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Efficacy

PANEL SESSION: INTEGRATING EVIDENCE, VALUES AND ETHICS FROM POLICY TO PRACTICE: A MULTICRITERIA REFLECTION A REFLECTION ON ETHICAL DILEMMAS IN HEALTHCARE DECISOBNAKING AND THE ETHICAL FOUNDATIONS OF MCDA April 14 tH 2015 CADTH Symposium , Saskatoon Mireille Goetghebeur MEng PhD

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Efficacy

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  1. PANEL SESSION: INTEGRATING EVIDENCE, VALUES AND ETHICS FROM POLICY TO PRACTICE: A MULTICRITERIA REFLECTION A REFLECTION ON ETHICAL DILEMMAS IN HEALTHCARE DECISOBNAKING AND THE ETHICAL FOUNDATIONS OF MCDA April 14tH 2015 CADTH Symposium , Saskatoon Mireille Goetghebeur MEng PhD Global Scientist, LASER Analytica Associate Professor, School of Public health, University of Montreal President EVIDEM Collaboration

  2. The art of decision making in healthcare www Disease severity Feasibility Patient-reported outcomes System capacity Safety • CADTH 2015: • Suzanne McGurn • “Decisions are made with head heart, and hands” Social values Quality of evidence Unmet needs Efficacy Individual perspective Ethics Cost Population Priorities • Relying on evidence • Relying on social values* • Substantive values (CRITERIA - what & why) • Procedural values (PROCESS - who & how) • Fair and accountable decisionmaking processes** (A4R) • Ethical dilemmas Expert opinion Affordability Historical context *Clark and Weale. J Health Org Manag 2012; 26:293; NICE Social Value Judgments 2nd Ed **Daniels and Sabin. Philos Pub Health 1997; 26:305 (4 conditions: Relevance, publicity, revision, leadership).

  3. MCDA - A definition • Definition: • Multicriteria decision analysis (MCDA) is an application of analytical methods to • explicitly consider multiple criteria Process Procedural values Content Substantive values

  4. MCDA – supporting the art of decision making MCDA mapping METHODOLOGY 1st STEP OF MCDA – DEFINING OBJECTIVE EVIDEM Collaboration, a not-for-profit organization developing collaboratively an open source multipurpose MCDA-based approach translated in 10 languages and used throughout the world www.evidem.orgg

  5. MCDA – step 1 - defining objectives • Common goal: develop & promote interventions that optimize health of patients and populations as well as equitable, sustainable and efficient health care systems • Goodness in it widest sense (axiology)

  6. MCDA – defining substantive values • SUBSTANTIVE VALUES • WHAT & WHY

  7. MCDA – substantive values • Ethical dilemmas • Imperative to help - beneficence, non-maleficence (deontology) • Greatest good for greatest number (utilitarianism) • Prioritizing those who are worst off (fairness, theory of justice); e.g. rare diseases • Practical wisdom & goodness (virtue ethics) • CADTH 2015: • Eduard Hendricks: • “Doing what is best”

  8. MCDA – substantive values • Ethical dilemmas • Revealed by a holistic perspective • Select criteria to encompass all ethical aspects to tackle these dilemmas

  9. Mcda – substantive values Methodology What? Identify all criteria (quantitative and qualitative) that contributes to evaluation of an intervention Why? Realize ethicalandmethodological implications of criteria selection (signals ) 2- CRITERIA SELECTION With the goal in mind!

  10. Imperative to help - beneficence, non-maleficence MCDA – substantive values -criteria • Hippocratic Oath: “I will prescribe for the good of my patients according to my ability and my judgment and never do harm to anyone.” • Criteria: • Maximize efficacy/effectiveness • Maximize safety • Maximize patient reported outcomes • Type of therapeutic benefit (cure vs symptom relief) • Type of preventive benefit - Public health (eradication vs risk reduction) • Extent • of help • Extent • of help • Type • of help

  11. Imperative to help - beneficence, non-maleficence (deontology) MCDA – substantive values - criteria • Criteria: • Alignment with mandate/scope of healthcare system • Environmental sustainability

  12. Greatest good for greatest number (utilitarianism) MCDA – substantive values - criteria • Criteria: • Size of population (greatest number) • Maximize resources (see Practical wisdom) • Opportunity cost and affordability

  13. Prioritizing those who are worst off (fairness, theory of justice) MCDA – substantive values - criteria • Criteria: • Disease severity • Unmet needs • Established priorities (e.g., vulnerable populations, rare disease)

  14. Virtue ethics &practical wisdom MCDA – substantive values - criteria • Criteria • Relevance and validity of study data • Knowledge from experience: clinicians (clinical practice guidelines) & patients • Cost of intervention • Impact on medical cost • Impact on non-medical cost Wise use & Devlpt of Knowledge Wise use of resouces & valuing savings

  15. Virtue ethics & practical wisdom MCDA – substantive values - criteria • Criteria: awareness of context • System capacity and appropriate use of intervention • Stakeholders pressures and barriers • Political and historical context

  16. MCDA – procedural values • PRODEDURAL VALUES • WHO & HOW • Ethics in action

  17. A common road map across the decision continuum? Who? How? Collaborative development of an holistic criteria set? Patients Resource allocation Alleviate suffering Perceived health Unmet needs Benefit risk HTA HC Systems Payers Clinicians Regulators Criteria? Developers Criteria? • Procedural values • Reflective • Systematic • Collaborative • Adaptable to context • Specific goals/mandates • Qualitative/quantitative Criteria? Criteria? Align development with systems efficiency, equity and sustainability, and health needs Criteria?

  18. Mcda – procedural values methodology How? Kepner Tregoe (10 pts scale), Point allocation, ranking, Analytical hierarchy process (AHP), Swing Weigths, Discrte choice experiment (DCE) etc Who? Committee members - include the diversity of perspectives 3-WEIGTHS • Procedural values • Participative • Transparent

  19. Mcda – procedural values methodology How? Evidence modeling, evidence synthesis principles Who? Analysts and communicators CADTH 2015, Eduard Hendricks: Address the failure to communicate`` 4- EVIDENCE • Procedural values • Transparent on data • Systematic

  20. Mcda – PROCEDURAL VALUES methodology Sir Rawlins, NICE: “Accept that interpretation of data requires judgement” How? Scoring scales capturing judgment on data (quantum leap) Who? Committee members 5- PERFORMANCE SCORES • Procedural values • Participatory • Reflective • Transparent on judgment • Systematic

  21. MCDA – procedural values CADTH 2015. Jon Witt: “Invest in programs addressing determinants of health” QUANTITATIVE CRITERIA Value *= ∑NWeights x Scores QUALITATIVE CRITERIA Max value 1 B A A High value: Invest Low value: disinvest B Impact of context • Procedural values • Guide investment/disinvestment • based on common goal • Transparent on decision • Holistic Value of Interventions C C D D No value: 0 Feasibility Normative

  22. MULTICRITERIA REFLECTION – future directions • Ethical foundations • Methodological foundations • Applications & process developments • With the goal in mind! Thank you

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