Disruption of hospital care during the first year of the COVID-19 pandemic impacted socioeconomic groups differently: population based study using routine registration data.

BACKGROUND: During the COVID-19 pandemic, provision of non-COVID healthcare was recurrently severely disrupted. The objective was to determine whether disruption of non-COVID hospital use, either due to cancelled, postponed, or forgone care, during the first pandemic year of COVID-19 impacted socioeconomic groups differently compared with pre-pandemic use. METHODS: National population registry data, individually linked with data of non-COVID hospital use in the Netherlands (2017-2020). in non-institutionalised population of 25-79 years, in standardised household income deciles (1 = low, 10 = high) as proxy for socioeconomic status. Generic outcome measures included patients who received hospital care (dichotomous): outpatient contact, day treatment, inpatient clinic, and surgery. Specific procedures were included as examples of frequently performed elective and acute procedures, e.g.: elective knee/hip replacement and cataract surgery, and acute percutaneous coronary interventions (PCI). Relative risks (RR) for hospital use were reported as outcomes from generalised linear regression models (binomial) with log-link. An interaction term was included to assess whether income differences in hospital use during the pandemic deviated from pre-pandemic use. RESULTS: Hospital use rates declined in 2020 across all income groups. With baseline (2019) higher hospital use rates among lower than higher income groups, relatively stronger declines were found for lower income groups. The lowest income groups experienced a 10% larger decline in surgery received than the highest income group (RR 0.90, 95% CI 0.87 - 0.93). Patterns were similar for inpatient clinic, elective knee/hip replacement and cataract surgery. We found small or no significant income differences for outpatient clinic, day treatment, and acute PCI. CONCLUSIONS: Disruption of non-COVID hospital use in 2020 was substantial across all income groups during the acute phases of the pandemic, but relatively stronger for lower income groups than could be expected compared with pre-pandemic hospital use. Although the pandemic's impact on the health system was unprecedented, healthcare service shortages are here to stay. It is therefore pivotal to realise that lower income groups may be at risk for underuse in times of scarcity.

Cost-effectiveness of screening for chronic hepatitis B and C among migrant populations in a low endemic country.

BACKGROUND: Chronic infection with hepatitis B or C virus (HBV/HCV) can progress to cirrhosis, liver cancer, and even death. In a low endemic country as the Netherlands, migrants are a key risk group and could benefit from early diagnosis and antiviral treatment. We assessed the cost-effectiveness of screening foreign-born migrants for chronic HBV and/or HCV using a societal perspective. METHODS: The cost-effectiveness was evaluated using a Markov model. Estimates on prevalence, screening programme costs, participation and treatment uptake, transition probabilities, healthcare costs, productivity losses and utilities were derived from the literature. The cost per Quality Adjusted Life Year (QALY) gained was estimated and sensitivity analyses were performed. RESULTS: For most migrant groups with an expected high number of chronically infected cases in the Netherlands combined screening is cost-effective, with incremental cost-effectiveness ratios (ICERs) ranging from €4,962/QALY gained for migrants originating from the Former Soviet Union and Vietnam to €9,375/QALY gained for Polish migrants. HBV and HCV screening proved to be cost-effective for migrants from countries with chronic HBV or HCV prevalence of ≥0.41% and ≥0.22%, with ICERs below the Dutch cost-effectiveness reference value of €20,000/QALY gained. Sensitivity analysis showed that treatment costs influenced the ICER for both infections. CONCLUSIONS: For most migrant populations in a low-endemic country offering combined HBV and HCV screening is cost-effective. Implementation of targeted HBV and HCV screening programmes to increase early diagnosis and treatment is important to reduce the burden of chronic hepatitis B and C among migrants.

A new prevention paradox: the trade-off between reducing incentives for risk selection and increasing the incentives for prevention for health insurers.

The Dutch risk equalization scheme has been improved over the years by including health related risk adjusters. The purpose of the Dutch risk equalization scheme is to prevent risk selection and to correct for predictable losses and gains for insurers. The objective of this paper is to explore the financial incentives for risk selection under the Dutch risk equalization scheme. We used a simulation model to estimate lifetime health care costs and risk equalization contributions for three cohorts (a smoking; an obese; and a healthy living cohort). Financial differences for the three cohorts were assessed by subtracting health care costs from risk equalization contributions. Even under an elaborate risk equalization system, the healthy living cohort was still most financially attractive for insurers. Smokers were somewhat less attractive, while the obese cohort was least attractive. Lifetime differences with healthy living individuals (revenues minus costs) were modest: €4840 for obese individuals and €1101 for smokers. Under a simple form of risk equalization these differences were higher, €8542 and €4620 respectively. Improvement of the risk equalization scheme reduced the gap between costs and revenues. Incentives for undesirable risk selection were reduced, but simultaneously incentives for health promotion were weakened. This highlights a new prevention paradox: improving the level playing field for health insurers will inevitably limit their incentives for promoting the health of their clients.

Economic evaluation and the postponement of health care costs.

