Search

Objective: To assess the effectiveness of duloxetine in addition to usual care in patients with chronic osteoarthritis (OA) pain. The cost-effectiveness and whether the presence of symptoms of centralized pain alters the response to duloxetine were secondary objectives. Methods: We conducted an open-label, cluster-randomized trial. Patients with chronic hip or knee OA pain who had an insufficient response to acetaminophen and nonsteroidal antiinflammatory drugs were included. Randomization took place at the general practice level, and patients received duloxetine (60 mg/day) in addition to usual care or usual care alone. The presence of centralized pain was defined as a modified PainDETECT Questionnaire score >12. The primary outcome measure was Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain scores (scale 0–20) at 3 months after the initiation of treatment. Our aim was to detect a difference between the groups of a clinically relevant effect of 1.9 points (effect size 0.4). We used a linear mixed model with repeated measurements to analyze the data. Results: In total, 133 patients were included, and 132 patients were randomized into treatment groups. A total of 66 patients (at 31 practices) were randomized to receive duloxetine in addition to usual care, and 66 patients (at 35 practices) were randomized to receive usual care alone. We found no differences in WOMAC pain scores between the groups at 3 months (adjusted difference –0.58 [95% confidence interval (95% CI) –1.80, 0.63]) or at 12 months (adjusted difference –0.26 [95% CI –1.86, 1.34]). In the subgroup of patients with centralized pain symptoms, we also found no effect of duloxetine compared to usual care alone (adjusted difference –0.32 [95% CI –2.32, 1.67]). Conclusion: We found no effect of duloxetine added to usual care compared to usual care alone in patients with chronic knee or hip OA pain. Another trial including patients with centralized pain symptoms should be conducted to validate our results.

ObjectivesTo conduct a cost-utility analysis for two commonly used treatment strategies for patients after ACL rupture; early ACL reconstruction (index) versus rehabilitation plus an optional reconstruction in case of persistent instability (comparator).MethodsPatients aged between 18 and 65 years of age with a recent ACL rupture (ResultsA total of 167 patients were included in the study, of which 85 were randomised to the early ACL reconstruction (index) group and 82 to the rehabilitation and optional reconstruction group (comparator). From the healthcare perspective it takes 48 460 € and from a societal perspective 78 179 €, to gain a QALY when performing early surgery compared with rehabilitation plus an optional reconstruction. This is unlikely to be cost-effective.ConclusionRoutine early ACL reconstruction (index) is not considered cost-effective as compared with rehabilitation plus optional reconstruction for a standard ACL population (comparator) given the maximum willingness to pay of 20 000 €/QALY. Early recognition of the patients that have better outcome of early ACL reconstruction might make rehabilitation and optional reconstruction even more cost-effective.

Background Worldwide, socioeconomic differences in health and use of healthcare resources have been reported, even in countries providing universal healthcare coverage. However, it is unclear how large these socioeconomic differences are for different types of care and to what extent health status plays a role. Therefore, our aim was to examine to what extent healthcare expenditure and utilization differ according to educational level and income, and whether these differences can be explained by health inequalities. Methods Data from 18,936 participants aged 25–79 years of the Dutch Health Interview Survey were linked at the individual level to nationwide claims data that included healthcare expenditure covered in 2017. For healthcare utilization, participants reported use of different types of healthcare in the past 12 months. The association of education/income with healthcare expenditure/utilization was studied separately for different types of healthcare such as GP and hospital care. Subsequently, analyses were adjusted for general health, physical limitations, and mental health. Results For most types of healthcare, participants with lower educational and income levels had higher healthcare expenditure and used more healthcare compared to participants with the highest educational and income levels. Total healthcare expenditure was approximately between 50 and 150 % higher (depending on age group) among people in the lowest educational and income levels. These differences generally disappeared or decreased after including health covariates in the analyses. After adjustment for health, socioeconomic differences in total healthcare expenditure were reduced by 74–91 %. Conclusions In this study among Dutch adults, lower socioeconomic status was associated with increased healthcare expenditure and utilization. These socioeconomic differences largely disappeared after taking into account health status, which implies that, within the universal Dutch healthcare system, resources are being spent where they are most needed. Improving health among lower socioeconomic groups may contribute to decreasing health inequalities and healthcare spending.

Samenvatting Inleiding We hebben berekend hoeveel er in 2015 aan preventie is uitgegeven. We maakten onderscheid tussen gezondheidsbescherming, gezondheidsbevordering en ziektepreventie. Bij de berekening van de uitgaven beperkten we ons tot universele, selectieve en geïndiceerde preventie. Zorggerelateerde preventie kan nauwelijks onderscheiden worden van curatieve zorg. De uitgaven aan preventie zijn berekend vanuit een maatschappelijk perspectief. Methode We hebben gevarieerde bronnen gebruikt om de uitgaven aan preventie te onderzoeken. Voor zover de kosten onderdeel waren van de uitgaven aan zorg zijn de berekeningen gebaseerd op de gegevens van het CBS. Voor het overige is gebruikgemaakt van jaarrapporten en jaarrekeningen van ministeries en andere organisaties. Ook uitgaven van consumenten, het bedrijfsleven, ngo’s en verzekeringsmaatschappijen zijn opgenomen. Resultaten In 2015 werd 12,5 miljard euro (1,8% van het bruto binnenlands product) uitgegeven aan preventie: 2,4 miljard aan ziektepreventie (18,8%), 0,6 miljard aan gezondheidsbevordering (5,2%) en 9,5 miljard aan gezondheidsbescherming (76%). Dit is 17% minder dan er in 2007 is uitgegeven, het laatste jaar dat een dergelijk onderzoek is uitgevoerd. Conclusie De uitgaven aan preventie zijn relatief laag vergeleken met de totale uitgaven aan zorg. Het grootste gedeelte gaat naar gezondheidsbescherming. In de komende jaren is er mogelijk een stijging aan uitgaven voor gezondheidsbevordering door regeringsbeleid, zoals het Nationaal Preventieakkoord.

It is unclear to what extent self‐employed choose to become self‐employed. This study aimed to compare the health care expenditures—as a proxy for health—of self‐employed individuals in the year before they started their business, to that of employees. Differences by sex, age, and industry were studied. In total, 5,741,457 individuals aged 25–65 years who were listed in the tax data between 2010 and 2015 with data on their health insurance claims were included. Self‐employed and employees were stratified according to sex, age, household position, personal income, region, and industry for each of the years covered. Weighted linear regression was used to compare health care expenditures in the preceding (year x–1) between self‐employed and employees (in year x). Compared with employees, expenditures for hospital care, pharmaceutical care and mental health care were lower among self‐employed in the year before they started their business. Differences were most pronounced for men, individuals ≥40 years and those working in the industry and energy sector, construction, financial institutions, and government and care. We conclude that healthy individuals are overrepresented among the self‐employed, which is more pronounced in certain subgroups. Further qualitative research is needed to investigate the reasons why these subgroups are more likely to choose to become self‐employed.

Introduction: Disease related malnutrition (DRM) is a serious medical condition which is associated with an increase in morbidity and mortality, augmenting resource use and associated costs. DRM can be detected by actively and fully assessing the nutritional status. Studies in adult malnourished patients have shown that the additional health care costs are about (sic) 2 billion ((sic) 2000 million) per year. The objective of the current study was to estimate the annual additional costs of DRM for pediatric patients as was done for adults. Methods: A cost-of-illness analysis was performed to calculate the annual additional costs of DRM in 2015 pediatric patients (aged 1 month up to and including 17 years) admitted to non-academic hospitals in The Netherlands. DRM was assessed with weight-for-age, weight-for-height and height-for-age. Input variables in the formula used were length of stay and prevalence of DRM. The costs were estimated per disease as classified in the International Classification of Diseases by the WHO (ICD-10), per gender and age group. The results were expressed as an absolute monetary value as well as a percentage of the Dutch national health expenditure. Robustness of the results was checked by a sensitivity analysis. Results: The total additional direct medical costs of DRM in pediatric patients in 2013 were estimated to be (sic) 51 million for acute malnutrition, (sic) 46 million when focused on chronic malnutrition and (sic) 80 million in case of overall malnourished children. This equals 5.6% of the total Dutch hospital costs for these hospitalized children. Conclusions: This study has shown that DRM in hospitalized children is associated with an increase in annual hospital costs with an additional amount of (sic) 80 million, of which acute malnutrition account for the largest part. (c) 2017 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.

