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Abstract Introduction To make efficient use of available resources, decision-makers in healthcare may assess the costs and (health) benefits of health interventions. For interventions aimed at improving mental health capturing the full health benefits is an important challenge. The Mental Health Quality of Life (MHQoL) instrument was recently developed to meet this challenge. Evaluating the pyschometric properties of this instrument in different contexts remains important. Methods A psychometric evaluation of the MHQoL was performed using existing international, cross-sectional data with 7155 respondents from seven European countries (Denmark, France, Germany, Italy, Portugal, The Netherlands, Portugal and the United Kingdom). Reliability was examined by calculating Cronbach’s alpha, a measure of internal consistency of the seven MHQoL dimensions, and by examining the association of the MHQoL sum scores with the MHQoL-VAS scores. Construct validity was examined by calculating Spearman’s rank correlation coefficients between the MHQoL sum scores and EQ-5D index scores, EQ-VAS scores, EQ-5D anxiety/depression dimension scores, ICECAP-A index scores and PHQ-4 sum scores. Results The MHQoL was found to have good internal consistency for all seven countries. The MHQoL sum score and the MHQoL-VAS had a high correlation. Spearman’s rank correlation coefficients were moderate to very high for all outcomes. Conclusion Our results, based on data gathered in seven European countries, suggest that the MHQoL shows favourable psychometrical characteristics. While further validation remains important, the MHQoL may be a useful instrument in measuring mental health-related quality of life in the Western European context.

Abstract Introduction Drug reimbursement decisions are often made based on a price set by the manufacturer. In some cases, this price leads to public and scientific debates about whether its level can be justified in relation to its costs, including those related to research and development (R&D) and manufacturing. Such considerations could enter the decision process in collectively financed health care systems. This paper investigates whether manufacturers’ costs in relation to drug prices, or profit margins, are explicitly mentioned and considered by health technology assessment (HTA) organisations. Method An analysis of reimbursement reports for cancer drugs was performed. All relevant Dutch HTA-reports, published between 2017 and 2019, were selected and matched with HTA-reports from three other jurisdictions (England, Canada, Australia). Information was extracted. Additionally, reimbursement reports for three cases of expensive non-oncolytic orphan drugs prominent in pricing debates in the Netherlands were investigated in depth to examine consideration of profit margins. Results A total of 66 HTA-reports concerning 15 cancer drugs were included. None of these reports contained information on manufacturer’s costs or profit margins. Some reports contained general considerations of the HTA organisation which related prices to manufacturers’ costs: six contained a statement on the lack of price setting transparency, one mentioned recouping R&D costs as a potential argument to justify a high price. For the case studies, 21 HTA-reports were selected. One contained a cost-based price justification provided by the manufacturer. None of the other reports contained information on manufacturer’s costs or profit margins. Six reports contained a discussion about lack of transparency. Reports from two jurisdictions contained invitations to justify high prices by demonstrating high costs. Conclusion Despite the attention given to manufacturers’ costs in relation to price in public debates and in the literature, this issue does not seem to get explicit systematic consideration in the reimbursement reports of expensive drugs.

Abstract Background Valid measures of the well-being of older people are important for the evaluation of health and social care services. The nine-item Well-being of Older People measure (WOOP) was based on a novel framework derived from a recent Q-methodology study, and was developed to capture a comprehensive set of well-being domains relevant to older people, as identified by themselves. This study introduces the WOOP and describes the qualitative assessment of its feasibility and content validity. Methods Between December 2017 and January 2018, a sampling agency retrieved data from 269 adults aged 65 years and older in the Netherlands. Using an online survey, participants were asked to complete the WOOP and to indicate the importance of each item to their well-being. Open-ended questions were used to collect information about participants’ own definition of well-being, their interpretation of the items of the WOOP, and their assessment of the descriptions and response options provided with each item. Data were analysed using inductive content analysis with the software package ATLAS.ti. Results The WOOP closely resembled respondents’ own description of what well-being means to them. The majority of the respondents reported no important well-being aspects to be missing from the WOOP, and indicated all WOOP items to be at least ‘reasonably important’ to their well-being. Many linked the WOOP items to well-being aspects as intended, and only a few had suggestions for improving the items’ descriptions and response options. Conclusions Given these results, all nine items were retained, and no items were added to the measure. Based on respondents’ feedback, minor changes were made to the wording of some descriptions and response options of items. Concluding, the feasibility and content validity of the WOOP seem satisfactory. Further validation of this new measure is required, in different health and social care settings and among subgroups of older people with potentially different views on what constitutes well-being.

