Utilization)of)Multiple/Criteria)Decision)Analysis)(MCDA))to)!
Support)Healthcare)Decision)Making)
FIFARMA,!2016!
!
!
interventions! that! address! a! specific!
need.! An! effort! should! be! made! to!
Key(Points(for(Decision(Makers)
allocate! sufficient! budget! for! the!
MCDA%is%a%decision.making%tool%with%
reimbursement! of! medicines,! allowing!
increasing%use%in%the%healthcare%sector,%
more! flexibility! in! healthcare! decision!
including%HTA%(Health%Technology%
Assessment).%By%using%multiple%criteria%in% making.! ! Systems! that! operate! with! a!
fixed! costJeffectiveness! threshold! risk!
a%comprehensive,%structured%and%explicit%
ignoring!need:!where!society!feels!there!
manner,%MCDA%fosters%a%transparent,%
is! a! great! need,! we! are! willing! to! pay!
participative,%consistent%and%legitimate%
1
much! more! and! thus! accept! less!
decision.making%process.%A%deliberative %
efficiency;!while!in!conditions!perceived!
(partial)%MCDA%may%be%a%more%
as!minor!or!for!which!there!are!already!
pragmatic,%agile%approach,%especially%
very! effective! treatments,! we! may! be!
when%newly%implemented.!
less!willing!to!cover!a!new!intervention,!
!
even! if! it! has! an! excellent! incremental!
I. INTRODUCTION!
This! paper! aims! to! present! MCDA! as! a! costJeffectiveness! ratio! (Aitken,! 2014).!!
decisionJmaking!tool!that!can!be!applied! Emphasis! on! costJeffectiveness! risks!
in! the! healthcare! sector! due! to! the! reducing! equity! in! patient! access! to!
comprehensive! and! consistent! yet! innovative! medications.! ! A! 2014! study!
flexible! and! transparent! methodology;! performed! by! the! IMS! Institute! (Aitken,!
fostering! collaboration! amongst! all! 2014)! compared! costJper! QALY! focused!
countries!(CPQ)!to!countries!that!used!a!
healthcare!stakeholders.!!!
more! holistic! assessment! approach!
!
Current!
HTA!
approaches!
have! (nonJCPQ).!!This!study!concluded!that:!
overemphasized!
costJeffectiveness,! • Patients! in! CPQ! countries! have! less!
access! to! new! cancer! drugs! than!
incremental! costJeffectiveness! ratio!
patients! in! nonJCPQ! countries;!
(ICERs)! and! thresholds.! Too! much!
reimbursement! decisions! take!
emphasis!on!costJeffectiveness!presents!
longer;! and! new! cancer! drugs! have!
limitations! on! holistic! decision! making!
historically! been! adopted! more!
in! that! it! excludes! important! factors!
slowly!at!lower!rates!
such!as!innovation,!disease!severity,!size!
•
CPQ! analyses! are! subject! to! many!
of! patient! population,! equity,! or! clinical!
uncertainties! and! inconsistencies!
guidelines!(Marsh!et!al,!2014).!Also,!lack!
due! to! the! nature! of! the! variables!
of! costJeffectiveness! is! not! a! necessary!
used!and!their!interpretation!
or!sufficient!condition!to!reject!access!to!
treatments,!especially!in!the!case!of!rare! • CPQ! countries! do! not! necessarily!
spend! less! overall! on! cancer,! but!
diseases!(McKenna!et!al,!2015).!
they!may!achieve!less!for!patients!!
FIFARMA! recognizes! that! while!
!
important,! the! role! of! costJeffectiveness!
is! limited! in! helping! choose! among! Placing!too!much!weight!on!few!criteria!
(efficacy! and! costs! only)! and! narrow!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
perspective!(not!societal)!can!negatively!
1!A!deliberative!MCDA!can!also!be!considered!a!Multiple!
impact! patient! equity! in! access! to!
Criteria!Decision!Making!(MCDM)!
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Utilization)of)Multiple/Criteria)Decision)Analysis)(MCDA))to)!
Support)Healthcare)Decision)Making)
FIFARMA,!2016!
!
medications.!!FIFARMA’s!recommends!a! healthcare!decision!making!is!achievable!
multiple! set! of! criteria! for! a! more! by! utilizing! a! systematic! process,!
holistic!and!fair!valuation!approach.!
referencing! real! world! examples! and!
!
ongoing! research! from! various! decision!
The! emphasis! on! and! utilization! of! making!bodies!and!countries.!This!paper!
MCDA!in!healthcare!decision!making!has! is! in! line! with! FIFARMA’s! position! that!
increased! over! the! past! 5! years,! as! an! efficient! HTA! process! should! be!
demonstrated! by! the! increase! in! transparent,! fair,! consultative,! and!
publications! since! 2011! (Marsh,! Lantis,! focused!on!clinical!excellence.!
Neasham,! Orfanos,! and! Caro,! 2014)! and! !
the! prevalence! of! the! topic! in! II. MCDA!AS!A!DELIBERATIVE!TOOL!IN!
international! healthcare! congresses!
HEALTHCARE!DECISION!MAKING!
such! as! by! the! International! Society! of! A! serious! concern! for! patients,!
Pharmacoeconomic! Outcomes! Research! clinicians,! and! other! stakeholders! is! the!
(ISPOR),! including! the! Latin! America! narrowness! and! lack! of! transparency! in!
Conferences! (eg! the! ISPOR! 5th! Latin! healthcare!decision!making,!especially!in!
America!Conference).!!!ISPOR!has!also!a! regards!to!coverage!and!reimbursement.!!
dedicated! Task! Force! for! MCDA,! MCDA% Notable! deficiencies! in! decision! making!
for% Healthcare% Decision% Making,% have! prompted! proposals! to! use! MCDA!
Emerging% Good% Practices% Task% Force% because! it! has! the! potential! to! consider!
<http://www.ispor.org/MultiJCriteriaJDecisionJ whatever! criteria! a! stakeholder! judges!
AnalysisJguideline.asp>! publishing! reports,! relevant! (Marsh! et! al,! 2014)! ! MCDA!
guidelines!(Devlin!et!al,!2016).!
takes! into! consideration! the! different!
MCDA! can! be! applied! on! a! macro! or! institutional! contexts! while! fostering! a!
micro! level! at! various! stages! of! the! comprehensive,! consistent,! transparent,!
health! technology! development! and! and! flexible! approach.! ! ! By! structuring!
assessment! process! (Goetgherbeur,! the! process! of! selection! and! evaluation!
2015).!!!For!this!paper,!emphasis!will!be! of! alternatives,! MCDA! quantifies!
placed! on! the! utilization! of! MCDA! in! evidence! to! identify! best! alternatives!
