Distributional cost-effectiveness analysis in genomic medicine: Considerations for addressing health equity.

OBJECTIVE: Distributional cost-effectiveness analysis (DCEA) supports equitable resource allocation by quantifying equity-efficiency trade-offs. DCEA may be particularly useful to understand equity impacts in the context of genomic medicine, a rapidly growing clinical area that has prompted concerns about its potential to exacerbate health inequities by differentially benefitting some population groups over others due to disparities in research inclusion and access to specialty care. This article critically examines the application of DCEA in the context of genomic medicine. METHODS: We articulate steps for distributional impact assessment in the context of genomic medicine by adapting an existing conceptual framework for understanding the causal pathway between a health care intervention and the distribution of costs and effects among social groups, the inequality staircase. We discuss related data equity considerations and evidence requirements specific to genomic medicine interventions. RESULTS: The need for and receipt of a genomic medicine intervention, as well as an intervention's short-term and long-term effects, may vary across equity-relevant subgroups. Research to enhance the relevance of DCEA in genomic medicine should avoid conflation of biological and social factors, empower populations that are underrepresented in genomics research, accurately assess variation in outcomes across equity-relevant subgroups, and develop methods for incorporation of non-health outcomes within a DCEA framework. CONCLUSIONS: Best practice-aligned applications of DCEA may facilitate transparent discussions of health equity in coverage and implementation decisions. This article provides guidance to researchers on the use of DCEA in genomic medicine and other clinical areas with similarly complex considerations around equity.