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BACKGROUND AND AIMS Diabetic nephropathy (DN), chronic loss of kidney function due to diabetes mellitus, is a common complication in diabetes which currently lacks effective long-term treatment. Microalbuminuria is now the earliest marker for DN, thereby disregarding renal changes that occur before this first indication of decreased kidney function. For better diagnosis and treatment strategies, it is important to study diabetes induced early renal changes. Renal-specific changes of the lipid metabolism could serve as an indicator for early kidney damage. Mass spectrometry imaging (MSI) allows to study the lipid metabolism in the context of tissue histology without the need for labeling (i.e. antibody or radioactive). Existing literature applying this technique focuses on later stages of diabetic kidney disease, thereby overlooking its potential to serve in an earlier stage of diagnosis. The aim of this project is to identify renal cell-specific lipid changes using MSI which could serve as damage markers for early diabetes induced renal pathology. METHOD To study diabetic renal changes, apolipoprotein E-knockout mice were treated with streptozotocin (STZ) and put on an enriched cholesterol diet to induce diabetes. After 12 weeks, both control (n = 4) and diabetic (n = 4) mice were sacrificed and kidneys were harvested for immunohistochemical and matrix assisted laser desorption/ionization (MALDI) MSI. Post-MSI immunofluorescent staining in combination with tissue morphology was used to identify different renal cell types. Analysis of MALDI-MSI data allows us to spatially segment the results per cell type for further statistical analysis of the metabolic MSI data (Figure 1A). RESULTS Two weeks after STZ induction, blood glucose levels of the diabetic mice were significantly elevated compared to control. Spatial segmentation analysis of the MSI data revealed that in both groups different renal cell types could clearly be distinguished based on their metabolic profile. Using the immunofluorescence-based cell type annotation, we zoomed in on various morphological regions of the kidney to specifically test for changes in lipid profiles. Here, the proximal tubular cells in the cortex and the outer stripe of outer medulla had the highest number of significantly changed lipids (Figure 1B). Focusing the analysis on these two groups of cells revealed specific molecular signatures to be discriminative between diabetes and control (Figure 1C). CONCLUSION Using MSI, we were able to identify renal cell type-specific differentially expressed lipids in diabetic mice compared to the healthy control group. The proximal tubular cells in the cortex and outer stripe of the outer medulla had the most altered lipid composition. These molecular signatures might serve as an early indicator of diabetes induced renal changes, thereby opening up a potential window for treatment before the kidney is damaged beyond repair.

BACKGROUND AND AIMS The gut microbiota has emerged as an important modulator of cardiovascular and renal diseases, including diabetic nephropathy (DN), one of the most common complications caused by diabetes mellitus. Importantly, diabetic patients display a reduction in bacteria producing short chain fatty acids (SCFAs) when compared with healthy individuals. SCFAs are generally associated with beneficial effects on the vascular system, as they help to reduce both oxidative stress and pro-inflammatory stimuli [1]. Although SCFAs help to protect against DN, their mechanisms of action at cell level remain largely unknown. For this reason, we aimed to study the effect of two SCFAs, butyrate and acetate, on human glomerular microvascular endothelial cells (hgMVECs) that represent one of the main components of the glomerular filtration barrier. In case of DN, glomerular endothelium shows multiple signs of dysfunction, such as uncontrolled proliferation [2], mitochondrial fragmentation [3] and monolayer disruption [4]. METHOD hgMVECs have been exposed to different concentrations of butyrate and acetate for 24 h and/or 48 h. After treatment with SCFAs, cells have been collected for qPCR, stained for mitochondrial mass or fixated for immunocytochemistry. For the latter, we have used antibodies for the proliferation marker ki-67 and cell-to-cell junction proteins. To measure the resistance of the endothelial monolayer, electric cell-substrate impedance sensing (ECIS) was used. This system lets a current go over and between cells and the tighter the monolayer, the higher the resistance. For this type of experiment, hgMVECs have been cultured on a specific plate that is located in the ECIS machine throughout the whole experiments (before and after treatment with SCFAs). RESULTS Butyrate decreases the number of ki-67 positive nuclei in a concentration-dependent manner, which implies lower cellular proliferation. On the other hand, at the highest concentration tested (500 uM), butyrate increases mitochondrial mass and elongation, as opposite to acetate, which does not show any effect on mitochondrial mass. These results are also supported by qPCR analysis, where it is possible to observe a decrease of genes involved in mitochondrial fragmentation upon butyrate exposure. MOreover, butyrate increases the resistance of the endothelial monolayer, as we can see in the results of the ECIS experiments. After an initial decrease, butyrate induces a steady increase of the resistance of the monolayer, which does not happen with acetate. We believe that the increase in resistance is due to a higher expression of genes and proteins involved in the formation of tight junctions. For instance, in cells treated with butyrate, gene expression of ve-cadherin, ZO-1, claudin 5 and occludin is upregulated and especially for ve-cadherin this is also observed by immunocytochemistry. CONCLUSION Our results show that in hgMVECs, on the one hand butyrate especially can increase monolayer resistance and influence mitochondrial morphology and possibly its metabolism, while on the other hand it decreases cellular proliferation. Therefore, at cellular level, butyrate can help against several hallmarks of endothelial dysfunction Of DN.

Objective: To identify and assess the preferences of people with long-term health conditions toward generalizable characteristics of self-management support interventions, with the objective to inform the design of more person-centered support services. Data Sources: Primary qualitative and quantitative data collected on a representative sample of individuals with at least one of the fifteen most prevalent long-term conditions in the UK. Study Design: Targeted literature review followed by a series of one-to-one qualitative semistructured interviews and a large-scale discrete choice experiment. Data Collection: Digital recording of one-to-one qualitative interviews, one-to-one cognitive interviews, and a series of online quantitative surveys, including two best-worst scaling and one discrete choice experiment, with individuals with long-term conditions. Principal Findings: On average, patients preferred a self-management support intervention that (a) discusses the options available to the patient and make her choose, (b) is individual-based, (c) face to face (d) with doctor or nurse, (e) at the GP practice, (f) sessions shorter than 1 hour, and (g) occurring annually for two-third of the sample and monthly for the rest. We found heterogeneity in preferences via three latent classes, with class sizes of 41% (C1), 30% (C2), and 29% (C3). The individuals’ gender [P

Background: Carers’ end-of-life caregiving greatly benefits society but little is known about the monetary value of this care. Aim: Within an end-of-life cancer setting: (1) to assess the feasibility and content validity of a post-bereavement measure of hours of care; and (2) to obtain a monetary value of this informal care and identify variation in this value among sub-groups. Design and setting: A census based cross-sectional survey of all cancer deaths from a 2-week period in England collected detailed data on caregiving activity (10 caregiving tasks and the time spent on each). We descriptively analyse the information carers provided in ‘other’ tasks to inform content validity. We assigned a monetary value of caregiving via the proxy good method and examined variation in the value via regression analysis. Results: The majority of carers (89.9%) were able to complete the detailed questions about hours and tasks. Only 153 carers reported engaging in ‘other’ tasks. The monetary value of caregiving at end-of-life was £948.86 per week with social and emotional support and symptom management tasks representing the largest proportion of this monetary valuation. Time of recall did not substantially relate to variation in the monetary value, whereas there was a stronger association for the relationship between the carer and recipient, carer gender and recipient daily living restrictions. Conclusion: The monetary valuation we produce for carers’ work is substantial, for example the weekly UK Carers’ Allowance only amounts to 7% of our estimated value of £948.86 per week. Our research provides further information on subgroup variation, and a valid carer time instrument and method to inform economic evaluation and policy.

