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DeBoer RJ, Ho A, Mutoniwase E, Nguyen C, Umutesi G, Bigirimana JB, Nsabimana N, Van Loon K, Shulman LN, Triedman SA, Cubaka VK, Shyirambere C. Ethical dilemmas in prioritizing patients for scarce radiotherapy resources. BMC Med Ethics 2024; 25:12. [PMID: 38297294 PMCID: PMC10829165 DOI: 10.1186/s12910-024-01005-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 01/18/2024] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND Radiotherapy is an essential component of cancer treatment, yet many countries do not have adequate capacity to serve all patients who would benefit from it. Allocation systems are needed to guide patient prioritization for radiotherapy in resource-limited contexts. These systems should be informed by allocation principles deemed relevant to stakeholders. This study explores the ethical dilemmas and views of decision-makers engaged in real-world prioritization of scarce radiotherapy resources at a cancer center in Rwanda in order to identify relevant principles. METHODS Semi-structured interviews were conducted with a purposive sample of 22 oncology clinicians, program leaders, and clinical advisors. Interviews explored the factors considered by decision-makers when prioritizing patients for radiotherapy. The framework method of thematic analysis was used to characterize these factors. Bioethical analysis was then applied to determine their underlying normative principles. RESULTS Participants considered both clinical and non-clinical factors relevant to patient prioritization for radiotherapy. They widely agreed that disease curability should be the primary overarching driver of prioritization, with the goal of saving the most lives. However, they described tension between curability and competing factors including age, palliative benefit, and waiting time. They were divided about the role that non-clinical factors such as social value should play, and agreed that poverty should not be a barrier. CONCLUSIONS Multiple competing principles create tension with the agreed upon overarching goal of maximizing lives saved, including another utilitarian approach of maximizing life-years saved as well as non-utilitarian principles, such as egalitarianism, prioritarianism, and deontology. Clinical guidelines for patient prioritization for radiotherapy can combine multiple principles into a single allocation system to a significant extent. However, conflicting views about the role that social factors should play, and the dynamic nature of resource availability, highlight the need for ongoing work to evaluate and refine priority setting systems based on stakeholder views.
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Affiliation(s)
- Rebecca J DeBoer
- Division of Hematology/Oncology, University of California, San Francisco, San Francisco, CA, USA.
| | - Anita Ho
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Cam Nguyen
- University of Colorado Cancer Center, Aurora, CO, USA
| | | | | | | | - Katherine Van Loon
- Division of Hematology/Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Lawrence N Shulman
- University of Pennsylvania Abramson Cancer Center, Philadelphia, PA, USA
| | - Scott A Triedman
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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2
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Grundy EAC, Kelly LE, Kneipp E, Clynes L, Saeri AK, Bragge P. Prioritising research funding for cardiovascular disease and diabetes in Australia. J Public Health Policy 2023; 44:658-673. [PMID: 38017149 PMCID: PMC10709470 DOI: 10.1057/s41271-023-00441-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2023] [Indexed: 11/30/2023]
Abstract
The Targeted Translation Research Accelerator program was created to address cardiovascular disease and diabetes in Australia. To maximise the impact of the considerable investment in this program, a structured prioritisation project was undertaken to determine the highest priority health and medical unmet needs in cardiovascular disease and diabetes. The project was led by Monash University's Behaviour Works Australia in collaboration with Australian National University, Research Australia, and MTPConnect. We conducted an online survey with 318 experts and community representatives to generate a 'long list' of unmet needs for (1) cardiovascular disease; (2) diabetes; and (3) interactions in the pathogenesis of Type 1 diabetes, Type 2 diabetes, and cardiovascular disease. We then convened roundtables of clinical, research, and community leaders to discuss survey results. They prioritised unmet needs against six predefined criteria then discussed results. We present the final priority areas for funding. We demonstrate how a feasible, reproducible, and collaborative prioritisation methodology can be used when designing research funding programs. Such approaches can ensure that funding is directed towards projects that are valuable to the community and reflective of expert opinion.
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Affiliation(s)
- Emily A C Grundy
- BehaviourWorks Australia, Monash Sustainable Development Institute, Monash University, 8 Scenic Blvd, Clayton, Melbourne, VIC, 3800, Australia.
| | | | - Erica Kneipp
- Australian National University, Canberra, Australia
| | | | - Alexander K Saeri
- BehaviourWorks Australia, Monash Sustainable Development Institute, Monash University, 8 Scenic Blvd, Clayton, Melbourne, VIC, 3800, Australia
| | - Peter Bragge
- BehaviourWorks Australia, Monash Sustainable Development Institute, Monash University, 8 Scenic Blvd, Clayton, Melbourne, VIC, 3800, Australia.
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3
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Saeedzai SA, Blanchet K, Alwan A, Safi N, Salehi A, Singh NS, Abou Jaoude GJ, Mirzazada S, Majrooh W, Jan Naeem A, Skordis-Worral J, Bhutta ZA, Haghparast-Bidgoli H, Farewar F, Lange I, Newbrander W, Kakuma R, Reynolds T, Feroz F. Lessons from the development process of the Afghanistan integrated package of essential health services. BMJ Glob Health 2023; 8:e012508. [PMID: 37775105 PMCID: PMC10546159 DOI: 10.1136/bmjgh-2023-012508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 08/06/2023] [Indexed: 10/01/2023] Open
Abstract
In 2017, in the middle of the armed conflict with the Taliban, the Ministry of Public Health decided that the Afghan health system needed a well-defined priority package of health services taking into account the increasing burden of non-communicable diseases and injuries and benefiting from the latest evidence published by DCP3. This leads to a 2-year process involving data analysis, modelling and national consultations, which produce this Integrated Package of Essential health Services (IPEHS). The IPEHS was finalised just before the takeover by the Taliban and could not be implemented. The Afghanistan experience has highlighted the need to address not only the content of a more comprehensive benefit package, but also its implementation and financing. The IPEHS could be used as a basis to help professionals and the new authorities to define their priorities.
