The Societal Burden associated with Adolescent Idiopathic Scoliosis: a cross-sectional burden-of-disease study

The Societal Burden associated with Adolescent Idiopathic Scoliosis: a cross-sectional burden-of-disease study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Societal Burden associated with Adolescent Idiopathic Scoliosis: a cross-sectional burden-of-disease study Thomáy-Claire Ayala Hoelen, Silvia M. Evers, Jacobus J. Arts, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4377673/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 06 Nov, 2024 Read the published version in BMC Public Health → Version 1 posted 4 You are reading this latest preprint version Abstract Background Adolescent idiopathic scoliosis (AIS) has a general population prevalence of 2–3%. The impact of AIS on the patients’ quality of life is increasingly recognized. However, there is limited knowledge on the societal burden of AIS. Therefore, this study aimed to determine societal burden of AIS. Methods A cross-sectional, prevalence-based, bottom-up burden of disease study was conducted. AIS patients or parents of a child with AIS residing in the Netherlands were eligible for inclusion. The survey was distributed between June - December 2022 and was completed once by each participant. The institute for Medical Technology Assessment - Medical Consumption and Productivity Cost Questionnaires were used to assess costs. The health-related quality of life (HRQoL) was assessed using the EuroQol 5D-5L/EuroQol 5D Youth and the Scoliosis Research Society-22 revised questionnaires. Costs and HRQoL were identified, measured, and valued. Results Participants (n = 229) were predominantly female (92%), on average 35 years old, and were employed (65%). The societal cost for a patient with AIS in the Netherlands was €12,275 per year. The largest costs were estimated for the healthcare and productivity sectors. The mean utility score for adults was 0.7 (SD 0.20). Severe pain was experienced by 10% of the adult participants and 44% reported to experience moderate pain/discomfort. Statistically significant differences between different age groups were present for individual sector costs and HRQoL. Conclusions AIS negatively impacts societal costs and the HRQoL. Reducing the productivity sector burden and further improving the HRQoL of life for patients with AIS is needed. Adolescent idiopathic scoliosis Burden of disease Cost of illness Dutch Population Health-related quality of life Figures Figure 1 Background Adolescent idiopathic scoliosis (AIS) is a spinal deformity with unknown etiology and has a general population prevalence of 2–3% 1 . AIS occurs in adolescents (10–18 years old) and predominantly affects females. During the growth spurt in adolescence, spinal deformity tends to progress most rapidly. The burden AIS poses on health-related quality of life (HRQoL) aspects such as psychological well-being and physical functioning is increasingly recognized 1–3 . Patients with AIS have significant issues with body image perceptions and are at a higher risk for developing mood disorders 4 . Sanders et al. found that 32% of the AIS patients suffer from significant psychological and emotional distress 5 . To help mitigate these effects and prevent curve progression conservative treatment can be started in mild to moderative spinal curves. Correction of the scoliotic curve achieved conservatively or surgically can alter aesthetic and thereby significantly improve individuals' perception of their body 6, 7 . More severe curves are best treated surgically to reduce serious health complications such as impaired pulmonary function, cardiovascular complications, chronic pain or psychological strain 8, 9 . Corrective spinal fusion is major invasive surgery with reported complication rates of 5–25% 10 . Furthermore, surgical correction is also considered a high-cost intervention. Overall, patients with AIS consume a substantial amount of healthcare resources, with treatment costs increasing with the severity of symptoms 11 . Furthermore, AIS patients are more likely to be disabled and unemployed if they have more severe clinical symptoms 12 . This poses a supplementary societal burden on an already overloaded healthcare system. To reduce the burden of AIS, researchers have suggested (institutionalized) screening by, e.g., school doctors to detect children with AIS earlier. The notion rests on the idea that early detection may help prevent progression and more severe symptoms. Subsequently, it may be deduced that less invasive treatment with fewer costs will be incurred. However, controversy surrounding the benefits of early screening remains 13, 14 . There is a growing body of evidence on the impact of AIS both on the patient and on the healthcare system. However, to the best of our knowledge, there are no publications available that assess the total burden in terms of societal costs and HRQoL of AIS. Further understanding on the burden of AIS will help to attain the attention of policy and research agendas, thereby highlighting the need for more adequate preventive and treatment methods. Therefore, this cross-sectional, prevalence-based, bottom-up burden of disease study aims to determine the associated impact of AIS on patients residing in the Netherlands. As such the costs and generic health-related quality of life will be considered from a societal perspective. Methodology Study design This cross-sectional, prevalence-based, bottom-up approach cost-of-illness study adopted a societal perspective. The cross-sectional nature of the study implied that measurements were done at one point in time 15 . Prevalence-based studies consider the costs attributable to the total number of cases in a set time frame (usually a year). On the contrary, incidence-based studies refer to the number of new cases that arise within a set time frame and attempt to estimate the life-time costs. A societal perspective means that all costs regardless of who incurred them were considered. This study aggregated data at the population level from two questionnaires considering costs and two questionnaires considering the self-perceived health-related quality of life. The study was conducted at the Maastricht University Medical Centre (MUMC+). Non-WMO approval was obtained from the Medical Ethical Testing Committee (METC) of the MUMC + as well as consent from the advisory board (METC 2022–3166). Informed consent was obtained from all participants prior to the start of the study. The study followed the Dutch guidelines for costing studies. It was written in accordance with the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) to enhance reporting quality and transparency and takes the guidelines published by Larg and Moss into account 16–18 . A detailed study protocol was published prior to completion of the current study 19 . Participants and procedure All persons diagnosed with AIS or parents of a child with AIS, in case a child was unable to fill-out the questionnaire, that were willing and able to answer the questionnaires were eligible to partake in this study. Participants had to be residing in the Netherlands and able to read and write in the Dutch language. Participants diagnosed with other types of scoliosis were excluded. Despite the lack of a standard sample size calculation methodology, a sample of least 100 participants was aimed for based on prior research and in order to get enough variation in the patient population 20 . Patients were included consecutively over the course of three months between June and December 2022. Patients were approached by their treating physician and asked to complete the digital questionnaire. Furthermore, the Dutch scoliosis patient society and Stichting I love my back were requested to distribute the digital questionnaire among their members. Paper versions of the questionnaires or a telephone consultation were available upon request. Data collection The questionnaires consisted of generic questions regarding patient demographics such as age and gender, followed by the cost questionnaires and finally the health-related quality of life questions. The questionnaires were distributed using the online survey tool Qualtrics 21 and required approximately 20–30 minutes to complete. Cost-estimation A bottom-up costing approach was used whereby cost estimation was made using three steps: ( 1 ) identification, ( 2 ) measurement and ( 3 ) valuation, to estimate the associated costs with AIS 15, 22 . Identification of costs According to the patient’s pathway, cost categories were used to help identify and structure relevant costs. Health sector costs included costs related to the diagnosis and treatment of AIS such as costs for radiographs, consultations, and surgical interventions. Any costs incurred or contributes made by the patient or family such as transportation costs to and from the hospital, were presented under patient and family costs. Productivity losses made by days off work or unemployment of patients resulting from AIS were considered. The final category included costs such as loss of schooldays. Measurement of costs To assess the costs associated with AIS the institute for Medical Technology Assessment - Medical Consumption Questionnaire (iMTA-MCQ) and the institute for Medical Technology Assessment – Productivity Cost Questionnaire (iMTA-PCQ) were used 23 . The iMTA-MCQ is a generic instrument that measures medical consumption. It consists of 36 questions and considers a prior period of three months. The iMTA-PCQ consists of 18 questions and aims to assess all aspects concerning productivity losses e.g. absenteeism, presenteeism and productivity losses related to unpaid work 24 . The questions concern a prior period of 4 weeks to limit recall bias. Further, assessment of validity and reliability of the iMTA-MCQ and the iMTA-PCQ still needs to be conducted. Valuation of costs Data on the healthcare consumption was obtained from the iMTA-MCQ 23 . In addition, the Dutch guidelines for pricing of existing costs was used 17, 25, 26 . The existing costs consist of prices such as the cost of healthcare consultations, operations and/or medication. Inflation of prices is considered, and costs were indexed to the year 2022 using rates from the Dutch Central Bureau for Statistics 27 . All costs are presented in euros. The unit cost per item was calculated based on the cost per item and multiplied by the volume of resource use 17 . In case of medication cost data, the lowest cost price was used 25 . Additionally, a delivery cost was added to the cost of the prescribed medication. Furthermore, if participants did not specify the number of appointments or consultations, a volume of one unit was applied. As described by the Dutch Costing Guidelines productivity losses were calculated based on the total time of absenteeism multiplied by the regular cost of an employee, using the friction cost method (FCM). FCM assumes that after a friction period an absent employee will be replaced 17 . Although a friction period of 12 weeks is advised in the Dutch Costing Guidelines, a friction period of 19.6 weeks was calculated reflecting the current labour market in the Netherlands. In line with the Dutch Costing Guidelines informal care was calculated using the replacement cost method 17 . Regardless of recall periods used by the questionnaires, all costing data was presented as covering a three-month period and were subsequently extrapolated to 12 months. Self-perceived health-related quality of life assessment Identification of health-related quality of life (HRQoL) Health-related quality of life (HRQoL) was used to determine the burden of disease on physical health, mental health, social functioning and wellbeing of an individual 22 . To assess the HRQoL of AIS patients the EuroQol 5-dimensions (EQ-5D-5L) or EuroQol 5-dimensions Youth (EQ-5D-Y) questionnaire and the Scoliosis Research Society-22 (SRS-22r) revised questionnaire were considered 28, 29 . Measurement of HRQoL The EQ-5D-5L is a generic questionnaire assessing overall health status of a patient. Generic questionnaires allow for comparison of outcomes across populations and interventions since they are not disease-specific but rather adopt a more general perspective 30 . The EQ-5D-5L is commonly used and recommended for economic evaluation 15, 17 . It consists of five domains each consisting of one question: ( 1 ) mobility, ( 2 ) self-care, ( 3 ) pain/discomfort, ( 4 ) usual activities and ( 5 ) anxiety/depression. Each domain is scored using a 5-level scale consisting of the options: no problems, some problems, mediocre problems, severe problems, and extreme problems/inability to complete a task. Additionally, the questionnaire consists of a visual analogue scale (EQ-VAS) assessing the patient’s self-reported health-status. Overall, the EQ-5D-5L has been established to have adequate psychometric properties since it is a valid and reliable tool in addition to having acceptable responsiveness 31, 32 . Participants younger than 15 years old were provided with the EQ-5D-Y instead of the EQ-5D-5L questionnaire. The EQ-5D-Y is a child-friendly EQ-5D questionnaire that is based on the EQ-5D-3L version 33 . It consists of the same five domains as the EQ-5D and each domain is scored using a 3-level scale e.g. no problems, some problems and a lot of problems. In addition to the EQ-5D-5L, a population specific quality of life questionnaire was provided namely the SRS-22r questionnaire 34, 35 . Disease-specific questionnaires are designed for specific patient populations making them pertinent to measuring aspects that are not covered in generic questionnaires but are relevant in capturing the HRQoL of specific patient populations 30, 36 . However, they are less compatible for comparison to other diseases or populations 30 . The SRS-22r is a self-assessed questionnaire and consists of five domains: ( 1 ) function, ( 2 ) pain, ( 3 ) mental health, ( 4 ) self-image and ( 5 ) management satisfaction/dissatisfaction. The SRS-22r includes a total of 22 questions divided among the above mentioned five domains (each domain has five questions apart from the fifth domain consisting of two questions). The scoring of each question ranges from 1 (worst) to 5 (best), with a maximum score of 110 (higher score indicates better HRQoL). Further details can be found in the study protocol 19 . Valuation of HRQoL The answer to the EQ-5D domains were summed to provide a total of 3125 health condition states 32 . Subsequently, these health conditions were assigned an index or utility value based which was used for the economic evaluation. Utility scores are specific for the Netherlands and version of the EuroQol questionnaires e.g. EQ-5D-5L 37 and EQ-5D-Y 38 . The EQ-5D-5L utility scores were reported. The SRS-22r instrument was used to address AIS specific effects on the self- perceived health-related quality of life that was not included in the generic EQ-5D-5L instrument. Analyses The normality assumption is usually violated for the cost data, therefore non-parametric bootstrapping was performed (1000 replications) per cost category 15 . An alpha level was set at 0.05 for all cost analyses. Normality of the HRQoL data was tested using the Shapiro-Wilk test. In case data was not normally distributed a non-parametric test (Mann-Whitney U or Kruskal-Wallis in case of multiple groups) was performed. Continuous data was described as mean (standard deviation) and categorical data was presented as count (percentage). A p-value ≤ 0.05 was considered statistically significant. Inconsistencies and completeness of data was assessed. Participants were excluded pairwise in case of missing data. Analyses was performed using R-software version 4.0.3 (package: summarytools, forcats, dplyr, tableone, Eq. 5d). Subgroup and sensitivity analyses To assess the robustness of the methodological and parametric approach chosen sensitivity analyses were conducted. To test the methodological uncertainty, a sensitivity analysis was done using the UK and USA-tariff instead of the Dutch tariff. The minimally important difference (MID) of the EQ-5D-5L index score has been reported to be