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Background Preeclampsia is a female-specific risk factor for the development of future cardiovascular disease. Whether early preventive cardiovascular disease risk screenings combined with risk-based lifestyle interventions in women with previous preeclampsia are beneficial and cost-effective is unknown. Methods A micro-simulation model was developed to assess the life-long impact of preventive cardiovascular screening strategies initiated after women experienced preeclampsia during pregnancy. Screening was started at the age of 30 or 40 years and repeated every five years. Data (initial and follow-up) from women with a history of preeclampsia was used to calculate 10-year cardiovascular disease risk estimates according to Framingham Risk Score. An absolute risk threshold of 2% was evaluated for treatment selection, i.e. lifestyle interventions (e.g. increasing physical activity). Screening benefits were assessed in terms of costs and quality-adjusted-life-years, and incremental cost-effectiveness ratios compared with no screening. Results Expected health outcomes for no screening are 27.35 quality-adjusted-life-years and increase to 27.43 quality-adjusted-life-years (screening at 30 years with 2% threshold). The expected costs for no screening are €9426 and around €13,881 for screening at 30 years (for a 2% threshold). Preventive screening at 40 years with a 2% threshold has the most favourable incremental cost-effectiveness ratio, i.e. €34,996/quality-adjusted-life-year, compared with other screening scenarios and no screening. Conclusions Early cardiovascular disease risk screening followed by risk-based lifestyle interventions may lead to small long-term health benefits in women with a history of preeclampsia. However, the cost-effectiveness of a lifelong cardiovascular prevention programme starting early after preeclampsia with risk-based lifestyle advice alone is relatively unfavourable. A combination of risk-based lifestyle advice plus medical therapy may be more beneficial.

Background and objectives It is unclear if hemodiafiltration leads to a better quality of life compared with hemodialysis. It was, therefore, the aim of this study to assess the effect of hemodiafiltration on quality of life compared with hemodialysis in patients with ESRD. Design, setting, participants, & measurements This study analyzed the data of 714 patients with a median follow-up of 2 years from the Convective Transport Study. The patients were enrolled between June of 2004 and December of 2009. The Convective Transport Study is a randomized controlled trial on the effect of online hemodiafiltration versus low-flux hemodialysis on all-cause mortality. Quality of life was assessed with the Kidney Disease Quality of Life Short Form. This questionnaire provides data for a physical and mental composite score and describes kidney disease-specific quality of life in 12 domains. The domains have scales from 0 to 100. Results There were no significant differences in changes in health-related quality of life over time between patients treated with hemodialysis (n=358) or hemodiafiltration (n=356). The quality of life domain patient satisfaction declined over time in both dialysis modalities (hemodialysis: -2.5/yr, -3.4 to -1.5, P

Item does not contain fulltext BACKGROUND: Improving the health-related quality of life (HRQOL) for haemodialysis patients is a considerable challenge. The aim of the present study was to compare changes in HRQOL in haemodialysis patients with those observed in the general population over a 10-year period and explore factors that might explain possible differences. METHODS: We compared 126 haemodialysis patients assessed in 1995 in the Netherlands Cooperative Study on the Adequacy of Dialysis-1 (NECOSAD-I) with 515 patients enrolled in 2006 in the ongoing Convective Transport Study (CONTRAST). Changes in HRQOL in these cohorts were compared with two representative samples from the general Dutch population, assessed in 1992 (n = 1,063) and 2001 (n = 10,600). HRQOL was measured with the SF-36 questionnaire. Differences in HRQOL were analysed with ANCOVA to adjust for demographic variables. To assess possible differences, we used multivariable regression analysis. RESULTS: HRQOL in haemodialysis patients in 2006 [CONTRAST, mean age 63 +/- 14 years (SD), 62% male] was significantly better than in 1995 (NECOSAD-I, 59 +/- 16 years, 53% male) in four domains of the SF-36: bodily pain (+ 5 points, P = 0.009), vitality (+ 7, P < 0.001), role-emotional (+ 14, P < 0.001) and mental health (+ 8, P < 0.001), after adjusting for demographic variables. This increment could partly be explained by improved haemoglobin and phosphate levels. Compared to the general population, HRQOL improvement was most outspoken in two domains: bodily pain (+ 6, P = 0.01) and role-emotional (+ 8, P = 0.007). CONCLUSIONS: This study showed an improvement of HRQOL in haemodialysis patients over an 11-year period of time, independent of global changes in the general population.

