Societal views in the Netherlands on active disinvestment of publicly funded healthcare interventions.

OBJECTIVES: To obtain public support for the active disinvestment (i.e. policy decision to stop reimbursement) of healthcare interventions, it is important to have insight in what the public thinks about disinvestment and which considerations they find relevant in this context. Currently, evidence on relevant considerations in the disinvestment context is limited. Therefore, this study aimed to explore the societal views in the Netherlands on the active disinvestment of healthcare interventions and obtain insight into the considerations that are relevant for those holding the different views. METHODS: A Q-methodology study was conducted among a purposively selected sample of citizens (n = 43). Data were collected in June and July 2019. Participants individually ranked a set of 43 statements broadly covering the issues that participants could consider relevant in the disinvestment context, from 'least agree' to 'most agree'. Qualitative feedback on the statement ranking was collected from each participant using a questionnaire. Principal component analysis followed by oblimin rotation was used to identify clusters of participants with similar statement rankings. These clusters/factors were interpreted as distinct viewpoints using the factor arrays and qualitative questionnaire responses of participants. RESULTS: Four viewpoints were identified. People holding viewpoint I believe that reimbursement of necessary healthcare should be maintained, irrespective of its costs. People holding viewpoint II agree with viewpoint I, although they believe that necessity should be objectively determined. People holding viewpoint III think that unnecessary, ineffective and inefficient healthcare should be disinvested. People holding viewpoint IV, consider it most important that disinvestment decision-making processes are transparent and consistent. CONCLUSION: Insight in the distinct viewpoints identified in this study contributes to a better understanding of why it has been considered difficult to obtain public support for disinvestment of healthcare interventions, and can help policymakers to change their approach to disinvestment to increase public support.

Looking back and moving forward: On the application of proportional shortfall in healthcare priority setting in the Netherlands.

The increasing demand for healthcare and the resulting pressure on available budgets render priority setting inevitable. If societies aim to improve health and distribute health(care) fairly, equity-efficiency trade-offs are necessary. In the Netherlands, proportional shortfall (PS) was introduced to quantify necessity of care, allowing a direct equity-efficiency trade-off. This study describes the history and application of PS in the Netherlands and examines the theoretical and empirical support for PS as well as its current role in healthcare decision making. We reviewed the international literature on PS from 2001 onwards, along with publicly accessible meeting reports from the Dutch appraisal committee, Adviescommissie Pakket (ACP), from 2013 to 2016. Our results indicate that there is support for the decision model in which necessity is quantified and incremental cost-effectiveness ratios are evaluated against associated monetary reference values. The model enables a uniform framework for priority setting across all healthcare sectors. Although consensus about the application of PS has not yet been reached and alternative ways to quantify necessity were found in ACP reports, PS has increasingly been applied in decision making since 2015. However, empirical support for PS is limited and it may insufficiently reflect societal preferences regarding age and reducing lifetime-health inequalities. Hence, further investigation into refining PS-or exploration of another approach-appears warranted for operationalising the equity-efficiency trade-off.

Acceptable health and priority weighting: Discussing a reference-level approach using sufficientarian reasoning.

Health care systems are challenged in allocating scarce health care resources, which are typically insufficient to fulfil all health care wants and needs. One criterion for priority setting may be the 'acceptable health' approach, which suggests that society may want to assign higher priority to health benefits in people with "unacceptable" than in people with "acceptable" health. A level of acceptable health then serves as a reference point for priority setting. Empirical research has indicated that people may be able and willing to define health states as "unacceptable" or "acceptable", but little attention has been given to the normative implications of evaluating health benefits in relation to a reference level of acceptable health. The current paper aims to address this gap by relating insights from the distributive justice literature, i.e. the sufficientarian literature, to the acceptable health approach, as we argue that these approaches are related. We specifically focus on the implications of an 'acceptability' approach for priority weighting of health benefits, derived from sufficientarian reasoning and debates, and assess the moral implications of such weighting.

Health or Happiness? A Note on Trading Off Health and Happiness in Rationing Decisions.

