The HTA Core Model®-10 Years of Developing an International Framework to Share Multidimensional Value Assessment

BACKGROUND AND OBJECTIVES

The HTA Core Model^® as a science-based framework for assessing dimensions of value was developed as a part of the European network for Health Technology Assessment project in the period 2006 to 2008 to facilitate production and sharing of health technology assessment (HTA) information, such as evidence on efficacy and effectiveness and patient aspects, to inform decisions.

METHODS

It covers clinical value as well as organizational, economic, and patient aspects of technologies and has been field-tested in two consecutive joint actions in the period 2010 to 2016. A large number of HTA institutions were involved in the work.

RESULTS

The model has undergone revisions and improvement after iterations of piloting and can be used in a local, national, or international context to produce structured HTA information that can be taken forward by users into their own frameworks to fit their specific needs when informing decisions on technology. The model has a broad scope and offers a common ground to various stakeholders through offering a standard structure and a transparent set of proposed HTA questions. It consists of three main components: 1) the HTA ontology, 2) methodological guidance, and 3) a common reporting structure. It covers domains such as effectiveness, safety, and economics, and also includes domains covering organizational, patient, social, and legal aspects. There is a full model and a focused rapid relative effectiveness assessment model, and a third joint action is to continue till 2020.

CONCLUSION

The HTA Core Model is now available for everyone around the world as a framework for assessing value.

Between January 2009 and April 2016, 134 novel anticancer therapies were approved: what is the level of knowledge concerning the clinical benefit at the time of approval?

Objective

In the last decade an increasing number of high-priced, new cancer treatments received marketing authorisation in Europe. What is actually known about the clinical benefit of those therapies at the time of approval needs to be elucidated in order to inform decisions about the use and reimbursement of these novel treatment options. Thus, the aim of the current analysis was to systematically investigate oncological therapies approved between January 2009 and April 2016 and extract as well as quantify the level of knowledge of the clinical benefit at the time of marketing authorisation.

Methods

To assess the benefit of new interventions as well as expanded indications, we extracted the median gain of the two study end points: progression-free survival (PFS) and overall survival (OS). Information is based on approval documents provided by the European Medicines Agency and assessments from the Austrian Horizon Scanning programme. We included all cancer therapies approved in Europe between 2009 (January 1) and 2016 (April 15).

Results

Cancer drugs for 134 new indications approved since 2009 were identified. In the case of 37 indications (27%), no data were available for PFS or for OS. A positive difference in median OS was reached by 76 licensed indications (55.5%); 22 (16%) of them showed a difference of more than 3 months. Regarding the study end point PFS, an improvement was shown in 90 indications (65.2%).

Conclusion

Scarce knowledge regarding the clinical benefit of anticancer therapies is available at the time of approval. In addition, the survival benefit of the approved indications is less than 3 months in the majority of approved therapies.

Successful Treatment of Life-threatening Bleeding after Cesarean Section with Recombinant Activated Factor VII

Hemorrhagic shock developed in a 29-year-old nullipara without coagulopathy after emergency caesarean section. Treatment with uterotonic drugs, prostaglandins, and conservative procedures with transfusion of packed red cells and fresh-frozen plasma failed to control the diffuse vaginal and uterine bleeding. Finally an intravenous bolus injection of 90 μg/kg recombinant activated factor VII (rFVIIa, NovoSeven®, Novo Nordisk A/S, Bagsvaerd, Denmark), was given and showed success within 20 minutes after administration, without any side effects.

Impacts of a high-discharge submarine sewage outfall on water quality in the coastal zone of Salvador (Bahia, Brazil)

Carbon and nitrogen stable isotopic signatures of suspended particulate organic matter and seawater biological oxygen demand (BOD) were measured along a coastal transect during summer 2015 to investigate pollution impacts of a high-discharge submarine sewage outfall close to Salvador, Brazil. Impacts of untreated sewage discharge were evident at the outfall site by depleted δ(13)Corg and δ(15)N signatures and 4-fold increased BOD rates. Pollution effects of a sewage plume were detectable for more than 6km downstream from the outfall site, as seasonal wind- and tide-driven shelf hydrodynamics facilitated its advective transport into near-shore waters. There, sewage pollution was detectable at recreational beaches by depleted stable isotope signatures and elevated BOD rates at high tides, suggesting high bacterial activity and increased infection risk by human pathogens. These findings indicate the urgent necessity for appropriate wastewater treatment in Salvador to achieve acceptable standards for released effluents and coastal zone water quality.

[Overtreatment: Initiatives to identify ineffective and inappropriate medical interventions]

A growing number of international initiatives rise to the challenge of reduction of medical overuse. Increasingly, these activities are promoted by physicians and clinicians, and aim to identify and avoid inappropriate health interventions. This article places the Choosing Wisely initiative within the context of less well-known activities, 13 all together, and briefly describes their characteristics; in addition, similarities and differences regarding their methods are elaborated.

