[Costs and benefits of smoking]. / De rekening van roken.

- Two recent societal cost-benefit analyses have documented the costs of smoking and the cost-effectiveness of preventing smoking.- Smoking costs the Netherlands society EUR 33 billion per year.- The majority of this is the monetary value of health loss; these are "soft" euros that cannot be re-spent.- There is not a great deal of difference between costs and benefits when expressed in "hard" euros, which means that there is no clear business case for anti-smoking policy.- The greatest benefit of discouraging smoking is improved health for the individual and increased productivity for the business sector; however, the benefits cannot be easily realised, because even in the most favourable scenario the number of smokers will decrease slowly.- Excise duties seem to offer the most promising avenue for combating smoking. The benefits of anti-smoking policy, therefore, consist mainly of tax revenues for the government.- Stringent policy is required to transform tax revenues into health gains.

The impact of healthcare costs in the last year of life and in all life years gained on the cost-effectiveness of cancer screening.

It is under debate whether healthcare costs related to death and in life years gained (LysG) due to life saving interventions should be included in economic evaluations. We estimated the impact of including these costs on cost-effectiveness of cancer screening. We obtained health insurance, home care, nursing homes, and mortality data for 2.1 million inhabitants in the Netherlands in 1998-1999. Costs related to death were approximated by the healthcare costs in the last year of life (LastYL), by cause and age of death. Costs in LYsG were estimated by calculating the healthcare costs in any life year. We calculated the change in cost-effectiveness ratios (CERs) if unrelated healthcare costs in the LastYL or in LYsG would be included. Costs in the LastYL were on average 33% higher for persons dying from cancer than from any cause. Including costs in LysG increased the CER by 4040 euro in women, and by 4100 euro in men. Of these, 660 euro in women, and 890 euro in men, were costs in the LastYL. Including unrelated healthcare costs in the LastYL or in LYsG will change the comparative cost-effectiveness of healthcare programmes. The CERs of cancer screening programmes will clearly increase, with approximately 4000 euro. However, because of the favourable CER's, including unrelated healthcare costs will in general have limited policy implications.

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.

Community income and surgical rates in the Netherlands.

BACKGROUND: The study describes variations in use of surgical procedures by community income in the Netherlands. From the literature it is known that surgical rates have a socioeconomic gradient. Both positive and negative associations of socioeconomic factors of patients (for example, income, education) with surgical rates have been reported. The question raised here is: how do (possible) socioeconomic variations in surgery in the Netherlands compare with variations observed elsewhere? DATA AND METHODS: The data comprised Dutch hospital discharges and population estimates for 1999. Socioeconomic status was indicated by a patient's income and based on the average family income of the postcode area of residence. Poisson regression was used to compute relative incidence (odds ratios) for 10 common surgical procedures. The model included age, gender, degree of urbanisation, and province of residence. RESULTS: The association between surgical rates and community level income is rather weak. For half of the surgical rates the authors observed higher utilisation rates in communities with low income levels, but the differences are small. The range of odds ratios in the lowest income quintile group (compared with the group with the highest income) observed is: 0.87 to 1.18. Men from a low income community received more appendicectomies (1.18), cholecystectomies (1.12), knee replacements (1.06), and prostatectomies (1.14) and less tonsillectomies (0.90). Women from a low income community received more appendicectomies (1.12), caesarean sections (1.18), hip and knee replacements (1.05,1.17), and hysterectomies (1.14). Whereas they received less coronary artery bypass grafts (0.92), cholecystectomies (0.87), and tonsillectomies (0.92). CONCLUSIONS: Compared with findings reported in the international literature, this study indicates that variations in use of surgical procedures by community income in the Netherlands are comparatively small. Because of lack of data the authors could not study the influence of variations in need for surgical care by community income, but as the incidence of conditions requiring surgical interventions generally is higher in lower income groups, it is suspected some degree of underutilisation exists in these groups.

Healthcare costs of intellectual disability in the Netherlands: a cost-of-illness perspective.

Healthcare costs are continuously increasing, and impose a strong responsibility on governments for an adequate allocation of resources among healthcare provisions and patients. The aims of the present study were to describe the healthcare costs of intellectual disability (ID) and other mental disorders in the context of the total costs of all other diseases, and to determinate the future need of healthcare resources, especially for ID and mental disorders. The present authors performed a top-down cost-of-illness study comprising all healthcare costs of the Netherlands in 1994. Data on healthcare use were obtained for all 22 healthcare sectors, and used to ascribe costs to disease groups, age and sex. Costs of mental disorders are by far the largest in the Dutch healthcare system. Some 25.8% of total disease-specific costs could be ascribed to mental disorders: psychiatric conditions, 10.6%; ID, 9.0%; and dementia, 6.2%. There are large differences between age and sex groups. The costs of ID and schizophrenia are higher among men, and the costs of dementia and depression are higher among women. The age pattern shows two peaks: the first occurs at 25-35 years of age (ID and psychiatric conditions); and the second at 75-85 years of age (dementia). Time trends between 1988 and 1994 show an average annual growth rate of 5.2% for total healthcare costs: psychiatric conditions, 4.8%; ID, 5.4%; and dementia, 9.4%. Demographic projections suggest a less-than-average cost increase for ID and psychiatric disorders (with annual growth rates of 0.2% and 0.4%, respectively) compared to the costs of dementia and total healthcare (with annual growth rates of 1.6% and 0.9%, respectively). Intellectual disability and mental disorders represent a large part of healthcare use in the Netherlands. The costs will inevitably increase because of the ageing of the population and increasing life expectancy among people with disabilities. Non-specific cost containment measures may endanger the quality of care for vulnerable people at younger and older ages.

