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Quality as an Intermediate Goal of the Dutch Healthcare System: Presentation and Evaluation of the Quality of Cancer Care

Quality as an Intermediate Goal of the Dutch Healthcare System: Presentation and Evaluation of... Cancer care represents a challenge for the healthcare systems of OECD member states. This also applies to the Netherlands, as cancer is the leading cause of death. High quality of care is essential to effectively tackle the burden of disease caused by cancer. According to the WHO health systems framework, quality is an intermediate goal of health systems, alongside safety, access and coverage. This study aimed to assess the quality of cancer care in the Netherlands, especially in terms of effectiveness. To assess the quality of cancer care in the Netherlands, participation rates in screening and 5-year survival rates for breast, cervical and colorectal cancer were used. The Netherlands is interested in ensuring quality healthcare, and quality is one of the three main objectives of the healthcare system. The 5-year survival rates for breast, cervical and colorectal cancer were above the respective OECD averages in 2014, but some countries are better positioned. Participation in screening for cervical cancer was relatively low in the Netherlands in 2017, below the OECD average. It can be concluded that the Netherlands has high-quality, effective cancer care and is striving to continuously improve it. However, there is room for improvement , especially with regard to participation in cervical cancer screening, transparency about the quality of healthcare and regional differences in the quality of care. Keywords Cancer care, quality of care, survival, breast cancer, cervical cancer, colorectal cancer This study aimed to assess the quality of cancer care in the Introduction Netherlands, particularly in terms of effectiveness. First, the As the Netherlands is one of the five wealthiest countries in selected country is described using economic and socio- the euro zone, the population holds high expectations demographic factors, followed by a description of the health regarding the quality of healthcare (Kroneman et al., 2016, p. status of its population. The Dutch healthcare system is then 198). As in many other industrialised countries, the presented. This is followed by a conceptual explanation of the Netherlands’ number of people with chronic diseases and intermediate objective of the quality of a healthcare system, multimorbidity is increasing due to rising life expectancy and based on which the quality of cancer care in the Netherlands associated demographic changes, as well as medical and is presented and assessed. technological progress. Due to improvements in diagnosis and The Netherlands had a total of 17,231,017 inhabitants in treatment options, cancer is increasingly developing into a 2018. Over the past decades, life expectancy has continuously chronic disease (Kroneman et al., 2016, p. 12). In 2016, cancer improved. From 1990 to 2017, it rose from 77 to 82 years (see was the main cause of death, representing a major challenge Table 1 ). Life expectancy in the Netherlands in 2017 is thus for healthcare in the Netherlands (Organisation for Economic Co-operation and Development [OECD], 2020). According to estimates by the OECD, a third of cases could Institute of Social Medicine and Health Systems Research, Otto-von- be cured with timely detection and appropriate treatment, and Guericke University Magdeburg, Faculty of Medicine, Magdeburg, Germany another 30% could be prevented by adequate public health Berlin School of Public Health, Charité-Universitätsmedizin Berlin, Berlin, measures. Although OECD member states have made Germany numerous efforts to improve cancer prevention and treatment, Corresponding Author: there is still room for improvement (OECD, 2013, p. 3). Ilona Hrudey, Institute of Social Medicine and Health Systems Research, Cancer care in the Netherlands performs well, but can still be Otto-von-Guericke University Magdeburg, Faculty of Medicine, 39120 developed further in international comparison (OECD, 2013, Magdeburg, Germany. pp. 35–108). E-mail: ilona.hrudey@med.ovgu.de Hrudey 241 higher than the average of 80 years in OECD member states. prescription of generic medicine) point to improvements in The life expectancy of women at 83 years is in line with the efficiency (Kroneman et al., 2016, p. 187). Nevertheless, OECD average (83 years) and that of men at 80 years is healthcare expenditure is high by global comparison and higher (78 years) (The World Bank, 2020). amounted to 9.9% of GDP in 2018 (see Figure 2). The mortality rates shown in Table 1 imply that they are declining for all age groups. The increase in life expectancy is based, in particular, on the decline in cardiovascular The Dutch Healthcare System mortality (OECD and European Observatory on Health Systems and Policies, 2017, p. 2). The main cause of death The Dutch government pursues three overarching objectives is cancer for both women and men. Cardiovascular diseases regarding the healthcare system: quality, accessibility and are in the second place. In 2016, malignant neoplasms affordability (Kroneman et al., 2016, p. 187). Before accounted for 35% of deaths in men and 28% in women describing and assessing the quality of cancer care in the (see Figure 1). The greatest burden of disease is caused by Netherlands, a general description of the healthcare system is mental disorders, cardiovascular diseases and cancer fundamental. (Kroneman et al., 2016, p. 10). The Dutch Ministry of Health, Welfare and Sport is The gross domestic product (GDP) per capita (56,772.0 primarily responsible for healthcare and holds a regulatory PPP) was higher than the OECD average in 2018 (45,935.3 role. It develops strategies and legislation to promote the PPP). Between the years 2000–2012, health expenditure in health of the people and is responsible for ensuring that the the Netherlands has continuously increased. Since 2012, a slight downward trend can be observed (The World Bank, three main objectives of the health system are met. The 2020). Some indicators (e.g., the length of stay and the Ministry increasingly shares this responsibility with local Table 1. Mortality and Health Indicators, 1990–2018 (selected years). Indicator 1990 2000 2010 2018 Population 14,951,510 15,925,513 16,615,394 17,231,017 Life expectancy at birth, total (years) 77 78 81 82* Life expectancy at birth, women (years) 80 81 83 83* Life expectancy at birth, men (years) 74 76 79 80* Mortality rate, women (per 1,000 female adults) 67 67 55 51** Mortality rate, men (per 1,000 male adults) 116 100 74 66** Mortality rate, infants (per 1,000 live births) 7 5 4 3* Source: Data taken from The World Bank (2020), *2017 and **2016. Women Men (Numberofdeathcases: 76.817) (Numberof death cases: 72.180) 16% 17% 28% 35% 5% 6% 8% 8% 10% 16% 27% 25% Diseases of thecirculatory Diseases of the nervous Cancer System system (including dementia) Diseases of therespiratory External causes Othercauses system Figure 1. Main Causes of Death by Gender in 2016. Source: Data taken from OECD (2020). 242 Journal of Health Management 24(2) Figure 2. Health Expenditure as a Share of GDP, 2018. Source: Data taken from OECD (2020). authorities. Within the framework of service provision, there targets for participation rates (Kroneman et al., 2016, p. 197). is an extensive delegation to private institutions (Kroneman In well-developed primary care, a large proportion of patients et al., 2016, p. 25). (approx. 