnen, het gebruik van het daghospitaal voor chirurgische ingrepen en een daling van de verblijfsduur voor een normale bevalling. De positieve boodschap moet echter worden gematigd door de ongeschiktheid en dus verspilling van middelen, zoals blijkt uit een aantal indicatoren, waaronder de bovengenoemde mammogrammen buiten de doelgroep.

Tot slot werd de gezondheidspromotie vooral benaderd aan de hand van conventionele gezondheids- en levensstijlindicatoren, aangevuld met een aantal indicatoren met betrekking tot het gezondheidsbeleid, gezonde leefomgeving en individuele vaardigheden. Door de zeer beperkte beschikbaarheid van geschikte indicatoren en gegevens buiten de conventionele gezondheid/levensstijlindicatoren, kon er slechts een fragmentarisch overzicht worden gegeven. De meeste gezondheid/levensstijlindicatoren wijzen op een middelmatig nationaal cijfer in vergelijking met de EU-15 landen, maar er werden belangrijke regionale/sociale verschillen waargenomen. We wijzen op het probleem van obesitas/overgewicht dat een vrij hoge en stijgende trend met grote verschillen laat zien. De tabaksconsumptie daalt, maar met grote sociale en regionale verschillen. De consumptie van groenten en fruit is veel lager dan de dagelijkse behoeften, maar gaat erop vooruit. Het gebrek aan sociale steun vertoont ook belangrijke sociale en regionale verschillen, en baart vooral zorgen bij ouderen. België staat op een middelmatig niveau op de internationale Tobacco Control Scale Policies. Sommige complexe indices hebben tot doel de kracht van het lokale beleid inzake gezondheidspromotie in verschillende settings te meten (scholen, gemeenten, bedrijven), maar ze zijn alleen beschikbaar in Vlaanderen en zijn moeilijk te interpreteren zonder een grondige analyse.

Duurzaamheid van het gezondheidssysteem (6 indicatoren) De duurzaamheid van het gezondheidssysteem laat enkele resultaten zien die vragen doen rijzen met betrekking tot het gebrek aan vervanging van de huidige cohort van huisartsen. Er zijn gegevens nodig over de behoefte aan verpleegkundigen, gekoppeld aan gegevens over de evolutie van het aanbod van verpleegkundigen.

Billijkheid (analyses van alle indicatoren per socioeconomische status en 2 contextuele indicatoren) De billijkheidsdimensie werd benaderd op twee complementaire manieren. Ten eerste werden ongelijkheden in gezondheidstoestand, levensstijlfactoren en het gebruik van gezondheidszorg geanalyseerd per socio-economische status. Er werden sterke ongelijkheden waargenomen in de gezondheids- en levensstijlindicatoren. Ook werden er ongelijkheden waargenomen voor kankerscreening en voor de opvolging van chronische patiënten. De meeste ziekenhuisgebaseerde indicatoren konden echter niet worden onderzocht per sociale status in dit werk, en de conclusies zijn nog grotendeels onvolledig qua ongelijkheden in de zorgverlening en kwaliteit. De billijkheid werd ook benaderd aan de hand van twee indicatoren die dit probleem op macroniveau benadrukken. De progressiviteit van de financiering van de gezondheidszorg neemt af, wat een evolutie is naar minder billijkheid. De Gini-index komt overeen met het niveau van ongelijkheid in de globale verdeling van de inkomens in België, en blijkt samen te hangen met een lagere globale gezondheidsstatus. Hij is relatief laag, maar neemt alsmaar toe, wat wijst op een minder gelijke verdeling van de inkomsten in België.

vi


DISCUSSIE EN CONCLUSIE Aan de hand van 74 indicatoren geeft dit rapport een breed beeld van de performantie van het Belgische gezondheidssysteem. Het wijst in bepaalde richtingen voor beleidsmaatregelen en doet vragen rijzen voor de verdere opvolging of voor verder onderzoek. Voortbouwend op de eerste HSPA, die de haalbaarheid beoordeelde om een tool op te stellen voor het meten van de performantie van het Belgische gezondheidssysteem, vormt dit rapport een aanzienlijke verbetering van de vorige tool: het is meer omvattend en zorgt voor een update van de voormalige reeks indicatoren met meer relevante indicatoren. Bovendien maakt het in sommige gevallen de meting van de evolutie mogelijk. Voormalige hiaten in de basisgegevens werden ook opgevuld, zoals de zuigelingensterfte of cijfers over patiënten die kanker overleven. Niet alle domeinen van de zorg of specifieke patiëntgroepen kwamen echter in gelijke mate aan bod. De indicatoren geven waarschuwingssignalen met betrekking tot de status van het gezondheidssysteem op het vlak van toegankelijkheid, kwaliteit, efficiëntie, duurzaamheid en billijkheid. In sommige gevallen zijn de beleidsmakers al op de hoogte van de problemen, en gaven ze opdracht voor aanvullende analyses om te weten welke actie ondernomen moet worden. In andere gevallen zijn deze signalen nieuw voor de beleidsmakers, en moeten ze dus grondiger geanalyseerd worden. In ieder geval moet de uitgebreide en gestructureerde manier waarop indicatoren worden voorgesteld ervoor zorgen dat er gemakkelijker prioriteiten gesteld kunnen worden betreffende de nodige acties en/of verdere studies. België is niet het eerste land dat deze uitdaging aangaat. Met de ondertekening in 2008 van het Verdrag van Tallinn inzake gezondheidssystemen, hebben de lidstaten zich er formeel toe verbonden om de performantie van het gezondheidssysteem te monitoren en te evalueren. Verschillende buurlanden met jaren ervaring in het meten van de performantie van gezondheidssystemen dienden als voorbeeld voor dit rapport, zoals het Nederlandse Performantierapport. Een van de tekortkomingen die het nut van de performantiemeting belemmert (en die ook werd vastgesteld in eerdere Nederlandse performantierapporten), is de lage beschikbaarheid van up-to-date gegevens. Het regelmatig

KCE Reports 196A

actualiseren van administratieve gegevens en het dynamisch publiceren van resultaten op een website is één van de pistes die moet worden onderzocht. Met de Europese Richtlijn betreffende de toepassing van de rechten van patiënten bij grensoverschrijdende zorg wordt dit engagement een gemeenschappelijke bezorgdheid onder de lidstatena. Vanaf de implementatie van de Richtlijn in de nationale wetgeving in oktober 2013 zullen de lidstaten ervoor moeten zorgen dat patiënten uit een andere lidstaat relevante informatie kunnen krijgen over de veiligheids- en kwaliteitsnormen om een weloverwogen beslissing voor grensoverschrijdende gezondheidszorg te maken. In deze context legt dit rapport niet alleen de basis van een toekomstige systematische beoordeling van de performantie, maar kan het ook worden beschouwd als een eerste stap op weg naar de verantwoordelijkheid van België om veilige, kwaliteitsvolle, toegankelijke en efficiënte gezondheidszorg voor zowel Belgische als buitenlandse patiënten te verzekeren.

a

Richtlijn 2011/24/EU van het Europees Parlement en de Raad van 9 maart 2011 betreffende de toepassing van de rechten van patiënten bij grensoverschrijdende gezondheidszorg, Publicatieblad L 88/45, 4 april 2011

KCE Report 196A

AANBEVELINGENb

b


vii

Algemene aanbevelingen voor de politieke verantwoordelijken Het concept performantie hangt impliciet samen met het bereiken van doelstellingen. Terwijl het huidige rapport vooral een ‘vaststelling’ van de situatie is, moet het grote belang ervan worden gezocht in het uiteindelijke doel, nl. ‘een verbetering’ van de situatie. De politieke verantwoordelijken zouden derhalve meetbare doelstellingen moeten vooropstellen en termijnen vastleggen om die te realiseren, rekening houdend met de hierna volgende aanbevelingen. Positieve bevindingen (te behouden) en negatieve bevindingen (aandachtspunten): Over het algemeen wordt aanbevolen dat de betrokken instellingen en instanties zich baseren op de hierna volgende bevindingen, zodat ze op dezelfde koers kunnen doorgaan in de domeinen met positieve bevindingen, ofwel van koers kunnen veranderen om de situatie te verbeteren in de domeinen waar aandachtspunten werden gesignaleerd. Positieve bevindingen (te behouden): •

Gezondheidstoestand: de 'gerapporteerde' of 'waargenomen' gezondheidstoestand, gemeten via de gezondheidsenquêtes (Wetenschappelijk Instituut Volksgezondheid) is beter dan het Europese gemiddelde.

•

Dekking van de preventieve maatregelen: de vaccinatiegraad bij kinderen is beter dan het Europese gemiddelde.

•

Zorgkwaliteit: o Effectiviteit van de curatieve zorg: zeer goede resultaten voor de overleving op 5 jaar na borstkanker of na colorectale kanker in vergelijking met de andere Europese landen. o De indicatoren tonen aan dat de Belgen een zeer goede en continue relatie met de huisarts onderhouden en dat ze erg tevreden zijn (meer dan 90 %) over hun contacten met de gezondheidszorg.

•

Efficiëntie: een verbetering van de efficiëntie kan worden afgeleid uit het stijgend percentage opnames in dagziekenhuis en een toenemend gebruik van goedkopere geneesmiddelen.

Alleen het KCE is verantwoordelijk voor de aanbevelingen aan de overheid.

viii


KCE Reports 196A

Aandachtspunten voor het oriënteren van het toekomstige gezondheidszorgbeleid: •

Gezondheidstoestand: o De zeer hoge percentages van zelfdoding in vergelijking met het Europese gemiddelde vragen om opheldering. o In vergelijking met het Europese gemiddelde stelt men vast dat het percentage personen met overgewicht of obesitas stijgt en dat het nemen van lichaamsbeweging eerder laag scoort.

•

Dekking van de preventieve maatregelen: De dekkingsgraad in de doelgroepen van de opsporing van borstkanker en baarmoederhalskanker is laag in vergelijking met het Europese gemiddelde. De dekking van de georganiseerde opsporing van borstkanker is onvoldoende om efficiënt te zijn. Een ander aandachtspunt is de hoge opsporingsgraad van borstkanker buiten de doelgroepen van de georganiseerde screening en deze neemt toe voor leeftijdscategorieën van 40-49 jaar en 70-79 jaar, hetgeen contraproductief is in termen van volksgezondheid en het gebruik van de collectieve middelen.

•

Sociale billijkheid/ongelijkheid: Vergeleken met personen uit een hogere klasse hebben personen met een socioeconomisch lagere status (gemeten op basis van het opleidingsniveau of de toegang tot verhoogde terugbetaling van de gezondheidszorg) een slechtere gezondheidstoestand (levensverwachting, levensverwachting in goede gezondheid, zuigelingensterfte, obesitas), een minder gezonde levensstijl (voeding, roken, lichaamsbeweging), een minder goede dekking van de opsporing van kanker, een minder goede opvolging voor diabetici, minder sociale ondersteuning en ze overlijden vaker in het ziekenhuis dan in hun eigen woning.

•

Zorgkwaliteit: o (Onaan)gepaste zorg: uit meerdere indicatoren blijkt dat de medische praktijk niet altijd aangepast is. Bijvoorbeeld: De eerste keuze van de voorgeschreven antibiotica komt te weinig overeen met de aanbevelingen en er is geen verbetering merkbaar doorheen de tijd (behalve bij kinderen). Het percentage diabetische patiënten dat op de juiste manier volgens de aanbevelingen wordt opgevolgd, is onvoldoende. Hoewel het niveau enigszins lager ligt dan het gemiddelde van de andere Europese landen is het percentage keizersneden hoog. Men ziet ook bij niet-gecompliceerde zwangerschappen een grote variabiliteit tussen de ziekenhuizen.

KCE Report 196A


o

o

ix

Veiligheid van de zorg: blootselling aan straling van medische oorsprong: hoewel lichtjes gedaald in 2011, blijft het niveau erg hoog in vergelijking met het Europese gemiddelde. Zorgcontinuïteit: sommige indicatoren wijzen erop dat in dit domein zwak gescoord wordt. Bijvoorbeeld: Ondanks een constante stijging is het percentage patiënten dat over een globaal medisch dossier (GMD) beschikt nog te laag. Het percentage heropnames in de psychiatrische ziekenhuizen is relatief hoog vergeleken met het Europese gemiddelde.

•

Duurzaamheid van het systeem: Het gezondheidssysteem steunt op een eerstelijnszorg waarin de huisartsgeneeskunde een belangrijke schakel vormt. Verontrustend is dat de gemiddelde leeftijd van de huisartsen blijft stijgen, en dat de quota die werden voorzien door de Planningscommissie sinds enkele jaren niet ingevuld geraken. Wanneer deze tendens zich doorzet, zal dit snel leiden tot problemen voor de werking van de eerstelijnszorg. Verbetering van de informatiesystemen voor de gezondheidszorg De kwaliteit van de gegevens en de snelheid waarmee ze beschikbaar worden gesteld zijn essentieel voor de relevantie van de indicatoren die erop gebaseerd zijn. •

Termijn van de ter beschikking stelling van de gegevens o Voorzetten van de inspanningen teneinde geactualiseerde gegevens over te maken aan de internationale organisaties (OESO, Eurostat, WGO) o Ervoor zorgen dat de administratieve databanken (Minimale ZiekenshuisGegevens) sneller ter beschikking worden gesteld.

•

Gegevens per zorgdomein: o Geestelijke gezondheidszorg: hervormen van de Minimale Psychiatrische Gegevens teneinde deze aan te passen aan de internationale normen (identificatie van unieke patiënt) en aan de evolutie binnen de sector. Dit vraagt een herziening die toelaat om het ganse zorgtraject van de patiënten, ook buiten het ziekenhuis, te volgen. o Langdurige zorg: zorgen voor een gedegen beschikbaarheid op nationaal niveau van de gegevens die worden verzameld in het kader van het project BelRai om het meten van de verschillende geselecteerde indicatoren mogelijk te maken. o Mondhygiëne: oververtegenwoordigen van de groep kinderen van 12 jaar in de enquête over mondhygiëne teneinde de internationale indicatoren correct te kunnen

x


KCE Reports 196A

berekenen. o Zorg bij het levenseinde: verbeteren van het gebruik van bestaande gegevens (Kankerregister en het netwerk van Huisartsen Peilpraktijken) o Volksgezondheid: aanvullen van de databank van geneesmiddelengebruik teneinde over de totaliteit van de informatie te kunnen beschikken, met inbegrip van de middelen die niet worden terugbetaald, maar waarvan de analyse essentieel is voor de volksgezondheid of de veiligheid van de patiënt (benzodiazepines, bepaalde ontstekingsremmers). Aanbeveling voor het verzamelen van nieuwe gegevens of voor bijkomend onderzoek Sommige gegevens die nodig zijn voor het uitwerken van geselecteerde indicatoren moeten nog worden verzameld. •

Op de vraag over de socio-economische ongelijkheid kunnen de administratieve databanken slechts een gedeeltelijk antwoord geven. Bepaalde gegevens ontbreken volledig (bijvoorbeeld, socio-economische status in de ziekenhuisgegevens, etniciteit), andere zijn weinig nauwkeurig of hebben weinig onderscheidend vermogen (Omnio/Verhoogde terugbetaling).

•

Financiële toegankelijkheid: verbeteren van de enquête over het budget van de huisgezinnen teneinde alle financiële lasten van de patiënten die samenhangen met hun gezondheidszorg te registreren en een analyse per socio-economisch niveau mogelijk te maken.

•

Wat “Patiëntervaring" betreft, zullen gegevens beschikbaar zijn dankzij de volgende gezondheidsenquête van het WIV (deze gegevens zullen betrekking hebben op de huisartsen en op alle specialisten zonder onderscheid). Het is echter nuttig gegevens te verzamelen volgens het type specialisme (in alle zorglijnen).

•

Gezondheidspromotie: o Er zijn geen gegevens beschikbaar over het "gezondheids-alfabetisatie-graad" (‘health literacy’) in België. In het bijzonder wordt aanbevolen dat België deelneemt aan de Europese onderzoeken inzake de ontwikkeling van hulpmiddelen voor het meten van health literacy, met het oog op toekomstige gegevensverzameling. o Gezondheidsbevordering in de leefomgeving: er bestaan talrijke gegevens in Vlaanderen met betrekking tot gezondheidsbevordering in bepaalde leefomgevingen (scholen, gemeenschappen, bedrijven). Deze worden verzameld door middel van de enquêtes van het VIGeZ (Vlaams Instituut voor Gezondheidspromotie en Ziektepreventie). Aanbevolen wordt dat de andere gewesten eveneens gegevens zouden verzamelen over de leefomgevingen, in functie van hun behoefte aan

KCE Report 196A


xi

beleidsondersteunende informatie. o Ten slotte wordt ook aanbevolen om na te gaan of men in het volgende rapport de indicatoren voor gezondheidsbevordering specifiek in het domein van de gezondheidszorg op kan nemen. Aanbevelingen voor het volgende performantierapport (voorzien voor december 2015) •

Ten aanzien van FOD Volksgezondheid, RIZIV en WIV o Berekenen van de indicatoren waarvoor de gegevens nog niet beschikbaar zijn, maar die het wel zullen zijn tegen het volgende rapport (project over de ambulante zorgtrajecten, project BelRAI, ervaring van de patiënten in de gezondheidsenquête, prevalentie van ziekenhuisinfecties, termijn voor de registratie van nieuwe geneesmiddelen). o In de toekomst is het voor een goede opvolging aangewezen om de meest recente beschikbare resultaten op te nemen. De indicatoren moeten bij voorkeur routinematig worden gemeten door de instellingen/administraties, respectievelijke beheerders van de administratieve databanken. De resultaten zullen overgemaakt worden aan de teams die belast zijn met de actualisering van het rapport, volgens een termijnplanning en een stramien dat nog moet worden gepreciseerd. o Opvolgen van de internationale evoluties (OESO, WGO, Eurostat) teneinde de Belgische indicatorenset aan te passen indien nodig.

•

Ten aanzien van de onderzoeksequipes o Identificeren van nieuwe indicatoren voor weinig gedocumenteerde thema's (probleem van beschikbaarheid van verpleegkundig personeel, bijvoorbeeld). o Actualiseren van de evaluatie van de performantie via de meest recente data. o Analyseren van de globale coherentie (vooral voor het versterken van de dimensies met betrekking tot efficiëntie en duurzaamheid) en het actualiseren van de indicatorenset in het licht van nieuwe evidentie of nieuwe prioritaire thema's.

Belgian n Health System Performance

KCE Report 196 6

TABL LE OF CO ONTENT TS LIST T OF FIGURES ................................................................................................................................. 5 LIST T OF TABLES .................................................................................................................................. 7 LIST T OF ABBREVIA ATIONS .................................................................................................................. 9 SYNTHESE ........................................................................................................................... 12 1 1 ACHTERGR ROND, CONCEP PTUEEL KADER R EN DOELSTE ELLINGEN ............................... 12 1 1.1 1.2 1.3

ACHTERGRO OND ................................................................................................................................... 12 1 CONCEPTUE EEL KADER TER EVALUATIE VAN N DE PERFORMA ANTIE VAN HET BELGISCHE GEZONDHEIDSSYSTEEM ................................................................................................................... 13 1 DOELSTELLIINGEN VAN DIT RAPPORT ............................................................................................ 15 1 1.3.1 Strattegische doelstellingen van het pro oces van Health System Performance Assessment . 15 1 1.3.2 Alge emene en operatio onele doelstellinge en van het rapporrt van 2012 .................................... 15 1

2

STERKE EN N ZWAKKE PUN NTEN VAN HET T BELGISCHE GEZONDHEIDS G SSYSTEEM ..... 16 1

2.1 2.2 2.3

HOE DE SYN NOPTISCHE TABELLEN LEZEN? ................................................................................... 16 1 GEZONDHEIDSTOESTAND ................................................................................................................. 18 1 TOEGANKEL LIJKHEID VAN DE E ZORG ................................................................................................ 19 1 2.3.1 Besc chikbaar personee el: praktiserende artsen a en verpleegkundigen .................................... 19 1 2.3.2 Financiële toegankelijjkheid .................................................................................................... 19 1 2.3.3 Dekk kingsgraad van prreventieve maatre egelen ........................................................................ 19 1 ZORGKWALIITEIT ................................................................................................................................. 22 2 2.4.1 Doelltreffendheid ...................................................................................................................... 22 2 2.4.2 Aang gepastheid......................................................................................................................... 24 2 2.4.3 Veilig gheid ................................................................................................................................. 25 2 2.4.4 Conttinuïteit van zorg ............................ . .................................................................................. 26 2 2.4.5 Patië ëntgerichtheid .................................................................................................................... 28 2 EFFICIËNTIE E VAN HET GEZO ONDHEIDSSYSTE EEM .......................................................................... 29 2 DUURZAAMH HEID .................................................................................................................................. 30 3 GEZONDHEIDSPROMOTIE ................................................................................................................. 31 3

2.4

2.5 2.6 2.7

1


2

2.8

KCE Reportt 196

2.9

BILLIJKHEID EN GELIJKHEID D............................................................................................................. 33 3 2.8.1 Socio-economische ongelijkheden ......................................................................................... 33 3 2.8.2 Conttextuele indicatore en van billijkheid ................................................................................... 35 3 CONCLUSIES S OVER ZWAKKE EN STERKE PU UNTEN ..................................................................... 37 3

3

HET 2012 HSPA-RAPPORT H T: NUT, TOEGE EVOEGDE WAA ARDE EN BEPE ERKINGEN ..... 39 3

3.1 3.2

WAT IS HET NUT VAN DIT HS SPA-RAPPORT? .................................................................................. 39 3 WAT IS DE TOEGEVOEGDE T W WAARDE VAN DIT RAPPORT VE ERGELEKEN MET T HET VORIGE? ............................................................................................................................................... 40 4 WAT ZIJN DE E BEPERKINGEN N VAN DIT RAPPO ORT? ........................................................................ 41 4 3.3.1 Perfo ormantie tegenov ver welk streefdoel? Benchmarking met andere Europese landen lost het probleem niet op ............................................................................................ 41 4 3.3.2 Beslissingen nemen op o basis van verou uderde gegevens s? ................................................... 41 4 3.3.3 Een uitgebreider beeld, maar nog steed ds hiaten in het in nstrument....................................... 41 4

3.3

4 1

ALGEMENE E CONCLUSIE .................................................................................................... 43 4 SCIENTIFIC C REPORT........................................................................................................... 45 4 BACKGROU UND AND APPR ROACH ...................................................................................... 45 4

1.1

1.4 1.5

CONTEXT .............................................................................................................................................. 45 4 1.1.1 Interrnational context ................................................................................................................ 45 4 1.1.2 Natio onal context ....................................................................................................................... 46 4 THE BELGIAN PERFORMANC CE FRAMEWORK K AND DEFINITIO ONS .............................................. 46 4 OBJECTIVES S OF THE PERFO ORMANCE PROJECT .......................................................................... 50 5 1.3.1 Strattegic objectives off the HSPA proce ess .............................................................................. 50 5 1.3.2 Overrall and operational objectives of th he 2012 report ........................................................... 50 5 METHODS TO REACH OPER RATIONAL OBJEC CTIVES ...................................................................... 50 5 THE 2012 SE ET OF PERFORM MANCE INDICATO ORS AND STRUC CTURE OF THIS R REPORT ........... 52 5

2

OVERALL HEALTH H STATU US OF THE POP PULATION........................................................ 53 5

2.1 2.2 2.3

HOW DID WE E DESCRIBE THE E OVERALL HEA ALTH STATUS OF F THE POPULATIION? ................. 53 5 FACTS AND FIGURES ......................................................................................................................... 53 5 KEY FINDING GS ..................................................................................................................................... 57 5

3

ACCESSIBIILITY OF CARE E .................................................................................................. 57 5

1.2 1.3


KCE Report 196 6

3.1 3.2 3.3

HOW DID WE E EVALUATE THE ACCESSIBILIT TY OF HEALTHCA ARE?............................................. 57 5 FACTS AND FIGURES ......................................................................................................................... 58 5 KEY FINDING GS ..................................................................................................................................... 67 6

4

QUALITY OF O HEALTHCAR RE ............................................................................................... 68 6

4.1

EFFECTIVEN NESS OF CARE ................................................................................................................ 68 6 4.1.1 How w did we evaluate the t effectiveness of care? .................................................................... 68 6 4.1.2 Factts and figures ..................................................................................................................... 69 6 4.1.3 Key findings ............................................................................................................................. 74 7 APPROPRIAT TENESS ........................................................................................................................... 75 7 4.2.1 How w did we evaluate the t appropriatene ess of care? ............................................................... 75 7 4.2.2 Factts and figures ..................................................................................................................... 75 7 4.2.3 Key findings ............................................................................................................................. 81 8 SAFETY OF CARE C ................................................................................................................................ 81 8 4.3.1 How w did we evaluate the t safety of care? ............................................................................... 81 8 4.3.2 Factts and figures ..................................................................................................................... 82 8 4.3.3 Key findings ............................................................................................................................. 86 8 CONTINUITY Y OF CARE ........................................................................................................................ 86 8 4.4.1 How w did we evaluate the t continuity of care? c .......................................................................... 86 8 4.4.2 Factts and figures ..................................................................................................................... 87 8 4.4.3 Key findings ............................................................................................................................. 90 9 PATIENT CENTEREDNESS ................................................................................................................. 90 9 4.5.1 How w did we evaluate patient centeredn ness?.......................................................................... 90 9 4.5.2 Factts and figures ..................................................................................................................... 91 9 4.5.3 Key findings ............................................................................................................................. 92 9

4.2

4.3

4.4

4.5

5

EFFICIENCY Y IN HEALTHCA ARE ........................................................................................... 93 9

5.1 5.2 5.3

HOW DID WE E EVALUATE THE EFFICIENCY IN N HEALTHCARE? ? ................................................... 93 9 FACTS AND FIGURES ......................................................................................................................... 93 9 KEY FINDING GS ..................................................................................................................................... 96 9

6

SUSTAINAB BILITY OF THE HEALTH SYST TEM ................................................................... 97 9

3


4

KCE Reportt 196

6.1 6.2 6.3

HOW DID WE E EVALUATE THE SUSTAINABILITY OF THE HEA ALTH SYSTEM? ............................ 97 9 FACTS AND FIGURES ......................................................................................................................... 97 9 KEY FINDING GS ................................................................................................................................... 10 04

7

PERFORMA ANCE OF HEAL LTH PROMOTIO ON.................................................................... 10 04

7.1 7.2

7.3

HOW DID WE E EVALUATE THE PERFORMANC CE OF HEALTH PROMOTION? P ............................ 10 04 FIGURES ........... FACTS AND ............................................................................................................ 10 07 7.2.1 Heallth outcomes ................................................................................................................... 10 07 7.2.2 Interrmediate health ou utcomes .............................................................................................. 11 12 7.2.3 Heallth Promotion outc comes ................................................................................................. 11 16 KEY FINDING GS ................................................................................................................................... 11 19

8

EQUITY AND EQUALITY ................................................................................................... 12 20

8.1 8.2

INTRODUCTION ................................................................................................................................. 12 20 SOCIO-ECON NOMIC INEQUAL LITIES ................................................................................................. 12 20 8.2.1 How w did we evaluate socio-economic s in nequalities? ............................................................. 12 20 8.2.2 Factts and figures ................................................................................................................... 12 22 8.2.3 Key findings ........................................................................................................................... 12 27 EQUITY OF THE T HEALTH SYSTEM AT A GLO OBAL LEVEL ............................................................ 12 27 8.3.1 How w did we evaluate the t equity of the health h system at a global level? ............................. 12 27 8.3.2 Factts and figures ................................................................................................................... 12 28 8.3.3 Key findings ........................................................................................................................... 13 30

8.3

9

TOWARDS A MORE COMP PREHENSIVE HEALTH H SYSTE EM PERFORMA ANCE ASSESSME ENT: ADDRESS SING CURRENT T SHORTCOMIN NGS ........................................ 13 30 GENERAL CONCLUSION C .................................................................................................. 13 34 10 APPENDICE ES ..................................................................................................................... 13 35 APPENDIX 1. LIST T OF INDICATO ORS MEASURE ED IN THE 2012 REPORT, CLA ASSIFIED BY TIER OF F THE HEALTH SYSTEM, DOM MAIN OF CARE AND DIMENSIO ON ................ 13 35 APPENDIX 2. LIST T OF CHANGES S TO INDICATO ORS COMPARE ED TO THE 2010 0 REPORT ... 13 39 APPENDIX 3. LIST T OF INDICATO ORS MEASURA ABLE IN A NEAR R FUTURE ............................. 14 44 REFERENC CES .................................................................................................................... 14 47

KCE Report 196 6

LIST OF FIGURES F

Belgian n Health System Performance Figuu ur 1 – Conceptuee el kader ter evalua atie van de performantie van het Be elgische gezondheidssysteem ..... 14 1 Figuu ur 2 – Indicator va an billijkheid: Gini--coëfficiënt na bela asting en overdra achten, in België e en gewesten....... 37 3 Figurre 3 – The concep ptual framework to o evaluate the perrformance of the Belgian B health sysstem ................... 47 4 Figurre 4 – Life expecta ancy at birth: interrnational comparis son (2000-2010) ........................................................ 55 5 Figurre 5 – Infant morta ality rate: international comparison ................................................................................... 56 5 Figurre 6 – Number of practising p physicia ans (per 1000 pop pulation): international comparison .......................... 59 5 Figurre 7 – Out-of-pock ket expenditures (as a percentage of o total health exp penditures): international comp parison ........................................................................................................................................................... 61 6 Figurre 8 – Percentage of women (aged 50-69) who had a mammogram (w within program (a) or overa all (b)) within the la ast two years, by region (2006-2010) .............................................................................. 63 6 Figurre 9 – Breast canc cer and cervical ca ancer screening: international i comparison (2000-2010)..................... 64 6 Figurre 10 – Percentage of children cove ered by main vacc cinations (2000-20 009): international comparison ..... 65 6 Figurre 11 – 5-year rela ative survival afterr breast, cervix an nd colorectal canc cer for females: intternational comp parison (2004) ............................................................................................................................................... 71 7 Figurre 12 – Suicide rattes (number per 100 1 000 population) per region (199 99-2008) and international comp parison ........................................................................................................................................................... 72 7 Figurre 13 – Percentage of involuntary committals in psyc chiatric hospitals, by b region (2000-2 2009) .................. 73 7 Figurre 14 – Employme ent rates by health h condition, as a ratio of the employ yment rate of all p people with disability: d internatiional comparison (2002) .................................................................................................. 74 7 Figurre 15 – Mammogram coverage of women w aged 40-49 9 years and of wo omen aged 70-79 years, by ye ear and region ............................................................................................................................................... 76 7 Figurre 16 – C-sections s per 1000 live birtths: international comparison ............................................................... 78 7 Figurre 17 – Defined da aily dosage of antidepressants per 1000 population per p day: by region n (2004 4-2010) and intern national comparison (2000-2010) .................................................................................... 79 7 Figurre 18 – Chemothe erapy near end-of--life for patients with w cancer, by place of death ................................... 80 8 Figurre 19 – Exposition n to medical radiattion per inhabitantt (most 20 exams, expressed in mS Sv): intern national compariso on ...................................................................................................................................... 82 8 Figurre 20 – Mean incid dence of Healthca are Acquired MRS SA, per 1000 admissions (1994-201 10) ..................... 84 8 Figurre 21 – Percentage of population with a global medic cal record (GMD – DMG), by region n (2006-2009) .... 87 8 Figurre 22 – Percentage of hospitalisatio ons for the elderly (aged 65 and ove er) followed by a conta act with a GP within 1 week after discharge, by regio on (2003-2009) ........................................................... 88 8

5

6


KCE Reportt 196

Figurre 23 – Degree of satisfaction with healthcare h service es, by type of serv vice (2008) .................................... 91 9 Figurre 24 – Percentage of low-cost med dication delivered in ambulatory settting (DDDs) (200 00-2010) ............. 94 9 Figurre 25 – Percentage of surgical one--day hospitalisatio ons on all surgical hospitalisations: intern national compariso on ...................................................................................................................................... 95 9 Figurre 26 – Average le ength of stay for a normal delivery: international com mparison ......................................... 96 9 Figurre 27 – Age distrib bution of GPs (200 00-2004-2009) ...................................................................................... 97 9 Figurre 28 – Medical an nd nursing gradua ates (per 100 000 pop): internationa al comparison (20 010) .................... 99 9 Figurre 29 – Acute care e bed days per capita, international comparison ............................................................ 10 00 Figurre 30 – Health exp penditures in Belg gium by main func ction in the System m of Health Accou unts (2010) ....... 10 02 Figurre 31 – Total healtth expenditures as s a % of GDP: international compa arison ........................................... 10 03 Figurre 32 – The Nutbe eam’s framework and a selected indic cators to measure e performance of h health promotion ........................................................................................................................................................... 10 06 Figurre 33 – Percentag ge of the adult population (aged 18 8 years or older) with w obesity (BMI ≥ ≥30), by region (1997-2008), an nd international co omparison (2000-2008........................................................................ 10 08 Figurre 34 – Diagnostic c rate of HIV by re egion, for all cases s (a) and for Belgian cases only (b)) (1985-2010) .. 11 10 Figurre 35 – Rate of the e new HIV diagno osis per 100 000 in nhabitants: Interna ational compariso on ..................... 11 11 Figurre 36 – Percentage of the populatio on (a) smoking daily, (b) with proble ematic alcohol consu umption, (c) consu uming at least 2 frruits and 200 vegetables daily, (d) performing at leasst 30 min of physical activ vity per day, by re egion (1997/2001--2008)...................................................................... 11 13 Figurre 37 – Internation nal comparisons on o the Tobacco Co ontrol Scale in Eu urope (2010) ................................ 11 18 Figurre 38 – Gini coeffic cient before and after a taxation and transfers (1998-2 2010): Belgium and in nternational comp parison ............................................................................................................................. 12 29

KCE Report 196 6

LIST OF TABLES T

Belgian n Health System Performance Tabel 1 – Indicatoren die d de globale gez zondheidstoestand beoordelen ............................................................ 18 1 Tabel 2 – Indicatoren ter t beoordeling va an de toegankelijk kheid van de gezo ondheidszorg ................................. 21 2 Tabel 3 – Indicatoren ter t beoordeling va an de doeltreffend dheid van de zorg ..................................................... 23 2 Tabel 4 – Indicatoren ter t beoordeling va an de aangepastheid van de zorg......................................................... 24 2 Tabel 5 – Indicatoren ter t beoordeling va an de veiligheid va an de zorg ................................................................. 25 2 Tabel 6 – Indicatoren ter t beoordeling va an de continuïteit en e coördinatie van de zorg ...................................... 27 2 Tabel 7 – Indicatoren ter t beoordeling va an de patiëntgerichtheid van de zorrg ................................................... 28 2 Tabel 8 – Indicatoren ter t beoordeling va an de efficiëntie va an de zorg ................................................................. 29 2 Tabel 9 – Indicatoren ter t beoordeling va an de duurzaamhe eid van het gezon ndheidssysteem ............................ 30 3 Tabel 10 – Indicatoren n van gezondheids spromotie .............................................................................................. 32 3 Tabel 11 – Overzichtsttabel van socio-ec conomische onge elijkheden ................................................................... 34 3 Tabel 12 – Indicator va an billijkheid: prog gressiviteitsindicattoren van de publieke financiering van het h gezondheidssy ysteem............................................................................................................................... 36 3 Table e 13 – Life expectancy at birth (2010), and Healthy Life L Years at age 25 2 (2008), by sex and region ........ 54 5 Table e 14 – Number of practising physiciians, estimation of o Full Time Equiva alent, and densityy (/1000 population) (2010) ..................................................................................................................................... 58 5 Table e 15 – Out-of-pock ket expenditures (2003-2010) ( .......................................................................................... 61 6 Table e 16 – Number of accredited beds in homes for the elderly e and nursing g homes per 100 population 65 ye ears and older, pe er region, 2010 ................................................................................................................... 66 6 Table e 17 – 5-year relattive survival by sta age, period 2004--2008: Belgium .......................................................... 70 7 Table e 18 – Exposition to medical radiation per inhabitant (expressed in nb mSv): Belgium (2 2004-2011) ........ 82 8 Table e 19 – Percentage e of cancer patients who had a MOC – COM, per reg gion, (2005-2008) ......................... 89 8 Table e 20 – Evolution of o place of death over o time in Flande ers and Brussels (1998-2007) ................................. 92 9 Table e 21 – Mean age of o practising GPs (2000-2009) ......................................................................................... 98 9 Table e 22 – Progression n between 1996 and a 2008 of gradu uates in medicine in the two years ffollowing gradu uation according to t type of specialis sation .................................................................................................... 98 9 Table e 23 – Percentage e of GPs using rec commended softw ware to maintain th heir patients’ med dical records .... 10 01 Table e 24 – Total health h expenditures ac ccording to the System of Health Ac ccounts (2003-2010)................... 10 02 Table e 25 – Alcohol con nsumption habits for f the population n (aged 15 or olde er) (1997-2008) ............................ 11 12 Table e 26 – Offer of phy ysical activity in se econdary schools s in Flanders ............................................................ 11 16

7

8


KCE Reportt 196

Table e 27 – Life expectancy at 25 years by sex and educa ational level, abso olute difference to highest educa ational level and concentration c ineq quality indices (CIII) (Belgium 2001)) .................................................. 12 22 Table e 28 – Health expe ectancy at 25 yea ars by sex and edu ucational level, ab bsolute difference to highest educa ational level and concentration c ineq quality indices (Be elgium 2004) ........................................................... 12 23 Table e 29 – Inequalities s expressed with absolute a differenc ce, relative differen nce, and summarry measures ..... 12 25 Table e 30 – Progressiviity indicators of the financing of the public healthcare e system (2005-20 011) ................. 12 29

KCE Report 196 6

LIST OF ABBREVIA A ATIONS


9

ABBREVIATION N

DEFINITIION

ADL ADQ AIDS BIM – RVV

Activities of Daily Living Average Daily Quantity Acquired Immunodeficienc cy Syndrome Bénéficia aire de l’Interven ntion Majorée – Rechthebbende en op de Verho oogde (verzekerrings)tegemoetkoming Body Mass Index Commun nity Acquired Pneu umonia Concentrration Index of Ine equalities Christelijk ke Mutualiteiten – Mutualités Chréttiennes – Christian n Sickness Funds s Defined Daily D Dose Direction générale Statisttique et Informattion économique – Algemene Directie Statistiek k en Economische e informatie Decayed, Missing, Filled Teeth T Diphteria - Tetanos - Pertu ussis European n Antimicrobial Re esistance Surveilla ance System European n Centre for Disea ase Control and Prevention P European n Community Hea alth Indicators Monitoring European n Medical Agency y Echantillo on Permanent – Permanente P Steek kproef Emergen ncy Room European n Union European n Union Statistics on Income and Living L Conditions Faecal Occult O Blood Test Federal Public P Service Full Time e Equivalent Gross Do omestic Product Globaal Medisch M Dossier – Dossier Médical Global Global Medical Record

BMI CAP CII CM – MC DDD DGSIE – ADSEI DMFT DTP EARSS ECDC ECHIM EMA EPS ER EU EU – SILC FOBT FPS FTE GDP GMD – DMG GMR

10


KCE Reportt 196

GP HAI HBSC HCQI Hib HIS HIV HLY HSPA IMA – AIM IMR ISCED LE LOS MAB MMR MOC – COM MRPA – ROB MRS – RVT MRSA NSIH OECD

General Practitioner P Healthcare Acquired Infecttions Health Be ehaviour in Schoo ol-aged Children HealthCa are Quality Indicattor Haemoph hilus Influenzae B Health Interview Survey Human Im mmunodeficiency Virus Healthy Life L Years Health Sy ystem Performanc ce Assessment Intermutu ualistic Agency - In nterMutualistisch Agentschap – Ag gence InterMutualiste Infant Mo ortality Rate Internatio onal Standard Cla assification of Education Life Expe ectancy Length off Stay Maximum m Billing System Measles - Mumps - Rubella Multidisciiplinair Oncologish Consult – Consultation Multidisciplinaire d'Oncolog gie Maisons de Repos pour Pe ersonnes Agées - Rustoorden voorr Bejaarden Maison de d Repos et de So oins – Rust- en Ve erzorgingstehuis Methicillin n-Resistant Staph hylococcus Aureus s National Surveillance of Infections in Hospittals Organisa ation for Economic c Co-operation and Development (O OESO – OCDE)

ONE – KG OOP OR PA PAF PPP PSI

Office Na ational de l'Enfanc ce – Kind en Gezin Out-of-Po ocket Odds Ratio Physical Activity Populatio on Attributable Fra action Purchasin ng Power Parities s Patient Safety S Indicator

KCE Report 196 6

Belgian n Health System Performance PYLL RAI RHM – MZG RIZIV – INAMI RR SE SHA SP SPMA SSF THE UK UPC VIGeZ WHO WIV – ISP

11

Potential Years of Life Los st Resident Assessment Instrument Résumé Hospitalier Minim mal - Minimale Ziek kenhuisgegevens Rijksinstittuut voor ziekte- en invaliditeitsverrzekering – Institu ut national d’assurrance maladie-iinvalidité- Nationa al Institute for Hea alth and Disability Insurance Relative Risk Socio-eco onomic System of o Health Accounts s Specialis st Physician Standard dized Procedures for Mortality Analy ysis Special Solidarity S Fund Total Hea alth Expenditures United Kiingdom Usual Pro ovider Index Vlaams In nstituut voor Gezo ondheidspromotie e en Ziektepreventie World He ealth Organisation n Wetensch happelijk Instituutt Volksgezondheid d – Institut de Sa anté Publique- Ins stitute of Public Health

12

SYNT THESE


KCE Reportt 196

1 ACHTER RGROND, CONCEPT TUEEL KADER EN DOELS STELLING GEN 1 1.1

Achtergro ond

De eerste Belgische Health System D S Performa ance Assessmen nt of b beoordeling van de d performantie van het gezondheidssysteem (H HSPA) w werd gepubliceerd d in juni 2010.1 Het H rapport beston nd uit twee belangrijke d delen. Ten eerste werd het Belgisch he HSPA-kader u uitgewerkt op basis van in nternationale erva aringen die aan de Belgische conte ext werden aange epast. T tweede werd een set van 55 in Ten ndicatoren gesele ecteerd, waarvan er 40 u uiteindelijk gemetten konden worden. De sterke e en zwakke punten, de e evolutie in de loop p van de tijd en voorgestelde acties werden besproke en. W is een Health Wat h System Perform mance Assessment (HSPA)? Een E HSPA is een landg gebonden procces waarmee het g gezondheidssyste em holistisch kan worden beoord deeld, een "chec ck-up" v het volledige gezondheidssyste van g eem. Dit instrument beoogt bij te drragen to ot de strategische e planning van he et gezondheidssyssteem door indica atoren te e berekenen diie een “signaalfunctie” hebben. Elke HSPA wordt w o ontwikkeld volgens s een strategisch kader dat landspe ecifiek is.2 Na de publicatie van N v dit eerste rapp port vroegen de o opdrachtgevers va an de B Belgische HSPA om het project verder te zette en met als doell een s systematische ev valuatie van hett Belgische gezo ondheidssysteem m. De o opdrachtgevers v vroegen ook om de indicatorense et uit te breiden n met in ndicatoren in sp pecifieke domein nen: gezondheidsspromotie, geesttelijke g gezondheidszorg, huisartsgeneesk kunde, zorg op lange termijn en zorg ro ondom het levens seinde, aangezien deze domeinen n onvoldoende we erden b behandeld in hett eerste rapport. Tenslotte werde en drie dimensies s (nl. patiëntgerichtheiid en billijkheid) beschouwd als z zorgcontinuïteit, o onvoldoende verte egenwoordigd. D Daarom moesten n nieuwe indica atoren worden vvoorgesteld om deze d dimensies te beoo ordelen. Het huidig ge rapport over de an het e performantie va B Belgische gezond dheidssysteem 20 012 geeft de ressultaten van dit werk w weer.

KCE Report 196 6


Het Handvest van v Tallinn (2008 8): een internatio onale verbintenis s om de performantie van v de Europese e gezondheidssys stemen te meten n. In juni 2008 on ndertekenden de 53 ministers van volksgezondheid d van de landen die behoren tot de Europe ese regio va an de Wereldgezondh heidsorganisatie (WGO) het Han ndvest van Tallin nn “The Tallinn Charter on Health Systems for Health and Wealth”. Van de d zeven ondertekende verbintenissen v hee eft de derde betre ekking op de perfo ormantie van het gezo ondheidssysteem: "de lidstaten verbinden zich tot het bevorderen van n transparantie e en het afleggen van v rekenschap over de performantie van v de gezondh heidssystemen door d de publica atie van meetbare resulttaten".3

1.2

Concep ptueel kader te er evaluatie van n de performan ntie van het Belgische gezzondheidssyste eem

Het conceptuee el kader wordt wee ergegeven in Figu uur 1.

13

14


KCE Reportt 196

Figuur 1 – Con nceptueel kader tter evaluatie van n de performantie e van het Belgisc che gezondheids ssysteem

Noot: In dit rappo ort is er geen speciifiek hoofdstuk gewi wijd aan niet-medisch he determinanten van v gezondheidsind dicatoren. Indicatore en van levenswijze worden weergegev ven en besproken in het hoofdstuk over gezzondheidspromotie.

KCE Report 196 6

1.3


Doelste ellingen van ditt rapport

De systemattische evaluatie e van de performantie p va an het gezondheidssys steem is een co ontinu proces waarbij de publica atie van HSPA-rapporte en belangrijke m mijlpalen zijn. Strrategische doelsttellingen kunnen worden n gedefinieerd alss de doelstellingen van dit continu proces. Ze moeten onderscheiden worrden van de spe ecifieke doelstellin ngen en operationele su ubdoelstellingen van het huidige rap pport.

1.3.1

Strate egische doelstelllingen van het proces van Healtth System Performance Assessment

Het HSPA-proc ces streeft drie stra ategische doelste ellingen na: 1. De gezond dheidsautoriteiten informeren over de performantie van het gezondheid dssysteem, en ee en draagvlak biede en voor beleidspla anning; 2. Een trans sparant en con ntroleerbaar beleid schetsen van v de performanttie van het Belgissch gezondheidss systeem, in overee enkomst met het engagement in het H Handvest van Tallinn; 3. Op lange termijn t de perform mantie van het ge ezondheidssystee em in de tijd volgen.

1.3.2

Algem mene en operatio onele doelstellin ngen van het rap pport van 2012

Een reeks van n indicatoren voorrstellen en meten n voor alle dome einen en gekozen dimen nsies van het Be elgisch gezondhe eidssysteem, waa arbij het aantal indicatorren beheersbaar b blijft (in dit rapportt zijn dat er 74). Vier operatione ele doelstellingen w werden gedefiniee erd: 1. De kernsett van 55 indicatore en van het vorige e rapport herzien, met een speciale fo ocus op de 11 indicatoren waa arvoor er in 201 10 geen gegevens beschikbaar b ware ena; a

Het aanta al praktiserende verrpleegkundigen; bijk komende ziektegere elateerde kosten vo oor chronisch zieke en; voorschriften in n overeenstemming g met de richtlijnen;; screening voor colorectale kanke er; cariës, tandve erlies en tandvulling gen op de leeftijd d van 12 jaar; carrdiovasculaire screening bij personen tussen 45-75 jaarr; 5-jaars overlevingspercentage (bors st, colon, derhals); vroegtijdig g overlijden, incide entie van doorligwo onden in baarmoed residentiële zorg en bij risicop personen.

2 2.

3 3. 4 4.

15

De kernset uitbreiden met indicatoren uit volgende dome einen: gezondheidsp promotie, h huisartsgeneeskun nde, geesttelijke gezondheidsz zorg, zorg op lange termijn, palliattieve zorg; indica atoren toevoegen inzake patiëntgeric chtheid en zorgccontinuïteit (twee subdimensies va an kwaliteit), en tot slot indicatorren voorstellen in nzake billijkheid in he et gezondheidssy ysteem; De geselecte eerde indicatoren waar mogelijk m meten, of hiaten in de beschikbaarhe eid van gegevens s identificeren; De resultaten interpreteren me et het oog op een n globale evaluatie e van de performan ntie van het Belgische gezondheidssysteem door middel m van verschille ende criteria, waarronder een interna ationale benchma arking indien aangew wezen.

Het H HSPA-rapp port is een rapport waarin het Belg gische g gezondheidssyste em op nationaa al niveau wordt opgevolgd en waarin w B België ook wordt gepositioneerd g in een internationale e context. Door middel m v van 74 indicatorren probeert he et HSPA-rapport de toegankelijk kheid, k kwaliteit, efficiënttie, duurzaamheid en billijkheid d van het Belg gische g gezondheidssyste em te monito oren, om te kunnen dienen als in nformatiebron voo or de verschillend de beleidsmakers die bevoegd zijn n voor g gezondheid en gez zondheidspromottie.


