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and price in making decisions on financing&#44; provision&#44; and prioritization of health resources&#44; when presenting two alternatives in the provision of a care service&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methodology</span><p id="par0020" class="elsevierStylePara elsevierViewall">In a multi-criteria decision context&#44; the main issues are&#58; 1&#41; problem structuring and identification of alternatives&#59; 2&#41; evidence review&#59; 3&#41; modeling &#40;identifying and establishing evaluation criteria for the different alternatives&#59; measuring and prioritizing interventions according to the established criteria&#59; weighting to obtain the relative importance of each criterion and an overall evaluation of each intervention&#41; and 4&#41; deliberation&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The development of the MCDA workshop was carried out virtually and used the EVIDEM &#40;<span class="elsevierStyleItalic">Evidence and Value&#58; Impact on DEcision-Making</span>&#41; framework&#44; which is freely available through its website &#40;The EVIDEM Collaboration&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> This framework consists of 22 criteria &#40;15 quantitative and seven qualitative&#41; and requires that evidence meet three characteristics&#58; 1&#41; broad &#40;covering all areas related to the health issue in question&#41;&#59; 2&#41; relevant &#40;key to the decision&#41; and 3&#41; explicit&#44; as a key element of transparency and accountability in decision-making&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">To carry out the MCDA&#44; a group of 23 participants was formed&#44; balancing different levels of responsibility&#44; from the Andalusian Public Health System &#40;SSPA&#41; made up of directors and managers &#40;n&#8239;&#61;&#8239;3&#41;&#44; representatives of the Association for the Fight Against Kidney Diseases &#40;ALCER&#41; &#40;n&#8239;&#61;&#8239;2&#41;&#44; health evaluation and management professionals &#40;n&#8239;&#61;&#8239;5&#41;&#44; healthcare practitioners &#40;n&#8239;&#61;&#8239;3&#41;&#44; nephrology nursing professionals &#40;n&#8239;&#61;&#8239;5&#41;&#44; and nephrology unit managers &#40;n&#8239;&#61;&#8239;3&#41;&#46; In addition&#44; to include other organizational perspectives&#44; two supervising nephrologists from other autonomous communities were invited&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In the first part of the workshop&#44; participants were offered a training session on the MCDA methodology as a decision-making tool by an expert in health technology assessment&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In the second part&#44; and before the participants were familiarized with the methodology under study&#44; weights were assigned to the evaluation framework&#58; each participant scored each criterion according to importance between 1 &#40;least relevant&#41; and 5 &#40;most relevant&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Subsequently&#44; participants were presented with the results of the scoping review of the literature on the subject&#44; according to the different domains of the evaluation framework&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> For this review&#44; the following databases were consulted&#58; PubMed&#44; Embase&#44; Web of Science&#44; CINAHL&#44; Scopus&#44; and The Cochrane Library&#46; We included articles comparing outsourced versus hospital dialysis&#44; according to the EVIDEM framework criteria&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">After this&#44; each participant scored the absolute criteria &#40;those not involving a comparison between alternatives&#41; between 0 &#40;lowest value&#41; and 5 &#40;highest value&#41; and the relative criteria &#40;involving a comparison between both dialysis delivery modalities&#41; between &#8722;5 and 5 points&#46; Finally&#44; an evaluation was made of the 7 qualitative criteria&#44; based on the available evidence and the experience of the participants&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The estimated value for each intervention was obtained using a linear additive model&#44; combining the relative weighting of each criterion with the score reported for each intervention&#46; Each estimated value was transformed into a scale from 0 to 100&#44; to facilitate its interpretation and its standard deviation &#40;SD&#41;&#44; which represents the synthesis of the overall value of each alternative as an expression of the degree to which one of them is preferred to another&#46; To check the degree of consistency and replicability of the analysis&#44; the model was weighted by scoring the criteria from 1 to 5&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Finally&#44; although different programs are available for multicriteria decision analysis&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> we designed a tool in Microsoft Excel format that allowed the information collected to be obtained and displayed in a more explicit&#44; dynamic&#44; and transparent way&#46; At the end of the workshop&#44; the participants discussed the results&#44; and held a final debate on the contribution of this methodology and its application to decision-making in different areas of nephrology&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">In the first part of the model weighting&#44; workshop