Table A3.

Using economics in the context of multi‐criteria decisions

Level	Quotations
Macro	“… the clinical, the economics, the total impact on the budget, and then the ethics framework. So I think all the right pieces are there.”
	“… economic evaluation results […] size of the clinical results and the meaningfulness of them […] population we're treating […] I am biased toward first line treatments […] probably favour the (younger population)…”
	“… how much weight I should put on the economic analysis […] what is the cost per QALY […] are there any other options […]”
	“… the clinical evidence, the economic evidence […] other dimensions […] ethical and feasibility …”
	“… overall benefit, overall cost, is this good value […] from patient care perspective […] from overall public purse […] ethical decisions …”
Meso	Need consistent framework
	“I am a true believer in the power of economic evaluation and explicit decision making. We need to put a number and put a weight on these things to arrive at a fair but more importantly a legitimate and justifiable outcome … we're just looking at disparate pieces of evidence without putting it into that framework. And I choose to put one set of weights on this information, and you choose to put one set of weights on that information, to me, we're not arriving at a fair outcome.”
	“A sort of reproducibility and justifiability and legitimacy, all those things come out of having an explicit decision‐making process as opposed to just a committee of people that meet and make a decision on the basis that no one can quite quantify.”
	“…has to be almost pre‐determined before you can discuss the economics, you have to decide what the parameters are, as we often do it backwards…”
	Lack of budget
	“… we never really have a budget, we just have the impact on the budget. We never say, well, we only have $50 million to spend on chemotherapy … no overall budget for the program”
	“… in this particular decision process, we never see the budget. We actually have no idea. […] I'd rather, if there is a budget […] tell us what it is, give us the tools to work with so we can make our recommendations.”
	“If the budget was defined in black and while, that would be fine … but … in provincial governments and provincial budgets, there are many influences that make that budget very flexible.”
	“We don't usually go into the meetings saying this is the budget you have available.”
	“….there is a budget for oncology drugs in Nova Scotia … I have never talked to the minister about it, but I'm sure there is … at one point I talked to the Deputy about giving us the budget …”
	“… you have to look at the whole budget, and then you have to realize the decisions that you are making have to fall within the budget.”
Micro	“To me, I can't separate out like do I give this 25% weight and adopt it? […] I look at the total picture […] life years gained and the QALYs are just a component […] I also have to consider the strength of the whole analysis […] how much weight you put on those markers is really informed by the whole presentation …”
	“Well, for me because it's so hard to understand the language, so I really look to the presenter to inform me, you know, of basically all the key information […] I trust that she is presenting the information I need to make decisions because I have a difficult time deciphering.”
	“I don't have any budget in there with regards to the economic component so that's also a big piece that is missing …”
	“The budget often gets misused […] it's a small budget, so we don't care what the evaluation side says, we're just going to go ahead with it…”