Perspective and Costing in Cost-Effectiveness Analysis, 1974–2018

David D Kim,Peter J Neumann,Joshua T Cohen,Daniel A Ollendorf,Natalia Kunst,Madison C Silver

doi:10.1007/s40273-020-00942-2

Abstract

ObjectiveOur objective was to examine perspective and costing approaches used in cost-effectiveness analyses (CEAs) and the distribution of reported incremental cost-effectiveness ratios (ICERs).MethodsWe analyzed the Tufts Medical Center’s CEA and Global Health CEA registries, containing 6907 cost-per-quality-adjusted-life-year (QALY) and 698 cost-per-disability-adjusted-life-year (DALY) studies published through 2018. We examined how often published CEAs included non-health consequences and their impact on ICERs. We also reviewed 45 country-specific guidelines to examine recommended analytic perspectives.ResultsStudy authors often mis-specified or did not clearly state the perspective used. After re-classification by registry reviewers, a healthcare sector or payer perspective was most prevalent (74%). CEAs rarely included unrelated medical costs and impacts on non-healthcare sectors. The most common non-health consequence included was productivity loss in the cost-per-QALY studies (12%) and patient transportation in the cost-per-DALY studies (21%). Of 19,946 cost-per-QALY ratios, the median ICER was $US26,000/QALY (interquartile range [IQR] 2900–110,000), and 18% were cost saving and QALY increasing. Of 5572 cost-per-DALY ratios, the median ICER was $US430/DALY (IQR 67–3400), and 8% were cost saving and DALY averting. Based on 16 cost-per-QALY studies (2017–2018) reporting 68 ICERs from both the healthcare sector and societal perspectives, the median ICER from a societal perspective ($US22,710/QALY [IQR 11,991–49,603]) was more favorable than from a healthcare sector perspective ($US30,402/QALY [IQR 10,486–77,179]). Most governmental guidelines (67%) recommended either a healthcare sector or a payer perspective.ConclusionResearchers should justify and be transparent about their choice of perspective and costing approaches. The use of the impact inventory and reporting of disaggregate outcomes can reduce inconsistencies and confusion.Electronic supplementary materialThe online version of this article (10.1007/s40273-020-00942-2) contains supplementary material, which is available to authorized users.

Highlights

Practice guidelines for cost-effectiveness analysis (CEAs) emphasize the importance of the analytic perspective assumed in the analysis because it determines which costs and benefits are included [1,2,3,4]
We examined how often published CEAs included cost components beyond those traditionally included in an analysis from a healthcare sector perspective
After the registry reviewers reclassified the study perspective based on types of costs or benefits evaluated, the study perspective was unable to be determined in only 7% of CEAs

Summary

Introduction

Practice guidelines for cost-effectiveness analysis (CEAs) emphasize the importance of the analytic perspective assumed in the analysis because it determines which costs and benefits are included [1,2,3,4]. The choice of perspective and included cost components may have a substantial impact on the cost-effectiveness of interventions and, policy and resource allocation decision making [5,6,7]. The relevant audience—i.e., the population “on whose behalf are decisions made”—influences the choice of perspective [8]. Practice guidelines that endorse a broader societal perspective argue that considering everyone affected and counting all benefits and costs, regardless of who gains or loses, can provide the basis for fair decisions in the

Methods

Results

Discussion

Conclusion