Evaluation of Nutri-Score in Relation to Dietary Guidelines and Food Reformulation in The Netherlands

An unhealthy dietary pattern is an important risk factor for non-communicable diseases. Front-of-Pack nutritional labels such as Nutri-Score can be used to improve food choices. In addition, products can be improved through reformulation. The current study investigates to what extent Nutri-Score aligns with the Dutch Health Council dietary guidelines and whether it can be used as an incentive for reformulation. Nutri-Score calculations were based on the Dutch Branded Food database (2018). The potential shift in Nutri-Score was calculated with product improvement scenarios. The Nutri-Score classification is in line with these dietary guidelines: increase the consumption of fruit and vegetables, pulses, and unsalted nuts. It is, however, less in line with the recommendations to limit (dairy) drinks with added sugar, reduce the consumption of red meat and replace refined cereal products with whole-grain products. The scenario analyses indicated that a reduction in sodium, saturated fat or sugars resulted in a more favourable Nutri-Score in a large variety of food groups. However, the percentage of products with an improved Nutri-Score varied greatly between the different food groups. Alterations to the algorithm may strengthen Nutri-Score in order to help consumers with their food choices.

The impact of conducting preclinical systematic reviews on researchers and their research: A mixed method case study

Background Systematic reviews (SRs) are cornerstones of evidence-based medicine and have contributed significantly to breakthroughs since the 1980’s. However, preclinical SRs remain relatively rare despite their many advantages. Since 2011 the Dutch health funding organisation (ZonMw) has run a grant scheme dedicated to promoting the training, coaching and conduct of preclinical SRs. Our study focuses on this funding scheme to investigate the relevance, effects and benefits of conducting preclinical SRs on researchers and their research. Methods We recruited researchers who attended funded preclinical SR workshops and who conducted, are still conducting, or prematurely stopped a SR with funded coaching. We gathered data using online questionnaires followed by semi-structured interviews. Both aimed to explore the impact of conducting a SR on researchers’ subsequent work, attitudes, and views about their research field. Data-analysis was performed using Excel and ATLAS.ti. Results Conducting preclinical SRs had two distinct types of impact. First, the researchers acquired new skills and insights, leading to a change in mindset regarding the quality of animal research. This was mainly seen in the way participants planned, conducted and reported their subsequent animal studies, which were more transparent and of a higher quality than their previous work. Second, participants were eager to share their newly acquired knowledge within their laboratories and to advocate for change within their research teams and fields of interest. In particular, they emphasised the need for preclinical SRs and improved experimental design within preclinical research, promoting these through education and published opinion papers. Conclusion Being trained and coached in the conduct of preclinical SRs appears to be a contributing factor to many beneficial changes which will impact the quality of preclinical research in the long-term. Our findings suggest that this ZonMw funding scheme is helpful in improving the quality and transparency of preclinical research. Similar funding schemes should be encouraged, preferably by a broader group of funders or financers, in the future.

Factors Influencing Procurement of Digital Health Care: A Case Study in Dutch District Nursing

Background: Digital health is considered a promising solution in keeping health care accessible and affordable. However, implementation is often complex and sustainable funding schemes are lacking. Despite supporting policy, scaling up innovative forms of health care progresses much slower than intended in Dutch national framework agreements. The aim of this study is to identify factors that influence the procurement of digital health particular in district nursing. Methods: A case study approach was used, in which multiple stakeholder perspectives are compared using thematic framework analysis. The case studied was the procurement of digital health in Dutch district nursing. Literature on implementation of digital health, public procurement and payment models was used to build the analytic framework. We analysed fourteen interviews (secondary data), two focus groups organised by the national task force procurement and eight governmental and third-party reports. Results: Five themes emerged from the analysis: 1) rationale 2) provider-payer relationship, 3) resources, 4) evidence, and 5) the payment model. Per theme a number of factors were identified, mostly related to the design and functioning of the Dutch health system and to the implementation process at providers' side. Conclusions: This study identified factors influencing the procurement of digital health in Dutch district nursing. The findings, however, are not unique for digital health, district nursing or the Dutch health system. The results presented will support policy makers, and decision makers to improve procurement of digital health. Investing in better relationships between payer and care provider organisations and professionals is an important next step towards scaling digital health.

