http://repub.eur.nl/res/aut/2612/ List of Publications en http://repub.eur.nl/static-eur/img/logo.png http://repub.eur.nl http://repub.eur.nl/res/pub/40042/ 2013-04-19T00:00:00Z Background: Common mental disorders (CMD) have a major impact on both society and individual workers, so return to work (RTW) is an important issue. In The Netherlands, the occupational physician plays a central role in the guidance of sick-listed workers with respect to RTW. Evidence-based guidelines are available, but seem not to be effective in improving RTW in people with CMD. An intervention supporting the occupational physician in guidance of sick-listed workers combined with specific guidance regarding RTW is needed. A blended E-health module embedded in collaborative occupational health care is now available, and comprises a decision aid supporting the occupational physician and an E-health module, Return@Work, to support sick-listed workers in the RTW process. The cost-effectiveness of this intervention will be evaluated in this study and compared with that of care as usual. Methods: This study is a two-armed cluster randomized controlled trial, with randomization done at the level of occupational physicians. Two hundred workers with CMD on sickness absence for 4-26 weeks will be included in the study. Workers whose occupational physician is allocated to the intervention group will receive the collaborative occupational health care intervention. Occupational physicians allocated to the care as usual group will give conventional sickness guidance. Follow-up assessments will be done at 3, 6, 9, and 12 months after baseline. The primary outcome is duration until RTW. The secondary outcome is severity of symptoms of CMD. An economic evaluation will be performed as part of this trial. Conclusion: It is hypothesized that collaborative occupational health care intervention will be more (cost)-effective than care as usual. This intervention is innovative in its combination of a decision aid by email sent to the occupational physician and an E-health module aimed at RTW for the sick-listed worker. http://repub.eur.nl/res/pub/38179/ 2012-10-22T00:00:00Z Objectives: Diagnosis Related Group (DRG) systems aim to classify patients into mutually exclusive groups of patients, with the patients in each group having the same expected length of stay (LOS). We examined the ability of current classification variables to explain LOS variation between DRG-like Diagnosis Treatment Combination (DBC)s for ten episodes of care in the Netherlands, including breast cancer, stroke and inguinal hernia repair. Additionally, we assessed the predictive ability of some other classification variables. Methods: For each episode of care, the relevant DBC codes of all hospitalizations in 2008 were identified and all available determinants that may serve as classification variables were acquired from the national database. Ordinary least squares regression was used to examine the predictive ability of these classification variables. Results: The current classification variables are not sufficiently distinct to classify patients into mutually exclusive groups of patients. ICU admissions and hospital type may serve as valuable classification variables. Additionally, episode-specific variables may improve the Dutch grouping algorithm. Conclusions: Although it may not be feasible in the short term, grouping algorithms would benefit greatly from the introduction of classification variables tailored to the needs of specific episodes of care. A first step would be to focus on 'general' classification variables meaningful for specific episodes of care. http://repub.eur.nl/res/pub/37646/ 2012-10-15T00:00:00Z Background: Practice variation in the primary care treatment of depression may be considerable in the Netherlands, due to relatively small and unregulated practices. We adapted the collaborative care model for the treatment of Major Depressive Disorder (MDD) to accommodate existing practice variation and tested whether this had added value over Care as Usual (CAU). Methods: A cluster randomized controlled trial was conducted to compare an adapted target driven collaborative care model with Care as Usual (CAU). Randomization was at the level of 18 (sub)urban primary care centers. The care manager and GP were supported by a web-based tracking and decision aid system that advised targeted treatment actions to achieve rapid response and if possible remission, and that warned the consultant psychiatrist if such treatment advice was not followed up. Eligible patients had a score of 10 or higher on the PHQ9, and met diagnostic criteria for major depression at the subsequent MINI Neuropsychiatric interview. A total of 93 patients were identified by screening. They received either collaborative care (CC) or CAU. Another 56 patients received collaborative care after identification by the GP. The outcome measures were response to treatment (50% or greater reduction of the PHQ9-total score from baseline) at three, six, nine and twelve months, and remission (a score of 0-4 on the PHQ9 at follow-up). Results: Treatment response and remission in CAU were low. Collaborative care was more effective on achieving treatment response than CAU at three months for the total group of patients who received collaborative care [OR 5.2 ((1.41-16.09), NNT 2] and at nine months [OR 5.6 ((1.40-22.58)), NNT 3]. The effect was not statistically significant at 6 and 12 months. Limitations: A relatively high percentage of patients (36.5%) did not return one or more follow-up questionnaires. There was no evidence for selective non response. Conclusions: Our adapted target driven CC was considerably more effective than CAU for MDD in primary care in the Netherlands. The Numbers Needed To Treat (NNT) to achieve response in one additional patient were low (2-3), which suggest that introducing CC at a larger scale may be beneficial. The relatively large effects may be due to our focus on reducing practice variation through the introduction of easy to use web based tracking and decision aids. The findings are highly relevant for the application of the model in areas where practices tend to be small and for mixed healthcare systems such as in many countries in Europe. Trial registration: Dutch trial register ISRCTN15266438 (http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=820). http://repub.eur.nl/res/pub/37339/ 2012-01-01T00:00:00Z Psychische problemen bij kinderen van 0 tot 19 jaar vormen een belangrijk maatschappelijk probleem. Wanneer deze problemen leiden tot crimineel gedrag, staat deze problematiek nog hoger op de politieke agenda. De afgelopen jaren is in de jeugd-GGZ gewerkt aan verbetering van de zorg. Dit heeft erin geresulteerd dat de jeugd-GGZ meer en sneller zorg is gaan bieden tegen minder kosten. In 