Evaluation Design of EFFICHRONIC: The Chronic Disease Self-Management Programme (CDSMP) Intervention for Citizens with a Low Socioeconomic Position.

Background/rationale: The Chronic Disease Self-Management Programme (CDSMP) intervention is an evidence-based program that aims to encourage citizens with a chronic condition, as well as their caregivers, to better manage and maintain their own health. CDSMP intervention is expected to achieve greater health gains in citizens with a low socioeconomic position (SEP), because citizens with a low SEP have fewer opportunities to adhere to a healthy lifestyle, more adverse chronic conditions and a poorer overall health compared to citizens with a higher SEP. In the EFFICHRONIC project, CDSMP intervention is offered specifically to adults with a chronic condition and a low SEP, as well as to their caregivers (target population). Study objective: The objective of our study is to evaluate the benefits of offering CDSMP intervention to the target population. Methods: A total of 2500 participants (500 in each study site) are recruited to receive the CDSMP intervention. The evaluation study has a pre-post design. Data will be collected from participants before the start of the intervention (baseline) and six months later (follow up). Benefits of the intervention include self-management in healthy lifestyle, depression, sleep and fatigue, medication adherence and health-related quality of life, health literacy, communication with healthcare professionals, prevalence of perceived medical errors and satisfaction with the intervention. The study further includes a preliminary cost-effectiveness analysis with a time horizon of six months. Conclusion: The EFFICHRONIC project will measure the effects of the CDSMP intervention on the target population and the societal cost savings in five European settings.

Update of the Dutch manual for costing studies in health care.

OBJECTIVES: Dutch health economic guidelines include a costing manual, which describes preferred research methodology for costing studies and reference prices to ensure high quality studies and comparability between study outcomes. This paper describes the most important revisions of the costing manual compared to the previous version. METHODS: An online survey was sent out to potential users of the costing manual to identify topics for improvement. The costing manual was aligned with contemporary health economic guidelines. All methodology sections and parameter values needed for costing studies, particularly reference prices, were updated. An expert panel of health economists was consulted several times during the review process. The revised manual was reviewed by two members of the expert panel and by reviewers of the Dutch Health Care Institute. RESULTS: The majority of survey respondents was satisfied with content and usability of the existing costing manual. Respondents recommended updating reference prices and adding some particular commonly needed reference prices. Costs categories were adjusted to the international standard: 1) costs within the health care sector; 2) patient and family costs; and 3) costs in other sectors. Reference prices were updated to reflect 2014 values. The methodology chapter was rewritten to match the requirements of the costing manual and preferences of the users. Reference prices for nursing days of specific wards, for diagnostic procedures and nurse practitioners were added. CONCLUSIONS: The usability of the costing manual was increased and parameter values were updated. The costing manual became integrated in the new health economic guidelines.

Towards Integrated Health Technology Assessment for Improving Decision Making in Selected Countries.

OBJECTIVES: To assess the level of comprehensiveness of health technology assessment (HTA) practices around the globe and to formulate recommendations for enhancing legitimacy and fairness of related decision-making processes. METHODS: To identify best practices, we developed an evaluation framework consisting of 13 criteria on the basis of the INTEGRATE-HTA model (integrative perspective on assessing health technologies) and the Accountability for Reasonableness framework (deliberative appraisal process). We examined different HTA systems in middle-income countries (Argentina, Brazil, and Thailand) and high-income countries (Australia, Canada, England, France, Germany, Scotland, and South Korea). For this purpose, desk research and structured interviews with relevant key stakeholders (N = 32) in the selected countries were conducted. RESULTS: HTA systems in Canada, England, and Scotland appear relatively well aligned with our framework, followed by Australia, Germany, and France. Argentina and South Korea are at an early stage, whereas Brazil and Thailand are at an intermediate level. Both desk research and interviews revealed that scoping is often not part of the HTA process. In contrast, providing evidence reports for assessment is well established. Indirect and unintended outcomes are increasingly considered, but there is room for improvement. Monitoring and evaluation of the HTA process is not well established across countries. Finally, adopting transparent and robust processes, including stakeholder consultation, takes time. CONCLUSIONS: This study presents a framework for assessing the level of comprehensiveness of the HTA process in a country. On the basis of applying the framework, we formulate recommendations on how the HTA community can move toward a more integrated decision-making process using HTA.

