Multicriteria Decision Analysis to Support Health Technology Assessment Agencies: Benefits, Limitations, and the Way Forward

SMART Multi-Criteria Decision Analysis (MCDA)-One of the Keys to Future Pandemic Strategies

Background/Objectives: The COVID-19 pandemic underscored the need for adaptive public health strategies and effective decision-making tools to optimize clinical responses and policy measures based on regional contexts. This study aims to identify key criteria for developing a patient-centered strategy to enhance the resilience of Romania's healthcare system during the pandemic. Methods: This research introduces a Multi-Criteria Decision Analysis (MCDA) model using the Simple Multiple Attribute Assessment Technique (SMART) to integrate quantitative and qualitative data, providing decision-makers with a structured tool for improving healthcare resilience. A survey of 412 Romanian healthcare professionals identified critical risks and opportunities. The study followed a two-phase approach: first, analyzing expert perceptions to determine key challenges; second, applying a mixed-methods evaluation to prioritize resilience-building strategies. Results: Four main challenges emerged: (1) healthcare workforce shortages causing excessive workload and stress, (2) poor communication and systemic inefficiencies limiting patient access, (3) weak crisis management due to delayed control measures, and (4) regulatory gaps leading to fragmented responses. Proposed solutions included workforce training, improved communication, telemedicine integration, increased financial support, and a unified legal framework. The SMART method facilitated the structured prioritization of these measures, with long-term system sustainability emerging as the most effective strategy for preventing future crises. Conclusions: This study demonstrates the value of integrating MCDA into healthcare decision-making, offering a scalable model for policymakers to enhance crisis response and resource allocation. By incorporating expert insights and patient needs, the proposed framework strengthens healthcare system preparedness, contributing to informed, patient-centered decision-making and long-term resilience. Ultimately, our findings not only contribute to the existing literature but may also open new directions to facilitate informed, patient-centered decision making, thereby strengthening the resilience of healthcare systems in crisis situations.

Understanding What Matters: Stakeholder Views on Decision Criteria for Cancer Drug Selection in the Public Sector in Malaysia

OBJECTIVE

This study aimed to determine stakeholders' decision criteria preferences for formulary decisions of cancer drugs in the Ministry of Health. The secondary objective was to identify the outcome measures of interest for assessment of clinical benefits for cancer drugs.

METHODS

A survey questionnaire was administered online and as hard copy using purposive sampling to 32 healthcare facilities providing cancer services and the Formulary Management Branch in the Ministry of Health. Respondents reported whether a criterion "will be considered" and weighted its relative importance on a 5-point scale. The choice of safety and efficacy/effectiveness outcomes were ranked from 1 to 5, and the minimum value of benefit for the efficacy/effectiveness outcome ranked 1 was provided. Trade-offs between survival and quality of life were also explored. Inferential statistics were used to explore difference in responses.

RESULTS

A total of 316 healthcare professionals responded to the survey. The most important criteria for value assessment of cancer drug were safety and effectiveness. Other criteria deemed important were quality of evidence, disease severity, and patient-reported outcomes. There was no difference in the criteria preference and weights across the various respondent groups. Overall survival was the most preferred clinical benefit outcome. Overall, willingness to pay was higher for life-prolonging treatment than treatment that improved quality of life.

CONCLUSIONS

This study revealed that a wide range of criteria beyond the traditional decision-making criteria of efficacy, safety, and cost-effectiveness are important for value assessment of cancer drugs for the purpose of formulary decisions.

How should medicines reimbursement work? The views of Spanish experts

Although the criteria that support reimbursement decisions for medicines are often set by legislation, as is the case in Spain, in many cases neither the definition nor the measurement methods for these criteria are provided. Our goal was to elicit the views of a large sample of Spanish technical specialists on how to evaluate each one of the criteria that inform pricing and reimbursement decisions in Spain. Professionals from various stakeholder groups involved in health economics, health technology assessment, and industry participated in a survey. Participants recommended that reimbursement decisions should take specific account of unmet medical need and rare diseases. Health benefit should be measured using quality-adjusted life-years. There should be an explicit cost-effectiveness threshold, and this threshold should take account of population groups and special situations.

Good Practices for Health Technology Assessment Guideline Development: A Report of the Health Technology Assessment International, HTAsiaLink, and ISPOR Special Task Force

OBJECTIVES

Health technology assessment (HTA) guidelines are intended to support the successful implementation of HTA by enhancing consistency and transparency in concepts, methods, processes, and use, thereby enhancing the legitimacy of the decision-making process. This report lays out good practices and practical recommendations for developing or updating HTA guidelines to ensure successful implementation.

METHODS

The task force was established in 2022 and comprised experts and academics from various geographical regions, each with substantial experience in developing HTA guidelines for national health policy making. Literature reviews and key informant interviews were conducted to inform these good practices. Stakeholder consultations, open peer reviews, and expert opinions validated the recommendations. A series of teleconferences among task force members was held to iteratively refine the report.

RESULTS

The recommendations cover six key aspects throughout the guideline development cycle: (1) setting objectives, scope, and principles of the guideline, (2) building a team for a quality guideline, (3) defining a stakeholder engagement plan, (4) developing content and utilizing available resources, (5) putting in place appropriate institutional arrangements, and (6) monitoring and evaluating guideline success.

CONCLUSION

This report presents a set of resources and context-appropriate practices for developing or updating HTA guidelines. Across all contexts, the recommendations emphasize transparency, building trust among stakeholders, and fostering a culture of ongoing learning and improvement. The report recommends timing development and revision of guidelines according to the HTA landscape and pace of HTA institutionalization. Because HTA is increasingly used to inform different kinds of decision making in a variety of country contexts, it will be important to continue to monitor lessons learned to ensure the recommendations remain relevant and effective.

The valuation of older adult homecare services under a joint medical-social budgetary perspective

Background

Homecare, a cornerstone of public health, is essential for health systems to achieve the Sustainable Development Goal (SDG) of universal health coverage while maintaining its own sustainability. Notwithstanding homecare's system-level significance, there is a lack of economic evaluations of homecare services in terms of their system-wide cost-savings. Specifically, decisions informed by a joint medical-social budgetary perspective can maximize the allocative efficiency of assigning a diverse service mix to address the complex needs of the older adult population. However, little is known regarding which homecare service mix is most system-wide cost-effective when paired with which clinical profiles.

Methods

Valuation of homecare's complex interventions was performed under a generalized cost-effectiveness analysis (GCEA) framework with proportional hazard-adjusted metrics representing the common numeraire between medical and social care.

Results

Instrumental homecare, on its own or combined with either one or both of the other homecare services, yielded the greatest cost savings compared to other services or the lack thereof. When expressed under a joint medical-social budgetary perspective, instrumental homecare can reduce medical costs of HK$34.53 (US$4.40) and HK$85.03 (US$10.84) for every HK$1 (US$0.13) invested in instrumental and instrumental-restorative homecare, respectively.

Conclusion

Instrumental homecare can increase hospitalization-free days among community-dwelling older adult and yield significant net system-wide cost savings. Thus, the current study demonstrated the feasibility of data-informed decision-making in system-wide resource allocation under a joint medical-social budget perspective.

Research priorities to support typhoid conjugate vaccine decision-making in India: evidence assessment and stakeholder survey

Background

India has a high typhoid fever burden. In 2022, the National Technical Advisory Group on Immunisation recommended introducing typhoid conjugate vaccine (TCV) into the Universal Immunisation Programme. Our study aims to identify research priorities to support ongoing TCV decision-making in India.

Methods

We identified 45 evidence factors for TCV decision-making in India by adapting WHO's Evidence-to-Recommendation framework. We assigned an evidence gap score for each evidence factor from 0 (low) to 4 (high) based on the availability and sufficiency, quality, breadth and applicability of evidence identified in a literature review (end date 30 November 2023). We assigned each evidence factor an importance score based on the results of an online survey conducted among national immunisation stakeholders (n=22, 1 July 2023-31 October 2023), where they ranked the importance of seven WHO's Evidence-to-Recommendation criteria and several evidence factors within them. We rescaled mean stakeholder rankings into importance scores from 0 (low) to 4 (high). Finally, we added the evidence gap score to the importance score and used the overall scores to identify research priorities to support ongoing TCV decision-making in India.

Results

We estimated the highest evidence priority scores for public perception of typhoid fever, vaccination budget impact, vaccine availability, socioeconomic impact, fiscal space, antimicrobial resistance tracking, typhoid fever mortality, public perception of TCV, immunisation managers' acceptance and vaccine schedule preferences among caregivers.

Conclusion

By adapting WHO's Evidence-to-Recommendation framework to the Indian context, we systematically identified several research priorities to support ongoing decision-making on TCV in India. These priorities will evolve as new research studies and questions emerge about the optimal scheduling, roll-out and implementation of TCV in India.

Value contribution of etranacogene dezaparvovec gene therapy in moderately severe and severe haemophilia B through multi-criteria decision analysis

INTRODUCTION

The value of gene therapies for haemophilia needs to be assessed holistically.

AIM

To determine the value of etranacogene dezaparvovec (ED) compared to current extended half-life (EHL) recombinant factors (rFIX), using multi-criteria decision analysis (MCDA).

