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INTRODUCTION: Many women experience bleeding disorders that may have an anatomical or unexplained origin. Although hysterectomy is the most definitive and common treatment, it is highly invasive and resource-intensive. Less invasive therapies are therefore advised before hysterectomy for women with fibroids or bleeding disorders. This study has two aims related to treating bleeding disorders and uterine fibroids in the Netherlands: (1) to evaluate the regional variations in prevalence and surgical approaches; and (2) to assess the associations between regional rates of hysterectomies and less invasive surgical techniques to analyze whether hysterectomy can be replaced in routine practice. MATERIAL AND METHODS: We completed a register-based study of claims data for bleeding disorders and fibroids in women between 2016 and 2020 using data from Statistics Netherlands for case-mix adjustment. Crude and case-mix adjusted regional hysterectomy rates were examined overall and by surgical approach. Coefficients of variation were used to measure regional variation and regression analyses were used to evaluate the association between hysterectomy and less invasive procedure rates across regions. RESULTS: Overall, 14 186 and 8821 hysterectomies were performed for bleeding disorders and fibroids, respectively. Laparoscopic approaches predominated (bleeding disorders 65%, fibroids 49%), followed by vaginal (bleeding disorders 24%, fibroids 5%) and abdominal (bleeding disorders 11%, fibroids 46%) approaches. Substantial regional differences were noted in both hysterectomy rates and the surgical approaches. For bleeding disorders, regional hysterectomy rates were positively associated with endometrial ablation rates (ß = 0.11; P = 0.21) and therapeutic hysteroscopy rates (ß = 0.14; P = 0.31). For fibroids, regional hysterectomy rates were positively associated with therapeutic hysteroscopy rates (ß = 0.10; P = 0.34) and negatively associated with both embolization rates (ß = -0.08; P = 0.08) and myomectomy rates (ß = -0.03; P = 0.82). CONCLUSIONS: Regional variation exists in the rates of hysterectomy and minimally invasive techniques. The absence of a significant substitution effect provides no clear evidence that minimally invasive techniques have replaced hysterectomy in clinical practice. However, although the result was not significant, embolization could be an exception based on its stronger negative association.
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Histerectomia , Leiomioma , Padrões de Prática Médica , Sistema de Registros , Neoplasias Uterinas , Humanos , Feminino , Países Baixos , Histerectomia/estatística & dados numéricos , Histerectomia/métodos , Leiomioma/cirurgia , Adulto , Pessoa de Meia-Idade , Padrões de Prática Médica/estatística & dados numéricos , Neoplasias Uterinas/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/estatística & dados numéricos , Laparoscopia/estatística & dados numéricos , Hemorragia Uterina/cirurgia , Hemorragia Uterina/epidemiologiaRESUMO
BACKGROUND: In patient choice, patients are expected to select the provider that best fits their preferences. In this study, we assess to what extent the hospital choice of patients in practice corresponds with their preferred choice. METHODS: Dutch patients with breast cancer (n = 631) and cataract (n = 1109) were recruited. We employed a discrete choice experiment (DCE) per condition to measure stated preferences and predict the distribution of patients across four hospitals. Each DCE included five attributes: patient experiences, a clinical outcome indicator, waiting time, travel distance and whether the hospital had been recommended (e.g., by the General Practitioner (GP)). Revealed choices were derived from claims data. RESULTS: Hospital quality was valued as most important in the DCE; the largest marginal rates of substitution (willingness to wait) were observed for the clinical outcome indicator (breast cancer: 38.6 days (95% confidence interval (95%CI): 32.9-44.2); cataract: 210.5 days (95%CI: 140.8-280.2)). In practice, it was of lesser importance. In revealed choices, travel distance became the most important attribute; it accounted for 85.5% (breast cancer) and 95.5% (cataract) of the log-likelihood. The predicted distribution of patients differed from that observed in practice in terms of absolute value and, for breast cancer, also in relative order. Similar results were observed in population weighted analyses. DISCUSSION: Study findings show that patients highly valued quality information in the choice for a hospital. However, in practice these preferences did not prevail. Our findings suggest that GPs played a major role and that patients mostly ended up selecting the nearest hospital.
