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League Tables for Incremental Cost-Effectiveness Ratios
A cost-effectiveness league table is a listing of health interventions ranked by their incremental cost-effectiveness ratios (ICERs) presented in terms of cost per life years, or cost per quality-adjusted life years (QALYs) gained. A typical table (see Table 1) starts with the most favorable (lowest ICER) intervention and ends with the least favorable one (highest ICER). League tables are used to place findings of a cost-effectiveness analysis in a broader context and help determine whether a specific intervention presents “good value for the money.” They may be used for informing resource allocation decisions: Under a fixed budget constraint, healthcare resources are allocated starting with interventions with the lowest ICER and moving to higher ICERs until the entire budget is consumed.
Cost-Effectiveness Analysis and Rationing
Cost-effectiveness analysis is a method of economic evaluation in which costs and outcomes of a program and at least one alternative are compared. The difference in cost (incremental cost) is divided by the difference in outcomes (incremental effect) to derive the incremental cost-effectiveness ratio. Although any natural unit of outcome can be used to determine a program's effect, the common metrics used are life years or QALYs gained because they allow for comparisons across diverse treatments and diseases.
An analysis using cost per QALY as an outcome measure is sometimes referenced as a cost-utility analysis. This is the most widely used method for informing resource allocation decisions in healthcare. As opposed to benefit-cost analysis, cost-effectiveness studies do not present health outcomes in monetary terms, which would permit a straightforward comparison of costs and benefits to determine whether an intervention is worthwhile. As a result, the relative value for the money of an intervention can only be interpreted by a reference to an external standard. This standard can be a benchmark or threshold value (e.g., $50,000 per QALY gained) below which an intervention can be considered to be “good value for the money” or a comparison of the relative cost-effectiveness of various interventions of which some may be already covered by health plans.
History of League Table Presentation
The presentation of league tables (so called after the tables used for British soccer league standings) and comparisons between healthcare interventions in terms of their relative cost-effectiveness became fashionable in the 1980s. Since a common metric is used (life years or QALYs), league tables can be useful for the comparison and ranking of diverse interventions to improve health, from public health or environmental programs to medical technology. One of the first league tables was presented by John Graham and James Vaupel and included estimates of cost per life saved and cost per life year saved. Allan Williams presented a league table for the United Kingdom in his seminal work on the economics of coronary artery bypass grafting (CABG). Other examples of comprehensive league tables can be found in the work of Tammy Tengs and colleagues, who presented in 1996 a list of more than 500 “life-saving” interventions and their relative cost-effectiveness and, more recently, in the data presented in the Tufts Medical Center Cost-Effectiveness Analysis Registry, gathered through an extensive review of cost-effectiveness analyses published since 1976.
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- Basis for Making the Decision
- Acceptability Curves and Confidence Ellipses
- Beneficence
- Bioethics
- Choice Theories
- Construction of Values
- Cost-Benefit Analysis
- Cost-Comparison Analysis
- Cost-Consequence Analysis
- Cost-Effectiveness Analysis
- Cost-Minimization Analysis
- Cost-Utility Analysis
- Decision Quality
- Distributive Justice
- Dominance
- Equity
- Evaluating Consequences
- Expected Utility Theory
- Expected Value of Perfect Information
- Extended Dominance
- Health Production Function
- League Tables for Incremental Cost-Effectivenes: Ratios
- Marginal or Incremental Analysis, Cost-Effectiveness Ratio
- Monetary Value
- Moral Choice and Public Policy
- Net Benefit Regression
- Net Monetary Benefit
- Nonexpected Utility Theories
- Pharmacoeconomics
- Protected Values
- Rank-Dependent Utility Theory
- Return on Investment
- Risk-Benefit Trade-Off
- Subjective Expected Utility Theory
- Toss-Ups and Close Calls
- Value-Based Insurance Design
