1
|
Eckhardt H, Felgner S, Dreger M, Fuchs S, Ermann H, Rödiger H, Rombey T, Busse R, Henschke C, Panteli D. Utilization of innovative medical technologies in German inpatient care: does evidence matter? Health Res Policy Syst 2023; 21:100. [PMID: 37784100 PMCID: PMC10546629 DOI: 10.1186/s12961-023-01047-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 08/26/2023] [Indexed: 10/04/2023] Open
Abstract
BACKGROUND The reimbursement of new technologies in inpatient care is not always linked to a requirement for evidence-based evaluation of patient benefit. In Germany, every new technology approved for market was until recently eligible for reimbursement in inpatient care unless explicitly excluded. The aim of this work was (1) to investigate the type of evidence that was available at the time of introduction of 25 innovative technologies and how this evidence evolved over time, and (2) to explore the relationship between clinical evidence and utilization for these technologies in German inpatient care. METHODS This study combined different methods. A systematic search for evidence published between 2003 and 2017 was conducted in four bibliographic databases, clinical trial registries, resources for clinical guidelines, and health technology assessment-databases. Information was also collected on funding mechanisms and safety notices. Utilization was measured by hospital procedures captured in claims data. The body of evidence, funding and safety notices per technology were analyzed descriptively. The relationship between utilization and evidence was explored empirically using a multilevel regression analysis. RESULTS The number of included publications per technology ranges from two to 498. For all technologies, non-comparative studies form the bulk of the evidence. The number of randomized controlled clinical trials per technology ranges from zero to 19. Some technologies were utilized for several years without an adequate evidence base. A relationship between evidence and utilization could be shown for several but not all technologies. CONCLUSIONS This study reveals a mixed picture regarding the evidence available for new technologies, and the relationship between the development of evidence and the use of technologies over time. Although the influence of funding and safety notices requires further investigation, these results re-emphasize the need for strengthening market approval standards and HTA pathways as well as approaches such as coverage with evidence development.
Collapse
Affiliation(s)
- Helene Eckhardt
- Department of Health Care Management, Technische Universität Berlin, Straße Des 17. Juni 135, 10623, Berlin, Germany.
| | - Susanne Felgner
- Department of Health Care Management, Technische Universität Berlin, Straße Des 17. Juni 135, 10623, Berlin, Germany
- Berlin Centre for Health Economics Research (BerlinHECOR), Technische Universität Berlin, Straße Des 17. Juni 135, 10623, Berlin, Germany
| | - Marie Dreger
- Department of Health Care Management, Technische Universität Berlin, Straße Des 17. Juni 135, 10623, Berlin, Germany
- Berlin Centre for Health Economics Research (BerlinHECOR), Technische Universität Berlin, Straße Des 17. Juni 135, 10623, Berlin, Germany
| | - Sabine Fuchs
- Department of Health Care Management, Technische Universität Berlin, Straße Des 17. Juni 135, 10623, Berlin, Germany
| | - Hanna Ermann
- Department of Health Care Management, Technische Universität Berlin, Straße Des 17. Juni 135, 10623, Berlin, Germany
| | - Hendrikje Rödiger
- Department of Health Care Management, Technische Universität Berlin, Straße Des 17. Juni 135, 10623, Berlin, Germany
| | - Tanja Rombey
- Department of Health Care Management, Technische Universität Berlin, Straße Des 17. Juni 135, 10623, Berlin, Germany
| | - Reinhard Busse
- Department of Health Care Management, Technische Universität Berlin, Straße Des 17. Juni 135, 10623, Berlin, Germany
- Berlin Centre for Health Economics Research (BerlinHECOR), Technische Universität Berlin, Straße Des 17. Juni 135, 10623, Berlin, Germany
| | - Cornelia Henschke
- Department of Health Care Management, Technische Universität Berlin, Straße Des 17. Juni 135, 10623, Berlin, Germany
- Berlin Centre for Health Economics Research (BerlinHECOR), Technische Universität Berlin, Straße Des 17. Juni 135, 10623, Berlin, Germany
| | - Dimitra Panteli
- Department of Health Care Management, Technische Universität Berlin, Straße Des 17. Juni 135, 10623, Berlin, Germany
| |
Collapse
|
2
|