Aim: Children spend substantial amounts of time receiving medical care (patients' time), and this patients' time plays an important role in parental choices for paediatric care. However, it is usually ignored in economic evaluations. This is a concern because economic evaluations are increasingly being used to inform child health policy decision-making. This study aims to quantify the time children spend receiving medical care and attach a monetary value to it for use in economic evaluations. It applied the parents' perspective. Consequently, the derived money values are the time values for both child and the accompanying parent. Methods: We used the contingent valuation methodology. We collected data on 83 children undergoing orthopaedic treatment in a Dutch hospital. Accompanying parents were asked to quantify and value the patients' time of their children. We separately explored travel, waiting and treatment time. We also checked whether the monetary valuation varied across parents' financial situation, children's health and level of pain. Results: Parents were willing to pay about €33 (confidence interval (CI) 21.2–48.1) for a 1-day reduction in treatment time; about €11.5 (CI 4.2–19.1) for an hour's reduction in waiting time; and about €4.5 (CI 1.5–7.4) for an hour's reduction in travel time. In addition, respondents with better financial conditions have, on average higher, willingness to pays. Conclusions: To our knowledge, this is the first instance that patients' time of children has been monetarily valued. This methodology can be used to further develop economic evaluations of paediatric care and could be applied to larger samples with varying clinical conditions.

It is hard to ignore the importance of patient time investment in the production of health since the influential paper by Grossman (1972). Patients' time includes time to admission, travel time, waiting time, and treatment time and can be substantial. Patients' time is, however, often ignored in economic analyses. This may lead to biased results and inappropriate policy recommendations, which may eventually influence patients' health, wellbeing and welfare.How to value patient time is not straightforward. Although there is some emerging literature on the monetary valuation of patient time, an important challenge remains to develop an approach that can be used to monetarily value time of patients not participating in the labour market. We aim to contribute to the health economics literature by describing and empirically illustrating how to monetarily value the time of patients not participating in the labour market comprehensively, using the contingent valuation method. It is worth noting that our method can also be applied to people participating in the labour market.This paper describes the development of the contingent valuation survey. We apply our survey approach to a sample of 238 Dutch patients not participating in the labour market: n = 107 Radiotherapy department (data collected between November 2011 and January 2013); n = 44 Rehabilitation department (March 2012 May 2012); n = 87 Orthopaedics department (January to June 2013). Results show that those patients value waiting time the highest ((sic)30.10 per hour) and value travel and treatment time equally with respectively (sic)13.20 and (sic)13.32 per hour.This paper encourages future empirical research refining and applying the developed survey methodology to create more data on how other subgroups of individuals value their patients' time. (C) 2017 Elsevier Ltd. All rights reserved.

BackgroundUnpaid carers are the mainstay of support for people with dementia. Admiral Nursing (AN) is the only specialist nursing service that specifically focuses on supporting such carers, but evidence of its effectiveness, costs and relationships with other health and social care services is limited. This project aimed to address this gap and explore the feasibility of a full-scale formal evaluation.ObjectivesTo explore the relationships between characteristics of carers and people with dementia, service type and input and outcomes; to develop and test data collection methods for subsequent economic evaluation; to explore the effect of AN on outcomes and costs, compared with usual care; to explore the perceived system-wide impact of specialist support for carers of people with dementia, compared with usual care; and to implement new data collection methods in AN, which could also be used by other services, to facilitate evaluation.DesignA mixed-methods study, using secondary analysis of an administrative data set, and primary (cross-sectional) quantitative and qualitative data collection.SettingQualitative research with carers in four areas of England; a survey of carers in 32 local authority areas (16 with and 16 without AN); and qualitative interviews with professionals in four areas.ParticipantsThirty-five carers of people with dementia and 20 professionals were interviewed qualitatively; 346 carers completed in-scope questionnaires (46% through AN services and 54% from matched non-AN areas).InterventionsSpecialist nursing support for carers of people with dementia (with AN as an exemplar) compared with usual care.Main outcome measuresThe Adult Social Care Outcomes Toolkit for Carers; the EuroQol-5 Dimensions, five-level version; and the Caregiver Self-Efficacy for Managing Dementia Scale.Data sourcesDementia UK’s AN administrative data set.ResultsAdmiral Nurses are successfully targeting the most complex cases. They work predominantly with older carers who have the main responsibility for the person with dementia, who are heavily involved in caring activity and who may be at risk. Three outcome areas that are important to carers of people with dementia and are potentially affected by receiving support are (1) carer self-efficacy, (2) carer quality of life (3) and carer mental and physical health. The carers in the survey receiving support from AN were older, were more heavily involved in caring and had poorer outcomes than carers not in receipt of such support. When these differences were controlled for, carers supported by AN had better outcomes, although the differences did not reach statistical significance. Health and social care costs were similar in both groups. The perceived system-wide impact of services, such as AN, is not well understood by professional stakeholders.LimitationsChallenges were experienced in identifying similar carers in areas with or without an AN service and in the cross-sectional nature of the work.ConclusionsSpecialist nursing support to carers of people with dementia may enable them to continue providing care to the end or very close to the end of the dementia journey. The outcomes for such carers may be no different from, or even slightly better than, those of similar carers without this support, although the costs to health and social care services are the same in each case.Future workFuture research could investigate the impact of specialist support for carers on admission to long-term care. There is also a need for more work to encourage routine use of the selected outcome measures in dementia service delivery.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

BackgroundEconomic evaluation studies often neglect the impact of disease and ill health on the social network of people living with HIV (PLHIV) and the wider community. An important concern relates to informal care requirements which, for some diseases such as HIV/AIDS, can be substantial.ObjectivesTo measure and value informal care provided to PLHIV in Malawi.MethodsA modified diary that divided a day into natural calendar changes was used to measure informal care time. The monetary valuation was undertaken by using four approaches: opportunity cost (official minimum wage used to value caregiving time), modified opportunity cost (caregiver’s reservation wage), willingness to pay (amount of money caregiver would pay for care), and willingness to accept (amount of money caregiver would accept for providing care to someone else) approaches. Data were collected from 130 caregivers of PLHIV who were accessing antiretroviral therapy from six facilities in Phalombe district in southeast Malawi.ResultsOf the 130 caregivers, 62 (48%) provided informal care in the survey week. On average, caregivers provided care of 8 h/wk. The estimated monetary values of informal care provided per week were US $1.40 (opportunity cost), US $2.41 (modified opportunity cost), US $0.40 (willingness to pay), and US $2.07 (willingness to accept).ConclusionsExclusion of informal care commitments may be a notable limitation of many applied economic evaluations. This work demonstrates that inclusion of informal care in economic evaluations in a low-income context is feasible.

