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Valuing inter-sectoral costs and benefits of interventions in the healthcare sector: methods for obtaining unit prices
Expert Review of Pharmacoeconomics & Outcomes Research
Abstract
Introduction:
There is a lack of knowledge about methods for valuing health intervention-related costs and monetary benefits in the education and criminal justice sectors, also known as 'inter-sectoral costs and benefits' (ICBs). The objective of this study was to develop methods for obtaining unit prices for the valuation of ICBs.
Methods:
By conducting an exploratory literature study and expert interviews, several generic methods were developed. The methods' feasibility was assessed through application in the Netherlands. Results were validated in an expert meeting, which was attended by policy makers, public health experts, health economists and HTA-experts, and discussed at several international conferences and symposia.
Results:
The study resulted in four methods, including the opportunity cost method (A) and valuation using available unit prices (B), self-constructed unit prices (C) or hourly labor costs (D).
Discussion:
The methods developed can be used internationally and are valuable for the broad international field of HTA.
... In recent research, generic methods for valuing ICB unit costs have been developed and applied in the context of the Dutch education and criminal justice system [11]. However, the issue of how to measure such intersectoral resource use in trial-based economic evaluations and costof-illness studies with standardized resource-use measurement (RUM) instruments has received little systematic scientific attention to date [12]. ...
... Therefore, the first step in developing a new ICB instrument would include a literature search to identify the main cost-driving elements from relevant economic evaluations in a specific disease area [21]. This was selectively performed in prior research [11,70]; however, given that the inclusion of ICBs does not seem to have a long tradition [71], these empirical studies might be missing such cost elements for this very reason [72]. Thus, collating ICBs that were mentioned in studies but not necessarily measured appears more reasonable [2]. ...
Background:
Intersectoral costs and benefits (ICBs), i.e. costs and benefits of healthcare interventions outside the healthcare sector, can be a crucial component in economic evaluations from the societal perspective. Pivotal to their estimation is the existence of sound resource-use measurement (RUM) instruments; however, RUM instruments for ICBs in the education or criminal justice sectors have not yet been systematically collated or their psychometric quality assessed. This review aims to fill this gap.
Methods:
To identify relevant instruments, the Database of Instruments for Resource Use Measurement (DIRUM) was searched. Additionally, a systematic literature review was conducted in seven electronic databases to detect instruments containing ICB items used in economic evaluations. Finally, studies evaluating the psychometric quality of these instruments were searched.
Results:
Twenty-six unique instruments were included. Most frequently, ICB items measured school absenteeism, tutoring, classroom assistance or contacts with legal representatives, police custody/prison detainment and court appearances, with the highest number of items listed in the Client Service Receipt Inventory/Client Sociodemographic and Service Receipt Inventory/Client Service Receipt Inventory-Children's Version (CSRI/CSSRI/CSRI-C), Studying the Scope of Parental Expenditures (SCOPE) and Self-Harm Intervention, Family Therapy (SHIFT) instruments. ICBs in the education sector were especially relevant for age-related developmental disorders and chronic diseases, while criminal justice resource use seems more important in mental health, including alcohol-related disorders or substance abuse. Evidence on the validity or reliability of ICB items was published for two instruments only.
Conclusion:
With a heterogeneous variety of ICBs found to be relevant for several disease areas but many ICB instruments applied in one study only (21/26 instruments), setting-up an international task force to, for example, develop an internationally adaptable instrument is recommended.
... A recent survey among Dutch researchers revealed a considerable discrepancy in this respect: Although the majority of the respondents claimed that the inclusion of ICBs in economic evaluations is important, only a minority have previously done so [49]. At the same time, the Netherlands is one of the few countries with comprehensive, published unit costs for ICBs and a compulsory societal perspective [50]. ...
Evidence-informed healthcare decision-making relies on high quality data inputs, including robust unit costs, which in many countries are not readily available. The objective of the Department of Health Economics’ Unit Cost Online Database, developed based on systematic reviews of Austrian costing studies, is to make conducting economic evaluations from healthcare and societal perspectives more feasible with publicly available unit cost information in Austria. This article aims to describe trends in unit cost data sources and reporting using this comprehensive database as a case study to encourage relevant national and international methodological discussions. Database analysis and synthesis included publication/study characteristics and costing reporting details in line with the Consolidated Health Economic Evaluation Reporting Standards (CHEERS 2022) with the year of the database launch as the cut-off point to assess how the methods have developed over time. Forty-two full economic evaluations and 278 unit costs were analyzed (2004–2016: 34 studies/232 unit costs, 2017–2022: 8 studies/46 unit costs). Although the reporting quality of costing details including the study perspective, unit cost sources and years has improved since 2017, the unit cost estimates and sources remained heterogeneous in Austria. While methodologically standardized national-level unit costs would be the gold standard, a systematically collated list of unit costs is a first step towards supporting health economic evaluations nationally.
... A final limitation of this model is that there remains room for further model development and implementation of novel concepts in health economic modeling. Examples of such novel concepts are the use of the expected value of (partial) perfect information (EV(P)PI), the value of hope, the inclusion of a broader societal perspective (i.e., costs related to public health, criminal justice, education, housing, or the environment), or alternative quality of life measures such as the Capabilities Approach, which contrasts the use of utilities in mental health by focusing on an individual's subjective wellbeing (76,77). The use of EV(P)PI could, for example, provide insight in the expected costs of the decision uncertainty surrounding model input parameters, such as the transition probabilities. ...
Background
Bipolar disorder is an often recurrent mood disorder that is associated with a significant economic and health-related burden. Increasing the availability of health-economic evidence may aid in reducing this burden. The aim of this study is to describe the design of an open-source health-economic Markov model for assessing the cost-effectiveness of interventions in the treatment of Bipolar Disorders type I and II, TiBipoMod.
Methods
TiBipoMod is a decision-analytic Markov model that allows for user-defined incorporation of both pharmacological and non-pharmacological interventions for the treatment of BD. TiBipoMod includes the health states remission, depression, (hypo)mania and death. Costs and effects are modeled over a lifetime horizon from a societal and healthcare perspective, and results are presented as the total costs, Quality-Adjusted Life Years (QALY), Life Years (LY), and incremental costs per QALYs and LYs gained.