BACKGROUND: Economic evaluations typically value the effects of an intervention in terms of quality-adjusted life-years, which combine length and health-related quality of life. It has been suggested that economic evaluations should incorporate broader outcomes than health-related quality of life. Broader well-being, for instance measured as happiness, could be a better measure of the overall welfare effects in patients because of treatment. An underexplored question is whether and how people trade off information on health and broader outcomes from treatment in rationing decisions. OBJECTIVES: This article presents the results of a first experiment aimed at exploring such trade-offs between health and happiness. METHODS: We used a Web-based questionnaire in a representative sample of the public from the Netherlands (N = 1015). People made choices between two groups of patients differing in terms of their health and happiness levels before treatment and gains from treatment. RESULTS: The results showed that about half the respondents were willing to discriminate between patient groups on the basis of their health and happiness levels before and after treatment. In the trader group, health gains were considered somewhat more important than happiness gains. CONCLUSIONS: Our findings suggest that both health and happiness levels of patients may play a role in priority setting.

"Back to the future": Influence of beliefs regarding the future on TTO answers.

BACKGROUND: A common approach to obtain health state valuations is the time-tradeoff (TTO) method. Much remains unknown regarding the influence of responder characteristics on TTO answers. The objective of this study is to increase understanding of the influence that beliefs regarding future health and death, as well as desires to witness certain life events, have on respondents' health state valuations. METHODS: An online survey was designed, including three TTO questions using a 10 year timeframe. Moreover, respondents completed demographic questions, the Health-Risk Attitude Scale (HRAS), the Expectations Regarding Aging (ERA) questionnaire, questions about beliefs regarding future health (i.e. life expectancy) and death (i.e. fear of death, belief in life after death and opinion about euthanasia), and about important life events taking place within the TTO timeframe. Regression analyses were performed in order to assess the influence of these different variables. RESULTS: One thousand sixty-seven respondents were included in the analyses. The following variables were significantly associated with years traded off: ERA mental health (decrease), ERA physical health (increase), HRAS (increase), support for euthanasia (increase), fear of death (decrease) and consideration of an important life event (decrease). The explained variance of the final model was low (0.08). CONCLUSION: TTO responses may be influenced by considerations of future health, including life events and attitudes regarding health risks and death. Further investigation of TTO responses remains warranted.

Are some QALYs more equal than others?

Including societal preferences in allocation decisions is an important challenge for the health care sector. Here, we present results of a phased discrete choice experiment investigating the impact of various attributes on respondents' preferences for distribution of health and health care. In addition to the renowned equity principles severity of illness (operationalized as initial health) and fair innings (operationalized as age), some characteristics of beneficiaries (culpability and having dependents) and the disease (rarity) were included in the choice experiment. We used a nested logit model to analyse the data. We found that all selected attributes significantly influenced respondents' choices. The phased inclusion showed that additional attributes affected respondents' preferences for previously-included attributes and reduced unobserved variance. Although not all these attributes may be considered relevant for decision making from a normative perspective, including them in choice experiments contributes to our understanding of societal preferences for each single attribute.

"Married with children" the influence of significant others in TTO exercises.

BACKGROUND: Which responder characteristics influence TTO scores remains underexplored. More research is needed in order to understand (differences in) TTO scores, but also in the context of generating representative health state valuations for some population. Previous studies have found age, gender, marital status and subjective life expectancy to influence the number of years traded off. OBJECTIVE: This study aimed to investigate which other responder characteristics influence TTO responses, with an emphasis on consideration of significant others, such as partners and children. METHODS AND DESIGN: We performed a web-based survey in a representative sample of the Dutch general public (aged 18-65). Data on demographics, health status and expectations about future length and quality of life were gathered. Respondents valued three distinct health states using TTO. RESULTS: A total of 1067 respondents completed the questionnaire. Sixty percent of respondents had children and 49 % were married. The mean number of years traded off increased with severity of health states. Higher age and living together were positively associated with number of years traded off. Increases in subjective life expectancy, having children and being male (were negatively associated with the number of years traded-off. CONCLUSION: Age, gender and subjective life expectancy, living together and having children were significantly associated with TTO responses. Consideration of significant others in TTO exercises thus may be important in understanding (differences in) TTO responses and when drawing representative samples from the general public.

Are all health gains equally important? An exploration of acceptable health as a reference point in health care priority setting.

BACKGROUND: Accumulating evidence suggests that members of society prefer some QALY gains over others. In this paper, we explore the notion of acceptable health as a reference point in assessing the value of health gains. The value of health benefits may be assessed in terms of their position relative to this reference level, benefits above the level of acceptable health being valued differently from benefits below this level. In this paper we focus on assessing the level of acceptable health at different ages and associations with background variables. METHODS: We recruited a sample of the adult population from the Netherlands (n = 1067) to investigate which level of health problems they consider to be acceptable for people aged 40 to 90, using 10-year intervals. We constructed acceptable health curves and associated acceptable health with background characteristics using linear regressions. RESULTS: The results of this study indicate that the level of health problems considered acceptable increases with age. This level was associated with respondents' age, age of death of next of kin, health and health behaviour. CONCLUSIONS: Our results suggest that people are capable of indicating acceptable levels of health at different ages, implying that a reference point of acceptable health may exist. While more investigation into the measurement of acceptable health remains necessary, future studies may also focus on how health gains may be valued relative to this reference level. Gains below the reference point may receive higher weight than those above this level since the former improve unacceptable health states while the latter improve acceptable health states.

