Johan J. Polder

Hip fracture in elderly patients: outcomes for function, quality of life, and type of residence.

A prospective study was done to investigate functional outcome, quality of life, and type of residence after hip fracture in patients 65 years of age and older. One hundred two patients admitted consecutively to a university and a general hospital were followed up as long as 4 months after admission. The mean age of the participants was 83 years; 58% of patients came from their own home, and 42% of patients came from institutions. Nearly 70% of patients had two or more diagnoses other than the hip fracture. Cumulative mortality was 20% at 4 months after fracture. Of surviving patients, 57% were back in their original situation for accommodation, 43% reached the same level of walking ability, and 17% achieved the same level of activities of daily living as before fracture. Patients experienced on average three complications, 26% of which were severe. Quality of life improved in the followup period of 4 months; however, the quality of life at 4 months was worse than the quality of life reported in a reference population. Average costs amounted to ε (Euro) 15.338 (which at the time was nearly equivalent to the US dollar) per patient, with nearly 50% of the costs attributable to hospital costs and 30% attributable to nursing home costs. The results of this study show a poor outcome after hip fracture in elderly patients.

Explorative study of costs, effects and savings of screening for female fragile X premutation and full mutation carriers in the general population.

Objective: Evaluation of the costs, effects and savings of three strategies for female fragile X premutation and full mutation carrier screening in the general population. Methods: We calculated the costs, effects and savings by using a general model for prenatal, preconceptional, and school carrier screening. Assumptions were based on literature data, expert opinions, prices and tariffs. Results: Prenatal screening will detect most carriers and will lead to the highest number of avoided fragile X syndrome patients. The costs per detected carrier are quite similar for all screening programmes (around USD 45,000). All screening strategies have a favourable cost-savings balance (USD 14 million for prenatal screening, USD 9 million for preconceptional screening and USD 2 million for school screening). Conclusions: From an economic point of view, there is no obstacle to fragile X screening. The decision to screen or not can (and should) therefore concentrate on discussion of medical, social, psychological and ethical considerations.

Early discharge of hip fracture patients from hospital: transfer of costs from hospital to nursing home.

Hip fracture patients occupy more and more hospital beds. One of the strategies for coping with this problem is early discharge from the hospital to institutions with rehabilitation facilities. We studied whether early discharge affects outcome and costs. 208 elderly patients with a hip fracture were followed up to 4 months after the fracture. First, a group of 102 patients stayed in our hospital for the usual period (median 18 days). Then, 106 patients were assigned to a group for early discharge (median 11 days). We measured disabilities, health-related quality of life and cognition at 1 week, 1, and 4 months after hospitalization. To calculate total societal costs, inpatient days, the efforts of professionals in- and outside institutions, and interventions/examinations were recorded during this 4-month period. At 4 months, we found no differences in mortality, ADL level, complications, quality of life, and type of residence. More patients in the early discharge group were discharged to nursing homes with rehabilitation facilities (76% versus 53%), but the median total stay in hospital and nursing home was the same (26 days). Early discharge from hospital did not substantially reduce the total costs (conventional management ] 15,338 per patient and early discharge ] 14,281 per patient), but merely shifted them from the hospital to the nursing home.

Anticipated costs of hospitalization for respiratory syncytial virus infection in young children at risk.