Objective Knee osteoarthritis (OA) is associated with high medical costs and especially with high productivity costs, in particular in patients in their working years. High molecular weight (HMW) hyaluronic acid (HA) is an alternative treatment for nonsteroidal antiinflammatory drugs, which are known for their serious side-effects. The cost-utility of intraarticular HMW-HA treatment in these patients is unknown, however, and was assessed in this study. Methods Secondary care patients ages 18–65 years with knee OA were randomized to usual care plus HMW-HA (intervention group) or to usual care only (control group). A cost-utility analysis over 52 weeks from the societal and health care perspective was performed. Uncertainty for costs, effects, and cost-utility ratio was analyzed by nonparametric bootstrapping. Baseline imbalance adjustment was done by inverse probability of treatment weighting. Results In total, 156 subjects were included (intervention group n = 77, control group n = 79). The total of productivity and medical costs was €475 higher in the intervention group at €7,754 (95% confidence interval [95% CI] 5,426, 10,436) versus €7,270 (95% CI 5,453, 9,262). The amount of quality-adjusted life years (QALYs) gained during followup was also higher in the intervention group (0.779 versus 0.727). This variation resulted in an incremental cost-effectiveness ratio of €9,100/QALY from a societal perspective and €8,700/QALY from a health care perspective. When the maximum willingness to pay for conditions similar to knee OA is considered, the probability on cost-effectiveness is 64% and 86%, respectively. Conclusion Intraarticular HMW-HA added to usual care for knee OA is probably cost-effective in the treatment of knee OA.

IntroductionSome scaphoid fractures become visible on radiographs weeks after a trauma which makes normal radiographs directly after trauma unreliable. Untreated scaphoid fractures can lead to scaphoid non-union progressing to osteoarthritis. Therefore, the general treatment for patients with a clinically suspected scaphoid fracture and normal initial radiographs is immobilisation with below-elbow cast for 2 weeks. However, most of these patients are treated unnecessarily because eventually less than 10% of them are diagnosed with an occult scaphoid fracture. To reduce overtreatment and costs as a result of unnecessary cast treatment in patients with a clinically suspected scaphoid fracture and normal initial radiographs, we designed a study to compare below-elbow cast treatment with supportive bandage treatment. We hypothesise that the functional outcome after 3 months is not inferior in patients treated with supportive bandage compared to patients treated with below-elbow cast, but with lower costs in the supportive bandage group.Methods and analysisThe SUSPECT study is an open-labelled multicentre randomised controlled trial with non-inferiority design. A total of 180 adult patients with a clinically suspected scaphoid fracture and normal initial radiographs are randomised between two groups: 3 days of supportive bandage or 2 weeks of below-elbow cast. We aim to evaluate the functional outcome and cost-effectiveness of both treatments. The primary outcome is the functional outcome after 3 months, assessed with the Quick Disability of the Arm, Shoulder and Hand score. Secondary outcomes include functional outcome, recovery of function, pain, patient satisfaction, quality of life and cost-effectiveness measured by medical consumption, absence from work or decreased productivity.Ethics and disseminationThe Medical Ethics Committee of the Erasmus MC Medical Centre, Rotterdam, approved the study protocol (MEC-2017-504). We plan to present the results after completion of the study at (inter)national conferences and publish in general peer-reviewed journals.Trial registration numberNL6976.

Introduction In 2015, Dutch healthcare expenditure exceeded 85 billion euros. But what about prevention? In this study we estimated national expenditure on prevention. A distinction was made between health protection, health promotion and disease prevention. In the estimation of prevention expenditures, this study is limited to universal, selective and indicated prevention, as healthcare-related prevention can hardly be distinguished from curative care. This study analyzed expenditure on preventive activities in the Netherlands in 2015 and took a societal perspective. Methods We used various sources to investigate spending on prevention in 2015. Insofar as costs were part of healthcare expenditure, estimates were based on the Care Accounts of Statistics Netherlands. For the remainder, we estimated expenditure using annual reports and annual accounts of governments and other organizations. We included preventive activities by consumers, industry, NGOs, insurance companies, and government. Results In 2015, an estimated € 12.4 billion (1.8% of the GDP) was spent on prevention: € 2.4 billion on disease prevention (19%), € 0.6 billion on health promotion (5%) and € 9.4 billion on health protection (76%). This is a decrease of 17% compared to 2007, the last year that a similar estimate was made. Within health promotion, the largest expenditure was for working conditions and safety: € 160 million. € 67 million was spent on mental disorders. The largest expenditure item within disease prevention was dental care: € 675 million. Within health protection, this was the sewer by more than € 3 billion. Conclusions Spending on prevention is relatively low compared to total spending on healthcare. The largest part is targeted at health protection. In the coming years there may be an increase in expenditure, due to more governmental prevention policies such as the National Prevention Agreement. Key messages Spending on prevention is relatively low compared to total spending on healthcare. Relatively little money for health protection.

IntroductionShoulder pain is common and the prognosis is often unfavourable. Dutch guidelines on the treatment of shoulder pain in primary care recommend a corticosteroid injection or a referral to exercise therapy, if initial pain management fails and pain persists. However, evidence of the effectiveness of a corticosteroid injection compared with exercise therapy, especially in the long term, is limited. This trial will assess the clinical effectiveness and cost effectiveness of a corticosteroid injection compared with physiotherapist-led exercise therapy over 12 months follow-up in patients with shoulder pain in primary care.Methods and analysisThe SIX Study is a multicentre, pragmatic randomised clinical trial in primary care. A total of 213 patients with shoulder pain, aged ≥18 years presenting in general practice will be included. Patients will be randomised (1:1) into two groups: a corticosteroid injection or 12 sessions of physiotherapist-led exercise therapy. The effect of the allocated treatment will be assessed through questionnaires at 6 weeks and after 3, 6, 9 and 12 months. The primary outcome is patient’s reported shoulder pain-intensity and function, measured with the Shoulder Pain and Disability Index, over 12 months follow-up. Secondary outcomes include cost effectiveness, pain-intensity, function, health-related quality of life, sleep quality, patient’s global perceived effect, work absence, healthcare utilisation and adverse events. Between group differences will be evaluated using a repeated measurements analysis with linear effects models. A cost-utility analysis will be performed to assess the cost effectiveness using quality-adjusted life years from a medical and societal perspective.Ethics and disseminationThis study was approved by the Medical Ethics Committee of Erasmus MC University Medical Center Rotterdam (MEC 2020-0300). All participants will give written informed consent prior to data collection. The results from this study will be disseminated in international journals and implemented in the primary care guidelines on shoulder pain.Trial registration numberDutch Trial Registry (NL8854).

