http://repub.eur.nl/res/aut/22270/ List of Publications en http://repub.eur.nl/static-eur/img/logo.png http://repub.eur.nl http://repub.eur.nl/res/pub/39311/ 2013-04-01T00:00:00Z Introduction: Wrist fractures are common in older adults and are expected to increase because of ageing populations worldwide. The introduction of plate and screw fixation has changed the management of this trauma in many patients. For policymaking it is essential to gain insight into trends in epidemiology and healthcare utilisation. The purpose of this study was to determine trends in incidence, hospitalisation and operative treatment of wrist fractures. Methods: A population-based study of patients aged 50 years and older using the Dutch National Injury Surveillance System and the National Hospital Discharge Registry. Data on emergency department visits, hospitalisations and operative treatment for wrist fractures within the period 1997-2009 were analysed. Results: In women, the age-standardised incidence rate of wrist fractures decreased from 497.2 per 100,000 persons (95% confidence interval, 472.3-522.1) in 1997 to 445.1 (422.8-467.4) in 2009 (P for trend <0.001). In men, no significant trends were observed in the same time period. Hospitalisation rates increased from 30.1 (28.3-31.9) in 1997 to 78.9 (75.1-82.8) in 2009 in women (P < 0.001), and from 6.4 (6.0-6.8) to 18.4 (17.3-19.5) in men (P < 0.001). There was a strong increase in operative treatment of distal radius fractures, especially due to plate fixation techniques in all age groups. Conclusion: Incidence rates of wrist fractures decreased in women and remained stable in men, but hospitalisation rates strongly increased due to a steep rise in operative treatments. The use of plate and screw fixation techniques for distal radius fractures increased in all age groups. http://repub.eur.nl/res/pub/39590/ 2012-12-27T00:00:00Z Background: Among trauma patients relatively high prevalence rates of posttraumatic stress disorder (PTSD) have been found. To identify opportunities for prevention and early treatment, predictors and course of PTSD need to be investigated. Long-term follow-up studies of injury patients may help gain more insight into the course of PTSD and subgroups at risk for PTSD. The aim of our long-term prospective cohort study was to assess the prevalence rate and predictors, including pre-hospital trauma care (assistance of physician staffed Emergency Medical Services (EMS) at the scene of the accident), of probable PTSD in a sample of major trauma patients at one and two years after injury. The second aim was to assess the long-term course of probable PTSD following injury.Methods: A prospective cohort study was conducted of 332 major trauma patients with an Injury Severity Score (ISS) of 16 or higher. We used data from the hospital trauma registry and self-assessment surveys that included the Impact of Event Scale (IES) to measure probable PTSD symptoms. An IES-score of 35 or higher was used as indication for the presence of probable PTSD.Results: One year after injury measurements of 226 major trauma patients were obtained (response rate 68%). Of these patients 23% had an IES-score of 35 or higher, indicating probable PTSD. At two years after trauma the prevalence rate of probable PTSD was 20%. Female gender and co-morbid disease were strong predictors of probable PTSD one year following injury, whereas minor to moderate head injury and injury of the extremities (AIS less than 3) were strong predictors of this disorder at two year follow-up. Of the patients with probable PTSD at one year follow-up 79% had persistent PTSD symptoms a year later.Conclusions: Up to two years after injury probable PTSD is highly prevalent in a population of patients with major trauma. The majority of patients suffered from prolonged effects of PTSD, underlining the importance of prevention, early detection, and treatment of injury-related PTSD. http://repub.eur.nl/res/pub/39363/ 2012-07-01T00:00:00Z Background: Falls are a common mechanism of injury in the older population, putting an increasing demand on scarce healthcare resources. The objective of this study was to determine healthcare costs due to falls in the older population. Methods: An incidence-based cost model was used to estimate the annual healthcare costs and costs per case spent on fall-related injuries in patients ≥65 years, The Netherlands (2007-2009). Costs were subdivided by age, gender, nature of injury, and type of resource use. Results: In the period 2007-2009, each year 3% of all persons aged ≥65 years visited the Emergency Department due to a fall incident. Related medical costs were estimated at €675.4 million annually. Fractures led to 80% (€540 million) of the fall-related healthcare costs. The mean costs per fall were €9370, and were higher for women (€9990) than men (€7510) and increased with age (from €3900 at ages 65-69 years to €14,600 at ages ≥85 year). Persons ≥80 years accounted for 47% of all fall-related Emergency Department visits, and 66% of total costs. The costs of long-term care at home and in nursing homes showed the largest age-related increases and accounted together for 54% of the fall-related costs in older people. Discussion: Fall-related injuries are leading to a high healthcare consumption and related healthcare costs, which increases with age. Programmes to prevent falls and fractures should be further implemented in order to reduce costs due to falls in the older population and to avoid that healthcare systems become overburdened. http://repub.eur.nl/res/pub/39303/ 2012-05-01T00:00:00Z Objectives: We determined time trends in numbers and rates of fall-related mortality in an aging population, for men and women. Methods. We performed secular trend analysis of fall-related deaths in the older Dutch population (persons aged 65 years or older) from 1969 to 2008, using the national Official-Cause-of-Death-Statistics. Results. Between 1969 and 2008, the age-adjusted fall-related mortality rate decreased from 202.1 to 66.7 per 100 000 older persons (decrease of 67%). However, the annual percentage change (change per year) in mortality rates was not constant, and could be divided into 3 phases: (1) a rapid decrease until the mid-1980s (men -4.1%; 95% confidence interval [CI] = -4.9, -3.2; women -6.5%; 95% CI, -7.1, -5.9), (2) flattening of the decrease until the mid-1990s (men -1.4%; 95% CI = -2.4, -0.4; women -2.0%; 95% CI = -3.4, -0.6), and (3) stable mortality rates for women (0.0%; 95% CI = -1.2, 1.3) and rising rates for men (1.9%; 95% CI = 0.6, 3.2) over the last decade. Conclusions. The spectacular decrease in fall-related mortality ended in the mid-1990s and is currently increasing in older men at similar rates to those seen in women. Because of the aging society, absolute numbers in fall-related deaths are increasing rapidly. http://repub.eur.nl/res/pub/38192/ 2012-03-01T00:00:00Z Objective: To review and assess the quality of economic evaluation studies on injury prevention measures. Design: Systematic review. Data sources: Electronic databases searched included Medline (Pubmed), EMBASE, Web of Science, PsycINFO, and Safetylit. Inclusion criteria: Empirical studies published in English in international peer-reviewed journals in the period 1998-2009. The subject of the study was economic evaluation of prevention of unintentional injury. Cost-effectiveness (CEA), cost-benefit (CBA) and cost utility (CUA) analyses were included. Methods: Methodological details, study designs, and analysis and interpretation of results of the included articles were reviewed and extracted into summary tables. Study quality was judged using the criteria recommended by the Panel on cost-effectiveness in health and medicine and the British Medical Journal (BMJ) checklist for economic evaluations. Results: Forty-eight studies met the inclusion criteria of our review. Interventions assessed most frequently were hip protectors and exercise programs for the elderly. A wide variety of methodological approaches was found, including differences in type of economic evaluation, perspective, time horizon, study design, cost categories, effect outcomes, and adjustments for timing and uncertainty used. The majority of studies performed a