OBJECTIVES: To investigate alternative rationing frameworks that may enable us to maximise QALYs in decisions about interventions that have high budget impact and non-monetary constraints, where standard Cost-Utility Analysis may be ill-equipped to consider all applicable resource constraints.

METHODS: Using literature on rationing and reimbursement in healthcare, we identified seven alternative frameworks for simultaneous decisions about investment and disinvestment and propose ways that these could be adapted to deal with multiple constraints: constrained optimisation; cost-effectiveness league table; Birch & Gafni’s ‘Step-in-the-right-direction’ approach; heuristics based on effective gradients; van Baal’s weighted cost-effectiveness ratios; multi-criteria decision analysis (MCDA); and programme budgeting and marginal analysis (PBMA). We use numerical examples to demonstrate how five of these alternative frameworks would operate if we were considering expanding use of joint replacement within a hypothetical set of existing treatments.

RESULTS: Constrained optimisation and weighting the cost of constrained resources when calculating ICERs maximised the health gains from the budget when partial adoption was permitted. These approaches gave the same resource allocation in this example, although this is not necessarily true in all cases because the weighted ICERs rely on additional information about the weight for spending on constrained resources. MCDA and PBMA take account of outcomes other than QALYs, such as equity, but an MCDA based league table will maximise the weighted sum of performance values and will not necessarily maximise health subject to a budget/resource constraint. All of the algorithms discussed require more data than standard CUA.

CONCLUSIONS: The modified frameworks we propose could be used in local commissioning and/or health technology assessment to supplement standard cost-utility analysis for interventions that have large budget impact and/or are subject to additional constraints.