93%) are handled by general practitioners who act as With the implementation of the health insurance reform in gatekeepers to the healthcare system. Access to secondary 2006, the Netherlands introduced compulsory insurance for care requires a referral from the general practitioner. After the entire population in the field of curative care. Since then, receiving the referral, patients have a free choice of hospital. the Health Insurance Act (Zorgverzekeringswet) requires all Due to the increase in chronic diseases and multimorbidity, people of legal age to procure an insurance with a private integrative care is gaining more and more attention (Kroneman health insurance company. The benefit basket is the same for et al., 2016, pp. 129–140). all insurance companies and includes, in particular, general The government has enacted various laws to ensure quality practitioner and hospital care, the provision of medicines, healthcare. The Health Care Inspectorate (IGZ) and the pregnancy and maternity benefits, the care of mental disorders National Healthcare Institute (ZinNL) are responsible for and home nursing care. Voluntary health insurance policies supervising the quality of care (Kroneman et al., 2016, pp. can be used to ensure benefits excluded in the benefit basket 44–47). Quality assurance is carried out, in particular, by the (e.g., dental care). service providers, sometimes in cooperation with health Health insurance is financed in equal parts by a community- insurers, as well as with patients and consumer organisations. rated premium paid by the insured and an income-related Over the past decades, many parties have worked on the employer's contribution (Kroneman et al., 2016, p. 66). The implementation of quality registers. Progress has been made premiums and employer contributions are pooled within a in the area of public reporting on the quality of healthcare central health insurance fund and then, assigned to the health outcomes, but this is still in its initial stages (Wammes et al., insurance companies, adjusted for risk. The state finances 2017, p. 117). This problem is currently being addressed by healthcare for children and young people under the age of 18 the ‘Outcome-based healthcare 2018–2022’ initiative of the (OECD and European Observatory on Health Systems and Ministry of Health, Welfare and Sport. The aim is to make Policies, 2017, p. 5). Service providers and health insurers outcome indicators related to treatment transparent for 50% negotiate the quality and price of care, with competition for of the disease burden by 2022 (Ministerie van quality still in its infancy (Kroneman et al., 2016, pp. 57–58). Volksgezondheid, 2018, p. 10). In the context of healthcare, a distinction is made between preventive, primary, secondary and long-term care (Kroneman et al., 2016, p. 129). Public health services are the Description and Evaluation of the responsibility of the municipalities and include, for example, Intermediate Objective Quality screening, vaccinations and health promotion. Population- based screening programmes exist for breast cancer, cervical This section provides a conceptual description of the cancer and colon cancer (OECD and European Observatory intermediate objective of quality in a healthcare system. This on Health Systems and Policies, 2017, p. 7). Participation in is followed by a description and assessment of the quality of the screening is voluntary, and the Netherlands does not set cancer care in the Netherlands. GDPin% 16.9 12.2 11.2 11.2 11.0 10.9 10.7 10.5 10.4 10.3 10.2 9.9 9.8 9.3 9.3 9.1 9.1 8.9 8.9 8.8 8.8 8.3 8.1 7.9 7.8 7.5 7.5 7.0 6.8 6.7 6.6 6.4 6.3 5.9 5.5 5.4 4.2 Hrudey 243 Conceptual Explanation of Quality The Quality of Cancer Care in the Netherlands The understanding of quality in healthcare varies across Cancer care represents a challenge for the healthcare systems different contexts, levels of analysis and disciplines. In 1980, of OECD member states. This also applies to the Netherlands, Avedis Donabedian made a distinction between the terms: as cancer is the leading cause of death (OECD, 2020). High quality and quality of care. He assumed that the quality of quality of care is essential to effectively tackle the burden of care goes hand in hand with the care processes and that disease caused by cancer. There are three areas of importance maximizing the well-being of the patient is the goal of quality for ensuring high-quality cancer care (OECD, 2013, p. 12): care (Busse et al., 2019, pp. 5–6). • Resources: Medicine, personnel, institutions and equipment Quality is the ability to achieve desirable objectives using • Practices: Access to evidence-based care, including legitimate means. prevention and screening Quality of care is the kind of care that is expected to maximize • Regulation and governance: National cancer control an inclusive measure of patient welfare after one has taken plans that include guidelines for care and monitoring, account of the balance of expected gains and losses that and set targets to be achieved and regulatory aspects of attend the process of care in all its parts. (Donabedian, 1980) care (e.g., accreditation of services) Five-year survival rates are often used to assess the quality of Ten years later, the Institute of Medicine (IOM, 1990, p. 21) cancer care in a country. These reflect both the early detection defined the quality of healthcare as follows: of the disease and the effectiveness of treatment (OECD, 2013, p. 25). Early detection of cancer through screening and Quality of care is the degree to which health services for adequate treatment contributes to improved survival (van den individuals and populations increase the likelihood of desired Berg et al., 2014, p. 134). health outcomes and are consistent with current professional knowledge. Participation rates in mammography screening (2016: 77.3%) and colorectal cancer screening (2017: 72.7%) were In contrast to other definitions, the IOM definition does not relatively high in the Netherlands (Rijksinstituut voor exclusively focus on medical care, but on healthcare in Volksgezondheid en Milieu, 2020a, 2020c). Participation in general (including health promotion and prevention) and cervical cancer screening was 56.9% in 2017, below the takes a salutogenic perspective by addressing individuals and OECD average of 59.5% (OECD, 2020). population groups and not only patients (Busse et al., 2019, For those cancer types for which screening programmes pp. 6–7). are available in the Netherlands, the 5-year survival rates The World Health Organization (WHO) defines the quality were in the upper to middle range by international standards. of healthcare according to three main dimensions: From 2000 to 2014, the respective survival rates slightly effectiveness, safety and person-centeredness. In addition, increased (see Figures 3–5). Figure 3 shows that the 5-year further attributes of qualitative healthcare, such as equity and survival rate for breast cancer (87%) was slightly above the efficiency are named, but these are distinguished from the OECD average (85%). The Netherlands was also well- core dimensions (WHO, 2018, p. 13). positioned with a survival rate of 68% for cervical cancer For the evaluation of the quality of healthcare, the use of (OECD: 66%) (see Figure 4). The survival rate for colorectal quality indicators is necessary. The most frequently used is cancer (63%) was almost in line with the OECD average Donabedian’s Triad, which differentiates between structural, (62%) (see Figure 5). process and outcome quality (Quentin et al., 2019, pp. The 5-year survival for breast cancer improved by about 37–38). Donabedian (1988, p. 1745) assumes that ‘[..] a 3% in the Netherlands between 2000 and 2014 (OECD, good structure increases the likelihood of good process, and 2020). This is due to the screening programme that was a good process increases the likelihood of a good outcome’. introduced in 1990 and improved treatment. Screening is Structures include the characteristics of the settings in used to detect less aggressive and smaller tumours more which care is provided, the characteristics of resources frequently. This allows earlier treatment initiation and less (human and material resources) and organisational invasive therapy. As a part of the treatment, improvements structures (e.g., organisation of medical staff). Processes have been achieved in adjuvant therapies (hormonal and are activities, which are performed when care is given and chemical) and surgical interventions (van den Berg et al., received. The effects of care on the health status of patients 2014, p. 133). and population groups are defined as outcomes (Donabedian, Figure 4 shows that the Dutch survival rate for cervical 1988, p. 1745). cancer has virtually remained unchanged from 2000-2014. 