Priority setting in practice: what is the best way to compare costs and benefits?

Abstract

Prioritizing candidates for health-care expenditure using cost per Quality-Adjusted Life Year (QALY) is a helpful but insufficient means of ranking alternative uses for scarce health-care funds at the local level. This is because QALYs do not by themselves capture all criteria decision makers need to take into account. Other criteria such as reducing inequalities, meeting national and local priorities and public acceptability also feature in the decision maker's utility function. Programme budgeting and marginal analysis (PBMA) is an established framework for systematic priority setting in which a 'weighted benefit score' for each option is calculated based on all relevant decision-making criteria. Ranking options as a ratio of cost to benefit is desirable and necessary to ensure efficiency. In this paper we review a number of approaches to scoring costs and benefits of options in a PBMA context. Several approaches rank by benefit score alone, rather than efficiency (cost per unit of benefit). Of those that do rank by efficiency, we discuss the benefits and drawbacks. The optimal approach is far from clear, with each technique having its own strengths and weaknesses. A deliberative approach using summaries of costs and benefits of options as a basis for discussion may be preferable.

Resource Allocation and Priority Setting in Health Care: A Multi‐criteria Decision Analysis Problem of Value?

“…The application of MCDA methods have been proposed for use in the field of health care (Baltussen and Niessen, ; Baltussen et al., ; Wilson et al., ;), including for priority setting of health programmes or interventions (Baltussen et al., , ; Youngkong et al., , ), the regulatory approval of pharmaceuticals (Mussen, et al., ; Phillips et al., ; Walker and Cone, ), and more recently for use in HTA (Angelis and Kanavos, ; Devlin and Sussex, ; Goetghebeur et al., ; Health England, ; Sussex et al., 2013; Thokala, ; Thokala et al., ); and treatment selection (Felli et al., ; Naci, ; Tervonen et al., ), recognising its potential value in the evaluation process and arguing that it could be used as an aid to decision‐making. However, attention should be paid on the theoretical foundations of decision theory and particularly in the required properties the criteria need to possess in order for the analysis to be robust and results useful to decision‐makers (Angelis and Kanavos, ; Del Rio Vilas et al, ; Keeney, ).…”

Managing Healthcare Budgets in Times of Austerity: The Role of Program Budgeting and Marginal Analysis

“…Again referring to Table 1, MCDA can be used in step 5 for determining the level of benefit associated with the proposals for change (i.e., marginal proposals) under consideration. In its simplest form, MCDA involves identifying a set of evaluation criteria and then rating each service option against each criterion to come up with a ‘benefit score’ reflecting the level of benefit associated with the given proposal [15]. Using a symmetric negative-to-positive rating scale, options for investment and disinvestment can be compared directly [16].…”

Bridging Health Technology Assessment (HTA) and Efficient Health Care Decision Making with Multicriteria Decision Analysis (MCDA)

“…[18][19][20] There have been a number of advances in this direction. [10][11][12][13][21][22][23][24][25] For example, Mullen 24 reviewed initiatives by regional UK Health Authorities that aim to enhance transparency and accountability in prioritization decision making. The field of health technology assessment (HTA), in particular, views itself as a bridge between evidence and decision making by improving synthesis, communication, and dissemination of information.…”