Laura Vallejo-Torres1, Borja García-Lorenzo2, Iván Castilla3, Cristina Valcárcel-Nazco4, Lidia García-Pérez4, Renata Linertová4, Elena Polentinos-Castro5, Pedro Serrano-Aguilar6. 1. Departamento de Economía Aplicada y Métodos Cuantitativos, Universidad de la Laguna; Centre for Biomedical Research of the Canary Islands (CIBICAN); Spanish Network of Health Services Research for Chronic Diseases (REDISSEC); Department of Applied Health Research, University College London, London, UK. Electronic address: lvallejo@ull.es. 2. Canary Foundation for Health Care Research (FUNCANIS). 3. Centre for Biomedical Research of the Canary Islands (CIBICAN); Spanish Network of Health Services Research for Chronic Diseases (REDISSEC); Departamento de Ingeniería Informática y de Sistemas, Universidad de La Laguna. 4. Spanish Network of Health Services Research for Chronic Diseases (REDISSEC); Canary Foundation for Health Care Research (FUNCANIS). 5. Spanish Network of Health Services Research for Chronic Diseases (REDISSEC); Unidad Docente de Atención Familiar y Comunitaria Norte, Gerencia de Atención Primaria, Servicio Madrileño de Salud. 6. Spanish Network of Health Services Research for Chronic Diseases (REDISSEC); Servicio de Evaluación del Servicio Canario de la Salud (SESCS), Canary Islands, Spain.
Abstract
BACKGROUND: Many health care systems claim to incorporate the cost-effectiveness criterion in their investment decisions. Information on the system's willingness to pay per effectiveness unit, normally measured as quality-adjusted life-years (QALYs), however, is not available in most countries. This is partly because of the controversy that remains around the use of a cost-effectiveness threshold, about what the threshold ought to represent, and about the appropriate methodology to arrive at a threshold value. OBJECTIVES: The aim of this article was to identify and critically appraise the conceptual perspectives and methodologies used to date to estimate the cost-effectiveness threshold. METHODS: We provided an in-depth discussion of different conceptual views and undertook a systematic review of empirical analyses. Identified studies were categorized into the two main conceptual perspectives that argue that the threshold should reflect 1) the value that society places on a QALY and 2) the opportunity cost of investment to the system given budget constraints. RESULTS: These studies showed different underpinning assumptions, strengths, and limitations, which are highlighted and discussed. Furthermore, this review allowed us to compare the cost-effectiveness threshold estimates derived from different types of studies. We found that thresholds based on society's valuation of a QALY are generally larger than thresholds resulting from estimating the opportunity cost to the health care system. CONCLUSIONS: This implies that some interventions with positive social net benefits, as informed by individuals' preferences, might not be an appropriate use of resources under fixed budget constraints.
BACKGROUND: Many health care systems claim to incorporate the cost-effectiveness criterion in their investment decisions. Information on the system's willingness to pay per effectiveness unit, normally measured as quality-adjusted life-years (QALYs), however, is not available in most countries. This is partly because of the controversy that remains around the use of a cost-effectiveness threshold, about what the threshold ought to represent, and about the appropriate methodology to arrive at a threshold value. OBJECTIVES: The aim of this article was to identify and critically appraise the conceptual perspectives and methodologies used to date to estimate the cost-effectiveness threshold. METHODS: We provided an in-depth discussion of different conceptual views and undertook a systematic review of empirical analyses. Identified studies were categorized into the two main conceptual perspectives that argue that the threshold should reflect 1) the value that society places on a QALY and 2) the opportunity cost of investment to the system given budget constraints. RESULTS: These studies showed different underpinning assumptions, strengths, and limitations, which are highlighted and discussed. Furthermore, this review allowed us to compare the cost-effectiveness threshold estimates derived from different types of studies. We found that thresholds based on society's valuation of a QALY are generally larger than thresholds resulting from estimating the opportunity cost to the health care system. CONCLUSIONS: This implies that some interventions with positive social net benefits, as informed by individuals' preferences, might not be an appropriate use of resources under fixed budget constraints.
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