Susanne Mayer

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.

Socioeconomic determinants of prescribed and non-prescribed medicine consumption in Austria.

BACKGROUND Equitable access to health care is a goal subscribed to in many European economies. But while a growing body of literature studies socioeconomic inequalities in health service use, relatively little is still known about inequalities in medicine consumption. Against this background, this study investigates the (socioeconomic) determinants of medicine use in the Austrian context. METHODS Multivariate logistic regressions were estimated based on the European Health Interview Survey, including representative information of the Austrian population above age 25 (n = 13 291) for 2006/2007. As dependent variables, we used prescribed and non-prescribed medicine consumption as well as prescribed polypharmacy. Socioeconomic status was operationalized by employment status, education and net equivalent income. Health indicators (self-assessed health, chronic conditions), demographic characteristics (age, sex) and outpatient visits were included as control variables. RESULTS Socioeconomic status revealed opposing utilization patterns: while individuals with higher education and income were more likely to consume non-prescribed medicines, the less educated were more likely to take prescribed medicines. Lower socioeconomic groups also showed a higher likelihood for prescribed polypharmacy. For the consumption of both medicine types, the main socioeconomic determinant was high income. In an additional analysis, lower socioeconomic groups were found to more likely report prescription purposes as the main reason for consulting a practitioner. CONCLUSION These results point to different behavioural responses to ill health, not least determined by institutional incentives in the Austrian health care system.

Economic Evaluation of Obesity Prevention in Early Childhood: Methods, Limitations and Recommendations

Despite methodological advances in the field of economic evaluations of interventions, economic evaluations of obesity prevention programmes in early childhood are seldom conducted. The aim of the present study was to explore existing methods and applications of economic evaluations, examining their limitations and making recommendations for future cost-effectiveness assessments. A systematic literature search was conducted using PubMed, Cochrane Library, the British National Health Service Economic Evaluation Databases and EconLit. Eligible studies included trial-based or simulation-based cost-effectiveness analyses of obesity prevention programmes targeting preschool children and/or their parents. The quality of included studies was assessed. Of the six studies included, five were intervention studies and one was based on a simulation approach conducted on secondary data. We identified three main conceptual and methodological limitations of their economic evaluations: Insufficient conceptual approach considering the complexity of childhood obesity, inadequate measurement of effects of interventions, and lack of valid instruments to measure child-related quality of life and costs. Despite the need for economic evaluations of obesity prevention programmes in early childhood, only a few studies of varying quality have been conducted. Moreover, due to methodological and conceptual weaknesses, they offer only limited information for policy makers and intervention providers. We elaborate reasons for the limitations of these studies and offer guidance for designing better economic evaluations of early obesity prevention.

Caring for informal caregivers: policy approaches to the provision of direct support services

Despite being the backbone of modern welfare states, the informal care sector for elderly people in need of long-term care is highly dysfunctional. The majority of informal caregivers are overburdened on account of their care-related activities, although an evolving market for support services directly aimed at relieving informal caregivers is observable. In this paper, we examine the reasons for the imperfect exchange between demand and supply in this market, applying the economic theory of market failure. Through a case study of Austria based on an empirical, qualitative survey of all direct support services and their suppliers on the national level as well as in three provinces, an understanding of this markets main players and mechanisms is derived. Thus, the authors determine that three different system types can be identified beyond the historical regional discrepancies. They illustrate the approaches to service provision for informal caregivers: centralized and public, laissez-faire and private, and a radically decentralized network for informal caregivers. Still, lack of information, social and psychological barriers, as well as high transaction costs, are identified which undermine the support service market for informal care. If the costs of the formal long-term care sector are to be contained despite demographic developments, better policy approaches will be necessary to overcome this challenge. In light of this, recommendations are derived to ensure a better exchange between supply and demand. By providing an initial empirical understanding and analysis of this market and its imperfections, the authors pioneer future quantitative research in this field.

