Diagnosis Treatment Combination Research Articles

P029 Successful treatment of Rapidly progressive MDA-5 with dual combination therapy as a bridge to lung transplantation

Abstract Background/Aims Anti-melanoma differentiation-associated gene 5 (MDA5) is known to be associated with rapidly progressive interstitial lung disease (RP-ILD) and is fatal in most cases. The aim of this case report is to highlight the importance of early detection and aggressive treatment in improving the survival of these patients. Methods A 48-year-old Caucasian man, ex-smoker with 20 pack year history with well-controlled asthma, GORD, hiatus hernia and chondrocalcinosis in right knee on hydroxychloroquine was noted to have finger clubbing and decreased air entry at the right lung base on routine follow up. He worked in print finishing for 18 years. Results Investigations: CXR-increased interstitial shadowing. CT chest-extensive fibrosis NSIP pattern with honey combing, traction bronchiectasis throughout both lung fields and ground glass changes at the lower lobes. FVC 2.99 (63% predicted), FEV1 2.82 (73% predicted), FEV1/FVC ratio 0.95%, TLCO 2.75 (25% predicted), KCO 0.70 (46% predicted). CK- 76, Myositis blot- MDA 5 +ve, c ANCA +ve, PR3&MPO -ve and ANA -ve. CRP 70. Bronchoscopy-normal. He received IV methyl prednisolone 1 gm x 3 followed by prednisolone 60 mg daily and tapering dose along with Cyclophosphamide IVI 1 gm x 6 cycles. Long term home oxygen was prescribed. As he did not improve on initial immunosuppressive treatment, Rituximab IVI 1 gm x 2 was administered within two months of initial therapy. He was referred for lung transplant. As maintenance, he was on mycophenolate 1.5 gm BD, prednisolone 10 mg OD, Co-trimoxazole 960 mg x 3 days per week and rituximab 1 gm at six months and 12 months. He had bilateral lung transplant in Cambridge after two years from the diagnosis. Unfortunately, he developed organizing pneumonia, primary graft dysfunction requiring a brief ITU admission and tracheostomy soon after the transplant. His current medications include Prednisolone 5mg, Mycophenolate 2g Tacrolimus 3mg mane, 2mg nocte, Azithromycin 250mg three times weekly and Septrin 480mg od. He is now managing well, cycling 10-15 miles daily. He no longer requires ambulatory oxygen. His most recent FEV1 4.1L, FVC4.9L and resting saturation 97%. Dual combination aggressive immunosuppressive therapy led to significant disease control in this patient, enabling him to be enlisted for and finally to receive a double lung transplant within a reasonable time limit. It has been reported that patients with MDA 5 ILD have a 1-year survival of 67.5% and a 3-year survival of 46.7%. Conclusion Key Learning Points: Patients with MDA5-ILD have significantly high mortality rate but early diagnosis and optimal treatment combination can lead to favourable outcomes. These patients should be monitored for opportunistic infections. Patient commitment is important. Our patient stopped smoking, reduced weight to improve fitness to optimise the transplant success. Disclosure K. Yein: None. S. Sadiq: None. S. Zeb: None. A. Ahmed: None. E. Price: None.

Abstract 14711: Prediction of Persistent High-Need High-Cost Cardiology Patients With and Without Renal Failure