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 euro (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.

Professional autonomy in the health care system.

Professional autonomy interferes at a structural level with the various aspects of the health care system. The health care systems that can be distinguished all feature a specific design of professional autonomy, but experience their own governance problems. Empirical health care systems in the West are a nationally coloured blend of ideal type health care systems. From a normative perspective, the optimal health care system should consist of elements of all the ideal types. A workable optimum taking national values into account could be attained by governance structures that also introduce elements from other ideal type systems. Thus a normative approach to medical practice guaranteeing an essential degree of professional autonomy for a relationship of trust between the patient and the physician, could be combined with an efficient and equitable allocation of health care resources.

Efficacy of cascade testing for fragile X syndrome.

OBJECTIVE: Fragile 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. METHODS: With 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. RESULTS: In 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. CONCLUSIONS: The results of our analysis show that cascade testing is not very effective in detecting carriers.

[The cost of sickness in the Netherlands in 1994; the main determinants were advanced age and disabling conditions]. / Kosten van ziekten in Nederland in 1994; grootste zorgverbruik door hoge leeftijd en beperkende aandoeningen.

OBJECTIVE: To estimate the costs of health care in 1994, the development of the costs assigned to specific diseases, and the future costs. DESIGN: Descriptive. SETTING: Erasmus University, Department of Public Health, Rotterdam, the Netherlands. METHOD: For each health care sector, costs were allocated to 62 diagnostic groups, age and sex making maximal use of national registries and other sources with data on health care use in the Netherlands. RESULTS: More than 80% of the 60 billion Dutch guilders that were spent on health care in 1994 could be assigned to specific diseases. Most costs were made for non-fatal diseases like mental deficiency, dementia and musculoskeletal disease. Except for cardiovascular disease, the share of major causes of death in the total costs was not significant. Average costs per inhabitant were low during youth and adulthood but increased exponentially with age from age 50 onwards. Between 1988 en 1994, health care costs experienced an annual growth rate of 5.2%, caused by price and wage increases (one half), ageing (a quarter) and other effects on health care costs such as epidemiological and technological change (a quarter). CONCLUSION: The main determinants of health care use in the Netherlands were old age and disabling conditions. Due to ageing and other influences, real health care costs in the years to come will increase by an average annual rate of 2.4%.

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

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 (> or = 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.

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.

[Ultrasonography of the leg veins is cost-effective and can be the preferred diagnostic study in suspected pulmonary embolism]. / Bij vermoeden van longembolie kan echografie van de beenvenen onderzoek van eerste keuze zijn omdat het kosteneffectief is.

OBJECTIVE: To determine whether compression ultrasound examination of both legs, to detect deep venous thrombosis, can be the examination of first choice in patients clinically suspected of pulmonary embolism, assuming that the therapy of thrombosis is the same as the therapy of embolism. DESIGN: Prospective study. SETTING: St. Clara Hospital, Rotterdam, the Netherlands. METHODS: 337 consecutive patients (157 women and 180 men, mean age 65 years, SD: 17.4) suspected of pulmonary embolism underwent compression ultrasound examination of the femoral and popliteal veins to detect deep venous thrombosis, and perfusion lung scintigraphy, with ventilation scintigraphy if indicated. Ultrasound examinations and lung scans were interpreted independently and blinded. A financial analysis of the various strategies was made. RESULTS: Deep venous thrombosis was demonstrated ultrasonographically in four (2%) of 208 patients with a normal lung scan, in four (9%) of 43 patients with a non-diagnostic lung scan, and in 30 (35%) of 86 patients with a high probability lung scan. By starting the diagnostic investigation with ultrasound examination 38 lung scans and chest X-rays would be saved at the cost of 294 extra ultrasound examinations. Because ultrasound examinations are relatively inexpensive a cost reduction of 3.4% would be realised, for the Netherlands approximately 1.4 million guilders. In the United States, however, costs would increase because of the high prices of ultrasound examinations. CONCLUSION: Compression ultrasound examination of both legs can be the examination of first choice in the Netherlands in patients suspected of pulmonary embolism, as it is cost effective.