Equal in ashes? Exploring socioeconomic inequalities in lifespan based on obituary data in Austria.

Understanding the emergence of and changes in socioeconomic inequalities in lifespan requires reliable, longitudinal data. In the absence of administrative data, published obituaries may be one such alternative source. With the validity of drawing relevant data from obituaries not yet established in population health research, this study addresses this gap by estimating socioeconomic inequalities in lifespan in Vorarlberg, Austria. Data for all individuals (n = 1490) with obituaries published (July to December 2022) in a regional newspaper (market share: 56%) were extracted, including different markers of the deceased's socioeconomic status. Linear regression analyses showed that, on average, individuals with medium-sized obituaries lived 6.02 years (95% CI: 4.19, 7.85) and individuals with the largest obituaries 12.04 years (95% CI: 7.04, 17.04) longer than individuals with small obituaries while blue-collar workers lived 10.50 years (95% CI: -14.51, -6.49) shorter than individuals with no occupation (reported). This socioeconomic gradient is in line with findings based on national data sources, and comparisons with official regional data are promising regarding data representativeness and completeness. With obituary size reflecting different costs (€210-€1626) and thus being a novel marker for financial ability, obituaries could also be a useful, innovative data source internationally for historical analyses or "nowcasting" health inequalities.

The identification of economically relevant health and social care services for mental disorders in the PECUNIA project.

BACKGROUND: Health economic research is still facing significant problems regarding the standardization and international comparability of health care services. As a result, comparative effectiveness studies and cost-effectiveness analyses are often not comparable. This study is part of the PECUNIA project, which aimed to improve the comparability of economic evaluations by developing instruments for the internationally standardized measurement and valuation of health care services for mental disorders. The aim of this study was to identify internationally relevant services in the health and social care sectors relevant for health economic studies for mental disorders. METHODS: A systematic literature review on cost-of-illness studies and economic evaluations was conducted to identify relevant services, complemented by an additional grey literature search and a search of resource use measurement (RUM) questionnaires. A preliminary long-list of identified services was explored and reduced to a short-list by multiple consolidation rounds within the international research team and an external international expert survey in six European countries. RESULTS: After duplicate removal, the systematic search yielded 15,218 hits. From these 295 potential services could be identified. The grey literature search led to 368 and the RUM search to 36 additional potential services. The consolidation process resulted in a preliminary list of 186 health and social care services which underwent an external expert survey. A final consolidation step led to a basic list of 56 services grouped into residential care, daycare, outpatient care, information for care, accessibility to care, and self-help and voluntary care. CONCLUSIONS: The initial literature searches led to an extensive number of potential service items for health and social care. Many of these items turned out to be procedures, interventions or providing professionals rather than services and were removed from further analysis. The resulting list was used as a basis for typological coding, the development of RUM questionnaires and corresponding unit costs for international mental health economic studies in the PECUNIA project.

Development of an Instrument for the Assessment of Health-Related Multi-sectoral Resource Use in Europe: The PECUNIA RUM.

BACKGROUND: Measuring objective resource-use quantities is important for generating valid cost estimates in economic evaluations. In the absence of acknowledged guidelines, measurement methods are often chosen based on practicality rather than methodological evidence. Furthermore, few resource-use measurement (RUM) instruments focus on the measurement of resource use in multiple societal sectors and their development process is rarely described. Thorn and colleagues proposed a stepwise approach to the development of RUM instruments, which has been used for developing cost questionnaires for specific trials. However, it remains unclear how this approach can be translated into practice and whether it is applicable to the development of generic self-reported RUM instruments and instruments measuring resource use in multiple sectors. This study provides a detailed description of the practical application of this stepwise approach to the development of a multi-sectoral RUM instrument developed within the ProgrammE in Costing, resource use measurement and outcome valuation for Use in multi-sectoral National and International health economic evaluAtions (PECUNIA) project. METHODS: For the development of the PECUNIA RUM, the methodological approach was based on best practice guidelines. The process included six steps, including the definition of the instrument attributes, identification of cost-driving elements in each sector, review of methodological literature and development of a harmonized cross-sectorial approach, development of questionnaire modules and their subsequent harmonization. RESULTS: The selected development approach was, overall, applicable to the development of the PECUNIA RUM. However, due to the complexity of the development of a multi-sectoral RUM instrument, additional steps such as establishing a uniform methodological basis, harmonization of questionnaire modules and involvement of a broader range of stakeholders (healthcare professionals, sector-specific experts, health economists) were needed. CONCLUSION: This is the first study that transparently describes the development process of a generic multi-sectoral RUM instrument in health economics and provides insights into the methodological aspects and overall validity of its development process.

