Upcoming

 

Since 1994, the Canadian Agency for Drugs and Technologies in Health (CADTH), and its precursor, the Canadian Coordinating Office for Health Technology Assessment (CCOHTA), have published guidelines for the economic evaluation of health technologies in Canada.

A particularly controversial topic in these guidelines concerns the primary ‘perspective’ for the evaluation. The 2nd edition of these guidelines, published in 1997, recommended that “the primary analytic perspective or viewpoint for pharmacoeconomic studies should be the comprehensive societal perspective; that is, all costs and benefits should be identified regardless of who incurs the costs or who receives the benefits”. However, the 3rd edition, published in 2006, instead recommended that the primary analysis should “use the perspective of the publicly funded health care system”. This narrower perspective was retained in the most recent 4th edition, published in 2017.

In April 2023, the National Advisory Committee on Immunization (NACI) published a competing set of guidelines, intended for economic evaluations of vaccination programs. An important distinction between these and CADTH’s guidelines is that NACI recommends that both a ‘societal’ and a ‘publicly funded health care system’ perspective should be reported by analysts.

It is therefore an opportune time to consider whether CADTH should change its primary perspective back to a ‘societal’ perspective, or maintain its current ‘publicly funded health care system’ perspective, or (in common with NACI) require that both perspectives be reported.

This seminar will consider the arguments in favour of and against each of these options. It will also consider the practical implications of any change in CADTH’s perspective, including the need to modify (perhaps substantially) the $50,000 per QALY ‘threshold’ that CADTH informally uses to assess the cost-effectiveness of technologies so that this would be consistent with a societal perspective. It will be argued that a change in CADTH’s perspective, if appropriately implemented, would not systematically result in more technologies appearing cost-effective, nor would it systematically result in smaller average price reductions being required for technologies to appear cost-effective.

In contrast, a ‘naive’ implementation of a societal perspective, with no corresponding modification of CADTH’s cost-effectiveness ‘threshold’, would be expected to bias CADTH’s economic evaluations in favour of manufacturers and the subset of patients who benefit from new technologies, at the expense of other patients. This could diminish both population health outcomes and broader societal outcomes, and exacerbate health inequalities. The potential equity and policy implications of this will be discussed.