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. 2018;11(1):1447828.
doi: 10.1080/16549716.2018.1447828.

On what basis are medical cost-effectiveness thresholds set? Clashing opinions and an absence of data: a systematic review

David Cameron  1 , Jasper Ubels  1 , Fredrik Norström  1
Affiliations

On what basis are medical cost-effectiveness thresholds set? Clashing opinions and an absence of data: a systematic review

David Cameron et al. Glob Health Action. 2018.

Abstract

Background: The amount a government should be willing to invest in adopting new medical treatments has long been under debate. With many countries using formal cost-effectiveness (C/E) thresholds when examining potential new treatments and ever-growing medical costs, accurately setting the level of a C/E threshold can be essential for an efficient healthcare system.

Objectives: The aim of this systematic review is to describe the prominent approaches to setting a C/E threshold, compile available national-level C/E threshold data and willingness-to-pay (WTP) data, and to discern whether associations exist between these values, gross domestic product (GDP) and health-adjusted life expectancy (HALE). This review further examines current obstacles faced with the presently available data.

Methods: A systematic review was performed to collect articles which have studied national C/E thresholds and willingness-to-pay (WTP) per quality-adjusted life year (QALY) in the general population. Associations between GDP, HALE, WTP, and C/E thresholds were analyzed with correlations.

Results: Seventeen countries were identified from nine unique sources to have formal C/E thresholds within our inclusion criteria. Thirteen countries from nine sources were identified to have WTP per QALY data within our inclusion criteria. Two possible associations were identified: C/E thresholds with HALE (quadratic correlation of 0.63), and C/E thresholds with GDP per capita (polynomial correlation of 0.84). However, these results are based on few observations and therefore firm conclusions cannot be made.

Conclusions: Most national C/E thresholds identified in our review fall within the WHO's recommended range of one-to-three times GDP per capita. However, the quality and quantity of data available regarding national average WTP per QALY, opportunity costs, and C/E thresholds is poor in comparison to the importance of adequate investment in healthcare. There exists an obvious risk that countries might either over- or underinvest in healthcare if they base their decision-making process on erroneous presumptions or non-evidence-based methodologies. The commonly referred to value of 100,000$ USD per QALY may potentially have some basis.

Keywords: C/E thresholds; HALE; QALY; WTP; cost-effective; decision-making; healthy adjusted life expectancy; international; systematic review; willing-to-pay.

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Conflict of interest statement

No potential conflict of interest was reported by the authors.

Figures

Figure 1.
Figure 1.
Stream diagram of C/E threshold article search.
Figure 2.
Figure 2.
Stream diagram WTP per QALY studies.
Figure 3.
Figure 3.
Cost-effectiveness thresholds in purchasing power parity adjusted 2015 US dollars compared to healthy adjusted life expectancy by country.
Figure 4.
Figure 4.
Cost-effectiveness threshold plotted against GDP per capita.
Figure B1.
Figure B1.
WTP per QALY plotted against HALEs by country. The Y-axis has been truncated for clarity.
Figure B2.
Figure B2.
GDP per capita plotted against WTP per QALY by country.
Figure B3.
Figure B3.
C/E Threshold plotted against WTP per QALY by country.
Figure C1.
Figure C1.
Expenditure and opportunity costs in healthcare investments (adapted from Baker et al. [5], used with permission from authors and publisher).
See this image and copyright information in PMC

References

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