The inclusion of medical costs in life years gained in economic evaluations of health care technologies has long been controversial. Arguments in favour of the inclusion of such costs are gaining support, which shifts the question from whether to how to include these costs. This paper elaborates on the issue how to include cost in life years gained in cost effectiveness analysis given the current practice of economic evaluations in which costs of related diseases are included. We combine insights from the theoretical literature on the inclusion of unrelated medical costs in life years gained with insights from the so-called 'red herring' literature. It is argued that for most interventions it would be incorrect to simply add all medical costs in life years gained to an ICER, even when these are corrected for postponement of the expensive last year of life. This is the case since some of the postponement mechanism is already captured in the unadjusted ICER by modelling the costs of related diseases. Using the example of smoking cessation, we illustrate the differences and similarities between different approaches. The paper concludes with a discussion about the proper way to account for medical costs in life years gained in economic evaluations.

Exploring the influence of proximity to death on disease-specific hospital expenditures: a carpaccio of red herrings.

It has been demonstrated repeatedly that time to death is a much better predictor of health care expenditures than age. This is known as the 'red herring' hypothesis. In this article, we investigate whether this is also the case regarding disease-specific hospital expenditures. Longitudinal data samples from the Dutch hospital register (n=11 253 455) were used to estimate 94 disease-specific two-part models. Based on these models, Monte Carlo simulations were used to assess the predictive value of proximity to death and age on disease-specific expenditures. Results revealed that there was a clear effect of proximity of death on health care expenditures. This effect was present for most diseases and was strongest for most cancers. However, even for some less fatal diseases, proximity to death was found to be an important predictor of expenditures. Controlling for proximity to death, age was found to be a significant predictor of expenditures for most diseases. However, its impact is modest when compared to proximity to death. Considering the large variation in the degree to which proximity to death and age matter for each specific disease, we may speak not only of age as a 'red herring' but also of a 'carpaccio of red herrings'.

Passive immunisation against respiratory syncytial virus: a cost-effectiveness analysis.

AIM: The cost-effectiveness of passive immunisation against respiratory syncytial virus (RSV) in the Netherlands was studied by assessing incremental costs to prevent one hospitalisation in high-risk children using a novel individualised monthly approach. METHODS: Cost-effectiveness analysis was performed by combining estimates of individual hospitalisation costs and monthly hospitalisation risks, with immunisation costs, parental costs and efficacy of passive immunisation for a reference case with the highest hospitalisation risks and costs of hospitalisation during the RSV season (male, gestational age < or =28 weeks, birth weight < or =2500 g, having bronchopulmonary dysplasia (BPD), aged 0 months at the beginning of the season (October)). Various sensitivity analyses and a cost-neutrality analysis were performed. RESULTS: Cost-effectiveness of passive immunisation varied widely by child characteristics and seasonal month. For the reference case it was most cost effective in December at euro13,190 per hospitalisation averted. Cost-effectiveness was most sensitive to changes in hospitalisation risk. For the reference case, cost neutrality was reached in December, if acquisition costs of passive immunisation decreased from euro 930 to euro 375, monthly hospitalisation risk increased from 7.6% to 17%, or hospitalisation costs increased from euro 10 250 to euro 23 250 per hospitalisation. Even if passive immunisation prevented all hospitalisations, costs per hospitalisation averted in December would still exceed euro 2645. CONCLUSIONS: Although cost-effectiveness of passive immunisation varied strongly by child characteristics and seasonal month, incremental costs per hospitalisation averted were always high. A restrictive immunisation policy only immunising children with BPD in high-risk months is therefore recommended. The costs of passive immunisation would have to be considerably reduced to achieve cost-effectiveness.

Lifetime medical costs of obesity: prevention no cure for increasing health expenditure.

BACKGROUND: Obesity is a major cause of morbidity and mortality and is associated with high medical expenditures. It has been suggested that obesity prevention could result in cost savings. The objective of this study was to estimate the annual and lifetime medical costs attributable to obesity, to compare those to similar costs attributable to smoking, and to discuss the implications for prevention. METHODS AND FINDINGS: With a simulation model, lifetime health-care costs were estimated for a cohort of obese people aged 20 y at baseline. To assess the impact of obesity, comparisons were made with similar cohorts of smokers and "healthy-living" persons (defined as nonsmokers with a body mass index between 18.5 and 25). Except for relative risk values, all input parameters of the simulation model were based on data from The Netherlands. In sensitivity analyses the effects of epidemiologic parameters and cost definitions were assessed. Until age 56 y, annual health expenditure was highest for obese people. At older ages, smokers incurred higher costs. Because of differences in life expectancy, however, lifetime health expenditure was highest among healthy-living people and lowest for smokers. Obese individuals held an intermediate position. Alternative values of epidemiologic parameters and cost definitions did not alter these conclusions. CONCLUSIONS: Although effective obesity prevention leads to a decrease in costs of obesity-related diseases, this decrease is offset by cost increases due to diseases unrelated to obesity in life-years gained. Obesity prevention may be an important and cost-effective way of improving public health, but it is not a cure for increasing health expenditures.

Health care costs in the last year of life--the Dutch experience.

