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This study involving women with early-stage breast cancer showed an association between the presence of isolated tumor cells or micrometastases in sentinel or axillary lymph nodes and the 5-year rate of disease-free survival. Women with such findings in these lymph nodes who received systemic adjuvant therapy had an improved outcome. This study involving women with early-stage breast cancer showed an association between the presence of isolated tumor cells or micrometastases in sentinel or axillary lymph nodes and the 5-year rate of disease-free survival. Women with such findings in these lymph nodes who received systemic adjuvant therapy had an improved outcome. The status of the axillary lymph nodes is the most important prognostic factor in breast cancer. 1 These nodes can be sampled by axillary lymph-node dissection or sentinel-node biopsy with or without subsequent axillary lymph-node dissection (these additional lymph nodes are denoted as nonsentinel nodes). Detailed examination of the sentinel node by means of serial sectioning with optional immunohistochemical staining permits the detection of small metastases or isolated tumor cells. 2 – 4 Isolated tumor cells (staged as pN0[i+], with deposits ≤0.2 mm) and micrometastases (staged as pN1mi, with deposits >0.2 to ≤2.0 mm) have been separate categories in the American Joint Committee . . .

Pelvic organ prolapse is a common condition in females. The reported lifetime risk of undergoing pelvic organ prolapse surgery is estimated to affect up to 20% of women. Recently, a higher level of surgical success after the Manchester procedure has been shown compared to sacrospinous hysteropexy. As the costs in healthcare are rising, it is also important to consider the resources and associated cost implications of the choice between these two procedures. An economic evaluation was conducted to compare the alternative costs and benefits. An economic evaluation alongside a randomized controlled trial (RCT) was performed from a societal and healthcare perspective at 2 years of follow-up according to the intention to treat principle. The RCT was a multicenter, randomized, open label trial, executed in 26 Dutch hospitals. 434 women were randomly assigned to the Manchester procedure or sacrospinous hysteropexy. Direct costing data were obtained from electronic case report forms and Medical Consumption Questionnaires. Indirect costing data were obtained by the Productivity Cost Questionnaire. Quality-adjusted Life Years (QALYs) were calculated from the scores on the Euroqol5D-5L questionnaire. Mean cost differences and their 95% confidence intervals (CI) were calculated. From the societal perspective, the Manchester procedure was significantly less expensive than sacrospinous hysteropexy, with a mean difference of 1458.34 euros (95% CI -2746.16 to -170.52). There was no significant difference in the number of QALYs gained over period of 2 years between the arms: 1.67 QALYs (95% confidence interval (95% CI) 1.63 to 1.71) for the sacrospinous hysteropexy group and 1.68 QALYs (95% CI 1.65 to 1.72) for the Manchester procedure group (p = 0.346). During two years of follow-up the Manchester procedure and sacrospinous hysteropexy showed no statistically significant different effectiveness in terms of QALYs gained against significantly higher costs for sacrospinous hysteropexy.

ObjectiveTo evaluate age-dependent productivity loss caused by menstruation-related symptoms, measured in absenteeism (time away from work or school) and presenteeism (productivity loss while present at work or school).MethodsDesign/setting: internet-based, cross-sectional survey conducted in the Netherlands from July to October 2017.Participants: 32 748 women aged 15–45 years, recruited through social media.Outcome measures: self-reported lost productivity in days, divided into absenteeism and presenteeism; impact of menstrual symptoms; reasons women give when calling in sick; and women’s preferences regarding the implications of menstruation-related symptoms for schools and workplaces.ResultsA total of 13.8% (n=4514) of all women reported absenteeism during their menstrual periods with 3.4% (n=1108) reporting absenteeism every or almost every menstrual cycle. The mean absenteeism related to a woman’s period was 1.3 days per year. A total of 80.7% (n=26 438) of the respondents reported presenteeism and decreased productivity a mean of 23.2 days per year. An average productivity loss of 33% resulted in a mean of 8.9 days of total lost productivity per year due to presenteeism. Women under 21 years were more likely to report absenteeism due to menstruation-related symptoms (OR 3.3, 95% CI 3.1 to 3.6). When women called in sick due to their periods, only 20.1% (n=908) told their employer or school that their absence was due to menstrual complaints. Notably, 67.7% (n=22 154) of the participants wished they had greater flexibility in their tasks and working hours at work or school during their periods.ConclusionsMenstruation-related symptoms cause a great deal of lost productivity, and presenteeism is a bigger contributor to this than absenteeism. There is an urgent need for more focus on the impact of these symptoms, especially in women aged under 21 years, for discussions of treatment options with women of all ages and, ideally, more flexibility for women who work or go to school.

