Value Assessment Frameworks for HTA Agencies: The Organization of Evidence-Informed Deliberative Processes

Selecting topic areas for developing quality standards in a resource-limited setting

Variation in practices of and access to health promotion and disease prevention (P&P) across geographical areas have been studied in Thailand as well as other healthcare settings. The implementation of quality standards (QS)—a concise set of evidence-informed quality statements designed to drive and measure priority quality improvements—can be an option to solve the problem. This paper aims to provide an overview of the priority setting process of topic areas for developing QS and describes the criteria used. Topic selection consisted of an iterative process involving several steps and relevant stakeholders. Review of existing documents on the principles and criteria used for prioritising health technology assessment topics were performed. Problems with healthcare services were reviewed, and stakeholder consultation meetings were conducted to discuss current problems and comment on the proposed prioritisation criteria. Topics were then prioritised based on both empirical evidence derived from literature review and stakeholders’ experiences through a deliberative process. Preterm birth, pre-eclampsia and postpartum haemorrhage were selected. The three health problems had significant disease burden; were prevalent among pregnant women in Thailand; led to high mortality and morbidity in mothers and children and caused variation in the practices and service uptake at health facilities. Having agreed-on criteria is one of the important elements of the priority setting process. The criteria should be discussed and refined with various stakeholders. Moreover, key stakeholders, especially the implementers of QS initiative, should be engaged in a constructive way and should be encouraged to actively participate and contribute significantly in the process.

The WHO-INTEGRATE evidence to decision framework version 1.0: integrating WHO norms and values and a complexity perspective

INTRODUCTION

Evidence-to-decision (EtD) frameworks intend to ensure that all criteria of relevance to a health decision are systematically considered. This paper, part of a series commissioned by the WHO, reports on the development of an EtD framework that is rooted in WHO norms and values, reflective of the changing global health landscape, and suitable for a range of interventions and complexity features. We also sought to assess the value of this framework to decision-makers at global and national levels, and to facilitate uptake through suggestions on how to prioritise criteria and methods to collect evidence.

METHODS

In an iterative, principles-based approach, we developed the framework structure from WHO norms and values. Preliminary criteria were derived from key documents and supplemented with comprehensive subcriteria obtained through an overview of systematic reviews of criteria employed in health decision-making. We assessed to what extent the framework can accommodate features of complexity, and conducted key informant interviews among WHO guideline developers. Suggestions on methods were drawn from the literature and expert consultation.

RESULTS

The new WHO-INTEGRATE (INTEGRATe Evidence) framework comprises six substantive criteria-balance of health benefits and harms, human rights and sociocultural acceptability, health equity, equality and non-discrimination, societal implications, financial and economic considerations, and feasibility and health system considerations-and the meta-criterion quality of evidence. It is intended to facilitate a structured process of reflection and discussion in a problem-specific and context-specific manner from the start of a guideline development or other health decision-making process. For each criterion, the framework offers a definition, subcriteria and example questions; it also suggests relevant primary research and evidence synthesis methods and approaches to assessing quality of evidence.

CONCLUSION

The framework is deliberately labelled version 1.0. We expect further modifications based on focus group discussions in four countries, example applications and input across concerned disciplines.

Identifying the Need for Good Practices in Health Technology Assessment: Summary of the ISPOR HTA Council Working Group Report on Good Practices in HTA

The systematic use of evidence to inform healthcare decisions, particularly health technology assessment (HTA), has gained increased recognition. HTA has become a standard policy tool for informing decision makers who must manage the entry and use of pharmaceuticals, medical devices, and other technologies (including complex interventions) within health systems, for example, through reimbursement and pricing. Despite increasing attention to HTA activities, there has been no attempt to comprehensively synthesize good practices or emerging good practices to support population-based decision-making in recent years. After the identification of some good practices through the release of the ISPOR Guidelines Index in 2013, the ISPOR HTA Council identified a need to more thoroughly review existing guidance. The purpose of this effort was to create a basis for capacity building, education, and improved consistency in approaches to HTA-informed decision-making. Our findings suggest that although many good practices have been developed in areas of assessment and some other key aspects of defining HTA processes, there are also many areas where good practices are lacking. This includes good practices in defining the organizational aspects of HTA, the use of deliberative processes, and measuring the impact of HTA. The extent to which these good practices are used and applied by HTA bodies is beyond the scope of this report, but may be of interest to future researchers.