participants scored all criteria above 3 &#40;out of 5&#41;&#44; except the indirect cost criterion&#44; which scored 2&#46;8 &#40;SD&#58; &#177;0&#46;8&#41;&#46; The highest mean score was 4&#46;3 for the criteria &#8220;comparative effectiveness&#8221; &#40;SD&#58; &#177;0&#46;8&#41; and &#8220;comparative safety&#47;tolerability&#8221; &#40;SD&#58; &#177;1&#46;0&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; We observed high consistency between the scores using the 0&#8211;5 scale and the 0&#8211;100 scale &#40;Figs&#46; S1A&#8211;S1F in Appendix A show the mean score according to professional profile&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">With regard to the absolute criteria scores&#44; in the hospital dialysis option&#44; the criterion with the highest mean score was &#8220;unmet needs&#8221; with 3&#46;8 &#40;out of 5&#41; and high consistency &#40;SD&#58; &#177;0&#46;8&#41;&#59; the other criteria with the highest mean scores were &#8220;severity of disease&#44;&#8221; &#8220;quality of evidence&#44;&#8221; and &#8220;type of therapeutic benefit&#8221; with a score of 3&#46;3&#44; with a standard deviation ranging from 0&#46;8 to 1&#46;2&#46; In contrast&#44; the criterion with the lowest score was &#8220;type of preventive benefit&#8221; with score 2&#46;3 &#40;SD&#58; &#177;1&#46;0&#41;&#46; As for the comparative criteria&#44; the criterion with the highest score was &#8220;comparative safety&#47;tolerability&#8221; with a mean score of 1&#46;2 &#40;SD&#58; &#177;2&#46;6&#41;&#59; the remaining criteria ranged from 0&#46;3 &#40;SD&#58; &#177;3&#41; for &#8220;patient-reported outcomes&#8221; to &#8722;0&#46;2 &#40;SD&#58; &#177;3&#46;1&#41; for &#8220;indirect costs&#8221; and &#8220;fixed health care costs&#8221; &#40;SD&#58; &#177;2&#46;5&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">In the outsourced dialysis option&#44; the highest mean score was 3&#46;7 &#40;SD&#58; &#177;1&#46;2&#41; for the criterion &#8220;size of the affected population&#44;&#8221; followed by &#8220;unmet need&#8221; with a score of 3&#46;5 &#40;SD&#58; &#177;0&#46;5&#41;&#46; In contrast&#44; the lowest mean score was for &#34;type of preventive benefit&#8221; with a mean of 2&#46;3 &#40;SD&#58; &#177;1&#46;5&#41;&#46; The relative criteria scores ranged from 0&#46;8 &#40;SD&#58; &#177;3&#46;3&#41; for the criterion &#8220;comparative costs of the intervention&#46;&#8221; The lowest were for &#8220;compared efficacy&#47;effectiveness&#8221; and &#8220;compared non-health costs&#44;&#8221; with a score of &#8722;0&#46;8&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">When the scores were analyzed according to the profile of the participants&#44; it was observed that&#44; in general&#44; executives and managers gave a higher score to those dimensions related to cost&#44; whereas patients gave them the lowest score&#46; In contrast&#44; the &#8220;quality of evidence&#8221; item scored lowest among patients and had the highest mean score among evaluators &#40;Figs&#46; S1A&#8211;S1E in Appendix A&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The overall value estimate integrates the weights and scores of each panelist on a scale from 0 to 100&#46; Thus&#44; <a class="elsevierStyleCrossRefs" href="#fig0010">Figs&#46; 2 and 3</a> show the mean contribution of each criterion to the overall value estimate for hospital and outsourced dialysis&#44; respectively&#46; The estimate of the value of the outsourced dialysis was 0&#46;29 &#40;SD&#58; &#177;0&#46;2&#41; and for hospital dialysis 0&#46;39 &#40;SD&#58; &#177;0&#46;2&#41;&#46; When analyzing the mean score of the overall value&#44; according to professional profile&#44; it can be seen that all the profiles gave a higher value to hospital hemodialysis &#40;range&#58; 0&#46;44&#8211;0&#46;36 for patients and managers&#44; respectively&#41; than to conventional dialysis &#40;range&#58; 0&#46;31&#8211;0&#46;27 for patients and middle management&#44; respectively&#41; &#40;Figs&#46; S2A&#8211;S2E in Appendix B for hospital dialysis and Figs&#46; S3A&#8211;S3E for conventional dialysis&#44; according to professional profile&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Finally&#44; the workshop participants evaluated the impact of each qualitative or contextual criterion&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> with the criterion &#8220;common objective and specific interests&#8221; showing the greatest negative impact &#40;12 participants rated it as such&#41;&#46; On the other hand&#44; &#8220;opportunity cost and affordability&#44;&#8221; and &#8220;population priorities and access were the two criteria that showed the greatest positive impact&#8221; &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">MCDA is increasingly used worldwide for health care decisions to improve the consistency and transparency of policy decisions&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> MCDA applications can be classified into two categories<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;15</span></a>&#58; 1&#41; resource allocation&#44; assigning priority based on the outcome of MCDA application<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> &#40;reimbursement and authorization decisions or budget allocation&#41; and 2&#41; ranking therapeutic alternatives for specific clinical problems&#44; developing clinical guidelines or incorporating patient preferences in shared