Item does not contain fulltext BACKGROUND: Protein-energy wasting is tightly associated with mortality in haemodialysis patients. An expert panel of the International Society of Renal Nutrition and Metabolism (ISRNM) has published a consensus on the parameters that define protein-energy nutritional status and posed the question, 'which scoring system most effectively predicts outcome?' The aim of our study was therefore to develop a composite score of protein-energy nutritional status (cPENS) and to assess its prediction of all-cause mortality. METHODS: We used the data of 560 haemodialysis patients participating in the CONvective TRAnsport STudy (CONTRAST). All participants were followed for occurrence of death. Internationally recommended nutritional targets were used as components of the cPENS, including the subjective global assessment (target score >/= 6), albumin (>/= 4.0 g/dL), normalized protein nitrogen appearance (>/= 0.8 g/kg/day), cholesterol (>/= 100 mg/dL), creatinine (>/= 10 mg/dL) and BMI (> 23 kg/m(2)). A Cox regression model was used to analyse the relation between different cPENS variants and mortality. RESULTS: The median follow-up time was 1.4 years (max 4.2). One hundred and five patients (19%) died. A cPENS variant based on albumin, BMI, creatinine and the nPNA yielded the strongest relation with mortality (hazard ratio 0.63, 95% confidence interval 0.54-0.74, P < 0.001), after adjustments for confounders. Some of the individual parameters of the cPENS, notably albumin and creatinine, were related to mortality with similar strength and magnitude. CONCLUSIONS: In conclusion, albumin reflects mortality risk similarly to multiple nutritional parameters combined. This questions the clinical value of the proposed diagnostic criteria for protein-energy wasting.

Background The aim of this study was to evaluate the cost-effectiveness of the on-going decentralised targeted hepatitis B vaccination program for behavioural high-risk groups operated by regional public health services in the Netherlands since 1-November-2002. Target groups for free vaccination are men having sex with men (MSM), commercial sex workers (CSW) and hard drug users (HDU). Heterosexuals with a high partner change rate (HRP) were included until 1-November-2007. Methods Based on participant, vaccination and serology data collected up to 31-December-2012, the number of participants and program costs were estimated. Observed anti-HBc prevalence was used to estimate the probability of susceptible individuals per risk-group to become infected with hepatitis B virus (HBV) in their remaining life. We distinguished two time-periods: 2002–2006 and 2007–2012, representing different recruitment strategies and target groups. Correcting for observed vaccination compliance, the number of future HBV-infections avoided was estimated per risk-group. By combining these numbers with estimates of life-years lost, quality-of-life losses and healthcare costs of HBV-infections - as obtained from a Markov model-, the benefit of the program was estimated for each risk-group separately. Results The overall incremental cost-effectiveness ratio of the program was €30,400/QALY gained, with effects and costs discounted at 1.5% and 4%, respectively. The program was more cost-effective in the first period (€24,200/QALY) than in the second period (€42,400/QALY). In particular, the cost-effectiveness for MSM decreased from €20,700/QALY to €47,700/QALY. Discussion and conclusion This decentralised targeted HBV-vaccination program is a cost-effective intervention in certain unvaccinated high-risk adults. Saturation within the risk-groups, participation of individuals with less risky behaviour, and increased recruitment investments in the second period made the program less cost-effective over time. The project should therefore discus how to reduce costs per risk-group, increase effects or when to integrate the vaccination in regular healthcare.

