"Yes", "No" or "Yes, but"? Multinomial modelling of NICE decision-making

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

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.

Algorithms and heuristics of health technology assessments: A retrospective analysis of factors associated with HTA outcomes for new drugs across seven OECD countries

CONTEXT

Positive health technology assessment (HTA) outcomes can have important implications for equity, efficiency and timely patient access to novel therapies. Several outcomes and dimensions of benefit beyond utility feed into HTA processes.

OBJECTIVE

We analyse a proprietary dataset of HTA outcomes in 7 countries, to (a) test whether HTA decision-making is grounded in welfarist or extra-welfarist approaches; and (b) empirically determine the factors associated with positive HTA outcomes, the time to achieve these and establish the magnitude of inter-country differences in assessment processes.

METHODS

Data were extracted from publicly available HTA reports on drugs that received marketing authorisation between 2009 and 2018 (N = 1415). The outcomes of interest were the probability of positive HTA outcomes and the time-to-HTA outcome; these were examined with respect to clinical, regulatory, product- and disease-related, evidence uncertainty and contextual variables. Econometric models utilising survival analysis and multinomial logistic regression were specified.

FINDINGS

Positive HTA outcomes accounted for 87.3% of the sample (n = 1235), of which 71% (n = 1004) were restricted. Drugs with positive HTA outcomes were subject to clinical restrictions (n = 652, 46%), financial risk-sharing (n = 439, 31%) or had been rejected at least once (n = 282, 20%). Significant predictors of positive HTA outcomes were orphan drugs with cancer indications, high quality of evidence linked to clinical and economic evidence uncertainties which had been overcome, and contextual considerations, particularly innovativeness and unmet need. Comparative analyses revealed systematic differences between countries in their propensity to accept the same drugs, particularly oncology and orphan drugs.

CONCLUSIONS

Our results are contextual and reinforce arguments in favour of explicitly accounting for social value judgements, establishing separate assessment frameworks for highly uncertain products, adopting risk mitigation strategies for novel therapies with early phase evidence, and sharing of HTA practices across settings. Lastly, HTA agencies have adopted an extra-welfarist approach to value assessment and resource allocation.

HTA Barriers for Conditional Approval Drugs

BACKGROUND

Conditional approval pathways facilitate accelerated marketing authorisation based on immature clinical evidence for drugs that address an unmet medical need in a life-threatening or chronically debilitating condition. Lowering evidence requirements for marketing authorisation results in higher clinical uncertainty, which may present challenges for the health technology assessment (HTA) of these products.

OBJECTIVES

The objective of this study is to assess whether conditionally approved drugs face higher probabilities of HTA rejection or delays in HTA approval relative to drugs with standard marketing authorisation.

METHODS

This paper adopts a mixed-methods approach to provide a meta-analysis of HTA outcomes across 80 drug-indication pairs in France, England, Scotland and Canada. Differences in the characteristics (i.e. disease rarity and clinical trial design) of conditionally approved drugs and drugs with standard marketing authorisation and drivers of HTA outcomes are assessed through logistics regressions. Delays in HTA approval are assessed through a survival analysis.

RESULTS

Relative to standard approval drugs, conditionally approved drugs are less likely to include phase III trial designs, less likely to include clinical endpoints and less likely to include an active comparator. Uncertainties in clinical and economic evidence are raised more frequently by HTA agencies for conditionally approved drugs, which have a marginally lower probability of receiving HTA approval relative to drugs with standard approval. Conditionally approved drugs face moderate delays (an average of 6 months) in receiving HTA approval relative to standard approval drugs.

CONCLUSIONS

Overall, conditionally approved drugs likely face increased barriers at the HTA level.

Role of Economic Evaluations on Pricing of Medicines Reimbursed by the Italian National Health Service

OBJECTIVE

The main objective of this study was to explore the extent to which the incremental cost-effectiveness ratio (ICER), alongside other factors, predicts the final outcome of medicine price negotiation in Italy. The second objective was to depict the mean ICER of medicines obtained after negotiation.

METHODS

Data were extracted from company dossiers submitted to the Italian Medicines Agency (AIFA) from October 2016 to January 2021 and AIFA's internal database. Beta-based regression analyses were used to test the effect of ICER and other variables on the outcome of price negotiation (ΔP), defined as the percentage difference between the list price requested by manufacturers and the final price paid by the Italian National Health Service (INHS).

RESULTS

In our dataset of 48 pricing and reimbursement procedures, the ICER before negotiation was one of the variables with a major impact on the outcome of negotiation when ≥ 40,000€/QALY. As resulting from multiple regression analyses, the effect of the ICER on ΔP seemed driven by medicines for non-onco-immunological and non-rare diseases. Overall, the negotiation process granted mean incremental costs of €64,688 and mean incremental QALYs of 1.96, yielding an average ICER of €33,004/QALY.

CONCLUSIONS

This study provides support on the influence of cost-effectiveness analysis on price negotiation in the Italian context, providing an estimate of the mean ICER of reimbursed medicines, calculated using net confidential prices charged by the INHS. The role and use of economic evaluations in medicines pricing should be further improved to get the best value for money.

What are the impacts of increasing cost-effectiveness Threshold? a protocol on an empirical study based on economic evaluations conducted in Thailand

Background

Economic evaluations have been widely used to inform and guide policy-making process in healthcare resources allocation as a part of an evidence package. An intervention is considered cost-effective if an ICER is less than a cost-effectiveness threshold (CET), where a CET represents the acceptable price for a unit of additional health gain which a decision-maker is willing to pay. There has been discussion to increase a CET in many settings such as the United Kingdom and Thailand. To the best of our knowledge, Thailand is the only country that has an explicit CET and has revised their CET, not once but twice. Hence, the situation in Thailand provides a unique opportunity for evaluating the impact of changing CET on healthcare expenditure and manufacturers’ behaviours in the real-world setting. Before we decide whether a CET should be increased, information on what happened after the CET was increased in the past could be informative and helpful.

Objectives

This study protocol describes a proposed plan to investigate the impact of increased cost-effectiveness threshold using Thailand as a case study. Specifically, we will examine the impact of increasing CET on the drug prices submitted by pharmaceutical companies to the National List of Essential Medicine (NLEM), the decision to include or exclude medications in the NLEM, and the overall budget impact.