2009 werden 270.000 kinderen en hun ouders behandeld; circa 15% meer dan in 2007. De wachttijd nam af met 10% en de kosten van zorg per kind daalden jaarlijks met 1 à 2% (GGZ Nederland, 2011). Geen reden om achterover te leunen. Integendeel, er liggen nog tal van uitdagingen. In een tijd van bezuinigingen is het van groot belang dat wordt aangetoond wat de jeugd-GGZ betekent voor de samenleving en hoe er in de sector efficiënter gewerkt kan worden. Op dit moment voorziet de jeugd-GGZ twee derde van de kinderen die geestelijke gezondheidszorg behoeven, van zorg. Nog niet alle kinderen en ouders krijgen de juiste zorg in de juiste vorm en op het juiste moment (GGZ Nederland, 2011). Onderzoek naar doelmatig-heid kan helpen de kwaliteit en de kosteneffectiviteit van de jeugd-GGZ verder te verbeteren. Bij doelmatigheid draait het om de balans tussen kosten (menskracht, geld) en opbrengsten (gezondheidsverbetering, kwaliteit van leven, maatschappelijke besparingen). Doelmatigheid kan ook worden aangeduid als kosteneffectiviteit. Doelmatigheidsonderzoek binnen de jeugd-GGZ staat momenteel echter nog in de kinderschoenen. In dit artikel lichten we toe waarom en op welke manier meer doelmatigheidsonderzoek binnen deze sector gewenst is. http://repub.eur.nl/res/pub/38175/ 2012-01-01T00:00:00Z Het doel van de kostenhandleiding is het verschaffen van een instrument dat onderzoekers en beleidsmakers faciliteert bij de uitvoering en beoordeling van kostenonderzoek in economische evaluaties. In dit artikel wordt de kern van de kostenhandleiding 2010 beschreven en in een internationale context geplaatst aan de hand van het stappenplan voor kostenonderzoek. In dit stappenplan wordt het berekenen van kosten gezien als een proces waarbij zeven stappen chronologisch doorlopen worden. Waar duidelijke aanbevelingen worden gedaan voor de bepaling van de reikwijdte van de economische evaluatie (stap 1), de keuze van de kostencategoriee¨n (stap 2), omgaan met onzekerheid (stap 6) en rapportage van kosten (stap 7), wordt de keuze met betrekking tot de identificatie (stap 3), volumemeting (stap 4) en waardering van eenheden (stap 5) neergelegd bij de onderzoeker. Hoewel de aanbevelingen in Nederland op specifieke onderwerpen iets afwijkt van andere Westerse landen, is het stappenplan voor kostenonderzoek vergelijkbaar met het proces dat beschreven wordt in de internationale richtlijnen. De kostenhandleiding sluit aan bij de uitgangspunten en de terminologie uit de Nederlandse richtlijnen voor farmaco-economisch onderzoek, maar de beschreven methoden kunnen ook in andere soorten onderzoek worden gebruikt. http://repub.eur.nl/res/pub/38353/ 2012-01-01T00:00:00Z Background: Many interventions initiated within and financed from the health care sector are not necessarily primarily aimed at improving health. This poses important questions regarding the operationalisation of economic evaluations in such contexts. Aims of the Study: We investigated whether assessing costeffectiveness using state-of-the-art methods commonly applied in health care evaluations is feasible and meaningful when evaluating interventions aimed at reducing youth delinquency. Methods: A probabilistic Markov model was constructed to create a framework for the assessment of the cost-effectiveness of systemic interventions in delinquent youth. For illustrative purposes, Functional Family Therapy (FFT), a systemic intervention aimed at improving family functioning and, primarily, reducing delinquent activity in youths, was compared to Treatment as Usual (TAU). ‘‘Criminal activity free years’’ (CAFYs) were introduced as central outcome measure. Criminal activity may e.g. be based on police contacts or committed crimes. In absence of extensive data and for illustrative purposes the current study based criminal activity on available literature on recidivism. Furthermore, a literature search was performed to deduce the model’s structure and parameters. http://repub.eur.nl/res/pub/31247/ 2011-08-01T00:00:00Z Studies of interventions for dyslexia have focused entirely on outcomes related to literacy. In this study, we considered a broader picture assessing improved quality of life compared with costs. A model served as a tool to compare costs and effects of treatment according to a new protocol and care as usual. Quality of life was measured and valued by proxies using a general quality-of-life instrument (EQ-5D). We considered medical cost and non-medical cost (e.g. remedial teaching). The model computed cost per successful treatment and cost per quality adjusted life year (QALY) in time. About 75% of the total costs was related to diagnostic tests to distinguish between children with severe dyslexia and children who have reading difficulties for other reasons. The costs per successful treatment of severe dyslexia were €36 366. Successful treatment showed a quality-of-life gain of about 11%. At primary school, the average cost per QALY for severe dyslexia amounted to €58 647. In the long term, the cost per QALY decreased to €26 386 at secondary school and €17 663 thereafter. The results of this study provide evidence that treatment of severe dyslexia is cost-effective when the investigated protocol is followed. Copyright http://repub.eur.nl/res/pub/26477/ 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. http://repub.eur.nl/res/pub/31769/ 2011-01-01T00:00:00Z The aim of the present study is to determine and compare initial treatment costs of microsurgery, linear accelerator (LINAC) radiosurgery, and gamma knife radiosurgery in meningioma patients. Additionally, the follow-up costs in the first year after initial treatment were assessed. Cost analyses were performed at two neurosurgical departments in The Netherlands from the healthcare providers' perspective. A total of 59 patients were included, of whom 18 underwent microsurgery, 15 underwent LINAC radiosurgery, and 26 underwent gamma knife radiosurgery. A standardized microcosting methodology was employed to ensure that the identified cost differences would reflect only actual cost differences. Initial treatment costs, using equipment costs per fraction, were €12,288 for microsurgery, €1,547 for LINAC radiosurgery, and €2,412 for gamma knife radiosurgery. Higher initial treatment costs for microsurgery were predominantly due to inpatient stay (€5,321) and indirect costs (€4,350). LINAC and gamma knife radiosurgery were equally expensive when equipment was valued per treatment (€2,198 and €2,412, respectively). Follow-up costs were slightly, but not significantly, higher for microsurgery compared with LINAC and gamma knife radiosurgery. Even though initial treatment costs were over five times higher for microsurgery compared with both radiosurgical treatments, our study gives indications that the relative cost difference may decrease when