cost-effectiveness analysis from a societal perspective with a time horizon of one to five years, in which the effect was expressed in terms of injuries prevented and only direct health care costs were included. Most studies deviated from one or more of the Panel recommendations or BMJ guidelines; e.g. not adopting the societal perspective, not including all relevant costs, no incremental analysis. Conclusions: This review has shown that approaches to economic evaluation of injury prevention vary widely and most studies do not fulfill methodological rigour. Improving quality and harmonization of economic evaluation studies in the field of injury prevention is needed. One way of achieving this would be to establish international guidelines on economic evaluation for injury prevention interventions, based on established economic evaluation checklists, to assist researchers in the design and reporting of economic evaluations. http://repub.eur.nl/res/pub/35014/ 2012-01-09T00:00:00Z Background: Among injury victims relatively high prevalence rates of posttraumatic stress disorder (PTSD) have been found. PTSD is associated with functional impairments and decreased health-related quality of life (HRQoL). Previous studies that addressed the latter were restricted to injuries at the higher end of the severity spectrum. This study examined the association between PTSD symptoms and health-related quality of life (HRQoL) in a comprehensive population of injury patients of all severity levels and external causes.Methods: We conducted a self-assessment survey which included items regarding demographics of the patient, accident type, sustained injuries, EuroQol health classification system (EQ-5D) and Health Utilities Index (HUI) to measure functional outcome and HRQoL, and the Impact of Event Scale (IES) to measure PTSD symptoms. An IES-score of 35 or higher was used as indication for the presence of PTSD. The survey was completed by 1,781 injury patients two years after they were treated at the Emergency Department (ED), followed by either hospital admission or direct discharge to the home environment.Results: Symptoms indicative of PTSD were associated with more problems on all EQ-5D and HUI3 domains of functional outcome and a considerable utility loss in both hospitalized (0.23-0.24) and non-hospitalized (0.32-0.33) patients. Differences in reported problems between patients with IES scores higher or lower than 35 were largest for EQ-5D health domains pain/discomfort (82% versus 28%) and anxiety/depression (53% versus 11%) and HUI domains emotion (92% versus 33%) and pain (84% versus 38%). After adjusting for potential confounders, PTSD remained strongly associated with adverse HRQoL.Conclusions: Among patients treated at an ED posttraumatic stress symptoms indicative of PTSD were associated with a considerable decrease in HRQoL in both hospitalized and non-hospitalized patients. PTSD symptoms may therefore raise a major barrier for full recovery of injury patients of even minor levels of severity. http://repub.eur.nl/res/pub/34871/ 2012-01-01T00:00:00Z Background: The impact of trauma on population health is underestimated because comprehensive overviews of the entire severity spectrum of injuries are scarce. The aim of this study was to measure the total health impact of fatal and non-fatal unintentional injury in the Netherlands. Methods: Epidemiological data for the four levels of the injury pyramid (general practitioner (GP) registry, emergency department (ED) registers, hospital discharge and mortality data) were obtained for the whole country. For all levels, the incidence and years of life lost (YLL) owing to premature death, years lived with disability (YLD) and disability-adjusted life-years (DALYs) were calculated. Results: Unintentional injury resulted in 67 547 YLL and 161 775 YLD respectively, amounting to 229 322 DALYs (14·1 per 1000 inhabitants). Home and leisure, and traffic injuries caused most DALYs. Minor injury (GP and ED treatment) contributed 37·3 per cent (85 504 DALYs; 5·2 per 1000) to the total burden of injury, whereas injuries requiring hospital admission contributed 33·3 per cent (76 271 DALYs; 4·7 per 1000) and fatalities contributed 29·5 per cent (67 547 DALYs; 4·1 per 1000). Men aged 15-65 years had the greatest burden of injury, resulting in a share of 39·6 per cent for total DALYs owing to unintentional injury. The highest individual burden resulted from death (19 DALYs per patient). Conclusion: Trauma causes a major burden to society. For priority setting in public health and the identification of opportunities for prevention it is important that burden-of-injury estimates cover the entire spectrum of injuries, ranging from minor injury to death. Copyright http://repub.eur.nl/res/pub/34355/ 2011-10-03T00:00:00Z Background: Public health authorities have recognized lack of hand hygiene in hospitals as one of the important causes of preventable mortality and morbidity at population level. The implementation strategy ACCOMPLISH (Actively Creating COMPLIance Saving Health) targets both individual and environmental determinants of hand hygiene. This study aims to evaluate the cost-effectiveness of a multicomponent implementation strategy aimed at the reduction of healthcare associated infections in Dutch hospital care, by promotion of hand hygiene. Methods/design. The ACCOMPLISH package will be evaluated in a two-arm cluster randomised trial in 16 hospitals in the Netherlands, in one intensive care unit and one surgical ward per hospital. Intervention. A multicomponent package, including e-learning, team training, introduction of electronic alcohol based hand rub dispensers and performance feedback. Variables. The primary outcome measure will be the observed hand hygiene compliance rate, measured at baseline and after 6, 12 and 18 months; as a secondary outcome measure the prevalence of healthcare associated infections will be measured at the same time points. Process indicators of the intervention will be collected pre and post intervention. An ex-post economic evaluation of the ACCOMPLISH package from a healthcare perspective will be performed. Statistical analysis. Multilevel analysis, using mixed linear modelling techniques will be conducted to assess the effect of the intervention strategy on the overall compliance rate among healthcare workers and on prevalence of healthcare associated infections. Questionnaires on process indicators will be analysed with multivariable linear regression, and will include both behavioural determinants and determinants of innovation. Cost-effectiveness will be assessed by calculating the incremental cost-effectiveness ratio, defined here as the costs for the intervention divided by the difference in prevalence of healthcare associated infections between the intervention and control group. Discussion. This study is the first RCT to investigate the effects of a hand hygiene intervention programme on the number of healthcare associated infections, and the first to investigate the cost-effectiveness of such an intervention. In addition, if the ACCOMPLISH package proves successful in improving hand hygiene compliance and lowering the prevalence of healthcare associated infections, the package could be disseminated at (inter)national level. Trial registration. NTR2448. http://repub.eur.nl/res/pub/33274/ 2011-10-01T00:00:00Z Background: General information of health-related quality of life pathways to recovery after injury are largely absent from the literature. This article describes a study which: (1) collated and synthesized individual patient data of injured persons from an earlier systematic review and (2) produced general predictions of health-related quality of life for different injury groups for up to 1 year postinjury. Methods: A systematic search of literature from January 1990 to December 2008 was completed. Researchers were approached to share their anonymous individual level data. Injuries were grouped into 39 categories based on the Eurocost injury classifications. Multilevel mixed effects models were used to produce predictions across both the five dimensions and the visual analog scale of the EQ-5D measure at 3 days, 30 days, 120 days, and 360 days postinjury. Results: Individual