decision-making&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">This article presents an assessment&#44; using the MCDA methodology&#44; of two non-exclusive alternatives in the field of the provision of treatment for a highly prevalent chronic disease whose assessment does not imply the allocation of resources toward one modality or the other&#46; To the authors&#8217; knowledge&#44; there is little experience in the application of this methodology for decisions of this nature applied to the field of nephrology&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The complexity of the healthcare sectors&#44; budgetary constraints&#44; and the need to offer high quality services have led healthcare organizations to adopt new management approaches&#46; Thus&#44; outsourcing of services has been considered in recent years by health care decision-makers as one of the tools for improving organization&#44; development&#44; and productivity&#46; The outsourcing of services is a mechanism for assigning some of the organization&#8217;s activities to an external provider&#46; Among the various reasons for outsourcing are&#58; cost reduction&#44; increased efficiency by focusing on value-adding processes&#44; improved skills&#44; reduced service delivery time&#44; and increased competitive advantage&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The outsourcing of services is especially relevant in the treatment of chronic kidney disease&#59; in Spain&#44; public&#8211;private collaboration plays an important role in the dialysis provision model and many patients receive hemodialysis in out-of-hospital clinics&#44; through agreements with the different health services&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">The prevalence of chronic kidney disease in Spain is around 15&#37; and the results have shown that it can be considered a cardiovascular condition&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Moreover&#44; CKD represents a very high cost<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#58; it accounts for 3&#37; of total health expenditure and requires health care that involves a multitude of health professionals at different levels&#44; with a high level of coordination for adequate prevention&#44; diagnosis and treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Bearing in mind that we are situated in a setting characterized by the high cost to the health system of treating chronic renal failure&#44; this work has approximated a measure that compares the value that two forms of service provision of dialysis through out-of-hospital clinics and hospitals can provide&#46; A similar initiative developed a multicriteria evaluation methodology for dialysis centers based on the value of health care and understood as the ratio of patient benefit per monetary unit invested&#46; Four criteria were used &#40;evidence-based clinical performance&#44; annual mortality&#44; patient satisfaction&#44; and health-related quality of life&#41; and MCDA was used in the phase of assigning weights or weighting of criteria and sub-criteria&#46; Although the number of external dialysis clinics included in the study was not high &#40;n&#8239;&#61;&#8239;5&#41;&#44; the three clinics that provided the highest value were all external&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Regardless of the results&#44; there is no doubt that a value approach&#44; through MCDA or other similar methodology&#44; has the potential to integrate different perceptions of all stakeholders and create a context for improving a treatment or the way in which a care service is provided&#44; innovate processes&#44; pay for performance&#44; and improve transparency&#46; Moreover&#44; the results can be easily understood by the different stakeholders involved &#40;by patients and their families&#44; dialysis center health professionals&#44; managers&#44; providers&#44; or political decision-makers&#41; and are reproducible in different evaluation contexts&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">At the end of the workshop&#44; there was a space to collect the opinions of the participants on the applicability and utility of this methodology&#46; In general&#44; the panelists affirmed that it is a useful and interesting exercise and that&#44; to a certain extent&#44; it provides security in decision-making&#44; since it allows different criteria considered to be ordered&#44; justified&#44; and explicitly considered&#46; They also stated that the exchange of opinions among the participants enriched the process&#44; especially because of the diversity of profiles&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">These aspects are particularly relevant in the context of healthcare organizations&#44; which are characterized by a high level of complexity and a very dynamic environment&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Although the participants were offered a theoretical session on MCDA and an attempt was made to adapt the language to all the panelists&#44; they reported difficulties with the terminology used&#44; which required a certain familiarity&#44; and uncertainty interpreting the evidence and the type of concepts used&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> especially among those with less experience in health technology assessment&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">This work has several limitations that may affect the