N. van der Linden
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Instruments to measure nurses' intention-to-stay in the profession
A systematic literature review
Review
(2026)
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Myrthe van der Zanden, Saba Hinrichs-Krapels, Christa Niehot, Anna Teeuw, Swasti Madan, Naomi van der Linden
Introduction There is a large and increasing shortage of nursing staff. To alleviate this problem, healthcare systems should prioritize healthcare interventions that improve nurse retention over healthcare interventions that reduce it or leave it unchanged. One way to do so is to evaluate interventions on their anticipated impact on nurse intention-to-stay, which is an important precursor of retention. An overview of available instruments to quantify nurse intention-to-stay is lacking, resulting in researchers re-inventing the wheel. This review aims to fill this gap. Methods A systematic literature search was performed in the databases Medline ALL via Ovid, Embase.com, Web of Science Core Collection, CINAHL Plus, PsycINFO, the Cochrane Central Register of Controlled Trials via Wiley, and Google Scholar (200 highest-ranked references only). The search string consisted of terms and associated synonyms for 1) nursing staff, 2) personnel intent to stay/leave, and 3) surveys. Articles were included when there was a quantitative method mentioned for measuring the intention of nurses to stay or quit nursing and/or their job/position/organization. Information was extracted on the year of publication, study design, study population, number of participants, instrument used for measuring intention-to-stay, and whether the instrument was focused on leaving the job, organization, or profession. In addition, we checked whether the instrument was used to evaluate the (expected or realized) impact of an intervention and if an association was determined between intention-to-stay (measured through the instrument) and retention. The protocol was not registered. Results 967 articles fulfilled our inclusion criteria, most of which were published in recent years. A total of 485 instruments were found. Nine regularly used instruments were identified, differing in their respective popularity over time, their size, the population for which they were developed and the strength of their link to actual retention. Notably, compared with the large body of literature on nurse intention-to-stay generally, the number of studies specifically measuring the impact of an intervention on nurse intention-to-stay is limited (n=20). Most of these intervention studies focused on changes in nurse training/mentorship or mental health support. Discussion & conclusion Many different instruments exist to measure nurses' intention-to-stay. To add to our identified instruments, a comparative study is needed to identify which instrument offers the strongest predictive value for nurse retention. The absence of studies specifically evaluating the impact of interventions on nurses' intention-to-stay creates a critical gap in understanding how health interventions influence retention. Funding Dutch Research Council, 406.XS.04.151.
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Introduction There is a large and increasing shortage of nursing staff. To alleviate this problem, healthcare systems should prioritize healthcare interventions that improve nurse retention over healthcare interventions that reduce it or leave it unchanged. One way to do so is to evaluate interventions on their anticipated impact on nurse intention-to-stay, which is an important precursor of retention. An overview of available instruments to quantify nurse intention-to-stay is lacking, resulting in researchers re-inventing the wheel. This review aims to fill this gap. Methods A systematic literature search was performed in the databases Medline ALL via Ovid, Embase.com, Web of Science Core Collection, CINAHL Plus, PsycINFO, the Cochrane Central Register of Controlled Trials via Wiley, and Google Scholar (200 highest-ranked references only). The search string consisted of terms and associated synonyms for 1) nursing staff, 2) personnel intent to stay/leave, and 3) surveys. Articles were included when there was a quantitative method mentioned for measuring the intention of nurses to stay or quit nursing and/or their job/position/organization. Information was extracted on the year of publication, study design, study population, number of participants, instrument used for measuring intention-to-stay, and whether the instrument was focused on leaving the job, organization, or profession. In addition, we checked whether the instrument was used to evaluate the (expected or realized) impact of an intervention and if an association was determined between intention-to-stay (measured through the instrument) and retention. The protocol was not registered. Results 967 articles fulfilled our inclusion criteria, most of which were published in recent years. A total of 485 instruments were found. Nine regularly used instruments were identified, differing in their respective popularity over time, their size, the population for which they were developed and the strength of their link to actual retention. Notably, compared with the large body of literature on nurse intention-to-stay generally, the number of studies specifically measuring the impact of an intervention on nurse intention-to-stay is limited (n=20). Most of these intervention studies focused on changes in nurse training/mentorship or mental health support. Discussion & conclusion Many different instruments exist to measure nurses' intention-to-stay. To add to our identified instruments, a comparative study is needed to identify which instrument offers the strongest predictive value for nurse retention. The absence of studies specifically evaluating the impact of interventions on nurses' intention-to-stay creates a critical gap in understanding how health interventions influence retention. Funding Dutch Research Council, 406.XS.04.151.
Youth visiting the emergency department after a suicide attempt, suicidal ideation or non-suicidal self-injury
Trends, repeat visits and costs
Journal article
(2026)
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Naomi Van Der Linden, Leona Hakkaart-Van Roijen, Kinke Lommerse, Merel Van Loon-Van Gaalen, Shanna Van Der Linden, Yvonne Bal, Christien Van Der Linden
Background In The Netherlands, it is unknown whether the number of youth suicide-related emergency department visits has changed over time. Also, insight is needed in the hospital costs for managing these patients, as a first step toward the economic evaluation of suicide prevention measures. Aims This study examines (a) changes in emergency department-recorded suicide attempts, suicidal ideation and non-suicidal self-injury in youth, including repeat emergency department visits; and (b) related hospital costs for these patients, from a health insurer perspective. Method In this cross-sectional study, data from various sources was combined to identify all youth aged ≤27 years visiting a Dutch inner-city emergency department between 2016 and 2023 for a suicide attempt, suicidal ideation or non-suicidal self-injury. Hospital records were reviewed manually to determine inclusion. Ambiguities were discussed within an expert panel and descriptive analyses, Poisson regression and logistic regression analyses were performed. For a subset of 30 patients, invoiced costs were determined. Results The number of suicide attempts increased by approximately 5% annually, peaking in 2022 (n = 172); there were significantly more female patients (71%), and the median age was 21 years. Cases of suicidal ideation showed a similar trend, whereas the number of recorded non-suicidal self-injuries reduced. A total of 28.5% of all patients (n = 281) had one or multiple repeat visits for the above reasons. Median suicide attempt-related costs per case were €930, range €385-€33 473. Conclusions Since 2016, an increasing number of youth visited the emergency department of a Dutch hospital after a suicide attempt, but this increase does not seem to continue after 2022. Hospital-invoiced costs differ substantially between patients.
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Background In The Netherlands, it is unknown whether the number of youth suicide-related emergency department visits has changed over time. Also, insight is needed in the hospital costs for managing these patients, as a first step toward the economic evaluation of suicide prevention measures. Aims This study examines (a) changes in emergency department-recorded suicide attempts, suicidal ideation and non-suicidal self-injury in youth, including repeat emergency department visits; and (b) related hospital costs for these patients, from a health insurer perspective. Method In this cross-sectional study, data from various sources was combined to identify all youth aged ≤27 years visiting a Dutch inner-city emergency department between 2016 and 2023 for a suicide attempt, suicidal ideation or non-suicidal self-injury. Hospital records were reviewed manually to determine inclusion. Ambiguities were discussed within an expert panel and descriptive analyses, Poisson regression and logistic regression analyses were performed. For a subset of 30 patients, invoiced costs were determined. Results The number of suicide attempts increased by approximately 5% annually, peaking in 2022 (n = 172); there were significantly more female patients (71%), and the median age was 21 years. Cases of suicidal ideation showed a similar trend, whereas the number of recorded non-suicidal self-injuries reduced. A total of 28.5% of all patients (n = 281) had one or multiple repeat visits for the above reasons. Median suicide attempt-related costs per case were €930, range €385-€33 473. Conclusions Since 2016, an increasing number of youth visited the emergency department of a Dutch hospital after a suicide attempt, but this increase does not seem to continue after 2022. Hospital-invoiced costs differ substantially between patients.
