Are Estimates of the Health Opportunity Cost Being Used to Draw Conclusions in Published Cost-Effectiveness Analyses? A Scoping Review in Four Countries

Use of Cost-Effectiveness Thresholds in Healthcare Public Policy: Progress and Challenges

The article offers a comparative analysis of the influence of cost-effectiveness thresholds in the decision-making processes in financing policies, coverage, and price regulation of health technologies in nine countries. We investigated whether countries used cost-effectiveness thresholds for public health policy decision making and found that few countries have adopted the cost-effectiveness threshold as an official criterion for financing, reimbursement, or pricing. However, in countries where it is applied, such as Thailand, the results have been very favorable in terms of minimizing health technology prices and ensuring the financial sustainability of the health system. Although the cost-effectiveness threshold has opportunities for improvement, particularly in certain institutional contexts and with adequate participation of the different strategic actors in the formulation of public policy, its potential use and added value are significant in various aspects.

Factors associated with the author-reported cost-effectiveness threshold in high-income countries: systematic review and multivariable modelling

OBJECTIVE

The cost-effectiveness threshold (CET) is a key parameter to guide objective reimbursement decisions, yet very few countries have defined a reference CET, and there is no reference method for defining it. Our objective was to determine the factors explaining the author-reported CETs in the literature.

METHODS

Our systematic review targeted original articles referenced in EMBASE and published between 2010 and 2021. Selected studies had to use Quality-Adjusted Life-Year (QALY), and being conducted in high-income countries. Our explanatory variables were: estimated cost-effectiveness ratio (ICER), region of the world, source of funding, type of intervention, disease, year of publication, justification of the author-reported Cost-Effectiveness Threshold (ar-CET), economic perspective, and declaration of interest. Multivariable linear regression models implemented on R software were used, guided by a Directed Acyclic Graph.

RESULTS

Two hundred and fifty four studies were included. The mean ar-CET was €63,338/QALY (standard deviation (SD) 34,965) overall, and €37,748/QALY (SD 20,750) in studies conducted in the British Commonwealth. The ar-CET increased slightly with the ICER (+ 66€/QALY for each additional 10,000€/QALY in the ICER, 95% confidence interval (IC) [31-102], p < 0.001), was higher in the United States (+ 36,225€/QALY; IC [25,582; 46,869]) and Europe (+ 10,352€/QALY; IC [72; 20,631]) compared to the British Commonwealth (p < 0.001), and was higher when the ar-CET was not defined a priori (+ 22,393€/QALY; [5809; 38,876]) compared to state recommendations defined ar-CET (p < 0.001).

CONCLUSIONS

Our results underline the virtuous role of state recommendations in the choice of a low and homogeneous CET. We also highlight the need to integrate the a priori justification of the CET into good publishing guidelines.

Cost-effectiveness Analysis of Single-Use Duodenoscope Applied to Endoscopic Retrograde Cholangiopancreatography

OBJECTIVES

Secondary infections due to transmission via the duodenoscope have been reported in up to 3% of endoscopic retrograde cholangiopancreatographies. The use of single-use duodenoscopes has been suggested. We investigate the cost-effectiveness of these duodenoscopes use in cholangiopancreatography.

MATERIALS AND METHODS

A cost-effectiveness analysis was implemented to compare the performance of cholangiopancreatographies with reusable duodenoscopes versus single-use duodenoscopes. Effectiveness was analyzed by calculating quality-adjusted life years (QALY) from the perspective of the National Health System. Possibility of crossover from single-use to reusable duodenoscopes was considered. A willingness-to-pay of €25,000/QALY was set, the incremental cost-effectiveness ratio (ICER) was calculated, and deterministic and probabilistic sensitivity analyses were performed.

RESULTS

Considering cholangiopancreatographies with single-use and reusable duodenoscopes at a cost of €2900 and €1333, respectively, and a 10% rate of single-use duodenoscopes, ICER was greater than €3,000,000/QALY. A lower single-use duodenoscope cost of €1211 resulted in an ICER of €23,583/QALY. When the unit cost of the single-use duodenoscope was €1211, a crossover rate of more than 9.5% made the use of the single-use duodenoscope inefficient.

