This article, “The New Dutch Guideline for Economic Evaluations in Healthcare: Taking the Societal Perspective to the Next Level” by H. Amarens Geuzinge and colleagues, addresses the critical and ongoing need for periodic revisions of guidelines for health economic evaluations. Given continuous methodological developments within the field of Health Technology Assessment (HTA) and economic evaluations, the Dutch guideline, last updated in 2016, required a comprehensive revision. Published as a policy perspective in VALUE HEALTH, this article offers an in-depth discussion of the latest revision of the Dutch guideline, which was officially launched in January 2024.
The primary objectives of this publication are threefold: to briefly discuss the process of the latest revision, to highlight the most significant changes, and to present a research agenda outlining topics that warrant further investigation. The overarching aim of these efforts is to promote uniform and high-quality economic evaluations in The Netherlands that can effectively inform health policy decisions from a broad societal perspective. A defining characteristic of the Dutch guidelines since their initial release in 1999 has been their commitment to a societal perspective, a feature that has been further strengthened in this fourth version.
The revision process was meticulously conducted, initiated in autumn 2022 by the National Health Care Institute, with four of its employees leading the process and writing the revised guideline. To gather feedback on the 2016 version and suggestions for adjustments, a survey was distributed in September 2022 to various stakeholders, including pharmaceutical companies, academic research groups in health economics, governmental organizations, and consultancy companies. After summarizing and prioritizing the 30 responses received, an independent advisory committee comprising 8 Dutch academic HTA experts from 6 universities and research institutes was installed. This committee, possessing expertise across different elements of health economics and economic evaluations, held three meetings to discuss survey results and support the guideline authors. A draft version of the revised guideline was subsequently opened for stakeholder feedback, receiving 20 responses, predominantly from pharmaceutical companies (55%) and academic research groups (30%). This feedback was then discussed during a fourth advisory committee meeting in September 2023, leading to the finalization of the guideline, which was launched in January 2024.
The revised guideline includes three updated in-depth modules: “The costing manual,” “Quality-adjusted life years (QALY) and quality-of-life measurements,” and “Uncertainty and value of information analyses“. The revision of the costing manual, which involved updating reference prices from 2014 to the new index year 2022, was outsourced and included a survey to identify necessary updates.
Key Revisions and Enhanced Guidance:
The article details several important adjustments to the reference case, which is provided to ensure comparability and quality of economic evaluations submitted to the National Health Care Institute. These adjustments, applicable to all types of health technologies, include:
- Discount rates: The discount rate for costs has been lowered from 4% to 3%, while the rate for effects remains at 1.5%. This adjustment aligns with current capital costs and recent changes in Dutch guidelines for societal cost-benefit analysis, reflecting a revised annual growth rate of the consumption value of health from 2.5% to 1.5%.
- Expert opinion and expert elicitation: The new guideline provides additional, mandatory guidance for the conduct and reporting of expert judgment, addressing previous limitations that led to suboptimal processes and lack of transparency. It distinguishes between expert elicitation (quantitative information) and expert opinion (qualitative information) and requires transparency regarding questions asked, potential conflicts of interest, and individual expert answers in reimbursement dossiers.
- Health-related quality of life of informal caregivers: While costs related to informal care were already included, the revised guideline now explicitly states that health-related quality-of-life changes in informal caregivers should be included in a scenario analysis when relevant. This inclusion, measured using the EQ-5D-5L, aligns with the societal perspective and the already included costs, despite acknowledged methodological challenges.
- Probabilistic analysis for main results: The revised guideline mandates that base-case analysis and scenario analyses be based on probabilistic analysis, moving away from a deterministic approach. This change is driven by methodological considerations, as deterministic outputs based on parameter means can provide biased estimates of true values in nonlinear health economic models.
- Indirect medical costs in life years gained: Previously recommended for scenario analysis, these costs, representing other medical conditions occurring during gained life years, must now be included in the base-case analysis. The committee notes that this will increase the incremental cost-effectiveness ratios (ICERs) for life-prolonging interventions, but justifies it on the grounds of consistency (since benefits of unrelated medical conditions are implicitly included) and representing real opportunity costs.
- Empirical (trial-based) economic evaluations: The guideline provides more extensive guidance on performing trial-based economic evaluations. It addresses common issues such as baseline imbalances, skewed costs/effects, correlation between costs and effects, data clustering, and missing data, aiming to improve the validity and usefulness of these evaluations for decision-makers.
- Value of information (VOI) analyses: Estimation of both Expected Value of Perfect Information (EVPI) and Expected Value of Partial Perfect Information (EVPPI) has become mandatory for model-based evaluations and is now part of the reference case. These analyses, which do not require additional data collection, help indicate the consequences of uncertainty related to a decision and must be reported using patient and population EVPI/EVPPI curves over a 5-year time horizon.
Furthermore, the updated costing manual now includes new reference price categories for diagnostics, medical devices, mental healthcare, and drug administration. Importantly, to further strengthen the societal perspective, it also adds cost categories outside the healthcare sector, specifically costs related to education and justice.
Research Agenda and Future Outlook:
Despite these comprehensive updates, the advisory committee identified areas requiring further guidance and research, formulating a research agenda. Key topics include:
- Updating willingness-to-pay thresholds: The article highlights the need to re-examine the current societal willingness-to-pay thresholds (€20,000, €50,000, and €80,000 per QALY gained), which have not been updated since 2015, considering societal, healthcare, and cultural developments.
- Developing a generic outcome measure of well-being: For non-curative interventions, where improving health may not be the primary aim, the EQ-5D-5L may be unsuitable. Researchers are encouraged to develop a widely supported, preference-based generic outcome measure for well-being, suitable for economic evaluations, along with appropriate thresholds for evaluating outcomes using these broader measures.
The article concludes by emphasizing the Dutch guideline’s distinctive features, such as differential discounting, its broad societal perspective, and the mandatory inclusion of VOI analysis. By encompassing productivity costs (using the friction cost method), costs of informal care, and now explicitly including quality-of-life effects on informal caregivers, the guideline aims to inform decision-makers about the full consequences of reimbursement decisions. The National Health Care Institute also expresses an ambition for more frequent, potentially modular, updates of the guideline in the future, possibly every five years.
APA Reference: Geuzinge, H. A., El Alili, M., Enzing, J. J., Huis in ’t Veld, L. M., Knies, S., & de Wit, G. A. (2025). The New Dutch Guideline for Economic Evaluations in Healthcare: Taking the Societal Perspective to the Next Level. VALUE HEALTH, 28(6), 930–935. https://doi.org/10.1016/j.jval.2025.03.002