around 0.061 and 0.063 for Spain and England respectively 39 and thus 0.06 was used as threshold to determine whether differences in tariff between the Netherlands, UK and USA were relevant. Additionally, the Human Capital Approach (HCA) rather than the FCM approach was used to determine productivity losses 17 . To test the influence of alternative perspectives on cost outcomes, bootstrapped costs were estimated from the healthcare perspective rather than a societal perspective. Furthermore, the Kruskal-Wallis test and pairwise Wilcox test were used to determine whether there were significant differences between sub-groups based on age. Results Patient characteristics The online questionnaire was distributed from June to December 2022 and yielded 342 respondents. However, only 241 surveys were considered eligible for inclusion in the analysis since 101 surveys were merely registrations of opening the questionnaire without any questions being completed. Of these, five respondents did not consent to take part in the study, six respondents were excluded since they were not diagnosed with AIS, and one was below the age of 10 and thus did not have the correct diagnosis. Subsequently, 229 participants were included in this study. Further details on the completeness of data can be found in Fig. 1 . Of the 229 questionnaires, the majority was completed by respondents 16 years or older (n = 197, 86%), 24 questionnaires were completed by participants between the age of 12–15 years old (10.5%) and 8 (3.5%) questionnaires were filled in on behalf of someone else i.e., a parent of a child younger than 12 years old. Participants were predominantly female with an average age of 35.1 (SD 18.6) years. Most of the participants had an intermediate or higher level of education and approximately 65% had paid employment. Characteristics of patients who completed the questionnaire are presented in Table 1 . Table 1 Baseline characteristics people with adolescent idiopathic scoliosis, (n = 229) Characteristics n (%) Gender Female 211 (92.1) Male 17 (7.4) Other 1 (0.4) Age (yrs), mean (SD) 35.1 (18.6) 11–18 53 (23.1) 19–29 65 (28.4) 30–49 45 (19.7) 50+ 66 (28.8) Level of education a Lower level 30 (13.1) Intermediate level of education 95 (41.9) High level of education 93 (40.6) Other 10 (4.4) Currently in school/college 80 (34.9) Work status Paid work 148 (64.6) Unpaid work 81 (35.4) Unemployed 5 (2.2) Incapacitated 19 (8.3) Pre-pension/pension 14 (6.1) a Lower level of education defined as: no completed education, lower vocational education and intermediate level of education defined as: pre-vocational secondary education, senior secondary general education, pre-university education. High level of education defined as: higher professional education, university education. Cost analyses An overview of all items belonging to one of the four main categories e.g. healthcare sector costs, patient and family costs, other sector costs and productivity costs as well as the corresponding costs of these items are presented in Table 2 . Table 2 Societal Costs in 2022 for people with adolescent idiopathic scoliosis Resource use: 3 months Costs* (€), Mean (SD) Category Unit Unit Price Min Max Mean (SD) Time period: 3 months 12 months** Healthcare Sector Costs General Practitioner Consult €40.3 0 20 1.3 (2.70) €52.1 (108.80) €208.3 (435.36) Social Worker Consult €79.4 0 4 0.1 (0.51) €8.8 (41.01) €35.3 (164.03) Physical therapist/ caesar therapist/ mensendieck/ manual therapist Consult €40.3 0 50 5.5 (7.08) €222.3 (285.60) €889.3 (1142.54) Occupational therapist Consult €40.3 0 7 0.08 (0.65) €3.2 (26.04) €12.7 (104.15) Speech therapist Consult €36.7 0 4 0.03 (0.29) €1.02 (10.56) €4.07 (42.22) Dietician Consult €60.0 0 3 0.08 (0.38) €5.0 (22.60) €20.0 (90.39) Homeopath/acupuncturist Consult €55.0 0 6 0.1 (0.66) €7.1 (36.44) €28.5 (145.75) Psychologist, psychiatrist, psychotherapist Consult €107.2 0 12 0.7 (2.05) €74.9 (220.20) €299.7 (880.61) Occupational physician Consult €100.0 0 2 0.1 (0.38) €10.2 (38.43) €40.7 (153.74) Inpatient care (overnight hospital stay) Days €581.6 0 13 0.2 (1.14) €88.9 (663.60) €355.4 (2654.45) Day treatment Consult €337.2 0 5 0.1 (0.51) €46.8 (171.80) €187.3 (687.35) Outpatient care (less than 24 hours) Consult €111.2 0 10 0.7 (1.31) €74.6 (145.80) €298.5 (583.14) Emergency care (EHBO) Consult €316.4 0 1 0.02 (0.15) €7.3 (47.69) €29.3 (190.77) Ambulance Ride €629.2 0 0 0 €0.0 €0.0 Medication prescription costs Number Variable 0 10 1.3 (1.87) €231.8 (1345.79) €927.1 (5383.17) Home care- Household activities Hours €24.4 0 13 0.2 (1.49) €4.8 (36.27) €19.0 (145.07) Home care- Personal care at home Hours €61.1 0 0 0 €0.0 €0.0 Home care- Nursing at home Hours €89.2 0 0 0 €0.0 €0.0 Total Healthcare Sector Costs ¶ €849.05 (121.72) €3,396.2 (486.87) Patient & Family Costs Transportation costs Trip Variable 0 50 7.7 (8.48) €9.8 (10.69) €39.07 (42.75) Parking costs per visit at hospital Trip €3.7 0 11 0.9 (1.66) €3.2 (6.11) €12.7 (24.42) Medication OTC costs Number Variable 0 2 0.5 (0.66) €1.2 (5.89) €4.9 (23.56) Total Patient & Family Costs ¶ €14.2 (1.16) €56.7 (4.62) Other Sector Costs School days Days €46.0 0 30 2.5 (6.17) €115.6 (283.96) €461.9 (1135.84) Total Other Costs ¶ €30.2 (10.50) €120.9 (42.00) Productivity costs Absenteeism Working hours €42.5 0 366 5.8 (39.00) €639.6 (3,797.76) €639.6 (3797.76) Presenteeism Working hours €42.5 0 18 0.8 (1.90) €97.04 (241.56) €420.5 (1,046.77) Productivity loss unpaid work Hours €17.1 0 180 8.0 (23.82) €409.0 (1,221.74) €1,772.1 (5,294.23) Total Productivity Costs ¶ €944.4 (248.64) €2,319.9 (420.47) Total Societal Costs ¶ €1,562.7 (270.95) €12,274.5 (3,094.71) SD: standard deviation, OTC: over the counter drug *All prices are indexed for the year 2022 **Prices are extrapolated to 12 months ¶ Bootstrapped total costs The total bootstrapped societal costs for a patient with AIS amounted to approximately €12,274 (SD €3,094.71) per year. The healthcare sector and productivity sector accounted for approximately 50% and 42% of the total societal costs, respectively (Appendix I). The bootstrapped healthcare sector costs were estimated at just below €3400, - annually. The majority share was accounted for by prescribed medication costs, physical therapy treatments, inpatient and outpatient care as well as consultations for psychological well-being. A more detailed description of the prescribed and over the counter (OTC) medication used by the participants is presented in Appendix II. Costs for the productivity sector were estimated at €2,320 (SD 420.47) per year. Of the 229 participants included in this study 65% indicated to have paid work. Participants reported being absent from work on average 6 days every 4 weeks. Physical or mental complaints during work was experienced by 46% of the participants. This resulted in annual presenteeism costs being around €420,- (SD 1,046.77). Additionally, 45% of the participants experienced physical and/or mental complaints during unpaid work, which resulted in the loss of unpaid work to amount €1,772 (SD 5,294.23) per year. Furthermore, the estimated costs for the patient and family sector and other sectors were €57,- (SD 4.62) and €121,- (SD 42.00), respectively. HRQoL The average utility score of the respondents (≥ 12 years old) was 0.71 (SD 0.2). The Dutch general population reference values are presented in Appendix III, Table S2. Severe pain was experienced by 10% of the participants, moderate pain and/or discomfort was experienced by 44% and 30% of the participants indicated to experience slight pain and/discomfort. Additionally, 31% of the participants experienced moderate problems and 35% experienced slight problems whilst performing their usual activities. Furthermore, 41% of the respondents reported to have slight problems for the dimension anxiety/depression. Participants reported an average EQ-VAS score of 71.7 (SD 15.2, n = 159). The average score per domain as well as the number of participants that indicated having no problems, slight, moderate, severe or extreme problems per domain are presented in Table 3 . Table 3 EQ-5D, (n = 160) Dimension Mobility n (%) Self-care n (%) Usual activities n (%) Pain/ discomfort n (%) Anxiety/ depression n (%) Level 1 (No problems) 87 (54.4) 139 (86.9) 46 (28.7) 24 (15.0) 65 (40.6) Level 2 (Slight problems) 46 (28.7) 15 (9.4) 56 (35.0) 48 (30.0) 65 (40.6) Level 3 (Moderate problems) 24 (15.0) 4 (2.5) 49 (30.6) 71 (44.4) 24 (15.0) Level 4 (Severe problems) 3 (1.9) 2 (1.2) 9 (5.6) 16 (10.0) 6 (3.8) Level 5 (Extreme problems/unable to do) 0 (0.0) 0 (0.0) 0 (0.0) 1 (0.6) 0 (0.0) The average utility score of the six participants younger than 12 years old was 0.61 (SD 0.18). The average score per domain as well as the number of participants that indicated having no problems, some problems or severe problems per domain are presented in Appendix III, Table S3. The average EQ_VAS score was 86.3 (SD 9.9). The average scores per domain of the SRS-22r for the entire cohort are presented in Table 4 . Although variation in average scores among the domains is minimal, the domain management (dis)satisfaction (3.0, SD 0.5) followed by the domain pain (3.0, SD 0.6) and the domain self-image (3.4, SD 0.7) scored the lowest. Overall, participants scored best on the domain of physical functioning. The mean score across all domains was 3.4 (SD 0.4) indicating a moderately good health-related quality of life. Table 4 SRS-22r, (n = 166) Domain Mean* SD Range Function 3.8 0.7 2.0–5.0 Pain 3.0 0.6 1.4–4.4 Mental health 3.6 0.7 1.6-5.0 Self-image 3.4 0.7 1.8-5.0 Management (dis)satisfaction 3.0 0.5 2.0-4.5 All domains 3.4 0.4 2.3–4.4 *Mean score: 5 = best, 1 = worst Sensitivity analyses Multiple sensitivity analyses were performed to test for the robustness of the methodological and parametric approach. As an alternative to the Dutch tariff, the UK tariff was used to calculate the total societal costs associated with AIS. When considering the burden of AIS from a healthcare perspective rather than from a societal perspective only costs in the healthcare sector are considered. The burden associated with AIS from a healthcare perspective is thus estimated to be around €3400,- (SD 486.87) per year. Additionally, the HCA approach was used to determine the costs associated with productivity losses. When using the HCA approach is used the friction period is disregarded. The bootstrapped HCA productivity costs are estimated to be around €14,310 (SD €6,497) per individual with AIS per year. Furthermore, when considering the utility score of the respondents (≥ 12 years old) according to the Netherlands, UK and the USA value set an average utility score 0.87 (SD 0.17), 0.77 (SD 0.16) and 0.72 (SD 0.21) was found, respectively. In all cases, the average utility score reported by the participants in this study (0.71, SD 0.2) was lower than the average population utility scores. Additionally, the MID threshold of 0.06 has been met when comparing the utility score in this study by the average utility score of the Netherlands, UK and USA. This indicates that the change in utility score is important from a patient’s or clinician’s perspective. Subgroup analyses To assess whether the burden of AIS varied for participants with different ages and gender, subgroup analyses were performed (Appendix IV, Table S4-9). The individual sector costs differed significantly between the different age groups (Appendix IV, Table S4). However, the overall societal costs did not indicate any significant differences. The youngest age group (11–18 years old) differed significantly from the participants in the 30–49 years old group in all sectors. Costs calculated for the healthcare sector and patient and family sector were significantly higher for participants aged 11–18 years old compared to 19–29 year old participants whilst costs calculated for the productivity sector were significantly lower. Other sector costs were higher for participants between 11–18 years old compared to participants aged between 30–49 and 50+. Productivity costs were statistically significantly different between 11–18 and 50+, 19–29 and 30–49, 19–29 and 50 + year old participants, with 30–49 year old participants having the highest productivity costs. Furthermore, productivity costs were statistically significantly higher for females compared to males (Appendix IV, Table S5). Subgroup analyses were performed to assess whether HRQoL outcomes differed between participants of different ages and gender. Statistically significant differences were found in the mean EQ-5D scores between participants in different age groups with 11–18 year old participants scoring lower on the domains: mobility (p < 0.01), usual activities (p < 0.01) and pain and discomfort (p < 0.01) and for the mean utility scores (p < 0.01) (Appendix IV, Table S6). When comparing EQ-5D scores of male and female participants, males were found to have significantly lower scores for the domains: usual activities (p < 0.05), pain and discomfort (p < 0.05), anxiety and depression (p < 0.05) and the utility scores (p < 0.05) (Appendix IV, Table S7). For the SRS-22r, statistically significant differences in age groups were found for the domains: function (p < 0.01), pain (p < 0.01), self-image (p = 0.01) and the overall score (p = 0.01) (Appendix IV, Table S8), with older participants scoring lower on the domains. No statistically significant differences were found when looking at the SRS-22r scores between male and female participants with AIS (Appendix IV, Table S9). Discussion This burden of disease study determined the burden associated with AIS in the Netherlands from a societal perspective. The study findings indicate that the societal burden of AIS is estimated to be €12,275 per individual with AIS annually in the Netherlands. For AIS patients, the healthcare sector followed by the productivity costs are the largest contributors to the overall societal costs namely €3,396 and €2,320 per individual per year, respectively. These costs are also reflective of the physical and mental symptoms patients experience, with 10% of the participants indicating to experience severe pain/discomfort and 40% of the patients reporting to experience moderate pain/discomfort. The average EQ-5D-5L utility score of the participants in this study was 0.7 (SD 0.2) indicating that AIS has a significant impact on their health state. When solely considering a healthcare perspective, the burden of AIS is significantly reduced compared to the societal perspective. The healthcare perspective excludes any costs other than direct costs associated with the provision of healthcare. However, since the second highest contribution to the burden is due to the productivity losses, solely the healthcare perspective would provide an underestimation of the true burden of AIS on society. With costs in the productivity sector accounting for over 40% of the total societal burden, the impact of AIS goes beyond costs made in the healthcare sector. Similar conclusions were reported in a study on the burden of overweight and obesity 20 . Hecker et al. reported a societal burden of approximately €11,500 per year for obesity, with the largest share of the costs accounted for by the productivity sector 20 . Additionally, Mastrigt et al. investigated the societal burden of stroke and reported that non-healthcare costs such as productivity losses and informal care significantly contribute to the total costs 40 . Furthermore, a large study on the economic cost of brain disorders also found that indirect costs such as absenteeism from work account for 40% of the costs 41 . Thus, more consideration for non-healthcare costs such as maintaining labour feasibility is essential and may deem more effective in reducing the overall societal costs compared to focussing primarily on reducing healthcare costs. When comparing the utility score among patients with AIS (0.7) to the utility score for the general Dutch population (0.87 SD 0.17), it can be seen that AIS has a large impact on the experienced quality of life 37 . The Hence, the MID in utility scores between AIS patients and the healthy Dutch population indicates that the threshold