HTA methodology and value frameworks for evaluation and policy making for cell and gene therapies

This last decade has been marked by significant advances in the development of cell and gene (C&G) therapies, such as gene targeting or stem cell-based therapies. C&G therapies offer transformative benefits to patients but present a challenge to current health technology decision-making systems because they are typically reviewed when clinical efficacy data are very limited and when there is uncertainty about the long-term durability of outcomes. These challenges are not unique to C&G therapies, but they face more of these barriers, reflecting the need for adapting existing value assessment frameworks. Still, C&G therapies have the potential to be cost-effective even at very high price points. The impact on healthcare budgets will depend on the success rate of pipeline assets and on the extent to which C&G therapies will expand to wider pathologies beyond rare or ultra-rare diseases. Getting pricing and reimbursement models right is important for incentivising research and development investment while not jeopardising the sustainability of healthcare systems. Payers and manufacturers therefore need to acknowledge each other's constraints-limitations in the evidence generation on the manufacturer side, budget considerations on the payer side-and embrace innovative thinking and approaches to ensure timely delivery of therapies to patients. Several experts in health technology assessment and clinical experts have worked together to produce this publication and identify methodological and policy options to improve the assessment of C&G therapies, and make it happen better, faster and sustainably in the coming years.

Fuzzy fractional-order model of the novel coronavirus

In this paper, a novel coronavirus infection system with a fuzzy fractional differential equation defined in Caputo's sense is developed. By using the fuzzy Laplace method coupled with Adomian decomposition transform, numerical results are obtained for better understanding of the dynamical structures of the physical behavior of COVID-19. Such behavior on the general properties of RNA in COVID-19 is also investigated for the governing model. The results demonstrate the efficiency of the proposed approach to address the uncertainty condition in the pandemic situation.

International Valuation Protocol for the EQ-5D-Y-3L

The EQ-5D-Y-3L is a generic, health-related, quality-of-life instrument for use in younger populations. Some methodological studies have explored the valuation of children's EQ-5D-Y-3L health states. There are currently no published value sets available for the EQ-5D-Y-3L that are appropriate for use in a cost-utility analysis. The aim of this article was to describe the development of the valuation protocol for the EQ-5D-Y-3L instrument. There were several research questions that needed to be answered to develop a valuation protocol for EQ-5D-Y-3L health states. Most important of these were: (1) Do we need to obtain separate values for the EQ-5D-Y-3L, or can we use the ones from the EQ-5D-3L? (2) Whose values should we elicit: children or adults? (3) Which valuation methods should be used to obtain values for child's health states that are anchored in Full health = 1 and Dead = 0? The EuroQol Research Foundation has pursued a research programme to provide insight into these questions. In this article, we summarized the results of the research programme concluding with the description of the features of the EQ-5D-Y-3L valuation protocol. The tasks included in the protocol for valuing EQ-5D-Y-3L health states are discrete choice experiments for obtaining the relative importance of dimensions/levels and composite time-trade-off for anchoring the discrete choice experiment values on 1 = Full Health and 0 = Dead. This protocol is now available for use by research teams to generate EQ-5D-Y-3L value sets for their countries allowing the implementation of a cost-utility analysis for younger populations.

Using EQ-5D Data to Measure Hospital Performance: Are General Population Values Distorting Patients' Choices?

