Examining the Use of Real-World Evidence in the Regulatory Process

The 21st Century Cures Act passed by the United States Congress mandates the US Food and Drug Administration to develop guidance to evaluate the use of real-world evidence (RWE) to support the regulatory process. RWE has generated important medical discoveries, especially in areas where traditional clinical trials would be unethical or infeasible. However, RWE suffers from several issues that hinder its ability to provide proof of treatment efficacy at a level comparable to randomized controlled trials. In this review article, we summarized the advantages and limitations of RWE, identified the key opportunities for RWE, and pointed the way forward to maximize the potential of RWE for regulatory purposes.

The New FDA Real-World Evidence Program to Support Development of Drugs and Biologics

FDA has launched a Real World Evidence (RWE) Program for using real-world evidence (RWE) to help support new indications for already approved drugs or biologics and postapproval studies. The plan also includes stakeholder engagement efforts, demonstration projects, leadership activities, and development of guidance documents to assist developers interested in using real-world data (RWD) to develop RWE to support FDA regulatory decisions. This plan was mandated by the Cures Act passed in 2016. Over the 24-month period from passage of the law until FDA officially announced their program, FDA has gone to considerable efforts to educate the public about the benefits of RWE and encourage researchers to consider situations where RWE trials can generate useful information. Through a variety of stakeholder engagement projects, including publication of articles in medical journals, participation in public meetings, and development of initiatives, FDA has put more effort into preparing the medical community for its new emphasis on RWE than any other new policy that I can recall.

ISPOR, the FDA, and the Evolving Regulatory Science of Medical Device Products

The International Society for Pharmacoeconomics and Outcomes Research (ISPOR) is a key venue for members from private industry, government, and academia to collaborate and share advances in regulatory, clinical, and reimbursement science for drugs, devices, and diagnostics. In parallel, the US Food and Drug Administration (FDA) "is responsible for advancing the public health by helping to speed innovations that make medical products more effective, safer, and more affordable." In 2012, the Medical Device Innovation Consortium (MDIC) was formed as a public-private partnership bringing together government, industry, and nonprofit organizations to advance approaches that promote patient access to safe, innovative medical technologies. With a focus on regulatory science, the MDIC has been assessing how to apply real-world evidence (RWE) regulatory science to medical devices. A key goal of this project is to review the history of RWE regulatory science, define terms, and explain why and how RWE is being considered across the total product life cycle, including regulatory assessment. Unique considerations of real-world data for in vitro diagnostics are also taken into account. We envision that these activities will help ensure a high level of rigor and integrity of RWE necessary for regulatory use cases and demonstrate where RWE can be successfully used for regulatory decision making. The ISPOR, FDA, and MDIC are providing the needed leadership in ensuring that diverse stakeholders share a meaningful voice in determining RWE use and, by so doing, are improving the quality and efficiency of care, enhancing health outcomes, and addressing broader societal concerns of reducing health disparities and costs.

Government policy interventions to reduce human antimicrobial use: A systematic review and evidence map

BACKGROUND

Growing political attention to antimicrobial resistance (AMR) offers a rare opportunity for achieving meaningful action. Many governments have developed national AMR action plans, but most have not yet implemented policy interventions to reduce antimicrobial overuse. A systematic evidence map can support governments in making evidence-informed decisions about implementing programs to reduce AMR, by identifying, describing, and assessing the full range of evaluated government policy options to reduce antimicrobial use in humans.

