P11.65.B GBM AGILE: A global, phase 2/3 adaptive platform trial to evaluate multiple treatment regimens in newly diagnosed and recurrent glioblastoma

Background

GBM AGILE (Glioblastoma Adaptive, Global, Innovative Learning Environment) is a biomarker based, multi-arm, international, seamless Phase 2/3 Response Adaptive Randomization platform trial designed to rapidly identify experimental therapies that improve overall survival and confirm efficacious experimental therapies and associated biomarker signatures to support new drug approvals and registration. It is a collaboration between academic investigators, patient organizations and industry, under the sponsorship of the non-profit organization, Global Coalition for Adaptive Research, to support new drug applications for newly diagnosed and recurrent GBM.

Material and Methods

The primary objective of GBM AGILE is to identify therapies that effectively improve overall survival in patients with newly diagnosed or recurrent GBM. Bayesian response adaptive randomization is used within subtypes of the disease to assign participants to investigational arms based on their performance. Operating under a master protocol, GBM AGILE allows multiple drugs from different pharmaceutical companies to be evaluated simultaneously and/or over time against a common control arm. Based on performance, a drug may graduate and move to a Stage 2 (Phase 3) within the trial, and the totality of the data can be used for a new drug application and registration process. New experimental therapies are added as information about promising new drugs is identified while other therapies are removed as they complete their evaluation. The master protocol/ trial infrastructure includes efficiencies through an adaptive trial design, shared control arm and operational processes such as risk-based monitoring and enhanced remote activities. With its adaptable structure, GBM AGILE has continued trial activation, inclusion of new investigational therapies, and enrollment globally through the challenges of a global pandemic.GBM AGILE provides an efficient mechanism to screen and develop robust information regarding the efficacy of proposed novel therapeutics and associated biomarkers for GBM and to quickly move therapies and biomarkers into clinic. GBM AGILE received initial approval from the United States FDA in April 2019, and in Europe through the Voluntary Harmonization Procedure (VHP) in April, 2021. As of 2022, AGILE has screened over 1000 patients studying multiple investigational treatments. Enrollment rates are 3 to 4 times greater than traditional GBM trials, with active sites averaging 0.75 to 1 patients/site/month.

Currently, there are 41 sites activated in the US, 4 in Canada and 2 in Switzerland and an estimated 24 sites yet to open in Germany, France, Switzerland, Italy and Austria. In addition to the continued expansion in Europe, effort is undergoing to extend the trial to China and Australia as well. Clinical trial information: NCT03970447

Abstract P3-05-02: Quantitative ERα measurements in TNBC from the I-SPY 2 TRIAL correlate with HER2-EGFR co-activation and heterodimerization

Background: We have previously described that TNBC patients whose tumors have both HER2 Y1248 phosphorylation (pHER2) “high” and phospho-EGFR Y1173 (pEGFR) “high” have increased response (pCR) to neratinib in the I-SPY2 TRIAL. We hypothesize that the paradoxical finding of a response prediction signature comprised of HER2 activation in a HER2 IHC/FISH-negative population means there must be a ligand-driven biochemical event responsible for the HER2 phosphorylation because HER2 mutations were also not found to be significant. Exploratory analysis of additional cellular signaling events and protein expression levels in pre-treatment, LCM-purified tumor epithelium by reverse phase protein microarray (RPPA) included semi-quantitative measurement of total levels of estrogen receptor alpha (ERα), which has been previously shown to be able to act as a membrane non-genomic signaling molecule through direct interaction with various tyrosine kinases including EGFR and HER2. Since ERα has been previously shown to act as a ligand and co-stimulate (activate) HER2 and EGFR when present at low levels, we investigated whether or not RPPA-measured ERα levels in the TNBC cohort analyzed to date were higher in tumors with both pHER2 “high” and pEGFR “high” levels and thus provide evidence explaining how HER2-EGFR activation is occurring in TNBC.

Methods: Using RPPA analysis, we measured 118 analytes in lysates of LCM tumor epithelium obtained from the pre-treatment biopsy samples of 86 TNBC (Allred=0) patients in the I-SPY2 TRIAL analyzed to date. Cutpoints for pEGFR and pHER2 were determined previously by ROC analysis for pCR correlation in the neratinib treated TNBC population, and used here to dichotomize the pHER2 and pEGFR data in the larger TNBC population. Wilcoxon Rank Sum testing was performed using the continuous variable total ERα data and compared the TNBC that were both pHER2 and pEGFR “high” (N=39) to the rest of the TNBC population (N=47). Total ERα values were then divided into “high” and “low” groups based on the TNBC population median value in order to determine frequency/percentages within each class. Our study is exploratory with no claims for generalizability of the data, and calculations are descriptive (e.g. p-values are measures of distance with no inferential content).

Results: Total ERα values were obtained in 84/86 TNBC tumors analyzed. Total levels of ERα were higher (p< 0.006) in TNBC tumors with pHER2 and pEGFR “high” levels. 68% (26/38) of tumors in the pHER2 and pEGFR “high” group had ERα levels above the population median compared to 35% (16/46) in the rest of the TNBC population.

Conclusion: Our exploratory analysis reveals that ERα levels are significantly higher in TNBC with pHER2 and pEGFR activation and may be behaving as a direct signaling ligand in TNBC and driving HER2-EGFR signaling. This ERα-pHER2/pEGFR association was missed by current ER and HER2 clinical laboratory testing techniques, and if validated in larger independent study sets could suggest that utilization of new protein-based techniques defining ER more quantitatively could be helpful to understand tumor biology and therapeutic response prediction, especially in the context of TNBC that are ostensibly ER negative.

Citation Format: Gallagher RI, Yau C, Wolf DM, Dong T, Hirst G, Brown-Swigart L, ISPY-2 TRIAL Investigators, Buxton M, DeMichele A, van't Veer L, Yee D, Paoloni M, Esserman L, Berry D, Park J, Petricoin EF, Wulfkuhle JD. Quantitative ERα measurements in TNBC from the I-SPY 2 TRIAL correlate with HER2-EGFR co-activation and heterodimerization [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-05-02.

Abstract P1-14-03: The evaluation of trebananib plus standard neoadjuvant therapy in high-risk breast cancer: Results from the I-SPY 2 TRIAL

Background: I-SPY 2 is a multicenter phase 2 trial using response-adaptive randomization within biomarker subtypes to evaluate a series of novel agents when added to standard neoadjuvant therapy for women with high-risk stage II/III breast cancer. The primary endpoint is pathologic complete response (pCR). The goal is to identify/graduate regimens with ≥85% Bayesian predictive probability of success (statistical significance) in a 300-patient phase 3 neoadjuvant trial defined by hormone-receptor (HR), HER2 status & MammaPrint (MP). Regimens may also leave the trial for futility (< 10% probability of success) or following accrual of maximum sample size (10%< probability of success <85%). We report the results for trebananib, an angiopoietin-1/2-neutralizing peptibody that inhibits interaction with the Tie2 receptor.

Methods: Women with tumors ≥2.5cm were eligible for screening. MP low/HR+/HER2- tumors were ineligible for randomization. Serial MRI scans (baseline, 2 during treatment and pre-surgery) were used in a longitudinal model to improve the efficiency of adaptive randomization. Participants are categorized into 8 subtypes based on: HR status, HER2 status and MP High 1 (MP1) or High 2 (MP2). MP1 and MP2 are determined by a predefined median cut-point of I-SPY 1 participants who fit the eligibility criteria for I-SPY 2. Trebananib was initially assigned to HER2- patients only; once safety data with trastuzumab (H) were obtained, it was also assigned to HER2+ patients. Analysis was intent to treat -- patients who switched to non-protocol therapy were designated non-pCRs.

Results: Trebananib +/-H did not meet the criteria for graduation in any of the 10 signatures tested. When the maximum sample size was reached, accrual ceased. We report probabilities of trebananib +/-H being superior to control and Bayesian predictive probabilities of success in a 1:1 randomized neoadjuvant phase 3 trial for the 10 biomarker signatures, using the final pCR data from all patients.

