Europe aims at combining income growth with improvements in social cohesion as measured by income... more Europe aims at combining income growth with improvements in social cohesion as measured by income and health inequalities. We show that, theoretically, both aims can be reconciled only under very specific conditions concerning the type of growth and the income responsiveness of health. We investigate whether these conditions held in Europe in the nineties using panel data from the European Community Household Panel surveys. We use pooled interval regressions and inequality decompositions to demonstrate that (i) in all countries except Austria, the income elasticity of health is positive and increases with income, and (ii) that income growth was not pro-rich in most EU countries, resulting in little or no reductions in income inequality and modest increases in income-related health inequality in the majority of countries.
Governments of EU countries have declared that they would like to couple income growth with reduc... more Governments of EU countries have declared that they would like to couple income growth with reductions in social inequalities in income and health. We show that, theoretically, both aims can be reconciled only under very specific conditions concerning the type of growth and the income responsiveness of health. We investigate whether these conditions were met in Europe in the 1990s using panel data from the European Community Household Panel. We demonstrate that (i) in most countries, the income elasticity of health was positive and increases with income, and (ii) that income growth was not pro-rich in most EU countries, resulting in small or negligible reductions in income inequality. The combination of both findings explains the modest increases we observe in income-related health inequality in the majority of countries.
International Journal of Technology Assessment in Health Care, Apr 1, 2010
The aim of this study was to get insight in what criteria as presented in Health technology asses... more The aim of this study was to get insight in what criteria as presented in Health technology assessment (HTA) studies are important for decision makers in healthcare priority setting. Methods: We performed a discrete choice experiment among Dutch healthcare professionals (policy makers, HTA experts, advanced HTA students). In twenty-seven choice sets, we asked respondents to elect reimbursement of one of two different healthcare interventions, which represented unlabeled, curative treatments. Both treatments were incrementally compared with usual care. The results of the interventions were normal outputs of HTA studies with a societal perspective. Results were analyzed using a multinomial logistic regression model. Upon completion of the questionnaire, we discussed the exercise with policy makers. Results: Severity of disease, costs per quality-adjusted life-year gained, individual health gain, and the budget impact were the most decisive decision criteria. A program targeting more severe diseases increased the probability of reimbursement dramatically. Uncertainty related to cost-effectiveness was also important. Respondents preferred health gains that include quality of life improvements over extension of life without improved quality of life. Savings in productivity costs were not crucial in decision making, although these are to be included in Dutch reimbursement dossiers for new drugs. Regarding subgroups, we found that policy makers attached relatively more weight to disease severity than others but less to uncertainty. Conclusions: Dutch policy makers and other healthcare professionals seem to have reasonably well articulated preferences: six of seven attributes were significant. Disease severity, budget impact, and cost-effectiveness were very important. The results are comparable to international studies, but reveal a larger set of important decision criteria.
paper derives from the project "Economic determinants of the distribution of health and health ca... more paper derives from the project "Economic determinants of the distribution of health and health care in Europe" (known as the ECuity II Project), which is funded in part by the European Community's Biomed II programme (contract BMH4-CT98-3352). We are grateful to the EC for financial support, to Eurostat for access to the ECHP data and to Andrew Jones and Tom Van Ourti for stimulating discussions from which the paper benefited considerably and Evertjan Jansen and two anonymous referees for useful suggestions and comments on an earlier version of the paper.
New technologies may displace existing, higher-value care under a fixed budget. Countries aim to ... more New technologies may displace existing, higher-value care under a fixed budget. Countries aim to curtail adoption of low-value technologies, for example, by installing cost-effectiveness thresholds. Our objective is to estimate the opportunity cost of hospital care to identify a threshold value for the Netherlands. To this aim, we combine claims data, mortality data and quality of life questionnaires from 2012 to 2014 for 11,000 patient groups to obtain qualityadjusted life-year (QALY) outcomes and spending. Using a fixed effects translog model, we estimate that a 1% increase in hospital spending on average increases QALY outcomes by 0.2%. This implies a threshold of €73,600 per QALY, with 95% confidence intervals ranging from €53,000 to €94,000 per QALY. The results stipulate that new technologies with incremental cost effectiveness ratios exceeding the Dutch upper reference value of €80,000 may indeed displace more valuable care.
Aim: To investigate if subjective life expectancy (SLE) impacts the willingness to trade-off (WTT... more Aim: To investigate if subjective life expectancy (SLE) impacts the willingness to trade-off (WTT) and the number of years traded-off in a 10-years time trade-off (TTO) exercise to obtain health state valuations. Methods: An Internet-based questionnaire was administered in a sample representative for the Dutch general public. Next to basic demographic characteristics and SLE, respondents were asked to perform three TTO exercises. The following EQ-5D health states were included 21211 (TTO1), 22221 (TTO2) and 33312 (TTO3). The WTT was studied using a probit regression model. The number of years traded-off was investigated using a generalized negative binomial regression model. The independent variables used in both models were age, gender, quality of life, education, the difference between age and expected age of death (SLE), and a variable indicating whether the SLE was less than 10 years (SLEo10). Results: Three hundred and thirty nine respondents completed the questionnaire. The mean utility scores were 0.96 (TTO1), 0.94 (TTO2) and 0.79 (TTO3). The probit model showed that SLE was the only variable with a significant influence on WTT. The gnbreg showed that the number of years traded-off was also significantly influenced by SLE. In addition, age and education significantly influenced the number of years traded-off. Conclusion: The WTT years and the number of years traded-off were both influenced by SLE in 10-years TTO exercises. Reducing remaining life expectancy to 10 years in a TTO may thus increase loss aversion and, especially in respondents losing relatively many expected life years, diminish WTT and the amount of time traded off.
