OBJECTIVES: To review the literature that discusses rationale, methods, and use of cost-effectiveness thresholds (CETs) across countries.

METHODS: A systematic literature review was performed using the pearl-growing approach with no language restrictions. The studies identified have described at least one of the following: rationale for the use of a CET, estimation methods used to derive CET values, or use of a CET value in reimbursement and pricing decisions.

RESULTS: The primary rationales for estimating quantitative CETs included increased transparency and consistency in decision-making. There was lack of consensus regarding the methods used to determine the CET value(s), ranging from no clear justification to CET values that reflected opportunity costs or willingness to pay. However, there was consensus that CET values should vary across countries due to differences in gross domestic product, purchasing power, and public preferences. The CET values identified ranged from 160,000 THB in Thailand (~US $5,000) to US $150,000 in the United States. Some countries used multiple CET estimates adjusted by factors such as disease severity and end-of-life care. In addition, while some countries used the incremental cost-effectiveness ratio (ICER) as the primary outcome of economic evaluations and the ICER comparison to the CET as the primary determinant of product value and price, other countries used this comparison as one of multiple determinants of product value and acceptability for reimbursement. Inclusion of uncertainty and disease severity in the CET value estimation has been shown to be consistent with economic theory.

CONCLUSIONS: There was little agreement across countries on both the methods used to estimate CET values and how CETs were used in reimbursement decisions. Given the lack of data and the lack of consensus on CET estimation methods, it may be more appropriate to consider the ICER/CET outcome combination as one of multiple criteria when assessing a new health technology.