Excess resource use and costs of physical comorbidities in individuals with mental health disorders: A systematic literature review and meta-analysis.

Individuals with mental health disorders (MHDs) have worse physical health than the general population, utilise healthcare resources more frequently and intensively, incurring higher costs. We provide a first comprehensive overview and quantitative synthesis of literature on the magnitude of excess resource use and costs for those with MHDs and comorbid physical health conditions (PHCs). This systematic review (PROSPERO CRD42017075319) searched studies comparing resource use or costs of individuals with MHDs and comorbid PHCs versus individuals without comorbid conditions published between 2007 and 2021. We conducted narrative and quantitative syntheses, using random-effects meta-analyses to explore ranges of excess resource use and costs across care segments, comparing to MHD only, PHC only, or general population controls (GPC). Of 20,075 records, 228 and 100 were eligible for narrative and quantitative syntheses, respectively. Most studies were from the US, covered depression or schizophrenia, reporting endocrine/metabolic or circulatory comorbidities. Frequently investigated healthcare segments were inpatient, outpatient, emergency care and medications. Evidence on lost productivity, long-term and informal care was rare. Substantial differences exist between MHDs, with depressive disorder tending towards lower average excess resource use and cost estimates, while excess resource use ranges between +6% to +320% and excess costs between +14% to +614%. PHCs are major drivers of resource use and costs for individuals with MHDs, affecting care segments differently. Significant physical health gains and cost savings are potentially achievable through prevention, earlier identification, management and treatment, using more integrated care approaches. Current international evidence, however, is heterogeneous with limited geographical representativeness and comparability.

Effects of add-on Celecoxib treatment on patients with schizophrenia spectrum disorders and inflammatory cytokine profile trial (TargetFlame): study design and methodology of a multicentre randomized, placebo-controlled trial.

Neuroinflammation has been proposed to impact symptomatology in patients with schizophrenia spectrum disorders. While previous studies have shown equivocal effects of treatments with add-on anti-inflammatory drugs such as Aspirin, N-acetylcysteine and Celecoxib, none have used a subset of prospectively recruited patients exhibiting an inflammatory profile. The aim of the study is to evaluate the efficacy and safety as well as the cost-effectiveness of a treatment with 400 mg Celecoxib added to an ongoing antipsychotic treatment in patients with schizophrenia spectrum disorders exhibiting an inflammatory profile. The "Add-on Celecoxib treatment in patients with schizophrenia spectrum disorders and inflammatory cytokine profile trial (TargetFlame)" is a multicentre randomized, placebo-controlled phase III investigator-initiated clinical trial with the following two arms: patients exhibiting an inflammatory profile receiving either add-on Celecoxib 400 mg/day or add-on placebo. A total of 199 patients will be assessed for eligibility by measuring blood levels of three pro-inflammatory cytokines, and 109 patients with an inflammatory profile, i.e. inflamed, will be randomized, treated for 8 weeks and followed-up for additional four months. The primary endpoint will be changes in symptom severity as assessed by total Positive and Negative Syndrome Scale (PANSS) score changes from baseline to week 8. Secondary endpoints include various other measures of psychopathology and safety. Additional health economic analyses will be performed. TargetFlame is the first study aimed at evaluating the efficacy, safety and cost-effectiveness of the antiphlogistic agent Celecoxib in a subset of patients with schizophrenia spectrum disorders exhibiting an inflammatory profile. With TargetFlame, we intended to investigate a novel precision medicine approach towards anti-inflammatory antipsychotic treatment augmentation using drug repurposing. Clinical trial registration: http://www.drks.de/DRKS00029044 and https://trialsearch.who.int/Trial2.aspx?TrialID=DRKS00029044.