CONCLUSIONS

Single-use duodenoscopes are cost-effective in a proportion of cholangiopancreatographies if its cost is reduced. Increased crossover rate makes single-use duodenoscope use not cost-effective.

Willingness to pay for cancer prevention versus treatment in China: implications for cost-effectiveness threshold

BACKGROUND

Empirical support for the appropriate cost-effectiveness threshold (CET) in China remains sparse.

OBJECTIVE

This study aimed to estimate the willingness to pay (WTP) for cancer prevention and treatment from the perspective of healthcare policy-makers (i.e. supply side) and to investigate whether there is a difference between the estimated WTP in two scenarios.

METHODS

We conducted a web-based survey from May to July 2022 among experts who offering consultation to the government. We surveyed 79 experts from a national think-tank (84.81% response rate) using contingent valuation method, a method for estimating the monetary value that individuals place on a non-market service.

RESULTS

The mean WTP for two scenarios were estimated at 1.29 times of per capita Gross Domestic Product (GDP) of China and 1.90 times of per capita GDP, respectively. There was a difference between the WTP in the two scenarios and the WTP for treatment was significantly higher than prevention.

CONCLUSION

The findings suggest that though there is a smaller gap between the two scenarios in China as compared to other countries, the WTP may vary under different scenarios. So there's a need to further refine the development of CET by adding parameters like prevention instead of defining one universal threshold.

The Broader Opportunity Costs in the Broader Cost-Effectiveness Analysis Framework

BACKGROUND

The traditional cost-effectiveness analysis framework usually takes a healthcare system perspective, where the aim is to maximise population health from a fixed budget allocated to healthcare. Extensions to this framework have been suggested, including: (i) incorporating impacts that fall outside the healthcare sector; (ii) accounting for outcomes beyond health; and (iii) assessing equity considerations. Several alternatives have been proposed that serve these purposes, for example, the extended "impact inventory", the "beyond-the-QALY" approach and the distributional cost-effectiveness analysis.

OBJECTIVE

This paper aims to develop a comprehensive framework that incorporates into the cost-effectiveness analysis framework some of its most advocated extensions and provides a means of arriving at a unidimensional cost-effectiveness analysis result measure.

METHODS

Building on previous work, I proposed a framework that explicitly incorporates the full extent of the opportunity costs that arise when new dimensions and distributional concerns are included in cost-effectiveness analyses. A hypothetical example is provided as a way of illustration.

RESULTS

Operationalising the proposed framework requires system-wide representative values and/or robust estimates concerning: (i) selecting dimensions; (ii) measuring opportunity costs associated with each dimension; (iii) quantifying equity weights and percentages of beneficiaries and losers meeting equity considerations; and (iv) attaching monetary values to dimensions measured using a non-monetary metric.

CONCLUSIONS

Extending the cost-effectiveness analysis framework entails extending the measurement of the opportunity costs of funding decisions. This implies populating an ambitious puzzle that in some cases poses fundamental conceptual and empirical questions. Potential routes of further research that might facilitate such undertaking are proposed.

Supply-Side Cost-Effectiveness Thresholds: Questions for Evidence-Based Policy

There is growing interest in cost-effectiveness thresholds as a tool to inform resource allocation decisions in health care. Studies from several countries have sought to estimate health system opportunity costs, which supply-side cost-effectiveness thresholds are intended to represent. In this paper, we consider the role of empirical estimates of supply-side thresholds in policy-making. Recent studies estimate the cost per unit of health based on average displacement or outcome elasticity. We distinguish the types of point estimates reported in empirical work, including marginal productivity, average displacement, and outcome elasticity. Using this classification, we summarise the limitations of current approaches to threshold estimation in terms of theory, methods, and data. We highlight the questions that arise from alternative interpretations of thresholds and provide recommendations to policymakers seeking to use a supply-side threshold where the evidence base is emerging or incomplete. We recommend that: (1) policymakers must clearly define the scope of the application of a threshold, and the theoretical basis for empirical estimates should be consistent with that scope; (2) a process for the assessment of new evidence and for determining changes in the threshold to be applied in policy-making should be created; (3) decision-making processes should retain flexibility in the application of a threshold; and (4) policymakers should provide support for decision-makers relating to the use of thresholds and the implementation of decisions stemming from their application.