Results
Functionalities of TiBipoMod are demonstrated by performing a cost-utility analysis of mindfulness-based cognitive therapy (MBCT) compared to the standard of care. Treatment with MBCT resulted in an increase of 0.18 QALYs per patient, and a dominant incremental cost-effectiveness ratio per QALY gained for MBCT at a probability of being cost-effective of 71% when assuming a €50,000 willingness-to-pay threshold.
Conclusion
TiBipoMod can easily be adapted and used to determine the cost-effectiveness of interventions in the treatment in Bipolar Disorder type I and II, and is freely available for academic purposes upon request at the authors.
... The methodology for the valuation of health-related service use in the education and (criminal) justice sectors is less established. A first major step towards the valuation of such service use was recently taken by determining several methods and testing their applicability in the Netherlands [59]. The four methods suggested for consideration based on their accuracy in a hierarchical manner include i) the opportunity cost method based on micro-costing, ii) utilisation of market prices from governmental reports, iii) selfconstructed unit prices based on the information given in governmental reports, and iv) hourly labour costs for the provision of the relevant services. ...
Background
Valuation is a critical part of the costing process in health economic evaluations. However, an overview of specific issues relevant to the European context on harmonizing methodological requirements for the valuation of costs to be used in health economic evaluation is lacking. We aimed to inform the development of an international, harmonized and multi-sectoral costing framework, as sought in the European PECUNIA (ProgrammE in Costing, resource use measurement and outcome valuation for Use in multi-sectoral National and International health economic evaluAtions) project.
Methods
We conducted a scoping review (information extraction 2008–2021) to a) to demonstrate the degree of heterogeneity that currently exists in the literature regarding central terminology, b) to generate an overview of the most relevant areas for harmonization in multi-sectoral and multi-national costing processes for health economic evaluations, and c) to provide insights into country level variation regarding economic evaluation guidance. A complex search strategy was applied covering key publications on costing methods, glossaries, and international costing recommendations augmented by a targeted author and reference search as well as snowballing. Six European countries served as case studies to describe country-specific harmonization issues. Identified information was qualitatively synthesized and cross-checked using a newly developed, pilot-tested data extraction form.
Results
Costing methods for services were found to be heterogeneous between sectors and country guidelines and may, in practice, be often driven by data availability and reimbursement systems in place. The lack of detailed guidance regarding specific costing methods, recommended data sources, double-counting of costs between sectors, adjustment of unit costs for inflation, transparent handling of overhead costs as well as the unavailability of standardized unit costing estimates in most countries were identified as main drivers of country specific differences in costing methods with a major impact on valuation and cost-effectiveness evidence.
Conclusion
This review provides a basic summary of existing costing practices for evaluative purposes across sectors and countries and highlights several common methodological factors influencing divergence in cost valuation methods that would need to be systematically incorporated and addressed in future costing practices to achieve more comparable, harmonized health economic evaluation evidence.
... This might be due to the lack of available data and valuation methods [20]. At the same time, these inter-sectoral costs were found to contribute a considerable proportion to the total costs of mental diseases [7,15,21,22]. With economic evaluations being increasingly used as a base for decision making in healthcare, a comprehensive reflection of the societal costs associated with a disease is also vital in this context and has been already recommended in national health economics guidelines in the Netherlands and Spain [23,24]. ...
Background
A comprehensive, comparable assessment of the economic disease burden and the value of relevant care forms a major challenge in the case of mental diseases. This study aimed to inform the development of a resource use measurement (RUM) instrument and harmonized reference unit costs valid for multi-sectoral and multi-national cost assessments for mental health diseases as part of the European PECUNIA project.
Methods
An iterative, multi-methods approach was applied. Systematic literature reviews appended with national grey literature searches in six European countries were conducted to generate preliminary, literature-based, international, mental health-related service and resource use lists for all investigated sectors in 2018. As part of a multi-national expert survey, these lists were reviewed by 18 Austrian sector-specific experts regarding the clarity, relevance, comprehensiveness and availability in the Austrian context.
Results
Out of 295 items included in the preliminary, international, sector-specific lists (health and social care—201 items, criminal justice—35 items, education—39 items; patient, family and informal care—20 items), a total of 261 items and descriptions (88%) were considered clear by all experts. 42 items (14%) were considered not existing in Austria, and 111 items (38%) were prioritized regarding their relevance in the national context. Thirteen additional items (4%) were suggested to be added to accommodate for Austria-specific features of the individual sectors. Major typological difficulties based on item names were observed.
Conclusions
The identified country-specific variations and general typological bias and their potential contributions to service and resource use cost variations across countries and sectors call for further systematic investigation. Next, PECUNIA will develop internationally harmonized and comparable definitions of the listed items and their units of analysis based on a new conceptual multi-sectoral costing framework. The developed lists will require consolidation and further prioritization for the development of a patient-reported RUM instrument and consequent reference unit cost valuation.
... Despite recent methodological developments in identifying, measuring, and valuing education costs [12][13][14][15][16], their inclusion in costing research remains limited [17]. This could be attributed to several reasons. ...
Background
Psychosocial (e.g., anxiety or behavior) problems lead to costs not only in the healthcare sector but also in education and other sectors. As psychosocial problems develop during the critical period of establishing educational trajectories, education costs are particularly relevant in the context of psychosocial problems among children and adolescents.Objectives
This study aimed to gain insights into the methods used for the inclusion of education costs in health economics studies and into the proportion of the education costs in relation to the total costs associated with a condition or an intervention.Methods
We systematically searched the PubMed, Embase, SSCI, CINAHL, PsycINFO, ERIC, and Econlit databases in August 2019 for economic evaluations of mental health, psychosocial and educational interventions, and cost-of-illness studies of mental, behavioral, and neurodevelopmental disorders conducted from a societal perspective in populations of children and adolescents. An additional search was conducted in February 2021 to update the review.ResultsIn total, 49 articles were included in the analysis. The most common cost items were special education, school absenteeism, and various educational professionals (educational psychologist). A variety of methods were employed for the identification, measurement, and/or valuation of education costs. The proportion of education costs to the total costs of condition/intervention ranged from 0 to 67%, with the mean being 18.5%.DiscussionSince education costs can constitute a significant proportion of the total costs of an intervention or condition, including them in health economics studies might be important in informing optimal resource allocation decisions. Although various methods are available for including education costs in health economics studies, further research is needed to develop evidence-based methods for producing comparable estimates.