HTA! processes! across! Latin! America! and! helps! eliminate! contradictions!
given! decision! makers! and! appraisal! between! stakeholders! (Thokala! and!
committees! can! systematically! appraise! Duenas,! 2012).! An! additional! benefit! is!
health!technology!in!light!of!a!multitude! that! MCDA! can! help! sharpen! signals! to!
of! decision! criteria.! It! should! be! noted! manufacturers! in! advance,! to! focus! on!
that! MCDA! can! also! be! effectively! used! providing! data! that! matters! most! to!
for!tenders!and!contracts.!!FIFARMA!and! decision! makers! (Marsh,! Caro,! and!
its! represented! member! organizations! Muszbek,!2012).!
maintain!that!healthcare!decisions!must! MCDA! provides! a! framework! for!
be! high! quality! and! autonomous,! while! breaking! down! a! complex! decision! into!
relevant! to! the! local! market! conditions! more! manageable! components,! defining!
and! patient! populations.! ! A! secondary! and! understanding! the! relationship!
goal! of! this! paper! is! to! show! that! the! between! these! components.! Additional,!
implementation!
of!
MCDA!
into! but! not! mandatory,! steps! would! be!
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Utilization)of)Multiple/Criteria)Decision)Analysis)(MCDA))to)!
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FIFARMA,!2016!
!
measuring! each! component,! and! then! the! performance! of! other! criteria!
combining! them! to! identify! solutions.!! (Devlin!et!al,!2016).!!!
MCDA! also! serves! the! difficult! task! of! !
quantifying! stakeholders´! priorities! and! It!should!be!noted!that!while!there!is!no!
preferences!while!forming!a!transparent! rule! on! how! many! criteria! should! be!
link! between! judgments! and! decisions! included!in!an!analysis,!a!higher!number!
(Baltussen!and!Niessen,!2006).!!!
of! criteria! increases! the! complexity! and!
!
cognitive! effort,! introducing! the! risk! of!
By! taking! into! account! and! measuring! tiring!decision!makers!and!reducing!the!
criteria! other! than! costJeffectiveness! or! quality! of! responses.! (Thokala,! Devlin,!
budget! impact,! as! for! example! equity! in! Marsh,! and! Ijzerman,! 2015).! ! It! is!
patient! access! and! local! health! system! FIFARMA’s! position! that! criteria! should!
priorities,! MCDA! ensures! that! social! remain! straightJforward! in! order! to!
preferences,! epidemiological! priorities,! reduce! the! likelihood! of! uncertainty! in!
and! ethical! values! are! not! neglected! in! outcomes.!
the!decision!making!process.!
Upon! reviewing! literature! of! MCDA!
In! regards! to! approaches! within! MCDA,! utilized! in! healthcare! decision! making!
FIFARMA! supports! the! broad! position! (Golan,! et! al! 2011;! Toumi,! 2013;! Marsh!
approach! adopted! by! the! ISPOR! Task! et! al,! 2014;! Endrei! et! al,! 2011;! Sussex,!
Force! (Devlin! et! al,! 2016).! ! The! MCDA! 2013)!including!the!EVIDEM!framework!
ISPOR!TF!included!MCDA!methods!“that% <https://www.evidem.org/>,!
FIFARMA!
help% deliberative% discussions% using% recommends! the! criterion! listed! in!
explicitly% defined% criteria,% but% without% Table1.! Additional! criteria! may! be!
quantitative%
modelling.%
…Decision% included! if! considered! pertinent! to! the!
makers% can% find% this% “partial”% respective! context! (country,! group! of!
[deliberative]%form%of%MCDA%a%useful%way% patients,! indication! etc).! A! brief!
of% summarizing% the% relevant% evidence,% to% explanation!of!the!criteria!is!provided!in!
help% structure% their% deliberations% about% the! footnotes.! Selection! and! extensive!
which%alternatives%are%best”%(Devlin!et!al,! definition! and! application! of! each!
2016).!!.%
criterion! may! be! reached! via! consensus!
!
among! all! stakeholders! respecting!
III. MCDA!CRITERION!FOR!INCLUSION!!! legitimacy!of!the!participative!process.!!
In! order! to! facilitate! a! holistic! and! fair! CostJeffectiveness! is! not! recommended!
assessment!
of!
any!
healthcare! as! a! criterion! to! avoid! doubleJcounting!
technology,! criteria! included! in! the! given!economic!impact!and!effectiveness!
decision! making! process! must! be! already!listed!as!separate!criteria.!
relevant! to! local! market! conditions! and! !
comprehensive! in! that! they! include! !
considerations!
of!
all!
relevant! !
stakeholders! and! ethical! values.! ! The! !
ISPOR! MCDA! Task! Force! recommends! Table!1:!FIFARMA!recommended!MCDA!criteria!
selecting! and! structuring! criteria! that! for!healthcare!decision!making!
are! nonJredundant! and! independent! of! !
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Qualitative)
Criterion)
Quantitative)Criterion)
Utilization)of)Multiple/Criteria)Decision)Analysis)(MCDA))to)!
Support)Healthcare)Decision)Making)
FIFARMA,!2016!
!
!
!
!
!
!
!
)
Description)of)Criteria)
!
Added)therapeutic)benefit/innovation2)
IV. REALJWORLD!EXAMPLES!!
Improved!efficacy/effectiveness)
MCDA! is! more! than! an! academic,!
Improved!safety)
theoretical! decision! making! model.! ! It!
Unmet!medical!need!addressed!by!new!
has!been!successfully!applied!to!various!
technology!
therapeutic! areas! and! types! of!
Quality!of!life!(patients,!families,!
healthcare!decisions!in!countries!around!
caregivers))
Economic)Impact3)
the! world.! ! Table! 2! displays! examples!
Economic!impact!from!a!societal!
illustrating!how!decisionJmaking!bodies!
perspective!!
apply! MCDA.! ! This! table! is! meant! to!
Local)health)system)priorities)
capture! actual! utilization! versus!
Disease!severity/progression4!
research! or! recommendations! for!
Health!prioritization5!
Clinical)guidelines)and)international)
utilization.!!Note!that!this!is!by!no!means!
health)standards)
an!exhaustive!list!of!real!world!examples!
Completeness!in!international!and!local!
of! MCDA! utilization.! ! Literature! on! the!
clinical!practice!guidelines!
Medications!approved!by!globally!
utilization! of! MCDA! is! sparse! and! it! is!
recognized!healthcare!organizations6!!
assumed! that! many! more! formal! and!
Quality)of)evidence)
informal!examples!exist.!!The!successful!
Integrity!and!consistency!of!evidence)
utilization! of! MCDA! for! various!
Relevance!and!validity!of!evidence!
therapeutic!areas,!as!cited,!indicates!that!
Equity)7!
Patient!access!
MCDA! can! be! applied! effectively! to!
Other!
support!healthcare!decision!making.!
Sustainability!of!manufacturer!business!
practices8!!
Capacity!of!local!system!to!use!appropriate!
interventions!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
2!Innovation! (eg! breakthrough! designation! therapy)! can! be!
captured! via! subcriteria! (eg! effectiveness,! safety! QoL)! or! an!
as!an!independent!criterion!including!broader!definition!!(eg!
training!and!publications!through!clinical!trials!in!country)!
3 Economic! impact! refers! to! net! costs! considering!
components! such! as! lost! productivity! costs! avoided!
(patients,! families,! caregivers)! and! improved! efficiency! in!
healthcare!delivery.!
4 !Disease! severity/progression! should! consider! survival!
prognosis! with! current! standard! of! care,! disease!
morbidity/clinical!disability.!
5!Consideration!of!disease!in!regards!to!local!system’s!public!
health!priorities.!
6!World! Health! Organization,! Food! &! Drug! Administration,!