A novel set of Austrian reference unit costs for comprehensive societal perspectives consistent with latest European costing methods for economic evaluations.

Decision making in public health often happens against the background of scarce resources. The systematic use of economic evaluations can be a main enabler in the alignment of public health goals with budgetary constraints. However, the lack of standardized methodology in terms of costing method and perspective are a critical barrier to the implementation of economic evaluations and the international comparability of results. We present a novel set of 22 reference unit costs (RUCs) optimized for cross-sectoral economic evaluations in Austria suitable for international comparability calculated using the standardized PECUNIA RUC Template. The common framework for costing and reporting, as well as the easy availability of the RUCs will reduce the burden on researchers and policy makers in future economic evaluations. The higher quality, accuracy, transparency and availability of economic evidence for policy design will help to improve the efficiency of public health-relevant healthcare decisions and make it easier for policy makers to bring funding arrangements and decision making across multiple sectors in line with Health-in-All-Policies goals.

Harmonization issues in unit costing of service use for multi-country, multi-sectoral health economic evaluations: a scoping review.

BACKGROUND: Valuation is a critical part of the costing process in health economic evaluations. However, an overview of specific issues relevant to the European context on harmonizing methodological requirements for the valuation of costs to be used in health economic evaluation is lacking. We aimed to inform the development of an international, harmonized and multi-sectoral costing framework, as sought in the European PECUNIA (ProgrammE in Costing, resource use measurement and outcome valuation for Use in multi-sectoral National and International health economic evaluAtions) project. METHODS: We conducted a scoping review (information extraction 2008-2021) to a) to demonstrate the degree of heterogeneity that currently exists in the literature regarding central terminology, b) to generate an overview of the most relevant areas for harmonization in multi-sectoral and multi-national costing processes for health economic evaluations, and c) to provide insights into country level variation regarding economic evaluation guidance. A complex search strategy was applied covering key publications on costing methods, glossaries, and international costing recommendations augmented by a targeted author and reference search as well as snowballing. Six European countries served as case studies to describe country-specific harmonization issues. Identified information was qualitatively synthesized and cross-checked using a newly developed, pilot-tested data extraction form. RESULTS: Costing methods for services were found to be heterogeneous between sectors and country guidelines and may, in practice, be often driven by data availability and reimbursement systems in place. The lack of detailed guidance regarding specific costing methods, recommended data sources, double-counting of costs between sectors, adjustment of unit costs for inflation, transparent handling of overhead costs as well as the unavailability of standardized unit costing estimates in most countries were identified as main drivers of country specific differences in costing methods with a major impact on valuation and cost-effectiveness evidence. CONCLUSION: This review provides a basic summary of existing costing practices for evaluative purposes across sectors and countries and highlights several common methodological factors influencing divergence in cost valuation methods that would need to be systematically incorporated and addressed in future costing practices to achieve more comparable, harmonized health economic evaluation evidence.

In Search for Comparability: The PECUNIA Reference Unit Costs for Health and Social Care Services in Europe.

