Costs attributable to hypercholesterolemia in a single period and over the life cycle.

Hypercholesterolemia is a major risk factor for atherosclerotic cardiovascular disease leading to reduced (healthy) life years. The aim of this study is to quantify the societal costs associated with hypercholesterolemia. We use epidemiologic data on the distribution of cholesterol levels as well as data on relative risks regarding ischemic heart disease, stroke, and other cardiovascular diseases. The analytical approach is based on the use of population-attributable fractions applied to direct medical, direct non-medical and indirect costs using data of Austria. Within a life-cycle analysis we sum up the costs of hypercholesterolemia for the population of 2019 and, thus, consider future morbidity and mortality effects on this population. Epidemiologic data suggest that approximately half of Austria's population have low-density lipoprotein cholesterol (LDL-C) levels above the target levels (i.e., are exposed to increased risk). We estimate that 8.2% of deaths are attributable to hypercholesterolemia. Total costs amount to about 0.33% of GDP in the single-period view. In the life-cycle perspective, total costs amount to €806.06 million, €312.1 million of which are medical costs, and about €494 million arise due to production loss associated with hypercholesterolemia. The study points out that significant shares of deaths, entries into disability pension and care allowance, full-time equivalents lost to the labor market as well as monetary costs for the health system and the society could be avoided if LDL-C-levels of the population were reduced.

Policy implications of heterogeneous demand reactions to changes in cost-sharing: Patient-level evidence from Austria.

Cost-sharing is a prominent tool in many healthcare systems, both for raising revenue and steering patient behaviour. Although the effect of cost-sharing on demand for healthcare services has been heavily studied in the literature, researchers often apply a macro-perspective to these issues, opening the door for policy makers to the fallacy of assuming uniform demand reactions across a spectrum of different forms of treatments and diagnostic procedures. We use a simple classification system to categorize 11 such healthcare services along the dimensions of urgency and price to estimate patients' (anticipatory) demand reactions to a reduction in the co-insurance rate by a sickness fund in the Austrian social health insurance system. We use a two-stage study design combining matching and two-way fixed effects difference-in-differences estimation. Our results highlight how an overall joint estimate of an average increase in healthcare service utilization (0.8%) across all healthcare services can be driven by healthcare services that are deferrable (+1%), comparatively costly (+1.4%) or both (+1.6%) and for which patients also postponed their consumption until after the cost-sharing reduction. In contrast, we do not find a clear demand reaction for inexpensive or urgent services. The detailed analysis of the demand reaction for each individual healthcare service further illustrates their heterogeneity. We show that even comparatively minor changes to the costs borne by patients may already evoke tangible (anticipatory) demand reactions. Our findings help policy makers better understand the implications of heterogeneous demand reactions across healthcare services for using cost-sharing as a policy tool.

Divergent COVID-19 vaccine policies: Policy mapping of ten European countries.

BACKGROUND: The COVID-19 pandemic highlighted the fragmented nature of governmental policy decisions in Europe. However, the extent to which COVID-19 vaccination policies differed between European countries remains unclear. Here, we mapped the COVID-19 vaccination policies that were in effect in January 2022 as well as booster regulations in April 2022 in Austria, Denmark, England, France, Germany, Ireland, Italy, the Netherlands, Poland, and Spain. METHODS: National public health and health policy experts from these ten European nations developed and completed an electronic questionnaire. The questionnaire included a series of questions that addressed six critical components of vaccine implementation, including (1) authorization, (2) prioritization, (3) procurement and distribution, (4) data collection, (5) administration, and (6) mandate requirements. RESULTS: Our findings revealed significant variations in COVID-19 vaccination policies across Europe. We observed critical differences in COVID-19 vaccine formulations authorized for use, as well as the specific groups that were provided with priority access. We also identified discrepancies in how vaccination-related data were recorded in each country and what vaccination requirements were implemented. CONCLUSION: Each of the ten European nations surveyed in this study reported different COVID-19 vaccination policies. These differences complicated efforts to provide a coordinated pandemic response. These findings might alert policymakers in Europe of the need to coordinate their efforts to avoid fostering divergent and socially disruptive policies.

Exploring the effectiveness of demand-side retail pharmaceutical expenditure reforms : Cross-country evidence from weighted-average least squares estimation.

