MCDA

6TH FUTURE TRENDS LATAM 2016

Multicriteria decision analysis:

Opportunities for changing the paradigm on healthcare

decision making to tackle ethical dilemmas

12 October 2016 / Panama City, Panama

Mireille Goetghebeur MEng PhD Global Scientist, LASER Analytica, Montreal, Québec, Canada Adjunct Professor,

School of Public Health, University of Montreal, Quebec Canada / President,

EVIDEM Collaboration Research Associate, Research Center, Ste Justine

Hospital University Center, Montreal,Quebec Canada

• Multiple technologies, procedures & programs call for fair

decisions for prioritization.

• Fair decisions are value-laden and based on a complex

reasoning.

• There is a diversity of perspectives of what constitutes a fair

decision.

• Perception of decisions as fair is crucial and depends on

communication of the reasoning that has been performed

through a fair process.

• Pragmatic approaches to support reasoning underlying fair

decisions are lacking.

The need for a new paradigm in

healthcare decision making

Voting Question:

Do you think MCDA can help address legitimacy of healthcare decisions?

1. Strongly disagree

2. Disagree

3. Neither agree nor disagree

4. Agree

5. Strongly agree

Open-ended question:

Could you elaborate why do you think MCDA can help address legitimacy of healthcare decisions or not?

MCDA to support decision making?

• MCDA is a reductionist approach to a decision problem.

• We cannot reduce human reasoning to a series of steps driven by an

algorithm.

• We cannot make complex calculation that drives us even more away than

current approaches from our individual interpretive frames.

Voting Question:

Do you think MCDA should be used as an algorithm or as a support to the decision making process (DMP)?

1. Absolutely as an algorithm

2. Mostly as an algorithm

3. Neither as an algorithm nor as a support to DMP

4. Mostly as a support to DMP

5. Absolutely as a support to DMP

• Motivation

• Actual decision

• Evidence

• Values

• Substantive values (criteria)

• Procedural values (process)

• Communication

• Implementation

• Revision

Accountability for reasonableness (A4R)

Relevance

Publicity

Leadership

Revision

Daniels and Sabin. Philos Pub Health 1997; 26:305.; Baltusen et al. Cost Eff Resour Alloc 2006; 4:14; Goetghebeur et al. BMC Health Serv Res 2008; 8:270 ;

Battista IJTAHC 2010Clark and Weale. J Health Org Manag 2012; 26:293;

Anatomy of the natural decision process

General motivation is to achieve health which can be further defined into:

• Ethical imperatives (normative aspects) to:

• Prevent/alleviate suffering in individual

patients with meaningful healthcare.

• Prioritize those who are worst off while

providing the greatest benefit for the

greatest number

• Ensure long term sustainability.

• Wisdom to make decisions adapted to the context

(feasibility aspect).

Includes aspects of deontology, distributive justice, utilitarianism & virtue ethics (practical wisdom)

Anatomy of the natural decision in healthM

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Natural decision relies on all types of

evidence

• Scientific

• Colloquial

• Imputed by logic

Anatomy of the natural decision in healthE

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Substantive values can be made explicit by:

• Criteria derived from the motivation and its

underlying aspects.

• By identifying trade-offs between generic criteria

(weights), which represent the individual value

system.

Anatomy of the natural decision in health

Procedural values can be operationalized by

• A decision committee with members representing

the diverse perspectives of stakeholders in a given

society; representativeness ensures legitimacy of

the decision.

• A deliberation process with democratic participation

by which each member can share their individual

interpretive frames to reach an equilibrium.


Communication

• Increase acceptability of decisions by

communicating the reasoning (rooted in the

common goal) on which they are based.

Implementation

• Success of implementation is dependent on

acceptability.

Revision

• Revision is performed based on an

assessment of whether the initial motivation of

the decision is fulfilled in real life, on the long

run (new evidence, different reasoning).


• A bottom up approach based on the natural decision

process (not a specific methodology) calls for the

integration of several domains of research such as

ethics (substantive & procedural), human rights,

evidence-based medicine, health economics, health

technology assessment, decision analytics and

communication.

• MCDA adapted to healthcare might provide a mean to

develop such an approach.

MCDA Framework that support the natural

decision process?

1. Goal

2. Criteria

3. Weights

4. Evidence

5. Scores

6. Visualization & uncertainty

7. Ranking and deliberation

Methodological choices for a MCDA framework to support evaluation and

prioritization at system level need to be made with the natural decision in mind

Adapted from Thokala et al. 2016

MCDA Steps

The framework needs to be rooted in the common goal and its

underlying ethical imperatives, so the motivation can be

acceptable by all, so:

• Derive criteria from a major ethical position (e.g.,

utilitarianism)? This will not address the point that

several aspects of the major ethical positions are

considered in a natural decision process.

• Derive criteria from aspects of major ethical positions

derived from the common goal?

