Costbenefit analysis

Cost-benefit analysis (CBA) differs from CEA and CUA in that the results are reported as differences between the costs and health benefits of the therapeutic programme. The health benefits are represented in monetary terms, usually by asking subjects how much they would be willing to pay for the therapy. The interpretation of a CBA is also different from that of a CEA or CUA. The CEA/CUA results give the value of a particular therapy relative to a standard therapy. However, in order to decide whether the new therapy is worth adapting at the expense of forgoing a different therapy, the reader must invoke some external criterion of value, such as the CE threshold. The CBA, in contrast, allows the investigator to determine whether the therapy is worth the costs without an external criterion since all benefits in CBA are valued in monetary terms.

We10 compared Goeckerman therapy with methotrexate for psoriasis using CBA in addition to the CUA described above. We queried a sample of "society" for the amount that they would be willing to pay for each therapy if their insurance company did not provide cover for it. We found that there was no net benefit of Goeckerman therapy over methotrexate for mild, moderate and severe psoriasis. When we compared each therapy with a "do nothing" approach for all three severity levels of psoriasis, only methotrexate produced net benefits for severe psoriasis.

Detractors of CBA cite a wariness of assigning monetary value to health because of moral and ethical issues.5 However, proponents of the method point out that decision-makers who use the CEA/CUA must either implicitly or explicitly place a monetary value on the health outcome since they will need to choose some threshold below which they consider that the outcome is worth the cost.4 Another disadvantage to the CBA method lies in the validity of the "willingness to pay" estimate of the value of the health benefits. Fortunately, many dermatological therapeutic programmes are neither overly expensive nor complex, and thus it is reasonable to expect subjects to be able to conceptualise how much they would be willing to pay for a dermatological therapy.

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