[The danger to health from fine dust particles in the air].
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Air Pollutants↗
Biomedical subjects
L Bonneux
Publications and source records attributed to L Bonneux.
[The threatening influenza pandemic: a national store ofoseltamivir is a waste of money].
In the treatment of confirmed influenza, neuraminidase inhibitors yield only a limited reduction in the duration of disease and are neither efficacious nor cost-effective. Neuraminidase inhibitors would be cost-effective if a deadly influenza virus that is highly sensitive to oseltamivir causes a pandemic soon. If not, then the money invested in establishing a store of oseltamivir is wasted and lost to the health-care sector.
Acetamides↗
[The unreasonableness of prostate-cancer screening and the ethical problems pertaining to its investigation].
Since the early 1990s, screening with prostate-specific antigen (PSA) testing has increased the incidence of prostate cancer. Any decrease in mortality will not be seen for at least a decade, due to the long natural history of prostate cancer. Death due to prostate cancer is rare, while the prevalence oflocalised tumours is high. The prognosis of these early-detected localised tumours is uncertain, because most patients will die from other causes. Complications of prostate-cancer therapy are common, with high rates of impotence, incontinence and gastrointestinal problems after prostatectomy or radiotherapy. Randomised trials of prostate-cancer screening, notably the 'European randomised screening for prostate cancer' (ERSPC) trial, began with the consent of ethical committees. There is a real uncertainty regarding the benefits of prostate-cancer screening. However, it is clear that these benefits are limited, because prostate-cancer death is rare before the age of 75 years. There is no real uncertainty about the harms of prostate-cancer screening. High prevalence and high rates of treatment complications deduct many disease- and disability-free years from the eligible population (men aged 55-74 years). Therefore, there has been no real uncertainty over the balance of harms and benefits in prostate-cancer screening trials. Days may be added to old age, at the cost of months of disease- and disability-free living. It is not in the best interest of eligible men to participate in these trials. Randomised trials evaluating prostate-cancer screening violate in principle and practice the Helsinki Declaration of the rights of human subjects in medical research.
Aged↗
Risk factors for stroke among urbanised Indonesian women of reproductive age: a hospital-based case-control study.
BACKGROUND: Stroke is a major cause of death in South-East Asia, but few empirical data exist on its risks in Asian populations. METHODS: 235 cases and 682 age-matched controls of women of reproductive age (20-44 years) were recruited in 14 hospitals in Jakarta, Indonesia, between 1989 and 1993. Medical history was collected by a structured interview. In subsamples, glucosuria, serum cholesterol level and body mass index (BMI) were assessed. RESULTS: In these young and lean Muslim women, with few users of tobacco, alcohol or oral contraceptives, risk factors related to increased weight were strongly related to stroke occurrence. A history of hypertension or diabetes or increased serum cholesterol level showed odds ratios (ORs) of 13.9, 7.4 and 3.7, respectively. A BMI >27 (unadjusted for its potential consequences) caused an OR of 2.9. High social class and higher level of education (both OR 0.7) were associated with a lower risk of stroke, but levels of risk factors were higher in higher socio-economic classes. CONCLUSION: The expected transition in lifestyle, characterised by a higher intake of calories and less physical activity, will increase stroke risks in Indonesian women. Increasing wealth should go together with raising levels of health education on nutrition and physical activity.
Adult↗
[Diseases and the diseased--scientific and alternative medicine].
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Evidence-Based Medicine↗
High coronary heart disease rates among Dutch women of the baby boom, born 1945-1959: age-cohort analysis and projection.
BACKGROUND: After a steep decline in older generations, coronary heart disease mortality is stagnating in female cohorts born after the Second World War. We analysed past trends and predicted future health care needs for coronary heart disease in the Dutch population. METHODS: A loglinear age-cohort model relates numbers of deaths and hospital admissions for coronary heart disease to sex, age, birth cohort and population size, and projects age-cohort changes over the future population. Population size, population forecasts and coronary heart disease mortality (period 1970-1999) are from vital statistics. Numbers of hospitalised acute coronary events are from the nationwide hospital register (period 1980-1999). RESULTS: Among men, the rate ratios of deaths and hospital admissions were, respectively, 0.21 (death) and 0.78 (survivors at discharge) in the cohorts born in the period 1948-1962 compared to the period 1918-1922. Among women, the same rate ratios were 0.41 and 1.89. The projection model predicts 22% less deaths from coronary heart disease and 22% more survivors of an infarction in 2015, among men. Among women, there will be 5% less deaths and 70% more survivors of an infarction, most of these being middle age members of the baby boom cohorts. CONCLUSIONS: Stagnating all-cause mortality is correlated with an upward trend in coronary heart disease risk in the female baby boomers. Heart health care needs among middle-aged women will increase sharply. These changes are correlated to high lung cancer mortality and high smoking rates in these cohorts.