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Neoplasias da Mama , Catarata , Neoplasias da Mama/terapia , Comportamento de Escolha , Feminino , Hospitais , Humanos , Preferência do PacienteRESUMO
Hospital quality indicators provide valuable insights for quality improvement, empower patients to choose providers, and have become a cornerstone of value-based payment. As outcome indicators are cumbersome and expensive to measure, many health systems have relied on proxy indicators, such as structure and process indicators. In this paper, we assess the extent to which publicly reported structure and process indicators are correlated with outcome indicators, to determine if these provide useful signals to inform the public about the outcomes. Quality indicators for three conditions (breast and colorectal cancer, and hip replacement surgery) for Dutch hospitals (2011-2018) were collected. Structure and process indicators were compared to condition-specific outcome indicators and in-hospital mortality ratios in a between-hospital comparison (cross-sectional and between-effects models) and in within-hospital comparison (fixed-effects models). Systematic association could not be observed for any of the models. Both positive and negative signs were observed where negative associations were to be expected. Despite sufficient statistical power, the share of significant correlations was small [mean share: 13.2% (cross-sectional); 26.3% (between-effects); 13.2% (fixed-effects)]. These findings persisted in stratified analyses by type of hospital and in models using a multivariate approach. We conclude that, in the context of compulsory public reporting, structure and process indicators are not correlated with outcome indicators, neither in between-hospital comparisons nor in within-hospital comparisons. While structure and process indicators remain valuable for internal quality improvement, they are unsuitable as signals for informing the public about hospital differences in health outcomes.
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Hospitais , Saúde Pública , Estudos Transversais , Mortalidade Hospitalar , Humanos , Melhoria de Qualidade , Indicadores de Qualidade em Assistência à SaúdeRESUMO
BACKGROUND: There is an increasing number of quality indicators being reported publicly with aim to improve the transparency on hospital care quality. However, they are little used by patients. Knowledge on patients' preferences regarding quality may help to optimise the information presented to them. OBJECTIVE: To measure the preferences of patients with breast and colon cancers regarding publicly reported quality indicators of Dutch hospital care. METHODS: From the existing set of clinical quality indicators, participants of patient group discussions first assessed an indicator's suitability as choice information and then identified the most relevant ones. We used the final selection as attributes in two discrete choice experiments (DCEs). Questionnaires included choice vignettes as well as a direct ranking exercise, and were distributed among patient communities. Data were analysed using mixed logit models. RESULTS: Based on the patient group discussions, 6 of 52 indicators (breast cancer) and 5 of 21 indicators (colon cancer) were selected as attributes. The questionnaire was completed by 84 (breast cancer) and 145 respondents (colon cancer). In the patient group discussions and in the DCEs, respondents valued outcome indicators as most important: those reflecting tumour residual (breast cancer) and failure to rescue (colon cancer). Probability analyses revealed a larger range in percentage change of choice probabilities for breast cancer (10.9%-69.9%) relative to colon cancer (7.9%-20.9%). Subgroup analyses showed few differences in preferences across ages and educational levels. DCE findings partly matched with those of direct ranking. CONCLUSION: Study findings show that patients focused on a subset of indicators when making their choice of hospital and that they valued outcome indicators the most. In addition, patients with breast cancer were more responsive to quality information than patients with colon cancer.
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Neoplasias do Colo , Indicadores de Qualidade em Assistência à Saúde , Comportamento de Escolha , Hospitais , Humanos , Preferência do PacienteRESUMO
AIM: Children spend substantial amounts of time receiving medical care (patients' time), and this patients' time plays an important role in parental choices for paediatric care. However, it is usually ignored in economic evaluations. This is a concern because economic evaluations are increasingly being used to inform child health policy decision-making. This study aims to quantify the time children spend receiving medical care and attach a monetary value to it for use in economic evaluations. It applied the parents' perspective. Consequently, the derived money values are the time values for both child and the accompanying parent. METHODS: We used the contingent valuation methodology. We collected data on 83 children undergoing orthopaedic treatment in a Dutch hospital. Accompanying parents were asked to quantify and value the patients' time of their children. We separately explored travel, waiting and treatment time. We also checked whether the monetary valuation varied across parents' financial situation, children's health and level of pain. RESULTS: Parents were willing to pay about 33 (confidence interval (CI) 21.2-48.1) for a 1-day reduction in treatment time; about 11.5 (CI 4.2-19.1) for an hour's reduction in waiting time; and about 4.5 (CI 1.5-7.4) for an hour's reduction in travel time. In addition, respondents with better financial conditions have, on average higher, willingness to pays. CONCLUSIONS: To our knowledge, this is the first instance that patients' time of children has been monetarily valued. This methodology can be used to further develop economic evaluations of paediatric care and could be applied to larger samples with varying clinical conditions.