244 Journal of Health Management 24(2) Age-standardisednet Confidence Interval 2010-2014 2000-2004 2010-2014 survival (%) 89 89 89 89 88 88 88 88 88 87 87 86 86 86 86 86 86 86 85 90 85 85 82 82 82 77 77 76 76 Figure 3. Breast Cancer 5-year Net Survival, 2000–2004, 2010–2014. Source: Data taken from OECD (2020). Age-standardised net Confidence Interval 2010-2014 2000-2004 2010-2014 survival (%) 71 71 68 67 67 67 67 67 66 66 66 65 65 70 65 64 64 64 61 61 60 55 Figure 4. Cervical Cancer 5-year Net Survival, 2000–2004, 2010–2014. Source: Data taken from OECD (2020). Age-standardised net survival (%) Confidence Interval 2010-2014 2000-2004 2010-2014 80 72 68 68 68 67 67 65 65 65 65 64 64 64 64 63 63 62 62 61 61 56 56 Figure 5. Colorectal Cancer 5-year Net Survival, 2000–2004, 2010–2014. Source: Data taken from OECD (2020). Hrudey 245 The effects of treatment improvements (e.g., combined On the other hand, there are areas in which the Netherlands is radiotherapy and hyperthermia) and the screening positioned lower in international comparison: the time between programme are not reflected in this figure. The confidence diagnosis and the start of treatment (especially, for colorectal intervals of survival rates are relatively large due to the low cancer), evaluation of the performance of the healthcare system, incidence and mortality of cervical cancer (van den Berg transparency with regard to the quality of healthcare, quality et al., 2014, p. 136). differences between hospitals and benchmarking of healthcare For colorectal cancer, the 5-year survival rate has increased providers (OECD, 2013, pp. 35–108). from 58% to 63% (OECD, 2020). The improved survival is In addition to global comparisons, regional differences are based on advances in treatment, particularly, the more also relevant for assessing the quality of cancer care in the frequent use of adjuvant chemotherapy. Screening for Netherlands. In 2007, the Dutch Cancer Society founded a colorectal cancer was introduced in the Netherlands in 2014, Quality of Cancer Care Taskforce to evaluate the quality of and therefore, does not provide an explanatory approach (van cancer care. The results of the study showed that the quality den Berg et al., 2014, pp. 137–139). of care varies according to region and hospital. The differences Global comparisons show large differences in survival between hospitals can be explained in part by the procedural rates and consistent patterns of countries with stronger and volume and the type of hospital (general hospital, educational weaker performance. It is reasonable to assume that these hospital for surgery or university hospital) (Wouters et al., differences do not occur by chance, but rather result from 2010, pp. 3–10). Study results indicated that cancer patients systematic differences in the organization, funding and in the Netherlands are more often treated according to current management of cancer treatment programmes (OECD & standards and have higher survival rates in university European Commission, 2013, p. 2). hospitals and hospitals with a high procedural volume. National cancer control plans are an important part of However, differences in the quality of care are mainly due to quality cancer care. In the Netherlands, such a plan (National the variation level of individual hospitals. Since the NCR Cancer Control Programme) exists since 2004 and covers not lacks relevant information on differences in the case mix only prevention and diagnosis but also treatment, follow-up between hospitals, it is not possible to adequately explain the and psychosocial care, as well as aspects of education and variation. One potential reason is the fast pace with which research (OECD, 2013, pp. 93–97). To improve the quality new, evidence-based treatment strategies are introduced and coordination of care, seven regional comprehensive (Elferink et al., 2010a, pp. 74–81; 2010b, pp. 64–72; Wouters cancer centres (CCC) have been established in the Netherlands et al., 2010, pp. 3–10). According to Elferink et al. (2010b, p. since 1978. The CCCs each cover an area with 5–20 hospitals 66), the regional differences result, among other things, from and each hospital is assigned to a Centre. The Centres are the fact that each CCC region treatment guideline is discussed responsible, among other things, for the development and in multidisciplinary meetings. implementation of guidelines, for the administration of the From the presentation of the quality of cancer care, it can Netherlands Cancer Registry (NCR) and for improving the be concluded that, compared to other OECD member states, coordination of cancer and palliative care. Since 2011, they the Netherlands is in the middle to upper range. Potential for have been organised under the umbrella of the nationwide improvement lies in the reduction of regional differences in organization IKNL (Integraal Kankercentrum Nederland) the provision of cancer care above all. (Elferink et al., 2010a, p. 75; Rijksinstituut voor Volksgezondheid en Milieu, 2020b). Since 1989, the NCR has been collecting data for all cancer patients with regard to Discussion diagnosis, tumour characteristics and initial treatment. The data are made available to policymakers (Ministry of Health, The Netherlands is interested in ensuring quality healthcare Welfare and Sport), the healthcare sector (hospitals and other and quality is one of the three main objectives of the healthcare health care facilities, professionals and patient organisations) system (Kroneman et al., 2016, p. 187). This paper aimed to and the scientific community (IKNL). assess the quality of cancer care in the Netherlands, especially The OECD study ‘Cancer Care: Assuring Quality to Improve in terms of effectiveness. Survival’ compares the quality of cancer care in OECD member Due to the decline in cardiovascular mortality, cancer is states in a comprehensive manner. Cancer care in the the main cause of death in the Netherlands (OECD, 2020). Netherlands has many positive aspects, such as the existence of The Dutch healthcare system has made progress in fighting population-based screening programmes, good access to care, cancer by introducing population-based screening the existence of a national cancer control plan and treatment programmes and implementing treatment improvements (van guidelines, the accreditation of facilities and services, as well as den Berg et al., 2014, pp. 133–139). This is reflected in the various strategies to ensure sufficient human resources (e.g., increased 5-year survival rates (OECD, 2020). The National certification systems for the training of medical personnel with Cancer Control Programme, introduced in 2004, is another expertise in cancer care and nurse practitioners in oncology). important element in ensuring the quality of cancer care. It 246 Journal of Health Management 24(2) takes a holistic approach by addressing issues that go beyond consideration of other factors, such as differences between prevention and diagnosis (OECD, 2013, 93–97). service providers, resources for cancer care and other Since coordination is also highly relevant in the context of dimensions of quality (safety and person-centeredness). quality care, seven regional Comprehensive Cancer Centres Taking into account the limitations mentioned above, it have been implemented (Rijksinstituut voor Volksgezondheid can be concluded that the Netherlands has high-quality, en Milieu, 2020b). In addition, the Netherlands is devoting effective cancer care and is striving