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Szamreta EA, Monberg MJ, Desai KD, Li Y, Othus M. Prognosis and conditional survival among women with newly diagnosed ovarian cancer. Gynecol Oncol 2024; 180:170-177. [PMID: 38211405 DOI: 10.1016/j.ygyno.2023.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 10/31/2023] [Accepted: 11/16/2023] [Indexed: 01/13/2024]
Abstract
OBJECTIVE An important question in determining long-term prognosis for women with ovarian cancer is whether risk of death changes the longer a woman lives. Large real-world datasets permit assessment of conditional survival (CS) given both prior overall survival (OS) and real-world progression-free survival (rwPFS). METHODS Using a longitudinal dataset from US oncology centers, this study included 6778 women with ovarian cancer. We calculated CS rates as the Kaplan-Meier probability of surviving an additional 1 or 5 years, given no mortality (OS) or disease progression (rwPFS) event in the previous 0.5-5 years since first-line chemotherapy initiation, adjusted for factors associated with OS based on multivariable Cox regression. RESULTS Median study follow-up was 9 years (range, 1-44) from first-line initiation to data cutoff (17-Feb-2021). Median OS was 58.0 months (95% CI, 54.9-60.8); median rwPFS was 18.4 months (17.4-19.4). The adjusted 1-year CS rate (ie, rate of 1 year additional survival) did not vary based on time alive, whereas the adjusted 5-year CS rate increased from 48.5% (47.0%-50.1%) for women who had already survived 6 months to 66.4% (63.3%-69.6%) for those already surviving 5 years (thus surviving 10 years total). The adjusted 1-year CS rate increased from 90.4% (89.5%-91.4%) with no rwPFS event at 6 months to 97.6% (96.4%-98.8%) with no rwPFS event at 5 years; adjusted 5-year CS rate increased from 53.7% (52.0%-55.5%) to 85.0% (81.2%-88.9%), respectively. CONCLUSIONS This analysis extends the concept of CS by also conditioning on time progression-free. Patients with longer rwPFS experience longer survival than patients with shorter rwPFS.
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Affiliation(s)
- Elizabeth A Szamreta
- Center for Observational & Real-World Evidence (CORE), Merck & Co., Inc., 126 East Lincoln Avenue, Rahway, NJ 07065, USA.
| | - Matthew J Monberg
- Center for Observational & Real-World Evidence (CORE), Merck & Co., Inc., 126 East Lincoln Avenue, Rahway, NJ 07065, USA.
| | - Kaushal D Desai
- Center for Observational & Real-World Evidence (CORE), Merck & Co., Inc., 126 East Lincoln Avenue, Rahway, NJ 07065, USA.
| | - Yeran Li
- Center for Observational & Real-World Evidence (CORE), Merck & Co., Inc., 126 East Lincoln Avenue, Rahway, NJ 07065, USA.
| | - Megan Othus
- Fred Hutchinson Cancer Center, 1100 Fairview Ave N, Seattle, WA 98109, USA.
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Julian E, Pavlovic M, Sola-Morales O, Gianfrate F, Toumi M, Bucher HC, Dierks C, Greiner W, Mol P, Bergmann JF, Salmonson T, Hebborn A, Grande M, Cardone A, Ruof J. Shaping a research agenda to ensure a successful European health technology assessment: insights generated during the inaugural convention of the European access academy. HEALTH ECONOMICS REVIEW 2022; 12:54. [PMID: 36333433 PMCID: PMC9636785 DOI: 10.1186/s13561-022-00402-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 10/18/2022] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Key challenges for a joint European Health Technology Assessment (HTA) include consolidated approaches towards the choice of adequate comparator(s), selection of endpoints that are relevant to patients with a given disease, dealing with remaining uncertainties as well as transparent and consistent management of related processes. We aimed to further crystallize related core domains within these four areas that warrant further research and scrutiny. METHODS Building on the outcomes of a previously conducted questionnaire survey, four key areas, processes, uncertainty, comparator choice and endpoint selection, were identified. At the inaugural convention of the European Access Academy dedicated working groups were established defining and prioritizing core domains for each of the four areas. The working groups consisted of ~ 10 participants each, representing all relevant stakeholder groups (patients/ clinicians/ regulators/ HTA & payers/ academia/ industry). Story books identifying the work assignments were shared in advance. Two leads and one note taker per working group facilitated the process. All rankings were conducted on an ordinal Likert Response Scale scoring from 1 (low priority) to 7 (high priority). RESULTS Identified key domains include for processes: i) address (resource-) challenge of multiple PICOs (Patient/ Intervention/ Comparator/ Outcomes), ii) time and capacity challenges, iii) integrating all involved stakeholders, iv) conflicts and aligning between different multi-national stakeholders, v) interaction with health technology developer; for uncertainty: i) early and inclusive collaboration, ii) agreement on feasibility of RCT and acceptance of uncertainty, iii) alignment on closing evidence gaps, iv) capacity gaps; for comparator choice: i) criteria for the choice of comparator in an increasingly fragmented treatment landscape, ii) reasonable number of comparators in PICOs, iii) shape Early Advice so that comparator fulfils both regulatory and HTA needs, iv) acceptability of Indirect Treatment Comparisons (ITC), v) ensure broad stakeholder involvement in comparator selection; for endpoint selection: i) approaching new endpoints; ii) patient preferences on endpoints; iii) position of HTA and other stakeholders; iv) long-term generation and secondary use of data; v) endpoint challenges in RCTs. CONCLUSIONS The implementation of a joint European HTA assessment is a unique opportunity for a stronger European Health Union. We identified 19 domains related to the four key areas, processes, uncertainty, comparator choice and endpoint selection that urgently need to be addressed for this regulation to become a success.