Contains fulltext : 117631.pdf (Publisher’s version ) (Open Access) OBJECTIVE: To determine costs and effects of selective digestive tract decontamination (SDD) and selective oropharyngeal decontamination (SOD) as compared with standard care (ie, no SDD/SOD (SC)) from a healthcare perspective in Dutch Intensive Care Units (ICUs). DESIGN: A post hoc analysis of a previously performed cluster-randomised trial (NEJM 2009;360:20). SETTING: 13 Dutch ICUs. PARTICIPANTS: Patients with ICU-stay of >48 h that received SDD (n=2045), SOD (n=1904) or SC (n=1990). INTERVENTIONS: SDD or SOD. PRIMARY AND SECONDARY OUTCOME MEASURES: Effects were based on hospital survival, expressed as crude Life Years Gained (cLYG). The incremental cost-effectiveness ratio (ICER) was calculated, with corresponding cost acceptability curves. Sensitivity analyses were performed for discount rates, costs of SDD, SOD and mechanical ventilation. RESULTS: Total costs per patient were euro41 941 for SC (95% CI euro40 184 to euro43 698), euro40 433 for SOD (95% CI euro38 838 to euro42 029) and euro41 183 for SOD (95% CI euro39 408 to euro42 958). SOD and SDD resulted in crude LYG of +0.04 and +0.25, respectively, as compared with SC, implying that both SDD and SOD are dominant (ie, cheaper and more beneficial) over SC. In cost-effectiveness acceptability curves probabilities for cost-effectiveness, compared with standard care, ranged from 89% to 93% for SOD and from 63% to 72% for SDD, for acceptable costs for 1 LYG ranging from euro0 to euro20 000. Sensitivity analysis for mechanical ventilation and discount rates did not change interpretation. Yet, if costs of the topical component of SDD and SOD would increase 40-fold to euro400/day and euro40/day (maximum values based on free market prices in 2012), the estimated ICER as compared with SC for SDD would be euro21 590 per LYG. SOD would remain cost-saving. CONCLUSIONS: SDD and SOD were both effective and cost-saving in Dutch ICUs.

QUESTION: Is an injury prevention program consisting of 10 exercises designed to improve stability, muscle strength, co-ordination, and flexibility of the trunk, hip and leg muscles (known as The11) cost effective in adult male amateur soccer players?DESIGN: Cost-effectiveness analysis of a cluster-randomised controlled trial. PARTICIPANTS: 479 adult male amateur soccer players aged 18-40 years. INTERVENTION: The intervention group was instructed to perform the exercises at each training session (2 to 3 sessions per week) during one soccer season. The exercises focus on core stability, eccentric training of thigh muscles, proprioceptive training, dynamic stabilisation, and plyometrics with straight leg alignment. The control group continued their usual warm-up.OUTCOME MEASURES: All injuries and costs associated with these injuries were compared between groups after bootstrapping (5000 replications).RESULTS: No significant differences in the proportion of injured players and injury rate were found between the two groups. Mean overall costs in the intervention group were €161 (SD 447) per athlete and €256 (SD 555) per injured athlete. Mean overall costs in the control group were €361 (SD 1529) per athlete and €606 (SD 1944) per injured athlete. Statistically significant cost differences in favour of the intervention group were found per player (mean difference €201, 95% CI 15 to 426) and per injured player (mean difference €350, 95% CI 51 to 733).CONCLUSIONS: The exercises failed to significantly reduce the number of injuries in male amateur soccer players within one season, but did significantly reduce injury-related costs. The cost savings might be the result of a preventive effect on knee injuries, which often have substantial costs due to lengthy rehabilitation and lost productivity. Trial registration: NTR2416.

Item does not contain fulltext PURPOSE: Hemodialysis patients undergo frequent and long visits to the clinic to receive adequate dialysis treatment, medical guidance, and support. This may affect health-related quality of life (HRQOL). Although HRQOL is a very important management aspect in hemodialysis patients, there is a paucity of information on the differences in HRQOL between centers. We set out to assess the differences in HRQOL of hemodialysis patients between dialysis centers and explore which modifiable center characteristics could explain possible differences. METHODS: This cross-sectional study evaluated 570 hemodialysis patients from 24 Dutch dialysis centers. HRQOL was measured with the Kidney Disease Quality Of Life-Short Form (KDQOL-SF). RESULTS: After adjustment for differences in case-mix, three HRQOL domains differed between dialysis centers: the physical composite score (PCS, P = 0.01), quality of social interaction (P = 0.04), and dialysis staff encouragement (P = 0.001). These center differences had a range of 11-21 points on a scale of 0-100, depending on the domain. Two center characteristics showed a clinical relevant relation with patients' HRQOL: dieticians' fulltime-equivalent and the type of dialysis center. CONCLUSION: This study showed that clinical relevant differences exist between dialysis centers in multiple HRQOL domains. This is especially remarkable as hemodialysis is a highly standardized therapy. 01 maart 2012

