, Volume 26, Issue 10, pp 815–830 | Cite as

Unrelated Medical Costs in Life-Years Gained

Should They be Included in Economic Evaluations of Healthcare Interventions?
  • David R. RappangeEmail author
  • Pieter H. M. van Baal
  • N. Job A. van Exel
  • Talitha L. Feenstra
  • Frans F. H. Rutten
  • Werner B. F. Brouwer
Current Opinion


Which costs and benefits to consider in economic evaluations of healthcare interventions remains an area of much controversy. Unrelated medical costs in life-years gained is an important cost category that is normally ignored in economic evaluations, irrespective of the perspective chosen for the analysis. National guidelines for pharmacoeconomic research largely endorse this practice, either by explicitly requiring researchers to exclude these costs from the analysis or by leaving inclusion or exclusion up to the discretion of the analyst. However, the inclusion of unrelated medical costs in life-years gained appears to be gaining support in the literature.

This article provides an overview of the discussions to date. The inclusion of unrelated medical costs in life-years gained seems warranted, in terms of both optimality and internal and external consistency. We use an example of a smoking-cessation intervention to highlight the consequences of different practices of accounting for costs and effects in economic evaluations. Only inclusion of all costs and effects of unrelated medical care in life-years gained can be considered both internally and externally consistent. Including or excluding unrelated future medical costs may have important distributional consequences, especially for interventions that substantially increase length of life. Regarding practical objections against inclusion of future costs, it is important to note that it is becoming increasingly possible to accurately estimate unrelated medical costs in life-years gained. We therefore conclude that the inclusion of unrelated medical costs should become the new standard.


Economic Evaluation Cost Category Healthcare Decision Maker Healthcare Perspective External Consistency 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



This study was part of the project ‘Living longer in good health’, which was financially supported by Netspar. The opinions expressed in the paper are those of the authors.

The authors have no conflicts of interest that are directly relevant to the content of this article.