European!Medical!Association!
7!Equity! means! all! patients! have! access! to! medications! and!
treatment!facilities!regardless!of!income,!gender,!race,!age!or!
any!other!status.!
8!Sustainability! of! manufacturer! business! practices! refers! to!
environmental!aspects!as!well!as!consistency!and!reliability!
in!the!production!of!technologies.!
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Utilization)of)Multiple/Criteria)Decision)Analysis)(MCDA))to)!
Support)Healthcare)Decision)Making)
FIFARMA,!2016!
!
!
!
Country)
Example(s))of)Utilization)
Source))
England/UK!
i.!Orphan!drugs,!AGNSS/NICE!
ii.!Respiratory,!mental,!children’s!health,!
cardiovascular,!and!cancer!interventions,!
NHS/Primary!Care!Trusts!
iii.!Major!capital!expenditures,!NHS!
i.!Diagnosis!and!treatment!decisions!
ii.!Clinical!trial!design!
i.!Healthcare!priority!setting!
ii.!Budgeting!
iii.!Interventions!for!chronic!nonJcancer!
pain!
Incorporation!of!patient!involvement!with!
MCDA!quantitative!approaches,!IQWIG!
i.!Orphan!drug!coverage,!TLV!
ii.!HighJcost!biologics,!TLV!
Devlin!&!Sussex,!2011!
Adams!et!al,!2013!
Airoldi!et!al,!2014!
Orphan!drug!coverage!
Obesity!research!and!prevention!
i.!Orphan!drug!coverage!
ii.!PublicallyJfunded!healthcare!priority!
setting!
iii.!AnkleJfoot!repair!in!stroke!
EVIDEM!Framework!used!with!medical!
devices,!diagnostic!assessments,!and!
pharmaceuticals!!
Screenings!
Healthcare!priority!setting!
Hospital!medical!technologies,!OEP!
Orphan!drug!coverage,!NHS!
Algorithmic!approach!using!1000Minds!
software!used!to!analyze!coronary!artery!
bypass!graft!surgery,!MoH!
Private!health!plan!used!for!liquidJbased!
cytology!for!cervical!cancer!screening!
Healthcare!priority!setting!
Health!interventions!in!the!universal!health!
coverage!benefit!package,!NHS!
New!health!care!technologies,!Health!
Basket!Committee!!
Deans!et!al,!2014!
Borg!&!Fogelhol,!2007!
Van!Til,!2009!
Devlin!&!Sussex,!2011!
Baeten!et!al,!2010!
USA!
Canada!
Germany!
Sweden!
Denmark!
Finland!
The!Netherlands!
Italy!
France!
Norway!
Hungary!
Scotland!
New!Zealand!
South!Africa!
Ghana!
Thailand!
Israel!
Adunlin!et!al,!2014!
Guest,!et!al,!2012!
Diaby!et!al,!2015!
Tony!et!al,!2011!
Danner!et!al,!2011!
World!Health!Organization,!2015!
Deans!et!al,!2014!
Radaelli!et!al,!2014!
World!Health!Organization,!2015!
Defechereux!et!al,!2012!
Devlin!et!al,!2015!
Kanters!et!al,!2015!
Devlin!&!Sussex,!2011!
Hansen!et!al,!2012!
Miot!et!al,!2012!
JehuJAppiah,!2008!
Youngkong!et!al,!2012!
Devlin!&!Sussex,!2011!
!
!
Table!2:!Real!world!examples!of!MCDA!utilization!to!support!healthcare!decision!making!(exJLatAm)!
!
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Utilization)of)Multiple/Criteria)Decision)Analysis)(MCDA))to)!
Support)Healthcare)Decision)Making)
FIFARMA,!2016!
!
MCDA! is! also! being! considered! in! many! The! purpose! of! illustrating! these! realJ
markets! across! LatAm,! as! reflected! in! world! applications! of! MCDA! is! to! stress!
Table! 3.! ! It! should! be! noted! that! that! MCDA! can! be! implemented! as! a!
utilization! of! MCDA! in! LatAm! is! even! useful! tool! to! support! healthcare!
more! sparsely! published.! ! Information! decision! making! and! foster! a! fair! and!
has! been! gleaned! from! local! market! transparent! decision! making! process!
insight! as! well! as! the! 2015! ISPOR! 5th! with!a!patientJcentric!approach.!!It!is!the!
Latin!America!Conference!presentations! position! of! FIFARMA! that! MCDA! can! be!
with!the!exception!of!the!literature!cited! broadly! applied! to! the! HTA! process! in!
in!the!table.!
order!to!support!healthcare!decision!!
!
making.!
!
Country)
Brazil!
Argentina!
Colombia!
Chile!
Dominican!
Republic!
Ecuador!
Implementation)Progress)by)Stakeholders)
a.!MCDA!proposal!for!rare!disease,!Interfarma!!
b.!MCDA!used!for!hospital!investment,!RJ!Uni.!Hospital!!
Incorporation!of!MCDA!into!the!SUMAR!Project,!
Ministry!of!Health!
Pilot!completed!in!2013!and!MCDA!implemented!for!
healthcare!prioritization,!IETS!!
Utilization!of!MCDA!in!considering!tender!offers,!
University!of!Chile!Hospital!!
Seeking!insight!from!external!consultants,!Ministry!of!
Public!Health!
Prioritization!process!for!HTA!utilizing!MCDA!
recommended,!Ministry!of!Public!Health!!
Source)
Brito!et!al,!2015!
Nobre!et!al,!1999!
PichonJRiviere,!2015!
!
Jaramillo,!2013!
“Informe,”!2014!
Espinoza,!2015!
Sotomayer!et!al,!2015!
!
Table!3:!Examples!of!recommended!or!actual!realJworld!utilization!of!MCDA!in!LATAM.!
!
!
V. IMPLEMENTATION!
CONSIDERATIONS!
In! considering! the! implementation! of!
MCDA! or! any! other! healthcare! decision!
making!process,!sufficient!budget!should!
first!be!allocated!for!the!reimbursement!
of! medicines.! Furthermore,! policy!
setting! should! be! proJinnovation,!
meaning! decision! makers! value!
additional! clinical! benefits! and! unmet!
medical! needs! achieved! by! new!
healthcare!technologies.!!!!!
The! main! aspects! of! any! MCDA! method!
are! 1)! the! alternatives! to! be! appraised,!
2)! the! criteria! against! which! the!
alternatives! are! appraised.! Additional!
steps!for!quantitative!or!complete!MCDA!
would!still!require!3)!scores!that!reflect!
the! value! of! an! alternative's! expected!
performance! on! the! criteria,! and! 4)!
criteria! weights! that! measure! the!
relative! importance! of! each! criterion! as!
compared! with! others.! (Thokala! and!
Duenas,! 2012).! Key! steps! to! conducting!
an! MCDA! analysis! as! adapted! from! the!
ISPOR! MCDA! Task! Force! (Devlin! et! al,!
2016)! and! MCDM! (Multiple! Criteria!
Decision! Making)! Tool! (ZRx! Outcomes!
Resources! Inc.)! and! are! reflected! in!
Table!4.!FIFARMA!recommends!the!first!
three! steps,! which! constitutes! the!
deliberative,!partial!MCDA.!