SignatureEstimated pCR Rate (95% probability interval)Probability Trebananib Is Superior to ControlPredictive Probability of Success in Phase 3Trebananib (n=134)Control (n=133)ALL0.259(0.16 -0.36)0.158(0.09-0.23)0.9860.564HR+0.157(0.05-0.26)0.115(0.03- 0.20)0.8050.281HR-0.378(0.22-0.53)0.207(0.11- 0.31)0.9910.784HER2+0.279(0.07-0.49)0.17(0.04-0.30)0.8790.553HER2-0.254(0.15-0.36)0.155(0.08-0.23)0.9810.555MP20.342 (0.19-0.49)0.177(0.07-0.28)0.9910.786HR-/HER2-0.368 (0.21-0.53)0.201(0.10-0.30)0.9880.771HR-/HER2+0.444(0.15-0.74)0.244(0.07-0.42)0.9260.739HR+/HER2+0.201(0.01-0.39)0.135(0.01-0.26)0.7750.41HR+/HER2-0.143(0.04-0.24)0.11(0.03-0.19)0.7580.248

Citation Format: Albain KS, Leyland-Jones B, Symmans F, Paoloni M, van 't Veer L, DeMichele A, Buxton M, Hylton N, Yee D, Lyandres Clennell J, Yau C, Sanil A, I-SPY 2 Trial Investigators, Berry D, Esserman L. The evaluation of trebananib plus standard neoadjuvant therapy in high-risk breast cancer: Results from the I-SPY 2 TRIAL. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-14-03.

Clinical effectiveness and cost-effectiveness of endobronchial and endoscopic ultrasound relative to surgical staging in potentially resectable lung cancer: results from the ASTER randomised controlled trial

OBJECTIVE

To assess the clinical effectiveness and cost-effectiveness of endosonography (followed by surgical staging if endosonography was negative), compared with standard surgical staging alone, in patients with non-small cell lung cancer (NSCLC) who are otherwise candidates for surgery with curative intent.

DESIGN

A prospective, international, open-label, randomised controlled study, with a trial-based economic analysis.

SETTING

Four centres: Ghent University Hospital, Belgium; Leuven University Hospitals, Belgium; Leiden University Medical Centre, the Netherlands; and Papworth Hospital, UK.

PARTICIPANTS

INCLUSION CRITERIA

known/suspected NSCLC, with suspected mediastinal lymph node involvement; otherwise eligible for surgery with curative intent; clinically fit for endosonography and surgery; and no evidence of metastatic disease.

EXCLUSION CRITERIA

previous lung cancer treatment; concurrent malignancy; uncorrected coagulopathy; and not suitable for surgical staging.

INTERVENTIONS

Study patients were randomised to either surgical staging alone (n = 118) or endosonography followed by surgical staging if endosonography was negative (n = 123). Endosonography diagnostic strategy used endoscopic ultrasound-guided fine-needle aspiration combined with endobronchial ultrasound-guided transbronchial needle aspiration, followed by surgical staging if these tests were negative. Patients with no evidence of mediastinal metastases or tumour invasion were referred for surgery with curative intent. If evidence of malignancy was found, patients were referred for chemoradiotherapy.

MAIN OUTCOME MEASURES

The main clinical outcomes were sensitivity (positive diagnostic test/nodal involvement during any diagnostic test or thoracotomy) and negative predictive value (NPV) of each diagnostic strategy for the detection of N2/N3 metastases, unnecessary thoracotomy and complication rates. The primary economic outcome was cost-utility of the endosonography strategy compared with surgical staging alone, up to 6 months after randomisation, from a UK NHS perspective.

RESULTS

Clinical and resource-use data were available for all 241 patients, and complete utilities were available for 144. Sensitivity for detecting N2/N3 metastases was 79% [41/52; 95% confidence interval (CI) 66% to 88%] for the surgical arm compared with 94% (62/66; 95% CI 85% to 98%) for the endosonography strategy (p = 0.02). Corresponding NPVs were 86% (66/77; 95% CI 76% to 92%) and 93% (57/61; 95% CI 84% to 97%; p = 0.26). There were 21/118 (18%) unnecessary thoracotomies in the surgical arm compared with 9/123 (7%) in the endosonography arm (p = 0.02). Complications occurred in 7/118 (6%) in the surgical arm and 6/123 (5%) in the endosonography arm (p = 0.78): one pneumothorax related to endosonography and 12 complications related to surgical staging. Patients in the endosonography arm had greater EQ-5D (European Quality of Life-5 Dimensions) utility at the end of staging (0.117; 95% CI 0.042 to 0.192; p = 0.003). There were no other significant differences in utility. The main difference in resource use was the number of thoracotomies: 66% patients in the surgical arm compared with 53% in the endosonography arm. Resource use was similar between the groups in all other items. The 6-month cost of the endosonography strategy was £9713 (95% CI £7209 to £13,307) per patient versus £10,459 (£7732 to £13,890) for the surgical arm, mean difference £746 (95% CI -£756 to £2494). The mean difference in quality-adjusted life-year was 0.015 (95% CI -0.023 to 0.052) in favour of endosonography, so this strategy was cheaper and more effective.

CONCLUSIONS

Endosonography (followed by surgical staging if negative) had higher sensitivity and NPVs, resulted in fewer unnecessary thoracotomies and better quality of life during staging, and was slightly more effective and less expensive than surgical staging alone. Future work could investigate the need for confirmatory mediastinoscopy following negative endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA), the diagnostic accuracy of EUS-FNA or EBUS-TBNA separately and the delivery of both EUS-FNA or EBUS-TBNA by suitably trained chest physicians.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN 97311620.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 16, No. 18. See the HTA programme website for further project information.

P1-06-11: Comparison of Community and Central Her2 Assessment on Outcome of Neoadjuvant Chemotherapy in the I-SPY Trial

Background: Her-2/neu overexpression, by immunohistochemistry (IHC) or fluorescence in-situ hybridization (FISH), is highly correlated with response to trastuzumab and these are currently the gold-standard, FDA-cleared testing methods for assigning treatment to Her-2-directed therapies. However, substantial variability has been documented between community and central laboratory IHC and FISH testing. Biologically, Her-2 overexpression may reflect increased gene copy number, gene expression and/or protein production, and these can be measured by other platforms, including comparative genomic hybridization (CGH), expression arrays and quantitative protein assays, respectively. We sought to determine the degree to which community IHC/FISH results differed from centrally-assessed IHC, FISH, and other assessment platforms within the I-SPY Trial and whether response to neoadjuvant chemotherapy (NAC) differed by platform.

Methods: The I-SPY Trial enrolled 237 women 2002–06 with invasive breast tumors at least 3 cm in clinical/radiographic size who subsequently underwent anthracycline/taxane NAC, serial core biopsies and imaging. Pathologic complete response (pCR) was determined at time of surgery and 3-year follow up has been reached. Trastuzumab was given to Her2+ patients at physician discretion, based upon community IHC/FISH results, and became more widespread after 2005. Central I-SPY laboratories determined Her2 copy number by MIP array, gene expression by Affymetrix and Agilent arrays, and Her2 protein by reverse-phase protein array (RPMA). Unsupervised clustering algorithms were used to evaluate expression patterns. Composite variables were constructed for DNA, RNA and protein positivity as well as for community and central IHC/FISH. Platforms were compared and Kaplan-Meier curves were constructed to compare outcomes by platform.

Results: 222 women were evaluable, though not all patients had results for all platforms. Community composite IHC/FISH was positive in 64/214 (30%) but only 41 of these (64%) were confirmed by central IHC/FISH and 4 additional cases were centrally positive despite negative community testing. Concordance was high among centrally-assessed Her2 platforms, but was lower between community IHC/protein and central RNA (90%), DNA (91%) and protein (91%). Among patients receiving trastuzumab (n=36), the pCR rate was ∼50% regardless of Her2-assessment platform; in contrast, those not receiving trastuzumab had pCR rates below 30%. Among the 64 patients deemed Her2+ by community IHC/FISH, 30 (48%) had pCR and 15 (25%) have had distant relapse. Five distant relapses have occurred despite pCR; all received trastuzumab, all were Her2 positive by multiple central platforms and 3/5 were ER-positive. Sites of distant relapse included brain, bone and viscera; only 1 of 5 had isolated brain relapse.

