Perspective

This page explains how perspective determines whose costs and outcomes count in an economic evaluation. It compares commonly used perspectives, shows how perspective changes the evidence included in an analysis, and explains how to select and report a perspective transparently.

Why perspective matters

Perspective defines the viewpoint from which costs and outcomes are identified, measured and valued. It affects which people, organisations and sectors are represented in the analysis. Two evaluations of the same intervention can therefore reach different results because they adopt different perspectives.

• A healthcare-system perspective includes consequences borne by the healthcare system.
• A payer perspective includes consequences relevant to a specified insurer, government programme or other payer.
• A patient perspective includes costs and outcomes experienced directly by patients.
• A societal perspective aims to include relevant consequences regardless of who experiences them.
• An employer perspective includes work-related costs and consequences borne by employers.
• A provider perspective includes resources, expenditure and operational consequences affecting healthcare providers.

Perspective should be specified before resource use, costs and outcomes are selected. Choosing the perspective after seeing the results can introduce bias by favouring the viewpoint that produces the preferred conclusion.

How common perspectives differ

Each perspective establishes a different analytical boundary. The appropriate perspective depends on the decision problem, the decision-maker and any applicable reference case or methodological guidance. The labels should not be treated as interchangeable.

Perspective	Whose consequences are considered?	Costs commonly included	Outcomes commonly included
Healthcare-system	The healthcare system and its services	Healthcare staff, medicines, hospital care, tests, devices and other healthcare resources	Patient health outcomes relevant to the healthcare decision
Payer	A specified public or private payer	Reimbursed services, covered medicines, programme expenditure and other payer liabilities	Outcomes required by the payer’s decision framework
Patient	Patients and, when stated, their households	Out-of-pocket payments, travel, accommodation, unpaid time and other patient expenses	Health, functioning, wellbeing and other patient-relevant outcomes
Societal	All relevant people, organisations and sectors	Healthcare costs, patient costs, informal care, productivity consequences and relevant non-healthcare costs	Health and other material consequences across society
Employer	Employers and workplaces	Absence, reduced productivity, employee replacement and workplace adaptations	Work participation and productivity-related outcomes
Provider	Hospitals, clinics and other service providers	Staff time, facilities, equipment, supplies and implementation costs	Service capacity, activity and provider-relevant consequences

A perspective label does not prove that every relevant consequence has been included. The evaluation should state the actual categories included and excluded.

How perspective changes the costs included

The same resource or expenditure may be included under one perspective and excluded under another. The analyst must determine who bears each cost and whether it falls within the stated analytical boundary. Transfers between parties should be distinguished from resource costs when that distinction matters to the analysis.

For example:

• A patient copayment is a cost from the patient perspective.
• A reimbursed medicine is an expenditure from the payer perspective.
• Unpaid caregiver time may be included under a societal or household perspective.
• Productivity losses may be included under a societal or employer perspective.
• Hospital staff time may be included under healthcare-system and provider perspectives.
• Travel costs may be excluded from a healthcare-system perspective but included from a patient or societal perspective.

The analysis should avoid double counting when the same payment appears from more than one viewpoint. A patient payment and a payer reimbursement may finance the same healthcare service but represent different financial flows.

How perspective changes the outcomes included

Perspective can also affect which outcomes are considered relevant. Most health economic evaluations include patient health outcomes, but broader perspectives may include consequences for caregivers, families, employers or other sectors. These wider outcomes should be measured and reported separately when combining them would obscure who experiences each effect.

• A patient perspective may include treatment burden, time costs and out-of-pocket consequences.
• A healthcare-system perspective may focus on patient health outcomes produced by healthcare resources.
• A societal perspective may include caregiver health, productivity and consequences outside healthcare.
• An employer perspective may include work absence, presenteeism and return to work.
• A provider perspective may include service capacity, waiting times and implementation effects.

Including a wider range of outcomes does not automatically improve an evaluation. Each outcome must be relevant to the decision problem, measured credibly and included without overlap.