to continuously improve increasing attention to integrated care in order to meet the it. However, there is room for improvement, especially with complex needs of cancer patients (OECD, 2013, p. 97). In the regard to participation in cervical cancer screening, field of monitoring, the Netherlands Cancer Registry is an transparency about the quality of healthcare and regional established information structure (IKNL). differences in the quality of care The Dutch survival rates for breast, cervical and colorectal Acknowledgements cancers were above the respective OECD averages in 2014, but some countries are better positioned. There is potential for I want to thank Anne Spranger for her general support during the improvement, especially regarding the survival of colorectal implementation of the study. I would also like to thank Christoph cancer (OECD, 2020). It should be noted that screening for Stallmann for his critical review of the manuscript. colorectal cancer has only been available since 2014 (van den Declaration of Conflicting Interests Berg et al., 2014, p. 139). The data on 5-year survival are from the same year. It can be assumed that the positive effect The author declared no potential conflicts of interest with respect to of screening will be reflected in future survival rates. the research, authorship, and/or publication of this article. The international differences in survival rates are not random (OECD & European Commission, 2013, p. 2). The Funding orientation towards other countries that perform better in The author received no financial support for the research, authorship terms of quality represents an approach to improving cancer and/or publication of this article. care in the Netherlands. This includes all the above Scandinavian countries (see Figures 3–5). Participation in References screening is recommended in the Netherlands, but not Busse, R., Panteli, D., & Quentin, W. (2019). An Introduction to mandatory. No targets are set for participation rates healthcare quality: Defining and explaining its role in health sys- (Kroneman et al., 2016, p. 197). Participation in screening for tems. In R. Busse, N. Klazinga, D. Panteli, & W. Quentin (Eds.), cervical cancer was relatively low in the Netherlands in 2017, Improving healthcare quality in Europe: Characteristics, effec- below the OECD average (OECD, 2020). This can be tiveness and implementation of different strategies (pp. 1–17). increased, for example, by setting higher targets for WHO Regional Office for Europe, European Observatory on participation rates. Another challenge is the variation in the Health Systems and Policies. Donabedian, A., & Ann Arbor (1980). The definition of quality and quality of care by a region and a hospital (Wouters et al., approaches to its assessment. Vol 1. Explorations in Quality 2010, pp. 3–10). The underlying causes have not yet been Assessment and Monitoring. Michigan: Health Administration adequately identified. First, there is a need for research to Press. identify the factors causing this variation. The next step Donabedian, A. (1988). The quality of care: How can it be should be focused on implications to reduce the differences. assessed? Journal of the American Medical Association, The present analysis has some limitations. The most recent 260(12), 1743–1748. data for 5-year survival are from 2014 and are, therefore, not Elferink, M. A. G., Krijnen, P., Wouters, M. W. J. M., Lemmens, V. sufficiently up-to-date. No more recent data were found in the E. P. P., Jansen-Landheer, M. L. E. A., van de Velde, C. J. H., database analysis. The author used studies from 2010 and Langendijk, J. A., Marijnen, C. A. M., Siesling, S., & Tollenaar, 2013 to describe regional differences in the quality of care. R. A. E. M. (2010a). Variation in treatment and outcome of The Netherlands Cancer Registry could have been used for patients with rectal cancer by region, hospital type and volume in the Netherlands. European Journal of Surgical Oncology, this subject area, but public access to the data is limited. Only 36(Suppl. 1), S74–S82. nationwide survival rates are included in the Registry, regional Elferink, M. A. G., Wouters, M. W. J. M., Krijnen, P., Lemmens, survival data are missing. Furthermore, the comparison of V. E. P. P., Jansen-Landheer, M. L. E. A., van de Velde, C. J. survival rates is subject to limitations. Screening programmes H., Siesling, S., & Tollenaar, R. A. E. M. (2010b). Disparities contribute to an improvement of the survival statistics through in quality of care for colon cancer between hospitals in the lead-time bias and the length-time bias. Besides, survival the Netherlands. European Journal of Surgical Oncology, rates are not adapted to the tumour stage at the time of 36(Suppl. 1), S64–S73. diagnosis, thus making it more difficult to evaluate the effects IKNL. Netherlands Cancer Registry (NCR): Record, report, of screening programmes and treatment improvements improve and regulate. https://iknl.nl/en/ncr (OECD, 2013, p. 25). Furthermore, a more differentiated IOM (Ed.). (1990). Medicare: A strategy for quality assurance: assessment of the quality of cancer care requires the Volume 1. National Academies Press (US), 1–441. Hrudey 247 Kroneman, M., Boerma, W., van den Berg, M., Groenewegen, P., de Regional Office for Europe, European Observatory on Health Jong, J., & van Ginneken, E. (2016). The Netherlands: Health Systems and Policies. system review: Health Systems in Transition. 2: Vol. 18. WHO Rijksinstituut voor Volksgezondheid en Milieu. (2020a). Regional Office for Europe, European Observatory on Health Deelnamebevolkingsonderzoekborstkanker [Participation in Systems and Policies. population screening for breast cancer]. Ministerie van Volksgezondheid. (2018). Outcome based healthcare Rijksinstituut voor Volksgezondheid en Milieu. (2020b). 2018-2022. Ministerie van Volksgezondheid, Welzijn en Sport. Integralekankercentra [Comprehensive Cancer Center of the https://www.government.nl/documents/reports/2018/07/02/ Netherlands]. outcome-based-healthcare2018-202 Rijksinstituut voor Volksgezondheid en Milieu. (2020c). Landelijkbevolkingsonderzoekdarmkanker [Nationwide popu- OECD. (2013). Cancer Care: Assuring quality to improve survival. lation screening for colon cancer]. OECD health policy studies. OECD Publishing. OECD. (2020). OECD health statistics [Online database]. https:// van den Berg, M. J., de Boer, D., Gijsen, R., Heijink, R., Limburg, stats.oecd.org/ L. C. M., & Zwakhals, S. L. N. (2014). Dutch health care per- formance report. RIVM. OECD, & European Commission. (2013). Focus on health: Wammes, J., Jeurissen, P., Westert, G., & Tanke, M. (2017). The Cancer Care: Assuring quality to improve survival. https:// Dutch Health Care System. In The Commonwealth Fund (Ed.), www.oecd.org/els/health-systems/Focus-on-Health_Cancer- Care-2013.pdf International profiles of health care systems (pp. 113–119). The OECD, & European Observatory on Health Systems Policies. Commonwealth Fund. WHO. (2018). Handbook for national quality policy and strategy: (2017). Netherlands: Country Health Profile 2017: State of A practical approach for developing policy and strategy to Health in the EU. OECD Publishing, European Observatory on improve quality of care. WHO. Health Systems and Policies. Quentin, W., Partanen, V. M., Brownwood, I., & Klazinga, The World Bank. (2020). World Bank open data (Online database). https://data.worldbank.org/ N. (2019). Measuring healthcare quality. In R. Busse, N. Wouters, M. W. J. M., Jansen-Landheer, M. L. E. A., & van de Velde, C. Klazinga, D. Panteli, & W. Quentin (Eds.), Improving health- J. H. (2010). The Quality of cancer care initiative in the Netherlands. care quality in Europe: Characteristics, effectiveness and European Journal of Surgical Oncology, 36(Suppl.1), S3–S13. implementation of different strategies (pp. 31–62). WHO http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Health Management SAGE