Materials and designs

Retrospective data analysis of the impact of increased CET on national drug committee decisions in Thailand (an upper middle-income country) will be conducted and included data from various sources such as literature, local organizations (e.g. Thai Food and Drug Administration), and inputs from stakeholder consultation meetings. The outcomes include: (1) drug price submitted by the manufacturers and final drug price included in the NLEM if available; (2) decisions about whether the drug was included in the NLEM for reimbursement; and (3) budget impact. The independent variables include a CET, the variable of interest, which can take values of THB100,000, THB120,000, or THB160,000, and potential confounders such as whether this drug was for a chronic disease, market size, and primary endpoint. We will conduct separate multivariable regression analysis for each outcome specified above.

Discussion

Understanding the impact of increasing the CET would be helpful in assisting the decision to use and develop an appropriate threshold for one’s own setting. Due to the nature of the study design, the findings will be prone to confounding effect and biases; therefore, the analyses will be adjusted for potential confounders and statistical methods will be explored to minimize biases. Knowledge gained from the study will be conveyed to the public through various disseminations such as reports, policy briefs, academic journals, and presentations.

The normative grounds for NICE decision-making: a narrative cross-disciplinary review of empirical studies

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.

Non-Price-Related Determinants of Value and Access for Novel Non-small Cell Lung Cancer Treatments: A Cross-Country Review of HTA Decision Making

INTRODUCTION

Access and funding for newly approved treatments for non-small cell lung cancer (NSCLC) are often dependent on Health Technology Assessment (HTA) involving cost-effectiveness analysis. Whilst methods used by HTA agencies share many similarities, final decisions may differ. This may be the result, not just of price considerations, but also of variation in value judgements by different agencies. The aim of this study was to review international HTA evaluations to identify determinants of value and access for NSCLC treatments.

METHODS

A targeted review and analysis was undertaken of published HTAs for NSCLC across HTA agencies in six countries (Australia, Canada, England, France, Ireland and Scotland). Analysis of extracted data consisted of three stages: descriptive analysis, bivariate analysis and multivariable analysis.

RESULTS

The analysis included 163 HTAs that assessed oncological treatments for NSCLC from 2003 to 2019. The majority of HTA decisions (67.5%) were positive. However, some evidence of heterogeneity in HTA decisions and the factors informing them were identified. The most influential factors included in the multivariate model related to the HTA agency conducting the appraisal, the year of market authorisation, treatment type and the line of treatment.

CONCLUSION

Heterogenous decision-making frameworks can present a challenge to developing HTA submissions. This research contributes to understanding decision-making factors and why countries make different decisions.

Decision models in type 2 diabetes mellitus: A systematic review

AIMS

To reduce the burden of type 2 diabetes (T2DM), the disease decision model plays a vital role in supporting decision-making. Currently, there is no comprehensive summary and assessment of the existing decision models for T2DM. The objective of this review is to provide an overview of the characteristics and capabilities of published decision models for T2DM. We also discuss which models are suitable for different study demands.

MATERIALS AND METHODS

Four databases (PubMed, Web of Science, Embase, and the Cochrane Library) were electronically searched for papers published from inception to August 2020. Search terms were: "Diabetes-Mellitus, Type 2", "cost-utility", "quality-of-life", and "decision model". Reference lists of the included studies were manually searched. Two reviewers independently screened the titles and abstracts following the inclusion and exclusion criteria. If there was insufficient information to include or exclude a study, then a full-text version was sought. The extracted information included basic information, study details, population characteristics, basic modeling methodologies, model structure, and data inputs for the included applications, model outcomes, model validation, and uncertainty.

RESULTS

Fourteen unique decision models for T2DM were identified. Markov chains and risk equations were utilized by four and three models, respectively. Three models utilized both. Except for the Archimedes model, all other models (n = 13) implemented an annual cycle length. The time horizon of most models was flexible. Fourteen models had differences in the division of health states. Ten models emphasized macrovascular and microvascular complications. Six models included adverse events. Majority of the models (n = 11) were patient-level simulation models. Eleven models simulated annual changes in risk factors (body mass index, glycemia, HbA1c, blood pressure (systolic and/or diastolic), and lipids (total cholesterol and/or high-density lipoprotein)). All models reported the main data sources used to develop health states of complications. Most models (n = 11) could deal with the uncertainty of models, which were described in varying levels of detail in the primary studies. Eleven studies reported that one or more validation checks were performed.

CONCLUSIONS

The existing decision models for T2DM are heterogeneous in terms of the level of detail in the classification of health states. Thus, more attention should be focused on balancing the desired level of complexity against the required level of transparency in the development of T2DM decision models.

Evaluation of the National Institute for Health and Care Excellence Diagnostics Assessment Program Decisions: Incremental Cost-Effectiveness Ratio Thresholds and Decision-Modifying Factors

OBJECTIVES

The National Institute for Health and Care Excellence (NICE) Diagnostics Assessment Programme (DAP) evaluates the cost-effectiveness of diagnostic technologies. A decision-making process benchmarking the incremental cost-effectiveness ratio (ICER) against a threshold while considering decision-modifying factors is common to NICE evaluations. This study investigated whether DAP decisions are consistent with the ICER thresholds described in the DAP manual, and to assess the impact of decision-modifying factors.

METHODS

DAP evaluations published before March 2018 were reviewed, and the following items were extracted: diagnostic technologies evaluated, decision problems assessed, Diagnostics Advisory Committee (DAC) decisions, incremental quality-adjusted life years (QALYs), incremental costs, ICERs considered to be most plausible by the DAC, and decision justifications.

RESULTS

All 30 evaluations were reviewed; 8 were excluded because the DAC concluded there was "insufficient evidence" for decision making. In the remaining 22 evaluations, 91 decision problems were identified for further analysis, of which 52, 15, and 24 received "recommended," "not recommended," and "not recommended-only in research" guidance, respectively. The overall consistency rate of the DAC decisions with the £20 000/QALY threshold was 73.6%. Diagnostic technologies that were not recommended, despite an ICER less than £20 000/QALY, were associated with a larger number of decision-modifying factors favoring the comparator, versus recommended diagnostic technologies with ICERs less than £20 000/QALY. For technologies with ICERs greater than £20 000/QALY, the number of decision-modifying factors was comparable for positive and negative recommendations.

CONCLUSIONS

Most DAP decisions were consistent with the ICER threshold. However, cost-effectiveness was not the only determining factor in decision making; recommendations also considered patient- and healthcare-centric factors and uncertainty.

Disagreement on cancer drug decisions in Europe

OBJECTIVES

Despite the efforts of the European Union (EU) to promote voluntary cooperation among Health Technology Assessment (HTA) agencies, different reimbursement decisions for the same drug are made across European countries. The aim of this paper is to compare the agreement of cancer drug reimbursement decisions using inter-rater reliability measures.

