Stolk, E.A.

Balancing equity and efficiency in the Dutch basic benefits package using the principle of proportional shortfall (Article)

2013-02-01T00:00:00Z

Economic evaluations are increasingly used to inform decisions regarding the allocation of scarce health care resources. To systematically incorporate societal preferences into these evaluations, quality-adjusted life year gains could be weighted according to some equity principle, the most suitable of which is a matter of frequent debate. While many countries still struggle with equity concerns for priority setting in health care, the Netherlands has reached a broad consensus to use the concept of proportional shortfall. Our study evaluates the concept and its support in the Dutch health care context. We discuss arguments in the Netherlands for using proportional shortfall and difficulties in transitioning from principle to practice. In doing so, we address universal issues leading to a systematic consideration of equity concerns for priority setting in health care. The article thus has relevance to all countries struggling with the formalization of equity concerns for priority setting.

Mapping QLQ-C30, HAQ, and MSIS-29 on EQ-5D (Article)

2012-07-01T00:00:00Z

Background. Responses on condition-specific instruments can be mapped on the EQ-5D to estimate utility values for economic evaluation. Mapping functions differ in predictive quality, and not all condition-specific measures are suitable for estimating EQ-5D utilities. We mapped QLQC30, HAQ, and MSIS-29 on the EQ-5D and compared the quality of the mapping functions with statistical and clinical indicators. Methods. We used 4 data sets that included both the EQ-5D and a condition-specific measure to develop ordinary least squares regression equations. For the QLQ-C30, we used a multiple myeloma data set and a non-Hodgkin lymphoma one. An early arthritis cohort was used for the HAQ, and a cohort of patients with relapsing remitting or secondary progressive multiple sclerosis was used for the MSIS-29. We assessed the predictive quality of the mapping functions with the root mean square error (RMSE) and mean absolute error (MAE) and the ability to discriminate among relevant clinical subgroups. Pearson correlations between the condition-specific measures and items of the EQ-5D were used to determine if there is a relationship between the quality of the mapping functions and the amount of correlated content between the used measures. Results. The QLQ-C30 had the highest correlation with EQ-5D items. Average %RMSE was best for the QLQ-C30 with 10.9%, 12.2% for the HAQ, and 13.6% for the MSIS-29. The mappings predicted mean EQ-5D utilities without significant differences with observed utilities and discriminated between relevant clinical groups, except for the HAQ model. Conclusions. The preferred mapping functions in this study seem suitable for estimating EQ-5D utilities for economic evaluation. However, this research shows that lower correlations between instruments lead to less predictive quality. Using additional validation tests besides reporting statistical measures of error improves the assessment of predictive quality.

Lead Time Tto: Leading To Better Health State Valuations? (Article)

2012-03-08T00:00:00Z

SUMMARY: Preference elicitation tasks for better than dead (BTD) and worse than dead (WTD) health states vary in the conventional time trade-off (TTO) procedure, casting doubt on uniformity of scale. 'Lead time TTO' (LT-TTO) was recently introduced to overcome the problem. We tested different specifications of LT-TTO in comparison with TTO in a within-subject design. We elicited preferences for six health states and employed an intertemporal ranking task as a benchmark to test the validity of the two methods. We also tested constant proportional trade-offs (CPTO), while correcting for discounting, and the effect of extending the lead time if a health state is considered substantially WTD. LT-TTO produced lower values for BTD states and higher values for WTD states. The validity of CPTO varied across tasks, but it was higher for LT-TTO than for TTO. Results indicate that the ratio of lead time to disease time has a greater impact on results than the total duration of the time frame. The intertemporal ranking task could not discriminate between TTO and LT-TTO.

