Group decision making with the analytic hierarchy process in benefit-risk assessment: a tutorial

Willingness to participate in combination screening for lung cancer, chronic obstructive pulmonary disease and cardiovascular disease in four European countries

OBJECTIVES

Lung cancer screening (LCS), using low-dose computed tomography (LDCT), can be more efficient by simultaneously screening for chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD), the Big-3 diseases. This study aimed to determine the willingness to participate in (combinations of) Big-3 screening in four European countries and the relative importance of amendable participation barriers.

METHODS

An online cross-sectional survey aimed at (former) smokers aged 50-75 years elicited the willingness of individuals to participate in Big-3 screening and used analytical hierarchy processing (AHP) to determine the importance of participation barriers.

RESULTS

Respondents were from France (n = 391), Germany (n = 338), Italy (n = 399), and the Netherlands (n = 342), and consisted of 51.2% men. The willingness to participate in screening was marginally influenced by the diseases screened for (maximum difference of 3.1%, for Big-3 screening (73.4%) vs. lung cancer and COPD screening (70.3%)) and by country (maximum difference of 3.7%, between France (68.5%) and the Netherlands (72.3%)). The largest effect on willingness to participate was personal perceived risk of lung cancer. The most important barriers were the missed cases during screening (weight 0.19) and frequency of screening (weight 0.14), while diseases screened for (weight 0.11) ranked low.

CONCLUSIONS

The difference in willingness to participate in LCS showed marginal increase with inclusion of more diseases and limited variation between countries. A marginal increase in participation might result in a marginal additional benefit of Big-3 screening. The amendable participation barriers are similar to previous studies, and the new criterion, diseases screened for, is relatively unimportant.

CLINICAL RELEVANCE STATEMENT

Adding diseases to combination screening modestly improves participation, driven by personal perceived risk. These findings guide program design and campaigns for lung cancer and Big-3 screening. Benefits of Big-3 screening lie in long-term health and economic impact, not participation increase.

KEY POINTS

• It is unknown whether or how combination screening might affect participation. • The addition of chronic obstructive pulmonary disease and cardiovascular disease to lung cancer screening resulted in a marginal increase in willingness to participate. • The primary determinant influencing individuals' engagement in such programs is their personal perceived risk of the disease.

Developing and validating a multi-criteria decision analytic tool to assess the value of cancer clinical trials: evaluating cancer clinical trial value

BACKGROUND

Demonstrating safety and efficacy of new medical treatments requires clinical trials but clinical trials are costly and may not provide value proportionate to their costs. As most health systems have limited resources, it is therefore important to identify the trials with the highest value. Tools exist to assess elements of a clinical trial such as statistical validity but are not wholistic in their valuation of a clinical trial. This study aims to develop a measure of clinical trials value and provide an online tool for clinical trial prioritisation.

METHODS

A search of the academic and grey literature and stakeholder consultation was undertaken to identify a set of criteria to aid clinical trial valuation using multi-criteria decision analysis. Swing weighting and ranking exercises were used to calculate appropriate weights of each of the included criteria and to estimate the partial-value function for each underlying metric. The set of criteria and their respective weights were applied to the results of six different clinical trials to calculate their value.

RESULTS

Seven criteria were identified: 'unmet need', 'size of target population', 'eligible participants can access the trial', 'patient outcomes', 'total trial cost', 'academic impact' and 'use of trial results'. The survey had 80 complete sets of responses (51% response rate). A trial designed to address an 'Unmet Need' was most commonly ranked as the most important with a weight of 24.4%, followed by trials demonstrating improved 'Patient Outcomes' with a weight of 21.2%. The value calculated for each trial allowed for their clear delineation and thus a final value ranking for each of the six trials.

CONCLUSION

We confirmed that the use of the decision tool for valuing clinical trials is feasible and that the results are face valid based on the evaluation of six trials. A proof-of-concept applying this tool to a larger set of trials with an external validation is currently underway.

Do They Align? Congruence Between Patient Preferences of People Living with Cognitive Impairments and Physicians' Judgements for Person-Centered Care: An Analytic Hierarchy Process Study

BACKGROUND

Person-centered care (PCC) requires knowledge about patient preferences. Among people living with cognitive impairments (PlwCI), evidence on quantitative, choice-based preferences, which allow to quantify, weigh, and rank care elements, is limited. Furthermore, data on the congruence of patient preferences with physicians' judgements for PCC are missing. Such information is expected to support the implementation of PCC; state-of-the-art medical care aligned with patients' preferences.

OBJECTIVE

To elicit patient preferences and physicians' judgements for PCC and their congruence.

METHODS

Data from the mixed-methods PreDemCare study, including a cross-sectional, paper-and-pencil, interviewer-assisted analytic hierarchy process (AHP) survey conducted with n = 50 community-dwelling PlwCI and n = 25 physicians. Individual AHP weights (preferences/judgements) were calculated with the principal eigenvector method and aggregated per group by aggregation of individual priorities mode. Individual consistency ratios (CRs) were calculated and aggregated per group. Group differences in preferences/judgements were investigated descriptively by means and standard deviations (SDs) of AHP weights, resulting ranks, and boxplots. Additionally, differences between groups were investigated with independent paired t-test/Mann Whitney U-test. Sensitivity of AHP results was tested by inclusion/exclusion of inconsistent respondents, with an accepted threshold at CR≤0.3 for patients, and CR≤0.2 for physicians, due to better cognitive fitness of the latter group.

