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Santi I, Vellekoop H, M Versteegh M, A Huygens S, Dinjens WNM, Mölken MRV. Estimating the Prognostic Value of the NTRK Fusion Biomarker for Comparative Effectiveness Research in The Netherlands. Mol Diagn Ther 2024; 28:319-328. [PMID: 38616205 PMCID: PMC11068666 DOI: 10.1007/s40291-024-00704-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2024] [Indexed: 04/16/2024]
Abstract
OBJECTIVES We evaluated the prognostic value of the neurotrophic tyrosine receptor kinase (NTRK) gene fusions by comparing the survival of patients with NTRK+ tumours with patients without NTRK+ tumours. METHODS We used genomic and clinical registry data from the Center for Personalized Cancer Treatment (CPCT-02) study containing a cohort of cancer patients who were treated in Dutch clinical practice between 2012 and 2020. We performed a propensity score matching analysis, where NTRK+ patients were matched to NTRK- patients in a 1:4 ratio. We subsequently analysed the survival of the matched sample of NTRK+ and NTRK- patients using the Kaplan-Meier method and Cox regression, and performed an analysis of credibility to evaluate the plausibility of our result. RESULTS Among 3556 patients from the CPCT-02 study with known tumour location, 24 NTRK+ patients were identified. NTRK+ patients were distributed across nine different tumour types: bone/soft tissue, breast, colorectal, head and neck, lung, pancreas, prostate, skin and urinary tract. NTRK fusions involving the NTRK3 gene (46%) and NTRK1 gene (33%) were most common. The survival analysis rendered a hazard ratio (HR) of 1.44 (95% CI 0.81-2.55) for NTRK+ patients. Using the point estimates of three prior studies on the prognostic value of NTRK fusions, our finding that the HR is > 1 was deemed plausible. CONCLUSIONS NTRK+ patients may have an increased risk of death compared with NTRK- patients. When using historic control data to assess the comparative effectiveness of TRK inhibitors, the prognostic value of the NTRK fusion biomarker should therefore be accounted for.
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Affiliation(s)
- Irene Santi
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Burgemeester Oudlaan 50, 3062 PA, Rotterdam, The Netherlands.
| | - Heleen Vellekoop
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Burgemeester Oudlaan 50, 3062 PA, Rotterdam, The Netherlands
| | - Matthijs M Versteegh
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Burgemeester Oudlaan 50, 3062 PA, Rotterdam, The Netherlands
| | - Simone A Huygens
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Burgemeester Oudlaan 50, 3062 PA, Rotterdam, The Netherlands
| | - Winand N M Dinjens
- Department of Pathology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Maureen Rutten-van Mölken
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Burgemeester Oudlaan 50, 3062 PA, Rotterdam, The Netherlands
- School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
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2
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Graziadio S, Gregg E, Allen AJ, Neveux P, Monz BU, Davenport C, Mealing S, Holmes H, Ferrante di Ruffano L. Is the Comparator in Your Diagnostic Cost-Effectiveness Model "Standard of Care"? Recommendations from Literature Reviews and Expert Interviews on How to Identify and Operationalize It. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024; 27:585-597. [PMID: 38401794 DOI: 10.1016/j.jval.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 02/08/2024] [Accepted: 02/14/2024] [Indexed: 02/26/2024]
Abstract
OBJECTIVES This research aimed to develop best-practice recommendations for identifying the "standard of care" (SoC) and integrate it when it is the comparator in diagnostic economic models (SoC comparator). METHODS A multi-methods approach comprising 2 pragmatic literature reviews and 9 expert interviews was used. Experts rated their agreement with draft recommendations based on the authors' analysis of the reviews. These were refined iteratively to produce final recommendations. RESULTS Fourteen best-practice recommendations are provided. Care pathway mapping (using quantitative, qualitative, or mixed-methods approaches) should be used for identifying the SoC comparator. Guidelines analysis can be integrated with expert opinion to identify pathway variability and discrepancies from clinical practice. For integrating the SoC comparator into the model, recommendations around structure, input sourcing, data aggregation and reporting, input uncertainty, and model variability are presented. For example, modelers should consider that the reference standard is not synonymous with the SoC, and the SoC may not be the only comparator. The comparator limitations should be discussed with clinical experts, but elicitation of its diagnostic accuracy is not recommended. Probabilistic sensitivity analysis is recommended when evaluating the overall input uncertainty, and deterministic sensitivity analysis is useful when there is high model uncertainty or SoC variability. Consensus could not be reached for some topics (eg, the role of real-world data, model averaging, and alternative model structures), but the reported discussions provide points for consideration. CONCLUSIONS To our knowledge, this is the first guidance to support modelers when identifying and operationalizing the SoC comparator in diagnostic cost-effectiveness models.
