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Zhang W, Hou Y, Yin S, Miao Q, Lee K, Zhou X, Wang Y. Advanced gene nanocarriers/scaffolds in nonviral-mediated delivery system for tissue regeneration and repair. J Nanobiotechnology 2024; 22:376. [PMID: 38926780 PMCID: PMC11200991 DOI: 10.1186/s12951-024-02580-8] [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: 03/09/2024] [Accepted: 05/24/2024] [Indexed: 06/28/2024] Open
Abstract
Tissue regeneration technology has been rapidly developed and widely applied in tissue engineering and repair. Compared with traditional approaches like surgical treatment, the rising gene therapy is able to have a durable effect on tissue regeneration, such as impaired bone regeneration, articular cartilage repair and cancer-resected tissue repair. Gene therapy can also facilitate the production of in situ therapeutic factors, thus minimizing the diffusion or loss of gene complexes and enabling spatiotemporally controlled release of gene products for tissue regeneration. Among different gene delivery vectors and supportive gene-activated matrices, advanced gene/drug nanocarriers attract exceptional attraction due to their tunable physiochemical properties, as well as excellent adaptive performance in gene therapy for tissue regeneration, such as bone, cartilage, blood vessel, nerve and cancer-resected tissue repair. This paper reviews the recent advances on nonviral-mediated gene delivery systems with an emphasis on the important role of advanced nanocarriers in gene therapy and tissue regeneration.
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Affiliation(s)
- Wanheng Zhang
- Institute of Geriatrics, School of Medicine, Affiliated Nantong Hospital of Shanghai University (The Sixth People's Hospital of Nantong), Shanghai University, Shanghai, 200444, China
- Department of Pharmacy, China Pharmaceutical University, Nanjing, 210009, China
| | - Yan Hou
- Institute of Geriatrics, School of Medicine, Affiliated Nantong Hospital of Shanghai University (The Sixth People's Hospital of Nantong), Shanghai University, Shanghai, 200444, China
- Joint International Research Laboratory of Biomaterials and Biotechnology in Organ Repair (Ministry of Education), Shanghai University, Shanghai, 200444, China
| | - Shiyi Yin
- Department of Pharmacy, China Pharmaceutical University, Nanjing, 210009, China
| | - Qi Miao
- Department of Pharmacy, China Pharmaceutical University, Nanjing, 210009, China
| | - Kyubae Lee
- Department of Biomedical Materials, Konyang University, Daejeon, 35365, Republic of Korea
| | - Xiaojian Zhou
- Department of Pediatrics, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200080, China.
| | - Yongtao Wang
- Institute of Geriatrics, School of Medicine, Affiliated Nantong Hospital of Shanghai University (The Sixth People's Hospital of Nantong), Shanghai University, Shanghai, 200444, China.
- Joint International Research Laboratory of Biomaterials and Biotechnology in Organ Repair (Ministry of Education), Shanghai University, Shanghai, 200444, China.
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Ossandon H, Armijo N, Vargas C, Repetto GM, Espinoza MA. Challenges for gene therapy in the financial sustainability of health systems: a scoping review. Orphanet J Rare Dis 2024; 19:243. [PMID: 38915120 PMCID: PMC11197217 DOI: 10.1186/s13023-024-03249-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 06/10/2024] [Indexed: 06/26/2024] Open
Abstract
AIM To review the available evidence about the strategies implemented or proposed for coverage or reimbursement for currently approved gene therapies. METHODS A scoping review was conducted to analyze the evidence published during the years 2016 to 2023. The main search criteria were coverage or reimbursement of gene therapy by healthcare systems. The eligible articles were those that described or proposed a financing model used to provide coverage in the various systems around the world. RESULTS The study identified 279 publications, and after removing duplicates and screening for eligibility, 10 were included in the study. The results show that various financing models have been proposed, including subscription-based payment models, outcome-based payment models, and amortization strategies. However, several barriers to implementing these models were identified, such as deficiencies in informatics systems for data collection, changes in laws or regulations, the lack of accessible clinical endpoints and administrative costs. CONCLUSION This scoping review provides an overview of financing strategies for gene therapies. Gene therapies can cure rare or previously intractable diseases, but their high cost can make access difficult. Publishing experiences with these models can help evaluate their use and gather more evidence for their effectiveness.
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Affiliation(s)
- Hugo Ossandon
- Departamento de Coordinación de Garantías y Prestaciones de Salud, División de Planificación Sanitaria, Ministerio de Salud de Chile, Enrique McIver 421, Santiago, Chile
| | - Nicolás Armijo
- Centro de Investigación Clínica, Unidad de Evaluación de Tecnologías en Salud (ETESA UC), Pontificia Universidad Católica de Chile, Santiago, Chile
- Centro Para la Prevención y Control del cáncer, Santiago, Chile
| | - Constanza Vargas
- Centre for Health Economics Research and Evaluation (CHERE), University of Technology Sydney, Sydney, Australia
| | - Gabriela M Repetto
- Rare Diseases Program, Institute of Science and Innovation in Medicine, Facultad de Medicina, Clinica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Manuel Antonio Espinoza
- Centro de Investigación Clínica, Unidad de Evaluación de Tecnologías en Salud (ETESA UC), Pontificia Universidad Católica de Chile, Santiago, Chile.
- Centro Para la Prevención y Control del cáncer, Santiago, Chile.
- Departamento de Salud Pública, Pontificia Universidad Católica de Chile, Santiago, Chile.