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Affiliation(s)
| | - Mira Pavlovic
- Medicines Development and Training (MDT) Services, Paris, France
| | | | | | - Mondher Toumi
- Faculty of Medicine, Public Health Department, Aix-Marseille University, Marseille, France
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics (CEB), University Hospital Basel and University of Basel, Basel, Switzerland
| | | | - Wolfgang Greiner
- School of Public Health, Bielefeld University, Bielefeld, Germany
| | - Peter Mol
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | | | | | | | | | - Jörg Ruof
- R-Connect Ltd, Basel, Switzerland.
- Medical School of Hanover, Hanover, Germany.
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Lux MP, Ciani O, Dunlop WCN, Ferris A, Friedlander M. The Impasse on Overall Survival in Oncology Reimbursement Decision-Making: How Can We Resolve This? Cancer Manag Res 2021; 13:8457-8471. [PMID: 34795526 PMCID: PMC8592394 DOI: 10.2147/cmar.s328058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/27/2021] [Indexed: 11/23/2022] Open
Abstract
Mature overall survival (OS) data are often unavailable at the time of regulatory and reimbursement decisions for a new cancer treatment. For patients with early-stage cancers treated with potentially curative treatments, demonstrating an OS benefit may take years and may be confounded by subsequent lines of therapy or crossover to the investigational treatment. For patients with advanced-stage cancers, mature OS data may be available but difficult to interpret for similar reasons. There are strong opinions about approval and reimbursement in the absence of mature OS data, with concerns over delay in patient access set against concerns about uncertainty in long-term benefit. This position paper reflects our individual views as patient advocate, clinician or health economist on one aspect of this debate. We look at payer decisions in the absence of mature OS data, considering when and how non-OS trial outcomes could inform decision-making and how uncertainty can be addressed beyond the trial, supporting these views with evidence from the literature. We consider when it is reasonable for payers to expect or not expect mature OS data at the initial reimbursement decision (based on criteria such as cancer stage and treatment efficacy) acknowledging that there are settings in which mature OS data are expected. We propose flexible strategies for generating and appraising patient-relevant evidence, including context-relevant endpoints and quality of life measures, when survival rates are good and mature OS data are not expected. We note that fair reimbursement is important; this means valuing patient benefit as shown through prespecified endpoints and reappraising if there is ongoing uncertainty or failure to show a sustained benefit. We suggest that reimbursement systems continue to evolve to align with scientific advances, because innovation is only meaningful if readily accessible to patients. The proposed strategies have the potential to promote thorough assessment of potential benefit to patients and lead to timely access to effective medicines.
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Affiliation(s)
- Michael Patrick Lux
- Department of Gynecology and Obstetrics, Frauenklinik St. Louise Paderborn, St. Josefs-Krankenhaus Salzkotten, Frauen- und Kinderklinik St. Louise Paderborn, Paderborn, Germany
| | - Oriana Ciani
- Centre for Research on Health and Social Care Management, SDA Bocconi, Milan, Italy
| | | | | | - Michael Friedlander
- Prince of Wales Clinical School, University of New South Wales and Department of Medical Oncology, The Prince of Wales Hospital, Sydney, NSW, Australia
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Ciani O, Grigore B, Blommestein H, de Groot S, Möllenkamp M, Rabbe S, Daubner-Bendes R, Taylor RS. Validity of Surrogate Endpoints and Their Impact on Coverage Recommendations: A Retrospective Analysis across International Health Technology Assessment Agencies. Med Decis Making 2021; 41:439-452. [PMID: 33719711 PMCID: PMC8108112 DOI: 10.1177/0272989x21994553] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 01/21/2021] [Indexed: 12/03/2022]
Abstract
BACKGROUND Surrogate endpoints (i.e., intermediate endpoints intended to predict for patient-centered outcomes) are increasingly common. However, little is known about how surrogate evidence is handled in the context of health technology assessment (HTA). OBJECTIVES 1) To map methodologies for the validation of surrogate endpoints and 2) to determine their impact on acceptability of surrogates and coverage decisions made by HTA agencies. METHODS We sought HTA reports where evaluation relied on a surrogate from 8 HTA agencies. We extracted data on the methods applied for surrogate validation. We assessed the level of agreement between agencies and fitted mixed-effects logistic regression models to test the impact of validation approaches on the agency's acceptability of the surrogate endpoint and their coverage recommendation. RESULTS Of the 124 included reports, 61 (49%) discussed the level of evidence to support the relationship between the surrogate and the patient-centered endpoint, 27 (22%) reported a correlation coefficient/association measure, and 40 (32%) quantified the expected effect on the patient-centered outcome. Overall, the surrogate endpoint was deemed acceptable in 49 (40%) reports (k-coefficient 0.10, P = 0.004). Any consideration of the level of evidence was associated with accepting the surrogate endpoint as valid (odds ratio [OR], 4.60; 95% confidence interval [CI], 1.60-13.18, P = 0.005). However, we did not find strong evidence of an association between accepting the surrogate endpoint and agency coverage recommendation (OR, 0.71; 95% CI, 0.23-2.20; P = 0.55). CONCLUSIONS Handling of surrogate endpoint evidence in reports varied greatly across HTA agencies, with inconsistent consideration of the level of evidence and statistical validation. Our findings call for careful reconsideration of the issue of surrogacy and the need for harmonization of practices across international HTA agencies.
