interventions, for producing estimates in studies that include nonmarket goods, and
for studying within-procedure cost variation.^14 Microcosting is frequently applied
in economic evaluations of health care interventions where they make up an
important part of sensitivity analysis in economic evaluations. In practice, applying
micro- or macrocosting exclusively is almost never reported; instead, mixed
methods are commonly used, depending on the different elements of cost required
for conducting a particular economic evaluation.
2.3 Decision Rule for CUA
The first decision rule that is applied in cost-effectiveness analysis is that if any
health care intervention is strictly dominated by another intervention or a combi-
nation of alternative interventions (i.e., either it is more effective and costs the same
or is cheaper and equally effective), it should be rejected. Conversely, the domi-
nated intervention either requires greater cost but offers no greater benefits or offers
lower benefits without reducing the costs. However, the choice between the
nondominated alternatives is less straightforward. Increasingly, decision makers
are relying on a threshold value as the decision rule for judging the results of
economic evaluations. In this case, the value of the ICER obtained from an
economic evaluation is directly compared to an explicit monetary threshold
value, and the decision rule states that the ICER must be lower than the threshold
if the intervention is to be regarded as cost-effective. Where more than one
intervention can be used (or reimbursed), the ICERs for all intervention combina-
tions should be calculated to determine which intervention is relatively most cost-
effective and whether one meets the threshold value requirement.
Economic evaluations can be performed either from a (narrow) health care
perspective or a broader, societal perspective.^15 It has been argued that all relevant
costs and effects should be included in deliberation and analysis, regardless of
where they fall. This would imply the use of the societal perspective in economic
evaluations. The strict application of the societal perspective in CUA would require
that all effects of an intervention on persons’welfare are measured and included in
the analysis (primarily through changes in nonhealth consumption and health).
From such a broad perspective, a general decision rule for judging health care
interventions can be formalized as follows:
(^14) For details and further analysis on costing methods, see Gold et al. ( 1996 ), Fishman and
Hornbrook ( 2009 ), pp. 70–75; and Frick ( 2010 ), pp. 76–81.
(^15) More debate on the important topic of an appropriate perspective for economic evaluations
available in Gold et al. ( 1996 ); Brouwer et al. ( 2008 ), pp. 325–338; Gravelle et al. 2007 ,
pp. 307–317; Claxton et al. ( 2010 ); Bobinac ( 2012 ).
114 A. Bobinac and M. Vehovec