The incidence rate of breast cancer is increasing and has become the most common cancer in Vietnamese women while the survival rate is lower than that of developed countries. Early detection to improve breast cancer survival as well as reducing risk factors remains the cornerstone of breast cancer control according to the World Health Organization (WHO). This study aims to evaluate the costs and outcomes of introducing a mammography screening program for Vietnamese women aged 45-64 years, compared to the current situation of no screening. Decision analytical modeling using Markov chain analysis was used to estimate costs and health outcomes over a lifetime horizon. Model inputs were derived from published literature and the results were reported as incremental cost-effectiveness ratios (ICERs) and/or incremental net monetary benefits (INMBs). One-way sensitivity analyses and probabilistic sensitivity analyses were performed to assess parameter uncertainty. The ICER per life year gained of the first round of mammography screening was US$3647.06 and US$4405.44 for women aged 50-54 years and 55-59 years, respectively. In probabilistic sensitivity analyses, mammography screening in the 50-54 age group and the 55-59 age group were cost-effective in 100% of cases at a threshold of three times the Vietnamese Gross Domestic Product (GDP) i.e., US$6332.70. However, less than 50% of the cases in the 60-64 age group and 0% of the cases in the 45-49 age group were cost effective at the WHO threshold. The ICERs were sensitive to the discount rate, mammography sensitivity, and transition probability from remission to distant recurrence in stage II for all age groups. From the healthcare payer viewpoint, offering the first round of mammography screening to Vietnamese women aged 50-59 years should be considered, with the given threshold of three times the Vietnamese GDP per capita.

Abstract BACKGROUND Admitting patients to an intensive care or medium care unit (ICU/MCU) after adult supratentorial tumor craniotomy remains common practice even though some studies have suggested lower level care is sufficient for selected patients. We have introduced a “no ICU, unless” policy for tumor craniotomy patients. OBJECTIVE To provide a quieter postoperative environment for patients, reduce the burden on the ICU department, and to evaluate whether costs can be reduced. METHODS A cohort study was performed comparing patients that underwent tumor craniotomy for supratentorial tumors during 1 yr after introduction (n = 109) of the new policy with the year before (n = 107). Rate of complications was evaluated, as was the length of stay and patient satisfaction using qualitative evaluation. Finally, costs were evaluated comparing the situation before and after implementation of the new protocol. RESULTS A reduction in ICU/MCU admittance from 64% to 24% of patients was found resulting in 13.3% cost reduction (€1950 per case), without increasing the length of stay at the ward. The length of stay in the hospital was similar. Complications were significantly reduced after implementing the new policy (0.98 vs 0.53 per patient, P = .003). Patients that were interviewed after the new policy reported feeling safe and at ease at the ward. CONCLUSION Changing our policy from “ICU, unless” to “no ICU, unless” reduced complication rates and length of stay in the hospital while keeping patients satisfied. Hospital costs related to the admission have been significantly reduced by the new policy.

In case of early pregnancy loss (EPL) women can either choose for expectant, medical or surgical management. One week of expectant management is known to lead to spontaneous abortion in approximately 50% of women. Medical treatment with misoprostol is known to be safe and less costly than surgical management, however less effective in reaching complete evacuation of the uterus. Recently, a number of trials showed that prompt treatment with the sequential combination of mifepristone with misoprostol is superior to misoprostol alone in reaching complete evacuation. In this analysis we evaluate whether the sequential combination of mifepristone with misoprostol is cost-effective compared to misoprostol alone, in the treatment of EPL. A cost-effectiveness analysis (CEA) from a healthcare perspective was performed alongside a randomised controlled trial (RCT) in which standard treatment with misoprostol only was compared with a combination of mifepristone and misoprostol, in women with EPL after a minimum of one week of unsuccessful management. A limited societal perspective scenario was added. This RCT, the Triple M trial, was a multicentre, randomized, double-blinded, placebo-controlled trial executed at 17 hospitals in the Netherlands. The trial started on June 27th 2018, and ended prematurely in January 2020 due to highly significant outcomes from the predefined interim-analysis. We included 351 women with a diagnosis of EPL between 6 and 14 weeks gestation after at least one week of unsuccessful expectant management. They were randomized between double blinded pre-treatment with oral mifepristone 600mg (N = 175) or placebo (N = 176) taken on day one, both followed by misoprostol orally. In both groups, an intention-to-treat analysis was performed for 172 patients, showing a significant difference in success rates between participants treated with mifepristone and misoprostol versus those treated with misoprostol alone (79.1% vs 58.7% respectively). In this cost-effective analysis we measured the direct, medical costs related to treatment (planned and unplanned hospital visits, medication, additional treatment) and indirect costs based on the IMTA Productivity Cost Questionnaire (iPCQ). Quality Adjusted Life Years (QALY's) were calculated from participants' scores on the SF-36 questionnaires sent digitally at treatment start, and one, two and six weeks later. We found medical treatment with placebo followed by misoprostol to be 26% more expensive compared to mifepristone followed by misoprostol (p = 0.001). Mean average medical costs per patient were significantly lower in the mifepristone group compared to the placebo group (€528.95 ± 328.93 vs €663.77 ± 456.03, respectively; absolute difference €134.82, 95% CI 50,46-219,18, p = 0.002). Both indirect costs and QALY's were similar between both groups. The sequential combination of mifepristone with misoprostol is cost-effective compared with misoprostol alone, for treatment of EPL after a minimum of one week of unsuccessful expectant management.

