Scarce Health Care Resources Research Articles

Impact of COVID-19 pandemic on diagnostic pathology in the Netherlands

BackgroundThe COVID-19 pandemic has a huge impact on healthcare provided. The nationwide pathology registry of the Netherlands, PALGA, offers an outstanding opportunity to measure this impact for diseases in which pathology examinations are involved.MethodsPathology specimen numbers in 2020 were compared with specimen numbers in 2019 for 5 periods of 4 weeks, representing two lockdowns and the periods in between, taking into account localization, procedure and benign versus malignant diagnosis.ResultsThe largest decrease was seen during the first lockdown (spring 2020), when numbers of pathology reports declined up to 88% and almost all specimen types were affected. Afterwards each specimen type showed its own dynamics with a decrease during the second lockdown for some, while for others numbers remained relatively low during the whole year. Generally, for most tissue types resections, cytology and malignant diagnoses showed less decrease than biopsies and benign diagnoses. A significant but small catch-up (up to 17%) was seen for benign cervical cytology, benign resections of the lower gastro-intestinal tract, malignant skin resections and gallbladder resections.ConclusionThe COVID-19 pandemic has had a significant effect on pathology diagnostics in 2020. This effect was most pronounced during the first lockdown, diverse for different anatomical sites and for cytology compared with histology. The data presented here can help to assess the consequences on (public) health and provide a starting point in the discussion on how to make the best choices in times of scarce healthcare resources, considering the impact of both benign and malignant disease on quality of life.

Economic Evaluation of Digital Health Interventions: Methodological Issues and Recommendations for Practice.

Health care interventions are increasingly being delivered through digital technologies, offering major opportunities for delivering more health gains from scarce health care resources. Digital health interventions (DHIs) raise distinct challenges for economic evaluations compared with drugs and medical devices, not least due to their interacting, evolving features. The implications of the distinctive nature of DHIs for the methodological choices underpinning their economic evaluation is not well understood. This paper provides an in-depth discussion of distinct features of DHIs and how they might impact the design, measurement, analysis and reporting of cost-effectiveness analysis conducted alongside both randomised and non-randomised studies. These include aspects related to choice of comparator, costs and benefits assessment, study perspective and type of economic analysis. We argue that typical methodological standpoints, such as taking a health service perspective, focusing on health-related benefits and adopting cost-utility analyses, as typically adopted in the economic evaluation of non-digital technologies (pharmaceutical drugs and medical devices), are unlikely to be appropriate for DHIs. We illustrate how these methodological aspects can be appropriately addressed in an evaluation of a digitally supported, remote rehabilitation programme for patients with Long Covid in England. We highlight several methodological considerations for improving practice and areas where further methodological work is required.

Organ donation in the time of COVID-19: the Israeli experience one year into the pandemic\u2014ethical and policy implications

PurposeTo present the response of the Israel National Transplantation Center (NTC) to the evolving challenge of COVID-19, the impact on deceased organ donation and living organ kidney donation during 2020, and resultant policy and ethical implications.MethodsData collected included (i) for deceased donors, the total number of potential organ donors, if hospitalized in ICU or general ward, cause of death, number of family authorizations and refusals, number of actual donors, number of organs transplanted/donor and total number of transplants performed; (ii) for living-kidney-donors (related or altruistic), the number of procedures performed; and (iii) the number of patients registered on the national organ waiting-list.ResultsFollowing the first case (February 2020), deceased organ donation continued uninterrupted. The total number of potential donors was similar to 2019 (181 vs. 189). However, the number of families approached for donation decreased significantly (P = 0.02). This may be attributed to COVID-19-imposed limitations including fewer brain death determinations due to limited possibilities for face-to-face donor coordinator-donor family interactions providing emotional support and visual explanations of the medical situation. Fewer donors were admitted to ICU (P = 0.1) and the number of organs retrieved/donor decreased (3.8/donor to 3.4/donor). The overall result was a decrease of 24.2% in the number of transplant procedures (306 vs. 232). Living kidney donation, initially halted, resumed in May and the total number of procedures increased compared to 2019 due to a significant increase in altruistic donations (P < 0.0001), while the number of related-living donations decreased.ConclusionThis study of organ donation during a crisis has informed the introduction of policy changes in the NTC including the necessity to mobilize rapidly a “war room”, the use of innovative virtual tools for contact-less communication, and the importance of cooperation with hospital authorities in allocating scarce health-care resources. Finally, the pandemic highlighted and intensified ethical considerations, such as under what circumstances living kidney donation be continued in the face of uncertainty, and what information to provide to altruistic donors regarding a prospective recipient, in particular whether all options for related living donation have been exhausted. These should be addressed now.

