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Background: The outbreak of COVID-19 was followed by an unprecedented package of measures to protect public health. Over 150 countries mandated school closures to reduce the risk of transmission. Decisions on whether to close schools involve trade-offs between important effects on public health, learning outcomes, well-being of children, productivity of parents., Objectives: Investigate Peruvian citizens' preferences for schools opening during a public-health crisis such as the COVID-19 pandemic in two scenarios: (i) when the threat from COVID-19 is low and schools are open; and, (ii) when the threat from COVID-19 is high and schools are closed., Methods: We conducted a Participatory Value Evaluation (PVE) from 22 September to 17 October 2022, on which 2007 respondents assessed which policy measures to implement in the two scenarios. (i) In Scenario 1 "Schools are open", children go to school, teachers and parents go to their jobs, but children still experience learning deficits from previous school closures. (ii) In Scenario 2 "Schools are closed", children cannot go to school and do not receive any formal teaching, leading to learning losses; many teachers must change careers; and, many parents have to stay at home to take care of their children and lose income. Respondents were shown a range of policy measures in each of the scenarios and received information about the effects of each measure on public health, children's well-being and learning loss., Results: We found that most respondents in Scenario 1 preferred mandatory vaccination for teachers and quarantine measures. In Scenario 2 we found that most respondents were positive towards reopening school policies. In both Scenarios respondents prioritized mandatory vaccination and quarantine measures over other mitigation measures. In Scenario 2, most respondents from the Highland region selected opening schools with 100% on-location teaching while hybrid teaching was mostly selected in the Coast region. Most respondents (82%) evaluated PVE as a good method to involve citizens in policy decision-making., Conclusions: Policies that focus on prevention (e.g. mandatory vaccination for teachers and quarantine measures) can count on substantial support in a scenario when schools are open. The strong preference for opening schools with a noticeable difference in the way classes are provided (e.g. teaching on location most preferred by respondents from the Highlands and hybrid teaching by respondents from the Coast) show the importance of introducing differentiated strategies among regions., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Alemtuzumab is approved in the European Union for treating highly active relapsing-remitting multiple sclerosis (RRMS). Patient-reported outcomes measure the treatment impact on quality of life (QoL), including fatigue, a common symptom in multiple sclerosis (MS). Chronic diseases like MS also affect the patient's caregiver. Thus, understanding the impact on both patients and caregivers is essential for a comprehensive view of MS treatment outcomes., Methods: This multi-center prospective, observational study assessed RRMS patients undergoing alemtuzumab treatment, and their caregivers across three European countries (Denmark, Norway, and Italy). The study visits were conducted at baseline, and at Months 3, 6, 12, 18, 24, and 36 (± 1 month). The primary endpoint assessed the effect of alemtuzumab on MS-related fatigue (Fatigue Scale for Motor and Cognitive Functions [FSMC] score). Secondary endpoints included changes in cognition (Symbol Digit Modalities Test [SDMT]), depression (Beck Depression Inventory-Version II [BDI-II]), QoL (29-item Multiple Sclerosis Impact Scale [MSIS-29]), treatment satisfaction (Treatment Satisfaction Questionnaire for Medication [TSQM]), working capacity/daily life activity (Health-Related Productivity Questionnaire [HRPQ]), and clinical evaluation (number of relapses, improvement in Expanded Disability Status Scale [EDSS] score, and need for re-treatment with alemtuzumab/any other treatment). Exploratory endpoints included caregiver perception of patient's QoL, caregiver QoL, and caregiver burden. The sample size (N = 80) was determined based on the 2-sided t-test at 5 % significance level. Data were analyzed descriptively. Safety was also evaluated., Results: Of 87 enrolled patients, 72.4 % (n = 63) completed all follow-ups. Significant improvement was observed in fatigue (p < 0.01), with a median (min, max) FSMC score change of -7.3 (-56.0, 34.0) units at the end-of-study (EOS), and clinically relevant improvement (≥ 9 units) noted in approximately 12.5 months. SDMT (3-5 units, p < 0.05), BDI-II (median score of 9.5, i.e., no depression, p < 0.01), and MSIS-29 (median change in physical and psychological impact scores -9.2, p < 0.01 and -14.8, p < 0.001, respectively) improved significantly from baseline to EOS. Global treatment satisfaction (p < 0.001), effectiveness (p < 0.05), and side effects (p < 0.05) significant improved exept at EOS, whereas treatment convenience remained same throughout the study. The percentage of patients with at least one relapse was similar each year of the study (10.8-13.2 %). A statistically significant improvement (p < 0.05) in EDSS was reported over time. At EOS, 4.5 % patients needed retreatment with alemtuzumab. Caregivers also reported improvement in patients' QoL over time, but the median change from baseline (physical and psychological impact scores:10.0 and -14.8, respectively) was not statistically significant (p > 0.05). Caregivers reported similar QoL and caregiver burden at baseline and EOS, apart from an increase in emotional QoL. Headache (51.2 %), pyrexia (44.2 %), and rash (34.9 %) were the most common adverse events (AEs). Majority of the AEs were either mild or moderate, apart from 25 severe AEs. Three patients discontinued prematurely, of which one patient died of sepsis related to treatment., Conclusion: This real-world study showed beneficial impact of alemtuzumab on fatigue, cognition, depression, QoL, and treatment satisfaction. Improvement in patient disability, and caregiver-reported outcomes indicated enhanced patients' QoL., Competing Interests: Declaration of competing interest Jette Lautrup Frederiksen: Served on scientific advisory boards for and received funding for travel related to these activities as well as honoraria from Biogen Idec, Merck Serono, Sanofi-Aventis, Teva, Novartis, and Almirall. Received speaker honoraria from Biogen Idec, Teva, and Novartis. Luca Massacesi: Received educational grants and/or research funds from Biogen, Merck-Serono, Genzyme, and Roche and honoraria or consultation fees from Biogen, Roche, Merck-Serono, Sanofi, Viatris, Horizon, Alexion, and Novartis. Helle Hvilsted Nielsen: Received research support, travel grants, and/or teaching honoraria from Biogen Inc., Merck Serono, Novartis, Sanofi, Teva, and Roche. Augusto Rini: Received a grant for the organization of a scientific congress or speaker honoraria from Biogen Idec, Sanofi, Merck Serono, Bristol, and Roche. Eleonora Baldi: Received a grant for the organization of a scientific congress from Biogen Idec and also received travel or speaker honoraria from Biogen Idec, Sanofi, Merck Serono, Novartis, and Roche. Massimiliano Mirabella: Reported scientific advisory board membership with Bayer Schering, Biogen, Sanofi, Merck, Novartis, and Roche; received consulting and/or speaking fees and research support or travel grants from Almirall, Alexion, Bayer Schering, Bristol-Myers-Squibb, Biogen, Janssen, Sanofi, Merck, Novartis, Roche, and Viatris; reported to be a principal investigator in clinical trials conducted by Biogen, Merck, Novartis, Roche, and Sanofi. Falzone Francesca Maria Antonella: Received travel or speaker honoraria and grants to attend scientific congresses from Biogen, Sanofi, Merck Serono, and Teva. Received a grant for the organization of a scientific congress from Biogen. Giacomo Lus: Received speaker, travel, and advisory board membership honoraria from Almirall, Alexion, Bayer, Biogen, Novartis, Sanofi, Merck, Bristol-Myers-Squibb, and Horizon Therapeutics. Damiano Paolicelli: Received speaker honoraria from Novartis, Sanofi, Biogen Idec, Merck-Serono, Roche, BMS, and Almirall. Matthias Kant: Has nothing to disclose. Giuseppe Salemi: Received grants to attend scientific congresses or speaker honoraria from Biogen, Merck-Serono, Novartis, Roche, Sanofi, and Teva. Umberto Aguglia: Received grants to attend scientific congresses or speaker honoraria from Biogen, Merck-Serono, Novartis, Roche, Sanofi, and Teva. Cristoforo Comi: Received grants to attend scientific congresses or speaker honoraria from Merck-Serono, Novartis, Roche, Sanofi, and Almirall. Milena De Riz: Received grants to attend scientific congresses or speaker honoraria from Merck-Serono, Novartis, Roche, Sanofi, Biogen, Teva, Almirall, Bristol-Myers-Squibb, and Horizon Therapeutics. Valeria Barcella: Received grants to attend scientific congresses or speaker honoraria from Biogen, Merck-Serono, Novartis, Roche, Sanofi, and Teva. Heidi Ø. Flemmen: Received unrestricted research grants from Biogen and Novartis and advisory board and/or speaker honoraria from Sanofi, Merck, and Biogen. Alessandra Protti: Has nothing to disclose. Elisabeth Farbu: Received unrestricted grants from Novartis and participated in advisory boards from Biogen, Merck, Novartis, Roche, and Sanofi. Job van Exel: Received research funds from AstraZeneca, GSK, Janssen, Merck, Novartis, Pfizer, Sanofi, and Takeda. Øivind Torkildsen: Received speaker honoraria from and served on scientific advisory boards of Biogen, Sanofi-Aventis, Merck, and Novartis., (Copyright © 2024. Published by Elsevier B.V.)

