Does Cost-Effectiveness Analysis Really Need to Abandon the Incremental Cost-Effectiveness Ratio to Embrace Net Benefit?
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EDITORIAL
Does Cost‑Effectiveness Analysis Really Need to Abandon the Incremental Cost‑Effectiveness Ratio to Embrace Net Benefit? James F. O’Mahony1
© Springer Nature Switzerland AG 2020
1 Advantages of Net Benefit
2 Critiquing Paulden’s Arguments
Dr Paulden has made the strong statement that it is time to abandon the incremental cost-effectiveness ratio (ICER) [1]. His call is supported by an accompanying tutorial article on the advantages of the net benefit (NB) approach over the ICER [2]. Strong statements deserve cross-examination. This editorial questions whether it is necessary to abandon the ICER in order to fully embrace the benefits of NB. At the outset, I should make my disclosures clear that Mike and I are research collaborators and friends. The central task of cost-effectiveness analysis (CEA) is to identify strategies that maximise health within finite budgets. Paulden notes that the ICER and NB perform this task equally well. He outlines the advantages NB has, both in terms of being easier to calculate and interpret as well as informing decision makers beyond simply picking the optimal strategy. NB undoubtedly has important advantages over ICERs and these have been ably articulated by Paulden. Chief among these for me is the ability to appraise the cost effectiveness of dominated and dominant strategies. Dominated strategies may be of interest if they support other objectives such as satisfying patient preferences. Another substantive advantage is added clarity in sensitivity and scenario analysis. In particular, NB permits analysis of changes in relative cost effectiveness across multiple strategies in a way that is not possible with ICERs.
I want to briefly critically appraise some of Paulden’s other arguments in favour of NB before considering if there is any remaining role for the ICER. First, Paulden explains calculating ICERs is more laborious than NB. While true, in the context of the significant analytical effort of a typical CEA, this extra effort is arguably marginal. Paulden also states that interpretation of the ICER is not intuitive, with the tutorial supporting this with examinations of ICERs in the southwest quadrant of the cost-effectiveness plane and negative ICERs. I consider this criticism a little overstated and its exposition unnecessarily complex. It is established that negative ICERs for the northwest and southeast quadrants should not be reported as they have no meaningful interpretation [3]. Accordingly, there are no negative ICERs to misinterpret; rather, the advantage of NB appears to be its ability to quantify the extent of dominance. Regarding the southwest quadrant, the complication seems to stem from Paulden’s assumption that the ICER belongs to the less effective strategy, rather than that strategy serving as the comparator. If, as commonly assumed, the ICER belongs to the more effective strategy, then this confusion disappears. Equity weighting is likely to become an increasingly important part of CEA. Paulden’s commentary explains that this is better handled
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