COVID-19 mortality, excess mortality, deaths per million and infection fatality ratio, Belgium, 9 March 2020 to 28 June 2020.

BackgroundCOVID-19 mortality, excess mortality, deaths per million population (DPM), infection fatality ratio (IFR) and case fatality ratio (CFR) are reported and compared for many countries globally. These measures may appear objective, however, they should be interpreted with caution.AimWe examined reported COVID-19-related mortality in Belgium from 9 March 2020 to 28 June 2020, placing it against the background of excess mortality and compared the DPM and IFR between countries and within subgroups.MethodsThe relation between COVID-19-related mortality and excess mortality was evaluated by comparing COVID-19 mortality and the difference between observed and weekly average predictions of all-cause mortality. DPM were evaluated using demographic data of the Belgian population. The number of infections was estimated by a stochastic compartmental model. The IFR was estimated using a delay distribution between infection and death.ResultsIn the study period, 9,621 COVID-19-related deaths were reported, which is close to the excess mortality estimated using weekly averages (8,985 deaths). This translates to 837 DPM and an IFR of 1.5% in the general population. Both DPM and IFR increase with age and are substantially larger in the nursing home population.DiscussionDuring the first pandemic wave, Belgium had no discrepancy between COVID-19-related mortality and excess mortality. In light of this close agreement, it is useful to consider the DPM and IFR, which are both age, sex, and nursing home population-dependent. Comparison of COVID-19 mortality between countries should rather be based on excess mortality than on COVID-19-related mortality.

Assessing polypharmacy in the older population: Comparison of a self-reported and prescription based method.

PURPOSE: To explore differences in the prevalence and determinants of polypharmacy in the older general population in Belgium between self-reported and prescription based estimates and assess the relative merits of each data source. METHODS: Data were used from participants aged ≥65 years of the Belgian national health survey 2013 (n = 1950). Detailed information was asked on the use of medicines in the past 24 h and linked with prescription data from the Belgian compulsory health insurance (BCHI). Agreement between polypharmacy (use or prescription ≥5 medicines) and excessive polypharmacy (≥10 medicines) between both sources was assessed with kappa statistics. Multinomial logistic regression was used to study determinants of moderate (5-9 medicines) and excessive polypharmacy (≥10 medicines) and over- and underestimation of prescription based compared to self-reported polypharmacy. RESULTS: Self-reported and prescription based polypharmacy prevalence estimates were respectively 27% and 32%. Overall agreement was moderate, but better in men (kappa 0.60) than in women (0.45). Determinants of moderate polypharmacy did not vary substantially by source of outcome indicator, but restrictions in activities of daily living (ADL), living in an institution and a history of a hospital admission was associated with self-reported based excessive polypharmacy only. CONCLUSIONS: Surveys and prescription data measure polypharmacy from a different perspective, but overall conclusions in terms of prevalence and determinants of polypharmacy do not differ substantially by data source. Linking survey data with prescription data can combine the strengths of both data sources resulting in a better tool to explore polypharmacy at population level.

Validity of self-reported mammography uptake in the Belgian health interview survey: selection and reporting bias.

BACKGROUND: The validity of self-reported mammography uptake is often questioned. We assessed the related selection and reporting biases among women aged 50-69 years in the Belgian Health Interview Survey (BHIS) using reimbursement data for mammography stemming from the Belgian Compulsory Health Insurance organizations (BCHI). METHODS: Individual BHIS 2013 data (n = 1040) were linked to BCHI data 2010-13 (BHIS-BCHI sample). Being reimbursed for mammography within the last 2-years was used as the gold standard. Selection bias was assessed by comparing BHIS estimates reimbursement rates in BHIS-BCHI with similar estimates from the Echantillon Permanent/Permanente Steekproef (EPS), a random sample of BCHI data, while reporting bias was investigated by comparing self-reported versus reimbursement information in the BHIS-BCHI. Reporting bias was further explored through measures of agreement and logistic regression. RESULTS: Mammography uptake rates based on self-reported information and reimbursement from the BHIS-BCHI were 75.5% and 69.8%, respectively. In the EPS, it was 64.1%. The validity is significantly affected by both selection bias {relative size = 8.93% [95% confidence interval (CI): 3.21-14.64]} and reporting bias [relative size = 8.22% (95% CI: 0.76-15.68)]. Sensitivity was excellent (93.7%), while the specificity was fair (66.4%). The agreement was moderate (kappa = 0.63). Women born in non-EU countries (OR = 2.81, 95% CI: 1.54-5.13), with high household income (OR = 1.27, 95% CI: 1.02-1.60) and those reporting poor perceived health (OR = 1.41, 95% CI: 1.14-1.73) were more likely to inaccurately report their mammography uptake. CONCLUSIONS: The validity of self-reported mammography uptake in women aged 50-69 years is affected by both selection and reporting bias. Both administrative and survey data are complementary when assessing mammography uptake.