Background. The English National Health Service publishes hospital performance indicators based on average postoperative EQ-5D index scores after hip replacement surgery to inform prospective patients' choices of hospital. Unidimensional index scores are derived from multidimensional health-related quality-of-life data using preference weights estimated from a sample of the UK general population. This raises normative concerns if general population preferences differ from those of the patients who are to be informed. This study explores how the source of valuation affects hospital performance estimates. Methods. Four different value sets reflecting source of valuation (general population v. patients), valuation technique (visual analog scale [VAS] v. time tradeoff [TTO]), and experience with health states (currently experienced vs. experimentally estimated) were used to derive and compare performance estimates for 243 hospitals. Two value sets were newly estimated from EQ-5D-3L data on 122,921 hip replacement patients and 3381 members of the UK general public. Changes in hospital ranking (nationally) and performance outlier status (nationally; among patients' 5 closest hospitals) were compared across valuations. Results. National rankings were stable under different valuations (rank correlations >0.92). Twenty-three (9.5%) hospitals changed outlier status when using patient VAS valuations instead of general population TTO valuations, the current approach. Outlier status also changed substantially at the local level. This was explained mostly by the valuation technique, not the source of valuations or experience with the health states. Limitations. No patient TTO valuations were available. The effect of value set characteristics could be established only through indirect comparisons. Conclusion. Different value sets may lead to prospective patients choosing different hospitals. Normative concerns about the use of general population valuations are not supported by empirical evidence based on VAS valuations.

Do people with private health insurance attach a higher value to health than those without insurance? Results from an EQ-5D-5 L valuation study in Ireland

BACKGROUND

Differences in healthcare use could relate to differences in the values assigned health as well as to differences in access. We sought to establish whether there existed evidence of differences in values assigned health states between individuals with and without insurance in Ireland.

METHODS

Using the EuroQol Valuation Technology (EQ-VT), EQ-5D-5 L valuation tasks were administered to a sample of 1160 residents of Ireland in 2015/16. Censored panel regression analyses were used to estimate the values assigned health states. Private insurance was entered among a range of covariates to explain health preferences as a binary variable. A range of confirmatory analyses were undertaken.

RESULTS

In the primary analysis, possession of private health insurance was not a significant determinant of health preferences. Across a range of confirmatory analyses limited evidence of any difference in values related to health insurance emerged.

CONCLUSIONS

Insurance status has been shown to be a significant determinant of healthcare utilization in Ireland after need has been controlled for. Our analysis provides no compelling evidence that meaningful differences exist in the values accorded health between those with and without health insurance.

0869 Slow Wave Sleep Is Associated With Decreased Risk Of Gestational Diabetes Mellitus

Introduction

Pregnancy is associated with disrupted slow-wave sleep (SWS) and a high prevalence of sleep disordered breathing (SDB), which may further exacerbate the decrease of deep sleep. Reduced slow wave sleep may impair glucose homeostasis, contributing to Gestational Diabetes Mellitus (GDM). Studies investigating EEG markers of deep and light sleep, and their associations with SDB and GDM are lacking. In this study, we measured associations of EEG Delta-power with objective SDB measures assessed in late-pregnancy to determine if changes in these bands are associated with GDM risk.

Methods

74 women (24-36 weeks pregnancy) underwent overnight polysomnography. Spectral profiles for Delta relative power were created for NREM and REM sleep after removing epochs with movements or muscle artifacts. The association of Delta power with SDB, assessed by the Apnea Hypopnea-Index (AHI) and AHI-based SDB severity (none, mild, moderate, severe) was tested by multivariate linear regression including demographic variables with bivariate correlations (p<0.2) versus Delta-power. Conditional-regression was used to explore relationships between Delta-power and GDM, controlling for covariates.

Results

Obstructive Sleep Apnea (OSA, AHI>5) was present in 14% of subjects (8 GDM-cases and 3 controls). In bivariate analyses, AHI, AHI-severity categories and OSA were associated with Delta-power in NREM (all p<0.2) and AHI was associated with Delta relative-power in REM (p=0.18). However, these associations did not remain significant after adjusting for covariates. Delta relative-power in NREM was significantly associated with decreased risk of GDM (OR:0.50, 95%CI-0.25,0.91), but, in REM sleep, was not associated with GDM risk (OR:1.25, 95%CI-0.79,1.97).

Conclusion

These analyses failed to demonstrate an association between OSA or OSA severity and EEG Delta power. However, lower levels of SWS, characterized by low Delta power were associated with increased GDM risk.