Systematic review of cost-effectiveness of myocardial perfusion scintigraphy in patients with ischaemic heart disease: A report from the cardiovascular committee of the European Association of Nuclear Medicine. Endorsed by the European Association of Cardiovascular Imaging.

Coronary artery disease (CAD) is a major cause of death and disability. Several diagnostic tests, such as myocardial perfusion scintigraphy (MPS), are accurate for the detection of CAD, as well as having prognostic value for the prediction of cardiovascular events. Nevertheless, the diagnostic and prognostic value of these tests should be cost-effective and should lead to improved clinical outcome. We have reviewed the literature on the cost-effectiveness of MPS in different circumstances: (i) the diagnosis and management of CAD; (ii) comparison with exercise electrocardiography (ECG) and other imaging tests; (iii) as gatekeeper to invasive coronary angiography (ICA), (iv) the impact of appropriate use criteria; (v) acute chest pain, and (vi) screening of asymptomatic patients with type-2 diabetes. In total 57 reports were included. Although most non-invasive imaging tests are cost-effective compared with alternatives, the data conflict on which non-invasive strategy is the most cost-effective. Different definitions of cost-effectiveness further confound the subject. Computer simulations of clinical diagnosis and management are influenced by the assumptions made. For instance, diagnostic accuracy is often defined against an anatomical standard that is wrongly assumed to be perfect. Conflicting data arise most commonly from these incorrect or differing assumptions.

A microcosting study of the surgical correction of upper extremity deformity in children with spastic cerebral palsy.

OBJECTIVE: Determine healthcare costs of upper-extremity surgical correction in children with spastic cerebral palsy (CP). METHOD: This cohort study included 39 children with spastic CP who had surgery for their upper extremity at a Dutch hospital. A retrospective cost analysis was performed including both hospital and rehabilitation costs. Hospital costs were determined using microcosting methodology. Rehabilitation costs were estimated using reference prices. RESULTS: Hospital costs averaged €6813 per child. Labor (50%), overheads (29%), and medical aids (15%) were important cost drivers. Rehabilitation costs were estimated at €3599 per child. CONCLUSIONS: Surgery of the upper extremity is an important contributor to the healthcare costs of children with CP. Our study shows that labor is the most important cost driver for hospital costs, owing to the multidisciplinary approach and patient-specific treatment plan. A remarkable finding was the substantial amount of rehabilitation costs.

Costs and Cost-Effectiveness of Hypertension Screening and Treatment in Adults with Hypertension in Rural Nigeria in the Context of a Health Insurance Program.

BACKGROUND: High blood pressure is a leading risk factor for death and disability in sub-Saharan Africa (SSA). We evaluated the costs and cost-effectiveness of hypertension care provided within the Kwara State Health Insurance (KSHI) program in rural Nigeria. METHODS: A Markov model was developed to assess the costs and cost-effectiveness of population-level hypertension screening and subsequent antihypertensive treatment for the population at-risk of cardiovascular disease (CVD) within the KSHI program. The primary outcome was the incremental cost per disability-adjusted life year (DALY) averted in the KSHI scenario compared to no access to hypertension care. We used setting-specific and empirically-collected data to inform the model. We defined two strategies to assess eligibility for antihypertensive treatment based on 1) presence of hypertension grade 1 and 10-year CVD risk of >20%, or grade 2 hypertension irrespective of 10-year CVD risk (hypertension and risk based strategy) and 2) presence of hypertension in combination with a CVD risk of >20% (risk based strategy). We generated 95% confidence intervals around the primary outcome through probabilistic sensitivity analysis. We conducted one-way sensitivity analyses across key model parameters and assessed the sensitivity of our results to the performance of the reference scenario. RESULTS: Screening and treatment for hypertension was potentially cost-effective but the results were sensitive to changes in underlying assumptions with a wide range of uncertainty. The incremental cost-effectiveness ratio for the first and second strategy respectively ranged from US$ 1,406 to US$ 7,815 and US$ 732 to US$ 2,959 per DALY averted, depending on the assumptions on risk reduction after treatment and compared to no access to antihypertensive treatment. CONCLUSIONS: Hypertension care within a subsidized private health insurance program may be cost-effective in rural Nigeria and public-private partnerships such as the KSHI program may provide opportunities to finance CVD prevention care in SSA.

