Dealing with Uncertainty in Cost-Effectiveness and Affordability to Inform Risk-Averse Healthcare Decision Makers

OBJECTIVES:

Decision makers are increasingly concerned about both cost-effectiveness and affordability, resulting in the use of willingness-to-pay (WTP) and budget impact thresholds. The cost-effectiveness acceptability curve (CEAC) is widely used to summarize uncertainty in cost-effectiveness analysis (CEA) results. As CEAC ignores the resources necessary to fund the intervention and assumes a risk neutral attitude for decision makers, cost-effectiveness affordability curves (CEAFC), and since 2021, cost-effectiveness risk-aversion curves (CERAC) have been proposed to complement CEACs. We aim to assess whether the use of CEAFC has increased and where CERAC has been applied in economic evaluations of healthcare technologies.

METHODS:

A literature review was performed to update a previous review on the use of CEAFC in 2017. We searched MEDLINE, EconLit, and EMBASE databases and Google Scholar using the term “cost-effectiveness" and "affordability curve” or "risk-aversion curve". Articles considering both cost-effectiveness and affordability using CEAFC or CERAC to evaluate healthcare technologies/programs, published in English since 2017, were included. Where and how CEAFCs and CERACs are used in economic evaluations were critically reviewed.

RESULTS:

Based on the search eleven papers were reviewed. The application of CEAFC has been extended from preventative interventions only, to further disease areas such as cancer treatments. Previously, CEAFC was mainly used in developing countries but use has recently extended to developed countries. The CERAC has been used alongside CEACs and CEAFCs in CEAs for dental care in the UK and for cancer treatments in Switzerland. In all included studies, CEAFC and CERAC provided additional helpful information for decision makers.

CONCLUSIONS:

CEAFC and CERAC are useful tools to add to standard CEAs to provide more comprehensive information required by risk-averse healthcare decision makers. There has been increased use and extension in the areas of application of these methods to communicate health economic evaluation results.