Oral Drug Delivery Systems Applied to Launched Products: Value for the Patients and Industrial Considerations

Drug delivery systems (DDS) control the amount, rate, and site of administration of drug substances in the body as well as their release and ADME (absorption, distribution, metabolism, excretion). Among the various types of DDS, amount-controlled DDS for solubilization and absorption increase the bioavailability. Time- and amount-controlled DDS are controlled release formulations classified as (1) membrane-type, (2) matrix-type, (3) osmotic-type, and (4) ion-exchange type. Timed-release formulations also control the time and amount of release and the absorption of drugs. Site- and amount-controlled DDS are characterized by colonic delivery and intestinal lymph-targeting to improve release and ADME of drug substances. Finally, site-, time-, and amount-controlled DDS are gastroretentive formulations and local delivery in the oral cavity to improve site retention, release, and ADME of drugs. DDS can enhance efficacy, reduce adverse effects, and optimize the dosing frequency of various drug products to increase patient value. This review focuses on patient value and industrial considerations of launched oral DDS. We provide a technological overview of candidate and marketed DDS, as well as the pros/cons of the technologies for industrialization with consideration to excipients, manufacturing, and storage stability. Moreover, to demonstrate the usefulness of the technology and support the selection and development of the best technologies for patients, we also describe patient value from clinical studies and analyses, particularly with regard to increased new medical options, higher efficacy, reduced adverse effects, reduced number of doses and clinic visits, easier administration, higher quality of life, greater adherence, and satisfaction.

Direct admission versus interhospital transfer for revascularisation in non-ST-segment elevation myocardial infarction

BACKGROUND

The differences in outcomes and process parameters for NSTEMI patients who are directly admitted to an intervention centre and patients who are first admitted to a general centre are largely unknown.

HYPOTHESIS

There are differences in process indicators, but not for clinical outcomes, for NSTEMI who are directly admitted to an intervention centre and patients who are first admitted to a general centre.

METHODS

We aim to compare process indicators, costs and clinical outcomes of non-ST-segment elevation myocardial infarction (NSTEMI) patients stratified by center of first presentation and revascularisation strategy. Hospital claim data from patients admitted with a NSTEMI between 2017 and 2019 were used for this study. Included patients were stratified by center of admission (intervention vs. general center) and subdivided by revascularisation strategy (PCI, CABG, or no revascularisation [noRevasc]). The primary outcome was length of hospital stay. Secondary outcomes included: duration between admission and diagnostic angiography and revascularisation, number of intracoronary procedures, clinical outcomes at 30 days (MACE: all-cause mortality, recurrent myocardial infarction and cardiac readmission) and total costs (accumulation of costs for hospital claims and interhospital ambulance rides).

RESULTS

A total of 9641 NSTEMI events (9167 unique patients) were analyzed of which 5399 patients (56%) were admitted at an intervention center and 4242 patients to a general center. Duration of hospitalization was significantly shorter at direct presentation at an intervention centre for all study groups (5 days [2-11] vs. 7 days [4-12], p < 0.001). For PCI, direct presentation at an intervention center yielded shorter time to diagnostic angiography (1 day [0-2] vs. 1 day [1-2], p < 0.01) and revascularisation (1 day [0-3] vs. 4 days [1-7], p < 0.001) and less intracoronary procedures per patient (2 [1-2] vs. 2 [2-2], p < 0.001). For CABG, time to revascularisation was shorter (8 days [5-12] vs. 10 days [7-14], p < 0.001). Total costs were significantly lower in case of direct presentation in an intervention center for all treatment groups €10.211 (8750-18.192) versus €13.741 (11.588-19.381), p < 0.001) while MACE was similar 11.8% versus 12.4%, p = 0.344).

CONCLUSION

NSTEMI patients who were directly presented to an intervention center account for shorter duration of hospitalization, less time to revascularisation, less interhospital transfers, less intracoronary procedures and lower costs compared to patients who present at a general center.

How Do Patients Value the Benefit of Minimally Invasive Surgery in Cancer Treatment?

OBJECTIVES

Due to the increasing cost of cancer treatment, the demand for value-based healthcare is increasing. Although several value frameworks have been developed recently in the field of oncology, the nononcological benefits of minimally invasive surgery have not been addressed. This study aimed to estimate how patients value nononcological benefits in minimally invasive cancer surgery.

METHODS

The value that patients placed on various benefits of cancer surgery was termed throughout the study as patient value (PV). To quantize PVs for the benefits of cancer surgery, a one-tiered analytic hierarchy process model was constructed. The model includes 6 well-known surgical outcomes, including nononcological benefits. The study participants included 303 patients with cancer and family caregivers who participated in a questionnaire survey.