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Affiliation(s)
| | - Karl Blanchet
- Global Health Development, University of Geneva Faculty of Medicine, Geneva, Switzerland
| | - Ala Alwan
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Najibullah Safi
- Health System Development, WHO Country office for Afghanistan, Kabul, Afghanistan
| | - Ahmad Salehi
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Neha S Singh
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Shafiq Mirzazada
- Geneva Centre of Humanitarian Studies, Faculty of Medicine, University of Geneva, Geneve, Switzerland
| | | | | | | | - Zulfiqar A Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | | | - Isabelle Lange
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Ritsuko Kakuma
- Centre for Global Mental Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Teri Reynolds
- Integrated Health Services, World Health Organization, Geneva, Switzerland
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4
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Ahuja S, Phillips L, Smartt C, Khalid S, Coldham T, Fischer L, Rae S, Sevdalis N, Boaz A, Robinson S, Gaughran F, Lelliott Z, Jones P, Thornicroft G, Munshi JD, Drummond C, Perez J, Littlejohns P. What interventions should we implement in England's mental health services? The mental health implementation network (MHIN) mixed-methods approach to rapid prioritisation. FRONTIERS IN HEALTH SERVICES 2023; 3:1204207. [PMID: 37638343 PMCID: PMC10456870 DOI: 10.3389/frhs.2023.1204207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 07/17/2023] [Indexed: 08/29/2023]
Abstract
Introduction Setting mental health priorities helps researchers, policy makers, and service funders improve mental health services. In the context of a national mental health implementation programme in England, this study aims to identify implementable evidence-based interventions in key priority areas to improve mental health service delivery. Methods A mixed-methods research design was used for a three step prioritisation approach involving systematic scoping reviews (additional manuscript under development), expert consultations and data triangulation. Groups with diverse expertise, including experts by experience, worked together to improve decision-making quality by promoting more inclusive and comprehensive discussions. A multi-criteria decision analysis (MCDA) model was used to combine participants' varied opinions, data and judgments about the data's relevance to the issues at hand during a decision conferencing workshop where the priorities were finalised. Results The study identified mental health interventions in three mental health priority areas: mental health inequalities, child and adolescent mental health, comorbidities with a focus on integration of mental and physical health services and mental health and substance misuse problems. Key interventions in all the priority areas are outlined. The programme is putting some of these evidence-based interventions into action nationwide in each of these three priority mental health priority areas. Conclusion We report an inclusive attempt to ensure that the list of mental health service priorities agrees with perceived needs on the ground and focuses on evidence-based interventions. Other fields of healthcare may also benefit from this methodological approach if they need to make rapid health-prioritisation decisions.
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Affiliation(s)
- Shalini Ahuja
- Methodologies Research Division, Florence Nightingale Faculty of Nursing Midwifery and Palliative Care, King's College London, London, United Kingdom
| | - Lawrence Phillips
- Department of Management, London School of Economics and Political Science, London, United Kingdom
| | - Caroline Smartt
- Department of Health Service & Population Research, School of Mental Health & Psychological Sciences, King's College London, London, United Kingdom
| | - Sundus Khalid
- Department of Health Service & Population Research, School of Mental Health & Psychological Sciences, King's College London, London, United Kingdom
| | - Tina Coldham
- Participation Involvement & Engagement Advisor at NIHR (National Institute for Health Research), London, United Kingdom
| | - Laura Fischer
- Department of Health Service & Population Research, School of Mental Health & Psychological Sciences, King's College London, London, United Kingdom
| | - Sarah Rae
- Independent Expert by Experience, and Patient Community Involvement and Engagement Participation (PCIEP) Lead, co-Lead Workstream 2 (Patient and Public Involvement), London, United Kingdom
| | - Nick Sevdalis
- Department of Psychological Medicine, National University of Singapore, Singapore, Singapore
| | - Annette Boaz
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, University of London, London, United Kingdom
| | - Sarah Robinson
- Eastern Academic Health Science Network, Cambridge, United Kingdom
| | - Fiona Gaughran
- Social and Psychiatric Epidemiology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Zoe Lelliott
- Social and Psychiatric Epidemiology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Peter Jones
- Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
| | - Graham Thornicroft
- Department of Health Service & Population Research, School of Mental Health & Psychological Sciences, King's College London, London, United Kingdom
| | - Jayati-Das Munshi
- Social and Psychiatric Epidemiology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Colin Drummond
- Social and Psychiatric Epidemiology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Jesus Perez
- Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
| | - Peter Littlejohns
- Social and Psychiatric Epidemiology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
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Wagner M, Goetghebeur MM, Ganache I, Demers-Payette O, Auclair Y, Olivier C, Arbour S, de Guise M. HTA challenges for appraising rare disease interventions viewed through the lens of an institutional multidimensional value framework. Expert Rev Pharmacoecon Outcomes Res 2023; 23:143-152. [PMID: 36542763 DOI: 10.1080/14737167.2023.2161513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Evaluating rare disease interventions poses challenges for HTA agencies, including uncertainties and ethical issues and tensions. INESSS has recently adopted a Statement of Principles and Ethical Foundations which proposes a multidimensional approach to value appraisal as well as five principles to frame the evaluation process. AREAS COVERED Our aim was to identify and analyze HTA challenges for appraising interventions for rare diseases, using the Statement's approach to value appraisal as an analytical framework, and outline how the Statement's principles can help address these challenges. Challenges, covering a diversity of aspects, were identified by leveraging institutional experience in diverse domains of expertise and consolidated through narrative literature review. Challenges were categorized by value dimension (clinical, populational, economic, organizational, and sociocultural), which allowed to pinpoint how each challenge affects the ability to appraise the value of an intervention. Key ethical tensions across dimensions were also identified. Specific approaches to addressing these challenges - related to knowledge mobilization and integration, deliberation, and recommendation-making - were outlined on the basis of the principles promulgated in the Statement. EXPERT OPINION A multidimensional approach can be fruitful for analyzing challenges for appraising the value of rare disease interventions and help guide approaches to tackle them.