Background: Low-value care is unnecessary care that contributes to inefficient use of health resources and constitutes a considerable proportion of healthcare expenditures worldwide. Factors contributing to patients' demand for low-value care have often been overlooked and are dispersed in the literature. Therefore, the current study aimed to systematically summarize factors associated with patients' demand for low-value care., Methods: In this scoping review, scientific articles were identified based on a search query conducted in Embase and Scopus. We identified articles using search terms related to low-value care and demand-related factors, published in peer-reviewed journals, and written in English or Dutch. The titles, abstracts, results, and conclusions were inspected to only include articles that were deemed relevant for this topic. From these articles we extracted text fragments that contained factors associated with patients' demand for low-value care. Hereafter, a thematic analysis was applied to openly, axially, and selectively code textual fragments to identify themes within the data., Results: Forty-seven articles were included in this review. We identified eight core themes associated with patients' demand for low-value care: cognitive biases, emotions, preferences and expectations, knowledge-related factors, socio-cultural factors, biomedical and care-related factors, economic factors, and factors related to the interaction with the healthcare provider. Within these core themes, thirty-three subthemes were identified. For example, risk aversion and anticipated regret aversion are sub-themes of cognitive biases, while consumerism and present and future income effects are sub-themes of economic factors., Conclusions: Through this review we provide a systematic overview of factors associated with the demand for low-value care. We found that patients' demand for low-value care could relate to a multitude of factors that were clustered into eight core themes and thirty-three subthemes. To understand the demand for low-value care from the patient's perspective in greater detail, future research should focus on the interaction between and importance of these factors in different care contexts., Competing Interests: Ethics approval and consent to participate: Not applicable. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Background: The scarcity of resources in long-term care demands more than ever that organizations in this sector are prepared for innovation to ensure affordable access to care for older adults. Organizations that are innovation ready are more capable of implementing innovations. Therefore, a better understanding of how stakeholders view innovation readiness in long-term care can provide actionable strategies to enhance their innovative capacities. 'Innovation readiness' indicates the level of maturity of an organization to succeed in any type of innovation. Our study explored perspectives among stakeholders on what they consider important for organizations in long-term care for older adults to be innovation ready., Methods: Q-methodology, a mixed-methods approach, was used to investigate the perspectives of 30 stakeholders connected to long-term care for older adults in the Netherlands: academics, (top)management, innovation managers, client representatives, staff, and consultants. Stakeholders were asked to rank 36 statements on innovation readiness on importance. Statements were extracted from literature research and qualitative interviews. Thereafter in the post-interviews stakeholders explained their ranking and reflected on the statements. By-person factor analysis was used to identify clusters in the ranking data. Together with the qualitative data from follow-up interviews, these clusters were interpreted and described as perspectives of the stakeholders., Results: Four distinct perspectives were identified on what they consider important for innovation readiness in long-term care: (1) 'supportive role of management' (2) 'participation of the client (system) and employees' (3) 'setting the course and creating conditions' and (4) 'structuring decision-making, roles and responsibilities'. The 36 statements represented a complete overview of innovation readiness factors. No additional innovation factors to those previously identified in the literature emerged from the interviews., Conclusions: Stakeholders agree that all factors contributing to innovation readiness of long-term care organizations for older adults are accounted for. The variety of perspectives on what is most important shows there is no agreement among stakeholders about a fixed route toward innovation readiness. However, stakeholders suggested a temporal order of the innovation readiness factors, preferably starting with formulating the innovation ambition. This study's results could contribute to developing an assessment tool to deliver a structured approach for managers to assess the innovation readiness of their organization., Registration: The study received ethical approval on April 13, 2022 from the Medical Ethics Board of Zuyderland Medical Center in the Netherlands with the number METCZ20220036., Competing Interests: Declarations. Ethics approval and consent to participate: The study received ethical approval from the Medical Ethics Board of Zuyderland Medical Center in the Netherlands with the number METCZ20220036. Permission to conduct the interviews for this study was granted by each respondent individually. Respondents were made aware of the study objectives, and written informed consent was obtained from respondents before the beginning of the interviews. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Objectives: The Epilepsy Support Dog Evaluation study was commissioned by the Dutch Ministry of Health, Welfare and Sports to inform a reimbursement decision on seizure dogs. The randomized trial found that seizure dogs reduce seizure frequency and improve health-related quality of life of persons with severe refractory epilepsy (PSREs). This article examined the cost-effectiveness (CE) of adding seizure dogs to usual care for PSREs in The Netherlands., Methods: A microsimulation model was developed, informed by generalized linear mixed models using patient-level trial data from the Epilepsy Support Dog Evaluation study. The model adopted a 10-year time horizon and took a societal perspective. Seizure frequency was predicted as a function of time with the seizure dog. Patient utilities, caregiver utilities, and costs were predicted as a function of seizure frequency and time with the seizure dog., Results: Quality-adjusted life-years (QALYs) of PSREs with a seizure dog and usual care alone were estimated at 6.28 and 5.65, respectively (Δ 0.63). For caregivers, estimated QALYs were 6.94 and 6.52, respectively (Δ 0.42). Total costs were respectively €228 691 and €226 261 (Δ €2430). Intervention costs were largely offset by savings in informal care and healthcare. The incremental CE ratio was €2314/QALY. Probabilistic sensitivity analysis indicated a 91% probability of seizure dogs being cost-effective at the €50 000/QALY threshold. The incremental CE ratio fell well below this threshold in scenario analyses., Conclusions: Seizure dogs are likely to be a cost-effective addition to usual care for PSREs in The Netherlands., Competing Interests: Author Disclosures Author disclosure forms can be accessed below in the Supplemental Material section., (Copyright © 2024. Published by Elsevier Inc.)