of 0.06 has been surpassed. The utility score derived from this study is slightly lower compared to previous studies looking at the HRQoL among AIS patients. Diarbakerli et al. measured HRQoL using the EQ-5D and reported utility scores of 0.82 for untreated patients, 0.82 for previously braced patients and 0.79 for surgically treated patients 42 . Larson et al. reported similar utility measures of 0.85 for untreated patients, 0.88 for patients in the bracing cohort and 0.83 for surgically treated patients 43 . Chua et al. reported slightly higher EQ-5D-5L utility scores of 0.90 (SD 0.17) and 0.88 (SD 0.19) for patients treated with observation and bracing respectively 44 . Variations in utility scores may be due to differences in study design, country of study conduction as well as sample population. The study by Diarbakerli et al. performed in Sweden included patients with juvenile and adolescent idiopathic scoliosis whilst the study by Chua was conducted in Singapore. Although, the SRS-22r results showed minor differences between the domains it is interesting to note that patients scored lowest on the domains pain (3.0), management (dis)satisfaction (3.0) and self-image (3.4). These are important domains to consider since they can influence successful treatment outcomes. Although the average score for the domain management (dis)satisfaction varies among studies, it receives the worst scores when compared to the other domains 43–45 . Unlike previous publications, the average scores for the domain pain are relatively low e.g. 3.0 vs scores > 4.0 42, 44 . However, our study includes AIS patients of all ages rather than patients aged between 11–21 years old and our subgroup analyses showed that pain worsens with age. Additionally, variations in pain perception and adaptation may be present due to factors such as cultural experience 46 . In contrast to the study findings of Diarbakerli et al. differences in SRS-22r scores for patients of different ages for the domains function, pain and self-image were found. Diarbakerli et al. included patients with juvenile and adolescent idiopathic scoliosis as well as comparing various treatment modalities which could have accounted for the differences in findings 42 . Generalizability and transferability Although this study may be used as a blueprint for studies in alternative settings, the question rises whether the study findings are generalizable across regions and countries. Considering the differences in healthcare system organization and financing between countries, country-specific analysis may provide the most accurate results. Although the FCM is advised by the Dutch Costing Guidelines 17 the HCA was also performed for comparison since this is recommended in numerous other countries. Since the adoption of either method depends largely on subjective evaluation and preference, providing both estimates ensures transferability and generalizability 47 . The SRS-22r is a standardized, generally acknowledged questionnaire which allows for between-study comparisons. The EQ-5D is also standardized and internationally well recognized but the utility value sets are country specific making comparison more challenging. Implications The findings of this study may be relevant to both health care and general policy, as well as clinical practice. Firstly, there is need for more education on the effects of scoliosis and the difficulties that patients may experience in their working environment. The societal impact of AIS is predominantly due to the healthcare and productivity sectors. In an already burdened labour market, more attention towards an ergonomic workplace may help to avoid presenteeism and absenteeism. Consequently, productivity costs can be reduced drastically. More qualitative research is needed to determine what problems patients with AIS experience in the workplace and how this affects their productivity and presenteeism at work. Furthermore, the main domains that patients identified as experiencing problems in were pain/discomfort, anxiety/depression and management/satisfaction with their healthcare trajectory. Pain management, mental well-being and the dissatisfaction with the healthcare trajectory is a point of concern and warrants further research since it can impact successful treatment outcome. Considering the societal costs presented are most likely an underestimation since the burden on family and caretakers could not be assessed completely, more research is needed. Additionally, more extensive research in the Netherlands and other countries will help gain a broader perspective of all aspects that impact AIS and allow for between country comparison. Strengths and limitations The standardization and transparency with which the methodological steps are portrayed are a major strength of this study. Additionally, the use of the Dutch costing guideline, the Dutch value sets for EQ-5D utility, the methodological reporting guidelines and protocol registration helped ensure research integrity 16, 18 . Furthermore, the costing and quality of life measurements were performed using the preferred bottom-up method 48, 49 . However, this study also has limitations. The diagnosis of patients could not be verified using the survey. However, the definition of AIS was extensively described in the questionnaire to help participants determine whether their diagnosis was AIS. Due to participation on a voluntary basis, there is also a risk of selection bias, which may reduce generalizability. Additionally, there was incompleteness of data. The most likely reasons for incompleteness of data is the extensiveness of the survey considering completing the questionnaires required a considerable amount of time. The mean utility score for the EQ-5D-Y was 0.61. However, this score is not very informative considering the lack of power due to the small sample size of n = 6. Also, due to time constraints a prevalence-based approach was adopted implying that costs could only be estimated for the period of one year rather than a lifetime and hence the impact of quality of life over time could not be measured. Another limitation was that retrospective, self-reported questionnaires may have led to recall bias and inaccuracy of the answers provided. For example, the SRS-22r refers to a recall period of 6 months in some questions but also contains questions which refer to the past week which may be answered with less recall error as a result 50 . Regardless, the SRS-22r questionnaire is specific to the studied population and useful for between-study comparisons. Additionally, due to use of standardized questionnaires no additional information was obtained via follow-up questions. Conclusion The estimated societal burden associated with AIS in the Netherlands was €12,275 per individual per year. The average EQ-5D utility score was 0.7 and patients indicated that AIS caused them pain and induced problems with daily functioning and self-image. This indicates that AIS has an impact on the societal costs and health-related quality of life. More than 90% of the societal impact can be accounted for by costs associated with healthcare related (50%) and productivity losses (42%). It is crucial to identify factors that prohibit patients with AIS to perform their work optimally and to reduce the number of days absent from work due to illness or complaints. Thus, to reduce this burden more political and clinical attention should be paid to the prevention of symptoms and limitations within the labour sector and patient-centred healthcare trajectories. Furthermore, attention should be paid to pain management and shared decision making to increase patient satisfaction with the adopted treatment. Abbreviations AIS: Adolescent Idiopathic Scoliosis CHEERS: Consolidated Health Economic Evaluation Reporting Standards EQ-5D-5L: EuroQol 5-level EQ-5D-Y: EuroQol 5-dimensions Youth EQ-VAS: EuroQol Visual Analogue Scale FCM: Friction Cost Method HCA: Human Capital Approach HRQoL: Health-related Quality of Life ICC: Intraclass Correlation Coefficient iMTA-MCQ: Institute for Medical Technology Assessment - Medical Consumption Questionnaire iMTA-PCQ: Institute for Medical Technology Assessment – Productivity Cost Questionnaire METC: Medical Ethical Testing Committee MUMC+: Maastricht University Medical Centre SRS-22r: Scoliosis Research Society-22 Revised Version Declarations Ethics approval and consent to participate: Non-WMO approval was obtained from the Medical Ethical Testing Committee (METC) of the MUMC+ as well as consent from the advisory board (METC 2022-3166). Informed consent was obtained from all participants prior to the start of the study. Consent for publication: Not applicable. Availability of data and materials: The datasets generated and/or analysed during the study are available from the corresponding author upon reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: The research for this paper was financially supported by the PRosPERoS-II project, funded by the Interreg VA Flanders – the Netherlands program, CCI grant no. 2021TC16RFCB041. The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Author’s contributions: Concept and design: TH, SA, PW, GM; analysis and interpretation: TH, SA, PW, GM; drafting manuscript: TH, SA; obtaining funding: JA; critical revision: TH, SA, JA, PW, GM; Supervision: SA, JA, PW, GM. Acknowledgements: The authors would like to express their gratitude to the Dutch Scoliosis Patient Society, Stichting I love my back, physicians, therapists and participants in the Netherlands for investing time in this study by raising attention, distributing and completing the questionnaire. References Negrini S, Donzelli S, Aulisa AG, Czaprowski D, Schreiber S, de Mauroy JC, et al. 2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth. 2018;13(1):3. Piątek E, Zawadzka D, Ostrowska B. Correlation between clinical condition of scoliosis and perception of one’s body image by girls with adolescent idiopathic scoliosis. Physiotherapy Quarterly. 2018;26(3):34. Wang H, Tetteroo D, Arts J, Markopoulos P, Ito K. Quality of life of adolescent idiopathic scoliosis patients under brace treatment: a brief communication of literature review. Quality of Life Research. 2021;30(3):703-11. Gallant J-N, Morgan CD, Stoklosa JB, Gannon SR, Shannon CN, Bonfield CM. Psychosocial difficulties in adolescent idiopathic scoliosis: body image, eating behaviors, and mood disorders. World neurosurgery. 2018;116:421-32. e1. Sanders AE, Andras LM, Iantorno SE, Hamilton A, Choi PD, Skaggs DL. Clinically significant psychological and emotional distress in 32% of adolescent idiopathic scoliosis patients. Spine deformity. 2018;6(4):435-40. Duramaz A, Yılmaz S, Ziroğlu N, Duramaz BB, Kara T. The effect of deformity correction on psychiatric condition of the adolescent with adolescent idiopathic scoliosis. European Spine Journal. 2018;27(9):2233-40. Jain A, Yeramaneni S, Kebaish KM, Raad M, Gum JL, Klineberg EO, et al. Cost-Utility Analysis of rhBMP-2 Use in Adult Spinal Deformity Surgery. Spine (Phila Pa 1976). 2020;45(14):1009-15. Choi J-H, Oh E-G, Lee H-J. Comparisons of postural habits, body image, and peer attachment for adolescents with idiopathic scoliosis and healthy adolescents. Child Health Nursing Research. 2011;17(3):167-73. Kontodimopoulos N, Damianou K, Stamatopoulou E, Kalampokis A, Loukos I. Children’s and parents’ perspectives of health-related quality of life in newly diagnosed adolescent idiopathic scoliosis. Journal of orthopaedics. 2018;15(2):319-23. Al-Mohrej OA, Aldakhil SS, Al-Rabiah MA, Al-Rabiah AM. Surgical treatment of adolescent idiopathic scoliosis: Complications. Annals of Medicine and Surgery. 2020;52:19-23. Glassman SD, Carreon LY, Shaffrey CI, Polly DW, Ondra SL, Berven SH, et al. The costs and benefits of nonoperative management for adult scoliosis. Spine. 2010;35(5):578-82. Glassman SD, Berven S, Kostuik J, Dimar JR, Horton WC, Bridwell K. Nonsurgical resource utilization in adult spinal deformity. Spine. 2006;31(8):941-7. Dunn J, Henrikson NB, Morrison CC, Blasi PR, Nguyen M, Lin JS. Screening for adolescent idiopathic scoliosis: evidence report and systematic review for the US preventive services task force. Jama. 2018;319(2):173-87. Deurloo J, Verkerk P. To screen or not to screen for adolescent idiopathic scoliosis? A review of the literature. Public health. 2015;129(9):1267-72. van den Boom N, van den Hurk A, Kalmet P, Poeze M, Evers S. Economic evaluations in fracture research An Introduction with examples of foot fractures. Injury. 2022. Husereau D, Drummond M, Augustovski F, de Bekker-Grob E, Briggs AH, Carswell C, et al. Consolidated Health Economic Evaluation Reporting Standards 2022 (CHEERS 2022) statement: updated reporting guidance for health economic evaluations. International Journal of Technology Assessment in Health Care. 2022;38(1). Hakkaart-van Roijen L, Van der Linden N, Bouwmans C, Kanters T, Tan SS. Kostenhandleiding. Methodologie van kostenonderzoek en referentieprijzen voor economische evaluaties in de gezondheidszorg In opdracht van Zorginstituut Nederland Geactualiseerde versie. 2015. Larg A, Moss JR. Cost-of-illness studies. Pharmacoeconomics. 2011;29(8):653-71. Hoelen T-CA, Willems PC, Arts JJ, van Mastrigt G, Evers S. The economic and societal burden associated with adolescent idiopathic scoliosis: A burden-of-disease study protocol. North American Spine Society Journal (NASSJ). 2023;14:100231. Hecker J, Freijer K, Hiligsmann M, Evers SMAA. Burden of disease study of overweight and obesity; the societal impact in terms of cost-of-illness and health-related quality of life. BMC Public Health. 2022;22(1). Tharp K, Landrum J, editors. Qualtrics Advanced Survey Software Tools2017: Indiana University Workshop in Methods. Dahham J, Rizk R, Hiligsmann M, Daccache C, Khoury SJ, Darwish H, et al. The Economic and societal burden of multiple sclerosis on lebanese society: a cost-of-illness and quality of life study protocol. Expert review of pharmacoeconomics & outcomes research. 2021:1-8. Bouwmans C, Hakkaart-van Roijen L, Koopmanschap M, Krol M, Severens H, Brouwer W. Manual iMTA medical cost questionnaire (iMCQ). Rotterdam: iMTA, Erasmus Universiteit Rotterdam. 2013. Bouwmans C, Krol M, Severens H, Koopmanschap M, Brouwer W, Hakkaart-van Roijen L. The iMTA productivity cost questionnaire: a standardized instrument for measuring and valuing health-related productivity losses. Value in health. 2015;18(6):753-8. Nederland Z. Medicijnkosten. Medicijnkosten nl (2022, accessed October 20022). 2022. Nederland Z. Farmacotherapeutisch kompas. 2022. Centraal Bureau Statistiek C. Jaarmutatie consumentenprijsindex; vanaf 1963: CBS; 2021 [Available from: https://opendata.cbs.nl/statline/#/CBS/nl/dataset/70936ned/table. Devlin NJ, Brooks R. EQ-5D and the EuroQol Group: Past, Present and Future. Applied Health Economics and Health Policy. 2017;15(2):127-37. Schlösser TP, Stadhouder A, Schimmel JJ, Lehr AM, van der Heijden GJ, Castelein RM. Reliability and validity of the adapted Dutch version of the revised Scoliosis Research Society 22-item questionnaire. The Spine Journal. 2014;14(8):1663-72. Patrick DL, Deyo RA. Generic and disease-specific measures in assessing health status and quality of life. Med Care. 1989;27(3 Suppl):S217-32. Feng Y-S, Kohlmann T, Janssen MF, Buchholz I. Psychometric properties of the EQ-5D-5L: a systematic review of the literature. Quality of Life Research. 2020:1-27. Buchholz I, Janssen MF, Kohlmann T, Feng Y-S. A systematic review of studies comparing the measurement properties of the three-level and five-level versions of the EQ-5D. Pharmacoeconomics. 2018;36(6):645-61. Van Reenen M, Janssen B, Oppe M, Kreimeier S, Greiner W, Stolk E. EuroQol Research Foundation. EQ-5d-Y User Guide. 2020. Monticone M, Nava C, Leggero V, Rocca B, Salvaderi S, Ferrante S, et al. Measurement properties of translated versions of the Scoliosis Research Society-22 Patient Questionnaire, SRS-22: a systematic review. Quality of Life Research. 2015;24(8):1981-98. Haher TR, Gorup JM, Shin TM, Homel P, Merola AA, Grogan DP, et al. Results of the Scoliosis Research Society instrument for evaluation of surgical outcome in adolescent idiopathic scoliosis. A multicenter study of 244 patients. Spine (Phila Pa 1976). 