Perceived involvement in emergency department care
An observational study of nurse-led bedside shift handover
Journal article
(2026)
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M. C. Van Der Linden, R. Oueslati, A. R. C. Lam, H. Krapels, S. Van Vliet, A. De Graaf, N. Van Der Linden
Background
Involving patients in their care is an important aspect of quality emergency nursing, but remains difficult to achieve in busy and time-pressured settings. Bedside shift handover (BSH), where nurses exchange information in the patient’s presence, may support engagement, yet evidence from emergency departments (EDs) is limited.
Aim
To explore how patients perceived their involvement in communication and care during their ED stay, and whether exposure to nurse-led BSH, structured using the Situation-Background-Assessment-Recommendation (SBAR) format, was associated with higher perceived involvement.
Methods
A cross-sectional telephone survey was conducted among 104 recently discharged ED patients. Perceived involvement was assessed with the three-item CollaboRATE questionnaire. Additional data included patient and visit characteristics, crowding levels, and BSH exposure based on nursing documentation.
Results
Patients reported moderate-to-high perceived involvement (mean CollaboRATE 21.8 of 27), though only 11.5 % gave top scores across all items. BSH was documented in 36 % of eligible cases. No significant association was observed between documented BSH and perceived involvement (p = 0.81), nor between crowding and involvement (r = –.05, p = 0.59).
Conclusion
Most patients felt involved, yet optimal engagement was uncommon. No association was found between BSH and perceived involvement, likely reflecting variation in implementation. Consistent and inclusive handover practices may help support patient engagement, but this requires further study. ...
Involving patients in their care is an important aspect of quality emergency nursing, but remains difficult to achieve in busy and time-pressured settings. Bedside shift handover (BSH), where nurses exchange information in the patient’s presence, may support engagement, yet evidence from emergency departments (EDs) is limited.
Aim
To explore how patients perceived their involvement in communication and care during their ED stay, and whether exposure to nurse-led BSH, structured using the Situation-Background-Assessment-Recommendation (SBAR) format, was associated with higher perceived involvement.
Methods
A cross-sectional telephone survey was conducted among 104 recently discharged ED patients. Perceived involvement was assessed with the three-item CollaboRATE questionnaire. Additional data included patient and visit characteristics, crowding levels, and BSH exposure based on nursing documentation.
Results
Patients reported moderate-to-high perceived involvement (mean CollaboRATE 21.8 of 27), though only 11.5 % gave top scores across all items. BSH was documented in 36 % of eligible cases. No significant association was observed between documented BSH and perceived involvement (p = 0.81), nor between crowding and involvement (r = –.05, p = 0.59).
Conclusion
Most patients felt involved, yet optimal engagement was uncommon. No association was found between BSH and perceived involvement, likely reflecting variation in implementation. Consistent and inclusive handover practices may help support patient engagement, but this requires further study. ...
Background
Involving patients in their care is an important aspect of quality emergency nursing, but remains difficult to achieve in busy and time-pressured settings. Bedside shift handover (BSH), where nurses exchange information in the patient’s presence, may support engagement, yet evidence from emergency departments (EDs) is limited.
Aim
To explore how patients perceived their involvement in communication and care during their ED stay, and whether exposure to nurse-led BSH, structured using the Situation-Background-Assessment-Recommendation (SBAR) format, was associated with higher perceived involvement.
Methods
A cross-sectional telephone survey was conducted among 104 recently discharged ED patients. Perceived involvement was assessed with the three-item CollaboRATE questionnaire. Additional data included patient and visit characteristics, crowding levels, and BSH exposure based on nursing documentation.
Results
Patients reported moderate-to-high perceived involvement (mean CollaboRATE 21.8 of 27), though only 11.5 % gave top scores across all items. BSH was documented in 36 % of eligible cases. No significant association was observed between documented BSH and perceived involvement (p = 0.81), nor between crowding and involvement (r = –.05, p = 0.59).
Conclusion
Most patients felt involved, yet optimal engagement was uncommon. No association was found between BSH and perceived involvement, likely reflecting variation in implementation. Consistent and inclusive handover practices may help support patient engagement, but this requires further study.
Involving patients in their care is an important aspect of quality emergency nursing, but remains difficult to achieve in busy and time-pressured settings. Bedside shift handover (BSH), where nurses exchange information in the patient’s presence, may support engagement, yet evidence from emergency departments (EDs) is limited.
Aim
To explore how patients perceived their involvement in communication and care during their ED stay, and whether exposure to nurse-led BSH, structured using the Situation-Background-Assessment-Recommendation (SBAR) format, was associated with higher perceived involvement.
Methods
A cross-sectional telephone survey was conducted among 104 recently discharged ED patients. Perceived involvement was assessed with the three-item CollaboRATE questionnaire. Additional data included patient and visit characteristics, crowding levels, and BSH exposure based on nursing documentation.
Results
Patients reported moderate-to-high perceived involvement (mean CollaboRATE 21.8 of 27), though only 11.5 % gave top scores across all items. BSH was documented in 36 % of eligible cases. No significant association was observed between documented BSH and perceived involvement (p = 0.81), nor between crowding and involvement (r = –.05, p = 0.59).
Conclusion
Most patients felt involved, yet optimal engagement was uncommon. No association was found between BSH and perceived involvement, likely reflecting variation in implementation. Consistent and inclusive handover practices may help support patient engagement, but this requires further study.
Objectives: Data needed for economic evaluations in healthcare are often subject to privacy regulations and confidentiality, limiting accessibility. This poses challenges for conducting, reviewing, and validating health economic evaluations. The use of “synthetic data” may solve this problem. Methods: An economic evaluation compared “shamectomy” with “usual care” for the prevention of a fictitious disease called shame. A data set (Dorg) was created, consisting of 1000 patients in the base case. Next, synthetic data (Dsyn) were created from Dorg. Dorg and Dsyn were used, separately, to inform a model-based economic evaluation, and the similarity of the results was assessed for various scenarios: different sizes of Dorg, order of synthetization, method of synthetization, number of synthesized data sets, and missing data. Results: With standard settings, incremental cost-effectiveness ratio (ICER)-results for shamectomy were €25 848/quality-adjusted life-year in Dorg and on average €25 857 in 500 Dsyns, 95% CI (€16 776; €60 021). In the base case, 15% of the generated Dsyns resulted in an ICER leading to a positive reimbursement decision, as opposed to a negative decision when using Dorg. With smaller Dorg data sets (n = 50 and n = 500), ICER ranges increased to 95% CI (negative; €151 542) and 95% CI (negative; €669 717), respectively. Conclusions: Outcomes and conclusions of economic analyses based on synthetic data may deviate from those obtained by using the original data. For data sets < 1000 patients, which are common, deviations may be substantial and lead to suboptimal policy decisions. Based on our results, we propose a stepwise approach to using synthetic data for model-based health economic evaluations, using a large number of synthetic data sets (ie, >100) with the same size as the original data.
