Who contextualises clinical epidemiological evidence? A political analysis of the problem of evidence-based medicine in the layered Dutch healthcare system.

We critically examine the discussion on the role of evidence-based medicine (EBM) in healthcare governance. We take the institutionally layered Dutch healthcare system as our case study. Here, different actors are involved in the regulation, provision and financing of healthcare services. Over the last decades, these actors have related to EBM to inform their actor specific roles. At the same time, EBM has increasingly been problematised. To better understand this problematisation, we organised focus groups and interviews. We noticed that particularly EBM's reductionist epistemology and its uncritical use by 'professional others' are considered problematic. However, our analysis also reveals that something else seems to be at stake. In fact, all the actors involved underwrite EBM's reductionist epistemology and emphasise that evidence should be contextualised. They however do so in different ways and with different contexts in mind. Moreover, the ways in which some actors contextualise evidence has consequences for the ways in which others can do the same. We therefore emphasise that behind EBM's scientific problematisation lurks a political issue. A dispute over who should contextualise evidence how, in a layered healthcare system with interdependent actors that cater to both individual patients and the public. We urge public administration scholars and policymakers to open-up the political confrontation between healthcare actors and their sometimes irreconcilable, yet evidence-informed perspectives.

Validation of the Dutch version of the DN4 diagnostic questionnaire for neuropathic pain.

Difficulties in diagnosing neuropathic pain in routine clinical practice support the need for validated and easy-to-use diagnostic tools. The DN4 neuropathic pain diagnostic questionnaire aims to discriminate neuropathic pain from nociceptive pain, but needs clinical validation. A total of 269 patients with chronic pain in three pain clinics were included in the study of which 248 had analyzable data. The mean duration of pain was 4.9 years. The most frequent etiologies were posttraumatic (36%), (pseudo) radicular (14%), and mechanical back pain (12%). The mean intensity of pain at visit was 5.6 on a 0-10 scale. Hundred and ninety-six of 248 patients had an identical pain diagnosis from both physicians: 85 had neuropathic pain, 57 had nociceptive pain, and 54 had mixed pain. Among patients with identical diagnoses of neuropathic or nociceptive pain, using a receiver operating characteristic curve analysis, the area under the curve (AUC) was 0.81 for the DN4 7-item and 0.82 for the 10-item version. A cutoff point of 5/10 for the full questionnaire resulted in a sensitivity of 75% and a specificity of 79%, while a cutoff point of 4/7 for the partial questionnaire resulted in a sensitivity of 74% and a specificity of 79%. The items "brushing," "painful cold," and "numbness" were most discriminating. The DN4 is an easy-to-use screening tool that is reliable for discriminating between neuropathic and nociceptive pain conditions in daily practice. Item-specific scores provide important information in addition to the total score.

Cholesterol level goal attainment with statins: clinical management guideline recommendations versus management in actual clinical practice.

STUDY OBJECTIVES: To compare the cholesterol level goal attainment rates in patients receiving simvastatin doses recommended in clinical practice guidelines and simvastatin doses most frequently prescribed in clinical practice versus other statins at various dose levels, and to assess statin adherence rates in patients receiving all statins. DESIGN: Retrospective cohort study. DATA SOURCE: PHARMO database, which contains linked prescription drug information, hospitalization records, and laboratory test results of over 1 million patients in the Netherlands. PATIENTS: A total of 7355 new statin users with available cholesterol level measurements before and 12 months after starting statin treatment between 1999 and 2006. MEASUREMENTS AND MAIN RESULTS: Simvastatin was chosen as the reference drug because policy makers in the Netherlands have promoted the use of generically available statins to reduce costs. Cholesterol level goal attainment rates were compared in patients receiving simvastatin 40 mg/day, which was the statin dose promoted in the 2006 Dutch cardiovascular risk management guidelines, or simvastatin 20 mg/day, which was the most frequently prescribed dose up to 2006, versus other statins at various dose levels. Relative risks (RRs) were adjusted for age, sex, year of therapy initiation, cardiovascular disease, type 2 diabetes mellitus, hypertension, baseline low-density lipoprotein cholesterol level, and adherence during the 3 months before the 12-month follow-up cholesterol measurement. Compared with simvastatin 40 mg/day, cholesterol goal attainment rates were significantly higher with atorvastatin 40 mg/day (RR 1.15, 95% confidence interval [CI] 1.04-1.28) and rosuvastatin 10 mg/day (RR 1.13, 95% CI 1.04-1.23), were similar with atorvastatin 20 mg/day (RR 1.06, 95% CI 0.97-1.16) and rosuvastatin 20 mg/day (RR 1.14, 95% CI 0.93-1.39), and were significantly lower with all other frequently used statin dose levels. Compared with simvastatin 20 mg/day, cholesterol goal attainment was significantly higher with any dose of atorvastatin and rosuvastatin, but were lower with any dose of pravastatin. Goal attainment rates were similar among patients with lower and higher cardiovascular risk. Among the 13-18% of patients who had follow-up cholesterol level measurements at 12 months in all statin groups, the proportion of adherent patients was approximately 75%; this was higher than the proportion of adherent patients in the total population (48-55%), which included patients without follow-up cholesterol levels. CONCLUSION: A larger proportion of patients reached cholesterol lipid goals with simvastatin 40 mg/day. Cholesterol level goals were achieved by many patients using the recommended simvastatin 40 mg/day, but by fewer patients among those using the more commonly prescribed simvastatin 20 mg/day. Therefore, especially in high-risk patients, the choice of statin should be based on baseline cholesterol levels and expected reductions in these levels, and treatment should be adapted if targets are not met. Improved cholesterol level monitoring may increase adherence and cholesterol management.

