Postponed healthcare in The Netherlands during the COVID-19 pandemic and its impact on self-reported health.

Background: Healthcare services have been seriously disrupted during the COVID-19 pandemic. The aim of this study was to examine the extent to which Dutch citizens have experienced postponed healthcare and how this affected their self-reported health. In addition, individual characteristics that were associated with experiencing postponed healthcare and with self-reported negative health effects were investigated. Methods: An online survey about postponed healthcare and its consequences was developed, and sent out to participants of the Dutch LISS (Longitudinal Internet Studies for the Social Sciences) panel (n = 2.043). Data were collected in August 2022. Multivariable logistic regression analyses were carried out to explore characteristics associated with postponed care and self-reported negative health outcomes. Results: Of the total population surveyed, 31% of the panel experienced postponed healthcare, either initiated by the healthcare provider (14%), on their own initiative (12%) or as a combination of both (5%). Postponed healthcare was associated with being female (OR = 1.61; 95% CI = 1.32; 1.96), presence of chronic diseases (OR = 1.55, 95% CI = 1.24; 1.95), high income (OR = 0.62, 95% CI = 0.48; 0.80) and worse self-reported health (poor vs. excellent OR = 2.88, 95% CI = 1.17; 7.11). Overall, 40% experienced temporary or permanent self-reported negative health effects due to postponed care. Negative health effects as a result of postponed care were associated with presence of chronic conditions and low income levels (p < 0.05). More respondents with worse self-reported health and foregone healthcare reported permanent health effects as compared to those with temporary health effects (p < 0.05). Discussion: People with an impaired health status are most likely to experiencing postponed healthcare and negative health consequences as a result. Furthermore, those with negative health consequences decided to forego health by themselves more often. As part of long-term plans to maintain the accessibility of healthcare services, specific attention should be paid to reaching out to people with an impaired health status.

Estimating the health impact of delayed elective care during the COVID -19 pandemic in the Netherlands.

BACKGROUND: The COVID-19 pandemic had a major impact on the continuity of healthcare provision. Appointments, treatments and surgeries for non-COVID patients were often delayed, with associated health losses for patients involved. OBJECTIVE: To develop a method to quantify the health impact of delayed elective care for non-COVID patients. METHODS: A model was developed that estimated the backlog of surgical procedures in 2020 and 2021 using hospital registry data. Quality-adjusted life years (QALYs) were obtained from the literature to estimate the non-generated QALYs related to the backlog. In sensitivity analyses QALY values were varied by type of patient prioritization. Scenario analyses for future increased surgical capacity were performed. RESULTS: In 2020 and 2021 an estimated total of 305,374 elective surgeries were delayed. These delays corresponded with 319,483 non-generated QALYs. In sensitivity analyses where QALYs varied by type of patient prioritization, non-generated QALYs amounted to 150,973 and 488,195 QALYs respectively. In scenario analyses for future increased surgical capacity in 2022-2026, the non-generated QALYs decreased to 311,220 (2% future capacity increase per year) and 300,710 (5% future capacity increase per year). Large differences exist in the extent to which different treatments contributed to the total health losses. CONCLUSIONS: The method sheds light on the indirect harm related to the COVID-19 pandemic. The results can be used for policy evaluations of COVID-19 responses, in preparations for future waves or other pandemics and in prioritizing the allocation of resources for capacity increases.

BMI trajectories after primary school-based lifestyle intervention: Unravelling an uncertain future. A mixed methods study.

