When does quality-adjusting life-years matter in cost-effectiveness analysis?

Purpose: This paper investigates the impact of quality-of-life adjustment on cost-effectiveness analyses, by comparing ratios from published studies that have reported both incremental costs per (unadjusted) life-year and per quality-adjusted life-year for the same intervention.<P>Methods: A systematic literature search identified 228 original cost-utility analyses published prior to 1998. Sixty-three of these analyses (173 ratio pairs) reported both cost|LY and cost|QALY ratios for the same intervention, from which we calculated medians and means, the difference between ratios (cost|LY minus cost|QALY) and between reciprocals of the ratios, and cost|LY as a percentage of the corresponding cost|QALY ratio. We also compared the ratios using rank-order correlation, and assessed the frequency with which quality-adjustment resulted in a ratio crossing the widely used cost-effectiveness thresholds of $20000, $50000, and $100000|QALY or LY. Results: The mean ratios were $69100|LY and $103100|QALY, with corresponding medians of $24600|LY and $20400|QALY. The mean difference between ratios was approximately −$34300 (median difference: $1300), with 60% of ratio pairs differing by $10000|year or less. Mean difference between reciprocals was 59 (QA)LYs per million dollars (median: 2.1). The Spearman rank-order correlation between ratio types was 0.86 (p<0.001). Quality-adjustment led to a ratio moving either above or below $50000|LY (or QALY) in 8% of ratio pairs, and across $100000 in 6% of cases. Conclusions: In a sizable fraction of cost-utility analyses, quality adjusting did not substantially alter the estimated cost-effectiveness of an intervention, suggesting that sensitivity analyses using ad hoc adjustments or 'off-the-shelf' utility weights may be sufficient for many analyses. The collection of preference weight data should be subjected to the same scrutiny as other data inputs to cost-effectiveness analyses, and should only be under-taken if the value of this information is likely to be greater than the cost of obtaining it. Copyright © 2004 John Wiley & Sons, Ltd.