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Petrov P. Institutional design and moral conflict in health care priority-setting. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2024; 27:285-298. [PMID: 38573406 DOI: 10.1007/s11019-024-10201-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/15/2024] [Indexed: 04/05/2024]
Abstract
Priority-setting policy-makers often face moral and political pressure to balance the conflicting motivations of efficiency and rescue/non-abandonment. Using the conflict between these motivations as a case study can enrich the understanding of institutional design in developed democracies. This essay presents a cognitive-psychological account of the conflict between efficiency and rescue/non-abandonment in health care priority-setting. It then describes three sets of institutional arrangements-in Australia, England/Wales, and Germany, respectively-that contend with this conflict in interestingly different ways. The analysis yields at least three implications for institutional design in developed democracies: (1) indeterminacy at the level of moral psychology can increase the probability of indeterminacy at the level of institutional design; (2) situational constraints in effect require priority-setting policy-makers to adopt normative-moral pluralism; and (3) the U.S. health care system may be in an anti-priority-setting equilibrium.
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Affiliation(s)
- Philip Petrov
- Wachtell Fellow in Behavioral Law and Economics, University of Chicago Law School, 1111 East 60th Street, Chicago, IL, 60637, USA.
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2
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Son KB. Public value judgments about the criteria for reimbursement of medicines in South Korea. Expert Rev Pharmacoecon Outcomes Res 2024:1-9. [PMID: 39093034 DOI: 10.1080/14737167.2024.2388815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 07/05/2024] [Accepted: 07/09/2024] [Indexed: 08/04/2024]
Abstract
OBJECTIVES This study quantified the public value (PV) of the criteria and sub-criteria in the current drug reimbursement systems in South Korea and examined sociodemographic factors that associated with PV. METHODS The Analytic Hierarchy Process (AHP) was used to quantify the PVs of criteria and sub-criteria. We developed a questionnaire to generate pairwise comparison matrices among criteria and sub-criteria. From 27 March to 1 April 2023, we recruited 1,000 study participants using a quota sampling method stratified by age, sex, and region based on Korean census data. RESULTS The PVs for the criteria were highest for clinical usefulness (28.5%), followed by cost-effectiveness (27.1%), budget impact (24.3%), and reimbursement in other countries (20.1%). The sociodemographic characteristics of the participants had a significant impact on the PVs of the criteria. Willingness to pay additional premiums for national health insurance was negatively associated with PV for clinical usefulness and cost-effectiveness and positively associated with PV for reimbursement in other countries. CONCLUSIONS The public prioritized clinical usefulness and cost-effectiveness as the main criteria. However, the PVs of the criteria were divergent and associated with sociodemographic factors. Divergent public interests require an evidence-informed deliberative process for reimbursement decisions.
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Affiliation(s)
- Kyung-Bok Son
- College of Pharmacy, Hanyang University, Ansan, Gyeonggi-do, South Korea
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Espinosa O, Rodríguez-Lesmes P, Romano G, Orozco E, Basto S, Ávila D, Mesa L, Enríquez H. Use of Cost-Effectiveness Thresholds in Healthcare Public Policy: Progress and Challenges. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2024:10.1007/s40258-024-00900-5. [PMID: 38995492 DOI: 10.1007/s40258-024-00900-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/18/2024] [Indexed: 07/13/2024]
Abstract
The article offers a comparative analysis of the influence of cost-effectiveness thresholds in the decision-making processes in financing policies, coverage, and price regulation of health technologies in nine countries. We investigated whether countries used cost-effectiveness thresholds for public health policy decision making and found that few countries have adopted the cost-effectiveness threshold as an official criterion for financing, reimbursement, or pricing. However, in countries where it is applied, such as Thailand, the results have been very favorable in terms of minimizing health technology prices and ensuring the financial sustainability of the health system. Although the cost-effectiveness threshold has opportunities for improvement, particularly in certain institutional contexts and with adequate participation of the different strategic actors in the formulation of public policy, its potential use and added value are significant in various aspects.
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Affiliation(s)
- Oscar Espinosa
- Economic Models and Quantitative Methods Research Group, Centro de Investigaciones para el Desarrollo, Universidad Nacional de Colombia and Directorate of Analytical, Economic and Actuarial Studies in Health, Instituto de Evaluación Tecnológica en Salud (IETS), Bogotá, DC, Colombia
| | | | - Giancarlo Romano
- Directorate of Analytical, Economic and Actuarial Studies in Health, Instituto de Evaluación Tecnológica en Salud (IETS), Bogotá, DC, Colombia
| | - Esteban Orozco
- Directorate of Analytical, Economic and Actuarial Studies in Health, Instituto de Evaluación Tecnológica en Salud (IETS), Bogotá, DC, Colombia
- School of Economics, Universidad de Antioquia, Bogotá, DC, Colombia
| | - Sergio Basto
- Directorate of Analytical, Economic and Actuarial Studies in Health, Instituto de Evaluación Tecnológica en Salud (IETS), Bogotá, DC, Colombia
| | - Diego Ávila
- Economic Models and Quantitative Methods Research Group, Centro de Investigaciones para el Desarrollo, Universidad Nacional de Colombia and Directorate of Analytical, Economic and Actuarial Studies in Health, Instituto de Evaluación Tecnológica en Salud (IETS), Bogotá, DC, Colombia
| | - Lorena Mesa
- Directorate of Qualitative Methods and Social Research, Instituto de Evaluación Tecnológica en Salud (IETS), Duitama, Colombia
| | - Hernán Enríquez
- School of Economics, Universidad del Rosario, Bogotá, DC, Colombia
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Barman-Aksözen J, Hentschel N, Pettersson M, Schupp E, Granata F, Dechant C, Aksözen MH, Falchetto R. Fair Funding Decisions: Consistency of the Time Horizons Used in the Calculation of Quality-Adjusted Life Years for Therapies for Very Rare Diseases by the National Institute for Health and Care Excellence in England. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:616. [PMID: 38791830 PMCID: PMC11121024 DOI: 10.3390/ijerph21050616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 05/02/2024] [Accepted: 05/09/2024] [Indexed: 05/26/2024]
Abstract
The National Institute for Health and Care Excellence (NICE) in England uses quality-adjusted life years (QALYs) to assess the cost-effectiveness of treatments. A QALY is a measure that combines the size of the clinical benefit of a treatment with the time the patient benefits from it, i.e., the time horizon. We wanted to know how consistently QALY gains are calculated at NICE. Therefore, we have analysed information on the time horizons used for the QALY calculations of the concluded evaluations conducted under the Highly Specialised Technologies programme for treatments of very rare diseases at NICE. For treatments with final guidance published by December 2023 (n = 29), a time horizon of median 97.5 years (range: 35 to 125 years) was used to calculate the QALY gains. For most QALY calculations, the accepted time horizon was longer than either the expected treatment duration or the estimated life expectancy. In contrast, for the only technology with a final negative funding decision, i.e., afamelanotide for treating the lifelong chronic disease erythropoietic protoporphyria, a time horizon that was shorter than the expected treatment duration was used. The fairness and consistency of the evaluation process of treatments for very rare diseases at NICE should be reviewed.
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Affiliation(s)
- Jasmin Barman-Aksözen
- International Porphyria Patient Network (IPPN), Hegarstrasse 3, 8032 Zurich, Switzerland
| | - Nicole Hentschel
- Independent Researcher, Hegarstrasse 3, 8032 Zurich, Switzerland
| | - Mårten Pettersson
- International Porphyria Patient Network (IPPN), Hegarstrasse 3, 8032 Zurich, Switzerland
| | - Eva Schupp
- International Porphyria Patient Network (IPPN), Hegarstrasse 3, 8032 Zurich, Switzerland
| | - Francesca Granata
- International Porphyria Patient Network (IPPN), Hegarstrasse 3, 8032 Zurich, Switzerland
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, S.C Medicina ad Indirizzo Metabolico, 20122 Milano, Italy
| | - Cornelia Dechant
- International Porphyria Patient Network (IPPN), Hegarstrasse 3, 8032 Zurich, Switzerland
| | - Mehmet Hakan Aksözen
- International Porphyria Patient Network (IPPN), Hegarstrasse 3, 8032 Zurich, Switzerland
| | - Rocco Falchetto
- International Porphyria Patient Network (IPPN), Hegarstrasse 3, 8032 Zurich, Switzerland
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Kieslich K, Coultas C, Littlejohns P. How reforms hamper priority-setting in health care: an interview study with local decision-makers in London. HEALTH ECONOMICS, POLICY, AND LAW 2024; 19:253-268. [PMID: 37705170 DOI: 10.1017/s174413312300021x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
The fair allocation of scarce resources for health remains a salient topic in health care systems. Approaches for setting priorities in an equitable manner include technical ones based on health economic analyses, and ethical ones based on procedural justice. Knowledge on real-world factors that influence prioritisation at a local level, however, remains sparse. This article contributes to the empirical literature on priority-setting at the meso level by exploring how health care planners make decisions on which services to fund and to prioritise, and to what extent they consider principles of fair priority-setting. It presents the findings of an interview study with commissioners and stakeholders in South London between 2017 and 2018. Interviewees considered principles of fair prioritisation such as transparency and accountability important for offering guidance. However, the data show that in practice the adherence to principles is hampered by the difficulty of conceptualising and operationalising principles on the one hand, and the political realities in relation to reform processes on the other. To address this challenge, we apply insights from the policy and political sciences and propose a set of considerations by which current frameworks of priority-setting might be adapted to better incorporate issues of context and politics.