RESULTS

The PVs for "decreased operation time," "reduced length of hospital stay," and "improved cosmetic results" were 0.050, 0.044, and 0.045, respectively, whereas the PVs for "increased survival," "prevention of disease recurrence," and "avoidance of complications" were 0.366, 0.292, and 0.203, respectively. The PV placed on nononcological benefits from minimally invasive surgery was one-tenth (10.2%) of the total value.

CONCLUSIONS

Nononcological benefits arising from minimally invasive surgery were relatively small but nonnegligible. This value should be considered in the process of developing a value framework for cancer surgery and shared decision making.

Value Cocreation in Health Care: Systematic Review

Background

Value cocreation in health care (VCCH), mainly based on service-dominant logic, emphasizes that participants, including both patients and physicians, can effectively enroll in the health care value creation process. Effective VCCH is of great significance for realizing value-based health care and improving doctor-patient relationships. Therefore, a comprehensive understanding of VCCH is critical. However, the current literature on VCCH is fragmented and not well studied.

Objective

The goal of the research is to investigate the antecedents, consequences, and dimensions of VCCH by systematically searching, selecting, summarizing, and evaluating relevant literature.

Methods

English-language articles on VCCH in the Web of Science, PubMed, and Scopus databases published from January 2008 to December 2019 were identified. The articles were screened using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol, and the quality of studies included were appraised using the Mixed Methods Appraisal Tool.

Results

Out of the 181 publications initially identified through the bibliographic searches, 28 publications met the inclusion criteria. This review summarizes antecedents, consequences, and dimensions of VCCH, as well as possible associations among them. An integrative framework is also proposed for mapping the literature of VCCH grounded on social cognitive theory to reveal the whole process of VCCH.

Conclusions

The findings of this systematic review provide implications for continued development of VCCH and contribute to inspire more research in the future.

Innovative Patient Involvement During Covid-19: Keeping Patients at the Heart of HTA

The COVID-19 pandemic and lockdown measures in the United Kingdom resulted in significant challenges and created opportunities for innovation to keep patients at the heart of HTA. The introduction of the Coronavirus Act 2020 and the associated public health guidance meant that NICE's conventional HTA methods were no longer feasible. NICE introduced rapid, innovative updates to patient and public involvement (PPI), decision-making meetings, and consultations to harness the expertise of patients and the public to ensure guidance addressed the expected concerns and identified barriers which could impact access. This article describes the PPI support for NICE's rapid shift to virtual meetings and virtual engagement. We utilize the authors' experience and patient and public contributor feedback to understand the experience of participating in a virtual setting and identify four themes: accessibility; inclusivity; transparency; and intrapersonal relationships and committee dynamics. The article also considers how patient representatives participated in, and facilitated, the development of guidance for a hypothetical technology to keep patients and the public at the heart of expedited and novel HTA processes to identify and understand the expected patient concerns and potential barriers for when a technology would be introduced.

Measuring Patient Value after Total Shoulder Arthroplasty

Evaluating the value of health care is of paramount importance to keep improving patients' quality of life and optimizing associated costs. Our objective was to present a calculation method based on Michael Porter's formula and standard references to estimate patient value delivered by total shoulder arthroplasty (TSA). We retrospectively reviewed the records of 116 consecutive TSAs performed between June 2015 and June 2019. Patient value was defined as quality of care divided by direct costs of surgery. Quality metrics included intra- and postoperative complications as well as weighted improvements in three different patient-reported outcome measures at a minimum of one-year follow-up. Direct costs of surgery were retrieved from the management accounting analyses. Substantial clinical benefit (SCB) thresholds and the standard reimbursement system were used as references for quality and cost dimensions. A multivariable linear regression was performed to identify factors associated with patient delivered value. Compared to a reference of 1.0, the quality of care delivered to patients was 1.3 ± 0.3 (range, 0.6-2.0) and the associated direct cost was 1.0 ± 0.2 (range, 0.7-1.6). Ninety patients (78%) had a quality of care ≥1.0 and 61 patients (53%) had direct costs related to surgery ≤1.0. The average value delivered to patients was 1.3 ± 0.4 (range, 0.5-2.5) with 91 patients (78%) ≥ 1.0, was higher for non-smokers (beta, 0.12; p = 0.044), anatomic TSA (beta, 0.53; p < 0.001), increased with higher pre-operative pain (beta, 0.08; p < 0.001) and lower pre-operative Constant score (beta, -0.06; p = 0.001). Our results revealed that almost 80% of TSAs provided substantial patient value. Patient pre-operative pain/function, tobacco use, and procedure type are important factors associated with delivered patient value.

