Multicriteria decision analysis (MCDA) in health care: a systematic review of the main characteristics and methodological steps

A Vulnerability Analysis for the Management of and Response to the COVID-19 Epidemic in the Second Most Populous State in Brazil

The COVID-19 pandemic has the potential to affect all individuals, however in a heterogeneous way. In this sense, identifying specificities of each location is essential to minimize the damage caused by the disease. Therefore, the aim of this research was to assess the vulnerability of 853 municipalities in the second most populous state in Brazil, Minas Gerais (MG), in order to direct public policies. An epidemiological study was carried out based on Multi-Criteria Decision Analysis (MCDA) using indicators with some relation to the process of illness and death caused by COVID-19. The indicators were selected by a literature search and categorized into: demographic, social, economic, health infrastructure, population at risk and epidemiological. The variables were collected in Brazilian government databases at the municipal level and evaluated according to MCDA, through the Program to Support Decision Making based on Indicators (PRADIN). Based on this approach, the study performed simulations by category of indicators and a general simulation that allowed to divide the municipalities into groups of 1-5, with 1 being the least vulnerable and 5 being the most vulnerable. The groupings of municipalities were exposed in their respective mesoregions of MG in a thematic map, using the software Tabwin 32. The results revealed that the mesoregion of Norte de Minas stands out with more than 40% of its municipalities belonging to group 5, according to economic, social and health infrastructure indicators. Similarly, the Jequitinhonha mesoregion exhibited almost 60% of the municipalities in this group for economic and health infrastructure indicators. For demographic and epidemiological criteria, the Metropolitana de Belo Horizonte was the most vulnerable mesoregion, with 42.9 and 26.7% of the municipalities in group 5, respectively. Considering the presence of a population at risk, Zona da Mata reported 42.3% of the municipalities in the most vulnerable group. In the joint analysis of data, the Jequitinhonha, Vale do Mucuri and Vale do Rio Doce mesoregions were the most vulnerable in the state of MG. Thus, through the outlined profile, the present study proved how socioeconomic diversity affects the vulnerability of the municipalities to face COVID-19 outbreak, highlighting the need for interventions directed to each reality.

Can We Incorporate Societal Values in Resource Allocation Decisions Among Disease Categories? An Empirical Approach

OBJECTIVES

Historically, resource allocation decisions in healthcare are based on univariate approaches, inevitably overlooking value dimensions that are essential from a societal welfare maximization perspective. This article aims to present a wider perspective on decision making that incorporates societal values when prioritizing future resource allocation among disease areas.

METHODS

Sociotechnical application of multiple-criteria decision analysis with a set of criteria (value judgments) that are based on positive as well as normative dimensions of resource allocation. We use Greece as a case study. Societal value judgments were sourced via a multidisciplinary panel of experts who collectively provided criteria weights and scores for each alternative (16 disease categories, classified according to the Global Burden of Disease study) against each criterion. An additive value function provided the total value in priority preference for each alternative.

RESULTS

The criteria that were deemed relevant to the decision-making process and their respective relative weights were burden of disease (0.245), capacity to benefit (0.190), direct cost and projected changes in the next 5 years (0.160), indirect cost (0.132), intensity of unmet needs (0.109), incidence of catastrophic expenditure (0.091), and caring externalities (0.073). The additive value function revealed that the top 5 priorities in highest total value scores were neoplasms, circulatory diseases, injuries, neurologic diseases, and musculoskeletal diseases.

CONCLUSIONS

Incorporation of societal value criteria in resource allocation decisions can highlight priorities and lead to different sets of planning decisions than solely demand-driven allocation.

Optimising Vaccine Dose in Inoculation against SARS-CoV-2, a Multi-Factor Optimisation Modelling Study to Maximise Vaccine Safety and Efficacy

Developing a vaccine against the global pandemic SARS-CoV-2 is a critical area of active research. Modelling can be used to identify optimal vaccine dosing; maximising vaccine efficacy and safety and minimising cost. We calibrated statistical models to published dose-dependent seroconversion and adverse event data of a recombinant adenovirus type-5 (Ad5) SARS-CoV-2 vaccine given at doses 5.0 × 10¹⁰, 1.0 × 10¹¹ and 1.5 × 10¹¹ viral particles. We estimated the optimal dose for three objectives, finding: (A) the minimum dose that may induce herd immunity, (B) the dose that maximises immunogenicity and safety and (C) the dose that maximises immunogenicity and safety whilst minimising cost. Results suggest optimal dose [95% confidence interval] in viral particles per person was (A) 1.3 × 10¹¹ [0.8–7.9 × 10¹¹], (B) 1.5 × 10¹¹ [0.3–5.0 × 10¹¹] and (C) 1.1 × 10¹¹ [0.2–1.5 × 10¹¹]. Optimal dose exceeded 5.0 × 10¹⁰ viral particles only if the cost of delivery exceeded £0.65 or cost per 10¹¹ viral particles was less than £6.23. Optimal dose may differ depending on the objectives of developers and policy-makers, but further research is required to improve the accuracy of optimal-dose estimates.

