Zamora Bernarda, Garrison Louis P, Unuigbe Aig, Towse Adrian
Office of Health Economics, Southside, 105 Victoria Street, London, SW1E 6QT, UK.
The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Magnuson Health Sciences Building, H Wing, H-375, Box 357630, 98195, Seattle, WA, USA.
Cost Eff Resour Alloc. 2021 Mar 1;19(1):13. doi: 10.1186/s12962-021-00266-8.
The ISPOR Special Task Force (STF) on US Value Assessment Frameworks was agnostic about exactly how to implement the quality-adjusted life year (QALY) as a key element in an overall cost-effectiveness evaluation. But the STF recommended using the cost-per-QALY gained as a starting point in deliberations about including a new technology in a health plan benefit. The STF offered two major alternative approaches-augmented cost-effectiveness analysis (ACEA) and multi-criteria decision analysis (MCDA)-while emphasizing the need to apply either a willingness-to-pay (WTP) or opportunity cost threshold rule to operationalize the inclusion decision.
The MCDA model uses the multi-attribute utility function. The ACEA model is based on the expected utility theory. In both ACEA and MCDA models, value trade-offs are derived in a hierarchical model with two high-level objectives which measure overall health gain separately from financial attributes affecting consumption.
Even though value trade-offs can be elicited or revealed without considering budget constraints, we demonstrate that they can be used similarly to WTP-based cost-effectiveness thresholds for resource allocation decisions. The consideration of how costs of medical technology, income, and severity of disease affect value trade-offs demonstrates, however, that reconciling decisions in ACEA and MCDA requires that health and consumption are either complements or independent attributes.
We conclude that value trade-offs derived either from ACEA or MCDA move similarly with changes in main factors considered by enrollees and decision makers-costs of the medical technology, income, and severity of disease. Consequently, this complementarity between health and consumption is a necessary condition for reconciling ACEA and MCDA. Moreover, their similarity would be further enhanced if the QALY is used as the key attribute or anchor in the MCDA value function: the choice between the two is a pragmatic question that is still open.
美国价值评估框架的药物经济学与结果研究协会（ISPOR）特别工作组（STF）对于如何具体实施质量调整生命年（QALY）作为整体成本效益评估的关键要素并无定论。但该特别工作组建议，在考虑将一项新技术纳入健康计划福利时，将每获得一个QALY的成本作为讨论的起点。该特别工作组提供了两种主要的替代方法——增强成本效益分析（ACEA）和多标准决策分析（MCDA），同时强调需要应用支付意愿（WTP）或机会成本阈值规则来实施纳入决策。
MCDA模型使用多属性效用函数。ACEA模型基于期望效用理论。在ACEA和MCDA模型中，价值权衡是在一个层次模型中得出的，该模型有两个高层次目标，分别衡量总体健康收益与影响消费的财务属性。
尽管在不考虑预算限制的情况下也能得出或揭示价值权衡，但我们证明，它们可用于类似基于WTP的成本效益阈值进行资源分配决策。然而，对医疗技术成本、收入和疾病严重程度如何影响价值权衡的考虑表明，要协调ACEA和MCDA中的决策，健康和消费要么是互补属性，要么是独立属性。
我们得出结论，ACEA或MCDA得出的价值权衡随参保者和决策者考虑的主要因素——医疗技术成本、收入和疾病严重程度的变化而产生类似的变动。因此，健康与消费之间的这种互补性是协调ACEA和MCDA的必要条件。此外，如果将QALY用作MCDA价值函数中的关键属性或锚点，它们之间的相似性将进一步增强：两者之间的选择是一个仍未解决的实际问题。