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Objectives: Data needed for economic evaluations in healthcare are often subject to privacy regulations and confidentiality, limiting accessibility. This poses challenges for conducting, reviewing, and validating health economic evaluations. The use of “synthetic data” may solve this problem. Methods: An economic evaluation compared “shamectomy” with “usual care” for the prevention of a fictitious disease called shame. A data set (Dorg) was created, consisting of 1000 patients in the base case. Next, synthetic data (Dsyn) were created from Dorg. Dorg and Dsyn were used, separately, to inform a model-based economic evaluation, and the similarity of the results was assessed for various scenarios: different sizes of Dorg, order of synthetization, method of synthetization, number of synthesized data sets, and missing data. Results: With standard settings, incremental cost-effectiveness ratio (ICER)-results for shamectomy were €25 848/quality-adjusted life-year in Dorg and on average €25 857 in 500 Dsyns, 95% CI (€16 776; €60 021). In the base case, 15% of the generated Dsyns resulted in an ICER leading to a positive reimbursement decision, as opposed to a negative decision when using Dorg. With smaller Dorg data sets (n = 50 and n = 500), ICER ranges increased to 95% CI (negative; €151 542) and 95% CI (negative; €669 717), respectively. Conclusions: Outcomes and conclusions of economic analyses based on synthetic data may deviate from those obtained by using the original data. For data sets < 1000 patients, which are common, deviations may be substantial and lead to suboptimal policy decisions. Based on our results, we propose a stepwise approach to using synthetic data for model-based health economic evaluations, using a large number of synthetic data sets (ie, >100) with the same size as the original data.
Implementation and effectiveness of teleneonatology for neonatal intensive care units
A protocol for a hybrid type III implementation pilot
Journal article
(2025)
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Josephine Wagenaar, Ron Van Beek, Henrike Pas, Martijn Suurveld, Naomi Van Der Linden, Julia Broos, Maaike Kleinsmann, Saba Hinrichs, H. Rob Taal
Background: Telemedicine in neonatal care (TeleNeonatology) has the potential to improve neonatal outcomes, address capacity challenges and influence the emotional burden on parents. TeleNeonatology allows for real-time audiovisual communication between healthcare providers at different neonatal intensive care units (NICUs). Despite the high potential for multiple neonatal use-cases, TeleNeonatology is primarily being used for neonatal resuscitation and has yet to be widely implemented in Europe. Our study aims to evaluate both implementation strategies and effectiveness of TeleNeonatology in a pilot study in The Netherlands.
Methods: A pre-post implementation study with hybrid type III design will be conducted from 1 January 2023 to 31 December 2024. The year 2023 will serve as a baseline period pre-implementation. From 1 January 2024, a TeleNeonatology device will be integrated within all communication between the NICU-level IV of the Erasmus MC hospital and the NICU-level II at Amphia Hospital. Outcomes of the implementation of the TeleNeo programme will be evaluated using a mixed-methods approach evaluating implementation outcomes, service outcomes and client outcomes. Feasibility, the primary implementation outcome, will be evaluated via a validated questionnaire for parents and personnel. Secondary implementation outcomes will be barriers and facilitators of implementation, based on semi-structured interviews and focus groups. A cost minimisation analysis, using decision trees, will be evaluated as service outcomes. Client outcomes will be assessed via parent-reported transfer experience questionnaires and interviews and the clinical outcomes NICU-level III transfer rate and length of stay.
Ethics and dissemination: This study was reviewed by the Medical Ethical Committee of the Erasmus Medical Centre, who confirmed that the rules laid down in the Medical Research Involving Human Subjects Act do not apply (identification number: MEC-2023–0561). Results will be published in peer-reviewed journals in two separate scientific articles: the primary evaluation and the cost evaluation. ...
Methods: A pre-post implementation study with hybrid type III design will be conducted from 1 January 2023 to 31 December 2024. The year 2023 will serve as a baseline period pre-implementation. From 1 January 2024, a TeleNeonatology device will be integrated within all communication between the NICU-level IV of the Erasmus MC hospital and the NICU-level II at Amphia Hospital. Outcomes of the implementation of the TeleNeo programme will be evaluated using a mixed-methods approach evaluating implementation outcomes, service outcomes and client outcomes. Feasibility, the primary implementation outcome, will be evaluated via a validated questionnaire for parents and personnel. Secondary implementation outcomes will be barriers and facilitators of implementation, based on semi-structured interviews and focus groups. A cost minimisation analysis, using decision trees, will be evaluated as service outcomes. Client outcomes will be assessed via parent-reported transfer experience questionnaires and interviews and the clinical outcomes NICU-level III transfer rate and length of stay.
Ethics and dissemination: This study was reviewed by the Medical Ethical Committee of the Erasmus Medical Centre, who confirmed that the rules laid down in the Medical Research Involving Human Subjects Act do not apply (identification number: MEC-2023–0561). Results will be published in peer-reviewed journals in two separate scientific articles: the primary evaluation and the cost evaluation. ...
Background: Telemedicine in neonatal care (TeleNeonatology) has the potential to improve neonatal outcomes, address capacity challenges and influence the emotional burden on parents. TeleNeonatology allows for real-time audiovisual communication between healthcare providers at different neonatal intensive care units (NICUs). Despite the high potential for multiple neonatal use-cases, TeleNeonatology is primarily being used for neonatal resuscitation and has yet to be widely implemented in Europe. Our study aims to evaluate both implementation strategies and effectiveness of TeleNeonatology in a pilot study in The Netherlands.
Methods: A pre-post implementation study with hybrid type III design will be conducted from 1 January 2023 to 31 December 2024. The year 2023 will serve as a baseline period pre-implementation. From 1 January 2024, a TeleNeonatology device will be integrated within all communication between the NICU-level IV of the Erasmus MC hospital and the NICU-level II at Amphia Hospital. Outcomes of the implementation of the TeleNeo programme will be evaluated using a mixed-methods approach evaluating implementation outcomes, service outcomes and client outcomes. Feasibility, the primary implementation outcome, will be evaluated via a validated questionnaire for parents and personnel. Secondary implementation outcomes will be barriers and facilitators of implementation, based on semi-structured interviews and focus groups. A cost minimisation analysis, using decision trees, will be evaluated as service outcomes. Client outcomes will be assessed via parent-reported transfer experience questionnaires and interviews and the clinical outcomes NICU-level III transfer rate and length of stay.
Ethics and dissemination: This study was reviewed by the Medical Ethical Committee of the Erasmus Medical Centre, who confirmed that the rules laid down in the Medical Research Involving Human Subjects Act do not apply (identification number: MEC-2023–0561). Results will be published in peer-reviewed journals in two separate scientific articles: the primary evaluation and the cost evaluation.
Methods: A pre-post implementation study with hybrid type III design will be conducted from 1 January 2023 to 31 December 2024. The year 2023 will serve as a baseline period pre-implementation. From 1 January 2024, a TeleNeonatology device will be integrated within all communication between the NICU-level IV of the Erasmus MC hospital and the NICU-level II at Amphia Hospital. Outcomes of the implementation of the TeleNeo programme will be evaluated using a mixed-methods approach evaluating implementation outcomes, service outcomes and client outcomes. Feasibility, the primary implementation outcome, will be evaluated via a validated questionnaire for parents and personnel. Secondary implementation outcomes will be barriers and facilitators of implementation, based on semi-structured interviews and focus groups. A cost minimisation analysis, using decision trees, will be evaluated as service outcomes. Client outcomes will be assessed via parent-reported transfer experience questionnaires and interviews and the clinical outcomes NICU-level III transfer rate and length of stay.
