De definitie van specialistische geneesmiddelen

Samenvatting Vanwege bekostigingsproblemen met bepaalde geneesmiddelen is er een afbakeningsdiscussie rond dit onderwerp ontstaan. Buiten het ziekenhuis worden soms geneesmiddelen gebruikt waarvan zorgverzekeraars vinden dat ze niet via de extramurale geneesmiddelfinanciering moeten worden bekostigd maar dat ze ten laste van het ziekenhuisbudget zouden moeten komen. Ziekenhuizen zijn bereid deze geneesmiddelen te betalen als ze er maar voor gecompenseerd worden. Tegen deze achtergrond is een mogelijke oplossing voor de financieringsproblematiek om extramuraal afgeleverde geneesmiddelen te scheiden in specialistische en generalistische middelen. Door de specialistische geneesmiddelen medisch-inhoudelijk, beleidsmatig en financieel onder de reikwijdte van het ziekenhuis te brengen kan de continuïteit in behandeling door de medisch specialist ook worden doorgetrokken naar de farmacotherapie, ongeacht waar de patiënt zich bevindt (intramuraal of extramuraal). Voor generalistische middelen zou de medisch-inhoudelijke, beleidsmatige en financiële praktijk niet anders zijn dan in de huidige situatie. etc ..

Mapping onto Eq-5 D for patients in poor health

<p>Abstract</p> <p>Background</p> <p>An increasing amount of studies report mapping algorithms which predict EQ-5 D utility values using disease specific non-preference-based measures. Yet many mapping algorithms have been found to systematically overpredict EQ-5 D utility values for patients in poor health. Currently there are no guidelines on how to deal with this problem. This paper is concerned with the question of why overestimation of EQ-5 D utility values occurs for patients in poor health, and explores possible solutions.</p> <p>Method</p> <p>Three existing datasets are used to estimate mapping algorithms and assess existing mapping algorithms from the literature mapping the cancer-specific EORTC-QLQ C-30 and the arthritis-specific Health Assessment Questionnaire (HAQ) onto the EQ-5 D. Separate mapping algorithms are estimated for poor health states. Poor health states are defined using a cut-off point for QLQ-C30 and HAQ, which is determined using association with EQ-5 D values.</p> <p>Results</p> <p>All mapping algorithms suffer from overprediction of utility values for patients in poor health. The large decrement of reporting 'extreme problems' in the EQ-5 D tariff, few observations with the most severe level in any EQ-5 D dimension and many observations at the least severe level in any EQ-5 D dimension led to a bimodal distribution of EQ-5 D index values, which is related to the overprediction of utility values for patients in poor health. Separate algorithms are here proposed to predict utility values for patients in poor health, where these are selected using cut-off points for HAQ-DI (> 2.0) and QLQ C-30 (< 45 average of QLQ C-30 functioning scales). The QLQ-C30 separate algorithm performed better than existing mapping algorithms for predicting utility values for patients in poor health, but still did not accurately predict mean utility values. A HAQ separate algorithm could not be estimated due to data restrictions.</p> <p>Conclusion</p> <p>Mapping algorithms overpredict utility values for patients in poor health but are used in cost-effectiveness analyses nonetheless. Guidelines can be developed on when the use of a mapping algorithms is inappropriate, for instance through the identification of cut-off points. Cut-off points on a disease specific questionnaire can be identified through association with the causes of overprediction. The cut-off points found in this study represent severely impaired health. Specifying a separate mapping algorithm to predict utility values for individuals in poor health greatly reduces overprediction, but does not fully solve the problem.</p

EQ-5D-Y-3L and EQ-5D-Y-5L proxy report:psychometric performance and agreement with self-report

