Public preferences for policies promoting a healthy diet: a discrete choice experiment.

BACKGROUND: Worldwide obesity rates have nearly tripled over the past five decades. So far, policies to promote a healthier diet have been less intrusive than those to reduce tobacco and alcohol consumption. Not much is known about public support for policies that aim to promote a healthy diet. In this study, a discrete choice experiment (DCE) was used to elicit stated preferences for policies varying in intrusiveness among a representative sample of the public of The Netherlands. METHODS: The choice tasks presented respondents a hypothetical scenario of two policy packages, each comprising a mix of seven potential policies that differed in level of intrusiveness. We estimated mixed logit models (MXL) to estimate respondents' preferences for these policies and performed latent class analyses to identify heterogeneity in preferences. RESULTS: The MXL model showed that positive financial incentives like subsidies for vegetables and fruit yielded most utility. A tax of 50% on sugary drinks was associated with disutility while a tax of 20% was associated with positive utility compared to no tax at all. We identified three subgroups with distinct preferences for the seven policies to promote a healthy diet, which were characterized as being "against", "mixed" and "pro" policies to promote a healthy diet. CONCLUSION: Preferences for policies promoting a healthy diet vary considerably in the Dutch population, particularly in relation to more intrusive policies. This makes selection and implementation of a policy package that has wide public support challenging.

The Mental Health Quality of Life Questionnaire (MHQoL): development and first psychometric evaluation of a new measure to assess quality of life in people with mental health problems.

PURPOSE: The purpose of this study was to develop and psychometrically evaluate a new quality of life measure for use in people with mental health problems-the Mental Health Quality of Life questionnaire (MHQoL). METHODS: The MHQoL dimensions were based on prior research by Connell and colleagues, highlighting the seven most important quality of life dimensions in the context of mental health. Items were generated following a systematic review we performed and through inviting expert opinion. A focus group and an online qualitative study (N = 120) were carried out to assess the face and content validity of the MHQoL. The MHQoL was further tested for its internal consistency, convergent validity, known-group validity and test-retest reliability among mental healthcare service users (N = 479) and members of the general population (N = 110). RESULTS: The MHQoL consists of a descriptive system (MHQoL-7D), including s items covering seven dimensions (self-image, independence, mood, relationships, daily activities, physical health, future) and a visual analogue scale of general psychological well-being (MHQoL-VAS). Internal consistency was high (Cronbach's ∝ = 0.85) and correlations between MHQoL-7D scores and related measures (EQ-5D-5L, MANSA, ICECAP-A, and BSI) supported convergent validity. The intraclass correlation coefficient of the MHQoL-7D sum score for test-retest reliability was 0.85. Known-group validity was supported by the ability to detect significant differences in MHQoL-7D levels between service users and the general population, and between groups with different levels of psychological distress. CONCLUSION: The MHQoL demonstrated favourable psychometric properties and showed promise as a simple and effective measure to assess quality of life in people with mental health problems.

Instruments to assess quality of life in people with mental health problems: a systematic review and dimension analysis of generic, domain- and disease-specific instruments.

OBJECTIVES: The importance of economic evaluations of mental healthcare interventions is increasingly recognized. Despite the multitude of available quality of life instruments, concerns have been raised regarding the content validity of these instruments, and hence suitability for use in mental health. The aim of this paper, therefore, was to assess the content validity and the suitability of existing quality of life instruments for use in economic evaluations in mental health problems. METHODS: In order to identify available quality of life instruments used in people with mental health problems, a systematic review was performed using the Embase, Medline and PsycINFO databases (time period January 2012 to January 2018). Two reviewers independently assessed study eligibility and executed data extraction. The evaluation framework of Connell and colleagues was used to assess whether the identified quality of life instruments cover the dimensions valued highly by people with mental health problems. Two reviewers independently mapped the content of each identified instrument onto the evaluation framework and indicated the extent to which the instrument covered each of the dimensions of the evaluation framework. RESULTS: Searches of databases yielded a total of 5727 references. Following duplicate removal and double-independent screening, 949 studies were included in the qualitative synthesis. A total of 44 unique quality of life instruments were identified, of which 12 were adapted versions of original instruments. The best coverage of the dimensions of the evaluation framework of Connell and colleagues was by the WHOQOL-100, S-QoL, SQLS, EDQoL, QLI and the IMHQOL, but none fully covered all dimensions of the evaluation framework. CONCLUSIONS: The results of this study highlight the multitude of available quality of life instruments used in people with mental health problems and indicate that none of the available quality of life instruments fully cover the dimensions previously found to be important in people with mental health problems. Future research should explore the possibilities of refining or expanding existing instruments as well as the development and testing of new quality of life instruments to ensure that all relevant quality of life dimensions for people with mental health problems are covered in evaluations.