This mixed methods study aimed to examine plausible body mass index (BMI) trajectories after exposure to a primary school-based lifestyle intervention to aid in estimating the long-term intervention benefits. BMI trajectories for children at control schools (mean 7.6 years of age) were modelled until 20 years of age through extrapolating trial evidence (N = 1647). A reference scenario assumed that the observed 2-year effects of the 'Healthy Primary Schools of the Future' (HPSF) and 'Physical Activity Schools' (PAS) were fully maintained over time. This was modelled by applying the observed 2-year BMI effects until 20 years of age. Expert opinions on likely trends in effect maintenance after the 2-year intervention period were elicited qualitatively and quantitatively, and were used for developing alternative scenarios. Expert elicitation revealed three scenarios: (a) a constant exposure-effect and an uncontrolled environment with effect decay scenario, (b) a household multiplier and an uncontrolled environment with effect decay scenario, and (c) a household multiplier and maintainer scenario. The relative effect of HPSF at 20 years of age was -0.21 kg/m2 under the reference scenario, and varied from -0.04 kg/m2 (a) to -0.06 kg/m2 (b), and -0.50 kg/m2 (c). For PAS, the relative effect was -0.17 kg/m2 under the reference scenario, and varied from -0.04 kg/m2 (a, b), to -0.21 kg/m2 (c). The mixed methods approach proved to be useful in modelling plausible BMI trajectories and specifying uncertainty on effect maintenance. Further observations until adulthood could reduce the uncertainty around future benefits. This trial was retrospectively registered at Clinicaltrials.gov (NCT02800616).

Lifetime cost-effectiveness and equity impacts of the Healthy Primary School of the Future initiative.

BACKGROUND: This study estimated the lifetime cost-effectiveness and equity impacts associated with two lifestyle interventions in the Dutch primary school setting (targeting 4-12 year olds). METHODS: The Healthy Primary School of the Future (HPSF; a healthy school lunch and structured physical activity) and the Physical Activity School (PAS; structured physical activity) were compared to the regular Dutch curriculum (N = 1676). An adolescence model, calculating weight development, and the RIVM Chronic Disease Model, calculating overweight-related chronic diseases, were linked to estimate the lifetime impact on chronic diseases, quality adjusted life years (QALYs), healthcare, and productivity costs. Cost-effectiveness was expressed as the additional costs/QALY gained and we used €20,000 as threshold. Scenario analyses accounted for alternative effect maintenance scenarios and equity analyses examined cost-effectiveness in different socioeconomic status (SES) groups. RESULTS: HPSF resulted in a lifetime costs of €773 (societal perspective) and a lifetime QALY gain of 0.039 per child versus control schools. HPSF led to lower costs and more QALYs as compared to PAS. From a societal perspective, HPSF had a cost/QALY gained of €19,734 versus control schools, 50% probability of being cost-effective, and beneficial equity impact (0.02 QALYs gained/child for low versus high SES). The cost-effectiveness threshold was surpassed when intervention effects decayed over time. CONCLUSIONS: HPSF may be a cost-effective and equitable strategy for combatting the lifetime burden of unhealthy lifestyles. The win-win situation will, however, only be realised if the intervention effect is sustained into adulthood for all SES groups. TRIAL REGISTRATION: Clinicaltrials.gov ( NCT02800616 ). Registered 15 June 2016 - Retrospectively registered.

The Short-Term Value of the "Healthy Primary School of the Future" Initiative: A Social Return on Investment Analysis.

Background: This study examines the social return on investment (SROI) of the "Healthy Primary School of the Future" initiative after 2 years. Methods: Healthy Primary Schools of the Future (HPSF) provide a healthy lunch and daily structured physical activity sessions, whereas Physical Activity Schools (PAS) focus on physical activity only. We evaluated the 2-years investments and effects (N = 1,676 children) of both school environments (four schools) compared to control schools (four schools). Investments and outcomes were grouped within the healthcare, education, household & leisure, and labor & social security sector. Outcomes that could be expressed in monetary terms were used for the calculation of social return on investment. Results: HPSF and PAS created outcomes for the healthcare sector by favorable changes in health behaviors, body mass index [both significant], and medical resource use [not significant]. Outcomes for the education sector included a favorable impact on perceived social behaviors and school satisfaction, and absenteeism from school [latter not significant], and more engagement with the community was experienced. The per child investments, €859 (HPSF) and €1017 (PAS), generated a benefit of €8 (HPSF) and €49 (PAS) due to reduced school absenteeism and medical resource use. Conclusions: Within 2 years of intervention implementation, the HPSF initiative created outcomes in several sectors, but the benefits did not outweigh the investments. Follow-up assessments as well as modeling long-term outcomes are needed to assess the total value of the interventions. Until then, the SROI framework can inform strategies for obtaining stakeholder support and intervention implementation. Trial registration: The study was registered in the ClinicalTrials.gov database on 14 June 2016 (NCT02800616).