The cost-effectiveness of an intensive treatment protocol for severe dyslexia in children (Article)

2011-08-01T00:00:00Z

Studies of interventions for dyslexia have focused entirely on outcomes related to literacy. In this study, we considered a broader picture assessing improved quality of life compared with costs. A model served as a tool to compare costs and effects of treatment according to a new protocol and care as usual. Quality of life was measured and valued by proxies using a general quality-of-life instrument (EQ-5D). We considered medical cost and non-medical cost (e.g. remedial teaching). The model computed cost per successful treatment and cost per quality adjusted life year (QALY) in time. About 75% of the total costs was related to diagnostic tests to distinguish between children with severe dyslexia and children who have reading difficulties for other reasons. The costs per successful treatment of severe dyslexia were €36 366. Successful treatment showed a quality-of-life gain of about 11%. At primary school, the average cost per QALY for severe dyslexia amounted to €58 647. In the long term, the cost per QALY decreased to €26 386 at secondary school and €17 663 thereafter. The results of this study provide evidence that treatment of severe dyslexia is cost-effective when the investigated protocol is followed. Copyright

Quality of life in adults who stutter (Article)

2011-07-01T00:00:00Z

Although persistent developmental stuttering is known to affect daily living, just how great the impact is remains unclear. Furthermore, little is known about the underlying mechanisms which lead to a diminished quality of life (QoL). The primary objective of this study is to explore to what extent QoL is impaired in adults who stutter (AWS). In addition, this study aims to identify determinants of QoL in AWS by testing relationships between stuttering severity, coping, functioning and QoL and by testing for differences in variable scores between two AWS subgroups: receiving therapy versus not receiving therapy. A total of 91 AWS filled in several questionnaires to assess their stuttering severity, daily functioning, coping style and QoL. The QoL instruments used were the Health Utility Index 3 (HUI3) and the EuroQoL EQ-5D and EQ-VAS. The results indicated that moderate to severe stuttering has a negative impact on overall quality of life; HUI3 derived QoL values varied from .91 (for mild stuttering) to .73 (for severe stuttering). The domains of functioning that were predominantly affected were the individual's speech, emotion, cognition and pain as measured by the HUI3 and daily activities and anxiety/depression as measured by the EQ-5D. AWS in the therapy group rated their stuttering as more severe and recorded more problems on the HUI3 speech domain than AWS in the non-therapy group. The EQ-VAS was the only instrument that showed a significant difference in overall QoL between groups. Finally, it was found that the relationship between stuttering severity and QoL was influenced by the individual's coping style (emotion-oriented and task-oriented). These findings highlight the need for further research into stuttering in relation to QoL, and for a broader perspective on the diagnosis and treatment of stuttering, which would take into consideration quality of life and its determinants.Learning outcomes: Readers will be able to: (1) Understand how the Wilson and Cleary (1995) model of quality of life could be applied to comprehensively assess the quality of life in adults who stutter, (2) describe how health related quality of life is impaired in adults who stutter, (3) mention affected domains of functioning that are related to health related quality of life impairment in adults who stutter, (4) describe the relationship between stuttering severity, functioning, coping and health related quality of life in adults who stutter, (5) describe differences in stuttering severity, coping style, functioning and health related quality of life between adults who stutter who have registered for therapy and adults who stutter who have not.

Physicians underestimate the importance of patient-centredness to patients: A discrete choice experiment in fertility care (Article)

2011-03-01T00:00:00Z

Background: High-quality healthcare should be effective, safe and patient-centred. How important patient-centredness is in relation to effectiveness of fertility care has never been investigated. This study aimed to determine and compare the importance of patient-centredness, relative to pregnancy rates, to patients and physicians. Methods A discrete choice experiment (DCE) was designed. Participants had to choose between hypothetical fertility clinics differing in following attributes: travel time; pregnancy rate (effectiveness); physicians attitude; information on treatment; and continuity of physicians (the latter three represent patient-centredness). A total of 1378 patients and 268 physicians from eight Dutch and Belgian fertility clinics received the DCE-questionnaire. The attributes relative importance was analysed using multinomial logistic regression. Additionally, patients actual choice behaviour was investigated. Results In total, 925 patients and 227 physicians participated. Pregnancy rates were relatively more important to physicians. Patients assigned more value to patient-centredness (P< 0.001) and were willing to trade-off a higher pregnancy rate for patient-centredness than physicians recommended them to do (P< 0.05). For example, patients considered pregnancy rates 1.5 times as important as an interested physicians attitude, whereas physicians considered this 2.4 times as important (P< 0.001). The willingness to trade-off pregnancy rate for this attitude was 9.8 for patients and 6.3 for physicians (P< 0.001). A lack of patient-centredness was the most cited non-medical reason for changing fertility clinics. Conclusions Patients and physicians put considerable value on pregnancy rates. However, physicians significantly undervalue the importance of patient-centredness to patients. Clinics aiming to optimize the quality of their services should be aware of the substantial importance their patients assign to patient-centredness.