Don't forget about the future: The impact of including future costs on the cost-effectiveness of adult pneumococcal conjugate vaccination with PCV13 in the Netherlands.

BACKGROUND: When vaccines increase longevity, vaccinated people may experience costs and benefits during added life-years. These future benefits and costs may include increased productivity as well as medical and non-medical costs. Such impacts should be considered in cost-effectiveness analyses (CEA) of vaccines but are often omitted. Here, we illustrate the impact of including future costs on the cost-effectiveness of vaccination against pneumococcus disease. We emphasize the relevance of differentiating cost estimates between risk groups. METHODS: We updated an existing Dutch CEA of vaccination against pneumococcus disease with the 13-valent pneumococcal conjugate vaccine (PCV13) to include all future medical and non-medical costs. We linked costs by age and risk with survival information and estimates of cases prevented per vaccination strategy based on the original study to calculate the impact of inclusion. Future medical costs were adjusted for relevant risk groups. RESULTS: For the base-case strategy, the original incremental cost-effectiveness ratio (ICER) of PVC13 was €9,157 per quality adjusted life-year (QALY). Including all future medical costs increased the ICER to €28,540 per QALY. Also including future non-medical costs resulted in an ICER of €45,691 per QALY. The impact of future medical costs varied considerably per risk group and generally increased with age. DISCUSSION AND CONCLUSION: This study showed a substantial effect of the inclusion of future costs on the ICER of vaccinating with PCV13. Especially when lives of people with underlying health conditions are extended, the impact of future medical costs is large. This inclusion may make vaccination a less attractive option, especially in relation to low thresholds as often applied for prevention. Although this raises important questions, ignoring these real future costs may lead to an inefficient use of healthcare resources. Our results may imply that prices for some vaccines need to be lowered to be cost-effective.

[Opinions about oral care: an online questionnaire among readers of NTvT]. / Meningen over mondzorg: een online-onderzoek onder NTVT-lezers.

By means of a brief online questionnaire with 12 statements about the organisation, quality and impact of oral care in the Netherlands, the readers of the Netherlands Journal of Dentistry (NTVT) were asked to express their opinions on a number of important subjects concerning oral care in the Netherlands with respect to health economic matters. A total of 237 readers (61% men, 39% women) completed the online questionnaire. 70% of them were working as dentists and had been active in a practice for between 31 and 40 years. According to the study, a shift from curing to prevention was considered to be necessary. Most of the respondents also thought inequality in oral health in the Netherlands is increasing and people avoid going to the dentist due to the associated costs. In conclusion, most oral care providers appear to be reasonably positive about Dutch oral care. Attention for prevention, appreciation of oral health and the reduction of inequality in oral care continue to be necessary.

[Health economics and oral care: an introductory anthology]. / Gezondheidseconomie en mondzorg: een inleidende bloemlezing.

Healthcare expenditures will continue to increase in the coming years, raising questions regarding the sustainability of the Dutch healthcare system and solidarity, but also about the optimal use of available resources. Given the issues in the oral care sector, attention for economic insights is appropriate there as well. Relevant issues in this regard are the design of the basic and supplementary health insurance schemes for oral care, the market structure and financing of oral care, questions regarding task shifting in oral care, as well as socio-economic inequalities in oral health. A closer cooperative relationship between oral care and the health economy can help in achieving an optimal and sustainable organisation of the Dutch oral care sector. In other words, an organisation contributing in an efficient and fair way to good oral care for all Dutch citizens.

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.

Indicators to facilitate the early identification of patients with major depressive disorder in need of highly specialized care: A concept mapping study.

