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EXPLORING VALUES OF HEALTH TECHNOLOGY ASSESSMENT AGENCIES USING REFLECTIVE MULTICRITERIA AND RARE DISEASE CASE
- Mireille M. Goetghebeur, Monika Wagner, Dima Samaha, William O'Neil, Danielle Badgley, Hector Castro-Jaramillo, Payam Abrishami, Antonio Sarria-Santamera, Irina Cleemput, Michele Tringali
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- Journal:
- International Journal of Technology Assessment in Health Care / Volume 33 / Issue 4 / 2017
- Published online by Cambridge University Press:
- 11 October 2017, pp. 504-520
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Objectives: Tackling ethical dilemmas faced by reimbursement decision makers requires deeper understanding of values on which health technology assessment (HTA) agencies are founded and how trade-offs are made. This was explored in this study including the case of rare disease.
Methods: Representatives from eight HTA explored values on which institutions are founded using a narrative approach and reflective multicriteria (developed from EVIDEM, criteria derived from ethical imperatives of health care). Trade-offs between criteria and the impact of incorporating defined priorities (including for rare diseases) were explored through a quantitative values elicitation exercise.
Results: Participants reported a diversity of substantive and procedural values with a common emphasis on scientific excellence, stakeholder involvement, independence, and transparency. Examining the ethical imperatives behind EVIDEM criteria was found to be useful to further explore substantive values. Most criteria were deemed to reflect institutions’ values, while 70 percent of the criteria were reported by at least half of participants to be considered formally by their institutions. The quantitative values elicitation highlighted the difficulty to balance imperatives of “alleviating or preventing patient suffering,” “serving the whole population equitably,” “upholding healthcare system sustainability,” and “making decisions informed by evidence and context” but may help share the ethical reasoning behind decisions. Incorporating “Priorities” (including for rare diseases) helped reveal trade-offs from other criteria and their underlying ethical imperatives.
Conclusions: Reflective multicriteria are useful to explore substantive values of HTAs, reflect how these values and their ethical underpinnings can be operationalized into criteria, and explore the ethical reasoning at the heart of the healthcare debate.
Diversification of mammals from the Miocene of Spain
- M. Soledad Domingo, Catherine Badgley, Beatriz Azanza, Daniel DeMiguel, M. Teresa Alberdi
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- Journal:
- Paleobiology / Volume 40 / Issue 2 / Spring 2014
- Published online by Cambridge University Press:
- 08 April 2016, pp. 197-221
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The mammalian fossil record of Spain is long and taxonomically well resolved, offering the most complete record of faunal change for the Neogene of Europe. We evaluated changes in diversification, composition, trophic structure, and size structure of large mammals over the middle and late Miocene with methods applied to this record for the first time, including ordination of fossil localities to improve temporal resolution and estimation of confidence intervals on taxa temporal ranges. By contrast, analysis within the traditional Mammal Neogene (MN) biochronology obscures important aspects of diversification. We used inferred temporal ranges of species and evaluated per capita rates of origination, extinction, diversification, and turnover over 0.5-Myr time intervals.
Three periods of significant faunal change occurred between 12.0 and 5.5 Ma: (1) From 12.0 to 10.5 Ma, elevated origination rates led to an increase in diversity without significant change in ecological structure. Immigrants and geographic-range shifts of species to lower latitudes during an interval of global cooling contributed to these faunal changes. (2) From 9.5 to 7.5 Ma, high extinction rates followed by high origination rates coincided with significant changes in taxonomic composition and ecological structure. These changes represent the Vallesian Crisis, with replacement of a fauna of forest affinities (with frugivores and browsers) by a fauna of open woodlands (with grazers and mixed feeders). (3) From 6.5 to 5.5 Ma, high extinction rates reduced diversity without substantial changes in ecological structure, and large mammal faunas became highly endemic across the northern Mediterranean region. This interval includes the Messinian Salinity Crisis, the desiccation of the Mediterranean basin. Extinction may have been caused by geographic isolation and aridification, with evolution of endemic lineages giving rise to new species in the early Pliocene. These distinct macroevolutionary patterns of faunal change correspond to different geographic scales of inferred climatic and tectonic drivers.