• A conceptual framework for budget allocation in the RIVM Chronic Disease Model - A case study of Diabetes Mellitus

      Hoogenveen RT; Feenstra TL; Baal PHM van; Baan CA; PZO (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2005-05-02)
      The research project 'Priority setting in chronic diseases: methodology for budget allocation' aims to develop a methodology to support optimal allocation of the health care budget with respect to chronic diseases. The current report describes the modelling steps required to address budget allocation questions regarding the prevention of chronic diseases and their complications with the RIVM Chronic Disease Model, with specific attention to diabetes mellitus. An extension of the RIVM Chronic Disease Model deals with the links between diabetes, its risk factors and its macrovascular complications. A health economics module computes outcomes in terms of intervention costs, costs of care and composite health effects. Finally, it is discussed how to formalize different preferences of policy makers in various objective functions and constraints. These three elements form the basis for the analysis of budget allocation questions in diabetes care. The model allows for the comparison of primary prevention with the prevention of complications in diagnosed patients as to costs of care and health effects. Furthermore, as it stands, the model with the health economics module per se is a useful tool for policy analysis, for instance, to compare the costs and effects of different interventions.
    • Cost Effectiveness Analysis with the RIVM Chronic Disease Model

      Baal PHM van; Feenstra TL; Hoogeveen RT; Wit GA de; PZO (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2005-10-20)
      Support of decision makers in health care priority setting is one of the objectives of cost effectiveness analysis. Cost effectiveness analysis presents the costs and effects of an intervention compared to an alternative in cost effectiveness ratios. The denominator of the ratio measures the health gain from the intervention and the numerator measures the costs of obtaining that health gain. The objective was to develop a methodology to be used with economic evaluations conducted with the RIVM Chronic Disease Model (CDM). Using the CDM to compute health effects and costs ensures that the same model is used for all different economic evaluations, which improves their comparability. The current report describes how cost effectiveness ratios are computed with the CDM. Special attention is paid to the selection and estimation of the costs and effects to be included during years of life gained. A cost effectiveness module was written to be attached to the RIVM Chronic Disease Model (CDM). To decide what costs and effects to include, a distinction was made between diseases causally related and diseases indirectly related to the intervention. Given this distinction the approach from Nyman (Health Economics 2004) was followed: all costs that directly produce the utility measured in the denominator have to be included in the numerator of the cost effectiveness ratio. To estimate the impact of indirectly related diseases on quality of life we use data from the Dutch Burden of Disease study. Data from the Costs of Illness study in the Netherlands were used to estimate the impact of an intervention on total health care costs. We argue that for comparison of different interventions with the RIVM CDM, one should include the costs and effects of both causally related and indirectly related diseases, since it seems impossible to isolate the precise effects of an intervention.
    • Cost-effectiveness of interventions to reduce tobacco smoking in the Netherlands. An application of the RIVM Chronic Disease Model

      Feenstra TL; Baal PHM van; Hoogenveen RT; Vijgen SMC; Stolk E; Bemelmans WJE; PZO (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2006-05-09)
      Introduction:Smoking is the most important single risk factor for mortality in the Netherlands and has been related to 12% of the burden of disease in Western Europe. Hence the Dutch Ministry of Health has asked to assess the cost-effectiveness of interventions to enhance smoking cessation in adults. Objective:To evaluate eight interventions for smoking cessation, namely increased tobacco taxes, mass media campaigns, minimal counseling, GP support, telephone counseling, minimal counseling plus nicotine replacement therapy, intensive counseling plus nicotine replacement therapy and intensive counseling plus bupropion. Methods: Costs per smoker were estimated based on bottom-up cost analysis. Combined with effectiveness data from meta-analyses and Dutch trials this gave us costs per quitter. To estimate costs per quality adjusted life year (QALY) gained, scenarios for each intervention were compared to current practice in the Netherlands. A dynamic population model, the RIVM Chronic Disease Model, was used to project future health gains and effects on health care costs. This model allows the repetitive application of increased cessation rates to a population with a changing demographic and risk factor mix, and accounts for risks of relapse and incidence of smoking related diseases that depend on time since cessation. Sensitivity analyses were performed for variations in costs, effects, time horizon, program size and discount rates. Results: A tax increase was the most efficient intervention with zero intervention costs from the health care perspective. Additional tax revenues resulting from a 20% tax increase were about 5 billion euro. Costs per smoker for a mass media campaign were relatively low (3 euro) and costs per QALY were below 10.000 euro.The effectiveness of these two population measures was uncertain. Costs per smoker for individual cessation support varied from 5 to almost 400 euro. Although all individual interventions had proven effectiveness, the cheapest intervention had an effect that did not differ significantly from current practice cessation rates. Compared to current practice, cost-effectiveness ratios varied between about 8,800 euro for structured GP stop-advice (H-MIS) to 21,500 euro for telephone counseling for implementation periods of 5 years. Discussion and conclusions: All smoking cessation interventions were cost-effective compared to current practice. Comparison of interventions is difficult, especially for population and individual interventions, because they are often applied in combination. Taking that into account, taxes seem to provide most value for money, especially since additional tax revenues outweigh the health care costs in life years gained.
    • Kosteneffectiviteit en gezondheidswinst van behalen beleidsdoelen bewegen en overgewicht - Onderbouwing Nationaal Actieplan Sport en Bewegen