Background and aims Approximately 16% of all sports injuries in the Netherlands are caused by outdoor soccer. A cluster-randomised controlled trial has been designed to investigate the effectiveness and cost-effectiveness of an injury prevention programme ('The11') for male amateur soccer players. The injury prevention programme The11, developed with the support of the World Football Association FIFA, aims to reduce the impact of intrinsic injury risk factors in soccer. Methods Teams playing at first-class amateur level in two districts in the Netherlands are participating in the study. Teams in the intervention group were instructed to apply The11 during each practice session throughout the 2009e10 season. All participants of the control group continued their practice sessions as usual. All soccer-related injuries and related costs for each team were systematically reported online by a member of the medical staff. Player exposure to practice sessions and matches was reported weekly by the coaches. Also the use of The11 during the season after the intervention season will be monitored. Discussion Our hypothesis is that integrating the The11 exercises in the warm-up for each practice session is effective in terms of injury incidence, injury severity, healthcare use, and its associated costs and/or absenteeism. Prevention of soccer injuries is expected to be beneficial to adult soccer players, soccer clubs, the Royal Dutch Football Association (KNVB), health insurance companies and society.

De ongunstige ontwikkeling in beweeggedrag en overgewicht van de afgelopen jaren kan gedeeltelijk worden gekeerd door intensief interventiebeleid. De kosten hiervan zijn hoog, maar de gezondheidswinst weegt daar tegenop. Dit onderzoek is een onderbouwing van het Nationaal Actieplan Sport en Bewegen van het Ministerie van Volksgezondheid Welzijn en Sport. Dit plan moet vanaf 2006 de lichamelijke activiteit in Nederland bevorderen. Het rapport beschrijft de randvoorwaarden voor succesvol beweegbeleid. Het moet een geïntegreerde aanpak zijn die door meer partijen wordt uitgevoerd en dat bestaat uit een mix van interventiemaatregelen voor verschillende doelgroepen. Voldoende budget en goede coördinatie zijn hierbij vereist, ook ten aanzien van verder wetenschappelijk onderzoek. Vervolgens is een realistisch beleidsdoel voor beweeggedrag vastgesteld op grond van twee interventiemaatregelen met bewezen effecten, namelijk een wijkgerichte benadering en een intensief leefstijlprogramma. Daling in het percentage inactieven van 1% tot 2% over vijf jaar en het percentage overgewicht met 1% tot 3% wordt realistisch geacht. Het behalen van deze beleidsdoelen voorkomt duizenden ziektegevallen in de komende twintig jaar. Voorwaarde is wel een grootschalig inzet van de interventiemaatregelen. De kosten per gewonnen levensjaar bedragen omstreeks 6000 euro, rekening houden met kosten in gewonnen levensjaren. Ze liggen daarmee onder de maatschappelijk aanvaarde grens.

Contains fulltext : mmubn000001_25192792x.pdf (Publisher’s version ) (Open Access) Promotor : P. Calon 108 p.