A noticeable difference? Productivity costs related to paid and unpaid work in economic evaluations on expensive drugs.

Productivity costs can strongly impact cost-effectiveness outcomes. This study investigated the impact in the context of expensive hospital drugs. This study aimed to: (1) investigate the effect of productivity costs on cost-effectiveness outcomes, (2) determine whether economic evaluations of expensive drugs commonly include productivity costs related to paid and unpaid work, and (3) explore potential reasons for excluding productivity costs from the economic evaluation. We conducted a systematic literature review to identify economic evaluations of 33 expensive drugs. We analysed whether evaluations included productivity costs and whether inclusion or exclusion was related to the study population's age, health and national health economic guidelines. The impact on cost-effectiveness outcomes was assessed in studies that included productivity costs. Of 249 identified economic evaluations of expensive drugs, 22 (9 %) included productivity costs related to paid work. One study included unpaid productivity. Mostly, productivity cost exclusion could not be explained by the study population's age and health status, but national guidelines appeared influential. Productivity costs proved often highly influential. This study indicates that productivity costs in economic evaluations of expensive hospital drugs are commonly and inconsistently ignored in economic evaluations. This warrants caution in interpreting and comparing the results of these evaluations.

Hospital costs of ischemic stroke and TIA in the Netherlands.

OBJECTIVES: There have been no ischemic stroke costing studies since major improvements were implemented in stroke care. We therefore determined hospital resource use and costs of ischemic stroke and TIA in the Netherlands for 2012. METHODS: We conducted a retrospective cost analysis using individual patient data from a national diagnosis-related group registry. We analyzed 4 subgroups: inpatient ischemic stroke, inpatient TIA, outpatient ischemic stroke, and outpatient TIA. Costs of carotid endarterectomy and costs of an extra follow-up visit were also estimated. Unit costs were based on reference prices from the Dutch Healthcare Insurance Board and tariffs provided by the Dutch Healthcare Authority. Linear regression analysis was used to examine the association between hospital costs and various patient and hospital characteristics. RESULTS: A total of 35,903 ischemic stroke and 21,653 TIA patients were included. Inpatient costs were €5,328 ($6,845) for ischemic stroke and €2,470 ($3,173) for TIA. Outpatient costs were €495 ($636) for ischemic stroke and €587 ($754) for TIA. Costs of carotid endarterectomy were €6,836 ($8,783). Costs of inpatient days were the largest contributor to hospital costs. Age, hospital type, and region were strongly associated with hospital costs. CONCLUSIONS: Hospital costs are higher for inpatients and ischemic strokes compared with outpatients and TIAs, with length of stay (LOS) the most important contributor. LOS and hospital costs have substantially declined over the last 10 years, possibly due to improved hospital stroke care and efficient integrated stroke services.

Cost-utility of a lifestyle intervention in adolescents and young adults with spastic cerebral palsy.

OBJECTIVE: To evaluate the cost-utility of a lifestyle intervention among adolescents and young adults with cerebral palsy. DESIGN: Single-blind, randomized controlled trial. SETTING: Six university hospital/clinics in the Netherlands. PARTICIPANTS: Fifty-seven adolescents and young adults with spastic cerebral palsy classified as Gross Motor Functioning Classification System (GMFCS) level I-IV. INTERVENTION: A 6-month lifestyle intervention consisting of physical fitness training combined with counselling sessions focusing on physical behaviour and sports participation. MAIN OUTCOME MEASURES: Data on quality of life, direct medical costs and productivity costs were collected using standardized questionnaires. Quality adjusted life years (QALYs) were derived from the Short-Form 36 questionnaire using the Short-Form 6D. RESULTS: Quality of life remained stable over time for both groups. No significant differences between groups were found for direct medical costs or productivity costs. A cost-utility ratio of -€23,664 per QALY was found for the lifestyle intervention compared with no treatment. CONCLUSION: The results of this study are exploratory, but indicate that implementing a lifestyle intervention for the cerebral palsy population might be cost-effective or cost-saving compared with offering no intervention to improve physical behaviour and fitness. However, the large range of uncertainty for the cost-utility ratio should be taken into account and the results interpreted with caution.

Costs of cardiovascular disease prevention care and scenarios for cost saving: a micro-costing study from rural Nigeria.