Establishing an ad hoc COVID-19 mortality surveillance during the first epidemic wave in Belgium, 1 March to 21 June 2020.

BackgroundCOVID-19-related mortality in Belgium has drawn attention for two reasons: its high level, and a good completeness in reporting of deaths. An ad hoc surveillance was established to register COVID-19 death numbers in hospitals, long-term care facilities (LTCF) and the community. Belgium adopted broad inclusion criteria for the COVID-19 death notifications, also including possible cases, resulting in a robust correlation between COVID-19 and all-cause mortality.AimTo document and assess the COVID-19 mortality surveillance in Belgium.MethodsWe described the content and data flows of the registration and we assessed the situation as of 21 June 2020, 103 days after the first death attributable to COVID-19 in Belgium. We calculated the participation rate, the notification delay, the percentage of error detected, and the results of additional investigations.ResultsThe participation rate was 100% for hospitals and 83% for nursing homes. Of all deaths, 85% were recorded within 2 calendar days: 11% within the same day, 41% after 1 day and 33% after 2 days, with a quicker notification in hospitals than in LTCF. Corrections of detected errors reduced the death toll by 5%.ConclusionBelgium implemented a rather complete surveillance of COVID-19 mortality, on account of a rapid investment of the hospitals and LTCF. LTCF could build on past experience of previous surveys and surveillance activities. The adoption of an extended definition of 'COVID-19-related deaths' in a context of limited testing capacity has provided timely information about the severity of the epidemic.

High impact of COVID-19 in long-term care facilities, suggestion for monitoring in the EU/EEA, May 2020.

Residents in long-term care facilities (LTCF) are a vulnerable population group. Coronavirus disease (COVID-19)-related deaths in LTCF residents represent 30-60% of all COVID-19 deaths in many European countries. This situation demands that countries implement local and national testing, infection prevention and control, and monitoring programmes for COVID-19 in LTCF in order to identify clusters early, decrease the spread within and between facilities and reduce the size and severity of outbreaks.

Monitoring health inequalities when the socio-economic composition changes: are the slope and relative indices of inequality appropriate? Results of a simulation study.

BACKGROUND: The slope (SII) and relative (RII) indices of inequality are commonly recommended to monitor health inequality policies. As an upwards shift of the educational level distribution (ELD) can be part of those policies, we examine how such a shift affects the SII, the RII and the population attributable fraction (PAF). METHODS: We simulated 632 distributions of 4 educational levels (ELs) by varying the share (p1 to p4) of each EL, with constant mortality rates (MR) and calculated the corresponding RII, SII and PAF. Second, we decomposed the effect on the three indices of a change affecting both the ELD and the MRs, into the contributions of each component. RESULTS: RIIs and SIIs sharply increase with p4 at fixed p1 values and evolve as reversed U-curves for p1 changing in complement to p4. The RII reaches a maximum, at much higher p4 values than the SII. PAFs monotonically decrease when p4 increases. CONCLUSION: If improving the educational attainment is part of a policy, an upwards shift of EL should be assessed as a progress; however the RII, and to a lesser extent the SII, frequently translate an increased EL4 share as a worsening. We warn against the use of SII and RII for monitoring inequality-tackling policies at changing socio-economic structures. Rather, we recommend to complement the assessment of changes in absolute and relative pairwise differentials, with changes in PAF and in the socio-economic group shares.

Contribution of chronic conditions to gender disparities in health expectancies in Belgium, 2001, 2004 and 2008.