Development of the Dutch Structure for Integrated Children’s Palliative Care

Children’s palliative care (CPC) is gaining attention worldwide, facilitated by the exchange of knowledge during regular specialised congresses. This article describes the developments in the Netherlands over the past 15 years. The Foundation for Children’s Palliative Expertise (PAL) was established as a nationwide initiative committed to improving palliative care for children countrywide. This led to the development of the first hospital-based CPC team in 2012, which expanded to a total of seven teams adjacent to children’s university hospitals. Regional networks for CPC were developed in parallel to these teams from 2014 onwards. The networks are a collaboration of professionals from different disciplines and organisations, from hospital to homecare, and have covered the aspects of CPC nationally from 2019 onwards. They are connected through the Dutch Knowledge Centre for CPC. This centre was established in 2018 by the PAL Foundation in collaboration with the Dutch Association for Pediatrics. In 2013, the first evidence-based guideline, ‘palliative care for children’, provided access to knowledge for parents and healthcare providers, and in 2017, a format for an individual palliative care plan was established. Within the Knowledge Centre for CPC, a physician’s support centre for dilemma’s regarding the end of life of children was set up. The efforts to have children’s palliative care embedded in the regular Dutch health care insurance are ongoing.

Relationship between trust and patient involvement in medical decision-making: A cross-sectional study

Introduction Patients vary in their preferences regarding involvement in medical decision-making. Current research does not provide complete explanation for this observed variation. Patient involvement in medical decision-making has been found to be influenced by various mechanisms, one of which could be patients’ trust in physicians. The aim of this study was to examine whether trust in physicians fosters or impairs patient involvement in medical decision-making. This study also aimed to determine to what extent the relationship between trust and preferences regarding decision-making roles was influenced by the sociodemographic characteristics of the patients. We hypothesised that trust can both foster and impair patient involvement in medical decision-making. Materials and methods A survey was sent out to members of the Nivel Dutch Health Care Consumer Panel in February 2016 (response rate = 47%, N = 703). The Wake Forest Physician Trust Scale was used to measure trust. Patient involvement was measured using two items based on the study published by Flynn and colleagues in 2006. Multiple regression analysis was used to analyse the relationship between trust and patient involvement. Results We found a negative relationship between trust and patient involvement in medical decision-making in men. Women with high trust reported to be more involved in medical decision-making compared to men with high trust. Conclusion The results suggest that trust impairs involvement in medical decision-making for men but not for women. Further research could provide a more comprehensive explanation of the variation in patient preferences regarding involvement in medical decision-making to further elucidate which underlying mechanisms could enhance patient participation.

The Potential Risk of Using Historic Claims to Set Bundled Payment Prices: The Case of Physical Therapy After Lower Extremity Joint Replacement

Background One of the most significant challenges of implementing a multi-provider bundled payment contract is to determine an appropriate, casemix adjusted total bundle price. The most frequently used approach is to leverage historic care utilization based on claims data. However, those claims data may not accurately reflect appropriate care (e.g. due to supplier induced demand and moral hazard effects). This study aims to examine variation in claims-based costs of post-discharge physical therapy (PT) utilization after total knee and hip arthroplasties (TKA/THA) for osteoarthritis patients.Methods This retrospective cohort study used multilevel linear regression analyses to predict the factors that explain the variation in the utilization of post-discharge PT after TKA or THA for osteoarthritis patients, based on the historic (2015-2018) claims data of a large Dutch health insurer. The factors were structured as predisposing, enabling or need factors according to the behavioral model of Andersen.Results The 15,309 TKA and 14,325 THA patients included in this study received an average of 20.7 (SD 11.3) and 16.7 (SD 10.1) post-discharge PT sessions, respectively. Results showed that the enabling factor ‘presence of supplementary insurance’ was the strongest predictor for post-discharge PT utilization in both groups (TKA: β=7.46, SE=0.498, p-value<0.001; THA: β=5.72, SE=0.515, p-value<0.001). There were also some statistically significant predisposing and need factors, but their effects were smaller.Conclusions This study shows that enabling factors such as the presence of supplementary insurance can cause historic claims-based pricing methods to potentially overestimate clinically appropriate post-discharge PT use, which would result in a bundle price that is too high. Clinical guidelines and best practice standards should be leveraged more often in bundled payment pricing methods to target this potentially avoidable utilization of care, and to stimulate the implementation of multi-provider bundled payment contracts.

