Health technology prioritization: Which criteria for prioritizing new technologies and what are their relative weights?

Abstract

Objectives

To review the criteria and ‘other’ considerations used internationally for prioritizing new health technologies, and to demonstrate a conjoint-analysis methodology (also known as discrete choice experiments) for deriving relative weights for the criteria.

Methods

We searched the literature for criteria and other considerations for prioritizing new technologies. A convenience sample of 74 respondents completed a conjoint-analysis survey involving criteria related to technologies’ ‘benefits’.

Results

Encompassing 11 countries and the US state of Oregon, we were able to distinguish three main groups of criteria: (a) Need, appropriateness and clinical benefits; (b) Efficiency (including cost-effectiveness); and (c) Equality, solidarity and other ethical or social values. For several countries, the quality of the clinical and economic evidence and factors related to strategic issues and procedural justice respectively are also considered. The criteria and their weights from the conjoint-analysis survey are: ‘Lives saved’ = 0.343, ‘Life-prolongation benefits’ = 0.243, ‘Quality-of-life gains’ = 0.217, a criterion representing the availability of alternative treatments = 0.107, and ‘Other important social/ethical benefits’ = 0.087.

Conclusions

The criteria represent a pluralistic combination of needs-based, maximizing and egalitarian principles, and we demonstrated a methodology for deriving the weights for criteria related to technologies’ ‘benefits’.

Introduction

Due to scarce health care resources and on-going advances in health technologies – which tend to be increasingly expensive – all health systems face the challenge of prioritizing new technologies for funding. Such prioritization decisions inherently involve ethical dilemmas and tradeoffs between conflicting objectives or criteria. Unfortunately, most attempts at explicitly prioritizing technologies at the macro level have been criticized for inadequately identifying their values, principles and other normative concepts [1], and for their values frameworks having had little apparent effect on health policy [2]. “Mounting disenchantment with simple solutions to the problems” tends to be followed by “a shift in emphasis from the product of priority-setting to the process of priority-setting” [3; our italics]. These reactions can be at least partially attributed to the “lack of clarity and rigor regarding the normative/ethical issues involved in explicit prioritization” [1].

National commissions convened to outline abstract principles have had little direct impact on their countries’ prioritization policies, whereas other decision-making forums have applied sets of criteria and principles without a clear framework for resolving conflicts between them [2]. One of the main findings of Martin et al.’s study of prioritization decisions for new cancer drugs in Canada was that priority-setting rationales involve clusters of factors [4]. There is also a lack of consensus about which criteria should guide prioritization decisions [1], [5], [6], [7], about how they should be weighted and balanced against one another [3], [5], [6], and even about the definition of fundamental principles like need or the severity of a disease [3], [8], [9].

The likelihood of these issues being resolved has often been met with skepticism. For example, it has been suggested that “we will never reach agreement about an explicit framework for priority-setting” [2]. Other, less pessimistic commentators claim only that these issues “are unsolved now and that we have no real prospect of arriving at solutions that would be publicly acceptable in the foreseeable future” [10]. Also, that until more work is done on the substantive issues of equity in health care, “we will not know how deep the conflicts go and the degree to which any can be resolved” [11].

It is unsurprising, therefore, that decision-makers struggle to prioritize new health technologies and that they desire an explicit framework for doing so [7]. In the absence of principles-based methodologies, decision-makers have been advised to concentrate on developing and following fair procedures in order to arrive at legitimate solutions [3], [10].

Logically, though, this does not mean that we should settle for following fair procedures only. “In the meantime, a systematic and explicit consideration of ethical issues in the decision-making process is clearly desirable” [5]. Moreover, the ‘accountability for reasonableness’ framework includes the ‘relevance condition’: that decisions should rest on evidence, reasons and principles that all fair-minded people can agree are relevant [10]. Clearly, this requires consensus about the underlying reasons and principles. Hence, one of the criteria suggested for evaluating the success of prioritization efforts is the articulation of appropriate principles [2], as well as reasons that are grounded in clear value choices [7].

In our opinion, it is therefore worthwhile pursuing a greater understanding of the main criteria for prioritizing new health technologies and their relative weights. Accordingly, in the study reported here we surveyed the literature in order to catalogue and analyze the range of criteria and ‘other’ considerations used internationally for prioritizing technologies. And then, based on this review, and primarily for the purpose of demonstrating the methodology, we derived weights for a set of criteria related to the ‘benefits’ from technologies via a conjoint-analysis survey with a convenience sample of respondents. Although these weights are not generalizable to any overall population, they are intended to be indicative of the kind of results obtainable from this approach.