Instituut Beleid en Management Gezondheidszorg - Health policy and management (iBMG)

Empirical Studies in the Measurement of Socio-economic Inequality in Health (Doctoral Thesis)

Baeten, S.A. — 2013-05-24T00:00:00Z

Despite a long-term and intensive interest in the measurement of socio-economic health inequalities, the collection of accurate and comparable information still is a daunting task. This thesis presents several challenges that researchers face. It also provides new empirical evidence on socio-economic inequalities in different areas. The results confirm previous findings of a better health experience for the rich and highly educated. Moreover, the results show that with the right techniques and data many of the measurement problems that researchers face can be accounted for.

Blended E-health module on return to work embedded in collaborative occupational health care for common mental disorders: Design of a cluster randomized controlled trial (Article)

Volker, D. — 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.

Deriving Time Discounting Correction Factors For Tto Tariffs (Article)

Attema, A.E. — 2013-04-10T00:00:00Z

The Time Trade-off (TTO) method is a popular method for valuing health state utilities and is frequently used in economic evaluations. However, this method produces utilities that are distorted by several biases. One important bias entails the failure to incorporate time discounting. This paper aims to measure time discounting for health outcomes in a sample representative for the general population. In particular, we estimate TTO scores alongside time discounting in order to derive a set of correction factors that can be employed to correct raw TTO scores for the downward bias caused by time discounting. We find substantial positive correction factors, which are increasing with the severity of the health state. Furthermore, higher discounting is found when using more severe health states in the discounting elicitation task. More research is needed to further develop discount rate elicitation procedures and test their validity, especially in general public samples. Moreover, future research should investigate the correction of TTO values for other biases as well, such as loss aversion, and to develop a criterion to test the external validity of TTO scores.

A validation of the ICECAP-O in a population of post-hospitalized older people in the Netherlands (Article)

Makai, P. — 2013-04-08T00:00:00Z

Background: Various healthcare and social services may impact not only health, but wellbeing as well. Such effects may be more fully captured by capability-wellbeing instruments than with Health-related Quality of Life (HrQol) instruments. The aim of this study is to validate the ICEpop (Investigating Choice Experiments for the Preferences of Older People) CAPability measure for Older people (ICECAP-O) capability wellbeing instrument in a population of post-hospitalized older people admitted to a hospital 3 months earlier.Methods: 296 post-hospitalized older people in the Netherlands were interviewed 3 months after admission between September 2010 and January 2011. We investigated the convergent validity of the ICECAP-O and overall wellbeing measures (Cantril's ladder and Social Production Function: Instrument for Level of Well-being (SPF-IL)), as well as with various health measures (EQ5D, Katz-15 Instrumental Activities of Daily Living (IADL) scale, Geriatric Depression Scale (GDS) and the Medical Outcomes Study Short form (SF-20) social functioning dimension). Additionally, we assessed discriminant validity by comparing several relevant subgroups in our sample (based on age, depression, IADL dependency, living situation, etc.). We also investigated the relationship between overall wellbeing and the ICECAP-O, controlling for HrQol and background characteristics.Results: This study suggests that the ICECAP-O has good convergent validity with wellbeing measures as well as health measures and discriminates between various groups of post-hospitalized older people. Wellbeing measured by both Cantril's ladder and SPF-IL is associated with the ICECAP-O in a multivariate analysis controlling for HRQoL as well.Conclusion: The ICECAP-O seems to be a valid instrument of capability-wellbeing in older, post-hospitalized people, showing good convergent validity with health and wellbeing instruments, and is able to discriminate between elderly with various health profiles. The ICECAP-O measure seems to capture both health and wellbeing. Therefore it is a promising instrument for assessing the outcomes of health and social services aimed at older people.