patient data from 10,496 injured persons (76% of known data worldwide) was retrieved. Predictions were fitted to 27 of the 39 injury categories covering a wide spectrum of injury types. Across most injuries, pain, or discomfort, usual activities and mobility were the most commonly impaired dimensions. Recovery for pain or discomfort was generally more gradual than other health dimensions. For many injury categories, a considerable proportion of people reported residual impairment at 360 days. Regardless of the anatomic location of injury, similar patterns of recovery or persistent impairment were seen for fractures and strains/sprains. Recovery patterns differed and took much longer than estimated in the Global Burden of Disease Study. Conclusions: This study has produced recovery patterns for 27 injury groups using most of the worldwide individual-level data. For many injury categories, recovery is incomplete and takes much longer than estimated. This study infers that the burden of injury is likely being underestimated. Copyright http://repub.eur.nl/res/pub/30927/ 2011-09-01T00:00:00Z BACKGROUND:: Fall incidents are a major cause of morbidity and mortality in older adults. The aim of this cohort study was to determine the incidence, costs, and quality of life for fall-related injuries in the older Dutch population presenting at the emergency department. METHODS:: Data on fall-related injuries in persons aged 65 years or older were retrieved from the Dutch Injury Surveillance System, which records injuries treated at the emergency department, and a patient follow-up survey conducted between 2003 and 2007. Injury incidence, discharge rates, healthcare costs, and quality of life measures were calculated. RESULTS:: Fall-related injuries were to the upper or lower limb in 70% of cases and consisted mainly of fractures (60%), superficial injuries (21%), and open wounds (8%). Falls led to a total healthcare cost of €474.4 million, which represents 21% of total healthcare expenses due to injuries. Both admitted and nonadmitted patients reported a reduced quality of life up to 9 months after the injury. CONCLUSIONS:: Fall-related injuries in older adults are age and gender related, leading to high healthcare consumption, costs, and long-term reduced quality of life. Further implementation of falls prevention strategies is needed to control the burden of fall-related injuries in the aging population. http://repub.eur.nl/res/pub/31218/ 2011-09-01T00:00:00Z The aim of our study was to assess prevalence and correlates related to sub optimal outcome after pediatric burns and to make a comparison with pediatric injuries not related to burns. We conducted a cross-sectional study on quality of life (QOL) after burns in a sample (n = 138; median 24 months post-burn) of Dutch and Flemish children (5-15 years) with an admission to a burn center. QOL was assessed with the Burn Outcomes Questionnaire (BOQ). The generic EuroQol-5D was used to allow for a comparison with children after injuries not related to burns. More than half of the children had long-term limitations. According to the BOQ, children frequently (>50%) experienced sub optimal functioning on 5 out of 12 dimensions, concerning 'appearance', 'parental concern', 'itch', 'emotional health' and 'satisfaction with current state'. Children with a high total burned surface area (TBSA ≥10%) showed significantly more sub optimal functioning on 'upper extremity function' (OR = 5.3; ≥20% TBSA), 'appearance' (OR = 5.5; ≥10-20% TBSA), 'satisfaction with current state' (OR = 3.4; ≥10-20% TBSA) and 'parental concern' (OR = 3.4; ≥10-20% TBSA), compared to children with less than 10% TBSA. Burn victims at 9 months post-injury appeared to be worse off at several health dimensions. After 24 months generic quality of life of in pediatric burns was more comparable to pediatric injuries not related to burns. Children after burns experience substantial problems, mainly on itch and appearance and several psychosocial dimensions. More extensive burns are related to sub optimal functioning. These problems are in part specific for burns and not picked up by generic measures. http://repub.eur.nl/res/pub/30917/ 2011-08-23T00:00:00Z Background: Fall incidents represent an increasing public health problem in aging societies worldwide. A major risk factor for falls is the use of fall-risk increasing drugs. The primary aim of the study is to compare the effect of a structured medication assessment including the withdrawal of fall-risk increasing drugs on the number of new falls versus 'care as usual' in older adults presenting at the Emergency Department after a fall. Methods/Design. A prospective, multi-center, randomized controlled trial will be conducted in hospitals in the Netherlands. Persons aged 65 years who visit the Emergency Department due to a fall are invited to participate in this trial. All patients receive a full geriatric assessment at the research outpatient clinic. Patients are randomized between a structured medication assessment including withdrawal of fall-risk increasing drugs and 'care as usual'. A 3-monthly falls calendar is used for assessing the number of falls, fallers and associated injuries over a one-year follow-up period. Measurements will be at three, six, nine, and twelve months and include functional outcome, healthcare consumption, socio-demographic characteristics, and clinical information. After twelve months a second visit to the research outpatient clinic will be performed, and adherence to the new medication regimen in the intervention group will be measured. The primary outcome will be the incidence of new falls. Secondary outcome measurements are possible health effects of medication withdrawal, health-related quality of life (Short Form-12 and EuroQol-5D), costs, and cost-effectiveness of the intervention. Data will be analyzed using an intention-to-treat analysis. Discussion. The successful completion of this trial will provide evidence on the effectiveness of withdrawal of fall-risk increasing drugs in older patients as a method for falls reduction. Trial Registration. The trial is registered in the Netherlands Trial Register (NTR1593). http://repub.eur.nl/res/pub/34579/ 2011-08-01T00:00:00Z Background: Free flap breast reconstruction (BR) is generally believed to be more expensive than implant BR, but costs were previously shown to level out over time due to complications and re-operations. The aim of this study was to assess the economic implications of four BR techniques: silicone prosthesis (SP), implant preceded by tissue expansion (TE/SP), latissimus dorsi transposition with or without implant (LD ± SP) and deep inferior epigastric perforator (DIEP) flap. Methods: A prospective historic cohort study was performed to evaluate intramural medical costs in 427 patients, who had undergone BR between 2002 and 2009. Short- and medium-term complications were incorporated. In addition, 58 patients, who had recently undergone BR, participated in a questionnaire study to prospectively evaluate extramural medical and non-medical costs. Estimates of mean short- and medium-term costs are presented per patient. Results: Intramural medical costs for BR and short-term complications for unilateral DIEP flaps (12,848) and TE/SP reconstructions (12,400) were significantly higher than those for LD ± SP reconstructions (5804), which, in turn, were more expensive than SP reconstructions (4731). In bilateral cases, costs of TE/SP (12,723) and LD ± SP (10,760) reconstructions were comparable, while DIEP flaps (15,747) were significantly more expensive and SP reconstructions were significantly cheaper (6784). Overall, the medium-term costs for complications and additional operations were not significantly different (3017-4503). Extramural medical costs and non-medical costs were approximately 9300 per stage, regardless of technique. Conclusions: Differences in short-term costs between techniques did not level out during follow-up and SP reconstructions remained least expensive. Single-stage SP reconstructions, however, are not suitable for all patients due to high complication rates. Definite implant placement is therefore increasingly preceded by tissue expansion at more comparable costs to autologous