[Ethics in health technology assessment. Review]

INTRODUCTION

Bioethics and the health technologies assessment emerged to help make decisions. The objective of the work was to know, with respect to the health technologies assessment, the scientific production on its ethical issues, the degree of incorporation of these in practice, the inclusion of the values in the deliberative processes and the most relevant approaches to ethical analysis.

METHODOLOGY

A narrative review was made, based on a systematic search of literature in both natural and hierarchical language, using the terms technology assessment biomedical, ethics and deliberation (and its related terms). All types of papers published between May 2007 and April 2017 in Spanish, French, English or Italian that included both ethical aspects and health technology assessment were included. The PUBMED, OVID-Medline, Scopus databases and secondary searches were explored from the identified works. The information was extracted by a single researcher and managed with Mendeley and EPIINFO 7.2.

RESULTS

A total of 141 papers were identified, including 85 after revision by title and summary, with the following characteristics: 29 reviews (5 systematic), 16 frameworks, 18 methodological works and 29 with description of experiences. Multiple frameworks, approaches and methods in ethical analysis were identified.

CONCLUSION

The health technologies assessment has an approach excessively mechanistic, and can be improved by incorporating the values of the stakeholder, through deliberative processes. The methods of ethical analysis that seem most suitable are the axiological ones and those developed specifically for the health technologies assessment.

How can MCDA tools improve priority setting? Four critical questions

This comment argues that four critical questions needs to be resolved before MCDA tools can improve priority setting in health: how to merge the quantitative and deliberative elements of MCDA; how to select criteria; how to weigh them, and whom to bring to the table.

Can reflective multicriteria be the new paradigm for healthcare decision-making? The EVIDEM journey

Background

Multiple technologies, procedures and programs call for fairly-based decisions for prioritization of healthcare interventions. There is a diversity of perspectives of what constitutes a legitimate decision, which depends on both the process and the reasoning applied. Current approaches focus on technical aspects while methods to support alignment of decisions with the compassionate impetus of healthcare systems is lacking.

Methods

The framework was developed based on an analysis of the foundations of healthcare systems, the reasoning underlying decisions and fair processes. The concept of reflective multicriteria was created: it assumes that decisionmakers guided by a generic interpretative frame rooted in the compassionate impetus of healthcare systems, can sharpen their reasoning, raise awareness of their motivation and increase legitimacy of decisions. The initial framework was made available through a not for profit organization (the EVIDEM Collaboration, 2006–2017) to stimulate its development with thought leaders and stakeholders in an open source philosophy. Development was tailored to the real-life needs of decisionmakers and drew on several domains of knowledge including healthcare ethics, evidenced-based medicine, health economics, health technology assessment and multicriteria approaches.

Results

The 10th edition framework builds on four dimensions: (1) the universal impetus of healthcare systems, (2) reasoning, values and ethics, (3) evidence and knowledge on interventions, and (4) a transformative process. Mathematical aspects of the framework are designed to help clarify, express and share individual reasoning; this non-conventional use of numbers requires a cultural change and needs to be phased in slowly. The framework includes four tools for easy adaptation and operationalization: (a) concepts and operationalization, (b) adapt and pilot, (c) evidence matrix, (d) mathematical representation of reasoning. Application is useful throughout all types of healthcare interventions, for all levels of decision, and across the globe.

Conclusion

By clarifying their reasoning while keeping decisionmakers aware of the impetus of healthcare systems, reflective multicriteria provides an effective approach to increase the legitimacy of decisions. Beyond a tool, reflective multicriteria pioneered by EVIDEM is geared to transform our vision of the value of healthcare interventions and how they might contribute to relevant, equitable and sustainable healthcare systems.

Electronic supplementary material

The online version of this article (10.1186/s12962-018-0116-9) contains supplementary material, which is available to authorized users.