Quality as an Intermediate Goal of the Dutch Healthcare System: Presentation and Evaluation of the Quality of Cancer Care

Hrudey, Ilona
Journal of Health Management , Volume 24 (2): 8 – Jun 1, 2022
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0972-0634
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Abstract

Cancer care represents a challenge for the healthcare systems of OECD member states. This also applies to the Netherlands, as cancer is the leading cause of death. High quality of care is essential to effectively tackle the burden of disease caused by cancer. According to the WHO health systems framework, quality is an intermediate goal of health systems, alongside safety, access and coverage. This study aimed to assess the quality of cancer care in the Netherlands, especially in terms of effectiveness. To assess the quality of cancer care in the Netherlands, participation rates in screening and 5-year survival rates for breast, cervical and colorectal cancer were used. The Netherlands is interested in ensuring quality healthcare, and quality is one of the three main objectives of the healthcare system. The 5-year survival rates for breast, cervical and colorectal cancer were above the respective OECD averages in 2014, but some countries are better positioned. Participation in screening for cervical cancer was relatively low in the Netherlands in 2017, below the OECD average. It can be concluded that the Netherlands has high-quality, effective cancer care and is striving to continuously improve it. However, there is room for improvement , especially with regard to participation in cervical cancer screening, transparency about the quality of healthcare and regional differences in the quality of care. Keywords Cancer care, quality of care, survival, breast cancer, cervical cancer, colorectal cancer This study aimed to assess the quality of cancer care in the Introduction Netherlands, particularly in terms of effectiveness. First, the As the Netherlands is one of the five wealthiest countries in selected country is described using economic and socio- the euro zone, the population holds high expectations demographic factors, followed by a description of the health regarding the quality of healthcare (Kroneman et al., 2016, p. status of its population. The Dutch healthcare system is then 198). As in many other industrialised countries, the presented. This is followed by a conceptual explanation of the Netherlands’ number of people with chronic diseases and intermediate objective of the quality of a healthcare system, multimorbidity is increasing due to rising life expectancy and based on which the quality of cancer care in the Netherlands associated demographic changes, as well as medical and is presented and assessed. technological progress. Due to improvements in diagnosis and The Netherlands had a total of 17,231,017 inhabitants in treatment options, cancer is increasingly developing into a 2018. Over the past decades, life expectancy has continuously chronic disease (Kroneman et al., 2016, p. 12). In 2016, cancer improved. From 1990 to 2017, it rose from 77 to 82 years (see was the main cause of death, representing a major challenge Table 1 ). Life expectancy in the Netherlands in 2017 is thus for healthcare in the Netherlands (Organisation for Economic Co-operation and Development [OECD], 2020). According to estimates by the OECD, a third of cases could Institute of Social Medicine and Health Systems Research, Otto-von- be cured with timely detection and appropriate treatment, and Guericke University Magdeburg, Faculty of Medicine, Magdeburg, Germany another 30% could be prevented by adequate public health Berlin School of Public Health, Charité-Universitätsmedizin Berlin, Berlin, measures. Although OECD member states have made Germany numerous efforts to improve cancer prevention and treatment, Corresponding Author: there is still room for improvement (OECD, 2013, p. 3). Ilona Hrudey, Institute of Social Medicine and Health Systems Research, Cancer care in the Netherlands performs well, but can still be Otto-von-Guericke University Magdeburg, Faculty of Medicine, 39120 developed further in international comparison (OECD, 2013, Magdeburg, Germany. pp. 35–108). E-mail: ilona.hrudey@med.ovgu.de Hrudey 241 higher than the average of 80 years in OECD member states. prescription of generic medicine) point to improvements in The life expectancy of women at 83 years is in line with the efficiency (Kroneman et al., 2016, p. 187). Nevertheless, OECD average (83 years) and that of men at 80 years is healthcare expenditure is high by global comparison and higher (78 years) (The World Bank, 2020). amounted to 9.9% of GDP in 2018 (see Figure 2). The mortality rates shown in Table 1 imply that they are declining for all age groups. The increase in life expectancy is based, in particular, on the decline in cardiovascular The Dutch Healthcare System mortality (OECD and European Observatory on Health Systems and Policies, 2017, p. 2). The main cause of death The Dutch government pursues three overarching objectives is cancer for both women and men. Cardiovascular diseases regarding the healthcare system: quality, accessibility and are in the second place. In 2016, malignant neoplasms affordability (Kroneman et al., 2016, p. 187). Before accounted for 35% of deaths in men and 28% in women describing and assessing the quality of cancer care in the (see Figure 1). The greatest burden of disease is caused by Netherlands, a general description of the healthcare system is mental disorders, cardiovascular diseases and cancer fundamental. (Kroneman et al., 2016, p. 10). The Dutch Ministry of Health, Welfare and Sport is The gross domestic product (GDP) per capita (56,772.0 primarily responsible for healthcare and holds a regulatory PPP) was higher than the OECD average in 2018 (45,935.3 role. It develops strategies and legislation to promote the PPP). Between the years 2000–2012, health expenditure in health of the people and is responsible for ensuring that the the Netherlands has continuously increased. Since 2012, a slight downward trend can be observed (The World Bank, three main objectives of the health system are met. The 2020). Some indicators (e.g., the length of stay and the Ministry increasingly shares this responsibility with local Table 1. Mortality and Health Indicators, 1990–2018 (selected years). Indicator 1990 2000 2010 2018 Population 14,951,510 15,925,513 16,615,394 17,231,017 Life expectancy at birth, total (years) 77 78 81 82* Life expectancy at birth, women (years) 80 81 83 83* Life expectancy at birth, men (years) 74 76 79 80* Mortality rate, women (per 1,000 female adults) 67 67 55 51** Mortality rate, men (per 1,000 male adults) 116 100 74 66** Mortality rate, infants (per 1,000 live births) 7 5 4 3* Source: Data taken from The World Bank (2020), *2017 and **2016. Women Men (Numberofdeathcases: 76.817) (Numberof death cases: 72.180) 16% 17% 28% 35% 5% 6% 8% 8% 10% 16% 27% 25% Diseases of thecirculatory Diseases of the nervous Cancer System system (including dementia) Diseases of therespiratory External causes Othercauses system Figure 1. Main Causes of Death by Gender in 2016. Source: Data taken from OECD (2020). 242 Journal of Health Management 24(2) Figure 2. Health Expenditure as a Share of GDP, 2018. Source: Data taken from OECD (2020). authorities. Within the framework of service provision, there targets for participation rates (Kroneman et al., 2016, p. 197). is an extensive delegation to private institutions (Kroneman In well-developed primary care, a large proportion of patients et al., 2016, p. 25). (approx. 