Hospital managers' need for information in decision-making--An interview study in nine European countries

Assessments of new health technologies in Europe are often made at the hospital level. However, the guidelines for health technology assessment (HTA), e.g. the EUnetHTA Core Model, are produced by national HTA organizations and focus on decision-making at the national level. This paper describes the results of an interview study with European hospital managers about their need for information when deciding about investments in new treatments. The study is part of the AdHopHTA project. Face-to-face, structured interviews were conducted with 53 hospital managers from nine European countries. The hospital managers identified the clinical, economic, safety and organizational aspects of new treatments as being the most relevant for decision-making. With regard to economic aspects, the hospital managers typically had a narrower focus on budget impact and reimbursement. In addition to the information included in traditional HTAs, hospital managers sometimes needed information on the political and strategic aspects of new treatments, in particular the relationship between the treatment and the strategic goals of the hospital. If further studies are able to verify our results, guidelines for hospital-based HTA should be altered to reflect the information needs of hospital managers when deciding about investments in new treatments.

Health technology assessment of medical devices: What is different? An overview of three European projects

BACKGROUND

With the growing use and importance of health technology assessment (HTA) in decision making during recent years, health technology assessors, decision makers and stakeholders are confronted with methodological challenges due to specific characteristics of health technologies (e. g., pharmaceuticals, diagnostic tests, screening programs), their developmental environment, and their regulation process. Being aware of the necessity to use HTA as a policy instrument for sustainable health care systems in a regulatory environment of decentralized Conformité Européenne (CE) marking, the European Union (EU) is increasingly supporting the development of methods for the assessment of medical devices (MD) on different levels: within the scope of European research projects and within joint assessment activities of the member states of the European network for Health Technology Assessment (EUnetHTA).

OBJECTIVE

First, this article describes three projects: MedtecHTA-Methods for Health Technology Assessment of Medical Devices, a European Perspective Work Package 3 (WP3), Comparative Effectiveness of Medical Devices led by the University for Health Sciences, Medical Informatics and Technology (UMIT). Second, we discuss the experiences of the Ludwig Boltzmann Institute Health Technology Assessment (LBI HTA) with the joint production of rapid assessments of medical devices by several European HTA agencies within EUnetHTA. Third, a brief outline is given of the framework of joint methodological guideline elaboration by the EUnetHTA partner organizations because a guideline for therapeutic MD is also being developed here.

METHODS

We will describe aims, methods and some preliminary results of MedtecHTA and EUnetHTA Joint Action 2 Work Package 5 Strand B (WP5B) applying the HTA Core Model for Rapid Assessment for national adaptation and reporting, and give an overview of the development process of methodological guidelines within WP 7 of EUnetHTA Joint Action 2.

RESULTS

Based on a literature review in MedtecHTA WP3 incremental development, context dependency and the physical mode of action of MD were identified as those characteristics making therapeutic MD different from drugs with regard to evaluation methods. In addition, regulation does not stipulate clinical trials. These characteristics were also identified as challenges for the production of joint assessments of MD within the HTA network EUnetHTA. Furthermore, adequate timing of assessment production, the variety of involved manufacturers, the non-transparent regulation process of MD in Europe and the often poor evidence base pose a challenge to EUnetHTA assessors. As a consequence, processes and methods for the joint production of rapid assessments must be continuously adapted and improved.

DISCUSSION

Research on HTA methods for the assessment of MD tries to provide tools to deal with rapidly developing devices during evidence generation, dependence of clinical effectiveness of MD on user experience and context factors. There are also tools to integrate evidence from different sources adjusting for different levels of validity, but these methods are not established and need high epidemiological and statistical expertise. A framework for deciding whether additional evidence is needed to reduce uncertainty regarding safety, clinical effectiveness and cost-effectiveness will be adapted to MD. The whole process of evidence generation before and after market access has to be considered to provide an environment for conclusive HTA recommendations informing health care decision making. In Joint Action 2, EUnetHTA develops transparent processes for the early dialogue with stakeholders and fosters dissemination of appropriate HTA methods. In the case of MD, there are special accumulated needs for such efforts.

First high-convergence cryogenic implosion in a near-vacuum hohlraum

Recent experiments on the National Ignition Facility [M. J. Edwards et al., Phys. Plasmas 20, 070501 (2013)] demonstrate that utilizing a near-vacuum hohlraum (low pressure gas-filled) is a viable option for high convergence cryogenic deuterium-tritium (DT) layered capsule implosions. This is made possible by using a dense ablator (high-density carbon), which shortens the drive duration needed to achieve high convergence: a measured 40% higher hohlraum efficiency than typical gas-filled hohlraums, which requires less laser energy going into the hohlraum, and an observed better symmetry control than anticipated by standard hydrodynamics simulations. The first series of near-vacuum hohlraum experiments culminated in a 6.8 ns, 1.2 MJ laser pulse driving a 2-shock, high adiabat (α∼3.5) cryogenic DT layered high density carbon capsule. This resulted in one of the best performances so far on the NIF relative to laser energy, with a measured primary neutron yield of 1.8×10(15) neutrons, with 20% calculated alpha heating at convergence ∼27×.