Functionality of Scarce Healthcare Resource Triage Teams During the COVID-19 Pandemic: A Multi-Institutional Simulation Study.

High-fidelity triage-team simulation study. Healthcare institutions in Washington state. Triage teams, consisting of at least two senior clinicians and a bioethicist. Participants reviewed a limited amount of deidentified information for a diverse sample of critically ill patients. Teams then assigned each patient to one of five prioritization categories defined by likelihood of survival to hospital discharge. The process was refined based on observation and participant feedback after which a second phase of simulations was conducted. Feasibility was assessed by the time required for teams to perform their task. Prognostic accuracy was assessed by comparing teams' prediction about likelihood of survival to hospital discharge with real-world discharge outcomes. Agreement between the teams on prognostic categorization was evaluated using kappa statistics. Eleven triage team simulations (eight in phase 1 and three in phase 2) were conducted from December 2020 to February 2021. Overall, teams reviewed a median of 23 patient cases in each session (interquartile range [IQR], 17-29) and spent a median of 102 seconds (IQR, 50-268) per case. The concordance between expected survival and real-world survival to discharge was 71% (IQR, 64-76%). The overall agreement between teams for placement of patients into prognostic categories was moderate (weighted kappa = 0.53). These findings support the potential feasibility, accuracy, and effectiveness of institutional triage teams informed by a limited set of patient information items as part of a strategy for allocating scarce resources in healthcare emergencies. Additional work is needed to refine the process and adapt it to local contexts.

Resource planning strategies for healthcare systems during a pandemic

We study resource planning strategies, including the integrated healthcare resources’ allocation and sharing as well as patients’ transfer, to improve the response of health systems to massive increases in demand during epidemics and pandemics. Our study considers various types of patients and resources to provide access to patient care with minimum capacity extension. Adding new resources takes time that most patients don't have during pandemics. The number of patients requiring scarce healthcare resources is uncertain and dependent on the speed of the pandemic's transmission through a region. We develop a multi-stage stochastic program to optimize various strategies for planning limited and necessary healthcare resources. We simulate uncertain parameters by deploying an agent-based continuous-time stochastic model, and then capture the uncertainty by a forward scenario tree construction approach. Finally, we propose a data-driven rolling horizon procedure to facilitate decision-making in real-time, which mitigates some critical limitations of stochastic programming approaches and makes the resulting strategies implementable in practice. We use two different case studies related to COVID-19 to examine our optimization and simulation tools by extensive computational results. The results highlight these strategies can significantly improve patient access to care during pandemics; their significance will vary under different situations. Our methodology is not limited to the presented setting and can be employed in other service industries where urgent access matters.

Symposium

BACKGROUND: The national record crime bureau of India reported more than 1.53 lakh suicide in 2020, which is the highest in the last decade. Suicide can be considered a public health problem. Suicide risk assessment is complex, having contributions from biopsychosocial and environmental influences. We aim to discuss the role of COVID Pandemic, behavioural addictions and climate change in suicidality.FINDINGS: COVID has brought grief, physical disability, loss of employment and financial constraints, loneliness, and scarcity of healthcare resources. Isolation and pandemic related anxiety can lead to self-harm ideation in certain vulnerable populations like elderly, homeless, dependent and those having chronic physical and mental illnesses. Additionally, there is a high probability of neuropsychiatric symptoms in individuals with post-COVID syndrome with an increase in suicidal behaviour.Behavioural addictions like gambling disorder, gaming disorder and sexual addictions have a high association with suicidality. Premorbid impulsivity, male gender, unemployment, comorbidities and poor support have been demonstrated to have a higher association in people with a behavioural addiction and suicidality.Increased suicide risk along with other neuropsychiatric complications has been reported due to poor air quality, increased temperature & rainfall changes. Natural disasters like hurricanes or earthquakes are known to have both acute and long term impacts on mental health & suicidality with higher impact on environmentally motivated migrants and displaced populations.CONCLUSION: There is a convincing association of these three conditions in increasing suicide risk, making these an issue of global concern. Robust scientific evidence should be generated for the same which can then guide clinicians & policymakers to act decisively on the issue.