METHOD

MCDA EVIDEM methodology adapted to orphan drugs was used, with nine quantitative criteria and four contextual criteria. The MCDA framework was rated by 28 multidisciplinary experts. Descriptive statistics were performed for quantitative and qualitative criteria.

RESULTS

Haemophilia B (HB) was considered a severe disease (mean ± SD: 4.3 ± 0.7) with some unmet needs (mean ± SD 3.3 ± 0.9). Experts found ED more effective (mean ± SD 2.0 ± 2.3) and provide better quality of life (QoL) (mean ± SD: 1.8 ± 1.5) than the comparative HB treatments but with safety uncertainties (mean ± SD -1.2 ± 1.8). ED could lead to medical cost and non-medical cost savings over time (mean ± SD: 1.6 ± 2.0 and 2.0 ± 1.5, respectively). The quality of the evidence was high (mean ± SD: 3.9 ± 0.9). ED was considered aligned with the priorities of the National Health System (NHS) and the specific interests of patients. ED's value contribution was 0.45 (+1 = highest value).

CONCLUSIONS

ED brings added value in the treatment of moderately severe and severe HB (sHB) compared to current EHL rFIX, addressing the severity of the disease and increasing efficacy and patients' QoL especially related to the single dose and low bleeding rate. Concerns about long-term safety need to be addressed.

Societal Preferences in Health Technology Assessments for Rare Diseases and Orphan Drugs: A Systematic Literature Review of New Analytic Approaches

OBJECTIVES

This systematic literature review aimed to explore experiences worldwide of societal preferences integration into health technology assessments (HTAs) for rare diseases (RDs) and orphan drugs (ODs) through the implementation of multicriteria decision analysis (MCDA), discrete choice experiments (DCEs), and person trade-off (PTO) methods, among others.

METHODS

A systematic search of the literature was conducted in April 2021 using PubMed, Cochrane, Embase, and Scopus databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses approach was used for the review phases. Finally, the Promoting Action on Research Implementation in Health Services framework was used to discuss the implementation of these instruments in the RD context.

RESULTS

A total of 33 articles met the inclusion criteria. The studies measured societal preferences for RD and OD as part of HTA using MCDA (n = 17), DCE (n = 8), and PTO (n = 4), among other methods (n = 4). These found that patients and clinicians do not prioritize funding based on rarity. The public is willing to allocate funds only if the OD demonstrates effectiveness and improves the quality of life, considering as relevant factors disease severity, unmet health needs, and quality of life. Conversely, HTA agency experts preferred their current approach, placing more weight on cost-effectiveness and evidence quality, even though they expressed concern about the fairness of the drug review process.

CONCLUSIONS

MCDA, PTO, and DCE are helpful and transparent methods for assessing societal preferences in HTA for RD and OD. However, their methodological limitations, such as arbitrary criteria selection, subjective scoring methods, framing effects, weighting adaptation, and value measurement models, could make implementation challenging.

Equity in national healthcare economic evaluation guidelines: Essential or extraneous?

BACKGROUND

The focus on health maximisation in a healthcare economic evaluation (HEE) - that is health gains are of equal value regardless of the recipient- has significant implications as health systems attempt to address persistent and growing health inequities. This study aimed to systematically compare and contrast the equity principles of different health technology assessment (HTA) agencies and how equity is addressed in HEE guidelines.

METHODS

HTA agencies were identified through the ISPOR, GEAR, iDSI, HTAi, INAHTA, HTAsiaLink, and RedETSA websites in June 2021 and updated in August 2023. Agencies websites were then searched to retrieve HEE guidelines. The guidelines were grouped into two categories: well-established and newly-developed agency guidelines, based on whether or not they published their first guidelines before 2009. Data extracted summarised the methodological details in the reference cases, including specifics on how equity featured and in what role. In those agencies where equity did not feature explicitly in the HEE guidelines, an additional search of the agency website was undertaken to understand if equity featured in those agencies' decision-making frameworks.

RESULTS

The study included 46 guidelines from 51 countries. Only 30% of the guidelines were explicit about the equity assumptions. Health equity (using a broad definition) was mentioned in 29 guidelines and 14 included a specific definition while only seven recommended specific methods to incorporate inequalities. Addressing equity concerns was usually suggested as an additional analyses rather than a key part of the assessment. It was unclear how equity was incorporated into decision-making processes. In addition, equity was mentioned in other guidance - such as decision-making frameworks - provided by five agencies that did not mention it in the HEE guidelines, and 7 of 14 topic selection criteria that were identified.

CONCLUSION

Equity is given less attention than efficiency in HEE guidelines. This indicates that HTA agencies while subscribing to an extra-welfarist approach have a narrow evaluative space - focusing on maximising health and not considering the opportunity cost of the equity constraint. The omission of equity and the lack of systematic approaches in guidelines poses a threat to the international endeavours to reduce inequities. It is timely for HTA agencies to reconsider their positions on equity explicitly.

Using a Patient-Centered Multicriteria Decision Analysis to Assess the Value of Multiple Sclerosis Treatments in the US: A Study Protocol

OBJECTIVE

The engagement of patients and family caregivers in value assessment is pivotal since they provide valuable contributions to assessment acceptability and relevance. The proposed study aims to use patient-centered techniques and multicriteria decision analysis (MCDA) to evaluate the values of disease-modifying therapies (DMTs) for multiple sclerosis (MS) from the perspectives of patients and family caregivers living in three 'Deep South' States of the US-Alabama, Louisiana, and Mississippi.

METHODS

This study will follow guidance from the Patient-Centered Outcomes Research Institute (PCORI) for patient engagement and two best practice reports for MCDA from the Professional Society for Health Economics and Outcomes Research (ISPOR) to complete value assessment. Throughout the study, we will engage multiple stakeholders, including patients, family caregivers, healthcare providers, and payers. Forty patients with MS and their family caregivers from Alabama, Louisiana, and Mississippi will be invited to participate in this study. We will intensively train them for value assessment knowledge and MCDA before we engage them in MCDA to determine the value of DMTs for MS.

DISCUSSIONS

Our approach differs from common MCDA since we incorporated a patient-centered framework in this study. Unlike previous studies only briefly inform or prepare participants before the MCDA process, in this study, we will provide basic value assessment trainings for patients and family caregivers to ensure they can effectively engage throughout the patient-centered MCDA process. We expect this study will demonstrate that the patient-centered MCDA approach is feasible and likely leads to improved patients' and family caregivers' engagement in value assessment.

A new approach to Health Benefits Package design: an application of the Thanzi La Onse model in Malawi

An efficient allocation of limited resources in low-income settings offers the opportunity to improve population-health outcomes given the available health system capacity. Efforts to achieve this are often framed through the lens of "health benefits packages" (HBPs), which seek to establish which services the public healthcare system should include in its provision. Analytic approaches widely used to weigh evidence in support of different interventions and inform the broader HBP deliberative process however have limitations. In this work, we propose the individual-based Thanzi La Onse (TLO) model as a uniquely-tailored tool to assist in the evaluation of Malawi-specific HBPs while addressing these limitations. By mechanistically modelling-and calibrating to extensive, country-specific data-the incidence of disease, health-seeking behaviour, and the capacity of the healthcare system to meet the demand for care under realistic constraints on human resources for health available, we were able to simulate the health gains achievable under a number of plausible HBP strategies for the country. We found that the HBP emerging from a linear constrained optimisation analysis (LCOA) achieved the largest health gain-∼8% reduction in disability adjusted life years (DALYs) between 2023 and 2042 compared to the benchmark scenario-by concentrating resources on high-impact treatments. This HBP however incurred a relative excess in DALYs in the first few years of its implementation. Other feasible approaches to prioritisation were assessed, including service prioritisation based on patient characteristics, rather than service type. Unlike the LCOA-based HBP, this approach achieved consistent health gains relative to the benchmark scenario on a year- to-year basis, and a 5% reduction in DALYs over the whole period, which suggests an approach based upon patient characteristics might prove beneficial in the future.

Development of a Value Assessment Framework for Pediatric Health Technologies Using Multicriteria Decision Analysis: Expanding the Value Lens for Funding Decision Making

OBJECTIVES

A health technology assessment (HTA) does not systematically account for the circumstances and needs of children and youth. To supplement HTA processes, we aimed to develop a child-tailored value assessment framework using a multicriteria decision analysis approach.

METHODS

We constructed a multicriteria-decision-analysis-based model in multiple phases to create the Comprehensive Assessment of Technologies for Child Health (CATCH) framework. Using a modified Delphi process with stakeholders having broad disciplinary and geographic variation (N = 23), we refined previously generated criteria and developed rank-based weights. We established a criterion-pertinent scoring rubric for assessing incremental benefits of new drugs. Three clinicians independently assessed comprehension by pilotscoring 9 drugs. We then validated CATCH for 2 childhood cancer therapies through structured deliberation with an expert panel (N = 10), obtaining individual scores, consensus scores, and verbal feedback. Analyses included descriptive statistics, thematic analysis, exploratory disagreement indices, and sensitivity analysis.

RESULTS

The modified Delphi process yielded 10 criteria, based on absolute importance/relevance and agreed importance (median disagreement indices = 0.34): Effectiveness, Child-specific Health-related Quality of Life, Disease Severity, Unmet Need, Therapeutic Safety, Equity, Family Impacts, Life-course Development, Rarity, and Fair Share of Life. Pilot scoring resulted in adjusted criteria definitions and more precise score-scaling guidelines. Validation panelists endorsed the framework's key modifiers of value. Modes of their individual prescores aligned closely with deliberative consensus scores.