Ethics and dissemination: This study was reviewed by the Medical Ethical Committee of the Erasmus Medical Centre, who confirmed that the rules laid down in the Medical Research Involving Human Subjects Act do not apply (identification number: MEC-2023–0561). Results will be published in peer-reviewed journals in two separate scientific articles: the primary evaluation and the cost evaluation.
Improving emergency department flow by introducing four interventions simultaneously
A quality improvement project
Review
(2024)
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Christien van der Linden, Merel van Loon-van Gaalen, Sven Meylaerts, Jet Quarles van Ufford, Annemarie Woldhek, Geesje van Woerden, Naomi van der Linden
Background: Emergency department (ED) crowding is a widespread issue with adverse effects on patient care and outcomes. Local problem: ED crowding exacerbates wait times and compromises patient care, prompting opportunities for internal process improvement. Method: Over one week, the ED flow project team implemented four interventions, including an additional triage station, to optimize patient flow. We compared triage times, length of stay, crowding levels, and patient experiences with two control periods. Results: During peak hours, waiting times to triage decreased significantly with a median of 20 min (IQR 15–30) in the project week and 26 min (IQR 18–37) in the control weeks. Self-referrals decreased, while general practitioner referrals remained unchanged. Individual patient length of stay was unaffected, but crowding reduced notably during the project week. We found no difference in patient experiences between the periods. Conclusion: The interventions contributed to reduced crowding and improved patient flow. The dedication of the ED flow project team and the ED nurses was crucial to these outcomes. An additional triage station during peak hours in the ED was established as a structural change.
...
Background: Emergency department (ED) crowding is a widespread issue with adverse effects on patient care and outcomes. Local problem: ED crowding exacerbates wait times and compromises patient care, prompting opportunities for internal process improvement. Method: Over one week, the ED flow project team implemented four interventions, including an additional triage station, to optimize patient flow. We compared triage times, length of stay, crowding levels, and patient experiences with two control periods. Results: During peak hours, waiting times to triage decreased significantly with a median of 20 min (IQR 15–30) in the project week and 26 min (IQR 18–37) in the control weeks. Self-referrals decreased, while general practitioner referrals remained unchanged. Individual patient length of stay was unaffected, but crowding reduced notably during the project week. We found no difference in patient experiences between the periods. Conclusion: The interventions contributed to reduced crowding and improved patient flow. The dedication of the ED flow project team and the ED nurses was crucial to these outcomes. An additional triage station during peak hours in the ED was established as a structural change.
Journal article
(2024)
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Xavier G.L.V. Pouwels, Karel Kroeze, Naomi van der Linden, Michelle M.A. Kip, Hendrik Koffijberg
Objectives: Health economic (HE) models are often considered as “black boxes” because they are not publicly available and lack transparency, which prevents independent scrutiny of HE models. Additionally, validation efforts and validation status of HE models are not systematically reported. Methods to validate HE models in absence of their full underlying code are therefore urgently needed to improve health policy making. This study aimed to develop and test a generic dashboard to systematically explore the workings of HE models and validate their model parameters and outcomes. Methods: The Probabilistic Analysis Check dashBOARD (PACBOARD) was developed using insights from literature, health economists, and a data scientist. Functionalities of PACBOARD are (1) exploring and validating model parameters and outcomes using standardized validation tests and interactive plots, (2) visualizing and investigating the relationship between model parameters and outcomes using metamodeling, and (3) predicting HE outcomes using the fitted metamodel. To test PACBOARD, 2 mock HE models were developed, and errors were introduced in these models, eg, negative costs inputs, utility values exceeding 1. PACBOARD metamodeling predictions of incremental net monetary benefit were validated against the original model's outcomes. Results: PACBOARD automatically identified all errors introduced in the erroneous HE models. Metamodel predictions were accurate compared with the original model outcomes. Conclusions: PACBOARD is a unique dashboard aiming at improving the feasibility and transparency of validation efforts of HE models. PACBOARD allows users to explore the working of HE models using metamodeling based on HE models’ parameters and outcomes.
...
Objectives: Health economic (HE) models are often considered as “black boxes” because they are not publicly available and lack transparency, which prevents independent scrutiny of HE models. Additionally, validation efforts and validation status of HE models are not systematically reported. Methods to validate HE models in absence of their full underlying code are therefore urgently needed to improve health policy making. This study aimed to develop and test a generic dashboard to systematically explore the workings of HE models and validate their model parameters and outcomes. Methods: The Probabilistic Analysis Check dashBOARD (PACBOARD) was developed using insights from literature, health economists, and a data scientist. Functionalities of PACBOARD are (1) exploring and validating model parameters and outcomes using standardized validation tests and interactive plots, (2) visualizing and investigating the relationship between model parameters and outcomes using metamodeling, and (3) predicting HE outcomes using the fitted metamodel. To test PACBOARD, 2 mock HE models were developed, and errors were introduced in these models, eg, negative costs inputs, utility values exceeding 1. PACBOARD metamodeling predictions of incremental net monetary benefit were validated against the original model's outcomes. Results: PACBOARD automatically identified all errors introduced in the erroneous HE models. Metamodel predictions were accurate compared with the original model outcomes. Conclusions: PACBOARD is a unique dashboard aiming at improving the feasibility and transparency of validation efforts of HE models. PACBOARD allows users to explore the working of HE models using metamodeling based on HE models’ parameters and outcomes.
Journal article
(2023)
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M. Christien Van Der Linden, Lisette Kunz, Merel Van Loon-Van Gaalen, Geesje Van Woerden, Naomi Van Der Linden
Background: Preparations for Covid-19 in the Netherlands included hospital reconfigurations to increase capacity for the expected surge at the emergency department (ED). We describe patients’ ED length of stay (LOS), crowding and experiences of patients with respiratory complaints during the first Covid-19 peak. Methods: Retrospective analysis of demand, ED LOS, crowding, and a patient experience survey during a 12-week period in 2020 and similar periods in 2018 and 2019. Crowding levels were calculated using the National ED OverCrowding Scale. Results: The number of patients with respiratory complaints increased significantly, while total ED numbers were unchanged. Although presentation during the Covid-19 peak and needing hospital admission were associated with a longer ED LOS in patients with respiratory complaints, significantly less crowding occurred compared with the 2018 and 2019 periods. Increased ED LOS was associated with lower patient experience scores. Conclusion: Advanced warning and its associated preparation within the hospital and the community prevented significant delays in ED throughput during the first Covid-19 peak.
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Background: Preparations for Covid-19 in the Netherlands included hospital reconfigurations to increase capacity for the expected surge at the emergency department (ED). We describe patients’ ED length of stay (LOS), crowding and experiences of patients with respiratory complaints during the first Covid-19 peak. Methods: Retrospective analysis of demand, ED LOS, crowding, and a patient experience survey during a 12-week period in 2020 and similar periods in 2018 and 2019. Crowding levels were calculated using the National ED OverCrowding Scale. Results: The number of patients with respiratory complaints increased significantly, while total ED numbers were unchanged. Although presentation during the Covid-19 peak and needing hospital admission were associated with a longer ED LOS in patients with respiratory complaints, significantly less crowding occurred compared with the 2018 and 2019 periods. Increased ED LOS was associated with lower patient experience scores. Conclusion: Advanced warning and its associated preparation within the hospital and the community prevented significant delays in ED throughput during the first Covid-19 peak.