follow-up costs occurring during the first year after initial treatment are incorporated. This reinforces the need to consider follow-up costs after initial treatment when examining the relative costs of alternative treatments. http://repub.eur.nl/res/pub/33927/ 2011-01-01T00:00:00Z Aims: The impact of depression on patients with chronic medical illnesses such as diabetes is well documented. Depression is relatively common in diabetes patients with diabetes-related complications and they are more likely to be referred to specialized outpatient facilities. Only a few studies have addressed the association between depression and multiple diabetes-related complications at these specialized outpatient facilities. The aim of this study was to determine the association between diabetes with multiple complications and depression in patients with Type 2 diabetes at a specialized outpatient clinic. Methods: After giving informed consent, 1194 patients were screened for depression using the Patient Health Questionnaire (PHQ-9). Additional data on the type of diabetes and complications were taken from the medical records. Logistic regression analysis was conducted, with complications as the predictor variable and the probability of depression as the dependent variable. Results: A total of 596 (63%) patients with Type 2 diabetes participated in the study. The presence of two or more complications (OR 2.23, 95% CI 1.02-2.94) was significantly associated with depression. Neuropathy (OR 1.7, 95% CI 1.10-2.77) and nephropathy (OR 1.68, 95% CI 1.00-2.48) were especially related to depression. Conclusions: Patients with Type 2 diabetes with two or more complications, especially neuropathy or nephropathy, are at high risk of depression. Knowing this can help clinicians identify patients at risk for depression and facilitate timely and adequate treatment. © 2010 The Authors. Diabetic Medicine http://repub.eur.nl/res/pub/24008/ 2010-11-01T00:00:00Z Introduction: Hospitals are increasingly forced to consider the economics of technology use. We estimated the incremental cost-consequences of remifentanil-based analgo-sedation (RS) vs. conventional analgesia and sedation (CS) in patients requiring mechanical ventilation (MV) in the intensive care unit (ICU), using a modelling approach. Methods: A Markov model was developed to describe patient flow in the ICU. The hourly probabilities to move from one state to another were derived from UltiSAFE, a Dutch clinical study involving ICU patients with an expected MV-time of 2-3 days requiring analgesia and sedation. Study medication was either: CS (morphine or fentanyl combined with propofol, midazolam or lorazepam) or: RS (remifentanil, combined with propofol when required). Study drug costs were derived from the trial, whereas all other ICU costs were estimated separately in a Dutch micro-costing study. All costs were measured from the hospital perspective (price level of 2006). Patients were followed in the model for 28 days. We also studied the sub-population where weaning had started within 72 hours. Results: The average total 28-day costs were 15,626 euros with RS versus 17,100 euros with CS, meaning a difference in costs of 1474 euros (95% CI -2163, 5110). The average length-of-stay (LOS) in the ICU was 7.6 days in the RS group versus 8.5 days in the CS group (difference 1.0, 95% CI -0.7, 2.6), while the average MV time was 5.0 days for RS versus 6.0 days for CS. Similar differences were found in the subgroup analysis. Conclusions: Compared to CS, RS significantly decreases the overall costs in the ICU. http://repub.eur.nl/res/pub/21009/ 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 http://repub.eur.nl/res/pub/28589/ 2010-07-01T00:00:00Z Long-term psychoanalytic treatment is perceived as an expensive ambulatory treatment for mental illnesses. However, there are indications that psychoanalytic treatment can result in cost savings in the long term. In this study, we investigated the effects of long-term psychoanalytic treatment on healthcare utilization and work impairment and calculated the associated societal costs. We assessed healthcare utilization and work impairment of patients before, during, and after long-term psychoanalytic treatment (N=231). Our results show that the difference in total costs associated with healthcare utilization and work impairment between pre- and post-treatment was €2444 (U.S.$3070 using average exchange rates for 2006, the year for which these data were calculated) per person per year. Two years after treatment termination, these cost savings had increased to €3632 ($4563) per person per year. This indicates that we can expect decreased consumption of medical care and higher work productivity right after psychoanalytic treatment, but also that longterm psychoanalytic treatment can generate economical benefits in the long run. However, we cannot conclude that all invested costs will be earned back eventually. More research is needed on the cost-effectiveness of psychoanalytic treatment. Copyright http://repub.eur.nl/res/pub/19869/ 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. http://repub.eur.nl/res/pub/23141/ 2010-01-01T00:00:00Z Objectives: Despite the considerable and growing body of research about the clinical effectiveness of long-term psychoanalytic treatment, relatively little attention has been paid to economic evaluations, particularly with reference to the broader range of societal effects. In this cost-utility study, we examined the incremental cost-effectiveness ratio (ICER) of psychoanalysis versus psychoanalytic psychotherapy. Methods: Incremental costs and effects were estimated by means of cross-sectional measurements in a cohort design (psychoanalysis, n = 78; psychoanalytic psychotherapy, n = 104). Quality-adjusted life-years (QALYs) were estimated for each treatment strategy using the SF-6D. Total costs were calculated from a societal perspective (treatment costs plus other societal costs) and discounted at 4 percent. Results: Psychoanalysis was more costly than psychoanalytic psychotherapy, but also more effective from a health-related quality of life perspective. The ICER—that is, the extra costs to gain one additional QALY by delivering psychoanalysis instead of psychoanalytic psychotherapy—was estimated at €52,384 per QALY gained. Conclusions: Our findings show that the cost-utility ratio of psychoanalysis relative to psychoanalytic psychotherapy is within an acceptable range. More research is needed to find out whether cost-utility ratios vary with different types of patients. We also encourage cost-utility analyses comparing psychoanalytic treatment to other forms of (long-term) treatment. http://repub.eur.nl/res/pub/33045/ 2010-01-01T00:00:00Z Objectives: Despite the considerable and growing body of research about the clinical