CONCLUSIONS

We iteratively developed a value assessment framework that captures dimensions of child-specific health and nonhealth gains. CATCH could improve the richness and relevance of HTA decision making for children in Canada and comparable health systems.

An overview of the perspectives used in health economic evaluations

The term 'perspective' in the context of economic evaluations and costing studies in healthcare refers to the viewpoint that an analyst has adopted to define the types of costs and outcomes to consider in their studies. However, there are currently notable variations in terms of methodological recommendations, definitions, and applications of different perspectives, depending on the objective or intended user of the study. This can make it a complex area for stakeholders when interpreting these studies. Consequently, there is a need for a comprehensive overview regarding the different types of perspectives employed in such analyses, along with the corresponding implications of their use. This is particularly important, in the context of low-and-middle-income countries (LMICs), where practical guidelines may be less well-established and infrastructure for conducting economic evaluations may be more limited. This article addresses this gap by summarising the main types of perspectives commonly found in the literature to a broad audience (namely the patient, payer, health care providers, healthcare sector, health system, and societal perspectives), providing their most established definitions and outlining the corresponding implications of their uses in health economic studies, with examples particularly from LMIC settings. We then discuss important considerations when selecting the perspective and present key arguments to consider when deciding whether the societal perspective should be used. We conclude that there is no one-size-fits-all answer to what perspective should be used and the perspective chosen will be influenced by the context, policymakers'/stakeholders' viewpoints, resource/data availability, and intended use of the analysis. Moving forward, considering the ongoing issues regarding the variation in terminology and practice in this area, we urge that more standardised definitions of the different perspectives and the boundaries between them are further developed to support future studies and guidelines, as well as to improve the interpretation and comparison of health economic evidence.

The Full Value of Vaccine Assessments Concept-Current Opportunities and Recommendations

For vaccine development and adoption decisions, the 'Full Value of Vaccine Assessment' (FVVA) framework has been proposed by the WHO to expand the range of evidence available to support the prioritization of candidate vaccines for investment and eventual uptake by low- and middle-income countries. Recent applications of the FVVA framework have already shown benefits. Building on the success of these applications, we see important new opportunities to maximize the future utility of FVVAs to country and global stakeholders and provide a proof-of-concept for analyses in other areas of disease control and prevention. These opportunities include the following: (1) FVVA producers should aim to create evidence that explicitly meets the needs of multiple key FVVA consumers, (2) the WHO and other key stakeholders should develop standardized methodologies for FVVAs, as well as guidance for how different stakeholders can explicitly reflect their values within the FVVA framework, and (3) the WHO should convene experts to further develop and prioritize the research agenda for outcomes and benefits relevant to the FVVA and elucidate methodological approaches and opportunities for standardization not only for less well-established benefits, but also for any relevant research gaps. We encourage FVVA stakeholders to engage with these opportunities.

Design of a multiple criteria decision analysis framework for prioritizing high-impact health technologies in a regional health service

OBJECTIVES

This study aims to develop a framework for establishing priorities in the regional health service of Murcia, Spain, to facilitate the creation of a comprehensive multiple criteria decision analysis (MCDA) framework. This framework will aid in decision-making processes related to the assessment, reimbursement, and utilization of high-impact health technologies.

METHOD

Based on the results of a review of existing frameworks for MCDA of health technologies, a set of criteria was proposed to be used in the context of evaluating high-impact health technologies. Key stakeholders within regional healthcare services, including clinical leaders and management personnel, participated in a focus group (n = 11) to discuss the proposed criteria and select the final fifteen. To elicit the weights of the criteria, two surveys were administered, one to a small sample of healthcare professionals (n = 35) and another to a larger representative sample of the general population (n = 494).

RESULTS

The responses obtained from health professionals in the weighting procedure exhibited greater consistency compared to those provided by the general public. The criteria more highly weighted were "Need for intervention" and "Intervention outcomes." The weights finally assigned to each item in the multicriteria framework were derived as the equal-weighted sum of the mean weights from the two samples.

CONCLUSIONS

A multi-attribute function capable of generating a composite measure (multicriteria) to assess the value of high-impact health interventions has been developed. Furthermore, it is recommended to pilot this procedure in a specific decision context to evaluate the efficacy, feasibility, usefulness, and reliability of the proposed tool.

Application of Multi-Criteria Decision Analysis (MCDA) to Prioritize Real-World Evidence Studies for Health Technology Management: Outcomes and Lessons Learned by the Canadian Real-World Evidence for Value of Cancer Drugs (CanREValue) Collaboration

Multi-criteria decision analysis (MCDA) is a value assessment tool designed to help support complex decision-making by incorporating multiple factors and perspectives in a transparent, structured approach. We developed an MCDA rating tool, consisting of seven criteria evaluating the importance and feasibility of conducting potential real-world evidence (RWE) studies aimed at addressing uncertainties stemming from initial cancer drug funding recommendations. In collaboration with the Canadian Agency for Drugs and Technologies in Health's Provincial Advisory Group, a validation exercise was conducted to further evaluate the application of the rating tool using RWE proposals varying in complexity. Through this exercise, we aimed to gain insight into consensus building and deliberation processes and to identify efficiencies in the application of the rating tool. An experienced facilitator led a multidisciplinary committee, consisting of 11 Canadian experts, through consensus building, deliberation, and prioritization. A total of nine RWE proposals were evaluated and prioritized as low (n = 4), medium (n = 3), or high (n = 2) priority. Through an iterative process, efficiencies and recommendations to improve the rating tool and associated procedures were identified. The refined MCDA rating tool can help decision-makers prioritize important and feasible RWE studies for research and can enable the use of RWE for the life-cycle evaluation of cancer drugs.

National Immunization Program Decision Making Using the CAPACITI Decision-Support Tool: User Feedback from Indonesia and Ethiopia

To ensure that limited domestic resources are invested in the most effective interventions, immunization programs in low- and middle-income countries (LMICs) must prioritize a growing number of new vaccines while considering opportunities to optimize the vaccine portfolio, as well as other components of the health system. There is a strong impetus for immunization decision-making to engage and coordinate various stakeholders across the health system in prioritization. To address this, national immunization program decision-makers in LMICs collaborated with WHO to structure deliberation among stakeholders and document an evidence-based, context-specific, and transparent process for prioritization or selection among multiple vaccination products, services, or strategies. The output of this effort is the Country-led Assessment for Prioritization on Immunization (CAPACITI) decision-support tool, which supports using multiple criteria and stakeholder perspectives to evaluate trade-offs affecting health interventions, taking into account variable data quality. Here, we describe the user feedback from Indonesia and Ethiopia, two initial countries that piloted the CAPACITI decision-support tool, highlighting enabling and constraining factors. Potential immunization program benefits and lessons learned are also summarized for consideration in other settings.

Cost and economic evidence for asset-based approaches to health improvement and their evaluation methods: a systematic review

BACKGROUND

Asset-based approaches (ABAs) tackle health inequalities by empowering people in more disadvantaged communities, or targeted populations, to better utilise pre-existing local community-based resources. Using existing resources supports individuals to better manage their own health and its determinants, potentially at low cost. Targeting individuals disengaged with traditional service delivery methods offers further potential for meaningful cost-savings, since these people often require costly care. Thus, improving prevention, and management, of ill-health in these groups may have considerable cost implications.

AIM

To systematically review the extent of current cost and economic evidence on ABAs, and methods used to develop it.

METHODS

Search strategy terms encompassed: i) costing; ii) intervention detail; and iii) locality. Databases searched: Medline, CENTRAL and Wed of Science. Researchers screened 9,116 articles. Risk of bias was assessed using the Critical Appraisal Skills Programme (CASP) tool. Narrative synthesis summarised findings.

RESULTS

Twelve papers met inclusion criteria, representing eleven different ABAs. Within studies, methods varied widely, not only in design and comparators, but also in terms of included costs and outcome measures. Studies suggested economic efficiency, but lack of suitable comparators made more definitive conclusions difficult.

CONCLUSION

Economic evidence around ABAs is limited. ABAs may be a promising way to engage underserved or minority groups, that may have lower net costs compared to alternative health and wellbeing improvement approaches. ABAs, an example of embedded services, suffer in the context of economic evaluation, which typically consider services as mutually exclusive alternatives. Economics of the surrounding services, mechanisms of information sharing, and collaboration underpin the success of assets and ABAs. The economic evidence, and evaluations in general, would benefit from increased context and detail to help ensure more nuanced and sophisticated understanding of the economics of ABAs. Further evidence is needed to reach conclusions about cost-effectiveness of ABAs.

The Use of Evidence to Design an Essential Package of Health Services in Pakistan: A Review and Analysis of Prioritisation Decisions at Different Stages of the Appraisal Process

BACKGROUND

Pakistan embarked on a process of designing an essential package of health services (EPHS) as a pathway towards universal health coverage (UHC). The EPHS design followed an evidence-informed deliberative process; evidence on 170 interventions was introduced along multiple stages of appraisal engaging different stakeholders tasked with prioritising interventions for inclusion. We report on the composition of the package at different stages, analyse trends of prioritised and deprioritised interventions and reflect on the trade-offs made.

