The Use of MCDA in HTA: Great Potential, but More Effort Needed

Multicriteria Decision Analysis to Support Health Technology Assessment Agencies: Benefits, Limitations, and the Way Forward

Introduction:The use of multi-criteria decision analysis (MCDA) in health technology assessment (HTA) studies has become more common due to the fact that MCDA offers a comprehensive technique for decisions that involve multiple criteria and stakeholders. How MCDA contributes to the HTA decision making process is an issue to be investigated. A systematic review was carried out in order to provide an overview of the benefits identified in MCDA applications for the strategic HTA decision making process.Methods:A systematic review developed by Philip Wahlster et al. (2014) was updated. The papers were analyzed in order to determine how MCDA is connected with traditional HTA, and to identify opportunities through the application of MCDA. In total 965 papers were found, and 43 articles were included in the review. The included articles detailed MCDA applications oriented to tactical and strategic decision making processes. The review was conducted by two researchers.Results:Of the available studies published on MCDA, 76 percent were published between 2014 and 2017, and 24 percent were published prior to 2014. Regarding the MCDA methodology defined in the included studies, 10 used the analytical hierarchy process, four used multi-attribute theory, and others refer the methodology only as “MCDA”. Seventeen studies also included health technology economic analysis, in special cost-effectiveness, safety and technological innovation. The studies suggest MCDA adds value since it allows different stakeholders to be engaged in the decision making process.Conclusions:The increase in studies on MCDA and healthcare point to the possibility to add different criteria, engage people with different knowledge levels, and make the decision-making process more transparent. In comparison with other technical areas, the use of MCDA in healthcare is more focused on achieving the decision about adding the new technology, and to show how to engage stakeholders than to explain how to develop the algorithms and methodologies.

The objective of this study is to review applications of multicriteria decision analysis (MCDA) methods to provide structure for and practical insights on how MCDA methods are applied in different healthcare areas. Four databases (Embase, Medline, Web of Science, and PubMed) were searched from 1980 to February 7, 2018. A scoping review was performed to outline the most frequently applied MCDA methods, in which only case studies were considered, as the objective was to assess the applications of MCDA methods. Seventy case studies were selected. The review showed that the first real‐life application was published in 1990. With regard to areas of application, three aspects were analysed: type of health services (public or private), type of intervention (preventive, diagnostic, or treatment), and healthcare area (policymaking; resource allocation; health technology assessment; pharmaceutics; and hospital, clinical, or patient level). Data revealed that MCDA was principally used in public health services (n = 59). Three types of interventions were identified: prevention (n = 36), diagnosis (n = 32), and treatment (n = 2). An MCDA process of application was then followed to provide practical insights. During the problem‐structuring phase, results showed that processes for selecting stakeholders and criteria differed among healthcare areas. For model building, authors preferred value measurement methods and especially the analytical hierarchy process. Authors of the 70 case studies included and confirmed the usefulness of MCDA in different healthcare contexts. The stakeholders, criteria, and MCDA methods chosen differ from one study to another, answering different research objectives in different healthcare areas. This scoping review highlights the importance of each MCDA step (using Belton and Stewart's framework), from problem structuring (including the selection of stakeholders) to the model building phase (encompassing the selection of the appropriate MCDA method). We recommend structured and justified analysis so that decision makers and stakeholders can feel confident during the application process in order to make final decisions more meaningful. Further work is needed to help researchers and decision makers when choosing a suitable MCDA method.