BACKGROUND: Early identification of the subgroup of patients with major depressive disorder (MDD) in need of highly specialized care could enhance personalized intervention. This, in turn, may reduce the number of treatment steps needed to achieve and sustain an adequate treatment response. The aim of this study was to identify patient-related indicators that could facilitate the early identification of the subgroup of patients with MDD in need of highly specialized care. METHODS: Initial patient indicators were derived from a systematic review. Subsequently, a structured conceptualization methodology known as concept mapping was employed to complement the initial list of indicators by clinical expertise and develop a consensus-based conceptual framework. Subject-matter experts were invited to participate in the subsequent steps (brainstorming, sorting, and rating) of the concept mapping process. A final concept map solution was generated using nonmetric multidimensional scaling and agglomerative hierarchical cluster analyses. RESULTS: In total, 67 subject-matter experts participated in the concept mapping process. The final concept map revealed the following 10 major clusters of indicators: 1-depression severity, 2-onset and (treatment) course, 3-comorbid personality disorder, 4-comorbid substance use disorder, 5-other psychiatric comorbidity, 6-somatic comorbidity, 7-maladaptive coping, 8-childhood trauma, 9-social factors, and 10-psychosocial dysfunction. CONCLUSIONS: The study findings highlight the need for a comprehensive assessment of patient indicators in determining the need for highly specialized care, and suggest that the treatment allocation of patients with MDD to highly specialized mental healthcare settings should be guided by the assessment of clinical and nonclinical patient factors.

A (Latent) Class of Their Own: Response Patterns in Trading Off Quantity and Quality of Life in Time Trade-Off Exercises.

BACKGROUND: Conflicting results regarding associations of time trade-off (TTO) valuations with respondent characteristics have been reported, mostly on the basis of regression analyses. Alternative approaches, such as the latent class analysis (LCA), may add to the further understanding of variations in TTO responses. OBJECTIVES: To identify whether subgroups of respondents can be identified on the basis of their responses to TTO exercises and to investigate which respondent characteristics are associated with membership of the identified subgroups. METHODS: Members of the Dutch general public, aged 18 to 65 years, completed a Web-based questionnaire concerning sociodemographic characteristics, three TTO exercises valuing health states described using the domains of the EuroQol five-dimensional questionnaire, and preference for quality versus quantity of life. LCA was used to identify patterns in the responses. Predictive variables were included in the final LCA model to identify the particular respondent characteristics that predict subgroup membership. RESULTS: The sample consisted of 1067 respondents. Four latent classes were identified in the responses to TTO exercises. Two were high traders, focusing on quality of life and trading off a relatively high number of years. The other two were low traders, focusing on length of life. Predictive analyses revealed significant differences between subgroups in terms of age, sex, subjective life expectancy, and preference for quantity over quality of life. CONCLUSIONS: We showed that distinct classes of respondents can be discerned in TTO responses from the general public, distinguishing subgroups of low and high traders. More research in this area should confirm our findings and investigate their implications for health state valuation exercises.

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.

Patient and general public preferences for health states: A call to reconsider current guidelines.

In economic evaluations of health care interventions, benefits are often expressed in terms of Quality-Adjusted Life-Years (QALYs). The QALY comprises length and quality of life into one measure which allows cross-disease comparability. The quality adjustment of the QALY is based on preferences for health states. An important normative choice is the question whose preferences for states of health we wish to capture. The answer to this question is directly related to the normative question regarding the appropriate maximand in health care decisions. Currently, preferences are commonly derived from the general public, rather than from actual patients. This choice, which can have large consequences on final outcomes of economic evaluations, has always been a topic of debate. This paper clarifies and furthers the discussion regarding the appropriate source of preferences for health state valuations, acknowledges the plurality of different perspectives, and argues that health economic guidelines could require analysis of benefit in terms of QALYs based on both patient and general public preferences.

"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.

[The cost-effectiveness evaluation of 2 caries prevention strategies compared with the standard approach]. / Een economische evaluatie van 2 cariëspreventieve strategieën vergeleken met standaardzorg.