The impact of health technologies may extend beyond the patient and affect the health of people in their network, like their informal carers. The National Institute for Health and Care Excellence (NICE) methods guide explicitly allows the inclusion of health-related quality of life (HRQoL) effects on carers in economic evaluations when these effects are substantial, but the proportion of NICE appraisals that includes carer HRQoL remains small. This paper discusses when inclusion of carer HRQoL is justified, how inclusion can be substantiated, and how carer HRQoL can be measured and included in health economic models. Inclusion of HRQoL in economic evaluations can best be substantiated by data collected in (carers for) patients eligible for receiving the intervention. To facilitate combining patient and carer utilities on the benefit side of economic evaluations, using EQ-5D to measure impacts on carers seems the most successful strategy in the UK context. Alternatives to primary data collection of EQ-5D include vignette studies, using existing values, and mapping algorithms. Carer HRQoL was most often incorporated in economic models in NICE appraisals by employing (dis)utilities as a function of the patient's health state or disease severity. For consistency and comparability, economic evaluations including carer HRQoL should present analyses with and without carer HRQoL.

An important issue in economic evaluations is determining whether all relevant impacts are considered, given the perspective chosen for the analysis. Acknowledging that patients are not isolated individuals has important implications in this context. Increasingly, the term "spillovers" is used to label consequences of health interventions on others. However, a clear definition of spillovers is lacking, and as a result, the scope of the concept remains unclear. In this study, we aim to clarify the concept of spillovers by proposing a definition applicable in health economic evaluations. To illustrate the implications of this definition, we highlight the diversity of potential spillovers through an expanded impact inventory and conduct a mapping review that outlines the evidence base for the different types of spillovers. In the context of economic evaluations of health interventions, we define spillovers as all impacts from an intervention on all parties or entities other than the users of the intervention under evaluation. This definition encompasses a broader range of potential costs and effects, beyond informal caregivers and family members. The expanded impact inventory enables a systematic approach to identifying broader impacts of health interventions. The mapping review shows that the relevance of different types of spillovers is context-specific. Some spillovers are regularly included in economic evaluations, although not always recognised as such, while others are not. A consistent use of the term "spillovers", improved measurement of these costs and effects, and increased transparency in reporting them are still necessary. To that end, we propose a research agenda., (© 2024. The Author(s).)

Objectives: Economic evaluations of interventions in health and social care require outcome measures that capture their full benefits, including those beyond health. This study aimed to assess construct validity, test-retest reliability, and responsiveness of the newly developed 10-item Well-being instrument (WiX)., Methods: Data were gathered via an online survey in a representative sample of the adult general population in The Netherlands (N = 1045). Construct validity was assessed by inspecting convergent, structural, and discriminant validity, following the COnsensus-based Standards for the selection of health status Measurement INstruments methodology. Regression analyses of the WiX and its items on other validated measures of well-being were performed to assess the convergent validity of the instrument and the relevance of its items. Dimensionality of the WiX was assessed using exploratory factor analysis. To assess discriminant validity, several hypotheses in terms of well-being differences were assessed. Finally, a second survey was sent out 2 weeks after the initial survey (n = 563; 53.9% response rate) to assess the test-retest reliability and responsiveness of the WiX., Results: The WiX showed to be correlated with alternative well-being measures as expected and able to sufficiently differentiate between relevant subgroups in the population. Moreover, the dimensionality analysis indicated that the WiX captures a broad array of elements relevant to well-being, including physical and mental health. The test-retest reliability was good, with an intraclass correlation coefficient of 0.82., Conclusions: The results regarding the WiX are favorable and indicate that this new instrument may be a promising alternative for existing measures of well-being for evaluating interventions in health and social care., Competing Interests: Author Disclosures Author disclosure forms can be accessed below in the Supplemental Material section., (Copyright © 2024. Published by Elsevier Inc.)