... The inclusion of education and criminal justice ICBs in economic evaluations is supported by several national pharmacoeconomic guidelines [14][15][16]. Furthermore, several studies investigated the identification, measurement, and valuation of education and criminal justice ICBs in health economics research [10,17,18]. Nevertheless, to date, few economic evaluations incorporate these ICBs, even though they might be relevant to the study context [19,20]. ...
Objectives
Mental and behavioural disorders (MBDs) and interventions targeting MBDs lead to costs and cost savings in the healthcare sector, but also in other sectors. The latter are referred to as intersectoral costs and benefits (ICBs). Interventions targeting MBDs often lead to ICBs in the education and criminal justice sectors, yet these are rarely included in economic evaluations. This study aimed to investigate the attitudes held by health economists and health technology assessment experts towards education and criminal justice ICBs in economic evaluations and to quantify the relative importance of these ICBs in the context of MBDs.
Methods
An online survey containing open-ended questions and two best–worst scaling object case studies was conducted in order to prioritise a list of 20 education ICBs and 20 criminal justice ICBs. Mean relative importance scores for each ICB were generated using hierarchical Bayes analysis.
Results
Thirty-nine experts completed the survey. The majority of the respondents (68%) reported that ICBs were relevant, but only a few (32%) included them in economic evaluations. The most important education ICBs were “special education school attendance”, “absenteeism from school”, and “reduced school attainment”. The most important criminal justice ICBs were “decreased chance of committing a crime as a consequence/effect of mental health programmes/interventions”, “jail and prison expenditures”, and “long-term pain and suffering of victims/victimisation”.
Conclusions
This study identified the most important education and criminal justice ICBs for economic evaluations of interventions targeting MBDs and suggests that it could be relevant to include these ICBs in economic evaluations.
... 185,186 Current work, including this report chapter, has, however, not yet explicitly integrated consideration of potential intersectoral impacts of active classroom interventions into cost-effectiveness analysis. 187 Explicit consideration of intersectoral effects could provide a new perspective on the estimated long-term cost-effectiveness of interventions, such as the Stand Out in Class intervention. ...
Background
Sedentary behaviour (sitting) is a highly prevalent negative health behaviour, with individuals of all ages exposed to environments that promote prolonged sitting. The school classroom represents an ideal setting for environmental change through the provision of sit–stand desks.
Objectives
The aim of this study was to undertake a pilot cluster randomised controlled trial of the introduction of sit–stand desks in primary school classrooms, to inform a definitive trial. Objectives included providing information on school and participant recruitment and retention, acceptability of the intervention, and outcome measures. A preliminary estimate of the intervention’s effectiveness on the proposed primary outcome (change in weekday sitting time) for inclusion in a definitive trial was calculated, along with a preliminary assessment of potential cost-effectiveness. A full process evaluation was also undertaken.
Design
A two-armed pilot cluster randomised controlled trial with economic and qualitative evaluations. Schools were randomised on a 1 : 1 basis to the intervention ( n = 4) or control ( n = 4) trial arms.
Setting
Primary schools in Bradford, West Yorkshire, UK.
Participants
Children in Year 5 (i.e. aged 9–10 years).
Intervention
Six sit–stand desks replaced three standard desks (sitting six children) in the intervention classrooms for 4.5 months. Teachers were encouraged to ensure that all pupils were exposed to the sit–stand desks for at least 1 hour per day, on average, using a rotation system. Schools assigned to the control arm continued with their usual practice.
Main outcome measures
Trial feasibility outcomes included school and participant recruitment and attrition, acceptability of the intervention, and acceptability of and compliance with the proposed outcome measures [including weekday sitting measured using activPAL™ (PAL Technologies Ltd, Glasgow, UK) accelerometers, physical activity, adiposity, blood pressure, cognitive function, musculoskeletal comfort, academic progress, engagement and behaviour].
Results
Thirty-three per cent of schools approached and 75% ( n = 176) of eligible children took part. At the 7-month follow-up, retention rates were 100% for schools and 97% for children. Outcome measure completion rates ranged from 63% to 97%. A preliminary estimate of intervention effectiveness, from a weighted linear regression model (adjusting for baseline sitting time and wear time) revealed a mean difference in change in sitting of –30.6 minutes per day (95% confidence interval –56.42 to –4.84 minutes per day) between the intervention and control trial arms. The process evaluation revealed that the intervention, recruitment and evaluation procedures were acceptable to teachers and children, with the exception of minor issues around activPAL attachment. A preliminary within-trial economic analysis revealed no difference between intervention and control trial arms in health and education resource use or outcomes. Long-term modelling estimated an unadjusted incremental cost-effectiveness ratio of Stand Out in Class of £78,986 per quality-adjusted life-year gained.
Conclusion
This study has provided evidence of the acceptability and feasibility of the Stand Out in Class intervention and evaluation methods. Preliminary evidence suggests that the intervention may have a positive direction of effect on weekday sitting time, which warrants testing in a full cluster randomised controlled trial. Lessons learnt from this trial will inform the planning of a definitive trial.
Trial registration
Current Controlled Trials ISRCTN12915848.
Funding
This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research ; Vol. 8, No. 8. See the NIHR Journals Library website for further project information.
... Drost et al. published a study on a methodology for estimating intersectoral costs and benefits of mental health interventions aimed at reducing delinquency. 18 They calculated the overall unit costs of services (e.g. services relating to criminal proceedings and hourly costs for police officers and lawyers), rather than the unit costs of specific delinquent acts, which limits their ease of use in economic evaluations. ...
Background:
Youth mental health interventions aimed at reducing substance use and delinquency in adolescents compete with other types of interventions for reimbursement from public funding. Within the youth mental health domain, delinquent acts impose high costs on society. These costs should be included in economic evaluations conducted from a societal perspective. Although the relevance of these costs is recognized, they are often left out because the unit costs of delinquent acts are unknown.
Aims of the study:
This study aims to provide a method for estimating the unit costs per perpetrator of 14 delinquent acts common in the Netherlands and included in self reported delinquency questionnaires: robbery/theft with violence, simple theft/pickpocketing, receiving stolen goods, destruction/vandalism of private or public property, disorderly conduct/discrimination, arson, cybercrime, simple and aggravated assault, threat, forced sexual contact, unauthorised driving, driving under the influence, dealing in soft drugs, and dealing in hard drugs.