METHODS AND FINDINGS

Seven databases were searched from inception to January 28, 2019, (MEDLINE, CINAHL, EMBASE, PAIS Index, Cochrane Central Register of Controlled Trials, Web of Science, and PubMed). We identified studies that (1) clearly described a government policy intervention aimed at reducing human antimicrobial use, and (2) applied a quantitative design to measure the impact. We found 69 unique evaluations of government policy interventions carried out across 4 of the 6 WHO regions. These evaluations included randomized controlled trials (n = 4), non-randomized controlled trials (n = 3), controlled before-and-after designs (n = 7), interrupted time series designs (n = 25), uncontrolled before-and-after designs (n = 18), descriptive designs (n = 10), and cohort designs (n = 2). From these we identified 17 unique policy options for governments to reduce the human use of antimicrobials. Many studies evaluated public awareness campaigns (n = 17) and antimicrobial guidelines (n = 13); however, others offered different policy options such as professional regulation, restricted reimbursement, pay for performance, and prescription requirements. Identifying these policies can inform the development of future policies and evaluations in different contexts and health systems. Limitations of our study include the possible omission of unpublished initiatives, and that policies not evaluated with respect to antimicrobial use have not been captured in this review.

CONCLUSIONS

To our knowledge this is the first study to provide policy makers with synthesized evidence on specific government policy interventions addressing AMR. In the future, governments should ensure that AMR policy interventions are evaluated using rigorous study designs and that study results are published.

PROTOCOL REGISTRATION

PROSPERO CRD42017067514.

Judges' socio-technical review of contested expertise

This article investigates how civil court judges practice meta-expertise in cases that feature contradictory and inconclusive medical expertise. The empirical case study consists of a sample of eleven Helsinki district court verdicts from 2014-2017, drawn from a larger number of similar traffic insurance compensation cases. The case-type features a medical controversy concerning traumatic brain injury (TBI) diagnostics. I contend that the difficulties judges face in evaluating the medical expertise result from epistemic asymmetries between legal and medical professionals. This study highlights the importance of explaining and understanding how judges overcome uncertainty and discriminate between expert positions. Drawing from earlier studies on meta-expertise and judges' practice of evaluating expertise in court, I introduce the concept 'socio-technical review' to describe judges' practice of facilitating highly technical and esoteric scientific expertise to needs of judicial decision making. I argue that socio-technical review is a special form of practicing meta-expertise, which effectively allows meta-experts to manage epistemic asymmetries. In examining how meta-expertise is practiced in the TBI case-type, the paper contributes to general sociological understanding of decision-making under uncertainty and suggests further studies in comparable settings.

Limitations for health research with restricted data collection from UK primary care

Purpose

UK primary care provides a rich data source for research. The impact of proposed data collection restrictions is unknown. This study aimed to assess the impact of restricting the scope of electronic health record (EHR) data collection on the ability to conduct research. The study estimated the consequences of restricted data collection on published Clinical Practice Research Datalink studies from high impact journals or referenced in clinical guidelines.

Methods

A structured form was used to systematically analyse the extent to which individual studies would have been possible using a database with data collection restrictions in place: (1) retrospective collection of specified diseases only; (2) retrospective collection restricted to a 6‐ or 12‐year period; (3) prospective and retrospective collection restricted to non‐sensitive data. Outcomes were categorised as unfeasible (not reproducible without major bias); compromised (feasible with design modification); or unaffected.

Results

Overall, 91% studies were compromised with all restrictions in place; 56% studies were unfeasible even with design modification. With restrictions on diseases alone, 74% studies were compromised; 51% were unfeasible. Restricting collection to 6/12 years had a major impact, with 67 and 22% of studies compromised, respectively. Restricting collection of sensitive data had a lesser but marked impact with 10% studies compromised.

Conclusion

EHR data collection restrictions can profoundly reduce the capacity for public health research that underpins evidence‐based medicine and clinical guidance. National initiatives seeking to collect EHRs should consider the implications of restricting data collection on the ability to address vital public health questions.

