Multiple criteria decision analysis in the context of health technology assessment: a simulation exercise on metastatic colorectal cancer with multiple stakeholders in the English setting

Health Decision Analysis: Evolution, Trends, and Emerging Topics

Health remains one of the most challenging realms for decision makers and policy making while critical for the well-being of humans, the stability of societies, and the development of economies. Decision making in this field ranges from medical doctors identifying the best treatments for patients, healthcare companies selecting the most promising drugs for development, healthcare providers deciding for adequate levels of resourcing, health regulators deciding whether to approve a new medicine or health technology, to regional and national health departments identifying how to increase the health security of regions and countries. In this positioning paper, and introduction to this Special Issue, we present the history, evolution, and trends of health decision analysis and suggest that these developments and news trends can be conceptualized as an emerging field of applied research for our discipline: Health Decision Analysis.

Multiple Criteria Decision Analysis (MCDA) for evaluating cancer treatments in hospital-based health technology assessment: The Paraconsistent Value Framework

Background

In recent years, the potential of multi-criteria decision analysis (MCDA) in the health field has been discussed widely. However, most MCDA methodologies have given little attention to the aggregation of different stakeholder individual perspectives.

Objective

To illustrate how a paraconsistent theory-based MCDA reusable framework, designed to aid hospital-based Health Technology Assessment (HTA), could be used to aggregate individual expert perspectives when valuing cancer treatments.

Methods

An MCDA methodological process was adopted based on paraconsistent theory and following ISPOR recommended steps in conducting an MCDA study. A proof-of-concept exercise focusing on identifying and assessing the global value of first-line treatments for metastatic colorectal cancer (mCRC) was conducted to foster the development of the MCDA framework.

Results

On consultation with hospital-based HTA committee members, 11 perspectives were considered in an expert panel: medical oncology, oncologic surgery, radiotherapy, palliative care, pharmacist, health economist, epidemiologist, public health expert, health media expert, pharmaceutical industry, and patient advocate. The highest weights were assigned to the criteria “overall survival” (mean 0.22), “burden of disease” (mean 0.21) and “adverse events” (mean 0.20), and the lowest weights were given to “progression-free survival” and “cost of treatment” (mean 0.18 for both). FOLFIRI and mFlox scored the highest global value score of 0.75, followed by mFOLFOX6 with a global value score of 0.71. mIFL was ranked last with a global value score of 0.62. The paraconsistent analysis (para-analysis) of 6 first-line treatments for mCRC indicated that FOLFIRI and mFlox were the appropriate options for reimbursement in the context of this study.

Conclusion

The Paraconsistent Value Framework is proposed as a step beyond the current MCDA practices, in order to improve means of dealing with individual expert perspectives in hospital-based HTA of cancer treatments.

Model to support intervention prioritization for the control of Aedes aegypti in Brazil: a multi-criteria approach

Background

Despite continuous strategic investments to mitigate the complexity involving arboviruses control, it is still necessary to further research methods and techniques to achieve in depth knowledge and shorter response times in the application of intervention activities. Consequently, the current work focused its efforts on the development of a multicriteria decision support model for the prioritization of prompt response activities for Aedes aegypti control, based on a case study in the city of Natal/RN.

Method

The research was carried out in three stages: a) preliminary; b) modelling and choice; and c) finalization; the second stage was made possible by the Flexible and Interactive Tradeoff (FITradeoff) method for ranking problematic. Furthermore, the research encompassed ten actors who were involved in the model construction, eight internal and two external to the Natal Zoonoses Control Center (ZCC-Natal) as well as the observation of four operating scenarios for arboviruses control, based on transmission levels; and, evaluation of eleven alternatives from six different criteria perspectives.

Results

Rankings of the interventions evaluated in each of the four control operation scenarios present in the city of Natal/RN were obtained, considering technical criteria guided by the Pan American Health Organization (PAHO).

Conclusions

As a result, it was developed a structured decision-making model that could help decision makers to minimize the effects and risks associated with the proliferation of the vector.

How innovation can be defined, evaluated and rewarded in health technology assessment

BACKGROUND

What constitutes innovation in health technologies can be defined and measured in a number of ways and it has been widely researched and published about. However, while many countries mention it as a criterion for pricing or reimbursement of health technologies, countries differ widely in how they define and operationalise it.