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Affiliation(s)
- Katharina Kieslich
- Department of Political Science, Centre for the Study of Contemporary Solidarity, University of Vienna, 1010 Vienna, Austria
| | - Clare Coultas
- School of Education, Communication and Society, King's College London, London SE1 9NS, UK
| | - Peter Littlejohns
- Centre for Implementation Science, Institute of Psychiatry, Psychology and Neurosciences, King's College London, London SE5 8AB, UK
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Charlton V, DiStefano M, Mitchell P, Morrell L, Rand L, Badano G, Baker R, Calnan M, Chalkidou K, Culyer A, Howdon D, Hughes D, Lomas J, Max C, McCabe C, O'Mahony JF, Paulden M, Pemberton-Whiteley Z, Rid A, Scuffham P, Sculpher M, Shah K, Weale A, Wester G. We need to talk about values: a proposed framework for the articulation of normative reasoning in health technology assessment. HEALTH ECONOMICS, POLICY, AND LAW 2024; 19:153-173. [PMID: 37752732 DOI: 10.1017/s1744133123000038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
It is acknowledged that health technology assessment (HTA) is an inherently value-based activity that makes use of normative reasoning alongside empirical evidence. But the language used to conceptualise and articulate HTA's normative aspects is demonstrably unnuanced, imprecise, and inconsistently employed, undermining transparency and preventing proper scrutiny of the rationales on which decisions are based. This paper - developed through a cross-disciplinary collaboration of 24 researchers with expertise in healthcare priority-setting - seeks to address this problem by offering a clear definition of key terms and distinguishing between the types of normative commitment invoked during HTA, thus providing a novel conceptual framework for the articulation of reasoning. Through application to a hypothetical case, it is illustrated how this framework can operate as a practical tool through which HTA practitioners and policymakers can enhance the transparency and coherence of their decision-making, while enabling others to hold them more easily to account. The framework is offered as a starting point for further discussion amongst those with a desire to enhance the legitimacy and fairness of HTA by facilitating practical public reasoning, in which decisions are made on behalf of the public, in public view, through a chain of reasoning that withstands ethical scrutiny.
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Affiliation(s)
- Victoria Charlton
- Department of Global Health and Social Medicine, King's College London, London, UK
| | - Michael DiStefano
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD, USA
| | - Polly Mitchell
- School of Education, Communication and Society, King's College London, London, UK
| | - Liz Morrell
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Leah Rand
- Program on Regulation, Therapeutics and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Center for Bioethics, Harvard Medical School, Boston, MA, USA
| | | | - Rachel Baker
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, Scotland, UK
| | - Michael Calnan
- School of Social Policy, Sociology and Social Research, University of Kent, Canterbury, UK
| | | | - Anthony Culyer
- Centre for Health Economics, University of York, York, UK
| | - Daniel Howdon
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Dyfrig Hughes
- Centre for Health Economics and Medicines Evaluation, School of Medical and Health Sciences, Bangor University, Bangor, UK
| | - James Lomas
- Centre for Health Economics, University of York, York, UK
| | | | - Christopher McCabe
- Centre for Public Health and Queens Management School, Queens University Belfast, Belfast, UK
| | - James F O'Mahony
- Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland
| | - Mike Paulden
- School of Public Health, University of Alberta, Edmonton, Canada
| | | | - Annette Rid
- Department of Bioethics, The Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Paul Scuffham
- Centre for Applied Health Economics, Menzies Health Institute Queensland, Griffith University, Gold Coast, Australia
| | - Mark Sculpher
- Centre for Health Economics, University of York, York, UK
| | - Koonal Shah
- Science Policy and Research Programme, National Institute for Health and Care Excellence, London, UK
| | - Albert Weale
- School of Public Policy, University College London, London, UK
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Razvi Y, Horwitz SL, Cressman C, Wang DE, Shaul RZ, Denburg A. Priority-setting for hospital funding of high-cost innovative drugs and therapeutics: A qualitative institutional case study. PLoS One 2024; 19:e0300519. [PMID: 38498497 PMCID: PMC10947676 DOI: 10.1371/journal.pone.0300519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 02/28/2024] [Indexed: 03/20/2024] Open
Abstract
OBJECTIVES Rising costs of innovative drugs and therapeutics (D&Ts) have led to resource allocation challenges for healthcare institutions. There is limited evidence to guide priority-setting for institutional funding of high-cost D&Ts. This study sought to identify and elaborate on the substantive principles and procedures that should inform institutional funding decisions for high-cost off-formulary D&Ts through a case study of a quaternary care paediatric hospital. METHODS Semi-structured, qualitative interviews, both virtual and in-person, were conducted with institutional stakeholders (i.e. staff clinicians, senior leadership, and pharmacists) (n = 23) and two focus groups at The Hospital for Sick Children in Toronto, Canada. Participants involved in, and impacted by, high-cost off-formulary drug funding decisions were recruited through stratified, purposive sampling. Participants were approached for study involvement between July 27, 2020 and June 7, 2022. Data was analysed through reflexive thematic analysis. RESULTS Institutional resource allocation for high-cost D&Ts was identified as ethically challenging but critical to sustainable access to novel therapies. Important substantive principles included: 1) clinical evidence of safety and efficacy, 2) economic considerations (direct costs, opportunity costs, value for money), 3) ethical principles (social justice, professional/organizational responsibility), and 4) disease-specific considerations. Multidisciplinary deliberation was identified as an essential procedural component of decision-making. Participants identified tension between innovation and the need for evidence-based decision-making; clinician and institutional responsibilities; and value for money and social justice. Participants emphasized the role of health system-level funding allocation in alleviating the financial and moral burden of decision-making by institutions. CONCLUSIONS This study identifies values and processes to aid in the development and implementation of institutional resource allocation frameworks for high-cost innovative D&Ts.
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Affiliation(s)
- Yasmeen Razvi
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- SickKids Research Institute, Child Health Evaluative Sciences, Toronto, ON, Canada
| | - Simonne L. Horwitz
- Department of Paediatrics, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Celine Cressman
- SickKids Research Institute, Child Health Evaluative Sciences, Toronto, ON, Canada
| | - Daniel E. Wang
- Department of Paediatrics, University of Toronto, The Hospital for Sick Children, Toronto, ON, Canada
| | - Randi Zlotnik Shaul
- SickKids Research Institute, Child Health Evaluative Sciences, Toronto, ON, Canada
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
- Department of Bioethics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Avram Denburg
- SickKids Research Institute, Child Health Evaluative Sciences, Toronto, ON, Canada
- Department of Paediatrics, Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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8
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Charlton V, DiStefano M. An empirical ethics study of the coherence of NICE technology appraisal policy and its implications for moral justification. BMC Med Ethics 2024; 25:28. [PMID: 38448909 PMCID: PMC10918908 DOI: 10.1186/s12910-024-01016-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 02/12/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND As the UK's main healthcare priority-setter, the National Institute for Health and Care Excellence (NICE) has good reason to want to demonstrate that its decisions are morally justified. In doing so, it has tended to rely on the moral plausibility of its principle of cost-effectiveness and the assertion that it has adopted a fair procedure. But neither approach provides wholly satisfactory grounds for morally defending NICE's decisions. In this study we adopt a complementary approach, based on the proposition that a priority-setter's claim to moral justification can be assessed, in part, based on the coherence of its approach and that the reliability of any such claim is undermined by the presence of dissonance within its moral system. This study is the first to empirically assess the coherence of NICE's formal approach and in doing so to generate evidence-based conclusions about the extent to which this approach is morally justified. METHODS The study is grounded in the theory, methods and standards of empirical bioethics. Twenty NICE policy documents were coded to identify and classify the normative commitments contained within NICE technology appraisal policy as of 31 December 2021. Coherence was systematically assessed by attempting to bring these commitments into narrow reflective equilibrium (NRE) and by identifying sources of dissonance. FINDINGS Much of NICE policy rests on coherent values that provide a strong foundation for morally justified decision-making. However, NICE's formal approach also contains several instances of dissonance which undermine coherence and prevent NRE from being fully established. Dissonance arises primarily from four sources: i) NICE's specification of the principle of cost-effectiveness; ii) its approach to prioritising the needs of particular groups; iii) its conception of reasonableness in the context of uncertainty, and iv) its concern for innovation as an independent value. CONCLUSION At the time of analysis, the level of coherence across NICE policy provides reason to question the extent to which its formal approach to technology appraisal is morally justified. Some thoughts are offered on why, given these findings, NICE has been able to maintain its legitimacy as a healthcare priority-setter and on what could be done to enhance coherence.