Gumbie M, Costa M, Erb M, Dissanayake G. Innovative technologies for reverse total shoulder arthroplasty in Australia: Market access challenges and implications for patients, decision-makers, and manufacturers. JOURNAL OF MARKET ACCESS & HEALTH POLICY 2022; 11:2154420. [PMID: 36506841 PMCID: PMC9731581 DOI: 10.1080/20016689.2022.2154420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 11/24/2022] [Accepted: 11/29/2022] [Indexed: 06/17/2023]
Abstract
PURPOSE The success of reverse total shoulder arthroplasty (RTSA) has expanded its use for a broader range of shoulder indications worldwide. Evidence regarding the relative efficacy and long-term safety of medical technologies used in RTSA is subjected to rigorous assessment. Nonetheless, substantial challenges impede market access for innovative shoulder implant technologies for RTSA in Australia, resulting in delayed patient access. APPROACH This paper addresses the key challenges associated with generating evidence for the health technology assessments of innovative medical technologies for RTSA that are required for access to the Australian market. The transition to value-based care requires establishing a benchmarking reference that incorporates patient-reported outcome measures (PROMs) and combines revision outcomes with additional clinical outcomes to increase patient cohort sizes. Establishing the benchmark would require agreement on the outcome measures to be collected for each indication, and investment in reporting patient-reported outcomes for RTSA to the national orthopaedic registry. IMPLICATIONS FOR PRACTICE The need for increased flexibility in developing evidence for health technology assessment of RTSA medical technologies is required. Optimised approaches for benchmarking RTSA require extensive stakeholder discussions, including the agreement on evidence requirements and follow-up periods, selection of clinical outcomes, as well as pre-operative and post-operative PROMs as a value assessment.
Collapse
Affiliation(s)
- Mutsa Gumbie
- Macquarie University Centre for the Health Economy, Sydney, NSW, Australia
- Johnson & Johnson MedTech, North Ryde, NSW, Australia
| | | | | | - Gnanadarsha Dissanayake
- New South Wales Ministry of Health, St Leonards, NSW, Australia
- School of Mathematics and Statistics, University of Sydney, Sydney, NSW, Australia
- Statistical Society of Australia, Belconnen, NSW, Australia
| |
Collapse
|
3
|
Phillips KA. CMS Coverage With Evidence Development-Challenges and Opportunities for Improvement. JAMA HEALTH FORUM 2022; 3:e223061. [PMID: 36218935 PMCID: PMC9972405 DOI: 10.1001/jamahealthforum.2022.3061] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
This Viewpoint describes the recent Centers for Medicare & Medicaid Services requirement of coverage with evidence development for aducanumab and other Alzheimer disease drugs and considers how this policy tool could be improved.
Collapse
Affiliation(s)
- Kathryn A. Phillips
- UCSF Center for Translational and Policy Research on Precision Medicine (TRANSPERS), Department of Clinical Pharmacy, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| |
Collapse
|
4
|
Drummond M, Federici C, Reckers‐Droog V, Torbica A, Blankart CR, Ciani O, Kaló Z, Kovács S, Brouwer W. Coverage with evidence development for medical devices in Europe: Can practice meet theory? HEALTH ECONOMICS 2022; 31 Suppl 1:179-194. [PMID: 35220644 PMCID: PMC9545598 DOI: 10.1002/hec.4478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 12/26/2021] [Accepted: 01/12/2022] [Indexed: 06/14/2023]
Abstract
Health economists have written extensively on the design and implementation of coverage with evidence development (CED) schemes and have proposed theoretical frameworks based on cost-effectiveness modeling and value of information analysis. CED may aid decision-makers when there is uncertainty about the (cost-)effectiveness of a new health technology at the time of reimbursement. Medical devices are potential candidates for CED schemes, as regulatory regimes do not usually require the same level of efficacy and safety data normally needed for pharmaceuticals. The purpose of this research is to assess whether the actual practice of CED for medical devices in Europe meets the theoretical principles proposed by health economists and whether theory and practice can be more closely aligned. Based on decision-makers' perceptions of the challenges associated with CED schemes, plus examples from the schemes themselves, we discuss a series of proposals for assessing the desirability of schemes, their design, implementation, and evaluation. These proposals, while reflecting the practical challenges with developing CED programs, embody many of the principles suggested by economists and should support decision-makers in dealing with uncertainty about the real-world performance of devices.
