DEFINING INNOVATION WITH RESPECT TO NEW MEDICINES: A SYSTEMATIC REVIEW FROM A PAYER PERSPECTIVE

New Anticancer Drugs: Reliably Assessing "Value" While Addressing High Prices

Countries face challenges in paying for new drugs. High prices are driven in part by exploding drug development costs, which, in turn, are driven by essential but excessive regulation. Burdensome regulation also delays drug development, and this can translate into thousands of life-years lost. We need system-wide reform that will enable less expensive, faster drug development. The speed with which COVID-19 vaccines and AIDS therapies were developed indicates this is possible if governments prioritize it. Countries also differ in how they value drugs, and generally, those willing to pay more have better, faster access. Canada is used as an example to illustrate how "incremental cost-effectiveness ratios" (ICERs) based on measures such as gains in "quality-adjusted life-years" (QALYs) may be used to determine a drug's value but are often problematic, imprecise assessments. Generally, ICER/QALY estimates inadequately consider the impact of patient crossover or long post-progression survival, therapy benefits in distinct subpopulations, positive impacts of the therapy on other healthcare or societal costs, how much governments willingly might pay for other things, etc. Furthermore, a QALY value should be higher for a lethal or uncommon disease than for a common, nonlethal disease. Compared to international comparators, Canada is particularly ineffective in initiating public funding for essential new medications. Addressing these disparities demands urgent reform.

The Evaluation of Drug Innovativeness in Italy: Key Determinants and Internal Consistency

BACKGROUND

Innovative medicines are provided with dedicated funds and immediate market access in Italy. Innovativeness evaluation considers unmet need, added therapeutic value, and quality of the evidence.

OBJECTIVE

We aimed to evaluate the internal consistency and drivers of the innovativeness appraisal process.

METHODS

Appraisal reports on innovativeness refer to 1997-2021. We used both a descriptive approach and probabilistic multivariate analysis, using logistic regression models to compute odds ratios and 95% confidence intervals. The dependent variable is innovativeness status (innovative vs. non-innovative; full innovativeness vs. conditional innovativeness). Explanatory variables, besides the three above-mentioned domains, are the year of evaluation, drug type, target disease and population, and the number and type of available studies.

RESULTS

Among the 141 medicines scrutinized, 31.9%, 29.8%, and 38.3% were evaluated as fully innovative, conditionally innovative, and non-innovative, respectively. Added therapeutic value and the quality of the evidence were associated with the odds of receiving innovative status, and full compared with conditional innovativeness; unmet need was not a predictive variable. Other factors played a minor role: medicines for both solid tumours and rare diseases are more likely to be judged innovative; conditional innovativeness is more probable for medicines for rare diseases.

CONCLUSIONS

Innovativeness status is driven by the added therapeutic value and quality of evidence. The appraisal process is internally consistent and predictable. This provides industry with a clear indication of what is needed to ensure that access to their medicines is prioritized.

The Value of New: Consideration of Product Novelty in Health Technology Assessments of Pharmaceuticals

BACKGROUND

Efforts to understand how treatments affect patients and society have broadened the criteria that health technology assessment (HTA) organizations apply to value assessments. We examined whether HTA agencies in eight countries consider treatment novelty in methods and deliberations.

METHODS

We defined a novel pharmaceutical product to be one that offers a new approach to treatment (e.g., new mechanism of action), addresses an unmet need (e.g., targets a rare condition without effective treatments), or has a broader impact beyond what is typically measured in an HTA. We reviewed peer-reviewed publications and technical guidance materials from HTA organizations in Australia, Canada, England, France, The Netherlands, Norway, Sweden, and the United States (US). In addition, we explored how HTA organizations integrated novelty considerations into deliberations and recommendations related to two newer therapies-voretigene neparvovec for an inherited retinal disorder and ocrelizumab for multiple sclerosis.