Increasing expenditures on retail pharmaceuticals bring a critical challenge to the financial stability of healthcare systems worldwide. Policy makers have reacted by introducing a range of measures to control the growth of public pharmaceutical expenditure (PPE). Using panel data on European and non-European OECD member countries from 1990 to 2015, we evaluate the effectiveness of six types of demand-side expenditure control measures including physician-level behaviour measures, system-level price-control measures and substitution measures, alongside a proxy for cost-sharing and add a new dimension to the existing empirical evidence hitherto based on national-level and meta-studies. We use the weighted-average least squares regression framework adapted for estimation with panel-corrected standard errors. Our empirical analysis suggests that direct patient cost-sharing and some-but not all-demand-side measures successfully dampened PPE growth in the past. Cost-sharing schemes stand out as a powerful mechanism to curb PPE growth, but bear a high risk of adverse effects. Other demand-side measures are more limited in effect, though may be more equitable. Due to limitations inherent in the study approach and the data, the results are only explorative.

Risk assessment of COVID-19 epidemic resurgence in relation to SARS-CoV-2 variants and vaccination passes.

The introduction of COVID-19 vaccination passes (VPs) by many countries coincided with the Delta variant fast becoming dominant across Europe. A thorough assessment of their impact on epidemic dynamics is still lacking. Here, we propose the VAP-SIRS model that considers possibly lower restrictions for the VP holders than for the rest of the population, imperfect vaccination effectiveness against infection, rates of (re-)vaccination and waning immunity, fraction of never-vaccinated, and the increased transmissibility of the Delta variant. Some predicted epidemic scenarios for realistic parameter values yield new COVID-19 infection waves within two years, and high daily case numbers in the endemic state, even without introducing VPs and granting more freedom to their holders. Still, suitable adaptive policies can avoid unfavorable outcomes. While VP holders could initially be allowed more freedom, the lack of full vaccine effectiveness and increased transmissibility will require accelerated (re-)vaccination, wide-spread immunity surveillance, and/or minimal long-term common restrictions.

When to end a lock down? How fast must vaccination campaigns proceed in order to keep health costs in check?

We propose a simple rule of thumb for countries which have embarked on a vaccination campaign while still facing the need to keep non-pharmaceutical interventions (NPI) in place because of the ongoing spread of SARS-CoV-2. If the aim is to keep the death rate from increasing, NPIs can be loosened when it is possible to vaccinate more than twice the growth rate of new cases. If the aim is to keep the pressure on hospitals under control, the vaccination rate has to be about four times higher. These simple rules can be derived from the observation that the risk of death or a severe course requiring hospitalization from a COVID-19 infection increases exponentially with age and that the sizes of age cohorts decrease linearly at the top of the population pyramid. Protecting the over 60-year-olds, which constitute approximately one-quarter of the population in Europe (and most OECD countries), reduces the potential loss of life by 95 percent.

The benefits, costs and feasibility of a low incidence COVID-19 strategy.

In the summer of 2021, European governments removed most NPIs after experiencing prolonged second and third waves of the COVID-19 pandemic. Most countries failed to achieve immunization rates high enough to avoid resurgence of the virus. Public health strategies for autumn and winter 2021 have ranged from countries aiming at low incidence by re-introducing NPIs to accepting high incidence levels. However, such high incidence strategies almost certainly lead to the very consequences that they seek to avoid: restrictions that harm people and economies. At high incidence, the important pandemic containment measure 'test-trace-isolate-support' becomes inefficient. At that point, the spread of SARS-CoV-2 and its numerous harmful consequences can likely only be controlled through restrictions. We argue that all European countries need to pursue a low incidence strategy in a coordinated manner. Such an endeavour can only be successful if it is built on open communication and trust.

Regional medical practice variation in high-cost healthcare services : Evidence from diagnostic imaging in Austria.

