Systematic Review on the Cost Effectiveness of Prostate Cancer Screening in Europe.

BACKGROUND AND OBJECTIVE: In Europe, prostate cancer (PCa) is the most common cancer in men. Screening may therefore be crucial to lower health care costs, morbidity, and mortality. This systematic review aimed to provide a contemporary overview of the costs and benefits of PCa screening programmes. METHODS: A peer-reviewed literature search was conducted, using the PICO method. A detailed search strategy was developed in four databases based on the following key search terms: "PCa", "screening", and "cost effectiveness". Any type of economic evaluation was included. The search strategy was restricted to European countries, but no restrictions were set on the year of publication. KEY FINDINGS AND LIMITATIONS: A total of 7484 studies were identified initially. Of these, 19 studies described the cost effectiveness of PCa screening in Europe. Among the studies using an initially healthy study population, most focussed on risk- and/or age- and/or magnetic resonance imaging (MRI)-based screening in addition to prostate-specific antigen (PSA) testing and compared this with no screening. Incremental cost ratios (ICERs) varied from €5872 per quality-adjusted life year (QALY) to €372 948/QALY, with a median of €56 487/QALY. Risk-based screening followed by MRI testing seemed to be a more cost-effective strategy than no screening. CONCLUSIONS AND CLINICAL IMPLICATIONS: This systematic review indicates that screening programmes incorporating a risk-based approach and MRI have the potential to be cost effective. PATIENT SUMMARY: In this review, we looked at the cost effectiveness of prostate cancer screening in Europe. We found that a risk-based approach and incorporation of magnetic resonance imaging has the potential to be cost effective. However, there remains a knowledge gap regarding cost effectiveness of prostate cancer screening. Therefore, determinants of cost effectiveness require further investigation.

Evolving assessment pathways for precision oncology medicines to improve patient access: a tumor-agnostic lens.

BACKGROUND: Genomic and molecular alterations are increasingly important in cancer diagnosis, and scientific advances are opening new treatment avenues. Precision oncology (PO) uses a patient's genomic profile to determine optimal treatment, promising fewer side effects and higher success rates. Within PO, tumor-agnostic (TA) therapies target genomic alterations irrespective of tumor location. However, traditional value frameworks and approval pathways pose challenges which may limit patient access to PO therapies. OBJECTIVES: This study describes challenges in assessing PO and TA medicines, explores possible solutions, and provides actionable recommendations to facilitate an iterative life-cycle assessment of these medicines. METHODS: After reviewing the published literature, we obtained insights from key stakeholders and European experts across a range of disciplines, through individual interviews and an industry workshop. The research was guided and refined by an international expert committee through 2 sounding board meetings. RESULTS: The current challenges faced by PO and TA medicines are multiple and can be demonstrated through real-world examples of the current barriers and opportunities. A life-cycle approach to assessment should be taken, including key actions at the early stages of evidence generation, regulatory and reimbursement stage, as well as payment and adoption solutions that make use of the evolving evidence base. Working toward these solutions to maximize PO medicine value is a shared responsibility and stands to benefit all stakeholders. CONCLUSIONS: Our call to action is to expand access to comprehensive genomic testing, foster a learning health care system, enable fast and equitable access to cost-effective treatments, and ultimately improve health outcomes.

Health Policy for Prostate Cancer Early Detection in the European Union and the Impact of Opportunistic Screening: PRAISE-U Consortium.

With the new policy recommendation in 2022 to explore the possibilities of screening for prostate cancer by the European Commission, the landscape for prostate cancer early detection is evolving. In line with this recommendation, the PRAISE-U project aims to evaluate the early detection and diagnosis of prostate cancer through customised and risk-based screening programmes, with the goal to align protocols across European Union member states. This systematic review is part of the PRAISE-U project, with the goal to review the policy, medical guideline recommendations, and the current level of opportunistic screening presented in the scientific literature on prostate cancer early detection from 2016 to 2023 in European Union member states. An extensive literature search was performed on 1 June 2023 in a large number of databases, including Embase.com, Medline (Ovid), Web of Science Core Collection, Google Scholar, and Policy Commons. We identified 318 articles (qualitative, quantitative, and reviews), of which 41 were included in the full-text screening. Seventeen articles were ultimately identified as eligible for inclusion. The included articles revealed significant variations towards PSA-based early detection policies for prostate cancer in nine European countries. Despite official recommendations, opportunistic screening was prevalent across all nine countries regardless of recommendations for or against PSA-based early detection. This systematic review suggests that the current early detection policies are not fit for purpose. High levels of opportunistic screening and overdiagnosis persist, prompting policy recommendations for standardised guidelines, informed decision making, and increased awareness to improve efficiency and effectiveness in early detection.