Methods:
Information on government expenditures and the incidence of crimes, number of perpetrators, and the percentage of solved and reported crimes was obtained from the national database on crime and justice of the Research and Documentation Centre of the Ministry of Justice and Security, Statistics Netherlands, and the Council for the Judiciary in the Netherlands. We applied a top-down micro costing approach to calculate the point estimate of the unit costs for each of the delinquent acts and, subsequently, estimated the mean (SD) unit costs for each of the delinquent acts by taking random draws from a triangular distribution while taking into account a 10% uncertainty associated with the associated point estimate.
Results:
The mean (SD) unit costs per delinquent act per perpetrator ranged between EUR495 (EUR1.30) for "Driving under the influence" and EUR33,813 (EUR78.30) for a "Cybercrime". These unit costs may be considered as outliers as most unit costs ranged between EUR 2,600 and EUR 13,500 per delinquent act per perpetrator.
Discussion:
This study is the first to estimate the unit costs per delinquent act per perpetrator in the Netherlands. The results of this study enable the inclusion of government expenditures associated with crime and justice in economic evaluations conducted from a societal perspective.
Implications for health care provision and use:
Youth mental health interventions aimed at reducing substance use and delinquency in adolescents are increasingly subjected to economic evaluations. These evaluations are used to inform decisions concerning the allocation of scarce healthcare resources and should cover all the costs and benefits for society, including those associated with delinquent acts.
Implications for health policies:
The results of this study facilitate economic evaluations of youth mental health interventions aimed at reducing substance use and delinquency in adolescents, conducted from a societal perspective.
Implications for further research:
Based on health-economic evaluations conducted in the field of youth mental health and the results of the current study, we recommend including the estimated unit costs in guidelines for health-economic evaluations conducted from a societal perspective. Future research could aim at examining whether these unit costs require regular updating. The methodology applied in this study allows for this.
... Beispielsweise im Zusammenhang mit psychischen Erkrankungen betreffen diese Effekte häufig den Bildungs-und Justizsektor. Seit wenigen Jahren setzt sich in der ökonomischen Evaluation zunehmend die Ansicht durch, dass auch diese intersektoralen Kosten und Kosteneinsparungen (englisch: intersectoral costs and benefits) ein zentraler Baustein sind, wenn gesundheitsökonomische Analysen aus gesellschaftlicher Perspektive durchgeführt werden sollen [2][3][4]. ...
There is growing interest in extending the evaluative space of the quality-adjusted life-year framework beyond health. Using a critical interpretive synthesis approach, the objective was to review peer-reviewed literature that has discussed non-health outcomes within the context of quality-adjusted life-years and synthesise information into a thematic framework. Papers were identified through searches conducted in Web of Science, using forward citation searching. A critical interpretive synthesis allows for the development of interpretations (synthetic constructs) that go beyond those offered in the original sources. The final output of a critical interpretive synthesis is the synthesising argument, which integrates evidence from across studies into a coherent thematic framework. A concept map was developed to show the relationships between different types of non-health benefits. The critical interpretive synthesis was based on 99 papers. The thematic framework was constructed around four themes: (1) benefits affecting well-being (subjective well-being, psychological well-being, capability and empowerment); (2) benefits derived from the process of healthcare delivery; (3) benefits beyond the recipient of care (spillover effects, externalities, option value and distributional benefits); and (4) benefits beyond the healthcare sector. There is a wealth of research concerning non-health benefits and the evaluative space of the quality-adjusted life-year. Further dialogue and debate are necessary to address conceptual and normative challenges, to explore the societal willingness to sacrifice health for benefits beyond health and to consider the equity implications of different courses of action.
Background
Mental health problems can lead to costs and benefits in other sectors (e.g. in the education sector) in addition to the healthcare sector. These related costs and benefits are known as intersectoral costs and benefits (ICBs). Although some ICBs within the education sector have been identified previously, little is known about their extensiveness and transferability, which is crucial for their inclusion in health economics research.
Objectives
The aim of this study was to identify ICBs in the education sector, to validate the list of ICBs in a broader European context, and to categorize the ICBs using mental health as a case study.
Methods
Previously identified ICBs in the education sector were used as a basis for this study. Additional ICBs were extracted from peer-reviewed literature in PubMed and grey literature from six European countries. A comprehensive list of unique items was developed based on the identified ICBs. The list was validated by surveying an international group of educational experts. The survey results were used to finalize the list, which was categorized according to the care atom.
Results
Additional ICBs in the education sector were retrieved from ninety-six sources. Fourteen experts from six European countries assessed the list for completeness, clarity, and relevance. The final list contained twenty-four ICBs categorized into input, throughput, and output.
Conclusion
By providing a comprehensive list of ICBs in the education sector, this study laid further foundations for the inclusion of important societal costs in health economics research in the broader European context.
In economic evaluation, the healthcare perspective has gradually given way to use of the societal perspective, as this perspective is often advocated for support in making optimal societal decisions. In practice, economic evaluations conducted from the societal perspective ignore, fail to measure and/or fail to monetize many of the costs that fall outside of the healthcare sector. To limit bias and increase decision-supportive power, researchers could strengthen their evaluations by adhering to a few basic principles. Five “pillars for the societal perspective” are proposed. First, who bears the cost and who does not is irrelevant. Second, it is imperative to consider including costs for sectors outside the healthcare sector. Third, both high frequent costs and costs with high unit prices should be considered. Fourth, double counting should be avoided. And fifth, researchers should reflect on choices related to costs, i.e. cost omission and problems with identifying, measuring, and valuing costs.
Background: While primary health care (PHC)-based prevention and management of heavy drinking is clinically effective and cost-effective, it remains poorly implemented in routine practice. Systematic reviews and multi-country studies have demonstrated the ability of training and support programmes to increase PHC-based screening and brief advice activity to reduce heavy drinking. However, gains have been only modest and short term at best. WHO studies have concluded that a more effective uptake could be achieved by embedding PHC activity within broader community and municipal support.
