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1.  Good practice characteristics of diet and physical activity interventions and policies: an umbrella review 
BMC Public Health  2015;15:19.
This umbrella review aimed at eliciting good practice characteristics of interventions and policies aiming at healthy diet, increasing physical activity, and lowering sedentary behaviors. Applying the World Health Organization’s framework, we sought for 3 types of characteristics, reflecting: (1) main intervention/policy characteristics, referring to the design, targets, and participants, (2) monitoring and evaluation processes, and (3) implementation issues. This investigation was undertaken by the DEDPIAC Knowledge Hub (the Knowledge Hub on the DEterminants of DIet and Physical ACtivity), which is an action of the European Union’s joint programming initiative.
A systematic review of reviews and stakeholder documents was conducted. Data from 7 databases was analyzed (99 documents met inclusion criteria). Additionally, resources of 7 major stakeholders (e.g., World Health Organization) were systematically searched (10 documents met inclusion criteria). Overall, the review yielded 74 systematic reviews, 16 position review papers, and 19 stakeholders’ documents. Across characteristics, 25% were supported by ≥ 4 systematic reviews. Further, 25% characteristics were supported by ≥ 3 stakeholders’ documents. If identified characteristics were included in at least 4 systematic reviews or at least 3 stakeholders’ documents, these good practice characteristics were classified as relevant.
We derived a list of 149 potential good practice characteristics, of which 53 were classified as relevant. The main characteristics of intervention/policy (n = 18) fell into 6 categories: the use of theory, participants, target behavior, content development/management, multidimensionality, practitioners/settings. Monitoring and evaluation characteristics (n = 18) were grouped into 6 categories: costs/funding, outcomes, evaluation of effects, time/effect size, reach, the evaluation of participation and generalizability, active components/underlying processes. Implementation characteristics (n = 17) were grouped into eight categories: participation processes, training for practitioners, the use/integration of existing resources, feasibility, maintenance/sustainability, implementation partnerships, implementation consistency/adaptation processes, transferability.
The use of the proposed list of 53 good practice characteristics may foster further development of health promotion sciences, as it would allow for identification of success vectors in the domains of main characteristics of interventions/policies, their implementation, evaluation and monitoring processes.
Electronic supplementary material
The online version of this article (doi:10.1186/s12889-015-1354-9) contains supplementary material, which is available to authorized users.
PMCID: PMC4306239  PMID: 25604454
Physical activity; Sedentary behavior; Diet; Good practice; Intervention; Policy; Systematic review
2.  Cost-effectiveness of counseling and pedometer use to increase physical activity in the Netherlands: a modeling study 
Counseling in combination with pedometer use has proven to be effective in increasing physical activity and improving health outcomes. We investigated the cost-effectiveness of this intervention targeted at one million insufficiently active adults who visit their general practitioner in the Netherlands.
We used the RIVM chronic disease model to estimate the long-term effects of increased physical activity on the future health care costs and quality adjusted life years (QALY) gained, from a health care perspective.
The intervention resulted in almost 6000 people shifting to more favorable physical-activity levels, and in 5100 life years and 6100 QALYs gained, at an additional total cost of EUR 67.6 million. The incremental cost-effectiveness ratio (ICER) was EUR 13,200 per life year gained and EUR 11,100 per QALY gained. The intervention has a probability of 0.66 to be cost-effective if a QALY gained is valued at the Dutch informal threshold for cost-effectiveness of preventive intervention of EUR 20,000. A sensitivity analysis showed substantial uncertainty of ICER values.
Counseling in combination with pedometer use aiming to increase physical activity may be a cost-effective intervention. However, the intervention only yields relatively small health benefits in the Netherlands.
PMCID: PMC3495195  PMID: 23006466
Economic evaluation; Prevention; Modeling; Counseling; Pedometer use; Physical activity; Primary care
3.  The polypill in the primary prevention of cardiovascular disease: cost-effectiveness in the Dutch population 
BMJ Open  2011;1(2):e000363.
The aim of the present study was to estimate the cost-effectiveness of the polypill in the primary prevention of cardiovascular disease.