Can the Healthy Primary School of the Future offer perspective in the ongoing obesity epidemic in young children? A Dutch quasi-experimental study.

OBJECTIVES: Schools play an important role in promoting healthy behaviours in children and can offer perspective in the ongoing obesity epidemic. The 'Healthy Primary School of the Future' (HPSF) aims to improve children's health and well-being by enhancing school health promotion. The current study aims to assess the effect of HPSF on children's body mass index (BMI) z-score after 1 and 2 years follow-up and to investigate whether HPSF has different effects within specific subgroups of children. DESIGN: A longitudinal quasi-experimental design. SETTING: Four intervention and four control schools participated; located in a low socioeconomic status region in the Netherlands. PARTICIPANTS: 1676 children (aged 4-12 years). INTERVENTIONS: HPSF uses a contextual systems approach and includes health-promoting changes in the school. Central to HPSF is the provision of a daily healthy lunch and structured physical activity sessions each day. Two intervention schools implemented both changes (full HPSF), two intervention schools implemented only the physical activity change (partial HPSF). MAIN OUTCOME MEASURES: BMI z-score, determined by measurements of children's height and weight at baseline, after 1 and 2 years follow-up. RESULTS: The intervention effect was significant after 1-year follow-up in the partial HPSF (standardised effect size (ES)=-0.05), not significant in the full HPSF (ES=-0.04). After 2 years follow-up, BMI z-score had significantly decreased in children of both the full HPSF (ES=-0.08) and the partial HPSF (ES=-0.07) compared with children of the control schools, whose mean BMI z-score increased from baseline to 2 years. None of the potential effect modifiers (gender, baseline study year, socioeconomic status and baseline weight status) were significant. CONCLUSIONS: HPSF was effective after 1 and 2 years follow-up in lowering children's BMI z-scores. No specific subgroups of children could be identified who benefitted more from the intervention. TRIAL REGISTRATION NUMBER: NCT02800616.

Correction to: A Cost Analysis of School-Based Lifestyle Interventions.

In the article, 'A Cost Analysis of School-Based Lifestyle Interventions', we calculated the societal costs of two school-based lifestyle interventions: 'the Healthy Primary School of the Future' and 'the Physical Activity School'.

Longitudinal analysis of health disparities in childhood.

OBJECTIVE: Combatting disparities in health outcomes among children is a major public health concern. This study focuses on two questions: (1) To what extent does socioeconomic status (SES) contribute to disparities in health outcomes? and (2) To what extent can social inequalities in health outcomes be explained by differences in children's health behaviours? DESIGN: This study included 2-year follow-up data of 1259 children (4-12 years of age) who participated in the 'Healthy Primary School of the Future' project (ClinicalTrials.gov NCT02800616). SES was measured by maternal and paternal education and household income (adjusted for family size). Health outcomes were body mass index (BMI) z-score, health resource use, school absenteeism, health-related quality of life and psychosocial health, measured over 2 years of follow-up (2015-2017). Health behaviours included physical activity, and consumption of fruits, vegetables and sweetened beverages. Associations between SES and baseline health behaviours were examined, and mixed models for repeated measures were used to assess associations between SES and health outcomes over 2 years of follow-up. RESULTS: A high socioeconomic background was significantly associated with better health outcomes (all outcomes). For example, children with a low SES had higher BMI z-scores (beta coefficient: 0.42, 95% CI 0.22 to 0.62) and higher consumption healthcare costs (ratio of mean costs: 2.21, 95% CI 1.57 to 3.10). Effects of SES changed very little after controlling for health behaviours. DISCUSSION: Our findings strongly suggest that socioeconomic background has a pervasive impact on disparities in child health, but gives little support to the idea that social inequalities in child health can be tackled by means of lifestyle interventions.