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Utilization(of(Multiple9Criteria(Decision(Analysis)(MCDA)(to)!
Support)Healthcare)Decision)Making)
FIFARMA,!2015!
!
!
formalized! approach,! and! validation! of!
Typically,!the!most!complex!parts!of!the! the! process! are! required! for! MCDA!
MCDA! process! is! determining! how! to! implementation.! ! Organizational! change!
measure! criterion’s! performance! and! will! also! be! necessary! and! therefore,!
manage!uncertainty!in!outcomes9.!!!
engaging! experienced! independent!
It!is!out!of!the!scope!of!this!paper!to!do!a! consultants!is!recommended.!
deep! dive! into! measurement! models.!! !
FIFARMA!recommendation!is!that!MCDA! !
Steps)to)
Description)
be! implemented! in! a! deliberative! Implementation)
manner!and!not!rigid,!fixed!mechanism.! Define)the)
Identify)type)of)
)
!
objectives)
decision,)alternatives,)
)
and)relevant)
As! with! any! complex! decision! making!
)
stakeholders)
process,! the! output! of! MCDA! is! subject!
)
to! uncertainty! and! the! impact! of! this! Select)the)criteria) Influenced)by)scientific) Deliberative)
literature)and)specific)
MCDA)
uncertainty! should! be! addressed.! ! It! is!
local)needs)
the!view!of!the!ISPOR!MCDA!Task!Force! Measure)the)
Options)must)be)able)to)
and! FIFARMA! that! uncertainty! not! be! alternative’s)
incorporate)qualitative)
and)quantitative)
included! as! a! criterion! in! MCDA.! ! A! performance)
information,)
scenario! analysis! or! sensitivity! analysis!
“performance)matrix”)
is! recommended! for! considering! this!
to)summarize)
impact,! but! it! is! out! of! the! scope! of! this! Score!options!and! Scoring!helps!produce!an!
paper! to! analyze! and! explain! these! aggregate!scores!!
overall!estimate!of!value!
payJoff!for!each!
approaches!(Thokala!et!al,!2015).!
alternative!
!
Apply!scores!and!
Multiply!the!alternatives’!
Although! MCDA! may! present! such! weights!to!rank!
scores!on!the!criteria!by!
methodological! variety,! its! main! alternatives!
the!weights!and!sum!to!
contribution! is! indeed! the! deliberative!
get!the!total!scores!!
Perform!a!scenario!or!
process! allowed! still! by! the! partial! Explore!and!
analyze!uncertainty!
sensitivity!analysis!
approach.!!!MCDA!has!proven!significant!
Validate!and!
Interpret!outputs!and!
value! in! that! it! is! possible! to!
interpret!finds!
align!with!decision!
systematically! assess! any! disease! in!
maker!priorities!to!
context!of!the!treatment!that!is!available!
support!decision!making!
and!
local!
market!
priorities! !
(Omelyanovsky,!
Fedyaevam,!
and! Table! 4:! MCDA! implementation! considerations,!
Rebrova,! 2015).! ! Consensus,! a! Deliberative!MCDA!highlighted!
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
!The! types! of! MCDA! models! that! are! most! commonly! used!
include! weighted! sum! or! value! measurement,! outranking,!
and!goals!programming.!!Although!there!is!no!consensus!on!
the! best! MCDA! to! utilize,! the! weighted! sum! or! value!
measurement!model!is!most!utilized!in!healthcare!decisionJ
making.!(Marsh!et!al,!2014).!!The!value!measurement!model!
assesses! interventions! based! on! an! overall! benefit! score.!!
This! benefit! score! is! calculated! as! the! weighted! average! of!
the!criteria.!!
9
!
!
!
MCDA!can!be!implemented!at!the!macro!
and! micro! levels,! such! as! national! and!
state,! or! at! the! hospital! and! healthcare!
provider!levels.!!It!should!be!noted!that!
successful!implementation!of!MCDA!will!
be!an!iterative!process.!!Prior!to!a!broad!
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!
roll! out! of! MCDA,! it! is! recommended! to!
analysis! in! healthcare:! a! systematic!
pilot! the! methodology,! in! prioritized!
review! and! bibliometric! analysis.”!
high!cost!disease!states!such!as!oncology!
Health!Expect.!2014!Oct!2018.!
or! orphan! diseases,! for! which! costJ 4) Aitken! M.! Impact! of! costJper! QALY!
effectiveness! limitations! are! even!
reimbursement! criteria! on! access! to!
stronger.!
cancer! drugs.! IMS% Institute% for%
!
Healthcare% Informatics.! September!
VII.!SUMMARY!
2014.!
In! conclusion,! MCDA! is! a! structured,! 5) Airoldi!M,!Morton!A,!Smith!JA,!Bevan!
transparent,! participative,! consistent!
G.!
STARJJpeopleJpowered!
and! legitimate! tool! to! support!
prioritization:!
a!
21stJcentury!
healthcare! decision! making! as! it!
solution! to! allocation! headaches.!
provides! a! systematic! framework! for!
Med! Decision! Making! 2014!
breaking!down!a!complex!decision!into!a!
Nov;34(8):965J75.!
transparent! and! rationale! process! that! 6) Baeten! SA,! Baltussen! RMPM,! UylJde!
incorporates!the!priorities!and!values!of!
Groot! CA,! Bridges! J,! Louis! WN.!
stakeholders.! ! RealJworld! examples! of!
Incorporating!
equityJefficiency!
effective! MCDA! implementation! in!
interactions! in! costJeffectiveness!
healthcare! decision! making! in! both! the!
analysis:!three!approaches!applied!to!
public! and! private! sector! validate! that!
breast! cancer! control.! Value! Health.!
MCDA!can!be!applied!to!facilitate!holistic!
2010;13(5):573–9!
assessments.!!It!is!the!view!of!FIFARMA! 7) Baltussen,! Rob,! and! Louis! Niessen.!
that! MCDA! should! strongly! be!
“Priority!
Setting!
of!
Health!
considered!as!a!tool!to!support!HTA!and!
Interventions:! The! Need! for! MultiJ
broader! healthcare! decision! making!
Criteria! Decision! Analysis.”! Cost%
such! as! the! contracts! and! tenders!
Effectiveness% and% Resource% Allocation!
process! in! order! to! foster! transparency,!
4! (2006):! 14.! PMC.! Web.! 14! Oct.!
fairness,! and! collaboration! amongst!
2015.!
stakeholders.!
8) Borg! P,! Fogelholm! M.! Stakeholder!
!
appraisal! of! policy! options! for!
VII.!REFERENCES!!
responding! to! obesity! in! Finland.!
Obes!Rev.!2007;8(Suppl2):47J52.!
1) Access! to! new! medicines! in! Europe:! 9) Brito! A,! Fagundes! M,! Nunes! O,!
Technical!review!of!policy!initiatives!
Simones! M,! Hirai! S,! Lazarini! P.!!
and! opportunities! for! collaboration!
“Proposra! para! Incorporacao! de!
and! research.! ! World! Health!
medicamentos! em! Doencas! Raras:!
Organization! Regional! Office! for!
Definicao!de!Criterios!para!Avaliacao!
Europe.!2015.!
de! Reembolso! de! Medicamentos!