Protocol: A quasi-experimental study will compare PHC-based prevention and management of heavy drinking in three intervention cities from Colombia, Mexico and Peru with three comparator cities from the same countries. In the implementation cities, primary health care units (PHCUs) will receive training embedded within ongoing supportive municipal action over an 18-month implementation period. In the comparator cities, practice as usual will continue at both municipal and PHCU levels. The primary outcome will be the proportion of consulting adult patients intervened with (screened and advice given to screen positives). The study is powered to detect a doubling of the outcome measure from an estimated 2.5/1,000 patients at baseline. Formal evaluation points will be at baseline, mid-point and end-point of the 18-month implementation period. We will present the ratio (plus 95% confidence interval) of the proportion of patients receiving intervention in the implementation cities with the proportions in the comparator cities. Full process evaluation will be undertaken, coupled with an analysis of potential contextual, financial and political-economy influencing factors.
Discussion: This multi-country study will test the extent to which embedding PHC-based prevention and management of alcohol use disorder with supportive municipal action leads to improved scale-up of more patients with heavy drinking receiving appropriate advice and treatment.
Study status: The four-year study will start on 1 st December 2017.
Background: While primary health care (PHC)-based prevention and management of alcohol use disorder (AUD) is clinically effective and cost-effective, it remains poorly implemented in routine practice. Systematic reviews and multi-country studies have demonstrated the ability of training and support programmes to increase PHC-based screening and brief advice activity to reduce heavy drinking. However, gains have been only modest and short term at best. WHO studies have concluded that a more effective uptake could be achieved by embedding PHC activity within broader community and municipal support. Protocol: A quasi-experimental study will compare PHC-based prevention and management of AUD, operationalized by heavy drinking, in three intervention cities from Colombia, Mexico and Peru with three comparator cities from the same countries. In the implementation cities, primary health care units (PHCUs) will receive training embedded within ongoing supportive municipal action over an 18-month implementation period. In the comparator cities, practice as usual will continue at both municipal and PHCU levels. The primary outcome will be the proportion of consulting adult patients intervened with (screened and advice given to screen positives). The study is powered to detect a doubling of the outcome measure from an estimated 2.5/1,000 patients at baseline. Formal evaluation points will be at baseline, mid-point and end-point of the 18-month implementation period. We will present the ratio (plus 95% confidence interval) of the proportion of patients receiving intervention in the implementation cities with the proportions in the comparator cities. Full process evaluation will be undertaken, coupled with an analysis of potential contextual, financial and political-economy influencing factors. Discussion: This multi-country study will test the extent to which embedding PHC-based prevention and management of alcohol use disorder with supportive municipal action leads to improved scale-up of more patients with heavy drinking receiving appropriate advice and treatment.
Background: While primary health care (PHC)-based prevention and management of alcohol use disorder (AUD) is clinically effective and cost-effective, it remains poorly implemented in routine practice. Systematic reviews and multi-country studies have demonstrated the ability of training and support programmes to increase PHC-based screening and brief advice activity to reduce heavy drinking. However, gains have been only modest and short term at best. WHO studies have concluded that a more effective uptake could be achieved by embedding PHC activity within broader community and municipal support. Protocol: A quasi-experimental study will compare PHC-based prevention and management of AUD, operationalized by heavy drinking, in three intervention cities from Colombia, Mexico and Peru with three comparator cities from the same countries. In the implementation cities, primary health care units (PHCUs) will receive training embedded within ongoing supportive municipal action over an 18-month implementation period. In the comparator cities, practice as usual will continue at both municipal and PHCU levels. The primary outcome will be the proportion of consulting adult patients intervened with (screened and advice given to screen positives). The study is powered to detect a doubling of the outcome measure from an estimated 2.5/1,000 patients at baseline. Formal evaluation points will be at baseline, mid-point and end-point of the 18-month implementation period. We will present the ratio (plus 95% confidence interval) of the proportion of patients receiving intervention in the implementation cities with the proportions in the comparator cities. Full process evaluation will be undertaken, coupled with an analysis of potential contextual, financial and political-economy influencing factors. Discussion: This multi-country study will test the extent to which embedding PHC-based prevention and management of alcohol use disorder with supportive municipal action leads to improved scale-up of more patients with heavy drinking receiving appropriate advice and treatment.
Een maatschappelijke kosten-batenanalyse (MKBA) biedt een overzicht van de voor- en nadelen van een maatregel, zoals de aanleg van een weg of woonwijk. Door deze voor- en nadelen zoveel mogelijk te kwantificeren en in euro's uit te drukken, geeft een MKBA inzicht in het effect van de maatregel op de welvaart in Nederland. Met die informatie kan een MKBA de politieke besluitvorming ondersteunen en verhelderen.
Om de kwaliteit en de vergelijkbaarheid van MKBA's te waarborgen hebben het Centraal Planbureau (CPB) en het Planbureau voor de Leefomgeving (PBL) in 2013 een algemene MKBA-leidraad opgesteld. De ministeries zullen de komende jaren werkwijzers maken, waarin de principes van de algemene leidraad worden geconcretiseerd voor het eigen beleidsterrein. Dit rapport van het RIVM is bedoeld als een eerste stap om te komen tot zo'n werkwijzer voor volksgezondheid en zorg. In het rapport laten we zien wat de consequenties zijn als vanuit de MKBA-methode naar dit terrein wordt gekeken.
Een goede MKBA kan ook op het terrein van volksgezondheid en zorg een bijdrage leveren aan de beleidsvoorbereiding en de besluitvorming. Daarvoor moeten nog wel enkele methodologische aspecten nader uitgewerkt en bediscussieerd worden. Belangrijke thema's daarbij zijn: effecten op de verdeling van welvaart tussen groepen mensen, de waarde van gezondheid in euro's, het kwantificeren van arbeidsbaten en het waarderen van toekomstige baten (de 'discontovoet'). In dit rapport signaleert en expliciteert het RIVM de belangrijkste vragen en dilemma's waarop de werkwijzer een antwoord moet geven.
