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Quality of health care is a hot topic, especially with regard to cancer. Although rectal cancer is, in many aspects, a model oncologic entity, there seem to be substantial differences in quality of care between countries, hospitals and physicians. PROCARE, a Belgian multidisciplinary national project to improve outcome in all patients with rectum cancer, identified a set of quality of care indicators covering all aspects of the management of rectal cancer. This set should permit national and international benchmarking, i.e. comparing results from individual hospitals or teams with national and international performances with feedback to participating teams. Such comparison could indicate whether further improvement is possible and/or warranted.

Pancreatic Neuroendocrine Neoplasms comprise a group of rare tumours with special biology, an often indolent behaviour and particular diagnostic and therapeutic requirements. The specialized biochemical tests and radiological investigations, the complexity of surgical options and the variety of medical treatments that require individual tailoring, mandate a multidisciplinary approach that can be optimally achieved through an organized network. The present study describes currents concepts in the management of these tumours as well as an insight into the challenges of delivering the pathway in and outside a Network.

Background: The EUROCARE-5 study revealed disparities in childhood cancer survival among European countries, giving rise to important initiatives across Europe to reduce the gap. Extending its representativeness through increased coverage of eastern European countries, the EUROCARE-6 study aimed to update survival progress across countries and years of diagnosis and provide new analytical perspectives on estimates of long-term survival and the cured fraction of patients with childhood cancer. Methods: In this population-based study, we analysed 135 847 children (aged 0–14 years) diagnosed during 2000–13 and followed up to the end of 2014, recruited from 80 population-based cancer registries in 31 European countries. We calculated age-adjusted 5-year survival differences by country and over time using period analysis, for all cancers combined and for major cancer types. We applied a variant of standard mixture cure models for survival data to estimate the cure fraction of patients by childhood cancer and to estimate projected 15-year survival. Findings: 5-year survival for all childhood cancer combined in Europe in 2010–14 was 81% (95% CI 81–82), showing an increase of three percentage points compared with 2004–06. Significant progress over time was observed for almost all cancers. Survival remained stable for osteosarcomas, Ewing sarcoma, Burkitt lymphoma, non-Hodgkin lymphomas, and rhabdomyoscarcomas. For all cancers combined, inequalities still persisted among European countries (with age-adjusted 5-year survival ranging from 71% [95% CI 60–79] to 87% [77–93]). The 15-year survival projection for all patients with childhood cancer diagnosed in 2010–13 was 78%. We estimated the yearly long-term mortality rate due to causes other than the diagnosed cancer to be around 2 per 1000 patients for all childhood cancer combined, but to approach zero for retinoblastoma. The cure fraction for patients with childhood cancer increased over time from 74% (95% CI 73–75) in 1998–2001 to 80% (79–81) in 2010–13. In the latter cohort, the cure fraction rate ranged from 99% (95% CI 74–100) for retinoblastoma to 60% (58–63) for CNS tumours and reached 90% (95% CI 87–93) for lymphoid leukaemia and 70% (67–73) for acute myeloid leukaemia. Interpretation: Childhood cancer survival is increasing over time in Europe but there are still some differences among countries. Regular monitoring of childhood cancer survival and estimation of the cure fraction through population-based registry data are crucial for evaluating advances in paediatric cancer care. Funding: European Commission.

11 pp. Aims: The study assessed the quality of diagnosis and staging offered to patients with a head and neck squamous cell carcinoma (HNSCC) and the variability across Belgian hospitals. Methods: In total, 9,245 patients diagnosed with HNSCC between 2009 and 2014, were identified in the population-based Belgian Cancer Registry (BCR). The BCR data were coupled with other databases providing information on diagnostic and therapeutic procedures reimbursed by the compulsory health insurance, vital status data, and comorbidities. The use of diagnosis and staging procedures was assessed by four quality indicators (QI) (i.e., use of dedicated head and neck imaging studies, use of PET-CT, TNM reporting and interval between diagnosis and start of treatment), for which a target was defined before the analysis. The association between the binary QIs and observed survival was assessed using Cox proportional hazard models adjusted for potential confounders. Results: Overall, 82.5% of patients received staging by MRI and/or CT of the head and neck region before the start of treatment. In 47.6% of stage III-IV patients eligible for treatment with curative intent, a whole-body FDG-PET(/CT) was performed. The proportion of patients whose cTNM and pTNM stage was reported to the BCR was 80.5 and 78.4%, respectively. The median interval from diagnosis to first treatment with curative intent was 32 days (IQR: 19-46). For none of these QIs the pre-set targets were reached and a substantial variability between centers was observed for all quality indicators. No binary QI was significantly associated with observed survival. Conclusions: The four quality indicators related to diagnosis and staging in HNSCC all showed substantial room for improvement. For none of them the pre-set targets were met at the national level and the variability between centers was substantial. Each Belgian hospital received an individual feedback report in order to stimulate reflection and quality improvement processes.

Patients with soft tissue sarcoma (STS) experienced better outcomes when treated according to existing clinical practice guidelines either at reference institution or dedicated treatment networks. Despite increasing evidence supporting referral to sarcoma specialised units, up to half of patients are not managed according to guidelines, particularly those in the early stage of their disease requiring surgery. Also, criteria to certify expertise of institutions, such as the treatment volume, are debated and health authorities have only recently started identification of these centres and creation of treatment networks in Europe as well as in several countries. This process have important implications for both patient outcomes and innovation of existing treatment strategies through clinical research, making improvement of clinical pathways a priority for health care authorities. This article will discuss issues with management of patients with STS, such as pathological diagnosis and adherence to guidelines, and the definition of referral centres and networks will be illustrated along with existing experiences and population-based data.

Germ-cell tumours (GCT) of the testis and penile squamous cell carcinoma (PeSCC) are a rare and a very rare uro-genital cancers, respectively. Both tumours are well defined entities in terms of management, where specific recommendations - in the form of continuously up-to-dated guide lines- are provided. Impact of these tumour is relevant. Testicular GCT affects young, healthy men at the beginning of their adult life. PeSCC affects older men, but a proportion of these patients are young and the personal consequences of the disease may be devastating. Deviation from recommended management may be a reason of a significant prognostic worsening, as proper treatment favourably impacts on these tumours, dramatically on GCT and significantly on PeSCC. RARECAREnet data may permit to analyse how survivals may vary according to geographical areas, histology and age, leading to assume that non-homogeneous health-care resources may impact the cure and definitive outcomes. In support of this hypothesis, some epidemiologic datasets and clinical findings would indicate that survival may improve when appropriate treatments are delivered, linked to a different accessibility to the best health institutions, as a consequence of geographical, cultural and economic barriers. Finally, strong clues based on epidemiological and clinical data support the hypothesis that treatment delivered at reference centres or under the aegis of a qualified multi-institutional network is associated with a better prognosis of patients with these malignancies. The ERN EURACAN represents the best current European effort to answer this clinical need.

No validated prognostic tool is available for predicting overall survival (OS) of patients with well-differentiated neuroendocrine tumors (WDNETs). This study, conducted in three independent cohorts of patients from five different European countries, aimed to develop and validate a classification prognostic score for OS in patients with stage IV WDNETs. We retrospectively collected data on 1387 patients: (i) patients treated at the Istituto Nazionale Tumori (Milan, Italy; n = 515); (ii) European cohort of rare NET patients included in the European RARECAREnet database (n = 457); (iii) Italian multicentric cohort of pancreatic NET (pNETs) patients treated at 24 Italian institutions (n = 415). The score was developed using data from patients included in cohort (i) (training set); external validation was performed by applying the score to the data of the two independent cohorts (ii) and (iii) evaluating both calibration and discriminative ability (Harrell C statistic). We used data on age, primary tumor site, metastasis (synchronous vs metachronous), Ki-67, functional status and primary surgery to build the score, which was developed for classifying patients into three groups with differential 10-year OS: (I) favorable risk group: 10-year OS ≥70%; (II) intermediate risk group: 30% ≤ 10-year OS

Background Cancer registries (CRs) are fundamental for estimating cancer burden, evaluating screening and monitoring health service performance. Stage at diagnosis—an essential information item collected by CRs—has been made available, for the first time, by CRs participating in EUROCARE-5. We analysed the quality of this information and estimated stage-specific survival across Europe for CRs with good data quality. Data and methods Sixty-two CRs sent stage (as TNM, condensed TNM or extent of disease) for 15 cancers diagnosed in 2000–2007. We assessed the quality, partly by comparing stage according to the three systems. We also developed procedures to reconstruct stage (categories: local, regional, metastatic and unknown) using information from all three systems, thus minimising the amount of missing information. Results Moderate-to-excellent stage concordance was found for practically all 24 CRs, for which it was possible to compare at least two staging systems. However, since stage was often incorrectly assigned, and information on the presence/absence of metastases was often lacking, data on only 7/15 cancers from 34/62 CRs (15 countries) were of sufficient quality for further analysis. Cases diagnosed ≥70 years had more advanced (or lacking) stage– and worse stage-specific survival than those Conclusions Many European CRs collect and record reasonably accurate stage information. Others have difficulties. Both the completeness of primary data and the accuracy of stage coding need to be improved in order for CRs to fulfil their expanding roles in cancer control. We propose our stage reconstruction/checking procedures as a means of fully exploiting the stage information provided by EUROCARE CRs. More advanced (or lacking) stage at diagnosis plus poorer stage-specific survival in the elderly are worrying.