Sentinel surveillance of Lyme disease risk in Canada, 2019: Results from the first year of the Canadian Lyme Sentinel Network (CaLSeN)

Background

Lyme disease is an emerging vector-borne zoonotic disease of increasing public health importance in Canada. As part of its mandate, the Canadian Lyme Disease Research Network (CLyDRN) launched a pan-Canadian sentinel surveillance initiative, the Canadian Lyme Sentinel Network (CaLSeN), in 2019.

Objectives

To create a standardized, national sentinel surveillance network providing a real-time portrait of the evolving environmental risk of Lyme disease in each province.

Methods

A multicriteria decision analysis (MCDA) approach was used in the selection of sentinel regions. Within each sentinel region, a systematic drag sampling protocol was performed in selected sampling sites. Ticks collected during these active surveillance visits were identified to species, and Ixodes spp. ticks were tested for infection with Borrelia burgdorferi, Borrelia miyamotoi, Anaplasma phagocytophilum, Babesia microti and Powassan virus.

Results

In 2019, a total of 567 Ixodes spp. ticks (I. scapularis [n=550]; I. pacificus [n=10]; and I. angustus [n=7]) were collected in seven provinces: British Columbia, Manitoba, Ontario, Québec, New Brunswick, Nova Scotia and Prince Edward Island. The highest mean tick densities (nymphs/100 m²) were found in sentinel regions of Lunenburg (0.45), Montréal (0.43) and Granby (0.38). Overall, the Borrelia burgdorferi prevalence in ticks was 25.2% (0%-45.0%). One I. angustus nymph from British Columbia was positive for Babesia microti, a first for the province. The deer tick lineage of Powassan virus was detected in one adult I. scapularis in Nova Scotia.

Conclusion

CaLSeN provides the first coordinated national active surveillance initiative for tick-borne disease in Canada. Through multidisciplinary collaborations between experts in each province, the pilot year was successful in establishing a baseline for Lyme disease risk across the country, allowing future trends to be detected and studied.

Potential Criteria for Frameworks to Support the Evaluation of Innovative Medicines in Upper Middle-Income Countries-A Systematic Literature Review on Value Frameworks and Multi-Criteria Decision Analyses

Background

Multicriteria Decision Analysis (MCDA), a formal decision support framework, has been growing in popularity recently in the field of health care. MCDA can support pricing and reimbursement decisions on the macro level, which is of great importance especially in countries with more limited resources.

Objectives

The aim of this systematic review was to facilitate the development of future MCDA frameworks, by proposing a set of criteria focusing on the purchasing decisions of single-source innovative pharmaceuticals in upper middle-income countries.

Methods

A systematic literature review was conducted on the decision criteria included in value frameworks (VFs) or MCDA tools. Scopus, Medline, databases of universities, websites of Health Technology Assessment Agencies, and other relevant organizations were included in the search. Double title-abstract screening and double full-text review were conducted, and all extracted data were double-checked. A team of researchers performed the merging and selection process of the extracted criteria.

Results

A total of 1,878 articles entered the title and abstract screening. From these, 341 were eligible to the full-text review, and 36 were included in the final data extraction phase. From these articles 394 criteria were extracted in total. After deduplication and clustering, 26 different criteria were identified. After the merging and selection process, a set of 16 general criteria was proposed.

Conclusion

Based on the results of the systematic literature review, a pool of 16 criteria was selected. This can serve as a starting point for constructing MCDA frameworks in upper middle-income countries after careful adaptation to the local context.

'It takes two to tango': Bridging the gap between country need and vaccine product innovation

Background

Despite a growing global commitment to universal health coverage, considerable vaccine coverage and uptake gaps persist in resource-constrained settings. One way of addressing the gaps is by ensuring product innovation is relevant and responsive to the needs of these contexts. Total Systems Effectiveness (TSE) framework has been developed to characterize preferred vaccine attributes from the perspective of country decision-makers to inform research and development (R&D) of products. A proof of concept pilot study took place in Thailand in 2018 to examine the feasibility and usefulness of the TSE approach using a rotavirus hypothetical test-case.

Methods

The excel-based model used multiple-criteria decision analysis (MCDA) to compare and evaluate five hypothetical rotavirus vaccine products. The model was populated with local data and products were ranked against decision criteria identified by Thai stakeholders. A one-way sensitivity analysis was performed to identify criteria that influenced vaccine ranking. Self-assessment forms were distributed to R&D stakeholders on the usability of the approach and were subsequently analysed.

Results

The model identified significant parameters that impacted on MCDA rankings. Self-assessment forms revealed that TSE was perceived as being able to encourage closer collaboration between country decision makers and vaccine developers.

Conclusions

The pilot study demonstrates that it is feasible to use an MCDA approach to elicit stakeholder preferences and determine influential parameters to help identify the preferred product characteristics for R&D from the perspective of country decision-makers. It found that TSE can help steer manufacturers to develop products that are better aligned with country need. Findings will guide further development of the TSE concept.