Trends in appropriateness of end-of-life care in people with cancer, COPD or with dementia measured with population-level quality indicators.

INTRODUCTION: Measuring changes in the appropriateness of end-of-life care provided to patients with advanced illness such as cancer, COPD or dementia can help governments and practitioners improve service delivery and quality of life. However, an assessment of a possible shift in appropriateness of end-of-life care across the population is lacking. AIM: Measuring quality indicators with routinely collected population-level data, this study aims to evaluate the appropriateness of end-of-life care for people with cancer, COPD or dementia in Belgium. DESIGN: A population-level decedent cohort study, using data from eight population-level databases, including death certificate and health claims data. We measured validated sets of quality indicators for appropriateness of end-of-life care. SETTING/PARTICIPANTS: All people who died from cancer or COPD or with dementia between 1st January 2010 and 1st January 2016 in Belgium. RESULTS: We identified three main trends over time across the three disease groups of increasing use of: family physicians in the last 30 days of life (+21.7% in cancer, +33.7% in COPD and +89.4% in dementia); specialist palliative care in the last 14 days of life (+4.6% in cancer, +36.9% in COPD, +17.8% in dementia); and emergency department in the last 30 days of life (+7.0% in cancer, +4.4% in COPD and +8.2% in dementia). CONCLUSIONS: Although we found an increase of both specialized palliative care and generalist palliative care use, we also found an increase in potentially inappropriate care, including ED and ICU admissions. To increase the quality of end-of-life care, both timely initiating (generalist and specialist) palliative care and avoiding potentially inappropriate care transitions, treatments and medications need to be quality performance targets.

Last year of life of adults with congenital heart diseases: causes of death and patterns of care.

AIMS: Although life expectancy in adults with congenital heart diseases (CHD) has increased dramatically over the past five decades, still a substantial number of patients dies prematurely. To gain understanding in the trajectories of dying in adults with CHD, the last year of life warrants further investigation. Therefore, our study aimed to (i) define the causes of death and (ii) describe the patterns of healthcare utilization in the last year of life of adults with CHD. METHODS AND RESULTS: This retrospective mortality follow-back study used healthcare claims and clinical data from BELCODAC, which includes patients with CHD from Belgium. Healthcare utilization comprises cardiovascular procedures, CHD physician contacts, general practitioner visits, hospitalizations, emergency department (ED) visits, intensive care unit (ICU) admissions, and specialist palliative care, and was identified using nomenclature codes. Of the 390 included patients, almost half of the study population (45%) died from a cardiovascular cause. In the last year of life, 87% of patients were hospitalized, 78% of patients had an ED visit, and 19% of patients had an ICU admission. Specialist palliative care was provided to 17% of patients, and to only 4% when looking at the patients with cardiovascular causes of death. CONCLUSIONS: There is a high use of intensive and potentially avoidable care at the end of life. This may imply that end-of-life care provision can be improved. Future studies should further examine end-of-life care provision in the light of patient's needs and preferences, and how the healthcare system can adequately respond.

Fighting the unbearable lightness of neglecting kidney health: the decade of the kidney.