BR. Incorporation of non-medical costs into the cost analysis would render two-stage procedures more costly than autologous BR. To achieve the optimal result, careful patient selection is critical. Only in select cases where two options are equally applicable, cost comparison becomes a valid argument for treatment selection. http://repub.eur.nl/res/pub/25650/ 2011-07-01T00:00:00Z BACKGROUND: The objective was to determine secular trends in unintentional fall-related hospitalizations in people aged 65 years and older in the United States. MATERIALS: Data were obtained from a nationally representative sample of emergency department visits from January 1, 2001, to December 31, 2008, available through the National Electronic Injury Surveillance System-All Injury Program. These data were weighted to estimate the number, incidence rates, and the annual percent change of fall-related hospitalizations. RESULTS: From 2001 to 2008, the estimated number of fall-related hospitalizations in older adults increased 50%, from 373,128 to 559,355 cases. During the same time period, the age-adjusted incidence rate, expressed per 100,000 population, increased from 1,046 to 1,368. Rates were higher in women compared with men throughout the study period. The age-adjusted incidence rate showed an average annual increase of 3.3% (95% CI, 1.66-4.95). DISCUSSION: Both the number and rate of fall-related hospitalizations in the United States increased significantly over the 8-year study period. Unless preventive action is taken, rising hospitalization rates in combination with the aging US population over the next decades will exacerbate the already stressed healthcare system and may result in poorer health outcomes for older adults in the future. Further research is needed to determine the underlying causes for this rising trend. Copyright http://repub.eur.nl/res/pub/25565/ 2011-05-01T00:00:00Z Falls occur frequently in older adults. With ageing populations worldwide, an increase in fall-related traumatic head injuries can be expected. The aim of our study was to determine trends in traumatic head-injury-related hospitalizations among older adults. Therefore, a secular trend analysis of fall-related traumatic head injuries in the older Dutch population between 1986 and 2008 was performed, using the National Hospital Discharge Registry. All significant fall-related traumatic head injury hospitalizations in persons aged ≥65 years were extracted from this database. During the study period, traumatic head-injury-related hospitalizations increased by 213% to 3,010 in 2008. The incidence rate increased annually by 1.2% (95% CI: 0.6; 1.9) between 1986 and 2000. Since 2001, the increase has accelerated up to 11.6% (95% CI: 9.5; 13.8) per year. Overall, the age-adjusted incidence rate increased from 53.1 in 1986 to 119.1 per 100,000 older persons in 2008. Age-specific incidence rates increased in all age groups, especially in persons aged ≥85 years. Despite an overall reduction in the length of hospital stay per admission, the total number of hospital-bed-days increased with 31.5% to 20,250 between 1991 and 2008. In conclusion, numbers and incidence rates of significant traumatic head-injury-related hospitalization after a fall are increasing rapidly in the older Dutch population, especially in the oldest old, resulting in an increased health care demand. The recent increase might be explained by the ageing population, but also other factors may have contributed to the increase, such as an increased awareness of traumatic head injuries, the implementation of renewed guidelines for traumatic head injuries, and improved radiographic tools. http://repub.eur.nl/res/pub/26446/ 2011-04-24T00:00:00Z Background: Three approaches exist to deal with the impact of comorbidity in burden of disease studies - the maximum limit approach, the additive approach, and the multiplicative approach. The aim of this study was to compare the three comorbidity approaches in patients with temporary injury consequences as well as comorbid chronic conditions with nontrivial health impacts.Methods: Disability weights were assessed using data from the EQ-5D instrument developed by the EuroQol Group and derived from a postal survey among 2,295 injury patients at 2.5 and 9 months after being treated at an emergency department. We compared the observed and predicted EQ-5D disability weights in comorbid cases using data from injury patients with and without comorbidity who were restored from their injuries at 9 months follow-up. The predicted disability weights were calculated using the maximum limit approach, additive approach, and multiplicative approach. The intraclass correlation coefficient (ICC) was used to test whether the values of the observed disability weights and the three model-predicted disability weights were correlated.Results: The EQ-5D disability weight of injury patients increased significantly with the number of comorbid diseases. The ICCs of the additive, multiplicative, and maximum limit models were 0.817, 0.778, and 0.674, respectively. Although the 95% confidence intervals of the ICCs of the three models overlap, the maximum limit model seems to fit less well than the additive and multiplicative models. For mild to moderate chronic disease (disability weight below 0.21), the association between predicted and observed disability weights was low.Conclusions: Comorbidity has a high impact on disability measured with EQ-5D. Ignoring the effect of comorbidity restricts the use of the burden of disease concept in multimorbid populations. Gains from health care or interventions may be easily overestimated if a substantial number of patients suffer from additional conditions. The results of this study found that in accounting for comorbidity effects, all three models showed a strong association between the predicted and observed morbid disability weight, though the maximum limit model seems to fit less well than the additive and multiplicative models. The three models do not fit well in the case of mild to moderate pre-existing disease. http://repub.eur.nl/res/pub/25638/ 2011-04-01T00:00:00Z Background: The primary aim of this study was to assess the health-related quality of life of survivors of severe trauma 1 year after injury, specified according to all the separate dimensions of the EuroQol-5D (EQ-5D) and the Health Utilities Index (HUI). Methods: A prospective cohort study was conducted in which all severely injured trauma patients presented at a Level I trauma center were included. After 12 months, the EQ-5D, HUI2 and HUI3 were used to analyze the health status. Results: Follow-up assessments were obtained from 246 patients (response rate, 68%). The overall population EQ-5D (median) utility score was 0.73 (EQ-5D Dutch general population norm, 0.88). HUI2, HUI3, and EQ-5D Visual Analog Scale scores were 0.81, 0.65, and 70, respectively. Eighteen percent had at least one functional limitation 1 year after trauma, and 60% reported functional limitations on two or more domains using the EQ-5D. The female gender and comorbidity were significant independent predictors of disability. Conclusion: Functional outcome and quality of life of survivors of severe injury have not returned to normal 1 year after trauma. The prevalence of specific limitations in this population is very high (40-70%). Female gender and comorbidity are predictors of long-term disability. Copyright http://repub.eur.nl/res/pub/25566/ 2011-01-01T00:00:00Z OBJECTIVE: To assess the health-related quality of life and prognostic factors of disability in survivors of severe trauma one year after injury. DESIGN:Prospective cohort study. METHOD: All severely-injured trauma patients presenting at a level I trauma centre during a 30-month period and surviving 30 days after admission were included. The EuroQol-5D (EQ-5D) and Health Utilities Index (HUI) were used to determine the health status 12 months after injury. RESULTS: 362 patients were included during the study period, 246 of whom returned the follow-up assessments (response rate: 68%). The median EQ-5D utility score was 0.73 (EQ-5D Dutch general population norm: 0.88). The HUI2, HUI3 and EQ-5D Visual Analogue Scale scores were 0.81, 0.65 and 70, respectively. One year