Carers contribute essential support to enable people with dementia to continue living within the community. Admiral Nurses provide specialist dementia support for carers of people with dementia, including offering expert emotional support and guidance, and work to join up different parts of the health and social care system to address needs in a co‐ordinated way. The cost‐effectiveness of this service is not clear. We undertook a feasibility study to explore related outcomes and costs for these carers. A cross‐sectional, clustered survey was undertaken in England in 2017, in areas with and without Admiral Nursing (AN). The survey questionnaire included questions on the characteristics of the carers and the person with dementia, outcomes (care‐related quality of life [CRQoL], self‐efficacy and subjective well‐being), use of health and social care services, out‐of‐pocket costs and time spent on informal care. We used different econometric techniques to compare the outcomes and the costs of the carers with and without AN services: linear regression, propensity score matching and instrumental variables analysis. These techniques allowed us to control for differences in observed and unobserved characteristics between the two groups of carers which determined outcomes and costs. We concluded that AN services might have a positive effect on carers' CRQoL, self‐efficacy and subjective well‐being. Furthermore, we found little difference in costs between carers using AN and those using usual care, or in the costs of the people with dementia they care for. Our findings provided an initial indication as to whether AN services could be good value for money. The key limitation of the study was the difficulty in controlling for unobserved characteristics because of the cross‐sectional nature of our observational data. To diminish this limitation, our survey could be used in future studies following carers with and without AN services over time.

Background: Family members provide vital care at end of life, enabling patients to remain at home. Such informal care contributes significantly to the economy while supporting patients’ preferences and government policy. However, the value of care-givers’ contributions is often underestimated or overlooked in evaluations. Without information on the activities and expenditures involved in informal care-giving, it is impossible to provide an accurate assessment of carers’ contribution to end-of-life care. Aim: The aim of this study was to investigate the contributions and expenditure of informal, family care-giving in end-of-life cancer care. Design: A national census survey of English cancer carers was conducted. Survey packs were mailed to 5271 people who registered the death of a relative to cancer during 1–16 May 2015. Data were collected on decedents’ health and situation, care support given, financial expenditure resulting from care, carer well-being and general background information. Results: In all, 1504 completed surveys were returned (28.5%). Over 90% of respondents reported spending time on care-giving in the last 3 months of the decedent’s life, contributing a median 69 h 30 min of care-giving each week. Those who reported details of expenditure (72.5%) spent a median £370 in the last 3 months of the decedent’s life. Conclusion: Carers contribute a great deal of time and money for day-to-day support and care of patients. This study has yielded a unique, population-level data set of end-of-life care-giving and future analyses will provide estimates of the economic value of family care-givers’ contributions.

Background and objectives: The Dutch healthcare system is in transition towards managed competition. In theory, a system of managed competition involves incentives for quality and efficiency of provided care. This is mainly because health insurers contract on behalf of their clients with healthcare providers on, potentially, quality and costs. The paper develops a strategy to comprehensively analyse available multidimensional data on quality and costs to assess and report on the relative performance of healthcare providers within managed competition. Data and methods: We had access to individual information on 2409 clients of 19 Dutch diabetes care groups on a broad range of (outcome and process related) quality and cost indicators. We carried out a cost-consequences analysis and corrected for differences in case mix to reduce incentives for risk selection by healthcare providers. Results and conclusion: There is substantial heterogeneity between diabetes care groups' performances as measured using multidimensional indicators on quality and costs. Better quality diabetes care can be achieved with lower or higher costs. Routine monitoring using multidimensional data on quality and costs merged at the individual level would allow a systematic and comprehensive analysis of healthcare providers' performances within managed competition. Copyright © 2015 John Wiley & Sons, Ltd.

This paper estimates the impact of informal caregiving on self-reported well-being. It uses a sample of 23,285 respondents of the first eleven waves of the Household, Income and Labour Dynamics in Australia (HILDA).We apply a relatively new analytical method that enables us to estimate fixed effects ordered logit to analyse subjective well-being. The econometric estimates show that providing informal care has a negative effect on subjective well-being.The empirical evidence of our paper could be helpful to inform policy makers to better understand the impact of caregiving and design the appropriate long term care policies and support services. © 2014.

Objectives: The assessment of quality of life (QOL) in children has been underresearched in high- and low-income countries alike. This is partly due to practical and methodological challenges in characterizing and assessing children’s QOL. This article explores these challenges and highlights considerations in developing age-specific instruments for children affected by HIV and other health conditions in Africa and other lowincome settings. Methods: A literature search identified works that have 1) developed, 2) derived utilities for, or 3) applied QOL tools for use in economic evaluations of HIV interventions for children. We analyzed the existing tools specifically in terms of domains considered, variations in age bands, the recommended respondents, and the relevance of the tools to African and also other low-income country contexts. Results: Only limited QOL research has been conducted in low-income settings on either adults or children with HIV. A few studies have developed and applied tools for children (e.g., in Thailand, Brazil, and India), but none have been in Africa. The existing methodological literature is inconclusive on the appropriate width or depth by which to define pediatric QOL. The existing instruments include QOL domains such as “physical functioning, ”“ emotional and cognitive functioning, ”“ general behavior (social, school, home), ”“ health perception, ”“ coping and adaptation, ”“ pain and discomfort, ”“ extended effects, ”“ life perspective,” and “autonomy.” Conclusions: QOL assessment in children presents a series of practical and methodological challenges. Its application in low-income settings requires careful consideration of a number of context-specifi cf actors.

Healthcare quality information is crucial for the system of managed competition. Within a system of managed competition, health insurers can selectively contract care providers and are allowed to channel patients towards contracted providers. The idea is that insurers have a stronger bargaining position compared to care providers when they are able to channel patients. In the Dutch system of managed competition that was implemented in 2006, channelling patients to preferred providers has not yet been very successful. Empirical knowledge of which sources of hospital quality information they find important may help us to understand how to channel patients to preferred providers. The objective of this survey was to measure how patients rank various sources of information when they compare hospital quality in a system of managed competition. A written survey was conducted among clients of a large Dutch health insurance company. These clients underwent orthopedic surgery on the hip or knee no longer than 12 months ago. Two major players within a system of managed competition—health insurers and the government—were not seen as important sources of hospital quality information. In contrast, own experience and general practitioners (GPs) were seen as the most important sources of hospital quality information within the Dutch system of managed competition. Health insurers should take the main finding—that GPs are the most important source of hospital quality information—into account when they contract care providers and develop strategies for channeling patients towards preferred providers. A well-functioning system of managed competition will benefit patients, as it involves incentives for care providers to increase healthcare quality and to produce at the lowest cost per unit of quality.

Informal caregivers make a substantial contribution to the care of people with mental health disorders, enabling them to continue living in the community. To provide care, individuals may reduce their paid working hours or leave their jobs, take less leisure time, incur out-of-pocket costs, and experience changes in their health and well-being. The value of this care is widely acknowledged but rarely quantified.