      Wendel-Vos GCW; Ooijendijk WTM; Baal PHM van; Storm I; Vijgen SMC; Jans M; Hopman-Rock M; Schuit AJ; Wit GA de; Bemelmans WJE; et al. (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2005-10-25)
      An integrated policy, with broad implementation of interventions, will at least partially counteract the expected negative future trends in overweight and physical activity. Accompanying costs are high but outweighed by the health benefits. The costs per life year gained are approximately 6000 euros, accounting for the costs in life years gained, and stay well within socially accepted boundaries. The goal of the present research was to underpin both the aims and content of the national action plan for sports and physical activity through a literature study, more than 80 expert interviews and a comparison with national action plans in other countries. The Dutch Ministry of Public Health, Welfare and Sport is aiming to implement this action plan by the year 2006. Important conditions for a successful physical activity policy were identified. The approach should be an integrated one, supported by relevant stakeholders. Within this framework a mix of interventions should offered to several target groups. Sufficient budget and good coordination are essential, also with regard further scientific research. A realistic policy ambition for physical activity was estimated on the basis of two interventions with established long-term effectiveness, e.g. a community based approach and an intensive lifestyle programme. A realistic aim is a reduction in the prevalence rate of inactive persons of one to two percentage points over a period of five years. In addition, the prevalence rate of overweight people can be decreased by one to three percentage points. Achieving these policy targets could prevent thousands of disease cases during the next 20 years on condition that the abovementioned effective interventions are broadly implemented. The cost-effectiveness ratio per life year gained is estimated to be 6000 to 6500 euros and about 5600 to 6100 euros per quality-adjusted life year (QALY) gained.
    • Kosteneffectiviteitsanalyses over de keten van preventie, cure en care - Discussie van een raamwerk voor integrale kosteneffectiviteitsanalyse

      Feenstra TL; Baal PHM van; Wit GA de; Polder JJ; Hollander AEM de; VTV (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2006-09-04)
      Cost-effectiveness analyses (CEA) give important information about the efficiency of health care interventions. Consistent evaluation of cost-effectiveness over the disease trajectory from prevention to care may provide useful data to support health care priority setting. Health care budgets rank high in political concern and economic evaluations of health care programs may get to play an increasingly important role. Yet the methods of cost-effectiveness analysis have also been criticized. The current report examined the CEA methodology and its critiques, to find a useful method for quantifying revenues and costs of interventions over the complete trajectory from prevention to curative care. The method used was a discussion over selected methodological issues, putting up a framework for application in future analyses. The big advantage of cost-effectiveness analysis is the request to gather explicit and consistent information. This information is then summarized in the cost-effectiveness ratio. If practiced with due consideration, the results will provide decision makers with useful figures, despite the need to make assumptions. Cost-effectiveness analyses, however, will support and not replace conscious decision making. The loss of information implied by summarizing results in cost-effectiveness ratios is a disadvantage. Furthermore, other arguments than costs and efficiency will play a role in health care priority setting. To conclude, sensible use of economic evaluations requires decision makers to go beyond single cost-effectiveness ratios.
    • Potential health benefits and cost effectiveness of tobacco tax increases and school intervention programs targeted at adolescents in the Netherlands

      Baal PHM van; Vijgen SMC; Bemelmans WJE; Hoogenveen RT; Feenstra TL; PZO (Rijksinstituut voor Volksgezondheid en Milieu RIVM, 2006-05-09)
      Increasing tobacco taxes is a cost effective measure to reduce smoking among youth. A price increase on tobacco products reduces the number of young smokers by almost 20,000 in the short run. Although, in the end, effects of current price increases on smoking behaviour will fade away, tobacco taxes still are a good strategy to gain health effects since no intervention costs are involved. Cost effectiveness ratios for tobacco tax increases amount to 4,500 per QALY gained including medical costs in life years gained, but excluding tobacco tax revenues. This report presents estimates of health gains and cost effectiveness of two types of interventions targeted at smoking reduction among adolescents in the Netherlands: school interventions and tobacco tax increases. Effects in terms of smokers averted were determined from the literature. To translate these effects into health gains and cost effectiveness the RIVM Chronic Disease Model (CDM) is used. This dynamic population model allows estimating effects on smoking related diseases, gains in (quality adjusted) life years and differences in health care costs. For the school interventions, three different programs were investigated. The intervention costs per participant ranged from 20 to 75. Since there is much uncertainty about the effectiveness of the school interventions with regard to daily smoking among adolescents, results of the scenario analyses should be interpreted with caution. The conclusion that can be drawn from the scenario analyses with the CDM is that much health gains can be attained by preventing adolescents from smoking initiation and that tobacco tax increase may contribute to this in a cost effective way.