Abstract Background We aimed to investigate the acceptability of imperfect health states in relation to age in Hungary and analyse its determinants. Results are contrasted to age-matched actual population health scores and to findings from a previous study in The Netherlands. Methods A cross-sectional online survey was performed. The same survey questions were applied as in a previous study in The Netherlands in order to enable inter-country comparisons. The descriptive system of the EQ-5D-3L health status questionnaire was used to assess the acceptability of moderate and severe health problems at ages from 30 to 80 by 10-year age-groups. Descriptive statistics were performed and linear regression analysis was used to investigate the determinants of acceptability. Results Altogether 9281 (female 32.8%) were involved with mean age 36.0 years and EQ-5D-3L index score of 0.852 (SD 0.177). Acceptability of health problems increased with age, differed per health domain and with severity of the problems. Except for ‘Self-care’, moderate health problems were acceptable by the majority from age 70 and acceptability scores were lower than EQ-5D-3L population norms from that age. The lowest average acceptability age was found in the ‘Anxiety/depression’ and dimension the highest in the ‘Self-care’ dimension. Respondents’ age, current health, and lifestyle were significant determinants (R2: 0.041–0.130). With a few minor exceptions in some health dimensions, acceptability levels and patterns were strikingly similar to the Dutch findings. Conclusion In Hungary, acceptability of health problems increases with age and the majority found severe problems never acceptable. Views on acceptability of health problems seem to be fairly generalizable across European countries with different health and economic indicators.

Abstract Background Health behaviours like smoking, nutrition, alcohol consumption and physical activity (SNAP) are often studied separately, while combinations can be particularly harmful. This study aims to contribute to a better understanding of lifestyle choices by studying the prevalence of (combinations of) unhealthy SNAP behaviours in relation to attitudinal factors (time orientation, risk attitude) and subjective health (self-rated health, life expectancy) among the adult Dutch population. Methods In total 1006 respondents, representative of the Dutch adult population (18–75 years) in terms of sex, age, and education, were drawn from a panel in 2016. They completed an online questionnaire. Groups comparisons and logistic regression analyses (crude and adjusted) were applied to analyse (combinations of) SNAP behaviours in relation to time orientation (using the Consideration of Future Consequences scale comprising Immediate (CFC-I) and Future (CFC-F) scales) and risk attitude (Health-Risk Attitude Scale; HRAS-6), as well as subjective health (visual analogue scale and subjective life expectancy). Results In the analyses, 989 respondents (51% men, average 52 years, 22% low, 48% middle, and 30% high educated) were included. About 8% of respondents engaged in four unhealthy SNAP behaviours and 18% in none. Self-rated health varied from 5.5 to 7.6 in these groups, whilst subjective life expectancy ranged between 73.7 and 85.5 years. Logistic regression analyses, adjusted for socio-demographic variables, showed that smoking, excessive drinking and combining two or more unhealthy SNAP behaviours were significantly associated with CFC-I scores, which increased the odds by 30%, 18% and 19%, respectively. Only physical inactivity was significantly associated with CFC-F scores, which increased the odds by 20%. Three out of the four SNAP behaviours were significantly associated with HRAS-6, which increased the odds between 6% and 12%. An unhealthy diet, excessive drinking, and physical inactivity were significantly associated with SRH, which decreased the odds by 11%. Only smoking was significantly associated with subjective life expectancy, which decreased the odds by 3%. Conclusion Our findings suggest that attitudinal factors and subjective health are relevant in the context of understanding unhealthy SNAP behaviours and their clustering. This emphasizes the relevance of a holistic approach to health prevention rather than focusing on a single unhealthy SNAP behaviour.

