Using health technology assessment to support evidence-based decision-making in Canada: an academic perspective

Application of Multi-Criteria Decision Analysis (MCDA) to Prioritize Real-World Evidence Studies for Health Technology Management: Outcomes and Lessons Learned by the Canadian Real-World Evidence for Value of Cancer Drugs (CanREValue) Collaboration

Multi-criteria decision analysis (MCDA) is a value assessment tool designed to help support complex decision-making by incorporating multiple factors and perspectives in a transparent, structured approach. We developed an MCDA rating tool, consisting of seven criteria evaluating the importance and feasibility of conducting potential real-world evidence (RWE) studies aimed at addressing uncertainties stemming from initial cancer drug funding recommendations. In collaboration with the Canadian Agency for Drugs and Technologies in Health's Provincial Advisory Group, a validation exercise was conducted to further evaluate the application of the rating tool using RWE proposals varying in complexity. Through this exercise, we aimed to gain insight into consensus building and deliberation processes and to identify efficiencies in the application of the rating tool. An experienced facilitator led a multidisciplinary committee, consisting of 11 Canadian experts, through consensus building, deliberation, and prioritization. A total of nine RWE proposals were evaluated and prioritized as low (n = 4), medium (n = 3), or high (n = 2) priority. Through an iterative process, efficiencies and recommendations to improve the rating tool and associated procedures were identified. The refined MCDA rating tool can help decision-makers prioritize important and feasible RWE studies for research and can enable the use of RWE for the life-cycle evaluation of cancer drugs.

Reimbursement decision-making system in Poland systematically compared to other countries

Introduction: Our objective was to analyze and compare systematically and structurally reimbursement systems in Poland and other countries. Methods: The systems were selected based on recommendations issued by the Polish Agency for Health Technology Assessment and Tariffication (AHTAPol), which explicitly referred to other countries and agencies). Consequently, apart from Poland, the countries included in the analysis were England, Scotland, Wales, Ireland, France, Netherlands, Germany, Norway, Sweden, Canada, Australia and New Zealand. Relevant information and data were collected through a systematic search of PubMed (Medline), Embase and The Cochrane Library as well as competent authority websites and grey literature sources. Results and discussion: In most of the countries, the submission of a reimbursement application is initiated by a pharmaceutical company, and only a few countries allow it before a product is approved for marketing. All of the agencies analyzed are independent and some have regulatory function of reimbursement decision making body. A key criterion differentiating the various agencies in terms of HTA is the cost-effectiveness threshold. Most of the countries have specific mechanisms to improve access to expensive specialty drugs, including cancer drugs and those used for rare diseases. Reimbursement systems often lack consistency in appreciating the same stages, leading to heterogeneous decision-making processes. The analysis of recommendations issued in different countries for the same medicinal product will allow a better understanding of the relations between the reimbursement system, HTA assessment, stakeholders involvement and decision on reimbursement of innovative drugs.

Emergency contraception subsidy in Canada: a comparative policy analysis

BACKGROUND

In Canada, cost prohibits access to emergency contraception (EC) which may assist to prevent unintended pregnancy. The drug, ulipristal acetate (UPA-EC), is more clinically effective and cost-effective than the prior standard levonorgestrel (LNG-EC). We analyzed provincial EC subsidization policies and examined underlying decision-making processes.

METHODS

We undertook documentary analysis of provincial EC subsidization policies in publicly available drug formularies. We conducted semi-structured interviews with key informants to explore the processes underlying current policies.

RESULTS

Quebec is the only province to subsidize UPA-EC, whilst all ten provinces subsidize LNG-EC. As such, provincial EC subsidization policies do not align with the latest UPA-EC evidence. Interviews revealed that evidence was valued in the policymaking process and formulary decisions were made through interdisciplinary consensus.

CONCLUSIONS

We identify a gap between EC subsidization policies and the latest evidence. Institutional structures affect policies reflecting evolving evidence. Increasing interdisciplinary mechanisms may encourage evidence-based policies.

Mapping of Health Technology Assessment (HTA) teaching and training initiatives: Landscape for evidence-based policy decisions in India

Demographic transitions accompanied with epidemiological shifts are affecting many countries around the globe. These apprehensions have raised the concern for constructing and sustaining healthcare systems especially among resource-constrained low- and middle-income-countries (LMICs) such as India. Introducing Health-Technology-Assessment (HTA) in the educational initiatives could support planners and policy-makers in formulating evidence-based-decision-making along with tackling inequalities/inefficiencies and promoting cost-effectiveness in resource allocation. A mapping exercise has been undertaken for examining the feasibility and implementation of HTA curriculum in the existing courses in India. To gain best possible insight on HTA curriculum, a situational analysis was conducted using systematic search strategy through search engines such as Google, Google Scholar, ProQuest and PubMed. Currently, seventy-one institutes in India are offering one or more courses through regular mode at undergraduate/postgraduate/diploma-certificate/doctorate-level pertaining to Medical-technology (MT), Biostatistics (BS), and Health-economics (HE). MT was offered in 37 institutes (52.12%), followed by BS in 23 (32.39%), and HE in nine (12.67%). Only two institutes (2.81%) are offering certificate-courses on HTA, mainly confined in virtual modules. This review reveals noticeable gaps in the existing curriculum in India and necessitates a novel academic initiative by introducing HTA in a full-fledged manner. Reforms in the research and educational initiatives need to be brought for promoting awareness regarding HTA. The application of domain needs to be widened from the field of health-policy formulators to research and teaching. This should be further strengthened with the strong academic collaborations to generate replicable findings, address challenges, and offer solutions for existing threats to HTA.

