Willem Jan Meerding

Demographic and epidemiological determinants of healthcare costs in Netherlands: cost of illness study

abstract Objectives: To determine the demands on healthcare resources caused by different types of illnesses and variation with age and sex. Design: Information on healthcare use was obtained from all 22 healthcare sectors in the Netherlands. Most important sectors (hospitals, nursing homes, inpatient psychiatric care, institutions for mentally disabled people) have national registries. Total expenditures for each sector were subdivided into 21 age groups, sex, and 34 diagnostic groups. Setting: Netherlands, 1994. Main outcome measures: Proportion of healthcare budget spent on each category of disease and cost of health care per person at various ages. Results: After the first year of life, costs per person for children were lowest. Costs rose slowly throughout adult life and increased exponentially from age 50 onwards till the oldest age group (95). The top five areas of healthcare costs were mental retardation, musculoskeletal disease (predominantly joint disease and dorsopathy), dementia, a heterogeneous group of other mental disorders, and ill defined conditions. Stroke, all cancers combined, and coronary heart disease ranked 7, 8, and 10, respectively. Conclusions: The main determinants of healthcare use in the Netherlands are old age and disabling conditions, particularly mental disability. A large share of the healthcare budget is spent on long term nursing care, and this cost will inevitably increase further in an ageing population. Non-specific cost containment measures may endanger the quality of care for old and mentally disabled people. Key messages Little is known about demands for health care outside acute sectors In the Netherlands health costs are strongly age dependent, increasing exponentially after age 50 The five highest healthcare costs are for mental retardation, musculoskeletal disease, dementia, other mental disorders, and ill defined conditions Coronary heart disease, all cancers, and stroke accounted for only 9% of costs The main healthcare costs are for care not cure and costs are likely to increase rapidly in an ageing society

Distribution and determinants of health and work status in a comprehensive population of injury patients.

BACKGROUND Insight into the distribution and determinants of both short- and long-term disability can be used to prioritize the development of prevention policies and to improve trauma care. We report on a large follow-up study in a comprehensive population of injury patients. METHODS We fielded a postal questionnaire in a stratified sample of 4,639 nonhospitalized and hospitalized injury patients aged 15 years and older, at 2, 5, and 9 months after injury. We gathered sociodemographic information, data on functional outcome with a generic instrument for health status measurement (EuroQol EQ-5D+) and data on work absence. RESULTS The response rates were 39%, 75%, and 68% after 2, 5, and 9 months, respectively. The reported data were adjusted for response bias and stratification. The 2-month health status of nonhospitalized patients was comparable to the general populations health when measured by the EQ-5D summary score, although considerable prevalence of restrictions in usual activities (24.0%) and pain and discomfort (34.8%) were reported. Hospitalized patients reported higher prevalences of disability in all health domains. Their mean EQ-5D summary score increased from 0.62 at 2 months to 0.74 at 5 months but remained below the population norm at 9 months, particularly for patients with a long hospital stay. Patients with injuries of the spinal cord and vertebral column, hip fracture, and other lower extremity fractures reported the worst health status, also when adjusted for age, sex, and educational level. Age, sex, type of injury, length of stay, educational level, motor vehicle injury, medical operation, intensive care unit admission, and number of injuries were all significant predictors of functioning. Nonhospitalized and hospitalized injury patients lost on average 5.2 and 72.1 work days, respectively. Of nonhospitalized patients, 5% had not yet returned to work after 2 months, and 39%, 20%, and 10% of hospitalized patients had not yet returned to work after 2, 5, and 9 months, respectively. In a multivariate regression analysis, length of stay, type of injury, level of education, and intensive care unit admission appeared to be significant predictors of absence duration and return to work. CONCLUSION Injury is a major source of disease burden and work absence. Both hospitalized and nonhospitalized patients contribute significantly to this burden.

Measuring productivity changes in economic evaluation: Setting the research agenda

Productivity costs related to illness may be relevant in assessing healthcare programmes for patients, as well as occupational interventions for workers. When performing an economic evaluation for both types of programmes, a sound methodology for measuring and valuing these productivity costs is essential. This article reviews research questions related to productivity and health, focusing on the costs of short-term absence from work, productivity costs without absence (‘presenteeism’) and possible compensation mechanisms and circumstances that may affect productivity costs. Furthermore, the important but under-explored relationship between productivity and QOL is analysed.Strategies for better answers on these research questions, such as developing more valid measurement instruments, are discussed. It is stressed that the analysis of productivity costs should not be restricted to the level of the individual patient and worker but extended to the level of teams of workers and firms. It may be advisable to explore several issues such as compensation mechanisms and efficiency losses in detail using employee questionnaires and consecutively applying the key elements in patient settings. It seems advisable to develop flexible, modular instruments for measuring and valuing absence from work, compensation mechanisms, efficiency loss and details of jobs and organisation in an integrative and consistent way. Further, it seems crucial to identify what determinants of jobs and organisations are the key factors in estimating productivity costs. This list of determinants could be mapped with a classification of jobs, to be used as a screener in patient questionnaires.