Background: In 2006, the Dutch hospital market was reformed to create a more efficient delivery s... more Background: In 2006, the Dutch hospital market was reformed to create a more efficient delivery system through managed competition. To allow competition on quality, patient experiences were measured using the Consumer Quality index (CQI). We study whether public reporting and competition had an effect on the CQI between 2006 and 2009. Methods: We analyzed 8,311 respondents covering 31 hospitals in 2006, 22,333 respondents covering 78 hospitals in 2007 and 24,246 respondents covering 94 hospitals in 2009. We describe CQI trends over the period 2006-2009. In addition we compare hospitals that varied in the level of competition they faced and hospitals that were forced to publish CQI results publicly and those that were not. We corrected for observable covariates between hospital respondents using a multi level linear regression. We used the Herfindahl Hirschman Index to indicate the level of competition. Results: Between 2006 and 2009 hospitals showed a CQI improvement of 0.034 (p < 0.05) to 0.060 (p < 0.01) points on a scale between one and four. Hospitals that were forced to publish their scores showed a further improvement of 0.027 (p < 0.01) to 0.030 (p < 0.05). Furthermore, hospitals that faced more competition from geographically close competitors showed a more pronounced improvement of CQI-scores 0.004 to 0.05 than other hospitals (p < 0.001). Conclusion: Our results show that patients reported improved experiences measured by the CQI between 2006 and 2009. CQI levels improve at a faster rate in areas with higher levels of competition. Hospitals confronted with forced public publication of their CQI responded by enhancing the experiences of their patients.
paper derives from the project "Economic determinants of the distribution of health and health ca... more paper derives from the project "Economic determinants of the distribution of health and health care in Europe" (known as the ECuity II Project), which is funded in part by the European Community's Biomed II programme (contract BMH4-CT98-3352). We are grateful to the EC for financial support and to Hugh Gravelle, Tom van Ourti, and participants of the ECuity II Project Workshop in Rome, 20-22 March, 2002 for helpful comments on an earlier draft.
Background: Evidence based medicine aims to integrate scientific evidence, clinical experience, a... more Background: Evidence based medicine aims to integrate scientific evidence, clinical experience, and patient values and preferences. Individual health care professionals need to appraise the evidence from randomized trials and observational studies when guidelines are not yet available. To date, tools for assessment of bias and terminologies for bias are specific for each study design. Moreover, most tools appeal only to methodological knowledge to detect bias, not to subject matter knowledge, i.e. in-depth medical knowledge about a topic. We propose a unified framework that enables the coherent assessment of bias across designs. Methods: Epidemiologists traditionally distinguish between three types of bias in observational studies: confounding, information bias, and selection bias. These biases result from a common cause, systematic error in the measurement or common effect of the intervention and outcome respectively. We applied this conceptual framework to randomized trials and show how it can be used to identify bias. The three sources of bias were illustrated with graphs that visually represent researchers' assumptions about the relationships between the investigated variables (causal diagrams). Results: Critical appraisal of evidence started with the definition of the research question in terms of the population of interest, the compared interventions and the main outcome. Next, we used causal diagrams to illustrate how each source of bias can lead to over-or underestimated treatment effects. Then, we discussed how randomization, blinded outcome measurement and intention-to-treat analysis minimize bias in trials. Finally, we identified study aspects that can only be appraised with subject matter knowledge, irrespective of study design. Conclusions: The unified framework encompassed the three main sources of bias for the effect of an assigned intervention on an outcome. It facilitated the integration of methodological and subject matter knowledge in the assessment of bias. We hope that graphical diagrams will help clarify debate among professionals by reducing misunderstandings based on different terminology for bias.