One- and Two-Year Effects of the Healthy Primary School of the Future on Children's Dietary and Physical Activity Behaviours: A Quasi-Experimental Study.

Schools can help to improve children's health. The 'Healthy Primary School of the Future' (HPSF) aims to sustainably integrate health and well-being into the school system. This study examined the effects of HPSF on children's dietary and physical activity (PA) behaviours after 1 and 2 years' follow-up. The study (n = 1676 children) has a quasi-experimental design with four intervention schools, i.e., two full HPSF (focus: nutrition and PA) and two partial HPSF (focus: PA), and four control schools. Accelerometers and child- and parent-reported questionnaires were used at baseline, after 1 (T1) and 2 (T2) years. Mixed-model analyses showed significant favourable effects for the full HPSF versus control schools for, among others, school water consumption (effect size (ES) = 1.03 (T1), 1.14 (T2)), lunch intake of vegetables (odds ratio (OR) = 3.17 (T1), 4.39 (T2)) and dairy products (OR = 4.43 (T1), 4.52 (T2)), sedentary time (ES = -0.23 (T2)) and light PA (ES = 0.22 (T2)). Almost no significant favourable effects were found for partial HPSF compared to control schools. We conclude that the full HPSF is effective in promoting children's health behaviours at T1 and T2 compared with control schools. Focusing on both nutrition and PA components seems to be more effective in promoting healthy behaviours than focusing exclusively on PA.

A systematic review on economic evaluations of school-based lifestyle interventions targeting weight-related behaviours among 4-12 year olds: Issues and ways forward.

Current guidelines for economic evaluations do not provide specific recommendations for the evaluation of school-based lifestyle interventions. This study examined and discussed the key aspects in the design of economic evaluations on school-based interventions targeting weight-related behaviours among 4-12 year olds. The PubMed and CRD databases (NHS EED) were searched. Grey literature was identified from reference lists and websites of relevant organizations. Full economic evaluations on school-based interventions targeting physical activity, sedentariness, or diet were selected. Key aspects included the objective, audience, intervention, comparator, population, type of analysis, perspective, costs, outcomes, and time horizon. Information was also extracted on measuring and valuing costs and outcomes, linking and extrapolating outcomes, and the maintenance of intervention effects. The 23 included studies reported on cost-effectiveness (CEAs) (N = 12), cost-utility (CUAs) (N = 9), social cost benefit (SCBA) (N = 2), and social return on investment (SROI) (N = 1) analysis. The usual practice comparator was generally not clearly defined. The SROI analysis was the single study that included outcomes in other persons than the child. Healthcare costs (N = 14), productivity costs (N = 4), and costs to the household (N = 3), or education (N = 2) sector were examined. The outcome in trial-based CEAs consisted of a variety of weight-related measures. Seven distinctive models were used to extrapolate health and/or productivity costs. To enhance the usefulness of economic evaluations on school-based lifestyle interventions in allocating public health budgets, transparent reporting on key aspects, broadening the scope of economic evaluations, and standardizing the measurement, valuation, and extrapolation of costs and outcomes should be improved. This study was conducted in Maastricht, the Netherlands.

A Cost Analysis of School-Based Lifestyle Interventions.

