Omalizumab for the treatment of severe persistent allergic asthma: a systematic review and economic evaluation

BACKGROUND

Allergic asthma is a long-term disorder of the airways resulting from overexpression of immunoglobulin E (IgE) in response to environmental allergens. Patients with poorly controlled asthma are at high risk of exacerbations requiring additional treatment, including hospitalisations. Severe exacerbations are potentially life threatening. Guidelines identify five treatment steps for both adults and children. Omalizumab (Xolair(®)) is a recombinant DNA-derived humanised monoclonal antibody indicated as an add-on therapy in patients aged ≥ 6 years with severe persistent allergic asthma uncontrolled at treatment step 4 or 5.

OBJECTIVE

To determine the clinical effectiveness, safety and cost-effectiveness of omalizumab, as an add-on therapy to standard care, within its licensed indication, compared with standard therapy alone for the treatment of severe persistent allergic asthma in adults and adolescents aged ≥ 12 years and children aged 6-11 years.

DATA SOURCES

Eleven electronic databases (including MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials) and additional sources including regulatory agency reports were searched from inception to October 2011. Additional data sources include: the manufacturer's submission (MS); two previous National Institute for Health and Care Excellence (NICE) single technology appraisal (STA) submissions; and existing reviews on the safety of omalizumab and oral corticosteroids (OCSs).

REVIEW METHODS

Systematic reviews of the clinical effectiveness and cost-effectiveness evidence for omalizumab were performed. The primary outcome was number of clinically significant (CS) exacerbations. Other outcomes included asthma symptoms, unscheduled health-care use, asthma-related mortality, OCS use and health-related quality of life (HRQoL). Because of methodological and clinical heterogeneity between trials, a narrative synthesis was applied. Pragmatic reviews with best evidence syntheses were used to assess adverse events of omalizumab and OCSs. The cost-effectiveness of omalizumab was assessed from the perspective of the UK NHS in the two separate populations: adults and adolescents, and children, using a cohort Markov model. Costs and outcomes were discounted at 3.5% per annum. Results are presented for additional subgroup populations: (1) hospitalised for asthma in the previous year, (2) adults and adolescents on maintenance OCSs and (3) three or more exacerbations in the previous year.

RESULTS

Eleven randomised controlled trials (RCTs) and 13 observational studies were identified, including four RCTs/subgroups in the adult licensed population and one subgroup in children. A minority of patients were on maintenance OCSs. No evidence comparing omalizumab with OCSs was identified. Omalizumab significantly reduced the incidence of CS exacerbations in both adults and children [adults: INvestigatioN of Omalizumab in seVere Asthma Trial (INNOVATE): rate ratio 0.74; 95% CI 0.55 to 1.00; children IA-05 EUP (the a priori subgroup of patients who met the European Medicines Agency license criteria) 0.66; 95% CI 0.44 to 1.00]. Significant benefits were observed for a range of other outcomes in adults. Subgroup evidence showed benefits in adults on maintenance OCSs. Evidence for an OCS-sparing effect of omalizumab was limited but consistent. Omalizumab is available as 75 mg and 150 mg prefilled syringes at prices of £128.07 and £256.15 respectively. The incremental cost-effectiveness ratio (ICER) for adults and adolescents is £83,822 per quality-adjusted life-year (QALY) gained, whereas the ICER for children is £78,009 per QALY gained. The results are similar for the subgroup population of ≥ 3 exacerbations in the previous year, whereas the ICER for the other subgroup populations are lower; £46,431 for the hospitalisation subgroup in adults and adolescents, £44,142 for the hospitalisation subgroup in children and £50,181 for the maintenance OCS subgroup.

CONCLUSION

Omalizumab reduces the incidence of CS exacerbations in adults and children, with benefits on other outcomes in adults. Limited, underpowered subgroup evidence exists that omalizumab reduces exacerbations and OCS requirements in adults on OCSs. Evidence in children is weaker and more uncertain. The ICERs are above conventional NHS thresholds of cost-effectiveness. The key drivers of cost-effectiveness are asthma-related mortality risk and, to a lesser extent, HRQoL improvement and OCS-related adverse effects. An adequately powered double-blind RCT in both adults and children on maintenance OCSs and an individual patient data meta-analysis of existing trials should be considered. A registry of all patients on omalizumab should be established.