2) Adams!B,!Megget!K,!Bowie!C,!Hone!J.!
Orfaos! para! Tratamento! de! Doencas!
“Orphan! Drugs,! Raw! Deal?”!
Raras! no! SUS.”! Interfarma,! February!
PharmaTimes!Magazine,!May!2013.!!
2015.!
3) Adunlin! G,! Diaby! V,! Xiao! H.! 10)Danner! M,! Hummel! JM,! Volz! F,! et! al.!
“Application!of!multicriteria!decision!
Integrating! patients'! views! into!
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!
health! technology! assessment:!
Experiences! from! Hungary.! Value% in%
Analytic! hierarchy! process! (AHP)! as!
Health.%17!(2014)!487J489.!
a! method! to! elicit! patient! 18)Espinoza,! Manuel! Antonio.! “Análisis
de Decisiones Multicrietrios. Es la
preferences.! Int! J! Technol! Assess!
mejor manera de conducir decisiones
Healthcare!2011!Oct:!27(4):369J75.!
en! Latinoamerica.” ISPOR! LA! Chile!
11)Deans! M,! De! Rosch! M,! Voisin% E.!!
2015.!
“Regulatory! approval! and! market!
access:! a! winning! combination! for! 19)Guest! J,! Harrop! JS,! Aarabi! B,!
Grossman! RG,! Fawcett! JW,! Fehlings!
drug!
launch!
optimization.”!
MG,! et! al.! Optimization! of! the!
www.scriptsregulatorsaffairs.com,!
decisionJmaking! process! for! the!
October!2014.!
selection! of! therapeutics! to! undergo!
12)Defechereux! T,! Paolucci! F,! Mirelman!
clinical! testing! for! spinal! cord! injury!
A,! Youngkong! S,! Botten! G,! Hagen! TP!
in!the!North!American!Clinical!Trials!
et! al.! Healthcare! priority! setting! in!
Network.! J! Neurosurg! Spine.!
Norway! a! multicriteria! decision!
2012;17(1!Suppl):94–101.!
analysis.! BMC! Health! Serv! Res.!
20)Golan! O,! Hansen! P,! Kaplan! G,! Tal! O.!
2012;12:39J45.!!
Health! technology! prioritization:!
13)Devlin! N,! Ijzerman! M,! Marsh! K,!
Which! criteria! for! prioritizing! new!
Thokala! P.! MCDA! for! Healthcare!
technologies! and! what! are! their!
Decision! Making! –! An! Introduction:!
relative! weights?! Health% Policy.!
Report! 1! of! the! ISPOR! MCDA!
Volume! 102,! Issues! 2J3,! October!
Emerging!Good!Practices!Task!Force.!
2011,!Pages!126J135.!
Value!in!Health,!vol.19!issue!1!2016.!
14)Devlin! N,! Sussex! J.! “Incorporating! 21)Hansen!P,!Hendry!A,!Naden!R,!et!al.!A!
new! process! for! creating! points!
Multi! Criteria! in! HTA:! Methods! and!
systems! for! prioritising! patients! for!
Process.”!Office!of!Health!Economics.!
elective! health! services.! Clinical!
March!2011.!
Governance:!
An!
International!
15)Diaby!V,!Goeree!R,!Hoch!J,!Siebert!U.!
Journal!2012.!!
MultiJcriteria! decision! analysis! for!
health! technology! assessment! in! 22)Héctor!Eduardo!Castro!Jaramillo!MD,!
MSc,! PhD.! “Uso! de! Analysis! de!
Canada:! insights! from! an! expert!
Decision!
MultiJCriterio!
Para!
panel! discussion.! Expert! Rev!
Priorizar!
en!
Colombia.”!
Pharmacoecon!
Outcomes!
IETS.ORG.COM.!2013.!
Res.2015;15(1):13J9.!
16)Dolan! JG,! Boohaker! E,! Allison! J,! 23)Informe! de! Evaluacíon.! ! Licitacíon!
Publíca! Para! la! Adquisicion! de!
Imperiale! TF.! Patients'! preferences!
Infliximab! 100MG! Para! el! Hospital!
and! priorities! regarding! colorectal!
Clinco! de! la! Universidad! de! Chile.!!
cancer! screening.! Med! Decis! Making!
09.09.14.!
2013!Jan;33(1):59J70.!
24)
JehuJAppiah! C,! Baltussen! R,! Acquah!
17)Endrei! D,! Molics! B,! Agoston! I.!
C,!Aikins!M,!d’Almeida!SA,!Bosu!WK,!
Multicriteria!Decision!Analysis!in!the!
et!al.!Balancing!equity!and!efficiency!
Reimbursement! of! New! Medical!
in!health!priorities!in!Ghana:!the!use!
Technologies:!
RealJWorld!
Federación!Latinoamericana!de!La!Industria!Farmacéutica!!!!
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!
of! multicriteria! decision! analysis.! 31)Omelyanovsky! V,! Fedyaeva! V,!
Value!Health!J!Int!Soc!Pharmacoecon!
Rebrova! O.! Application! of! MultiJ
Outcomes!Res.!2008;11(7):1081–7.!
Criteria!Decision!Analysis!in!Russian!
25)Kanters! TA,! Hakkaart! L,! RuttenJvan!
Healthcare.!
!
Health%
Policy.!
Mölken! MP,! Redekop! WK.! Access! to!
March/April!2015.!
orphan!drugs!in!western!Europe:!can! 32)!PichonJRiviere,! A.! IP3:! “Planes! de!
more!systematic!policymaking!really!
Beneficios!
en!
salud!
en!
help! to! avoid! different! decisions!
Latinoamerica:! Cúal! es! el! Estado!
about! the! same! drug?! Expert% Rev%
Actual! y! Cúales! son! los! Desafios!
Pharmacoeconomics% Outcomes% Res.!
Futuros”,!ISPOR!LA!Chile!2015.!
2015;15(4):557J9.!
33)Radaelli! G,! Lettieri! E,! Masella! C,!
26)Marsh! K,! Caro! J,! Muszbek! N.! ! “Does!
Merlino! L,! Strada! A,! Tringali! M.!
the! Future! Belong! to! MCDA?”! ISPOR!
“Implementation! of! EUnetHTA®
CONNECTIONS!
Core! Model! in! Lombardia:! the! VTS!
November/December!2012.!
framework.”!Int!J!Technology!Assess!
27)Marsh! K,! Lanitis! T,! Neasham! D,!
Healthcare.!2014!Jan;30(1):105J12.!
Orfanos! P,! Caro! J.! Assessing! the! 34)Sotomayor! R,! Sanchez! X,! Armijos! L.!
Value! of! Healthcare! Interventions!
“Health! Technology! Assessment! in!
Using!
MultiJCriteria!
Decision!
Ecuador”! Health! Policy! In! Latin!
Analysis:!A!Review!of!the!Literature.!
America,! ISPOR! Latin! American!
PharmacoEconomics.! 2014;! 32:345J
Consortium! News! Across! Latin!
365.!
America.! Volume! 3,! Issue! 1,!
28)McKenna! C,! Soares! M,! Claxton! K,!
February/March!2015.!
Bojke! L,! Griffin! S,! Palmer! S,! 35)Sussex!J,!Rollet!P,!Garau!M,!Schmitt!C,!
