Rutten, F.F.H.

Electrocardiographic characteristics of patients with chronic obstructive pulmonary disease (Article)

2013-02-01T00:00:00Z

Patients with chronic obstructive pulmonary disease (COPD) are at increased risk of cardiovascular disease. Electrocardiography (ECG) carries information about cardiac disease and prognosis, but studies comparing ECG characteristics between patients with and without COPD are lacking. We related ECG characteristics of patients with COPD, to ECG characteristics of patients without COPD, and determined whether ECG abnormalities are related to COPD severity. A cross-sectional study was conducted within a cohort of 243 COPD patients, aged 65 years or older. All patients underwent extensive examinations, including resting 12-lead ECG and pulmonary function tests. The reference group (n = 293) was a sample from the general population, also aged 65 or older, without COPD. Abnormal ECGs were more prevalent in COPD patients (50%) than in patients without COPD (36%, p = 0.054). Conduction abnormalities were the most common ECG abnormality in COPD patients (28%) being significantly more prevalent than in patients without COPD (11%, p < 0.001). The mean heart rate was higher in COPD patients (72 bpm (SD 14)) compared to controls (65 bpm (SD 13), p < 0.001), and QTc prolongation was less frequent in COPD patients (9% versus 14%, p = 0.01). The prevalence of ECG abnormalities increased with severity of pulmonary obstruction. ECG abnormalities, especially conduction abnormalities are common in COPD patients, and the prevalence of ECG abnormalities increases with severity of COPD. This underlines the importance of an integrated-care approach for COPD patients, paying attention to early detection of unrecognized coexisting cardiac disorders.

Assessing the Determinants of the Potential for Cost-Effectiveness Over Time: The Empirical Case of COPD (Article)

2013-01-01T00:00:00Z

The objective of this study was to assess the potential for cost-effectiveness of new technologies for chronic obstructive pulmonary disease (COPD) over the period from 2001 to 2010. Methods Lung function outcomes and drug prices were observed for a UK COPD population over the period from 2001 to 2010. Cost-effectiveness was assessed at regular intervals on the basis of an established cost-effectiveness model, and the maximum price a technology providing cure could achieve under the current cost-effectiveness rules was estimated. Results The results of this study show that although the scope for clinical improvement in COPD was still considerable, during the 10 years studied, the potential for cost-effectiveness at each point in time was dependent on momentary market characteristics, such as the changing price of comparators and improvements in clinical effectiveness. As a result, the analysis demonstrates that the future cost-effectiveness of a technology in development depends on the manner pricing and clinical effectiveness evolve throughout time. Conclusions Because any predictions will be short-lived and dependent on a number of uncertain factors, we conclude that producing accurate forecasts on the potential for cost-effectiveness of new therapies earlier during the development process is especially difficult under the current static cost-effectiveness framework.

Gezondheidseconomie: de sleutel tot gepaste zorg The Impact of economic evaluation on healthcare decision-making (Farewell Lecture)

2012-10-04T00:00:00Z

Afscheidscollege Professor Frans Rutten op 4 oktober 2012. Gezondheidseconomie, ofwel ‘health economics’, is een fascinerend deel - terrein van de economie dat gemakkelijk 40 jaar lang kan boeien. Dat geldt zeker als je, zoals ik, bij de start en ontwikkeling ervan nauw betrokken bent geweest. Het vakgebied is in deze 40 jaar gegroeid van een onbeduidend wetenschapsgebied tot een belangrijke en relevante subdiscipline van de economie, gemeten naar zowel wetenschappelijke output als maatschappelijke impact (Wagstaff en Culyer 2012). De onderwerpen, die in de loop der tijd door gezondheidseconomen onder de loep zijn genomen, variëren van macro-vraagstukken over de ordening van de zorg tot de bepaling van de kosten en baten van individuele programma’s, en van vraagstukken in Europa en de VS tot die m.b.t. de zorg Afrika en Azië. Op al die terreinen spelen we in Rotterdam een voortrekkersrol, zoals ook blijkt uit het feit dat wij gemeten naar wetenschappelijke output het 11e instituut in de wereld zijn en het 2e in Europa.

