Value-based assessment of new medical technologies: towards a robust methodological framework for the application of multiple criteria decision analysis in the context of health technology assessment

In recent years, multiple criteria decision analysis (MCDA) has emerged as a likely alternative to address shortcomings in health technology assessment (HTA) by offering a more holistic perspective to value assessment and acting as an alternative priority setting tool. In this paper, we argue that MCDA needs to subscribe to robust methodological processes related to the selection of objectives, criteria and attributes in order to be meaningful in the context of healthcare decision making and fulfil its role in value-based assessment (VBA). We propose a methodological process, based on multi-attribute value theory (MAVT) methods comprising five distinct phases, outline the stages involved in each phase and discuss their relevance in the HTA process. Importantly, criteria and attributes need to satisfy a set of desired properties, otherwise the outcome of the analysis can produce spurious results and misleading recommendations. Assuming the methodological process we propose is adhered to, the application of MCDA presents three very distinct advantages to decision makers in the context of HTA and VBA: first, it acts as an instrument for eliciting preferences on the performance of alternative options across a wider set of explicit criteria, leading to a more complete assessment of value; second, it allows the elicitation of preferences across the criteria themselves to reflect differences in their relative importance; and, third, the entire process of preference elicitation can be informed by direct stakeholder engagement, and can therefore reflect their own preferences. All features are fully transparent and facilitate decision making

A critical structured review of economic evaluations of interventions for the prevention and treatment of osteoporosis

Osteoporosis is a major cause of morbidity, mortality and resource cost amongst the elderly population. Hip fracture is the most serious of the osteoporotic fractures, with approximately 10-20% of patients dying within six months of sustaining a fracture. Furthermore, hip fractures are the most expensive manifestation of osteoporosis, incurring about 87% of the total costs of osteoporotic fractures. This public health and economic burden is likely to increase in developed nations due, in part, to ageing populations. In addition, there is strong evidence that the age-specific incidence of fracture is rising. There are a number of treatments which can be used to prevent fracture including hormone replacement therapy (HRT), bisphosphonates, vitamin D and calcium. These interventions have been used for primary prevention, secondary prevention and the treatment of established osteoporosis. This Discussion Paper details the results of a structured review, the purpose of which was to identify and critically appraise economic evaluations relating to interventions for osteoporosis. The focus of the work is a critical assessment of the methodology of those studies. A total of 16 economic evaluations was identified on the basis of a computerised search of three bibliographic databases. All studies were based on decision analytical models and all took the form of cost-effectiveness analysis. Seven studies were from the US and four from the UK. The majority of studies focused on either primary prevention alone (seven) or both primary and secondary prevention where high-risk women were identified on the basis of bone mineral density screening (seven). Most studies considered the cost-effectiveness of HRT. Most of the published studies conclude that treatment using HRT is relatively cost-effective among symptomatic women or women who have had a prior hysterectomy. In contrast, for asymptomatic women, the results are more equivocal. The most recent cost-effectiveness analysis was undertaken by the National Osteoporosis Foundation (NOF) which makes the explicit assumption that HRT is the treatment of choice. For women unwilling or unable to take HRT, the next recommended treatment was alendronate; should alendronate not be tolerated, calcitonin was recommended. Many of the models included in the review exhibit methodological weaknesses which suggest heir results should be treated with some caution. One of these concerns the dearth of formally elicited health state preference data from patients or members of the public: only two studies in the review derive preferences empirically rather than use the authors’ judgement. A second limitation of many studies is the inappropriate application of costeffectiveness decision rules with the frequent use of average cost-effectiveness ratios. Areas of methodological controversy, such as whether or not to include costs unrelated to osteoporosis in life-years added as a result of treatment, increase uncertainty regarding how to interpret the results of the studies.osteoporosis, HRT

Agile preference models based on soft constraints

An accurate model of the user’s preferences is a crucial element of most decision support systems. It is often assumed that users have a well-defined and stable set of preferences that can be elicited through a set of questions. However, recent research has shown that people very often construct their preferences on the fly depending on the available decision options. Thus, their answers to a series of questions before seeing decision options are likely to be inconsistent and often lead to erroneous models. To accurately capture preference expressions as people make them, it is necessary for the preference model to be agile: it should allow decision making with an incomplete preference model, and it should let users add, retract or revise individual preferences easily. We show how constraint satisfaction and in particular soft constraints provide the right formalism to do this, and give examples of its implementation in a travel planning tool

Value-based assessment of new medical technologies: towards a robust methodological framework for the application of multiple criteria decision analysis in the context of health technology assessment

In recent years, multiple criteria decision analysis (MCDA) has emerged as a likely alternative to address shortcomings in health technology assessment (HTA) by offering a more holistic perspective to value assessment and acting as an alternative priority setting tool. In this paper, we argue that MCDA needs to subscribe to robust methodological processes related to the selection of objectives, criteria and attributes in order to be meaningful in the context of healthcare decision making and fulfil its role in value-based assessment (VBA). We propose a methodological process, based on multi-attribute value theory (MAVT) methods comprising five distinct phases, outline the stages involved in each phase and discuss their relevance in the HTA process. Importantly, criteria and attributes need to satisfy a set of desired properties, otherwise the outcome of the analysis can produce spurious results and misleading recommendations. Assuming the methodological process we propose is adhered to, the application of MCDA presents three very distinct advantages to decision makers in the context of HTA and VBA: first, it acts as an instrument for eliciting preferences on the performance of alternative options across a wider set of explicit criteria, leading to a more complete assessment of value; second, it allows the elicitation of preferences across the criteria themselves to reflect differences in their relative importance; and, third, the entire process of preference elicitation can be informed by direct stakeholder engagement, and can therefore reflect their own preferences. All features are fully transparent and facilitate decision making

The Structure of Rural Landscape in Monetary Evaluation Studies: Main Analytical Approaches in Literature

Over recent years considerable research has been devoted to the assessment of the rural landscape value. These studies have concerned both use and non-use value estimation. An important issue in monetary evaluations is about taking (or not) into account the structural complexity of landscape. Three analytical approaches may be recognized on the basis of whether landscape structural attributes are involved (global, mono-attribute and multi-attribute approach). The present work is part of a research aimed to seek out rational instruments for guidance policies on rural landscape. It consists in a survey of the main studies appeared in literature. The specific purpose is to classify these empirical analyses in accordance both to the approaches mentioned above and to the landscape typologies (agricultural or forestry) involved.rural landscape, structural attributes, landscape demand, contingent valuation models, choice experiment, Land Economics/Use, Q26,