Objective : To investigate population health-related quality of life norms in an Australian general sample by age, gender, BMI, education and socioeconomic status. Method : The SF-36 was included in the 2009/10 wave of the Household, Income and Labour Dynamics in Australia (HILDA) survey (n=17,630 individuals across 7,234 households), and converted into SF-6D utility scores. Trends across the various population subgroups were investigated employing population weights to ensure a balanced panel, and were all sub-stratified by gender. Results : SF-6D scores decline with age beyond 40 years, with decreasing education and by higher levels of socioeconomic disadvantage. Scores were also lower at very low and very high BMI levels. Males reported higher SF-6D scores than females across most analyses. Conclusions : This study reports Australian population utility data measured using the SF-6D, based on a national representative sample. These results can be used in a range of policy settings such as cost-utility analysis or exploration of health-related inequality. In general, the patterns are similar to those reported using other multi-attribute utility instruments and in different countries.

Changes in cost sharing and remuneration system in the Netherlands in 2006 led to clear changes in financial incentives faced by both consumers and general practitioner (GPs). For privately insured consumers, cost sharing was abolished, whereas those socially insured never faced cost sharing. The separate remuneration systems for socially insured consumers (capitation) and privately insured consumers (fee-for-service) changed to a combined system of capitation and fee-for-service for both groups. Our first hypothesis was that privately insured consumers had a higher increase in patient-initiated GP contact rates compared with socially insured consumers. Our second hypothesis was that socially insured consumers had a higher increase in physician-initiated contact rates. Data were used from electronic medical records from 32 GP-practices and 35 336 consumers in 2005–2007. A difference-in-differences approach was applied to study the effect of changes in cost sharing and remuneration system on contact rates. Abolition of cost sharing led to a higher increase in patient-initiated utilisation for privately insured consumers in persons aged 65 and older. Introduction of fee-for-service for socially insured consumers led to a higher increase in physician-initiated utilisation. This was most apparent in persons aged 25 to 54. Differences in the trend in physician-initiated utilisation point to an effect of supplier-induced demand. Differences in patient-initiated utilisation indicate limited evidence for moral hazard. Copyright © 2012 John Wiley & Sons, Ltd.

The aging of Western societies together with social changes places the question of how best to finance and deliver long-term care (LTC) services at the forefront of policy debates. The Congressional Budget Office noted that expenditures for nursing homes, home health care and other long-term treatment accounted for 8.5% of all U.S. health care spending.

Many recent writings in health policy have proposed that health be valued directly and in monetary terms using the new well-being valuation method. Yet there is currently no clear consensus on what the best measure of individual’s experience may be for the evaluation process. To shed light on this issue, monetary values for a number of health problems are compared across different well-being measures within the same UK data set. We find that, while there is strong internal consistency of health impacts within each well-being measure, hugely different monetary valuations are obtained for the same health problem across different well-being measures. Our results, although should only viewed as illustrative, call for economists to rethink about which measure of well-being or experienced utility to be used in the well-being valuation method, should the approach ever be implemented in real policy contexts.

This study analyzes peoples' social preferences for individual responsibility to health-risk behaviour in health care using the contingent valuation method adopting a societal perspective. We measure peoples' willingness to pay for inclusion of a treatment in basic health insurance of a hypothetical lifestyle dependent (smoking) and lifestyle independent (chronic) health problem. Our hypothesis is that peoples' willingness to pay for the independent and the dependent health problems are similar. As a methodological challenge, this study also analyzes the extent to which people consider their personal situation when answering contingent valuation questions adopting a societal perspective. 513 Dutch inhabitants responded to the questionnaire. They were asked to state their maximum willingness to pay for inclusion of treatments in basic health insurance package for two health problems. We asked them to assume that one hypothetical health problem was totally independent of behaviour (for simplicity called chronic disease). Alternatively, we asked them to assume that the other hypothetical health problem was totally caused by health-risk behaviour (for simplicity called smoking disease). We applied the payment card method to guide respondents to answer the contingent valuation method questions. Mean willingness to pay was 42.39 Euros (CI=37.24-47.55) for inclusion of treatment for health problem that was unrelated to behaviour, with '5-10' and '10-20 Euros' as most frequently stated answers. In contrast, mean willingness to pay for inclusion treatment for health-risk related problem was 11.29 Euros (CI=8.83-14.55), with '0' and '0-5 Euros' as most frequently provided answers. Difference in mean willingness to pay was substantial (over 30 Euros) and statistically significant (p-value=0.000). Smokers were statistically significantly more (p-value

The Netherlands was the first country that introduced a universal mandatory social health insurance scheme for covering a broad range of long-term care (LTC) services provided in a variety of care settings. Compared with most other OECD countries, both total and public expenditure on LTC is high, particularly since the Dutch population is relatively young. On the other hand, coverage of LTC services is relatively comprehensive. In this article we examine the past experiences, current deficiencies and future prospects of LTC financing in the Netherlands. By rationing of supply and tight budgetary restrictions, the government managed to effectively control the growth of LTC expenditure, but at the expense of growing waiting lists and deteriorating quality of care. Reform plans aim to make the LTC system more efficient and consumer-directed. We discuss whether the proposed reforms offer a perspective on a sustainable system of comprehensive LTC insurance. This is especially important in view of the ageing of the population and the expected increase in demand for LTC services. We conclude that the success of the reforms heavily depends on the definition of entitlements, the accuracy of needs assessment and the feasibility of determining appropriate client-based budgets.

Including informal care in economic evaluations is increasingly advocated but problematic. We investigated three well-known concerns regarding contingent valuation (CV): (1) the item non-response of CV values, (2) the sensitivity of CV values to the individual circumstances of caring, and (3) the choice of valuation method by comparing willingness-to-pay (WTP) and willingness-to-accept (WTA) values for a hypothetical marginal change in hours of informal care currently provided. The study sample consisted of 1453 caregivers and 787 care recipients. Of the caregivers, 603 caregivers (41.5%) provided both WTP and WTA values, 983 (67.7%) provided at least one. Determinants of non-response were dependent on the valuation method; primary determinants were education and satisfaction with amount of informal care provided. Caregivers' mean WTP (WTA) for reducing (increasing) informal care by 1 h was €9.13 (10.52). Care recipients' mean WTA (WTP) for reducing (increasing) informal care by 1 h was €8.88 (€6.85). Values were associated with a variety of characteristics of the caregiving situation; explanatory variables differed between WTP and WTA valuations. The differences between WTP and WTA valuations were small. Based on sensitivity CV appears to be a useful method to value informal care for use in economic evalations, non-response, however, remains a matter of concern. Copyright © 2009 John Wiley & Sons, Ltd.

This study values informal care for disabled stroke survivors in Thailand. It applies the conventional recommended opportunity cost method to value informal care in monetary terms. Data were collected by means of face-to-face interviews conducted during 2006. The sample consisted of 101 disabled persons who had suffered a stroke at least six months prior to the interview, and who had a functional status score of less than 95 as measured by the Barthel Index. Average monthly time spent on informal care was 94.6 hours, and the major source of opportunity cost was forgone unpaid work (43.5%). The average monthly monetary value of informal care was 4642.6 baht, based on 2006 prices. This study shows that providing informal care involves a substantial opportunity cost, implying a hidden value to Thai society. © 2009 Elsevier Ltd. All rights reserved.