after trauma only 22% of the patients reported no functional limitation in the 5 domains of the EQ-D5. Females and patients with co-morbidity at the time of the injury had a higher risk of low scores after 1 year. CONCLUSION: One year after severe injury, the functional outcome and quality of life of trauma patients were far from normalized. Female gender and comorbidity were predictors of poorer functional outcome. http://repub.eur.nl/res/pub/28431/ 2010-12-27T00:00:00Z Background. It is important to obtain greater insight into health-related quality of life (HRQL) of injury patients in order to document people's pathways to recovery and to quantify the impact of injury on population health over time. We performed a systematic review of studies measuring HRQL in general injury populations with a generic health state measure to summarize existing knowledge. Methods. Injury studies (1995-2009) were identified with main inclusion criteria being the use of a generic health status measure and not being restricted to one specific type of injury. Articles were collated by study design, HRQL instrument used, timing of assessment(s), predictive variables and ability to detect change over time. Results. Forty one studies met inclusion criteria, using 24 different generic HRQL and functional status measures (most used were SF-36, FIM, GOS, EQ-5D). The majority of the studies used a longitudinal design, but with different lengths and timings of follow-up (mostly 6, 12, and 24 months). Different generic health measures were able to discriminate between the health status of subgroups and picked up changes in health status between discharge and 12 month follow-up. Most studies reported high prevalences of health problems within the first year after injury. The twelve studies that reported HRQL utility scores showed considerable but incomplete recovery in the first year after discharge. Conclusion. This systematic review demonstrates large variation in use of HRQL instruments, study populations, and assessment time points used in studies measuring HRQL of general injury populations. This variability impedes comparison of HRQL summary scores between studies and prevented formal meta-analyses aiming to quantify and improve precision of the impact of injury on population health over time. http://repub.eur.nl/res/pub/25677/ 2010-11-16T00:00:00Z Background. Elbow dislocations can be classified as simple or complex. Simple dislocations are characterized by the absence of fractures, while complex dislocations are associated with fractures. After reduction of a simple dislocation, treatment options include immobilization in a static plaster for different periods of time or so-called functional treatment. Functional treatment is characterized by early active motion within the limits of pain with or without the use of a sling or hinged brace. Theoretically, functional treatment should prevent stiffness without introducing increased joint instability. The primary aim of this randomized controlled trial is to compare early functional treatment versus plaster immobilization following simple dislocations of the elbow. Methods/Design. The design of the study will be a multicenter randomized controlled trial of 100 patients who have sustained a simple elbow dislocation. After reduction of the dislocation, patients are randomized between a pressure bandage for 5-7 days and early functional treatment or a plaster in 90 degrees flexion, neutral position for pro-supination for a period of three weeks. In the functional group, treatment is started with early active motion within the limits of pain. Function, pain, and radiographic recovery will be evaluated at regular intervals over the subsequent 12 months. The primary outcome measure is the Quick Disabilities of the Arm, Shoulder, and Hand score. The secondary outcome measures are the Mayo Elbow Performance Index, Oxford elbow score, pain level at both sides, range of motion of the elbow joint at both sides, rate of secondary interventions and complication rates in both groups (secondary dislocation, instability, relaxation), health-related quality of life (Short-Form 36 and EuroQol-5D), radiographic appearance of the elbow joint (degenerative changes and heterotopic ossifications), costs, and cost-effectiveness. Discussion. The successful completion of this trial will provide evidence on the effectiveness of a functional treatment for the management of simple elbow dislocations. Trial Registration. The trial is registered at the Netherlands Trial Register (NTR2025). http://repub.eur.nl/res/pub/24003/ 2010-11-01T00:00:00Z Background: With 249,007 new leprosy patients detected globally in 2008, it remains necessary to develop new and effective interventions to interrupt the transmission of M. leprae. We assessed the economic benefits of single dose rifampicin (SDR) for contacts as chemoprophylactic intervention in the control of leprosy. Methods: We conducted a single centre, double blind, cluster randomised, placebo controlled trial in northwest t Bangladeshbetween 2002 and 2007, including 21,711 close contacts of 1,037 patients with newly diagnosed leprosy. We gave a single dose of rifampicin or placebo to close contacts, with follow-up for four years. The main outcome measure was the development of clinical leprosy. We assessed the cost effectiveness by calculating the incremental cost effectiveness ratio (ICER) between the standard multidrug therapy (MDT) program with the additional chemoprophylaxis intervention versus the standard MDT program only. The ICER was expressed in US dollars per prevented leprosy case. Findings: Chemoprophylaxis with SDR for preventing leprosy among contacts of leprosy patients is cost-effective at all contact levels and thereby a cost-effective prevention strategy. In total, $6,009 incremental cost was invested and 38 incremental leprosy cases were prevented, resulting in an ICER of $158 per one additional prevented leprosy case. It was the most cost-effective in neighbours of neighbours and social contacts (ICER $214), slightly less cost-effective in next door neighbours (ICER $497) and least cost-effective among household contacts (ICER $856). Conclusion: Chemoprophylaxis with single dose rifampicin given to contacts of newly diagnosed leprosy patients is a costeffective intervention strategy. Implementation studies are necessary to establish whether this intervention is acceptable and feasible in other leprosy endemic areas of the world. http://repub.eur.nl/res/pub/25671/ 2010-05-27T00:00:00Z Background. Fractures of the proximal humerus are associated with a profound temporary and sometimes permanent, impairment of function and quality of life. The treatment of comminuted fractures of the proximal humerus like selected three-or four-part fractures and split fractures of the humeral head is a demanding and unresolved problem, especially in the elderly. Locking plates appear to offer improved fixation; however, screw cut-out rates ranges due to fracture collapse are high. As this may lead to higher rates of revision surgery, it may be preferable to treat comminuted fractures in the elderly primarily with a prosthesis or non-operatively. Results from case series and a small-sample randomized controlled trial (RCT) suggest improved function and less pain after primary hemiarthroplasty (HA); however these studies had some limitations and a RCT is needed. The primary aim of this study is to compare the Constant scores (reflecting functional outcome and pain) at one year after primary HA versus non-operative treatment in elderly patients who sustained a comminuted proximal humeral fracture. Secondary aims include effects on functional outcome, pain, complications, quality of life, and cost-effectiveness. Methods/Design. A prospective, multi-center RCT will be conducted in nine centers in the Netherlands and Belgium. Eighty patients over 65 years of age, who have sustained a three-or four part, or split head proximal humeral fracture will be randomized between primary hemiarthroplasty and conservative treatment. The primary outcome is the Constant score, which indicates pain and function. Secondary outcomes include the Disability of the Arm and Shoulder (DASH) score, Visual Analogue Scale (VAS) for