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Affiliation(s)
- Monika Wagner
- Bureau - Méthodologies et éthique, Institut national d'excellence en santé et en services sociaux (INESSS), 2021 Avenue Union, bureau 1200; Montréal H3A 2S9, Quebec, Canada
| | - Mireille M Goetghebeur
- Bureau - Méthodologies et éthique, Institut national d'excellence en santé et en services sociaux (INESSS), 2021 Avenue Union, bureau 1200; Montréal H3A 2S9, Quebec, Canada.,School of Public Health, Department of Management, Evaluation and Health Policy, Université de Montréal; 7101, avenue du Parc, 3e étage H3N 1X9 Montréal, Quebec, Canada
| | - Isabelle Ganache
- Bureau - Méthodologies et éthique, Institut national d'excellence en santé et en services sociaux (INESSS), 2021 Avenue Union, bureau 1200; Montréal H3A 2S9, Quebec, Canada.,School of Public Health, Department of Social and Preventive Medicine, Université de Montréal, 7101avenue du Parc, 3e étage H3N 1X9 Montréal, Quebec, Canada
| | - Olivier Demers-Payette
- Bureau - Méthodologies et éthique, Institut national d'excellence en santé et en services sociaux (INESSS), 2021 Avenue Union, bureau 1200; Montréal H3A 2S9, Quebec, Canada.,School of Public Health, Department of Management, Evaluation and Health Policy, Université de Montréal; 7101, avenue du Parc, 3e étage H3N 1X9 Montréal, Quebec, Canada
| | - Yannick Auclair
- Bureau - Méthodologies et éthique, Institut national d'excellence en santé et en services sociaux (INESSS), 2021 Avenue Union, bureau 1200; Montréal H3A 2S9, Quebec, Canada
| | - Catherine Olivier
- Bureau - Méthodologies et éthique, Institut national d'excellence en santé et en services sociaux (INESSS), 2021 Avenue Union, bureau 1200; Montréal H3A 2S9, Quebec, Canada.,School of Public Health, Department of Social and Preventive Medicine, Université de Montréal, 7101avenue du Parc, 3e étage H3N 1X9 Montréal, Quebec, Canada
| | - Sylvie Arbour
- Bureau - Méthodologies et éthique, Institut national d'excellence en santé et en services sociaux (INESSS), 2021 Avenue Union, bureau 1200; Montréal H3A 2S9, Quebec, Canada
| | - Michèle de Guise
- Bureau - Méthodologies et éthique, Institut national d'excellence en santé et en services sociaux (INESSS), 2021 Avenue Union, bureau 1200; Montréal H3A 2S9, Quebec, Canada.,Institut national d'excellence en santé et en services sociaux (INESSS), 2021 Avenue Union, bureau 1200; Montréal H3A 2S9, Québec, Canada
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6
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Dorris ER, Grealis S, Kegl K, Kennedy N, Larkin L, Lynch B, Moran A, O'Brien J, Skeffington S, Slater K, Ward R, Willett A. Priorities for rheumatic and musculoskeletal disease research in Ireland. BMC Rheumatol 2022; 6:55. [PMID: 35948949 PMCID: PMC9365446 DOI: 10.1186/s41927-022-00285-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 06/15/2022] [Indexed: 11/13/2022] Open
Abstract
Background Research priority setting is a useful approach to decide which unanswered questions are most worth trying to solve through research. The aim is to reduce bias in the research agenda. Traditionally, research was decided by funders, policymakers, and academics with limited influence from other stakeholders like people living with health conditions, caregivers, or the community. This can lead to research gaps that fail to address these important stakeholder needs. The objective of this study is to identify the top research priorities for Rheumatic and Musculoskeletal Disease (RMD) research in Ireland.
Methods The process framework included a design workshop, two online surveys and a review of the literature. Participants 545 people completed the first survey to identify RMD research topics relevant to Ireland, of which 72% identified as a person living with RMD. 460 people completed the second survey to prioritise these research topics. Results The first survey had 2185 research topics submitted. These were analysed and grouped into 38 topic areas which were ranked in the second survey. The top three research priorities for RMD research in Ireland focused on preventing RMD progression, RMD diagnosis and its impact, and pain management.
Conclusions The prioritised research topics indicate important areas of RMD research for Ireland. Research funded in response to these co-created research priorities will have increased relevance and impact.
Supplementary Information The online version contains supplementary material available at 10.1186/s41927-022-00285-9.
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Affiliation(s)
- Emma R Dorris
- University College Dublin, Belfield, Dublin 04, D04V1W8, Ireland.
| | | | | | - Norelee Kennedy
- Discipline of Physiotherapy, School of Allied Health, Faculty of Education and Health Sciences, University of Limerick and Health Research Institute (HRI), University of Limerick, Limerick, Ireland
| | - Louise Larkin
- Health Research Institute (HRI), University of Limerick, Limerick, Ireland
| | | | - Ailis Moran
- UCD School of Biomolecular and Biomedical Science, University College Dublin, Dublin 04, Ireland
| | - Justine O'Brien
- UCD School of Biomolecular and Biomedical Science, University College Dublin, Dublin 04, Ireland
| | | | - Kayleigh Slater
- UCD School of Biomolecular and Biomedical Science, University College Dublin, Dublin 04, Ireland
| | - Rebecca Ward
- UCD School of Biomolecular and Biomedical Science, University College Dublin, Dublin 04, Ireland
| | - Allison Willett
- UCD College of Social Sciences & Law, University College Dublin, Belfield, Dublin 4, Ireland
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7
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Verguet S, Norheim OF. Estimating and Comparing Health and Financial Risk Protection Outcomes in Economic Evaluations. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:238-246. [PMID: 35094797 DOI: 10.1016/j.jval.2021.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 07/19/2021] [Accepted: 08/16/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Improving health and financial risk protection (FRP, the prevention of medical impoverishment) and their distributions is a major objective of national health systems. Explicitly describing FRP and disaggregated (eg, across socioeconomic groups) impact of health interventions in economic evaluations can provide decision makers with a broader set of health and financial outcomes to compare and prioritize interventions against each other. METHODS We propose methods to synthesize such a broader set of outcomes by estimating and comparing the distributions in both health and FRP benefits procured by health interventions. We build on benefit-cost analysis frameworks and utility-based models, and we illustrate our methods with the case study of universal public finance (financing by government regardless of whom an intervention is targeting) of disease treatment in a low- and middle-income country setting. RESULTS Two key findings seem to emerge: FRP is critical when diseases are less lethal (eg, case fatality rates <1% or so), and quantitative valuation of inequality aversion across income groups matters greatly. We recommend the use of numerous sensitivity analyses and that all distributional health and financial outcomes be first presented in a disaggregated form (before potential subsequent aggregation). CONCLUSIONS Estimation approaches such as the one we propose provide explicit disaggregated considerations of equity, FRP, and poverty impact for the development of health sector policies, with high relevance for population-based preventive measures.
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Affiliation(s)
- Stéphane Verguet
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Ole F Norheim
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
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8
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Goetghebeur M, Cellier M. Deliberative Processes by Health Technology Assessment Agencies: A Reflection on Legitimacy, Values and Patient and Public Involvement Comment on "Use of Evidence-informed Deliberative Processes by Health Technology Assessment Agencies Around the Globe". Int J Health Policy Manag 2021; 10:228-231. [PMID: 32610794 PMCID: PMC8167272 DOI: 10.34172/ijhpm.2020.46] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 03/24/2020] [Indexed: 11/25/2022] Open
Abstract
Legitimacy of deliberation processes leading to recommendations for public financing or clinical practice depends on the data considered, stakeholders involved and the process by which both of these are selected and organised. Oortwijn et al provides an interesting exploration of processes currently in place in health technology assessment (HTA) agencies. However, agencies are struggling with core issues central to their legitimacy that goes beyond the procedural exploration of Oortwijn et al, such as: how processes reflect the mission and values of the agencies? How they ensure that recommendations are fair and reasonable? Which role should be given to public and patient involvement? Do agencies have a positive impact on the healthcare system and the populations served? What are the drivers of their evolution? We concur with Culyer commentary on the need of learning from doing what works best and that a reflection is indeed needed to "enhance the fairness and legitimacy of HTA."