METHODS

Quantitative evidence on cost-effectiveness, budget impact, and avoidable burden of disease was presented to stakeholders in stages. We recorded which interventions were prioritised and deprioritised at each stage and carried out three analyses: (1) a review of total number of interventions prioritised at each stage, along with associated costs per capita and disability-adjusted life years (DALYs) averted, to understand changes in affordability and efficiency in the package, (2) an analysis of interventions broken down by decision criteria and intervention characteristics to analyse prioritisation trends across different stages, and (3) a description of the trajectory of interventions broken down by current coverage and cost-effectiveness.

RESULTS

Value for money generally increased throughout the process, although not uniformly. Stakeholders largely prioritised interventions with low budget impact and those preventing a high burden of disease. Highly cost-effective interventions were also prioritised, but less consistently throughout the stages of the process. Interventions with high current coverage were overwhelmingly prioritised for inclusion.

CONCLUSION

Evidence-informed deliberative processes can produce actionable and affordable health benefit packages. While cost-effective interventions are generally preferred, other factors play a role and limit efficiency.

A health technology assessment of personalized nutrition interventions using the EUnetHTA HTA Core Model

OBJECTIVES

Poor nutrition links to chronic diseases, emphasizing the need for optimized diets. The EU-funded project PREVENTOMICS, introduced personalized nutrition to address this. This study aims to perform a health technology assessment (HTA) comparing personalized nutrition interventions developed through this project, with non-personalized nutrition interventions (control) for people with normal weight, overweight, or obesity. The goal is to support decisions about further development and implementation of personalized nutrition.

METHODS

The PREVENTOMICS interventions were evaluated using the European Network for HTA Core Model, which includes a methodological framework that encompasses different domains for value assessment. Information was gathered via [1] different statistical analyses and modeling studies, [2] questions asked of project partners and, [3] other (un)published materials.

RESULTS

Clinical trials of PREVENTOMICS interventions demonstrated different body mass index changes compared to control; differences ranged from -0.80 to 0.20 kg/m2. Long-term outcome predictions showed generally improved health outcomes for the interventions; some appeared cost-effective (e.g., interventions in UK). Ethical concerns around health inequality and the lack of specific legal regulations for personalized nutrition interventions were identified. Choice modeling studies indicated openness to personalized nutrition interventions; decisions were primarily affected by intervention's price.

CONCLUSIONS

PREVENTOMICS clinical trials have shown promising effectiveness with no major safety concerns, although uncertainties about effectiveness exist due to small samples (n=60-264) and short follow-ups (10-16 weeks). Larger, longer trials are needed for robust evidence before implementation could be considered. Among other considerations, developers should explore financing options and collaborate with policymakers to prevent exclusion of specific groups due to information shortages.

Assessing clinical benefit in the Medicare Drug Price Negotiation Program: A 2-step approach for improving transparency, consistency, and meaningful patient engagement

In early 2024, the Centers for Medicare & Medicaid Services (CMS) will send initial price offers to the manufacturers of the first 10 drugs selected for the Medicare Drug Price Negotiation Program, established under the Inflation Reduction Act. However, CMS has not specified exactly how it will adjust the starting point for an initial price offer based on assessment of a drug's clinical benefit. This article addresses unanswered questions relating to CMS' methods for assessing clinical benefit. Specifically, we address how CMS can weigh various measures of evidence, ensure transparency and consistency, meaningfully incorporate patient and other stakeholder perspectives, and support addressing evidence gaps. We propose a 2-step approach for assessing the overall clinical benefit of a selected drug compared with its therapeutic alternatives that builds on the framework outlined by CMS. In step 1, CMS would evaluate conventional clinical benefit, defined in terms of outcomes commonly used in clinical studies for the selected drug and indications. In step 2, CMS would evaluate other outcomes broadly related to patient experience that are not adequately represented in the clinical literature. Overall, our approach incorporates the advantages of both qualitative and quantitative approaches to value assessment and decision-making. We describe a set of loose decision rules to improve transparency and consistency, recommend incorporating ranks and weights to signal to researchers and manufacturers which elements of clinical benefit and sources of data are the most important, and center meaningful deliberation with clinical experts, patients, and caregivers.

Alternative approaches to measuring value: an update on innovative methods in the context of the United States Medicare drug price negotiation program

INTRODUCTION

The United States has begun assessing the value of pharmaceuticals to inform negotiated prices in the Medicare program. Given strong political objections in the United States to the use of QALYs, Medicare will need to adopt an alternative approach to measuring value.

AREAS COVERED

In this narrative review, we identified six alternative approaches to measuring value (equal value life-years, health years in total, generalized risk-adjusted cost-effectiveness, severity weighting based on absolute or proportional shortfall, comparative effectiveness based on conventional clinical endpoints, and comparative effectiveness based on both conventional endpoints and patient-centric value elements) and five criteria for assessing these approaches (responsiveness to concerns about discrimination, feasibility, transparency, flexibility, and the ability to incorporate factors beyond traditional value elements).

EXPERT OPINION

Four of the alternatives are broadly aligned with the cost-effectiveness framework, but none fully addresses all aspects of the stated concerns that QALYs may be used to unintentionally implement discrimination. We note, however, that the extent to which these concerns lead to discrimination in practice is unknown. Finally, we recommend an approach for measuring value in terms of comparative effectiveness that combines quantitative ranking and weighting of distinct criteria (including patient-centric value elements) with deliberation.

A Step Toward the Development of the First National Multi-Criteria Decision Analysis Framework to Support Healthcare Decision Making in Saudi Arabia

OBJECTIVES

To assess the feasibility of implementing multi-criteria decision analysis (MCDA) and to select the criteria for preparing a national MCDA framework for health technology assessment of orphan drugs in the Kingdom of Saudi Arabia (KSA).

METHODS

The study was conducted in 3 phases. In phase I, a targeted literature review was performed to gather relevant information on the implementation of MCDA in healthcare decision making. Phase II was a cross-sectional survey, conducted to obtain insights from different stakeholders and key opinion leaders on specific topics from the KSA perspective. Phase III included a round-table discussion involving experts to validate the results obtained in the phase II survey and further elaborate on specific requirements that may be critical for developing the first national MCDA framework in the KSA.

RESULTS

All the key opinion leaders involved in the study acknowledged the importance of implementing MCDA in the KSA. The Ministry of Health was assigned the responsibility of chairing the MCDA decision process. The experts selected the quantitative, qualitative, and economic criteria to be considered for the MCDA framework. The stakeholders decided to initiate a pilot phase using the deliberative MCDA methodology for the assessment of orphan drugs based on the selected criteria for a period of 1 year and then reevaluate the need to adapt the pragmatic MCDA model.

CONCLUSION

This article describes the novel initiative that examined the feasibility and process required for the development of the first MCDA framework in the KSA to support healthcare decision making.

Importance of aligning the implementation of new payment models for innovative pharmaceuticals in European countries

INTRODUCTION

The uptake of complex technologies and platforms has resulted in several challenges in the pricing and reimbursement of innovative pharmaceuticals. To address these challenges, plenty of concepts have already been described in the scientific literature about innovative value judgment or payment models, which are either (1) remaining theoretical; or (2) applied only in pilots with limited impact on patient access; or (3) applied so heterogeneously in many different countries that it prevents the health care industry from meeting expectations of HTA bodies and health care payers in the evidence requirements or offerings in different jurisdictions.

AREAS COVERED

This paper provides perspectives on how to reduce the heterogeneity of pharmaceutical payment models across European countries in five areas, including 1) extended evaluation frameworks, 2) performance-based risk-sharing agreements, 3) pooled procurement for low volume or urgent technologies, 4) alternative access schemes, and 5) delayed payment models for technologies with high upfront costs.

EXPERT OPINION

Whilst pricing and reimbursement decisions will remain a competence of EU member states, there is a need for alignment of European pharmaceutical payment model components in critical areas with the ultimate objective of improving the equitable access of European patients to increasingly complex pharmaceutical technologies.

The impact of China's universal two-child policy on total, preterm, and multiple births: a nationwide interrupted time-series analysis

BACKGROUND

Although years have passed since the implementation of China's universal two-child policy, the effectiveness of this policy remains unclear. To address this knowledge gap, we, here, assessed the impact of the two-child policy on total live births, preterm births, and multiple live births.

METHODS

Data identifying pregnancies resulting in at least one live birth between April 1 2013 and December 31 2018 were collected from the Hospital Quality Monitoring System database. Using an interrupted time-series analysis, we estimated immediate level changes and long-term trends in total, preterm (birth before 37 weeks' gestation), and multiple live births that had occurred after July 2016, when the universal two-child policy had taken effect.

RESULTS

A total of 8,273,622 live births were reported during the study time frame. The number of live births (p = 0.277), preterm births (p = 0.052), and multiple births (p = 0.856) per month slightly increased immediately after July 2016, but these increases did not meet statistical significance. Further, all three outcomes showed a significant downward trend that lasted until the end of 2018 (p < 0.0001 for all). Among all live births, the percentage of preterm births remained stable (p = 0.101), while the percentage of multiple live births that were preterm significantly increased (trend change = 0.21% per month, 95% CI 0.14 to 0.28, p < 0.0001). The percentage of live multiple births among all live births significantly decreased (p for trend = 0.0039).

