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Zozaya N, Villaseca J, Fernández I, Abdalla F, Cadenas-Noreña B, Calleja MÁ, Gómez-Pajuelo P, Mestre-Ferrándiz J, Oliva-Moreno J, Trillo JL, Hidalgo-Vega Á. A Review of Current Approaches to Evaluating and Reimbursing New Medicines in a Subset of OECD Countries. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2024; 22:297-313. [PMID: 38214848 DOI: 10.1007/s40258-023-00867-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/14/2023] [Indexed: 01/13/2024]
Abstract
OBJECTIVES The aim of this study was to review the current evaluation and funding processes for new drugs in different developed countries, to provide a comparative framework with detailed, homogeneous, and up-to-date information. METHODS Scientific publications, reports and websites were reviewed between July and December 2021 using PubMed, Google Scholar, and grey literature sources. The main items searched were actors and processes, including timelines, characteristics of clinical and economic evaluations, participation of stakeholders, elements of price and reimbursement decisions, cost-effectiveness thresholds and specific funds. The analysed 13 countries were Australia, Canada, England, France, Germany, Italy, Japan, the Netherlands, Portugal, Scotland, South Korea, Spain and Sweden. RESULTS Eight countries perform the assessment process separated from the pricing decision. Countries measure each drug's added therapeutic value through multi-attribute value scales, algorithms, non-prescriptive lists of criteria, or quality-adjusted life years (QALYs). Health technology assessment (HTA) methodologies differ in their outcome measures, elicitation techniques, comparators, and perspectives. The criteria used for pricing and reimbursement include humanistic, clinical, and economic aspects. Only Scotland, England, the Netherlands, Canada and Portugal use explicit efficiency thresholds. Health care professionals participate in all assessment committees, and patients are becoming increasingly involved in most countries. The official time from marketing authorisation to the completion of the evaluation and pricing processes varied from 126 to 540 days. CONCLUSIONS Most analysed countries show a trend towards value-based approaches that consider value for money to society, but also other economic, clinical, and humanistic criteria. Good practices included robustness, transparency, independence, and participation.
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Affiliation(s)
- Néboa Zozaya
- Department of Health Economics, Weber, C/Moreto 17, 5D, 28014, Madrid, Spain.
- Department of Quantitative Methods in Economics and Management, Faculty of Economics, Business and Tourism, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain.
| | - Javier Villaseca
- Department of Health Economics, Weber, C/Moreto 17, 5D, 28014, Madrid, Spain
| | - Irene Fernández
- Department of Health Economics, Weber, C/Moreto 17, 5D, 28014, Madrid, Spain
| | - Fernando Abdalla
- Department of Health Economics, Weber, C/Moreto 17, 5D, 28014, Madrid, Spain
| | | | | | | | | | - Juan Oliva-Moreno
- Department of Economic Analysis and Finance, University of Castilla-La Mancha, Toledo, Spain
| | - José Luis Trillo
- Department of Pharmacy, Health Area of the Malvarrosa Valencia Clinical Department, Valencia, Spain
| | - Álvaro Hidalgo-Vega
- Department of Economic Analysis and Finance, University of Castilla-La Mancha, Toledo, Spain
- Weber Foundation, Madrid, Spain
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Dakin H, Tsiachristas A. Rationing in an Era of Multiple Tight Constraints: Is Cost-Utility Analysis Still Fit for Purpose? APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2024; 22:315-329. [PMID: 38329700 PMCID: PMC7615833 DOI: 10.1007/s40258-023-00858-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/14/2023] [Indexed: 02/09/2024]
Abstract
Cost-utility analysis may not be sufficient to support reimbursement decisions when the assessed health intervention requires a large proportion of the healthcare budget or when the monetary healthcare budget is not the only resource constraint. Such cases include joint replacement, coronavirus disease 2019 (COVID-19) interventions and settings where all resources are constrained (e.g. post-COVID-19 or in low/middle-income countries). Using literature on health technology assessment, rationing and reimbursement in healthcare, we identified seven alternative frameworks for simultaneous decisions about (dis)investment and proposed modifications to deal with multiple resource constraints. These frameworks comprised constrained optimisation; cost-effectiveness league table; 'step-in-the-right-direction' approach; heuristics based on effective gradients; weighted cost-effectiveness ratios; multicriteria decision analysis (MCDA); and programme budgeting and marginal analysis (PBMA). We used numerical examples to demonstrate how five of these alternative frameworks would operate. The modified frameworks we propose could be used in local commissioning and/or health technology assessment to supplement standard cost-utility analysis for interventions that have large budget impact and/or are subject to additional constraints.
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Affiliation(s)
- Helen Dakin
- Health Economics Research Centre, Nuffield Department of Population Health, Old Road Campus, Headington, OX3 7LF, Oxford, UK.
| | - Apostolos Tsiachristas
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Department of Psychiatry, University of Oxford, Oxford, UK
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Mela A, Lis D, Rdzanek E, Jaroszyński J, Furtak-Niczyporuk M, Drop B, Blicharski T, Niewada M. AOTMiT reimbursement recommendations compared to other HTA agencies. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2024:10.1007/s10198-023-01655-x. [PMID: 38261131 DOI: 10.1007/s10198-023-01655-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 11/24/2023] [Indexed: 01/24/2024]
Abstract
Our objective was to compare AOTMiT (Polish: Agencja Oceny Technologii Medycznych i Taryfikacji) recommendations to other HTA (Health Technology Assessment) agencies for newly registered drugs and new registration indications issued by the European Medicines Agency between 2014 and 2019. The study aims to assess the consistency and justifications of AOTMiT recommendations compared to that of other HTA agencies in 11 countries. A total of 2494 reimbursement recommendations published by 12 HTA agencies for 464 medicinal products and 525 indications were analyzed. Our analysis confirmed that the Polish AOTMiT agency seems to bear the closest resemblance to the corresponding HTA agencies from Canada (CADTH) and New Zealand (PHARMAC), when it comes to the outcome of HTA recommendations (positive or negative). Poland had a general scheme for justifying recommendations, similar to that of Ireland-four aspects (i.e., clinical efficacy, safety profile, cost-effectiveness, and impact on the payer's budget) are important for Poland when formulating the final decision. Compared to other countries, Poland shows a noticeably different pattern of justifying reimbursement recommendations, as revealed primarily in terms of budget impact and somewhat less so for cost-effectiveness rationales.
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Affiliation(s)
- Aneta Mela
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology (CePT), Medical University of Warsaw, Banacha 1B, 02-097, Warsaw, Poland.
| | - Dorota Lis
- HealthQuest Sp z o.o. Sp. K, 01-625, Warsaw, Poland
| | - Elżbieta Rdzanek
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology (CePT), Medical University of Warsaw, Banacha 1B, 02-097, Warsaw, Poland
| | - Janusz Jaroszyński
- Department of Administrative Procedure, Faculty of Law and Administration, Maria Curie-Skłodowska University of Lublin, Marii Curie-Skłodowskiej 5, 20-031, Lublin, Poland
| | | | - Bartłomiej Drop
- Department of Information Technology and Medical Statistics, Faculty of Health Sciences, Medical University of Lublin, 20-093, Lublin, Poland
| | - Tomasz Blicharski
- Department of Orthopeadics and Rehabilitation, Medical University of Lublin, K. Jaczewskiego 8, 20-090, Lublin, Poland
| | - Maciej Niewada
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology (CePT), Medical University of Warsaw, Banacha 1B, 02-097, Warsaw, Poland
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He Z, Huang X, Chen D, Wang G, Zhu Y, Li H, Han S, Shi L, Guan X. Sponsorship bias in published pharmacoeconomic evaluations of national reimbursement negotiation drugs in China: a systematic review. BMJ Glob Health 2023; 8:e012780. [PMID: 38030227 PMCID: PMC10689407 DOI: 10.1136/bmjgh-2023-012780] [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: 05/07/2023] [Accepted: 10/31/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND China's National Reimbursement Drug List (NRDL) has become the primary route for drug reimbursement in China. More recently, the authority has made pharmacoeconomic evaluation an integral part of the application for NRDL inclusion. The underlying financial conflict of interests (FCOI) of pharmacoeconomic evaluations, however, has the potential to influence evidence generated and thus subsequent decision-making yet remains poorly understood. METHODS We searched for studies published between January 2012 and January 2022 on the 174 drugs added to the 2017-2020 NRDLs after successful negotiation. We categorised the study's FCOI status into no funding, industry funding, non-profit funding and multiple fundings based on authors' disclosure and assessed the reporting quality of included studies using the Consolidated Health Economic Evaluation Reporting Standards 2022 checklist. We compiled descriptive statistics of funding types and study outcomes using t-tests and χ2 tests and conducted multivariate regression analysis. RESULTS We identified 378 records and our final sample included 92 pharmacoeconomic evaluations, among which 69.6% were conducted with at least one funding source. More than half (57.6%) of the evaluations reached favourable conclusions towards the intervention drug and 12.6% reached a dominant result of the intervention drug over the comparison from model simulation. The reporting quality of included studies ranged from 19 to 25 (on a scale of 28), with an average of 22.3. The statistical tests indicated that industry-funded studies were significantly more likely to conclude that the intervention therapy was economical (p<0.01) and had a significantly higher proportion of resulting target drug economically dominated the comparison drug (p<0.05). CONCLUSION The study revealed that FCOI bias is common in published pharmacoeconomic evaluations conducted in Chinese settings and could significantly influence the study's economical results and conclusions through various mechanisms. Multifaceted efforts are needed to improve transparency, comparability and reporting standardisation.
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Affiliation(s)
- Zixuan He
- International Research Center for Medicinal Administration, Peking University, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Xianqin Huang
- International Research Center for Medicinal Administration, Peking University, Beijing, China
| | - Dingyi Chen
- International Research Center for Medicinal Administration, Peking University, Beijing, China
| | - Guoan Wang
- International Research Center for Medicinal Administration, Peking University, Beijing, China
| | - Yuezhen Zhu
- International Research Center for Medicinal Administration, Peking University, Beijing, China
| | - Huangqianyu Li
- International Research Center for Medicinal Administration, Peking University, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Sheng Han
- International Research Center for Medicinal Administration, Peking University, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Luwen Shi
- International Research Center for Medicinal Administration, Peking University, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Xiaodong Guan
- International Research Center for Medicinal Administration, Peking University, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
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5
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Mela A, Rdzanek E, Jaroszyński J, Furtak-Niczyporuk M, Jabłoński M, Niewada M. Reimbursement decision-making system in Poland systematically compared to other countries. Front Pharmacol 2023; 14:1153680. [PMID: 37900165 PMCID: PMC10611478 DOI: 10.3389/fphar.2023.1153680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 08/24/2023] [Indexed: 10/31/2023] Open
Abstract
Introduction: Our objective was to analyze and compare systematically and structurally reimbursement systems in Poland and other countries. Methods: The systems were selected based on recommendations issued by the Polish Agency for Health Technology Assessment and Tariffication (AHTAPol), which explicitly referred to other countries and agencies). Consequently, apart from Poland, the countries included in the analysis were England, Scotland, Wales, Ireland, France, Netherlands, Germany, Norway, Sweden, Canada, Australia and New Zealand. Relevant information and data were collected through a systematic search of PubMed (Medline), Embase and The Cochrane Library as well as competent authority websites and grey literature sources. Results and discussion: In most of the countries, the submission of a reimbursement application is initiated by a pharmaceutical company, and only a few countries allow it before a product is approved for marketing. All of the agencies analyzed are independent and some have regulatory function of reimbursement decision making body. A key criterion differentiating the various agencies in terms of HTA is the cost-effectiveness threshold. Most of the countries have specific mechanisms to improve access to expensive specialty drugs, including cancer drugs and those used for rare diseases. Reimbursement systems often lack consistency in appreciating the same stages, leading to heterogeneous decision-making processes. The analysis of recommendations issued in different countries for the same medicinal product will allow a better understanding of the relations between the reimbursement system, HTA assessment, stakeholders involvement and decision on reimbursement of innovative drugs.