16

2 STERK KE EN ZWA AKKE PUN NTEN VAN HET BELGISCHE B E GEZONDHEIDSS SYSTEEM 2.1

Hoe de e synoptische tabellen lezen? ?

De resultaten van de 74 indicatoren worden hieronder h besprok ken, per domein en/of dimensie. Aan gezondheidspro omotie is een specifiek s hoofdstuk gewijjd. Deze synoptisc che tabellen bevattten volgende info ormatie: •

• •

•

b

•

In de eerste plaats toont een pictogram, wa aar mogelijk, een globale evaluatie van v de resultate en van de indic cator, gebaseerd op de integratie van verschillend de criteria: waard de op nationaal niveau versus nationale doelstellingen (wanneer die bestaan) off versus internationa ale benchmarks, tendensen over verloop v van tijd, re egionale of socio-ec conomische onge elijkheden. Er die ent opgemerkt te worden dat deze ev valuatie niet volledig mogelijk is voor alle indicatoren n. In de kolom m “België” wordt d de waarde van de indicator voor Be elgië vergeleken n met de resultaten van de landen van v de EU-15b (internation nale benchmarking), en weergegev ven met een kleurc code. De volgen nde kolom identiificeert het jaar van de meest recente resultaten die beschikbaa ar zijn voor Be elgië. Dit is belangrijke informatie voor v beleidsmake ers, bijv. om te voo orkomen dat beslissingen worden ge enomen op basiss van verouderd de gegevens en om de verzamelin ng van meer reccente gegevens aan te moedigen n indien nodig. s wordt, indien m mogelijk, een ruw we tendens overr de tijd Vervolgens weergegev ven (stijging, da aling, en stabiell), over de laatste vijf beschikbarre jaren. Er is gee en evaluatie van de d omvang of hett klinisch belang van n de wijzigingen. De term EU-15 E verwijst naar de 15 lidstaten van n de Europese Unie vanaf 31 decemberr 2003, vooraleer de e nieuwe lidstaten bij b de EU kwamen. Deze 15 lidstaten zijn z Oostenrijk, Belg gië, Denemarken, Finland, F Frankrijk, Duitsland, D Griekenland, Ierland, Italië, Luxemburg, Ned derland, Portugal, Spanje, Zweden en e het Verenigd Kon ninkrijk.

•

KCE Reportt 196

De laatste kolommen k geven subgroepanalysses weer (indien n van toepassing, en e als gegevens beschikbaar zijn n) per geslacht, socios economische status (laag off hoog)c en per gewest (Vlaand deren, Wallonië en Brussel). B Voor dez ze subgroepanalyyses helpen kleure en de lezer de groottte van de relatiev ve verschillen naa ar waarde te scha atten. Met betrekkin ng tot de vergelijk king tussen de ge ewesten moet rekening worden gehou uden met de spec cifieke context van n het Brussels ge ewest: het Brussels gewest bestaat immers alleen u uit één enkel ste edelijk gebied, terwijl de twee andere e gewesten besta aan uit een meng gvorm van stedelijke e, voorstedelijke en landelijke gebie eden. Tenslotte wo orden gebieden waar bijkomend onderzoek nod dig is aangeduid me et een .

B Bron van de gege evens Er werd zoveel mogelijk E m gebruik gemaakt van rou utinematig verzam melde g gegevens (bijv. administratieve databanken, na ationale registerrs of e enquêtes die regelmatig h herhaald worde en): de Minimale Z Ziekenhuisgegeve ens (MZG), de EPS (perm manente steekp proef), d databanken van het RIZIV (doc ( N, Pharm manet), het Bellgisch K Kankerregister, het register van nosocom miale infecties, de g gezondheidsenquê êtes (HIS – Health H Interview Survey), vaccin natiee enquetes en de databank van de Algemene D Directie Statistiek en E Economische inforrmatie (ADSEI).

c

Afhankelijk van de gegeven nsbron is de socio-economische status o ofwel het opleid dingsniveau, ofwel het recht op verho oogde gebaseerd op terugbetaling van gezondheidszo orguitgaven.


KCE Report 196 6

17

Legende voor de synoptische tabellen

Globale evaluattie

Internationa ale vergelijking (EU-15) § België is gesitueerd g in de e groep van landen met:

Relatief risic co per geslacht, socio-economisch s e status en gewesst

Zeerr slechte resultaten

De slechtstte resultaten

Zeer grote verschillen tusse en groepen: De resultaten zijn m minstens twee keer zo slecht of minstens m half zo goed g in de groep p waarmee verge eleken wordt als in de referentiegrroep£

chte resultaten Slec

Resultaten slechter dan gemiddeld

Grote versc chillen tussen groe epen: resultaten zijn z minstens 50% slechter of beter

middelde Gem resultaten Goede resultaten Zeerr goede resultaten, aan alle criteria werd voldaan Meer gege evens/onderzoek nodig

Gemiddelde e resultaten

Matige vers schillen tussen grroepen: resultaten zijn tussen 20% % en 50% slechtter of beter

Resultaten beter dan gemiddeld

Kleine of ge een verschillen tu ussen groepen: re esultaten zijn maxximaal 20% slechter of beter Kenmerk niet relevant voor deze d indicator

De beste re esultaten Geen gegev vens beschikbaarr

§ Kwintielen word den berekend op de e resultaten van alle e landen. £ Referentiegroep p: de hogere socio--economische statu us, de geslachtsgroe ep (mannelijk/vrouw welijk) met de beste e resultaten, het gew west (Wallonië, Vlaa anderen, Brussel) met m de beste resultaten. s in lage socio-economische groep vers sus 10% rokers in hoge h socio-economische groep OF Half zo goed: 13% gez zonde Fictieve voorbeellden: Tweemaal zo slecht: 20% rokers voeding in lage socio-economische s g groep versus 26% in i hoge socio-econo omische groep.


18

2.2

Gezond dheidstoestand d

We beschrijven n 4 indicatoren ovver de globale gez zondheidstoestan nd. Deze kunnen worden n beschouwd alss algemene en ultieme resultaten van de interventies inz zake gezondheidsssysteem/gezondh heidspromotie, na aast alle andere determinanten van de ge ezondheid. De vier indicato oren laten een possitieve evolutie in de tijd zien (Tabe el 1). Het resultaat van de e levensverwachtting is iets lager in n vergelijking met het EU15-gemiddelde (0,7 jaar ond der het EU-15-g gemiddelde), terrwijl de levensverwachtting in goede gezzondheid (gedefinieerd als de res sterende jaren vanaf een e bepaalde lleeftijd zonder activiteitsbeperkin ng), en

KCE Reportt 196

zuigelingensterfte op een middelmatige plaats staan z n. Het percentage e van m mensen dat hun gezondheid als (minstens) ( goed beschouwt, ligt hoger h d het EU-15-gem dan middelde. Er word den grote verschilllen vastgesteld tu ussen m mannen en vrou uwen, behalve voor v de levensvverwachting in goede g g gezondheid op 25 jaar. Vrouwen lev ven langer dan m mannen maar met meer ja aren van beperkin ngen en zij ervare en hun gezondheid d als minder goed d. Alle p parameters zijn slechter voor de la agere socio-econo omische groepen. Wat d gewesten bettreft, zijn er bete de ere uitkomsten vvoor Vlaanderen,, met u uitzondering van de d kindersterfte.

catoren die de glo obale gezondheiidstoestand beoo ordelen Tabel 1 – Indic Indicator

België B

Meest recentte gegeve ens

Tendens in de loop p van de tijd

M

V

Sociaal S la aag

Sociaall hoog

Vlaanderen

Wallonië

Brus ssel

Levensverwac chting (jaren)

80,0 8

2010

Stijging

77,4

82,6

M:47,6i M V 54,0 V:

M:55,0 V: 59,9

80,9

78,5

80,0 0

Levensverwac chting (op 25 jaarr)

41,0 ii

2008

Stijging

41,3

41,2

M:27,7 M V 28,9 V:

M:46,3 V: 47,1

M:43,7 V: 42,3

M:37,4 V:39,1

M:38 8,5 V:40 0,6

Zelfevaluatie gezondheid g (% in goede of in zeer goed de gezondheid)

76,8 7

2008

Stijging

79,5

74,3

5 57,4

85,7

78,6

73,7

74,3 3

Percentage zuigelingensterfte (aantal overlijdens/1 00 00 levendgeboorttes)

3,5 3

2010

Daling

4,2

3,4

4,0

3,1

4,6

i

Globaal

Levensverwach hting volgens socio-e economische status s verwijst naar de le evensverwachting op p de leeftijd van 25 jaar. Internationale vergelijking ve is gebasseerd op de levensv verwachting in goede e gezondheid bij de e geboorte. iii Kleurcodering voor v socio-economiische verschillen in levensverwachting g en levensverwach hting in goede gezo ondheid is niet geba aseerd op de groottte van het relatieve risico (zoals voor alle andere a indicatoren), maar op de grootte e van de absolute ve erschillen: geel (1 to ot 2 jaar verschil), oranje o (2 tot 6 jaar verschil), v rood (meerr dan 6 jaar verschill). ii

KCE Report 196 6

2.3


Toegan nkelijkheid van de zorg

Toegankelijkheid wordt gedefiinieerd als de mate waarin patiënten p gemakkelijk toe egang hebben to ot de gezondheidsdiensten in term men van fysieke toega ang (geografiscche verspreiding), kosten, tiijd, en beschikbaarheid van gekwalifice eerd personeel.4 De toegankelijkh heid van een gezondheidssysteem is e een noodzakelijke e voorwaarde vo oor een kwaliteitsvol en efficiënt gezondh heidssysteem. Dertien van de e 74 indicatoren beoordelen de toegankelijkheid van het gezondheidssys steem en zijn gegroepeerd in verschillende thema's: t beschikbaar pe ersoneel in gezo ondheidszorg, financiële toeganke elijkheid, dekkingsgraad van preventieve maatregelen n, toegankelijkhe eid van residentiële zorrg voor ouderen, beschikbaarheid d van mantelzorge ers voor ouderen en tijdiigheid van palliatie eve zorg op het einde e van het leven.

2.3.1

Besch hikbaar personeel: praktiserende e artsen en verple eegkundigen

Er werden veel inspanningen geleverd om een betere raming te kunnen geven van het h beschikbaarr personeel (prraktiserende arts sen en verpleegkundigen) in België. Ditt wordt bevestigd d door de toevoeg ging van deze twee indiicatoren waarvoo or er in het vorige rapport geen volledige v resultaten besc chikbaar waren. M Met deze indicatorren alleen kan ec chter niet beoordeeld worrden of dit person neelsbestand vold doende is om tege emoet te komen aan de gezondheidsbeho g oeften van de populatie.

2.3.2

Financiële toegankelijijkheid

Ondanks het be estaan van een un niversele ziekteve erzekering en het bestaan van veel soc ciale vangnetten n (maximumfacttuur, Omnio, Bijzonder B solidariteitsfond ds) verklaarde 14 4% van de huish houdens dat zij sommige s gezondheidszorgen (medische zorg, chirurgie, geneesmiddelen, bril of lenzen, geeste elijke gezondheid dszorg) moesten uitstellen om financiële redenen. Dit percentage p is toe egenomen sinds het einde van de d jaren oordigen de pers negentig. Bove endien vertegenwo soonlijke uitgaven n van de patiënt 19% van v de totale uitgaven voor ge ezondheidszorg, hetgeen aanzienlijk hoge er is dan het EU-1 15-gemiddelde va an 15%.

2 2.3.3

19

Dekkingsgraad van prev ventieve maatreg gelen

Wat de dekkingsg W graad van preven ntieve maatregele en betreft, kan België B z zeker beter preste eren. D dekkingsgraad De d van borstkankers screening (60%) is laag vergeleken n met h EU-15-gemidd het delde (68,3%). Deze D verhouding bleef stabiel ond danks h bestaan van een het e georganiseerd d borstkankerscre eeningsprogramma. Dit la aatste neemt sle echts de helft va an de gescreend de vrouwen voor zijn re ekening. De versc chillen tussen de gewesten zijn bovvendien erg opva allend. M kan zich dus vragen stellen bij de efficiëntie van Men n het programma. V Voor de dekkings sgraad van screening van baarmo oederhalskanker (62%) ( z er minder afwijkingen tussen de zijn e gewesten. De rresultaten situeren n zich ro ond het EU-15-gemiddelde, maar blijven middelma atig met betrekkin ng tot d de algemeen aanvaarde Euro opese doelstelliing van 80%. De d dekkingsgraad blijft ook stabiel in de e loop van de tijd.. E worden geen gegevens geprese Er enteerd inzake de dekkingsgraad va an de s screening van colo onkanker, aangez zien het nog te vrroeg is om het nieuwe p programma in de Franstalige F gemeenschap te evalue eren. W de griepvacc Wat cinatie van ouderren betreft, word dt het WGO-stree efdoel (75%) niet behaalld en stijgt de dekkingsgraad maa ar heel geleidelijk. Wat d vaccinatie van kinderen betreft, doet de d België het go oed.

20


Toegankelijkhe eid van zorg op lange termijn Het aantal bed dden in residenttiële zorgfaciliteite en is constant gebleven g tijdens de laats ste tien jaar (nl. 70 bedden per 1 000 0 personen van n 65 jaar en ouder). Ove er het algemeen is dit aantal ve eel hoger in Walllonië en Brussel dan in Vlaanderen. V Mantelzorgers, gedefinieerd a als personen diie hulp bieden bij de basisactiviteiten n van het dagelijkkse leven (Activitiies of Daily Living g - ADL) gedurende min nstens een uur pe er week, zijn bela angrijk onderdeell van de langetermijnszo orgverlening.5 Hett percentage van de populatie van n 50 jaar en ouder dat fu ungeert als manttelzorger varieerd de van 8% in Zwe eden tot 16,2% in Italië.. Het Belgische ccijfer van 12,1% is lichtjes hoger dan het totale gemiddelde van de OESO O-landen (11,7%)). Dit moet in zijn n context worden geplaa atst vermits dit cijjfer beïnvloed wo ordt door de man nier van leven, maatsch happelijke waarde en en het al dan n niet aanwezig zijn van specifieke stimu ulerende maatreg gelen om mantelzo org te ondersteunen. Aangezien er momenteel m geen gegevens zijn ov ver de behoeften n van de patiënt zijn de eze twee indica atoren nog steed ds onvoldoende om de toegankelijkheid d van de zorg op lange termijn te beoordelen. b Tijdigheid bij palliatieve p zorg Het starten mett palliatieve zorg w wordt soms uitges steld tot de patiën nten zich in de termina ale fase bevinde en. Dit kan wijz zen op problem men van toegankelijkheid d van palliatieve zorg, of op het feit f dat de beslissing om met palliatieve zorg te starten te laat werd ge enomen. In 20% van de gevallen overle eden de patiënten n binnen de wee ek van aanvraag voor de palliatieve forfa aitaire vergoeding g (ingediend bij het h ziekenfonds). Dit lijkt eerder op een late start te wijze en. Het zou nuttig g zijn om meer ge egevens over deze ind dicator te beko omen (evolutie over o de tijd, re egionale verschillen).

KCE Reportt 196


KCE Report 196 6

21

Tabel 2 – Indic catoren ter beoorrdeling van de to oegankelijkheid van v de gezondhe eidszorg

zorg op lange termijn

Dekking van preventieve maatregelen

Financiële toegankelijkheid

Personeels bestand

Indicatorr

België

Meest recente gegeven ns

Tendens in de tijd

Sociaal laag

Sociaal hoog

Vlaandere en

Wallonië

Brussel

Aantal (p per 1 000 inwoners)): - praktise erende artsen

2,9

2010

stabiel

- praktise erende verpleegkun ndigen

9.9i

2009

de

99,0

2010

stabiel

Remgeld d en persoonlijke uitgaven (% van totale gezondh heidszorguitgaven)

19,4

2010

stabiel

Uitgestelde contacten met g gezondheidsdienste en om financiële redenen (%)

14

2008

stijging

27,0

4,0

11,0

14,0

26 6,0

Kankersc creening - Borst (% % vrouwen 50-69 ja aar oud)

60,1

2010

stabiel

48,6

62,9

64,9

55,3

51,9

- Baarmo oederhals (% vrouw wen 25-64 jaar oud)

61,8

2010

stabiel

48,9

64,2

61,0

64,6

63 3,6

Vaccinattiedekking kinderen - % DTP P-Hib (3)

97,9

2009

stijging

98,3

96,9

98 8,6

- % MMR R (1)

94,5

2009

stijging

Griepvac ccinatie (% 65+)

65,0 ii

2009

stijging

Aantal bedden in woonzzorgcentra en rus st- en ngstehuizen (per 1 000 inw. 65+) verzorgin

70,3 iii

2011

stabiel

Mantelzo orgers (% bevolking g 50+)

12,1

Dekking verplichte bevolking g (%)

Globaal

ziektteverzekering

van n

Tijdigheid van pa alliatieve zorg: o overlijdens binnen n een week na de start van v de palliatieve zzorg (%)

(20,0)

M

V

63,5

46,3

96,8

92,4

91,1

65,8

60,9

59 9,2

58

83

10 01

2007 iv

2006

i OESO-gegeven ns over het aantal vverpleegkundigen on nvoldoende vergelijjkbaar. ii nationale waard den gebaseerd op H HIS (basis van intern nationale vergelijkin ng in OESO-Gezond dheidsgegevens), socio-economische s ongelijkheden geba aseerd op EPS. iii Waarde en inte ernationale vergelijkiing gebaseerd op gegevens g 2010. iv Geen nationale e gegevens, waarde e gebaseerd op één n enkele studie van het Christelijk Zieke enfonds. DTP-Hib (3) Difte erie-Tetanus-Kinkho oest (Pertussis)-Hae emophilus Influenza ae B (dekking met derde d dosis; BMR (1 1) Bof-Mazelen-Rod dehond (eerste dosiss).


22

2.4

Zorgkw waliteit

Kwaliteit wordt gedefinieerd als "de mate waarin gezondheidszorg g, zowel voor het individ du als voor de b bevolking, de kan ns vergroot op ge ewenste uitkomsten en waarbij de verleende zorg in overeenstemming o g is met gangbare medische kennis en in nzichten".6 Dit wo ordt verder onderv verdeeld in 5 subdim mensies: doeltreffendheid, aan ngepastheid, ve eiligheid, zorgcontinuïteitt en patiëntgerichttheid.

2.4.1

Doeltrreffendheid

Doeltreffendheid wordt gedefiniieerd als "de ma ate waarin de gewenste uitkomsten worrden bekomen, o op voorwaarde va an een juist aanb bod van evidence-based d gezondheidsdie ensten voor al wie er baat bij hee eft, maar niet voor diege enen die er geen baat bij zouden hebben". Alle ind dicatoren zijn dus uitkoms st (resultaats) indicatoren. Er werden zev ven indicatoren g gekozen om de doeltreffendheid van de gezondheidzorg g te beoordele en: overlevingspercentage na borst-, baarmoederhals- of colorectale e kanker, percenttage hospitalisaties door astma, en drie e nieuwe indicatoren voor gees stelijke gezondhe eidszorg: aantal zelfdodin ngen per 100 000 0 inwoners (dit is ook een indicatorr van de algemene gezo ondheidstoestand van de bevolking g), de verhouding g tussen het tewerksttellingspercentage e van personen met ge eestelijke gezondheidspro oblemen en het percentage voo or personen met andere handicaps (zoa als musculoskele etale aandoeningen), de verhoud ding van gedwongen opn names gerelateerrd aan alle psychia atrische hospitalis saties. De overleving na n colon- en borsstkanker is goed in vergelijking mett andere Europese lande en. Er zijn, tot op p heden, nog gee en cijfers over de evolutie van de overlevingspercentages b beschikbaar. Ziekenhuisopna ames omwille van astma – die te ekorten in de am mbulante diensten weers spiegelen – zijn iiets hoger (d.w.z z. slechter in term men van doeltreffendheid d) dan het EU-15--gemiddelde.

KCE Reportt 196

Bij de indicatorren over de doeltreffendheid B d van de geesttelijke g gezondheidszorg stellen we een zeer z hoog aantal zelfdodingen va ast in v vergelijking met andere Europese e landen. Het a aantal zelfdodinge en is e echter ook afha ankelijk van persoonsgebonden en maatschapp pelijke fa actoren. Daarom m is het alleen maar een indire ecte indicator va an de d doeltreffendheid v van de geestelijk ke gezondheidszo org. Hoe dan ook, de re esultaten geven aan dat gezam menlijke actie nod dig is om het aantal a z zelfdodingen in België te verm minderen. De tw weede indicatorr, de a arbeidsparticipatie e van mensen me et geestelijke gezzondheidsproblem men in v vergelijking met de arbeidspartic cipatie van menssen met een an ndere h handicap, is moe eilijk te interprete eren en toont de e noodzaak om meer g gegevens te verz zamelen. Een la aatste indicator geeft aan dat in de a afgelopen jaren, het percentage gedwongen psyychiatrische opnames (c collocaties) toege enomen is. Het ho oogste percentag ge, dat in Brussel werd v vastgesteld, moett met de nodige voorzichtigheid v w worden geïnterpre eteerd (Deze verschillen zouden immers s kunnen toegesschreven worden n aan s stedelijke fenomen nen eerder dan aa an regionale verscchillen).


KCE Report 196 6

23

Tabel 3 – Indic catoren ter beoorrdeling van de do oeltreffendheid van v de zorg

Geestelijke gezondheid Curatieve zorg

Indicator

Bellgië

Meest recente gegevens s

Vlaanderen

Wallonië

B Brussel

Relatief overlevingspercentage e na 5 jaar - borstkanker

88,,0

2008 ii

87,6

88,8

8 88,0

- baarmoederha alskanker

69,,8

2008 ii

70,6

69,1

6 67,7

- colonkanker

M:6 62,3i V: 64,6 6

2008 ii

M:62,5 V: 64,5

M:62,5 V: 64,9

M:59,9 M V 64,3 V:

Hospitalisaties voor astma (/100 000 inw. 15+)

48,,4iii

2009 ii

Zelfdoding (aantal/100 000 0 inw.)

18,,6

2008iv

17

24

1 14

Tewerkstellings spercentage van n personen met een geestelijke e gezondheidssto oornisv

7 0,7

2002vi

Onvrijwillige opnames (% van n alle psychiatrische e hospitalisaties)

8

2009

8

7

1 14

i

Globaal

Tendens in de tijd

M

V

62,3

64,6

stabiel

28

52

stabiel

28

10

stijging

Sociaal S laag

Sociaa al hoog

Resultaten voorr colorectale kanker in OESO-Gezondh heidsgegevens voorr België. Laatste beschik kbare gegevens voo or België in OESO-G Gezondheidsgegeve ens: 2004 (dit was de d basis van de inte ernationale vergelijk king). iii Dit is het resulta aat van de OESO-G Gezondheidsgegeve ens voor België, na aanpassing voor le eeftijd. Percentage voor v België zonder aanpassing a is 40/10 00 000. iv Laatste beschik kbare gegevens in O OESO-Gezondheids sgegevens voor België: 2005 (dit was de d basis van de inte ernationale vergelijk king). v Verhouding van n tewerkstellingsperrcentage van person nen met een geeste elijke stoornis met het tewerkingstelling gspercentage van allle personen met ee en handicap. vi Resultaten van de laatste EU Labo our Force Survey. ii


24

2.4.2

Aange epastheid

Aangepastheid van zorg kan wo orden gedefinieerd d als "de mate waarin de verleende gezo ondheidszorg een n antwoord biedt op de medische e noden, rekening houdend met de best beschikb bare wetenscha appelijke bewijskracht (‘best-available tussen evidence’)". Het verband doeltreffendheid d en aangepasttheid weerspiege elt het verband tussen zorguitkomsten en zorgprocesse en. Er werden ach ht indicatoren gesselecteerd om de e aangepastheid van de zorg te meten. De resultaten zijjn in het algemee en niet al te best, vooral voor die indic catoren die verrband houden met m aangepasthe eid van borstkankerscre eening (niet in doelpopulatie) of he et opvolgen van richtlijnen (voor antibiotica a of voor opvolgin ng van diabetici).

KCE Reportt 196

Het aantal keizerrsneden neemt toe H t en vertoont een grote variab biliteit tu ussen de ziekenh huizen. T Twee indicatoren n beschrijven het h verbruik van antidepressiva a en a antipsychotica in de d algemene bev volking. Ze tonen dat dit verbruik boven b h het EU-15-gemid ddelde ligt. Bove endien stijgt het verbruik van deze g geneesmiddelen n steeds. nog T Tenslotte werd één é indicator ge emeten over de agressiviteit van de b behandeling op het einde va an het leven (Kankerpatiënten die c chemotherapie kriijgen tijdens de la aatste 14 dagen van hun leven). Deze g gegevens zijn ec chter moeilijk te e interpreteren b bij gebrek aan norm, n b benchmarking of te endens over de tijjd.

Tabel 4 – Indic catoren ter beoorrdeling van de aa angepastheid va an de zorg Indicator

Globaal

Mammogrammen n buiten de doelgroe ep (%) - Vrouwen in de leeftijd van 40-49 jaar - Vrouwen in de leeftijd van 71-79 jaar Antibiotica (% amoxicilline vvergeleken met amoxyclav) Correcte opvolgin ng van patiënten me et diabetes (%)* Keizersneden (pe er 1 000 levendgebo oortes) Voorschrijven van hoeveelheid//1 00 00 inw) Antideprressiva Antipsyc chotica

(gemiddellde

Meest recente gegevens

Tendens in de tijd

M

35,5 20,8 44,9

2010 2010 2008

sta abiel stijjging sta abiel

46,4

54

2008

sta abiel

193

2009

stijjging

68,4

2010

10,5 (12%/ 23%)i

2010 2005

V

Sociaal laag

Soc ciaal hoo og

Vlaanderen

Wallonië

Brussel

51,1

28,6 16,2 44,4

36,,6 23,,2 49,,4

28,6 16,4 46,0

46,4 27,7 42,8

47,7 31,2 47,1

54

55

48

58

57

52

48

stijjging

43,1

92,8

60,6

85,8

57,1

stijjging

10,8

10,3

9,6

11,9

11,7

dagelijkse

Kankerpatiënten die chemotherapie krijgen tijdens de laatste 14 dag gen van hun leven (%) i

België

Van hen die thuiis overleden/of van hen die in het zieke enhuis overleden, geen g nationale gege evens, waarden geb baseerd op één enke ele studie van het C Christelijk Ziekenfon nds. * Volwassen diab betespatiënten met regelmatige onderz zoeken van de retina a en bloedonderzoe eken (%).


KCE Report 196 6

2.4.3

25

Veiligh heid

Veiligheid kan worden gedefinie eerd als “de mate e waarin het systteem de patiënt geen sc chade berokkent”. Zes indicatoren n evalueren de vveiligheid van de zorg. De resulta aten zijn eerder matig. Er is nog steedss een hoge blo ootstelling aan medische m straling, maar er lijkt een daling g te zijn in 2011. Er is een daling in het aantal nosoc comiale infectiess door MRSA A (Meticilline-re esistente Staphylococcus s aureus) en de zziekenhuismortaliteit na een heupfractuur. De incidentie van postoperattieve sepsis en het voorschrijv ven van antidepressiva met anticholine ergische nevenwe erkingen bij oud deren is stabiel. Alleen de d incidentie van d doorligwonden in ziekenhuizen nee emt toe. Tabel 5 – Indic catoren ter beoorrdeling van de ve eiligheid van de zorg Indicator

Blootstelling B aan medische m straling van de d Belgische bevo olking (MSv/capita a) Incidentie van nos socomiale infecties door MRSA M (1/1 000 op pnames) Incidentie van pos stoperatieve sepsiis (/100 ( 000 ontslage en) Incidentie van doo orligwonden in ziekenhuizen z (%) Ziekenhuismortalit Z teit na een heupfrractuur (%) ( Ouderen O die antidepressiva met anticholinergische a e nevenwerkingen voorgeschreven v kregen (% patiënte en van 65 6 jaar en ouder die d antidepressiva a nemen) n I

OR Odds Ratio.

Globaal

België

Mees st recente gege evens

Tendens in de tijd

M

2,2

2011 1

1,5

2010 0

kleine da aling in 2011 daling

1224

2007 7

stabiel

16,8

2007 7

stijging

6,3

2007 7

daling

1,84i

14

2010 0

stabiel

13

V

14

Sociaal laag

Soc ciaal hoo og

Vlaandere en

Wallonië

B Brussel

1,2

2,2

1

17

11

1 10


26

2.4.4

Contin nuïteit van zorg

Continuïteit van n zorg is een concept dat verschillende dimensies s omvat, zoals de continuïteit in informatie e tussen de zorgv verleners, de plann ning van contacten met de verschillende zorgverleners, het relationele asp pect van de contacten tussen patiënt e en huisarts of de e coördinatie tus ssen de zorgverlenende e instanties of organisaties. De huid dige set van 7 ind dicatoren laat toe om conclusies te trekke en over elk van deze d dimensies, hetgeen een duidelijke verbetering v is verg geleken met het vorige v HSPA-rappo ort. In tegenstelling tot de gevestigde e indicatoren overr de gezondheidsttoestand van de bevolkin ng of over doeltre effendheid van zo org, is het erg moeilijk om de resultaten van v de zorgcoördinatie in België te e vergelijken met die van andere Europes se landen. Somm mige indicatoren zijn z erg specifiek voor v ons gezondheidssys steem (globaal medisch do ossier, multidisc ciplinaire teammeeting - “multidisciplinair oncologisch consult” (MOC)). Andere indicatoren worden goed besch hreven in de wettenschappelijke litteratuur, zoals de Usua al Provider of Ca are index (UPC)d. Maar er zijn niet n veel landen die besc chikken over de ju uiste nationale da atabanken met ind dividuele patiëntgegeven ns die nodig zijn om dit te meten. Eén resultaat, de UPC-index, kan als positieff worden bescho ouwd en veronderstelt een e goede relatie e met de vertrou uwde behandelen nde arts. Matige resultaten worden gevon nden voor contac ct met de huisarts s binnen de 7 dagen na a hospitalisatie en n bespreking op het MOC. De ne egatieve resultaten hebb ben betrekking o op het gebruik van v het globaal medisch dossier en de heropnames in p psychiatrische zie ekenhuizen. Dit la aatste is het enige dat momenteel m wordt verzameld door de d OESO en dit richt r zich specifiek op gee estelijke gezondh heidszorg.

d

De UPC, de Usual Provider o of Care index, is de e proportie van de contacten c atiënt heeft met zijn n eigen huisarts; 1 wijst w erop dat de pattiënt altijd die een pa dezelfde huisarts h bezoekt; de e indicator geeft het percentage patiën nten weer die een UPC van minstens 0,75 hadden, d.w.z. die minstens 3 conttacten op 4 met hun n gebruikelijke huisa arts hadden.

KCE Reportt 196


KCE Report 196 6

27

Tabel 6 – Indic catoren ter beoorrdeling van de co ontinuïteit en coö ördinatie van de zorg Indicator

België

Mees st recen nte gege evens

Tendens in de tijd

M

V

Sociaal laag

Socia aal hoog

Vlaanderen

Wallonië

Brus ssel

Patiënten met een globaal me edisch dossier (%)

47

2010 0

stijging

42

50

54

44

58

32

29

Patiënten me et kanker besp proken tijdens de e multidiscip plinaire teammeeting (% %)

68,8

2008 8

stijging

73,8

62,7

55,7 7

Ontmoeting me et huisarts binne en de week na ontsla ag uit het ziekenhuis (% patiënt van 65 jaar en ouder)

58,4

2009 9

stabiel

55,4

60,8

64,2

54,6

60,6

57,8

42,5 5

Proportie van contacten c met de e vaste huisarts (%), UP PC index (%) iii

71,4

2010 0

stabiel

72,1

71,2

76,7

70,5

70,8

74,4

65,9 9

20,2

2009 9i

stijging

25,2

17,2

10,2 2

15,6

2009 9i

stabiel

19,7

13,4

7,1

Heropname bin nnen de 30 dag gen in hetzelfde psyc chiatrische zieke enhuis (% ) - diagnose van schizofrenie - diagnose van bipolaire stoorniss Patiënten die contact c hadden met hun huisarts tijdens s de laatste wee ek van hun leven (%) i

Globaal

(72%)

ii

2005 5

: Dit zijn de laats ste nationale gegeve ens, terwijl de laatstte OESO-gegevens voor België dateren n uit 2007. 72% van de perrsonen die thuis ove erlijden hebben een n huisarts gezien tijd dens de laatste leve ensweek (geen natiionale gegevens, waarden w gebaseerd o op één enkele stud die van het Christelijk Zie ekenfonds). iii UPC, de Usual Provider of Care in ndex, is het percenttage contacten met de eigen huisarts van v een patiënt; 1 wijst w erop dat de pattiënt altijd dezelfde h huisarts zag; de ind dicator vertegenwoordigtt het percentage pa atiënten met een UP PC van minstens 0,7 75; d.w.z. die minste ens 3 contacten op 4 hadden met hun eigen huisarts. ii


28

2.4.5

Patiën ntgerichtheid

Patiëntgerichthe eid wordt gedefin nieerd als "zorgve erlening die respe ect toont en ontvankelijk k is voor de voorkeuren, node en en waarden van de individuele patiënt, en ervoor zo orgt dat alle klinis sche beslissingen worden geleid door de waarden van de patiënt". Het vorige HSPA-rapportt bevatte geen indicator die patiëntgericchtheid beoordee elde. Na een die epgaand onderzoek naar indicatoren en gegevens kunnen n slechts drie ind dicatoren worden voorge elegd. Dit weerspiegelt het feit datt er momenteel een e echt gebrek aan ge egevens is, en de weinige mee etbare indicatoren n geven slechts versnipp perde informatie o over een complex x onderwerp.

KCE Reportt 196

Uit de resultaten komt U k tot uiting datt patiënten over h het algemeen tevrreden z over de versc zijn chillende gezondheidsdiensten. Slechts één studie e kon g gegevens geven over o het centrale onderwerp o van piijncontrole. België ë doet h relatief slecht in vergelijking met het m andere landen n. Tenslotte toont één in ndicator over de plaats van overliijden een positievve tendens in de e loop v de tijd (minde van er patiënten overliijden in het ziekenhuis) maar met grote v verschillen afhank kelijk van de socio-economische sta atus.

Tabel 7 – Indic catoren ter beoorrdeling van de pa atiëntgerichtheid d van de zorg Indicator

België


Tevredenheid met gezondheidsdie ensten (% goed of zeer goed)

>90% ii

2008

Pijn altijd gecontroleerd hospitalisatie (% % patiënten)

(41,0) iii

2009

(45,1)i

2007

Patiënten die e overlijden gebruikelijke wo oonplaats (%) i

Globaall

tijdens in n

hun

Te endens in de tijd

M

V

Geen verschil

Sttijging

Sociaal laag

Soc ciaal hoo og

Vlaanderen

Wallonië

Brus ssel

Geen verschil

Hoger

Lager

Laag gste

iv

45,1i

45,1 1i

Nationale gegev vens zijn nog niet be eschikbaar. Resulta aten voor Vlaandere en en Brussel worde en gezamenlijk gera apporteerd. Het niveau van n tevredenheid ligt b boven 90% voor co ontacten met huisarrts, tandartsen, spe ecialisten en dienstten voor thuiszorg. Alleen voor ziekenhuizen is het nivea au van tevredenheid iets s lager (87%). iii Resultaten van één enkele studie a alleen in RN4cast project. p iv Gebaseerd op een e studie van het C Christelijk Ziekenfon nds en andere publlicaties. ii


KCE Report 196 6

2.5

Efficiën ntie van het gezzondheidssyste eem

Efficiëntie word dt gedefinieerd alls "de mate waarin de juiste hoev veelheid middelen (d.w.z. geld, tijd en p personeel, input genoemd) ingeze et wordt voor het syste eem (macronivea au) en ervoor gezorgd g wordt dat deze middelen worde en gebruikt om ee en zo groot mogelijke winst of een zo goed mogelijk resulta aat te behalen (ou utput genoemd)”.4,, 7 Drie indicatore en werden gesselecteerd om de efficiëntie van v het gezondheidssys steem te evaluere en. Net zoals in an ndere Europese la anden is er in België een n tendens naar ee en meer efficiënt gebruik g van zorgd diensten. De drie indicato oren evolueren im mmers positief in de loop van de tijd: stijging van voorschriften voor goed dkope geneesm middelen, toenam me van chirurgische da aghospitalisatie, e en daling van de verblijfsduur voor een normale bevallling (hetgeen ee en meer vergelijk kbare indicator is s tussen landen dan de gemiddelde verbllijfsduur voor de totale t ziekenhuisp populatie die in het eerste e HSPA-rapport w werd gebruikt), ma aar nog steeds ho oger dan het EU-15-gemiddelde.

29

Andere indicatoren A n die in dit rapport worden geanalyyseerd geven ook k een in ndicatie van de efficiëntie e van he et systeem. De sstijging van het aantal a p patiënten met een n globaal medisch h dossier kan bijvo oorbeeld leiden to ot een v vermindering van het aantal dubbele onderzoeken. D De tendens van an ndere in ndicatoren is min nder positief. Bijv voorbeeld, aange ezien de helft va an de b borstkankerscreen ning gebeurt buite en het nationale programma kan men z zich vragen stellen over de efficiën ntie hiervan. Onve erklaarbare variab biliteit in n gezondheidszo orginterventies kan k ook een p proxy zijn voor niet a aangepaste zorg (‘non appropriate’), hetgeen rech htstreeks samenh hangt m efficiëntie. Dit werd, bijvoorbeeld, aangetoond vvoor keizersnedes met s.

Tabel 8 – Indic catoren ter beoorrdeling van de effficiëntie van de zorg Indicator

Globa aal

Chirurgische da aghospitalisatie (% %) Gemiddelde verblijfsduur normale bevalling (dagen)

vo oor

een

Voorschrijven van v ambulante g goedkope geneesmiddele en (% DDD op tota aal) Andere indica atoren besproken n in de sectie over aangepastheid DDD = Standaard d dagdosering (defiined daily dose).

België


Tend dens in de e tijd

46,2

2008

Stijging

4,3

2008

Dalin ng

46,0

2010

Stijging

M

V

Sociaal laag

Socia aal hoog g

Vlaanderen

Wallonië

Brus ssel

46,2

45,9

45,3 3


30

2.6

Duurza aamheid

Duurzaamheid wordt gedefinieerrd als het vermoge en van het systee em om: •

en personeelsbes stand, ter beschikking te een infrasttructuur, zoals ee stellen en te t behouden (bijvv. door opleiding en e training, voorziieningen en uitrustin ng);

•

innoverend d te zijn;

•

te reageren n op nieuw ontsta ane noden;

• duurzaam gefinancierd te blijven door collectieve ontvangsten. Voor de vier elementen e uit de e definitie werde en specifieke ind dicatoren geselecteerd. De D laatste indicato or, totale gezondh heidszorguitgaven n, is een generische indicator voor financiële duurzaamheid d.

KCE Reportt 196

De resultaten tonen een mix van negatieve resulta D aten (slecht verm mogen v het systeem om van o de groep huisartsen te vervang gen die ouder worrdt en b bijna op pensioen n gaat); matige re esultaten (aantal lligdagen in acute e zorg p inwoner; onvo per oldoende gebruik van elektronisch medisch dossierr door h huisartsen), en ind dicatoren die niet kunnen worden g geïnterpreteerd zo onder g gegevens over noden (afgestudeerd den verpleegkund de). H Het percentage van het Bruto o Binnenlands Product (BBP) dat g gespendeerd word dt aan gezondheid dsuitgaven bedroeg 10,5% in 2010 0. Het b bedrag in absolute e cijfers bedroeg €27,6 € miljard in 20 003 en €37,3 milja ard in 2 2010.

catoren ter beoorrdeling van de du uurzaamheid van n het gezondheid dssysteem Tabel 9 – Indic Indicator

B België


Tend dens in de tiijd

Nederlandstalig

Frans s taligi

% afgestudeerrden in geneeskunde die huisartts worden

3 30,1

2009

dalin ng

29,2

31,0

Gemiddelde lee eftijd huisarts

5 51,4

2009

stijg ging

51

52

1 00 00

4 41,7

2010

stab biel

% huisartsen da at een elektroniscch medisch dossie er gebruikt

7 74,0

2010

stijg ging

83,7

62,5

Beddagen acutte zorg (aantal beddage en per capita)iii

1 1,2

2009

stab biel

Totale gezondh heidszorguitgaven n (% BBP)

1 10,5

2010

stijg ging

Afgestudeerden n inwoners)ii

Globaal

verpleegkund de

(per

i Voor deze reeks s indicatoren zijn ge een gegevens besch hikbaar per gewest,, maar per taal (Fran ns- of Nederlandsta alig). ii Deze indicator moet m worden geïnte erpreteerd samen met m de indicator van de dichtheid van prraktiserende verpleegkundigen (in secttie over toegankelijkkheid). iii Deze indicator moet worden geïntterpreteerd samen met m de indicator van n het percentage ch hirurgische dagopna ames (in sectie overr efficiëntie). enlands Product. BBP Bruto Binne

KCE Report 196 6

2.7


Gezond dheidspromotie e

Om verschillend de redenen was h het niet mogelijk om o binnen het be ereik van dit rapport een volledig overzichtt te geven van de e performantie op het vlak van gezondheid dspromotie. 1. Gezondheiidspromotie, het ""proces dat mens sen toelaat meer controle uit te oefen nen over hun gezzondheid en die te t verbeteren", is een erg ruim begrip p. De strategische e lijnen (zoals ged definieerd in het Handvest H van Ottaw wa) omvatten verrantwoordelijkheden die zich grottendeels buiten hett gezondheidszorrgsysteem bevind den en zelfs buiten het gezondheid dssysteeme. Een groot aantal ind dicatoren, gestructureerd binnen een n specifiek concep ptueel kader, zoud den noodzakelijk zijn. z 2. De mees ste indicatoren die nodig zouden zijn om o de gezondheid dspromotie te e evalueren zijn niet n klaar voor gebruik. Sommige worden w nog ontw wikkeld, terwijl and dere nog moeten worden aangepast aan de Belgische e/regionale contex xt. 3. Er zijn wein nig gegevens besschikbaar. 4. De conven ntionele, gemakke elijk te meten (hoewel met een beperkte b van kijk) uitkomstindicatore en op het vlak gezondheid d/gezondheidsged drag zijn distale uitkomsten u beïnvlo oed door gezondheid dspromotie evena als door andere fa actoren. Er zijn ve eel meer indicatoren n, met hun waarde en en enige vorm van benchmarkin ng, nodig om de koers te bepalen van het beleid.

e

De vijf lijne en van het Handvesst van Ottawa zijn: - het uitw werken van een gezzond overheidsbele eid (de verantwoord delijkheid van de zo orginstanties is om gezondheid op he et agenda van elk beleid te plaatsen) - het creërren van ondersteun nende omgevingen (life ( settings) - het ontw wikkelen van individu uele vaardigheden - het verstterken van de actiess van de gemeensc chap - het heroriënteren van de ge ezondheidsdiensten en dimensies van gezondheidsprom motie zijn: De belangrijkste waarden e e, empowerment,, billijkheid, duu urzaamheid, multistrategie, participatie multisecto orialiteit.

31

Bijgevolg wordt hier slechts ee B en partieel bee eld gegeven van n de p performantie van gezondheidsprom motie door midde el van 15 indicattoren, z zoals getoond in Tabel T 10. V Voor veel van de klassieke indicatoren vvan de catego orieën g gezondheidsuitkom msten en gezo onde levensstijl zijn de nationale p percentages midd delmatig. Er word den echter belang grijke regionale/so ociale o ongelijkheden vas stgesteld, met een n gunstiger levensstijl in Vlaandere en en in n de beter opgeleide klassen (met uitzondering van alcoholconsumptiie). In nternationale ben nchmarking was slechts mogelijk vo oor enkele indicattoren. W wijzen op het We h probleem va an obesitas/overg gewicht dat erg veel v voorkomt, nog steeds toeneemt en dat ernstige onge elijkheden vertoon nt. De ta abaksconsumptie e daalt, hoewel ze e met 20% dagelijjkse rokers nog steeds te e hoog is, maar ook hier treffen we grote sociale e ongelijkheden en e vrij g grote regionale on ngelijkheden aan. De consumptie vvan fruit en groenten is v veel lager dan de e dagelijkse beho oeften, maar er w wordt een verbettering o opgemerkt. De we ekelijkse alcoholc consumptie is nie et erg hoog, maa ar het lijkt dat de ve erslaving in stijgende lijn ga aat. Het percen ntage a alcoholconsumptie e moet echter met m de nodige o omzichtigheid wo orden g geïnterpreteerd aa angezien het bijzo onder gevoelig is voor vertekening g door s sociaal wenselijk antwoordgedrag g. Er worden g geen regionale/so ociale o ongelijkheden va astgesteld voor deze indicatorr (tenzij een hoger h p percentage "problematisch drinken n", d.w.z. een tendens tot verslavin ng, in B Brussel). H percentage HIIV-diagnoses bij Belgische Het B burgerss steeg langzaam in de la aatste jaren. Daarenboven wordt er e een grote toena ame vastgesteld bij de m mannelijke homos seksuele bevolkin ng. Er worden hier geen internationale v vergelijkingen ge etoond, aangezie en het diagnose epercentage bij nietB Belgische person nen zou kunnen n bestaan uit een grote fractie e van g geïmporteerde g gevallen die niet zo releva ant zijn voor het g gezondheidspromo otiebeleid in België. H Het percentage van de bevolking dat een gebrek aan so ociale o ondersteuning erv vaart ligt, gemidd deld genomen, niet zo hoog. Nochtans z er grote socia zijn ale en regionale verschillen. v Boven ndien is dit percentage v veel hoger bij oude eren.


32

De Tobacco Control Scale Policcies maakt een internationale i verrgelijking over het overhe eidsbeleid om de tabaksconsumptie te verminderen n. België staat hier op ee en middelmatige p plaats. De andere indicatoren zijn indexxen die tot doel hebben h de kracht van het lokale beleid inzake i gezondhe eidspromotie in verschillende v setttings te meten. Ze zijn alleen beschikbaar in Vlaand deren (door de VIGeZ-

KCE Reportt 196

enquêtes). Ze zijn e n moeilijk te interpreteren zonder e een grondige ana alyse. T Tendensen gemetten door opeenvo olgende enquêtess lijken er op te wijzen w d de cultuur van dat n gezondheidspromotie in de schollen aan het verbe eteren is s (de cultuur om o deel te nem men is vrij goe ed), het aanbod van het wordt lichaamsbeweging g verbetert. In veel gemeenten g gezondheidspromo otiebeleid echter niet goed geïmple ementeerd.

Tabel 10 – Indiicatoren van gezzondheidspromo otie Indicator

Volw wassenen met ove ergewicht of obesiitas (%) Obe ese volwassenen (% %) Tan ndbederf, ontbreken nde tanden , tand den mett vullingen in de leeftijdsgroep 12-14 (gem middelde score) Perrcentage HIV-diag gnose in Belgiscche bev volking (/100 000 inw w) Dag gelijkse rokers (% 15+) Alco oholconsumptie (% 15+) -Pro oblematischi -Ov verconsumptieii -Co omazuipeniii Minstens 200g groentten en 2 stukken ffruit per dag (%) Minstens 30 minuten lichaamsbeweging per g (%) dag Slec chte sociale onders steuning (%) Tob bacco Control Scale e Sco ore van aanbod va an lichaamsbeweg ging op school s Gez zondheidspromotieb beleid in de gem meentenVII % scholen s met een gez zondheidsteamVII

Globaal

België B

Meest recente e gegeve ens

Tendens in de tijd

M

V

Sociaal laag

Sociaal hoog

Vlaandere en

Wallonië

B Brussel

46,9 4

2008

stijging

53,7

40,4

57,8

40 0

47,1

48,9

3 39,8

13,8 1 iv 1.3 1

2008 2010

stijging

13,1

14,4

19,1

9,,1

13,6

14,6

1 11,9

3,9 3

2010

stijging

6,9

0,7

3,8

2,40

8 8,9

20,5 2

2008

daling

23,6

17,7

22,1

13 3,1

18,6

24

2 22,3

10,2 1 7,9 7 8,1 8 26,0 2

2008 2008 2008 2008

stijging stabiel stijging

13,1 10,1 12,8 23,4

7,3 5,9 3,7 28,5

11,5 5,9 8,3 21,7

11 8,,4 7,,6 29 9,4

9,5 7,9 8,9 30,0

10,7 8,4 7 19,2

14,4 1 6 6,7 6 6,2 2 25,3

38,1 3

2008

stabiel

48,7

28,3

24,0

42 2,8

45,1

28,4

2 24,7

15,5 1

2008

15,1

16

24,4

10 0,1

12,4

20,0

2 22,9

50/100 5

2010

40%v

40% v 4

2009

stijging

37/36/50vi

2009 2009

5,5/10

Stijging

42/64/54 vvi

KCE Report 196 6


33

i

: Berekend op de e populatie persone en die alcohol drinke en (niet-geheelontho ouder) en gebaseerrd op CAGE, 2+ cutt off. ii 15+ bij vrouwen n; 22+ bij mannen. iii Risicovol drinke en tijdens één geleg genheid (≥6 drinks) minstens een keer per week. iv Enkele gegeven ns maar te weinig la anden. v Voor Wallonië en e Brussel samen. vi Indicatoren van n VIGeZ; respectievvelijk bij tabakspreve entie, gezonde voed ding en lichaamsbew weging (scores van VIGeZ).