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Affiliation(s)
- Sara Graziadio
- York Health Economics Consortium, Enterprise House, University of York, Innovation Way, York, England, UK.
| | - Emily Gregg
- York Health Economics Consortium, Enterprise House, University of York, Innovation Way, York, England, UK
| | - A Joy Allen
- Health Economics, Roche Diagnostics UK and Ireland, Burgess Hill, England, UK
| | - Paul Neveux
- Global Access & Policy, Roche Diagnostics International AG, Rotkreuz, Switzerland
| | - Brigitta U Monz
- Global Access & Policy, Roche Diagnostics International AG, Rotkreuz, Switzerland
| | - Clare Davenport
- Institute of Applied Health Research, University of Birmingham, Birmingham, England, UK
| | - Stuart Mealing
- York Health Economics Consortium, Enterprise House, University of York, Innovation Way, York, England, UK
| | - Hayden Holmes
- York Health Economics Consortium, Enterprise House, University of York, Innovation Way, York, England, UK
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3
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Weymann D, Pollard S, Lam H, Krebs E, Regier DA. Toward Best Practices for Economic Evaluations of Tumor-Agnostic Therapies: A Review of Current Barriers and Solutions. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:1608-1617. [PMID: 37543205 DOI: 10.1016/j.jval.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 06/28/2023] [Accepted: 07/26/2023] [Indexed: 08/07/2023]
Abstract
OBJECTIVES Cancer therapies targeting tumor-agnostic biomarkers are challenging traditional health technology assessment (HTA) frameworks. The high prevalence of nonrandomized single-arm trials, heterogeneity, and small benefiting populations are driving outcomes uncertainty, challenging healthcare decision making. We conducted a structured literature review to identify barriers and prioritize solutions to generating economic evidence for tumor-agnostic therapies. METHODS We searched MEDLINE and Embase for English-language studies conducting economic evaluations of tumor-agnostic treatments or exploring related challenges and solutions. We included studies published by December 2022 and supplemented our review with Canadian Agency for Drugs and Technologies in Health and National Institute for Health and Care Excellence technical reports for approved tumor-agnostic therapies. Three reviewers abstracted and summarized key methodological and empirical study characteristics. Challenges and solutions were identified through authors' statements and categorized using directed content analysis. RESULTS Twenty-six studies met our inclusion criteria. Studies spanned economic evaluations (n = 5), reimbursement reviews (n = 4), qualitative research (n = 1), methods validations (n = 3), and commentaries or literature reviews (n = 13). Challenges encountered related to (1) the treatment setting and clinical trial designs, (2) a lack of data or low-quality data on clinical and cost parameters, and (3) an inability to produce evidence that meets HTA guidelines. Although attempted solutions centered on analytic approaches for managing missing data, proposed solutions highlighted the need for real-world evidence combined with life-cycle HTA to reduce future evidentiary uncertainty. CONCLUSIONS Therapeutic innovation outpaces HTA evidence generation and the methods that support it. Existing HTA frameworks must be adapted for tumor-agnostic treatments to support future economic evaluations enabling timely patient access.
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Affiliation(s)
| | | | - Halina Lam
- Cancer Control Research, BC Cancer, Vancouver, Canada
| | - Emanuel Krebs
- Cancer Control Research, BC Cancer, Vancouver, Canada
| | - Dean A Regier
- Cancer Control Research, BC Cancer, Vancouver, Canada; School of Population and Public Health, University of British Columbia, Vancouver, Canada.