Improving the efficiency of mental healthcare service delivery by learning from international best-practice examples requires valid data, including robust unit costs, which currently often lack cross-country comparability. The European ProgrammE in Costing, resource use measurement and outcome valuation for Use in multi-sectoral National and International health economic evaluAtions (PECUNIA) aimed to harmonize the international unit cost development. This article presents the methodology and set of 36 externally validated, standardized reference unit costs (RUCs) for five health and social care services (general practitioner, dentist, help-line, day-care center, nursing home) in Austria, England, Germany, Hungary, The Netherlands, and Spain based on unambiguous service definitions using the extended DESDE PECUNIA coding framework. The resulting PECUNIA RUCs are largely comparable across countries, with any causes for deviations (e.g., country-specific scope of services) transparently documented. Even under standardized methods, notable limitations due to data-driven divergences in key costing parameters remain. Increased cross-country comparability by adopting a uniform methodology and definitions can advance the quality of evidence-based policy guidance derived from health economic evaluations. The PECUNIA RUCs are available free of charge and aim to significantly improve the quality and feasibility of future economic evaluations and their transferability across mental health systems.

Establishing a comprehensive list of mental health-related services and resource use items in Austria: A national-level, cross-sectoral country report for the PECUNIA project.

BACKGROUND: A comprehensive, comparable assessment of the economic disease burden and the value of relevant care forms a major challenge in the case of mental diseases. This study aimed to inform the development of a resource use measurement (RUM) instrument and harmonized reference unit costs valid for multi-sectoral and multi-national cost assessments for mental health diseases as part of the European PECUNIA project. METHODS: An iterative, multi-methods approach was applied. Systematic literature reviews appended with national grey literature searches in six European countries were conducted to generate preliminary, literature-based, international, mental health-related service and resource use lists for all investigated sectors in 2018. As part of a multi-national expert survey, these lists were reviewed by 18 Austrian sector-specific experts regarding the clarity, relevance, comprehensiveness and availability in the Austrian context. RESULTS: Out of 295 items included in the preliminary, international, sector-specific lists (health and social care-201 items, criminal justice-35 items, education-39 items; patient, family and informal care-20 items), a total of 261 items and descriptions (88%) were considered clear by all experts. 42 items (14%) were considered not existing in Austria, and 111 items (38%) were prioritized regarding their relevance in the national context. Thirteen additional items (4%) were suggested to be added to accommodate for Austria-specific features of the individual sectors. Major typological difficulties based on item names were observed. CONCLUSIONS: The identified country-specific variations and general typological bias and their potential contributions to service and resource use cost variations across countries and sectors call for further systematic investigation. Next, PECUNIA will develop internationally harmonized and comparable definitions of the listed items and their units of analysis based on a new conceptual multi-sectoral costing framework. The developed lists will require consolidation and further prioritization for the development of a patient-reported RUM instrument and consequent reference unit cost valuation.

Unit Costs in Health Economic Evaluations: Quo Vadis, Austria?

Evidence-informed healthcare decision-making relies on high quality data inputs, including robust unit costs, which in many countries are not readily available. The objective of the Department of Health Economics' Unit Cost Online Database, developed based on systematic reviews of Austrian costing studies, is to make conducting economic evaluations from healthcare and societal perspectives more feasible with publicly available unit cost information in Austria. This article aims to describe trends in unit cost data sources and reporting using this comprehensive database as a case study to encourage relevant national and international methodological discussions. Database analysis and synthesis included publication/study characteristics and costing reporting details in line with the Consolidated Health Economic Evaluation Reporting Standards (CHEERS 2022) with the year of the database launch as the cut-off point to assess how the methods have developed over time. Forty-two full economic evaluations and 278 unit costs were analyzed (2004-2016: 34 studies/232 unit costs, 2017-2022: 8 studies/46 unit costs). Although the reporting quality of costing details including the study perspective, unit cost sources and years has improved since 2017, the unit cost estimates and sources remained heterogeneous in Austria. While methodologically standardized national-level unit costs would be the gold standard, a systematically collated list of unit costs is a first step towards supporting health economic evaluations nationally.

The most important facilitators and barriers to the use of Health Technology Assessment in Canada: a best-worst scaling approach.

