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_Objectives:_ Decision-making frameworks that draw on economic evaluations increasingly use equity weights to facilitate a more equitable and fair allocation of healthcare resources. These weights can be attached to health gains or reflected in the monetary threshold against which the incremental cost-effectiveness ratios of (new) health technologies are evaluated. Currently applied weights are based on different definitions of disease severity and do not account for age-related preferences in society. However, age has been shown to be an important equity-relevant characteristic. This study examines the willingness to pay (WTP) for health-related quality of life (QOL) gains in relation to the disease severity and age of patients, and the outcome of the disease. _Methods:_ We obtained WTP estimates by applying contingent-valuation tasks in a representative sample of the public in The Netherlands (n = 2023). We applied random-effects generalized least squares regression models to estimate the effect of patients’ disease severity and age, size of QOL gains, disease outcome (full recovery/death 1 year after falling ill), and respondent characteristics on the WTP. _Results:_ Respondents’WTP was higher for more severely ill and younger patients and for larger-sized QOL gains, but lower for patients who died. However, the relations were nonlinear and context dependent. Respondents with a lower age, who were male, had a higher household income, and a higher QOL stated a higher WTP for QOL gains. _Conclusions:_ Our results suggest that—if the aim is to align resource-allocation decisions in healthcare with societal preferences—currently applied equity weights do not suffice.

Objectives: To obtain public support for the active disinvestment (i.e. policy decision to stop reimbursement) of healthcare interventions, it is important to have insight in what the public thinks about disinvestment and which considerations they find relevant in this context. Currently, evidence on relevant considerations in the disinvestment context is limited. Therefore, this study aimed to explore the societal views in the Netherlands on the active disinvestment of healthcare interventions and obtain insight into the considerations that are relevant for those holding the different views. Methods: A Q-methodology study was conducted among a purposively selected sample of citizens (n = 43). Data were collected in June and July 2019. Participants individually ranked a set of 43 statements broadly covering the issues that participants could consider relevant in the disinvestment context, from ‘least agree’ to ‘most agree’. Qualitative feedback on the statement ranking was collected from each participant using a questionnaire. Principal component analysis followed by oblimin rotation was used to identify clusters of participants with similar statement rankings. These clusters/factors were interpreted as distinct viewpoints using the factor arrays and qualitative questionnaire responses of participants. Results: Four viewpoints were identified. People holding viewpoint I believe that reimbursement of necessary healthcare should be maintained, irrespective of its costs. People holding viewpoint II agree with viewpoint I, although they believe that necessity should be objectively determined. People holding viewpoint III think that unnecessary, ineffective and inefficient healthcare should be disinvested. People holding viewpoint IV, consider it most important that disinvestment decision-making processes are transparent and consistent. Conclusion: Insight in the distinct viewpoints identified in this study contributes to a better understanding of why it has been conside

To appropriately weight dimensions of quality of life instruments for health economic evaluations, population and patient preferences need to be elicited. Two commonly used elicitation methods for this purpose are discrete choice experiments (DCE) and case 2 best-worst scaling (BWS). These methods differ in terms of their cognitive burden, which is especially relevant when eliciting preferences among older people. Using a randomised experiment with respondents from an online panel, this paper examines the cognitive burden associated with colour-coded and level overlapped DCE, colour-coded BWS, and ‘standard’ BWS choice tasks in a complex health state valuation setting. Our sample included 469 individuals aged 65 and above. Based on both revealed and stated cognitive burden, we found that the DCE tasks were less cognitively burdensome than case 2 BWS. Colour coding case 2 BWS cannot be recommended as its effect on cognitive burden was less clear and the colour coding lead to undesired choice heuristics. Our results have implications for future health state valuations of complex quality of life instruments and at least serve as an example of assessing cognitive burden associated with different types of choice experiments.

Background: Egg freezing has emerged as a technology of assisted reproductive medicine that allows women to plan for the anticipated loss of fertility and hence to preserve the option to conceive with their own eggs. The technology is surrounded by value-conflicts and is subject to ongoing discussions. This study aims at contributing to the empirical-ethical debate by exploring women’s viewpoints on egg freezing in Austria, where egg freezing for social reasons is currently not allowed. Methods: Q-methodology was used to identify prevailing viewpoints on egg freezing. 46 female participants ranked a set of 40 statements onto a 9-column forced choice ranking grid according to the level of agreement. Participants were asked to explain their ranking in a follow-up survey. By-person factor analysis was used to identify distinct viewpoints which were interpreted using both the quantitative and the qualitative data. Results: Three distinct viewpoints were identified: (1) “women should decide for themselves”, (2) “we should accept nature but change policy”, and (3) “we need an informed societal debate”. These viewpoints provide insights into how biomedical innovations such as egg freezing are perceived by women in Austria and illustrate the normative tensions regarding such innovations. Conclusions: Acknowledging the different prioritizations of values regarding assisted reproductive technologies is important to better understand the underlying normative tensions in a country where egg freezing for social reasons is currently not allowed. The study adds new empirical insights to the ongoing debate by outlining and discussing viewpoints of those directly affected: women. Following up on the lay persons perspective is particularly important in the context of future biomedical innovations that may challenge established norms and create new tensions. It therefore also adds to the societal debate and supports evidence-informed policy making in that regard.

Background: Epilepsy is associated with a high disease burden, impacting the lives of people with epilepsy and their caregivers and family. Persons with medically refractory epilepsy experience the greatest burden, suffering from profound physical, psychological, and social consequences. Anecdotal evidence suggests these persons may benefit from a seizure dog. As the training of a seizure dog is a substantial investment, their accessibility is limited in the absence of collective reimbursement as is seen in the Netherlands. Despite sustained interest in seizure dogs, scientific knowledge on their benefits and costs remains scarce. To substantiate reimbursement decisions stronger evidence is required. The EPISODE study aims to provide this evidence by evaluating the effectiveness and cost-effectiveness of seizure dogs in adults with medically refractory epilepsy. Methods: The study is designed as a stepped wedge randomized controlled trial that compares the use of seizure dogs in addition to usual care, with usual care alone. The study includes adults with epilepsy for whom current treatment options failed to achieve seizure freedom. Seizure frequency of participants should be at least two seizures per week, and the seizures should be associated with a high risk of injury or dysfunction. During the 3 year follow-up period, participants receive a seizure dog in a randomized order. Outcome measures are taken at multiple time points both before and after receiving the seizure dog. Seizure frequency is the primary outcome of the study and will be recorded continuously using a seizure diary. Questionnaires measuring seizure severity, quality of life, well-being, resource use, productivity, social participation, and caregiver burden will be completed at baseline and every 3 months thereafter. The study is designed to include a minimum of 25 participants. Discussion: This protocol describes the first randomized controlled trial on seizure dogs. The study will provide compre

