HOW ATTRACTIVE DOES A SET OF GUIDELINES HAVE TO BE TO WARRANT CORRECT ADOPTION AND UTILIZATION? THE USE AND MISUSE OF AN INFLUENTIAL SET OF GUIDELINES FOR USING COST-EFFECTIVENESS ANALYSIS

Background:  What is good value for money?  Some believe that willingness to pay (WTP) thresholds must be defined in order to facilitate the appraisal of health technology assessment results, which can then be used to determine whether a new technology is good value for money.  Much debate has centered around the "correct" threshold or range of values.  In 1992, Laupacis et al. published an influential set of guidelines on how to use cost-effectiveness analysis (CEA) for decision making: "How attractive does a new technology have to be to warrant adoption and utilization?" (Laupacis et al, 1992)   

Purpose: The objective of this study is to assess the impact of these seminal guidelines and examine how they have been used, misused and criticized in the 15 years following their publication.   

Method: Articles from 1992 to 2007 referencing Laupacis' guidelines were examined. These papers were located through a systematic search and were categorized based on how the authors used the guidelines.  Conference abstracts were excluded from this analysis.   

Result: Laupacis' paper was widely cited (827 times) over 15 years. More than 70% of the English citations used it to justify WTP thresholds. Many sourced Laupacis to justify a single WTP threshold value, in spite of the suggested range recommended in Laupacis' article.  In fact, the most commonly referenced value was $50,000/QALY, although this value was not mentioned in the original guidelines.  While many find thresholds useful, around 5% of the citations criticized Laupacis' guidelines, mainly arguing that thresholds lead to uncontrolled growth in healthcare expenditures.  One of the main messages in the original guidelines was that cost-effectiveness is not the only decision criterion, and that other factors should be considered.  However, only 7 articles sourced Laupacis for this message.   

Conclusion: Our findings show evidence of a strong desire for clear standards to justify economic attractiveness, despite criticisms on various fronts.  This desire will most likely continue to grow as health technology assessment plays a bigger role in decision making.  Laupacis' highly influential and yet often mis-cited guidelines reveal the need for more careful knowledge translation in CEA. We conclude that the best cost-effectiveness threshold is no threshold until a consensus can be reached regarding what constitutes good value for money.