OBJECTIVE: To assess the costs of cardiovascular disease (CVD) prevention care according to international guidelines, in a primary healthcare clinic in rural Nigeria, participating in a health insurance programme. METHODS: A micro-costing study was conducted from a healthcare provider perspective. Activities per patient per year (e.g., consultations, diagnostic tests) were based on clinical practice in the study clinic. Direct (e.g., staff, drugs) and indirect cost items (overheads) for each activity were measured. A cohort study, patient and staff observations, and interviews in the study clinic provided patient resource utilization data. Univariate sensitivity analyses were performed. Scenario analyses evaluated cost-saving options. The main outcome was the costs of CVD prevention care per patient per year. RESULTS: The costs of CVD prevention care were United States dollars (USD) 144 (range 130-158) per patient per year. Direct costs were USD 82 and indirect costs were USD 62. The main cost drivers were drugs (USD 39) and diagnostic tests (USD 36). The costs of hypertension care were USD 118 (107-132) and that of diabetes care USD 263 (236-289) per patient per year. A combination of task-shifting from doctors to nurses, reduction of appointment frequencies, and minimal organ damage screening would result in a direct cost reduction of 42%. CONCLUSION: This is the first study to report the costs of CVD prevention care in sub-Saharan Africa, based on prospectively collected operational data. The costs observed in our study are unaffordable in many countries in sub-Saharan Africa, highlighting the need for innovative financing mechanisms to fund CVD prevention care.

DRG systems in Europe: variations in cost accounting systems among 12 countries.

BACKGROUND: Diagnosis-related group (DRG)-based hospital payment systems have gradually become the principal means of reimbursing hospitals in many European countries. Owing to the absence or inaccuracy of costs related to DRGs, these countries have started to routinely collect cost accounting data. The aim of the present article was to compare the cost accounting systems of 12 European countries. METHODS: A standardized questionnaire was developed to guide comprehensive cost accounting system descriptions for each of the 12 participating countries. RESULTS: The cost accounting systems of European countries vary widely by the share of hospital costs reimbursed through DRG payment, the presence of mandatory cost accounting and/or costing guidelines, the share of cost collecting hospitals, costing methods and data checks on reported cost data. Each of these aspects entails a trade-off between accuracy of the cost data and feasibility constraints. CONCLUSION: Although a 'best' cost accounting system does not exist, our cross-country comparison gives insight into international differences and may help regulatory authorities and hospital managers to identify and improve areas of weakness in their cost accounting systems. Moreover, it may help health policymakers to underpin the development of a cost accounting system.

Childbirth and Diagnosis Related Groups (DRGs): patient classification and hospital reimbursement in 11 European countries.

OBJECTIVES: The study compares how Diagnosis-Related Group (DRG) based hospital payment systems in eleven European countries (Austria, England, Estonia, Finland, France, Germany, Ireland, Netherlands, Poland, Spain, and Sweden) deal with women giving birth in hospitals. It aims to assist gynaecologists and national authorities in optimizing their DRG systems. METHODS: National or regional databases were used to identify childbirth cases. DRG grouping algorithms and indicators of resource consumption were compared for those DRGs which account for at least 1% of all childbirth cases in the respective database. Five standardized case vignettes were defined and quasi prices (i.e. administrative prices or tariffs) of hospital deliveries according to national DRG-based hospital payment systems were ascertained. RESULTS: European DRG systems classify childbirth cases according to different sets of variables (between one and eight variables) into diverging numbers of DRGs (between three and eight DRGs). The most complex DRG is valued 3.5 times more resource intensive than an index case in Ireland but only 1.1 times more resource intensive than an index case in The Netherlands. Comparisons of quasi prices for the vignettes show that hypothetical payments for the most complex case amount to only € 479 in Poland but to € 5532 in Ireland. CONCLUSIONS: Differences in the classification of hospital childbirth cases into DRGs raise concerns whether European systems rely on the most appropriate classification variables. Physicians, hospitals and national DRG authorities should consider how other countries' DRG systems classify cases to optimize their system and to ensure fair and appropriate reimbursement.

Knee replacement and Diagnosis-Related Groups (DRGs): patient classification and hospital reimbursement in 11 European countries.

