Methodological limitations of cost-effectiveness analysis in health care: implications for decision making and service provision.

This article reviews the methodological limitations identified in a recent authoritative US report by the Public Health Service, which provides the theoretical background to several other guidelines on cost effectiveness, such as those of the British Medical Journal. It places each limitation in context and discusses the implications of each individually and collectively. It concludes that while the report's interim solution by consensus agreement offers a way forward in the short term, the complexities identified reveal a range of limitations to the more heroic uses of cost effectiveness analysis in healthcare. More modest approaches, it is suggested, may have greater practical relevance.