Long-Acting Metformin Vs. Metformin Immediate Release in Patients With Type 2 Diabetes: A Systematic Review

Background: Metformin, a commonly used antidiabetic medication, is available in both an immediate-release (IR) formulation and a long-acting formulation (metformin extended-release; XR). Objective: We performed a systematic review to compare the effectiveness, safety, and patient compliance and satisfaction between the metformin IR and XR formulations. Method: We searched for randomized control trials (RCTs) and observational studies comparing the effectiveness, safety, or patient compliance and satisfaction of metformin XR with metformin IR using the MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases. Following report screening, data collection, and risk of bias assessment, we separately pooled data from RCTs and observational studies using the Grading of Recommendation Assessment, Development, and Evaluation approach to rate the quality of evidence. Result: We included five RCTs, comprising a total of 1,662 patients, and one observational study, comprising 10,909 patients. In the meta-analyses, no differences were identified in outcomes of effectiveness and safety between the two forms of metformin (including change in HbA1c: mean difference (MD), 0.04%, 95% confidence interval [CI], -0.05-0.13%, fasting blood glucose: MD, -0.03 mmol/L, 95% CI, -0.22-0.15 mmol/L, postprandial blood glucose: MD, 0.50 mmol/L, 95% CI, -0.71-1.72 mmol/L, adverse events of abdominal pain: relative risk (RR), 1.15, 95% CI, 0.57-2.33, all-cause death (RR, 3.02, 95% CI 0.12-73.85), any adverse events (RR, 1.14, 95% CI 0.97-1.34), any adverse events leading to treatment discontinuation: RR, 1.51, 95% CI, 0.82-2.8, any gastrointestinal adverse events: RR, 1.09, 95% CI, 0.93-1.29, diarrhea: RR, 0.82, 95% CI, 0.53-1.27, flatulence: RR, 0.43, 95% CI, 0.15-1.23, nausea: RR, 0.97, 95% CI, 0.64-1.47, severe adverse events: RR, 0.64, 95% CI, 0.28-1.42, and vomiting: RR, 1.46, 95% CI, 0.6-3.56). Data from both the RCTs and the observational study indicate mildly superior patient compliance with metformin XR use compared with metformin IR use; this result was attributable to the preference for once-daily administration with metformin XR. Conclusion: Our systematic review indicates that metformin XR and IR formulations have similar effectiveness and safety, but that metformin XR is associated with improved compliance to treatment.

Communication and Respect for Patient Value as Significant Factors in Patient-Centered Infertility Care: A Survey of Patients' Experiences in Two Infertility Centers

Context:

The patient-centered infertility care (PCIC) approach emphasizes the patient's role in choosing the most appropriate clinical approach in infertility care. The concept can improve the patient satisfaction with care performed as well as the efficacy of the treatment. In addition, this concept can also lead to improve collaboration between patient and care provider, ultimately supporting a more cost-effective health-care scheme.

Aims:

This study was developed in order to determine patients' experience in their PCIC.

Settings and Design:

This is a descriptive study. We conducted the study in two fertility care clinics, Clinic A and Clinic B.

Subjects and Methods:

The Patient-Centeredness Questionnaire-Infertility (PCQ-I) was used, consisting of 7 essential themes. The questionnaire was completed by consenting patients in two infertility clinics.

Statistical Analysis Used:

The questionnaire was analyzed using the Statistical Package for the Social Sciences 21 version statistical software.

Results:

Eighty-eight Clinic A patients who completed the questionnaire responded that the best element of their treatment received was communication (correlation with global score [CGS]: 0.747), whereas the least acceptable aspect was the low accessibility (CGS: 0.211). A total of 20 Clinic B patients responded that the best element of their treatment received was respect for the patient's value (CGS: 0.866), whereas the least acceptable aspect was also the low level of accessibility (CGS: 0.193).

Conclusions:

The PCQ-I can be used to evaluate patients' experience during treatment and may help the health-care provider to improve their performance.

A Review of the Psychometric Properties and Use of the Rheumatoid Arthritis Quality of Life Questionnaire (RAQoL) in Clinical Research

BACKGROUND

Several Patient-Reported Outcome Measures (PROMs) have been used in studies of Rheumatoid Arthritis (RA). Most of these assess Health-Related Quality of Life (HRQL). The exception is the Rheumatoid Arthritis Quality of Life questionnaire (RAQoL). This scale measures the impact of RA and its treatment from the patient's perspective, making it suitable for determining the value patients gain from interventions.

OBJECTIVE

This review collates literature reporting on the efficacy of the RAQoL as a measure of patient value in clinical studies.

METHOD

A literature search was conducted to identify published articles reporting on the use of the RAQoL. Psychometric and clinical research studies were included in the review.