METHODS

We performed a literature review, using a snowballing search. In this paper, we explore how innovation has been defined in the literature in relation to health technology assessment. We also describe how a selection of countries (England, France, Italy, Spain and Japan) take account of innovation in their health technology assessment frameworks and explore the key methodologies that can capture it as a dimension of value in a new health technology. We propose a way of coming to, and incorporating into health technology assessment systems, a definition of innovation for health technologies that is independent of other dimensions of value that they already account for in their systems, such as clinical benefit. We use Spain as an illustrative example of how innovation might be operationalised as a criterion for decision making in health technology assessment.

RESULTS

The countries analysed here can be divided into 2 groups with respect to how they define innovation. France, Japan and Italy use features such as severity, unmet need and therapeutic added value as indicators of the degree of innovation of a health technology, while England, Spain consider the degree of innovation as a separate and additional criterion from others. In the case of Spain, a notion of innovation might be constructed around concepts of `step-change', `convenience', `strength of evidence base' and `impact on future research & development'.

CONCLUSIONS

If innovation is to be used as operational criteria for adoption, pricing and reimbursement of health technologies, the concept must be clearly defined, and it ought to be independent from other value dimensions already captured in their health technology assessment systems.

Multicriteria decision analysis in health care decision in oncology: a systematic review

INTRODUCTION

Multicriteria decision analysis (MCDA) has been used to inform health decisions in health technology assessments (HTA) processes. This is particularly important to complex treatment decisions in oncology.

AREAS COVERED

Five databases (PubMed, EMBASE, LILACS, Web of Science and CRD's NHS Economic Evaluation Database) were searched for studies comparing health technologies in oncology, involving the concept MCDA. The ISPOR MCDA Good Practices Guidelines were used to assess the reporting quality. Study selection, appraisal, and data extraction were performed by two reviewers. Fifteen studies were included. The main decision problem was related to health technology assessment of cancer treatments. Clinicians and public health experts were the most frequent stakeholders. The most frequently included criteria comprised therapeutic benefit, and socio-economic impact. Value measurement approach, direct rating techniques, and additive model for aggregation were used in most studies. Uncertainty analysis revealed the impact of posology and costs on the studies' results. All studies showed some level of overlapping decision criteria.

EXPERT OPINION

There is considerable diversity of methods in MCDA for healthcare decision-making in oncology. The evidence presented can serve as a resource when considering which stakeholders, criteria, and techniques to include in future MCDA studies in oncology.

In silico assessment of collateral eddy current heating in biocompatible implants subjected to magnetic hyperthermia treatments

Purpose: Bearing partially or fully metallic passive implants represents an exclusion criterion for patients undergoing a magnetic hyperthermia procedure, but there are no specific studies backing this restrictive decision. This work assesses how the secondary magnetic field generated at the surface of two common types of prostheses affects the safety and efficiency of magnetic hyperthermia treatments of localized tumors. The paper also proposes the combination of a multi-criteria decision analysis and a graphical representation of calculated data as an initial screening during the preclinical risk assessment for each patient.Materials and methods: Heating of a hip joint and a dental implant during the treatment of prostate, colorectal and head and neck tumors have been assessed considering different external field conditions and exposure times. The Maxwell equations including the secondary field produced by metallic prostheses have been solved numerically in a discretized computable human model. The heat exchange problem has been solved through a modified version of the Pennes' bioheat equation assuming a temperature dependency of blood perfusion and metabolic heat, i.e. thermorregulation. The degree of risk has been assessed using a risk index with parameters coming from custom graphs plotting the specific absorption rate (SAR) vs temperature increase, and coefficients derived from a multi-criteria decision analysis performed following the MACBETH approach.Results: The comparison of two common biomaterials for passive implants - Ti6Al4V and CoCrMo - shows that both specific absorption rate (SAR) and local temperature increase are found to be higher for the hip prosthesis made by Ti6Al4V despite its lower electrical and thermal conductivity. By tracking the time evolution of temperature upon field application, it has been established that there is a 30 s delay between the time point for which the thermal equilibrium is reached at prostheses and tissues. Likewise, damage may appear in those tissues adjacent to the prostheses at initial stages of treatment, since recommended thermal thresholds are soon surpassed for higher field intensities. However, it has also been found that under some operational conditions the typical safety rule of staying below or attain a maximum temperature increase or SAR value is met.Conclusion: The current exclusion criterion for implant-bearing patients in magnetic hyperthermia should be revised, since it may be too restrictive for a range of the typical field conditions used. Systematic in silico treatment planning using the proposed methodology after a well-focused diagnostic procedure can aid the clinical staff to find the appropriate limits for a safe treatment window.