Objective: To determine the cost-effectiveness (CE) of exercise therapy (intervention group) compared to 'general practitioner (GP) care' (control group) in patients with hip osteoarthritis (OA) in primary care. Method: This cost-utility analysis was conducted with 120 GPs in the Netherlands from the societal and healthcare perspective. Data on direct medical costs, productivity costs and quality of life (QoL) was collected using standardised questionnaires which were sent to the patients at baseline and at 6, 13, 26, 39 and 52 weeks follow-up. All costs were based on Euro 2011 cost data. Results: A total of 203 patients were included. The annual direct medical costs per patient were significantly lower for the intervention group ((sic) 1233) compared to the control group ((sic) 1331). The average annual societal costs per patient were lower in the intervention group ((sic) 2634 vs (sic) 3241). Productivity costs were higher than direct medical costs. There was a very small adjusted difference in QoL of 0.006 in favour of the control group (95% CI: -0.04 to +0.02). Conclusion: Our study revealed that exercise therapy is probably cost saving, without the risk of noteworthy negative health effects. (C) 2015 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.

BACKGROUND: Neuropsychiatric symptoms (NPS) are very common in patients with mild cognitive impairment (MCI) and Alzheimer's disease (AD) dementia and are associated with various disadvantageous clinical outcomes including a negative impact on quality of life, caregiver burden, and accelerated disease progression. Despite growing evidence of the efficacy of (non)pharmacological interventions to reduce these symptoms, NPS remain underrecognized and undertreated in memory clinics. The BEhavioural symptoms in Alzheimer's disease Towards early Identification and Treatment (BEAT-IT) study is developed to (1) investigate the neurobiological etiology of NPS in AD and (2) study the effectiveness of the Describe, Investigate, Create, Evaluate (DICE) approach to structure and standardize the current care of NPS in AD. By means of the DICE method, we aim to improve the quality of life of AD patients with NPS and their caregivers who visit the memory clinic. This paper describes the protocol for the intervention study that incorporates the latter aim.METHODS: We aim to enroll a total of 150 community-dwelling patients with MCI or AD and their caregivers in two waves. First, we will recruit a control group who will receive care as usual. Next, the second wave of participants will undergo the DICE method. This approach consists of the following steps: (1) describe the context in which NPS occur, (2) investigate the possible causes, (3) create and implement a treatment plan, and (4) evaluate whether these interventions are effective. Primary outcomes are the quality of life of patients and their caregivers. Secondary outcomes include NPS change, caregiver burden, caregivers' confidence managing NPS, psychotropic medication use, the experiences of patients and caregivers who underwent the DICE method, and the cost-effectiveness of the intervention.CONCLUSIONS: This paper describes the protocol of an intervention study that is part of the BEAT-IT study and aims to improve current recognition and treatment of NPS in AD by structuring and standardizing the detection and treatment of NPS in AD using the DICE approach.TRIAL REGISTRATION: The trial was registered on the Netherlands Trial Registry ( NTR7459 ); registered 6 September 2018.

BackgroundAlthough job loss has been associated with decline in health, the effect of long term unemployment is less clear and under-researched. Furthermore, the impact of an economic recession on this relationship is unclear. We investigated the associations of single transitions and persistence of unemployment with health. We subsequently examined whether these associations are affected by the latest recession, which began in 2008.MethodsIn total, 57,911 participants from the Dutch Health Interview Survey who belonged to the labour force between 2004 and 2014 were included. Based on longitudinal tax registration data, single employment transitions between time point 1 (t1) and time point 2 (t2) and persistent unemployment (i.e. number of years individuals were unemployed) between t1 and time point 5 (t5) were defined. General and mental health, smoking and obesity were assessed at respectively time point 3 (t3) and time point 6 (t6). Logistic regression models were performed and interactions with recession indicators (year, annual gross domestic product estimates and regional unemployment rates) were tested.ResultsCompared with individuals who stayed employed at t1 and t2, the likelihood of poor mental health at the subsequent year was significantly higher in those who became unemployed at t2. Persistent unemployment was associated with poor mental health, especially for those who were persistently unemployed for 5 years. Similar patterns, although less pronounced for smoking, were found for general health and obesity. Indicators of the economic recession did not modify these associations.ConclusionsSingle transitions into unemployment and persistent unemployment are associated with poor mental and general health, obesity, and to a lesser extend smoking. Our study suggests that re-employment might be an important strategy to improve health of unemployed individuals. The relatively extensive Dutch social security system may explain that the economic recession did not modify these associations.

Purpose: Comparing the quality of care provided by a hospitalbased shared care glaucoma follow-up unit with care as usual. Patients and Methods: This randomized controlled trial included stable glaucoma patients and patients at risk for developing glaucoma. Patients in the Usual Care group (n=410) were seen by glaucoma specialists. In the glaucoma follow-up unit group (n=405), patients visited the glaucoma follow-up unit twice followed by a visit to a glaucoma specialist. The main outcome measures were: compliance to the working protocol by glaucoma follow-up unit employees; difference in intraocular pressure between baseline and at ≥18 months; and patient satisfaction. Results: Glaucoma follow-up unit employees closely adhered to the working protocol for the measurement of intraocular pressure, visual acuity and GDx (≥97.5% of all visits). Humphrey Field Analyzer examinations were not performed as frequently as prescribed by the working protocol, but more often than in the Usual Care group. In a small minority of patients that required backreferral, the protocol was disregarded, notably when criteria were only slightly exceeded. There was no statistically significant difference in changes in intraocular pressure between the 2 treatment groups (P=0.854). Patients were slightly more satisfied with the glaucoma follow-up unit employees than with the glaucoma specialists (scores: 8.56 vs. 8.40; P=0.006). Conclusions: In general, the hospital-based shared care glaucoma follow-up closely observed its working protocol and patients preferred it slightly over the usual care provided by medical doctors. The glaucoma follow-up unit operated satisfactorily and might serve as a model for shared care strategies elsewhere.

Objective: To assess the effectiveness of exercise therapy added to general practitioner (GP) care compared with GP care alone, in patients with hip osteoarthritis (OA) during 12 months follow-up. Methods: We performed a multi-center parallel pragmatic randomized controlled trial in 120 general practices in the Netherlands. 203 patients, aged >= 45 years, with a new episode of hip complaints, complying with the ACR criteria for hip OA were randomized to the intervention group (n = 101; GP care with additional exercise therapy) or the control group (n = 102; GP care only). GP care was given by patient's own GP. The intervention group received, in addition, a maximum of 12 exercise therapy sessions in the first 3 months and hereafter three booster sessions. Blinding was not possible. Primary outcomes were hip pain and hip-related function measured with the HOOS questionnaire (score 0-100). Results: The overall estimates on hip pain and function during the 12-month follow-up showed no between-group difference (intention-to-treat). At 3-months follow-up there was a statistically significant between-group difference for HOOS pain -3.7 (95% CI: -7.3; -0.2), effect size -0.23 and HOOS function -5.3 (95% CI: -8.9; -1.6), effect size -0.31. No adverse events were reported. Conclusions: No differences were found during 12-months follow-up on pain and function. At 3-months follow-up, pain and function scores differed in favor of patients allocated to the additional exercise therapy compared with GP care alone. (C) 2015 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.

Background Productivity losses often contribute significantly to the total costs in economic evaluations adopting a societal perspective. Currently, no consensus exists on the measurement and valuation of productivity losses. Objective We aimed to develop a standardized instrument for measuring and valuing productivity losses. Methods A group of researchers with extensive experience in measuring and valuing productivity losses designed an instrument suitable for self-completion, building on preknowledge and evidence on validity. The instrument was designed to cover all domains of productivity losses, thus allowing quantification and valuation of all productivity losses. A feasibility study was performed to check the questionnaire's consistency and intelligibility. Results The iMTA Productivity Cost Questionnaire ( i PCQ) includes three modules measuring productivity losses of paid work due to 1) absenteeism and 2) presenteeism and productivity losses related to 3) unpaid work. Questions for measuring absenteeism and presenteeism were derived from existing validated questionnaires. Because validated measures of losses of unpaid work are scarce, the questions of this module were newly developed. To enhance the instrument's feasibility, simple language was used. The feasibility study included 195 respondents (response rate 80%) older than 18 years. Seven percent (n = 13) identified problems while filling in the i PCQ, including problems with the questionnaire's instructions and routing (n = 6) and wording (n = 2). Five respondents experienced difficulties in estimating the time that would be needed for other people to make up for lost unpaid work. Conclusions Most modules of the i PCQ are based on validated questions derived from previously available instruments. The instrument is understandable for most of the general public.