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Affiliation(s)
- Mireille Goetghebeur
- Department of management, Evaluation and Health Policy, School of Public Health, University of Montreal, Montreal, QC, Canada
| | - Marjo Cellier
- Research Center, University Hospital Center Ste Justine, Montreal, QC, Canada
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9
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Suwantika AA, Purwadi FV, Zakiyah N, Puspitasari IM, Abdulah R, Diantini A, Boersma C, Postma MJ. Multi-criteria decision analysis to prioritize the introduction of new vaccines in Indonesia by using the framework of the strategic multi-attribute ranking tool for vaccines (SMART vaccines). Expert Rev Vaccines 2021; 20:83-91. [PMID: 33428502 DOI: 10.1080/14760584.2021.1874926] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Background: Decision-making processes regarding new vaccine prioritizations are complex. The objective of this study was to prioritize the introduction of new vaccines in Indonesia.Methods: A multi-criteria decision analysis (MCDA) was applied in this study. A preliminary data collection form was developed to collect country-specific data in relation to 30 pre-defined attributes. In particular, an open-ended questionnaire was conducted among targeted respondents from global level, national level and vaccine manufacturers, which were involved in the financial flows of new vaccine procurement in Indonesia. For setting new vaccines priorities, targeted respondents were asked to assign weight on 10 selected criteria.Results: Top 3 attributes with the highest weight from respondents were premature deaths averted per year, incident cases prevented per year, and cost-effectiveness. Applying criteria scores and weight assessment, the result showed that PCV, rotavirus, HPV, and JE would be on the 1st, 2nd, 3rd, and 4th rank for setting new vaccine priority in Indonesia. There was a significant difference score (p value <0.05) between all these vaccines.Conclusions: PCV, rotavirus and HPV vaccines should be more prioritized than JE vaccine. This ranking is in line with the WHO's priority list, which potentially illustrates the validity and usefulness of our MCDA-approach.
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Affiliation(s)
- Auliya A Suwantika
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia.,Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia.,Center for Health Technology Assessment, Universitas Padjadjaran, Bandung, Indonesia
| | - Febby V Purwadi
- Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia
| | - Neily Zakiyah
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia.,Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia
| | - Irma M Puspitasari
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia.,Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia
| | - Rizky Abdulah
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia.,Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia
| | - Ajeng Diantini
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia.,Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia
| | - Cornelis Boersma
- Unit of Global Health, Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Maarten J Postma
- Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia.,Unit of Global Health, Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Economics, Econometrics & Finance, Faculty of Economics & Business, University of Groningen, Groningen, The Netherlands.,Unit of PharmacoTherapy, -Epidemiology & -Economics, Department of Pharmacy, University of Groningen, Groningen, The Netherlands
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Azzano P, Dufresne É, Poder T, Bégin P. Economic considerations on the usage of biologics in the allergy clinic. Allergy 2021; 76:191-209. [PMID: 32656802 DOI: 10.1111/all.14494] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 07/04/2020] [Accepted: 07/08/2020] [Indexed: 12/27/2022]
Abstract
The advent of biologic therapies has transformed care for severe atopic disorders but their high cost poses new challenges with regard to long-term sustainability and fair allocation of resources. This article covers the basic concepts of cost-utility analyses and reviews the available literature on cost utility of biologic drugs in atopic disorders. When used within their limits as part of a multi-dimensional assessment, economic analyses can be extremely useful to guide decision-making and prioritization of care. Despite the good quality of most cost-utility analyses conducted for the use of biologics in asthma and other atopic diseases, their conclusions regarding cost-effectiveness are extremely variable. This is mainly due to the use of inconsistent estimates of health utility benefit with therapy. Development of reliable and validated instruments to measure disutility in atopic disorders and measure of indirect costs in atopic disease are identified as a priority for future research.
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Affiliation(s)
- Pauline Azzano
- Department of Pediatrics CHU Sainte‐Justine Montreal QC Canada
| | - Élise Dufresne
- Department of Pediatrics CHU Sainte‐Justine Montreal QC Canada
| | - Thomas Poder
- Department of Management, Evaluation and Health Policy School of Public Health University of Montreal Montreal QC Canada
- Research Center of the Institut Universitaire en Santé Mentale de Montréal Montreal QC Canada
| | - Philippe Bégin
- Department of Pediatrics CHU Sainte‐Justine Montreal QC Canada
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11
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Barra M, Broqvist M, Gustavsson E, Henriksson M, Juth N, Sandman L, Solberg CT. Severity as a Priority Setting Criterion: Setting a Challenging Research Agenda. HEALTH CARE ANALYSIS 2020; 28:25-44. [PMID: 31119609 PMCID: PMC7045747 DOI: 10.1007/s10728-019-00371-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Priority setting in health care is ubiquitous and health authorities are increasingly recognising the need for priority setting guidelines to ensure efficient, fair, and equitable resource allocation. While cost-effectiveness concerns seem to dominate many policies, the tension between utilitarian and deontological concerns is salient to many, and various severity criteria appear to fill this gap. Severity, then, must be subjected to rigorous ethical and philosophical analysis. Here we first give a brief history of the path to today’s severity criteria in Norway and Sweden. The Scandinavian perspective on severity might be conducive to the international discussion, given its long-standing use as a priority setting criterion, despite having reached rather different conclusions so far. We then argue that severity can be viewed as a multidimensional concept, drawing on accounts of need, urgency, fairness, duty to save lives, and human dignity. Such concerns will often be relative to local mores, and the weighting placed on the various dimensions cannot be expected to be fixed. Thirdly, we present what we think are the most pertinent questions to answer about severity in order to facilitate decision making in the coming years of increased scarcity, and to further the understanding of underlying assumptions and values that go into these decisions. We conclude that severity is poorly understood, and that the topic needs substantial further inquiry; thus we hope this article may set a challenging and important research agenda.