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Affiliation(s)
- Victoria Charlton
- Department of Global Health and Social Medicine, King's College London, London, UK.
| | - Michael DiStefano
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora, USA
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Osipenko L, Ul-Hasan SA, Winberg D, Prudyus K, Kousta M, Rizoglou A, Rustignoli I, van der Maas L. Assessment of quality of data submitted for NICE technology appraisals over two decades. BMJ Open 2024; 14:e074341. [PMID: 38351112 PMCID: PMC10870012 DOI: 10.1136/bmjopen-2023-074341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 11/17/2023] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND The National Institute for Health and Care Excellence (NICE) pioneered the Health Technology Assessment (HTA) processes and methodologies. Technology appraisals (TAs) focus on pharmaceutical products and clinical and economic data, which are presented by the product manufacturers to the NICE appraisal committee for decision-making. Uncertainty in data reduces the chance of a positive outcome from the HTA process or requires a higher discount. OBJECTIVE To investigate the quality of clinical data (comparator, quality of life (QoL), randomised controlled trials (RCTs) and overall quality of evidence) submitted by the manufacturers to NICE. DESIGN This retrospective evaluation analysed active TAs published between 2000 and 2019 (up to TA600). METHODS For all TAs, we extracted data from the Assessment Group and Evidence Review Group reports and Final Appraisal Determinations on (1) the quality of submitted RCTs and (2) the overall quality of evidence submitted for decision-making. For single TAs, we also extracted data and its critique on QoL and comparators. Each category was scored for quality and analysed using descriptive statistics. RESULTS 409 TAs were analysed (multiple technology appraisals (MTA)=104, single technology appraisal (STA)=305). In two-thirds of TAs, the overall quality of evidence was either poor (n=224, 55%) or unacceptable (n=41, 10%). In 39% (n=119) of the STAs, the quality of comparative evidence was considered poor, and in 17% (n=51) unacceptable. In 44% (n=135) of STAs, the quality of QoL data was considered poor, 15% (n=47) unacceptable, 33% (n=102) acceptable and 7% (n=21) as good. Over 20 years of longitudinal analysis did not show improvements in the quality of evidence submitted to NICE. CONCLUSION We found that the primary components of clinical evidence influencing NICE's decision-making framework were of poor quality. It is essential to continue to generate robust clinical data for premarket and postmarket introduction of medicines into clinical practice to ensure they deliver benefits to patients.
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Affiliation(s)
- Leeza Osipenko
- The London School of Economics and Political Science, London, UK
- Consilium Scientific, London, UK
| | - Saba Ajwat Ul-Hasan
- The London School of Economics and Political Science, London, UK
- Consilium Scientific, London, UK
| | - Debra Winberg
- Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, USA
| | - Kseniia Prudyus
- The London School of Economics and Political Science, London, UK
| | | | - Artemis Rizoglou
- The London School of Economics and Political Science, London, UK
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10
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Sellars M, Carter SM, Lancsar E, Howard K, Coast J. Making recommendations to subsidize new health technologies in Australia: A qualitative study of decision-makers' perspectives on committee processes. Health Policy 2024; 139:104963. [PMID: 38104371 DOI: 10.1016/j.healthpol.2023.104963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 10/26/2023] [Accepted: 12/08/2023] [Indexed: 12/19/2023]
Abstract
OBJECTIVES To explore experiences of, and perspectives on, health technology assessment (HTA) processes used to produce recommendations about subsidizing new medicines, and medical technologies in Australia, from the perspectives of those experienced in these processes. METHODS Semi-structured interviews with a diverse group of 18 informants currently or previously members of the Pharmaceutical Benefits Advisory Committee (PBAC) or the Medical Services Advisory Committee (MSAC). Participants were interviewed September 2021-February 2022. Transcripts were analyzed using reflexive thematic analysis. RESULTS 3 major themes were identified: contrasting technical and decision-making stages, resisting reductionist approaches, and navigating decision-making trade-offs. Participants discussed the complexities of the evaluative HTA process, especially when considering uncertainty in the evidence. As part of the current process, a deliberative decision-making stage was considered essential, allowing a flexible approach to decision making to consider factors beyond strength and quality of quantifiable data in the technical evaluation. Participants acknowledged these less-quantifiable factors were sometimes considered implicitly or were difficult to describe and this, paired with commercial in confidence requirements, presented challenges with respect to the desire to increase transparency. CONCLUSION (S) As HTA processes for new medicines and medical technologies in Australia continue to be reviewed, the balance between retaining flexibility during deliberation, confidentiality for sponsors and the public's desire for greater transparency may be a fruitful area for continuing research.
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Affiliation(s)
- Marcus Sellars
- Department of Health Economics Wellbeing and Society, National Centre for Epidemiology and Population Health, The Australian National University, Canberra, Australia.
| | - Stacy M Carter
- Australian Centre for Health Engagement, Evidence and Values (ACHEEV), School of Health and Society, Faculty of the Arts, Humanities and Social Sciences, University of Wollongong, Keiraville, New South Wales, 2522, Australia
| | - Emily Lancsar
- Department of Health Economics Wellbeing and Society, National Centre for Epidemiology and Population Health, The Australian National University, Canberra, Australia
| | - Kirsten Howard
- School of Public Health, Faculty of Medicine & Health, University of Sydney, Sydney, NSW, 2006, Australia; Menzies Centre for Health Policy and Economics, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, 2006, Australia
| | - Joanna Coast
- Health Economics Bristol, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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11
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Dale E, Peacocke EF, Movik E, Voorhoeve A, Ottersen T, Kurowski C, Evans DB, Norheim OF, Gopinathan U. Criteria for the procedural fairness of health financing decisions: a scoping review. Health Policy Plan 2023; 38:i13-i35. [PMID: 37963078 PMCID: PMC10645052 DOI: 10.1093/heapol/czad066] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 06/19/2023] [Accepted: 08/02/2023] [Indexed: 11/16/2023] Open
Abstract
Due to constraints on institutional capacity and financial resources, the road to universal health coverage (UHC) involves difficult policy choices. To assist with these choices, scholars and policy makers have done extensive work on criteria to assess the substantive fairness of health financing policies: their impact on the distribution of rights, duties, benefits and burdens on the path towards UHC. However, less attention has been paid to the procedural fairness of health financing decisions. The Accountability for Reasonableness Framework (A4R), which is widely applied to assess procedural fairness, has primarily been used in priority-setting for purchasing decisions, with revenue mobilization and pooling receiving limited attention. Furthermore, the sufficiency of the A4R framework's four criteria (publicity, relevance, revisions and appeals, and enforcement) has been questioned. Moreover, research in political theory and public administration (including deliberative democracy), public finance, environmental management, psychology, and health financing has examined the key features of procedural fairness, but these insights have not been synthesized into a comprehensive set of criteria for fair decision-making processes in health financing. A systematic study of how these criteria have been applied in decision-making situations related to health financing and in other areas is also lacking. This paper addresses these gaps through a scoping review. It argues that the literature across many disciplines can be synthesized into 10 core criteria with common philosophical foundations. These go beyond A4R and encompass equality, impartiality, consistency over time, reason-giving, transparency, accuracy of information, participation, inclusiveness, revisability and enforcement. These criteria can be used to evaluate and guide decision-making processes for financing UHC across different country income levels and health financing arrangements. The review also presents examples of how these criteria have been applied to decisions in health financing and other sectors.