2.8

Billijkhe eid en gelijkheiid

Billijkheid is een n kernelement bij de evaluatie van de performantie van een gezondheidssys steem.1 Het is ook een controversieel en normatief n onderwerp, dat verwijst naar o oordeel en politiieke standpunten n. In de literatuur werd d een ruim aa anbod aan pers spectieven en definities d voorgesteld. Wij W geven deze we eer in Supplemen nt S2 van dit rapp port: "De plaats van billijkheid bij de beoordeling van n de performan ntie van gezondheidssys stemen" (beschikbaar op de website). Aangezien we ons o bewust waren n van dit kenmerk k, hebben we de dimensie d van billijkheid op o twee complem mentaire manieren n benaderd. In de e eerste plaats hebb ben we de e ongelijkhede en in gezo ondheid, gezondheidsde eterminanten en gebruik van gez zondheidszorg in n België gedocumenteerrd per socio-econ nomische status (resultaten in Ta abel 11). Ten tweede hebben we contextu uele indicatoren voorgesteld die pro oblemen van billijkheid in de gezondhe eidszorg op een globaal niveau kunnen markeren (resultaten in Tabel 12 2 en Afbeelding 2)). Billijkheid in gezondheid wordt ssoms gedefinieerd d als "de afwezigh heid van systematische ongelijkheden in gezondheid/ge ezondheidsdeterm minanten tussen sociale groepen die versschillende posities s innemen in een n sociale hiërarchie". Om m die reden conccentreert dit hooffdstuk zich alleen n op de socio-economis sche ongelijkhede en. Andere ongelijjkheden (bijv. op het vlak van geslacht off gewest) worden n weergegeven in n de synoptische tabellen

voor elke dimens v sie, en worden besproken in d de gedetailleerde e per in ndicator (zie Supplement S1). We e hebben de socio o-economische positie p o ook beperkt tot slechts één ken nmerk: het opleid dingsniveau (voo or de in ndicatoren van de e HIS) of de statu us van preferentië ële terugbetaling voor d de administratieve databanken. Andere dime ensies van so ociale o ongelijkheid, zoals s tewerkstellingsstatus, inkomen off etniciteit, werden n hier n onderzocht. niet

2 2.8.1

Socio-ec conomische ong gelijkheden

Er werden grote socio-economisch E he ongelijkheden gemeten op hett vlak en v van algemen ne gezondh heidsuitkomsten (levenszijn o overlijdensverwac htingen, zelfra apportage gezo ondheid); dit e eindpuntmetingen die wijzen op billijkheidsproblem men in de keten n van minanten. Ongellijkheden werden g gezondheidsdeter n ook vastgesteld bij ta alrijke indicatore en op het vlak k van gezondh heidspromotie (roken, o overgewicht/obesi tas, te weinig g fruit en g groenten eten, aan lichaamsbeweging g doen en socia ale steun). Er w werden ongelijkh heden v vastgesteld voor de d dimensie van to oegankelijkheid. JJammer genoeg waren w v voor de meeste indicatoren van n de andere dim mensies geen socios e economische geg gevens beschikba aar, en konden de ongelijkheden n niet w worden gemeten.

34


KCE Reportt 196

Tabel 11 – Ove erzichtstabel van n socio-economis sche ongelijkhed den

Algemene gezon ndheidstoestand Levensverwachting op 25 jaar bij ma annen, 2001 i; ii Levensverwachting op 25 jaar bij vro ouwen, 2001 i; ii Levensverwachting in goede gezon ndheid op 25 jaar bij b mannen, 2001 i; ii Levensverwachting in goede gezon ndheid op 25 jaar bij b vrouwen, i; ii 2001 g % van de bevolking (leeftijd 15 jaar en ouder) die hun gezondheid als goed of zeer goed g beoordelen iii Toegankelijkheid van zorg Uitgestelde contacten met ge ezondheidszorgdien nsten om financiële redene en (% huishoudens)) iv Borstkankerscree ening (% vrouwen in n de leeftijd van 50--69 jaar) v Borstkankerscree ening (% vrouwen in n de leeftijd van 25--64 jaar) v Aangepastheid % volwassen dia abetici die aangepasste zorg krijgen, in termen t van regelmatige onde erzoeken van de rettina en bloedonderz zoeken v Gezondheidspro omotie % van de popula atie (leeftijd 15 jaa ar en ouder) dat ve ermeldt dat hij/zij dagelijks ro ookt iii % van de populatie (leeftijd 15 jaa ar en ouder) dat een e slechte sociale steun meldtiii % van de volwa assen populatie datt wordt beschouwd als obees (BMI ≥ 30) iii % van de volw wassen populatie dat wordt besch houwd als zwaarlijvig of obe ees (BMI ≥ 25) iii % van de populatie dat meldt dat ze e minstens 200g gro oenten en 2 stukken fruit per dag d eten iii % van de popu ulatie dat meldt d dat ze minstens 30 3 minuten iii lichaamsbewegin ng per dag heeft

Totalle waarrde (f)

Waarde in laagste sociale groep (ff)

Waarde in n hogere so ociale groep (f)

Absoluut verschil v (laagste vs s hoogste)

Relattief risico o (laag gste vs hoog gste)

Overziicht meting g (CII of PAF)

51,38 8 57,09 9 40,47 7

47,56 53,98 27,75

55,03 59,9 46,33

-7,47 -5,92 -18,58

n.v.t. n.v.t. n.v.t.

3,73% 1,43% 15,30% %

40,42 2

28,92

47,1

-18,18

n.v.t.

16,56% %

76,8% %

57,4%

85,7%

-28,3%

0,67

11,6%

14,0% %

27,0%

4,0%

23,0%

6,75

-71,4% %

60,1% % 61,8% %

48,6% 48,9%

62,9% 64,2%

-14,3% -15,3%

0,77 0,76

4,7% 3,9%

% 54,0%

48,0%

58,0%

-10,0%

0,83

7,4%

20,5% %

22,0%

13,1%

8,9%

1,68

-36,1% %

15,5% %

24,4%

10,1%

14,3%

2,42

-34,8% %

13,8% %

19,2%

9,1%

10,1%

2,11

-34,1% %

46,9% %

57,8%

40,0%

17,8%

1,45

-14,7% %

26,0% %

21,7%

29,4%

-7,7%

0,74

13,1%

38,1% %

24,0%

42,8%

-18,8%

0,56

12,3%

KCE Report 196 6


i

35

in jaren; ii 5 ople eidingsniveaus; iii 4 o opleidingsniveaus; ivi 5 inkomensniveau us; v 2 terugbetaling gscategorieën. percentages zijn niet aangepast aan n leeftijd; samenvatttende metingen= CII (Concentration In ndex of inequalities) van toepassing op p levensverwachting g en levensverwachting in n Attributable Fractio on) voor alle andere e indicatoren. goede gezondheid, PAF (Population Bron: Gezondheiidsenquêtes (HIS) e en EPS (WIV – ISP en KCE-berekening gen). PA lichaamsbewe eging.

2.8.2

Conte extuele indicatorren van billijkheid d

We hebben tw wee contextuele billijkheidsindicatoren geselectee erd: een indicator van prrogressiviteit van overheidsfinancie ering en een indic cator van de verdeling va an het nationaal inkomen. Ten ee erste tonen de be erekende ratio’s in Tabel 12 dat het aand deel van regressieve financieringsbronnen (indirecte belas stingen) gestege en is. Over het algemeen zijn indirecte i belastingen reg gressief omdat de e rijken en de arm men hetzelfde perrcentage indirecte belas stingen betalen o op consumptiego oederen en diensten en rijkere personen n een hoger deel van hun inkomen n sparen. Vandaar dat het gemiddelde percentage indire ecte belastingen n (indirecte bela astingen gedeeld door het h inkomen) daalt met het inkom men. We moeten n echter voorzichtig zijn met de interpreta atie van de tenden ns omdat het bij de e laatste twee jaren slechts om gebudgettteerde bedragen gaat. g Ten tweede, om mdat de gezondh heidstoestand kan n worden beïnvlo oed door het niveau van inkomensongelijkkheid in een land, tonen we de evolutie van de Gini-coëfficië ënt sinds 1988 in België. Aangezie en de waarde van de Ginicoëfficiënt stijgtt met de inkomensongelijkheid, ste ellen we vast dat in België de ongelijkheid d toeneemt en ho oger is in Brusse el dan in de ande ere twee gewesten.

36


KCE Reportt 196

Tabel 12 – Indiicator van billijkh heid: progressiviteitsindicatoren n van de publieke e financiering van het gezondheidssysteem Indicatoren va an progressiviteitt

2005 (definitieve rekeningen)

2006 ((definitieve re ekeningen)

2007 (definitieve rek keningen)

2008 (v voorlopige re ekeningen)

2009 ((voorlopige r rekeningen)

2010 ((budget)

2011 (budget)

Ratio proportio onele ontvangste en/totale ontvangsten

71,1%

71,0%

72,0%

70,6%

69,4%

64,8%

6 61,4%

Ratio progress sieve ontvangste en/totale ontvangsten

18,9%

19,0%

18,0%

17,3%

17,2%

19,4%

18,4%

Ratio regressie eve ontvangsten n/totale ontvangsten

10,0%

10,0%

10,0%

12,1%

13,4%

15,8%

2 20,2%

100,0%

100,0%

100,0%

100,0%

100,0%

100,0%

10 00,0%

Totaal

Bron: Vademecum van de sociale ze ekerheid, RIZIV – IN NAMI, KCE-bereken ningen.

KCE Report 196 6


Figuur 2 – Ind dicator van billijjkheid: Gini-coëffficiënt na belas sting en overdrachten, in België en gew westen

2 2.9

37

Conclusie es over zwakke e en sterke pun nten

G Gezondheidstoes stand De vier indicatoren D n laten een positie eve evolutie in de e tijd zien. Het resultaat v van de levensverrwachting is iets s lager in vergelijking met het EU-15 E g gemiddelde, terwijjl de gezonde lev vensverwachting (dit zijn de resterrende g geleefde jaren va anaf een bepaald de leeftijd zonder activiteitbeperkin ng op la ange termijn) en de zuigelingenste erfte op een midd delmatige plaats staan. s H percentage van Het v mensen die hun gezondheid d als (minstens) goed b beschouwen, is ho oger dan het EU-1 15 gemiddelde. T Toegankelijkheid d

Bron: ADSEI (Be elgië) Noot: de Gini-co oëfficiënt is een coë ëfficiënt voor ongellijkheid van inkome en in een bevolking. Wanneer er perfecte geliijkheid is (iedereen heeft hetzelfde ink komen) is ecte ongelijkheid is s (één persoon hee eft al het de coëfficiënt 0. Wanneer er perfe inkomen), is de coëfficiënt 1. Een n lagere coëfficiëntt wijst op een mee er gelijke verdeling van de inkomens.

Met betrekking tot de financiële to M oegankelijkheid, iss er sprake van enige b bezorgdheid (hoge mate van pers soonlijke uitgaven n van de patiënt en in z zekere mate uitg gestelde contacte en met de gezzondheidsdiensten n om fiinanciële redenen), ondanks een n universele ziekkteverzekering en n het b bestaan van soc ciale vangnetten (maximumfactuur, Omnio, Bijzo onder . De toegankelijkh S Solidariteitsfonds) heid van preventieve maatregelen toont u uiteenlopende res sultaten. De cijfers s voor kankerscre eening (met socia ale en e enkele regionale verschillen) zijn n relatief laag, tterwijl de cijfers over v vaccinatiegraad tegen griep bij b ouderen middelmatig zijn. De v vaccinatiegraad bij kinderen is s goed. Een ander aspect van to oegankelijkheid is s een beschikba aar aanbod aan gezondheidspersoneel m betrekking to met ot de behoeften. Er werden aanzzienlijke inspanningen g geleverd om gegevens over de aa anbodzijde te verkkrijgen, maar er is s nog te e weinig informatiie over de behoeft ften.

38


KCE Reportt 196

Zorgkwaliteit

E Efficiëntie

De kwaliteit werd w onderzocht door middel van 5 dimensies. De doeltreffendheid d liet een gemeng gd beeld zien waa arbij goed werd gescoord g op het vlak van n overlevingskanse en bij kanker. Er is i echter wel bezo orgdheid op het vlak va an de geestelijke e gezondheidszorrg, aangezien Be elgië het tweede hoogstte aantal zelfdod dingen in Europa a heeft (met zee er grote regionale versc chillen), en een ho oog en toenemend d percentage ged dwongen opnames in ps sychiatrische ziekkenhuizen. Meer indicatoren en ge egevens zijn nodig om de doeltreffendheid d in geestelijke ge ezondheid te besc chrijven. Wat de aangepastheid van zorg betreft zijn n de resultaten eerder teleurstellend te t noemen, met hoge en nog stiijgende percentag ges van borstkankerscre eening buiten d de doelgroepen, matige opvolgiing van richtlijnen (an ntibiotica, diabe etespatiënten), stijgende perc centages keizersneden met m een grote varriabiliteit tussen de d ziekenhuizen. Voor de veiligheid van zorg zijn de resu ultaten bemoedigend, met dalende e trends wat betreft de blootstelling aan medische stralin ng, de ziekenhuis sbacterie MRSA en zieke enhuismortaliteit n na heupfractuur, en e een stabiele in ncidentie van postoperattieve sepsis en h het voorschrijven van antidepress siva met anticholinergisc che nevenwerkin ngen aan ouderren. De inciden ntie van doorligwonden neemt echter toe e. Voor de contin nuïteit en coördinatie van de zorg zijn de resultaten gemen ngd, met een goe ede relationele con ntinuïteit bij dezelfde arts, gemiddelde en stijgen nde percentages voor multidisciplinairre consultaties vo oor kankergevallen n, maar een lage dekking van het globaal medisch dossier en een hoog pe ercentage heropn names in psychiatrische ziekenhuizen. Pa atiëntgerichtheid kon k slechts deels worden beoordeeld. Er E werd een hoge tevrede enheidsgraad ov ver de gezondheidszorg vastgesteld, evenals een toe enemende trend om te sterven in de eigen woonplaa ats. Er moeten meer gegevens worden verzameld overr dit onderwerp.

De efficiëntie van D n het gezondheid dssysteem toont g gemiddelde tot goede g re esultaten met een stijging in n het voorschriijven van goed dkope g geneesmiddelen, het gebruik van n het dagziekenh huis voor chirurg gische in ngrepen en een daling van de ve erblijfsduur voor e een normale beva alling. D positieve bood De dschap moet echter worden getem mperd door de slechte re esultaten van sommige indicatore en die wijzen op een zekere mate e van o ongeschiktheid, en n dus verspilling van v middelen, zoa als de bovengenoe emde m mammogrammen buiten de doelgro oep. D Duurzaamheid De duurzaamheid van het Belgisch D he gezondheidssyysteem vertoont enkele o opmerkelijke resultaten met betrek kking tot de verva anging van de hu uidige g groep van ouder wordende huisa artsen. Zoals hie erboven vermeld is er d dringend nood aa an gegevens ove er de behoefte a aan verpleegkund digen, g gekoppeld aan gegevens over de evolutie van het aa anbod. B Billijkheid De dimensie van D n billijkheid werd d benaderd op twee complementaire m manieren. Ten eerste werde en ongelijkhede en in gezond dheid, g gezondheidsdeter minanten en gebrruik van gezondhe eidszorg geanalys seerd p socio-econom per mische status. Vo oor de indicatoren van gezondheid en le evensstijl werden sterke ongelijkhe eden vastgesteld, die hierboven we erden b besproken. Ook voor kankerscrreening en voo or de opvolging van c chronische patiënten werden onge elijkheden waarge enomen. In dit ra apport k konden de meeste ziekenhuisgeba aseerde indicatoren echter niet wo orden o onderzocht per sociale s status, en e de conclusie e is nog grotendeels o onvolledig wat bettreft ongelijkheden n in zorgverlening g en kwaliteit. Billijkheid w werd ook benaderd via twee conte extuele indicatore en die dit problee em op e globaal niveau onder de aanda een acht brengen. De e progressiviteit va an de fiinanciering van de d gezondheidszo org daalt, hetgeen n een evolutie is naar m minder billijkheid. De Gini- coëfficiënt stemt overee en met het niveau u van o ongelijkheid in de d globale verde eling van inkome ens in België. Er is a aangetoond datt de coëfficiën nt samenhangt met de globale g gezondheidstoesta and. In België lig gt de coëfficiënt rrelatief laag (dus geen g grote ongelijkheid d), maar hij stijgtt in de loop van de tijd, hetgeen n kan w worden geïnterpre eteerd als een min nder gelijke verdelling van de inkom msten.

KCE Report 196 6


Gezondheidsp promotie Tenslotte werd gezondheidspromotie vooral ben naderd aan de ha and van conventionele gezondheidsg en levensstijlindicato oren, aangevuld met een aantal indicato oren met betrekkking tot het gezo ondheidsbeleid, gezonde g leefomgeving en individuele vvaardigheden. Gezien G de erg beperkte b beschikbaarheid van geschikte indicatoren en gegevens g kon alle een een versnipperd beeld wo meeste orden getoon nd. De gezondheids/levensstijlindicatore en wijzen op ee en middelmatig nationaal n cijfer, maar er e worden wel grote regionale/sociale ongelijkheden vastgesteld. We e wijzen op het probleem van obes sitas/overgewicht dat een vrij hoge, en stijgende trend d met grote ve erschillen laat zien. De tabaksconsump ptie daalt, maar m met grote sociale en regionale verrschillen. De consumptie e van fruit en groenten is veel lager dan de da agelijkse behoeften, maa ar gaat erop voorruit. Het gebrek aa an sociale steun vertoont ook belangrijke e sociale en region nale verschillen, en e baart vooral zo orgen bij ouderen. Belg gië bevindt zich h op een midd delmatig niveau op de internationale Tobacco Contro ol Scale Policie es. Sommige co omplexe indexen hebbe en tot doel de kracht van het lokale beleid inzake gezondheidspro omotie in verscchillende settings s (scholen, gem meenten, ondernemingen n) te meten, maarr zijn alleen beschikbaar in Vlaand deren en zijn moeilijk te interpreteren zond der een grondige analyse. Meer gegevens s op onze website e! Voor elk van de e hierboven beschreven indicatore en is een technisc che fiche beschikbaar op p de KCE-website e in het documentt met als titel Sup pplement S1. Het vat de d rationale sam men voor het kiezen van de in ndicator, technische info ormatie over de e gegevensbronn nen en berekening, alle resultaten, waa aronder subgroepa analyses en benc chmarking, beperk kingen in interpretatie, en n alle bibliografiscche referenties.

39

3 HET 201 12 HSPA-R RAPPORT: NUT, TOEGEV VOEGDE WAARDE W E EN BEPERK KINGEN 3 3.1

Wat is he et nut van dit HS SPA-rapport?

Het uiteindelijke doel H d van het gez zondheidssysteem m is om in Belgïe e een h hoog performant systeem aan te bieden dat een bijdrage levert to ot het v verbeteren van de e gezondheid van n de inwoners op p zijn grondgebied d. Dit b betekent dat de informatie die in dit rapport word dt weergegeven moet d dienen om, indien n nodig, de performantie van het gezondheidssystee em te v verbeteren. Het moet m de beleidsma akers ook helpen bij het formuleren n van n nieuwe gezondhe eidsgerelateerde doelstellingen d op federaal of regionaal n niveau. De formu ulering van gezon ndheids(gerelatee erde) doelstellingen is e een belangrijke sttap in het proces s van de beoorde eling van performantie. D zou immers to Dit oelaten om in de volgende evaluatties een vergelijkiing te m maken tussen de vooropgestelde v e de bereikte ressultaten. en A de hand van 74 indicatoren ge Aan eeft dit rapport ee en breed beeld va an de p performantie van het Belgische gezondheidssystteem. De indica atoren fu ungeren als alarmsignalen a w wat betreft de toestand van het g gezondheidssyste em in termen van toegankelijkheid, kwaliteit, efficiëntie, d duurzaamheid en billijkheid. In som mmige gevallen zzijn beleidsmakers s zich a bewust van de problemen en hebben ze al opdracht gegeve al en tot b bijkomende analy yses om te weten w welke acties moeten wo orden o ondernomen. In andere gevallen n zijn deze sign nalen nieuw voo or de b beleidsmakers, en n zal dus een verrdere diepgaande e analyse nodig zijn. In ie eder geval moet de uitgebreide en e gestructureerd de manier waaro op de in ndicatoren worde en voorgesteld ervoor zorgen dat er gemakke elijker p prioriteiten gesteld d kunnen worde en betreffende de e nodige acties en/of v verdere studies.


40

3.2

Wat is de toegevoegd de waarde van dit rapport vergele eken met het vo orige?

Het eerste rapp port, met als onde ertitel "eerste stap ppen naar het me eten van de performantiie" was voornam melijk een piloots studie. De voorn naamste conclusie ervan n was dat het in België haalbaar wa as om dergelijke evaluatie e uit te voeren, niet n in het minst d dankzij de goede samenwerking tu ussen de administraties. Dit tweede rappo ort biedt de eerste volledige evalu uatie van de performantie e van het Belgiscche gezondheidss systeem. Volgende sterke punten kunnen worden geïdentifficeerd. Verbeterde bes schikbaarheid va an gegevens van de Er was een aanzienlijke a verb betering in de beschikbaarheid b gegevens: gegevens zijn nu beschikbaar voor het overlevingsperrcentage bij kanker, voo or kindersterfte, en de vertraging g met betrekking g tot de beschikbaarheid van nationale e overlijdensgege evens werd grottendeels weggewerkt. Een uitgebreid dere set indicattoren voor een globaler beeld van v het systeem Zoals uiteengez zet in de operatio onele doelstellinge en werd de indica atorenset uitgebreid voorr die domeinen o of dimensies die minder of helem maal niet werden behand deld in het vorige e rapport. Indicato oren werden toeg gevoegd op het vlak van geestelijke gezondheidszorrg, zorg voor ouderen, o zorgcontinuïteitt, en in mindere e mate, palliatiev ve zorg, zorg op lange termijn, patiëntgerichtheid en gezondheidsprom motie. Twee con ntextuele indicatoren van n billijkheid werde en toegevoegd, en e de indicatoren werden systematisch geanalyseerd g volg gens socio-econo omische status (w wanneer de gegevens be eschikbaar waren n).

KCE Reportt 196

Vereenvoudiging V g van de structu uur van de indicatorenset voorr een m makkelijker begriip De structuur van D n de indicatoren nset werd op ve erschillende man nieren v verduidelijkt. Allee en gemeten indica atoren werden be ehouden in de hu uidige s set. Indicatoren waarvoor w we gee en gegevens ko onden vinden, we erden b besproken in de e sectie "gegevens zijn binnen nkort beschikbaa ar" of "indicatoren in ontwikkeling" o (beschreven in S Supplement S1). Dit v vergemakkelijkt he et begrip van de indicatorenset, vvestigt de aandac cht op w wijzigingen in de beschikbaarheid van gegevens e en wijst op lacun nes in g gegevens. Het eerdere e onderscheid tussen prim maire en secun ndaire in ndicatoren werd verwijderd v aangezien dit geen rol bleek te spelen bij b de in nterpretatie ervan n. S Systematisatie in n gegevensanaly yse De analyse van gegevens werd gesystematiseerrd, en de indica D atoren w werden altijd voorg gesteld door midd del van dezelfde sstructuur: evolutie in de lo oop van de tiijd, per gewestt, subgroepanalyyses volgens socios e economische kenm merken en interna ationale benchmarking. G Gebruik van al be eschikbare inform matie Er werd maxima E aal gebruik gem maakt van routtinematig verzam melde g gegevens (bijv. in administratieve databanken of in n nationale registers s): de g gezondheidsenquê êtes (Health Intterview Survey – HIS), de Minimale Z Ziekenhuisgegeve ens (MZG), de EPS (permane ente steekproef)), de d databanken van het RIZIV (do oc N, Pharmane et), het registerr van n nosocomiale infec cties, vaccinatie-e enquêtes, het Be elgisch Kankerreg gister. H gebruik van routineus beschikbare gegevens die geen bijkom Het mende k kosten met zich meebrengen m voor gegevensverzam meling, vergemakkelijkt d analyse van ten de ndensen in de tijd d. V Verbetering van de d communicatie e van resultaten Tenslotte werden synoptische tabellen met kleurcod T des ontwikkeld om m snel e gemakkelijk ee en en overzicht te ku unnen krijgen van n de resultaten en n van d interpretatie erv de van; dit laat ook vergelijking v van ind dicatoren toe.

KCE Report 196 6

3.3 3.3.1


Wat zijn de beperking gen van dit rapport? Perforrmantie tegenovver welk streefdo oel? Benchmark king met anderre Europese land den lost het prob bleem niet op

Jammer genoeg g werden zeer we einig specifieke en n meetbare doelsttellingen gedefinieerd in n België. Waar d dergelijke streefdoelen bestaan, werd w de waarde van de indicator beoord deeld door vergeliijking met de waa arde van de doelstelling.. Anderzijds was het oordeel geb baseerd op externe (bijv. WGO-gedefinie eerde) streefdoele en, of door verge elijking met de re esultaten van andere lan nden. Waar moge elijk werden de ind dicatoren vergele eken met het gemiddelde van de EU-1 15-landen. Hierdo oor kan België worden gepositioneerd in vergelijking to ot de naaste buurlanden, maar dit d biedt geen antwoord d op de vraag "Z Zijn onze resultatten nu goed of slecht?". s Sommige resu ultaten kunnen in nderdaad goed zijn z wanneer ze worden vergeleken mett andere landen, terwijl ze dat niett zijn wanneer ze e worden geconfronteerd met de lan nddoelstellingen. Bovendien sta aat het interpreteren van v de resultatten van internattionale vergelijkiing van performantie nog n ter discusssie8, en zijn err veel valkuilen n, zoals methodologisch he en contextuele variaties, waarrdoor het moeilijk is om zinvolle vergelijkingen te maken.

Verschillende in nternationale orga anisaties vergelijk ken België al mett andere Europese land den voor indicattoren van gezon ndheidstoestand en van gezondheidszorg: de WGO me et het “World He ealth Report 200 00”9, het 10,11 tweejaarlijks rapport “Health at a glance Europe” dat voortvloeit uit een samenwerking van de OESO e en de Europese Unie, U de website van de ECHI-indicatore en, ondersteund door de Europe ese Unie12 en de d Euro Health Consum mer Index13 van de private Zwe eedse organisatie e Health Consumer Pow werhouse.

3 3.3.2

41

Beslissin ngen nemen op basis van verou uderde gegevens s?

Sommige gegevens zijn duidelijk verouderd, en ze S elfs de meest recente d dateren al van 2 jaar geleden. Dit is inherent aan het gebruik k van a administratieve ge egevens of registters. Voor de inte ernationale vergellijking m moesten we vaak steunen op gege evens uit 2005! In verschillende gev vallen z zou het voor bele eidsmakers moeilijk zijn om beslissingen te neme en op b basis van dergeliijke verouderde informatie. Wat betreft de indica atoren g geleverd door het HIS worden ze eer recente gege evens verwacht in het v volgende HSPA-ra apport aangezien een nieuwe HIS zal worden uitgev voerd in n 2013.

3 3.3.3

Een uitg gebreider beeld, maar nog steed ds hiaten in het instrume ent

De meeste proble D emen hebben te maken met een gebrek aan gesc chikte in ndicatoren, het ge ebrek aan (recente) gegevens, de e nood om uit te kijken k n naar een betere in ndicator of naar meer details. 1. Globale gezo ondheidstoestan nd: een indicatorr toevoegen mett een hoog actieve ermogen: vermijd dbare mortaliteit Het vorige rap pport omvatte vroegtijdig overlijden n als een indicatorr voor gezondheidsto oestand, uitgedru ukt als mogelijk verloren levens sjaren (PYLL – Pote ential years of life e lost) vóór de le eeftijd van 70 jaa ar. De studie van vro oegtijdige sterfte per categorie van oorzaak en mo ogelijk ook de verm mijdbare sterfte, zou een interressante kijk op p de gezondheidsz zorgdiensten kunn nen toevoegen. 2 Financiële to 2. oegankelijkheid: nood aan een uitgebreider beeld d Een noodzake elijke voorwaarde e om het beleid aa an te sturen binne en het domein van financiële toeganke elijkheid is een ve erbeterde transparrantie in ambula ante supplem menten evenals in private hospitalisatiev verzekeringen (he et percentage perrsonen met een private hospitalisatiev verzekering, en wat w specifiek wo ordt gedekt door deze private verzek keringen, en aan welke w kost).

42

3.

4.

5.

Belgian n Health System Performance Financiële e toegankelijkheid en billijkheid Een meer volledige v manier o om de billijkheid van v het systeem te t meten is rekening g te houden mett de verdeling van persoonlijke uitgaven u (officiële re emgelden, supple ementen, netto te erugbetalingen do oor privé verzekering gen en tussenkom mst van de maxim mumfactuur) in fun nctie van de socio-e economische sta atus. Individuele patiëntengegevens over inkomen en e alle uitgaven zzijn nodig om ee en dergelijke verd deling te berekenen. Personeelstellingen Er zijn nu betere gegevenss beschikbaar ov ver het aanbod, maar m de gegevens over o de behoeften n ontbreken nog steeds. s Een doelttreffende planning van v de persone eelsbezetting in gezondheidszorrg moet worden overwogen binnen een globaal beleid rekening houdend met het aanbod d en met de beho oeften van de pa atiënt. Gegevens over het aanbod zijjn de laatste jarren ongetwijfeld veel verbeterd. Maar er werden no og geen indicato oren voor de behoeften b in dit rapport gedefinieerrd. Anderzijds iss het benodigde e personeel niet alleen afhankelijk van de medische behoeften, maar m ook van de e manier waarop het gezondheidsssysteem georgan niseerd is, bijvo oorbeeld eerstelijns-- versus ziekenhuiszorg. Geestelijke gezondheidszo org De huidige e indicatoren weerrspiegelen de rec cente veranderingen in de sector niet. De meest reccente hervorming gsinspanningen om o een evenwichtig g geïntegreerd zo orgmodel te beko omen, richten zic ch op de ontwikkelin ng van "zorgne etwerken" (het zogenoemde “A Art. 107 project”'). Het H hoofddoel is d dat, waar mogelijk k, gemeenschapsd diensten moeten wo orden aangeboden, waarbij ziekenhuisdiensten besc chikbaar moeten zijn n wanneer ambulante zorg geen goed antwoord kan n bieden op de nod den van de pattiënt. Enkele nieuwe indicatoren werden voorgesteld d om deze evoluties te monitore en (bijv. het perrcentage patiënten met case mana agement; het pe ercentage uitgave en voor ambulante zorg en zorg in d de thuisomgeving vergeleken met de d totale uitgaven vo oor geestelijke ge ezondheidszorg). Maar ze konden nog niet worden gemeten omwille va an de beperkingen n in de huidige geg gevens.

6 6.

7 7.

8 8.

KCE Reportt 196

Zorgcontinuiiïteit en -coördinatie Met de nieuw we trajecten in am mbulante zorg zu ullen nieuwe gege evens binnenkort be eschikbaar zijn, maar er blijven toch h nog veel lacune es. De resultaten van n de nieuwe traje ecten in ambulante zorg (zorgtraje ecten) voor type 2-diabetes of chronische nierrinsufficiëntie wo orden momenteel ge eëvalueerd. Die elementen e zullen worden opgenom men in de volgende editie van dit rapport. r Er ontbreken gegevens over andere releva ante indicatoren, zoals de ervarin ng van patiënten n met zorgcoördinattie, of de be eschikbaarheid vvan informatie over gezondheid va an patiënten op eender e welk ogenb blik. Patiëntgerich htheid: veel in nitiatieven maarr weinig gege evens. Patiëntgerichttheid is intrinsiek k moeilijk te meten met kwantita atieve gegevens, omdat het samenhangt met hett vermogen van n het gezondheidss systeem om een succesvol antwo oord te bieden op o de bijzondere no oden van de pattiënt of om de b betrokkenheid va an de patiënt te stim muleren. Om ons begrip in dat dom mein te verbeteren, zal de volgende golf van de Health Interview Su urvey een set vrragen bevatten overr de ervaring van de patiënt met am mbulante zorgdiensten (huisartsen of specialisten), gebaseerd g op de OESO-vragenlijs st om internationale vergelijking te vergemakkelijken n.14 De ervaring g van patiënten me et ambulante zorrg zal dus worde en opgenomen in de volgende update van dit rapporrt. Zorg op lang ge termijn: er we erden verschillend de indicatoren gek kozen om de kwaliiteit van de zorg op lange term mijn voor oudere en te beoordelen, zoals z de prevalen ntie van ondervoeding, het percentage oudere patiën nten die fysiek gefixeerd g worden n, de prevalentie e van vallen, de in ncidentie van doorligwonden d en n het probleem van polymedicatie e. Die indicatoren konden nog niet w worden gemeten en dit markeert het huidige gebrek aan a gegevens in d dit domein. De BelRAI zal echter spoedig gegevens verstrekken over enkele geselecte eerde indicatoren. De D BelRAI is een instrument dat w werd ontwikkeld om o de noden te beoo ordelen van oude eren in residentiëlle voorzieningen of o die een beroep do oen op thuiszorg.

KCE Report 196 6

9.


Palliatieve e zorg: veel loka ale onderzoeken in België, maarr weinig nationale gegevens. De enkele indicatorren in dit rapp port zijn gebaseerd op de populatie van terminale kankerpatiënten, of o op de populatie patiënten p die thuis palliatieve zorg g krijgen. Hierdoo or wordt niet de hele populatie van patiënten die in aanmerking kom men voor palliatieve zorg omvat, hetg geen wijst op een duidelijke lacun ne in de beschikbaa arheid van gegevvens. Bovendien werden tot dusv ver geen gegevens op nationaal nivveau gepubliceerrd over toeganke elijkheid, noch over de kwaliteit van de palliatieve zorrg. In vergelijking g met de andere zo orgdomeinen is p palliatieve zorg weinig w of helem maal niet vertegenwo oordigd in databanken van internattionale organisatie es. 10. Gezondhe eidspromotie: g gegevens over gezondheidsalfa abetisme (health literracy) ontbreken, tterwijl ze wel al beschikbaar b zijn in n andere Europese landen. Gezond dheidsalfabetisme e is een relatief nieuw begrip datt als een esse entieel hulpmidde el wordt bescho ouwd in gezondheid dsmanagement. Het kan worde en gedefinieerd als de individuele vaardigheden die noodzakelijk k zijn om facto oren die interageren n met de gezond dheid van het ind dividu te begrijpe en en te beheersen. Dit geeft individu uen de gelegenhe eid om gezondere e keuzes te maken. Het werd gedefin nieerd als een acttieprioriteit voor de d 20082013 strate egie van de Europ pese Unie, en voo or sommige landen zijn de resultaten uit de EU Health L Literacy Survey nu beschikbaar. e moet meer a aandacht krijgen in het toeko omstige 11. Efficiëntie rapport. Het H is duidelijk dat efficiëntie in gezondheidszo org niet voldoende kan worden beoo ordeeld met de en nkele indicatoren die d in dit rapport we erden geselecteerd. In de interna ationale literatuur worden vaak metin ngen voor efficiën ntie voorgesteld die d uitdrukkelijk in nputs en outputs identificeren.7,15 Dit kan ze eker een inte eressant onderzoeks sgebied vormen. 12. Ongelijkhe eden konden niett worden onderzo ocht voor alle indiicatoren, omdat in sommige gegeve ensbronnen (RHM – MZG) geen n socioeconomisc che gegevens besschikbaar waren. In de gegevens s van de e status ziekteverze ekering is de info ormatie over de socio-economisch s eerder onn nauwkeurig en ben naderend.

43

4 ALGEMENE CONC CLUSIE Dit rapport geeft de D d resultaten wee er van een eerste e globale evaluatie e van d performantie van het Belgisch gezondheidssyste de g eem, voortbouwen nd op e een eerdere haa albaarheidsstudie e. Aan de hand d van vierenzev ventig in ndicatoren met numerieke waarde en tracht dit rapp port een totaalbee eld te g geven van de performantie van het h gezondheidssyysteem, waarbij wordt w g gewezen op enk kele richtingen voor v beleidsacties en waarbij vrragen w worden gegeneree erd voor verdere opvolging o of onde erzoek. D rapport is ee Dit en aanzienlijke verbetering vergeleken met het vorige v ra apport, doordat het uitgebreiderr is en doordat de vorige set werd g geactualiseerd met meer relevante indicatoren. B Bovendien laat het h in e enkele gevallen het meten van evolutie toe. Oo ok werden belangrijke la acunes in basisge egevens ingevuld d sinds de vorige editie, bijvoorbee eld de o oorzaakspecifieke mortaliteitspercentages of kankero overleving. B België is niet he et eerste land dat d deze uitdagin ng aangaat. Me et het o ondertekenen in n 2008 van het Verdrag van Tallinn in nzake men hebben de lidstaten g gezondheidssyste l zich er fformeel toe verbo onden o de performan om ntie van het gez zondheidssysteem m te monitoren en e te e evalueren. Versch hillende buurlande en met jaren erva aring in het meten n van d performantie van de v het gezondhe eidssysteem, fung geerden als voorbeeld v voor dit rapport, vooral v het Nederla andse Performanttierapport. Een va an de te ekortkomingen die het succesvol meten m van perform mantie in de weg staat (o ook vastgesteld in de eerdere Nederlandse perform mantierapporten) is de la age beschikbaarrheid van geactu ualiseerde gegevvens. Het regelmatig a actualiseren van administratieve a g gegevens en het dynamisch public ceren v van resultaten op p een website is één van de pisstes die moet wo orden o onderzocht. S Samen met de Europese E Richtlijjn betreffende de toepassing va an de re echten van de patiënt bij grensov verschrijdende ge ezondheidszorg, wordt w d deze verbintenis een e gemeenschap ppelijke bezorgdhe eid onder de lidsttatenf.

f

Richtlijn 2011 1/24/EU van het Europese Parlementt en van de Raad van 9 maart 2011 betreffende de toe epassing van de re echten van patiëntten bij hrijdende gezondhe eidszorg, Official JJournal L 88/45, 4 april grensoversch 2011

44


Zodra de Rich htlijn wordt geïm mplementeerd als nationale wetge eving in oktober 2013, zullen z de lidstate en ervoor moeten zorgen dat patië ënten uit een andere lidstaat l relevante informatie ku unnen krijgen over o de veiligheids- en kwaliteitsnormen n om een welov verwogen beslissiing voor grensoverschrijdende gezondheidszorg te maken n. In deze context legt dit rapport niet alleen a de basiss van een toe ekomstige system matische beoordeling van n de performantie e, maar kan het oo ok worden bescho ouwd als een eerste sta ap naar de vera antwoordelijkheid van België om veilige, kwaliteitsvolle, toegankelijke en n efficiënte gezo ondheidszorg voo or zowel Belgische als buitenlandse patiënten te garandere en.

KCE Reportt 196

KCE Report 196 6

SCIENTIFIC REPORT T


45

1 BACKGROUND AND APPRO OACH 1 1.1 1 1.1.1

Context Internatiional context

T Tallinn Chartter in 2008 The In n June 2008, the e 53 Ministers of Health from the countries belongiing to th he European region of the World Health H Organisatio on (WHO) signed “The T Tallinn Charter on n Health Systems s for Health and Wealth”. The primary o objective of the Tallinn T Charter is to commit mem mber states to improve p people’s health by y strengthening their t respective h health systems. Of O the s seven commitme ents signed, the e third is relate ed to health sy ystem p performance: “(the e member states commit) to prom mote transparency y and b accountable fo be or health systems performance to o achieve measu urable re esults”. The rationale of that comm mitment is given e earlier in the text: “well fu unctioning health systems are esse ential to improving g health, and therrefore h health systems ne eed to demonstratte good performance”. The Charter also a acknowledged tha at health systems s are more than h healthcare and include d disease prevention n, health promotio on and efforts to iinfluence other se ectors to o address health concerns in theirr policies, an apprroach that was alrready e extensively develo oped by the WHO O in its “Health in n All Policies”.17 Other O c commitments in the Tallinn Charte er include promo oting shared values of s solidarity, equity and participatin ng, investing in health systems and fo ostering investme ent across sectorrs that influence health, making health h s systems more responsive to people e‘s needs, prefere ences and expecta ations a ensure that he and ealth systems are e prepared and ab ble to respond to crisis. c T The last commitm ment proved afterw wards to be visio onary, as no long after th he Tallinn Conference the world was struck by a global economic c and fiinancial crisis. F From values to actions, from Talllinn to Health 202 20 By signing the Tallinn B T Charter, all a member statess of the WHO in n the E European region reinforced that they t share the ccommon value of o the h highest attainable standard of healtth as a fundamen ntal human right. From th his common valu ue a set of goa als were listed: improve health on o an e equitable basis, contribute to so ocial well-being a and cohesivenes ss by


46

KCE Reportt 196

distributing the burden of funding g fairly according to people’s abilitty to pay and aim at effic ciency by making g the best use of available resourc ces.3 An interim report on o the implemen ntation of the Talllinn Charter deta ails how member states s have made ope erational these va arious commitme ents.18 In parallel, the WHO W European re egion has launche ed in 2010 a new w health 19 policy, Health 2020. 2 It aims to provide a coherent evidence-base ed health policy framewo ork in light of the trends that have become salient over o the past decades in Europe: chan nges in demogra aphy (increasing ageing, decreasing fertility), globalisation n and migration (including health workers), w accelerating technological t innovation (includ ding genetics), rapidly increasing acce ess to information n for patients and d the general pub blic. The four policy priorrities focus on: (1) Investing in n health through a life-course ap pproach and emp powering people, demon nstrating the imp portance for the WHO of the expected e benefits of health promotion, (2) Tackling Eu urope’s major hea alth challenges (a among which reco ognising the burden of non-communicab ble diseases, tob bacco, diet and physical activity, HIV/AID DS, antibiotic resisstance), (3) Strengtheniing people-centre ed health systems, public health capacity and preparedne ess for emergenciies and (4) Creating a healthy h and suppo ortive environment.19

new collaborations between administrations of the n e federal and reg gional le evels had to be initiated, and sta akeholders were consulted extens sively. T The report was articulated a around d two main sectio ons. First, the Be elgian H HSPA framework was constructed d based upon inte ernational experie ences ta ailored to the Be elgian context. Se econd, a core sett of 55 indicators s was s selected, and 40 of o them could be e measured. Base ed on these indica ators, re esults, strengths, weaknesses, evolution over time and proposed ac ctions w were discussed. A After the publication of the first rep port, the commissioners of the Be elgian H HSPA requested the project to be b continued, aiming at a systematic e evaluation of the e Belgian Healtth System. The commissioners also re equested to enric ch the set of indica ators with indicato ors in specific dom mains s such as mental healthcare, long-te erm care and end d-of-life care, as those t w were insufficiently y covered in this first f report. In add dition, the regions s and c communities reque ested new indicattors to assess the performance of health h p promotion by enlarging the set from f the evaluation of the healthcare s system to a full ev valuation of the health h system. La astly, three dimen nsions (i.e. continuity of care, c patient centteredness and eq quity) were consid dered to o be insufficiently y represented, and d new indicators had to be propos sed to a assess these dime ensions.

1.1.2

The Belgian perfo T ormance report makes m use of a conceptual frame ework (s see Figure 3) in nspired by the Dutch D and Canad dian frameworks,20, 21 ta ailored to the Belg gian health system m. T The conceptual framework f is com mposed of three e interconnected tiers, w which do not reprresent a hierarchy y. The three tierss include health status, n non-medical deterrminants of health h and the health system itself, cons sisting o 5 domains: hea of alth promotion, prreventive care, cu urative care, long g-term c care and end-of-life care. Each of these domains can be evaluate ed on d different dimensions: their quality, accessibility, a efficciency or sustaina ability. E Equity has been defined as an overrarching dimensio on.

Nation nal context

2010, publicatiion of the report on Belgian Heallth System Perfo ormance Assessment Two years afterr the signature of the Tallinn Charter, the first Belgia an report on Health Sys stem Performance e Assessment (H HSPA) was published in June 2010.1 Th he title of this rep port “A first step towards t measurin ng of the performance of o the Belgian h healthcare system m” is illustrative of the prudence of the e authors: healthccare system is me entioned instead of o health system (a much h broader scope),, and it is the firstt step only… The reasons of this prudenc ce lie in the amou unt of work neede ed for this first eva aluation:

1 1.2

The Belgian performanc ce framework a and definitions

KCE Report 196 6


Figure 3 – The e conceptual fram mework to evalua ate the performance of the Belgia an health system m

47


48

KCE Reportt 196

testing, scree ening for diseases s, and other services that detect health h problems early before they man nifest symptoms)..

Definitions use ed in the concep ptual framework 3

These definition ns are based on the following sources: WHO (2008 8) , Arah (2006)4, Vlaye en (2006)6, Au ustralian Nationa al Health Perfo ormance Committee (200 01)22 and the Otta awa Charter23.

•

e: healthcare that tends to ove ercome disease, and Curative care promote recov very.

Health status

•

Long-term ca are: The term “lo ong-term care se ervices” refers to o the organisation and a delivery of services s and assistance to people e who are limited in their ability to fu unction independently on a daily basis over an exte ended period of time. There are e two compleme entary components of o this definition: first, f the care conttinues over a long g time period, and second, s the care e is usually proviided as an integ grated program acro oss service comp ponents.24 This rreport focuses on n two main populations: first, long-term care for older persons, and second, long-term care e for persons with h mental disorder. Long-term carre for older perso ons include the folllowing major serv vices: home nursing care, homes for the t elderly and nu ursing homes.g

•

p from the m moment it has become End-of-life care: the care of a person clear that the e person is in a progressive p state of decline. End-of-life care includes palliative care bu ut also broader so ocial, legal and sp piritual elements of ca are relevant to the e end of the life.

•

Health promo otion has been de efined by the WH HO as “the proce ess of enabling peo ople to increase e control over their health and its determinants, and thereby improve their health". The health prom motion

g

Home nursin ng care is available e for persons with low to severe activitties of daily living (A ADL) and/or cognitiv ve limitations, irresp pective of their age. Care provided by home nurses inc cludes technical nu ursing interventions (for example wou und dressing and administering a mediccation) and basic nursing care (mainly hygienic care in pattients with ADL dysffunction). In the reside ential sector, hom mes for the elderly y (“maison de repos s pour personnes âg gées”, MRPA /”woo onzorgcentra”, prevviously called “rusto oorden voor bejaarde en” ROB) provide nursing n and person nal care as well as living facilities to older o persons with mainly low to mo oderate limitations. Older persons who o are strongly de ependent on care but who do not need permanent hospital treatment arre admitted to nurs sing homes (“mais son de repos et de soins” MRS/”rust- en verzorgingstehu uis” RVT). While medical m costs and co osts of care in resid dential care facilitie es are covered by public health insurance, board and lodg ging costs are to be e paid by the residen nt.

This tier addres sses the question “How healthy is the population residing in Belgium?”, cov vering several dim mensions, such as a health (prevalence of disease, disord der, injury, traum ma or other health-related states),, human functions (altera ations to body, sttructure or functio on [impairment], activities a [activity limitatiion] and participation [restrictions s in participation n]), wellbeing (physical, mental, and social well-being), an nd death. Non-medical determinants d of h health This tier encom mpasses the deterrminants that have an effect on he ealth and on if, when an nd how we use care. These dete erminants include e health behaviour/lifesttyle (e.g. smoking g, physical activitty), genetic factorrs, living and working conditions, person nal resources, an nd environmentall factors (e.g. air, water,, food and soil qu uality resulting fro om chemical pollution and waste disposal)). Health system Within the polittical and institutio onal framework of o each country, a health system is the ensemble e of all pu ublic and private organizations, ins stitutions and resources mandated to improve, maintain or o restore health. Health system encomp passes both perssonal and popula ation services as well as activities to influence the policie es and actions of other sectors to address the social, envirronmental and ecconomic determina ants of health. Domains of the e health system and health prom motion The health sys stem has been g grouped into 4 do omains: preventiv ve care, curative care, long-term l care and end-of-life carre. The health prromotion goes far beyond d the boundaries of the health system. •

Preventive care: healthcare e aiming to prev vent the occurren nce of a disease (p primary prevention n, i.e. vaccination n; secondary pre evention, i.e. taking medication to p prevent myocardial infarction after a first episode) or o to detect hea alth problems beffore they occur (regular

KCE Report 196 6


goes far be eyond the bounda aries of the health sector: indeed on ne of the means of health promotion n occur through developing d health hy public policy thatt addresses the prerequisites of health such as income, housing, fo ood security, emp ployment, and qu uality working conditions. The other axes defined in the Ottawa Cha arter are: create healthy settings, in ncrease the role o of the community, increase the skills of the individuals, reorientation of tthe health service es.23 Health system performance This is a much h broader concep ptual approach to o measuring perfo ormance than healthcarre system performance by explicitly using non--medical determinants, healthcare and contextual inform mation to give a clearer picture of popullation health. Dimensions off Health System Performance Health system performance, wh hich is presented d and analysed for f each health system domain, d is groupe ed into four main dimensions: acce essibility, quality, efficien ncy and sustaina ability, and the overarching o dimen nsion of equity. Accessibility is defined as “th he ease with wh hich health serviices are reached”. It rec covers physical ((geographical dis stribution), organiz zational, financial, culturral, psychological dimensions of access. Access requires that health serv vices are a priori a available. Quality is defin ned as “the degre ee to which healtth services for ind dividuals and populations s increase the like elihood of desired health outcomes and are consistent with h current professiional knowledge”. It is further subdivided into five sub-dimensions, includiing effectiveness,, appropriateness s, safety, patient-centered dness and continu uity. •

•

Effectivene ess is defined as “the degree of achieving desirable d outcomes, given the correcct provision of ev vidence-based he ealthcare services to o all who could ben nefit but not those e who would not benefit”. b It is therefo ore closely related d to appropriatene ess, which can be e defined as “the deg gree to which pro ovided healthcare is relevant to the e clinical needs, give en the current besst evidence and th he provider’s expe erience”. The link be etween effectiven ness and approprriateness reflects the link between ou utcomes and proccesses.