pain, radiographic healing, health-related quality of life (Short-form-36, EuroQol-5D) and healthcare consumption. Cost-effectiveness ratios will be determined for both trial arms. Outcome will be monitored at regular intervals over the subsequent 24 months (1, 3 and 6 weeks, and 3, 6, 12, 18, and 24 months). Data will be analyzed on an intention to treat basis, using univariate and multivariable analyses. Discussion. This trial will provide level-1 evidence on the effectiveness of the two mostly applied treatment options for three-or four part and split head proximal humeral fractures in the elderly. These data may support the development of a clinical guideline for treatment of these traumatic injuries. Trial registration. Netherlands Trial Register (NTR2040). http://repub.eur.nl/res/pub/28153/ 2010-05-01T00:00:00Z Background: Gastrojejunostomy (GJJ) and stent placement are the most commonly used palliative treatments for malignant gastric outlet obstruction (GOO). In a recent randomized trial, stent placement was preferred in patients with a relatively short survival and GJJ in patients with a longer survival. As health economic aspects have only been studied in general terms, we estimated the cost of GJJ and that of stent placement in such patients. Methods: In the SUSTENT study, patients were randomized to GJJ (n = 18) or stent placement (n = 21). Pancreatic cancer was the most common cause of GOO. We compared initial costs and costs during follow-up. For cost-effectiveness, the incremental cost-effectiveness ratio was calculated. Results: Food intake improved more rapidly after stent placement than after GJJ, but long-term relief of obstructive symptoms was better after GJJ. More major complications (P = 0.02) occurred and more reinterventions were performed (P < 0.01) after stent placement than after GJJ. Initial costs were higher for GJJ compared to stent placement (€8315 vs. €4820, P < 0.001). We found no difference in follow-up costs. Total costs per patient were higher for GJJ compared to stent placement (€12433 vs. €8819, P = 0.049). The incremental cost-effectiveness ratio of GJJ compared to stent placement was €164 per extra day with a gastric outlet obstruction scoring system (GOOSS) ≥2 adjusted for survival. Conclusions: Medical effects were better after GJJ, although GJJ had higher total costs. Since the cost difference between the two treatments was only small, cost should not play a predominant role when deciding on the type of treatment assigned to patients with malignant GOO (ISRCTN 06702358). http://repub.eur.nl/res/pub/18676/ 2010-03-01T00:00:00Z The objective of this study was to assess whether the emergency department (ED) injury surveillance systems in Europe are suitable for cross-country comparisons. For this, the ED injury surveillance systems in Austria, Denmark, Greece, Ireland, the Netherlands, Norway and the UK (England, Wales) were considered. Standardised injury incidence and healthcare utilisation indices were calculated and the influence of measurement bias due to data collection and sampling differences, as well as trauma policy and health systems characteristics were assessed. The results showed that there was an over 3-fold variation of the grossly estimated incidence for home and leisure injuries (HLIs), with the highest values observed in England and Greece (111 and 104 per 1000 person years), and the lowest in Ireland and the Netherlands (27 and 48 per 1000 person years). The ranking of countries changed, however, when only injuries with an inherent need for ED treatment were considered (selected radiological verifiable fractures) with Austria topping the table followed by Greece and England. Thus, it is concluded that the naive use of ED injury surveillance systems for cross-country comparisons should be discouraged, as this is subject to measurement bias. Nevertheless, the observed variation in the healthcare utilisation and injury incidence, particularly among children and older people, indicates the potential to reduce the burden of HLI in Europe. http://repub.eur.nl/res/pub/23999/ 2010-01-01T00:00:00Z Injury is the major cause of death and suffering among children and adolescents, but awareness of the problem and political commitment for preventive actions remain unacceptably low. We have assessed variation in the burden of injuries in childhood and adolescence in eight European countries. Hospital, emergency department, and mortality databases of injury patients aged 0-24 years were analyzed for Austria, Denmark, Ireland, Latvia, Netherlands, Norway, Slovenia and the United Kingdom (England, Wales). Years lost due to premature mortality (YLL), years lived with disability (YLD), and disability adjusted life years (DALYs) were calculated. Differences in the burden of injury in childhood and adolescence are large, with a fourfold gap between the safest countries (Netherlands and UK) in western-Europe and the relatively unsafe countries (Latvia and Slovenia) in the east. Variation between countries is attributable to high variation in premature mortality (YLL varied from 14-58 per 1000 persons) and disability (YLD varied from 3-10 per 1000 persons). Highest burden is observed among males ages 15-24. If childhood and adolescence injuries are reduced to the level of current best injury prevention practices, 6 DALYs per 1000 child years can be avoided. Injuries in childhood and adolescence cause a high disability and mortality burden in Europe. In all developmental stages large inequalities between west and east are observed. Potential benefits up to almost 1 million healthy child years gained across Europe are possible, if proven ways for prevention are more widely implemented. Our children deserve action now. http://repub.eur.nl/res/pub/24074/ 2009-11-01T00:00:00Z Background: The long-term health outcomes and costs of helicopter emergency medical services (HEMS) assistance remain uncertain. The aim of this study was to investigate the cost-effectiveness of HEMS assistance compared with emergency medical services (EMS). Methods: A prospective cohort study was performed at a level I trauma centre. Quality-of-life measurements were obtained at 2 years after trauma, using the EuroQol - Five Dimensions (EQ-5D) as generic measure to determine health status. Health outcomes and costs were combined into costs per quality-adjusted life year (QALY). Results: The study population receiving HEMS assistance was more severely injured than that receiving EMS assistance only. Over the 4-year study interval, HEMS assistance saved a total of 29 additional lives. No statistically significant differences in quality of life were found between assistance with HEMS or with EMS. Two years after trauma the mean EQ-5D utility score was 0.70 versus 0.71 respectively. The incremental cost-effectiveness ratio for HEMS versus EMS was €28 327 per QALY. The sensitivity analysis showed a cost-effectiveness ratio between €16 000 and €62 000. Conclusion: In the Netherlands, the costs of HEMS assistance per QALY remain below the acceptance threshold. HEMS should therefore be considered as cost effective. Copyright http://repub.eur.nl/res/pub/16352/ 2009-07-31T00:00:00Z BACKGROUND: In burden of disease studies, several approaches are used to assess disability weights, a scaling factor necessary to compute years lived with disability (YLD). The aim of this study was to quantify disability weights for injury consequences with two competing approaches, (a) standard QALY/DALY model (SQM) which derives disability weights from patient survey data and (b) the annual profile model (APM) which derives weights for the same patient data valued by a panel. METHODS: Disability weights were assessed using (a) EQ-5D data from a postal survey among 8,564 injury patients 2(1/2), 5, and 9 months after attending the Emergency Department, and (b) preferences of 143 laymen elicited with the time trade-off method. RESULTS: Compared with APM, SQM disability weights were consistently higher. YLD calculated with SQM disability weights was more than three times higher compared with YLD calculated with APM disability weights, for mild injuries with short duration, this increase was six fold. CONCLUSIONS: The APM seems the preferred method in burden of injury