Fully or partially withdrawing the reimbursement of healthcare interventions that are currently being used and reimbursed in the healthcare system but that are unsafe, ineffective or do not provide value for money (i.e. disinvestment) may contribute to the efficient allocation of the healthcare budget. However, disinvestment decisions have been perceived as challenging. Specific mechanisms and considerations may be at play, affecting the perceived difficulty and the feasibility of these decisions. Therefore, the objectives of this thesis were 1) to obtain insight in the mechanisms and considerations that are relevant in disinvestment decisions, and 2) to investigate aspects affecting the feasibility of disinvestment decisions. Chapter 2 describes a qualitative interview study that showed that the outcome of disinvestment processes is affected by the contextual factors support from the public and stakeholders, institutional role and financial interests of stakeholders, the organizational skills of patient groups, and the possibility to relieve the consequences of disinvestment for current patients. No evidence was found of a consistent role of the formal Dutch reimbursement criteria in disinvestment processes. In Chapters 3 and 4, four distinct societal viewpoints on the disinvestment of healthcare interventions were identified, each supported by approximately half of Dutch citizens, that differ on their support for disinvestment and on the considerations that are found relevant in disinvestment decisions. Common aspects considered relevant by those holding the different viewpoints are transparency of decision-making and medical necessity of the concerned healthcare intervention. Resistance to disinvestment may partly be explained by the consequences of disinvestment citizens anticipate to experience themselves as well as by not considering the increase in healthcare expenditure a large problem. Chapter 5 describes a review of the available evidence on the disparity between willingness-to-accept (WTA) and willingness-to-pay (WTP) for healthcare goods and services. In this review, we found that to compensate for the disinvestment of healthcare interventions, 1.58 to 1.86 times higher savings are required compared to the amount of money that people are willing to pay to reimburse these healthcare interventions in the first instance, indicating that loss aversion may play a role in disinvestment decisions. Chapter 6 describes a participatory value evaluation (PVE) on the relative importance of attributes of healthcare interventions in the context of disinvestment in the Netherlands. This PVE showed that Dutch citizens prefer to disinvest those healthcare interventions with limited to no health gain and that are targeted at patients of older age. Furthermore, it shows that citizens prefer smaller savings over larger savings. Finally, Chapter 7 concludes that contextual factors are most important in disinvestment decisions. However, this large role of contextual factors may result in unfair differences between patient groups. The consistent and transparent application of a well-considered assessment framework for disinvestment decisions may increase the fairness and acceptability of disinvestment decisions. Furthermore, making citizens aware of the displacement resulting from not disinvesting a healthcare intervention my increase the feasibility of disinvestment decisions. Nevertheless, disinvestment decisions will remain difficult, even when it concerns healthcare interventions with limited health effects.

One approach to improve public health is to implement preventive programs that have been proven effective and cost-effective. For any preventive program to be successful, it is of paramount importance that a large majority of the target population participates. Unfortunately, it is not self-evident that high participation rates will be attained once preventive programs become available. Identification of characteristics that influence individuals’ participation decisions enable understanding why people decide (not) to participate in effective preventive programs. Evidently, some characteristics, such as high cost, may hamper participation, while others, such as high effectiveness, may have positive influence on participation rates. Discrete Choice Experiments (DCEs) are relatively new in the field of public health but have acquired an established position for studying decision-making behavior in marketing and transportation. The DCE methodology is a stated preference method that requires respondents to choose between different sets of program characteristics. This method enables researchers to determine preferred program characteristics, to quantify the importance of those program characteristics relative to each other and to determine potential uptake rates. In this dissertation, we explored if DCEs can be used to study individuals’ preferences concerning characteristics of specific preventive programs. In the first part of this thesis, we used DCEs to determine individuals’ preferences for three specific preventive interventions in three different public health domains, i.e. healthy lifestyle, vaccination and screening. We concluded that, all associated measures such as the relative importance of attributes, trade-offs between attributes, willingness-to-pay and potential participation rates could be estimated. Those results provide specific recommendations for program developers and policy makers to facilitate the development, implementation and marketing of effective preventive interventions. In part two of this thesis, we studied three aspects regarding the validity of the preferences that were measured by a public health related DCE. We concluded that the vast majority of the population is very well capable of completing public health related DCEs and the results could be used to predict engaging behavior. However, DCEs in their current form might not measure preferences validly among all members of the target population. Therefore, the extent to which alternative questioning methods, such as interviews or online interfaces, may improve the ability of older respondents and respondents with a lower educational level and/or health literacy to complete a DCE accurately should be verified. In the third part of this thesis, we explored if and concluded that presenting choice tasks in different ways influences respondents’ decision-making behavior and DCE study outcomes. Based on additional research the DCE method should be adapted and existing guidelines for best practice DCEs should be complemented. In conclusion, DCEs can be used to measure individuals’ preferences for public health interventions. There are several options to improve this method specifically for the public health setting. By combining additional research, knowledge from other scientific disciplines, well-designed experiments and advanced analytical models, our capacity to measure individuals’ preferences and to understand individuals’ decisions will increase further. Therefore, DCEs are a promising method to contribute to the improvement of the overall public health.