INTRODUCTION:Priority setting in health care has been long recognized as an intrinsically complex and value-laden process. Yet, Health Technology Assessment (HTA) agencies presently employ value assessment frameworks that are ill-fitted to capture the range and diversity of stakeholder values, and thereby risk to compromise the legitimacy of their recommendations. We propose ‘evidence-informed deliberative processes’ as an alternative framework with the aim to enhance this legitimacy.METHODS:The framework is based on an integration of two increasingly popular and complementary frameworks for priority setting: multi-criteria decision analysis (MCDA) and accountability for reasonableness (A4R), Evidence-informed deliberative processes are, on the one hand, based on early, continued stakeholder deliberation to learn about the importance of relevant social values. On the other hand, they are based on rational decision-making – through evidence-informed evaluation of the identified values.RESULTS:The framework has important implications for how HTA agencies should ideally organize their processes. Firstly, HTA agencies should take the responsibility to organize stakeholder involvement. Second, agencies are advised to integrate their assessment and appraisal phase, allowing for the timely collection of evidence on values that are considered relevant. Third, HTA agencies should subject their specification of decision-making criteria to public scrutiny. Fourth, agencies are advised to use a checklist of potentially relevant criteria, and to provide argumentation how each criterion affected the recommendation. Fifth, HTA agencies must publish their argumentation and install options for appeal.CONCLUSIONS:Adopting ‘evidence-informed deliberative processes’ as a value assessment framework could be an important step forward for HTA agencies to optimize the legitimacy of their priority setting decisions. Agencies can incorporate elements according to their needs and affordances.

Background: Multi-criteria decision analysis (MCDA) is a decision-making tool that can take into account multidimensional factors and enables comparison of (medical) technologies by combining individual criteria into one overall appraisal. The MCDA approach has slowly gained traction within Health Technology Assessment (HTA) and its elements are gradually being incorporated into HTA across Europe. Several groups of scientists have proposed MCDA approaches targeted toward orphan drugs and rare diseases by including criteria specific to rare diseases. The goal of this article is to provide an overview of the current state of knowledge and latest developments in the field of MCDA in HTA for orphan drugs, to review existing models, their design characteristics, as well as to identify opportunities for further model improvement.Methods: A systematic literature search was conducted in January 2018 using four databases: MEDLINE (Pubmed), EBSCO HOST, EMBASE, and Web of science to find publications related to use of MCDA in the rare disease field (keywords: MCDA/orphan drug/rare disease and synonyms). Identified MCDA models were analyzed, e.g., structure, criteria, scoring, and weighting methodology.Results: Two hundred and eleven publications were identified, of which 29 were included after removal of duplicates. 9 authors developed own MCDA models, 7 of which based on literature reviews intended to identify the most important and relevant decision criteria in the model. In 13 publications (8 models) weights were assigned to criteria based on stakeholder input. The most commonly chosen criteria for creation of the MCDA models were: comparative effectiveness/efficacy, the need for intervention, and disease severity. Some models have overlapping criteria, especially in the treatment cost and effectiveness areas.Conclusions: A range of MCDA models for HTA have been developed, each with a slightly different approach, focus, and complexity, including several that specifically target rare diseases and orphan drug appraisal. Models have slowly progressed over the years based on pilots, stakeholder input, sharing experiences and scientific publications. However, full consensus on model structure, criteria selection and weighting is still lacking. A simplification of the MCDA model approach may increase its acceptance. A multi-stakeholder discussion on fundamental design and implementation strategies for MCDA models would be beneficial to this end.

Background: There is a perception held by payers that orphan products are expensive. As a result, the current health technology assessment systems might be too restrictive for orphan drugs, therefore potentially denying patients access to life-saving medicines. While price is important, it should be considered in relation to a broader range of disease-related product attributes that are not necessarily considered by many health technology assessment agencies. To overcome these challenges, multi-criteria decision analysis has been proposed as an alternative to evaluate technologies. Methods: A targeted literature review was conducted to identify the most frequently cited attributes in multi-criteria decision analysis (MCDA) in rare diseases. From the leading attributes identified, we developed a multi-criteria decision analysis framework with which to aggregate the orphan drug values. We subsequently reviewed and plotted the relationship between single attributes and the average annual treatment costs for 8 drugs used in the treatment of rare endocrine diseases. The annual treatment costs were based on UK list prices for the average daily dose per patient. Results: The five most frequently mentioned attributes in the literature were as follows: Disease severity, Unmet need (or availability of therapeutic alternatives), Comparative effectiveness or efficacy, Quality of evidence and Safety & tolerability. Results from the multi-criteria decision analysis framework indicate a wide range of average annual per-patients costs for drugs intended for the same diseases, and likewise for diseases with a similar level of Disease severity. Conclusions: Multi-criteria decision analysis may offer a viable alternative to support discussion in reimbursement decisions for orphan drugs. The analyses can be used to inform investigations on the application of MCDAs in rare diseases.