METHODS

This study is based on primary data on 161 cancer drug reimbursement decisions from nine European countries from 2002 to 2014. To achieve our goal, we use two measures to analyze agreement, in other words, congruency: (i) percentage of agreement and (ii) the κ score.

RESULTS

One main conclusion can be drawn from the analysis. There is a weak to medium agreement among cancer drug decisions in the European countries analyzed (based on the percentage of agreement and the κ score). England and Scotland show the highest consistency between the two measures, showing a medium agreement. These results are in line with previous literature on the congruency of HTA decisions.

CONCLUSIONS

This paper contributes to the HTA literature, by highlighting the extent of weak to medium agreement among cancer decisions in Europe.

Are Recently Evaluated Drugs More Likely to Receive Positive Reimbursement Recommendations in South Korea? 11-year Experience of the South Korean Positive List System

PURPOSE

The South Korean government in 2014 introduced various policies to enhance accessibility of pharmaceuticals. This study sought to examine whether positive reimbursement recommendations of pharmaceuticals have increased since 2014.

METHODS

Industry submissions evaluated from January 2007 to December 2018 were identified, and characteristics relevant to reimbursement recommendations were extracted. Logistic regression analyses with robust SEs were used to quantify the likelihood of positive recommendations for pharmaceuticals, after controlling for relevant factors influencing the recommendations.

FINDINGS

During the study period, 355 (72.9%) of 487 submissions were positively recommended; the drugs evaluated after 2014 (77.8%) were significantly more likely to receive positive reimbursement recommendations than the drugs evaluated before 2014 (69.5%). In the multivariable logistic regression analysis, several factors (labeled a noncancer drug, priced less than alternatives, considered clinically superior, and having budget impact >10 billion South Korean won) were significantly associated with positive recommendations (P < 0.05). When considering interaction effects between evaluation year and other variables, only the interaction between comparative clinical benefit and evaluation year was significant. Specifically, clinically noninferior drugs evaluated after 2014 had 2.85 times the odds of receiving positive recommendations compared with the clinically noninferior drugs evaluated earlier.

IMPLICATIONS

Recently evaluated drugs are more likely to receive positive reimbursement recommendations, especially those drugs whose comparative clinical benefits are noninferior.

Ranking the Criteria Used in the Appraisal of Drugs for Reimbursement: A Stated Preferences Elicitation With Health Technology Assessment Stakeholders Across Jurisdictional Contexts

OBJECTIVES

Our goal was to estimate the relative importance assigned to health technology assessment (HTA) criteria by stakeholders involved in the HTA process. HTA is an increasingly common framework used in the appraisal of drugs for public reimbursement. It identifies clinical, economic, social, and organizational criteria to be considered. The criteria can vary across jurisdictions and are typically appraised by multidisciplinary expert committees. Guidance on the relative weighing of criteria is often absent.

METHODS

We elicited stakeholders' preferences using a single-scenario discrete choice experiment and a best-worst scaling model with conviction scores to assess the weights assigned to selected criteria by HTA stakeholders. We recruited 111 HTA stakeholders across multiple jurisdictions, including members of expert committees, clinical and economic experts, patients, and public payer representatives. Each judged twelve hypothetical cancer drug profiles for suitability for public funding and identified which characteristics were best and worst. In addition to standard discrete choice experiment and best-worst scaling models, we estimated a hybrid model to obtain a ranking of criteria by importance they played in the appraisal.

RESULTS

A strong clinical benefit proved the most important criterion, followed by cost considerations, presence of adverse events, and availability of other treatments. The importance of clinical benefit was moderated by unmet need, adverse events, and number of patients.

CONCLUSION

Policymakers might want to consider providing an explicit weighing scheme, or moving to a 2-stage selection process with an assessment of the quality of clinical evidence as a gatekeeping step for a full HTA review.

Decision-making by the NICE Interventional Procedures Advisory Committee

BACKGROUND

This study explored the evidence base for recommendations by the National Institute of Health and Care Excellence (NICE) Interventional Procedures Advisory Committee, the only NICE committee not to consider cost. The four potential recommendations are: Standard Arrangements (can be performed as routine practice in the NHS); Special Arrangements (can be done under certain conditions); Research Only; and Do Not Do.

METHODS

Quantitative content analysis of data extracted from all published Interventional Procedure Guidance (IPG) for 2003-2018 (n = 496) was undertaken. All data were extracted independently by two researchers; disagreements were clarified by consensus. Data were tabulated, descriptive statistics produced, and regression analyses performed.

RESULTS

The proportion of IPGs by recommendation was: 50·0 per cent Standard Arrangements; 37·2 per cent Special Arrangements; 11·1 per cent Research Only; and 1·6 per cent Do Not Do. There was a clear trend over time: the proportion of recommendations for Standard Arrangements decreased, whereas the evidence threshold increased. Adjusted mean numbers of patients in the evidence base by recommendation type were: Standard, 4867; Special, 709; Research Only, 386. Regression analyses confirmed that the year of recommendation, numbers of patients and levels of evidence all affected the likely recommendation.

CONCLUSION

This study suggests that the likelihood of achieving the most positive recommendation (Standard Arrangements) is decreasing, and that this is most likely due to evidential requirements becoming more demanding. These findings are distinct from those reported for other NICE committees, for which the cost and statistical superiority of new therapies are among the drivers of recommendations.

Why do health technology assessment drug reimbursement recommendations differ between countries? A parallel convergent mixed methods study

Using quantitative and qualitative research designs, respectively, two studies investigated why countries make different health technology assessment (HTA) drug reimbursement recommendations. Building on these, the objective of this study was to (a) develop a conceptual framework integrating the factors explaining these decisions, (b) explore their relationship and (c) assess if they are congruent, complementary or discrepant. A parallel convergent mixed methods design was used. Countries included in both previous studies were selected (England, Sweden, Scotland and France). A conceptual framework that integrated and organised the factors explaining the decisions from the two studies was developed. Relationships between factors were explored and illustrated through case studies. The framework distinguishes macro-level factors from micro-level ones. Only two of the factors common to both studies were congruent, while two others reached discrepant conclusions (stakeholder input and external review of the evidence processes). The remaining factors identified within one or both studies were complementary. Bringing together these findings contributed to generating a more complete picture of why countries make different HTA recommendations. Results were mostly complementary, explaining and enhancing each other. We conclude that differences often result from a combination of factors, with an important component relating to what occurs during the deliberative process.