results of the study&#46; First&#44; due to the pandemic&#44; the workshop was conducted virtually&#44; which may have affected the interaction between participants and the discussion generated&#46; On the other hand&#44; the uncertainty and care overload generated during the pandemic made it impossible to carry out a subsequent retest to assess the consistency of the scores&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">The EVIDEM evaluation framework was used for this evaluation&#44; but it is possible that it omitted certain criteria that might have been relevant such a specific evaluation as the one proposed in this work&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Nevertheless&#44; three professionals not participating in the workshop were asked for a prior individual evaluation in order to consider the adequacy of the criteria considered in the workshop&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> The EVIDEM framework was considered to cover all aspects relevant to the evaluation&#44; did not require complicated calculations&#44; and there was experience in its use&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">The relevant aspect of the result is not the absolute values obtained&#44; but the comparison between the two values&#46; Thus&#44; the main contribution of the MCDA is the deliberative process itself and the discussion of the results&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;28</span></a> Thus&#44; according to this study&#44; the fact that professionals give more value to hospital dialysis than to conventional dialysis should translate into a prioritization in the allocation of health resources&#44; decision-making and formulation of health policies&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Financing</span><p id="par0150" class="elsevierStylePara elsevierViewall">The Andalusian School of Public Health &#40;Escuela Andaluza de Salud P&#250;blica&#41;&#44; the institution responsible for the management and development of the project&#44; received funding from <span class="elsevierStyleGrantSponsor" id="gs0005">Vifor Pharma</span>&#46; Vifor Pharma had no role in the study design&#44; data collection and analysis&#44; decision to publish&#44; or preparation of the manuscript&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflict of interest</span><p id="par0155" class="elsevierStylePara elsevierViewall">The laboratory that funded this work did not participate or intervene in the group&#8217;s decisions including the choice of the problem&#44; selection of workshop participants&#44; or in the analysis&#44; writing&#44; presentation&#44; and approval of the manuscript&#46; The authors of this article declare that they are not subject to any conflict of interest related to the subject that may affect the design&#44; analysis&#44; or presentation of results&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">To evaluate the value of the provision of contracted versus hospital dialysis services for the treatment of chronic kidney disease in Spain using the multicriteria decision analysis methodology&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Method</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The EVIDEM &#40;Evidence and Value&#58; Impact on Decision Making&#41; evaluation framework was used to calculate the estimated value of both dialysis delivery models &#40;arranged vs&#46; hospital&#41; through a virtual workshop in which different profiles participated&#58; directors and managers&#44; professionals and heads of units and representatives of patients and relatives&#46; The scores were combined using an additive lineal model&#44; which combined the weight of the model with the individual score of the criteria&#44; and each value was transformed to a scale between 0 and 1&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The estimated value for arranged dialysis was 0&#46;29 &#40;DS&#58; &#177;0&#46;2&#41; and 0&#46;39 &#40;DS&#58; &#177;0&#46;2&#41; for hospital dialysis&#46; All profiles gave a higher value to hospital hemodialysis compared to contracted hemodialysis&#46; The highest value for hospital dialysis was for patients &#40;0&#46;44&#41;&#44; with the lowest mean value for directors &#40;0&#46;36&#41; and the range for arranged dialysis being between patients &#40;0&#46;31&#41; and intermediate positions &#40;0&#46;27&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Hospital hemodialysis obtained a higher value than concerted dialysis&#46; In general&#44; the panelists affirmed that it is a useful and interesting exercise and that&#44; to a certain extent&#44; it provides security in decision-making&#44; since it allows ordering&#44; rationalizing and considering&#44; in an explicit and transparent manner&#44; the different criteria involved&#46;</p></span>"
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Original article
Value of concerted and hospital hemodialysis through a multi-criteria decision analysis
Valor de la hemodiálisis concertada y la hospitalaria mediante un análisis de decisión multicriterio
Araceli Caro Martíneza,b, María del Carmen Valcárcel Cabreraa, Antonio Olry de Labry Limac,d,e,
Corresponding author
a Escuela Andaluza de Salud Pública, Granada, Spain
b Programa de Doctorado Interuniversitario en Ciencias de la Salud, Universidad de Jaén-Universidad de Sevilla (UJA-US), Sevilla, Spain
c Centro Andaluz de Documentación e Información de Medicamentos (CADIME), Escuela Andaluza de Salud Pública, Granada, Spain