A cost-effectiveness evaluation was conducted with a randomised controlled clinical trial of caries prevention measures among 6-year-old children who were assigned to either a control group or 1 of 2 experimental groups (IPFA: 2 extra professionally-delivered fluoride applications per year, or NOCTP: a non-operative caries treatment programme, like the one that was previously carried out in Nexø, Denmark. In order to determine the cost of the prevention of 1 DMFS in comparison with the control practice information on expenses incurred was collected for 3 years. The prevention of a single DMFS - depending on whether costs of dental treatment only were taken into consideration or also other social costs - were, in the IPFA programme, 269 and 1,369 euro respectively and, in the NOCTP programme, 30 and 100 euro respectively. On the basis of these results, it can be concluded that from both a dental and cost-effective perspective the NOCTP programme produces the most favourable results. Following the NOCTP strategy - during the 3-year period - just like following the IPFA approach was, however, more expensive than the standard approach.

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.

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.

Value for money: economic evaluation of two different caries prevention programmes compared with standard care in a randomized controlled trial.

A cost-effectiveness analysis was conducted during a 3-year randomized controlled clinical trial in a general dental practice in the Netherlands in which 230 6-year-old children (± 3 months) were assigned to either regular dental care, an increased professional fluoride application (IPFA) programme or a non-operative caries treatment and prevention (NOCTP) programme. Information on resource use during the 3-year period was documented by the dental nurse at every patient visit, such as treatment time, travel time and travel distance. Caries increment scores (at D3MFS level) were used to assess effectiveness. Cost calculations were performed using bottom-up micro-costing. Incremental cost-effectiveness ratios (ICERs) were expressed as additional average costs per prevented DMFS. The ICERs compared with regular dental care from a health care system perspective and societal perspective were, respectively, EUR 269 and EUR 1,369 per prevented DMFS in the IPFA programme, and EUR 30 and EUR 100 in the NOCTP programme. The largest investments for the NOCTP group were made in the first year of the study; they decreased in the second and equalled the costs of control group in third year of the study. From both medical and economic points of view, the NOCTP strategy may be considered the preferred strategy for caries prevention.

Thirty down, only ten to go?! Awareness and influence of a 10-year time frame in TTO.

BACKGROUND: Time trade-off (TTO) exercises typically present respondents with a limited time horizon, for example 10 years, thus implicitly considerably reducing remaining life expectancy for the average respondent. It is unclear how this affects health state valuations. AIM: The aim of the study is to investigate how awareness of the reduced life span implied by a 10-year TTO affects health state valuations, using an experimental design. METHODS: Two Web-based questionnaires (Q1 and Q2) were administered in a sample representative of the Dutch population. Both questionnaires contained three 10-year TTO exercises valuing three distinct health states, specified using the EQ-5D. Q1 used a TTO instruction not explicitly emphasizing the fact that remaining life expectancy was reduced to 10 years, while in Q2 respondents were explicitly made aware of this fact by emphasizing their implied age of death. Respondents answering Q1 were asked retrospectively whether they had been aware of their reduced life span due to the 10-year TTO. RESULTS: In total, 656 respondents completed the questionnaires (Q1: 339 and Q2: 317). The average age of the respondents was 43 years and 51 % of respondents were male. The average numbers of years traded off for the respondents of Q1 were for TTO1 0.443, TTO2 0.552, and TTO3 2.083 years. For the respondents of Q2, these averages were lower, i.e., TTO1 0.401 (p = 0.085 vs. Q1), TTO2: 0.546 (p = 0.036 vs. Q1), and TTO3: 1.467 years (p = 0.000 vs. Q1). Fifty-seven percent of respondents in Q1 confirmed that they were aware of the reduced life span. This spontaneous awareness had a limited and mixed influence on results. The generalized negative binomial regression analysis, explaining the time traded off showed that age, subjective life expectancy, and questionnaire Q2 (vs. Q1) were negatively associated with the years traded off, whereas education and worse health states in the TTO exercise had a significant positive impact on the years traded off. The probit model investigating the impact on the willingness to trade showed that age (-), education (+), subjective life expectancy (-), questionnaire Q2 versus Q1 (-), the interaction between Q2 and male gender (+), and worse health states in the TTO exercise (+) had a significant impact on the willingness to trade. CONCLUSION: These findings emphasize the importance of expected and implied life expectancy in TTOs.