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Why it’s Time to Abandon the ICER
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“This study’s negative ICERs are ambiguous to interpret and therefore not ideal to present (44, 45).”
From Trial-based economic evaluation of the BrainACT study: acceptance and commitment therapy for anxiety and/or depressive symptoms after acquired brain injury. (2025) · cites this paper as [45]
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Citations
Cites
Representing uncertainty: the role of cost‐effectiveness acceptability curves
Fenwick, E. A. L., Claxton, K., & Sculpher, M. J. (2001) · Health Economics · doi:10.1002/hec.635 · Cited by 1,112
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Exploring Uncertainty in Cost-Effectiveness Analysis
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Edney, L. C., Lomas, J., Karnon, J. D., Vallejo‐Torres, L., Stadhouders, N. W., Siverskog, J., Paulden, M., Edoka, I., & Ochalek, J. (2021) · PharmacoEconomics · doi:10.1007/s40273-021-01087-6 · Cited by 37
Self-citationValuing health outcomes: developing better defaults based on health opportunity costs
Ochalek, J., Claxton, K., Lomas, J. R. S., & Thompson, K. M. (2020) · Expert Review of Pharmacoeconomics & Outcomes Research · doi:10.1080/14737167.2020.1812387 · Cited by 24
Raeissadat, S. A., Rahimi, M., Rayegani, S. M., & Moradi, N. (2023) · BMC Musculoskeletal Disorders · doi:10.1186/s12891-022-06114-x · Cited by 23
“[32], the NMB is could be considered as an alternative way to assess the economic efficiency of interventions when there are multiple treatment strategies.”
BackgroundJames, L. P., Klaassen, F., Sweeney, S., Furin, J., Franke, M., Yaesoubi, R., Chesov, D., Ciobanu, N., Codreanu, A., Crudu, V., et al. (2024) · PLoS Medicine · doi:10.1371/journal.pmed.1004401 · Cited by 17
“As the interpretation of ICERs may be challenging in some circumstances [48], we also calculated the net health benefit (NHB) of each strategy (see S1 Appendix), with the cost-effective strategy identified as that with the highest NHB [43].”
Parikh, N. R., Chang, E. M., Nickols, N. G., Rettig, M. B., Raldow, A. C., Steinberg, M. L., Koontz, B. F., Vapiwala, N., Deville, C., Feng, F. Y.-C., et al. (2020) · International Journal of Radiation Oncology*Biology*Physics · doi:10.1016/j.ijrobp.2020.06.009 · Cited by 16
Cost Effectiveness of Deep Brain Stimulation for Parkinson’s Disease: A Systematic Review
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“We chose to present INBs because of the ambiguity in interpreting ICURs and their inherent limitations [31].”
Sasidharan, A., Sajith Kumar, S., Jagadeesh, K. V., Natarajan, M., & Bagepally, B. S. (2022) · PLoS ONE · doi:10.1371/journal.pone.0264563 · Cited by 14
Nguyen, Q. D., & Prokopenko, M. (2022) · Scientific Reports · doi:10.1038/s41598-022-23668-x · Cited by 14
“Traditional approaches quantifying the cost-effectiveness of interventions, such as the methods based on incremental cost-effective ratio (ICER) [41, 42], have encountered some limitations in determining and interpreting cost-effectiveness outcomes, carrying out sensitivity or scenario analysis, ranking strategies, as…”
BackgroundMethodO’Mahony, J. F. (2020) · PharmacoEconomics · doi:10.1007/s40273-020-00931-5 · Cited by 13
Kalske, R., Kiadaliri, A., Sihvonen, R., Englund, M., Turkiewicz, A., Paavola, M. P., Malmivaara, A. V., Itälä, A., Joukainen, A., Nurmi, H., et al. (2024) · Clinical Orthopaedics and Related Research · doi:10.1097/corr.0000000000003094 · Cited by 12
“We chose the INMB over the conventionally used incremental cost-effectiveness ratios because the INMB is considered easier to interpret: A treatment (here, APM) is deemed cost effective if the INMB is positive [32].”