d Consorcio de Investigación Biomédica en Red Epidemiología y Salud Pública, CIBERESP
e Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, Spain
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&#40;n&#8239;&#61;&#8239;2&#41;&#44; health evaluation and management professionals &#40;n&#8239;&#61;&#8239;5&#41;&#44; healthcare practitioners &#40;n&#8239;&#61;&#8239;3&#41;&#44; nephrology nursing professionals &#40;n&#8239;&#61;&#8239;5&#41;&#44; and nephrology unit managers &#40;n&#8239;&#61;&#8239;3&#41;&#46; In addition&#44; to include other organizational perspectives&#44; two supervising nephrologists from other autonomous communities were invited&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In the first part of the workshop&#44; participants were offered a training session on the MCDA methodology as a decision-making tool by an expert in health technology assessment&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In the second part&#44; and before the participants were familiarized with the methodology under study&#44; weights were assigned to the evaluation framework&#58; each participant scored each criterion according to importance between 1 &#40;least relevant&#41; and 5 &#40;most relevant&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Subsequently&#44; participants were presented with the results of the scoping review of the literature on the subject&#44; according to the different domains of the evaluation framework&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> For this review&#44; the following databases were consulted&#58; PubMed&#44; Embase&#44; Web of Science&#44; CINAHL&#44; Scopus&#44; and The Cochrane Library&#46; We included articles comparing outsourced versus hospital dialysis&#44; according to the EVIDEM framework criteria&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">After this&#44; each participant scored the absolute criteria &#40;those not involving a comparison between alternatives&#41; between 0 &#40;lowest value&#41; and 5 &#40;highest value&#41; and the relative criteria &#40;involving a comparison between both dialysis delivery modalities&#41; between &#8722;5 and 5 points&#46; Finally&#44; an evaluation was made of the 7 qualitative criteria&#44; based on the available evidence and the experience of the participants&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The estimated value for each intervention was obtained using a linear additive model&#44; combining the relative weighting of each criterion with the score reported for each intervention&#46; Each estimated value was transformed into a scale from 0 to 100&#44; to facilitate its interpretation and its standard deviation &#40;SD&#41;&#44; which represents the synthesis of the overall value of each alternative as an expression of the degree to which one of them is preferred to another&#46; To check the degree of consistency and replicability of the analysis&#44; the model was weighted by scoring the criteria from 1 to 5&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Finally&#44; although different programs are available for multicriteria decision analysis&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> we designed a tool in Microsoft Excel format that allowed the information collected to be obtained and displayed in a more explicit&#44; dynamic&#44; and transparent way&#46; At the end of the workshop&#44; the participants discussed the results&#44; and held a final debate on the contribution of this methodology and its application to decision-making in different areas of nephrology&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">In the first part of the model weighting&#44; workshop participants scored all criteria above 3 &#40;out of 5&#41;&#44; except the indirect cost criterion&#44; which scored 2&#46;8 &#40;SD&#58; &#177;0&#46;8&#41;&#46; The highest mean score was 4&#46;3 for the criteria &#8220;comparative effectiveness&#8221; &#40;SD&#58; &#177;0&#46;8&#41; and &#8220;comparative safety&#47;tolerability&#8221; &#40;SD&#58; &#177;1&#46;0&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; We observed high consistency between the scores using the 0&#8211;5 scale and the 0&#8211;100 scale &#40;Figs&#46; S1A&#8211;S1F in Appendix A show the mean score according to professional profile&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">With regard to the absolute criteria scores&#44; in the hospital dialysis option&#44; the criterion with the highest mean score was &#8220;unmet needs&#8221; with 3&#46;8 &#40;out of 5&#41; and high consistency &#40;SD&#58; &#177;0&#46;8&#41;&#59; the other criteria with the highest mean scores were &#8220;severity of disease&#44;&#8221; &#8220;quality of evidence&#44;&#8221; and &#8220;type of therapeutic benefit&#8221; with a score of 3&#46;3&#44; with a standard deviation ranging from 0&#46;8 to 1&#46;2&#46; In contrast&#44; the criterion with the lowest score was &#8220;type of preventive benefit&#8221; with score 2&#46;3 &#40;SD&#58; &#177;1&#46;0&#41;&#46; As for the comparative criteria&#44; the criterion with the highest score was &#8220;comparative safety&#47;tolerability&#8221; with a mean score of 1&#46;2 &#40;SD&#58; &#177;2&#46;6&#41;&#59; the remaining criteria ranged from 0&#46;3 &#40;SD&#58; &#177;3&#41; for &#8220;patient-reported outcomes&#8221; to &#8722;0&#46;2 &#40;SD&#58; &#177;3&#46;1&#41; for &#8220;indirect