Do reassessments reduce the uncertainty of decision making? Reviewing reimbursement reports and economic evaluations of three expensive drugs over time

How to Prevent Vaccines Falling Victim to Their Own Success: Intertemporal Dependency of Incidence Levels on Indirect Effects in Economic Reevaluations

OBJECTIVES

Incremental cost-effectiveness analyses may inform the optimal choice of healthcare interventions. Nevertheless, for many vaccines, benefits fluctuate with incidence levels over time. Reevaluating a vaccine after it has successfully decreased incidences may eventually cause a disease resurgence if switching to a vaccine with lower indirect benefits. Decisions may successively alternate between vaccines alongside repeated rises and falls in incidence and when indirect effects from historic use are ignored. Our suggested proposal aims to prevent suboptimal decision making.

METHODS

We used a conceptual model of demand to illustrate alternating decisions between vaccines because of time-varying levels of indirect effects. Similar to the concept of subsidies, we propose internalizing the indirect effects achievable with vaccines. In a case study over 60 years, we simulated a hypothetical 10-year reevaluation of 2 oncogenic human papillomavirus vaccines, of which only 1 protects additionally against anogenital warts.

RESULTS

Our case study showed that the vaccine with additional warts protection is initially valued higher than the vaccine without additional warts protection. After 10 years, this differential decreases because of declines in warts incidence, which supports switching to the nonwarts vaccine that causes a warts resurgence eventually. Instead, pricing the indirect effects separately supports continuing with the warts vaccine.

CONCLUSIONS

Ignoring how the observed incidences depend on the indirect effects achieved with a particular vaccine may lead to repeated changes in vaccines at successive reevaluations, with unintended resurgences, economic inefficiencies, and eroding vaccine confidence. We propose internalizing indirect effects to prevent vaccines falling victim to their own success.

Health-related quality of life using EQ-5D among chronic myeloid leukaemia patients in health centres in Klang Valley, Malaysia

Chronic Myeloid Leukaemia (CML) responds well with the targeted therapy drugs, Tyrosine Kinase Inhibitors (TKI), that give potentially long-term disease control for the patients. The objective of this study was to determine the disease burden and factors influencing the health-related quality of life (HRQoL) and health status of CML patients in Klang Valley, Malaysia. CML patients were recruited from haematological outpatient clinics in health centres in Klang Valley, Malaysia. A semi-guided self-administered questionnaire was used. HRQoL was measured by EQ-5D utility value and health status was by visual analogue score (VAS). Logistic regression analysis was conducted to determine the factors influencing HRQoL and health status. A total of 221 respondents participated, where more than half were Malay (56.6%), male (53.4%), and an Imatinib user (68.8%). Majority were diagnosed at the chronic phase (89.5%). The mean age of diagnosis was 41 years old. Significant determinant associated with HRQoL was age of diagnosis. These factors had no significant effect on the HRQoL of these patients regardless of types of TKI used and initial phase of CML. The overall HRQoL of CML patients were comparable to, if not higher, than the general population. Any TKI that was good enough to eliminate disease symptoms and erase patient's worries, can possibly make CML patients have a better quality of life than typical cancer patients and even the general population.

A Preliminary Study of the Comfort in Patients with Leukemia Staying in a Positive Pressure Isolation Room

Background and Aim: Patients with leukemia who are isolated in positive pressure rooms for infection prevention usually experience significant physical and psychological distress. This study aimed to examine changes in leukemia patients' comfort level during chemotherapy in isolation wards. Methods: A longitudinal survey was conducted with measures which were repeated four times. Data were collected before chemotherapy, on the first and second week after receiving chemotherapy in positive pressure isolation rooms, and on the third week in the non-isolated hematology ward. Each patient received six questionnaires measuring demographic data, comfort status, functional status, fatigue related to cancer therapy, anxiety level, and distress symptoms. A mixed model with repeated measure analysis was used to examine the changing trajectories in physical and psychological health. Results: Twenty-one patients completed the study. During the process, the highest score for comfort level was shown before chemotherapy, and this decreased from the second week under isolation. Anxiety and uncertainty (p < 0.05) declined over time, and emotional states improved during the recovery period in the third and fourth weeks outside isolation. Physical well-being (p < 0.01), cancer-related fatigue (p < 0.05), hemoglobin (p < 0.01) and white blood cell count (p < 0.05) began to rise two weeks after chemotherapy. Conclusion: Comfort levels declined after chemotherapy until the third week of treatment. Anxiety, fatigue and distress symptoms varied across the four time points of chemotherapy from isolation to return to the non-isolated ward. Health care professionals should be aware of psychological symptoms when patients are in isolation rooms, and interventions for promoting a humanized environment, quality of life, and comfort should be considered and provided along with the treatment stages of chemotherapy.

Governance of conditional reimbursement practices in The Netherlands

When entering the market, orphan drugs are associated with substantial prices and a high degree of uncertainty regarding safety and effectiveness. This makes decision making about the reimbursement of these drugs a complex exercise. To advance on this, the Dutch government introduced a conditional reimbursement trajectory that requires a re-evaluation after four years. This article focuses on the origins, governance and outcomes of such a conditional reimbursement trajectory for orphan drugs. We find that the conditional reimbursement scheme is the result of years of discussion and returning public pressure about unequal access to expensive drugs. During the implementation of the scheme the actors involved went through a learning process about the regulation. Our analysis shows that previous collaborations or already existing organisational structures led to faster production of the required data on cost-effectiveness. However, cost-effectiveness evidence resulting from additional research seems to weigh less than political, judicial and ethical considerations in decision making on reimbursement of orphan drugs in The Netherlands.