Dutch Healthcare Setting Research Articles

Cost Effectiveness of Adding Dapagliflozin to Insulin for the Treatment of Type 2 Diabetes Mellitus in the Netherlands

Many patients with type 2 diabetes mellitus (T2DM) on insulin therapy have inadequate glycaemic control. In such cases, Dutch guidelines recommend unlimited up-titration of insulin, yet in practice many patients never reach their glycaemic target. Clinical evidence shows that dapagliflozin-a highly selective sodium-glucose cotransporter 2 inhibitor-meets a need for these patients, i.e. by reducing glycated haemoglobin levels and bodyweight. We estimated the cost effectiveness and cost utility of adding dapagliflozin to insulin compared with not adding dapagliflozin in patients with T2DM who have inadequate glycaemic control while on insulin. The cost effectiveness of dapagliflozin was estimated using the Cardiff Diabetes Model, using direct comparative efficacy data from a randomized placebo-controlled trial (ClinicalTrials.gov identifier NCT00673231). In this trial, up-titration of insulin was allowed in case of severe glycaemic imbalance. Risk factor progression and the occurrence of future vascular events were estimated using the United Kingdom Prospective Diabetes Study 68 risk equations. Costs and utilities were derived from the literature. The analysis was conducted from the societal perspective, simulating the remaining lifetime of the patients. The overall incidence of macro- and microvascular complications was lower, and life expectancy was greater (19.43 versus 19.35 life-years [LYs]) in patients receiving dapagliflozin than in those not receiving dapagliflozin. Patients in the dapagliflozin arm obtained an incremental benefit of 0.42 quality-adjusted life-years (QALYs). The lifetime incremental cost per patient in the dapagliflozin arm was €2,293, resulting in an incremental cost-effectiveness ratio of €27,779 per LY gained and an incremental cost-utility ratio of €5,502 per QALY gained. Sensitivity and scenario analyses showed that the results were insensitive to variations in modelling assumptions and input variables. Dapagliflozin in combination with insulin was estimated to be a cost-effective treatment option for patients with T2DM whose insulin treatment regimen does not provide adequate glycaemic control in a Dutch healthcare setting.

PRM86 - How to Select the Right Cost-Effectiveness Model? A Systematic Review and Stepwise Approach for Transferring an Existing Health Economic Model for Rheumatoid Arthritis

To a) to perform a systematic literature review to identify existing models for cost-effectiveness analysis of disease modifying anti rheumatic drugs in Rheumatoid Arthritis, and b) to develop and test a method for the selection of a model that is transferable to the Dutch health care setting by simple adaptation.

Cetuximab in locally advanced squamous cell carcinoma of the head and neck: generalizability of EMR 062202-006 trial results

In a randomized controlled trial in patients with locally advanced squamous cell carcinoma of the head and neck (LA SCCHN), treatment with RT plus cetuximab resulted in improved survival compared to treatment with RT alone. Uncertainty exists about the generalizability of the trial results for the Dutch healthcare setting due to possible discrepancies in treatment allocation. Retrospective patient chart review was performed for 141 patients treated with first line RT plus cetuximab or RT alone, diagnosed in 2007-2010 in two head and neck treatment centers. Combined with aggregated population-based data from the Netherlands Cancer Registry and patient level clinical trial data, use of cetuximab in Dutch daily practice was assessed through comparison of patient characteristics, treatment characteristics and treatment outcomes between trial and daily practice. 61 daily practice patients fulfilled the selection criteria. In line with Dutch guidelines, RT plus cetuximab is prescribed in patients requiring combined therapy unfit to receive traditional platinum-based chemotherapeutics. These patients have unfavorable baseline characteristics, due to selection on--amongst others--high age of the patients. Beyond 1 year after treatment start, patients treated with RT plus cetuximab in daily practice died earlier than patients treated with RT plus cetuximab in the trial. Selective treatment allocation in daily practice limits generalizability of EMR 062202-006 trial results. Evidence is needed about the effectiveness of RT plus cetuximab compared to other treatments for patients with unfavorable clinical baseline characteristics.