effectiveness of long-term psychoanalytic treatment, relatively little attention has been paid to economic evaluations, particularly with reference to the broader range of societal effects. In this cost-utility study, we examined the incremental cost-effectiveness ratio (ICER) of psychoanalysis versus psychoanalytic psychotherapy. Methods: Incremental costs and effects were estimated by means of cross-sectional measurements in a cohort design (psychoanalysis, n = 78; psychoanalytic psychotherapy, n = 104). Quality-adjusted life-years (QALYs) were estimated for each treatment strategy using the SF-6D. Total costs were calculated from a societal perspective (treatment costs plus other societal costs) and discounted at 4 percent. Results: Psychoanalysis was more costly than psychoanalytic psychotherapy, but also more effective from a health-related quality of life perspective. The ICERthat is, the extra costs to gain one additional QALY by delivering psychoanalysis instead of psychoanalytic psychotherapywas estimated at 52,384 per QALY gained. Conclusions: Our findings show that the cost-utility ratio of psychoanalysis relative to psychoanalytic psychotherapy is within an acceptable range. More research is needed to find out whether cost-utility ratios vary with different types of patients. We also encourage cost-utility analyses comparing psychoanalytic treatment to other forms of (long-term) treatment. http://repub.eur.nl/res/pub/17777/ 2009-10-15T00:00:00Z Background. Panic disorder (PD) and generalized anxiety disorder (GAD) are two of the most disabling and costly anxiety disorders seen in primary care. However, treatment quality of these disorders in primary care generally falls beneath the standard of international guidelines. Collaborative stepped care is recommended for improving treatment of anxiety disorders, but cost-effectiveness of such an intervention has not yet been assessed in primary care. This article describes the aims and design of a study that is currently underway. The aim of this study is to evaluate effects and costs of a collaborative stepped care approach in the primary care setting for patients with PD and GAD compared with care as usual. Methods/design. The study is a two armed, cluster randomized controlled trial. Care managers and their primary care practices will be randomized to deliver either collaborative stepped care (CSC) or care as usual (CAU). In the CSC group a general practitioner, care manager and psychiatrist work together in a collaborative care framework. Stepped care is provided in three steps: 1) guided self-help, 2) cognitive behavioral therapy and 3) antidepressant medication. Primary care patients with a DSM-IV diagnosis of PD and/or GAD will be included. 134 completers are needed to attain sufficient power to show a clinically significant effect of 1/2 SD on the primary outcome measure, the Beck Anxiety Inventory (BAI). Data on anxiety symptoms, mental and physical health, quality of life, health resource use and productivity will be collected at baseline and after three, six, nine and twelve months. Discussion. It is hypothesized that the collaborative stepped care intervention will be more cost-effective than care as usual. The pragmatic design of this study will enable the researchers to evaluate what is possible in real clinical practice, rather than under ideal circumstances. Many requirements for a high quality trial are being met. Results of this study will contribute to treatment options for GAD and PD in the primary care setting. Results will become available in 2011. Trial registration. NTR1071. http://repub.eur.nl/res/pub/17950/ 2009-10-01T00:00:00Z Objective: The primary aim of the present study was to calculate the actual costs of four diagnostic tests for the detection of coronary artery disease in the Netherlands using a microcosting methodology. As a secondary objective, the cost effectiveness of eight diagnostic strategies was examined, using microcosting and reimbursement fees subsequently as the cost estimate. Design: A multicenter, retrospective cost analysis from a hospital perspective. Setting: The study was conducted in three general hospitals in the Netherlands for 2006. Interventions: Exercise electrocardiography (exECG), stress echocardiography (sECHO), single-photon emission computed tomography (SPECT) and coronary angiography (CA). Results: The actual costs of exECG, sECHO, SPECT and CA were €33, 216, 614 and 1300 respectively. For all diagnostic tests, labour and indirect cost components (overheads and capital) together accounted for over 75% of the total costs. Consumables played a relatively important role in SPECT (14%). Hotel and nutrition were only applicable to SPECT and CA. Diagnostic services were solely performed for CA, but their costs were negligible (2%). Using microcosting estimates, exECG-sECHO-SPECT-CA was the most and CA the least cost effective strategy (€397 and 1302 per accurately diagnosed patient). Using reimbursement fees, exECG-sECHO-CA was most and SPECT-CA least cost effective (€147 and 567 per accurately diagnosed patient). Conclusions: The use of microcosting estimates instead of reimbursement fees led to different conclusions regarding the relative cost effectiveness of alternative strategies. http://repub.eur.nl/res/pub/19409/ 2009-06-01T00:00:00Z BACKGROUND: Typically, little consideration is given to the allocation of indirect costs (overheads and capital) to hospital services, compared to the allocation of direct costs. Weighted service allocation is believed to provide the most accurate indirect cost estimation, but the method is time consuming. OBJECTIVE: To determine whether hourly rate, inpatient day, and marginal mark-up allocation are reliable alternatives for weighted service allocation. METHODS: The cost approaches were compared independently for appendectomy, hip replacement, cataract, and stroke in representative general hospitals in The Netherlands for 2005. RESULTS: Hourly rate allocation and inpatient day allocation produce estimates that are not significantly different from weighted service allocation. CONCLUSIONS: Hourly rate allocation may be a strong alternative to weighted service allocation for hospital services with a relatively short inpatient stay. The use of inpatient day allocation would likely most closely reflect the indirect cost estimates obtained by the weighted service method. http://repub.eur.nl/res/pub/19413/ 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. http://repub.eur.nl/res/pub/20861/ 2009-01-01T00:00:00Z Abstract BACKGROUND: Standardised evaluation studies performed in the Netherlands in a large number of inpatient and day-treatment hospitals providing psychotherapy have shown significant symptomatic improvements in patients between the date of entry to the studies and