Support

NIH-R00-NR013187

The EQ-5D-5L Value Set for England: Response to the "Quality Assurance"

OBJECTIVES

To respond to the 'quality assurance' of the EQ-5D-5L value set for England study.

METHODS

We provide a point-by-point response to the issues raised by the authors of the quality assurance paper, drawing on theoretical arguments, empirical analyses and practical considerations.

RESULTS

We provide evidence to show that many of the points made by the authors of the quality assurance are misleading, suggest misunderstandings, or are irrelevant.

CONCLUSIONS

The modeling approaches which were used appropriately address the characteristics of the data and provide a reasonable representation of the average stated preferences of general public in England. We provide reflections on the conduct of stated preference studies, and suggestions for the way forward.

62 Geriatric Surgical Liaison Staff Perspectives of Geriatric Care Before and After Introduction of An Embedded Service

Introduction

National evidence demonstrates that older people having surgery, both in the elective and emergency setting, have more adverse outcomes postoperatively when compared with their younger counterparts (1). National reports have recommended daily input from a geriatric team for older patients having surgery (2). At our hospital we have introduced a geriatric surgical liaison consultant as a formal post to ensure daily geriatric input or review for patients over the age of 70 or comorbid younger patients as requested. The aim of this study was to review perspectives across the multi-disciplinary team on care provided to these patients before and after introduction of the surgical liaison team.

Methods

We created a 10 part questionnaire, which was distributed amongst all members of the multi-disciplinary team, asking them to rate confidence out of 10 in management of comorbidity, polypharmacy, discharge planning, pain assessments and nutrition. These data were then analysed to produce median scores for each category before and after the introduction of the service. We compared the change in scores between the foundation year 1 (FY1) doctors and the remainder of the respondents.

Results

The below table demonstrates the median scores across all 36 respondents in their confidence with the assessment and management of the 10 key domains before and after the liaison service was introduced:

Conclusions

Universally within our survey, staff reported improvement in all 10 key indicators of care of older patients on surgery with the introduction of a geriatric surgical liaison team. Greatest benefit was seen within the FY1 group.

References

1. McVeigh TP, Al-Azawi D, O'Donoghue GT, Kerin MJ. Assessing the impact of an ageing population on complication rates and in-patient length of stay, Int J Surg, 2013, vol. 11 (pg. 872–5).

2. Wilkinson K. An age old Problem: A Review of the Care Received by Elderly Patients Undergoing Surgery: A Report by the National Confidential Enquiry Into Patient Outcome and Death. London, 2010.

Influence of pyrolysis parameters on phosphorus fractions of biosolids derived biochar

Transforming biosolids into biochar, through pyrolysis, could result in more sustainable waste management. Influence of pyrolysis conditions (temperature, heating rate and residence time) on physico-chemical properties of biosolids (collected at Mount Martha Water Recycling Plant, Melbourne), phosphorus fractions and phosphorus forms was investigated. Twelve different biochar samples were produced at 400, 500 and 600 °C, at two heating rates (5 and 20 °C/min) and at two residence times (30 and 120 min). Biochar yield, pH, electrical conductivity (EC), elements (C, H and N) and BET surface area were analysed. Sequential extraction of P in biosolids and resultant biochars was done using Hedley method. Characterization was completed with SEM images and results from ³¹P liquid state NMR. Increased temperatures would not only increase the alkalinity, decrease EC and increase the adsorption capacity by increasing the surface area but also convert the readily available P to a less available pool. Therefore, this nutrient might be released to soil slowly over a longer period of time. The results showed that temperature, along with residence time and heating rate, had a significant effect on the characteristics observed. Therefore, all these factors need to be carefully considered when preparing biochar for use as a soil amendment.

Woodhouse-Sakati syndrome in a family is associated with a homozygous start loss mutation in the DCAF17 gene

BACKGROUND

Woodhouse-Sakati syndrome (WSS) is a rare neuroendocrine and ectodermal disorder inherited in an autosomal recessive pattern. The syndrome presents prominent clinical features, including alopecia, neuroendocrine defects, neurological findings and progressive hearing loss. The condition results from mutations in the DCAF17 gene.