Conclusions: Community IHC/FISH testing for Her2 expression in the I-SPY Trial overcalled Her2 positivity compared to central testing while central results were highly concordant among DNA, RNA and protein platforms. Despite the high rate of community “false positives”, relapse after pCR occurred only in central Her2 “true positives,” exclusively among those receiving trastuzumab, and was rarely isolated to CNS sanctuary sites.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P1-06-11.

Abstract PD07-03: A Genomic Predictor of Survival Following Taxane-Anthracycline Chemotherapy for Breast Cancer

Background: There is currently no predictive assay for patients with clinical Stage II-III breast cancer from which predicted sensitivity to treatment is associated with high probability of survival following chemotherapy.

Patients & Methods: We performed Affymetrix gene expression microarrays of prospectively collected tumor biopsies from 508 patients with newly diagnosed HER2-normal invasive breast cancer prior to neoadjuvant taxane-anthracycline chemotherapy followed by adjuvant endocrine therapy (if hormone receptor-positive). The predictor was developed from 310 samples (from MDACC & I-SPY) by combining: 1) a signature to predict sensitivity to endocrine therapy (SET); 2) estrogen receptor (ER)-stratified predictive signatures of resistance to chemotherapy, defined as extensive residual cancer burden (RCB-III) or relapse within 3 years; and 3) ER-stratified predictive signatures of response to chemotherapy, defined as pathologic complete response (pCR) or minimal RCB (RCB-I). The predictor classified tumors as treatment sensitive if high or intermediate SET, or if predicted to be responsive (and not resistant) to chemotherapy. Otherwise, tumors were classified as treatment insensitive. The predictor was then tested on an independent cohort (N= 198, 98% with clinical Stage II-III) who received neoadjuvant (N= 180) or adjuvant (N= 18) taxane-anthracycline chemotherapy (from MDACC, USO, GEICAM, Peru, LBJ). Distant relapse-free survival (DRFS) was evaluated at a 3-year median follow up using negative predictive value (NPV, absence of event if predicted to be sensitive), and absolute risk reduction (ARR) for those predicted to be sensitive (versus insensitive), with 95% confidence interval (CI). The independent predictive value was assessed in multivariate Cox regression analysis based on the likelihood ratio test (P≥0.05). Results: Patients in the independent validation cohort who were predicted to be treatment sensitive (28%) had excellent DRFS, with NPV 92% (CI 85-100) and significant absolute risk reduction (ARR 18%, CI 6-28) at 3 years, compared to those predicted to be insensitive. This was similar to the DRFS observed in patients who achieved pCR after they completed neoadjuvant chemotherapy (NPV 93%, CI 85-100). Predictions were accurate in each phenotypic subset: ER+/HER2- (30% predicted sensitive, NPV 97%, CI 91-100; ARR 11%, CI 0.1-21) and ER-/HER2- (26% predicted sensitive, NPV 83%, CI 68-100; ARR 26%, CI 4-28). Predicted treatment sensitivity (HR 0.20, CI 0.07-0.57), ER+ status (HR 0.32, CI 0.17-0.63), clinical tumor stage T3-4 (HR 2.04, CI 1.07-3.88) and age >50 (HR 0.50, CI 0.25-0.98) were significant in a multivariate model that also included clinical nodal status, grade, and type of taxane used.

Conclusion: We report validation results for the first molecular predictor of sensitivity to neoadjuvant/adjuvant systemic therapy for clinical Stage II-III breast cancer that is independently associated with excellent DRFS in those predicted to be sensitive. Predictions were accurate for both ER+/HER2- and ER-/HER2- invasive breast cancer.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr PD07-03.

Assessment of potential measures in models of progression in Alzheimer disease

BACKGROUND

In estimating the potential benefits of treatment, it is often necessary to extrapolate beyond clinical trial results using economic modeling. Previous attempts in Alzheimer disease (AD) were primarily based on the Mini-Mental State Examination (MMSE) due to its widespread use. These models were criticized as not accurately reflecting the total impact of the disease, providing untrustworthy estimates of treatment benefit. We compared 3 alternatives to the MMSE with respect to bridging between clinical outcomes needed for regulatory approval and economic and quality of life (QOL) outcomes important to reimbursement agencies.

METHODS

The MMSE, Disability Assessment in Dementia (DAD) scale, Clinical Dementia Rating (CDR) scale, and Dependence Scale (DS) were compared in their ability to explain variation in cognitive, functional, and behavioral measures as well as economic and QOL outcomes using univariate (Pearson correlations) and multivariate (linear regression) analyses of data from research sites in the United States and Europe.

RESULTS

Subjects with mild to moderate AD (n = 196; mean 75.9 years; 56% female) were evaluated. The DS, DAD, and CDR were moderately correlated with the MMSE (Pearson correlations, range 0.54-0.58) but performed better (higher adjusted R(2)) than the MMSE in explaining variations in subject behavior, QOL, and health status. The DS and DAD performed better in explaining variation in medical costs, caregiver QOL, and caregiver time.

CONCLUSIONS

Measures of function (DAD) or dependence on others (DS), or global measures (CDR), appear to be better candidates than the MMSE for modeling AD progression.

The economic consequences of non-adherence to lipid-lowering therapy: results from the Anglo-Scandinavian-Cardiac Outcomes Trial

BACKGROUND

Adherence to lipid-lowering therapy in clinical practice is less than ideal. Analysis of registry data has indicated that this is associated with poor outcomes. The objective of the present analysis was to assess the impact of high adherence to drug (defined as > 80% of days covered), compared with low adherence to drug (< 50% of days covered) in terms of risk of events and long-term economic consequences.

DESIGN

Open-label follow up of a randomised placebo-controlled trial in hypertensive patients.

METHODS

Cox proportional hazards and Poisson regression models were used to assess the hazard ratio of patients with high adherence compared with low adherence while controlling for cardiovascular risk. A Markov model was used to predict the long-term costs and health outcomes associated with poor adherence during the follow-up period.

RESULTS

Both statistical models indicated that high adherence is associated with improved prognosis [Cox model: 0.75; 95% confidence interval (CI): 0.56-0.98, Poisson model hazard ratio: 0.73; 95% CI: 0.58-0.98]. Discounted at 3.5% per year, the Markov model predicts that as a consequence of higher adherence during the follow-up period, costs would be higher (1689 pounds per patient compared with 1323 pounds per patient) because of higher drug costs, but the projected survival and quality-adjusted survival (QALY) would also be longer (10.83 compared with 10.81 life years and 8.13 compared with 8.11 QALYs).

CONCLUSION

Given the higher risk of cardiovascular events associated with low adherence shown here, measures to improve adherence are an important part of the prevention of cardiovascular disease.

An assessment of the impact of the NHS Health Technology Assessment Programme

OBJECTIVES

To consider how the impact of the NHS Health Technology Assessment (HTA) Programme should be measured. To determine what models are available and their strengths and weaknesses. To assess the impact of the first 10 years of the NHS HTA programme from its inception in 1993 to June 2003 and to identify the factors associated with HTA research that are making an impact.

DATA SOURCES

Main electronic databases from 1990 to June 2005. The documentation of the National Coordinating Centre for Health Technology Assessment (NCCHTA). Questionnaires to eligible researchers. Interviews with lead investigators. Case study documentation.

REVIEW METHODS

A literature review of research programmes was carried out, the work of the NCCHTA was reviewed, lead researchers were surveyed and 16 detailed case studies were undertaken. Each case study was written up using the payback framework. A cross-case analysis informed the analysis of factors associated with achieving payback. Each case study was scored for impact before and after the interview to assess the gain in information due to the interview. The draft write-up of each study was checked with each respondent for accuracy and changed if necessary.