The health care burden and societal impact of acute otitis media in seven European countries: results of an Internet survey (Article)

2010-11-01T00:00:00Z

This paper estimates medical resource use, direct costs, and productivity losses and costs (indirect costs) during episodes of acute otitis media (AOM) in young children. A 24-item Internet questionnaire was developed for parents in Belgium (Flanders), France, Germany, Italy, The Netherlands, Spain, and the United Kingdom (UK) to report health care resource use and productivity losses during the most recent episode of AOM in their child, younger than 5 years. The percentage who did not seek medical help for AOM was considerable in The Netherlands (28.3%) and the UK (19.7%). Antibiotic use was high, ranging from 60.8% (Germany) to 87.1% (Italy). Total costs per AOM episode ranged from D 332.00 (The Netherlands) to D 752.49 (UK). Losses in productivity accounted for 61% (France) to 83% (Germany) of the total costs. AOM poses a significant medical and economic burden to society.

The health care burden and societal impact of acute otitis media in seven European countries: results of an Internet survey (Article)

2010-11-01T00:00:00Z

The health care burden and societal impact of acute otitis media in seven European countries: Results of an Internet survey (Article)

2010-11-01T00:00:00Z

This paper estimates medical resource use, direct costs, and productivity losses and costs (indirect costs) during episodes of acute otitis media (AOM) in young children. A 24-item Internet questionnaire was developed for parents in Belgium (Flanders), France, Germany, Italy, The Netherlands, Spain, and the United Kingdom (UK) to report health care resource use and productivity losses during the most recent episode of AOM in their child, younger than 5 years. The percentage who did not seek medical help for AOM was considerable in The Netherlands (28.3%) and the UK (19.7%). Antibiotic use was high, ranging from 60.8% (Germany) to 87.1% (Italy). Total costs per AOM episode ranged from €332.00 (The Netherlands) to €752.49 (UK). Losses in productivity accounted for 61% (France) to 83% (Germany) of the total costs. AOM poses a significant medical and economic burden to society.

Discrete Choice Modeling for the Quantification of Health States: The Case of the EQ-5D (Article)

2010-09-01T00:00:00Z

Objectives: Probabilistic models have been developed to establish the relative merit of subjective phenomena by means of specific judgmental tasks involving discrete choices (DCs). The attractiveness of these DC models is that they are embedded in a strong theoretical measurement framework and are based on relatively simple judgmental tasks. The aim of our study was to determine whether the values derived from a DC experiment are comparable to those obtained using other valuation techniques, in particular the time trade-off (TTO). Methods: Two hundred nine students completed several tasks in which we collected DC, rank, visual analog scale, and TTO responses. DC data were also collected in a general population sample (N = 444). The DC experiment was designed using a Bayesian approach, and involved 60 choices between two health states and a comparison of all health states to being dead. The DC data were analyzed using a conditional logit and a rank-ordered logit model, relying, respectively, on TTO values and the value for being dead to anchor the DC-derived values to the 0 to 1 quality-adjusted life-year (QALY) scale. Results: Although modeled DC data broadly replicated the pattern found in TTO responses, the DC consistently produced higher values. The two methods for anchoring DC-derived values on the QALY scale produced similar results. Conclusions: On the basis of the high level of comparability between DC-derived values and TTO values, future valuation studies based on a combination of these two techniques may be considered. The results further suggest that DC can potentially be used as a substitute for TTO.