Background: Reliable estimates of hospitalization costs for severe respiratory syncytial virus (RSV) infection are necessary to perform economic analyses of preventive strategies of severe RSV disease. We aimed to develop a model that predicts anticipated mean RSV hospitalization costs of groups of young children at risk for hospitalization, but not yet hospitalized, based on readily available child characteristics. Methods: We determined real direct medical costs of RSV hospitalization from a societal perspective, using a bottom-up strategy, in 3458 infants and young children hospitalized for severe RSV disease during the RSV seasons 1996–1997 to 1999–2000 in the Southwest of the Netherlands. We used a linear regression model to predict anticipated mean RSV hospitalization costs of groups of children at risk, based on 4 child characteristics [age, gestational age, birth weight and bronchopulmonary dysplasia (BPD)], expressed in EC Euros as of the year 2000. Findings: The mean RSV hospitalization costs of all patients were &U20AC;3110. RSV hospitalization costs were higher for patients with lower gestational age (&U20AC;5555; gestational age, ≤28 weeks), lower birth weight (&U20AC;3895; birth weight ≤2500 g), BPD (&U20AC;5785; with BPD) and young age (&U20AC;4730; first month of life). The linear regression model had an adjusted R2 of 0.08. This indicates a low explanatory ability for hospitalization costs of individual children. However, the model could accurately estimate the anticipated mean hospitalization costs of groups of children with the same characteristics. Interpretation: RSV hospitalization costs were substantial, especially of specific high risk groups. Anticipated mean hospitalization costs of groups of children at risk for RSV hospitalization, but not yet hospitalized, could well be estimated with 4 child characteristics (age, gestational age, birth weight and BPD). These estimated costs can be used for economic analyses of preventive strategies for severe RSV disease.

A cluster-randomised trial of screening for language disorders in toddlers

Objective: To assess the screening performance of a specific language-screening instrument at 18 and 24 months of age and to assess its effect on the early detection and prognosis of language delay. Design: Child health care physicians were randomised to the intervention group, in which specific language screening was conducted twice (at age 18 months and 24 months), or to the control group (usual care). The specific screening instrument consisted of a uniform set of questions for the parents and test elements for the child, with scaled scores to assess responses. Setting: Child health care in the Netherlands and referral of screen-positive children. Subjects: 5734 children in the intervention group and 4621 in the control group. Main outcome measures: Test characteristics and disorders at 24 months, and confirmed diagnoses of a language disorder before 36 months in both groups. Gold standard based on reports of parents, specialists and expert panel. Prognosis estimated from two diagnostic language development performance scores at 36 months (in questionnaire). Results: In the intervention group, 3147 of the 5734 children (55%) were screened with the specific screening instrument and 73 of the screened children (2.3%) were screen-positive. Of the screen-positive children, 41 (55%) had confirmed language delay (diagnostic assessment and/or reported treatment). The estimated sensitivity of the test ranged between 24–52% depending on the severity of language disorders. The prevalence of language disorders in three-year olds was estimated to be 2.4–5.3%. In the intervention group, 1.25–2 times more children with language delay had been diagnosed before 36 months. The assessment of language development at 36 months showed no statistically significant differences between the intervention and the control groups. Conclusions: The inclusion of a specific language-screening instrument in child health centre activities resulted in the earlier detection of children with language delay. Short-term health benefits could not be demonstrated. Large-scale introduction cannot be recommended on the basis of this information alone.

Passive immunisation against respiratory syncytial virus: a cost-effectiveness analysis

Aim The cost-effectiveness of passive immunisation against respiratory syncytial virus (RSV) in the Netherlands was studied by assessing incremental costs to prevent one hospitalisation in high-risk children using a novel individualised monthly approach. Methods Cost-effectiveness analysis was performed by combining estimates of individual hospitalisation costs and monthly hospitalisation risks, with immunisation costs, parental costs and efficacy of passive immunisation for a reference case with the highest hospitalisation risks and costs of hospitalisation during the RSV season (male, gestational age ≤28 weeks, birth weight ≤2500 g, having bronchopulmonary dysplasia (BPD), aged 0 months at the beginning of the season (October)). Various sensitivity analyses and a cost-neutrality analysis were performed. Results Cost-effectiveness of passive immunisation varied widely by child characteristics and seasonal month. For the reference case it was most cost effective in December at €13 190 per hospitalisation averted. Cost-effectiveness was most sensitive to changes in hospitalisation risk. For the reference case, cost neutrality was reached in December, if acquisition costs of passive immunisation decreased from €930 to €375, monthly hospitalisation risk increased from 7.6% to 17%, or hospitalisation costs increased from €10 250 to €23 250 per hospitalisation. Even if passive immunisation prevented all hospitalisations, costs per hospitalisation averted in December would still exceed €2645. Conclusions Although cost-effectiveness of passive immunisation varied strongly by child characteristics and seasonal month, incremental costs per hospitalisation averted were always high. A restrictive immunisation policy only immunising children with BPD in high-risk months is therefore recommended. The costs of passive immunisation would have to be considerably reduced to achieve cost-effectiveness.

