Should health technology assessment (HTA) processes consider using distributional cost effectiveness analysis (DCEA) to incorporate technology impacts on inequality? Some say ‘yes’ and some say ‘no’. Let’s take a look at both sides.
No
In a
Letter to the Editor in Value in Health, Sreeram Ramagopalan noted
that NICE currently has a number of concerns with potentially implementing
distributional cost effectiveness analysis (DCEA) as part of decisions
making. Ramagopalan writes:
“The NICE technical team clarified that NICE’s position is that the NICE health technology evaluations manual does not allow for a quantitative modifier for health inequalities. NICE does not consider that there is sufficiently robust evidence to support using aversion weights as part of a DCEA. But, taken together, the NICE health technology evaluations manual, statutory duties, principles and deliberative decision making provide the flexibility to take into account relevant considerations.”
One reason is that it is known known with certainty how much
people actually are willing to trade of health gains to the average person in
order to reduce inequality. The most
commonly used inequality aversion parameter used in the literature is 11
(Atkinson relative inequality aversion index) from Robson et al. 2017; however, NICE’s
external assessment group (EAG) preferred to use a value of 3.5, taken
from a more recent estimate (Robson et al. 2024)
A second issue is over which groups should inequality
aversion be reduced? Race? Geography?
Income? They note inequality over
different racial groups is highly relevant for beta thalassemia, but for an
evaluation of exagamglogene autotemcel (TA1033)
quintiles of the index of multiple deprivation (IMD) were used as a proxy for
race/ethnicity. NICE’s EAG noted in their review that IMD was a highlight
imperfect proxy for ethnicity-specific quality-adjusted life expectancy (QALE)
data.
Ramagopalan also notes that in the US, the Institute for
Clinical and Economic Review (ICER) has not adopted DCEA [see ICER
white paper]. While there are
estimates of quality adjusted life expectancy in the US (Kowal et al. 2023) and the
UK (Love-Koh et al. 2015)
Yes
A ViH letter to the editor by Koh, Murray, Brooke, Owen and Shah (2025) responds to Ramagopalan and argues that, yes, DCEA should be included in HTA. Koh and colleagues state that NICE has long considered health disparities and inequities in their evaluations, just more frequently from a qualitative—rather than quantitative—perspective. The authors cite recent NICE guidelines on how to address health inequalities in breast cancer (Slade et al. 2024) NICE guidelines (NG246) also states that:
“…local commissioners and providers of healthcare have a responsibility…to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities”
In fact, in May 2024, NICE updated their methods around
health inequalities (Hughes
2025, PMG36)
and have published a methods support document on DCEA usage which includes stratification
of social groups, uncertainty, health opportunity cost and reporting outputs (NICE
implementation support, 13 May 2025).
While Koh and co-authors do argue that there is some good
evidence on inequality aversion preferences, they admit that there is no
consensus on the exact degree of this trade-off as well as no precise process
in terms of how DCEA should be operationalized. Additionally, DCEAs are more complex
to implement that traditional CEA. The authors agree that a DCEA is not needed
for every intervention; however, when new health technologies can materially
impact health disparities—for the positive or the negative—DCEA is a useful
tool for HTA bodies can use to help inform their decisionmaking.
The debate
So which side do you take?
