Use and Misuse of Cost-Effectiveness Analysis Thresholds in Low- and Middle-Income Countries: Trends in Cost-per-DALY Studies

Abstract

ObjectivesTo determine what thresholds are most often cited in the cost-effectiveness literature for low- and middle-income countries (LMICs), given various recommendations proposed and used in the literature to date, and thereafter to assess whether studies appropriately justified their use of threshold values.MethodsWe reviewed the contents of the Tufts Medical Center Global Health Cost-Effectiveness Analysis Registry, a repository of all English language cost-per-disability-adjusted life-year averted studies indexed in PubMed. Our review included all catalogued cost-per-disability-adjusted life-year studies published from 2000 through 2015. We restricted attention to studies that investigated interventions in LMICs.ResultsOur analysis identified 381 studies (80%) focused on LMICs. Of these studies, 250 (66%) cited the World Health Organization’s 1 to 3 times gross domestic product per capita threshold. A full-text review of 60 (24%) of these articles (randomly selected) revealed that none justified use of this threshold in the particular country or countries studied beyond citing (generic) guideline documents.ConclusionsCost-effectiveness analysis can help inform health care spending, but its value depends on incorporating assumptions that are valid for the applicable setting. Rather than rely on commonly used, generic economic thresholds, we encourage authors to use context-specific thresholds that reflect local preferences.

Cost‐effectiveness and health‐related outcomes of screening for hepatitis C in Korean population

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“…Although there is no universally accepted standard to determine the appropriate cost‐effectiveness justifying the implementation of a new strategy, an ICER less than 1 to 3 times of GDP per capita can be regarded as cost‐effective . However, some analysts have argued that this threshold is not valid for low or mid‐income countries, and should be lower for them.…”

Cost‐effectiveness of sofosbuvir plus ribavirin therapy for hepatitis C virus genotype 2 infection in South Korea

“…Although there is no universally accepted standard to determine the appropriate cost‐effectiveness, World Health Organization has suggested that interventions with a cost‐effectiveness ratio less than the country's GDP can be considered to very cost‐effective, and those with a cost‐effectiveness ratio of between one and three times of GDP can be considered cost‐effective . However, some analysts have argued that this threshold is not valid for low‐income or mid‐income countries, and it should be lower for them . Thus, this paper used a conservative threshold of GDP‐per‐capita to define cost‐effectiveness and also to be consistent with previous studies in Korea …”

Economic evaluations of onchocerciasis interventions: a systematic review and research needs

“…In cost‐effectiveness analyses, the cost per DALY averted is compared to a willingness to pay threshold to determine whether an intervention is cost effective. However, the most appropriate cost‐effectiveness thresholds are debated and remain somewhat arbitrary . The cost‐effectiveness threshold set by the WHO‐CHOICE (a cost per DALY averted < 3 times the country's GDP per capita) is now considered to be too high .…”

“…However, the most appropriate cost‐effectiveness thresholds are debated and remain somewhat arbitrary . The cost‐effectiveness threshold set by the WHO‐CHOICE (a cost per DALY averted < 3 times the country's GDP per capita) is now considered to be too high . Most analyses within the NTD field have not used it , many opting instead for the more conservative cost‐effectiveness threshold set by the World Bank (≤ US$251 per DALY averted, when adjusted for inflation to 2016 prices ).…”