RESULTS

The literature review identified a highly diverse literature but confirmed that the 'payback' framework pioneered by Buxton and Hanney was the most widely used and most appropriate model available. The review also confirmed that impact on knowledge generation was more easily quantified than that on policy, behaviour or especially health gain. The review of the included studies indicated a higher level of impact on policy than is often assumed to occur. The survey showed that data pertinent to payback exist and can be collected. The completed questionnaires showed that the HTA Programme had considerable impact in terms of publications, dissemination, policy and behaviour. It also showed, as expected, that different parts of the Programme had different impacts. The Technology Assessment Reports (TARs) for the National Institute for Health and Clinical Excellence (NICE) had the clearest impact on policy in the form of NICE guidance. Mean publications per project were 2.93 (1.98 excluding the monographs), above the level reported for other programmes. The case studies revealed the large diversity in the levels and forms of impacts and the ways in which they arise. All the NICE TARs and more than half of the other case studies had some impact on policy making at the national level whether through NICE, the National Screening Committee, the National Service Frameworks, professional bodies or the Department of Health. This underlines the importance of having a customer or 'receptor' body. A few case studies had very considerable impact in terms of knowledge production and in informing national and international policies. In some of these the principal investigator had prior expertise and/or a research record in the topic. The case studies confirmed the questionnaire responses but also showed how some projects led to further research.

CONCLUSIONS

This study concluded that the HTA Programme has had considerable impact in terms of knowledge generation and perceived impact on policy and to some extent on practice. This high impact may have resulted partly from the HTA Programme's objectives, in that topics tend to be of relevance to the NHS and have policy customers. The required use of scientific methods, notably systematic reviews and trials, coupled with strict peer reviewing, may have helped projects publish in high-quality peer-reviewed journals. Further research should cover more detailed, comprehensive case studies, as well as enhancement of the 'payback framework'. A project that collated health research impact studies in an ongoing manner and analysed them in a consistent fashion would also be valuable.

Economic evaluation of ASCOT-BPLA: antihypertensive treatment with an amlodipine-based regimen is cost effective compared with an atenolol-based regimen

OBJECTIVE

To compare the cost effectiveness of an amlodipine-based strategy and an atenolol-based strategy in the treatment of hypertension in the UK and Sweden.

DESIGN

A prospective, randomised trial complemented with a Markov model to assess long-term costs and health effects.

SETTING

Primary care.

PATIENTS

Patients with moderate hypertension and three or more additional risk factors.

INTERVENTIONS

Amlodipine 5-10 mg with perindopril 4-8 mg added as needed or atenolol 50-100 mg with bendroflumethiazide 1.25-2.5 mg and potassium added as needed

MAIN OUTCOME MEASURES

Cost per cardiovascular event and procedure avoided, and cost per quality-adjusted life-year gained.

RESULTS

In the UK, the cost to avoid one cardiovascular event or procedure would be euro18 965, and the cost to gain one quality-adjusted life-year would be euro21 875. The corresponding figures for Sweden were euro13 210 and euro16 856.

CONCLUSIONS

Compared with the thresholds applied by NICE and in the Swedish National Board of Health and Welfare's Guidelines for Cardiac Care, an amlodipine-based regimen is cost effective for the treatment of hypertension compared with an atenolol-based regimen in the population studied.

Evaluation of the ventricular assist device programme in the UK

OBJECTIVES

To summarise the relevant clinical effectiveness and cost-effectiveness literature, to collect data on survival, transplantation rates, health-related quality of life (HRQoL) and resource use for ventricular assist device (VAD) and non-VAD transplant candidates in the UK, and to construct cost-effectiveness and cost-utility models of VADs in a UK context. Also to investigate the factors that drive costs and survival.

DESIGN

A comprehensive systematic review was carried out. Data were collected from April 2002 to December 2004, with follow-up to March 2005. Cost-effectiveness and cost-utility models of VAD devices were developed based on UK activity and outcomes collected from April 2002 to March 2005.

SETTING

National Specialist Commissioning Advisory Group funded VAD implantation was carried out at the Freeman, Harefield and Papworth transplant centres in the UK.

PARTICIPANTS

Seventy patients were implanted with a VAD as a bridge to transplantation between April 2002 and December 2004. Non-VAD-supported transplant candidates (n = 250), listed at the three centres between April 2002 and December 2004, were divided into an inotrope-dependent group (n = 71) and a non-inotrope-dependent group (n = 179). Although patients in the inotrope-dependent group were closest to the VAD group they were less sick. The last group comprised a hypothetical worst case scenario, which assumed that all VAD patients would die in the intensive care unit (ICU) within 1 month without VAD technology.

INTERVENTIONS

Patients were included who were implanted with a VAD designed for circulatory support for more than 30 days, with intention to bridge to transplantation. A multistate model of VAD and transplant activity was constructed; this was populated by data from the UK.

MAIN OUTCOME MEASURES

Survival from VAD implant or from transplant listing for non-VAD patients to 31 March 2005. Serious adverse events and quality of life measures were used. Cognitive functioning was also assessed. Utility weights were derived from EuroQoL responses to estimate quality-adjusted life-years (QALYs). Incremental cost-effectiveness ratios (ICERs) were defined as the additional cost of VADs divided by additional QALYs. Time-horizons were 3 years, 10 years and the lifetime of the patients.

RESULTS

Of 70 VAD patients, 30 (43%) died pretransplant, 31 (44%) underwent transplantation, and four (6%) recovered and had the VAD removed. Five patients (7%) were still supported for median of 279 days at the end of March 2005. Successful bridge-to-transplantation/recovery rates were consistent with published rates. Survival from VAD implantation was 74% at 30 days and 52% at 12 months. There were 320 non-fatal adverse events in 62 patients during 300 months of VAD support, mostly in the first month after implantation. Commonly observed events were bleeding, infection and respiratory dysfunction. Twenty-nine (41%) patients were discharged from hospital with a VAD. The 1-year survival post-transplantation was 84%. For the inotrope-dependent and non-inotrope-dependent transplant candidates, death rates while listed were 10% and 8% and the median waiting times were 16 and 87 days, respectively. For transplant recipients, 1-year survival was 85% and 84%, respectively. Both VAD and non-VAD patients demonstrated similar significant improvements in their New York Heart Association class after transplantation. All patients had poor EQ-5D pretransplantation; after transplantation the groups had similar EQ-5D of 0.76 irrespective of time after surgery. HRQoL was poor in the first month for VAD patients but better for those who waited longer in all groups. VAD patients reported more problems with sleep and rest and with ambulation in the first month. Symptom scores were similar in all groups pretransplant. After transplantation all groups showed a marked and similar improvement in physical and psychosocial function. Mean VAD implant cost, including device, was pound 63,830, with costs of VAD support for survivors of pound 21,696 in month 1 and pound 11,312 in month 2. Main cost drivers were device itself, staffing, ICU stay, hospital stay and events such as bleeding, stroke and infection. For the base case, extrapolating over the lifetime of the patients the mean cost for a VAD patient was pound 173,841, with mean survival of 5.63 years and mean QALYs of 3.27. Corresponding costs for inotrope-dependent patients were pound 130,905, with mean survival 8.62 years and mean QALYs 4.99. Since inotrope-dependent patients had lower costs and higher QALYs than VAD patients, this group is said to be dominant. Non-inotrope-dependent transplant candidates had similar survival rates to those on inotropes but lower costs, also dominant. Compared with the worst case scenario the mean lifetime ICER for VADs was pound 49,384 per QALY. In a range of sensitivity analyses this ranged from pound 35,121 if the device cost was zero to pound 49,384. Since neither inotrope-dependent transplant candidates nor the worst case scenario were considered fair controls the assumption was investigated that, without VAD technology, there would be a mixture of these situations. For mixtures considered the ICER for VADs ranged from pound 79,212 per QALY to the non-VAD group being both cheaper and more effective.

CONCLUSIONS

There are insufficient data from either published studies or the current study to construct a fair comparison group for VADs. Overall survival of 52% is an excellent clinical achievement for those young patients with rapidly failing hearts. However, if the worst case scenario were plausible, and one could reliably extrapolate results to the lifetime of the patients, VADs would not be cost-effective at traditional thresholds. Further randomised controlled trials are required, using current second generation devices or subsequent devices and conducted in the UK.

