Ethics in HTA: Examining the "Need for Expansion"

Expanding HTA – Correcting a Misattribution, Clarifying the Scope of HTA and CEA Comment on "Ethics in HTA: Examining the ‘Need for Expansion’"

Abrishami, Oortwijn, and Hofman (AOH) attribute to me a position I do not hold and an argument I did not make. The purpose of this note is make clear what my position actually is and to clarify the main differences between health technology assessment (HTA) and cost-effectiveness analysis (CEA).

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

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.

Defining priority medical devices for cancer management: a WHO initiative

Medical devices are indispensable for cancer management across the entire cancer care continuum, yet many existing medical interventions are not equally accessible to the global population, contributing to disparate mortality rates between countries with different income levels. Improved access to priority medical technologies is required to implement universal health coverage and deliver high-quality cancer care. However, the selection of appropriate medical devices at all income and hospital levels has been difficult because of the extremely large number of devices needed for the full spectrum of cancer care; the wide variety of options within the medical device sector, ranging from small inexpensive disposable devices to sophisticated diagnostic imaging and treatment units; and insufficient in-country expertise, in many countries, to prioritise cancer interventions and to determine associated technologies. In this Policy Review, we describe the methods, process, and outcome of a WHO initiative to define a list of priority medical devices for cancer management. The methods, approved by the WHO Guidelines Review Committee, can be used as a model approach for future endeavours to define and select medical devices for disease management. The resulting list provides ready-to-use guidance for the selection of devices to establish, maintain, and operate necessary clinical units within the continuum of care for six cancer types, with the goal of promoting efficient resource allocation and increasing access to priority medical devices, particularly in low-income and middle-income countries.

Addressing Health System Values in Health Technology Assessment: The Use of Evidence-Informed Deliberative Processes

Health technology assessment (HTA) is increasingly used around the globe to inform resource allocation decisions. Furthermore, the importance of using explicit and transparent criteria for coverage decision making in line with health system values has been acknowledged. However, the values of a health system are often not explicitly taken into account in the HTA process. This situation influences the allocation of scarce resources and could lead to a discord between the HTA outcome and the values of the health system. We describe how evidence-informed deliberative processes (EDPs) can help to improve this situation. EDPs are integrating two theoretical frameworks; multi-criteria decision-analysis and accountability for reasonableness. Through the use of EDPs, HTA agencies can ensure that health system values are more explicitly and consistently taken into account in the HTA process, enhancing the legitimacy of coverage decisions.

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

Background

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

Methods

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

Results

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

Conclusion

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

Electronic supplementary material

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

Multicriteria decision analysis (MCDA) for health technology assessment: the Queensland Health experience

Objectives In determining whether new health technologies should be funded, health technology assessment (HTA) committees prefer explicit to implicit methods of analysis in enhancing transparency and consistency of decision making. The aim of this study was to develop and pilot a multicriteria decision analysis (MCDA) framework for the Queensland Department of Health HTA program committee, which weighted decision making criteria according to their perceived importance as determined by group consensus. Methods The criteria used in the MCDA framework were identified by reviewing the five unweighted criteria used in the existing process, consultation with committee members and literature review. Criteria were clearly defined and ordinal categories of lowest to highest preferred were assigned against which technology submissions would be rated. Criteria weights were determined through a discrete choice experiment (DCE) survey of committee members using validated software. Mean weighted technology scores were then used to guide deliberative discussions in determining final funding decisions. Results The MCDA framework created one additional criterion to the previous five. The criteria and their mean weights identified through the DCE survey were clinical benefit and safety (27.2%), quality of evidence (19.2%), implementation capacity (16.9%), innovation (15.4%), burden of disease and clinical need (13.3%) and societal and ethical values (8.0%). Criterion weights varied considerably between individual committee members, with one criterion having a difference of 36.9% between the highest and lowest preference weights. Following deliberative discussions, all but one of 10 submissions were awarded funding. The submission not supported received the third lowest score through the MCDA model. Conclusions This pilot application of an MCDA framework, as a complement to committee deliberation, conferred greater transparency and objectivity on HTA assessment of technologies. The framework converted an implicit, unweighted review process to one that is more explicit, flexible in weighting importance and pragmatic. What is known about the topic? HTA programs involve complex decision-making processes requiring the consideration of multiple criteria. Explicit methods of analysis that use weighted criteria according to their relative importance enhance transparency and consistency of decision making by HTA committees, and are preferred to implicit reviews using unweighted criteria. What does this paper add? This article describes the development and piloting of an MCDA framework that aims to improve transparency, objectivity and consistency of funding decisions of the Queensland HTA committee. Criteria were identified through a review of current processes, committee discussions and a literature review, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) quality of evidence system. Criteria were weighted using a discrete choice experiment involving committee members. Using weighted criteria, mean technology scores were calculated and incorporated into deliberative discussions to determine funding decisions. What are the implications for practitioners? The MCDA framework described here converted a more implicit, unweighted process to one that was more pragmatic, explicit and flexible in scoring HTA submissions. This framework may be useful to other HTA programs and could be expanded to resource allocation decision making in many other healthcare settings.