A health economic modelling study.
Primary healthcare in the Netherlands.
Simulated individuals from the general Dutch population, aged 45–75 years.
Opportunistic screening followed by prescription of the polypill to eligible individuals. Eligibility was defined as having a minimum 10-year risk of cardiovascular death as assessed with the Systematic Coronary Risk Evaluation function of alternatively 5%, 7.5% or 10%. Different versions of the polypill were considered, depending on composition: (1) the Indian polycap, with three different types of blood pressure-lowering drugs, a statin and aspirin; (2) as (1) but without aspirin and (3) as (2) but with a double statin dose. In addition, a scenario of (targeted) separate antihypertensive and/or statin medication was simulated.
Primary outcome measures
Cases of acute myocardial infarction or stroke prevented, quality-adjusted life years (QALYs) gained and the costs per QALY gained. All interventions were compared with usual care.
All scenarios were cost-effective with an incremental cost-effectiveness ratio between €7900 and 12 300 per QALY compared with usual care. Most health gains were achieved with the polypill without aspirin and containing a double dose of statins. With a 10-year risk of 7.5% as the threshold, this pill would prevent approximately 3.5% of all cardiovascular events.
Opportunistic screening based on global cardiovascular risk assessment followed by polypill prescription to those with increased risk offers a cost-effective strategy. Most health gain is achieved by the polypill without aspirin and a double statin dose.
Article summary
Article focus
Cardiovascular diseases continue to be still a major, partly preventable, cause of illness and death.
A polypill that lowers by targeting several risk factors simultaneously is in line with the concept that the aim in primary prevention should be to bring down ‘global’ cardiovascular risk.
The aim of this study was to estimate the potential cost-effectiveness of polypill prescription after opportunistic screening.
Key messages
The results of this study suggest that opportunistic screening and offering a polypill to people with a minimum 10-year risk of cardiovascular mortality of alternatively 5%, 7.5% or 10% is a cost-effective strategy.
A polypill without aspirin but with a double dose of simvastatin leads to most health gains at all risk thresholds considered. At a 10-year risk of cardiovascular death of ≥7.5%, such a strategy would lead to an estimated decrease in the incidence of myocardial infarction and stroke of about 3.5%, at a cost of €8900 per quality-adjusted life year.
Opportunistic screening of the population of ≥40 years to select individuals with a mild to moderately increased risk for cardiovascular diseases, followed by polypill prescription would prevent approximately 3.5% of all cardiovascular events.
Strengths and limitations of this study
Strong point of the study is that different compositions of the polypill have been modelled. Also, realistic estimates for adherence and compliance have been used.
As only preliminary results of a phase II clinical trial on efficacy of the polypill were available, we had to apply mathematical modelling to estimate cost-effectiveness. This provides insight into the range of health benefits that can be expected. Pending results with regard to established clinical endpoints from large-scale phase III trials, the results of this study should not be taken as a precise estimate of the cost-effectiveness of the polypill.
PMCID: PMC3278482  PMID: 22189351
4.  Willingness to participate in a lifestyle intervention program of patients with type 2 diabetes mellitus: a conjoint analysis 
Several studies suggest that lifestyle interventions can be effective for people with, or at risk for, diabetes. The participation in lifestyle interventions is generally low. Financial incentives may encourage participation in lifestyle intervention programs.
The main aim of this exploratory analysis is to study empirically potential effects of financial incentives on diabetes patients’ willingness to participate in lifestyle interventions. One financial incentive is negative (“copayment”) and the other incentive is positive (“bonus”). The key part of this research is to contrast both incentives. The second aim is to investigate the factors that influence participation in a lifestyle intervention program.
Conjoint analysis techniques were used to empirically identify factors that influence willingness to participate in a lifestyle intervention. For this purpose diabetic patients received a questionnaire with descriptions of various forms of hypothetical lifestyle interventions. They were asked if they would be willing to participate in these hypothetical programs.
In total, 174 observations were rated by 46 respondents. Analysis showed that money was an important factor independently associated with respondents’ willingness to participate. Receiving a bonus seemed to be associated with a higher willingness to participate, but having to pay was negatively associated with participation in the lifestyle intervention.