Magnetic resonance imaging (MRI) is a popular yet cost-intensive diagnostic measure whose strengths compared to other medical imaging technologies have led to increased application. But the benefits of aggressive testing are doubtful. The comparatively high MRI usage in Austria in combination with substantial regional variation has hence become a concern for its policy makers. We use a set of routine healthcare data on outpatient MRI service consumption of Austrian patients between Q3-2015 and Q2-2016 on the district level to investigate the extent of medical practice variation in a two-step statistical analysis combining multivariate regression models and Blinder-Oaxaca decomposition. District-level MRI exam rates per 1.000 inhabitants range from 52.38 to 128.69. Controlling for a set of regional characteristics in a multivariate regression model, we identify payer autonomy in regulating access to MRI scans as the biggest contributor to regional variation. Nevertheless, the statistical decomposition highlights that more than 70% of the regional variation remains unexplained by differences between the observable district characteristics. In the absence of epidemiological explanations, the substantial regional medical practice variation calls the efficiency of resource deployment into question.

The patient at the centre: evidence from 17 European integrated care programmes for persons with complex needs.

BACKGROUND: As the prevalence of multi-morbidity increases in ageing societies, health and social care systems face the challenge of providing adequate care to persons with complex needs. Approaches that integrate care across sectors and disciplines have been increasingly developed and implemented in European countries in order to tackle this challenge. The aim of the article is to identify success factors and crucial elements in the process of integrated care delivery for persons with complex needs as seen from the practical perspective of the involved stakeholders (patients, professionals, informal caregivers, managers, initiators, payers). METHODS: Seventeen integrated care programmes for persons with complex needs in 8 European countries were investigated using a qualitative approach, namely thick description, based on semi-structured interviews and document analysis. In total, 233 face-to-face interviews were conducted with stakeholders of the programmes between March and September 2016. Meta-analysis of the individual thick description reports was performed with a focus on the process of care delivery. RESULTS: Four categories that emerged from the overarching analysis are discussed in the article: (1) a holistic view of the patient, considering both mental health and the social situation in addition to physical health, (2) continuity of care in the form of single contact points, alignment of services and good relationships between patients and professionals, (3) relationships between professionals built on trust and facilitated by continuous communication, and (4) patient involvement in goal-setting and decision-making, allowing patients to adapt to reorganised service delivery. CONCLUSIONS: We were able to identify several key aspects for a well-functioning integrated care process for complex patients and how these are put into actual practice. The article sets itself apart from the existing literature by specifically focussing on the growing share of the population with complex care needs and by providing an analysis of actual processes and interpersonal relationships that shape integrated care in practice, incorporating evidence from a variety of programmes in several countries.

Determinants of soft budget constraints: How public debt affects hospital performance in Austria.

Soft budget constraints (SBCs) undermine reforms to increase hospital service efficiency when hospital management can count on being bailed out by (subnational) governments in case of deficits. Using cost accounting data on publicly financed, non-profit hospitals in Austria from 2002 to 2015, we analyse the association between SBCs and hospital efficiency change in a setting with negligible risk of hospital closure in a two-stage study design based on bias-corrected non-radial input-oriented data envelopment analysis and ordinary least squares regression. We find that the European debt crisis altered the pattern of hospital efficiency development: after the economic crisis, hospitals in low-debt states had a 1.1 percentage point lower annual efficiency change compared to hospitals in high-debt states. No such systematic difference is found before the economic crisis. The results suggest that sudden exogenous shocks to public finances can increase the budgetary pressure on publicly financed institutions, thereby counteracting a pre-existing SBC.

Budget Impact Analysis of Dalbavancin in the Treatment of Acute Bacterial Skin and Skin Structure Infections in Three European Countries.