Between Trust and Accountability: Different Perspectives on the Modernization of Postgraduate Medical Training in the Netherlands (Article)

2010-06-01T00:00:00Z

Abstract. PURPOSE: Postgraduate medical training was reformed to be more responsive to changing societal needs. In the Netherlands, as in various other Western countries, a competency-based curriculum was introduced reflecting the clinical and nonclinical roles a modern doctor should fulfill. It is still unclear, however, what this modernization process exactly comprises and what its consequences might be for clinical practice and medical work. METHOD: The authors conducted a Q methodological study to investigate which different perspectives exist on the modernization of postgraduate medical training among actors involved. RESULTS: The authors found four distinct perspectives, reflecting the different features of medical training. The accountability perspective stresses the importance of formal regulations within medical training and the monitoring of results in order to be more transparent and accountable to society. According to the educational perspective, medical training should be more formalized and directed at the educational process. The work-life balance perspective stresses the balance between a working life and a private life, as well as the changing professional relationship between staff members and residents. The trust-based perspective reflects the classic view of medical training in which role modeling and trust are considered most important. CONCLUSIONS: The four perspectives on the modernization of postgraduate medical training show that various aspects of the modernization process are valued differently by stakeholders, highlighting important sources of agreement and disagreement between them. An important source of disagreement is diverging expectations of the role of physicians in modern medical practice.

Dear Policymaker: Have you made up your mind? (Article)

2010-05-01T00:00:00Z

Objectives: To get insight in what criteria as presented in Health Technology Assessment (HTA) studies are important for decision makers in health care priority setting. Methods: We performed a discrete choice experiment (DCE) among Dutch health care professionals (policymakers, HTA experts, advanced HTA students). In 27 choice sets, we asked respondents to elect reimbursement of one of two different health care interventions, which represented unlabeled, curative treatments. Both treatments were incrementally compared to usual care. The results of the interventions were normal outputs of HTA studies with a societal perspective. Results were analysed using a multinomial logistic regression model. Upon completion of the questionnaire we discussed the exercise with policymakers. Results: Severity of disease, costs per QALY gained, individual health gain, and the budget impact were the most decisive decision criteria. A program targeting more severe diseases increased the probability of reimbursement dramatically. Uncertainty related to cost-effectiveness was also important. Respondents preferred health gains that include quality of life improvements over extension of life without improved quality of life. Savings in productivity costs were not crucial in decision making, although these are to be included in Dutch reimbursement dossiers for new drugs. Regarding subgroups, we found that policymakers attached relatively more weight to disease severity than others but less to uncertainty. Conclusions: Dutch policymakers and other health care professionals seem to have reasonably well articulated preferences: six of seven attributes were significant. Disease severity, budget impact, and cost-effectiveness were very important. The results are comparable to international studies, but reveal a larger set of important decision criteria.

Preferences for long-term care services: Willingness to pay estimates derived from a discrete choice experiment (Article)

2010-05-01T00:00:00Z

Abstract: Ageing populations increase pressure on long-term care. Optimal resource allocation requires an optimal mix of care services based on costs and benefits. Contrary to costs, benefits remain largely unknown. This study elicits preferences in the general elderly population for long-term care services for varying types of patients. A discrete choice experiment was conducted in a general population subsample aged 50-65 years (N = 1082) drawn from the Dutch Survey Sampling International panel. To ascertain relative preferences for long-term care and willingness to pay for these, participants were asked to choose the best of two care scenarios for four groups of hypothetical patients: frail and demented elderly, with and without partner. The scenarios described long-term care using ten attributes based on Social Production Function theory: hours of care, organized social activities, transportation, living situation, same person delivering care, room for individual preferences, coordination of services, punctuality, time on waiting list, and co-payments. We found the greatest value was attached to same person delivering care and transportation services. Low value was attached to punctuality and room for individual preferences. Nursing homes were generally considered to be detrimental for well-being except for dementia patients without a partner. Overall, long-term care services were thought to produce greatest well-being for the patients 'without a partner' and those 'with dementia'. Individuals combining these two risk factors would benefit the most from all services except transportation which was considered more important for the frail elderly. The results support the notion that long-term care services represent different value for different types of patients and that the value of a service depends upon the social context. Examination of patient profiles confirmed the notion that physical, mental and social vulnerability affect valuation of the services. Policy-making would profit from allocation models in which budgetary requirements of different services can be balanced against the well-being they produce for individuals.