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4
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AbouAitah K, Sabbagh F, Kim BS. Graphene Oxide Nanostructures as Nanoplatforms for Delivering Natural Therapeutic Agents: Applications in Cancer Treatment, Bacterial Infections, and Bone Regeneration Medicine. NANOMATERIALS (BASEL, SWITZERLAND) 2023; 13:2666. [PMID: 37836307 PMCID: PMC10574074 DOI: 10.3390/nano13192666] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 09/23/2023] [Accepted: 09/26/2023] [Indexed: 10/15/2023]
Abstract
Graphene, fullerenes, diamond, carbon nanotubes, and carbon dots are just a few of the carbon-based nanomaterials that have gained enormous popularity in a variety of scientific disciplines and industrial uses. As a two-dimensional material in the creation of therapeutic delivery systems for many illnesses, nanosized graphene oxide (NGO) is now garnering a large amount of attention among these materials. In addition to other benefits, NGO functions as a drug nanocarrier with remarkable biocompatibility, high pharmaceutical loading capacity, controlled drug release capability, biological imaging efficiency, multifunctional nanoplatform properties, and the power to increase the therapeutic efficacy of loaded agents. Thus, NGO is a perfect nanoplatform for the development of drug delivery systems (DDSs) to both detect and treat a variety of ailments. This review article's main focus is on investigating surface functionality, drug-loading methods, and drug release patterns designed particularly for smart delivery systems. The paper also examines the relevance of using NGOs to build DDSs and considers prospective uses in the treatment of diseases including cancer, infection by bacteria, and bone regeneration medicine. These factors cover the use of naturally occurring medicinal substances produced from plant-based sources.
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Affiliation(s)
- Khaled AbouAitah
- Department of Chemical Engineering, Chungbuk National University, Cheongju 28644, Republic of Korea; (K.A.); (F.S.)
- Medicinal and Aromatic Plants Research Department, Pharmaceutical and Drug Industries Research Institute, National Research Centre (NRC), 33 El-Behouth Street, Dokki, Giza 12622, Egypt
| | - Farzaneh Sabbagh
- Department of Chemical Engineering, Chungbuk National University, Cheongju 28644, Republic of Korea; (K.A.); (F.S.)
| | - Beom Soo Kim
- Department of Chemical Engineering, Chungbuk National University, Cheongju 28644, Republic of Korea; (K.A.); (F.S.)
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Romanko AA, Mulkidjan RS, Tiurin VI, Saitova ES, Preobrazhenskaya EV, Krivosheyeva EA, Mitiushkina NV, Shestakova AD, Belogubova EV, Ivantsov AO, Iyevleva AG, Imyanitov EN. Cost-Efficient Detection of NTRK1/2/3 Gene Fusions: Single-Center Analysis of 8075 Tumor Samples. Int J Mol Sci 2023; 24:14203. [PMID: 37762506 PMCID: PMC10531831 DOI: 10.3390/ijms241814203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 08/26/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
The majority of NTRK1, NTRK2, and NTRK3 rearrangements result in increased expression of the kinase portion of the involved gene due to its fusion to an actively transcribed gene partner. Consequently, the analysis of 5'/3'-end expression imbalances is potentially capable of detecting the entire spectrum of NTRK gene fusions. Archival tumor specimens obtained from 8075 patients were subjected to manual dissection of tumor cells, DNA/RNA isolation, and cDNA synthesis. The 5'/3'-end expression imbalances in NTRK genes were analyzed by real-time PCR. Further identification of gene rearrangements was performed by variant-specific PCR for 44 common NTRK fusions, and, whenever necessary, by RNA-based next-generation sequencing (NGS). cDNA of sufficient quality was obtained in 7424/8075 (91.9%) tumors. NTRK rearrangements were detected in 7/6436 (0.1%) lung carcinomas, 11/137 (8.0%) pediatric tumors, and 13/851 (1.5%) adult non-lung malignancies. The highest incidence of NTRK translocations was observed in pediatric sarcomas (7/39, 17.9%). Increased frequency of NTRK fusions was seen in microsatellite-unstable colorectal tumors (6/48, 12.5%), salivary gland carcinomas (5/93, 5.4%), and sarcomas (7/143, 4.9%). None of the 1293 lung carcinomas with driver alterations in EGFR/ALK/ROS1/RET/MET oncogenes had NTRK 5'/3'-end expression imbalances. Variant-specific PCR was performed for 744 tumors with a normal 5'/3'-end expression ratio: there were no rearrangements in 172 EGFR/ALK/ROS1/RET/MET-negative lung cancers and 125 pediatric tumors, while NTRK3 fusions were detected in 2/447 (0.5%) non-lung adult malignancies. In conclusion, this study describes a diagnostic pipeline that can be used as a cost-efficient alternative to conventional methods of NTRK1-3 analysis.