Introduction: Heart failure (HF) and coronary artery disease (CAD) are increasingly complex disease entities, in particular in older patients with multiple long-term conditions. High-Need High-Cost (HNHC) patients are at risk of receiving inefficient care that does not contribute to better outcomes. Prediction models may help to identify patients at risk of becoming HNHC with potential benefit for care coordination interventions. Aim: To predict persistent HNHC status at outpatient presentation for cardiovascular populations with HF, CAD, with and without renal failure (HF&RF; CAD&RF). Methods: We performed a retrospective cohort study in the claims database of a large healthcare insurer in the Netherlands. We included patients with consecutive data between 2015 - 2019, at their first outpatient appointment in 2016. Potential predictors were based on the previously published Persistent High Utilizer (PHU) model and collected in the year prior to presentation. HF, CAD and RF were defined by Diagnosis Treatment Combination insurance codes. The outcome of interest was PHU status, defined as belonging to the top 10% of total annualized healthcare expenditures for three consecutive years. To account for inflation, all costs were scaled towards 2015. Predictor effects were quantified through logistic multivariable regression analysis as odds ratios. Models were validated internally by bootstrapping procedure. Model performance was assessed as discrimination, quantified by the C-statistic. Results: 219.567 patients were included, of whom 2.0% ( n =4286) became PHU. The most important predictors were chronic kidney disease diagnosis (OR 3.1 95%CI 2.4-4.1), gastroenterology involvement (OR 3.0 95%CI 2.7-3.3) and COPD diagnosis (OR 2.1 95%CI 1.8-2.5). Model performance in the overall population was good (C-statistic 0.77). Model performance varied in the more homogeneous populations with HF ( n =2261; n =157 PHU), CAD ( n =7221; n =292 PHU), HF&RF ( n =163; n =40 PHU) and CAD&RF ( n = 196; n =34 PHU) resulting in C-statistics of 0.74, 0.78, 0.60 and 0.67 respectively. Conclusions: Persistent HNHC status can be predicted in the outpatient setting for patients with HF and CAD. These models can be used to select cardiology patients for HNHC care coordination.

Medical Care Use Among Patients with Monogenic Osteoporosis Due to Rare Variants in LRP5, PLS3, or WNT1

Pathogenic variants in the LRP5, PLS3, or WNT1 genes can significantly affect bone mineral density, causing monogenic osteoporosis. Much remains to be discovered about the phenotype and medical care needs of these patients. The purpose of this study was to examine the use of medical care among Dutch individuals identified between 2014 and 2021 with a pathogenic or suspicious rare variant in LRP5, PLS3, or WNT1. In addition, the aim was to compare their medical care utilization to both the overall Dutch population and the Dutch Osteogenesis Imperfecta (OI) population. The Amsterdam UMC Genome Database was used to match 92 patients with the Statistics Netherlands (CBS) cohort. Patients were categorized based on their harbored variants: LRP5, PLS3, or WNT1. Hospital admissions, outpatient visits, medication data, and diagnosis treatment combinations (DTCs) were compared between the variant groups and, when possible, to the total population and OI population. Compared to the total population, patients with an LRP5, PLS3, or WNT1 variant had 1.63 times more hospital admissions, 2.0 times more opened DTCs, and a greater proportion using medication. Compared to OI patients, they had 0.62 times fewer admissions. Dutch patients with an LRP5, PLS3, or WNT1 variant appear to require on average more medical care than the total population. As expected, they made higher use of care at the surgical and orthopedic departments. Additionally, they used more care at the audiological centers and the otorhinolaryngology (ENT) department, suggesting a higher risk of hearing-related problems.

Changes in healthcare utilisation and declarable care products during the implementation of a remote atrial fibrillation management pathway: The TeleCheck-AF project