Dear Policymaker: Have you made up your mind? (Article)

2010-04-01T00:00:00Z

Discrete Choice Modeling for the Quantification of Health States: The Case of the EQ-5D (Article)

2010-01-01T00:00:00Z

Role of health technology assessment in shaping the benefits package in the Netherlands (Article)

2009-02-01T00:00:00Z

In many countries of the Western world, the role of health technology assessment (HTA) in funding decisions of medical technologies is increasing. HTAs are expected to support decision-makers in delineating the collectively funded benefits package. To maximize their potential, it is essential that assessments are valid, reliable and timely, and that it is transparent how information provided in assessments is used in decision-making. Against this background, this article aims to review the current state of affairs regarding the use of HTA in the area of medical specialist care in The Netherlands and to evaluate strengths and weaknesses of the HTA-based system for priority setting. The reason to do so was the introduction of a new hospital financing system in The Netherlands, which allowed for expansion of the HTA system that already existed for pharmaceuticals to medical specialist care. A comprehensive account of the HTA system for medical specialist care was created using the so-called Hutton framework, followed by an exploration of its strengths and weaknesses. An important lesson to be learned from the early Dutch experiences with HTA in the area of medical specialist care is that the nature and complexity of health technologies in this area create practical problems regarding the amount and quality of available data needed to make the HTA-based system work. This hampers an unambiguous interpretation of assessment data and thus calls for stronger requirements regarding transparency and stakeholder participation. Future work focusing on the role of HTA in funding decisions is needed to provide insights in best practices for HTA systems in circumstances where a delicate balance needs to be achieved between promoting innovation, supporting effective and timely decision-making and preventing the coverage of technologies that represent a waste of resources.

Willingness to pay for lives saved by helicopter emergency medical services (Article)

2009-01-01T00:00:00Z

Introduction. Currently, policy makers in the Netherlands are discussing the possibility to expand the availability of Helicopter Emergency Medical Services (HEMS) from 12 hours to 24 hours per day. For this, the preferences of the general public towards both the positive effects and negative consequences of HEMS should be taken into account. Therefore, the willingness to pay (WTP) for lives saved by HEMS was calculated. Methods. A discrete choice experiment (DCE) was performed in order to explore the preferences of respondents towards (expansion of) HEMS availability. The attributes: costs (for HEMS) per household number of additional lives saved (by HEMS), number of noise disturbances (caused by HEMS) during day time or night time were used. A written questionnaire was presented to 150 individuals by convenience sampling. Result. One hundred and thirty-six (91%) of the 150 individuals completed the DCE questionnaire. The marginal WTP for one additional life saved (in a month) was 3.43 (95% CI; 2.96-3.90) per month per household. Overall, the WTP for expansion to a 24-hour availability of HEMS can therefore be estimated at 12.29 (∼ US$ 17.50) per household per month. Conclusion. The WTP derived from this study is by far exceeding the 1-1.5 Million-euro necessary per HEMS per year for the expansion from a daytime HEMS to a 24-h availability in the Netherlands. Respondents are willing to pay for lives saved by HEMS in spite of increases in flights and concurrent noise disturbances. These results may be helpful for the decision-making process, and may provide a positive argument for the expansion of HEMS availability.

