As in other developed countries, a large proportion of the Dutch Gross Domestic Product is spent on healthcare, and this proportion has grown during the last decade, from 9% in 2004 to 11% in 2014 [1]. It has been suggested that such increases can be explained by factors outside the healthcare sector (e.g. ageing population, increased prevalence of chronic diseases), the absence of a competitive market within healthcare systems, the absence of strong cost-containment measures, and technological innovation [2, 3]. Of them, technological innovation is often cited as the main driver of the long-term growth in healthcare costs [3–5]. It must be noted that high and rising healthcare costs are not necessarily associated with negative connotations. Cost increases may be synonymous with improved health outcomes, increases in job opportunities in the sector, and improved quality of services delivered [2, 6]. However, since the rate of increase in healthcare costs currently exceeds economic growth, its continued growth at current rates is not sustainable and public spending on healthcare is crowding out public spending on other services. As a consequence, there is a strong (political) call for healthcare cost-containment and healthcare decision-makers are increasingly being confronted with choices about which treatments to reimburse and which to not reimburse [7].
Economic evaluations provide an indication of the relative efficiency of treatments by comparing the costs and consequences of alternative programs or interventions [8]. Such studies can help healthcare decision-makers to determine how best to allocate scarce resources at the macro-, meso-, and micro-level. At the macro-level, the Dutch Ministry of Health, Welfare, and Sports has to decide upon the content of the basic health insurance package (i.e. a compulsory insurance for all Dutch citizens). In making such decisions they are advised by the Dutch National Healthcare Institute, an independent governing body that, amongst others, provides evidence-based guidance and advice on the in- or exclusion of healthcare services in the basic health insurance package as well as the conduct of economic evaluations [9, 10]. The majority of the content of the basic health insurance package, however, is somewhat openly formulated [10]. This means that ‘insured care’ is defined in terms of functions of care rather than in specific healthcare services [10]. As a consequence, the responsibility for ‘appropriate use’ of insured care, and thus the allocation of the healthcare budget, is partly transferred to institutions and healthcare providers working at the regional or local level (i.e. meso-level) and in the individual patient setting (i.e. micro-level) [11].
Various studies indicated that healthcare decision-makers in many Western countries have a positive attitude towards the use of economic evaluations for resource allocation decision-making, but that their use and knowledge of economic evaluations is limited [12–17]. This discrepancy is likely due to the various barriers that decision-makers experience preventing their use in day-to-day decision-making, such as a lack of resources, political opposition, and a lack of relevant studies [12–17]. The only Dutch study to explore the use of economic evaluations in healthcare decision-making was performed more than a decade ago (i.e. 1998–1999) [17]. However, in an effort to improve the quality and efficiency of care, the Dutch government introduced a new Health Insurance Act in 2006, changing the healthcare system from a partly public and partly private, predominantly government-run system, into a universal insurance market that aims to be competitive [10]. Amongst others, the new act mandates all Dutch citizens to purchase the basic health insurance package, all insurance companies have to offer the basic health insurance package, and competing health insurance companies are obliged to accept all applicants during an annual enrollment period [10]. As one of the main aims of the Dutch healthcare reform was to improve the efficiency of healthcare [10, 18], it is conceivable that the decision-makers’ knowledge and use of economic evaluations have increased since then. Whether this is indeed the case, however, is currently unknown. Therefore, this study aimed to gain insight into the current and potential use of economic evaluations in Dutch healthcare decision-making and to identify barriers and facilitators to the use of such studies.