Evaluating facts and facting evaluations: On the fact-value relationship in HTA

Health technology assessment (HTA) is an evaluation of health technologies in terms of facts and evidence. However, the relationship between facts and values is still not clear in HTA. This is problematic in an era of "fake facts" and "truth production." Accordingly, the objective of this study is to clarify the relationship between facts and values in HTA. We start with the perspectives of the traditional positivist account of "evaluating facts" and the social-constructivist account of "facting values." Our analysis reveals diverse relationships between facts and a spectrum of values, ranging from basic human values, to the values of health professionals, and values of and in HTA, as well as for decision making. We argue for sensitivity to the relationship between facts and values on all levels of HTA, for being open and transparent about the values guiding the production of facts, and for a primacy for the values close to the principal goals of health care, ie, relieving suffering. We maintain that philosophy (in particular ethics) may have an important role in addressing the relationship between facts and values in HTA. Philosophy may help us to avoid fallacies of inferring values from facts; to disentangle the normative assumptions in the production or presentation of facts and to tease out implicit value judgements in HTA; to analyse evaluative argumentation relating to facts about technologies; to address conceptual issues of normative importance; and to promote reflection on HTA's own value system. In this we argue for a(n Aristotelian) middle way between the traditional positivist account of "evaluating facts" and the social-constructivist account of "facting values," which we call "factuation." We conclude that HTA is unique in bringing together facts and values and that being conscious and explicit about this "factuation" is key to making HTA valuable to both individual decision makers and society as a whole.

A multicriteria resource allocation model for the redesign of services following birth

BACKGROUND

Many healthcare services are under considerable pressure to reduce costs while improving quality. This is particularly true in the United Kingdom's National Health Service where postnatal care is sometimes viewed as having a low priority. There is much debate about the service's redesign and the reallocation of resources, both along care pathways and between groups of mothers and babies with different needs. The aim of this study was to develop a decision support tool that would encourage a systemic approach to service redesign and that could assess the various quality and financial implications of service change options making the consequent trade-offs explicit. The paper describes the development process and an initial implementation as a preliminary exploration of the possible merits of this approach.

METHODS

Other studies have suggested that combining multicriteria decision analysis with programme budgeting and marginal analysis might offer a suitable basis for resource allocation decisions in healthcare systems. The Postnatal care Resource Allocation Model incorporated this approach in a decision support tool to analyse the consequences of varying design parameters, notably staff contacts and time, on the various quality domains and costs. The initial phase of the study focussed on mapping postnatal care, involving interviews and workshops with a variety of stakeholders. This was supplemented with a literature review and the resultant knowledge base was encoded in the decision support tool. The model was then tested with various stakeholders before being used in an NHS Trust in England.

RESULTS

The model provides practical support, helping staff explore options and articulate their proposals for the redesign of postnatal care. The integration of cost and quality domains facilitates trade-offs, allowing staff to explore the benefits of reallocating resources between hospital and community-based care, and different patient-categories.

CONCLUSIONS

The main benefits of the model include its structure for assembling the key data, sharing evidence amongst multi-professional teams and encouraging constructive, systemic debate. Although the model was developed in the context of the routine maternity services for mothers and babies in the days following birth it could be adapted for use in other health care services.

Determining the Value of Two Biologic Drugs for Chronic Inflammatory Skin Diseases: Results of a Multi-Criteria Decision Analysis

BACKGROUND AND OBJECTIVE

Multi-criteria decision analysis (MCDA) is a tool that systematically considers multiple factors relevant to health decision-making. The aim of this study was to use an MCDA to assess the value of dupilumab for severe atopic dermatitis compared with secukinumab for moderate to severe plaque psoriasis in Spain.

METHOD

Following the EVIDEM (Evidence and Value: Impact on DEcision Making) methodology, the estimated value of both interventions was obtained by means of an additive linear model that combined the individual weighting (between 1 and 5) of each criterion with the individual scoring of each intervention in each criterion. Dupilumab was evaluated against placebo, while secukinumab was evaluated against placebo, etanercept and ustekinumab. A retest was performed to assess the reproducibility of weights, scores and value estimates.

RESULTS

The overall MCDA value estimate for dupilumab versus placebo was 0.51 ± 0.14. This value was higher than those obtained for secukinumab: 0.48 ± 0.15 versus placebo, 0.45 ± 0.15 versus etanercept and 0.39 ± 0.18 versus ustekinumab. The highest-value contribution was reported by the patients' group, followed by the clinical professionals and the decision makers. A fundamental element that explained the difference in the scoring between pathologies was the availability of therapeutic alternatives. The retest confirmed the consistency and replicability of the analysis.