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Affiliation(s)
- Aneta Mela
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology (CePT), Medical University of Warsaw, Warsaw, Poland
| | - Elżbieta Rdzanek
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology (CePT), Medical University of Warsaw, Warsaw, Poland
| | - Janusz Jaroszyński
- Department of Administrative Proceedings, Faculty of Law and Administration, Marie Curie-Sklodowska University, Lublin, Poland
| | | | - Mirosław Jabłoński
- Department of Orthopeadics and Rehabilitation, Medical University of Lublin, Lublin, Poland
| | - Maciej Niewada
- Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology (CePT), Medical University of Warsaw, Warsaw, Poland
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Moons P, Norekvål TM, Arbelo E, Borregaard B, Casadei B, Cosyns B, Cowie MR, Fitzsimons D, Fraser AG, Jaarsma T, Kirchhof P, Mauri J, Mindham R, Sanders J, Schiele F, Torbica A, Zwisler AD. Placing patient-reported outcomes at the centre of cardiovascular clinical practice: implications for quality of care and management. Eur Heart J 2023; 44:3405-3422. [PMID: 37606064 DOI: 10.1093/eurheartj/ehad514] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 05/01/2023] [Accepted: 07/25/2023] [Indexed: 08/23/2023] Open
Abstract
Patient-reported outcomes (PROs) provide important insights into patients' own perspectives about their health and medical condition, and there is evidence that their use can lead to improvements in the quality of care and to better-informed clinical decisions. Their application in cardiovascular populations has grown over the past decades. This statement describes what PROs are, and it provides an inventory of disease-specific and domain-specific PROs that have been developed for cardiovascular populations. International standards and quality indices have been published, which can guide the selection of PROs for clinical practice and in clinical trials and research; patients as well as experts in psychometrics should be involved in choosing which are most appropriate. Collaborations are needed to define criteria for using PROs to guide regulatory decisions, and the utility of PROs for comparing and monitoring the quality of care and for allocating resources should be evaluated. New sources for recording PROs include wearable digital health devices, medical registries, and electronic health record. Advice is given for the optimal use of PROs in shared clinical decision-making in cardiovascular medicine, and concerning future directions for their wider application.
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Affiliation(s)
- Philip Moons
- KU Leuven Department of Public Health and Primary Care, KU Leuven - University of Leuven, Kapucijnenvoer 35 PB7001, 3000 Leuven, Belgium
- Institute of Health and Care Sciences, University of Gothenburg, Arvid Wallgrens backe 1, 413 46 Gothenburg, Sweden
- Department of Paediatrics and Child Health, University of Cape Town, Klipfontein Rd, Rondebosch, 7700 Cape Town, South Africa
| | - Tone M Norekvål
- Department of Heart Disease, Haukeland University Hospital, Haukelandsveien 22, 5009 Bergen, Norway
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Jonas Lies veg, 875021 Bergen, Norway
| | - Elena Arbelo
- Cardiology Department, Hospital Clínic, Universitat de Barcelona, C/Villarroel 170, 08036 Barcelona, Spain
- Institut d'Investigació August Pi i Sunyer (IDIBAPS). Rosselló 149-153, 08036 Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Av. Monforte de Lemos, 3-5. Pabellón 11. Planta 0, 28029 Madrid, Spain
| | - Britt Borregaard
- Department of Cardiology, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 19, 5000 Odense, Denmark
| | - Barbara Casadei
- Division of Cardiovascular Medicine, RDM, University of Oxford; Headley Way, Headington Oxford OX3 9DU, UK
- NIHR Biomedical Research Centre, Headley Way, Headington Oxford OX3 9DU, UK
| | - Bernard Cosyns
- Department of Cardiology, University Hospital Brussels, Laarbeeklaan 101, 1090 Jette, Belgium
| | - Martin R Cowie
- Royal Brompton Hospital & School of Cardiovascular Medicine, Faculty of Medicine & Lifesciences, King's College London, Sydney St, London SW3 6NP, UK
| | - Donna Fitzsimons
- School of Nursing & Midwifery, Queens University Belfast, 97 Lisburn Road, Belfast | BT9 7BL, Northern Ireland
| | - Alan G Fraser
- School of Medicine, Cardiff University, Heath Park, Cardiff CF14 4XW, UK
| | - Tiny Jaarsma
- Department of Medicine, Health and Caring Sciences, Linköping University, Campus Norrköping, 601 74 Norrköping, Sweden
- Nursing Science, Julius Center, University Medical Centre Utrecht, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, Martinistrasse 52, D-20246 Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Martinistrasse 52, D-20246 Hamburg, Germany
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, Edgbaston Birmingham B15 2TT, UK
| | - Josepa Mauri
- Department of Cardiology, Hospital Universitari Germans Trias i Pujol, Carretera de Canyet, s/n, 08916 Badalona, Barcelona, Spain
| | - Richard Mindham
- European Society of Cardiology (ESC) Patient Forum, 2035 route des colles, CS 80179 Biot, 06903 Sophia Antipolis Cedex, France
| | - Julie Sanders
- St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, London EC1A 7BE, UK
- William Harvey Research Institute, Charterhouse Square, Queen Mary University of London, London EC1M 6BQ, UK
| | - Francois Schiele
- Department of Cardiology, University Hospital Besancon, 3 Bd Alexandre Fleming, 25030 Besançon, France
| | - Aleksandra Torbica
- Centre for Research on Health and Social Care Management (CERGAS), Bocconi University, Via Sarfatti, 10 20136 Milan, Italy
| | - Ann Dorthe Zwisler
- Department of Cardiology, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense, Denmark
- REHPA, The Danish Knowledge Centre for Rehabilitation and Palliative Care, Odense University Hospital, Vestergade 17, 5800 Nyborg, Denmark
- Department of Clinical Research, University of Southern Denmark, Campusvej 55, DK-5230 Odense, Denmark
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Sharman Moser S, Tanser F, Siegelmann-Danieli N, Apter L, Chodick G, Solomon J. The reimbursement process in three national healthcare systems: variation in time to reimbursement of pembrolizumab for metastatic non-small cell lung cancer. J Pharm Policy Pract 2023; 16:22. [PMID: 36797806 PMCID: PMC9936745 DOI: 10.1186/s40545-023-00529-0] [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: 12/08/2022] [Accepted: 02/07/2023] [Indexed: 02/18/2023] Open
Abstract
In this article, we focus on the reimbursement process, and as an example, characterize the time to reimbursement of pembrolizumab, a PD-1 immune checkpoint inhibitor for treatment of metastatic NSCLC from publicly available websites, in three different healthcare systems: The National Institute for Health and Care Excellence (NICE) in the UK, the Pharmaceutical Benefits Advisory Committee (PBAC) in Australia, and the National Advisory Committee for the Basket of Health Services in Israel, all who have publicly funded health systems which include drug coverage. Our study found that there are substantial differences in time to reimbursement of pembrolizumab for the same conditions in different countries, with NICE and The National Advisory Committee for the Basket of Health Services in Israel approving one condition at the same time, Israel approving two conditions earlier than NICE, and PBAC lagging behind for every condition. These differences could be due to the differences in health policy systems and the many factors that affect reimbursement. Comparing the reimbursement process between different countries can highlight the challenges facing their health systems in early adoption of new treatments.
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Affiliation(s)
- Sarah Sharman Moser
- Maccabi Institute for Research and Innovation (Maccabitech), Maccabi Healthcare Services, 27 Hamered St, 6812509, Tel Aviv, Israel.
| | - Frank Tanser
- grid.36511.300000 0004 0420 4262Lincoln International Institute of Rural Health, Lincoln Medical School, University of Lincoln, Brayford Way, Brayford Pool, Lincoln, LN6 7TS UK
| | - Nava Siegelmann-Danieli
- grid.425380.8Maccabi Institute for Research and Innovation (Maccabitech), Maccabi Healthcare Services, 27 Hamered St, 6812509 Tel Aviv, Israel ,grid.12136.370000 0004 1937 0546Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Lior Apter
- grid.425380.8Maccabi Institute for Research and Innovation (Maccabitech), Maccabi Healthcare Services, 27 Hamered St, 6812509 Tel Aviv, Israel ,grid.7489.20000 0004 1937 0511Department of Health Systems Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Gabriel Chodick
- grid.425380.8Maccabi Institute for Research and Innovation (Maccabitech), Maccabi Healthcare Services, 27 Hamered St, 6812509 Tel Aviv, Israel ,grid.12136.370000 0004 1937 0546Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Josie Solomon
- grid.36511.300000 0004 0420 4262The School of Pharmacy, Joseph Banks Laboratories, University of Lincoln, Beevor Street, Lincoln, LN6 7DL UK
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Djordjevic D, McFadyen A, Anderson JA. Ethical challenges and opportunities in the development and approval of novel therapeutics for rare diseases. THE JOURNAL OF MEDICINE ACCESS 2023; 7:27550834231177507. [PMID: 37323852 PMCID: PMC10262601 DOI: 10.1177/27550834231177507] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 05/05/2023] [Indexed: 06/17/2023]
Abstract
The development of novel therapeutics for rare "orphan" diseases has brought a growing tension between the desire to accelerate access to these breakthrough therapies and the need to generate quality evidence regarding their safety and efficacy. Accelerating the pace of drug development and approval may facilitate the rapid delivery of benefits to patients and cost savings for research and development, which theoretically improves affordability of drugs for the health system. However, several ethical challenges arise with expedited approval, compassionate release of drugs, and subsequent study of drugs in "real-world" settings. In this article, we explore the changing landscape of drug approval and the ethical challenges expedited approval creates for patients, caregivers, clinicians, and institutions, and propose tangible strategies to maximize the benefits of "real-world" data acquisition while mitigating risks to patients, clinicians, and institutions.
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9
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Chauca Strand G, Bonander C, Jakobsson N, Johansson N, Svensson M. Assessment of the clinical and cost-effectiveness evidence in the reimbursement decisions of new cancer drugs. ESMO Open 2022; 7:100569. [PMID: 36037568 PMCID: PMC9588887 DOI: 10.1016/j.esmoop.2022.100569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/06/2022] [Accepted: 07/24/2022] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND This study aimed to describe the clinical and cost-effectiveness evidence supporting reimbursement decisions of new cancer drugs and analyze the influence of trial characteristics and the cost per quality-adjusted life years (QALYs) on the likelihood of reimbursement in Sweden. PATIENTS AND METHODS Data were extracted from all appraisal dossiers for new cancer drugs seeking reimbursement in Sweden and claiming added therapeutical value between the years 2010 and 2020. The data were analyzed using descriptive statistics, and logistic regression models were also used with the cost per QALY, study design, comparator, and evidence on final outcomes in the clinical trials as predictors of reimbursement. RESULTS All 60 included appraisals were based on trial evidence that assessed at least one final outcome (overall survival [OS] or quality of life [QoL]), although rarely as a primary outcome. Of the appraisals with a final decision (n = 58), 79% were approved for reimbursement. Among the reimbursed drugs, only half had trial evidence demonstrating improved OS or QoL. Only one drug had trial evidence supporting improvements in both OS and QoL. The average cost per QALY for reimbursed cancer drugs was estimated to be 748 560 SEK (€73 583). A higher cost per QALY was found to decrease the likelihood of reimbursement by 9.4% for every 100 000 SEK (€9830) higher cost per QALY (P = 0.03). For cost-effectiveness models without direct evidence of improvements in final outcomes, a larger QALY gain was observed compared with those with evidence mainly relying on intermediate and surrogate outcomes. CONCLUSIONS There are substantial uncertainties in the clinical and cost-effectiveness evidence underlying reimbursement decisions of new cancer drugs. Decision makers should be cautious of the limited evidence on patient-centered outcomes and the implications of allocating resources to expensive treatments with uncertain value for money.
