OBJECTIVES:

Distributional cost-effectiveness analysis (DCEA) is an extension of cost-effectiveness analysis that looks at the equity impact of adopting interventions, evaluating how health outcomes and costs are distributed in the population, and quantifying trade-offs between health maximisation and health equity. The National Institute of Health and Care Excellence (NICE) in the UK is exploring DCEA to support the development of its Technology Appraisals. The prevalence of diabetes and thus diabetic macular edema (DME), a complication of diabetes, is higher in more deprived areas. We aimed to conduct an aggregate DCEA from an English NHS perspective of treatments for DME recommended by NICE to capture the value of these treatments more comprehensively.

METHODS:

Population subgroups were defined based on socio-economic deprivation using the index of multiple deprivation. Data on health outcomes and costs were derived from a cost-effectiveness model of faricimab compared to ranibizumab, aflibercept, and bevacizumab in DME using a societal perspective in the base-case and a healthcare payer perspective in scenario analysis. Distributions of England’s population baseline lifetime health and health opportunity costs were taken from the literature. Trade-offs between health maximisation and health equity were assessed using the Atkinson inequality index.

RESULTS:

Faricimab was found to be equity improving under a societal perspective at thresholds of £20,000 per quality-adjusted life-year (QALY) and £15,000/QALY, driven by faricimab being cost-effective and the patient distribution being skewed towards the most deprived. Using a healthcare perspective, faricimab was equity-improving in most scenarios.

CONCLUSIONS:

In addition to being cost-effective, this study shows that faricimab improves health equity. Incorporating quantitative equity impact estimates enables a more comprehensive assessment of value. Detailed methodology to construct DCEAs, criteria leading to DCEAs being a requirement, and how the results would be interpreted and integrated into decision-making by HTA bodies such as NICE would be valuable to analysts, manufacturers, and researchers.