Abstract Background Selection of the optimal initial treatment in patients with major depressive disorder (MDD) in need of highly specialized care has the potential to benefit treatment outcomes and cost-effectiveness of treatment strategies. However, to date, there is a paucity of measures that could guide the selection of the initial treatment, in particular to indicate which patients with MDD are in need of highly specialized care. Recognizing this gap, this paper reports on the development and psychometric evaluation of the Decision Tool Unipolar Depression (DTUD), aimed to facilitate the early identification of patients with MDD in need of highly specialized care. Methods The DTUD was developed using a mixed-methods approach, consisting of a systematic review and a concept mapping study. To evaluate the psychometric features of the DTUD, a cross-sectional multicenter study was conducted. A total of 243 patients with MDD were evaluated with the DTUD. Feasibility was operationalized as the time required to complete the DTUD and the content clarity of the DTUD. Inter-rater reliability was evaluated using Krippendorf’s alpha. The Maudsley Staging Method (MSM) and the Dutch Measure for quantification of Treatment Resistance in Depression (DM-TRD) were administered to assess the convergent validity. A receiver operator characteristic curve was generated to evaluate the criterion validity and establish the optimal cut-off value. Results The mean administration time was 4.49 min (SD = 2.71), and the content of the total DTUD was judged as clear in 94.7% of the evaluations. Inter-rater reliability values ranged from 0.69 to 0.91. Higher scores on the DTUD were associated with higher scores on the MSM (rs = 0.47) and DM-TRD (rs = 0.53). Based on the maximum Youden index (0.494), maximum discrimination was reached at a cut-off score of ≥5 (sensitivity 67%, specificity 83%). Conclusion The DTUD demonstrated to be a tool with solid psychometric properties and, therefore, is a promising measure for the early identification of patients with MDD in need of highly specialized care. Use of the DTUD has the potential to facilitate the selection and initiation of the optimal initial treatment in patients with MDD, which in turn may improve the clinical effectiveness and cost-effectiveness of treatment strategies.

BackgroundEarly identification of patients with mental health problems in need of highly specialised care could enhance the timely provision of appropriate care and improve the clinical and cost-effectiveness of treatment strategies. Recent research on the development and psychometric evaluation of diagnosis-specific decision-support algorithms suggested that the treatment allocation of patients to highly specialised mental healthcare settings may be guided by a core set of transdiagnostic patient factors.AimsTo develop and psychometrically evaluate a transdiagnostic decision tool to facilitate the uniform assessment of highly specialised mental healthcare need in heterogeneous patient groups.MethodThe Transdiagnostic Decision Tool was developed based on an analysis of transdiagnostic items of earlier developed diagnosis-specific decision tools. The Transdiagnostic Decision Tool was psychometrically evaluated in 505 patients with a somatic symptom disorder or post-traumatic stress disorder. Feasibility, interrater reliability, convergent validity and criterion validity were assessed. In order to evaluate convergent validity, the five-level EuroQol five-dimensional questionnaire (EQ-5D-5L) and the ICEpop CAPability measure for Adults (ICECAP-A) were administered.ResultsThe six-item clinician-administered Transdiagnostic Decision Tool demonstrated excellent feasibility and acceptable interrater reliability. Spearman's rank correlations between the Transdiagnostic Decision Tool and ICECAP-A (−0.335), EQ-5D-5L index (−0.386) and EQ-5D-visual analogue scale (−0.348) supported convergent validity. The area under the curve was 0.81 and a cut-off value of ≥3 was found to represent the optimal cut-off value.ConclusionsThe Transdiagnostic Decision Tool demonstrated solid psychometric properties and showed promise as a measure for the early detection of patients in need of highly specialised mental healthcare.