Background Due to the ageing population, the number of visually impaired people in the Netherlands will increase. To ensure the future availability of services in rehabilitative eye care, we aim to assess the cost-effectiveness of information and communication technology (ICT) training among visually impaired adults from a societal perspective, using primary data from two large rehabilitative eye care providers in the Netherlands. Methods Participants were asked to fill in a questionnaire, which used six different instruments at three different time points: pre training, post training and three months post training. We investigated whether the participants’ quality of life and well-being improved after the training and whether this improvement persisted three months post training. Economic evaluation was conducted by comparing costs and outcomes before and after training. Quality of life and well-being were derived from the EQ-5D and ICECAP-O, respectively. Costs for productivity losses and medical consumption were obtained from the questionnaires. Information regarding the costs of training sessions was provided by the providers. Results Thirty-eight participants filled in all three questionnaires. The mean age at baseline was 63 years (SD = 16). The effect of ICT training on ICT skills and participants’ well-being was positive and persisted three months after the last training session. Assuming these effects remain constant for 10 years, this would result in an incremental cost-effectiveness ratio (ICER) of € 11,000 per quality-adjusted life-year (QALY) and € 8000 per year of well-being gained, when only the costs of ICT training are considered. When the total costs of medical consumption are included, the ICER increases to € 17,000 per QALY gained and € 12,000 per year of well-being gained. Furthermore, when the willingness-to-pay threshold is € 20,000 per year of well-being, the probability that ICT training will be cost-effective is 75% (91% when including only the costs of ICT training). Conclusion Our study suggests that ICT training among the visually impaired is cost-effective when the effects of ICT training on well-being persist for several years. However, further research involving a larger sample and incorporating long-term effects should be conducted.

Background Acute appendicitis is one of the most common indications for emergency surgery. In patients with a complex appendicitis, prolonged antibiotic prophylaxis is recommended after appendectomy. There is no consensus regarding the optimum duration of antibiotics. Guidelines propose 3 to 7 days of treatment, but shorter courses may be as effective in the prevention of infectious complications. At the same time, the global issue of increasing antimicrobial resistance urges for optimization of antibiotic strategies. The aim of this study is to determine whether a short course (48 h) of postoperative antibiotics is non-inferior to current standard practice of 5 days. Methods Patients of 8 years and older undergoing appendectomy for acute complex appendicitis – defined as a gangrenous and/or perforated appendicitis or appendicitis in presence of an abscess – are eligible for inclusion. Immunocompromised or pregnant patients are excluded, as well as patients with a contraindication to the study antibiotics. In total, 1066 patients will be randomly allocated in a 1:1 ratio to the experimental treatment arm (48 h of postoperative intravenously administered (IV) antibiotics) or the control arm (5 days of postoperative IV antibiotics). After discharge from the hospital, patients participate in a productivity-cost-questionnaire at 4 weeks and a standardized telephone follow-up at 90 days after appendectomy. The primary outcome is a composite endpoint of infectious complications, including intra-abdominal abscess (IAA) and surgical site infection (SSI), and mortality within 90 days after appendectomy. Secondary outcomes include IAA, SSI, restart of antibiotics, length of hospital stay (LOS), reoperation, percutaneous drainage, readmission rate, and cost-effectiveness. The non-inferiority margin for the difference in the primary endpoint rate is set at 7.5% (one-sided test at ɑ 0.025). Both per-protocol and intention-to-treat analyses will be performed. Discussion This trial will provide evidence on whether 48 h of postoperative antibiotics is non-inferior to a standard course of 5 days of antibiotics. If non-inferiority is established, longer intravenous administration following appendectomy for complex appendicitis can be abandoned, and guidelines need to be adjusted accordingly. Trial registration Dutch Trial Register, NTR6128. Registered on 20 December 2016. Electronic supplementary material The online version of this article (10.1186/s13063-018-2629-0) contains supplementary material, which is available to authorized users.

Health-care systems are currently facing tremendous budget constraints resulting in growing pressure on decision makers and health-care providers to obtain the maximum possible health benefits of the resources available. Choices have to be made, and health economics can help in allocating limited health-care resources among unlimited wants and needs. Attempts to achieve cost reductions often focus on severe pathologies and chronic diseases as they commonly represent high health-care expenditures. In this context, awareness of the considerable financial burden caused by disease-related malnutrition (DRM) is lacking. Possibilities of reducing costs by optimising the management of DRM through medical nutrition will mostly not even be taken into account. During a European expert meeting, the total evaluation of medical nutrition was viewed and discussed. The aim of this meeting was to gain an experts' outline of the key issues relating to the health economic assessment of the use of medical nutrition. This article provides a summary of the observations per discussed item and describes the next steps suggested.

Kirsten J Asmus-Szepesi,1 Linda E Flinterman,1 Marc A Koopmanschap,2 Anna P Nieboer,2 Ton J Bakker,3 Johan P Mackenbach,1 Ewout W Steyerberg1 1Department of Public Health, Erasmus University Medical Center, 2Institute of Health Policy and Management, Erasmus University, 3Stichting Wetenschap Balans, Rotterdam, the Netherlands Background: The hospitalized elderly are at risk of functional decline. We evaluated the effects and care costs of a specialized geriatric rehabilitation program aimed at preventing functional decline among at-risk hospitalized elderly.Methods: The prospective nonrandomized controlled trial reported here was performed in three hospitals in the Netherlands. One hospital implemented the Prevention and Reactivation Care Program (PReCaP), while two other hospitals providing usual care served as control settings. Within the PReCaP hospital we compared patients pre-implementation with patients post-implementation of the PReCaP (“within-hospital analysis”), while our nonrandomized controlled trial compared patients of the PReCaP hospital post-implementation with patients from the two control hospitals providing usual care (“between-hospital analysis”). Hospitalized patients 65 years or older and at risk of functional decline were interviewed at baseline and at 3 and 12 months using validated questionnaires to score functioning, depression, and health-related quality of life (HRQoL). We estimated costs per unit of care from hospital information systems and national data sources. We used adjusted general linear mixed models to analyze functioning and HRQoL.Results: Between-hospital analysis showed no difference in activities of daily living (ADL) or instrumental activities of daily living (IADL) between PReCaP patients and control groups. PReCaP patients did have slightly better cognitive functioning (Mini Mental State Examination; 0.4 [95% confidence interval (CI) 0.2–0.6]), lower depression (Geriatric Depression Scale 15; -0.9 [95% -1.1 to -0.6]) and higher perceived health (Short-Form 20; 5.6 [95% CI 2.8–8.4]) than control patients. Analyses within the PReCaP hospital comparing patients pre- and post-implementation of the PReCaP showed no improvement over time in functioning, depression, and HRQoL. One-year health care costs were higher for PReCaP patients, both for the within-hospital analysis (+€7,000) and the between-hospital analysis (+€2,500).Conclusion: We did not find any effect of the PReCaP on ADL and IADL. The PReCaP may possibly provide some benefits to hospitalized patients at risk of functional decline with respect to cognitive functioning, depression, and perceived health. Further evaluations of integrated intervention programs to limit functional decline are therefore required. Keywords: functional decline, geriatric rehabilitation, health-related quality of life, activities of daily living