328 p. ill., Accompanying explanation 1 -- MDC PP pre-MDC 2 -- APR-DRG 001 Liver Transplant And/Or Intestinal Transplant 2 -- APR-DRG 002 Heart &/Or Lung Transplant 3 -- APR-DRG 003 Bone Marrow Transplant 4 -- APR-DRG 004 Ecmo Or Tracheostomy With Long Term Mechanical Ventilation With Extensive Procedure or ECMO 5 -- APR-DRG 005 Tracheostomy W Long Term Mechanical Ventilation W/O Extensive Proc 6 -- APR-DRG 006 Pancreas Transplant 7 -- MDC 01 Diseases & disorders of the nervous system 8 -- APR-DRG 020 Craniotomy For Trauma 8 -- APR-DRG 021 Craniotomy Except For Trauma 9 -- APR-DRG 022 Ventricular Shunt Procedures 10 -- APR-DRG 023 Spinal Procedures 11 -- APR-DRG 024 Extracranial Vascular Procedures 12 -- APR-DRG 026 Other Nervous System & Related Procedures 13 -- APR-DRG 040 Spinal Disorders & Injuries 14 -- APR-DRG 041 Nervous System Malignancy 15 -- APR-DRG 042 Degenerative Nervous System Disorders Exc Multiple Sclerosis 16 -- APR-DRG 043 Multiple Sclerosis & Other Demyelinating Diseases 17 -- APR-DRG 044 Intracranial Hemorrhage 18 -- APR-DRG 045 Cerebral Vascular Accident and Precerebral Occlusion with infarct 19 -- APR-DRG 046 Nonspecific Cva & Precerebral Occlusion W/O Infarct 20 -- APR-DRG 047 Transient Ischemia 21 -- APR-DRG 048 Peripheral,Cranial & Autonomic Nerve Disorders 22 -- APR-DRG 049 Bacterial & Tuberculous Infections Of Nervous System 23 -- APR-DRG 050 Non-Bacterial Infections Of Nervous System Exc Viral Meningitis 24 -- APR-DRG 051 Viral Meningitis 25 -- APR-DRG 052 Nontraumatic Stupor & Coma 26 -- APR-DRG 053 Seizure 27 -- APR-DRG 054 Migraine & Other Headaches 28 -- APR-DRG 055 Head Trauma W Coma > 1 Hr Or Hemorrhage 29 -- APR-DRG 056 Brain Contusion/.Laceration & Complicated Skull Fx, Coma < 1Hr Or 30 -- APR-DRG 057 Concussion, Closed Skull Fx Nos, Uncomplicated Intracranial Injury, Coma < 1 Hr Or No Coma 31 -- APR-DRG 058 Other Disorders Of Nervous System 32 -- MDC 02 Diseases & disorders of the eye 33 -- APR-DRG 070 Orbital Procedures 33 -- APR-DRG 073 Eye Procedures Except Orbital 34 -- APR-DRG 080 Acute Major Eye Infections 35 -- APR-DRG 082 Eye Disorders Except Major Infections 36 -- MDC 03 Diseases & disorders of the ear, nose, mouth & throat 37 -- APR-DRG 089 Major Facial/Cranial Bone Procedures 37 -- APR-DRG 090 Major Larynx & Tracheal Procedures 38 -- APR-DRG 091 Other Major Head & Neck Procedures 39 -- APR-DRG 092 Facial Bone Procedures Except Major Cranial/Facial Bone Procedure 40 -- APR-DRG 093 Sinus & Mastoid Procedures 41 -- APR-DRG 095 Cleft Lip & Palate Repair 42 -- APR-DRG 097 Tonsil & Adenoid Procedures 43 -- APR-DRG 098 Other Ear, Nose, Mouth & Throat Procedures 44 -- APR-DRG 110 Ear, Nose, Mouth, Throat, Cranial/Facial Malignancies 45 -- APR-DRG 111 Vertigo & Other Labyrinth Disorders 46 -- APR-DRG 113 Infections Of Uppr Respiratory Tract 47 -- APR-DRG 114 Dental & Oral Diseases And Injuries 48 -- APR-DRG 115 Other Ear, Nose, Mouth, Throat, Cranial/Facial Diagnoses 49 -- MDC 04 Diseases & disorders of the respiratory system 50 -- APR-DRG 120 Major Respiratory & Chest Procedures 50 -- APR-DRG 121 Other Respiratory & Chest Procedures 51 -- APR-DRG 130 Respiratory System Diagnosis W Ventilator Support 96+ Hours 52 -- APR-DRG 131 Cystic Fibrosis - Pulmonary Disease 53 -- APR-DRG 132 Bpd & Oth Chronic Respiratory Dis Arising In Perinatal Period 54 -- APR-DRG 133 Pulmonary Edema & Respiratory Failure 55 -- APR-DRG 134 Pulmonary Embolism 56 -- APR-DRG 135 Major Chest & Respiratory Trauma 57 -- APR-DRG 136 Respiratory Malignancy 58 -- APR-DRG 137 Major Respiratory Infections & Inflammations 59 -- APR-DRG 138 Bronchiolitis and RSV Pneumonia 60 -- APR-DRG 139 Other Pneumonia 61 -- APR-DRG 140 Chronic Obstructive Pulmonary Disease 62 -- APR-DRG 141 Asthma 63 -- APR-DRG 142 Interstitial Lung Disease 64 -- APR-DRG 143 Other Respiratory Diagnoses Except Signs, Symptoms & Minor Diagnoses 65 -- APR-DRG 144 Respiratory Signs, Symptoms and Minor Diagnoses 66 -- MDC 05 Diseases & disorders of the circulatory system 67 -- APR-DRG 160 Major Cardiothoracic Repair Of Heart Anomaly 67 -- APR-DRG 161 Cardiac Defibrillator & Heart Assist Implant 68 -- APR-DRG 162 Cardiac Valve Procedures W Cardiac Catheterization 69 -- APR-DRG 163 Cardiac Valve Procedures W/O Cardiac Catheterization 70 -- APR-DRG 165 Coronary Bypass with Cardiac Cath Or Percutaneous Cardiac Procedure 71 -- APR-DRG 166 Coronary Bypass without Cardiac Cath Or Percutaneous Cardiac Procedure 72 -- APR-DRG 167 Other Cardiothoracic Procedures 73 -- APR-DRG 169 Major Thoracic And Abdominal Vascular Procedures 74 -- APR-DRG 170 Permanent Cardiac Pacemaker Implant W Ami, Heart Failure Or Shock 75 -- APR-DRG 171 Permanent Cardiac Pacemaker Implant W/O Ami, Heart Failure Or Shock 76 -- APR-DRG 173 Other Vascular Procedures 77 -- APR-DRG 174 Percutaneous Cardiovascular Procedures W Ami 78 -- APR-DRG 175 Percutaneous Cardiovascular Procedures W/O Ami 79 -- APR-DRG 176 Cardiac Pacemaker & Defibrillator Device Replacement 80 -- APR-DRG 177 Cardiac Pacemaker & Defibrillator Revision Except Device Replacement 81 -- APR-DRG 180 Other Circulatory System Procedures 82 -- APR-DRG 190 Acute Myocardial Infarction 83 -- APR-DRG 191 Cardiac Catheterization W Circ Disord Exc Ischemic Heart Disease 84 -- APR-DRG 192 Cardiac Catheterization For Ischemic Heart Disease 85 -- APR-DRG 193 Acute & Subacute Endocarditis 86 -- APR-DRG 194 Heart Failure 87 -- APR-DRG 196 Cardiac Arrest 88 -- APR-DRG 197 Peripheral & Other Vascular Disorders 89 -- APR-DRG 198 Angina Pectoris & Coronary Atherosclerosis 90 -- APR-DRG 199 Hypertension 91 -- APR-DRG 200 Cardiac Structural & Valvular Disorders 92 -- APR-DRG 201 Cardiac Arrhythmia & Conduction Disorders 93 -- APR-DRG 203 Chest Pain 94 -- APR-DRG 204 Syncope & Collapse 95 -- APR-DRG 205 Cardiomyopathy 96 -- APR-DRG 206 Malfunction, Reaction & Comp Of Cardiac Or Vasc Device Or Procedure 97 -- APR-DRG 207 Other Circulatory System Diagnoses 98 -- MDC 06 Diseases & disorders of the digestive system 99 -- APR-DRG 220 Major Stomach, Esophageal & Duodenal Procedures 99 -- APR-DRG 221 Major Small & Large Bowel Procedures 100 -- APR-DRG 222 Other Stomach, Esophageal & Duodenal Procedures 101 -- APR-DRG 223 Other Small & Large Bowel Procedures 102 -- APR-DRG 224 Peritoneal Adhesiolysis 103 -- APR-DRG 225 Appendectomy 104 -- APR-DRG 226 Anal Procedures 105 -- APR-DRG 227 Hernia Procedures Except Inguinal, Femoral & Umbilical 106 -- APR-DRG 228 Inguinal, Femoral & Umbilical Hernia Procedures 107 -- APR-DRG 229 Other Digestive System & Abdominalprocedures 108 -- APR-DRG 240 Digestive Malignancy 109 -- APR-DRG 241 Peptic Ulcer & Gastritis 110 -- APR-DRG 242 Major Esophageal Disorders 111 -- APR-DRG 243 Other Esophageal Disorders 112 -- APR-DRG 244 Diverticulitis & Diverticulosis 113 -- APR-DRG 245 Inflammatory Bowel Disease 114 -- APR-DRG 246 G.I. Vascular Insufficiency 115 -- APR-DRG 247 Intestinal Obstruction 116 -- APR-DRG 248 Major G.I. & Peritoneal Infections 117 -- APR-DRG 249 Nonbacterial Gastroenteritis, Nausea & Vomiting 118 -- APR-DRG 251 Abdominal Pain 119 -- APR-DRG 252 Mallfunction, Reaction & Complication Of Gi Device Or Procedure 120 -- APR-DRG 253 Other & Unspecified Gastro-Intestinal Hemorrhage 121 -- APR-DRG 254 Other Digestive System Diagnoses 122 -- MDC 07 Diseases & disorders of the hepatobiliary system & pancreas 123 -- APR-DRG 260 Major Pancreas, Liver & Shunt Procedures 123 -- APR-DRG 261 Major Biliary Tract Procedures 124 -- APR-DRG 262 Cholecystectomy Except Laparoscopic 125 -- APR-DRG 263 Laparoscopic Cholecystectomy 126 -- APR-DRG 264 Other Hepatobiliary & Pancreas, Abdominal Procedures 127 -- APR-DRG 279 Hepatic Coma & Other Major Acute Liver Disorders 128 -- APR-DRG 280 Alcoholic Liver Disease 129 -- APR-DRG 281 Malignancy Of Hepatobiliary System & Pancreas 130 -- APR-DRG 282 Disorders Of Pancreas Except Malignancy 131 -- APR-DRG 283 Other Disorders Of Liver 132 -- APR-DRG 284 Disorders Of The Gallbladder & Biliary Tract 133 -- MDC 08 Diseases & disorders of the musculoskeletal system & connective tissue 134 -- APR-DRG 301 Hip Joint Replacement 134 -- APR-DRG 302 Knee Joint Replacement 135 -- APR-DRG 303 Dorsal & Lumbar Fusion Proc For Curvature Of Back 136 -- APR-DRG 304 Dorsal & Lumbar Fusion Proc Except For Curvature Of Back 137 -- APR-DRG 305 Amputation Of Lower Limb, Except Toes 138 -- APR-DRG 308 Hip & Femur Procedures For Trauma, Except Joint Replacement 139 -- APR-DRG 309 Hip & Femur Procedures For Nontrauma, Except Joint Replacement 140 -- APR-DRG 310 Intervetebral Disc Excision & Decompression 141 -- APR-DRG 312 Skin Graft, Except Hand, For Musculoskeletal & Connective Tissu Diagnoses 142 -- APR-DRG 313 Knee & Lower LegProcedures -- Except Foot 143 -- APR-DRG 314 Foot & Toe Procedures 144 -- APR-DRG 315 Shoulder, Upperarm & Forearm Procedures 145 -- APR-DRG 316 Hand & Wrist Procedures 146 -- APR-DRG 317 Tendon, Muscle & Other Soft Tissue Procedures 147 -- APR-DRG 320 Other Musculoskeletel System & Connective Tissue Procedures 148 -- APR-DRG 321 Cervical Spinal Fusion & Other Back/Neck Proc except Disc Excis/Decomp 149 -- APR-DRG 340 Fractures Of Femur 150 -- APR-DRG 341 Fracture Of Pelvis Or Dislocation Of Hip 151 -- APR-DRG 342 Fracture Or Dislocation Except Femur, Pelvis & Back 152 -- APR-DRG 343 Musculoskeletal Malignancy & Pathological Fractures D/T Musckel Malignancy 153 -- APR-DRG 344 Osteomyelitis, Septic Arthitis & Other Musculoskeletal Infections 154 -- APR-DRG 346 Connective Tissue Disorders 155 -- APR-DRG 347 Other Back & Neck Disorders, Fractures & Injuries 156 -- APR-DRG 349 Malfunction, Reaction & Comp Of Orthopedic Device Or Procedure 157 -- APR-DRG 351 Other Musculoskeletal System & Connective Tissue Diagnoses 158 -- MDC 09 Diseases & disorders of the skin, subcutaneous tissue and breast 159 -- APR-DRG 361 Skin Graft For Skin & Subcutaneous Tissue Diagnoses 159 -- APR-DRG 362 Mastectomy Procedures 160 -- APR-DRG 363 Breast Procedures Except Mastectomy 161 -- APR-DRG 364 Other Skin, Subcutaneous Tissue & Related Procedures 162 -- APR-DRG 380 Skin Ulcers 163 -- APR-DRG 381 Major Skin Disorders 164 -- APR-DRG 382 Malignant Breast Disorders 165 -- APR-DRG 383 Cellulitis & Other Bacterial Skin Infections 166 -- APR-DRG 384 Contusion,Open Wound & Other Trauma To Skin & Subcutaneous Tissue 167 -- APR-DRG 385 Other Skin, Subcutaneous Tissue & Breast Disorders 168 -- MDC 10 Endocrine, nutritional & metabolic diseases & disorders 169 -- APR-DRG 401 Adrenal & Pituitary Procedures 169 -- APR-DRG 403 Procedures For Obesity 170 -- APR-DRG 404 Thyroid, Parathyroid & Thyroglossal Procedures 171 -- APR-DRG 405 Other Procedures For Endocrine, Nutrititional & Metabolic Disorders 172 -- APR-DRG 420 Diabetes 173 -- APR-DRG 421 Malnutrition, Failure To Thrive & Other Nutritional Disorders 174 -- APR-DRG 422 Hypovolemia & Related Electrolyte Disorders 175 -- APR-DRG 423 Inborn Errors Of Metabolism 176 -- APR-DRG 424 Other Endocrine Disorders 177 -- APR-DRG 425 Electrolyte Disorders Except Hypovolemia Related 178 -- MDC 11 Diseases & disorders of the kidney & urinary tract 179 -- APR-DRG 440 Kidney Transplant 179 -- APR-DRG 441 Major Bladder Procedures 180 -- APR-DRG 442 Kidney & Urinary Tract Procedures For Malignancy 181 -- APR-DRG 443 Kidney & Urinary Tract Procedures For Nonmalignancy 182 -- APR-DRG 444 Renal Dialysis Access Device Procedure Only 183 -- APR-DRG 445 Other Bladder Procedures 184 -- APR-DRG 446 Urethral & Transurethral Procedures 185 -- APR-DRG 447 Other Kidney, Urinary Tract & Related Procedures 186 -- APR-DRG 460 Renal Failure 187 -- APR-DRG 461 Kidney & Urinary Tract Malignancy 188 -- APR-DRG 462 Nephritis & Nephrosis 189 -- APR-DRG 463 Kidney & Urinary Tract Infections 190 -- APR-DRG 465 Urinary Stones & Acquired Upper Urinary Tract Obstruction 191 -- APR-DRG 466 Malfunctions, Reactions & Complication Of Gentourinary Device Or Proc 192 -- APR-DRG 468 Other Kidney & Urinary Tract Diagnoses, Signs & Symptoms 193 -- MDC 12 Diseases & disorders of the male reproductive system 194 -- APR-DRG 480 Major Male Pelvic Procedures 194 -- APR-DRG 481 Penis Procedures 195 -- APR-DRG 482 Transurethral Prostatectomy 196 -- APR-DRG 483 Testes & Scrotalprocedures 197 -- APR-DRG 484 Other Male Reproductive System & Related Procedures 198 -- APR-DRG 500 Malignancy, Male Reproductive System 199 -- APR-DRG 501 Male Reproductive System Diagnoses Except Malignancy 200 -- MDC 13 Diseases & disorders of the female reproductive system 201 -- APR-DRG 510 Pelvic Evisceration, Radical Hysterectomy & Other Radical Gyn Proc 201 -- APR-DRG 511 Uterine & Adnexa Procedures For Ovarian & Adnexal Malignancy 202 -- APR-DRG 512 Uterine & Adnexa Procedures For Non-Ovarian & Non-Adnexal Malignancy 203 -- APR-DRG 513 Uterine & Adnexa Procedures For Non-Malignancy Except Leiomyoma 204 -- APR-DRG 514 Female Reproductive System Reconstructive Procedures 205 -- APR-DRG 517 Dilatation & Curettage For Non-Obstetric Diagnoses 206 -- APR-DRG 518 Other Female Reproductive System & Related Procedures 207 -- APR-DRG 519 Uterine & Adnexa Procedures For Leiomyoma 208 -- APR-DRG 530 Female Reproductive System Malignancy 209 -- APR-DRG 531 Female Reproductive System Infections 210 -- APR-DRG 532 Menstrual & Other Female Reproductive System Disorders 211 -- MDC 14 Pregnancy, childbirth & the puerperium 212 -- APR-DRG 540 Caesarean Delivery 212 -- APR-DRG 541 Vaginal Delivery W Sterilization &/Or D&C 213 -- APR-DRG 542 Vaginal Delivery W Complicating Proc Except Sterilization &/Or D&C 214 -- APR-DRG 544 D, Aspiration Curettage Or Hysterotomy For Obstetric Diagnoses 215 -- APR-DRG 545 Ectopic Pregnancy Procedure 216 -- APR-DRG 546 Other O.R. Procedures For Obstetric Diagnoses Except Delivery Diagnoses 217 -- APR-DRG 560 Vaginal Delivery 218 -- APR-DRG 561 Postpartum & Post Abortion Diagnoses W/O Procedure 219 -- APR-DRG 563 Threatened Abortion 220 -- APR-DRG 564 Abortion W/O D, Aspiration Curettage Or Hysterotomy 221 -- APR-DRG 565 False Labor 222 -- APR-DRG 566 Other Antepartum Diagnoses 223 -- MDC 15 Newborns & other neonates 224 -- APR-DRG 580 Neonate, Transferred 2499G W Major Cardiovasc Procedure 245 -- APR-DRG 631 Neonate, Birthwt > 2499G W Other Major Procedure 246 -- APR-DRG 633 Neonate, Birthwt > 2499G W Major Anomaly 247 -- APR-DRG 634 Neonate, Birthwt > 2499G W Respiratory Distress Syndrome/Other 248 -- APR-DRG 636 Neonate, Birthwt > 2499G W Congenital/Perinatal Infections 249 -- APR-DRG 639 Neonate, Birthwt > 2499G, W Other Signif Condition 250 -- APR-DRG 640 Neonate, Birthwt > 2499G, Normal Nb & Nb W Other Problem 251 -- MDC 16 Diseases & disorders of blood, blood forming organs and immunological disorders 252 -- APR-DRG 650 Splenectomy 252 -- APR-DRG 651 Other Procedures Of Blood & Blood Forming Organs 253 -- APR-DRG 660 Major Hematological/Immunologic Diag Exc Sickle Cell Crisis & Coagulation Disorders 254 -- APR-DRG 661 Coagulation and Platelet Disorders 255 -- APR-DRG 662 Sickle Cell Anemia Crisis 256 -- APR-DRG 663 Other Anemia and disorders of blood and blood-forming organs 257 -- MDC 17 Myeloproliferative diseases & disorders, poorly differentiated 258 -- APR-DRG 680 Major Or Proc For Lymphatic/Hematopoietic/Other Neoplasms 258 -- APR-DRG 681 Other Or Proc For Lymphatic/Hematopoietic/Other Neoplasms 259 -- APR-DRG 690 Acute Leukemia 260 -- APR-DRG 691 Lymphoma, Myeloma & Non-Acute Leukemia 261 -- APR-DRG 692 Radiotherapy 262 -- APR-DRG 693 Chemotherapy 263 -- APR-DRG 694 Lymphatic & Other Malignancies & Neoplasms Of Uncertain Behaviour 264 -- MDC 18 Infectious & parasitic diseases, systemic or unspecified sites 265 -- APR-DRG 710 Infectious & Parasitic Diseases Including HIV W Or Proc 265 -- APR-DRG 711 Post-Op, Post-Trauma, Other Device Infections W Or Proc 266 -- APR-DRG 720 Septicemia & Disseminated Infections 267 -- APR-DRG 721 Postoperative, Post-Traumatic, Other Device Infections 268 -- APR-DRG 722 Fever 269 -- APR-DRG 723 Viral Illness 270 -- APR-DRG 724 Other Infectious & Parasitic Diseases 271 -- MDC 19 Mental diseases & disorders 272 -- APR-DRG 740 Mental Illness Diagnoses W Or Procedure 272 -- APR-DRG 750 Schizophrenia 273 -- APR-DRG 751 Major Depressive Disorders & Other/Unspecified Psychoses 274 -- APR-DRG 752 Disorders Of Personality & Impulse Control 275 -- APR-DRG 753 Bipolar Disorders 276 -- APR-DRG 754 Depression, Except Major Depressive Disorder 277 -- APR-DRG 755 Adjustment Disorder & Neuroses Exc Depressive Diagnoses 278 -- APR-DRG 756 Acute Anxiety & Delirium States 279 -- APR-DRG 757 Organic Mental Health Disturbances 280 -- APR-DRG 758 Childhood Behavioral Disorders 281 -- APR-DRG 759 Eating Disorders 282 -- APR-DRG 760 Other Mental Health Disorders 283 -- MDC 20 Alcohol/drug use & alcohol/drug induced organic mental disorders 284 -- APR-DRG 770 Drug & Alcohol Abuse Or Dependence, Left Against Medical Advice 284 -- APR-DRG 772 Alcohol & Drug Dependence WRehabilitation -- Therapy Or Rehab/Detox 285 -- APR-DRG 773 Opioid Abuse & Dependence 286 -- APR-DRG 774 Cocaine Abuse & Dependence 287 -- APR-DRG 775 Alcohol Abuse & Dependence 288 -- APR-DRG 776 Other Drug Abuse & Dependence 289 -- MDC 21 Injuries, poisonings & toxic effects of drugs 290 -- APR-DRG 791 Or Procedures For Other Complications Of Treatment 290 -- APR-DRG 811 Allergic Reactions 291 -- APR-DRG 812 Poisoning Of Medicinal Agents 292 -- APR-DRG 813 Other Complications Of Treatment 293 -- APR-DRG 815 Other Injury, Poisoning & Toxic Effect Diagnoses 294 -- APR-DRG 816 Toxic Effect Of Non-Medicinal Substances 295 -- MDC 22 Burns 296 -- APR-DRG 841 Extensive 3rd Degree Burns W Skin Graft 296 -- APR-DRG 842 Full Thickness Burns W Skin Graft 297 -- APR-DRG 843 Extensive 3rd Degree Or Full Thickness Burns W/O Skin Graft 298 -- APR-DRG 844 Partial Thickness Burns W Or W/O Skin Graft 299 -- MDC 23 Factors influencing health status & other contacts with health services 300 -- APR-DRG 850 Procedure W Diagnoses Of Rehab,Aftercare Or Other Contact With Health Services 300 -- APR-DRG 860 Rehabilitation 301 -- APR-DRG 861 Signs, Symptoms & Other Factors Influencing Health Status 302 -- APR-DRG 862 Other Aftercare & Convalescence 303 -- APR-DRG 863 Neonatal Aftercare 304 -- MDC 24 HIV infections 305 -- APR-DRG 890 HIV W Multiple Major Hiv Related Conditions 305 -- APR-DRG 892 HIV W Major Hiv Related Conditions 306 -- APR-DRG 893 HIV W Multiple Significant Hiv Related Conditions 307 -- APR-DRG 894 HIV W One Significant Hiv Condition Or W/O Significant Related Conditions 308 -- MDC 25 Multiple significant trauma 309 -- APR-DRG 910 Craniotomy For Multiple Significant Trauma 309 -- APR-DRG 911 Extensive Abdominal/Thoracic Procedures For Multiple Significant Trauma 310 -- APR-DRG 912 Musculo-Skeletlal & Other Procedures For Multiple Significant Trauma 311 -- APR-DRG 930 Multiple Significant Trauma W/O Or Proc 312 -- MDC 00 Residual group 313 -- APR-DRG 950 Extensive Procedure Unrelated To Principal Diagnosis 313 -- APR-DRG 951 Moderately Extensive Procedure Unrelated To Principal Diagnosis 314 -- APR-DRG 952 Nonextensive Procedure Unrelated To Principal Diagnosis 315 -- APR-DRG 955 Principal Diagnosis Invalid As Discharge Diagnosis 316 -- APR-DRG 956 Ungroupable 317 -- MDC Long term stays 318 -- APR-DRG Long term stays with less than 365 days 318 -- APR-DRG Long term stays equal to 365 days 319 -- APR-DRG Long term stays with more than 365 days 320 -- Chronic care in S-beds 321 -- APR-DRG Chronic care in bedtype S1 321 -- APR-DRG Chronic care in bedtype S2 322 -- APR-DRG Chronic care in bedtype S3 323 -- APR-DRG Chronic care in bedtype S4 324 -- APR-DRG Chronic care in bedtype S5 325 -- APR-DRG Chronic care in bedtype S6 326 -- APR-DRG Chronic care in different S-bedtypes 327 -- Hospital stays of foreign patients 328