Value Assessment Frameworks in Latin America: "Il buono, il brutto e il cattivo"

OBJECTIVES

Using a taxonomy previously developed, we assessed the strengths and limitations of available value assessment frameworks (VAF) in Latin America.

METHODS

Systematic review of peer-reviewed journals, gray literature review, and surveys to ISPOR Latin America Industry Committee members were done to identify and select current VAF. Once selected, independent reviewers, organized by pairs, assessed each framework's input, methodology, and outputs.

RESULTS

We assessed 7 of 9 VAF in the region, excluding 2 that were not currently in use. The review included 1 framework developed by a regional entity, and 6 country frameworks for either price assessment or to inform reimbursement. Most of these frameworks had a clear definition of the purpose (6 of 7) but could provide more details on the conceptual approach, including perspectives, methods for obtaining preferences, and the ability to incorporate multiple value dimensions (2 of 7). Most lacked information about inclusions/exclusions of elements included in the framework, and whether it assumes a base case comparator and how it is selected. The description of the evaluation of data sources and their scientific validity was inconsistently reported (3 of 7). Few included an assessment of the intervention's effect on total costs of treating a defined population (2 of 7), or a description of how uncertainty could be incorporated (3 of 7). Finally, potential conflicts of interest among those creating the framework are not sufficiently addressed (0 of 7).

CONCLUSIONS

In the 7 frameworks assessed in Latin America, there are opportunities to improve dimensions, methods, and scope. Addressing these issues will strengthen these VAF for policy and clinical decision making.

Early Health Technology Assessment during Nonalcoholic Steatohepatitis Drug Development: A Two-Round, Cross-Country, Multicriteria Decision Analysis

Background. The assessment of value along the clinical development of new biopharmaceutical compounds is a challenging task. Complex and uncertain evidence has to be analyzed, considering a multitude of value preferences from different stakeholders. Objective. To investigate the use of multicriteria decision analysis (MCDA) to support decision making during drug development while considering payer and health technology assessment (HTA) value concerns, by applying the Advance Value Framework in nonalcoholic steatohepatitis (NASH) and testing for the consistency of the results. Design. A multiattribute value theory methodology was applied and 2 rounds of decision conferences (DCs) were organized in 3 countries (England, France, and Germany), with the participation of national key experts and stakeholders using the MACBETH questioning protocol and algorithm. A total of 51 health care professionals, patient advocates, and methodologists, including (ex-) committee members or assessors from national HTA bodies, participated in 6 DCs in the study countries. Target Population. NASH patients in fibrosis stages F2 to 3 were considered. Interventions. The value of a hypothetical product profile was assessed against 3 compounds under development using their phase 2 results. Outcome Measures. DC participants' value preferences were elicited involving criteria selection, options scoring, and criteria weighting. Results. Highly consistent valuation rankings were observed in all DCs, always favoring the same compound. Highly consistent rankings of criteria clusters were observed, favoring therapeutic benefit criteria, followed by safety profile and innovation level criteria. Limitations. There was a lack of comparative treatment effects, early evidence on surrogate endpoints was used, and stakeholder representativeness was limited in some DCs. Conclusions. The use of MCDA is promising in supporting early HTA, illustrating high consistency in results across countries and between study rounds.

ICER Value Framework 2020 Update: Recommendations on the Aggregation of Benefits and Contextual Considerations

The Institute for Clinical and Economic Review (ICER) in the United States recently published a 2020 update to its value assessment framework. We are commenting on the method by which the benefits of health interventions are integrated, relating to contextual considerations and other factors relevant to an intervention's value. We start by discussing the theoretical foundations of decision analysis and its extension to multiple criteria decision analysis (MCDA). Then we provide a detailed, evidence-based response to some of the claims made by ICER with regard to the use of MCDA methods and stakeholder engagement. Finally, we provide a number of recommendations on the use of quantitative decision analysis and decision conferencing that could be of relevance to the ICER methodology. Overall, we agree that some of the proposed changes by ICER are moving in the right direction toward improving transparency in the value assessment process, but these changes are probably inadequate. We advocate that more serious attention should be paid to the use of quantitative decision analysis together with decision conferencing for the construction of value preferences via group processes for the integration of an intervention's various benefit components.