RESULTS

Patient preferences and physicians' judgements did not differ significantly, except for the criterion Memory Exercises (AHP weights (mean (SD)): 0.135 (0.066) versus 0.099 (0.068), p = 0.01). We did not see rank-reversals of criteria after exclusion of inconsistent participants. Mean CR for patients at the criteria level was 0.261, and 0.181 for physicians.

CONCLUSION

Physicians' judgements in our setting aligned well with patients' preferences. Our findings may be used to guide the implementation of preference-based PCC.

How to Enhance Citizens' Sense of Gain in Smart Cities? A SWOT-AHP-TOWS Approach

The previous technology-centric development of smart cities mainly focuses on the numbers, diversities, and types of applied intelligent technologies, while the citizen-centric smart city has become an important paradigm for improving the sustainability of cities around the world. The citizens' sense of gain (CSG), which considers both material acquisition and spiritual feelings of smart city services, is thus proposed and regarded as one of the core orientations in the smart cities' transformation development process from the centric of advanced technology applied to the centric of citizen subjective perception. To shift smart cities from being technology-centric to citizen-centric, it is critical to identify the factors influencing CSG and develop appropriate strategies to enhance CSG in smart cities. Hence, this work identifies 17 key CSG influencing factors based on the dimensions dissected from the definition of CSG and it further formulates 15 strategies for enhancing CSG by adopting the SWOT-AHP-TOWS method based on data collected from Nanjing citizens. The results indicate that the most important criteria for enhancing CSG in smart cities are the external opportunities, which are originated from citizens' attitudes and behaviors, and the top-ranked strategy is "dividing smart infrastructure into different categories according to the hierarchy needs of citizens and promoting the synergy development of smart infrastructure within and among different categories". Finally, four implications are proposed, including (i) strengthening publicity and encouraging citizen participation, (ii) clarifying the responsibilities of local governments, (iii) prioritizing citizens' needs, and (iv) promoting age-friendly, vulnerable-friendly, and environmental-friendly development.

Construction and case study of a novel lung cancer risk index

PURPOSE

This study constructs a lung cancer risk index (LCRI) that incorporates many modifiable risk factors using an easily reproducible and adaptable method that relies on publicly available data.

METHODS

We used meta-analysis followed by Analytic Hierarchy Process (AHP) to generate a lung cancer risk index (LCRI) that incorporates seven modifiable risk factors (active smoking, indoor air pollution, occupational exposure, alcohol consumption, secondhand smoke exposure, outdoor air pollution, and radon exposure) for lung cancer. Using county-level population data, we then performed a case study in which we tailored the LCRI for use in the state of Illinois (LCRI_IL).

RESULTS

For both the LCRI and the LCRI_IL, active smoking had the highest weights (46.1% and 70%, respectively), whereas radon had the lowest weights (3.0% and 5.7%, respectively). The weights for alcohol consumption were 7.8% and 14.7% for the LCRI and the LCRI_IL, respectively, and were 3.8% and 0.95% for outdoor air pollution. Three variables were only included in the LCRI: indoor air pollution (18.5%), occupational exposure (13.2%), and secondhand smoke exposure (7.6%). The Consistency Ratio (CR) was well below the 0.1 cut point. The LCRI_IL was moderate though significantly correlated with age-adjusted lung cancer incidence (r = 0.449, P < 0.05) and mortality rates (r = 0.495, P < 0.05).

CONCLUSION

This study presents an index that incorporates multiple modifiable risk factors for lung cancer into one composite score. Since the LCRI allows data comprising the composite score to vary based on the location of interest, this measurement tool can be used for any geographic location where population-based data for individual risk factors exist. Researchers, policymakers, and public health professionals may utilize this framework to determine areas that are most in need of lung cancer-related interventions and resources.

Development of a Quantitative Preference Instrument for Person-Centered Dementia Care—Stage 2: Insights from a Formative Qualitative Study to Design and Pretest a Dementia-Friendly Analytic Hierarchy Process Survey

Person-centered care (PCC) requires knowledge about patient preferences. An analytic hierarchy process (AHP) is one approach to quantify, weigh and rank patient preferences suitable for People living with Dementia (PlwD), due to simple pairwise comparisons of individual criteria from a complex decision problem. The objective of the present study was to design and pretest a dementia-friendly AHP survey. Methods: Two expert panels consisting of n = 4 Dementia Care Managers and n = 4 physicians to ensure content-validity, and “thinking-aloud” interviews with n = 11 PlwD and n = 3 family caregivers to ensure the face validity of the AHP survey. Following a semi-structured interview guide, PlwD were asked to assess appropriateness and comprehensibility. Data, field notes and partial interview transcripts were analyzed with a constant comparative approach, and feedback was incorporated continuously until PlwD had no further comments or struggles with survey completion. Consistency ratios (CRs) were calculated with Microsoft® Excel and ExpertChoice Comparion®. Results: Three main categories with sub-categories emerged: (1) Content: clear task introduction, (sub)criteria description, criteria homogeneity, (sub)criteria appropriateness, retest questions and sociodemography for heterogeneity; (2) Format: survey structure, pairwise comparison sequence, survey length, graphical design (incl. AHP scale), survey procedure explanation, survey assistance and response perspective; and (3) Layout: easy wording, short sentences and visual aids. Individual CRs ranged from 0.08 to 0.859, and the consolidated CR was 0.37 (0.038). Conclusions: Our formative qualitative study provides initial data for the design of a dementia-friendly AHP survey. Consideration of our findings may contribute to face and content validity in future quantitative preference research in dementia.