Abstract Funding Acknowledgements Type of funding sources: None. Background TeleCheck-AF is a digital care pathway, which consists of a structured teleconsultation ("Tele") preceded by an app-based on-demand heart rate and rhythm monitoring infrastructure ("Check") and the consecutive integration of the app-derived findings in a comprehensive atrial fibrillation (AF) management. Purpose To evaluate changes in healthcare utilisation and declarable care products during the implementation of the TeleCheck-AF approach in a Dutch AF-clinic. Methods Healthcare provided to patients in the Netherlands is based on a diagnosis-treatment combination (Dutch: DBC). Once a patient visits the hospital, a treatment trajectory is opened, which contains the DBC care product. The DBC care products contain diagnostic and therapeutic performances for a certain diagnosis as well as information about reimbursement and are weighted in light (≤ € 200), medium (€ 300-500) and heavy (≥ € 600) depending on the performed diagnostic tests. Patients with AF who were treated with both a conventional approach in 2019 (standard care) and by the TeleCheck-AF approach in 2020 in a Dutch AF-clinic, were compared in this prospective case-crossover analysis. Healthcare utilisation in terms of numbers and modes of outpatient contacts (teleconsultation vs face-to-face), number of emergency department (ED) presentations, use of diagnostic resources (i.e. ECG, Holter) and related reimbursement were analysed. A patient experience survey which encompassed five questions regarding use of the app and patient satisfaction with the remote heart rate and rhythm control was performed. Results Ninety-one patients with AF from a Dutch AF-clinic (median age 68 years; 43% women) were analysed. Within the conventional approach in 2019, 113 face-to-face consultations and 1 teleconsultation were performed. After the implementation of TeleCheck-AF in 2020 the number of face-to-face consultations reduced by 53% and teleconsultations increased by 2900%. While 151 ECGs and 42 Holter-ECGs were performed within the conventional approach, the number of ECGs in the TeleCheck-AF approach decreased by 48% and number of Holters decreased by 35%. ED presentations did not differ significantly in the conventional compared to TeleCheck-AF approach (22 vs 17). Patients’ satisfaction within the TeleCheck-AF approach was high. The change in healthcare utilisation in TeleCheck-AF treated patients resulted in a mutation in declarable care products weights (towards light weighted DBC) and associated reimbursement. Conclusion The implementation of TeleCheck-AF was associated with a change in health care utilisation which resulted in a disproportional drop in reimbursement by health insurances due to a shift in declarable care products weights. Results of this analysis were basis to design a new reimbursement code for the TeleCheck-AF approach in the Netherlands.

Geriatric rehabilitation care after hip fracture

Key summary pointsAimTo describe the care provided in the Netherlands in geriatric rehabilitation (GR) after a hip fracture, using care pathways and diagnosis treatment combinations from various geriatric rehabilitation facilities.FindingsCare provided in GR after hip fracture is difficult to define due to the diversity in care pathways and large practice variation.MessageFurther research is needed to investigate whether a standardized care pathway is effective for GR.

From Genetics to Clinical Implications: A Study of 675 Dutch Osteogenesis Imperfecta Patients.

Osteogenesis imperfecta (OI) is a heritable connective tissue disorder that causes bone fragility due to pathogenic variants in genes responsible for the synthesis of type I collagen. Efforts to classify the high clinical variability in OI led to the Sillence classification. However, this classification only partially takes into account extraskeletal manifestations and the high genetic variability. Little is known about the relation between genetic variants and phenotype as of yet. The aim of the study was to create a clinically relevant genetic stratification of a cohort of 675 Dutch OI patients based on their pathogenic variant types and to provide an overview of their respective medical care demands. The clinical records of 675 OI patients were extracted from the Amsterdam UMC Genome Database and matched with the records from Statistics Netherlands (CBS). The patients were categorized based on their harbored pathogenic variant. The information on hospital admissions, outpatient clinic visits, medication, and diagnosis-treatment combinations (DTCs) was compared between the variant groups. OI patients in the Netherlands appear to have a higher number of DTCs, outpatient clinic visits, and hospital admissions when compared to the general Dutch population. Furthermore, medication usage seems higher in the OI cohort in comparison to the general population. The patients with a COL1A1 or COL1A2 dominant negative missense non-glycine substitution appear to have a lower health care need compared to the other groups, and even lower than patients with COL1A1 or COL1A2 haploinsufficiency. It would be useful to include the variant type in addition to the Sillence classification when categorizing a patient's phenotype.

Impact of the COVID-19 pandemic on mental health in parents of infants with colic and on healthcare use.