74 p. ill., In het kader van haar plannen voor de hervorming van het ziekenhuislandschap vroeg minister De Block aan het Federaal Kenniscentrum voor de Gezondheidszorg (KCE) om na te gaan hoeveel bedden de Belgische algemene ziekenhuizen in 2025 nodig zullen hebben. Het blijkt dat er vandaag in het algemeen al teveel capaciteit is, en dat deze trend zich zal voortzetten. De grote uitzondering hierop zijn de bedden voor geriatrie en revalidatie, waaraan er nu reeds een tekort is, dat alleen maar zal toenemen. We moeten ook nog veel meer in het dagziekenhuis behandelen dan nu het geval is. Het KCE onderzocht ook de huidige en toekomstige behoeften voor een aantal specifieke types van zorg: de materniteiten, complexe kankerchirurgie en radiotherapie. Operaties bij complexe kankers en radiotherapie zouden enkel nog mogen worden uitgevoerd in een klein aantal ziekenhuizen, met gespecialiseerde expertise, die zo voldoende ervaring kunnen opbouwen en behouden. Hierdoor verhoogt de kans op overleving van de patiënt. Er zijn daarnaast teveel kleine materniteiten die maar 1 of twee bevallingen per dag hebben. Het KCE berekende dat we tegen 2025 een derde van de huidige bedden in de materniteiten kunnen sluiten. VOORWOORD.1 -- SYNTHESE2 -- 1. ACHTERGROND 7 -- 1.1. HUIDIGE SAMENWERKING TUSSEN DE BELGISCHE ZIEKENHUIZEN LEIDT NIET TOT BETERE TAAKVERDELING 7 -- 1.2. NAAR EEN HERVORMING VAN HET ZIEKENHUISLANDSCHAP.8 -- 1.2.1. KCE rapport van 2014: een kader voor een hervormd ziekenhuislandschap 8 -- 1.2.2. Hervormingsplannen van de huidige minister: van ‘Plan van Aanpak’ naar een concrete Conceptnota.8 -- 1.2.3. De rol van programmatie in de huidige ziekenhuishervorming 9 -- 1.2.4. Opdracht van deze studie: berekening benodigde ziekenhuiscapaciteit en bepalen van programmatiecriteria voor een selectie van zorgopdrachten 10 -- 2. CAPACITEITSPLANNING AAN DE HAND VAN EEN TRENDANALYSE.10 -- 2.1. CAPACITEITSPLANNING: AFSTEMMING OP DE BEHOEFTEN VAN DE BEVOLKING IS NODIG10 2.2. CAPACITEITSPLANNING MET BEHULP VAN EEN TRENDANALYSE .11 -- 2.2.1. Trends leren ons wat in het verleden gebeurde en wat we in de toekomst kunnen verwachten 11 -- 2.2.2. ‘Wat als’ scenario’s zijn nodig om opkomende trends en eenmalige veranderingen te vatten 11 -- 3. HUIDIGE TRENDS EN VOORSPELLINGEN VOOR 2025 12 -- 3.1. TRENDANALYSE: DEMOGRAFISCHE EN ANDERE ONTWIKKELINGEN 12 -- 3.2. DE BEVOLKINGSGROEI EN DE VERGRIJZING ZULLEN HET AANTAL KLASSIEKE ZIEKENHUISVERBLIJVEN MET BIJNA 12% DOEN TOENEMEN 13 -- 3.3. GEMIDDELDE VERBLIJFSDUUR BLIJFT VERDER INKRIMPEN 13 -- 3.3.1. Jaarlijkse vermindering met 1,5% of met 1 dag op 10 jaar tijd…13 -- 3.3.2. …voor bijna alle aandoeningen . 13 -- 3.3.3. Een snellere inkorting van de verblijfsduur bij de minder ernstige gevallen 14 -- 3.4. EEN AFNAME VAN HET AANTAL VERPLEEGDAGEN MET 5%, MET EEN VERSCHUIVING VAN ACUTE NAAR CHRONISCHE ZORG 15 -- 3.4.1. Door verblijven in te korten, kan men capaciteit voor een groter aantal verblijven creëren .15 -- 3.4.2. Minder verpleegdagen voor 2 op de 3 pathologiegroepen, met een verschuiving van acute -- naar chronische zorg . 17 -- 3.5. GROTE TOENAME VAN DAGOPNAMES 17 -- 3.6. DEMOGRAFISCHE VERSCHILLEN TUSSEN DE REGIO’S VRAGEN EEN AANGEPASTE BENADERING 18 -- 3.6.1. Sterkere vergrijzing in Vlaanderen en Wallonië 19 -- 3.6.2. Meer dagopnames in Vlaanderen . 20 -- 3.6.3. Groot verschil in gemiddelde verblijfsduur . 20 -- 4. VEREISTE BEDCAPACITEIT VOOR 2025 20 -- 4.1. HET CONCEPT ‘NORMATIEVE BEHOEFTE AAN BEDCAPACITEIT’ 20 -- 4.2. MINDER BEHOEFTE AAN KLASSIEKE ZIEKENHUISBEDDEN, MAAR MEER PLAATSEN VOOR DAGOPNAMES NODIG. 22 -- 4.3. OVERAANBOD IN MATERNITEITEN EN CHIRURGISCHE BEDDEN 23 -- 4.4. HET BELANG VAN DEMOGRAFIE EN MOBILITEIT VAN PATIËNTEN TUSSEN DE REGIO'S 23 -- 4.5. VERSNELDE VERSCHUIVING NAAR DAGOPNAMES 24 -- 4.6. VERSNELDE VERGRIJZING VANAF 2030 24 -- 4.6.1. 75-plussers zullen 28% van het aantal ziekenhuisopnames innemen .24 -- 4.6.2. Scenario van versnelde veroudering 24 -- 4.6.3. Ziekenhuisactiviteit neemt sterk toe . 25 -- 4.6.4. Meer langdurige klassieke verblijven en grotere behoefte aan G- en S-bedden 25 -- 4.7. GERIATRISCHE BEDDEN: DEMENTIE ALS VOORBEELD 25 -- 4.7.1. Waarom deze groep? 25 -- 4.7.2. Capaciteitsproblemen bij geriatrie: een reeds lang bestaand probleem dat wordt aangepakt 25 -- 4.7.3. Patiënten met dementie worden vaker gehospitaliseerd 26 -- 4.7.4. Patiënten met dementie verblijven langer in het ziekenhuis dan hun niet-demente -- leeftijdsgenoten 27 -- 4.7.5. Ziekenhuisopname niet altijd nodig 27 -- 4.7.6. Interventies om het ziekenhuisgebruik te verminderen worden uitvoerig beschreven en -- getest: maar werken ze? 28 -- 5. DE ROL VAN ‘EVIDENCE-INFORMED’ PROGRAMMATIE 29 -- 5.1. TYPERING VAN ZORGOPDRACHTEN 29 -- 5.2. HET CONCEPT VAN WETENSCHAPPELIJK GEÏNFORMEERDE PROGRAMMATIE.30 -- 5.2.1. Informatie om beleidsbeslissingen te ondersteunen: weegt de mening van experten even zwaar als wetenschappelijk bewijsmateriaal? 31 -- 5.2.2. Een wetenschappelijk geïnformeerd besluitvormingsproces 32 -- 6. COMPLEXE CHIRURGIE BIJ KANKER VAN DE PANCREAS, SLOKDARM EN LONG33 -- 6.1. HET CENTRALISEREN VAN ZELDZAME EN COMPLEXE ZORG IN REFERENTIECENTRA IS INTERNATIONAAL DE STANDAARD 33 -- 6.2. SCOPE EN DOEL VAN HET ONDERZOEK 33 -- 6.3. HET VOORBEREIDENDE WERK IS AL GEBEURD 34 -- 6.4. PANCREASKANKER 34 -- 6.4.1. Pancreaskanker in België: een versnipperde expertise. 34 -- 6.4.2. Minimale volumecriteria per ziekenhuis en per chirurg 36 -- 6.4.3. 2 tot 13 referentiecentra voldoen aan de minimale volumecriteria 36 -- 6.4.4. 10 referentiecentra moeten het stijgend aantal patiënten kunnen opvangen 38 -- 6.4.5. Jaarlijkse toename van 36 tot 39 patiënten per centrum 38 -- 6.5. SLOKDARMKANKER . 38 -- 6.5.1. Slokdarmkanker in België: een versnipperde expertise. 38 -- 6.5.2. Minimale volumecriteria per ziekenhuis en per chirurg 39 -- 6.5.3. 4 à 5 referentiecentra voldoen aan de minimale volumecriteria.39 -- 6.5.4. 5 referentiecentra moeten het stijgend aantal patiënten kunnen opvangen 40 -- 6.5.5. Jaarlijkse toename van 64 tot 82 patiënten per centrum 40 -- 6.6. LONGKANKER . 40 -- 6.6.1. Longkanker in België: een versnipperde expertise . 40 -- 6.6.2. Minimale volumecriteria per ziekenhuis en per chirurg 41 -- 6.6.3. 23 referentiecentra voldoen aan de minimale volumecriteria 42 -- 6.6.4. 23 referentiecentra moeten het stijgend aantal patiënten kunnen opvangen 42 -- 6.6.5. Jaarlijkse toename van 62 tot 84 patiënten per centrum 42 -- 6.7. KWALITEIT VRAAGT CONCENTRATIE, MAAR CONCENTRATIE MAG NIET LEIDEN TOT WACHTLIJSTEN 43 -- 7. RADIOTHERAPIE 43 -- 7.1. DOEL VAN DE STUDIE. 43 -- 7.2. 24 RADIOTHERAPIECENTRA OP 37 LOCATIES, NIET GELIJKMATIG VERSPREID OVER GRONDGEBIED 43 -- 7.3. GROTE VARIABILITEIT IN ACTIVITEIT TUSSEN RADIOTHERAPIECENTRA 46 -- 7.4. HET AANTAL BESTRAALDE KANKERPATIËNTEN LIGT LAGER DAN AANGEWEZEN VOLGENS DE BESCHIKBARE RICHTLIJNEN 46 -- 7.5. COMPLEXITEIT VAN DE BEHANDELINGEN NEEMT TOE 46 -- 7.6. AANTAL TOESTELLEN LIJKT MOMENTEEL VOLDOENDE… . 47 -- 7.7. …MAAR EEN UITBREIDING VAN DE CAPACITEIT ZAL NODIG ZIJN 49 -- 7.8. OPROEP TOT MEER CENTRALISATIE . 49 -- 7.9. OPENEN NIEUWE CENTRA VERMIJDEN EN OVERWEGEN OM KLEINERE TE SLUITEN50 -- 8. MATERNITEITEN. 50 -- 8.1. SCOPE EN DOEL VAN HET ONDERZOEK 50 -- 8.2. 111 MATERNITEITEN DIE ONGELIJKMATIG VERSPREID ZIJN. 50 -- 8.3. MATERNITEITEN ZIJN BELANGRIJK, ZEKER VOOR KLEINERE ZIEKENHUIZEN.52 -- 8.4. AANTAL GEBOORTEN STABIEL, MAAR VERBLIJFSDUUR VERMINDERT 52 -- 8.5. AANTAL BEVALLINGEN VERSCHILT STERK TUSSEN DE MATERNITEITEN EN REGIO’S 52 -- 8.6. LAGE BEZETTINGSGRAAD, BEHALVE IN DE BRUSSELSE MATERNITEITEN 54 -- 8.7. DE HUIDIGE OVERCAPACITEIT ZAL NOG TOENEMEN IN DE TOEKOMST 55 -- 8.8. VRAAG EN AANBOD BETER OP ELKAAR AFSTEMMEN 55 -- 8.8.1. Aanpassen van de programmatiecriteria aan de huidige en toekomstige realiteit 55 -- 8.9. ENKEL HET AANTAL M-BEDDEN VERMINDEREN IS ONVOLDOENDE.56 -- 8.10. EEN SPECIFIEKE EVALUATIE VOOR DE MIC-BEDDEN 57 -- 9. DISCUSSIE.58 -- 9.1. VOLDOENDE ZIEKENHUISCAPACITEIT MAAR EEN GROTE NOOD OM MIDDELEN ANDERS IN TE ZETTEN 58 -- 9.1.1. Locoregionale netwerken: rationaliseren en heroriënteren van algemene en gespecialiseerde zorgopdrachten . 58 -- 9.1.2. Concentratie van zorg op supraregionaal niveau: implicaties voor kleine en grote -- ziekenhuizen . 60 -- 9.2. VISIE – GOVERNANCE – KENNIS OM HERVORMING OP DUURZAME WIJZE TE REALISEREN 60 -- AANBEVELINGEN 63