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Affiliation(s)
- G Chauca Strand
- Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg.
| | - C Bonander
- Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg
| | - N Jakobsson
- Karlstad Business School, Karlstad University Faculty of Arts and Social Sciences, Karlstads Business School, Karlstad
| | - N Johansson
- Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg; University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - M Svensson
- Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg; Department of Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, Florida, USA
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10
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Using the Dynamic SWOT Analysis to Assess Options for Implementing the HB-HTA Model. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19127281. [PMID: 35742532 PMCID: PMC9224318 DOI: 10.3390/ijerph19127281] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/05/2022] [Accepted: 06/11/2022] [Indexed: 02/04/2023]
Abstract
This paper is aimed at exploring the role of the HB-HTA ecosystem as an important pathway for popularizing the implementation of innovations in healthcare organizations. The scientific debate has largely been focused on the rising importance of HB-HTA and the principles guiding the process. Solutions implemented by individual countries differ, which may be rooted in historical, cultural, and institutional differences. Our understanding of the impact of individual countries’ healthcare systems on HB-HTA solutions and infrastructure still lacks a basis in interpretative studies. A conceptual framework is proposed to assess the aptness of the HB-HTA model designed for hospitals operating in a country or region, focused on the concepts of adaptiveness and responsiveness to features of the healthcare system present there. A tool is proposed for investigating factors that are likely to assist the successful implementation of the HB-HTA ecosystem. A dynamic SWOT analysis on the case of the HB-HTA model designed for Poland provides interesting insights into the building of the conceptual framework. The results of this study help explain how to create an HB-HTA model that is best adapted to the regional or national healthcare system, including potential risks and opportunities.
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Sehdev S, Chambers A. Is It Time to Commit to a Process to Re-Evaluate Oncology Drugs? A Descriptive Analysis of Systemic Therapies for Solid Tumour Indications Reviewed in Canada from 2017 to 2021. Curr Oncol 2022; 29:1919-1931. [PMID: 35323356 PMCID: PMC8947363 DOI: 10.3390/curroncol29030156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 03/02/2022] [Accepted: 03/08/2022] [Indexed: 11/20/2022] Open
Abstract
We undertook an analysis of the Canadian Agency for Drugs and Technologies in Health (CADTH)’s health technology assessments (HTAs) of systemic therapies for solid tumour indications to determine if a mechanism to re-evaluate HTA decisions is needed based on the level of certainty supporting the original recommendation. To measure the certainty in the evidence, we analysed if: (1) overall survival (OS) was the primary endpoint in the pivotal trial, (2) median OS was available at the time of the recommendation, and (3) the expert review committee explicitly identified gaps in the evidence. There were 96 drugs approved by Health Canada that met our eligibility criteria between 1 January 2017 and 31 October 2021. Median OS was not estimable at the time of the recommendation in 57% of the positive recommendations, and the uncertainty in the magnitude of clinical benefit was identified by the expert review committee in 21% of the positive recommendations. There is uncertainty at the time of the HTA recommendation for many drugs, and thus a need to implement a process to re-evaluate drugs in Canada to allow patients timely access to promising therapies while ensuring long-term value of therapies to patients and the healthcare system.
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Affiliation(s)
- Sandeep Sehdev
- Division of Medical Oncology, Department of Medicine, The Ottawa Hospital Cancer Centre and The University of Ottawa, Ottawa, ON K1N 6N5, Canada;
| | - Alexandra Chambers
- Novartis Pharmaceuticals Inc. Canada, Dorval, ON H9S 1A9, Canada
- Correspondence:
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12
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Gałązka-Sobotka M, Kowalska-Bobko I, Lach K, Mela A, Furman M, Lipska I. Recommendations for the Implementation of Hospital Based HTA in Poland: Lessons Learned From International Experience. Front Pharmacol 2021; 11:594644. [PMID: 34054508 PMCID: PMC8155722 DOI: 10.3389/fphar.2020.594644] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 12/29/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction: The main challenge of modern hospitals is purchasing medical technologies. Hospital-based health technology assessments (HB-HTAs) are used in healthcare facilities around the world to support management boards in providing relevant technologies for patients. Aim: This study was undertaken to update the existing body of knowledge on the characteristics of HB-HTA systems/models in the selected European countries. Insights gained from this study were used to provide an optimal approach for implementing HB-HTA in Poland. Materials and methods: Firstly, we carried out a systematic review in PubMed and embase. Secondly, we searched for gray literature via the AdHopHTA online handbook and the design book of the AdHopHTA project, as well as literature describing healthcare systems provided by the WHO. Then, we conducted in-depth interviews with HB-HTA experts from four countries. Finally, we selected ten countries from Europe and prepared frameworks for data collection and analyses. Results: The selected countries (Switzerland, Spain, France, Italy, Denmark, Finland, Sweden, the Netherlands, and Austria) are examples of decentralized or deconcentrated healthcare systems. In terms of HB-HTA, differences in organisational models (independent group, stand-alone, integrated-essential, integrated-specialised), type of financing (internally vs. externally), collaboration with an HTA National Agency and other stakeholders (e.g., Patients' Associations) were identified. HB-HTA engages multi-skilled staff with various academic backgrounds and operates mainly on a voluntary basis. Conclusion: Strengths and weaknesses associated with various organisational models must be carefully considered in the context of support for decentralized or centralized models of implementation while embarking on HTA activities in Polish hospitals.
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Affiliation(s)
| | - Iwona Kowalska-Bobko
- Institute of Public Health, Faculty of Health Science, Jagiellonian University Medical College, Krakow, Poland
| | - Krzysztof Lach
- National Institute of Cardiology (Poland), Warsaw, Poland
| | - Aneta Mela
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Warsaw, Poland
| | - Maciej Furman
- Institute of Public Health, Faculty of Health Science, Jagiellonian University Medical College, Krakow, Poland
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13
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Bloem LT, Vreman RA, Peeters NWL, Hoekman J, van der Elst ME, Leufkens HGM, Klungel OH, Goettsch WG, Mantel-Teeuwisse AK. Associations between uncertainties identified by the European Medicines Agency and national decision making on reimbursement by HTA agencies. Clin Transl Sci 2021; 14:1566-1577. [PMID: 33786991 PMCID: PMC8301545 DOI: 10.1111/cts.13027] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 03/02/2021] [Accepted: 03/09/2021] [Indexed: 11/30/2022] Open
Abstract
We aimed to determine whether uncertainties identified by the European Medicines Agency (EMA) were associated with negative relative effectiveness assessments (REAs) and negative overall reimbursement recommendations by national health technology assessment (HTA) agencies. Therefore, we identified all HTA reports from Haute Autorité de Santé (HAS; France), National Institute for Health and Care Excellence (NICE; England/Wales), Scottish Medicine Consortium (SMC; Scotland), and Zorginstituut Nederland (ZIN; The Netherlands) for a cohort of innovative medicines that the EMA had approved in 2009 to 2010 (excluding vaccines). Uncertainty regarding pivotal trial methodology, clinical outcomes, and their clinical relevance were combined to reflect a low, medium, or high level of uncertainty. We assessed associations by calculating risk ratios (RRs) and 95% confidence intervals (CIs), and agreement between REA and overall reimbursement recommendation outcomes. We identified 36 medicines for which 121 reimbursement recommendations had been issued by the HTA agencies between September 2009 and July 2018. High versus low uncertainty was associated with an increased risk for negative REAs and negative overall reimbursement recommendations: RRs 1.9 (95% CI 0.9-3.9) and 1.6 (95% CI 0.7-3.5), respectively, which was supported by further sensitivity analyses. We identified a lack of agreement between 33 (27%) REA and overall reimbursement recommendation outcomes, which were mostly restricted recommendations that followed on negative REAs in case of low or medium uncertainty. In conclusion, high uncertainty identified by the EMA was associated with negative REAs and negative overall reimbursement recommendations. To reduce uncertainty and ultimately facilitate efficient patient access, regulators, HTA agencies, and other stakeholders should discuss how uncertainties should be weighed and addressed early in the drug life cycle of innovative treatments.
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Affiliation(s)
- Lourens T Bloem
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,Dutch Medicines Evaluation Board, Utrecht, The Netherlands
| | - Rick A Vreman
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,National Healthcare Institute, Diemen, The Netherlands
| | - Niels W L Peeters
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Jarno Hoekman
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,Innovation Studies, Copernicus Institute of Sustainable Development, Utrecht University, Utrecht, The Netherlands
| | | | - Hubert G M Leufkens
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Olaf H Klungel
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.,Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | | | - Aukje K Mantel-Teeuwisse
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
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14
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Wranik WD, Székely RR, Mayer S, Hiligsmann M, Cheung KL. The most important facilitators and barriers to the use of Health Technology Assessment in Canada: a best-worst scaling approach. J Med Econ 2021; 24:846-856. [PMID: 34162282 DOI: 10.1080/13696998.2021.1946326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Health Technology Assessment (HTA), which can support public drug reimbursement decisions will play a core function in the planned national Pharmacare program in Canada. To address existing barriers to the use of HTA, these must be ranked in order of priority. The goal of this study was to access the relative importance of known facilitators and barriers to the use of HTA in the context of the Canadian health care system, with attention to differences between regions and stakeholder groups. METHODS We used the best-worst scaling object case approach to elicit a quantitative ranking of a list of 20 facilitators and 22 barriers. A sample of 68 Canadian HTA stakeholders, including members of expert committees, decision/policymakers, researchers/academics, and others participated in the study. Their task was to identify the most important and the least important item in 12 sub-sets of five facilitators and 14 sub-sets of five barriers. FINDINGS Relative Importance Scores derived via hierarchical Bayes analysis revealed relations, engagement, and contact between stakeholders as most important on both the barrier and facilitator sides. Other top-ranked facilitators included the availably of credible and relevant research. Other top-ranked barriers included inconsistencies in the evidence and limited generalizability. The availability of HTA guidelines did not rank highly on either side. The main limitation of the study was the challenge with reaching the relevant respondents; this was mitigated by involving the national HTA agency in the research. CONCLUSION Canadian stakeholders consider the relationships within the HTA network among the most important. Policies should focus on strengthening these relationships. Future research should focus on the connectivity and distribution of knowledge and power within the HTA network.
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Affiliation(s)
- Wiesława Dominika Wranik
- Faculty of Management, School of Public Administration, Dalhousie University, Halifax, Canada
- Faculty of Medicine, Department of Community Health and Epidemiology, Dalhousie University, Halifax, Canada
- Jean Monnet European Union Centre of Excellence, Dalhousie University, Halifax, Canada
| | - Ronaldo-Raul Székely
- Division of Academic Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Susanne Mayer
- Department of Health Economics, Center for Public Health, Medical University of Vienna, Vienna, Austria
| | - Mickaël Hiligsmann
- Faculty of Health Medicine and Life Sciences, School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Kei Long Cheung
- Health Behaviour Change Research Group, Department of Health Sciences, College of Health and Life Sciences, Brunel University London, London, UK
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15
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Vanness DJ, Lomas J, Ahn H. A Health Opportunity Cost Threshold for Cost-Effectiveness Analysis in the United States. Ann Intern Med 2021; 174:25-32. [PMID: 33136426 DOI: 10.7326/m20-1392] [Citation(s) in RCA: 91] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Cost-effectiveness analysis is an important tool for informing treatment coverage and pricing decisions, yet no consensus exists about what threshold for the incremental cost-effectiveness ratio (ICER) in dollars per quality-adjusted life-year (QALY) gained indicates whether treatments are likely to be cost-effective in the United States. OBJECTIVE To estimate a U.S. cost-effectiveness threshold based on health opportunity costs. DESIGN Simulation of short-term mortality and morbidity attributable to persons dropping health insurance due to increased health care expenditures passed though as premium increases. Model inputs came from demographic data and the literature; 95% uncertainty intervals (UIs) were constructed. SETTING Population-based. PARTICIPANTS Simulated cohort of 100 000 individuals from the U.S. population with direct-purchase private health insurance. MEASUREMENTS Number of persons dropping insurance coverage, number of additional deaths, and QALYs lost from increased mortality and morbidity, all per increase of $10 000 000 (2019 U.S. dollars) in population treatment cost. RESULTS Per $10 000 000 increase in health care expenditures, 1860 persons (95% UI, 1080 to 2840 persons) were simulated to become uninsured, causing 5 deaths (UI, 3 to 11 deaths), 81 QALYs (UI, 40 to 170 QALYs) lost due to death, and 15 QALYs (UI, 6 to 32 QALYs) lost due to illness; this implies a cost-effectiveness threshold of $104 000 per QALY (UI, $51 000 to $209 000 per QALY) in 2019 U.S. dollars. Given available evidence, there is about 14% probability that the threshold exceeds $150 000 per QALY and about 48% probability that it lies below $100 000 per QALY. LIMITATIONS Estimates were sensitive to inputs, most notably the effects of losing insurance on mortality and of premium increases on becoming uninsured. Health opportunity costs may vary by population. Nonhealth opportunity costs were excluded. CONCLUSION Given current evidence, treatments with ICERs above the range $100 000 to $150 000 per QALY are unlikely to be cost-effective in the United States. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- David J Vanness
- Pennsylvania State University, University Park, Pennsylvania (D.J.V., H.A.)
| | - James Lomas
- University of York, York, United Kingdom (J.L.)
| | - Hannah Ahn
- Pennsylvania State University, University Park, Pennsylvania (D.J.V., H.A.)