Costing evidence for health care decision-making in Austria: A systematic review

Background With rising healthcare costs comes an increasing demand for evidence-informed resource allocation using economic evaluations worldwide. Furthermore, standardization of costing and reporting methods both at international and national levels are imperative to make economic evaluations a valid tool for decision-making. The aim of this review is to assess the availability and consistency of costing evidence that could be used for decision-making in Austria. It describes systematically the current economic evaluation and costing studies landscape focusing on the applied costing methods and their reporting standards. Findings are discussed in terms of their likely impacts on evidence-based decision-making and potential suggestions for areas of development. Methods A systematic literature review of English and German language peer-reviewed as well as grey literature (2004–2015) was conducted to identify Austrian economic analyses. The databases MEDLINE, EMBASE, SSCI, EconLit, NHS EED and Scopus were searched. Publication and study characteristics, costing methods, reporting standards and valuation sources were systematically synthesised and assessed. Results A total of 93 studies were included. 87% were journal articles, 13% were reports. 41% of all studies were full economic evaluations, mostly cost-effectiveness analyses. Based on relevant standards the most commonly observed limitations were that 60% of the studies did not clearly state an analytical perspective, 25% of the studies did not provide the year of costing, 27% did not comprehensively list all valuation sources, and 38% did not report all applied unit costs. Conclusion There are substantial inconsistencies in the costing methods and reporting standards in economic analyses in Austria, which may contribute to a low acceptance and lack of interest in economic evaluation-informed decision making. To improve comparability and quality of future studies, national costing guidelines should be updated with more specific methodological guidance and a national reference cost library should be set up to allow harmonisation of valuation methods.

Inequalities in medicine use in Central Eastern Europe: an empirical investigation of socioeconomic determinants in eight countries

BackgroundEquitable access to essential medicines is a major challenge for policy-makers world-wide, including Central and Eastern European countries. Member States of the European Union situated in Central and Eastern Europe have publicly funded pharmaceutical reimbursement systems that should promote accessibility and affordability of, at least essential medicines. However, there is no knowledge whether socioeconomic inequalities exist in these countries. Against this backdrop, this study analyses whether socioeconomic determinants influence the use of prescribed and non-prescribed medicines in eight Central and Eastern European countries (Bulgaria, Czech Republic, Hungary, Latvia, Poland, Romania, Slovenia, Slovakia). Further, the study discusses observed (in)equalities in medicine use in the context of the pharmaceutical policy framework and the implementation in these countries.MethodsThe study is based on cross-sectional data from the first wave of the European Health Interview Survey (2007–2009). Multivariate logistic regression analyses were carried out to determine the association between socioeconomic status (measured by employment status, education, income; controlled for age, gender, health status) and medicine use (prescribed and non-prescribed medicines). This was supplemented by a pharmaceutical policy analysis based on indicators in four policy dimensions (sustainable funding, affordability, availability and accessibility, and rational selection and use of medicines).ResultsOverall, the analysis showed a gradient favouring individuals from higher socioeconomic groups in the consumption of non-prescribed medicines in the eight surveyed countries, and for prescribed medicines in three countries (Latvia, Poland, Romania). The pharmaceutical systems in the eight countries were, to varying degrees, characterized by a lack of (public) funding, thus resulting in high and growing shares of private financing (including co-payments for prescribed medicines), inefficiencies in the selection of medicines into reimbursement and limitations in medicines availability.ConclusionPharmaceutical policies aiming at reducing inequalities in medicine use require not only a consideration of the role of co-payments and other private expenditure but also adequate investment in medicines and transparent and clear processes regarding the inclusion of medicines into reimbursement.

Most important barriers and facilitators of HTA usage in decision-making in Europe

ABSTRACT Background: To enhance usage of health technology assessment (HTA) in decision-making, it is important to prioritise important barriers and facilitators to the uptake of HTA. This study aims to quantify and compare the relative importance of barriers and facilitators regarding the use of HTA in several European countries. Methods: A survey containing two best-worst scaling (BWS) object case studies (i.e. barriers and facilitators) were conducted among 136 policy makers and HTA researchers from the Netherlands, Germany, France, and United Kingdom. Hierarchical Bayes analysis generated the mean relative importance score (RIS) for each factor and subgroup analyses assessed differences between countries. Results: Six barriers (RIS≥5) and five facilitators (RIS≥6) were deemed highly important. Eleven barriers and ten facilitators differed in their importance between countries. Policy characteristics, research & researcher characteristics, and organisation & resources were particularly important to facilitate uptake of HTA, such as an explicit framework for decision-making and research of sufficient quality. Conclusion: The most paramount barriers and facilitators to HTA usage were quantified. For all countries it is crucial to create an explicit framework for the decision-making context to include HTA evidence. Country differences in the quality of research emphasize the need for enhanced international collaboration in HTA.

