Valeurs seuils pour le rapport coût-efficacité en soins de santé - KCE
Valeurs seuils pour le rapport coût-efficacité en soins de santé - KCE
Valeurs seuils pour le rapport coût-efficacité en soins de santé - KCE
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40 ICER Thresholds <strong>KCE</strong> Reports 100<br />
As a consequ<strong>en</strong>ce, <strong>de</strong>cision makers are sometimes in a position of having to take<br />
<strong>de</strong>cisions without having a<strong>de</strong>quate cost-effectiv<strong>en</strong>ess data at their disposal. 139<br />
Moreover, clinical effectiv<strong>en</strong>ess and cost-effectiv<strong>en</strong>ess are only two of many<br />
consi<strong>de</strong>rations in making policy choices. Valuing differ<strong>en</strong>t types of outcomes is<br />
inher<strong>en</strong>tly value-lad<strong>en</strong>, where economic evid<strong>en</strong>ce needs to be combined with<br />
stakehol<strong>de</strong>r <strong>de</strong>liberation. 114<br />
Key points<br />
• Barriers in the use of economic evaluation studies have be<strong>en</strong> summarized<br />
as issues of accessibility of research evid<strong>en</strong>ce and acceptability of research<br />
evid<strong>en</strong>ce<br />
• The capacity to un<strong>de</strong>rstand economic analysis, attitu<strong>de</strong>s to economic<br />
evaluations (including concerns about the basis of the analyses and their<br />
use), the scope of the research questions and the scope of the policy<br />
question, hamper the use of cost-effectiv<strong>en</strong>ess analysis in <strong>de</strong>cision making<br />
• Effectiv<strong>en</strong>ess and cost-effectiv<strong>en</strong>ess are only two of many consi<strong>de</strong>rations<br />
in making policy choices. Economic evid<strong>en</strong>ce needs to be combined with<br />
stakehol<strong>de</strong>r <strong>de</strong>liberation.<br />
3.4 COST-EFFECTIVENESS ANALYSIS, ICER THRESHOLD<br />
VALUES AND DECISION MAKING<br />
Internationally there is an ongoing methodological <strong>de</strong>bate on what could be the ro<strong>le</strong> of<br />
CEA and ICERs in health care <strong>de</strong>cision making. International ag<strong>en</strong>cies such as the World<br />
Health Organization u and the World Bank v promote the use of CEA. Eich<strong>le</strong>r and<br />
col<strong>le</strong>agues 125 predict “CE thresholds will gradually become a reality, irrespective of whether<br />
local <strong>de</strong>cision makers welcome them or remain critical, because it is meaning<strong>le</strong>ss to perform<br />
CE-studies in the abs<strong>en</strong>ce of an acceptance threshold […] neither theory nor empiric evid<strong>en</strong>ce<br />
supports the expectation that CE thresholds will evolve as the so<strong>le</strong> <strong>de</strong>cision criterion” (p525)<br />
Although some scholars are convinced about the pervasiv<strong>en</strong>ess of the use of ICERs,<br />
there still is fundam<strong>en</strong>tal methodological <strong>de</strong>bate on the foundations for using an ICER<br />
threshold value in <strong>de</strong>cision making. The methodological issues have be<strong>en</strong> discussed<br />
ext<strong>en</strong>sively previously in this report. Some authors have docum<strong>en</strong>ted that curr<strong>en</strong>tly<br />
accepted thresholds are <strong>de</strong>termined rather arbitrarily, and that further methodological<br />
<strong>de</strong>bate is nee<strong>de</strong>d. 47, 48, 140 A large number of factors might be expected to g<strong>en</strong>erate<br />
variation in the cost-effectiv<strong>en</strong>ess of healthcare interv<strong>en</strong>tions across locations. 137<br />
Argum<strong>en</strong>ts have be<strong>en</strong> <strong>de</strong>veloped that differ<strong>en</strong>tial threshold values are nee<strong>de</strong>d for<br />
diverse disease and treatm<strong>en</strong>t characteristics (e.g. higher thresholds for life-saving<br />
treatm<strong>en</strong>ts), age, g<strong>en</strong><strong>de</strong>r and race factors, and argum<strong>en</strong>ts are being <strong>de</strong>veloped to<br />
<strong>de</strong>velop equity adjustm<strong>en</strong>t procedures to cost-effectiv<strong>en</strong>ess thresholds. 141<br />
The main message of the critiques is that in real world <strong>de</strong>cision making some of the<br />
theoretical assumptions of ICER threshold values do not hold (see 2.7) and<br />
consi<strong>de</strong>rations of cost-effectiv<strong>en</strong>ess are insuffici<strong>en</strong>t to inform <strong>de</strong>cision makers.<br />
Moreover there remains the issue of implicit and explicit threshold values. Many<br />
countries do not use explicit thresholds for coverage <strong>de</strong>cisions (see also 3.5), whi<strong>le</strong><br />
some countries use an implicit ICER threshold value, above which the <strong>de</strong>cision would<br />
usually be negative (e.g. Australia, New Zealand and Canada).<br />
u The “Making Choices in Health: WHO Gui<strong>de</strong> to Cost-Effectiv<strong>en</strong>ess Analysis” seeks to provi<strong>de</strong> analysts<br />
with a method of assessing whether the curr<strong>en</strong>t as well as proposed mix of interv<strong>en</strong>tions is effici<strong>en</strong>t. It<br />
also seeks to maximize the g<strong>en</strong>eralizability of results across settings.<br />
http://www.who.int/choice/<strong>en</strong>/in<strong>de</strong>x.html<br />
v The World <strong>de</strong>velopm<strong>en</strong>t report 1993 “Investing in health” proposed a universal method to set health<br />
priorities for all countries based on the c<strong>en</strong>tral i<strong>de</strong>a that priority in allocating means and resources should<br />
go to prob<strong>le</strong>ms that cause a large disease burd<strong>en</strong> and with cost-effective interv<strong>en</strong>tions that are availab<strong>le</strong>.