• This will be helpful if each criteria are justified by at

least one ethical foundation, allowing to tackle, by

design, the ethical dilemmas

From Reflection

For an application at the system level, the framework

need to rank interventions based on their value towards

the common goal, so:

• Value measurement based on everything but

cost? This will not address the sustainability

imperative, which is inherent to the common

goal.

• Value measurement integrating all the criteria?

• This will be helpful if it criteria are defined to fulfil

the principles of non-redundancy, independence,

operationalizability and completeness of MCDA.

From Reflection

ETC…

The framework cannot be reductionist but it has to be

pragmatic, so:

• Few criteria in framework to keep it simple? This

will not address the point that many criteria will

anyway be considered.

• Generic criteria to structure high level value

system which can be further defined with sub-

criteria? This will be helpful if it does not

constrain reasoning and support individual

interpretive frame.

From Reflection

Many jurisdictions use cost-effectiveness but this is a

composite measure combing data from several concepts

(efficacy, safety, cost of intervention, other types of cost, etc.)

which does not allow for interpretation of these concepts, so:

• Keep it in the framework? But does not address the

point that effectiveness and other concepts will be

anyway considered separately, which will create

distortion in reasoning & double counting.

• Make it optional? Will be helpful to transition from

current paradigm but recommend to remove it to

support the interpretation of distinct concepts to

clarify reasoning.

From Reflection

The framework cannot be reductionist but it has to be

pragmatic, so:

• Scoring based on numbers? This will not address

the point that “interpretation of data that takes

place during appraisals requires judgement” Sir

Rawlins, NICE 2013.

• Interpretive scoring scales? This will be helpful as

it can capture the interpretation of numbers, but

we need agreement upon what constitutes low

and high of such scale and thus criteria may be

considered quantitatively; if not, no scoring but

rather qualitative consideration

From Reflection

• Provide a basis for fair decision rooted in the common goal and

operationalization of all its ethical aspects (pervasive ethics).

• 2006: Initial framework

• 2009: Collaboration:

• Share the framework: independent not-for-profit organization, free

membership,

• Enrich it collaboratively: open source philosophy (volunteering, feedback

from users,)

• Protect it: int’l board of directors, cannot be commercialized, rules &

regulations,

• Sustainable: volunteering, current funding based on user fees as

applicable, public funds

To Action

www.evidem.org

23 www.evidem.org

Initial framework the natural decision

process; Pr M Goetghebeur PhD, U Of

Montreal, LSER; Dr M Wagner PhD

LASER, Canada.

MCDA Pr. R Baltusen PhD, Radboud U,

Netherlands.

HTA Pr. R Battista MD PhD, Quebec Research

Funding Agency, Canada.

Health economics: Pr. P Kind, U of York, UK.

Policy decision makers Dr M Tringali MD

PhD, Health Directorate, Milan, Italy; Pr. J

Miot PhD, U of Witwatersrand, South Africa;

Dr H Castro MD PhD, Ministry of Health,

ColombiaClinical decision makers, Pr. C Deal MD PhD,

Univ. Hospital Center, Montreal; Pr. J Dolan, MD

U of Rochester, NY, USA

Global health: A Velasquez, MSc WHO, Switzerland

Ethics: Pr. N Daniels PhD, Harvard U, Boston, MA, USA

A platform for an international reflection

• Success:

• 300 members across the decision continuum, >40 countries,

• Translated in >10 languages

• V3.2 in Dec 2016 (10th release)

• Implemented in Europe, Americas and Asia

• Challenges

• Misunderstanding of its intention / design

• Misuse

To Action

NB: users create their team and seek resources/funding/expertise

to adapt & apply framework,

www.evidem.org

1-GENERIC GOAL : HEALTH

Tool EVIDEM v3.1 Conceptual approach and

operationalization

Goal is further defined in 4 substantive aspects rooted in decision

ethics:

• Patient: imperative to prevent/alleviate suffering (aspect of

deontology).

• Population: prioritize those who are worst off (aspect of

distributive justice) and greatest good to greatest number

(aspect of utilitarianism).

• Sustainability : ensure sustainable healthcare system (aspect of

utilitarianism).

• Context awareness: practical wisdom (aspect of virtue ethics).

Four aspects are further defined in 20 generic criteria abiding with

MCDA principles

Evidence and Values Impact On Decision Making

Output : Generic criteria operationalizing the motivation of healthcare

decisions and its underlying ethical imperatives

Interactive exerciseAs a policy decisionmaker, which criteria would you keep into your framework to support

deliberation and to rank interventions according to their holisitic value in your context?