CONCLUSIONS

Under this methodology, and assuming similar economic costs per patient for both treatments, the results indicated that the overall value estimated of dupilumab for severe atopic dermatitis was similar to, or slightly higher than, that of secukinumab for moderate to severe plaque psoriasis.

IMPORTANCE OF CONTEXTUAL DATA IN PRODUCING HEALTH TECHNOLOGY ASSESSMENT RECOMMENDATIONS: A CASE STUDY

OBJECTIVES

Contextual data and local expertise are important sources of data that cannot be ignored in hospital-based health technology assessment (HTA) processes. Despite a lack of or unconvincing evidence in the scientific literature, technology can be recommended in a given context. We illustrate this using a case study regarding biplane angiography for vascular neurointervention.

METHODS

A systematic literature review was conducted, along with an analysis of the context in our setting. The outcomes of interest were radiation doses, clinical complications, procedure times, purchase cost, impact on teaching program, the confidence of clinicians in the technology, quality of care, accessibility, and the volume of activity. A committee comprising managers, clinical experts, physicians, physicists and HTA experts was created to produce a recommendation regarding biplane technology acquisition to replace a monoplane device.

RESULTS

The systematic literature review yielded nine eligible articles for analysis. Despite a very low level of evidence in the literature, the biplane system appears to reduce ionizing radiation and medical complications, as well as shorten procedure time. Contextual data indicated that the biplane system could improve operator confidence, which could translate into reduced risk, particularly for complex procedures. In addition, the biplane system can support our institution in its advanced procedures teaching program.

CONCLUSIONS

Given the advantages provided by the biplane technology in our setting, the committee has recommended its acquisition. Contextual data were of utmost importance in this recommendation. Moreover, this technology should be implemented alongside a responsibility to collect outcome data to optimize clinical protocol in the doses of ionizing delivered.

Defining Elements of Value in Health Care-A Health Economics Approach: An ISPOR Special Task Force Report [3]

The third section of our Special Task Force report identifies and defines a series of elements that warrant consideration in value assessments of medical technologies. We aim to broaden the view of what constitutes value in health care and to spur new research on incorporating additional elements of value into cost-effectiveness analysis (CEA). Twelve potential elements of value are considered. Four of them-quality-adjusted life-years, net costs, productivity, and adherence-improving factors-are conventionally included or considered in value assessments. Eight others, which would be more novel in economic assessments, are defined and discussed: reduction in uncertainty, fear of contagion, insurance value, severity of disease, value of hope, real option value, equity, and scientific spillovers. Most of these are theoretically well understood and available for inclusion in value assessments. The two exceptions are equity and scientific spillover effects, which require more theoretical development and consensus. A number of regulatory authorities around the globe have shown interest in some of these novel elements. Augmenting CEA to consider these additional elements would result in a more comprehensive CEA in line with the "impact inventory" of the Second Panel on Cost-Effectiveness in Health and Medicine. Possible approaches for valuation and inclusion of these elements include integrating them as part of a net monetary benefit calculation, including elements as attributes in health state descriptions, or using them as criteria in a multicriteria decision analysis. Further research is needed on how best to measure and include them in decision making.

Progressive realisation of universal health coverage: what are the required processes and evidence?

Progressive realisation is invoked as the guiding principle for countries on their own path to universal health coverage (UHC). It refers to the governmental obligations to immediately and progressively move towards the full realisation of UHC. This paper provides procedural guidance for countries, that is, how they can best organise their processes and evidence collection to make decisions on what services to provide first under progressive realisation. We thereby use 'evidence-informed deliberative processes', a generic value assessment framework to guide decision making on the choice of health services. We apply this to the concept of progressive realisation of UHC. We reason that countries face two important choices to achieve UHC. First, they need to define which services they consider as high priority, on the basis of their social values, including cost-effectiveness, priority to the worse off and financial risk protection. Second, they need to make tough choices whether they should first include more priority services, first expand coverage of existing priority services or first reduce co-payments of existing priority services. Evidence informed deliberative processes can facilitate these choices for UHC, and are also essential to the progressive realisation of the right to health. The framework informs health authorities on how they can best organise their processes in terms of composition of an appraisal committee including stakeholders, of decision-making criteria, collection of evidence and development of recommendations, including their communication. In conclusion, this paper fills in an important gap in the literature by providing procedural guidance for countries to progressively realise UHC.