Het doel van de kostenhandleiding is het verschaffen van een instrument dat onderzoekers en beleidsmakers faciliteert bij de uitvoering en beoordeling van kostenonderzoek in economische evaluaties. In dit artikel wordt de kern van de kostenhandleiding 2010 beschreven en in een internationale context geplaatst aan de hand van het stappenplan voor kostenonderzoek. In dit stappenplan wordt het berekenen van kosten gezien als een proces waarbij zeven stappen chronologisch doorlopen worden. Waar duidelijke aanbevelingen worden gedaan voor de bepaling van de reikwijdte van de economische evaluatie (stap 1), de keuze van de kostencategorieën (stap 2), omgaan met onzekerheid (stap 6) en rapportage van kosten (stap 7), wordt de keuze met betrekking tot de identificatie (stap 3), volumemeting (stap 4) en waardering van eenheden (stap 5) neergelegd bij de onderzoeker. Hoewel de aanbevelingen in Nederland op specifieke onderwerpen iets afwijkt van andere Westerse landen, is het stappenplan voor kostenonderzoek vergelijkbaar met het proces dat beschreven wordt in de internationale richtlijnen. De kostenhandleiding sluit aan bij de uitgangspunten en de terminologie uit de Nederlandse richtlijnen voor farmaco-economisch onderzoek, maar de beschreven methoden kunnen ook in andere soorten onderzoekworden gebruikt.
Background:
Patient self-report allows collecting comprehensive data for the purpose of performing economic evaluations. The aim of the current study was to assess the feasibility, reliability and a part of the construct validity of a commonly applied questionnaire on healthcare utilization and productivity losses in patients with a psychiatric disorder (TiC-P).
Methods:
Data were derived alongside two clinical trials performed in the Netherlands in patients with mental health problems. The response rate, average time of filling out the questionnaire and proportions of missing values were used as indicators of feasibility of the questionnaire. Test-retest analyses were performed including Cohen's kappa and intra class correlation coefficients to assess reliability of the data. The construct validity was assessed by comparing patient reported data on contacts with psychotherapists and reported data on long-term absence from work with data derived from registries.
Results:
The response rate was 72%. The mean time needed for filling out the first TiC-P was 9.4 minutes. The time needed for filling out the questionnaire was 2.3 minutes less for follow up measurements. Proportions of missing values were limited (< 2.4%) except for medication for which in 10% of the cases costs could not be calculated. Cohen's kappa was satisfactory to almost perfect for most items related to healthcare consumption and satisfactory for items on absence from work and presenteeism. Comparable results were shown by the ICCs on variables measuring volumes of medical consumption and productivity losses indicating good reliability of the questionnaire.Absolute agreement between patient-reported data and data derived from medical registrations of the psychotherapists was satisfactory. Accepting a margin of +/- seven days, the agreement on reported and registered data on long-term absence from work was satisfactory. The validity of self-reported data using the TiC-P is promising.
Conclusions:
The results indicate that the TiC-P is a feasible and reliable instrument for collecting data on medical consumption and productivity losses in patients with mild to moderate mental health problems. Additionally, the construct validity of questions related to contacts with psychotherapist and long-term absence from work was satisfactory.
This highly successful textbook is now available in its third edition. Over the years it has become the standard textbook in the field world-wide. It mirrors the huge expansion of the field of economic evaluation in health care, since the last edition was published in 1997. This new edition builds on the strengths of previous editions, being clearly written in a style accessible to a wide readership. Key methodological principles are outlined using a critical appraisal checklist that can be applied to any published study. The methodological features of the basic forms of analysis are then explained in more detail with special emphasis of the latest views on productivity costs, the characterisation of uncertainty and the concept of net benefit. The book has been greatly revised and expanded especially concerning analysing patient-level data and decision-analytic modelling. There is discussion of new methodological approaches, including cost effectiveness acceptability curves, net benefit regression, probalistic sensitivity analysis and value of information analysis. There is an expanded chapter on the use of economic evaluation, including discussion of the use of cost-effectiveness thresholds, equity considerations and the transferability of economic data. This new edition is required reading for anyone commissioning, undertaking or using economic evaluations in health care, and will be popular with health service professionals, health economists, pharmacand health care decision makers. It is especially relevant for those taking pharmacoeconomics courses.
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.
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.
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.
Intersectoral collaboration is an important part of many health promotion programmes. The reasons for the local organisations to collaborate, i.e. to finance programmes, are presumably based on benefits they derive from the collaboration. The aim of this study is to discuss whether subsector financial analyses based on data from cost-effectiveness analyses reflect incentives of collaborating organisations in two intersectoral health promotion programmes.
Within economics, financial incentives are important reasons for actions. The financial incentives of collaborators are exemplified with two subsector financial analyses containing avoided disease-related costs as estimated in two cost-effectiveness analyses, on an elderly safety promotion programme (Safe Seniors in Sundbyberg) and on a diabetes prevention programme (Stockholm Diabetes Prevention Program, SDPP) from Stockholm, Sweden.
The subsector financial analyses indicate that there are financial incentives for the key local community organisation, i.e. the local authority, to collaborate in one of the programmes but not the other. There are no financial benefits for other important community organisations, such as non-governmental organisations.
The reasons for collaborating organisations to collaborate within intersectoral health promotion programmes extend beyond financial benefits from averted disease. Thus, the reported subsector financial analyses are only partial reflections of the incentives of collaborators, but they might be used as a starting point for discussions on cost sharing among potential intersectoral collaborators.
Public health interventions have received increased attention from policy makers, and there has been a corresponding increase in the number of economic evaluations within the domain of public health. However, methods to evaluate public health interventions are less well established than those for medical interventions. Focusing on health as an outcome measure is likely to underestimate the impact of many public health interventions. This paper provides a review of outcome measures in public health; and describes the benefits of using the capability approach as a means to developing an all encompassing outcome measure.
Unpaid time represents a potentially significant input into the health production function. The paper sets out the basis for valuation of time inputs consistent with the notion of opportunity cost. Such analysis requires consideration of whether time displaced in the production of health involves lost work or lost leisure. Furthermore, because valuation of opportunity cost requires the consistent treatment of costs and benefits, the study also considers the valuation of outputs. The basis for valuing the shadow price of work time is examined by firstly assuming perfect competition. The analysis then considers the presence of monopoly and monopsony in product markets and income and sales taxes. The basis for valuing the shadow price of leisure ("leisure' being all uses of time except paid employment) is restricted to an examination of methods previously used to value unpaid housework. The two methods examined are the replacement cost and the opportunity cost method. As the methods are not equivalent, the circumstances where each is appropriate vary depending on whether the output lost in producing health is replaced. Although not set out as the primary focus of the paper, the issues surrounding the valuation of outputs generated by non-market and quasi-market activity are examined. In particular, where activities such as informal care result in indirect utility to the carers (and patients) themselves, it is likely the full market wage provides a lower bound estimate of the value of marginal benefit. Finally the paper provides a practical approach to examining opportunity cost of unpaid inputs consistent with the concepts set out in preceding sections.