Fuzzy Multicriteria Modelling of Decision Making in the Renewal of Healthcare Technologies

In the current literature, there are a clear lack of systems to assist in making decisions about the renewal of technology for healthcare equipment, which means that the limited capacity to invest in new equipment cannot usually be appropriately applied as determined by the care requirements of a community. This may have important repercussions for patients, such as the inability to offer treatment or diagnosis, having to delay treatment or diagnosis, increase the risk of patients and care staff of using obsolete equipment, and preventing early, accurate, and reliable diagnosis, all of which have effects on the quality of care to a community. This study therefore describes the first multicriteria model in a fuzzy environment to assist in decision making related to the renewal of healthcare equipment. The fuzzy analytic hierarchy process (FAHP), which allows for ambiguities, uncertainties, and doubts inherent in real-world decision processes to be taken into account, was used to do this. The model produces a plan with actions to be taken depending on the obtained results. The model includes a novel methodology that consists of modifying the top–down technique to allow for the levels of priority for renewing healthcare equipment to be determined from judgements given by three experts. The model was validated by applying it to a set of medical devices, and we show the results for a surgical C-arm, an X-ray CT room, a neonatal ventilator, a defibrillator, and a video-colonoscope. A program was also created using the NI Labview software to process the model so that it could be applied with a user interface that acts quickly, simply, and intuitively.

Assessment and prioritization of the WHO "best buys" and other recommended interventions for the prevention and control of non-communicable diseases in Iran

BACKGROUND

The WHO's "best buys" and other recommended interventions are a menu of policy options and cost-effective interventions for the prevention and control of major noncommunicable diseases (NCDs). The menu has six objectives, implementing which by member states is expected to promote the achievement of the nine NCD targets by 2025. In line with their context, countries can select from the menu of best buys and other recommended interventions. Iran adopted its national action plan on NCDs, 2015, including global as well as some specific goals and targets. This study had two objectives: analyzing the gaps to reach the national targets on NCDs; and prioritizing the best buys and other recommended interventions based on multi-criteria decision-making (MCDA) method for the context of Iran.

METHODS

This is a mixed-methods study. We used qualitative textual evidence (documentary content analysis) and MCDA for prioritization of interventions based on five criteria, including a number of people to be potentially affected by the intervention, cost-effectiveness of the intervention, attributable burden (DALY per 100,000), hospitalization and variations among income levels. Data related to five criteria for each intervention were extracted from national studies and relevant international organizations. The weight of each criterion determines based on the opinions of national experts.

RESULTS

Out of 105 actions and interventions recommended by WHO, only 12 of them were not on the national agenda in Iran, while the six missed interventions were related to objective number 4. Only one of the best buys Group's interventions was not targeted (vaccination against human papillomavirus, two doses of 9-13-year-old girls), for which arrangements are being made for the implementation. Encouraging and educating healthy dietary habits and increasing public awareness about the side effects of smoking and exposure to second-hand smoke, e.g., through mass media campaigns, are among the interventions in need of serious prioritization. The priority of interventions was independently calculated in the area of risk factors and clinical preventive interventions.

CONCLUSION

Due to limited resources, low and middle-income countries (LMICs) need to identify and prioritize more cost-effective and more equitable interventions to combat the NCD epidemic. Based on our findings, we advocate more investment in the mass and social media campaigns to promote a healthy diet, avoid tobacco use, as well as the inclusion of some effective clinical preventive interventions into the national action plan, along the long pathway to tackle NCDs and ultimately reach sustainable health development in Iran. The use of the MCDA approach assisted us in formulating a simultaneous use of efficiency and equity, and other indices for prioritizing the interventions.

Value assessment of oncology drugs using a weighted criterion-based approach

BACKGROUND

Globally, the rising cost of anticancer therapy has motivated efforts to quantify the overall value of new cancer treatments. Multicriteria decision analysis offers a novel approach to incorporate multiple criteria and perspectives into value assessment.

METHODS

The authors recruited a diverse, multistakeholder group who identified and weighted key criteria to establish the drug assessment framework (DAF). Construct validity assessed the degree to which DAF scores were associated with past pan-Canadian Oncology Drug Review (pCODR) funding recommendations and European Society for Medical Oncology Magnitude of Clinical Benefit Scale (ESMO-MCBS; version 1.1) scores.