costs&#8221; and &#8220;fixed health care costs&#8221; &#40;SD&#58; &#177;2&#46;5&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">In the outsourced dialysis option&#44; the highest mean score was 3&#46;7 &#40;SD&#58; &#177;1&#46;2&#41; for the criterion &#8220;size of the affected population&#44;&#8221; followed by &#8220;unmet need&#8221; with a score of 3&#46;5 &#40;SD&#58; &#177;0&#46;5&#41;&#46; In contrast&#44; the lowest mean score was for &#34;type of preventive benefit&#8221; with a mean of 2&#46;3 &#40;SD&#58; &#177;1&#46;5&#41;&#46; The relative criteria scores ranged from 0&#46;8 &#40;SD&#58; &#177;3&#46;3&#41; for the criterion &#8220;comparative costs of the intervention&#46;&#8221; The lowest were for &#8220;compared efficacy&#47;effectiveness&#8221; and &#8220;compared non-health costs&#44;&#8221; with a score of &#8722;0&#46;8&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">When the scores were analyzed according to the profile of the participants&#44; it was observed that&#44; in general&#44; executives and managers gave a higher score to those dimensions related to cost&#44; whereas patients gave them the lowest score&#46; In contrast&#44; the &#8220;quality of evidence&#8221; item scored lowest among patients and had the highest mean score among evaluators &#40;Figs&#46; S1A&#8211;S1E in Appendix A&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The overall value estimate integrates the weights and scores of each panelist on a scale from 0 to 100&#46; Thus&#44; <a class="elsevierStyleCrossRefs" href="#fig0010">Figs&#46; 2 and 3</a> show the mean contribution of each criterion to the overall value estimate for hospital and outsourced dialysis&#44; respectively&#46; The estimate of the value of the outsourced dialysis was 0&#46;29 &#40;SD&#58; &#177;0&#46;2&#41; and for hospital dialysis 0&#46;39 &#40;SD&#58; &#177;0&#46;2&#41;&#46; When analyzing the mean score of the overall value&#44; according to professional profile&#44; it can be seen that all the profiles gave a higher value to hospital hemodialysis &#40;range&#58; 0&#46;44&#8211;0&#46;36 for patients and managers&#44; respectively&#41; than to conventional dialysis &#40;range&#58; 0&#46;31&#8211;0&#46;27 for patients and middle management&#44; respectively&#41; &#40;Figs&#46; S2A&#8211;S2E in Appendix B for hospital dialysis and Figs&#46; S3A&#8211;S3E for conventional dialysis&#44; according to professional profile&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Finally&#44; the workshop participants evaluated the impact of each qualitative or contextual criterion&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> with the criterion &#8220;common objective and specific interests&#8221; showing the greatest negative impact &#40;12 participants rated it as such&#41;&#46; On the other hand&#44; &#8220;opportunity cost and affordability&#44;&#8221; and &#8220;population priorities and access were the two criteria that showed the greatest positive impact&#8221; &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">MCDA is increasingly used worldwide for health care decisions to improve the consistency and transparency of policy decisions&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> MCDA applications can be classified into two categories<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;15</span></a>&#58; 1&#41; resource allocation&#44; assigning priority based on the outcome of MCDA application<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> &#40;reimbursement and authorization decisions or budget allocation&#41; and 2&#41; ranking therapeutic alternatives for specific clinical problems&#44; developing clinical guidelines or incorporating patient preferences in shared decision-making&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">This article presents an assessment&#44; using the MCDA methodology&#44; of two non-exclusive alternatives in the field of the provision of treatment for a highly prevalent chronic disease whose assessment does not imply the allocation of resources toward one modality or the other&#46; To the authors&#8217; knowledge&#44; there is little experience in the application of this methodology for decisions of this nature applied to the field of nephrology&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The complexity of the healthcare sectors&#44; budgetary constraints&#44; and the need to offer high quality services have led healthcare organizations to adopt new management approaches&#46; Thus&#44; outsourcing of services has been considered in recent years by health care decision-makers as one of the tools for improving organization&#44; development&#44; and productivity&#46; The outsourcing of services is a mechanism for assigning some of the organization&#8217;s activities to an external provider&#46; Among the various reasons for outsourcing are&#58; cost reduction&#44; increased efficiency by focusing on value-adding processes&#44; improved skills&#44; reduced service delivery time&#44; and increased competitive advantage&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The outsourcing of services is especially relevant in the treatment of chronic kidney disease&#59; in Spain&#44; public&#8211;private collaboration plays an important role in the dialysis provision model and many patients receive hemodialysis in out-of-hospital clinics&#44; through agreements with the different health services&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">The