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Watson S, Ngo KJ, Stevens HA, Wong DY, Kim J, Song Y, Han B, Hyun SI, Khang R, Ryu SW, Lee E, Seo G, Lee H, Lajonchere C, Fogel BL. Cross-Sectional Analysis of Exome Sequencing Diagnosis in Patients With Neurologic Phenotypes Facing Barriers to Clinical Testing. Neurol Genet 2024; 10:e200133. [PMID: 38617022 PMCID: PMC11010248 DOI: 10.1212/nxg.0000000000200133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/19/2024] [Indexed: 04/16/2024]
Abstract
Background and Objectives Exome sequencing (ES) demonstrates a 20-50 percent diagnostic yield for patients with a suspected monogenic neurologic disease. Despite the proven efficacy in achieving a diagnosis for such patients, multiple barriers for obtaining exome sequencing remain. This study set out to assess the efficacy of ES in patients with primary neurologic phenotypes who were appropriate candidates for testing but had been unable to pursue clinical testing. Methods A total of 297 patients were identified from the UCLA Clinical Neurogenomics Research Center Biobank, and ES was performed, including bioinformatic assessment of copy number variation and repeat expansions. Information regarding demographics, clinical indication for ES, and reason for not pursuing ES clinically were recorded. To assess diagnostic efficacy, variants were interpreted by a multidisciplinary team of clinicians, bioinformaticians, and genetic counselors in accordance with the American College of Medical Genetics and Genomics variant classification guidelines. We next examined the specific barriers to testing for these patients, including how frequently insurance-related barriers such as coverage denials and inadequate coverage of cost were obstacles to pursuing exome sequencing. Results The cohort primarily consisted of patients with sporadic conditions (n = 126, 42.4%) of adult-onset (n = 239, 80.5%). Cerebellar ataxia (n = 225, 75.8%) was the most common presenting neurologic phenotype. Our study found that in this population of mostly adult patients with primary neurologic phenotypes that were unable to pursue exome sequencing clinically, 47 (15.8%) had diagnostic results while an additional 24 patients (8.1%) had uncertain results. Of the 297 patients, 206 were initially recommended for clinical exome but 88 (42.7%) could not pursue ES because of insurance barriers, of whom 14 (15.9%) had diagnostic findings, representing 29.8% of all patients with diagnostic findings. In addition, the incorporation of bioinformatic repeat expansion testing was valuable, identifying a total of 8 pathogenic repeat expansions (17.0% of all diagnostic findings) including 3 of the common spinocerebellar ataxias and 2 patients with Huntington disease. Discussion These findings underscore the importance and value of clinical ES as a diagnostic tool for neurogenetic disease and highlight key barriers that prevent patients from receiving important clinical information with potential treatment and psychosocial implications for patients and family members.
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Affiliation(s)
- Sonya Watson
- From the Department of Neurology (S.W., K.J.N., H.A.S., D.Y.W., C.L., B.L.F.), the Clinical Neurogenomics Research Center (S.W., H.A.S., D.Y.W., C.L., B.L.F.), the Institute for Precision Health (S.W., C.L., B.L.F.), and the Department of Human Genetics (S.W., B.L.F.), David Geffen School of Medicine, University of California at Los Angeles (UCLA); 3billion, Inc. (J.K., Y.S., B.H., S.-I.H., R.K., S.W.R., E.L., G.S., H.L.)
| | - Kathie J Ngo
- From the Department of Neurology (S.W., K.J.N., H.A.S., D.Y.W., C.L., B.L.F.), the Clinical Neurogenomics Research Center (S.W., H.A.S., D.Y.W., C.L., B.L.F.), the Institute for Precision Health (S.W., C.L., B.L.F.), and the Department of Human Genetics (S.W., B.L.F.), David Geffen School of Medicine, University of California at Los Angeles (UCLA); 3billion, Inc. (J.K., Y.S., B.H., S.-I.H., R.K., S.W.R., E.L., G.S., H.L.)
| | - Hannah A Stevens
- From the Department of Neurology (S.W., K.J.N., H.A.S., D.Y.W., C.L., B.L.F.), the Clinical Neurogenomics Research Center (S.W., H.A.S., D.Y.W., C.L., B.L.F.), the Institute for Precision Health (S.W., C.L., B.L.F.), and the Department of Human Genetics (S.W., B.L.F.), David Geffen School of Medicine, University of California at Los Angeles (UCLA); 3billion, Inc. (J.K., Y.S., B.H., S.-I.H., R.K., S.W.R., E.L., G.S., H.L.)
| | - Darice Y Wong
- From the Department of Neurology (S.W., K.J.N., H.A.S., D.Y.W., C.L., B.L.F.), the Clinical Neurogenomics Research Center (S.W., H.A.S., D.Y.W., C.L., B.L.F.), the Institute for Precision Health (S.W., C.L., B.L.F.), and the Department of Human Genetics (S.W., B.L.F.), David Geffen School of Medicine, University of California at Los Angeles (UCLA); 3billion, Inc. (J.K., Y.S., B.H., S.-I.H., R.K., S.W.R., E.L., G.S., H.L.)
| | - Jihye Kim
- From the Department of Neurology (S.W., K.J.N., H.A.S., D.Y.W., C.L., B.L.F.), the Clinical Neurogenomics Research Center (S.W., H.A.S., D.Y.W., C.L., B.L.F.), the Institute for Precision Health (S.W., C.L., B.L.F.), and the Department of Human Genetics (S.W., B.L.F.), David Geffen School of Medicine, University of California at Los Angeles (UCLA); 3billion, Inc. (J.K., Y.S., B.H., S.-I.H., R.K., S.W.R., E.L., G.S., H.L.)
| | - Yongjun Song
- From the Department of Neurology (S.W., K.J.N., H.A.S., D.Y.W., C.L., B.L.F.), the Clinical Neurogenomics Research Center (S.W., H.A.S., D.Y.W., C.L., B.L.F.), the Institute for Precision Health (S.W., C.L., B.L.F.), and the Department of Human Genetics (S.W., B.L.F.), David Geffen School of Medicine, University of California at Los Angeles (UCLA); 3billion, Inc. (J.K., Y.S., B.H., S.-I.H., R.K., S.W.R., E.L., G.S., H.L.)
| | - Beomman Han
- From the Department of Neurology (S.W., K.J.N., H.A.S., D.Y.W., C.L., B.L.F.), the Clinical Neurogenomics Research Center (S.W., H.A.S., D.Y.W., C.L., B.L.F.), the Institute for Precision Health (S.W., C.L., B.L.F.), and the Department of Human Genetics (S.W., B.L.F.), David Geffen School of Medicine, University of California at Los Angeles (UCLA); 3billion, Inc. (J.K., Y.S., B.H., S.-I.H., R.K., S.W.R., E.L., G.S., H.L.)
| | - Seong-In Hyun
- From the Department of Neurology (S.W., K.J.N., H.A.S., D.Y.W., C.L., B.L.F.), the Clinical Neurogenomics Research Center (S.W., H.A.S., D.Y.W., C.L., B.L.F.), the Institute for Precision Health (S.W., C.L., B.L.F.), and the Department of Human Genetics (S.W., B.L.F.), David Geffen School of Medicine, University of California at Los Angeles (UCLA); 3billion, Inc. (J.K., Y.S., B.H., S.-I.H., R.K., S.W.R., E.L., G.S., H.L.)