A review of the evidence on the effects and costs of implantable cardioverter defibrillator therapy in different patient groups, and the modelling of cost-effectivenessan cost-utility for these groups in a UK context

OBJECTIVES

To update the systematic review evidence on the effectiveness, health-related quality of life (HRQoL) and cost-effectiveness of implantable cardioverter defibrillators (ICDs); compilation of new data on the service provision in the UK; and on the clinical characteristics, survival, quality of life and costs of ICD patients in the UK, and a new cost-effectiveness model using both international RCT and UK-specific data.

DATA SOURCES

Electronic databases searched from November 1999 to March 2003, this was supplemented by a systematic review of research published during 2003-5. Survey data.

REVIEW METHODS

Studies were selected and assessed. A survey of ICD centres was carried out. Basic data were obtained from two major implanting centres including 535 patients (approximately 10% of overall UK activity) implanted between 1991 and 2002, and retrieval of fuller data, on patient characteristics, management and resource use, from patient notes for a sample of 426 patients was attempted. A cross-sectional survey collected HRQoL data (using the Nottingham Health Profile, Short Form 36, Hospital Anxiety and Depression questionnaire, EuroQoL 5 Dimensions and disease-specific questions) on a sample of 229 patients. A Markov model combined UK patient data with data from published randomised controlled trials (RCTs) to estimate incremental costs per life-year or quality-adjusted life-year (QALY) gained.

RESULTS

None of the economic analyses in the studies found could be directly applied to the UK. The multiple sources of routine data available (including the national ICD database) provide an imperfect picture of the need for and use of ICDs. Implantation rates have been rising to a rate of around 20 per million population. Mean age is increasing and most ICDs are implanted into men aged 45-74 years. There is significant geographical variation. A survey of 41 UK centres provided additional evidence, particularly of variation in level of activity and resourcing. Most detailed data were obtained for 380 patients (89%). The postal survey produced a 73% response rate. Demographic characteristics of these patients were similar to ICD recipients in the UK as a whole and patients included in secondary prevention RCTs. Mean actuarial survival at 1, 3 and 5 years was 92%, 86% and 71%, respectively. Patient age at implantation and functional status significantly affected survival. Levels of most of the HRQoL measures were lower than for a UK general population. There was no evidence of a change with time from implantation. Patients who had suffered ICD shocks had significantly poorer HRQoL. Most patients nevertheless expressed a high level of satisfaction with ICD therapy. Mean initial costs of implantation showed little variation between centres (23,300 pounds versus 22,100 pounds) or between earlier and more recent implants. There appeared to be greater variation between patients presenting along different pathways. Postdischarge costs (tests, medications and follow-up consultations) and costs of additional hospitalisations were also calculated. Using the Markov model it was found that over a 20-year horizon, mean discounted incremental costs were 70,900 pounds (35,000-142,400 pounds). Mean discounted gain was 1.24 years (0.29-2.32) or 0.93 QALYs. Cost-effectiveness was most favourable for men aged over 70 years with a left ventricular ejection fraction (LVEF) below 35%. If the treatment effect were to continue, then the cost per life-year over a lifetime might fall to around 32,000 pounds. Five RCTs of ICDs, a meta-analysis and, a cost-effectiveness analysis of ICDs used in primary prevention, and a meta-analysis of ICDs in patients with non-ischaemic cardiomyopathy have been published recently. These trials provide confirmation of survival benefit of ICDs used in primary prevention in both ischaemic and non-ischaemic cardiomyopathy patients. Costs per QALY ranged from US$34,000 in older trials to controls being both less expensive and more effective (CABG Patch, DINAMIT). More recent trials estimated cost per QALY between $50,300 and $70,200. The inconsistency in evidence for a HRQoL benefit has not been resolved and further work on risk stratification is necessary.

CONCLUSIONS

The evidence of short- to medium-term patient benefit from ICDs is strong but cost-effectiveness modelling indicates that the extent of that benefit is probably not sufficient to make the technology cost-effective as used currently in the UK. One reason is the high rates of postimplantation hospitalisation. Better patient targeting and efforts to reduce the need for such hospitalisation may improve cost-effectiveness. Further cost-effectiveness modelling, underpinned by an improved ICD database with reliable long-term follow-up, is required. The absence of a robust measure of the incidence of sudden cardiac death is noted and this may be an area where further organisational changes with improved data collection would help.

Gene expression subtype and p53 mutational status are correlated among neoadjuvantly treated breast cancers in UNC LCCC9819 and I-SPY1 (CALGB 150007/ACRIN 6657)

10048

Background: LCCC9819 and I-SPY1 are designed to examine multiple potential predictive markers and assays simultaneously in biopsies from neoadjuvantly treated patients. Both p53 mutation status and molecular ‘intrinsic‘ subtype have been associated with chemosensitivity. In this preliminary analysis, we present the p53 mutation spectra by molecular subtype from patients enrolled in the combined LCCC 9819 and I-SPY1 datasets. Methods: Patients received neoadjuvant anthracycline-based chemotherapy with pre-therapy biopsies. p53 mutation analysis was performed by p53 GeneChip assay for point mutations/1 bp deletions followed by SSCP if GeneChip-negative. Abnormal GeneChip or SSCP were confirmed by sequencing. DNA microarrays used Agilent human microarrays and a common reference strategy approach. Results: 51 patients were treated on LCCC9819 and have available molecular analyses; 87 from I-SPY1. 111 patients have completed p53 mutation analysis, revealing a high proportion (42%) with abnormal p53. Of these, several were in known hotspots, including R175H (4 mutations), R248L (1), R273H (3), and R273C (2). Most were missense mutations (81%), however, there were 8 (17%) null and 1 (2%) silent mutations. Most (91%) mutations were in the DNA binding domain. Molecular subtypes are known on 111 tumors: 22% Luminal A, 22% Luminal B, 3% Normal-like, 23% HER2+/ER−, 27% Basal-like, and 3% unclassified. Among those with both assays complete, we found that p53 mutations differed by subtype (Table). Conclusions: P53 mutations are common in these independent neoadjuvant datasets, and differ in frequency between molecular subtypes, which may have implications for predictive factor identification. Future analyses will include aCGH, cell cycle protein analysis, proteomics, and clinical data including response to chemotherapy. (supported by UNC Breast SPORE-CA58223, NIH M01RR00046, DAMD 17–02–1-0521).

[Table: see text]

No significant financial relationships to disclose.

Payback arising from research funding: evaluation of the Arthritis Research Campaign

OBJECTIVES

Using a structured evaluation framework to systematically review and document the outputs and outcomes of research funded by the Arthritis Research Campaign in the early 1990s. To illustrate the strengths and weaknesses of different modes of research funding.

METHODS

The payback framework was applied to 16 case studies of research grants funded in the early 1990s. Case study methodology included bibliometric analysis, literature and archival document review and key informant interviews.

RESULTS

A range of research paybacks was identified from the 16 research grants. The payback included 302 peer-reviewed papers, postgraduate training and career development, including 28 PhD/MDs, research informing recommendations in clinical guidelines, improved quality of life for people with RA and the reduction of the likelihood of recurrent miscarriage for women with antiphospholipid syndrome. The payback arising from project grants appeared to be similar to that arising from other modes of funding that were better resourced.

CONCLUSIONS

There is a wide diversity of research payback. Short focused project grants seem to provide value for money.

A randomised controlled trial to compare the cost-effectiveness of tricyclic antidepressants, selective serotonin reuptake inhibitors and lofepramine

OBJECTIVE

To determine the relative cost-effectiveness of three classes of antidepressants: tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and the modified TCA lofepramine, as first choice treatments for depression in primary care.

DESIGN

Open, pragmatic, controlled trial with three randomised arms and one preference arm. Patients were followed up for 12 months.

SETTING

UK primary care: 73 practices in urban and rural areas in England.

PARTICIPANTS

Patients with a new episode of depressive illness according to GP diagnosis.

INTERVENTIONS

Patients were randomised to receive a TCA (amitriptyline, dothiepin or imipramine), an SSRI (fluoxetine, sertraline or paroxetine) or lofepramine. Patients or GPs were able to choose an alternative treatment if preferred.