Research integrity and the law that never was

Evidence-based medicine is arguably among the most important innovations of the modern era, but publication bias and inadequate research transparency are serious issues affecting the very foundation of evidence-based practice. Despite this truth, these crucial issues have gone largely unaddressed or inadequately addressed for a distressingly long period of time. Regulatory efforts have thus far proven insufficient in eliminating these issues. Fortunately, the last 5 years in particular have seen developments that one hopes will contribute to the eradication of these issues and a future where we can look back on these issues as a sordid story of our past. However, much like the purported fixes of the past, time will be the final arbiter of the efficacy of remedial measures currently underway. This article chronicles the history of these issues, failed attempts to fix these issues, and what can be and is being done with the hope of bringing about true resolution.

Legitimacy in bioethics: challenging the orthodoxy

Several prominent writers including Norman Daniels, James Sabin, Amy Gutmann, Dennis Thompson and Leonard Fleck advance a view of legitimacy according to which, roughly, policies are legitimate if and only if they result from democratic deliberation, which employs only public reasons that are publicised to stakeholders. Yet, the process described by this view contrasts with the actual processes involved in creating the Affordable Care Act (ACA) and in attempting to pass the Health Securities Act (HSA). Since the ACA seems to be legitimate, as the HSA would have been had it passed, there seem to be counterexamples to this view. In this essay, I clarify the concept of legitimacy as employed in bioethics discourse. I then use that clarification to develop these examples into a criticism of the orthodox view-that it implies that legitimacy requires counterintuitively large sacrifices of justice in cases where important advancement of healthcare rights depends on violations of publicity. Finally, I reply to three responses to this challenge: (1) that some revision to the orthodox view salvages its core commitments, (2) that its views of publicity and substantive considerations do not have the implications that I claim and (3) that arguments for it are strong enough to support even counterintuitive results. My arguments suggest a greater role for substantive considerations than the orthodox view allows.

Policies for Use of Real-World Data in Health Technology Assessment (HTA): A Comparative Study of Six HTA Agencies

BACKGROUND

Randomized controlled trials provide robust data on the efficacy of interventions rather than on effectiveness. Health technology assessment (HTA) agencies worldwide are thus exploring whether real-world data (RWD) may provide alternative sources of data on effectiveness of interventions. Presently, an overview of HTA agencies' policies for RWD use in relative effectiveness assessments (REA) is lacking.

OBJECTIVES

To review policies of six European HTA agencies on RWD use in REA of drugs. A literature review and stakeholder interviews were conducted to collect information on RWD policies for six agencies: the Dental and Pharmaceutical Benefits Agency (Sweden), the National Institute for Health and Care Excellence (United Kingdom), the Institute for Quality and Efficiency in Healthcare (Germany), the High Authority for Health (France), the Italian Medicines Agency (Italy), and the National Healthcare Institute (The Netherlands). The following contexts for RWD use in REA of drugs were reviewed: initial reimbursement discussions, pharmacoeconomic analyses, and conditional reimbursement schemes. We identified 13 policy documents and 9 academic publications, and conducted 6 interviews.

RESULTS

Policies for RWD use in REA of drugs notably differed across contexts. Moreover, policies differed between HTA agencies. Such variations might discourage the use of RWD for HTA.

CONCLUSIONS

To facilitate the use of RWD for HTA across Europe, more alignment of policies seems necessary. Recent articles and project proposals of the European network of HTA may provide a starting point to achieve this.

What's the Rush? Tort Laws and Elective Early-term Induction of Labor

Tort laws aim to deter risky medical practices and increase accountability for harm. This research examines their effects on deterrence of a high-risk obstetric practice in the United States: elective early-term (37-38 weeks gestation) induction of labor. Using birth certificate data from the Natality Detail Files and state-level data from publicly available sources, this study analyzes the effects of tort laws on labor induction with multilevel models (MLM) of 665,491 early-term births nested in states. Results reveal that caps on damages are associated with significantly higher odds of early-term induction and Proportionate Liability (PL) is associated with significantly lower odds compared to Joint and Several Liability (JSL). The findings suggest that clinicians are more likely to engage in practices that defy professional guidelines in tort environments with lower legal burdens. I discuss the implications of the findings for patient safety and the deterrence of high-risk practices.

