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Evaluation of screening

The demand for and challenges of early detection of diseases is growing rapidly due to technological developments. We aim to quantify the effects of screening for a wide range of diseases to help individuals, clinicians and policymakers make an informed choice about the potential/most optimal implementation of screening and informed (non-) participation.

Screening for diseases is a popular concept. Early detection of disease can considerably improve survival and/or quality of life. However, it can also result in false-positive test results or detection of clinically irrelevant disease, leading to unnecessary interventions. Screening can have a beneficial as well as a harmful impact on health, quality of life, and societal cost. Our research focuses on quantifying these health benefits, unfavourable side-effects, impact on quality of life, and cost consequences of introducing screening programmes, and/or tests for high risk patients.

Our investigations result in recommendations as to whether or not to introduce screening for specific diseases, and on policy decisions to introduce screening in specific ways, also in clinical care and surveillance. We have made major scientific contributions in the areas of:

  1. Designing, running and evaluating large-scale multidisciplinary population-based randomised controlled screening trials to establish the efficacy of screening. Examples include trials for screening on lung (NELSON), 4-IN-THE-LUNG-RUN, breast (MyPeBS) and gastric cancer, and cardiovascular disease (ROBINSCA).
  2. Evaluating existing (inter)national screening programmes. We are the national evaluation unit for the breast, cervical and colorectal cancer screening programmes in the Netherlands, and also evaluate programmes in the EU (EU-TOPIA), US and worldwide.
  3. Guiding public health policies on screening using predictions of favourable and unfavourable effects and the cost of screening, based on micro-simulation modelling (CISNET). The United States guidelines for breast, colorectal and lung cancer screening were (in part) based on modelling by our research section.

Population health varies by social determinants. Understanding and improving population health calls for an inclusion of the social conditions in which people are born, grow, live, work and age in public health research, with a focus on those in the most disadvantaged conditions.

Unfavourable health patterns in the most socioeconomically disadvantaged groups are widely observed. Yet, the variation in the magnitude of health inequalities over time, across countries, between and within cities and within socioeconomic groups allow for social-epidemiological research aimed at improving health in the most disadvantaged groups in societies. A unique database developed in the Lifepath project allows studying trends and underlying pathways in the magnitude of socioeconomic inequalities in health in many European countries over decades. The variation in physical and social living conditions across cities is used to study the role of urban environments for mental wellbeing of older urban residents in cities in Europe, the US and Canada the MINDMAP project. To further improve understanding mechanisms, we study socioeconomic inequalities in early child development, and the role of cultural capital for socioeconomic inequalities in adulthood. We emphasize a socioecological approach, recognize the importance of the life course and the intergenerational transmission of health inequalities, and use state-of-the-art methods with a focus on causal inference. The crucially important question is how to intervene such that those in lower socioeconomic groups benefit most receives increasing attention? We acknowledge the role of social conditions, and study the effects of social policies and natural experiments, such as the implementation of playgrounds in deprived neighbourhoods. Increasingly, we adopt a systems-perspective for this purpose. Collaborations are crucial for this purpose, such as with the Rotterdam Municipality and the Erasmus University. Our research is closely related to teaching, for example in the NIHES Erasmus Summer Programme course on Social Epidemiology and Public Health Research methods.

Infectious diseases remain an important global public health problem, especially in developing countries. HIV/AIDS, malaria and tuberculosis still challenge healthcare resources. The so-called neglected tropical diseases are far from eliminated, and newly emerging infections surprise the world continuously.

Our main research activities cover neglected tropical diseases (NTDs), including various species of parasitic worm infections, leishmaniasis and leprosy, as well as tuberculosis, HIV/AIDS and other sexually transmitted infections. We also study infectious diseases common in migrant populations in Rotterdam, as well as hand hygiene in healthcare settings and antimicrobial resistance. Our research methodologies include mathematical modelling, epidemiological data analysis, and behavioral studies. Most NTD research is part of or linked to the NTD Modelling Consortium, a collaboration of various international modelling teams, funded by the Bill & Melinda Gates Foundation. Findings and insights have been published in special issues of the high-impact scientific journals Clinical Infectious Diseases, PLoS Neglected Tropical Diseases and Journal of Infectious Diseases, and have also been summarized in two well-received booklets for non-specialist readers.