In de nieuwe zorgverzekering onderhandelen zorgverzekeraars met zorgaanbieders over de kwaliteit en de prijs van de te leveren zorg. Het is de bedoeling dat zorgverzekeraars mede op basis van de gecontracteerde kwaliteit van zorg met elkaar gaan concurreren op de zorgverzekeringsmarkt. Inzicht in de preferenties van consumenten is daarbij cruciaal. Dit onderzoek presenteert de resultaten van een vignettenmethode waarmee de stated preferences van individuen voor de hoogte van de verzekeringspremie, de kwaliteit van dienstverlening en de kwaliteit van de door zorgverzekeraars gecontracteerde zorg worden gemeten. In het onderzoek wordt voorts empirisch getoetst of mensen met een chronische aandoening andere preferenties hebben ten aanzien van hun zorgverzekeraar dan mensen zonder chronische aandoening. De vignettenmethode laat zien dat zowel mensen met als zonder chronische aandoening bereid zijn een hogere premie te betalen als zorgverzekeraars objectief zouden kunnen aantonen dat dankzij hun zorginkoop/contracteerbeleid verzekerden bij bepaalde aandoeningen een grotere kans hebben op een verbetering van hun gezondheid. Het kan dus lonen voor een zorgverzekeraar om te investeren in de kwaliteit van zorg, mits hij de opbrengst van deze investeringen duidelijk kan maken en op dit terrein een reputatie kan verwerven. Meer procesmatige aspecten van zorgverlening en service aspecten van de zorgverzekeraar spelen een minder belangrijke rol.

Objectives: This article reports the results of the application of conjoint analysis (CA) to derive a monetary value of informal care. Compared with normally recommended valuation methods such as the opportunity cost method and proxy good method, a valuation elicited through a CA might be more sensitive to the heterogeneity and dynamics of informal care. Methods: We developed a questionnaire and conducted a survey in which informal caregivers were asked to rate four different hypothetical informal caregiving situations (reflecting different combinations of care hours, care tasks, and monetary compensation). They were also asked to rate their current informal care situation compared with the four hypothetical situations. Data were obtained from postal questionnaires. These questionnaires were sent through regional support centres for informal caregivers of care recipients with various health problems. A total of 865 informal caregivers from this heterogeneous population returned a completed survey. Results: Informal caregivers require an increase of 81% in their hourly compensation for providing 21 instead of 7 hours informal care per week. This implies a compensation of €12.36 per hour at a mean hypothetical compensation in the presented scenarios. We also found that an informal caregiver's current caregiving situation and other background characteristics were associated with the scenario ratings. Conclusions: We conclude that a CA is a promising alternative for existing methods to determine a monetary value of informal care and encourage more experiments in this area. © 2008, International Society for Pharmacoeconomics and Outcomes Research (ISPOR).

In de nieuwe zorgverzekering onderhandelen zorgverzekeraars met zorgaanbieders over de kwaliteit en de prijs van te leveren zorg. Mede op basis van de gecontracteerde kwaliteit en prijs van zorg concurreren zorgverzekeraars met elkaar op de zorgverzekeringsmarkt. Dit onderzoek presenteert de resultaten van een vergelijking tussen een nieuwe manier om preferenties voor kwaliteit van zorg te meten, de vignettenmethode, met een meer traditionele meetmethode. Mensen met diabetes is gevraagd welke structuuraspect (financien), procesaspecten en uitkomstaspecten van zorgconsumptie ze belangrijk vinden. Voordeel van de vignettenmethode ten opzichte van de traditionele meetmethode is dat respondenten een integrale afweging moeten maken. Volgens de traditionele meetmethode vindt een grote meerderheid van mensen met diabetes procesaspecten belangrijk, terwijl gemeten via de vignettenmethode slechts twee van de zes procesaspecten, namelijk serieus genomen worden en meebeslissen bij de handeling, belangrijk zijn. Daarentegen zijn drie van de vijf uitkomstaspecten van belang, waarbij niet bedlegerig zijn na zorggebruik het belangrijkste is. Dit zou kunnen duiden op een probleem met de construct validiteit van de traditionele meetmethode toegepast op mensen met diabetes. De vignettenmethode is een bruikbare aanvulling en mogelijk zelfs een beter alternatief meetinstrument om preferenties voor kwaliteit van zorg te meten dat zowel door patienten/consumenten organisaties als verzekeraars kan worden gebruikt in de nieuwe zorgverzekering.

This paper estimates the monetary value of providing informal care by means of a well-being valuation method. This is done by assessing the compensating variation necessary to maintain the same level of well-being after an informal caregiver provides an extra hour of informal care. The informal caregiver's well-being is proxied by the answer to two subjective well-being questions that were posed in a questionnaire answered by 865 Dutch informal caregivers between the end of 2001 and the beginning of 2002. In the econometric analysis, a distinction is made between the care recipients who are and the ones who are not a family member of the informal caregiver. The results indicate that an extra hour of informal care is worth about 9 or 10 Euros. This equals 8 or 9 Euros if the care recipient is a family member and about 7 or 9 Euros if not. When applying the contingent valuation method to the same sample, the value obtained was 10.52 Euros per hour. This paper concludes that the well-being valuation method is a useful complement to the more traditional valuation methods in the health economics literature in general and more particularly for the economic valuation of informal care: it includes all costs and effects associated with providing care from the perspective of the informal caregiver, it is relatively cheap to implement, and it offers an additional possibility to determine the convergent validity of the different monetary valuation methods. Copyright © 2007 John Wiley & Sons, Ltd.

This paper reports the results of the application of the opportunity costs and proxy good methods to determine a monetary value of informal care. We developed a survey in which we asked informal caregivers in The Netherlands to indicate the different types of time forgone (paid work, unpaid work and leisure) in order to be able to provide care. Moreover, we asked informal caregivers how much time they spent on a list of 16 informal care tasks during the week before the interview. Data were obtained from surveys in two different populations: informal caregivers and their care recipients with stroke and with rheumatoid arthritis (RA). A total of 218 care recipients with stroke and their primary informal caregivers completed a survey as well as 147 caregivers and their care recipients with RA. The measurement of care according to both methods is more problematic compared to the valuation. This is especially the case for the opportunity costs method and for the housework part in the proxy good method. More precise guidelines are necessary for the consistent application of both methods in order to ensure comparability of results and of economic evaluations of health care.