__Background__ Risk communication is a key component of public health interventions during an outbreak. As the coronavirus pandemic unfolde

There is a need for comprehensive measures to evaluate the benefits of health and social care services for older people. The newly developed Well-being of Older People measure (WOOP) aims to capture all aspects that older people find important to their well-being. This study explores the validity and test-retest reliability of the WOOP. Between December 2017 and January 2018, an online survey was used to retrieve data from 1113 people aged 65 years and older in the Netherlands. Regression analyses on Cantril's Ladder scores were conducted to explore the relative importance of the items of the WOOP. Dimensionality was checked using exploratory factor analysis. Convergent and discriminant validity were investigated by relating the WOOP to several measures of health and well-being. Test-retest reliability was examined using data from 269 respondents that participated in a second online survey, distributed one week after the first. The items of the WOOP were significantly associated with Cantril's Ladder scores. When regressed simultaneously this was still true for all but the ‘social contacts’ item and one level of the ‘acceptance and resilience’ item. The dimensionality analysis revealed three factors, of which two included items of the WOOP and the EQ-5D-5L and the third only items of the WOOP. The WOOP correlated moderately to highly with physical health, and (very) highly with (mental) health and well-being measures. The test-retest reliability in terms of ICC was high, whereas the kappa for the items was fair to good, except for two items. Overall, the WOOP seems to capture aspects relevant to the well-being of older people adequately, and the results of first validity and reliability tests were satisfactory. Before the WOOP can be used in economic evaluations, further validation in a variety of health and social care settings is recommended, and utility weights need to be determined.

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 fndings 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, difered 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 signifcant determinants (R2 : 0.041–0.130). With a few minor exceptions in some health dimensions, acceptability levels and patterns were str

__Background:__ There is debate around the composition of life years gained from smoking elimination. The aim of this study was to conduct a systematic review of the literature to synthesize existing evidence on the effect of smoking status on health expectancy and to examine whether smoking elimination leads to compression of morbidity. __Methods:__ Five databases were systematically searched for peer-reviewed articles. Studies that presented quantitative estimates of health expectancy for smokers and non-/never-smokers were eligible for inclusion. Studies were searched, selected and reviewed by two reviewers who extracted the relevant data and assessed the risk of bias of the included articles independently. __Results:__ The search identified 2491 unique records, whereof 20 articles were eligible for inclusion (including 26 cohorts). The indicators used to measure health included disability/activity limitations (n¼9), health-related quality of life (EQ-5D) (n¼2), weighted disabilities (n¼1), self-rated health (n¼9), chronic diseases (n¼6), cardiovascular diseases (n¼4) and cognitive impairment (n¼1). Available evidence showed consistently that non-/never-smokers experience more healthy life years throughout their lives than smokers. Findings were inconsistent on the effect of smoking on the absolute number of unhealthy life years. Findings concerning the time proportionally spent unhealthy were less heterogeneous: nearly all included articles reported that non-/never-smokers experience relatively less unhealthy life years (e.g. relative compression of morbidity). __Conclusions:__ Support for the relative compression of morbidity due to smoking elimination was evident. Further research is needed into the absolute compression of morbidity hypothesis since current evidence is mixed, and methodology of studies needs to be harmonized.

It was highlighted that in the original article [1] the graphs in Fig. 1 were duplicated. This Correction article shows the correct Fig. 1. The original article has been updated. Author details 1Erasmus University Rotterdam, Erasmus School of Health Policy & Management, P.O. Box 1738, 3000, DR, Rotterdam, the Netherlands. 2Erasmus University Rotterdam, Erasmus School of Economics, Rotterdam, The Netherlands.

Background: Quality of life measures going beyond health, like the ICECAP-A, are gaining importance in health technology assessment. The assessment of the monetary value of gains in this broader quality of life is needed to use these measurements in a cost-effectiveness framework. Methods: We applied the well-being valuation approach to calculate a first monetary value for capability well-being in comparison to health, derived by ICECAP-A and EQ-5D-5L, respectively. Data from an online survey administered in February 2018 to a representative sample of UK citizens aged 18–65 was used (N = 1512). To overcome the endogeneity of income, we applied an instrumental variable regression. Several alternative model specifications were calculated to test the robustness of the results. Results: The base case empirical estimate for the implied monetary value of a year in full capability well-being was £66,597. The estimate of the monetary value of a QALY, obtained from the same sample and using the same methodology amounted to £30,786, which compares well to previous estimates from the willingness to pay literature. Throughout the conducted robustness checks, the value of capability well-being was found to be between 1.7 and 2.6 times larger than the value of health. Conclusion: While the applied approach is not without limitations, the generated insights, especially concerning the relative magnitude of valuations, may be useful for decision-makers having to decide based on economic evaluations using the ICECAP-A measure or, to a lesser extent, other (capability) well-being outcome measures.

Purpose: Informal care constitutes an important part of the total care for people with dementia. Therefore, the impact of the syndrome on their caregivers as well as that of health and social care services for people with dementia should be considered. This study investigated the convergent and clinical validity of the CarerQol instrument, which measures and values the impact of providing informal care, in a multi-country sample of caregivers for people with dementia. Methods: Cross-sectional data from a sample of 451 respondents in eight European countries, collected by the Actifcare project, were evaluated. Convergent validity was analysed with Spearman's correlation coefficients and multivariate correlations between the CarerQol-7D utility score and dimension scores, and other similar quality of life measures such as CarerQol-VAS, ICECAP-O, and EQ-5D. Clinical validity was evaluated by bivariate and multivariate analyses of the degree to which the CarerQol instrument can differentiate between characteristics of caregivers, care receivers and caregiving situation. Country dummies were added to test CarerQol score differences between countries. Results: The mean CarerQol utility score was 77.6 and varied across countries from 74.3 (Italy) to 82.3 (Norway). The scores showed moderate to strong positive correlations with the CarerQol-VAS, ICECAP-O, and EQ-5D health problems score of the caregiver. Multivariate regression analysis showed that various characteristics of the caregiver, care receiver and caregiving situation were associated with caregiver outcomes, but there was no evidence of a country-level effect. Conclusion: This study demonstrates the convergent and clinical validity of the CarerQol instrument to evaluate the impact of providing informal care for people with dementia.