GOLD or lower limit of normal definition? a letter and authors' response (Article)

2012-07-26T00:00:00Z

Antihypertensive drugs: A perspective on pharmaceutical price erosion and its impact on cost-effectiveness (Article)

2012-03-01T00:00:00Z

Objective: When comparators' prices decrease due to market competition and loss of exclusivity, the incremental clinical effectiveness required for a new technology to be cost-effective is expected to increase; and/or the minimum price at which it will be funded will tend to decrease. This may be, however, either unattainable physiologically or financially unviable for drug development. The objective of this study is to provide an empirical basis for this discussion by estimating the potential for price decreases to impact on the cost-effectiveness of new therapies in hypertension. Methods: Cost-effectiveness at launch was estimated for all antihypertensive drugs launched between 1998 and 2008 in the United Kingdom using hypothetical degrees of incremental clinical effectiveness within the methodologic framework applied by the UK National Institute for Health and Clinical Excellence. Incremental cost-effectiveness ratios were computed and compared with funding thresholds. In addition, the levels of incremental clinical effectiveness required to achieve specific cost-effectiveness thresholds at given prices were estimated. Results: Significant price decreases were observed for existing drugs. This was shown to markedly affect cost-effectiveness of technologies entering the market. The required incremental clinical effectiveness was in many cases greater than physiologically possible so, as a consequence, a number of products might not be available today if current methods of economic appraisal had been applied. Conclusions: We conclude that the definition of cost-effectiveness thresholds is fundamental in promoting efficient innovation. Our findings demonstrate that comparator price attrition has the potential to put pressure in the pharmaceutical research model and presents a challenge to new therapies being accepted for funding. Copyright

Reimbursement of pharmaceuticals: Reference pricing versus health technology assessment (Article)

2011-06-01T00:00:00Z

Reference pricing and health technology assessment are policies commonly applied in order to obtain more value for money from pharmaceuticals. This study focussed on decisions about the initial price and reimbursement status of innovative drugs and discussed the consequences for market access and cost. Four countries were studied: Germany, The Netherlands, Sweden and the United Kingdom. These countries have operated one, or both, of the two policies at certain points in time, sometimes in parallel. Drugs in four groups were considered: cholesterol-lowering agents, insulin analogues, biologic drugs for rheumatoid arthritis and "atypical" drugs for schizophrenia. Compared with HTA, reference pricing is a relatively blunt instrument for obtaining value for money from pharmaceuticals. Thus, its role in making reimbursement decisions should be limited to drugs which are therapeutically equivalent. HTA is a superior strategy for obtaining value for money because it addresses not only price but also the appropriate indications for the use of the drug and the relation between additional value and additional costs. However, given the relatively higher costs of conducting HTAs, the most efficient approach might be a combination of both policies.

Differences in overweight and obesity among children from migrant and native origin: A systematic review of the European literature (Article)

2011-05-01T00:00:00Z

To review the prevalence regarding overweight and obesity among children and adolescents from migrant and native origin within Europe, a systematic review (1999-2009) was performed, using Embase, PubMed and citation snowballing. Literature research resulted in 19 manuscripts, reporting studies in six countries, mostly situated in Western and Central Europe. From this review, it appears that, in most of the European countries for which data are available, especially non-European migrant children are at higher risk for overweight and obesity than their native counterparts. The prevalence of overweight in migrant children ranged from 8.9% to 37.5% and from 8.8% to 27.3% in native children. The prevalence of obesity in migrant children ranged from 1.2% to 15.4% and from 0.6% to 11.6% in native children. Some limitations of the review are discussed, especially the problematic classification of migrant and native children. Apparently, migrant children display an even more sedentary way of life or adverse dietary patterns, as compared with native children. To what degree these differences can be explained by socioeconomic and cultural factors remains to be investigated. As overweight and obese children are at risk for many chronic health problems, further research is urgently needed in order to develop preventive interventions. © 2011 The Authors. obesity reviews

Burden of illness of Pompe disease in patients only receiving supportive care (Article)

