Understanding the adoption and use of point-of-care tests in Dutch general practices using multi-criteria decision analysis.

BACKGROUND: The increasing number of available point-of-care (POC) tests challenges clinicians regarding decisions on which tests to use, how to efficiently use them, and how to interpret the results. Although POC tests may offer benefits in terms of low turn-around-time, improved patient's satisfaction, and health outcomes, only few are actually used in clinical practice. Therefore, this study aims to identify which criteria are, in general, important in the decision to implement a POC test, and to determine their weight. Two POC tests available for use in Dutch general practices (i.e. the C-reactive protein (CRP) test and the glycated haemoglobin (HbA1c) test) serve as case studies. The information obtained from this study can be used to guide POC test development and their introduction in clinical practice. METHODS: Relevant criteria were identified based on a literature review and semi-structured interviews with twelve experts in the field. Subsequently, the criteria were clustered in four groups (i.e. user, organization, clinical value, and socio-political context) and the relative importance of each criterion was determined by calculating geometric means as implemented in the Analytic Hierarchy Process. Of these twelve experts, ten participated in a facilitated group session, in which their priorities regarding both POC tests (compared to central laboratory testing) were elicited. RESULTS: Of 20 criteria in four clusters, the test's clinical utility, its technical performance, and risks (associated with the treatment decision based on the test result) were considered most important for using a POC test, with relative weights of 22.2, 12.6 and 8.5%, respectively. Overall, the experts preferred the POC CRP test over its laboratory equivalent, whereas they did not prefer the POC HbA1c test. This difference was mainly explained by their strong preference for the POC CRP test with regard to the subcriterion 'clinical utility'. CONCLUSIONS: The list of identified criteria, and the insights in their relative impact on successful implementation of POC tests, may facilitate implementation and use of existing POC tests in clinical practice. In addition, having experts score new POC tests on these criteria, provides developers with specific recommendations on how to increase the probability of successful implementation and use.

A review and classification of approaches for dealing with uncertainty in multi-criteria decision analysis for healthcare decisions.

Multi-criteria decision analysis (MCDA) is increasingly used to support decisions in healthcare involving multiple and conflicting criteria. Although uncertainty is usually carefully addressed in health economic evaluations, whether and how the different sources of uncertainty are dealt with and with what methods in MCDA is less known. The objective of this study is to review how uncertainty can be explicitly taken into account in MCDA and to discuss which approach may be appropriate for healthcare decision makers. A literature review was conducted in the Scopus and PubMed databases. Two reviewers independently categorized studies according to research areas, the type of MCDA used, and the approach used to quantify uncertainty. Selected full text articles were read for methodological details. The search strategy identified 569 studies. The five approaches most identified were fuzzy set theory (45% of studies), probabilistic sensitivity analysis (15%), deterministic sensitivity analysis (31%), Bayesian framework (6%), and grey theory (3%). A large number of papers considered the analytic hierarchy process in combination with fuzzy set theory (31%). Only 3% of studies were published in healthcare-related journals. In conclusion, our review identified five different approaches to take uncertainty into account in MCDA. The deterministic approach is most likely sufficient for most healthcare policy decisions because of its low complexity and straightforward implementation. However, more complex approaches may be needed when multiple sources of uncertainty must be considered simultaneously.

Group decision making with the analytic hierarchy process in benefit-risk assessment: a tutorial.

The analytic hierarchy process (AHP) has been increasingly applied as a technique for multi-criteria decision analysis in healthcare. The AHP can aid decision makers in selecting the most valuable technology for patients, while taking into account multiple, and even conflicting, decision criteria. This tutorial illustrates the procedural steps of the AHP in supporting group decision making about new healthcare technology, including (1) identifying the decision goal, decision criteria, and alternative healthcare technologies to compare, (2) structuring the decision criteria, (3) judging the value of the alternative technologies on each decision criterion, (4) judging the importance of the decision criteria, (5) calculating group judgments, (6) analyzing the inconsistency in judgments, (7) calculating the overall value of the technologies, and (8) conducting sensitivity analyses. The AHP is illustrated via a hypothetical example, adapted from an empirical AHP analysis on the benefits and risks of tissue regeneration to repair small cartilage lesions in the knee.

Preferences for colorectal cancer screening techniques and intention to attend: a multi-criteria decision analysis.