AIMS

To search for the underlying genetic defect in a Pakistani family with WSS phenotypes.

METHODOLOGY

Whole exome sequencing was used to search for the disease-causing variant.

RESULTS

Analysis of the exome data revealed a start loss sequence variant (c.1A>G, p.M1?) in DCAF17.

CONCLUSION

This variant is predicted to abolish translation of the DCAF17 polypeptide. To our knowledge, this is the first start loss variant identified in the DCAF17.

The applicability of the Demirjian, Willems and Chaillet standards to age estimation of 5-15 year old Indian children

BACKGROUND

Demirjian's method of age estimation has been reported to overestimate age and Willems' method to give consistently more accurate results. Not enough, however, is known about the applicability of Chaillet's standards.

AIM

The present study aimed to compare the accuracy of Demirjian's, Willems' and Chaillet's standards in age estimation of 5 to 15 year-old Indian children.

DESIGN

In this cross-sectional observational study, three methods were compared for accuracy in estimating the age of 1200 Indian children aged 5-15 years.

RESULTS

Demirjian's method overestimated age by +0.24 ± 0.80 years, +0.11 ± 0.81years and +0.19 ± 0.80 years in boys, girls and the total sample, respectively. With Willems' method, overestimations of +0.09 ± 0.80 years, +0.08 ± 0.80 years and +0.09 ± 0.80 years were obtained in boys, girls and the total sample, respectively. Chaillet's method underestimated age by -0.12 ± 0.69 years, -0.45 ± 0.88 years and -0.25 ± 0.83 years in boys, girls and the total sample, respectively. Statistically significant differences were observed between dental and chronological ages with all methods (p < 0.001). Significant sex-based differences were observed only with Demirjian's and Chaillet's methods (p < 0.05).

CONCLUSION

Willems' method was the most accurate in age estimation, followed by Demirjian's and Chaillet's methods. While Demirjian's method was more accurate than Chaillet's in females, Chaillet's method better predicted the age of males.

The value of international volunteers experience to the NHS

Background

Global Engagement works with health partnerships to establish workforce and educational translation on a global scale to support the National Health Service (NHS). There is growing evidence on how international experiences (through volunteering, exchanges and placements) benefit the NHS through an innovative workforce that develops international best practice and promotes lifelong learning. Most of this evidence has been captured though surveys to returned international volunteers. However, there is limited evidence about how to quantify the value that returned international healthcare volunteers bring back to their country of residence.

Methods

This paper identifies the various benefits to the NHS from returned international healthcare volunteers. The outcomes from returned international volunteers, which have been identified as relevant form a NHS perspective, are linked to three key areas in a multisector analytical framework used by the World Bank to evaluate labour market programmes: (1) Investment climate and Infrastructure, (2) Labor market regulations and institutions, and (3) Education and skills development. The monetary value of these outcomes is quantified through productivity indices which capture the economic value that the achievement of these outcomes have on the quality of the NHS labor force. This model is applied to a dataset of international volunteers provided by the Global Engagement health partnerships.

Results

The results suggest that international volunteering generates average productivity gains of up to 37% for doctors and up to 62% for nurses. Average productivity gains estimated from health partnerships data vary depending on duration of volunteering periods and occupational category mix.

Conclusions

Our analysis offers a value for money rationale for international volunteering programmes purely from a domestic and NHS perspective. The valuation method considers only one of the aims of international volunteering programmes: the development of the existing and future NHS workforce. Broader benefits for health system strengthening at a global level are acknowledged but not accounted for. Overall, we conclude that if the acquisition of volunteering outcomes is realised, the NHS can accrue a productivity increase of between 24 and 41% per volunteer, with a value ranging from £13,215 to £25,934 per volunteer.

Electronic supplementary material

The online version of this article (10.1186/s12992-019-0473-y) contains supplementary material, which is available to authorized users.