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Affiliation(s)
- Aleksandr A. Romanko
- Department of Tumor Growth Biology, N.N. Petrov Institute of Oncology, 197758 St.-Petersburg, Russia (V.I.T.)
| | - Rimma S. Mulkidjan
- Department of Tumor Growth Biology, N.N. Petrov Institute of Oncology, 197758 St.-Petersburg, Russia (V.I.T.)
| | - Vladislav I. Tiurin
- Department of Tumor Growth Biology, N.N. Petrov Institute of Oncology, 197758 St.-Petersburg, Russia (V.I.T.)
| | - Evgeniya S. Saitova
- Department of Tumor Growth Biology, N.N. Petrov Institute of Oncology, 197758 St.-Petersburg, Russia (V.I.T.)
| | - Elena V. Preobrazhenskaya
- Department of Tumor Growth Biology, N.N. Petrov Institute of Oncology, 197758 St.-Petersburg, Russia (V.I.T.)
- Department of Medical Genetics, St.-Petersburg Pediatric Medical University, 194100 St.-Petersburg, Russia
| | - Elena A. Krivosheyeva
- Department of Tumor Growth Biology, N.N. Petrov Institute of Oncology, 197758 St.-Petersburg, Russia (V.I.T.)
| | - Natalia V. Mitiushkina
- Department of Tumor Growth Biology, N.N. Petrov Institute of Oncology, 197758 St.-Petersburg, Russia (V.I.T.)
| | - Anna D. Shestakova
- Department of Tumor Growth Biology, N.N. Petrov Institute of Oncology, 197758 St.-Petersburg, Russia (V.I.T.)
| | - Evgeniya V. Belogubova
- Department of Tumor Growth Biology, N.N. Petrov Institute of Oncology, 197758 St.-Petersburg, Russia (V.I.T.)
| | - Alexandr O. Ivantsov
- Department of Tumor Growth Biology, N.N. Petrov Institute of Oncology, 197758 St.-Petersburg, Russia (V.I.T.)
| | - Aglaya G. Iyevleva
- Department of Tumor Growth Biology, N.N. Petrov Institute of Oncology, 197758 St.-Petersburg, Russia (V.I.T.)
- Department of Medical Genetics, St.-Petersburg Pediatric Medical University, 194100 St.-Petersburg, Russia
| | - Evgeny N. Imyanitov
- Department of Tumor Growth Biology, N.N. Petrov Institute of Oncology, 197758 St.-Petersburg, Russia (V.I.T.)
- Department of Medical Genetics, St.-Petersburg Pediatric Medical University, 194100 St.-Petersburg, Russia
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6
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Rutten-van Mölken M, Versteegh M, Nagy B, Wordsworth S. HEcoPerMed, personalized medicine from a health economic perspective: lessons learned and potential opportunities ahead. Per Med 2023; 20:299-303. [PMID: 37736874 DOI: 10.2217/pme-2022-0074] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Affiliation(s)
- Maureen Rutten-van Mölken
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR, Rotterdam, The Netherlands
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Burgemeester Oudlaan 50, 3062 PA, Rotterdam, The Netherlands
| | - Matthijs Versteegh
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Burgemeester Oudlaan 50, 3062 PA, Rotterdam, The Netherlands
| | - Balázs Nagy
- Syreon Research Institute, Mexikoi street 65/A, 1142 Budapest, Hungary
- Center for Health Technology Assessment, Semmelweis University, Üllői út 25, 1091 Budapest, Hungary
| | - Sarah Wordsworth
- Health Economics Research Centre, University of Oxford, Old Road Campus, Oxford OX3 7LF, UK
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7
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Vellekoop H, Huygens S, Versteegh M, Szilberhorn L, Zelei T, Nagy B, Koleva-Kolarova R, Wordsworth S, Rutten-van Mölken M. Cost-effectiveness of alternative NTRK testing strategies in cancer patients followed by histology-independent therapy with entrectinib: an analysis of three European countries. Per Med 2023; 20:321-338. [PMID: 37746727 DOI: 10.2217/pme-2022-0070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
Aim: To explore variations in the cost-effectiveness of entrectinib across different testing strategies and settings. Methods: Four testing strategies where adult cancer patients received entrectinib if they tested positive for NTRK gene fusions compared with 'no testing' and standard of care (SoC) for all patients were evaluated. Results: Immunohistochemistry for all patients followed by RNA-based next-generation sequencing after a positive result was the optimal strategy in all included countries. However, the incremental net monetary benefit compared with SoC was negative in all countries, ranging between international euros (int€) -206 and -404. In a subgroup analysis with only NTRK-positive patients, the incremental net monetary benefit was int€ 8405 in England, int€ -53,088 in Hungary and int€ 54,372 in The Netherlands. Conclusion: Using the cost-effectiveness thresholds recommended by national guidelines, none of the testing strategies were cost-effective compared with no testing. The implementation of entrectinib is unlikely to become cost-effective in Hungary, due to the large cost difference between the entrectinib and SoC arms, while there might be more potential in England and The Netherlands.
