Integrating MCDA and economic evaluation into a rule-based framework for hospital-level health technology assessment

Health Technology Assessment (HTA) supports evidence-based decision-making, but integrating economic evaluation within Multi-Criteria Decision Analysis (MCDA) remains challenging in hospital-level HTA. This study developed and preliminarily applied an integrated decision-support framework combining MCDA, economic evaluation, and contextualized evidence assessment to support adoption recommendations.

A pragmatic digital framework integrated MCDA with Budget Impact Analysis (BIA) and Cost-Consequence Analysis (CCA) within a rule-based decision matrix. The economic module estimated cost per patient, incremental cost, budget impact, cost-consequence outputs, and, when appropriate, a supportive soft ICER. Evidence was assessed through structured critical appraisal, Summary of Findings tables, and outcome relevance, using a GRADE-informed approach mapped onto the predefined 0-1-3-5-7-9 MCDA evidence scale. Operational robustness was assessed through Failure Mode and Effects Analysis (FMEA) and self-audit controls.

In a case study comparing disposable and reusable continence care systems, the disposable option showed a lower MCDA score than the current standard (2.60 vs 4.80; ΔMCDA = -2.20) and a higher cost per patient (€1.00 vs €0.65; incremental cost €0.35). Although the 3-year budget impact was €2,634 and remained within the institutional affordability threshold, the technology was classified as dominated because it generated lower value at a higher cost. The final recommendation was not favorable for routine adoption.

The framework supports transparent integration of MCDA and economic evaluation in hospital-level HTA and helps distinguish affordability from overall value. The case study suggests that technologies should not be adopted solely because their budget impact is acceptable when the value-risk profile is unfavorable. Further validation across technologies and settings is required.