Not playing with a full DEC: why development and evaluation committee methods for appraising new drugs may be inadequate

Decision-making by surgeons about referral for adjuvant therapy for patients with non-small-cell lung, breast or colorectal cancer: a qualitative study

BACKGROUND

Because surgeons are the main gatekeepers to oncology services, understanding how they make decisions related to referral for adjuvant therapies is important to optimize referral rates and use of oncology services for patients with potentially curable disease. We examined decision-making by surgeons related to referral to oncology services for patients having undergone curative-intent surgery for non-small-cell lung, breast or colorectal cancer.

METHODS

We conducted a qualitative study, whose design was guided by the principles of grounded theory. Semi-structured interviews were held with 29 surgeons who performed non-small-cell lung, breast or colorectal cancer surgery in the province of Nova Scotia. Data were collected and analyzed concurrently. Analysis involved an inductive, grounded approach using constant comparative analysis. Data collection and analysis continued until theoretical saturation was reached.

RESULTS

Seven factors influenced the surgeons' decision-making related to referral to oncology services: indications and contraindications for therapy; patients' beliefs and preferences; a belief that oncologists are the experts; knowledge of local standards of care; consultation with oncology colleagues; navigating patient logistics (e.g., lodging, caregiving responsibilities, insurance coverage); and system resources and capacity.

INTERPRETATION

Our study's findings provide a novel understanding of how surgeons make decisions about oncology referral and point to potential areas for intervention to promote referral to oncology services for patients for whom adjuvant therapy is recommended.

Cost-consequence analysis of long-term prophylaxis in the treatment of von Willebrand disease in the Italian context

Purpose

Prophylaxis with von Willebrand factor (VWF)/factor VIII (FVIII) concentrates is a potential approach for patients with severe von Willebrand disease (VWD). As far as we are aware, to date there have been no pharmacoeconomic analyses in order to assess the economic impact of treatments for severe VWD. The analysis presented here estimates the cost–benefit ratio of VWF with a low FVIII content when compared with VWF/FVIII concentrates currently used in Italy for long-term prophylaxis in patients with severe VWD.

Methods

A cost–consequence analysis was undertaken to assess the economic impact of the treatment of severe VWD from the perspective both of the Italian National Health Service and society. The analysis was based on four case reports of long-term prophylaxis with VWD with VWF/FVIII concentrates and VWF with a low FVIII content. The costs per patient included direct and indirect costs for each treatment.

Results

Considering the four case reports, health care costs (without cost of treatment) and indirect costs per patient per year were lower with VWF with a low FVIII content than VWF/FVIII concentrates. The total health care costs (without cost of treatment) and indirect costs avoided with VWF with a low FVIII content per patient per year ranged from €2,295 to €17,530 and from €1,867 to €4,978, respectively.

Conclusion

VWF with a low FVIII content seems to be a cost-effective treatment option for patients with severe VWD. Although the drug cost per se is higher, the use of VWF with a low FVIII content is associated with decreased consumption of hospital resources and fewer lost working days due to bleedings and consequently with an improvement of the quality of life of the patients.

Emerging health technologies: informing and supporting health policy early

OBJECTIVES

All western healthcare systems are confronted with a rising number of new health technologies. To support decision-making processes with sound information about new health technologies, some countries have established "Horizon Scanning Systems (HSS)". This paper gives an overview of processes and practices of HSS.

METHOD

The paper is based on a literature review (Medline and Embase) and on unpublished information gathered from HSS-agencies.

RESULTS

The 13 current HSS have been collaborating in the EuroScan network since 1999. EuroScan has agreed on a common terminology, classification and understanding of their activities. All their activities consist of 5 sequenced main components: identification and filtering, prioritization, early assessment, dissemination and monitoring the assessed technologies. Although there is a common understanding with regard to function and processes there are some differences in the scope of the national/regional HSS.

CONCLUSION

EuroScan has played an important role in the harmonization process so that effective collaboration, reduction of duplication and the further development of procedures have become possible. Because of the common understanding there is a certain stability and integration across the functions of HSS. Nonetheless there are some obvious "blank spots" susceptible to subjectivity, such as an implicit prioritization process.

Understanding the limited impact of economic evaluation in health care resource allocation: a conceptual framework

Concern has increasingly been expressed at the low level of impact that economic evaluations have on the priority setting decisions they are designed to inform. The concern to maximise the impact of economic evaluation in health care is reminiscent of research utilisation debates rehearsed in the various policy studies disciplines. This paper draws on selected themes and frameworks from this literature in order to explore issues and map out an agenda relating to the uptake and use of cost effectiveness analysis in health policy decisions. The authors consider the implications for health economics, and other policy-related research and evaluation, of adopting either a rational or interactive model of research utilisation. Economic evaluations can be normative or descriptive decision tools. The choice of approach will reflect the assumed model of research utilisation and has implications for overcoming barriers to impact on policy. There is an underlying conceptual link between the rational model of research utilisation, the normative approach to economic evaluation and a focus on barriers to the accessibility of published analyses. In contrast, acknowledgement of an interactive and incremental policy process predisposes the analyst to a more descriptive approach and suggests the importance of broader systems, process and ethical barriers to the use of economic evaluation. We address the crucial issue of the importance of establishing objectives and discuss how this issue effects how those seeking to influence policy should proceed. Finally, we discuss indirect or 'enlightenment' models of research utilisation and the implications of these for the community of health economists.