Conjoint analysis results suggest that financial considerations may influence willingness to participate in lifestyle intervention programs. Financial disincentives in the form of copayments might discourage participation. Although the positive impact of bonuses is smaller than the negative impact of copayments, bonuses could still be used to encourage willingness to participate.
PMCID: PMC3218115  PMID: 22114468
incentives; bonus; copayment; conjoint analysis; willingness to participate
5.  Cost-Effectiveness of Opportunistic Screening and Minimal Contact Psychotherapy to Prevent Depression in Primary Care Patients 
PLoS ONE  2011;6(8):e22884.
Depression causes a large burden of disease worldwide. Effective prevention has the potential to reduce that burden considerably. This study aimed to investigate the cost-effectiveness of minimal contact psychotherapy, based on Lewinsohn's ‘Coping with depression’ course, targeted at opportunistically screened individuals with sub-threshold depression.
Methods and Results
Using a Markov model, future health effects and costs of an intervention scenario and a current practice scenario were estimated. The time horizon was five years. Incremental cost-effectiveness ratios were expressed in euro per Disability Adjusted Life Year (DALY) averted. Probabilistic sensitivity analysis was employed to study the effect of uncertainty in the model parameters. From the health care perspective the incremental cost-effectiveness ratio was € 1,400 per DALY, and from the societal perspective the intervention was cost-saving. Although the estimated incremental costs and effects were surrounded with large uncertainty, given a willingness to pay of € 20,000 per DALY, the probability that the intervention is cost-effective was around 80%.
This modelling study showed that opportunistic screening in primary care for sub-threshold depression in combination with minimal contact psychotherapy may be cost-effective in the prevention of major depression.
PMCID: PMC3154255  PMID: 21853053
6.  Primary prevention of cardiovascular diseases: a cost study in family practices 
BMC Family Practice  2011;12:69.
Considering the scarcity of health care resources and the high costs associated with cardiovascular diseases, we investigated the spending on cardiovascular primary preventive activities and the prescribing behaviour of primary preventive cardiovascular medication (PPCM) in Dutch family practices (FPs).
A mixed methods design was used, which consisted of a questionnaire (n = 80 FPs), video recordings of hypertension- or cholesterol-related general practitioner visits (n = 56), and the database of Netherlands Information Network of General Practice (n = 45 FPs; n = 157,137 patients). The questionnaire and video recordings were used to determine the average frequency and time spent on cardiovascular primary preventive activities per FP respectively. Taking into account the annual income and full time equivalents of general practitioners, health care assistants, and practice nurses as well as the practice costs, the total spending on cardiovascular primary preventive activities in Dutch FPs was calculated. The database of Netherlands Information Network of General Practice was used to determine the prescribing behaviour in Dutch FPs by conducting multilevel regression models and adjusting for patient and practice characteristics.
Total expenditure on cardiovascular primary preventive activities in FPs in 2009 was €38.8 million (€2.35 per capita), of which 47% was spent on blood pressure measurements, 26% on cardiovascular risk profiling, and 11% on lifestyle counselling. Fifteen percent (€11 per capita) of all cardiovascular medication prescribed in FPs was a PPCM. FPs differed greatly on prescription of PPCM (odds ratio of 3.1).
Total costs of cardiovascular primary preventive activities in FPs such as blood pressure measurements and lifestyle counselling are relatively low compared to the costs of PPCM. There is considerable heterogeneity in prescribing behaviour of PPCM between FPs. Further research is needed to determine whether such large differences in prescription rates are justified. Striving for an optimal use of cardiovascular primary preventive activities might lead to similar health outcomes, but may achieve important cost savings.
PMCID: PMC3160896  PMID: 21733183
7.  The scope of costs in alcohol studies: Cost-of-illness studies differ from economic evaluations 
Alcohol abuse results in problems on various levels in society. In terms of health, alcohol abuse is not only an important risk factor for chronic disease, but it is also related to injuries. Social harms which can be related to drinking include interpersonal problems, work problems, violent and other crimes. The scope of societal costs related to alcohol abuse in principle should be the same for both economic evaluations and cost-of-illness studies. In general, economic evaluations report a small part of all societal costs. To determine the cost- effectiveness of an intervention it is necessary that all costs and benefits are included. The purpose of this study is to describe and quantify the difference in societal costs incorporated in economic evaluations and cost-of-illness studies on alcohol abuse.