BACKGROUND: Health Technology Assessment (HTA), which can support public drug reimbursement decisions will play a core function in the planned national Pharmacare program in Canada. To address existing barriers to the use of HTA, these must be ranked in order of priority. The goal of this study was to access the relative importance of known facilitators and barriers to the use of HTA in the context of the Canadian health care system, with attention to differences between regions and stakeholder groups. METHODS: We used the best-worst scaling object case approach to elicit a quantitative ranking of a list of 20 facilitators and 22 barriers. A sample of 68 Canadian HTA stakeholders, including members of expert committees, decision/policymakers, researchers/academics, and others participated in the study. Their task was to identify the most important and the least important item in 12 sub-sets of five facilitators and 14 sub-sets of five barriers. FINDINGS: Relative Importance Scores derived via hierarchical Bayes analysis revealed relations, engagement, and contact between stakeholders as most important on both the barrier and facilitator sides. Other top-ranked facilitators included the availably of credible and relevant research. Other top-ranked barriers included inconsistencies in the evidence and limited generalizability. The availability of HTA guidelines did not rank highly on either side. The main limitation of the study was the challenge with reaching the relevant respondents; this was mitigated by involving the national HTA agency in the research. CONCLUSION: Canadian stakeholders consider the relationships within the HTA network among the most important. Policies should focus on strengthening these relationships. Future research should focus on the connectivity and distribution of knowledge and power within the HTA network.

Cost and quality-of-life impacts of community treatment orders (CTOs) for patients with psychosis: economic evaluation of the OCTET trial.

PURPOSE: Current RCT and meta-analyses have not found any effect of community treatment orders (CTOs) on hospital or social outcomes. Assumed positive impacts of CTOs on quality-of-life outcomes and reduced hospital costs are potentially in conflict with patient autonomy. Therefore, an analysis of the cost and quality-of-life consequences of CTOs was conducted within the OCTET trial. METHODS: The economic evaluation was carried out comparing patients (n = 328) with psychosis discharged from involuntary hospitalisation either to treatment under a CTO (CTO group) or voluntary status via Section 17 leave (non-CTO group) from the health and social care and broader societal perspectives (including cost implication of informal family care and legal procedures). Differences in costs and outcomes defined as quality-adjusted life years (QALYs) based on the EQ-5D-3L or capability-weighted life years (CWLYs) based on the OxCAP-MH were assessed over 12 months (£, 2012/13 tariffs). RESULTS: Mean total costs from the health and social care perspective [CTO: £35,595 (SD: £44,886); non-CTO: £36,003 (SD: £41,406)] were not statistically significantly different in any of the analyses or cost categories. Mental health hospitalisation costs contributed to more than 85% of annual health and social care costs. Informal care costs were significantly higher in the CTO group, in which there were also significantly more manager hearings and tribunals. No difference in health-related quality of life or capability wellbeing was found between the groups. CONCLUSION: CTOs are unlikely to be cost-effective. No evidence supports the hypothesis that CTOs decrease hospitalisation costs or improve quality of life. Future decisions should consider impacts outside the healthcare sector such as higher informal care costs and legal procedure burden of CTOs.

[Exercise Behavior, Costs of Physical Inactivity, and Physical Activity Promotion in Austria]. / Bewegungsverhalten, Kosten mangelnder körperlicher Aktivität und Bewegungsförderung in Österreich.

In this article, we present the Austrian data on physical activity, the societal costs and outcomes of physical inactivity, and the areas of influence to promote physical activity. Based on an analysis of the status quo and its consequences, suggestions on relevant measures to counter physical inactivity are made. While the proportion of Austrians that do not fulfill the current recommendations on physical activity is high, the Austrian population is physically more active than many populations of other countries. In Austria, major differences in physical activity are associated with demographic, socio-economic, and geographic factors. The economic burden related to physical inactivity is considerable, with regard to both societal costs and outcomes. This includes major health and social care costs, productivity losses (estimated at around 248 million Euro in 2017 in Austria), and life years lost due to premature death. Evidence-based areas of influence to increase physical activity include kindergartens and schools, the workplace, communities, cities, long-term care facilities, and nature.

