NICE's cost effectiveness threshold

In exposing the “uncomfortable truths” that NICE’s quality adjusted
life year (QALY) cost threshold has no basis in either theory or evidence,
John Appleby and colleagues conveniently overlook a a number of other
uncomfortable truths. That the concept of quality of life and its
measurement is contested and that to compress the complexities of health
outcomes into a measure between 0 and 1 reflects a triumph of hope over
both evidence and experience.

The confident assumption is that the NHS acts as a machine that is the sum
of its component parts. Resources may be diverted from one health care
service to another to give better value for money like pieces on board
game. There is a common perception that there is a simple relationship
between cause and effect over which there is political and managerial
control. This overlooks the complex and uncertain interdependencies that
characterise the NHS and the international experience that suggests that
resource decision making is inherently messy.

An alternative perspective is to develop qualitative approaches that are
more flexible and sensitive to the heterogeneity of patients, doctors and
their treatments. To recognise that the resources of human complexity
i.e. intuition, common sense and the integrated judgement of a collection
of stakeholders and experts may be better suited to the resolution of
complex resource allocation problems than forcing reality into unrealistic
technical considerations (1).

Kernick D. Health economics and insights from complexity theory.
In: Getting health economics into practice. (Editor: Kernick D) Radcliffe
Medical Press 2002, Abingdon.

Competing interests:
None declared

One of the major concerns of rheumatologists (who have been involved
with NICE submissions for a series of expensive drugs for the treatment of
rheumatoid arthritis (RA) and other inflammatory joint diseases) is "what
is contained in a QUALY assessment". The answer, many believe, is not
enough. If it were clear that there was a cost assessment of the
potential reduction in orthopaedic costs, of the economic cost of putting
someone on the sick register, or of the similar costs to carers, then we
might be happier to accept that patients might be denied treatment.

If someone with RA is turned from a working taxpayer into a benefit
recipient then the drug cost might be totally offset by the difference
between the tax revenue lost added to the disability benefits paid. For
biologic agents, which are often considered in people of working age, the
income level of a patient to be in positive credit balance may be quite
low.

There is the additional question of whether the exhibition of
biologics and other similar drugs might, if given early enough, provike
sustained disease remissions - which would significantly reduce the
medical on-costs of the drugs themselves. Much as I hate to use that
hackneyed phrase "more research is needed" it would be helpful to have
clear answers to these two questions.

Competing interests:
I am a physician with an interest in offering effective and expensive treatments to patients, and current President of the British Society for Rheumatology

Appleby and colleagues suggest that the cost-effectiveness threshold
used by NICE Technology Appraisals (TAs) is too high, seemingly because
the £20-30 000 per QALY guideline is higher than average NHS expenditure
per QALY gained.1 Accordingly NICE decisions may be making the NHS less
efficient.

But this comparison appears misplaced. There are a number of reasons
for that:

1. NICE TAs deal with a selected group of expensive new technologies for
the most part; in themselves these would be expected to be less cost-
effective than average.

2. The average NHS cost/QALY gained has been established over decades of
health care, but funding of newly introduced technologies should reflect
the current funding base not that of the past; typically NICE decisions
are funded out of new money.

3. The opportunity funding forgone by paying for new technologies
recommended by NICE would have been most likely to be used to gain more
marginal (high cost) QALYs in the service.

4. While new drugs (and other technologies) are usually more expensive and
less cost-effective than currently used medications, the latter are
getting cheaper notably through coming off patent. This allows room for
newer less-cost effective technologies without the overall cost per QALY
gained necessarily rising. Examples are many, but cholesterol-lowering
drugs and breast cancer chemotherapy would both show increased overall
cost-effectiveness without the newer drugs NICE has approved.

Disclaimer: The views expressed are those of the author and do not
purport to represent those of NICE.

Competing interests:
PDH advises manufacturers on new drug/technology developments, and is Vice-chair of the NICE Appraisals Committee.