Effects of process changes on emergency department crowding in a changing world
An interrupted time-series analysis
Journal article
(2023)
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M. Christien Van Der Linden, Merel Van Loon-Van Gaalen, John R. Richards, Geesje Van Woerden, Naomi Van Der Linden
Background: During a 6-year period, several process changes were introduced at the emergency department (ED) to decrease crowding, such as the implementation of a general practitioner cooperative (GPC) and additional medical staff during peak hours. In this study, we assessed the effects of these process changes on three crowding measures: patients’ length of stay (LOS), the modified National ED OverCrowding Score (mNEDOCS), and exit block while taking into account changing external circumstances, such as the COVID-19 pandemic and centralization of acute care. Methods: We determined time points of the various interventions and external circumstances and built an interrupted time-series (ITS) model per outcome measure. We analyzed changes in level and trend before and after the selected time points using ARIMA modeling, to account for autocorrelation in the outcome measures. Results: Longer patients’ ED LOS was associated with more inpatient admissions and more urgent patients. The mNEDOCS decreased with the integration of the GPC and the expansion of the ED to 34 beds and increased with the closure of a neighboring ED and ICU. More exit blocks occurred when more patients with shortness of breath and more patients > 70 years of age presented to the ED. During the severe influenza wave of 2018–2019, patients’ ED LOS and the number of exit blocks increased. Conclusions: In the ongoing battle against ED crowding, it is pivotal to understand the effect of interventions, corrected for changing circumstances and patient and visit characteristics. In our ED, interventions which were associated with decreased crowding measures included the expansion of the ED with more beds and the integration of the GPC on the ED.
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Background: During a 6-year period, several process changes were introduced at the emergency department (ED) to decrease crowding, such as the implementation of a general practitioner cooperative (GPC) and additional medical staff during peak hours. In this study, we assessed the effects of these process changes on three crowding measures: patients’ length of stay (LOS), the modified National ED OverCrowding Score (mNEDOCS), and exit block while taking into account changing external circumstances, such as the COVID-19 pandemic and centralization of acute care. Methods: We determined time points of the various interventions and external circumstances and built an interrupted time-series (ITS) model per outcome measure. We analyzed changes in level and trend before and after the selected time points using ARIMA modeling, to account for autocorrelation in the outcome measures. Results: Longer patients’ ED LOS was associated with more inpatient admissions and more urgent patients. The mNEDOCS decreased with the integration of the GPC and the expansion of the ED to 34 beds and increased with the closure of a neighboring ED and ICU. More exit blocks occurred when more patients with shortness of breath and more patients > 70 years of age presented to the ED. During the severe influenza wave of 2018–2019, patients’ ED LOS and the number of exit blocks increased. Conclusions: In the ongoing battle against ED crowding, it is pivotal to understand the effect of interventions, corrected for changing circumstances and patient and visit characteristics. In our ED, interventions which were associated with decreased crowding measures included the expansion of the ED with more beds and the integration of the GPC on the ED.
The impact of prehospital blood sampling on the emergency department process of patients with chest pain
A pragmatic non-randomized controlled trial
Journal article
(2023)
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Johan L. Van Nieuwkerk, M. Christien Van Der Linden, Rolf J. Verheul, Merel Van Loon-Van Gaalen, Marije Janmaat, Naomi Van Der Linden
BACKGROUND: In patients with chest pain who arrive at the emergency department (ED) by ambulance, venous access is frequently established prehospital, and could be utilized to sample blood. Prehospital blood sampling may save time in the diagnostic process. In this study, the association of prehospital blood draw with blood sample arrival times, troponin turnaround times, and ED length of stay (LOS), number of blood sample mix-ups and blood sample quality were assessed. METHODS: The study was conducted from October 1, 2019 to February 29, 2020. In patients who were transported to the ED with acute chest pain with low suspicion for acute coronary syndrome (ACS), outcomes were compared between cases, in whom prehospital blood draw was performed, and controls, in whom blood was drawn at the ED. Regression analyses were used to assess the association of prehospital blood draw with the time intervals. RESULTS: Prehospital blood draw was performed in 100 patients. In 406 patients, blood draw was performed at the ED. Prehospital blood draw was independently associated with shorter blood sample arrival times, shorter troponin turnaround times and decreased LOS (P<0.001). No differences in the number of blood sample mix-ups and quality were observed (P>0.05). CONCLUSION: For patients with acute chest pain with low suspicion for ACS, prehospital blood sampling is associated with shorter time intervals, while there were no significant differences between the two groups in the validity of the blood samples.
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BACKGROUND: In patients with chest pain who arrive at the emergency department (ED) by ambulance, venous access is frequently established prehospital, and could be utilized to sample blood. Prehospital blood sampling may save time in the diagnostic process. In this study, the association of prehospital blood draw with blood sample arrival times, troponin turnaround times, and ED length of stay (LOS), number of blood sample mix-ups and blood sample quality were assessed. METHODS: The study was conducted from October 1, 2019 to February 29, 2020. In patients who were transported to the ED with acute chest pain with low suspicion for acute coronary syndrome (ACS), outcomes were compared between cases, in whom prehospital blood draw was performed, and controls, in whom blood was drawn at the ED. Regression analyses were used to assess the association of prehospital blood draw with the time intervals. RESULTS: Prehospital blood draw was performed in 100 patients. In 406 patients, blood draw was performed at the ED. Prehospital blood draw was independently associated with shorter blood sample arrival times, shorter troponin turnaround times and decreased LOS (P<0.001). No differences in the number of blood sample mix-ups and quality were observed (P>0.05). CONCLUSION: For patients with acute chest pain with low suspicion for ACS, prehospital blood sampling is associated with shorter time intervals, while there were no significant differences between the two groups in the validity of the blood samples.
Journal article
(2022)
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Margaret Campbell, Naomi Van Der Linden, Kees Van Gool, Karen Gardner, Helen Dickinson, Jason Agostino, Michelle Dowden, Irene O’Meara, Meg Scolyer, Hannah Woerle, Rosalie Viney
Background Crusted scabies is a debilitating dermatological condition. Although still relatively rare in the urban areas of Australia, rates of crusted scabies in remote Aboriginal communities in the Northern Territory (NT) are reported to be among the highest in the world. Objective To estimate the health system costs associated with diagnosing, treating and managing crusted scabies. Methods A disease pathway model was developed to identify the major phases of managing crusted scabies. In recognition of the higher resource use required to treat more severe cases, the pathway differentiates between crusted scabies severity grades. The disease pathway model was populated with data from a clinical audit of 42 crusted scabies patients diagnosed in the Top-End of Australia’s Northern Territory between July 1, 2016 and May 1, 2018. These data were combined with standard Australian unit costs to calculate the expected costs per patient over a 12-month period, as well as the overall population cost for treating crusted scabies. Findings The expected health care cost per patient diagnosed with crusted scabies is $35,418 Aus- tralian dollars (AUD) (95% CI: $27,000 to $43,800), resulting in an overall cost of $1,558,392AUD (95% CI: $1,188,000 to $1,927,200) for managing all patients diagnosed in data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist. the Northern Territory in a given year (2018). By far, the biggest component of the health care costs falls on the hospital system. Discussion This is the first cost-of-illness analysis for treating crusted scabies. Such analysis will be of value to policy makers and researchers by informing future evaluations of crusted scabies prevention programs and resource allocation decisions. Further research is needed on the wider costs of crusted scabies including non-financial impacts such as the loss in quality of life as well as the burden of care and loss of well-being for patients, families and communities.