Objectives: This paper describes the first months of the COVID-19 pandemic in the Netherlands, in... more Objectives: This paper describes the first months of the COVID-19 pandemic in the Netherlands, including policies to reduce the health-related and economic consequences. The Netherlands started with containment and shifted to mitigation within three weeks when implementing a 'mild' lockdown. The initial focus was to obtain herd immunity while preventing Intensive Care Units from getting overwhelmed. Methods: An in-depth analysis of available national and international COVID-19 data sources was conducted. Due to regional variation in COVID-19 hospitalization rates, this paper focuses on three distinct regions; the initial epicenter; the most northern provinces which-contrary to national policy-decided not to switch to mitigation; and the Bible Belt, as congregations of religious groups were initially excluded from the ban on group formation. Results: On August 11 th , 6,159 COVID-19 deaths were reported with at the peak an excess mortality Zscore of 21.7. As a result of the pandemic, the economy took a severe hit and is predicted to shrink 6.5% compared to projection. The hospitalization rates in the northern regions were over 70% lower compared to the rest of the country (18 versus 66 per 10 0,0 0 0 inhabitants). Differences between the Bible Belt and the rest of the country were hardly detectable. Conclusion: The Dutch have shown a way to effectively slow down transmission while allowing more personal and economic freedom than most other countries. Furthermore, the regional differences suggest that containment prevented a surge of infections in the northern provinces. The results should be interpreted with caution, due to the descriptive nature of this study.
Unsustainable growth in healthcare expenditure demands effective cost-containment policies. We re... more Unsustainable growth in healthcare expenditure demands effective cost-containment policies. We review policy effectiveness using total payer expenditure as primary outcome measure. We included all OECD member states from 1970 onward. After a rigorous quality appraisal, we included 43 original studies and 18 systematic reviews that cover 341 studies. Policies most often evaluated were payment reforms (10 studies), managed care (8 studies) and cost sharing (6 studies). Despite the importance of this topic, for many widely-used policies very limited evidence is available on their effectiveness in containing healthcare costs. We found no evidence for 21 of 41 major groups of cost-containment policies. Furthermore, many evaluations displayed a high risk of bias. Therefore, policies should be more routinely and rigorously evaluated after implementation. The available high-quality evidence suggests that the cost curve may best be bent using a combination of cost sharing, managed care competition, reference pricing, generic substitution and tort reform.
Kabinet en RIVM zijn onhelder over wat de Nederlandse COVID-19-strategie precies is. Het begrip ‘... more Kabinet en RIVM zijn onhelder over wat de Nederlandse COVID-19-strategie precies is. Het begrip ‘maximale controle’ wordt door het kabinet geduid als een indamstrategie, terwijl het RIVM en GGD’s zowel in interviews als in de praktijk met suboptimale organisatie van testen en bron- en contactonderzoek hinten op het vasthouden aan een strategie van groepsimmuniteit. — Uit deze rapportage blijkt dat de indamstrategie significante voordelen heeft voor zowel economie als volksgezondheid. Een indamstrategie levert cumulatief in 2020-2022 EUR 123 miljard op hetgeen gelijk staat aan 3,1% BBP-groei in 2022. Als andere Europese landen ook meedoen met deze strategie, lopen de revenuen verder op tot potentieel 16,9% van het BBP in 2022. Ook voorkomen we met een indamstrategie mogelijk tot zo’n 50.000 COVID-19-doden. — Uit onze modellering blijkt dat het huidige testbeleid en de ingezette bron- en contactopsporing waarschijnlijk onvoldoende zijn om een indamstrategie (Rt < 1) te bewerkstelligen. Het inplannen van en testen zelf gaat te traag, te weinig mensen worden gestimuleerd te komen testen en te weinig contacten worden tijdig gevonden. De huidige opzet levert een daling van Rt 0,15 op, terwijl met het door ons voorgestelde protocol de Rt met 0,40 daalt: genoeg voor het inzetten van een indamstrategie. — Met het lage aantal besmettingen hebben we nu een eenmalige kans om de indamstrategie tot een succes te maken. De volgende acties zijn vereist: 1. 2. 3. 4. 5. 6. 7. Kabinet, RIVM en OMT spreken zich ten volle uit voor een indammingsstrategie (ook containment, eliminatie of uitdoven genoemd), zonder mitsen en maren. Dat is een strategie waarmee de Rt duurzaam < 1 is. Belangrijke kanttekening hierbij is dat het gaat om een doelstelling en geen resultaatsverplichting, daarvoor zijn de onzekerheden simpelweg te groot. Het publiek en de Tweede Kamer hebben begrip voor de onzekerheid of deze doelstelling behaald kan worden. We gaan door met het stap voor stap openen van de economie conform de routekaart van het kabinet. De experts in het OMT volgen de mogelijke impact hiervan nauwgezet. Het zou goed zijn als zij de verwachte impact per stap op de Rt modelleren en publiceren. Het RIVM scherpt het test- en bron en contactonderzoek (BCO) protocol verder aan: a. Er wordt een uitgebreide informatiecampagne richting publiek en werkgevers opgezet om het belang van testen te onderstrepen. b. Inplannen van tests gebeurt primair online, real-time. c. Uitslagen testen worden verder versneld (< 24 uur of idealiter < 8 uur). d. Er wordt ingezet op 90% contactopsporing door GGD’s. e. Het totale BCO wordt in 4 dagen na aanvragen test afgerond. De doelstelling wordt uitgesproken FFP1-mondkapjes te bemachtigen voor het brede publiek op drukke plaatsen zoals het openbaar vervoer. Er zijn verschillende berichten dat de schaarste inmiddels voorbij is. Zodra we voldoende voorraad hebben, worden deze FFP1-maskers door het publiek standaard gebruikt op drukke plaatsen. We blijven inzetten op social distancing en hygienemaatregelen. We voegen waar mogelijk het optimaal ventileren van ruimtes toe aan de adviezen. Er wordt onderzocht hoe in een open economie als de Nederlandse het aantal besmettingen vanuit het buitenland geminimaliseerd kan worden. Eerste gedachten hierbij zijn: a. Het verplicht testen van mensen bij binnenkomst via Schiphol. b. Het screenen op temperatuur bij passagiers op Schiphol. c. Het weren van vluchten uit gebieden met hoge besmettingsaantallen en/of 14 dagen quarantaine. d. Een permanente FFP1-mondkapplicht van 14 dagen voor buitenlanders. e. Idealiter stemmen we ons indambeleid Europees af, zodat 6a-d niet nodig is voor Europeanen. Het dashboard wordt verder verrijkt en genormeerd: a. Het maximaal aantal besmettingen per veiligheidsregio wordt gedefinieerd. b. Er worden leading procesindicatoren toegevoegd (o.a. % contacten opgespoord, % besmette patienten getest). c. Per veiligheidsregio wordt een escalatieladder geformuleerd van maatregelen indien normen niet gehaald zouden worden.