The COVID-19 pandemic considerably impacted the lives of European citizens. This study aims to provide a nuanced picture of well-being patterns during the pandemic across Europe with a special focus on relevant socio-economic sub-groups. This observational study uses data from a repeated, cross-sectional, representative population survey with nine waves of data from seven European countries from April 2020 to January 2022. The analysis sample contains a total of 25,062 individuals providing 64,303 observations. Well-being is measured using the ICECAP-A, a multi-dimensional instrument for approximating capability well-being. Average levels of ICECAP-A index values and sub-dimension scores were calculated across waves, countries, and relevant sub-groups. In a fixed effects regression framework, associations of capability well-being with COVID-19 incidence, mortality, and the stringency of the imposed lockdown measures were estimated. Denmark, the Netherlands, and France experienced a U-shaped pattern in well-being (lowest point in winter 2020/21), while well-being in the UK, Germany, Portugal, and Italy followed an M-shape, with increases after April 2020, a drop in winter 2020, a recovery in the summer of 2021, and a decline in winter 2021. However, observed average well-being reductions were generally small. The largest declines were found in the well-being dimensions attachment and enjoyment and among individuals with a younger age, a financially unstable situation, and lower health. COVID-19 mortality was consistently negatively associated with capability well-being and its sub-dimensions, while stringency and incidence rate were generally not significantly associated with well-being. Further investigation is needed to understand underlying mechanisms of presented patterns., (© 2023. The Author(s).)

Background: Informal care features high on the policy agenda of many countries to deal with workforce shortages. As a consequence, care provision increasingly takes place in the care triad of care recipients, informal caregivers and care professionals. How collaboration between care partners takes shape depends on how the different partners perceive this collaboration. This paper aims to investigate the relative importance of the different aspects of collaboration from the perspectives of care recipients, informal caregivers and care professionals in the context of the care for older persons in The Netherlands., Methods: Using Q-methodology, 32 participants ranked 28 statements that reflect different aspects of collaboration in the care triad and explained their ranking during a follow-up interview. Participants comprised 9 older persons, 10 informal caregivers and 13 care professionals. Data were analysed using by-person factor analysis to identify common patterns in the rankings of the statements. Emerging patterns were interpreted and described as views on collaboration using aggregated rankings and qualitative data from the interviews., Results: Five distinct views on collaboration were found: (1) Emphasizing warm collaboration, (2) trusting care professional's expertise, (3) open and compassionate care professionals, (4) responsive decision-making by autonomous care professionals and (5) prioritizing care recipient's and informal caregiver's interests. Care recipients and/or informal caregivers were associated with views 1, 3 and, 5, whereas care professionals were associated with all five views., Conclusions: Our study highlights the importance of recognizing the potential diversity of views between and within different partner groups in care triads. Governmental and organizational policy makers, as well as healthcare professionals who aim to increase or support the involvement of informal caregivers, should take this heterogeneity into consideration., Patient or Public Contribution: An advisory board of older persons (care recipients and informal caregivers) was involved in the recruitment of the participants, the formulation of the statements and the reflection on the findings of the study and potential implications., (© 2024 The Authors. Health Expectations published by John Wiley & Sons Ltd.)

Efficiently allocating scarce healthcare resources requires nuanced understanding of individual and collective interests as well as relative concerns, which may overlap or conflict. This paper is the first to empirically investigate whether and to what extent self-interest (SI), positional concerns (PC) and distributional considerations (DC) simultaneously explain individual decision making related to access to healthcare services. Our investigation is based on a stated choice experiment conducted in two countries with different healthcare systems, the United States (US) and the United Kingdom (UK). The choice experiment is on allocation of medical treatment waiting times for a hypothetical disease. We carry out the investigation under two different perspectives: (i) in a socially inclusive personal perspective decision makers were asked to choose between waiting time distributions for themselves and (ii) in a social perspective decision makers were asked to make similar choices for a close relative or friend of opposite gender. The results obtained by estimating a variety of advanced choice models indicate that DC, SI and PC, in this order of importance, are significant drivers of choice behaviour in our empirical context. These findings are consistent regardless of the choice perspective and the country where decision makers live. Comparing the results from different choice perspectives, we find that US respondents who chose for their close relative or friend attach significantly larger weight to their close relative's or friend's waiting times as well as to the overall distribution of waiting times than US respondents who chose for themselves. Looking at differences between countries, our results show that UK respondents who made choices for themselves placed significantly larger weight on SI and DC than US respondents, while US respondents, in turn, displayed relatively stronger but not significantly different positional concerns than UK respondents. In addition, we observe that UK respondents who chose for their close relative or friend put a larger weight on DC than their US counterparts. We conclude that the methodological (data collection and analysis) approach allows for disentangling the relative importance of the three motivations and discusses the potential implications of these findings for healthcare decision making., (© 2023. The Author(s).)

Background and Objectives: The aim of this study was to evaluate whether people living with severe medically refractory epilepsy (PSRE) benefit from a seizure dog., Methods: An individual-level stepped-wedge randomized controlled trial was conducted. The study was conducted in the Netherlands among adults with daily to weekly seizures. All participants were included simultaneously (on June 1, 2019) while receiving usual care. Then, during the 36-month follow-up, they received a seizure dog in a randomized sequence. Participants kept a seizure diary and completed 3-monthly surveys. Seizure frequency was the primary outcome. Secondary outcomes included seizure-free days, seizure severity, health-related quality of life (HRQoL), and well-being. Data were analyzed using generalized linear mixed modeling (GLMM). The models assumed a delayed intervention effect, starting when the seizure dog reached an advanced stage of training. Effects were calculated as changes per 28-day period with the intervention., Results: Data were collected from 25 participants, of whom 20 crossed over to the intervention condition. The median follow-up was 19 months with usual care and 12 months with the intervention. On average, participants experienced 115 (SD 164) seizures per 28-day period in the usual care condition and 73 (SD 131) seizures in the intervention condition. Seven participants achieved a reduction of 50% or more at the end of follow-up. GLMM indicated a 3.1% decrease in seizure frequency for each consecutive 28-day period with the intervention (0.969, 95% CI 0.960-0.977). Furthermore, an increase in the number of seizure-free days was observed (1.012, 95% CI 1.009, 1.015), but no effect on seizure severity measured with the NHS3. Generic HRQoL scores improved, as reflected in the decrease in EQ-5D-5L utility decrement (0.975, 95% CI 0.954-0.997). Smaller improvements were observed on overall self-rated HRQoL, epilepsy-specific HRQoL, and well-being, measured with the EQ VAS, QOLIE-31-P, and ICECAP-A, respectively., Discussion: Seizure dogs reduce seizure frequency, increase the number of seizure-free days, and improve the quality of life of PSRE. The magnitude of the effect on generic HRQoL indicates that seizure dogs benefit PSRE beyond the impact on seizure frequency alone. Early discontinuation of seizure dog partnerships suggests that this intervention is not suitable for all PSRE and requires further study., Trial Registration Information: This study was registered in the Dutch Trial Register (NL6682) on November 28, 2017. Participants were enrolled on June 1, 2019., Classification of Evidence: This study provides Class III evidence that seizure dogs are associated with a decrease in seizure frequency in adult patients with medically refractory epilepsy.