Validation of the Care-Related Quality of Life Instrument in different study settings: findings from The Older Persons and Informal Caregivers Survey Minimum DataSet (TOPICS-MDS).

PURPOSE: Validity is a contextual aspect of a scale which may differ across sample populations and study protocols. The objective of our study was to validate the Care-Related Quality of Life Instrument (CarerQol) across two different study design features, sampling framework (general population vs. different care settings) and survey mode (interview vs. written questionnaire). METHODS: Data were extracted from The Older Persons and Informal Caregivers Minimum DataSet (TOPICS-MDS, www.topics-mds.eu ), a pooled public-access data set with information on >3,000 informal caregivers throughout the Netherlands. Meta-correlations and linear mixed models between the CarerQol's seven dimensions (CarerQol-7D) and caregiver's level of happiness (CarerQol-VAS) and self-rated burden (SRB) were performed. RESULTS: The CarerQol-7D dimensions were correlated to the CarerQol-VAS and SRB in the pooled data set and the subgroups. The strength of correlations between CarerQol-7D dimensions and SRB was weaker among caregivers who were interviewed versus those who completed a written questionnaire. The directionality of associations between the CarerQol-VAS, SRB and the CarerQol-7D dimensions in the multivariate model supported the construct validity of the CarerQol in the pooled population. Significant interaction terms were observed in several dimensions of the CarerQol-7D across sampling frame and survey mode, suggesting meaningful differences in reporting levels. CONCLUSIONS: Although good scientific practice emphasises the importance of re-evaluating instrument properties in individual research studies, our findings support the validity and applicability of the CarerQol instrument in a variety of settings. Due to minor differential reporting, pooling CarerQol data collected using mixed administration modes should be interpreted with caution; for TOPICS-MDS, meta-analytic techniques may be warranted.

Do people desire to be healthier than other people? A short note on positional concerns for health.

Contrary to traditional economic postulates, people do not only care about their absolute position but also about their relative position. However, empirical evidence on positional concerns in the context of health is scarce, despite its relevance for health care policy. This paper presents a first explorative study on positional concerns in the context of health. Using a 'two-world' survey method, a convenience sample of 143 people chose between two options (having more in absolute terms or having more in relative terms) in several health and non-health domains. Our results for the non-health domains compare reasonably well to previous studies, with 22-47% of respondents preferring the positional option. In the health domain, these percentages were significantly lower, indicating a stronger focus on absolute positions. The finding that positional concerns are less prominent in the health domain has important implications for health policy, for instance in balancing reduction of socio-economic inequalities and absolute health improvements.

Balancing equity and efficiency in the Dutch basic benefits package using the principle of proportional shortfall.

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.

Putting your money where your mouth is: parents' valuation of good oral health of their children.

The aim of this study was to investigate the parental willingness to invest in good oral health for their child in terms of money and time and to relate this to oral health related knowledge and behavioral aspects. 290 parents of 6-year-old children, participating in a RCT on caries preventive strategies in The Netherlands were asked to provide information on education, oral health habits, dietary habits, knowledge on dental topics, willingness to pay and perceived resistance against investing in preventive oral health actions for their children. Despite the fact that parents overall valued oral health for their child highly, still 12% of the parents were unwilling to spend any money, nor to invest any time by brushing their children's teeth to maintain good oral health for their child. Additionally, they indicated that they were unwilling to visit the dentist for preventive measures more than once a year. These children may certainly be considered at higher risk of developing oral diseases because worse oral hygiene habits and dietary habits were found in this group. Given the results, it may be necessary to differentiate in allocating caries prevention programmes to target parents or (school-based) children directly.

Perceptions of team workers in youth care of what makes teamwork effective.

