In this pilot study Sitagliptin showed the highest value and Saxagliptin received the lowest score. The hospital HTA group gave a value order for decision makers on the hospital PMC, therefore it is feasible to use the EVIDEM framework and MCDA in purchasing medicine for Chinese public hospitals.
To our knowledge, this is the first time that MCDA and EVIDEM frameworks were used in drug purchasing in a Chinese hospital. The MCDA is used in China for the decision-making framework for medical insurance reimbursement and medical device assessment [15, 16]. Our study makes it possible for estimating medicine value with quantitative calculation and includes more comprehensive considerations for the value of medicines by using the EVIDEM framework. Prior to this, the valuation of drug value was qualitative. An HTA group in a hospital in Beijing evaluated DPP-4 inhibitors by using a systematic review that qualitatively described effectiveness, safety and economics [17-19].
The application of EVIDEM and MCDA is still an indirect comparison of drugs. Although there were head-to-head meta-analysis results in terms of safety and effectiveness, no direct comparison data was there for other dimensions of criteria, such as cost. The drug value range was similar with other studies estimating the value by EVIDEM-MCDA. For example, the obinutuzumab for rituximabrefractory indolent non-Hodgkin lymphoma obtained a value of 0.45 in Italy [20]. Interestingly, even though comparative data in the net-meta analysis showed no significant differences between the drugs, value differences still existed [21-25]. Since the weights and scores generated by the committee would inevitably revolve around their own perceptions, experience, training and value judgments, it is critical to have a multi-disciplinary vision.
In applying EVIDEM-MCDA, the participating experts noted that this work was meaningful and inspiring, and the exchange of opinions between them enriched the analysis. However, they also emphasized that the evaluation process requires a good understanding of the amount of evidence provided, and the concepts and terminologies used. In this regard, it is important to emphasize the importance of providing the best understanding. On the other hand, it is worth noting the difference between the specialties of experts that make up the committee. Their weights and scores were inevitably influenced by their own opinions, experience, training and value judgments, thus showing the importance of having such a multidisciplinary vision.
Although this study provides guidance for decision makers, there are still some limitations. Firstly, DPP-4 inhibitors were used a lot in treatment programs of clinical trials such as a DPP-4 inhibitor versus placebo/metformin/other anti-diabetes drugs or a DPP-4 inhibitor/anti-diabetes drugs versus other anti-diabetes drugs [26, 27]. Based on time limitation and feasibility, we chose the placebo as the comparator. There was no consideration from other comparators due to only comparing to the placebo. Secondly, in terms of costs, sufficient data in China was not available since there was little research on Pharmacoeconomics from a Chinese social perspective, especially for the cost of drugs. Due to this, the panelist did not give a score for other-medical costs. Thirdly, although the EVIDEM contained 13 widely identified criteria, other relevant criteria might have been excluded. Fourthly, members of the committee and drug administration in this study limited representation to only one hospital. Thus, the estimated value of the MCDA needs additional interpretation. The MCDA used for complementing pharmacoeconomic analyses lacks the broader perspective, meanwhile it also lacks the discussion basis of ordering health technology [28, 29]. Lastly, we didn’t test the internal consistency of the result, which took the insufficient of the result. This needs to be improved in future research.