49

•

Safety can be e defined as “the degree d to which th he system has the e right structures, renders services, and a attains resultss in ways that prevent harm to the us ser, provider, or environment”. e Including the provide er and environment in this definition ex xtends the dimenssion beyond qualiity.

•

d as “providing ca are that is respecttful of Patient-centerredness is defined and responsiv ve to individual patient p preference es, needs, and va alues, and ensuring that patient value es guide all clinical decisions”.

•

Finally, continuity addresses “the extent to which healthcarre for specified users, over time, is smoothly organissed within and across stitutions and regions”, and to which the entire dis sease providers, ins trajectory is covered. c This also o means that ‘coo ordination’ (i.e. sm mooth organisation across a providers, institutions and regions) is consid dered to be part of continuity. c E Efficiency is defin ned as “the degre ee to which the rright level of resources (i.e. money, time and a personnel) is found for the sysstem (macro-levell) and e ensuring that these resources are e used to yield maximum beneffits or re esults (i.e. allocattive efficiency)”. S Sustainability is s the system’s capacity to provide and maintain in nfrastructure such as workforce (e.g. through ed ducation and train ning), fa acilities and equiipment, and be innovative and re esponsive to eme erging n needs. Important factors f for the ma aintenance of the workforce also include th he health personn nel’s satisfaction and a working conditions. E Equity is a transv versal dimension, being considered and presented across a three tiers of the framework. Equ all uity is concerned w with the fairness of o the d distribution of he ealthcare across populations and with the fairness of p payment for healtthcare. Above this, “equity” can b be estimated for nonm medical determina ants of health an nd for health sta atus. There are many o overlaps with the dimension d of acce essibility. A Assessment of th he Health promotion Only a partial ass O sessment of the health h promotion performance cou uld be m made into the sc cope of this work k. More details arre given in Chap pter 7 P Performance of he ealth promotion. •

Outcomes of the health prom motion can be cattegorized (see fu urther, Nutbeam’s fra amework in Chap pter 7 Performancce of health promo otion)


50

into outcom mes very distal to action (like health h outcomes), interrmediate health outtcomes (like ado opting healthy life estyle), and morre direct outcomes, called “health pro omotion outcomes s” (like health litera acy). •

The main values and principles of the health promotion are: on, empowerme ent, equity, multistrategic/multi m participatio sectorial intervention ns, sustainability.

1. 2 2.

3 3.

KCE Reportt 196

To inform the e health authoritties of the performance of the health h system and to o be a support for policy planning; To provide a transparent and accountable view w of the Belgian health h system perforrmance, in accord dance with the commitment made in the Tallinn Charte er; On the long-te erm, to monitor the health system p performance over time.

Health system design and con ntext

1 1.3.2

This includes th he important desig gn and contextua al information thatt may be specific to the e Belgian health system, and which w are necess sary for interpreting the health system pe erformance. Conttext should be interpreted in a broad wa ay, encompassin ng both the loca al (national) factors that influence the health system ((e.g. federal vs. regional contex xt, legal framework, fina nternational conte ancing) and the in ext factors (e.g. Europe). E This also mea ans that the articculation between the different au uthorities (federal, region nal, local) is considered to be a ch haracteristic of the health system influen ncing its perforrmance, rather than a dimension of performance itself. An addition nal contextual fac ctor is the local culture, which has an im mportant influence e on ethical questiions.

Overall objective: O T propose and measure a set of To o indicators cove ering all domains s and c chosen dimension ns of our health system, while kkeeping a reasonable n number of indica ators. With a too o small set, imp portant dimension ns or d domains would be e missed. But a too o large set is difficcult to manage an nd the p profusion of resultts would dilute main messages. Fo or the 2012 reporrt, we a aimed at a set of about a 80 indicatorrs. F Four operational objectives o have be een defined: 1. To review the e core set of 55 indicators of the p previous report, with w a special focus on the 11 indicators for which tthere were no da ata in 2010; 2 To enrich the 2. e core set with indicators i from th he following dom mains: health promo otion, general me edicine, mental h health, long-term care, end-of-life ca are; to add indiicators on patient centeredness and continuity of care (two sub-d dimensions of quality); and finally to propose indica ators on equity in the health system m; 3 To measure the selected indica 3. ators, when possiible, or to identify gaps in the availabiility of data; 4 To interpret th 4. he results in orde er to provide a gllobal evaluation of o the performance of o the Belgian health system by mean of several crriteria, including an in nternational bench hmarking when ap ppropriate.

Health in all po olicies This is a dime ension linking no on-medical determ minants of health h to the health system. It can be define ed as a horizonta al, complementary y policyrelated strate health egy contributing g to improve ed population (http://www.eurro.who.int/docume ent/E89260.pdf). The T core of “health in all policies” is to examine determ minants of health that can be alttered to improve health, but which are m mainly controlled by the policies off sectors other than healtth.

1.3

Objectiives of the perfformance proje ect

Systematic eva aluation of health system perfo ormance is an on-going o process, with publication of H HSPA reports as a important mile estones. Strategic objecttives, defined as tthe objective of the on-going proces ss, have to be differentia ated from the speccific objective of the t present reportt, and its operational sub b-objectives.

1.3.1

Strate egic objectives o of the HSPA proc cess

The HSPA proc cess pursues three strategic objectives:

1 1.4

Overall and a operational objectives of the e 2012 report

Methods to reach opera ational objective es

Operational objec O ctive 1: To review w the core set off 55 indicators, with w a s special focus on th he 11 indicators fo or which there were no data in 2010 0. T update of the former 55 indicators was made in The n a consensus me eeting b between the rese earch team and a specialist in he ealth indicators of o the F Federal Public Serrvice (FPS) Public c Health.

KCE Report 196 6


Operational objjective 2: To enri rich the core set with w indicators illu ustrating the following do omains: health prromotion, generall medicine, menta al health, long-term care, end-of-life care; to add indicators s on patient cente eredness and continuity of care (two sub b-dimensions of th he quality); and finally f to introduce indica ators on equity-ine equality in health//health system. The strategy for the selection of new indicators in a variety of doma ains and dimensions con nsisted of the follo owing: The indexed litterature was sea arched using usual standards of literature search for Hea alth Services Stud dies.25 Many indic cators were also found in the grey literatture, mainly repo orts of national (e.g. ( Dutch perfo ormance report) or inte ernational organizzations (e.g. OE ECD Health Data a, WHO Health for All Database, D Eurosttat, and reports specific s to the do omain or dimension stud died). This resulte ed in long lists of indicators. The selection s process occurrred on an iterativve way, involving both the researc ch team and panels of expert e specific fo or each topics. In some cases, a two t step scoring allowed d to select the mo ore appropriate in ndicators, with regards to many criteria (relevance, ( conte ent validity, reliability, interpretability and potential for ac ction). In the other cases, the se election was base ed on a consensus amo ong experts. Indicators on th he performance o of general mediciine were selected d from a recent RIZIV – INAMI project using the same meth hodology.26 Indicators on the t equity of the e system were derived from interrnational literature. A spe ecific working pap per “The place of equity in assessm ments of the performanc ce of health system ms can be found in Supplement S2 S of this report. The whole set of indicators wass then reviewed by the research team to avoid redundan ncies in indicators and enhance the e consistency of th he set. Operational objjective 3: To mea asure the indicators selected in ope erational objective 2, and d to identify gaps iin the available da ata. After the settin ng up of an upda ated set of indica ators, the researc ch team gathered the da ata to measure th hem. Indicators without (yet) availa able data were classified into two categorries: those for which data will be available a within the next two years, and tthose for which itt is not clear how w and by whom these indicators should b be collected. Nev vertheless, in spitte of the lack of relevan nt data, these ind dicators were sellected by the exp perts as

51

being relevant, and were kept under a section “indicators under b u d development”. F each measurrable indicator, a complete docu For umentation sheett was w written with detaile ed results, includin ng international co omparisons. O Operational objecttive 4: To interpre et the results in orrder to provide a global g e evaluation of the performance p of the e Belgian health ssystem. W When the data were w available, th he following analyyses were perforrmed: a analysis at nationa al and regional le evel (with trends o over time), analys sis by d demographic and socioeconomic fa actors, and finally benchmarking off most re ecent results compared to Europ pean Union (EU)-15 countries. These T re esults were discu ussed with the expert e groups to facilitate interprettation a identify shortc and coming and areas for further develo opment. T The documentatio on sheets and the detailed resultss of the indicatorrs are g gathered in Suppllement 1. A syno optic table summa arises the main re esults fo or all indicators us sing colour-coded d cells.

52

1.5


The 20 012 set of perfo ormance indica ators and structture of this rep port

The selected 74 7 indicators whiich could be me easured are class sified by domain and by y performance dim mension in Appen ndix A of this rep port. The results (values) of the indicatorrs are summarize ed and discussed d in the following chapte ers of this report. Chapters 2 to 6 have the sam me structure. Eac ch chapter discus sses the indicators illus strating one dimension (e.g. quality, sustainabiliity) and consists of three parts: 1. First, we explain e how the dimension was eva aluated which boils down to a motiva ation of the selection of the indicato ors. 2. The “facts and figures” secttion is the core of o each chapter. For F each indicator we w present the ma ain results of the data d analysis for Belgium, B for the three regions ‘(wh here possible) and put these re esults in perspective e with international results and tre ends. Detailed res sults are also availa able in each doccumentation shee et in the Supplem ment S1 (available on o the website). 3. At the end d of each section n, we summarize e the results of the t data analysis in key findings – mo ostly one key finding per indicator. The following chapters c illustrate some specific iss sues: health prom motion is discussed in Chapter C 7 and Ch hapter 8 discusse es the aspects of o health inequalities and d equity. The concclusion and discussion are in the synthesis at the beginning g of this documen nt. Indicators for which w there are ccurrently no data have been discu ussed to identify gaps in availability of data in Be elgium, and to provide recommendatio ons to policy make ers in Chapter 9. The result of re eviewing the 2010 0 set of indicators s (operational obje ective 1) can be found in Appendix 2. Frrom the 11 indica ators with data missing in 2010, 5 indicato ors could be mea asured in this repo ort. The others ha ave been either removed from the set, eith her moved to the indicators to be measured m soon. Another 12 indicators h have been remov ved from the 20 010 set, because they were w deemed as not being releva ant anymore, or because b data were outda ated. In addition to th hese 74 indicatorss, 11 indicators forr which data are expected e within a two-ye ear timeframe ha ave been selected d. Probably, they y will be

KCE Reportt 196

in ncluded in the nex xt edition of the performance reporrt. These indicatorrs are listed in Appendix 3. M More documents are a available on th he KCE website: •

In Supplemen nt S1: one docum mentation sheet p per indicator has been presented, summarising the rationale for ch hoosing the indic cator, technical information on data sources s and com mputation, limitatio ons in interpretation,, and the bibliogra aphical referencess. A list of indicators that were deemed d pertinent by the expert grroups, but for which no initiatives are e currently taken to collect data, is s also presented in this Supplement S1. These indicators have been discussed to identify gaps in availability of da ata in Belgium, and to provide recom mmendations to policy makers which are discussed in details in Cha apter 9.

•

In Supplement S2: “The pla ace of equity in assessments of o the performance of o health systems s” (author: Christia an Léonard): a sp pecific paper on equ uity, indicators fo or equity and revview of available work performed in Belgium. B

•

In Supplemen nt S3: All techniical details of literature searches s and selection of indicators (MESH H terms, databa ases searched, list of indicators initially selected, scoring s of experts) for the follo owing domains: Hea alth promotion / Mental health / Continuity of care c / Patient centeredness / Long-te erm care and carre of the elderly / Endof-life care.

KCE Report 196 6


2 OVERA ALL HEAL LTH STATU US OF THE E POPULATION 2.1

How did we describe the overall hea alth status of th he population?

The objective of this perform mance report was w not to perfform an assessment of the health statuss of the Belgian population. We describe d anyway 4 globa al health status indicators. Those can c be seen as ve ery distal general outcom mes of the health system/health promotion interventtions, as well as a reflec ction of the global developmental le evel of a society. Those 4 indicators are: 1. Life expecttancy 2. Health exp pectancy 3. Percentage e of population pe erceiving their hea alth as good or very good 4. Infant morttality rate Four other health status indicato ors were describe ed in other section ns. As a matter of fact, while those four particular indicato ors can be influe enced by individuals and societal actors, they make part of o the evaluation of some specific domain n or dimensions. T Those four indicators are: •

Suicide ratte (described in se ection 4.1.1, effec ctiveness of menta al health care)

•

es (described in section 7.2.1, health and Overweight and obesity rate social outcomes)

•

ew HIV diagnosiss (described in section s 7.2.1, hea alth and Rate of ne social outcomes)

•

missing, filled teeth hes in children (de escribed Mean number of decayed, m and social outcom mes) in the section 7.2.1, health a

2 2.2

53

Facts and d figures

This section is a short summary of the T t detailed resultts which are prese ented fo or each indicatorr in the Supplement S1 of this re eport (available on the w website). L expectancy and Life a Health expec ctancy Life expectancy (L L LE) at birth in Be elgium was 80 ye ears as of 2010.27 Life e expectancy has remarkably r incre eased since deca ades, reflecting sharp s re eductions in morttality rates at all ages. These gain ns in longevity ca an be a attributed to a number n of facto ors, including rissing living stand dards, im mproved lifestyle, better education n and greater acccess to quality health h 5 s services. L was 5.3 years higher in women (82.6 years) than in men (77.4 yea LE ars) in 2 2010 and is highe er in Flanders tha an in Wallonia (difference of 3 yea ars in m men and 1.8 yearrs in women) (Ta able 13). Life exp pectancy in Belgiu um is s slightly lower than the average of th he EU-15, 80.7 years in 2010 (Figure 4). H Health expectancy y represents the remaining years lived from a partticular a age without long--term activity limitation. This is the structural Euro opean in ndicator named ‘H Healthy Life Years s’ (HLY).28 It exte ends the concept of life e expectancy to mo orbidity and disab bility in order to assess the quallity of y years lived. HLY can be computted for several ages. In order to t be c consistent with pre evious published work, we present the HLY at 25 years, y b data for many other reference ages but a can be found d. H HLY at 25 in Belg gium was 41 years in men and women in 2008h. Wo omen live thus about 5 years longer tha an men, but those additional yearrs are lived in activity lim mitation. HLY incre eases slowly in m men but remains stable s in n women. The HL LY at 25 is highe er in Flanders than in the other reg gions, fo or both sexes (Ta able 13).

h

SPMA: https:://stats.wivisp.be/SASSttoredProcess/guestt?_program=%2FEh hleis%2FStored+Pro ocess %2FHealth+E Expectancy+Statistiics&_action=properrties


54

For internation nal comparisons, Eurostat compu utes the HLY att birth.29 Belgium is situated close to the e average of EU--15 countries: forr women 62.6 years vers sus 63.0 years in n EU-15, and for men 64.0 versus s 63.1 in EU-15. e expectancy att birth (2010), an nd Healthy Life Years Y at Table 13 – Life age 25 (2008), by sex and regio on Belgiu um

Brussels

Flanders F

Wallon nia

Life Expectancy y at birth*

77.4

76.9

78.5 7

75.5

Healthy life yea ars at 25**

41.3

38.5

43.7 4

37.4

Life Expectancy y at birth*

82.6

82.8

83.3 8

81.5

Healthy life yea ars at 25**

41.2

40.6

42.3 4

39.1

Male

Female

i

Source: * DGSIE E, data 2010; ** SPM MA , data 2008

i

https://stats.wivuest?_program=%2F FEhleis%2FStored+ +Process isp.be/SASStoredProcess/gu %2FHealtth+Expectancy+Statistics&_action=properties

KCE Reportt 196


KCE Report 196 6

55

Figure 4 – Life e expectancy at b birth: international comparison (2 2000-2010)

Life expectancy at birth (years)

82 81 80 79 78 77 76 75 74 2000 0 2001 2002 2003 2004 2005 2006 20 007 2008 2009 2010 Belgium

France

Germany

Nettherlands

United Kingdom

United States

EU--15

Source: OECD Health H Data 2012

S Spain Sw weden Frrance Ireland Netherrlands Luxemb bourg Austria E EU-15 United King gdom Grreece Germany Belgium Finland Porrtugal Den nmark

82.2 81.5 81.3 81.0 80.8 8 80.7 8 80.7 8 80.7 8 80.6 8 80.6 80 0.5 80.3 3 80.2 79.8 79.3 77

78

79

80

8 81

82

Life e expectancy at birtth (2010)

83


56

Self-perceived d health Self-perceived health has been p proven as a reliab ble reflection of morbidity, m and as highly predictive of morta ality. In 2008, 77% of o the people age ed 15 years or older rated their health as good or very good. This rate e has slightly inc creased over tim me. The subjective apprraisal of health sta atus was slightly le ess favourable in women, even after adju usting for age. It was higher in Fllanders than in th he other regions. Two databases s provide informa ation for the interrnational comparis son: the OECD Health Data D (in which da ata from Belgium come from the HIS) H and the European Union U Statistics on n Income and Living Conditions (E EU-SILC) survey. The forrmer database wa as chosen for its comparability with h results

KCE Reportt 196

above. Belgium co a ompares very well with other EU-15 5 countries (avera age of 7 71.7%). In nfant mortality ra ate The infant mortalitty rate (IMR) is a basic T b indicator forr population health h and q quality of health care services, and d is highly correlatted to a country's s level o development. The of T IMR has regullarly decreased ovver the last decad des in E countries, such EU h as in Belgium (a around 5 deaths/1 1000 live births in 2000 to o 3.5/1000 live births b in 2010, which w is within the EU-15 averag ge of 3 3.4/1000 live birth hs (Figure 5). Datta per region (fro om 2008) show similar s ra ates in the three regions. r Rates are e also higher for m male infants (4.2/1 1000) th han for female inffants (3.4/1000).

Figure 5 – Infa ant mortality rate: international co omparison

Deaths per 1000 live births (infant mortality)

8 7 6 5 4 3 2 000 2001 2002 200 03 2004 2005 2006 6 2007 2008 2009 2010 20 Bellgium

France

Germany

Nettherlands

United Kingdom

United States s

EU-15 Source: OECD Health H Data 2012

United Kingdom Austria Netherlands Ireland Greece France B Belgium Luxem mbourg Italy Ge ermany De enmark EU-15 Spain S Sweden P Portugal Finland

4.2 3.9 3 3.8 3 3.8 3 3.8 3.6 3.5 3.4 3.4 3.4 3.4 3.4 3.2 2.5 2.5 2.3 0.0

1.0

2.0

3.0

4..0

mber of deaths perr 1 000 live births (2010) Num

5.0

KCE Report 196 6

2.3 •


Key findings Life expec ctancy at birth in Belgium was 80 0 years as of 2010. It is increasing g over time, and is higher for wom men. It is higher in Flanders. Life expectancy in Belgium is sliightly lower than n the average off the EU-15 (80.7 7 years in 2010).

•

Although women w live long ger than men, the ey do not live mu uch longer in good g health sinc ce the number off years with (self-reported) activity a limitation n is higher in wo omen. Belgium is s ranking within the average e as compared with w the EU-15.

•

77% of the e population repo orted their health h to be good to very v good in 20 008. This proporttion is higher forr men as comparred to women, an nd drops with ag ge. Belgium compares very good d with other EU-1 15 countries (ave erage of 71.7%).

•

Infant morrtality has decrea ased regularly ov ver the last deca ades. The figure es are similar in tthe three regions s and are close to o 4 for 1000 live births b in 2010. Infant mortality rattes in Belgium are close to th he average EU-15 5 rates, and bette er than in the neighbourring countries.

57

3 ACCESS SIBILITY OF O CARE 3 3.1

How did we w evaluate the e accessibility of healthcare? ?

Accessibility is deffined as the ease with which health A h services are rea ached in n terms of physic cal access (geog graphical distributtion), costs, time, and a availability of qua alified personnel.4 Accessibility of a health system m is a p prerequisite of a qualitative and effic cient health system. In n this report, we w have defined d twelve indicattors to evaluate e the a accessibility of the e healthcare system. Some indica ators are related to t the w workforce, addres ssing the availability of healthcare personnel, otherrs are u used to determine e financial access s, focusing on inssurance status, out-ofo p pocket payments and delaying contacts with healthcare due to fina ancial re easons. Another group of indicattors measures th he coverage rate es for p preventive policies s such as cancer screenings and d vaccinations. Fiinally, o one indicator rela ates to the timing g (or timeliness) o of access to pallliative s services. W Workforce 1. Number of pra actising physician ns per 100 000 population 2 Number of pra 2. actising nurses pe er 100 000 popula ation F Financial accessib bility 3 Coverage of the 3. t population in terms t of health inssurance 4 Amount of co--payments and ou 4. ut-of-pocket paym ments 5 Percentage of 5. o consumers wh ho delay contactt with health serrvices because of fin nancial reasons C Coverage of preve entive measures 6 Breast cancerr screening (wome 6. en aged 50-69 ye ears) 7 Cervix cancerr screening (wome 7. en aged 25-64 years) 8 Coverage of vaccination 8. v for you ung children 9 Coverage of influenza vaccinattion for the elderlyy (65 years and older) 9. A Accessibility of lo ong-term care (re esidential care for elderly and info ormal c carers) 10. Number of be eds in residential care facilities pe er population 65 years and older


58

KCE Reportt 196

11. Percentage e of population ovver 50 years old re eporting to be an informal carer Accessibility of end-of life-care: ttimeliness of start of palliative care 12. Start of pallliative care very cclose to death

Table 14 – Numb T ber of practising g physicians, esttimation of Full Time E Equivalent, and density d (/1000 po opulation) (2010)

3.2

M Medical doctors

Facts and a figures

P Profession

GPs This section is a short summary of the detailed res sults which are prresented for each indica ator in the Supple ement S1 of this report (available e on the website). Workforce The number of care providers g gives information on o the medical workforce w currently active e in the healthccare sector, and d thus indirectly on the accessibility of the healthcare syystem. The number off practising physiiciansj increased from 28 999 in 2000 to 31 815 in 2010 0, corresponding to a density of 2.91/1000 2 popula ation. Of these, 38.4% were w GPs and 6 6.07% psychiatris sts and 56% whe ere nonpsychiatrist spe ecialists. Expresse ed in full-time equ uivalents (as calcu ulated by the RIZIV – INAMI since 2009), this density y reduces to 1.99/1000 population (Tab ble 14). Few EU-15 Eurropean countries report the numbe er of practising ph hysicians to the OECD. Before B 2009, Belg gian data on practtising physicians included all registered physicians at the R RIZIV – INAMI (po otentially practisin ng). This way of countin ng resulted in a p physician density y of 4.03/1000 po opulation which was one of the highest in n Europe.1 Since 2009 2 (and retrosp pectively on data older th han 2009) the density is based on the number of practising physicians, giv ving a better piccture of the ‘useful’ medical de ensity in Belgium. Comp pared to other OECD countries which also report the e density of practising ph hysicians, the den nsity in Belgium is s lower than in Germany, G but is slightly higher than in the U UK (in 2009) (Figu ure 6).

j

For intern national comparisons, the practising physicians are de efined by RIZIV – INAMI as those wh ho provided more th han one reimburse ed clinical service du uring a year.

Psychiatrrists

Tottal practisin ng

Density

Total FTE

De ensity

31 81 15

2.92

21 691

1.99

12 22 28

1.12

8 646

0.79

1 93 32

0.18

1 260

0.12

Source: RIZIV – INA S AMI N Note: Practising phy ysicians are defined as those who proviided more than one e re eimbursed clinical service s during a yea ar.


KCE Report 196 6

59

Number of practising physicians per 1000 population

Figure 6 – Num mber of practisin ng physicians (pe er 1000 populatio on): internationa al comparison 4 Au ustria

3.5

4.8

S Spain

3 3.8

2.5

Germ many

3..7

2

EU U-15

3

1.5

3.4

gium Belg

1

2.9

Luxembourg

2.8

United Kingdom

2.7

0.5 0 2 2000 2001 2002 2003 2004 2005 2006 20 007 2008 2009 2010 Belg gium

F France

Germany

United Kingdom

U United States

EU-15

0

1

2

3

4

5

6

Number practis sing physicians per 1 000 population (2010)


Nurses are ge enerally the mostt numerous heallth professionals,, greatly 5 outnumbering physicians p in alm most all OECD countries. c Estima ating the number of prac ctising nurses is e even more challen nging than evalua ating the number of practising medical d doctors; indeed, many m nurses are e on the payroll of hospiitals or nursing ho omes, and there is i no centralized counting c of them. Only nurses outside th he hospitals are registered in the RIZIV – INAMI databas ses. For that reason, the FPS Pu ublic Health orga anized a large survey to measure the num mber of practising g nurses in 2009. Results showed that on n the 152 376 nursses included in th he study, 70% werre active in the healthcare sector (39% in n hospitals, and th he rest in residen ntial care for older person ns or in nursing h home care). This corresponds to a density

30 of practising nurs o ses of 9.9/1000 population. p How wever, we still do o not k know the number of corresponding FTE. In nternational com mparison based on OECD Health Data is currently m meaningless, as Belgian B data still re epresent all nurse es (on the basis off their d diploma, and not on o their working sttatus in healthcare e).

60


Financial acce essibility A prerequisite for f financial accesssibility is coverage with health ins surance. A compulsory health h insurance, in principle, coverrs the whole popu ulation of citizens living in i Belgium. In prractice, some categories of citize ens (e.g. asylum seekers s) may not fulfil ad dministrative and//or financial requirrements, and hence are not affiliated to a sickness fund. This does not me ean that they have no right to necesssary medical care, but their he ealthcare expenses are covered c by the public municipal welfare w centres (O OCMW – CPAS), and not by the sicknesss funds. The da ata for Belgium in n OECD Health Data report a constant p percentage of 99% % insured person ns, up to 99.5% in 2009. Other European n countries reporrt similarly high coverage c (with many countries reporting 100%). Neverthele ess, total health in nsurance coverage, both public and privatte, is an imperfectt indicator to compare the level of access sibility across the e countries, sinc ce the range of services covered and the degree of cost-sharing applied to o those services can c vary across countrie es. Another indicattor of financial acc cessibility is the coverage c of complementtary health insurrance (usually prrivate), but no data d are currently available in Belgium. Low out-of-poc cket (OOP) payyments are anotther condition fo or good accessibility to o the healthcare e system. Out-o of-pocket payme ents are expenditures bo orne directly by a patient where health h insurance does d not cover the (full) cost of the he ealth good or se ervice. They include copayments (tick ket modérateur / remgeld), co osts of over-the-counter medications an nd other expendittures paid directly y by private hous seholds. Between 2003 and 2010, the OOP expenditu ures rose from €5.33 € to €7.25 billion, but compared to tthe total health expenditures, e the eir share remained consttant during the sa ame time period (20.0% ( in 2003, 19.4% 1 in 2010). Co-paym ments represente ed 26.7% of all ou ut-of-pocket expe enditures in 2010. Expre essed per inhabittant, out-of-pocke et payments reprresent a total of €665 in 2010.

KCE Reportt 196

Comparison of he C ealth expenditures s across Europea an countries are based b o the System of Health Accounts (SHA). The SHA on A, developed jointly by E Eurostat, WHO an nd OECD, is a common way to rep port and classify health h e expenditures at a national level. The comparison shows that OOP e expenditures in Belgium (expresse ed as a % of tota al health expendittures) a at the higher end, are e with countrie es such as France e, the Netherlands s and U lying below 10 UK 0% (Figure 7). Aga ain, this statemen nt should require a very d detailed scrutiny of all expenses included or nott by countries in n the c calculation of theirr System of Health h Accounts.


KCE Report 196 6

61

Table 15 – Outt-of-pocket expen nditures (2003-2010) Year All out-of-pocke et expenditures Billion € % expenditure on o health €/capita Co-payments only o Billion € % of all out-of-p pocket expenditurres

2003

2004

20 005

2006

2007

20 008

2009

2010

5.53374 4 20.0 533.31

5.53049 18.8 530.70

5.68334 18 8.6 54 42.37

6.27044 4 20.5 594.47

6.73778 20.9 634.10

7.0 02868 20 0.3 65 56.27

6.85982 2 18.9 635.38

7.25518 19.4 665.88

1.8 85261 26 6.4

1.96620 0 28.7

1.93881 26.7

Source: e System m of Health Accoun nts (SHA), OECD He ealth Data 2012 - Out-of-pocket expenditures: - Co-payments (ttickets modérateurs//remgeld):RIZIV – INAMI

Figure 7 – Out-of-pocket expen nditures (as a pe ercentage of total health expendittures): internatio onal comparison n



62

To guarantee financial f accessib bility of healthcarre in Belgium, leg gislators have introduce ed several “social care nets”, which w aim is to protect households wiith low financiall means or with very high he ealthcare expenses against catastrophic healthcare expensesk. However, despite these social ca are nets, 14% of the households declared d that they y had to postpone healtthcare (medical care, surgery, drrugs, glasses or lenses, mental healthc care) for financia al reasons. In Brussels, this perrcentage reaches 26% of the households (14% in Wallonia and 11% in Flanders). In 1997, this perce entage was below w 10%. It is difficult to benchmark b these data: indeed, data on global unme et clinical needs are availlable in OECD He ealth Data, but tho ose also include problems p due to waiting times t or distancess. The five follow wing indicators m measure in which way specific preventive measures are effectively e accessiible and used by the t population.

•

For breast cancer, a national screening s program m exists (since 20 001 in Flanders and 2002 in Wallonia a and Brussels) ffor women aged 50-69 5 years. The lattter co-exists with opportunistic scrreening (mammog grams performed outside of the progrram). Mammogram ms within this pro ogram are called hereafter “mammote ests”, to be distin nguished from all other mammograms s (opportunistic sc creening or diagnostic test)m. Result: In 2010, the total cov verage of breast cancer screening g was 60%, far belo ow the EU-15 ave erage of 68%, an nd even further of o the 75% target set s by the EU.5 (Figure 9) Moreo over, only half of o this coverage occ curred within the program p (30% sccreening coverage e with the “mammottests” in 2010). Differences D betwee en regions are sttriking with regard to o the coverage witthin the program: 4 46% in Flanders, while only 11% in Brussels B and 7% in Wallonia. (Figu ure 8) This is pro obably partially due to the persiste ence of pre-exissting higher leve els of opportunistic screening in Wa allonia and Brusse els before the start of 3 the program.34

•

Cervical canc cer, a cancer with a low incidence and a medium to o poor prognosis, ca an be largely dete ected in a curable stage by the smear s 35 test (or Pap test). t This test is recommended every three years for women aged 25-64 years. Currrently, the screening for cervix cancer is essentially op pportunistic. Result: The cervical c cancer sc creening coverage e has remained stable s around 62% between b 2007 and 2010. In a prevvious study from 19981 2000, the co overage rate was s already 59%.36 Compared to other European cou untries, Belgium caught up with tthe EU-15 average of 61% in 2008, but is still far from m some countriess such as UK (80%) or Finland (70%)) (Figure 9).

m

It is not poss sible to distinguish in the nomenclature e between mammog grams done for oppo ortunistic screening from mammograms done for a diagno ostic.

Coverage of sc creening for brea ast and cervical cancer These two in nterventions currrently run with different organizational modalities: org ganized national program for the t breast canc cer and opportunistic sc creening for the ccervix cancer. It is s still too early to evaluate e the colorectal cancer screening p program.l

k

l

Only to ciite some of them: tthe entitlement to increased i reimburs sement of co-payme ents (introduced in 1963), the Maxim mum Billing System m (MAB, implemented in 2002) and the e OMNIO status (introduced in 2007). For colore ectal cancer, there is no national program in place, butt different regional approaches a co-exisst: in the French Community (Wallo onia and Brussels),, a screening progrramme was started d in March 2009. Every E two years, perrsons aged 50-74 yyears old are invite ed to perform a FOBT (fecal occult blo ood test), or directlyy a colonoscopy for individuals at high or very 3 high risk.31 There has been n a preliminary evaluation of the sta art of the program, but it is still too early to evaluate e the global coverrage.32 In Flanders, pilot projects were also started.33

KCE Reportt 196

KCE Report 196 6


63

Figure 8 – Perrcentage of women (aged 50-69) who had a mammogram (within program (a) or overall o (b)) within n the last two ye ears, by region (2 20062010)

Note: mammotes st = organised scree ening program, mam mmogram = organiz zed + opportunistic screening s + diagnos stic test; Source: IM MA-EPS, KCE calcullation


64

KCE Reportt 196

90

%females 20-69 years screened for cervical cancer

%females 50-69 years screened for breast cancer

Figure 9 – Brea ast cancer and c cervical cancer screening: s international comparis son (2000-2010)

80 70 60 50 40 30 20 10 0

90 80 70 60 50 40 30 20 10 0

2000 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2

2000 2001 2002 2003 2004 2005 2006 2 2007 2008 20 009 2010

Belgium

France

Germany

Belgium

Germany

Netherlands

United Kingdom

EU-15

United Kingdom

EU-15

Netherla ands

Source: OECD Health H Data 2012, exxcept IMA-EPS for Belgium B 2008-2010 0 (KCE calculation)

Coverage of va accination Immunisation is one of the most powerful and d cost-effective forms f of primary preven ntion. The choice of the vaccinatio ons included in ou ur set is based on the international indiccators from Euro opean Community y Health Indicators Moniitoring (ECHIM) a and OECD. In Bellgium, as vaccina ation is a regional health h competence, tthe vaccination rates are meas sured at regional level, and a a national ra ate is computed as a a weighted ave erage of the three region nal rates. The WHO-reco ommended target rate for a collecttive immunisation n is 90% for Diphteria-Te etanos-Pertussis (DTP) and 95 % for measles. In general,

th he recommended d coverage rates are reached in Belgium. The 3rd dosed c coverage of Diphtteria-Tetanos-Perttussis (DTP3), Ha aemophilus Influe enzae B (Hib), poliomye elitis (Polio3), he epatitis B (Hep3 3) has increased d and e exceeds 95%. Only for Measles-Mu umps-Rubella (MM MR) the coverage e was s just below 95% still % in 2009. It mus st be noticed thatt some small epid demic o outbreaks of meas sles have occurre ed in recent yearrs, in all regions and a a la arge outbreak of measles m occurred d in 2011.37 C Compared with other European countries, Belgium m ranks very goo od for D DTP3 coverage, particularly p since 2003. 2 For measless (1st dose), the global g c coverage ranks good, has much h improved and reaches almos st the re ecommended level.


KCE Report 196 6

65

100 %children vaccinated against measles

%children vaccinated against DTP

100

95

90

85

80

95

90

85

80

75

75 006 2007 2008 2009 2010 0 2000 2001 2002 2003 2004 2005 20

2000

2001

2002

2003

2004

2005

2006

2007

2008

Belgium

France

Germany

Belgium

France

Germany

Netherla ands

United Kingdo om

United States

Netherlands

United Kingdom

United States

EU-15

EU-15

2009

2010

%children vaccinated against hepatitis

Figure 10 – Pe ercentage of child dren covered by main vaccinatio ons (2000-2009): international com mparison 100 90 80 70 60 50 40 30 20 10 0 20 000 2001 2002 2003 2004 2005 2 2006 2007 2008 2009 2010 B Belgium

Franc e

U United States

EU-15 5

Germany

Source: OECD Health H data 2012

In Belgium, sea asonal influenza vvaccination is currrently recommended in 5 groups of perrsons defined ass being of influe enza complicatio ons (like persons aged >65 > years and all persons living in institutions; he ealthcare professionals; pregnant women n; persons aged 50-64 years with h health risks like obesity; chicken and pig farmers).38 The T WHO recomm mends a target vaccination rate of 75% for the elderly.39 The last Intermu utualistic Agency (IMA) report which coverrs the winters 07-08 and 08-09, sho ows that the vaccination coverage of elderly does not reach h the WHO targett (63% in 2008-2009)40, except e for elderly residing in instituttions (83%). Compared to other countries, coverage in Bellgium is lower tha an in France, UK and the Netherlands (between 70% and d 80%), and similar to the EU-15 average (63%).

Accessibility of long-term care A e (residential c care for elderly and in nformal carers) Relative to the 65+ population, th R he number of be eds in residential care fa acilities has rema ained constant ov ver the past decade, at 7 beds pe er 100 p persons of 65 and over in 2010.41 This T stable figure h hides large shifts in the s sector: the numbe er of beds in home es for the elderly h has decreased ste eadily in n the last decade,, from around 88 000 0 in 2000 to 64 000 in 2011, while the n number of beds in n nursing homes almost doubled, ffrom around 33 000 0 to 6 000 over the same 65 s period. The ere are also large e differences bettween re egions. In 2010, the number of beds b in homes fo or the elderly per 100 in nhabitants of 65 years y and older was w considerably higher in Wallonia a and B Brussels than in Flanders (Table 16) while the density of nursing home b beds does not div verge much betwe een the regions. O Overall, the numb ber of b beds in residentia al facilities in rela ation to the elderrly population is much h higher in Wallonia and Brussels tha an in Flanders.


66

KCE Reportt 196

Table 16 – Num mber of accredite ed beds in home es for the elderly y and nursing hom mes per 100 pop pulation 65 years s and older, per rregion, 2010 Bed ds in homes for the elderly

Number of beds s /100 inhabitants s 65 +

Beds in i nursing homes s

Wallonia

Flanders

Brussels

Wallon nia

Flanders

Brussels

4.9

2.5

6.3

3.4

3.3

3.8

Source: RIZIV – INAMI I 2011

Data are available internationallyy for the proportions of population over o 65+ recipient of lon ng-term care (LTC C) in residential care. With a perrcentage between 6% an nd 7%, Belgium is higher than the e EU-15 average e (that is between 4% and a 5%), and ssimilar to the Ne etherlands. No data d are available for rec cipients of home ccare. Informal carers s, defined as p people providing g assistance with basic activities of da aily living (ADL) for at least one hour per week, are an important component in the lo ong-term care prrocess.5 The number of informal carers is estimated to de ecrease in the com ming decades, as s a result of declining family size, changes in residential patterns of people with disabilities and rising participation rates of women n in the labour marrket. The average proportion p of inforrmal carers varied d from 8% in Sw weden to 16.2% in Italy. The Belgian ave erage of 12.1% of the population aged a 50 and older is slig ghtly higher than tthe overall averag ge of the OECD-c countries (11.7%).5 Other results are a available in th he documentation n sheets (Supplem ment S1 available on the e web) and includ de data on share of women, week kly hours of care, distribu ution of care recip pients, employmen nt rate and hours of work, leave from wo ork, flexible workk schedule, and mental health problems p related to inform mal care giving. As there are cu urrently no data o on patient needs, these two indica ators are still insufficient to evaluate the acccessibility of long g-term care.

A Accessibility of end-of-life e care: timeliness t to sta art palliative care e The last indicator of accessibility is specific to end-o T of-life care. The sttart of p palliative care is sometimes s delaye ed until patients are in terminal phase. T This can denote either e problems of o accessibility of end-of-life care, either e th hat the decision to start palliativ ve care was take en too late. The ere is c currently very little e information on the t real moment w when palliative ca are is s started, but the time t when the palliative p lump su um is requested for a p patient can provid de some indication n.n A study from tthe Christian Sick kness F Funds (2006) give es some indication ns: the application n for the palliative lump s sum occurred for half of the patie ents in less than a month before their d death. In 20% of the cases, patients died within the wee ek of 42,43 a application. Mo ore data are need ded on this indicator.

n

Patients who o stay at home and d have a life expecctancy of less than three months can benefit b from a “pallia ative statute”. It invo olves a lump sum an nd the abolition of patient co-paymen nt for nursing, GP visits and visits of o the d from physiotherapist. The use of pallliative lump sums at home increased 8 504 lump sum in 2004 to 20 17 70 in 2010 (source: RIZIV – INAMI).

KCE Report 196 6

3.3


Key findings

Workforce •

The densitty of practising p physicians (thos se who performed d more than one reimbursed r clinic cal act) increased slightly from 2.83 2 /1000 popu ulation in 2000 to o 2.91/1000 popu ulation in 2010. Expressed d in full-time equ uivalents, medica al density decrea ased to 1.95 /1000 population.

Coverage of prev C ventive measures s • During the la ast five years, the e coverage of org ganized breast cancer scree ening stagnates around a 30%, with h huge differences in participation between regions (Brussels: 12% %, Flanders: 46% %, Wallonia: 7% %). Overall covera age, including all mammograms,, stabilized aro ound 60%, which h is far below the e EU-15 target (75%). •

Coverage of cervical cancer screening s was s stable between 20 007 and 2010 (62%-63%), while th he number of tes sts performed annually was s divided by 2 be etween 2008 and 2010, due to changes in re eimbursement ru ules. Coverage in n Belgium is with hin the EU-15 average (63%) but lower than in the e UK (around 80%).

•

In general, th he WHO-recomm mended coverage e rates of children vaccination are a reached in Be elgium. The cove erage rates of diphtheria-te etanus-pertussis,, poliomyelitis, h hepatitis B have increased an nd are now above e 95%. Only for m measles the coverage was still just below w 95% in 2009.

•

The WHO-rec commended cov verage of elderly vaccination aga ainst influenza is not n met: 63% in the t winter 2008-2 2009 against a 75 5% target. Vaccination rates for elderly e residing in an institution are higher (82%).

•

The densitty of practising n nurses in the hea althcare sector was w 10/1000 po opulation in 2009 9. On 100% nurse es, 68% were acttive in the healthcare sector (37% % in hospitals, an nd the rest in res sidential care for ollder persons or in nursing home care). This result was not availab ble in the previous report. Financial acce essibility •

The coverrage of populatio on by health insu urance is very hig gh (99.5%), du ue to compulsorry affiliation to a sickness fund.

•

Between 2003 2 and 2010, th he out-of-pocket (OOP) expenditu ures rose from €5.33 to €7.25 billion. Their sharre in total health expenditures remained co onstant during the same time perriod: 20.0% in 2003 2 and 19.4% in n 2010. OOP exp penditures per ca apita amounted to €665 in 2010.. Comparison witth other Europea an countries shows that OOP P expenditures (e expressed as a % of total health expenditures) in Belgium are at a the higher end d, with countries such as France, the Netherlands s and the United Kingdom lying l below 10%.

•

In 2008, 14 4% of the househ holds declared th hat they had to postpone some of their he ealthcare (medica al care, surgery, drugs, glasses orr lenses, mental healthcare) due to problems of financial accessibility. a In 1 1997, this percen ntage was below 10%.

67

68


Accessibility of long-term c care (residential care for elderly and informal carers s) •

Relative to o the 65+ population, the numberr of beds in resid dential care facilitties has remaine ed more or less constant c over the e past decade, frrom 71 beds per 1000 persons off 65 years and ov ver in 2000 to 70 0 beds in 2010. W With 6%-7% of 65+ residing in res sidential care, Belgium is higher tha an the EU-15 ave erage, between 4% 4 and 5%, and is s similar to the Netherlands. No data d on home care users are available for inte ernational compa arison.

•

Informal carers, c defined as s people providin ng assistance with basic activ vities of daily living (ADL) for at least l one hour per week, are an important component in the long-term care process. The Belgia an average of 12.1% of the popullation aged 50 an nd older reporting to t be an informa al carer is slightly y higher than the e overall ave erage of the OEC CD-countries (11.7%). Timeliness to start s palliative ca are •

There is currently little info ormation about the t moment whe en a palliative status s is requestted. A study from m the Christian Sickness Funds F (2006) giv ves some indicattions: the applica ation for the pallliative lump sum m occurred for ha alf of the patients s in less than a month before d death. In 20%, pa atients died within the week of ap pplication. More data are needed d (trend over time e, internation nal comparison) on this indicator.

KCE Reportt 196

4 QUALIT TY OF HEA ALTHCARE E Quality is defined as “the degree to Q t which health sservices for individuals a populations in and ncrease the likelihood of desired he ealth outcomes an nd are c consistent with cu urrent professiona al knowledge”.6 Itt is further subdivided in nto 5 sub-dimensions: effectivenes ss, appropriatenesss, safety, continu uity of c care and patient centeredness.

4 4.1

Effectiven ness of care

4 4.1.1

How did d we evaluate the e effectiveness o of care?

Effectiveness is defined as “the de E egree of achieving desirable outco omes, g given the correct provision of evid dence-based hea althcare services to all w could benefit but not those wh who ho would not ben nefit”. All indicatorrs are th hus outcome (results) indicators.

4 4.1.1.1

Preventive care

No indicator provides information on N o the effectivene ess of preventive care, a updating this set as s of indicators fo or preventive care e did not belong to t the o operational objecttives of this 2012 2 report. Examples of such indic cators in nclude: declines in mortality for cancer c for which there is a screening p programme, shifts s in staging at diagnosis d of can ncer and incidenc ce or m mortality of epidem mics for which vac ccination exits.

4 4.1.1.2

Curatiive care

Four indicators ha F ave been selected d to assess the efffectiveness of curative c care: three indicators related to th he survival after a diagnosis of ca ancer, a and one indicatorr on the effective eness of ambula atory services to treat p patients with a chrronic condition (in this case: asthma a). C Cancer Care 1. 5-year relative e survival after bre east cancer, by sttage 2 5-year relative 2. e survival after cervical cancer, by sstage 3 5-year relative 3. e survival after colon cancer, by sta age C Chronic care 4 Avoidable hos 4. spital admissions for asthma

KCE Report 196 6

4.1.1.3


Lon ng-term care

Three indicators are selected to assess the effectiveness off mental healthcare: 1. Suicide rate 2. Rate of inv voluntary committa als as a percentag ge of all hospitaliz zations 3. Participatio on rates by peop ple with mental illness of working g age in employmen nt With regard to the effectivenesss of long-term carre for the elderly, no data are currently available a at a national level. Ho owever, the BelR RAIo will provide data so oon on a selected indicator: the pre evalence of malnu utrition in elderly being in residential care ffacility or receiving g home care (BMII<19)p.

4.1.1.4

End d-of-life care

Some indicatorrs have been pro oposed by the expert groups, such h as the percentage of palliative patients for which phys sical symptoms (pain ( for instance) have been assessed and controlled, but b there are currrently no data available for f this indicator.