Background: We aimed to investigate the contribution of chronic conditions to gender differences in disability-free life expectancy (DFLE) and life expectancy with disability (LED) in Belgium in 2001, 2004 and 2008. Methods: Data on disability and chronic conditions from participants of the 2001, 2004 and 2008 Health Interview Surveys in Belgium were used to estimate disability prevalence by cause using the attribution method. Disability prevalence was applied to life tables to estimate DFLE and LED using the Sullivan method. Decomposition techniques were used to assess the contribution of mortality and disability and further of causes of death and disability to gender disparities in DFLE and LED. Results: Higher LE, DFLE and LED were observed for women compared with men in all years studied. A decrease in the gender gap in LE (2001: 5.9; 2004: 5.6; 2008: 5.3) was observed in our cross-sectional approach followed by a decrease in gender differences in DFLE (2001: 1.9; 2004: 1.3; 2008: 0.5) and increase in LED (2001: 4.0; 2004: 4.4; 2008: 4.8). The higher LED in women was attributed to their lower mortality due to lung/larynx/trachea cancer, ischaemic heart diseases, and external causes (2001 and 2004) and higher disability prevalence due to musculoskeletal conditions (2008). Higher DFLE was observed in women owing to their lower mortality from lung/larynx/trachea cancer, ischaemic heart diseases, digestive cancer and chronic respiratory diseases. Conclusion: To promote healthy ageing of populations, priority should be given to reduce the LED disadvantage in women by targeting non-fatal diseases, such as musculoskeletal conditions.

Estimating the prevalence of diabetes mellitus and thyroid disorders using medication data in Flanders, Belgium.

Background: Various methods exist to estimate disease prevalences. The aim of this study was to determine whether dispensed, self-reported and prescribed medication data could be used to estimate the prevalence of diabetes mellitus and thyroid disorders. Second, these pharmaco-epidemiological estimates were compared with prevalences based on self-reported diagnoses and doctor-registered diagnoses. Methods: Data on medication for diabetes and thyroid disorders were obtained from three different sources in Flanders (Belgium) for 2008: a purely administrative database containing data on dispensed medication, the Belgian National Health Interview Survey for self-reported medication and diagnoses, and a patient record database for prescribed medication and doctor-registered diagnoses. Prevalences were estimated based on medication data and compared with each other. Cross-tabulations of dispensed medication and self-reported diagnoses, and prescribed medication and doctor-registered diagnoses, were investigated. Results: Prevalences based on dispensed medication were the highest (4.39 and 2.98% for diabetes and thyroid disorders, respectively). The lowest prevalences were found using prescribed medication (2.39 and 1.72%, respectively). Cross-tabulating dispensed medication and self-reported diagnoses yielded a moderate to high sensitivity for diabetes (90.4%) and thyroid disorders (77.5%), while prescribed medication showed a low sensitivity for doctor-registered diagnoses (56.5 and 43.6%, respectively). The specificity remained above 99% in all cases. Conclusions: This study was the first to perform cross-tabulations for disease prevalence estimates between different databases and within (sub)populations. Purely administrative database was shown to be a reliable source to estimate disease prevalence based on dispensed medication. Prevalence estimates based on prescribed or self-reported medication were shown to have important limitations.

Using multiple measures to assess changes in social inequalities for breast cancer screening.

OBJECTIVES: To identify changes in social inequalities for mammograms uptake in Belgium over the period 1997-2008 using multiple indices, and to assess the contribution of the national breast cancer screening programme in these changes. METHODS: Data were obtained from four waves of the Belgian Health Interview Survey. The socio-economic position was defined by the educational level. Inequalities were measured both with pairwise measures comparing extreme educational groups (prevalence difference and prevalence ratio), and with indices measuring the total inequality impact at population level: the Population Attributable Fraction (PAF), the Relative Index of Inequality (RII) and the Slope Index of Inequality (SII). RESULTS: All indices show a substantial decrease in inequalities in mammographic uptake between 1997 and 2008. For the indices of total impact (PAF, RII, SII), the change occurred between the first two waves (1997 and 2001) and stabilized afterwards, while for pairwise indices the evolution continued over the whole period. CONCLUSION: Using multiple indices of inequality is necessary for a more complete understanding of the changes: total impact inequality indices should always complement simple pairwise measures. The inequalities in mammograms uptake, as measured with total impact indices, only decreased before the start of the national screening programme.

All-cause mortality supports the COVID-19 mortality in Belgium and comparison with major fatal events of the last century.

