Lamers, L.M.

Cost-effectiveness of temozolomide for the treatment of newly diagnosed glioblastoma multiforme: A report from the EORTC 26981/22981 NCI-C CE3 intergroup study (Article)

2008-03-15T00:00:00Z

BACKGROUND. The study aimed to compare the cost-effectiveness of concomitant and adjuvant temozolomide (TMZ) for the treatment of newly diagnosed glioblastoma multiforme versus initial radiotherapy alone from a public health care perspective. METHODS. The economic evaluation was performed alongside a randomized, multicenter, phase 3 trial. The primary endpoint of the trial was overall survival. Costs included all direct medical costs. Economic data were collected prospectively for a subgroup of 219 patients (38%). Unit costs for drugs, procedures, laboratory and imaging, radiotherapy, and hospital costs per day were collected from the official national reimbursement lists based on 2004. For the cost-effectiveness analysis, survival was expressed as 2.5 years restricted mean estimates. The incremental cost-effectiveness ratio (ICER) was constructed. Confidence intervals for the ICER were calculated using the Fieller method and bootstrapping. RESULTS. The difference in 2.5 years restricted mean survival between the treatment arms was 0.25 life-years and the ICER was €37,361 per life-year gained with a 95% confidence interval (CI) ranging from €19,544 to €123,616. The area between the survival curves of the treatment arms suggests an increase of the overall survival gain for a longer follow-up. An extrapolation of the overall survival per treatment arm and imputation of costs for the extrapolated survival showed a substantial reduction in ICER. CONCLUSIONS. The ICER of €37,361 per life-year gained is a conservative estimate. We concluded that despite the high TMZ acquisition costs, the costs per life-year gained are comparable to accepted first-line treatment with chemotherapy in patients with cancer.

On the assessment of preferences for health and duration: Maximal endurable time and better than dead preferences (Article)

2007-09-01T00:00:00Z

BACKGROUND: Several studies revealed difficulties with the valuation and analysis of health states deemed worse than dead. These problems may be linked to maximal endurable time (MET) preferences, the phenomenon that for severe states better than dead (BTD), shorter durations are often preferred to longer durations. OBJECTIVE: To test the association between the duration of health states and their valuation. METHODS: A representative sample of 123 Dutch respondents (age range, 18-45 years) valued 5 EQ-5D health states. With a straightforward method using BTD preferences, respondents indicated whether a state of a certain duration is better, equal to, or worse than dead. To validate these BTD preferences, MET preferences (whether a longer duration of a health state is better, equal, or worse than a shorter duration) were collected. RESULTS: BTD and MET preferences were strongly related (P < 0.001). For severe health states, although still judged as better than dead, BTD preferences curved downwards with increasing duration. Such curved BTD patterns occurred in 28% of the respondents, especially for more severe states (P < 0.001). CONCLUSIONS: BTD preferences revealed that the value of moderate and severe states declines with increasing duration, suggesting that health and duration interact. For states worse than dead versus states better than dead, traditional valuation techniques have the drawback that different preference questions are used. Using BTD preferences, however, a single simple preference question can assess states better than dead, as well as states worse than dead.

Cost-effectiveness of physical therapy and general practitioner care for sciatica (Article)

2007-08-01T00:00:00Z

STUDY DESIGN. An economic evaluation alongside a randomized clinical trial in primary care. A total of 135 patients were randomly allocated to physical therapy added to general practitioners' care (n = 67) or to general practitioners' care alone (n = 68). OBJECTIVE. To evaluate the cost-effectiveness of physical therapy and general practitioner care for patients with an acute lumbosacral radicular syndrome (LRS, also called sciatica) compared with general practitioner care only. SUMMARY OF BACKGROUND DATA. There is a lack of knowledge concerning the cost-effectiveness of physical therapy in patients with sciatica. METHODS. The clinical outcomes were global perceived effect and quality of life. The direct and indirect costs were measured by means of questionnaires. The follow-up period was 1 year. The Incremental Cost-effectiveness Ratio (ICER) between both study arms was constructed. Confidence intervals for the ICER were calculated using Fieller's method and using bootstrapping. RESULTS. There was a significant difference on perceived recovery at 1-year follow-up in favor of the physical therapy group. The additional physical therapy did not have an incremental effect on quality of life. At 1-year follow-up, the ICER for the total costs was €6224 (95% confidence interval, -10419, 27551) per improved patient gained. For direct costs only, the ICER was €837 (95% confidence interval, -731, 3186). CONCLUSION. The treatment of patients with LRS with physical therapy and general practitioners'care is not more cost-effective than general practitioners'care alone.