A brief comprehensive overview is provided of the elements constituting the burden of kidney disease [chronic kidney disease (CKD) and acute kidney injury]. This publication can be used for advocacy, emphasizing the importance and urgency of reducing this heavy and rapidly growing burden. Kidney diseases contribute to significant physical limitations, loss of quality of life, emotional and cognitive disorders, social isolation and premature death. CKD affects close to 100 million Europeans, with 300 million being at risk, and is projected to become the fifth cause of worldwide death by 2040. Kidney disease also imposes financial burdens, given the costs of accessing healthcare and inability to work. The extrapolated annual cost of all CKD is at least as high as that for cancer or diabetes. In addition, dialysis treatment of kidney diseases imposes environmental burdens by necessitating high energy and water consumption and producing plastic waste. Acute kidney injury is associated with further increases in global morbidity, mortality and economic burden. Yet investment in research for treatment of kidney disease lags behind that of other diseases. This publication is a call for European investment in research for kidney health. The innovations generated should mirror the successful European Union actions against cancer over the last 30 years. It is also a plea to nephrology professionals, patients and their families, caregivers and kidney health advocacy organizations to draw, during the Decade of the Kidney (2020-30), the attention of authorities to realize changes in understanding, research and treatment of kidney disease.

An early health technology assessment of 3D anatomic models in pediatric congenital heart surgery: potential cost-effectiveness and decision uncertainty.

Background: Three-dimensional anatomic models have been used for surgical planning and simulation in pediatric congenital heart surgery. This research is the first to evaluate the potential cost-effectiveness of 3D anatomic models with the intent to guide surgeons and decision makers on its use.Method: A decision tree and subsequent Markov model with a 15-year time horizon was constructed and analyzed for nine cardiovascular surgeries. Epidemiological, clinical, and economic data were derived from databases. Literature and experts were consulted to close data gaps. Scenario, one-way, threshold, and probabilistic sensitivity analysis captured methodological and parameter uncertainty.Results: Incremental costs of using anatomical models ranged from -366€ (95% credibility interval: -2595€; 1049€) in the Norwood operation to 1485€ (95% CI: 1206€; 1792€) in atrial septal defect repair. Incremental health-benefits ranged from negligible in atrial septal defect repair to 0.54 Quality Adjusted Life Years (95% CI: 0.06; 1.43) in truncus arteriosus repair. Variability in the results was mainly caused by a temporary postoperative quality-adjusted life years gain.Conclusion: For complex operations, the implementation of anatomic models is likely to be cost-effective on a 15 year time horizon. For the right indication, these models thus provide a clinical advantage at an acceptable cost.

Do custom 3D-printed revision acetabular implants provide enough value to justify the additional costs? The health-economic comparison of a new porous 3D-printed hip implant for revision arthroplasty of Paprosky type 3B acetabular defects and its closest alternative.

PURPOSE: Total hip arthroplasty (THA) is a common operation for patients suffering from hip arthrosis. It has been proven effective in improving quality of life while being cost-effective. Meanwhile, the number of revision hip arthroplasty is growing and those may require bone reconstruction and are potential indications for 3D custom implants. In these specific indications, medical 3D-printing has grown over the years and the use of 3D-printed implants has become more frequent. To date, the cost-effectiveness of 3D-printed implants for acetabular revision THA has not been evaluated. Therefore we performed a health economic analysis to: (1) analyse the cost-effectiveness of the aMace implant compared to its closest alternative on the market, (2) have a better insight into Belgian costs of revision hip arthroplasties and (3) estimate the budget impact in Belgium. HYPOTHESIS: 3D-printed acetabular implants provide good value-for-health in Paprosky type 3B defects in a Belgian setting. MATERIAL AND METHODS: Custom Three-flanged Acetabular Components (CTAC) were compared to a 3D-printed implant (aMace) by means of a Markov model with four states (successful, re-revision, resection and dead). The cycle length was set at 6 months with a 10-year time horizon. Data was obtained through systematic literature search and provided by a large social security agency. The analysis was performed from a societal perspective. All amounts are displayed in 2019 euros. Discount rates were applied for future cost (3%) and QALY (1.5%) estimates. RESULTS: Revision hip arthroplasty has an average societal cost of €9950 without implant. Based on the outcomes of our model, aMace provides an excellent value for money compared to CTAC. The Incremental Cost-Effectiveness Ratio (ICER) was negative for all age groups. The base case of a 65 year old person, showed a QALY gain of 0.05 with a cost reduction of €1265 compared to CTAC. The advantage of using aMace was found to be greater if a patient is younger. The re-revision rates of both CTAC and aMace and the utility of successful revision have the highest impact on costs and effects. A Monte Carlo simulation showed aMace to be a cost-effective strategy in 90% of simulations for younger patients and in 88% of simulations for patients above 85 years old. In Belgium it would imply a cost reduction of €20500 on an annual basis. CONCLUSIONS: Based on the findings of this model, the new 3D-printed aMace implant has the potential to bring an excellent value for money when used in revision arthroplasty of Paprosky type 3B acetabular defects. For all patients, aMace resulted in a dominant, cost-saving strategy in Belgium compared to CTAC. LEVEL OF EVIDENCE: III, comparative medico economical diagnostic tool.

