A Multinational European Study of Patient Preferences for Novel Diagnostics to Manage Antimicrobial Resistance

Pricing, Procurement and Reimbursement Policies for Incentivizing Market Entry of Novel Antibiotics and Diagnostics: Learnings from 10 Countries Globally

BACKGROUND

Fostering market entry of novel antibiotics and enhanced use of diagnostics to improve the quality of antibiotic prescribing are avenues to tackle antimicrobial resistance (AMR), which is a major public health threat. Pricing, procurement and reimbursement policies may work as AMR 'pull incentives' to support these objectives. This paper studies pull incentives in pricing, procurement and reimbursement policies (e.g., additions to, modifications of, and exemptions from standard policies) for novel antibiotics, diagnostics and health products with a similar profile in 10 study countries. It also explores whether incentives for non-AMR health products could be transferred to AMR health products.

METHODS

This research included a review of policies in 10 G20 countries based on literature and unpublished documents, and the production of country fact sheets that were validated by country experts. Initial research was conducted in 2020 and updated in 2023.

RESULTS

Identified pull incentives in pricing policies include free pricing, higher prices at launch and price increases over time, managed-entry agreements, and waiving or reducing mandatory discounts. Incentives in procurement comprise value-based procurement, pooled procurement and models that delink prices from volumes (subscription-based schemes), whereas incentives in reimbursement include lower evidence requirements for inclusion in the reimbursement scheme, accelerated reimbursement processes, separate budgets that offer add-on funding, and adapted prescribing conditions.

CONCLUSIONS

While a few pull incentives have been piloted or implemented for antibiotics in recent years, these mechanisms have been mainly used to incentivize launch of certain non-AMR health products, such as orphan medicines. Given similarities in their product characteristics, transferability of some of these pull incentives appears to be possible; however, it would be essential to conduct impact assessments of these incentives. Trade-offs between incentives to foster market entry and thus potentially improve access and the financial sustainability for payers need to be addressed.

The Sensitivity and Specificity of Repeated and Dominant Choice Tasks in Discrete Choice Experiments

OBJECTIVES

This study aimed to identify the most commonly used internal validity tests in the discrete choice experiment (DCE) literature and establish their sensitivity and specificity.

METHODS

A structured literature review of recent DCE articles (2018-2020Q1) published in the health, marketing, transport economics, and environmental science literature was used to identify commonly used internal validity tests. The 2 most frequently used internal validity tests were incorporated in 4 new data collections. Respondent preferences in each application were summarized using a mixed logit model, which served as the benchmark for the subsequent sensitivity and specificity calculations. The performance of the internal validity tests was also compared with that of the root likelihood (RLH) test, which is a likelihood-based statistical validity test that is commonly used in marketing applications.

RESULTS

Dominant and repeated choice tasks were most commonly included in health-related DCE designs. Based on 4 applications, their specificity and sensitivity depend on the type of incorrect response pattern to be detected and on design characteristics such as the number of choice options per choice task and the number of internal validity tests as included in the experimental design. In all but one scenario, the performance of the dominant and repeated choice tasks was considerably worse than that of the RLH test.

CONCLUSIONS

Dominant and repeated choice tasks are unreliable screening tests and costly in terms of statistical power. The RLH test, which is a statistical test that does not require additional choice tasks to be included in the DCE design, provides a more reliable alternative.

Prescribing antibiotics: Factors driving decision-making in general practice. A discrete choice experiment

BACKGROUND

Antimicrobial resistance is a threat to human health. We need to strive for a rational use of antibiotics to reduce the selection of resistant bacteria. Most antibiotics are prescribed in general practice, but little is known about factors influencing general practitioners' (GPs) decision-making when prescribing antibiotics.

AIM

To 1) assess the importance of factors that influence decisions by GPs to prescribe antibiotics for acute respiratory tract infections (RTIs) and 2) identify segments of GPs influenced differently when deciding to prescribe antibiotics.

METHODS

A questionnaire survey including a discrete choice experiment was conducted. Danish GPs were asked to indicate whether they would prescribe antibiotics in six hypothetical choice sets with six variables: whether the GP is behind schedule, patient's temperature, patient's general condition, lung auscultation findings, C-reactive protein (CRP) level, and whether the patient expects antibiotics. Error component and latent class models were estimated and the probabilities of prescribing in different scenarios were calculated.

RESULTS

The questionnaire was distributed to every Danish GP (n = 3,336); 1,152 (35%) responded. Results showed that GPs were influenced by (in prioritised order): CRP level (Relative importance (RI) 0.54), patient's general condition (RI 0.20), crackles at auscultation (RI 0.15), and fever (RI 0.10). Being behind schedule and patient expectations had no significant impact on antibiotic prescription at the aggregate level. The latent class analysis identified five classes of GPs: generalists, CRP-guided, general condition-guided, reluctant prescribers, and stethoscopy-guided. For all classes, CRP was the most important driver, while GPs were heterogeneously affected by other drivers.

CONCLUSION

The most important factor affecting Danish GPs' decision to prescribe antibiotics at the aggregate level, in subgroups of GPs, and across latent classes was the CRP value. Hence, the use of CRP testing is an important factor to consider in order to promote rational antibiotic use in the battle against antimicrobial resistance.

A General Public Study on Preferences and Welfare Impacts of Antimicrobial Resistance in the United Kingdom

BACKGROUND

Antibiotics have led to considerable increases in life expectancy. However, over time, antimicrobial resistance has accelerated and is now a significant global public health concern. Understanding societal preferences for the use of antibiotics as well as eliciting the willingness to pay for future research is crucial.

OBJECTIVE

To investigate preferences for different strategies to optimize antibiotic use and to understand the willingness to pay for future research in antimicrobial resistance and antimicrobial drug development.

METHODS

A discrete-choice experiment was administered to a sample of the UK general population. Respondents were asked to make nine choices, each offering three options-two hypothetical "doctor and antibiotics" and one "no doctor-no antibiotics"-defined by five attributes: treatment, days needed to recover, risk of bacterial infection that needs antibiotics, risk of common side effects, and risk of antimicrobial resistance by 2050. Data were analyzed using random parameters logit models. A double-bounded contingent valuation was also included in the survey to explore the willingness to pay for policies to contain antimicrobial resistance.

RESULTS

Among the 2579 respondents who completed the survey, 1151 always selected "no doctor-no antibiotics" and 57 never varied their choices; therefore, 1371 responses were used in the analysis. Risk of antimicrobial resistance by 2050 was the most important attribute and the "treatment" was the least important attribute, although this was sensitive to a higher risk of bacterial infection. The aggregate annual willingness to pay for containing antimicrobial resistance was approximately £8.35 billion (~£5-£10 billion).

CONCLUSIONS

The antimicrobial resistance risk is relevant and important to the general public. The high willingness to pay suggests that large investments in policies or interventions to combat antimicrobial resistance are justified.