RESULTS

None of the HTA organizations acknowledge treatment novelty as an explicit value criterion in their assessments of pharmaceutical products. However, drugs that have novel characteristics are given special consideration, particularly when they address an unmet need. Several organizations document a willingness to expend more resources and accept greater evidence uncertainty for such treatments. Qualitative deliberations about the additional unquantified potential benefits of treatment may also influence HTA recommendations.

CONCLUSION

Major HTA organizations do not recognize novelty as an explicit value criterion, although drugs with novel characteristics may receive special consideration. There is an opportunity for organizations to codify their approach to evaluating novelty in value assessment.

Assessing Definitions and Incentives Adopted for Innovation for Pharmaceutical Products in Five High-Income Countries: A Systematic Literature Review

BACKGROUND

The concept of health care innovation varies across organizations and countries. Harmonizing the definitions of innovation can augment the discovery of new therapies, minimize costs, and streamline drug development and approval processes. A systematic literature review (SLR) was conducted to gather insights surrounding different elements of innovation in the USA, the UK, France, Germany, and Japan. The SLR identified studies that have defined innovation and captured the types of incentives provided to promote innovation.

METHODS

The MEDLINE, Embase, and EconLit databases were searched via the OVID SP platform on October 22, 2020. A secondary desk search literature review was performed to identify additional information of interest in regional languages: French, German, and Japanese. All the relevant literature in English was screened using the Linguamatics natural language processing (NLP) tool, except for articles from EconLit, which were screened manually using structured search strategies. Articles that describe a definition of innovation or refer to a definition of innovation published were included. All full-text articles were reviewed manually, and two reviewers independently screened the full texts for eligibility.

RESULTS

After screening, 90 articles were considered to meet the SLR objectives. The most common dimension of innovation identified was therapeutic benefit as a measure of innovation, followed by newness and novelty aspects of innovations. Incentives around exclusivities were found to be the most prevalent in the data set, followed by rewards and premiums. Among the different therapy areas, the largest number of innovations was targeted at oncology.

CONCLUSIONS

This SLR highlights the lack of a unified definition of innovation among regulatory authorities and health technology assessment bodies in five countries, and variation in the types of incentives associated with innovation. The targeted countries cover different dimensions of definition and incentives of innovation at varying levels, with a few focused on specific therapy areas. Harmonization and consensus for innovation would be needed across countries because drug development is a global undertaking. This SLR envisages a more holistic approach to evaluation, wherein the value provided to patients and health systems is accounted for. The results of this SLR will help to promote broader discussion among different stakeholders and decision makers across countries to identify gaps in policies and develop sustainable strategies to promote innovation for pharmaceutical products.

How innovation can be defined, evaluated and rewarded in health technology assessment

BACKGROUND

What constitutes innovation in health technologies can be defined and measured in a number of ways and it has been widely researched and published about. However, while many countries mention it as a criterion for pricing or reimbursement of health technologies, countries differ widely in how they define and operationalise it.

METHODS

We performed a literature review, using a snowballing search. In this paper, we explore how innovation has been defined in the literature in relation to health technology assessment. We also describe how a selection of countries (England, France, Italy, Spain and Japan) take account of innovation in their health technology assessment frameworks and explore the key methodologies that can capture it as a dimension of value in a new health technology. We propose a way of coming to, and incorporating into health technology assessment systems, a definition of innovation for health technologies that is independent of other dimensions of value that they already account for in their systems, such as clinical benefit. We use Spain as an illustrative example of how innovation might be operationalised as a criterion for decision making in health technology assessment.

RESULTS

The countries analysed here can be divided into 2 groups with respect to how they define innovation. France, Japan and Italy use features such as severity, unmet need and therapeutic added value as indicators of the degree of innovation of a health technology, while England, Spain consider the degree of innovation as a separate and additional criterion from others. In the case of Spain, a notion of innovation might be constructed around concepts of `step-change', `convenience', `strength of evidence base' and `impact on future research & development'.

CONCLUSIONS

If innovation is to be used as operational criteria for adoption, pricing and reimbursement of health technologies, the concept must be clearly defined, and it ought to be independent from other value dimensions already captured in their health technology assessment systems.