| | - Rin Khang
- From the Department of Neurology (S.W., K.J.N., H.A.S., D.Y.W., C.L., B.L.F.), the Clinical Neurogenomics Research Center (S.W., H.A.S., D.Y.W., C.L., B.L.F.), the Institute for Precision Health (S.W., C.L., B.L.F.), and the Department of Human Genetics (S.W., B.L.F.), David Geffen School of Medicine, University of California at Los Angeles (UCLA); 3billion, Inc. (J.K., Y.S., B.H., S.-I.H., R.K., S.W.R., E.L., G.S., H.L.)
| | - Seung Woo Ryu
- From the Department of Neurology (S.W., K.J.N., H.A.S., D.Y.W., C.L., B.L.F.), the Clinical Neurogenomics Research Center (S.W., H.A.S., D.Y.W., C.L., B.L.F.), the Institute for Precision Health (S.W., C.L., B.L.F.), and the Department of Human Genetics (S.W., B.L.F.), David Geffen School of Medicine, University of California at Los Angeles (UCLA); 3billion, Inc. (J.K., Y.S., B.H., S.-I.H., R.K., S.W.R., E.L., G.S., H.L.)
| | - Eugene Lee
- From the Department of Neurology (S.W., K.J.N., H.A.S., D.Y.W., C.L., B.L.F.), the Clinical Neurogenomics Research Center (S.W., H.A.S., D.Y.W., C.L., B.L.F.), the Institute for Precision Health (S.W., C.L., B.L.F.), and the Department of Human Genetics (S.W., B.L.F.), David Geffen School of Medicine, University of California at Los Angeles (UCLA); 3billion, Inc. (J.K., Y.S., B.H., S.-I.H., R.K., S.W.R., E.L., G.S., H.L.)
| | - Gohun Seo
- From the Department of Neurology (S.W., K.J.N., H.A.S., D.Y.W., C.L., B.L.F.), the Clinical Neurogenomics Research Center (S.W., H.A.S., D.Y.W., C.L., B.L.F.), the Institute for Precision Health (S.W., C.L., B.L.F.), and the Department of Human Genetics (S.W., B.L.F.), David Geffen School of Medicine, University of California at Los Angeles (UCLA); 3billion, Inc. (J.K., Y.S., B.H., S.-I.H., R.K., S.W.R., E.L., G.S., H.L.)
| | - Hane Lee
- From the Department of Neurology (S.W., K.J.N., H.A.S., D.Y.W., C.L., B.L.F.), the Clinical Neurogenomics Research Center (S.W., H.A.S., D.Y.W., C.L., B.L.F.), the Institute for Precision Health (S.W., C.L., B.L.F.), and the Department of Human Genetics (S.W., B.L.F.), David Geffen School of Medicine, University of California at Los Angeles (UCLA); 3billion, Inc. (J.K., Y.S., B.H., S.-I.H., R.K., S.W.R., E.L., G.S., H.L.)
| | - Clara Lajonchere
- From the Department of Neurology (S.W., K.J.N., H.A.S., D.Y.W., C.L., B.L.F.), the Clinical Neurogenomics Research Center (S.W., H.A.S., D.Y.W., C.L., B.L.F.), the Institute for Precision Health (S.W., C.L., B.L.F.), and the Department of Human Genetics (S.W., B.L.F.), David Geffen School of Medicine, University of California at Los Angeles (UCLA); 3billion, Inc. (J.K., Y.S., B.H., S.-I.H., R.K., S.W.R., E.L., G.S., H.L.)
| | - Brent L Fogel
- From the Department of Neurology (S.W., K.J.N., H.A.S., D.Y.W., C.L., B.L.F.), the Clinical Neurogenomics Research Center (S.W., H.A.S., D.Y.W., C.L., B.L.F.), the Institute for Precision Health (S.W., C.L., B.L.F.), and the Department of Human Genetics (S.W., B.L.F.), David Geffen School of Medicine, University of California at Los Angeles (UCLA); 3billion, Inc. (J.K., Y.S., B.H., S.-I.H., R.K., S.W.R., E.L., G.S., H.L.)
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Bala NS, Thornburg CD. Gene Therapy in Hemophilia A: Achievements, Challenges, and Perspectives. Semin Thromb Hemost 2024. [PMID: 38588706 DOI: 10.1055/s-0044-1785483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
Strides in advancements of care of persons with hemophilia include development of long-acting factor replacement therapies, novel substitution and hemostatic rebalancing agents, and most recently approved gene therapy. Several decades of preclinical and clinical trials have led to development of adeno-associated viral (AAV) vector-mediated gene transfer for endogenous production of factor VIII (FVIII) in hemophilia A (HA). Only one gene therapy product for HA (valoctocogene roxaparvovec) has been approved by regulatory authorities. Results of valoctocogene roxaparvovec trial show significant improvement in bleeding rates and use of factor replacement therapy; however, sustainability and duration of response show variability with overall decline in FVIII expression over time. Further challenges include untoward adverse effects involving liver toxicity requiring immunosuppression and development of neutralizing antibodies to AAV vector rendering future doses ineffective. Real-life applicability of gene therapy for HA will require appropriate patient screening, infrastructure setup, long-term monitoring including data collection of patient-reported outcomes and innovative payment schemes. This review article highlights the success and development of HA gene therapy trials, challenges including adverse outcomes and variability of response, and perspectives on approach to gene therapy including shared decision-making and need for future strategies to overcome the several unmet needs.