__Objectives:__ The aim of this study was to assess the reliability, dimensionality and validity of the self-report questionnaire Health-Risk Attitude Scale (HRAS-13) in a sample of the general population and a patient population. __Methods:__ Sample 1 (_n_ = 930) was recruited from the general population aged 18–65 years in the Netherlands. Sample 2 (_n_ = 486) was recruited from the population of knee and hip osteoarthritis patients aged 45 and over, also from the Netherlands. Reliability was assessed using Cronbach’s alpha, average inter-item correlation and item-total correlations. Dimensionality was examined using confirmatory factor analysis (CFA), principal component analysis (PCA) and bifactor analysis. Validity was assessed by performing known-group analysis using ANOVA tests. __Results:__ Cronbach’s alphas of the HRAS-13 were 0.73 in sample 1 and 0.69 in sample 2. Reliability and dimensionality analyses differed slightly between the samples, and suggest that a short version of the HRAS may capture a general component of health-risk attitude. Validity assessment of known groups showed that the HRAS-13 and a likely HRAS-6 distinguished between subgroups of respondents based on most of the assessed characteristics, but not all. __Discussion:__ These findings are a preliminary indication that the HRAS-13 is a promising multidimensional instrument for measuring health-risk attitude. However, further research in various samples on decisions where health risks play a role is warranted to confirm the dimensionality of the HRAS-13 and the items to be retained in a full or a shorter version.

The Healthy Aging Index (HAI), an index of physiological aging, has been demonstrated to predicts mortality, morbidity and disability. We studied the longitudinal development of the HAI to identify aging trajectories and evaluated the role of baseline sociodemographic characteristics and lifestyle factors of the trajectories. Four measurements with intervals of 5 years were included from the Doetinchem Cohort Study. The HAI reflects levels of systolic blood pressure, non-fasting plasma glucose levels, global cognitive functioning, plasma creatinine levels and lung functioning. The HAI score ranges from 0 to 10: higher scores indicate a better health profile. Latent class mixture modelling was used to model within-person change and to identify aging trajectories. Area under the curve was calculated per trajectory to estimate total healthy years. In total, 2324 women and 2013 men were included. One HAI trajectory was identified for women, and two trajectories for men, labelled ‘gradual’ aging and ‘early’ aging. Men who were medium/high educated, below 36 years at baseline, complied with guidelines on physical activity and were not obese in any round were associated with increased odds to ‘gradual’ aging of 1.46, 1.93, 1.26 and 1.76, respectively. Between 30 and 70 years of age, men in the ‘early’ aging trajectory had the least healthy years, followed by women, and ‘gradual’ aging men. This study emphasizes that ‘physiological aging’ is not only an issue of older ages. Between 30 and 70 years of age, ‘early’ aging men and women had approximately five healthy years less compared to ‘gradual’ aging men. Lifestyle factors seem to play an important role in optimal aging.

Background: Epilepsy is associated with a high disease burden, impacting the lives of people with epilepsy and their caregivers and family. Persons with medically refractory epilepsy experience the greatest burden, suffering from profound physical, psychological, and social consequences. Anecdotal evidence suggests these persons may benefit from a seizure dog. As the training of a seizure dog is a substantial investment, their accessibility is limited in the absence of collective reimbursement as is seen in the Netherlands. Despite sustained interest in seizure dogs, scientific knowledge on their benefits and costs remains scarce. To substantiate reimbursement decisions stronger evidence is required. The EPISODE study aims to provide this evidence by evaluating the effectiveness and cost-effectiveness of seizure dogs in adults with medically refractory epilepsy. Methods: The study is designed as a stepped wedge randomized controlled trial that compares the use of seizure dogs in addition to usual care, with usual care alone. The study includes adults with epilepsy for whom current treatment options failed to achieve seizure freedom. Seizure frequency of participants should be at least two seizures per week, and the seizures should be associated with a high risk of injury or dysfunction. During the 3 year follow-up period, participants receive a seizure dog in a randomized order. Outcome measures are taken at multiple time points both before and after receiving the seizure dog. Seizure frequency is the primary outcome of the study and will be recorded continuously using a seizure diary. Questionnaires measuring seizure severity, quality of life, well-being, resource use, productivity, social participation, and caregiver burden will be completed at baseline and every 3 months thereafter. The study is designed to include a minimum of 25 participants. Discussion: This protocol describes the first randomized controlled trial on seizure dogs. The study will provide compre

To understand the public sentiment toward the measures used by policymakers for COVID-19 containment, a survey among representative samples of the population in seven European countries was carried out in the first two weeks of April 2020. The study addressed people’s support for containment policies, worries about COVID-19 consequences, and trust in sources of information. Citizens were overall satisfied with their government’s response to the pandemic; however, the extent of approval differed across countries and policy measures. A north-south divide in public opinion was noticeable across the European states. It was particularly pronounced for intrusive policy measures, such as mobile data use for movement tracking, economic concerns, and trust in the information from the national government. Considerable differences in people’s attitudes were noticed within countries, especially across individual regions and age groups. The findings suggest that the epidemic acts as a stressor, causing health and economic anxieties even in households that were not directly affected by the virus. At the same time, the burden of stress was unequally distributed across regions and age groups. Based on the data collected, we draw lessons from the containment stage and identify several insights that can facilitate the design of lockdown exit strategies and future containment policies so that a high level of compliance can be expected.

In this editorial, we provide some first insights into this willingness to be vaccinated, based on a multi-country European study.