Informal care makes up a significant part of the total amount of care provided to care recipients with chronic and terminal diseases. Still, informal care is often neglected in economic evaluations of health care programs. Probably this is related to the fact that the costs of informal care are to an important extent related to time inputs by relatives and friends of care recipients and time is not easy to value. Development of theoretically sound, yet easily applicable valuation methods is therefore important since ignoring the costs of informal care may lead to undesirable shifts between formal and informal care. Moreover, there is increasing evidence that providing informal care may lead to health problems for the caregiver, both in terms of morbidity and mortality. Until now these health effects have not been incorporated in economic evaluations. More attention for the identification and valuation of the full costs and (health) effects of informal care for the informal caregiver seems needed therefore. This contribution presents a critical evaluation of the available methods to incorporate informal care in economic evaluations.
This paper compares several applied valuation methods for including informal care in economic evaluations of healthcare programmes: the proxy good method; the opportunity cost method; the contingent valuation method (CVM); conjoint measurement (CM); and valuation of health effects in terms of health-related quality of life (HR-QOL) and well-being. The comparison focuses on three questions: what outcome measures are available for including informal care in economic evaluations of healthcare programmes; whether these measures are compatible with the common types of economic evaluation; and, when applying these measures, whether all relevant aspects of informal care are incorporated.
All types of economic evaluation can incorporate a monetary value of informal care (using the opportunity cost method, the proxy good method, CVM and CM) on the cost side of an analysis, but only when the relevant aspects of time costs have been valued. On the effect side of a cost-effectiveness or cost-utility analysis, the health effects (for the patient and/or caregiver) measured in natural units or QALYs can be combined with cost estimates based on the opportunity cost method or the proxy good method. One should be careful when incorporating CVM and CM in cost-minimization, cost-effectiveness and cost-utility analyses, as the health effects of patients receiving informal care and the carers themselves may also have been valued separately. One should determine whether the caregiver valuation exercise allows combination with other valuation techniques.
In cost-benefit analyses, CVM and CM appear to be the best tools for the valuation of informal care. When researchers decide to use the well-being method, we recommend applying it in a cost-benefit analysis framework. This method values overall QOL (happiness); hence it is broader than just HR-QOL, which complicates inclusion in traditional health economic evaluations that normally define outcomes more narrowly. Using broader, non-monetary valuation techniques, such as the CarerQol instrument, requires a broader evaluation framework than cost-effectiveness/cost-utility analysis, such as cost-consequence or multi-criteria analysis.
Mental health and substance use disorders among children, youth, and young adults are major threats to the health and well-being of younger populations which often carryover into adulthood. The costs of treatment for mental health and addictive disorders, which create an enormous burden on the affected individuals, their families, and society, have stimulated increasing interest in prevention practices that can impede the onset or reduce the severity of the disorders. Prevention practices have emerged in a variety of settings, including programs for selected at-risk populations (such as children and youth in the child welfare system), school-based interventions, interventions in primary care settings, and community services designed to address a broad array of mental health needs and populations. Preventing Mental, Emotional, and Behavioral Disorders Among Young People updates a 1994 Institute of Medicine book, Reducing Risks for Mental Disorders, focusing special attention on the research base and program experience with younger populations that have emerged since that time. Researchers, such as those involved in prevention science, mental health, education, substance abuse, juvenile justice, health, child and youth development, as well as policy makers involved in state and local mental health, substance abuse, welfare, education, and justice will depend on this updated information on the status of research and suggested directions for the field of mental health and prevention of disorders. © 2009 by the National Academy of Sciences. All rights reserved.
Many preventive interventions for mental disorders have costs and benefits that spill over to sectors outside the healthcare sector. Little is known about these "inter-sectoral costs and benefits" (ICBs) of prevention. However, to achieve an efficient allocation of scarce resources, insights on ICBs are indispensable.
The main aim was to identify the ICBs related to the prevention of mental disorders and provide a sector-specific classification scheme for these ICBs.
Using PubMed, a literature search was conducted for ICBs of mental disorders and related (psycho)social effects. A policy perspective was used to build the scheme's structure, which was adapted to the outcomes of the literature search. In order to validate the scheme's international applicability inside and outside the mental health domain, semi-structured interviews were conducted with (inter)national experts in the broad fields of health promotion and disease prevention.
The searched-for items appeared in a total of 52 studies. The ICBs found were classified in one of four sectors: "Education", "Labor and Social Security", "Household and Leisure" or "Criminal Justice System". Psycho(social) effects were placed in a separate section under "Individual and Family". Based on interviews, the scheme remained unadjusted, apart from adding a population-based dimension.
This is the first study which offers a sector-specific classification of ICBs. Given the explorative nature of the study, no guidelines on sector-specific classification of ICBs were available. Nevertheless, the classification scheme was acknowledged by an international audience and could therefore provide added value to researchers and policymakers in the field of mental health economics and prevention.
The identification and classification of ICBs offers decision makers supporting information on how to optimally allocate scarce resources with respect to preventive interventions for mental disorders.
By exploring a new area of research, which has remained largely unexplored until now, the current study has an added value as it may form the basis for the development of a tool which can be used to calculate the ICBs of specific mental health related preventive interventions.
Een gestandaardiseerde methode voor het meten van directe medische kosten en indirecte kosten vergoot de vergelijkbaarheid van de resultaten van economische evaluaties. Het instituut voor Medische Technology Assessment (iMTA) heeft in samenwerking met het Trimbos instituut een vragenlijst ontwikkeld voor het meten directe medische kosten en indirecte kosten die samenhangen met psychische aandoeningen. Deel I van de vragenlijst heeft betrekking op de directe medische kosten. Deel II is een verkorte versie van de Health and Labour Questionnaire (HLQ) voor meten van de indirecte kosten (SF-HLQ). Deel II is niet ziekte-specifiek en is daarom ook van toepassing op andere indicaties. In de handleiding wordt een beschrijving gegeven van de items en de scoring daarvan.