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Affiliation(s)
- Elina Dale
- Norwegian Institute of Public Health, Sandakerveien 24C, Oslo 0473, Norway
| | | | - Espen Movik
- Norwegian Institute of Public Health, Sandakerveien 24C, Oslo 0473, Norway
| | - Alex Voorhoeve
- Philosophy, Logic and Scientific Method, London School of Economics and Political Science (LSE), Houghton Street, London WC2A 2AE, UK
| | - Trygve Ottersen
- Norwegian Institute of Public Health, Sandakerveien 24C, Oslo 0473, Norway
| | - Christoph Kurowski
- Health, Nutrition and Population, World Bank Group, 1818 H Street, NW, Washington, DC 20433, USA
| | - David B Evans
- Health, Nutrition and Population, World Bank Group, 1818 H Street, NW, Washington, DC 20433, USA
| | - Ole Frithjof Norheim
- Bergen Centre for Ethics and Priority Setting (BCEPS), University of Bergen, Årstadveien 21, Bergen 5018, Norway
| | - Unni Gopinathan
- Norwegian Institute of Public Health, Sandakerveien 24C, Oslo 0473, Norway
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12
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Tam W, Alajlani M, Abd-Alrazaq A. An Exploration of Wearable Device Features Used in UK Hospital Parkinson Disease Care: Scoping Review. J Med Internet Res 2023; 25:e42950. [PMID: 37594791 PMCID: PMC10474516 DOI: 10.2196/42950] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 03/13/2023] [Accepted: 04/14/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND The prevalence of Parkinson disease (PD) is becoming an increasing concern owing to the aging population in the United Kingdom. Wearable devices have the potential to improve the clinical care of patients with PD while reducing health care costs. Consequently, exploring the features of these wearable devices is important to identify the limitations and further areas of investigation of how wearable devices are currently used in clinical care in the United Kingdom. OBJECTIVE In this scoping review, we aimed to explore the features of wearable devices used for PD in hospitals in the United Kingdom. METHODS A scoping review of the current research was undertaken and reported according to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. The literature search was undertaken on June 6, 2022, and publications were obtained from MEDLINE or PubMed, Embase, and the Cochrane Library. Eligible publications were initially screened by their titles and abstracts. Publications that passed the initial screening underwent a full review. The study characteristics were extracted from the final publications, and the evidence was synthesized using a narrative approach. Any queries were reviewed by the first and second authors. RESULTS Of the 4543 publications identified, 39 (0.86%) publications underwent a full review, and 20 (0.44%) publications were included in the scoping review. Most studies (11/20, 55%) were conducted at the Newcastle upon Tyne Hospitals NHS Foundation Trust, with sample sizes ranging from 10 to 418. Most study participants were male individuals with a mean age ranging from 57.7 to 78.0 years. The AX3 was the most popular device brand used, and it was commercially manufactured by Axivity. Common wearable device types included body-worn sensors, inertial measurement units, and smartwatches that used accelerometers and gyroscopes to measure the clinical features of PD. Most wearable device primary measures involved the measured gait, bradykinesia, and dyskinesia. The most common wearable device placements were the lumbar region, head, and wrist. Furthermore, 65% (13/20) of the studies used artificial intelligence or machine learning to support PD data analysis. CONCLUSIONS This study demonstrated that wearable devices could help provide a more detailed analysis of PD symptoms during the assessment phase and personalize treatment. Using machine learning, wearable devices could differentiate PD from other neurodegenerative diseases. The identified evidence gaps include the lack of analysis of wearable device cybersecurity and data management. The lack of cost-effectiveness analysis and large-scale participation in studies resulted in uncertainty regarding the feasibility of the widespread use of wearable devices. The uncertainty around the identified research gaps was further exacerbated by the lack of medical regulation of wearable devices for PD, particularly in the United Kingdom where regulations were changing due to the political landscape.
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Affiliation(s)
- William Tam
- Insitute of Digital Healthcare, Warwick Manufacturing Group, University of Warwick, Coventry, United Kingdom
| | - Mohannad Alajlani
- Insitute of Digital Healthcare, Warwick Manufacturing Group, University of Warwick, Coventry, United Kingdom
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13
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Schaefer R, Hernández D, Bärnighausen T, Kolominsky-Rabas P, Schlander M. Health Technology Assessment-Informed Decision Making by the Federal Joint Committee/Institute for Quality and Efficiency in Health Care in Germany and the National Institute for Health and Care Excellence in England: The Role of Budget Impact. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:1032-1044. [PMID: 36921901 DOI: 10.1016/j.jval.2023.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 02/24/2023] [Accepted: 02/28/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVES This study aimed to test (official) evaluation criteria including the potential role of budget impact (BI) on health technology assessment (HTA) outcomes published by the Federal Joint Committee (Gemeinsamer Bundesausschuss [GBA]) and the Institute for Quality and Efficiency in Health Care (Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen [IQWiG]) in Germany as well as the National Institute for Health and Care Excellence (NICE) in England. METHODS Data were extracted from all publicly available GBA decisions and IQWiG assessments as well as NICE single technology appraisals between January 2011 and June 2018, and information with regard to evaluation criteria used by these agencies was collected. Data were analyzed using logistic regression to estimate the effect of the BI on the HTA outcomes while controlling for criteria used by GBA/IQWiG and NICE. RESULTS NICE recommendations are largely driven by the incremental cost-effectiveness ratio and, if applicable, by end-of-life criteria (P < .01). While IQWiG assessments are significantly affected by the availability of randomized controlled trials and patient-relevant endpoints (P < .01), GBA appraisals primarily focus on endpoints (P < .01). The BI correlated with NICE single technology appraisals (inverted-U relationship, P < .1) and IQWiG recommendations (increasing linear relationship, P < .05), but not with GBA decisions (P > .1). Nevertheless, given that IQWiG assessments seem to be more rigorous than GBA appraisals regarding the consideration of evidence-based evaluation criteria, decisions by GBA might be negatively associated with the BI. CONCLUSIONS Results reveal that GBA/IQWiG and NICE follow their official evaluation criteria consistently. After controlling for all significant variables, the BI seems to have an (independent) effect on HTA outcomes as well.
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Affiliation(s)
- Ramon Schaefer
- Division of Health Economics, German Cancer Research Center (DKFZ), Heidelberg, Germany; Mannheim Medical Faculty, Heidelberg University, Mannheim, Germany; Institute for Innovation & Valuation in Health Care (InnoVal(HC)), Wiesbaden, Germany.
| | - Diego Hernández
- Division of Health Economics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Till Bärnighausen
- Heidelberg Institute of Global Health (HIGH), Heidelberg University, Heidelberg, Germany; Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Peter Kolominsky-Rabas
- Interdisciplinary Center for Health Technology Assessment and Public Health (IZPH), University of Erlangen-Nürnberg, Erlangen, Germany
| | - Michael Schlander
- Division of Health Economics, German Cancer Research Center (DKFZ), Heidelberg, Germany; Mannheim Medical Faculty, Heidelberg University, Mannheim, Germany; Institute for Innovation & Valuation in Health Care (InnoVal(HC)), Wiesbaden, Germany; Alfred-Weber-Institute, Heidelberg University, Heidelberg, Germany
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14
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Kim S, Lee JY, Cho SH, Shin EJ, Kim M, Lee JH. An Industry Survey on Unmet Needs in South Korea's New Drug Listing System. Ther Innov Regul Sci 2023; 57:759-768. [PMID: 37183236 DOI: 10.1007/s43441-023-00531-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 04/28/2023] [Indexed: 05/16/2023]
Abstract
INTRODUCTION Since introducing the positive listing system in 2007, the South Korean government has undergone multiple changes in its drug listing system. As there is a lack of studies that evaluate the system from an industry perspective, this paper examined South Korea's new drug listing system from the suppliers' perspective. METHODS We surveyed members of the three main pharmaceutical industry associations online. The survey (a 5-point Likert scale) covered their satisfactory levels, demands, and updates on the current new drug listing system, especially pharmacoeconomic evaluation, pharmacoeconomic evaluation exemption, and risk-sharing agreement. RESULTS A total of 56 respondents participated in the survey. The self-reported satisfaction level for value recognition of new drugs was 1.6 (± 0.7) points (5 points = very satisfied). The most highly demanded reforms for PE, RSA, and PEE were incremental cost-effectiveness ratio threshold (92.9%), reimbursement scope expansion (91.1%), and eligible disease (83.9%). Lastly, they also claimed that the indication-based pricing system must be introduced (83.9%). CONCLUSIONS Pricing and reimbursement policies need to improve in such a way that would enable better access to new drugs while still facilitating their development. Given the nature of the current system, some innovative rare disease treatments and anticancer drugs remain unreimbursed, resulting in low satisfaction levels across the pharmaceutical industry. Hence, pathways to speed up the reimbursement assessment process and expand the range of reimbursable diseases are required. Pharmaceutical companies are also important stakeholders, like in the case of clinicians and patients, and their opinions should also be considered in the process of pricing and reimbursement policy reforms.
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Affiliation(s)
- Sungju Kim
- Healthcare Group, Lee & Ko, Seoul, 04532, Republic of Korea
| | - Ji Yeon Lee
- Healthcare Group, Lee & Ko, Seoul, 04532, Republic of Korea
| | - Seong Ha Cho
- College of Pharmacy, Chung-Ang University, Seoul, 06974, Republic of Korea
| | - Eileen J Shin
- Healthcare Group, Lee & Ko, Seoul, 04532, Republic of Korea
| | - Minyoung Kim
- College of Pharmacy, Chung-Ang University, Seoul, 06974, Republic of Korea
| | - Jong Hyuk Lee
- College of Pharmacy, Chung-Ang University, Seoul, 06974, Republic of Korea.