Information Asymmetry in Hospitals: Evidence of the Lack of Cost Awareness in Clinicians.

BackgroundInformation asymmetries and the agency relationship are two defining features of the healthcare system. These market failures are often used as a rationale for government intervention. Many countries have government financing and provision of healthcare in order to correct for this, while health technology agencies also exist to improve efficiency. However, informational asymmetries and the resulting principal-agent problem still persist, and one example is the lack of cost awareness amongst clinicians. This study explores the cost awareness of clinicians across different settings.MethodsWe targeted four clinical cohorts: medical students, Senior House Officers/Interns, Mid-grade Senior Registrar/Residents, and Consultant/Attending Physicians, in six hospitals in the United Kingdom, the United States, Australia, New Zealand and Spain. The survey asked respondents to report the cost (as they recalled) of different types of scans, visits, medications and tests. Our analysis focused on the differential between the perceived/recalled cost and the actual cost. We explored variation across speciality, country and other potential confounders. Cost-awareness levels were estimated based on the cost estimates within 25% of the actual cost.ResultsWe received 705 complete responses from six sites across five countries. Our analysis found that respondents often overestimated the cost of common tests while underestimating high-cost tests. The mean cost-awareness levels varied between 4 and 23% for different items. Respondents acknowledged that they did not feel they had received adequate training in cost awareness.DiscussionThe current financial climate means that cost awareness and the appropriate use of scarce healthcare resources is more paramount than perhaps ever before. Much of the focus of health economics research is on high-cost innovative technologies, yet there is considerable waste in the system with respect to overtreatment and overdiagnosis. Common reasons put forward for this include defensive medicine, poor education, clinical uncertainty and the institution of protocols.ConclusionGiven the role of clinicians in the healthcare system, as agents both for patients and for providers, more needs to be done to remove informational asymmetries and improve clinician cost awareness.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40258-022-00736-x.

Lessons learned from offering a telehealth intervention for people with dementia and their caregivers

AbstractBackgroundThere is good evidence that dyadic interventions (working with people with dementia and their caregivers) are beneficial for both the person and their caregiver. Dyadic interventions typically involve information provision, education and skills training in order to work towards goals or overcome particular care challenges. A key limitation of dyadic interventions is that they have typically been delivered over a number of consultations in the person’s home. In the context of scarce resources in health care and a global pandemic there has been increasing interest in how to offer evidence‐based services using telehealth delivery.MethodIn this presentation we will share our experience and tips on telehealth delivery for people with dementia and their carers. We conducted a randomised controlled trial in which 63 dyads all received the same dyadic intervention. However, 32 dyads received visits in their own home and 31 dyads used telehealth methods to access the program. We collected information about whether or not the person had existing internet access or devices and we loaned a device (connected to the internet) if required. We established procedures for troubleshooting and for ensuring that people with dementia and their carers could use the technology easily, could communicate effectively and could adapt in‐person consultations to telehealth consultations.ResultCaregivers took primary responsibility for use of the device and scheduling appointments. The average age of caregivers was 69 in the telehealth group. None of the participants withdrew due to challenges in technology and few technological issues arose or impacted on the trial. Our experiences in using telehealth with this population will be discussed.ConclusionTelehealth for people with dementia and their caregiver poses challenges however these can be overcome. Dyadic interventions can be offered using telehealth delivery and are beneficial in improving access and reducing the costs associated with travel time.

Scarce Health Care Resources and Equity during COVID-19: Lessons from the History of Kidney Failure Treatment.

This is an Early Access article. Please select the PDF button, above, to view it.

Commentary on "The Father-Daughter Dinner Dance: A Waltz With Ethics and COVID-19".