Antihypertensive drugs: a perspective on pharmaceutical price erosion and its impact on cost-effectiveness.

OBJECTIVE: When comparators' prices decrease due to market competition and loss of exclusivity, the incremental clinical effectiveness required for a new technology to be cost-effective is expected to increase; and/or the minimum price at which it will be funded will tend to decrease. This may be, however, either unattainable physiologically or financially unviable for drug development. The objective of this study is to provide an empirical basis for this discussion by estimating the potential for price decreases to impact on the cost-effectiveness of new therapies in hypertension. METHODS: Cost-effectiveness at launch was estimated for all antihypertensive drugs launched between 1998 and 2008 in the United Kingdom using hypothetical degrees of incremental clinical effectiveness within the methodologic framework applied by the UK National Institute for Health and Clinical Excellence. Incremental cost-effectiveness ratios were computed and compared with funding thresholds. In addition, the levels of incremental clinical effectiveness required to achieve specific cost-effectiveness thresholds at given prices were estimated. RESULTS: Significant price decreases were observed for existing drugs. This was shown to markedly affect cost-effectiveness of technologies entering the market. The required incremental clinical effectiveness was in many cases greater than physiologically possible so, as a consequence, a number of products might not be available today if current methods of economic appraisal had been applied. CONCLUSIONS: We conclude that the definition of cost-effectiveness thresholds is fundamental in promoting efficient innovation. Our findings demonstrate that comparator price attrition has the potential to put pressure in the pharmaceutical research model and presents a challenge to new therapies being accepted for funding.

Evaluation of smoking cessation drug use and outcomes in the Netherlands.

OBJECTIVE: Several pharmacological therapies are available to help smokers quit. The aim was to investigate the utilisation and effectiveness of smoking cessation drugs in daily practice in the Netherlands. METHODS: Subjects aged ≥18 years with a pharmacy prescription of varenicline, bupropion, nicotine replacement therapy (NRT) or nortriptyline between March 2007 and September 2008 were identified from the PHARMO data warehouse, which includes drug dispensing, hospitalisation and other data from approximately 2.5 million residents in the Netherlands. Using an encrypted methodology, corresponding non-person-identifiable dispensing IDs were linked to a web-based system for patient-reported data collection. Corresponding pharmacists asked the subjects to participate in the study and complete a web-based questionnaire on smoking history and cessation, including utilisation of (pharmaco) therapies. RESULTS: Of 2,684 invited subjects, 698 responded (26%), of whom 612 were included in the analyses. Bupropion was the most frequently used smoking cessation drug (35% of patients), followed by varenicline (28%), bupropion + NRT (12%) and varenicline + NRT (9%). Overall, 51% of patients also reported behavioural therapy. A total of 53% of bupropion users, 51% of varenicline users, 42% of NRT users and 20-40% of patients using multiple drugs reported to not smoke at the time of questionnaire. Median (interquartile range) number of days between time of questionnaire and start date of last quit attempt ranged from 271 (104-432) for varenicline + bupropion to 356 (205-518) for bupropion. Mean duration of drug use ranged from 42 to 53 days among quitters and from 19 to 42 days among relapsers. CONCLUSION: In this study up to 50% of patients who obtained smoking cessation drugs at the pharmacy stopped smoking. Better access to smoking cessation drugs as recommended in guidelines will help to further decrease smoking prevalence.

