Abstract
Concern with the threshold applied in cost-effectiveness analyses by bodies such as NICE distracts attention from their biased use of the principle. The bias results from the prior requirement that an intervention be effective (usually 'clinically effective') before its cost-effectiveness is considered. The underlying justification for the use of cost-effectiveness as a criterion, whatever the threshold adopted, is that decisions in a resource-constrained system have opportunity costs. Their existence rules out any restriction to those interventions that are 'incrementally cost-effective' at a chosen threshold and requires acceptance of those that are 'decrementally cost-effective' at the same threshold. Interventions that fall under the linear ICER line in the South-West quadrant of the cost-effectiveness plane are cost-effective because they create net health benefits, as do those in the North-East quadrant. If there is objection to the fact that they are cost-effective by reducing effectiveness as well as costs, it is possible to reject them, but only on policy grounds other than their failure to be cost-effective. Having established this, the paper considers and seeks to counter the arguments based on these other grounds. Most notably these include those proposing a different threshold in the South-West quadrant from the North-East one, i.e. propose a 'kinked ICER'. Another undesirable consequence of the biased use of cost-effectiveness is the failure to stimulate innovations that would increase overall health gain by being less effective in the condition concerned, but generate more benefits elsewhere. NICE can only reward innovations that cost more.
Highlights
The publication of the Claxton report containing an estimate of the willingness to pay for an incremental Quality-Adjusted Life Year (QALY) implicit in the expenditure patterns of the NHS of England and Wales has refocused attention on the use by the National Institute for Care and Health Excellence (NICE) of costeffectiveness as one criterion in its reimbursement decisions[1,2]
We argue that the inability to relate emotionally to the loss of a relatively small amount of health by very large numbers, compared to the ability to relate to the gain of even a moderate amount for an identified individual – say one QALDay for 30,000 people compared with 1 QALY for one person - is to be treated as a problem to be addressed and overcome at the policy level, not to be automatically accommodated
NICE is charged with objectives other than maximising the increase in public health and among its other obligations is to support innovation. This turns out to be biased support, in that no support can be provided for the development of technologies that are cost-effective. These would include innovations which could improve population health by being less costly and less effective – such as SWA in Figure 1, or ones further to the east of the SW quadrant, including the ones that would fall under a kinked Incremental Cost-Effectiveness Ratio (ICER), or meet the Maximally Acceptable Difference (MAD) test of Kent et al No innovation in the SW quadrant can meet the filter test of clinical effectiveness administered prior to the test of cost-effectiveness
Summary
1. Jeffrey Braithwaite, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia. 2. Jes Søgaard, Aarhus University, Aarhus, Denmark Danish Cancer Society, Copenhagen, Denmark. Any reports and responses or comments on the article can be found at the end of the article. Keywords cost-effectiveness , incremental cost-effectiveness , decremental costeffectiveness , south-west quadrant
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