2011-04-18T00:00:00Z

Background: Pompe disease is an orphan disease for which enzyme replacement therapy (ERT) recently became available. This study aims to estimate all relevant aspects of burden of illness-societal costs, use of home care and informal care, productivity losses, and losses in health-related quality of life (HRQoL)-for adult Pompe patients only receiving supportive care. Methods: We collected data on all relevant aspects of burden of illness via a questionnaire. We applied a societal perspective in calculating costs. The EQ-5D was used to estimate HRQoL. Results: Eighty adult patients (87% of the total Dutch adult Pompe population) completed a questionnaire. Disease severity ranged from mild to severe. Total annual costs were estimated at €22,475 (range €0-169,539) per adult Pompe patient. Patients on average received 8 h of home care and 19 h of informal care per week. Eighty-five percent of the patients received informal care from one or more caregivers; 40% had stopped working due to their disease; another 20% had reduced their working hours. HRQoL for Pompe patients who only received supportive care was estimated at 0.72, 17% lower than the Dutch population at large. Conclusions: Adult Pompe disease is associated with a considerable burden of illness at both the societal and patient levels. The disease leads to substantial costs and dependency on medical devices, home care, and informal care, and has a high impact on the patient's social network. In addition, patients are limited in their ability to work and have significantly reduced HRQoL.

Health effects in significant others: Separating family and care-giving effects (Article)

2011-03-01T00:00:00Z

Background. Changes in the health of patients may affect the health of so-called "significant others" in 2 distinct ways. First, an individual may provide informal care to the patient and be burdened by the process of care giving. We label this indirect effect of a patient's health on the health of the care giver the "care-giving effect." Second, a person may suffer from health losses because someone in his or her social environment is ill, regardless of his or her care-giving status. The health of the patient then directly affects the health of this significant other, which we label the "family effect." Methods. We investigate the occurrence of the family and care-giving effect in a convenience sample of Dutch care givers (n = 751). The family effect was approximated by the health status of the patient (measured on EuroQol-VAS), and the caregiving effect by the number of the care-giving tasks was provided. It was assumed that care givers' health is positively associated with patients' health, that is, the family effect, and negatively associated with care-giving burden, that is, the care-giving effect. Relationships are studied using multivariate regressions. Results. Our results support the existence of both types of health effects. The analysis shows that the 2 effects are separable and independently associated with the health of care givers. Not accounting for the family effect conflates the care-giving effect. Conclusions. If the goal of health care policy is to optimize health, all important effects should be captured. The scope of economic evaluations should also include health effects in significant others. This study suggests that significant others include both care givers and broader groups of affected individuals, such as family members.

The efficiency frontier approach to economic evaluation: Will it help German policy making? (Article)

2010-10-01T00:00:00Z

Lifestyle intervention: from cost savings to value for money (Article)

2010-09-01T00:00:00Z

Abstract Prevention of unhealthy lifestyles has sometimes been promoted as simultaneously reducing costs and improving public health but this will unlikely prove to be true. Additional medical costs in life years gained due to treatment of unrelated diseases may offset possible savings in related diseases, but are often ignored both in health promotion policies and in economic evaluations of life-prolonging interventions. Many national guidelines explicitly recommend excluding these costs from economic evaluations or leave inclusion up to the discretion of the analyst. This may result in too favorable estimations of cost-effectiveness, feeding the unjustified optimism among policymakers regarding lifestyle interventions as a cost-saving option. However, prevention may still be a cost-effective way to improve public health, even when it does not result in cost savings, but this should be judged taking all future costs into account and be based on the true value for money provided by lifestyle interventions.

Validation of the PHQ-9 as a screening instrument for depression in diabetes patients in specialized outpatient clinics (Article)

2010-08-16T00:00:00Z

Background. For the treatment of depression in diabetes patients, it is important that depression is recognized at an early stage. A screening method for depression is the patient health questionnaire (PHQ-9). The aim of this study is to validate the 9-item Patient Health Questionnaire (PHQ-9) as a screening instrument for depression in diabetes patients in outpatient clinics. Methods. 197 diabetes patients from outpatient clinics in the Netherlands filled in the PHQ-9. Within 2 weeks they were approached for an interview with the Mini Neuropsychiatric Interview. DSM-IV diagnoses of Major Depressive Disorder (MDD) were the criterion for which the sensitivity, specificity, positive- and negative predictive values and Receiver Operator Curves (ROC) for the PHQ-9 were calculated. Results. The cut-off point of a summed score of 12 on the PHQ-9 resulted in a sensitivity of 75.7% and a specificity of 80.0%. Predictive values for negative and positive test results were respectively 93.4% and 46.7%. The ROC showed an area under the curve of 0.77. Conclusions. The PHQ-9 proved to be an efficient and well-received screening instrument for MDD in this sample of diabetes patients in a specialized outpatient clinic. The higher cut-off point of 12 that was needed and somewhat lower sensitivity than had been reported elsewhere may be due to the fact that the patients from a specialized diabetes clinic have more severe pathology and more complications, which could be recognized by the PHQ-9 as depression symptoms, while instead being diabetes symptoms

