Outcome Domains


Outcome indicators capture the performance of the CC&TH service, other than patient self-care and engagement (see patient adherence outcomes)


Case Ascertainment

Captures the extent and precision with which the service manages its population.

Success of the service is captured by how well the diagnosis and treatment is for those on the service and how well the service addresses the needs of the population as a whole.

At population level: by means of registries.


  • Coverage: how well the population demand for the service is addressed by the service.
  • Diagnosis: how well the population is correctly diagnosed.
  • Treatment: how well the population is correctly treated.


Health Outcomes

Captures what the effect of the CCTH service is on patient physical & mental health, functional limitations and quality of life.

Health outcomes have a direct meaning to the patient.


  • General: all cause deaths, SF-12
  • COPD: COPD related deaths, SGRQ 
  • DM: DM related deaths, DQOL 
  • HF: HF related deaths, MLHFQ


Clinical Management Goals

Captures how well the patient is reaching the clinical goals set by guidelines and clinical protocols.

Clinical management goals correspond to the clinical values and goals. These have no direct meaning to the patient, but are relevant for the clinician.

It is not enough to keep patients outside the hospital, it is important to keep patients stable, with clinical values within safe ranges.


  • General: % patients not having hospitalizations and ED visits
  • COPD: Average number of exacerbations per patient
  • DM: Most recent systolic blood pressure <130 mmHg
  • HF: % patients with ejection fraction <40%


Process Outcomes

Captures how well the care pathways are working in practice, and how clinical guidelines and good practices are being followed

Adherence to clinical guidelines is recommended to apply evidenced-based medicine.


  • General: % patients contacted <48 hours post discharge
  • COPD: % patients with spirometry follow-up within 3 years
  • DM: % patients treated with a statin
  • HF: % patients with ACEI/ARBs


Service Utilization

Captures the effect of the CCTH service on the utilization of health care services

The CCTH service should be cost effective.

We measure the use of health care services in numbers, from which economic outcomes can be derived.


  • Nr of hospitalizations
  • Nr of AED visits
  • Nr primary care visits


Economic Outcomes

Captures the cost of the use of health care service utilization

The CCTH service should be cost effective. Here, we measure the burden on the health system, expressed in cost and time


  • Cost per service: the unit cost per service to derive the total cost for service utilization: e.g. cost per ED visit
  • Aggregated cost: high level cost figures about CCTH expenditure in a region: e.g. pharmaceutical spending