기회비용 기반 임계값 추정 연구에 대한 체계적 문헌고찰
A systematic review of studies estimating opportunity cost-based cost-effectiveness thresholds
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초록
새로운 의료기술의 비용-효과성을 판단하기 위해서는 일반적으로 임계값이 필요하다. 임계값이 무엇을 반영해야 하는지에 대해 아직 합의된 의견은 없으나, 일반적으로 건강 한 단위에 대해 사회가 부여한 한계가치를 반영해야 한다는 수요 측면의 접근과 새로운 기술 도입으로 인해 발생하는 기회비용을 반영해야 한다는 공급 측면의 접근이 있다. 지금까지는 대체로 수요 측면의 관점에서 임계값을 논의하거나 실증적으로 분석하였을 뿐 기회비용 관점은 크게 주목받지 못하였다. 본 연구에서는 체계적 문헌고찰을 통해 기회비용 기반 임계값 추정 연구의 현황과 방법론에 대해 자세히 고찰하였다. 주요 데이터베이스와 검색어를 활용하여 최종적으로 총 17개의 연구를 선별하였는데, 이 중 14개가 국가별 분석을 수행하였다. 이들은 기회비용 기반 임계값을 추정하기 위해 대체로 보건의료체계 내에서 생산된 건강 한 단위당 한계비용을 산출하였다. 임계값 추정치는 미국과 북유럽 국가보다는 중국과 콜롬비아 등의 상위 중간소득 국가와 영국과 호주에서 상대적으로 낮게 나타났는데, 이는 대체로 1인당 GDP에 못 미치는 수준이었다. 아직 우리나라에서는 이러한 연구가 수행된 바 없어 의사결정의 기회비용을 가늠하기 어렵다. 초고가 의약품이나 의료기술이 점차 늘어나고 있는 현 상황에서 이러한 도입 결정의 기회비용이나 전체 보건의료예산을 제대로 고려하지 않는다면 이는 자칫 총 건강 감소 및 재정 건전성 악화로 이어질 수도 있다. 자원 배분의 합리적 의사결정을 위해서는 건강에 대한 사회적 선호와 지불의사뿐만 아니라 보건의료에 할당된 예산 수준과 의사결정의 기회비용을 함께 고려할 필요가 있다. 기회비용 기반 임계값 추정 연구가 조속히 추진될 수 있도록 이 연구에서는 추가로 임계값 추정 시 고려해야 할 여러 방법론적 고려사항이나 쟁점들에 대해 자세히 논의하였다.
Abstract
A cost-effectiveness threshold is required when deciding whether a new healthcare technology is too expensive. There are generally two perspectives on what a cost-effectiveness threshold should reflect. A demand-side approach emphasizes the consumption value of health, whereas a supply-side approach emphasizes the opportunity costs of funding decisions. In recent years, there has been growing attention on the opportunity cost-based threshold, especially with the rise of high-cost healthcare technologies. This study, therefore, conducted a systematic review of studies estimating the opportunity cost-based thresholds. A total of 17 studies were included in this review, of which 14 conducted country-specific analyses. These studies generally estimated the marginal cost per unit of health produced within the health care system. Threshold estimates were relatively lower in the UK, Australia, and other upper-middle-income countries such as China and Colombia than in the United States and Nordic countries, which were well below the GDP per capita. In addition, methodological approaches taken in the included studies were thoroughly reviewed and analyzed to derive methodological implications and insights. These findings, together with the local context and the type of data available, should be fully taken into account when estimating one such threshold in Korea.
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