BACKGROUND: Self-report is the standard for measuring people’s health-related quality of life (HRQoL), including children. However, in certain circumstances children cannot report their own health. For this reason, children’s HRQoL measures often provide both a self-report and a proxy-report form. It is not clear whether the measurement properties will be the same for these two forms. We investigated whether it would be beneficial to extend the classification system of the EQ-5D-Y proxy questionnaire from 3 to 5 response levels. The agreement between self-report and proxy-report was assessed for both EQ-5D-Y measures. METHODS: The study included 286 pediatric patients and their caregivers as proxies. At three consecutive measurements—baseline, test–retest and follow-up—the proxies assessed the child’s HRQoL using the EQ-5D-Y-3L, EQ-5D-Y-5L, the PedsQL Generic, and matched disease-specific instruments. The proxy versions of EQ-5D-Y-3L and EQ-5D-Y-5L were compared in terms of feasibility, distribution properties, convergent validity, test–retest and responsiveness. Agreement between both EQ-5D-Y proxy versions to their respective self-report versions was assessed at baseline and follow-up. RESULTS: The proportion of missing responses was 1% for the EQ-5D-Y-3L and 1.4% for the EQ-5D-Y-5L. The frequency of health state with no problems in all dimensions (11111) was slightly lower for the EQ-5D-Y-5L (21.3% vs 16.7%). Regarding the convergent validity with the PedsQL and disease-specific measures, the proxy versions of EQ-5D-Y-3L and EQ-5D-Y-5L had similar magnitudes of associations between similar dimensions. The means of test–retest coefficients between the two versions of the EQ-5D-Y proxy were comparable (0.83 vs. 0.84). Regarding reported improved conditions, responsiveness of the EQ-5D-Y-5L proxy (26.6–54.1%) was higher than that of the EQ-5D-Y-3L proxy (20.7–46.4%). Except for acutely ill patients, agreement between the EQ-5D-Y-5L proxy and self-reports was at least moderate. CONCLUSIONS: Extending the number of levels of the proxy version of EQ-5D-Y can improve the classification accuracy and the ability to detect health changes over time. The level structure of EQ-5D-Y-5L was associated with a closer agreement between proxy and self-report. The study findings support extending the EQ-5D-Y descriptive system from 3 to 5 levels when administered by a proxy, which is often the case in the pediatric population

Establishing disability weights for congenital pediatric surgical conditions: A multi-modal approach

__Background:__ Burden of disease (BoD) as measured by Disability-Adjusted Life Years (DALYs) is one of the criteria for priority-setting in health care resource allocation. DALYs incorporate disability weights (DWs), which are currently expert-derived estimates or non-existent for most pediatric surgical conditions. The objective of this study is to establish DWs for a subset of key pediatric congenital anomalies using a range of health valuation metrics with caregivers in both high- and low-resource settings. __Method:__ We described 15 health states to health professionals (physicians, nurses, social workers, and therapists) and community caregivers in Kenya and Canada. The health states summaries were expert- and community-derived, consisting of a narrated description of the disease and a functional profile described in EQ-5D-5 L style. DWs for each health state were elicited using four health valuation exercises (preference ranking, visual analogue scale (VAS), paired comparison (PC), and time trade-off (TTO)). The PC data were anchored internally to the TTO and externally to existing data to yield DWs for each health state on a scale from 0 (health) to 1 (dead). Any differences in DWs between the two countries were analyzed. __Results:__ In total, 154 participants, matched by profession, were recruited from Kijabe, Kenya (n = 78) and Hamilton, Canada (n = 76). Overall calculated DWs for 15 health states ranged from 0.13 to 0.77, with little difference between countries (intra-class coefficient 0.97). However, DWs generated in Kenya for severe hypospadias and undescended testes were higher than Canadian-derived DWs (p = 0.04 and p < 0.003, respectively). __Conclusions:__ We have derived country-specific DWs for pediatric congenital anomalies using several low-cost methods and inter-professional and community caregivers. The TTO-anchored PC method appears best suited for future use. The majority of DWs do not appear to differ significantly between the two cultural contexts and could be used to inform further work of estimating the burden of global pediatric surgical disease. Care should be taken in comparing the DWs obtained in the current study to the existent list of DWs because methodological differences may impact on their compatibility

Finding legitimacy for the role of budget impact in drug reimbursement decisions

OBJECTIVES: Research has shown that effectiveness, cost-effectiveness, and severity of illness each play a role in drug reimbursement decisions. However, the role of budget impact in such decisions is less obvious. Policy makers almost always demand a budget impact estimate yet seem reluctant to formally include budget impact as a rationing criterion. Health economists even reject budget impact as a legitimate criterion. For these reasons, it is important to examine its use in rationing decisions, and rationales underlying its use. METHODS: We trace several rationales supporting the use of budget impact through a literature review, supplemented by semistructured interviews with eleven key stakeholders involved in drug reimbursement decisions in the Netherlands. RESULTS: Budget impact arguments are used in certain instances, although policy makers appear uncomfortable with its use because well described rationales still are lacking. In addition, we identify the following rationales to support budget impact as a rationing criterion: opportunity costs, loss aversion, uncertainty and equal opportunity. CONCLUSIONS: Budget impact plays a role in drug reimbursement decisions and has rationales to support its use. However, policy makers do not easily admit that they consider budget impact and are even reluctant to explicitly use budget impact as a formal criterion. A debate would strengthen the theoretical foundation of budget impact a

Estimating an EQ-5D-Y-3L Value Set for Indonesia by Mapping the DCE onto TTO Values

