Exploring trends of cost-effectiveness thresholds in South Korea: systematic review of pharmacoeconomic evaluations since introduction of the positive list system

BACKGROUND: Pharmacoeconomic evaluations are critical for healthcare decision-making, especially as South Korea has emphasized cost-effectiveness since the 2006 positive list system. However, no official cost-effectiveness threshold (CET) has been established. This study aimed to systematically review cost-utility analyses (CUAs) conducted in South Korea since 2007 and to describe how CET values have been reported and applied in published pharmacoeconomic studies. METHODS: We conducted this systematic review following the PRISMA guidelines. We searched five databases, including PubMed and KoreaMed, for CUAs published after 2007. We included CUAs of medications conducted in South Korea that reported CET. Data on baseline year, outcome measures, CET values, drug type (anticancer drugs, vaccines, and other treatments), and funding sources were extracted. We assessed the association between CETs and categorical variables using the chi-square tests or Fisher's exact tests, as appropriate. RESULTS: A total of 8,510 studies were initially identified, of which 53 met the inclusion criteria after screening. Median CETs showed an increasing trend over time. GDP per capita-based references were more frequently used than WTP-based approaches (60.4% vs. 37.7%). Anticancer drugs consistently demonstrated higher CET values than other treatment categories, and drug type was significantly associated with CET levels (p < 0.05). In contrast, other study characteristics, including funding source, were not significantly associated in categorical analyses. CONCLUSION: This study provides an overview of CET trends in South Korea, highlighting differences by drug type. As the number of high-cost drugs and healthcare demands increase, CETs are expected to play a key role in balancing financial sustainability and patient access. These findings offer insights into how CET values have been applied in the literature and may inform ongoing discussions on the use of CETs in health economic evaluations.