Multiple effects cost-effectiveness analysis in cost-disutility space

Chapter 10 shows that the net benefit correspondence theorem methods, introduced and shown to have distinct advantages for multiple strategy comparisons in Chap. 8 and for multiple provider efficiency comparison consistent with maximising net benefit in Chap. 9, naturally extend such advantages to robust multiple domain comparisons under uncertainty. In Chap. 4 we highlighted that robust and generalisable methods to enable jointly considering costs and multiple effects under uncertainty are required to better inform funding decisions in complex clinical areas such as palliative care. While quality-adjusted life years (QALYs) enable integration of patient survival with morbidity, they are either unable, or struggle, to incorporate domains such as carer impacts, family distress, finalising personal and financial affairs and being in community of choice for place of palliative care and place of death. Consequently, without robust multiple domain methods of cost-effectiveness analysis, the use of conventional single outcome evaluation (QALY measures or otherwise) can misrepresent key palliative care preferences. Scarce resources and funds can easily end up supporting interventions, strategies or programmes with overall negative impacts and not supporting options that maximise palliative care outcomes from limited resources. In this chapter we show how cost-effectiveness analysis in cost-disutility (CDU) space enables robust joint consideration of costs and multiple effects under uncertainty facilitating improved societal decision making. We outline and illustrate how the net benefit correspondence theorem (NBCT) and comparison on the CDU plane introduced in Chap. 8 also facilitate robust multiple effect comparison under uncertainty with analogous multiple effect summary measures. New summary measures identify across any set of threshold values for multiple domains of effect the strategies with lowest expected net loss (ENL) or highest expected net benefit with ENL planes and the potential value of undertaking further research for the optimal strategy as the ENL contour as well as the probability of strategies having highest expected net benefit (CEA planes).