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Affiliation(s)
- Oriana Ciani
- />Centre for Research on Health and Social Care Management, SDA Bocconi, Milan, Lombardia, Italy
- />Evidence Synthesis & Modelling for Health Improvement, University of Exeter Medical School, Exeter, Devon, UK
| | - Bogdan Grigore
- Evidence Synthesis & Modelling for Health Improvement, University of Exeter Medical School, Exeter, Devon, UK
| | - Hedwig Blommestein
- Institute for Medical Technology Assessment, Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Saskia de Groot
- Institute for Medical Technology Assessment, Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Meilin Möllenkamp
- Hamburg Center for Health Economics, Universität Hamburg, Hamburg, Germany
| | - Stefan Rabbe
- Hamburg Center for Health Economics, Universität Hamburg, Hamburg, Germany
| | - Rita Daubner-Bendes
- />Syreon Research Institute, Budapest, Hungary
- />MRC/CSO Social and Public Health Sciences Unit & Robertson Centre for Biostatistics, Institute of Health and Well Being, University of Glasgow, Glasgow, Scotland, UK
| | - Rod S. Taylor
- />Evidence Synthesis & Modelling for Health Improvement, University of Exeter Medical School, Exeter, Devon, UK
- />MRC/CSO Social and Public Health Sciences Unit & Robertson Centre for Biostatistics, Institute of Health and Well Being, University of Glasgow, Glasgow, Scotland, UK
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Grigore B, Ciani O, Dams F, Federici C, de Groot S, Möllenkamp M, Rabbe S, Shatrov K, Zemplenyi A, Taylor RS. Surrogate Endpoints in Health Technology Assessment: An International Review of Methodological Guidelines. PHARMACOECONOMICS 2020; 38:1055-1070. [PMID: 32572825 DOI: 10.1007/s40273-020-00935-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
In the drive towards faster patient access to treatments, health technology assessment (HTA) agencies are increasingly faced with reliance on evidence from surrogate endpoints, leading to increased decision uncertainty. This study undertook an updated survey of methodological guidance for using surrogate endpoints across international HTA agencies. We reviewed HTA and economic evaluation methods guidance from European, Australian and Canadian HTA agencies. We considered how guidelines addressed the methods for handling surrogate endpoints, including (1) level of evidence, (2) methods of validation, and (3) thresholds of acceptability. Across the 73 HTA agencies surveyed, 29 (40%) had methodological guidelines that made specific reference to consideration of surrogate outcomes. Of the 45 methods documents analysed, the majority [27 (60%)] were non-technology specific, 15 (33%) focused on pharmaceuticals and three (7%) on medical devices. The principles of the European network for Health Technology Assessment (EUnetHTA) guidelines published in 2015 on the handling of surrogate endpoints appear to have been adopted by many European HTA agencies, i.e. preference for final patient-relevant outcomes and reliance on surrogate endpoints with biological plausibility and epidemiological evidence of the association between the surrogate and final endpoint. Only a small number of HTA agencies (UK National Institute for Care and Excellence; the German Institute for Medical Documentation and Information and Institute for Quality and Efficiency in Health Care; the Australian Pharmaceutical Benefits Advisory Committee; and the Canadian Agency for Drugs and Technologies in Health) have developed more detailed prescriptive criteria for the acceptance of surrogate endpoints, e.g. meta-analyses of randomised controlled trials showing strong association between the treatment effect on the surrogate and final outcomes. As the decision uncertainty associated with reliance on surrogate endpoints carries a risk to patients and society, there is a need for HTA agencies to develop more detailed methodological guidance for consistent selection and evaluation of health technologies that lack definitive final patient-relevant outcome evidence at the time of the assessment.
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Affiliation(s)
- Bogdan Grigore
- Evidence Synthesis and Modelling for Health Improvement, College of Medicine and Health, Institute of Health Research, University of Exeter, Exeter, UK.