AimTo examine the impact of the COVID‐19 pandemic on the mental health of parents of infants with colic and on healthcare use.MethodsRetrospective cohort study. Data of 64 parents of infants with colic prepandemic and 43 parents of infants with colic during the pandemic were analysed using validated questionnaires on parental stress, depression and anxiety. Additionally, we evaluated the number of outpatient clinic visits and admission rates pre‐ and during the pandemic by collecting data on the diagnosis treatment combination ‘excessive crying’ from electronic patient files in three secondary hospitals in the Netherlands.ResultsMothers in the pandemic group reported significantly higher levels of depression than mothers in the prepandemic group (12.3 ± 7.0 and 8.8 ± 5.2; p = 0.04). Moreover, mothers showed a trend towards higher stress levels during the pandemic (29.6 ± 9.6 and 25.2 ± 8.1; p = 0.06). During the pandemic, admission numbers of infants with colic compared to prepandemic data increased with 34% (146 vs. 196).ConclusionMothers of infants with colic reported significantly more feelings of depression during the COVID‐19 pandemic. Furthermore, the pandemic was associated with increased healthcare use amongst infants with colic. With the continuing pandemic, we recommend active perinatal support for this vulnerable population.

Medication Use and Clinical Outcomes by the Dutch Institute for Clinical Auditing Medicines Program: Quantitative Analysis

BackgroundThe Dutch Institute for Clinical Auditing (DICA) Medicines Program was set up in September 2018 to evaluate expensive medicine use in daily practice in terms of real-world effectiveness using only existing data sources.ObjectiveThe aim of this study is to describe the potential of the addition of declaration data to quality registries to provide participating centers with benchmark information about the use of medicines and outcomes among patients.MethodsA total of 3 national population-based registries were linked to clinical and financial data from the hospital pharmacy, the Dutch diagnosis treatment combinations information system including in-hospital activities, and survival data from health care insurers. The first results of the real-world data (RWD) linkage are presented using descriptive statistics to assess patient, tumor, and treatment characteristics. Time-to-next-treatment (TTNT) and overall survival (OS) were estimated using the Kaplan-Meier method.ResultsA total of 21 Dutch hospitals participated in the DICA Medicines Program, which included 7412 patients with colorectal cancer, 1981 patients with metastasized colon cancer, 3860 patients with lung cancer, 1253 patients with metastasized breast cancer, and 7564 patients with rheumatic disease. The data were used for hospital benchmarking to gain insights into medication use in specific patient populations, treatment information, clinical outcomes, and costs. Detailed treatment information (duration and treatment steps) led to insights into differences between hospitals in daily clinical practices. Furthermore, exploratory analyses on clinical outcomes (TTNT and OS) were possible.ConclusionsThe DICA Medicines Program shows that it is possible to gather and link RWD about medicines to 4 disease-specific population-based registries. Since these RWD became available with minimal registration burden and effort for hospitals, this method can be explored in other population-based registries to evaluate real-world efficacy.

The impact of hospital competition and insurer concentration on health care volume and cost in Dutch hospitals

This study analyses the effect of spatial concentration of general hospitals, the appearance of independent treatment centers (in Dutch: Zelfstandige Behandelcentra: ZBCs) and the concentration of health insurers on production volume and costs since the introduction of market-oriented health care reforms in the Netherlands. We use regression analyses of 1,345,144 patient-level hospital data for fifteen major diagnosis treatment combinations (in Dutch: Diagnose Behandeling Combinaties: DBCs), representing 70% of the managed competition segment (the so-called B-segment). We find that spatial concentration of hospitals and concentration of insurers do not affect health care production volume. More competitive hospital markets are associated with higher cost of most DBCs studied. Surprisingly, hospitals operating under insurers with high monopsonic power incur higher average DBC-cost than hospitals operating under insurers with more dispersed power. The number of independent treatment centers in the hospital’s vicinity is positively related to health care volume and average cost.