Healthcare resource utilization in patients on lipid-lowering therapies outside Western Europe and North America: findings of the cross-sectional observational International ChoLesterol management Practice Study (ICLPS).

BACKGROUND: Few recent large-scale studies have examined healthcare consumption associated with dyslipidemia in countries outside Western Europe and North America. METHODS: This analysis, from a cross-sectional observational study conducted in 18 countries in Eastern Europe, Asia, Africa, the Middle East and Latin America, evaluated avoidable healthcare consumption (defined as ≥1 hospitalization for cardiovascular reasons or ≥1 visit to the emergency room for any reason in the previous 12 months) in patients receiving stable lipid-lowering therapy (LLT). A total of 9049 patients (aged ≥18 years) receiving LLT for ≥3 months and who had had their low-density lipoprotein cholesterol (LDL-C) value measured on stable LLT in the previous 12 months were enrolled between August 2015 and August 2016. Patients who had received a proprotein convertase subtilisin/kexin type 9 inhibitor in the previous 6 months were excluded. Patients were stratified by cardiovascular risk level using the Systematic Coronary Risk Estimation chart for high-risk countries. RESULTS: The proportion of patients at their LDL-C goal was 32.1% for very-high risk patients compared with 55.7 and 51.9% for patients at moderate and high cardiovascular risk, respectively. Overall, 20.1% of patients had ≥1 reported hospitalization in the previous 12 months (7.9% for cardiovascular reasons), 35.2% had ≥1 intensive care unit stay and 13.8% visited the emergency room. Avoidable healthcare resource consumption was reported for 18.7% patients overall, and in 27.8, 7.7, 7.7 and 13.2% of patients at very-high, high, moderate and low risk, respectively. Across all risk groups 22.4% of patients not at LDL-C goal and 16.6% of patients at LDL-C goal had avoidable healthcare resource consumption. Being at very-high cardiovascular risk, having cardiovascular risk factors (including hypertension and smoking), and having factors indicating that the patient may be difficult to treat (including statin intolerance, comorbidities and chronic medication), were independent risk factors for avoidable healthcare resource consumption (all p <0.05). CONCLUSIONS: Healthcare resource consumption associated with adverse clinical outcomes was observed in patients on stable LLT in countries outside Western Europe and North America, particularly those at very-high cardiovascular risk and those who were difficult to treat.

Belgian multicentre study on lumbar spine imaging: Radiation dose and cost analysis; Evaluation of compliance with recommendations for efficient use of medical imaging.

PURPOSE: To assess compliance of lumbar spine imaging referrals with national imaging recommendations and to evaluate the impact of inappropriate imaging on the collective radiation dose and health insurance costs. METHOD: In 2011 and 2015, 633 lumbar spine imaging referrals were evaluated across 9 Belgian hospitals. For each patient, a new clinical anamnesis and physical examination were performed. Together with the referral, this data were confronted with the national imaging recommendations. Collective radiation dose was estimated for the radiography and CT procedures. Cost analysis was based on national reimbursement fees. Statistical analysis was performed using multilevel linear and logistic regression models. RESULTS: The fraction of unjustified imaging referrals decreased from 50 % in 2011 to 41 % in 2015 (p = 0.255). The odds of a justified examination are 3.1 times higher when the referral is done by a specialist instead of a general practitioner. The highest percentage of unjustified examinations was found for CT (85 % in 2011, 81 % in 2015; p = 0.044). Seventy-five percent of the collective dose of both the 2011 and the 2015 study population was not justified. Adherence to the recommendations could result in an estimated 16 % and 5 % cost reduction for the 2011 and 2015 study samples, respectively. CONCLUSIONS: Between 2011 and 2015, no significant improvement was found in requesting justified lumbar spine imaging procedures, although a positive trend was observed for CT. A shift from CT to MRI is necessary to improve the appropriateness of lumbar spine imaging referrals and to reduce the collective radiation dose.