Sajith Kumar, S., Haridoss, M., Venkataraman, K., & Bagepally, B. S. (2022) · Frontiers in Pharmacology · doi:10.3389/fphar.2022.1090361 · Cited by 12
“(O’Mahony et al., 2015; Bagepally et al., 2019; Paulden, 2020).”
The Broader Opportunity Costs in the Broader Cost-Effectiveness Analysis Framework
Vallejo‐Torres, L. (2023) · Applied Health Economics and Health Policy · doi:10.1007/s40258-023-00801-z · Cited by 12
Ming, J., Hong, G., Xu, Y., Mernagh, P., Pochopień, M., & Li, H. (2024) · Advances in Therapy · doi:10.1007/s12325-024-02906-w · Cited by 10
“NMB allows easy interpretation of model sensitivity, whereas the ICER is more complex as it the decision rules are different in each quadrant of the incremental cost-effectiveness plane [34].”
Woods, B. S., Palacios, A., & Sculpher, M. J. (2024) · PharmacoEconomics · doi:10.1007/s40273-024-01450-3 · Cited by 9
Saramago, P., Gkekas, A., Arundel, C., Chetter, I. C., the SWHSI-2 Trial Investigators, Martin, B. C., Hewitt, C. E., Mott, A., Swan, S., Torgerson, D. J., et al. (2025) · British journal of surgery · doi:10.1093/bjs/znaf077 · Cited by 9
“Costs and QALYs were used to derive the net monetary benefit (NMB) for each treatment 22 , the incremental NMB, and the probability of NPWT being cost-effective 23 .”
Mac, S., O’Reilly, R., Adhikari, N. K. J., Fowler, R., & Sander, B. (2020) · PLoS ONE · doi:10.1371/journal.pone.0242255 · Cited by 9
Sajith Kumar, S., Bagepally, B. S., & Sasidharan, A. (2023) · Clinical Drug Investigation · doi:10.1007/s40261-022-01238-3 · Cited by 12
Jais, S., Oe, M., Sanada, H., Sasongko, A. S., & Haryanto, H. (2023) · Wound Repair and Regeneration · doi:10.1111/wrr.13147 · Cited by 7
“22,23 Based on these quadrants, our study illustrated a wound care strategy that is more effective and less expensive than conventional treatment (the predominant therapy and therefore typically preferred) and a wound care strategy that is costlier and less effective (and therefore typically…”
BackgroundNaghavi‐Behzad, M., Gerke, O., Kodahl, A. R., Vogsen, M., Asmussen, J. T., Weber, W., Hildebrandt, M. G., & Kidholm, K. (2023) · Scientific Reports · doi:10.1038/s41598-023-43446-7 · Cited by 7
“Our results suggest 2-[ 18 F]FDG-PET/CT as a cost-effective modality based on ICER assessments, but other clinical and logistical considerations need to be taken into account 35 .”
ResultLi, Y., Zhu, S., Liu, Y., He, D., Liu, Y., & Li, H. (2025) · Scandinavian Journal of Gastroenterology · doi:10.1080/00365521.2025.2473020 · Cited by 7
“Since ICERs is difficult to interpret when a negative ICER was calculated or comparing three or more strategies [36], incremental net monetary benefits (INMB) was calculated using 1 times GDP per capita ($12,445).”