BACKGROUND: The COVID-19 mortality rate in Belgium has been ranked among the highest in the world. To assess the appropriateness of the country's COVID-19 mortality surveillance, that includes long-term care facilities deaths and deaths in possible cases, the number of COVID-19 deaths was compared with the number of deaths from all-cause mortality. Mortality during the COVID-19 pandemic was also compared with historical mortality rates from the last century including those of the Spanish influenza pandemic. METHODS: Excess mortality predictions and COVID-19 mortality data were analysed for the period March 10th to June 21st 2020. The number of COVID-19 deaths and the COVID-19 mortality rate per million were calculated for hospitals, nursing homes and other places of death, according to diagnostic status (confirmed/possible infection). To evaluate historical mortality, monthly mortality rates were calculated from January 1900 to June 2020. RESULTS: Nine thousand five hundred ninety-one COVID-19 deaths and 39,076 deaths from all-causes were recorded, with a correlation of 94% (Spearman's rho, p < 0,01). During the period with statistically significant excess mortality (March 20th to April 28th; total excess mortality 64.7%), 7917 excess deaths were observed among the 20,159 deaths from all-causes. In the same period, 7576 COVID-19 deaths were notified, indicating that 96% of the excess mortality were likely attributable to COVID-19. The inclusion of deaths in nursing homes doubled the COVID-19 mortality rate, while adding deaths in possible cases increased it by 27%. Deaths in laboratory-confirmed cases accounted for 69% of total COVID-19-related deaths and 43% of in-hospital deaths. Although the number of deaths was historically high, the monthly mortality rate was lower in April 2020 compared to the major fatal events of the last century. CONCLUSIONS: Trends in all-cause mortality during the first wave of the epidemic was a key indicator to validate the Belgium's high COVID-19 mortality figures. A COVID-19 mortality surveillance limited to deaths from hospitalised and selected laboratory-confirmed cases would have underestimated the magnitude of the epidemic. Excess mortality, daily and monthly number of deaths in Belgium were historically high classifying undeniably the first wave of the COVID-19 epidemic as a fatal event.

Evolution of educational inequalities in life and health expectancies at 25 years in Belgium between 2001 and 2011: a census-based study.

BACKGROUND: Reducing socio-economic health inequalities is a public health priority, necessitating careful monitoring that should take into account changes in the population composition. We analyzed the evolution of educational inequalities in life expectancy and disability-free life expectancy at age 25 (LE25 and DFLE25) in Belgium between 2001 and 2011. METHODS: The 2001 and 2011 census data were linked with the national register data for a five-year mortality follow up. Disability prevalence estimates from the health interview surveys (2001 to 2013) were used to compute DFLE according to Sullivan's method. LE25 and DFLE25 were computed by educational level (EL). Absolute differentials of LE25 and DFLE25 were calculated for each EL and for each period, as well as composite inequality indices (CII) of population-level impact of inequality. Changes over the 10-year period were then calculated for each inequality index. RESULTS: The LE25 increased in all ELs and both genders, except in the lowest EL for women. The increase was larger in the highest EL, leading in 2011 to 6.07 and 4.58 years for the low-versus-high LE25 gaps respectively in men and women, compared to 5.19 and 3.76 in 2001, namely 17 and 22% increases. The upwards shift of the EL distribution led to a limited 7% increase of the CII among men but no change in women.The substantial increase of the DFLE25 in males with high EL (+ 4.5 years) and the decrease of the DFLE25 in women with low EL, results in a substantial increase of all considered DFLE25 inequality measures in both genders. In 2011, DFLE25 gaps were respectively 10.4 and 13.5 years in males and females compared to 6.51 and 9.30 in 2001, representing increases of 61 and 44% for the gaps, and 72 and 20% for the CII. CONCLUSION: The LE25 increased in all ELs, but at a higher pace in highly educated, leading to an increase in the LE25 gaps in both genders. After accounting for the upwards shift of the educational distribution, the population-level inequality index increased only for men. The DFLE25 increased only in highly educated men, and decreased in low educated women, leading to large increases of inequalities in both genders. A general plan to tackle health inequality should be set up, with particular efforts to improve the health of the low educated women.

A federal audit of the Belgian radiotherapy departments in breast cancer treatment.