This story—“The Father-Daughter Dinner Dance: A Waltz With Ethics and COVID-19”—is based on conversations I have had with friends, family, and colleagues about the allocation of medical resources during the COVID-19 pandemic. The characters and conversation in this story are all fictional. Although there is a strong public health effort to flatten the curve of infected individuals with COVID-19 over a longer period of time so that the health care system does not become overwhelmed, it is very likely that this pandemic will cause medical shortages. We are already hearing about a lack of personal protective equipment, ICU beds, and lifesaving technologies such as ventilators.1 During medical shortages, decision makers turn to bioethicists for advice on how to prioritize difficult decisions in an ethical and systematic manner. It is well noted that utilitarian approaches to decision making during times of scarce resources in health care are deemed acceptable.2 The basic criterion of utilitarianism as formulated by Jeremy Bentham in 1789 is the greatest happiness for the greatest number.3 In health care, it is desirable to save the greatest number of lives or the most life-years by giving priority to individuals likely to survive the longest after a given treatment.4 One of the most influential medical journals recently published an article that offered 6 recommendations for the fair allocation of scarce medical resources using a utilitarian perspective.1 Utilitarian approaches do not take into account that some health care professionals discriminate against certain groups of people. Although most health professionals are not likely to intentionally discriminate against their patients, they may hold negative attitudes that could cause their patients to feel disrespected and misunderstood.5 Research has demonstrated how some negative attitudes toward certain stigmatized groups are more acceptable than others. For example, negative attitudes toward people with mental illness or obesity are more acceptable than explicit racist or sexist beliefs.6,7 Negative attitudes become harmful stereotypes that create systemic barriers to health equity and result in biased clinical decision making in diagnosis and treatment of marginalized groups. In light of the knowledge we have about the negative health effects of discrimination on marginalized groups, it is frightening to think how a utilitarian approach could create life-threatening disadvantages during discussions of the fair allocation of scarce resources. This story highlights how social positions and identities intersect to create an environment of bias and discrimination against certain members of society.8 The daughter is a young, educated woman. She does not seem to have a chronic illness. She has completed a philosophy degree, but there is some pressure on universities to eliminate the humanities in favor of degrees deemed more productive. We do not have information on the father’s educational attainment, but we know that he has a blue-collar job and that he has a mental illness. The father and daughter’s social identities interact with the concept of ageism, which usually occurs against older adults; in this case, though, ageism is shown to affect younger adults depending on their health status. The mother, who comes into the story briefly, brings issues of gender and body image as intersections that combine with mental health to highlight further injustice and inequity. The purpose of creating a story on such a timely and complicated topic is to encourage the reader to think about how injustice toward one group can end up perpetuating systems of inequities toward other groups of people, especially when utilitarian approaches to lifesaving resource allocation are left unquestioned.

Drivers and social implications of Artificial Intelligence adoption in healthcare during the COVID-19 pandemic.

The COVID-19 pandemic continues to impact people worldwide–steadily depleting scarce resources in healthcare. Medical Artificial Intelligence (AI) promises a much-needed relief but only if the technology gets adopted at scale. The present research investigates people’s intention to adopt medical AI as well as the drivers of this adoption in a representative study of two European countries (Denmark and France, N = 1068) during the initial phase of the COVID-19 pandemic. Results reveal AI aversion; only 1 of 10 individuals choose medical AI over human physicians in a hypothetical triage-phase of COVID-19 pre-hospital entrance. Key predictors of medical AI adoption are people’s trust in medical AI and, to a lesser extent, the trait of open-mindedness. More importantly, our results reveal that mistrust and perceived uniqueness neglect from human physicians, as well as a lack of social belonging significantly increase people’s medical AI adoption. These results suggest that for medical AI to be widely adopted, people may need to express less confidence in human physicians and to even feel disconnected from humanity. We discuss the social implications of these findings and propose that successful medical AI adoption policy should focus on trust building measures–without eroding trust in human physicians.

The United States 2020 Census data: implications for precision medicine and theresearch landscape.

The United States 2020 Census data: implications for precision medicine and theresearch landscape.

Dignity in Red Envelopes: Disreputable Exchange and Cultural Reproduction of Inequality in Informal Medical Payment

Disreputable exchanges are morally disapproved and often legally prohibited exchanges that exacerbate and reproduce social inequality but remain ubiquitous. Although previous literature explains the phenomenon by material interests and structural relations, we propose a cultural approach based on three major conceptions of culture: culture in relations, culture in interactions, and culture in inequality. We illustrate this approach by a case study of China’s hongbao (the red envelope) exchange, a typical disreputable exchange through informal medical payment. Drawing on interviews with doctors and patients, we find that participants of the exchange mobilize items from their cultural repertoires, such as professional ethics, face, power, fairness, and affection, to redefine different situations of interactions and project positive self–images to render their problematic exchanges morally acceptable to each other. Moreover, as the participants’ responses to our vignettes show, they negatively evaluate the exchanges in general moral terms, such as equality and fairness, but culturally justify their own involvement. This discrepancy between saying and doing tends to legitimize the disreputable exchange amid enduring public outrage and institutional prohibition. These cultural processes contribute to the reproduction of unequal access to scarce health care resources. Findings of this research not only offer insights into understanding disreputable exchanges but also contribute to research on other cases of social problems in which deviant behaviors are morally and culturally justified.