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Affiliation(s)
- Mathias Barra
- The Health Services Research Unit - HØKH, Akershus University Hospital, Sykehusveien 25, Postboks 1000, 1473, Lørenskog, Norway.
| | - Mari Broqvist
- Department of Medical and Health Sciences, The National Centre for Priorities in Health, Linköping University, Linköping, Sweden
| | - Erik Gustavsson
- Department of Culture and Communication, Centre for Applied Ethics, Linköping University, Linköping, Sweden.,Division of Health Care Analysis, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Martin Henriksson
- Department of Medical and Health Sciences, Center for Medical Technology Assessment, Linköping University, Linköping, Sweden
| | - Niklas Juth
- Stockholm Centre for Healthcare Ethics (CHE), LIME, Karolinska Institutet, Solna, Sweden
| | - Lars Sandman
- Department of Medical and Health Sciences, The National Centre for Priorities in Health, Linköping University, Linköping, Sweden
| | - Carl Tollef Solberg
- The Health Services Research Unit - HØKH, Akershus University Hospital, Sykehusveien 25, Postboks 1000, 1473, Lørenskog, Norway.,Global Health Priorities, Department of Global Public Health and Primary Care, Faculty of Medicine, University of Bergen, Bergen, Norway
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12
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Botwright S, Kahn AL, Hutubessy R, Lydon P, Biey J, Karim Sidibe A, Diarra I, Nadjib M, Suwantika AA, Setiawan E, Archer R, Kristensen D, Menozzi-Arnaud M, Mpia Bwaka A, Mwenda JM, Giersing BK. How can we evaluate the potential of innovative vaccine products and technologies in resource constrained settings? A total systems effectiveness (TSE) approach to decision-making. Vaccine X 2020; 6:100078. [PMID: 33196036 PMCID: PMC7644745 DOI: 10.1016/j.jvacx.2020.100078] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/14/2020] [Accepted: 10/04/2020] [Indexed: 11/04/2022] Open
Abstract
Innovations in vaccine product attributes could play an important role in addressing coverage and equity (C&E) gaps, but there is currently a poor understanding of the full system impact and trade-offs associated with investing in such technologies, both from the perspective of national immunisation programmes (NIPs) and vaccine developers. Total Systems Effectiveness (TSE) was developed as an approach to evaluate vaccines with different product attributes from a systems perspective, in order to analyse and compare the value of innovative vaccine products in different settings. The TSE approach has been advanced over the years by various stakeholders including the Bill and Melinda Gates Foundation (BMGF), Gavi, PATH, UNICEF and WHO. WHO further developed the TSE approach to incorporate the country perspective into immunisation decision-making, in order for countries to evaluate innovative products for introduction and product switch decisions, and for vaccine development stakeholders to conduct their assessments of product value in line with country preferences. This paper describes the original TSE approach, development of the tool and processes for NIPs to apply the WHO TSE approach, and results from piloting in 12 countries across Africa, Asia and the Americas. The WHO TSE framework emerged from this piloting effort. The WHO TSE approach has been welcomed by NIP and vaccine development stakeholders as a useful tool to evaluate trade-offs between different products. It was emphasised that the concept of “total systems effectiveness” is likely to be context-specific and that TSE is valuable in facilitating a deliberative process to articulate NIP priorities, for decisions around product choice, and for prioritising the development of future vaccine innovations.
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Affiliation(s)
- Siobhan Botwright
- Department of Immunization, Vaccines & Biologicals, World Health Organization Headquarters, 20 Avenue Appia, 1211-CH 27 Geneva, Switzerland
| | - Anna-Lea Kahn
- Department of Immunization, Vaccines & Biologicals, World Health Organization Headquarters, 20 Avenue Appia, 1211-CH 27 Geneva, Switzerland
| | - Raymond Hutubessy
- Department of Immunization, Vaccines & Biologicals, World Health Organization Headquarters, 20 Avenue Appia, 1211-CH 27 Geneva, Switzerland
| | - Patrick Lydon
- Department of Immunization, Vaccines & Biologicals, World Health Organization Headquarters, 20 Avenue Appia, 1211-CH 27 Geneva, Switzerland
| | - Joseph Biey
- Inter-Country Support Team, Regional Office for Africa, World Health Organization, Ouagadougou, Burkina Faso
| | - Abdoul Karim Sidibe
- WHO Country Office for Mali (OMS/MALI), Quartier Ntomiboro-Bougou, B.P. 99, Bamako, Mali
| | - Ibrahima Diarra
- Direction Générale de la Santé et de l'Hygiène Publique, Cité Administrative Bamako, Bamako BP 232, Mali
| | - Mardiati Nadjib
- Health Financing Activity, United States Agency for International Development (USAID), Daerah Khusus Ibukota Jakarta 10110, Indonesia
| | - Auliya A Suwantika
- Department of Pharmacology and Clinical Pharmacy, Universitas Padjadjaran, Indonesia Jl. Raya Bandung-Sumedang Km. 21 Jatinangor, Sumedang, West Java 45363, Indonesia.,Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Indonesia Jl. Raya Bandung-Sumedang Km. 21 Jatinangor, Sumedang, West Java 45363, Indonesia
| | - Ery Setiawan
- Health Financing Activity, United States Agency for International Development (USAID), Daerah Khusus Ibukota Jakarta 10110, Indonesia
| | - Rachel Archer
- Health Intervention and Technology Assessment Program (HITAP), Ministry of Public Health, 6th Floor, 6th Building, Department of Health, Ministry of Public Health, Tiwanon Road, Muang, Nonthaburi 11000, Thailand
| | | | - Marion Menozzi-Arnaud
- Gavi, the Vaccine Alliance, Global Health Campus, Chemin du Pommier 40, 1218 Grand, Saconnex, Geneva, Switzerland
| | - Ado Mpia Bwaka
- Inter-Country Support Team, Regional Office for Africa, World Health Organization, Ouagadougou, Burkina Faso
| | - Jason M Mwenda
- Regional Office for Africa, World Health Organization, Brazzaville, Congo
| | - Birgitte K Giersing
- Department of Immunization, Vaccines & Biologicals, World Health Organization Headquarters, 20 Avenue Appia, 1211-CH 27 Geneva, Switzerland
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13
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Bégin P, Chan ES, Kim H, Wagner M, Cellier MS, Favron-Godbout C, Abrams EM, Ben-Shoshan M, Cameron SB, Carr S, Fischer D, Haynes A, Kapur S, Primeau MN, Upton J, Vander Leek TK, Goetghebeur MM. CSACI guidelines for the ethical, evidence-based and patient-oriented clinical practice of oral immunotherapy in IgE-mediated food allergy. Allergy Asthma Clin Immunol 2020; 16:20. [PMID: 32206067 PMCID: PMC7079444 DOI: 10.1186/s13223-020-0413-7] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 02/14/2020] [Indexed: 12/17/2022] Open
Abstract
Background Oral immunotherapy (OIT) is an emerging approach to the treatment of patients with IgE-mediated food allergy and is in the process of transitioning to clinical practice. Objective To develop patient-oriented clinical practice guidelines on oral immunotherapy based on evidence and ethical imperatives for the provision of safe and efficient food allergy management. Materials and methods Recommendations were developed using a reflective patient-centered multicriteria approach including 22 criteria organized in five dimensions (clinical, populational, economic, organizational and sociopolitical). Data was obtained from: (1) a review of scientific and ethic literature; (2) consultations of allergists, other healthcare professionals (pediatricians, family physicians, nurses, registered dieticians, psychologists, peer supporters), patients and caregivers; and patient associations through structured consultative panels, interviews and on-line questionnaire; and (3) organizational and economic data from the milieu of care. All data was synthesized by criteria in a multicriteria deliberative guide that served as a platform for structured discussion and development of recommendations for each dimension, based on evidence, ethical imperatives and other considerations. Results The deliberative grid included 162 articles from the literature and media reviews and data from consultations involving 85 individuals. Thirty-eight (38) recommendations were made for the practice of oral immunotherapy for the treatment of IgE mediated food allergy, based on evidence and a diversity of ethical imperatives. All recommendations were aimed at fostering a context conducive to achieving objectives identified by patients and caregivers with food allergy. Notably, specific recommendations were developed to promote a culture of shared responsibility between patients and healthcare system, equity in access, patient empowerment, shared decision making and personalization of OIT protocols to reflect patients' needs. It also provides recommendations to optimize organization of care to generate capacity to meet demand according to patient choice, e.g. OIT or avoidance. These recommendations were made acknowledging the necessity of ensuring sustainability of the clinical offer in light of various economic considerations. Conclusions This innovative CPG methodology was guided by patients' perspectives, clinical evidence as well as ethical and other rationales. This allowed for the creation of a broad set of recommendations that chart optimal clinical practice and define the conditions required to bring about changes to food allergy care that will be sustainable, equitable and conducive to the well-being of all patients in need.
