Systematic review of the impact of health care expenditure on health outcome measures: implications for cost-effectiveness thresholds

Abstract

Objective: Empirical estimates of the impact of healthcare expenditure on health outcome measures may inform the cost-effectiveness threshold (CET) for guiding funding decisions. This study aims to systematically review studies that estimated this, summarize and compare the estimates by country income level. Methods: We searched PubMed, Scopus, York Research database, and [anonymized] for Reviews and Dissemination database from inception to 1 August 2023. For inclusion, a study had to be an original article, estimating the impact of healthcare expenditure on health outcome measures at a country level, and presented estimates, in terms of cost per quality-adjusted life year (QALY) or disability-adjusted life year (DALY). Results: We included 18 studies with 385 estimates. The median (range) estimates were PPP$ 11,224 (PPP$ 223–PPP$ 288,816) per QALY gained and PPP$ 5,963 (PPP$ 71–PPP$ 165,629) per DALY averted. As ratios of Gross Domestic Product per capita (GDPPC), these estimates were 0.376 (0.041–182.840) and 0.318 (0.004–37.315) times of GDPPC, respectively. Conclusions: The commonly used CET of GDPPC seems to be too high for all countries, but especially low-to-middle-income countries where the potential health losses from misallocation of the same money are greater. Registration: The review protocol was published and registered in PROSPERO (CRD42020147276).