Caring for and caring about: Disentangling the caregiver effect and the family effect (Article)

2010-07-01T00:00:00Z

Besides patients' health and well-being, healthcare interventions may affect the well-being of significant others. Such 'spill over effects' in significant others may be distinguished in two distinct effects: (i) the caregiving effect and (ii) the family effect. The first refers to the welfare effects of providing informal care, i.e., the effects of caring for someone who is ill. The second refers to a direct influence of the health of a patient on others' well-being, i.e., the effects of caring about other people. Using a sample of Dutch informal caregivers we found that both effects exist and may be comparable in size. Our results, while explorative, indicate that economic evaluations adopting a societal perspective should include both the family and the caregiving effects measured in the relevant individuals.

The potential yield of ECG screening of hypertensive patients: The Utrecht Health Project (Article)

2010-07-01T00:00:00Z

Objective: Several guidelines for hypertension and cardiovascular risk management recommend an ECG in hypertensive patients to improve risk prediction. We estimated the prevalence of clinically relevant ECG abnormalities and the number needed to screen (NNS) with a routine ECG to prevent the occurrence of one death in the next 10 years conditional on adequate treatment and follow-up. Methods: The study population consisted of 866 hypertensive participants recruited from the Utrecht Health Project (UHP), a dynamic population study in Utrecht. Baseline measurements included an ECG and the risk factors that enable a Systematic COronary Risk Evaluation (SCORE) risk estimation for each participant. ECGs were interpreted using Modular ECG Analysis System for computerized recognition of ECG abnormalities. NNS to prevent one death was computed by the reciprocal of the prevalence of the ECG abnormalities multiplied by number needed to treat to prevent one death when the ECG abnormality is managed according to the prevailing clinical guidelines. Results: The population consisted of 54.2% men with a mean age of 53.2 years (SD 11.5). The prevalence of ECG abnormalities was 17.6 [n = 95% confidence interval (CI) 15.0-20.1]. Prevalence of atrial fibrillation or prior myocardial infarction was 2.1% (95%CI 1.1-3.0) and of other ECG abnormalities related to increased cardiovascular disease risk 15.4% (95%CI 13.1-17.9). NNS to prevent one death from cardiovascular disease within 10 years was estimated at 260 (95%CI 220-308). Conclusion: Our findings support the existing recommendations to routinely record an ECG in unselected hypertensive patients as the prevalence of relevant abnormalities is considerable and NNS to prevent one death is lower than that in other widely accepted tests.

Cost-effectiveness of collaborative care for the treatment of major depressive disorder in primary care. A systematic review (Article)

2010-03-04T00:00:00Z

Background. The effectiveness of collaborative care for patients with major depressive disorder in primary care has been established. Assessing its cost-effectiveness is important for deciding on implementation. This review therefore evaluates the cost-effectiveness of collaborative care for major depressive disorder in primary care. Methods. A systematic search on economic evaluations of collaborative care was conducted in Pubmed and PsychInfo. Quality of the studies was measured with the Cochrane checklist and the CHEC-list for economic evaluations. Cost-effectiveness and costs per depression-free days were reported. Results. 8 studies were found, involving 4868 patients. The quality of the cost effectiveness studies, according to the CHEC-list, could be improved. Generally, the studies did not include all relevant costs and did not perform sensitivity analysis. Only 4 out of 8 studies reported cost per QALY, 6 out of 8 reported costs per depression-free days. The highest costs per QALY reported were $49,500, the highest costs per depression-free day were $24. Conclusions. Although studies did not fulfil all criteria of the CHEC-list, collaborative care is a promising intervention and it may be cost-effective. However, to conclude on the cost-effectiveness, depression research should follow economic guidelines to improve the quality of the economic evaluations.

