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

• Published in: Global health action 2018, Vol.11 (1), p.1447828-14
• Main Authors: Cameron, David, Ubels, Jasper, Norström, Fredrik
• Format: Article
• Language: English
• Subjects: Averages; C/E thresholds; Cost analysis; Cost-Benefit Analysis; cost-effective; Decision making; Delivery of Health Care - economics; Economic models; Expected utility; Expenditures; GDP; Gross Domestic Product; HALE; Health care expenditures; Health Expenditures - statistics & numerical data; healthy adjusted life expectancy; Humans; international; Intervention; Life expectancy; Medical treatment; Opportunity costs; Per capita; Population; Presumptions; Purchasing power parity; QALY; Quality adjusted life years; Review; Systematic review; Thresholds; Values; willing-to-pay; Willingness to pay; WTP
• ISSN: 1654-9716; 1654-9880; 1654-9880
• DOI: 10.1080/16549716.2018.1447828

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.