STUDY REGISTRATION

The study was registered as PROSPERO CRD42011001625.

FUNDING

This report was commissioned by the National Institute for Health Research Health Technology Assessment programme on behalf of NICE as project number HTA 10/128/01.

The impact of cortical remapping interventions on pain and disability in chronic low back pain: a systematic review

BACKGROUND

Cortical change, in the manner of cortical remapping is a common feature of and potential driver for chronic low back pain (CLBP). Novel interventions such as graded motor imagery (GMI) and mirror visual feedback (MVF) have been shown to facilitate correction of cortical changes and improve symptoms in other chronic pain states. However, little is known regarding the effectiveness of these treatment approaches in CLBP.

OBJECTIVE

To identify and assess the current evidence regarding the effectiveness of interventions which target cortical remapping in the management of CLBP.

DATA SOURCES

The electronic databases Medline, Embase, CINAHL, AMED, OVID, PEDro, BNI, PsycINFO, HMIC, and Cochrane library were systematically searched.

STUDY SELECTION

Of 11 potential citations identified, 5 articles were identified for inclusion and critiqued. These comprised 3 randomised controlled trials (RCTs), 1 randomised cross-over study, and 1 multiple case study design.

RESULTS

Visualisation of lumbar movement may significantly improve movement-related pain severity and duration. A combined sensorimotor retraining approach has been shown to produce short-term improvements in both pain and disability outcomes in CLBP. The relative effectiveness of individual interventions and their long-term efficacy have yet to be established.

CONCLUSIONS

There is a paucity of robust literature which has examined the application and efficacy of these novel treatments in the management of CLBP. Results from the few CLBP studies which are available are encouraging. Further, robust research is needed to optimise treatment protocols and establish their long-term effectiveness in CLBP.

Integrated care pathways for airway diseases (AIRWAYS-ICPs)

The objective of Integrated Care Pathways for Airway Diseases (AIRWAYS-ICPs) is to launch a collaboration to develop multi-sectoral care pathways for chronic respiratory diseases in European countries and regions. AIRWAYS-ICPs has strategic relevance to the European Union Health Strategy and will add value to existing public health knowledge by: 1) proposing a common framework of care pathways for chronic respiratory diseases, which will facilitate comparability and trans-national initiatives; 2) informing cost-effective policy development, strengthening in particular those on smoking and environmental exposure; 3) aiding risk stratification in chronic disease patients, using a common strategy; 4) having a significant impact on the health of citizens in the short term (reduction of morbidity, improvement of education in children and of work in adults) and in the long-term (healthy ageing); 5) proposing a common simulation tool to assist physicians; and 6) ultimately reducing the healthcare burden (emergency visits, avoidable hospitalisations, disability and costs) while improving quality of life. In the longer term, the incidence of disease may be reduced by innovative prevention strategies. AIRWAYSICPs was initiated by Area 5 of the Action Plan B3 of the European Innovation Partnership on Active and Healthy Ageing. All stakeholders are involved (health and social care, patients, and policy makers).

Cost-effectiveness of combining systematic identification and treatment of co-morbid major depression for people with chronic diseases: the example of cancer

BACKGROUND

Co-morbid major depression occurs in approximately 10% of people suffering from a chronic medical condition such as cancer. Systematic integrated management that includes both identification and treatment has been advocated. However, we lack information on the cost-effectiveness of this combined approach, as published evaluations have focused solely on the systematic (collaborative care) treatment stage. We therefore aimed to use the best available evidence to estimate the cost-effectiveness of systematic integrated management (both identification and treatment) compared with usual practice, for patients attending specialist cancer clinics.

METHOD

We conducted a cost-effectiveness analysis using a decision analytic model structured to reflect both the identification and treatment processes. Evidence was taken from reviews of relevant clinical trials and from observational studies, together with data from a large depression screening service. Sensitivity and scenario analyses were undertaken to determine the effects of variations in depression incidence rates, time horizons and patient characteristics.

RESULTS

Systematic integrated depression management generated more costs than usual practice, but also more quality-adjusted life years (QALYs). The incremental cost-effectiveness ratio (ICER) was £11,765 per QALY. This finding was robust to tests of uncertainty and variation in key model parameters.