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15
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Charlton V. All health is not equal: the use of modifiers in NICE technology appraisal. BMJ Evid Based Med 2023:bmjebm-2022-112159. [PMID: 36707223 DOI: 10.1136/bmjebm-2022-112159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/02/2022] [Indexed: 01/28/2023]
Affiliation(s)
- Victoria Charlton
- Global Health and Social Medicine, King's College London, London, UK
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16
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Kang J, Cairns J. Exploring uncertainty and use of real-world data in the National Institute for Health and Care Excellence single technology appraisals of targeted cancer therapy. BMC Cancer 2022; 22:1268. [PMID: 36471259 PMCID: PMC9724266 DOI: 10.1186/s12885-022-10350-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 11/22/2022] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Dealing with uncertainty is one of the critical topics in health technology assessment. The greater decision uncertainty in appraisals, the less clear the clinical- and cost-effectiveness of the health technology. Although the development of targeted cancer therapies (TCTs) has improved patient health care, additional complexity has been introduced in drug appraisals due to targeting more specific populations. Real-world data (RWD) are expected to provide helpful information to fill the evidence gaps in appraisals. This study compared appraisals of TCTs with those of non-targeted cancer therapies (non-TCTs) regarding sources of uncertainty and reviewed how RWD have been used to supplement the information in these appraisals. METHODS This study reviews single technology appraisals (STAs) of oncology medicines performed by the National Institute for Health and Care Excellence (NICE) over 11 years up to December 2021. Three key sources of uncertainty were identified for comparison (generalisability of clinical trials, availability of direct treatment comparison, maturity of survival data in clinical trials). To measure the intensity of use of RWD in appraisals, three components were identified (overall survival, volume of treatment, and choice of comparators). RESULTS TCTs received more recommendations for provision through the Cancer Drugs Fund (27.7, 23.6% for non-TCT), whereas similar proportions were recommended for routine commissioning. With respect to sources of uncertainty, the external validity of clinical trials was greater in TCT appraisals (p = 0.026), whereas mature survival data were available in fewer TCT appraisals (p = 0.027). Both groups showed similar patterns of use of RWD. There was no clear evidence that RWD have been used more intensively in appraisals of TCT. CONCLUSIONS Some differences in uncertainty were found between TCT and non-TCT appraisals. The appraisal of TCT is generally challenging, but these challenges are neither new nor distinctive. The same sources of uncertainty were often found in the non-TCT appraisals. The uncertainty when appraising TCT stems from insufficient data rather than the characteristics of the drugs. Although RWD might be expected to play a more active role in appraisals of TCT, the use of RWD has generally been limited.
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Affiliation(s)
- Jiyeon Kang
- grid.8991.90000 0004 0425 469XDepartment of Health Service Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock place, London, WC1H 9SH UK ,grid.7914.b0000 0004 1936 7443Centre for Cancer Biomarkers (CCBIO), University of Bergen, Bergen, Norway
| | - John Cairns
- grid.8991.90000 0004 0425 469XDepartment of Health Service Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock place, London, WC1H 9SH UK ,grid.7914.b0000 0004 1936 7443Centre for Cancer Biomarkers (CCBIO), University of Bergen, Bergen, Norway
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17
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Affiliation(s)
- Victoria Charlton
- Department of Global Health and Social Medicine, King's College London, London, UK
| | - James Lomas
- Department of Economics and Related Studies, University of York, York, UK
| | - Polly Mitchell
- Centre for Public Policy Research, King's College London, London, UK
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18
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Charlton V. The normative grounds for NICE decision-making: a narrative cross-disciplinary review of empirical studies. HEALTH ECONOMICS, POLICY, AND LAW 2022; 17:444-470. [PMID: 35293306 DOI: 10.1017/s1744133122000032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
The National Institute for Health and Care Excellence (NICE) is the UK's primary health care priority-setter, responsible for advising the National Health Service on its adoption of health technologies. The normative basis for NICE's advice has long been the subject of public and academic interest, but the existing literature does not include any comprehensive summary of the factors observed to have substantively shaped NICE's recommendations. The current review addresses this gap by bringing together 29 studies that have explored NICE decision-making from different disciplinary perspectives, using a range of quantitative and qualitative methods. It finds that although cost-effectiveness has historically played a central role in NICE decision-making, 10 other factors (uncertainty, budget impact, clinical need, innovation, rarity, age, cause of disease, wider societal impacts, stakeholder influence and process factors) are also demonstrably influential and interact with one another in ways that are not well understood. The review also highlights an over-representation in the literature of appraisals conducted prior to 2009, according to methods that have since been superseded. It suggests that this may present a misleading view of the importance of allocative efficiency to NICE's current approach and illustrates the need for further up-to-date research into the normative grounds for NICE's decisions.
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Affiliation(s)
- Victoria Charlton
- Department of Global Health & Social Medicine, King's College London, London, UK
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19
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Sampson C, Zamora B, Watson S, Cairns J, Chalkidou K, Cubi-Molla P, Devlin N, García-Lorenzo B, Hughes DA, Leech AA, Towse A. Supply-Side Cost-Effectiveness Thresholds: Questions for Evidence-Based Policy. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2022; 20:651-667. [PMID: 35668345 PMCID: PMC9385803 DOI: 10.1007/s40258-022-00730-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/29/2022] [Indexed: 05/04/2023]
Abstract
There is growing interest in cost-effectiveness thresholds as a tool to inform resource allocation decisions in health care. Studies from several countries have sought to estimate health system opportunity costs, which supply-side cost-effectiveness thresholds are intended to represent. In this paper, we consider the role of empirical estimates of supply-side thresholds in policy-making. Recent studies estimate the cost per unit of health based on average displacement or outcome elasticity. We distinguish the types of point estimates reported in empirical work, including marginal productivity, average displacement, and outcome elasticity. Using this classification, we summarise the limitations of current approaches to threshold estimation in terms of theory, methods, and data. We highlight the questions that arise from alternative interpretations of thresholds and provide recommendations to policymakers seeking to use a supply-side threshold where the evidence base is emerging or incomplete. We recommend that: (1) policymakers must clearly define the scope of the application of a threshold, and the theoretical basis for empirical estimates should be consistent with that scope; (2) a process for the assessment of new evidence and for determining changes in the threshold to be applied in policy-making should be created; (3) decision-making processes should retain flexibility in the application of a threshold; and (4) policymakers should provide support for decision-makers relating to the use of thresholds and the implementation of decisions stemming from their application.
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Affiliation(s)
| | | | - Sam Watson
- University of Birmingham, Birmingham, UK
| | - John Cairns
- London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | - Borja García-Lorenzo
- Kronikgune Institute for Health Services Research, Basque Country, Spain
- Assessment of Innovations and New Technologies Unit, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Spain
| | - Dyfrig A Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
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20
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Bond K. Challenges and Opportunities for Deliberative Processes for Healthcare Decision-Making Comment on "Evidence-Informed Deliberative Processes for Health Benefit Package Design - Part II: A Practical Guide". Int J Health Policy Manag 2022; 12:7458. [PMID: 35988028 PMCID: PMC10125176 DOI: 10.34172/ijhpm.2022.7458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 07/31/2022] [Indexed: 11/09/2022] Open
Abstract
The second edition of the practical guide for evidence-informed deliberative processes (EDPs) is an important addition to the growing guidance on deliberative processes supporting priority setting in healthcare. While the practical guide draws on an extensive amount of information collected on established and developing processes within a range of countries, EDPs present health technology assessment (HTA) bodies with several challenges. (1) Basing recommendations on current processes that have not been well-evaluated and that have changed over time may lead to weaker legitimacy than desired. (2) The requirement for social learning among stakeholders may require increased resourcing and blur the boundary between moral deliberation and political negotiation. (3) Robust evaluation should be based on an explicit theory of change, and some process outcomes may be poor guides to overall improvement of EDPs. This comment clarifies and reinforces the recommendations provided in the practical guide.
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Affiliation(s)
- Kenneth Bond
- Institute of Health Economics, Edmonton, AB, Canada
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21
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Garattini L, Bozzetto M, Nobili A, Mannucci PM. Health technology assessment for pharmaceuticals in the European Union: what lessons after two decades? Intern Emerg Med 2022; 17:1251-1253. [PMID: 35674925 DOI: 10.1007/s11739-022-03008-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 05/16/2022] [Indexed: 11/05/2022]
Affiliation(s)
- L Garattini
- Department of Health Policy, Institute for Pharmacological Research Mario Negri IRCCS, Milan, Italy
| | - M Bozzetto
- Department of Health Policy, Institute for Pharmacological Research Mario Negri IRCCS, Milan, Italy
| | - A Nobili
- Department of Health Policy, Institute for Pharmacological Research Mario Negri IRCCS, Milan, Italy
| | - P M Mannucci
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
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22
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Cowie MR, Bozkurt B, Butler J, Briggs A, Kubin M, Jonas A, Adler AI, Patrick-Lake B, Zannad F. How can we optimise health technology assessment and reimbursement decisions to accelerate access to new cardiovascular medicines? Int J Cardiol 2022; 365:61-68. [PMID: 35905826 DOI: 10.1016/j.ijcard.2022.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 06/26/2022] [Accepted: 07/12/2022] [Indexed: 11/18/2022]
Abstract
Regulatory approvals of, and subsequent access to, innovative cardiovascular medications have declined. How much of this decline relates to the final step of gaining reimbursement for new treatments is unknown. Payers and health technology assessment (HTA) bodies look beyond efficacy and safety to assess whether a new drug improves patient outcomes, quality of life, or satisfaction at a cost that is affordable compared to existing treatments. HTA bodies work within a limited healthcare budget, and this is one of the reasons why only half of newly approved drugs are accepted for reimbursement, or receive restricted or "optimised" recommendations from HTA bodies. All stakeholders have the common goal of facilitating access to safe, effective, and affordable treatments to appropriate patients. An important strategy to expedite this is providing optimal data. This is demonstrably facilitated by early (and ongoing) discussions between all stakeholders. Many countries have formal programmes to provide collaborative regulatory and HTA advice to developers. Other strategies include aligning regulatory and HTA processes, increasing use of real-world evidence, formally defining the decision-making process, and educating stakeholders on the criteria for positive decision making. Industry should focus on developing treatments for unmet medical needs, seek early engagement with HTA and regulatory bodies, improve methodologies for optimal price setting, develop internal systems to collaborate with national and international stakeholders, and conduct post-approval studies. Patient involvement in all stages of development, including HTA, is critical to capture the lived experience and priorities of those whose lives will be impacted by new treatment approvals.
