Incremental cost-effectiveness ratio and net monetary benefit: Current use in pharmacoeconomics and future perspectives.

In evaluating the cost/effectiveness of therapeutic interventions (e.g. those based on innovative drugs or on Class-III medical devices), two main pharmacoeconomic parameters have been used over the past decades: the incremental cost-effectiveness ratio (ICER [1–3]) and the net monetary benefit (NMB [4–6]). The ICER and the NMB share some common features because they both require a pre-defined willingness-to-pay threshold (WTPt) and the acceptance of qualityadjusted life years (QALYs). Despite this, the differences between these two parameters prevail over the common features, and involve both theoretical and practical issues that can be summarised as follows: (i) the ICER is more suitable for speculative pharmacoeconomic research, whereas the NMB has a more “practical” nature and deals with the application of pharmacoeconomics in real life; (ii) from a mathematical viewpoint, the ICER is more complex than the NMB because the relationship between ICER and costs is nonlinear while the relationship between NMB and costs is linear; (iii) the “typical” health professionals, who are likely to be involved in real-life pharmacoeconomic decisions, are more familiar with ICER than with NMB, whereas the opposite would be preferable; (iiii) as a matter of fact, the ICER is used muchmore frequently than theNMB, but this simply reflects the greater use of pharmacoeconomics for speculative purposes than for practical applications. In fact, if one counts the occurrences of the term “ICER” (or its synonyms) across the entire database of PuBMed, 8184 citations are found, but if the search regards the term “NMB” (or its synonyms) the citations are only 148. In countrieswhere the healthcare system is publicly funded, theprocurement of medicines andmedical devices relies, particularly in hospitals, on competitive tenders. However, tenders can either be a purely administrative tool or a tool that incorporates the basic criteria of cost-effectiveness into the process of procurement. Using the entire database of PubMed, if one extracts the citations containing the word “QALY” (or its synonyms), a total of 14,311 occurrences are found. However, if one searches howmany citations meet the simultaneous occurrence of “QALY” and “tender(s)”, only 11 citations are returned, but the great majority of these (N = 8) are false positive because they refer to medical terms such as “tender joint” or “tenderness”. In summary, the combination of “QALYs” and “tenders” (with tenders representing a procurement tool) counts only 3 citations in the whole archive of PubMed. The present empirical picture aimed at assessing to what extent the procurement ofmedicines ormedical devices in the everyday practice is