PMD57 The Costs-Effectiveness of Coban 2 for the Treatment of Venous Leg Ulcers in the Netherlands

To assess the cost-effectiveness of 3M™ Coban™2 Layer Compression System (Coban 2) for the treatment of venous leg ulcers in the Dutch health care setting. The health economic evaluation consists of a cost-effectiveness analysis. A Markov model was developed in order to determine the cost-effectiveness of Coban 2, which was based on different health states and allowed transitions between these states. Upon initiation of the compression system Coban 2, the patient is supposed to have an ulcer. Over time, the ulcer may heal, but it may also recur. The treatment with Coban 2 is compared with traditional treatment (Short Stretch Bandages (SSB)). The primary perspective of the study is that of the Dutch insurer in 2012. The actual costs, which are included in the study, are product costs and treatment costs. Clinical probabilities on healing and recurrence are derived from clinical published literature. The use of Coban 2 leads to a total cost of € 600 compared to € 2,663 for traditional care, which leads to cost saving of € 2,063 per patient over a period of 1 year. The effectiveness for Coban 2 is 84.5% time without symptoms; the effectiveness for traditional care is 65.0% time without symptoms, which is leading to a gain of 2.3 months without symptoms over period of 1 year. The use of Coban 2 versus traditional treatment is cost-effective, because it is cost saving in combination with a higher effectiveness. As a consequence the cost savings by Coban 2 also translates into a positive impact on total health care budget.

Cost-Effectiveness of Escitalopram in Major Depressive Disorder in the Dutch Health Care Setting

ObjectiveThis study assessed the cost-effectiveness of escitalopram for the treatment of depression in the Netherlands from a societal perspective. MethodsA decision tree model was constructed using decision analytical techniques. Data sources included published literature, clinical trials, official price/tariff lists, national population statistics, and Delphi panel data. The comparators were venlafaxine XR and citalopram. The primary perspective of this health economic evaluation was that of the society in the Netherlands in 2010. The time horizon was 26 weeks. The effectiveness outcomes of the study were quality-adjusted life-years (QALYs). ResultsEscitalopram was associated with a cost savings per patient of €263 versus venlafaxine XR and €1992 versus citalopram over a period of 26 weeks from a societal perspective. Escitalopram was also associated with a gains QALYs: 0.0062 versus venlafaxine XR and 0.0166 versus citalopram. Escitalopram was dominant over both venlafaxine XR and citalopram. ConclusionBased on the findings from this cost-effectiveness analysis, the favorable clinical benefit of escitalopram resulted in a positive health economic benefit in the Netherlands.

Benefits and problems of electronic information exchange as perceived by health care professionals: an interview study

BackgroundVarious countries are currently implementing a national electronic patient record (n-EPR). Despite the assumed positive effects of n-EPRs, their overall adoption remains low and meets resistance from health care providers. This study aims to increase our understanding of health care providers' attitude towards the n-EPR, by investigating their perceptions of the benefits and problems of electronic information exchange in health care and the n-EPR in particular.MethodsThe study was conducted in three Dutch health care settings: acute care, diabetes care, and ambulatory mental health care. Two health care organisations were included per setting. Between January and June 2010, interviews were conducted with 17 stakeholders working in these organisations. Relevant themes were deduced by means of thematic qualitative analysis.ResultsHealth care providers perceived electronic information exchange to promote the efficiency and quality of care. The problems they perceived in electronic information exchange mainly concerned the confidentiality and safety of information exchange and the reliability and quality of patient data. Many problems perceived by health care providers did not specifically apply to the n-EPR, but to electronic information exchange in general.ConclusionsThe implementation of the Dutch n-EPR has mainly followed a top-down approach, thereby neglecting the fact that the perceptions and preferences of its users (health care providers) need to be addressed in order to achieve successful implementation. The results of this study provide valuable suggestions about how to promote health care providers' willingness to adopt electronic information exchange, which can be useful for other countries currently implementing an n-EPR. Apart from providing information about the benefits and usefulness of electronic information exchange, efforts should be focused on minimising the problems as perceived by health care providers. The safety and confidentiality of electronic information exchange can be improved by developing tools to evaluate the legitimacy of access to electronic records, by increasing health care providers' awareness of the need to be careful when using patient data, and by measures to limit access to sensitive patient data. Improving health care providers' recording behaviour is important to improve the reliability and quality of electronically exchanged patient data.