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Affiliation(s)
- Martin R Cowie
- Royal Brompton Hospital & School of Cardiovascular Medicine & Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK.
| | - Biykem Bozkurt
- Winters Center for Heart Failure, Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Andrew Briggs
- Department of Health Services Research & Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Maria Kubin
- Department of Integrated Evidence Generation, Bayer AG, Wuppertal, Germany
| | - Adrian Jonas
- National Institute for Health and Care Excellence (NICE), London, UK
| | - Amanda I Adler
- Diabetes Trial Unit, Oxford Centre for Diabetes, Endocrinology, and Metabolism (OCDEM), Oxford, UK
| | - Bray Patrick-Lake
- Department of Strategic Partnerships, Evidation Health, San Mateo, CA, USA
| | - Faiez Zannad
- Université de Lorraine, Inserm Clinical Investigation Center at Institut Lorrain du Coeur et des Vaisseaux, University Hospital of Nancy, Nancy, France
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23
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Hakimi Z, Wilson K, McAughey E, Pochopien M, Wojciechowski P, Toumi M, Knight C, Sarda SP, Patel N, Wiseman C, de Castro NP, Nazir J, Kelly RJ. The cost-effectiveness, of pegcetacoplan compared with ravulizumab for the treatment of paroxysmal nocturnal hemoglobinuria, in a UK setting. J Comp Eff Res 2022; 11:969-985. [PMID: 35796199 DOI: 10.2217/cer-2022-0076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: Paroxysmal nocturnal hemoglobinuria (PNH) is a rare blood disorder characterized by hemolytic anemia, bone marrow failure and thrombosis. We evaluated, the cost-effectiveness of pegcetacoplan, a novel proximal C3 inhibitor, versus ravulizumab in patients with PNH and hemoglobin levels <10.5 g/dl despite eculizumab treatment in the UK healthcare and social services setting. Materials & methods: A Markov cohort framework model, based on the data from the pivotal trial of pegcetacoplan (PEGASUS/NCT03500549), evaluated lifetime costs and outcomes. Patients transitioned through 3 PNH hemoglobin level/red blood cell transfusion health states. Results: Pegcetacoplan provides lower lifetime costs/greater quality-adjusted life years (£6,409,166/14.694QALYs, respectively) versus ravulizumab (£6,660,676/12.942QALYs). Conclusion: Pegcetacoplan is associated with enhanced anemia control, greater QALYs and reduced healthcare costs versus ravulizumab in the UK healthcare and social services setting.
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Affiliation(s)
- Zalmai Hakimi
- Swedish Orphan Biovitrum AB, Stockholm, SE-112 76, Sweden
| | - Koo Wilson
- Swedish Orphan Biovitrum AB, Stockholm, SE-112 76, Sweden
| | | | | | | | | | | | | | | | | | | | - Jameel Nazir
- Swedish Orphan Biovitrum AB, Stockholm, SE-112 76, Sweden
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24
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Main B, Csanadi M, Ozieranski P. Pricing strategies, executive committee power and negotiation leverage in New Zealand's containment of public spending on pharmaceuticals. HEALTH ECONOMICS, POLICY, AND LAW 2022; 17:348-365. [PMID: 35382921 DOI: 10.1017/s1744133122000068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
This paper explores policy mechanisms behind New Zealand's remarkable track record of cost containment in public pharmaceutical spending, contrasting with most other advanced economies. We drew on a review of official policy documents and 28 semi-structured expert interviews. We found that decision making in pricing and reimbursement policy was dominated by a small group of managers at the Pharmaceutical Management Agency (PHARMAC), the country's drug reimbursement and Health Technology Assessment Agency, who negotiated pharmaceutical prices on behalf of the public payer. In formal negotiation over patented pharmaceutical prices these managers applied an array of pricing strategies, most notably, 'bundling' consisting of discounted package deals for multiple pharmaceuticals, and 'play-off tenders', whereby two or more pharmaceutical companies bid for exclusive contracts. The key pricing strategy for generic drugs, in contrast, was 'blind-tenders' taking the form of an annual bidding process for supply contracts. An additional contextual condition on bargaining over pharmaceutical prices was an indirect strategy that involved the cultivation of the PHARMAC's 'negotiation leverage'. We derived two cost containment mechanisms consisting in the relationship between pricing strategy options and various reimbursement actors. Our findings shed light on aspects of the institutional design of drug reimbursement that may promote the effective use of competitive negotiations of pharmaceutical prices, including specific pricing strategies, by specialist public payer institutions. On this basis, we formulate recommendations for countries seeking to develop or reform policy frameworks to better meet the budgetary challenge posed by pharmaceutical expenditure.
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Affiliation(s)
- Ben Main
- Department of Sociology, University of Durham, Durham, UK
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25
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McPherson SJ, Speed E. NICE rapid guidelines: exploring political influence on guidelines. BMJ Evid Based Med 2022; 27:137-140. [PMID: 33849986 DOI: 10.1136/bmjebm-2020-111635] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/03/2021] [Indexed: 11/04/2022]
Abstract
The National Institute for Health and Care Excellence (NICE) has been presented as politically independent, asserting it is free from industry influence and conflicts of interest so that its decisions may be led by evidence and science. We consider the ways in which soft political factors operate in guideline development processes at NICE such that guidelines are not truly led by science. We suggest that while NICE procedures explicitly incorporate scientific principles and mechanisms, including independent committees and quality assurance, these fail to operate as scientific practices because, for example, decisions may only be challenged through the courts, which regard NICE as a scientific authority. We then examine what the NICE rapid guideline procedure for COVID-19 reveals about the practical reality of claims about the scientific integrity of NICE guidelines. Changes to guideline development processes during the COVID-19 emergency demonstrated how easy it is to undermine the scientific integrity of NICE's decision-making. The cancellation of the guideline programme and the publication of a rapid guideline process specifically to address the COVID-19 pandemic removed scientific checks and balances, including independent committees, stakeholder consultation and quality assurance, demonstrating that the relationship between NICE and the UK government is more complex than a scientific principle truism. We suggest that NICE is not (and indeed cannot be) truly independent of government in practice, nor can it be truly led by science, in part because of its relationship to the state, which it is simultaneously constituted by and constitutive of.
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Affiliation(s)
- S J McPherson
- School of Health and Social Care, University of Essex, Colchester, UK
| | - Ewen Speed
- School of Health and Social Care, University of Essex, Colchester, UK
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Charlton V. Justice, Transparency and the Guiding Principles of the UK's National Institute for Health and Care Excellence. HEALTH CARE ANALYSIS 2022; 30:115-145. [PMID: 34750743 PMCID: PMC8575159 DOI: 10.1007/s10728-021-00444-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2021] [Indexed: 11/29/2022]
Abstract
The National Institute for Health and Care Excellence (NICE) is the UK's primary healthcare priority-setting body, responsible for advising the National Health Service in England on which technologies to fund and which to reject. Until recently, the normative approach underlying this advice was described in a 2008 document entitled 'Social value judgements: Principles for the development of NICE guidance' (SVJ). In January 2020, however, NICE replaced SVJ with a new articulation of its guiding principles. Given the significant evolution of NICE's methods between 2008 and 2020, this study examines whether this new document ('Principles') offers a transparent account of NICE's current normative approach. It finds that it does not, deriving much of its content directly from SVJ and failing to fully acknowledge or explain how and why NICE's approach has since changed. In particular, Principles is found to offer a largely procedural account of NICE decision-making, despite evidence of the increasing reliance of NICE's methods on substantive decision-rules and 'modifiers' that cannot be justified in purely procedural terms. Thus, while Principles tells NICE's stakeholders much about how the organisation goes about the process of decision-making, it tells them little about the substantive grounds on which its decisions are now based. It is therefore argued that Principles does not offer a transparent account of NICE's normative approach (either alone, or alongside other documents) and that, given NICE's reliance on transparency as a requirement of procedural justice, NICE does not in this respect satisfy its own specification of a just decision-maker.