studies that includes mild conditions with a rapid course, since the SQM approach might overestimate the impact of the latter. The APM, however, might underestimate the impact of injury consequences, especially in case of severe injuries. http://repub.eur.nl/res/pub/16356/ 2009-07-31T00:00:00Z Background and aim Costs of follow-up strategies in patients after surgery for oesophageal cancer have not been evaluated. We therefore randomised 109 patients to standard outpatient clinic follow-up by a surgeon (n = 55) or home visits by a specialist nurse (n = 54) and compared costs between these two strategies. Method Cost comparisons included comprehensive data on hospital costs, diagnostic interventions and extramural care. Detailed information on health care consumption was obtained from a case record form at 6 weeks, and 3, 6, 9 and 12 months after randomisation. Results Total medical costs were lower for nurse-led follow-up (€2592 versus €3798) than standard follow-up, although this difference was not statistically significant (p = 0.11). This advantage in the nurse-led follow-up group was mainly due to lower costs for follow-up visits (€234 versus €503; p < 0.001), and a trend towards lower costs for total intramural care (€1477 versus €2277; p = 0.19). Conclusion Nurse-led follow-up of patients after oesophageal cancer surgery is likely to be cost effective and may even generate cost savings. The results of this study further support a specific role of nurses in the medical care of patients with malignant diseases. http://repub.eur.nl/res/pub/25075/ 2009-01-13T00:00:00Z Between January 2004 and February 2006, 109 patients after intentionally curative surgery for oesophageal or gastric cardia cancer were randomised to standard follow-up of surgeons at the outpatient clinic (standard follow-up; n=55) or by regular home visits of a specialist nurse (nurse-led follow-up; n=54). Longitudinal data on generic (EuroQuol-5D, European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30) and disease-specific quality of life (EORTC QLQ-OES18), patient satisfaction and costs were collected at baseline and at 6 weeks and 4, 7 and 13 months afterwards. We found largely similar quality-of-life scores in the two follow-up groups over time. At 4 and 7 months, slightly more improvement on the EQ-VAS was noted in the nurse-led compared with the standard follow-up group (P=0.13 and 0.12, respectively). Small differences were also found in patient satisfaction between the two groups (P=0.14), with spouses being more satisfied with nurse-led follow-up (P=0.03). No differences were found in most medical outcomes. However, body weight of patients of the standard follow-up group deteriorated slightly (P=0.04), whereas body weight of patients of the nurse-led follow-up group remained stable. Medical costs were lower in the nurse-led follow-up group (\[euro]2600 vs \[euro]3800), however, due to the large variation between patients, this was not statistically significant (P=0.11). A cost effectiveness acceptability curve showed that the probability of being cost effective for costs per one point gain in general quality-of-life exceeded 90 and 75% after 4 and 13 months of follow-up, respectively. Nurse-led follow-up at home does not adversely affect quality of life or satisfaction of patients compared with standard follow-up by clinicians at the outpatient clinic. This type of care is very likely to be more cost effective than physician-led follow-up. http://repub.eur.nl/res/pub/30129/ 2008-12-15T00:00:00Z Background. Invasive aspergillosis (IA) is a leading cause of mortality in patients with acute leukemia. Management of IA is expensive, which makes prevention desirable. Because hospital resources are limited, prevention costs have to be compared with treatment costs and outcome. Methods. In 269 patients treated for acute myelogenous leukemia-myelodysplastic syndrome (AML-MDS) during 2002-2007, evidence of IA was collected using high-resolution computed tomography and galactomannan measurement in bronchoalveolar lavage fluid specimens. IA was classified on the basis of updated European Organization for Research and Treatment of Cancer/Mycoses Study Group definitions. Outcome of infection was registered. Diagnostic and therapeutic IA-related costs, corrected for neutropenia duration, were comprehensively analyzed from a hospital perspective. Voriconazole treatment was given orally from day 1 if possible. Results. A total of 80 patients developed IA; 48 (18%) had probable or proven infection, and 32 (12%) had possible IA. Seventy-three patients were treated with voriconazole; 55 (75%) took oral voriconazole from day 1. In patients with IA, the mortality rate 12 weeks after starting antifungal therapy was 22% (16 of 73 patients). The overall mortality rate, registered 12 weeks after neutrophil recovery from the last dose of antileukemic treatment, was 26% in patients with IA versus 16% in patients without IA (P = .08), reflecting an IA-attributable mortality rate of 10%. In a Cox regression analysis, IA was associated with an increased mortality risk (hazard ratio, 2.4; 95% confidence interval, 1.3-4.4). Total IA-related costs increased to €8360 and €15,280 for patients with possible and probable or proven IA, respectively, compared with patients without IA (P < .001). Conclusions. Early diagnosis and treatment of IA with oral voriconazole result in acceptable mortality rates. Nevertheless, IA continues to have substantial attributable mortality combined with a major impact on hospital resource use, so effective prevention in high-incidence populations has the potential to save lives and costs. http://repub.eur.nl/res/pub/28890/ 2008-07-09T00:00:00Z Objective. To assess the accuracy of a new ingestion protocol for capsule endoscopy (CE) in evaluating patients with gastro-oesophageal reflux disease (GORD). Methods. Oesophago-gastroduodenoscopy (OGD) was performed 1 week prior to CE. The first 28 subjects swallowed the capsule following the original ingestion protocol (OIP) and the subsequent 30 subjects following a simplified ingestion protocol (SIP). CE videos were reviewed by two independent investigators who were blinded to the OGD findings. Results. Of 48 patients included, 24 were diagnosed with reflux oesophagitis (67% male, mean age 49.5±13 years) and 24 with Barrett oesophagus (BO) (88% male, 55.6±10 years) by OGD. In addition, 10 asymptomatic healthy controls (50% male, 45.8±7.1 years) were included. Oesophageal transit time was faster in patients using the SIP compared to the OIP (126±26 s versus 214±33; p=0.04). Complete evaluation of the Z-line was possible in 19/28 (68%) of the OIPs compared to 28/30 (93%) of the SIPs (p=0.04). Sensitivity for detecting any oesophageal abnormality was higher in the SIP group than in the OIP group (97% versus 89%; p=0.11). Overall, CE detected oesophagitis in 22/24 patients (sensitivity, 92%; specificity, 88%) and BO in 23/24 patients (sensitivity, 96%; specificity, 91%). Furthermore, 41/44 (93%) preferred CE over OGD and experienced less discomfort and pain during CE. Conclusion. CE is an accurate method for detecting mucosal oesophageal abnormalities. The new ingestion protocol improves the visualization of the Z-line, which is likely to increase the diagnostic yield of CE. http://repub.eur.nl/res/pub/29465/ 2008-02-01T00:00:00Z BACKGROUND: Conventional ovarian stimulation and the transfer of two embryos in IVF exhibits an inherent high probability of multiple pregnancies, resulting in high costs. We evaluated the cost-effectiveness of a mild compared with a conventional strategy for IVF. METHODS: Four hundred and four patients were randomly assigned to undergo either mild ovarian stimulation/GnRH antagonist co-treatment combined with single embryo transfer, or standard stimulation/GnRH agonist long protocol and the transfer of two embryos. The main outcome measures are total costs of treatment within a 12 months period after randomization, and the relationship between total costs and proportion of cumulative pregnancies resulting in term live birth within 1 year of randomization. RESULTS: Despite a significantly increased average number of IVF cycles (2.3 versus 1.7; P < 0.001), lower average total costs over a 12-month