Department of Health Service Research

Head: Prof. Dr. Ansgar Gerhardus

Integration: What is it, why is it important, and how do you do it?

P. Wahlster, R. Baltussen, L. Brereton, J. Burns, B. Hofmann, K. Mozygemba, W. Oortwijn, L. Pfadenhauer, S. Polus, E. Rehfuess, I. Schilling, R. van Hoorn, G.J.

van der Wilt, R. Baltussen, A. Gerhardus

INTEGRATE-HTA Conference, 13.11.2015, Amsterdam

INTEGRATE-HTA

Starting points: What is integration?

The Oxford English dictionary defines integration as “…the making up or composition of a whole by adding together or combining the separate parts or elements; combination into an integral whole.”

INTEGRATE-HTA

Starting points: What is integration?

The Oxford English dictionary defines integration as “…the making up or composition of a whole by adding together or combining the separate parts or elements; combination into an integral whole.”

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What are the separate parts in INTEGRATE-HTA?

New Concepts and methods for a comprehensive, patient–centred assessment of complex technologies that include

• effectiveness and economic, sociocultural, ethical, and legal aspects,

• patient preferences and patient-specific moderators of treatment,

• context and implementation issues.

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Why is integration of these aspects important?

Accordingly, the aspects were assigned to different dimensions of information that need to be integrated in

HTA.

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Similar to comparing apples and oranges!

Which aspects are the apples? Which aspects are the oranges?

Dimension 1: Different assessment aspects of a health technology produce different assessment results

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HTA

asp

ects

Effectiveness

Socio- Cultural

Assessment

results

Economic

Ethical

Legal

Dimension 2: Modifying factors, context, implementation issues and patient characteristics

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Modifying factors (Dimension 2)

Patient characteristics

Implementation issues Context

HTA

asp

ects

(Dim

ensi

on 1

) Effectiveness

Assessment results

Socio- Cultural

Economic

Ethical

Legal

Dimension 3: Degree of uncertainty of the assessment results

INTEGRATE-HTA

Modifying factors (Dimension 2)

Patient

characteristics Implementation

issues Context

H

TA a

spec

ts (D

imen

sion

1)

Effectiveness

Assessment results

AND

Degree of

uncertainty

Uncertainty of the assessm

ent results (Dim

ension 3)

Socio- Cultural

Economic

Ethical

Legal

Dimension 4: Representation of stakeholders, including their values and preferences

INTEGRATE-HTA

Stakeholders with their values and preferences (Dimension 4)

Modifying factors (Dimension 2)

Patient characteristics

Implementation issues Context

HTA

asp

ects

(Dim

ensi

on 1

) Effectiveness Assessment results

AND

Degree of uncertainty

Uncertainty of the assessm

ent results (D

imension 3)

Socio- Cultural

Economic

Ethical

Legal

How can we achieve an integrated view on these apples and oranges?

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How can we systematically integrate the different dimensions in HTA?

As the different dimensions to be integrated require different methods for integration, we conducted a mapping review of the medical and non-medical literature to identify methods to integrate the different dimensions of information in HTA.

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Methods

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Information sources and search

Web of Science; Medline, PsycINFO and the non-medical databases Econlit, ASSIA, International Bibliography of the Social Sciences, Sociological abstracts were searched from January 2004 up to April 2014.

Inclusion criteria

• Approaches that describe how these relevant issues should be considered: Should include connective elements to merge/ aggregate/ address interdependencies between aspects

• Address the dimensions of information to be integrated in HTA

Exclusion criteria

• Simply side-by-side assessment, frameworks that only provide decision criteria

Results of search strategy

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30 approaches included in the synthesis.

2054 records assigned to the approach that was applied

Records excluded (Different topic e.g. basic research)

3848 Records identified after dublicates removed.

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Data extraction

30 approaches: MCDA approaches Analytic approaches Preference elicitation approaches Consensus methods

Do

they

add

ress

…

Dimension 1: Different assessment aspects

Dimension 2: Modifying factors, such as patient

characteristics

Dimension 3: Uncertainty of the

assessment results

Dimension 4: Representation of

stakeholders

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9 integration techniques extracted from the methods identified

a. Structuring of the HTA objective into assessment criteria

b. Performance matrix of the assessment results

c. Qualitative modelling techniques

d. Process based integration

e. Scoring and calculation approaches to integrate criteria

f. Providing structured input for deliberative discussions

g. Structuring a deliberative discussion

h. Integrating uncertainty by using assessment criteria

i. Integrating uncertainty of evidence

Dimension 1: Different assessment aspects of a health technology produce different assessment results

INTEGRATE-HTA

HTA

asp

ects

(Dim

ensi

on 1

) Effectiveness

Socio- Cultural

Assessment results

Economic

Ethical

Legal

a. Structuring of the HTA objective into assessment criteria

Example: Meaningfulness, Acceptability

b. Performance matrix of the assessment results

Dimension 2: Modifying factors, context, implementation issues and patient characteristics

INTEGRATE-HTA

Modifying factors (Dimension 2)

Patient

characteristics Implementation

issues Context

HTA

asp

ects

(Dim

ensi

on 1

) Effectiveness

Assessment results

Socio- Cultural

Economic

Ethical

Legal

c. Qualitative modelling techniques Example: Logic models

c. Qualitative modelling techniques Example: Logic models

Dimension 3: Degree of uncertainty of the assessment results

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Modifying factors (Dimension 2)

Patient

characteristics Implementation

issues Context

HTA

asp

ects

(Dim

ensi

on 1

)

Effectiveness Assessment

results

AND

Degree of uncertainty

Uncertainty of the assessm

ent results (D

imension 3)

Socio- Cultural

Economic

Ethical

Legal

h. Integrating uncertainty by using assessment

criteria Example: GRADE (Grading of Recommendations, Assessment, Development and Evaluation) i. Integrating uncertainty of evidence Example: Decision trees

Source: www.gradeworkinggroup.org

Dimension 4: Representation of stakeholders, including their values and preferences

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d. Process based integration Example: GRADE e. Scoring and calculation techniques to

integrate criteria Example: EVIDEM (EVIdence Based DEcision-Making)

g. Structuring a deliberative discussion Example: Nominal Group Technique

Source: Evidem.org

Conclusion

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• Integration between the different dimensions is a continuous process. It is not possible to assess the different, interacting dimensions independently first, and complete the integration afterwards.

• The results of this review provide guidance on suitable combinations of different methods.

philip.wahlster@uni-bremen.de

This project is co-funded by the European Union under the Seventh Framework

Programme (Grant Agreement No. 306141)

www.integrate-hta.eu

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