Background The PACE Plus trial was a multi-center, double-blinded, superiority randomized controlled trial (RCT) conducted in patients from Dutch general practice to investigate the efficacy of paracetamol and NSAIDs in acute non-specific low back pain (LBP). Because insufficient numbers of patients could be recruited (only four out of the required 800 patients could be recruited over a period of 6 months), the trial was prematurely terminated in February 2017, 6 months after the start of recruitment. This article aims to transparently communicate the discontinuation of PACE Plus and to make recommendations for future studies. Methods General Practitioners (GPs) from 36 participating practices received a one-question survey in which they were asked to give the three most important factors that in their opinion contributed to failure of patient recruitment. Results GPs of 33 out of 36 (92%) participating practices sent a response. A total of 81 factors were reported. These have been categorized into patient factors (26 out of 81 comments, 32%), GP factors (39 out of 81 comments, 48%) and research factors (16 out of 81 comments, 20%). Discussion Patient recruitment in the PACE Plus trial may have failed due to inefficient medication distribution, recruitment of incident rather than prevalent cases, a design that was too complicated, adequate self-management of LBP, patient expectations different from the trial’s scope and lack of time of participating GPs. Substantial differences in design may explain why the preceding PACE trial did manage to successfully complete patient recruitment. Conclusion Although the PACE Plus trial was terminated as a result of insufficient patient inclusion, the research questions addressed in this trial remain relevant but unanswered. We hope that lessons learned from the discontinuation of PACE Plus and corresponding recommendations may be helpful in the design of upcoming research projects in LBP in general practice. Trial registration Dutch Trial Registration NTR6089, registered September 14th 2016.

Health technology assessment already informed Dutch policymaking in the early 1980s. Evidence of health economic evaluations is, however, only systematically used in drug reimbursement decision making. Outpatient drugs with an added therapeutic value and expensive specialist drugs require evidence from an economic evaluation. Due to many exemptions, however, the availability of evidence of health economic evaluations remains rather low. Although the Dutch reimbursement agency suggested a cost-effectiveness threshold range depending on the severity of the disease (i.e., €10,000 - 80,000 per Quality Adjusted Life Year), it was never confirmed nor endorsed by the Ministry of Health. It is highly questionable whether health economic evaluations currently play a role in actual Dutch reimbursement decision making. Although the requirements exist in policy procedures, recent cases show that Dutch policymakers experience great difficulties in putting restrictions on reimbursement based on evidence from health economic evaluations. The near future will show whether the need will increase to base decisions on societal value for money, and whether Dutch policymakers show the courage to take health economic evaluations seriously.

Objective To investigate the desirability and feasibility of a cyclic reimbursement process to address uncertainty accompanying initial decision making. Methods We performed desk research for three expensive outpatient drugs: imatinib, pegfilgrastim, and adalimumab. We analysed the evidence base at the time of decision making ( T = 0) and May 2011 ( T = 1). For T = 0, public reports of the Dutch reimbursement agency were investigated regarding available clinical and economic evidence, and a systematic review was performed to retrieve additional economic evidence. For T = 1, the systematic review was extended till May 2011. Results The evidence base at T = 0 lacked information on clinically relevant outcomes such as mortality, morbidity, and quality of life (5/8 reports), (long-term) adverse events (2/8 reports) and experience in use (1/8 reports). One budget impact analysis and one economic evaluation were available but no pharmacoeconomic dossiers. The systematic review identified 39 cost-utility studies (of 52 economic evaluations) for T = 1, characterised by methodological heterogeneity. Conclusions Given the considerable uncertainty accompanying initial decision-making, a more cyclic reimbursement process seems feasible to reduce uncertainty regarding the therapeutical and economical value of expensive drugs. A mandatory evidence development requirement seems desirable to sufficiently meet decision makers’ needs.

Low back pain is common and associated with a considerable burden to patients and society. There is uncertainty regarding the relative benefit of paracetamol and diclofenac and regarding the additional effect of pain medication compared with advice only in patients with acute low back pain. This trial will assess the effectiveness of paracetamol, diclofenac and placebo for acute low back pain over a period of 4 weeks. Furthermore, this trial will assess the additional effectiveness of paracetamol, diclofenac and placebo compared with advice only for acute low back pain over a period of 4 weeks. The PACE Plus trial is a multi-center, placebo-blinded, superiority randomized controlled trial in primary care, with a follow-up of 12 weeks. Patients with acute low back pain aged 18–60 years presenting in general practice will be included. Patients are randomized into four groups: 1) Advice only (usual care conforming with the clinical guideline of the Dutch College of General Practitioners); 2) Advice and paracetamol; 3) Advice and diclofenac; 4) Advice and placebo. The primary outcome is low back pain intensity measured with a numerical rating scale (0–10). Secondary outcomes include compliance to treatment, disability, perceived recovery, costs, adverse reactions, satisfaction, sleep quality, co-interventions and adequacy of blinding. Between group differences for low back pain intensity will be evaluated using a repeated measurements analysis with linear effects models. An economic evaluation will be performed using a cost-effectiveness analysis with low back pain intensity and a cost-utility analysis with quality of life. Explorative analyses will be performed to assess effect modification by predefined variables. Ethical approval has been granted. Trial results will be released to an appropriate peer-viewed journal. This paper presents the design of the PACE Plus trial: a multi-center, placebo-blinded, superiority randomized controlled trial in primary care that will assess the effectiveness of advice only, paracetamol, diclofenac and placebo for acute low back pain. Dutch Trial Registration NTR6089 , registered September 14th, 2016. Protocol: Version 4, June 2016.

This discussion paper resulted in an article in the Journal of Health Economics (2013). Volume 32, pages 88-105. Explanations of growth in health expenditures have restricted attention to the mean. We explain change throughout the distribution of expenditures, providing insight into how growth and its explanation differ along the distribution. We analyse Dutch data on actual health expenditures linked to hospital discharge and mortality registers. Full distribution decomposition delivers findings that would be overlooked by examination of changes in the mean alone. The growth in expenditures on hospital care is strongest at the middle of the distribution and is driven mainly by changes in the distributions of determinants. Pharmaceutical expenditures increase most at the top of the distribution and are mainly attributable to structural changes, including technological progress, making treatment of the highest cost cases even more expensive. Changes in hospital practice styles make the largest contribution of all determinants to increased spending not only on hospital care but also on pharmaceuticals, suggesting important spill over effects.

Although the consequences of population aging for growth in health expenditures have been widely investigated, research on this topic is rather fragmented. Therefore, these consequences are not fully understood. This paper reviews the consequences of population aging for health expenditure growth in Western countries by combining insights from epidemiological and health economics research. Based on a conceptual model of health care use, we first review evidence on the relationship between age and health expenditures to provide insight into the direct effect of aging on health expenditure growth. Second, we discuss the interaction between aging and the main societal drivers of health expenditures. Aging most likely influences growth in health expenditures indirectly, through its influence on these societal factors. The literature shows that the direct effect of aging depends strongly on underlying health and disability. Commonly used approximations of health, like age or mortality, insufficiently capture complex dynamics in health. Population aging moderately increases expenditures on acute care and strongly increases expenditures on long-term care. The evidence further shows that the most important driver of health expenditure growth, medical technology, interacts strongly with age and health, i.e., population aging reinforces the influence of medical technology on health expenditure growth and vice versa. We therefore conclude that population aging will remain in the centre of policy debate. Further research should focus on the changes in health that explain the effect of longevity gains on health expenditures, and on the interactions between aging and other societal factors driving expenditure growth. Keywords: Population aging, Morbidity, Technology, Health expenditures, Acute care, Long-term care