International comparison of systems to determine entitlements to medical specialist care: performance and organizational issues (Research Paper)

2008-08-01T00:00:00Z

Summary Objective: CVZ has asked us to provide a comparison of criteria and procedures that different countries use to determine entitlements to medical specialist care. This question was asked within the context of the recent introduction of the DBC (diagnosis treatment combinations) system as an alternative to existing methods of financing of hospital services. Methods The analysis covered priority systems in nine countries: Australia, Belgium, Canada, France, Germany, the Netherlands, Sweden, Switzerland, and the UK. To meaningfully compare existing criteria and procedures of different countries and analyze the possibilities and limitations of priority setting systems, we used an analytical framework for international comparison recently developed by Hutton and co-workers (Hutton et al., 2006). The framework was created to encompass the many aspects of fourth hurdle systems. It can deal with the legal and political characteristics at the system level and the detailed nuances of varying assessment and decision-making procedures at the decisional level. It analyses priority systems at two levels: 1. Policy implementation: the establishment of the fourth hurdle system as a policy decision of the government, the policy objectives of the system, its legal status, and its relationships with the remainder of the health system, with other public sector bodies, and with other stakeholders, such as industry and patient groups; 2. Individual technology decision: the processes by which individual technologies are dealt with by the system, for example, assessment processes, how decisions are made, and how they are implemented. ... etc.

Role of budget impact in drug reimbursement decisions (Article)

2008-04-01T00:00:00Z

There are three known criteria that underlie drug reimbursement decisions: therapeutic value, cost-effectiveness, and burden of disease. However, evidence from recent reimbursement decisions in several jurisdictions points to residual, unexplained variables, among which is budget impact. Budget impact refers to the total costs that drug reimbursement and use entail with respect to one part of the health care system, pharmaceutical care, or to the entire health care system, taking into account the possible reallocation of resources across budgets or sectors of the health care system. The economic and equity rationale for carrying out budget impact analyses is opportunity cost, or benefits forgone, measured in terms of utility or equitable distribution, by using resources in one way rather than another. In other words, by choosing to draw down the budget in one way, decision makers forgo other opportunities to use the same resources. Under a set of unrealistic assumptions, cost-effectiveness analysis accounts for opportunity cost while conveying to the decision maker the price of maximizing health gains, subject to a budget or resource constraint. However, the underlying assumptions are implausible, particularly in the context of pharmaceutical care. Moreover, budget impact analysis is more useful to the decision maker than cost-effectiveness analysis if the objective is not to maximize health gains subject to a budget or resource constraint, but to reduce variance in health gains. With respect to equitable distribution, budget impact analyses lay bare the individuals or groups who lose out - those who bear the opportunity cost of spending resources in accordance with one decision rule rather than another.

Conditional reimbursement within the Dutch drug policy (Article)

2007-11-01T00:00:00Z

In The Netherlands, conditional reimbursement is considered to be a promising approach to achieving more effective and efficient pharmaceutical care. Because of its formal status and nationwide regulation, conditional reimbursement may allow governments to better control medical decision-making. To evaluate the effects of conditional reimbursement on medicine use and its performance as a policy tool, we compared observed volumes of medicine use with expected volumes. In addition, we mapped the annual growth by analysing trends in the volumes of use of all conditionally reimbursed drugs; starting with the year the drug entered the market (using macro-level data). Next we explored five cases in depth (using micro-level data) in order to explore what fraction of individual prescriptions met the requirements. We also performed qualitative research (document analysis, interviews (N = 65)) in order to obtain the stakeholders' perspectives on how the measure functions, as well as to interpret the case studies data further. The findings suggest that conditional reimbursement may be an effective policy instrument, but that several changes are needed to optimize its impact. These changes are predominantly related to transparency (e.g. conditions are set following clear procedures and criteria), legitimacy (conditions should be consistent with criteria for prioritization), feasibility of procedures to control appropriate use, and timely and appropriate commitment of the stakeholders.