PCN184 - COST-EFFECTIVENESS OF NIVOLUMAB PLUS IPILIMUMAB IN ADVANCED MELANOMA

Nivolumab (NIV) and ipilimumab (IPI) are both new and expensive agents used in first-line immunotherapies for patients with unresectable/metastatic (stage III-IV) advanced melanoma (AM). The study aimed to assess if combination therapy (NIV+IPI) is more cost-effective compared to monotherapy (NIV) for untreated AM patients in the Netherlands. A Markov model was constructed with a life-time horizon from Dutch healthcare perspective. Future effects and costs were discounted at 1.5% and 4%, respectively. Risks of progression and death were based on progression-free survivals (PFSs) obtained from a phase III clinical trial (NIV+IPI and NIV versus IPI) and conjectural overall survivals (OSs) calculated indirectly by using PFSs and OSs from another one (NIV versus dacarbazine), which were extrapolated by Weibull distribution lateron. Utility values of health states and disutility values of adverse events were derived from literature. Unit costs were taken from Dutch Diagnosis Treatment Combination Care Products Tariff, Erasmus MC prices and Dutch pharmacy purchase prices. Chronic management costs of AM and treatment costs of adverse events were calculated based on a survey done among clinicians determining necessary healthcare services and their utilization rates. Over life-time, on average an AM patient being treated by NIV+IPI was estimated to live 4.22 years and 2.59 QALYs at a (discounted) net cost of 262,824.61 EUR, while another being treated by NIV was estimated to live 3.26 years and 2.00 QALYs at a (discounted) net cost of 195,341.79 EUR, per individual. So, the incremental cost-effectiveness ratio was 70,770.30 EUR per life year saved and the incremental cost-utility ratio was 115,533.29 EUR per QALY gained. At a willingness to pay threshold of 80,000.00 EUR per QALY gained, NIV+IPI compared to NIV may not be accepted as a cost-effective tool, from Dutch healthcare perspective, in order to prevent high mortality and morbidity rates of AM.

PP146 Cost-Effectiveness Of Nivolumab Plus Ipilimumab In Advanced Melanoma

Introduction:This study was done to assess the cost effectiveness of nivolumab plus ipilimumab (NIV+IPI) versus nivolumab alone (NIV) for previously untreated patients with advanced melanoma (AM) from the Dutch health system perspective.Methods:A Markov model was constructed with a lifetime horizon. Future effects and costs were discounted at 1.5 and four percent, respectively. Risks of progression and death were based on progression-free survival rates obtained from a phase III clinical trial (NIV+IPI and NIV versus ipilimumab). Conjectural overall survival rates were calculated indirectly by using progression-free survival and overall survival rates from another trial (NIV versus dacarbazine), and were extrapolated later using the Weibull distribution. Utility values of health states and disutility values of adverse events were derived from the literature. Unit costs were derived from the Dutch Diagnosis Treatment Combination Care Products Tariff, Erasmus University Medical Center prices, and Dutch pharmacy purchase prices. Chronic management costs of AM and treatment costs of adverse events were calculated based on the results of a survey of clinicians that determined the necessary healthcare services and their utilization rates.Results:On average, over a lifetime an AM patient treated with NIV+IPI was estimated to live 4.2 years and 2.6 quality-adjusted life-years (QALYs) at a discounted net cost of EUR 262,824 per patient, while a patient treated with NIV was estimated to live 3.3 years and 2.0 QALYs at a discounted net cost of EUR 195,341 per patient. The incremental cost-effectiveness ratio was EUR 70,770 per life-year saved, and the incremental cost-utility ratio was EUR 115,533 per QALY gained.Conclusions:At a willingness-to-pay threshold of EUR 80,000 per QALY gained, NIV+IPI may not be a cost-effective tool, compared with NIV, for preventing the high mortality and morbidity associated with AM from the Dutch health system perspective.