How adequate are emergency department home and leisure injury surveillance systems for cross-country comparisons in Europe?

The objective of this study was to assess whether the emergency department (ED) injury surveillance systems in Europe are suitable for cross-country comparisons. For this, the ED injury surveillance systems in Austria, Denmark, Greece, Ireland, the Netherlands, Norway and the UK (England, Wales) were considered. Standardised injury incidence and healthcare utilisation indices were calculated and the influence of measurement bias due to data collection and sampling differences, as well as trauma policy and health systems characteristics were assessed. The results showed that there was an over 3-fold variation of the grossly estimated incidence for home and leisure injuries (HLIs), with the highest values observed in England and Greece (111 and 104 per 1000 person years), and the lowest in Ireland and the Netherlands (27 and 48 per 1000 person years). The ranking of countries changed, however, when only injuries with an inherent need for ED treatment were considered (selected radiological verifiable fractures) with Austria topping the table followed by Greece and England. Thus, it is concluded that the naive use of ED injury surveillance systems for cross-country comparisons should be discouraged, as this is subject to measurement bias. Nevertheless, the observed variation in the healthcare utilisation and injury incidence, particularly among children and older people, indicates the potential to reduce the burden of HLI in Europe.

Social time preferences for health and money elicited with a choice experiment.

OBJECTIVES: In economic evaluations future health and monetary outcomes are commonly discounted at equal and constant rates. The theoretical foundation of this practice is being debated and appropriate discount rates for costs and health effects are sought. Here, we have derived social discount rates for health, money, and environmental benefits by means of a choice experiment. METHODS: All choices were framed from a social perspective. We investigated differences in time preference by domain (health, monetary benefits, environmental benefits), time delay (5, 10, and 40 years), and respondent characteristics. Respondents were 173 health-care professionals and 34 health policymakers. Choice titration was used to determine when the respondent was indifferent between future and present benefits. RESULTS: At least two-thirds of respondents preferred an intervention with immediate benefits to delayed benefits in the different domains. The median (mean) yearly discount rates for health benefits were 2.7% (10.7%), 1.3% (3.5%), and 1.1% (2.3%) assuming a 5, 10, and 40 years delay, respectively. Social time preference for monetary benefits was significantly stronger, with median (mean) yearly discount rates of 6.6% (18.7%) and 4.8% (11.2%) assuming a 5 and 10 years delay, respectively. The social time preference with regard to environmental benefits was similar to the monetary benefits. Social time preference for the different domains was significantly correlated at the individual level. CONCLUSIONS: The empirically derived social time preference is in line with current theoretical arguments for a lower discount rate for health benefits than for monetary benefits. Moreover, the implied median discount rates for health were lower than those commonly used or advocated in guidelines.

Preferences of GPs and patients for preventive osteoporosis drug treatment: a discrete-choice experiment.

BACKGROUND: Osteoporotic fractures have a serious economic impact on society and on the quality of life of patients. Differences in opinions on the desirability of preventive treatment initiation may hamper the process and outcome of shared decision making between physician and patient. OBJECTIVE: To evaluate and compare preferences of GPs and patients for preventive osteoporosis drug treatment. METHODS: Discrete-choice experiment (DCE) involving 34 general practices in the area of Rotterdam, the Netherlands. Participants included 40 GPs and 120 women aged > or = 60 years who participated in a study on osteoporosis case finding. We included any woman aged >60 years, with an over-representation of women with a high fracture risk (n = 60). OUTCOMES: (i) The relative weights that GPs and patients place on five treatment attributes of preventive osteoporosis drug treatment: effectiveness, nausea as an adverse effect, total treatment duration, route of drug administration and out-of-pocket costs; and (ii) the determinants of any differences in preferences between GPs and patients. RESULTS: The response rate was 40/59 (68%) for GPs and 120/181 (66%) for patients. All treatment attributes proved to be important for preferences of GPs and patients. GPs had a significantly less favourable attitude towards preventive osteoporosis drug treatment than patients; they placed significantly higher values on effectiveness of preventive drug treatment and short total preventive treatment duration than patients. CONCLUSIONS: GPs and patients showed different preferences towards preventive osteoporosis drug treatment. Addressing each of these differences may have a positive effect on the process and outcomes of shared decision making regarding preventive treatment initiation.