Qualitative methods tend to be used to incorporate patient preferences into healthcare decision making. However, for patient preferences to be given adequate consideration by decision makers they need to be quantified. Multi-criteria decision analysis (MCDA) is one way to quantify and capture the patient voice. The objective of this review was to report on existing MCDAs involving patients to support the future use of MCDA to capture the patient voice. MEDLINE and EMBASE were searched in June 2014 for English-language papers with no date restriction. The following search terms were used: 'multi-criteria decision*', 'multiple criteria decision*', 'MCDA', 'benefit risk assessment*', 'risk benefit assessment*', 'multicriteri* decision*', 'MCDM', 'multi-criteri* decision*'. Abstracts were included if they reported the application of MCDA to assess healthcare interventions where patients were the source of weights. Abstracts were excluded if they did not apply MCDA, such as discussions of how MCDA could be used; or did not evaluate healthcare interventions, such as MCDAs to assess the level of health need in a locality. Data were extracted on weighting method, variation in patient and expert preferences, and discussion on different weighting techniques. The review identified ten English-language studies that reported an MCDA to assess healthcare interventions and involved patients as a source of weights. These studies reported 12 applications of MCDA. Different methods of preference elicitation were employed: direct weighting in workshops; discrete choice experiment surveys; and the analytical hierarchy process using both workshops and surveys. There was significant heterogeneity in patient responses and differences between patients, who put greater weight on disease characteristics and treatment convenience, and experts, who put more weight on efficacy. The studies highlighted cognitive challenges associated with some weighting methods, though patients' views on their ability to undertake weighting tasks was positive. This review identified several recent examples of MCDA used to elicit patient preferences, which support the feasibility of using MCDA to capture the patient voice. Challenges identified included, how best to reflect the heterogeneity of patient preferences in decision making and how to manage the cognitive burden associated with some MCDA tasks.

IntroductionOmics technologies enable the measurements of genes (genomics), mRNA (transcriptomics), proteins (proteomics) and metabolites (metabolomics) and thus proved to be valuable tools for personalized decision-making in clinical practice. For their evaluation, a health technology assessment (HTA) framework is not standardized and accepted, yet. Therefore, we aim at designing an omics-technologies HTA evaluation framework to facilitate their assessment, through a mixed-method approach. This work is part of the ExACT project, which aims to produce a range of tools to facilitate the implementation of precision health in clinical practice.MethodsA systematic review was conducted to identify the existing HTA frameworks used for the evaluation of omics-technologies. Desk research on the HTA agencies’ websites was performed to identify the reports on omics-technologies HTA evaluation frameworks used by these agencies. A questionnaire evaluating HTA agencies’ experience on evaluation of omics-technologies was designed. The new framework will be elaborated based on the findings from the three methodological steps, and will be validated through a Delphi process.ResultsTwenty-three articles were included in the systematic review. The main identified HTA frameworks were ACCE and “Evaluation of Genomic Applications in Practice and Prevention” (EGAPP). The desk research showed that these frameworks were seldom used by HTA agencies, which for the evaluation of omics-technologies mostly refer to the HTA Core Model®, mainly assessing the following domains: clinical effectiveness and economic evaluation. Data collection process of the questionnaire HTA agencies’ experience is in progress.ConclusionsAlthough two main HTA frameworks for the evaluation of omics-technologies have been identified, these frameworks are sporadically used by HTA agencies in their practice. The particular interest of HTA agencies on clinical effectiveness and economic evaluation, might potentially reflect the uncertainty and difficulties when evaluating omics-technologies. This could indicate that these HTA frameworks are not feasible and practical to be used in routine HTA agency processes for omics technologies, emphasizing the need for a new framework. Our methodological approach might contribute to the development of a new HTA framework, feasible and practical to use not only for HTA agencies.