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Background Crusted scabies is a debilitating dermatological condition. Although still relatively rare in the urban areas of Australia, rates of crusted scabies in remote Aboriginal communities in the Northern Territory (NT) are reported to be among the highest in the world. Objective To estimate the health system costs associated with diagnosing, treating and managing crusted scabies. Methods A disease pathway model was developed to identify the major phases of managing crusted scabies. In recognition of the higher resource use required to treat more severe cases, the pathway differentiates between crusted scabies severity grades. The disease pathway model was populated with data from a clinical audit of 42 crusted scabies patients diagnosed in the Top-End of Australia’s Northern Territory between July 1, 2016 and May 1, 2018. These data were combined with standard Australian unit costs to calculate the expected costs per patient over a 12-month period, as well as the overall population cost for treating crusted scabies. Findings The expected health care cost per patient diagnosed with crusted scabies is $35,418 Aus- tralian dollars (AUD) (95% CI: $27,000 to $43,800), resulting in an overall cost of $1,558,392AUD (95% CI: $1,188,000 to $1,927,200) for managing all patients diagnosed in data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist. the Northern Territory in a given year (2018). By far, the biggest component of the health care costs falls on the hospital system. Discussion This is the first cost-of-illness analysis for treating crusted scabies. Such analysis will be of value to policy makers and researchers by informing future evaluations of crusted scabies prevention programs and resource allocation decisions. Further research is needed on the wider costs of crusted scabies including non-financial impacts such as the loss in quality of life as well as the burden of care and loss of well-being for patients, families and communities.
Journal article
(2021)
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M. Christien van der Linden, Naomi van der Linden, Rianne C. Lam, Peter Stap, Crispijn L. van den Brand, Tamara Vermeulen, Korné Jellema, Ido R. van den Wijngaard
When acute stroke care is organised using a “drip-and-ship” model, patients receive immediate treatment at the nearest primary stroke centre followed by transfer to a comprehensive stroke centre (CSC). When stroke care is further centralised into the “direct-to-mothership” model, patients with stroke symptoms are immediately brought to a CSC to further reduce treatment times and enhance stroke outcomes. We investigated the effects of the ongoing centralization in a Dutch urban setting on treatment times of patients with confirmed ischemic stroke in a 4-year period. Next, in a non-randomized controlled trial, we assessed treatment times of patients with suspected ischemic stroke, and treatment times of patients with neurologic disorders other than suspected ischemic stroke, before and after the intervention in the CSC and the decentralized hospitals, the intervention being the change from “drip and ship” into “direct-to-mothership”. Our findings provide support for the ongoing centralization of acute stroke care in urban areas. Treatment times for patients with ischemic stroke decreased significantly, potentially improving functional outcomes. Improvements in treatment times for patients with suspected ischemic stroke were achieved without negative side effects for self-referrals with stroke symptoms and patients with other neurological disorders.
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When acute stroke care is organised using a “drip-and-ship” model, patients receive immediate treatment at the nearest primary stroke centre followed by transfer to a comprehensive stroke centre (CSC). When stroke care is further centralised into the “direct-to-mothership” model, patients with stroke symptoms are immediately brought to a CSC to further reduce treatment times and enhance stroke outcomes. We investigated the effects of the ongoing centralization in a Dutch urban setting on treatment times of patients with confirmed ischemic stroke in a 4-year period. Next, in a non-randomized controlled trial, we assessed treatment times of patients with suspected ischemic stroke, and treatment times of patients with neurologic disorders other than suspected ischemic stroke, before and after the intervention in the CSC and the decentralized hospitals, the intervention being the change from “drip and ship” into “direct-to-mothership”. Our findings provide support for the ongoing centralization of acute stroke care in urban areas. Treatment times for patients with ischemic stroke decreased significantly, potentially improving functional outcomes. Improvements in treatment times for patients with suspected ischemic stroke were achieved without negative side effects for self-referrals with stroke symptoms and patients with other neurological disorders.
Journal article
(2020)
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Henri B. Wolff, Leonie Alberts, Elisabeth A. Kastelijn, Franz M.N.H. Schramel, Veerle M.H. Coupé, Naomi van der Linden, Mathilda L. Bongers, Naomi E. Verstegen, Frank J. Lagerwaard, Frederik N. Hofman, Carin A. Uyl-de Groot, Suresh Senan, Sherif Y. El Sharouni
Objectives: Stage I non-small cell lung cancer (NSCLC) can be treated with either Stereotactic Body Radiotherapy (SBRT) or Video Assisted Thoracic Surgery (VATS) resection. To support decision making, not only the impact on survival needs to be taken into account, but also on quality of life, costs and cost-effectiveness. Therefore, we performed a cost-effectiveness analysis comparing SBRT to VATS resection with respect to quality adjusted life years (QALY) lived and costs in operable stage I NSCLC. Materials and methods: Patient level and aggregate data from eight Dutch databases were used to estimate costs, health utilities, recurrence free and overall survival. Propensity score matching was used to minimize selection bias in these studies. A microsimulation model predicting lifetime outcomes after treatment in stage I NSCLC patients was used for the cost-effectiveness analysis. Model outcomes for the two treatments were overall survival, QALYs, and total costs. We used a Dutch health care perspective with 1.5 % discounting for health effects, and 4 % discounting for costs, using 2018 cost data. The impact of model parameter uncertainty was assessed with deterministic and probabilistic sensitivity analyses. Results: Patients receiving either VATS resection or SBRT were estimated to live 5.81 and 5.86 discounted QALYs, respectively. Average discounted lifetime costs in the VATS group were €29,269 versus €21,175 for SBRT. Difference in 90-day excess mortality between SBRT and VATS resection was the main driver for the difference in QALYs. SBRT was dominant in at least 74 % of the probabilistic simulations. Conclusion: Using a microsimulation model to combine available evidence on survival, costs, and health utilities in a cost-effectiveness analysis for stage I NSCLC led to the conclusion that SBRT dominates VATS resection in the majority of simulations.
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Objectives: Stage I non-small cell lung cancer (NSCLC) can be treated with either Stereotactic Body Radiotherapy (SBRT) or Video Assisted Thoracic Surgery (VATS) resection. To support decision making, not only the impact on survival needs to be taken into account, but also on quality of life, costs and cost-effectiveness. Therefore, we performed a cost-effectiveness analysis comparing SBRT to VATS resection with respect to quality adjusted life years (QALY) lived and costs in operable stage I NSCLC. Materials and methods: Patient level and aggregate data from eight Dutch databases were used to estimate costs, health utilities, recurrence free and overall survival. Propensity score matching was used to minimize selection bias in these studies. A microsimulation model predicting lifetime outcomes after treatment in stage I NSCLC patients was used for the cost-effectiveness analysis. Model outcomes for the two treatments were overall survival, QALYs, and total costs. We used a Dutch health care perspective with 1.5 % discounting for health effects, and 4 % discounting for costs, using 2018 cost data. The impact of model parameter uncertainty was assessed with deterministic and probabilistic sensitivity analyses. Results: Patients receiving either VATS resection or SBRT were estimated to live 5.81 and 5.86 discounted QALYs, respectively. Average discounted lifetime costs in the VATS group were €29,269 versus €21,175 for SBRT. Difference in 90-day excess mortality between SBRT and VATS resection was the main driver for the difference in QALYs. SBRT was dominant in at least 74 % of the probabilistic simulations. Conclusion: Using a microsimulation model to combine available evidence on survival, costs, and health utilities in a cost-effectiveness analysis for stage I NSCLC led to the conclusion that SBRT dominates VATS resection in the majority of simulations.