CONCLUSIONS

Overall, our data reveal a transient baby boom, as well as an increase in the proportion of live multiple births that were preterm, after China's two-child policy took effect. The latter should be noted by healthcare professionals due to the high risk of complications and special medical care required by preterm babies.

Protocol of the development of a core outcome set for stroke in multidimensional value assessment of traditional Chinese medicine

INTRODUCTION

Stroke is the most common cause of death in China. In Chinese clinical practise, traditional Chinese medicine (TCM) and integrative medicine have been widely used as adjuvant therapies for the treatment of stroke. However, their clinical effectiveness, particularly their clinical value, has been inconsistent in the literature mainly because various outcome measures have been used and reported in clinical research. Hence, obtaining a comprehensive list of outcomes for TCM value assessment is crucial for a multidimensional value assessment. Therefore, the main objective of this protocol was to develop an outcome set used in health technology assessment (HTA) decision-making for TCM treatment of stroke.

METHODS AND ANALYSIS

The outcome set will be developed in four phases: (1) we will perform a systematic literature review to identify candidate outcomes that have been previously measured in published studies; (2) we will develop a comprehensive list of outcome measures by conducting a multistakeholder semistructured interview; (3) we will conduct two-round Delphi surveys to prioritise outcomes for each HTA domain; and (4) we will finalise the outcome sets by holding a ratification meeting with multiple stakeholder groups. The developed outcome set should be measured and reported as the minimum set of outcomes for HTA assessment for the TCM treatment of acute ischaemic stroke (AIS).

ETHICS AND DISSEMINATION

This protocol was reviewed and approved by the Institutional Review Board of the Minhang Hospital of Fudan University. Our findings will be shared at academic conferences and in peer-reviewed publications.

Establishing cost-effectiveness threshold in China: a community survey of willingness to pay for a healthylife year

INTRODUCTION

The willingness to pay per quality-adjusted life year gained (WTP/Q) is commonly used to determine whether an intervention is cost-effective in health technology assessment. This study aimed to evaluate the WTP/Q for different disease scenarios in a Chinese population.

METHODS

The study employed a quadruple-bounded dichotomous choice contingent valuation method to estimate the WTP/Q in the general public. The estimation was conducted across chronic, terminal and rare disease scenarios. Face-to-face interviews were conducted in a Chinese general population recruited from Jiangsu province using a convenience sampling method. Interval regression analysis was performed to determine the relationship between respondents' demographic and socioeconomic conditions and WTP/Q. Sensitivity analyses of removing protest responses and open question analyses were conducted.

RESULTS

A total of 896 individuals participated in the study. The WTP/Q thresholds were 128 000 Chinese renminbi (RMB) ($36 364) for chronic diseases, 149 500 RMB ($42 472) for rare diseases and 140 800 RMB ($40 000) for terminal diseases, equivalent to 1.76, 2.06 and 1.94 times the gross domestic product per capita in China, respectively. The starting bid value had a positive influence on participants' WTP/Q. Additionally, residing in an urban area (p<0.01), and higher household expenditure (p<0.01), educational attainment (p<0.02) and quality of life (p<0.02) were significantly associated with higher WTP/Q. Sensitivity analyses demonstrated the robustness of the results.

CONCLUSION

This study implies that tailored or varied rather than a single cost-effectiveness threshold could better reflect community preferences for the value of a healthy year. Our estimates hold significance in informing reimbursement decision-making in health technology assessment in China.

Insights into implementation planning for point-of-care testing to guide treatment of chronic obstructive pulmonary disease exacerbation: a mixed methods feasibility study

The purpose of this mixed methods feasibility study was to gain insights into unmet clinical needs, stakeholder preferences and potential barriers and enablers to adoption for planning the implementation of point-of-care testing for earlier detection and guided treatment of chronic obstructive pulmonary disease (COPD) acute exacerbation in the NHS in England. Exacerbations of COPD cause considerable mortality and morbidity. Earlier identification of exacerbations and guided treatment would lead to reduced exacerbation duration, reduced hospitalizations and mortality, improve health-related quality of life, reduce unnecessary treatments (including inappropriate antibiotic prescribing) which could save the NHS over £400 per patient. During the early stages of product design, we took a multi-disciplinary approach to evidence generation, gaining insights from key stakeholders to test the product concept and inform evidence-based implementation planning. Primary data was collected from 11 health care and service professionals involved in the management of acute COPD exacerbations. Overall, participants agreed that by earlier differentiation of acute exacerbation from stable COPD, patients could be started on appropriate treatment. To implement point-of-care testing into clinical practice, evidence is required to demonstrate the accuracy of differentiating between exacerbation etiologies and to provide information on the beneficial impact to the system in terms of optimized management, reduced long-term side effects, admission avoidance, and cost-effectiveness. This research provides an evidence base for future implementation planning of point-of-care testing for earlier detection and guided treatment of COPD acute exacerbation. Moreover, the technology developers can decide whether to refine the product design and value proposition thereby de-risking product development.

Value of concerted and hospital hemodialysis through a multi-criteria decision analysis

OBJECTIVE

To evaluate the value of the provision of contracted versus hospital dialysis services for the treatment of chronic kidney disease in Spain using the multicriteria decision analysis methodology.

METHOD

The EVIDEM (Evidence and Value: Impact on Decision Making) evaluation framework was used to calculate the estimated value of both dialysis delivery models (arranged vs. hospital) through a virtual workshop in which different profiles participated: directors and managers, professionals and heads of units and representatives of patients and relatives. The scores were combined using an additive lineal model, which combined the weight of the model with the individual score of the criteria, and each value was transformed to a scale between 0 and 1.

RESULTS

The estimated value for arranged dialysis was 0.29 (DS: ±0.2) and 0.39 (DS: ±0.2) for hospital dialysis. All profiles gave a higher value to hospital hemodialysis compared to contracted hemodialysis. The highest value for hospital dialysis was for patients (0.44), with the lowest mean value for directors (0.36) and the range for arranged dialysis being between patients (0.31) and intermediate positions (0.27).

CONCLUSIONS

Hospital hemodialysis obtained a higher value than concerted dialysis. In general, the panelists affirmed that it is a useful and interesting exercise and that, to a certain extent, it provides security in decision-making, since it allows ordering, rationalizing and considering, in an explicit and transparent manner, the different criteria involved.

Reconstructing the value puzzle in health technology assessment: a pragmatic review to determine which modelling methods can account for additional value elements

Health technology assessment (HTA) has traditionally relied on cost-effectiveness analysis (CEA) as a cornerstone of evaluation of new therapies, assessing the clinical validity and utility, the efficacy, and the cost-effectiveness of new interventions. The current format of cost-effectiveness analysis, however, does not allow for inclusion of more holistic aspects of health and, therefore, value elements for new technologies such as the impact on patients and society beyond its pure clinical and economic value. This study aimed to review the recent modelling attempts to expand the traditional cost-effectiveness analysis approach by incorporating additional elements of value in health technology assessment. A pragmatic literature review was conducted for articles published between 2012 and 2022 reporting cost-effectiveness analysis including value aspects beyond the clinical and cost-effectiveness estimates; searches identified 13 articles that were eligible for inclusion. These expanded modelling approaches mainly focused on integrating the impact of societal values and health equity in cost-effectiveness analysis, both of which were championed as important aspects of health technology assessment that should be incorporated into future technology assessments. The reviewed cost-effectiveness analysis methods included modification of the current cost-effectiveness analysis methodology (distributional cost-effectiveness analysis, augmented cost-effectiveness analysis, extended cost-effectiveness analysis) or the use of multi-criteria decision analysis. Of these approaches, augmented cost-effectiveness analysis appears to have the most potential by expanding traditional aspects of value, as it uses techniques already familiar to health technology assessment agencies but also allows space for incorporation of qualitative aspects of a product's value. This review showcases that methods to unravel additional value elements for technology assessment exist, therefore, patient access to promising technologies can be improved by moving the discussion from "if" to "how" additional value elements can inform decision-making.

Using multi-criteria decision analysis to describe stakeholder preferences for new quality improvement initiatives that could optimise prescribing in England

Background

Hospital decision-makers have limited resources to implement quality improvement projects. To decide which interventions to take forward, trade-offs must be considered that inevitably turn on stakeholder preferences. The multi-criteria decision analysis (MCDA) approach could make this decision process more transparent.

Method

An MCDA was conducted to rank-order four types of interventions that could optimise medication use in England's National Healthcare System (NHS) hospitals, including Computerised Interface, Built Environment, Written Communication, and Face-to-Face Interactions. Initially, a core group of quality improvers (N = 10) was convened to determine criteria that could influence which interventions are taken forward according to the Consolidated Framework for Implementation Research. Next, to determine preference weightings, a preference survey was conducted with a diverse group of quality improvers (N = 356) according to the Potentially All Pairwise Ranking of All Possible Alternatives method. Then, rank orders of four intervention types were calculated according to models with criteria unweighted and weighted according to participant preferences using an additive function. Uncertainty was estimated by probabilistic sensitivity analysis using 1,000 Monte Carlo Simulation iterations.