- Welfare, Welfarism, and Extrawelfarism
- Biostatistics and Clinical Epidemiology
- Analysis of Covariance (ANCOVA)
- Analysis of Variance (ANOVA)
- Attributable Risk
- Basic Common Statistical Tests: Chi-Square Test, t Test, Nonparametric Test
- Bayes's Theorem
- Bayesian Analysis
- Bayesian Evidence Synthesis
- Bayesian Networks
- Bias
- Bias in Scientific Studies
- Brier Scores
- Calibration
- Case Control
- Causal Inference and Diagrams
- Causal Inference in Medical Decision Making
- Conditional Independence
- Conditional Probability
- Confidence Intervals
- Confounding and Effect Modulation
- Cox Proportional Hazards Regression
- Decision Rules
- Diagnostic Tests
- Discrimination
- Distributions: Overview
- Dynamic Treatment Regimens
- Effect Size
- Equivalence Testing
- Experimental Designs
- Factor Analysis and Principal Components Analysis
- Fixed Versus Random Effects
- Frequentist Approach
- Hazard Ratio
- Hypothesis Testing
- Index Test
- Intraclass Correlation Coefficient
- Likelihood Ratio
- Log-Rank Test
- Logic Regression
- Logistic Regression
- Maximum Likelihood Estimation Methods
- Measures of Central Tendency
- Measures of Frequency and Summary
- Measures of Variability
- Meta-Analysis and Literature Review
- Mixed and Indirect Comparisons
- Multivariate Analysis of Variance (MANOVA)
- Nomograms
- Number Needed to Treat
- Odds and Odds Ratio, Risk Ratio
- Ordinary Least Squares Regression
- Parametric Survival Analysis
- Poisson and Negative Binomial Regression
- Positivity Criterion and Cutoff Values
- Prediction Rules and Modeling
- Probability
- Propensity Scores
- Randomized Clinical Trials
- Receiver Operating Characteristic (ROC) Curve
- Recurrent Events
- Recursive Partitioning
- Regression to the Mean
- Sample Size and Power
- Screening Programs
- Statistical Notations
- Statistical Testing: Overview
- Subjective Probability
- Subset Analysis: Insights and Pitfalls
- Survival Analysis
- Tables, Two-by-Two and Contingency
- Variance and Covariance
- Violations of Probability Theory
- Weighted Least Squares
- Decision Analysis and Related Mathematical Models
- Applied Decision Analysis
- Boolean Algebra and Nodes
- Decision Analyses, Common Errors Made in Conducting
- Decision Curve Analysis
- Decision Tree: Introduction
- Decision Trees, Advanced Techniques in Constructing
- Decision Trees, Construction
- Decision Trees, Evaluation
- Decision Trees, Evaluation With Monte Carlo
- Decision Trees: Sensitivity Analysis, Basic and Probabilistic
- Decision Trees: Sensitivity Analysis, Deterministic
- Declining Exponential Approximation of Life Expectancy
- Deterministic Analysis
- Discrete-Event Simulation
- Disease Management Simulation Modeling
- Expected Value of Sample Information, Net Benefit of Sampling
- Influence Diagrams
- Markov Models
- Markov Models, Applications to Medical Decision Making
- Markov Models, Cycles
- Markov Processes
- Reference Case
- Steady-State Models
- Stochastic Medical Informatics
- Subtrees, Use in Constructing Decision Trees
- Test-Treatment Threshold
- Time Horizon
- Tornado Diagram
- Tree Structure, Advanced Techniques
- Health Outcomes and Measurement
- Complications or Adverse Effects of Treatment
- Cost-Identification Analysis
- Costs, Direct Versus Indirect
- Costs, Fixed Versus Variable
- Costs, Opportunity
- Costs, Out-of-Pocket
- Costs, Semifixed Versus Semivariable
- Costs, Spillover
- Economics, Health Economics
- Efficacy Versus Effectiveness
- Efficient Frontier
- Health Outcomes Assessment
- Health Status Measurement Standards
- Health Status Measurement, Assessing Meaningful Change
- Health Status Measurement, Construct Validity
- Health Status Measurement, Face and Content Validity
- Health Status Measurement, Floor and Ceiling Effects
- Health Status Measurement, Generic Versus Condition-Specific Measures
- Health Status Measurement, Minimal Clinically Significant Differences, and Anchor Versus Distribution Methods
- Health Status Measurement, Reliability and Internal Consistency
- Health Status Measurement, Responsiveness and Sensitivity to Change
- Human Capital Approach
- Life Expectancy
- Morbidity
- Mortality
- Oncology Health-Related Quality of Life Assessment
- Outcomes Research
- Patient Satisfaction
- Regret
- Report Cards, Hospitals and Physicians
- Risk Adjustment of Outcomes
- SF-36 and SF-12 Health Surveys
- SF-6D
- Sickness Impact Profile
- Sunk Costs
- Impact or Weight or Utility of the Possible Outcomes
- Certainty Equivalent
- Chained Gamble
- Conjoint Analysis
- Contingent Valuation
- Cost Measurement Methods