A Trial-Based Cost-Utility Analysis of Metastasis-Directed Therapy for Oligorecurrent Prostate Cancer.

The optimal management of patients with oligorecurrent prostate cancer (PCa) is unknown. There is growing interest in metastasis-directed therapy (MDT) for this population. The objective was to assess cost-utility from a Belgian healthcare payer's perspective of MDT and delayed androgen deprivation therapy (ADT) in comparison with surveillance and delayed ADT, and with immediate ADT. A Markov decision-analytic trial-based model was developed, projecting the results over a 5-year time horizon with one-month cycles. Clinical data were derived from the STOMP trial and literature. Treatment costs were derived from official government documents. Probabilistic sensitivity analyses showed that MDT is cost-effective compared to surveillance (ICER: €8393/quality adjusted life year (QALY)) and immediate ADT (dominant strategy). The ICER is most sensitive to utilities in the different health states and the first month MDT cost. At a willingness-to-pay threshold of €40,000 per QALY, the cost of the first month MDT should not exceed €8136 to be cost-effective compared to surveillance. The Markov-model suggests that MDT for oligorecurrent PCa is potentially cost-effective in comparison with surveillance and delayed ADT, and in comparison with immediate ADT.

A model-based economic evaluation of four newborn screening strategies for cystic fibrosis in Flanders, Belgium.

Objectives: The most cost-effective newborn screening strategy for cystic fibrosis (CF) for Flanders, Belgium, is unknown. The aim of this study was to assess the cost-effectiveness of four existing newborn screening strategies for CF: IRT-DNA (immunoreactive trypsinogen, cystic fibrosis transmembrane conductance regulator (CFTR) gene mutation analysis), IRT-PAP (pancreatitis-associated protein), IRT-PAP-DNA, and IRT-PAP-DNA-EGA (extended CFTR gene analysis).Methods: Using data from published literature, the cost-effectiveness of the screening strategies was calculated for a hypothetical cohort of 65,606 newborns in Flanders, Belgium. A healthcare payer perspective was used, and the direct medical costs associated with screening were taken into account. The robustness of the model outcomes was assessed in sensitivity analyses.Results: The IRT-PAP strategy was the most cost-effective strategy in terms of costs per CF case detected (€9314 per CF case detected). The IRT-DNA strategy was more costly (€13,966 per CF case detected), but with an expected sensitivity of 93.4% also the most effective strategy, and was expected to detect 2.2 more cases of CF than the IRT-PAP strategy. The incremental cost-effectiveness ratio of IRT-DNA vs. IRT-PAP was €54,180/extra CF case detected. The IRT-PAP-DNA strategy and the IRT-PAP-DNA-EGA strategy were both strongly dominated by the IRT-PAP strategy.Conclusion: The IRT-PAP strategy was the most cost-effective strategy in terms of costs per CF case detected. However, the strategy did not fulfil the European Cystic Fibrosis Society guidelines for sensitivity and positive predictive value. Therefore, the more costly and more effective IRT-DNA strategy may be the most appropriate newborn screening strategy for Flanders.

Opinions of general and adult congenital heart disease cardiologists on care for adults with congenital heart disease in Belgium: a qualitative study.

BACKGROUND: The growing adult congenital heart disease (CHD) population requires efficient healthcare organisation. It has been suggested that clinically appropriate care be provided for individual patients on the least complex level possible, in order to alleviate saturation of special care programmes. METHODS: Semi-structured interviews with 10 general and 10 adult CHD cardiologists were conducted to elucidate opinions on healthcare organisation in Belgium. A particular focus was placed on the potential role of general cardiologists. The software program NVivo 12 facilitated thematic analysis. RESULTS: A discrepancy existed between how general cardiologists thought about congenital care and what adult CHD cardiologists considered the minimum knowledge required to adequately treat patients. Qualitative data were categorised under the following themes: knowledge dissemination, certification, (de)centralisation of care, the role of adult CHD cardiologists, the role of dedicated nurse specialists, and patient referral. It appeared to be pivotal to organise care in such a way that providing basic care locally does not impede the generation of sufficient patient volume, and to continue improving communications between different care levels when there is no referral back. Moreover, practical knowledge is best disseminated locally. Cardiologists' opinions on certification and on the role of dedicated nurse specialists were mixed. CONCLUSION: On the basis of the results, we propose five recommendations for improving the provision of care to adults with CHD. A multidimensional approach to defining the role of different healthcare professionals, to improving communication channels, and to effectively sensitising healthcare professionals is needed to improve the organisation of care.