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Affiliation(s)
- P Bégin
- 1Division of Clinical Immunology, Rheumatology and Allergy, Department of Pediatrics, Sainte-Justine University Hospital Centre, Montreal, QC Canada.,2Division of Allergy and Clinical Immunology, Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, QC Canada.,3Research Center of the Sainte-Justine University Hospital Center, Montreal, QC Canada
| | - E S Chan
- 4Division of Allergy & Immunology, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, BC Canada
| | - H Kim
- 5Division of Clinical Immunology and Allergy, Department of Medicine, Western University, London, ON Canada.,6Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, ON Canada
| | - M Wagner
- 7Unit Methods, Ethics and Participation, INESSS, National Institute for Excellence in Health and Social Services, Montreal, QC Canada
| | - M S Cellier
- 3Research Center of the Sainte-Justine University Hospital Center, Montreal, QC Canada
| | - C Favron-Godbout
- 8Department of Bioethics, School of Public Health of the University of Montreal, Montreal, Canada
| | - E M Abrams
- 9Section of Allergy and Clinical Immunology, Department of Pediatrics, University of Manitoba, Winnipeg, MB Canada
| | - M Ben-Shoshan
- 10Division of Allergy Immunology and Dermatology, Department of Pediatrics, Montreal Children's Hospital, Montreal, QC Canada
| | - S B Cameron
- 4Division of Allergy & Immunology, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, BC Canada.,Community Allergy Clinic, Victoria, BC Canada
| | - S Carr
- 12Department of Pediatrics, University of Alberta, Edmonton, AB Canada
| | - D Fischer
- 5Division of Clinical Immunology and Allergy, Department of Medicine, Western University, London, ON Canada
| | - A Haynes
- 13Discipline of Pediatrics, Memorial University of Newfoundland, St. John's, NL Canada
| | - S Kapur
- 14Department of Pediatrics, Dalhousie University, Halifax, NS Canada
| | - M N Primeau
- 15Division of Allergy and Clinical Immunology, Department of Medicine, CISSS Laval, Laval, QC Canada
| | - J Upton
- 16Division of Immunology and Allergy, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON Canada
| | - T K Vander Leek
- 12Department of Pediatrics, University of Alberta, Edmonton, AB Canada
| | - M M Goetghebeur
- 7Unit Methods, Ethics and Participation, INESSS, National Institute for Excellence in Health and Social Services, Montreal, QC Canada
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14
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Baltussen R, Marsh K, Thokala P, Diaby V, Castro H, Cleemput I, Garau M, Iskrov G, Olyaeemanesh A, Mirelman A, Mobinizadeh M, Morton A, Tringali M, van Til J, Valentim J, Wagner M, Youngkong S, Zah V, Toll A, Jansen M, Bijlmakers L, Oortwijn W, Broekhuizen H. Multicriteria Decision Analysis to Support Health Technology Assessment Agencies: Benefits, Limitations, and the Way Forward. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:1283-1288. [PMID: 31708065 DOI: 10.1016/j.jval.2019.06.014] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 05/13/2019] [Accepted: 06/04/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Recent years have witnessed an increased interest in the use of multicriteria decision analysis (MCDA) to support health technology assessment (HTA) agencies for setting healthcare priorities. However, its implementation to date has been criticized for being "entirely mechanistic," ignoring opportunity costs, and not following best practice guidelines. This article provides guidance on the use of MCDA in this context. METHODS The present study was based on a systematic review and consensus development. We developed a typology of MCDA studies and good implementation practice. We reviewed 36 studies over the period 1990 to 2018 on their compliance with good practice and developed recommendations. We reached consensus among authors over the course of several review rounds. RESULTS We identified 3 MCDA study types: qualitative MCDA, quantitative MCDA, and MCDA with decision rules. The types perform differently in terms of quality, consistency, and transparency of recommendations on healthcare priorities. We advise HTA agencies to always include a deliberative component. Agencies should, at a minimum, undertake qualitative MCDA. The use of quantitative MCDA has additional benefits but also poses design challenges. MCDA with decision rules, used by HTA agencies in The Netherlands and the United Kingdom and typically referred to as structured deliberation, has the potential to further improve the formulation of recommendations but has not yet been subjected to broad experimentation and evaluation. CONCLUSION MCDA holds large potential to support HTA agencies in setting healthcare priorities, but its implementation needs to be improved.
