Does Health Technology Assessment guidance give adequate consideration to decisions about less costly and less effective alternatives?

Susan Griffin, Francesco Fusco, Bhash Naidoo, Matthew Taylor, Simon Mark Walker

Research output: Working paper


Cost-effectiveness analysis (CEA) plays a key role informing decision-making in healthcare and,
consequently, the interpretation of its results is discussed in formal guidance from health technology
assessment (HTA) organisations. A body of research indicates different willingness to pay for more
effective interventions than willingness to accept less effective interventions, which some suggest
supports application of different cost-effectiveness thresholds depending on whether an
intervention is considered more or less effective than the comparator. We review the theoretical
basis for the use of differential thresholds within HTA organisations, and question whether they are
compatible with coherent decisions and social values. The National Institute for Health and Care
Excellence (NICE) is one such organisation, providing recommendations on which healthcare
interventions to adopt in the United Kingdom. NICE guidance describes the decision rules it employs,
including comparing CEA results to a cost-effectiveness threshold that defines the boundaries
beyond which an intervention is no longer considered to provide value for money. Our review of
NICE guidance finds that it describes a common threshold range for all alternatives, in line with the
theoretical basis for a supply-side threshold. However, we also find that the guidance focuses on the
application of the threshold as a decision rule for more effective and more expensive treatments,
with less guidance provided on less effective and less expensive treatments. We make suggestions
for how HTA organisations can better support application of decision rules to interventions that are
less effective and less expensive.
Original languageEnglish
Place of PublicationYork, UK
PublisherCentre for Health Economics, University of York
Number of pages19
Publication statusPublished - 4 Nov 2020

Publication series

NameCHE Research Paper
PublisherCentre for Health Economics, University of York


  • Cost‐effectiveness analysis
  • willingness to pay
  • willingness to accept
  • opportunity cost
  • cost‐effectiveness thresholds
  • priority setting

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