Spackman!E.!!“Unifying!Research!and!
Alastair! K,! Hutchings! A.! ! A! Pilot!
Reimbursement! Decisions:! Case!
Study! of! Multicriteria! Decision!
Studies!Demonstrating!the!Sequence!
Analysis! for! Valuing! Orphan!
of! Assessment! and! Judgments!
Medicines.!2013!Dec;!16(8):1163J69.!
Required.”! ! VALUE! IN! HEALTH! 18! 36)Thokala! P,! Devlin! N,! Marsh! K,!
(2015)!865!–!875.!
Ijzerman! M.! ! MCDA! for! Healthcare!
29)Miot! J,! Wagner! M,! Khoury! H,!
DecisionsJ! Emerging! Good! Practices:!
Rindress! D,! Goetghebeur! MM.! Field!
Report! 2! of! the! ISPOR! MCDA! Task!
testing! of! a! multicriteria! decision!
Force!DRAFT.!2015.!
analysis! (MCDA)! framework! for! 37)Thokala! P,! Duenas! A.! “Multiple!
coverage! of! a! screening! test! for!
criteria! decision! analysis! for! health!
cervical! cancer! in! South! Africa.! Cost%
technology! assessment.”! Value!
Effective% Resource% Allocation.! 2012!
Health.!2012!Dec;15(8):1172J81.!
Feb!29;10(1):2!
38)Tony! M,! Wagner! M,! Khoury! H,!
30)Nobre! FF,! Trotta! LTF,! Gomes! LFAM.!
Rindress! D,! Papastavros! T,! Oh! P,!
MultiJCriteria! decision! making:! an!
Goetghebeur! MM.! Bridging! health!
approach! to! setting! priorities! in!
technology! assessment! (HTA)! with!
healthcare.! ! Stat! Med.! 1999;!
multicriteria! decision! analyses!
18(23):3345J54.!
(MCDA):! field! testing! of! the! EVIDEM!
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!
framework!for!coverage!decisions!by!
a!public!payer!in!Canada.!BMC%Health%
Services% Resources.! 2011! Nov!
30;11:329.!
39)Toumi,! M.! “MCDA! Utiliztion! for!
Public! Health! Decision! Process.”!
ISPOR!LA!Buenos!Aires!2013.!
40)Van! Til! JA.! Integrating! preferences!
into! decision! making:! the! treatment!
of! ankleJfood! impairment! in! stroke.!
Twente!
University,!
Enschede,!
Netherlands.!2009.!
41)Youngkong! S,! Baltussen! R,! Tantivess!
S,! Mohara! A,! Teerawattananon! Y.!
Multicriteria! decision! analysis! for!
including!health!interventions!in!the!
universal! health! coverage! benefit!
package! in! Thailand.! Value% Health.!
2012,!SepJOct;15(6):961J70.!
Federación!Latinoamericana!de!La!Industria!Farmacéutica!!!!
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FIFARMA,!2015!
!
I.
REAL!WORLD!EXAMPLES!OF!MCDA!
UTILIZATION!
!
A. The!United!Kingdom!!
i.
The! Advisory! Group! for! National!
Specialized! Services! (AGNSS)! developed!
a! framework! utilizing! MCDA! to! support!
reimbursement! decisions! for! orphan!
drugs.! ! In! 2012,! National! Institute! for!
Health! and! Care! Excellence! (NICE)! then!
assumed! responsibility! for! analyzing!
orphan! drugs! using! the! framework!
presented!by!AGNSS.!
ii.
Use! of! MCDA! in! a! Local!
Healthcare! Plan! in! the! English! NHS:!
MCDA!was!utilized!to!support!the!Isle!of!
Wight! Primary! Care! Trust! (PCT)! in! the!
allocation! of! resources! across! 21!
interventions! in! five! priority! areas:!
respiratory,! mental! and! children’s!
health,! cardiovascular! disease,! and!
cancer.! Interventions! were! assessed! on!
three!criteria:!increased!health!(reduced!
mortality! and! increased! quality! of! life);!
reduced! health! inequalities;! and!
operational! and! political! feasibility.! The!
resulting! estimate! of! value! was!
combined! with! data! on! the! cost! to!
estimate! “valueJcost! triangles”,! which!
were! ordered! to! construct! an! efficiency!
frontier.!!
Key! stakeholders! were! engaged! in! the!
analysis:!
clinicians,!
council!
representatives,!
voluntary!
sector!
representatives,! nurses,! public! and!
patients’! representatives,! hospital!
managers! and! the! ambulance! service.!
Participants!agreed!on!the!interventions!
to! be! evaluated! and! the! research! team!
collected! data! on! the! performance! of!
these!interventions.!Stakeholders!scored!
the! interventions! using! a! 0J100! visual!
analogue!scale,!and!weighted!the!criteria!
using!a!swing!weighting!approach.!!
Interviews! with! participants! revealed!
the!benefit!of!the!MCDA!approach.!First,!
most! stakeholders! found! the! approach!
accessible,! something! the! authors!
attribute! to! their! being! continuously!
engaged!
in!
the!
design!
and!
implementation! of! the! MCDA,! and! the!
use! of! visual! aids! to! communicate!
results.! Second,! stakeholders! found! the!
approach! acceptable,! except! in! a! minor!
of! cases,! such! as! palliative! care,! which!
generated! benefits! that! fell! beyond! the!
three! criteria.! Third,! stakeholders!
appreciated! the! logic! of! the! approach,!
which! they! considered! “an! advance! on!
just!sitting!around!a!table!and!talking!it!
through”! (Airoldi,! Morton,! Smith,! and!
Bevan,!2011).!
!
B. Canada!
Tramadol! for! chronic! nonJcancer! pain!
was! selected! by! the! public! health! plan!
for! assessment.! Based! on! extensive!
literature! review! 14! criteria! for! the!
MCDA! Core! Model! and! 6! qualitative!
criteria! for! the! Contextual! Tool! as!
developed! by! EVIDEM! were! utilized.!!
During! workshop! sessions,! committee!
members!tested!the!framework!in!three!
steps! by! assigning:! 1)! weights! to! each!
criterion! of! the! MCDA! Core! Model!
representing! individual! perspective;! 2)!
scores!for!tramadol!for!each!criterion!of!
the!MCDA!Core!Model;!and!3)!qualitative!
impacts! of! criteria! of! the! Contextual!
Tool! on! the! appraisal.! Utility! and!
reliability! of! the! approach! were!
explored!through!discussion,!survey!and!
testJretest.!Agreement!between!test!and!
retest! data! was! analyzed! by! calculating!
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FIFARMA,!2015!
!
intraJrater! correlation! coefficients! (fictitious)! hepatitis! C! treatment!
(ICCs)! for! weights,! scores! and! MCDA! alternatives! that! were! composed! of!
value!
estimates….Overall,!
the! various!
treatment!
characteristics!
framework!was!found!useful!by!the!drug! (attributes,! e.g.! outcomes)! and! that!
advisory! committee! in! supporting! differed! according! to! the! levels! of! the!
systematic! consideration! of! a! broad! characteristics.!The!results!of!all!of!these!
range!of!criteria!to!promote!a!consistent! choices! were! analysed! using! logistic!
approach! to! appraising! healthcare! regression! models! to! estimate! the!
interventions.”!(Tony!et!al,!2011).!
importance!(weighting)!of!the!individual!