Background: Incidence rates of thyroid cancer (TC) increased in several countries during the last 30 years, while mortality rates remained unchanged, raising important questions for treatment and follow-up of TC patients. This study updates population-based estimates of relative survival (RS) after TC diagnosis in Europe by sex, country, age, period and histology.Methods: Data from 87 cancer registries in 29 countries were extracted from the EUROCARE-5 dataset. One-and 5-year RS were estimated using the cohort approach for 86,690 adult TC patients diagnosed in 2000-2007 and followed-up to 12/31/2008. RS trends in 1999-2007 and 10-year RS in 2005-2007 were estimated using the period approach.Results: In Europe 2000-2007, 5-year RS after TC was 88% in women and 81% in men. Survival rates varied by country and were strongly correlated (Pearson rho = 75%) with country-specific incidence rates. Five-year RS decreased with age (in women from > 95% at age 15-54 to 57% at age 75+), from 98% in women and 94% in men with papillary TC to 14% in women and 12% in men with anaplastic TC. Proportion of papillary TC varied by country and increased over time, while survival rates were similar across areas and periods. In 1999-2007, 5-year RS increased by five percentage points for all TCs but only by two for papillary and by four for follicular TC. Ten-year RS in 2005-2007 was 89% in women and 79% in men.Conclusions: The reported increasing TC survival trend and differences by area are mainly explained by the varying histological case-mix of cases. (C) 2017 Elsevier Ltd. All rights reserved.