Characterizing attributes of innovation of technologies for healthcare: a systematic review

OBJECTIVES

Characterizing and evaluating the holistic value of innovative healthcare technologies (e.g. treatments, services) constitutes a crucial goal to maximize limited resources. However, the characteristics of innovation have not been well identified. This review aims to describe the characteristics of healthcare innovation.

METHODS

We performed a comprehensive systematic search using PubMed, Embase, PsycINFO, and Econlit from inception to July 2022. Articles were included if they described innovation or the characteristics of innovation of the technologies in healthcare. Characteristics or definitions of innovation directly or indirectly described as innovation were extracted from the included articles. Two independent reviewers then conceptualized the identified characteristics of innovation to generate innovation attributes in healthcare.

RESULTS

In total, 103 articles were included in this review. Eight attributes describing innovation, i.e. novelty, step change, substantial benefits, an improvement over existing technologies, convenience and/or adherence, added value, acceptable cost, and uncounted benefits, were conceptualized. Most of the identified innovation attributes were based on the researchers' perspective.

CONCLUSIONS

This study conceptualized innovation attributes in healthcare based on the characteristics of healthcare innovation as defined in the literature. Further research is warranted to obtain a complete understanding of the perspectives of researchers and other stakeholders, including patients, healthcare providers, healthcare payers, and the pharmaceutical industry, on recognizing innovation in healthcare.KEY POINTSThis is the first systematic review to conceptualize attributes of healthcare innovation.We conceptualized eight attributes describing innovation, i.e. novelty, step change, substantial benefits, an improvement over existing technologies, convenience and/or adherence, added value, acceptable cost, and uncounted benefits based on the similar concept.In existing literature, patients' and caregivers' perspectives were less frequently found to describe the innovation attributes.Future research is needed to identify, measure, and value various stakeholders, including patients' and caregivers' perspectives on healthcare innovation.

A Review of Current Approaches to Defining and Valuing Innovation in Health Technology Assessment

OBJECTIVES

The growing focus on the value of new drugs for patients and society has led to a more differentiated notion of innovation in the context of pharmaceutical products. The goal of this article is to provide an overview of the current debate about the definition and assessment of innovation and how innovation is considered in reimbursement and pricing decisions.

METHODS

To compile the relevant literature, we followed a 2-step approach. First, we searched for peer-reviewed literature that deals with the definition of pharmaceutical innovation. Second, we reviewed health technology assessment (HTA) guidelines of 11 selected countries (Australia, Belgium, Canada, England, France, Germany, Italy, Japan, Norway, Sweden, and The Netherlands) regarding aspects of innovation that are currently considered as relevant by the respective HTA bodies.

RESULTS

All countries in our sample use 1 of 2 types of reward mechanism for novel drugs that they consider provide some sort of benefit. Generally, the focus is on the therapeutic benefit of a drug, whereas, depending on the exact arrangement, other aspects can also be taken into account. A reduction in side effects and aspects of treatment convenience can be invoked in some of the countries. Mostly, however, they are not considered unless they are already captured in the clinical outcomes used to measure the therapeutic benefit.

CONCLUSION

Our review shows that although the health economic literature discusses a range of aspects on how innovation may generate value even without providing an immediate added therapeutic benefit (or on top of it), these are only selectively considered in the reviewed HTA guidelines. For most part, only the added therapeutic value is crucial when it comes to pricing and reimbursement decisions.

Non-Price-Related Determinants of Value and Access for Novel Non-small Cell Lung Cancer Treatments: A Cross-Country Review of HTA Decision Making

INTRODUCTION

Access and funding for newly approved treatments for non-small cell lung cancer (NSCLC) are often dependent on Health Technology Assessment (HTA) involving cost-effectiveness analysis. Whilst methods used by HTA agencies share many similarities, final decisions may differ. This may be the result, not just of price considerations, but also of variation in value judgements by different agencies. The aim of this study was to review international HTA evaluations to identify determinants of value and access for NSCLC treatments.