Guidelines for Utility Measurement for Economic Analysis: The Brazilian Policy
Santos, M., Monteiro, A. L., Biz, A. N., Guerra, A. A., Cramer, H., Canuto, V., Cruz, L. N., Pinto, M., Viegas, M., Fernandes, R. R. A., et al. (2022) · Value in Health Regional Issues · doi:10.1016/j.vhri.2022.03.004 · Cited by 8
Cost Effectiveness of Digital Interventions for Generalised Anxiety Disorder: A Model-Based Analysis
Janković, D., Saramago, P., Gega, L., Marshall, D. C., Wright, K. E., Hafidh, M., Churchill, R. C., & Bojke, L. (2021) · PharmacoEconomics - Open · doi:10.1007/s41669-021-00318-y · Cited by 9
State of the ART? Two New Tools for Risk Communication in Health Technology Assessments
Grimm, S. E., Pouwels, X., Ramaekers, B. L. T., Wijnen, B. F. M., Otten, T., Grutters, J. P. C., & Joore, M. A. (2021) · PharmacoEconomics · doi:10.1007/s40273-021-01060-3 · Cited by 6
“Assessment outcomes ICER (with upper and lower bound) Probability cost-effective Budget impact 3.”
BackgroundMethodInfluentialYaesoubi, R., & Kunst, N. (2024) · Medical Decision Making · doi:10.1177/0272989x241262343 · Cited by 6
“24,25 For a risk-neutral decision maker, the optimal option is the alternative with the highest expected incremental NMB given the current uncertainty in parameters.”
Ming, J., Wu, Y., Han, R., Xu, X., Waldeck, R., & Hu, S. (2022) · Advances in Therapy · doi:10.1007/s12325-022-02389-7 · Cited by 6
“NMB allows sensitivity to be easily interpreted, while incremental cost-effectiveness ratio (ICER) requires consideration of different decision rules in each ‘‘quadrant’’ of the incremental cost-effectiveness plane [22].”
BackgroundSajith Kumar, S., Lakshmi, G. S., Sohail, A., Jagadeesh, K. V., & Bagepally, B. S. (2025) · Expert Review of Pharmacoeconomics & Outcomes Research · doi:10.1080/14737167.2025.2451733 · Cited by 5
“INB was used as an effect measure instead of ICER due to the statistical advantages of INB and the uncertainties associated with interpreting ICER values [19,20].”
Yuan, F., Bangdiwala, S. I., Tong, W., & Lamy, A. L. (2022) · Expert Review of Pharmacoeconomics & Outcomes Research · doi:10.1080/14737167.2023.2144838 · Cited by 5
Higginbotham, B., Perez, J. K., Louie, E., Haber, P., Lubman, D. I., Arunogiri, S., Chatterton, M. L., & Morley, K. C. (2023) · Australian & New Zealand Journal of Psychiatry · doi:10.1177/00048674231201541 · Cited by 5
“…ratio ( ICER) , which is expressed as the ratio of the difference in costs between two strategies to the difference in effectiveness (Paulden, 2020) in addition to the willingness-to-pay (WTP) threshold which is the maximum price which a healthcare consumer might pay for health…”
BackgroundArfuch, V. M., Martín, C. A., Berenguera, A., Angelats, R. C., Gonçalves, A. Q., Carrasco-Querol, N., Serra, G. G., Sol, M. C. S., Anguera, I. F., Friberg, E., et al. (2023) · Journal of Rehabilitation Medicine · doi:10.2340/jrm.v55.12361 · Cited by 7
“Paulden (60, 61) claims it may be time to replace the ICER with measurements such as net benefit.”
BackgroundEconomic evaluation of self-help group interventions for health in LMICs: a scoping review
Ochalek, J., Gibbs, N., Faria, R., Darlong, J., Govindasamy, K., Harden, M., Meka, A., Shrestha, D., Napit, I. B., Lilford, R. J., et al. (2023) · Health Policy and Planning · doi:10.1093/heapol/czad060 · Cited by 4
“C o m p a r i s on t o t h e s t a t u s qu o metric over ICERs have been described in detail elsewhere (Paulden, 2020a,b).”