CONCLUSIONS

Systematic integrated management of co-morbid major depression in cancer patients is likely to be cost-effective at widely accepted threshold values and may be a better way of generating QALYs for cancer patients than some existing medical and surgical treatments. It could usefully be applied to other chronic medical conditions.

Evidence-Based Medicine applied to the control of communicable disease incidents when evidence is scarce and the time is limited

Binary file ES_Abstracts_Final_ECDC.txt matches

Informing a decision framework for when NICE should recommend the use of health technologies only in the context of an appropriately designed programme of evidence development

BACKGROUND

The general issue of balancing the value of evidence about the performance of a technology and the value of access to a technology can be seen as central to a number of policy questions. Establishing the key principles of what assessments are needed, as well as how they should be made, will enable them to be addressed in an explicit and transparent manner.

OBJECTIVES

The aims of this research are to (1) establish the key principles of what assessments are needed to inform an 'only in research' (OIR) or 'approval with research' (AWR) recommendation, (2) evaluate previous National Institute for Health and Clinical Evidence (NICE) guidance in which OIR or AWR recommendations were made or considered and (3) evaluate a range of alternative options to establish criteria, additional information and/or analysis that could be made available to inform the assessments needed.

DATA SOURCES

All NICE draft and final guidance up to January 2010 was considered in the review of NICE technology appraisal guidance. Four case studies were used to evaluate the range of options of what information and analysis could be made available to inform the assessment required. These were based on a reanalysis of existing health technology appraisals for NICE or the Health Technology Assessment programme.

REVIEW METHODS

A critical review of policies, practice and literature was undertaken using traditional systematic searching based on initial search terms informed by key publications. An iterative approach was adopted using 'pearl growing' evaluated through capture-recapture methods. In addition, grey literature, policy documents and other sources, such as special interest groups and the expertise of the Advisory Group for the project, were used to contribute to this process.

RESULTS

A series of recommendations, or options, for NICE to consider were developed with the involvement of key stakeholders. These establish the key principles and associated criteria that might guide OIR and AWR recommendations and identify what, if any, additional information or analysis might be included in the technology appraisal process, including how such recommendations might be more likely to be implemented through publically funded and sponsored research. To meet these aims the research is broadly structured as follows. A critical review of policy, practice and literature in this area informs the development of a coherent conceptual framework to establish the key principles and the sequence of assessment and judgements required. This sequence of assessment and judgement is represented as an algorithm, which can also be summarised as a simple set of explicit criteria or a 7-point checklist of assessments. A review of previous NICE guidance in which OIR or AWR recommendations were either made or considered was undertaken to examine the extent to which the key principles are evident. The application of the checklist of assessment to a series of four case studies informs considerations of whether or not such assessments can be made based on existing information and analysis in current NICE appraisal and in what circumstances could additional information and/or analysis be useful. Finally, some of the implications that this more explicit assessment of OIR and AWR might have for policy (e.g. NICE guidance and drug pricing), the process of appraisal (e.g. greater involvement of research commissioners) and methods of appraisal (e.g. should additional information, evidence and analysis be required) are drawn together. At each stage this research has been informed by a diverse and international Advisory Group and the feedback from participants at two workshops involving a wide range of key stakeholders, which included members of NICE and its Advisory Committees (including lay members and other NICE programmes), patient advocates, manufacturers, and research and NHS commissioners, as well as relevant academics.

LIMITATIONS

Further research is required to establish how these considerations could be integrated within a practical value-based pricing scheme. In addition, irrecoverable opportunity costs are commonly associated with many health technologies that offer future benefits following treatment. The significance of these types of irrecoverable costs is not widely recognised and further research to demonstrate their potential impact more generally is needed.

CONCLUSIONS

The categories of guidance available to NICE have a wider application than is reflected in the review of previous guidance. Importantly, determining which category of guidance will be appropriate depends only partly on an assessment of expected cost-effectiveness. As well as AWR for technologies expected to be cost-effective and OIR for those not expected to be cost-effective, there are other important circumstances when OIR should be considered. In particular, for technologies expected to be cost-effective, OIR rather than approve may be appropriate when research is not possible with approval and OIR or even reject, rather than AWR or approve, may be appropriate even if research is possible with approval when there are significant irrecoverable costs.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.