Relationships among Self-Management, Patient Perceptions of Care, and Health Economic Outcomes for Decision-Making and Clinical Practice in Type 2 Diabetes (Article)

2010-01-01T00:00:00Z

Abstract. OBJECTIVES: Type 2 diabetes (T2D) treatment involves complex interactions between biological, psychological, and behavioral factors of care, requiring multifaceted efforts in clinical practice and disease management to reduce health and economic burdens. We aimed to quantify correlations among these factors and characterize their level of inclusion in economic analyses that are part of informed medical decision-making. METHODS: A comprehensive, stepwise systematic literature review was performed on published articles dated 1993 to 2008 using medical subject heading and keyword searches in electronic reference libraries. Data were collected using standardized techniques and were analyzed descriptively. RESULTS: A total of 97 articles fulfilling all inclusion criteria were reviewed, including 16 on economic models (17% of articles). Most studies were retrospective (41 of 97; 42%) and from managed care perspectives (66%). Oral antidiabetic drugs were a central focus, appearing in 83% of studies. Patient behaviors, particularly medication adherence and persistence in real-world settings, are well researched (n=65) and may influence diabetes outcomes, cardiovascular risk, mortality rates, and treatment-specific resource use (e.g., hospitalizations) and costs (

Transferability of economic evaluations across jurisdictions: ISPOR good research practices task force report (Article)

2009-06-01T00:00:00Z

A growing number of jurisdictions now request economic data in support of their decision-making procedures for the pricing and/or reimbursement of health technologies. Because more jurisdictions request economic data, the burden on study sponsors and researchers increases. There are many reasons why the cost-effectiveness of health technologies might vary from place to place. Therefore, this report of an ISPOR Good Practices Task Force reviews what national guidelines for economic evaluation say about transferability, discusses which elements of data could potentially vary from place to place, and recommends good research practices for dealing with aspects of transferability, including strategies based on the analysis of individual patient data and based on decision-analytic modeling.

Comparing methodologies for the cost estimation of hospital services (Article)

2009-02-01T00:00:00Z

The aim of the study was to determine whether the total cost estimate of a hospital service remains reliable when the cost components of bottom-up microcosting were replaced by the cost components of top-down microcosting or gross costing. Total cost estimates were determined in representative general hospitals in the Netherlands for appendectomy, normal delivery, stroke and acute myocardial infarction for 2005. It was concluded that restricting the use of bottom-up microcosting to those cost components that have a great impact on the total costs (i.e., labour and inpatient stay) would likely result in reliable cost estimates.

Self-reported healthcare decision-makers' attitudes towards economic evaluations of medical technologies (Article)

2008-12-01T00:00:00Z

Background: Increasing costs have generated concern among governments and healthcare providers who have realized the need for cost containment measures and more efficient resource utilization. Health economics is one potential source of information that can make healthcare more efficient. Scope: This review article summarizes the published literature on self-reported attitudes of healthcare decision-makers towards economic evaluations of medical technologies and examines the extent to which economic evaluations are used in health policy decisions. Methods: A systematic literature review of published English language studies was conducted using MEDLINE, EMBASE, and HEED from January 1995 to December 2007. Findings: Fifty-five articles investigated the use of economic evaluations on three levels of decision-making: central, local, and physician level. Results indicate the use of economic evaluation information increased from limited/ minor to moderate use. The influence of economic evaluations increased with the level of centralization of healthcare system. Barriers to use health economics research varied across levels and included health economics research-related barriers such as timely availability, lack of credibility, insufficient methodological quality and decision-context-related barriers including limited decision makers' knowledge, inflexibility in healthcare budgets and variability among healthcare organizations. Conclusions: For consistent policy-making it is important that similar recommendations for cost-effective interventions and programs are developed at all levels and that implementation is promoted by incorporating the appropriate incentives in healthcare provision.

Costs and effects of secondary prevention with perindopril in stable coronary heart disease in Poland: An analysis of the EUROPA study including 1251 Polish patients (Article)