Adult↗
Healthcare costs of intellectual disability in the Netherlands: a cost-of-illness perspective.
Healthcare costs are continuously increasing, and impose a strong responsibility on governments for an adequate allocation of resources among healthcare provisions and patients. The aims of the present study were to describe the healthcare costs of intellectual disability (ID) and other mental disorders in the context of the total costs of all other diseases, and to determinate the future need of healthcare resources, especially for ID and mental disorders. The present authors performed a top-down cost-of-illness study comprising all healthcare costs of the Netherlands in 1994. Data on healthcare use were obtained for all 22 healthcare sectors, and used to ascribe costs to disease groups, age and sex. Costs of mental disorders are by far the largest in the Dutch healthcare system. Some 25.8% of total disease-specific costs could be ascribed to mental disorders: psychiatric conditions, 10.6%; ID, 9.0%; and dementia, 6.2%. There are large differences between age and sex groups. The costs of ID and schizophrenia are higher among men, and the costs of dementia and depression are higher among women. The age pattern shows two peaks: the first occurs at 25-35 years of age (ID and psychiatric conditions); and the second at 75-85 years of age (dementia). Time trends between 1988 and 1994 show an average annual growth rate of 5.2% for total healthcare costs: psychiatric conditions, 4.8%; ID, 5.4%; and dementia, 9.4%. Demographic projections suggest a less-than-average cost increase for ID and psychiatric disorders (with annual growth rates of 0.2% and 0.4%, respectively) compared to the costs of dementia and total healthcare (with annual growth rates of 1.6% and 0.9%, respectively). Intellectual disability and mental disorders represent a large part of healthcare use in the Netherlands. The costs will inevitably increase because of the ageing of the population and increasing life expectancy among people with disabilities. Non-specific cost containment measures may endanger the quality of care for vulnerable people at younger and older ages.
Adult↗
A cardiovascular life history. A life course analysis of the original Framingham Heart Study cohort.
AIMS The objective of this paper is to measure the potential burden of cardiovascular disease within the original Framingham Heart Study cohort by transforming its well-described epidemiological measures into time-based health policy measures, such as life years lost to or lived with the disease. METHODS AND RESULTS We constructed multi-state life tables of the Framingham Heart Study cohort to calculate dwelling times with a history of cardiovascular disease. Age-specific probabilities determined transitions from healthy through disease to death. For this synthetic cohort, from age 50 men (women) live on average 26 (32) years; 20 (26) free of cardiovascular disease. Allowing occupancy of more than one disease state, 50-year-old males (females) live 2 X 9 (1 X 2) years with a history of myocardial infarction, 0 X 93 (1 X 2) with a history of stroke, and 0 X 67 (0 X 93) with congestive heart failure. Having ever suffered acute myocardial infarction, stroke or congestive heart failure, life expectancy is reduced by 9 (13), 12 (15) or 16 (16) years, respectively in 60-year-old men (women). CONCLUSIONS Transforming occurrence probabilities into time-based health measures, the prevalence of cardiovascular disease is remarkable: from age 50, 20% of remaining life expectancy is lived with the disease. Such measures are integral to appropriate health planning and assessment of the potential population health value of various treatment and prevention strategies.
Adult↗
Cost-effectiveness of a family and DNA based screening programme on familial hypercholesterolaemia in The Netherlands.