PURPOSE: Researchers from 11 countries (Austria, England, Estonia, Finland, France, Germany, Ireland, Netherlands, Poland, Spain, and Sweden) compared how their Diagnosis-Related Group (DRG) systems deal with knee replacement cases. The study aims to assist knee surgeons and national authorities to optimize the grouping algorithm of their DRG systems. METHODS: National or regional databases were used to identify hospital cases treated with a procedure of knee replacement. DRG classification algorithms and indicators of resource consumption were compared for those DRGs that together comprised at least 97 % of cases. Five standardized case scenarios were defined and quasi-prices according to national DRG-based hospital payment systems ascertained. RESULTS: Grouping algorithms for knee replacement vary widely across countries: they classify cases according to different variables (between one and five classification variables) into diverging numbers of DRGs (between one and five DRGs). Even the most expensive DRGs generally have a cost index below 2.00, implying that grouping algorithms do not adequately account for cases that are more than twice as costly as the index DRG. Quasi-prices for the most complex case vary between euro 4,920 in Estonia and euro 14,081 in Spain. CONCLUSIONS: Most European DRG systems were observed to insufficiently consider the most important determinants of resource consumption. Several countries' DRG system might be improved through the introduction of classification variables for revision of knee replacement or for the presence of complications or comorbidities. Ultimately, this would contribute to assuring adequate performance comparisons and fair hospital reimbursement on the basis of DRGs.

The economic costs of disease related malnutrition.

BACKGROUND & AIMS: Disease related malnutrition (under-nutrition caused by illness) is a worldwide problem in all health care settings with potentially serious consequences on a physical as well as a psycho-social level. In the European Union countries about 20 million patients are affected by disease related malnutrition, costing EU governments up to € 120 billion annually. The aim of this study is to calculate the total additional costs of disease related malnutrition in The Netherlands. METHODS: A cost-of-illness analysis was used to calculate the additional total costs of disease related malnutrition in adults (>18 years of age) for The Netherlands in 2011 in the hospital, nursing- and residential home and home care setting, expressed as an absolute monetary value as well as a percentage of the total Dutch national health expenditure and as a percentage of the total costs of the studied health care sectors in The Netherlands. RESULTS: The total additional costs of managing adult patients with disease related malnutrition were estimated to be € 1.9 billion in 2011 which equals 2.1% of the total Dutch national health expenditure and 4.9% of the total costs of the health care sectors analyzed in this study. CONCLUSIONS: The results of this study show that the additional costs of disease related malnutrition in adults in The Netherlands are considerable.

Explaining length of stay variation of episodes of care in the Netherlands.

OBJECTIVES: Diagnosis Related Group (DRG) systems aim to classify patients into mutually exclusive groups of patients, with the patients in each group having the same expected length of stay (LOS). We examined the ability of current classification variables to explain LOS variation between DRG-like Diagnosis Treatment Combination (DBC)s for ten episodes of care in the Netherlands, including breast cancer, stroke and inguinal hernia repair. Additionally, we assessed the predictive ability of some other classification variables. METHODS: For each episode of care, the relevant DBC codes of all hospitalizations in 2008 were identified and all available determinants that may serve as classification variables were acquired from the national database. Ordinary least squares regression was used to examine the predictive ability of these classification variables. RESULTS: The current classification variables are not sufficiently distinct to classify patients into mutually exclusive groups of patients. ICU admissions and hospital type may serve as valuable classification variables. Additionally, episode-specific variables may improve the Dutch grouping algorithm. CONCLUSIONS: Although it may not be feasible in the short term, grouping algorithms would benefit greatly from the introduction of classification variables tailored to the needs of specific episodes of care. A first step would be to focus on 'general' classification variables meaningful for specific episodes of care.

Update of the Dutch Manual for Costing in Economic Evaluations.

OBJECTIVES: In 2000, the first "Dutch Manual for Costing: METHODS and Reference Prices for Economic Evaluations in Healthcare" was published, followed by an updated version in 2004. The purpose of the Manual is to facilitate the implementation and assessment of costing studies in economic evaluations. New developments necessitated the publication of a thoroughly updated version of the Manual in 2010. The present study aims to describe the main changes of the 2010 Manual compared with earlier editions of the Manual. METHODS: New and updated topics of the Manual were identified. The recommendations of the Manual were compared with the health economic guidelines of other countries, eliciting strengths and limitations of alternative methods. RESULTS: New topics in the Manual concern medical costs in life-years gained, the database of the Diagnosis Treatment Combination (DBC) casemix System, reference prices for the mental healthcare sector and the costs borne by informal care-givers. Updated topics relate to the friction cost method, discounting future effects and options for transferring cost results from international studies to the Dutch situation. CONCLUSIONS: The Action Plan is quite similar to many health economic guidelines in healthcare. However, the recommendations on particular aspects may differ between national guidelines in some respects. Although the Manual may serve as an example to countries intending to develop a manual of this kind, it should always be kept in mind that preferred methods predominantly depend on a country's specific context.