A uniform approach for costing school-based lifestyle interventions is currently lacking. The objective of this study was to develop a template for costing primary school-based lifestyle interventions and apply this to the costing of the "Healthy Primary School of the Future" (HPSF) and the "Physical Activity School" (PAS), which aim to improve physical activity and dietary behaviors. Cost-effectiveness studies were reviewed to identify the cost items. Societal costs were reflected by summing up the education, household and leisure, labor and social security, and health perspectives. Cost inputs for HPSF and PAS were obtained for the first year after implementation. In a scenario analysis, the costs were explored for a hypothetical steady state. From a societal perspective, the per child costs were €2.7/$3.3 (HPSF) and €- 0.3/$- 0.4 (PAS) per day during the first year after implementation, and €1.0/$1.2 and €- 1.3/$- 1.6 in a steady state, respectively (2016 prices). The highest costs were incurred by the education perspective (first year: €8.7/$10.6 (HPSF) and €4.0/$4.9 (PAS); steady state: €6.1/$7.4 (HPSF) and €2.1/$2.6 (PAS)), whereas most of the cost offsets were received by the household and leisure perspective (first year: €- 6.0/$- 7.3 (HPSF) and €- 4.4/$- 5.4 (PAS); steady state: €- 5.0/$- 6.1 (HPSF) and €- 3.4/$- 4.1 (PAS)). The template proved helpful for costing HPSF and PAS from various stakeholder perspectives. The costs for the education sector were fully (PAS) and almost fully (HPSF) compensated by the savings within the household sector. Whether the additional costs of HPSF over PAS represent value for money will depend on their relative effectiveness.

Socioeconomic multi-domain health inequalities in Dutch primary school children.

Background: This study assesses socio-economic health inequalities (SEHI) over primary school-age (4- to 12-years old) across 13 outcomes (i.e. body-mass index [BMI], handgrip strength, cardiovascular fitness, current physical conditions, moderate to vigorous physical activity, sleep duration, daily fruit and vegetable consumption, daily breakfast, exposure to smoking, mental strengths and difficulties, self-efficacy, school absenteeism and learning disabilities), covering four health domains (i.e. physical health, health behaviour, mental health and academic health). Methods: Multilevel mixed effect (linear and logistic) regression analyses were applied to cross-sectional data of a Dutch quasi-experimental study that included 1403 pupils from nine primary schools. Socioeconomic background (high-middle-low) was indicated by maternal education (n = 976) and parental material deprivation (n = 784). Results: Pupils with higher educated mothers had lower BMIs, higher handgrip strength and higher cardiovascular fitness; their parents reported more daily fruit and vegetable consumption, daily breakfast and less exposure to smoking. Furthermore these pupils showed less mental difficulties and less school absenteeism compared with pupils whose mothers had a lower education level. When using parental material deprivation as socio-economic indicator, similar results were found for BMI, cardiovascular fitness, sleep duration, exposure to smoking and mental strengths and difficulties. Socio-economic differences in handgrip strength, cardiovascular fitness and sleep duration were larger in older than in younger pupils. Conclusions: Childhood SEHI are clearly found across multiple domains, and some are larger in older than in younger pupils. Interventions aiming to tackle SEHI may therefore need a comprehensive and perhaps more fundamental approach.

Ixekizumab for Treating Moderate-to-Severe Plaque Psoriasis: An Evidence Review Group Perspective of a NICE Single Technology Appraisal.