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Affiliation(s)
- Victoria Charlton
- Department of Global Health and Social Medicine, King's College London, 40 Aldwych, London, WC2B 4BG, United Kingdom.
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27
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DiStefano MJ, Abdool Karim S, Krubiner CB. Integrating health technology assessment and the right to health: a qualitative content analysis of procedural values in South African judicial decisions. Health Policy Plan 2022; 37:644-654. [PMID: 34792599 PMCID: PMC9113169 DOI: 10.1093/heapol/czab132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/08/2021] [Accepted: 11/11/2021] [Indexed: 11/28/2022] Open
Abstract
South Africa's move towards implementing National Health Insurance includes a commitment to establish a health technology assessment (HTA) body to inform health priority-setting decisions. This study sought to analyse health rights cases in South Africa to inform the identification of country-specific procedural values related to health priority-setting and their implementation in a South African HTA body. The focus on health rights cases is motivated in part by the fact that case law can be an important source of insight into the values of a particular country. This focus is further motivated by a desire to mitigate the potential tension between a rights-based approach to healthcare access and national efforts to set health priorities. A qualitative content analysis of eight South African court cases related to the right to health was conducted. Cases were identified through a LexisNexis search and supplemented with expert judgement. Procedural values identified from the health priority-setting literature, including those comprising Accountability for Reasonableness (A4R), structured the thematic analysis. The importance of transparency and revision-two elements of A4R-is evident in our findings, suggesting that the courts can help to enforce elements of A4R. Yet our findings also indicate that A4R is likely to be insufficient for ensuring that HTA in South Africa meets the procedural demands of a constitutional rights-based approach to healthcare access. Accordingly, we also suggest that a South African HTA body ought to consider more demanding considerations related to transparency and revisions as well as explicit considerations related to inclusivity.
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Affiliation(s)
- Michael J DiStefano
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA
- Berman Institute of Bioethics, 1809 Ashland Avenue, Baltimore, MD 21205, USA
| | - Safura Abdool Karim
- SAMRC/WITS Centre for Health Economics and Decision Science (PRICELESS SA), Office 233, 2nd floor, Wits Education Campus, 27 St Andrews Road, Parktown, Johannesburg 2193, South Africa
| | - Carleigh B Krubiner
- Berman Institute of Bioethics, 1809 Ashland Avenue, Baltimore, MD 21205, USA
- Center for Global Development, 2055 L St., Washington, DC 20036, USA
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28
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Vicente G, Calnan M, Rech N, Leite S. Pharmaceutical policies for gaining access to high-priced medicines: a comparative analysis between England and Brazil. SAÚDE EM DEBATE 2022. [DOI: 10.1590/0103-1104202213422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
ABSTRACT Although the National Health Service (NHS) and the Unified Health System (SUS) are systems with similar universal principles, they can show different political measure patterns in the pharmaceutical field. This paper aimed to provide a comparative analysis of pharmaceutical policies highlighting strategies to guarantee access and sustainability to High-Price Medicines (HPMs) in Brazil and England. We performed an integrative literature review in electronic databases, supplemented by grey literature searched on governmental platforms (laws, decrees, ordinances, and resolutions). A total of Forty-seven articles and seven policies were selected and categorized for analysis. The results showed that both countries apply distinct policies to ensure access to HPMs, among them, policies to define price and reimbursement and actions to regulate the use inside the system. Also, these countries apply distinct policies to their sustainability as local partnerships for product development in Brazil and confidential managed agreements with multinational industries in the England. In conclusion, despite similarities in principles, these countries have been proposing and applying distinct pharmaceutical policies to maintain access and ensure the sustainability of their health systems.
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29
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John S. Science, politics and regulation: The trust-based approach to the demarcation problem. STUDIES IN HISTORY AND PHILOSOPHY OF SCIENCE 2021; 90:1-9. [PMID: 34500262 DOI: 10.1016/j.shpsa.2021.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 08/06/2021] [Accepted: 08/13/2021] [Indexed: 06/13/2023]
Abstract
Drawing on literature on values in science and a case-study of UK cancer policy, this paper argues for a novel account of the demarcation project in terms of trustworthiness. The first part of the paper addresses the relationship between science, politics and demarcation. In 2010, the UK government decided to pay more for cancer drugs than for drugs for other diseases; in 2016, this Cancer Drugs Fund was reformed so as to lower the evidential standards for approving cancer drugs, rather than paying more for them. Are these two ways of treating cancer as "special" importantly different? This paper argues that, if we the argument from inductive risk seriously, they seem equivalent. This result provides further reason to doubt the notion of demarcating science from non-science. However, the second part of the paper complicates this story, arguing that considerations of epistemic trust might give us reasons to prefer epistemic communities centred around "broadly acceptable" standards, and which are "sociologically well-ordered", regardless of inductive risk concerns. After developing these claims through the cancer case-study, the final section suggests how these concerns might motivate novel versions of the demarcation project.
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Affiliation(s)
- Stephen John
- Department of History and Philosophy of Science, University of Cambridge, Cambridge, CB2 3RH, UK.
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30
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Schaefer R, Hernandez D, Selberg L, Schlander M. Health technology assessment (HTA) in England, France and Germany: what do matched drug pairs tell us about recommendations by national HTA agencies? J Comp Eff Res 2021; 10:1187-1195. [PMID: 34583534 DOI: 10.2217/cer-2021-0047] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aims: To explore health technology assessment (HTA) outcomes of matched drug pairs by national agencies in Germany (Gemeinsamer Bundesausschuss, GBA), France (Haute Autorité de Santé, HAS) and England and Wales (NICE). Methods: We considered published GBA decisions, HAS reports and NICE guidance from January 2011 to June 2018. HTAs of matched pairs were compared overall, and for non-cancer and cancer drugs separately. We further analyzed the role of additional attributes related to cancer therapies. Results: Matched pairs show higher concordance for GBA/HAS than for GBA/NICE and HAS/NICE. Overall, NICE evaluated technologies more favorably than GBA and HAS. GBA appraisals of cancer drugs, however, tended to be more positive than cancer-related recommendations by NICE and HAS. Conclusion: The findings indicate substantial variations in HTAs, although cancer-related outcomes seem to diverge less than non-cancer results.
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Affiliation(s)
- Ramon Schaefer
- Division of Health Economics, German Cancer Research Center (Deutsches Krebsforschungszentrum, DKFZ), Heidelberg, Germany.,Mannheim Medical Faculty, University of Heidelberg, Mannheim, Germany.,Institute for Innovation & Valuation in Health Care (InnoValHC), Wiesbaden, Germany
| | - Diego Hernandez
- Division of Health Economics, German Cancer Research Center (Deutsches Krebsforschungszentrum, DKFZ), Heidelberg, Germany
| | - Lorenz Selberg
- Division of Health Economics, German Cancer Research Center (Deutsches Krebsforschungszentrum, DKFZ), Heidelberg, Germany
| | - Michael Schlander
- Division of Health Economics, German Cancer Research Center (Deutsches Krebsforschungszentrum, DKFZ), Heidelberg, Germany.,Mannheim Medical Faculty, University of Heidelberg, Mannheim, Germany.,Institute for Innovation & Valuation in Health Care (InnoVal), Wiesbaden, Germany.,Alfred Weber Institute (AWI), University of Heidelberg, Heidelberg, Germany
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Keltie K, Cognigni P, Gross S, Urwin S, Burn J, Cole H, Berry L, Patrick H, Sims A. Comparison of identifiable and non-identifiable data linkage: health technology assessment of MitraClip using registry, administrative and mortality datasets. BMJ Health Care Inform 2021; 28:bmjhci-2020-100223. [PMID: 33820808 PMCID: PMC8030467 DOI: 10.1136/bmjhci-2020-100223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 01/21/2021] [Accepted: 03/08/2021] [Indexed: 12/28/2022] Open
Abstract
Objectives The UK MitraClip registry was commissioned by National Health Service (NHS) England to assess real-world outcomes from percutaneous mitral valve repair for mitral regurgitation using a new technology, MitraClip. This study aimed to determine longitudinal patient outcomes by linking to routine datasets: Hospital Episode Statistics (HES) Admitted Patient Care (APC) and Office of National Statistics. Methods Two methods of linkage were compared, using identifiable (NHS number, date of birth, postcode, gender) and non-identifiable data (hospital trust, age in years, admission, discharge and operation dates, operation and diagnosis codes). Outcome measures included: matching success, patient demographics, all-cause mortality and subsequent cardiac intervention. Results A total of 197 registry patients were eligible for matching with routine administrative data. Using identifiable linkage, a total of 187 patients (94.9%) were matched with the HES APC dataset. However, 21 matched individuals (11.2%) had inconsistencies across the datasets (eg, different gender) and were subsequently removed, leaving 166 (84.3%) for analysis. Using non-identifiable data linkage, a total of 170 patients (86.3%) were uniquely matched with the HES APC dataset. Baseline patient characteristics were not significantly different between the two methods of data linkage. The total number of deaths (all causes) identified from identifiable and non-identifiable linkage methods was 37 and 40, respectively, and the difference in subsequent cardiac interventions identified between the two methods was negligible. Conclusions Patients from a bespoke clinical procedural registry were matched to routine administrative data using identifiable and non-identifiable methods with equivalent matching success rates, similar baseline characteristics and similar 2-year outcomes.