Our ambition is to do research that has tangible influence on policy and practice. A good example is that the World Health Organization (WHO) invited the NTD Modelling Consortium to reflect on their proposed new 2030 targets and guidelines. The outcomes of this exercise have been documented in a series of publications in Gates Open Research and are summarized on the WHO website. Another example is that our modelling work on the impact of HPV vaccination strategies was part of the reason why the Dutch government has recently decided to also include boys in routine HPV vaccination. Furthermore, our study on the impact of combination HIV prevention in Zimbabwe was directly used in the next national strategic plan for HIV control.

Our research supports healthy growth and development of all children. We also apply the pro-active, preventive public health approach with a combination of health and social care to other vulnerable groups such as citizens with multiple chronic conditions and frailty.  

Worldwide, socioeconomic inequalities in health and health care exist. We focus on the mechanisms that cause health inequalities among families with children, older people, and other vulnerable groups in the Netherlands, Europe and other countries.

We collaborate in the Generation R birth cohort and the INRICH network to study the mechanisms that play a role regarding health inequalities. Our focus is on the promotion of healthy lifestyles obesity prevention, determinants of health-related quality of life, and the evaluation of integrated, value-based health & social care.

Together with professionals, policymakers and individuals we develop, implement and evaluate preventive programmes and policies. For example, in the project Promising Neighbourhoods, together with partners, health inequalities are targeted by a broad community program for a promising, safe, and healthy development of youth. At the national level we lead a consortium integrating knowledge on effectiveness of interventions that promote parenting; we identify the ‘effective elements’ of parenting interventions (CIKEO).

Within the context of the overloaded healthcare and welfare systems, the ability of individuals to take care of themselves has become increasingly important. Therefore, we apply knowledge from child public health in various programmes supporting active and healthy ageing. In the SEFAC-project, the aim is to reduce the burden of individuals with a chronic condition and increase the sustainability of the health system by supporting self-management. The EFFICHRONIC-project aims to provide evidence on the positive return of investment and cost-efficiency of the application of the Chronic Disease Self-Management Programme in five European countries.

Medical decision-making aims to support patients, clinicians and healthcare policymakers in making the best decisions about diagnostic, therapeutic and other medical interventions.

For many interventions in healthcare it remains unclear what the effectiveness is. In addition, optimal care may also depend on patient characteristics and preferences. Further, quality of care varies substantially between providers. Our mission is to contribute to optimal evidence-based and personalised decisions in healthcare through outstanding quantitative research. We work on the development of quantitative methods to inform decisions. These include prediction modelling, methods for causal inference from observational data, measuring quality of care, and comparative effectiveness research (CER). For example, we develop statistical methods to study the effectiveness of treatments based on between-hospital variation in treatment and outcomes. Another example is prediction modelling to predict treatment benefit in individual patients. We apply our methods in collaboration with multiple clinical groups within and outside Erasmus MC to directly improve patient care. For example, within Erasmus MC we collaborate with various clinical departments and lead the Academic Centre for Quality of Care and Outcomes of Erasmus MC. With researchers from Erasmus University we work on ways to create a more sustainable and effective healthcare system in the programme ‘Smarter choices for better health’. In the national CONTRAST consortium, we aim to improve the effectiveness and safety of acute treatment for stroke. In CENTER-TBI (an international project funded by the European Union) we aim to optimise treatment for patients with traumatic brain injury.

We all die, mostly after a period of illness and decline, during which adequate self-management, multifaceted care from professional and non-professionals caregivers, and sensible medical decision making are of the essence.

Medical care and decision-making at the end of life are prominent in both the societal and scientific debate. Contemporary societal issues in end-of-life care include: i) the ageing population with patients dying from chronic deteriorating illnesses such as cancer, organ failure or dementia, ii) the medicalization of dying and the fragmentation of care that involve challenges in communication and cooperation, and iii) an increasing emphasis on patient engagement and self-determination. Examples of frequently discussed topics are euthanasia and other forms of assisted dying, the role of palliative care and palliative sedation, overuse and underuse of medical treatment at the end of life, the (cost)effectiveness of end-of-life care, and advance care planning. Our group has performed different studies to describe and elucidate these complex phenomena, as well as experimental studies to evaluate interventions aimed at improving patients’ quality of life and the quality of care and decision-making. Studies on end-of-life care involve various thought-provoking ethical and methodological challenges. Our research projects include: quantitative and qualitative studies on symptoms and quality of life; medication management; palliative care in hospitals; collaboration between different health care settings and disciplines; management of cardiac devices; spiritual care; prognostication; advance care planning; and self-management. In these investigations, we collaborate with partners throughout the Netherlands, Europe and beyond. At the regional level, we participate in a consortium dedicated to improve the quality of palliative and end-of-life care in the southwest region of the Netherlands. We also participate in a regional academic network of hospice facilities and coordinate a patient advisory panel.