The transformation of utilities for health states worse than death: Consequences for the estimation of EQ-5D value sets (Article)

2007-03-01T00:00:00Z

BACKGROUND: Utilities for health are measured on an interval scale, where 1 refers to full health and 0 refers to death. No theoretical lower boundary on the utilities for states worse than death exists. As a consequence, negative values receive greater weight in the calculation of mean utilities. To avoid this, negative values often are bound at -1. OBJECTIVE: The objective of this study was to compare the effect of 3 methods to bound negative values at -1 on the estimation of EQ-5D value sets: truncation, monotonic, and linear transformation. METHOD: Data of the Dutch EQ-5D valuation study were used. A total of 298 respondents directly valued 17 EQ-5D health states using the time trade-off (TTO) method. Random effects regression analysis was used to interpolate TTO values for all possible EQ-5D states. In the regression analysis the dependent variable is 1 minus the TTO value and the independent variables describe the health state. Two widely used models to estimate EQ-5D value were applied after truncation of negative values and monotonic and linear transformation of negative values. Both models also were estimated on medians. RESULTS: Truncation of negative values gave the largest mean absolute error (MAE); the linear transformation resulted in the smallest MAE. When medians were used for estimation, the MAEs were comparable with the estimation on means. CONCLUSION: The choice of a method to bound negative values is arbitrary and affects the resulting value set. For the estimation of EQ-5D value sets from a societal perspective the use of medians should be considered. Copyright

Gender and health care utilization: The role of mental distress and help-seeking propensity (Article)

2007-03-01T00:00:00Z

Many studies report higher levels of health care utilization among women. Understanding how gender influences health care utilization is still unresolved. We developed a model that could explain these gender-related differences. The possible pathways assumed by this model that relate gender to utilization, can be summarized as follows: (1) utilization may be influenced by somatic morbidity, mental distress, perceived symptoms, poor subjective health and propensity to use services; (2) women have higher levels of these variables than men (mediating effect); and (3) the direct effects of some of these variables on utililization are moderated by gender, i.e. they are stronger for women than for men (moderating effect). Data were drawn from a community-based sample of adult enrollees of a sickness fund in the Netherlands, who had responded to a mailed health survey (N=8698). This survey contained questions on somatic morbidity, mental distress and other mediating variables. Health care utilization was measured prospectively, using data extracted from a claims database held by the sickness fund that covers all types of general health services except general practitioner consultations. The model was tested using structural equation modelling. Women reported more somatic morbidity and mental distress than men did, as well as elevated levels of other mediating variables, which might explain-at least partly-gender related differences in utilization. Differences in propensity to use services were not found. The expected moderating effect of gender could not be demonstrated. That is, we did not find gender related differences in the strength of the relations between mental distress, other mediating variables and utilization. Mental distress is related to utilization in a way that is not gender specific, however, because women report higher levels of mental distress (as well as somatic morbidity), this results in a greater utilization of somatic health care services.

