Access to novel drugs and therapeutics for children and youth: Eliciting citizens' values to inform public funding decisions

What should be publicly funded in the Colombian health system? A mixed methods study of citizens' perceptions

BACKGROUND

In recent years, citizens have become more interested and willing to influence health policy decision-making, and governments worldwide are more prone to citizen engagement in such processes. Prioritising which health technologies should be publicly funded is one decision that requires prudence and consideration of the values and expectations of the people who will be affected by it.

OBJECTIVE

To identify and understand the citizens' perceptions about which health technologies should be publicly funded in Colombia.

DESIGN

Sequential exploratory mixed methods study; the first was a qualitative embedded case study, and the second was a Q methodology study.

PARTICIPANTS

46 citizens were interviewed, and 30 citizens ordered a Q-sample of 45 statements.

ANALYSIS

Interviews were content analysed. We performed a content analysis of the interviews, and, for the quantitative strand, we performed a principal component analysis and varimax rotation to identify view patterns. We also estimated the z-scores of each statement and the load to each factor. We jointly interpreted both sets of findings.

RESULTS

We identified two general approaches citizens used to consider public funding of healthcare technologies. One approach endorsed full coverage of all health technologies required by every Colombian. In the second approach, public funding is conditional on the characteristics of the person who needs the technology, their disease/condition, the kind of technology required and the expectation of efficient health system performance. When integrating the results of the Q methodology, we found five patterns of points of view about the public funding of health technologies.

CONCLUSION

Colombian citizens consider and balance a range of different factors when making decisions about which health technologies are publicly funded. Citizens not only use technical criteria to decide but also provide the perspective and values of those affected by the decision.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Population-based integrated care funding values and guiding principles: An empirical qualitative study

There is wide agreement on the benefits of integrated care; yet funding barriers persist. We suggest that funding models could currently hinder quality of care and that identifying values is necessary to designing adequate funding models. Yet it is currently unclear what are these values that ought to shape healthcare policy decisions. To fill in this gap, we conducted semi-structure interviews with fourteen health policy officials, managers, and researchers to elicit and explore how they conceptualize the values and guiding principles underlying these funding policies. Our findings suggest that values guide population-based integrated funding models, namely: accountability & integrity, transparency, equity, and innovation. Overall, funding mechanisms could incentivize integrated population-based care when the following conditions are met: a) there is transparent governance, with a whole-system approach, political will, and engagement and collaboration across health system partners, organizations and institutions, b) regulatory and evaluative frameworks support accountability including in decision-making, in outcomes and quality of care, as well as financial accountability; c) funding is equitable with a fair distribution of resources and supports accessibility to services; and d) funding mechanisms design and implementation include innovation enabling change, which are continuously evaluated. These values and guiding principles could be used in the development of funding models and future studies need to evaluate the effect of these values on decisions made by policy makers with respect to funding allocations and investments.

Systematic Review of the Relative Social Value of Child and Adult Health

OBJECTIVES

We aimed to synthesise knowledge on the relative social value of child and adult health.

METHODS

Quantitative and qualitative studies that evaluated the willingness of the public to prioritise treatments for children over adults were included. A search to September 2023 was undertaken. Completeness of reporting was assessed using a checklist derived from Johnston et al. Findings were tabulated by study type (matching/person trade-off, discrete choice experiment, willingness to pay, opinion survey or qualitative). Evidence in favour of children was considered in total, by length or quality of life, methodology and respondent characteristics.

RESULTS

Eighty-eight studies were included; willingness to pay (n = 9), matching/person trade-off (n = 12), discrete choice experiments (n = 29), opinion surveys (n = 22) and qualitative (n = 16), with one study simultaneously included as an opinion survey. From 88 studies, 81 results could be ascertained. Across all studies irrespective of method or other characteristics, 42 findings supported prioritising children, while 12 provided evidence favouring adults in preference to children. The remainder supported equal prioritisation or found diverse or unclear views. Of those studies considering prioritisation within the under 18 years of age group, nine findings favoured older children over younger children (including for life saving interventions), six favoured younger children and five found diverse views.

CONCLUSIONS

The balance of evidence suggests the general public favours prioritising children over adults, but this view was not found across all studies. There are research gaps in understanding the public's views on the value of health gains to very young children and the motivation behind the public's views on the value of child relative to adult health gains.

CLINICAL TRIAL REGISTRATION

The review is registered at PROSPERO number: CRD42021244593. There were two amendments to the protocol: (1) some additional search terms were added to the search strategy prior to screening to ensure coverage and (2) a more formal quality assessment was added to the process at the data extraction stage. This assessment had not been identified at the protocol writing stage.

Translating Precision Health for Pediatrics: A Scoping Review

Precision health aims to personalize treatment and prevention strategies based on individual genetic differences. While it has significantly improved healthcare for specific patient groups, broader translation faces challenges with evidence development, evidence appraisal, and implementation. These challenges are compounded in child health as existing methods fail to incorporate the physiology and socio-biology unique to childhood. This scoping review synthesizes the existing literature on evidence development, appraisal, prioritization, and implementation of precision child health. PubMed, Scopus, Web of Science, and Embase were searched. The included articles were related to pediatrics, precision health, and the translational pathway. Articles were excluded if they were too narrow in scope. In total, 74 articles identified challenges and solutions for putting pediatric precision health interventions into practice. The literature reinforced the unique attributes of children and their implications for study design and identified major themes for the value assessment of precision health interventions for children, including clinical benefit, cost-effectiveness, stakeholder values and preferences, and ethics and equity. Tackling these identified challenges will require developing international data networks and guidelines, re-thinking methods for value assessment, and broadening stakeholder support for the effective implementation of precision health within healthcare organizations. This research was funded by the SickKids Precision Child Health Catalyst Grant.