International variation in clinical injury incidence: exploring the performance of indicators based on health care, anatomical and outcome criteria.

OBJECTIVE: To analyse international variation in clinical injury incidence, and explore the performance of different injury indicators in cross-country comparisons. METHODS: Hospital discharge data of seven European countries (Austria, Denmark, Ireland, Netherlands, Norway, England and Wales) were analysed. We tested existing and newly developed indicators based on (a) health care use, (b) anatomical criteria, or (c) expected health outcome: admissions excluding day-cases (a), hospital stay 4+ (a) and 7+ days (a), (serious) long-bone fractures (b), selected radiological verifiable fractures 'SRVFs' (b), and indicators based on international (Global Burden of Disease) and Dutch disability weights). Assessment criteria were reduction in incidence variation and length of stay in hospital, and the association between incidence and mortality rates. RESULTS: Indicators based on health care use led to increased variation in incidence rates. Long bone fractures and SRVFs, and both indicators based on injuries with moderate to high disability showed similar variation in clinical incidence compared to the crude rates, smaller variation in median length of stay in hospital and a good association with mortality rates. CONCLUSION: No perfect or near perfect indicators of clinical injury incidence exist. For international comparisons, indicators based on disability weights, SRVFs and long bone fractures may be sensible indicators to use, in the absence of a direct measure of anatomical severity.

Towards a comprehensive estimate of national spending on prevention.

BACKGROUND: Comprehensive information about national spending on prevention is crucial for health policy development and evaluation. This study provides a comprehensive overview of prevention spending in the Netherlands, including those activities beyond the national health accounts. METHODS: National spending on health-related primary and secondary preventive activities was examined by funding source with the use of national statistics, government reports, sector reports, and data from individual health associations and corporations, public services, occupational health services, and personal prevention. Costs were broken down by diseases, age groups and gender using population-attributable risks and other key variables. RESULTS: Total expenditures on prevention were euro12.5 billion or euro769 per capita in the Netherlands in 2003, of which 20% was included in the national health accounts. 82% was spent on health protection, 16% on disease prevention, and 2% on health promotion activities. Most of the spending was aimed at the prevention of infectious diseases (34%) and acute physical injuries (29%). Per capita spending on prevention increased steeply by age. CONCLUSION: Total expenditure on health-related prevention is much higher than normally reported due to the inclusion of health protection activities beyond the national health accounts. The allocative efficiency of prevention spending, particularly the high costs of health protection and the low costs of health promotion activities, should be addressed with information on their relative cost effectiveness.

Human papillomavirus triage of women with persistent borderline or mildly dyskaryotic smears: Comparison of costs and side effects of three alternative strategies.

The conventional direct referral to colposcopy of persistent borderline or mildly dyskaryotic (BMD) smears in cervical cancer screening leads to considerable unnecessary referrals and associated anxiety and costs. This may be improved by including testing for oncogenic human papillomavirus (HPV) in the triage. We assessed costs and side effects (referrals, treatments and time in follow-up) for 3 possible HPV triage strategies (immediate HPV testing, a 6-month delay in HPV testing, a 2-stage combination of both) and compared them with the conventional strategy. The assessments are based on recent Dutch data from various national databases and trials. We estimated that the referral rate could be reduced by 49, 58 and 58% with immediate, delayed and 2-stage HPV testing, respectively. As a consequence, the average length of follow-up, as well as average costs, also decrease. Therefore, we advocate including HPV testing before referring to colposcopy. Among the 3 HPV strategies, analysis of additional aspects favors implementation of immediate HPV testing.

Individual differences in the use of the response scale determine valuations of hypothetical health states: an empirical study.

BACKGROUND: The effects of socio-demographic characteristics of the respondent, including age, on valuation scores of hypothetical health states remain inconclusive. Therefore, we analyzed data from a study designed to discriminate between the effects of respondents' age and time preference on valuations of health states to gain insight in the contribution of individual response patterns to the variance in valuation scores. METHODS: A total of 212 respondents from three age groups valued the same six hypothetical health states using three different methods: a Visual Analogue Scale (VAS) and two variants of the Time trade-off (TTO). Analyses included a generalizability study, principal components analysis, and cluster analysis. RESULTS: Valuation scores differed significantly, but not systematically, between valuation methods. A total of 36.8% of variance was explained by health states, 1.6% by the elicitation method, and 0.2% by age group. Individual differences in the use of the response scales (e.g. a tendency to give either high or low TTO scores, or a high or low scoring tendency on the VAS) were the main source of remaining variance. These response patterns were not related to age or other identifiable respondent characteristics. CONCLUSION: Individual response patterns in this study were more important determinants of TTO or VAS valuations of health states than age or other respondent characteristics measured. Further valuation research should focus on explaining individual response patterns as a possible key to understanding the determinants of health state valuations.