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16
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Neubert A, Brito Fernandes Ó, Lucevic A, Pavlova M, Gulácsi L, Baji P, Klazinga N, Kringos D. Understanding the use of patient-reported data by health care insurers: A scoping review. PLoS One 2020; 15:e0244546. [PMID: 33370405 PMCID: PMC7769438 DOI: 10.1371/journal.pone.0244546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 12/11/2020] [Indexed: 12/03/2022] Open
Abstract
Background Patient-reported data are widely used for many purposes by different actors within a health system. However, little is known about the use of such data by health insurers. Our study aims to map the evidence on the use of patient-reported data by health insurers; to explore how collected patient-reported data are utilized; and to elucidate the motives of why patient-reported data are collected by health insurers. Methods The study design is that of a scoping review. In total, 11 databases were searched on. Relevant grey literature was identified through online searches, reference mining and recommendations from experts. Forty-two documents were included. We synthesized the evidence on the uses of patient-reported data by insurers following a structure-process-outcome approach; we also mapped the use and function of those data by a health insurer. Results Health insurers use patient-reported data for assurance and improvement of quality of care and value-based health care. The patient-reported data most often collected are those of outcomes, experiences and satisfaction measures; structure indicators are used to a lesser extent and often combined with process indicators. These data are mainly used for the purposes of procurement and purchasing of services, quality assurance, improvement and reporting, and strengthening the involvement of insured people. Conclusions The breadth to which insurers use patient-reported data in their business models varies greatly. Some hindering factors to the uptake of such data are the varying and overlapping terminology in use in the field and the limited involvement of insured people in a health insurer’s business. Health insurers are advised to be more explicit in regard to the role they want to play within the health system and society at large, and accommodate implications for the use of patient-reported data accordingly.
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Affiliation(s)
- Anne Neubert
- Department of Orthopaedics and Traumatology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Institute for Health Service Research and Health Economics, Centre for Health and Society, Heinrich-Heine-University, Düsseldorf, Germany
| | - Óscar Brito Fernandes
- Department of Health Economics, Corvinus University of Budapest, Budapest, Hungary
- Department of Public and Occupational Health, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health research institute, Amsterdam, The Netherlands
- * E-mail:
| | - Armin Lucevic
- Department of Health Economics, Corvinus University of Budapest, Budapest, Hungary
- Department of Public and Occupational Health, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health research institute, Amsterdam, The Netherlands
| | - Milena Pavlova
- Department of Health Services Research, CAPHRI, Maastricht University Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht University, The Netherlands
| | - László Gulácsi
- Department of Health Economics, Corvinus University of Budapest, Budapest, Hungary
| | - Petra Baji
- Department of Health Economics, Corvinus University of Budapest, Budapest, Hungary
| | - Niek Klazinga
- Department of Public and Occupational Health, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health research institute, Amsterdam, The Netherlands
| | - Dionne Kringos
- Department of Public and Occupational Health, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health research institute, Amsterdam, The Netherlands
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17
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Wranik WD, Gambold L, Peacock S. Uncertainty tolerance among experts involved in drug reimbursement recommendations: Qualitative evidence from HTA committees in Canada and Poland. Health Policy 2020; 125:307-319. [PMID: 33388158 DOI: 10.1016/j.healthpol.2020.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 11/09/2020] [Accepted: 12/15/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Drug reimbursement decisions often rely on health technology assessment (HTA). Increasingly, new drugs have limited clinical evidence and uncertain clinical benefit. Our goal was to describe how members of drug advisory committees and other stakeholders conceptualize and tolerate uncertainty and how they rationalize uncertainty tolerance. METHODS Our triangulated parallel design applied two qualitative methods. We interviewed 31 members of drug advisory committees in Canada and Poland about their information needs and included hypothetical scenarios with uncertain clinical benefits. Respondents speculated about their likely reimbursement recommendation. We analyzed written recommendations of the pan Canadian Oncology Drug Review for drugs with uncertain benefit and compared initial recommendations to the responses from patient and clinician groups. RESULTS Uncertainty tolerance varied among committee members and across jurisdictions. In the scenario analysis, 7 Canadian and 11 Polish respondents leaned against recommending a hypothetical drug with uncertain clinical benefit, whereas 5 Canadian and 5 Polish respondents leaned in favour. Those against rationalized that uncertainty increases potential harm; those in favour rationalized that patients often have no alternatives. The document analysis revealed that patients had higher uncertainty tolerance in general. CONCLUSIONS Uncertainty tolerance varies among committee members and other stakeholders depending on their backgrounds and on the decision contexts. We argue that policy guidance around uncertainty management could improve the transparency and consistency of recommendations.
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Affiliation(s)
- Wiesława Dominika Wranik
- School of Public Administration, Faculty of Management, Dahousie University, 6100 University Avenue, Halifax, Nova Scotia, B3H 3N4, Canada; Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Jean Monnet European Union Centre for Excellence, Dalhousie University, 6299 South Street, Halifax, Nova Scotia, B3H 4R2, Canada; College of Economic Analysis, SGH Warsaw School of Economics, ul. Madalińskiego 6/8, 02-513 Warszawa, Poland.
| | - Liesl Gambold
- Department of Sociology and Social Anthropology, Dalhousie University, 6135 University Avenue, Halifax, Nova Scotia, B3H 4R2, Canada; Jean Monnet European Union Centre for Excellence, Dalhousie University, 6299 South Street, Halifax, Nova Scotia, B3H 4R2, Canada
| | - Stuart Peacock
- Canadian Centre for Applied Research in Cancer Control ARCC, 675 West 10(th) Avenue, Vancouver, British Columbia V5Z 1L3, Canada; Cancer Control Research, BC Cancer Agency Research Centre, 675 West 10(th) Avenue, Vancouver, British Columbia V5Z 1L3, Canada; Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, British Columbia, V5A 1S6, Canada
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18
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Hill-McManus D, Hughes DA. Combining Model-Based Clinical Trial Simulation, Pharmacoeconomics, and Value of Information to Optimize Trial Design. CPT-PHARMACOMETRICS & SYSTEMS PHARMACOLOGY 2020; 10:75-83. [PMID: 33314752 PMCID: PMC7825194 DOI: 10.1002/psp4.12579] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 10/20/2020] [Indexed: 11/25/2022]
Abstract
The Bayesian decision‐analytic approach to trial design uses prior distributions for treatment effects, updated with likelihoods for proposed trial data. Prior distributions for treatment effects based on previous trial results risks sample selection bias and difficulties when a proposed trial differs in terms of patient characteristics, medication adherence, or treatment doses and regimens. The aim of this study was to demonstrate the utility of using pharmacometric‐based clinical trial simulation (CTS) to generate prior distributions for use in Bayesian decision‐theoretic trial design. The methods consisted of four principal stages: a CTS to predict the distribution of treatment response for a range of trial designs; Bayesian updating for a proposed sample size; a pharmacoeconomic model to represent the perspective of a reimbursement authority in which price is contingent on trial outcome; and a model of the pharmaceutical company return on investment linking drug prices to sales revenue. We used a case study of febuxostat versus allopurinol for the treatment of hyperuricemia in patients with gout. Trial design scenarios studied included alternative treatment doses, inclusion criteria, input uncertainty, and sample size. Optimal trial sample sizes varied depending on the uncertainty of model inputs, trial inclusion criteria, and treatment doses. This interdisciplinary framework for trial design and sample size calculation may have value in supporting decisions during later phases of drug development and in identifying costly sources of uncertainty, and thus inform future research and development strategies.
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Affiliation(s)
- Daniel Hill-McManus
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Dyfrig A Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
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19
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Hill-McManus D, Marshall S, Liu J, Willke RJ, Hughes DA. Linked Pharmacometric-Pharmacoeconomic Modeling and Simulation in Clinical Drug Development. Clin Pharmacol Ther 2020; 110:49-63. [PMID: 32936931 DOI: 10.1002/cpt.2051] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 08/24/2020] [Indexed: 12/16/2022]
Abstract
Market access and pricing of pharmaceuticals are increasingly contingent on the ability to demonstrate comparative effectiveness and cost-effectiveness. As such, it is widely recognized that predictions of the economic potential of drug candidates in development could inform decisions across the product life cycle. This may be challenging when safety and efficacy profiles in terms of the relevant clinical outcomes are unknown or highly uncertain early in product development. Linking pharmacometrics and pharmacoeconomics, such that outputs from pharmacometric models serve as inputs to pharmacoeconomic models, may provide a framework for extrapolating from early-phase studies to predict economic outcomes and characterize decision uncertainty. This article reviews the published studies that have implemented this methodology and used simulation to inform drug development decisions and/or to optimize the use of drug treatments. Some of the key practical issues involved in linking pharmacometrics and pharmacoeconomics, including the choice of final outcome measures, methods of incorporating evidence on comparator treatments, approaches to handling multiple intermediate end points, approaches to quantifying uncertainty, and issues of model validation are also discussed. Finally, we have considered the potential barriers that may have limited the adoption of this methodology and suggest that closer alignment between the disciplines of clinical pharmacology, pharmacometrics, and pharmacoeconomics, may help to realize the potential benefits associated with linked pharmacometric-pharmacoeconomic modeling and simulation.
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Affiliation(s)
- Daniel Hill-McManus
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | | | - Jing Liu
- Clinical Pharmacology, Pfizer Inc, Groton, Connecticut, USA
| | | | - Dyfrig A Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
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20
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Abstract
OBJECTIVES Despite the efforts of the European Union (EU) to promote voluntary cooperation among Health Technology Assessment (HTA) agencies, different reimbursement decisions for the same drug are made across European countries. The aim of this paper is to compare the agreement of cancer drug reimbursement decisions using inter-rater reliability measures. METHODS This study is based on primary data on 161 cancer drug reimbursement decisions from nine European countries from 2002 to 2014. To achieve our goal, we use two measures to analyze agreement, in other words, congruency: (i) percentage of agreement and (ii) the κ score. RESULTS One main conclusion can be drawn from the analysis. There is a weak to medium agreement among cancer drug decisions in the European countries analyzed (based on the percentage of agreement and the κ score). England and Scotland show the highest consistency between the two measures, showing a medium agreement. These results are in line with previous literature on the congruency of HTA decisions. CONCLUSIONS This paper contributes to the HTA literature, by highlighting the extent of weak to medium agreement among cancer decisions in Europe.
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21
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Salas-Vega S, Shearer E, Mossialos E. Relationship between costs and clinical benefits of new cancer medicines in Australia, France, the UK, and the US. Soc Sci Med 2020; 258:113042. [PMID: 32480184 DOI: 10.1016/j.socscimed.2020.113042] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 04/30/2020] [Accepted: 05/05/2020] [Indexed: 12/19/2022]
Abstract
As cancer drug prices rise, it remains unclear whether the cost of new interventions is related to their beneficial impact for patients at a societal-level. Using data for 2003-2015 from the IQVIA MIDAS® dataset, the relationship between cancer drug costs and drug clinical benefits was studied in four countries with different approaches to drug pricing. Summary measures of drug clinical effects on overall survival, quality of life, and safety were obtained from a review of health technology assessments. Mean total drug costs for a full course of treatment were estimated using standard posology for each medicine and in each country. Regression analysis was used to test whether, at a societal-level, the cost of recently licensed drugs is related to their beneficial impact for patients. Across all eligible medicines, average treatment costs were lowest in France and Australia and highest in the UK and US. Compared with Australia, France, and the UK, cancer medicines were on average between 1.2 and 1.9 times more expensive in the US, where the average total per patient cost for treatment was $68,255.17. Costs for new cancer medicines are high and, at best, only weakly associated with drug clinical benefits. The strength of this relationship nevertheless varied across countries. Some new cancer drugs-particularly in the US-may be neither affordable nor clinically beneficial over existing treatments. While all countries can benefit from strategies that more robustly align price with therapeutic benefit in cancer drugs, the US stands out in its opportunity to improve both affordability and value in cancer drug treatment.