period (8333 versus €10 745; P = 0.006) were observed using the mild strategy. This was mainly due to higher costs of the obstetric and post-natal period for the standard strategy, related to multiple pregnancies. The costs per pregnancy leading to term live birth were €19 156 in the mild strategy and €24 038 in the standard. The incremental cost-effectiveness ratio of the standard strategy compared with the mild strategy was €185 000 per extra pregnancy leading to term live birth. CONCLUSIONS: Despite an increased mean number of IVF cycles within 1 year, from an economic perspective, the mild treatment strategy is more advantageous per term live birth. It is unlikely, over a wide range of society's willingness-to-pay, that the standard treatment strategy is cost-effective, compared with the mild strategy. http://repub.eur.nl/res/pub/28927/ 2008-01-01T00:00:00Z Objective: To analyse international variation in clinical injury incidence, and explore the performance of different injury indicators in cross-country comparisons. Methods: Hospital discharge data of seven European countries (Austria, Denmark, Ireland, Netherlands, Norway, England and Wales) were analysed. We tested existing and newly developed indicators based on (a) health care use, (b) anatomical criteria, or (c) expected health outcome: admissions excluding day-cases (a), hospital stay 4+ (a) and 7+ days (a), (serious) long-bone fractures (b), selected radiological verifiable fractures 'SRVFs' (b), and indicators based on international (Global Burden of Disease) and Dutch disability weights). Assessment criteria were reduction in incidence variation and length of stay in hospital, and the association between incidence and mortality rates. Results: Indicators based on health care use led to increased variation in incidence rates. Long bone fractures and SRVFs, and both indicators based on injuries with moderate to high disability showed similar variation in clinical incidence compared to the crude rates, smaller variation in median length of stay in hospital and a good association with mortality rates. Conclusion: No perfect or near perfect indicators of clinical injury incidence exist. For international comparisons, indicators based on disability weights, SRVFs and long bone fractures may be sensible indicators to use, in the absence of a direct measure of anatomical severity. http://repub.eur.nl/res/pub/35834/ 2007-03-03T00:00:00Z Background: Mild in-vitro fertilisation (IVF) treatment might lessen both patients' discomfort and multiple births, with their associated risks. We aimed to test the hypothesis that mild IVF treatment can achieve the same chance of a pregnancy resulting in term livebirth within 1 year compared with standard treatment, and can also reduce patients' discomfort, multiple pregnancies, and costs. Methods: We did a randomised, non-inferiority effectiveness trial. 404 patients were randomly assigned to undergo either mild treatment (mild ovarian stimulation with gonadotropin-releasing hormone [GnRH] antagonist co-treatment combined with single embryo transfer) or a standard treatment (stimulation with a GnRH agonist long-protocol and transfer of two embryos). Primary endpoints were proportion of cumulative pregnancies leading to term livebirth within 1 year after randomisation (with a non-inferiority threshold of -12·5%), total costs per couple up to 6 weeks after expected date of delivery, and overall discomfort for patients. Analysis was by intention to treat. This trial is registered as an International Standard Randomised Clinical Trial, number ISRCTN35766970. Findings: The proportions of cumulative pregnancies that resulted in term livebirth after 1 year were 43·4% with mild treatment and 44·7% with standard treatment (absolute number of patients=86 for both groups). The lower limit of the one-sided 95% CI was -9·8%. The proportion of couples with multiple pregnancy outcomes was 0·5% with mild IVF treatment versus 13·1% (p<0·0001) with standard treatment, and mean total costs were €8333 and €10745, respectively (difference €2412, 95% CI 703-4131). There were no significant differences between the groups in the anxiety, depression, physical discomfort, or sleep quality of the mother. Interpretation: Over 1 year of treatment, cumulative rates of term livebirths and patients' discomfort are much the same for mild ovarian stimulation with single embryos transferred and for standard stimulation with two embryos transferred. However, a mild IVF treatment protocol can substantially reduce multiple pregnancy rates and overall costs. http://repub.eur.nl/res/pub/8230/ 2007-01-10T00:00:00Z Acute lichamelijke letsels, veroorzaakt door ongevallen vormen een altijd aanwezig en dynamisch volksgezondheidsprobleem. Elk jaar raken alleen al in Nederland ca 1 miljoen mensen zodanig gewond dat zij onderzocht en behandeld moeten worden op de Spoed Eisende Hulp van een ziekenhuis. In dit proefschrift worden de medische kosten en de ziektelast van ongevallen voor Nederland en Europa bestudeerd. Hiermee kunnen ziekten, risicofactoren, en bevolkingsgroepen geïdentificeerd worden met de grootste behoefte aan zorginterventies. In een Europese studie worden de kosten van acht Europese landen vergeleken met elkaar, waarbij grote internationale verschillen zijn waargenomen. Belangrijke veroorzakers van hoge kosten zijn het veel voorkomen van ernstige letsels (Oostenrijk en Griekenland), verschillen in gezondheidszorgsystemen en traumazorg (hoge opnamekans en opnameduur voor Oostenrijk en Noorwegen), en hoge kostprijzen voor de gezondheidszorg (Noorwegen en Denemarken). Mensen ouder dan 65 jaar, in het bijzonder vrouwen, nemen een groot deel (meer dan een derde) van de totale zorgkosten voor hun rekening, met name veroorzaakt door botbreuken (heup- en knie/onderbeen). Jonge kinderen en mannen van middelbare leeftijd zijn ook groepen met relatief hoge medische kosten. Functionele gevolgen zijn gemeten bij een brede populatie ongevalspatiënten die zijn behandeld op de spoedeisende hulp in Nederland, 2½, 5, 9 en 24 maanden na het ongeval. Ongevalspatiënten die voor langere tijd opgenomen zijn geweest (> 7 dagen), ervaren twee jaar na het ongeval nog steeds aanzienlijke gezondheidsbeperkingen. Leeftijd (65+), Geslacht (vrouwen), specifieke letsels (heupfractuur, ruggenmergletsel, schedel-hersenletsel), en de aanwezigheid van andere ziekten (comorbiditeit) geven een verhoogd risico op langdurige gevolgen van een ongeval. http://repub.eur.nl/res/pub/35679/ 2007-01-01T00:00:00Z BACKGROUND: The collection of empirical data on the frequency, severity, and duration of functioning is a prerequisite to identify patient groups with long term or permanent disability. METHODS: We fielded postal questionnaires in a stratified sample of 8,564 injury patients aged 15 years and older, who had visited an emergency department in the Netherlands. Measurements were at 2.5, 5, 9, and 24 months after the injury and included a generic health status classification (EQ-5D), socio-demographic, and medical information. We analyzed determinants of long-term functional outcome by multivariate regression analysis. RESULTS: Five months after the injury health status of nonhospitalized injury patients was comparable to the general population's health (EQ-5D summary measure 0.87). Health status of patients admitted for 3 days or less improved until 9 months (0.82). For those admitted more than 3 days health status improved until 24 months (0.48 toward 0.67), but remained below population norms. Hospitalization, age and sex (females), type of injury (spinal cord injury, hip fracture, and lower extremity injury), and comorbidity were significant predictors of poor functioning in the long term. CONCLUSIONS: Recovery patterns vary widely between nonhospitalized, shortly, and long hospitalized injury patients. Nonhospitalized injury patients recover within 5 months from an injury whereas a considerable group of hospitalized injury patients suffer from persistent health problems. Our study indicates the importance of health monitoring with an adapted longitudinal design for injury patients. The time intervals used should match the various stages of the recovery process, which depends on the severity of the injury studied.