4.1.2

Facts and figures

This section is a short summary of the detailed res sults which are prresented for each indica ator in the Supple ement S1 of this report (available e on the website).

o

p

The Resident Assessment Instrument (RAI)444 is originally deve eloped to assess th he care needs of tthe elderly in instittutions, and has la ater been extended with instruments ffor different care settings and subgrroups. In Belgium a national pilot pro oject (the BelRAI) is ongoing, but is s not yet implemented in all care settin ngs: the assessmen nt instruments for ho ome care, for long-te erm care facilities a and acute care hav ve already been ad dapted to the Belgia an situation (details in Appendix C). This indic cator is already mea asured in the Netherlands (Dutch Hea alth Care Performan nce Report 20103,220) and also belon ngs to the set of indicators proposed by the OECD working group on long-te erm care quality ind dicators.45

4 4.1.2.1

69

Surviv val after a cance er

Survival rates after cancer are one of the kkey indicators off the S e effectiveness of th he healthcare sys stem and are commonly used to track p progress in treatin ng disease over time. They reflect both how early the c cancer was detec cted, and the effectiveness of the ttreatment.5 In Belgium n national 5-year re elative survival da ata became availa able only recently y and n evolution of re no elative survival ca an be given alrea ady in this reportt. For in nternational comp parisons, data refe er to the incidence e year 2004. Rate es are e expressed as “rela ative 5-year surviv val years”, meanin ng that they have been c corrected for the age-specific a expec cted mortality. T The 5-year breas st cancer relative e survival rate is 80% in most OECD O 5 c countries and has s improved in all countries c between n 1997-2002 and 20042 2 2009. In Belgium m, the 5-year re elative survival o of women diagn nosed 46 b between 2004 and 2008 was 88%. 8 Survival rates are very good c compared to otherr European countrries (Figure 11). T The 5-year cervic cal cancer relative survival rate w was 69.8% for wo omen d diagnosed betwee en 2004 and 2008 8. Compared to o other EU-15 coun ntries, re elative survival rates r of patients diagnosed in 20 004 are within the EU a average (Figure 11). A countries have All e also shown improvement in 5-yyear colorectal ca ancer re elative survival ov ver the years. There are difference es in colorectal ca ancer re elative survival between gender across countrie es: survival rates s are 5 u usually higher for females. f In Belgium, on the cohortt of patients diagn nosed w colon cancer between 2004 an with nd 2008, the relatiive survival was 62.3% 6 fo or males and 64 4.6% for female es. Again, relative survival rates after c colorectal cancerq are very good compared c to othe er European countries (Figure 11). O Only for breast ca ancer and colon cancer, c the US ha as higher survival rates th han Belgium (datta shown in docum mentation sheet iin Supplement S1 1). To b able to distinguish the effect off early screening from the actual care, be re elative survival rates r should be compared across countries by stage, s in nformation which is not yet availablle at international level. q

Survival rates s after colorectal ca ancer, and not speccifically colon cance er, are available in th he OECD Health Da ata 2012.


70

Table 17 – 5-year 5 relative survival by sta age, period 200 04-2008: Belgium Stage Cancer type

All patients

I

II

III I

IV

missing

Female breastt cancer

88.0%

99.8%

93.3%

73.8% 7

29.2%

73.4%

Cervical cancer

69.8%

92.2%

63.6%

54.5% 5

17.0%

64.6%

Colon cancer:: males

62.3%

91.6%

86.1%

61.7% 6

14.5%

54.5%

Colon cancer:: females

64.6%

96.3%

86.1%

62.1% 6

16.0%

55.5%

46 Source: Belgian Cancer C Registry and Evaluation of Can ncer Plan (Cancer Centre) C

KCE Reportt 196

KCE Report 196 6


71

Figure 11 – 5-y year relative surv vival after breastt, cervix and colo orectal cancer fo or females: intern national compariison (2004)

Source: OECD Health H Data 2012 Note: results for colorectal c cancer m males give similar res sults for Belgium

Effectiveness of ambulatory ca are for a chronic c condition Asthma, a chro onic condition, is either preventab ble or manageable on an outpatient basis through properr prevention or primary p care interrvention. Proper manag gement of asthm ma in primary care c setting can reduce exacerbation and costly hospita alisations. The ho ospital admission rate for asthma commo only serves as a p proxy for primary care quality. Hen nce, high admission rates s may indicate po oor effectiveness of primary care, or poor care coordinatio on or continuity.5 This indicator be elongs to the set of HCQI (healthcare qua ality indicator) of th he OECD. Across OECD countries, therre is an 11-fold d difference in hospital admission rate e for asthma. Females have cons sistently higher rates r for asthma admiss sions compared to o males (on avera age 85% higher).5 This is also the case in Belgium: in 200 09, the asthma ad dmission rate for females

was 52/100 000 in w nhabitants and 28 8/100 000 inhabita ants for males. Be elgian ra ates in the OECD D Health data (20 007) show that 48 8.4/100 000 inhab bitants a slightly above are e the EU-15 ave erage (47.2/100 0 000 inhabitants). This m might highlight the e need for more effective and tarrgeted care in primary c care setting. Effectiveness off mental health E hcare: suicide rate in the ge eneral p population, inv voluntary com mmittals within n the psychiatric h hospitalization an nd working statu us of persons witth mental illness s

72


Suicide rate Despite a slight decrease (from 20.05/100 000 0 inhabitants in 1998 to 18.75/100 000 inhabitants in 20 008) the number of suicide deaths in the general popula ation is conside erably higher th han in other European countries. For the t time period off the analysis, suicides rates are higher h in Wallonia than in Flanders and B Brussels (Figure 12). 1 Important diffferences within regions were also found d in previous res search. In Wallo onia, the highest suicide e rates are found d in the province of Namur (25.4//100 000 inhabitants) wh hile in Flanders the highest rate es are observed in East Flanders (21.4//100 000 inhabita ants).47 The suicid de rate is also hiigher for men than for women, and hig gher for middle-a aged adults (aged 40-64 years). Figure 12 – Su uicide rates (num mber per 100 000 population) per region (1999-200 08) and internatio onal comparison n

Source: DGSIE (Belgium) ( and OECD D Health Data 2012 2 (international, data a for Belgium only available a in 2004-20 005)

KCE Reportt 196


Involuntary com mmittal in psychiattric hospitals The percenta age of involun ntary psychiatric c hospitalization ns (”for observation”; “internment”; ”prolongation involuntary i adm mission”; “probation”; “other judicial con nditions”;) in Belgium steadily in ncreased between 2000 0 and 2009 fro om 5.8% to 8.2% 8 of all psychiatric hospitalizations s (Figure 13). T The rate in Bru ussels is twice as high compared to the t two other re egions (Brussels 14.2%, Flanderrs 7.7%, Wallonia 7.2% %). The three most common conditions amo ong the 7 719 involunta ary committals rregistered in 20 009 were schizo ophrenia (n=1 579 or 20.46%); 2 psychottic conditions (n= =1 270 or 16.45 5%) and alcohol abuse (n=723 or 9.37% %). The three co onditions with the e largest share of involluntary committa als in 2009 were paraphilia (57 7/157 or 36.31%); schizophrenia (n=1 579/6 274 or 25.17%) 2 and psychotic p conditions (n=1 1 270/5 747 or 22 2.10%). Results based on old da ata (year 1998) showed that rates of invo oluntary committal are very low in Belgium compared to other European n countries. The ese results hav ve been confirmed in an nalyses of involunttary committal pop pulation rates.

73

Figure 13 – Percentage of inv F voluntary comm mittals in psychiatric h hospitals, by region (2000-2009) 16 Involuntary admission rate (%)

KCE Report 196 6

14 12 10 8 6 4 2 0 2000 20 001 2002 2003 2004 2005 20 006 2007 2008 2009 Belgiu um

Flanderrs

Brusselss

Wallonia

S Source: FPS Public Health, Minimum Psychiatric P data (RP PM – MPG)

Participation rate by people witth mental illnesss of working ag P ge in e employment The last EU Labo T our Force Survey y performed in 2 2002 showed tha at the e employment rate of o people with me ental disabilities iss low compared to t the e employment rate of o people with oth her disabilities.29 Belgium performs s well b is ranked lowe but er than Norway, the t Netherlands, Sweden and Porrtugal (Figure 14). An up pdate of this study y (year 2011) is exxpected to be rele eased s soon.

74


Figure 14 – Em mployment rates s by health condition, as a ratio o of the employment rate of all p people with disability: d intern national comparison (2 2002)

4 4.1.3

KCE Reportt 196

Key findi dings

•

The relative survival s 5 years after a diagnosis s of breast cance er, cervix cancer and colon canc cer is respectively 88%, 70% and d 63% (62% for men n, 65% for women). Belgium has the highest 5-ye ear relative surviival rate in Europ pe for female bre east cancer, and colon cancerr, but the cervica al cancer surviva al is lower than th he EU-15 averag ge.

•

Hospital adm mission rates for asthma are stab ble over time (200 042009), and Be elgium is just ab bove the EU-15 av verage.

•

The suicide rate r is considera ably high comparred to other European co ountries, even if it decreased slightly in Belgium between 1998 8 and 2008. The suicide rate is higher for men than for women, and a higher for miiddle-aged adults s (aged 40-64 ye ears). For the perio od analysed, the rate is higher in Wallonia than in n Flanders and d Brussels.

•

The percenta age of involuntarry psychiatric ho ospitalizations in Belgium stea adily increased between b 2000 and d 2009 from 5.8% % to 8.2% of all ps sychiatric hospittalisations. The rrate in Brussels is i twice as high h as in the two otther regions (Bru ussels 14.2%, Flanders 7.7% % and Wallonia 7.2%). 7 Results arre based on old data d (year 1998). They T showed tha at rates of involu untary committal are very low in Belgium B compare ed to other Europ pean countries.

•

The last EU labour survey (in n 2002) showed tthat Belgium performs well compared to EU E countries con ncerning the employment rate of people with w mental disab bilities, but more recent data are a lacking.

Source: Europea an Labour Force Stu udy 2002

KCE Report 196 6

4.2 4.2.1


Approp priateness How did d we evaluate the appropriaten ness of care?

Appropriatenes ss can be defin ned as “the deg gree to which provided p healthcare is relevant to the clinical needs, given the curre ent best evidence”. The link between effe ectiveness and ap ppropriateness reflects the link between ou utcomes and proccesses. Seven indicatorrs were selected tto measure the ap ppropriateness of care: Screening out of o the target group ps 1. Breast can ncer screening fo or women younge er than target ag ge group (aged 40-4 49) 2. Breast can ncer screening forr women older tha an target age grou up (aged 71-79) Application of guidelines g 3. Follow-up of o diabetic patientts (blood and eye exams) 4. Prescription of antibiotics acccording to guidelines Geographic varriation in surgical interventions 5. Geographic cal variation in ca aesarean sections per 1000 live birtths Mental Health 6. Average daily quantity (ADQ) of medication pre escribed (antidepres ssants / antipsych hotics / hypnotics and a anxiolytics) Aggressiveness s of care at the en nd-of-life 7. Proportion of cancer patien nts receiving chem motherapy in the e last 14 days of the eir life

4 4.2.2

75

Facts an nd figures

This section is a short summary of the T t detailed resultts which are prese ented fo or each indicatorr in the Supplement S1 of this re eport (available on the w website). Mammograms co M overage outside of the target gro oups T national breas The st cancer screeniing programme se et up since 2001--2002 ta argets women aged 50-69. Two re ecent guidelines have not recomme ended th he extension of this target grou up to younger (40-49) or olderr age c categories (70-79)) in Belgium.48, 49 Those two indica ators reflect the extent e to o which the scree ening is performed d outside of the target group. T percentage off women aged 40-49 who received a mammogramr in the The la ast 2 years was stable around 35 5% between 2006 6 and 2010, with large d differences across s regions. For women w 71-79 yea ars old, the rates s are lo ower (21% in 2010), but increasing g, and also with higher rates in Bru ussels a and Wallonia (Fig gure 15). It should be noted that a small proportion of th hose mammogra ams are perform med for diagnosttic reasons47(it is s not p possible to distinguish between opportunistic o scre eening and diagn nostic m mammograms, ba ased on the reimbu ursement codes).

r

This include es all mammogram ms, for opportunistic screening an nd for diagnosis


76

KCE Reportt 196

Figure 15 – Ma ammogram coverage of women aged a 40-49 years s and of women aged a 70-79 years s, by year and re egion 50%

% females 70-79 years screened

% females 40-49 years screened

50%

40%

30%

20%

10%

40%

30%

20%

10%

0%

0% 2006 B Belgium

200 07 Bru ussels

Source: IMA-EPS S, KCE calculation

2008 Fland ders

2009

2 2010 Wallon nia

6 2006 Belgium m

2007 Brussels

2008

200 09

Flanders

2010 Wallonia

KCE Report 196 6


Application of guidelines: follo ow up of diabetic c patients (chron nic care) and prescriptio on of antibiotics (acute care) Several situatio ons permit evalu uation of the qua ality of the monittoring of chronic patien nts, in particula ar the integrate ed and multidisciplinary management of o diabetic patien nts. For diabetic patients, the gu uidelines recommend th hat glycated hae emoglobin, album min and creatin nine are monitored prefferably once a ye ear, and never le ess often than every e 15 months. It is als so recommended that an ophthalm mologist performs a dilated fundus examination every year in order to t early detect ocular complications. Over O a 15-month period, 95% of in nsulin-dependent patients received a blo ood sugar checkk, 93% a creatin nine check and 56% an albumin check.. In the last 12 m months 57% had undergone a che eck and, over a period of three years, 20% of patients s had no ophthalmologic consultation. The T recommenda ations are relativ vely well observ ved with regard to glyca ated haemoglobin n. The situation is s less satisfactory y among diabetic patients who are not treated with insu ulin. The ophthalmologic consultation ap ppears to be an issue for one thirrd of diabetics. Subgroup analyses showed that guidelines are less well fo ollowed for patien nts older 2 than 75 years and a for patients in residential care.26 The appropriate eness of therapeutic prescription is i evaluated on th he basis of the prescripttion of antibioticss according to gu uidelines. Since the early 2000s, the auth horities have been n raising awarene ess among the pu ublic and physicians conc cerning the issue of antibiotic resis stance. Antibiotics s should be prescribed only o where they a are really necessa ary and the choice e should preferably tend towards first--line antibiotics. For most indications, amoxicillin shou uld be prescribed in first intention without w clavulanic acid.

77

43% of patients who 4 w consult a GP receive at leasst one prescriptio on for a antibiotics during the t year. This – high – figure has been stable since 2006. 2 T The number of da ays of treatment is increasing (23 3.9 in 2008 comp pared w 21.2 in 2006)). Furthermore, th with he antibiotics presscribed are not allways fiirst-line. For exam mple, a combinatiion of amoxicillin and clavulanic acid is v very often prescrribed even thoug gh a prescription for amoxicillin alone w would suffice (the 45% has been stable s since 2006 6). In addition, a much h higher rate of pres scriptions to patien nts over the age o of 75 in residential care is s observed in com mparison with the over-75s in generral.26 T There are no interrnational data for this t specific indica ator, but comparis son of a antibiotics prescrib bed per capita re eveals that Belgium is in the top 5, 5 and m more than twice as a much as the Netherlands (Bellgium, 27.5 DDD//1000 p pop/day versus the e Netherlands, 11 1.4 DDD/1000 pop p/day).5 Geographic variation in surgiical intervention G ns as evidenc ce of in nappropriate carre: the case of ca aesarian section Results from international comparis R son show that C-ssections are increasing in n the majority of European E countrie es, with EU-15 avverage at 251/100 00 live b births in 2009. Be elgium has a C-se ection rate similarr to France, and lower th han the EU-15 average. a In 2009 9, the C-section rate in Belgium m was 193/1000 live birth hs. Despite this somehow s reassuring result, the ra ate is c continuously incre easing. Moreover,, an analysis of tthe FPS Public Health H re evealed a very hig gh variability betw ween hospitals; in the period 2004-2 2007, th he national rate was w 13.7% (based d on a selection o of low-risk pregna ancies frrom 2004-2007) and a relative differe ences ranged from 61% to 70% arround th his average.50 Ge eographic variabillity for elective su urgical procedures s has a also been shown in Belgium for hip replacement a and knee replacement, tw wo procedures for which Belgium ranks r in the top off EU-15 countries..5, 51


78

KCE Reportt 196

Figure 16 – C-s sections per 100 00 live births: inte ernational comparison

Source: OECD Health H data 2012, exxcept for Belgium 20 009 (FPS Public He ealth)

Appropriatene ess antidepressants

of

pres scriptions

in

mental

hea althcare:

Average daily quantity q of antide epressants prescri ribed (Defined Daily Dose (DDD) per 1000 0 population) The prescription of the average daily quantity an ntidepressants pre escribed per 1000 pop pulation increase ed from 51.4 (2004) ( to 68.4 (2010). Prescription off antidepressant drugs are high hest in Wallonia a (85.9,

compared to 57.1 c 1 in Brussels and d 60.7 in Flande ers). It is conside erably h higher for females (92.8) compared to males (43.1). In nternational com mparison shows that t Belgium ran nks high in term ms of a antidepressant co onsumption (see e documentationss sheet). We ca annot c conclude from these figures if Be elgium is perform ming better or worse. w N Nevertheless, the e large difference es (between sexxes; between reg gions; in nternational conte ext) pinpoint that the appropriaten ness of antidepre essant d drugs (e.g. over-- and underconsumption) needss to be studied and m monitored.


KCE Report 196 6

79

100 90 80 70 60 50 40 30 20 10 0

80 DDD per 1 000 population per day

Daily consumption of antidepressant per 1000 population

Figure 17 – De efined daily dosa age of antidepres ssants per 1000 population p per day: by region (20 004-2010) and international comp parison (2000-20 010) Denmark

70

Portugal

60

Sweden

83.8 78..7 75.8

50

Finland

68.8

40

Belgium

68.7

30

United Kingdom

20 10

65.9

EU-15

61.3

Spain

61.2

Germany

0

4 46.7

Luxembourg

Belgium

Frrance

Belgium

B Brussels

Germ many

Ne etherlands

Flanders

W Wallonia

Unite ed Kingdom

EU U-15

4.6 44

Netherlands

40.6

Italy

40.0 0.0

10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 DDD D per 1 000 population per da ay - Antidepressant (2010)

90.0

Source: Pharman net (RIZIV – INAMI, for Belgium) and OECD O Health Data 2012 2 for internationa al comparison

Average daily quantity of antipssychotics prescrib bed (per 1000 po opulation per day) The prescription of antipsychoticc medication incre eased from 2004 (8.0 per 1000 populatio on) to 2010 (10.5 5 per 1000 popu ulation), with diffferences between region ns (higher in Brusssels and Wallonia than in Flanders)). Aggressiveness s of care at th he end-of-life: ch hemotherapy forr cancer patients Receiving (or in nitiating) a sessio on of chemotherap py near the end-o of-life for cancer patients s is considered un nappropriate aggressiveness of tre eatment.

The percentage off people receiving T g chemotherapy near the end of the eir life is s an internationa ally used indicato or. A study of th he Christian Sick kness F Funds on end-of-life care for cance er patients (data 2005)43,42 showed d that th he highest use off chemotherapy du uring last month o of life was observe ed for c cancer patients who w died in hospital (23.1%). The use of chemothe erapy w was 12.1% for patients p dying at home and 11.5 5% for those dying in p palliative care unitts. The lowest us se of chemotherap py was seen in ca ancer p patients who died in residential care e for elderly (3.4% %).


80

Figure 18 – Ch hemotherapy nea ar end-of-life for patients with can ncer, by place off death nit in hospital Palliative care un Residential care for elderly Hospital Home 0

5

10

15

20

25

30

35

eople %of pe Last week

1m month ‐ 1 week

3 3‐1 months

Source: Results from f study “De CM neemt het levenseiinde onder de loep: de cijfers” 43

KCE Reportt 196

KCE Report 196 6

4.2.3 •


Key fiindings

Breast can ncer screening is s recommended for women aged d 50-69 years. How wever, there is a large group of women w who are screened before that age ((36% in Belgium overall, 48% in Brussels, 46% in Wallonia and 39% in Flan nders). Evolution n over time show ws no real decliniing trend. Older women w undergo o less often a ma ammography: 21% of 71-79 years s old women had da mammogrraphy in the last two years (Bruss sels 31%, Wallon nia 28% and Flanders 16%). Evoluttion over time sh hows rising trend ds (from 18% in 200 06).

•

Over a 15--month period, 95% of insulin-de ependent patients s received a blood sugar check, 93% a creattinine check and 56% an albumin check. In the la ast 12 months 57 7% had undergone a test and, over o a period of tthree years, 20% % of patients had no ophthalmo ological consulta ation.

•

The percentage of prescrip ption with amoxiicillin alone (com mpared to amoxicillin and clavulan nic acid) is stable e, around 45% (Brussels:: 43%, Flanders: 46%, Wallonia: 41%). 4 Belgium ra anks very high internationally in n terms of antibio otic prescription n but there are concerns c about c comparability off results in total of o Defined Da aily Doses (DDD D), especially if diifferences in pac ckage size exist between countries.

•

Caesarean n rates in Belgium m are lower than n the EU-15 avera age (in Belgium 193/1000 live birth hs in 2009, EU-15 average 251/10 000 live births), bu ut increasing, as in the majority of o European coun ntries. Several studies on Belgian n data have show wn a large variab bility in caesarean n rates between h hospitals.

•

The prescription of antidepressants also in ncreased from 2004 to 2010, with large difference es between regio ons (higher in Wa allonia than in Brussels and Fland ders). Internation nal comparison shows s that Belgiu um ranks high in n terms of antide epressant consum mption.

•

81

The use of ch hemotherapy during the last day ys of life for patie ents dying from cancer is an indic cator of the aggre essiveness of ca are. There are currently no nation nal data on this in ndicator. In a stu udy from the Chrristian Sickness Funds, F the highe est use was observed forr cancer patients s who died in hos spital (23.1%) and d the lowest for pa atients who died in residential ca are (3.4%). To interpret this s indicator correc ctly, more data a are needed on tre ends over time, reg gional difference es and internatio onal comparabilitty.

4 4.3 4 4.3.1

Safety of care How did d we evaluate the e safety of care? ?

Safety can be deffined as “the deg S gree to which the e system has the e right s structures, renders s services, and atttains results in w ways that prevent harm to o the user, pro ovider, or enviro onment”.4 Including the providerr and e environment in this s definition extend ds the dimension beyond quality. S indicators to ev Six valuate the safety y of healthcare havve been studied: A generic indicator 1. Medical radiattion exposure of the t Belgian popula ation H Healthcare Acquired Infections 2 Incidence of MRSA 2. M in hospital 3 Incidence of post-operative sepsis 3. s (Patient S Safety Indicator, PSI, calculated on hospital discharg ge databases) O Other safety indica ators in hospital 4 Incidence of pressure 4. p ulcer in hospitals (Patientt Safety Indicator, PSI, calculated on hospital discharg ge databases) 5 In-hospital mo 5. ortality after hip fra acture P Prescription of anttidepressants to elderly e 6 Percentage of persons age 6. ed 65 years a and older presc cribed antidepressan nts using an antich holinergic antidep pressant F Four other indicato ors related to safe ety of long-term ccare for elderly patients a not yet measurable, but data fro are om the BelRAI will probably be ava ailable fo or the next perform mance report (dettails on those indicators in Appendix C).


82

4.3.2

Facts and figures

This section is a short summary of the detailed res sults which are prresented for each indica ator in the Supple ement S1 of this report (available e on the website). Medical radiation Medical ionising g radiation is parrticularly high in Belgium, B in particular due to a large use of scanner and m medical imaging in n general. The irrradiation level is measu ured in millisieverrts (mSv). The average a level of medical radiation by inhabitant increase ed from 2004 to 2009, stabilized in 2010 (2.29 mSv/pop)) and decreased in 2011 (2.22 mSv v/pop). The patien nts more exposed are chronic c patients, patients in reside ential care, and persons above 45 yearrs old. Children a are less exposed. Prescription of medical imaging is morre frequent and more intense in Wallonia.26 Resu ults from international co omparisons show that average dos ses of medical irrradiation are particularly high in Belgium (Figure 19).

KCE Reportt 196

Table 18 – Expos T sition to medica al radiation per in nhabitant (expre essed in n nb mSv): Belgiium (2004-2011)

nb n m mSv/inhab.

20 004

2005

2006 6

2007

2008

2009

2010

2 2011

00 2.0

2.01

2.11

2.18

2.25

2.29

2.29

2 2.22

0.4%

4.6% %

3.6%

3.4%

1.6%

0.1%

-2 2.9%

Evolution E y year (X+1)/X S Source: RIZIV – INA AMI

Figure 19 – Ex xposition to mediical radiation perr inhabitant (mos st 20 exams, exp pressed in mSv): international co omparison

Source: Europea an Population Dose from Radiodiagnostic Procedures – Re esults of Dose Datamed 2 (http://ddmed.eu/_media/results s:ddm2_results_irpa a13v2.pdf)

KCE Report 196 6


Healthcare-acq quired infections s (HAI) Healthcare-acquired infections occur after exposure e to hea althcare. According to th he European Ce entre for Disease Control and Pre evention (ECDC, www.ecdc.europa.eu) ea ach year 4 million n patients acquire a HAI in the EU and ab bout 37 000 of th hem die as the direct consequenc ce of the infection. The most frequent tyypes of HAIs are e surgical site inffections, urinary tract infections, pne eumonia, bloodstream infection ns and gastrointestinal infections. In Belgium, the last pre evalence survey in half of the acute hospiitals occurred in 2 2007, and showed d that 6.2% of the patients were infected by b a HAI.52 New results of prevalence are expecte ed to be available at the e end of 2012, ba ased on a commo on protocol developed by the ECDC. In Belgium, surveillance of HAIss is under the re esponsibility of the WIV – ISP, and is organized o by the e NSIH group (National Surveillance of Infections in Hospitals). For MR RSA, the surveilla ance is mandato ory in all acute care ho ospitals (since 20 007). The third indicator, post-o operative sepsis, belongs s to the set of safe ety indicators from m the OECD. Incidence of MR RSA A decreasing in ncidence was found between 1994 4 and 1999 (from 4.1 to 2 cases/1000 ad dmissions), afterr which the incidence again in ncreased reaching 4.3 in n 2003. Since 2 2003, we measurre a slow, consttant and statistically sign nificant decrease of the incidence of nosocomial MRSA M in acute care hospitals, finally re eaching 1.5 new cases/1000 adm missions during the seco ond semester of 2010 (test for lin near trend for a cohort c of hospitals participating at least att 5 surveillance pe eriods since 2003 3: annual decrease of -0.29 new cases/10 000 admissions, p<0.001) p (Figure 20). 2 This decrease was most impressive in the Brussels hospitals. Proba ably, the application of the recommendations for the contrrol of MRSA (sinc ce 2003, actually in rev vision), the natio onal hand hygiene campaigns, and a the rationalization of o the use of antibiotics influenced d positively this ev volution. Nevertheless, the t interpretation of the indicator remains influenced d by the screening prac ctices which varyy in coverage ratte and intensity between b hospitals.53

83

No international organisations inclu N ude data on MRSA, making compa arison d difficult. An exc ception is the European Antimicrobial Resistance S Surveillance Syste em (EARSS), but this European prrogram does not focus o nosocomial acq on quisition.


84

KCE Reportt 196

Figure 20 – Me ean incidence of Healthcare Acqu uired MRSA, perr 1000 admission ns (1994-2010)

MR RSA in Belgian acute ca are hospitals s: incidence of nos socomial MRS SA (clinical sam mples) per 100 00 admissions

nosocomial MRSA/1000 admissions

5

3 4,3

4,5 4,1 4

3,2

3,5

4

4 3,4 3

3

3,7

3,5

2,7

2,6

3

2,9 2,4 2,4

2 2,2

2,5

3,4

3,3

2,1 1 2

2 2,7

2 2,6 2,6

2,5

2,8 2,7 7 2,4

2,2

2,2 2,1 2,2 1 1,8

2

1,5

1,5 1 0,5

Source e: National surveilla ance, B. Jans Source: National Surveillance of Infe ections in Hospitals (NSIH), WIV – ISP

Surveillance pe eriods

2010/2

2010/1

2009/2

2009/1

2008/2

2008/1

2007/2

2007/1

2006/2

2006/1

200 /2 2005/2

2005/1

2004/2

2004/1

2003/2

2003/1

2002/2

2002/1

2001/2

2001/1

2000/2

2000/1

1999/2

1999/1

1998/2

1998/1

1997/2

1997/1

1996/2

1996/1

1995/2

1995/1

1994/2

0

KCE Report 196 6


85

Patient Safety Indicators (PSI)

In n-hospital morta ality after hip frac cture

Incidence of po ost-operative sepssis Incidence of po ost-operative sep psis is an internattional indicator off patient safety in hospittal (Patient Safetyy Indicator, PSI)54, 55, which is monitored on the basis of ho ospital discharge d data. This indicattor has also been n studied 56 on Belgian data a, although with a slightly different methodology. m Between 2000 and 2007, the inccidence of post-op perative sepsis wa as stable around 8 cases s per 1000 admisssions. However, when w compared to o the few other European n countries which provided data, Belgium B ranks rath her high, but it is unclearr whether this is d due to higher incid dence rates or diffferences in coding of sec condary diagnoses. Incidence of pre essure ulcer The occurrence e of a pressure ullcer in a hospitalis sed patient has a serious negative impac ct on the individu ual’s health57 and d often leads to a longer hospital stay. Pressure P ulcers ccan be prevented with appropriate nursing care.58, 59 This indicator also belo ongs to the set of safety indicators that can be calculated based b on discharge data, but its accuracy a largely depends d on the accuracy y of the coding pra actices in hospitals. The global rate e of pressure ulce ers in acute hospittals was 12/1000 stays in 2000 and reach hed 17/1000 stayss in 2007, with inc creasing trends over o time for both surgical and medical h hospitalisations. No N more recent data d are available on the e OECD Health Data for Belgium. Other data tha an administrative e discharge data abases are available to estimate prevalence of pressure e ulcers. In 2008 a prevalence stu udy was organised for the t first time, following the last European E Pressure Ulcer Advisory Panel guidelines (spe ecific for registrattion and classific cation of pressure ulcers s). This study wa as organized in 84 8 hospitals in 20 008, and included 19 96 64 patients. A pressure ulcer prevalence of 12.1 1% was observed. Con ntrary to previo ous Belgian pre essure ulcer pre evalence measurements,, no distinction w was made betwee en a pressure ullcer and incontinence associated a derma atitis. The preva alence of grade 2 to 4 pressure ulcers s was 7%.60

Hip fractures are frequent H f causes of o disability in elde erly and are assoc ciated w with an importantt mortality risk. Because B in-hospital mortality afte er hip frracture gives dire ect information ab bout outcomes an nd indirectly abou ut the te echnical quality of o care, it is first considered c as an indicator of in-ho ospital s safety, and secon ndly as an indicattor of quality-effecctiveness of care. The in n-hospital mortalitty rate after a hip fracture was 6.3% in Belgium bettween 2 2004 and 2007. Th here was also a high h variability in m mortality rates bettween 50 h hospitals. P Patients aged 65 5 years and olde er prescribed an ntidepressants using u a anticholinergic antidepressant drug (%) an W While elderly indiividuals can be treated effectivelly with antidepre essant m medications, they are at greater ris sk of adverse drug reactions due to t the p physiological chan nges associated with the aging process. In particular, a antidepressants w with strong anticholinergic effeccts (e.g., imipramine, a amitriptyline and doxepin) d are not recommended fo or ongoing use in the e elderly as they can n cause orthostattic hypotension, se edation and confu usion. U Use of these age ents has been associated a with h high rates of adverse e effects, including falls, among eld derly patients. Th he health system m has c considerable influence over this in ndicator, as it is treatment-based. The a appropriateness o prescribing beh of haviours by cliniccians within the health h s system can be increased through education and trraining and the use u of 61, 62 g guidelines. D During the last 5 years y the prescrip ption of antidepre essants known forr their a anticholinergic sid de-effects for elderly (≥65 years) is stable (14%).. The p percentages are consistently higher in Flanders (17%) compare ed to W Wallonia (11%) an nd Brussels (10% %). It should be n noted that interna ational c comparisons are hampered h by abs sence of available e data but also by y lack o consensus abo of out what is an an ntidepressant with anticholinergic side63,64,65 e effects. Nev vertheless, the relatively high prescription rate es of a antidepressants w (potential) antticholinergic side effects warrant fu with urther in nvestigation. Problems with the appropriateness a of the prescriptio on of p psychopharmacolo ogical drugs in the elderly po opulation have been d documented beforre66 and should be e a continuous are ea of attention.


86

4.3.3 •

Key fiindings

The averag ge level of medic cal irradiation inc creased from 2004 to 2009, stab bilized in 2010 (2..29 mSv/pop) and d decreased in 2011 2 (2.22 mSv//pop). The patien nts more at risk are a chronic patie ents, patients in n residential care e, and persons above 45 years olld. Children are a less exposed. Prescription off medical imaging g is more frequ uent and more in ntense in Wallonia. Results from internation nal comparisons s show that avera age doses of me edical radiation are a particulary high in Belgium.

•

A decreas sing incidence in healthcare-acqu uired MRSA was observed between 1994 an nd 1999, after wh hich the incidenc ce again increased in 2003. Since 2 2003, we measure e a slow and con nstant decrease of o the incidence of MRSA in acutte care hospitals s. This decrease was w most impres ssive in the Brus ssels hospitals.

•

Incidence of post-operativ ve sepsis is an in nternational indic cator of patient saffety (PSI) which is monitored on the basis of hos spital discharge data. Between 2 2000 and 2007, th he incidence of postp operative sepsis was stable around 8 case es per 1000 admiissions. Belgium ra anks high in com mparison with other European countries, but this might b be due to large differences in cod ding practices between countries.

•

Incidence of pressure ulce er is another PSI. The incidence rate r of pressure ulcers u in acute hospitals was 12//1000 stays in 20 000 and reached 17 7/1000 stays in 2 2007, with increa asing trends overr time for both su urgical and medical hospitalisatiions.

•

The in-hos spital mortality ra ate after a hip fra acture was 6.3% in Belgium between b 2004 and d 2007, with large variability betw ween hospitals. More data are needed on trends s over time, and few f data are av vailable for benc chmarking at inte ernational level.

•

During the e last 5 years the e prescription of antidepressants s known for their an nticholinergic sid de-effects for eld derly (≥65 years) is stable (13--14%). The perce entages are higher in Flanders (16-17%) compared to Wallonia (13--14%) and Brussels (10%).

4 4.4 4 4.4.1

KCE Reportt 196

Continuity y of care How did d we evaluate the e continuity of ca are?

Continuity address C ses “the extent to o which healthcare for specified users, u o over time, is smoothly organised within w and acrosss providers, institu utions a regions”4, and and d to which the entire disease trajecttory is covered.1 S Several aspects of o continuity have e been distinguish hed, based on the e fact th hat continuity is the result of goo od information flo ow, good interperrsonal s skills, and good co oordination of care e.67-72 In nformational continuity: availability and use of da ata from prior events e d during current patient encounters; information links ccare from one pro ovider to o another and from m one health event to another70; M Management conttinuity: coherent delivery d of care fro om different providers, m most commonly whether w follow-up p visits are made when care cro osses o organisational bou undaries (often fo ocus on care pla an for specific, ch hronic h health problem)69; R Relational continuity: an ongoing re elationship betwee en patients and one o or m more providers th hat connects care e over time and bridges discontin nuous 68 e events ; C Coordination: the integration, coord dination and share ed information bettween 70 p professionals or be etween provider organisations. o Six indicators thatt assess the four above-mentioned S d aspects of conttinuity a presented: are In nformational continuity 1. Percentage of o persons who have h a global medical record (GMD – DMG) M Management conttinuity 2 Percentage of 2. o hospital discharge followed with a GP’s enco ounter within a 6-wee eks period for sen nior patients (65+)) R Relational Continu uity 3 Proportion of encounters that were conducted by the GP cons 3. sulted most frequenttly: Usual Provider Continuity (UPC C) index.

KCE Report 196 6


Coordination 4. Proportion of cancer patiients discussed at the multidisciplinary meeting 5. Number off re-admissions p per 100 patients with a diagnosis s of (a ) schizophre enia or (b) bipolar disorder 6. Number off contacts betwee en the GP and the e palliative patien nt during the 3 last months m of his/her life

4.4.2

87

Figure 21 – Perc F centage of popu ulation with a gllobal medical re ecord (GMD – DMG), by y region (2006-20 009)

Facts and figures

This section is a short summary of the detailed res sults which are prresented for each indica ator in the Supple ement S1 of this report (available e on the website). Informational continuity c Since 2001, th he global medicall record (GMD – DMG) allows pattients to entrust a GP with w the task of m managing their me edical data. The use u of a GMD – DMG in ncreases progressively and reache ed 46% in 2009 but with large difference es between regions (Flanders 58%, Wallonia 31 1%, and Brussels 28%). The coverage byy the GMD – DMG G is higher for the e elderly (78% coverag ge for the 75+ +), and persons s entitled to in ncreased reimbursement (entitled 54% verrsus not entitled 44%). 4

S Source: RIZIV – INA AMI

M Management con ntinuity Link Hospital-GPs L s A hospitalisation discharge is a pivotal As p moment in n the care of an older p person, a GP’s en ncounter in the 6 weeks w following d discharge is advis sed in th he U.K.73 We ha ave adapted the definition to one week, which is more re elevant in Belgium m. A majority of elderly e (58%) havve at least one co ontact w a GP in the week with w after a disch harge from the ho ospital. In the Bru ussels re egion, this perce entage is lower (4 42.5%). This ressult is an indication of c continuity of care between b the hosp pitals and the first line, even if we do d not k know if the GP’s encounter e followe ed a discharge pla an from the hospiital or frrom the patient’s own o initiative.

88


Figure 22 – Percentage P of ho ospitalisations fo or the elderly (a aged 65 and over) followed by a contact with a GP within 1 wee ek after discharge, by region (2003-200 09)

KCE Reportt 196

between GPs and b a specialists. Possible explanations for the low p percentage found in the data are a lack of knowle edge by GPs or a too h heavy administratiive burden. R Relational contin nuity

Source: IMA – EP PS, KCE calculation n

Link GPs-speciialists Since 2007, patients p with a GMD – DMG are entitled to a larger reimbursement of health expend ditures for a spec cialist consultation n if they are referred by y a GP. The mea asure is limited in scope: it applies s only to certain specialiists and to one cconsultation per year per specialist. This measure aims to t improve the sp pecialist-general practitioner’s p colla aboration and to stimulate e a first encounte er with a GP beca ause in Belgium, patients are free to go directly to the ssecond line. How wever, the percen ntage of specialist consultations identified as prescribed by a GP and lea ading to increased reimbursement is veryy small (around 2% 2 of all consulta ations at specialists). This result does nott allow drawing any conclusion on the real proportion of re eferrals between G GPs and specialis sts. However, it drraws the attention to a re eimbursement me easure aimed at fa acilitating the coorrdination

A longitudinal rela ationship between physician and pa atient is acknowle edged to o encourage communication, improve satiisfaction, medic cation c compliance, and behavioural b proble ems, and stimulatte receipt of preve entive s services and decrrease hospitalisattions and emerge ency department visits fo or patients with chronic disease e.74 There are several measure es of lo ongitudinal contin nuity with the Usua al Provider of Care (UPC) index as s one o the most common index used. Th of he advantage of this indicator is its easy in nterpretation. In n the population of o patients who had at least 3 contacts with a GP during d tw wo years, around d 44% have seen n the same GP (n not taking into account o out-of-hours conta acts). This perce entage was stable e in the period 20032 2 2009. It reaches 55% 5 for patients aged 65-84 yearss. 72% of the patients m meet the less strin ngent criteria of ha aving seen the same GP at least 75 5% of th he time (UPC ≥ 0.75). 0 Some differrences are observved between the three re egions, with a grreater proportion of patients havin ng encounters witth the s same GP at leastt in 75% of the cases c (UPC ≥ 0.7 75) in Wallonia (7 74%), F Flanders (71%) an nd a smaller propo ortion in Brussels (66%). T These results als so show that th he relational con ntinuity with the main p provider of care is s good and stable e over time. It also o shows that the lower c coverage rates off the GMD – DMG G in Wallonia do not implicate a worse w re elational continuitty with the GP. C Coordination: Mu ultidisciplinary te eam for cancer p patients Multidisciplinary te M eam meetings (MOC – COM) have e been implementted in m many countries as s the predominantt model of cancerr care to ensure th hat all p patients receive timely diagnosis and treatment, tha at patient manage ement is s evidence-based d, and that there e is continuity off care.75 In all ca ancer g guidelines develo oped by the KCE K and the C College of Onco ology, m multidisciplinary discussion is reco ommended to deccide on the diagn nostic, s staging and treatment plan of can ncer patients. Sin nce its introduction in 2 2003, a clear inc crease of its use e is noticed for all cancer types s and d discussions aboutt how to better involve GPs are e currently condu ucted.


KCE Report 196 6

Overall, about 69% 6 of cancer pa atients were discu ussed at the MOC C – COM in 2008, with la arge variations between types of cancer (in 2008: 84% of breast cancer patients, p 74% lung g cancer, 59% pro ostate cancer).46 Although A an increasing use u is noticed for a all three regions, cancer patients are a more frequently disc cussed at the MO OC – COM in Flanders F (74% in n 2008), followed by Wa allonia (63% in 200 08) and Brussels (56% in 2008). Table 19 – Perrcentage of canc cer patients who had a MOC – CO OM, per region, (2005-2 2008) 80% 70%

%MOC-COm

60% 50% 40% 30% 20% 10% 0% 2005

2006

Belgium

Bruss els

200 07 Flanderss

2008 8 Wallonia

Source: Belgian Cancer C Registry and evaluation of Can ncer Plan46 Note: all tumours s excl. non-melanom ma

89

C Coordination: Me ental health care Although unforese A een and unavoid dable emergencie es do arise in mental m h health, mental hea alth related emerg gency room (ER)) admission is use ed as a indicator of poo an or coordination of care and service failures. Due to delays d in n receiving data, results r on the ER R use for mental health problems arre not a available for this re eport. They will be e analysed for the e next update. H Hospital readmiss sion rates are also o widely used as proxies for relap pse or c complications follo owing an inpatientt stay for psychiattric and substance e use d disorders since th hey indicate premature discharge ((sub-optimal disch harge p planning: follow-u up care and su upport have no ot been approprriately c coordinated before e discharge) or la ack of continuity o of services (e.g. fo ollowu visits after discharge). up T The re-admission n rates for patients with schizo ophrenia and bipolar d disorders within the t 30-days of the initial hospittalisation are situ uated a around the OECD D-average of EU--15 countries (20 0.2% for schizoph hrenia a and 15.6% for bip polar disorders). For both conditio ons these readmiission ra ates are the high hest in Flanders (schizophrenia ( 25 5.2%; bipolar diso orders 19.7%) and lowes st in Brussels (s schizophrenia 10..2%; bipolar diso orders 7 7.1%). For schizo ophrenia, there is an overall increa asing trend in Belgium (e especially in Flan nders and Wallon nia). For bipolar d disorders, there is s only a increasing tren an nd in Flanders. The T re-admission rates for patients s with b bipolar disorders are a decreasing in Wallonia. C Coordination: En nd-of-life of pallia ative patients With the regulation W n of palliative care e services in the residence of the patient (a at home or in a residential setting g) a more promin nent role of the GP G is n needed for the coordination c of services. s This is thus an indicattor of c continuity of care. There are currently no national data on the contacts s with G GPs during end-of-life of palliative patients but some results can be given frrom different stu udies. A study on n Christian Sickn ness Funds mem mbers s shows that 72% of o the palliative pa atients who died at home in 2005--2006 h a contact with had h a GP during the e last week of their life.42, 43 The nu umber o contacts betwe of een palliative patients and their G GP appeared how wever h higher in the Nethe erlands than in Be elgium.76


90

4.4.3 •

•

Key fiindings

The contin nuity of medical information man naged by GPs is stimulated d since 2001 by tthe global medical record (GMD – DMG) in Belgium m. Since its introd duction, the use of the GMD – DM MG shows an increasing trend d. Moreover, the GMD – DMG particularlly reaches the vu ulnerable popula ation (elderly and d persons entitled to increas sed reimburseme ent) but it could be improved, especially in Brrussels and in Wallonia. The manag gement continuity between hosp pital and GPs is a interesting g indicator, overa all for elderly. Within W one week after a a hospitalisa ation discharge, a majority of eld derly patients (58 8%) have at lea ast one contact w with a GP. Results are however lower in Brussels compared c to the two other region ns.

•

The relatio onal continuity w with the same GP P is good in Belgium, particularlly in the age grou up 65-84 years and a in Wallonia.

•

The coord dination of care fo or cancer patients is organised by b multidisciplinary oncology y meetings for ab bout 69% of canc cer patients, with w large variatio ons between typ pes of cancer (89 9% breast can ncer), and betwee en regions.

•

The coord dination of menta al health care req quires a broad arrray of services (e e.g. assertive co ommunity care; fo ollow-up by GPs s) in the communitty. The re-admiss sion rate within the t same hospita al for patients with w schizophrenia and bipolar disorders are situa ated around the e OECD-average e, with higher and d increasing rate es in Flanders.

•

The coord dination of palliattive care at home e or in nursing homes should be at the level of th he GP. However, national data arre lacking an nd some studies showed less con ntacts between palliative patients p and theiir GP when they compared the Belgian B situation to t the Netherland ds.

4 4.5

KCE Reportt 196

Patient Centeredness C

4 4.5.1

How did d we evaluate pa atient centeredne ess?

Patient-centeredne P ess is defined as “providing care th hat is respectful of o and re esponsive to ind dividual patient preferences, p nee eds, and values,, and e ensuring that patie ent values guide all a clinical decision ns”.6 A According to this definition, severral categories are e used to classiffy the in ndicators: •

Acknowledgement of patients s needs, wants, preference: pattients’ right; patients s’ needs; preferen nce of care; pain management; priivacy; spiritual supp port; cultural nee eds; patients’ strrengths; psycho-s social aspects; comffort; social supporrt.

•

Providers skill of communicattion: providers ab bility to listen to their patients care efully; providers s ability to exxplain things clearly; courtesy/respect; spent enough h time to their patiient; emotional su upport to relieve fea ar and anxiety; language; global communication skills; poor commun nication.

•

Patients and carers involveme ent (enabling pattients to manage their care and to make m informed de ecisions about their treatment options): patients/carerrs information; informed conse ent; self-manage ement support; patie ents/carers involve ement in services and delivery plan nning; patients involv vement in quality y improvement; pa atients’ participatiion in decision or sh hared decision-ma aking. T Three indicators re elated to centered dness are availablle: 1. Percentage of o population ab bove 15 years o old who report to t be satisfied with healthcare service es 2 Percentage of adult inpatients who reported how often their pain 2. n was controlled 3 Percentage of 3. o patients dying in their usual placce of residence (h home or institution)

KCE Report 196 6

4.5.2


Facts and figures

91

Figure 23 – Degre F ee of satisfaction n with healthcare e services, by ty ype of s service (2008)

This section is a short summary of the detailed res sults which are prresented for each indica ator in the Supple ement S1 of this report (available e on the website). Patients’ satisfaction Patients have often other exxpectations, wish hes and prioritie es than healthcare prov viders and their satisfaction depends of the ans swers to these issues. Although A patients’ satisfaction is on nly one limited asp pect of a patient’s experrience with the healthcare system m, it is still a very y widely used measure in i evaluating patie ents’ care experie ence.77, 78 Belgian citizens s reported in the HIS that they are e in general satisffied with their contact with w the healthcarre system: the sa atisfaction level is above 90% for contac cts with GP, denttists, specialists and a home care services. s Only for hospita als the satisfaction n level is lower (87 7%). Differences be etween men and women are neg gligible. Differenc ces with respect to age e are limited. T The satisfaction level l also hardly y differs between socioe economic groups. Large differenc ces are however observed with re egard to the geog graphical location of the patient: satisfaction is systematica ally lower in cities s than in rural areas. Als so, large difference es exist between regions, as satisffaction is always higher in Flanders than in Wallonia. Low west satisfaction ra ates are observed in Bru ussels.

Source: Results from S m Health Interview Survey, S Scientific In nstitute of Public Hea alth (WIV – ISP)

P Pain control Pain control or pa P ain assessment is s paramount in a patients’ perspe ective. T The RN4CAST-prroject included a one-off internatio onal survey (Euro opean c countries) of nurs ses and patients. Sixty Belgian ho ospitals participatted in th he patient survey y, with 2 623 patiients surveyed an nd a response ra ate of 79 6 68%. Results sh howed that 69% of patients need ded medicine forr pain d during their hospital stay and amo ong them 41% de eclared that theirr pain w always well controlled. was c This pla aces Belgium verry low compared to t the a average of 54% fo or the 8 countries s who participated d. Other data from m the s study show that 47% 4 of the patien nts said that their pain was usually y well c controlled. Less th han 2% said their pain was neve er controlled. The e vast m majority of patientts considered tha at the hospital sta aff did everything g they c could to help them m with their pain (always 71% of pa atients; usually 23 3% of p patients).


92

KCE Reportt 196

Place of death

4 4.5.3

Place of death is considered an n important indica ator of quality of palliative p care. A survey y showed that in Flanders, 71.6% % of persons inte erviewed expressed a preference p for dyying at home.80 There are curre ently no national data published on the e place of death h of patients elig gible for palliative care in Belgium. Data are howeve er available from m death certificates (pallliative or not) in Flanders and in Brussels. A rece ent study (2007) on thes se death certificattes showed a sh hift from dying in hospital (55.1% of all de eaths in 1998 to 5 51.7% in 2007) to o dying in a nursin ng home (18.3% in 1998 8 to 22.6% in 20 007). The percen ntage of deaths at a home remained stable e.81 The decline in hospital beds and a the increased number of deaths in nursing n homes ccan be explained d by the substittution of residential beds s by skilled nursin ng beds in care ho omes.

•

There is currrently a real lack of data on patients’ centerednes ss. The few measurable indicato ors only provided d fragmented information of o a complex sub bject.

•

Belgian patie ents are in generral satisfied with their contact witth the healthcarre system. Data of o the patients’ e experience will be b available in the new wave of the Health Interv view Survey.