MAIN OUTCOME MEASURES

At baseline the Clinical Interview Schedule, Revised (CIS-R PROQSY computerised version) was administered to establish symptom profiles. Outcome measures over the 12-month follow-up included the Hospital Anxiety and Depression Scale self-rating of depression (HAD-D), CIS-R, EuroQol (EQ-5D) for quality of life, Short Form (SF-36) for generic health status, and patient and practice records of use of health and social services. The primary effectiveness outcome was the number of depression-free weeks (HAD-D less than 8, with interpolation of intervening values) and the primary cost outcome total direct NHS costs. Quality-adjusted life-years (QALYs) were used as the outcome measure in a secondary analysis. Incremental cost-effectiveness ratios and cost-effectiveness acceptability curves were computed. Estimates were bootstrapped with 5000 replications.

RESULTS

In total, 327 patients were randomised. Follow-up rates were 68% at 3 months and 52% at 1 year. Linear regression analysis revealed no significant differences between groups in number of depression-free weeks when adjusted for baseline HAD-D. A higher proportion of patients randomised to TCAs entered the preference arm than those allocated to the other choices. Switching to another class of antidepressant in the first few weeks of treatment occurred significantly more often in the lofepramine arm and less in the preference arm. There were no significant differences between arms in mean cost per depression-free week. For values placed on an additional QALY of over 5000 pounds, treatment with SSRIs was likely to be the most cost-effective strategy. TCAs were the least likely to be cost-effective as first choice of antidepressant for most values of a depression-free week or QALY respectively, but these differences were relatively modest.

CONCLUSIONS

When comparing the different treatment options, no significant differences were found in outcomes or costs within the sample, but when outcomes and costs were analysed together, the resulting cost-effectiveness acceptability curves suggested that SSRIs were likely to be the most cost-effective option, although the probability of this did not rise above 0.6. Choosing lofepramine is likely to lead to a greater proportion of patients switching treatment in the first few weeks. Further research is still needed on the management of depressive illness in primary care. This should address areas such as the optimum severity threshold at which medication should be used; the feasibility and effectiveness of adopting structured depression management programmes in the UK context; the importance of factors such as physical co-morbidity and recent life events in GPs' prescribing decisions; alternative ways of collecting data; and the factors that give rise to many patients being reluctant to accept medication and discontinue treatment early.

One year comparison of costs of coronary surgery versus percutaneous coronary intervention in the stent or surgery trial

OBJECTIVES

To compare initial and one year costs of coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) in the stent or surgery trial.

DESIGN

Prospective, unblinded, randomised trial.

SETTING

Multicentre study.

PATIENTS

988 patients with multivessel disease.

INTERVENTIONS

CABG and stent assisted PCI.

MAIN OUTCOME MEASURES

Initial hospitalisation and one year follow up costs.

RESULTS

At one year mortality was 2.5% in the PCI arm and 0.8% in the CABG arm (p = 0.05). There was no difference in the composite of death or Q wave myocardial infarction (6.9% for PCI v 8.1% for CABG, p = 0.49). There were more repeat revascularisations with PCI (17.2% v 4.2% for CABG). There was no significant difference in utility between arms at six months or at one year. Quality adjusted life years were similar 0.6938 for PCI v 0.6954 for PCI, Delta = 0.00154, 95% confidence interval (CI) -0.0242 to 0.0273). Initial length of stay was longer with CABG (12.2 v 5.4 days with PCI, p < 0.0001) and initial hospitalisation costs were higher (7321 pounds sterling v 3884 pounds sterling for PCI, Delta = 3437 pounds sterling, 95% CI 3040 pounds sterling to 3848 pounds sterling). At one year the cost difference narrowed but costs remained higher for CABG (8905 pounds sterling v 6296 pounds sterling for PCI, Delta = 2609 pounds sterling, 95% CI 1769 pounds sterling to 3314 pounds sterling).

CONCLUSIONS

Over one year, CABG was more expensive and offered greater survival than PCI but little added benefit in terms of quality adjusted life years. The additional cost of CABG can be justified only if it offers continuing benefit at no further increase in cost relative to PCI over several years.

Patients' preferences for characteristics associated with treatments for osteoarthritis

OBJECTIVE

The purpose of this study was to investigate patient preferences for attributes associated with the efficacy and side-effects of treatment for osteoarthritis.

METHODS

A stated preference design questionnaire was administered to a sample of 412 individuals diagnosed with osteoarthritis (OA).

RESULTS

Statistically significant attributes in influencing treatment preferences were the level of joint aches, the level of physical mobility and the risk of experiencing serious side-effects from treatment. Respondents were relatively more concerned about the risk of serious side-effects (even with a very low probability) than mild to moderate side-effects (at a much higher probability). Data segmentation revealed some variations in preferences according to respondent characteristics. The importance of joint aches increased according to the severity of the symptoms of osteoarthritis, indicating that this attribute is more troublesome to those respondents with more severe symptoms. Older respondents were more willing than younger respondents to accept an increased risk of experiencing serious side-effects for an improvement in the symptoms of OA. Individuals in lower income brackets appeared to attach greater importance to joint aches and the level of mobility experienced than those in higher income brackets. Respondents who had previously experienced gastrointestinal side-effects from treatment were, as expected, more tolerant of them than those who had not.

CONCLUSION

The use of conjoint analysis to assess patient preferences provides a useful insight to the likely attitudes of patients to novel treatments for osteoarthritis.

Prioritisation of health technology assessment. The PATHS model: methods and case studies

OBJECTIVES

To develop a method of economic evaluation and triage for research prioritisation, before the funding decision.

DATA SOURCES

Existing models were researched focusing on MEDLINE, HealthSTAR, IBSS and HEED.

REVIEW METHODS

Papers of primary relevance that included a proposed model were reviewed in detail, and their models appraised using criteria adapted from the EUR-ASSESS project and the authors' previous experience. From this the PATHS model was developed. It assumes three or more possible alternative outcomes or scenarios in terms of research results: 'favourable' to the technology being assessed, 'unfavourable' or 'inconclusive'. An associated flow of benefits or disbenefits, costs or savings is identified for each potential research outcome depending on the likely implementation of the results as judged by experts. These benefits and costs are weighted and discounted in the model to give an expected incremental cost-effectiveness ratio (EICER). EICERS could be estimated for any number of research areas or proposals to inform funding prioritisation. The model was tested and evaluated on three case studies identified in liaison with the NHS R&D HTA programme and the UK Medical Research Council. These case studies were funded research projects, where full evaluation was underway and where results would be reported during the PATHS project. The studies were selected to include surgery or other invasive procedures, and non-invasive health services projects (a fourth case study did not complete during the course of the study). The three case studies included randomised controlled trials of early surgery or observation for small abdominal aortic aneurysms, infusion protocols for adult pre-hospital care, and postnatal midwifery support.

RESULTS

Each of the three assessments indicated net clinical benefit or no clinical loss of benefit, in addition to health service cost savings in excess of the cost of the trial. For two case studies, the value of the proposed trial, as evaluated by the model in the prediction, was consistent with the ex post evaluation, thus providing positive tests of the value of the model. In the third case meaningful ex post analysis was not possible as very poor compliance with the trial protocol (indicated in the ex ante evaluation) seriously undermined its conclusions. During the study, at the request of the UK HTA programme, the model was also applied to a funding request for a large randomised trial of beta-interferon for multiple sclerosis treatment.

CONCLUSION

The PATHS model has a useful part to play in the research prioritisation process. Its strengths lie in its emphasis on the impact of research results on policy and practice (the keystone for NHS research) and net effects on health benefits and costs. It assesses the cost-effectiveness of the research and may identify ways to enhance the research design, endpoints relevant to implementation, analytical methods and dissemination. Further research is recommended to investigate the scope for synthesising the strengths of the PATHS model with other approaches including value of information; to compare ex ante and immediate ex post assessments of implementation with long term follow-up of actual implementation; and to assess the robustness of such approaches to the choice and number of experts used.