A large-scale longitudinal study indicating the importance of perceived effectiveness, organizational and management support for innovative culture (Article)

Cramm, J.M. — 2013-04-01T00:00:00Z

Teams participating in QI collaboratives reportedly enhance innovative culture in long-term care, but we currently lack empirical evidence of the ability of such teams to enhance (determinants of) innovative culture over time. The objectives of our study are therefore to explore innovative cultures in QI teams over time and identify its determinants. The study included QI teams participating between 2006 and 2011 in a national Dutch quality program (Care for Better), using an adapted version of the Breakthrough Method. Each QI team member received a questionnaire by mail within one week after the second (2-3 months post-implementation of the collaborative = T0) and final conference (12 months post-implementation = T1). A total of 859 (out of 1161) respondents filled in the questionnaire at T0 and 541 at T1 (47% response). A total of 307 team members filled in the questionnaire at both T0 and T1. We measured innovative culture, respondent characteristics (age, gender, education), perceived team effectiveness, organizational support, and management support. Two-tailed paired t-tests showed that innovative culture was slightly but significantly lower at T1 compared to T0 (12 months and 2-3 months after the start of the collaborative, respectively). Univariate analyses revealed that perceived effectiveness, organizational and management support were significantly related to innovative culture at T1 (all at p ≤ 0.001). Multilevel analyses showed that perceived effectiveness, organizational support, and management support predicted innovative culture. Our QI teams were not able to improve innovative culture over time, but their innovative culture scores were higher than non-participant professionals. QI interventions require organizational and management support to enhance innovative culture in long-term care settings.

Development and Validation of the Older Patient Assessment of Chronic Illness Care (O-PACIC) Scale After Hospitalization (Article)

Cramm, J.M. — 2013-03-25T00:00:00Z

Objectives of this study were to develop and validate an instrument to assess older patients' experiences with integrated care delivery after hospitalization. Our study was conducted among older individuals (≥65) who had recently been discharged from a hospital. At T1, 3 months after hospital admission, 296/457 patients (65 % response) were interviewed in their homes. At T2 12 months after hospital admission, 242/436 patients (56 % response) were interviewed. Point of departure for the development of the scale was the 20-item Patient Assessment of Chronic Illness Care (PACIC), which is proven to be a valid measure to assess chronically-ill patients' assessment of integrated primary care delivery. We tested both the PACIC and new instrument by means of structural equation modeling, and examined its validity and reliability. After eliminating 10 items of the PACIC, the confirmatory factor analyses revealed good indices of fit with the 10-item Older Patient Assessment of Chronic Illness Care (O-PACIC) Scale. To estimate construct validity of the instrument, we looked at correlations between PACIC and O-PACIC scores and the satisfaction with stroke care home subscale (SASC-Home) questionnaire. Both the PACIC and O-PACIC significantly correlated with SASC-Home subscale (at p ≤ 0.001), which indicated validity. This study demonstrated that O-PACIC is a feasible, reliable and valid tool, with strong psychometric properties. We conclude that the O-PACIC is a promising instrument to evaluate integrated care delivery after hospitalization among older patients.

The experiences of neighbour, volunteer and professional support-givers in supporting community dwelling older people (Article)

Dijk, H.M. van — 2013-03-01T00:00:00Z

Public policy increasingly emphasises the importance of informal support networks to meet the needs of the ageing population. Evidence for the types of support neighbours provide to older people and how neighbours collaborate with formal support-givers is currently insufficient. Our study therefore explored (i) types of informal neighbour support and (ii) experiences of neighbours, volunteers and professionals providing support. Interviews with nine Dutch neighbour support-givers, five volunteers and 12 professionals were conducted and subjected to latent content analysis. Findings indicate that commitment occurred naturally among neighbours; along with providing instrumental and emotional support, neighbour support seems to be a matter of carefully 'watching over each other'. Neighbour support-givers, however, are often frail themselves and become overburdened; they furthermore lack support from professionals. Neighbour, volunteer and professional support-givers seem to operate in distinct, non-collaborative spheres. Findings suggest that policy-makers should consider the opportunities and limitations of neighbour and volunteer support. Professionals have an indispensable role in providing back-up and accountable, specialised support. They may be trained to adopt a visible and proactive attitude in neighbourhoods to facilitate, cooperate with and mediate between neighbour and volunteer support-givers.