•

One survey in hospitals show wed a relatively g good manageme ent of pain. The vas st majority of pattients considered that the hospittal staff does ev verything they ca an to help them w with their pain (always 71% of patients; usually 23% of patie ents).

•

A recent stud dy on death certiificates in Flande ers and Brussels s showed a shift from dying in hospital to dying in a nursing ho ome. The percenta age of deaths at home remained stable. There are e large differen nces between co ountries with rega ard to the place of death for pattients with cance er. The percentag ge of cancer patiients dying at hom me is very low in Norway (13%), h higher in Flanderrs (28%) and mu uch higher in the e Netherlands (45%).

Table 20 – Ev volution of plac ce of death overr time in Flande ers and Brussels (1998 8-2007) Period

Home

H Hospital

Nu ursing Ho ome

Oth her

1998

23.0%

55.1%

18 8.3%

3.6% %

2007

22.5%

51.7%

22 2.6%

Source: A study on o death certificatess in Flanders and Brussels B

3.1% % 81

There are large e differences betw ween countries with w regard to the place of death of patien nts with cancer. T The percentage off cancer patients dying at home is very lo ow in Norway (13%), higher in Fllanders (28%) an nd much higher in the Ne etherlands (45%).

Key findi dings

KCE Report 196 6


5 EFFICIENCY IN H HEALTHCA ARE 5.1

How did we evaluate the efficiency in healthcare?

Efficiency is de efined as “the deg gree to which the e right level of re esources (i.e. money, tim me and personnel, called input) is found for the system (macro-level) and a ensuring th hat these resourrces are used to yield maximum bene efits or results (callled output)”.4, 8 Three indicators measure specifically the effic ciency of the he ealthcare system: 1. Percentage e of prescription o of low-cost drugs in ambulatory settting 2. Rates of on ne-day hospitalisa ations for surgery 3. Length of hospitalisation h for a normal delivery y Other indicatorrs already mentio oned above can also a help to illusttrate the efficiency of the e health system (ffor instance the co overage of mamm mograms outside target groups g for breast ccancer screening)).

5.2

Facts and a figures

This section is a short summary of the detailed res sults which are prresented for each indica ator in the Supple ement S1 of this report (available e on the website). Utilisation of le ess costly drugs s in ambulatory care c The price of ge eneric drugs is minimally 31% less expensive than the t price of the original drug. Low-cost d drugs are defined as (1) original drugs d for which a generric alternative exists and which have lowered their public retail price to th he reimbursementt basis so that there is no suppleme ent to be paid by the patient; (2) gen neric drugs and copies. Promotting the prescription off low-costs drugs is thus a go ood way to limitt health expenditures, both b for the third-p party payer and fo or the patient. De epending on their specia alty, physicians a and dentists are required to pres scribe a certain minimu um percentage of low-cost drugs, the so-called “quotas”, “ introduced in 20 006 and revised (higher) in December 2010.

93

Between 2000 and B a 2010, the total number off DDD prescribe ed in a ambulatory setting g increased from 2.76 billion to 4.7 7 billion. On the same p period, the proportion of low-cost DDD continuoussly increased to reach r 4 46.0% in 2010 (2 27.1% from generic drugs and 18 8.9% as original drugs d w which lowered their price).

94


Figure 24 – Percentage o of low-cost me edication delive ered in ambulatory se etting (DDDs) (2000-2010)

Note: DDD Defined Daily Doses Source: RIZIV – INAMI, I Pharmanet

Utilisation of less costly inffrastructures (on ne day versus classic hospitalisation n) Carrying out ellective procedure es as day cases when allowed by y clinical circumstances (e.g. inguinal herrnia repair, circum mcision, cataract surgery, etc.) saves mo oney on bed occcupancy and nurs sing care. It is therefore considered as an a indicator of efficiency. The Belgian su urgical day-case rrate grew from 42 2.1% in 2004 to 46.2% 4 in 2008. The comparison with o other European countries shows s similar increasing trend ds, with Belgium higher than the European E average e (Figure 25).

KCE Reportt 196


KCE Report 196 6

95

Figure 25 – Pe ercentage of surg gical one-day hos spitalisations on n all surgical hos spitalisations: intternational comp parison

surgical day case rate

70 United Kingdom

60

58%

Denmark

50 40

Belgium

30

EU-15

20

Ireland

10

50% 6% 46 42% 41%

Finland

0 0 2000

2001

2002

2003

2004

200 05

2006

2007

Belgium

France

Germany

Netherlands

United Kingdom

United States

2008

36% 25% % 0%

10 0%

20%

30 0%

40%

50%

Surgical day care rate (2008)

Source: OECD Health H data 2010 82, except KCE calcula ation for Belgium 20 008

costly

Spain Germany

EU 15 - Average

Utilisation off less hospitalisation ns)

39%

infrastructures s

(shortening

classic

The length of stay after a norma al delivery is deterrmined more by fa actors of organisation and a care provid der characteristic cs than clinical patient characteristics only (e.g. severityy of illness). It is therefore t a good indicator i to benchmark th he efficiency of th he healthcare systtem. In Belgium, the e duration of hosspitalization for a normal delivery y slightly decreased from m 5 days in 2000 to 4.3 days in 20 008. This is approximately 1.5 day above the t EU-15 averag ge of 2.9 days (Fig gure 26).

60%

7 70%


96

KCE Reportt 196

Figure 26 – Av verage length of s stay for a norma al delivery: intern national comparison

average length of stays in days

6 5 4 3 2 1 0 6 2007 2008 2009 9 2010 2000 2001 2002 2003 2004 2005 2006 Belgium Netherlands

France United King gdom

Germ many Unite ed States


5.3

Key findings

•

The percentage of low-cos st drugs in ambu ulatory setting increased from 7% in 2001 1 to 46% in 2010.

•

The percentage of surgica al hospitalisation ns that were perfo ormed in one-day y hospital grew ffrom 42.1% in 200 04 to 46.2% in 20 008. These incrreasing trends are observed ove erall in Europe. Belgium B is situated d above the EU-15 average.

•

The duratiion of hospitaliza ation for a norma al delivery slighttly decreased d from 5 days in 2 2000 to 4.3 days in 2008. This is approxima ately 1.5 day abo ove the EU-15 ave erage of 2.9 days s.

Belgium France Austria Luxembourg Italy Germany Finland EU-15 Portugal Denmark Spain Sweden Ireland Netherlands United Kingdom

4.5 4.3 4.1 4.0 3 3.5 3.2 3.2 3.1 2.7 2.7 2.5 2.4 2.1 1.9 1.8

0 1 2 3 4 5 ntaneous delivery - average length of stay in days Single spon 009) (20

KCE Report 196 6


6 SUSTA AINABILITY OF THE HEALTH SYSTE EM 6.1

How did we evaluate the sustainability of the healtth m? system

Sustainability is s defined as the syystem’s capacity: •

To provide and maintain infrrastructure such as a workforce (e.g. through education and a training, facilities and equipme ent;

•

To be innovative;

•

s; To stay durably financed by collective receipts

ponsive to emergin ng needs. • To be resp For all four ele ements of the de efinition, specific indicators i were selected. s The last indica ator, total health h expenditures, is s a generic indicator of financial sustain nability. Maintenance off workforce 1. Evolution over o time of the mean age of practis sing GPs 2. Medical gra aduates becoming g GPs 3. Nursing gra aduates Maintenance off facilities 4. Acute care e bed days (numbe er per capita) Innovation 5. Number of GPs using an ele ectronic medical file Financial Susta ainability 6. Health exp penditures accord ding to the Systtem of Health Accounts A (Total, repa artition, % gross d domestic product (GDP), per capita a)

6 6.2

97

Facts and d figures

This section is a short summary of the T t detailed resultts which are prese ented fo or each indicatorr in the Supplement S1 of this re eport (available on the w website). M Maintenance of workforce: w GPs The cohort of activ T ve GPs is changin ng: it is very fast a approaching retire ement a age, as shown by y the lines superiimposed for the yyears 2000, 2004 4 and 2 2009 of physicians with over 1 250 0 contacts (Figurre 27). Another way w of m measuring this ch hange is to calculate the average age of GPs currrently p practising. The av verage age of full time equivalents (FTE) was 51.4 years in n 2009, while it wa as 47.3 years in 2000. 2 F Figure 27 – Age distribution d of GP Ps (2000-2004-20 009)

Note: only GPs with more than 1 250 co N ontacts /year S Source: Performanc ce of general mediciine in Belgium, a ch heck up (RIZIV – INA AMI)26


98

KCE Reportt 196

Table 21 – Mea an age of practis sing GPs (2000-2009) 2000

2004

2008 2

2009 9

Number of GP P smoothed FTE E

8 515

8 472

8 336

8 28 83

Mean age

47.3

49.2

51.3 5

51.4 4

Source: Performa ance of general med dicine in Belgium, a check up (RIZIV – INAMI)26

One of the reas sons for this agein ng of GPs is the problematic p recruitment of new GPs. As a matter of fact, the non-replacement of older GPs is s directly related to the numbers n of new p physicians enterin ng the medical pro ofession and, of these, the t percentage entering general medicine. m The perrcentage of newly-graduated generalists is calculated by comparing c the nu umber of graduates entering general med dicine to all graduates entering a specialist s area in the two o years following g graduation (upon completion of the e sevenyear study cycle). This percenta age currently stan nds at 30%, while it was 34% in 1996.26 Table 22 – Pro ogression betwee en 1996 and 2008 8 of graduates in n medicine in the e two years follow wing graduation according to typ pe of specialisation Graduates afte er 2 years number of phy ysicians (after 7 y years) physicians witthout specialisattion

1 1996 1 105

912

2000

1 235

193 17%

% physicians without w specialis sation physicians witth a specialisatio on (GP+SP) specialists (SP P) generalists (GP) %GP compare ed to GP +SP

1998 8

600 312 34%

Source: RIZIV – INAMI I

Compared to other European co ountries, Belgium has a number of medical graduates (all) of 9 medical grad duates per 100 00 00 pop, slightly low wer than the 11.5/100 00 00 pop EU-15 ave erage (Figure 28).

1 172

247 20% 988 8

2002

628 360 36%

1 180

202 2 17% 970

2004

211 18% 969

632 6 3 338 35 5%

20 006

1 142

684 285 29%

8 814

118 10% 1 024 756 268 26%

2008 941

110 14% 7 704

160 17% 781

493 211 30%

554 227 29%


KCE Report 196 6

Workforce: nursing There is curren ntly no indicator att the macro level to t document the question q on workforce in nursing. H However, macro--level data sho ould be complemented with data that re eflect the situatio on at the micro le evel. An example of mic cro-level data is the recent large-scale European nursing workforce study y based on survey data. It was illustrated that in Belgian hospitals nurse es have, on avverage, to take care for more patients compared to other EU countries.79

99

Contrary to the GP C Ps, the source of this problem doe es not seem to be e from th he education sid de, as Belgium forms f a very hig gh number of nu ursing s students every yea ar, where the num mber for 100 000 iis 41.7, high abov ve the E EU-15 average off 31.3. A word of caution is necessary when interprreting th his figure, as also o foreign studentts are counted, and those will pro obably n work in Belgium not m.

Figure 28 – Me edical and nursin ng graduates (pe er 100 000 pop): international i com mparison (2010) Ireland

Finland

18

Denmark

16

Germany Portugal

12 2

Ireland

EU-15

5 11.5

Portugal

Spain

8

Netherlands

Lu uxembourg

8 0

2

14 16 4 6 8 10 12 pulation (2010) Medical graduates per 100 000 pop


33.2

Germany

9

Spain

34.4 33.2

EU-15

9.3

Belgium

34.8

Unite ed Kingdom

11

United Kingdom

40.1 36.7

France

11

Finland

41.7

N Netherlands

1 12

Italy

58.7

Belgium

18

20

Italy

28.2 20.9 19.9 16.2

60.0 0.0 1 10.0 20.0 30.0 0 40.0 50.0 Number of Nursing graduates per 100 000 population n (2010)

70.0


100

KCE Reportt 196

Maintenance of o facilities: number of acute bed d days The number of o acute care be ed days per capita is indicative e of the population’s ne eed for acute ccare beds, and thus about the needed infrastructure. This T indicator indiccates how this need is met. In 2009, there were 13 million d days spent in acu ute care hospitals (classic hospitalisation only, excluding o one day). Per ca apita, this represe ents 1.2 acute care bed d days. This figurre is decreasing between b 2000 an nd 2003, and stable sin nce 2003. The EU-15 average is a bit lower, around 1 day/inhabitant. Of the neighb bouring countries s, only Germany y has a higher utilisation of acute care ho ospitals per inhabitant. Figure 29 – Ac cute care bed day ys per capita, intternational comp parison Number of acute care bed days per capita

2

Germany

1.8

Austria

1.6

Luxembourg

1.4

Belgium

1.2

EU-15

1

France

0.8

Un nited Kingdom

0.6

Portugal

0.4

Italy

0.2

Ireland

0 0 2000

2001

2002

2003

2004

2005

200 06

2007

2008

200 09

Belgium

France

Germany

Netherlands

United Kingdom

United States s

EU-15


2010

Spain Netherlands Finland 0.0

0.5 1.0 1.5 a care bed da ays (2009) Number of acute

2.0 0


KCE Report 196 6

Innovation: the e percentage of GPs using an electronic file to maintain m their patients’ medical records s The percentag ge of GPs using g an electronic file with recom mmended software to maintain their patien nt’s medical recorrd increased from m 61% in 2004 to 74% in 2010. P of G GPs using reco ommended softw ware to Table 23 – Percentage maintain their patients’ medica al records

% of GPs who received a lump sum for using an electronic medical records.

2004

2008

20 009

2010 0

61%

72%

75 5%

74% %

Source: RIZIV – INAMI I

Total healthc care sustainability

expenditu ures

as

an

indicator

of

financial

Trends in health expenditure are e an important indicator of affordability, and thus sustaina ability. For inte ernational comp parisons, the standard s international de efinitions for healthcare and healthcare expenditurre of the OECD’s System m of Health Accou unts (SHA) are classically used. SH HA aims at measuring co onsumption of hea alth and long-term m care services. Health Accoun nts are only com mparable since 2003. The total health expenditures in ncreased from €27 7.6 billion in 2003 3 to €37.3 billion in 2010. Per capita, this s represents an increase from €26 660/inhabitant in 2003 to €3430/inhabitan nt in 2010. To allo ow comparisons between countrie es, these data are also expressed e in 200 05 US$ Purchasin ng Power Parities s (PPP). Finally, the sha are of Total Hea alth Expenditures (THE) in Belgia an gross domestic produ uct (GDP) accoun nts for 10.5% of GDP, G compared to o 10.0% in 2003.

101


102

KCE Reportt 196

Table 24 – Tota al health expend ditures according g to the System of o Health Accoun nts (2003-2010) 2003

2004

2005 5

2006

2007

2008

2009

2010

Absolute amounts (in billions €)

27.6023

29.4811

30.60 064

30.5214

32.2427

34.59 992

36.303

37.3737

Per capita

2660.18

2828.97

2920 0.84

2893.59

3034.41

3230.56

3362.48

3430.17

Per capita (US$ $ PPP)

3026.8

3155.5

3246 6.8

3277.6

3423.3

3698.4

3911.4

3968.8

% GDP

10.0

10.1

10.1

9.6

9.6

10

10.7

10.5


More than half of the total health expenditures (5 53%) is spent for curative care (HC.1) or rehabilitation care e (HC.2). The follo owing two most im mportant contributors are e services for lon ng-term care (LTC C) (specifically the health component, no ot the social com mponent, HC.3, 20 0%)s and medica al goods (mainly pharma aceuticals productts, HC.5, 17%).

s

Roughly speaking, s one could d define healthcare e as care helping in ndividuals performing g activities of dailyy living (ADLs) (e.g. dressing, eating g…), and social carre as care helping iindividuals performing instrumental ac ctivities of daily living g (IADLs) (e.g. sho opping, laundry, …)). In practice, the division d of LTC into its i health and socia al components is ch hallenging as many y services provided to t LTC recipients h have both a health h and social compo onent. To ensure co omparability of the S System of Health Accounts A (SHA) for long-term l care, the OECD O issued speciific guidelines.24

Figure 30 – Heallth expenditures F s in Belgium by main function in n the S System of Health h Accounts (2010 0)

S Source: OECD Heallth Data 2012

Expressed as a percentage of the GDP, Belgium iss very close to the E e EU15 average. But caution is need ded when compa aring total health hcare e expenditures, as the better and th he more exhausttive the registration of h healthcare expend ditures, the higherr the level of these e expenditures.


KCE Report 196 6

103

Total health expenditure as %GDP

Figure 31 – To otal health expenditures as a % of GDP: internatio onal comparison n 20 18 16 14 12 10 8 6 4 2 0 00 2001 2002 200 03 2004 2005 200 06 2007 2008 20 009 2010 200 Be elgium

France

Germany y

Ne etherlands

United Kingdom m

United Sttates

EU U-15 Source: OECD Health H data 2012

Netherlands France Germany Denmark Austria Portugal Belgium EU-15 Greece Un nited Kingdom Sweden Italy Ireland Finland

12% 12% 12% 11% 11% 11% 11% 10% 10% 10% 10% 9 9% 9 9% 9% % 0% 2% 4% 6% 8% 10% 12% 14% % E Expenditure Healtth care - % gross s domestic produ uct (2010)


104

6.3 •

•

•

Key findings Concernin ng the Belgian he ealthcare workfo orce, some resultts are challengin ng since GPs are e aging. The averrage age of FTEs s of GPs is currentlly 51.4 years. This average age has h risen very rap pidly since 2000 0, when it was 47 7.3 years. One off the reasons of this t ageing of GPs is the problematic recruitem ment of new GPs s. The number off graduates who specialize eitherr in general medicine or in anotherr specialty was 7 781 in 2008. Among these gradua ates, the percentage of graduates in n general mediciine was 34% in 1996 and is actu ually (2008) 29%. The numb ber of nursing gra aduates per 100 000 population is very high in Be elgium compared d to other EU-15 countries: 41.7/1 100 000 population n compared to th he average EU-15 5 of 31.3 /100 000 0 population n but the foreign students are co ounted although they will probably not work in B Belgium. The analys sis of the mainte enance of the fac cilities shows a relative r high utilisation of acute ca are hospitals perr inhabitant. In 20 009, there were e 13 million days s spent in acute care c hospitals (c classic hospitalisa ation only, exclu uding one day). Per P capita, this represents s 1.2 acute care bed days in 2009 9, a bit higher tha an the EU-15 ave erage (1 bed day//inhabitant).

•

The innovative perspective e of the health sy ystem is measurred by the percen ntage of GPs using an electronic c file to maintain their patient’s medical m record. T This percentage increased from 61% 6 in 2004 to 74 4% in 2010.

•

Concernin ng the financial s sustainability, the e total health expenditures increased fro om €27.6 billion in 2003 to €37.3 billion in 2010. Pe er capita, this represents an incrrease from €2 660/inh habitant to €3 430 0/inhabitant in 20 010. The share of total health exp penditures in Bellgian gross dome estic product (GDP) accounts for f 10.5%, compared to 10.0% in 2003, which is very v close to th he EU-15 average e.

KCE Reportt 196

7 PERFOR RMANCE OF O HEALTH PROMO OTION 7 7.1

How did we w evaluate the e performance e of health promotion n?

According to the Ottawa charter233, “health promottion is the proce A ess of e enabling people to o increase controll over, and to imp prove their health””. The p process of health promotion is com mplex and can be e understood as all a the e efforts that a socie ety does to promo ote the health of the citizens. It cov vers a w whole range off interventions (e.g., policies, law, environm mental in nterventions), situ uated for a considerable part outsid de the health syste em. It is s also largely situa ated outside the so-called s “health p promotion sector”t. T guiding princip The ples of health promotion are the folllowing: •

Participation

•

nt Empowermen

•

Sustainability

•

Multistrategic

•

Equity

•

Multisectorial

t

In Belgium, the t “health promotion sector” is repre esented by the structures depending on n the Health Admin nistrations and Minisstries of the Region ns and Communities s.

KCE Report 196 6


Several framew works have been n proposed to classify c health prromotion indicators. Nutbeam83 has prop posed a framewo ork that classifies s health promotion indic cators in 4 broa ad classes ranking from most proximal p indicators (health promotion actions), through he ealth promotion ou utcomes (health literacy y, social influen nce and policie es), intermediate e health outcomes (healthy lifestyle, effecctive health servic ces and healthy settings), s to final health and social outco omes (physical health h like morbid dity and mortality, and social s health like e well-being and equity). In this work, w we adopted the Nutbeam’s framew work to classify th he indicators, because it corresponds la argely to the bro oad axes and principles p of the Ottawa Charter.23 In the context of this project, itt has not been possible p to perforrm a full evaluation of health promotion iin Belgium since this would neces ssitate a complete study y in itself. With reg gard to the limitattions we faced (co onstraint of a limited set of indicators and unavailability of data d for many ind dicators), we illustrated some s categories o of the Nutbeam’s framework. Altho ough the most distal fro om action outco omes like health outcomes and healthy lifestyles are easier e to document, we also tried to define indicattors and present results s for more proxiimal indicators (as healthy envirronment, health promotio on outcomes).

105

106


KCE Reportt 196

Figure 32 – The Nutbeam’s framework and sele ected indicators to measure perfformance of heallth promotion The Nutbeam’s s framework

In ndicators selected d and classified within the Nutbeam m framework H Health and Sociall outcomes •

Overweight an nd obesity

•

Dental health: decayed, missing g, filled teeth at ag ge 12

•

H Incidence of HIV

In ntermediate Heallth outcomes H Healthy Lifestyles •

s Daily smokers

•

Alcohol consu umption

•

Physical activiity

Nutrition (fruits s and vegetables)) • H Healthy Environme ent •

Composite ind dex of health prom motion policies in tthe municipalities

•

Percentage off schools with a pa articipative health promotion team

•

Offer of physic cal activity at seco ondary school

H Health Promotion n outcomes •

Health Literac cy: health literacy level l (not measured)

•

Social influenc ce and action: poo or social support

•

Healthy public policy and orrganisation practtice: Tobacco Co ontrol Policies Scale e

Source: adapted from the Nutbeam framework83 “Health promotion n actions”, the last ccategory in the Nutb beam’s framework, is not represented here h

KCE Report 196 6

7.2


Facts and a figures


7.2.1

Health h outcomes

Four important indicators of ge eneral health outc come have alread dy been described abov ve in the chapter on the health sta atus of the popula ation: life expectancy, he ealth expectancy, self-perceived he ealth and infant mortality, m as they are less s specific to health h promotion. Overweight an nd obesity Adult population n (aged 18 years or older) In 2008, 47% of the Belgian p population (aged 18 years or old der) was considered as being overweightt or obese (Body y Mass Index (BM MI) ≥25), % was considered d as obese (BMI ≥30). Results arre based and almost 14% on the reported d weight and heiight. Overweight is more frequentt in men than in women. For obesity, no differences were found between men m and women. Although the obesity o and overrweight rates are e slightly lower than t the average EU-ratte, they gradually increased over tiime. After standarrdization for age, the rate e of obese people e is higher in Wallonia than in the tw wo other regions, but the e difference tendss to have decreas sed over time (Fig gure 33). As for other ind dicators related to o overweight, like poor nutritional habits h or lack of physical activity, a strong social gradient is s observed.

107

108


KCE Reportt 196

Figure 33 – Pe ercentage of the adult population n (aged 18 years or older) with ob besity (BMI ≥30),, by region (1997 7-2008), and interrnational comparison (2000-2008

Source: Health In nterview Survey, Sccientific Institute of Public P Health (WIV – ISP), and OECD Health H Data for international compariso on

Overweight and d obesity in childre en and adolescen nts The HIS surve ey provides inforrmation about th he overall prevalence of overweight and d obesity in youn ng people (2-17 years) (https://w www.wivisp.be/epidemio o/epifr/CROSPFR R/HISFR/his08fr/9..etat%20nutritionn nel.pdf): overall 18% off the young peo ople (aged 2-17 years) are found to be overweighed and 5% was foun nd to be obese. There T was no diifference between gende ers. Dental health: decayed, missin ng, filled teeth (D DMFT) at age 12 DMFT is an intternational index describing the am mount – the preva alence – of dental caries s in an individuall. DMFT numerica ally expresses the caries prevalence and d is obtained by calculating the number of Decay yed (D), Missing (M), Filled F (F) teeth (T T). WHO goals set s for the year 2010 a maximum mean n DMFT score below 1.0 for 12-yea ar-olds.

84 In n a national surve ey performed in 2009-2010 2 , the m mean DMFT score e in a s sample of 30 child dren aged 12 wa as 0.9 (± 1.37). This confirms the result (1.0) from a previo ous study based on o a large sample performed in Flan nders in n 2001. Neverthelless, 43% of these e children had sig gn(s) of dental carries in p permanent teeth. The mean DMFT T score was 1.3 (± 1.82) for the 12-14 1 y year-olds (n=95). The very small sample does no ot allow any stra atified a analysis by sex, re egion or by socioe economic status. T number of stu The udies performed in Belgium to datte still remains lim mited. M Moreover, the scope is often limited d to small selected d areas.85

KCE Report 196 6


Incidence of HIV H HIV is an imporrtant communicab ble disease in Eurrope. It is associa ated with serious morbidity, high costs off treatment and care, c significant mortality m and shortened life expectancy. It is also a perffectly avoidable in nfection, since the transm mission is largelyy avoidable by behavioural measurres (safe sex, safe injecttion). Therefore, iits incidence in a defined populatio on is an indicator of the success/failure off health promotion n. In Belgium, the true incidence ra ate is not known, and a is approache ed by the diagnostic rate. This is an apprroximation since the diagnostic ca an occur long after the in nfection (the HIV-infection remaining long asymptomatic). The diagnostic c rate in Belgium for all cas ses is around 10 per 100 000 inhabittants. Belgium has the particularity to have a large proportion of no on-Belgian casess (60% of cases with w a known nationality), being a mix of resident and non-resident people. A large proportio on of the non-Belgian ca ases originate from m countries with a high prevalence e of HIV (such as Sub-S Saharan African countries). Parts of this large nu umber of non-Belgian cases are imported cases, and as su uch cannot be interpreted as a failure of o health promotion in Belgium.. There is no clear-cut c explanation forr the large numbe er of imported ca ases in Belgium. Further analysis is nee eded. For Belgian cases only, the rate is fluctuating g around 3-4 per 100 000 0 inhabitants. Figure 34 (a and b) show the e evolution of the diagnostic d rate off HIV by region from 1985 to 2010, for a all cases and for Belgian cases only. The rates in Flande ers and Wallonia are quite comparrable. However, a steady increase is obs served in Flanders since 1997. The T rates in Brussels are much higher tha an in the other reg gions. The Brusse els region mainly consists of a large city, with w the socio-cultural characteristiics of an urban co ontext. A high HIV-rate is s a usual phenom menon observed in large towns. The T HIVrates in the tw wo other regions rrepresent an ave erage of rates fro om rural, semi-urban and d urban contexts. For Belgian patients, p the mosst frequent way of infection wa as male homosexual contact (see Supple ement S1).86

109

110


Figure 34 – Dia agnostic rate of HIV by region, fo or all cases (a) an nd for Belgian ca ases only (b) (1985-2010)

Source:Scientific Institute of Public H Health (WIV – ISP) 86

KCE Reportt 196

KCE Report 196 6


Figure 35 – Ra ate of the new HIV V diagnosis per 100 000 inhabita ants: Internationa al comparison


111


112

7.2.2 Interm mediate health outcomes 7.2.2.1 Hea althy Lifestyle

Table 25 – Alcohol consumption habits for the po T opulation (aged 15 or o older) (1997-2008 8)

Daily smokers s The percentage e of daily smoke ers was around 20% 2 in Belgium in 2008, which is slightly y lower than the E EU average. It ha as significantly de ecreased since 10 years,, mostly in men, in whom the rate of daily smoking g passed from 31% in 19 997 to 23.7% in 2008. The rate in women is lowe er, but it remained stable e until 2004. The decrease in the rate of smoking is s mainly found in highly-educated people e. The rate of sm moking in young people p is as high as for the t rest of the pop pulation. However, a closer examin nation of the data in this age group revealls that smoking prrevalence peaks between b 21 and 24 years s, a priority targett for prevention. The comparison between region ns shows that the e rate of smoking is lower in Flanders than n in the other regiions. Alcohol consu umption The consumptio on of alcohol is asssessed on the ba asis of three indica ators: •

Percentage e of men and women aged 15 yea ars and over repo orting an excessive alcohol consumpttion (more than 21 glasses/210g a week in men and 14 glasses/140g a week in women);;

•

e of the non-abstinent population (aged ( 15 years and over) Percentage reporting a problematic alco ohol consumption (defined as a tend dency to addiction based b on CAGE sccale, 2+ cut off);877

•

Percentage e of the populatio on (aged 15 yea ars and over) rep porting a risky single e-occasion drinkin ng (≥ 6 drinks) at le east once a week k. The percentage e of excessive a alcohol consumpttion has remained stable around 8%. However, H the rate of people with w problematic drinking behaviour (tend dency to addiction n) is increasing, mostly m in Brussels.. Alcohol consumption be ehaviour is more typically masculin ne. Risky single-o occasion drinking is highe est in the 15-24 a age group.

KCE Reportt 196

D Drinks alcohol in excess Exhibits problem E matic drinking b behaviour (CAGE E q questionnaire) Drinks 6 or more drinks in a D s single occasion at a least w weakly

1997

2001

2004

200 08

7%

9%

9%

8%

7%

8%

10% %

8%

S Source: Health Interrview Survey, Scientific Institute of Public Health (WIV – IS SP)


KCE Report 196 6

113

Figure 36 – Pe ercentage of the e population (a) smoking daily, (b) with problem matic alcohol co onsumption, (c) consuming at le east 2 fruits and d 200 vegetables daiily, (d) performin ng at least 30 min n of physical activity per day, by region (1997/200 01-2008)

50%

Age-adjusted % of people practising at least 30 min of physical activity per day

Adjusted % of people eating 2 fruits & 200g vegetables daily

30%

25%

20%

15%

10%

5%

0% 2004

45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 2001 Belg ium

Belgium

Bruss sels

2004

2008

2008 Flanders

Wallonia

Source: Health In nterview Survey 200 08, Scientific Institutte of Public Health (WIV ( – ISP)

Brussels

Flanders

Wallonia


114

KCE Reportt 196

Consumption of fruits and veg getables

7 7.2.2.2

The consumpttion of fruits and vegetables is expressed by b three complementary y indicators:

In n Flanders, the Vlaams V Instituut voor v Gezondheidsspromotie (VIGeZ Z) has d developed a set off global indices aiming to measure the level of intens sity of "health promotion"" in several settin ngs (schools, worrk, and municipalities). S Such indicators focus f on public health authoritie es responsibilities s (as o opposed to the usual measures of health h behaviour).. Itt is in line with two o axes of the Otta awa charter:23

•

Percentage e of the population n reporting to eat fruits daily;

•

Percentage e of the population n reporting to eat vegetables daily;

•

Percentage e of the population reporting to eatt at least 200g veg getables and 2 fruits s per day. The daily consumption of fruits and vegetables (in the whole pop pulation) has progressed over time, an nd reaches 65% for fruits and 84% 8 for vegetables. Altthough this is an encouraging progression, p the quantity consumed is fa ar too low. Only 2 25% of the peop ple reports to eat at least 200g vegetable es and 2 fruits d daily, which is a proxy of the nu utritional recommendatio ons (which are ““300g vegetables s and 2 fruits per p day” according to th he “Actieve Voed dingsdriehoek”,88 or five portions of o either fruits or vegeta ables, according tto the WHO89 an nd the Belgian Nu utritional 90 Plan ). Physical activiity Strong evidenc ce demonstrates that compared to o less active ind dividuals, more active people have lower rrates of all-cause mortality, corona ary heart disease, high blood pressure, strroke, type 2 diabe etes, metabolic sy yndrome, colon and breas st cancers, and depression.91, 92 Bu ut the quantity of physical activity is difficu ult to measure. Th he questionnaires s and the develop pment of indicators raise ed many question ns and criticism. The T questionnaire e will be changed in the e next (E)-HIS. M Moreover, very fe ew international data d are currently available. This being sa aid, we present th he currently availa able data on physical actiivity in Belgium. The global perc centage of people e (15 years or mo ore) practising at least 30 minutes of any type of (at least m moderate) physica al activity per day y is 38%. There is a lott of room for im mproving this glo obal level. The (at ( least moderate) phys sical activity rate is almost twice as a higher in men n than in women. There are important re egional difference es with a higherr rate of practising (at le east moderate) p physical activity in n Flanders (45%)) than in Wallonia (27%)) or Brussels (22% %).

•

Health hy Environment

Developing he ealthy public polic cies

• Developing he ealthy environmen nt T Three specific th hemes were ana alysed: smoking,, healthy eating and p physical activity. Those T indicators of health promottion in settings ca an be s seen globally as a summary resullt, or can be deccomposed into sp pecific d dimensions. They y can be used as s an (auto)-evalu uation indicator fo or the m municipalities, which can compare e themselves to tthe others. The trrends o over time can allso be followed (with caution). F For the indicatorrs on s schools, results ca an also be obtaine ed from the Health h Behaviour in Sc choola aged Children (HB BSC) studies in Wallonia W and Brusssels. In ndex of health promotion policie es in the municip palities The municipalities T s represent the most m close-to-the--citizen level of public p a authority. R Results are only available for Fla anders. The score es, that represen nt the w weighted sum off “good” answers s to questions related to the health h p promotion policies s at municipality--level (in the field of tobacco, he ealthy e eating and phys sical activity), range r between 0 and 100%. The m municipalities sco ore low for tobacc co prevention (gllobal score=37%)) and h healthy eating (glo obal score=36%),, a bit better for p physical activity (g global s score=50%). The average scores hide a large disp persion of scores s with s some municipalitie es doing nothing,, and others perfforming very well. It is im mportant to further analyse the re eason for those low rates and fo or the v variability, in orderr to intervene effic ciently.

KCE Report 196 6


Percentage of schools with a h health promotion n working group The percentag ges of schools with activities in n health promottion are calculated sepa arately for 3 theme es: smoking preve ention, healthy ea ating and physical activitty. The existence e of a working group g working on n health promotion as a whole cannot directly be dedu uced from those results. However, the se eparate indicatorss are a good proxy y of the situation. For Flanders, the following ressults are extracte ed from the VIGe eZ 2009 report:93 •

•

•

orking group is ratther good implem mented in The existence of such a wo dary schools (42% % for smoking pre evention, 64% forr healthy the second eating and d 54% for physical activity; the main m roles of the working group are “to “ give advice to o the Direction” orr “taking part in se etting up the health promotion policiess of the schools”. t theme, in the e majority of scho ools, the working group is Whatever the composed mostly of teacherrs; parents and sttudents are not pa art of the team as su uch.

However, other participatio on mechanisms exist e for the stud dents: a feedback of o the discussionss of the working group g is given to students s and parentts. In almost half of the schools, th he students can take part in the dec cisions. In 38% they only can giv ve their opinion or o make suggestion ns. From the VIGe eZ report we can conclude that a working group fo or health promotion is im mplemented in a majority of scho ools. While stude ents and parents are selldom part of thosse groups, other participation p mechanisms exist. The auth hors conclude tha at the participatio on culture is quite e largely implemented. In Wallonia and d Brussels, the H Health Behaviour in School-aged Children (HBSC) study y is a cross-na ational research h survey conducted in collaboration with w WHO-Europe.. The HBSC aims s to gain new ins sight into young people's s health, well-be eing, health beha aviours, and their social context. A parrt of the survey is devoted to th he health strateg gies and environmental context of the sschool, and is answered a by the e school directors.

115

In n the French spe eaking part of Be elgium (Wallonia and Brussels) survey 2010, 44 second 2 dary schools dire ectors were interrviewed regarding g the h health related pro ojects conducted in the school. So ome indicators tha at we re etained as perform mance indicators could be extracte ed from the report.. A Almost half of the schools report they have a permanent health cell (4 40%). H However, it seem ms that the particiipation of studentts is quite poor, since s students are only y implied in 7.7% % of the cases. Other mechanism ms of p participation are maybe m present, but b were not partt of this questionnaire. T This point could be e explored more profoundly p in the future. As particip pation is s an essential dimension in the success of h health promotion,, this d dimension should be further improv ved. O Offer of physical activity at secon ndary school Physical activity in P n young people is s an important hea alth-enhancing ac ctivity. S Schools can offe er many opportunities to young people to engag ge in p physical activities. For Flanders, th he following resu ults are extracted from th he VIGeZ 2009 re eport93.


116

Table 26 – Offe er of physical ac ctivity in seconda ary schools in Flanders N

Minim mum

Maximum m

Mean

Std d. De eviation

Education

416

.00

10.00

6.0643

2.0 08702

Supply

416

.00

8.59

5.4758

1.2 29252

Reglementatio on

416

1.21

10.00

6.9500

1.7 74638

Participation

416

.00

10.00

5.3100

2.3 31019

Networking

416

.00

10.00

4.7332

3.4 41978

Total

416

8.74

84.27

56.3475

14 4.46473

Note: The table provides p an overview w of the partial scorres for several healtth promotion dimensions. Those partiall scores are calcula ated as a 0-10 index x resulting from the e weighted sum of “g “good” answers to a long questionnaire. The score of “supply” is one of those parrtial scores. The glob bal score, called “To otal score of the phys sical activity policy in n the secondary sch hools” (calculated as a percent), represe ents a global intensiity of the health prom motion policies on th he theme of physical activitty, in all respondentt schools. The globa al score ranges betw ween 0 and 100, and sho ould be interpreted a as a “percentage” of o a perfect score (in n terms of health promotion policy). eport93 Source: VIGeZ re

In summary, we w can conclude that health prom motion policies re elated to physical activity y in Flemish scho ools are in progre ess, score quite good and are generally in ntegrated in a glo obal school policy y. A separate ana alysis of the dimension “supply” revealss that infrastructture scores quite e good. Nearly 100% of o schools have (access to) a gym g but with som metimes insufficient spac ce available. How wever, the availability of a swimming g pool is more problema atic. Although the e range of activitties has increase ed since 2006, the acces ssibility of facilitiess could improve.

KCE Reportt 196

Data for Brussels D s and Wallonia are a extracted from m the HBSC surv vey.94 T This report shows s that 20% of the e responding scho ools had no adeq quate s sport facilities, an nd that another 10% had no sport facilities. In those s schools, the childrren are going to an nother place to ha ave the sport lessons. D Data on the availa ability of (extra) ph hysical activity an nd on the integration of th he physical activ vity in the global school-policy should be collected in W Wallonia and Brrussels in orderr to conclude a and eventually make re ecommendations.

7.2.3 Health Promotion 7 P outcom mes 7 7.2.3.1 Health h Literacy Health literacy is one H o of the most im mportant indicatorrs for health promotion. Itt can be defined as “the individua al skills to undersstand and manag ge the in nformation related d to health, healtth determinants, and health care”. It is re elated to the “e empowerment” dimension, which is one of the most re epresentative asp pects of health pro omotion.95 U Unfortunately, no data exist in Belg gium yet. At intern national level, the tools to o adequately mea asure health literacy are still under vvalidation.96, 97

7 7.2.3.2

Sociall influence and action a

S Social support Social support is a protective factor in times of stresss. It is a resource S e that h helps individuals to t deal with the difficulties d of life (according to diffferent m modalities, like em motional support, material aid, information…). Low levels l o social support have been link of ked to increased rates of depres ssion, s somatic illnesses and a mortality. F Fifteen percent off the population aged 15 years o or older reported poor s social support in 2008. 2 There is no o significant gende er difference. The e lack o social support is gradually incre of easing with age. T There is also a strong s a association with educational e level (age-adjusted ratte equals 22% on the lo owest educationa al level versus 10% in the highest). The rate is much lo ower in Flanders than t in the other regions, r especiallyy in Brussels.

KCE Report 196 6

7.2.3.3


Hea althy Public Poliicy

The Tobacco Control C Policies Scale The concept of multi-pronged d and “comprehensive” tobacco control policies arose from governmen nts’ and non-gov vernmental organ nisations’ policy initiative es during the 90 0s. The interest of the compositte index “Tobacco Contrrol Policies Scale e” is to provide a global and internationally comparable lev vel of the Tobacco Control Policies in a counttry. It is composed of th he following eleme ents98: •

Price incre eases through higher taxes on ciga arettes and other tobacco products;

•

g in public and wo ork places; Bans/restrictions on smoking

•

sumer information n, including public information cam mpaigns, Better cons media cove erage, and publiciising research find dings;

•

Comprehensive bans on the e advertising and promotion of all tobacco products, lo ogos and brand names;

•

Large, dire ect health warnin ng labels on cig garette boxes an nd other tobacco pro oducts;

•

Treatment to help depende ent-smokers stopp ping, including in ncreased access to medications. m Belgium is situ uated on the 10th h place out of 32 2, with a global score s of 50/100. The sc cores of the more e extreme countrries were respecttively 32 (Greece) and 77 (UK). The au uthors conclude that “Belgium missed m a golden opportu unity to adopt com mprehensive smo oke-free legislatio on when the parliament modified legislation in December 2009 (articles 4 and 5). The new law sttill permits smokin ng in bars, discoth heques and casin nos. Also smoking is still allowed in som me public places in smoking-room ms under strict rules. Datta from the Ministry of Health show that half of the e bars in 2010 do not re espect the weak rrestrictions which applied to them.. On the other side, Belg gium was the firsst EU country to introduce pictoria al health warnings in 2006 and to print th he number of the e quit line on all cigarette c packs in 2011”.

117

118


Figure 37 – Intternational comp parisons on the Tobacco T Control Scale in Europe e (2010)

Source: A survey y of tobacco control activity in 31 Europ pean countries in 20 01098

KCE Reportt 196

KCE Report 196 6

7.3


Key findings

•

In 2008, 47 7% of the popula ation was in overrweight, and 14% % was obese. The ese percentages s are increasing over o time. Both overweigh ht and obesity inc crease sharply with w age until the e age of 65, and are e strongly assoc ciated with educa ational level. The e obesity rate in the lowest e educational leve el is twice as high h as in the higherr educational levels. Differences between regions s are small.

•

The numb ber of studies perrformed in Belgiu um on oral health of the population n is scarce and a are often limited to small selected d areas. In a 2009-2 2010 study, the m mean DMFT (den ntal health: decay yed, missing, filled teeth) score e was 0.9. This sc core meets the WHO W goals set for f the year 2010 0 (maximum mea an DMFT score below b 1.0 for 12-year-olds). Howe ever, more data are a needed on la arger samples.

•

•

The rate of o new HIV diagno osis in Belgium is a bit higher than the European (EU-15) mean. A large proportion of those new diagnosis are made in non n-Belgian people e. Those are prob bably imported cases, c with different patterns of transmission t tha an those of th he Belgian cases s. The rate in Bru ussels is higher than t in the other regions, r representing an urban phenomenon. p The male homosexu ual transmission is the main way y of transmission n for the Belgian ca ases. The numbe er of cases resultting from this transmission way is increa asing; the numbe er of cases trans smitted by other ways w is not dimin nishing either. The percentage of daily sm mokers was arou und 20% in Belgium in 2008. It ha as significantly decreased since 10 1 years. It is hig gher in men than in women, in all age groups. How wever, the rate is s more decreasing g in men than in women. The Belgian rate is slightly below the EU-15 average rrate.

•

•

119

In 2008, 8% of o the population n was considered d to have a week kly alcohol over--consumption. Over-consumptio O on is already common in young y people (ag ged 15-24 years).. Regional differences are a observed in this age group, w with more young people reporrting over-consumption in Flande ers than in the otther regions. The problematic alco ohol consumptio on (trends to dependency)) seems to increa ase in all regions s and mostly in Brussels. The regular risky single-occasion s d drinking (more th han 5 glasses) amo ong young peoplle is of concern. In 2008, almo ost two-third of the population atte fruit every day y, which is an improvement com mpared to 2004. The daily vegeta ables consumption n was still higherr than that of fruiits (84%). Howev ver, only 26% of the t people ate 2 fruits and 200g v vegetables daily, with even low wer rates in Wallonia (F: 28.5%, B B: 24.6%, W: 18.2 2%).

•

The global pe ercentage of peo ople practising at least 30 minute es of any type of physical p activity per day is low, a at 38%. It is lowerr in women. It is much higher in Flanders F (45%) than in the two otther regions, and is especially low w in Brussels. Th he rate is also surprisingly declining in Wallonia.

•

When assess sing the global public p policy on ttobacco control with w the Global To obacco Scale, Be elgium is ranking g at an intermediate position.


120

KCE Reportt 196

8 EQUIT TY AND EQ QUALITY

T measurementt of health inequallities requires cho The oosing:

8.1

•

a characteristtic defining the soc cial groups

•

one or more e synthetic inequ uality measures in the health-re elated indicator(s).

Introdu uction

Equity is a key y feature in the e evaluation of the performance of a health system.1 It is also a a controversial normative issu ue, referring to jud dgement and political po osition. A broad ra ange of perspecttives and definitio ons have been proposed d, and are discusssed in the Supplement S2 of this s report: “The place off equity in asse essments of the performance off health systems.” Being aware off this feature, we have approached d the dimension of o equity with two comple ementary ways: 1. In a first subchapter, called “S Socio-economic in nequalities“, we do ocument the inequalities s in health, health determinants and healthcare utiliz zation in Belgium across s the socioecono omic position. Ind deed, for the purrpose of operationalisation and measurements, Braveman n99, 100 suggests defining equity in health h as “the absence e of systematic ine equalities in healtth/health determinants between social gro oups who have diifferent social pos sitions in a social hierarchy”. 2. In a second subchapter, we have proposed contextual c indicattors that can highlight is ssues of equity in n healthcare at a global level. This is the purpose of the e second part of the chapter, called “Equity of the e health system at a global level”.

8.2 8.2.1

Socio-e economic inequalities How did d we evaluate socio-economic c inequalities?

Socio-economic c health inequ ualities refer to o disparities in health status/health determinants/utiliz d zation of health services, most often in disfavour of th he social groups that are already y disadvantaged by their position on the social scale. The e presence of socio-economic inequalities is consistent and has long b been recognized d.101, 102 Tackling g health inequalities has s long been a prio ority for the WHO O.103 It has become a high level priority ta arget at Europea an level, with the DG Sanco 2d d Health Programme104 and in the US SA.105 To assess s the progress towards reducing sociall inequalities in h health, it is imporrtant to measure them100, and to monittor if they cha ange over time e (by repeating g those measurements)).

C Characteristics u used to define the e social groups The social groups can be defined by T b different characcteristics at house ehold, in ndividual or eve en geographical levels: the household income, the e educational level, the occupation, a deprivation inde ex, or a combinatiion of s some of those variables. S Social groups’ definition varies acc cording to the avvailability of the socios e economic variable es in the different data d sources we u used. F the indicators issued from the Health For H Interview S Survey, different socios e economic (SE) va ariables are availa able. For most indicators of this re eport, th he highest educa ational level attained by the referen nce person and his/her p partner was chose en to define the so ocial position. Indeed, this informattion is c considered to be the most compa arable and robustt choice, because e it is la argely available, less l sensitive and d prone to bias th han the income lev vel. It w was coded acco ording to the International Stand dard Classificatio on of E Education (ISCED D) summarized as lower education (no diploma or prrimary s school diploma), lower l secondary education, higherr secondary educ cation a and higher educa ation. For the in ndicator “delayed contacts with health h s services for finan ncial reasons”, the income level o of the household d was c chosen as proxy for the SE level.. Indeed, this cho oice is more pertinent w when explaining purely financial barrriers. F the indicators of Life and Health For h Expectancy, the e educational leve el was g grouped into 5 gro oups (no education n and primary level were split). F the indicators For s calculated from m the Permanentt Sample or from m the R RIZIV – INAMI, th he status of incre eased reimburse ement was chose en as p proxy for the SE E level. Two soc cial categories w were defined with h this v variable, the BIM Mu (increased reim mbursement, mo ostly correspondin ng to p people with a low income level) and d BO (normal reim mbursement).

u

BIM: Bénéfiiciaire à Interven ntion Majorée (be eneficiary of increased reimburseme ent); BO: Bénéficiairre Ordinaire

KCE Report 196 6


121

Measurement of inequalities

L Limitations

In a first step, we w showed the dissparities across th he socio-economic c groups for all the indica ators for which da ata were available e (this detailed info ormation can be found in n the documentatio on sheets in the Supplement S S1). In a second ste ep, we summarizzed the detailed information by co omputing indices, allowin ng quantifying the e size of the inequ ualities. A wide variety v of summary indice es can be used.1106 They differ by y several properties: their nature (absolute versus relativve), their scope and complexity:: simple pairwise measu ures (like the rate e difference, or the e relative risk) co omparing only two groups s are easy to com mpute and to unde erstand. Howeverr, from a public health perspective, p more e complex meas sures involving all a social groups are mo ore useful since e they measure the total impactt of the inequality on the population health.107 The following in nequality indices a are described in th his chapter:

The inequalities co T ould not be meas sured for all the in ndicators due to la ack of d data on social pos sition. This is the case for many off the quality indica ators. T Therefore, our con nclusions for this dimension d are larg gely incomplete. S Some issues know wn to be related to social inequalitiies were not studied in th his work (like the waiting time for some intervention ns). A deeper foc cus of th he topics specific cally linked to the inequalities should be performed in i the n next report. F the indicators from the Permane For ent Sample (EPS), only two statute es are a available. It is diffficult to measure the impact of ine equalities at population le evel with the BIM status. Indeed, people with a prefe erential reimburse ement s status for financ cial reasons are e people with a very low inc come, re epresenting less than 5% of the e population. On n the other hand d, the p preferential reimbursement status also comprises p people with a phy ysical h handicap but no financial f disadvan ntage. The definitiion could be refin ned in th he next survey. W did not perform We m an analysis of the small scale geographical dispa arities in n the indicators. Such a represe entation is a wa ay to highlight health h in nequalities relate ed to ecological poverty p indices. This was beyond d the s scope of this work k. Moreover, the data d originating frrom the HIS cann not be a analysed on a sma all scale, because e of the size of the e sample.