Journal article
(2020)
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M. Christien Van Der Linden, Ido R. Van Den Wijngaard, Shanna Van Der Linden, Naomi Van Der Linden
For patients with acute ischaemic stroke, faster recanalisation improves the chances of a disability-free life and a quick discharge from the hospital. Hospital discharge, certainly after suffering a major life-changing event such as a stroke, is a complex and vulnerable phase in the patient's journey. Elderly are particularly vulnerable to the stressors caused by hospitalisation. Recently hospitalised patients are not only recovering from their acute illness; they also experience a period of generalised risk for a range of adverse events. At the same time, elderly generally prefer living in their own homes and should be discharged from the hospital and return home as quickly as possible. Both premature and delayed discharge are potential threats to patient well-being. We present a 90-year-old patient who underwent successful thrombectomy but suffered from night-time confusion at the hospital and discuss the transition process from hospital to home.
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For patients with acute ischaemic stroke, faster recanalisation improves the chances of a disability-free life and a quick discharge from the hospital. Hospital discharge, certainly after suffering a major life-changing event such as a stroke, is a complex and vulnerable phase in the patient's journey. Elderly are particularly vulnerable to the stressors caused by hospitalisation. Recently hospitalised patients are not only recovering from their acute illness; they also experience a period of generalised risk for a range of adverse events. At the same time, elderly generally prefer living in their own homes and should be discharged from the hospital and return home as quickly as possible. Both premature and delayed discharge are potential threats to patient well-being. We present a 90-year-old patient who underwent successful thrombectomy but suffered from night-time confusion at the hospital and discuss the transition process from hospital to home.
Driving Change Across Boundaries
Eliminating Crusted Scabies in Northern Territory, Australia
Book chapter
(2020)
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Helen Dickinson, Karen Gardner, Michelle Dowden, Naomi van der Linden
Collaboration is a key component of high-quality health systems and is particularly important when facing so-called wicked issues. This chapter examines cross-sector collaboration as a function of the notion of ‘boundary work’. It examines the wicked issue of the prevalence of crusted scabies in Indigenous populations living in remote communities in the Northern Territory of Australia, which will require significant collaborative work across a range of different organisational and institutional boundaries if it is to be successful. We research a new approach driven by a philanthropic organisation called One Disease and find this programme has been successful in many respects principally because of this organisation’s ability to work closely with a range of stakeholders.
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Collaboration is a key component of high-quality health systems and is particularly important when facing so-called wicked issues. This chapter examines cross-sector collaboration as a function of the notion of ‘boundary work’. It examines the wicked issue of the prevalence of crusted scabies in Indigenous populations living in remote communities in the Northern Territory of Australia, which will require significant collaborative work across a range of different organisational and institutional boundaries if it is to be successful. We research a new approach driven by a philanthropic organisation called One Disease and find this programme has been successful in many respects principally because of this organisation’s ability to work closely with a range of stakeholders.
Journal article
(2019)
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M. Christien Van Der Linden, Roeline A.Y. De Beaufort, Sven A.G. Meylaerts, Crispijn L. Van Den Brand, Naomi Van Der Linden
Objective: The aim of this study was to describe the impact of additional medical specialists, non-emergency physicians (non-EPs), performing direct supervision or a combination of direct and indirect supervision at an EP-led emergency department (ED), on patient flow and satisfaction. Patients and methods: An observational, cross-sectional, three-part study was carried out including staff surveys (n=379), a before and after 16-week data collection using data of visits during the peak hours (n=5270), and patient questionnaires during 1 week before the pilot and during week 5 of the pilot. Content analysis and descriptive statistics were used for analyses. Results: The value of being present at the ED was acknowledged by medical specialists in 49% of their surveys and 35% of the EPs' and ED nurses' surveys, especially during busy shifts. Radiologists were most often (67.3%) convinced of their value of being on-site, which was agreed upon by the ED professionals. Perceived improved quality of care, shortening of length of stay, and enhanced peer consultation were mentioned most often. During the pilot period, length of stay of boarded patients decreased from 197 min (interquartile range: 121 min) to 181 min (interquartile range: 113 min, P=0.006), and patient recommendation scores increased from -15 to +20. Conclusion: Although limited by the mix of direct and indirect supervision, our results suggest a positive impact of additional medical specialists during busy shifts. Throughput of admitted patients and patient satisfaction improved during the pilot period. Whether these findings differ between direct supervision and combination of direct and indirect supervision by the medical specialists requires further investigation.
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Objective: The aim of this study was to describe the impact of additional medical specialists, non-emergency physicians (non-EPs), performing direct supervision or a combination of direct and indirect supervision at an EP-led emergency department (ED), on patient flow and satisfaction. Patients and methods: An observational, cross-sectional, three-part study was carried out including staff surveys (n=379), a before and after 16-week data collection using data of visits during the peak hours (n=5270), and patient questionnaires during 1 week before the pilot and during week 5 of the pilot. Content analysis and descriptive statistics were used for analyses. Results: The value of being present at the ED was acknowledged by medical specialists in 49% of their surveys and 35% of the EPs' and ED nurses' surveys, especially during busy shifts. Radiologists were most often (67.3%) convinced of their value of being on-site, which was agreed upon by the ED professionals. Perceived improved quality of care, shortening of length of stay, and enhanced peer consultation were mentioned most often. During the pilot period, length of stay of boarded patients decreased from 197 min (interquartile range: 121 min) to 181 min (interquartile range: 113 min, P=0.006), and patient recommendation scores increased from -15 to +20. Conclusion: Although limited by the mix of direct and indirect supervision, our results suggest a positive impact of additional medical specialists during busy shifts. Throughput of admitted patients and patient satisfaction improved during the pilot period. Whether these findings differ between direct supervision and combination of direct and indirect supervision by the medical specialists requires further investigation.
Journal article
(2019)
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Marscha S. Holleman, Carin A. Uyl-de Groot, Stephen Goodall, Naomi van der Linden
Background: Risk-sharing arrangements (RSAs) can be used to mitigate uncertainty about the value of a drug by sharing the financial risk between payer and pharmaceutical company. We evaluated the projected impact of alternative RSAs for non–small cell lung cancer (NSCLC) therapies based on real-world data. Methods: Data on treatment patterns of Dutch NSCLC patients from four different hospitals were used to perform “what-if” analyses, evaluating the costs and benefits likely associated with various RSAs. In the scenarios, drug costs or refunds were based on response evaluation criteria in solid tumors (RECIST) response, survival compared to the pivotal trial, treatment duration, or a fixed cost per patient. Analyses were done for erlotinib, gemcitabine/cisplatin, and pemetrexed/platinum for metastatic NSCLC, and gemcitabine/cisplatin, pemetrexed/cisplatin, and vinorelbine/cisplatin for nonmetastatic NSCLC. Results: Money-back guarantees led to moderate cost reductions to the payer. For conditional treatment continuation schemes, costs and outcomes associated with the different treatments were dispersed. When price was linked to the outcome, the payer's drug costs reduced by 2.5% to 26.7%. Discounted treatment initiation schemes yielded large cost reductions. Utilization caps mainly reduced the costs of erlotinib treatment (by 16%). Given a fixed cost per patient based on projected average use of the drug, risk sharing was unfavorable to the payer because of the lower than projected use. The impact of RSAs on a national scale was dispersed. Conclusions: For erlotinib and pemetrexed/platinum, large cost reductions were observed with risk sharing. RSAs can mitigate uncertainty around the incremental cost-effectiveness or budget impact of drugs, but only when the type of arrangement matches the setting and type of uncertainty.