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Affiliation(s)
- Sebastian Salas-Vega
- Fellow in Health Policy and Economics, London School of Economics and Political Science, Houghton Street, London, UK.
| | - Emily Shearer
- Research Associate, Department of Health Research and Policy, Stanford University, Palo Alto, CA, USA
| | - Elias Mossialos
- Brian-Abel Smith Professor of Health Policy, London School of Economics and Political Science, Houghton Street, London, UK
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22
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Ueda A, Toki S, Kitayama C, Akazawa M. Reduction in the Doses of Direct Oral Anticoagulants and Risk of Ischemic Stroke Events: A Hospital Survey. Biol Pharm Bull 2020; 43:1135-1140. [PMID: 32404542 DOI: 10.1248/bpb.b19-00798] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Inappropriately reduced doses (IRDs) of direct oral anticoagulants (DOACs) are common in clinical practice. We performed a retrospective review using electronic medical records of St. Marianna University School of Medicine Hospital (a 1200-bed teaching hospital in Japan) to address the prevalence of IRDs and patient-related factors that result in IRDs. We also surveyed DOAC-treated patients who were hospitalized due to a stroke during the 5-year study period to analyze the association between stroke events and IRDs. We found that one in five patients who were newly prescribed a DOAC was treated with IRDs. Patients treated with edoxaban received the most IRDs (64%, 7/11), followed by those treated with dabigatran (50%, 1/2), apixaban (32%, 19/61), and rivaroxaban (27%, 12/44). Our analysis showed that the renal function (measured as serum creatinine and creatinine clearance values) and age are possible factors influencing dose reduction. The HAS-BLED score and antiplatelet use were not associated with IRD prescription. An analysis of the 5-year hospital records revealed 20 stroke cases despite ongoing treatments with DOACs, and IRDs were noted in three of these cases. In all three cases, the patients had been on an IRD of rivaroxaban. To prevent IRDs of DOACs, we suggest that a clinical protocol be incorporated into formularies to support the prescription process.
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Affiliation(s)
- Aya Ueda
- Nihon Chouzai Co., Ltd.,Department of Pharmacy, St. Marianna School of Medicine Hospital.,Department of Public Health and Epidemiology, Meiji Pharmaceutical University
| | - Shinji Toki
- Department of Pharmacy, St. Marianna School of Medicine Hospital
| | - Chisato Kitayama
- Department of Pharmacy, St. Marianna School of Medicine Hospital
| | - Manabu Akazawa
- Department of Public Health and Epidemiology, Meiji Pharmaceutical University
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Govaerts L, Simoens S, Van Dyck W, Huys I. Shedding Light on Reimbursement Policies of Companion Diagnostics in European Countries. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:606-615. [PMID: 32389226 DOI: 10.1016/j.jval.2020.01.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 01/12/2020] [Accepted: 01/24/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES Ensuring access to precision medicine has been an issue because in some European countries, desynchronized reimbursement decision-making occurs between the medicine and the companion diagnostic (CDx). This has resulted in cases in which precision medicine is reimbursed but not the CDx. In overcoming this issue, an alignment of the decision-making process for reimbursement between the 2 entities should be considered. As pharmaceutical reimbursement procedures are meticulously covered in the literature, we set out to systematically map in vitro diagnostic (IVD) reimbursement procedures and identify policies for aligning these procedures with the pharmaceutical reimbursement procedures. METHODS We selected 8 European countries for this analysis. For each country, we characterized the national benefit basket entailing the IVD medical acts in outpatient care, evaluated the procedure for inclusion, and identified alternative reimbursement practices for CDx. Targeted searches, using publicly accessible sources, were conducted to identify relevant reimbursement policies and laws. RESULTS We systematically describe the reimbursement process in 8 European countries. Alternative procedures for CDx reimbursement were identified in Belgium and Germany. Alternative policies attributed to the practice of precision medicine were identified in England and Italy. In France, some CDx are included in the "coverage with evidence" development program. Specifically, the health technology assessment agencies of France and England commented on the assessment of companion diagnostics and their clinical utility. CONCLUSION CDx reimbursement procedures have recently been implemented in some countries. This was seemingly done primarily to ensure access to the precision medicine and only secondary to the value they would provide.
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Affiliation(s)
- Laurenz Govaerts
- Department of Pharmaceutical and Pharmacological Sciences, Catholic University of Leuven, Leuven, Belgium; Healthcare Management Centre, Vlerick Business School, Ghent, Belgium.
| | - Steven Simoens
- Department of Pharmaceutical and Pharmacological Sciences, Catholic University of Leuven, Leuven, Belgium
| | - Walter Van Dyck
- Healthcare Management Centre, Vlerick Business School, Ghent, Belgium
| | - Isabelle Huys
- Department of Pharmaceutical and Pharmacological Sciences, Catholic University of Leuven, Leuven, Belgium
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Wranik WD, Jakubczyk M, Drachal K. Ranking the Criteria Used in the Appraisal of Drugs for Reimbursement: A Stated Preferences Elicitation With Health Technology Assessment Stakeholders Across Jurisdictional Contexts. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:471-480. [PMID: 32327164 DOI: 10.1016/j.jval.2019.10.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 09/27/2019] [Accepted: 10/28/2019] [Indexed: 06/11/2023]
Abstract
OBJECTIVES Our goal was to estimate the relative importance assigned to health technology assessment (HTA) criteria by stakeholders involved in the HTA process. HTA is an increasingly common framework used in the appraisal of drugs for public reimbursement. It identifies clinical, economic, social, and organizational criteria to be considered. The criteria can vary across jurisdictions and are typically appraised by multidisciplinary expert committees. Guidance on the relative weighing of criteria is often absent. METHODS We elicited stakeholders' preferences using a single-scenario discrete choice experiment and a best-worst scaling model with conviction scores to assess the weights assigned to selected criteria by HTA stakeholders. We recruited 111 HTA stakeholders across multiple jurisdictions, including members of expert committees, clinical and economic experts, patients, and public payer representatives. Each judged twelve hypothetical cancer drug profiles for suitability for public funding and identified which characteristics were best and worst. In addition to standard discrete choice experiment and best-worst scaling models, we estimated a hybrid model to obtain a ranking of criteria by importance they played in the appraisal. RESULTS A strong clinical benefit proved the most important criterion, followed by cost considerations, presence of adverse events, and availability of other treatments. The importance of clinical benefit was moderated by unmet need, adverse events, and number of patients. CONCLUSION Policymakers might want to consider providing an explicit weighing scheme, or moving to a 2-stage selection process with an assessment of the quality of clinical evidence as a gatekeeping step for a full HTA review.
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Affiliation(s)
- Wiesława Dominika Wranik
- School of Public Administration, Dalhousie University, Halifax, Canada; College of Economic Analysis, SGH Warsaw School of Economics, Warszawa, Poland; Department of Community Health and Epidemiology, Dalhousie University, Halifax, Canada.
| | - Michał Jakubczyk
- College of Economic Analysis, SGH Warsaw School of Economics, Warszawa, Poland
| | - Krzysztof Drachal
- Faculty of Economic Sciences, University of Warsaw, Warszawa, Poland
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Torbica A, Fornaro G, Tarricone R, Drummond MF. Do Social Values and Institutional Context Shape the Use of Economic Evaluation in Reimbursement Decisions? An Empirical Analysis. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:17-24. [PMID: 31952668 DOI: 10.1016/j.jval.2019.11.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 11/01/2019] [Accepted: 11/01/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To investigate whether the use of economic evaluation (EE) in healthcare decision making is influenced by the social values and institutional context in a given country. METHODS We developed and tested a conceptual framework for the 36 Organisation for Economic Co-operation and Development (OECD) countries. The countries were divided into two groups based on the extent of their use of EE in drug reimbursement. The key social values were efficiency, equity, and personal responsibility, measured in an international survey. Countries were classified based on their institutional context in terms of their general welfare paradigm/type of healthcare system and the administrative tradition to which they belong. We performed correlation tests and ran path analysis regression models to test our hypotheses. RESULTS EE high users included significantly more Beveridge-type systems (50% vs 31%) and fewer Bismarck-type (15% vs 56%). Napoleonic tradition countries seemed to reject personal responsibility in health (r = -0.511, P = .009), whereas Germanic tradition countries embraced it (r = 0.572, P = .003); Anglo-American tradition countries exhibited a significant association with efficiency (r = 0.444, P = .026), whereas Scandinavian tradition countries appeared to reject it as a criterion for rationing in healthcare (r = -0.454, P = .023). No significant direct association was found between social values and use of EE. CONCLUSION Our exploratory analysis suggests that institutional context and, indirectly, social values may play a role in shaping the use of EE in healthcare decision making. Because of the differences among countries in terms of institutional context, which may in part be influenced by social values, it is unlikely that there will ever be a single, harmonious approach to the use of EE.
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Affiliation(s)
- Aleksandra Torbica
- Centre for Research on Health and Social Care Management, Bocconi University, Milan, Italy.
| | - Giulia Fornaro
- Centre for Research on Health and Social Care Management, Bocconi University, Milan, Italy
| | - Rosanna Tarricone
- Centre for Research on Health and Social Care Management, Bocconi University, Milan, Italy
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Tesar T, Golias P, Inotai A, Kawalec P, Wawruch M. The impact of implemented regulations on biosimilars in Slovakia. HEALTH POLICY AND TECHNOLOGY 2019. [DOI: 10.1016/j.hlpt.2019.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Schwarzinger M, Luchini S. Estimating health state utility from activities of daily living in the French National Hospital Discharge Database: a feasibility study with head and neck cancer. Health Qual Life Outcomes 2019; 17:129. [PMID: 31345227 PMCID: PMC6659251 DOI: 10.1186/s12955-019-1195-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 07/10/2019] [Indexed: 11/24/2022] Open
Abstract
Background Health state utility (HSU) is a core component of QALYs and cost-effectiveness analysis, although HSU is rarely estimated among a representative sample of patients. We explored the feasibility of assessing HSU in head and neck cancer from the French National Hospital Discharge database. Methods An exhaustive sample of 53,258 incident adult patients with a first diagnosis of head and neck cancer was identified in 2010–2012. We used a cross-sectional approach to define five health states over two periods: three "cancer stages at initial treatment" (early, locally advanced or metastatic stage); a "relapse state" and otherwise a "relapse-free state" in the follow-up of patients initially treated at early or locally advanced stage. In patients admitted in post-acute care, a two-parameter graded response model (Item Response Theory) was estimated from all 144,012 records of six Activities of Daily Living (ADLs) and the latent health state scale underlying ADLs was calibrated with the French EQ-5D-3 L social value set. Following linear interpolation between all assessments of the patient, daily estimates of utility in post-acute care were averaged by health state, patient and month of follow-up. Finally, HSU was estimated by health state and month of follow-up for the whole patient population after controlling for survivorship and selection in post-acute care. Results Head and neck cancer was generally associated with poor HSU estimates in a real-life setting. As compared to “distant metastasis at initial treatment”, mean HSU was higher in other health states, although numerical differences were small (0.45 versus around 0.54). It was primarily explained by the negative effects on HSU of an older age (38.4% aged ≥70 years in “early stage at initial treatment”) and comorbidities (> 50% in other health states). HSU estimates significantly improved over time in the “relapse-free state” (from 8 to 12 months of follow-up). Conclusions HSU estimates in head and neck cancer were primarily driven by age at diagnosis, comorbidities, and time to assessment of cancer survivors. This feasibility study highlights the potential of estimating HSU within and across severe conditions in a systematic way at the national level. Electronic supplementary material The online version of this article (10.1186/s12955-019-1195-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michaël Schwarzinger
- Translational Health Economics Network (THEN), 39 quai de Valmy, 75010, Paris, France. .,Infection Antimicrobials Modeling & Evolution (IAME), UMR 1137, Institut National de la Santé et de la Recherche Médicale (INSERM), Université Paris Diderot, Sorbonne Paris Cité, Paris, France.
