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      Perspective and Costing in Cost-Effectiveness Analysis, 1974–2018

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          Abstract

          Objective

          Our objective was to examine perspective and costing approaches used in cost-effectiveness analyses (CEAs) and the distribution of reported incremental cost-effectiveness ratios (ICERs).

          Methods

          We analyzed the Tufts Medical Center’s CEA and Global Health CEA registries, containing 6907 cost-per-quality-adjusted-life-year (QALY) and 698 cost-per-disability-adjusted-life-year (DALY) studies published through 2018. We examined how often published CEAs included non-health consequences and their impact on ICERs. We also reviewed 45 country-specific guidelines to examine recommended analytic perspectives.

          Results

          Study authors often mis-specified or did not clearly state the perspective used. After re-classification by registry reviewers, a healthcare sector or payer perspective was most prevalent (74%). CEAs rarely included unrelated medical costs and impacts on non-healthcare sectors. The most common non-health consequence included was productivity loss in the cost-per-QALY studies (12%) and patient transportation in the cost-per-DALY studies (21%). Of 19,946 cost-per-QALY ratios, the median ICER was $US26,000/QALY (interquartile range [IQR] 2900–110,000), and 18% were cost saving and QALY increasing. Of 5572 cost-per-DALY ratios, the median ICER was $US430/DALY (IQR 67–3400), and 8% were cost saving and DALY averting. Based on 16 cost-per-QALY studies (2017–2018) reporting 68 ICERs from both the healthcare sector and societal perspectives, the median ICER from a societal perspective ($US22,710/QALY [IQR 11,991–49,603]) was more favorable than from a healthcare sector perspective ($US30,402/QALY [IQR 10,486–77,179]). Most governmental guidelines (67%) recommended either a healthcare sector or a payer perspective.

          Conclusion

          Researchers should justify and be transparent about their choice of perspective and costing approaches. The use of the impact inventory and reporting of disaggregate outcomes can reduce inconsistencies and confusion.

          Electronic supplementary material

          The online version of this article (10.1007/s40273-020-00942-2) contains supplementary material, which is available to authorized users.

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          Most cited references52

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          Recommendations for Conduct, Methodological Practices, and Reporting of Cost-effectiveness Analyses: Second Panel on Cost-Effectiveness in Health and Medicine.

          Since publication of the report by the Panel on Cost-Effectiveness in Health and Medicine in 1996, researchers have advanced the methods of cost-effectiveness analysis, and policy makers have experimented with its application. The need to deliver health care efficiently and the importance of using analytic techniques to understand the clinical and economic consequences of strategies to improve health have increased in recent years.
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            The International Decision Support Initiative Reference Case for Economic Evaluation: An Aid to Thought.

            Policymakers in high-, low-, and middle-income countries alike face challenging choices about resource allocation in health. Economic evaluation can be useful in providing decision makers with the best evidence of the anticipated benefits of new investments, as well as their expected opportunity costs-the benefits forgone of the options not chosen. To guide the decisions of health systems effectively, it is important that the methods of economic evaluation are founded on clear principles, are applied systematically, and are appropriate to the decision problems they seek to inform.
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              Does including informal care in economic evaluations matter? A systematic review of inclusion and impact of informal care in cost-effectiveness studies.

              Informal care makes an important contribution to societal welfare. However, it may involve substantial time costs and can have a considerable negative effect on the health and well-being of informal caregivers. These costs and effects of informal caregiving are often excluded in economic evaluations of healthcare interventions. The impact of this exclusion on the outcomes of these evaluations is largely unknown.
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                Author and article information

                Contributors
                dkim3@tuftsmedicalcenter.org
                Journal
                Pharmacoeconomics
                Pharmacoeconomics
                Pharmacoeconomics
                Springer International Publishing (Cham )
                1170-7690
                1179-2027
                22 July 2020
                22 July 2020
                : 1-11
                Affiliations
                [1 ]GRID grid.67033.31, ISNI 0000 0000 8934 4045, Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, , Tufts Medical Center, ; 800 Washington St, Box 063, Boston, MA 02111 USA
                [2 ]GRID grid.67033.31, ISNI 0000 0000 8934 4045, Department of Medicine, , Tufts University School of Medicine, ; Boston, MA USA
                [3 ]GRID grid.5510.1, ISNI 0000 0004 1936 8921, Department of Health Management and Health Economics, , University of Oslo, ; Oslo, Norway
                [4 ]GRID grid.47100.32, ISNI 0000000419368710, Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, , Yale University School of Medicine, ; New Haven, CT USA
                [5 ]LINK Medical Research, Oslo, Norway
                Author information
                http://orcid.org/0000-0002-3383-8972
                Article
                942
                10.1007/s40273-020-00942-2
                7373843
                32696192
                a31e2cea-2948-49da-9f31-b1062259033f
                © The Author(s) 2020

                Open AccessThis article is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, which permits any non-commercial use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc/4.0/.

                History
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/100001797, Pharmaceutical Research and Manufacturers of America Foundation;
                Award ID: Center of Excellence in Value Assessment Award
                Award Recipient :
                Categories
                Original Research Article

                Economics of health & social care
                Economics of health & social care

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