544 p. ill., SCIENTIFIC REPORT 33 -- INTRODUCTION AND BACKGROUND 33 -- 1 PROJECTED FUTURE TRENDS OF HOSPITAL USE IN BELGIUM 35 -- 1.1 INTRODUCTION 35 -- 1.2 TREND ANALYSIS 36 -- 1.3 DATA 37 -- 1.3.1 Population data 37 -- 1.3.2 Hospital data 39 -- 1.4 EVALUATION OF THE REPORT CANNOODT 40 -- 1.4.1 Projection model 41 -- 1.4.2 Comments on the research methodology 45 -- 1.4.3 Evaluation of the projection outcomes 46 -- 1.5 PROJECTION MODEL DEVELOPED FOR THE CURRENT STUDY 59 -- 1.5.1 Defining scope and concepts 61 -- 1.5.2 Rationale for statistical trend analysis 68 -- 1.5.3 Statistical trend model 70 -- 1.5.4 Projection outcomes 78 -- 1.6 INTRODUCTION RESULTS 80 -- 1.7 BASELINE FORECAST RESULTS OF THE PROJECTION MODEL 81 -- 1.7.1 Future need for hospital inpatient care 81 -- 1.7.2 Future need for hospital day care 104 -- 1.7.3 Capacity requirements for isolated categorical hospitals and foreign patients 112 -- 1.7.4 Summary of baseline forecast results 116 -- 1.8 PROJECTION RESULTS SCENARIO WITH ACCELERATED SUBSTITUTION TO DAY CARE 124 -- 1.8.1 Methodology 125 -- 1.8.2 Results 130 -- 1.9 PROJECTION RESULTS SCENARIO WITH ACCELERATED POPULATION AGEING 135 -- 1.9.1 Methodology 135 -- 1.9.2 Results 137 -- 2 HOSPITAL USE BY PATIENTS WITH DEMENTIA 145 -- 2.1 BACKGROUND AND AIM OF THE STUDY 145 -- 2.2 METHOD 147 -- 2.2.1 Literature review 147 -- 2.2.2 Analysis of Belgian hospital registry data 148 -- 2.3 RESULTS ON EPIDEMIOLOGICAL DATA 150 -- 2.3.1 Incidence/prevalence of dementia 150 -- 2.3.2 Hospital use by dementia patients 154 -- 2.4 RESULTS ON INTERVENTIONS TO REDUCE HOSPITAL USE BY DEMENTIA PATIENTS 162 -- 2.4.1 Strategies outside the hospital with an impact on hospital use 162 -- 2.4.2 Strategies in the hospital 164 -- 2.4.3 Strategies with regard to fall prevention 166 -- 2.5 DISCUSSION AND CONCLUSION 166 -- 3 ENGLAND 169 -- 3.1 BACKGROUND 169 -- 3.1.1 Country context 169 -- 3.1.2 Hospital classification 170 -- 3.1.3 Hospital capacity and use 170 -- 3.1.4 English hospitals underwent several changes in service reconfiguration 171 -- 3.1.5 Financial sustainability NHS hospitals 172 -- 3.2 PROXIMITY SERVICES AND SMALL HOSPITALS 172 -- 3.3 CONCENTRATION OF SPECIALISED SERVICES 175 -- 3.3.1 Specialised services are commissioned by NHS England 175 -- 3.4 THE ROLE OF ACUTE CARE HOSPITALS IN INTEGRATED CARE 179 -- 3.5 COLLABORATION FORMS BETWEEN HOSPITALS 179 -- 3.5.1 Mergers: the dominant form of structural collaboration form between English hospitals 179 -- 3.5.2 Collaborative organisation forms 182 -- 3.5.3 Contractual collaboration forms 183 -- 3.5.4 Consolidated collaboration forms 185 -- 3.5.5 Adopt collaboration forms that suit local circumstances 186 -- 3.6 VISION ON THE FUTURE 188 -- 3.6.1 Five Year Forward View 188 -- 3.6.2 From vision towards implementation 190 -- 3.6.3 The envisaged benefits of the reforms plans are overestimated 191 -- 4 FRANCE 193 -- 4.1 BACKGROUND 193 -- 4.1.1 Healthcare regionalisation 193 -- 4.1.2 Health areas 196 -- 4.1.3 Hospital and medical equipment planning 198 -- 4.1.4 Hospital landscape and trends 203 -- 4.2 CONCENTRATION OF COMPLEX SERVICES 206 -- 4.3 SPECIALISATION 209 -- 4.4 PROXIMITY SERVICES AND SMALL HOSPITALS 210 -- 4.5 INTEGRATION OF SERVICES 213 -- 4.6 COLLABORATION FORMS BETWEEN HOSPITALS 215 -- 4.6.1 Hospitals groups 215 -- 4.6.2 Networks 216 -- 4.7 VISION ON THE FUTURE 219 -- 5 THE NETHERLANDS 220 -- 5.1 INTRODUCTION 220 -- 5.2 HOSPITALS IN THE NETHERLANDS 221 -- 5.2.1 The Dutch healthcare system 221 -- 5.2.2 Market reform’ of the healthcare sector 224 -- 5.2.3 Hospital classification, levels and types 226 -- 5.2.4 Hospital capacity: centralised planning and decentralised influences 230 -- 5.3 CONCENTRATION OF SPECIALISED AND HIGHLY SPECIALISED SERVICES 233 -- 5.3.1 Introduction 233 -- 5.3.2 Organisation: dispersion and concentration 233 -- 5.3.3 Planning of specific procedures 234 -- 5.3.4 Contracting specialised services 235 -- 5.4 DISTRIBUTION OF SERVICES 236 -- 5.4.1 Shifts in provision 236 -- 5.5 EFFORTS TO INTEGRATE CARE 237 -- 5.6 CONCLUSIONS AND FUTURE CHALLENGES. 238 -- 5.6.1 Conclusions 238 -- 5.6.2 Future challenges 239 -- 6 COMPLEX SURGERY FOR CANCER OF THE PANCREAS, OESOPHAGUS AND LUNG 240 -- 6.1 INTRODUCTION 240 -- 6.1.1 Background 240 -- 6.1.2 Organisation of care for adults with rare and complex cancers in reference centres 241 -- 6.1.3 Rare and complex cancers: definition and incidence in Belgium 242 -- 6.1.4 Study objectives and research questions 242 -- 6.1.5 Data sources and methods 243 -- 6.2 BRIEF VIEW ON THE ORGANISATION OF ONCOLOGICAL CARE IN BELGIUM AND IN A SELECTION OF COUNTRIES 245 -- 6.2.1 Introduction 245 -- 6.2.2 Belgium 245 -- 6.2.3 France 245 -- 6.2.4 England 252 -- 6.2.5 The Netherlands 254 -- 6.2.6 Denmark 256 -- 6.2.7 A focus on implementation modalities of reference centres or specialised services. 258 -- 6.3 CANCER OF THE PANCREAS 259 -- 6.3.1 Description of the pathology 259 -- 6.3.2 Burden of pancreatic cancer in Belgium 260 -- 6.3.3 Current practice in Belgium 263 -- 6.3.4 International standards for pancreatic resections 269 -- 6.3.5 What is the required number of reference centres in Belgium in 2017? 272 -- 6.3.6 What is the future number of reference centres required (horizon 2025)? 278 -- 6.4 OESOPHAGEAL CANCER 280 -- 6.4.1 Description of the pathology 280 -- 6.4.2 Burden of oesophageal cancer in Belgium 281 -- 6.4.3 Current practice in Belgium 282 -- 6.4.4 International standards for oesophageal resections 289 -- 6.4.5 What is the required number of reference centres in 2017? 292 -- 6.4.6 What is the future number of required reference centres (horizon 2025)? 297 -- 6.5 LUNG CANCER 298 -- 6.5.1 Description of the pathology 298 -- 6.5.2 Burden of lung cancer in Belgium 300 -- 6.5.3 Current practice in Belgium 303 -- 6.5.4 International standards for lung resections 306 -- 6.5.5 What is the required number of reference centres in 2017? 309 -- 6.5.6 What is the future number of required reference centres (horizon 2025)? 314 -- 7 RADIOTHERAPY SERVICES 316 -- 7.1 INTRODUCTION 316 -- 7.2 AVAILABILITY – CURRENT SITUATION IN BELGIUM 317 -- 7.2.1 Programming and licensing rules for radiotherapy departments 317 -- 7.2.2 Current legislation concerning reimbursement 319 -- 7.2.3 Radiotherapy infrastructure in Belgium 319 -- 7.2.4 Activity profile of radiotherapy centres and satellites 329 -- 7.3 NEEDS – CURRENT AND FUTURE SITUATION IN BELGIUM 333 -- 7.3.1 Introduction 333 -- 7.3.2 Methodology 334 -- 7.3.3 Results 356 -- 7.4 HOW ARE RADIOTHERAPY SERVICES ORGANISED IN A SELECTION OF COUNTRIES? 367 -- 7.4.1 Introduction 367 -- 7.4.2 England 372 -- 7.4.3 France 373 -- 7.4.4 Ireland 375 -- 7.4.5 The Netherlands 376 -- 7.4.6 Denmark 378 -- 7.4.7 Summary and conclusion 379 -- 8 MATERNITY SERVICES 379 -- 8.1 INTRODUCTION 379 -- 8.2 ORGANISATION OF MATERNITY SERVICES IN BELGIUM 380 -- 8.2.1 Current organisation and legislation 380 -- 8.2.2 Maternity services activity profile 390 -- 8.2.3 Geographic distribution 410 -- 8.3 ESTIMATION OF (FUTURE) NEEDS 417 -- 8.3.1 Current situation 417 -- 8.3.2 Baseline forecast 417 -- 8.3.3 Alternative scenario 420 -- 8.3.4 Update of programming criteria 424 -- 8.4 ORGANISATION OF MATERNITY SERVICES IN A SELECTION OF COUNTRIES 425 -- 8.4.1 International overview 425 -- 8.4.2 France 430 -- 8.4.3 England 436 -- 8.4.4 Sweden 441 -- 8.5 CRITERIA FOR CONCENTRATION OF CARE 445 -- 8.5.1 Introduction 445 -- 8.5.2 Costs savings 445 -- 8.5.3 Occupancy rate 448 -- 8.5.4 Volume and outcome 448 -- 8.5.5 Access / Distance 449 -- DISCUSSION AND CONCLUSION 450 -- APPENDICES 451 -- REFERENCES 503

