The European Journal of Health Economics

, Volume 15, Issue 7, pp 709–716 | Cite as

A multi-criteria decision analysis perspective on the health economic evaluation of medical interventions

  • Douwe PostmusEmail author
  • Tommi Tervonen
  • Gert van Valkenhoef
  • Hans L. Hillege
  • Erik Buskens
Original Paper


A standard practice in health economic evaluation is to monetize health effects by assuming a certain societal willingness-to-pay per unit of health gain. Although the resulting net monetary benefit (NMB) is easy to compute, the use of a single willingness-to-pay threshold assumes expressibility of the health effects on a single non-monetary scale. To relax this assumption, this article proves that the NMB framework is a special case of the more general stochastic multi-criteria acceptability analysis (SMAA) method. Specifically, as SMAA does not restrict the number of criteria to two and also does not require the marginal rates of substitution to be constant, there are problem instances for which the use of this more general method may result in a better understanding of the trade-offs underlying the reimbursement decision-making problem. This is illustrated by applying both methods in a case study related to infertility treatment.


Health economic evaluation Multi-criteria decision analysis Infertility treatment 

JEL Classification

C44 I18 



This research was conducted within the framework of the Center for Translational Molecular Medicine, project PREDICCt (grant 01C-104) and supported by the Dutch Heart Foundation, Dutch Diabetes Research Foundation, and Dutch Kidney Foundation.


