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Purpose: To develop a multidisciplinary outpatient rehabilitation intervention for people with neuromuscular diseases (NMD) based on the capability approach: capability care for persons with NMD., Materials and Methods: The development process is described using a framework of actions for intervention development. It has been an iterative process consisting of a design phase based on theoretical insights and project group discussions, and a refine phase involving input from relevant stakeholders., Results: Multidisciplinary efforts have resulted in the development of capability care for rehabilitation of persons with NMD. It can focus both on facilitating and achieving functionings (beings and doings), as well as looking for alternative functionings that fulfil the same underlying value, thereby contributing to the persons' well-being. To facilitate a conversation on broader aspects that impact on well-being, persons with NMD receive a preparation letter and healthcare professionals are provided with guiding questions and practical tools to use., Conclusions: We have shown that it is possible to develop a healthcare intervention based on the capability approach. We hope that rehabilitation professionals will be encouraged to use capability care and that other medical professionals will be inspired to develop capability care in their respective fields., Registration: Registered at trialregister.nl NL8946.

Objective: The aim of this report was to describe the history of health technology assessment (HTA) in The Netherlands., Methods: This article is a descriptive review from two people who have been very much involved in the events described and is based on review of relevant policy documents and Web sites., Results: HTA has been progressively developed in The Netherlands since (at least) the early 1980s. Beginning in 1985, there were progressive attempts to expand and institutionalized HTA in The Netherlands healthcare system. These attempts were generally successful, but did not result in a national agency for HTA. An important development in HTA in The Netherlands was a special fund (Ontwikkelingsgeneeskunde) designed to support prospective HTAs with the main purpose of affecting insurance coverage decisions. The administration of this fund moved progressively to broaden the subjects chosen for analysis to include such subjects as chronic illness and disability. A more-or-less hidden conflict developed in the question of the leadership and orientation of this fund, with the result that it was largely moved to a more research-oriented and less policy-oriented site., Conclusions: The situation today is that HTA is visible and is used by the government in policy decisions, especially in the areas of prevention and screening. In addition, HTA is influential in insurance coverage decision making, especially in the field of pharmaceuticals. The principles of HTA and evidence-based medicine are generally familiar to physicians and other clinicians, however, the influence of HTA on clinical and administrative decisions is less than in some other countries.

Objectives: Investments in health research should lead to improvements in health and health care. This is also the remit of the main HTA program in the Netherlands. The aims of this study were to assess whether the results of this program have led to such improvements and to analyze how best to assess the impact from health research., Methods: We assessed the impact of individual HTA projects by adapting the "payback framework" developed in the United Kingdom. We conducted dossier reviews and sent a survey to principal investigators of forty-three projects awarded between 2000 and 2003. We then provided an overview of documented output and outcome that was assessed by ten HTA experts using a scoring method. Finally, we conducted five case studies using information from additional dossier review and semistructured key informant interviews., Results: The findings confirm that the payback framework is a useful approach to assess the impact of HTA projects. We identified over 101 peer reviewed papers, more than twenty-five PhDs, citations of research in guidelines (six projects), and implementation of new treatment strategies (eleven projects). The case studies provided greater depth and understanding about the levels of impact that arise and why and how they have been achieved., Conclusions: It is generally too early to determine whether the HTA program led to actual changes in healthcare policy and practice. However, the results can be used as a baseline measurement for future evaluation and can help funding organizations or HTA agencies consider how to assess impact, possibly routinely. This, in turn, could help inform research strategies and justify expenditure for health research.

The resources for health technology assessment fall short of that needed to evaluate all health technologies. Therefore, priorities have to be set. In The Netherlands, the Health Care Insurance Board tried to address this issue by developing a more explicit priority setting procedure for the Fund for Investigative Medicine, which is the most important health technology assessment programme in The Netherlands. The procedure provides one of the first examples of the application of theoretical principles for priority setting. The aim is to select those health technologies for assessment that are most relevant for policy-making. To determine the policy relevance of research proposals, different procedures for categorising, scoring, and weighting policy criteria were defined, and different classification strategies were explored. Our first experiences using the priority setting procedure are described by means of an example on low back pain. Subsequently, the procedure has been applied to research proposals submitted to the Fund for Investigative Medicine in 1998 to illustrate how decisions on the funding of health technology assessments can be guided. The results show a different rating of research proposals into one of three predefined categories of policy relevance, high, intermediate and low, implying that decisions about funding can heavily dependent on the selected procedure. Therefore, it seems to be important that the selected procedure reflects the viewpoint of the organisation wishing to set priorities. The different ratings of the research proposals using a more explicit procedure suggest that there may be scope for further development and application of the procedure.

The classical clinical signs of deep vein thrombosis (DVT) are unspecific and may be found in several other conditions besides DVT. Therefore, patients suspicious of DVT are subjected to elaborate invasive or noninvasive evidence-based procedures that actually confirm DVT in only 20% to 30% of patients in this setting. However, simple laboratory tests and noninvasive strategies to exclude and diagnose DVT are becoming available in the clinical emergency setting of outpatients. In the presented literature, a sound basis is provided for quantifying clinical judgment for the diagnosis of acute proximal DVT. The number of positive clinical findings at time of first suspicion of DVT appears to correlate directly with the probability of acute proximal DVT. The modified clinical model of Landefeld and Wells for DVT allows reasonable accurate classification of patients into low, moderate, and high probability for suffering DVT. The rapid automated enzyme-linked immunoabsorbant assay (ELISA) VIDAS D-dimer presently available can be rapidly performed in daily practice and emergency situations and is accurate to a high degree, especially in ruling out ongoing venous thromboembolic processes. The sequential use of the rapid ELISA VIDAS D-dimer test and compression ultrasonography in a well-designed clinical setting using a simple clinical model predicts a significant improvement due to a high sensitivity near 100% for the exclusion and diagnosis of DVT in the majority of outpatients with suspect DVT. A prospective decision analysis management study is proposed to exclude and diagnose DVT based on the rapid ELISA VIDAS D-dimer test and compression ultrasonography within the context of a ready-to-use simple clinical model. The proposed simple model of a rational diagnosis of deep vein thrombosis (RADIA DVT) has to be tested in a large multicenter study of more than 1,000 outpatients with suspected DVT. This model would be less expensive, easy to perform, and likely yield a significant simplification and improvement of highly accurate evidence-based exclusion or diagnosis of DVT on the basis of which clear-cut indications of anticoagulation could be appropriately initiated or safely withheld.

Priority setting for the evaluation of health technologies in the Netherlands is exclusively based on the scientific merits of individual research proposals. This process has not resulted in satisfactory allocation of resources. Therefore, societal criteria for setting priorities for health technology assessment have been proposed as an adjunct to scientific criteria. These societal criteria include the burden of disease, uncertainty about the (cost-)effectiveness of the intervention at issue, the potential benefits of the research project, and its potential impact on health care. To realize the full potential of this model for priority setting, a number of methodological issues need to be addressed. Joint efforts of researchers and policy makers in this field are necessary for future progress.