74 p. ill., Dans le cadre de ses plans de réforme du paysage hospitalier, la ministre De Block a demandé au Centre fédéral d’Expertise des Soins de Santé (KCE) de calculer le nombre de lits dont nous aurons besoin dans les hôpitaux généraux en 2025. Il semble que nous ayons déjà une capacité trop élevée à l’heure actuelle et que cette situation va encore se marquer davantage dans les années à venir. Quelques exceptions importantes à ce constat : il manque de lits pour les patients gériatriques et la revalidation, et ces déficits vont encore se creuser. Il faut également traiter beaucoup plus de patients en hôpital de jour. Le KCE a également analysé les besoins actuels et à venir pour quelques types de soins spécifiques : les maternités, la chirurgie des cancers complexes et la radiothérapie. Conclusion : les interventions pour cancers complexes et la radiothérapie ne devraient être pratiquées que dans quelques hôpitaux détenant une expertise spécialisée, qui développent et maintiennent une expérience suffisante, car cela augmente les chances de survie pour le patient. Il y a par ailleurs trop de petites maternités où l’on ne pratique que un ou deux accouchements par jour ; le KCE a calculé que l’on devra fermer un tiers des lits actuels de maternité d’ici 2025.  PRÉFACE. 1 --  SYNTHÈSE . 2 -- 1. CONTEXTE. 8 -- 1.1. DANS SA FORME ACTUELLE, LA COLLABORATION ENTRE LES HÔPITAUX BELGES N’AMÉLIORE PAS LA RÉPARTITION DES TÂCHES . 8 -- 1.2. VERS UNE RÉFORME DU PAYSAGE HOSPITALIER 9 -- 1.2.1. Rapport 2014 du KCE : un cadre pour une réforme du paysage hospitalier 9 -- 1.2.2. Les projets de réforme de la ministre actuelle : d’un « Plan d’Approche » à une note conceptuelle concrète . 9 -- 1.2.3. Le rôle de la programmation dans la réforme hospitalière actuelle 10 -- 1.2.4. Objectif de la présente étude : évaluer la capacité hospitalière requise et définir les critères de programmation pour un certain nombre de missions de soins 11 -- 2. PLANIFICATION DE LA CAPACITÉ À L’AIDE D’UNE ANALYSE DES TENDANCES 12 -- 2.1. PLANIFICATION DE LA CAPACITÉ EN FONCTION DES BESOINS DE LA POPULATION 12 -- 2.2. PLANIFICATION DE LA CAPACITÉ À L’AIDE D’UNE ANALYSE DES TENDANCES.12 -- 2.2.1. Les tendances nous renseignent sur le passé et nous prédisent ce que l’avenir pourrait nous réserver 12 -- 2.2.2. Des scénarios de type « et si… » sont nécessaires pour cerner les tendances émergentes et les changements ponctuels 13 -- 3. TENDANCES ACTUELLES ET PRÉVISIONS À L’HORIZON 2025 .13 -- 3.1. ANALYSE DES TENDANCES : DÉVELOPPEMENTS DÉMOGRAPHIQUES ET AUTRES .13 -- 3.2. LES HOSPITALISATIONS CLASSIQUES EN HAUSSE DE PRÈS DE 12 % SOUS L’EFFET DE LA CROISSANCE DE LA POPULATION ET DU VIEILLISSEMENT .14 -- 3.3. LA DURÉE DE SÉJOUR CONTINUE À SE RACCOURCIR 15 -- 3.3.1. Une baisse annuelle de 1,5 %, soit 1 jour sur une période de 10 ans…15 -- 3.3.2. … pour presque toutes les pathologies 15 -- 3.3.3. Une baisse plus rapide pour les cas les moins sévères .15 -- 3.4. UNE BAISSE DE 5 % DU NOMBRE DE JOURNÉES D’HOSPITALISATION, AVEC UN GLISSEMENT DES SOINS AIGUS VERS LES SOINS CHRONIQUES 17 -- 3.4.1. Réduire la durée de séjour permet d’accroître la capacité en termes de nombre de séjours 17 -- 3.4.2. Moins de journées d’hospitalisation pour 2/3 des groupes de pathologies, avec un glissement des soins aigus vers les soins chroniques 18 -- 3.5. UNE PROGRESSION MARQUÉE DES HOSPITALISATIONS DE JOUR 18 -- 3.6. LES DIFFÉRENCES DÉMOGRAPHIQUES ENTRE RÉGIONS APPELLENT UNE APPROCHE ADAPTÉE 20 -- 3.6.1. Un vieillissement plus marqué en Flandre et en Wallonie .20 -- 3.6.2. Davantage d’hospitalisations de jour en Flandre 21 -- 3.6.3. De grandes différences dans la durée moyenne de séjour 21 -- 4. NOMBRE DE LITS NÉCESSAIRES À L’HORIZON 2025 21 -- 4.1. LA NOTION DE « BESOIN NORMATIF EN LITS HOSPITALIERS » 21 -- 4.2. UN BESOIN RÉDUIT EN LITS CLASSIQUES, MAIS DAVANTAGE DE PLACES NÉCESSAIRES EN HÔPITAL DE JOUR . 23 -- 4.3. UNE OFFRE SURABONDANTE DE LITS DE MATERNITÉ ET DE CHIRURGIE 24 -- 4.4. L’IMPORTANCE DE LA DÉMOGRAPHIE ET DE LA MOBILITÉ DES PATIENTS ENTRE RÉGIONS 24 -- 4.5. UN GLISSEMENT ACCÉLÉRÉ VERS L’HÔPITAL DE JOUR 25 -- 4.6. UN VIEILLISSEMENT ACCÉLÉRÉ À PARTIR DE 2030 25 -- 4.6.1. Les patients de plus de 75 ans représenteront 28 % des admissions hospitalières 25 -- 4.6.2. Scénario de vieillissement accéléré 25 -- 4.6.3. Une activité hospitalière en forte hausse 25 -- 4.6.4. Davantage d’hospitalisations classiques de longue durée et un besoin accru en lits G et S 26 -- 4.7. LITS GÉRIATRIQUES : L’EXEMPLE DE LA DÉMENCE 26 -- 4.7.1. Pourquoi cette catégorie de patients ? 26 -- 4.7.2. Problèmes de capacité en gériatrie : prise en main d’un problème de longue date.26 -- 4.7.3. Les patients déments sont plus souvent hospitalisés 27 -- 4.7.4. Une hospitalisation plus longue chez les patients atteints de démence que chez des sujets non déments du même âge. 28 -- 4.7.5. Une hospitalisation pas toujours nécessaire. 28 -- 4.7.6. Des interventions pour réduire la consommation hospitalière ont été abondamment décrites et testées… mais sont-elles réellement efficaces ?29 -- 5. LE RÔLE DE LA PROGRAMMATION « EVIDENCE-INFORMED ».30 -- 5.1. CARACTÉRISATION DES MISSIONS DE SOINS 30 -- 5.2. LE CONCEPT DE PROGRAMMATION SCIENTIFIQUE . 31 -- 5.2.1. Étayer les décisions politiques : l'avis des experts a-t-il autant de poids que les preuves scientifiques ? 31 -- 5.2.2. Un processus de prise de décision scientifiquement éclairé 32 -- 6. CHIRURGIE COMPLEXE POUR LES CANCERS DU PANCRÉAS, DE L'ŒSOPHAGE ET DU POUMON 34 -- 6.1. LA CENTRALISATION DE SOINS RARES ET COMPLEXES DANS DES CENTRES DE REFERENCE EST LA NORME INTERNATIONALE 34 -- 6.2. PORTEE ET OBJECTIF DE L’ETUDE 34 -- 6.3. LE TRAVAIL PREPARATOIRE A DEJA ETE REALISE 34 -- 6.4. CANCER DU PANCREAS 35 -- 6.4.1. Le cancer du pancréas en Belgique : une expertise fragmentée 35 -- 6.4.2. Critères de volume minimal par hôpital et par chirurgien 37 -- 6.4.3. Deux à treize centres de référence répondent aux critères de volume minimal.37 -- 6.4.4. Dix centres de référence doivent pouvoir absorber le nombre croissant de patients 39 -- 6.4.5. Augmentation annuelle de 36 à 39 patients par centre 39 -- 6.5. CANCER DE L'ŒSOPHAGE 39 -- 6.5.1. Le cancer de l'œsophage en Belgique : une expertise fragmentée .39 -- 6.5.2. Critères de volume minimal par hôpital et par chirurgien 40 -- 6.5.3. Quatre à cinq centres de référence répondent aux critères de volume minimal 40 -- 6.5.4. Cinq centres de référence doivent pouvoir absorber le nombre croissant de patients41 -- 6.5.5. Augmentation annuelle de 76 à 99 patients par centre 41 -- 6.6. CANCER DU POUMON. 42 -- 6.6.1. Le cancer du poumon en Belgique : une expertise fragmentée .42 -- 6.6.2. Critères de volume minimal par hôpital et par chirurgien 43 -- 6.6.3. Vingt-trois centres de référence répondent aux critères de volume minimal43 -- 6.6.4. Vingt-trois centres de référence doivent pouvoir absorber le nombre croissant de patients. 44 -- 6.6.5. Augmentation annuelle de 62 à 84 patients par centre 44 -- 6.7. LA QUALITE REQUIERT LA CONCENTRATION, MAIS LA CONCENTRATION NE PEUT PAS ENTRAINER DES LISTES D'ATTENTE 44 -- 7. RADIOTHÉRAPIE. 45 -- 7.1. OBJECTIF DE L’ETUDE 45 -- 7.2. VINGT-QUATRE CENTRES DE RADIOTHERAPIE SUR 37 SITES, INEGALEMENT REPARTIS SUR LE TERRITOIRE. 45 -- 7.3. GRANDE VARIABILITE D'ACTIVITE ENTRE LES CENTRES DE RADIOTHERAPIE.48 -- 7.4. LE NOMBRE DE PATIENTS ATTEINTS DE CANCER IRRADIÉS EST INFÉRIEUR AUX RECOMMANDATIONS SELON LES DIRECTIVES DISPONIBLES 48 -- 7.5. AUGMENTATION DE LA COMPLEXITE DES TRAITEMENTS48 -- 7.6. LE NOMBRE D'APPAREILS SEMBLE SUFFISANT POUR L'INSTANT .49 -- 7.7. MAIS LA CAPACITE DEVRA ETRE AUGMENTEE 50 -- 7.8. APPEL A PLUS DE CENTRALISATION 51 -- 7.9. ÉVITER L’OUVERTURE DE NOUVEAUX CENTRES ET ENVISAGER LA FERMETURE DES PLUS PETITS 52 -- 8. MATERNITÉS 52 -- 8.1. PORTEE ET OBJECTIF DE L’ETUDE 52 -- 8.2. 111 MATERNITES INEGALEMENT REPARTIES 52 -- 8.3. LES MATERNITES ONT UN POIDS IMPORTANT, EN PARTICULIER POUR LES PLUS PETITS HOPITAUX 54 -- 8.4. LE NOMBRE DE NAISSANCES EST STABLE, MAIS LA DUREE DE SEJOUR DIMINUE 54 -- 8.5. LE NOMBRE D'ACCOUCHEMENTS DIFFERE FORTEMENT ENTRE LES MATERNITES ET -- ENTRE LES REGIONS 54 -- 8.6. FAIBLE TAUX D’OCCUPATION, EXCEPTE DANS LES MATERNITES BRUXELLOISES 56 -- 8.7. LA SURCAPACITE ACTUELLE VA ENCORE AUGMENTER A L’AVENIR57 -- 8.8. MIEUX FAIRE CORRESPONDRE L’OFFRE ET LA DEMANDE .57 -- 8.9. REDUIRE UNIQUEMENT LE NOMBRE DE LITS M EST INSUFFISANT 59 -- 8.10. UNE EVALUATION SPECIFIQUE POUR LES LITS MIC. 60 -- 9. DISCUSSION 60 -- 9.1. UNE CAPACITE HOSPITALIERE SUFFISANTE, MAIS UN BESOIN CRIANT DE REVOIR L’UTILISATION DES MOYENS 60 -- 9.1.1. Réseaux locorégionaux : rationaliser et réorienter les missions de soins générales et spécialisées 60 -- 9.1.2. Concentration des soins à l’échelon suprarégional : implications pour les hôpitaux de petite et grande taille. 62 -- 9.2. VISION — GOUVERNANCE — CONNAISSANCES POUR REALISER LA REFORME D’UNE FAÇON DURABLE 63 -- RECOMMANDATIONS 66 -- REFERENCES 72