- Decomposed Measurement
- Disability-Adjusted Life Years (DALYs)
- Discounting
- Discrete Choice
- Disutility
- EuroQol (EQ-5D)
- Health Utilities Index Mark 2 and 3 (HUI2, HUI3)
- Healthy Years Equivalents
- Holistic Measurement
- Multi-Attribute Utility Theory
- Person Trade-Off
- Quality of Well-Being Scale
- Quality-Adjusted Life Years (QALYs)
- Quality-Adjusted Time Without Symptoms or Toxicity (Q-TWiST)
- SMARTS and SMARTER
- Split Choice
- Utilities for Joint Health States
- Utility Assessment Techniques
- Willingness to Pay
- Other Techniques, Theories, and Tools
- Artificial Neural Networks
- Bayesian Networks
- Bioinformatics
- Chaos Theory
- Clinical Algorithms and Practice Guidelines
- Complexity
- Computer-Assisted Decision Making
- Constraint Theory
- Decision Board
- Decisional Conflict
- Error and Human Factors Analyses
- Ethnographic Methods
- Expert Systems
- Patient Decision Aids
- Qualitative Methods
- Story-Based Decision Making
- Support Vector Machines
- Team Dynamics and Group Decision Making
- Threshold Technique
- Perspective of the Decision Maker
- Advance Directives and End-of-Life Decision Making
- Consumer-Directed Health Plans
- Cultural Issues
- Data Quality
- Decision Making in Advanced Disease
- Decisions Faced by Hospital Ethics Committees
- Decisions Faced by Institutional Review Boards
- Decisions Faced by Nongovernment Payers of Healthcare: Managed Care
- Decisions Faced by Patients: Primary Care
- Decisions Faced by Surrogates or Proxies for the Patient, Durable Power of Attorney
- Diagnostic Process, Making a Diagnosis
- Differential Diagnosis
- Evaluating and Integrating Research Into Clinical Practice
- Evidence Synthesis
- Evidence-Based Medicine
- Expert Opinion
- Genetic Testing
- Government Perspective, General Healthcare
- Government Perspective, Informed Policy Choice
- Government Perspective, Public Health Issues
- Health Insurance Portability and Accountability Act Privacy Rule
- Health Risk Management
- Informed Consent
- Informed Decision Making
- International Differences in Healthcare Systems
- Law and Court Decision Making
- Medicaid
- Medical Decisions and Ethics in the Military Context
- Medical Errors and Errors in Healthcare Delivery
- Medicare
- Models of Physician–Patient Relationship
- Patient Rights
- Physician Estimates of Prognosis
- Rationing
- Religious Factors
- Shared Decision Making
- Surrogate Decision Making
- Teaching Diagnostic Clinical Reasoning
- Technology Assessments
- Terminating Treatment, Physician Perspective
- Treatment Choices
- Trust in Healthcare
- The Psychology Underlying Decision Making
- Accountability
- Allais Paradox
- Associative Thinking
- Attention Limits
- Attraction Effect
- Automatic Thinking
- Axioms
- Biases in Human Prediction
- Bounded Rationality and Emotions
- Certainty Effect
- Cognitive Psychology and Processes
- Coincidence
- Computational Limitations
- Confirmation Bias
- Conflicts of Interest and Evidence-Based Clinical Medicine
- Conjunction Probability Error
- Context Effects
- Contextual Error
- Counterfactual Thinking
- Cues
- Decision Making and Affect
- Decision Modes
- Decision Psychology
- Decision Weights
- Decision-Making Competence, Aging and Mental Status
- Deliberation and Choice Processes
- Developmental Theories
- Dual-Process Theory
- Dynamic Decision Making
- Editing, Segregation of Prospects
- Emotion and Choice
- Errors in Clinical Reasoning
- Experience and Evaluations
- Fear
- Frequency Estimation
- Fuzzy-Trace Theory
- Gain/Loss Framing Effects
- Gambles
- Hedonic Prediction and Relativism
- Heuristics
- Human Cognitive Systems
- Information Integration Theory
- Intuition Versus Analysis
- Irrational Persistence in Belief
- Judgment
- Judgment Modes
- Learning and Memory in Medical Training
- Lens Model
- Lottery
- Managing Variability and Uncertainty
- Memory Reconstruction
- Mental Accounting
- Minerva-DM
- Mood Effects
- Moral Factors
- Motivation
- Numeracy
- Overinclusive Thinking
- Pain
- Pattern Recognition
- Personality, Choices
- Preference Reversals
- Probability Errors
- Probability, Verbal Expressions of
- Problem Solving
- Procedural Invariance and Its Violations
- Prospect Theory
- Range-Frequency Theory
- Risk Attitude
- Risk Aversion
- Risk Communication
- Risk Perception
- Scaling
- Social Factors
- Social Judgment Theory
- Stigma Susceptibility
- Support Theory
- Uncertainty in Medical Decisions
- Unreliability of Memory
- Value Functions in Domains of Gains and Losses
- Worldviews
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