The National Institute for Health and Care Excellence invited Eli Lilly and Company Ltd, the company manufacturing ixekizumab (tradename Taltz®), to submit evidence for the clinical and cost effectiveness of ixekizumab. Ixekizumab was compared with tumour necrosis factor-α inhibitors (etanercept, infliximab, adalimumab), ustekinumab, secukinumab, best supportive care and, if non-biological treatment or phototherapy is suitable, also compared with systemic non-biological therapies and phototherapy with ultraviolet B radiation for adults with moderate-to-severe plaque psoriasis. Kleijnen Systematic Reviews Ltd, in collaboration with Maastricht University Medical Center, was commissioned as the independent Evidence Review Group. This article presents a summary of the company submission, the Evidence Review Group report and the development of the National Institute for Health and Care Excellence guidance for the use of this drug in England and Wales by the Appraisal Committee. The Evidence Review Group produced a critical review of the clinical and cost effectiveness of ixekizumab based on the company submission. The company submission presented three randomised controlled trials identified in a systematic review. All randomised controlled trials were phase III, multicentre placebo-controlled trials including 3866 participants with moderate-to-severe psoriasis. Two trials also included an active comparator (etanercept). All randomised controlled trials showed statistically significant increases in two primary outcomes, static Physician Global Assessment (0,1) and improvement of 75% from baseline in the Psoriasis Area and Severity Index. Ixekizumab was generally well tolerated in the randomised controlled trials, with similar discontinuation rates because of adverse events as placebo or etanercept. The most frequent adverse events of special interest were infections and injection-site reactions. The company submission also included a network meta-analysis of relevant comparators. The Evidence Review Group highlighted some issues regarding the systematic review process and an issue with the generalisability of the findings in that the trials failed to include patients with moderate psoriasis according to a widely used definition. This issue was considered by the Appraisal Committee and the population was deemed generalisable to patients in England and Wales. Based on the network meta-analysis, the Appraisal Committee concluded that ixekizumab was more clinically effective than adalimumab and ustekinumab, and agreed it was likely that ixekizumab was similarly effective compared with secukinumab and infliximab while tolerability was similar to other biological treatments approved for treating psoriasis. The Evidence Review Group's critical assessment of the company's economic evaluation highlighted a number of concerns, including (1) the use of relative outcomes such as Psoriasis Area and Severity Index response to model the cost effectiveness; (2) the exclusion of the consequences of adverse events; (3) the assumption of no utility gain in the induction phase; (4) equal annual discontinuation rates for all treatments; (5) the selection of treatment sequences for consideration in the analyses and; (6) the transparency of the Visual Basic for Applications code used to develop the model. Although some of these issues were adjusted in the Evidence Review Group base case, the Evidence Review Group could not estimate the impact of all of these issues, and thus acknowledges that there are still uncertainties concerning the cost-effectiveness evidence. In the Evidence Review Group base-case incremental analysis, the treatment sequence incorporating ixekizumab in the second line has an incremental cost-effectiveness ratio of £25,532 per quality-adjusted life-year gained vs. the etanercept sequence. Ixekizumab in the first-line sequence has an incremental cost-effectiveness ratio of £39,129 per quality-adjusted life-year gained compared with the treatment sequence incorporating ixekizumab in the second line. Consistent with its conclusion regarding clinical effectiveness, the Appraisal Committee concluded that the cost effectiveness of ixekizumab for treating moderate-to-severe plaque psoriasis was similar to that of other biological treatments, already recommended in previous National Institute for Health and Care Excellence guidance. The committee concluded that the incremental cost-effectiveness ratio was within the range that could be considered a cost-effective use of National Health Service resources.

A Systematic Review of Health Economic Evaluations of Diagnostic Biomarkers.

BACKGROUND: Diagnostic biomarkers have multiple applications along the care process and have a large potential in optimizing treatment decisions. However, many diagnostic biomarkers struggle to gain market access and obtain appropriate coverage because of a lack of evidence on their health economic impact. OBJECTIVES: The aim was to review the (methodological) characteristics of recent economic evaluations on diagnostic biomarkers and examine whether these studies dealt with specific issues such as different payer perspectives, preference heterogeneity, and multiple applications in subpopulations. METHODS: The PubMed database and the National Health Service Economic Evaluation Database were searched. Full economic evaluations published after 2009 assessing diagnostic biomarkers for the main non-communicable diseases in middle-income or high-income countries were considered eligible. Empirical and methodological study characteristics were summarized, as was the handling of specific issues related to the economic evaluation of personalized medicine. RESULTS: Thirty-three economic evaluations were included, of which 25 were model-based analyses. The number of strategies compared ranged from two to 17 per study, and was especially large in studies assessing genetic testing in patients and their relatives. Cost-effectiveness results were most sensitive to test accuracy and costs of the biomarker (N = 7), the relative risk of an event (N = 4), and the proportion of people accepting genetic testing (N = 2). One study incorporated patient preferences, and none of the studies considered different payer perspectives, cost sharing arrangements or variable opportunity costs due to population density variability. CONCLUSIONS: Published health economic evaluations of biomarkers used for diagnosing, staging diseases, and guiding treatment selection are characterized by a large number of comparators to model the potential clinical applications and to determine their value. Assessing outcomes beyond health as well as specific issues, such as different payer perspectives and patient preferences, is crucial to fully capture the potential health economic impact of diagnostic biomarkers and to inform value-based reimbursement.