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Background: Risk-sharing arrangements (RSAs) can be used to mitigate uncertainty about the value of a drug by sharing the financial risk between payer and pharmaceutical company. We evaluated the projected impact of alternative RSAs for non–small cell lung cancer (NSCLC) therapies based on real-world data. Methods: Data on treatment patterns of Dutch NSCLC patients from four different hospitals were used to perform “what-if” analyses, evaluating the costs and benefits likely associated with various RSAs. In the scenarios, drug costs or refunds were based on response evaluation criteria in solid tumors (RECIST) response, survival compared to the pivotal trial, treatment duration, or a fixed cost per patient. Analyses were done for erlotinib, gemcitabine/cisplatin, and pemetrexed/platinum for metastatic NSCLC, and gemcitabine/cisplatin, pemetrexed/cisplatin, and vinorelbine/cisplatin for nonmetastatic NSCLC. Results: Money-back guarantees led to moderate cost reductions to the payer. For conditional treatment continuation schemes, costs and outcomes associated with the different treatments were dispersed. When price was linked to the outcome, the payer's drug costs reduced by 2.5% to 26.7%. Discounted treatment initiation schemes yielded large cost reductions. Utilization caps mainly reduced the costs of erlotinib treatment (by 16%). Given a fixed cost per patient based on projected average use of the drug, risk sharing was unfavorable to the payer because of the lower than projected use. The impact of RSAs on a national scale was dispersed. Conclusions: For erlotinib and pemetrexed/platinum, large cost reductions were observed with risk sharing. RSAs can mitigate uncertainty around the incremental cost-effectiveness or budget impact of drugs, but only when the type of arrangement matches the setting and type of uncertainty.
An evidence-based model to consolidate medication adherence cost estimation
The medication adherence cost estimation framework
Journal article
(2019)
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Rachelle L. Cutler, Naomi Van Der Linden, Shalom I.Charlie Benrimoj, Fernando Fernandez-Llimos, Victoria Garcia-Cardenas
Aim: To develop a standardized framework determining the economic impact of medication nonadherence. Materials & methods: Secondary analysis of existing literature reported cost data, aggregating cost outcome indicators. Weighted-average cost analysis performed, determining the proportional contribution to total cost. Results: Direct costs were reported in 92% of studies and indirect costs in 4% of studies. Three most utilized cost categories were hospital (68%), primary care (18%) and pharmacy costs (72%). Average unadjusted direct costs ranged from $625 to $154,203 contributing to 88% of the total cost; adjusted medical costs ranged from $565 to $56,313 representing 96% of the total cost. Conclusion: The medication adherence cost estimation framework enables the comparison of costing studies, facilitating informed health policy decision-making based on consistent evidence and terminology.
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Aim: To develop a standardized framework determining the economic impact of medication nonadherence. Materials & methods: Secondary analysis of existing literature reported cost data, aggregating cost outcome indicators. Weighted-average cost analysis performed, determining the proportional contribution to total cost. Results: Direct costs were reported in 92% of studies and indirect costs in 4% of studies. Three most utilized cost categories were hospital (68%), primary care (18%) and pharmacy costs (72%). Average unadjusted direct costs ranged from $625 to $154,203 contributing to 88% of the total cost; adjusted medical costs ranged from $565 to $56,313 representing 96% of the total cost. Conclusion: The medication adherence cost estimation framework enables the comparison of costing studies, facilitating informed health policy decision-making based on consistent evidence and terminology.
Journal article
(2019)
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Naomi van der Linden, Thomas Longden, John R. Richards, Munawar Khursheed, Wilhelmina M.T. Goddijn, Michiel J. van Veelen, Uzma Rahim Khan, M. Christien van der Linden
Background Heatwaves have been linked to increased risk of mortality and morbidity and are projected to increase in frequency and intensity due to climate change. The current study uses emergency department (ED) data from Australia, Botswana, Netherlands, Pakistan, and the United States of America to evaluate the impact of heatwaves on ED attendances, admissions and mortality. Methods Routinely collected time series data were obtained from 18 hospitals. Two separate thresholds (4 and 7) of the acclimatisation excess heat index (EHIaccl) were used to define “hot days”. Analyses included descriptive statistics, independent samples T-tests to determine differences in case mix between hot days and other days, and threshold regression to determine which temperature thresholds correspond to large increases in ED attendances. Findings In all regions, increases in temperature that did not coincide with time to acclimatise resulted in increases in ED attendances, and the EHIaccl performed in a similar manner. During hot days in California and The Netherlands, significantly more children ended up in the ED, while in Pakistan more elderly people attended. Hot days were associated with more patient admissions in the ages 5–11 in California, 65–74 in Karachi, and 75–84 in The Hague. During hot days in The Hague, patients with psychiatric symptoms were more likely to die. The current study did not identify a threshold temperature associated with particularly large increases in ED demand. Interpretation The association between heat and ED demand differs between regions. A limitation of the current study is that it does not consider delayed effects or influences of other environmental factors. Given the association between heat and ED use, hospitals and governmental authorities should recognise the demands that heat can place on local health care systems. These demands differ substantially between regions, with Pakistan being the most heavily affected within our study sample.
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Background Heatwaves have been linked to increased risk of mortality and morbidity and are projected to increase in frequency and intensity due to climate change. The current study uses emergency department (ED) data from Australia, Botswana, Netherlands, Pakistan, and the United States of America to evaluate the impact of heatwaves on ED attendances, admissions and mortality. Methods Routinely collected time series data were obtained from 18 hospitals. Two separate thresholds (4 and 7) of the acclimatisation excess heat index (EHIaccl) were used to define “hot days”. Analyses included descriptive statistics, independent samples T-tests to determine differences in case mix between hot days and other days, and threshold regression to determine which temperature thresholds correspond to large increases in ED attendances. Findings In all regions, increases in temperature that did not coincide with time to acclimatise resulted in increases in ED attendances, and the EHIaccl performed in a similar manner. During hot days in California and The Netherlands, significantly more children ended up in the ED, while in Pakistan more elderly people attended. Hot days were associated with more patient admissions in the ages 5–11 in California, 65–74 in Karachi, and 75–84 in The Hague. During hot days in The Hague, patients with psychiatric symptoms were more likely to die. The current study did not identify a threshold temperature associated with particularly large increases in ED demand. Interpretation The association between heat and ED demand differs between regions. A limitation of the current study is that it does not consider delayed effects or influences of other environmental factors. Given the association between heat and ED use, hospitals and governmental authorities should recognise the demands that heat can place on local health care systems. These demands differ substantially between regions, with Pakistan being the most heavily affected within our study sample.