Reconciling ACEA and MCDA: is there a way forward for measuring cost-effectiveness in the U.S. healthcare setting?

Abstract

Background The ISPOR Special Task Force (STF) on US Value Assessment Frameworks was agnostic about exactly how to implement the quality-adjusted life year (QALY) as a key element in an overall cost-effectiveness evaluation. But the STF recommended using the cost-per-QALY gained as a starting point in deliberations about including a new technology in a health plan benefit. The STF offered two major alternative approaches—augmented cost-effectiveness analysis (ACEA) and multi-criteria decision analysis (MCDA)—while emphasizing the need to apply either a willingness-to-pay (WTP) or opportunity cost threshold rule to operationalize the inclusion decision. Methods The MCDA model uses the multi-attribute utility function. The ACEA model is based on the expected utility theory. In both ACEA and MCDA models, value trade-offs are derived in a hierarchical model with two high-level objectives which measure overall health gain separately from financial attributes affecting consumption. Results Even though value trade-offs can be elicited or revealed without considering budget constraints, we demonstrate that they can be used similarly to WTP-based cost-effectiveness thresholds for resource allocation decisions. The consideration of how costs of medical technology, income, and severity of disease affect value trade-offs demonstrates, however, that reconciling decisions in ACEA and MCDA requires that health and consumption are either complements or independent attributes. Conclusions We conclude that value trade-offs derived either from ACEA or MCDA move similarly with changes in main factors considered by enrollees and decision makers—costs of the medical technology, income, and severity of disease. Consequently, this complementarity between health and consumption is a necessary condition for reconciling ACEA and MCDA. Moreover, their similarity would be further enhanced if the QALY is used as the key attribute or anchor in the MCDA value function: the choice between the two is a pragmatic question that is still open.

Reconstructing the value puzzle in health technology assessment: a pragmatic review to determine which modelling methods can account for additional value elements

“…The main theses and conclusions of the included peer-reviewed articles are summarized in Table 2. mCEA Four articles (Kristensen et al, 2017;Pearson et al, 2019;Diaby et al, 2021;Zamora et al, 2021) recommended mCEA as an expanded CEA method to incorporate additional value elements, albeit their suggestions differed considerably. Kristensen et al, 2017(Kristensen et al, 2017 summarized the results of a decade-long analysis of HTA methods by the European Network for HTA (EUnetHTA), which recommends a tiered system that accounts for typical domains such as effectiveness, safety, and health economics but also includes domains addressing social, patient, legal, and organizational elements.…”

“…The CBV score is a composite, qualitative rating calculated using elements such as innovativeness, disease severity, and unmet need (Goldman et al, 2010;Diaby et al, 2021) which provides a more holistic assessment of the non-economic aspects of a given intervention. Zamora et al, 2021(Zamora et al, 2021 examined the potential of ACEA to incorporate additional individual value elements such as insurance value, option value, and the value of hope to the traditional ICER approach. Any health gains from new elements are measured in equivalent or risk-adjusted QALYs.…”

“…Nine articles (Dionne et al, 2015;Angelis and Kanavos, 2017;Baltussen et al, 2017;Phelps and Madhavan, 2017;Goetghebeur and Cellier, 2018;Krahn et al, 2018;DiStefano and Levin, 2019;Diaby et al, 2021;Zamora et al, 2021) recommended the adoption of some version of MCDA as a method for future CEA. MCDA methods The authors outline drawbacks of current "utilitarian" HTA frameworks, including the inability of current methods to account for social values such as disease severity and rarity, burden of illness and the ability of curative treatments to extend life, especially that of children.…”

“…As such, a combination of quantifiable criteria and non-quantifiable (i.e., qualitative) criteria should be considered, with both ultimately being used as inputs into the deliberative process. Phelps, et al, 2017 (Phelps andMadhavan, 2017), Dionne et al, 2015(Dionne et al, 2015, and Zamora et al, 2021(Zamora et al, 2021 also advocated for the use of MCDA methods as a way to maintain objectivity in decision-making, while still taking into account societal elements such as patient preference/ autonomy and health equity. Diaby et al, 2021(Diaby et al, 2021 similarly suggested using MCDA methods as part of an "equitable MCDA" approach, one that is transparent and results in clear and consistent decisions.…”

Model to support intervention prioritization for the control of Aedes aegypti in Brazil: a multi-criteria approach

“…In order to address the inherent complexity of health decisions derived from factors such as uncertainty, conflicts of interest and subjectivity in the assessment of health technologies, amongst other aspects [ 1 , 2 ], the multi-criteria decision analysis (MCDA) emerges as a structured methodology to support the decision-making processes, differing from other formal approaches due to its characteristic of mathematically modelling the subjectivity present in the f decision-makers’ judgement [ 3 ]. Hence, this methodological approach analytically guides decision support in a rational and transparent manner by aiming at the best choice in face of a set of alternatives, based on the decision maker’s preferences [ 4 , 5 ].…”