BACKGROUND AND OBJECTIVES: Methods for estimating health values in adult populations are well developed, but lag behind in children. The EuroQol standard protocol to arrive at value sets for the youth version of the EQ-5D-Y-3L combines discrete choice experiments with ten composite time trade-off values. Whether ten composite time trade-off values are sufficient remains to be seen and this is one of the reasons the protocol allows for experimental expansion. In this study, 23 health states were administered for the composite time trade-off. This methodological research is embedded in a study aimed at generating a representative value set for EQ-5D-Y-3L in Indonesia. METHODS: A representative sample of 1072 Indonesian adults each completed 15 discrete choice experiment choice pairs via face-to-face interviews. The discrete choice experiment responses were analysed using a mixed-logit model. To anchor the discrete choice experiment values onto the full health-dead quality-adjusted life-year scale, composite time trade-off values were separately obtained from 222 adults living in Java for 23 EQ-5D-Y-3L states. The derived latent discrete choice experiment values were mapped onto the mean observed composite time trade-off values to create a value set for the EQ-5D-Y-3L. Linear and non-linear mapping models were explored to estimate the most efficient and valid model for the value set. RESULTS: Coefficients obtained from the choice model were consistent with the monotonic structure of the EQ-5D-Y-3L instrument. The composite time trade-off data showed non-linearity, as the values for the two worst states being evaluated were much lower than predicted by a standard linear model estimated over all composite time trade-off data. Thus, the non-linear mapping strategies with a power term outperformed the linear mapping in terms of mean absolute error. The final model gave a value range from 1.000 for full health (11111) to − 0.086 for the worst health state (33333). Values were most affected by pain/discomfort and least by self-care. CONCLUSIONS: This article presents the first EQ-5D-Y-3L value set for Indonesia based on the stated preferences of adults asked to consider their views about a 10-year-old child. Mapping the mixed-logit discrete choice experiment model with the inclusion of a power term (without a constant) allowed us to generate a consistent value set for Indonesian youth. Our findings support the expansion of the composite time trade-off part of the EQ-5D-Y valuation study design and show that it would be wise to account for possible non-linearities in updates of the design

The cost-utility of Viagra® in The Netherlands

OBJECTIVE: Clinical trials suggest that sildenafil is an effective treatment for erectile dysfunction. Nevertheless, reimbursement is controversial: sildenafil is expected to be more effective than conservative therapy (papaverine/ phentolamine injections), but also more costly to society. Economic appraisal of sildenafil is of interest given the prevalence of the disorder. DESIGN: We analyzed the cost-effectiveness of a sildenafil scenario (allowing a switch to injection therapy) and the papaverine/ phentolamine scenario (conservative therapy, no switch allowed). Analyses were performed from the societal perspective. Values for health states of erectile dysfunction were collected using time trade-off. Using these values (N=169), we converted trial outcomes (Goldstein, 1998) into quality adjusted lif

Importancia del aprestamiento en Educación Inicial para el desarrollo del pensamiento lógico matemático de los niños y niñas de multinivel, turno matutino de la Escuela Adic-Venancia del departamento de Matagalpa, durante el segundo semestre del año 2016

Mediante la presente investigación se estudió: El aprestamiento en educación inicial para la adquisición del aprendizaje. Se aborda además la importancia del aprestamiento en educación inicial para el desarrollo del pensamiento lógico matemático de los niños y niñas de multinivel, turno matutino de la Escuela Adic-Venancia del departamento de Matagalpa, durante el segundo semestre del 2016, con el objetivo de analizar la importancia del aprestamiento en educación inicial para el desarrollo del pensamiento lógico matemático de los niños y niñas. Esta temática es importante debido a que las actividades lúdicas son poco apreciadas como una herramienta básica para lograr el desarrollo del pensamiento lógico matemático de los educandos. Por eso mediante esta investigación se pretende identificar las actividades que se implementan para el aprestamiento del pensamiento lógico. Además de describir la importancia del aprestamiento en el pensamiento lógico matemático de los niños y niñas de multinivel de educación inicial. El aprestamiento para el desarrollo del pensamiento lógico matemático es importante, porque a través de él se estimula la evolución de las capacidades innatas del niño y la niña de educación inicial sin embargo, en los salones de clase no se están implementando estrategias metodológicas que le ayuden al niño en dicho desarrollo es por ello que se proponen actividades para favorecer el desarrollo del pensamiento lógico matemático tales como: ejercicios de ubicación espacial, clasificación, seriación, bloques lógicos, rompecabezas, domino de diferencias, cantos, otro