Multi-criteria decision analysis (MCDA), a decision-making tool, has received increasing attention in recent years, notably in the healthcare field. For Canada, it is unclear whether and how MCDA should be incorporated into the existing health technology assessment (HTA) decision-making process. To facilitate debate on improving HTA decision-making in Canada, a workshop was held in conjunction with the 8th World Congress on Health Economics of the International Health Economics Association in Toronto, Canada in July 2011. The objective of the workshop was to discuss the potential benefits and challenges related to the use of MCDA for HTA decision-making in Canada. This paper summarizes and discusses the recommendations of an expert panel convened at the workshop to discuss opportunities and concerns with reference to the implementation of MCDA in Canada.

BackgroundThere has been a growing interest in the development and application of alternative decision-making frameworks within health care, including multicriteria decision analysis (MCDA). Even though the literature includes several reviews on MCDA methods, applications of MCDA in oncology are lacking.AimThe aim of this paper is to discuss a rationale for the use of MCDA in oncology. In this context, the following research question emerged: How can MCDA be used to develop a clinical decision support tool in oncology?MethodsIn this paper, a brief background on decision making is presented, followed by an overview of MCDA methods and process. The paper discusses some applications of MCDA, proposes research opportunities in the context of oncology and presents an illustrative example of how MCDA can be applied to oncology.FindingsDecisions in oncology involve trade-offs between possible benefits and harms. MCDA can help analyse trade-off preferences. A wide range of MCDA methods exist. Each method has its strengths and weaknesses. Choosing the appropriate method varies depending on the source and nature of information used to inform decision making. The literature review identified eight studies. The analytical hierarchy process (AHP) was the most often used method in the identified studies.ConclusionOverall, MCDA appears to be a promising tool that can be used to assist clinical decision making in oncology. Nonetheless, field testing is desirable before MCDA becomes an established decision-making tool in this field.

BackgroundThe use of Multi-Criteria Decision Analysis (MCDA) in health care has become common. However, the literature lacks systematic review trend analysis on the application of MCDA in health care.AimTo systematically identify applications of MCDA to the areas of health care, and to report on publication trends.MethodsEnglish language studies published from January 1, 1980 until October 1, 2013 were included. Electronic databases searches were supplemented by searching conference proceedings and relevant journals. Studies considered for inclusion were those using MCDA techniques within the areas of health care, and involving the participation of decision makers. A bibliometric analysis was undertaken to present the publication trends.ResultsA total of 66 citations met the inclusion criteria. An increase in publication trend occurred in the years 1990, 1997, 1999, 2005, 2008, and 2012. For the remaining years, the publication trend was either steady or declining. The trend shows that the number of publications reached its highest peak in 2012 (n = 9). Medical Decision Making was the dominant with the highest number published papers (n = 7). The majority of the studies were conducted in the US (n = 29). Medical Decision Making journal published the highest number of articles (n = 7). Analytic Hierarchy Process (n = 33) was the most used MCDA technique. Cancer was the most researched disease topic (n = 12). The most covered area of application was diagnosis and treatment (n = 26).ConclusionThe review shows that MCDA has been applied to a broad range of areas in the health care, with the use of a variety of methodological approaches. Further research is needed to develop practice guidelines for the appropriate application and reporting of MCDA methods.