BackgroundJiang, Z., Hang, H., Wu, X., Xiang, S., & Pan, S. (2025) · Journal of Medical Education and Curricular Development · doi:10.1177/23821205251368247 · Cited by 4
“15 For example, the Incremental Cost-Effectiveness Ratio (ICER), the most commonly reported cost-effectiveness indicator by Health Technology Assessment organizations, does not require a threshold for its calculation, but a threshold is needed to interpret ICER after the results have been…”
Rao, M., Walker, S., Claxton, K., Bland, S., Ochalek, J., Phillips, A. N., Sculpher, M. J., & Revill, P. A. (2025) · Applied Health Economics and Health Policy · doi:10.1007/s40258-025-00964-x · Cited by 4
Cost-Effectiveness Analysis of Contemporary Advanced Prostate Cancer Treatment Sequences
Litvin, V., Aprikian, A. G., & Dragomir, A. (2025) · Current Oncology · doi:10.3390/curroncol32040240 · Cited by 4
“…clarity, we present the calculation of incremental NHB below: We opt to report incremental NHB instead of an incremental cost-effectiveness ratio (ICER), in line with contemporary recommendations on the use of net health benefit or net monetary benefit instead of an ICER in reporting results [46].”
Hagendijk, M. E., van der Schans, S., Boersma, C., Postma, M. J., & van der Pol, S. (2021) · The European Journal of Health Economics · doi:10.1007/s10198-021-01303-2 · Cited by 4
“However, this approach has its limitations, as the ICER can be difficult to interpret [44, 45] and does not reflect additional criteria such as affordability and sustainability of health systems or transparency of pricing.”
BackgroundCost utility of vitamin D supplementation in adults with mild to moderate asthma
Buendía, J. A., Rodríguez‐Martínez, C. E., & Sossa‐Briceño, M. P. (2022) · Journal of Asthma · doi:10.1080/02770903.2022.2110113 · Cited by 4
The risk-based price: incorporating uncertainty and risk attitudes in health technology pricingPreprint
Kirwin, E. M., Paulden, M., McCabe, C. J., Round, J. A., Sutton, M., & Meacock, R. (2021) · SSRN Electronic Journal · doi:10.2139/ssrn.3956084 · Cited by 4
Self-citationPandya, A., Zhu, J., Luviano, A., James, L. P., & Goshua, G. (2025) · Value in Health · doi:10.1016/j.jval.2025.09.3064 · Cited by 3
Davis, M. L., Hall, J., Taylor, R. A., Klemisch, R. J., Farjah, F., & Hall, M. K. (2025) · Journal of the American College of Emergency Physicians Open · doi:10.1016/j.acepjo.2025.100209 · Cited by 3
“43 NMB assigns a dollar value to the health bene fi ts of a treatment based on a WTP threshold per QALY gained and subtracts its cost.”
Campbell, H., Ratushnyak, S., Georgieva, A., Impey, L. W. M., & Rivero‐Arias, O. (2024) · Cost Effectiveness and Resource Allocation · doi:10.1186/s12962-024-00580-x · Cited by 3
“If the resulting figure is positive, then the value of the health gains brought about by the tool would be considered greater than the incremental costs and its use would be considered cost-effective [50].”