Procesindicatoren beschrijven processen en, zoals de naam zegt, geen uitkomsten van zorg. Toch ha... more Procesindicatoren beschrijven processen en, zoals de naam zegt, geen uitkomsten van zorg. Toch hangen processen vaak samen met uitkomsten. Daarom zouden procesindicatoren patiënten en zorginkopers kunnen dienen bij het selecteren van zorgaanbieders
Om goed voorbereid te zijn op een uitbraak van meningokokken, moet de overheid slim schakelen, be... more Om goed voorbereid te zijn op een uitbraak van meningokokken, moet de overheid slim schakelen, betoogt gezondheidseconoom Xander Koolman.
This paper considers health-related non-response in the first eleven waves of the British Househo... more This paper considers health-related non-response in the first eleven waves of the British Household Panel Survey (BHPS) and the full eight waves of the European Community Household Panel (ECHP) and explores its consequences for dynamic models of the association between socioeconomic status and self-assessed health (SAH). We describe the pattern of health-related non-response revealed by the BHPS and ECHP data. We both test and correct for non-response in empirical models of the impact of socioeconomic status on self-assessed health. Descriptive evidence shows that there is health-related non-response in the data, with those in very poor initial health more likely to drop out, and variable addition tests provide evidence of nonresponse bias in the panel data models of SAH. Nevertheless a comparison of estimates-based on the balanced sample, the unbalanced sample and corrected for non-response using inverse probability weights (IPW)-shows that, on the whole, there are not substantive differences in the average partial effects (APE) of the variables of interest. The main differences are between unweighted and one form of IPW-weighted estimates for the APE of income and education in those countries that have fewer than eight waves of data. Similar findings have been reported concerning the limited influence of non-response bias in models of various labour market outcomes; we discuss possible explanations for our results.
Background: Cost-sharing programs are often too complex to be easily understood by the average in... more Background: Cost-sharing programs are often too complex to be easily understood by the average insured individual. Consequently, it is often difficult to determine the amount of expenses in advance. This may preclude well-informed decisions of insured individuals to adhere to medical treatment advised by the treating physician. Preliminary research has showed that the uncertainty in these cost-sharing payments are affected by four design characteristics, i.e. 1) type of payments (copayments, coinsurances or deductibles), 2) rate of payments, 3) annual caps on cost-sharing and 4) moment that these payments must be made (directly at point of care or billed afterwards by the insurer). Methods: An online discrete choice experiment was used to assess the extent to which design characteristics of cost-sharing programs affect the decision of individuals to adhere to recommended care (prescribed medications, ordered diagnostic tests and referrals to medical specialist care). Analyses were performed using mixed multinomial logits. Results: The questionnaire was completed by 7921 members of a patient organization. Analyses showed that 1) costsharing programs that offer clear information in advance on actual expenses that are billed afterwards, stimulate adherence to care recommended by the treating physician; 2) the relative importance of the design characteristics differed between respondents who reported to have forgone health care due to cost-sharing and those who did not; 3) price-awareness among respondents was limited; 4) the utility derived from attributes and respondents' characteristics were positively correlated; 5) an optimized cost-sharing program revealed an adherence of more than 72.9% among those who reported to have forgone health care. Conclusions: The analyses revealed that less complex cost-sharing programs stimulate adherence to recommended care. If these programs are redesigned accordingly, individuals who had reported to have forgone a health service recommended by their treating physician due to cost-sharing, would be more likely to use this service. Such redesigned programs provide a policy option to reduce adverse health effects of cost-sharing in these groups. Considering the upcoming shift from volumebased to value-based health care provision, insights into the characteristics of a cost-sharing program that stimulates the use of recommended care may help to design value-based insurance plans.