Effectiveness of a back pain prevention program: a cluster randomized controlled trial in an occupational setting.

STUDY DESIGN: A cluster randomized controlled trial and economic evaluation with a 12-month follow-up and with work department as the unit of randomization. OBJECTIVE: To evaluate the effectiveness of a prevention program for low back pain (LBP) in an occupational setting with an economic evaluation. SUMMARY OF BACKGROUND DATA: LBP accounts for high economic costs in Western societies. Little is known on the effectiveness and related costs and savings of prevention programs for LBP. METHODS: The study population consisted of workers in physically demanding jobs from 9 large companies located throughout The Netherlands. In each company, 2 comparable work units were randomly allocated, resulting in 18 clusters with 258 workers assigned to the intervention group and 231 workers to the control group. RESULTS: Results in our study did not show significant differences in effects or costs savings of the program. Indirect costs related to work absence and productivity losses accounted for the majority (84%) of total costs due to LBP. CONCLUSIONS: This study provides no evidence for the adoption of this worksite prevention program for LBP.

Guidelines for the conduction of follow-up studies measuring injury-related disability.

BACKGROUND: Scientific knowledge on functional outcome after injury is limited. During the past decade, a variety of measures have been used at various moments in different study populations. Guidelines are needed to increase comparability between studies. METHODS: A working group of the European Consumer Safety Association conducted a literature review of empirical studies into injury-related disability (1995-2005). We included injury from all levels of severity and selected studies using generic health status measures with both short-term and long-term follow up. The results were used as input for a consensus procedure toward the development of guidelines for defining the study populations, selecting the health status measures, selecting the timings of the assessments, and data collection procedures. RESULTS: The group reached consensus on a common core of health status measures and assessment moments. The group advises to use a combination of EuroQol-5D and Health Utilities Mark III in all studies on injury-related disability. This combination covers all relevant health domains, is applicable in all kinds of injury populations and in widely different age ranges, provides a link with utility scores, and has several practical advantages (e.g., brevity, availability in different languages). For specific types of injury, the common core may be supplemented by injury-specific measures. The group advises a common core of assessments at 1, 2, 4, and 12 months after injury. CONCLUSIONS: Our guidelines should be tested and may lead to improved and more consistent epidemiologic data on the incidence, severity, and duration of injury-related disability.

Functional outcome at 2.5, 5, 9, and 24 months after injury in the Netherlands.

BACKGROUND: The collection of empirical data on the frequency, severity, and duration of functioning is a prerequisite to identify patient groups with long term or permanent disability. METHODS: We fielded postal questionnaires in a stratified sample of 8,564 injury patients aged 15 years and older, who had visited an emergency department in the Netherlands. Measurements were at 2.5, 5, 9, and 24 months after the injury and included a generic health status classification (EQ-5D), socio-demographic, and medical information. We analyzed determinants of long-term functional outcome by multivariate regression analysis. RESULTS: Five months after the injury health status of nonhospitalized injury patients was comparable to the general population's health (EQ-5D summary measure 0.87). Health status of patients admitted for 3 days or less improved until 9 months (0.82). For those admitted more than 3 days health status improved until 24 months (0.48 toward 0.67), but remained below population norms. Hospitalization, age and sex (females), type of injury (spinal cord injury, hip fracture, and lower extremity injury), and comorbidity were significant predictors of poor functioning in the long term. CONCLUSIONS: Recovery patterns vary widely between nonhospitalized, shortly, and long hospitalized injury patients. Nonhospitalized injury patients recover within 5 months from an injury whereas a considerable group of hospitalized injury patients suffer from persistent health problems. Our study indicates the importance of health monitoring with an adapted longitudinal design for injury patients. The time intervals used should match the various stages of the recovery process, which depends on the severity of the injury studied.

Assessing the burden of injury in six European countries.