Multicolumn spinal cord stimulation for predominant back pain in failed back surgery syndrome patients: a multicenter randomized controlled trial.

Despite optimal medical management (OMM), low back pain (LBP) can be disabling, particularly after spinal surgery. Spinal cord stimulation (SCS) is effective in reducing neuropathic leg pain; however, evidence is limited for LBP. This prospective, open-label, parallel-group trial randomized (1:1) failed back surgery syndrome (FBSS) patients with predominant LBP to SCS plus OMM (SCS group) or OMM alone (OMM group) at 28 sites in Europe and the Americas. If trial stimulation was successful, a multicolumn SCS system was implanted. Outcomes were assessed at baseline (before randomization) and at 1, 3, 6, and 12 months after randomization. Patients could change treatment groups at 6 months. The primary outcome was the proportion of patients with ≥50% reduction in LBP (responder) at 6 months. Secondary outcomes included change in pain intensity, functional disability, and health-related quality of life (HRQoL). The results are posted at ClinicalTrials.gov under registration number NCT01697358. In the intent-to-treat analysis, there were more responders in the SCS group than in the OMM group (13.6%, 15/110 vs 4.6%, 5/108, difference 9% with 95% confidence interval 0.6%-17.5%, P = 0.036) at 6 months. The SCS group improved in all secondary outcomes compared with the OMM group. The OMM group only improved in HRQoL. In the SCS group, 17.6% (18/102) experienced SCS-related adverse events through 6 months, with 11.8% (12/102) requiring surgical reintervention. Adding multicolumn SCS to OMM improved pain relief, HRQoL, and function in a traditionally difficult-to-treat population of failed back surgery syndrome patients with predominant LBP. Improvements were sustained at 12 and 24 months.

Direct Medical Costs of Pediatric Congenital Heart Disease Surgery in a Belgian University Hospital.

OBJECTIVES: The recent trend to optimize the efficiency of health-care systems requires objective clinical and economic data. European data on the cost of surgical procedures to repair or palliate congenital heart disease in pediatric patients are lacking. METHODS: A single-center study was conducted. Bootstrap analysis of variance and bootstrap independent t test assessed the excess direct medical costs associated with minor and major complications in nine surgical procedure types, from a health-care payer perspective. Generalized linear models with log-link function and inverse Gaussian family were used to determine associated covariates with the total hospitalization cost. Descriptive statistics show the repartition between out-of-pocket expenditures and reimbursed costs. RESULTS: Four hundred thirty-seven patients were included. Mean hospitalization costs ranged from €11,106 (atrial septal defect repair) to €33,865 (Norwood operation). Operations with major complications yielded excess costs compared to operations with no complications, ranging from €7,105 (+65.2%) for a truncus arteriosus repair to €27,438 (+251.7%) for a tetralogy of Fallot repair. Differences in costs were limited between operations with minor versus no complications. Age at procedure, intensive care unit stay, procedure risk category, reintervention, and postoperative mechanical circulatory support were associated with higher total hospitalization costs. Out-of-pocket expenditures represented 6% of total hospitalization costs. CONCLUSION: Operations with major complications yield excess costs, compared to operations with minor or no complications. Cost data and attribution are important to improve clinical practice in a cost-effective manner. The health-care system benefits from strategies and technological advancements that have an impact on modifiable cost-affecting parameters.

Impact of palliative home care support on the quality and costs of care at the end of life: a population-level matched cohort study.

