OBJECTIVES

: Cost-effectiveness thresholds (CETs) are used to inform decisionmakers about the value for money of health technologies; however the application of one single CET is heavily debated. We aimed to identify European countries with multi-level thresholds to better understand the methodology they use to allocate their health care funds and the criteria settings for the limits of their CETs.

METHODS

: A systematic literature review (SLR) was conducted following the PRISMA guideline principles to retrieve publications in English from Pubmed, Scopus and EBSCO Academic Search Complete database limited to the last ten years. In addition, guidelines of pre-selected HTA organizations have been screened and experts from the relevant countries were consulted. Empirical evidence on cost-effectiveness thresholds were retrieved and extracted into a predefined data extraction table.

RESULTS

: 1,962 articles were identified by the SLR for abstract/title screening and 10 studies were included in the final qualitative synthesis, while HTA guidelines from 21 countries were reviewed. Multi-level thresholds are used in Lithuania, Netherlands, Norway, Slovakia, Sweden and the UK. The main criteria to define multi-level thresholds are based on absolute or proportional shortfall of QALYs, incremental QALY gain, rare disease designation and end-of-life treatment status. The lower limits of multilevel thresholds range from 0.3 to 1.8 times GDP per capita, while the highest boundaries are from 0.7 to 5.0 times the GDP per capita. In general, under the lower threshold a technology is considered cost-effective, however higher limit of the threshold is used to incorporate additional criteria representing different preference concepts (disease severity, fair innings, equity).

CONCLUSIONS

: Threshold limits in relation to the GDP per capita vary widely between European countries. Multi-level thresholds can be set to reflect different preferences of resource allocation in health care funds providing advantage for example to highly specialized technologies or diseases with high humanistic burden.