To HTA or Not to HTA: Identifying the Factors Influencing the Rapid Review Outcome in Ireland

OBJECTIVES

Reimbursement systems are evolving and endeavor to balance access and affordability. One such evolution in Ireland is the compulsory rapid review (RR) process, the outcome from which is a recommendation for a health technology assessment (HTA) or no HTA. For drugs that avoid an HTA, evaluation times are shorter, lengthy price negotiations are avoided, and access is faster. In the absence of formal decision-making criteria around the requirement of an HTA, this study examines the factors influencing the outcome of the RR process in Ireland.

METHODS

A database was developed combining data from publicly available sources for drug evaluations conducted by the National Centre for PharmacoEconomics (NCPE) (January 2010-June 2017, n = 296). Because Irish cost data were not publicly available for all drugs, cost data from the Scottish Medicines Consortium were employed as a proxy. Employing logistic regressions, the factors influencing the RR outcome are revealed.

RESULTS

After an RR, an HTA was recommended for 55% of drugs. The regression results revealed therapeutic area (endocrine, musculoskeletal, and neoplasm), first-in-class and orphan disease increased the probability of an HTA. Furthermore, when proxy costs were included, results revealed that every €1000 increase in annual drug costs per patient increased the probability of an HTA being required by 1% and that an HTA was more likely than no HTA when annual drug costs exceeded €15 000.

CONCLUSION

Given the current focus on access and affordability, this study identifies the factors influencing the requirement of an HTA in Ireland.

Did we learn the lesson after 60 years of Management by Objectives? A survey among former physician executives in German hospitals

BACKGROUND

Management by Objectives (MbO) has been shown to establish efficient team work in both industry and medicine. Its most important prerequisite for success is target agreements between managers and medical professionals on equal footing. In medicine, lump-sum financing urges the delivery of a health care service with minimal effort. Consequently, daily clinical life changed, with economic goals seeming to become priority over medical principles.

OBJECTIVE

To determine how well MbO can still be practiced in hospitals with lumped treatment prices.

METHODS

We used an anonymized questionnaire for already retired physician executives who completed their active leadership positions between 2010 and 2015 in Saxony (Germany). We asked various type of target agreements that had been used in order to achieve medical or economic targets.

RESULTS AND CONCLUSIONS

Out of 111 former executives, the questionnaires of 25 respondents could be analysed. Eight respondents confirmed target agreements that were mostly set by managing directors. If used, most targets had not been adapted to the infrastructure and personnel strength, nor were they coordinated with neighbouring departments. Four respondents received financial incentives. Most medical executives were unsatisfied and preferred to abandon further goal setting. Due to the low number of cases, the representativeness of the study is limited. Nevertheless, it might be questioned if a flat-rate remuneration system facilitates the change into an authoritarian leadership concept.

Is the National Institute for Health and Care Excellence (NICE) in England more 'innovation-friendly' than the Federal Joint Committee (G-BA) in Germany?

Objectives: Our study explores whether, and how, different methodological choices are associated with different health technology assessment (HTA) outcomes. We focus on the Federal Joint Committee (Gemeinsamer Bundesausschuss, G-BA) in Germany and the National Institute for Health and Care Excellence (NICE) in England. Both agencies may be considered as exemplars for the application of the principles of evidence-based medicine and the logic of cost-effectiveness, respectively. Methods: We extracted data from all publically available G-BA appraisals until April 2015, as well as all NICE single technology appraisals completed during this period. We compared HTA results for matched condition-intervention pairs by G-BA and NICE, and explored other factors including therapeutic area, clinical effectiveness and cost-effectiveness. Results: NICE issued guidance for 88 technologies (125 subgroups) and recommended 67/88 technologies (99/125 subgroups). G-BA completed 105 appraisals (226 subgroups) and determined additional benefit for 64/105 appraisals (90/226 subgroups). We identified 37 matched pairs; for 24/37 drugs, evaluations diverged. NICE recommended 78% (29/37) of technologies appraised, whereas G-BA confirmed additional benefit for 57% (21/37) only (p < 0.05). Conclusions: NICE evaluates new drugs more favorably than G-BA. However, our analysis suggests differences by therapeutic area. Results indicate that different methods are associated with systematic differences in HTA outcomes.

What is driving HTA decision-making? Evidence from cancer drug reimbursement decisions from 6 European countries

BACKGROUND

Decisions on the reimbursement of the same cancer drugs are different across European countries, but empirical work on the reasons behind these differences has been scarce. The main objective of this paper is to make a methodological contribution to existing research, specifically by outlining the systematic process of analysis to address such questions and determining the factors that might lead to different drug reimbursement decisions, and to explore its application in the field of oncology.

METHODS

Reimbursement decisions on cancer drugs in six European countries (Belgium, England, Poland, Portugal, Scotland, and Sweden) between 2006 and 2014 were included in the study. A taxonomy was developed, comprising two groups of variables (system-level and product-specific) and an econometric model was specified (multilevel mixed-effects ordered probit).

RESULTS

Only one in six evaluations in the sample reach the same reimbursement recommendation. Most health system variables were not determinants of a higher or lower probability of a positive reimbursement recommendation. However, the probability of reimbursement was higher when a drug was considered cost-effective by NICE/SMC and when there was a financial Managed Entry Agreement. This work also demonstrated a possible econometric approach for analysing differences in reimbursement decisions and contributes a structured approach for collecting and preparing data for such analyses.

CONCLUSIONS

Drug reimbursement decisions can be analysed in detail along a set of factors that are related to each decision. This information is essential, not only for understanding why a particular drug is accepted in one country and not in another but also when trying to implement a new HTA system or reform an existing one. This analysis provides policy makers and stakeholders with a model that enables a better understanding of the factors that drive HTA decisions and is adaptable to answer similar questions. Moreover, the data collection limitations encountered and described in this work shed light on the need for greater accessibility and transparency in HTA systems and regarding HTA outcomes.

Role of economic evidence in coverage decision-making in South Korea

OBJECTIVES

The South Korean government required the submission of economic evidence when it implemented the Positive-List System in December 2006. This study investigates the key factors that influenced actual public insurance reimbursement decisions, including the role of economic evidence, after 10 years of decision practice under compulsory health technology assessment (HTA) for new drugs.

METHOD

Logistic regression analysis was used to estimate the impact of the variables involved, including cost-effectiveness ratio as a key variable, on reimbursement decisions. The latter were defined as "yes" or "no" at a submitted price and indication. Only cases (n = 91) that present a cost-effectiveness ratio, and that have been reviewed based on this ratio from January 2007 to December 2016, were included in the analysis.