2008-09-25T00:00:00Z

Objectives: To estimate the long-term impact of treatment with perindopril on costs and health effects in patients with stable coronary artery disease in Poland. Methods: The cost-effectiveness analysis was based on data from a randomized double-blind, placebo-controlled trial. A decision-tree analysis was employed, including Monte Carlo and bootstrapping techniques. This study was a sub-study of the EUROPA (European Trial on Reduction of Cardiac Events with Perindopril in Stable Coronary Artery Disease) trial (n = 12 218; mean follow-up 4.2 years). Resource use was based on data from Polish EUROPA study patients (n = 1251), while effectiveness was based on the whole EUROPA study. The health gain of perindopril in life-years was based on overall EUROPA study results, and the adapted Polish life expectancy of patients not dying during the trial. Costs were calculated in new Polish zloty (PLN), year 2003 values; €1 = PLN4.053. Only direct healthcare costs related to cardiovascular events and medication use were studied. Results: When observed mortality was combined with life expectancy beyond the end of the study, perindopril use showed a gain in life expectancy of 0.182 life-years (SD ± 0.129) at a cost of PLN1983 (SD ± 103) with discounting of 5% per annum on costs and no discounting on effects. This resulted in an incremental cost-effectiveness ratio (ICER) of PLN10 896 per life-year gained. The probability that the ICER for perindopril was below the threshold of PLN60 000 was 88%. The overall results were insensitive to discount rates for costs and life-years. Conclusions: Perindopril leads to a reduction in the risk of coronary events among patients with stable heart disease. When the expected improvement in life expectancy is combined with associated medical costs, there is a high probability that perindopril is cost effective, given the threshold of PLN60 000 per life-year gained.

Unrelated medical costs in life-years gained: Should they be included in economic evaluations of healthcare interventions? (Article)

2008-09-23T00:00:00Z

Which costs and benefits to consider in economic evaluations of healthcare interventions remains an area of much controversy. Unrelated medical costs in life-years gained is an important cost category that is normally ignored in economic evaluations, irrespective of the perspective chosen for the analysis. National guidelines for pharmacoeconomic research largely endorse this practice, either by explicitly requiring researchers to exclude these costs from the analysis or by leaving inclusion or exclusion up to the discretion of the analyst. However, the inclusion of unrelated medical costs in life-years gained appears to be gaining support in the literature. This article provides an overview of the discussions to date. The inclusion of unrelated medical costs in life-years gained seems warranted, in terms of both optimality and internal and external consistency. We use an example of a smoking-cessation intervention to highlight the consequences of different practices of accounting for costs and effects in economic evaluations. Only inclusion of all costs and effects of unrelated medical care in life-years gained can be considered both internally and externally consistent. Including or excluding unrelated future medical costs may have important distributional consequences, especially for interventions that substantially increase length of life. Regarding practical objections against inclusion of future costs, it is important to note that it is becoming increasingly possible to accurately estimate unrelated medical costs in life-years gained. We therefore conclude that the inclusion of unrelated medical costs should become the new standard.

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.

Pharmacoeconomics: science, practice and challenges (Article)

2008-01-01T00:00:00Z

In most European countries the first wave of reform in hospital finance was the introduction of some form of hospital budgeting. This changed the environment of the hospital pharmacist, who assumed more responsibility for the efficient delivery of pharmaceuticals. As a consequence of the current trend towards more demand driven healthcare systems with further reliance on market mechanisms, a second wave of reform in hospital finance is taking place. This is the introduction of case payment systems, generally based on some adaptation of the diagnosis-related groups system (DRGs), established in 1983 as the basis for reimbursing providers in the US Medicare system.

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.

Need for differential discounting of costs and health effects in cost effectiveness analyses (Article)

2005-01-01T00:00:00Z

Richtlijnenprogramma (1997-2002). Deelprogramma iMTA; Eindrapportage maart 2002 (Research Paper)

2002-01-01T00:00:00Z

Deze rapportage beschrijft de activiteiten die door het iMTA zijn uitgevoerd om samen met (para-) medische beroepsgroepen richtlijnen voor kosten-effectieve patiëntenzorg te ontwikkelen. Dit Richtlijnenproject vormde een onderdeel van het programma "bevordering doelmatig handelen", dat in het najaar van 1997 van start is gegaan. Het iMTA heeft uitgebreid overlegd met de betrokken richtlijnontwikkelaars over de keuze van richtlijnonderwerpen. Daarbij werden naast de gebruikelijke criteria voor de keuze van onderwerpen voor richtlijnontwikkeling mede in beschouwing genomen of een kosten-effectiviteitsanalyse een duidelijk toegevoegde waarde bood en of er voldoende gegevens op dat terrein beschikbaar waren. Uiteindelijk werden 17 onderwerpen geselecteerd. Dit rapport geeft een korte beschrijving van elk van de richtlijnen en beschrijft het doel van de richtlijnontwikkeling, een samenvatting van de uiteindelijke aanbevelingen en de toegevoegde waarde van het kosten-effectiviteitsonderdeel. Aanvullend hierop heeft het iMTA een apart onderzoek geïnitieerd, waarin de evaluatie van zowel het proces als de uitkomsten van het richtlijnenprogramma centraal stonden. Dit onderzoek heeft geleid tot concrete aanbevelingen, welke tevens in dit rapport beschreven zijn. Naast de werkzaamheden aan de richtlijnontwikkeling op zich heeft het iMTA twee producten vervaardigd, die bij de richtlijnontwikkeling in de toekomst van nut kunnen zijn. Er is een handboek voor evaluatie- studies in de gezondheidszorg gepubliceerd, dat met name goed toegankelijk is voor die leden van richtlijncommissies, die nog geen kennis hebben genomen van het terrein van kosten-effectiviteitsanalyses. Daarnaast is een meetinstrument ontwikkeld voor het waarderen van productieverliezen bij betaald en onbetaald werk, hetgeen kan worden ingezet voor het schatten van indirecte kosten.