Europe aims at combining income growth with improvements in social cohesion as measured by income... more Europe aims at combining income growth with improvements in social cohesion as measured by income and health inequalities. We show that, theoretically, both aims can be reconciled only under very specific conditions concerning the type of growth and the income responsiveness of health. We investigate whether these conditions held in Europe in the nineties using panel data from the European Community Household Panel surveys. We use pooled interval regressions and inequality decompositions to demonstrate that (i) in all countries except Austria, the income elasticity of health is positive and increases with income, and (ii) that income growth was not pro-rich in most EU countries, resulting in little or no reductions in income inequality and modest increases in income-related health inequality in the majority of countries.
Governments of EU countries have declared that they would like to couple income growth with reduc... more Governments of EU countries have declared that they would like to couple income growth with reductions in social inequalities in income and health. We show that, theoretically, both aims can be reconciled only under very specific conditions concerning the type of growth and the income responsiveness of health. We investigate whether these conditions were met in Europe in the 1990s using panel data from the European Community Household Panel. We demonstrate that (i) in most countries, the income elasticity of health was positive and increases with income, and (ii) that income growth was not pro-rich in most EU countries, resulting in small or negligible reductions in income inequality. The combination of both findings explains the modest increases we observe in income-related health inequality in the majority of countries.
International Journal of Technology Assessment in Health Care, Apr 1, 2010
The aim of this study was to get insight in what criteria as presented in Health technology asses... more The aim of this study was to get insight in what criteria as presented in Health technology assessment (HTA) studies are important for decision makers in healthcare priority setting. Methods: We performed a discrete choice experiment among Dutch healthcare professionals (policy makers, HTA experts, advanced HTA students). In twenty-seven choice sets, we asked respondents to elect reimbursement of one of two different healthcare interventions, which represented unlabeled, curative treatments. Both treatments were incrementally compared with usual care. The results of the interventions were normal outputs of HTA studies with a societal perspective. Results were analyzed using a multinomial logistic regression model. Upon completion of the questionnaire, we discussed the exercise with policy makers. Results: Severity of disease, costs per quality-adjusted life-year gained, individual health gain, and the budget impact were the most decisive decision criteria. A program targeting more severe diseases increased the probability of reimbursement dramatically. Uncertainty related to cost-effectiveness was also important. Respondents preferred health gains that include quality of life improvements over extension of life without improved quality of life. Savings in productivity costs were not crucial in decision making, although these are to be included in Dutch reimbursement dossiers for new drugs. Regarding subgroups, we found that policy makers attached relatively more weight to disease severity than others but less to uncertainty. Conclusions: Dutch policy makers and other healthcare professionals seem to have reasonably well articulated preferences: six of seven attributes were significant. Disease severity, budget impact, and cost-effectiveness were very important. The results are comparable to international studies, but reveal a larger set of important decision criteria.
paper derives from the project "Economic determinants of the distribution of health and health ca... more paper derives from the project "Economic determinants of the distribution of health and health care in Europe" (known as the ECuity II Project), which is funded in part by the European Community's Biomed II programme (contract BMH4-CT98-3352). We are grateful to the EC for financial support, to Eurostat for access to the ECHP data and to Andrew Jones and Tom Van Ourti for stimulating discussions from which the paper benefited considerably and Evertjan Jansen and two anonymous referees for useful suggestions and comments on an earlier version of the paper.
New technologies may displace existing, higher-value care under a fixed budget. Countries aim to ... more New technologies may displace existing, higher-value care under a fixed budget. Countries aim to curtail adoption of low-value technologies, for example, by installing cost-effectiveness thresholds. Our objective is to estimate the opportunity cost of hospital care to identify a threshold value for the Netherlands. To this aim, we combine claims data, mortality data and quality of life questionnaires from 2012 to 2014 for 11,000 patient groups to obtain qualityadjusted life-year (QALY) outcomes and spending. Using a fixed effects translog model, we estimate that a 1% increase in hospital spending on average increases QALY outcomes by 0.2%. This implies a threshold of €73,600 per QALY, with 95% confidence intervals ranging from €53,000 to €94,000 per QALY. The results stipulate that new technologies with incremental cost effectiveness ratios exceeding the Dutch upper reference value of €80,000 may indeed displace more valuable care.
Aim: To investigate if subjective life expectancy (SLE) impacts the willingness to trade-off (WTT... more Aim: To investigate if subjective life expectancy (SLE) impacts the willingness to trade-off (WTT) and the number of years traded-off in a 10-years time trade-off (TTO) exercise to obtain health state valuations. Methods: An Internet-based questionnaire was administered in a sample representative for the Dutch general public. Next to basic demographic characteristics and SLE, respondents were asked to perform three TTO exercises. The following EQ-5D health states were included 21211 (TTO1), 22221 (TTO2) and 33312 (TTO3). The WTT was studied using a probit regression model. The number of years traded-off was investigated using a generalized negative binomial regression model. The independent variables used in both models were age, gender, quality of life, education, the difference between age and expected age of death (SLE), and a variable indicating whether the SLE was less than 10 years (SLEo10). Results: Three hundred and thirty nine respondents completed the questionnaire. The mean utility scores were 0.96 (TTO1), 0.94 (TTO2) and 0.79 (TTO3). The probit model showed that SLE was the only variable with a significant influence on WTT. The gnbreg showed that the number of years traded-off was also significantly influenced by SLE. In addition, age and education significantly influenced the number of years traded-off. Conclusion: The WTT years and the number of years traded-off were both influenced by SLE in 10-years TTO exercises. Reducing remaining life expectancy to 10 years in a TTO may thus increase loss aversion and, especially in respondents losing relatively many expected life years, diminish WTT and the amount of time traded off.