1999;24(14):1435-40. Peters M, Crocker H. Disease-Specific Questionnaire. In: Michalos AC, editor. Encyclopedia of Quality of Life and Well-Being Research. Dordrecht: Springer Netherlands; 2014. p. 1667-8. Versteegh MM, Vermeulen KM, Evers SM, De Wit GA, Prenger R, Stolk EA. Dutch tariff for the five-level version of EQ-5D. Value in health. 2016;19(4):343-52. Roudijk B, Sajjad A, Essers B, Lipman S, Stalmeier P, Finch AP. A Value Set for the EQ-5D-Y-3L in the Netherlands. PharmacoEconomics. 2022. McClure NS, Al Sayah F, Xie F, Luo N, Johnson JA. Instrument-defined estimates of the minimally important difference for EQ-5D-5L index scores. Value in Health. 2017;20(4):644-50. van Mastrigt G, van Heugten C, Visser-Meily A, Bremmers L, Evers S. Estimating the burden of stroke: two-year societal costs and generic health-related quality of life of the Restore4Stroke Cohort. International Journal of Environmental Research and Public Health. 2022;19(17):11110. Olesen J, Gustavsson A, Svensson M, Wittchen HU, Jönsson B, Group CS, et al. The economic cost of brain disorders in Europe. European journal of neurology. 2012;19(1):155-62. Diarbakerli E, Grauers A, Danielsson A, Gerdhem P. Health-related quality of life in adulthood in untreated and treated individuals with adolescent or juvenile idiopathic scoliosis. JBJS. 2018;100(10):811-7. Larson AN, Baky F, Ashraf A, Baghdadi YM, Treder V, Polly DW, et al. Minimum 20-year health-related quality of life and surgical rates after the treatment of adolescent idiopathic scoliosis. Spine deformity. 2019;7(3):417-27. Chua YL, Toh AJN, Tan XYB, Pan DCY, Lee NKL, Lim KBL. Aspects of Patient Experience Associated With Improved Scoliosis Research Society-22 Revised (SRS-22R) and European Quality of Life Five-Dimension Five-Level (EQ-5D-5L) Scores in Patients With Adolescent Idiopathic Scoliosis Managed With Observation or Bracing. Spine. 2023;48(9):617-24. Cheung PWH, Wong CKH, Cheung JPY. An insight into the health-related quality of life of adolescent idiopathic scoliosis patients who are braced, observed, and previously braced. Spine. 2019;44(10):E596-E605. Sharma S, Ferreira-Valente A, de C. Williams AC, Abbott JH, Pais-Ribeiro J, Jensen MP. Group Differences Between Countries and Between Languages in Pain-Related Beliefs, Coping, and Catastrophizing in Chronic Pain: A Systematic Review. Pain Medicine. 2020;21(9):1847-62. Krol M, Brouwer W. How to estimate productivity costs in economic evaluations. Pharmacoeconomics. 2014;32(4):335-44. Tan SS, Rutten F, Van Ineveld B, Redekop W, Hakkaart-van Roijen L. Comparing methodologies for the cost estimation of hospital services. The European Journal of Health Economics. 2009;10(1):39-45. Wordsworth S, Ludbrook A. Comparing costing results in across country economic evaluations: the use of technology specific purchasing power parities. Health economics. 2005;14(1):93-9. Clarke PM, Fiebig DG, Gerdtham U-G. Optimal recall length in survey design. Journal of health economics. 2008;27(5):1275-84. Additional Declarations No competing interests reported. Supplementary Files Hoelenetal.SocietalBurdenAISSupplementarymaterial.docx Cite Share Download PDF Status: Published Journal Publication published 06 Nov, 2024 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 14 May, 2024 Submission checks completed at journal 09 May, 2024 Editor assigned by journal 09 May, 2024 First submitted to journal 06 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4377673","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":302216884,"identity":"dbd8a88e-b288-4bfe-b1c7-69e74c67f5bb","order_by":0,"name":"Thomáy-Claire Ayala Hoelen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3UlEQVRIiWNgGAWjYDACCQiVwMDA3MDAUAEVfYBHBw9CCyNQyxkGOJdILYxtRGixl24+uuFnG0MeP3tj4+PCedsS17YfYHuA1xaZY2k3e9sYiiV7DjYbz9x2O3HbmQR2A/wOyzG7wdvGkLjhRmKbNC9Iyw0GNglCWm7+BWm5/7D9N+8cIrXchtjC2MbM20CMlhtpabdlzkkkzuxJbJbmOXbbeNuZxDa8WthnJB+7+abMJrGf/fDBzzw1t2W3HT98TOIDHi1gwMgmgcJtIKQBCP4QoWYUjIJRMApGLgAA1KFTkXRLk+QAAAAASUVORK5CYII=","orcid":"","institution":"Maastricht University Medical Centre","correspondingAuthor":true,"prefix":"","firstName":"Thomáy-Claire","middleName":"Ayala","lastName":"Hoelen","suffix":""},{"id":302216885,"identity":"10cc7a97-24c1-40a8-8827-c3c920a045d8","order_by":1,"name":"Silvia M. Evers","email":"","orcid":"","institution":"Maastricht University","correspondingAuthor":false,"prefix":"","firstName":"Silvia","middleName":"M.","lastName":"Evers","suffix":""},{"id":302216888,"identity":"115c381a-15ae-44d1-809c-c13dffcc490e","order_by":2,"name":"Jacobus J. Arts","email":"","orcid":"","institution":"Maastricht University Medical Centre","correspondingAuthor":false,"prefix":"","firstName":"Jacobus","middleName":"J.","lastName":"Arts","suffix":""},{"id":302216890,"identity":"d4a85ea4-0eda-4c1f-a00d-8986463bd2c6","order_by":3,"name":"Paul C. Willems","email":"","orcid":"","institution":"Maastricht University Medical Centre","correspondingAuthor":false,"prefix":"","firstName":"Paul","middleName":"C.","lastName":"Willems","suffix":""},{"id":302216892,"identity":"f7b7d0eb-e626-4cad-bab3-e5d994b3649a","order_by":4,"name":"Ghislaine van Mastrigt","email":"","orcid":"","institution":"Maastricht University","correspondingAuthor":false,"prefix":"","firstName":"Ghislaine","middleName":"van","lastName":"Mastrigt","suffix":""}],"badges":[],"createdAt":"2024-05-06 14:51:34","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4377673/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4377673/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-024-20423-x","type":"published","date":"2024-11-06T15:57:04+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":56887984,"identity":"0ddd233f-8e5b-4c13-9f1e-5928de55a697","added_by":"auto","created_at":"2024-05-21 19:00:12","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":30438,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart inclusion participants and completeness of data\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4377673/v1/b514a1de0190443c7f5ff2e9.png"},{"id":68750923,"identity":"226faf05-3ef9-43ef-ab7f-3c3a1fdcfd34","added_by":"auto","created_at":"2024-11-11 16:12:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":940090,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4377673/v1/ef7c64fd-d50b-4f3e-8c6f-705a80f9eca6.pdf"},{"id":56888026,"identity":"c1d0a49d-9002-4b74-9ca7-385642b55655","added_by":"auto","created_at":"2024-05-21 19:00:13","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":51217,"visible":true,"origin":"","legend":"","description":"","filename":"Hoelenetal.SocietalBurdenAISSupplementarymaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-4377673/v1/f286db73cdbcfc0b922bece2.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Societal Burden associated with Adolescent Idiopathic Scoliosis: a cross-sectional burden-of-disease study","fulltext":[{"header":"Background","content":"\u003cp\u003eAdolescent idiopathic scoliosis (AIS) is a spinal deformity with unknown etiology and has a general population prevalence of 2\u0026ndash;3%\u003csup\u003e1\u003c/sup\u003e. AIS occurs in adolescents (10\u0026ndash;18 years old) and predominantly affects females. During the growth spurt in adolescence, spinal deformity tends to progress most rapidly. The burden AIS poses on health-related quality of life (HRQoL) aspects such as psychological well-being and physical functioning is increasingly recognized\u003csup\u003e1\u0026ndash;3\u003c/sup\u003e. Patients with AIS have significant issues with body image perceptions and are at a higher risk for developing mood disorders\u003csup\u003e4\u003c/sup\u003e. Sanders et al. found that 32% of the AIS patients suffer from significant psychological and emotional distress\u003csup\u003e5\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eTo help mitigate these effects and prevent curve progression conservative treatment can be started in mild to moderative spinal curves. Correction of the scoliotic curve achieved conservatively or surgically can alter aesthetic and thereby significantly improve individuals' perception of their body\u003csup\u003e6, 7\u003c/sup\u003e. More severe curves are best treated surgically to reduce serious health complications such as impaired pulmonary function, cardiovascular complications, chronic pain or psychological strain\u003csup\u003e8, 9\u003c/sup\u003e. Corrective spinal fusion is major invasive surgery with reported complication rates of 5\u0026ndash;25%\u003csup\u003e10\u003c/sup\u003e. Furthermore, surgical correction is also considered a high-cost intervention.\u003c/p\u003e \u003cp\u003eOverall, patients with AIS consume a substantial amount of healthcare resources, with treatment costs increasing with the severity of symptoms\u003csup\u003e11\u003c/sup\u003e. Furthermore, AIS patients are more likely to be disabled and unemployed if they have more severe clinical symptoms\u003csup\u003e12\u003c/sup\u003e. This poses a supplementary societal burden on an already overloaded healthcare system. To reduce the burden of AIS, researchers have suggested (institutionalized) screening by, e.g., school doctors to detect children with AIS earlier. The notion rests on the idea that early detection may help prevent progression and more severe symptoms. Subsequently, it may be deduced that less invasive treatment with fewer costs will be incurred. However, controversy surrounding the benefits of early screening remains\u003csup\u003e13, 14\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThere is a growing body of evidence on the impact of AIS both on the patient and on the healthcare system. However, to the best of our knowledge, there are no publications available that assess the total burden in terms of societal costs and HRQoL of AIS. Further understanding on the burden of AIS will help to attain the attention of policy and research agendas, thereby highlighting the need for more adequate preventive and treatment methods. Therefore, this cross-sectional, prevalence-based, bottom-up burden of disease study aims to determine the associated impact of AIS on patients residing in the Netherlands. As such the costs and generic health-related quality of life will be considered from a societal perspective.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003eThis cross-sectional, prevalence-based, bottom-up approach cost-of-illness study adopted a societal perspective. The cross-sectional nature of the study implied that measurements were done at one point in time\u003csup\u003e15\u003c/sup\u003e. Prevalence-based studies consider the costs attributable to the total number of cases in a set time frame (usually a year). On the contrary, incidence-based studies refer to the number of new cases that arise within a set time frame and attempt to estimate the life-time costs. A societal perspective means that all costs regardless of who incurred them were considered. This study aggregated data at the population level from two questionnaires considering costs and two questionnaires considering the self-perceived health-related quality of life. The study was conducted at the Maastricht University Medical Centre (MUMC+). Non-WMO approval was obtained from the Medical Ethical Testing Committee (METC) of the MUMC\u0026thinsp;+\u0026thinsp;as well as consent from the advisory board (METC 2022\u0026ndash;3166). Informed consent was obtained from all participants prior to the start of the study. The study followed the Dutch guidelines for costing studies. It was written in accordance with the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) to enhance reporting quality and transparency and takes the guidelines published by Larg and Moss into account\u003csup\u003e16\u0026ndash;18\u003c/sup\u003e. A detailed study protocol was published prior to completion of the current study\u003csup\u003e19\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eParticipants and procedure\u003c/h2\u003e \u003cp\u003eAll persons diagnosed with AIS or parents of a child with AIS, in case a child was unable to fill-out the questionnaire, that were willing and able to answer the questionnaires were eligible to partake in this study. Participants had to be residing in the Netherlands and able to read and write in the Dutch language. Participants diagnosed with other types of scoliosis were excluded. Despite the lack of a standard sample size calculation methodology, a sample of least 100 participants was aimed for based on prior research and in order to get enough variation in the patient population\u003csup\u003e20\u003c/sup\u003e. Patients were included consecutively over the course of three months between June and December 2022. Patients were approached by their treating physician and asked to complete the digital questionnaire. Furthermore, the Dutch scoliosis patient society and Stichting I love my back were requested to distribute the digital questionnaire among their members. Paper versions of the questionnaires or a telephone consultation were available upon request.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eThe questionnaires consisted of generic questions regarding patient demographics such as age and gender, followed by the cost questionnaires and finally the health-related quality of life questions. The questionnaires were distributed using the online survey tool Qualtrics\u003csup\u003e21\u003c/sup\u003e and required approximately 20\u0026ndash;30 minutes to complete.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eCost-estimation\u003c/h2\u003e \u003cp\u003eA bottom-up costing approach was used whereby cost estimation was made using three steps: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) identification, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) measurement and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) valuation, to estimate the associated costs with AIS\u003csup\u003e15, 22\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eIdentification of costs\u003c/h2\u003e \u003cp\u003eAccording to the patient\u0026rsquo;s pathway, cost categories were used to help identify and structure relevant costs. Health sector costs included costs related to the diagnosis and treatment of AIS such as costs for radiographs, consultations, and surgical interventions. Any costs incurred or contributes made by the patient or family such as transportation costs to and from the hospital, were presented under patient and family costs. Productivity losses made by days off work or unemployment of patients resulting from AIS were considered. The final category included costs such as loss of schooldays.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eMeasurement of costs\u003c/h2\u003e \u003cp\u003eTo assess the costs associated with AIS the institute for Medical Technology Assessment - Medical Consumption Questionnaire (iMTA-MCQ) and the institute for Medical Technology Assessment \u0026ndash; Productivity Cost Questionnaire (iMTA-PCQ) were used\u003csup\u003e23\u003c/sup\u003e. The iMTA-MCQ is a generic instrument that measures medical consumption. It consists of 36 questions and considers a prior period of three months. The iMTA-PCQ consists of 18 questions and aims to assess all aspects concerning productivity losses e.g. absenteeism, presenteeism and productivity losses related to unpaid work\u003csup\u003e24\u003c/sup\u003e. The questions concern a prior period of 4 weeks to limit recall bias. Further, assessment of validity and reliability of the iMTA-MCQ and the iMTA-PCQ still needs to be conducted.