Should health technology assessment (HTA) processes consider using the distribution cost effective analysis (DCEA) to incorporate technology effects on inequality? Some people say ‘yes’ and some say ‘no’. Let’s take a look at both sides.
No
In a letter to the editor Health valueSriram Ramagopalan said that currently there are many concerns as part of the decision making with the potentially distribution cost effective analysis (DCEA) in Nice. Ramagopalan writes:
“NICE Technical Team clarified that the situation of NICE is that NICE health technology assessment does not allow for a quantitative modifier for manual health inequalities. Nice does not assume that there are sufficiently strong evidence to use the nuisance load as part of DCEA.
One reason is that it is certainly known that people are really ready to trade health benefits to the average person to reduce inequality. The most commonly used inequality Evercen Parameter 11 (Atkinson Relative inequality Index) is from Robson et al. 2017; However, NICE’s external assessment group (EAG) preferred to use the value of 3.5, taken from another recent estimate (Robson et al. 2024)
Another issue is which groups should face inequality? Race? Geography? Income? They note that inequality on various racial groups is highly relevant to beta thalassemia, but the quintals of the index of many deprived (IMD) were used as a proxy for race/ethnicity to evaluate exgamgogogen autotamsale (TA1033). Nice’s Eg mentioned in its review that IMD was a highlight incomplete proxy for ethnicity-specific quality-perfect life expectancy (QALE) data.
Ramgopalan also noted that in the US, Clinical and Economic Review Institute (ICER) has not adopted DCEA [see ICER
white paper]While quality adjusted life expectations in the US are estimated (Koval et al. 2023) and UK (Love-Koh et al. 2015)
Yes
A Vih The letter to the editor by Koh, Murray, Brooke, Owen and Shah (2025) responds to Ramagopalan and argues that, yes, DCEA must be included in HTA. KOH and colleagues said that Nice has long been considered healthy inequalities and inequalities in its evaluation, simply more than a qualitative -from the Holty -Partial -Sampradaya. Writers cite recent good guidelines about how to address health inequalities in breast cancer (Slade et al. 2024) Nice Guidelines (NG246) also says that:
“… It is the responsibility of local commissioners and providers of healthcare … to eliminate illegal discrimination, to further the equality of opportunity and reduce health inequalities”
In fact, in May 2024, NICE updated its methods about health inequalities (Hughs 2025, PMG 36) and published a way on DCEA use support documents including stratification, uncertainty, health opportunity costs and reporting output (good implementation support, 13 May 2025).
While Koh and co-author argue that there are some good evidence on the preferences of inequality, they admit that there is no consensus on the exact degree of this trade-band and also there is no accurate process in the context of how DCEA should be operated. Additionally, DCEAS is more complex to apply that traditional CEA. The author agrees that every intervention does not require a DCEA; However, when new health technologies can physically affect health inequalities – for positive or negative – DCEA is a useful tool for HTA bodies that can be used to help inform their decision.
Discussion
So what side do you take?