BACKGROUND AND OBJECTIVE: Acute bacterial skin and skin structure infections (ABSSSIs) have been defined by the US Food and Drug Administration (FDA) in 2013 to include a subset of complicated skin and skin structure infections commonly treated with parenteral antibiotic therapy. Inpatient treatment of ABSSSIs involves a significant economic burden on the healthcare system. This study aimed to evaluate the economic impact on the National Health System associated with the management of non-severe ABSSSIs treated in hospitals with innovative long-acting dalbavancin compared to standard antibiotic therapy in Italy, Spain, and Austria. METHODS: A budget impact analysis was developed to evaluate the direct costs associated with the management of ABSSSI from the national public health system perspective. The model considered the possibility of early discharge of patients directly from the Emergency Department (ED), after 1 night in the hospital, or after two or three nights in the hospital. A scenario with Standard of Care was compared with a dalbavancin scenario, where patients had the possibility of being discharged early. The epidemiological and cost parameters were extrapolated from national administrative databases and from a systematic literature review for each country. The analysis was conducted in a 3-year time horizon. A one-way deterministic sensitivity analysis was conducted to examine the robustness of the results. RESULTS: The model estimated an average annual number of patients with non-severe ABSSSI in Italy, Spain, and Austria equal to 5396, 7884, and 1788, respectively. A total annual expenditure of about €9.9 million, €13.5 million, and €3.4 million was estimated for treating the full set of ABSSSI patients in Italy, Spain, and Austria, respectively. Dalbavancin reduced the in-hospital length of stay in each country. In the first year of its introduction, dalbavancin significantly reduced the total economic burden in Italy and Spain (- €352,252 and - €233,991, respectively), while it increased the total economic burden in Austria (€80,769, 0.7% of the total expenditure for these patients); in the third year of its introduction, dalbavancin reduced the total economic burden in each Country (- €1.1 million, - €810,650, and - €70,269, respectively). CONCLUSIONS: The introduction of dalbavancin in a new patient pathway to treat non-severe ABSSSI could generate a significant reduction in hospitalized patients and the overall patient length of stay in hospital.

Strengthening the evidence-base of integrated care for people with multi-morbidity in Europe using Multi-Criteria Decision Analysis (MCDA).

BACKGROUND: Evaluation of integrated care programmes for individuals with multi-morbidity requires a broader evaluation framework and a broader definition of added value than is common in cost-utility analysis. This is possible through the use of Multi-Criteria Decision Analysis (MCDA). METHODS AND RESULTS: This paper presents the seven steps of an MCDA to evaluate 17 different integrated care programmes for individuals with multi-morbidity in 8 European countries participating in the 4-year, EU-funded SELFIE project. In step one, qualitative research was undertaken to better understand the decision-context of these programmes. The programmes faced decisions related to their sustainability in terms of reimbursement, continuation, extension, and/or wider implementation. In step two, a uniform set of decision criteria was defined in terms of outcomes measured across the 17 programmes: physical functioning, psychological well-being, social relationships and participation, enjoyment of life, resilience, person-centeredness, continuity of care, and total health and social care costs. These were supplemented by programme-type specific outcomes. Step three presents the quasi-experimental studies designed to measure the performance of the programmes on the decision criteria. Step four gives details of the methods (Discrete Choice Experiment, Swing Weighting) to determine the relative importance of the decision criteria among five stakeholder groups per country. An example in step five illustrates the value-based method of MCDA by which the performance of the programmes on each decision criterion is combined with the weight of the respective criterion to derive an overall value score. Step six describes how we deal with uncertainty and introduces the Conditional Multi-Attribute Acceptability Curve. Step seven addresses the interpretation of results in stakeholder workshops. DISCUSSION: By discussing our solutions to the challenges involved in creating a uniform MCDA approach for the evaluation of different programmes, this paper provides guidance to future evaluations and stimulates debate on how to evaluate integrated care for multi-morbidity.

Can people afford to pay for health care? New evidence on financial protection in Austria

The incidence of catastrophic health spending is lower in Austria than in many countries in Europe, but higher than in countries such as France, Slovenia, Sweden and the United Kingdom. The main gap in health coverage comes from user charges (co-payments), which are applied to most health services and can be high for some groups of people. Importantly, the type and level of co-payment often vary significantly across social insurance schemes and funds, exacerbating inequality in access to health care. Co-payments for outpatient medicines, however, are uniform across the country, and made more affordable by an income-related cap set at 2% of household income. To improve financial protection in Austria, policy attention should focus on ensuring that low-income households are systematically exempt from all co-payments, and on extending the income-related cap to co-payments for all health services. Some of this could be financed by better use of public resources and redistribution across social insurance schemes through a risk-equalization mechanism.This review is part of a series of country-based studies generating newevidence on financial protection in European health systems.

Explaining differences in stakeholder take up of disease management programmes: A comparative analysis of policy implementation in Austria and Germany.