Background: In 2006, the Dutch hospital market was reformed to create a more efficient delivery s... more Background: In 2006, the Dutch hospital market was reformed to create a more efficient delivery system through managed competition. To allow competition on quality, patient experiences were measured using the Consumer Quality index (CQI). We study whether public reporting and competition had an effect on the CQI between 2006 and 2009. Methods: We analyzed 8,311 respondents covering 31 hospitals in 2006, 22,333 respondents covering 78 hospitals in 2007 and 24,246 respondents covering 94 hospitals in 2009. We describe CQI trends over the period 2006-2009. In addition we compare hospitals that varied in the level of competition they faced and hospitals that were forced to publish CQI results publicly and those that were not. We corrected for observable covariates between hospital respondents using a multi level linear regression. We used the Herfindahl Hirschman Index to indicate the level of competition. Results: Between 2006 and 2009 hospitals showed a CQI improvement of 0.034 (p < 0.05) to 0.060 (p < 0.01) points on a scale between one and four. Hospitals that were forced to publish their scores showed a further improvement of 0.027 (p < 0.01) to 0.030 (p < 0.05). Furthermore, hospitals that faced more competition from geographically close competitors showed a more pronounced improvement of CQI-scores 0.004 to 0.05 than other hospitals (p < 0.001). Conclusion: Our results show that patients reported improved experiences measured by the CQI between 2006 and 2009. CQI levels improve at a faster rate in areas with higher levels of competition. Hospitals confronted with forced public publication of their CQI responded by enhancing the experiences of their patients.
paper derives from the project "Economic determinants of the distribution of health and health ca... more paper derives from the project "Economic determinants of the distribution of health and health care in Europe" (known as the ECuity II Project), which is funded in part by the European Community's Biomed II programme (contract BMH4-CT98-3352). We are grateful to the EC for financial support and to Hugh Gravelle, Tom van Ourti, and participants of the ECuity II Project Workshop in Rome, 20-22 March, 2002 for helpful comments on an earlier draft.
Background: Evidence based medicine aims to integrate scientific evidence, clinical experience, a... more Background: Evidence based medicine aims to integrate scientific evidence, clinical experience, and patient values and preferences. Individual health care professionals need to appraise the evidence from randomized trials and observational studies when guidelines are not yet available. To date, tools for assessment of bias and terminologies for bias are specific for each study design. Moreover, most tools appeal only to methodological knowledge to detect bias, not to subject matter knowledge, i.e. in-depth medical knowledge about a topic. We propose a unified framework that enables the coherent assessment of bias across designs. Methods: Epidemiologists traditionally distinguish between three types of bias in observational studies: confounding, information bias, and selection bias. These biases result from a common cause, systematic error in the measurement or common effect of the intervention and outcome respectively. We applied this conceptual framework to randomized trials and show how it can be used to identify bias. The three sources of bias were illustrated with graphs that visually represent researchers' assumptions about the relationships between the investigated variables (causal diagrams). Results: Critical appraisal of evidence started with the definition of the research question in terms of the population of interest, the compared interventions and the main outcome. Next, we used causal diagrams to illustrate how each source of bias can lead to over-or underestimated treatment effects. Then, we discussed how randomization, blinded outcome measurement and intention-to-treat analysis minimize bias in trials. Finally, we identified study aspects that can only be appraised with subject matter knowledge, irrespective of study design. Conclusions: The unified framework encompassed the three main sources of bias for the effect of an assigned intervention on an outcome. It facilitated the integration of methodological and subject matter knowledge in the assessment of bias. We hope that graphical diagrams will help clarify debate among professionals by reducing misunderstandings based on different terminology for bias.