Post-Panoptic Surveillance through Healthcare Rating Sites: Who's watching whom? (Article)

Adams, S.A. — 2013-03-01T00:00:00Z

This article examines websites where patients rate and evaluate healthcare services as mechanisms for transforming citizens into surveillers of public services in order to generate knowledge about the everyday performance of professionals and institutions. Using post-panoptic theories about the use of information and communication technologies in daily life, it questions how such sites, and the knowledge they generate, relate to existing surveillance structures. It begins with a review of current surveillance literature before turning to the empirical case of the Dutch website Zoekdokter. It situates the site in its specific national health and policy context, which enables not only an analysis of the site, but also the existing rules, norms and structures for monitoring performance and the dynamic between multiple types of surveillance that occur simultaneously in practice. Zoekdokter.nl is one of six cases in this research project and is the only case where patients are encouraged to evaluate individual professionals identified by name and location. I analyze website texts and 15 stakeholder interviews using the post-panoptic concepts of sousveillance, coveillance and infoveillance. In the discussion, I use the case to reflect on several assumptions made in current post-panoptic theory and, more specifically, on the transferability of these ideas to specific sectors, such as healthcare.

The influence of organizational characteristics on employee solidarity in the long-term care sector (Article)

Cramm, J.M. — 2013-03-01T00:00:00Z

Aim. This article is a report of a study that identifies organizational characteristics explaining employee solidarity in the long-term care sector. Background. Employee solidarity reportedly improves organizations' effectiveness and efficiency. Although general research on solidarity in organizations is available, the impact of the organizational context on solidarity in long-term care settings is lacking. Design. Cross-sectional survey. Method. The study was carried out in Dutch long-term care. A total of 313 nurses, managers and other care professionals in 23 organizations were involved. Organizational characteristics studied were centralization, hierarchical culture, formal and informal exchange of information and leadership style. The study was carried out in 2009. Findings. All organizational characteristics significantly correlated with employee solidarity in the univariate analyses. In the multivariate analyses hierarchical culture, centralization, exchange of formal and informal information and transformational leadership appears to be important for solidarity among nurses, managers and other professionals in long-term care organizations, but not transactional and passive leadership styles. Conclusion. The study increased our knowledge of solidarity among nurses, managers and other professionals in the long-term care settings. Organizational characteristics that enhance solidarity are high levels of formal and informal information exchange, less hierarchical authority, decentralization and transformational leadership styles.

Beyond Two Communities. The co-production of research, policy and practice in collaborative public health settings (Doctoral Thesis)

Wehrens, R.L.E. — 2013-03-01T00:00:00Z

This thesis empirically focuses on the phenomenon of the ACCs. It does so in several ways: by investigating the general development of the ACCs over the last five years, but also by an in-depth analysis of four collaborative research projects that have been conducted in the context of these ACCs. However, this thesis does not take the notion of ‘two communities’ for granted, but rather seeks to take into account other conceptualizations of the relation between scientific knowledge production, policy development and professional practice. One of the most promising conceptualizations, which may provide analysts with more ‘analytical rigor’ than the ‘two communities’ framework is able to provide, is the notion of ‘co-production’ (Jasanoff, 2004). This radically different view on science/ policy relations focuses on how natural and social orders, or science and policy, are being produced simultaneously and interactively. Such a perspective sheds a radically different light on the interactions between researchers and policy makers. The aim of this thesis is to investigate whether a conceptualization of research/policy/practice relations in terms of this co-production framework serves as a better tool to understand these relations and interactions than the two communities perspective is able to provide.