Participatory value evaluation (PVE) has recently been introduced in the field of health as a new method to elicit stated preferences for public policies. PVE is a method in which respondents in a choice experiment are presented with various policy options and their attributes, and are asked to compose their portfolio of preference given a public-resource constraint. This paper aims to illustrate PVE's potential for informing healthcare decision making and to position it relative to established preference-elicitation methods. We first describe PVE and its theoretical background. Next, by means of a narrative review of the eight existing PVE applications within and outside the health domain, we illustrate the different implementations of the main features of the method. We then compare PVE to several established preference-elicitation methods in terms of the structure and nature of the choice tasks presented to respondents. The portfolio-based choice task in a PVE requires respondents to consider a set of policy alternatives in relation to each other and to make trade-offs subject to one or more constraints, which more closely resembles decision making by policymakers. When using a flexible budget constraint, respondents can trade-off their private income with public expenditures. Relative to other methods, a PVE may be cognitively more demanding and is less efficient; however, it seems a promising complementary method for the preference-based assessment of health policies. Further research into the feasibility and validity of the method is required before researchers and policymakers can fully appreciate the advantages and disadvantages of the PVE as a preference-elicitation method., (© 2023. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Based on theoretical notions, there is consensus that alternative payment models to the common fee-for-service model have the potential to improve healthcare quality through increased collaboration and reduced under- and overuse. This is particularly relevant for maternity care in the Netherlands because perinatal mortality rates are relatively high in comparison to other Western countries. Therefore, an experiment with bundled payments for maternity care was initiated in 2017. However, the uptake of this alternative payment model remains low, as also seen in other countries, and fee-for-service models prevail. A deeper understanding of stakeholders' perspectives on payment reform in maternity care is necessary to inform policy makers about the obstacles to implementing alternative payment models and potential ways forward. We conducted a Q-methodology study to explore perspectives of stakeholders (postpartum care managers, midwives, gynecologists, managers, health insurers) in maternity care in the Netherlands on payment reform. Participants were asked to rank a set of statements relevant to payment reform in maternity care and explain their ranking during an interview. Factor analysis was used to identify patterns in the rankings of statements. We identified three distinct perspectives on payment reform in maternity care. One general perspective, broadly supported within the sector, focusing mainly on outcomes, and two complementary perspectives, one focusing more on equality and one focusing more on collaboration. This study shows there is consensus among stakeholders in maternity care in the Netherlands that payment reform is required. However, stakeholders have different views on the purpose and desired design of the payment reform and set different conditions. Working towards payment reform in co-creation with all involved parties may improve the general attitude towards payment reform, may enhance the level of trust among stakeholders, and may contribute to a higher uptake in practice., Competing Interests: Declaration of competing interest The authors declare that there are no conflicts of interests., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Productivity costs can form a large and influential component of total costs in an economic evaluation taking a societal perspective. In calculating productivity costs, estimating productivity losses is a central element. Compensation mechanisms and multiplier effects may influence these losses but remain understudied. Compensation mechanisms could reduce productivity losses while multiplier effects may increase them., Methods: Data on productivity losses were collected in 2015 using an online survey among a sample of persons aged 15-65 years in The Netherlands who worked at least 12 h per week and reported to have experienced absenteeism and/or presenteeism during the past 4 weeks. A total of 877 respondents completed the survey that contained questions on productivity losses, compensation mechanisms, and multiplier effects., Results: We found that 45.5% of the respondents reported absenteeism (average 6.5 days) during the past 4 weeks, losing on average 48.7 working hours, while presenteeism was experienced by 75.9% of respondents, with an average loss of 10.7 working hours. Compensation mechanisms were reported by 76.9% of respondents, compensating almost 80% of their lost production, while multiplier effects were reported by 23.6% of respondents, reducing the productivity of 4.2 colleagues by 27.8% on average, implying a multiplier of 2.1 in that subgroup., Conclusions: This study highlights that compensation mechanisms and multiplier effects are common and may substantially affect production losses. Investigating these mechanisms and effects further, as well as their interactions, remains important. Translating these findings into productivity cost calculations in economic evaluations is not straightforward and requires attention, especially since compensation mechanisms may not be costless and, for multiplier effects, the value of hours of colleagues may not be similar to that of the person experiencing health problems., (© 2023. The Author(s).)

