BackgroundInfection with HPV 16 and 18, the major causative agents of cervical cancer, can be prevented through vaccination with a bivalent or quadrivalent vaccine. Both vaccines provide cross-protection against HPV-types not included in the vaccines. In particular, the bivalent vaccine provides additional protection against HPV 31, 33, and 45 and the quadrivalent vaccine against HPV31. The quadrivalent vaccine additionally protects against low-risk HPV type 6 and 11, responsible for most cases of genital warts. In this study, we made an analytical comparison of the two vaccines in terms of cost-effectiveness including the additional benefits of cross-protection and protection against genital warts in comparison with a screening-only strategy.MethodsWe used a Markov model, simulating the progression from HPV infection to cervical cancer or genital warts. The model was used to estimate the difference in future costs and health effects of both HPV-vaccines separately.ResultsIn a cohort of 100,000 women, use of the bivalent or quadrivalent vaccine (both at 50% vaccination coverage) reduces the cervical cancer incidence by 221 and 207 cases, corresponding to ICERs of €17,600/QALY and €18,900/QALY, respectively. It was estimated that the quadrivalent vaccine additionally prevents 4390 cases of genital warts, reducing the ICER to €16,300/QALY. Assuming a comparable willingness to pay for cancer and genital warts prevention, the difference in ICERs could justify a slightly higher price (~7% per dose) in favor of the quadrivalent vaccine.ConclusionsClearly, HPV vaccination has been implemented for the prevention of cervical cancer. From this perspective, use of the bivalent HPV vaccine appears to be most effective and cost-effective. Including the benefits of prevention against genital warts, the ICER of the quadrivalent HPV vaccine was found to be slightly more favourable. However, current decision-making on the introduction of HPV is driven by the primary cervical cancer outcome. New vaccine tenders could consider the benefits of cross-protection and the benefits of genital warts, which requires more balanced decision-making.

BackgroundA multidisciplinary, guideline-based Stepped-Care-Strategy (SCS), has recently been developed to improve the management of hip and knee osteoarthritis (OA). To date, it is unknown to what extent current Dutch OA care is consistent with the SCS, both with respect to the content of care as well as the sequence of care. Furthermore, there is a lack of clarity regarding the role of different health care providers in the performance of OA care according to the SCS. Therefore, the main purpose of this study is to describe the content of primary care in patients with hip/knee OA, including the compliance to the SCS and taking into account the introduction of patient self-referral to physical therapy.MethodsData were used from NIVEL Primary Care Database. In total, 12.118 patients with hip/knee OA who visited their GP or physical therapist were selected. Descriptive statistics were used to compare the content of care in GP-referred and self-referred patients to physical therapy.ResultsContent of care performed by GPs mostly concerned consultations, followed by NSAID prescriptions and referrals to secondary care. Both prescriptions of acetaminophen and referrals to physical therapy respectively dietary therapy were rarely mentioned. Nevertheless, still 65% of the patients in physical therapy practice were referred by their GP. Compared to GP-referred patients, self-referred patients more often presented recurrent complaints and were treated less often by activity-related exercise therapy. Education was rarely registered as singular intervention, neither in GP-referred nor in self-referred patients.ConclusionIn accordance with the SCS, less advanced interventions are more often applied than more advanced interventions. To optimize the adherence to the SCS, GPs could reconsider the frequent use of NSAIDs instead of analgesics and the low referral rate to allied health care. Self-referral to physical therapy partially distorts both the low referral rate in general practice and the low application rate of education as singular intervention in physical therapy practice. Further research is recommended to evaluate the effects of task-shifting in OA care, taking into account the content of the SCS.Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-015-0295-9) contains supplementary material, which is available to authorized users.

ObjectivesTo examine the role of general practitioners (GPs) in HIV counselling and testing over a 22-year period.DesignA dynamic cohort study.SettingGeneral practices (N=42) participating in the Dutch Sentinel General Practice Network at Nivel with a nationally representative patient population by age, gender, regional distribution and population density.Outcome measuresHIV-related consultations from 1988 to 2009 were recorded using a questionnaire in which patient's characteristics, interventions and test results were recorded. Trends over time and effects of urbanisation (3 categories) were assessed by multilevel analysis to control for clustering of observations within general practices.ResultsTime trend analyses show an increasing trend in HIV-related consultations and in the total number of HIV tests per 10 000 registered patients from 1988 to 1996, followed by a declining period and an increase again in the period 2007–2009. Over the whole period, the number of HIV-related consultations was highest in the urban areas with a maximum of 18 per 10 000 patients in 1996. The proportion of people high at risk, men who have sex with men, decreased. The proportion of HIV-related consultations initiated by the GPs increased from 11% in 1988 to 23% in 2009.ConclusionIn this 22-year period, HIV-related consultations and provider-initiated HIV testing in the Dutch general practice have increased. More attention for sexual health in general practice is required that focuses on high-risk groups and on more routine testing in high prevalence areas.

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Poster presentations Methods An inner-city ED implemented an opt-in rapid oral-fluid HIV screening programme since 2005; during the summer of 2007, HIV testing facilitators offered 24/7 bedside rapid testing to patients aged 18-64 years. During the same period, an HIV seroprevalence study enrolled adult patients who gave consent for use of their blood samples. Known HIV positivity was determined by either chart review or self-report. Serum samples were tested for HIV by EIA and all positives were confirmed by Western blot followed by RNA viral load testing. Results There were 3,884 samples, including 153 from known HIV positives for the seroprevalence study. Among the remaining 3,731 visits, 1,286(34%) were offered bedside HIV testing; 2,445(66%) were not. Among those offered, 693 declined, and 561 were tested (32 accepted but were never tested). Seroprevalence data revealed the following rates of undiagnosed HIV infections: 2.0% in those offered versus 5.3% in those not offered(p < 0.001); 2.5% in those who declined, 0.6% in those tested, and 15.6% in those accepted but not tested(p < 0.001). Mean viral load was significantly higher in those not offered the screening as compared to those offered (difference: 63,441, 95%: 3,310-123,572). Conclusion There was a disporportinately high prevalence of undiagnosed HIV infection in ED patients who were not offered HIV screening and in those who declined screening, versus those who accepted testing. This indicates that even with an intensive established opt-in counsellor-based rapid HIV screening model, significant missed opportunities remain with regard to identifying undiagnosed HIV-infected individuals in the ED.