Coronary angioplasty versus medical therapy for angina. Health service costs based on the second Randomized Intervention Treatment of Angina (RITA-2) trial

AIMS

The second Randomized Intervention Treatment of Angina (RITA-2) trial compares an initial strategy of PTCA with continued medical management in patients with arteriographically proven coronary artery disease. This paper employs resource use data collected in the trial to compare the health service costs of the two strategies over 3 years follow-up.

METHODS AND RESULTS

1018 patients were randomized, 504 to PTCA and 514 to continued medical management. Health service resource use data were collected prospectively on all patients. Hospital unit costs were estimated in collaboration with five U.K. centres. PTCA patients underwent more subsequent coronary arteriograms, but subsequent (non-randomized) PTCAs were more common in patients randomized to medical management (118 procedures in 102 patients) compared to those randomized to PTCA (73 procedures in 62 patients). The likelihood of undergoing CABG was similar in the two groups. The use of antianginal medications was higher in patients randomized to an initial strategy of medical management. There was an overall mean additional cost per patient over 3 years in patients randomized to PTCA of pound 2685 (95% CI pound 2074- pound 3322).

CONCLUSIONS

In RITA-2, the cost of an initial strategy of PTCA exceeded the cost of an initial strategy of medical management by 74% over 3 years.

Assessing patients' preferences for characteristics associated with homeopathic and conventional treatment of asthma: a conjoint analysis study

BACKGROUND

A study was undertaken to investigate the preferences of patients with asthma for attributes or characteristics associated with treatment for their asthma and to investigate the extent to which such preferences may differ between patient subgroups.

METHODS

The economic technique of conjoint analysis (CA) was used to investigate patients' strength of preference for several key attributes associated with services for the treatment of asthma. A CA questionnaire was administered to two groups of asthma outpatients aged 18 years or older, 150 receiving conventional treatment at Whipps Cross Hospital (WC) and 150 receiving homeopathic treatment at the Royal London Homoeopathic Hospital (RL).

RESULTS

An overall response rate of 47% (n=142) was achieved. Statistically significant attributes in influencing preferences for both the WC and RL respondents were (1) the extent to which the doctor gave sufficient time to listen to what the patient has to say, (2) the extent to which the treatment seemed to relieve symptoms, and (3) the travel costs of attending for an asthma consultation. The extent to which the doctor treated the patient as a whole person was also a statistically significant attribute for the RL respondents.

CONCLUSIONS

This study has shown that aspects associated with the process of delivery of asthma services are important to patients in addition to treatment outcomes. The homeopathic respondents expressed stronger preferences for the doctor to treat them as a whole person than the patients receiving conventional treatment. Overall, the preferences for the attributes included in the study were similar for both groups.

Routine monitoring of performance: what makes health research and development different?

Increasing attention is being directed to measuring and monitoring the use of health-related R&D funding, partly to justify this expenditure and partly to ensure that R&D effort is directed to achieving the paybacks desired by funders. These paybacks include contributing to knowledge, contributing to R&D capacity, political benefits, benefits to the health service and to patients, and more general economic benefits. This paper addresses the issues that must be considered when designing a routine performance management system for health R&D. Conventional methods of routine performance management are often rendered inappropriate in this context by the intangible and unpredictable outcomes of research, which are heterogeneous across projects and programmes and which can be hard to attribute to particular R&D support. Instead, to be effective in this context, a routine system must combine quantitative and qualitative indicators, utilising information from a number of different sources. The system must achieve acceptable levels (defined by the funder) on each of the following criteria: it must measure those dimensions of payback that are valued by the funder; it must be decision-relevant; it must be consistent with truthful compliance; it must minimise perverse incentives; and it must have acceptable net costs. It is vitally important that the system itself generates a positive payback. We illustrate these issues by outlining a system that might be used to monitor the payback from government-funded R&D.

Design and analytic considerations in determining the cost-effectiveness of early intervention in asthma from a multinational clinical trial

Demand for economic and outcomes data in support of drug formulary listing in private and government-sponsored health programs has led to fundamental changes in drug development. In part as a response to these pressures, the pharmaceutical industry has begun to include economic and quality-of-life endpoints in clinical trials with the hope of providing information to answer health policy questions on the economic value of its products. Here, the design and health economic techniques that will be used to analyze the START (inhaled Steroid Treatment As Regular Therapy in early asthma) study-a multinational (31 countries), randomized, placebo-controlled trial of 7240 patients with mild asthma over 3 years-will be presented. START compares the effect of once-daily administration of an inhaled glucocorticosteroid (Pulmicort Turbuhaler to conventional therapy in the management of newly diagnosed asthma, for which the use of this therapy is currently not the standard. The START study will examine both clinical effectiveness (measured as symptom-free days) and asthma-related costs for both treatment arms, aggregated for all patients across all countries. We believe that presenting the analytical plan prior to disseminating the results is an important way of increasing the credibility of economic evaluations. However, using clinical trials for collecting economic data poses several challenges, and the methods for conducting such evaluations are being developed. This paper will present and discuss several methodological options and the current state of the art for conducting economic evaluations alongside multinational clinical trials.

A simulation modelling approach to evaluating alternative policies for the management of the waiting list for liver transplantation

A shortage of donor liver grafts unfortunately results in approximately 10% of patients dying whilst listed for a liver transplant in Europe and the United States. Thus it is imperative that all available organs are used as efficiently as possible. This paper reports upon the application of a simulation modelling approach to assess the impact of several alternative allocation policies upon the cost effectiveness of this technology at one liver transplant centre in the UK. The impact of changes in allocation criteria on the estimated net life expectancy, average net costs and overall cost effectiveness of the transplantation programme were evaluated. The incremental cost effectiveness ratio (ICER) for the base case allocation policy, based upon the time spent on the waiting list (i.e., longest wait first) was 11,557 pounds sterling at 1999 prices. The ICERs associated with an allocation policy based upon age (lowest age first), and an allocation policy based upon the severity of the pre-transplant condition of the patient (with most severely ill patients given a lower priority) were lower than the base case at 10,424 pounds sterling and 9,077 pounds sterling, respectively. The results of this modelling study suggest that the overall cost effectiveness of the liver transplantation programme could be improved if the current allocation policy were modified to give more weight to the age of the patient and the reduced chances of success of the most severely ill patients.

Implications of the appraisal function of the National Institute for Clinical Excellence (NICE)

The National Institute of Clinical Excellence (NICE) has three main roles. It provides guidance to the National Health Service (NHS) on the use of selected new and existing technologies (the appraisal process), provides clinical guidelines for clinicians and physicians in important treatment areas, and develops audit methodologies. This paper discusses the NICE appraisal process. The specific steps of the appraisal process are described, including the basis for topic selection. An overview of NICE guidelines for manufacturers and sponsors is reported. First-year experience is assessed, reflecting on the quality of submitted evidence, and the content of the forthcoming program is presented. Finally, the impact of NICE appraisals is explored in terms of potential benefits and risks.

A model for analyzing the cost of the main clinical events after lung transplantation

BACKGROUND

The aim of this project was to model clinically important events experienced by lung transplant patients (from the day after transplant to 5 years or death) and costs associated with these events, and to assess the economic impact of different immunosuppression therapies.

METHODS

The population comprised 356 lung transplant patients (223 heart-lung, 102 single lung and 31 double lung) transplanted between April 1984 and December 1997. All patients received a cyclosporine-based triple-immunosuppression protocol. We designed a Markov model that included 3 time periods (0 to 6, 7 to 12, and 13 to 60 months), 5 clinical states (well, acute rejection, cytomegalovirus infection, non-cytomegalovirus infection and bronchiolitis obliterans syndrome), and death. For the well state, cost elements were immunosuppression, prophylaxis, and routine clinic visits. For all other states, cost elements were diagnosis, treatment, and bed days/visits. We excluded costs of the procedure.