AIMS: To estimate the cost-effectiveness of the current screening programme on Familial Hypercholesterolaemia (FH) in relatives of diagnosed FH-patients in The Netherlands. METHODS AND RESULTS: Data from 2229 screened FH-relatives, including age, sex, risk factor status and screening outcome, were combined with the Framingham risk function and national disease-specific cost data to arrive at a model-based comparison of survival and costs, with and without the screening programme. Cost-effectiveness ratios were computed for various treatment strategies, with no screening as reference. Costs per life year gained varied between 25.5- and 32-thousand Euros, depending upon the precise treatment strategy after a positive screen. The costs for screening (tracing the FH-positive individuals) were much lower than the follow-up costs (treatment), of which 80% were costs for statins. Consequently, the costs per life year gained of alternative screening programmes are about the same. CONCLUSION: The cost-effectiveness ratio of FH screening is within the range requiring explicit political consideration in The Netherlands. As the costs of statin treatment are the single most important determinant of costs, policy decisions reduce to decisions on the acceptability of statin treatment for this risk group. Pending major changes in statin price, clear guidelines should be developed on how screen positive individuals should be treated, since not all of them have an elevated cholesterol level.
Adolescent↗
How to measure the burden of mortality?
OBJECTIVES: To explore various methods to quantify the burden of mortality, with a special interest for the more recent method at the core of calculations of disability adjusted life years (DALY). DESIGN: Various methods calculating the age schedule at death are applied to two historical life table populations. One method calculates the "years of life lost", by multiplying the numbers of deaths at age x by the residual life expectancy. This residual life expectancy may be discounted and age weighted. The other method calculates the "potential years of life lost" by multiplying the numbers of deaths at age x by the years missing to reach a defined threshold (65 years or 75 years). METHODS: The period life tables describing the mortality of Dutch male populations from 1900-10 (high mortality) and from 1990-1994 (low mortality). RESULTS: A standard life table with idealised long life expectancy increases the burden of death more if mortality is lower. People at old age, more prevalent if mortality is low, lose more life years in an idealised life table. The discounted life table decreases the burden of death strongly if mortality is high: the life lost by a person dying at a young age is discounted. Age weighting the discounted life table balances the effect of discounting. CONCLUSIONS: For the purpose of description of the burden of mortality, the aggregate life table of the studied populations gives the better description of the age schedule at death. Discounting and the use of idealised lifetables as a standard increase the burden of mortality of degenerative disease at the end of life. The age weighted discounted life table violates the principle of parsimony.
Adolescent↗
The discount rate in the economic evaluation of prevention: a thought experiment.
OBJECTIVES: In the standard economic model of evaluation, constant discount rates devalue the long term health benefits of prevention strongly. This study shows that it is unlikely that this reflects societal preference. DESIGN: A thought experiment in a cause elimination life table calculates savings of eliminating cardiovascular disease from the Dutch population. A cost effectiveness analysis calculates the acceptable costs of such an intervention at a threshold of 18 000 Euro per saved life year. METHODS: Cause specific mortality (all cardiovascular causes of death and all other causes) and health care costs (all costs of cardiovascular disease and all other causes of costs) by age and male sex of 1994. RESULTS: At a 0% discount rate, an intervention eliminating cardiovascular disease may cost 71 100 Euro. At the same threshold but at discount rates of 3% or 6%, the same intervention may cost 8100 Euro (8.8 times less) or 1100 Euro (65 times less). CONCLUSIONS: The standard economic model needs more realistic duration dependent models of time preference, which reflect societal preference.
Adult↗
Cholesterol-lowering therapy for smokers and non-smokers: a life-table analysis.
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Aged↗
[Increasing inequality in health care by separating medical indication from financial responsibility].
Guidelines for clinical practice have as their primary aim to improve that practice. However, the increasing flow of medical technology threatens to exhaust the financial reserves. There is now an undeniable conflict between what can be done and what can be paid for. This leads to a conflict between the responsibility of the caregiver for the individual patient and for society. Either available care is denied or health insurance is ruined. This inevitably leads to increasing inequality: only the better off can afford a therapy which is effective but not efficient. The individuals right to health care can never entirely be reconciled with the societal imperative for a more just distribution of financial resources. Guidelines which are a result of a bargain between all stakeholders are therefore more just: they are a compromise between the rights of the individual and those of the society. The legal status of guidelines should be reinforced.
Cost-Benefit Analysis↗
[Summary of the 'Cholesterol' guideline (first revision) of the Dutch College of Family Practice].
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Age Factors↗
Postmenopausal hormone therapy: less favourable risk-benefit ratios in healthy Dutch women.
