The pan Canadian Oncology Drug Review (pCODR) was formed to support a nationally uniform cancer drug review process. Committee members are asked to consider four types of evidence: clinical, economic, patient-based values, and feasibility of adoption. This is the Canadian health technologies assessment (HTA) framework for cancer.
The use of multiple criteria is challenging. Our research focuses on how multiple criteria are used by expert advisory committees in the context of drug reimbursement.
We use mixed methods, including qualitative interviews with knowledge users and knowledge producers, quantitative exercises, intensive roundtable consultations, and online iterative feedback, to ensure that our results are relevant to the pCODR and Canadian decision-makers, while at the same time applicable to broader conceptual frameworks that guide HTA processes in the world.
Uncertainty in evidence, HTA and error in recommendations (planned to start in 2020)
This future study will focus on the challenges associated with uncertainty that is present in clinical and economic evidence, and the potential for error in drug reimbursement recommendations and decisions.
Currently we are exploring the recommendations made for oncology and cardiology drugs in several jurisdictions and tracking the evidence used. First, we want to assess whether the same evidence leads to different conclusions across jurisdictional contexts. Second, we want to identify any post-recommendation evidence and assess whether recommendations are supported by later evidence or not supported.
Given uncertainty, error in recommendations/decisions is unavoidable, the process has an element of risk of (i) funding drugs that are not effective; or (ii) not funding drugs that are effective. This study will assess the preferences of four stakeholder groups about the two types of error, with and without caveats. We will ask patients, the public, members of expert committees, and decision makers whether they prefer one type of error over the other, and whether their preferences are affected by drug characteristics (e.g. toxicity, indication, patient population profile, disease severity, rarity, etc.).
The facilitators and barriers to HTA use (2018 - present)
The current study will assess the barriers and facilitators to the use of health technologies assessment (HTA) in health care allocation decisions in Canada. This study will add to similar studies that have been conducted in Austria, Colombia, France, the Netherlands, and the United Kingdom. Our results will show which facilitators and which barriers are the most impactful in the Canadian policy process, and how this compares to other jurisdictions.
The AFFORD project (2013 - 2016)
The study focused on the challenges of using multiple HTA criteria in the context of appraisal of drugs for reimbursement. The goal was to characterize what the challenges are, describe what review committees needed in the form of evidence or guidance to address these challenges, and to identify policies and knowledge translation strategies that would support their needs.
The AFFORD study combined qualitative analysis with a quantitative stated-preferences elicitation. The preference elicitation was informed by a completed qualitative background study funded by the Canadian Centre for Applied Research in Cancer Control (ARCC). The AFFORD study builds on the ARCC funded proof-of-principle pilot study (see the Our Research page for more details), expanding the research design and increasing the sample size.
Component 1: State-Preferences Elicitation
Choice-based stated preference methods are used to quantify the relative impact of different attributes in a funding decision, including economic, clinical, and other types of evidence, and to derive how different levels of these factors may influence funding decisions. To address these objectives, we are using Best-Worst Scaling nested within a binary Discrete Choice Experiment.
Stated-preference techniques are based on the idea that although people may not be able to provide direct values or weights, they are typically able to indicate which good or scenario they prefer. Discrete choice experiments (DCEs) ask respondents to identify their preferred choice from alternatives described in terms of specific attributes and levels. DCEs encourage respondents to consider trade-offs and opportunity costs.
The proposed DCE presents a series of binary choices between funding and not funding specific hypothetical cancer therapies. Each therapy is described in terms of relevant attributes and levels (e.g., high, medium, low illness severity; number of life years gained; cost-utility ratio).
Component 2: Qualitative Interviews
In the AFFORD study, qualitative interviews will reveal how economic, clinical, patient input, input from provincial groups, and other evidence is understood and the process by which it is used in decision making. Thematic qualitative analysis will be applied to identify the challenges associated with the use of economic, clinical and other evidence, as well as potential improvements. Participatory consultation and qualitative iterative analysis will be used in the development of a procedural framework for the production and use of economic evidence in the multi-criteria decision making context.
Qualitative interviews will be held with economists and health services researchers (producers of knowledge) and decision-makers (users of knowledge) to describe their understanding of the role and use of economic analyses in combination with clinical and other evidence. Thematic analysis will be used to characterize the issues highlighted by the producers and users of economic evidence. Thematic analysis will focus on predetermined dimensions (priorities, objectives, sequencing, timing, information needs and availability, and applicability), however new dimensions may be added to accommodate the data.