HTA and economics in the United States: A systematic review of ICER reports to evaluate trends, identify factors associated with recommendations, and understand implications

Denise T. Kruzikas, Daniel C. Malone, Sissi Pham, Tyler K. Reinsch, Ron Akehurst

Research output: Contribution to journalArticlepeer-review


BACKGROUND: The Institute for Clinical and Economic Review (ICER) is a prominent health technology assessment (HTA) entity in the United States that considers costs and applies economic analyses to derive pricebased recommendations. ICER continues to adjust its value framework, yet discussion persists regarding whether ICER methodologies align with established research standards. This work evaluates ICER assessments relative to those standards, providing a benchmark with the release of ICER's most recent value framework update. OBJECTIVES: To evaluate ICER economic assessments for trends, factors related to recommendations, and quality for use in U.S. decision making. METHODS: We evaluated all ICER final evidence reports published between 2006 and August 31, 2019, with regard to base-case result trends over time, pricing sources, comparator selection, analytic perspectives, model uncertainty, how modeling results aligned with ICER's determinations of value for money, and comparison of ICER methodological approaches with established modeling standards. Analyses were stratified by time period, where appropriate, to account for changes in ICER's framework over time. RESULTS: Of 58 ICER final evidence reports, 47 used the most commonly reported outcome (cost per quality-adjusted life-year [QALY]); ICER-developed models evaluated 131 interventions and comparators with 238 base-case results. Pricing sources for ICER reports became more standardized in 2017, although sources were not associated with the likelihood of falling below ICER's costeffectiveness thresholds. In 30% of base-case analyses (n = 72), ICER did not use a clinical comparator, although reasonable treatments were available. In modified societal perspectives scenarios applied in later assessments, 75% of analyses (n = 76) included productivity but did not specify how it was quantified. Reports did not explain how sensitivity and scenario analyses were selected or implications of results. ICER value for money determinations generally aligned with cost-effectiveness results, although 2 of 33 (6%) interventions ranked as low value and 3 of 5 (60%) interventions ranked as low-moderate value, met a $150,000 per QALY threshold, and 14 of 37 (38%) moderate-value interventions exceeded this threshold; the most common rationale was related to national budget impact. CONCLUSIONS: While some progress has been made, further improvement is needed to ensure that ICER assessments address the most relevant questions for target audiences, adhere to established research standards, and are reported in a manner that can be readily interpreted and applied to policymaking.

Original languageEnglish (US)
Pages (from-to)1548-1557
Number of pages10
JournalJournal of Managed Care and Specialty Pharmacy
Issue number12
StatePublished - Dec 2020

ASJC Scopus subject areas

  • Pharmacy
  • Pharmaceutical Science
  • Health Policy


Dive into the research topics of 'HTA and economics in the United States: A systematic review of ICER reports to evaluate trends, identify factors associated with recommendations, and understand implications'. Together they form a unique fingerprint.

Cite this