!
treatment! attributes.! ! Overall,! MCDA!
C. Germany:!The!Case!of!IQWIG!
was! carried! out! in! a! realJworld! context!
In!2010,!the!German!Institute!for!Quality! and! was! successfully! used! to! increase!
and! Efficiency! in! Healthcare! (IQWiG)! rational,! transparent,! and! fair! priority!
initiated! a! study! to! explore! the! use! of! setting.! (Danner,! Hummel,! and! Volz,!
MCDA! methods! as! a! means! of! 2011).!
incorporating! patient! involvement! into!
!
its! HTA! process.! Patient! involvement! is! D. Lombardy,!Italy!
widely!acknowledged!to!be!important!in! This! study! describes! the! health!
HTA! and! healthcare! decision! making.! technology!
assessment!
(HTA)!
However,! quantitative! approaches! to! framework! introduced! by! Regione!
ascertain! patients’! preferences! for! Lombardia! to! regulate! the! introduction!
treatment! endpoints! are! not! yet! of! new! technologies.! The! study! outlines!
established.! The! project! used! the! the! process! and! dimensions! adopted! to!
analytic! hierarchy! process! (AHP)! and! prioritize,! assess! and! appraise! the!
conjoint! analysis! (CA)! as! preference! requests!of!new!technologies.!
elicitation!methods!for!use!in!HTA.!!
The! HTA! framework! incorporates! and!
The! AHP! study! included! two! AHP! adapts! elements! from! the! EUnetHTA!
workshops:! one! with! twelve! patients! Core!Model!and!the!EVIDEM!framework.!
and! one! with! seven! healthcare! It! includes! dimensions,! topics,! and!
professionals.! In! the! workshops,! issues! provided! by! EUnetHTA! Core!
patients! and! professionals! rated! their! Model! to! collect! data! and! process! the!
preferences! with! respect! to! the! assessment.! However,! decision! making!
importance! of! different! endpoints! of! is! supported! by! the! criteria! and! MultiJ
antidepressant! treatment! by! a! pairwise! Criteria! Decision! Analysis! technique!
comparison! of! individual! endpoints.!! from!the!EVIDEM!consortium.)
These!comparisons!were!performed!and! The! HTA! framework! moves! along! three!
evaluated! by! the! AHP! method! and! process! stages:! (i)! prioritization! of!
relative! weights! were! generated! for! requests,! (ii)! assessment! of! prioritized!
each!endpoint.!
technology,! (iii)! appraisal! of! technology!
A!discrete!choice!experiment!(DCE),!the! in!support!of!decision!making.!Requests!
choiceJbased! variation! of! CA,! was! used.! received!by!Regione!Lombardia!are!first!
Patients! and! healthcare! professionals! prioritized! according! to! their! relevance!
were! asked! to! choose! between! two! along! eight! dimensions! (e.g.,! costs,!
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!
efficiency! and! efficacy,! organizational! reimbursement! if! it! achieves! 60%! of!
impact,! safety).! Evidence! about! the! total! available! points,! and! achieves! at!
impacts!of!the!prioritized!technologies!is! least! 40%! of! the! available! points! on! all!
then! collected! following! the! issues! and! the!six!criteria.!The!points!achieved!by!a!
topics! provided! by! EUnetHTA! Core! technology! are! not! made! public.!
Model.! Finally,! the! MultiJCriteria! Between! 2010! and! 2013,! 14!
Decision! Analysis! technique! is! used! to! applications! were! consideration! using!
appraise! the! novel! technology! and! the! MCDA! method.! Six! resulted! in! a!
support! Regione! Lombardia! decision! formal! decision! (supporting! or!
making.)
rejecting).! Three! were! terminated!
The! VTS! (Valutazione! delle! Tecnologie! because! of! a! lack! of! information.! Five!
Sanitarie)! framework! was! successfully! cases! are! still! in! progress.! ! (Devlin,!
implemented! at! the! end! of! 2011.! From! Ijzerman,!Marsh,!and!Thokala,!2015).!
its! inception,! twentyJsix! technologies! !
have! been! processed.! (Radaelli! et! al,! F. South!Africa!
2014).!
MCDA! was! utilized! to! assess! liquidJ
!
based! cytology! for! cervical! cancer!
E. Hungary!
screening!for!a!private!health!plan.!!The!
MCDA! was! introduced! in! Hungary! in! committee!utilized!14!criteria!input!into!
2010! for! the! evaluation! of! new! hospital! the! MCDA! model! and! 4! contextual!
medical! technologies.! The! MDCA! criterions,! extracted! from! literature!
includes! the! evaluation! of! six! criteria:! review! and! input! from! the! health! plan.!!
healthcare!priorities,!severity!of!disease,! A! workshop! was! held! in! which! the! 14!
equity,! costJeffectiveness! and! quality! of! criteria! were! weighted! and! scored! and!
life,! budget! impact,! and! international! the! impact! of! the! 4! contextual! criteria!
reputation.! These! criteria! and! their! were! discussed.! ! When! appraising! LBC!
weights! were! established! by! a! for! cervical! cancer! screening,! the!
committee! comprising! the! healthcare! committee! assigned! the! highest! scores!
financing!agency,!the!Ministry!of!Health,! to! "Relevance! and! validity! of! evidence"!
clinical! experts! and! health! economists.! and! "Disease! severity".! ! Overall,! the!
Weights! were! determined! by! allocating! committee! felt! the! framework! brought!
100! points! across! the! criteria! to! reflect! greater! clarity! to! the! decision! making!
their! relative! importance.! The! criteria! process! and! was! easily! adaptable! to!
and! weights! were! submitted! to! other! different! types! of! health! interventions.!!
stakeholders!
for!
validation.! The! EVIDEM! framework! was! easily!
Manufacturers! submit! a! formal! HTA! adapted! to! evaluating! a! screening!
report,! including! a! healthJeconomic! technology! in! South! Africa,! thereby!
analysis,! clinical! evaluation,! clinical! broadening!
its!
applicability!
in!
expert! opinion,! and! detailed! cost! healthcare! decision! making.! (Miot,!
calculation.! Technologies! are! then! Wagner,! Khoury,! Rindress,! and!
scored! against! the! criteria! by! the! Goetghebeur,!2012).!
healthcare! financing! agency.! A! !
technology! is! considered! suitable! for! !
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G. Thailand!!
concerned,! in! consultation! with! patient!
MCDA! was! successfully! utilized! for! groups! and! other! clinicians.! The! MCDA!
including! health! interventions! in! the! process! consisted! of! seven! steps! as!
universal! health! coverage! benefit! below!!
package! in! Thailand.! ! In! 2012,! the!
• Rank!patient!case!vignettes!using!
National! Health! Security! Office,! the!
individual!clinical!judgments!and!
institute! managing! the! Universal!
then!by!consensus.!!
Coverage!Scheme!in!Thailand,!called!for!
• Draft! the! criteria! and! the!
more! rational,! transparent,! and! fair!
categories! within! each! criterion!
decisions! on! the! public! reimbursement!
for!prioritizing!patients.!!
of!health!interventions.!!To!address!this!
