Abstract
BackgroundSystematic and transparent approaches to priority setting are needed, particularly in low-resource settings, to produce decisions that are sound and acceptable to stakeholders. The EVIDEM framework brings together Health Technology Assessment (HTA) and multi-criteria decision analysis (MCDA) by proposing a comprehensive set of decision criteria together with standardized processes to support decisionmaking. The objective of the study was to field test the framework for decisionmaking on a screening test by a private health plan in South Africa.MethodsLiquid-based cytology (LBC) for cervical cancer screening was selected by the health plan for this field test. An HTA report structured by decision criterion (14 criteria organized in the MCDA matrix and 4 contextual criteria) was produced based on a literature review and input from the health plan. During workshop sessions, committee members 1) weighted each MCDA decision criterion to express their individual perspectives, and 2) to appraise LBC, assigned scores to each MCDA criterion on the basis of the by-criterion HTA report.Committee members then considered the potential impacts of four contextual criteria on the use of LBC in the context of their health plan. Feedback on the framework and process was collected through discussion and from a questionnaire.ResultsFor 9 of the MCDA matrix decision criteria, 89% or more of committee members thought they should always be considered in decisionmaking. Greatest weights were given to the criteria "Budget impact", "Cost-effectiveness" and "Completeness and consistency of reporting evidence". When appraising LBC for cervical cancer screening, the committee assigned the highest scores to "Relevance and validity of evidence" and "Disease severity". Combination of weights and scores yielded a mean MCDA value estimate of 46% (SD 7%) of the potential maximum value. Overall, the committee felt the framework brought greater clarity to the decisionmaking process and was easily adaptable to different types of health interventions.ConclusionsThe EVIDEM framework was easily adapted to evaluating a screening technology in South Africa, thereby broadening its applicability in healthcare decision making.
Highlights
Systematic and transparent approaches to priority setting are needed, in low-resource settings, to produce decisions that are sound and acceptable to stakeholders
Based on a literature review and input from the clinical committee of the health plan, a structured Health Technology Assessment (HTA) report on Liquid Based Cytology (LBC) for cervical cancer screening was produced and tailored to investigate each of the multi-criteria decision analysis (MCDA) decision criteria of the framework organized in the MCDA matrix [22]. (Note that the framework contains MCDA decision criteria; the criterion “Adherence to requirements of decisionmaking body” was not considered for appraisal in this field test.) Four contextual criteria were proposed by the healthcare funder: “Impact on future decisions”, “Relationship with pathology providers”, “Impact on screening intervals” and “Patient expectation"; these criteria were appraised qualitatively
“Political context” received least approval among all criteria included in the survey, with only one (11%) committee member expressing the opinion that it should always be considered
Summary
Systematic and transparent approaches to priority setting are needed, in low-resource settings, to produce decisions that are sound and acceptable to stakeholders. CEA/CUA is being used for priority setting at all levels: the patient; the healthcare service; and within populations. This is evident in the field of HIV/AIDS where cost-effectiveness analyses of antiretroviral (ARV) medicines has enhanced access to treatment and reduced drug prices [9,10]. A simple cost-minimization approach is all that is attempted This approach has shortcomings, as there are a number of additional important dimensions, such as budget impact, equity, availability of alternatives, disease severity, etc. Where these are taken into consideration, they are often assessed in an ad hoc manner and there is a lack of transparency as to how they impact the final decision [1]
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