The biggest bang for the buck or bigger bucks for the bang: the fallacy of the cost-effectiveness threshold

摘要

It has been suggested that scepticism among decision-makers about using cost-e!ectiveness analysisn(CEA) is caused in part by the low level of the cost-e!ectiveness ‘thresholds’ in the economic evaluation literature.nThis has led Ubel and colleagues to call for higher threshold values of US$200,000 or more per quality-nadjusted life-year.We show that these arguments fail to identify the objective of CEA and hence do notnconsider whether or how the threshold relates to this objective.We show that incremental cost-e!ectivenessnratios (ICERs) cannot be used to identify an e⁄cient use of resources -- the ‘biggest bang for the bucks’ --nallocated to health care. On the contrary, the practical consequence of using the ICER approach is shown tonbe an increase in health care expenditures, or ‘bigger bucks for making a bang’, without any evidence of thenbang being bigger (i.e. that this leads to an increase in bene￠ts to the population).We present an alternativenapproach that provides an unambiguous method of determining whether a new intervention leads to an increasenin health gains fromwhatever resources are to bemade available to health care decision-makers.