Relational coordination between community health nurses and other professionals in delivering care to community-dwelling frail people (Article)

Cramm, J.M. — 2013-03-01T00:00:00Z

Aims: The first aim of this study was to investigate whether relational coordination is higher between primary care professionals and community health nurses than among other professionals. The second aim of this study was to investigate the relationship between different levels of relational coordination and primary care professionals' satisfaction with the care delivery of community health nurses. Background: Community health nursing is based on the notion that all activities should respond to frail people's needs in a coordinated way, together with other professionals. Relational coordination is therefore important for the effective health-care delivery by these nurses. Methods: This cross-sectional study was performed among 167 professionals (n = 323, response rate 52%) who regularly worked with community health nurses. Results: The results showed a higher degree of relational coordination with community health nurses than with other primary care professionals. Multilevel analyses revealed that professionals' satisfaction with the care delivered by community health nurses was influenced positively by relational coordination. Conclusion: Enhancing relational coordination between community health nurses and other primary care professionals in the neighborhood may improve the delivery of care to community-dwelling frail people. Implications for nursing management: Comprehensive care delivery to community-dwelling frail people requires strong connections between all health and social care professionals. Community health nurses may be an important factor in strengthening these connections.

Making Franchising Work: A Framework Based on a Systematic Review (Article)

Nijmeijer, K.J. — 2013-02-20T00:00:00Z

There is a large and fragmented literature that examines the nature of franchising. This paper aims to collect all the empirical evidence on the factors that make franchising work and to integrate this evidence in a framework. A narrative synthesis was performed of 126 peer-reviewed empirical journal articles. This review shows how the outcomes of franchising are determined by five major clusters of factors: ownership structure, business format design, contract design, behavior of the franchisor and the franchisee and their interaction, and the age and size of the system and its units. It identifies what franchisors and franchisees need to do to be successful and which evidence gaps and conflicting results remain. To yield better outcomes for both the franchisor and the franchisee, they should work on a recognizable brand name and a good working relationship; in addition, they should have suitable skills and attitudes as well as contractual exclusive territories. For further improvement of franchisee outcomes, high-quality franchisor support, decentralized decision-making, selection tools and fair contracts are essential. The effects of a high franchise proportion, active ownership, knowledge exchange and standardized operating instructions are contingent on other structural and contextual factors in the system. Conflicts and tying should be prevented. Hardly any research has been undertaken into which franchise designs are valued by customers. The authors have launched a research agenda for further research, from various theoretical perspectives, into the interactions between system elements, actors and contexts.

Statutory health insurance competition in Europe: A four-country comparison (Article)

Thomson, S. — 2013-02-08T00:00:00Z

This paper explores the goals and implementation of reforms introducing choice of and competition among insurers providing statutory health coverage in Belgium, Germany, the Netherlands and Switzerland. In theory, health insurance competition can enhance efficiency in health care administration and delivery only if people have free choice of insurer (consumer mobility), if insurers do not have incentives to select risks, and if insurers are able to influence health service quality and costs. In practice, reforms in the four countries have not always prioritised efficiency and implementation has varied. Differences in policy goals explain some but not all of the differences in implementation. Despite significant investment in risk adjustment, incentives for risk selection remain and consumer mobility is not evenly distributed across the population. Better risk adjustment might make it easier for older and less healthy people to change insurer. Policy makers could also do more to prevent insurers from linking the sale of statutory and voluntary health insurance, particularly where take-up of voluntary coverage is widespread. Collective negotiation between insurers and providers in Belgium, Germany and Switzerland curbs insurers' ability to influence health care quality and costs. Nevertheless, while insurers in the Netherlands have good access to efficiency-enhancing tools, data and capacity constraints and resistance from stakeholders limit the extent to which tools are used. The experience of these countries offers an important lesson to other countries: it is not straightforward to put in place the conditions under which health insurance competition can enhance efficiency. Policy makers should not, therefore, underestimate the challenges involved.

Effects of pay for performance in health care: A systematic review of systematic reviews (Article)