RESULTS

The final DAF included 10 criteria: overall survival, progression-free survival, response rate, quality of life, toxicity, unmet need, equity, feasibility, disease severity, and caregiver well-being. The first 5 clinical benefit criteria represent approximately 64% of the total weight. DAF scores ranged from 0 to 300, reflecting both the expected impact of the drug and the quality of supporting evidence. When the DAF was applied to the last 60 drugs (with reviewers blinded) reviewed by pCODR (2015-2018), those drugs with positive pCODR funding recommendations were found to have higher DAF scores compared with drugs not recommended (103 vs 63; Student t test P = .0007). DAF clinical benefit criteria mildly correlated with ESMO-MCBS scores (correlation coefficient, 0.33; 95% CI, 0.009-0.59). Sensitivity analyses that varied the criteria scores did not change the results.

CONCLUSIONS

Using a structured and explicit approach, a criterion-based valuation framework was designed to provide a transparent and consistent method with which to value and prioritize cancer drugs to facilitate the delivery of affordable cancer care.

Comprehensive value assessment of drugs using a multi-criteria decision analysis: An example of targeted therapies for metastatic colorectal cancer treatment

OBJECTIVE

This study is aimed toward establishing a decision-making model with multiple criteria for appraisal and reimbursement to compare the attitudes of different stakeholders toward various dimensions and criteria and to evaluate the five targeted therapies (bevacizumab, cetuximab, panitumumab, aflibercept, and regorafenib) for metastatic colorectal cancer.

METHOD

This study is a multi-criteria decision analysis (MCDA) using a model that includes three dimensions and nine criteria. Both the overall and individual scores of the respective targeted therapies in different dimensions and criteria were calculated. A sensitivity analysis was carried out in order to evaluate the robustness of the research results. An interview-based questionnaire survey was applied to obtain the performance information for the targeted therapies and the weights of the dimensions and criteria.

RESULTS

Overall, the clinical dimension had the highest weight, followed by the economic dimension, and finally, the social dimension. In the clinical dimension, the "comparative efficacy" criterion had the highest weight; in the economic dimension, the "cost-effectiveness" criterion" was given the greatest importance; in the social dimension, the "social concern and patient needs" criterion was given more emphasis. The overall values ranked from high to low as follows: cetuximab (overall score 3.3666), bevacizumab (3.3043), panitumumab (3.2030), aflibercept (2.8923) and regorafenib (2.8366).

CONCLUSIONS

A comprehensive value assessment system combining "multi-dimensional criteria," "multi-perspectives," and an "integrative assessment" is necessary to evaluate the value of medicines. The results showed not only the order of weights of different dimensions or criteria, but also the rankings of the value of the targeted therapies.

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

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.

Multi-criteria decision analysis for health technology assessment: addressing methodological challenges to improve the state of the art

BACKGROUND

Multi-criteria decision analysis (MCDA) concepts, models and tools have been used increasingly in health technology assessment (HTA), with several studies pointing out practical and theoretical issues related to its use. This study provides a critical review of published studies on MCDA in the context of HTA by assessing their methodological quality and summarising methodological challenges.

METHODS

A systematic review was conducted to identify studies discussing, developing or reviewing the use of MCDA in HTA using aggregation approaches. Studies were classified according to publication time and type, country of study, technology type and study type. The PROACTIVE-S approach was constructed and used to analyse methodological quality. Challenges and limitations reported in eligible studies were collected and summarised; this was followed by a critical discussion on research requirements to address the identified challenges.

RESULTS

129 journal articles were eligible for review, 56% of which were published in 2015-2017; 42% focused on pharmaceuticals; 36, 26 and 18% reported model applications, issues regarding MCDA implementation analyses, and proposing frameworks, respectively. Poor compliance with good methodological practice (< 25% complying studies) was found regarding behavioural analyses, discussion of model assumptions and uncertainties, modelling of value functions, and dealing with judgment inconsistencies. The five most reported challenges related to evidence and data synthesis; value system differences and participant selection issues; participant difficulties; methodological complexity and resource balance; and criteria and attributes modelling. A critical discussion on ways to address these challenges ensues.

DISCUSSION

Results highlight the need for advancement in robust methodologies, procedures and tools to improve methodological quality of MCDA in HTA studies. Research pathways include developing new model features, good practice guidelines, technologies to enable participation and behavioural research.