__Background:__ The CarerQol instrument can be used in economic evaluations to measure the care-related quality of life of informal caregivers. Tariff sets are available for Australia, Germany, Sweden, the Netherlands, the UK, and the USA. __Objective:__ Our objective was to develop tariff sets for the CarerQol instrument for Hungary, Poland and Slovenia and to compare these with the existing value sets. __Methods:__ Discrete-choice experiments were carried out in Hungary, Poland and Slovenia. Data were collected through an online survey between November 2018 and January 2019, using representative samples of 1000 respondents per country. Tariffs were calculated from coefficient estimates from panel mixed multinomial logit models with random parameters. __Results:__ All seven CarerQol domains contributed significantly to the utility associated with different caregiving situations. Attributes valued highest were ‘physical health’

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, whic

Early warning systems for infectious diseases and foodborne outbreaks are designed with the aim of increasing the health safety of citizens. As a first step to determine whether investing in such a system offers value for money, this study used contingent valuation to estimate people’s willingness to pay for such an early warning system in six European countries. The contingent valuation experiment was conducted through online questionnaires administered in February to March 2018 to cross-sectional, representative samples in the UK, Denmark, Germany, Hungary, Italy, and The Netherlands, yielding a total sample size of 3140. Mean willingness to pay for an early warning system was €21.80 (median €10.00) per household per month. Pooled regression results indicate that willingness to pay increased with household income and risk aversion, while they decreased with age. Overall, our results indicate that approximately 80–90% of people would be willing to pay for an increase in health safety in the form of an early warning system for infectious diseases and food-borne outbreaks. However, our results have to be interpreted in light of the usual drawbacks of willingness to pay experiments.

__Background__ The ICECAP-O and the ICECAP-A are validated capability well-being instruments. To be used in economic evaluations, multidimensional instruments require weighting of the distinguished well-being states. These weights are usually obtained through ex ante preference elicitation (i.e., decision utility) but could also be based on experienced utility. __Objective__ This article describes the development of value sets for ICECAP-O and ICECAP-A based on experienced utility and compares them with current decision utility weights. __Methods__ Data from 2 cross-sectional samples corresponding to the target groups of ICECAP-O and ICECAP-A were used in 2 separate analyses. The utility impacts of ICECAP-O and ICECAP-A levels were assessed through regression models using a composite measure of subjective well-being as a proxy for experienced utility. The observed utility impacts were rescaled to match the 0 to 1 range of the existing value set. __Results__ The calculated experienced utility values were similar to the decision utility weights for some of the ICECAP dimensions but deviated for others. The largest differences were found for weights of the ICECAP-O dimension enjoyment and the ICECAP-A dimensions attachment and autonomy. __Conclusions__

Objective: The objective of this systematic review was to review the available evidence on the disparity between willingness to accept (WTA) and willingness to pay (WTP) for healthcare goods and services. Methods: A tiered approach consisting of (1) a systematic review, (2) an aggregate data meta-analysis, and (3) an individual participant data meta-analysis was used. MEDLINE, EMBASE, Scopus, Scisearch, and Econlit were searched for articles reporting both WTA and WTP for healthcare goods and services. Individual participant data were requested from the authors of the included studies. Results: Thirteen papers, reporting WTA and WTP from 19 experiments/subgroups, were included in the review. The WTA/WTP ratios reported in these papers, varied from 0.60 to 4.01, with means of 1.73 (median 1.31) for 15 estimates of the mean and 1.58 (median 1.00) for nine estimates of the median. Individual data obtained from six papers, covering 71.2% of the subjects included in the review, yielded an unadjusted WTA/WTP ratio of 1.86 (95% confidence interval 1.52–2.28) and a WTA/WTP ratio adjusted for age, sex, and income of 1.70 (95% confidence interval 1.42–2.02). Income category and age had a statistically significant effect on the WTA/WTP ratio. The approach to handling zero WTA and WTP values has a considerable impact on the WTA/WTP ratio found. Conclusions and Implications: The results of this study imply that losses in healthcare goods and services are valued differently from gains (ratio > 1), but that the degree of disparity found depends on the method used to obtain the WTA/WTP ratio, including the approach to zero responses. Irrespective of the method used, the ratios found in our meta-analysis are smaller than the ratios found in previous meta-analyses.

__Background:__ Epilepsy is associated with a high disease burden, impacting the lives of people with epilepsy and their caregivers and family. Persons with medically refractory epilepsy experience the greatest burden, suffering from profound physical, psychological, and social consequences. Anecdotal evidence suggests these persons may benefit from a seizure dog. As the training of a seizure dog is a substantial investment, their accessibility is limited in the absence of collective reimbursement as is seen in the Netherlands. Despite sustained interest in seizure dogs, scientific knowledge on their benefits and costs remains scarce. To substantiate reimbursement decisions stronger evidence is required. The EPISODE study aims to provide this evidence by evaluating the effectiveness and cost-effectiveness of seizure dogs in adults with medically refractory epilepsy. __Methods:__ The study is designed as a stepped wedge randomized controlled trial that compares the use of seizure dogs in addition to usual care, with usual care alone. The study includes adults with epilepsy for whom current treatment options failed to achieve seizure freedom. Seizure frequency of participants should be at least two seizures per week, and the seizures should be associated with a high risk of injury or dysfunction. During the 3 year follow-up period, participants receive a seizure dog in a randomized order. Outcome measures are taken at multiple time points both before and after receiving the seizure dog. Seizure frequency is the primary outcome of the study and will be recorded continuously using a seizure diary. Questionnaires measuring seizure severity, quality of life, well-being, resource use, productivity, social participation, and caregiver burden will be completed at baseline and every 3 months thereafter. The study is designed to include a minimum of 25 participants. __Discussion:__ This protocol describes the first randomized controlled trial on seizure dogs. The study will pr

How we perceive the future can greatly affect how we feel in the present. Even a currently positive situation is hard to bear when we know the future will be grim. Indeed, previous research has found that more hopeful people are happier. However, both hope and subjective well-being are multidimensional concepts comprising emotion (i.e., anticipation and affect), cognition (expectation and satisfaction) and, to some degree, motivation. Since most studies include only one dimension of hope and subjective well-being, little is known about how different aspects of hope relate to different aspects of subjective well-being. This study aims to gain insight into these relationships by providing an overview of the existing empirical literature on hope and subjective well-being. Subsequently, cross-sectional data of a representative sample of the American population are used to further examine the relationship between hope and subjective well-being. Our findings from both the literature and our empirical analysis show that positive expectations are only weakly associated with all domains of subjective well-being, whereas cognitive and emotional hope are most strongly related to subjective well-being. This finding indicates that the more passive characteristics of positive expectations have less of an impact on subjective well-being than a more agentic hopeful disposition.