BackgroundSkinner, J. A., Leary, M., Wynne, O., Hay, P., Collins, C. E., & Burrows, T. L. (2024) · Journal of Public Health · doi:10.1093/pubmed/fdae273 · Cited by 3
“25,27 iNMB is expressed as monetary value and was calculated as the incremental benefit (defined in the current analysis as QALYs gained) multiplied by the willingness to pay threshold minus the incremental cost. iNMB can be easier to interpret than ICERs because results of a positive iNMB means…”
Chen, J., Luo, Q., Wang, L., Zheng, L., Zhang, Y., Liu, Y., Peng, L., & Xu, W. (2025) · Therapeutics and Clinical Risk Management · doi:10.2147/tcrm.s521406 · Cited by 2
Sajith Kumar, S., & Bagepally, B. S. (2023) · Expert Review of Pharmacoeconomics & Outcomes Research · doi:10.1080/14737167.2023.2249610 · Cited by 2
Ofosu, W. K. (2023) · Texila international journal of academic research · doi:10.21522/tijar.2014.10.04.art005 · Cited by 2
Groessl, E. J., & Rutledge, T. R. (2025) · PLoS ONE · doi:10.1371/journal.pone.0316995 · Cited by 3
Sabahi, S. A., & Almasharfi, A. (2023) · Oman Medical Journal · doi:10.5001/omj.2024.40 · Cited by 2
Kuwornu, J. P., Maldonado, F., Groot, G., Penz, E. D., Cooper, E. J., Reid, A., & Marciniuk, D. D. (2024) · Health Services Insights · doi:10.1177/11786329231224621 · Cited by 1
“However, decision-makers may find it difficult to interpret ICERs and ICURs, 19 and may not often consider these when making resource allocation decisions.”
BackgroundOptimizing prehospital acute stroke care in the presence of economic constraints
Vogel, N. E. (2024) · Linköping University medical dissertations · doi:10.3384/9789180753982 · Cited by 1
Exploring Heterogeneity in Cost-Effectiveness Using Machine Learning Methods
Hattab, Z., Doherty, E., Sadique, Z., Ramnarayan, P., & O’Neill, S. (2024) · Medical Care · doi:10.1097/mlr.0000000000002010 · Cited by 1
Osstyn, S., Rauwenhoff, J., Handels, R., de Vugt, M. E., Evers, S., van Mastrigt, G. A. P. G., & van Heugten, C. M. (2025) · International Journal of Technology Assessment in Health Care · doi:10.1017/s0266462324004811
"Numerous advantages" of net benefit vs ICERs for economic evaluations
(2020) · PharmacoEconomics & Outcomes News · doi:10.1007/s40274-020-6832-3
James, L. P., Klaassen, F., Sweeney, S., Furin, J., Franke, M., Yaesoubi, R., Chesov, D., Ciobanu, N., Codreanu, A., Crudu, V., et al. (2023) · medRxiv · doi:10.1101/2023.07.28.23293104
Hariz, A. J., Chevreul, K., Daval, L., Husson, M., Alberti, C., & Michel, M. (2025) · Value in Health · doi:10.1016/j.jval.2025.01.023
Economic Evaluation Under Ambiguity and Structural Uncertainties
Andrews, B. P. (2024) · Journal of Benefit-Cost Analysis · doi:10.1017/bca.2024.39
“Also, CEA is often used to avoid explicit specification of g , which is required in welfare analyses and CBA (Phelps & Mushlin, 1991; Garber, 2000; Paulden, 2020).”
Buendía, J. A., Sánchez, J. A. B., & Patiño, D. G. (2025) · BMC Pulmonary Medicine · doi:10.1186/s12890-025-03797-5
“NMB was used alongside ICER to leverage its advantages in multi-strategy comparisons, such as easier interpretation, ranking of strategies, and robust handling of uncertainty in sensitivity analyses, particularly in the tornado diagram [19].”
Drabo, E. F., McKinney, C. D., Martin, L., Nair, D., Coughlin, J. W., Chen, T., Borahay, M. A., Wang, N., & Bennett, W. L. (2025) · Contemporary Clinical Trials · doi:10.1016/j.cct.2025.108037
Osstyn, S. L., Handels, R. L. H., Rupprecht, C., Boots, L. M. M., & de Vugt, M. E. (2025) · Aging & Mental Health · doi:10.1080/13607863.2025.2573845
“Second, a cost-consequence analysis is argued to be more understandable and approachable for policymakers than a classic economic evaluation as the results are not presented in an aggregated cost-effectiveness ratio (Mauskopf et al., 1998) which is often ambiguous to interpret (Paulden, 2020).”
