Net Monetary Benefit Lines Augmented with Value-of-Information Measures to Present the Results of Economic Evaluations under Uncertainty

Background Methods to present the result of cost-effectiveness analyses under parameter uncertainty include cost-effectiveness planes (CEPs), cost-effectiveness acceptability curves/frontier (CEACs/CEAF), expected loss curves (ELCs), and net monetary benefit (NMB) lines. We describe how NMB lines can be augmented to present NMB values that could be achieved by reducing or resolving parameter uncertainty. We evaluated the ability of these methods to correctly 1) identify the alternative with the highest expected NMB and 2) communicate the magnitude of parameter and decision uncertainty. Methods We considered 4 hypothetical decision problems representing scenarios with high variance or correlated cost and effect estimates and alternatives with similar cost-effectiveness ratios. We used these decision problems to demonstrate the limitations of existing methods and the potential of augmented NMB lines to resolve these issues. Results CEPs and CEACs/CEAF could falsely imply the lack of sufficient evidence to identify the optimal option if cost and effect estimates have high variance, are correlated across alternatives, or when alternatives have similar cost-effectiveness ratios. The augmented NMB lines and ELCs can correctly identify the option with the highest expected NMB and communicate the potential benefit of resolving uncertainties. Like ELCs, the augmented NMB lines provide information about the value of resolving parameter uncertainties, but augmented NMB lines may be easier to interpret for decision makers. Conclusions Our analysis supports recommending the augment NMB lines as an important method to present the results of economic evaluation studies under parameter uncertainty. Highlights The results of cost-effectiveness analyses (CEAs) when the cost and effect estimates of alternatives are uncertain are commonly presented using cost-effectiveness planes (CEPs), cost-effectiveness acceptability curves/frontier (CEACs/CEAF), and expected loss curves (ELCs). Although currently not often used, net monetary benefit (NMB) lines could present the results of cost-effectiveness to identify the alternative with the highest expected NMB values given the current level of uncertainty. Furthermore, NMB lines can be augmented to 1) show metrics of value of information, which measure the value of additional research to reduce or eliminate the decision uncertainty, and 2) display the confidence intervals along the NMB lines to ensure that NMB values are estimated accurately using a sufficiently large number of parameter samples. Using several decision problems, we demonstrate the limitation of existing methods to present the results of CEAs under parameter uncertainty and how augmented NMB lines could resolve these issues. Our analysis supports recommending augmented NMB lines as an important method to present the results of CEA under uncertainty since they 1) correctly identify the alternative with the highest expected NMB value given the current evidence, 2) provide information about the potential value of additional research to improve the decision by reducing or resolving uncertainty in model parameters, 3) assist the analysis to visually ensure that enough parameter samples are used to estimate the expected NMB of alternatives, and 4) are easier to interpret for decision makers compared with other methods.