The incorporation of informal care into economic evaluations of health care is troublesome. The debate focuses on the valuation of time spent on informal caregiving, while time measurement, a related and may be even a more important issue, tends to be neglected. Valid time measurement is a necessary condition for the valuation of informal care. In this paper, two methods of time measurement are compared and evaluated: the diary, which is considered the gold standard, and the recall method, which is applied more often. The main objective of this comparison is to explore the validity of the measurement of time spent on providing informal care. In addition, this paper gives empirical evidence regarding the measurement of joint production and the separation between 'normal' housework and additional housework due to the care demands of the care recipients. Finally, the test-retest stability for the recall method is assessed. A total of 199 persons giving informal care to a heterogeneous population of care recipients completed the diary and the recall questionnaire. Corrected for joint production, informal caregivers spent almost 5.8 h a day on providing informal care. If one assumes that respondents take into account joint production when completing the recall questionnaire, the recall method is a valid instrument to measure time spent on providing informal care compared to the diary. Otherwise, the recall method is likely to overestimate the time spent on providing informal care. Moreover, the recall method proves to be unstable over time. This could be due to learning effects from completing a diary.

This paper reports the results of the application of the conjoint measurement method (CM) to determine a monetary value of informal care. Compared to the normally recommended valuation methods, like the opportunity cost method and proxy good method, CM is probably better able to capture the heterogeneity of informal care. We developed a survey in which informal caregivers were asked to rate four different hypothetical informal caregiving situations, which differed with respect to care hours, care tasks and monetary compensation. Data were obtained from postal surveys. A total of 135 pairs of informal caregivers and care recipients with rheumatoid arthritis (RA) from the Netherlands returned a completed survey and were used in the analysis. Informal caregivers require an extra compensation of 1.00 euro per hour for providing one additional hour of the same informal care task (meaning that from the seventh to the eighth hour, they require 8 euro). For providing two extra hours of care, they require 2.00 euro compensation per hour. The relative valuation of informal care tasks is very diverse. Respondents require a compensation of 13.43 euro per hour for switching from providing light housework to personal care and 0.56 euro per hour for switching from providing personal care to heavy housework. Though CM is sometimes regarded as cognitively complex, 70% of the respondents were able and willing to evaluate the hypothetical caregiving scenarios. Elderly respondents especially had more difficulty with the method. In sum, CM is seen as a promising alternative for existing methods to determine a monetary value of informal care. The presented valuations of informal care can be incorporated in the numerator of a cost-effectiveness ratio in economic evaluations of health care.

This paper reports the results of the application of the contingent valuation method (CVM) to determine a monetary value of informal care. We discuss the current practice in valuing informal care and a theoretical model of the costs and benefits related to the provision of informal care. In addition, we developed a survey in which informal caregivers' willingness to accept (WTA) to provide an additional hour of informal care was elicited. This method is better than normally recommended valuation methods able to capture the heterogeneity and dynamics of informal care. Data were obtained from postal surveys. A total of 153 informal caregivers and 149 care recipients with rheumatoid arthritis returned a completed survey. Informal caregivers reported a mean WTA to provide a hypothetical additional hour of informal care of 9.52 Euro (n=124). Many hypotheses derived from the theoretical model and the literature were supported by the data.CVM is a promising alternative for existing methods like the opportunity cost method and the proxy good method to determine a monetary value of informal care that can be incorporated in the numerator of any economic evaluation.

Objective: To compare the feasibility, convergent and clinical validity of three commonly used burden scales: Caregiver Strain Index (CSI), Caregiver Reaction Assessment (CRA) and Sense of Competence Questionnaire (SCQ), with a self-developed single question on self-rated burden (SRB). Subjects: Stroke patients receiving support from an informal caregiver ( n=148) and their caregivers were followed up to six months after stroke. Intervention: Feasibility was assessed with several measures of missing values. Convergent validity was assessed on the basis of the correlation patterns between the burden scales, and clinical validity through evaluation of expected associations between levels of burden and explanatory patients' and caregivers' characteristics. Results: Missing values were less often observed on CSI and SRB than SCQ and CRA. Significant correlation coefficients ( p Conclusions: A concise and simple measure would facilitate early detection of caregivers at risk in clinical practice and research. CSI and SRB are more feasible and at least as valid instruments for assessment of caregiver burden in stroke than the longer and more complex SCQ and CRA. SRB could be used for quick screening of caregivers at risk. CSI is indicated for further diagnosis of the burden of informal caregivers.

Informal care makes up a significant part of the total amount of care provided to care recipients with chronic and terminal diseases. Still, informal care is often neglected in economic evaluations of health care programs. Probably this is related to the fact that the costs of informal care are to an important extent related to time inputs by relatives and friends of care recipients and time is not easy to value. Development of theoretically sound, yet easily applicable valuation methods is therefore important since ignoring the costs of informal care may lead to undesirable shifts between formal and informal care. Moreover, there is increasing evidence that providing informal care may lead to health problems for the caregiver, both in terms of morbidity and mortality. Until now these health effects have not been incorporated in economic evaluations. More attention for the identification and valuation of the full costs and (health) effects of informal care for the informal caregiver seems needed therefore. This contribution presents a critical evaluation of the available methods to incorporate informal care in economic evaluations.

We demonstrated that infusion with hyaluronidase of C57Bl/6 mice for 4 wks to chronically reduce EC surface hyaluronan expression resulted in glomerular albumin passage and podocyte injury. However, with systemic hyaluronan degradation it precludes definitive conclusions on cellular-specific effects. Here we investigated the hypothesis that it is specifically the structure and integrity of the glomerular EC glycocalyx that determines whether or not albumin passage across the capillary wall occurs, and subsequently protects against development of kidney injury. To this end, we generated a conditional EC specific hyaluronan synthase2-knock out (HAS2–KO) mouse model. 8 Week old B6.VECad-creERT2.has2f/f.Rosa26-tdTomato were injected i.p. for 5 consecutive days with 2mg/0.2μL tamoxifen (control B6.VECad-creERT2.Rosa26-tdTomato) to induce an endothelial specific deletion of has2. Compared to ctrl, these mice show that 4 wks after induction, weight gain was significantly more increased (mean ± SEM; 2.9 ± 0.7 [n=8] vs. 5.2 ± 0.6g [n=11], p=0.02). With prominent endogenous albumin passage over the barrier, visualized as a DAB reaction product in electron microscopy after anti-albumin-HRP antibody incubation of 2%PFA fixated tissue slides, visible 2 wks after induction, a significant (p=0.036) increased ACR (36.0 ± 1.9 [n=8] vs. 57.7 ± 7.9 [n=11]) was found only at wk 4. During this period no significant change in BP (85 ± 2/114 ± 2 [n=8] vs. 90 ± 4/119 ± 4mmHg [n=10], diastolic/systolic) or in heart rate (712 ± 14 [n=8] vs. 747 ± 8beats/min [n=10]) was observed. Renal morphology revealed with comparable glomerular surface area (5342 ± 270 [n=3] vs. 5508 ± 250 μm2 [n=6]), significant increase of glomerular mesangial area (20.1 ± 0.9 [n=3]) vs. 38.4 ± 1.2% [n=6], p

With rising healthcare expenditure and limited budgets available, countries are having to make choices about the content of health insurance plans. The views of the general population can help determine such priorities. In this article, we investigate whether preferences of the general population regarding the content of health insurance plans could be measured with the help of a stated preference method: the Basket Method (BM). In this method, people use an online tool to include or exclude healthcare interventions from their hypothetical insurance package; this then affects their monthly premium. The study was conducted in the Netherlands. In total, 1007 members of two panels managed by the NIVEL filled out an online questionnaire that included the BM. The suitability of the BM was tested with the help of five criteria, e.g. the BM's ability to distinguish between healthcare interventions. Our results suggest that the BM is suitable for measuring preferences of the general population regarding the content of the health insurance plan, as it performs well on most criteria. Policy makers can use these preferences when deciding the content of the health insurance plan. Its contents will then be more aligned to the population's needs and preferences.