Background:
When guidelines for health economic evaluations prescribe that a societal perspective should be adopted, productivity costs should be included. However, previous research suggests that, in practice, productivity costs are often neglected. This may considerably bias the results of cost-effectiveness studies, particularly those regarding treatments targeted at diseases with a high incidence rate in the working population, such as depressive disorders.
Objectives:
This study aimed to, first, investigate whether economic evaluations of treatments for depressive disorders include productivity costs and, if so, how. Second, to investigate how the inclusion or exclusion of productivity costs affects incremental costs.
Methods:
A systematic literature review was performed. Included articles were reviewed to determine (i) whether productivity costs had been included and (ii) whether the studies adhered to national health economic guidelines about the inclusion or exclusion of these costs. For those studies that did include productivity costs, we calculated what proportion of total costs were productivity costs. Subsequently, the incremental costs, excluding productivity costs, were calculated and compared with the incremental costs presented in the original article, to analyse the impact of productivity costs on final results. Regression analyses were used to investigate the relationship between the level of productivity costs and the type of depressive disorder, the type of treatment and study characteristics such as time horizon used and productivity cost valuation method.
Results:
A total of 81 unique economic evaluations of treatments for adults with depressive disorders were identified, 24 of which included productivity costs in the numerator and one in the denominator. Approximately 69% of the economic evaluations ignored productivity costs. Two-thirds of the studies complied with national guidelines regarding the inclusion of productivity costs. For the studies that included productivity costs, these costs reflected an average of 60% of total costs per treatment arm. The inclusion or exclusion of productivity costs substantially affected incremental costs in a number of studies. Regression analyses showed that the level of productivity costs was significantly associated with study characteristics such as average age, the methods of data collection regarding work time lost, the values attached to lost work time, the type of depressive disorder, the type of treatment provided and the level of direct costs.
Conclusions:
Studies that do not include productivity costs may, in many cases, poorly reflect full societal costs (or savings) of an intervention. Furthermore, when comparing total costs reported in studies that include productivity costs, it should be noted that study characteristics such as the methods used to assess productivity costs may affect their level.
Increasing attention is being given to the evaluation of public health interventions. Methods for the economic evaluation of clinical interventions are well established. In contrast, the economic evaluation of public health interventions raises additional methodological challenges. The paper identifies these challenges and provides suggestions for overcoming them.
To identify the methodological challenges, five reviews that explored the economics of public health were consulted. From these, four main methodological challenges for the economic evaluation of public health interventions were identified. A review of empirical studies was conducted to explore how the methodological challenges had been approached in practice and an expert workshop convened to discuss how they could be tackled in the future.
The empirical review confirmed that the four methodological challenges were important. In all, 154 empirical studies were identified, covering areas as diverse as alcohol, drug use, obesity and physical activity, and smoking. However, the four methodological challenges were handled badly, or ignored in most of the studies reviewed.
The empirical review offered few insights into ways of addressing the methodological challenges. The expert workshop suggested a number of ways forward for overcoming the methodological challenges.
Although the existing empirical literature offers few insights on how to respond to these challenges, expert opinion suggests a number of ways forward. Much of what is suggested here has not yet been applied in practice, and there is an urgent need both for pilot studies and more methodological research.
A new approach for estimating the indirect costs of disease, which explicitly considers economic circumstances that limit production losses due to disease, is presented (the friction cost method). For the Netherlands the short-term friction costs in 1990 amount to 1.5-2.5% of net national income (NNI), depending on the extent to which short-term absence from work induces production loss and costs. The medium-term macro-economic consequences of absence from work and disability reduce NNI by an additional 0.8%. These estimates are considerably lower than estimates based on the traditional human capital approach, but they better reflect the economic impact of illness.
In cost-utility analyses of pharmaceutical treatments, the costs are measured in monetary terms and the effects are measured as quality-adjusted life years (QALYs) gained. QALYs are constructed by assigning life years a quality weight between 0 (dead) and 1 (full health).
A potential problem in cost-utility analysis is that some consequences, in principle, can be included both in the costs and in the quality adjustment, which can lead to double-counting.
This article outlines the double-counting problem in cost-utility analysis. It shows that the potential for double-counting depends on how healthcare and income losses resulting from disease are financed, and on how the questions that assess the quality weights are phrased. Double-counting can be avoided by telling respondents to assume that healthcare costs and income losses are fully reimbursed when quality weights are assessed. The quality weights would then capture the change in health and leisure, and the other consequences could be included in the cost estimation.
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• Depending on the type of health-care intervention being evaluated, including ICBs within costing research may improve the reliability of economic analyses. The types of analyses for which this might be the case are
- Cua Cea
• Depending on the type of health-care intervention being evaluated, including ICBs within costing research may improve the reliability of economic
analyses. The types of analyses for which this might be the case are, among others, CEA, CUA and CBA.
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Synopsis: This Dutch guideline supports researchers and policymakers in conducting and assessing research involving ICBs. It contains a classification scheme and unit prices which can be used to identify and value ICBs
- Rmwa Drost
- Atg Paulus
- D Ruwaard
Drost RMWA, Paulus ATG, Ruwaard D, et al. Handleiding intersectorale kosten en baten van (preventieve) interventies: classificatie,
identificatie en kostprijzen. Maastricht: Maastricht University,
Department of Health Services Research; 2014.
• Synopsis: This Dutch guideline supports researchers and policymakers in conducting and assessing research involving
ICBs. It contains a classification scheme and unit prices
which can be used to identify and value ICBs, along with an
extensive description of the methods used to find and calculate these.
Synopsis: Lorgelly et al. acknowledge that the widely used outcome measure quality adjusted life years and associated quality of life measures do not reflect broader outcomes of interventions
- P K Lorgelly
- K D Lawson
- E A Fenwick
Op weg naar maatschappelijke kosten-baten analyses voor preventie en zorg. Bilthoven: Rijksinstituut voor Volksgezondheid en Milieu
- M Pomp
- C G Schoemaker
- J J Polder
Synopsis: This study provides an overview of the contents of the current Dutch manual for costing in economic evaluations and mentions costs in the criminal justice and educational sectors as possibly important for economic evaluations
- S S Tan
- C A Bouwmans
- F F Rutten