PURPOSE: Understanding why policies to improve care for people with chronic conditions fail to be implemented is a pressing issue in health system reform. We explore reasons for the relatively high uptake of disease management programmes (DMPs) in Germany, in contrast to low uptake in Austria. We focus on the motivation, information and power of key stakeholder groups (payers, physician associations, individual physicians and patients). METHODS: We conducted a comparative stakeholder analysis using qualitative data from interviews (n=15 in Austria and n=26 in Germany), legal documents and media reports. RESULTS: Stakeholders in Germany appeared to have systematically stronger motivation, exposure to more positive information about DMPs and better ability to implement DMPs than their counterparts in Austria. Policy in Austria focused on financial incentives to physicians only. In Germany, limited evidence about the quality improvement and cost savings potential of DMPs was mitigated by strong financial incentives to sickness funds but proved a fundamental obstacle in Austria. CONCLUSIONS: Efforts to promote DMPs should seek to ensure the cooperation of payers and patients, not just physicians, using a mix of financial and non-financial instruments suited to the context. A singular focus on financially incentivising providers is unlikely to stimulate uptake of DMPs.

A gap analysis for future supply of and demand for psychiatrists in Austria.

BACKGROUND: In the recent past, a rising caseload demonstrates increasing demand for psychiatrists, and ageing of the current mental health workforce will soon result in growing numbers of retirees. Under these conditions there is some concern whether we soon will face widening gaps in supply. AIMS OF THE STUDY: This study calculates projections of future use and supply of psychiatrists' services in Austria until 2030. Resulting gaps are calculated for different scenarios. DATA AND METHODS: We mostly use administrative data from several public authorities. To estimate the demand for services, we start from utilization data rather than medical need for services, as we do not have sufficient epidemiological information for Austria. We define several scenarios for the future development of use, all calculated separately for hospital and non-hospital services. Future supply of psychiatric services is projected by applying activity levels to projected numbers of physicians, which are calculated using a stock and flow model. Outflows are modeled using assumptions derived from past activity patterns and current legislation on retirement. To model inflows, we need to gauge the impact of recent developments: Entrance barriers into medical education were introduced, Austria experienced a surge of medical students coming from Germany, and medical schools implemented quotas for different nationalities. Scenarios take several factors into account, like the shifting sex composition of the medical workforce, re-migration of foreign students, and the impact of entrance barriers on enrolment and drop-out rates. RESULTS: Depending on scenario assumptions, demand for psychiatrists will increase by 8% to 52%. But in all supply scenarios, supply will decline from 2016 onwards, thus widening gaps between supply and demand. Even in the most optimistic scenario, supply will have fallen below current levels by 2030. DISCUSSION: Compared to current rates of service use, a gap between supply and demand will start to widen soon. In the most optimistic combination of scenarios, demand will exceed supply from 2028 onwards, and the projected gap will amount to about 5% of projected demand for services in 2030. LIMITATIONS: Gaps could be miscalculated due to lack of more detailed data, such as retirement patterns of psychiatrists. Shifting responsibilities between psychiatrists and other (mental) health workers as well as changes in psychiatrists' "productivity", e.g. due to more effective medications, were not modeled but would affect results. IMPLICATIONS FOR HEALTH POLICIES: It will be necessary to improve working and training conditions in order to avoid emigration and to attract a sufficient number of young entrants into the profession.

Efficiency, ownership, and financing of hospitals: the case of Austria.

While standard economic theory posits that privately owned hospitals are more efficient than their public counterparts, no clear conclusion can yet be drawn for Austria in this regard. As previous Austrian efficiency studies rely on data from the 1990s only and are based on small hospital samples, the generalizability of these results is questionable. To examine the impact of ownership type on efficiency, we apply a Data Envelopment Analysis which extends the existing literature in two respects: first, it evaluates the efficiency of the Austrian acute care sector, using data on 128 public and private non-profit hospitals from the year 2010; second, it additionally focusses on the inpatient sector alone, thus increasing the comparability between hospitals. Overall, the results show that in Austria, private non-profit hospitals outperform public hospitals in terms of technical efficiency. A multiple regression analysis confirms the significant association between efficiency and ownership type. This conclusive result contrasts some international evidence and can most likely be attributed to differences in financial incentives for public and private non-profit hospitals in Austria. Therefore, by drawing on the example of the Austrian acute care hospital sector and existing literature on the German acute care hospital sector, we also discuss the impact of hospital financing systems and their incentives on efficiency. This paper thus also aims at providing a proof of principle, pointing out the importance of the respective market conditions when internationally comparing hospital efficiency by ownership type.