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Affiliation(s)
- Natasha S Bala
- Rady Children's Hospital San Diego, Hemophilia and Thrombosis Treatment Center, San Diego, California
- Department of Pediatrics, UC San Diego School of Medicine, La Jolla, California
| | - Courtney D Thornburg
- Rady Children's Hospital San Diego, Hemophilia and Thrombosis Treatment Center, San Diego, California
- Department of Pediatrics, UC San Diego School of Medicine, La Jolla, California
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Gladwell D, Ciani O, Parnaby A, Palmer S. Surrogacy and the Valuation of ATMPs: Taking Our Place in the Evidence Generation/Assessment Continuum. PHARMACOECONOMICS 2024; 42:137-144. [PMID: 37991631 DOI: 10.1007/s40273-023-01334-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/30/2023] [Indexed: 11/23/2023]
Abstract
Medical technology is advancing rapidly, but established methods for health technology assessment are struggling to keep up. This challenge is particularly stark for the assessment of advanced therapy medicinal products-therapies often launched on the basis of single-arm studies powered to a surrogate primary endpoint. The most robust surrogacy methods investigate trial-level correlations between the treatment effect on the surrogate and the outcome of ultimate interest. However, these methods are often impossible with the evidence usually available for advanced therapy medicinal products at the time of the launch (randomized controlled trials are necessary for these advanced methods). Additionally, these surrogacy relationships are usually considered to be technology specific, adding uncertainty for any approach that primarily relies on historic data to estimate the surrogacy relationship for novel interventions such as advanced therapy medicinal products. The literature has already highlighted the need for early dialogue, staged assessment processes, and pricing arrangements that responsibly share the risk between the manufacturer and payer. However, it is our view that in addition to these critical developments, the modeling methods employed could also improve. Currently, health technology assessment practitioners typically either ignore the surrogate and simply extrapolate the endpoint of greatest patient relevance irrespective of the degree of maturity or assume historic surrogate relationships apply to the novel technology. In this opinion piece, we outline an additional avenue. By drawing on the understanding of the mechanism of action and insights generated earlier in the evidence generation/assessment continuum, cost-effectiveness modelers can make better use of the wider data available. These efforts are expected to reduce uncertainty at the time of the initial launch of pharmaceutical products and increase the value of subsequent data collection efforts.
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Affiliation(s)
| | | | | | - Stephen Palmer
- Centre for Health Economics (CHE), University of York, York, UK
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Horrow C, Kesselheim AS. Confronting High Costs And Clinical Uncertainty: Innovative Payment Models For Gene Therapies. Health Aff (Millwood) 2023; 42:1532-1540. [PMID: 37931198 DOI: 10.1377/hlthaff.2023.00527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
Gene therapies offer potentially life-changing benefits for patients, but their unprecedented high prices exacerbate challenges for reimbursement. Payers must confront high budgetary impacts, as a large up-front payment for each patient makes it difficult to predict and absorb costs. Payers also face considerable clinical uncertainty, as evidence for efficacy and durability is limited at approval. Alternative payment models may address these reimbursement problems and ensure equitable patient access. We developed a taxonomy of possible payment mechanisms for gene therapies, including installments, risk pools, reinsurance, price-volume agreements, expenditure caps, subscriptions, outcomes-based payments and rebates, warranties, population outcomes-based agreements, and coverage with evidence development. We illustrate how these payment models take three main approaches: amortization, which mitigates initial budget impact by spreading payments over time; risk spreading, which makes budgets more predictable by pooling costs with other payers or capping costs based on expected volume; and performance-based payment, which addresses clinical uncertainty by tying prices to patient- or population-level outcomes. We discuss each payment model, its advantages and challenges, and considerations for US payers.
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Affiliation(s)
- Caroline Horrow
- Caroline Horrow, Brigham and Women's Hospital, Boston, Massachusetts
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Ghanem B, Seoane-Vazquez E, Brown L, Rodriguez-Monguio R. Analysis of the Gene Therapies Authorized by the United States Food and Drug Administration and the European Medicines Agency. Med Care 2023; 61:438-447. [PMID: 36884030 DOI: 10.1097/mlr.0000000000001840] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
BACKGROUND Gene therapy, altering the genes inside human cells, has recently emerged as an alternative for preventing and treating disease. Concerns have been expressed about the clinical value and the high cost of gene therapies. OBJECTIVE This study assessed the characteristics of the clinical trials, authorizations, and prices of gene therapies in the United States and the European Union. RESEARCH DESIGN We collected regulatory information from the Food and Drug Administration (FDA) and the European Medicines Agency (EMA) and manufacturer-listed prices from the United States, UK, and Germany. Descriptive statistics and t tests were conducted in the study. RESULTS As of January 1, 2022, the FDA and EMA authorized 8 and 10 gene therapies, respectively. The FDA and EMA granted orphan designation to all gene therapies except talimogene laherparepvec. Pivotal clinical trials were nonrandomized, open level, uncontrolled, phase I-III, and included a limited number of patients. Study primary outcomes were mainly surrogate endpoints without demonstration of direct patient benefit. The price of gene therapies at market entry ranged from $200,064 to $2,125,000 million. CONCLUSIONS Gene therapy is used to treat incurable diseases that affect only a small number of patients (orphan diseases). Based on this, they are approved by the EMA and FDA with insufficient clinical evidence to ensure safety and efficacy, in addition to the high cost.
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Affiliation(s)
- Buthainah Ghanem
- Department of Pharmaceutical Economics and Policy, Chapman University School of Pharmacy, Irvine
| | - Enrique Seoane-Vazquez
- Department of Pharmaceutical Economics and Policy, Chapman University School of Pharmacy, Irvine
- Economic Science Institute, Chapman University, Orange
| | - Lawrence Brown
- Department of Pharmaceutical Economics and Policy, Chapman University School of Pharmacy, Irvine
| | - Rosa Rodriguez-Monguio
- Department of Clinical Pharmacy
- Medication Outcomes Center
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA
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Drummond M, Ciani O, Fornaro G, Jommi C, Dietrich ES, Espin J, Mossman J, de Pouvourville G. How are health technology assessment bodies responding to the assessment challenges posed by cell and gene therapy? BMC Health Serv Res 2023; 23:484. [PMID: 37179322 PMCID: PMC10182681 DOI: 10.1186/s12913-023-09494-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 05/03/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND The aims of this research were to provide a better understanding of the specific evidence needs for assessment of clinical and cost-effectiveness of cell and gene therapies, and to explore the extent that the relevant categories of evidence are considered in health technology assessment (HTA) processes. METHODS A targeted literature review was conducted to identify the specific categories of evidence relevant to the assessment of these therapies. Forty-six HTA reports for 9 products in 10 cell and gene therapy indications across 8 jurisdictions were analysed to determine the extent to which various items of evidence were considered. RESULTS The items to which the HTA bodies reacted positively were: treatment was for a rare disease or serious condition, lack of alternative therapies, evidence indicating substantial health gains, and when alternative payment models could be agreed. The items to which they reacted negatively were: use of unvalidated surrogate endpoints, single arm trials without an adequately matched alternative therapy, inadequate reporting of adverse consequences and risks, short length of follow-up in clinical trials, extrapolating to long-term outcomes, and uncertainty around the economic estimates. CONCLUSIONS The consideration by HTA bodies of evidence relating to the particular features of cell and gene therapies is variable. Several suggestions are made for addressing the assessment challenges posed by these therapies. Jurisdictions conducting HTAs of these therapies can consider whether these suggestions could be incorporated within their existing approach through strengthening deliberative decision-making or performing additional analyses.