To investigate the economic costs attributable to alcohol in cost-of-illness studies we used the results of a recent systematic review (June 2009). We performed a PubMed search to identify economic evaluations on alcohol interventions. Only economic evaluations in which two or more interventions were compared from a societal perspective were included. The proportion of health care costs and the proportion of societal costs were estimated in both type of studies.
The proportion of healthcare costs in cost-of-illness studies was 17% and the proportion of societal costs 83%. In economic evaluations, the proportion of healthcare costs was 57%, and the proportion of societal costs was 43%.
The costs included in economic evaluations performed from a societal perspective do not correspond with those included in cost-of-illness studies. Economic evaluations on alcohol abuse underreport true societal cost of alcohol abuse. When considering implementation of alcohol abuse interventions, policy makers should take into account that economic evaluations from the societal perspective might underestimate the total effects and costs of interventions.
PMCID: PMC2907313  PMID: 20602804
8.  Cost-Effectiveness of an Opportunistic Screening Programme and Brief Intervention for Excessive Alcohol Use in Primary Care 
PLoS ONE  2009;4(5):e5696.
Effective prevention of excessive alcohol use has the potential to reduce the public burden of disease considerably. We investigated the cost-effectiveness of Screening and Brief Intervention (SBI) for excessive alcohol use in primary care in the Netherlands, which is targeted at early detection and treatment of ‘at-risk’ drinkers.
Methodology and Results
We compared a SBI scenario (opportunistic screening and brief intervention for ‘at-risk’ drinkers) in general practices with the current practice scenario (no SBI) in the Netherlands. We used the RIVM Chronic Disease Model (CDM) to extrapolate from decreased alcohol consumption to effects on health care costs and Quality Adjusted Life Years (QALYs) gained. Probabilistic sensitivity analysis was employed to study the effect of uncertainty in the model parameters. In total, 56,000 QALYs were gained at an additional cost of €298,000,000 due to providing alcohol SBI in the target population, resulting in a cost-effectiveness ratio of €5,400 per QALY gained.
Prevention of excessive alcohol use by implementing SBI for excessive alcohol use in primary care settings appears to be cost-effective.
PMCID: PMC2682644  PMID: 19479081
9.  The cost-effectiveness of increasing alcohol taxes: a modelling study 
BMC Medicine  2008;6:36.
Excessive alcohol use increases risks of chronic diseases such as coronary heart disease and several types of cancer, with associated losses of quality of life and life-years. Alcohol taxes can be considered as a public health instrument as they are known to be able to decrease alcohol consumption. In this paper, we estimate the cost-effectiveness of an alcohol tax increase for the entire Dutch population from a health-care perspective focusing on health benefits and health-care costs in alcohol users.
The chronic disease model of the National Institute for Public Health and the Environment was used to extrapolate from decreased alcohol consumption due to tax increases to effects on health-care costs, life-years gained and quality-adjusted life-years gained, A Dutch scenario in which tax increases for beer are planned, and a Swedish scenario representing one of the highest alcohol taxes in Europe, were compared with current practice in the Netherlands. To estimate cost-effectiveness ratios, yearly differences in model outcomes between intervention and current practice scenarios were discounted and added over the time horizon of 100 years to find net present values for incremental life-years gained, quality-adjusted life-years gained, and health-care costs.
In the Swedish scenario, many more quality-adjusted life-years were gained than in the Dutch scenario, but both scenarios had almost equal incremental cost-effectiveness ratios: €5100 per quality-adjusted life-year and €5300 per quality-adjusted life-year, respectively.
Focusing on health-care costs and health consequences for drinkers, an alcohol tax increase is a cost-effective policy instrument.
PMCID: PMC2637894  PMID: 19040717

Results 1-9 (9)