Using MCDA for HTA, Opportunities, Challenges and Possible Ways Forward

Using MCDA for HTA, Opportunities, Challenges and Possible Ways Forward

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  Martina Garau andNancy Devlin USING MCDA FOR HTA. OPPORTUNITIES, CHALLENGES AND POSSIBLE WAYS FORWARD 1
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  Agenda • Introduction • Whydo we need MCDA in Health Technology Assessment (HTA)? • Examples of applications of MCDA in HTA • Critical issues: – Criteria and weights need to be ‘fixed’? – Whose criteria? – Whose preferences for weighting the criteria? – How to factor in opportunity cost? – How can uncertainty be addressed? • Conclusions This presentation is based on a book chapter (Garau and Devlin, forthcoming) 2
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  Introduction • Many countrieshave developed/are developing collectively- funded health care systems to ensure universal coverage and access to health care for their populations • HTA on individual or groups of technologies can be used to allocate limited funds efficiently • However, existing HTA processes vary in their remit and their objectives – QALY -maximisers given the budget constraint; explicit or implicit consideration of opportunity cost of new technologies – HTA systems which do not consider costs (e.g. US) and focus on relative/comparative effectiveness 3
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  Why do weneed MCDA in HTA? (1) • Health care systems face multiple objectives that might go beyond improvements in population health • HTA systems vary in how far they are explicit and consistent in considering multiple elements of value  Policy initiatives suggest a need for approaches that could take into account multiple criteria simultaneously and in a systematic way (e.g. VBA in the UK; GPS-Health in global context – Norheim et al., 2014) • Increasingly a wide range of stakeholders, including patients and clinicians, have been involved in HTA (e.g. PACE in Scotland)  But how do stakeholders’ views influence final decisions?  How can stakeholders views be taken into account in a systematic way and weigh up against other types of evidence? 4
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  Criteria used internationallyfor prioritising new health technologies (source: Golan et al. 2011) 5
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  Why do weneed MCDA in HTA? (2) • Weighing up complex information is cognitively demanding – Literature shows that individuals are subject to “cognitive bias” (add reference) – Deliberative processes are influenced by group dynamics and factors including chairing styles and dominant people → “the preferred options identified by MCDA are likely to out-perform the use of intuitive judgement alone” (Devlin and Sussex, 2011) 6
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  Growing interest inMCDA in HTA • NICE: – ‘Structured decision making’ included for the first time in the 2013 methods review – Exploration of its use in clinical guidelines – Explicit criteria for new highly specialised technologies process – Public health • Some examples of one-off uses but no current systematic use: – Israeli Health Basket Committee (Golan and Hansen, 2012) – Italy (Radaelli et al., 2014) – Thailand (Youngkong et al., 2012) – Germany (Danner et al., 2011) 7
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  Israel’s Health Basket Committee pilot • Bubble size = qualityof evidence • Used to inform a deliberativ e process Source: adaptation of Golan and Hansen (2012) 8
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  MCDA in Italianregion Lombardia • For the implementation of new health technologies, the Lombardia region in Italy has introduced a system combining elements of the EUnetHTA Core model (for the assessment) and of an MCDA approach (EVIDEM) as a decision-making aid • The MCDA framework includes 9 broad dimensions and 20 criteria, including disease-, treatment-, financial- and social- related aspects • This approach has been deemed successful and used for 26 technologies (Radaelli et al., 2014) 9
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  Thai pilot (1) Performance matrixfor the selection of interventions for assessment Source: Youngkong et al., 2012 10
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  Thai pilot (2) •Assessment and appraisal of selected interventions based on – Value for money (incremental cost effectiveness ratio against a threshold) – Budget impact Source: Youngkong et al., 2012 11
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  IQWiG pilots • Aimswere: – Identifying patient-relevant outcomes in depression and hepatitis C – Eliciting patient preferences on the selected outcomes using two approaches (Analytic Hierarchy Process (AHP) and Discrete Choice Experiment (DCE)) – Enabling aggregation of outcome-specific efficiency frontiers based on obtained weights • Both pilots concluded that MCDA approaches can be used to support the HTA process to incorporate patient preferences (Thokala et al., 2016) 12
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  Critical issues • Criteriaand weights need to be ‘fixed’? • Whose criteria? • Whose preferences for weighting the criteria? • How can the opportunity cost of new technologies be incorporated? • How can uncertainty be addressed? 13
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  Criteria and weightsneed to be ‘fixed’? 1. Established in advance; the same across all decisions – Allows using same metric to measure lost and added benefit – Consistency between decisions – Issue of different scale ranges 2. Chosen on a case-by case basis and varying across technologies or disease areas – It can hinder systematic consideration of all criteria and predictability of decision making process 14
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  Whose criteria? 1. CurrentHTA bodies’ criteria – Do they have any legitimacy? 2. Members of an HTA committee on behalf of payers or NHS budget-holders – This can encourage alignment of objectives across healthcare decision makers 3. Reflect views of the general public – Reflecting tax-payers’/potential users’ view 15
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  Whose preferences forweighting the criteria? 1. Stakeholders as defined by the decision maker – In line with extra-welfarist foundation of HTA – Variations of stakeholders among diseases requires flexible weights? 2. Members of an HTA committee – Pragmatic approach which can avoid conducting large preference-based studies – Structure the deliberative process 3. Members of the general public – Consistent with the approach taken to valuing QoL in QALYs 16