prevalence of chronic kidney disease in Spain is around 15&#37; and the results have shown that it can be considered a cardiovascular condition&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Moreover&#44; CKD represents a very high cost<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>&#58; it accounts for 3&#37; of total health expenditure and requires health care that involves a multitude of health professionals at different levels&#44; with a high level of coordination for adequate prevention&#44; diagnosis and treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Bearing in mind that we are situated in a setting characterized by the high cost to the health system of treating chronic renal failure&#44; this work has approximated a measure that compares the value that two forms of service provision of dialysis through out-of-hospital clinics and hospitals can provide&#46; A similar initiative developed a multicriteria evaluation methodology for dialysis centers based on the value of health care and understood as the ratio of patient benefit per monetary unit invested&#46; Four criteria were used &#40;evidence-based clinical performance&#44; annual mortality&#44; patient satisfaction&#44; and health-related quality of life&#41; and MCDA was used in the phase of assigning weights or weighting of criteria and sub-criteria&#46; Although the number of external dialysis clinics included in the study was not high &#40;n&#8239;&#61;&#8239;5&#41;&#44; the three clinics that provided the highest value were all external&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Regardless of the results&#44; there is no doubt that a value approach&#44; through MCDA or other similar methodology&#44; has the potential to integrate different perceptions of all stakeholders and create a context for improving a treatment or the way in which a care service is provided&#44; innovate processes&#44; pay for performance&#44; and improve transparency&#46; Moreover&#44; the results can be easily understood by the different stakeholders involved &#40;by patients and their families&#44; dialysis center health professionals&#44; managers&#44; providers&#44; or political decision-makers&#41; and are reproducible in different evaluation contexts&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">At the end of the workshop&#44; there was a space to collect the opinions of the participants on the applicability and utility of this methodology&#46; In general&#44; the panelists affirmed that it is a useful and interesting exercise and that&#44; to a certain extent&#44; it provides security in decision-making&#44; since it allows different criteria considered to be ordered&#44; justified&#44; and explicitly considered&#46; They also stated that the exchange of opinions among the participants enriched the process&#44; especially because of the diversity of profiles&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">These aspects are particularly relevant in the context of healthcare organizations&#44; which are characterized by a high level of complexity and a very dynamic environment&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Although the participants were offered a theoretical session on MCDA and an attempt was made to adapt the language to all the panelists&#44; they reported difficulties with the terminology used&#44; which required a certain familiarity&#44; and uncertainty interpreting the evidence and the type of concepts used&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> especially among those with less experience in health technology assessment&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">This work has several limitations that may affect the results of the study&#46; First&#44; due to the pandemic&#44; the workshop was conducted virtually&#44; which may have affected the interaction between participants and the discussion generated&#46; On the other hand&#44; the uncertainty and care overload generated during the pandemic made it impossible to carry out a subsequent retest to assess the consistency of the scores&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">The EVIDEM evaluation framework was used for this evaluation&#44; but it is possible that it omitted certain criteria that might have been relevant such a specific evaluation as the one proposed in this work&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Nevertheless&#44; three professionals not participating in the workshop were asked for a prior individual evaluation in order to consider the adequacy of the criteria considered in the workshop&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> The EVIDEM framework was considered to cover all aspects relevant to the evaluation&#44; did not require complicated calculations&#44; and there was experience in its use&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">The relevant aspect of the result is not the absolute values obtained&#44; but the comparison between the two values&#46; Thus&#44; the main contribution of the MCDA is the deliberative process itself and the discussion of the results&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;28</span></a> Thus&#44; according to this study&#44; the fact that professionals give more value to hospital dialysis than to conventional dialysis should translate into a prioritization in the allocation of health resources&#44; decision-making and formulation of health