Are Unit Costs the Same? A Case Study Comparing Different Valuation Methods for Unit Cost Calculation of General Practitioner Consultations.

OBJECTIVES: To inform allocation decisions in any healthcare system, robust cost data are indispensable. Nevertheless, recommendations on the most appropriate valuation approaches vary or are nonexistent, and no internationally accepted gold standard exists. This costing analysis exercise aims to assess the impact and implications of different calculation methods and sources based on the unit cost of general practitioner (GP) consultations in Austria. METHODS: Six costing methods for unit cost calculation were explored, following 3 Austrian methodological approaches (AT-1, AT-2, AT-3) and 3 approaches applied in 3 other European countries (Germany, The Netherlands, United Kingdom). Drawing on Austrian data, mean unit costs per GP consultation were calculated in euros for 2015. RESULTS: Mean unit costs ranged from €15.6 to €42.6 based on the German top-down costing approach (DE) and the Austrian Physicians' Chamber's price recommendations (AT-3), respectively. The mean unit cost was estimated at €18.9 based on Austrian economic evaluations (AT-1) and €17.9 based on health insurance payment tariffs (AT-2). The Dutch top-down (NL) and the UK bottom-up approaches (UK) yielded higher estimates (NL: €25.3, UK: €29.8). Overall variation reached 173%. CONCLUSIONS: Our study is the first to systematically investigate the impact of differing calculation methods on unit cost estimates. It shows large variations with potential impact on the conclusions in an economic evaluation. Although different methodological choices may be justified by the adopted study perspective, different costing approaches introduce variation in cross-study/cross-country cost estimates, leading to decreased confidence in data quality in economic evaluations.

Photo-induced and Rapid Labeling of Tetrazine-Bearing Proteins via Cyclopropenone-Caged Bicyclononynes.

Inverse electron-demand Diels-Alder cycloadditions (iEDDAC) between tetrazines and strained alkenes/alkynes have emerged as essential tools for studying and manipulating biomolecules. A light-triggered version of iEDDAC (photo-iEDDAC) is presented that confers spatio-temporal control to bioorthogonal labeling in vitro and in cellulo. A cyclopropenone-caged dibenzoannulated bicyclo[6.1.0]nonyne probe (photo-DMBO) was designed that is unreactive towards tetrazines before light-activation, but engages in iEDDAC after irradiation at 365 nm. Aminoacyl tRNA synthetase/tRNA pairs were discovered for efficient site-specific incorporation of tetrazine-containing amino acids into proteins in living cells. In situ light activation of photo-DMBO conjugates allows labeling of tetrazine-modified proteins in living E. coli. This allows proteins in living cells to be modified in a spatio-temporally controlled manner and may be extended to photo-induced and site-specific protein labeling in animals.

Cost-of-illness studies in nine Central and Eastern European countries.

BACKGROUND: To date, a multi-country review evaluating the cost-of-illness (COI) studies from the Central and Eastern European (CEE) region has not yet been published. Our main objective was to provide a general description about published COI studies from CEE. METHODS: A systematic search was performed between 1 January 2006 and 1 June 2017 in Medline, EMBASE, The Cochrane Library, CINAHL, and Web of Science to identify all relevant COI studies from nine CEE countries. COI studies reporting costs without any restrictions by age, co-morbidities, or treatment were included. Methodology, publication standards, and cost results were analysed. RESULTS: We identified 58 studies providing 83 country-specific COI results: Austria (n = 9), Bulgaria (n = 16), Croatia (n = 3), the Czech Republic (n = 10), Hungary (n = 24), Poland (n = 11), Romania (n = 3), Slovakia (n = 3), and Slovenia (n = 4). Endocrine, nutritional, and metabolic diseases (18%), neoplasms (12%), infections (11%), and neurological disorders (11%) were the most frequently studied clinical areas, and multiple sclerosis was the most commonly studied disease. Overall, 57 (98%) of the studies explicitly stated the source of resource use data, 45 (78%) the study perspective, 34 (64%) the costing method, and 24 (58%) reported at least one unit costs. Regardless of methodological differences, a positive relationship was observed between costs of diseases and countries' per capita GDP. CONCLUSIONS: Cost-of-illness studies varied considerably in terms of methodology, publication practice, and clinical areas. Due to these heterogeneities, transferability of the COI results is limited across Central and Eastern European countries.