Prioritisation by physicians in the Netherlands-The growth hormone example in drug reimbursement decisions (Article)

2007-03-01T00:00:00Z

Drug treatment and reimbursement is an area of ever growing complexity in health priority setting. This paper assesses the National Registry of Growth Hormone Treatment (LRG) responsible for making prioritisation decisions in the Dutch drug reimbursement system in the treatment of growth hormone, using the framework for fairness. We used qualitative research consisting of semi-structured interviews and focus group sessions combined with quantitative methods to audit the decisions of the forum. The rationing decisions of the forum demonstrate accountability for reasonableness by the conditions for transparency, relevance, and appeal. Most rationales for the decisions are public and transparent. The patients and paediatricians see decisions made by the LRG as clinical and therefore relevant decisions. They also refer to extensive appeal procedures. The case also raises important issues regarding the legitimacy of expert-based priority setting as the cyclic nature of guideline development conflicts with the need for maintaining strict rationing criteria. In 13% of the patients, the sick funds did cover treatment as the forum advised them to do, but according to guideline criteria it may be unlikely that these patients have growth hormone deficiency. According to the LRG, however, only 2% of the decisions are inconsistent with the guidelines, as some criteria on what to do in case of more uncertainty, shifted. For the forum, it seems rather unthinkable to go against the professional norms, in spite of formal national regulations. For the Health Care Insurance Board (CVZ), it was not considered possible to go against national regulations, especially as professional norms have shifted without informing policy makers and patient representatives.

De definitie van specialistische geneesmiddelen (Research Paper)

2006-05-01T00:00:00Z

Samenvatting Vanwege bekostigingsproblemen met bepaalde geneesmiddelen is er een afbakeningsdiscussie rond dit onderwerp ontstaan. Buiten het ziekenhuis worden soms geneesmiddelen gebruikt waarvan zorgverzekeraars vinden dat ze niet via de extramurale geneesmiddelfinanciering moeten worden bekostigd maar dat ze ten laste van het ziekenhuisbudget zouden moeten komen. Ziekenhuizen zijn bereid deze geneesmiddelen te betalen als ze er maar voor gecompenseerd worden. Tegen deze achtergrond is een mogelijke oplossing voor de financieringsproblematiek om extramuraal afgeleverde geneesmiddelen te scheiden in specialistische en generalistische middelen. Door de specialistische geneesmiddelen medisch-inhoudelijk, beleidsmatig en financieel onder de reikwijdte van het ziekenhuis te brengen kan de continuïteit in behandeling door de medisch specialist ook worden doorgetrokken naar de farmacotherapie, ongeacht waar de patiënt zich bevindt (intramuraal of extramuraal). Voor generalistische middelen zou de medisch-inhoudelijke, beleidsmatige en financiële praktijk niet anders zijn dan in de huidige situatie. etc ...

The "health benefit basket" in the Netherlands. (Article)

2005-11-01T00:00:00Z

This contribution describes the entitlements in Dutch health care and explores how these entitlements are determined and to whom they apply. The focus is on services of curative care. No comprehensive positive or negative list of individual services is included in formal laws. Instead, the legislation states only what general types of medical services are covered and generally the "usual care" criterion determines to which interventions patients are entitled. This criterion is not very restrictive and yields local variations in service provision, which are moderated by practice guidelines. It is conceivable, however, that the recent introduction of the DBC financing system will change the reimbursement and therefore benefit-setting policy.

Equity and Efficiency in Health Care PrioritySetting: how to Get the Balance Right (Doctoral Thesis)

2005-09-02T00:00:00Z

A Nonparametric Elicitation of the Equity-Efficiency Tradeoff in Cost-Utility Analysis (Article)

2005-07-01T00:00:00Z

We performed an empirical elicitation of the equity-efficiency trade-off in cost-utility analysis using the rank-dependent quality-adjusted life-year (QALY) model, a model that includes as special cases many of the social welfare functions that have been proposed in the literature. Our elicitation method corrects for utility curvature and, therefore, our estimated equity weights are not affected by diminishing marginal utility. We observed a preference for equality in the allocation of health. The data suggest that the elicited equity weights were jointly determined by preferences for equality and by insensitivity to group size. A procedure is proposed to correct the equity weights for insensitivity to group size. Finally, we give an illustration how our method can be implemented in health policy.

