Introduction: Some decisions in the Austrian healthcare system are informed by evidence-based recommendations from Health Technology Assessment (HTA) reports. However, Austria lacks a formal, publicly endorsed health economic evaluation guideline (HEEG) with detailed methodological specifications, which hinders the broader application of health economic evidence in reimbursement decisions. This review systematically examined international HEEGs to identify common standards of health economic evaluations (HEEs) and inform the development of an Austrian guideline.

Methods: We conducted a comparative analysis of national HEEGs from countries with healthcare systems comparable to Austria's. Through a comprehensive manual search, we identified guidelines meeting the following inclusion criteria: mandatory regulatory status in the given national jurisdiction; published or updated by June 2025; originating in a high-income country; available in English or a European Union language. Recommendations on the core methodological domains of HEEGs were systematically extracted and summarised to identify common patterns and variations. The endorsed methodological choices and their implications were then critically examined in the light of their possible implementation in the Austrian context.

Results: Sixteen HEEGs were included. The analysis revealed a strong international convergence on the preferred analytic technique, the outcome measure and measurement tool, the time horizon, the preferred sources of effectiveness evidence, and reliance on modelling. Greatest methodological variation was observed in the defined scope of the HEEGs, the approach to equity, the comprehensiveness of guidance on modelling, the instructions for reporting results, and the prescribed discount rate. The remaining methodological aspects were characterised by a shared underlying principle but slightly divergent operationalisation. Broadly, these methodological differences can be attributed to strategic decisions and value judgements (e.g., legal status, scope, discount rate, and equity approach), differences in local analytical capacities (e.g., modelling and uncertainty analysis requirements), and data availability (e.g., perspective and outcome valuation). Several outliers originate from jurisdictions with well-established HTA traditions and therefore demonstrate more comprehensive and advanced approaches to HEE.

Conclusion: International HEEGs demonstrate substantial methodological harmonisation that supports credible, evidence-based decision-making while accommodating jurisdiction-specific preferences. The development of an Austrian HEEG should build on this convergence by prioritising capacity-building in those identified areas that require pre-existing data infrastructure, while involving policymakers early in discussions of methodological requirements that reflect their preferences.