Safety and Efficacy of Oral Anticoagulants Therapies in Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention: A Network Meta-Analysis

Background:

Different antithrombotic treatments, from vitamin K antagonists to direct oral anticoagulants (DOACs), are available to reduce ischemic risks in patients with atrial fibrillation (AF) after percutaneous coronary intervention (PCI). Objective: To synthetize evidence about the benefit–risk ratio of antithrombotic treatments and their combinations in patients with AF and PCI.

Methods:

A network meta-analysis and a stochastic multicriteria acceptability analysis (SMAA) were performed including randomized controlled trials (RCT) that evaluate antithrombotic treatments in adults with AF and PCI. Searches were conducted in PubMed and Scopus (updated November-2019). Outcomes compared included bleeding, stroke, and death (Prospero registration: CRD42019146813).

Results:

Five RCTs were included (11 532 patients). Vitamin K antagonists + dual antiplatelet therapy was associated with major bleeding (odds ratio: 0.52 [95% CI: 0.32-0.86]) compared to DOAC + P2Y12. No statistical differences were found among DOAC regimens for the main outcomes, including bleeding, stroke, and death. Surface under the cumulative ranking curve analysis (SUCRA) and SMAA demonstrated edoxaban 60 mg + P2Y12 inhibitor as the worst option (28%). Apixaban 5 mg + P2Y12 inhibitor was the safest alternative (63%) in all scenarios.

Conclusions:

Insufficient evidence on the clinical superiority among anticoagulant regimens exists, although apixaban slightly stands out. Edoxaban was associated with more adverse events. To strength this evidence, well-designed, low risk of bias clinical trials are needed. Cost-minimization analyses are required to provide further information for clinical decision-making.

The need to prioritize "prioritization" in clinical pharmacy service practice and implementation

Pharmacists are increasingly asked to incorporate new and greater amounts of clinical services into their traditional medication distribution responsibilities, but many barriers exist. Given the demanding pharmacy practice environment, improved time management may improve implementation rates. One area not previously explored within this area is the clinical skill of "prioritization" of medication related problems (MRPs). Prioritization is vital as the workload demand for pharmacist time exceeds time available; however, the underdeveloped skills of prioritizing is a concern in the field of pharmacy practice, as it also is across professions in healthcare. Previous research has suggested that pharmacists and student pharmacists inexperienced in implementing clinical services struggle knowing where to begin when providing direct patient care, given the complex patient care regimens, a complex pharmacy practice workload, and the numerous preventative care interventions possible for a given patient. This paper provides a review of theory and science of prioritization in patient care service delivery, including Multicriteria Decision Analysis (MCDA), Lean Six Sigma (LSS), and Jaen's Competing Demands framework. A case study is shared which emphasizes both the need for and potential impact of a renewed focus on workload management skills, such as prioritization.

Multi-criteria analysis in the health area: selection of the most appropriate triage system for the emergency care units in natal

Background

Multiobjective decision-making processes present a high degree of complexity in their solution, and tools such as multicriteria decision analysis appear as a way to facilitate the decision-makers’ solution and ensure that the decision is made cohesively and efficiently. In the public health sector, decisions are even more delicate because they work not only with the direct influence of human needs, but also with limited financial resources. An important point for the emergency care units is the triage system, which consists of a pre-evaluation of the patients, classifying them according to the degree of life risk. Through triage, the patient can be attended more quickly and efficiently, streamlining the whole process. Thus, the present research endeavored to determine the most appropriate triage protocol for emergency healthcare units in Natal-RN city in Brazil and may help others less advanced countries to determine the most appropriate triage protocol for emergency healthcare.

Methods

In this study, we used the multicriteria analysis method known as FITradeoff. In addition, interviews and structured questionnaires applied with nurses, specialists and directors.

Results

Based on the questionnaires and preferences presented by the decision-makers, the Spanish Triage System was the most suitable protocol for the emergency care units, which presented with high ease of use and implementation.

Conclusions

This study reached its main objective, which was to determine the most appropriate triage protocol. In addition, it was observed the possibility of new research, such as the development of a specific protocol for this emergency care units and the creation of an application software for this new protocol.

Tendering and biosimilars: what role for value-added services?

Background: Access to biologic medicines (including biosimilars) across Europe is largely governed by a process of tendering conducted by health authorities. Over-reliance on treatment costs in awarding tenders has the potential to hinder competition and undermine the long-term sustainability of biosimilars. Objective: To assess the extent and impact of consideration of 'value-added services' (VAS) in tendering for biosimilars, we conducted a narrative review of published literature. Results: Findings from survey-based publications indicated that tendering practices for biosimilars are widely used, with cost being the main determinant of success and little detail being available on other criteria where these apply. Criteria (of therapeutic and technical interest) beyond price were included in one tendering specification for infliximab (originator and biosimilars), while a separate tender for the same product included VAS in the form of therapeutic drug monitoring, measurement of antibodies and calprotectin. Conclusions: Published evidence concerning inclusion of VAS in tendering for biosimilars is lacking. Development and implementation of standardized criteria and methods of assessment for tenders may avoid manufacturers facing segmented markets, encourage competition and the longer-term sustainability of biosimilars, and realize the healthcare system and patient benefits these treatments can bring.