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Affiliation(s)
- Kim Keltie
- Northern Medical Physics and Clinical Engineering, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, Tyne and Wear, UK.,Translational and Clinical Research Institute, University of Newcastle upon Tyne, Newcastle upon Tyne, UK
| | - Paola Cognigni
- Northern Medical Physics and Clinical Engineering, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, Tyne and Wear, UK
| | - Sam Gross
- Data Management Services, NHS Digital, Leeds, Leeds, UK
| | - Samuel Urwin
- Translational and Clinical Research Institute, University of Newcastle upon Tyne, Newcastle upon Tyne, UK
| | - Julie Burn
- Northern Medical Physics and Clinical Engineering, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, Tyne and Wear, UK
| | - Helen Cole
- The Northern Health Science Alliance, Manchester, UK
| | - Lee Berry
- Observational Data Unit, National Institute for Health and Care Excellence, London, London, UK
| | - Hannah Patrick
- Observational Data Unit, National Institute for Health and Care Excellence, London, London, UK
| | - Andrew Sims
- Northern Medical Physics and Clinical Engineering, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, Tyne and Wear, UK .,Translational and Clinical Research Institute, University of Newcastle upon Tyne, Newcastle upon Tyne, UK
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32
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Exorcising the positivist ghost in the priority-setting machine: NICE and the demise of the 'social value judgement'. HEALTH ECONOMICS POLICY AND LAW 2021; 16:505-511. [PMID: 33568251 DOI: 10.1017/s1744133121000049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The National Institute for Health and Care Excellence (NICE), the UK's primary health care priority-setting body, has traditionally described its decisions as being informed by 'social value judgements' about how resources should be allocated across society. This paper traces the intellectual history of this term and suggests that, in NICE's adoption of the idea of the 'social value judgement', we are hearing the echoes of welfare economics at a particular stage of its development, when logical positivism provided the basis for thinking about public policy choice. As such, it is argued that the term offers an overly simplistic conceptualisation of NICE's normative approach and contributes to a situation in which NICE finds itself without the necessary language fully and accurately to articulate its basis for decision-making. It is suggested that the notion of practical public reasoning, based on reflection about coherent principles of action, might provide a better characterisation of the enterprise in which NICE is, or hopes to be, engaged.
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33
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Lawlor R, Wilsdon T, Darquennes E, Hemelsoet D, Huismans J, Normand R, Roediger A. Accelerating patient access to oncology medicines with multiple indications in Europe. JOURNAL OF MARKET ACCESS & HEALTH POLICY 2021; 9:1964791. [PMID: 34436506 PMCID: PMC8381976 DOI: 10.1080/20016689.2021.1964791] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Background: In recent years, innovation in oncology has created new challenges for pricing and reimbursement systems. Oncology medicines with multiple indications face a number of access challenges: (1) the number of assessments and administrative burden; (2) aligning price to different values of the same product; (3) managing clinical uncertainty at time of launch; and (4) managing budget uncertainty. These challenges impact a range of stakeholders and can result in delayed patient access to life-saving treatments. Consequently, countries have taken steps to facilitate patient access. Methods: Drawing on the experience across Europe we have reviewed different mechanisms countries have adopted that address these challenges. These include approaches aimed directly at the issue, multi-year-multi-indication (MYMI) agreements (BE, NL), and other approaches to manage access: flexible access agreements for new indications with clinical uncertainty (UK); development of a new agreement for each new indication (IT); and immediate access for new indications and bundled assessments (DE). Results: MYMI agreements are valuable where existing rules mean that every indication faces the same upfront evaluation process that delays patient access. They are also useful in managing budget impact and uncertainty. Other approaches that adopt an indication-specific approach helps manage clinical uncertainty at the time of launch and realise different values for the same product. They can help align price to value, even though indication-based pricing does not exist. Bundled assessments reduce the administrative burden for stakeholders, and the benefits of immediate reimbursement is that patient access is not delayed. Conclusion: The challenges for medicines with multiple indications impact a range of stakeholders and can result in delayed patient access to life-saving treatments. MYMI agreements have created a more pragmatic approach to HTA for medicines with multiple indications to ensure both fast and broad patient access. Continued innovation in oncology will require further innovative approaches in pricing and reimbursement. It is important that policymakers, payers and manufacturers engage in early discussions and are willing to find new solutions to help accelerate patient access to innovative therapies.
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Affiliation(s)
- R. Lawlor
- Life Sciences, Charles River Associates, London, UK
- CONTACT R. Lawlor Life Sciences, Charles River Associates, LondonEC2M 7EA, UK
| | - T. Wilsdon
- Life Sciences, Charles River Associates, London, UK
| | - E. Darquennes
- MSD Belgium, Merck Sharp and Dohme Corp, Brussels, Belgium
| | - D. Hemelsoet
- MSD Belgium, Merck Sharp and Dohme Corp, Brussels, Belgium
| | - J. Huismans
- MSD Netherlands, Merck Sharp and Dohme Corp, Amsterdam, Netherlands
| | - R. Normand
- Merck Canada, Merck Sharp and Dohme Corp, Montreal, Canada
| | - A. Roediger
- Oncology Policy Europe, MSD International Business GmbH, Lucerne, Switzerland
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Grimm SE, Pouwels X, Ramaekers BLT, Wijnen B, Knies S, Grutters J, Joore MA. Development and Validation of the TRansparent Uncertainty ASsessmenT (TRUST) Tool for Assessing Uncertainties in Health Economic Decision Models. PHARMACOECONOMICS 2020; 38:205-216. [PMID: 31709496 PMCID: PMC7081657 DOI: 10.1007/s40273-019-00855-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
BACKGROUND An increasing number of technologies are obtaining marketing authorisation based on sparse evidence, which causes growing uncertainty and risk within health technology reimbursement decision making. To ensure that uncertainty is considered and addressed within health technology assessment (HTA) recommendations, uncertainties need to be identified, included in health economic models, and reported. OBJECTIVE Our objective was to develop the TRansparent Uncertainty ASsessmenT (TRUST) tool for systematically identifying, assessing, and reporting uncertainties in decision models, with the aim of making uncertainties and their impact on cost effectiveness more explicit and transparent. METHODS TRUST was developed by drawing on the uncertainty and risk assessment literature. To develop and validate this tool, we conducted HTA stakeholder discussion meetings and interviews and applied it in six real-world HTA case studies in the Netherlands and the UK. RESULTS The TRUST tool enables the identification and categorisation of uncertainty according to its source (transparency issues, methodology issues, and issues with evidence: imprecision, bias and indirectness, and unavailability) in each model aspect. The source of uncertainty determines the appropriate analysis. The impact of uncertainties on cost effectiveness is also assessed. Stakeholders found using the tool to be feasible and of value for transparent uncertainty assessment. TRUST can be used during model development and/or model review. CONCLUSION The TRUST tool enables systematic identification, assessment, and reporting of uncertainties in health economic models and may contribute to more informed and transparent decision making in the face of uncertainty.
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Affiliation(s)
- Sabine E Grimm
- Maastricht University Medical Centre, Department of Clinical Epidemiology and Medical Technology Assessment, School for Public Health and Primary Care (CAPHRI), P. Debyelaan 25, PO Box 5800, 6202 AZ, Maastricht, The Netherlands.
| | - Xavier Pouwels
- Maastricht University Medical Centre, Department of Clinical Epidemiology and Medical Technology Assessment, School for Public Health and Primary Care (CAPHRI), P. Debyelaan 25, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Bram L T Ramaekers
- Maastricht University Medical Centre, Department of Clinical Epidemiology and Medical Technology Assessment, School for Public Health and Primary Care (CAPHRI), P. Debyelaan 25, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Ben Wijnen
- Maastricht University Medical Centre, Department of Clinical Epidemiology and Medical Technology Assessment, School for Public Health and Primary Care (CAPHRI), P. Debyelaan 25, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Saskia Knies
- Zorginstituut Nederland, Willem Dudokhof 1, 1112 ZA, Diemen, The Netherlands
| | - Janneke Grutters
- Department for Health Evidence, Radboud University Medical Centre, Post 133, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Manuela A Joore
- Maastricht University Medical Centre, Department of Clinical Epidemiology and Medical Technology Assessment, School for Public Health and Primary Care (CAPHRI), P. Debyelaan 25, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
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