OBJECTIVES: This analysis investigates the implicit cost-effectiveness requirements for new therapies used earlier in a treatment sequence when cost-effectiveness thresh-olds have been relaxed for for later lines of therapies. Two examples of this are: 1) The National Institute for Health and Clinical Excellence (NICE) decision to allow higher cost-effectiveness thresholds for later lines of therapy in certain oncology indi-cations, and 2) The Swedish Dental and Pharmaceutical Benefits Board (TLV) implicit decisions to accept higher thresholds with later line restrictions. METHODS: A simple example is constructed where a new competing 1st line therapy (A) can replace the currently used therapy (B). It is assumed that if no further lines of therapy exists then therapy A would be considered cost-effective compared to B using a formal threshold level of T. A third therapy (C) is approved to be used only in 2nd line therapy and is accepted at a higher cost-effectiveness threshold than T. The problem is focused on the formal evaluation of the incremental cost-effectiveness ratio of the new therapy A vs. B in the presence of therapy C. RESULTS: The implication of relaxing the cost-effectiveness requirement for later lines of therapies is a further strengthening of the requirement of new therapies for earlier use in treatment sequences. In the most extreme scenario a new therapy, with less cost and higher effectiveness compared to standard therapy in a specific line, may not be considered cost-effective. CONCLU-SIONS: This increased implicit cost-effectiveness threshold by the new regulations may risk crowding-out of new cost-effective therapies in earlier lines unless the explicit requirements/thresholds are modified using the highest accepted ratio between the costs and efficacy in the treatment sequence. Another solution is to evaluate and compare complete treatment sequences.
Liwing, J., & Lothgren, M. (2009). EE5 THE SEESAW OF COST-EFFECTIVENESS THRESHOLDS: HOW RELAXED REQUIREMENTS FOR LATER LINES OF TREATMENT WILL INCREASE HURDLES FOR NEW THERAPIES. Value in Health, 12(7), A230. https://doi.org/10.1016/s1098-3015(10)74120-6