Results

The most important criteria influencing what interventions were preferred was whether they addressed "patient needs" (17.6%)' and their financial "cost (11.5%)". The interventions' total scores (unweighted score out of 30 | weighted out of 100%) were: Computerised Interface (25 | 83.8%), Built Environment (24 | 79.6%), Written Communication (22 | 71.6%), and Face-to-Face (22 | 67.8%). The probabilistic sensitivity analysis revealed that the Computerised Interface would be the most preferred intervention over various degrees of uncertainty.

Conclusions

An MCDA was conducted to rank order intervention types that stand to increase medication optimisation across hospitals in England. The top-ranked intervention type was the Computerised Interface. This finding does not imply Computerised Interface interventions are the most effective interventions but suggests that successfully implementing lower-ranked interventions may require more conversations that acknowledge stakeholder concerns.

The Use of Multicriteria Decision Analysis to Support Decision Making in Healthcare: An Updated Systematic Literature Review

OBJECTIVES

Multicriteria decision analysis (MCDA) is increasingly used for decision making in healthcare. However, its application in different decision-making contexts is still unclear. This study aimed to provide a comprehensive review of MCDA studies performed to inform decisions in healthcare and to summarize its application in different decision contexts.

METHODS

We updated a systematic review conducted in 2013 by searching Embase, MEDLINE, and Google Scholar for MCDA studies in healthcare, published in English between August 2013 and November 2020. We also expanded the search by reviewing grey literature found via Trip Medical Database and Google, published between January 1990 and November 2020. A comprehensive template was developed to extract information about the decision context, criteria, methods, stakeholders involved, and sensitivity analyses conducted.

RESULTS

From the 4295 identified studies, 473 studies were eligible for full-text review after assessing titles and abstracts. Of those, 228 studies met the inclusion criteria and underwent data extraction. The use of MCDA continues to grow in healthcare literature, with most of the studies (49%) informing priority-setting decisions. Safety, cost, and quality of care delivery are the most frequently used criteria, although there are considerable differences across decision contexts. Almost half of the MCDA studies used the linear additive model whereas scales and the analytical hierarchy process were the most used techniques for scoring and weighting, respectively. Not all studies report on each one of the MCDA steps, consider axiomatic properties, or justify the methods used.

CONCLUSIONS

A guide on how to conduct and report MCDA that acknowledges the particularities of the different decision contexts and methods needs to be developed.

Equitable Prioritization of Health Interventions by Incorporating Financial Risk Protection Weights Into Economic Evaluations

OBJECTIVES

Financial risk protection (FRP), or the prevention of medical impoverishment, is a major objective of health systems, particularly in low- and middle-income countries where the extent of out-of-pocket (OOP) health expenditures can be substantial. We sought to develop a method that allows decision makers to explicitly integrate FRP outcomes into their priority-setting activities.

METHODS

We used literature review to identify 31 interventions in low- and middle-income countries, each of which provided measures of health outcomes, costs, OOP health expenditures averted, and FRP (proxied by OOP health expenditures averted as a percentage of income), all disaggregated by income quintile. We developed weights drawn from the Z-score of each quintile-intervention pair based on the distribution of FRP of all quintile-intervention pairs. We next ranked the interventions by unweighted and weighted health outcomes for each income quintile. We also evaluated how pro-poor they were by, first, ordering the interventions by cost-effectiveness for each quintile and, next, calculating the proportion of interventions each income quintile would be targeted for a given random budget. A ranking was said to be pro-poor if each quintile received the same or higher proportion of interventions than richer quintiles.

RESULTS

Using FRP weights produced a more pro-poor priority setting than unweighted outcomes. Most of the reordering produced by the inclusion of FRP weights occurred in interventions of moderate cost-effectiveness, suggesting that these weights would be most useful as a way of distinguishing moderately cost-effective interventions with relatively high potential FRP.

CONCLUSIONS

This preliminary method of integrating FRP into priority-setting would likely be most suitable to deciding between health interventions with intermediate cost-effectiveness.

Willingness to pay for cancer prevention, screening, diagnosis, and treatment: a systematic review

INTRODUCTION

Willingness to pay (WTP) studies examine the maximum amount of money an individual is willing to pay for a specified health intervention, and can be used to inform coverage and reimbursement decisions. Our objectives were to assess how people value cancer-related interventions, identify differences in the methodologies used, and review the trends in studies' publication.

AREAS COVERED

We extracted PubMed and EconLit articles published in 1997-2020 that reported WTP for cancer-related interventions, characterized the methodological differences and summarized each intervention's mean and median WTP values. We reviewed 1,331 abstracts and identified 103 relevant WTP studies, of which 37 (36%) focused on treatment followed by screening (26), prevention (21), diagnosis (7) and other interventions (12). The methods used to determine WTP values were primarily discrete-choice questions (n = 54, 52%), bidding games (15), payment cards (12) and open-ended questions (12). We found a wide variation in WTP reported values ranged from below $100 to over $20,000.

EXPERT OPINION

The WTP literature on oncology interventions has grown rapidly. There is considerable heterogeneity with respect to the type of interventions and diseases assessed, the respondents' characteristics, and the study methodologies. This points to the need to establish international guidelines for best practices in this field.

The Value of Explicit, Deliberative, and Context-Specified Ethics Analysis for Health Technology Assessment: Evidence From a Novel Approach Piloted in South Africa

OBJECTIVES

This article explores the perceived value, including associated strengths and challenges, of using a context-specified ethics framework to guide deliberative health technology appraisals.

METHODS

The South African Values and Ethics for Universal Health Coverage (SAVE-UHC) approach, piloted in South Africa, consisted of 2 phases: (1) convening a national multistakeholder working group to develop a provisional ethics framework and (2) testing the provisional ethics framework through simulated health technology assessment appraisal committee meetings (SACs). Three SACs each reviewed 2 case studies of sample health interventions using the framework. Participants completed postappraisal questionnaires and engaged in focus group discussions.

RESULTS

The SACs involved 27 participants across 3 provinces. Findings from the postappraisal questionnaires demonstrated general support for the SAVE-UHC approach and content of the framework, high levels of satisfaction with the recommendations produced, and general sentiment that participants were able to actively contribute to appraisals. Qualitative data showed participants perceived using a context-specified ethics framework in deliberative decision making: (1) supported wider consideration of and deliberation about morally relevant features of the health coverage decisions, thereby contributing to quality of appraisals; (2) could improve transparency; and (3) offered benefits to those directly involved in the priority-setting process. Participants also identified some challenges and concerns associated with the approach.

CONCLUSIONS

The SAVE-UHC approach presents a novel way to develop and pilot a locally contextualized, explicit ethics framework for health priority setting. This work highlights how the combination of a context-specified ethics framework and structured deliberative appraisals can contribute to the quality of health technology appraisals and transparency of health priority setting.

Decision-making processes for essential packages of health services: experience from six countries

Many countries around the world strive for universal health coverage, and an essential packages of health services (EPHS) is a central policy instrument for countries to achieve this. It defines the coverage of services that are made available, as well as the proportion of the costs that are covered from different financial schemes and who can receive these services. This paper reports on the development of an analytical framework on the decision-making process of EPHS revision, and the review of practices of six countries (Afghanistan, Ethiopia, Pakistan, Somalia, Sudan and Zanzibar-Tanzania).The analytical framework distinguishes the practical organisation, fairness and institutionalisation of decision-making processes. The review shows that countries: (1) largely follow a similar practical stepwise process but differ in their implementation of some steps, such as the choice of decision criteria; (2) promote fairness in their EPHS process by involving a range of stakeholders, which in the case of Zanzibar included patients and community members; (3) are transparent in terms of at least some of the steps of their decision-making process and (4) in terms of institutionalisation, express a high degree of political will for ongoing EPHS revision with almost all countries having a designated governing institute for EPHS revision.We advise countries to organise meaningful stakeholder involvement and foster the transparency of the decision-making process, as these are key to fairness in decision-making. We also recommend countries to take steps towards the institutionalisation of their EPHS revision process.

Impact of information and deliberation on the consistency of preferences for prioritization in health care - evidence from discrete choice experiments undertaken alongside citizens' juries

BACKGROUND

Public preferences are an important consideration for priority-setting. Critics suggest preferences of the public who are potentially naïve to the issue under consideration may lead to sub-optimal decisions. We assessed the impact of information and deliberation via a Citizens' Jury (CJ) or preference elicitation methods (Discrete Choice Experiment, DCE) on preferences for prioritizing access to bariatric surgery.

METHODS

Preferences for seven prioritization criteria (e.g. obesity level, obesity-related comorbidities) were elicited from three groups who completed a DCE: (i) participants from two CJs (n = 28); (ii) controls who did not participate in the jury (n = 21); (iii) population sample (n = 1,994). Participants in the jury and control groups completed the DCE pre- and post-jury. DCE data were analyzed using multinomial logit models to derive "priority weights" for criteria for access to surgery. The rank order of criteria was compared across groups, time points and CJ recommendations.

RESULTS

The extent to which the criteria were considered important were broadly consistent across groups and were similar to jury recommendations but with variation in the rank order. Preferences of jurors but not controls were more differentiated (that is, criteria were assigned a greater range of priority weights) after than before the jury. Juror preferences pre-jury were similar to that of the public but appeared to change during the course of the jury with greater priority given to a person with comorbidity. Conversely, controls appeared to give a lower priority to those with comorbidity and higher priority to treating very severe obesity after than before the jury.

