Health technology assessment of health care innovations in chronic lymphocytic leukaemia and glaucoma care

This doctoral thesis addresses the implications of two health care innovations. One in glaucoma care and one in chronic lymphocytic leukaemia. The implications are expressed in terms of costs and health effects. Furthermore, in the case of one innovation, the implications of relations between professions are also discussed

A cost-effectiveness study of ICT training among the visually impaired in the Netherlands

Background: Due to the ageing population, the number of visually impaired people in the Netherlands will increase. To ensure the future availability of services in rehabilitative eye care, we aim to assess the cost-effectiveness of information and communication technology (ICT) training among visually impaired adults from a societal perspective, using primary data from two large rehabilitative eye care providers in the Netherlands. Methods: Participants were asked to fill in a questionnaire, which used six different instruments at three different time points: pre training, post training and three months post training. We investigated whether the participants' quality of life and well-being improved after the training and whether this improvement persisted three months post training. Economic evaluation was conducted by comparing costs and outcomes before and after training. Quality of life and well-being were derived from the EQ-5D and ICECAP-O, respectively. Costs for productivity losses and medical consumption were obtained from the questionnaires. Information regarding the costs of training sessions was provided by the providers. Results: Thirty-eight participants filled in all three questionnaires. The mean age at baseline was 63 years (SD = 16). The effect of ICT training on ICT skills and participants' well-being was positive and persisted three months after the last training session. Assuming these effects remain constant for 10 years, this would result in an incremental cost-effectiveness ratio (ICER) of € 11,000 per quality-adjusted life-year (QALY) and € 8000 per year of well-being gained, when only the costs of ICT training are considered. When the total costs of medical consumption are included, the ICER increases to € 17,000 per QALY gained and € 12,000 per year of well-being gained. Furthermore, when the willingness-to-pay threshold is € 20,000 per year of well-being, the probability that ICT training will be cost-effective is 75% (91% when including only the costs of ICT training). Conclusion: Our study suggests that ICT training among the visually impaired is cost-effective when the effects of ICT training on well-being persist for several years. However, further research involving a larger sample and incorporating long-term effects should be conducted

Radiotherapie versus CO2-laserbehandeling voor de behandeling van het T1a glottisch larynxcarcinoom

In dit onderzoek werden de kosten en effecten van de meest voorkomende behandelingen voor het T1a larynxcarcinoom, radiotherapie en de CO2-laserbehandeling, met elkaar vergeleken. De kostenberekening werd gebaseerd op een inventarisatie van de totale medische consumptie tussen eerste bezoek en 2 ja

Monitoring of stable glaucoma patients

A high workload for ophthalmologists and long waiting lists for patients challenge the organization of ophthalmic care. Tasks that require less specialized skills, like the monitoring of stable (well controlled) glaucoma patients could be substituted from ophthalmologists to other professionals (substitution in person). In addition, care could perhaps be provided in an ambulatory setting (substitution in location of care). To date, little is known about substituting care in ophthalmology, the organizational and professional dynamics involved and any consequences for both the quality of care and cost effectiveness. Glaucoma is the name given to a group of eye diseases characterized by damage to the optic nerve yielding gradual, irreversible loss of visual field. Glaucoma is often related to too high an intraocular pressure (IOP) and is age related. The usual care for glaucoma patients consists of diagnosis, lifelong monitoring, and treatment and is provided by ophthalmologists. However, monitoring stable glaucoma patients will presumably not require the specialist expertise of an ophthalmologist and may be carried out by less specialized professionals. Therefore, the quality of care given to stable glaucoma patients was evaluated when provided by ophthalmic technicians or optometrists based on pre-set protocols and under supervision of ophthalmologists in a Glaucoma follow-up unit (GFU) within The Rotterdam Eye Hospital (REH). The objective of this study is to evaluate an organizational intervention, a GFU for monitoring stable glaucoma patients in a hospital setting, staffed by non-physician Health Care Professionals instead of ophthalmologists. Furthermore, conditions will be formulated that need to be fulfilled to successfully substitute the monitoring care for stable glaucoma patients to a primary care optometrist (substitution in person as well as in location). The conditions will be b

Cost-Effectiveness of Including a Nurse Specialist in the Treatment of Urinary Incontinence in Primary Care in the Netherlands.