Expanding the genetic code with a lysine derivative bearing an enzymatically removable phenylacetyl group.

We report the genetically encoded incorporation of phenylacetyl protected lysine (PacK) into proteins in Escherichia coli. This unnatural side-chain modification can be enzymatically removed using either penicillin G acylase (PGA) or, surprisingly, the sirtuin SrtN from Bacillus subtilis. Our approach expands the toolbox to reversibly control protein structure and function under very mild and non-denaturing conditions, as demonstrated by triggering the activity of the nonribosomal peptide synthetase GrsA.

The societal costs of chronic pain and its determinants: The case of Austria.

BACKGROUND: Chronic pain is among the most burdensome conditions. Its prevalence ranges between 12% and 30% in Europe, with an estimated 21% among Austrian adults. The economic impact of chronic pain from a societal perspective, however, has not been sufficiently researched. This study aims to provide an estimate of the societal costs for working-age adults with chronic pain in Austria. It explores the impact of sex, number of pain sites, self-reported pain severity, health literacy and private health insurance on costs associated with chronic pain. METHODS: A bottom-up cost-of-illness study was conducted based on data collected from 54 adult patients with chronic pain at three Viennese hospital outpatient departments. Information on healthcare costs including out-of-pocket expenses and productivity losses due to absenteeism and informal care were collected over 12 months. Resource use estimates were combined with unit costs and mean costs per patient were calculated in € for year 2016. RESULTS: Mean annual societal costs were estimated at EUR 10191. Direct medical costs were EUR 5725 including EUR 1799 out-of-pocket expenses (mainly pain relieving activities and private therapy). Productivity losses including informal care amounted to EUR 4466. Total costs for women and patients with three or more pain sites were significantly higher. No association with health literacy was found but there was a tendency towards higher out-of-pocket expenses for patients with complementary private health insurance. CONCLUSION: This study is the first to provide a comprehensive assessment of the individual and societal burden of chronic pain in Austria. It highlights that chronic pain is associated with substantial direct medical costs and productivity losses. Patient costs may show systematic differences by health insurance status, implying a need for future research in this area.

Comparison of statistical analysis methods for object case best-worst scaling.

Aims: Different methods have been used to analyze "object case" best-worst scaling (BWS). This study aims to compare the most common statistical analysis methods for object case BWS (i.e. the count analysis, multinomial logit, mixed logit, latent class analysis, and hierarchical Bayes estimation) and to analyze their potential advantages and limitations based on an applied example. Methods: Data were analyzed using the five analysis methods. Ranking results were compared among the methods, and methods that take respondent heterogeneity into account were presented specifically. A BWS object case survey with 22 factors was used as a case study, tested among 136 policy-makers and HTA experts from the Netherlands, Germany, France, and the UK to assess the most important barriers to HTA usage. Results: Overall, the five statistical methods yielded similar rankings, particularly in the extreme ends. Latent class analysis identified five clusters and the mixed logit model revealed significant preference heterogeneity for all, with the exception of three factors. Limitations: The variety of software used to analyze BWS data may affect the results. Moreover, this study focuses solely on the comparison of different analysis methods for the BWS object case. Conclusions: The most common statistical methods provide similar rankings of the factors. Therefore, for main preference elicitation, count analysis may be considered as a valid and simple first-choice approach. However, the latent class and mixed logit models reveal additional information: identifying latent segments and/or recognizing respondent heterogeneity.