The NICE Cost-Effectiveness Threshold

Abstract

The National Institute for Health and Clinical Excellence (NICE) has been using a cost-effectiveness threshold range between 20,000 pound sterling and 30,000 pound sterling for over 7 years. What the cost-effectiveness threshold represents, what the appropriate level is for NICE to use, and what the other factors are that NICE should consider have all been the subject of much discussion. In this article, we briefly review these questions, provide a critical assessment of NICE's utilization of the incremental cost-effectiveness ratio (ICER) threshold to inform its guidance, and suggest ways in which NICE's utilization of the ICER threshold could be developed to promote the efficient use of health service resources. We conclude that it is feasible and probably desirable to operate an explicit single threshold rather than the current range; the threshold should be seen as a threshold at which 'other' criteria beyond the ICER itself are taken into account; interventions with a large budgetary impact may need to be subject to a lower threshold as they are likely to displace more than the marginal activities; reimbursement at the threshold transfers the full value of an innovation to the manufacturer. Positive decisions above the threshold on the grounds of innovation reduce population health; the value of the threshold should be reconsidered regularly to ensure that it captures the impact of changes in efficiency and budget over time; the use of equity weights to sustain a positive recommendation when the ICER is above the threshold requires knowledge of the equity characteristics of those patients who bear the opportunity cost. Given the barriers to obtaining this knowledge and knowledge about the characteristics of typical beneficiaries of UK NHS care, caution is warranted before accepting claims from special pleaders; uncertainty in the evidence base should not be used to justify a positive recommendation when the ICER is above the threshold. The development of a programme of disinvestment guidance would enable NICE and the NHS to be more confident that the net health benefit of the Technology Appraisal Programme is positive.

The management of type 2 diabetes with fixed‐ratio combination insulin degludec/liraglutide (IDegLira) versus basal‐bolus therapy (insulin glargine U100 plus insulin aspart): A short‐term cost‐effectiveness analysis in the UK setting

“…38, 39 Application of the upper and lower 95% CIs for BMI and hypoglycaemia ETDs resulted in only small changes in the difference in quality of life reported from the base case, with upper and lower limits for the BMI ETD giving ICERs of GBP 5773 and GBP 6091 per QALY gained, respectively. For hypoglycaemic episodes, the differences were slightly greater, with the ICER falling to GBP 5524 per QALY gained for the upper limit and increasing to GBP 6644 per QALY gained for the lower limit.…”

“…Across a wide range of sensitivity analyses, ICERs remained under the willingness‐to‐pay threshold of GBP 20 000 per QALY in the UK 38, 39. Sensitivity analyses identified the importance of needle and SMBG costs in driving outcomes, as removing these costs from the analysis increased the ICER to GBP 15 505 per QALY gained for IDegLira versus BBT (the second largest increase seen across the sensitivity analyses).…”

“…This falls below the willingness‐to‐pay threshold of GBP 20 000 per QALY gained in the UK 38, 39. Therefore, IDegLira was considered to be cost‐effective versus BBT with insulin glargine U100 plus insulin aspart for the management of patients with type 2 diabetes in patients experiencing inadequate glycaemic control on a basal insulin regimen in the UK.…”

The economic case for precision medicine

“…Any resource allocation decision, therefore, has an opportunity cost, expressed in terms of health forgone, such that those same resources could have otherwise been used to provide an alternative health technology [30]. Population health is subsequently maximized by recommending health technologies if their expected health benefit exceeds their opportunity cost [31,32]. …”

Clinical and economic impact of aliskiren in uncontrolled hypertensive patients

“…Nonostante il valore di costo-efficacia sia normalmente citato nelle valutazioni farmacoeconomiche, nella maggior parte dei Paesi le Autorità Sanitarie non hanno definito in maniera esplicita un livello soglia. Analizzando retrospettivamente le allocazioni di risorse del National Institute for Clinical Excellence (NICE), nel Regno Unito il range al di sotto del quale un intervento viene considerato senza dubbio costo-efficace rispetto al trattamento standard oscilla fra € 29.000 e € 43.000 in base a un'analisi del 2004 [31][32][33][34][35]. In Italia, in assenza di riferimenti normativi sul valore soglia di costo-efficacia, viene a volte utilizzato in maniera informale un valore compreso tra € 22.170 e € 33.250 per QALY, che si basa sui valori delle più importanti agenzie internazionali (CADHT, NICE, CAHTA).…”