93%) are handled by general practitioners who act as With the implementation of the health insurance reform in gatekeepers to the healthcare system. Access to secondary 2006, the Netherlands introduced compulsory insurance for care requires a referral from the general practitioner. After the entire population in the field of curative care. Since then, receiving the referral, patients have a free choice of hospital. the Health Insurance Act (Zorgverzekeringswet) requires all Due to the increase in chronic diseases and multimorbidity, people of legal age to procure an insurance with a private integrative care is gaining more and more attention (Kroneman health insurance company. The benefit basket is the same for et al., 2016, pp. 129–140). all insurance companies and includes, in particular, general The government has enacted various laws to ensure quality practitioner and hospital care, the provision of medicines, healthcare. The Health Care Inspectorate (IGZ) and the pregnancy and maternity benefits, the care of mental disorders National Healthcare Institute (ZinNL) are responsible for and home nursing care. Voluntary health insurance policies supervising the quality of care (Kroneman et al., 2016, pp. can be used to ensure benefits excluded in the benefit basket 44–47). Quality assurance is carried out, in particular, by the (e.g., dental care). service providers, sometimes in cooperation with health Health insurance is financed in equal parts by a community- insurers, as well as with patients and consumer organisations. rated premium paid by the insured and an income-related Over the past decades, many parties have worked on the employer's contribution (Kroneman et al., 2016, p. 66). The implementation of quality registers. Progress has been made premiums and employer contributions are pooled within a in the area of public reporting on the quality of healthcare central health insurance fund and then, assigned to the health outcomes, but this is still in its initial stages (Wammes et al., insurance companies, adjusted for risk. The state finances 2017, p. 117). This problem is currently being addressed by healthcare for children and young people under the age of 18 the ‘Outcome-based healthcare 2018–2022’ initiative of the (OECD and European Observatory on Health Systems and Ministry of Health, Welfare and Sport. The aim is to make Policies, 2017, p. 5). Service providers and health insurers outcome indicators related to treatment transparent for 50% negotiate the quality and price of care, with competition for of the disease burden by 2022 (Ministerie van quality still in its infancy (Kroneman et al., 2016, pp. 57–58). Volksgezondheid, 2018, p. 10). In the context of healthcare, a distinction is made between preventive, primary, secondary and long-term care (Kroneman et al., 2016, p. 129). Public health services are the Description and Evaluation of the responsibility of the municipalities and include, for example, Intermediate Objective Quality screening, vaccinations and health promotion. Population- based screening programmes exist for breast cancer, cervical This section provides a conceptual description of the cancer and colon cancer (OECD and European Observatory intermediate objective of quality in a healthcare system. This on Health Systems and Policies, 2017, p. 7). Participation in is followed by a description and assessment of the quality of the screening is voluntary, and the Netherlands does not set cancer care in the Netherlands. GDPin% 16.9 12.2 11.2 11.2 11.0 10.9 10.7 10.5 10.4 10.3 10.2 9.9 9.8 9.3 9.3 9.1 9.1 8.9 8.9 8.8 8.8 8.3 8.1 7.9 7.8 7.5 7.5 7.0 6.8 6.7 6.6 6.4 6.3 5.9 5.5 5.4 4.2 Hrudey 243 Conceptual Explanation of Quality The Quality of Cancer Care in the Netherlands The understanding of quality in healthcare varies across Cancer care represents a challenge for the healthcare systems different contexts, levels of analysis and disciplines. In 1980, of OECD member states. This also applies to the Netherlands, Avedis Donabedian made a distinction between the terms: as cancer is the leading cause of death (OECD, 2020). High quality and quality of care. He assumed that the quality of quality of care is essential to effectively tackle the burden of care goes hand in hand with the care processes and that disease caused by cancer. There are three areas of importance maximizing the well-being of the patient is the goal of quality for ensuring high-quality cancer care (OECD, 2013, p. 12): care (Busse et al., 2019, pp. 5–6). • Resources: Medicine, personnel, institutions and equipment Quality is the ability to achieve desirable objectives using • Practices: Access to evidence-based care, including legitimate means. prevention and screening Quality of care is the kind of care that is expected to maximize • Regulation and governance: National cancer control an inclusive measure of patient welfare after one has taken plans that include guidelines for care and monitoring, account of the balance of expected gains and losses that and set targets to be achieved and regulatory aspects of attend the process of care in all its parts. (Donabedian, 1980) care (e.g., accreditation of services) Five-year survival rates are often used to assess the quality of Ten years later, the Institute of Medicine (IOM, 1990, p. 21) cancer care in a country. These reflect both the early detection defined the quality of healthcare as follows: of the disease and the effectiveness of treatment (OECD, 2013, p. 25). Early detection of cancer through screening and Quality of care is the degree to which health services for adequate treatment contributes to improved survival (van den individuals and populations increase the likelihood of desired Berg et al., 2014, p. 134). health outcomes and are consistent with current professional knowledge. Participation rates in mammography screening (2016: 77.3%) and colorectal cancer screening (2017: 72.7%) were In contrast to other definitions, the IOM definition does not relatively high in the Netherlands (Rijksinstituut voor exclusively focus on medical care, but on healthcare in Volksgezondheid en Milieu, 2020a, 2020c). Participation in general (including health promotion and prevention) and cervical cancer screening was 56.9% in 2017, below the takes a salutogenic perspective by addressing individuals and OECD average of 59.5% (OECD, 2020). population groups and not only patients (Busse et al., 2019, For those cancer types for which screening programmes pp. 6–7). are available in the Netherlands, the 5-year survival rates The World Health Organization (WHO) defines the quality were in the upper to middle range by international standards. of healthcare according to three main dimensions: From 2000 to 2014, the respective survival rates slightly effectiveness, safety and person-centeredness. In addition, increased (see Figures 3–5). Figure 3 shows that the 5-year further attributes of qualitative healthcare, such as equity and survival rate for breast cancer (87%) was slightly above the efficiency are named, but these are distinguished from the OECD average (85%). The Netherlands was also well- core dimensions (WHO, 2018, p. 13). positioned with a survival rate of 68% for cervical cancer For the evaluation of the quality of healthcare, the use of (OECD: 66%) (see Figure 4). The survival rate for colorectal quality indicators is necessary. The most frequently used is cancer (63%) was almost in line with the OECD average Donabedian’s Triad, which differentiates between structural, (62%) (see Figure 5). process and outcome quality (Quentin et al., 2019, pp. The 5-year survival for breast cancer improved by about 37–38). Donabedian (1988, p. 1745) assumes that ‘[..] a 3% in the Netherlands between 2000 and 2014 (OECD, good structure increases the likelihood of good process, and 2020). This is due to the screening programme that was a good process increases the likelihood of a good outcome’. introduced in 1990 and improved treatment. Screening is Structures include the characteristics of the settings in used to detect less aggressive and smaller tumours more which care is provided, the characteristics of resources frequently. This allows earlier treatment initiation and less (human and material resources) and organisational invasive therapy. As a part of the treatment, improvements structures (e.g., organisation of medical staff). Processes have been achieved in adjuvant therapies (hormonal and are activities, which are performed when care is given and chemical) and surgical interventions (van den Berg et al., received. The effects of care on the health status of patients 2014, p. 133). and population groups are defined as outcomes (Donabedian, Figure 4 shows that the Dutch survival rate for cervical 1988, p. 1745). cancer has virtually remained unchanged from 2000-2014. 