BACKGROUND: Despite the expected health benefits of colorectal cancer screening programs, participation rates remain low in countries that have implemented such a screening program. The perceived benefits and risks of the colorectal cancer screening technique are likely to influence the decision to attend the screening program. Besides the diagnostic accuracy and the risks of the screening technique, which can affect the health of the participants, additional factors, such as the burden of the test, may impact the individuals' decisions to participate. To maximise the participation rate of a screening program for a new colorectal cancer program in the Netherlands, it is important to know the preferences of the screening population for alternative screening techniques. OBJECTIVE: The aim of this study was to explore the impact of preferences for particular attributes of the screening tests on the intention to attend a colorectal cancer screening program. METHODS: We used a web-based questionnaire to elicit the preferences of the target population for a selection of colon-screening techniques. The target population consisted of Dutch men and women aged 55-75 years. The analytic hierarchy process (AHP), a technique for multi-criteria analysis, was used to estimate the colorectal cancer screening preferences. Respondents weighted the relevance of five criteria, i.e. the attributes of the screening techniques: sensitivity, specificity, safety, inconvenience, and frequency of the test. With regard to these criteria, preferences were estimated between four alternative screening techniques, namely, immunochemical fecal occult blood test (iFOBT), colonoscopy, sigmoidoscopy, and computerized tomographic (CT) colonography. A five-point ordinal scale was used to estimate the respondents' intention to attend the screening. We conducted a correlation analysis on the preferences for the screening techniques and the intention to attend. RESULTS: We included 167 respondents who were consistent in their judgments of the relevance of the criteria and their preferences for the screening techniques. The most preferred screening method for the national screening program was CT colonography. Sensitivity (weight = 0.26) and safety (weight = 0.26) were the strongest determinants of the overall preferences for the screening techniques. However, the screening test with the highest intention to attend was iFOBT. Inconvenience (correlation [r] = 0.69), safety (r = 0.58), and the frequency of the test (r = 0.58) were most strongly related to intention to attend. CONCLUSIONS: The multi-criteria decision analysis revealed the attributes of the screening techniques that are most important so as to increase intention to participate in a screening program. Even though the respondents may recognize the high importance of diagnostic effectiveness in the long term, their short-term decision to attend the screening tests may be less driven by this consideration. Our analysis suggests that inconvenience, safety, and frequency of the test are the strongest technique-related determinants of the respondents' intention to participate in colorectal screening programs.

Predicting the health economic performance of new non-fusion surgery in adolescent idiopathic scoliosis.

Adolescent idiopathic scoliosis (AIS) can lead to pain, impaired spinal function, and socio-psychological problems. Conventional surgical treatment of severe forms of AIS fuses the vertebrae, thereby restricting spinal function and growth of the adolescents. Non-fusion surgical treatment (NFS) is being proposed to prevent these drawbacks. To support the further development of NFS, this study aims to predict the health economic performance of the new NFS treatment and compare it with standard AIS treatment. A decision tree was constructed to compare NFS with bracing, possibly followed by posterior fusion surgery. The outcome measures were quality of life, complications, and costs. The Analytic Hierarchy Process (AHP), a technique for multi-criteria decision analysis, supported an expert panel of biomedical engineers and orthopaedic surgeons to predict the missing NFS performance data in the decision tree. The decision tree analysis showed that NFS is the preferred form of treatment in patients prone to disease progression. The advantages are its positive effect on spinal function and the self-esteem of the patient. Future clinical acceptance of NFS can be supported by reduced costs and an optimization of the prediction of progression. As more clinical evidence becomes available over time, these data can be added to the health economic model.

Integrating patients' views into health technology assessment: Analytic hierarchy process (AHP) as a method to elicit patient preferences.

BACKGROUND: Patient involvement is widely acknowledged to be a valuable component in health technology assessment (HTA) and healthcare decision making. However, quantitative approaches to ascertain patients' preferences for treatment endpoints are not yet established. The objective of this study is to introduce the analytic hierarchy process (AHP) as a preference elicitation method in HTA. Based on a systematic literature review on the use of AHP in health care in 2009, the German Institute for Quality and Efficiency in Health Care (IQWiG) initiated an AHP study related to its HTA work in 2010. METHODS: The AHP study included two AHP workshops, one with twelve patients and one with seven healthcare professionals. In these workshops, both patients and professionals rated their preferences with respect to the importance of different endpoints of antidepressant treatment by a pairwise comparison of individual endpoints. These comparisons were performed and evaluated by the AHP method and relative weights were generated for each endpoint. RESULTS: The AHP study indicates that AHP is a well-structured technique whose cognitive demands were well handled by patients and professionals. The two groups rated some of the included endpoints of antidepressant treatment differently. For both groups, however, the same six of the eleven endpoints analyzed accounted for more than 80 percent of the total weight. CONCLUSIONS: AHP can be used in HTA to give a quantitative dimension to patients' preferences for treatment endpoints. Preference elicitation could provide important information at various stages of HTA and challenge opinions on the importance of endpoints.