Aim: This paper investigates the prevalence and determinants of three main states of people's willingness to be vaccinated (WTBV) against COVID-19 - willing, unwilling and hesitant - and the occurrence and predictors of shifts between these states over time. Understanding the dynamics of vaccine intentions is crucial for developing targeted campaigns to increase uptake and emergency response preparedness., Study Design: A panel survey consisting of 9 quarterly waves of data collected between April 2020 and January 2022. Baseline data included 24 952 adults from Germany, UK, Denmark, the Netherlands, France, Portugal, and Italy recruited from online panels to construct census-matched nationally representative samples., Methods and Measures: Self-reported COVID-19 vaccine intention was the main outcome. Multinomial logit random effects models were used to analyze the relationships of interest. All results reported as relative risk ratios (RRR)., Results: Hesitancy to get vaccinated was the most unstable vaccine intention, with on average 42% of ever hesitant respondents remaining in this state through future waves, followed by the 'unwilling' (53%) and 'willing (82%). Following COVID-19 news, trust in information from the government, GPs and the WHO, risk preferences, risk perceptions, and confidence in vaccines (or lack thereof) predicted vaccination intention reversals. Risk preferences acted both as an impediment and as a facilitator for the vaccine uptake depending on the initial vaccine intention., Conclusions and Relevance: This study revealed the dynamic nature of COVID-19 vaccine intentions and its predictors in 7 European countries. The findings provide insights to policymakers for designing more effective communication strategies, particularly targeted at hesitant and unwilling to vaccinate population groups, to increase vaccine uptake for future public health emergencies., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Iryna Sabat reports financial support, article publishing charges, and travel were provided by Horizon 2020 Research and Innovation Programme of the European Union through the Marie Sklodowska-Curie Grant Agreement 721402. Tom Stargardt reports financial support was provided by German Research Foundation (DFG) under grant number 466310982. Tom Stargardt reports financial support, article publishing charges, and travel were provided by Horizon 2020 Research and Innovation Programme of the European Union through the Marie Sklodowska-Curie Grant Agreement 721402. Jonas Schreyogg reports financial support was provided by German Research Foundation (DFG) under grant number 466310982. Jonas Schreyogg reports financial support was provided by Excellence Strategy by the German federal and state governments. Jonas Schreyogg reports financial support, article publishing charges, and travel were provided by Horizon 2020 Research and Innovation Programme of the European Union through the Marie Sklodowska-Curie Grant Agreement 721402. Pedro Pita Barros reports financial support was provided by Nova School of Business and Economics Lisbon Chair BPI Fundacao La Caixa on Health Economics. Pedro Pita Barros reports financial support, article publishing charges, and travel were provided by Horizon 2020 Research and Innovation Programme of the European Union through the Marie Sklodowska-Curie Grant Agreement 721402. Sebastian Neumann-Bohme reports financial support, article publishing charges, and travel were provided by Horizon 2020 Research and Innovation Programme of the European Union through the Marie Sklodowska-Curie Grant Agreement 721402. Aleksandra Torbica reports financial support, article publishing charges, and travel were provided by Horizon 2020 Research and Innovation Programme of the European Union through the Marie Sklodowska-Curie Grant Agreement 721402. Job van Exel reports financial support, article publishing charges, and travel were provided by Horizon 2020 Research and Innovation Programme of the European Union through the Marie Sklodowska-Curie Grant Agreement 721402. Werner Brouwer reports financial support, article publishing charges, and travel were provided by Horizon 2020 Research and Innovation Programme of the European Union through the Marie Sklodowska-Curie Grant Agreement 721402., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Recently, due to the corona virus outbreak, pandemics and their effects have been at the forefront of the research agenda. However, estimates of the perceived value of early warning systems (EWSs) for identifying, containing, and mitigating outbreaks remain scarce. This paper aims to show how potential health gains due to an international EWS might be valued. This paper reports on a study into willingness to pay (WTP) in six European countries for health gains due to an EWS. The context in which health is gained, those affected, and the reduction in risk of contracting the disease generated by the EWS are varied across seven scenarios. Using linear regression, we analyse this 'augmented' willingness to pay for a QALY (WTP-Q) for each of the scenarios, where 'augmented' refers to the possible inclusion of context specific elements of value, such as feelings of safety. An initial WTP-Q estimate for the basic scenario is €17,400. This can be interpreted as a threshold for investment per QALY into an EWS. Overall, WTP estimates move in the expected directions (e.g. higher risk reduction leads to higher WTP). However, changes in respondents' WTP for reductions in risk were not proportional to the magnitude of the change in risk reduction. This study provided estimates of the monetary value of health gains in the context of a pandemic under seven scenarios which differ in terms of outcome, risk reduction and those affected. It also highlights the importance of future research into optimal ways of eliciting thresholds for investments in public health interventions., (© 2022. The Author(s).)

Experiencing deteriorating health has implications for your quality of life. The theory of adaptation suggests that with time spend living in a health state individuals can adapt, resulting in observed quality of life levels to revert or stagnate despite persistently decreased health. Adaptation has implications for the use of subjective quality of life indicators when quantifying the impact of health changes or the benefits from new medical technologies. As both the impact from ill health and the benefit from new interventions might be disease- or subgroup-specific adaptation further raises ethical concerns but empirical evidence on its existence, magnitude, and heterogeneity remains inconclusive. This paper uses a general population sample of 9,543 individuals that participate in the UK Understanding Society survey and experience the onset of a long-standing illness or disability to provide evidence on these questions. Using ordered-response fixed effects models we explore longitudinal changes in self-assessed health and life satisfaction around the onset of disability. Our results indicate that disability onset is associated with large decreases in subjective health and well-being. Over time this initial decrease in subjective quality of life indicators attenuates, especially in life satisfaction and to a lesser extent for self-assessed health. While the relative difference in adaptation across these two measures remains persistent, we find that across demographic and severity groups the initial impact of disability onset and adaptation differs considerably in its magnitude. These results have important implications for studies aiming to quantify the impact of health conditions on quality of life outcomes, especially when using observational datasets., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Purpose: To investigate health-related quality of life (HRQoL) over the course of the COVID-19 pandemic in seven European countries and its association with selected sociodemographic as well as COVID-19-related variables., Methods: We used longitudinal data from nine quarterly waves collected between April 2020 and January 2022 (sample size per wave ranging from N = 7025 to 7300) of the European COvid Survey (ECOS), a representative survey of adults in Germany, United Kingdom, Denmark, Netherlands, France, Portugal and Italy. HRQoL was measured using the EQ-5D-5L. The association of self-reported COVID-19 infection, perceived health risk from COVID-19, selected sociodemographic variables and the COVID-19 stringency index with HRQoL was analyzed by logistic and linear fixed effects regressions., Results: On average across all nine waves, the proportion of respondents reporting any problems in at least one of the EQ-5D dimensions ranged between 63.8% (Netherlands) and 71.0% (Denmark). Anxiety/depression was the most frequently affected EQ-5D dimension in four countries (Portugal: 52.0%; United Kingdom: 50.2%; Italy: 49.2%; France: 49.0%), whereas pain/discomfort ranked first in three countries (Denmark: 58.3%; Germany: 55.8%; Netherlands: 49.0%). On average across all nine waves, the EQ-VAS score ranged from 70.1 in the United Kingdom to 78.4 in Portugal. Moreover, the EQ-5D-5L index ranged from .82 in Denmark to .94 in France. The occurrence of COVID-19 infection, changes in the perceived risk to one's own health from COVID-19, the occurrence of income difficulties and an increase in the COVID-19 stringency index were associated with increased likelihood of problems in EQ-5D dimensions, reduced EQ-VAS score and reduced EQ-5D-5L index., Conclusions: Across seven European countries, we found large proportions of respondents reporting problems in HRQoL dimensions throughout the pandemic, especially for anxiety/depression. Various sociodemographic and COVID-19-related variables were associated with HRQoL in longitudinal analysis., (© 2023. The Author(s).)