Eijkenaar, F. — 2013-02-04T00:00:00Z

Background: A vast amount of literature on effects of pay-for-performance (P4P) in health care has been published. However, the evidence has become fragmented and it has become challenging to grasp the information included in it. Objectives: To provide a comprehensive overview of effects of P4P in a broad sense by synthesizing findings from published systematic reviews. Methods: Systematic literature search in five electronic databases for English, Spanish, and German language literature published between January 2000 and June 2011, supplemented by reference tracking and Internet searches. Two authors independently reviewed all titles, assessed articles' eligibility for inclusion, determined a methodological quality score for each included article, and extracted relevant data. Results: Twenty-two reviews contain evidence on a wide variety of effects. Findings suggest that P4P can potentially be (cost-)effective, but the evidence is not convincing; many studies failed to find an effect and there are still few studies that convincingly disentangled the P4P effect from the effect of other improvement initiatives. Inequalities among socioeconomic groups have been attenuated, but other inequalities have largely persisted. There is some evidence of unintended consequences, including spillover effects on unincentivized care. Several design features appear important in reaching desired effects. Conclusion: Although data is available on a wide variety of effects, strong conclusions cannot be drawn due to a limited number of studies with strong designs. In addition, relevant evidence on particular effects may have been missed because no review has explicitly focused on these effects. More research is necessary on the relative merits of P4P and other types of incentives, as well as on the long-term impact on patient health and costs.

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

Wetering, E.J. van de — 2013-02-01T00:00:00Z

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

Real-world health care costs of relapsed/refractory multiple myeloma during the era of novel cancer agents (Article)

Gaultney, J.G. — 2013-02-01T00:00:00Z

What is known and objective: High costs of novel agents increasingly put pressure on limited healthcare budgets. Demonstration of their real-world costs and cost-effectiveness is often required for reimbursement. However, few published economic evaluations of novel agents for multiple myeloma exist. Moreover, existing cost analyses were heavily based on conventionally treated patients. We investigated real-world health care costs of relapsed/refractory multiple myeloma in Dutch daily practice. Methods: A retrospective medical chart review was conducted for 139 patients treated between January 2001 and May 2009. Total monthly costs attributable to each cost component were described across all regimens and for bortezomib-, thalidomide- and lenalidomide-based treatment regimens. Results: Mean monthly total costs (€3,981) varied depending on the sequence of therapy (range: €442-€31,318). Significant cost drivers across all regimens included costs of therapy and hospital admissions. The acquisition costs for novel agents in particular accounted for 32% of mean total monthly costs. Prognostic factors associated with increased mean total monthly costs in multivariate regression analysis included low platelet counts (P = 0·01) and worsening performance status (P < 0·001). Mean total monthly costs of bortezomib- and lenalidomide-based regimens were significantly higher than those for thalidomide-based regimens in second, third and fourth treatment line. What is new and conclusions: Real-world costs during treatment of relapsed/refractory multiple myeloma vary greatly. Cost drivers include hospital admissions and acquisition costs of novel agents. Costs also vary by prognostic factors and treatment-related resource use. Future studies assessing the costs of combination therapy consisting of two or more novel agents are encouraged.

Childbirth and Diagnosis Related Groups (DRGs): patient classification and hospital reimbursement in 11 European countries (Article)

Bellanger, M.M. — 2013-01-31T00:00:00Z

Objectives: The study compares how Diagnosis-Related Group (DRG) based hospital payment systems in eleven European countries (Austria, England, Estonia, Finland, France, Germany, Ireland, Netherlands, Poland, Spain, and Sweden) deal with women giving birth in hospitals. It aims to assist gynaecologists and national authorities in optimizing their DRG systems. Methods: National or regional databases were used to identify childbirth cases. DRG grouping algorithms and indicators of resource consumption were compared for those DRGs which account for at least 1% of all childbirth cases in the respective database. Five standardized case vignettes were defined and quasi prices (i.e. administrative prices or tariffs) of hospital deliveries according to national DRG-based hospital payment systems were ascertained. Results: European DRG systems classify childbirth cases according to different sets of variables (between one and eight variables) into diverging numbers of DRGs (between three and eight DRGs). The most complex DRG is valued 3.5 times more resource intensive than an index case in Ireland but only 1.1 times more resource intensive than an index case in The Netherlands. Comparisons of quasi prices for the vignettes show that hypothetical payments for the most complex case amount to only €479 in Poland but to €5532 in Ireland. Conclusions: Differences in the classification of hospital childbirth cases into DRGs raise concerns whether European systems rely on the most appropriate classification variables. Physicians, hospitals and national DRG authorities should consider how other countries' DRG systems classify cases to optimize their system and to ensure fair and appropriate reimbursement.