Rankings of Unwarranted Variation in Healthcare Treatments

In this paper, we introduce a framework designed to identify and rank possible unwarranted variation of treatments in healthcare. The innovative aspect of this framework is a ranking procedure that aims to identify healthcare institutions where unwarranted variation is most severe, and diagnosis treatment combinations which appear to be the most sensitive to unwarranted variation. By adding a ranking procedure to our framework, we have taken our research a step beyond the existing literature. This ranking procedure is intended to assist health insurance companies in their search for violations, and to help find them more quickly, enabling more effective corrective and preventive actions on behalf of the healthcare institutions concerned.

Medical specialists care and hospital costs for low back pain in the Netherlands.

To examine the organization of medical specialist care and hospital costs for low back pain (LBP) in the Netherlands. Aggregated health insurance claims data were provided on all diagnosis treatment combination (DTC) declarations for LBP patients first referred to the hospital in the 2nd half of 2008 and retrieved from Vektis, an organization that collects health insurance claims data. Data were available up to 1 January 2012. The data included patient characteristics, DTC-specific information including: neurology, neurosurgery, orthopaedic surgery, anaesthesiology and radiology. In total 80,652 LBP patients were referred to the hospital for the first time in the second half of 2008 accumulating to a total of 173,620 DTC's with total costs of €194 million. Of these patients, 56% were female and 61% aged above 50years at first referral to the hospital. The average number of DTC's and costs per patient were 2.15 and €2410, respectively (during the follow-up period of 3.0-3.5year). Moreover, 51% of the patients needed only one DTC; less than 10% of patients needed 5 DTC's. Following the DTC number, the share of consultations to the neurologist decreased, whereas that of the anaesthesiology specialism increased. The largest portion of costs was allocated to the anaesthesiology and neurosurgery specialisms. In the Netherlands, LBP patients consult a variety of medical specialists, in particular, the neurology, hospital costs for LBP patients are expected to increase given the rising incidence. Optimal diagnosis and tailored treatment plans might result in reduced costs and improved patient outcomes. Low back pain patients consult various specialists, with the majority first referred to the neurologist. More than half of the LBD patients require only one DTC and less than 10% needed five DTC's or more. The largest portion of the hospital costs for LBP patients is allocated to the anaesthesiology and neurosurgery specialisms.

Competition in the Dutch hospital sector: an analysis of health care volume and cost

This paper evaluates the impact of market competition on health care volume and cost. At the start of 2005, the financing system of Dutch hospitals started to be gradually changed from a closed-end budgeting system to a non-regulated price competitive prospective reimbursement system. The gradual implementation of price competition is a ‘natural experiment’ that provides a unique opportunity to analyze the effects of market competition on hospital behavior. We have access to a unique database, which contains hospital discharge data of diagnosis treatment combinations (DBCs) of individual patients, including detailed care activities. Difference-in-difference estimates show that the implementation of market-based competition leads to relatively lower total costs, production volume and number of activities overall. Difference-in-difference estimates on treatment level show that the average costs for outpatient DBCs decreased due to a decrease in the number of activities per DBC. The introduction of market competition led to an increase of average costs of inpatient DBCs. Since both volume and number of activities have not changed significantly, we conclude that the cost increase is likely the result of more expensive activities. A possible explanation for our finding is that hospitals look for possible efficiency improvements in predominantly outpatient care products that are relatively straightforward, using easily analyzable technologies. The effects of competition on average cost and the relative shares of inpatient and outpatient treatments on specialty level are significant but contrary for cardiology and orthopedics, suggesting that specialties react differently to competitive incentives.