RESULTS

Cases with higher cost-effectiveness ratios were less likely to be accepted. In addition, drugs that were used to treat severe diseases and drugs with no substitute were more likely to be recommended. The probability of acceptance declined along with the level of uncertainty in the submitted evidence. The acceptance rate for severe-disease drugs has increased since 2013, when the government introduced several policies that lowered the existing barriers to positive reimbursement. However, such an increase was not statistically significant.

CONCLUSIONS

Cost-effectiveness is one of the most influential factors in drug-reimbursement decisions. However, inclusion of other explanatory variables, in addition to the cost-effectiveness ratio, predicted the results of decisions more accurately.

Development and validation of a Health Policy Model of Type 2 diabetes in Chinese setting

Aim: Due to the difference in epidemiology and outcomes between eastern and western populations with Type 2 diabetes mellitus (T2DM), an important challenge is determining how useful the outcomes from diabetes models based on western populations are for eastern patients. Consequently, the principal aim of this study was to develop and validate a Health Policy Model (Chinese Outcomes Model for T2DM [COMT]) for supporting Chinese medical and health economic studies. Methods: The model is created to simulate a series of important complications of T2DM diabetes based on the latest Risk Equations for Complications of Type 2 Diabetes, which was adjusted by adding the adjustment regulator to the linear predictor within the risk equation. The validity of the model was conducted by using a total of 171 validation outcomes from seven studies in eastern populations and ten studies in western populations. The simulation cohorts in the COMT model were generated by copying each validation study's baseline characteristics. Concordance was tested by assessing the difference between the identity (45°) line and the best-fitting regression of the scatterplots for the predicted versus observed outcomes. Results: The slope coefficients of the best-fitting regression line between the predicted and corresponding observed actual outcomes was 0.9631 and the R² was 0.8701. There were major differences between western and eastern populations. The slope and R² of predictions were 0.9473 and 0.9272 in the eastern population and 1.0566 and 0.8863 in the western population, which showed more perfect agreement with the observed values in the eastern population than the western populations. The subset of macro-vascular and micro-vascular outcomes in the eastern population showed an identical tendency (the slope coefficient was close to 1), and mortality outcomes showed a slight tendency toward overestimation (the slope coefficient was close to 0.9208). Some degree of underprediction of macro-vascular and micro-vascular end points and overprediction of mortality end point was found in the western population. Conclusion: The COMT diabetes model simulated the long-term patient outcomes observed in eastern Asian T2DM patients with prediction accuracy. This study supports the COMT as a credible tool for Chinese healthcare decision makers. Further work is necessary to incorporate new local data to improve model validity and credibility.

Cost-effectiveness and long-term follow-up of three forms of minimal-contact cognitive behaviour therapy for severe health anxiety: Results from a randomised controlled trial

Strategies to increase the availability of cognitive behaviour therapy (CBT) for severe health anxiety (SHA) are needed, and this study investigated the cost-effectiveness and long-term efficacy of three forms of minimal-contact CBT for SHA. We hypothesised that therapist-guided internet CBT (G-ICBT), unguided internet CBT (U-ICBT), and cognitive behavioural bibliotherapy (BIB-CBT) would all be more cost-effective than a waiting-list condition (WLC), as assessed over the main phase of the trial. We also hypothesised that improvements would remain stable up to one-year follow-up. Adults (N = 132) with principal SHA were randomised to 12 weeks of G-ICBT, U-ICBT, BIB-CBT, or WLC. The primary measure of cost-effectiveness was the incremental cost-effectiveness ratio, or the between-group difference in per capita costs divided by the between-group difference in proportion of participants in remission. The Health anxiety inventory (HAI) was the primary efficacy outcome. G-ICBT, U-ICBT, and BIB-CBT were more cost-effective than the WLC. Over the follow-up period, the G-ICBT and BIB-CBT groups made further improvements in health anxiety, whereas the U-ICBT group did not change. As expected, all three treatments were cost-effective with persistent long-term effects. CBT without therapist support appears to be a valuable alternative to G-ICBT for scaling up treatment for SHA.

The Relative Importance of Clinical, Economic, Patient Values and Feasibility Criteria in Cancer Drug Reimbursement in Canada: A Revealed Preferences Analysis of Recommendations of the Pan-Canadian Oncology Drug Review 2011-2017

BACKGROUND

Most Canadian provinces and territories rely on the pan-Canadian Oncology Drug Review (pCODR) to provide recommendations regarding public reimbursement of cancer drugs. The pCODR review process considers four dimensions of value-clinical benefit, economic evaluation, patient-based values and adoption feasibility-but they do not define weights for individual decision criteria or an acceptable threshold for any of the criteria. Given this implicit review process, it is of interest to understand which factors appear to carry the most weight in pCODR recommendations using a revealed preferences approach.

METHODS

Using publicly available decision summaries (n = 91) describing submissions and resulting recommendations 2011-2017, we extracted ten attributes that characterized each submission. Using logistic regression, we identified statistically significant attributes and estimated their relative impact in final recommendations.

RESULTS

Clinical aspects appear to carry the greatest weight in the decision to reject or not reject, along with aspects of patient value (treatments with no alternatives were less likely to be rejected). Cost effectiveness does not appear to play a role in the initial decision to reject or not reject but is critical in full versus conditional approvals. There is evidence of a maximum acceptable threshold of around $Can140,000 per quality-adjusted life-year (QALY) gained.

CONCLUSION

A set of factors driving pCODR recommendations is identifiable, supporting the consistency of the review process. However, the implicit nature of the review process and the difficulty of extracting and interpreting some of the attribute levels used in the analysis suggests that the process may still lack full transparency.

Revealed and Stated Preferences of Decision Makers for Priority Setting in Health Technology Assessment: A Systematic Review

BACKGROUND

There is much interest from stakeholders in understanding how health technology assessment (HTA) committees make national funding decisions for health technologies. A growing literature has analysed past decisions by committees (revealed preference, RP studies) and hypothetical decisions by committee members (stated preference, SP studies) to identify factors influencing decisions and assess their importance.

OBJECTIVES

A systematic review of the literature was undertaken to provide insight into committee preferences for these factors (after controlling for other factors) and the methods used to elicit them.

METHODS

Ovid Medline, Embase, Econlit and Web of Science were searched from inception to 11 May 2017. Included studies had to have investigated factors considered by HTA committees and to have conducted multivariate analysis to identify the effect of each factor on funding decisions. Factors were classified as being important based on statistical significance, and their impact on decisions was compared using marginal effects.