METHODS

A targeted review and analysis was undertaken of published HTAs for NSCLC across HTA agencies in six countries (Australia, Canada, England, France, Ireland and Scotland). Analysis of extracted data consisted of three stages: descriptive analysis, bivariate analysis and multivariable analysis.

RESULTS

The analysis included 163 HTAs that assessed oncological treatments for NSCLC from 2003 to 2019. The majority of HTA decisions (67.5%) were positive. However, some evidence of heterogeneity in HTA decisions and the factors informing them were identified. The most influential factors included in the multivariate model related to the HTA agency conducting the appraisal, the year of market authorisation, treatment type and the line of treatment.

CONCLUSION

Heterogenous decision-making frameworks can present a challenge to developing HTA submissions. This research contributes to understanding decision-making factors and why countries make different decisions.

The Promise and the Hope of Gene Therapy

It has been over 30 years since visionary scientists came up with the term "Gene Therapy," suggesting that for certain indications, mostly monogenic diseases, substitution of the missing or mutated gene with the normal allele via gene addition could provide long-lasting therapeutic effect to the affected patients and consequently improve their quality of life. This notion has recently become a reality for certain diseases such as hemoglobinopathies and immunodeficiencies and other monogenic diseases. However, the therapeutic wave of gene therapies was not only applied in this context but was more broadly employed to treat cancer with the advent of CAR-T cell therapies. This review will summarize the gradual advent of gene therapies from bench to bedside with a main focus on hemopoietic stem cell gene therapy and genome editing and will provide some useful insights into the future of genetic therapies and their gradual integration in the everyday clinical practice.

Determinants of radical drug innovation: a systematic literature review

Radical drug innovations are of great importance to pharmaceutical firms and public health. Understanding the determinants involved in successful radical drug innovations is key to increasing this type of output in the future. The objective of this review is to search the literature for key firm-level determinants of radical drug innovation. Following a systematic literature review approach, we considered more than 4100 peer-reviewed journal articles and PhD theses, of which we included 38 in the narrative synthesis. To guide the review, we use Crossan and Apaydin’s (J Manag Stud 47:1154–1191, 2010) model of firm-level determinants of innovation for the first time within the pharmaceutical industry, which is unique due to the risks, costs, and time frames associated with radical drug innovation. We focus on three groups of determinants: leadership, managerial levers, and business processes. We find the following to be particularly important for radical drug innovation: external knowledge sourcing (managerial lever); internal knowledge management (managerial lever); ability of top leaders to innovate, as determined by educational background and professional experience (leadership); and leaders’ focus on shaping innovation and performance cultures (leadership). We offer a conceptual framework of critical determinants of radical drug innovation and highlight managerial implications. We also discuss gaps in radical drug innovation research and provide suggestions for future study. Many of the findings discussed in this paper are contradictory because they rely on different definitions and measures, which inhibits our full and accurate understanding of radical drug innovation development. More research is needed to address untested measures of radical drug innovation.

Innovation as a value in healthcare priority-setting: the UK experience

All healthcare systems operate with limited resources and therefore need to set priorities for allocating resources across a population. Trade-offs between maximising health and promoting health equity are inevitable in this process. In this paper, we use the UK's National Institute for Health and Care Excellence (NICE) as an example to examine how efforts to promote healthcare innovation in the priority-setting process can complicate these trade-offs. Drawing on NICE guidance, health technology assessment reports and relevant policy documents, we analyse under what conditions NICE recommends the National Health Service fund technologies of an "innovative nature", even when these technologies do not satisfy NICE's cost-effectiveness criteria. Our findings fail to assuage pre-existing concerns that NICE's approach to appraising innovative technologies curtails its goals to promote health and health equity. They also reveal a lack of transparency and accountability regarding NICE's treatment of innovative technologies, as well as raising additional concerns about equity. We conclude that further research needs to evaluate how NICE can promote health and health equity alongside healthcare innovation and draw some general lessons for healthcare priority-setting bodies like NICE.