OBJECTIVE: To assess injury-related mortality, disability and disability-adjusted life years (DALYs) in six European countries. METHODS: Epidemiological data (hospital discharge registers, emergency department registers, mortality databases) were obtained for Austria, Denmark, Ireland, Netherlands, Norway, and the United Kingdom (England and Wales). For each country, the burden of injury was estimated in years lost due to premature mortality (YLL), years lived with disability (YLD), and DALYs (per 1000 persons). FINDINGS: We observed marked differences in the burden of injury between countries. Austria lost the largest number of DALYs (25 per 1000 persons), followed by Denmark, Norway and Ireland (17-20 per 1000 persons). In the Netherlands and United Kingdom, the total burden due to injuries was relatively low (12 per 1000 persons). The variation between countries was attributable to a high variation in premature mortality (YLL varied from 9-17 per 1000 persons) and disability (YLD varied from 2-8 per 1000 persons). In all countries, males aged 25-44 years represented one third of the total injury burden, mainly due to traffic and intentional injuries. Spinal cord injury and skull-brain injury resulted in the highest burden due to permanent disability. CONCLUSION: The burden of injury varies considerably among the six participating European countries, but males aged 15-24 years are responsible for a disproportionate share of the assessed burden of injury in all countries. Consistent injury control policy is supported by high-quality summary measures of population health. There is an urgent need for standardized data on the incidence and functional consequences of injury.

Incidence and costs of injuries in The Netherlands.

BACKGROUND: Injuries are a major and persistent public health problem, but a comprehensive and detailed overview of the economic burden is missing. We therefore estimated the number of emergency department (ED) attendances and health care costs as a result of injury. METHODS: We estimated lifetime health care costs of injuries occurring in The Netherlands in the year 1999. Patient groups were defined that are homogeneous in terms of health service use. Health service use and costs per patient group was estimated with data from national databases and a prospective study among 5755 injury patients. RESULTS: Total health care costs due to injury in 1999 were euro 1.15 billion, or 3.7% of the total health care budget. Major cost peaks were observed among males between ages 15 and 44 due to a high incidence, and among females from age 65 onwards due to a high incidence and high costs per patient. For the age groups 0-14, 15-44, 45-64, and 65+ ED attendances per 1000 person years were 85, 85, 43, and 49, respectively, and costs per capita were euro 38, euro 59, euro 43, and euro 210, respectively. Costs per patient rise about linearly up to age 60 and about exponentially thereafter. From age 25 onwards, females have higher costs per patient than males. Hip fracture (20%), superficial injury (13%), open wounds (7%), and skull-brain injury (6%) had the highest total costs. Most costs were attributable to falls (44%) and traffic injuries (19%). CONCLUSION: Young adult males, elderly females, falls, hip fractures, and minor injuries without medical need for hospitalization account for a substantial share of health care costs.

Prevalence and prognostic factors of disability after childhood injury.

OBJECTIVE: To assess the prevalence and the prognostic factors of disabilities after minor and major childhood injuries and to analyze which sociodemographic and injury-related factors are predictive for suboptimal functioning in the long term. METHOD: We conducted a patient follow-up study in a stratified sample of 1221 injured children who were aged 5 to 14 years and had visited an emergency department in The Netherlands. Our study sample was stratified so that severe, less common injuries were overrepresented. Postal questionnaires were sent 2.5, 5, and 9 months after the injury. We gathered injury and external cause data, sociodemographic information, and data on functional outcome with a generic health status measure EuroQol (EQ-5D) with an additional cognitive dimension. A nonresponse analysis was performed by multivariate logistic regression, and the data were adjusted for nonresponse and the sample stratification. We performed bootstrap analysis to estimate the prevalence of disability in terms of the EQ-5D summary score and the occurrence of limitations in separate health domains: mobility, self-care, usual activities, pain/discomfort, anxiety/depression, and cognition. Respondents also rated their own health state on a visual analog scale, between 0 (worst imaginable health state) and 100 (best imaginable health state). We analyzed the relationship between functional outcome and sociodemographic (age and gender) and injury-related determinants (type of injury, external cause, multiple injury, admission to hospital, and length of stay) by logistic regression analysis. RESULTS: Response rates with respect to the original sample were 43%, 31%, and 30%, respectively. A total of 37% of the children were admitted to the hospital. The mean age of the children was 9.6 years. In two thirds (65%) of the cases, the injury was attributed to a home and/or leisure injury. The health status of injured children improved from 0.92 (EQ-5D summary score) at 2.5 months to 0.96 at 5 months and 0.98 at 9 months. Of all injured children, 26% had at least 1 functional limitation after 2.5 months, 18% after 5 months, and 8% still experienced functional limitations after 9 months. After 2.5 months, lower extremity fractures and other injuries (eg, spinal cord injury, injury of the nerves) demonstrated the worst functional outcome. Independent of the type of injury, our sample of injured children generally showed good recovery between 2.5 and 9 months. The highest prevalence of dysfunction after 9 months existed for pain/discomfort (7%) and usual activities (5%). Hospital admission (odds ratio: 3.6-5.8) and female gender (odds ratio: 3.0) were predictive for long-term disability. Girls reported more problems for all health domains (except self-care) compared with boys after 9 months, which was also confirmed by the visual analog scale score for self-related health (89 for girls vs 95 for boys). Almost one fifth of injured children with a hospital stay of >3 days still had pain and problems with usual activities 9 months after the injury. Three quarters of all residual problems were caused by nonhospitalized injuries. CONCLUSION: Most children show quick and full recovery after injury, but a small subgroup of patients (8%) have residual disabilities after 9 months. Girls have a 3-fold risk compared with boys for long-term disability after childhood injury. Prognosis in the long-term is also negatively influenced by hospitalization, but in absolute terms, residual disabilities are frequently caused by injuries that are treated fully in the emergency department. The group of injured children with persistent health problems as identified in this study indicates the importance of health monitoring over a longer period in trauma care, whereas trauma care should be targeted at early identification and management of the particular needs of these patients.

