title: Balancing costs and benefits at different stages of medical innovation: a systematic review of Multi-criteria decision analysis (MCDA).
abstract: BACKGROUND
  The diffusion of health technologies from translational research to reimbursement depends on several factors included the results of health economic analysis. Recent research identified several flaws in health economic concepts. Additionally, the heterogeneous viewpoints of participating stakeholders are rarely systematically addressed in current decision-making. Multi-criteria Decision Analysis (MCDA) provides an opportunity to tackle these issues. The objective of this study was to review applications of MCDA methods in decisions addressing the trade-off between costs and benefits.
  
  
  METHODS
  Using basic steps of the PRISMA guidelines, a systematic review of the healthcare literature was performed to identify original research articles from January 1990 to April 2014. Medline, PubMed, Springer Link and specific journals were searched. Using predefined categories, bibliographic records were systematically extracted regarding the type of policy applications, MCDA methodology, criteria used and their definitions.
  
  
  RESULTS
  22 studies were included in the analysis. 15 studies (68 %) used direct MCDA approaches and seven studies (32 %) used preference elicitation approaches. Four studies (19 %) focused on technologies in the early innovation process. The majority (18 studies - 81 %) examined reimbursement decisions. Decision criteria used in studies were obtained from the literature research and context-specific studies, expert opinions, and group discussions. The number of criteria ranged between three up to 15. The most frequently used criteria were health outcomes (73 %), disease impact (59 %), and implementation of the intervention (40 %). Economic criteria included cost-effectiveness criteria (14 studies, 64 %), and total costs/budget impact of an intervention (eight studies, 36 %). The process of including economic aspects is very different among studies. Some studies directly compare costs with other criteria while some include economic consideration in a second step.
  
  
  CONCLUSIONS
  In early innovation processes, MCDA can provide information about stakeholder preferences as well as evidence needs in further development. However, only a minority of these studies include economic features due to the limited evidence. The most important economic criterion cost-effectiveness should not be included from a technical perspective as it is already a composite of costs and benefit. There is a significant lack of consensus in methodology employed by the various studies which highlights the need for guidance on application of MCDA at specific phases of an innovation.
authors.affiliation: Interdisciplinary Centre for Health Technology Assessment (HTA) and Public Health (IZPH), Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), National Cluster of Excellence "Medical Technologies - Medical Valley EMN", Bavaria, Germany. philip.wahlster@uni-bremen.de.
authors.forename: Philip
authors.initials: P
authors.lastname: Wahlster
authors.affiliation: School of Public Health, Universiy of Montreal & LASER Analytica, 1405 TransCanada Highway, Suite 310, Montréal, QC, H9P 2V9, Canada. mgoetghebeur@evidem.org.
authors.forename: Mireille
authors.initials: M
authors.lastname: Goetghebeur
authors.affiliation: Interdisciplinary Centre for Health Technology Assessment (HTA) and Public Health (IZPH), Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), National Cluster of Excellence "Medical Technologies - Medical Valley EMN", Bavaria, Germany. christine.kriza@uk-erlangen.de.
authors.forename: Christine
authors.initials: C
authors.lastname: Kriza
authors.affiliation: Interdisciplinary Centre for Health Technology Assessment (HTA) and Public Health (IZPH), Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), National Cluster of Excellence "Medical Technologies - Medical Valley EMN", Bavaria, Germany. charlotte.niederlaender@fau.de.
authors.forename: Charlotte
authors.initials: C
authors.lastname: Niederländer
authors.affiliation: Interdisciplinary Centre for Health Technology Assessment (HTA) and Public Health (IZPH), Friedrich-Alexander-University of Erlangen-Nuremberg (FAU), National Cluster of Excellence "Medical Technologies - Medical Valley EMN", Bavaria, Germany. peter.kolominsky@uk-erlangen.de.
authors.forename: Peter
authors.initials: P
authors.lastname: Kolominsky-Rabas
mesh_terms: D020811:Biomedical Technology; D032921:Consensus; D003362:Cost-Benefit Analysis; D003657:Decision Making; D003661:Decision Support Techniques; D003695:Delivery of Health Care; D004059:Diffusion of Innovation; D005260:Female; D006801:Humans