| | - Stéphane Luchini
- Aix-Marseille University (Aix-Marseille School of Economics), Centre National de la Recherche Scientifique and EHESS Marseille, Marseille, France
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Tesar T, Obsitnik B, Kaló Z, Kristensen FB. How Changes in Reimbursement Practices Influence the Financial Sustainability of Medicine Policy: Lessons Learned from Slovakia. Front Pharmacol 2019; 10:664. [PMID: 31249529 PMCID: PMC6584090 DOI: 10.3389/fphar.2019.00664] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 05/23/2019] [Indexed: 11/13/2022] Open
Abstract
Objectives: The aim of this study was to review the impact of new reimbursement requirements for medicines in the Slovak Republic based on legislation that came into force in January 2018. Methods: The new legislation was reviewed. The reimbursement dossiers for medicines and health technology assessments and appraisals, justifications for reimbursement decisions, final reimbursement decisions, and all aspects of the appeal mechanisms have been transparently published on the website of the Slovak Ministry of Health and were used for this analysis. Results: Based on the new legislation, there was no need to submit information about relative effectiveness and cost-effectiveness of medicines with less than 1:50,000 eligible patients prior to reimbursement decisions, and the cost-effectiveness threshold has been increased for all other medicines. The estimated impact of the 2-year budget for the 59 medicines submitted for reimbursement without relative effectiveness and cost-effectiveness analysis was €181,273,698, based on the published submission dossiers. The estimated impact of the 2-year budget for the 45 medicines with evidence of relative effectiveness and cost-effectiveness was €178,566,634. In contrast to the easier market access criteria for new original medicines, the new legislation enforces stricter price erosion criteria for generic and biosimilar medicines. Consequently, the number of generic and biosimilar entries was reduced from 242 in 2017 to 224 in 2018. Conclusions: Although some of the new reimbursement applications were not approved by the Ministry of Health, many new medicines were added to the Slovak pharmaceutical reimbursement list based on "balanced assessment" requirements; hence, the system became financially unsustainable. It was necessary to change the legislation from January 2019.
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Affiliation(s)
- Tomas Tesar
- Department of Organisation and Management in Pharmacy, Faculty of Pharmacy, Comenius University in Bratislava, Slovakia
| | | | - Zoltán Kaló
- Syreon Research Institute, Budapest, Hungary
- Department of Health Policy and Health Economics, Eötvös Loránd University (ELTE), Budapest, Hungary
| | - Finn Børlum Kristensen
- Research Unit of User Perspectives, Department of Public Health, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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Löblová O, Csanádi M, Ozierański P, Kaló Z, King L, McKee M. Patterns of alternative access: Unpacking the Slovak extraordinary drug reimbursement regime 2012-2016. Health Policy 2019; 123:713-720. [PMID: 31277882 DOI: 10.1016/j.healthpol.2019.05.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 05/23/2019] [Accepted: 05/31/2019] [Indexed: 01/13/2023]
Abstract
Many countries employ "alternative access schemes" (e.g. compassionate use, early access programs, off-label use) that seek to provide patients with access to drugs not included on a positive drug list. These schemes offer flexibility to policy-makers but often lack transparency and clear rules. This ambiguity allows for dynamic responses to weaknesses in the main drug approval and reimbursement systems, but also opportunistic use by the health professionals, industry or patients. Yet, most descriptions of these schemes focus on the de jure rather than the de facto situation, presenting a potentially misleading picture. We describe one such scheme in practice: the Slovak "extraordinary reimbursement regime" (ERR), using semi-structured interviews with 18 experts and a new dataset of ERR drugs. The ERR expanded rapidly, doubling between 2012 and 2016. It combined features of four reimbursement schemes: (1) a backdoor market access for expensive drugs; (2) a compassionate use scheme for investigational drugs combined with a "legacy drugs" scheme for older unlicensed drugs; (3) a disease-specific scheme for cancer and orphan drugs; and (4) a scheme for off-label and "off-indication" drugs. These four features reflect broader challenges facing the Slovak reimbursement system. We conclude that detailed study of the type, size and evolution over time of alternative access schemes can serve as indicators of health policy objectives neglected by standard reimbursement systems.
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Affiliation(s)
- Olga Löblová
- Department of Sociology, University of Cambridge, Cambridge, United Kingdom.
| | - Marcell Csanádi
- Doctoral School of Pharmacological and Pharmaceutical Sciences, University of Pécs, Hungary; Syreon Research Institute, Budapest, Hungary
| | - Piotr Ozierański
- Department of Social and Policy Sciences, University of Bath, Bath, United Kingdom
| | - Zoltán Kaló
- Department of Health Policy and Health Economics, Eötvös Loránd University, Budapest, Hungary; Syreon Research Institute, Budapest, Hungary
| | - Lawrence King
- Department of Economics, University of Massachusetts, Amherst, MA, United States
| | - Martin McKee
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
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HTA and decision-making processes in Central, Eastern and South Eastern Europe: Results from a survey. Health Policy 2019; 123:182-190. [DOI: 10.1016/j.healthpol.2017.03.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 01/04/2017] [Accepted: 03/20/2017] [Indexed: 11/20/2022]
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Maynou L, Cairns J. What is driving HTA decision-making? Evidence from cancer drug reimbursement decisions from 6 European countries. Health Policy 2018; 123:130-139. [PMID: 30477736 DOI: 10.1016/j.healthpol.2018.11.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 10/24/2018] [Accepted: 11/05/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Decisions on the reimbursement of the same cancer drugs are different across European countries, but empirical work on the reasons behind these differences has been scarce. The main objective of this paper is to make a methodological contribution to existing research, specifically by outlining the systematic process of analysis to address such questions and determining the factors that might lead to different drug reimbursement decisions, and to explore its application in the field of oncology. METHODS Reimbursement decisions on cancer drugs in six European countries (Belgium, England, Poland, Portugal, Scotland, and Sweden) between 2006 and 2014 were included in the study. A taxonomy was developed, comprising two groups of variables (system-level and product-specific) and an econometric model was specified (multilevel mixed-effects ordered probit). RESULTS Only one in six evaluations in the sample reach the same reimbursement recommendation. Most health system variables were not determinants of a higher or lower probability of a positive reimbursement recommendation. However, the probability of reimbursement was higher when a drug was considered cost-effective by NICE/SMC and when there was a financial Managed Entry Agreement. This work also demonstrated a possible econometric approach for analysing differences in reimbursement decisions and contributes a structured approach for collecting and preparing data for such analyses. CONCLUSIONS Drug reimbursement decisions can be analysed in detail along a set of factors that are related to each decision. This information is essential, not only for understanding why a particular drug is accepted in one country and not in another but also when trying to implement a new HTA system or reform an existing one. This analysis provides policy makers and stakeholders with a model that enables a better understanding of the factors that drive HTA decisions and is adaptable to answer similar questions. Moreover, the data collection limitations encountered and described in this work shed light on the need for greater accessibility and transparency in HTA systems and regarding HTA outcomes.
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Affiliation(s)
- Laia Maynou
- London School of Economics and Political Science, Health Policy, United Kingdom; Center for Research in Health and Economics (CRES), University Pompeu Fabra, Spain; Research Group on Statistics, Econometrics and Health (GRECS), University of Girona, Spain; London School of Hygiene and Tropical Medicine, United Kingdom.
| | - John Cairns
- London School of Hygiene and Tropical Medicine, United Kingdom; CCBIO, University of Bergen, Norway
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Wranik WD, Skedgel C, Hu M. Drug attributes associated with the selection of drugs for reimbursement: a pilot stated preferences experiment with Canadian stakeholders. Expert Rev Pharmacoecon Outcomes Res 2018; 19:59-69. [DOI: 10.1080/14737167.2018.1518135] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Wiesława Dominika Wranik
- School of Public Administration, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
- College of Economics Analysis, SGH Warsaw School of Economics, Warszawa, Poland
| | | | - Min Hu
- Department of Economics, Dalhousie University, Halifax, Nova Scotia, Canada
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Skedgel C, Wranik D, Hu M. The Relative Importance of Clinical, Economic, Patient Values and Feasibility Criteria in Cancer Drug Reimbursement in Canada: A Revealed Preferences Analysis of Recommendations of the Pan-Canadian Oncology Drug Review 2011-2017. PHARMACOECONOMICS 2018; 36:467-475. [PMID: 29353385 PMCID: PMC5840198 DOI: 10.1007/s40273-018-0610-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
BACKGROUND Most Canadian provinces and territories rely on the pan-Canadian Oncology Drug Review (pCODR) to provide recommendations regarding public reimbursement of cancer drugs. The pCODR review process considers four dimensions of value-clinical benefit, economic evaluation, patient-based values and adoption feasibility-but they do not define weights for individual decision criteria or an acceptable threshold for any of the criteria. Given this implicit review process, it is of interest to understand which factors appear to carry the most weight in pCODR recommendations using a revealed preferences approach. METHODS Using publicly available decision summaries (n = 91) describing submissions and resulting recommendations 2011-2017, we extracted ten attributes that characterized each submission. Using logistic regression, we identified statistically significant attributes and estimated their relative impact in final recommendations. RESULTS Clinical aspects appear to carry the greatest weight in the decision to reject or not reject, along with aspects of patient value (treatments with no alternatives were less likely to be rejected). Cost effectiveness does not appear to play a role in the initial decision to reject or not reject but is critical in full versus conditional approvals. There is evidence of a maximum acceptable threshold of around $Can140,000 per quality-adjusted life-year (QALY) gained. CONCLUSION A set of factors driving pCODR recommendations is identifiable, supporting the consistency of the review process. However, the implicit nature of the review process and the difficulty of extracting and interpreting some of the attribute levels used in the analysis suggests that the process may still lack full transparency.
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Affiliation(s)
- Chris Skedgel
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ, UK.
- School of Pharmacy, Dalhousie University, Halifax, NS, Canada.
| | - Dominika Wranik
- School of Public Administration, Dalhousie University, Halifax, NS, Canada
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, NS, Canada
| | - Min Hu
- Department of Economics, Dalhousie University, Halifax, NS, Canada
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Decimoni TC, Leandro R, Rozman LM, Craig D, Iglesias CP, Novaes HMD, de Soárez PC. Systematic Review of Health Economic Evaluation Studies Developed in Brazil from 1980 to 2013. Front Public Health 2018; 6:52. [PMID: 29541630 PMCID: PMC5835950 DOI: 10.3389/fpubh.2018.00052] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 02/09/2018] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Brazil has sought to use economic evaluation to support healthcare decision-making processes. While a number of health economic evaluations (HEEs) have been conducted, no study has systematically reviewed the quality of Brazilian HEE. The objective of this systematic review was to provide an overview regarding the state of HEE research and to evaluate the number, characteristics, and quality of reporting of published HEE studies conducted in a Brazilian setting. METHODS We systematically searched electronic databases (MEDLINE, EMBASE, Latin American, and Caribbean Literature on Health Sciences Database, Scientific Electronic Library Online, NHS Economic Evaluation Database, health technology assessment Database, Bireme, and Biblioteca Virtual em Saúde Economia da Saúde); citation indexes (SCOPUS, Web of Science), and Sistema de Informação da Rede Brasileira de Avaliação de Tecnologia em Saúde. Partial and full HEEs published between 1980 and 2013 that referred to a Brazilian setting were considered for inclusion. RESULTS In total, 535 studies were included in the review, 36.8% of these were considered to be full HEE. The category of healthcare technologies more frequently assessed were procedures (34.8%) and drugs (28.8%) which main objective was treatment (72.1%). Forty-four percent of the studies reported their funding source and 36% reported a conflict of interest. Overall, the full HEE quality of reporting was satisfactory. But some items were generally poorly reported and significant improvement is required: (1) methods used to estimate healthcare resource use quantities and unit costs, (2) methods used to estimate utility values, (3) sources of funding, and (4) conflicts of interest. CONCLUSION A steady number of HEE have been published in Brazil since 1980. To improve their contribution to inform national healthcare policy efforts need to be made to enhance the quality of reporting of HEEs and promote improvements in the way HEEs are designed, implemented (i.e., using sound methods for HEEs) and reported.