The knowledge and attitude of Ghanaian decision-makers and researchers towards health technology assessment

Although health technology assessment (HTA) is intended to provide policymakers with objective information, the likelihood that a health decision-maker (HDM) will use this information is associated with their knowledge, role and perception of the HTA process. In Ghana, policymakers are working towards formalising the use of HTA, but HDM knowledge of and attitude towards HTA are not known. Between March and May 2016, we conducted in-depth interviews and used inductive thematic analysis to explore Ghanaian HDMs (n = 23) and researchers' (n = 4) perceptions of and barriers to HTA and identify ways to promote HTA. We compare our findings with those reported in previous studies conducted in low-and-middle-income countries. Common themes were that resources, political and cultural factors act as barriers to HTA use. Recommendations made in previous studies which were also identified in this study included the need for the development of both human and data capacity, allocating funds to HTA and stakeholder involvement in HTA processes. Specific recommendations made by Ghanaian HDMs and researchers in this study focused on the establishment of an HTA body: its location, the constitution of the appraisal team, the type of evidence to appraise and who makes the final decision. The findings provide important information in the context of current planning to institutionalise HTA in Ghana. Addressing the identified barriers will enable policymakers to maximise the chances of realising the expected benefits of HTA, as participants who are potential producers and end-users are likely to use what they have contributed to.

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.

Establishment of a Quantitative Medical Technology Evaluation System and Indicators within Medical Institutions

Background:

The development and application of medical technologies reflect the medical quality and clinical capacity of a hospital. It is also an effective approach in upgrading medical service and core competitiveness among medical institutions. This study aimed to build a quantitative medical technology evaluation system through questionnaire survey within medical institutions to perform an assessment to medical technologies more objectively and accurately, and promote the management of medical quality technologies and ensure the medical safety of various operations among the hospitals.

Methods:

A two-leveled quantitative medical technology evaluation system was built through a two-round questionnaire survey of chosen experts. The Delphi method was applied in identifying the structure of evaluation system and indicators. The judgment of the experts on the indicators was adopted in building the matrix so that the weight coefficient and maximum eigenvalue (λ max), consistency index (CI), and random consistency ratio (CR) could be obtained and collected. The results were verified through consistency tests, and the index weight coefficient of each indicator was conducted and calculated through analytical hierarchy process.

Results:

Twenty-six experts of different medical fields were involved in the questionnaire survey, 25 of whom successfully responded to the two-round research. Altogether, 4 primary indicators (safety, effectiveness, innovativeness, and benefits), as well as 13 secondary indicators, were included in the evaluation system. The matrix is built to conduct the λ max, CI, and CR of each expert in the survey, and the index weight coefficients of primary indicators were 0.33, 0.28, 0.27, and 0.12, respectively, and the index weight coefficients of secondary indicators were conducted and calculated accordingly.

Conclusions:

As the two-round questionnaire survey of experts and statistical analysis were performed and credibility of the results was verified through consistency evaluation test, the study established a quantitative medical technology evaluation system model and assessment indicators within medical institutions based on the Delphi method and analytical hierarchy process. Moreover, further verifications, adjustments, and optimizations of the system and indicators will be performed in follow-up studies.

Outside the operating room: How a robotics program changed resource utilization on the inpatient Ward

OBJECTIVE

To analyze the changes in the composition of the gynecologic oncology inpatient ward following the implementation of a robotic surgery program and its impact on inpatient resource utilization and costs.

METHODS

Retrospective review of the medical charts of patients admitted onto the gynecologic oncology ward the year prior to and five years after the implementation of robotics. The following variables were collected: patient characteristics, hospitalization details (reason for admission and length of hospital stay), and resource utilization (number of hospitalization days, consultations, and imaging).

RESULTS

Following the introduction of robotic surgery, there were more admissions for elective surgery yet these accounted for only 21% of the inpatient ward in terms of number of hospital days, compared to 36% prior to the robotic program. This coincided with a sharp increase in the overall number of patients operated on by a minimally invasive approach (15% to 76%, p<0.0001). The cost per surgical admission on the inpatient ward decreased by 59% ($9827 vs. $4058) in the robotics era. The robotics program contributed to a ward with higher proportion of patients with complex comorbidities (Charlson≥5: RR 1.06), Stage IV disease (RR 1.30), and recurrent disease (RR 1.99).

CONCLUSION

Introduction of robotic surgery allowed for more patients to be treated surgically while simultaneously decreasing inpatient resource use. With more patients with non-surgical oncological issues and greater medical complexity, the gynecologic oncology ward functions more like a medical rather than surgical ward after the introduction of robotics, which has implications for hospital-wide resource planning.