Reduced productivity after sickness absence due to musculoskeletal disorders and its relation to health outcomes.

OBJECTIVES: This prospective cohort study quantified the reduced productivity of workers on full duty after sickness absence from a musculoskeletal disorder and determined the effect of health parameters such as perceived pain, functional disability, and general health on reduced productivity. METHODS: Workers were included who were returning to work from 2- to 6-week sickness absence due to a musculoskeletal disorder. Self-administered questionnaires at baseline, after return to work, and at a 12-month follow-up were used to collect information on productivity and health status. Logistic regression analyses evaluated the determinants of reduced productivity and determined the level of productivity loss shortly after return to work. RESULTS: Reduced productivity was prevalent for 60% of the workers after they returned to work, and for 40% still at the 12-month follow-up. The initial musculoskeletal disorder caused 75% of the productivity loss shortly after return to work and 60% at the follow-up. Among those with productivity loss, the median loss for an 8-hour workday was 1.6 hours shortly after return to work and also at the follow-up. Worse physical health, more functional disability, and poorer relations with the supervisor were associated with productivity loss shortly after return to work, whereas recurrent sick leave was the greatest predictor of productivity loss at the follow-up. CONCLUSIONS: Reduced productivity was common among workers returning to full duty after sickness absence due to a musculoskeletal disorder. Productivity loss illustrates the importance of the timing of return to work, especially among workers with residual functional disability after return to work. Moreover, the supervisor should be engaged early in the return-to-work process to guarantee an early, sustainable, and productive return to work for the employee.

Societal discounting of health effects in cost-effectiveness analyses: the influence of life expectancy.

BACKGROUND: Increasing life expectancy and decreasing marginal valuation of additional QALYs over time may serve as a basis for discounting future health effects from a societal perspective. Therefore, we tested the hypothesis that societal time preference for health is related to perceived future life expectancy. METHODS: A sample of 223 people from the general population prioritised healthcare programmes with differential timing of health benefits and costs from a societal perspective. Furthermore, we asked respondents to estimate future life expectancy. RESULTS: The relationship between future life expectancy and time preference for health is ambiguous. We observed that people who expected a higher future life expectancy elicited higher discount rates for health effects than those with lower life expectancy growth expectations for all four time periods (5, 10, 20 and 40 years into the future), but the differences were never significant. On average, providing explicit information on growth in life expectancy did significantly alter discount rates in the expected direction but, on an individual level, the results were rather inconsistent. We observed a significantly stronger time preference (i.e. higher discount rates) for health effects than for costs. As commonly observed, discount rates for health and money decreased with time delay following a hyperbolic function. CONCLUSION: Our data indicate that it is troublesome to elicit societal discount rates empirically, especially rates that are in line with the theoretical arguments on societal discounting. The influence of life expectancy remains ambiguous, but there seems to be at least some positive relationship between growth in life expectancy and discount rates that deserves additional attention.