Best-worst scaling to assess the most important barriers and facilitators for the use of health technology assessment in Austria

ABSTRACT Background: Although Health Technology Assessment (HTA) is increasingly used to support evidence-based decision-making in health care, several barriers and facilitators for the use of HTA have been identified. This best-worst scaling (BWS) study aims to assess the relative importance of selected barriers and facilitators of the uptake of HTA studies in Austria. Methods: A BWS object case survey was conducted among 37 experts in Austria to assess the relative importance of HTA barriers and facilitators. Hierarchical Bayes estimation was applied, with the best-worst count analysis as sensitivity analysis. Subgroup analyses were also performed on professional role and HTA experience. Results: The most important barriers were ‘lack of transparency in the decision-making process’, ‘fragmentation’, ‘absence of appropriate incentives’, ‘no explicit framework for decision-making process’, and ‘insufficient legal support’. The most important facilitators were ‘transparency in the decision-making process’, ‘availability of relevant HTA research for policy makers’, ‘availability of explicit framework for decision-making process’, ‘sufficient legal support’, and ‘appropriate incentives’. Conclusion: This study suggests that HTA barriers and facilitators related to the context of decision makers, especially ‘policy characteristics’ and ‘organization and resources’ are the most important in Austria. A transparent and participatory decision-making process could improve the adoption of HTA evidence.

Health-Related Resource-Use Measurement Instruments for Intersectoral Costs and Benefits in the Education and Criminal Justice Sectors

BackgroundIntersectoral costs and benefits (ICBs), i.e. costs and benefits of healthcare interventions outside the healthcare sector, can be a crucial component in economic evaluations from the societal perspective. Pivotal to their estimation is the existence of sound resource-use measurement (RUM) instruments; however, RUM instruments for ICBs in the education or criminal justice sectors have not yet been systematically collated or their psychometric quality assessed. This review aims to fill this gap.MethodsTo identify relevant instruments, the Database of Instruments for Resource Use Measurement (DIRUM) was searched. Additionally, a systematic literature review was conducted in seven electronic databases to detect instruments containing ICB items used in economic evaluations. Finally, studies evaluating the psychometric quality of these instruments were searched.ResultsTwenty-six unique instruments were included. Most frequently, ICB items measured school absenteeism, tutoring, classroom assistance or contacts with legal representatives, police custody/prison detainment and court appearances, with the highest number of items listed in the Client Service Receipt Inventory/Client Sociodemographic and Service Receipt Inventory/Client Service Receipt Inventory–Children’s Version (CSRI/CSSRI/CSRI-C), Studying the Scope of Parental Expenditures (SCOPE) and Self-Harm Intervention, Family Therapy (SHIFT) instruments. ICBs in the education sector were especially relevant for age-related developmental disorders and chronic diseases, while criminal justice resource use seems more important in mental health, including alcohol-related disorders or substance abuse. Evidence on the validity or reliability of ICB items was published for two instruments only.ConclusionWith a heterogeneous variety of ICBs found to be relevant for several disease areas but many ICB instruments applied in one study only (21/26 instruments), setting-up an international task force to, for example, develop an internationally adaptable instrument is recommended.

Cultural and linguistic transferability of the multi-dimensional OxCAP-MH capability instrument for outcome measurement in mental health: the German language version

BackgroundMental health conditions affect aspects of people’s lives that are often not captured in common health-related outcome measures. The OxCAP-MH self-reported, quality of life questionnaire based on Sen’s capability approach was developed in the UK to overcome these limitations. The aim of this study was to develop a linguistically and culturally valid German version of the questionnaire.MethodsFollowing forward and back translations, the wording underwent cultural and linguistic validation with input from a sample of 12 native German speaking mental health patients in Austria in 2015. Qualitative feedback from patients and carers was obtained via interviews and focus group meetings. Feedback from mental health researchers from Germany was incorporated to account for cross-country differences.ResultsNo significant item modifications were necessary. However, changes due to ambiguous wordings, possibilities for differential interpretations, politically unacceptable expressions, cross-country language differences and differences in political and social systems, were needed. The study confirmed that all questions are relevant and understandable for people with mental health conditions in a German speaking setting and transferability of the questionnaire from English to German speaking countries is feasible.ConclusionsProfessional translation is necessary for the linguistic accuracy of different language versions of patient-reported outcome measures but does not guarantee linguistic and cultural validity and cross-country transferability. Additional context-specific piloting is essential. The time and resources needed to achieve valid multi-lingual versions should not be underestimated. Further research is ongoing to confirm the psychometric properties of the German version.