It is an important challenge to enable persons to work longer in good health, in particular for vulnerable groups. Paid employment is an important determinant of health and health inequalities.

Society has to deal with large health inequalities in paid employment. Our research aims to contribute to the challenge of creating an inclusive labour market for all social groups. Important questions addressed by our research are: How important is work for health and how important is health for work? Is working until old age healthy or not? Which factors determine work ability and sustainable employment during the working life? How can workers with chronic diseases remain productive at work? What interventions and policies enhance sustainable employability? How (cost-)effective are these interventions and policies? We analyse data from large-scale epidemiological studies with state-of-the-art methods, and design, implement and evaluate interventions for sustainable employability among both unemployed and employed persons. To gain insight into the long-term effectiveness of interventions, and the consequences for the working life expectancy, we apply a life-course approach. We are specifically interested in vulnerable groups, e.g. individuals with chronic health problems, long-term unemployed individuals, and workers in a low socioeconomic position.

Evidence-based efficiency of curative and preventive care is important to simultaneously optimize health outcomes by improving treatment for patients, while keeping health care costs as low as possible. To achieve this, it is important to improve methods to measure outcome and to study the implementation and evaluation of interventions within health care.

Our work consists of a unique combination of health economic, epidemiologic and behavioral research, and of methodological development and implementation research. This multi-faceted approach allows us to contribute to evidence-based efficiency of curative and preventive care. The aim of our work is to simultaneously optimize health outcomes of patients by improving treatment, while keeping healthcare costs as low as possible. Two major pillars of our work are: a) improvement and application of methods to measure outcome (quality of life, burden of disease, costs and efficiency), and b) to study the implementation and evaluation of (prevention) interventions within healthcare. Therefore, our research consists of studies that explore methodological innovations within topics such as health-related quality of life, disability adjusted life years, disability weights, cost-utility analysis, social cost-benefit analysis, and implementation research. With its strong focus on methodology of outcome measurement, quantification of costs and disease burden and evaluation of interventions, our work is instrumental for the optimization of evidence-based care and prevention. Our primary area of application is the field of trauma and we collaborate with many clinical departments within Erasmus MC and national and international institutes. In addition, our work contributes to epidemiologic, economic and social research focusing on preventive interventions among vulnerable groups (e.g. elderly, obesity, low socioeconomic status) and translating this research into daily practice, thereby providing better care for our patients.

Future physicians will face a considerable increase in the numbers of patients with multiple chronic diseases and will need skills in teamwork, shared decision-making, prevention and population health, as well as in maintaining the quality, safety and efficacy of healthcare.

It is internationally recognised that current healthcare systems have to adapt to cope with the most important health problems of the 21st century. Ageing societies, and a substantial increase in the number of patients with (multiple) chronic diseases (often related to lifestyle and the environment and amenable to prevention), make a strong demand for alternative healthcare models. Future physicians will need to be highly skilled team players who can function well in a system, with more focus on prevention and general care, participation as main outcome, and able to bridge the gap between the medical and social domains.

In 2018-2019 we made major progress in adaptations of  the Erasmus MC curriculum to meet these new demands. In  close collaboration with the department of General Practice, the municipality of Rotterdam and other external and internal partners we implemented a novel 4-week master course “general practice and social medicine” focusing on the aforementioned aspects (5th year).  And we created a coalition with the municipality of Rotterdam to develop a novel internship social medicine to provide real-world insight in social determinants and solutions for health problems at both the individual and population level(5th year) . We also finalised the implementation of the ‘Collaboration for Optimal Care and Prevention’ (COCP, 1st -6th year) trajectory, consisting of training in interprofessional collaboration, shared decision-making, prevention and population health, as well as the quality, safety and efficiency of healthcare.