RESULTS

Twenty-three RP and four SP studies (containing 42 analyses) of 14 HTA committees met the inclusion criteria. Although factors were defined differently, the SP literature generally found clinical efficacy, cost-effectiveness and equity factors (such as disease severity) were each important to the Pharmaceutical Benefits Advisory Committee (PBAC), the National Institute for Health and Care Excellence (NICE) and the All Wales Medicines Strategy Group. These findings were supported by the RP studies of the PBAC, but not the other committees, which found funding decisions by these and other committees were mostly influenced by the acceptance of the clinical evidence and, where applicable, cost-effectiveness. Trust in the evidence was very important for decision makers, equivalent to reducing the incremental cost-effectiveness ratio (cost per quality-adjusted life-year) by A$38,000 (Australian dollars) for the PBAC and £15,000 for NICE.

CONCLUSIONS

This review found trust in the clinical evidence and, where applicable, cost-effectiveness were important for decision makers. Many methodological differences likely contributed to the diversity in some of the other findings across studies of the same committee. Further work is needed to better understand how competing factors are valued by different HTA committees.

Self-responsibility, rationing and treatment decision making - managing moral narratives alongside fiscal reality in the obesity surgery clinic

Background

Addressing the prevalence of severe obesity and its concomitant morbidities is widely acknowledged as one of the most pressing global health priorities. Nevertheless, a paucity of effective interventions and universal pressure on health‐care budgets means that access to obesity treatments is often limited. Although health‐care rationing can be conceived as a socially constructed process, little is known about how decisions emerge within the context of face‐to‐face doctor–patient interactions.

Methods

In this study, we used in‐depth interviews and clinic observations to investigate clinicians’ (n = 11) and patients’ (n = 22) experiences of the rationing of obesity surgery and to examine how broader cultural assumptions around personal responsibility for health emerged in the context of clinical interactions.

Results

Patients and clinicians worked within similar frameworks when it came to self‐responsibility for health and the appropriateness of providing publicly‐funded weight loss surgery. Issues around personal accountability dominated consultations, and patients were expected to provide narratives of the development of their obesity and to account for the failure of previous interventions. Clinicians faced the added pressure of having to prioritise a limited number of patients for surgery, which was predominantly managed through mandating pre‐referral weight loss targets.

Discussion

Although clinicians sought to maintain an empathic attitude towards individual patients, in practice they were conflicted by their responsibility to ration health‐care resources and tended to rely on entrenched models of behaviour change to allocate treatment. As a result, the content of consultations was mostly focused on issues of personal responsibility, reflecting wider stigmatized attitudes towards extreme obesity.

Using health technology assessment to assess the value of new medicines: results of a systematic review and expert consultation across eight European countries

BACKGROUND

Although health technology assessment (HTA) systems base their decision making process either on economic evaluations or comparative clinical benefit assessment, a central aim of recent approaches to value measurement, including value based assessment and pricing, points towards the incorporation of supplementary evidence and criteria that capture additional dimensions of value.

OBJECTIVE

To study the practices, processes and policies of value-assessment for new medicines across eight European countries and the role of HTA beyond economic evaluation and clinical benefit assessment.

METHODS

A systematic (peer review and grey) literature review was conducted using an analytical framework examining: (1) 'Responsibilities and structure of HTA agencies'; (2) 'Evidence and evaluation criteria considered in HTAs'; (3) 'Methods and techniques applied in HTAs'; and (4) 'Outcomes and implementation of HTAs'. Study countries were France, Germany, England, Sweden, Italy, Netherlands, Poland and Spain. Evidence from the literature was validated and updated through two rounds of feedback involving primary data collection from national experts.

RESULTS

All countries assess similar types of evidence; however, the specific criteria/endpoints used, their level of provision and requirement, and the way they are incorporated (e.g. explicitly vs. implicitly) varies across countries, with their relative importance remaining generally unknown. Incorporation of additional 'social value judgements' (beyond clinical benefit assessment) and economic evaluation could help explain heterogeneity in coverage recommendations and decision-making.

CONCLUSION

More comprehensive and systematic assessment procedures characterised by increased transparency, in terms of selection of evaluation criteria, their importance and intensity of use, could lead to more rational evidence-based decision-making, possibly improving efficiency in resource allocation, while also raising public confidence and fairness.

Healthcare quality and medicine reimbursement criteria in Iran

Purpose

This study aims to measure the quality of services provided to elderly people at the most crowded governmental ambulatory clinics of Tehran Province using the SERVQUAL scale (Study 1). Moreover, the research indicates the medicine reimbursement criteria to inform the decision-makers of public health insurance organizations using the Borda method (Study 2).

Design/methodology/approach

This study was done as a cross-sectional research on 425 elderly patients who came to the clinics during 2014 and 2015. Finally, using the paired t-test, Friedman test, Borda method, SPSS, Matlab software and Delphi method, the collected data were analysed.

Findings

Regarding the perceived quality, the services assurance dimension was ranked as having the highest quality (4.48) and the accessibility dimension as the lowest one (3.22). Based on the Borda method, the most important criterion for the Iranian health insurance companies to accept a medicine in their reimbursement list is the “life-threatening conditions” factor. On the other hand, “evidence quality” is accounted as the fifth important factor.

Research limitations/implications

The main limitation was the senility of participants that makes it difficult for understanding and completing the questionnaires.

Practical implications

The results can be useful for healthcare policy makers and related authorities. Besides, public health insurers can use the findings for decision-making about the elderly diseases and the problems such as the medical expenses.

Originality/value

The present research has been done in a two-year time frame, and it is more recent than other related studies. Thus, the results are far more authentic and applicable.

Pharmaceutical Pricing in Germany: How Is Value Determined within the Scope of AMNOG?

OBJECTIVES

To analyze how value is determined within the scope of the German Pharmaceutical Restructuring Act, which came into effect in 2011.

METHODS

Using data from all pharmaceuticals that had undergone assessment, appraisal, and price negotiations in Germany before June 30, 2016, we applied generalized linear model regression to analyze the impact of added benefit on the difference between negotiated prices and the prices of comparators. Data were extracted from the Federal Joint Committee's appraisals and price databases. We specified added benefit in various ways. In all models, we controlled for additional criteria such as size of patient population, European price levels, and whether the comparators were generic.

RESULTS

Our regression results confirmed the descriptive results, with price premiums reflecting the extent of added benefit as appraised by the Federal Joint Committee. On the substance level, an added benefit was associated with an increase in price premium of 227.2% (P < 0.001) compared with no added benefit. Moreover, we saw increases in price premium of 377.5% (P < 0.001), 90.0% (P < 0.001), and 336.8% (P < 0.001) for added benefits that were "considerable," "minor," and "not quantifiable," respectively. Beneficial effects on mortality were associated with the greatest price premium (624.3%; P < 0.001), followed by such effects on morbidity (174.7%; P < 0.001) and adverse events (93.1%; P = 0.019).