It is hard to ignore the importance of patient time investment in the production of health since the influential paper by Grossman (1972). Patient time includes time to admission, travel time, waiting time, and treatment time and can be substantial. Time to admission is the time between the first referral and the moment that the treatment actually starts. Travel time is the time that a patient needs to travel between the place where the patient lives and the medical care centre where the patient is treated. Waiting time is the time that the patient waits at the medical care centre before treatment. Treatment time is the time spent getting active treatment for example by a doctor or a nurse. Patient time is, however, often ignored in economic analyses. This may lead to biased results and inappropriate policy recommendations, which may eventually influence patients’ health, wellbeing and welfare. How to value patient time is not straightforward. It is even less straightforward for patients who are not participating in the labour market. Although there is some emerging literature on the monetary valuation of patient time, an important challenge remains to develop an approach that can be used to monetarily value time of patients not participating in the labour market. We aim to contribute to the health economics literature by describing and empirically illustrating how to monetarily value patients’ time comprehensively, using the contingent valuation method. Comprehensively means including various types of patient time (time to admission, travel time, waiting time, and treatment time) as the previous literature focused mainly on valuing a particular type of patient time, for instance waiting time. This paper describes the development of the contingent valuation survey. The survey is added as an appendix to this paper. This paper also presents the first empirical results of applying our survey approach in a sample of patients in the Netherlands not participating in the labour market. These results show that the monetary value of waiting time was the highest (€30.10/£34.76 per hour) and travel and treatment time were equally valued (respectively €13.20/£11.43 and €13.32/£11.54 per hour).

The Dutch healthcare system is in transition towards managed competition. In theory, a system of managed competition involves incentives for quality and efficiency of provided care. This is mainly because health insurers contract on behalf of their clients with healthcare providers on, potentially, quality and costs. The paper develops a strategy to comprehensively analyse available multidimensional data on quality and costs to assess and report on the relative performance of healthcare providers within managed competition.We had access to individual information on 2409 clients of 19 Dutch diabetes care groups on a broad range of (outcome and process related) quality and cost indicators. We carried out a cost-consequences analysis and corrected for differences in case mix to reduce incentives for risk selection by healthcare providers.There is substantial heterogeneity between diabetes care groups' performances as measured using multidimensional indicators on quality and costs. Better quality diabetes care can be achieved with lower or higher costs. Routine monitoring using multidimensional data on quality and costs merged at the individual level would allow a systematic and comprehensive analysis of healthcare providers' performances within managed competition.

The Netherlands was the first country to introduce a universal mandatory social health insurance scheme (AWBZ) for covering a broad range of long-term care (LTC) services provided in a variety of care settings. Compared with most other Organization for Economic Cooperation and Development (OECD) countries, coverage of LTC services is relatively comprehensive. This comprehensive coverage might explain why, in comparison with most other OECD countries, both total and public expenditure on LTC in the Netherlands are high, particularly since the percentage of elderly is similar to the OECD average (OECD, 2005). This can at least partly be explained by the relatively generous social health insurance scheme.

The opportunity costs associated with the provision of informal care are usually estimated based on the reduced potential of the caregiver to partake in paid work (both in terms of whether they are able to undertake paid work, and if so the hours of work undertaken). In addition to the hours of informal care provided, these opportunity costs are also likely determined by the necessity to perform particular informal care tasks at specific moments of the day. The literature, to date, has largely overlooked this dimension of informal care. We used Dutch data from time use diaries which report patterns of informal care throughout the day which enables investigation of when particular activities are undertaken. We found that whereas some tasks must be performed at a relatively fixed time of day, others are shiftable and can be performed at other times or even on different days. Household and organisation activities are more likely to be undertaken by employed caregivers, and seem largely to be shiftable; whereas personal care contains unshiftable activities. This implies additional opportunity costs of providing personal care tasks – we term these “time-bound” opportunity costs. Since the care recipient’s need for care may in part relate to unshiftable tasks, we conclude that one should be careful with using care need as an instrument of informal care in labour supply equations.

Changes in cost sharing and remuneration system in the Netherlands in 2006 led to clear changes in financial incentives faced by both consumers and general practitioner (GPs). For privately insured consumers, cost sharing was abolished, whereas those socially insured never faced cost sharing. The separate remuneration systems for socially insured consumers (capitation) and privately insured consumers (fee-for-service) changed to a combined system of capitation and fee-for-service for both groups. Our first hypothesis was that privately insured consumers had a higher increase in patient-initiated GP contact rates compared with socially insured consumers. Our second hypothesis was that socially insured consumers had a higher increase in physician-initiated contact rates. Data were used from electronic medical records from 32 GP-practices and 35336 consumers in 2005-2007. A difference-in-differences approach was applied to study the effect of changes in cost sharing and remuneration system on contact rates. Abolition of cost sharing led to a higher increase in patient-initiated utilisation for privately insured consumers in persons aged 65 and older. Introduction of fee-for-service for socially insured consumers led to a higher increase in physician-initiated utilisation. This was most apparent in persons aged 25 to 54. Differences in the trend in physician-initiated utilisation point to an effect of supplier-induced demand. Differences in patient-initiated utilisation indicate limited evidence for moral hazard.

Effect measure long-term care? Main aim of interventions in medical care is to achieve health gains. Cost-utility analysis is an important instrument to assess relative efficiency of health care interventions. Main effect measure in a cost-utility analysis is ‘health-related quality of life’. Interventions in long-term care focus to a considerable degree on managing or reducing the effect of impairment on people’s daily lives and therefore on maintaining or improving well-being. Therefore health-related quality of life cannot be used to measure outcomes in long-term care aimed primarily at well-being. A first step in development of an outcome measure for long-term care is determining which domains of well-being this sector aims to improve. This article presents and discusses which aspects play an important role in the well-being of people with long-term physical, cognitive, psychological and/or sensory impairments. Keywords: long-term care; social care; outcome measures; instruments; economic evaluations

Patient satisfaction surveys are increasingly used for benchmarking purposes. In the Netherlands, the results of these surveys are reported at the univariate level without taking case mix factors into account. The first objective of the present study was to determine whether differences in patient satisfaction are attributed to the hospital, department or patient characteristics. Our second aim was to investigate which case mix variables could be taken into account when satisfaction surveys are carried out for benchmarking purposes. Patients who either were discharged from eight academic and fourteen general Dutch hospitals or visited the outpatient departments of the same hospitals in 2005 participated in cross-sectional satisfaction surveys. Satisfaction was measured on six dimensions of care and one general dimension. We used multilevel analysis to estimate the proportion of variance in satisfaction scores determined by the hospital and department levels by calculating intra-class correlation coefficients (ICCs). Hospital size, hospital type, population density and response rate are four case mix variables we investigated at the hospital level. We also measured the effects of patient characteristics (gender, age, education, health status, and mother language) on satisfaction. We found ICCs on hospital and department levels ranging from 0% to 4% for all dimensions. This means that only a minor part of the variance in patient satisfaction scores is attributed to the hospital and department levels. Although all patient characteristics had some statistically significant influence on patient satisfaction, age, health status and education appeared to be the most important determinants of patient satisfaction and could be considered for case mix correction. Gender, mother language, hospital type, hospital size, population density and response rate seemed to be less important determinants. The explained variance of the patient and hospital characteristics ranged from 3% to 5% for the different dimensions. Our conclusions are, first, that a substantial part of the variance is on the patient level, while only a minor part of the variance is at the hospital and department levels. Second, patient satisfaction outcomes in the Netherlands can be corrected by the case mix variables age, health status and education. © 2009 Elsevier Ltd. All rights reserved.