The use of medical claims to assess incidence, diagnostic procedures and initial treatment of myelodysplastic syndromes and chronic myelomonocytic leukemia in the Netherlands

Myelodysplastic syndromes (MDS) and chronic myelomonocytic leukemia (CMML) may be underreported in cancer registries such as the Netherlands Cancer Registry (NCR). Analysis of Dutch medical claims can complement NCR data on MDS and CMML. We analyzed data on 3681 MDS patients and 235 CMML patients aged ≥18 years with initial claims for MDS or CMML from the Dutch nationwide medical claims-based Diagnosis Treatment Combination Information System (DIS) between 2008 and 2010. Clinical information was available in the DIS. MDS and CMML were diagnosed without a bone marrow (BM) examination in almost half of the patients. The age-standardized incidence rate (ASR) per 100,000 in the cohort that underwent BM examinations compared with NCR data was 2.8 vs. 3.3 for MDS and 0.2 vs. 0.4 for CMML in 2008–2010. A conservative treatment approach was associated with increasing age and absence of BM examination in MDS (p<0.001 for both) and CMML patients (p<0.033 for both). In conclusion, the ASR of MDS in the cohort that underwent BM examinations was comparable with the NCR. The majority of elderly patients, either with or without BM examinations, received no therapy. Together, MDS and CMML may be misdiagnosed and inappropriately managed without a BM confirmation.

Abstract P171: Ethnic Inequalities In Cardiac Revascularization After Acute Coronary Syndrome

Background: Extensive literature in the USA reports lower revascularization rates after coronary heart disease among African Americans than among White Americans. Ethnic differences in revascularization procedures in European countries with an egalitarian health care system are rarely studied. We investigated disparities in revascularization procedures after an acute coronary syndrome (ACS) between ethnic minority groups and the Dutch majority population. Methods: All ACS events between 2006 and 2011 were identified in the Agis insurance Health Database using Diagnosis Treatment Combinations. Multivariable logistic regression analyses (adjusted for age, sex, ACS type, degree of urbanisation, socioeconomic status and comorbidity) were used to identify ethnic differences in revascularization procedures (percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG)) within 30 days after the ACS event. Results: On average, after 41.3% of all ACS events a revascularization procedure was performed. In the fully adjusted model, no difference in revascularization rate between the Dutch majority population and the ethnic minority groups under study were found (Moroccan (1.05; 0.77-1.43), Turkish (0.94; 0.75-1.18), Hindustani Surinamese (0.92; 0.70-1.21), and non-Hindustani Surinamese (1.15; 0.61-2.17)). Also age-stratified results did not show significant differences. Conclusion: In the Netherlands, a country with an egalitarian health care system, no ethnic inequalities in revascularization rate within 30 days after an acute coronary syndrome were observed. ACS type, degree of urbanisation, SES, and comorbidity did not influence the findings. Future research should elucidate whether disease severity may have obscured results.

Treatment costs of acute myocardial infarction in the Netherlands

This study aimed to calculate the treatment costs of acute myocardial infarction (AMI) in the Netherlands for 2012. Also, the degree of association between treatment costs of AMI and some patient and hospital characteristics was examined. For this retrospective cost analysis, patients were drawn from the database of the Diagnosis Treatment Combination (Diagnose Behandeling Combinatie, DBC) casemix system, which contains data on the resource use of all hospitalisations in the Netherlands. All costs were based on Euro 2012 cost data. The analysis was based on data of 25,657 patients. Mean treatment costs were estimated at <euro> 5021, with significant cost increases for patients with percutaneous coronary intervention (PCI) treatment. ST-segment elevation myocardial infarction (STEMI) patients receiving thrombolysis incurred the lowest (<euro> 4286), while non-STEMI patients receiving PCI the highest costs (<euro> 6060). Length of stay and hospital type were strong predictors of treatment costs. This study is the most extensive cost assessment of the treatment costs of AMI in the Netherlands thus far. Our results may be used as input for health-economic models and economic evaluations to support the decision making of registration, reimbursement and pricing of interventions in healthcare.