  1. 1.
    Al, M., Feenstra, T., Van Hout, B.: Optimal allocation of resources over health care programmes: dealing with decreasing marginal utility and uncertainty. Health Econ. 14(7), 655–667 (2005). doi: 10.1002/hec.973 PubMedCrossRefGoogle Scholar
  2. 2.
    Belton, V., Stewart, T.J.: Multiple criteria decision analysis—an integrated approach. Kluwer Academic Publishers, Dordrecht (2002)CrossRefGoogle Scholar
  3. 3.
    Briggs, A.H., Claxton, K., Sculpher, M.: Decision modelling for health economic evaluation. Oxford University Press, Oxford (2006)Google Scholar
  4. 4.
    Brouwer, W., Koopmanschap, M.: On the economic foundations of CEA. ladies and gentlemen, take your positions! J. Health Econ. 19(4), 439–459 (2000). doi: 10.1016/S0167-6296(99)00038-7 PubMedCrossRefGoogle Scholar
  5. 5.
    Choo, E.U., Schoner, B., Wedley, W.C.: Interpretation of criteria weights in multicriteria decision making. Comput. Ind. Eng. 37(3), 527–541 (1999). doi: 10.1016/S0360-8352(00)00019-X CrossRefGoogle Scholar
  6. 6.
    Claxton, K., Posnett, J.: An economic approach to clinical trial design and research priority-setting. Health Econ. 5(6), 513–524 (1998). doi: 10.1002/(SICI)1099-1050(199611)5:6<513::AID-HEC237>3.0.CO;2-9 CrossRefGoogle Scholar
  7. 7.
    Dolan, P., Edlin, R.: Is it really possible to build a bridge between cost-benefit analysis and cost-effectiveness analysis? J. Health Econ. 21(5), 827–43 (2002). doi: 10.1016/S0167-6296(02)00011-5 PubMedCrossRefGoogle Scholar
  8. 8.
    Drummond, M., Sculpher, M., Torrance, G., O’Brien, B., Stoddart, G.: Methods for the economic evaluation of health care programmes. Oxford University Press, New York (2005)Google Scholar
  9. 9.
    Eichler, H., Kong, S., Gerth, W., Mavros, P., Jönsson, B.: Use of cost-effectiveness analysis in health-care resource allocation decision-making: how are cost-effectiveness thresholds expected to emerge? Value in Health 7(5), 518–528 (2004). doi: 10.1111/j.1524-4733.2004.75003.x PubMedCrossRefGoogle Scholar
  10. 10.
    Elixhauser, A., Halpern, M., Schmier, J., Luce, B.: Health care CBA and CEA from 1991 to 1996: an updated bibliography. Med. Care 36(5), MS1–MS9 (1998). doi: 10.1097/00005650-199805001-00001 PubMedGoogle Scholar
  11. 11.
    Fenwick, E., Claxton, K., Sculpher, M.: Representing uncertainty: the role of cost-effectiveness acceptability curves. Health Econ. 10(8), 779–787 (2001). doi: 10.1002/hec.635 PubMedCrossRefGoogle Scholar
  12. 12.
    Fiddelers, A.A.A., Dirksen, C.D., Dumoulin, J., van Montfoort, A., Land, J.A., Janssen, J.M., Evers, J.L.H., Severens, J.L.: Cost-effectiveness of seven IVF strategies: results of a Markov decision-analytic model. Hum. Reprod. 24(7), 1648–1655 (2009). doi: 10.1093/humrep/dep041 PubMedCrossRefGoogle Scholar
  13. 13.
    Goetghebeur, M., Wagner, M., Khoury, H., Levitt, R., Erickson, L., Rindress, D.: Bridging health technology assessment (HTA) and efficient health care decision making with multicriteria decision analysis (MCDA): applying the evidem framework to medicines appraisal. Med. Decis. Making 32(2), 376–388 (2012). doi: 10.1177/0272989X11416870 PubMedCrossRefGoogle Scholar
  14. 14.
    Keeney, R., Raiffa, H.: Decisions with multiple objectives: preferences and value tradeoffs. Wiley, New York (1976)Google Scholar
  15. 15.
    Lahdelma, R., Salminen, P.: SMAA-2: Stochastic multicriteria acceptability analysis for group decision making. Oper. Res. 49(3), 444–454 (2001). doi: 10.1287/opre.49.3.444.11220 CrossRefGoogle Scholar
  16. 16.
    Stinnett, A., Paltiel, A. et al.: Mathematical programming for the efficient allocation of health care resources. J. Health Econ. 15(5), 641–654 (1996). doi: 10.1016/S0167-6296(96)00493-6 PubMedCrossRefGoogle Scholar
  17. 17.
    Tervonen, T., van Valkenhoef, G., Buskens, E., Hillege, H.L., Postmus, D.: A stochastic multi-criteria model for evidence-based decision making in drug benefit-risk analysis. Stat. Med. 30(12), 1419–1428 (2011). doi: 10.1002/sim.4194 PubMedCrossRefGoogle Scholar
  18. 18.
    Thokala, P., Duenas, A.: Multiple criteria decision analysis for health technology assessment. Value Health 15(8), 1172–1181 (2012). doi: 10.1016/j.jval.2012.06.015 PubMedCrossRefGoogle Scholar
  19. 19.
    van Valkenhoef, G., Tervonen, T., Zhao, J., de Brock, B., Hillege, H.L., Postmus, D.: Multi-criteria benefit-risk assessment using network meta-analysis. J. Clin. Epidemiol. 65(4), 394–403 (2012). doi: 10.1016/j.jclinepi.2011.09.005 PubMedCrossRefGoogle Scholar
  20. 20.
    Van Hout, B., Al, M., Gordon, G., Rutten, F.: Costs, effects and c/e-ratios alongside a clinical trial. Health Econ. 3(5), 309–319 (1994). doi: 10.1002/hec.4730030505 PubMedCrossRefGoogle Scholar
  21. 21.
    Weinstein, M., Zeckhauser, R.: Critical ratios and efficient allocation. J. Public Econ. 2(2), 147–157 (1973). doi: 10.1016/0047-2727(73)90002-9 CrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • Douwe Postmus
    • 1
    Email author
  • Tommi Tervonen
    • 2
  • Gert van Valkenhoef
    • 1
  • Hans L. Hillege
    • 1
    • 3
  • Erik Buskens
    • 1
  1. 1.Department of EpidemiologyUniversity of Groningen, University Medical Center GroningenGroningenThe Netherlands
  2. 2.Econometric InstituteErasmus University RotterdamRotterdamThe Netherlands
  3. 3.Department of CardiologyUniversity of Groningen, University Medical Center GroningenGroningenThe Netherlands

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