Policy makers need to make decisions regarding the allocation of scarce healthcare resources. We study preferences for investment in additional healthcare capacity and allocation between two regions, focusing on reducing waiting time for elective surgery for a physical health problem. We elicit preferences from a societal and an individual perspective, with unequal initial waiting times between the two regions. In an online survey, 1039 respondents were randomly assigned to one of three versions of the experiment: (1) a social planner perspective, placing respondents in the role of a policy maker; (2) an individual perspective where the respondent's own region was better off regarding initial waiting times; (3) an individual perspective where the individual's own region was worse off regarding initial waiting times. Respondents were asked to rank the status quo and five scenarios where the investment in additional capacity led to different distributions of shorter waiting times between regions. For all allocations we presented both the reduction in waiting time and the resulting final waiting time for both regions. We find that in version 1 of the experiment, preferences were in line with inequality aversion and Rawlsian preferences regarding final waiting time. In version 3, similar preferences were found, although here they also align with individualistic preferences. In version 2, preferences were more heterogeneous, with both individualistic and egalitarian preferences present. Concluding, individualistic and egalitarian preferences mostly concerned final waiting time. We therefore recommend policy makers to focus on the effect on final waiting time instead of the reduction of waiting time., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

In the Netherlands, about one-third of the adult population provides unpaid care. Providing informal caregiving can be very straining in normal times, but the impact of a public health crisis on caregivers is largely unknown. This study focuses on the question of how caregiver burden changed following the COVID-19 pandemic, and what characteristics were related to these changes. We use self-reported data from a sample of 965 informal caregivers from the Netherlands 3 months into the pandemic to investigate how the objective burden (i.e. hours spent on caregiving) and the subjective burden had changed, and what their care-related quality of life (CarerQol) was. We found that on average the subjective burden had increased slightly (from 4.75 to 5.04 on a 0-10 scale). However, our analysis revealed that some caregivers were more affected than others. Most affected caregivers were women, and those with low income, better physical health, decreased psychological health, childcare responsibilities, longer duration of caregiving and those caring for someone with decreased physical and psychological health. On average, time spent on care remained the same (a median of 15 h per week), but certain groups of caregivers did experience a change, being those caring for people in an institution and for people with a better psychological health before the pandemic. Furthermore, caregivers experiencing changes in objective burden did not have the same characteristics as those experiencing changes in perceived burden and quality of life. This shows that the consequences of a public health crisis on caregivers cannot be captured by a focus on either objective or subjective burden measures or quality of life alone. Long-term care policies aiming to support caregivers to persevere during a future crisis should target caregivers at risk of increased subjective burden and a lower CarerQol, such as women, people with a low income and people with childcare responsibilities. Such policies should consider that reducing objective burden may not necessarily lead to a reduction in subjective burden for all caregivers., (© 2022 The Authors. Health and Social Care in the Community published by John Wiley & Sons Ltd.)

Background: A small group of people with epilepsy suffers from frequent seizures despite the available pharmacological and non-pharmacological interventions. The impact of epilepsy on these people extends beyond health-related quality of life (HRQoL), impacting a person's broader well-being and ability to participate in society. This study describes the burden of medically refractory epilepsy in people who suffer from daily to weekly seizures, in terms of HRQoL, well-being, and societal costs., Methods: Data from the EPISODE study on (cost-) effectiveness of seizure dogs for adults with severe medically refractory epilepsy were used, collected in 25 patients during the first 12 months before they were partnered with a certified seizure dog. Data comprised seizure diaries covering 365 days and five three-monthly surveys, including the EQ-5D-5L, QOLIE-31-P, and ICECAP-A to measure HRQoL and well-being. A societal perspective was applied to estimate costs using the iMCQ and iPCQ questionnaires about healthcare use, informal care, and productivity losses., Results: Daily seizure frequency and survey data were collected in 25 patients. A minimum of 114 observations was available for each instrument included in the survey. A total of 80% of participants experienced seizures on three or more days per week, with a median ranging from 1 to 17 seizures per seizure day. The mean EQ-5D-5L utility score was 0.682 (SD 0.235), which is considerably lower than the age-adjusted general population average. The mean QOLIE-31-P and ICECAP-A scores were 55.8 (SD 14.0) and 0.746 (SD 0.172), respectively. The average annual total cost amounted to €39,956 (range €3,804-€132,64). Informal care accounted for the largest share of costs (50%); those who received informal care reported, on average, 26 h per week (SD 30)., Conclusions: Severe medically refractory epilepsy is associated with a considerable burden of illness at the patient and societal level. People with this condition have significantly reduced HRQoL and well-being and are limited in their ability to work while having substantial medical costs and a strong dependency on informal care., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 van Hezik-Wester, de Groot, Kanters, Versteegh, Wagner, Ardesch, Brouwer and van Exel.)

Background: The Netherlands hosts, as many other European countries, three population-based cancer screening programmes (CSPs). The overall uptake among these CSPs is high, but has decreased over recent years. Especially in highly urbanized regions the uptake rates tend to fall below the minimal effective rate of 70% set by the World Health Organization. Understanding the reasons underlying the decision of citizens to partake in a CPS are essential in order to optimize the current screening participation rates. The aim of this study was to explore the various perspectives concerning cancer screening among inhabitants of The Hague, a highly urbanized region of the Netherlands., Methods: A Q-methodology study was conducted to provide insight in the prevailing perspectives on partaking in CSPs. All respondents were inhabitants of the city of The Hague, the Netherlands. In an online application they ranked a set of 31 statements, based on the current available literature and clustered by the Integrated Change model, into a 9-column forced ranking grid according to level of agreement, followed by a short survey. Respondents were asked to participate in a subsequent interview to explain their ranking. By-person factor analysis was used to identify distinct perspectives, which were interpreted using data from the rankings and interviews., Results: Three distinct perspectives were identified: 1). "Positive about participation", 2). "Thoughtful about participation", and 3). "Fear drives participation". These perspectives provide insight into how potential respondents, living in an urbanized region in the Netherlands, decide upon partaking in CSPs., Conclusions: Since CSPs will only be effective when participation rates are sufficiently high, it is essential to have insight into the different perspectives among potential respondents concerning partaking in a CSP. This study adds new insights concerning these perspectives and suggests several ideas for future optimization of the CSPs., (© 2022. The Author(s).)