Objective Although the knee joint is one of the joints most affected by osteoarthritis (OA), research on the economic implications of joint disease has generally focused only on OA. The goal of this study was to identify and quantify knee-related productivity and medical costs in knee OA patients with paid employment. Furthermore, we evaluated associations between productivity loss and relevant patient, health, and work characteristics. Methods Consecutive knee OA patients with mild to moderate knee OA who were 18–65 years of age, had conservative treatment for ≥6 months, and had paid employment were included. Productivity loss and health care consumption were measured by questionnaires. The associations between productivity loss and patient, health, and work characteristics were explored with regression analyses. Results In total, 117 knee OA patients with a mean age of 53.2 years and a mean body mass index of 28.8 kg/m2 were included. Total knee-related productivity costs and medical costs were €871 (median €411, interquartile range [IQR] €107–1,200) per patient per month, with total productivity costs of €722 (median €217, IQR €0–1,041) and total medical costs of €149 (median €137, IQR €72–198). More pain during activity and performing physically intensive work were significantly associated with productivity loss. Conclusion The total knee-related productivity costs and medical costs of conservatively treated symptomatic knee OA patients with paid employment in The Netherlands are €871 per patient per month, with productivity costs accounting for 83% and medical costs for 17%. Productivity loss is associated with having more pain during activity and performing physically intensive work. Developing adequate treatment strategies for knee OA may be cost beneficial.

We analyzed the cost-effectiveness of the International Conference on Harmonisation (ICH) E14 guideline that requires a thorough QT/QTc (TQT) study for all drugs under development. We compared two pharmacoeconomic scenarios: the health effects and costs resulting from implementing ICH E14 ("regulation" scenario) vs. not implementing ICH E14 ("no regulation" scenario). We used a dynamic population model to calculate the cost-effectiveness of ICH E14 for a prototype QT-prolonging antipsychotic drug entering the US and European markets. The incremental cost-effectiveness ratios of regulation vs. no regulation were ~€2.4 million per sudden cardiac death prevented and ~€187,000 per quality-adjusted life year (QALY) gained in users of antipsychotic drugs. The main driver of cost was the requirement for electrocardiogram (ECG) monitoring of users of QTc-prolonging drugs. Even when several of the assumptions in the model were varied, there were no results in favor of regulation. Our study shows that cost-effectiveness analysis of drug regulatory measures is feasible and should be considered before developing such measures.

Objectives. In a democratic system, decision makers are accountable for the reasonableness of their decisions. This presumes (i) transparency, (ii) relevance of the decision criteria, (iii) revisability of decisions, and (iv) enforcement/regulation. We aim to (i) evaluate the extent to which drug reimbursement decision-making processes in different contexts meet these conditions and (ii) develop, starting from these findings, a framework for improving the transparency and the relevance of used decision criteria.Methods. We evaluated the Austrian, Belgian, French, Dutch, and Swedish drug reimbursement systems. Based on this evaluation, we developed a framework for improving the transparency of drug reimbursement decision-making processes. It makes explicit the questions often addressed implicitly during decision-making processes as well as criteria for answering each question.Results. Transparency of appraisal processes varies across systems. Justification with explicit criteria is generally limited. Although relevant criteria are similar across systems, their operationalization varies and their role in the appraisal process is not always clear. All systems seem to implicitly address five key questions, relating to (i) the medical, therapeutic, and societal need for treatment; (ii) preparedness to pay for treating the condition as a principle and (iii) for using the treatment under consideration; (iv) preparedness to pay more compared with alternatives; and (v) actual willingness to pay from public resources.Conclusions. Transparency of the appraisal process can be improved by using an explicit decision framework. Systematic use of such a framework enhances consistency across decisions, allows justification of value judgments, and thus enhances legitimacy of societal decision making.

Background: Regulatory requirements for the pharmaceutical industry have become increasingly demanding with respect to the safety and effectiveness of drugs. Objective: The objective of this study was to determine the willingness to pay (WTP), of both the Dutch general public and dialysis patients, for regulatory requirements related to reducing the risk of pure red cell aplasia (PRCA) associated with epoetin alpha use. Methods: A survey was carried out in April 2009. The Dutch general public (n - 422) was approached through a survey sampling agency. Patients (n - 112) were included through several Dutch dialysis clinics because they are often treated with epoetin alpha and therefore were expected to have a higher WTP than the general public. The survey aimed to determine the WTP for reducing the risk of PRCA in epoetin alpha users from 4.5 to 0 per 10 000 patients per year, based on regulatory actions that have been taken by the European Medicines Agency (EMA). WTP was determined via a payment scale and an open-ended follow-up question. Patients were asked how much extra per year they would be willing to pay for their basic healthcare insurance. We used two censored regression models to test the association between WTP and a set of independent variables: a Tobit model with the stated WTP as the dependent variable and an interval regression model with the interval between the lower and upper bounds of the payment scale as the dependent variable. Results: The patients' mean WTP was significantly higher (&U20AC;46.52) than that of the general public (&U20AC;24.40). The Tobit model showed significant associations (α - 0.05) with WTP for dialysis patients, risk perception and respondents' opinions on costs of healthcare. The interval regression model showed significant associations with WTP for the same variables as the Tobit model and for one additional variable (risk aversion). Income did not significantly affect WTP. A scenario with a 10-fold larger risk reduction did not increase WTP significantly. Conclusion: This study is, as far as we know, one of the first attempts to analyse the WTP for drug regulation and should in future be used in studies of the societal costs of drug regulation for epoetin alpha use. Our results indicate that the Dutch general public, especially Dutch dialysis patients, are willing to pay limited amounts to reduce the risk of serious adverse events associated with drug use.

Background:Background: When guidelines for health economic evaluations prescribe that a societal perspective should be adopted, productivity costs should be included. However, previous research suggests that, in practice, productivity costs are often neglected. This may considerably bias the results of cost-effectiveness studies, particularly those regarding treatments targeted at diseases with a high incidence rate in the working population, such as depressive disorders. Abstract: Objectives:Objectives: This study aimed to, first, investigate whether economic evaluations of treatments for depressive disorders include productivity costs and, if so, how. Second, to investigate how the inclusion or exclusion of productivity costs affects incremental costs. Abstract: Methods:Methods: A systematic literature review was performed. Included articles were reviewed to determine (i) whether productivity costs had been included and (ii) whether the studies adhered to national health economic guidelines about the inclusion or exclusion of these costs. For those studies that did include productivity costs, we calculated what proportion of total costs were productivity costs. Subsequently, the incremental costs, excluding productivity costs, were calculated and compared with the incremental costs presented in the original article, to analyse the impact of productivity costs on final results. Regression analyses were used to investigate the relationship between the level of productivity costs and the type of depressive disorder, the type of treatment and study characteristics such as time horizon used and productivity cost valuation method. Abstract: Results:Results: A total of 81 unique economic evaluations of treatments for adults with depressive disorders were identified, 24 of which included productivity costs in the numerator and one in the denominator. Approximately 69% of the economic evaluations ignored productivity costs. Two-thirds of the studies complied with national guidelines regarding the inclusion of productivity costs. For the studies that included productivity costs, these costs reflected an average of 60% of total costs per treatment arm. The inclusion or exclusion of productivity costs substantially affected incremental costs in a number of studies. Regression analyses showed that the level of productivity costs was significantly associated with study characteristics such as average age, the methods of data collection regarding work time lost, the values attached to lost work time, the type of depressive disorder, the type of treatment provided and the level of direct costs. Abstract: Conclusions:Conclusions: Studies that do not include productivity costs may, in many cases, poorly reflect full societal costs (or savings) of an intervention. Furthermore, when comparing total costs reported in studies that include productivity costs, it should be noted that study characteristics such as the methods used to assess productivity costs may affect their level.

