title: On the Estimation of the Cost-Effectiveness Threshold: Why, What, How?
abstract: BACKGROUND
  Many health care systems claim to incorporate the cost-effectiveness criterion in their investment decisions. Information on the system's willingness to pay per effectiveness unit, normally measured as quality-adjusted life-years (QALYs), however, is not available in most countries. This is partly because of the controversy that remains around the use of a cost-effectiveness threshold, about what the threshold ought to represent, and about the appropriate methodology to arrive at a threshold value.
  
  
  OBJECTIVE
  The aim of this article was to identify and critically appraise the conceptual perspectives and methodologies used to date to estimate the cost-effectiveness threshold.
  
  
  METHODS
  We provided an in-depth discussion of different conceptual views and undertook a systematic review of empirical analyses. Identified studies were categorized into the two main conceptual perspectives that argue that the threshold should reflect 1) the value that society places on a QALY and 2) the opportunity cost of investment to the system given budget constraints.
  
  
  RESULTS
  These studies showed different underpinning assumptions, strengths, and limitations, which are highlighted and discussed. Furthermore, this review allowed us to compare the cost-effectiveness threshold estimates derived from different types of studies. We found that thresholds based on society's valuation of a QALY are generally larger than thresholds resulting from estimating the opportunity cost to the health care system.
  
  
  CONCLUSIONS
  This implies that some interventions with positive social net benefits, as informed by individuals' preferences, might not be an appropriate use of resources under fixed budget constraints.
authors: Departamento de Economía Aplicada y Métodos Cuantitativos, Universidad de la Laguna; Centre for Biomedical Research of the Canary Islands (CIBICAN); Spanish Network of Health Services Research for Chronic Diseases (REDISSEC); Department of Applied Health Research, University College London, London, UK. Electronic address: lvallejo@ull.es.
authors: Laura
authors: L
authors: Vallejo-Torres
authors: Canary Foundation for Health Care Research (FUNCANIS).
authors: Borja
authors: B
authors: García-Lorenzo
authors: Centre for Biomedical Research of the Canary Islands (CIBICAN); Spanish Network of Health Services Research for Chronic Diseases (REDISSEC); Departamento de Ingeniería Informática y de Sistemas, Universidad de La Laguna.
authors: Iván
authors: I
authors: Castilla
authors: Spanish Network of Health Services Research for Chronic Diseases (REDISSEC); Canary Foundation for Health Care Research (FUNCANIS).
authors: Cristina
authors: C
authors: Valcárcel-Nazco
authors: Spanish Network of Health Services Research for Chronic Diseases (REDISSEC); Canary Foundation for Health Care Research (FUNCANIS).
authors: Lidia
authors: L
authors: García-Pérez
authors: Spanish Network of Health Services Research for Chronic Diseases (REDISSEC); Canary Foundation for Health Care Research (FUNCANIS).
authors: Renata
authors: R
authors: Linertová
authors: Spanish Network of Health Services Research for Chronic Diseases (REDISSEC); Unidad Docente de Atención Familiar y Comunitaria Norte, Gerencia de Atención Primaria, Servicio Madrileño de Salud.
authors: Elena
authors: E
authors: Polentinos-Castro
authors: Spanish Network of Health Services Research for Chronic Diseases (REDISSEC); Servicio de Evaluación del Servicio Canario de la Salud (SESCS), Canary Islands, Spain.
authors: Pedro
authors: P
authors: Serrano-Aguilar
mesh_terms: D003362:Cost-Benefit Analysis / Q000379:methods*; D036262:Empirical Research; D006801:Humans; D018803:Models, Economic; D019057:Quality-Adjusted Life Years; D013673:Technology Assessment, Biomedical / Q000191:economics*
keywords: cost-effectiveness analysis; quality-adjusted life-year; threshold