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Jackson Brown
Jackson Brown

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Dutch health economic guidelines include a costing manual, which describes preferred research methodology for costing studies and reference prices to ensure high quality studies and comparability between study outcomes. This paper describes the most important revisions of the costing manual compared to the previous version.

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An online survey was sent out to potential users of the costing manual to identify topics for improvement. The costing manual was aligned with contemporary health economic guidelines. All methodology sections and parameter values needed for costing studies, particularly reference prices, were updated. An expert panel of health economists was consulted several times during the review process. The revised manual was reviewed by two members of the expert panel and by reviewers of the Dutch Health Care Institute.

The majority of survey respondents was satisfied with content and usability of the existing costing manual. Respondents recommended updating reference prices and adding some particular commonly needed reference prices. Costs categories were adjusted to the international standard: 1) costs within the health care sector; 2) patient and family costs; and 3) costs in other sectors. Reference prices were updated to reflect 2014 values. The methodology chapter was rewritten to match the requirements of the costing manual and preferences of the users. Reference prices for nursing days of specific wards, for diagnostic procedures and nurse practitioners were added.

Economic evaluations in health care are increasingly used to inform decision makers on value for money of health care interventions. Standardization of methodology for economic evaluations is needed to ensure high-quality evaluations and obtain outcomes that can be compared between health care interventions. For this purpose, pharmacoeconomic guidelines have been developed in various countries [1]. These guidelines differ between countries, for example with respect to which costs should be included, methodology of calculating costs and discounting.

The purpose of the costing manual is to provide guidance to researchers and policy makers to perform and evaluate economic evaluations of health care interventions. The first Dutch costing manual was published in 2000. Since then, two updates were published in 2004 and 2010 [4]. The instrument has been widely used since the publication of the first costing manual. Standard cost prices for various health care services, called reference prices, constitute an important part of the costing manual. Regular updates of the costing manual are essential in order to reflect changes in health care, price increases, and developments in HTA research. This paper reports on the update of the Dutch costing manual which serves the purpose of harmonizing the costing side of economic evaluations in health care. As the costing manual is written in Dutch, this paper can provide international readers with a better understanding of the content and methodologies used in the costing manual and provide them with the reference prices for healthcare services for the Netherlands.

The revision of the costing manual was part of the new edition of the Dutch health economic guidelines. The principles of the costing manual had to be aligned with these guidelines and the reference prices were to be updated. The update of the costing manual consisted of three separate steps. First, an inventory of user needs was made. Second, the content of the manual was updated to resemble the health economic guidelines and adjust methodological paragraphs. Furthermore, reference prices were updated through literature and database research and stakeholder consultation. Third, members of the expert committee supervising the guideline revision for ZIN were asked to comment on intermediate and final results of the revision of the costing manual. The revision of the costing manual was supervised by a team of ZIN with experience in health economics and project management.

An online survey was sent out to over 700 people (mainly from universities, industry, governmental bodies, health care institutions and consultancy) from the target audience of the costing manual to investigate user satisfaction with the previous costing manual, and to identify user needs and opportunities for improvement for the updated costing manual. The online survey consisted of 13 questions, and encompassed three themes: clarity and user-friendliness of the previous manual; methodological issues; and (need for additional) reference prices. The online survey opened on January 15th 2015 and closed on February 2nd 2015. During this period, one reminder was sent out to non-respondents. The survey questions are provided in S1 Appendix.

Reference prices for health care consumption, which are average unit costs, constitute a frequently used part of the costing manual. Reference prices were recalculated using recent information on costs, volume and prices for various types of health care services. Reference prices were updated using various techniques (summarized in Table 1), depending on data availability. If possible, bottom-up microcosting was used to calculate reference prices, as this is the gold standard for calculating cost prices [5]. When bottom-up microcosting data was not available, grosscosting methods were applied to calculate reference prices. Bottom-up microcosting studies, identifying and valuating resource use per individual patient, were used to calculate references prices for hospital care [Tan, S.S., et al. Reference unit prices for surgery, neurology and paediatrics. Submitted for publication]. Reference prices for emergency care, ambulances, blood products, daycare treatment in mental health care and rehabilitation were calculated using top-down grosscosting, for which data on costs and volumes were derived from health care providers. Data on expenditures and volumes derived from national health care database were used to calculate reference prices using top-down grosscosting, for primary care physicians, paramedical care, elderly care, home care, mental health care and health care for disabled patients [6]. Finally, tariffs were used to value diagnostic procedures [7]. For contacts with independent psychotherapists and psychiatrists, ambulatory consultation in a general institution and inpatients days in mental health care tariffs were used [8]. Relevant stakeholders were consulted to validate the updated reference prices. Updated informal care costs were derived from the website of the Central Administration Office (CAK). Productivity costs should be valued using the friction cost method based on the Dutch health economic guidelines. The friction period is equal to the average duration of a job vacancy plus an additional four weeks. The average duration of job vacancies was calculated with the following formula: 365 / (the number of filled vacancies in one year / the number of vacancies at a moment in that same year). The number of vacancies was derived from the website of Statistics Netherlands. Wage levels were also derived from the Statistics Netherlands website.

The costing manual is an essential part of the revised Dutch health economic guidelines, which were published in February 2016. The costing manual describes the methodology of costing studies and reference prices, which are used to increase the quality and comparability of costing studies. As such, the costing manual is a widely used instrument for costing studies and economic evaluations in health care in the Netherlands. This paper describes the updates in the revised version of the Dutch costing manual. Important revisions were simplification of methodology and updates of reference prices, including those for a number of hospital specialties and diagnostic procedures. The updated costing manual is freely available from the website from ZIN ( together with an online Microsoft Excel instrument containing the reference prices to ensure accessibility (available through

Health economic guidelines prescribe the use of country-specific unit prices, to reflect absolute and relative differences in unit prices [19]. However, a recent study found that a standard cost list, such as the reference prices provided in the costing manual, is only available in four out of 30 pharmacoeconomic guidelines [20]. Use of a costing manual and reference prices ensures that differences in costs result from differences in health care utilization and not from the methodology applied to calculate costs. The absence of standard prices leads to differences in valuation of the same health care service within a single country, and can influence study outcomes and potentially even reimbursement decisions. Next to reference prices published in the costing manual, the manual provides guidance on the methodology of calculating unit prices when reference prices are not available. As such, using standard methodology increases the comparability and transparency of unit prices used in costing studies. In this way, the Dutch costing manual can be a useful tool for developing costing manuals in other countries.

Bottom-up costing studies are considered the gold standard for calculating cost prices [5]. However, this method is time consuming and costly. Therefore, due to data availability, reference prices in the costing manual could not be based solely on bottom-up costing studies. When additional bottom-up costing studies will be performed in the future, the resulting prices might replace existing reference prices in future updates of the costing manual.

The values in the costing manual should be regularly updated, to ensure that methodology reflects current best practice and reference prices reflect current price levels. Future updates also entail including additional reference prices for other types of health care and more detailed reference prices, for instance for other hospital specialties. The expert committee proposed that one way to increase the availability of reference prices is to set up an open repository, in which researchers can share unit prices derived in their own studies. However, a number of questions need to be answered before such a repository could be establi