32 p. ill., Le cancer du poumon est un cancer fréquent, généralement lié au tabagisme. Son pronostic est sombre, en particulier quand il est découvert à un stade avancé. En Belgique, il est la première cause de décès par cancer chez l’homme et la seconde chez la femme. En agissant sur la qualité de sa prise en charge, on peut améliorer notablement son pronostic. Dans le cadre d’un programme d’amélioration globale des soins cancérologiques, le Centre Fédéral d’Expertise des Soins de Santé (KCE) publie une série de 23 indicateurs de qualité pour le diagnostic et le traitement de ce cancer. Même si la qualité des soins est globalement bonne dans les hôpitaux belges, le KCE constate une nouvelle fois que la mortalité après une opération chirurgicale pour cancer du poumon est plus élevée dans les hôpitaux où l’on effectue moins de 10 interventions sur le poumon par an, ce qui est le cas de la moitié des hôpitaux belges. Le KCE recommande donc que ces interventions soient centralisées dans les hôpitaux disposant de l’expertise suffisante. Le KCE plaide aussi pour qu’une grande attention soit portée aux souhaits et préférences du patient dans les décisions de poursuivre un traitement. PRÉFACE 1 -- MESSAGES CLÉS 2 -- SYNTHÈSE. 4 -- 1. CONTEXTE ET OBJECTIFS 7 -- 1.1. LE CANCER DU POUMON : UNE MALADIE FRÉQUENTE ET MORTELLE 7 -- 1.2. OBJECTIFS DE CE RAPPORT 8 -- 1.2.1. Trois objectifs 8 -- 1.2.2. Public cible : cliniciens spécialisés dans le cancer du poumon et équipes multidisciplinaires 8 -- 2. DONNÉES ET MÉTHODES 9 -- 2.1. LES DONNÉES : COUPLAGE ENTRE LES DONNÉES DU REGISTRE DU CANCER ET LES BASES DE DONNÉES ADMINISTRATIVES. 9 -- 2.2. LES PATIENTS : DIAGNOSTIC POSÉ EN 2010-2011, LES PATIENTS PORTEURS D’AUTRES TUMEURS INVASIVES ÉTANT EXCLUS 9 -- 2.3. AFFECTER CHAQUE PATIENT À UN SEUL CENTRE ? PAS SI SIMPLE… 10 -- 2.4. COMMENT IDENTIFIER LES COMORBIDITÉS À PARTIR DES DONNÉES DE FACTURATION DE MÉDICAMENTS ? 10 -- 2.5. ASSOCIATION ENTRE VOLUME ET RÉSULTATS 11 -- 3. QUE RÉVÈLENT LES INDICATEURS SUR LA QUALITÉ DES SOINS ?.12 -- 3.1. UNE ÉTUDE INCLUANT PRÈS DE 13 000 PATIENTS 12 -- 3.2. VINGT-TROIS INDICATEURS DE QUALITÉ MESURÉS : DU DIAGNOSTIC AUX SOINS EN FIN DE VIE. 12 -- 3.2.1. Survie un an après le diagnostic. 16 -- 3.2.2. Qualité de la notification des données au Registre du Cancer (BCR).16 -- 3.2.3. Diagnostic et stadification 16 -- 3.2.4. Traitement 17 -- 3.3. TROIS COMORBIDITÉS IDENTIFIÉES AU MOYEN DES DONNÉES DE FACTURATION DE -- MÉDICAMENTS. 22 -- 3.4. QUEL EST L’IMPACT DU VOLUME HOSPITALIER SUR LES RÉSULTATS ? 22 -- 3.4.1. Volume chirurgical 22 -- 3.4.2. Volume chirurgical et résultats. 23 -- 3.4.3. Volume de radiothérapies 24 -- 3.4.4. Volume de diagnostics 24 -- 4. POINTS FORTS ET LIMITES 25 -- 5. CONCLUSIONS ET PERSPECTIVES .27 -- RECOMMANDATIONS28 -- RÉFÉRENCES. 30

30 p. ill., FOREWORD 1 -- KEY MESSAGES 2 -- SYNTHESIS 4 -- 1 BACKGROUND AND OBJECTIVES 7 -- 1.1 LUNG CANCER, A FREQUENT AND LETHAL DISEASE 7 -- 1.2 IMPROVE QUALITY OF CARE THROUGH FEEDBACK 8 -- 1.2.1 Three objectives 8 -- 1.2.2 Target audience: clinicians specialized in lung cancer and multidisciplinary teams 8 -- 2 DATA AND METHODS 9 -- 2.1 THE DATA: A LINKAGE BETWEEN THE BELGIAN CANCER REGISTRY DATA AND ADMINISTRATIVE DATABASES 9 -- 2.2 THE PATIENTS: DIAGNOSED IN 2010-2011 WITH EXCLUSION OF PATIENTS WITH OTHER INVASIVE TUMOURS 9 -- 2.3 ASSIGNING EACH PATIENT TO A SINGLE CENTRE? NOT STRAIGHTFORWARD… 10 -- 2.4 HOW TO IDENTIFY COMORBIDITY BASED ON DATA OF PHARMACEUTICAL BILLING DATA? 10 -- 2.5 THE ASSOCIATION BETWEEN VOLUME AND OUTCOMES 11 -- 3 WHAT DO THE INDICATORS TELL ABOUT THE QUALITY OF CARE?.12 -- 3.1 A STUDY INCLUDING ALMOST 13 000 PATIENTS 12 -- 3.2 TWENTY-THREE QUALITY INDICATORS MEASURED: FROM DIAGNOSIS TO END-OF-LIFE CARE 12 -- 3.2.1 Survival one year after diagnosis 16 -- 3.2.2 Quality of data reporting to Belgian Cancer Registry (BCR) 16 -- 3.2.3 Diagnosis and staging 16 -- 3.2.4 Treatment 17 -- 3.3 THREE COMORBIDITIES IDENTIFIED USING PATIENT PHARMACEUTICAL BILLING DATA 21 -- 3.4 WHAT’S THE IMPACT OF HOSPITAL VOLUME ON THE OUTCOME? .21 -- 3.4.1 Surgical volume 21 -- 3.4.2 Radiotherapy volume .23 -- 3.4.3 Diagnostic volume 23 -- 4 STRENGTHS AND LIMITATIONS 24 -- 5 CONCLUSIONS AND FUTURE PROSPECTS 25 -- RECOMMENDATIONS 27 -- REFERENCES 28