policies&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Financing</span><p id="par0150" class="elsevierStylePara elsevierViewall">The Andalusian School of Public Health &#40;Escuela Andaluza de Salud P&#250;blica&#41;&#44; the institution responsible for the management and development of the project&#44; received funding from <span class="elsevierStyleGrantSponsor" id="gs0005">Vifor Pharma</span>&#46; Vifor Pharma had no role in the study design&#44; data collection and analysis&#44; decision to publish&#44; or preparation of the manuscript&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflict of interest</span><p id="par0155" class="elsevierStylePara elsevierViewall">The laboratory that funded this work did not participate or intervene in the group&#8217;s decisions including the choice of the problem&#44; selection of workshop participants&#44; or in the analysis&#44; writing&#44; presentation&#44; and approval of the manuscript&#46; The authors of this article declare that they are not subject to any conflict of interest related to the subject that may affect the design&#44; analysis&#44; or presentation of results&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">To evaluate the value of the provision of contracted versus hospital dialysis services for the treatment of chronic kidney disease in Spain using the multicriteria decision analysis methodology&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Method</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">The EVIDEM &#40;Evidence and Value&#58; Impact on Decision Making&#41; evaluation framework was used to calculate the estimated value of both dialysis delivery models &#40;arranged vs&#46; hospital&#41; through a virtual workshop in which different profiles participated&#58; directors and managers&#44; professionals and heads of units and representatives of patients and relatives&#46; The scores were combined using an additive lineal model&#44; which combined the weight of the model with the individual score of the criteria&#44; and each value was transformed to a scale between 0 and 1&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The estimated value for arranged dialysis was 0&#46;29 &#40;DS&#58; &#177;0&#46;2&#41; and 0&#46;39 &#40;DS&#58; &#177;0&#46;2&#41; for hospital dialysis&#46; All profiles gave a higher value to hospital hemodialysis compared to contracted hemodialysis&#46; The highest value for hospital dialysis was for patients &#40;0&#46;44&#41;&#44; with the lowest mean value for directors &#40;0&#46;36&#41; and the range for arranged dialysis being between patients &#40;0&#46;31&#41; and intermediate positions &#40;0&#46;27&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Hospital hemodialysis obtained a higher value than concerted dialysis&#46; In general&#44; the panelists affirmed that it is a useful and interesting exercise and that&#44; to a certain extent&#44; it provides security in decision-making&#44; since it allows ordering&#44; rationalizing and considering&#44; in an explicit and transparent manner&#44; the different criteria involved&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Evaluar el valor de la prestaci&#243;n de servicios de di&#225;lisis concertada frente a la hospitalaria para el tratamiento de la enfermedad renal cr&#243;nica en Espa&#241;a mediante la metodolog&#237;a de an&#225;lisis de decisi&#243;n multicriterio&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todo</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Se utiliz&#243; el marco de evaluaci&#243;n EVIDEM &#40;<span class="elsevierStyleItalic">Evidence and Value&#58; Impact on Decision Making</span>&#41; para el c&#225;lculo del valor estimado de ambos modelos de prestaci&#243;n de la di&#225;lisis &#40;concertada vs&#46; hospitalaria&#41; mediante un taller virtual en el que participaron diferentes perfiles&#58; directivos y gestores&#44; profesionales y responsables de unidades y representantes de pacientes y familiares&#46; Las puntuaciones se combinaron mediante un modelo lineal aditivo&#44; que combin&#243; la ponderaci&#243;n del modelo con la puntuaci&#243;n individual de los criterios&#44; y cada valor se transform&#243; a una escala entre el 0 y 1&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">La estimaci&#243;n del valor para la di&#225;lisis concertada fue de 0&#44;29 &#40;DE&#58; &#177;0&#44;2&#41; y de 0&#44;39 &#40;DE&#58; &#177;0&#44;2&#41; para la di&#225;lisis hospitalaria&#46; Todos los perfiles otorgaron un mayor valor a la hemodi&#225;lisis hospitalaria&#46; El mayor valor para la di&#225;lisis hospitalaria fue de los pacientes &#40;0&#44;44&#41;&#59; el menor valor medio fue de los directivos &#40;0&#44;36&#41; y el rango para la di&#225;lisis concertada estuvo entre los pacientes &#40;0&#44;31&#41; y los cargos intermedios &#40;0&#44;27&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">La hemodi&#225;lisis hospitalaria obtuvo un mayor valor que la di&#225;lisis concertada&#46; En general&#44; los panelistas afirmaron que resulta un ejercicio &#250;til e interesante y que&#44; en cierta medida&#44; aporta seguridad en la toma de decisiones&#44; ya que permite ordenar&#44; racionalizar y considerar&#44; de manera expl&#237;cita y transparente&#44; los diferentes criterios involucrados&#46;</p></span>"
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ISSN: 20132514
Original language: English
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