In health systems aiming to maximise population health from a constrained budget, published cost-effectiveness analyses (CEAs) should compare incremental cost-effectiveness ratios (ICERs) with cost-effectiveness thresholds (CETs) reflecting the health opportunity cost (HOC) of funding decisions.

HOC values were cited in 28% of CEAs in Spain and in 11% of studies conducted in Australia, but they were not referred to in CEAs undertaken in the Netherlands or South Africa.

Through regression analyses, we found that more recent studies, studies without a conflict of interest and studies estimating an ICER below the HOC value were more likely to use the HOC as a threshold reference.