General discussion 501 13 Challenges in clinical practice In the following paragraphs, the current and future challenges in clinical practice will be discussed, including aging, selective use of valuable resources, the combined use of additional diagnostics, the clinical relevance of missed thyroid malignancies, and the developments regarding MD-based instead of morphology-based diagnosis and treatment of thyroid nodules. The cost of aging: is the sky no longer the limit? The global population is aging [728]. On 1 January 2023, 20% of the Dutch population was 65 years old or older, as compared to 13% in 1990 [729]. Unfortunately, the disease-free life expectancy has not increased as much as the total life expectancy, resulting in an increase in people with chronic diseases, increased health care consumption, and increasing health care costs [728, 730]. Between 2016 and 2019 alone, the overall health care expenditure in the Health Insurance Act (Zorgverzekeringswet, Zvw) has increased by 7% from €41.5 billion to €44.5 billion annually, mainly through an increase in the overall costs of medical specialist care [730]. For each person aged 65 or older, there are currently three persons in the working age (20-64 years). This rate is decreasing to one in two, increasing the financial pressure regarding societal health care costs as well as the informal care requirements in the working age group [729]. Meanwhile, there are increasing staffing shortages in all layers of the health care systems, especially a shortage of nurses. Similar developments are observed in other countries worldwide [731, 732]. Concerns are regularly raised on how our society can continue to cope with the rising healthcare expenditure in the future while upholding our high health care standards. One year ago, the Integral Care Agreement (Integraal Zorgakkoord, IZA) was signed. With the catchphrase “the right care in the right place”, it aims to deal with the current challenges regarding the accessibility, quality and costs of health care in our country [733]. These developments endorse the great importance of careful cost-utility assessments prior to the implementation of a new diagnostic or therapeutic strategy. Even so, and without infringing on anyone’s right to a long and healthy life, in general we should be aware that our overall societal health care expenses will keep increasing if many of the advanced diagnostic and therapeutic strategies that we offer to our increasing number of patients are costeffective because they prolong life in good HRQoL or improve the quality of the existing lifespan (i.e., add quality-adjusted life years [QALYs]) with a significant price tag attached, as compared to cost-effectiveness by means of sustaining HRQoL at lower costs. After all: Net benefit = WTP * QALYs – costs (WTP; willingness-to-pay, with €50.000 being the recommended willingness-to-pay threshold by the Dutch Council for Public Health and Health Care for conditions with an intermediate disease burden [578]).
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