| | - Oriana Ciani
- Evidence Synthesis and Modelling for Health Improvement, College of Medicine and Health, Institute of Health Research, University of Exeter, Exeter, UK
- Center for Research on Health and Social Care Management, SDA Bocconi, Milan, Italy
| | - Florian Dams
- KPM Center for Public Management, University of Bern, Bern, Switzerland
| | - Carlo Federici
- Center for Research on Health and Social Care Management, SDA Bocconi, Milan, Italy
| | - Saskia de Groot
- Institute for Medical Technology Assessment, Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Meilin Möllenkamp
- Hamburg Center for Health Economics, Universität Hamburg, Hamburg, Germany
| | - Stefan Rabbe
- Hamburg Center for Health Economics, Universität Hamburg, Hamburg, Germany
| | - Kosta Shatrov
- KPM Center for Public Management, University of Bern, Bern, Switzerland
| | - Antal Zemplenyi
- Syreon Research Institute, Budapest, Hungary
- Division of Pharmacoeconomics, Faculty of Pharmacy, University of Pécs, Pécs, Hungary
| | - Rod S Taylor
- Evidence Synthesis and Modelling for Health Improvement, College of Medicine and Health, Institute of Health Research, University of Exeter, Exeter, UK
- MRC/CSO Social and Public Health Sciences Unit and Robertson Centre for Biostatistics, Institute of Health and Well Being, University of Glasgow, Glasgow, Scotland
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6
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Bauer A, Wittenberg R, Ly A, Gustavsson A, Bexelius C, Tochel C, Knapp M, Nelson M, Sudlow C. Valuing Alzheimer's disease drugs: a health technology assessment perspective on outcomes. Int J Technol Assess Health Care 2020; 36:1-7. [PMID: 32847642 DOI: 10.1017/s0266462320000574] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Due to the nature of Alzheimer's disease (AD), health technology assessment (HTA) agencies might face considerable challenges in choosing appropriate outcomes and outcome measures for drugs that treat the condition. This study sought to understand which outcomes informed previous HTAs, to explore possible reasons for prioritizations, and derive potential implications for future assessments of AD drugs. METHOD We conducted a literature review of studies that analyzed decisions made in HTAs (across disease areas) in three European countries: England, Germany, and The Netherlands. We then conducted case studies of technology assessments conducted for AD drugs in these countries. RESULTS Overall, outcomes measured using clinical scales dominated decisions or recommendations about whether to fund AD drugs, or price negotiations. HTA processes did not always allow the inclusion of outcomes relevant to people with AD, their carers, and families. Processes did not include early discussion and agreement on what would constitute appropriate outcome measures and cut-off points for effects. CONCLUSIONS We conclude that in order to ensure that future AD drugs are valued appropriately and timely, early agreement with various stakeholders about outcomes, outcome measures, and cut-offs is important.
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Affiliation(s)
- Annette Bauer
- Care Policy and Evaluation Centre, London School of Economics and Political Science, Houghton Street, LondonWC2A 2AE, UK
| | - Raphael Wittenberg
- Care Policy and Evaluation Centre, London School of Economics and Political Science, Houghton Street, LondonWC2A 2AE, UK
| | - Amanda Ly
- Centre for Medical Informatics, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Nine Edinburgh BioQuarter, 9 Little France Road, EdinburghEH16 4UX, UK
| | - Anders Gustavsson
- Quantify Research, Hantverkargatan 8, 112 21Stockholm, Sweden
- Department of Neurobiology, Care Sciences and Society, Karolinska Institute, Alfred Nobels allé 23, 141 83Stockholm, Sweden
| | - Christin Bexelius
- ROCHE. F. Hoffmann-La Roche Ltd, Grenzacherstrasse 124, 4070Basel, Switzerland
| | - Claire Tochel
- Centre for Medical Informatics, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Nine Edinburgh BioQuarter, 9 Little France Road, EdinburghEH16 4UX, UK
| | - Martin Knapp
- Care Policy and Evaluation Centre, London School of Economics and Political Science, Houghton Street, LondonWC2A 2AE, UK
| | - Mia Nelson
- Centre for Medical Informatics, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Nine Edinburgh BioQuarter, 9 Little France Road, EdinburghEH16 4UX, UK
| | - Catherine Sudlow
- Centre for Medical Informatics, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Nine Edinburgh BioQuarter, 9 Little France Road, EdinburghEH16 4UX, UK
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Dintsios CM, Beinhauer I. The impact of additive or substitutive clinical study design on the negotiated reimbursement for oncology pharmaceuticals after early benefit assessment in Germany. HEALTH ECONOMICS REVIEW 2020; 10:7. [PMID: 32172494 PMCID: PMC7071579 DOI: 10.1186/s13561-020-00263-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 02/28/2020] [Indexed: 05/03/2023]
Abstract
BACKGROUND We analysed the impact of clinical study design for oncological pharmaceuticals on the subsequent price negotiations after early benefit assessment between pharmaceutical companies and the German National Association of Statutory Health Insurance Funds. The analysis was conducted for all oncology pharmaceuticals that underwent the early benefit assessment in Germany since its introduction in 2011 up to September 2016. METHODS It was differentiated between additive (new therapy in addition to baseline therapy) and substitutive study designs (baseline therapy to be replaced). The study design was derived from the dossiers of the pharmaceutical companies submitted to the Federal Joint Committee. Subgroup specific costs in case of granted added benefit were calculated as annual therapy costs and compared with the costs of the appropriate comparators to quantify price premiums. Further price influencing factors were analysed in univariate and multivariate regression analysis considering the budget impact for the statutory health insurance as well. RESULTS The mean and the median of the additive premiums for substitutive designs (€50,477.68 and €49,841.24) were higher than for additive designs, if the comparator was different to best supportive care (€48,750.00 and €42,820.44). The mean multiplicative premium for the substitutive designs was 15.07 versus 2.29 for the additive designs. EU-Prices and target population size had a significant effect on the reimbursement. The adjusted R-square in the log Premium OLS-regressions reached 0.708 when including all explanatory variables and considering interaction between target population and annual costs of the comparator. CONCLUSIONS Study design as an additional important influencing factor of the negotiations next to those stated in the framework agreement was identified and verified. Therefore, study design should be considered by pharmaceutical companies and by decision makers and payers within strategic price planning as a potential predictor. For some specific categories the number of cases was small. Further analyses should be performed when more oncology pharmaceuticals have passed the early benefit assessment.