32 p. ill., Longkanker komt vaak voor en wordt meestal veroorzaakt door roken. De kanker heeft geen goede prognose, vooral als hij pas in een gevorderd stadium wordt ontdekt. In België vormt longkanker de eerste oorzaak van kankersterfte bij mannen, en de tweede bij vrouwen. Ondanks deze sombere resultaten is er toch nog vooruitgang mogelijk, door de zorgkwaliteit te verbeteren. Binnen het kader van een programma voor de verbetering van kankerzorg publiceerde het Federaal Kenniscentrum voor de Gezondheidszorg (KCE) een reeks van 23 kwaliteitsindicatoren voor de diagnose en de behandeling van longkanker. De zorgkwaliteit is in de Belgische ziekenhuizen over het algemeen goed. Toch stelde het KCE opnieuw vast dat de sterfte na de operatie van een longkanker hoger ligt in ziekenhuizen waar jaarlijks minder dan 10 van dergelijke ingrepen worden uitgevoerd. De helft van de ziekenhuizen in ons land blijkt deze drempel niet te halen. Het KCE beveelt daarom ook hier aan om deze ingrepen te centraliseren in ziekenhuizen met de nodige expertise. Daarnaast pleit het KCE ervoor dat er meer rekening wordt gehouden met de wensen en voorkeuren van de patiënt bij de beslissing om een behandeling al dan niet verder te zetten. VOORWOORD 1 -- KERN BOODSCHAPPEN 2 -- SYNTHESE. 4 -- 1. CONTEXT EN DOELSTELLINGEN 8 -- 1.1. LONGKANKER: EEN VEEL VOORKOMENDE EN DODELIJKE ZIEKTE. 8 -- 1.2. DOELSTELLINGEN VAN DIT RAPPORT 9 -- 1.2.1. De drie doelstellingen van dit rapport 9 -- 1.2.2. Doelgroep: in longkanker gespecialiseerde clinici en multidisciplinaire teams 9 -- 2. GEGEVENS EN METHODEN 10 -- 2.1. DE GEGEVENS: KOPPELING TUSSEN DE GEGEVENS VAN HET KANKERREGISTER EN DE ADMINISTRATIEVE DATABANKEN 10 -- 2.2. DE PATIËNTEN: DIAGNOSE GESTELD IN 2010-2011, PATIËNTEN MET ANDERE INVASIEVE TUMOREN WERDEN UITGESLOTEN 10 -- 2.3. ELKE PATIËNT TOEWIJZEN AAN ÉÉN CENTRUM? NIET ZO EENVOUDIG 11 -- 2.4. HOE COMORBIDITEITEN VASTSTELLEN OP BASIS VAN DE GEGEVENS VAN GENEESMIDDELENFACTUREN? 11 -- 2.5. RELATIE TUSSEN ZIEKENHUISVOLUME EN RESULTAAT12 -- 3. WAT VERTELLEN DE INDICATOREN ONS OVER DE KWALITEIT VAN DE ZORG? .13 -- 3.1. EEN STUDIE MET BIJNA 13 000 PATIËNTEN. 13 -- 3.2. DRIEËNTWINTIG GEMETEN KWALITEITSINDICATOREN: VAN DIAGNOSE TOT ZORG BIJ HET LEVENSEINDE 13 -- 3.2.1. Eenjaarsoverleving na de diagnose 17 -- 3.2.2. Kwaliteit van de rapportage aan het Kankerregister (BCR) 17 -- 3.2.3. Diagnose en stadiëring 17 -- 3.2.4. Behandeling 18 -- 3.3. DRIE COMORBIDITEITEN VASTGESTELD AAN DE HAND VAN DE GEGEVENS VAN GENEESMIDDELENFACTUREN 23 -- 3.4. WELKE IMPACT HEEFT HET ZIEKENHUISVOLUME OP DE RESULTATEN? .23 -- 3.4.1. Chirurgisch volume 23 -- 3.4.2. Chirurgisch volume en resultaten 24 -- 3.4.3. Radiotherapievolume 25 -- 3.4.4. Diagnosevolume 25 -- 4. STERKE PUNTEN EN BEPERKINGEN .26 -- 5. CONCLUSIES EN VOORUITZICHTEN 28 -- AANBEVELINGEN 29 -- REFERENTIES 30

376-386 This study aimed at developing and measuring quality indicators for oesophageal cancer (OC) and gastric cancer (GC) and to support quality improvement for practitioners. Quality indicators were identified from a systematic literature search including clinical guidelines. The selection process involved experts evaluating relevance, reliability, interpretability and actionability of each indicator. Three national databases were linked: the cancer registry, the population registry and the claims database. Completeness and validity of the data were validated before being measured for 10,660 patients diagnosed between 2004 and 2008. From a final set of 29 indicators, 18 were measurable using the available data. In 2008, less than 50% of patients were discussed at a multidisciplinary team meeting and less than 90% underwent a computed tomography scan 1 month after incidence date for cancer staging. Five-year relative survival was 22% for OC and 34.3% for GC. The post-operative mortality in OC patients was 4.8% (30 days) and 9.9% (90 days), whereas it reached 5.6 and 12.0% respectively in GC patients. This study demonstrates the feasibility to develop a set of quality indicators for gastro-oesophageal cancer. A mixed picture of the quality of care was illustrated for some relevant care processes. Nevertheless, 5-year survival is higher than reported in neighbouring countries.

Background The EUROCARE study collects and analyses survival data from population-based cancer registries (CRs) in Europe in order to provide data on between-country differences in survival and time trends in survival. Methods This study analyses data on liver cancer, gallbladder and extrahepatic biliary tract cancers (“biliary tract cancers”), and pancreatic cancer diagnosed in 2000–2007 from 88 CRs in 29 countries. Relative survival (RS) was estimated overall, by region, sex, age and period of diagnosis using the complete approach. Time trends in 5-year RS over 1999–2007 were also analysed using the period approach. Results The prognosis of the studied cancers was poor. Age-standardised 5-year RS was 12% for liver cancer, 17% for biliary tract cancers and 7% for pancreatic cancer. There were some between-country differences in survival. In general, RS was low in Eastern Europe and high in Central and Southern Europe. For all sites, 5-year RS was similar in men and women and decreased with advancing age. No substantial changes in survival were reported for pancreatic cancer over the period 1999–2007. On average, there was a crude increase in 5-year RS of 3 percentage points between the periods 1999–2001 and 2005–2007 for liver cancer and biliary tract cancers. Conclusions The major changes in imaging techniques over the study period for the diagnosis of the three studied cancers did not result in an improvement in the prognosis of these cancers. In the near future, new innovative treatments might be the best way to improve the prognosis in these cancers.

Background Since 25 years the EUROCARE study monitors the survival of cancer patients in Europe through centralised collection, quality check and statistical analysis of population-based cancer registries (CRs) data. The European population covered by the study increased remarkably in the latest round. The study design and statistical methods were also changed to improve timeliness and comparability of survival estimates. To interpret the EUROCARE-5 results on adult cancer patients better here we assess the impact of these changes on data quality and on survival comparisons. Methods In EUROCARE-5 the survival differences by area were studied applying the complete cohort approach to data on nearly nine million cancer patients diagnosed in 2000–2007 and followed up to 2008. Survival time trends were analysed applying the period approach to data on about 10 million cancer cases diagnosed from 1995 to 2007 and followed up to 2008. Differently from EUROCARE-4, multiple primary cancers were included and relative survival was estimated with the Ederer II method. Results EUROCARE-5 covered a population of 232 million resident persons, corresponding to 50% of the 29 participating countries. The population coverage increased particularly in Eastern Europe. Cases identified from death certificate only (DCO) were on average 2.9%, range 0–12%. Microscopically confirmed cases amounted to over 85% in most CRs. Compared to previous methods, including multiple cancers and using the Ederer II estimator reduced survival estimates by 0.4 and 0.3 absolute percentage points, on average. Conclusions The increased population size and registration coverage of the EUROCARE-5 study ensures more robust and comparable estimates across European countries. This enlargement did not impact on data quality, which was generally satisfactory. Estimates may be slightly inflated in countries with high or null DCO proportions, especially for poor prognosis cancers. The updated methods improved the comparability of survival estimates between recently and long-term established registries and reduced biases due to informative censoring.

253-260 PURPOSE: This study aimed at developing and measuring a set of indicators to monitor the quality of breast cancer care, to make comparisons over time and to support quality improvement for all practitioners and centres involved in the care of breast cancer women. METHODS: Quality indicators were identified from a systematic literature search and the 2010 Belgian evidence-based clinical practice guideline. The selection process involved an expert panel evaluating reliability, relevance, interpretability and actionability of each indicator. The quality indicators were tested using the Belgian Cancer Registry data linked with claims data for all women registered with breast cancer in Belgium between 2001 and 2006 (n=50,039). RESULTS: The selection process led to a final set of 32 indicators. Of these, 12 were measurable using the available data, while 1 indicator was measurable using proxy information. Five-year relative survival was 98%, 87%, 68% and 29% for pStage I, II, III and cStage IV respectively. Overall 5-year survival slightly improved for pStage II, III and cStage IV between 2001 and 2004. Of the surgically treated women, 60% underwent breast conserving surgery, 85% received adjuvant systemic treatment and 86% were irradiated postoperatively. In 80% of women treated for breast cancer, at least one mammography was performed within one year after the last treatment. CONCLUSION: The present study demonstrates the feasibility to develop a multidisciplinary set of quality indicators for breast cancer. Using national cancer registry data linked to claims data, 13 indicators were measurable, showing results that largely correspond to other studies in the field.

261-266 PURPOSE: To compare processes of care and survival for breast cancer by hospital volume in Belgium, based on 11 validated process quality indicators. METHODS: Three databases were linked at the patient level: the Cancer Registry, the population and the claims databases. All women with a diagnosis of invasive breast cancer between 2004 and 2006 were selected. Hospitals were classified according to their annual volume of treated patients: /= 150 patients (high). Cox and logistic regression models were used to test differences in 5-year survival and in achievement of process indicators across volume categories, adjusting for age, tumor grade and stage. RESULTS: A total of 25178 women with invasive breast cancer were treated in 111 hospitals. Half of the hospitals (N=57) treated

1133-1140 Purpose This study aimed at developing and measuring an indicator set to monitor the quality of testicular cancer care, to make comparisons over time and to support quality improvement for all practitioners and centres involved in the care of testicular cancer patients. Methods Quality indicators were identified from a systematic literature search and from the 2010 Belgian evidence-based clinical practice guidelines. The selection process involved an expert panel evaluating reliability, relevance, interpretability and actionability of each indicator. The quality indicators were pilot tested using the Belgian Cancer Registry (BCR) data linked with claims data for 1307 men with testicular cancer diagnosed between 2001 and 2006. The variability between centres was displayed using funnel plots. Results Of the 12 finally selected indicators, 5 were fully and 1 was partly measurable, while 2 indicators were measurable using proxy information. Five-year relative survival was 97%, 95% and 76% for pStage I–III, respectively. Overall 5-year survival slightly improved from 91% in 2001 to 94% in 2004. Between 2004 and 2006, 14 of 97 centres performed ⩾10 orchidectomies. Large variability was found between centres. The nine centres with a 5-year observed survival below the lower limit treated less than 20 patients between 2001 and 2006. Conclusions The present study demonstrates the feasibility to develop a multidisciplinary set of quality indicators for testicular cancer. Using national cancer registry data linked to claims data, eight indicators were measurable, showing a mixed picture of the quality of care for testicular cancer patients in Belgium.