OBJECTIVES: To evaluate the impact of palliative home care support on the quality of care and costs in the last 14 days of life. DESIGN: Matched cohort study using linked administrative databases. SETTING: All people who died in Belgium in 2012 (n=107 847). PARTICIPANTS: 8837 people who received palliative home care support in the last 720 to 15 days of life matched 1:1 by propensity score to 8837 people who received usual care. INTERVENTION: Receiving the allowance for palliative home patients, multidisciplinary palliative home care team visit or palliative nurse or physiotherapist visit at home. MAIN OUTCOME MEASURES: Home death, number of family physician contacts, number of primary caregiver contacts, hospital death, hospital admission, intensive care unit (ICU) admission, emergency department (ED) admission, diagnostic testing, blood transfusion and surgery. Total inpatient and outpatient costs. All outcomes were measured in the last 14 days of life. RESULTS: In the unmatched cohort, 11 149 (13.5%) people received palliative home care support in the last 720 to 15 days of life. After matching, those using palliative home care support had, compared with those who did not, more family physician contacts (mean 3.1 [SD=6.5] vs 0.8 [SD=1.2]), more chance of home death (56.2%vs13.8%; relative risk [RR]=4.08, 95% CI 3.86 to 4.31), lower risk of hospital admission (27.4%vs60.8%; RR=0.45, 95% CI 0.43 to 0.46), ICU admission (18.3%vs40.4%; RR=0.45, 95% CI 0.43 to 0.48) or ED admission (15.2%vs28.1%; RR=0.54, 95% CI 0.51 to 0.57). Mean total costs of care were lower for those using palliative home care support (€3081 [95% CI €3025 to €3136] vs €4698 [95% CI €4610 to €4787]; incremental cost: -€1617 [p<0.001]). CONCLUSIONS: Palliative home care support use positively impacts quality of care and reduces total costs of care at the end of life in Belgium. Policy makers and healthcare practitioners should increasingly focus on communicating the existing options for palliative home care support to patients and their caregivers.

A systematic review on costs and cost-effectiveness of screening and prevention of type 2 diabetes in women with prior gestational diabetes: Exploring uncharted territory.

AIMS: Women with gestational diabetes mellitus (GDM) are more likely to develop type 2 diabetes mellitus (T2DM) as compared to women with normoglycemic pregnancies. This study aims to explore the literature on cost(-effectiveness) of screening and prevention of T2DM in women with prior GDM. METHODS: Five databases were systematically searched, inclusion criteria were: (1) women with (prior) GDM; (2) post-partum screening or prevention of T2DM; and (3) health-economic evaluations. No year limits were applied. English, Dutch, French or German publications were included. Quality was assessed using the Consensus Health Economic Criteria checklist. RESULTS: Two cost-effectiveness analyses and two cost analyses were found. One study evaluated nine screening strategies. Three studies evaluated one prevention strategy each: intensive diet and behavioural modification; annual counseling; and an annual dietary consultation. Methodological quality was poor. Perspectives were unclear, time horizons were too short, and no incremental analyses were performed. CONCLUSION: An oral glucose tolerance test per three years leads to the lowest cost per case detected, and prevention is potentially cost-effective or cost-saving. More health economic evaluations are needed that compare all relevant alternatives, including 'doing nothing'.

A school- and community-based intervention to promote healthy lifestyle and prevent type 2 diabetes in vulnerable families across Europe: design and implementation of the Feel4Diabetes-study.

OBJECTIVE: To describe the design of the Feel4Diabetes-intervention and the baseline characteristics of the study sample. DESIGN: School- and community-based intervention with cluster-randomized design, aiming to promote healthy lifestyle and tackle obesity and obesity-related metabolic risk factors for the prevention of type 2 diabetes among families from vulnerable population groups. The intervention was implemented in 2016-2018 and included: (i) the 'all-families' component, provided to all children and their families via a school- and community-based intervention; and (ii) an additional component, the 'high-risk families' component, provided to high-risk families for diabetes as identified with a discrete manner by the FINDRISC questionnaire, which comprised seven counselling sessions (2016-2017) and a text-messaging intervention (2017-2018) delivered by trained health professionals in out-of-school settings. Although the intervention was adjusted to local needs and contextual circumstances, standardized protocols and procedures were used across all countries for the process, impact, outcome and cost-effectiveness evaluation of the intervention. SETTING: Primary schools and municipalities in six European countries. SUBJECTS: Families (primary-school children, their parents and grandparents) were recruited from the overall population in low/middle-income countries (Bulgaria, Hungary), from low socio-economic areas in high-income countries (Belgium, Finland) and from countries under austerity measures (Greece, Spain). RESULTS: The Feel4Diabetes-intervention reached 30 309 families from 236 primary schools. In total, 20 442 families were screened and 12 193 'all families' and 2230 'high-risk families' were measured at baseline. CONCLUSIONS: The Feel4Diabetes-intervention is expected to provide evidence-based results and key learnings that could guide the design and scaling-up of affordable and potentially cost-effective population-based interventions for the prevention of type 2 diabetes.