#### Objective Incontinence is an important health problem. Effectively treating incontinence could lead to important health gains in patients and caregivers. Management of incontinence is currently suboptimal, especially in elderly patients. To optimise the provision of incontinence care a global optimum continence service specification (OCSS) was developed. The current study evaluates the costs and effects of implementing this OCSS for community-dwelling patients older than 65 years with four or more chronic diseases in the Netherlands. #### Method A decision analytic model was developed comparing the current care pathway for urinary incontinence in the Netherlands with the pathway as described in the OCSS. The new care strategy was operationalised as the appointment of a continence nurse specialist (NS) located with the general practitioner (GP). This was assumed to increase case detection and to include initial assessment and treatment by the NS. The analysis used a societal perspective, including medical costs, containment products (out-of-pocket and paid by insurer), home care, informal care, and implementation costs. #### Results With the new care strategy a QALY gain of 0.005 per patient is achieved while saving €402 per patient over a 3 year period from a societal perspective. In interpreting these findings it is important to realise that many patients are undetected, even in the new care situation (36%), or receive care for containment only. In both of these groups no health gains were achieved. #### Conclusion Implementing the OCSS in the Netherlands by locating a NS in the GP practice is likely to reduce incontinence, improve quality of life, and reduce costs. Furth

The impact of knowledge of HPV positivity on cytology triage in primary high-risk HPV screening

Objective: Several studies have shown that there is an upward shift in the classification of cervical cytology when high-risk human papillomavirus (hrHPV) status is known to be positive. The Netherlands implemented primary hrHPV screening with reflex cytology as the primary screening test in 2017. Prior to implementation of the new programme, we investigated whether knowledge of hrHPV status influences cytology rating. Methods: Using a set of 200 cytology slides that had been previously tested, two pairs of cytotechnicians rated 100 slides per pair twice: first without knowledge of hrHPV status and then, after a wash-out period of two months, with knowledge of hrHPV status. Results: We found that hrHPV positive slides were more likely to be rated up over the referral threshold (i.e. from negative for intraepithelial lesion or malignancy to atypical squamous cells of undetermined significance+) than hrHPV negative slides at the second revi

Quality of life of patients with chronic lymphocytic leukaemia in the Netherlands: results of a longitudinal multicentre study

Purpose: To describe the health-related quality of life (HRQoL) of an unselected population of patients with chronic lymphocytic leukaemia (CLL) including untreated patients. Methods: HRQoL was measured by the EORTC QLQ-C30 including the CLL16 module, EQ-5D, and VAS in an observational study over multiple years. All HRQoL measurements per patient were connected and analysed using area under the curve analysis over the entire study duration. The total patient group was compared with the general population, and three groups of CLL patients were described separately, i.e. patients without any active treatment (“watch and wait”), chlorambucil treatment only, and patients with other treatment(s). Results: HRQoL in the total group of CLL patients was compromised when compared with age- and gender-matched norm scores of the general population. CLL patients scored statistically worse on the VAS and utility score of the EQ-5D, all functioning scales of the EORTC QLQ-C30, and the symptoms of fatigue, dyspnoea, sleeping disturbance, appetite loss, and financial difficulties. In untreated patients, the HRQoL was slightly reduced. In all treatment stages, HRQoL was compromised considerably. Patients treated with chlorambucil only scored worse on the EORTC QLQ-C30 than patients who were treated with other treatments with regard to emotional functioning, cognitive functioning, bruises, uncomfortable stomach, and apathy. Conclusions: CLL patients differ most from the general population on role functioning, fatigue, concerns about future health, and having not enough energy. Once treatment is indicated, HRQoL becomes considerably compromised. This applies to all treatments, including chlorambucil, which is considered to be a mild treatment

A cost of illness and equality of life study in patients with B-cell chronic lymphocytic leukemia (CLL) in the Netherlands

During the last decade the management of CLL was subject to progressive changes in diagnostic and prognostic procedures as well as the development of new alternative treatments. The aim of this study was to assess management, costs, quality of life and survival of CLL patients in daily practice. This information is becoming more important for reimbursement decsions, as new expensive drugs are only reimbursed when the incremental cost-effectiveness ratio lies within existing thresholds. Cost-effectiveness ratios are preferably calculated both in daily practice (or real world) setting and a clinical trial setting