•

For the Life e/Health Expectan ncy: o The absolute a differencce in years betw ween the lowest and the highes st educational groups o The Relative Concentra ation Inequality Ind dices (CII rel): the e relative concen ntration index is the sum of the diffference in life exp pectancy betwee en each group an nd the highest ed ducational level, weighted w by the size of each grou up, and divided by y the life expectan ncy

•

For the indicators issued from the Health Interview Survey a rate ratio (between the extreme edu ucational o The age-adjusted levels)) o The ab bsolute difference e in age-adjusted rates r (idem)

• The Popula ation Attributable Fraction (PAF): this t is the relative e gain in health (or healtth determinant) rrate that would be e expected at po opulation level if all the groups g experience ed the rate of the e more advantage ed social group. It is com mputed as the d difference betwee en the overall rate in the population and d the rate in the more advantage ed group, divided d by the overall rate in th he population. In this chapterr, we highlighted the indicators fo or which we obs served a relative risk (RR R) as large as 1.2 (or 0.83 when the e gradient was rev verse).


122

8.2.2

Facts and figures


8.2.2.1

KCE Reportt 196

Table 27 – Life expectancy T e at 25 5 years by sex and educational level, a absolute differen nce to highest educational e leve el and concentrration in nequality indices s (CII) (Belgium 2001) 2 Men D Diploma

Total

H Higher

55.0

Secondary S h higher

52.5

-2.5

5 58.5

-1.4

Secondary S lo ower

51.3

-3.7

5 58.0

-1.9

P Primary

49.3

-5.7

5 56.2

-3.7

N diploma No

47.6

-7.5

5 54.0

-5.9

T Total

51.4

-3.7

5 57.1

-2.8

Ineq qualities in indiccators of Genera al Health Status

Life and Health h Expectancies To assess ineq qualities in life and d health expectancies, complex pro ocessing of data on morttality, social position and disability are needed.108 Currently, C the most recent and robust data a in Belgium conc cern the year 2001 for the inequalities in life expectancy109, 110 and the yearr 2004 for the inequalities in health expec ctancy.111 As me entioned, in both studies, the edu ucational levels are reported in 5 categories (no diploma, primary, p secondarry lower, secondary high her, and higher ed ducation). With th his way of groupin ng, more extreme groups s are compared w with the pairwise indices than for the other indicators, mak king the difference es between the compared c appearring very large. Concenttration inequality indices are morre appropriate measures m because they ta ake into account tthe share of the so ocial levels. Table 27 show ws the life expectancy at 25 years s by educational level, in 2001. Large ine equalities in life e expectancy betwe een the educational levels are observed in both sexes, de efined as the diffe erence in life exp pectancy between a partticular educationa al level to the hig ghest level. A gra adient of inequalities is observed. o The diff fference between the extreme leve els is 7.5 years in men. The Relative Co oncentration Inde ex in men was 3.7%. 3 In women, the sa ame tendencies w were observed as for men, but th he gaps between each educational e level and the highest were w smaller than in men. The gap between the extreme e educational levels was 5.9 years in n women and the Relative e Concentration Index in men was 3.7 %.

W Women Diff to o the highest level

T Total

Diff to the highest level l

5 59.9

C absolute CII

1.9

0.8

C relative CII

3.7

1.4

S Source: Deboosere et al.112

Table 28 shows th T he health expecta ancy at 25 years b by educational lev vel, in 2 2001. Inequalities between the educational levels in health expectanc cy are m much larger than n for life expecta ancy. Again, a g gradient of increasing es is observed. The in nequalities when n the educationa al level decrease d difference between the extreme lev vels is 18.6 yearss in men. The Re elative C Concentration Ind dex in men is 15..3%, which is mu uch larger than fo or life e expectancy. In wo omen, the same tendencies were observed as for men. T The gap between n the extreme educational e levels was 18.2 yea ars in w women. The Rela ative Concentration Index in wom men was 16.6%. This m means that peoplle with low educa ational level not only live shorterr than th hose with a high educational leve el, but also that tthey spend much h less tiime in good health h.


KCE Report 196 6

Table 28 – He ealth expectancy y at 25 years by b sex and educ cational level, absolu ute difference to highest educational e leve el and concentration inequality indice es (Belgium 2004 4) Men

Women

Diploma

Total

Difff to the highest levvel

Total

Higher

46.33

0.0 0

47.1

Secondary higher

41.54

-4..8

41.27

-5.8

Secondary lower

39.71

-6..6

42.01

-5.1

Primary

36.65

-9..7

36.27

-10.8 8

No diploma

27.75

-18 8.6

28.92

-18.2 2

Total

40.5

5.9 9

40.4

6.7

CII absolute CII relative Source : Van Oye en et al.

Diff to the highe est level

6.2 2

6.7

15 5.3

16.6

113

The self-perce eived health Important inequ ualities are obserrved in self-perce eived health. An absolute a difference of 29% 2 is observed d between the lowest and the highest educational lev vels (Table 29); the relative risk is 67%. The Po opulation Attributable Fra action is 11%, mea aning that the global increase of the rate in the whole popu ulation would be 1 11.2% if all educa ational levels expe erienced the rate of subje ective health of th he people of the highest educationa al level. Infant mortality is also known to o be linked with socio-economic s status. In Belgium, only partial p data exist a and confirm this fact. f For instance, a clear association wa as found in Brusssels between th he number of ho ousehold

123

ncomes and infan nt mortality.114 Th hese data are nott presented in dettail in in th his report.

8 8.2.2.2

Inequa alities in the indiicators of accesssibility

The percentage off households repo T orting to have delayed contacts witth the h health system forr financial reason ns was strongly related to the income le evel, with 27% of delay in the hous seholds of the low west quintile versu us 4% in n the households s of the highest quintile (Table 2 29). This represents a re elative risk of 6.2 2. The population n attributable fracction was as larg ge as 7 71%. In nequalities of sm maller size are obs served for the sccreening of breas st and c cervix cancer. Low wer coverage rate es are observed for patients with lower s socio-economic s status (identified d by their entittlement to incre eased re eimbursement). The T absolute diffe erence of coverag ge between lowes st and h highest educational levels were res spectively 14.3% and 15.3% for breast b a cervix cancer screening. The relative and r risks were e respectively 0.77 7 and 0 0.76. F the indicators on vaccination (vaccination of ch For hildren and vaccin nation o the elderly), a reverse phenom of menon was observed. The vaccin nation a against influenza in the elderly, measured with the e EPS data, show wed a b better coverage in n the patients witth BIM. It could b be due to the fac ct that th hey reside more often o in institution ns for elderly, whe ere vaccination is more s systematic. For th he vaccination ra ate in children, in n the last vaccin nation s survey in children in Wallonia (200 09), children with lower socio-econ nomic s status (measured with the educattional level of the e mother) had sllightly b better coverage than t children fro om higher socio--economic level. This a association was no ot found in Flande ers.


124

8.2.2.3

Ineq qualities in the in ndicators of qua ality of care

Data by social status were only available for som me indicators of quality q of care. mic inequalities could be observe ed in: Socio-econom •

The follow w-up of diabetic patients: the ab bsolute difference e in the percentage e of patients with a correct follow-up was 10%, the e relative risk was 0.83, and the PAF w was 7.4%. No important inequality was obse erved for the follow wing indicators: •

ording to guideline es Prescription antibiotics acco

•

e after ho ospital discharge for f eldery patients s (65+) Physician encounter

•

% of people with at least a ccontact with a GP in the year

•

e of people with a high fidelity to their GP (Index of o Usual Percentage Provider off Care > 0.75) Reverse Inequ ualities Some interventions are not ap ppropriate. Hence e, a high rate fo or those interventions siigns a lack of appropriateness. Th his is the case fo or breast cancer screenin ng outside the tarrget groups (< 50 or ≥ 70 years). Since S the coverage is higher in the advantaged social group ps, the appropriateness is also worse in th his group. Missing data Unfortunately, for f a large numb ber of interesting indicators of qua ality, the socio-economic c inequality could d not be measure ed. Conclusions must be considered as largely incomplete e. The missing datta concern 14 indicators.v

v

Cancer 5-year 5 relative survvival rate after bre east cancer; Cance er 5-year relative su urvival rate after cerrvix cancer; Cancerr 5-year relative surrvival rate after colon n cancer; Deaths du ue to suicide (/100 000 pop); Patients who died within on ne week after sta art of palliative care c service (%); Hospital admission ns for asthma in adu ult patients (/100 00 00 pop); Caesarean n sections (per 1000 live births); Inciden nce of hospital acqu uired MRSA infection ns (/1000 ns); Incidence of p post-operative sepsis (/100 000 disc charges); admission Incidence of pressure ulcerss in hospitals (%); In-hospital mortality after hip %); Patients with ccancer discussed at a the multidisciplinary team fracture (% (MDT) me eeting (%); Number of contacts betwe een the patient and d the GP

8 8.2.2.4

KCE Reportt 196

Indica ators of the Healtth promotion dom main

Daily smoking and D d obesity present a high relative risk (respectively y 1.68 a and 2.11) betwee en the lowest and d highest educatio onal groups. For daily s smoking, the abso olute difference in rates is as high a as 8.9%. Moreove er, for d daily smoking and d obesity, a high Population P Attributtable Fraction (PA AF) is o observed (-36.1 % for smoking and -34.8% for obe esity). This means s that fo or those 2 factors, the inequalitie es have a large global impact on the p population health, and that a large gain g could be obta ained in the population h health if all sociial classes expe erienced the leve el of smoking/ob besity p prevailing in the more m educated gro oup. T The rate of overw weight people (de efined as the peo ople with a BMI ≥ 25) p presents more mo oderate inequalitie es, with a relative risk of 1.45 and a PAF o 14.7%. of F the determina For ants having a pos sitive impact on h health, a higher ra ate is g generally observe ed in the more educated classe es, meaning tha at the re elative risk will no ow be lower than 1. We observe im mportant inequalitie es for th he consumption of at least 200g of vegetables an nd 2 fruits daily (RR= 0 0.74, and PAF=13.1%). For physiical activity, the inequalities are rather r im mportant, with a RR R of 0.56 and a PAF P 12.3%. S Strong inequalitie es are observed in the level of social support, with 24.4% 2 o the people from of m the lowest educational level re eporting a poor social s s support, versus only o 10.1% for the t people of th he highest level. This re epresents a RR of o 2.4, and a PAF of -34.8%.

during the 3 last months of life e; Pain control durring hospitalisation (% of patients with pain always controlled).


KCE Report 196 6

125

No or weak ine equalities The daily cons sumption of fruitss or vegetables once a day sho owed no important link with w the social stattus. The link betwe een the consumption of alcohol and social status was not clear. Data by socio-e economic status were not available for: Decayed/ missing/ filled teeth at age 12 (mean sscore at age 12 2) and Incidence of HIV (/100 000 pop). qualities express sed with absolutte difference, rela ative difference, and summary measures m Table 29 – Ineq Overall value e (f)

Value in n lowest social s group (ff)

Value in higher social group (f)

Absolute difference d

Relattive Risk

Summ mary measu ure (CII or PAF F)

(lowest vs s highest)

(lowe est vs highe est)

Life Expectancy at a 25 in men, 2001 i; ii Life Expectancy at a 25 in women, 200 01 i; ii

51.38 8 57.09 9

47.56 53.98

55.03 59.9

-7.47 -5.92

n.a. n.a.

3.73% 1.43%

Healthy Life Yearrs at 25 in men, 200 01 i; ii Healthy Life Yearrs at 25 in women, 2 2001 i; ii

40.47 7 40.42 2

27.75 28.92

46.33 47.1

-18.58 -18.18

n.a. n.a.

15.30% % 16.56% %

% of the population (aged 15+) that assess their health as good or iii very good

76.8% %

57.4%

85.7%

-28.3%

0.67

11.6%

Delayed contactts with health se ervices because of o financial reasons (% of ho ouseholds) iv

14.0% %

27.0%

4.0%

23.0%

6.75

-71.4% %

Breast cancer screening (% women aged 50-69) v

60.1% %

48.6%

62.9%

-14.3%

0.77

4.7%

v

61.8% %

48.9%

64.2%

-15.3%

0.76

3.9%

54.0% %

48.0%

58.0%

-10.0%

0.83

7.4%

20.5% %

22.0%

13.1%

8.9%

1.68

-36.1% %

15.5% %

24.4%

10.1%

14.3%

2.42

-34.8% %

General Health h Status

Accessibility of o care

Cervix cancer scrreening (% women aged 25-64)

Appropriatene ess % of adult diabe etes patients receiviing appropriate carre, in terms of regular retinal exams and blood te ests v

Health promottion % of the population (aged 15+) that reports to smoke da aily iii % of the population (aged 15+) repo orting a poor social support s

iii

126


KCE Reportt 196

% of the adult population considered d as being obese (B BMI ≥ 30) iii % of the adult population conside ered as being ove erweight or iii obese (BMI ≥ 25))

13.8% % 46.9% %

19.2% 57.8%

9.1% 40.0%

10.1% 17.8%

2.11 1.45

-34.1% % -14.7% %

% of the population reporting to eatt at least 200g vege etables and 2 fruits per day iii

26.0% %

21.7%

29.4%

-7.7%

0.74

13.1%

% of the population reporting to pracctice at least 30 min nutes of PA iii per day

38.1% %

24.0%

42.8%

-18.8%

0.56

12.3%

i

in years; ii 5 edu ucational levels; iii 4 educational levels; iv 5 income levels; v 2 reimbursement categories; c rates are not adju usted for age; summ mary measures= CIII (Concentration Ind dex of Inequalities) relative r for life and health h expectancy, PAF (Population Atttributable Fraction) for all the other indicato ors Source: Health In nterview Survey and d EPS (WIV – ISP and a KCE calculation ns) PA: physical activ vity

KCE Report 196 6

8.2.3


Key fiindings

•

With regard to o general health s status: •

Life expec ctancy presents a strong increasing gradient with h the social pos sition. This gradient is still much more important with health exp pectancy. Inequa alities are observ ved in self-perceiived health.

•

Inequalitie es in those globa al and “end of co ourse” indicators s reflect inequalitie es in factors influ uencing them: so ocial and living conditions s, health determiinants, health sy ystem. Those sho ould be identified and tackled. With regard to o accessibility: •

Very large e inequality is ob bserved in the de elay of health carre for financial reasons. r

•

Moderate inequality is obs served in breast and cervix cance er screening.

•

On the con ntrary, for vaccin nation, it seems that the coverag ge in the disfavoure ed group is at lea ast as good as in n the favoured grroup (with some e partial data sho owing even a be etter coverage). This T is a good poin nt for the action o of preventive hea alth services.

•

Also the coverage c of the g global medical re ecord is better in the less advan ntaged groups. With regard to o the quality of ca are: •

For most of o the indicators, socio-economic inequalities co ould not be measurred. The conclus sions are incomp plete.

•

Moderate inequality was o observed for the surveillance of diabetic d people. With regard to o health promotio on indicators: •

Very impo ortant inequalities s are observed for f daily smoking g and obesity (w with a Population Attributable Fra action of more th han 30%). As obesity o and smoking are strongly y associated with a higher mo orbidity, tackling the inequality in n those factors represents s a top priority.

•

127

Inequalities are a also observe ed for overweightt, eating enough fruits and veg getables, and in a lesser extent ffor practising physical activity. Very importa ant inequalities are a observed for the social suppo ort.

8 8.3 8 8.3.1

Equity of the health systtem at a global level How did d we evaluate the e equity of the health system at a global le evel?

Equity is a controv E versial dimension n. Generally, equitty refers to “equality of s something”. Howe ever, there is a large heteroge eneity in the diffferent a approaches. Indee ed, vertical equity y is defined as the e unequal treatme ent of th he unequals and horizontal equity y is defined as e equal treatment of o the e equals. An examp ple of vertical equiity are tax system ms which are organized s that everyone pays taxes bas so sed on ability to pay. An examp ple of h horizontal equity is the attempt to provide the same e care to patients s who h have the same ne eeds. Equity implies therefore som me degree of solidarity b between the riche est and the poores st, between the h healthy and the sick. In a an attempt to reconcile solida arity and perso onal responsibillity115, a approaches have been proposed to define what should be equa alized a among individuals. Some propose to t equalize resourrces116-118, while others o p prefer to equalize outcomes119-121. These theories offer interesting lin nes of th hought and show w how the definitio on of fairness and how to achieve it, i are e essentially normattive issues and the erefore philosophical issues. T establish equity To y indicators in the e context of a repo ort on the perform mance o a healthcare sy of ystem requires an n approach as ne eutral as possible e and m must reflect societtal choices. In this s chapter, we havve evaluated the global g e equity of the health hcare system in an a indirect (or conttextual) way.


128

Belgium back kground: In Belg gium, some spe ecific measures such s as entitlement to increased reimbursement and the Omnio status have been taken to promo ote the financial a accessibility. The maximum billing aims to avoid “catastrop phic” health expenditures and othe er measures are targeting t categories of patients, p such as patients with ch hronic illness or children. c Several Belgia an studies, and their results, are e discussed in detail d in Supplement S2 2 of this report: “T The place of equity in assessmentts of the performance off health systems.”

8.3.1.1

Glo obal or contextua al indicators

Two contextual indicators are de escribed below: •

ssivity of the finan ncing of the health hcare system the progres

• the Gini co oefficient of inequa ality in income The progressivity of financing th he healthcare sys stem translates th he equity before using th he system. By p progressivity, we do not mean th he “cost sharing” at the e point of care (i.e. supplement, co-payment, c coins surance, non-reimbursab ble drugs, premiums to private insu urance …) but the e way to finance the public p system. A financing is defined as progressive (regressive) wh hen the average rate of “taxation”” (considered in a broad sense) is incre easing (decreasin ng) with the incom me. And the fina ancing is defined as prop portional when the e average rate off taxation is consttant. We characterize th he relative progre essivity of the mo ost important sou urces of financing of th he Belgian health hcare system: the e direct taxes are more progressive tha an the social conttributions which are more progress sive than are computed to describe the indirect taxe es. Simple ratios a d the prog gressivity of the financing g for the period 2 2005-2011. We do o not evaluate th he global redistribution effect e of the finan ncing and use of o the healthcare system because such an a evaluation implies the knowledg ge of individual da ata about consumption off care, all financing sources and ab bout the available income. These data are e not totally availa able for Belgium and a robust com mparison with other coun ntries is not possiible due to lack of o data. Wagstaff and van Doorslaer have e contributed in a substantive way y to the evaluatio on of the equity in financ cing and delivering g of healthcare but, b unfortunately, they do not mention Belgium in their work.122-128

KCE Reportt 196

We contextualize also the equity is W ssue by means off the income ineq quality m measured by the e Gini coefficien nt. Some authorrs have showed d the a association betwe een the income in nequality and som me indications off poor 1 o objective or subje ective health.100, 129-131 The Gini ccoefficient is simp ple to in nterpret and to co ompute for Belgium and internation nal organizations use it to o characterize the e income inequality in an internatio onal perspective. It has b been recently reco ommended by a WHO W workgroup which was workin ng on in ndicators for the "Health 2020 targe ets".132

8 8.3.2

Facts an nd figures

This section is a short summary of the T t detailed resultts which are prese ented fo or each indicatorr in the Supplement S1 of this re eport (available on the w website). The disparities of health status and health consumpttion are presented T d with th he indicators of the other dime ensions. The com mputation of the e two c contextual equity indicators (progressivity of the ffinancing and income in nequality) shows s that the public c financing of th he healthcare sy ystem b becomes less pro ogressive and th hat our redistribu ution system (tax x and trransfers) makes our o country one off the most egalitarrian in the world. T The public financiing of the healthc care system beco omes less progre essive e essentially for two o reasons: (1) the part of the regressive receipts (indirect ta axes) is increasin ng and (2) the part p of the progre essive receipts (direct ta axes and special contribution for social s security) iss decreasing. Glo obally, th hese two evolutions make the finan ncing less progresssive. N Nevertheless, the e Belgian society y is one of the m most egalitarian if we c compare the Gini coefficient pre and a after taxation n and transfers (s social a allowances). T These two results are not contradictory because the society can organ nize a s substantial income redistribution using u a large sysstem of transfers s and ta axes and finance e a specific colle ective sector (i.e. the public health hcare s system) using re esources (taxatio on and contributions) which are little p progressive.


KCE Report 196 6

129

Table 30 – Pro ogressivity indica ators of the finan ncing of the public healthcare sys stem (2005-2011) Indicators of progressivity p

2005 (final accounts)

20 006 (final ac ccounts)

200 07 (final acc counts)

2008 (prov visional acco ounts)

200 09 (pro ovisional acc counts)

201 10 (bu udget)

2011 (budg get)

Ratio proportio onal receipts/tottal receipts Ratio progress sive receipts/tota al receipts Ratio regressiv ve receipts/total receipts Total

71.1% 18.9% 10.0% 100.0%

71 1.0% 19 9.0% 10 0.0% 10 00.0%

72.0 0% 18.0 0% 10.0 0% 100 0.0%

70.6% % 17.3% % 12.1% % 100.0 0%

69.4 4% 17.2 2% 13.4 4% 100 0.0%

64..8% 19..4% 15..8% 100 0.0%

61.4% % 18.4% % 20.2% % 100.0% %

Source: Vade me ecum de la sécurité sociale, RIZIV – IN NAMI, KCE calculatio on

Figure 38 – Gin ni coefficient beffore and after tax xation and transffers (1998-2010): Belgium and in nternational comp parison

Source: DGSIE (Belgium) ( and OECD D Health Data 2012 2 (international comp parison) Note: the Gini coefficient is a coefficient for inequality off income in a popula ation. When there is s perfect equality (e everybody has the same s income, the co oefficient is 0). Whe en nequality, the coefficcient is 1 (one perso on has all the reven nues). A lower coeffi ficient indicates a more equal distributio on of the incomes. there is perfect in


130

8.3.3

Key fiindings

Equity in finan ncing •

Public fina ancing of the Belgian healthcare system become es less progressiv ve, certainly sinc ce 2005.

•

The intern national comparis son of the progre essivity is not re elevant because of o the great diverrsity of systems. Income inequa ality •

Income ine equality in Belgium is relatively high h before the redistributtive impact of tax xes and transferrs.

•

Thanks to the system of ta axation and trans sfers, Belgium is s one of the most egalitarian e counttries.

•

The high level of income rredistribution and d the more egalittarian distributio on of disposable incomes should d have a positive impact on Belgian n population hea alth.

KCE Reportt 196

9 TOWAR RDS A MOR RE COMPR REHENSIVE HEALTH H SYSTEM PERFORM MANCE ASSESS SMENT: AD DDRESSIN NG CURRE ENT SHORTC COMINGS In n this section, we w identified 10 limitations that sh hould be addressed to im mprove the evalu uation of the hea alth system perforrmance. Those is ssues re elate to the lack of suitable indicators, the lack off data, the need for a b better indicator or for more details. Some of the following conclu usions re esult from the ma any indicators for which we could not find any data a (see s section “Indicators s under developm ment” in Supplem ment S1 of this re eport, a available on the KCE website), and a from the disccussions with Be elgian e experts. An indicator off global health status with p A potential for ac ction: a avoidable/amena able mortality The previous rep T port included one e indicator of hea alth status which h was p premature mortalitty, expressed as potential years off life lost (PYLL) before b th he age of 70 yearrs. This indicator was w too general, limiting the potential of a action and was no ot retained in this report. Instead, th he avoidable/amenable m mortality expresse ed by group of ca auses could be more informative fo or the m measurement of the effectiveness of health servicess. A recent EU fu unded p project established the list of cond ditions for which variations in mo ortality b between countrie es are likely to reflect variation ns in performanc ce of h healthcare system ms.133 This indicato or could replace p premature mortalitty in a fu uture set of perforrmance indicators s. F Financial accessibility: need for a more comprehensive picture While the coverage of the compulso W ory health insuran nce is quasi exhau ustive in n terms of the proportion p of the e population cove ered, part of cov vered s services is paid directly by patients s. Out-of pocket p payments remain high, a and 14% of the people p report to delay healthcare e because of fina ancial re easons (with a strrong gradient with h household incom me). Several prote ection m mechanisms werre introduced to o maintain a financially acces ssible h healthcare system m. Examples are lu ump sums for the e chronically ill an nd the m maximum billing system (MAB).1334 In addition to these publicly-fu unded

KCE Report 196 6


mechanisms, in ndividual private insurances reimb burse several he ealthcare services. A pre erequisite to guide e policy within this domain is an im mproved transparency in n ambulatory sup pplements as we ell as in private hospital insurances (the e percentage of p people with private e hospital insuran nce, and what is specifically covered by th hese private insura ances).135, 136 unts: better data a on the supply side available, but b data Workforce cou on the need side still lacking An effective he ealthcare workforcce planning shoulld be considered within a global policy tak king into account supply and patien nt needs. Data on the sup pply side Current head counts c of practissing physicians undoubtedly repre esent an improvement of the information compared with the former situatio on when the medical workforce was esttimated by the total t number of licensed medical doctorrs (regardless off whether they worked w in the he ealthcare sector or not). However, H the rea al activity level of physicians was not taken into account. Since S 2009, this ccount is conducte ed by the RIZIV – INAMI, which evaluate es the number of full-time equivalents (FTE) of o active physicians. Fo or the first time, preliminary counts of the num mber of practising nurse es by sector of acctivity are now ava ailable. However, the density of pracctising healthcare e workers is diffficult to interpret, as no n optimal density to meet popu ulation needs ha as been defined. Interna ational comparisons are of little hellp here since they y are not interpretable without w taking into o account the org ganisation of care e, which varies across co ountries. Data on the nee ed side Workforce plan nning also require es information on n the need/demand side, information thatt is currently scarcce. Indeed, several informal sourcess point out that th he needs are insu ufficiently met, at least as s far as the nurse workforce is conc cerned. It is widely known that there is ge eneral lack of nursses in the Belgian n hospitals. Moreo over, the continuously rising and changiing demand for health services, due to ageing popula ations, technolo ogical advances s and higher patient expectations, re equire a larger and more skilled nursing workforce.1337

131

Macro-level data on the needs sh M hould be complem mented with data a that re eflect the situation n at the micro leve el. An example off micro data is a recent la arge-scale Europ pean nursing worrkforce study bassed on survey da ata. It illustrated that in Belgian B hospitals nurses have, on average, to take e care fo or more patients compared c to othe er EU countries.799 More nurses rep ported to o be dissatisfied d with their job and a have the in ntention to leave their jo ob.79,138 N indicators of the needs have been No b defined yet in this report, bu ut the re eflection should continue c on this to opic. Mental healthcare: current ind M dicators do nott reflect the re ecent c changes in the se ector In n the field of men ntal health, the currrently available in ndicators do not reflect r th he recent major changes c in the se ector. Indeed, sincce the end of the e 20th c century, a strong de-institutionalizat d tion movement in the mental health hcare s sector has led to the developmen nt of new modelss of organization. One m model, the “balanced care” model m is gaining g influence in most in ndustrialized countries.139 It implie es that community services should be o offered wheneverr possible, while hospital servicess should be ava ailable w when ambulatory care cannot pro ovide a good an nswer to the pattient’s n needs. In n Belgium, the most m recent reform m efforts to attain a balanced integ grated c care model focus on the developm ment of “care ne etworks” (the so-c called “A Art. 107 project”) oriented to 5 func ctional modules: 1. Prevention an nd promotion of mental m health; 2 Intensive, com 2. mmunity based, trreatment teams fo or acute as well as a for chronic physic cal conditions; 3 Rehabilitation teams focusing on 3. o social integratio on; 4 Intensive res 4. sidential teams for f acute and cchronic mental health h problems thatt require inpatient treatment; 5 Specific residential facilities in which care can b 5. be provided in a home or home-repla acing environmentt.140

132


Some indicatorrs can be propossed to monitor th hese evolutions (e.g. ( the percentage of patients with case manageme ent; the percen ntage of expenditures sp pent on communiity care compared d to total expenditures on mental health care). They co ould not yet be measured beca ause of limitations in the e current data. Insstead, we had to rely on general in ndicators (e.g. suicide rattes) or indicators focusing on the psychiatric p hospittalization episode (e.g. re e-admission rates; involuntary comm mittals). At internationa al level, despitte several perfformance measurement initiatives, a rec cent survey of tw wenty-five EU countries noted that data on suicide rates an nd the number of psychiatric beds were w readily availlable but other data we ere scarce.141 E Efforts are unde ertaken by interrnational organizations such as the OECD D62 to propose indicators specific fo or mental healthcare. How wever, the operational developmen nt and data availability are often limited. For F instance, desspite the inclusion of “Persons ag ged 65+ years prescribe ed antidepressantts using an antich holinergic anti-dep pressant drug (%)” in the OECD shortlistt for mental healtthcare indicators, there is no operational development o of this indicator. What’s more, the few published stud dies disagree a about what is an antidepressa ant with anticholinergic side effects.63, 64 As a con nsequence, interrnational comparison off mental healthcare system pe erformance is seriously s hampered. Continuity and d coordination off care: new data soon available with w the new pathways s in ambulatory c care, but still man ny gaps remain The fact that new n pathways in n ambulatory carre for type 2 dia abetic or chronic renal fa ailure patients were recently started and are currenttly being evaluated, show ws the importance of the coordination of care for th he policy makers.142 We plan to include the results of th hose projects in the t next edition of this re eport. Some other rele evant indicators h have been identifie ed, for instance: •

The experience of the patien nt with regard to the t coordination of o his/her care. Som me countries such as the Netherlands, France e, U.K., Germany, Canada, U.S. or Australia20, 143 have performed specific surveys to answer that quesstion. This indicato or, although being g central, is currently y still not measure ed in Belgium.

•

The availab bility of the whole e health informatio on of a patient at any a time by all care e providers is a ccentral question, linked to the one of the

KCE Reportt 196

patient electrronic medical re ecord, and to th he access to it. Two indicators under developmentt reflect this issu ue: the % of ge eneral practices with h access to the ho ospital data of theiir patient, and the e % of patients for which w information on o medication pre escribed at any setting is accessible at any setting. So ome initiatives are e already in place, such as the “Rése eau Santé Wallo on” (https://www.rreseausantewallon n.be/) and pilot pro ojects are being g run, such as Vitalink in Flan nders (http://www.vitalink.be/), but without many conne ections between them, t and currently without much da ata to evaluate the em. In this matte er, the e-Health platfo orm should have an important role to play. P Patient centeredn ness: many initia atives but few da ata Patient centeredness is intrinsically difficult to mea P asure with quantitative d data, because it is related to the health system’s ability to succes ssfully a answer to the partticular needs of th he patient or to e encourage the pattient’s in nvolvement. To effectively me easure this, th here are two main m methodological ap pproaches used:1444 • •

Self-report me easures of doctors s’ patient-centered dness;145

External obse ervation of consultation process: rrating scales or verbal v behaviour cod ding system. In n Belgium, the Health H Interview Survey S (HIS) is a major source off data s self-reported by the t population. Itt provides a mea asure of the pattient’s s satisfaction with th he health system m, an indicator tha at has been discu ussed a above, but which is subject to many critiques, both h on the validity of o the c concepts and on n the measures of satisfaction.777, 78 To improve e our u understanding on patient experienc ces, in the next wa ave of the HIS the e item o satisfaction willl be replaced by a question on th on he patient’s experrience w with ambulatory healthcare h servic ces (GP or speccialists), based on the O OECD questionna aire.15 Patient exp perience with ambulatory care willl thus b included in the following update of this report. be P Patient centeredness is neverthele ess a matter of co oncern for the Be elgian h healthcare system m: several initiatives have been launched in Belgium. T Three of them arre described belo ow. These 3 initiatives emphasize the c commitment of the t healthcare system to the patient centered dness a approach. More detailed d analysis should be perforrmed to evaluate their q quality.

KCE Report 196 6


First, since 2003, an ombudsm man service existts for managing patients’ complaints in public p hospitals. T This service reco ords the number and the motive of comp plaints each year but does not assess the justification and the follow-up of o the complaints. In 2010, 16 907 7 records were re egistered versus 9 026 in i 2006. Howeve er, these numberrs should be interpreted carefully: more registered comp plaints can refer to declining serv vices but also to more effective ombu udsman services s in terms of visibility, v availability, com mprehensivenesss of the recording… or a change e in the patients’ culturre of complaints. There is also an a international trend to develop a similar indicator for assessing the existence e of a co omplaint resolution proc cess in general p practice146-148. In Belgium, this is not yet operational. Second, since 1999, general and psychiatric Belg gian hospitals can n ask for financial suppo ort to create a po ost of interculturall mediator or inte ercultural mediation coorrdinator. Linguisttic and cultural barriers have in ndeed a negative impac ct on access an nd quality of carre. In 2009, inte ercultural mediators have e done more than 80 000 interventions in 17 languag ges. The mode of organ nization is hospita al dependent: one e or several med diator(s); availability durin ng office hours on nly or also very ex xceptionally during g out-ofhours in case of o an emergencyy. The coordinatio on cell of the FPS S Public Health ensures s the follow-up a and the assessme ent of the reques sts. The assessment en ncompasses patie ents encounters, care providers training, booklet editing... However, an asssessment of real patients’ (or phy ysicians’) needs and responses quality iss lacking. Moreov ver, it remains difficult to comply to all language translatio ons (no less than 170 different nationalities are taken care of in some hosp pitals). In this co ontext, a pilot pro oject has started recently (2012) to allo ow mediation support by internet (video conferences). In this pilot projecct, a network is set s up between hospitals h with intercultura al support and allso local medical home or health centres. This project willl be evaluated eacch year. Third, some pilot projects are rrecently launched in Flanders to stimulate s the patients' involvement in deccision concerning their disease in hospital quality manage ement systems. In n 2013, several public p hospitals will w allow the participation of patients’ rep presentatives in their t board of go overnors. Measurement of o quality indicatorrs is soon expecte ed in this domain.

133

Long-term care: no data currenttly, waiting for fiirst results using L g the B BelRAI assessme ent Long-term care in this report reffers to long-term L m care for the elderly e n needing assistanc ce (mainly in resid dential care or recceiving home care e) and lo ong-term care rela ated to mental he ealth problems. Indicators from the latter to opic have been diiscussed above. S Some indicators have been chos sen to assess th he long-term carre for d disabled elderly pa atients, as the pre evalence of malnu utrition in elderly being in n residential care e or receiving ho ome care (BMI <1 19), the percentage of e elderly physically restrained, the prevalence of fa alls, the incidenc ce of p pressure ulcers an nd the problem off polymedication. T Those indicators could n been measurred, which highliights the currentt lack of data in not n this d domain. However, the BelRAIw willl soon provide data on some selected in ndicators. A the international level, a working group from th At he OECD is currrently d developing a proje ect specifically fo or long-term care445, focusing on qu uality. T proposed fram The mework for monito oring and improving quality in long g-term c care services will be based on the t national fram mework of six OECDc countries (Australia, Canada, Englland, Finland, the e Netherlands and the U United States). This T framework prioritised p care efffectiveness and user s safety as key quality q dimension ns, followed by patient centered dness (including respons siveness, empow werment and com mmunication) and care c coordination and integration. The final phase in the report is s the d development of po olicies to achieve quality in long-terrm care and to address th he shortcomings. The release of th he report is planne ed for the end of 2012. 2

w

The Residen nt Assessment Ins strument (RAI)44 is originally develop ped to assess the care c needs of the elderly in institutio ons, and has later been extended witth instruments for different care setttings and subgroups. In Belgium a national n pilot projec ct (the BelRAI) is ongoing, but is no ot yet implemented in all care setting gs. The assessmen nt instruments for home care, for long g-term care facilities s and acute care ha ave already been ad dapted to the Belgia an situation. Data are a expected before e the edition of the e next performance report.

134


Efficiency deserves more atten ntion in future re eport Obviously, effic ciency in healthcare cannot be sufficiently assessed with the few indicators selected in thiss work. International literature proposes p 8 16 efficiency meas sures which explicitly identify inpu uts and outputs.8, This could certainly be an interesting area of research. udies in Belgium m, but few national data End-of-life carre: many local stu The few indicattors measured in this report are ba ased on the popu ulation of patients dying from cancer, orr on the populatiion of patients receiving r palliative care at home. This d does not cover the whole popullation of patients eligible e for palliative care, which highliights a real gap in data availability. Morreover, so far no data at national le evel have been published on accessibility y nor on quality off end-of-life care in Belgium. Resu ults from local studies (e especially from Fllanders) are well available, but arre based on restricted nu umber of patientss, do not allow stu udying evolution of o trends over time, and hence cannot be e included in a pe erformance reporrt whose aim is to be rep produced every fe ew years. Compa ared to the other domains d of care, end-of--life care is little o or not at all repres sented in databas ses from international org ganisations. Health promottion: data on health literacy are lacking, while they t are already availab ble in other Euro opean countries Health literacy is a relatively new w concept conside ered as a crucial resource r in health manag gement. It can be e defined as the individual skills ne ecessary to understand and a manage facto ors interacting with h one’s health. Th his gives individuals the opportunity to ma ake healthier cho oices. It has been defined as a priority of action a for the 200 08-2013 European n Union strategy. Different D tools have been n used in the worrld to measure it. The European prroject on health literacy has developed a comprehensive questionnaire aiming to build and valida ate 12 indicators. Those intend to measure various aspects of health litera acy. A first surve ey occurred in Eu urope in 2010-20 011, but Belgium did nott participate.97

KCE Reportt 196

1 GENERA 10 AL CONCL LUSION This report prese T ents the results of a first glob bal evaluation of the p performance of the Belgian health system, building on a former feas sibility s study. By means of seventy-four indicators with n numerical values s, this re eport intends to o provide an ov verall overview o of the health sy ystem p performance, poin nting to some dire ections for policy a actions and generrating q questions for further follow-up or res search. Itt represents a sub bstantial improvem ment over the pre evious report, by being m more comprehens sive and by upda ating the former sset with more relevant in ndicators. Moreo over, it allows in some cases the measurement of e evolution. Also, im mportant previous s gaps in basic data have been filled s since the last edittion, like the caus se-specific mortality rates or the ca ancer s survival. B Belgium is not the e first country hav ving exercised th his challenge. Witth the s signing of the 200 08 Tallinn Charter on health system ms, the Member States S fo ormally committed d themselves to the t monitoring an nd evaluation of health h s system performan nce. Several neiighbouring counttries, having yea ars of e experience with health system performance p mea asurement serve ed as e example for this report. r This is ce ertainly true for th he Dutch Perform mance R Report. One of the weaknesses s hampering successful perform mance m measurement (als so identified in forrmer Dutch performance reports) is the a availability of up to o date data. Regu ular updating of a administrative data a and d dynamic publishin ng of results on n a website could partially solve e this p problem. Yet, this is only one of the e options that can be considered if policy p m makers commit th hemselves to a sy ystematic measurrement and monittoring o the performance of e of the Belgian health care system m.


KCE Report 196 6

135

APPE ENDICES S APPENDIX 1. LIST OF INDICA ATORS ME EASURED IN THE 2012 REPOR RT, CLASSIFIED BY LTH SYSTE EM, DOMA AIN OF CAR RE AND DIIMENSION TIER OF THE HEAL Health Status • • • •

Life expec ctancy Health exp pectancy Self-perce eived health Infant morrtality rate Healthcare e Dom main of care

Dimension

Gen neric

Preventiv ve Care

Accessibility

•

•

• • • •

Number of practtising physicians (per 1000 population) Number of practtising nurses (per 1000 population) health h Coverage insurance status of the population Amount of copayments and out-ofpocket payments s % of people who delay con ntacts

• • •

erage breast Cove cance er screening Cove erage cervic cal cancer scree ening Cove erage vaccination coverrage children Cove erage influe enza for vaccination elderly

Cu urative Care

Long-tterm care (elderly y/mental health))

End-of-Life Ca are

•

•

•

Nu umber of beds in res sidential care fac cilities per 65 population years and older % of population over 50 years old porting to be an rep info formal carer

% of pa atients who died within w one week after of start palliative care service


136

KCE Reportt 196

because of fina ancial reasons •

Quality - Effectiveness

•

•

• •

Quality Appropriatene ess

•

Quality - Safety

•

Medical

radiiation

% of women aged 40-49 years old who w had a mammogram within n the last two years s % of women aged 70-79 years old who w had a mammogram within n the last two years s

• •

• •

•

5-year relative survival rate e after breast cance er, by stage relative 5-year e after survival rate cervix cance er, by stage relative 5-year e after survival rate colon cance er, by stage missions Hospital adm for asthma Prescription of antibiotics ac ccording to guidelines % of adult diabetics propriate receiving app care, in terrms of regular retinal exams and blood tests s Geographic va ariability in caesarean sections s (per 1000 live births) b Average daily quantity q of medication (antidepressan nts, antipsychotics,, and hypnotics anxiolytics) prescribed Incidence of hospital

• •

•

Su uicide rate Ra ate of involuntary committals as a percentage of all hospitalizations per year articipation rates Pa by people with me ental illness of wo orking age in em mployment

•

% of ca ancer patients receiving chemotherrapy in the las st 14 days of life e


KCE Report 196 6

exposure population

of

the • • • •

Quality - Contiinuity Care

of

• •

•

•

Assessment of o pain during level hospitalization

•

% surgical day y-case

Quality - Patient centeredness

•

Satisfaction with health care servic ces

Equity

•

Indicators of the progressivity of public p healthcare financ cing Gini coefficient before and after taxation n and transfers

•

Efficiency

•

acquired MRSA infections Incidence off postoperative seps sis Incidence of pressure p ulcers in hospittals In-hospital mortality m after hip fracture s aged % of persons 65 years or older prescribed antidepressantts using an anticho olinergic antidepressantt drug

Coverage of global g medical record Usual providerr of care index

% prescription off low-

•

137

% of cancer patients discussed a at the multidisciplinarry team meeting hysician % of ph after encounter hospital discha arge for elderly patients s (65+)

•

% of discharges fro om psychiatric incare patient rea admitted to psy ychiatric inpatient care that occurred within 30 days (sc chizophrenia, bip polar disorder)

•

Number of contacts between the patient and d the GP in the last 3 months of life

•

Patients dying in their usual place of residence


138

Sustainability

• • • • •

cost drugs

•

Average leng gth of normal stay for delivery

Medical gradu uates becoming GP Mean age of GP es Nursing graduate % of GPs using an electronic medica al file Health expenditures (total, distribution, % of gross dom mestic product, per capita)

•

Acute care be ed days (number per ca apita)

Health Promottion Type of indicator

Indicattor

Health outcom mes

• • •

% of overweight or obese adults Av verage number of decayed, missing g, filled teeth in ch hildren at age 12 Inc cidence of HIV

Intermediate health outtcomes: healthy lifes healthy styles and environments

• • • •

% of daily smokers cohol drinkers (3 indicators) % of problematic alc ption of fruits and vegetables v % of daily consump a % of daily physical activity

• • •

% offer of physical activity a at primary y and secondary le evel in schools unicipalities % health promotion policies in the mu d in their school project % of schools with health promotion dimension

• •

% of persons with poor p social supporrt obacco Control Sc cale To

Health promottion outcomes

KCE Reportt 196

KCE Report 196 6


139

APPENDIX 2. LIST OF CHANG GES TO IN NDICATOR RS COMPARED TO TH HE 2010 REPORT This section listts the modification ns that were done e to indicators sinc ce the 2010 reportt. Indicators for which no data were e available in 2010 0 are in red. Indicator in 20 010 report

Status in n 2012 Report

Accessibility A1: Number off physicians and d nurses No data available for the numb ber of nurses in 2010 2

Some data available in 2012

A4: Coverage of preventive ch hild health care

Removed d in 2012 Rationale e: this indicator was w defined as an n indicator of acccessibility, as its initial aim was to t focus on infantts from underprivilleged families (de efined according to six criteria) or o infants from migrants. The previious report showe ed that only resullts at national level were availa able, which makes s it less interesting as an indicato or of accessibiility.

A5: Additional illness-related c costs for chronic cally ill people No data available in 2010

Removed d in 2012 Rationale e: The calculation of additional illness-related co osts for chronically ill people would w require a go ood definition of chronic diseasess and a cost-of-illness study of each identified chronic c disease. This is a projectt in itself, and is s not feasible within w the time-frame of the presentt project.

Quality QA1: Prescrip ption according tto guidelines (Urinary tract infec ction, acute otitis me edia, uncomplica ated hypertensio on) No data available in 2010

Modified in 2012

QA3A: Utilisattion of minimal a and non-invasive e surgical techniiques (laparoscopic cholecystectomies, PCIs)

Removed d in 2012 Rationale e: the use of minimal-invasive tech hniques is a mea ans for reducing postp operative e complications, le ength of stay and d costs. It is therefore an indicato or of efficiency y. However, thes se techniques arre not considered appropriate fo or all patients and careful patie ent selection is necessary. The use of these ne ewer minimal-invasive techniques is also consid dered to be an indication of innova ation (sustaina ability). In 2012, la aparoscopic cholecystectomies an nd PCIs are standard interventions.

140


KCE Reportt 196

QA4: Percenttage of institutions that use special s protocols or guidelines outlining proced dures for hig gh-risk or com mplex processes

Removed d in 2012 Rationale e: this indicator, originally o from the e Dutch healthcarre performance set of indicators s, could only be estimated via the diffusion d and use o of clinical pathways in Belgian hospitals, h and was s furthermore bas sed on non-valida ated results. No better b data will be b available in the e near future.

QA6: Hysterec ctomy by social c class

Removed d in 2012 Rationale e: the results for 2010 2 showed no differences in hysterectomies rate es by social cla ass, and hysterectomies rates ha ave been declinin ng steadily since e the publicatio ons on which this indicator was orig ginally based.

QC1: Number of people who are not registered d with a GP

Modified in 2012 Rationale e: as the concept of “registered with h a GP” in Belgium m refers to the GM MD – DMG, this indicator was redefined r more sp pecifically as “percentage of popula ation with a GMD G – DMG”. It was also chang ged into a posittive indicator (higher percentag ge indicates bette er coverage).

QC2: Average length of stay (L LOS) in acute carre hospitals

Modified in 2012 Changed to more specific LOS for normal delivery Rationale e: this indicator wa as previously seen as an indicator of the good continuity of care. However, experts were convinced that it was mo ore indicative of how efficient the t healthcare sy ystem is. Instead of all hospitalizattions in acute carre, a specific diagnosis d was cho osen: LOS for norrmal delivery, whicch is also an indic cator used by the t OECD.

QE03: Colorec ctal cancer scree ening No data available in 2010

Some data available in 2012, but data still to oo premature to p perform evaluation n

QE06: Acute care hospitalization rates for f pneumonia and influenza

Modified in 2012 Rationale e: this indicator is s a measure of effectiveness e of p preventive care. Since S the mostt effective preve ention measure against influenza a and pneumoniia is vaccinatio on, which is alre eady an indicato or for influenza, makes the indic cator redundan nt. It was modifie ed into “Acute care hospitalizatio on rates for asthma”, which is also a an indicator used u by the OECD D.

QE07.3: Salt co onsumption

Removed d in 2012 Rationale e for exclusion: the results for thiis indicator were based on a Belgian study pub blished in 2008, which w will not be re epeated.

KCE Report 196 6


141

QE08: Breast feeding f at 6 mon nths of age

Removed d in 2012 Rationale e: a new set of ind dicators to assess s performance of health promotion was proposed d, and experts did d not retain this in ndicator, mainly b because six month hs of exclusive e breast feeding is s hardly compatiblle with the length of the maternity le eave in Belgium m. Moreover, the previous report showed s that data from Kind and Gezin G and ONE E were not compa arable, due to diffe erent time framess used (KG: 3 mon nths, ONE: 24 weeks).

QE09: Annual check-up at the dentist for children

Removed d in 2012 After a th horough examinattion of the nomen nclature codes, it appears that it is s not possible to t isolate preventive care at the dentist for children.