Preoperative colorectal cancer care pathways for older patients show considerable practice variation between Dutch hospitals due to differences in interpretation and implementation of guideline-based recommendations. This study aims to report this practice variation in preoperative care between Dutch hospitals in terms of technical efficiency and identifying associated factors. Data on preoperative involvement of geriatricians, physical therapists and dieticians and the clinicians' judgement on prehabilitation implementation were collected using quality indicators and questionnaires among colorectal cancer surgeons and specialized nurses. These data were combined with registry-based data on postoperative outcomes obtained from the Dutch Surgical Colorectal Audit for patients aged ≥75 years. A two-stage data envelopment analysis (DEA) approach was used to calculate bias-corrected DEA technical efficiency scores, reflecting the extent to which a hospital invests in multidisciplinary preoperative care (input) in relation to postoperative outcomes (output). In the second stage, hospital care characteristics were used in a bootstrap truncated regression to explain variations in measured efficiency scores. Data of 25 Dutch hospitals were analyzed. There was relevant practice variation in bias-corrected technical efficiency scores (ranging from 0.416 to 0.968) regarding preoperative colorectal cancer surgery. The average efficiency score of hospitals was significantly different from the efficient frontier (p = <0.001). After case-mix correction, higher technical efficiency was associated with larger practice size (p = <0.001), surgery performed in a general hospital versus a university hospital (p = <0.001) and implementation of prehabilitation (p = <0.001). This study showed considerable variation in technical efficiency of preoperative colorectal cancer care for older patients as provided by Dutch hospitals. In addition to higher technical efficiency in high-volume hospitals and general hospitals, offering a care pathway that includes prehabilitation was positively related to technical efficiency of hospitals offering colorectal cancer care.

The effectiveness of dementia-care mapping (DCM) for institutionalised people with dementia has been demonstrated in an explanatory cluster-randomised controlled trial (cRCT) with two DCM researchers carrying out the DCM intervention. In order to be able to inform daily practice, we studied DCM effectiveness in a pragmatic cRCT involving a wide range of care homes with trained nursing staff carrying out the intervention. Dementia special care units were randomly assigned to DCM or usual care. Nurses from the intervention care homes received DCM training and conducted the 4-months DCM-intervention twice during the study. The primary outcome was agitation, measured with the Cohen-Mansfield agitation inventory (CMAI). The secondary outcomes included residents' neuropsychiatric symptoms (NPSs) and quality of life, and staff stress and job satisfaction. The nursing staff made all measurements at baseline and two follow-ups at 4-month intervals. We used linear mixed-effect models to test treatment and time effects. 34 units from 11 care homes, including 434 residents and 382 nursing staff members, were randomly assigned. Ten nurses from the intervention units completed the basic and advanced DCM training. Intention-to-treat analysis showed no statistically significant effect on the CMAI (mean difference between groups 2·4, 95% CI -2·7 to 7·6; p = 0·34). More NPSs were reported in the intervention group than in usual care (p = 0·02). Intervention staff reported fewer negative and more positive emotional reactions during work (p = 0·02). There were no other significant effects. Our pragmatic findings did not confirm the effect on the primary outcome of agitation in the explanatory study. Perhaps the variability of the extent of implementation of DCM may explain the lack of effect. Dutch Trials Registry NTR2314.

