The hidden role of values in the evaluation of physiotherapy services Maude Laliberté, Université de Montréal 1 August 2013 This commentary responds to an article by Dionne and colleagues  that, in collaboration with the Canadian Physiotherapy Association, shows how to apply the Multi-Criteria Decision Analysis (MCDA) as a framework to develop accurate estimates of the value of specific physiotherapy interventions. The MCDA is a way to evaluate and weight different conflicting criteria in a decision-making process. At first glance, the MCDA seems to be an objective tool as it includes a multitude of criteria (such as the other health effects, the wider societal effects and the nonmonetary costs) in addition to economic efficiency. Physiotherapy services was evaluated using 11 criteria: resource impact, quality of life, patient and provider satisfaction, integration, access, equity, effectiveness, appropriateness, acceptability, implementation challenges and impact on future use of health care services. In the context of an aging population where life expectancy (and therefore the prevalence of chronic diseases) increases, the need for healthcare services for this population is also growing. To maintain effective management of the healthcare system while operating with limited human and financial resources, healthcare organizations need to prioritize some services at the expense of others. The MCDA methodology is thus useful for guiding decision makers in making resource allocation decisions in a period of fiscal restraint, because it allows them to consider criteria other than economic efficiency . However, there are many other factors that are not fully captured (or remain implicit) by the MCDA that can influence the allocation of resources, most notably the values of managers and institutions . Many decisions seem technical and objective when in fact they are biased by a set of values . For example, health can be seen as a reward for social merit (economic success) through a neoliberal perspective or be seen as a right for all, regardless of wealth, from a social democratic point of view . The approach to health will be radically different depending on the core values of the manager or the local organization. Navaro has demonstrated that there is a close relation between political ideology, health policy and health indicators; the distribution of wealth in a society depends closely on societal values, and these can even influence individual life expectancy . Another example is the famous Oregon Health Plan experiment, which attempted to create an ¿objective¿ list of services to be covered by the Oregon state Medicare program. In this case, health conditions were ranked according to their net benefit regarding the effectiveness of the treatment, and then validated through public consultations (Town Hall meetings) so as to reflect both public opinion and the judgment of healthcare professionals. In practice, however, the application of the list by the health administrator had more to do with their values and subjective judgment . Even if the manager of a hospital uses an objective economic analysis framework, the effectiveness of the whole system will be analysed and weighted through their own particular set of values, which may not be evident or transparent . In the MCDA, the 11 criteria have been defined very largely, without being supported by a clear conceptual framework. For example, equity is defined as the impact of physiotherapy on the health status of a group where there is a gap in the provision of service that would be avoidable, unfair and remediable. But does equity refer to a fundamental right based on capabilities or equality of opportunities, or is it rather equality before the law? The application of this concept is relative and dependent on the social values of a given society and for a given context . Dionne and colleagues reported one way that sufficient information could be gathered in order to implement the MCDA, even when there are gaps in the literature. The missing information of ¿objective¿ data on each criterion is based on interviews with 1 to 3 experts , designated by the Canadian Physiotherapy Association. These experts are not described in the article so we do not know either their disciplinary background or their respective ideological positions. Moreover, we can question whether a neutral position can be achieved with a small number of individuals all appointed by the same organization. For example, were these experts recruited in different provinces, according to different positions that can enrich the discussion, or rather were they recruited because they represented the interests of the association? The MCDA is a valuable tool as it considers other criteria than economic efficiency. But underlying the apparent objectivity and neutrality of the method chosen for the evaluation of physiotherapy services, important values remain implicit. To enrich this tool, it is essential to make explicit the values that help define the criteria and guide the expert opinion. Health system managers using the MCDA must also acknowledge their own beliefs and values, because these can have a major influence on their decisions on what and how to allocate resources. References 1. Dionne F, Mitton C, MacDonald T, Miller C, Brennan M: The challenge of obtaining information necessary for multi-criteria decision analysis implementation: the case of physiotherapy services in Canada. Cost Effectiveness and Resource Allocation 2013, 11:11. 2. Donabedian A: Specifying Requirements for Health Care: Social Values. In Aspects of Medical Care Administration. Edited by Havard University Press. Cambridge (Mass.); 1973: 1-30 3. Navarro V, Muntaner C, Borrell C, Benach J, Quiroga A, Rodriguez-Sanz M, Verges N, Pasarin MI: Politics and health outcomes. The Lancet 2006, 368:1033-1037. 4. Oberlander J, Marmor T, Jacobs L: Rationing medical care: rhetoric and reality in the Oregon Health Plan. CMAJ 2001, 164:1583-1587. 5. Contandriopoulos A-P: Inertie et changement. Ruptures, revue transdisciplinaire en santé 2003, 9:4-31. Competing interests Maude Laliberté, PT, MSc, is a PhD student in Bioethics at the University of Montreal (co-supervised by Dr Williams-Jones and Dr Feldman). A practicing physiotherapist and clinical assistant professor in the School of Rehabilitation at the University of Montreal, Ms Laliberté has taught professional ethics to physiotherapists for the past 5 years. Her doctoral research focuses on the distribution of and access to rehabilitation services in connection with third party payers. I wish to acknowledge Bryn Williams-Jones, Paul A. Lamarche and André-Paul Contandriopoulos for their comments and suggestions on this commentary. No competing interests to declare.