Direct cost analysis of intensive care unit stay in four European countries: applying a standardized costing methodology.

OBJECTIVES: The objective of the present study was to measure and compare the direct costs of intensive care unit (ICU) days at seven ICU departments in Germany, Italy, the Netherlands, and the United Kingdom by means of a standardized costing methodology. METHODS: A retrospective cost analysis of ICU patients was performed from the hospital's perspective. The standardized costing methodology was developed on the basis of the availability of data at the seven ICU departments. It entailed the application of the bottom-up approach for "hotel and nutrition" and the top-down approach for "diagnostics," "consumables," and "labor." RESULTS: Direct costs per ICU day ranged from €1168 to €2025. Even though the distribution of costs varied by cost component, labor was the most important cost driver at all departments. The costs for "labor" amounted to €1629 at department G but were fairly similar at the other departments (€711 ± 115). CONCLUSIONS: Direct costs of ICU days vary widely between the seven departments. Our standardized costing methodology could serve as a valuable instrument to compare actual cost differences, such as those resulting from differences in patient case-mix.

A microcosting study of microsurgery, LINAC radiosurgery, and gamma knife radiosurgery in meningioma patients.

The aim of the present study is to determine and compare initial treatment costs of microsurgery, linear accelerator (LINAC) radiosurgery, and gamma knife radiosurgery in meningioma patients. Additionally, the follow-up costs in the first year after initial treatment were assessed. Cost analyses were performed at two neurosurgical departments in The Netherlands from the healthcare providers' perspective. A total of 59 patients were included, of whom 18 underwent microsurgery, 15 underwent LINAC radiosurgery, and 26 underwent gamma knife radiosurgery. A standardized microcosting methodology was employed to ensure that the identified cost differences would reflect only actual cost differences. Initial treatment costs, using equipment costs per fraction, were 12,288 for microsurgery, 1,547 for LINAC radiosurgery, and 2,412 for gamma knife radiosurgery. Higher initial treatment costs for microsurgery were predominantly due to inpatient stay (5,321) and indirect costs (4,350). LINAC and gamma knife radiosurgery were equally expensive when equipment was valued per treatment (2,198 and 2,412, respectively). Follow-up costs were slightly, but not significantly, higher for microsurgery compared with LINAC and gamma knife radiosurgery. Even though initial treatment costs were over five times higher for microsurgery compared with both radiosurgical treatments, our study gives indications that the relative cost difference may decrease when follow-up costs occurring during the first year after initial treatment are incorporated. This reinforces the need to consider follow-up costs after initial treatment when examining the relative costs of alternative treatments.

Incorporation of economic evidence in the Dutch guideline 'cardiovascular risk management'.

RATIONALE, AIMS AND OBJECTIVES: The consideration of economic evidence in guideline development may be particularly important in health care management when different (drug) therapies show similar efficacy on clinical endpoints, such as in cardiovascular diseases. This article investigates to what extent the Dutch guideline 'cardiovascular risk management' (2006) considers cost-effectiveness and budget impact according to the most recent economic evidence. METHOD: We carried out a systematic review of economic evaluations on cholesterol-lowering drugs and antihypertensives followed by an assessment of guideline recommendations. RESULTS: The guideline does not consider the most recent economic evidence but does consider cost-effectiveness based on economic evaluations performed in conjunction with clinical trials. Their conclusions are largely in agreement with the most recent economic evidence. An innovative aspect in the guideline is the application of a budget impact analysis to take accessibility and affordability constraints into account when considering cost-effectiveness. CONCLUSIONS: Based on the most recent economic evidence, the guideline could be improved by more firmly formulating recommendations in favour of cost-effective drug therapies (simvastatin, pravastatin and low-dose diuretics) to stimulate compliance to the guideline in clinical practice.