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All health is not equal: the use of modifiers in NICE technology appraisal
  1. Victoria Charlton
  1. Global Health and Social Medicine, King's College London, London, UK
  1. Correspondence to Victoria Charlton, Global Health and Social Medicine, King's College London, London WC2R 2LS, UK; victoria.charlton{at}

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In 2004, former BMJ editor Richard Smith described the UK’s National Institute for Health and Care Excellence (NICE) as potentially ‘one of Britain’s greatest cultural exports, along with Shakespeare, Newtonian physics, the Beatles, Harry Potter, and the Teletubbies’.1 This slightly dubious honour was conferred on NICE for its pioneering work as a national healthcare priority setter, advising the National Health Service (NHS) on which technologies to adopt and which to reject through its technology appraisal programme.

Nineteen years on, NICE has maintained its reputation as an innovator, and its methods have evolved considerably.2 3 One change concerns its adoption of numerical ‘modifiers’ to adjust how the health needs of different groups are prioritised in evaluating new technologies. This article describes NICE’s current modifiers and briefly considers the implications of their use.

NICE’s methods: an overview

NICE’s approach to technology appraisal centres on the concept of cost-effectiveness: the amount of health a technology generates per pound spent, compared with current NHS practice.4 Generally speaking, technologies judged to be cost-effective are recommended, while those that are not are rejected.

NICE takes an evidence-based approach to assessing cost-effectiveness. In doing so, it relies heavily on an economic model developed by the technology’s manufacturer and critiqued by an independent evidence review group. This model uses evidence identified via systematic review to estimate the additional health that can be attributed to a technology’s use. This health is measured in quality-adjusted life-years (QALYs), a standardised unit that takes account of a technology’s impact on both length and quality of life. Having estimated the extra QALYs a technology is expected to deliver, the model estimates its cost compared with existing treatment. It then calculates the technology’s incremental cost-effectiveness ratio (ICER): the additional cost per QALY.

NICE’s appraisal committees use the ICER to help them evaluate a technology’s cost-effectiveness. …

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  • Contributors VC is the sole author and guarantor of this work.

  • Funding This research was funded by a Wellcome Trust Society and Ethics Doctoral Studentship (grant number 203351/Z/16/Z).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.