Never Waste a Pandemic: Strategies to Increase Advance Care Planning Now.

Coronavirus disease 2019 (COVID-19)–related deaths and hospitalizations have created a global health crisis with unprecedented scarcity of health care resources and staffing in parts of the United States and around the world. The pandemic has led to important discussions about just allocation of health care resources. News headlines about COVID-19 feature family members who announce hospitalized loved ones died after treatment options were denied. Other articles demonstrate that patients may not fully understand the ramifications of elected care in an intensive care setting, unpredictability of outcomes, and how this may impact future abilities.

Comparative Value of Cholinesterase Inhibitors and Memantine in Persons with Moderate-to-Severe Alzheimer's Disease in the United States: A Cost-Effectiveness Analysis.

Background:Pharmacological treatment of Alzheimer’s disease (AD) involves symptomatic improvement of cognition using cholinesterase inhibitors (ChEIs) and memantine. The cost-effectiveness of these medications will guide decision-makers in making judicious use of scarce healthcare resources, particularly during the advanced disease stages.Objective:To evaluate the cost-effectiveness of ChEIs, memantine, and ChEI-memantine combinations in persons with moderate-to-severe AD from the US healthcare perspective.Methods:This pharmacoeconomic evaluation study used a state-transition Markov cohort model to simulate the costs and effectiveness of ChEI-memantine combinations compared with monotherapies of ChEI (donepezil, galantamine and rivastigmine) and memantine in persons with moderate-to-severe AD over a lifetime horizon with a 1-year cycle length. We estimated expected quality-adjusted life-years (QALYs), costs (in 2020 $US), net monetary benefits, and incremental cost-effectiveness ratios (ICERs). We discounted future costs and QALYs at the rate of 3%.Results:In this study, donepezil monotherapy, galantamine-memantine combination, and rivastigmine transdermal patch formed the cost-effectiveness frontier. Findings suggests that rivastigmine transdermal patch is the optimal treatment strategy at a willingness-to-pay (WTP) threshold of $150,000/QALY (ICER = $93,307/QALY [versus donepezil monotherapy]). Results across subgroups by age and sex also suggest that the rivastigmine transdermal patch is the optimal treatment strategy with the highest net benefit.Conclusion:From the US healthcare perspective, we found that, for persons with moderate-to-severe AD at a WTP threshold of $150,000/QALY, the rivastigmine transdermal patch is the most cost-effective pharmacological treatment option. Given that the transdermal patch is a preferred route of administration for persons with AD and their caregivers due to its convenience, our findings provide additional incentives for its use.

Descriptive Data Analysis of Inequality of Economic Opportunity using the Queensland Family Cohort Pilot Study

AbstractThe Queensland Family Cohort Pilot Study follows 450 women over the course of their pregnancy and after giving birth, collecting a wealth of information on socioeconomic characteristics, health, healthcare use and biological samples. The focus of this paper is to demonstrate how these data may be used to measure inequality of opportunity, between advantaged and disadvantaged populations, for mothers, partners and babies, in terms of their mental health and use of scarce health care resources. This paper provides the foundation for future analyses when a wider Queensland study is proposed to collect data from 12,500 families.

The Economic evaluation of management information system (MIS) in health care management

There is undoubtedly a need to efficiently allocate the scarce resources related to health care so that the optimum utilization for the benefit of the society at large can be determined. In this process, the health management system plays an important role. A well-managed data becomes a significant source in making the organization efficient. Economics thus provides health sector a new paradigm- Health Economics. A branch of economics developed as Health economics deals mainly with how the scarce health care resources need to be allocated so as to bring the maximization of the health of the community. For such a decision making, an analytical tool is required which could involve both the cost and the benefit side. Economic evaluation serves such an analytical tool. The present paper focuses on the economic evaluation of the Management Information system (MIS) in Health care Management. MIS calls for such a strategy to effectively organize relevant information in the health care and manage the limited resources with optimization and is therefore considered superior to the traditional paper based system.

An empirical bioethical examination of Norwegian and British doctors' views of responsibility and (de)prioritization in healthcare.