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Affiliation(s)
- Rob Baltussen
- Radboud University Medical Center, Nijmegen, The Netherlands.
| | | | | | - Vakaramoko Diaby
- Florida Agricultural and Mechanical University, Tallahassee, FL, USA
| | | | | | | | - Georgi Iskrov
- Medical University of Plovdiv, Plovdiv, Bulgaria; Institute for Rare Diseases, Plovdiv, Bulgaria
| | | | | | | | - Alec Morton
- University of Strathclyde, Glasgow, Scotland
| | | | | | | | | | | | | | - Agnes Toll
- Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maarten Jansen
- Radboud University Medical Center, Nijmegen, The Netherlands
| | - Leon Bijlmakers
- Radboud University Medical Center, Nijmegen, The Netherlands
| | - Wija Oortwijn
- Radboud University Medical Center, Nijmegen, The Netherlands
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15
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Wagner M, Samaha D, Casciano R, Brougham M, Abrishami P, Petrie C, Avouac B, Mantovani L, Sarría-Santamera A, Kind P, Schlander M, Tringali M. Moving Towards Accountability for Reasonableness - A Systematic Exploration of the Features of Legitimate Healthcare Coverage Decision-Making Processes Using Rare Diseases and Regenerative Therapies as a Case Study. Int J Health Policy Manag 2019; 8:424-443. [PMID: 31441279 PMCID: PMC6706971 DOI: 10.15171/ijhpm.2019.24] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 04/17/2019] [Indexed: 12/26/2022] Open
Abstract
Background: The accountability for reasonableness (A4R) framework defines 4 conditions for legitimate healthcare coverage decision processes: Relevance, Publicity, Appeals, and Enforcement. The aim of this study was to reflect on how the diverse features of decision-making processes can be aligned with A4R conditions to guide decision-making towards legitimacy. Rare disease and regenerative therapies (RDRTs) pose special decision-making challenges and offer therefore a useful case study.
Methods: Features operationalizing each A4R condition as well as three different approaches to address these features (cost-per-QALY-focused and multicriteria-based) were defined and organized into a matrix. Seven experts explored these features during a panel run under the Chatham House Rule and provided general and RDRT-specific recommendations. Responses were analyzed to identify converging and diverging recommendations.
Results: Regarding Relevance, recommendations included supporting deliberation, stakeholder participation and grounding coverage decision criteria in normative and societal objectives. Thirteen of 17 proposed decision criteria were recommended by a majority of panelists. The usefulness of universal cost-effectiveness thresholds to inform allocative efficiency was challenged, particularly in the RDRT context. RDRTs raise specific issues that need to be considered; however, rarity should be viewed in relation to other aspects, such as disease severity and budget impact. Regarding Publicity, panelists recommended transparency about the values underlying a decision and value judgements used in selecting evidence. For Appeals, recommendations included a life-cycle approach with clear provisions for re-evaluations. For Enforcement, external quality reviews of decisions were recommended.
Conclusion: Moving coverage decision-making processes towards enhanced legitimacy in general and in the RDRT context involves designing and refining approaches to support participation and deliberation, enhancing transparency, and allowing explicit consideration of multiple decision criteria that reflect normative and societal objectives.
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Affiliation(s)
| | | | | | | | - Payam Abrishami
- National Health Care Institute (ZIN), Diemen, The Netherlands
| | | | | | - Lorenzo Mantovani
- Center for Public Health Research, University of Milan-Bicocca, Milan, Italy
| | - Antonio Sarría-Santamera
- National School of Public Health IMIENS-UNED, Madrid, Spain.,Department of Public Health, University of Alcalá, Alcalá de Henares, Spain
| | | | - Michael Schlander
- Division of Health Economics, German Cancer Research Center (DKFZ), Heidelberg, Germany.,University of Heidelberg, Heidelberg, Germany
| | - Michele Tringali
- ASST Niguarda and Regione Lombardia, Welfare Directorate, Milano, Italy
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16
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Guarga L, Badia X, Obach M, Fontanet M, Prat A, Vallano A, Torrent J, Pontes C. Implementing reflective multicriteria decision analysis (MCDA) to assess orphan drugs value in the Catalan Health Service (CatSalut). Orphanet J Rare Dis 2019; 14:157. [PMID: 31248421 PMCID: PMC6598260 DOI: 10.1186/s13023-019-1121-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 06/07/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Orphan medicines show some characteristics that hinder the evaluation of their clinical added value. The often low level of evidence available for orphan drugs, together with a high budget impact and an incremental cost-effectiveness ratio many times higher than drugs used for non-orphan diseases, represent challenges in their appraisal and effective access to clinical use. In order to explore how to handle these hurdles, the Catalan Health Service (CatSalut) began an initiative on a multidimensional assessment of drugs value during the appraisal process. Reflective multicriteria decision analysis (MCDA) using analytical methods was chosen, since it may help to standardise and contextualize all the relevant data related with the drug that could contribute to a decision. The aim of the study was to determine whether the implementation of reflective MCDA methodology could support the decision-making process about orphan medicines in the context of CatSalut. METHODS The assessment and decision-making process for orphan drugs in the Programa d'Harmonització Farmacoterapeutica (PHF) of CatSalut was prioritized to test the implementation of the reflective MCDA both a qualitative and quantitatively. A staged approach was used with the following main steps: selection and structuration of quantitative criteria (Core Model) and qualitative criteria (Contextual Tool), framework scoring and assessment of three orphan drug case studies. This proof-of-concept would grant a continued refinement of the methodology and, if and when validated, its potential integration to other therapeutic areas of the PHF. RESULTS The final framework was composed by 10 quantitative criteria (Core Model) and 4 qualitative criteria (Contextual Tool) according to the PHF goals being the most important criteria "disease severity", "unmet need", "comparative effectiveness" and "comparative safety /tolerability". The matrix developed for the case studies served as a guide for the selection of the essential information that the decision-makers were expected to include in a framework. The reflective discussion was considered the most relevant phase of the approach to support inputs for health decision-making processes reflecting both drug value and place in therapy. CONCLUSIONS The study showed that reflective MCDA methodology could be implemented to complement the decision-making process in CatSalut, as an aid to determine the clinical added value for orphan medicines. MCDA provided transparency and a structured discussion during the committee meetings, thus increasing transparency and predictability of the relevant items supporting the agreements adopted on orphan drugs access.