Collapse
Affiliation(s)
| | - Carlo Federici
- Centre for Research on Health and Social Care Management (CERGAS)Universitá BocconiMilanItaly
- School of EngineeringUniversity of WarwickCoventryUK
| | - Vivian Reckers‐Droog
- Erasmus School of Health Policy & ManagementErasmus UniversityRotterdamThe Netherlands
| | - Aleksandra Torbica
- Centre for Research on Health and Social Care Management (CERGAS)Universitá BocconiMilanItaly
| | - Carl Rudolf Blankart
- Kompetenzzentrum für Public ManagementUniversität BernBernSwitzerland
- Swiss Institute for Translational and Entrepreneurial MedicineBernSwitzerland
| | - Oriana Ciani
- Centre for Research on Health and Social Care Management (CERGAS)Universitá BocconiMilanItaly
| | - Zoltán Kaló
- Syreon Research InstituteBudapestHungary
- Centre for Health Technology AssessmentSemmelweis UniversityBudapestHungary
| | | | - Werner Brouwer
- Erasmus School of Health Policy & ManagementErasmus UniversityRotterdamThe Netherlands
- Erasmus School of EconomicsErasmus University RotterdamRotterdamThe Netherlands
| |
Collapse
|
5
|
Kovács S, Kaló Z, Daubner‐Bendes R, Kolasa K, Hren R, Tesar T, Reckers‐Droog V, Brouwer W, Federici C, Drummond M, Zemplényi AT. Implementation of coverage with evidence development schemes for medical devices: A decision tool for late technology adopter countries. HEALTH ECONOMICS 2022; 31 Suppl 1:195-206. [PMID: 35322478 PMCID: PMC9543994 DOI: 10.1002/hec.4504] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 02/26/2022] [Accepted: 02/28/2022] [Indexed: 06/14/2023]
Abstract
Experiences with coverage with evidence development (CED) schemes are fairly limited in Central and Eastern European (CEE) countries, which are usually late adopters of new health technologies. Our aim was to put forward recommendations on how CEE health technology assessment bodies and payer organizations can apply CED to reduce decision uncertainty on reimbursement of medical devices, with a particular focus on transferring the structure and data from CED schemes in early technology adopter countries in Western Europe. Structured interviews on the practices and feasibility of transferring CED schemes were conducted and subsequently, a draft tool for the systematic classification of decision alternatives and recommendations was developed. The decision tool was reviewed in a focus group discussion and validated within a wider group of CEE experts in a virtual workshop. Transferability assessment is needed in case of (1) joint implementation of a CED scheme; (2) transferring the structure of an existing CED scheme to a CEE country; (3) reimbursement decisions that are linked to outcomes of an ongoing CED scheme in another country and (4) real-world evidence transferred from completed CED schemes. Efficient use of available resources may be improved by adequately transferring evidence and policy tools from early technology adopter countries.
Collapse
Affiliation(s)
- Sandor Kovács
- Syreon Research InstituteBudapestHungary
- Center for Health Technology Assessment and Pharmacoeconomic ResearchFaculty of PharmacyUniversity of PécsPécsHungary
| | - Zoltán Kaló
- Syreon Research InstituteBudapestHungary
- Centre for Health Technology AssessmentSemmelweis UniversityBudapestHungary
| | | | - Katarzyna Kolasa
- Division of Health Economics and Healthcare ManagementKozminski UniversityWarsawPoland
| | - Rok Hren
- Institute of Mathematics, Physics, and MechanicsLjubljanaSlovenia
| | - Tomas Tesar
- Department of Organisation and Management of PharmacyFaculty of PharmacyComenius University in BratislavaBratislavaSlovakia
| | - Vivian Reckers‐Droog
- Erasmus School of Health Policy and ManagementErasmus University RotterdamRotterdamThe Netherlands
| | - Werner Brouwer
- Erasmus School of Health Policy and ManagementErasmus University RotterdamRotterdamThe Netherlands
- Erasmus School of EconomicsErasmus University RotterdamRotterdamThe Netherlands
| | - Carlo Federici
- Centre for Research on Health and Social Care Management (CERGAS)SDA Bocconi School of ManagementMilanItaly
- School of EngineeringWarwick UniversityCoventryUK
| | | | - Antal Tamás Zemplényi
- Syreon Research InstituteBudapestHungary
- Center for Health Technology Assessment and Pharmacoeconomic ResearchFaculty of PharmacyUniversity of PécsPécsHungary
| |
Collapse
|
6
|
Federici C, Pecchia L. Exploring the misalignment on the value of further research between payers and manufacturers. A case study on a novel total artificial heart. HEALTH ECONOMICS 2022; 31 Suppl 1:98-115. [PMID: 35460307 PMCID: PMC9546170 DOI: 10.1002/hec.4520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 03/09/2022] [Accepted: 03/29/2022] [Indexed: 06/14/2023]