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Affiliation(s)
- Michael Drummond
- Centre for Health Economics, University of York, York, UK.
- CERGAS, SDA Bocconi School of Management, Milan, Italy.
| | - Oriana Ciani
- CERGAS, SDA Bocconi School of Management, Milan, Italy
| | | | - Claudio Jommi
- CERGAS, SDA Bocconi School of Management, Milan, Italy
| | | | - Jaime Espin
- Andalusian School of Public Health, Andalusia, Spain
| | - Jean Mossman
- Patient Representative and Visiting Senior Research Associate in the Medical Technology Research Group, LSE Health, London School of Economics, London, UK
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Quinn C, Ciarametaro M, Sils B, Phares S, Trusheim M. Medicaid best price reforms to enable innovative payment models for cell and gene therapies. Expert Rev Pharmacoecon Outcomes Res 2023; 23:191-203. [PMID: 36579425 DOI: 10.1080/14737167.2023.2159813] [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: 12/30/2022]
Abstract
BACKGROUND Cell and gene therapies promise durable benefits but face financial challenges from the uncertainty in their performance. Value-based purchasing arrangements (VBPAs) can address uncertainty but have been inhibited in the US by the Medicaid Drug Rebate Program (MDRP) approach to determining Medicaid Best Price (MBP) rebates. The likely effectiveness of MDRP reform proposals enabling VBPAs is examined in this study for durable cell and gene therapies. METHODS Monte Carlo simulations examined three potential reforms (Multiple Best Prices, Bundled Sales, and National Pooling) to determine the impact on payment misalignment, the required payer size to participate, and the percentage of total lives covered by a VBPA. RESULTS Simulation results suggest that 11% to 54% of commercial US lives would be feasibly covered by a VBPA depending on reform type and condition size. MPB reform achieved the highest commercial contracted percentage and lowest misalignment for commercial payers compared to National Pooling and Bundled Sales. State Medicaid plan results suggest lower extreme misalignment across all successfully contracted instances than commercial payers. CONCLUSIONS The Multiple Best Prices will likely enable VBPAs for many durable cell and gene therapies and larger payers. Further reforms may be needed to extend VBPAs to ultra-orphan conditions.
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Affiliation(s)
- Casey Quinn
- Center for Biomedical Systems Design, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - Brian Sils
- National Pharmaceutical Council, Washington DC, USA
| | | | - Mark Trusheim
- Center for Biomedical Systems Design, Tufts Medical Center, Boston, Massachusetts, USA
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10
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Lee S, Lee JH. Cell and gene therapy regulatory, pricing, and reimbursement framework: With a focus on South Korea and the EU. Front Public Health 2023; 11:1109873. [PMID: 36908458 PMCID: PMC9998493 DOI: 10.3389/fpubh.2023.1109873] [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: 11/28/2022] [Accepted: 02/01/2023] [Indexed: 02/26/2023] Open
Abstract
Ever since relevant bioengineering technologies have sufficiently matured to the platformizable commercialization stage, a slew of money has flocked to the cell and gene therapy market over the last few years, resulting in an abundance of clinical studies in the field. Newer modalities have brought up a string of regulatory and legislative tasks, such as developing guidelines and legislative rules to systematically regulate newer pharmaceutical products. Accordingly, another layer of legislation and guidelines tailored for cell and gene therapies has been introduced and is expected to evolve on par with technological progress. Furthermore, authorities have shifted to pricing and reimbursement policies that can share risks for cost and outcome among stakeholders altogether, such as developers and the government, while expanding the accessibility of patients to innovative cell and gene therapies. This review attempts to capture the salient regulatory features of the cell and gene therapy market in the context of South Korea and the European Union and points out where two sovereign entities currently stand on each policy element and how each tackles regulatory challenges. We can observe the converging trend where regulatory, pricing and reimbursement rules of adjoining countries in the supranational union or member countries of a consortium are getting more aligned. Evidently, concerted efforts to share regulatory science knowledge and embrace reference pricing have played their parts. The authors argue that policy priorities should be placed on initiatives to harmonize with other medical authorities to better the rights of patients and clear out the uncertainties of developers, ultimately to share and advance regulatory science and layout forward-looking policies at opportune times.
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Affiliation(s)
- SungKyung Lee
- Center for Growth Engine Industries, Korea Institute for Industrial Economics and Trade (KIET), Sejong, Republic of Korea
| | - Jong Hyuk Lee
- College of Pharmacy, Chung-Ang University, Seoul, Republic of Korea
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11
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Landfeldt E. Gene Therapy for Neuromuscular Diseases: Health Economic Challenges and Future Perspectives. J Neuromuscul Dis 2022; 9:675-688. [DOI: 10.3233/jnd-221540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Highly efficacious, potentially curative gene therapies holds immense clinical promise, but also present complex challenges. At the time of regulatory approval and health technology assessment (HTA), evidence of efficacy and safety of gene therapies is often uncertain. In addition, research, development, and manufacturing costs, small pools of eligible patients, and the fact that many gene therapies are administered only once means that they frequently are associated with very high “one-off” price points. Although only a limited number of products have been brought to market globally, hundreds of clinical trials of gene therapies, including several of monogenetic neuromuscular diseases, are currently ongoing. Over time, as more and more conditions become amendable to gene therapy, the number of transformative, high-cost treatments is likely to increase considerably. For these reasons, concerns have been raised regarding the suitability of current health policy systems, including HTA frameworks, in ensuring appropriate access to these therapeutic innovations while simultaneously safeguarding value for taxpayers’ money, as well as affordability and sustainability. This review provides a summary overview of current challenges and future perspectives of gene therapies for neuromuscular diseases from a health economic point of view.