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eValuation of costs\u003c/h2\u003e \u003cp\u003eData on the healthcare consumption was obtained from the iMTA-MCQ\u003csup\u003e23\u003c/sup\u003e. In addition, the Dutch guidelines for pricing of existing costs was used\u003csup\u003e17, 25, 26\u003c/sup\u003e. The existing costs consist of prices such as the cost of healthcare consultations, operations and/or medication. Inflation of prices is considered, and costs were indexed to the year 2022 using rates from the Dutch Central Bureau for Statistics\u003csup\u003e27\u003c/sup\u003e. All costs are presented in euros. The unit cost per item was calculated based on the cost per item and multiplied by the volume of resource use\u003csup\u003e17\u003c/sup\u003e. In case of medication cost data, the lowest cost price was used\u003csup\u003e25\u003c/sup\u003e. Additionally, a delivery cost was added to the cost of the prescribed medication. Furthermore, if participants did not specify the number of appointments or consultations, a volume of one unit was applied. As described by the Dutch Costing Guidelines productivity losses were calculated based on the total time of absenteeism multiplied by the regular cost of an employee, using the friction cost method (FCM). FCM assumes that after a friction period an absent employee will be replaced\u003csup\u003e17\u003c/sup\u003e. Although a friction period of 12 weeks is advised in the Dutch Costing Guidelines, a friction period of 19.6 weeks was calculated reflecting the current labour market in the Netherlands. In line with the Dutch Costing Guidelines informal care was calculated using the replacement cost method\u003csup\u003e17\u003c/sup\u003e. Regardless of recall periods used by the questionnaires, all costing data was presented as covering a three-month period and were subsequently extrapolated to 12 months.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eSelf-perceived health-related quality of life assessment\u003c/h2\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003eIdentification of health-related quality of life (HRQoL)\u003c/h2\u003e \u003cp\u003eHealth-related quality of life (HRQoL) was used to determine the burden of disease on physical health, mental health, social functioning and wellbeing of an individual\u003csup\u003e22\u003c/sup\u003e. To assess the HRQoL of AIS patients the EuroQol 5-dimensions (EQ-5D-5L) or EuroQol 5-dimensions Youth (EQ-5D-Y) questionnaire and the Scoliosis Research Society-22 (SRS-22r) revised questionnaire were considered\u003csup\u003e28, 29\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eMeasurement of HRQoL\u003c/h2\u003e \u003cp\u003eThe EQ-5D-5L is a generic questionnaire assessing overall health status of a patient. Generic questionnaires allow for comparison of outcomes across populations and interventions since they are not disease-specific but rather adopt a more general perspective\u003csup\u003e30\u003c/sup\u003e. The EQ-5D-5L is commonly used and recommended for economic evaluation\u003csup\u003e15, 17\u003c/sup\u003e. It consists of five domains each consisting of one question: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) mobility, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) self-care, (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) pain/discomfort, (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) usual activities and (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) anxiety/depression. Each domain is scored using a 5-level scale consisting of the options: no problems, some problems, mediocre problems, severe problems, and extreme problems/inability to complete a task. Additionally, the questionnaire consists of a visual analogue scale (EQ-VAS) assessing the patient\u0026rsquo;s self-reported health-status. Overall, the EQ-5D-5L has been established to have adequate psychometric properties since it is a valid and reliable tool in addition to having acceptable responsiveness\u003csup\u003e31, 32\u003c/sup\u003e. Participants younger than 15 years old were provided with the EQ-5D-Y instead of the EQ-5D-5L questionnaire. The EQ-5D-Y is a child-friendly EQ-5D questionnaire that is based on the EQ-5D-3L version\u003csup\u003e33\u003c/sup\u003e. It consists of the same five domains as the EQ-5D and each domain is scored using a 3-level scale e.g. no problems, some problems and a lot of problems.\u003c/p\u003e \u003cp\u003eIn addition to the EQ-5D-5L, a population specific quality of life questionnaire was provided namely the SRS-22r questionnaire\u003csup\u003e34, 35\u003c/sup\u003e. Disease-specific questionnaires are designed for specific patient populations making them pertinent to measuring aspects that are not covered in generic questionnaires but are relevant in capturing the HRQoL of specific patient populations\u003csup\u003e30, 36\u003c/sup\u003e. However, they are less compatible for comparison to other diseases or populations\u003csup\u003e30\u003c/sup\u003e. The SRS-22r is a self-assessed questionnaire and consists of five domains: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) function, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) pain, (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) mental health, (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) self-image and (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) management satisfaction/dissatisfaction. The SRS-22r includes a total of 22 questions divided among the above mentioned five domains (each domain has five questions apart from the fifth domain consisting of two questions). The scoring of each question ranges from 1 (worst) to 5 (best), with a maximum score of 110 (higher score indicates better HRQoL). Further details can be found in the study protocol\u003csup\u003e19\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eValuation of HRQoL\u003c/h2\u003e \u003cp\u003eThe answer to the EQ-5D domains were summed to provide a total of 3125 health condition states\u003csup\u003e32\u003c/sup\u003e. Subsequently, these health conditions were assigned an index or utility value based which was used for the economic evaluation. Utility scores are specific for the Netherlands and version of the EuroQol questionnaires e.g. EQ-5D-5L\u003csup\u003e37\u003c/sup\u003e and EQ-5D-Y\u003csup\u003e38\u003c/sup\u003e. The EQ-5D-5L utility scores were reported. The SRS-22r instrument was used to address AIS specific effects on the self- perceived health-related quality of life that was not included in the generic EQ-5D-5L instrument.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eAnalyses\u003c/h2\u003e \u003cp\u003eThe normality assumption is usually violated for the cost data, therefore non-parametric bootstrapping was performed (1000 replications) per cost category\u003csup\u003e15\u003c/sup\u003e. An alpha level was set at 0.05 for all cost analyses. Normality of the HRQoL data was tested using the Shapiro-Wilk test. In case data was not normally distributed a non-parametric test (Mann-Whitney U or Kruskal-Wallis in case of multiple groups) was performed. Continuous data was described as mean (standard deviation) and categorical data was presented as count (percentage). A p-value\u0026thinsp;\u0026le;\u0026thinsp;0.05 was considered statistically significant. Inconsistencies and completeness of data was assessed. Participants were excluded pairwise in case of missing data. Analyses was performed using R-software version 4.0.3 (package: summarytools, forcats, dplyr, tableone, Eq.\u0026nbsp;5d).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eSubgroup and sensitivity analyses\u003c/h2\u003e \u003cp\u003eTo assess the robustness of the methodological and parametric approach chosen sensitivity analyses were conducted. To test the methodological uncertainty, a sensitivity analysis was done using the UK and USA-tariff instead of the Dutch tariff. The minimally important difference (MID) of the EQ-5D-5L index score has been reported to be around 0.061 and 0.063 for Spain and England respectively\u003csup\u003e39\u003c/sup\u003e and thus 0.06 was used as threshold to determine whether differences in tariff between the Netherlands, UK and USA were relevant. Additionally, the Human Capital Approach (HCA) rather than the FCM approach was used to determine productivity losses\u003csup\u003e17\u003c/sup\u003e. To test the influence of alternative perspectives on cost outcomes, bootstrapped costs were estimated from the healthcare perspective rather than a societal perspective. Furthermore, the Kruskal-Wallis test and pairwise Wilcox test were used to determine whether there were significant differences between sub-groups based on age.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003ePatient characteristics\u003c/h2\u003e \u003cp\u003eThe online questionnaire was distributed from June to December 2022 and yielded 342 respondents. However, only 241 surveys were considered eligible for inclusion in the analysis since 101 surveys were merely registrations of opening the questionnaire without any questions being completed. Of these, five respondents did not consent to take part in the study, six respondents were excluded since they were not diagnosed with AIS, and one was below the age of 10 and thus did not have the correct diagnosis. Subsequently, 229 participants were included in this study. Further details on the completeness of data can be found in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOf the 229 questionnaires, the majority was completed by respondents 16 years or older (n\u0026thinsp;=\u0026thinsp;197, 86%), 24 questionnaires were completed by participants between the age of 12\u0026ndash;15 years old (10.5%) and 8 (3.5%) questionnaires were filled in on behalf of someone else i.e., a parent of a child younger than 12 years old. Participants were predominantly female with an average age of 35.1 (SD 18.6) years. Most of the participants had an intermediate or higher level of education and approximately 65% had paid employment. Characteristics of patients who completed the questionnaire are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics people with adolescent idiopathic scoliosis, (n\u0026thinsp;=\u0026thinsp;229)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e211 (92.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (7.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (yrs), mean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35.1 (18.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u0026ndash;18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53 (23.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e19\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65 (28.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30\u0026ndash;49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (19.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e50+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66 (28.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel of education\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLower level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (13.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntermediate level of education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95 (41.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh level of education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e93 (40.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (4.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrently in school/college\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80 (34.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWork status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePaid work\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e148 (64.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnpaid work\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81 (35.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (2.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncapacitated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (8.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-pension/pension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (6.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003csup\u003ea\u003c/sup\u003eLower level of education defined as: no completed education, lower vocational education and intermediate level of education defined as: pre-vocational secondary education, senior secondary general education, pre-university education. High level of education defined as: higher professional education, university education.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eCost analyses\u003c/h2\u003e \u003cp\u003eAn overview of all items belonging to one of the four main categories e.g. healthcare sector costs, patient and family costs, other sector costs and productivity costs as well as the corresponding costs of these items are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocietal Costs in 2022 for people with adolescent idiopathic scoliosis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003eResource use: 3 months\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eCosts* (\u0026euro;), Mean (SD)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnit\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnit Price\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMin\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMax\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTime period: 3 months\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e12 months**\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHealthcare Sector Costs\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneral Practitioner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsult\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026euro;40.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.3 (2.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026euro;52.1 (108.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026euro;208.3 (435.36)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial Worker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsult\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026euro;79.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.1 (0.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026euro;8.8 (41.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026euro;35.3 (164.03)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysical therapist/ caesar therapist/\u003c/p\u003e \u003cp\u003emensendieck/ manual therapist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsult\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026euro;40.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.5 (7.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026euro;222.3 (285.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026euro;889.3 (1142.54)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOccupational therapist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsult\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026euro;40.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.08 (0.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026euro;3.2 (26.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026euro;12.7 (104.15)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpeech therapist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsult\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026euro;36.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.03 (0.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026euro;1.02 (10.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026euro;4.07 (42.22)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDietician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsult\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026euro;60.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.08 (0.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026euro;5.0 (22.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026euro;20.0 (90.39)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHomeopath/acupuncturist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsult\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026euro;55.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.1 (0.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026euro;7.1 (36.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026euro;28.5 (145.75)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePsychologist, psychiatrist, psychotherapist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsult\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026euro;107.