Recent advances in computer-aided text analysis (CATA) have allowed organizational scientists to construct reliable and convenient measures from open texts. As yet, there is a lack of research into using CATA to analyze responses to open survey questions and constructing text-based measures of psychological constructs. In our study, we demonstrated the potential of CATA methods for the construction of text-based job satisfaction measures based on responses to a completely open and semi-open question. To do this, we employed three sentiment analysis techniques: Linguistic Inquiry and Word Count 2015, SentimentR and SentiStrength, and quantified the forms of measurement error they introduced: specific factor error, algorithm error and transient error. We conducted an initial test of the textbased measures' validity, assessing their convergence with closed-question job satisfaction measures. We adopted a time-lagged survey design (Nwave 1 = 996; Nwave 2 = 116) to test our hypotheses. In line with our hypotheses, we found that specific factor error is higher in the open question text-based measure than in the semi-open question text-based measure. As expected, algorithm error was substantial for both the open and semi-open question textbased measures. Transient error in the text-based measures was higher than expected, as it generally exceeded the transient error in the human-coded and the closed job satisfaction question measures. Our initial test of convergent and discriminant validity indicated that the semi-open question text-based measure is especially suitable for measuring job satisfaction. Our article ends with a discussion of limitations and an agenda for future research.

A deliberative citizens panel was held to obtain insight into criteria considered relevant for healthcare priority setting in the Netherlands. Our aim was to examine whether and how panel participation influenced participants’ views on this topic. Participants (n = 24) deliberated on eight reimbursement cases in September and October, 2017. Using Q methodology, we identified three distinct viewpoints before (T0) and after (T1) panel participation. At T0, viewpoint 1 emphasised that access to healthcare is a right and that prioritisation should be based solely on patients’ needs. Viewpoint 2 acknowledged scarcity of resources and emphasised the importance of treatment-related health gains. Viewpoint 3 focused on helping those in need, favouring younger patients, patients with a family, and treating diseases that heavily burden the families of patients. At T1, viewpoint 1 had become less opposed to prioritisation and more considerate of costs. Viewpoint 2 supported out-of-pocket payments more strongly. A new viewpoint 3 emerged that emphasised the importance of cost-effectiveness and that prioritisation should consider patient characteristics, such as their age. Participants’ views partly remained stable, specifically regarding equal access and prioritisation based on need and health gains. Notable changes concerned increased support for prioritisation, consideration of costs, and cost-effectiveness. Further research into the effects of deliberative methods is required to better understand how they may contribute to the legitimacy of and public support for allocation decisions in healthcare.

Background: Patients with palliative care needs, require support with their physical needs, but also with their emotional, spiritual and social needs. Patient-Centred Care (PCC) may help organizations to support these patients according to their needs and so improve the quality of care. PCC has been shown to consist of eight dimensions, including for instance access to care and continuity of care, but these eight dimensions may not be equally important in all care settings and to all patients. Furthermore, the views of those involved in care provision may affect the choices they make concerning care and support to patients. Therefore, insight into how professionals and volunteers involved in palliative care delivery view PCC is important for understanding and improving the quality of care in the palliative sector. Methods: This study was conducted in the palliative care setting (hospices and hospitals) in the Netherlands. Views on palliative care were investigated using the Q-methodology. Participants were asked to rank 35 statements that represented the eight dimensions of PCC in palliative care settings, and to explain their ranking during a follow-up interview. Ranking data were analysed using by-person factor analysis. Interview materials were used to help interpret the resulting factors. Results: The analysis revealed two distinct viewpoints on PCC in palliative care: 'The patient in the driver seat', particularly emphasizing the importance of patient autonomy during the last phase of life, and 'The patient in the passenger seat', focussed on the value of coordination between professionals, volunteers and patients. Conclusions: The most distinguishing aspect between views on PCC in palliative care concerned control; a preference for the patient in the driver's seat versus shared decision-making by a team consistin

Background: Integrating patient preferences in Health Technology Assessment (HTA) is argued to improve uptake, adherence, and patient satisfaction. However, how to elicit and incorporate these preferences in HTA in a systematic and scientifically valid manner is subject to debate. Objective: This article provides a systematic review of the challenges to integrating patient preferences in HTA that have been raised in the literature about patient preferences in HTA. Methods: A systematic review of articles published between 2013 and 2017 addressing challenges to the integration of patient preferences in HTA was conducted in 7 databases. All issues with respect to the integration of patient preferences in HTA were extracted and divided into 5 categories: conceptual, norma

Population ageing and restricted budgets result in the need for an efficient allocation of scarce resources in care services for older people. As these services tend to address more than only health, diverse wellbeing measures have been developed to assess their benefits in economic evaluations. These measures are grounded in research on wellbeing of older people and its determinants. Little is known about possible heterogeneity in this context and the extent to which wellbeing measures cover the aspects of wellbeing that are most important to older people with different views on wellbeing. We conducted a Q-methodology study between December 2016 and October 2017 to investigate the variety in views among people aged 65 and older in the Netherlands on what is important to their wellbeing. A purposive sample of 53 respondents ranked 34 opinion statements according to importance to their wellbeing and explained their ranking during a follow-up interview. Data were analysed using by-person factor analysis to identify common patterns in the rankings of the statements. Five distinct views were extracted in which different aspects were considered important: (I) health, financial security and a lif

Background: Some studies in the Netherlands have gauged public views on principles for health care priority setting, but they fall short of comprehensively explaining the public disapproval of several recent reimbursement decisions. Objective: To obtain insight into citizens’ preferences and identify the criteria they would propose for decisions pertaining to the benefits package of basic health insurance. Methods: Twenty-four Dutch citizens were selected for participation in a Citizen Forum, which involved 3 weekends. Deliberations took place in small groups and in plenary, guided by 2 moderators, on the basis of 8 preselected case studies, which participants later compared and prioritized under the premise that not all treatments can or need to be reimbursed. Participants received opportunities to inform themselves through written brochures and live interactions with 3 experts. Results: The Citizen Forum identified 16 criteria for inclusion or exclusion of treatments in the benefits package; they relate to the condition (2 criteria), treatment (11 criteria), and individual characteristics of those affected by the condition (3 criteria). In most case studies, it was a combination of criteria that determined whether or not participants favored inclusion of the treatment under consideration in the benefits package. Participants differed in their opinion about the relative importance of criteria, and they had difficulty in operationalizing and trading off criteria to provide a recommendation. Conclusions: Informed citizens are prepared to make and, to a certain extent, capable of making reasoned choices about the reimbursement of health services. They realize that choices are both necessary and possible. Broad public support and understanding for making tough choices regarding the benefits package of basic health insurance is not automatic: it requires an investment.