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Affiliation(s)
- C. M. Dintsios
- Medical Faculty, Institute for Health Services Research and Health Economics, Heinrich Heine University, Building: 12.49, Moorenstr. 5, 40225 Düsseldorf, Germany
| | - I. Beinhauer
- Health Economics, Cologne, Trainee at Bayer Vital GmbH, Leverkusen, Germany
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Stahel RA, Lacombe D, Cardoso F, Casali PG, Negrouk A, Marais R, Hiltbrunner A, Vyas M. Current models, challenges and best practices for work conducted between European academic cooperative groups and industry. ESMO Open 2020; 5:e000628. [PMID: 32213534 PMCID: PMC7103800 DOI: 10.1136/esmoopen-2019-000628] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 01/15/2020] [Accepted: 01/20/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND The academia-industry interface is important, and, despite challenges that inevitably occur, bears the potential for positive synergies to emerge. Perceived barriers to wider collaboration in academia-industry oncology research in Europe need to be addressed, current academic cooperative group and industry models for collaboration need to be discussed, and a common terminology to facilitate understanding of both sectors' concerns needs to be established with an eye towards improving academia-industry partnerships on clinical trials for the benefit of patients with cancer. METHODOLOGY CAREFOR (Clinical Academic Cancer Research Forum), a multi-stakeholder platform formed to improve the direction for academic clinical trials in the field of oncology in Europe, formed the CAREFOR-Industry Working Group comprised of experienced professionals from European academic cooperative groups joined by industry representatives selected based on their activities in the area of medical oncology. They jointly discussed academic cooperative groups, clinical trials conducted between academic cooperative groups and industry, examples of successful collaborative models, common legal negotiation points in clinical trial contracts, data access, and principles of interaction. RESULTS Four principles of interaction between the academia and industry are proposed: (1) clarify the roles and responsibilities of all partners involved in the study, (2) involve legal teams from an early stage; (3) acknowledge that data is an important output of the study, (4) agree on the intent of the trial prior to its start. CONCLUSIONS The CAREFOR-Industry Working Group describes current models, challenges, and effective strategies for academia-industry research in Europe with an eye towards improving academia-industry partnerships on clinical trials for patients with cancer. Current perceived challenges are explained, and future opportunities/recommendations for improvement are described for the areas of most significant impact. Challenges are addressed from both the academic and industry perspectives, and principles of interaction for the optimal alignment between academia and industry in selected areas are proposed.
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Affiliation(s)
- Rolf A Stahel
- Medical Oncology and Hematology, University Hospital Zürich, Zurich, Switzerland
| | | | - Fatima Cardoso
- Breast Unit, Champalimaud Clinical Center/Champalimaud Foundation, Lisbon, Portugal
| | - Paolo G Casali
- Medical Oncology Unit 2, National Cancer Institute: Fondazione IRCCS, Milano, Italy
| | | | - Richard Marais
- Molecular Oncology, Cancer Research UK Manchester Institute, Greater Manchester, United Kingdom
| | | | - Malvika Vyas
- Public Policy, European Society for Medical Oncology, Lugano, Switzerland
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9
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Molitor M, Dintsios CM. Failure due to formal reasons within German benefit assessment of medicinal products: the dilemma between marketing authorization and HTA. Expert Rev Pharmacoecon Outcomes Res 2020; 21:145-157. [DOI: 10.1080/14737167.2020.1729131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
| | - Charalabos-Markos Dintsios
- Institute for Health Services Research and Health Economics, Heinrich Heine University, Düsseldorf, Germany
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10
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Isbary G, Staab TR, Amelung VE, Dintsios CM, Iking-Konert C, Nesurini SM, Walter M, Ruof J. Effect of Crossover in Oncology Clinical Trials on Evidence Levels in Early Benefit Assessment in Germany. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2018; 21:698-706. [PMID: 29909875 DOI: 10.1016/j.jval.2017.09.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 09/17/2017] [Indexed: 06/08/2023]
Abstract
BACKGROUND In oncology clinical trials, crossover is used frequently but may lead to uncertainties regarding treatment effects. OBJECTIVE To investigate the handling of evidence from crossover trials by the European Medicines Agency (EMA) and the German Federal Joint Committee (G-BA). METHODS For oncology medicines with early benefit assessments before January 2015, presence of crossover, clinical data, EMA requests for additional data, and G-BA benefit ratings/evidence levels were analyzed from manufacturers' dossiers, G-BA appraisals, European Public Assessment Reports, and original publications. RESULTS Eleven of 21 benefit assessments included crossover trials. Significant intergroup differences (P < 0.05) in overall survival (OS) were noted in 7 of 11 trials with and 7 of 10 without crossover. For 6 of 11 medicines with crossover, these were demonstrated before crossover. Treatment effects generally worsened with increasing proportions of crossover. The EMA requested additional data more frequently if crossover was performed, particularly if no OS data were available before crossover. The G-BA granted a considerable benefit to 73% of medicines with crossover and 40% of those without. Evidence levels were intermediate for 50% and 75%, respectively. None of the medicines received the highest evidence level. CONCLUSIONS In G-BA appraisals, oncology medicines with crossover received better additional benefit ratings, but were assigned lower evidence levels, than those without. The five medicines with crossover after progression were assigned lower evidence levels than the six medicines with crossover after demonstration of superior OS, indicating that the way in which crossover is implemented may be one factor influencing the assignment of evidence levels by the G-BA.