Abstract Background Most health valuation studies assume that individuals’ health valuations do not depend on social comparisons. However, there is some evidence that this assumption is not satisfied in practice. This paper tests whether self-rated health by means of a Visual Analogue Scale (VAS) is related to how one perceives the health of one’s contemporaries, while accounting for one’s health as classified by the EQ-5D classification system. Methods In a large sample (n = 1500), representative of the general public, we use a VAS to rate respondents’ own health and their assessment of their contemporaries’ health. In addition, we directly ask them whether they perceive their health to be better, the same, or worse than their contemporaries, and we measure their own health according to the EQ-5D-5 L. Results We find a positive relationship between own health rating and contemporaries’ health rating, after controlling for the respondents’ own health as classified according to the EQ-5D. Furthermore, we observe a discrepancy between relative health vis-à-vis age peers as measured by an ordinal comparison and relative health as measured by a VAS. Finally, respondents, especially women, tended to overestimate the health of other people of their age. Conclusions We provide evidence that people’s own health rating is related to the perception of health of contemporaries. Our results indicate that knowledge about a respondent’s perception of others’ health is useful in explaining health state valuations.

An amendment to this paper has been published and can be accessed via the original article.

BackgroundEarly identification of patients with an anxiety disorder, obsessive-compulsive disorder (OCD), or post-traumatic stress disorder (PTSD) in need of highly specialized care could facilitate the selection of the optimal initial treatment in these patients. This paper describes the development and psychometric evaluation of the Decision Tool Anxiety Disorders, OCD and PTSD (DTAOP), which aims to aid clinicians in the early identification of patients with an anxiety disorder, OCD, or PTSD in need of highly specialized mental healthcare.MethodsA systematic literature review and a concept mapping procedure were carried out to inform the development of the DTAOP. To evaluate the psychometric properties of the DTAOP, a cross-sectional study in 454 patients with a DSM-IV-TR anxiety disorder was carried out. Feasibility was evaluated by the completion time and the content clarity of the DTAOP. Inter-rater reliability was assessed in a subsample of 87 patients. Spearman's rank correlation coefficients between the DTAOP and EuroQol five-dimensional questionnaire (EQ-5D-5L) scores were computed to examine the convergent validity. Criterion validity was assessed against independent clinical judgments made by clinicians.ResultsThe average time required to complete the eight-item DTAOP was 4.6 min and the total DTAOP was evaluated as clear in the majority (93%) of the evaluations. Krippendorff's alpha estimates ranged from 0.427 to 0.839. Based on the qualitative feedback, item wording and instructions were improved. As hypothesized, the DTAOP correlated negatively with EQ-5D-5L scores. The area under the curve was 0.826 and the cut-off score of ≥4 optimized sensitivity (70%) and specificity (71%).ConclusionsThe DTAOP demonstrated excellent feasibility and good validity, but weak inter-rater reliability. Based on the qualitative feedback and reliability estimates, revisions and refinements of the wording and instructions were made, resulting in the final version of the DTAOP.

