Presentation (CTI)

OBJECTIVES: Results of cost-effectiveness analyses are commonly presented visually on a cost-effectiveness plane that is divided into four quadrants. Whilst the main focus of the literature lies on interventions that are more effective and more costly (North-East quadrant), our aim was to investigate how the UK National Institute for Health and Care Excellence (NICE) evaluates interventions that are deemed less effective and less costly (South-West quadrant; SWQ) than standard of care.
METHODS: The NICE website was searched pragmatically for relevant keywords related to the SWQ using the website’s own and the Google Advanced search engines. Manufacturer submissions, External Assessment Group reports, and NICE Committee documents related to identified Technology Appraisals (TAs) underwent a single round of in-depth review.
RESULTS: We identified forty completed NICE TAs in which a reference was made to the SWQ. In twenty-four cases, the new technology was considered less effective and less costly than relevant comparators in at least one target population. Such interventions were generally deemed cost-effective and recommended when they were expected to produce savings exceeding £20,000 to £30,000 per quality-adjusted life year (QALY) lost. Larger savings were required when there was more uncertainty in the evidence base. Argumentation around small QALY losses, better safety profiles, patients having few treatment options, and/or convenience (oral administration) were sometimes considered by NICE Committees. Actual ICERs were often kept confidential due to price discounts being offered. Because SWQ incremental cost-effectiveness ratios can be sensitive to small QALY differences, presentation of net health benefits sometimes facilitated interpretation of results.
CONCLUSIONS: This analysis demonstrates that NICE recommendations can be obtained for interventions less effective and less costly than comparators. The ICER remains a crucial factor in the SWQ, alongside specific clinical considerations. NICE consistently applies its £20,000 to £30,000 per QALY threshold, although debate exists regarding variations in willingness-to-pay thresholds between quadrants.