CONCLUSION

Being informed and undertaking deliberation had little impact on the criteria that were considered to be relevant for prioritizing access to bariatric surgery but may have a small impact on the relative importance of criteria. CJs may clarify underlying rationale but may not provide substantially different prioritization recommendations compared to a DCE.

Societal preferences for funding orphan drugs in China: An application of the discrete choice experiment method

Objectives

To explore whether a societal preference for orphan drugs exists in Chinese general public and to quantitatively measure the personal trade-off between essential attributes of orphan drugs through a discrete choice experiment.

Methods

A labeled discrete choice experiment was employed to measure public preference. Six attributes (impact of diseases on life-years, impact of diseases on quality of life, availability of alternative drug treatments, annual cost per patient paid by medical insurance, expected increases in life-expectancy, and improvements to the quality of life) were identified through a literature review, experts' suggestions, and stakeholders' semi-structured interviews, then refined through a pre-survey. The current study used a D-efficient design to yield 27 choice sets divided into three blocks with nine questions containing the labeled treatment (either orphan drugs or common drugs). Information on sociodemographic characteristics and individual preferences was collected through a web-based questionnaire using convenience sampling. A mixed logit model was used to test societal preferences for orphan drugs over common drugs, while a binary logit model was used to measure the relative importance of each attribute in orphan drug access for the National Reimbursement Drug List and its willingness to pay.

Results

A total of 323 persons participated in this study. Respondents largely had indifferent attitudes toward orphan drugs and common drugs. The binary logit model results showed that 5 of the 6 attributes were significant, except for the availability of alternative drug treatments. The most impacted factor was the annual cost per patient paid by medical insurance (β = -1.734, odds ratio [OR] = 0.177). Among non-economic attributes, the impact of diseases on life-years-with no treatment, the patient will die in the prime of life (β = 0.523, OR = 1.688, willingness to pay = 301,895)-was most concerning, followed by significant improvements to the quality of life (β = 0.516, OR = 1.676, willingness to pay = 297,773).

Conclusion

The general public in China does not value rarity as a sufficient reason to justify special consideration in funding orphan drugs. When making orphan drug coverage decisions, the public prioritized the annual cost, disease severity, and drug effects.

Quantitative Benefit-Risk Assessment of COVID-19 Vaccines Using the Multi-Criteria Decision Analysis

In the early SARS-CoV-2 (COVID-19) pandemic, four major vaccines were approved despite limited efficacy and safety data through short regulatory review periods. Thus, it is necessary to assess the benefit-risk (BR) profiles of the COVID-19 vaccines. We conducted a quantitative BR assessment for four COVID-19 vaccines (mRNA-based: mRNA-1273 and BNT162b2; viral vector-based: Ad26.COV.2 and ChAdOx1-S) using multi-criteria decision analysis. Three benefit criteria and two risk criteria were considered: preventing COVID-19 infection for (1) adults aged ≥18 years; (2) seniors aged 60 years or older; and (3) severe COVID-19, adverse events (AEs), and serious AEs. Data were retrieved from clinical trials, observational studies, and county-specific AE monitoring reports. Based on the collected data, vaccines were scored for each criterion. 22 professionals weighted each criterion. The overall BR score was calculated using scores and weights. mRNA-1273 was the most preferred vaccine in pre-authorization and BNT162b2 in post-authorization. We found that the mRNA vaccine had a good balance between the benefits and risks. Using this BR assessment, the benefit-risk profile of COVID-19 vaccines can be updated with cumulated data. It will contribute to building evidence for decision making by policy makers and health professionals.

Toward comprehensive value assessment for Alzheimer's disease innovations

INTRODUCTION

Assessing medical technologies for Alzheimer's disease (AD) creates challenges for current methods of value assessment. New value assessment approaches for AD are also needed.

METHODS

We adapted concepts from health economics to help guide decision makers to more informed decisions about AD therapies and diagnostics.

RESULTS

We propose a value framework based on five categories: perspective, value elements, analysis, reporting, and decision making. AD value assessments should include the perspective of the patient-caregiver dyad. We propose a broader array of value elements than currently used. Analytics and decision methods can synthesize evidence for all elements of value. Decisions should use a "deliberative appraisal" approach informed by the composite evidence and be transparently reported.

DISCUSSION

Using the proposed framework, the value of forthcoming innovations for AD may be more thoroughly assessed for and by all stakeholders. It can guide decision makers to carefully consider all relevant elements of value contributing to more holistic and transparent decision making.

RESEARCH HIGHLIGHTS

Alzheimer's disease challenges common methods of evaluating medical technology. Using current methods, new AD innovations might not be appropriately valued. Poor value assessments will adversely affect patient access to AD innovations. A full AD value framework expands perspective, elements, analysis, decision-making, reporting.

Evidence-Informed Deliberative Processes for Health Benefit Package Design - Part II: A Practical Guide

BACKGROUND

Countries around the world are using health technology assessment (HTA) for health benefit package design. Evidence-informed deliberative processes (EDPs) are a practical and stepwise approach to enhance legitimate health benefit package design based on deliberation between stakeholders to identify, reflect and learn about the meaning and importance of values, informed by evidence on these values. This paper reports on the development of practical guidance on EDPs, while the conceptual framework of EDPs is described in a companion paper.

METHODS

The first guide on EDPs (2019) is further developed based on academic knowledge exchange, surveying 27 HTA bodies and 66 experts around the globe, and the implementation of EDPs in several countries. We present the revised steps of EDPs and how selected HTA bodies (in Australia, Brazil, Canada, France, Germany, Scotland, Thailand and the United Kingdom) organize key issues of legitimacy in their processes. This is based on a review of literature via PubMed and HTA bodies' websites.

RESULTS

HTA bodies around the globe vary considerable in how they address legitimacy (stakeholder involvement ideally through participation with deliberation; evidence-informed evaluation; transparency; and appeal) in their processes. While there is increased attention for improving legitimacy in decision-making processes, we found that the selected HTA bodies are still lacking or just starting to develop activities in this area. We provide recommendations on how HTA bodies can improve on this.

CONCLUSION

The design and implementation of EDPs is in its infancy. We call for a systematic analysis of experiences of a variety of countries, from which general principles on EDPs might subsequently be inferred.

Systems Science and Evidence-Informed Deliberation to Mitigate Dilemmas in Situations of Dual Agency at the Hospital Level Comment on "Dual Agency in Hospitals: What Strategies Do Managers and Physicians Apply to Reconcile Dilemmas Between Clinical and Economic Considerations"

The article by Waitzberg et al on dual agency in hospitals reports on three strategies to mitigate dilemmas arising from conflicting clinical and economic considerations. This could be further explored by using systems science methods that allow in-depth analyses of (health) system dynamics, networks, and agent-based modelling, and that take into account local context, incentives and how institutions work. Future studies may also draw on the literature of multi-criteria decision-making and evidence-informed deliberative processes (EDPs) that are increasingly being used to optimise legitimate health benefit package design. Toolkits to assist hospital professionals in improving their decision-making need to be practical, with ample attention for the process of decision-making, including transparency, use of evidence, and opportunities for health professionals (and possibly others stakeholders) to contest or formally appeal against certain decisions.

Stakeholder perception of pharmaceutical value: A multicriteria decision analysis pilot case study for value assessment in the United States

BACKGROUND: Recent attention to value frameworks has highlighted limitations of current conventional value and health technology assessment (V/HTA) methods (eg, cost-effectiveness). Multicriteria decision analysis (MCDA) has potential as a supplemental tool to incorporate additional value criteria into conventional value assessment. OBJECTIVE: To conduct a pilot study to illustrate the impact of an MCDA approach on the value perceptions of hypothetical treatment profiles from a multistakeholder panel. METHODS: Participants voted on value perceptions of 2 hypothetical treatments with similar cost-effectiveness evidence: Treatment A for aggressive B-cell non-Hodgkin lymphoma in adults and treatment B for episodic migraine in adults. Participants voted treatments A and B as low, intermediate, or high value before and after a weighting exercise on prespecified, additional value criteria. Weights from participants were used to calculate treatment-specific MCDA scores from 0 (least favorable) to 100 (most favorable) and were presented to participants for a second value-perception vote. Analyses compared changes in value perceptions within treatments A and B post-MCDA exercise. RESULTS: Before considering MCDA scores for treatment A, 0% of participants considered it to be low, 52% intermediate, and 48% high value. After considering MCDA scores for treatment A, 4% considered it low, 29% intermediate, and 67% high value. Both before and after considering MCDA scores for treatment B, 13%, considered it low, 57% intermediate, and 30% high value. Mean MCDA scores for treatments A and B were 67 and 63, respectively. Of all stakeholders, 41% altered their perception of value for treatment A (9% negatively and 32% positively) and, separately, 45% for treatment B (23% both negatively and positively) after considering MCDA scores. CONCLUSIONS: With nearly half of participants altering their perception of value after consideration of additional value criteria, findings support the need for a more inclusive and flexible value assessment process. DISCLOSURES: This study was funded by The National Pharmaceutical Council. Dr Perfetto was employed by the National Health Council (NHC) at the time this work was completed, and all honoraria and consulting and travel fees were paid to the NHC. The NHC is a not-for-profit, membership organization. It is supported through membership dues and sponsorship funds. The complete list of members and sponsors is located on the NHC's website at www.nationalhealthcouncil.org. She is also an advisor for the Brain Injury Association of America, Dan Lewis Foundation, and Canter for Medical Technology Policy.