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.7 (2.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026euro;74.9 (220.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026euro;299.7 (880.61)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOccupational physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsult\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026euro;100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.1 (0.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026euro;10.2 (38.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026euro;40.7 (153.74)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInpatient care (overnight hospital stay)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDays\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026euro;581.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.2 (1.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026euro;88.9 (663.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026euro;355.4 (2654.45)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDay treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsult\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026euro;337.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.1 (0.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026euro;46.8 (171.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026euro;187.3 (687.35)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutpatient care (less than 24 hours)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsult\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026euro;111.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.7 (1.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026euro;74.6 (145.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026euro;298.5 (583.14)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmergency care (EHBO)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConsult\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026euro;316.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.02 (0.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026euro;7.3 (47.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026euro;29.3 (190.77)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmbulance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRide\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026euro;629.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026euro;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026euro;0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedication prescription costs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.3 (1.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026euro;231.8 (1345.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026euro;927.1 (5383.17)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHome care- Household activities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026euro;24.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.2 (1.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026euro;4.8 (36.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026euro;19.0 (145.07)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHome care- Personal care at home\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026euro;61.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026euro;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026euro;0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHome care- Nursing at home\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026euro;89.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026euro;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026euro;0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal Healthcare Sector Costs\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026para;\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026euro;849.05 (121.72)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026euro;3,396.2 (486.87)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePatient \u0026amp; Family Costs\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransportation costs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTrip\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.7 (8.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026euro;9.8 (10.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026euro;39.07 (42.75)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParking costs per visit at hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTrip\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026euro;3.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.9 (1.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026euro;3.2 (6.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026euro;12.7 (24.42)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedication OTC costs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.5 (0.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026euro;1.2 (5.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026euro;4.9 (23.56)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal Patient \u0026amp; Family Costs\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026para;\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026euro;14.2 (1.16)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026euro;56.7 (4.62)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eOther Sector Costs\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSchool days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDays\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026euro;46.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.5 (6.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026euro;115.6 (283.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026euro;461.9 (1135.84)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal Other Costs\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026para;\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026euro;30.2 (10.50)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026euro;120.9 (42.00)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eProductivity costs\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbsenteeism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWorking hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026euro;42.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e366\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.8 (39.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026euro;639.6 (3,797.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026euro;639.6 (3797.76)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePresenteeism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWorking hours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026euro;42.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.8 (1.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026euro;97.04 (241.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026euro;420.5 (1,046.77)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProductivity loss unpaid work\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHours\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026euro;17.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.0 (23.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026euro;409.0 (1,221.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u0026euro;1,772.1 (5,294.23)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal Productivity Costs\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026para;\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026euro;944.4 (248.64)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026euro;2,319.9 (420.47)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal Societal Costs\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u0026para;\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026euro;1,562.7 (270.95)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026euro;12,274.5 (3,094.71)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eSD: standard deviation, OTC: over the counter drug\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e*All prices are indexed for the year 2022\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e**Prices are extrapolated to 12 months\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003e\u003csup\u003e\u003cb\u003e\u0026para;\u003c/b\u003e\u003c/sup\u003eBootstrapped total costs\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe total bootstrapped societal costs for a patient with AIS amounted to approximately \u0026euro;12,274 (SD \u0026euro;3,094.71) per year. The healthcare sector and productivity sector accounted for approximately 50% and 42% of the total societal costs, respectively (Appendix I). The bootstrapped healthcare sector costs were estimated at just below \u0026euro;3400, - annually. The majority share was accounted for by prescribed medication costs, physical therapy treatments, inpatient and outpatient care as well as consultations for psychological well-being. A more detailed description of the prescribed and over the counter (OTC) medication used by the participants is presented in Appendix II. Costs for the productivity sector were estimated at \u0026euro;2,320 (SD 420.47) per year. Of the 229 participants included in this study 65% indicated to have paid work. Participants reported being absent from work on average 6 days every 4 weeks. Physical or mental complaints during work was experienced by 46% of the participants. This resulted in annual presenteeism costs being around \u0026euro;420,- (SD 1,046.77). Additionally, 45% of the participants experienced physical and/or mental complaints during unpaid work, which resulted in the loss of unpaid work to amount \u0026euro;1,772 (SD 5,294.23) per year. Furthermore, the estimated costs for the patient and family sector and other sectors were \u0026euro;57,- (SD 4.62) and \u0026euro;121,- (SD 42.00), respectively.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eHRQoL\u003c/h2\u003e \u003cp\u003eThe average utility score of the respondents (\u0026ge;\u0026thinsp;12 years old) was 0.71 (SD 0.2). The Dutch general population reference values are presented in Appendix III, Table S2. Severe pain was experienced by 10% of the participants, moderate pain and/or discomfort was experienced by 44% and 30% of the participants indicated to experience slight pain and/discomfort. Additionally, 31% of the participants experienced moderate problems and 35% experienced slight problems whilst performing their usual activities. Furthermore, 41% of the respondents reported to have slight problems for the dimension anxiety/depression. Participants reported an average EQ-VAS score of 71.7 (SD 15.2, n\u0026thinsp;=\u0026thinsp;159). The average score per domain as well as the number of participants that indicated having no problems, slight, moderate, severe or extreme problems per domain are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEQ-5D, (n\u0026thinsp;=\u0026thinsp;160)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDimension\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMobility\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSelf-care\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUsual activities\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePain/ discomfort\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAnxiety/ depression\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel 1\u003c/p\u003e \u003cp\u003e(No problems)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87 (54.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e139 (86.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46 (28.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24 (15.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e65 (40.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel 2\u003c/p\u003e \u003cp\u003e(Slight problems)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46 (28.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (9.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56 (35.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e48 (30.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e65 (40.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel 3\u003c/p\u003e \u003cp\u003e(Moderate problems)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (15.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49 (30.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e71 (44.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e24 (15.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel 4\u003c/p\u003e \u003cp\u003e(Severe problems)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (1.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9 (5.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16 (10.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6 (3.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel 5\u003c/p\u003e \u003cp\u003e(Extreme problems/unable to do)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe average utility score of the six participants younger than 12 years old was 0.61 (SD 0.18). The average score per domain as well as the number of participants that indicated having no problems, some problems or severe problems per domain are presented in Appendix III, Table S3. The average EQ_VAS score was 86.3 (SD 9.9).\u003c/p\u003e \u003cp\u003eThe average scores per domain of the SRS-22r for the entire cohort are presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Although variation in average scores among the domains is minimal, the domain management (dis)satisfaction (3.0, SD 0.5) followed by the domain pain (3.0, SD 0.6) and the domain self-image (3.4, SD 0.7) scored the lowest. Overall, participants scored best on the domain of physical functioning. The mean score across all domains was 3.4 (SD 0.4) indicating a moderately good health-related quality of life.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSRS-22r, (n\u0026thinsp;=\u0026thinsp;166)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDomain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFunction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.0\u0026ndash;5.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.4\u0026ndash;4.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMental health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.6-5.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-image\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.8-5.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eManagement (dis)satisfaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.0-4.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAll domains\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.3\u0026ndash;4.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e*Mean score: 5\u0026thinsp;=\u0026thinsp;best, 1\u0026thinsp;=\u0026thinsp;worst\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eSensitivity analyses\u003c/h2\u003e \u003cp\u003eMultiple sensitivity analyses were performed to test for the robustness of the methodological and parametric approach. As an alternative to the Dutch tariff, the UK tariff was used to calculate the total societal costs associated with AIS. When considering the burden of AIS from a healthcare perspective rather than from a societal perspective only costs in the healthcare sector are considered. The burden associated with AIS from a healthcare perspective is thus estimated to be around \u0026euro;3400,- (SD 486.87) per year. Additionally, the HCA approach was used to determine the costs associated with productivity losses. When using the HCA approach is used the friction period is disregarded. The bootstrapped HCA productivity costs are estimated to be around \u0026euro;14,310 (SD \u0026euro;6,497) per individual with AIS per year. Furthermore, when considering the utility score of the respondents (\u0026ge;\u0026thinsp;12 years old) according to the Netherlands, UK and the USA value set an average utility score 0.87 (SD 0.17), 0.77 (SD 0.16) and 0.72 (SD 0.21) was found, respectively. In all cases, the average utility score reported by the participants in this study (0.71, SD 0.2) was lower than the average population utility scores. Additionally, the MID threshold of 0.06 has been met when comparing the utility score in this study by the average utility score of the Netherlands, UK and USA. This indicates that the change in utility score is important from a patient\u0026rsquo;s or clinician\u0026rsquo;s perspective.