Quantifying Preferences in Drug Benefit-Risk Decisions

Benefit-risk assessment is used in various phases along the drug lifecycle, such as marketing authorization and surveillance, health technology assessment (HTA), and clinical decisions, to understand whether, and for which patients, a drug has a favorable or more valuable profile with reference to one or more comparators. Such assessments are inherently preference-based as several clinical and nonclinical outcomes of varying importance might act as evaluation criteria, and decision makers must establish acceptable trade-offs between these outcomes. Different healthcare stakeholder perspectives, such as those from patients and healthcare professionals, are key for informing benefit-risk trade-offs. However, the degree to which such preferences inform the decision is often unclear as formal preference-based evaluation frameworks are generally not used for regulatory decisions, and, if used, rarely communicated in HTA decisions. We argue that for better decisions, as well as for reasons of transparency, preferences in benefit-risk decisions should more often be quantified and communicated explicitly.

Barriers for Access to New Medicines: Searching for the Balance Between Rising Costs and Limited Budgets

Introduction: There is continued unmet medical need for new medicines across countries especially for cancer, immunological diseases, and orphan diseases. However, there are growing challenges with funding new medicines at ever increasing prices along with funding increased medicine volumes with the growth in both infectious diseases and non-communicable diseases across countries. This has resulted in the development of new models to better manage the entry of new medicines, new financial models being postulated to finance new medicines as well as strategies to improve prescribing efficiency. However, more needs to be done. Consequently, the primary aim of this paper is to consider potential ways to optimize the use of new medicines balancing rising costs with increasing budgetary pressures to stimulate debate especially from a payer perspective.

Methods: A narrative review of pharmaceutical policies and implications, as well as possible developments, based on key publications and initiatives known to the co-authors principally from a health authority perspective.

Results: A number of initiatives and approaches have been identified including new models to better manage the entry of new medicines based on three pillars (pre-, peri-, and post-launch activities). Within this, we see the growing role of horizon scanning activities starting up to 36 months before launch, managed entry agreements and post launch follow-up. It is also likely there will be greater scrutiny over the effectiveness and value of new cancer medicines given ever increasing prices. This could include establishing minimum effectiveness targets for premium pricing along with re-evaluating prices as more medicines for cancer lose their patent. There will also be a greater involvement of patients especially with orphan diseases. New initiatives could include a greater role of multicriteria decision analysis, as well as looking at the potential for de-linking research and development from commercial activities to enhance affordability.

Conclusion: There are a number of ongoing activities across countries to try and fund new valued medicines whilst attaining or maintaining universal healthcare. Such activities will grow with increasing resource pressures and continued unmet need.

Evaluating the Benefits of New Drugs in Health Technology Assessment Using Multiple Criteria Decision Analysis: A Case Study on Metastatic Prostate Cancer With the Dental and Pharmaceuticals Benefits Agency (TLV) in Sweden

Background. Multiple criteria decision analysis (MCDA) has been identified as a prospective methodology for assisting decision makers in evaluating the benefits of new medicines in health technology assessment (HTA); however, limited empirical evidence exists from real-world applications. Objective. To test in practice a recently developed MCDA methodological framework for HTA, the Advance Value Framework, in a proof-of-concept case study with decision makers. Methods. A multi-attribute value theory methodology was adopted applying the MACBETH questioning protocol through a facilitated decision-analysis modelling approach as part of a decision conference with four experts. Settings. The remit of the Swedish Dental and Pharmaceutical Benefits Agency (Tandvårds- och läkemedelsförmånsverket [TLV]) was adopted but in addition supplementary value dimensions were considered. Patients. Metastatic castrate-resistant prostate cancer patients were considered having received prior chemotherapy. Interventions. Abiraterone, cabazitaxel, and enzalutamide were evaluated as third-line treatments. Measurements. Participants’ value preferences were elicited involving criteria selection, options scoring, criteria weighting, and their aggregation. Results. Eight criteria attributes were finally included in the model relating to therapeutic impact, safety profile, socioeconomic impact, and innovation level with relative importance weights 44.5%, 33.3%, 14.8%, and 7.4% per cluster, respectively. Enzalutamide scored the highest overall weighted preference value score, followed by abiraterone and cabazitaxel. Dividing treatments’ overall weighted preference value scores by their costs derived “costs per unit of value” for ranking the treatments based on value-for-money grounds. Limitations. Study limitations included lack of comparative clinical effects across treatments and the small sample of participants. Conclusion. The Advance Value Framework has the prospects of facilitating the evaluation process in HTA and health care decision making; additional research is recommended to address technical challenges and optimize the use of MCDA for policy making.