Moving Beyond Quality-Adjusted Life-Years in Elderly Care: How Can Multicriteria Decision Analysis Complement Cost-Effectiveness Analysis in Local-Level Decision Making

OBJECTIVES

This study aimed to investigate how multicriteria decision analysis (MCDA) could complement cost-effectiveness analysis (CEA) to support investment decisions in elderly care at local level.

METHODS

We used an integrated elderly care program in The Netherlands as a case study to demonstrate the application of both methods. In a 12-month quasi-experimental study (n = 384), data on the following outcome measures were collected: quality-adjusted life-years (CEA) and physical functioning, psychological well-being, social relationships and participation, enjoyment of life, resilience, person centeredness, continuity of care, and costs (MCDA). We performed regression analysis on inversed probability weighted data and controlled for potential confounders to obtain a double robust estimate of the outcomes. Probabilistic sensitivity analyses determined uncertainty for both methods.

RESULTS

The integrated elderly care program was not likely (ie, 36%) to be cost-effective according to the CEA (incremental cost-effectiveness ratios: €88 249 from a societal perspective) using the conventional Dutch willingness-to-pay threshold (ie, €50 000). The MCDA demonstrated that informal caregivers and professionals slightly preferred the intervention over usual care, driven by enjoyment of life and person centeredness. Patients did not prefer either the intervention or usual care, whereas payers and policy makers slightly preferred usual care, mainly due to higher costs of the intervention.

CONCLUSIONS

MCDA could provide local-level decision makers with a broader measurement of effectiveness by including outcomes beyond health and longevity and the preferences of multiple stakeholders. This additional information could foster the acceptability and implementability of cost-effective innovations in elderly care.

The Use of Evidence-Informed Deliberative Processes for Health Benefit Package Design in Kazakhstan

Kazakhstan strives to obtain Universal Health Coverage (UHC) by using health technology assessment (HTA) for determining their health benefit package. This paper reports on employing evidence-informed deliberative processes (EDPs), a practical and stepwise approach to enhance legitimate health benefit package design in Kazakhstan.

METHODS

The Ministry of Health of Kazakhstan approved the operationalization and application of EDPs during March 2019 and December 2020. We used a combination of desk research, conducting HTA, online surveys as well as a face-to-face workshop in Nur-Sultan, Kazakhstan, and two online workshops to prioritize 25 selected health technologies. During the latter, we tested two alternative approaches to prioritization: quantitative multicriteria decision analysis (MCDA) and the use of decision rules.

RESULTS

For each of the HTA reports, evidence summaries were developed according to the decision criteria (safety, social priority disease, severity of disease, effectiveness, cost-effectiveness, level of evidence, financial risk protection and budget impact). When appraising the evidence, the advisory committee preferred using quantitative MCDA, and only when this would result in any controversy could decision rules be applied.

CONCLUSIONS

Despite several challenges, including a partial disruption because of the COVID-19 pandemic, implementation of the process will likely play a key role in determining an evidence-informed and transparent health benefit package.

Using decision analysis to support implementation planning in research and practice

BACKGROUND

The process of implementing evidence-based interventions, programs, and policies is difficult and complex. Planning for implementation is critical and likely plays a key role in the long-term impact and sustainability of interventions in practice. However, implementation planning is also difficult. Implementors must choose what to implement and how best to implement it, and each choice has costs and consequences to consider. As a step towards supporting structured and organized implementation planning, we advocate for increased use of decision analysis.

MAIN TEXT

When applied to implementation planning, decision analysis guides users to explicitly define the problem of interest, outline different plans (e.g., interventions/actions, implementation strategies, timelines), and assess the potential outcomes under each alternative in their context. We ground our discussion of decision analysis in the PROACTIVE framework, which guides teams through key steps in decision analyses. This framework includes three phases: (1) definition of the decision problems and overall objectives with purposeful stakeholder engagement, (2) identification and comparison of different alternatives, and (3) synthesis of information on each alternative, incorporating uncertainty. We present three examples to illustrate the breadth of relevant decision analysis approaches to implementation planning.

CONCLUSION

To further the use of decision analysis for implementation planning, we suggest areas for future research and practice: embrace model thinking; build the business case for decision analysis; identify when, how, and for whom decision analysis is more or less useful; improve reporting and transparency of cost data; and increase collaborative opportunities and training.

Health economic evaluation of digital nursing technologies: a review of methodological recommendations

BACKGROUND

Health economic evaluation of digital nursing technologies (DNT) is important to provide information that helps avoid undesirable developments and implementations as well as increase the chances of success of developed applications. At the same time, studies and evidence on cost-effectiveness are still very rare in this field. Review studies in related technology areas such as telemedicine frequently criticise the quality and comparability of health economic evaluations conducted in this field. Based on a content analysis of methodological literature on the economic evaluation of innovative (digital) technologies in health and nursing, this article aims to identify specific challenges in this research area and offers recommendations on how to address these challenges to promote more sound health economic evaluations in the future.

METHODS

A rapid review was conducted, consisting of a systematic search in the Pubmed database as well as Google Scholar. In addition, the literature lists of the analysed texts were scoured for additional texts to be included. Methodological literature, single studies, and reviews were included. A total of 536 studies were screened, of which 29 were included in the full text analysis.

RESULTS

Based on the systematic content analysis of the studies under consideration, 10 specific methodological challenges are identified, and the methodological recommendations were examined for consideration. A particular focus was given to whether specific methodological approaches might be needed in the context of evaluating the efficiency of DNT.

CONCLUSION

Many of the challenges identified for the health economic evaluations of digital nursing technologies are comparable to those of other complex health care interventions. The recommendations discussed can help to alleviate those challenges. Future research should focus on alternative approaches to assessing causality in different phases of technology development while maintaining high evidence standards. High-evidence economic assessment of technologies in nursing care should be carried out in routine use, especially if they are intended to be reimbursed by the social insurance.

Methods and criteria for the assessment of orphan drugs: a scoping review

OBJECTIVES

This study aimed to identify different criteria for priority setting of rare diseases to help policy makers in making evidence-informed decisions.

METHODS

A scoping review was conducted to comprehensively examine the existing various methods and criteria for prioritizing orphan drugs and rare diseases. We performed searching in Scopus, PubMed, Embase, and websites of health technology assessment (HTA) agencies, 2000-21, and data were extracted.

RESULTS

From the 1,580 identified publications, eleven articles were included. Multicriteria decision analysis was the most frequent method (seven out of eleven studies) used for priority setting. The extracted criteria for priority setting of orphan products were analyzed based on six main categories as follows: health outcomes and clinical implications (six subsets which showed clinical implications), economic aspects (four subsets that indicated the economic effects of orphan drugs and rare diseases), disease and population characteristics (six subsets that included the characteristics of the rare diseases), therapeutic alternatives and uniqueness of orphan technologies (two subsets which discussed the alternatives and uniqueness of orphan technologies), evidence (three subsets which regarded the quality and availability of evidence), and other criteria (three subsets dealing with social and organizational criteria). Cost-effectiveness, budget impact, and disease severity were the most frequent criteria in the studies.

CONCLUSIONS

Because of the high price of orphan drugs and limitations of using HTA for reimbursement of them, it is critical to explore them by precise technical methods like multiple criteria decision making in priority setting.

Value-based person-centred integrated care for frail elderly living at home: a quasi-experimental evaluation using multicriteria decision analysis

OBJECTIVE

To evaluate the value of the person-centred, integrated care programme Care Chain Frail Elderly (CCFE) compared with usual care, using multicriteria decision analysis (MCDA).

DESIGN

In a 12-month quasi-experimental study, triple-aim outcomes were measured at 0, 6 and 12 months by trained interviewers during home-visits.

SETTING

Primary care, community-based elderly care.

PARTICIPANTS

384 community-dwelling frail elderly were enrolled. The 12-month completion rate was 70% in both groups. Propensity score matching was used to balance age, gender, marital status, living situation, education, smoking status and 3 month costs prior to baseline between the two groups.

INTERVENTION

The CCFE is an integrated care programme with unique features like the presence of the elderly and informal caregiver at the multidisciplinary team meetings, and a bundled payment.

PRIMARY AND SECONDARY OUTCOMES MEASURES

The MCDA results in weighted overall value scores that combines the performance on physical functioning, psychological well-being, social relationships and participation, enjoyment of life, resilience, person-centredness, continuity of care and costs, with importance weights of patients, informal caregivers, professionals, payers and policy-makers.

RESULTS

At 6 months, the overall value scores of CCFE were higher in all stakeholder groups, driven by enjoyment of life (standardised performance scores 0.729 vs 0.685) and person-centredness (0.749 vs 0.663). At 12 months, the overall value scores in both groups were similar from a patient's perspective, slightly higher for CCFE from an informal caregiver's and professional's perspective, and lower for CCFE from a payer's and policy-maker's perspective. The latter was driven by a worse performance on physical functioning (0.682 vs 0.731) and higher costs (€22 816 vs €20 680).

CONCLUSIONS

The MCDA indicated that the CCFE is the preferred way of delivering care to frail elderly at 6 months. However, at 12 months, MCDA results showed little difference from the perspective of patients, informal caregivers and professionals, while payers and policy-makers seemed to prefer usual care.