Examining the barriers to operationalization of humanitarian supply chains: lessons learned from COVID-19 crisis

Humanitarian supply chains (HSC) have vital significance in mitigating different disruptive supply chain risks caused due to natural or man-made activities such as tsunami, earthquakes, flooding, warfare, or the recent COVID-19 pandemic. Each kind of disaster poses a unique set of challenges to the operationalization of HSC. This study attempts to determine the critical barriers to the operationalization of HSC in India during the COVID-19 pandemic. Initially, we determined and validated 10 critical barriers to HSC operationalization through a Delphi method. Further, we analyzed the barriers by computing the driving and dependence power of each barrier to determine the most critical ones. To do so, we coined a distinct form of interpretive structural modeling (ISM) by amalgamating it with the neutrosophic approach, i.e. Neutrosophic ISM. The findings indicate, "lack of Government subsidies and support, lack of skilled and experienced rescuers, and lack of technology usage" are the most critical barriers that influence the streamline operations of HSC during the COVID-19 outbreak, unlike other disruptions. This is the first-of-its-kind research work that has identified and analyzed the critical barriers to HSC operationalization during COVID-19 in the Indian context. The results and recommendations of the study can aid policymakers and HSC professionals in formulating suitable strategies for successful HSC operations.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10479-022-04752-x.

A multi-product and multi-period aggregate production plan: a case of automobile component manufacturing firm

Purpose

The study attempts to develop a multi-product multi-period (MPMP) aggregate production plan (APP) to fulfill the customers' demand in terms of throughput and lead time for achieving market competence.

Design/methodology/approach

This research proposes an integrated Fuzzy analytical hierarchy process (FAHP), multi-objective linear programming (MOLP), and simulation approach. Initially, FAHP is used to select the essential objectives a firm desires to achieve. Adopting the MOLP, an APP is formulated for the firm under study. Later, the simulation model of a firm is created in a discrete-event simulation (DES) software Arena© to evaluate the applicability of the proposed APP. A comparative analysis of the manufacturing performance levels (namely throughput, lead time, and resource utilization) achieved through the implication of an existing production plan and proposed APP is conducted further.

Findings

The findings from the study depict that the proposed MOLP-based APP can satisfy the customers' requirement (namely throughput and lead time) and improve the level of resource utilization compared with the firm's existing production plan.

Research limitations/implications

The proposed research facilitates researchers and practitioners to understand the process of developing MOLP-based MPMP APP and analyzing its applicability through simulation technique to be utilized for developing APP at their firm.

Originality/value

An integrated FAHP-MOLP-simulation framework is the novel contribution to the literature on production planning. It can be extended to solve strategic, tactical, and operational problems in different domains like service, healthcare, supply chain, logistics, and project management.

A survey of group decision making methods in Healthcare Industry 4.0: bibliometrics, applications, and directions

Healthcare Industry 4.0 refers to intelligent operation processes in the medical industry. With the development of information technology, large-scale group decision making (GDM), which allows a larger number of decision makers (DMs) from different places or sectors to participate in decision making, has been rapidly developed and applied in Healthcare Industry 4.0 to help to make decisions efficiently and smartly. To make full use of GDM methods to promote the developments of the medical industry, it is necessary to review the existing relevant achievements. Therefore, this paper conducts an overview to generate a comprehensive understanding of GDM in Healthcare Industry 4.0 and to identify future development directions. Bibliometric analyses are conducted in order to learn the development trends from published papers. The implementations of GDM methods in Healthcare Industry 4.0 are reviewed in accordance with the paradigm of the general GDM process, which includes information representation, dimension reduction, consensus reaching, and result elicitation. We also provide current research challenges and future directions regarding medical GDM. It is hoped that our study will be helpful for researchers in the field of GDM in Healthcare Industry 4.0.

Factors influence the housing price in Kuala Lumpur by using AHP

The housing affordability issue was bothered the B40 and M40 buyers where the income level of the buyers cannot afford the higher housing price in Kuala Lumpur. To understand the factors that contribute to the housing price can improve the planning for the buyers. The planning for purchasing the residential property should be construct by the buyers to analyze the financial ability. Analytical Hierarchical Process can show the hierarchical diagram for the factors interested which have the higher priority is define as the important factor towards the housing price.