Objectives: This paper describes the first months of the COVID-19 pandemic in the Netherlands, in... more Objectives: This paper describes the first months of the COVID-19 pandemic in the Netherlands, including policies to reduce the health-related and economic consequences. The Netherlands started with containment and shifted to mitigation within three weeks when implementing a 'mild' lockdown. The initial focus was to obtain herd immunity while preventing Intensive Care Units from getting overwhelmed. Methods: An in-depth analysis of available national and international COVID-19 data sources was conducted. Due to regional variation in COVID-19 hospitalization rates, this paper focuses on three distinct regions; the initial epicenter; the most northern provinces which-contrary to national policy-decided not to switch to mitigation; and the Bible Belt, as congregations of religious groups were initially excluded from the ban on group formation. Results: On August 11 th , 6,159 COVID-19 deaths were reported with at the peak an excess mortality Zscore of 21.7. As a result of the pandemic, the economy took a severe hit and is predicted to shrink 6.5% compared to projection. The hospitalization rates in the northern regions were over 70% lower compared to the rest of the country (18 versus 66 per 10 0,0 0 0 inhabitants). Differences between the Bible Belt and the rest of the country were hardly detectable. Conclusion: The Dutch have shown a way to effectively slow down transmission while allowing more personal and economic freedom than most other countries. Furthermore, the regional differences suggest that containment prevented a surge of infections in the northern provinces. The results should be interpreted with caution, due to the descriptive nature of this study.
Unsustainable growth in healthcare expenditure demands effective cost-containment policies. We re... more Unsustainable growth in healthcare expenditure demands effective cost-containment policies. We review policy effectiveness using total payer expenditure as primary outcome measure. We included all OECD member states from 1970 onward. After a rigorous quality appraisal, we included 43 original studies and 18 systematic reviews that cover 341 studies. Policies most often evaluated were payment reforms (10 studies), managed care (8 studies) and cost sharing (6 studies). Despite the importance of this topic, for many widely-used policies very limited evidence is available on their effectiveness in containing healthcare costs. We found no evidence for 21 of 41 major groups of cost-containment policies. Furthermore, many evaluations displayed a high risk of bias. Therefore, policies should be more routinely and rigorously evaluated after implementation. The available high-quality evidence suggests that the cost curve may best be bent using a combination of cost sharing, managed care competition, reference pricing, generic substitution and tort reform.
Kabinet en RIVM zijn onhelder over wat de Nederlandse COVID-19-strategie precies is. Het begrip ‘... more Kabinet en RIVM zijn onhelder over wat de Nederlandse COVID-19-strategie precies is. Het begrip ‘maximale controle’ wordt door het kabinet geduid als een indamstrategie, terwijl het RIVM en GGD’s zowel in interviews als in de praktijk met suboptimale organisatie van testen en bron- en contactonderzoek hinten op het vasthouden aan een strategie van groepsimmuniteit. — Uit deze rapportage blijkt dat de indamstrategie significante voordelen heeft voor zowel economie als volksgezondheid. Een indamstrategie levert cumulatief in 2020-2022 EUR 123 miljard op hetgeen gelijk staat aan 3,1% BBP-groei in 2022. Als andere Europese landen ook meedoen met deze strategie, lopen de revenuen verder op tot potentieel 16,9% van het BBP in 2022. Ook voorkomen we met een indamstrategie mogelijk tot zo’n 50.000 COVID-19-doden. — Uit onze modellering blijkt dat het huidige testbeleid en de ingezette bron- en contactopsporing waarschijnlijk onvoldoende zijn om een indamstrategie (Rt < 1) te bewerkstelligen. Het inplannen van en testen zelf gaat te traag, te weinig mensen worden gestimuleerd te komen testen en te weinig contacten worden tijdig gevonden. De huidige opzet levert een daling van Rt 0,15 op, terwijl met het door ons voorgestelde protocol de Rt met 0,40 daalt: genoeg voor het inzetten van een indamstrategie. — Met het lage aantal besmettingen hebben we nu een eenmalige kans om de indamstrategie tot een succes te maken. De volgende acties zijn vereist: 1. 2. 3. 4. 5. 6. 7. Kabinet, RIVM en OMT spreken zich ten volle uit voor een indammingsstrategie (ook containment, eliminatie of uitdoven genoemd), zonder mitsen en maren. Dat is een strategie waarmee de Rt duurzaam < 1 is. Belangrijke kanttekening hierbij is dat het gaat om een doelstelling en geen resultaatsverplichting, daarvoor zijn de onzekerheden simpelweg te groot. Het publiek en de Tweede Kamer hebben begrip voor de onzekerheid of deze doelstelling behaald kan worden. We gaan door met het stap voor stap openen van de economie conform de routekaart van het kabinet. De experts in het OMT volgen de mogelijke impact hiervan nauwgezet. Het zou goed zijn als zij de verwachte impact per stap op de Rt modelleren en publiceren. Het RIVM scherpt het test- en bron en contactonderzoek (BCO) protocol verder aan: a. Er wordt een uitgebreide informatiecampagne richting publiek en werkgevers opgezet om het belang van testen te onderstrepen. b. Inplannen van tests gebeurt primair online, real-time. c. Uitslagen testen worden verder versneld (< 24 uur of idealiter < 8 uur). d. Er wordt ingezet op 90% contactopsporing door GGD’s. e. Het totale BCO wordt in 4 dagen na aanvragen test afgerond. De doelstelling wordt uitgesproken FFP1-mondkapjes te bemachtigen voor het brede publiek op drukke plaatsen zoals het openbaar vervoer. Er zijn verschillende berichten dat de schaarste inmiddels voorbij is. Zodra we voldoende voorraad hebben, worden deze FFP1-maskers door het publiek standaard gebruikt op drukke plaatsen. We blijven inzetten op social distancing en hygienemaatregelen. We voegen waar mogelijk het optimaal ventileren van ruimtes toe aan de adviezen. Er wordt onderzocht hoe in een open economie als de Nederlandse het aantal besmettingen vanuit het buitenland geminimaliseerd kan worden. Eerste gedachten hierbij zijn: a. Het verplicht testen van mensen bij binnenkomst via Schiphol. b. Het screenen op temperatuur bij passagiers op Schiphol. c. Het weren van vluchten uit gebieden met hoge besmettingsaantallen en/of 14 dagen quarantaine. d. Een permanente FFP1-mondkapplicht van 14 dagen voor buitenlanders. e. Idealiter stemmen we ons indambeleid Europees af, zodat 6a-d niet nodig is voor Europeanen. Het dashboard wordt verder verrijkt en genormeerd: a. Het maximaal aantal besmettingen per veiligheidsregio wordt gedefinieerd. b. Er worden leading procesindicatoren toegevoegd (o.a. % contacten opgespoord, % besmette patienten getest). c. Per veiligheidsregio wordt een escalatieladder geformuleerd van maatregelen indien normen niet gehaald zouden worden.