  1. 1.
    Drummond MF, Sculpher MJ, Torrance GW, et al. Methods for the economic evaluation of health care programmes. 3rd ed. New York: Oxford University Press Inc, 2005Google Scholar
  2. 2.
    Gold MR, Siegel JE, Russel LB, et al., editors. Cost-effectiveness in health and medicine. Oxford: Oxford University Press, 1996Google Scholar
  3. 3.
    Johannesson M. A note on the depreciation of the societal perspective in economic evaluation of health care. Health Policy 1995; 33: 59–66PubMedCrossRefGoogle Scholar
  4. 4.
    National Institute for Health and Clinical Excellence. Guide to the methods of technology appraisal. London: NICE, 2008[online]. Available from URL: [Accessed 2008 Jul 17]
  5. 5.
    Johannesson M, Meltzer D. Some reflections on cost-effectiveness analysis. Health Econ 1998; 7 (1): 1–7PubMedCrossRefGoogle Scholar
  6. 6.
    Brouwer WBF, van Exel NJA, Koopmanschap MA, et al. Productivity costs before and after absence from work: as important as common? Health Policy 2002; 61: 173–87PubMedCrossRefGoogle Scholar
  7. 7.
    Brouwer WBF, Rutten FFH, Koopmanschap MA. Costing in economic evaluations. In: Drummond MF, McGuire A, editors. Economic evaluation in health care: merging theory with practice. New York: Oxford University Press, 2001Google Scholar
  8. 8.
    Russell LB. Is prevention better than cure? Washington, DC: The Brookings Institution, 1986Google Scholar
  9. 9.
    Garber AM, Phelps CE. Economic foundations of cost-effectiveness analysis. J Health Econ 1997; 16: 1–31PubMedCrossRefGoogle Scholar
  10. 10.
    Meltzer D, Johannesson M. Inconsistencies in the ‘societal perspective’ on costs of the panel on cost-effectiveness in health and medicine. Med Decis Making 1999; 19: 371–7PubMedCrossRefGoogle Scholar
  11. 11.
    Nyman JA. Should the consumption of survivors be included as a cost in cost-utility analysis? Health Econ 2004; 13: 417–27PubMedCrossRefGoogle Scholar
  12. 12.
    Gandjour A, Lauterbach KW. Does prevention save costs? Considering deferral of the expensive last year of life. J Health Econ 2005; 24: 715–24PubMedCrossRefGoogle Scholar
  13. 13.
    van Baal PHM, Feenstra TL, Hoogenveen RT, et al. Unrelated medical care in life years gained and the cost utility of primary prevention: in search of a ‘perfect’ cost-utility ratio. Health Econ 2007; 16: 421–33PubMedCrossRefGoogle Scholar
  14. 14.
    Health Care Insurance Board (CVZ). Guidelines for pharmacoeconomic research, actualized version [in Dutch]. Diemen: Health Care Insurance Board, 2006Google Scholar
  15. 15.
    Stone PW, Chapman RH, Sandberg EA, et al. Measuring costs in cost-utility analyses. Int Technol Assess Health Care 2000; 16: 111–24CrossRefGoogle Scholar
  16. 16.
    Clarke PM, Gray AM, Briggs A, et al. Cost-utility analyses of intensive blood glucose and tight blood pressure control in type 2 diabetes (UKPDS 72). Diabetologia 2005; 48: 868–77PubMedCrossRefGoogle Scholar
  17. 17.
    Godfrey C, Parrott S, Coleman T, et al. The cost-effectiveness of the English smoking treatment services: evidence from practice. Addiction 2005; 100 Suppl. 2: 70–83PubMedCrossRefGoogle Scholar
  18. 18.
    Meltzer D. Accounting for future costs in medical cost-effectiveness analysis. J Health Econ 1997; 16: 33–64PubMedCrossRefGoogle Scholar
  19. 19.
    Weinstein MC, Manning Jr WG. Theoretical issues in cost-effectiveness analysis. J Health Econ 1997; 16: 121–8PubMedCrossRefGoogle Scholar
  20. 20.
    Lee RH. Future costs in cost effectiveness analysis. J Health Econ 2008; 27 (4): 809–18PubMedCrossRefGoogle Scholar
  21. 21.
    van Baal PH, Polder JJ, de Wit GA, et al. Lifetime medical costs of obesity: prevention no cure for increasing health expenditure. PLoS Med 2008; 5 (2): e29CrossRefGoogle Scholar
  22. 22.
    Brouwer WBF, van Exel NJA, Baltussen RMPM, et dollar is a dollar is a dollar: or is it? Value Health 2005; 9: 341–7CrossRefGoogle Scholar
  23. 23.
    Koopmanschap MA, Rutten FFH, van Ineveld BM, et al. The friction cost method for measuring indirect costs of disease. J Health Econ 1995; 14: 171–89PubMedCrossRefGoogle Scholar
  24. 24.
    Brouwer WBF, Koopmanschap MA, Rutten FH. Productivity costs measurement through quality of life? A response to the recommendation of the Washington Panel. Health Econ 1997; 3: 253–9CrossRefGoogle Scholar
  25. 25.
    Brouwer WBF, Koopmanschap MA, Rutten FH. Productivity costs in cost-effectiveness analysis: numerator or denominator. A further discussion. Health Econ 1997; 6: 511–4PubMedCrossRefGoogle Scholar
  26. 26.
    Johannesson M, Karlsson G. The friction cost method: a comment. J Health Econ 1997; 16: 249–56PubMedCrossRefGoogle Scholar
  27. 27.
    Weinstein MC, Siegel JE, Garber AM, et al. Productivity costs and health-related quality of life: a response to the Erasmus Group. Health Econ 1997; 5: 505–10CrossRefGoogle Scholar