In a world with limited resources, allocation of resources to certain individuals and conditions inevitably means fewer resources allocated to other individuals and conditions. Should a patient's personal responsibility be relevant to decisions regarding allocation? In this project we combine the normative and the descriptive, conducting an empirical bioethical examination of how both Norwegian and British doctors think about principles of responsibility in allocating scarce healthcare resources. A large proportion of doctors in both countries supported including responsibility for illness in prioritization decisions. This finding was more prominent in zero‐sum scenarios where allocation to one patient means that another patient is denied treatment. There was most support for incorporating prospective responsibility (through patient contracts), and low support for integrating responsibility into co‐payments (i.e. through requiring responsible patients to pay part of the costs of treatment). Finally, some behaviours were considered more appropriate grounds for deprioritization (smoking, alcohol, drug use)—potentially because of the certainty of impact and direct link to ill health. In zero‐sum situations, prognosis also influenced prioritization (but did not outweigh responsibility). Ethical implications are discussed. We argue that the role that responsibility constructs appear to play in doctors' decisions indicates a needs for more nuanced—and clear—policy. Such policy should account for the distinctions we draw between responsibility‐sensitive and prognostic justifications for deprioritization.

Cost-effectiveness evidence on approved cancer drugs in Ireland: the limits of data availability and implications for public accountability

BackgroundWe surveyed evidence published by Ireland’s National Centre for Pharmacoeconomics (NCPE) on the cost-effectiveness of cancer drugs approved for funding within the Irish public healthcare system. The purpose is threefold: to assess the completeness and clarity of publicly available cost-effectiveness data of such therapies; to provide summary estimates of that data; to consider the implications of constraints on data availability for accountability regarding healthcare resource allocation.MethodsThe National Cancer Control Programme lists 91 drug-indication pairs approved between June 2012 and July 2020. Records were retrieved from the NCPE website for each drug-indication pair, including, where available, health technology assessment (HTA) summary reports. We assessed what cost-effectiveness data regarding approved interventions is available, aggregated it and considered the consequences of reporting constraints.ResultsAmong the 91 drug-indication pairs 61 were reimbursed following full HTA, 22 after a rapid review process and 8 have no corresponding NCPE record. Of the 61 where an HTA report was available, 41 presented costs and quality-adjusted life-year (QALY) estimates of the interventions compared. Cost estimates and corresponding incremental cost-effectiveness ratios (ICERs) are based on prices on application for reimbursement. Reimbursed prices are not published. Aggregating over the drug-indication pairs for which data is available, we find a mean incremental health gain of 0.85 QALY and an aggregate ICER of €100,295/QALY, which exceeds Ireland’s cost-effectiveness threshold of €45,000/QALY.ConclusionReimbursement applications by pharmaceutical manufacturers for cancer drugs typically exceed Ireland’s cost-effectiveness threshold, often by a considerable margin. On aggregate, the additional total net cost of new drugs relative to current treatments needs to be more than halved for the prices sought on application to be justified for reimbursement. Commercial confidentiality regarding prices and cost-effectiveness upon reimbursement compromises accountability regarding the fair and efficient allocation of scarce healthcare resources.

Economic evaluations and costing studies of lung transplantation: A scoping review

Evaluation of the joint clinical and economic impacts of lung transplant and associated technologies is crucial for evidence-informed decision-making and wise allocation of scarce healthcare resources. We performed a scoping review to summarize and categorize the available evidence of the costs and cost-effectiveness of lung transplantation. A systematic search of MEDLINE, EMBASE, NHS EED, and EconLit was performed to identify studies involving lung transplantation for adults that measured costs, cost-effectiveness, or which described themselves as economic evaluations. A scoping review was performed in adherence to the framework described by Arksey & O'Malley. Risk of bias was assessed in included studies using the ECOBIAS and CHEC-list tools. In total, 324 studies were identified, of which 28 met inclusion criteria. Cost-utility estimates of lung transplant versus waitlist, from the healthcare payer perspective and a time-horizon of at least 10-years ranged between $42,459 and $154,051 per quality-adjusted life year. Common topics of study included lung transplant versus waitlist care, immunosuppression, organ retrieval and allocation, and mechanical life support. Sources of variation in costs-assessments and economic evaluations included differences in the type of study performed, payer perspective adopted, study time horizon, and variation in clinical practice. The best available cost-utility estimates for lung transplant versus waitlist may represent cost-effectiveness under some circumstances, but high-quality evidence is lacking. Further cost-utility analyses, with sufficient methodologic rigour, are required to overcome the observed variation in results and confirm cost-effectiveness of the current standard of care in lung transplantation.