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12
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Bolous NS, Bhatt N, Bhakta N, Neufeld EJ, Davidoff AM, Reiss UM. Gene Therapy and Hemophilia: Where Do We Go from Here? J Blood Med 2022; 13:559-580. [PMID: 36226233 PMCID: PMC9550170 DOI: 10.2147/jbm.s371438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 09/22/2022] [Indexed: 11/17/2022] Open
Abstract
Gene therapy for hemophilia using adeno-associated virus (AAV) derived vectors can reduce or eliminate patients' disease-related complications and improve their quality of life. Broad implementation globally will lead to societal gains and foster health equity. Several vector products each for factor IX (FIX) or factor VIII (FVIII) deficiency are in advanced clinical development. Safety data are reassuring. Efficacy data for up to 8 and 5 years, respectively, vary considerably among vector types and among individuals, but indicate significant reduction in bleeds and factor use. Products will soon be approved for marketing. This review highlights the relevant considerations for implementation of hemophilia gene therapy, specifically across a broad range of socioeconomic backgrounds globally, based on recent publications and our own experience. We address the current efficacy and safety data and relevant aspects of vector immunology. We then discuss pertinent implementation steps including pre-implementation and readiness assessments, considerations on cost, cost-effectiveness and payment models, approaches to education and informed consent, and the operational needs as well as the need for monitoring of health outcomes and implementation outcomes. To prevent a lag or complete lack of establishing access to this life-changing therapy option for all patients with hemophilia worldwide, adaptable pathways supported by collaborative and international efforts of all stakeholders are needed.
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Affiliation(s)
- Nancy S Bolous
- Department of Global Pediatric Medicine – St. Jude Children’s Research Hospital, Memphis, TN, USA,Correspondence: Nancy S Bolous, Department of Global Pediatric Medicine, St. Jude Children’s Research Hospital, 262 Danny Thomas Place, Mail Stop 721, Memphis, TN, 38105, USA, Tel +1 901 595 1968, Fax +1 901 595 5319, Email
| | - Nidhi Bhatt
- Department of Hematology – St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Nickhill Bhakta
- Department of Global Pediatric Medicine – St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Ellis J Neufeld
- Department of Hematology – St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Andrew M Davidoff
- Department of Surgery – St. Jude Children’s Research Hospital, Memphis, TN, USA
| | - Ulrike M Reiss
- Department of Hematology – St. Jude Children’s Research Hospital, Memphis, TN, USA
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13
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Simoens S, Abdallah K, Barbier L, Lacosta TB, Blonda A, Car E, Claessens Z, Desmet T, De Sutter E, Govaerts L, Janssens R, Lalova T, Moorkens E, Saesen R, Schoefs E, Vandenplas Y, Van Overbeeke E, Verbaanderd C, Huys I. How to balance valuable innovation with affordable access to medicines in Belgium? Front Pharmacol 2022; 13:960701. [PMID: 36188534 PMCID: PMC9523170 DOI: 10.3389/fphar.2022.960701] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 08/29/2022] [Indexed: 11/30/2022] Open
Abstract
Background: Countries are struggling to provide affordable access to medicines while supporting the market entry of innovative, expensive products. This Perspective aims to discuss challenges and avenues for balancing health care system objectives of access, affordability and innovation related to medicines in Belgium (and in other countries). Methods: This Perspective focuses on the R&D, regulatory approval and market access phases, with particular attention to oncology medicines, precision medicines, orphan medicines, advanced therapies, repurposed medicines, generics and biosimilars. The authors conducted a narrative review of the peer-reviewed literature, of the grey literature (such as policy documents and reports of consultancy agencies), and of their own research. Results: Health care stakeholders need to consider various initiatives for balancing innovation with access to medicines, which relate to clinical and non-clinical outcomes (e.g. supporting the conduct of pragmatic clinical trials, treatment optimisation and patient preference studies, optimising the use of real-world evidence in market access decision making), value assessment (e.g. increasing the transparency of the reimbursement system and criteria, tailoring the design of managed entry agreements to specific types of uncertainty), affordability (e.g. harnessing the role of generics and biosimilars in encouraging price competition, maximising opportunities for personalising and repurposing medicines) and access mechanisms (e.g. promoting collaboration and early dialogue between stakeholders including patients). Conclusion: Although there is no silver bullet that can balance valuable innovation with affordable access to medicines, (Belgian) policy and decision makers should continue to explore initiatives that exploit the potential of both the on-patent and off-patent pharmaceutical markets.
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Affiliation(s)
- Steven Simoens
- KU Leuven Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
| | - Khadidja Abdallah
- KU Leuven Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
| | - Liese Barbier
- KU Leuven Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
| | | | - Alessandra Blonda
- KU Leuven Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
| | - Elif Car
- KU Leuven Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
| | - Zilke Claessens
- KU Leuven Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
| | - Thomas Desmet
- KU Leuven Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
| | - Evelien De Sutter
- KU Leuven Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
| | - Laurenz Govaerts
- KU Leuven Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
| | - Rosanne Janssens
- KU Leuven Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
| | - Teodora Lalova
- KU Leuven Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
- KU Leuven Centre for IT & IP Law (CiTiP), Leuven, Belgium
| | - Evelien Moorkens
- KU Leuven Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
| | - Robbe Saesen
- KU Leuven Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
- European Organisation for Research and Treatment of Cancer, Brussels, Belgium
| | - Elise Schoefs
- KU Leuven Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
| | - Yannick Vandenplas
- KU Leuven Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
| | - Eline Van Overbeeke
- KU Leuven Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
| | - Ciska Verbaanderd
- KU Leuven Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
- Anticancer Fund, Strombeek-Bever, Brussels, Belgium
| | - Isabelle Huys
- KU Leuven Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
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14
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Simoens S, De Groote K, Boersma C. Critical Reflections on Reimbursement and Access of Advanced Therapies. Front Pharmacol 2022; 13:771966. [PMID: 35662719 PMCID: PMC9157586 DOI: 10.3389/fphar.2022.771966] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 04/06/2022] [Indexed: 11/24/2022] Open
Abstract
Background: The health economic literature has questioned the cost-effectiveness and affordability of advanced therapies, proposed adjustments to value assessment frameworks, and discussed the use of outcome-based managed entry agreements and staggered payments in the last few years. The aim of this manuscript is to conduct a critical reflection on assessment criteria and access conditions for reimbursement of advanced therapies. Methods: A narrative review of the peer-reviewed literature and grey literature was conducted in April 2021 by searching PubMed; Google Scholar; policy and legislative documents; websites of health technology assessment agencies, advanced therapy organisations, governmental advanced therapy innovation programmes, consultancy agencies; ISPOR conference abstracts and presentations. Results: Based on the available evidence, this manuscript argues that: a) advanced therapies can be cost-effective at high prices set by manufacturers; b) the economic evaluation framework adopted by many payers under-values these products; c) advanced therapies can be affordable and may not require spread payments; d) outcome-based managed entry agreements are theoretically attractive, but challenging in practice; e) the cost-effectiveness of advanced therapies depends on the outcome-based managed entry agreement and payment approach; f) there is a role for multinational collaborations to manage reimbursement and access of advanced therapies. Conclusions: This manuscript shows that there is no single approach to reimbursement and access of advanced therapies. Instead, we support a more tailored assessment of health economic aspects of advanced therapies, which considers the heterogeneity of these products and their target populations.