  28. 28.
    Brouwer WBF, Koopmanschap MA. How to calculate indirect costs in economic evaluations. Pharmacoeconomics 1998; 13 (5 Pt 1): 563–9PubMedCrossRefGoogle Scholar
  29. 29.
    Brouwer WBF, Koopmanschap MA. On the economic foundations of CEA: ladies and gentlemen, take your positions! J Heath Econ 2000; 19: 439–59CrossRefGoogle Scholar
  30. 30.
    Brouwer WBF, Koopmanschap MA. The friction cost method: leisure for nothing and replacement for free? Pharmacoeconomics 2005; 23 (2): 105–11PubMedCrossRefGoogle Scholar
  31. 31.
    Weinstein MC, Fineberg HV, Elstein AS, et al. Clinical decision analysis. Philadelphia (PA): Saunders, 1980Google Scholar
  32. 32.
    Gandjour A. Consumption costs and earnings during added years of life: a reply to Nyman. Health Econ 2006; 15: 315–7PubMedCrossRefGoogle Scholar
  33. 33.
    Nyman JA. More on survival consumption costs in cost-utility analysis. Health Econ 2006; 15: 319–22CrossRefGoogle Scholar
  34. 34.
    Richardson JRJ, Olsen JA. In defence of societal sovereignty: a comment on Nyman ‘the inclusion of survivor consumption in CUA’. Health Econ 2006; 15: 311–3PubMedCrossRefGoogle Scholar
  35. 35.
    Lundin D, Ramsberg J. On survival consumption costs: a reply to Nyman. Health Econ 2008; 17: 293–7PubMedCrossRefGoogle Scholar
  36. 36.
    Liljas B, Karlsson GS, Stålhammer N. On future non-medical costs in economic evaluations. Health Econ 2008; 17: 579–91PubMedCrossRefGoogle Scholar
  37. 37.
    Mushlin AI, Fintor L. Is screening for breast cancer cost-effective? Cancer 1992; 69 Suppl. 7: 1957–62PubMedCrossRefGoogle Scholar
  38. 38.
    Pharmaceutical Benefits Board (LFN). General guidelines for economic evaluations from the Pharmaceutical Benefits Board. Solna: LFN, 2003[online]. Available from URL: [Accessed 2008 Jan 18]
  39. 39.
    Brouwer WBF, van Exel NJA, van Baal PHM. Costs in life-years gained: is it time for a new guideline? [in Dutch]. VGE-Informatiebulletin 2007; 24 (1): 11–4Google Scholar
  40. 40.
    Zweifel P, Felder S, Meiers M. Ageing of population and health care expenditure: a red herring? Health Econ 1999; 8: 485–96PubMedCrossRefGoogle Scholar
  41. 41.
    Serup-Hansen N, Wickstrøm J, Kristiansen I. Future health care costs: do health care costs during the last year of life matter? Health Policy 2002; 62: 161–72PubMedCrossRefGoogle Scholar
  42. 42.
    Seshamani M, Gray AM. Time to death and death expenditure: an improved model for the impact of demographic change on health care costs. Age Ageing 2004; 33: 556–61PubMedCrossRefGoogle Scholar
  43. 43.
    Werblow A, Felder S, Zweifel P, et al. Population ageing and health care expenditure: a school of ‘red herrings’? Health Econ 2007; 16: 1109–26PubMedCrossRefGoogle Scholar
  44. 44.
    Garber AM. Realistic rigor in cost-effectiveness methods. Med Decis Making 1999; 19: 378–9PubMedCrossRefGoogle Scholar
  45. 45.
    Garber AM, Phelps CE. Future costs and the future of cost-effectiveness analysis. J Health Econ 2008; 27 (4): 819–21PubMedCrossRefGoogle Scholar
  46. 46.
    Meltzer D. Response to ‘Future costs and the future of cost-effectiveness analysis’. J Health Econ 2008; 27 (4): 822–5PubMedCrossRefGoogle Scholar
  47. 47.
    Blomqvist Å. Defining the value of a statistical life: a comment. J Health Econ 2002; 21: 169–75CrossRefGoogle Scholar
  48. 48.
    Feenstra TL, Hamber-van Reenen HH, Hoogenveen RT, et al. Cost-effectiveness of face-to-face smoking cessation interventions: a dynamic modeling study. Value Health 2005; 8: 178–90PubMedCrossRefGoogle Scholar
  49. 49.
    Silagy C, Lancaster T, Stead L, et al. Nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev 2002: CD000146Google Scholar
  50. 50.
    Gyrd-Hansen D, Søgaard J, Kronborg O. Colorectal cancer screening: efficiency and effectiveness. Health Econ 1998; 7: 9–20PubMedCrossRefGoogle Scholar
  51. 51.
    Manns B, Meltzer D, Taub K, et al. Illustrating the impact of including future costs in economic evaluations: an application to end-stage renal disease care. Health Econ 2003; 12: 949–58PubMedCrossRefGoogle Scholar
  52. 52.
    Brouwer WBF, Culyer AJ, van Exel NJA, et al. Welfarism vs extra-welfarism. J Health Econ 2008; 27: 325–38PubMedCrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2008

Authors and Affiliations

  • David R. Rappange
    • 1
    Email author
  • Pieter H. M. van Baal
    • 1
    • 2
  • N. Job A. van Exel
    • 1
  • Talitha L. Feenstra
    • 2
  • Frans F. H. Rutten
    • 1
  • Werner B. F. Brouwer
    • 1
  1. 1.Department of Health Policy & Management and Institute for Medical Technology AssessmentErasmus University Medical CenterRotterdamthe Netherlands
  2. 2.Centre for Prevention and Health, Services ResearchNational Institute for Public Health and the EnvironmentBilthoventhe Netherlands

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