Risk-adjusted capitation based on the Diagnostic Cost Group Model: an empirical evaluation with health survey information (Article)

1999-01-01T00:00:00Z

OBJECTIVE: To evaluate the predictive accuracy of the Diagnostic Cost Group (DCG) model using health survey information. DATA SOURCES/STUDY SETTING: Longitudinal data collected for a sample of members of a Dutch sickness fund. In the Netherlands the sickness funds provide compulsory health insurance coverage for the 60 percent of the population in the lowest income brackets. STUDY DESIGN: A demographic model and DCG capitation models are estimated by means of ordinary least squares, with an individual's annual healthcare expenditures in 1994 as the dependent variable. For subgroups based on health survey information, costs predicted by the models are compared with actual costs. Using stepwise regression procedures a subset of relevant survey variables that could improve the predictive accuracy of the three-year DCG model was identified. Capitation models were extended with these variables. DATA COLLECTION/EXTRACTION METHODS: For the empirical analysis, panel data of sickness fund members were used that contained demographic information, annual healthcare expenditures, and diagnostic information from hospitalizations for each member. In 1993, a mailed health survey was conducted among a random sample of 15,000 persons in the panel data set, with a 70 percent response rate. PRINCIPAL FINDINGS: The predictive accuracy of the demographic model improves when it is extended with diagnostic information from prior hospitalizations (DCGs). A subset of survey variables further improves the predictive accuracy of the DCG capitation models. The predictable profits and losses based on survey information for the DCG models are smaller than for the demographic model. Most persons with predictable losses based on health survey information were not hospitalized in the preceding year. CONCLUSIONS: The use of diagnostic information from prior hospitalizations is a promising option for improving the demographic capitation payment formula. This study suggests that diagnostic information from outpatient utilization is complementary to DCGs in predicting future costs.

Capitation payments to competing Dutch sickness funds based on diagnostic information from prior hospitalizations (Doctoral Thesis)

1997-12-03T00:00:00Z

In many countries market-oriented health care reforms are high on the political agenda. The purpose of these reforms is to make resource allocation in health care more efficient, more innovative and more responsive to the consumers' preferences. The Netherlands is no exception in this respect. The Dutch health care reform shows close similarities with the reforms in, for instance, Belgium (Kesenne, 1996), Germany (Graf von der Schulenburg, 1994; Files and Murray, 1995), Switzerland (Beck and Zweifel, 1996), Israel (Chinitz, 1994) and the U.S. (Newhouse, 1994). A common element of these reforms is that the consumers may choose among competing health insurers or health plans, which are largely financed through premium-replacing capitation payments.

Risk-adjusted capitation: recent experiences in The Netherlands (Article)

1994-01-01T00:00:00Z

The market-oriented health care reforms taking place in the Netherlands show a clear resemblance to the proposals for managed competition in U.S. health care. In both countries good risk adjustment mechanisms that prevent cream skimming--that is, that prevent plans from selecting the best health risks--are critical to the success of the reforms. In this paper we present an overview of the Dutch reforms and of our research concerning risk-adjusted capitation payments. Although we are optimistic about the technical possibilities for solving the problem of cream skimming, the implementation of good risk-adjusted capitation is a long-term challenge.

Vertraging bij de opname van hartinfarctpatienten (Article)

1993-01-01T00:00:00Z

Timely treatment of patients with an evolving myocardial infarction improves the short and long term prognoses. Because of a wrong judgement of the situation by the patient, a significant other or by a general practitioner (GP), treatment may be delayed. To examine this delay 300 patients with myocardial infarction took part in a study between March 1990 and October 1991. After written consent was given, they were interviewed about the pre-hospital period. The significant others received a questionnaire about this period. Medical information was collected from the cardiologists. Fifty percent of all patients called for medical help within 30 minutes. The GP arrived within 11 minutes at the patient's place in 50% of all cases. However, in 50% of all cases the decision making of the GPs before the patient was sent to a hospital required more than 82 minutes. The ambulance arrived within 15 minutes at the patient's place in 90% of all cases. Stabilisation of the patient by the ambulance staff and transport to the hospital took slightly more time. Compared with earlier studies, the patient with a possible myocardial infarction calls for help sooner. Subsequently, in many cases it takes considerable time before the GP refers the patient to a hospital. Further research is needed to improve the diagnostic power of the GP.