Liquid-based cervical cytology†

The objective of the current study was to evaluate the applicability of liquid‐based cytology in the Netherlands population screening program for cervical cancer.

Assessing the burden of injury in six European countries

OBJECTIVE To assess injury-related mortality, disability and disability-adjusted life years (DALYs) in six European countries. METHODS Epidemiological data (hospital discharge registers, emergency department registers, mortality databases) were obtained for Austria, Denmark, Ireland, Netherlands, Norway, and the United Kingdom (England and Wales). For each country, the burden of injury was estimated in years lost due to premature mortality (YLL), years lived with disability (YLD), and DALYs (per 1000 persons). FINDINGS We observed marked differences in the burden of injury between countries. Austria lost the largest number of DALYs (25 per 1000 persons), followed by Denmark, Norway and Ireland (17-20 per 1000 persons). In the Netherlands and United Kingdom, the total burden due to injuries was relatively low (12 per 1000 persons). The variation between countries was attributable to a high variation in premature mortality (YLL varied from 9-17 per 1000 persons) and disability (YLD varied from 2-8 per 1000 persons). In all countries, males aged 25-44 years represented one third of the total injury burden, mainly due to traffic and intentional injuries. Spinal cord injury and skull-brain injury resulted in the highest burden due to permanent disability. CONCLUSION The burden of injury varies considerably among the six participating European countries, but males aged 15-24 years are responsible for a disproportionate share of the assessed burden of injury in all countries. Consistent injury control policy is supported by high-quality summary measures of population health. There is an urgent need for standardized data on the incidence and functional consequences of injury.

Prevalence and Prognostic Factors of Disability After Childhood Injury

Objective. To assess the prevalence and the prognostic factors of disabilities after minor and major childhood injuries and to analyze which sociodemographic and injury-related factors are predictive for suboptimal functioning in the long term. Method. We conducted a patient follow-up study in a stratified sample of 1221 injured children who were aged 5 to 14 years and had visited an emergency department in the Netherlands. Our study sample was stratified so that severe, less common injuries were overrepresented. Postal questionnaires were sent 2.5, 5, and 9 months after the injury. We gathered injury and external cause data, sociodemographic information, and data on functional outcome with a generic health status measure EuroQol (EQ-5D) with an additional cognitive dimension. A nonresponse analysis was performed by multivariate logistic regression, and the data were adjusted for nonresponse and the sample stratification. We performed bootstrap analysis to estimate the prevalence of disability in terms of the EQ-5D summary score and the occurrence of limitations in separate health domains: mobility, self-care, usual activities, pain/discomfort, anxiety/depression, and cognition. Respondents also rated their own health state on a visual analog scale, between 0 (worst imaginable health state) and 100 (best imaginable health state). We analyzed the relationship between functional outcome and sociodemographic (age and gender) and injury-related determinants (type of injury, external cause, multiple injury, admission to hospital, and length of stay) by logistic regression analysis. Results. Response rates with respect to the original sample were 43%, 31%, and 30%, respectively. A total of 37% of the children were admitted to the hospital. The mean age of the children was 9.6 years. In two thirds (65%) of the cases, the injury was attributed to a home and/or leisure injury. The health status of injured children improved from 0.92 (EQ-5D summary score) at 2.5 months to 0.96 at 5 months and 0.98 at 9 months. Of all injured children, 26% had at least 1 functional limitation after 2.5 months, 18% after 5 months, and 8% still experienced functional limitations after 9 months. After 2.5 months, lower extremity fractures and other injuries (eg, spinal cord injury, injury of the nerves) demonstrated the worst functional outcome. Independent of the type of injury, our sample of injured children generally showed good recovery between 2.5 and 9 months. The highest prevalence of dysfunction after 9 months existed for pain/discomfort (7%) and usual activities (5%). Hospital admission (odds ratio: 3.6–5.8) and female gender (odds ratio: 3.0) were predictive for long-term disability. Girls reported more problems for all health domains (except self-care) compared with boys after 9 months, which was also confirmed by the visual analog scale score for self-related health (89 for girls vs 95 for boys). Almost one fifth of injured children with a hospital stay of >3 days still had pain and problems with usual activities 9 months after the injury. Three quarters of all residual problems were caused by nonhospitalized injuries. Conclusion. Most children show quick and full recovery after injury, but a small subgroup of patients (8%) have residual disabilities after 9 months. Girls have a 3-fold risk compared with boys for long-term disability after childhood injury. Prognosis in the long-term is also negatively influenced by hospitalization, but in absolute terms, residual disabilities are frequently caused by injuries that are treated fully in the emergency department. The group of injured children with persistent health problems as identified in this study indicates the importance of health monitoring over a longer period in trauma care, whereas trauma care should be targeted at early identification and management of the particular needs of these patients.

