OBJECTIVES: Principle 9 of NICE’s charter aims to reduce health inequalities. NICE therefore considers health inequality to be an important factor in decision-making. Current approaches to valuing health inequalities in HTA decisions are, generally, unsystematic and thus untransparent. However, Distributional Cost-Effectiveness Analysis (DCEA) provides a systematic approach to valuing health inequalities. The aim of this study is to therefore develop a DCEA case-study to explore the prospects of DCEA in Health Technology Assessment (HTA).

METHODS: DCEA reweights standard cost-effectiveness outcomes, specifically incremental QALYs and costs, based on a decision-maker’s aversion to inequality and the pre-intervention health inequalities that exist within a general population. Since Hepatitis C disproportionately affects more deprived socio-economic groups within England, we use Hepatitis C as a case study. We derive incremental QALYs (1.24) and costs (£20,661) from NICE TA507 (Vosevi vs. Pegylated interferon alpha 2a), which reported an incremental cost-effectiveness ratio (ICER) of £16,654. From these data, we analyse the health equity impact of Vosevi within the chronic Hepatitis-C DAA-naive population of England.

RESULTS: Based on an aversion to inequality value of 11, the DCEA-weighted ICER reduces to £13,177 (a 21% reduction), with large concomitant gains in net health benefit (NHB). A Slope Index of Inequality (SII) regression (SII = -21,262) indicates the intervention reduces overall health inequality. However, since the majority of eligible patients (56%) fall within the most deprived socio-economic groups of England, a scenario analysis was performed where proportions of patients across deprivation quintiles were equal (20% per quintile). In this scenario, both health inequality (SII = 224) and the ICER increase (£24,194), while gains in NHB are minimal.

CONCLUSIONS: By providing quantitative estimates on both equity and efficiency of an intervention, DCEA enables a standardised and systematic approach for industry and HTA agencies to value how a medical product may affect health inequalities.