The objective of this paper was to determine the cost effectiveness of exercise therapy (intervention group) compared with "usual care" (control group) in adolescents and young adults with the patellofemoral pain syndrome in primary care. This multicenter prospective randomized clinical trial with cost-utility analysis was conducted at 38 general practices and three sport medical advice centers in the Netherlands for 2007. A total of 131 patients were included. The annual direct medical costs per patient were significantly higher for the intervention group (euro 434) compared with the control group (euro 299) mainly caused by additional physiotherapy visits. The average annual societal costs per patient were significantly lower in the intervention group (euro 1011 vs euro 1.166). Productivity costs were the largest cost component, in particular costs due to reduced efficiency at paid work which were responsible for 47% and 56% of the total costs in the intervention and control group respectively. Patients in the intervention group experienced a slightly, but not significantly, higher quality of life (0.8722 vs 0.8617). With a cost effectiveness ratio of -euro 14,738 per quality adjusted life year, exercise therapy appears to be cost effective as compared with "usual care."

Objective To examine the effects of different timing of structured interventions for workers on sick leave due to low back pain on return to work (RTW), and the consequences for costs and benefits. Methods Literature reviews were conducted to identify RTW curves and to estimate treatment effects, costs and benefits of structured interventions among workers on sick leave due to low back pain. RTW curves were mathematically described by Weibull functions and intervention effects, expressed by hazard ratios, were used to adjust these Weibull functions. Subsequently, these functions were used to evaluate the theoretical effects of interventions on reduction in number of days on sick leave and on the benefit–cost ratio. Results The cost-benefits of a RTW intervention among workers on sick leave due to low back pain were determined by the estimated effectiveness of the intervention, the costs of the intervention, the natural course of RTW in the target population, the timing of the enrolment of subjects into the intervention, and the duration of the intervention. Conclusion With a good RTW in the first weeks, the only early interventions likely to be cost-beneficial are inexpensive work-focused enhancements to early routine care, such as accommodating workplaces. Structured interventions are unlikely to have an additional impact on the already good prognosis when offered before the optimal time window at approximately 8 to 12 weeks. The generalisibility of the effectiveness of a RTW intervention depends on the comparability of baseline characteristics and RTW curves in target and source populations.

Including informal care in economic evaluations is increasingly advocated but problematic. We investigated three well-known concerns regarding contingent valuation (CV): (1) the item non-response of CV values, (2) the sensitivity of CV values to the individual circumstances of caring, and (3) the choice of valuation method by comparing willingness-to-pay (WTP) and willingness-to-accept (WTA) values for a hypothetical marginal change in hours of informal care currently provided. The study sample consisted of 1453 caregivers and 787 care recipients. Of the caregivers, 603 caregivers (41.5%) provided both WTP and WTA values, 983 (67.7%) provided at least one. Determinants of non-response were dependent on the valuation method; primary determinants were education and satisfaction with amount of informal care provided. Caregivers' mean WTP (WTA) for reducing (increasing) informal care by 1 h was €9.13 (10.52). Care recipients' mean WTA (WTP) for reducing (increasing) informal care by 1 h was €8.88 (€6.85). Values were associated with a variety of characteristics of the caregiving situation; explanatory variables differed between WTP and WTA valuations. The differences between WTP and WTA valuations were small. Based on sensitivity CV appears to be a useful method to value informal care for use in economic evalations, non-response, however, remains a matter of concern. Copyright © 2009 John Wiley & Sons, Ltd.

In view of aging populations, it is important to improve our understanding of the determination of long-term care (LTC) service use among the middle-aged and elderly population. We examined the likelihood of using 2 levels of LTC-homecare and institutional care-in the Netherlands and focused on the influence of the measured degree of disability.We pooled 2 cross-sectional surveys-one that excluded institutionalized and one that was targeted at institutionalized individuals aged 50+. Disability is measured by impairment in (instrumental) activities of daily living (iADL, ADL) and mobility. Consistency with official Dutch LTC eligibility criteria resulted in the selection of an ordered response model to analyze utilization. We compared a model with separate disability indicators to one with a disability index.Age and disability, but not general health, proved to be the main determinants of utilization, with the composite index sufficiently representing the disaggregated components. The presence of at least 1 disability displayed a greater effect on utilization than any additional disabilities. Apart from disability and age, sex, living alone, psychologic problems, and hospitalizations showed a significant influence on LTC use. Some determinants affected the likelihood of homecare or institutional care use differently.Even after extensive control for disability, age remains an important driver of LTC use. By contrast, general health status hardly affects LTC use. The model and disability index can be used as a policy tool for simulating LTC needs.

Objectives To assess international comparability of general cost of illness (COI) studies and to examine the extent to which COI estimates differ and why. Methods Five general COI studies were examined. COI estimates were classified by health provider using the system of health accounts (SHA). Provider groups fully included in all studies and matching SHA estimates were selected to create a common data set. In order to explain cost differences descriptive analyses were carried out on a number of determinants. Results In general similar COI patterns emerged for these countries, despite their health care system differences. In addition to these similarities, certain significant disease-specific differences were found. Comparisons of nursing and residential care expenditure by disease showed major variation. Epidemiological explanations of differences were hardly found, whereas demographic differences were influential. Significant treatment variation appeared from hospital data. Conclusions A systematic analysis of COI data from different countries may assist in comparing health expenditure internationally. All cost data dimensions shed greater light on the effects of health care system differences within various aspects of health care. Still, the study's objectives can only be reached by a further improvement of the SHA, by international use of the SHA in COI studies and by a standardized methodology.

Objectives: This article reports the results of the application of conjoint analysis (CA) to derive a monetary value of informal care. Compared with normally recommended valuation methods such as the opportunity cost method and proxy good method, a valuation elicited through a CA might be more sensitive to the heterogeneity and dynamics of informal care. Methods: We developed a questionnaire and conducted a survey in which informal caregivers were asked to rate four different hypothetical informal caregiving situations (reflecting different combinations of care hours, care tasks, and monetary compensation). They were also asked to rate their current informal care situation compared with the four hypothetical situations. Data were obtained from postal questionnaires. These questionnaires were sent through regional support centres for informal caregivers of care recipients with various health problems. A total of 865 informal caregivers from this heterogeneous population returned a completed survey. Results: Informal caregivers require an increase of 81% in their hourly compensation for providing 21 instead of 7 hours informal care per week. This implies a compensation of €12.36 per hour at a mean hypothetical compensation in the presented scenarios. We also found that an informal caregiver's current caregiving situation and other background characteristics were associated with the scenario ratings. Conclusions: We conclude that a CA is a promising alternative for existing methods to determine a monetary value of informal care and encourage more experiments in this area. © 2008, International Society for Pharmacoeconomics and Outcomes Research (ISPOR).