[Naturheilkunde und Komplementärmedizin in medizinischen Leitlinien - eine medizinrechtliche Perspektive]

Jeder Vertragsarzt ist schon konfrontiert worden mit der Diskrepanz zwischen leitliniengerechter Behandlung und Ausschlüssen in der Gesetzlichen Krankenversicherung (GKV). Um der wirtschaftlichen Gefahr durch Regresse, Honorarkürzungen und Plausibilitätsprüfungen zu entgehen, haben die Regeln der GKV Vorrang. Droht dann aber bei Abweichung von Leitlinien die zivilrechtliche oder gar strafrechtliche Haftung? Immer wieder fragen sich Ärzte, wie verbindlich Leitlinien sind und wie weit sie die Therapiefreiheit einschränken können.

Observational Evidence of For-Profit Delivery and Inferior Nursing Home Care: When Is There Enough Evidence for Policy Change?

Margaret McGregor and colleagues consider Bradford Hill's framework for examining causation in observational research for the association between nursing home care quality and for-profit ownership.

The Use of Economic Evidence to Inform Drug Pricing Decisions in Jordan

BACKGROUND

Drug pricing is an example of a priority setting in a developing country with official requirements for the use of cost-effectiveness (CE) evidence.

OBJECTIVE

To describe the role of economic evidence in drug pricing decisions in Jordan.

METHODS

A prospective review of all applications submitted between November 2013 and May 2015 to the Jordan Food and Drug Association's drug pricing committee was carried out. All applications that involved requests for CE evidence were reviewed. Details on the type of study, the extent, and whether the evidence submitted was part of the formal deliberations were extracted and summarized.

RESULTS

The committee reviewed a total of 1608 drug pricing applications over the period of the study. CE evidence was requested in only 11 applications. The submitted evidence was of limited use to the committee due to concerns about quality, relevance of studies, and lack of pharmacoeconomic expertise. There were also no clear rules describing how CE would inform pricing decisions.

CONCLUSIONS

Limited local data and health economic experience were the main barriers to the use of economic evidence in drug pricing decisions in Jordan. In addition, there are no official rules describing the elements and process by which the CE evidence would inform drug pricing decisions. This study summarized accumulated observations for the current use of economic evaluations and evidence-based decision making in Jordan. Recommendations have been proposed to applicants and key decision makers to enhance the role of economic evidence in influencing health policies and evidence-based decision making across priority settings.

Randomised trials in context: practical problems and social aspects of evidence-based medicine and policy

Randomised trials can provide excellent evidence of treatment benefit in medicine. Over the last 50 years, they have been cemented in the regulatory requirements for the approval of new treatments. Randomised trials make up a large and seemingly high-quality proportion of the medical evidence-base. However, it has also been acknowledged that a distorted evidence-base places a severe limitation on the practice of evidence-based medicine (EBM). We describe four important ways in which the evidence from randomised trials is limited or partial: the problem of applying results, the problem of bias in the conduct of randomised trials, the problem of conducting the wrong trials and the problem of conducting the right trials the wrong way. These problems are not intrinsic to the method of randomised trials or the EBM philosophy of evidence; nevertheless, they are genuine problems that undermine the evidence that randomised trials provide for decision-making and therefore undermine EBM in practice. Finally, we discuss the social dimensions of these problems and how they highlight the indispensable role of judgement when generating and using evidence for medicine. This is the paradox of randomised trial evidence: the trials open up expert judgment to scrutiny, but this scrutiny in turn requires further expertise.