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Affiliation(s)
- Tassia Cristina Decimoni
- Department of Preventive Medicine, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Roseli Leandro
- Department of Preventive Medicine, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Luciana Martins Rozman
- Department of Preventive Medicine, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Dawn Craig
- Institute of Health and Society, Newcastle University, Newcastle, United Kingdom
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Tesar T, Szilberhorn L, Nemeth B, Nagy B, Wawruch M, Kalo Z. Cost-Utility Analysis of Heberprot-P as an Add-on Therapy to Good Wound Care for Patients in Slovakia with Advanced Diabetic Foot Ulcer. Front Pharmacol 2018; 8:946. [PMID: 29311943 PMCID: PMC5743698 DOI: 10.3389/fphar.2017.00946] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 12/13/2017] [Indexed: 11/25/2022] Open
Abstract
Objectives: To explore whether Heberprot-P (an epidermal growth factor) is a cost-effective option for the treatment of advanced diabetic foot ulcer as an add-on therapy to good wound care (GWC) in Slovakia from the perspective of health care payers. Methods: A Markov model was constructed to compare the costs and effects of Heberprot-P plus GWC to those of GWC alone from the perspective of health care payers. The 52-week clinical trial period was extended to 5- and 10-year time horizons. Transition probabilities were calculated based on a previous clinical trial of Heberprot, utility values were derived from the scientific literature, and cost vectors were collected from the General Health Insurance Fund database in Slovakia. A one-way deterministic sensitivity analysis was employed to explore the influence of uncertainty for each input parameter on the incremental cost-effectiveness ratio (ICER). Results: Based on the ICER threshold of €30,030 per quality-adjusted life year (QALY) recommended by the Slovak Ministry of Health, Heberprot-P therapy plus GWC is not a cost-effective alternative to GWC alone over a 10-year time horizon. The ICER increases if a longer time horizon is applied, as the incremental costs are similar, but the aggregated utility gain from avoided amputation is lower. Based on the sensitivity analysis, the utility multiplier for the health state “no ulcer after small amputation” had the most impact on the ICER; however, the model was robust to changes in all input parameters. Conclusions: Heberprot-P, as an add-on therapy to GWC in the treatment of advanced diabetic foot ulcer, is not a cost-effective alternative to GWC alone. However, if the unit cost of Heberprot-P were to be reduced to <€273, its ICER would be <€30,030.
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Affiliation(s)
- Tomas Tesar
- Department of Organisation and Management in Pharmacy, Faculty of Pharmacy in Bratislava, Comenius University, Bratislava, Slovakia
| | - Laszlo Szilberhorn
- Syreon Research Institute, Budapest, Hungary.,Department of Health Policy and Health Economics, Eötvös Loránd University (ELTE), Budapest, Hungary
| | | | - Balazs Nagy
- Syreon Research Institute, Budapest, Hungary.,Department of Health Policy and Health Economics, Eötvös Loránd University (ELTE), Budapest, Hungary
| | - Martin Wawruch
- Faculty of Medicine in Bratislava, Institute of Pharmacology and Clinical Pharmacology, Comenius University, Bratislava, Slovakia
| | - Zoltan Kalo
- Syreon Research Institute, Budapest, Hungary.,Department of Health Policy and Health Economics, Eötvös Loránd University (ELTE), Budapest, Hungary
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Gandjour A. Patient preferences: a Trojan horse for evidence-based medicine? THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2018; 19:167-172. [PMID: 28667449 DOI: 10.1007/s10198-017-0916-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The evidence-based medicine (EBM) movement has long acknowledged the relevance of patient preferences and values. According to EBM, clinicians first clarify the medical evidence about the benefits and burdens of the treatment in question and then, as a second step, elicit values and preferences from patients. Importantly, however, values are placed on patient-relevant outcomes. Surrogate endpoints are only used if their validity is proven. This article shows that some recent patient-preference studies attribute value to surrogate endpoints even when there is no improvement in patient-relevant outcomes. The article points out their foundation in neoclassical economics and discusses their clash with principles of EBM and medical ethics.
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Affiliation(s)
- Afschin Gandjour
- Frankfurt School of Finance and Management, Sonnemannstr. 9-11, 60314, Frankfurt am Main, Germany.
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Bucek Psenkova M, Visnansky M, Mackovicova S, Tomek D. Drug Policy in Slovakia. Value Health Reg Issues 2017; 13:44-49. [PMID: 29073987 DOI: 10.1016/j.vhri.2017.07.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 07/20/2017] [Accepted: 07/20/2017] [Indexed: 11/19/2022]
Abstract
Slovak law sets clear rules and timelines in the process of approving the price and reimbursement of drugs. During the last decade, the Ministry of Health adopted several cost-containment measures in the price and reimbursement policy. The most effective measures were the implementation of the external referencing of drug prices in 2008 and the reimbursement law in 2011. The new act introduced several regulations such as making stricter rules for the referencing of prices, setting cost per quality-adjusted life-year threshold, and defining new rules for the setting of reimbursements. On one side, implementation of these measures helped to achieve visible cost savings, but, on the other side, cost-containment policies have had some unintended consequences. In recent years, Slovakia has been facing a decreased availability of drugs because of parallel exports. As a result of the government's effort, Slovakia is the only country in the European Union that implemented a legal ban on the re-export of medicines. During the decade before 2011, many innovative drugs were included in the reimbursement system. Because of stricter legal conditions introduced in 2011, there has been a gradual shift in reimbursing innovative drugs from the standard reimbursement system to reimbursement by way of exceptions of health insurance companies. Recently, there has been an ongoing discussion on possible changes to the reimbursement law.
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Affiliation(s)
| | - Martin Visnansky
- University of Veterinary Medicine and Pharmacy, Kosice, Slovakia
| | | | - Dominik Tomek
- Faculty of Medicine, Slovak Medical University in Bratislava, Bratislava, Slovakia
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Oortwijn W, Determann D, Schiffers K, Tan SS, van der Tuin J. Towards Integrated Health Technology Assessment for Improving Decision Making in Selected Countries. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2017; 20:1121-1130. [PMID: 28964444 DOI: 10.1016/j.jval.2017.03.011] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Revised: 03/10/2017] [Accepted: 03/11/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To assess the level of comprehensiveness of health technology assessment (HTA) practices around the globe and to formulate recommendations for enhancing legitimacy and fairness of related decision-making processes. METHODS To identify best practices, we developed an evaluation framework consisting of 13 criteria on the basis of the INTEGRATE-HTA model (integrative perspective on assessing health technologies) and the Accountability for Reasonableness framework (deliberative appraisal process). We examined different HTA systems in middle-income countries (Argentina, Brazil, and Thailand) and high-income countries (Australia, Canada, England, France, Germany, Scotland, and South Korea). For this purpose, desk research and structured interviews with relevant key stakeholders (N = 32) in the selected countries were conducted. RESULTS HTA systems in Canada, England, and Scotland appear relatively well aligned with our framework, followed by Australia, Germany, and France. Argentina and South Korea are at an early stage, whereas Brazil and Thailand are at an intermediate level. Both desk research and interviews revealed that scoping is often not part of the HTA process. In contrast, providing evidence reports for assessment is well established. Indirect and unintended outcomes are increasingly considered, but there is room for improvement. Monitoring and evaluation of the HTA process is not well established across countries. Finally, adopting transparent and robust processes, including stakeholder consultation, takes time. CONCLUSIONS This study presents a framework for assessing the level of comprehensiveness of the HTA process in a country. On the basis of applying the framework, we formulate recommendations on how the HTA community can move toward a more integrated decision-making process using HTA.
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Lim YW, Shafie AA, Chua GN, Ahmad Hassali MA. Determination of Cost-Effectiveness Threshold for Health Care Interventions in Malaysia. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2017; 20:1131-1138. [PMID: 28964445 DOI: 10.1016/j.jval.2017.04.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Revised: 04/04/2017] [Accepted: 04/08/2017] [Indexed: 05/26/2023]
Abstract
BACKGROUND One major challenge in prioritizing health care using cost-effectiveness (CE) information is when alternatives are more expensive but more effective than existing technology. In such a situation, an external criterion in the form of a CE threshold that reflects the willingness to pay (WTP) per quality-adjusted life-year is necessary. OBJECTIVES To determine a CE threshold for health care interventions in Malaysia. METHODS A cross-sectional, contingent valuation study was conducted using a stratified multistage cluster random sampling technique in four states in Malaysia. One thousand thirteen respondents were interviewed in person for their socioeconomic background, quality of life, and WTP for a hypothetical scenario. RESULTS The CE thresholds established using the nonparametric Turnbull method ranged from MYR12,810 to MYR22,840 (~US $4,000-US $7,000), whereas those estimated with the parametric interval regression model were between MYR19,929 and MYR28,470 (~US $6,200-US $8,900). Key factors that affected the CE thresholds were education level, estimated monthly household income, and the description of health state scenarios. CONCLUSIONS These findings suggest that there is no single WTP value for a quality-adjusted life-year. The CE threshold estimated for Malaysia was found to be lower than the threshold value recommended by the World Health Organization.
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Affiliation(s)
- Yen Wei Lim
- Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia.
| | - Asrul Akmal Shafie
- Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
| | - Gin Nie Chua
- Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia; Health Economics Research Unit/Academic Primary Care, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland
| | - Mohammed Azmi Ahmad Hassali
- Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Penang, Malaysia
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HEALTH TECHNOLOGY PERFORMANCE ASSESSMENT: REAL-WORLD EVIDENCE FOR PUBLIC HEALTHCARE SUSTAINABILITY. Int J Technol Assess Health Care 2017. [PMID: 28641588 DOI: 10.1017/s0266462317000423] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Health technology financing is often based on randomized controlled trials (RCTs), which are often the same ones used for licensing. Because they are designed to show the best possible results, typically Phase III studies are conducted under ideal and highly controlled conditions. Consequently, it is not surprising that technologies do not always perform in real life in the same way as controlled conditions. Because financing (and price paid) decisions can be made with overestimated results, health authorities need to ask whether health systems achieve the results they expect when they choose to pay for a technology. The optimal way to answer this question is to assess the performance of financed technologies in real-world settings. Health technology performance assessment (HTpA) refers to the systematic evaluation of the properties, effects, and/or impact of a health intervention or health technology in the real world to provide information for investment/disinvestment decisions and clinical guideline updates. The objective is to describe the development and principal aspects of the Guideline for HTpA commissioned by the Brazilian Ministry of Health. METHODS Our methods used include extensive literature review, refinement with experts across countries, and public consultation. RESULTS A comprehensive guideline was developed, which has been adopted by the Brazilian government. CONCLUSION We believe the guideline, with its particular focus on disinvestment, along with the creation of a specific program for HTpA, will allow the institutionalization and continuous improvement of the scientific methods to use real-world evidence to optimize available resources not only in Brazil but across countries.
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Abstract
OBJECTIVES The aim of our study was to describe approaches to health technology assessment (HTA) for medicines in the Slovak healthcare system and the related decision-making processes concerning reimbursement for medicines. METHODS Analysis of the Slovak legislative framework related to HTA and the reimbursement process for medicines was performed. Additionally, current practices of the Working Group for Pharmacoeconomics, Clinical Outcomes and Health Technology Assessment of the Slovak Ministry of Health were evaluated. RESULTS In Slovakia, there is always at least one treatment available in each determined therapeutic class with no co-payment. HTA is becoming an established method for the evaluation of cost-effectiveness of medicines in Slovak healthcare policy. The majority of decision makers within Slovakia support the idea of increased use of and the quality and efficiency of HTA methods. However, it is crucial to overcome several practical barriers to facilitate progress in the field of HTA in the Slovak Republic. CONCLUSIONS It can be seen that participation within the European Network for Health Technology Assessment (EUnetHTA JA 2 and EUnetHTA JA 3 projects) has significantly improved the quality of the process of HTA in Slovakia. Further legislative activities in this field are required due to the approved strategy for European Union cooperation on HTA.