Expert-based approach to rank critical asset assessment factors for healthcare facilities

Purpose

This research’s main objective is to develop an expert-based approach to rank critical asset assessment factors for health-care facilities. This approach will improve the asset management of health-care buildings. This paper aims to study and prioritize the relative importance of asset criticality factors.

Design/methodology/approach

The research methodology begins with a comprehensive literature review of state-of-the-art health-care facilities management, asset management tools, critical asset assessment and approaches to model techniques. Then, using the expert-based opinion and the collected data through the analytical hierarchy process approach to developing the asset assessment model contains physical, environmental, general safety and revenue loss assessment models.

Findings

Results showed that the general safety factors and the sub-factors of life safety and physical safety contributed to asset condition assessment.

Practical implications

The proposed critical asset assessment ranking will benefit health-care facility organizations by assessing their asset performance according to capital renewal needs.

Originality/value

This study offers a novel conceptual framework to understand and determine rank critical asset assessment factors for health-care facilities.

Appraising patient preference methods for decision-making in the medical product lifecycle: an empirical comparison

Background

Incorporating patient preference (PP) information into decision-making has become increasingly important to many stakeholders. However, there is little guidance on which patient preference assessment methods, including preference exploration (qualitative) and elicitation (quantitative) methods, are most suitable for decision-making at different stages in the medical product lifecycle (MPLC). This study aimed to use an empirical approach to assess which attributes of PP assessment methods are most important, and to identify which methods are most suitable, for decision-makers’ needs during different stages in the MPLC.

Methods

A four-step cumulative approach was taken: 1) Identify important criteria to appraise methods through a Q-methodology exercise, 2) Determine numerical weights to ascertain the relative importance of each criterion through an analytical hierarchy process, 3) Assess the performance of 33 PP methods by applying these weights, consulting international health preference research experts and review of literature, and 4) Compare and rank the methods within taxonomy groups reflecting their similar techniques to identify the most promising methods.

Results

The Q-methodology exercise was completed by 54 stakeholders with PP study experience, and the analytical hierarchy process was completed by 85 stakeholders with PP study experience. Additionally, 17 health preference research experts were consulted to assess the performance of the PP methods. Thirteen promising preference exploration and elicitation methods were identified as likely to meet decision-makers’ needs. Additionally, eight other methods that decision-makers might consider were identified, although they appeared appropriate only for some stages of the MPLC.

Conclusions

This transparent, weighted approach to the comparison of methods supports decision-makers and researchers in selecting PP methods most appropriate for a given application.

Influencing Factors and Mechanism of Urban Community Tourism Development: A Case Study of Beijing

Urban community tourism (UCT) is a tourism product that promotes the sustainable development of urban communities. This paper constructs an index system of the influencing factors of UCT development (UCTD), which includes five secondary and 15 tertiary indicators. The weights of the indicators are calculated through expert consultation and questionnaire surveys. Based on the index system, this paper empirically evaluates five typical urban tourism communities in Beijing (i.e., Nanluoguxiang, Shichahai, Dashilan, 798 Art District, and Sanlitun) using expert scoring and online comments. We further analyze the impact mechanism of UCTD qualitatively. The findings show that among the secondary indicators, cultural atmosphere and built environment have higher weights than location conditions, specialty shops, and community participation. Among all the tertiary indicators, eight of them (i.e., cultural themes, ornamental value, frequency of cultural activities, store longevity and popularity, cultural institutions, abundance of distinctive buildings, scenic integrity, and community managers’ willingness to support UCTD) account for 80% of the total weight. In terms of the impact mechanism, 15 factors further affect UCTD through demand for authentic travel experiences, reachability perception, travel shopping demand, and stakeholder coordination.

A multi-criteria methodology for evaluating alternative ultrasound devices

Several surveys and clinical studies report high prevalence of work-related musculoskeletal disorders (WMSDs) among sonographers and sonologists. Better performing ultrasound devices can increase the number and quality of examinations, but also reduce the user comfort and increase the risk of WMSDs. This should lead the choice of the device to buy and use. To support hospitals or diagnostic centres in selecting the best ultrasound device, this study provides a structured methodology based on a multi-criteria approach, the Analytic Hierarchy Process. It has a Goal (to optimise workers' well-being and satisfy company production objectives) and 45 evaluation elements. It was applied in an Italian hospital comparing 3 alternatives: wireless, portable, and cart-based. The latter proved to be the best in satisfying the Goal, whereas a previous study obtained that the wireless device was preferable considering only the ergonomic point of view. The case study validated the applicability of the methodology. Practitioner summary: This paper provides the decision-makers of hospitals or diagnostic centres with a multi-criteria methodology to select the best ultrasound device capable of optimising workers' well-being and satisfying company production objectives. The methodology can also support manufacturers of ultrasound devices in improving their products. Abbreviations: AHP: analytic hierarchy process; AIUM: American Institute of Ultrasound in Medicine; BSI: British Standards Institution; CEN: European Committee for Standardisation; EU-OSHA: EU Agency for Occupational Safety and Health; ISO: International Organisation for Standardisation; MCMD: multiple criteria decision-making; NIOSH: US National Institute for Occupational Safety and Health; SDMS: society of diagnostic medical sonography; WHO: World Health OrganizationWMSD: work-related musculoskeletal disorder.