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Affiliation(s)
| | - Thomas R Staab
- Roche Pharma AG, Grenzach-Wyhlen, Germany; Medical School of Hanover, Hanover, Germany
| | | | | | | | | | | | - Jörg Ruof
- Medical School of Hanover, Hanover, Germany; r-connect ltd, Basel, Switzerland.
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11
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Niehaus I, Dintsios CM. Confirmatory versus explorative endpoint analysis: Decision-making on the basis of evidence available from market authorization and early benefit assessment for oncology drugs. Health Policy 2018; 122:599-606. [PMID: 29605527 DOI: 10.1016/j.healthpol.2018.03.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 03/17/2018] [Accepted: 03/19/2018] [Indexed: 10/17/2022]
Abstract
The early benefit assessment of pharmaceuticals in Germany and their preceding market authorization pursue different objectives. This is reflected by the inclusion of varying confirmatory endpoints within the evaluation of oncology drugs in early benefit assessment versus market authorization, with both relying on the same evidence. Data from assessments up to July 2015 are used to estimate the impact of explorative in comparison to confirmatory endpoints on market authorization and early benefit assessment by contrasting the benefit-risk ratio of EMA and the benefit-harm balance of the HTA jurisdiction. Agreement between market authorization and early benefit assessment is examined by Cohen's kappa (k). 21 of 41 assessments were considered in the analysis. Market authorization is more confirmatory than early benefit assessment because it includes a higher proportion of primary endpoints. The latter implies a primary endpoint to be relevant for the benefit-harm balance in only 67% of cases (0.078). Explorative mortality endpoints reached the highest agreement regarding the mutual consideration for the risk-benefit ratio and the benefit-harm balance (0.000). For explorative morbidity endpoints (-0.600), quality of life (-0.600) and side effects (-0.949) no agreement is ascertainable. To warrant a broader confirmatory basis for decisions supported by HTA, closer inter-institutional cooperation of approval authorities and HTA jurisdictions by means of reliable joint advice for manufacturers regarding endpoint definition would be favorable.
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Affiliation(s)
- Ines Niehaus
- Cologne Institute for Health Economics and Clinical Epidemiology, University of Cologne, Cologne, Germany.
| | - Charalabos-Markos Dintsios
- Institute for Health Services Research and Health Economics, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany.
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Theidel U, von der Schulenburg JMG. Benefit assessment in Germany: implications for price discounts. HEALTH ECONOMICS REVIEW 2016; 6:33. [PMID: 27485438 PMCID: PMC4970987 DOI: 10.1186/s13561-016-0109-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 07/22/2016] [Indexed: 05/20/2023]
Abstract
BACKGROUND The AMNOG regulation, introduced in 2011 in Germany, changed the game for new drugs. Now, the industry is required to submit a dossier to the GBA (the central decision body in the German sickness fund system) to show additional benefit. After granting the magnitude of the additional benefit by the GBA, the manufacturer is entitled to negotiate the reimbursement price with the GKV-SV (National Association of Statutory Health Insurance Funds). The reimbursement price is defined as a discount on the drug price at launch. As the price or discount negotiations between the manufacturers and the GKV-SV takes place behind closed doors, the factors influencing the results of the negotiation are not known. OBJECTIVES The aim of this evaluation is to identify factors influencing the results of the AMNOG price negotiation process. METHODS The analysis was based on a dataset containing detailed information on all assessments until the end of 2015. A descriptive analysis was followed by an econometric analysis of various potential factors (benefit rating, size of target population, deviating from appropriate comparative therapy and incorporation of HRQoL-data). RESULTS Until December 2015, manufacturers and the GKV-SV finalized 96 negotiations in 193 therapeutic areas, based on assessment conducted by the GBA. The GBA has granted an additional benefit to 100/193 drug innovations. Negotiated discount was significantly higher for those drugs without additional benefit (p = 0.030) and non-orphan drugs (p = 0.015). Smaller population size, no deviation from recommended appropriate comparative therapy and the incorporation of HRQoL-data were associated with a lower discount on the price at launch. However, neither a uni- nor the multivariate linear regression showed enough power to predict the final discount. CONCLUSIONS Although the AMNOG regulation implemented binding and strict rules for the benefit assessment itself, the outcome of the discount negotiations are still unpredictable. Obviously, negotiation tactics, the current political situation and soft factors seem to play a more influential role for the outcome of the negotiations than the five hard and known factors analyzed in this study. Further research is needed to evaluate additional factors.