In youth care, little is known about what makes teamwork effective. What is known mostly reflects the view of managers in care organisations, as objective outcome measures are lacking. The objective of this article was to explore the views of youth care workers in different types of teams on the relative importance of characteristics of teamwork for its effectiveness. Q methodology was used. Fifty-one respondents rank-order 34 opinion statements regarding characteristics of teamwork. Individual Q sorts were analysed using by-person factor analysis. The resulting factors, which represented team workers' views of what is important for effective teamwork, were interpreted and described using composite rankings of the statements for each factor and corresponding team workers' explanations. We found three views of what makes teamwork effective. One view emphasised interaction between team members as most important for team effectiveness. A second view pointed to team characteristics that help sustain communication within teams as being most important. In the third view, the team characteristics that facilitate individuals to perform as a team member were put forward as most important for teamwork to be effective. In conclusion, different views exist on what makes a team effective in youth care. These views correspond with the different types of teams active in youth care as well as in other social care settings.

Willingness to pay for a quality-adjusted life-year: the individual perspective.

OBJECTIVE: The aim of this study was to elicit the individual willingness to pay (WTP) for a quality-adjusted life-year (QALY). METHODS: In a Web-based questionnaire containing contingent valuation exercises, respondents valued health changes in five scenarios. In each scenario, the respondents first valued two health states on a visual analog scale (VAS) and expressed their WTP for avoiding a decline in health from the better health state to the worse, using a payment scale followed by a bounded open contingent valuation question. ANALYSIS: WTP per QALY was calculated for QALY gains calculated using VAS valuations, as well as the Dutch EQ-5D tariffs, the two steps in the WTP estimations and each scenario. Heterogeneity in WTP per QALY ratios was examined from the perspective of: 1) household income; and 2) the level of certainty in WTP indicated by respondents. Theoretical validity was analyzed using clustered multivariate regressions. RESULTS: A total of 1091 respondents, representative of the Dutch population, participated in the survey. Mean WTP per QALY was € 12,900 based on VAS valuations, and € 24,500 based on the Dutch EuroQoL tariffs. WTP per QALY was strongly associated with income, varying from € 5000 in the lowest to € 75,400 in the highest income group. Respondents indicating higher certainty exhibited marginally higher WTP. Regression analyses confirmed expected relations between WTP per QALY, income, and other personal characteristics. CONCLUSION: Individual WTP per QALY values elicited in this study are similar to those found in comparable studies. The use of individual valuations in social decision-making deserves attention, however.

Attitudes towards oral health among parents of 6-year-old children at risk of developing caries.

OBJECTIVES: Parental attitudes are likely to play a role in achieving and maintaining a desired level of oral health in children. To be useful in individually delivered caries prevention programmes, parental attitudes should be identified at individual level. Q-methodology has been proved successful in identifying attitudes in a wide range of disciplines but in dentistry Q-studies are scarce. In this study Q-methodology was used to identify parents' prevailing attitudes towards the oral health of their children. METHODS: Thirty-nine parents ranked 37 statements regarding the dental health behaviour they apply to their 6-year-old child. They later explained their rankings during a short interview. In Q-methodology, rather than reporting one average composite attitude and opinion, various combinations of opinions and attitudes concerning these statements are identified using by-person factor analysis. RESULTS: Based on their beliefs, attitudes and cognitions, five categories of parents were found: (i) conscious and responsible, (ii) trivializing and fatalistic, (iii) appearance-driven and open-minded, (iv) knowledgeable but defensive and (v) conscious and concerned. CONCLUSIONS: Q-methodology appears to be a fruitful way to structure the complexity of parents' opinions and attitudes towards their children's dental health. It appears that Q-methodology provides comprehensive clusters of individual attitudes, based on various levels of responses to a wide range of questions. The five identified profiles may be useful in developing tailor-made prevention strategies in caries prevention.

"My lung disease won't go away, it's there to stay": profiles of adaptation to functional limitations in workers with asthma and COPD.

PURPOSE: Earlier research has shown that adaptation (i.e., the way in which employees cope with limitations resulting from their disease) is associated with sick leave. Our aim was to investigate signs of adequate or inadequate adaptation in employees with asthma and COPD. METHODS: A Q-methodological study was carried out among 34 workers with asthma or COPD. RESULTS: Four adaptation profiles were distinguished: the eager, the adjusted, the cautious, and the worried workers. The adaptation profiles provide insight into the different ways in which workers with asthma and COPD cope with their illness at work. CONCLUSIONS: The adaptation profiles serve as a starting point for the design of appropriate (occupational) care. The eager workers experience little difficulties at work; the cautious workers may need assistance in learning how to accept their disease; the worried workers need reassurance, and may need reactivation; the adjusted workers deserve extra attention, and, when necessary, advice on how to live with their asthma or COPD.

