Experiences of including costs of added life years in health economic evaluations in Sweden

Laura Pirhonen, Thomas Davidson

DOI: https://doi.org/10.7175/fe.v15i2.925


It is of importance to include the appropriate costs and outcomes when evaluating a health intervention. Sweden is the only country where the national guidelines of decisions on reimbursement explicitly state that costs of added life years should be accounted for when presenting health economic evaluations. The aim of this article is to, from a theoretical and empirical point of view, critically analyze the Swedish recommendations used by the Dental and Pharmaceutical Benefits Agency (TLV), when it comes to the use of costs of added life years in economic evaluations of health care. The aim is furthermore to analyze the numbers used in Sweden and discuss their impact on the incremental cost‑effectiveness ratios of assessed technologies. If following a societal perspective, based on welfare economics, there is strong support for the inclusion of costs of added life years in health economic evaluations. These costs have a large impact on the results. However this fact may be in conflict with ethical concerns of allocation of health care resources, such as favoring the younger part of the population over the older. It is important that the estimates of production and consumption reflect the true societal values, which is not the case with the values used in Sweden.


Health economic evaluation; Cost-effectiveness; Survival years

Full Text



  • Brouwer WB, Koopmanschap MA. On the economic foundations of CEA. Ladies and gentlemen, take your positions! J Health Econ 2000; 19: 439-59; http://dx.doi.org/10.1016/S0167-6296(99)00038-7
  • Weinstein MC, Manning WG Jr. Theoretical issues in cost-effectiveness analysis. J Health Econ 1997; 16: 121-8; http://dx.doi.org/10.1016/S0167-6296(96)00511-5
  • Garber AM, Phelps CE. Economic foundations of cost-effectiveness analysis. J Health Econ 1997; 16: 1-31; http://dx.doi.org/10.1016/S0167-6296(96)00506-1
  • Meltzer D. Accounting for future costs in medical cost-effectiveness analysis. J Health Econ 1997; 16: 33-64; http://dx.doi.org/10.1016/S0167-6296(96)00507-3
  • Nyman JA. Should the consumption of survivors be included as a cost in cost-utility analysis? Health Econ 2004; 13: 417-27; http://dx.doi.org/10.1002/hec.850
  • Rappange DR, van Baal PH, van Exel NJ, et al. Unrelated medical costs in life-years gained: should they be included in economic evaluations of healthcare interventions? Pharmacoeconomics 2008; 26: 815-30; http://dx.doi.org/10.2165/00019053-200826100-00003
  • van Baal P, Meltzer D, Brouwer W. Pharmacoeconomic guidelines should prescribe inclusion of indirect medical costs! A response to Grima et Al. Pharmacoeconomics 2013; 31: 369-73; http://dx.doi.org/10.1007/s40273-013-0042-9
  • Swedish Pharmaceutical Benefits Board (Läkemedelsförmånsnämnden). General Guidelines for Economic Evaluations. Stockholm: Pharmaceutical Benefits Board, 2003
  • Ministry of Health and Social Affairs. No easy choices: The difficult priorities of health care. Stockholm: SOU, 1993
  • Sen, A. Commodities and capabilities. Amsterdam: North-Holland, 1985
  • Mehrez A, Gafni A. Quality-adjusted life years, utility theory, and healthy-years equivalents. Med Decis Making 1989; 9: 142-9; http://dx.doi.org/10.1177/0272989X8900900209
  • Davidson T, Levin LA. Do individuals consider expected income when valuing health states? Int J Technol Assess Health Care 2008; 24: 488-94; http://dx.doi.org/10.1017/S0266462308080641
  • Krol M, Sendi P, Brouwer W. Breaking the silence: exploring the potential effects of explicit instructions on incorporating income and leisure in TTO exercises. Value Health 2009; 12: 172-80; http://dx.doi.org/10.1111/j.1524-4733.2008.00406.x
  • Myers J, McCabe S, Gohmann S. Quality-of-life assessment when there is a loss of income. Med Decis Making 2007; 27: 27-33; http://dx.doi.org/10.1177/0272989X06297100
  • Tilling C, Krol M, Tsuchiya A, et al. In or out? Income losses in health state valuations: a review. Value Health 2010; 13: 298-305; http://dx.doi.org/10.1111/j.1524-4733.2009.00614.x
  • Lundin D, Ramsberg J. On survival consumption costs: a reply to Nyman. Health Econ 2008; 17: 293-7; http://dx.doi.org/10.1002/hec.1290
  • Gandjour A. Consumption costs and earnings during added years of life - a reply to Nyman. Health Econ 2006; 15: 315-7; http://dx.doi.org/10.1002/hec.1065
  • Grima DT, Bernard LM, Dunn ES, et al. Cost-effectiveness analysis of therapies for chronic kidney disease patients on dialysis: a case for excluding dialysis costs. Pharmacoeconomics 2012; 30: 981-9; http://dx.doi.org/10.2165/11599390-000000000-00000
  • Ekman M. Studies in Health Economics: Modelling and Data Analysis of Costs and Survival. Dissertation for the degree of Doctor of Philosophy at the Stockholm School of Economics. EFI, Stockholm Sweden, 2002
  • Jegermalm M, Jeppsson Grassman E. Patterns of informal help and caregiving in Sweden: A thirteen-year perspective. Soc Pol Admin 2009; 43: 681-701; http://dx.doi.org/10.1111/j.1467-9515.2009.00689.x
  • Statistics Sweden Nr 62, 2012.Available at http://www.scb.se/Pages/Article____332790.aspx (last accessed September 2013)
  • National board of health and welfare. Läkemedel - statistik för år 2012. Available at www.socialstyrelsen.se (last accessed September 2013)
  • Davidson T, Husberg M, Janzon M, et al. Cost-effectiveness of dabigatran compared with warfarin for patients with atrial fibrillation in Sweden. Eur Heart J 2013; 34: 177-83; http://dx.doi.org/10.1093/eurheartj/ehs157
  • Swedish Dental and Pharmaceutical Benefits Board (TLV). Pradaxa. TLV, 2011. Available at http://www.tlv.se/Upload/Beslut_2011/111130-Pradaxa_dnr1222-2011.pdf (last accessed September 2013)
  • Swedish Dental and Pharmaceutical Benefits Board (TLV). Zytiga. TLV, 2012. Available at http://www.tlv.se/Upload/Beslut_2012/120530-zytiga.pdf (last accessed September 2013)
  • Swedish Dental and Pharmaceutical Benefits Board (TLV). Hälsoekonomiskt kunskapsunderlag – Zytiga. TLV, 2012. Available at http://www.tlv.se/Upload/Halsoekonomiska_bedomningar/halsoekonomiskt-kunskapsunderlag-zytiga.pdf (last accessed September 2013)
  • Swedish Law (Svensk författningssamling). Hälso- och sjukvårdslag (1982: 763) 2§
  • Williams A. Intergenerational equity: an exploration of the ‘fair innings’ argument. Health Econ 1997; 6: 117-32; http://dx.doi.org/10.1002/(SICI)1099-1050(199703)6:2<117::AID-HEC256>3.0.CO;2-B
  • Johannesson M, Meltzer D. Some reflections on cost-effectiveness analysis. Health Econ 1998; 7: 1-7; http://dx.doi.org/10.1002/(SICI)1099-1050(199802)7:1<1::AID-HEC327>3.0.CO;2-U
  • National board of health and welfare. Guideline, 2013. Available at www.socialstyrelsen.se (last accessed September 2013)


Abstract: 877 views
HTML: 602 views
PDF: 103 views


  • There are currently no refbacks.

© SEEd srl