Health expenditure depends heavily on age. Common wisdom is that the age pattern is dominated by costs in the last year of life. Knowledge about these costs is important for the debate on the future development of health expenditure. According to the 'red herring' argument traditional projection methods overestimate the influence of ageing because improvements in life expectancy will postpone rather than raise health expenditure. This paper has four objectives: (1) to estimate health care costs in the last year of life in the Netherlands; (2) to describe age patterns and differences between causes of death for men and women; (3) to compare cost profiles of decedents and survivors; and (4) to use these figures in projections of future health expenditure. We used health insurance data of 2.1 million persons (13% of the Dutch population), linked at the individual level with data on the use of home care and nursing homes and causes of death in 1999. On average, health care costs amounted to 1100 Euro per person. Costs per decedent were 13.5 times higher and approximated 14,906 Euro in the last year of life. Most costs related to hospital care (54%) and nursing home care (19%). Among the major causes of death, costs were highest for cancer (19,000 Euro) and lowest for myocardial infarctions (8068 Euro). Between the other causes of death, however, cost differences were rather limited. On average costs for the younger decedents were higher than for people who died at higher ages. Ten per cent of total health expenditure was associated with the health care use of people in their last year of life. Increasing longevity will result in higher costs because people live longer. The decline of costs in the last year of life with increasing age will have a moderate lowering effect. Our projection demonstrated a 10% decline in the growth rate of future health expenditure compared to conventional projection methods.

Preconception care: preliminary estimates of costs and effects of smoking cessation and folic acid supplementation.

OBJECTIVE: To assess costs and effectiveness of preconception counseling for all women planning pregnancy in The Netherlands with regard to folic acid supplementation and smoking cessation counseling. STUDY DESIGN: Costs and effects were estimated based on 200,000 women approached yearly and uptake rates of 50% and 75%. Effectiveness and potential savings were based on hospital costs of neural tube defects, low birth weight, very low birth weight and perinatal death attributable to maternal smoking. RESULTS: Total costs were estimated at dollar 5.1 million and dollar 7.2 million at uptake rates of 50% and 75%, respectively. If 50% of women would seek preconception counseling, 22 neural tube defects, 98 low-birth-weight infants, 10 very-low-birth-weight infants and 7 perinatal deaths could be avoided. At 75% uptake, 33 neural tube defects, 146 low- and 15 very-low-birth-weight infants, and 11 perinatal deaths could be avoided. CONCLUSION: Net costs of preconception counseling amount to dollar 3.7 million and dollar 5.0 million when considering cases prevented and subsequent potential savings in costs of neural tube defects and smoking-related morbidity only. However, in light of many other preventable adverse outcomes and the potential of preconception counseling to prevent significant lifetime costs for affected children, the net costs may ultimately result in a favorable cost-savings balance. Moreover, the importance of a healthy child cannot be expressed in terms of costs and savings alone.

Anticipated costs of hospitalization for respiratory syncytial virus infection in young children at risk.

BACKGROUND: Reliable estimates of hospitalization costs for severe respiratory syncytial virus (RSV) infection are necessary to perform economic analyses of preventive strategies of severe RSV disease. We aimed to develop a model that predicts anticipated mean RSV hospitalization costs of groups of young children at risk for hospitalization, but not yet hospitalized, based on readily available child characteristics. METHODS: We determined real direct medical costs of RSV hospitalization from a societal perspective, using a bottom-up strategy, in 3458 infants and young children hospitalized for severe RSV disease during the RSV seasons 1996-1997 to 1999-2000 in the Southwest of the Netherlands. We used a linear regression model to predict anticipated mean RSV hospitalization costs of groups of children at risk, based on 4 child characteristics [age, gestational age, birth weight and bronchopulmonary dysplasia (BPD)], expressed in EC Euros as of the year 2000. FINDINGS: The mean RSV hospitalization costs of all patients were 3110 Euros. RSV hospitalization costs were higher for patients with lower gestational age (5555 Euros; gestational age,

A cost-minimisation study of alternative discharge policies after hip fracture repair.

It is widely assumed that health care costs can be reduced considerably by providing care in appropriate health care institutions without unnecessary technological overhead. This assumption has been tested in a prospective study. Conventional discharge after hip fracture surgery was compared with an early discharge policy in which patients were discharged to a nursing home with specialised facilities for rehabilitation. We compared costs for both strategies from a societal perspective, using comprehensive and detailed data on type of residence and all kinds of medical consumption during a 4-month follow-up period. As expected, early discharge reduced the hospital stay (with 13 days, p=0.001). More patients were discharged to a nursing home (76% versus 53%). Total medical costs during follow-up were reduced from an average of euro;15338 to euro;14281, representing relatively small and not significant savings (p=0.3). There are two explanations for this unexpected result. First, costs incurred by hip fracture patients were relatively less while in hospital. Hence, nursing home costs almost equalled hospital costs per admission day. Second, compared with the conventionally discharged group early discharged patients were subjected to more medical procedures during the first post-operative days. We conclude that: (1). early discharge shifted rather than reduced costs; (2). the details of costing have a major influence on the cost-effectiveness of alternative discharge policies.