Equity Is Not Equal: A Comparative Study of How Equity Is Considered by NICE, ICER, CDA-AMC, and PBAC

OBJECTIVES: Health technology assessment (HTA) agencies tend to lack clear guidelines as to how manufacturers should generate and present equity relevant data for consideration and how these bodies will incorporate equity in their decision making. As such the role of equity in decision making by HTA agencies remains unclear. This study aimed to examine how equity is currently integrated in the processes of four HTA bodies: NICE (England), ICER (USA), CDA-AMC (formerly CADTH, Canada) and PBAC (Australia).

METHODS: Health technology appraisals published by the four agencies between 2021 and 2024 were assessed for equity considerations and classified based on data used (quantitative or qualitative) and therapeutic area. The domain of equity raised and acknowledgment in the final recommendation was also examined.

RESULTS: The proportion of appraisals identifying an equity issue was 62% (53/85) for NICE, 100% (16/16) for ICER, 92% (12/13) for CDA-AMC and 49% (64/130) for PBAC. For specific interventions evaluated by at least two agencies, there was only 60% cross-agency alignment regarding the presence and category of equity issues. ICER had the highest percentage of appraisals incorporating a quantitative approach (37%), all through the inequality-adjusted Human Development Index. Of the appraisals identifying equity issues, the most frequent therapeutic area was oncology (28%). Overall, ethnicity was the most commonly identified domain followed by socioeconomic status and geographic considerations. The acknowledgment of equity in final appraisal guidance was generally limited, being referred to in only 14% (12/85) of NICE and 32% (41/130) of PBAC appraisals.

CONCLUSIONS: Equity considerations are currently not being systematically considered by major HTA agencies. Approaches vary substantially across the globe and established methods to quantify the equity impact of new technologies like distributional cost-effectiveness analysis are not being employed. A more comprehensive approach to consider equity during HTA is urgently required.