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Serviço Hospitalar de Emergência/economia , Custos Hospitalares , Hospitalização/economia , Tempo de Internação/economia , Procedimentos Ortopédicos/estatística & dados numéricos , Ferimentos e Lesões/terapia , Adolescente , Criança , Proteção da Criança , Pré-Escolar , Análise Custo-Benefício , Bases de Dados Factuais , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Incidência , Masculino , Países Baixos , Procedimentos Ortopédicos/economia , Estudos Retrospectivos , Medição de Risco , Fatores de Tempo , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/economiaRESUMO
It is hard to ignore the importance of patient time investment in the production of health since the influential paper by Grossman (1972). Patients' time includes time to admission, travel time, waiting time, and treatment time and can be substantial. Patients' time is, however, often ignored in economic analyses. This may lead to biased results and inappropriate policy recommendations, which may eventually influence patients' health, wellbeing and welfare. How to value patient time is not straightforward. Although there is some emerging literature on the monetary valuation of patient time, an important challenge remains to develop an approach that can be used to monetarily value time of patients not participating in the labour market. We aim to contribute to the health economics literature by describing and empirically illustrating how to monetarily value the time of patients not participating in the labour market comprehensively, using the contingent valuation method. It is worth noting that our method can also be applied to people participating in the labour market. This paper describes the development of the contingent valuation survey. We apply our survey approach to a sample of 238 Dutch patients not participating in the labour market: n = 107 Radiotherapy department (data collected between November 2011 and January 2013); n = 44 Rehabilitation department (March 2012-May 2012); n = 87 Orthopaedics department (January to June 2013). Results show that those patients value waiting time the highest (30.10 per hour) and value travel and treatment time equally with respectively 13.20 and 13.32 per hour. This paper encourages future empirical research refining and applying the developed survey methodology to create more data on how other subgroups of individuals value their patients' time.
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Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Admissão do Paciente/economia , Pacientes/psicologia , Tempo , Meios de Transporte/economia , Listas de Espera , Humanos , Modelos Econométricos , Países Baixos , Ortopedia/estatística & dados numéricos , Admissão do Paciente/estatística & dados numéricos , Radioterapia/estatística & dados numéricos , Reabilitação/estatística & dados numéricos , Meios de Transporte/estatística & dados numéricos , DesempregoRESUMO
INTRODUCTION: Electronic nicotine delivery systems (ENDS) are rapidly increasing in popularity. However, little is known about sociodemographic differences in use of ENDS. This study aims to assess the sociodemographic characteristics associated with ENDS ever-use and use as a cessation tool in the European Union. METHODS: We analyzed data from the 2012 Eurobarometer wave 77.1, with 25 922 respondents aged 15 years or above from all 27 member states. We estimated the prevalence of ever-use and use as a cessation tool, and performed binary logistic regression to analyze associations with sociodemographic characteristics. RESULTS: Overall, 7.2% reported having ever used ENDS. Of all smokers who ever tried to quit, 7.0% used ENDS. Ever-use was inversely associated with being older than 34 years (odds ratio [OR] = 0.63, 95% confidence interval [CI] = 0.51-0.76 for 35-44 years, and OR = 0.34, 95% CI = 0.25-0.46 for at least 65 years), and positively associated with being higher educated (OR = 1.50, 95% CI = 1.22-1.84) or a student (OR = 2.34, 95% CI = 1.77-3.08). ENDS were more often used to quit smoking by students (OR = 2.05, 95% CI = 1.10-3.82), and were less likely to be used by those aged 65 or older (OR = 0.30, 95% CI = 0.15-0.61). No significant differences were found according to sex, social class, marital status or type of community. CONCLUSIONS: In 2012, ever-use of ENDS was low in the European population in general. However, younger people or those with a high education used ENDS more frequently. These results indicate a need for more appropriate product information targeted at these groups. IMPLICATIONS: This study shows that in the European Union in 2012, regular use of ENDS was rare, especially among nonsmokers. Only age and education were strongly associated with ENDS use. The increased prevalence of ever-use among the younger age groups is relevant, as in this age group smoking habits are established. The higher ever-use of ENDS among younger and higher educated people found in this study indicates a need to target appropriate product information, stressing that ENDS use does not imply zero harm.
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Sistemas Eletrônicos de Liberação de Nicotina/economia , Sistemas Eletrônicos de Liberação de Nicotina/estatística & dados numéricos , União Europeia/economia , Nicotina/administração & dosagem , Fumar/economia , Classe Social , Adolescente , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fumar/epidemiologia , Abandono do Hábito de Fumar/economia , Abandono do Hábito de Fumar/métodos , Inquéritos e Questionários , Adulto JovemRESUMO
This study focuses on gender differences in health profiles, and examines which health profiles drive gender differences in remaining life expectancy in women and men aged 65 and over in The Netherlands. Data from the first two cycles of the Longitudinal Aging Study Amsterdam (n = 2,141 and 1,659, respectively) were used to calculate health profiles for individuals of 65-85 years. For both women and men, six profiles were found: I. cancer; II. "other" chronic diseases; III. cognitive impairment; IV. frailty or multimorbidity; V. cardiovascular diseases; and VI. good health. The further characterization of these types showed some gender differences. Remaining life expectancy for women was greater than for men in each health profile. A decomposition into health expectancies showed that both women and men could expect to live about 5 years in good health from age 66. The greatest gender differences in years spent with health problems were found for profile IV and for profile III. Their greater number of years spent in these health states have direct consequences for the type and cost of care women need.