Breast cancer screening in the era of density notification legislation: summary of 2014 Massachusetts experience and suggestion of an evidence-based management algorithm by multi-disciplinary expert panel

Stemming from breast density notification legislation in Massachusetts effective 2015, we sought to develop a collaborative evidence-based approach to density notification that could be used by practitioners across the state. Our goal was to develop an evidence-based consensus management algorithm to help patients and health care providers follow best practices to implement a coordinated, evidence-based, cost-effective, sustainable practice and to standardize care in recommendations for supplemental screening. We formed the Massachusetts Breast Risk Education and Assessment Task Force (MA-BREAST) a multi-institutional, multi-disciplinary panel of expert radiologists, surgeons, primary care physicians, and oncologists to develop a collaborative approach to density notification legislation. Using evidence-based data from the Institute for Clinical and Economic Review, the Cochrane review, National Comprehensive Cancer Network guidelines, American Cancer Society recommendations, and American College of Radiology appropriateness criteria, the group collaboratively developed an evidence-based best-practices algorithm. The expert consensus algorithm uses breast density as one element in the risk stratification to determine the need for supplemental screening. Women with dense breasts and otherwise low risk (<15% lifetime risk), do not routinely require supplemental screening per the expert consensus. Women of high risk (>20% lifetime) should consider supplemental screening MRI in addition to routine mammography regardless of breast density. We report the development of the multi-disciplinary collaborative approach to density notification. We propose a risk stratification algorithm to assess personal level of risk to determine the need for supplemental screening for an individual woman.

When Does FDAMA Section 114 Apply? Ten Case Studies

BACKGROUND

Section 114 of the Food and Drug Administration Modernization Act of 1997 regulates the promotion of health economic information by pharmaceutical companies to US health plans. Greater clarity is important given demands by payers and other stakeholders for evidence of value.

OBJECTIVES

To develop hypothetical case studies of health economic promotions to examine legal and policy implications.

METHODS

We constructed for pedagogical purposes 10 categories of potential health economic promotions. We generated hypothetical case studies for each category, including questions about whether each might be allowable under Section 114. The case studies were developed around the following categories: 1) costing out on-label clinical end points; 2) promotion of a costing exercise to physicians working in an accountable care organization setting; 3) burden-of-illness claims; 4) economic analysis of a formulary restriction policy; 5) extrapolations to doses, populations, or settings not covered in trials; 6) adherence claims; 7) "utilization of care" as a secondary end point in randomized clinical trials; 8) costing out a competitor drug's adverse event; 9) economic analysis of comparative effectiveness claims using an indirect treatment comparison; and 10) extrapolating from surrogate to long-term outcomes in an economic model.

DISCUSSION

Most cases seem to fall into a gray zone given haziness around what constitutes "competent and reliable evidence" and "directly relate[d]" to an approved indication. In practice, it is difficult to know what the section allows given the imprecision of the statute and lack of guidance about its scope.

CONCLUSION

Ideally, future guidance will provide clarity and flexibility.

[Benefit assessment of drugs]

In Germany, new drugs are subject to a benefit assessment at the time of their market access. This "early benefit assessment" is the method primarily used for the benefit assessment of pharmaceuticals in Germany. While for the authorization of a drug a positive risk-benefit ratio is sufficient, early benefit assessment examines whether the new drug has an added benefit compared with other therapies, and thus differs significantly from authorization. For the evaluation, the manufacturer is required to submit a dossier, which must contain all the relevant studies. Early benefit assessment is very transparent in international comparisons, because all the relevant data and the evaluation report will be published. The assessment is carried out with regard to the evidence-based standard of care (the "appropriate comparator"). If the new drug is found to have an additional benefit, the extent of this added benefit is assessed. In addition, groups of patients should be identified with the particular extent of the added benefit. Therefore, subgroup analyses have to be carried out frequently. Often, for new drugs, only registration studies are available. General requirements for such studies (e.g., placebo comparison, endpoints) and decisions regarding the approval process (e.g., dosage regimens) can affect the level of confidence of these studies in the benefit assessment. Joint scientific advice by regulatory authorities and HTA (health technology assessment) agencies are provided to solve this problem. However, this is not possible without additional expense for the pharmaceutical companies.