Abstract
Payers and manufacturers can disagree on the appropriate level of evidence that is required for new medical devices, resulting in high societal costs due to decisions taken with sub-optimal information. A cost-effectiveness model of a hypothetical total artificial heart was built using data from the literature and the (simulated) results of a pivotal study. The expected value of perfect information (EVPI) was calculated from both the payer and manufacturer perspectives, using net monetary benefit and the company's return on investment respectively. A function was also defined, linking effectiveness to market shares. Additional constraints such as a minimum clinical difference or maximum budget impact were introduced into the company's decisions to simulate additional barriers to adoption. The difference in the EVPI between manufacturers and payers varied greatly depending on the underlying decision rules and constraints. The manufacturer's EVPI depends on the probability of being reimbursed, the uncertainty on the (cost-)effectiveness of the technology, as well as other parameters relating to initial investments, operating costs and market dynamics. The use of Value of information for both perspectives can outline potential misalignments and can be particularly useful to inform early dialogs between manufacturers and payers, or negotiations on conditional reimbursement schemes.
Collapse
Affiliation(s)
- Carlo Federici
- SDA Bocconi School of ManagementCentre for Research on Health and Social Care Management (CERGAS)MilanItaly
- School of EngineeringUniversity of WarwickCoventryUK
| | | |
Collapse
|
7
|
Drummond M, Tarricone R, Torbica A. European union regulation of health technology assessment: what is required for it to succeed? THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2022; 23:913-915. [PMID: 35348920 DOI: 10.1007/s10198-022-01458-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/09/2022] [Indexed: 06/14/2023]
Affiliation(s)
| | - Rosanna Tarricone
- CERGAS, SDA Bocconi School of Management, Milan, Italy
- Department of Social and Political Science, Bocconi University, Milan, Italy
| | - Aleksandra Torbica
- CERGAS, SDA Bocconi School of Management, Milan, Italy
- Department of Social and Political Science, Bocconi University, Milan, Italy
| |
Collapse
|
8
|
Boriani G, Vitolo M, Svennberg E, Casado-Arroyo R, Merino JL, Leclercq C. Performance-based risk-sharing arrangements for devices and procedures in cardiac electrophysiology: an innovative perspective. Europace 2022; 24:1541-1547. [PMID: 35531864 DOI: 10.1093/europace/euac045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 03/15/2022] [Indexed: 11/14/2022] Open
Abstract
There is an increasing pressure on demonstrating the value of medical interventions and medical technologies resulting in the proposal of new approaches for implementation in the daily practice of innovative treatments that might carry a substantial cost. While originally mainly adopted by pharmaceutical companies, in recent years medical technology companies have initiated novel value-based arrangements for using medical devices, in the form of 'outcomes-based contracts', 'performance-based contracts', or 'risk-sharing agreements'. These are all characterized by linking coverage, reimbursement, or payment for the innovative treatment to the attainment of pre-specified clinical outcomes. Risk-sharing agreements have been promoted also in the field of electrophysiology and offer the possibility to demonstrate the value of specific innovative technologies proposed in this rapidly advancing field, while relieving hospitals from taking on the whole financial risk themselves. Physicians deeply involved in the field of devices and technologies for arrhythmia management and invasive electrophysiology need to be prepared for involvement as stakeholders. This may imply engagement in the evaluation of risk-sharing agreements and specifically, in the process of assessment of technology performances or patient outcomes. Scientific Associations may have an important role in promoting the basis for value-based assessments, in promoting educational initiatives to help assess the determinants of the learning curve for innovative treatments, and in promoting large-scale registries for a precise assessment of patient outcomes and of specific technologies' performance.