244 Journal of Health Management 24(2) Age-standardisednet Confidence Interval 2010-2014 2000-2004 2010-2014 survival (%) 89 89 89 89 88 88 88 88 88 87 87 86 86 86 86 86 86 86 85 90 85 85 82 82 82 77 77 76 76 Figure 3. Breast Cancer 5-year Net Survival, 2000–2004, 2010–2014. Source: Data taken from OECD (2020). Age-standardised net Confidence Interval 2010-2014 2000-2004 2010-2014 survival (%) 71 71 68 67 67 67 67 67 66 66 66 65 65 70 65 64 64 64 61 61 60 55 Figure 4. Cervical Cancer 5-year Net Survival, 2000–2004, 2010–2014. Source: Data taken from OECD (2020). Age-standardised net survival (%) Confidence Interval 2010-2014 2000-2004 2010-2014 80 72 68 68 68 67 67 65 65 65 65 64 64 64 64 63 63 62 62 61 61 56 56 Figure 5. Colorectal Cancer 5-year Net Survival, 2000–2004, 2010–2014. Source: Data taken from OECD (2020). Hrudey 245 The effects of treatment improvements (e.g., combined On the other hand, there are areas in which the Netherlands is radiotherapy and hyperthermia) and the screening positioned lower in international comparison: the time between programme are not reflected in this figure. The confidence diagnosis and the start of treatment (especially, for colorectal intervals of survival rates are relatively large due to the low cancer), evaluation of the performance of the healthcare system, incidence and mortality of cervical cancer (van den Berg transparency with regard to the quality of healthcare, quality et al., 2014, p. 136). differences between hospitals and benchmarking of healthcare For colorectal cancer, the 5-year survival rate has increased providers (OECD, 2013, pp. 35–108). from 58% to 63% (OECD, 2020). The improved survival is In addition to global comparisons, regional differences are based on advances in treatment, particularly, the more also relevant for assessing the quality of cancer care in the frequent use of adjuvant chemotherapy. Screening for Netherlands. In 2007, the Dutch Cancer Society founded a colorectal cancer was introduced in the Netherlands in 2014, Quality of Cancer Care Taskforce to evaluate the quality of and therefore, does not provide an explanatory approach (van cancer care. The results of the study showed that the quality den Berg et al., 2014, pp. 137–139). of care varies according to region and hospital. The differences Global comparisons show large differences in survival between hospitals can be explained in part by the procedural rates and consistent patterns of countries with stronger and volume and the type of hospital (general hospital, educational weaker performance. It is reasonable to assume that these hospital for surgery or university hospital) (Wouters et al., differences do not occur by chance, but rather result from 2010, pp. 3–10). Study results indicated that cancer patients systematic differences in the organization, funding and in the Netherlands are more often treated according to current management of cancer treatment programmes (OECD & standards and have higher survival rates in university European Commission, 2013, p. 2). hospitals and hospitals with a high procedural volume. National cancer control plans are an important part of However, differences in the quality of care are mainly due to quality cancer care. In the Netherlands, such a plan (National the variation level of individual hospitals. Since the NCR Cancer Control Programme) exists since 2004 and covers not lacks relevant information on differences in the case mix only prevention and diagnosis but also treatment, follow-up between hospitals, it is not possible to adequately explain the and psychosocial care, as well as aspects of education and variation. One potential reason is the fast pace with which research (OECD, 2013, pp. 93–97). To improve the quality new, evidence-based treatment strategies are introduced and coordination of care, seven regional comprehensive (Elferink et al., 2010a, pp. 74–81; 2010b, pp. 64–72; Wouters cancer centres (CCC) have been established in the Netherlands et al., 2010, pp. 3–10). According to Elferink et al. (2010b, p. since 1978. The CCCs each cover an area with 5–20 hospitals 66), the regional differences result, among other things, from and each hospital is assigned to a Centre. The Centres are the fact that each CCC region treatment guideline is discussed responsible, among other things, for the development and in multidisciplinary meetings. implementation of guidelines, for the administration of the From the presentation of the quality of cancer care, it can Netherlands Cancer Registry (NCR) and for improving the be concluded that, compared to other OECD member states, coordination of cancer and palliative care. Since 2011, they the Netherlands is in the middle to upper range. Potential for have been organised under the umbrella of the nationwide improvement lies in the reduction of regional differences in organization IKNL (Integraal Kankercentrum Nederland) the provision of cancer care above all. (Elferink et al., 2010a, p. 75; Rijksinstituut voor Volksgezondheid en Milieu, 2020b). Since 1989, the NCR has been collecting data for all cancer patients with regard to Discussion diagnosis, tumour characteristics and initial treatment. The data are made available to policymakers (Ministry of Health, The Netherlands is interested in ensuring quality healthcare Welfare and Sport), the healthcare sector (hospitals and other and quality is one of the three main objectives of the healthcare health care facilities, professionals and patient organisations) system (Kroneman et al., 2016, p. 187). This paper aimed to and the scientific community (IKNL). assess the quality of cancer care in the Netherlands, especially The OECD study ‘Cancer Care: Assuring Quality to Improve in terms of effectiveness. Survival’ compares the quality of cancer care in OECD member Due to the decline in cardiovascular mortality, cancer is states in a comprehensive manner. Cancer care in the the main cause of death in the Netherlands (OECD, 2020). Netherlands has many positive aspects, such as the existence of The Dutch healthcare system has made progress in fighting population-based screening programmes, good access to care, cancer by introducing population-based screening the existence of a national cancer control plan and treatment programmes and implementing treatment improvements (van guidelines, the accreditation of facilities and services, as well as den Berg et al., 2014, pp. 133–139). This is reflected in the various strategies to ensure sufficient human resources (e.g., increased 5-year survival rates (OECD, 2020). The National certification systems for the training of medical personnel with Cancer Control Programme, introduced in 2004, is another expertise in cancer care and nurse practitioners in oncology). important element in ensuring the quality of cancer care. It 246 Journal of Health Management 24(2) takes a holistic approach by addressing issues that go beyond consideration of other factors, such as differences between prevention and diagnosis (OECD, 2013, 93–97). service providers, resources for cancer care and other Since coordination is also highly relevant in the context of dimensions of quality (safety and person-centeredness). quality care, seven regional Comprehensive Cancer Centres Taking into account the limitations mentioned above, it have been implemented (Rijksinstituut voor Volksgezondheid can be concluded that the Netherlands has high-quality, en Milieu, 2020b). In addition, the Netherlands is