BACKGROUND: The Belgian Federal College of Radiotherapy carried out an external audit of breast cancer patient documentation in the 26 Belgian radiotherapy centres. The objective was to assess compliance with the recommendations regarding minimal requirements for documentation of radiotherapy prescription and administration. All centres volunteered to take part in this audit. METHODS: Two experienced radiation oncologists site-visited the departments over a 6 month period (Sept. 2003-Feb. 2004), with a list of items to be verified, including details on the surgery, the pathological report, details on systemic treatments, details on the radiotherapy prescription (and consistency with therapeutic guidelines) and delay surgery/radiotherapy. FINDINGS: Three hundred and eighty-nine patients files were reviewed, for a total of 399 breast cancers (10 patients with bilateral cancer). Mean age was 57.8 y (range 29-96). Breast conservative surgery (BCS) was used in 71%; radical mastectomy in 29%. A complete pathological report was present in all files but 2 (99.5% conformity). 5.2% were treated for DCIS, 61.6% for pT1, 28.2% for pT2 and 5% for pT3-4. Data regarding resection margins were specified to be free in 76.2%, tangential in 12% (within 2 mm) and positive for DCIS in 3.8% or invasive cancer in 1.5% (no information, on margins in 6.5%). The pT stage was always specified, and consistent with the macroscopic and microscopic findings. Hormonal receptors were routinely assessed (94.7%), as well as Her2neu (87.4%). Axillary surgery was carried out in 92%, either by sentinel node biopsy or by complete clearance, in which case the median number of nodes analysed was 12 for all centres together (7-17). All radiotherapy prescriptions were in line with evidence-based standards of therapy (i.e., irradiation of breast after BCS or after mamectomy (in case of pN+), but one. The mean delay between surgery and radiotherapy was 5.5 weeks (SD 11 days). CONCLUSION: There was a high degree of conformity of the various centres with the minimal requirements for documentation of radiotherapy prescription and administration of the Federal College of Radiotherapy. In addition, the quality of surgery (assessed by margin clearance) and of pathological reports was excellent, whatever the institution of origin (teaching vs. non-teaching, private vs. public). Belgian patients referred for radiotherapy are treated with great care. Prescriptions are based on pathological evidence, gathered through appropriate surgery. All indications were evidence-based; there was no overuse of radiotherapy in early breast cancer treatment.

Educational inequalities in premature mortality by region in the Belgian population in the 2000s.

BACKGROUND: In Belgium, socio-economic inequalities in mortality have long been described at country-level. As Belgium is a federal state with many responsibilities in health policies being transferred to the regional levels, regional breakdown of health indicators is becoming increasingly relevant for policy-makers, as a tool for planning and evaluation. We analyzed the educational disparities by region for all-cause and cause-specific premature mortality in the Belgian population. METHODS: Residents with Belgian nationality at birth registered in the census 2001 aged 25-64 were included, and followed up for 10 years though a linkage with the cause-of-death database. The role of 3 socio-economic variables (education, employment and housing) in explaining the regional mortality difference was explored through a Poisson regression. Age-standardised mortality rates (ASMRs) by educational level (EL), rate differences (RD), rate ratios (RR), and population attributable fractions (PAF) were computed in the 3 regions of Belgium and compared with pairwise regional ratios. The global PAFs were also decomposed into the main causes of death. RESULTS: Regional health gaps are observed within each EL, with ASMRs in Brussels and Wallonia exceeding those of Flanders by about 50% in males and 40% in females among Belgian. Individual SE variables only explained up to half of the regional differences. Educational inequalities were also larger in Brussels and Wallonia than in Flanders, with RDs ratios reaching 1.8 and 1.6 for Brussels versus Flanders, and Wallonia versus Flanders respectively; regional ratios in relative inequalities (RRs and PAFs) were smaller. This pattern was observed for all-cause and most specific causes of premature mortality. Ranking the cause-specific PAFs revealed a higher health impact of inequalities in causes combining high mortality rate and relative inequality, with lung cancer and ischemic heart disease on top for all regions and both sexes. The ranking showed few regional differences. CONCLUSIONS: For the first time in Belgium, educational inequalities were studied by region. Among the Belgian, educational inequalities were higher in Brussels, followed by Wallonia and Flanders. The region-specific PAF decomposition, leading to a ranking of causes according to their population-level impact on overall inequality, is useful for regional policy-making processes.

