OBJECTIVES: Decision makers are increasingly concerned about both cost-effectiveness (CE) and affordability, which has resulted in additional price negotiations being implemented by HTA bodies, such as NICE. Cost-effectiveness plane and cost-effectiveness acceptability curves have been widely used to summarize CE analysis results under uncertainty. However, these methods ignore the resources necessary to fund the intervention. Sendi and Briggs (2001) proposed to use cost-effectiveness affordability curves (CEAFCs) to capture the joint probability that an intervention is both cost-effective and affordable. We aim to review the application of this method in the economic evaluation of healthcare technologies.

METHODS: We searched MEDLINE, EconLit, EMBASE, CDR and HEED databases using the terms “cost-effectiveness” and (“affordability or “cost control”). Sub-headings were not used given the breadth of the search’s scope. Studies considering both CE and affordability using CEAFCs to evaluate healthcare technologies or programs, published in English after 2010, were included. A qualitative narrative synthesis was performed.

RESULTS: Of the 1195 records screened, only eight utilized CEAFCs. Seven referred to a vaccine and one to promotion of breastfeeding; all were in developing countries and used both the societal and payer perspective. CEAFCs were used specifically to address concerns about affordability in situations where the incremental cost-effectiveness ratio for an individual healthcare technology was low but the overall budget impact was high. All used Markov models or decision trees and included probabilistic analyses by Monte Carlo simulations. The reported joint probability of cost-effectiveness and affordability ranged from 21% to 60%. Half of the studies were funded by pharmaceutical companies.

CONCLUSIONS: Findings indicate that CEAFCs are a useful but underused tool, especially for investigating the cost effectiveness and affordability of new treatments in developed countries. Increased use of CEAFCs may provide a beneficial framework to address affordability concerns alongside cost-effectiveness analysis.