Selecting the appropriate perspective

The selected perspective should match the purpose of the evaluation and the authority of the decision-maker. National or institutional reference cases may prescribe a primary perspective to improve consistency across submissions. A secondary perspective can be reported when important consequences fall outside the required primary viewpoint.

A clear selection process is:

1. Define the decision-maker. Identify the person or organisation using the evaluation.
2. State the decision problem. Specify the population, intervention, comparator and decision being considered.
3. Check applicable guidance. Determine whether a reference case requires a particular perspective.
4. Identify affected parties. List the patients, caregivers, payers, providers, employers and sectors that may experience material consequences.
5. Select the primary perspective. Choose the viewpoint that directly supports the decision.
6. Consider secondary analyses. Add another perspective when excluded consequences could materially change interpretation.
7. Document inclusions and exclusions. Explain which cost and outcome categories enter each analysis.

The primary perspective should not be broadened or narrowed without explanation. When several perspectives are reported, their results should remain clearly separated.

Worked example: how perspective changes a result

Consider a treatment that reduces hospital use but requires patients to travel regularly to a specialist clinic. It also allows some patients and caregivers to miss fewer working days. The clinical effect is unchanged across perspectives, but the included costs differ.

• The healthcare-system perspective includes the treatment, clinic visits and avoided hospital care.
• The payer perspective includes reimbursed treatment and services covered by the payer.
• The patient perspective includes travel, out-of-pocket payments and patient time.
• The societal perspective includes healthcare resources, patient costs, caregiver time and productivity consequences.
• The employer perspective includes changes in absence and workplace productivity.

The intervention may appear cost-increasing from one perspective and cost-saving from another. Neither result is meaningful unless the perspective and included categories are stated.

Using more than one perspective

Reporting more than one perspective can show whether a decision shifts costs or benefits between groups. This is especially useful when an intervention reduces healthcare expenditure but increases patient costs, or when it creates benefits outside the healthcare sector. Separate analyses are usually clearer than combining incompatible viewpoints into one total.

A multiple-perspective analysis should:

• Apply the same population, intervention, comparator and time horizon wherever possible.
• Identify each cost and outcome category consistently.
• Show which party bears each consequence.
• Prevent the same resource or outcome from being counted more than once.
• Report results separately for each perspective.
• Explain why differences between perspectives arise.

Results from different perspectives should not be compared as if they were generated from identical analytical boundaries.

Common mistakes when applying perspective

An evaluation becomes difficult to interpret when its stated perspective does not match the costs and outcomes actually included. These inconsistencies can alter incremental results and lead readers to misunderstand who gains, who pays and which resources are affected.

Common mistakes include:

• The evaluation states a societal perspective but includes only healthcare costs.
• The evaluation includes productivity losses without identifying the valuation method.
• The evaluation includes patient payments and full healthcare costs without checking for overlap.
• The evaluation excludes caregiver consequences without explaining why they are irrelevant.
• The evaluation changes perspective between cost categories.
• The evaluation combines results from different perspectives into one unexplained total.
• The evaluation uses a payer perspective without identifying the payer.
• The evaluation selects its perspective after examining the results.

These problems should be addressed through a prespecified analytical plan and a transparent cost-and-outcome inventory.

What should be reported

Transparent reporting allows readers to determine whether the selected perspective fits the decision problem. It also makes clear which consequences are represented and which remain outside the analysis. The report should provide enough detail for the analytical boundary to be reproduced.

Report:

• The primary perspective and why it was selected.
• The decision-maker associated with the perspective.
• Any reference case or guidance governing the selection.
• Every included cost category.
• Every included outcome category.
• The parties bearing each cost or receiving each outcome.
• Material categories that were excluded.
• Any secondary perspectives and why they were analysed.
• Methods used to value patient time, caregiver time or productivity.
• Steps taken to prevent double counting.
• The effect of perspective on incremental costs, outcomes and conclusions.
• Limitations created by the selected analytical boundary.

Perspective should be interpreted as a substantive design choice, not merely a reporting label. Decision-makers should consider whether consequences excluded from the primary analysis remain important to patients, caregivers, providers or society.