In patients with prostate cancer who are deemed to be at intermediate or high risk of having nodal metastases, invasive diagnostic pelvic lymph-node dissection (PLND) is the gold standard for the detection of nodal disease. However, a new lymph-node-specific MR-contrast agent ferumoxtran-10 can detect metastases in normal-sized nodes (ie, <8 mm in size) by use of MR lymphoangiography (MRL). In this prospective, multicentre cohort study, we aimed to compare the diagnostic accuracy of MRL with up-to-date multidetector CT (MDCT), and test the hypothesis that a negative MRL finding obviates the need for a PLND. We included consecutive patients with prostate cancer who had an intermediate or high risk (risk of >5% according to routinely used nomograms) of having lymph-node metastases. All patients were assessed by MDCT and MRL, and underwent PLND or fine-needle aspiration biopsy. Imaging results were correlated with histopathology. The primary outcomes were sensitivity, specificity, accuracy, NPV, and PPV of MRL and MDCT. This study is registered with ClinicalTrials.gov, number NCT00185029. The study was done in 11 hospitals in the Netherlands between April 8, 2003, and April 19, 2005. 375 consecutive patients were included. 61 of 375 (16%) patients had lymph-node metastases. Sensitivity was 34% (21 of 61; 95% CI 23–48) for MDCT and 82% (50 of 61; 70–90) for MRL (McNemar's test p<0·05). Specificity was 97% (303 of 314; 94–98) for MDCT and 93% (291 of 314; 89–95) for MRL. Positive predictive value (PPV) was 66% (21 of 32; 47–81) for MDCT and 69% (50 of 73; 56–79) for MRL. Negative predictive value (NPV) was 88% (303 of 343; 84–91) for MDCT and 96% (291 of 302; 93–98) for MRL (McNemar's test p<0·05). Of the 61 patients with lymph-node metastases, 50 were detected by MRL, of which 40 (80%) had metastases in normal-sized lymph nodes. The high sensitivity and NPV of MRL imply that in patients with a negative MRL, the chance of positive lymph nodes is less than 11/302 (4%). MRL had significantly higher sensitivity and NPV than MDCT for patients with prostate cancer who had intermediate or high risk of having lymph-node metastases. In such patients, after a negative MRL, the post-test probability of having lymph-node metastases is low enough to omit a PLND. The Netherlands Organisation for Health Research and Management (ZON-MW 945-02-051; The Hague, Netherlands), and TASK24 (Nieuwegein, Netherlands).

Background Under a constrained health care budget, cost-increasing technologies may displace funds from existing health services. However, it is unknown what services are displaced and how such displacement takes place in practice. The aim of our study was to investigate how the Dutch hospital sector has dealt with the introduction of cost-increasing health technologies, and to present evidence of the relative importance of three main options to deal with cost-increases in health care: increased spending, increased efficiency, or displacement of other services. Methods We conducted six case-studies and interviewed 84 professionals with various roles and responsibilities (practitioners, heads of clinical department, board of directors, insurers, and others) to investigate how they experienced decision making in response to the cost pressure of cost-increasing health technologies. Transcripts were analyzed thematically in Atlas.ti on the basis of an item list. Results Direct displacement of high-value care due to the introduction of new technologies was not observed; respondents primarily pointed to increased spending and efficiency measures to accommodate the introduction of the cost-increasing technologies. Respondents found it difficult to identify the opportunity costs; partly due to limited transparency in the internal allocation of funds within a hospital. Furthermore, respondents experienced the entry of new technologies and cost-containment as two parallel processes that are generally not causally linked: cost containment was experienced as a permanent issue to level costs and revenues, independent from entry of new technologies. Furthermore, the way of financing was found important in displacement in the Netherlands, especially as there is a separate budget for expensive drugs. This budget pressure was found to be reallocated horizontally across departments, whereas the budget pressure of other services is primarily reallocated vertically within departments or divisions. Respondents noted that hospitals have reacted to budget pressures primarily through a narrowing in the portfolio of their services, and a range of (other) efficiency measures. The board of directors is central in these processes, insurers are involved only to a limited extent. Conclusions Our findings indicate that new technologies were generally accommodated by greater efficiency and increased spending, and that hospitals sought savings or efficiency measures in response to cumulative cost pressures rather than in response to single cost-increasing technologies.