Purpose The pressure on healthcare budgets remains high, partially due to the ageing population. Economic evaluation can be a helpful tool to inform resource allocation in publicly financed systems. Such evaluations frequently use health-related outcome measures. However, in areas such as care of older people, improving health outcomes is not necessarily the main focus of care interventions and broader outcome measures, including outcomes for those providing informal care, may be preferred when evaluating such interventions. This paper validates a recently introduced well-being measure, the ICECAP-O, in a population of informal carers for people with dementia from eight European countries. Methods Convergent and discriminant validity tests were performed to validate the ICECAP-O using data obtained in a sample of 451 respondents from Germany, Ireland, Italy, the Netherlands, Norway, Portugal, Sweden and the UK. These respondents completed a number of standardized questionnaires within the framework of the Actifcare project. Results The ICECAP-O performed well among informal carers, in terms of both convergent and discriminant validity. In the multivariate analysis, it was found to be significantly associated with the age of the person with dementia, EQ-5D-5L health problem index of the person with dementia, carer–patient relationship, care recipient CDR, carer LSNS Score, the PAI score, and Perseverance Time. Conclusion The ICECAP-O appears to be a valid measure of well-being in informal carers for people with dementia. The ICECAP-O may therefore be useful as an outcome measure in economic evaluations of interventions aimed at such informal carers, when these aim to improve well-being beyond health.

Objective In the last 30 years, innovations in oral healthcare (OHC), such as advanced restorative techniques, shifts towards preventive and evidence-based care and changes in patients’ expectations, have increased the complexity of clinical decision-making in OHC. Little is known about the perspectives of general dental practitioners (GDPs) on the value of providing preventive, patient-centred and evidence-based OHC. This study aimed to explore the range of perspectives present amongst GDPs on OHC. Method Q-methodology was used to explore perspectives among 78 GDPs working in the Netherlands. Participants were asked to sort 50 statements representing three central domains in OHC: i.) restorative versus preventative OHC, ii.) disease-centred versus patient-centred OHC and iii.) expertise-based versus evidence-based OHC. Opinion statements about delivering OHC were formulated on the basis of published literatu

In many countries, such as the US, Germany, France, and the Netherlands, governments are dealing with a great shortage of organ donors. Even though people generally show positive attitudes towards organ donation, they often do not actually register as organ donors themselves. This study’s objective was to explore prevailing viewpoints among the Dutch population on deceased organ donation and the relation between aspects of the viewpoints potentially influencing the decision to register as an organ donor. Although substantive research about attitudes on organ donation has been conducted, this is the first study investigating people’s viewpoints focusing on the relation between beliefs, tastes, preferences, motives, goals and other constituents underlying people’s viewpoints on organ donation, such as the role of the media and public policies. This Q-methodology study revealed four viewpoints: “not donating your organs is a waste”, “it does not go with my religion”, “my family should decide”; and “it’s a good deed, but I’m doubtful”. These viewpoints convey informati

Medical leadership is an increasingly important aspect of hospital management. By engaging physicians in leadership roles, hospitals aim to improve their clinical and financial performances. Research has revealed numerous factors that are regarded as necessary for ‘medical leaders’ to master, however we lack insights into their relative importance. This study investigates the views of healthcare professionals and managers on what they consider the most important factors for medical leadership. Physicians (n = 11), nurses (n = 10), laboratory technicians (n = 4) and managers (n = 14) were interviewed using Q methodology. Participants ranked 34 statements on factors elicited from the scientific literature, including personal features, context-specific features, activities and roles. By-person factor analysis revealed three distinct views of medical leadership. The first view represents a strategic leader who prioritizes the interests of the hospital by participating in hospital strategy and decision making. The second view describes a social leader with strong collaboration and communication skills. The third view reflects an accepted leader among peers that is guided by a clear job description. Despite these differences, all respondents agreed upon the importance of personal skills in collaboration and communication, and having integrity and a clear vision. We find no differences in views related to particular healthcare professionals, managers, or departments as all views were defined by a mixture of departments and participants. The findings contribute to increased calls from both practice and literature to increase conceptual clarity by eliciting the relative importance of medical leadership-related factors. Hospitals that wish to increase the engagement of physicians in improving clinical and financial performances through medical leadership should focus on selecting and developing leaders who are strong strategists, socially skilled and accepted by clinical peer

Improving (feelings of) safety is an important goal of many health systems, especially in the context of recurrent threats of pandemics, and natural disasters. Measures to improve safety should be cost-effective, raising the issue of how to value safety. This is a complex task due to the intangible nature of safety. We aim to synthesize the current empirical literature on the evaluation of safety to gain insights into current methodological practices. After a thorough literature search in two databases for papers from the fields of life sciences, social sciences, physical sciences and health sciences that empirically measure the value of increasing safety, 33 papers were found and summarized. The focus of the research was to investigate the methodologies used. Attention was also paid to theoretical papers and the methodological issues they present, and the relationship between safety and three categories of covariate results: individual characteristics, individual relationship with risk, and study design. The field of research in which the most papers were found was environmental economics, followed by transportation and health. There appeared to be two main methods for valuating safety: Contingent Valuation and Discrete Choice Experiments, within which there were also differences—for example the use of open or dichotomous choice questions. Overall this paper finds that there still appears to be a long way ahead before consensus can be attained abou

Background: Families and friends provide a considerable proportion of care for patients and elderly people. Caregiving can have substantial effects on caregivers’ lives, health, and well-being. However, because clinical trials rarely assess these effects, no information on caregiver burden is available when evaluating the cost effectiveness of treatments. Objective: This study develops an algorithm for estimating caregiver time using information that is typically available in clinical trials: the EQ-5D scores of patients and their gender. Methods: Four datasets with a total of 8012 observations of dyads of caregivers and a gamma model with a log-link estimated with the Bayesian approach were used to estimate the statistical association between patient scores on the EQ-5D-3L dimensions and the numbers of hours of care provided by caregivers during the previous week. The model predicts hours of care as mean point estimates with 95% credible intervals or entire distributions. Results: Model predictions of hours of care based on the five EQ-5D dimensions ranged from 13.06 (12.7–14.5) h/week for female patients reporting no health problems but receiving informal care to 52.82 (39.38–66.26) for male patients with the highest level of problems on all EQ-5D dimensions. Conclusions: The iCARE algorithm developed in this study allows researchers who only have patient-level EQ-5D data to estimate the mean hours of informal care received per week, including a 95% Bayesian credible interval. Caregiver time can be multiplied with a monetary value for caregiving, enabling the inclusion of informal care costs in economic evaluations. We recommend using the tool for samples that fall within the confidence intervals of the characteristics of our samples: men (age range 47.0–104.2 years), women (age range 55–103 years).