This paper provides an overview of multi-criteria decision analysis (MCDA) applications in managing water-related disasters (WRD). Although MCDA has been widely used in managing natural disasters, it appears that no literature review has been conducted on the applications of MCDA in the disaster management phases of mitigation, preparedness, response, and recovery. Therefore, this paper fills this gap by providing a bibliometric analysis of MCDA applications in managing flood and drought events. Out of 818 articles retrieved from scientific databases, 149 articles were shortlisted and analyzed using a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) approach. The results show a significant growth in MCDA applications in the last five years, especially in managing flood events. Most articles focused on the mitigation phase of DMP, while other phases of preparedness, response, and recovery remained understudied. The analytical hierarchy process (AHP) was the most common MCDA technique used, followed by mixed-method techniques and TOPSIS. The article concludes the discussion by identifying a number of opportunities for future research in the use of MCDA for managing water-related disasters.

<p>THEORETICAL FOUNDATIONS AND USE OF MULTI-CRITERIA DECISION ANALYSIS IN THE PHARMACEUTICAL SECTOR OF UKRAINE ACCORDING TO THE EUROPEAN REFORMING VECTOR</p><p>O.B. Piniazhko, O.M. Zaliska</p><p>Danylo Halytsky Lviv National Medical University</p><p> </p><p>The reforming of health care system has been started to carry out in Ukraine. Assessing the value of medical technologies may require new approaches that take into account a more comprehensive set of parameters than the incremental cost-effectiveness ratio, ICER/ quality adjusted life years, QALY.</p><p>Technological advancements in combination with higher life expectancy, higher patient expectations, and increased prevalence of chronic diseases, have led to significant increases in public spending on pharmaceuticals, which, on average account for 9,3% of total health expenditure or about 1,4% of GDP across OECD countries (OECD, 2012). Given the resources governments and health systems can spend on healthcare, the pathway to optimal resource allocation passes through cost containment and efficiency improvement policies. </p><p>In the context of multi-criteria decision analysis (MCDA), elements of value can be measured and scored in their natural units or through constructed scales, quantitatively or qualitatively, and weights are assigned to reflect criteria’s importance when combining them. This approach may provide a more comprehensive account of value parameters, greater transparency in how multiple criteria are explicitly valued, weighted, and aggregated, and a more inclusive approach to stakeholder views on value.</p><p>Our aim was to perform a comparative analysis of the main approaches, methods and stages of MCDA, to determine the urgent and relevant use of MCDA in health care system of Ukraine based on the experience of developed countries.</p><p>We have analyzed the ukrainian and foreign publications, articles, systematic reviews, practical guidelines on MCDA in health care using PubMed, EMBASE, Internet resources as search tools.</p><p>Decision analysis can provide an alternative way of measuring and eliciting value. In particular, MCDA is both an approach and a set of techniques, with the goal of providing an overall ordering of options by looking at the extent to which a set of objectives are achieved. MCDA methodologies have been suggested for use in public services since 1960. MCDA has been used, on an experimental basis, in order to assess the benefit-risk (clinical) profile of new medicines for the purpose of regulatory approval during marketing authorisation stage by the European Medicines Agency and others. Its use has also been suggested in health care and value assessment in HTA also offering a conceptual framework.</p><p>Although a variety of MCDA methodologies exist, the process of MCDA includes a number of common stages as follows: 1) establishing the decision context by defining the aims of the MDCA, and who the decision makers and other key stakeholders are; 2) identifying the objectives and criteria that reflect the value associated with the consequences of each option; 3) «scoring» the value associated with the performance of each option against the criteria; 4) «weighting» each of the criteria to reflect their relative importance to the decision; 5) examine the results; 6) conducting a sensitivity analysis of the results to test the influence of changes in scores or weights.</p><p>As the results of our review we suggested the urgent and relevant use of MCDA in health care system of Ukraine based on the experience of developed countries. The comparative analysis of the main approaches, methods and stages of MCDA was performed and trends of it’s implementation in the pharmaceutical industry of our country were suggested.</p><p>Due to the performed analysis, in our opinion in order to optimize and improve the decision-making process in health care the implementation of MCDA approach will provide transparent and consistent management decisions in Ukraine.</p>