follow-up after one year. However, the work situation of ex-patients hardly changed and a large number of patients were still receiving psychotherapy. AIM: To examine the effectiveness of a specifically designed course of re-integration training. METHOD: A group of 128 patients were assigned randomly either to a re-integration training course aimed at improved functioning at work and improved relationships, or to booster sessions. Outcome measures were symptom level, work status, absence from work, and further psychotherapy. results After two years the number of patients in paid employment remained the same (76%) in the re-integration training course and increased from 67 to 87% in the booster sessions. Attendance was significantly higher in the booster sessions than in the re-integration training. There were no differences in the other outcome measures. CONCLUSION: We conclude that re-integration training was no more effective than the booster sessions. Our hypothesis is that continuity of care (therapists plus programme) explains the favourable result of the booster sessions. http://repub.eur.nl/res/pub/25027/ 2009-01-01T00:00:00Z Objectives: Overactive bladder may cause significant discomfort to patients. The standard therapy for overactive bladder includes behavioural therapy and sometimes medication. Recently, a new medication (solifenacin 5 and 10 mg) was developed for treatment of overactive bladder. The objective of this study was to assess the cost utility of solifenacin 5 and 10 mg for overactive bladder. Methods: We developed a Markov model to estimate the cost per quality adjusted life years (QALY) over a period of 12-months. Model parameters were based on randomized clinical trials for solifenacin 5 and 10 mg. Data on utility scores were taken from the literature. Results: The incremental cost per QALY for solifenacin 5 mg and solifenacin 10 mg compared with placebo were £17,602 and £24,464 respectively. Sensitivity analyses showed that these results were robust to changes of relevant input data. Conclusion: Solifenacin 5 and 10 mg are cost-effective treatments in patients with overactive bladder. http://repub.eur.nl/res/pub/14189/ 2008-11-28T00:00:00Z Objective. To assess productivity losses due to absence from work during in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) treatment and to describe the pattern of IVF-related absence from work. Additionally, the influence of general and psychological variables on IVF-related absence from work was analyzed. Design. Prospective cohort study. Setting. Eight IVF hospitals participated in the study. Sample. Women undergoing their first treatment with IVF/ICSI. Methods. The Health and Labour Questionnaire (HLQ) was used to estimate the costs of IVF-related absence from work (n=384). Diaries were used to collect background information and reasons for IVF-related absence. Psychological data were derived using the Spielberger State and Trait Anxiety Inventory (STAI), the Beck Depression Inventory for Primary Care (BDI-PC) and the Inventory Social Relations and the Illness Cognition Questionnaire. Regression analyses were performed using two models, one without and one with psychological data, to assess the impact of the different variables on IVF-related absence from work. Main outcome measure. IVF-related absence from work and the costs of productivity losses due to IVF/ICSI per treatment. Results. Overall absence from work during IVF/ICSI treatment was on average 33 hours, of which 23 hours were attributed to IVF/ICSI. Costs of productivity losses due to IVF/ICSI were €596 per woman. Significant predictors of IVF-related absence from work were the number of hours of paid work, age and self-reported physical and/or emotional problems due to IFV treatment. Conclusions. Women experiencing emotional complaints and women with physical complaints due to IVF/ICSI reported significantly more IVF-related absence from work. http://repub.eur.nl/res/pub/29821/ 2008-07-01T00:00:00Z The primary objective of this study was to estimate the actual daily costs of intensive care unit stay using a microcosting methodology. As a secondary objective, the degree of association between daily intensive care unit costs and some patient characteristics was examined. This multicenter, retrospective cost analysis was conducted in the medical-surgical adult intensive care units of 1 university and 2 general hospitals in the Netherlands for 2006, from a hospital perspective. A total of 576 adult patients were included, consuming a total of 2868 nursing days. The mean total costs per intensive care unit day were 1911, with labour (33%) and indirect costs (33%) as the most important cost drivers. An ordinary least squares analysis including age, Nine Equivalent of Nursing Manpower Use score/Therapeutic Intervention Scoring System score, mechanical ventilation, blood products, and renal replacement therapy was able to predict 50% of the daily intensive care unit costs. http://repub.eur.nl/res/pub/28825/ 2008-02-01T00:00:00Z Objective: To provide detailed information about costs of in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) treatment stages and to estimate the cost per IVF and ICSI treatment cycle and ongoing pregnancy. Design: Descriptive micro-costing study. Setting: Four Dutch IVF centers. Patient(s): Women undergoing their first treatment cycle with IVF or ICSI. Intervention(s): IVF or ICSI. Main Outcome Measure(s): Costs per treatment stage, per cycle started, and for ongoing pregnancy. Result(s): Average costs of IVF and ICSI hormonal stimulation were €1630 and €1585; the costs of oocyte retrieval were €500 and €725, respectively. The cost of embryo transfer was €185. Costs per IVF and ICSI cycle started were €2381 and €2578, respectively. Costs per ongoing pregnancy were €10,482 and €10,036, respectively. Conclusion(s): Hormonal stimulation covered the main part of the costs per cycle (on average 68% and 61% for IVF and ICSI, respectively) due to the relatively high cost of medication. The costs of medication increased with increasing age of the women, irrespective of the type of treatment (IVF or ICSI). Fertilization costs (IVF laboratory) constituted 12% and 20% of the total costs of IVF and ICSI. The total cost per ICSI cycle was 8.3% higher than IVF. http://repub.eur.nl/res/pub/29739/ 2008-02-01T00:00:00Z Introduction: Rapid bacterial identification and susceptibility tests can lead to earlier microbiological diagnosis and pathogen-directed, appropriate therapy. We studied whether accelerated diagnostics affected antibiotic use and patient outcomes. Patients and methods: A prospective randomized clinical trial was performed over a 2-year period. Inpatients were selected on the basis of a positive culture from normally sterile body fluids and randomly assigned to either a