Methods for Communicating the Impact of Parameter Uncertainty in a Multiple-Strategies Cost-Effectiveness Comparison

Henri B. Wolff, Venetia Qendri, Natalia Kunst, Fernando Alarid-Escudero, Veerle M. H. Coupé

Research output: Contribution to journalReview articleAcademicpeer-review

3 Citations (Scopus)


Purpose: Analyzing and communicating uncertainty is essential in medical decision making. To judge whether risks are acceptable, policy makers require information on the expected outcomes but also on the uncertainty and potential losses related to the chosen strategy. We aimed to compare methods used to represent the impact of uncertainty in decision problems involving many strategies, enhance existing methods, and provide an open-source and easy-to-use tool. Methods: We conducted a systematic literature search to identify methods used to represent the impact of uncertainty in cost-effectiveness analyses comparing multiple strategies. We applied the identified methods to probabilistic sensitivity analysis outputs of 3 published decision-analytic models comparing multiple strategies. Subsequently, we compared the following characteristics: type of information conveyed, use of a fixed or flexible willingness-to-pay threshold, output interpretability, and the graphical discriminatory ability. We further proposed adjustments and integration of methods to overcome identified limitations of existing methods. Results: The literature search resulted in the selection of 9 methods. The 3 methods with the most favorable characteristics to compare many strategies were 1) the cost-effectiveness acceptability curve (CEAC) and cost-effectiveness acceptability frontier (CEAF), 2) the expected loss curve (ELC), and 3) the incremental benefit curve (IBC). The information required to assess confidence in a decision often includes the average loss and the probability of cost-effectiveness associated with each strategy. Therefore, we proposed the integration of information presented in an ELC and CEAC into a single heat map. Conclusions: This article presents an overview of methods presenting uncertainty in multiple-strategy cost-effectiveness analyses, with their strengths and shortcomings. We proposed a heat map as an alternative method that integrates all relevant information required for health policy and medical decision making. To assess confidence in a chosen course of action, decision makers require information on both the probability and the consequences of making a wrong decision. This article contains an overview of methods for presenting uncertainty in multiple-strategy cost-effectiveness analyses. We propose a heat map that combines the probability of cost-effectiveness from the cost-effectiveness acceptability curve (CEAC) with the consequences of a wrong decision from the expected loss curve. Collapsing of the CEAC can be reduced by relaxing the CEAC, as proposed in this article. Code in Microsoft Excel and R is provided to easily analyze data using the methods discussed in this article.
Original languageEnglish
Pages (from-to)956-968
Number of pages13
JournalMedical decision making
Issue number7
Early online date2022
Publication statusPublished - Oct 2022


  • CEA
  • CEAC
  • ELC
  • PSA
  • many strategies
  • sensitivity analysis

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