Erasmus School of Health Policy & Management, Erasmus University, P.O. Box 1738, 3000 DR, Rotterdam, the Netherlands.
Copernicus Institute of Sustainable Development, Utrecht University, Utrecht, the Netherlands.
BMC Health Serv Res. 2022 Jun 7;22(1):756. doi: 10.1186/s12913-022-07781-1.
Health care coverage decisions deal with health care technology provision or reimbursement at a national level. The coverage decision report, i.e., the publicly available document giving reasons for the decision, may contain various elements: quantitative calculations like cost and clinical effectiveness analyses and formalised and non-formalised qualitative considerations. We know little about the process of combining these heterogeneous elements into robust decisions.
This study describes a model for combining different elements in coverage decisions. We build on two qualitative cases of coverage appraisals at the Dutch National Health Care Institute, for which we analysed observations at committee meetings (n = 2, with field notes taken) and the corresponding audio files (n = 3), interviews with appraisal committee members (n = 10 in seven interviews) and with Institute employees (n = 5 in three interviews), and relevant documents (n = 4).
We conceptualise decisions as combinations of elements, specifically (quantitative) findings and (qualitative) arguments and values. Our model contains three steps: 1) identifying elements; 2) designing the combinations of elements, which entails articulating links, broadening the scope of designed combinations, and black-boxing links; and 3) testing these combinations and choosing one as the final decision.
Based on the proposed model, we suggest actively identifying a wider variety of elements and stepping up in terms of engaging patients and the public, including facilitating appeals. Future research could explore how different actors perceive the robustness of decisions and how this relates to their perceived legitimacy.
医疗保健覆盖决策涉及国家层面的医疗保健技术提供或报销。覆盖决策报告，即公开的决策理由文件，可能包含各种要素：定量计算，如成本和临床效果分析，以及形式化和非形式化的定性考虑。我们对将这些异构要素组合成稳健决策的过程知之甚少。
本研究描述了一种将不同要素组合在覆盖决策中的模型。我们以荷兰国家卫生保健研究所的两个定性覆盖评估案例为基础，对委员会会议（n=2，附有现场记录）和相应的音频文件（n=3）、评估委员会成员（n=10，分 7 次访谈）和研究所员工（n=5，分 3 次访谈）进行了分析，并参考了相关文件（n=4）。
我们将决策概念化为要素的组合，特别是（定量）发现和（定性）论点和价值观。我们的模型包含三个步骤：1）识别要素；2）设计要素组合，包括阐明联系、扩大设计组合的范围和将联系黑箱化；3）测试这些组合并选择一个作为最终决策。
基于提出的模型，我们建议积极识别更多种类的要素，并在让患者和公众参与方面加大力度，包括促进申诉。未来的研究可以探索不同的参与者如何看待决策的稳健性，以及这与他们感知的合法性有何关系。