Kosten en effecten van esomeprazol in de behandeling van reflux ziekte (Research Paper)

2002-01-01T00:00:00Z

Doel. Het bepalen van de kosten-effectiviteit van esomeprazol (Nexium(r)) ten opzichte van alle andere in Nederland geregistreerde protonpomp remmers in de behandeling van reflux ziekte. Voor de effectiviteit vormt het hebben van voldoende controle over de symptomen het uitgangspunt. Perspectief. De studie is uitgevoerd zowel vanuit het perspectief van de verzekeraars als vanuit het maatschappelijk perspectief. Methoden. Gegevens met betrekking tot effectiviteit zijn afgeleid uit een systematische analyse van de literatuur. Gegevens omtrent zorgconsumptie zijn afkomstig uit interviews met huisartsen en gastro-enterologen. Een model is ontwikkeld, dat de gegevens over effectiviteit en kosten van behandeling bijeen brengt. De structuur van het model is vervolgens bediscussieerd met een panel van deskundigen. Tenslotte zijn de berekeningen uitgevoerd met het aangepaste model. Resultaten. Behandeling met esomeprazol 40 mg is dominant ten opzichte van de andere protonpomp remmers: 96,4% van de patiënten heeft na 8 weken voldoende controle over de klachten, tegen totale kosten van EUR 89 (maatschappelijk;m) / EUR 83 (verzekeraar;v). Na esomeprazol 40 mg is omeprazol 40 mg het meest effectief (95,2%), gevolgd door esomeprazol 20 mg (94%). Wat betreft kosten komt esomeprazol 20 mg op de tweede plaats (EUR 95 (m) /94 (v)). Het duurst is behandeling met omeprazol 40 mg (EUR 146 (m)/ 143 (v)). Conclusie. Voor de behandeling van de acute fase van reflux ziekte is behandeling met esomeprazol 40 mg het meest kosten-effectief, zowel vanuit het perspectief van de verzekeraars als vanuit het maatschappelijk perspectief. Voor een betrouwbare kosten-effectiviteitsanalyse tijdens de onderhoudsfase zijn onvoldoende gegevens aanwezig.

Multivariate Markov chain analysis of the probability of pregnancy in infertile couples undergoing assisted reproduction (Article)

2002-01-01T00:00:00Z

BACKGROUND: Estimating the probability of pregnancy leading to delivery and the influence of clinical factors on that probability is of fundamental importance in the treatment counselling of infertile couples. A variety of statistical techniques have been used to analyse fertility data, many borrowed from survival analysis. METHODS AND RESULTS: We propose an alternative method of analysis which is based on a discrete time Markov chain approach, with states 'pregnancy (leading to a delivery)', 'not pregnant', and 'censored' and in which the transition probabilities are dependent both on the clinical characteristics of the patient and the treatment given. CONCLUSIONS: We believe that the method of analysis presented here may be preferable to standard analyses in that it better reflects the clinical situation, it is a truly discrete time analysis applied to a discrete time situation, it explicitly models the censoring process (a process which in itself provides information of interest to the physician) and can be readily extended to a variety of clinical situations.

