Updating Cost-Effectiveness — The Curious Resilience of the $50,000-per-QALY Threshold

Neumann, Peter J.; Cohen, Joshua T.; Weinstein, Milton C.

doi:10.1056/nejmp1405158

Cited by 1,907 publications

(1,542 citation statements)

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“…In theory, a strong argument can be made to base C/E thresholds on population preferences; but, in practice, there are too many methodological problems with WTP per QALY studies to make any meaningful decisions based on the presently available data [21,43]. An opportunity cost based approach is an ideologically promising way of setting a C/E threshold; however, data regarding opportunity cost and calculating the impact of specific programs may be unduly complex [5].…”

Section: Discussionmentioning

confidence: 99%

“…In [21] it is stated that ‘there is mounting evidence that the average individual WTP for QALYs resulting from improvements in health status from relatively minor conditions is lower than the WTP gains from lifesaving interventions’. In current methodologies, it seems individuals don not always treat every QALY equally.…”

Section: Appendix Amentioning

confidence: 99%

“…Also commonly referenced in American health economic literature is the value of 50,000$ USD per QALY. According to Grosse [21], this value stems from the cost of dialysis in the 1980s. Similarly, 100,000$ USD per QALY is often referenced as the suitable C/E threshold without justification.…”

Section: Introductionmentioning

confidence: 99%

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On what basis are medical cost-effectiveness thresholds set? Clashing opinions and an absence of data: a systematic review

Cameron

Ubels

Norström

2018

Global Health Action

237

186

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Background: The amount a government should be willing to invest in adopting new medical treatments has long been under debate. With many countries using formal cost-effectiveness (C/E) thresholds when examining potential new treatments and ever-growing medical costs, accurately setting the level of a C/E threshold can be essential for an efficient healthcare system. Objectives: The aim of this systematic review is to describe the prominent approaches to setting a C/E threshold, compile available national-level C/E threshold data and willingness-to-pay (WTP) data, and to discern whether associations exist between these values, gross domestic product (GDP) and health-adjusted life expectancy (HALE). This review further examines current obstacles faced with the presently available data. Methods: A systematic review was performed to collect articles which have studied national C/E thresholds and willingness-to-pay (WTP) per quality-adjusted life year (QALY) in the general population. Associations between GDP, HALE, WTP, and C/E thresholds were analyzed with correlations. Results: Seventeen countries were identified from nine unique sources to have formal C/E thresholds within our inclusion criteria. Thirteen countries from nine sources were identified to have WTP per QALY data within our inclusion criteria. Two possible associations were identified: C/E thresholds with HALE (quadratic correlation of 0.63), and C/E thresholds with GDP per capita (polynomial correlation of 0.84). However, these results are based on few observations and therefore firm conclusions cannot be made. Conclusions: Most national C/E thresholds identified in our review fall within the WHO’s recommended range of one-to-three times GDP per capita. However, the quality and quantity of data available regarding national average WTP per QALY, opportunity costs, and C/E thresholds is poor in comparison to the importance of adequate investment in healthcare. There exists an obvious risk that countries might either over- or underinvest in healthcare if they base their decision-making process on erroneous presumptions or non-evidence-based methodologies. The commonly referred to value of 100,000$ USD per QALY may potentially have some basis.

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Section: Discussionmentioning

confidence: 99%

Section: Appendix Amentioning

confidence: 99%

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On what basis are medical cost-effectiveness thresholds set? Clashing opinions and an absence of data: a systematic review

Cameron

Ubels

Norström

2018

Global Health Action

237

186

View full text Add to dashboard Cite

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“…Cost‐effectiveness calculations determined that this strategy was well below the most commonly used threshold of US$50 000 per QALY. This threshold has become an accepted benchmark for cost‐effectiveness in the USA and is often attributed to the US decision to mandate Medicare coverage for patients with end‐stage renal disease in the 1970s 41. Some economists as well as the World Health Organization (WHO) have argued, on the basis of plausible assumptions about people's values and attitudes toward risk, for a threshold of 2–3 times the per capita annual income, which would imply a US threshold of US$110 000 to US$160 000 per QALY 42.…”

Section: Discussionmentioning

confidence: 99%

Pulmonary artery pressure‐guided heart failure management: US cost‐effectiveness analyses using the results of the CHAMPION clinical trial