Purpose: The ICEpop CAPability measure for Older people (ICECAP-O) is intended for use in economic evaluations of care services for older people. Although studies support the validity of the ICECAP-O, it does not directly ask older people about their health. This raises questions about its ability to capture health indirectly. Previous studies found mixed results in this aspect, especially for physical health. This study further investigates whether the ICECAP-O indirectly includes health. Methods: Using a cross-sectional design, a sampling agency retrieved data from 516 people aged 70 and older from the UK through an online questionnaire. The overlap in underlying constructs of the ICECAP-O and EQ-5D-5L was assessed using exploratory factor analysis. Spearman correlations and variance analysis were conducted by relating the ICECAP-O to measures of physical, mental and social functioning. Results: The ICECAP-O and EQ-5D-5L items loaded on two factors. Their overlap was limited, as four out of five EQ-5D-5L items loaded on the first factor, while four out of five ICECAP-O items loaded on the second. The ICECAP-O correlated highly with (mental and social functioning) health measures, and was able to differentiate between individuals with different scores on these measures. However, the correlation with the Barthel Index, a measure of physical functioning, was moderate. Conclusions: The ICECAP-O may not fully cover all aspects of health. Therefore, a complementary health measure should be used in addition to the ICECAP-O to capture the full benefits of care interventions for older people in economic evaluations.

__Background__ Interventions in health care often not only have an efect on patients, but also on their informal caregivers. Caregiving can have a profound impact on the health and wellbeing of carers. Ignoring these spillovers in economic evaluations risks labelling interventions mistakenly as cost-efective, at the expense of informal caregivers. __Objective__ This paper investigates willingness-to-accept (WTA) values for an hour of informal care, corrected for positive and negative impacts of informal care, to facilitate the inclusion of informal care hours on the cost side of economic evaluations without double-counting spillover efects. __Methods__ A discrete choice experiment (DCE) was conducted among a representative sample of the adult population in the Netherlands (n=552) in September 2011. An experimental design minimizing the D-error was used to construct choice sets with two unlabelled alternatives with the attributes ‘hours caregiving’, ‘monetary compensation for caregiving’ and seven impacts of caregiving. To operationalize the random utility model, we used a panel mixed multinomial logit (MMNL) parameter model. For calculation of WTA, we used both population-level parameters and individual-level parameters. __Results__ The mean WTA for an additional hour of informal care, corrected for positive and negative impacts of informal care, was €14.57. The signs of the coefcients were all in the expected directions. __Conclusions__ This study reports a preference-based monetary value for informal care, corrected for other impacts. This valuation facilitates the inclusion of informal care hours on the cost side in economic evaluations without double-counting any spillover efects included on the efects side.

Health problems may cause decreased productivity among working people. It is unclear if this also applies for people living with HIV (PLWH). This cross-sectional study compares data of PLWH of one of the main HIV treatment centres in the Netherlands (n = 298) to data of the general working population from a previously conducted study (n = 986). We investigate whether productivity at work differs between these groups. The questionnaires used in these studies contained a core of identical questions regarding productivity losses, in the form of absenteeism and presenteeism, over a four-week period and a variety of baseline characteristics, including health status measured with EQ-5D. For PLWH additional clinical data were collected from patient records. From the data, descriptive statistics were computed to characterize the samples. Pearson correlations were used to explore significant associations of productivity with baseline characteristics. A two-part model was used to evaluate both the occurrence and of size of productivity losses in working PLWH and an aggregated sample of PLWH and the general population. It was observed that, on average, total productivity losses do not differ significantly between working PWLH and the

__Introduction__ Policy makers increasingly need to prioritise between competing health technologies or patient populations. When aiming to align allocation decisions with societal preferences, knowledge and operationalisation of such preferences is indispensable. This study examines the distribution of three views on healthcare priority setting in the Netherlands, labelled "Equal right to healthcare", "Limits to healthcare", and "Effective and efficient healthcare", and their relationship with preferences in willingness to trade-off (WTT) exercises. __Methods__ A survey including four reimbursement scenarios was conducted in a representative sample of the adult population in the Netherlands (n = 261). Respondents were matched to one of the three views based on their agreement with 14 statements on principles for resource allocation. We tested for WTT differences between respondents with different views and applied logit regression models for examining the relationship between preferences and background characteristics, including views. __Results__ Nearly 65% of respondents held the view "Equal right to healthcare", followed by "Limits to healthcare" (22.5%), and "Effective and efficient healthcare" (7.1%). Most respondents (75.9%) expressed WTT in at least one scenario and preferred gains in quality of life over life expectancy, maximising gains over limiting inequality, treating children over elderly, and those with adversity over those with an unhealthy lifestyle. Various background characteristics, including the views, were associated with respondents' preferences. __Conclusions__ Most respondents held an egalitarian view on priority setting, yet the majority was willing to prioritise regardless of their view. Societal views and preferences concerning healthcare priority setting are related. However, respondents' views influence preferences differently in different reimbursement scenarios. As societal views and preferences are heterogeneous and may conflict, ali