Short term and long term health related quality of life after congenital anorectal malformations and congenital diaphragmatic hernia (Article)

2004-01-01T00:00:00Z

AIMS: To examine short term and long term health related quality of life (HRQoL) of survivors of congenital anorectal malformations (ARM) and congenital diaphragmatic hernia (CDH), and to compare these patients' HRQoL with that of the general population. METHODS: HRQoL was measured in 286 ARM patients and 111 CDH patients. All patients were administered a symptom checklist and a generic HRQoL measure. For the youngest children (aged 1-4) the TAIQOL (a preliminary version of the TAPQOL) was used, for the other children (aged 5-15) the TACQOL questionnaire, and for adults (aged >16) the SF-36. RESULTS: As appeared from the symptom checklists, many patients remained symptomatic into adulthood. In the youngest ARM patients (aged 1-4 years), generic HRQoL was severely affected, but the older ARM patients showed better HRQoL. In the CDH patients, the influence of symptoms on HRQoL seemed less profound. The instruments we used revealed little difference between adults treated for ARM or CDH and the general population. CONCLUSIONS: These results show that for two neonatal surgical procedures, improved survival does not come at the expense of poor HRQoL in adults. Even though there is considerable suffering in terms of both morbidity and mortality in the youngest group, the ultimate prognosis of survivors of the two studied congenital malformations is favourable. This finding can be used to reassure parents of patients in need of neonatal surgery for one of these conditions about the prospects for their child.

Cost utility analysis of sildenafil compared with papaverine-phentolamine injections (Article)

2000-01-01T00:00:00Z

OBJECTIVE: To compare the cost effectiveness of sildenafil and papaverine-phentolamine injections for treating erectile dysfunction. DESIGN: Cost utility analysis comparing treatment with sildenafil (allowing a switch to injection therapy) and treatment with papaverine-phentolamine (no switch allowed). Costs and effects were estimated from the societal perspective. Using time trade-off, a sample of the general public (n=169) valued health states relating to erectile dysfunction. These values were used to estimated health related quality of life by converting the clinical outcomes of a trial into quality adjusted life years (QALYs). PARTICIPANTS: 169 residents of Rotterdam. MAIN OUTCOME MEASURES: Cost per quality adjusted life year. RESULTS: Participants thought that erectile dysfunction limits quality of life considerably: the mean utility gain attributable to sildenafil is 0.11. Overall, treatment with sildenafil gained more QALYs, but the total costs were higher. The incremental cost effectiveness ratio for the introduction of sildenafil was pound sterling 3639 in the first year and fell in following years. Doubling the frequency of use of sildenafil almost doubled the cost per additional QALY. CONCLUSIONS: Treatment with sildenafil is cost effective. When considering funding sildenafil, healthcare systems should take into account that the frequency of use affects cost effectiveness.

The cost-utility of Viagra® in The Netherlands (Research Paper)

1999-01-01T00:00:00Z

OBJECTIVE: Clinical trials suggest that sildenafil is an effective treatment for erectile dysfunction. Nevertheless, reimbursement is controversial: sildenafil is expected to be more effective than conservative therapy (papaverine/ phentolamine injections), but also more costly to society. Economic appraisal of sildenafil is of interest given the prevalence of the disorder. DESIGN: We analyzed the cost-effectiveness of a sildenafil scenario (allowing a switch to injection therapy) and the papaverine/ phentolamine scenario (conservative therapy, no switch allowed). Analyses were performed from the societal perspective. Values for health states of erectile dysfunction were collected using time trade-off. Using these values (N=169), we converted trial outcomes (Goldstein, 1998) into quality adjusted life years (QALYs). RESULTS: The mean utility gain attributable to sildenafil is 0.11. In the sildenafil scenario, more QALYs are gained but the total costs are higher. The incremental cost-effectiveness ratio of sildenafil is $6037 (£3639) in the 1st year, improving in following years. CONCLUSIONS: This cost-utility analysis suggests that the clinical effect of sildenafil are derived at reasonable costs. When considering reimbursement of sildenafil, it should be taken into account that the frequency of use affects this cost-effectiveness ratio.