CONCLUSIONS

Price premiums, or "value," are driven by health gain, the share of patients benefiting from a pharmaceutical, European price levels, and whether comparators are generic. No statement can be made, however, about the appropriateness of the level of price premiums.

National reimbursement listing determinants of new cancer drugs: a retrospective analysis of 58 cancer treatment appraisals in 2007-2016 in South Korea

BACKGROUND

Since the positive-list system was introduced, concerns have been raised over restricting access to new cancer drugs in Korea. Policy changes in the decision-making process, such as risk-sharing agreement and the waiver of pharmacoeconomic data submission, were implemented to improve access to oncology medicines, and other factors are also involved in the reimbursement for cancer drugs. The aim of this study is to investigate the reimbursement listing determinants of new cancer drugs in Korea.

METHODS

All cancer treatment appraisals of Health Insurance Review and Assessment during 2007-2016 were analyzed based on 13 independent variables (comparative effectiveness, cost-effectiveness, drug-price comparison, oncology-specific policy, and innovation such as new mode of action). Univariate and multivariate logistic analyses were conducted.

RESULTS

Of 58 analyzed submissions, 40% were listed in the national reimbursement formulary. In univariate analysis, four variables were related to listing: comparative effectiveness, drug-price comparison, new mode of action, and risk-sharing agreement. In multivariate logistic analysis, three variables significantly increased the likelihood of listing: clinical improvement, below alternative's price, and risk-sharing arrangement. Cancer drug's listing increased from 17% to 47% after risk-sharing agreement implementation.

CONCLUSION

Clinical improvement, cost-effectiveness, and RSA application are critical to successful national reimbursement listing.

Identifying and Revealing the Importance of Decision-Making Criteria for Health Technology Assessment: A Retrospective Analysis of Reimbursement Recommendations in Ireland

BACKGROUND

Decisions on reimbursement of health interventions in many jurisdictions are informed by health technology assessments (HTAs). Historically, the focus of these has often been cost effectiveness or cost utility, while other criteria were considered informally. More recently, there has been an increasing interest in the formal incorporation of additional criteria using multi-criteria decision analysis. Such an approach has not yet formally been part of decision-making policy in Ireland.

OBJECTIVE

The objective of this analysis is to demonstrate that cost effectiveness is not the only criterion influencing reimbursement decisions in Ireland. Furthermore, the aim is to reveal criteria that may have informally influenced reimbursement decisions in the past.

METHODS

A list of potential criteria was identified based on the literature, national guidelines and experience of the national HTA agency. Information on each of these criteria was sought for every assessment conducted in Ireland up to July 2015. A logistic regression was fitted to the data to identify influential parameters. Model selection was performed using the Bolasso method.

RESULTS

Thirteen criteria were considered in the analysis. Two members of the HTA review team assessed the performance of the interventions against these criteria. Model selection suggests that the incremental cost-effectiveness ratio and quality of evidence could be important drivers of reimbursement recommendations in Ireland. Less important drivers suggested include the year of assessment, the level of uncertainty, as well as safety and tolerability.

CONCLUSION

The analysis demonstrates that recommendations for or against the reimbursement of technologies in Ireland are not only driven by cost effectiveness. This highlights the need for more formal inclusion of criteria in the process, to improve transparency and ensure consistency.

Using CART to Identify Thresholds and Hierarchies in the Determinants of Funding Decisions

There is much interest in understanding decision-making processes that determine funding outcomes for health interventions. We use classification and regression trees (CART) to identify cost-effectiveness thresholds and hierarchies in the determinants of funding decisions. The hierarchical structure of CART is suited to analyzing complex conditional and nonlinear relationships. Our analysis uncovered hierarchies where interventions were grouped according to their type and objective. Cost-effectiveness thresholds varied markedly depending on which group the intervention belonged to: lifestyle-type interventions with a prevention objective had an incremental cost-effectiveness threshold of $2356, suggesting that such interventions need to be close to cost saving or dominant to be funded. For lifestyle-type interventions with a treatment objective, the threshold was much higher at $37,024. Lower down the tree, intervention attributes such as the level of patient contribution and the eligibility for government reimbursement influenced the likelihood of funding within groups of similar interventions. Comparison between our CART models and previously published results demonstrated concurrence with standard regression techniques while providing additional insights regarding the role of the funding environment and the structure of decision-maker preferences.

Reimbursement Decisions for Pharmaceuticals in Sweden: The Impact of Disease Severity and Cost Effectiveness

OBJECTIVE

The Swedish Dental and Pharmaceutical Benefits Agency (TLV) is the government body responsible for deciding whether outpatient drugs are to be included in the pharmaceutical benefits scheme. This paper analyzes the impact of cost effectiveness and severity of disease on reimbursement decisions for new pharmaceuticals.

METHODS

Data has been extracted from all decisions made by the TLV between 2005 and 2011. Cost effectiveness is measured as the cost per quality-adjusted life-year (QALY) gained, whereas disease severity is a binary variable (severe-not severe). In total, the dataset consists of 102 decisions, with 86 approved and 16 declined reimbursements.

RESULTS

The lowest cost per QALY of declined reimbursements is Swedish kronor (SEK) 700,000 (€ 79,100), while the highest cost per QALY of approved reimbursements is SEK1,220,000 (€ 135,600). At a cost per QALY of SEK702,000 Swedish kronor (non-severe diseases) and SEK988,000 (severe diseases), the likelihood of approval is estimated to be 50/50 (€ 79,400 and € 111,700).

CONCLUSIONS

The TLV places substantial weight on both the cost effectiveness and the severity of disease in reimbursement decisions, and the implied willingness to pay for a QALY is higher than the often cited 'rule of thumb' in Swedish policy debates.