Explaining length of stay variation of episodes of care in the Netherlands

Diagnosis Related Group (DRG) systems aim to classify patients into mutually exclusive groups of patients, with the patients in each group having the same expected length of stay (LOS). We examined the ability of current classification variables to explain LOS variation between DRG-like Diagnosis Treatment Combination (DBC)s for ten episodes of care in the Netherlands, including breast cancer, stroke and inguinal hernia repair. Additionally, we assessed the predictive ability of some other classification variables. For each episode of care, the relevant DBC codes of all hospitalizations in 2008 were identified and all available determinants that may serve as classification variables were acquired from the national database. Ordinary least squares regression was used to examine the predictive ability of these classification variables. The current classification variables are not sufficiently distinct to classify patients into mutually exclusive groups of patients. ICU admissions and hospital type may serve as valuable classification variables. Additionally, episode-specific variables may improve the Dutch grouping algorithm. Although it may not be feasible in the short term, grouping algorithms would benefit greatly from the introduction of classification variables tailored to the needs of specific episodes of care. A first step would be to focus on 'general' classification variables meaningful for specific episodes of care.

Cost-effectiveness of Adding FDG-PET or CT to the Diagnostic Work-up of Patients With Stage III Melanoma

The aim of this prospective study was to assess predictive value of fludeoxyglucose-positron emission tomography (FDG-PET) and computed tomography (CT) and to analyze their cost-effectiveness in several diagnosis-treatment combinations. The incidence of melanoma continues to rise. A proportion will present or recur with lymph node metastases (American Joint Committee on Cancer/Union for International Cancer Control stage III). To detect distant metastases, CT and/or FDG-PET are available. However, few studies have assessed their value and costs in stage III. All consecutive patients with melanoma with palpable, proven lymph node metastases (2003-2008) referred for examination with FDG-PET and CT were prospectively included. Sensitivity, specificity, and accuracy, and positive predictive value (PPV) and negative predictive value (NPV) were calculated. In economic evaluation, the costs of diagnostic work-up with and without FDG-PET and CT were compared. Overall, 253 patients with melanoma were included. FDG-PET showed a higher sensitivity than CT: 86.1% compared with 78.2%. Specificity was higher for CT (93.7%) compared with FDG-PET (93.1%). Overall, FDG-PET showed a higher PPV and NPV. Cost-consequence analysis showed that adding CT (True-Positive upstaging in 61 patients) to diagnostic work-up decreased cost by 5.5%, adding FDG-PET (True-Positive upstaging in 68 patients) increased cost by 7.2%, and adding both (True-Positive upstaging in 78 patients) increased cost by 15.1%. In this study, FDG-PET had higher sensitivity and predictive value, whereas CT had a higher specificity. Adding one of these diagnostic tools improved the staging of stage III patients with less than 10% cost increase. A proposal for stage-specific use of imaging modalities for clinicians caring for patients with melanoma is presented.

UPDATE OF THE DUTCH MANUAL FOR COSTING IN ECONOMIC EVALUATIONS

In 2000, the first "Dutch Manual for Costing: METHODS and Reference Prices for Economic Evaluations in Healthcare" was published, followed by an updated version in 2004. The purpose of the Manual is to facilitate the implementation and assessment of costing studies in economic evaluations. New developments necessitated the publication of a thoroughly updated version of the Manual in 2010. The present study aims to describe the main changes of the 2010 Manual compared with earlier editions of the Manual. New and updated topics of the Manual were identified. The recommendations of the Manual were compared with the health economic guidelines of other countries, eliciting strengths and limitations of alternative methods. New topics in the Manual concern medical costs in life-years gained, the database of the Diagnosis Treatment Combination (DBC) casemix System, reference prices for the mental healthcare sector and the costs borne by informal care-givers. Updated topics relate to the friction cost method, discounting future effects and options for transferring cost results from international studies to the Dutch situation. The Action Plan is quite similar to many health economic guidelines in healthcare. However, the recommendations on particular aspects may differ between national guidelines in some respects. Although the Manual may serve as an example to countries intending to develop a manual of this kind, it should always be kept in mind that preferred methods predominantly depend on a country's specific context.