Assessing the Importance of Treatment Goals in Patients with Psoriasis: Analytic Hierarchy Process vs. Likert Scales

BACKGROUND

To define treatment benefit, the Patient Benefit Index contains a weighting of patient-relevant treatment goals using the Patient Needs Questionnaire, which includes a 5-point Likert scale ranging from 0 ("not important at all") to 4 ("very important"). These treatment goals have been assigned to five health dimensions. The importance of each dimension can be derived by averaging the importance ratings on the Likert scales of associated treatment goals.

OBJECTIVE

As the use of a Likert scale does not allow for a relative assessment of importance, the objective of this study was to estimate relative importance weights for health dimensions and associated treatment goals in patients with psoriasis by using the analytic hierarchy process and to compare these weights with the weights resulting from the Patient Needs Questionnaire. Furthermore, patients' judgments on the difficulty of the methods were investigated.

METHODS

Dimensions of the Patient Benefit Index and their treatment goals were mapped into a hierarchy of criteria and sub-criteria to develop the analytic hierarchy process questionnaire. Adult patients with psoriasis starting a new anti-psoriatic therapy in the outpatient clinic of the Institute for Health Services Research in Dermatology and Nursing at the University Medical Center Hamburg (Germany) were recruited and completed both methods (analytic hierarchy process, Patient Needs Questionnaire). Ratings of treatment goals on the Likert scales (Patient Needs Questionnaire) were summarized within each dimension to assess the importance of the respective health dimension/criterion. Following the analytic hierarchy process approach, consistency in judgments was assessed using a standardized measurement (consistency ratio).

RESULTS

At the analytic hierarchy process level of criteria, 78 of 140 patients achieved the accepted consistency. Using the analytic hierarchy process, the dimension "improvement of physical functioning" was most important, followed by "improvement of social functioning". Concerning the Patient Needs Questionnaire results, these dimensions were ranked in second and fifth position, whereas "strengthening of confidence in the therapy and in a possible healing" was ranked most important, which was least important in the analytic hierarchy process ranking. In both methods, "improvement of psychological well-being" and "reduction of impairments due to therapy" were equally ranked in positions three and four. In contrast to this, on the level of sub-criteria, predominantly a similar ranking of treatment goals could be observed between the analytic hierarchy process and the Patient Needs Questionnaire. From the patients' point of view, the Likert scales (Patient Needs Questionnaire) were easier to complete than the analytic hierarchy process pairwise comparisons.

CONCLUSIONS

Patients with psoriasis assign different importance to health dimensions and associated treatment goals. In choosing a method to assess the importance of health dimensions and/or treatment goals, it needs to be considered that resulting importance weights may differ in dependence on the used method. However, in this study, observed discrepancies in importance weights of the health dimensions were most likely caused by the different methodological approaches focusing on treatment goals to assess the importance of health dimensions on the one hand (Patient Needs Questionnaire) or directly assessing health dimensions on the other hand (analytic hierarchy process).

Understanding the adoption and use of point-of-care tests in Dutch general practices using multi-criteria decision analysis

BACKGROUND

The increasing number of available point-of-care (POC) tests challenges clinicians regarding decisions on which tests to use, how to efficiently use them, and how to interpret the results. Although POC tests may offer benefits in terms of low turn-around-time, improved patient's satisfaction, and health outcomes, only few are actually used in clinical practice. Therefore, this study aims to identify which criteria are, in general, important in the decision to implement a POC test, and to determine their weight. Two POC tests available for use in Dutch general practices (i.e. the C-reactive protein (CRP) test and the glycated haemoglobin (HbA_1c) test) serve as case studies. The information obtained from this study can be used to guide POC test development and their introduction in clinical practice.

METHODS

Relevant criteria were identified based on a literature review and semi-structured interviews with twelve experts in the field. Subsequently, the criteria were clustered in four groups (i.e. user, organization, clinical value, and socio-political context) and the relative importance of each criterion was determined by calculating geometric means as implemented in the Analytic Hierarchy Process. Of these twelve experts, ten participated in a facilitated group session, in which their priorities regarding both POC tests (compared to central laboratory testing) were elicited.

RESULTS

Of 20 criteria in four clusters, the test's clinical utility, its technical performance, and risks (associated with the treatment decision based on the test result) were considered most important for using a POC test, with relative weights of 22.2, 12.6 and 8.5%, respectively. Overall, the experts preferred the POC CRP test over its laboratory equivalent, whereas they did not prefer the POC HbA_1c test. This difference was mainly explained by their strong preference for the POC CRP test with regard to the subcriterion 'clinical utility'.

CONCLUSIONS

The list of identified criteria, and the insights in their relative impact on successful implementation of POC tests, may facilitate implementation and use of existing POC tests in clinical practice. In addition, having experts score new POC tests on these criteria, provides developers with specific recommendations on how to increase the probability of successful implementation and use.