Trends in educational inequalities in premature mortality in Belgium between the 1990s and the 2000s: the contribution of specific causes of deaths.

BACKGROUND: Reducing socioeconomic inequalities in mortality, a key public health objective may be supported by a careful monitoring and assessment of the contributions of specific causes of death to the global inequality. METHODS: The 1991 and 2001 Belgian censuses were linked with cause-of-death data, each yielding a study population of over 5 million individuals aged 25-64, followed up for 5 years. Age-standardised mortality rates (ASMR) were computed by educational level (EL) and cause. Inequalities were measured through rate differences (RDs), rate ratios (RRs) and population attributable fractions (PAFs). We analysed changes in educational inequalities between the 1990s and the 2000s, and decomposed the PAF into the main causes of death. RESULTS: All-cause and avoidable ASMR decreased in all ELs and both sexes. Lung cancer, ischaemic heart disease (IHD), chronic obstructive pulmonary disease (COPD) and suicide in men, and IHD, stroke, lung cancer and COPD in women had the highest impact on population mortality. RDs decreased in men but increased in women. RRs and PAFs increased in both sexes, albeit more in women. In men, the impact of lung cancer and COPD inequalities on population mortality decreased while that of suicide and IHD increased. In women, the impact of all causes except IHD increased. CONCLUSION: Absolute inequalities decreased in men while increasing in women; relative inequalities increased in both sexes. The PAFs decomposition revealed that targeting mortality inequalities from lung cancer, IHD, COPD in both sexes, suicide in men and stroke in women would have the largest impact at population level.

Mapping the cause-specific premature mortality reveals large between-districts disparity in Belgium, 2003-2009.

BACKGROUND: Reducing premature mortality is a crucial public health objective. The goal of this paper, beside updating previous mortality atlases with recent data, is to explore the relative between-districts disparity using a relative-scale map design. METHODS: Causes of deaths and population data were provided by Statistics Belgium. All deaths occurring in the periods 1993-1999 and 2003-2009, in people aged 1-74 residing in Belgium were included. Age-adjusted rates by cause of death were computed for both periods; the 2003-2009 rates were classified using a relative scale with a 10% change between each level and represented on chloropleths maps with a green-to-red divergent colour scheme centred on the national mean. This particular design allows the comparability across all the maps since a same meaning is given to a specific colour. The variation coefficient and the decile ratio were calculated and compared between the 2 periods. RESULTS: A clear-cut regional divide at the disadvantage of Wallonia, and to some extent, of Brussels, was seen for all-cause, cardiovascular, cerebrovascular, diabetes, alcohol-related, mental and neurological diseases and non-transport accidents premature mortality. A NE-SW pattern parallel to the French border was observed for Lip, Oral Cavity, Pharynx, Larynx and oesophageal cancers, while various patterns are observed for the other cancers. The highest rates of road accident mortality are observed in the Southern districts. Many of those patterns are in continuity with earlier observations. However, the pattern of diabetes and mental and neurological diseases are new features. The variation coefficient and the decile ratios increased by 10% between the 1993-1997 and 2003-2009 periods. CONCLUSIONS: The use of a relative scale in the maps highlights the importance of the between-districts disparity in premature mortality, with for most causes, a clear-cut regional divide at the disadvantage of Wallonia; this health gap results of complex interactions between various factors, including the socioeconomic context, cultural habits and environmental influences, as well as public health policies. It should be considered as a warning signal, warranting the attention of the policy makers. Meanwhile, these results also highlight the potential for improvement in the more disadvantaged regions.

Premature mortality in Belgium in 1993-2009: leading causes, regional disparities and 15 years change.