Martinson

Bharmi

Dalal

et al. 2016

European J of Heart Fail

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AimsHaemodynamic‐guided heart failure (HF) management effectively reduces decompensation events and need for hospitalizations. The economic benefit of clinical improvement requires further study.Methods and resultsAn estimate of the cost‐effectiveness of haemodynamic‐guided HF management was made based on observations published in the randomized, prospective single‐blinded CHAMPION trial. A comprehensive analysis was performed including healthcare utilization event rates, survival, and quality of life demonstrated in the randomized portion of the trial (18 months). Markov modelling with Monte Carlo simulation was used to approximate comprehensive costs and quality‐adjusted life years (QALYs) from a payer perspective. Unit costs were estimated using the Truven Health MarketScan database from April 2008 to March 2013. Over a 5‐year horizon, patients in the Treatment group had average QALYs of 2.56 with a total cost of US$56 974; patients in the Control group had QALYs of 2.16 with a total cost of US$52 149. The incremental cost‐effectiveness ratio (ICER) was US$12 262 per QALY. Using comprehensive cost modelling, including all anticipated costs of HF and non‐HF hospitalizations, physician visits, prescription drugs, long‐term care, and outpatient hospital visits over 5 years, the Treatment group had a total cost of US$212 004 and the Control group had a total cost of US$200 360. The ICER was US$29 593 per QALY.ConclusionsStandard economic modelling suggests that pulmonary artery pressure‐guided management of HF using the CardioMEMS™ HF System is cost‐effective from the US‐payer perspective. This analysis provides the background for further modelling in specific country healthcare systems and cost structures.

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“…[26][27][28]33,34,38,39,43 Screening programs accepted as cost-effective LS screening programs were accepted as cost-effective if their ICERs fell under the willingness-to-pay thresholds reported in their studies (Supplementary Table S9). For studies without stated ICER thresholds, we selected the following thresholds by reviewing the relevant economic literature and institutional guidelines: US dollars 100,000/QALY or LYG 47 for both Brown's study 25 and Ramsey's study, 26 euros 80,000/QALY or LYG 36,48 for Kievit's study, 28 and Canadian dollars 50,000/ QALY or LYG 49 for the Canadian Agency for Drugs & Technologies in Health study. 43 Since there was no defined or proposed ICER threshold in Denmark, 50,51 we accepted all the cost-effective programs extracted by Olsen's study 29 because their ICERs were well below the thresholds used in the other European studies included.…”

Section: Classification Of Ls Screening Programsmentioning

confidence: 99%

Which Lynch syndrome screening programs could be implemented in the “real world”? A systematic review of economic evaluations

Marco

D’Andrea

Panić

et al. 2018

Genetics in Medicine

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Purpose: Lynch syndrome (LS) screening can significantly reduce cancer morbidity and mortality in mutation carriers. Our aim was to identify cost-effective LS screening programs that can be implemented in the "real world."Methods: We performed a systematic review of full economic evaluations of genetic screening for LS in different target populations; health outcomes were estimated in life-years gained or quality-adjusted life-years.Results: Overall, 20 studies were included in the systematic review. Based on the study populations, we identified six categories of LS screening program: colorectal cancer (CRC)-based, endometrial cancer-based, general population-based, LS family registry-based, cascade testing-based, and genetics clinic-based screening programs. We performed an in-depth analysis of CRC-based LS programs, classifying them into three additional subcategories: universal, age-targeted, and selective. In five studies, universal programs based on immunohistochemistry, either alone or in combination with the BRAF test, were cost-effective compared with no screening, while in two studies age-targeted programs with a cutoff of 70 years were cost-effective when compared with agetargeted programs with lower age thresholds.Conclusion: Universal or o70 years-age-targeted CRC-based LS screening programs are cost-effective and should be implemented in the "real world." Genet Med advance online publication 4 January 2018Key Words: colorectal cancer; cost-effectiveness; Lynch syndrome; screening program; systematic review INTRODUCTIONLynch syndrome (LS) is the most common cause of inherited colorectal cancer (CRC), accounting for about 3% of newly diagnosed cases, and results from a mutation in one of the DNA mismatch repair (MMR) genes (MLH1, MSH2, MSH6, and PMS2). As LS is associated with an increased risk of colorectal, endometrial, and other cancers, it is important to identify both the probands and their family members. 1 In 2009, the Evaluation of Genomic Applications in Practice and Prevention Working Group recommended testing for LS in individuals with newly diagnosed CRC to reduce cancer morbidity and mortality in relatives. 2 The working group declared that there is a moderate certainty that this would provide moderate population benefit, but it did not recommend a specific genetic testing strategy among the several examined, nor did it deal with implementation issues. 2 Thereafter the US Department of Health and Human Services adopted the following as a Healthy People 2020 developmental objective: 3 "Increase the proportion of persons with newly diagnosed colorectal cancer who receive genetic testing to identify Lynch syndrome (or familial colorectal cancer syndromes)."Although genomic information has the potential to improve the delivery of patient-centered care through tailored preventive, diagnostic, and treatment strategies, there is a considerable gap between discoveries in genomics research and the translation of these findings into genetic services that benefit patients. 4,5 A previous study highl...

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Updating Cost-Effectiveness — The Curious Resilience of the $50,000-per-QALY Threshold

Cited by 1,907 publications

References 5 publications

On what basis are medical cost-effectiveness thresholds set? Clashing opinions and an absence of data: a systematic review

On what basis are medical cost-effectiveness thresholds set? Clashing opinions and an absence of data: a systematic review

Pulmonary artery pressure‐guided heart failure management: US cost‐effectiveness analyses using the results of the CHAMPION clinical trial

Which Lynch syndrome screening programs could be implemented in the “real world”? A systematic review of economic evaluations

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