rapid intervention arm or the control arm. The intervention arm used the Vitek 2 automated identification and susceptibility testing device, combined with direct inoculation of blood cultures. In the control arm, the Vitek 1 system inoculated from subcultures was used. Follow-up was 4 weeks after randomization. Results: A total of 1498 patients were randomized: 746 in the intervention arm and 752 in the control arm. For susceptibility testing, the rapid arm was 22 h faster than the control arm, and for identification, it was 13 h faster (P < 0.0001). In the rapid arm, antibiotic use was 6 defined daily doses lower per patient than in the control arm (P = 0.012). Whereas antibiotics were switched more in the rapid group on the day of randomization (P = 0.006), in the control group they were switched more on day two (P = 0.02). Mortality rates did not differ significantly between the two groups (17.6% versus 15.2%). Conclusions: While rapid bacterial identification and susceptibility testing led to earlier changes and a significant reduction in antibiotic use, they did not reduce mortality. http://repub.eur.nl/res/pub/35911/ 2007-09-01T00:00:00Z Background: The Dutch IVF guideline suggests triage of patients for IVF based on diagnostic category, duration of infertility and female age. There is no evidence for the effectiveness of these criteria. We evaluated the predictive value of patient characteristics that are used in the Dutch IVF guideline and developed a model that predicts the IVF ongoing pregnancy chance within 12 months. Methods: In a national prospective cohort study, pregnancy chances after IVF and ICSI treatment were assessed. Couples eligible for IVF or ICSI were followed during 12 months, using the databases of 11 IVF centres and 20 transport IVF clinics. Kaplan-Meier analysis was performed to estimate the cumulative probability of an ongoing pregnancy, and Cox regression was used for assessing the effects of predictors of pregnancy. Results: 4928 couples starting IVF/ICSI treatment were prospectively followed. On average, couples had 1.8 cycles in 12 months for both IVF and ICSI. The 1-year probability of ongoing pregnancy was 44.8% (95% CI 42.1-47.5%). ICSI for severe oligospermia had a significantly higher ongoing pregnancy rate than IVF indicated treatments, with a multivariate Hazard ratio (HR) of 1.22 (95% CI 1.07-1.39). The success rates were comparable for all diagnostic categories of IVF. The highest success rate is at age 30, with a slight decline towards younger women and women up to 35 and a sharp drop after 35. Primary subfertility with a HR of 0.90 (95% CI 0.83-0.99) and duration of subfertility with a HR of 0.97 (95% CI 0.95-0.99) per year significantly affected the pregnancy chance. Conclusions: The most important predictors of the pregnancy chance after IVF and ICSI are women's age and ICSI. The diagnostic category is of no consequence. Duration of subfertility and pregnancy history are of limited prognostic value. http://repub.eur.nl/res/pub/36605/ 2007-08-01T00:00:00Z Background: The impact of attention deficit hyperactive disorder (ADHD) in the Netherlands on health care utilisation, costs and quality of life of these children, as well as of their parents is unknown. Objective: The aim of this study was to assess the direct medical costs of patients suffering from ADHD and their quality of life as well as the direct medical costs of their mothers. Study design: We selected a group of 70 children who were being treated by a paediatrician for ADHD based on the DSM-IV diagnostic criteria for ADHD. For comparison's sake, we also included a non-matched group of 35 children with behaviour problems and 60 children with no behaviour problem from a large school population-based study on the detection of ADHD. We collected information on the health care utilisation of the children applying the Trimbos and iMTA questionnaire on Costs associated with Psychiatric illness' (TiC-P). Their health related quality of life was collected by using the Dutch 50-item parent version of the Child Health Questionnaire (CHQ PF-50). Measurements were at baseline and at 6 months. Subsequently, we collected data on the health utilisation of the mothers and their production losses due to absence from work and reduced efficiency. Results: The mean direct medical costs per ADHD patient per year were €2040 or €1173 when leaving out one patient with a long-term hospital admission, compared to €288 for the group of children with behaviour problems and €177 for the group of children with no behaviour problems. The direct medical costs for children who had psychiatric co-morbidities were significantly higher compared to children with ADHD alone. The mean medical costs per year for the mothers of the ADHD patients were significantly higher than for the mothers of the children with behaviour problems and the mothers of children with no behaviour problems respectively €728, €202 and €154. The physical summary score showed no significant differences between the groups. However, the score on the Psychosocial Summary Score dimension was significantly lower for ADHD patients compared to the scores of the children in the two other samples. The mean annual indirect costs due to absence from work and reduced efficiency at work were €2243 for the mothers of the ADHD patients compared to €408 for the mothers of children with behaviour problems and €674 for the mothers of children with no behaviour problems. Conclusion: Our study showed that the direct medical costs of ADHD patients were relatively high. Additionally, our study indicated that ADHD appears to be accompanied by higher (mental) health care costs for the mothers of ADHD patients and by increased indirect costs for this group. http://repub.eur.nl/res/pub/36924/ 2007-03-14T00:00:00Z Background. Depressive disorder is currently one of the most burdensome disorders worldwide. Evidence-based treatments for depressive disorder are already available, but these are used insufficiently, and with less positive results than possible. Earlier research in the USA has shown good results in the treatment of depressive disorder based on a collaborative care approach with Problem Solving Treatment and an antidepressant treatment algorithm, and research in the UK has also shown good results with Problem Solving Treatment. These treatment strategies may also work very well in the Netherlands too, even though health care systems differ between countries. Methods/design. This study is a two-armed randomised clinical trial, with randomization on patient-level. The aim of the trial is to evaluate the treatment of depressive disorder in primary care in the Netherlands by means of an adapted collaborative care framework, including contracting and adherence-improving strategies, combined with Problem Solving