OBJECTIVES: To estimate the health effects of postmenopausal hormone therapy used for 10 or 20 years in a population of intermediate cardiovascular risk. DESIGN: Using existing estimates of the effect of hormone therapy on rates of myocardial infarction, hip fracture and breast cancer, a proportional multistage life table was generated to calculate the effects of use for 10 and 20 years in a synthetic cohort of Dutch women aged 55 with an average and a high-risk profile for cardiovascular disease. RESULTS: A woman of the general population who starts hormone therapy at age 55 for 10 years can prolong her life by 1 month and may postpone the occurrence of first incidence of one of the diseases under consideration by 2.4 months. One excess breast cancer case is likely to occur per 5-6 averted cases of first myocardial infarction or hip fracture. If she prolongs her use to 20 years, the gain of life expectancy and disease-free life expectancy is doubled. The risk-benefit ratio worsens to one extra breast cancer per 3-4 averted cases of the preventable diseases. For a woman with a high-risk profile, the gains in health are about twice as high as for her counterpart in the general population, and her risk-benefit ratio is also more favourable. Yet, the risk-benefit ratio still worsens for 20 as compared with 10 years of use. CONCLUSIONS: Women from the general population in the Netherlands and similar populations can achieve only a modest gain in life expectancy by using hormones during 10 or 20 years following menopause. This is a consequence of the low incidence of myocardial infarction and hip fracture and the relatively high incidence of breast cancer before the age of 75. Women at increased cardiovascular risk can benefit more from hormone therapy. But even amongst these women, the risk of breast cancer incurred with long-term use offsets much of the benefit that could accrue from changing the risk of heart disease and hip fracture.
Aged↗
An indirect estimate of the incidence of non-insulin-dependent diabetes mellitus.
Our goal was to estimate non-insulin-dependent diabetes mellitus incidence in the Netherlands in the absence of equivocal empirical data. Incidence can be expressed as a function of age, sex, prevalence, and mortality. We obtained prevalence data from a study that pooled existing prevalence estimates. We calculated diabetes-related mortality using relative risks on all-cause mortality. Sensitivity for the rate of excess mortality was determined using the 95% confidence intervals (95% CI) of the relative risks. The estimated incidence increases exponentially with age, with a doubling time of 10 years for men and 9 years for women. The rate increases from 8.1 per 10,000 (95% CI = 7.7-8.8) for men ages 40-44 years and 7.0 (95% CI = 6.8-8.0) for women to 79.7 per 10,000 (95% CI = 69.5-90.9) for men ages 75-79 years and 85.8 (95% CI = 80.6-91.0) for women. When empirical estimates of incidence are largely lacking, the methodology described offers a useful alternative, in particular for the assessment of potential intervention effects.
Adolescent↗
[Primary prevention remains expensive, notwithstanding the consensus on lowering serum cholesterol levels].
Recently guidelines for cholesterol lowering therapy by means of 'statines' (HMG-CoA reductase inhibitors) were published by the National Organization of Quality Assurance in Hospitals. The part about primary prevention of cardiovascular disease is based on absolute risks for coronary heart disease as calculated by the Framingham Heart Study risk functions and on a cost-effectiveness analysis. However, the function predicts risk of disease such as silent infarction and angina pectoris. The incidence thus produced is higher than any observed clinical incidence. Absolute risk increases exponentially with age, but remaining life expectancy, and thus benefit, decreases. Therefore, decisions about treatment levels are based on arbitrary assumptions. The function is ultimately only used to advise treatment to the smoker, while the better choice is always to stop smoking. The effectiveness is overestimated by using a long time horizon of treatment of 25 years in the cost-effectiveness analysis. Primary prevention of coronary heart disease according to the new guidelines is still very expensive.
Adult↗
The new old epidemic of coronary heart disease.
OBJECTIVES: This study quantified the consequences for prevalence of increased survival of coronary heart disease (CHD) in the Netherlands from 1980 to 1993. METHODS: A multistage life table fitted observed mortality and registration rates from the nationwide hospital register. The outcome was prevalence by age, sex, period, and disease state. RESULTS: The prevalence of CHD from 1980 to 1993 was 4.4% (men, aged 25 to 84 years) and 1.4% (women, aged 25 to 84 years). Between 1980-1983 and 1990-1993, the incidence changed little, but age-adjusted prevalence increased by 19% (men) and 59% (women). CONCLUSIONS: Sharply decreasing mortality but near-constant attack rates of CHD caused distinct increases in prevalence, particularly among the elderly.
Adult↗