Preference elicitation studies reporting societal views on the relative value of end-of-life treatments have produced equivocal results. This paper presents an alternative method, combining Q methodology and survey techniques (Q2S) to determine the distribution of 3 viewpoints on the relative value of end-of-life treatments identified in a previous, published, phase of this work. These were Viewpoint 1, “A population perspective: value for money, no special cases”; Viewpoint 2, “Life is precious: valuing life-extension and patient choice”; and Viewpoint 3, “Valuing wider benefits and opportunity cost: the quality of life and death.”. A Q2S survey of 4,902 respondents across the United Kingdom measured agreement with these viewpoints; 37% most agreed with Viewpoint 1, 49% with Viewpoint 2, and 9% with Viewpoint 3. Regression analysis showed associations of viewpoints with gender, level of education, religion, voting preferences, and satisfaction with the NHS. The Q2S approach provides a promising means to investigate how in-depth views and opinions are represented in the wider populatio

The increasing demand for healthcare and the resulting pressure on available budgets render priority setting inevitable. If societies aim to improve health and distribute health(care) fairly, equity-efficiency trade-offs are necessary. In the Netherlands, proportional shortfall (PS) was introduced to quantify necessity of care, allowing a direct equity-efficiency trade-off. This study describes the history and application of PS in the Netherlands and examines the theoretical and empirical support for PS as well as its current role in healthcare decision making. We reviewed the international literature on PS from 2001 onwards, along with publicly accessible meeting reports from the Dutch appraisal committee, Adviescommissie Pakket (ACP), from 2013 to 2016. Our results indicate that there is support for the decision model in which necessity is quantified and incremental cost-effectiveness ratios are evaluated against associated monetary reference values. The model enables a uniform framework for priority setting across all healthcare sectors. Although consensus about the application of PS has not yet been reached and alternative ways to quantify necessity were found in ACP reports, PS has increasingly been applied in decision making since 2015. However, empirical support for PS is limited and it may insufficiently reflect societal preferences regarding age and reducing lifetime-health inequalities. Hence, further investigation into refining PS—or exploration of another approach—appears warranted for operationalising the equity-efficiency trade-off.

Background: Informal care is essential for many people with dementia (PwD), but it often results in a considerable burden for the caregiver. The perseverance time instrument integrates the aspect of perceived burden with the caregiver’s capacity to cope with the burden, in contrast to most available instruments, which measure solely the burden of caregiving. The aim of this study was to extend insight into psychometric properties of the perseverance time instrument, specifically the construct validity, responsiveness, and predictive validity, within the population of informal caregivers for PwD. Methods: Data from two studies among informal caregivers of community-dwelling PwD in the Netherlands were used. The first study included 198 caregivers from a single region in the Netherlands and lasted 1 year. The second was a cross-sectional nationwide study with 166 caregivers for PwD. Questionnaires of both studies included questions regarding demographics and informal care, perseverance time, and other informal caregiver outcomes (Caregiver Strain Index, Self-rated Burden scale, Care-related Quality of Life instrument, and visual analogue scale health scores). Construct validity and responsiveness were assessed using a hypothesis-testing approach. The predictive validity of demographic characteristics and perseverance time for living situation after 1 year (living at home, institutionalized, or deceased) was assessed with multivariable multinomial regression. Results: All but one of the hypotheses regarding construct validity were met. Three of five hypotheses regarding responsiveness were met. Perseverance time scores at baseline were associated with living situation after 1 year (p < 0.01), unlike age, sex, and relationship with PwD. Perseverance time strongly increased predictive power for living situation after 1 year (c-index between 0.671 and 0.775) in addition to demographic characteristics. Conclusions: This study supports previous findings regarding the constr

Background: Informal care is essential for many people with dementia (PwD), but it often results in a considerable burden for the caregiver. The perseverance time instrument

Students feel insufficiently supported in clinical environments to engage in active learning and achieve a high level of self-regulation. As a result clinical learning is highly demanding for students. Because of large differences between students, supervisors may not know how to support them in their learning process. We explored patterns in undergraduate students’ self-regulated learning behavior in the clinical environment, to improve tailored supervision, using Q-methodology. Q-methodology uses features of both qualitative and quantitative methods for the systematic investigation of subjective issues by having participants sort statements along a continuum to represent their opinion. We enrolled 74 students between December 2014 and April 2015 and had them characterize their learning behavior by sorting 52 statements about self-regulated learning behavior and explaining their response. The statements used for the sorting were extracted from a previous study. The data was analyzed using by-person factor analysis to identify clusters of individuals with similar sorts of the statements. The resulting factors and qualitative data were used to interpret and describe the patterns that emerged. Five resulting patterns were identified in students’ self-regulated learning behavior in the clinical environment, which we labelled: Engaged, Critically opportunistic, Uncertain, Restrained and Effortful. The five patterns varied mostly regarding goals, metacognition, communication, effort, and dependence on external regulation for learning. These discrete patterns in students’ self-regulated learning behavior in the clinical environment are part of a complex interaction between student and le

In this paper we empirically investigate how to appropriately model utility of wealth and health. We use a recently proposed alternative approach to value willingness to pay (WTP) for health, making use of trade-offs between income and life years or quality of life, which we extend to allow for a more realistic multiplicative utility function over health and money. Moreover, we show how reference-dependency can be incorporated into this model and derive its predictions for WTP elicitation. We propose three experimental elicitation procedures and test these in a feasibility study, analysing the responses under different assumptions about the discount rate. Several interesting results are reported: first, the data are highly skewed, but if we trim the 5% lowest and highest values, we obtain plausible WTP estimates. Second, the results differ considerably between procedures, indicating that WTP estimates are sensitive to the assumed utility function. Third, respondents appear to be loss averse for both health and money, which is consistent with assumptions from prospect theory. Finally, our results also indicate that respondents are more willing to trade quality of life than life years.

Understanding subjective longevity expectations is important, but measurement is not straightforward. Two common elicitation formats are the direct measurement of a subjective point estimate of life expectancy and the assessment of survival probabilities to a range of target ages. This study presents one of the few direct comparisons of these two methods. Results from a representative sample of the Dutch population indicate that respondents on average gave higher estimates of longevity using survival probabilities (83.6 years) compared to point estimates (80.2 years). Individual differences between elicitation methods were smaller for younger respondents and for respondents with a higher socioeconomic status. The correlation between the subjective longevity estimations was moderate, but their associations with respondents’ characteristics were similar. Our results are in line with existing literature and suggest that findings from both elicitation methods may not be directly comparable, especially in certain subgroups of the population. Implications of inconsistent and focal point answers, rounding and anchoring require further attention. More research on the measurement of subjective expectations is required.