Retrospective and prospectively assessed childhood adversity in association with major depression, alcohol consumption and painful conditions

BACKGROUND

Considerable evidence now links childhood adversity to a variety of adult health problems. Unfortunately, almost all of these studies have relied upon retrospective assessment of childhood events, creating a vulnerability to bias. In this study, we sought to examine three associations using data sources that allowed for both prospective and retrospective assessment of childhood events.

METHODS

A 1994 national survey of children between the ages of 0 and 11 collected data from a 'person most knowledgeable' (usually the mother) about a child. It was possible to link data for n = 1977 of these respondents to data collected from the same people in a subsequent adult study. The latter survey included retrospective reports of childhood adversity. We examined three adult health outcomes in relation to prospectively and retrospectively assessed childhood adversity: major depressive episodes, excessive alcohol consumption and painful conditions.

RESULTS

A strong association between childhood adversities (as assessed by both retrospective and prospective methods) and major depression was identified although the association with retrospective assessment was stronger. Weaker associations were found for painful conditions, but these did not depend on the method of assessment. Associations were not found for excessive alcohol consumption irrespective of the method of assessment.

CONCLUSIONS

These findings help to allay concerns that associations between childhood adversities and health outcomes during adulthood are merely artefacts of recall bias. In this study, retrospective and prospective assessment strategies produced similar results.

Contrasting clinical evidence for market authorisation of cardio-vascular devices in Europe and the USA: a systematic analysis of 10 devices based on Austrian pre-reimbursement assessments

BACKGROUND

European medical device regulation is under scrutiny and will be re-regulated with stricter rules concerning requirements for clinical evidence for high-risk medical devices. It is the aim of this study to analyse the differences between Europe and USA in dealing with risks and benefits of new cardio-vascular devices.

METHODS

Since no information is available on clinical data used by the Notified Body for CE-marking, data from Austrian pre-reimbursement assessments close to European market approval were used as proxy and compared with clinical data available at time of market approval by FDA in the USA.

RESULTS

10 cardio-vascular interventions with 27 newly CE approved medical devices were analysed. The time lag between market authorisation in Europe and in the USA is 3 to 7 years. Only 7 CE-marked devices also hold a FDA market approval, 7 further devices are in FDA approved ongoing efficacy trials. For 4 of the CE-marked devices the FDA market application or the approval-trial was either suspended due to efficacy or safety concerns or the approval was denied. Evidence available at time of CE-marking are most often case-series or small feasibility RCTs, while large RCTs and only in rare cases prospective cohort studies are the basis of FDA approvals. Additionally, the FDA often requires post-approval studies for high-risk devices.

CONCLUSIONS

Market authorisation based on mature clinical data deriving from larger RCTs and longer follow-ups do not only change the perspective on the risk-benefit ratio, but also secures real patient benefit and safety and assures payers of investing only in truly innovative devices.

Elektronischer Mutter(Eltern)-Kind Pass – Möglichkeiten, Zielsetzungen und internationale Erfahrungen

Vor dem Hintergrund einer Neugestaltung des Eltern-Kind-Vorsorgeprogramms in Österreich, welche auch eine elektronische statt papierbasierte Umsetzung beinhalten könnte, soll ein Überblick internationaler Pilotierungen elektronischer Eltern-Kind-Vorsorge Initiativen (eEKVI) gegeben, und für die Umsetzung relevanten Grenzen, Möglichkeiten und Zielsetzungen dieser Projekte aufgezeigt werden.

Datenbankrecherche sowie Handsuche nach internationalen (Pilot-) Projekten.

Von 30 ausgewählten eEKVI können 9 als elektronische Eltern- bzw. Kinder-Gesundheitsakten angesehen werden, welche entweder im Kontext einer umfassenden elektronischen Gesundheitsakte, als elektronische Umsetzung eines papierbasierten Dokuments oder als an eine Einrichtung gebundene IT-Lösung realisiert wurden. eEKVI sind bislang international noch kaum flächendeckend implementiert, einige wenige bedienen neben klassischen Kern-Zielen (Abwicklung und Administration der Versorgung usw.) auch planerische Zielsetzungen und ermöglichen dadurch ein systemisches Lernen aufgrund von Feedback und Evaluationszyklen.

Basierend auf Erfahrungen internationaler eEKVI sollten Kernaspekte einer erfolgreichen Planung und Umsetzung, wie beispielsweise die Definition von erwarteten Nutzen-Zielen und deren Monitoring oder die Bildung eines für Planung und Konzeption verantwortlichen Teams unter früher Einbeziehung von Endnutzern und Akteuren, berücksichtigt werden, um vermeidbare Fehler zu minimieren. Eine konsequente Technikfolgenabschätzung – auch von IT-basierten Interventionen im Gesundheitswesen – ist jedenfalls zu fordern, um ein reflektiertes Vorgehen zu ermöglichen.