Handbook of Health Economics (Article)

2001-01-01T00:00:00Z

Editors and authors should be complimented for their impressive attempt to provide a fair account of the state-of-the-art in health economics. To review such an extensive work in a short time span, we decided to select certain chapters for more in depth study. This selection was based on our areas of expertise under the restriction that all major research areas distinguished in the handbook should be covered. Before turning to the review of the separate chapters, let us first make some general comments about the handbook. An important first question is whether all relevant research areas are covered and whether this has been done in a balanced way. Of course, exhaustive coverage in one book is unattainable for a large area like health economics. Rather the question is that regarding balance and possible lack of bias. In that respect, the book focuses on the US literature and health care system with 24 chapters written by US authors and only 11 by European and Canadian authors. The more traditional economic areas are generally covered by the US authors, emphasising a neo-classical rather than an institutional paradigm, and boundary topics like ‘equity’ and the ‘measurement of health’ are covered by the non-US authors. This structure both reflects the contributions in the health economics literature and the large variation in US health care institutions, and is only troublesome in some chapters as suggested below.

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.

Cost-effectiveness of DNA-diagnosis for four monogenic diseases (Research Paper)

1994-01-01T00:00:00Z

In this paper the costs and benefits associated with DNA-diagnosis of individuals who are at risk of a child with a monogenic disease and who seek genetic counselling because of their reproductive plans are predicted under various assumptions using a mathematical model. Four monogenic diseases have been considered: cystic fibrosis, Duchenne muscular dystrophy, myotonic dystrophy and fragile X syndrome. Counselling (triggered by prior information) on the basis of DNA-diagnosis is compared to the situation that only risk evaluation based on pedigree analysis is possible. The results show for each disease that with DNA-diagnosis couples can be more confident in choosing (further) offspring leading to the birth of more healthy children while the number of affected children is reduced. The costs minus savings within the health care sector depend on the prior risks and to the future burden of the monogenic illness considered. DNA-diagnosis of relative "low" prior risks of a child with CF (e.g. 1:180, 1:240 and 1:480) leads to costs in stead of savings. For higher prior risks of CF and for the three other diseases DNA-diagnosis induces considerable savings. This result remains valid when assumptions regarding behaviour regarding reproduction and receiving DNA-diagnosis under different circumstances are varied.

Cost analysis and substitution of conventional treatment by autologous bone marrow transplantation for patients with (non) Hodgkin's lymphoma or acute myeloid leukemia (Research Paper)

1994-01-01T00:00:00Z

In a retrospective study we calculated the costs of introducing autologous BMT in the treatment of patients with malignant lymphoma and acute leukaemia in The Netherlands. The cost analysis has been performed in five university hospitals and one cancer centre, in a series of patients with intermediate and high grade non-Hodgkin's lymphoma (NHL) and patients with AML. Conventional treatment consisted of chemotherapy. The average costs of the conventional NHL treatment varied from US$3120 to U$12,900. The costs of autologous BMT amounted to US$40,220. In the AML group the costs of conventional treatment amounted to about US$11,040, as only 50% of the patients were treated further. The costs of autologous BMT including a follow-up period of 2 years, amounted to US$55,440. In The Netherlands the total number of autologous BMTs per year in these patient groups was estimated at 230; 180 in the NHL group and 50 in the AML group. The costs of introducing autologous BMT to the NHL group will vary between 4.93 and 6.68 million dollars and for the AML group these costs were estimated at 2.22 million dollars. As a result, the total extra costs of introducing autologous BMTs are expected to be between 7.15 and 8.9 million dollars.

Introduction (Article)

1994-01-01T00:00:00Z

Economic appraisal of asthma and COPD care: A literature review 1980–1991 (Article)

1992-01-01T00:00:00Z

Despite the considerable burden and costs of illness and despite the increasing need to set priorities on the basis of efficiency considerations, only 20 economic appraisals of asthma and COPD care have been published during the past 11 years. This paper provides a detailed summary of the cost-effectiveness ‘evidence’ given by these studies and a discussion of relevant methodological issues. The studies comparing programme costs of delivery methods for oxygen and for aerosol bronchodilator drugs, provide the most straightforward evidence in favour of the concentrator and the metered dose inhaler respectively. There also seems to be evidence in favour of hospital-based home care programmes as compared to community-based home care programs. Health education, especially directed at asthmatic children seems to reduce health care costs and improve attitude, compliance behaviour and self-management skills. Information on the cost-effectiveness of pharmacotherapy and diagnostic technologies, both important interventions in asthma and COPD, was found to be totally lacking.

Medische technology assessment: een uitdaging voor wetenschap en beleid (Inaugural Lecture)

1988-12-01T00:00:00Z