Endovascular Training Using a Simulation Based Curriculum is Less Expensive than Training in the Hybrid Angiosuite.

OBJECTIVE/BACKGROUND: This study aimed to determine the cost-effectiveness of a PROficiency based StePwise Endovascular Curricular Training (PROSPECT) program, including e-learning and hands on virtual reality simulation. METHODS: A prospective, single blinded, randomised controlled trial (RCT) was carried out to evaluate the impact of a PROSPECT training program on real life operative performance. Under supervision, all subjects performed two endovascular interventions on patients with symptomatic iliac and/or superficial femoral artery stenosis. Primary outcomes were technical performance (Global Rating Scale, Examiner Checklist), operative metrics, and patient outcomes, adjusted for case difficulty and the trainee's experience. Additionally, an analysis of costs and savings related to implementation of this endovascular training program was performed. Thirty-two general surgery trainees were randomised into three groups: group 1 (n = 11) received e-learning and simulation training (PROSPECT program); group 2 (n = 10) only had access to e-learning; group 3 (n = 11) did not receive supplementary education besides clinical training. Developmental cost, implementation cost, training time cost, and the operational cost of PROSPECT were determined. Time spent studying and practicing was converted to indirect saving of operating time. The costs of logistics, faculty time supervising simulation sessions, and 30 day complication rates were registered. Sensitivity analysis was performed to assess the robustness of the results. RESULTS: Fifty-eight peripheral endovascular interventions, performed by 29 surgical trainees (three dropouts) were included in this RCT from October 2014 to February 2016. Annual costs from the perspective of the hospital were €6589 for curriculum design, €31,484 for implementation, and €1143 in operational costs. Per trainee, simulation based training until proficiency cost €3806. In comparison, if endovascular proficiency levels were obtained with conventional training only, this may have cost €5001 per trainee. CONCLUSION: Simulation based training in endovascular procedures may be cost saving, because training occurs outside the angiosuite. It is possible that cost savings are underestimated as, in contrast to the literature, prevented costs related to complications could not be defined.

Appropriateness of End-of-Life Care in People Dying From COPD. Applying Quality Indicators on Linked Administrative Databases.

CONTEXT: Large-scale evaluations of the quality of end-of-life care in people with chronic obstructive pulmonary disease (COPD) are lacking. OBJECTIVES: By means of a validated set of quality indicators (QIs), this study aimed to 1) assess appropriateness of end-of-life care in people dying from COPD; 2) examine variation between care regions; 3) establish performance standards. METHODS: We conducted a retrospective observational study of all deaths from COPD (ICD-10 codes J41-J44) in 2012 in Belgium, using data from administrative population-level databases. QI scores were risk-adjusted for comparison between care regions. RESULTS: A total of 4231 people died from COPD. During the last 30 days of life, 60% was admitted to hospital and 11.8% received specialized palliative care. Large regional variation was found in specialized palliative care use (4.0%-32.0%) and diagnostic testing in the last 30 days of life (44.0%-69.7%). Based on best performing quartile scores, relative standards were set (e.g., ≤54.9% for diagnostic testing). CONCLUSION: Our study found indications of inappropriate end-of-life care in people with COPD, such as high percentages of diagnostic testing and hospital admissions and low proportions receiving specialized palliative care. Risk-adjusted variation between regions was high for several QIs, indicating the usefulness of relative performance standards to improve quality of end-of-life COPD care.