Economic costs of health inequalities in the European Union

Background In order to support the case for inter-sectoral policies to tackle health inequalities, the authors explored the economic costs of socioeconomic inequalities in health in the European Union (EU). Methods Using recent data on inequalities in self-assessed health and mortality covering most of the EU, health losses due to socioeconomic inequalities in health were calculated by applying a counterfactual scenario in which the health of those with lower secondary education or lower (roughly 50% of the population) would be improved to the average level of health of those with at least higher secondary education. We then calculated various economic effects of those health losses: healthcare costs, costs of social security schemes, losses to Gross Domestic Product (GDP) through reduced labour productivity and the monetary value of total losses in welfare. Results Inequality related losses to health amount to more than 700 000 deaths per year and 33 million prevalent cases of ill health in the EU as a whole. These losses account for 20% of the total costs of healthcare and 15% of the total costs of social security benefits. Inequality related losses to health reduce labour productivity and take 1.4% off GDP each year. The monetary value of health inequality related welfare losses is estimated to be €980 billion per year or 9.4% of GDP. Conclusion Our results suggest that the economic costs of socioeconomic inequalities in health in Europe are substantial. As this is a first attempt at quantifying the economic implications of health inequalities, the estimates are surrounded by considerable uncertainty and further research is needed to reduce this. If our results are confirmed in further studies, the economic implications of health inequalities warrant significant investments in policies and interventions to reduce them.

Methodological issues in comparing injury incidence across countries

The primary objective was to describe the methodological challenges and devise solutions to compare injury incidence across countries. The research design was a mixed methods study, consisting of a consultation with an expert group and comparison of injury surveillance systems and data from ten European countries. A subset of fractures, selected radiologically verifiable fractures and a method of checking the national representativeness of sample emergency department data were devised and are proposed for further development.These methodological considerations and developments will be further refined and tested and should prove useful tools for those who need to compare injury incidence data across countries.

Setting priorities in injury prevention: the application of an incidence based cost model

Objectives: To make detailed calculations on the direct medical costs of injuries in the Netherlands to support priority setting in prevention. Methods: A computerised, incidence based model for cost calculations was developed and incidence figures derived from the Dutch Injury Surveillance System (LIS) which provides national estimates of the annual number of patients treated at an emergency department. A comprehensive set of cost elements (that is, health care segments) was obtained from health care registrations and a LIS patient survey. Patients were assigned to specific groups based on LIS characteristics (for example, age, injury type). Average costs per patient group were calculated for each cost element and total costs estimated by adding costs for all patient groups. Results: The direct costs of injury average 2000 guilders per injury patient attending an emergency department. Home and leisure injuries account for over half of the costs, although cost per patient is highest for motor vehicle injuries. Injuries to the lower extremities account for almost half of the total costs and are incurred mainly in the home or recreation. Motor vehicle crashes are the major cause of head injuries. Conclusions: The model permits continuous and detailed monitoring of injury costs. Estimates can be compiled for any LIS patient group or injury subcategory. The results can be used to rank injuries for prioritisation of prevention by injury categories (for example, traffic, home, or leisure), or by specific scenarios (for example, fall at home).

Preferences of GPs and Patients for Preventive Osteoporosis Drug Treatment: A Discrete-Choice Experiment

AbstractBackground: Osteoporotic fractures have a serious economic impact on society and on the quality of life of patients. Differences in opinions on the desirability of preventive treatment initiation may hamper the process and outcome of shared decision making between physician and patient. Objective: To evaluate and compare preferences of GPs and patients for preventive osteoporosis drug treatment. Methods: Discrete-choice experiment (DCE) involving 34 general practices in the area of Rotterdam, the Netherlands. Participants included 40 GPs and 120 women aged ≥60 years who participated in a study on osteoporosis case finding. We included any woman aged >60 years, with an over-representation of women with a high fracture risk (n = 60). Outcomes: (i) The relative weights that GPs and patients place on five treatment attributes of preventive osteoporosis drug treatment: effectiveness, nausea as an adverse effect, total treatment duration, route of drug administration and out-of-pocket costs; and (ii) the determinants of any differences in preferences between GPs and patients. Results: The response rate was 40/59 (68%) for GPs and 120/181 (66%) for patients. All treatment attributes proved to be important for preferences of GPs and patients. GPs had a significantly less favourable attitude towards preventive osteoporosis drug treatment than patients; they placed significantly higher values on effectiveness of preventive drug treatment and short total preventive treatment duration than patients. Conclusions: GPs and patients showed different preferences towards preventive osteoporosis drug treatment. Addressing each of these differences may have a positive effect on the process and outcomes of shared decision making regarding preventive treatment initiation.