When Do Published Cost-Effectiveness Analyses Include Societal Costs? An Empirical Analysis, 2013–2023

Objective To examine trends in the inclusion of societal costs in published cost-effectiveness analyses (CEAs), factors associated with their inclusion, and the impact of societal costs on incremental costs and incremental cost-effectiveness ratios (ICERs). Methods We analyzed 7,800 CEAs from 2013 to 2023 using the Tufts Medical Center CEA registry. The inclusion of societal costs in CEAs was evaluated across study characteristics. Associations between study characteristics and the inclusion of societal costs were analyzed using multivariate logistic regression. For studies reporting health care and societal perspectives, we assessed the impact of including societal costs on incremental costs and ICERs. Results From 2013 to 2023, CEAs including societal costs increased from 19% to 28%. Productivity was the most frequently reported component (12%), followed by transportation (8%), caregiver time (6%), patient time (5%), and consumption costs (1%). Compared with US-based analyses, studies from Scandinavian countries (adjusted odds ratio [OR]: 3.6) and the Netherlands (5.6) had higher odds of including societal costs, whereas studies from Canada (0.7), Australia (0.6), and the United Kingdom (0.4) had lower odds. Studies on mental health disorders (6.2) and immunization (4.1) had the highest odds of including societal costs. Compared with CEAs focused on adults, CEAs targeting pediatric populations had higher odds (OR: 1.6), while those targeting the elderly had lower odds (OR: 0.7). Upon inclusion of societal costs, incremental costs decreased in 72% and increased in 28% of studies; the ICER decreased in 74% and increased in 26% of studies. Conclusion Despite the increase in recent years, societal costs are infrequently included in CEAs, with substantial variation by country, disease, and population. Including societal costs can meaningfully improve value assessments and should be guided by relevance, evidence, and decision context. Highlights Building on prior work by Kim et al. (2020), which analyzed approximately 6,900 cost-effectiveness analyses (CEAs), this study examined a larger and more recent sample of 7,800 CEAs from 2013 to 2023. In addition to updating the evidence base, we conducted new analyses to assess trends, associated factors, and the effect of including societal costs on incremental cost-effectiveness ratios (ICERs), thus providing insights that were not explored in prior work and addressing a key evidence gap in health economics. The inclusion of societal costs in CEAs rose modestly from 19% to 28% from 2013 to 2023, with substantial variation across countries, diseases, and intervention types. In some cases, the inclusion of societal costs affected incremental costs and ICERs enough to cross commonly used cost-effectiveness thresholds. The inclusion of societal costs can help improve value assessments in health care interventions, but it should be guided by relevance, available evidence, and the potential to influence decision making. Identifying when and where societal costs meaningfully affect outcomes can support more consistent and appropriate use.