Background: The first wave of the COVID-19 pandemic overwhelmed healthcare systems in many countries, and the rapid spread of the virus and the acute course of the disease resulted in a shortage of intensive care unit (ICU) beds. We studied preferences of the public in the Netherlands regarding the allocation of ICU beds during a health crisis., Methods: We distributed a cross-sectional online survey at the end of March 2020 to a representative sample of the adult population in the Netherlands. We collected preferences regarding the allocation of ICU beds, both in terms of who should be involved in the decision-making and which rationing criteria should be considered. We conducted Probit regression analyses to investigate associations between these preferences and several characteristics and opinions of the respondents., Results: A total of 1,019 respondents returned a completed survey. The majority favored having physicians (55%) and/or expert committees (51%) play a role in the allocation of ICU beds and approximately one-fifth did not favor any of the proposed decision-makers. Respondents preferred to assign higher priority to vulnerable patients and patients who have the best prospect of full recovery. They also preferred that personal characteristics, including age, play no role., Conclusion: "Our findings show that current guidelines for allocating ICU beds that include age as an independent criterion may not be consistent with societal preferences. Age may only play a role indirectly, in relation to the vulnerability of patients and their prospect of full recovery. Allocation of ICU beds during a health crisis requires a multivalue ethical framework.", Competing Interests: The authors have declared that no competing interests exist.

Objectives: The COVID-19 pandemic forms an unprecedented public health, economic, and social crisis. Uptake of vaccination is critical for controlling the pandemic. Nevertheless, vaccination hesitancy is considerable, requiring policies to promote uptake. We investigate Dutch citizens' preferences for policies that aim to promote vaccination through facilitating choice of vaccination, profiling it as the norm, making vaccination more attractive through rewards, or punishing people who reject vaccination., Methods: We conducted a discrete choice experiment in which 747 respondents were asked to choose between policies to promote vaccination uptake and their impacts on the number of deaths, people with permanent health problems, households with income loss, and a tax increase., Results: Respondents generally had a negative preference for policies that promote vaccination. They particularly disliked policies that punish those who reject the vaccine and were more favorable toward policies that reward vaccination, such as awarding additional rights to vaccinated individuals through vaccination passports. Respondents who reject vaccination were in general much more negative about the policy options than respondents who consider accepting the vaccine. Nevertheless, vaccination passports are supported by both respondents who accept the vaccine, those who reject vaccination, and those who are unsure about vaccination., Conclusions: This study provides concrete directions for governments attempting to increase the vaccination uptake in ways that are supported by the public. Our results could encourage policy makers to focus on policy options that make vaccination easier and reward people who take the vaccine, as especially the implementation of vaccination passports was supported., (Copyright © 2022. Published by Elsevier Inc.)

Objective: Health economic evaluations using common health-related quality of life measures may fall short in adequately incorporating all relevant benefits of health and social care interventions targeted at older people. The Well-being of Older People measure (WOOP) is a broader well-being measure that comprises nine well-being domains. The objective of this study was to estimate a utility tariff for the WOOP, to facilitate its application in cost-utility analyses., Methods: A discrete choice experiment (DCE) with duration approach was set up and fielded among 2,012 individuals from the Netherlands aged 65 years and above. Matched pairwise choice tasks, colour-coding and level overlap were used to reduce the cognitive burden of the DCE. The choice tasks were created using a Bayesian heterogeneous D-efficient design. The estimation procedure accommodated for nonlinear time preferences via an exponential discounting function., Results: The estimation results showed that 'physical health', 'mental health', and 'making ends meet' were the most important well-being domains for older people, followed by 'independence' and 'living situation'. Of somewhat lesser importance were domains like 'social life', 'receiving support' and 'feeling useful'. The generated utility tariffs can be used to translate well-being states described with the WOOP to a utility score between -0.616 and 1., Conclusions: This study established a tariff for the WOOP, which will facilitate its use in economic evaluations of health and social care interventions targeted at older people, first of all in the Netherlands., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

The COVID-19 pandemic highlights the need for effective infectious disease outbreak prevention. This could entail installing an integrated, international early warning system, aiming to contain and mitigate infectious diseases outbreaks. The amount of resources governments should spend on such preventive measures can be informed by the value citizens attach to such a system. This was already recognized in 2018, when a contingent valuation willingness to pay (WTP) experiment was fielded, eliciting the WTP for such a system in six European countries. We replicated that experiment in the spring of 2020 to test whether and how WTP had changed during an actual pandemic (COVID-19), taking into account differences in infection rates and stringency of measures by government between countries. Overall, we found significant increases in WTP between the two time points, with mean WTP for an early warning system increasing by about 50% (median 30%), from around €20 to €30 per month. However, there were marked differences between countries and subpopulations, and changes were only partially explained by COVID-19 burden. We discuss possible explanations for and implication of our findings., (© 2021. The Author(s).)

Context: It remains unclear whether there would be societal support for a lifestyle criterion for the healthcare priority setting. This study examines the viewpoints of experts in healthcare and the public regarding support for a lifestyle-related decision criterion, relative to support for the currently applied criteria, in the healthcare priority setting in the Netherlands., Methods: We conducted a Q methodology study in samples of experts in healthcare (n = 37) and the public (n = 44). Participants (total sample N = 81) ranked 34 statements that reflected currently applied decision criteria as well as a lifestyle criterion for setting priorities in healthcare. The ranking data were subjected to principal component analysis, followed by oblimin rotation, to identify clusters of participants with similar viewpoints., Findings: We identified four viewpoints. Participants with Viewpoint 1 believe that treatments that have been proven to be effective should be reimbursed. Those with Viewpoint 2 believe that life is precious and every effort should be made to save a life, even when treatment still results in a very poor state of health. Those with Viewpoint 3 accept government intervention in unhealthy lifestyles and believe that individual responsibility should be taken into account in reimbursement decisions. Participants with Viewpoint 4 attribute importance to the cost-effectiveness of treatments; however, when priorities have to be set, treatment effects are considered most important. All viewpoints were supported by a mix of public and experts, but Viewpoint 1 was mostly supported by experts and the other viewpoints were mostly supported by members of the public., Conclusions: This study identified four distinct viewpoints on the healthcare priority setting in the Netherlands, each supported by a mix of experts and members of the public. There seems to be some, but limited, support for a lifestyle criterion-in particular, among members of the public. Experts seem to favour the decision criteria that are currently applied. The diversity in views deserves attention when policymakers want to adhere to societal preferences and increase policy acceptance., (© 2021 The Authors. Health Expectations published by John Wiley & Sons Ltd.)