Describing health and medical costs, and the economic evaluation of health care: applications in injuries and cervical cancer

Since the late nineteenth century, population's health has improved tremendously, at least in wealthy nations. Life expectancy at birth in the Netherlands has increased at an unprecedented pace from less than 40 years in 1860 to currently 76 years for males and 81 years for females. It is widely accepted that better hygiene, housing and nutrition have contributed to this increase through a reduction in communicable diseases, rather than medical care. The small overlap between the period with the major declines in mortality and the period of major advances in medicine suggests that the contribution of medical care to population health is at least limited, and has even been doubted [170]. However, it is now commonly believed that many preventive and curative interventions have contributed to improved health [153]. Diseases that were killers in the past can now be cured or prevented. The improvement of population health comes at a price. Particularly from the 1970s onwards, health care spending has increased fast, and currently accounts for about 10% of the gross national product. The increase in health care spending is, apart from wage and price increases, generally attributed to two phenomena: the development of medical technology and, more recently, the ageing of society. It is too commonplace to claim that medical innovation is cost increasing in generaL Some innovations will increase costs, whereas others will be cost saving. In fact, the economic consequences of technologies can only be assessed for specific technologies related to specific indications [91]. For example, preventive interventions such as cervical and breast cancer screening are effectively reducing cancer incidence but costs have shown to outweigh savings [270 280]. In contrast, treatment of stroke patients in specialized stroke units results in more favourable health outcomes and cuts costs compared to treatment in general wards [122]. However, there are strong indications that on an aggregate level medical technology leads to increased health care spending [219]. An objective of health care policy is to provide health care in such manner that population's health is maximized with an efficient use of resources. The current situation has put pressure upon policy makers to contain health care costs, and to restrict access to health care interventions that are evidence based, with proven effectiveness, and with acceptable cost-effectiveness. However, health (care) policies that maximize the overall health benefit at contained costs can only be successful when data are available on a population's health and its determinants, on health care needs, and on the effectiveness and efficiency of existing and newly developed medical technology. In this thesis we present these data for two quite different health problems: injury and cervical cancer. For injury, population based estimates are presented of health care costs and post-injury functional outcome, subdivided by injury diagnoses. We also investigated determinants of injury related health care costs and functional outcome. For cervical cancer, we evaluated several options to improve the efficiency of population based screening and follow-up. The thesis starts with a chapter on the distribution of total health care costs by diseases and injuries, and by basic demographic indicators.

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