RESULTS

The monthly costs associated with the well state decreased over time, from pound sterlings 1,778 ($2,658) in the first 6 months to pound sterlings 503 ($752) in months 7 to 12 and pound sterlings 350 ($523) after the first 12 months. The cost per event of the acute states remained reasonably constant over the 3 periods: pound sterlings 1,850 ($2,766) for rejection, pound sterlings 3,380 ($5,053) for cytomegalovirus, and pound sterlings 2,790 ($4,171) for other infections. The average cost per patient, discounted at 6%, over 5 years was pound sterlings 35,429 ($52,966) (95% range, pound1,435 [$2,145] to pound67,079 [$100,283]). This estimate is most sensitive to changes in immunosuppression. Substituting tacrolimus for cyclosporine increased 5-year costs by 5%; substituting mycophenolate mofetil for azathioprine increased 5-year costs by 26%.

CONCLUSIONS

This model is valuable in estimating the effect of new immunosuppression agents on the costs of follow-up care.

Estimating the impact of a diffuse technology on the running costs of a hospital. A case study of a picture archiving and communication system

OBJECTIVES

This paper considers the methodological problems that arise in conducting cost analyses in economic evaluations where only observational (rather than experimental) data are available and where the technology being evaluated is diffuse, such that the unit of analysis has to be the institution rather than the patient.

METHODS

A case study is reported that concerns the application of computer technology in radiology: picture archiving and communication systems (PACS). A range of different approaches were used to estimate changes in running costs, including time series analyses of routine data and direct observation of resource use.

RESULTS

The analysis illustrates some of the difficulties involved in costing the introduction of a diffuse technology. Nevertheless, it provides a firm indication that, overall, the introduction of PACS was found to be associated with a significant increase in hospital costs, suggesting that the initial expectations of financial savings were unduly optimistic.

CONCLUSIONS

The research demonstrates that, using multiple methods, it is possible to estimate cost changes within a single hospital. In addition, the paper discusses the nature of the uncertainties in such analyses and possible ways of representing such uncertainty in terms of confidence intervals.

Preference measurement using conjoint methods: an empirical investigation of reliability

The application of conjoint measurement to the field of health economics is relatively new, although there is growing interest and there have been a number of studies undertaken recently. Wider acceptance of the technique requires methodological issues concerning both reliability and validity to be addressed. This paper reports an empirical investigation of the test-retest reliability of the discrete choice conjoint measurement approach in health care. This investigation of conjoint reliability was framed using the clinical context of investigation and treatment of knee injuries. A high level of reliability at both the input data and results levels was demonstrated.

Patients' preferences regarding the process and outcomes of life-saving technology. An application of conjoint analysis to liver transplantation

The economic technique of conjoint analysis was used to assess the relative importance of health outcome versus several process attributes (e.g., waiting time, continuity of contact with the same medical staff) in determining patients' preferences for liver transplantation services. The attributes were established by reference to the literature and through initial qualitative interviews with liver transplant recipients (n = 12). Following a pilot study of 40 patients, a sample of patients (n = 213) who have received a liver transplant at the Queen Elizabeth Hospital in Birmingham were surveyed. The technique of conjoint analysis was used to ascertain the relative importance of the attributes included in the exercise and to estimate the marginal rates of substitution (MRS) between different attributes. A useable response rate of 89% was achieved. Although a small proportion of respondents (15%) exhibited dominant preferences for the chance of success attribute, the majority of respondents indicated that they would be prepared to exchange a reduction in health outcome for an improvement in the process characteristics of the liver transplantation service. The results of this study have potentially important implications for the assessment of the benefits of medical technologies since they suggest that, even in the extreme case of life-saving interventions, the preferences of respondents may not be dependent solely upon health outcomes but may also be determined by attributes associated with the process of care.

Evaluation of a hospital picture archiving and communication system

OBJECTIVES

To establish the net costs to the hospital and the broad range of benefits associated with a hospital-wide picture archiving and communication system (PACS) that comprised digital acquisition, storage and transmission of radiological images via a hospital-wide network to 150 workstations.

METHODS

'Before and after' comparisons and time series analyses at Hammersmith Hospital (London, UK), and comparison with five other British hospitals where PACS was not being installed. The cost analysis considered implementation costs and changes in key elements of hospital running costs, including the impact of changes in the length of inpatient stays. A range of benefit measures were investigated, including image availability, avoidance of repeat imaging, avoidance of exposure to radiation, patient turn-round speed, time from examination to image availability in intensive care, avoidance of diagnostic 'errors' by casualty doctors, the additional diagnostic value of PACS-based images and clinician satisfaction.

RESULTS

The annual equivalent capital cost of the PACS was 1.7 million Pounds (annual equivalent replacement cost: 0.8 million Pound). Overall, the PACS substantially increased running costs. No convincing evidence of a PACS-induced change in length of inpatient stay was found. PACS was associated with some improvements in the performance of the radiology department: improved image availability (97.7% versus 86.9%), lower repeat imaging rate (7.3% versus 9.9%) and 20% lower total radiation doses for examinations of the lateral lumbar spine. No improvements were identified in the quality of the radiology reporting service. Benefits outside radiology included shorter time from examination to image availability for routine uses in intensive care (19 versus 37 minutes), and a lower rate of diagnostic 'errors' in casualty (0.65% versus 1.51%). High levels of satisfaction with PACS were found amongst both providers and clinical users.

CONCLUSIONS

PACS was almost universally preferred by users and brought many operational and clinical benefits. However, these advantages came at a significant capital and net running cost.

Transmyocardial laser revascularisation in patients with refractory angina: a randomised controlled trial

BACKGROUND

Transmyocardial laser revascularisation (TMLR) is used to treat patients with refractory angina due to severe coronary artery disease, not suitable for conventional revascularisation. We aimed in a randomised controlled trial to assess the effectiveness of TMLR compared with medical management.

METHODS

188 patients with refractory angina were randomly assigned TMLR plus normal medication or medical management alone. At 3 months, 6 months, and 12 months after surgery (TMLR) or initial assessment (medical management) we assessed exercise capacity with the treadmill test and the 12 min walk.

FINDINGS

Mean treadmill exercise time, adjusted for baseline values, was 40 s (95% CI -15 to 94) longer in the TMLR group than in the medical-management group at 12 months (p=0.152). Mean 12 min walk distance was 33 m (-7 to 74) further in TMLR patients than medical-management patients (p=0.108) at 12 months. The differences were not significant or clinically important. Perioperative mortality was 5%. Survival at 12 months was 89% (83-96) in the TMLR group and 96% (92-100) in the medical-management group (p=0.14). Canadian Cardiovascular Society score for angina had decreased by at least two classes in 25% of TMLR and 4% of medical-management patients at 12 months (p<0.001).

INTERPRETATION

Our findings show that the adoption of TMLR cannot be advocated. Further research may be appropriate to assess any potential benefit for sicker patients.

The preliminary economic evaluation of health technologies for the prioritization of health technology assessments. A discussion

This paper critically evaluates methods for the preliminary economic evaluation of health technologies and the prioritization of health technology assessment projects. It reports on the literature, and considers methods currently employed and the purposes of preliminary appraisal. It concludes that a preliminary economic appraisal needs to be applied to the two main stages of the prioritization process; to have transparent criteria; to allow for an appropriate range of potential outcomes; to be practicable, flexible, and efficient; and to be relevant to the assessment of different research projects.

Magnetic resonance imaging for the investigation of knee injuries: an investigation of preferences

The conventional approach to the diagnosis and treatment of severe knee injuries is arthroscopy, a minimally invasive surgical procedure. Since arthroscopy is an invasive technique that carries risks, magnetic resonance imaging (MRI) is increasingly being used for diagnosis. MRI is potentially associated with diagnostic and therapeutic 'impacts', in that arthroscopy can be avoided. This paper reports a discrete choice conjoint analysis exercise that assessed the value placed on such 'impacts' by potential patients and investigated the degree to which respondents were willing to trade between process and outcome. The marginal rates of substitution between attributes were estimated. The results suggest that the diagnostic and therapeutic 'impacts' of MRI were valued by many respondents. The study has highlighted a number of important issues for the design and analysis of future health-related conjoint studies, including the use of treatment cost as an attribute, dealing with data from lexicographic respondents, and distinguishing between points of indifference and missing data.