Annotation: Economic evaluations of child and adolescent mental health interventions: a systematic review

BACKGROUND

Recognition has grown over recent years of the need for economic information on the impacts of child and adolescent mental health problems and the cost-effectiveness of interventions.

METHODS

A range of electronic databases were examined using a predefined search strategy to identify economic studies which focused on services, pharmacological interventions and other treatments for children and adolescents with a diagnosed mental health problem or identified as at risk of mental illness. Published studies were included in the review if they assessed both costs and outcomes, with cost-effectiveness being the primary interest. Studies meeting the criteria for inclusion were assessed for quality.

RESULTS

There are still relatively few economic evaluations in this field. Behavioural disorders have been given relatively greater attention in economic evaluations of child and adolescent mental health. These studies tentatively suggest child behavioural gains and parent satisfaction from parent and child training programmes, although the cost-effectiveness of the location of delivery for behavioural therapies is less clear. In general, the quality of economic evaluations was limited by small sample sizes, constrained measurement of costs, narrow perspectives and over-simple statistical and econometric methods.

CONCLUSION

Economic evaluations in the field of child and adolescent mental health interventions are few in number and generally poor in quality, although the number of studies being undertaken now appears to be rising.

Regulating the economic evaluation of pharmaceuticals and medical devices: a European perspective

Throughout the developed world, economic evaluation of costly new pharmaceuticals and medical devices became increasingly widespread and systematic during the 1990s. However, serious concerns remain about the validity and relevance of this economic evidence, and about the transparency and accountability of its use in public sector reimbursement decisions. In this article, we summarise current concerns in Europe, based on interviews with European health economists from industry, universities, research institutes and consulting firms. We identify five challenges for European policy-makers, and conclude that there is considerable scope for improving decision-making without damaging incentives to innovate. The challenges are: (1). full publication of the economic evidence used in reimbursement decisions; (2). the redesign of licensing laws to improve the relevance of economic data available at product launch; (3). harmonisation of economic evaluation methodologies; (4). development of methodologies for evaluation of health inequality impacts; and (5). negotiation of price-performance deals to facilitate the use of economic evidence in post-launch pricing review decisions, as information is gathered from studies of product performance in routine use.

A role for two-stage pharmacoeconomic appraisal? Is there a role for interim approval of a drug for reimbursement based on modelling studies with subsequent full approval using phase III data?

Healthcare decision makers and pharmaceutical companies are increasingly using techniques of economic evaluation, particularly modelling, to assist them in their decisions about drug purchasing and drug development. The use of models in other types of policy decisions is also well established. One option, to shorten the time to a purchasing decision, would be for an interim decision for approval for reimbursement to be based on an economic model. Such a system would mainly benefit the drug development process and thus the pharmaceutical industry; however the approach could also lead to poor decision making, unethical marketing and withdrawal of drugs from the consumer. In this article, we consider the option of a two-stage economic appraisal process from the point of view of the seller, the purchaser and the patient and public. Although a two-stage process may offer some advantages in terms of early return on investment and access, there are significant disadvantages in terms of certainty about effects and public policy and expenditure. Until there are better methods of predicting the effectiveness of a new product, it is unlikely that interim decisions can be seen as a reasonable health policy alternative, although it seems likely that industry may continue to lobby for such an approach.

Evaluation of the impact of a technology appraisal process in England: the South and West Development and Evaluation Committee

OBJECTIVES

To examine the influence of the English National Health Service (NHS) South and West (S&W) region Development and Evaluation Committee (DEC) technology appraisal reports on purchasing and clinical decisions in the S&W and elsewhere in the NHS, and to estimate the cost of the DEC process.

METHODS

Two postal questionnaires examining issues of awareness, influence and quality of the DEC reports were sent to samples of clinical and managerial health service staff in S&W NHS region, the North West NHS region, and three other randomly selected health authorities elsewhere. Supplementary telephone interviews were undertaken with a subsample of staff. Trends in utilisation before and after the publication of four S&W DEC reports were examined using routine health service data.

RESULTS

Survey response rates ranged between 73% and 85%. Within health authorities in the S&W, agreement about the impact of the DEC in informing policy and purchasing decisions was consistently high, although responses from clinicians were more equivocal. In the topic areas examined, the impact of the DEC reports could not be separated from wider influences on practice. The cost of each DEC report is estimated to have been pounds sterling 24659.

CONCLUSIONS

Health service staff perceived that the S&W DEC process had had an impact on policy decisions and clinical practice locally; however, any actual impact on practice could not be identified with routine data. The approach used in this study would be valuable in evaluating the impact of the English NHS National Institute for Clinical Excellence.