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Ruof J, Staab T, Dintsios CM, Schröter J, Schwartz FW. Comparison of post-authorisation measures from regulatory authorities with additional evidence requirements from the HTA body in Germany - are additional data requirements by the Federal Joint Committee justified? HEALTH ECONOMICS REVIEW 2016; 6:46. [PMID: 27687714 PMCID: PMC5042914 DOI: 10.1186/s13561-016-0124-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Accepted: 09/16/2016] [Indexed: 05/31/2023]
Abstract
OBJECTIVES The aim of this study was to compare post-authorisation measures (PAMs) from the European Medicines Agency (EMA) with data requests in fixed-termed conditional appraisals of early benefit assessments from the German Federal Joint Committee (G-BA). METHODS Medicinal products with completed benefit assessments during an assessment period of 3.5 years were considered. PAMs extracted from European Public Assessment Reports (EPARs) were compared with data requests issued by the G-BA in the context of conditional appraisals. RESULTS Twenty conditional appraisals (19 products) and 34 EPARs containing PAMs (33 products) were identified. Data categories (efficacy, safety, etc.), data types (type of study required to address the request) and clarity of requests were determined. Conditional appraisals disproportionately focused on oncology products (13/19 products with conditional appraisals vs. 14/33 products with PAMs). No clear rationale for the G-BA issuing conditional appraisals could be identified in public sources. Both EMA and G-BA requested mainly efficacy and safety data (44/54 and 23/35 categories requested, respectively); however, 28/35 G-BA data requirements went beyond requests made by the EMA. Almost half of the G-BA requests (9/20), but no PAMs, were unclear, and no methodological guidance for fulfilling the data requirements was provided by the G-BA. CONCLUSIONS Better alignment between data requests from regulatory authorities and health technology assessment bodies is strongly recommended.
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Affiliation(s)
- Jörg Ruof
- Roche Pharma AG, Emil-Barrell-Str. 1, 79639 Grenzach-Wyhlen, Germany
- Medical School of Hanover, Hanover, Germany
| | - Thomas Staab
- Roche Pharma AG, Emil-Barrell-Str. 1, 79639 Grenzach-Wyhlen, Germany
| | | | - Jakob Schröter
- Baden-Württemberg Cooperative State University, Lörrach, Germany
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Ruof J, Staab T, Dintsios CM, Schröter J, Schwartz FW. Comparison of post-authorisation measures from regulatory authorities with additional evidence requirements from the HTA body in Germany - are additional data requirements by the Federal Joint Committee justified? HEALTH ECONOMICS REVIEW 2016. [PMID: 27687714 DOI: 10.11186/s13561-016-0124-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
OBJECTIVES The aim of this study was to compare post-authorisation measures (PAMs) from the European Medicines Agency (EMA) with data requests in fixed-termed conditional appraisals of early benefit assessments from the German Federal Joint Committee (G-BA). METHODS Medicinal products with completed benefit assessments during an assessment period of 3.5 years were considered. PAMs extracted from European Public Assessment Reports (EPARs) were compared with data requests issued by the G-BA in the context of conditional appraisals. RESULTS Twenty conditional appraisals (19 products) and 34 EPARs containing PAMs (33 products) were identified. Data categories (efficacy, safety, etc.), data types (type of study required to address the request) and clarity of requests were determined. Conditional appraisals disproportionately focused on oncology products (13/19 products with conditional appraisals vs. 14/33 products with PAMs). No clear rationale for the G-BA issuing conditional appraisals could be identified in public sources. Both EMA and G-BA requested mainly efficacy and safety data (44/54 and 23/35 categories requested, respectively); however, 28/35 G-BA data requirements went beyond requests made by the EMA. Almost half of the G-BA requests (9/20), but no PAMs, were unclear, and no methodological guidance for fulfilling the data requirements was provided by the G-BA. CONCLUSIONS Better alignment between data requests from regulatory authorities and health technology assessment bodies is strongly recommended.
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Affiliation(s)
- Jörg Ruof
- Roche Pharma AG, Emil-Barrell-Str. 1, 79639, Grenzach-Wyhlen, Germany.
- Medical School of Hanover, Hanover, Germany.