Patients' Priorities for Oral Anticoagulation Therapy in Non-valvular Atrial Fibrillation: a Multi-criteria Decision Analysis

Introduction

Effectiveness of oral anticoagulants (OACs) is critically dependent on patients’ adherence to intake regimens. We studied the relative impact of attributes related to effectiveness, safety, convenience, and costs on the value of OAC therapy from the perspective of patients with non-valvular atrial fibrillation.

Methods

Four attributes were identified by literature review and expert interviews: effectiveness (risk of ischemic stroke), safety (risk of major bleeding, minor bleeding, gastrointestinal complaints), convenience (intake frequency, diet restrictions, international normalized ratio [INR] blood monitoring, pill type/intake instructions), and out-of-pocket costs. Focus groups were held in Spain, Germany, France, Italy and the United Kingdom (N = 48) to elicit patients’ preferences through the use of the analytical hierarchy process method.

Results

Effectiveness (60%) and side effects (27%) have a higher impact on the perceived value of OACs than drug convenience (7%) and out-of-pocket costs (6%). As for convenience, eliminating monthly INR monitoring was given the highest priority (40%), followed by reducing diet restrictions (27%), reducing intake frequency (17%) and improving the pill type/intake instructions (15%). The most important side effect was major bleeding (75%), followed by minor bleeding (15%) and gastrointestinal complaints (10%). Furthermore, 71% of patients preferred once-daily intake to twice-daily intake.

Discussion

Although the relative impact of convenience on therapy value is small, patients have different preferences for options within convenience criteria. Besides considerations on safety and effectiveness, physicians should also discuss attributes of convenience with patients, as it can be assumed that alignment to patient preferences in drug prescription and better patient education could result in higher adherence.

Electronic supplementary material

The online version of this article (10.1007/s40256-018-0293-0) contains supplementary material, which is available to authorized users.

A Holistic Sustainability Framework for Waste Management in European Cities: Concept Development

Waste management represents a challenge for public authorities due to many reasons such as increased waste generation following urban population growth, economic burdens imposed on the municipal budget, and nuisances inevitably caused to the environment and local inhabitants. To optimize the system from a sustainability perspective, moving the transition towards a more circular economy, a better understanding of the different stages of waste management is necessary. A review of recently developed sustainability frameworks for waste management showed that no single framework captures all the instruments needed to ultimately provide a solid basis for comprehensive analyses of the potential burdens associated with urban waste management. Bearing this limitation in mind, the objective of this research is to propose a conceptual and comprehensive sustainability framework to support decision-making in waste management of European cities. The framework comprises a combination of methods capable of identifying future strategies and scenarios, to assess different types of impacts based on a life cycle perspective, and considers the value of waste streams, the actors involved, and possible constraints of implementing scenarios. The social, economic, environmental, technical and political domains are covered, and special attention is paid to impacts affecting foremost the local population.

How to weight patient-relevant treatment goals for assessing treatment benefit in psoriasis: preference elicitation methods vs. rating scales

In psoriasis, several patient-relevant treatment goals must be met to be able to consider a treatment beneficial. To assess treatment benefit, the validated questionnaire Patient Benefit Index (PBI) can be used. Its global score summarizes the degree of patient-relevant treatment goals achieved after treatment, weighted by their individual importance on rating scales. These treatment goals have empirically been assigned to five dimensions. While the weighting procedure of the PBI provides information about the importance patients attach to treatment goals on a rating scale from 0 to 4, methods of preference elicitation provide information on how patients would trade off certain treatment goals against each other. However, since the treatment goals defined in the PBI often overlap conceptually, the dimensions of the PBI might be more suitable for exploration in preference elicitation methods. We used an analytic hierarchy process (AHP) and a discrete choice experiment (DCE) to generate preference-based importance weights for the PBI dimensions, and compared these weights to those derived from the rating scales. We were further interested in the effect of importance weights on the calculation of the PBI score. A total of 120 patients with psoriasis completed a questionnaire at baseline, including AHP, DCE and the rating scales, and at follow-up, regarding the attainment of treatment goals, to calculate the PBI score. In contrast to the results derived from the average rating scores, use of AHP and DCE resulted in both similar importance weights and rankings of dimensions. Presumably, patients rated treatment goals differently than the respective dimension they belong to. However, the differently calculated importance weights led to similar values of the PBI score. Our findings nevertheless provide clear evidence that, regardless of the method used, the importance of treatment goals differs between psoriasis patients, and this should be reflected in treatment decisions.

Comparing Analytic Hierarchy Process and Discrete-Choice Experiment to Elicit Patient Preferences for Treatment Characteristics in Age-Related Macular Degeneration

BACKGROUND

In this study, we conducted an analytic hierarchy process (AHP) and a discrete choice experiment (DCE) to elicit the preferences of patients with age-related macular degeneration using identical attributes and levels.

OBJECTIVES

To compare preference-based weights for age-related macular degeneration treatment attributes and levels generated by two elicitation methods. The properties of both methods were assessed, including ease of instrument use.

METHODS

A DCE and an AHP experiment were designed on the basis of five attributes. Preference-based weights were generated using the matrix multiplication method for attributes and levels in AHP and a mixed multinomial logit model for levels in the DCE. Attribute importance was further compared using coefficient (DCE) and weight (AHP) level ranges. The questionnaire difficulty was rated on a qualitative scale. Patients were asked to think aloud while providing their judgments.