• PreJtest!
the! criteria! and!
issue,! “MCDA! was! applied! in! four! steps:!
categories!and!refine!them.!!
1)!17!interventions!were!nominated!for!
• Consult! with! patient! groups! and!
assessment;! 2)! nine! interventions! were!
other!clinicians.!!
selected! for! further! quantitative!
• Determine! the! point! values! for!
assessment!on!the!basis!of!the!following!
the!criteria!and!categories.!!
criteria:! size! of! population! affected! by!
• Check! the! testJretest! reliability!
disease,!
severity!
of!
disease,!
and! face! validity! of! the! points!
effectiveness! of! health! intervention,!
system.!!
variation! in! practice,! economic! impact!
• Revise! the! points! system! as! new!
on! household! expenditure,! and! equity!
evidence! emerges! or! clinical!
and! social! implications;! 3)! these!
judgments!change.!!
interventions! were! then! assessed! in! A! survey! of! the! participating! clinicians!
terms! of! costJeffectiveness! and! budget! revealed!high!levels!of!‘user’!satisfaction!
impact;! and! 4)! decision! makers! with! the! method/software.! The! CABG!
qualitatively!appraised,!deliberated,!and! points! systems! have! been! formally!
reached!
consensus!
on!
which! accepted! and! are! in! use! throughout! NZ.!
interventions! should! be! adopted! in! the! NZ’s! Ministry! of! Health! has! led! projects!
package.”!
(Youngkong,!
Baltussen,! to! create! and! validate! new! points!
Tantivess,!
Mohara,!
and! systems! for! elective! services! –! with! the!
Teerawattananon,!2012).!!!
ultimate! goal! of! more! equitable! access!
!
and! better! patient! outcomes! overall.!
H. New! Zealand:! 1000! Minds! Tool! Inspired!by!NZ’s!success,!since!2008!the!
Utilization!
same! process! has! been! used! in! the!
The! MCDA! process! supported! by! public! health! systems! of! Canada’s!
internetJbased!software!1000Minds!was! western! provinces.! (Hansen,! Hendry,!
performed! by! a! working! group! of! and!Naden,!2012).!!
clinical! leaders! for! the! elective! service! !
!
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!
II.
OVERVIEW!OF!MCDA!PROCESS!&!COMPARISON!OF!APPROACHES!
MCDA!Process
!
Classification!of!MCDA!Methods!
AHP:!Analytical!Hierarchy!Process!
PBMA:!Program!budgeting!and!marginal!analysis!
ELECTRE:!Elimination!and!Choice!Expressing!Reality!
PROMETHEEJGAIA:!Preference!ranking!organization!method!for!enrichment!evaluations!
!
!
!
!
!
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)
!
Comparison!of!Different!MCDA!Models
!
Value!Measurement!
Models!
Weights!
Swing!weights!are!used!
to!capture!both!the!effect!
of!measurement!scales!
and!the!importance!of!the!
criteria!
Weights!should!satisfy!
preferential!
independence!of!criteria!
and!the!tradeJoff!
requirements!
Measuring!the! Performance!scores!vi(a),!
performance!
monotonic!functions!of!
of!the!criteria! the!attribute!values!zi(a),!
need!to!be!developed!for!
all!criterion!
i.!Significant!effort!is!
needed!to!develop!
performance!scores!
Presentation!
Easy!to!follow!and!
of!the!results!
enables!further!
deliberation,!well!suited!
for!good!visual!
presentation!of!the!
results!
Incorporating! Probabilistic!sensitivity!
uncertainty!
analysis!can!be!used!to!
propagate!parameter!
uncertainty!quite!easily!
Outranking!Approach!
Goal!Programming!
Weights!are!uninfluenced!by!
the!scale!of!the!value!
functions.!!They!convey!the!
relative!importance!of!
criteria!in!the!assertion!that!
one!alternative!is!better!than!
the!other!!!
Weights!do!not!have!to!
satisfy!any!condition!
Weights!are!attached!
to!the!deviations!and!
represent!the!relative!
importance!of!criteria!
by!specifying!an!
overall!measure!of!
deviation!from!the!
goals!
Weights!do!not!have!to!
satisfy!any!conditions!
Easy!to!understand!but!
requires!significant!
computational!time!to!
provide!results.!!!
RealJtime!updating!is!
not!possible!
!
Intuitive!and!easy!to!follow.!!
With!right!software,!
assumptions!can!be!changed!
and!results!can!be!observed!
almost!instantaneously!
Moderately!easy!to!follow,!
can!be!presented!visually!but!
difficult!with!multiple!
alternatives!
Results!easy!to!follow,!
but!they!cannot!be!
represented!visually!
Moderately!difficult!to!
include!uncertainty,!need!
specialist!software!
Quite!difficult!to!
include!uncertainty,!
complex!stochastic!
programming!
techniques!needed!
!
Source:!Thokala!P,!Duenas!A.!“Multiple!Criteria!Decision!Analysis!for!Health!Technology!Assessment.”!
VALUE!IN!HEALTH!15!(2012)!1172–1181.!!
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!
STRENGTHS!&!CHALLENGES!OF!MCDA!
III.
!
Strengths/Opportunities!
Utility!
• Transparency,!if!algorithms!are!
public!
• Transferability,!adaptable!to!local!
markets!
• Flexibility,!can!vary!by!therapeutic!
area!
• Consistent/systematic!decision!
progress!
• Identifies!social!values!and!
encourages!unbiased!decision!
making!
• Incorporates!societal!preferences!
!
Methodology!
• Inclusion!of!innovation!as!a!
criterion!
• More!holistic,!considering!all!
relevant!dimensions!not!only!
economic!dimensions!
• Pragmatic,!userJoriented!and!
modular!
• Detailed!instructions!
Challenges!
!
•
•
•
•
•
Perception!of!complexity!in!
implementation!
Integration!into!existing!processes!
Risk!of!using!MCDA!as!a!formula!
rather!than!as!support!for!decision!
making/priority!setting!
Roles!of!decision!makers!in!making!
scientific!and!social!value!judgments!
Requires!significant!resources!to!
capture!population!preferences!
!
•
•
•
•
Data!requirements!
• Comprehensive!but!modular!
• Leverages!technology!
!
Capacity/training!requirements!
• Community!of!users!and!developers!
• Open!participation!to!all!
stakeholders,!likely!via!
representatives!from!societies!
!
Criteria!selection!and!measurement!
MCDA!model!selection!and!
mathematics!
Developing!a!consistent!framework!
to!represent!the!relative!importance!
of!each!criterion!to!society!
Managing!uncertainty!in!meaning!of!
results!
•
•
Data!synthesis!by!criteria!
Web!integration!
•
New!paradigm,!limited!training!and!
understanding!
Limited!MCDA!expertise!in!
healthcare!
•
Source:!Adapted!from!“Lessons!learned!from!a!multiJcriteria!decision!analysis!(MCDA)!framework”!
EVIDEM! presentation! to! the! Institute! of! Medicine! in! Washington,! DC.! ! July! 2011! and! Mondher!
Toumi’s!“MCDA!Utilization!for!Public!Health!Decision!Process.”!ISPOR!LA!Buenos!Aires!2013.!
!
!
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