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eSubgroup analyses\u003c/h2\u003e \u003cp\u003eTo assess whether the burden of AIS varied for participants with different ages and gender, subgroup analyses were performed (Appendix IV, Table S4-9). The individual sector costs differed significantly between the different age groups (Appendix IV, Table S4). However, the overall societal costs did not indicate any significant differences. The youngest age group (11\u0026ndash;18 years old) differed significantly from the participants in the 30\u0026ndash;49 years old group in all sectors. Costs calculated for the healthcare sector and patient and family sector were significantly higher for participants aged 11\u0026ndash;18 years old compared to 19\u0026ndash;29 year old participants whilst costs calculated for the productivity sector were significantly lower. Other sector costs were higher for participants between 11\u0026ndash;18 years old compared to participants aged between 30\u0026ndash;49 and 50+. Productivity costs were statistically significantly different between 11\u0026ndash;18 and 50+, 19\u0026ndash;29 and 30\u0026ndash;49, 19\u0026ndash;29 and 50\u0026thinsp;+\u0026thinsp;year old participants, with 30\u0026ndash;49 year old participants having the highest productivity costs. Furthermore, productivity costs were statistically significantly higher for females compared to males (Appendix IV, Table S5).\u003c/p\u003e \u003cp\u003eSubgroup analyses were performed to assess whether HRQoL outcomes differed between participants of different ages and gender. Statistically significant differences were found in the mean EQ-5D scores between participants in different age groups with 11\u0026ndash;18 year old participants scoring lower on the domains: mobility (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), usual activities (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and pain and discomfort (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and for the mean utility scores (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) (Appendix IV, Table S6). When comparing EQ-5D scores of male and female participants, males were found to have significantly lower scores for the domains: usual activities (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), pain and discomfort (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), anxiety and depression (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and the utility scores (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Appendix IV, Table S7). For the SRS-22r, statistically significant differences in age groups were found for the domains: function (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), pain (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), self-image (p\u0026thinsp;=\u0026thinsp;0.01) and the overall score (p\u0026thinsp;=\u0026thinsp;0.01) (Appendix IV, Table S8), with older participants scoring lower on the domains. No statistically significant differences were found when looking at the SRS-22r scores between male and female participants with AIS (Appendix IV, Table S9).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis burden of disease study determined the burden associated with AIS in the Netherlands from a societal perspective. The study findings indicate that the societal burden of AIS is estimated to be \u0026euro;12,275 per individual with AIS annually in the Netherlands. For AIS patients, the healthcare sector followed by the productivity costs are the largest contributors to the overall societal costs namely \u0026euro;3,396 and \u0026euro;2,320 per individual per year, respectively. These costs are also reflective of the physical and mental symptoms patients experience, with 10% of the participants indicating to experience severe pain/discomfort and 40% of the patients reporting to experience moderate pain/discomfort. The average EQ-5D-5L utility score of the participants in this study was 0.7 (SD 0.2) indicating that AIS has a significant impact on their health state.\u003c/p\u003e \u003cp\u003eWhen solely considering a healthcare perspective, the burden of AIS is significantly reduced compared to the societal perspective. The healthcare perspective excludes any costs other than direct costs associated with the provision of healthcare. However, since the second highest contribution to the burden is due to the productivity losses, solely the healthcare perspective would provide an underestimation of the true burden of AIS on society. With costs in the productivity sector accounting for over 40% of the total societal burden, the impact of AIS goes beyond costs made in the healthcare sector. Similar conclusions were reported in a study on the burden of overweight and obesity\u003csup\u003e20\u003c/sup\u003e. Hecker et al. reported a societal burden of approximately \u0026euro;11,500 per year for obesity, with the largest share of the costs accounted for by the productivity sector\u003csup\u003e20\u003c/sup\u003e. Additionally, Mastrigt et al. investigated the societal burden of stroke and reported that non-healthcare costs such as productivity losses and informal care significantly contribute to the total costs\u003csup\u003e40\u003c/sup\u003e. Furthermore, a large study on the economic cost of brain disorders also found that indirect costs such as absenteeism from work account for 40% of the costs\u003csup\u003e41\u003c/sup\u003e. Thus, more consideration for non-healthcare costs such as maintaining labour feasibility is essential and may deem more effective in reducing the overall societal costs compared to focussing primarily on reducing healthcare costs.\u003c/p\u003e \u003cp\u003eWhen comparing the utility score among patients with AIS (0.7) to the utility score for the general Dutch population (0.87 SD 0.17), it can be seen that AIS has a large impact on the experienced quality of life\u003csup\u003e37\u003c/sup\u003e. The Hence, the MID in utility scores between AIS patients and the healthy Dutch population indicates that the threshold of 0.06 has been surpassed. The utility score derived from this study is slightly lower compared to previous studies looking at the HRQoL among AIS patients. Diarbakerli et al. measured HRQoL using the EQ-5D and reported utility scores of 0.82 for untreated patients, 0.82 for previously braced patients and 0.79 for surgically treated patients\u003csup\u003e42\u003c/sup\u003e. Larson et al. reported similar utility measures of 0.85 for untreated patients, 0.88 for patients in the bracing cohort and 0.83 for surgically treated patients\u003csup\u003e43\u003c/sup\u003e. Chua et al. reported slightly higher EQ-5D-5L utility scores of 0.90 (SD 0.17) and 0.88 (SD 0.19) for patients treated with observation and bracing respectively\u003csup\u003e44\u003c/sup\u003e. Variations in utility scores may be due to differences in study design, country of study conduction as well as sample population. The study by Diarbakerli et al. performed in Sweden included patients with juvenile and adolescent idiopathic scoliosis whilst the study by Chua was conducted in Singapore. Although, the SRS-22r results showed minor differences between the domains it is interesting to note that patients scored lowest on the domains pain (3.0), management (dis)satisfaction (3.0) and self-image (3.4). These are important domains to consider since they can influence successful treatment outcomes. Although the average score for the domain management (dis)satisfaction varies among studies, it receives the worst scores when compared to the other domains\u003csup\u003e43\u0026ndash;45\u003c/sup\u003e. Unlike previous publications, the average scores for the domain pain are relatively low e.g. 3.0 vs scores\u0026thinsp;\u0026gt;\u0026thinsp;4.0\u003csup\u003e42, 44\u003c/sup\u003e. However, our study includes AIS patients of all ages rather than patients aged between 11\u0026ndash;21 years old and our subgroup analyses showed that pain worsens with age. Additionally, variations in pain perception and adaptation may be present due to factors such as cultural experience\u003csup\u003e46\u003c/sup\u003e. In contrast to the study findings of Diarbakerli et al. differences in SRS-22r scores for patients of different ages for the domains function, pain and self-image were found. Diarbakerli et al. included patients with juvenile and adolescent idiopathic scoliosis as well as comparing various treatment modalities which could have accounted for the differences in findings\u003csup\u003e42\u003c/sup\u003e.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003eGeneralizability and transferability\u003c/h2\u003e \u003cp\u003eAlthough this study may be used as a blueprint for studies in alternative settings, the question rises whether the study findings are generalizable across regions and countries. Considering the differences in healthcare system organization and financing between countries, country-specific analysis may provide the most accurate results. Although the FCM is advised by the Dutch Costing Guidelines\u003csup\u003e17\u003c/sup\u003e the HCA was also performed for comparison since this is recommended in numerous other countries. Since the adoption of either method depends largely on subjective evaluation and preference, providing both estimates ensures transferability and generalizability\u003csup\u003e47\u003c/sup\u003e. The SRS-22r is a standardized, generally acknowledged questionnaire which allows for between-study comparisons. The EQ-5D is also standardized and internationally well recognized but the utility value sets are country specific making comparison more challenging.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003eImplications\u003c/h2\u003e \u003cp\u003eThe findings of this study may be relevant to both health care and general policy, as well as clinical practice. Firstly, there is need for more education on the effects of scoliosis and the difficulties that patients may experience in their working environment. The societal impact of AIS is predominantly due to the healthcare and productivity sectors. In an already burdened labour market, more attention towards an ergonomic workplace may help to avoid presenteeism and absenteeism. Consequently, productivity costs can be reduced drastically. More qualitative research is needed to determine what problems patients with AIS experience in the workplace and how this affects their productivity and presenteeism at work. Furthermore, the main domains that patients identified as experiencing problems in were pain/discomfort, anxiety/depression and management/satisfaction with their healthcare trajectory. Pain management, mental well-being and the dissatisfaction with the healthcare trajectory is a point of concern and warrants further research since it can impact successful treatment outcome. Considering the societal costs presented are most likely an underestimation since the burden on family and caretakers could not be assessed completely, more research is needed. Additionally, more extensive research in the Netherlands and other countries will help gain a broader perspective of all aspects that impact AIS and allow for between country comparison.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThe standardization and transparency with which the methodological steps are portrayed are a major strength of this study. Additionally, the use of the Dutch costing guideline, the Dutch value sets for EQ-5D utility, the methodological reporting guidelines and protocol registration helped ensure research integrity\u003csup\u003e16, 18\u003c/sup\u003e. Furthermore, the costing and quality of life measurements were performed using the preferred bottom-up method\u003csup\u003e48, 49\u003c/sup\u003e. However, this study also has limitations. The diagnosis of patients could not be verified using the survey. However, the definition of AIS was extensively described in the questionnaire to help participants determine whether their diagnosis was AIS. Due to participation on a voluntary basis, there is also a risk of selection bias, which may reduce generalizability. Additionally, there was incompleteness of data. The most likely reasons for incompleteness of data is the extensiveness of the survey considering completing the questionnaires required a considerable amount of time. The mean utility score for the EQ-5D-Y was 0.61. However, this score is not very informative considering the lack of power due to the small sample size of n\u0026thinsp;=\u0026thinsp;6. Also, due to time constraints a prevalence-based approach was adopted implying that costs could only be estimated for the period of one year rather than a lifetime and hence the impact of quality of life over time could not be measured. Another limitation was that retrospective, self-reported questionnaires may have led to recall bias and inaccuracy of the answers provided. For example, the SRS-22r refers to a recall period of 6 months in some questions but also contains questions which refer to the past week which may be answered with less recall error as a result\u003csup\u003e50\u003c/sup\u003e. Regardless, the SRS-22r questionnaire is specific to the studied population and useful for between-study comparisons. Additionally, due to use of standardized questionnaires no additional information was obtained via follow-up questions.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe estimated societal burden associated with AIS in the Netherlands was \u0026euro;12,275 per individual per year. The average EQ-5D utility score was 0.7 and patients indicated that AIS caused them pain and induced problems with daily functioning and self-image. This indicates that AIS has an impact on the societal costs and health-related quality of life. More than 90% of the societal impact can be accounted for by costs associated with healthcare related (50%) and productivity losses (42%). It is crucial to identify factors that prohibit patients with AIS to perform their work optimally and to reduce the number of days absent from work due to illness or complaints. Thus, to reduce this burden more political and clinical attention should be paid to the prevention of symptoms and limitations within the labour sector and patient-centred healthcare trajectories. Furthermore, attention should be paid to pain management and shared decision making to increase patient satisfaction with the adopted treatment.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAIS: Adolescent Idiopathic Scoliosis\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCHEERS: Consolidated Health Economic Evaluation Reporting Standards\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEQ-5D-5L: EuroQol 5-level\u003c/p\u003e\n\u003cp\u003eEQ-5D-Y: EuroQol 5-dimensions Youth\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEQ-VAS: EuroQol Visual Analogue Scale\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFCM: \u0026nbsp;Friction Cost Method\u003c/p\u003e\n\u003cp\u003eHCA: Human Capital Approach \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHRQoL: Health-related Quality of Life\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eICC: Intraclass Correlation Coefficient\u003c/p\u003e\n\u003cp\u003eiMTA-MCQ: Institute for Medical Technology Assessment - Medical Consumption Questionnaire\u003c/p\u003e\n\u003cp\u003eiMTA-PCQ: Institute for Medical Technology Assessment \u0026ndash; Productivity Cost Questionnaire\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMETC: Medical Ethical Testing Committee\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMUMC+: Maastricht University Medical Centre\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSRS-22r: Scoliosis Research Society-22 Revised Version\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate: Non-WMO approval was obtained from the Medical Ethical Testing Committee (METC) of the MUMC+ as well as consent from the advisory board (METC 2022-3166). Informed consent was obtained from all participants prior to the start of the study.