The derivation of population norms using simple generic health-related quality of life measures to inform policy has been recommended in the literature. This letter illustrates the derivation of population norms for the SF-6D in the United Kingdom. It uses a sample of 22,166 respondents from the 2010 wave of the study Understanding Society. Understanding Society is a national representative sample of British citizens. The survey of this study contains the SF-12. It is possible to derive health state utilities from the SF-12 (and from the SF-36) using a relatively new instrument, the SF-6D. The SF-12 and the SF-36 belong to the most widely used generic health-related quality of life measures. Mean SF-6D utility scores for males and females are 0.81 and 0.79, respectively. Especially the older age categories have lower utility scores. The younger age categories have slightly higher utility scores. From a list of 17 conditions, people with congestive heart failure had the lowest (0.60) and people with diabetes the highest (0.76) SF-6D scores. This letter encourages the health economics research community to derive SF-6D population norms to inform policy.

Legislation that came into effect in 2006 has dramatically altered the health insurance system in the Netherlands, placing greater emphasis on consumer choice and competition among insurers. The potential for such competition depends largely on consumer preferences for price and quality of service by insurers and quality of affiliated providers. This study provides initial evidence on the preferences of Dutch consumers and how they view trade-offs between various aspects of health insurance product design. A key feature of the analysis is that we compare the responses of high and low risk individuals, where risk is defined by the presence of a costly chronic condition. This contrast is critically important for understanding incentives facing insurers and for identifying potential unanticipated consequences of market competition. The results from our conjoint analysis suggest that not only high risk but also low risk individuals are willing to pay substantially more for insurance products that can be shown to provide better health outcomes. This suggests that insurance products that are more expensive and provide better quality of care may also attract low risk individuals. Therefore, development and dissemination of good, reliable and understandable health plan performance indicators may effectively reduce the problem of adverse selection. © 2008 Elsevier Ltd. All rights reserved.

This paper compares several applied valuation methods for including informal care in economic evaluations of healthcare programmes: the proxy good method; the opportunity cost method; the contingent valuation method (CVM); conjoint measurement (CM); and valuation of health effects in terms of health-related quality of life (HR-QOL) and well-being. The comparison focuses on three questions: what outcome measures are available for including informal care in economic evaluations of healthcare programmes; whether these measures are compatible with the common types of economic evaluation; and, when applying these measures, whether all relevant aspects of informal care are incorporated. All types of economic evaluation can incorporate a monetary value of informal care (using the opportunity cost method, the proxy good method, CVM and CM) on the cost side of an analysis, but only when the relevant aspects of time costs have been valued. On the effect side of a cost-effectiveness or cost-utility analysis, the health effects (for the patient and/or caregiver) measured in natural units or QALYs can be combined with cost estimates based on the opportunity cost method or the proxy good method. One should be careful when incorporating CVM and CM in cost-minimization, cost-effectiveness and cost-utility analyses, as the health effects of patients receiving informal care and the carers themselves may also have been valued separately. One should determine whether the caregiver valuation exercise allows combination with other valuation techniques. In cost-benefit analyses, CVM and CM appear to be the best tools for the valuation of informal care. When researchers decide to use the well-being method, we recommend applying it in a cost-benefit analysis framework. This method values overall QOL (happiness); hence it is broader than just HR-QOL, which complicates inclusion in traditional health economic evaluations that normally define outcomes more narrowly. Using broader, non-monetary valuation techniques, such as the CarerQol instrument, requires a broader evaluation framework than cost-effectiveness/cost-utility analysis, such as cost-consequence or multi-criteria analysis. © 2008 Adis Data Information BV. All rights reserved.

This paper compares several applied valuation methods for including informal care in economic evaluations of healthcare programmes: the proxy good method; the opportunity cost method; the contingent valuation method (CVM); conjoint measurement (CM); and valuation of health effects in terms of health-related quality of life (HR-QOL) and well-being. The comparison focuses on three questions: what outcome measures are available for including informal care in economic evaluations of healthcare programmes; whether these measures are compatible with the common types of economic evaluation; and, when applying these measures, whether all relevant aspects of informal care are incorporated. All types of economic evaluation can incorporate a monetary value of informal care (using the opportunity cost method, the proxy good method, CVM and CM) on the cost side of an analysis, but only when the relevant aspects of time costs have been valued. On the effect side of a cost-effectiveness or cost-utility analysis, the health effects (for the patient and/or caregiver) measured in natural units or QALYs can be combined with cost estimates based on the opportunity cost method or the proxy good method. One should be careful when incorporating CVM and CM in cost-minimization, cost-effectiveness and cost-utility analyses, as the health effects of patients receiving informal care and the carers themselves may also have been valued separately. One should determine whether the caregiver valuation exercise allows combination with other valuation techniques. In cost-benefit analyses, CVM and CM appear to be the best tools for the valuation of informal care. When researchers decide to use the well-being method, we recommend applying it in a cost-benefit analysis framework. This method values overall QOL (happiness); hence it is broader than just HR-QOL, which complicates inclusion in traditional health economic evaluations that normally define outcomes more narrowly. Using broader, non-monetary valuation techniques, such as the CarerQol instrument, requires a broader evaluation framework than cost-effectiveness/cost-utility analysis, such as cost-consequence or multicriteria analysis.

This paper tests empirically for differences in prices paid between parts of the cash benefit that clients may and not may keep when it is unspent. In The Netherlands, demand-side subsidies were introduced in 1996. Clients receive a cash benefit to purchase the type of home care (housework, personal care, support with mobility, organisational tasks or social support) they need from the care supplier of their choice (private care provider, regular care agency, commercial care agency or paid informal care provider). Furthermore, they negotiate with the care supplier about price and quantity. Our main findings are the following: (1) the component of the cash benefit that a client may not keep when it is unspent has a positive impact on the price of care. (2) In contrast, the components of the cash benefit a client may keep when it is unspent, have no or a negative impact on the price of care. Both results have important implications for designing health policy. If cash benefits are introduced in long-term home care in an attempt to make consumers more conscious about prices, it is only successful when consumers may keep the unspent part of the cash benefit.