Abstract
The National Institute for Health and Care Excellence (NICE) emphasises that cost-effectiveness is not the only consideration in health technology appraisal and is increasingly explicit about other factors considered relevant but not the weight attached to each. The objective of this study is to investigate the influence of cost-effectiveness and other factors on NICE decisions and whether NICE's decision-making has changed over time. We model NICE's decisions as binary choices for or against a health care technology in a specific patient group. Independent variables comprised of the following: clinical and economic evidence; characteristics of patients, disease or treatment; and contextual factors potentially affecting decision-making. Data on all NICE decisions published by December 2011 were obtained from HTAinSite [www.htainsite.com]. Cost-effectiveness alone correctly predicted 82% of decisions; few other variables were significant and alternative model specifications had similar performance. There was no evidence that the threshold has changed significantly over time. The model with highest prediction accuracy suggested that technologies costing £40 000 per quality-adjusted life-year (QALY) have a 50% chance of NICE rejection (75% at £52 000/QALY; 25% at £27 000/QALY). Past NICE decisions appear to have been based on a higher threshold than £20 000-£30 000/QALY. However, this may reflect consideration of other factors that cannot be easily quantified. © 2014 The Authors. Health Economics published by John Wiley & Sons Ltd.
Highlights
The decisions made on clinical grounds were, on average, published 2 years earlier than the average decision based on cost-effectiveness (p < 0.001), had less RCT evidence (p = 0.006) and were more likely to be for children (p < 0.001), the characteristics were otherwise similar (Table II)
Seventeen decisions were based on cost/quality-adjusted life-year (QALY) incremental cost-effectiveness ratio (ICER) that were not available for analysis
The 174 decisions based on cost-effectiveness that lacked available north-east quadrant cost/QALY ICERs tended to be published about 4 years earlier than those included in regression analyses (p < 0.001) and were less likely to be single technology appraisals (STAs; p < 0.001) or only treatments (p < 0.001)
Summary
Health technology assessment (HTA) agencies’ decision-making criteria are important for health care providers, patients’ eligibility for health care and technology firms’ revenue and investment and production decisions about current and potential products. The National Institute of Health and Care Excellence (NICE) provides guidance on which health care interventions are available from the National Health Service (NHS) in England and Wales. Areas of considerable uncertainty remain about their decision-making criteria
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