Improving the evidence base in palliative care to inform practice and policy: thinking outside the box

The adoption of evidence-based hierarchies and research methods from other disciplines may not completely translate to complex palliative care settings. The heterogeneity of the palliative care population, complexity of clinical presentations, and fluctuating health states present significant research challenges. The aim of this narrative review was to explore the debate about the use of current evidence-based approaches for conducting research, such as randomized controlled trials and other study designs, in palliative care, and more specifically to (1) describe key myths about palliative care research; (2) highlight substantive challenges of conducting palliative care research, using case illustrations; and (3) propose specific strategies to address some of these challenges. Myths about research in palliative care revolve around evidence hierarchies, sample heterogeneity, random assignment, participant burden, and measurement issues. Challenges arise because of the complex physical, psychological, existential, and spiritual problems faced by patients, families, and service providers. These challenges can be organized according to six general domains: patient, system/organization, context/setting, study design, research team, and ethics. A number of approaches for dealing with challenges in conducting research fall into five separate domains: study design, sampling, conceptual, statistical, and measures and outcomes. Although randomized controlled trials have their place whenever possible, alternative designs may offer more feasible research protocols that can be successfully implemented in palliative care. Therefore, this article highlights "outside the box" approaches that would benefit both clinicians and researchers in the palliative care field. Ultimately, the selection of research designs is dependent on a clearly articulated research question, which drives the research process.

Comparative effectiveness research in clinical practice

The Agency for Healthcare Research and Quality (AHRQ) has funded systematic reviews of comparative effectiveness research in 17 areas over the last 10 years as part of a federal mandate. These reviews provide a reliable and unbiased source of comprehensive information about the effectiveness and risks of treatment alternatives for patients and clinicians. This article describes comparative effectiveness research, provides an overview of how physicians can use it in clinical practice, and references important contributions made by the Minnesota Evidence-based Practice Center.

[The periodic health examination: from law to the directive of the German Federal Joint Committee (G-BA)]

Since 1989 a periodic health examination beginning at the age of 35 for the early detection of "common diseases" (especially cardiovascular and kidney diseases as well as diabetes) by means of history-taking, physical examination, blood and urine tests and counselling has been available in Germany. Altogether, the respective directive of the Federal Joint Committee (G-BA) was revised six times, but a substantive change took place only once (i. e., the cancellation of uric acid, creatinine, and resting ECG in 1999). However, additional examinations (e.g., glaucoma screening) were not added to the health check after systematic assessments of the evidence were completed. In the mid-1990s, several evaluations were performed which showed that new diagnoses were established in a significant proportion of patients, and measures were initiated such as nutrition counselling. A patient-relevant benefit in terms of avoided adverse events (such as heart attacks) could, however, not be demonstrated due to methodological reasons. Criticism of the health examination is not new, in particular concerning the lack of evidence of benefit for the diagnostic procedures of the health examination. A draft law issued by the former Federal Government proposing an amendment to the health examination has recently been rejected in the Bundesrat (upper house of the German parliament).

[HTA-Perspective: Challenges in the early assessment of new oncological drugs]

Oncologic drug therapies have gained wide attention in the context of health policy priority setting for serious and socially significant diseases with high human and monetary costs. Due to uncertainties and scepticism about the actual therapeutic importance of newly approved oncology products, an early assessment programme was already established in Austria in 2007. The assessment of new oncology products is thereby faced with special challenges, since study populations are frequently not representative or the study design is laid out in such a manner that a definitive assessment of patient-relevant endpoints is not possible (cross-overs after interim assessments, surrogate parameters as primary endpoints, uncontrolled studies or those with unrealistic comparators, invalidated post-hoc identified biomarkers). On account of these major uncertainties, even the European Medicines Agency (EMA) is already contemplating multi-stage, "adaptive" approvals, and national reimbursement institutions are increasingly working with outcome-oriented, conditional reimbursement. (As supplied by publisher).

