NICE : biased use of cost - effectiveness is

Concern with the threshold applied in cost-effectiveness analyses by bodies such as NICE distracts attention from their biased use of the principle. The bias results from the prior requirement that an intervention be effective (usually 'clinically effective') before its cost-effectiveness is considered. The underlying justification for the use of cost-effectiveness as a criterion, whatever the threshold adopted, is that decisions in a resource-constrained system have opportunity costs. Their existence rules out any restriction to those interventions that are 'incrementally cost-effective' at a chosen threshold and requires acceptance of those that are 'decrementally cost-effective' at the same threshold. Interventions that fall under the linear ICER line in the South-West quadrant of the cost-effectiveness plane are cost-effective because they create net health benefits, as do those in the North-East quadrant. If there is objection to the fact that they are cost-effective by reducing effectiveness as well as costs, it is possible to reject them, but only on policy grounds other than their failure to be cost-effective. Having established this, the paper considers and seeks to counter the arguments based on these other grounds. Most notably these include those proposing a different threshold in the South-West quadrant from the North-East one, i.e. propose a 'kinked ICER'. Another undesirable consequence of the biased use of cost-effectiveness is the failure to stimulate innovations that would increase overall health gain by being less effective in the condition concerned, but generate more benefits elsewhere. NICE can only reward innovations that cost more. Jack Dowie ( ) Corresponding author: [email protected] Dowie J, Kaltoft MK, Nielsen JB and Salkeld G. How to cite this article: NICE: biased use of cost-effectiveness is inefficient Caveat emptor 2015, :1078 (doi: ) and inequitable [version 1; referees: 2 approved] F1000Research 4 10.12688/f1000research.7191.1 © 2015 Dowie J . This is an open access article distributed under the terms of the , which Copyright: et al Creative Commons Attribution Licence permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. MKK’s PhD study was funded by the Region of Southern Denmark, the University of Southern Denmark and The Health Grant information: Foundation (Helsefonden). The contribution of GS was supported by the Screening and diagnostic Test Evaluation Program (STEP) funded by the National Health and Medical Research Council of Australia under program grant number 633003. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: No competing interests were disclosed. 16 Oct 2015, :1078 (doi: ) First published: 4 10.12688/f1000research.7191.1 1 2 3