BACKGROUND: Reducing premature mortality is a crucial public health objective. After a long gap in the publication of Belgian mortality statistics, this paper presents the leading causes and the regional disparities in premature mortality in 2008-2009 and the changes since 1993. METHODS: All deaths occurring in the periods 1993-1999 and 2003-2009, in people aged 1-74 residing in Belgium were included. The cause of death and population data for Belgium were provided by Statistics Belgium , while data for international comparisons were extracted from the WHO mortality database. Age-adjusted mortality rates and Person Year of Life Lost (PYLL) were calculated. The Rate Ratios were computed for regional and international comparisons, using the region or country with the lowest rate as reference; statistical significance was tested assuming a Poisson distribution of the number of deaths. RESULTS: The burden of premature mortality is much higher in men than in women (respectively 42% and 24% of the total number of deaths). The 2008-9 burden of premature mortality in Belgium reaches 6410 and 3440 PYLL per 100,000, respectively in males and females, ranking 4th and 3rd worst within the EU15. The disparities between Belgian regions are substantial: for overall premature mortality, respective excess of 40% and 20% among males, 30% and 20% among females are observed in Wallonia and Brussels as compared to Flanders. Also in cause specific mortality, Wallonia experiences a clear disadvantage compared to Flanders. Brussels shows an intermediate level for natural causes, but ranks differently for external causes, with less road accidents and suicide and more non-transport accidents than in the other regions. Age-adjusted premature mortality rates decreased by 29% among men and by 22% among women over a period of 15 years. Among men, circulatory diseases death rates decreased the fastest (-43.4%), followed by the neoplasms (-26.6%), the other natural causes (-21.0%) and the external causes (-20.8%). The larger decrease in single cause is observed for stomach cancer (-48.4%), road accident (-44%), genital organs (-40.4%) and lung (-34.6%) cancers. On the opposite, liver cancer death rate increased by 16%. Among female, the most remarkable feature is the 50.2% increase in the lung cancer death rate. For most other causes, the decline is slightly weaker than in men. CONCLUSION: Despite a steady decrease over time, international comparisons of the premature mortality burden highlight the room for improvement in Belgium. The disadvantage in Wallonia and to some extent in Brussels suggest the role of socio-economic factors; well- designed health policies could contribute to reduce the regional disparities. The increase in female lung cancer mortality is worrying.

The Belgian Health System Performance Report 2012: snapshot of results and recommendations to policy makers.

Following the commitments of the Tallinn Charter, Belgium publishes the second report on the performance of its health system. A set of 74 measurable indicators is analysed, and results are interpreted following the five dimensions of the conceptual framework: accessibility, quality of care, efficiency, sustainability and equity. All domains of care are covered (preventive, curative, long-term and end-of-life care), as well as health status and health promotion. For all indicators, national/regional values are presented with their evolution over time. Benchmarking to results of other EU-15 countries is also systematic. The policy recommendations represent the most important output of the report.

High burden of breast cancer in Belgium: recent trends in incidence (1999-2006) and historical trends in mortality (1954-2006).

INTRODUCTION: In Belgium, breast cancer mortality has been monitored since 1954, whereas cancer incidence data have only been made available for a few years. In this article we update historical trends of breast cancer mortality and describe the recent breast cancer incidence. METHODS: Incidence data were extracted from the Belgium Cancer Registry from 2004 to 2006 for the Walloon and Brussels Regions and Belgium, and from 1999 to 2006 for the Flemish Region. The Directorate-general Statistics and Economic information provided the mortality data for the years 1954-1999 and 2004. The regional authorities of the Flemish and Brussels Regions provided the mortality data for the years 2000-2003 and 2005-2006. RESULTS: In 2004, the World age-standardised breast cancer incidence for the whole of Belgium was 110 per 100, 000 person-years for all ages; and 172, 390 and 345 per 100, 000 person-years for the 35-49, 50-69, and 70+ age groups, respectively. The incidence rate was slightly higher in each age group in the Brussels Region. In Flanders, where the incidence could be observed during a longer period, an increase was observed until 2003 in the 50-69 age group, followed by a decrease. To the contrary, in the oldest age group, incidence continued to rise over the whole period, whereas no change in incidence was observed between 1999 and 2006 in the 35-49 age group.Mortality increased until the late 1980s and afterwards decreased in all regions and in age groups younger than 70. In women of 70 years and older, the decline began later. CONCLUSIONS: The burden of breast cancer in Belgium is very high. In 2004, Belgium ranked first for the age-standardised incidence rate in Europe for all ages combined and in the 35-49 and 50-69 age groups. The impact of the known risk factors and of mammographic screening should be further studied. The mortality rate in Belgium ranked lower than incidence, suggesting favourable survival. Plausible explanations for the discrepancy between incidence and mortality are discussed.