[Off-label therapy from the perspective of the medical insurance service]

The assessment of off-label medications is one of the most common reasons for assessment of drugs for individual patients in the German medical services. Tension is not uncommon because of great expectations of patients and doctors on the one hand and the requirements of the law on the other. They often do not match. Even if there is a medically justified off-label use the road to drug approval is principally via the authorities with tested efficacy and safety in order not to deprive the patient of the protection of the Pharmaceuticals Act. The jurisdiction has approved criteria for reimbursement by the statutory health insurance only in clearly defined exception and one requirement is that there are no alternative forms of treatment. For serious diseases this is based on the evidence of drug approval; however, for immediately life-threatening situations a very low evidence level is sufficient.

[The 'Myozyme' decision of the Federal Supreme Court of Switzerland and German Law: a constitutional rights and health insurance law perspective]

In November 2010, the Federal Supreme Court of Switzerland dismissed a plea seeking reimbursement for treatment of glycogen storage disease type II - a very rare genetic metabolic disease also referred to as acid maltase deficiency (AMD) or Pompe disease -with a drug called 'Myozyme'. The Court held that the medication was not sufficiently effective or, alternatively, there was insufficient evidence for its effectiveness. The Court argued that the cost was out of balance with respect to the effects of the drug and concluded that it would be against the principle of legal equality if taxpayers were required to defray excessive expenses benefiting only an extremely small fraction of the population. Cost-effectiveness, however, cannot be accepted as a standard criterion governing the allocation of health insurance benefits because diversity of individual health must be regarded as a risk which nature has distributed equally among the members of the population. Therefore, it is a manifestation, rather than a violation, of the principle of legal equality that a public health insurance provider should pay for medical treatment in a particular case even if such treatment could not necessarily be administered to all other insured parties as well. At the same time, if cost-effectiveness in public health care is taken into account carefully, the risk of irrational resource allocation may be minimised. (As supplied by publisher).

Lack of proportionality. Seven specifications of public interest that override post-approval commercial interests on limited access to clinical data

For the protection of commercial interests, licensing bodies such as the EMA and health technology assessment institutions such as NICE restrict full access to unpublished evidence. Their respective policies on data transparency, however, lack a systematic account of (1) what kinds of commercial interests remain relevant after market approval has been granted, (2) what the specific types of public interest are that may override these commercial interests post approval, and, most importantly, (3) what criteria guide the trade-off between public interest and legitimate measures for the protection of commercial interest. Comparing potential commercial interests with seven specifications of relevant public interest reveals the lack of proportionality inherent in the current practices of EMA and NICE.

[Clinical assessment and prescriptive regulation]

Although it appears that the methods of medicine cannot be approached from a legal perspective, the law--as a code of conduct--establishes requirements for the effectiveness of treatment and standards for decision-making in healthcare. Central provisions of the relevant law relate to extraordinarily vague legal concepts, taking recourse to knowledge based on experience scattered across the profession. However, the sometimes explosive dissemination of new--heterogeneous or specific--knowledge and an increasing specialisation of treatment approaches very much relativise the importance of medical experience. This has promoted the rise of a professional evidence-based knowledge management in medicine, to which the law--especially case law--has only partially responded so far.

Group-based and personalized care in an age of genomic and evidence-based medicine: a reappraisal

This article addresses the philosophical and moral foundations of group-based and individualized therapy in connection with population care equality. The U.S. Food and Drug Administration (FDA) recently modified its public health policy by seeking to enhance the efficacy and equality of care through the approval of group-specific prescriptions and doses for some drugs. In the age of genomics, when individualization of care increasingly has become a major concern, investigating the relationship between population health, stratified medicine, and personalized therapy can improve our understanding of the ethical and biomedical implications of genomic medicine. I suggest that the need to optimize population health through population substructure-sensitive research and the need to individualize care through genetically targeted therapies are not necessarily incompatible. Accordingly, the article reconceptualizes a unified goal for modern scientific medicine in terms of individualized equal care.