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  How to factorin cost and opportunity cost? (1) • Separate criterion for cost (e.g. EVIDEM) or cost effectiveness which contributes to the overall intervention value – Need to avoid overlapping with other criteria • All (incremental) benefits, combined by using an MCDA aggregation approach (e.g. Israeli Health basket Committee in Golan and Hansen, 2012), weigh against all (incremental) costs – Still need to identify the “hurdle for adoption”, e.g. cost per incremental point score – Redefine the cost effectiveness threshold? 17
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  How to factorin cost and opportunity cost? (2) • Debate over the meaning and the measurement methods of the cost effectiveness threshold • Consideration of multiple attribute of values (beyond health gains) can complicate estimation of threshold – Need for a “cost per performance score” reflecting benefits forgone if the new technology is implemented 18
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  How can uncertaintybe addressed? • HTA bodies face high degree of uncertainty – Evidence base of new interventions can be limited (particularly near their launch) • Acceptable level of uncertainty is a matter of judgment – Currently, HTA bodies give large discretion to committees to decide on the appropriate level of acceptability  Separate criterion for uncertainty – Measuring and valuing it can be challenging  Use existing sensitivity analysis (SA) techniques – It leaves open the question of how SA results should affect decisions 19
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  MCDA pilots andcritical issues Pilot/Critical issue Criteria and weights ‘fixed’? Whose criteria? Whose preferences for weighting the criteria? How can the opportunity cost of new technologies be incorporated? How can uncertainty be addressed? Israel Yes Current HTA/priority setting’ criteria (based on literature review) Convenience sample Value for money chart (total net cost vs net benefit) and efficiency frontiers Quality of evidence shown via different size bubbles Italy Yes Mix of EUnetHTA Core Model and the EVIDEM framework Decision makers (i.e. committee members) Economic and Financial Impact cluster including ‘cost effectiveness’ criterion Not explained Thailand Yes Current HTA bodies’ criteria in seven countries Equal weight applied to all criteria (in nomination of intervention step) Value for money criterion (using cost per QALY threshold) Budget impact criterion Not explained Germany No (disease- specific) Outcome measures relevant to patients reported in the literature Patients Not considered Sensitivity analysis performed 20
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  Opportunities Challenges UnresolvedHTA issues Established HTA systems to increase their accountability - “show the quality and rigor of its work to others” (Walker, 2016) Balance between deliberation and more structured approaches - avoid asking committees “to rubber-stamp” decisions (Walker, 2016) How is the budget constraint reflected in the process? What does the threshold mean? Countries developing new HTA systems to avoid issues/limitations of existing systems Benefits, in terms of improved decision making, vs cost of implementing any given approach – would that minimise “wrong” decisions? Whose value to derive criteria and weights remains a normative question Align objectives across NHS decision makers Reconciling divergent views of multiple stakeholders How to deal with uncertainty? 21
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  Conclusions • It isdifficult to make ‘hard’ conclusions about how MCDA should be implemented in HTA given fundamental differences between health care systems and HTA processes (‘one size does not fit all’) • Consideration of cost and opportunity cost in a systematic way remains a methodological challenge (not only from an MCDA perspective) • Use of MCDA in HTA has the potential to provide a coherent/unifying framework for healthcare decision making • Need to consider the balance between additional costs of implementing an MCDA approach and additional benefits of improved decision making process • Even partial use of MCDA, e.g. performance matrix, may still improve decision making processes 22
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  References (1) • Danner,M., Hummel, J.M., Volz, F. et al. (2011). Integrating patients' views into health technology assessment: Analytic hierarchy process (AHP) as a method to elicit patient preferences. International Journal of Technology Assessment in Health Care. Oct;27(4):369- 75 • Devlin, N., and Sussex, J., (2011). Incorporating Multiple Criteria in HTA. Methods and processes. OHE research https://www.ohe.org/publications/incorporating-multiple-criteria- hta-methods-and-processes • Garau, M., Devlin, N., (forthcoming). Using MCDA as a decision aid in Health Technology Appraisal for coverage decisions: opportunities, challenges and unresolved questions. In “MCDA in health care decision making” published by Springer • Golan, O., Hansen, P., Kaplan, G., Tal, O., (2011). Health technology prioritization: which criteria for prioritizing new technologies and what are their relative weights? Health Policy Oct;102(2-3):126-35 • Golan,O., and Hansen, P., (2012). Which health technologies should be funded? A prioritization framework based explicitly on value for money. Israel Journal of Health Policy Research 1:44 23
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  References (2) • NorheimO. F., Baltussen R., Johri M., et al., 2014. Guidance on priority setting in health care (GPS-Health): the inclusion of equity criteria not captured by cost-effectiveness analysis. Cost Effectiveness and Resource Allocation 12:18 • Radaelli, G., Lettieri, E., Masella, C., (2014). Implementation of EUnetHTA core Model® in Lombardia: the VTS framework. International Journal of Technology Assessment in Health Care 30:1; 105-12 • Thokala, P., Devlin, N., Marsh, K., et al. (2016) Multiple Criteria Decision Analysis for Health Care Decision Making - An Introduction: Report 1 of the ISPOR MCDA Emerging Good Practices Task Force. Value in Health Jan;19(1):1-13 • Walker, A., (2016). Challenges in using MCDA for reimbursement decisions on new medicines? Value in Health 19: 123-124 • Youngkong, S., Baltussen, R., Tantivess, S., et al. (2012). Multicriteria decision analysis for including health interventions in the Universal Health Coverage Benefit package in Thailand. Value in Health 15; 961-970 24