ObjectivesTo validate the ICECAP-O capability wellbeing measure's German translation in older people with dementia living in a nursing home, and to investigate the influence of proxy characteristics on responses.MethodCross-sectional study. For 95 residents living in a German nursing home, questionnaires were completed by nursing professionals serving as proxy respondents. We investigated the convergent validity of the ICECAP-O with other Quality of Life (Qol) measures, the EQ-5D extended with a cognitive dimension (EQ-5D+C), the Alzheimer's Disease Related Quality of Life (ADRQL) measures, and the Barthel-index measure of Activities of Daily Living (ADL). Discriminant validity was investigated using bivariate and multivariate stepwise regression analysis, comparing ICECAP-O scores between subgroups varying in dementia severity, care dependency, ADL status and demographic characteristics.ResultsConvergent validity between the ICECAP-O, EQ-5D+C, ADRQL and Barthel-Index scores was moderate to good (with correlations of 0.72, 0.69 and 0.53 respectively), but differed considerably between dimensions of the instruments. Discriminant validity was confirmed by finding differences in ICECAP-O scores between subgroups based on ADL scores (0.58 below 65 points on the Barthel-index and 0.80 above 65 points) and other characteristics. The ICECAP-O scores based on available tariffs were related to proxy characteristics gender (0.52 males versus 0.65 females) and work experience (0.61 below 2 years of experience versus 0.68 above 2 years).DiscussionThe results of this study suggest that the ICECAP-O is a promising generic measure for general Qol and capability of people with dementia living in a nursing home. Validity tests generally yielded favorable results. Work experience and gender appeared to influence proxy response, which raises questions regarding appropriate proxies, especially since the ICECAP-O may be completed by proxies relatively often. Further research is necessary to validate the German version of the ICECAP-O, with specific attention to proxy completion for people with dementia.

BACKGROUND: Increasing attention is being paid to the affordability of medicines in low- and middle-income countries (LICs and MICs) where medicines are often highly priced in relation to income levels. The impoverishing effect of medicine purchases can be estimated by determining pre- and postpayment incomes, which are then compared to a poverty line. Here we estimate the impoverishing effects of four medicines in 16 LICs and MICs using the impoverishment method as a metric of affordability. METHODS AND FINDINGS: Affordability was assessed in terms of the proportion of the population being pushed below US$1.25 or US$2 per day poverty levels because of the purchase of medicines. The prices of salbutamol 100 mcg/dose inhaler, glibenclamide 5 mg cap/tab, atenolol 50 mg cap/tab, and amoxicillin 250 mg cap/tab were obtained from facility-based surveys undertaken using a standard measurement methodology. The World Bank's World Development Indicators provided household expenditure data and information on income distributions. In the countries studied, purchasing these medicines would impoverish large portions of the population (up to 86%). Originator brand products were less affordable than the lowest-priced generic equivalents. In the Philippines, for example, originator brand atenolol would push an additional 22% of the population below US$1.25 per day, whereas for the lowest priced generic equivalent this demographic shift is 7%. Given related prevalence figures, substantial numbers of people are affected by the unaffordability of medicines. CONCLUSIONS: Comparing medicine prices to available income in LICs and MICs shows that medicine purchases by individuals in those countries could lead to the impoverishment of large numbers of people. Action is needed to improve medicine affordability, such as promoting the use of quality assured, low-priced generics, and establishing health insurance systems. Please see later in the article for the Editors' Summary.

BackgroundObesity is a major cause of morbidity and mortality and is associated with high medical expenditures. It has been suggested that obesity prevention could result in cost savings. The objective of this study was to estimate the annual and lifetime medical costs attributable to obesity, to compare those to similar costs attributable to smoking, and to discuss the implications for prevention.Methods and findingsWith a simulation model, lifetime health-care costs were estimated for a cohort of obese people aged 20 y at baseline. To assess the impact of obesity, comparisons were made with similar cohorts of smokers and "healthy-living" persons (defined as nonsmokers with a body mass index between 18.5 and 25). Except for relative risk values, all input parameters of the simulation model were based on data from The Netherlands. In sensitivity analyses the effects of epidemiologic parameters and cost definitions were assessed. Until age 56 y, annual health expenditure was highest for obese people. At older ages, smokers incurred higher costs. Because of differences in life expectancy, however, lifetime health expenditure was highest among healthy-living people and lowest for smokers. Obese individuals held an intermediate position. Alternative values of epidemiologic parameters and cost definitions did not alter these conclusions.ConclusionsAlthough effective obesity prevention leads to a decrease in costs of obesity-related diseases, this decrease is offset by cost increases due to diseases unrelated to obesity in life-years gained. Obesity prevention may be an important and cost-effective way of improving public health, but it is not a cure for increasing health expenditures.