2- CRITERIA 3-WEIGTHS 4-EVIDENCE 5-SCORES & INSIGTHS

Quantitative Minimize mental distance

Scientific and colloquial Interpretive scales Narratives

Disease severity Direct rating scalePoint allocationetc

Turner syndrome: Female specific generic disorder characterized by reduced life expectancy(details)

3 Very severe 2 1 0 Not severe

Several of my patients have experienced etc…

Etc

Qualitative NA Scientific and colloquial Non-numerical impact

System capacity Risk of inappropriate use of growth hormone for Turner syndrome due to ….(details)

negative neutral positive

In my hospital, specific constraints due to etc…

Etc

Tool EVIDEM v3.1Evidence synthesis

& quality

Tool EVIDEM v3.1Weighing methods

Tool EVIDEM v3.1 Assessment package

Evidence and Values Impact On Decision Making

Output : Pragmatic multicriteria evidence matrix to support

reasoning & deliberation

INSIGTHS

Several of my patients

have experienced etc…

In my hospital, specific

constraints due to etc…

6 - Visualisation of Reasoning

QUANTITATIVE CRITERIA - VALUE OF INTERVENTION A

Criteria contribution to value & insights

Tool EVIDEM :

Calculator,

visualisation &

presentation

Output: Face validity of reasoning & uncertainty at group level.

INSIGTHS

Several of my patients have experienced etc…

In my hospital, specific constraints due to etc…

QUALITATIVE CRITERIA - IMPACT ON VALUE

Impact of criteria & insights

Tool EVIDEM :

Calculator,

visualisation &

presentation

6 - Visualisation of Reasoning

Output: Face validity of reasoning & uncertainty at group level.

Output: Final deliberation & decision based on a group reasoning on value and

opportunity cost (financial impact)

Output: Management of opportunity costs guided by identification of interventions with

“best value towards the goal”

7 - Ranking & Deliberation

Lombardie, Italy: Reimbursement decisions

• Adaptation of EVIDEM combined with

EUNetHTA core model.

• All EVIDEM modules used.

WHO: List of priority devices

• Adaptation of EVIDEM to devices.

• Qualitative MCDA.

• Tools transferable to member states.

Examples of applications of EVIDEM

Lead: Michele Tringali - Radaelli et al IJTAHC 2014;30(1); Tringali. HTAi Oslo 2015; http://vts-hta.asl.pavia.it

List of health technologies appraised for reimbursement in 2013-2014

Lombardy (Italy), Health Directorate

• In place since 2012.

• Web based system to

support deliberation.

• Transparent & efficient

process.

• Enhanced

communication and

acceptability of

decisions by

stakeholders.

http://vts-hta.asl.pavia.it/

Ranges of scores: High: XXX, Medium: XX, Low: X, Very

Low: 0, Not applicable: NA, Unknown: ?

• Working tools: collect data from experts & justify decision to include/exclude devices

A: Function/Intervention External beam radiation therapy

B: Contentious Option YES

C: Specific Medical DevicesLinear accelerator LNAC (at least 3D

conformal therapy,6MeV)

D: Contentious Option YES

E:

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Effectiveness XXX

Safety XX

Patient perspective XXX

Therapeutic benefit* XXX

Multi-disease applicability X

Multi-cancer applicability XXX

Ease of use XX

Ease of training XX

Remote communities NA

Affordability –device XX

Affordability –

maintenance & replacementX

Healthcare resources consequences XX

Quality of evidence XXX

Notes

Specialized Human resources needed,

5% of cancer care of the overall budget

(Radiotherapy)

A: Unit Radiotherapy

B: Basic Service or subunit External Radiotherapy

C: Category Therapeutic

D: Basic Function or Intervention External beam Radiation therapy

E: Expected Outcomes Eliminate malignancies by radiation.

F: Type of Cancer Breast, Cervical, Colorectal, Prostate, Leukemia, Lung.

G: Contentious Option (function) YES

H: Specific Basic Medical devicesLinear accelerator LNAC (at least 3D conformal

therapy,6MeV)

Notes NA

I: Contentious Option (device) YES

J:

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InterdependenciesSimulation and planning process, Mould make process,

Computerized treatment planning systems

HR requirements

1. Physicist

2. Radiation oncologist

3. Radiation technologist

Infrastructure requirements

Adequate Network Infrastructure and storage capacity,

space for adequate furniture for moulds storage, Closed-

circuit television system (and voice and audio), Oxygen

Supply

Key Associated devicesImmobilization and patient positioning systems,

Computerized treatment planning systems

QA & management

i.e. Dosimeter, Phantom for daily mechanical and light

field checks on teletherapy unit, Radiation survey meter.

Refer to Radiotherapy General Medical Devices (Quality

assurance equipment)

Other NA

K: General devices General Radiotherapy Devices

L: Level of Health Care DH, RH

Lead: Adriana Velazquez World Health Organization. WHO list of priority medical devices for cancer management. 2016.

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Canadian Minister of Health Jane

Philpott, seen at Parliament on Sept. 29,

2016

“We need to find ways to put health care

on the road to long-term sustainability”

Researchers &

Developers

Regulators

HTA

HC systems Payers

Hospitals

Clinicians

Patients

& carers

• Integrate the diversity of perspectives to tackle ethical

dilemmas across the decision continuum.

• Reach an equilibrium on what defines interventions with

“best value towards the goal”.

A Road Map to Achieve the Goal

of Healthcare Collectively

What are the major opportunities and challenges for MCDA in

Latin America?

Opportunities:

Challenges:

Open-ended question:

THANK YOU

Spiritual

MCDA