\u003c/p\u003e\n\u003cp\u003eConsent for publication: Not applicable. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials: The datasets generated and/or analysed during the study are available from the corresponding author upon reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting interests: The authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFunding: The research for this paper was financially supported by the PRosPERoS-II project, funded by the Interreg VA Flanders \u0026ndash; the Netherlands program, CCI grant no. 2021TC16RFCB041. The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.\u003c/p\u003e\n\u003cp\u003eAuthor\u0026rsquo;s contributions: Concept and design: TH, SA, PW, GM; analysis and interpretation: TH, SA, PW, GM; drafting manuscript: TH, SA; obtaining funding: JA; critical revision: TH, SA, JA, PW, GM; Supervision: SA, JA, PW, GM.\u003c/p\u003e\n\u003cp\u003eAcknowledgements: The authors would like to express their gratitude to the Dutch Scoliosis Patient Society, Stichting I love my back, physicians, therapists and participants in the Netherlands for investing time in this study by raising attention, distributing and completing the questionnaire.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eNegrini S, Donzelli S, Aulisa AG, Czaprowski D, Schreiber S, de Mauroy JC, et al. 2016 SOSORT guidelines: orthopaedic and rehabilitation treatment of idiopathic scoliosis during growth. 2018;13(1):3.\u003c/li\u003e\n\u003cli\u003ePiątek E, Zawadzka D, Ostrowska B. Correlation between clinical condition of scoliosis and perception of one\u0026rsquo;s body image by girls with adolescent idiopathic scoliosis. Physiotherapy Quarterly. 2018;26(3):34.\u003c/li\u003e\n\u003cli\u003eWang H, Tetteroo D, Arts J, Markopoulos P, Ito K. Quality of life of adolescent idiopathic scoliosis patients under brace treatment: a brief communication of literature review. Quality of Life Research. 2021;30(3):703-11.\u003c/li\u003e\n\u003cli\u003eGallant J-N, Morgan CD, Stoklosa JB, Gannon SR, Shannon CN, Bonfield CM. Psychosocial difficulties in adolescent idiopathic scoliosis: body image, eating behaviors, and mood disorders. World neurosurgery. 2018;116:421-32. e1.\u003c/li\u003e\n\u003cli\u003eSanders AE, Andras LM, Iantorno SE, Hamilton A, Choi PD, Skaggs DL. Clinically significant psychological and emotional distress in 32% of adolescent idiopathic scoliosis patients. Spine deformity. 2018;6(4):435-40.\u003c/li\u003e\n\u003cli\u003eDuramaz A, Yılmaz S, Ziroğlu N, Duramaz BB, Kara T. The effect of deformity correction on psychiatric condition of the adolescent with adolescent idiopathic scoliosis. European Spine Journal. 2018;27(9):2233-40.\u003c/li\u003e\n\u003cli\u003eJain A, Yeramaneni S, Kebaish KM, Raad M, Gum JL, Klineberg EO, et al. Cost-Utility Analysis of rhBMP-2 Use in Adult Spinal Deformity Surgery. Spine (Phila Pa 1976). 2020;45(14):1009-15.\u003c/li\u003e\n\u003cli\u003eChoi J-H, Oh E-G, Lee H-J. Comparisons of postural habits, body image, and peer attachment for adolescents with idiopathic scoliosis and healthy adolescents. Child Health Nursing Research. 2011;17(3):167-73.\u003c/li\u003e\n\u003cli\u003eKontodimopoulos N, Damianou K, Stamatopoulou E, Kalampokis A, Loukos I. Children\u0026rsquo;s and parents\u0026rsquo; perspectives of health-related quality of life in newly diagnosed adolescent idiopathic scoliosis. Journal of orthopaedics. 2018;15(2):319-23.\u003c/li\u003e\n\u003cli\u003eAl-Mohrej OA, Aldakhil SS, Al-Rabiah MA, Al-Rabiah AM. Surgical treatment of adolescent idiopathic scoliosis: Complications. Annals of Medicine and Surgery. 2020;52:19-23.\u003c/li\u003e\n\u003cli\u003eGlassman SD, Carreon LY, Shaffrey CI, Polly DW, Ondra SL, Berven SH, et al. The costs and benefits of nonoperative management for adult scoliosis. Spine. 2010;35(5):578-82.\u003c/li\u003e\n\u003cli\u003eGlassman SD, Berven S, Kostuik J, Dimar JR, Horton WC, Bridwell K. Nonsurgical resource utilization in adult spinal deformity. Spine. 2006;31(8):941-7.\u003c/li\u003e\n\u003cli\u003eDunn J, Henrikson NB, Morrison CC, Blasi PR, Nguyen M, Lin JS. Screening for adolescent idiopathic scoliosis: evidence report and systematic review for the US preventive services task force. Jama. 2018;319(2):173-87.\u003c/li\u003e\n\u003cli\u003eDeurloo J, Verkerk P. To screen or not to screen for adolescent idiopathic scoliosis? A review of the literature. Public health. 2015;129(9):1267-72.\u003c/li\u003e\n\u003cli\u003evan den Boom N, van den Hurk A, Kalmet P, Poeze M, Evers S. Economic evaluations in fracture research An Introduction with examples of foot fractures. Injury. 2022.\u003c/li\u003e\n\u003cli\u003eHusereau D, Drummond M, Augustovski F, de Bekker-Grob E, Briggs AH, Carswell C, et al. Consolidated Health Economic Evaluation Reporting Standards 2022 (CHEERS 2022) statement: updated reporting guidance for health economic evaluations. International Journal of Technology Assessment in Health Care. 2022;38(1).\u003c/li\u003e\n\u003cli\u003eHakkaart-van Roijen L, Van der Linden N, Bouwmans C, Kanters T, Tan SS. Kostenhandleiding. Methodologie van kostenonderzoek en referentieprijzen voor economische evaluaties in de gezondheidszorg In opdracht van Zorginstituut Nederland Geactualiseerde versie. 2015.\u003c/li\u003e\n\u003cli\u003eLarg A, Moss JR. Cost-of-illness studies. Pharmacoeconomics. 2011;29(8):653-71.\u003c/li\u003e\n\u003cli\u003eHoelen T-CA, Willems PC, Arts JJ, van Mastrigt G, Evers S. The economic and societal burden associated with adolescent idiopathic scoliosis: A burden-of-disease study protocol. North American Spine Society Journal (NASSJ). 2023;14:100231.\u003c/li\u003e\n\u003cli\u003eHecker J, Freijer K, Hiligsmann M, Evers SMAA. Burden of disease study of overweight and obesity; the societal impact in terms of cost-of-illness and health-related quality of life. BMC Public Health. 2022;22(1).\u003c/li\u003e\n\u003cli\u003eTharp K, Landrum J, editors. Qualtrics Advanced Survey Software Tools2017: Indiana University Workshop in Methods.\u003c/li\u003e\n\u003cli\u003eDahham J, Rizk R, Hiligsmann M, Daccache C, Khoury SJ, Darwish H, et al. The Economic and societal burden of multiple sclerosis on lebanese society: a cost-of-illness and quality of life study protocol. Expert review of pharmacoeconomics \u0026amp; outcomes research. 2021:1-8.\u003c/li\u003e\n\u003cli\u003eBouwmans C, Hakkaart-van Roijen L, Koopmanschap M, Krol M, Severens H, Brouwer W. Manual iMTA medical cost questionnaire (iMCQ). Rotterdam: iMTA, Erasmus Universiteit Rotterdam. 2013.\u003c/li\u003e\n\u003cli\u003eBouwmans C, Krol M, Severens H, Koopmanschap M, Brouwer W, Hakkaart-van Roijen L. The iMTA productivity cost questionnaire: a standardized instrument for measuring and valuing health-related productivity losses. Value in health. 2015;18(6):753-8.\u003c/li\u003e\n\u003cli\u003eNederland Z. Medicijnkosten. Medicijnkosten nl (2022, accessed October 20022). 2022.\u003c/li\u003e\n\u003cli\u003eNederland Z. Farmacotherapeutisch kompas. 2022.\u003c/li\u003e\n\u003cli\u003eCentraal Bureau Statistiek C. Jaarmutatie consumentenprijsindex; vanaf 1963: CBS; 2021 [Available from: https://opendata.cbs.nl/statline/#/CBS/nl/dataset/70936ned/table.\u003c/li\u003e\n\u003cli\u003eDevlin NJ, Brooks R. EQ-5D and the EuroQol Group: Past, Present and Future. Applied Health Economics and Health Policy. 2017;15(2):127-37.\u003c/li\u003e\n\u003cli\u003eSchl\u0026ouml;sser TP, Stadhouder A, Schimmel JJ, Lehr AM, van der Heijden GJ, Castelein RM. Reliability and validity of the adapted Dutch version of the revised Scoliosis Research Society 22-item questionnaire. The Spine Journal. 2014;14(8):1663-72.\u003c/li\u003e\n\u003cli\u003ePatrick DL, Deyo RA. Generic and disease-specific measures in assessing health status and quality of life. Med Care. 1989;27(3 Suppl):S217-32.\u003c/li\u003e\n\u003cli\u003eFeng Y-S, Kohlmann T, Janssen MF, Buchholz I. Psychometric properties of the EQ-5D-5L: a systematic review of the literature. Quality of Life Research. 2020:1-27.\u003c/li\u003e\n\u003cli\u003eBuchholz I, Janssen MF, Kohlmann T, Feng Y-S. A systematic review of studies comparing the measurement properties of the three-level and five-level versions of the EQ-5D. Pharmacoeconomics. 2018;36(6):645-61.\u003c/li\u003e\n\u003cli\u003eVan Reenen M, Janssen B, Oppe M, Kreimeier S, Greiner W, Stolk E. EuroQol Research Foundation. EQ-5d-Y User Guide. 2020.\u003c/li\u003e\n\u003cli\u003eMonticone M, Nava C, Leggero V, Rocca B, Salvaderi S, Ferrante S, et al. Measurement properties of translated versions of the Scoliosis Research Society-22 Patient Questionnaire, SRS-22: a systematic review. Quality of Life Research. 2015;24(8):1981-98.\u003c/li\u003e\n\u003cli\u003eHaher TR, Gorup JM, Shin TM, Homel P, Merola AA, Grogan DP, et al. Results of the Scoliosis Research Society instrument for evaluation of surgical outcome in adolescent idiopathic scoliosis. A multicenter study of 244 patients. Spine (Phila Pa 1976). 1999;24(14):1435-40.\u003c/li\u003e\n\u003cli\u003ePeters M, Crocker H. Disease-Specific Questionnaire. In: Michalos AC, editor. Encyclopedia of Quality of Life and Well-Being Research. Dordrecht: Springer Netherlands; 2014. p. 1667-8.\u003c/li\u003e\n\u003cli\u003eVersteegh MM, Vermeulen KM, Evers SM, De Wit GA, Prenger R, Stolk EA. Dutch tariff for the five-level version of EQ-5D. Value in health. 2016;19(4):343-52.\u003c/li\u003e\n\u003cli\u003eRoudijk B, Sajjad A, Essers B, Lipman S, Stalmeier P, Finch AP. A Value Set for the EQ-5D-Y-3L in the Netherlands. PharmacoEconomics. 2022.\u003c/li\u003e\n\u003cli\u003eMcClure NS, Al Sayah F, Xie F, Luo N, Johnson JA. Instrument-defined estimates of the minimally important difference for EQ-5D-5L index scores. Value in Health. 2017;20(4):644-50.\u003c/li\u003e\n\u003cli\u003evan Mastrigt G, van Heugten C, Visser-Meily A, Bremmers L, Evers S. Estimating the burden of stroke: two-year societal costs and generic health-related quality of life of the Restore4Stroke Cohort. International Journal of Environmental Research and Public Health. 2022;19(17):11110.\u003c/li\u003e\n\u003cli\u003eOlesen J, Gustavsson A, Svensson M, Wittchen HU, J\u0026ouml;nsson B, Group CS, et al. The economic cost of brain disorders in Europe. European journal of neurology. 2012;19(1):155-62.\u003c/li\u003e\n\u003cli\u003eDiarbakerli E, Grauers A, Danielsson A, Gerdhem P. Health-related quality of life in adulthood in untreated and treated individuals with adolescent or juvenile idiopathic scoliosis. JBJS. 2018;100(10):811-7.\u003c/li\u003e\n\u003cli\u003eLarson AN, Baky F, Ashraf A, Baghdadi YM, Treder V, Polly DW, et al. Minimum 20-year health-related quality of life and surgical rates after the treatment of adolescent idiopathic scoliosis. Spine deformity. 2019;7(3):417-27.\u003c/li\u003e\n\u003cli\u003eChua YL, Toh AJN, Tan XYB, Pan DCY, Lee NKL, Lim KBL. Aspects of Patient Experience Associated With Improved Scoliosis Research Society-22 Revised (SRS-22R) and European Quality of Life Five-Dimension Five-Level (EQ-5D-5L) Scores in Patients With Adolescent Idiopathic Scoliosis Managed With Observation or Bracing. Spine. 2023;48(9):617-24.\u003c/li\u003e\n\u003cli\u003eCheung PWH, Wong CKH, Cheung JPY. An insight into the health-related quality of life of adolescent idiopathic scoliosis patients who are braced, observed, and previously braced. Spine. 2019;44(10):E596-E605.\u003c/li\u003e\n\u003cli\u003eSharma S, Ferreira-Valente A, de C. Williams AC, Abbott JH, Pais-Ribeiro J, Jensen MP. Group Differences Between Countries and Between Languages in Pain-Related Beliefs, Coping, and Catastrophizing in Chronic Pain: A Systematic Review. Pain Medicine. 2020;21(9):1847-62.\u003c/li\u003e\n\u003cli\u003eKrol M, Brouwer W. How to estimate productivity costs in economic evaluations. Pharmacoeconomics. 2014;32(4):335-44.\u003c/li\u003e\n\u003cli\u003eTan SS, Rutten F, Van Ineveld B, Redekop W, Hakkaart-van Roijen L. Comparing methodologies for the cost estimation of hospital services. The European Journal of Health Economics. 2009;10(1):39-45.\u003c/li\u003e\n\u003cli\u003eWordsworth S, Ludbrook A. Comparing costing results in across country economic evaluations: the use of technology specific purchasing power parities. Health economics. 2005;14(1):93-9.\u003c/li\u003e\n\u003cli\u003eClarke PM, Fiebig DG, Gerdtham U-G. Optimal recall length in survey design. Journal of health economics. 2008;27(5):1275-84.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Adolescent idiopathic scoliosis, Burden of disease, Cost of illness, Dutch Population, Health-related quality of life","lastPublishedDoi":"10.21203/rs.3.rs-4377673/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4377673/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAdolescent idiopathic scoliosis (AIS) has a general population prevalence of 2\u0026ndash;3%. The impact of AIS on the patients\u0026rsquo; quality of life is increasingly recognized. However, there is limited knowledge on the societal burden of AIS. Therefore, this study aimed to determine societal burden of AIS.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA cross-sectional, prevalence-based, bottom-up burden of disease study was conducted. AIS patients or parents of a child with AIS residing in the Netherlands were eligible for inclusion. The survey was distributed between June - December 2022 and was completed once by each participant. The institute for Medical Technology Assessment - Medical Consumption and Productivity Cost Questionnaires were used to assess costs. The health-related quality of life (HRQoL) was assessed using the EuroQol 5D-5L/EuroQol 5D Youth and the Scoliosis Research Society-22 revised questionnaires. Costs and HRQoL were identified, measured, and valued.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eParticipants (n\u0026thinsp;=\u0026thinsp;229) were predominantly female (92%), on average 35 years old, and were employed (65%). The societal cost for a patient with AIS in the Netherlands was \u0026euro;12,275 per year. The largest costs were estimated for the healthcare and productivity sectors. The mean utility score for adults was 0.7 (SD 0.20). Severe pain was experienced by 10% of the adult participants and 44% reported to experience moderate pain/discomfort. Statistically significant differences between different age groups were present for individual sector costs and HRQoL.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eAIS negatively impacts societal costs and the HRQoL. Reducing the productivity sector burden and further improving the HRQoL of life for patients with AIS is needed.\u003c/p\u003e","manuscriptTitle":"The Societal Burden associated with Adolescent Idiopathic Scoliosis: a cross-sectional burden-of-disease study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-21 19:00:02","doi":"10.21203/rs.3.rs-4377673/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-05-14T07:48:50+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-10T01:34:42+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-10T01:34:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2024-05-06T14:49:51+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f26b2f8a-4bb7-43e6-8f1b-c692d7cf1f38","owner":[],"postedDate":"May 21st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-11-11T16:09:49+00:00","versionOfRecord":{"articleIdentity":"rs-4377673","link":"https://doi.org/10.1186/s12889-024-20423-x","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2024-11-06 15:57:04","publishedOnDateReadable":"November 6th, 2024"},"versionCreatedAt":"2024-05-21 19:00:02","video":"","vorDoi":"10.1186/s12889-024-20423-x","vorDoiUrl":"https://doi.org/10.1186/s12889-024-20423-x","workflowStages":[]},"version":"v1","identity":"rs-4377673","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4377673","identity":"rs-4377673","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}