INTRODUCTION:Selecting candidates for graduate programs is considered to be a complex task, often subject to failures, especially regarding to the appraisal of non-cognitive (1,2) skills (for example, Motivation). Identifying suitable candidates is important for the overall success of the graduate programs, since dropouts and low productivity negatively affect the program classification by the Brazilian Governmental Agency.This study aims to describe the use of Multicriteria Decision Analysis (3) in the selection of candidates for a master degree program in Health Technology Assessment (HTA).METHODS:The Multicriteria Decision Analysis (MCDA) technique was used to measure value in the selection of students applying for a masters degree program, in 2017, using Multi-Attribute Value Theory methods (MAVT) method. The examiners group consisting of full-time professors who selected the criteria, blinded ranked and assigned weight relative to each criterion, using swing weights technique, normalized to 100 percent. During the face to face interview with the students, each evaluator professor filled an individual spreadsheet based on pre-defined questions and curriculum analysis. The results were summarized with a mean. For criterion performance, a value from 0 until 3 was assigned if the candidate didn't meet the criterion, partially meet and fully meet. The performance scores were multiplied by the weight of each criterion, the results were summarized by simple additive model, and the candidates were ranked.RESULTS:An interview was conducted with the examining group evaluating MCDA asking for difficulties, time consumed and if the result was considered fair. Seven criteria were listed: “Comprehension of HTA”, “Motivation”, “Ability to disseminate information”, “Availability to attend the course”, “Scientific production”, “Potential to work in HTA area” and “Scientific writing skills”.The highest weight (24 percent) was attributed to the “Potential to work in HTA area” and “Scientific writing skills” (20 percent). The evaluating group was unanimous in considering the process easy, fast and fair.CONCLUSIONS:The MCDA technique was applied successfully in student selection. Further prospective studies are needed.

IntroductionManufacture, distribution, use, excretion, and disposal of health technologies all have environmental impacts (EIs). In the health technology assessment (HTA) definition, EI is recognized as a domain that should be assessed. However, EIs in HTA methods are lacking. The aim of this scoping review was to identify current advances and limitations in incorporating EI in HTA evaluation.MethodsWe searched two databases, PubMed and Embase (01/01/2019–20/10/2023, updated on 15/05/2025), using the following keywords: “HTA” and “environmental impact.” Articles published in English were included. Additionally, no filters by study design or type of evaluated technology were used.ResultsIn total, 264 studies were screened after duplicates had been removed. Among them, 15 articles were included. Identified publications highlighted the necessity of robust and clear methods of EI assessment and its inclusion in the HTA process. Several authors have outlined the importance of assessing the EI of health technology throughout its life cycle, including raw materials, manufacturing, use, and disposal. However, the EI assessment in HTA presents significant challenges, such as determining a clear domain of EI, the perspective, and the time horizon for the assessment. EI assessment challenges also include the lack of disaggregated data on pollutant emissions and natural resource consumption, as well as recommendations on the use of the EI data by decision makers and HTA agencies. In the literature, different methods and approaches have been proposed to incorporate EI in HTA; some rely on already establish assessment methods (“enriched” cost-utility analysis, adjusted willingness to pay, and multicriteria decision analysis) and others proposed more specific approaches, such as “information conduit,” “parallel evaluation,” “integrated evaluation,” and “environment-focused evaluation.”ConclusionHTA framework needs adjustments to incorporate environmental information, including environmental healthcare technology impact. Clear and robust methods on EI assessment and inclusion in the HTA process should be provided by HTA agencies and international societies. Further, manufacturers should improve the data generation on the EI of their products, with new studies able to generate individual-level data on environmental technology impact.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40258-025-00984-7.