Cost-effectiveness of low-dose amitriptyline for irritable bowel syndrome in primary care
Gkountouras, G., Ford, A. C., Wright-Hughes, A., Alderson, S. L., Ow, P.-L., Ridd, M. J., Foy, R., Bishop, F. L., Chaddock, M., Fernandez, C., et al. (2025) · Frontline Gastroenterology · doi:10.1136/flgastro-2025-103447
“25 Nevertheless, ICERs are provided with, where necessary, a note on their interpretation.”
Hsieh, S., Choi, M. J., Chen, Y.-C., Cheng, S., Liu, D.-P., Song, J. Y., Tang, X., Mould-Quevedo, J. F., Cheong, H. J., & Chang, C.-J. (2026) · Vaccine · doi:10.1016/j.vaccine.2026.128533
Igarashi, A., Shiraishi, K., Saito, S., Kudo, T., Iizuka, Y., Yamamura, E., & Hase, M. (2026) · Dermatology and Therapy · doi:10.1007/s13555-026-01788-w
“For example, since ICER is a pairwise comparison, multiple ICERs need to be calculated for evaluations of three or more strategies; ICERs also cannot be used to rank strategies as a higher/lower ICER does not necessarily imply that a strategy is more/less cost–effective than another [58].”
Comparing User-Written Codes for Performing Economic Evaluations in Stata
Barker-Jones, B., Navvuga, P., Baji, P., Marques, E. M. R., & Hollingworth, W. (2026) · PharmacoEconomics · doi:10.1007/s40273-026-01643-y
“Since ICERs alone can be difficult to interpret [21], this limits the usefulness of FSC for informing policy decision-making.”
Nemzoff, C., Grimm, S. E., Joore, M. A., Montero, A. M., Umuhoza, S. M., Humuza, J., Sweeney, S., Baltussen, R. M. P. M., & Vassall, A. (2026) · Applied Health Economics and Health Policy · doi:10.1007/s40258-026-01072-0
“While the original ARCH used net monetary benefit (NMB), which is the gold standard for measuring opportunity cost and is more appropriate for ranking interventions and determining VOI [14], the ICER is typically used in HBP design.”
Halahakone, U., Senanayake, S. J., McCreanor, V., Parsonage, W. A., & Brain, D. (2026) · Applied Health Economics and Health Policy · doi:10.1007/s40258-026-01073-z
Shi, B.-X., Tsai, D., Lin, C., Lin, S.-H., Hsieh, P.-H., & Fang, W. (2026) · Archives of Osteoporosis · doi:10.1007/s11657-026-01788-5
“To quantify the magnitude of economic value, the net monetary bene fi t (NMB) was also calculated using the following formula: NMB = WTP × Δ QALY – Δ cost [32].”
Metadata
- Authors
- Paulden, M.
- Affiliations
- University of Alberta (CA)
- Corresponding author
- Paulden, Mike
- ORCID
- Paulden, Mike
- Venue
- PharmacoEconomics
- Published
- 2020-05-11
- Volume
- 38
- Issue
- 8
- Pages
- 781-784
- ISSN
- 1170-7690 (ISSN-L)
- 1179-2027
- OpenAlex
- W3022637090
- Cited by
- 65
- References
- 21
- Citations by year
- 2026: 6 · 2025: 16 · 2024: 11 · 2023: 14 · 2022: 7 · 2021: 6 · 2020: 5
- FWCI
- 6.80
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- PharmacoEconomics (publishedVersion)
- PubMed (publishedVersion)
- RePEc: Research Papers in Economics (submittedVersion)
- Topics
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Health Systems, Economic Evaluations, Quality of Life
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Pharmaceutical Economics and Policy
- Social Sciences › Sociology and Political Science › Delphi Technique in Research
- Keywords
- incremental cost-effectiveness ratio, net benefit, economic evaluation of health technologies, health technology assessment, summary measures
- MeSH terms
- Cost-Benefit Analysis, Humans, Technology Assessment, Biomedical, Biomedical Technology
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