devoting effective cancer care and is striving to continuously improve increasing attention to integrated care in order to meet the it. However, there is room for improvement, especially with complex needs of cancer patients (OECD, 2013, p. 97). In the regard to participation in cervical cancer screening, field of monitoring, the Netherlands Cancer Registry is an transparency about the quality of healthcare and regional established information structure (IKNL). differences in the quality of care The Dutch survival rates for breast, cervical and colorectal Acknowledgements cancers were above the respective OECD averages in 2014, but some countries are better positioned. There is potential for I want to thank Anne Spranger for her general support during the improvement, especially regarding the survival of colorectal implementation of the study. I would also like to thank Christoph cancer (OECD, 2020). It should be noted that screening for Stallmann for his critical review of the manuscript. colorectal cancer has only been available since 2014 (van den Declaration of Conflicting Interests Berg et al., 2014, p. 139). The data on 5-year survival are from the same year. It can be assumed that the positive effect The author declared no potential conflicts of interest with respect to of screening will be reflected in future survival rates. the research, authorship, and/or publication of this article. The international differences in survival rates are not random (OECD & European Commission, 2013, p. 2). The Funding orientation towards other countries that perform better in The author received no financial support for the research, authorship terms of quality represents an approach to improving cancer and/or publication of this article. care in the Netherlands. This includes all the above Scandinavian countries (see Figures 3–5). Participation in References screening is recommended in the Netherlands, but not Busse, R., Panteli, D., & Quentin, W. (2019). An Introduction to mandatory. No targets are set for participation rates healthcare quality: Defining and explaining its role in health sys- (Kroneman et al., 2016, p. 197). Participation in screening for tems. In R. Busse, N. Klazinga, D. Panteli, & W. Quentin (Eds.), cervical cancer was relatively low in the Netherlands in 2017, Improving healthcare quality in Europe: Characteristics, effec- below the OECD average (OECD, 2020). This can be tiveness and implementation of different strategies (pp. 1–17). increased, for example, by setting higher targets for WHO Regional Office for Europe, European Observatory on participation rates. Another challenge is the variation in the Health Systems and Policies. Donabedian, A., & Ann Arbor (1980). The definition of quality and quality of care by a region and a hospital (Wouters et al., approaches to its assessment. Vol 1. Explorations in Quality 2010, pp. 3–10). The underlying causes have not yet been Assessment and Monitoring. Michigan: Health Administration adequately identified. First, there is a need for research to Press. identify the factors causing this variation. The next step Donabedian, A. (1988). The quality of care: How can it be should be focused on implications to reduce the differences. assessed? Journal of the American Medical Association, The present analysis has some limitations. The most recent 260(12), 1743–1748. data for 5-year survival are from 2014 and are, therefore, not Elferink, M. A. G., Krijnen, P., Wouters, M. W. J. M., Lemmens, V. sufficiently up-to-date. No more recent data were found in the E. P. P., Jansen-Landheer, M. L. E. A., van de Velde, C. J. H., database analysis. The author used studies from 2010 and Langendijk, J. A., Marijnen, C. A. M., Siesling, S., & Tollenaar, 2013 to describe regional differences in the quality of care. R. A. E. M. (2010a). Variation in treatment and outcome of The Netherlands Cancer Registry could have been used for patients with rectal cancer by region, hospital type and volume in the Netherlands. European Journal of Surgical Oncology, this subject area, but public access to the data is limited. Only 36(Suppl. 1), S74–S82. nationwide survival rates are included in the Registry, regional Elferink, M. A. G., Wouters, M. W. J. M., Krijnen, P., Lemmens, survival data are missing. Furthermore, the comparison of V. E. P. P., Jansen-Landheer, M. L. E. A., van de Velde, C. J. survival rates is subject to limitations. Screening programmes H., Siesling, S., & Tollenaar, R. A. E. M. (2010b). Disparities contribute to an improvement of the survival statistics through in quality of care for colon cancer between hospitals in the lead-time bias and the length-time bias. Besides, survival the Netherlands. European Journal of Surgical Oncology, rates are not adapted to the tumour stage at the time of 36(Suppl. 1), S64–S73. diagnosis, thus making it more difficult to evaluate the effects IKNL. Netherlands Cancer Registry (NCR): Record, report, of screening programmes and treatment improvements improve and regulate. https://iknl.nl/en/ncr (OECD, 2013, p. 25). Furthermore, a more differentiated IOM (Ed.). (1990). Medicare: A strategy for quality assurance: assessment of the quality of cancer care requires the Volume 1. National Academies Press (US), 1–441. Hrudey 247 Kroneman, M., Boerma, W., van den Berg, M., Groenewegen, P., de Regional Office for Europe, European Observatory on Health Jong, J., & van Ginneken, E. (2016). The Netherlands: Health Systems and Policies. system review: Health Systems in Transition. 2: Vol. 18. WHO Rijksinstituut voor Volksgezondheid en Milieu. (2020a). Regional Office for Europe, European Observatory on Health Deelnamebevolkingsonderzoekborstkanker [Participation in Systems and Policies. population screening for breast cancer]. Ministerie van Volksgezondheid. (2018). Outcome based healthcare Rijksinstituut voor Volksgezondheid en Milieu. (2020b). 2018-2022. Ministerie van Volksgezondheid, Welzijn en Sport. Integralekankercentra [Comprehensive Cancer Center of the https://www.government.nl/documents/reports/2018/07/02/ Netherlands]. outcome-based-healthcare2018-202 Rijksinstituut voor Volksgezondheid en Milieu. (2020c). Landelijkbevolkingsonderzoekdarmkanker [Nationwide popu- OECD. (2013). Cancer Care: Assuring quality to improve survival. lation screening for colon cancer]. OECD health policy studies. OECD Publishing. OECD. (2020). OECD health statistics [Online database]. https:// van den Berg, M. J., de Boer, D., Gijsen, R., Heijink, R., Limburg, stats.oecd.org/ L. C. M., & Zwakhals, S. L. N. (2014). Dutch health care per- formance report. RIVM. OECD, & European Commission. (2013). Focus on health: Wammes, J., Jeurissen, P., Westert, G., & Tanke, M. (2017). The Cancer Care: Assuring quality to improve survival. https:// Dutch Health Care System. In The Commonwealth Fund (Ed.), www.oecd.org/els/health-systems/Focus-on-Health_Cancer- Care-2013.pdf International profiles of health care systems (pp. 113–119). The OECD, & European Observatory on Health Systems Policies. Commonwealth Fund. WHO. (2018). Handbook for national quality policy and strategy: (2017). Netherlands: Country Health Profile 2017: State of A practical approach for developing policy and strategy to Health in the EU. OECD Publishing, European Observatory on improve quality of care. WHO. Health Systems and Policies. Quentin, W., Partanen, V. M., Brownwood, I., & Klazinga, The World Bank. (2020). World Bank open data (Online database). https://data.worldbank.org/ N. (2019). Measuring healthcare quality. In R. Busse, N. Wouters, M. W. J. M., Jansen-Landheer, M. L. E. A., & van de Velde, C. Klazinga, D. Panteli, & W. Quentin (Eds.), Improving health- J. H. (2010). The Quality of cancer care initiative in the Netherlands. care quality in Europe: Characteristics, effectiveness and European Journal of Surgical Oncology, 36(Suppl.1), S3–S13. implementation of different strategies (pp. 31–62). WHO

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