Collapse
Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.,EHRA mHEALTH and Health Economics Section, European Heart Rhythm Association, Biot, France
| | - Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy.,Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Emma Svennberg
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Ruben Casado-Arroyo
- Department of Cardiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Josè L Merino
- Arrhythmia & Robotic EP Unit, University Hospital La Paz, Autonoma University, IdiPaz, Clinica Viamed-Santa Elena, Madrid, Spain
| | | |
Collapse
|
9
|
Hill H, Mittal R, Merlin T. Evidence-based funding of new imaging applications and technologies by Medicare in Australia: How it happens and how it can be improved. J Med Imaging Radiat Oncol 2022; 66:215-224. [PMID: 35243777 PMCID: PMC9310840 DOI: 10.1111/1754-9485.13386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 01/26/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Medical Services Advisory Committee (MSAC) is responsible for the assessment of medical imaging tests proposed for public funding. A number of factors related to the clinical or cost effectiveness of an imaging service may impact on the funding decision. OBJECTIVE To determine what evidentiary and economic factors impact most on MSAC recommendations for the funding of imaging tests. METHODS Information was extracted on health technology assessments (HTAs) of medical imaging tests published on the MSAC website, with a funding decision between 2006 to July 2021. Imaging tests with diagnostic, staging or screening indications were eligible. Data were extracted in test-indication pairs and included data on evidence quality, quantity, consistency of findings, cost-effectiveness and financial impact. Multivariate logistic regression analysis was performed with adjustments for clustered data. RESULTS Overall, 42 imaging test applications to MSAC were included, representing 91 clinical indications. Most were diagnostic tests. The most common evidentiary concerns reported by MSAC were limited evidence (36%), low quality evidence (26%), and applicability of the data (22%). The reference standard for diagnostic accuracy was imperfect or not appropriate in 25% of the indications. In regression analyses, uncertainty about cost-effectiveness of an imaging service predicted most negative funding decisions. CONCLUSIONS The single biggest contributor to a negative funding decision by MSAC was uncertainty about the cost-effectiveness of the imaging service. This was likely driven by uncertainty regarding the impact on patient health. HTAs that are able to demonstrate the clinical utility of a new imaging service are more likely to publicly funded.
Collapse
Affiliation(s)
- Hayley Hill
- Adelaide Health Technology Assessment (AHTA), School of Public Health, University of Adelaide, Adelaide, South Australia, Australia
| | - Ruchi Mittal
- Adelaide Health Technology Assessment (AHTA), School of Public Health, University of Adelaide, Adelaide, South Australia, Australia
| | - Tracy Merlin
- Adelaide Health Technology Assessment (AHTA), School of Public Health, University of Adelaide, Adelaide, South Australia, Australia
| |
Collapse
|
10
|
Federici C, Pecchia L. Early health technology assessment using the MAFEIP tool. A case study on a wearable device for fall prediction in elderly patients. HEALTH AND TECHNOLOGY 2021. [DOI: 10.1007/s12553-021-00580-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AbstractBy using a case-study on a fall-prediction device for elderly patients with orthostatic hypotension we aim to demonstrate how the MAFEIP tool, developed as part of the European Innovation Programme on Active and Healthy Ageing (EIP on AHA), can be used to inform manufacturers on their product development based on a cost-effectiveness criterion. Secondly, we critically appraise the tool and suggest further improvements that may be needed for a larger-scale adoption of MAFEIP within and beside the EIP on AHA initiative. The model was implemented using the MAFEIP tool. Within the tool one way sensitivity analyses were performed to assess the robustness of the model against the relative effectiveness of the fall-prevention device at different price levels. The MAFEIP tool was applied to a novel fall-prediction device and used to estimate the expected cost-effectiveness and perform threshold analysis. In our case study, the device produced estimated gains of 0.035 QALYs per patient and incremental costs of £ 518 (incremental cost-effectiveness ratio £14,719). Based on the one-way sensitivity analysis, the maximum achievable price at a willingness to pay threshold of £20,000 per QALY is estimated close to £900. The MAFEIP allows to quickly create early economic models, and to explore model uncertainty by performing deterministic sensitivity analysis for single parameters. However, the integration within the MAFEIP of common analytical tools such as probabilistic sensitivity analysis and Value of information would greatly contribute to its relevance for evaluating innovative technologies within and beside the EIP on AHA initiative.
Collapse
|