The Longitudinal Relationship Between Satisfaction with Transitional Care and Social and Emotional Quality of Life Among Chronically Ill Adolescents (Article)

Cramm, J.M. — 2013-01-28T00:00:00Z

This study aimed to identify the relationship between satisfaction with transitional care and quality of life of chronically ill adolescents over time. This longitudinal study included adolescents with type I diabetes, juvenile idiopathic arthritis (JIA), and neuromuscular disorders (NMD). At baseline 138 respondents (response rate 31 %) filled in a questionnaire and 188 about 1 year later (response rate 43 %). Analysis of variance showed that adolescents with diabetes reported the highest physical quality of life, followed in order by those with NMD and JIA (p ≤ 0.01). Adolescents with diabetes reported the highest social quality of life, followed in order by those with JIA and NMD (both at p ≤ 0.001). Univariate analyses showed that satisfaction with transitional care at T0 was significantly related to emotional and physical quality of life at T1 (both at p ≤ 0.05). At T1, satisfaction with transitional care was significantly related to the emotional, physical, and social domains of quality of life (all at p ≤ 0.001). Multiple regression analyses revealed that satisfaction with transitional care at T1 was related to emotional (β -0.20; p ≤ 0.05) and social (β -0.35; p ≤ 0.01) quality of life domains over time. This indicates that lower gap scores, which measured differences between 'best care' and 'current care,' are associated with better social and emotional quality of life in this sample of adolescents. Satisfaction with transitional care and social and emotional quality of life are related over time.

Why a successful task substitution in glaucoma care could not be transferred from a hospital setting to a primary care setting: A qualitative study (Article)

Holtzer-Goor, K.M. — 2013-01-25T00:00:00Z

Background: Healthcare systems are challenged by a demand that exceeds available resources. One policy to meet this challenge is task substitution-transferring tasks to other professions and settings. Our study aimed to explore stakeholders' perceived feasibility of transferring hospital-based monitoring of stable glaucoma patients to primary care optometrists.Methods: A case study was undertaken in the Rotterdam Eye Hospital (REH) using semi-structured interviews and document reviews. They were inductively analysed using three implementation related theoretical perspectives: sociological theories on professionalism, management theories, and applied political analysis.Results: Currently it is not feasible to use primary care optometrists as substitutes for optometrists and ophthalmic technicians working in a hospital-based glaucoma follow-up unit (GFU). Respondents' narratives revealed that: the glaucoma specialists' sense of urgency for task substitution outside the hospital diminished after establishing a GFU that satisfied their professionalization needs; the return on investments were unclear; and reluctant key stakeholders with strong power positions blocked implementation. The window of opportunity that existed for task substitution in person and setting in 1999 closed with the institutionalization of the GFU.Conclusions: Transferring the monitoring of stable glaucoma patients to primary care optometrists in Rotterdam did not seem feasible. The main reasons were the lack of agreement on professional boundaries and work domains, the institutionalization of the GFU in the REH, and the absence of an appropriate reimbursement system. Policy makers considering substituting tasks to other professionals should carefully think about the implementation process, especially in a two-step implementation process (substitution in person and in setting) such as this case. Involving the substituting professionals early on to ensure all stakeholders see the change as a normal step in the professionalization of the substituting professionals is essential, as is implementing the task substitution within the window of opportunity.

Underestimated uncertainties. Hospital-at-home for COPD exacerbations and methodological issues in the economic evaluation of healthcare (Doctoral Thesis)

Goossens, L.M.A. — 2013-01-18T00:00:00Z

Economic evaluation has been defined as `the comparative analysis of alternative courses of action in terms of both their costs and consequences’. In an economic evaluation in healthcare, two or more interventions are compared in terms of costs and health outcomes. This results in estimates of the incremental health effects and the incremental costs. If one intervention leads to higher costs as well as more health benefits, an incremental costeffectiveness ratio (ICER) can be calculated. This ratio expresses the cost per additional unit of health gain. An economic evaluation can play a role in policy makers’ decisions on whether the health benefits of an intervention are worth the costs.