RESULTS

Sixty-three full articles were identified. Psychometric analyses demonstrated that the RAQoL meets the requirements for internal consistency, reproducibility and construct validity. There is evidence to support the unidimensionality and responsiveness of the RAQoL. The measure has been used in a wide range of research studies including interventional, correlational and nonexperimental studies. Several studies found the RAQoL to be sensitive to change following interventions.

CONCLUSION

The RAQoL has excellent psychometric properties and can detect the impact of both clinical and non-clinical interventions. As a patient-centric measure of patient value, the RAQoL will also prove valuable in big data analytics and for use in outcomes-based reimbursement (OBR).

Patient value: its nature, measurement, and role in real world evidence studies and outcomes-based reimbursement

The assessment of "patient value" is fundamental to clinical trials, real world evidence studies, and outcomes-based reimbursement schemes. Measures of health-related quality-of-life (HRQoL) are widely used in health research. Such measures are effective in determining the presence or absence of symptoms and functional ability. However, HRQoL measures were not intended, nor designed, to determine the value to patients of alternative health states. Functions have no intrinsic value-they are a means to fulfil human needs. However, needs can be met in a variety of ways, for example by adopting different functions or by the provision of social services. It is possible to analyze all functions in terms of the needs they satisfy. A needs model has been applied in health research since the 1990s. It is concerned with the extent to which human needs are fulfilled in the presence of disease and its treatment. It is argued that this is the major concern of the patient. Needs-based measures are patient-centric and produce a valid unidimensional index of outcome. Consequently, they provide a direct means of measuring patient value. This approach provides the possibility of evaluating health services in terms of the value they provide to consumers and payers. It also has a role to play in real-world evidence studies and outcomes-based reimbursement. It is recommended that greater attention is given in future to the development of patient-reported outcome measures that provide direct assessments of patient value.

Value of Developing Plain Language Summaries of Scientific and Clinical Articles: A Survey of Patients and Physicians

BACKGROUND

We sought to determine the value and feasibility of developing plain language summaries (PLS) of peer-reviewed articles for patients.

METHODS

Members of the European Patients Academy on Therapeutic Innovation or UCB Pharma (N = 74) with a diagnosis of chronic disease, as well as a group of randomly selected neurologists in the US (N = 90) participated in online surveys. Two physicians, 5 patients, and 1 caregiver participated in interviews.

RESULTS

Patient survey and interview participants reported that they routinely sought health-related information online. Articles in scientific journals were ranked the third most important source in the survey (47%), after general Internet searches (61%) and patient-specific websites (57%). Survey physicians were equivocal in their views; 46% rated PLS as valuable, 46% as neutral, and 8% as not valuable; however, 60% reported they would use them. A predominant theme emerging in patient interviews was the importance of knowledge and the sense of empowerment it engenders. Patients viewed PLS as tools to facilitate knowledge sharing and making important information accessible. In interviews, physicians noted the value of PLS in generating dialogue, saving time and streamlining communication with patients, as patients are not completely dependent on them for information.

CONCLUSION

Our results indicate PLS could play an important role in the patient-physician dialogue. Although patients in this study tended to be more informed and engaged than the general patient population, with continued expansion of online platforms and open-access publishing, it is likely that greater numbers of patients will seek more specialized health-related information in the future.

Endocrine surgery as a model for value-based health care delivery

Background:

Experts advocate restructuring health care in the United States into a value-based system that maximizes positive health outcomes achieved per dollar spent. We describe how a value-based system implemented by the University of California, Los Angeles UCLA Section of Endocrine Surgery (SES) has optimized both quality and costs while increasing patient volume.

Methods:

Two SES clinical pathways were studied, one allocating patients to the most appropriate surgical care setting based on clinical complexity, and another standardizing initial management of papillary thyroid carcinoma (PTC). The mean cost per endocrine case performed from 2005 to 2010 was determined at each of three care settings: A tertiary care inpatient facility, a community inpatient facility, and an ambulatory facility. Blood tumor marker levels (thyroglobulin, Tg) and reoperation rates were compared between PTC patients who underwent routine central neck dissection (CND) and those who did not. Surgical patient volume and regional market share were analyzed over time.

Results:

The cost of care was substantially lower in both the community inpatient facility (14% cost savings) and the ambulatory facility (58% cost savings) in comparison with the tertiary care inpatient facility. Patients who underwent CND had lower Tg levels (6.6 vs 15.0 ng/mL; P = 0.024) and a reduced need for re-operation (1.5 vs 6.1%; P = 0.004) compared with those who did not undergo CND. UCLA maintained its position as the market leader in endocrine procedures while expanding its market share by 151% from 4.9% in 2003 to 7.4% in 2010.

Conclusions:

A value-driven health care delivery system can deliver improved clinical outcomes while reducing costs within a subspecialty surgical service. Broader application of these principles may contribute to resolving current dilemmas in the provision of care nationally.