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Affiliation(s)
- Steven Simoens
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | | | - Cornelis Boersma
- Health Ecore, Zeist, Netherlands.,Open Universiteit, Heerlen, Netherlands.,University Medical Center Groningen, University of Groningen, Groningen, Netherlands
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15
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Bachmann M, Taha-Mehlitz S, Ochs V, Frey DM, Enodien B, Eriksson U, Taha A. The Increasing Investment of Real Estate in the Health System-A Comparison between the USA and Europe. Healthcare (Basel) 2021; 9:1633. [PMID: 34946358 PMCID: PMC8701979 DOI: 10.3390/healthcare9121633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/11/2021] [Accepted: 11/22/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND This study aimed to compare property development and increasing investment in real estate by the healthcare system organizations in the USA and Europe. Real estate investments have upsurged in healthcare due to the multiple benefits to patients and medical practitioners. METHODS The approach of acquiring data was through secondary sources and online questionnaires. The researchers applied inclusion and exclusion criteria by exclusively including the articles published after 2014 to ensure the validity and reliability of the information. RESULTS A total of 53.33% of the articles reviewed focused on the United States, while 46.67% concentrated on Europe. The development of real estate in healthcare is essential in both regions due to the challenges faced with the current infrastructure. Study Limitation: Currently, there are very few studies concentrating on the research topic. CONCLUSIONS The USA and Europe should focus on increasing real estate investments in healthcare by focusing on hospitals and trusts, rehabilitation centers, and nursing homes.
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Affiliation(s)
- Marta Bachmann
- Department of Cardiology, University Heart Center, University Hospital Zurich, 8952 Zurich, Switzerland; (M.B.); (U.E.)
- GZO Regional Health Center, Department of Medicine, Cardiology Division, 8620 Wetzikon, Switzerland
| | - Stephanie Taha-Mehlitz
- Clarunis, University Center for Gastrointestinal and Liver Diseases, 4002 Basel, Switzerland;
| | - Vincent Ochs
- Roche Innovation Center Basel, Department of Pharma Research & Early Development, 4070 Basel, Switzerland;
| | - Daniel. M. Frey
- Department of Surgery, Wetzikon Hospital, 8620 Wetzikon, Switzerland; (D.M.F.); (B.E.)
- Faculty of Medicine, University of Basel, 4001 Basel, Switzerland
| | - Bassey Enodien
- Department of Surgery, Wetzikon Hospital, 8620 Wetzikon, Switzerland; (D.M.F.); (B.E.)
| | - Urs Eriksson
- Department of Cardiology, University Heart Center, University Hospital Zurich, 8952 Zurich, Switzerland; (M.B.); (U.E.)
- GZO Regional Health Center, Department of Medicine, Cardiology Division, 8620 Wetzikon, Switzerland
| | - Anas Taha
- Department of Surgery, Wetzikon Hospital, 8620 Wetzikon, Switzerland; (D.M.F.); (B.E.)
- Department of Biomedical engineering, Faculty of medicine, University of Basel, 4123 Allschwil, Switzerland
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16
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Santomasso BD, Nastoupil LJ, Adkins S, Lacchetti C, Schneider BJ, Anadkat M, Atkins MB, Brassil KJ, Caterino JM, Chau I, Davies MJ, Ernstoff MS, Fecher L, Funchain P, Jaiyesimi I, Mammen JS, Naidoo J, Naing A, Phillips T, Porter LD, Reichner CA, Seigel C, Song JM, Spira A, Suarez-Almazor M, Swami U, Thompson JA, Vikas P, Wang Y, Weber JS, Bollin K, Ghosh M. Management of Immune-Related Adverse Events in Patients Treated With Chimeric Antigen Receptor T-Cell Therapy: ASCO Guideline. J Clin Oncol 2021; 39:3978-3992. [PMID: 34724386 DOI: 10.1200/jco.21.01992] [Citation(s) in RCA: 136] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To increase awareness, outline strategies, and offer guidance on the recommended management of immune-related adverse events (irAEs) in patients treated with chimeric antigen receptor (CAR) T-cell therapy. METHODS A multidisciplinary panel of medical oncology, neurology, hematology, emergency medicine, nursing, trialists, and advocacy experts was convened to develop the guideline. Guideline development involved a systematic literature review and an informal consensus process. The systematic review focused on evidence published from 2017 to 2021. RESULTS The systematic review identified 35 eligible publications. Because of the paucity of high-quality evidence, recommendations are based on expert consensus. RECOMMENDATIONS The multidisciplinary team issued recommendations to aid in the recognition, workup, evaluation, and management of the most common CAR T-cell-related toxicities, including cytokine release syndrome, immune effector cell-associated neurotoxicity syndrome, B-cell aplasia, cytopenias, and infections. Management of short-term toxicities associated with CAR T cells begins with supportive care for most patients, but may require pharmacologic interventions for those without adequate response. Management of patients with prolonged or severe CAR T-cell-associated cytokine release syndrome includes treatment with tocilizumab with or without a corticosteroid. On the basis of the potential for rapid decline, patients with moderate to severe immune effector cell-associated neurotoxicity syndrome should be managed with corticosteroids and supportive care.Additional information is available at www.asco.org/supportive-care-guidelines.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Ian Chau
- Royal Marsden Hospital and Institute of Cancer Research, London and Surrey, United Kingdom
| | | | | | | | | | | | | | - Jarushka Naidoo
- Beaumont Hospital, Dublin, Ireland and Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | | | | | | | | | | | | | | | | | - Umang Swami
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - John A Thompson
- Seattle Cancer Care Alliance, University of Washington/Fred Hutchinson, Seattle, WA
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17
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Kane PB, Bittlinger M, Kimmelman J. Individualized therapy trials: navigating patient care, research goals and ethics. Nat Med 2021; 27:1679-1686. [PMID: 34642487 DOI: 10.1038/s41591-021-01519-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/26/2021] [Indexed: 02/08/2023]
Abstract
'Individualized therapy' trials (sometimes called n-of-1 trials) use patients as their own controls to evaluate treatments. Here we divide such trials into three categories: multi-crossover trials aimed at individual patient management, multi-crossover trial series and pre-post trials. These trials all customize interventions for patients; however, the latter two categories also aim to inform medical practice and thus embody tensions between the goals of care and research that are typical of other types of clinical trials. In this Perspective, we discuss four domains where such tensions play out-clinical equipoise, informed consent, reporting and funding, and we provide recommendations for addressing each.