Shared treatment decision making in a collectively funded health care system: possible conflicts and some potential solutions

In recent years there has been a growth in the advocacy of shared decision making (SDM) between clinicians and patients as a way of practicing medicine. Although there is a range of perspectives on what SDM means, in essence it refers to greater involvement of the individual patient in deliberations about appropriate forms of clinical management. The patient's perception of the role of the doctor in SDM is crucial: for it to work successfully, the patient needs to be able to be confident that the doctor is focused on which treatment will generate the greatest benefit for them. However, the doctor also has responsibilities to others, in particular to other patients and potential patients within the collectively funded health care system. This dual responsibility can create a range of dilemmas for the clinician in the context of SDM: Should they inform patients about all effective treatments or just those that the health care system considers cost-effective? Do they risk losing patients from their books if they inform patients about their responsibilities to the health care system? SDM also raises questions about the wider principles of the health care system: Are its equity principles consistent with SDM? Should patients with a strong preference for an effective but non-cost-effective treatment be permitted to pay for it privately? This paper describes the nature of the conflicts that are likely to emerge if SDM diffuses within collectively funded health care systems, and considers a range of policy responses. It argues that the risk of conflict may be reduced by making a clear distinction between clinical guidelines (focusing on effectiveness) and system guidelines (focusing on cost-effectiveness).

Providing information on emerging health technologies to provincial decision makers: a pilot project

A pilot project to provide advice on new and emerging medical technologies to decision makers in a provincial health care system was undertaken by a health technology assessment (HTA) program. Briefs were prepared on technologies which were not yet available in the province and which might have a significant impact on health care. These were sent to the ministry of health and regional health authorities and made available through the agency's website. Reaction to the briefs was sought from decision makers. Decision makers in the health ministry and health authorities found the briefs helpful, and wished to continue receiving them. They had made limited use of them for planning purposes, but the briefs provided useful input to further consideration of technologies in several cases. Within the HTA program, the briefs and the process that produced them were valuable in increasing awareness of new health technologies that might require assessment in future. This pilot project demonstrated the feasibility of providing timely advice on emerging health technologies within a provincial health system. However, while decision makers found the information provided to be useful, this had not yet been integrated with provincial health care planning. Necessary machinery within policy areas and communication with the HTA process appear to be in need of development.

Methylphenidate in children with hyperactivity: review and cost-utility analysis

OBJECTIVE

To evaluate the effectiveness and cost effectiveness of methylphenidate in the treatment of children with hyperkinetic disorder as defined using ICD-10 criteria.

DESIGN

Comprehensive literature review and cost utility analysis comparing methylphenidate treatment with placebo. Costs and effects were estimated from a NHS perspective according to the methodology developed by the previous South and West Development and Evaluation Committee. The number of Quality Adjusted Life Years (QALYs) gained was estimated by using the Index of Health Related Quality of Life to model treatment effects.

RESULTS

Evidence from good and medium quality randomized controlled trials shows benefits of methylphenidate over weeks and months respectively. Evidence beyond 6 months is poorer and it is uncertain whether effects of methylphenidate persist into adolescence and adulthood. Methylphenidate is of reasonable cost-effectiveness when considering short- and medium- term benefits with an estimated cost per QALY of 7 pounds 400 to 9 pounds 200 at 1997 prices.

CONCLUSIONS

Short-term treatment of hyperkinetic children with methylphenidate is effective and cost effective.

Evidence-based medicine as Bayesian decision-making

We review two recent trends: the emergence of evidence-based medicine and the growing use of Bayesian statistics in medical applications. Evidence-based medicine requires an integrated assessment of the available evidence, and associated uncertainty, but there is also an emphasis on decision-making, for individual patients, or at other points in the health-care system. This demands consideration of the values and costs associated with potential outcomes. We argue that the natural statistical framework for evidence-based medicine is a Bayesian approach to decision-making that incorporates an integrated summary of the available evidence and associated uncertainty with assessment of utilities. We outline a practical agenda for further development.

The evidence-based approach in health policy and health care delivery

Evidence-based approaches are prominent on the national and international agendas for health policy and health research. It is unclear what the implications of this approach are for the production and distribution of health in populations, given the notion of multiple determinants in health. It is equally unclear what kind of barriers there are to the adoption of evidence-based approaches in health care practice. This paper sketches some developments in the way in which health policy is informed by the results from health research. It summarises evidence-based approaches in health at three impact levels: intersectoral assessment, national health care policy, and evidence-based medicine in everyday practice. Consensus is growing on the role of broad and specific health determinants, including health care, as well as on priority setting based on the burden of diseases. In spite of methodological constraints, there is a demand for intersectoral assessments, especially in health sector reform. Initiators of policy changes in other sectors may be held responsible for providing the evidence related to health. There are limited possibilities for priority setting at the national health care policy level. Hence, there is a decentralisation of responsibilities for resource use. Health care providers are encouraged to assume agency roles for both patients and society and asked to promote and deliver effective and efficient health care. Governments will have to design a national framework to facilitate their organisation and legal framework to enhance evidence-based health policy. Treatment guidelines supported by evidence on effectiveness and efficiency will be one essential element in this process. With the increasing number of advocates for the enhancement of population health in the policy arenas, evidence-based approaches provide the information and some of the tools to help with priority setting.