RESULTS

AHP and DCE generated similar results regarding levels, stressing a preference for visual improvement, frequent monitoring, on-demand and less frequent injection schemes, approved drugs, and mild side effects. Attribute weights derived on the basis of level ranges led to a ranking that was opposite to the AHP directly calculated attribute weights. For example, visual function ranked first in the AHP and last on the basis of level ranges.

CONCLUSIONS

The results across the methods were similar, with one exception: the directly measured AHP attribute weights were different from the level-based interpretation of attribute importance in both DCE and AHP. The dependence/independence of attribute importance on level ranges in DCE and AHP, respectively, should be taken into account when choosing a method to support decision making.

Using the Analytic Hierarchy Process for Prioritizing Imaging Tests in Diagnosis of Suspected Appendicitis

RATIONALE AND OBJECTIVES

In clinical guideline or criteria development processes, such as those used in developing American College of Radiology Appropriateness Criteria (ACR AC), experts subjectively evaluate benefits and risks associated with imaging tests and make complex decisions about imaging recommendations. The analytic hierarchy process (AHP) decomposes complex decisions into structured smaller decisions, incorporates quantitative evidence and qualitative expert opinion, and promotes structured consensus building. AHP may supplement and/or improve the transparency of expert opinion contributions to developing guidelines or criteria.

MATERIALS AND METHODS

To conduct an empirical test using health services research tools, we convened a mock ACR AC panel of emergency department radiology and nonradiology physicians to evaluate by multicriteria decision analysis, the relative appropriateness of imaging tests for diagnosing suspected appendicitis. Panel members selected benefit-risk criteria via an online survey and assessed contrast-enhanced computed tomography, magnetic resonance imaging, and ultrasound using an AHP-based software. Participants were asked whether the process was manageable, transparent, and improved shared understanding. Priority scores were converted to rankings and compared to the rank order of ACR AC ratings.

RESULTS

When compared to magnetic resonance and ultrasound imaging, participants agreed with the ACR AC that contrast-enhanced computed tomography is the most appropriate test. Contrary to the ACR AC ratings, study results suggest that magnetic resonance is preferable to ultrasound. When compared to nonradiologists, radiologists' priority scores reflect a stronger preference for computed tomography.

CONCLUSIONS

Study participants addressed decision-making challenges using a relatively efficient data collection mechanism, suggesting that AHP may benefit the ACR AC guideline development process in identifying the relative appropriateness of imaging tests. With additional development, AHP may improve transparency when expert opinion is used in clinical guideline or appropriateness criteria development.

A proposed approach for quantitative benefit-risk assessment in diagnostic radiology guideline development: the American College of Radiology Appropriateness Criteria Example

The American College of Radiology develops evidence-based practice guidelines to aid appropriate utilization of radiological procedures. Panel members use expert opinion to weight trade-offs and consensus methods to rate appropriateness of imaging tests. These ratings include an equivocal range, assigned when there is disagreement about a technology's appropriateness and the evidence base is weak or for special circumstances. It is not clear how expert consensus merges with the evidence base to arrive at an equivocal rating. Quantitative benefit-risk assessment (QBRA) methods may assist decision makers in this capacity. However, many methods exist and it is not clear which methods are best suited for this application. We perform a critical appraisal of QBRA methods and propose several steps that may aid in making transparent areas of weak evidence and barriers to consensus in guideline development. We identify QBRA methods with potential to facilitate decision making in guideline development and build a decision aid for selecting among these methods. This study identified 2 families of QBRA methods suited to guideline development when expert opinion is expected to contribute substantially to decision making. Key steps to deciding among QBRA methods involve identifying specific benefit-risk criteria and developing a state-of-evidence matrix. For equivocal ratings assigned for reasons other than disagreement or weak evidence base, QBRA may not be needed. In the presence of disagreement but the absence of a weak evidence base, multicriteria decision analysis approaches are recommended; and in the presence of weak evidence base and the absence of disagreement, incremental net health benefit alone or combined with multicriteria decision analysis is recommended. Our critical appraisal further extends investigation of the strengths and limitations of select QBRA methods in facilitating diagnostic radiology clinical guideline development. The process of using the decision aid exposes and makes transparent areas of weak evidence and barriers to consensus.

Use Effectiveness of Medical Devices: A Case Study on the Deployment of Ultrasonographic Devices

BACKGROUND

In the sense of Act No. 123/2000 Coll., as amended (hereinafter referred to as "the Act"), a medical device is understood to be a wide range of resources, especially medical equipment. To implement innovative technologies in practice, it is becoming extremely important to be cost-conscious and effective. The aim of the article is to use an ultrasonographic device case study in a selected hospital to show the possibility of solving the use effectiveness of medical devices.

METHODS

Within the first step, a summary of the use of ultrasonographic devices is developed in terms of performance number and time. Also, a summary of all costs for the last 5 years has been created. The analyzed ultrasonographic device set is evaluated in terms of activity indicators, profitability, and Du Pont decomposition. Revenues from the operation of individual instruments and payroll productivity are taken into account. All of this is evaluated in the context of the requirements of the department and the spectrum of ultrasonographic devices.