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Affiliation(s)
- Laura Guarga
- Àrea del Medicament, Servei Català de la Salut (CatSalut), Travessera de les Corts, 131-159, 08028 Barcelona, Spain
- Omakase Consulting S.L., Entença street 332334 Floor 6, door 4, 08029 Barcelona, Spain
| | - Xavier Badia
- Omakase Consulting S.L., Entença street 332334 Floor 6, door 4, 08029 Barcelona, Spain
| | - Mercè Obach
- Àrea del Medicament, Servei Català de la Salut (CatSalut), Travessera de les Corts, 131-159, 08028 Barcelona, Spain
| | - Manel Fontanet
- Àrea del Medicament, Servei Català de la Salut (CatSalut), Travessera de les Corts, 131-159, 08028 Barcelona, Spain
- Departament de Farmacologia, de Terapèutica i de Toxicologia, Universitat Autònoma de Barcelona, Av. de Can Domènech, 737, 08193 Cerdanyola del Vallès (Barcelona), Spain
| | - Alba Prat
- Àrea del Medicament, Servei Català de la Salut (CatSalut), Travessera de les Corts, 131-159, 08028 Barcelona, Spain
| | - Atonio Vallano
- Àrea del Medicament, Servei Català de la Salut (CatSalut), Travessera de les Corts, 131-159, 08028 Barcelona, Spain
| | - Josep Torrent
- Àrea del Medicament, Servei Català de la Salut (CatSalut), Travessera de les Corts, 131-159, 08028 Barcelona, Spain
| | - Caridad Pontes
- Àrea del Medicament, Servei Català de la Salut (CatSalut), Travessera de les Corts, 131-159, 08028 Barcelona, Spain
- Departament de Farmacologia, de Terapèutica i de Toxicologia, Universitat Autònoma de Barcelona, Av. de Can Domènech, 737, 08193 Cerdanyola del Vallès (Barcelona), Spain
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17
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Blanchet K, Ferozuddin F, Naeem AJJ, Farewar F, Saeedzai SA, Simmonds S. Priority setting in a context of insecurity, epidemiological transition and low financial risk protection, Afghanistan. Bull World Health Organ 2019; 97:374-376. [PMID: 31551635 PMCID: PMC6747028 DOI: 10.2471/blt.18.218941] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 02/15/2019] [Accepted: 03/06/2019] [Indexed: 11/27/2022] Open
Affiliation(s)
- Karl Blanchet
- Health in Humanitarian Crises Centre, London School of Hygiene & Tropical Medicine, Keppel Street, London, WC1E 7HT, England
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18
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Patient involvement in reflective multicriteria decision analysis to assist decision making in oncology. Int J Technol Assess Health Care 2019; 35:56-63. [PMID: 30730288 DOI: 10.1017/s0266462318003641] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Patient involvement in drug evaluation decision making is increasing. The aim of the current study was to develop a multi-criteria decision analysis (MCDA) framework that would enable the inclusion of the patient perspective in the selection of appropriate criteria for MCDAs being used in the value assessments of oncologic drugs. METHODS A literature review was conducted to identify and define criteria used in drug assessments from patient perspectives. The Evidence and Value: Impact on Decision Making methodology was used to develop a MCDA framework. Identified criteria were discussed by a sample of oncology patient association representatives who decided which criteria were important from patient perspectives. Selected criteria were rated by importance. The preliminary MCDA framework was tested through the assessment of a hypothetical oncology treatment. A discussion was carried out to agree on a final pilot MCDA framework. RESULTS Twenty-two criteria were extracted from the literature review. After criteria discussion, sixteen criteria remained. The most important criteria were comparative patient reported outcomes (PRO), comparative efficacy and disease severity. After the discussion generated by the scoring of the hypothetical oncology treatment, the final pilot MCDA framework included seven quantitative criteria ("disease severity", "unmet needs", "comparative efficacy / effectiveness", "comparative safety / tolerability", "comparative PROs", "contribution of oncological innovation") and one contextual criterion ("population priorities and access"). CONCLUSIONS The present study developed a pilot reflective MCDA framework that could increase patient's capability to participate in the decision-making process by providing systematic drug assessments from the patient perspective.
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19
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Bloom DE, Cadarette D, Dayalu R, Sullivan J. Introduction: priority setting in global health. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2018; 16:49. [PMID: 30455608 PMCID: PMC6225612 DOI: 10.1186/s12962-018-0115-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- David E Bloom
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Daniel Cadarette
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Rashmi Dayalu
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Jessica Sullivan
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA
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20
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Norheim OF. How can MCDA tools improve priority setting? Four critical questions. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2018; 16:44. [PMID: 30455603 PMCID: PMC6225650 DOI: 10.1186/s12962-018-0119-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Ole F Norheim
- 1Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,2Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA USA
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21
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Goetghebeur MM, Cellier MS. Can reflective multicriteria be the new paradigm for healthcare decision-making? The EVIDEM journey. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2018; 16:54. [PMID: 30455613 PMCID: PMC6225552 DOI: 10.1186/s12962-018-0116-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
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.
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Affiliation(s)
- Mireille M Goetghebeur
- 1School of Public Health, University of Montreal, 7101 Park Ave, Montreal, H3N QC Canada
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Norheim OF. Disease Control Priorities Third Edition Is Published: A Theory of Change Is Needed for Translating Evidence to Health Policy. Int J Health Policy Manag 2018; 7:771-777. [PMID: 30316224 PMCID: PMC6186484 DOI: 10.15171/ijhpm.2018.60] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 06/17/2018] [Indexed: 11/24/2022] Open
Abstract
How can evidence from economic evaluations of the type the Disease Control Priorities project have synthesized be translated to better priority setting? This evidence provides insights into how investing in health, particularly though priority interventions and expanded access to health insurance and prepaid care, can not only save lives but also help alleviate poverty and provide financial risk protection. The article discusses some of the relevant factors needed to develop a Theory of Change for translating economic evidence to better priority setting within countries, and proposes some key strategic choices that are necessary to achieve the desired outputs and outcomes.
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Affiliation(s)
- Ole F. Norheim
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
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Daniels N. Some Remarks on Accontability for Reasonableness. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2018; 18:42-43. [PMID: 29466134 DOI: 10.1080/15265161.2018.1427330] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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EXPLORING VALUES OF HEALTH TECHNOLOGY ASSESSMENT AGENCIES USING REFLECTIVE MULTICRITERIA AND RARE DISEASE CASE. Int J Technol Assess Health Care 2017; 33:504-520. [DOI: 10.1017/s0266462317000915] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Objectives: Tackling ethical dilemmas faced by reimbursement decision makers requires deeper understanding of values on which health technology assessment (HTA) agencies are founded and how trade-offs are made. This was explored in this study including the case of rare disease.Methods: Representatives from eight HTA explored values on which institutions are founded using a narrative approach and reflective multicriteria (developed from EVIDEM, criteria derived from ethical imperatives of health care). Trade-offs between criteria and the impact of incorporating defined priorities (including for rare diseases) were explored through a quantitative values elicitation exercise.Results: Participants reported a diversity of substantive and procedural values with a common emphasis on scientific excellence, stakeholder involvement, independence, and transparency. Examining the ethical imperatives behind EVIDEM criteria was found to be useful to further explore substantive values. Most criteria were deemed to reflect institutions’ values, while 70 percent of the criteria were reported by at least half of participants to be considered formally by their institutions. The quantitative values elicitation highlighted the difficulty to balance imperatives of “alleviating or preventing patient suffering,” “serving the whole population equitably,” “upholding healthcare system sustainability,” and “making decisions informed by evidence and context” but may help share the ethical reasoning behind decisions. Incorporating “Priorities” (including for rare diseases) helped reveal trade-offs from other criteria and their underlying ethical imperatives.Conclusions: Reflective multicriteria are useful to explore substantive values of HTAs, reflect how these values and their ethical underpinnings can be operationalized into criteria, and explore the ethical reasoning at the heart of the healthcare debate.
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