Realizing Universal Health Coverage in East Africa: the relevance of human rights

Applying a robust human rights framework would change thinking and decision-making in efforts to achieve Universal Health Coverage (UHC), and advance efforts to promote women's, children's, and adolescents' health in East Africa, which is a priority under the Sustainable Development Agenda. Nevertheless, there is a gap between global rhetoric of human rights and ongoing health reform efforts. This debate article seeks to fill part of that gap by setting out principles of human rights-based approaches (HRBAs), and then applying those principles to questions that countries undertaking efforts toward UHC and promoting women's, children's and adolescents' health, will need to face, focusing in particular on ensuring enabling legal and policy frameworks, establishing fair financing; priority-setting processes, and meaningful oversight and accountability mechanisms. In a region where democratic institutions are notoriously weak, we argue that the explicit application of a meaningful human rights framework could enhance equity, participation and accountability, and in turn the democratic legitimacy of health reform initiatives being undertaken in the region.

Balanced assessment systems revisited

In 2014, balanced assessment systems (BAS) were proposed as a resource-conscious, 'fit-for-purpose' form of health technology assessment for middle-income countries which lack resources and competences necessary for resource-intensive health technology assessment models. BAS has undergone extensive policy debate in the period since its publication but it has not been critically assessed in a structured form yet. This article aims to describe both the contributions and the weak spots of the original framework and to reflect on them with the intention of further developing the model.

How have systematic priority setting approaches influenced policy making? A synthesis of the current literature

BACKGROUND

There is a growing body of literature on systematic approaches to healthcare priority setting from various countries and different levels of decision making. This paper synthesizes the current literature in order to assess the extent to which program budgeting and marginal analysis (PBMA), burden of disease & cost-effectiveness analysis (BOD/CEA), multi-criteria decision analysis (MCDA), and accountability for reasonableness (A4R), are reported to have been institutionalized and influenced policy making and practice.

METHODS

We searched for English language publications on health care priority setting approaches (2000-2017). Our sources of literature included PubMed and Ovid databases (including Embase, Global Health, Medline, PsycINFO, EconLit).

FINDINGS

Of the four approaches PBMA and A4R were commonly applied in high income countries while BOD/CEA was exclusively applied in low income countries. PBMA and BOD/CEA were most commonly reported to have influenced policy making. The explanations for limited adoption of an approach were related to its complexity, poor policy maker understanding and resource requirements.

CONCLUSIONS

While systematic approaches have the potential to improve healthcare priority setting; most have not been adopted in routine policy making. The identified barriers call for sustained knowledge exchange between researchers and policy-makers and development of practical guidelines to ensure that these frameworks are more accessible, applicable and sustainable in informing policy making.

DEVELOPMENTS IN VALUE FRAMEWORKS TO INFORM THE ALLOCATION OF HEALTHCARE RESOURCES

Background:In recent years, there has been a surge in the development of frameworks to assess the value of different types of health technologies to inform healthcare resource allocation. The reasons for, and the potential of, these value frameworks were discussed during the 2017 Health Technology Assessment International (HTAi) Policy Forum Meeting.

Methods:This study reflects the discussion, drawing on presentations from invited experts and Policy Forum members, as well as a background paper.

Results:The reasons given for a proliferation of value frameworks included: rising healthcare costs; more complex health technology; perceived disconnect between price and value in some cases; changes in societal values; the need for inclusion of additional considerations, such as ethical issues; and greater empowerment of clinicians and patients in defining and using value frameworks. Many Policy Forum participants recommended learning from existing frameworks. Furthermore, there was a desire to agree on the core components of value frameworks, defining the additional value elements as necessary and considering how they might be measured and used in practice. Furthermore, adherence to the principles of transparency, predictability, broad stakeholder involvement, and accountability were widely supported, along with being forward looking, explicit, and consistent across decisions.

Conclusions:Value frameworks continue to evolve with significant implications for global incentives for innovation and access to health technologies. There is a role for the HTA community to address some of the key areas discussed during the meeting, such as defining the core components for assessing the value of a health technology.