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Affiliation(s)
- Heleen Vellekoop
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands
| | - Simone Huygens
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands
| | - Matthijs Versteegh
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands
| | | | - Tamás Zelei
- Syreon Research Institute, Mexikoi str. 65/A, 1142 Budapest, Hungary
| | - Balázs Nagy
- Syreon Research Institute, Mexikoi str. 65/A, 1142 Budapest, Hungary
| | | | - Sarah Wordsworth
- Health Economics Research Centre, University of Oxford, Oxford OX3 7LF, UK
| | - Maureen Rutten-van Mölken
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands
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8
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Penel N, Lebellec L, Blay JY. Why will there never be a randomized trial for NTRK-rearranged tumors? Ann Oncol 2023; 34:626-628. [PMID: 37068657 DOI: 10.1016/j.annonc.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 04/02/2023] [Indexed: 04/19/2023] Open
Affiliation(s)
- N Penel
- Department of Medical Oncology, Centre Oscar Lambret, Lille, France; University of Lille, CHU Lille, ULR 2694 - Metrics: Evaluation des technologies de santé et des pratiques médicales, Lille, France.
| | - L Lebellec
- Department of Medical Oncology, Centre Oscar Lambret, Lille, France
| | - J-Y Blay
- Department of Medical Oncology, Centre Léon Bérard, Lyon, France; Université Claude Bernard, Lyon, France
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9
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Nagy B, Zelei T, Vellekoop H, Huygens S, Versteegh M, Mölken MRV, Koleva-Kolarova R, Tsiachristas A, Wordsworth S, Szilberhorn L. Lessons learned from the application of the HEcoPerMed guidance to three modeling case studies. Per Med 2023; 20:401-411. [PMID: 37694556 DOI: 10.2217/pme-2023-0040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
Background: The HEcoPerMed consortium developed a methodological guidance for the harmonization and improvement of economic evaluations in personalized medicine. Materials & methods: In three therapeutic areas, health economic models were developed to scrutinize the recommendations of the guidance. Results: Altogether, 20 of the 23 recommendations of the guidance were addressed by the models. Seven recommendations were applied in all studies, six in two of the studies and seven in one of the studies. Recommendations with an essential role on the final conclusions of the analyses were identified in each study. Conclusion: The guidance was found to be best used as a tool to identify and prioritize issues, verify solutions and justify decisions during the economic analysis of personalized interventions.
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Affiliation(s)
- Balázs Nagy
- Syreon Research Institute, Budapest, Hungary
- Center for Health Technology Assessment, Semmelweis University, Budapest, Hungary
| | - Tamás Zelei
- Syreon Research Institute, Budapest, Hungary
| | - Heleen Vellekoop
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, 3000 DR, Rotterdam, The Netherlands
| | - Simone Huygens
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, 3000 DR, Rotterdam, The Netherlands
| | - Matthijs Versteegh
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, 3000 DR, Rotterdam, The Netherlands
| | - Maureen Rutten-van Mölken
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, 3000 DR, Rotterdam, The Netherlands
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | | | - Sarah Wordsworth
- Health Economics Research Centre, University of Oxford, Oxford, UK
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