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Wranik WD, Gambold L, Hanson N, Levy A. The evolution of the cancer formulary review in Canada: Can centralization improve the use of economic evaluation? Int J Health Plann Manage 2017; 32:e232-e260. [PMID: 27469429 PMCID: PMC5484361 DOI: 10.1002/hpm.2372] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 05/25/2016] [Accepted: 06/08/2016] [Indexed: 11/11/2022] Open
Abstract
Public reimbursement of drugs is a costly proposition for health care systems. Decisions to add drugs to the public formulary are often guided by review processes and committees. The evolution of the formulary review process in Canada's publicly funded health system is characterized by increased centralization and systematization. In the past, the review of evidence and recommendation was conducted at the regional level, but was replaced with the pan-Canadian Oncology Drug Review in 2011. We assess the extent to which centralization and systematization of the review process have responded to past challenges, focusing on the use of economic evaluation in the process. Past challenges with economic evaluation experienced by regionalized review committees were identified from literature and qualitative data collected in the province of Nova Scotia. We categorize these using a typology with a macro-, meso, and micro-level hierarchy, which provides a useful framework for understanding at which level change is required, and who has the authority to influence change. Using grounded theory methods, we identify approaches used by Nova Scotia past committee members to compensate for perceived shortcomings of the process. These include an undue reliance on other committee members, on the multidisciplinarity of the committee, and on past decisions. Using a policy analysis approach, we argue that centralization and systematization of the review process only partially address the shortcomings of the previous regionalized process. Lessons from Canada can inform policy discussions across all health systems, where similar challenges with the formulary review process have been identified. © 2016 The Authors. The International Journal of Health Planning and Management published by John Wiley & Sons Ltd.
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Affiliation(s)
- W. Dominika Wranik
- School of Public AdministrationDalhousie UniversityHalifaxNova ScotiaCanada
| | - Liesl Gambold
- Department of Sociology and Social AnthropologyDalhousie UniversityHalifaxNova ScotiaCanada
| | - Natasha Hanson
- Saint John Regional HospitalSaint JohnNew BrunswickCanada
| | - Adrian Levy
- Department of Community Health and EpidemiologyDalhousie UniversityHalifaxNova ScotiaCanada
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Kolasa K, Kalo Z, Zah V. The use of non-economic criteria in pricing and reimbursement decisions in Central and Eastern Europe: issues, trends and recommendations. Expert Rev Pharmacoecon Outcomes Res 2017; 16:483-8. [PMID: 27467881 DOI: 10.1080/14737167.2016.1215917] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION According to some experts, there is still room for improvement with regard to the inclusion of ethical considerations in Health Technology Assessment (HTA). AREAS COVERED The pros and cons of the introduction of non-economic criteria in the HTA process in Central and Eastern Europe (CEE) are discussed. In comparison to Western Europe, financial considerations are even more important in CEE settings; however, it could also be said that attachment to equity and justice is part of CEE's heritage. Therefore, the trade-off between conflicting principles is evaluated. Expert commentary: To ensure the right balance between equity and efficiency in decision making, the current HTA framework has to be further augmented to allow all conflicting criteria to be addressed to a satisfactory degree. Following other examples, the applicability of multi criteria decision analysis technique to CEE settings should be further investigated.
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Affiliation(s)
- Katarzyna Kolasa
- a Department of Public Health , Nicolaus Copernicus University, Collegium Medicum in Bydgoszcz , Bydgoszcz , Poland
| | - Zoltan Kalo
- b Department of Health Policy and Economics, Faculty of Social Sciences, Eötvös Loránd University , Budapest , Hungary.,c Syreon Research Institute , Budapest , Hungary
| | - Vladimir Zah
- d Health Economics and Outcomes Research, ZRx Outcomes Research Inc , Toronto , Canada
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Akehurst RL, Abadie E, Renaudin N, Sarkozy F. Variation in Health Technology Assessment and Reimbursement Processes in Europe. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2017; 20:67-76. [PMID: 28212972 DOI: 10.1016/j.jval.2016.08.725] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 07/12/2016] [Accepted: 08/06/2016] [Indexed: 05/03/2023]
Abstract
BACKGROUND It has been suggested that differences in health technology assessment (HTA) processes among countries, particularly within Europe, have led to inequity in patient access to new medicines. OBJECTIVES To provide an up-to-date snapshot analysis of the present status of HTA and reimbursement systems in select European countries, and to investigate the implications of these processes, especially with regard to delays in market and patient access. METHODS HTA and reimbursement processes were assessed through a review of published and gray literature, and through a series of interviews with HTA experts. To quantify the impact of differences among countries, we conducted case studies of 12 products introduced since 2009, including 10 cancer drugs. RESULTS In addition to the differences in HTA and reimbursement processes among countries, the influence of particular sources of information differs among HTA bodies. The variation in the time from the authorization by the European Medicines Agency to the publication of HTA decisions was considerable, both within and among countries, with a general lack of transparency as to why some assessments take longer than others. In most countries, market access for oncology products can occur outside the HTA process, with sales often preceding HTA decisions. CONCLUSIONS It is challenging even for those with considerable personal experience in European HTA processes to establish what is really happening in market access for new drugs. We recommend that efforts should be directed toward improving transparency in HTA, which should, in turn, lead to more effective processes.
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Affiliation(s)
- Ronald L Akehurst
- BresMed Health Solutions Ltd., Sheffield, UK; University of Sheffield, Sheffield, UK.
| | - Eric Abadie
- Cardiology Division, Ambroise Paré Hospital, Paris, France
| | - Noël Renaudin
- Membre du Conseil d'administration de l'APHP (Hôpitaux de Paris), Membre du Conseil d'administration de l'InCa, Paris, France
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Bochenek T, Kocot E, Rodzinka M, Godman B, Maciejewska K, Kamal S, Pilc A. The transparency of published health technology assessment-based recommendations on pharmaceutical reimbursement in Poland. Expert Rev Pharmacoecon Outcomes Res 2016; 17:385-400. [DOI: 10.1080/14737167.2017.1262767] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Tomasz Bochenek
- Department of Drug Management, Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - Ewa Kocot
- Health Economics and Social Security Department, Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - Marcin Rodzinka
- Health Promotion Department, Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - Brian Godman
- Division of Clinical Pharmacology, Karolinska Institute, Stockholm, Sweden
- Strathclyde Institute of Pharmacy and Biomedical Sciences, Strathclyde University, Glasgow, UK
| | - Katarzyna Maciejewska
- Health Promotion Department, Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - Susan Kamal
- Community Pharmacy Department, School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland
| | - Andrzej Pilc
- Department of Neurobiology, Institute of Pharmacology, Polish Academy of Sciences, Krakow, Poland
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Scotland G, Bryan S. Why Do Health Economists Promote Technology Adoption Rather Than the Search for Efficiency? A Proposal for a Change in Our Approach to Economic Evaluation in Health Care. Med Decis Making 2016; 37:139-147. [DOI: 10.1177/0272989x16653397] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
At a time of intense pressure on health care budgets, the technology management challenge is for disinvestment in low-value technologies and reinvestment in higher value alternatives. The aim of this article is to explore ways in which health economists might begin to redress the observed imbalance between the evaluation of new and existing in-use technologies. The argument is not against evaluating new technologies but in favor of the “search for efficiency,” where the ultimate objective is to identify reallocations that improve population health in the face of resource scarcity. We explore why in-use technologies may be of low value and consider how economic evaluation analysts might embrace a broader efficiency lens, first through “technology management” (a process of analysis and evidence-informed decision making throughout a technology’s life cycle) and progressing through “pathway management” (the search for efficiency gains across entire clinical care pathways). A number of model-based examples are used to illustrate the approaches.
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Affiliation(s)
- Graham Scotland
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK (GS, SB)
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK (GS)
- Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada (SB)
- School of Population & Public Health, University of British Columbia, Vancouver, BC, Canada (SB)
| | - Stirling Bryan
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK (GS, SB)
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK (GS)
- Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada (SB)
- School of Population & Public Health, University of British Columbia, Vancouver, BC, Canada (SB)
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From market access to patient access: overview of evidence-based approaches for the reimbursement and pricing of pharmaceuticals in 36 European countries. Health Res Policy Syst 2015; 13:39. [PMID: 26407728 PMCID: PMC4583728 DOI: 10.1186/s12961-015-0028-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 09/07/2015] [Indexed: 01/18/2023] Open
Abstract
Background Coverage decisions determining the benefit baskets of health systems have been increasingly relying on evidence regarding patient benefit and costs. Relevant structures, methodologies, and processes have especially been established for pharmaceuticals but approaches differ. The objective of this work was thus to identify institutions in a broad range of European countries (n = 36) in charge of determining the value of pharmaceuticals for pricing and reimbursement purposes and to map their decision-making process; to examine the different approaches and consider national and supranational possibilities for best practice. Methods Institutions were identified through websites of international networks, ministries, and published literature. Details on institutional practices were supplemented with information from institution websites and linked online sources. Results The type and extent of information available varied considerably across countries. Different types of public regulatory bodies are involved in pharmaceutical coverage decisions, assuming a range of responsibilities. As a rule, the assessment of scientific evidence is kept structurally separate from its appraisal. Recommendations on value are uniformly issued by specific committees within or commissioned by responsible institutions; these institutions often also act as decision-makers on reimbursement status and level or market price. While effectiveness and costs are important criteria in all countries, the latter are often considered on a case-by-case basis. In all countries, manufacturer applications, including relevant evidence, are used as one of the main sources of information for the assessment. Conclusion Transparency of evidence-based coverage decisions should be enhanced. International collaboration can facilitate knowledge exchange, improve efficiency of information production, and strengthen new or developing systems. Electronic supplementary material The online version of this article (doi:10.1186/s12961-015-0028-5) contains supplementary material, which is available to authorized users.
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Regulation, Reimbursement and Health Technology Assessment. Health Technol Assess 2015. [DOI: 10.1201/b18285-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Shafie AA, Lim YW, Chua GN, Hassali MAA. Exploring the willingness to pay for a quality-adjusted life-year in the state of Penang, Malaysia. CLINICOECONOMICS AND OUTCOMES RESEARCH 2014; 6:473-81. [PMID: 25364267 PMCID: PMC4211862 DOI: 10.2147/ceor.s67375] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction The incremental cost-effectiveness ratio (ICER) is typically compared with a reference value to support the cost-effectiveness of a decision. One method for estimating this value is to estimate the willingness-to-pay (WTP) for a quality-adjusted life-year (QALY). This study was conducted to explore the WTP for a QALY in the Malaysian population. Methods A cross-sectional, contingent valuation study was conducted in Penang, Malaysia. Respondents were selected from randomly chosen geographical grids of Penang. Respondents’ sociodemographic information, qualities of life, and WTP for one additional QALY were collected using predesigned questionnaires in face-to-face interviews. WTP values were elicited using a double-bound dichotomous choice via a bidding game approach. The Heckman selection model was applied to the analysis of the mean WTP/QALY values, where the “protest zero” values, which may contribute to selection bias, were excluded. Results The mean value of WTP for an additional QALY gained was estimated to be MYR (Malaysian Ringgit) 29,080 (~USD 9,000). Key factors that affected the WTP include ethnicity and estimated monthly household income. Conclusion The study findings suggested that the cost-effectiveness threshold value as studied in Penang, Malaysia was estimated to be MYR 29,080.
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Affiliation(s)
- Asrul Akmal Shafie
- Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains, Penang, Malaysia
| | - Yen Wei Lim
- Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains, Penang, Malaysia
| | - Gin Nie Chua
- Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains, Penang, Malaysia
| | - Mohammed Azmi Ahmad Hassali
- Discipline of Social and Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains, Penang, Malaysia
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