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

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.