QE10: Decayed d, missing, filled d teeth at age 12 No data available in 2010

Some data available in 2012

QE11: Cardiov vascular screenin ng in individuals s aged 45-75 No data available in 2010

This indic cator was removed. Rationale e: this indicator wa as not measurable in the 2010 report because of lac ck of specific nomenclature n cod des. Since 2011 cardiovascular c pre evention is part of the new GMD D – DMG+, which will be monitored d.

QE12: Colon Cancer C 5-year survival rate No data available in 2010.

Data available in 2012 Source: Belgian B Cancer Re egistry

QE13.1: Prema ature mortality. No data available in 2010

Removed d in 2012 Prematurre mortality, exp pressed as Pote ential Years of Life Lost (PYLL L) is correlated d with indicators already in the set (infant mortality, life expectancy) and has no potential for actiion, as it does not highlight the e potential proble ems. Avoidable e mortality would be a better indica ator.

QE14: Breast Cancer C 5-year su urvival rate No data available in 2010


QE15: Cervica al Cancer 5-year s survival rate No data available in 2010


QE16b: In-hos spital mortality a after community--acquired pneum monia (CAP)

Removed d in 2012 Rationale e: this indicator was w linked to the indicator “QE16a a: In-hospital morrtality after hip fracture”, both be eing indicators in ncluded in feedba ack on quality of care

142


KCE Reportt 196

sent by th he FPS Public He ealth to Belgian ho ospitals. During th he review process s, the team dec cided that the lattter indicator, mo ortality after hip fracture, was a better b indicator than mortality afte er CAP, to assess s safety of care (a and not efficacy, as a in the 2010 report). QS1: Incidence e of serious adve erse effects of blood transfusion n

Removed d in 2012 Extremely y rare events, so difficult to interpre et evolution over ttime.

QS2: Incidence e of healthcare rrelated infections s

Removed d in 2012 Changed to prevalence of HAI, currently no data. Rationale e: this indicator is not measurable (no surveillance syystem can monito or the incidence e of all healthca are related infecttions). This indiccator has thus been b redefined d more specifically as “the incide ence of hospital-a acquired bloodstrream infection””, which is measurrable.

QS4: Incidence e of post-operatiive surgical site infections

Changed to post-operative e sepsis Rationale e: this indicator ha as low coverage, in terms of numb ber of hospitals an nd of type of operations covered d. It has been cha anged into “incide ence of post-opera ative sepsis”, which can be measured m by adm ministrative data, and hence inclu udes national coverage c and a wider w range of inte erventions. It is also included in OECD indicators s.

QS5: Incidenc ce of pressure ulcers in long-terrm care facilities s and individuals at risk No data available in 2010

Data not yet available in 20 012 (but soon). Source: BelRAI B

Sustainability S1.1: Amount reimbursed by th he maximum billling system

Removed d in 2012

S2: Qualificatio on levels of heallthcare providers s

Modified in 2012.

S4: Yearly amo ount of the Spec cial Solidarity Fun nd (SSF)

Removed d in 2012 Rationale e: the SSF acts as s a safety net, bes sides the compulssory health insura ance, and decis sions to reimburse e treatment are based b on a case p per case basis. It was included in the previous set s as a sustaina ability indicator, sshowing the syste em’s t be responsive to emerging need ds. However, treatments reimburse ed by capacity to

KCE Report 196 6


143

the SSF are usually thos se waiting for ap pproval by Europ pean Medical Age ency (EMA), and a are reimburse ed by compulsory y health insurancce after this appro oval. This is th hus not a very re elevant indicator of the sustainability of the health hcare system. S6.1: Number of acute care beds (per 1000 pop pulation)

Removed d in 2012 Rationale e: this is a second dary indicator link ked to the indicato or “S6 acute care bed e it also accounts for days, num mber per capita”.. The latter was preferred p because occupanc cy rate and length h of stay.

144


renal failure on 31 October 2011.142 But the exact denominattor is currently unkn nown. This item will w be estimated by the ACHIL project which aims to o evaluate the pathways for chroniic care. Evaluatio on will be presented in May 2013. Source of data a: ACHIL project

APPENDIX 3. LIST OF INDICA ATORS RABLE IN A NEAR FU UTURE MEASUR This appendix lists the indicattors that were selected s as perttinent to evaluate the pe erformance of the Belgian health sy ystem, and for wh hich data will be available e in a near future e (i.e. in a 3-years s time frame). The e idea is to present those e results in the ne ext issue of this re eport. For each indica ator, a short ration nale is provided, and a (future) source e of data are indicated. Health Promotio on •

% of peop ple (aged 45-75) with a global medical mecord+ (GMD – DMG+) (specific ( consu ultation on health promotio on and preventive e care) The global medical record iis a medical file centrally c managed d by the GP. The GMD – DMG+, introduced in April A 2011, conta ains an additional component c of pre evention and healtth promotion. The e GP can play a major role in health p promotion. It is th he right person to make a state of play p of risk facctors, organize preventive interv ventions (vaccinatio on and screening)), and counsel forr healthy behaviours. The GMD – DM MG+ is a tool to help the GP in this task. Monito oring the coverage of the GMD – DMG+ is thus an indicator off health promotion. Source of data: d RIZIV – INA AMI Continuity of ca are •

Percentag ge of patients re egistered in an ambulatory a pathway for chronic ca are (diabetes/ren nal failure) and frequency of ph hysician encounterr for patients registered in an ambulatory a pathway for chronic ca are (diabetes/ren nal failure) Pathways for f chronic care a are set up in Belg gium since 2009. The aim of these pa athways is to imp prove follow-up and collaboration between b patients with w chronic diisease, general practitioner, specialist s physicians and other h healthcare profes ssionals. Becau use the registration n in a pathway is voluntary, the e percentage of patients registered in the pathwayss of care is a indicator of the patients’ participatio on in this public invvestment. Accord ding to the RIZIV – INAMI, there were e 20 176 registered pathways for diabetes and 15 428 for

KCE Reportt 196

•

% of visits to the Emergen ncy Rooms in g general hospitals for mental health h and/or substan nce-related probllems Although unfo oreseen and unav voidable emergencies do arise in mental m health, menta al health related emergency room m use is used as a an indicator of poor p coordination n of care and se ervice failures.1499 The community trreatment system to support servvices for people with mental health h related proble ems is regarded as ineffective when utilization rate es of emergency y departments of general hospitals are high.150 Highly y accessible outpatient care is con nsidered to help people to enter treatment before reac ching the crisis sttage and minimiz ze the need for eme ergency room vis sits.149 In additio on, it is assumed d that effective liaiso on between emergency rooms an nd mental health crisis resources red duces the use of o emergency roo oms for mental health h services/clients. High rates of mental health rellated emergency room visits are no ot only a concerrn for members of the mental health h community. It is also a concern c that em mergency departtment overcrowding results in decreased quality off care and incre eased likelihood of medical m error.150 In the US, it has h been illustrate ed that mental hea alth related emerg gency room visits arre on the rise for more m than one de ecade.151 This stre esses the importanc ce of the availab bility of expertise in the field of mental m health in emergency rooms to manage m these crises. Depending on o the number of visits for psychiatric problems, availab bility of a mental health h specialist in every e emergency room may not b be practical. Still, there should be a minimum protoco ol by which mental health expertise is accessible forr immediate care for f every citizen.1552 Source of datta: RHM – MZG since s 2008 (inform mation not availab ble in RCM – MKG). Due to delays in n accessing the da ata, this indicator could not be measured in this report.

KCE Report 196 6


Patient-centere edness

•

Evolution ov ver time in utiliz zation of BelRA AI (home care an nd in institution) Source: BelRA AI

•

Prevalence of o malnutrition by y elderly (BMI <19) Older person ns are particularrly vulnerable to o malnutrition du ue to complications s such as changes s in appetite and energy level, che ewing and swallowin ng problems, cha ange in nutritionall requirements, lo oss of cognitive fun nction and deterriorating vision.1555 The data forr this indicator will be available in the BelRAI dattabase. This indicator belongs to th he set of indicators in the OECD long-term care quality q project.45 Source of data a: BelRAI

•

Patient experiences with a ambulatory services Patient-cen ntered care is supported by good provider-patient communica ation so that patie ents’ needs and wants w are understtood and addressed and patients und derstand and partticipate in their ow wn care. A good com mmunication is no ot easy as it requires several competencies (listening, explaining, courttesy…) In 2011 the t OECD has edited e a questionna aire on patient exxperiences with so ome questions re elated to the quality of the consultatio on.15 The WIV – ISP decided to in nclude in the Health h Interview Survvey (2013) the module of the OECD instrument dedicated to the patient experienc ces with ambulatorry care. Source of data: d next Health Interview Survey,, WIV – ISP Long-term Care e The majority of indicators will be based on the BellRAI project x

x

The Resid dent Assessment Instrument (RAI)44 was originally deve eloped to assess the e care needs of the e elderly in institution ns, but is later exten nded with instrumen nts for different ca are settings and subgroups (post-acu ute care, institutiona al mental healthca are, ambulatory mental m healthcare, palliative care, acu ute hospital care and persons with h mental disabilitie es). The structured d and standardized assessment aims to t realize a high-quality care planning and quality monito oring. Different care e providers can as ssess the different ittems, resulting in a multidisciplinary ap pproach of the care needs of the elderly y. In Belgium m a pilot project (th he BelRAI) is ongoiing and is not yet nationally n implemented in all care setttings. The assessm ment instruments for f home care and for long-term care facilities, for acute care and for pallia ative care are adapte ed to the Belgian sittuation. The interrRAI for long-terrm care facilities s (interRAI-LTCF)153 is a standardiz zed instrument to e evaluate the needs s, the competences s and the preference es of the residents in a long-term care e setting (care home e or other institutiona al setting) and aim ms to stimulate th he continuity of ca are via a consistentt assessment sysstem and a patie ent-focused approa ach. The assessme ent instrument givess a description of th he most important aspects a of the functio onal capacity, the m mental and physica al health, the needs s and the use of ca are of the individu ual resident, where eby most items fun nction as specific trriggers for care planning. Next to the assessment ins strument,

145

analysis prottocols are develope ed as guidance forr the care planning g. The interRAI-LTFC has been adapte ed to the Belgian situ uation and translate ed into Dutch and Frrench (BelRAI-LTCF F). The InterRA AI for home care e (interRAI-HC)1544 is a person-cen ntered assessment system to guide the home care planning for chronic c care a for patients witth post-acute care needs (for example e after patients but also hospitalisatio on). The evaluation of the needs, the strengths and the preferences of o the client indicate e the functioning an nd the quality of life of the client. The interRAI-HC co onsists of the assessment instru ument d scoring scheme) and the CAPs (clinical analysis proto ocols). (standardised Some items of the instrument function f as triggers for specific proble ems or ctional deterioration n and link the inte erRAI-HC to a serries of risks for func CAPs. These e CAPs contain general guidelines for the further assessment and for indiv vidualized care an nd services. The 3 30 CAPs cover diffferent domains an nd each triggered d CAP needs to o be discussed during d multidisciplina ary consultation to determine the nece essary care service es and the priority off each CAP. The interRAI-HC has bee en adapted to the Belgian situation and translated into Dutc ch and French (BelR RAI-HC).

146

•

•

•

Belgian n Health System Performance Percentag ge of residents w who were physiically restrained d during the last 7 days d Restraint-frree care should be the aim of high quality nursin ng care. However, in reality, physical restraints are co ommonly used in geriatric 156 long-term care. c This indiccator belongs to th he set of indicators in the OECD long g-term care qualityy project.45 Source of data: d BelRAI Percentag ge of residents w who had a fall durring the last 30 days d Fall incide ents are a comm mon cause of morbidity and morrtality in elderly. Pe ersons who fell on nce, have an inc creased risk on fu uture fall incidents. The T most recent H Health Survey Intterview reports that in the 12 months s preceding the in nterview 7% of the Belgian population had an acciden nt resulting in a m medical consultatio on.157 The most common c cause of th he accidents were e falls (54%) and were common in children and in pers sons of 65 years a and older. In more e than 40% of the e elderly, the fall cau used a fracture. W Within the domain n of state of healtth of the BelRAI-LTC CF and the BellRAI-HC, a subd domain on fall incidents determines s the risk on futu ure fall incidents. In the OECD lo ong-term care qualitty project the ind dicator on the inc cidence of falls and a fallrelated frac ctures is proposed d as example of a quality outcome on user safety.45 Source of data: d BelRAI Incidence of pressure ulc cers: a. in long-tterm care facilities b. in individuals s at risk (home c care) The occurrrence of a presssure ulcer in a ho ospitalised patien nt has a serious neg gative impact on the individual’s health57 and often leads to a much prrolonged hospital stay. Pressure ulcers can be prrevented with good quality q nursing care.58, 59 Currently no data are availa able, but it will be possible p to evalua ate this indicator using BelRAI da ata. This indicator is s also included in n the set of OEC CD indicators in quality q of

KCE Reportt 196

long-term care e.45 Source of data a: BelRAI •

Prevalence of o MRSAs in nurs sing homes The WIV – ISP is currently fina alizing a study, off which the resultts will be avaiilable 2012 at the end of (http://www.ns sih.be/nursing_ho omes/inleiding_fr.a asp). Source: WIV – ISP E Efficiency •

e: patients with home dialysis as a percentage of all Chronic care patients with h dialysis There are diffferent treatment options o for patien nts whose kidneys fail. The patients can be dialyse ed, either with h haemodialysis or with peritoneal dia alysis. In both cas ses patients can also receive a kidney k transplant, eitther from a decea ased or a living do onor. Ultimately, kidney k transplantation is considered d to be the mo ost preferable option, whenever pos ssible. Substitution of o the more expe ensive haemodialyysis in hospital by b the less expensiv ve alternatives suc ch as low-care ha aemodialysis in sa atellite centres and peritoneal p dialysis s has been slow wer in Belgium than in many other co ountries. This is thought to be parttly due to the fina ancing mechanisms for dialysis. Sinc ce 1995 the Bellgian governmentt has modified the financing f system a couple of timess, with the explicitt goal of introducing incentives for su ubstitution. For this reason, the indicator is categorised d in the performa ance dimension e efficiency. Since home dialysis is nott indicated for all patients p with end--stage renal disea ase, it is also considered an indicator of appropriatenesss. Source of datta: IMA. Prelimina ary analyses for this report were ru un on the EPS, but the sample of patients under dia alysis was too sm mall to draw any con nclusion. Analyses s will have to be done on the tota al IMA database.

KCE Report 196 6

REFE ERENCES

Belgian n Health System Performance 1.

2 2.

3 3.

4 4.

5 5. 6 6.

7 7. 8 8.

9 9.

10. 11.

147

Vlayen J, Vanthomme K, Camberlin C, Piéra art J, Walckiers D,, Kohn L, ett al. A first step towards measuring the performance of the Belgia an healthcare systtem. Brussels: Belgian Health Care e Knowledge Centre (KCE); 2010. 2 KCE Reporrts 128 WHO Reg gional Office for Europe. Health sysstems performanc ce assessme ent, a tool for healtth governance in the 21st century. Copenhag gen: World Health h Organization, Re egional office for Europe; 20 012. WHO Reg gional Office for Europe. The Tallin Charter: Health Systems for f Health and We ealth. Copenhagen n: World Health Organisation; 2008. Availab ble from: http://www w.euro.who.int/__d data/assets/pdf_file/0008/88613/E9 9143 8.pdf Arah OA, Westert GP, Hurs st J, Klazinga NS. A conceptual framework k for the OECD He ealth Care Qualityy Indicators Project. Int. J. Qua al. Health Care. 20 006;18(SUPPL. 1):5-13. OECD. He ealth at a Glance 2011, OECD Indiccators. Organisation for Econom mic Co-operation and Developmen nt; 2011. Vlayen J, Van De Water G, Camberlin C, Paulus D, Leys M, Ramaekerrs D, et al. Indicatteurs de qualité cliniques. Brussels: Belgian He ealth Care Knowle edge Centre (KCE E); 2006. KCE rep ports 41 Coppens ES, E G. Van Auden nhove, C. De evaluatie van het Vla aams actieplan suïcidepreventie s ( (2006-2010). Leuvven: Lucas; 2011. AHRQ Ide entifying, Categorizing, and Evaluatting Health Care Efficiency Measures. AHRQ Q; 2008. AHRQ Publication No. 08--0030 Available from: f http://www.a ahrq.gov/qual/efficciency/efficiency.p pdf Smith PC,, Papanicolas I. Health System Perrformance comparrison: an agenda a for policy, inform mation and research. Brussels: WHO Europe an nd European Obse ervatory on Health h Systems and Policies; 2012. 2 Policy Summ mary 4 WHO. Wo orld Health Reportt 2000. Health sysstems: improving performan nce. Geneva: Worrld Health Organizzation; 2002. OECD. He ealth at a Glance 2010 Europe. OE ECD Publishing; 2010.

148

12. 13.

14. 15.

16. 17.

18.

19.

20.

21. 22.

23.

Belgian n Health System Performance OECD. Health at a Glancce Europe. Organ nisation for Econo omic Cooperatio on and Developm ment; 2012. Europe ean Commission H HEIDI data tool: he ealth status indica ators [2012. Available A from: http://ec c.europa.eu/healtth/indicators/indica ators/index_en.htm Björnbe erg A. Euro Health h Consumer Index x 2012. Health Co onsumer Powerh house; 2012. OECD. Health Care Qua ality Indicators. OE ECD pilot question ns on patient experiences. Parris: Organisation fo or Economic Cooperatio on and Developm ment; 2011. Jacobs s R., Smith PC, Street A. Measuring g Efficiency in Hea alth Care. Cambridge: C Camb bridge University Press; P 2006. Stahl T, T Wismar M, Olilla a E, Lahtinen E, Leppo L K. Health in n All Policies s, Prospects and Potentials. Europe ean Observatory on Health Systems and Policies; 2006. WHO re egional Office for Europe. Interm re eport on the implem mentation of the Ta allinn Charter (stilll in draft version). Copenh hagen: World Hea alth Organisation; 2012. WHO re egional Office for Europe. Developing the new Europ pean policy for f health - Health 2020 (working pa aper). Copenhagu ue: World Health H Organisatio on; 2011 Available e from: http://w www.euro.who.int/_ __data/assets/pdff_file/0010/134299/07E_ Health2 2020_110419_eng g.pdf Westerrt G, van den Berg g M, Koolman X, Verkleij V H. Dutch health h care pe erformance reportt 2008. Bilthoven. The Netherlands: Nationa al Institute for Pub blic Health and the e Environment; 20 008. CIHI. Health H indicatiors 2 2010: definitions, data sources and rationale. Ottowa: Canad dian Institute for Health H Information n; 2010. Nationa al Health Performa ance Commitee (NHPC). National Health Perform mance Frameworkk Report. Brisbane e: 2001. Queensla and Health WHO. Ottawa O Charter fo or Health Promotio on. World Health Organiz zation; 1986. Available from:

2 24.

2 25.

2 26.

2 27.

28. 2 2 29.

3 30.

3 31.

3 32. 3 33.

3 34.

KCE Reportt 196

http://www w.euro.who.int/__d data/assets/pdf_file/0004/129532/O Ottaw a_Charterr.pdf OECD, Eu urostat, WHO. Conceptual framewo ork and definition of longterm care c expenditure. Organisation for Economic Cooperation and Development; 2088. Van de Vo oorde C, Léonard C. Search for Eviidence and Critica al Appraisal, Health Services Research (HSR). Brussels: Belgian n Health Ca are Knowledge Ce entre (KCE); 2007. KCE Process no otes Meeus P.,, Van Aubel X. Pe erformance de la m médecine généralle, bilan de sa anté. Brussels: Na ational Institute fo or Health and Disa ability Insurance (NIHDI); 2012. DGSIE. Ev volution de l'espérance de vie à la naissance, en années - Belgique e et régions (1997-2010). Direction Générale Statistiq que et Informa ation Economique; 2012. European Commission - DG G Health and Con nsumers. 2012. Eurostat. Eurostat E database e. EUROSTAT; 20 012. Available fro om: http://epp.eurostat.ec.europ pa.eu/portal/page//portal/statistics/se earch _database e FPS Healtth Food Chain Sa afety and Environm ment - Cel Plannin ng Aanbod Gezondheidsberoe G epen - Dienst Stra ategische Coördinatie Gezondhe eidszorgberoepen n. Voorlopige resultaten PlanKAD Gegevens skoppeling Verpleegkunde 2004-20 009, Federal public Service Pu ublic Health 2012. Communa auté française Pro ogramme de dépisstage du cancer colorectal en Communauté française [Available from: http://www w.cancerintestin.be e/spip.php?rubriq que35&mode=pub blic&l ang=fr Candeur M., M Carbonnelle S., S Vandenbroucke e A. Cancer colore ectal: dépistage. Santé en Comm munauté française. Mars 2011;6. Hoeck S., Van Roosbroek S., S Van Hal G. Pilo ootproject bevolkings . 2011. Available from: sonderzoek naar dikkedarmkanker d http://www w.dikkedarmkanke er.be IMA-AIM. Programme de Dépistage D du Canccer du Sein. Pério odes 2002-2003 3 et 2004-2005. 2007 2 2007, Septem mber.

KCE Report 196 6

35.

36.

37.

38.

39.

40.

41.

42.

43.


Hulstae ert F, Ramaekers D, Puddu M, Vinc ck I, Huybrechts M, M Arbyn M. Dép pistage du cancer du col de l’utérus s et recherche du Papillom mavirus humain (HPV). Brussels: Belgian B Health Ca are Knowle edge Centre (KCE E); 2006. KCE Rep ports 38 Arbyn M, M Simoens C, Va an Oyen H, Foidarrt J-M, Goffin F, Simon S P, et al. Analysis of 13 millio on individual patie ent records pertaining to Pap sm mears, colposcopie es, biopsies and surgery s on the ute erine cervix (Belgium, ( 1996–2000). Preventive Medicine. 2009;48 8(5):438-43. Sabbe M, Hue D, Hutse V, Goubau P. Me easles resurgence e in Belgium m from January to o mid-April 2011: a preliminary repo ort. Euro Surveill. 2011;16(16). Superio or Health Council.. Vaccination conttre la grippe saiso onnière. Saison hivernale 2007 – 2008. In: Publica ation du Conseil Supérie eur de la santé n° 8354.; 2007. WHO. Prevention P and Control of Influenza a Pandemics and Annual Epidem mics. World Health h Organization; 20 003. Resolution off the Fifty-Six xth World Health Assembly (WHA5 56.19) Available frrom: http://apps.who.int/gb/arcchive/pdf_files/WH HA56/ea56r19.pd df IMA-AIM. Vaccination co ontre la grippe au cours des hivers 20072008 ett 2008-2009. 2011. Available from: http://www.nicima.be//library/documentss/health_monitoring/Grippe%20FR R%20Ra pport%20hivers%202007 7-2008%202008-2 2009%20AIM.pdff Van de en Bosch K, Willem mé P, Geerts J, Breda J, Peeters S, S Van de Sande S, et al. Residential care for old der persons in Belgium: Projections 2011-2025. B Brussels: Belgian Health Care Knowledge Centre (KCE); 2011. KCE Reports 169 Gielen B, Remacle A, Me ertens R. Patterns s of health care us se and expend diture during the la ast 6 months of life e in Belgium: diffe erences betwee en age categories in cancer and non-cancer patients. Health Policy. 2010;97:53-61. Gielen B, Remacle A, Me ertens R. De CM neemt het levens seinde onder de d loep: de cijfers. Christian Sickne ess Fund; 2008.

4 44.

4 45. 4 46.

4 47.

4 48.

4 49.

5 50.

5 51.

5 52.

5 53.

149

InterRAI An A overview of the e interRAI. Family of Assessment Systems [2012 [cited 30th of o Mai]. Available from: http://www w.interrai.org/section/view/?fnode=1 10 OECD. Lo ong-term care qua ality project: propo osed framework. Organisation for Economic Co-operation and d Development; 20 012. Van Hoof E, Remue E, Len naerts L, De Wand deler E, Mores B, Goolaerts J. Evaluatie van het Kankerplan 20 008-2010. Brusse el: Wetenschappelijk Instituut Volksgezondheid, V , Kankercentrum; 2012. Reynders AV, B. Scheedrer, G. Declercq, A. Molenberghs, G.., Van Audenhov ve, C. L'effet des facteurs f sociocognitifs et de la recherche e d'aide sur le com mportement suicidaire différences régionales s entre la Wallonie e, La Flandre et Les Pays-Bas. Leu uven: Lucas; 2011. Mambourg g F, Robays J, Ca amberlin C, Vlayen J, Gailly J. Dépistage e du cancer du seiin entre 40 et 49 a ans. Brussels: Belgian Health Ca are Knowledge Ce entre (KCE); 2010. KCE Reports 12 29 Mambourg g F, Robays J, Ge erkens S. Dépistage du cancer du sein s entre 70 et e 74 ans. Brussels s: Belgian Health Care Knowledge Centre (KC CE); 2012. KCE Reports R 176B FPS Healtth Food Chain Sa afety and Environm ment. Feedback multidimen nsionnel. Federal Public Service Health, Food Chain n Safety and d Environment; 20 008. Jacques J, J Gillain D, Feche er F, Van de Sand de S, Vrijens F, Ramaekerrs D, et al. Etude des disparités de la chirurgie électiive en Belgiqu ue. Brussels: Belg gian Health Care K Knowledge Centre e (KCE); 2006. KCE Reports 42 Gordts B, Vrijens F, Hulstae ert F, Devriese S, Van de Sande S. The 2007 Belg gian national preva alence survey for hospital-acquired d infections.. The Journal of hospital infection. 2 2010;75(3):163-7. Jans B, De enis O. Surveillan nce van MRSA in de Belgische acute ziekenhuiz zen: tweede seme ester 2010. 2010. Available from: http://www w.nsih.be/surv_mrrsa/download_fr.a asp and http://www w.nsih.be/surv_mrrsa/download_nl.a asp

150

54.

55.

56.

57.

58.

59. 60.

61.

62.

63.

Belgian n Health System Performance OECD HCQI Patient Saffety Indicators [Orrganisation of Eco onomic Co-ope eration and Develo opment;2009 [cite ed 21 Feb]. Availa able from: http://w www.oecd.org/document/34/0,3343,,en_2649_33929_ _370905 39_1_1 1_1_1,00.html AHRQ. Patient Safety Indicators Resources. Agency for Healthc care Research an nd Quality; 2011. 2012, 2 21 Feb Available from: http://w www.qualityindicattors.ahrq.gov/Mod dules/psi_resource es.aspx FPS He ealth Food Chain Safety and Enviro onment. Feedbac ck des Patient Safety Indicatorss: la Sécurité des Patients dans les Hôpitau ux Belges.. FPS H Health Food Chain n Safety and Environ nment, ; 2011 Aprril 2011. Goreck ki C, Brown JM, Nelson EA, Briggs M, Schoonhoven L, Dealey C, et al. Impact o of pressure ulcers on quality of life in i older patients s: a systematic re eview. J Am Geriatr Soc. 2009;57(7 7):117583. McInne es E, Jammali-Bla asi A, Bell-Syer SE E, Dumville JC, Cu ullum N. Supporrt surfaces for pressure ulcer preve ention. Cochrane Databa ase Syst Rev. 2011(4):CD001735. Reddy M, Gill SS, Rocho on PA. Preventing g pressure ulcers: a systematic review. JAMA A. 2006;296(8):97 74-84. Project PUMap. Studie vvan de decubitusp prevalentie in de Belgisc che ziekenhuizen 2008. 2008. Availlable from: http://w www.decubitus.be//downloads/PUMA AP_NL.pdf Herman nn RC, Mattke S. Selecting indicato ors for the quality of mental health care at the e health systems level l in OECD cou untries. Paris: OECD; O 2004. OEC CD Health Technical Papers 17 (17 7) OECD. Health Care Qua ality Indicators: ba ackground paper to t the mental health subgroup meeting. Paris: Organisation O for Ec conomic Co-ope eration and Develo opment; 2011. van Eijk k ME, Avorn J, Po orsius AJ, de Boer A. Reducing pre escribing of highlly anticholinergic a antidepressants fo or elderly people: random mised trial of group p versus individua al academic detailing. BMJ. 2001;322(7287):65 54-7.

6 64. 6 65.

6 66.

6 67.

6 68.

6 69.

7 70.

7 71.

7 72.

7 73.

KCE Reportt 196

Mintzer J, Burns A. Anticho olinergic side-effeccts of drugs in elderly people. J R Soc Med. 2000 0;93(9):457-62. van Eijk ME, M Bahri P, Dekke er G, Herings RM M, Porsius A, Avorn J, et al. Use of prevalence and d incidence meassures to describe agea related pre escribing of antide epressants with and without anticholine ergic effects. J Cliin Epidemiol. 2000;53(6):645-51. Vander Sttichele RH, Van de e Voorde C, Elsevviers M, Verrue C, C Soenen K, K Smet M, et al. Medication M use in rrest and nursing homes in Belgium. Brussels s: Belgian Health Care Knowledge Centre (KC CE); 2006. KCE Reports R 47C Berendsen n AJ, Groenier KH H, de Jong GM, M Meyboom-de Jong B, van der Ve een WJ, Dekker J, J et al. Assessme ent of patient's experience es across the inte erface between prrimary and second dary care: Cons sumer Quality Ind dex Continuum of care. Patient Edu uc Couns. 20 009;77(1):123-7. Haggerty JL, J Reid RJ, Free eman GK, Starfield d BH, Adair CE, McKendry y R. Continuity of care: c a multidiscip plinary review. BM MJ. 2003;327((7425):1219-21. Reid R, Ha aggerty J, McKen ndry R. Defusing the confusion: Concepts and measures of continuity of heallthcare. March 2002. Final repo ort. Canadian Health Services Rese earch Foundation.. 2002. Salisbury C, Sampson F, Ridd R M, Montgome ery AA. How should continuity of care in primary y health care be a assessed? Br J Ge en Pract. 200 09;59(561):e134-4 41. van Serve ellen G, Fongwa M, M Mockus D'Errico E. Continuity off care and quality y care outcomes for f people experie encing chronic conditions s: A literature revie ew. Nurs Health S Sci. 2006;8(3):185 5-95. van Walra aven C, Oake N, Jennings J A, Forste er AJ. The associa ation between continuity c of care and a outcomes: a ssystematic and crritical review. J Eval E Clin Pract. 20 010;16(5):947-56. Commission on Dignity in Care C for Older Peo ople. Delivering Dignity. Se ecuring dignity in care for older peo ople in hospitals and a care home es. A report for co onsultation. NHS C Confederation, the e Local Gov vernment, Associa ation and Age UK;; 2012.

KCE Report 196 6

74. 75.

76.

77.

78. 79.

80.

81.

82.

83. 84.


Cabana a MD, Jee SH. Do oes continuity of care c improve patie ent outcom mes? Journal of Fa amily Practice. 2004;53(12):974-80 0. Patkar V, Acosta D, Davvidson T, Jones A,, Fox J, Keshtgar M. Cancerr multidisciplinary team meetings: evidence, e challeng ges, and the role e of clinical decisio on support techno ology. Internationa al journal of breast cancer. 2011;2011:83160 05. Abarshi E, Echteld MA, V Van den Block L, Donker G, Bossu uyt N, Meeuss sen K, et al. Use o of palliative care services s and gene eral practitio oner visits at the e end-of-life in the Netherlands N and Belgium. B Journal of pain and symp ptom managemen nt. 2011;41(2):436 6-48. Davis S, S Byers S, Walsh h F. Measuring person-centred care e in a sub-acu ute health care se etting. Aust Health h Rev. 2008;32(3)):496504. Redma an RW, Lynn MR. Assessment of pa atient expectation ns for care. Res R Theory Nurs P Pract. 2005;19(3):275-85. Aiken LH, L Sermeus W, V Van den Heede K, Sloane DM, Bus sse R, McKee M, et al. Patient ssafety, satisfaction, and quality of hospital h care: crross sectional surrveys of nurses an nd patients in 12 countrie es in Europe and the United States s. BMJ. 2012;344::e1717. Gomes s B, Higginson IJ, Calanzani N, Coh hen J, Deliens L, Daveso on BA, et al. Prefe erences for place of death if faced with w advanc ces cancer: a popu ulation survey in England, E Flanders s, Germany, Italy, the Neth herlands, Portugal and Spain. Anna als of Oncolo ogy. 2012. Houttek kier D, Cohen J, S Surkyn J, Deliens L. Study of recen nt and future trends in place of death in Belgium using death certifficate data: a shift from hospita als to care homes. BMC Public Hea alth. 2011;11:228-38. OECD. Health Data 2010 0. Statistics and in ndicators for OEC CD countrie es. In: Organisatio on for Economic Co-operation C and Development; 2010. Nutbea am D. Evaluating H Health Promotion - progress, proble ems and sollutions. Health Pro omotion Internatio onal. 1998;13(1):2 27-44. Cellule Interuniversitaire d'Epidémiologie. Rapport final du projet « système d'enregistremen nt et de surveillan nce de la santé bu ucco-

8 85. 8 86.

8 87. 8 88.

8 89.

9 90.

9 91.

9 92.

9 93.

151

dentaire de la population be elge 2008- 2010 » ». 2012. Available from: http://www w.inami.fgov.be/infformation/fr/studie es/study53/index.htm Vanobberg gen J, Martens L, Declerk D. Carie es prevalence in Belgian ch hildren: a review. Int J Paediatr Den nt. 2001;11(3):164 4-70. Sasse A, Verbrugge V R, Van n Beekchoven D. Epidémiologie du u Sida et de l'infe ection à VIH en Be elgique; situation a au 31 décembre 2010. 2 Brussels: IPH, surveillance of communicale d diseases; 2011. Ewing JA. Detecting alcoho olism. The CAGE questionnaire. JA AMA. 1984;252((14):1905-7. VIGEZ De e actieve voedings sdriehoek [Vlaamss Instituut voor Gezondhe eidspromotie;2012 2. Available from: http://vig.k kanker.be/contentt/category/categorrycontent.aspx?Categ oryGUID= =025d941e-6a63-4 4540-a522-b3c20 08832529 al Activity and He WHO. WH HO Global Strateg gy on Diet, Physica ealth. Recomme endations for Phys sical Activity for H Health. Geneva: World W Health Org ganization; 2004. Ministère fédéral f de la Santté Publique et Min nistères des entité és fédérées belges b ayant la Sa anté publique dan ns leurs attribution ns. Plan natio onal nutrition santé é pour la Belgique e, 2005 -2010. 200 04. Pate RR, Pratt M, Blair SN, Haskell WL, Maccera CA, Boucharrd C, et al. Phys sical activity and public p health. A re ecommendation from the Centers for Disease Co ontrol and Preventtion and the Amerrican College off Sports Medicine. JAMA. 1995;273 3(5):402-7. Bouchard C, Shephard R, Stephens S T, Sutto on J, McPherson B. B Exercise, Fitness, and Health. A Consensus of Current Knowledge. In: IL C, editor. Human Kinetics Books; 1990. p. 3-28. 3 Buytaert B, B Moens O, Tamb buyzer J, Wouterss E, Vauhauwaertt E. Verslag va an de indicatorenm meting 2009 van h het gezondheidsb beleid (tabak, voeding, beweging) in Vlaamse bedriijven, scholen en gemeente en. Vlaams Instituu ut voor Gezondhe eidspromotie en Ziekteprev ventie; 2010. Avaiilable from: http://www w.vigez.be/uploads s/documentenban nk/f9c7c6490988b b8b4 49de67cf9 9835b9a1.pdf

152

94. 95. 96. 97. 98.

99. 100.

101. 102.

103.

104.

105.

106.

Belgian n Health System Performance Godin I, I Piette D. Etude écoles liées aux enquêtes e HBSC Commu unauté française d de Belgique, rapp port à paraître. 2010. Nutbea am D. Health prom motion glossary. Health H Promot. 1986;1(1):113-27. Nutbea am D. The evolving concept of health literacy. Soc Sc ci Med. 2008;67 7(12):2072-8. Consorrtium HLS-EU. The European Healtth Literacy Survey y. Joosse ens L, Raw M. The e Tobacco Contro ol Scale 2010 in Europe. Brussels: Association of the European Ca ancer Leagues; 20 010. Availab ble from: http://w www.ensp.org/sitess/default/files/TCS S_2010_in_Europ pe_FINA L.pdf Bravem man P, Gruskin S. Defining equity in n health. Journal of o epidem miology and comm munity health. 2003 3;57(4):254-8. Bravem man PA. Monitorin ng Equity in Health h and Healthcare: A Concep ptual Framework. Journal of Health h Population and Nutritio on. 2003;31(3):181 1-92. Black D. D Inequalities in h health. London: Re eport of a researc ch working g group- Department of Health and Social Security; 1980. 1 Feinste ein J. S. The relationship between socioeconomic s sta atus and health: A review of the litterature. The Milk kbank Quarterly. 1993;v7 71:p. 279-94. WHO Commission C on So ocial Determinants on Health. Closing the gap in a generation: hea alth equity through h action on the soc cial determinants of health G Geneva: World He ealth Organisation; 2008. EU Exe ecutive Agency for Health and Cons sumer. Second Program mme of Community Action in the Field of Health 200 08-2013. Europe ean Commission; 2 2007. Sondik EJ, Huang DT, K Klein RJ, Satcher D. D Progress towarrd the healthy y people 2010 goa als and objectives. Annu Rev Public c Health. 2010;31:271-81 4 p folliwng 81. Macken nbach JP, Kunst A AE. Measuring the e magnitude of so ocioeconom mic inequalities in health: an overvie ew of available measures

107.

108.

109.

110.

111.

112.

113.

114.

KCE Reportt 196

illustrated with two example es from Europe. S Social science & medicine. 1997;44(6):757-7 71. Harper S, King NB, Meersm man C, Reichman ME, Breen N, Lynch J. Implicit Value Judgments s in the Measurem ment of Health Inequalitie es. Milbank 2010;8 88(4-29). Charafedd dine R, Gadeyne S, S Deboosere P, B Berger N, Demare est S, Van Oyen H Social inequalities in healthy life e expectancy. Alternative e methods of estim mation in the abse ence of the nation nal census. Brussels: Direction Opérationnelle S Santé publique et surveillanc ce, Institut Scientiifique de Santé Pu ublique; 2011. Deboosere e P GS, Van Oyen H. The 1991-20 004 evolution in Liife Expectanc cy by educational level in Belgium b based on linked census an nd population regis ster data. Eur J P Popul. 2009;25:175 5-96. Van Oyen H CR, Debooserre P, Cox B, Loran nt V, Nusselder W, W Demarest S. Contribution of o mortality and dissability to the secu ular trend in he ealth inequality at the turn of centurry in Belgium. Eurr J Public Hea alth. 2011;21:781-7. Van Oyen H CR, Debooserre P, Cox B, Loran nt V, Demarest S. De evolutie va an sociale ongelijk kheid in gezonde levensverwachtin ng. In: Press A, editor. e Sociale ong gelijkheden in gezzondheid in België ë. Gent: Federaal Wetenschapsbeleid; 2011. p. 27-43. Deboosere e P, Gadeyne S, Van V Oyen H. L'évvolution des inéga alités sociales en e espérance de vie. v In: Van Oyen H. DP, Lorant V., Charafedinne R., editor. Les inégalités sociales de santé en Belgique. Brussels: Academ mia Press; 2010. Van Oyen H, Charafeddine R, Deboosere P, Cox B, Lorant V,, Demarest S. L'évolution des inégalités en esspérance de vie en n santé. In: Van Oyen H. DP, Lorant V., Chara afedinne R., editorr. Les inégalités sociales de santé é en Belgique. Bru ussels: Academia Press; 201 10. Haelterma an E, De Spiegela aere M, Masuy-Strroobant E. Les indicateurs s de santé périnatale en Région de e Bruxelles capitale 1998-2004 4. Brussels: Obse ervatoire de la san nté et du Social de e Bruxelles--Capitale; 2007.

KCE Report 196 6

115.

116. 117. 118. 119. 120. 121. 122.

123.

124.

125.

126.


Léonarrd C. La responsabilisation capacita ante: un nouveau paradig gme pour refonder l'Etat-providence e? Éthique et économ mique/Ethics and Economics. 2012;9(2):45-65. Dworkin R. What is Equa ality? Part 2: Equa ality of Resources s. Philoso ophy and Public A Affairs. 1981;10(4):283-345. Dworkin R. Sovereign Viirtue Revisited. Etthics. 2002;113(October):106-4 43. Dworkin R. Equality, Lucck and Hierarchy. Philosophy and Public P Affairs. 2003;31(2):190-8 8. Roeme er J. Egalitarianism m, responsibility, and a information. Econom mics and Philosop phy. 1987;3:215-4 44. Roeme er J. Equality and responsibility. Bos ston Review. 1995 5;XX(2 (April/M May)). Roeme er JE. Equality of O Opportunity. Cambridge: Harvard Univers sity Press; 1998. van Do oorslaer E, Masseria C, Koolman X.. Inequalities in ac ccess to medica al care by income in developed countries. Canadian Medical Associa ation Journal. 200 06;174(2):177-83. van Do oorslaer E, Wagsta aff A. Equity in the e delivery of healtth care: Some international comp parisons. Journal of Health Econom mics. 1992(11):389-411. van Do oorslaer E, Wagsta aff A, van der Burrg H, Christiansen T, Citoni G, G Di Biase R, et a al. The redistributive effect of health h care finance e in twelve OECD countries. Journa al of Health Econo omics. 1999;18 8(3):291-313. Wagsta aff A. Measuring E Equity in Health Care C Financing. refflections on (and d Alternatives to) tthe World Health Organization's Fa airness of Financing Index. In: P Policy Research Working W Paper. Washin ngton: World Bankk; 2001. Wagsta aff A, Van Doorsla aer E. Equity in the e finance of health care: Some international comp parisons. Journal of Health Econom mics. 1992;11(4):361-7.

127.

128.

129. 130. 131.

132.

133.

134.

135.

136.

153

Wagstaff A, A Van Doorslaer E. Equity in Healtth Care Finance and a Delivery. In: Culyer AJ, New whouse JP, editorrs. Handbook of health Economics: North-Holland; 2000. p. 1804-62 2. Wagstaff A, A van Doorslaer E, van der Burg H H, Calonge S, Christians sen T, Citoni G, ett al. Equity in the ffinance of health care: c some furth her international comparisons. c Jourrnal of Health Economics. 1999;18(3):263 3-90. Daniels N. Just Health. Mee eting Health Need ds Fairly. Cambrid dge: Cambridge e University Press s; 2008. Jackson T. T Prospérité sans s croissance. La trransition vers une économie durable. Bruxelle es; 2010. Van Oyen H CB, Nusselderr W, Jagger C, Ca ambois E, Robine JM. Gender ga aps in life expecta ancy and expected d years with activiity limitations s at age 50 in the European E Union: Associations with h macro-level structural factors. Eur J Ageing. 2010;7:229-39. WHO. Dev veloping indicatorrs for the health 20 020 targets. First meeting of the expert group p (18-19 June). Uttrecht: World Health Organization; 2012. Plug I, Hoffmann R, Mackenbach J. Avoidable mortality in the European Union: Towards better b indicators fo for the effectiveness of health sys stems. In: AMIEHS S (Amenable Morttality in the Europ pean Union, tow wards better Indica ators for the Effecctiveness of Health Systems); 2011. Schokkaert E, Guillaume J, Lecluyse A, Avallosse H, Cornelis K, De Graeve e D, et al. [Effects s of the Maximum Billing system on n health carre consumption an nd financial accesss to health care]. Brussels: Belgian Health Ca are Knowledge Centre (KCE); 2008 8. KCE reports 80 De Graeve e D, Lecluyse A, Schokkaert S E, Van Ourti T, Van de Voorde C.. [Personal contrib bution for health ccare in Belgium. Im mpact of supplem ments]. Brussels: Belgian Health Ca are Knowledge Centre (KCE); 2006. KCE reports 50 5 Van de Vo oorde C, Kohn L, Vinck V I. [Entitleme ent to a hospital insurance for persons with a chronic illness o or handicap]. Brus ssels:

154

137. 138.

139. 140.

141.

142.

143.

144.

145.

Belgian n Health System Performance Belgian n Health Care Kno owledge Centre (K KCE); 2011. KCE reports 166 Simoen ns S, Villeneuve, M M., Hurst, J. Tack kling Nurse Shorta ages in OECD Countries Paris: O OECD; 2005. Van de en Heede K, Florquin M, Bruyneel L, L Aiken L, Diya L,, Lesaffre e E, et al. Effectivve strategies for nurse retention in acute a hospita als: A mixed metho od study. Int J Nurs Stud. 2011. WHO. Policies P and practtices for mental he ealth in Europe: meeting m the cha allenges. Copenha agen: World Healtth Organization; 2008. 2 Eyssen n M, Leys M, Deso omer A, Arnaud S, S Léonard C. Orga anisatie van gee estelijke gezondheidszorg voor me ensen met een ern nstige en pers sisterende mentale aandoening. Wat is de wetens schappelijke basiss? Brussel: Belgian Health Care Knowle edge Centre (KCE E); 2010. KCE Rep ports 144 Garcia--Armesto S, Mede eiros H, Wei L. Infformation Availibility for measurring and comparin ng quality of menttal health care acrross OECD countries. Paris: O OECD; 2008. OECD Health Technical Papers s NIHDI. Evaluer les trajetts de soins: accord d sur la façon de récolter et d'éva aluer les donnéess. Bruxelles: National Institute for Health and Dis sability Insurance;; 2012. Communiq qué de presse Schoen n C, Osborn R, Ho ow SK, Doty MM, Peugh J. In chron nic conditio on: experiences o of patients with com mplex health care e needs, in eightt countries, 2008. Health Aff (Millwo ood). 2009;28(1):w w1-16. Mead N, N Bower P. Patient-centredness: a conceptual frame ework and rev view of the empiriccal literature. Soc Sci Med. 2000;51(7):1087-110. Davies E, Shaller D, Edg gman-Levitan S, Safran S DG, Ofteda ahl G, Sakows ski J, et al. Evalua ating the use of a modified CAHPS survey to supp port improvementss in patient-centre ed care: lessons frrom a quality improvement collaborative. Health Expect. 2008;11((2):16076.

146.

147.

148.

149.

150.

151.

152.

153.

154.

155.

KCE Reportt 196

European Practice Assessm ment - EPA. Easyy to use and scientifically developed qua ality management for general practiice. 2008. The Royal Australian Colleg ge of GPs Standa ards for General Practices, 4th Edition - 2010 0, [2011 [cited No ovember]. Available from: http://www w.racgp.org.au/Co ontent/NavigationM Menu/PracticeSup pport/ Standards sforGeneralPractic ces/Standards4thEdition.pdf The Royal New Zealand Co ollege of General Practitioners Aiming for Excelle ence – RNZCGP Standard S for New w Zealand General Practice 2011-2014 2 [2011 [cited [ November]. Available from: http://www w.rnzcgp.org.nz/qu uality-standards Merrick EL L, Hodgkin D, Horrgan CM, Garnickk DW, McLaughlin n TJ. Changing mental health gattekeeping: effectss on performance indicators.. J Behav Health Serv S Res. 2007;35(1):3-19. Owens PL L, Mutter R, Stock ks C. Mental Healtth and Substance Abuse-Re elated Emergency Department Visitts among Adults. AHRQ, HE EALTHCARE COS ST AND UTILIZA ATION PROJECT; 2010. Stattistical Briefs Larkin G, Claassen C, Emo ond J, al. e. Trends in US emergenc cy departmen nt visits for menta al health conditionss, 1992 to 2001. Psychiatric c Services. 2005;56(6):671-7. McEwan KL, K Goldner E. Ac ccountability and P Performance Indicators for Mental Health h Services and Su upports. Ottawa (O ON): Health Ca anada; 2001. Morris J, Berg B K, Fries B, Hawes H C, Phillips C CM, Mor V, et al. Gebruiksh handboek voor de InterRAI-LTCF (B BelRAI-LTCF). Washingto on, D.C.: InterRAI; 2006. Morris J, Fries F B, Bernabei R, Steel K, Ikegami N, Carpenter I, et al. Gebruikshandboek voor de interRAI-HC (BelRAI-HC). Washingto on, D.C.: InterRAI; 2006. WHO Nutrrition for older perrsons [World Heallth Organization;2 2012 [cited 30th h of Mai].

KCE Report 196 6

156.

157.


Mohler R, Richter T, Kop pke S, Meyer G. In nterventions for preventting and reducing the use of physic cal restraints in lon ng-term geriatric c care. Cochrane Database of Systtematic Reviews. 2011(2):CD007546. Van de er Heyden J, Gisle e L, Demarest S, Drieskens D S, Hess se E, Taffore eau J. Enquête de santé, 2008. Rap pport I - Etat de sa anté. Directio on Opérationnelle Santé publique et e surveillance, 20 010; Bruxelle es, Institut Scientifique de Santé Publique; 2010.

155

DE PERFORMANTIE VAN HET BELGISCHE GEZONDHEIDSSYSTEEM RAPPORT 2012

Recommend Documents