How employment support and social integration programmes are viewed by the intellectually disabled.

BACKGROUND: Supported employment is intended to facilitate and promote participation and integration of intellectually disabled citizens in society. This study investigated their view of the programme. METHODS: Q-methodology was used. Eighteen respondents with a mild intellectual disability rank-ordered 22 statements representing five main aspects of supported employment. The data were factor-analysed to group respondents according to their views. Q-methodology was a feasible approach that facilitated in-depth conversations with respondents with a mild intellectual disability in a playful manner. RESULTS: Two views on the impact of supported employment on social integration were observed: 'work as participation' and 'work as structure'. The first placed greater value on participation, task variety, belonging, and feeling appreciated; the second placed greater value on working independently, clear working agreements, and friendly co-workers. The views indicate two distinct approaches to effecting a positive relationship between supported employment and social integration. CONCLUSION: From the perspective of people with an intellectual disability supported employment contributes to self-development and has a positive effect on well-being, albeit in different ways for the individual groups.

Some pain, no gain: experiences with the no-claim rebate in the Dutch health care system.

To contain expenditures in an increasingly demand driven health care system, in 2005 a no-claim rebate was introduced in the Dutch health insurance system. Since demand-side cost sharing is a very controversial issue, the no-claim rebate was launched as a consumer friendly bonus system to reward prudent utilization of health services. Internationally, the introduction of a mandatory no-claim rebate in a social health insurance scheme is unprecedented. Consumers were entitled to an annual rebate of 255 eruos if no claims were made. During the year, all health care expenses except for GP visits and maternity care were deducted from the rebate until the rebate became zero. In this article, we discuss the rationale of the no-claim rebate and the available evidence of its effect. Using a questionnaire in a convenience sample, we examined people's knowledge, attitudes, and sensitivity to the incentive scheme. We find that only 4% of respondents stated that they would reduce consumption because of the no-claim rebate. Respondents also indicated that they were willing to accept a high loss of rebate in order to use a medical treatment. However, during the last month of the year many respondents seemed willing to postpone consumption until the next year in order to keep the rebate of the current year intact. A small majority of respondents considered the no-claim rebate to be unfair. Finally, we briefly discuss why in 2008 the no-claim rebate was replaced by a mandatory deductible.

The CarerQol instrument: a new instrument to measure care-related quality of life of informal caregivers for use in economic evaluations.

The societal perspective in economic evaluations dictates that costs and effects of informal care are included in the analyses. However, this incorporation depends on practically applicable, reliable and valid methods to register the impact of informal care. This paper presents the conceptualisation and a first test of the CarerQol instrument, aimed at measuring care-related quality of life in informal caregivers. The instrument combines the information density of a burden instrument (encompassing seven important burden dimensions) with a valuation component (a VAS scale for happiness). The instrument was tested in a Dutch sample of heterogeneous caregivers (n=175) approached through regional caregiver support centres. This first test describes the feasibility as well as convergent and clinical validity of the CarerQol instrument. The seven burden dimensions related well with differences in VAS scores. In all instances, the average CarerQol-VAS scores decreased as the severity of problems increased. Multivariate analyses showed that the seven burden dimensions explained 37-43% of the variation in CarerQol-VAS scores, depending on the model used. The CarerQol seems a promising new instrument to register the impact of informal caregivers in economic evaluations.

"Everyone dies, so you might as well have fun!" Attitudes of Dutch youths about their health lifestyle.

Most Western societies seem to have embarked on a runaway weight-gain train, equipped with too many accelerators and not enough brakes. Adolescents have been identified as a public health risk group in this area. To uncover youths' attitudes about their health lifestyle, with a focus on overweightness, we conducted a discourse analysis using Q-methodology. Female, Dutch youths between 12 and 15 years rank-ordered statements on issues like eating behaviour, overweightness, health risks, health perceptions and motivations/obstacles for adopting a healthier lifestyle. Q-factor analysis revealed five attitudes: "carefree sporty", "worrying dependent", "contended independent", "looks over content" and "indifferent solitary". The youths were all more or less uninterested in their own health but for different reasons. For most of these youths, neither current nor future health is of major concern, because they feel physically fit, are generally satisfied and happy, or simply do not care. Some are concerned about their eating behaviour due to the consequences it has on appearance, being physically unfit or overweight. Even so, this preoccupation with eating appears far from healthy. Only one of the five health lifestyle attitudes identified combines healthy eating and exercising behaviour. Most youths appear to have little knowledge and many questions regarding health and overweightness.