The Pharmacist Management Committee (PMC) makes decisions regarding medicine optimization in Chinese public hospitals[1, 2]. This decision-making progress is complex, subjective and requires both efficient and explicit methods to ensure transparency and consistency of the participating factors. Administration literature, such as work focused on cost-effectiveness analysis, does not systematically consider the multi-dimension value of a drug[3, 4].
Multicriteria decision analysis (MCDA) is a method used to appraise alternatives for the individual that often have conflicting criteria by combining these into a single appraisal[5]. Currently, MCDA is applied to health care decision making such as hospital purchasing[6, 7]. MCDA helps increase the consistency, transparency and legitimacy of decision making[8]. The Evidence and Value: Impact on Decision Making (EVIDEM) collaboration developed an EVIDEM framework that includes a core model containing 13 criteria that are adaptable to a contextual tool[9] (Table 1,2). EVIDEM framework bridges the MCDA with health technology assessment (HTA)[10].
Table 1
Domains | Criteria |
Need for Intervention | Disease severity |
Size of affected population |
Unmet needs |
Comparative Outcomes of Intervention | Comparative effectiveness |
Comparative safety/tolerability |
Comparative patient-perceived health / PRO |
Type of Benefit of Intervention | Type of preventive benefit |
Type of therapeutic benefit |
Economic Consequences of Intervention | Comparative cost consequences – cost of intervention |
Comparative cost consequences – other medical costs |
Comparative cost consequences – non-medical costs |
Knowledge about Intervention | Quality of evidence |
Expert consensus/clinical practice guidelines |
Table 2
Domains | Criteria |
Normative Contextual Criteria | Mandate and scope of healthcare system |
population priorities and access |
Common goal and specific |
Environmental impact |
Feasibility Contextual Criteria | System capacity and appropriate use of intervention |
Political/historical/cultural context |
Opportunity Cost | Opportunity costs and affordability |
DPP-4 inhibitors are anti-diabetic drugs that work by inhibiting the activation of the DPP-4 receptor. There are currently five DPP-4 inhibitors that are marketed in China including Sitagliptin which was approved in 2006, Linagliptin approved in 2011, Vildagliptin approved in 2007, Alogliptin approved in 2013 and Saxagliptin approved in 2009[11]. It is difficult to choose the most suitable medication when considering hospital purchasing while remaining fair, transparent and consistent..
The aim of this study was to appraise DPP-4 inhibitors with the goal of piloting the EVIDEM framework and MCDA to identify the most optimal medication.
Methods
Methodology of the EVIDEM framework was followed for MCDA[9]. MCDA was performed following reports published by ISPORT[12, 13]. The estimating program is shown in Fig. 1.
First, PubMed, Embase, The Cochrane Library and China Biology Medicine disc (CBM) from July 2019 onward were searched. Search terms included the five DPP-4 inhibitors and placebos, type 2 diabetes, clinical efficacy, safety, quality of life/QoL/HRQoL, epidemiol*/prevalence/incidence, mortality, guidelines, recommendations, clinical practice, patient-reported outcome*/PRO, cost*, econom*, meta-analysis and net meta-analysis. For the factors that are country-specific (e.g. cost-effectiveness and clinical guidelines), data was only included based on Chinese settings. Placebo was chosen as the comparator. To similarly compare the five DPP-4 inhibitors, meta-analysis comparing the five DPP-4 inhibitors with placebo was first performed. The HTA group analyzed and synthesized the data.
Second, a committee comprising two doctors, one nurse, one pharmacist, one health economist and one decision-maker was generated. All six members were already staff at the Gansu provinal hospital. Both the doctor and nurse worked in the Endocrinology Institute.
Next, following EVIDEM methodology, the committee assigned weight for each criterion according to their importance before it was known which medicines needed to be evaluated. Criterion scored as 5 were considered the most important and those scored as 1 were considered the least important.
Based on the evidence matrix synthesized by the HTA group (Appendix 1), experts assigned a score for each criterion. The scores for the absolute criteria (those that were not compared to placebo) ranged from 0 to 5, where 0 was the lowest value and 5 was the highest. For relative criteria (those compared to the placebo), the scale ranged from − 5 to 5 to reflect the full range of comparative effects. Criteria in the contextual tool were discussed.
Finally, a value estimate (V) of the intervention was calculated based on a linear additive model as a sum of the value contributions (Vx) [or combined normalized weights (Wx) and standardized scores (Sx)] of all (n) criteria of the quantitative EVIDEM Core Model. Each estimated value was transformed to a 0–1 scale.