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Affiliation(s)
- Patrick Bodilly Kane
- Studies in Translation, Ethics and Medicine, Biomedical Ethics Unit, McGill University, Montreal, Quebec, Canada
| | - Merlin Bittlinger
- Studies in Translation, Ethics and Medicine, Biomedical Ethics Unit, McGill University, Montreal, Quebec, Canada
| | - Jonathan Kimmelman
- Studies in Translation, Ethics and Medicine, Biomedical Ethics Unit, McGill University, Montreal, Quebec, Canada.
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18
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van Overbeeke E, Hauber B, Michelsen S, Peerlinck K, Lambert C, Hermans C, Lê PQ, Goldman M, Simoens S, Huys I. Patient preferences for gene therapy in haemophilia: Results from the PAVING threshold technique survey. Haemophilia 2021; 27:957-966. [PMID: 34472162 PMCID: PMC9293173 DOI: 10.1111/hae.14401] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 07/07/2021] [Accepted: 08/21/2021] [Indexed: 12/23/2022]
Abstract
OBJECTIVES The aim of the Patient preferences to Assess Value IN Gene therapies (PAVING) study was to investigate trade-offs that adult Belgian people with haemophilia (PWH) A and B are willing to make when choosing between prophylactic factor replacement therapy (PFRT) and gene therapy. METHODS The threshold technique was used to quantify the minimum acceptable benefit (MAB) of a switch from PFRT to gene therapy in terms of 'Annual bleeding rate' (ABR), 'Chance to stop prophylaxis' (STOP), and 'Quality of life' (QOL). The design was supported by stakeholder involvement and included an educational tool on gene therapy. Threshold intervals were analysed using interval regression models in Stata 16. RESULTS A total of 117 PWH completed the survey. Mean thresholds were identified for all benefits, but substantial preference heterogeneity was observed; especially for the STOP thresholds, where the distribution of preferences was bimodal. Time spent on the educational tool and residence were found to impact MAB thresholds. The most accepted (88% of PWH) gene therapy profile investigated in this study comprised of zero bleeds per year (vs. six for PFRT), 90% chance to stop prophylaxis, no impact on QoL, and 10 years of follow-up on side effects (vs. 30 for PFRT). CONCLUSIONS Results from this study proved the value of educating patients on novel treatments. Moreover, preference heterogeneity for novel treatments was confirmed in this study. In gene therapy decision-making, preference heterogeneity and the impact of patient education on acceptance should be considered.
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Affiliation(s)
- Eline van Overbeeke
- Clinical Pharmacology and Pharmacotherapy, University of Leuven, Leuven, Belgium
| | - Brett Hauber
- Health Preference Assessment, RTI Health Solutions, Research Triangle Park, North Carolina, USA.,Comparative Health Outcomes, Policy and Economics (CHOICE) Institute, University of Washington School of Pharmacy, Seattle, WA, USA
| | - Sissel Michelsen
- Clinical Pharmacology and Pharmacotherapy, University of Leuven, Leuven, Belgium
| | | | | | - Cedric Hermans
- Haemophilia Clinic, St-Luc University Hospital, Brussels, Belgium
| | - Phu Quoc Lê
- Hémato-Oncologie, Hôpital Universitaire des Enfants Reine Fabiola, Brussels, Belgium
| | - Michel Goldman
- Institute for Interdisciplinary Innovation in healthcare, Université libre de Bruxelles, Brussels, Belgium
| | - Steven Simoens
- Clinical Pharmacology and Pharmacotherapy, University of Leuven, Leuven, Belgium
| | - Isabelle Huys
- Clinical Pharmacology and Pharmacotherapy, University of Leuven, Leuven, Belgium
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19
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van Overbeeke E, Hauber B, Michelsen S, Goldman M, Simoens S, Huys I. Patient Preferences to Assess Value IN Gene Therapies: Protocol Development for the PAVING Study in Hemophilia. Front Med (Lausanne) 2021; 8:595797. [PMID: 33768101 PMCID: PMC7985056 DOI: 10.3389/fmed.2021.595797] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 02/15/2021] [Indexed: 12/16/2022] Open
Abstract
Introduction: Gene therapies are innovative therapies that are increasingly being developed. However, health technology assessment (HTA) and payer decision making on these therapies is impeded by uncertainties, especially regarding long-term outcomes. Through measuring patient preferences regarding gene therapies, the importance of unique elements that go beyond health gain can be quantified and inform value assessments. We designed a study, namely the Patient preferences to Assess Value IN Gene therapies (PAVING) study, that can inform HTA and payers by investigating trade-offs that adult Belgian hemophilia A and B patients are willing to make when asked to choose between a standard of care and gene therapy. Methods and Analysis: An eight-step approach was taken to establish the protocol for this study: (1) stated preference method selection, (2) initial attributes identification, (3) stakeholder (HTA and payer) needs identification, (4) patient relevant attributes and information needs identification, (5) level identification and choice task construction, (6) educational tool design, (7) survey integration, and (8) piloting and pretesting. In the end, a threshold technique survey was designed using the attributes “Annual bleeding rate,” “Chance to stop prophylaxis,” “Time that side effects have been studied,” and “Quality of Life.” Ethics and Dissemination: The Medical Ethics Committee of UZ KU Leuven/Research approved the study. Results from the study will be presented to stakeholders and patients at conferences and in peer-reviewed journals. We hope that results from the PAVING study can inform decision makers on the acceptability of uncertainties and the value of gene therapies to patients.
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Affiliation(s)
- Eline van Overbeeke
- Clinical Pharmacology and Pharmacotherapy, University of Leuven, Leuven, Belgium
| | - Brett Hauber
- Health Preference Assessment, RTI Health Solutions, Durham, NC, United States
| | - Sissel Michelsen
- Clinical Pharmacology and Pharmacotherapy, University of Leuven, Leuven, Belgium.,Healthcare Management Centre, Vlerick Business School, Ghent, Belgium
| | - Michel Goldman
- Institute for Interdisciplinary Innovation in Healthcare, Université Libre de Bruxelles, Brussels, Belgium
| | - Steven Simoens
- Clinical Pharmacology and Pharmacotherapy, University of Leuven, Leuven, Belgium
| | - Isabelle Huys
- Clinical Pharmacology and Pharmacotherapy, University of Leuven, Leuven, Belgium
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