Procesindicatoren beschrijven processen en, zoals de naam zegt, geen uitkomsten van zorg. Toch ha... more Procesindicatoren beschrijven processen en, zoals de naam zegt, geen uitkomsten van zorg. Toch hangen processen vaak samen met uitkomsten. Daarom zouden procesindicatoren patiënten en zorginkopers kunnen dienen bij het selecteren van zorgaanbieders
Om goed voorbereid te zijn op een uitbraak van meningokokken, moet de overheid slim schakelen, be... more Om goed voorbereid te zijn op een uitbraak van meningokokken, moet de overheid slim schakelen, betoogt gezondheidseconoom Xander Koolman.
This paper considers health-related non-response in the first eleven waves of the British Househo... more This paper considers health-related non-response in the first eleven waves of the British Household Panel Survey (BHPS) and the full eight waves of the European Community Household Panel (ECHP) and explores its consequences for dynamic models of the association between socioeconomic status and self-assessed health (SAH). We describe the pattern of health-related non-response revealed by the BHPS and ECHP data. We both test and correct for non-response in empirical models of the impact of socioeconomic status on self-assessed health. Descriptive evidence shows that there is health-related non-response in the data, with those in very poor initial health more likely to drop out, and variable addition tests provide evidence of nonresponse bias in the panel data models of SAH. Nevertheless a comparison of estimates-based on the balanced sample, the unbalanced sample and corrected for non-response using inverse probability weights (IPW)-shows that, on the whole, there are not substantive differences in the average partial effects (APE) of the variables of interest. The main differences are between unweighted and one form of IPW-weighted estimates for the APE of income and education in those countries that have fewer than eight waves of data. Similar findings have been reported concerning the limited influence of non-response bias in models of various labour market outcomes; we discuss possible explanations for our results.
Background: Cost-sharing programs are often too complex to be easily understood by the average in... more Background: Cost-sharing programs are often too complex to be easily understood by the average insured individual. Consequently, it is often difficult to determine the amount of expenses in advance. This may preclude well-informed decisions of insured individuals to adhere to medical treatment advised by the treating physician. Preliminary research has showed that the uncertainty in these cost-sharing payments are affected by four design characteristics, i.e. 1) type of payments (copayments, coinsurances or deductibles), 2) rate of payments, 3) annual caps on cost-sharing and 4) moment that these payments must be made (directly at point of care or billed afterwards by the insurer). Methods: An online discrete choice experiment was used to assess the extent to which design characteristics of cost-sharing programs affect the decision of individuals to adhere to recommended care (prescribed medications, ordered diagnostic tests and referrals to medical specialist care). Analyses were performed using mixed multinomial logits. Results: The questionnaire was completed by 7921 members of a patient organization. Analyses showed that 1) costsharing programs that offer clear information in advance on actual expenses that are billed afterwards, stimulate adherence to care recommended by the treating physician; 2) the relative importance of the design characteristics differed between respondents who reported to have forgone health care due to cost-sharing and those who did not; 3) price-awareness among respondents was limited; 4) the utility derived from attributes and respondents' characteristics were positively correlated; 5) an optimized cost-sharing program revealed an adherence of more than 72.9% among those who reported to have forgone health care. Conclusions: The analyses revealed that less complex cost-sharing programs stimulate adherence to recommended care. If these programs are redesigned accordingly, individuals who had reported to have forgone a health service recommended by their treating physician due to cost-sharing, would be more likely to use this service. Such redesigned programs provide a policy option to reduce adverse health effects of cost-sharing in these groups. Considering the upcoming shift from volumebased to value-based health care provision, insights into the characteristics of a cost-sharing program that stimulates the use of recommended care may help to design value-based insurance plans.
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Papers by Xander Koolman