Teirlinck CH, Luijsterburg PAJ, Dekker J, Bohnen AM, Verhaar JAN, Koopmanschap MA, et al. Effectiviteit van oefentherapie bij patienten met heupartrose. Huisarts Wet 2016;59(8):346-9. Volgens (inter)nationale richtlijnen is oefentherapie een belangrijk onderdeel van de conservatieve behandeling van patienten met heupartrose. We hebben bij patienten met heupartrose onderzoek gedaan naar de effectiviteit van oefentherapie in aanvulling op huisartsenzorg, vergeleken met alleen huisartsenzorg. We hebben een pragmatisch gerandomiseerd onderzoek uitgevoerd in 120 huisartsenpraktijken in Rotterdam en omstreken. Deelnemers waren 45 jaar of ouder, kwamen met een nieuwe episode van problemen met de heup bij de huisarts en voldeden aan de ACR-criteria voor heupartrose. We hebben 203 patienten geincludeerd, van wie we 101 random indeelden in de oefentherapie- en huisartsenzorggroep en 102 in de alleen-huisartsenzorggroep. De eigen huisarts leverde de huisartsenzorg. De oefentherapie, gegeven door fysiotherapeuten, bestond uit maximaal 12 sessies in de eerste 3 maanden en 3 booster-sessies (na maand 5, 7 en 9). Blinderen was niet mogelijk. We volgden de deelnemers totaal 12 maanden. Primaire uitkomsten waren pijn en functie, gemeten met de HOOS-vragenlijst (score tussen 0 en 100). Gemiddeld gedurende de twaalf maanden waren er geen verschillen zichtbaar in pijn en functie tussen de twee groepen. Na drie maanden was er een statistisch significant verschil in pijn van –3,7 (95%-BI –7,3 tot –0,2) op een schaal van 0-100, effectgrootte –0,23 en in functie van –5,3 (95%-BI –8,9 tot –1,6) op een schaal van 0 tot 100, effectgrootte –0,31 ten gunste van de oefentherapiegroep. De patienten rapporteerden geen bijwerkingen. Gemiddeld over de twaalf maanden vonden we geen verschillen op pijn en functie van de heup tussen patienten die wel en patienten die geen oefentherapie kregen in aanvulling op huisartsenzorg. Na drie maanden scoorden patienten met oefentherapie in aanvulling op huisartsenzorg beter op pijn en functie dan patienten die alleen huisartsenzorg kregen.

Objectives: Key to effectively implementing MCDA is to ensure the performance matrix offers a valid comparison across alternatives. We propose to bring econometric methods into the field of MCDA by estimating performance scores from patient-level panel data while matching on observable patient characteristics between different treatment alternatives. The aim of this study is to demonstrate the application of these methods to a case study using outcomes of disease management programs for Cardio-Vascular Risk Management (CVRM: n= 9) and Chronic Obstructive Pulmonary Disease (COPD: n= 4), prospectively monitored over a twoyear period. Methods: Performance scores were grouped according to the triple aim framework for the three aims of integrated care: 1) improving population health outcomes, 2) improving patient experience and 3) reducing costs. Included indicators were the EuroQol-5D, Short-Form-36, smoking and physical activity levels, the PACIC (Patient Assessment of Chronic Illness Care) and various cost measurements. Estimation was done by means of the average predicted outcomes from a generalised linear model. To increase comparability between programs a multinomial generalisation of propensity score matching (PSM) was applied. Results: Differences between the estimated treatment effects were expected based on the comprehensiveness of their interventions, e.g. estimated smoking rate was 28% in our most comprehensive COPD program, compared to 38% in our least significant program. PSM influenced the results, especially for costs and to a lesser extent for different dimensions of the EuroQol-5D. Overall, CVRM programs were more susceptible to changes resulting from PSM, which may be attributed to the higher number of programs. Conclusions: The proposed econometric methods offer a novel way to estimate performance scores from outcomes data in disease management programs. The estimated performance matrix offers useful distinctiveness between criteria and programs as an input for follow-up studies which further explore the performance matrix or attach relative weights to each performance indicator to allow a formal MCDA.

Objectives: A structured and comprehensive assessment of disease management implementations is not straightforward due to the broadness of the interventions and the various evaluation possibilities. The aim of this study was to develop a comprehensive framework for outcome measurement of disease management programs based on the triple aim framework of the Institute for Healthcare Improvement to facilitate future performance assessment using multi-criteria decision analysis (MCDA). Methods: Based on literature review and our expertise in performing economic evaluations in disease management we identified domains of outcomes for each aim of the triple aim framework. For each domain we identified indicators to assess the performance of disease management programs. Results: The first aim of the framework, population health improvement, was subdivided into the domains health-adjusted life years, mortality, wellbeing, health-related quality of life (HrQol), complications, symptoms, clinical outcomes, healthy behaviour, knowledge, and self-management skills. The second aim, improvement of patient experience, was subdivided into patient involvement, patient centeredness, continuity of care, coordination, communication, information systems, safety and access. The third aim of cost reductions distinguished program, medical and nonmedical costs. Potential Indicators of the identified sub-criteria include the ASCOT (Adult Social Care Outcomes Toolkit) for measuring wellbeing, smoking rates and BMI (Body Mass Index) to measure healthy behaviour, the EuroQol-5D and Short Form-36 for measuring physical, mental and social HrQol, different dimensions of the PACIC (Patient Assessment of Chronic Illness Care) and CAHPS (Consumer Assessment of Healthcare Providers and Systems) for measuring patient experience and several measurement tools for measuring friction costs and costs of informal care. Conclusions: In designing a structured outcome-based framework for the performance evaluation of disease management programs we paved the way for future work including a comprehensive evaluation of disease management using MCDA. MCDA not only requires measurement of indicators but also weighting of their relative importance.

Contingent valuation enjoys increasing popularity among transport, environmental and health economists, though the method has often been criticized. We discuss the main points of controversy, with a focus on anchoring effects. Available literature indicates that higher ambiguity, lower familiarity, relevance or involvement with the problem, a more trustworthy source and a more plausible bid tend to be associated with stronger anchoring effects. In two studies among informal caregivers we found that respondents use all sorts of anchors when eliciting their value of time. We end with a discussion of the substantive significance of CV for economics.

BackgroundLittle is known about the cost-effectiveness of preventing mental disorders.AimsTo study the cost-effectiveness of care as usual plus minimal contact psychotherapy relative to usual care alone in preventing depressive disorder.MethodAn economic evaluation was conducted alongside a randomised clinical trial. Primary care patients with sub-threshold depression were assigned to minimal contact psychotherapy plus usual care (n=107) or to usual care alone (n=109).ResultsPrimary care patients with sub-threshold depression benefited from minimal contact psychotherapy as it reduced the risk of developing a full-blown depressive disorder from 18% to 12%. In addition, this intervention had a 70% probability of being more cost-effective than usual care alone. A sensitivity analysis indicated the robustness of these results.ConclusionsOver 1 year adjunctive minimal contact psychotherapy improved outcomes and generated lower costs. This intervention is therefore superior to usual care alone in terms of cost-effectiveness.

This paper reports the results of the application of the opportunity costs and proxy good methods to determine a monetary value of informal care. We developed a survey in which we asked informal caregivers in The Netherlands to indicate the different types of time forgone (paid work, unpaid work and leisure) in order to be able to provide care. Moreover, we asked informal caregivers how much time they spent on a list of 16 informal care tasks during the week before the interview. Data were obtained from surveys in two different populations: informal caregivers and their care recipients with stroke and with rheumatoid arthritis (RA). A total of 218 care recipients with stroke and their primary informal caregivers completed a survey as well as 147 caregivers and their care recipients with RA. The measurement of care according to both methods is more problematic compared to the valuation. This is especially the case for the opportunity costs method and for the housework part in the proxy good method. More precise guidelines are necessary for the consistent application of both methods in order to ensure comparability of results and of economic evaluations of health care.

Objective To determine the medical consumption and associated treatment costs of patients with LUTS suggestive of BPH. Methods A prospective, cross-sectional, observational survey in six European countries: France, Germany, Italy, Poland, Spain and the United Kingdom, with a one-year follow-up of incident and prevalent patients. Results Treatment costs were estimated for 5,057 patients with a mean age of 66 years and a mean IPSS score at inclusion of 11.5. In 30% of patients watchful waiting was the therapy of choice for the full follow-up period, 57% were prescribed alpha-lockers, 11% finasteride and 10% phytotherapy at any moment during the follow-up (including switches and combination of treatment). Surgery rate was 4.9%. Mean one-year treatment costs were €858 per patient, three quarters of which concerned medication costs. Multivariate regression analysis showed that medication choice, complications and undergoing surgery were associated with higher costs. Conclusions Treatment costs for patients with LUTS suggestive of BPH were moderate and largely consisted of medication costs. Daily practice and associated costs varied considerably across the six countries.