Treatment and antidepressant medication according to a treatment algorithm. Forty general practices will be randomised to either the intervention group or the control group. Included will be patients who are diagnosed with moderate to severe depression, based on DSM-IV criteria, and stratified according to comorbid chronic physical illness. Patients in the intervention group will receive treatment based on the collaborative care approach, and patients in the control group will receive care as usual. Baseline measurements and follow up measures (3, 6, 9 and 12 months) are assessed using questionnaires and an interview. The primary outcome measure is severity of depressive symptoms, according to the PHQ9. Secondary outcome measures are remission as measured with the PHQ9 and the IDS-SR, and cost-effectiveness measured with the TiC-P, the EQ-5D and the SF-36. Discussion. In this study, an American model to enhance care for patients with a depressive disorder, the collaborative care model, will be evaluated for effectiveness in the primary care setting. If effective across the Atlantic and across different health care systems, it is also likely to be an effective strategy to implement in the treatment of major depressive disorder in the Netherlands. http://repub.eur.nl/res/pub/36928/ 2007-03-12T00:00:00Z Background. Depressive disorder is one of the most common disorders, and is highly prevalent in chronically ill patients. The presence of comorbid depression has a negative influence on quality of life, health care costs, self-care, morbidity, and mortality. Early diagnosis and well-organized treatment of depression has a positive influence on these aspects. Earlier research in the USA has reported good results with regard to the treatment of depression with a collaborative care approach and an antidepressant algorithm. In the UK 'Problem Solving Treatment' has proved to be feasible. However, in the general hospital setting this approach has not yet been evaluated. Methods/Design. CC: DIM (Collaborative Care: Depression Initiative in the Medical setting) is a two-armed randomised controlled trial with randomisation at patient level. The aim of the trial is to evaluate the treatment of depressive disorder in general hospitals in the Netherlands based on a collaborative care framework, including contracting, 'Problem Solving Treatment', antidepressant algorithm, and manual-guided self-help. 126 outpatients with diabetes mellitus, chronic obstructive pulmonary disease, or cardiovascular diseases will be randomised to either the intervention group or the control group. Patients will be included if they have been diagnosed with moderate to severe depression, based on the DSM-IV criteria in a two-step screening method. The intervention group will receive treatment based on the collaborative care approach; the control group will receive 'care as usual'. Baseline and follow-up measurements (after 3, 6, 9, and 12 months) will be performed by means of questionnaires. The primary outcome measure is severity of depressive symptoms, as measured with the PHQ-9. The secondary outcome measure is the cost-effectiveness of these treatments according to the TiC-P, the EuroQol and the SF-36. Discussion. Earlier research has indicated that depressive disorder is a chronic, mostly recurrent illness, which tends to cluster with physical comorbidity. Even though the treatment of depressive disorder based on the guidelines for depression is proven effective, these guidelines are often insufficiently adhered to. Collaborative care and 'Problem Solving Treatment' will be specifically tailored to patients with depressive disorders and evaluated in a general hospital setting in the Netherlands. http://repub.eur.nl/res/pub/1337/ 2002-01-01T00:00:00Z Een gestandaardiseerde methode voor het meten van directe medische kosten en indirecte kosten vergoot de vergelijkbaarheid van de resultaten van economische evaluaties. Het instituut voor Medische Technology Assessment (iMTA) heeft in samenwerking met het Trimbos instituut een vragenlijst ontwikkeld voor het meten directe medische kosten en indirecte kosten die samenhangen met psychische aandoeningen. Deel I van de vragenlijst heeft betrekking op de directe medische kosten. Deel II is een verkorte versie van de Health and Labour Questionnaire (HLQ) voor meten van de indirecte kosten (SF-HLQ). Deel II is niet ziekte-specifiek en is daarom ook van toepassing op andere indicaties. In de handleiding wordt een beschrijving gegeven van de items en de scoring daarvan. http://repub.eur.nl/res/pub/1319/ 2001-01-01T00:00:00Z The most frequently occurring type of dementia is Alzheimer's disease. Alzheimer's disease is a degenerative illness affecting the brain, decreasing the patient's memory and judgement. A cure is not available but it is possible to delay the cognitive decline with medication. New drugs like Aricept and Metrifonate appear to have no or minor side effects and have a positive effect on the cognitive functions and behavior of the patient. At this moment the iMTA is studying the cost-effectiveness of Metrifonate. This thesis is part of that study and focuses on the costs of Alzheimer's disease. The main question formulated in this thesis was: How do the costs of institutionalization compare with the costs of living at home for patients with Alzheimer's disease in The Netherlands and France? For The Netherlands earlier studies on the use of health care services by demented patients were used to estimate the costs for demented patients living at home. These costs depend on the amount of formal and informal health care services that demented patients use. The valuation of informal care also determines the amount of costs for patients living at home. The costs of living at home were compared with the costs of institutionalization. The costs of demented patients living at home are lower than the costs of institutionalization when informal care is not valued. When the costs of informal care are included in the costs for patients living at home, these costs exceed the costs of institutionalization for mildly demented patients as well as for severely demented patients by seven or more hours of informal care per day. A mildly demented patient probably does not need this amount of informal care per day. A severely demented patient could need seven hours of informal care per day. In that case costs of institutionalization are lower than the costs of living at home. In France admission of a mildly demented patient is cheaper when the patient needs more than two hours of informal care per day. As the severity of dementia increases, the increase in costs of institutionalization is not equal to the increase in costs of living at home. Therefore the thresholds at which the costs of living at home exceed the costs for