Using Different Cutoffs to Define Tinnitus and Assess Its Prevalence—A Survey in the Dutch General Population

Introduction: Tinnitus prevalence numbers in the literature range between 5 and 43%, depending on the studied population and definition. It is unclear when tinnitus becomes pathologic.Objectives: To assess the tinnitus prevalence in the Dutch general population with different cutoffs for definition.Methods: In this cross-sectional study, a questionnaire was sent to a sample (n = 2,251) of the Nivel (Netherlands Institute for Health Services Research) Dutch Health Care Consumer Panel. Three questions were asked to assess the presence of tinnitus, duration, and frequency of the complaint. We classified people as having pathologic tinnitus when participants experienced it for 5–60 min (daily or almost daily or weekly), or tinnitus for &gt;60 min or continuously (daily or almost daily or weekly or monthly), so tinnitus impact on daily life was measured with the Tinnitus Functional Index (TFI) and a single-item question. Answers were stratified to mid-decade years of age. Prevalence numbers were weighted by gender and age to match the Dutch population.Results: Nine hundred thirty-two of 2,251 participants (41%) filled out the questionnaire. The median age was 67.0 (IQR 17) years. Three hundred thirty-eight of 932 (36%) experienced tinnitus for an undefined amount of time during the last year. Two hundred sixteen of 932 (23%) met our definition of having pathologic tinnitus (21% when weighted for age and gender). The median TFI score for all pathologic tinnitus participants was 16.6 (IQR 21.8). A percentage of 50.4% of the pathologic tinnitus participants had a TFI in the range 0–17, which can be interpreted as not a problem.Conclusion: Twenty-three percent (unweighted) or 21% (weighted) of our sample met our definition of pathologic tinnitus, which was based on a combination of duration and frequency over the last year. The TFI score of 47.7% of the pathologic tinnitus participants is ≥18. This indicates that they consider the tinnitus to be at least “a small problem” [11.1% (unweighted) or 8.9% (weighted) of the total study group]. This study illustrates the difficulties with defining pathologic tinnitus. In addition, it demonstrates that tinnitus prevalence numbers vary with different definitions and, consequently, stresses the importance of using a uniform definition of tinnitus.

Preferences of Treatment Strategies among Women with Low-Risk DCIS and Oncologists

As ongoing trials study the safety of an active surveillance strategy for low-risk ductal carcinoma in situ (DCIS), there is a need to explain why particular choices regarding treatment strategies are made by eligible women as well as their oncologists, what factors enter the decision process, and how much each factor affects their choice. To measure preferences for treatment and surveillance strategies, women with newly-diagnosed, primary low-risk DCIS enrolled in the Dutch CONTROL DCIS Registration and LORD trial, and oncologists participating in the Dutch Health Professionals Study were invited to complete a discrete choice experiment (DCE). The relative importance of treatment strategy-related attributes (locoregional intervention, 10-year risk of ipsilateral invasive breast cancer (iIBC), and follow-up interval) were discerned using conditional logit models. A total of n = 172 patients and n = 30 oncologists completed the DCE. Patient respondents had very strong preferences for an active surveillance strategy with no surgery, irrespective of the 10-year risk of iIBC. Extensiveness of the locoregional treatment was consistently shown to be an important factor for patients and oncologists in deciding upon treatment strategies. Risk of iIBC was least important to patients and most important to oncologists. There was a stronger inclination toward a twice-yearly follow-up for both groups compared to annual follow-up.

A model for estimating the health economic impact of earlier diagnosis of chronic thromboembolic pulmonary hypertension

BackgroundDiagnostic delay of chronic thromboembolic pulmonary hypertension (CTEPH) exceeds >1 year, contributing to higher mortality. Health-economic consequences of late CTEPH diagnosis are unknown. We aimed to develop a model for quantifying the impact of diagnosing CTEPH earlier on survival, quality-adjusted life years (QALYs) and healthcare costs.Material and methodsA Markov model was developed to estimate lifelong outcomes, depending on the degree of delay. Data on survival and quality of life were obtained from published literature. Hospital costs were assessed from patient records (n=498) at the Amsterdam UMC - VUmc, which is a Dutch CTEPH referral center. Medication costs were based on a mix of standard medication regimens.ResultsFor 63-year-old CTEPH patients with a 14 months diagnostic delay of CTEPH (median age and delay of patients in the European CTEPH Registry), lifelong healthcare costs were estimated at €117 100 for a mix of treatment options. In a hypothetical scenario of maximal reduction of current delay, improved survival was estimated at a gain of 3.01 life years and 2.04 QALYs. The associated cost increase was €44 654, of which 87% was due to prolonged medication use. This accounts for an incremental cost-utility ratio of €21 900/QALY.ConclusionOur constructed model based on the Dutch healthcare setting demonstrates a substantial health gain when CTEPH is diagnosed earlier. According to Dutch health-economic standards, additional costs remain below the deemed acceptable limit of €50 000/QALY for the particular disease burden. This model can be used for evaluating cost-effectiveness of diagnostic strategies aimed at reducing the diagnostic delay.