RESULTS

The results show that the economic evaluation of device use efficiency, comparing the requirements of the department and spectrum of the devices, suggests a major revision in use of these devices and savings.

CONCLUSION

The new design of the most profitable system differs significantly in the arrangement of individual ultrasonographic devices. The benefit of the study is not just a newly designed organization-specific arrangement, but it can be perceived as a modeling approach that can be used to analyze other sets of medical technology.

Estimating the value of medical treatments to patients using probabilistic multi criteria decision analysis

BACKGROUND

Estimating the value of medical treatments to patients is an essential part of healthcare decision making, but is mostly done implicitly and without consulting patients. Multi criteria decision analysis (MCDA) has been proposed for the valuation task, while stated preference studies are increasingly used to measure patient preferences. In this study we propose a methodology for using stated preferences to weigh clinical evidence in an MCDA model that includes uncertainty in both patient preferences and clinical evidence explicitly.

METHODS

A probabilistic MCDA model with an additive value function was developed and illustrated using a case on hypothetical treatments for depression. The patient-weighted values were approximated with Monte Carlo simulations and compared to expert-weighted results. Decision uncertainty was calculated as the probability of rank reversal for the first rank. Furthermore, scenario analyses were done to assess the relative impact of uncertainty in preferences and clinical evidence, and of assuming uniform preference distributions.

RESULTS

The patient-weighted values for drug A, drug B, drug C, and placebo were 0.51 (95% CI: 0.48 to 0.54), 0.51 (95% CI: 0.48 to 0.54), 0.54 (0.49 to 0.58), and 0.15 (95% CI: 0.13 to 0.17), respectively. Drug C was the most preferred treatment and the rank reversal probability for first rank was 27%. This probability decreased to 18% when uncertainty in performances was not included and increased to 41% when uncertainty in criterion weights was not included. With uniform preference distributions, the first rank reversal probability increased to 61%. The expert-weighted values for drug A, drug B, drug C, and placebo were 0.67 (95% CI: 0.65 to 0.68), 0.57 (95% CI: 0.56 to 0.59), 0.67 (95% CI: 0.61 to 0.71), and 0.19 (95% CI: 0.17 to 0.21). The rank reversal probability for the first rank according to experts was 49%.

CONCLUSIONS

Preferences elicited from patients can be used to weigh clinical evidence in a probabilistic MCDA model. The resulting treatment values can be contrasted to results from experts, and the impact of uncertainty can be quantified using rank probabilities. Future research should focus on integrating the model with regulatory decision frameworks and on including other types of uncertainty.

A review and classification of approaches for dealing with uncertainty in multi-criteria decision analysis for healthcare decisions

Multi-criteria decision analysis (MCDA) is increasingly used to support decisions in healthcare involving multiple and conflicting criteria. Although uncertainty is usually carefully addressed in health economic evaluations, whether and how the different sources of uncertainty are dealt with and with what methods in MCDA is less known. The objective of this study is to review how uncertainty can be explicitly taken into account in MCDA and to discuss which approach may be appropriate for healthcare decision makers. A literature review was conducted in the Scopus and PubMed databases. Two reviewers independently categorized studies according to research areas, the type of MCDA used, and the approach used to quantify uncertainty. Selected full text articles were read for methodological details. The search strategy identified 569 studies. The five approaches most identified were fuzzy set theory (45% of studies), probabilistic sensitivity analysis (15%), deterministic sensitivity analysis (31%), Bayesian framework (6%), and grey theory (3%). A large number of papers considered the analytic hierarchy process in combination with fuzzy set theory (31%). Only 3% of studies were published in healthcare-related journals. In conclusion, our review identified five different approaches to take uncertainty into account in MCDA. The deterministic approach is most likely sufficient for most healthcare policy decisions because of its low complexity and straightforward implementation. However, more complex approaches may be needed when multiple sources of uncertainty must be considered simultaneously.

Selection of reference standard during method development using the analytical hierarchy process

Reference standard is critical for ensuring reliable and accurate method performance. One important issue is how to select the ideal one from the alternatives. Unlike the optimization of parameters, the criteria of the reference standard are always immeasurable. The aim of this paper is to recommend a quantitative approach for the selection of reference standard during method development based on the analytical hierarchy process (AHP) as a decision-making tool. Six alternative single reference standards were assessed in quantitative analysis of six phenolic acids from Salvia Miltiorrhiza and its preparations by using ultra-performance liquid chromatography. The AHP model simultaneously considered six criteria related to reference standard characteristics and method performance, containing feasibility to obtain, abundance in samples, chemical stability, accuracy, precision and robustness. The priority of each alternative was calculated using standard AHP analysis method. The results showed that protocatechuic aldehyde is the ideal reference standard, and rosmarinic acid is about 79.8% ability as the second choice. The determination results successfully verified the evaluation ability of this model. The AHP allowed us comprehensive considering the benefits and risks of the alternatives. It was an effective and practical tool for optimization of reference standards during method development.