title: Cost-Effectiveness in Global Surgery: Pearls, Pitfalls, and a Checklist.
abstract: Cost-effectiveness analysis can be a powerful policy-making tool. In the two decades since the first cost-effectiveness analyses in global surgery, the methodology has established the cost-effectiveness of many types of surgery in low- and middle-income countries (LMICs). However, with the crescendo of cost-effectiveness analyses in global surgery has come vast disparities in methodology, with only 15% of studies adhering to published guidelines. This has led to results that have varied up to 150-fold.
  
  
  
  The theoretical basis, common pitfalls, and guidelines-based recommendations for cost-effectiveness analyses are reviewed, and a checklist to be used for cost-effectiveness analyses in global surgery is created.
  
  
  
  Common pitfalls in global surgery cost-effectiveness analyses fall into five categories: the analytic perspective, cost measurement, effectiveness measurement, probability estimation, valuation of the counterfactual, and heterogeneity and uncertainty. These are reviewed in turn, and a checklist to avoid these pitfalls is developed.
  
  
  
  Cost-effectiveness analyses, when done rigorously, can be very useful for the development of efficient surgical systems in LMICs. This review highlights the common pitfalls in these analyses and methods to avoid these pitfalls.
authors.affiliation: Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA. shrime@mail.harvard.edu.|Office of Global Surgery and Health, Massachusetts Eye and Ear Infirmary, Boston, MA, USA. shrime@mail.harvard.edu.
authors.forename: Mark G
authors.initials: MG
authors.lastname: Shrime
authors.affiliation: Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.|Office of Global Surgery and Health, Massachusetts Eye and Ear Infirmary, Boston, MA, USA.
authors.forename: Blake C
authors.initials: BC
authors.lastname: Alkire
authors.affiliation: Kings Centre for Global Health and Kings Health Partners, Kings College, London, UK.
authors.forename: Caris
authors.initials: C
authors.lastname: Grimes
authors.affiliation: Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.
authors.forename: Tiffany E
authors.initials: TE
authors.lastname: Chao
authors.affiliation: MyungSung Medical College, Addis Ababa, Ethiopia.|Montreal Children's Hospital, Montreal, Canada.|Department of Surgery, McGill University, Montreal, Canada.
authors.forename: Dan
authors.initials: D
authors.lastname: Poenaru
authors.affiliation: Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
authors.forename: Stéphane
authors.initials: S
authors.lastname: Verguet
mesh_terms: D057189:Checklist; D003362:Cost-Benefit Analysis / Q000379:methods*; D013502:General Surgery / Q000191:economics*; D006801:Humans; D011050:Policy Making