Lack of Effectiveness of a Multidisciplinary Fall‐Prevention Program in Elderly People at Risk: A Randomized, Controlled Trial

To assess whether a pragmatic multidisciplinary fall-prevention program was more effective than usual care in preventing new falls and functional decline in elderly people. A two-group, randomized, controlled trial with 12 months of follow-up. University hospital and home-based intervention, the Netherlands. Three hundred thirty-three community-dwelling Dutch people aged 65 and over who were seen in an emergency department after a fall. Participants in the intervention group underwent a detailed medical and occupational-therapy assessment to evaluate and address risk factors for recurrent falls, followed by recommendations and referral if indicated. People in the control group received usual care. Number of people sustaining a fall (fall calendar) and daily functioning (Frenchay Activity Index). Results showed no statistically significantly favorable effects on falls (odds ratio=0.86, 95% confidence interval (CI)=0.50-1.49) or daily functioning (regression coefficient=0.37, CI=-0.90 to 1.63) after 12 months of follow-up. The multidisciplinary fall-prevention program was not effective in preventing falls and functional decline in this Dutch healthcare setting. Implementing the program in its present form in the Netherlands is not recommended. This trial shows that there can be considerable discrepancy between the "ideal" (experimental) version of a program and the implemented version of the same program. The importance of implementation research in assessing feasibility and effectiveness of such a program in a specific healthcare setting is therefore stressed.

A Multidisciplinary Fall Prevention Program for Elderly Persons: A Feasibility Study

Falling is a common problem among elderly people and has many negative consequences. In the Netherlands, there is a need for effective fall prevention interventions aimed at elderly persons with an increased risk of falling. For this reason, we adapted a successful British fall prevention program comprising a medical occupational therapy assessment to the Dutch health care setting. This article describes the adaptation of this program and a pilot study to assess its feasibility in Dutch health care according to the implementers of the intervention as well as the participants (n = 21). This study showed that the Dutch intervention protocol is feasible in Dutch health care for both participants and implementers of the program. However, minor refinement of the intervention is warranted to improve its feasibility. The structured approach to adapt and pretest an intervention protocol appeared to be essential when aiming to implement a complex intervention program in a different health care setting.

Ethical and organisational tensions for work‐based learners

PurposeThis paper aims to focus on examples of the perceived tensions of the healthcare work‐based learners as they experienced paradigm shifts in both practice and education.Design/methodology/approachExamples are drawn from a qualitative study to examine work‐based learning (WBL) workshops in a Dutch healthcare setting, and a developmental project led by an academic to implement a WBL accredited programme across Acute and Primary Care Trusts in a region of England. The paper also supports the argument of Flood and Romm that within complex organisations there is a need to develop “triple loop” learning as opposed to “double loop” learning. A discussion of the tensions which relate to experience and research is presented.FindingsThe paper finds that WBL is not easy, especially in times of rapid change and resistance to new ways of working by some colleagues. Managers, academics, mentors and healthcare learners need opportunities to discuss and interpret experience in order to construct meaning and new knowledge of practice. Key to enabling the development of the work‐based inquirer to cope with change and ethical dilemmas is the commitment of facilitators to inspire learning, support the exploitation of workplace resources and encourage networking within and external to the organisation.Practical implicationsA benefit of the WBL approach is that it engages the learner in problem solving and enhances the skills of inquiry, networking and creativity. It is important for the learner to gain awareness of the ethical knowledge underpinning practice. Tensions can arise as paradigms shift and when boundaries are misinterpeted, and personal and organisational values and beliefs conflict.Originality/valueWhile the focus is healthcare the discussion could be relevant and of interest to a wider international audience of WBL practitioners as it considers a topic that is undervalued in workplace learning journals but is a reality of shifting paradigms.