| | - Thomas Staab
- Roche Pharma AG, Emil-Barrell-Str. 1, 79639, Grenzach-Wyhlen, Germany
| | | | - Jakob Schröter
- Baden-Württemberg Cooperative State University, Lörrach, Germany
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Staab T, Isbary G, Amelung VE, Ruof J. Inconsistent approaches of the G-BA regarding acceptance of primary study endpoints as being relevant to patients - an analysis of three disease areas: oncological, metabolic, and infectious diseases. BMC Health Serv Res 2016; 16:651. [PMID: 27842592 PMCID: PMC5109700 DOI: 10.1186/s12913-016-1902-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 11/04/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Previous evaluations of oncological medicines in the German early benefit assessment (EBA) procedure have demonstrated inconsistent acceptance of endpoints by regulatory authorities and the Federal Joint Committee (G-BA). Accepted standard endpoints for regulatory purposes are frequently not considered as patient-relevant in the German EBA system. In this study the acceptance of clinically acknowledged primary endpoints (PEPs) from regulatory trials in EBAs conducted by the G-BA was evaluated across three therapeutic areas. METHODS Medicines for oncological, metabolic and infectious diseases with EBAs finalised before 25 January 2016 were evaluated. Respective manufacturer's dossiers, regulatory assessments, G-BA appraisals and oral hearing minutes were reviewed, and PEPs were examined to determine whether they were considered relevant to patients by the G-BA. Furthermore, the acceptance of symptomatic vs asymptomatic PEPs was also analysed. RESULTS A total of 65 EBAs were evaluated. Mortality PEPs were widely accepted as patient-relevant but were only used in a minority of EBAs and exclusively in oncological diseases. Morbidity PEPs constituted around 72 % of assessed PEPs, but were excluded from the EBA in over half of the corresponding assessments as they were not considered patient-relevant. Symptomatic endpoints were largely deemed patient-relevant, whereas acceptance of asymptomatic endpoints varied between therapeutic areas. CONCLUSIONS This evaluation identified inconsistencies in patient relevance of morbidity-related PEPs as well as in acceptance of asymptomatic endpoints by the G-BA in all three disease areas examined. Better harmonisation between the regulatory authorities and the G-BA is still required after 5 years of AMNOG health technology assessment in Germany.
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Affiliation(s)
- Thomas Staab
- Roche Pharma AG, Emil-Barrell-Str. 1, 79639 Grenzach-Wyhlen, Germany
| | - Georg Isbary
- Roche Pharma AG, Emil-Barrell-Str. 1, 79639 Grenzach-Wyhlen, Germany
| | | | - Jörg Ruof
- Roche Pharma AG, Emil-Barrell-Str. 1, 79639 Grenzach-Wyhlen, Germany
- Medical School of Hanover, Hanover, Germany
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Ruof J, Flückiger O, Andre N. Early Benefit Assessments in Oncology in Germany: How Can a Clinically Relevant Endpoint Not Be Relevant to Patients? Drugs R D 2015; 15:221-6. [PMID: 26286202 PMCID: PMC4561053 DOI: 10.1007/s40268-015-0100-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
After 4 years of early benefit assessment (EBA) in Germany, it is becoming evident that the Federal Joint Committee (FJC) frequently considers well-established clinical endpoints as not being relevant to patients. Focusing on assessments of oncology medicines, we analysed the FJC's view on primary endpoints and compared it with the approach used by regulatory authorities. Mortality data were accepted by both stakeholders. Whereas regulatory authorities accepted primary morbidity endpoints such as progression-free survival and response rates, the FJC mostly excluded these from its assessments. Health-related quality of life (HRQoL) data have been poorly reflected in the approval process; for EBAs, those data have rarely impacted on benefit ratings. We argue that agreement between regulatory authorities and the FJC is required regarding primary study endpoints that are relevant to patients, and that clarification of acceptable endpoints by the FJC, especially in the morbidity domain, has to be provided. Moreover, in order to fully acknowledge the benefit of a new medicinal product, mortality, morbidity and HRQoL should be weighted differentially, according to the condition.
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Affiliation(s)
- Jörg Ruof
- Roche Pharma AG, Emil-Barrell-Str. 1, 79639, Grenzach-Wyhlen, Germany,
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Bullinger M, Blome C, Sommer R, Lohrberg D, Augustin M. Gesundheitsbezogene Lebensqualität – ein zentraler patientenrelevanter Endpunkt in der Nutzenbewertung medizinischer Maßnahmen. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2015; 58:283-90. [DOI: 10.1007/s00103-014-2107-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Kaiser T, Vervölgyi V, Wieseler B. [Benefit assessment of drugs]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2015; 58:232-9. [PMID: 25566842 DOI: 10.1007/s00103-014-2110-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In Germany, new drugs are subject to a benefit assessment at the time of their market access. This "early benefit assessment" is the method primarily used for the benefit assessment of pharmaceuticals in Germany. While for the authorization of a drug a positive risk-benefit ratio is sufficient, early benefit assessment examines whether the new drug has an added benefit compared with other therapies, and thus differs significantly from authorization. For the evaluation, the manufacturer is required to submit a dossier, which must contain all the relevant studies. Early benefit assessment is very transparent in international comparisons, because all the relevant data and the evaluation report will be published. The assessment is carried out with regard to the evidence-based standard of care (the "appropriate comparator"). If the new drug is found to have an additional benefit, the extent of this added benefit is assessed. In addition, groups of patients should be identified with the particular extent of the added benefit. Therefore, subgroup analyses have to be carried out frequently. Often, for new drugs, only registration studies are available. General requirements for such studies (e.g., placebo comparison, endpoints) and decisions regarding the approval process (e.g., dosage regimens) can affect the level of confidence of these studies in the benefit assessment. Joint scientific advice by regulatory authorities and HTA (health technology assessment) agencies are provided to solve this problem. However, this is not possible without additional expense for the pharmaceutical companies.
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Affiliation(s)
- Thomas Kaiser
- Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen (IQWiG), Im Mediapark 8, 50670, Köln, Deutschland,
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