Additive Multicriteria Decision Analysis Models: Misleading Aids for Life-Critical Shared Decision Making

Background. There is growing interest in multicriteria decision analysis (MCDA) for shared decision making (SDM). A distinguishing feature is that a preferred treatment should extend years of life and/or improve health-related quality of life (HRQL). Additive MCDA models are inadequate for the task. A plethora of MCDA models exist, each claiming that it can correctly solve real-world problems. However, most were developed in nonhealth fields and rely on additive models. This makes the problem of choosing an MCDA model as an aid for SDM a challenging and urgent one. Methods. A published 2017 MCDA of a hypothetical prostate cancer patient is used as a case in point of how not to do and how to do MCDA for SDM. We critically review it and analyze it using several additive linear MCDA models with years of life and HRQL as attributes and the linear quality-adjusted life-year (QALY) model. The following simple reasonableness test is presented for applicability of a method as an aid for SDM: Can a treatment that causes premature death trump a treatment that causes acceptable adverse effects? Results. Additive MCDA models and the linear QALY recommend significantly different alternatives. Additive MCDA models fail the proposed reasonableness test; the linear QALY model passes. Conclusions. MCDA possesses a strong craft element in addition to its technical aspects. MCDA practitioners and clinicians need to understand model limitations to choose models appropriate to the context. Additive MCDA models are inadequate for life-critical SDM. We advocate QALY models with additional research for increased realism as a tool for SDM.