Efficacy of cascade testing for fragile X syndrome.

ObjectiveFragile X syndrome is the most common cause of mental retardation from a single gene defect, transmitted in an X-linked semidominant fashion. Cloning of the gene responsible for fragile X syndrome has made it possible to identify carriers who are at risk of giving birth to a child with fragile X syndrome. One of the proposed strategies for identifying carriers is cascade testing, in which relatives of a patient with fragile X syndrome (the index case) are tested. Because the effectiveness of this type of testing is unknown, the objective of this study was to develop a simulation model for studying the consequences of cascade testing for fragile X syndrome. MethodsWith this model, 100 000 five-generation pedigrees were simulated to assess the maximum number of carriers that would be detected for three scenarios: (a) only first degree relatives of the index case are tested; (b) relatives up to the third degree are tested; (c) relatives up to the fifth degree are tested. ResultsIn the start-up phase of the testing programme, 18% of couples who will have a fragile X syndrome child are detected. After this phase the (stabilised) cascade testing programme detects 7% of undetected couples who would have a fragile X syndrome child if only first degree relatives were tested, 12% if first to third degree relatives were tested, and 15% if first to fifth degree relatives were tested. To detect 90% of all premutation and full mutation carriers at least eight consecutive generations need to be tested. ConclusionsThe results of our analysis show that cascade testing is not very effective in detecting carriers.

Health-care costs of ageing

1touch on a persistent misunderstanding about the relation between demography, population health, and health-care costs. They argue that the costs of health care are related to the process of dying, not to age-related illness and disability, and that these costs are difficult to control; they base their argument on epidemiological data from primary care, and on hospital costs. However, they are misled by their narrow focus on acute health care. General practice generates less than 4% of total health-care costs in the Netherlands, and hospital care (excluding psychiatric hospitals) only 32%. The picture changes dramatically when all health-care costs in the Netherlands are taken into account for 1988 2 or 1994. 2,3 Contrary to what the investigators suggest, detailed data on the distribution of all health-care costs Diagnostic category (ICD-9 code) Men Women Total Dementia (290) 316 (12·8%) 1298 (19·2%) 1614 (17·5%) Stroke (430–38) 199 (8·0%) 477 (7·1%) 676 (7·3%) Musculoskeletal (710–39) 76 (3·1%) 350 (5·2%) 426 (4·6%) Falls (E880–888) 59 (2·4%) 339 (5·0%) 398 (4·3%) Symptoms and ill-defined (780–99) 112 (4·5%) 252 (3·7%) 364 (3·9%) Cancer (140–208) 148 (6·0%) 179 (2·7%) 327 (3·5%) Heart failure (428–29) 84 (3·4%) 165 (2·4%) 248 (2·7%) Other circulatory (390–98, 415–27, 440–59) 97 (3·9%) 142 (2·1%) 239 (2·6%) Nervous (320–359) 84 (3·4%) 145 (2·1%) 229 (2·5%) Other respiratory (460–87, 500–19) 79 (3·2%) 104 (1·5%) 183 (2·0%) Other mental (293–94, 297–99, 301–02, 306–16) 44 (1·8%) 137 (2·0%) 182 (2·0%) Eye (360–79) 48 (1·9%) 117 (1·7%) 164 (1·8%)

Code of Practice on Human Genetic Testing Services Supplied Direct to the Public

This article is also accessible online at: http://BioMedNet.com/karger 1. Testing Laboratories, Equipment and Reagents All equipment and reagents for testing should be manufactured and maintained to an appropriate level and provide assured levels of accuracy and reliability that reflects current best practice. All laboratories offering genetic testing services should be appropriately staffed and equipped, and should: (1) participate in an appropriate accreditation scheme; (2) join an appropriate external quality assurance scheme, and (3) perform adequate internal quality control. All such systems should reflect current best practice.