institutionalization for a mildly demented patient does not equal the threshold for a severely demented patient. In comparison with The Netherlands, the costs for demented patients living at home in France are lower than in the Netherlands. This is caused by the increased use of informal care and the decreased use of professional health care services in France compared with the Netherlands. The costs of institutionalization are also higher in the Netherlands than in France. The costs of the French institutions are lower than the costs of institutions in the Netherlands because the emphasis is more on the function of living than on the function of caring. When informal care is valued with the same tariff used in the Netherlands, admission of a severely demented patient needing more than seven hours of informal care per day is cheaper than living at home. This last mentioned threshold is comparable with the Netherlands. http://repub.eur.nl/res/pub/1313/ 2000-01-01T00:00:00Z When the indirect costs form a part of an economical evaluation, a standardised method for measuring production losses, as a result of illness, is required. Standardisation will increase the comparability and transparency of the results. The Health and Labour Questionnaire (HLQ) is designed to collect quantitative data on the relation between illness and treatment and work performance. The HLQ data permits the estimation of production losses (costs) of paid and unpaid labour. It contains also an indicator for impediments for paid and unpaid labour, one of the indicators for quality of life. The HLQ is divided into 4 modules to collect data about absence from work, reduced productivity at paid work, unpaid labour production and impediments to paid and unpaid labour. The modular structure permits the omission of questions that are not applicable to the study population. The questionnaire is suitable for self-assessment. This manual is a user guide for the HLQ. The scoring- and valuing methods are presented. Furthermore a survey of norm-scores for several groups of respondents is given. The manual contains also information with regard to feasibility and validity of the HLQ. Finally, the procedural aspects for using the questionnaire are given. Currently we are working on a short form version of the HLQ. http://repub.eur.nl/res/pub/1310/ 1999-01-01T00:00:00Z Indien indirecte kosten deel uit maken van een economische evaluatie dan is een gestandaardiseerde methode om de productieverliezen als gevolg van ziekte te meten een vereiste. Standaardisatie zal de vergelijkbaarheid en transparantie van de resultaten vergroten. De Vragenlijst over Ziekte en Werk is ontwikkeld om kwantitatieve data te verzamelen over de relatie tussen ziekte, behandeling en werkprestaties. Met de data uit de Vragenlijst over Ziekte en Werk kunnen schattingen van de productieverliezen (indirecte kosten) bij betaald en onbetaald werk gemaakt worden. Daarnaast bevat de vragenlijst een indicator voor hinder die ziekte oplevert om betaald en onbetaald werk te verrichten. Dit kan men zien als één aspect van kwaliteit van leven. De vragenlijst bestaat uit 4 modulen om data te verzamelen over verzuim van betaald werk, productieverliezen zonder verzuim bij betaald werk, productieverliezen bij onbetaald werk en hinder bij het uitoefenen van betaald en onbetaald werk. De modulaire opbouw biedt de mogelijkheid om, afhankelijk van de onderzoekspopulatie, een niet-relevante module achterwege te laten. De vragenlijst kan schriftelijk worden afgenomen en is geschikt voor invulling door de respondent zelf. Deze handleiding vormt een toelichting op de achtergrond van de vragenlijst. Tevens worden de scorings- en waarderingsmethoden uiteengezet. Voorts wordt een overzicht gegeven van de normscores voor verschillende groepen respondenten. De handleiding bevat daarnaast informatie met betrekking tot haalbaarheid, betrouwbaarheid en validiteit van de Vragenlijst over Ziekte en Werk. Tenslotte worden de procedurele aspecten bij het gebruik van de vragenlijst beschreven. http://repub.eur.nl/res/pub/17166/ 1998-03-06T00:00:00Z The rising casts of health care during the last decades ellhallced the importance of economie evaluations in support of decisions on resourc~ allocation. Questions may be raised as to whether the alloeation of resources is optimal when measured against the total health gain that an investment blings. Many health economists have emphasised that the high costs of disease may be a necessalY but cel1ainly not a sufficient condition for priotity-setting in health care (e.g. Dnllllmond, 1992). Additionally, data on the effectiveness of interventions themselves is needed, In health policy the high cost of diseases may lead te priority being given ta those health care programmes which are already costly. \\Vhereas ifpast resource allocation decisions have been made in an inational marmer, then sllbsequent poliey decisions perpehmte and amplifY the initial mistake (Sheill et al., 1987). From a poliey point of view, the eqllitable distribution of costs and consequences across socio-economie groups is a competing dimension upon which decisiolls are made. Therefore. apart from infonllation on cost-effectiveness, health poliey should also be based on ethical considerations (e.g. equity). http://repub.eur.nl/res/pub/1309/ 1995-01-01T00:00:00Z De studie geeft een overzicht van de maatschappelijke gevolgen van migraine. Wij onderzochten medische consumptie, de kosten van verzuim en produktieverlies zonder verzuim en de kwaliteit van leven. Het iMTA ontwikkelde een screeningsvragenlijst op grond van de IHS-criteria voor de selectie van migraine patiënten. Op grond hiervan zijn 846 migraine patiënten en een controle groep van 834 personen geselecteerd uit de gemiddelde populatie. De prevalentie van migraine bedraagt 9%, 5% voor mannen en 12% voor vrouwen. Voor het bepalen van produktie verliezen met en zonder verzuim is de 'Ziekte & Werk' vragenlijst van het iMTA vragenlijst gebruikt. Hieraan zijn vier gestandaardiseerde generieke kwaliteit van leven vragenlijsten toegevoegd. De totale kosten voor migraine bedragen volgens deze voorzichtige schatting 675 miljoen gulden per jaar. Hiervan zijn de directe kosten 134 miljoen gulden per jaar, de kosten van verzuim varieerde afhankelijk van de recall periode van 264 tot 473 miljoen gulden per jaar. De conservatieve schatting van de kosten van produktieverlies zonder verzuim op basis van de 'Ziekte & Werk' methode is 277 miljoen gulden per jaar. Schatting op grond van twee alternatieve methode voor het meten van productieverliezen zonder verzuim komen hoger uit, respectievelijk 968 en 1455 miljoen per jaar. Op grond van generieke vragenlijsten bleek dat de kwaliteit van leven van migraine patiënten ook buiten de aanvallen significant lager is dan van de controle groep.