The Influence of Cost-Effectiveness and Other Factors on Nice Decisions

The National Institute for Health and Care Excellence (NICE) emphasises that cost-effectiveness is not the only consideration in health technology appraisal and is increasingly explicit about other factors considered relevant but not the weight attached to each. The objective of this study is to investigate the influence of cost-effectiveness and other factors on NICE decisions and whether NICE's decision-making has changed over time. We model NICE's decisions as binary choices for or against a health care technology in a specific patient group. Independent variables comprised of the following: clinical and economic evidence; characteristics of patients, disease or treatment; and contextual factors potentially affecting decision-making. Data on all NICE decisions published by December 2011 were obtained from HTAinSite [www.htainsite.com]. Cost-effectiveness alone correctly predicted 82% of decisions; few other variables were significant and alternative model specifications had similar performance. There was no evidence that the threshold has changed significantly over time. The model with highest prediction accuracy suggested that technologies costing £40 000 per quality-adjusted life-year (QALY) have a 50% chance of NICE rejection (75% at £52 000/QALY; 25% at £27 000/QALY). Past NICE decisions appear to have been based on a higher threshold than £20 000-£30 000/QALY. However, this may reflect consideration of other factors that cannot be easily quantified. © 2014 The Authors. Health Economics published by John Wiley & Sons Ltd.

Acceptance of health technology assessment submissions with incremental cost-effectiveness ratios above the cost-effectiveness threshold

Objectives

In health technology assessment (HTA) agencies where cost-effectiveness plays a role in decision-making, an incremental cost-effectiveness ratio (ICER) threshold is often used to inform reimbursement decisions. The acceptance of submissions with ICERs higher than the threshold was assessed across different agencies and across indications, in order to inform future reimbursement submissions.

Methods

All HTA appraisals from May 2000 to May 2014 from National Institute for Health and Care Excellence (NICE), Scottish Medicines Consortium (SMC), Pharmaceutical Benefits Advisory Committee (PBAC), and Canadian Agency for Drugs and Technologies in Health (CADTH) were assessed. Multiple technology appraisals, resubmissions, vaccination programs, and requests for advice were excluded. Submissions not reporting an ICER, or for which an ICER could not be determined were also excluded. The remaining appraisals were reviewed, and the submitted ICER, recommendation, and reasoning behind the recommendation were extracted.

Results

NICE recommended the highest proportion of submissions with ICERs higher than the threshold (34% accepted without restrictions; 20% with restrictions), followed by PBAC (16% accepted without restrictions; 4% with restrictions), SMC (11% accepted without restrictions; 14% accepted with restrictions), and CADTH (0% accepted without restrictions; 26% with restrictions). Overall, the majority of higher-than-threshold ICER submissions were classified into the “malignant disease and immunosuppression” therapeutic category; however, there was no notable variation in acceptance rates by disease area. Reasons for accepting submissions reporting ICERs above the threshold included high clinical benefit over the standard of care, and addressing an unmet therapeutic need.

Conclusion

Acceptance of submissions with higher-than-threshold ICERs varied by HTA agency and was not significantly influenced by disease category. Such submissions must be accompanied by robust, concrete, and transparent evidence in order to achieve patient access.

The quality of economic evaluations of ultra-orphan drugs in Europe - a systematic review

An orphan disease is defined in the EU as a disorder affecting less than 1 in 2 000 individuals. The concept of ultra-orphan has been proposed for diseases with a prevalence of less than 1:50 000. Drugs for ultra-orphan diseases are amongst the most expensive medicines on a cost-per-patient basis. The extremely high prices have prompted initiatives to evaluate cost-effectiveness and cost-utility in EU-member states. The objective of this review was to evaluate the quality of cost-effectiveness and cost-utility studies on ultra-orphan drugs. We searched 2 databases and the reference lists of relevant systematic reviews. Studies reporting on full economic evaluations, or at least aiming at such evaluation, were eligible for inclusion. Quality was assessed with the use of the Consensus on Health Economic Criteria (CHEC)-list. Two-hundred-fifty-one studies were identified. Of these, 16 fitted our inclusion criteria. A study on enzyme replacement and substrate reduction therapies for lysosomal storage disorders did not perform a full economic evaluation due to the high drug costs and the lack of a measurable effect on either clinical or health-related quality of life outcomes. Likewise, a cost-effectiveness analysis of laronidase for mucopolysaccharidosis type 1 was considered unfeasible due to lack of clinical effectiveness data, while in the same study a crude model was used to estimate cost-utility of enzyme replacement therapy (ERT) for Fabry disease. Three additional studies, one on ERT for Fabry disease, one on ERT for Gaucher disease and one on eculizumab for paroxysmal nocturnal haemoglobinuria, used an approach that was too simplistic to lead to a realistic estimate of the incremental cost-effectiveness (ICER) or cost-utility ratio (ICUR). In all other studies (N = 11) more sophisticated pharmacoeconomic models were used to estimate cost-effectiveness and cost-utility of the specific drug, mostly ERT or drugs indicated for pulmonary arterial hypertension (PAH). Seven studies used a Markov-state-transition model. Other models used were patient-level simulation models (N = 3) and decision trees (N = 1). Only 4 studies adopted a societal perspective. All but 2 studies discounted costs and effects appropriately. Drugs for metabolic diseases appeared to be significantly less cost-effective than drugs indicated for PAH, with ICERs ranging from €43 532 (Gaucher disease) to €3 282 252 (Fabry disease). Quality of studies using a Markov-state-transition or patient-level simulation model is in general good with 14–19 points on the CHEC-list. We therefore conclude that economic evaluations of ultra-orphan drugs are feasible if pharmacoeconomic modelling is used. Considering the need for modelling of several disease states and the small patient groups, a Markov-state-transition model seems to be most suitable type of model. However, it should be realised that ultra-orphan drugs will usually not meet the conventional criteria for cost-effectiveness. Nevertheless, ultra-orphan drugs are often reimbursed. Further discussion on the use of economic evaluations and their consequences in case of ultra-orphan drugs is therefore warranted.

Incremental cost per quality-adjusted life year gained? The need for alternative methods to evaluate medical interventions for ultra-rare disorders

Drugs for ultra-rare disorders (URDs) rank prominently among the most expensive medicines on a cost-per-patient basis. Many of them do not meet conventional standards for cost-effectiveness. In light of the high fixed cost of R&D, this challenge is inversely related to the prevalence of URDs. The present paper sets out to explain the rationale underlying a recent expert consensus on these issues, recommending a more rigorous assessment of the clinical effectiveness of URDs, applying established standards of evidence-based medicine. This may include conditional approval and reimbursement policies, which should be combined with a firm expectation of proof of a minimum significant clinical benefit within a reasonable time. In contrast, current health economic evaluation paradigms fail to adequately reflect normative and empirical concerns (i.e., morally defensible 'social preferences') regarding healthcare resource allocation. Hence there is a strong need for alternative economic evaluation models for URDs.

Which factors enhance positive drug reimbursement recommendation in Scotland? A retrospective analysis 2006-2013

OBJECTIVES

To identify the factors that influence the Scottish Medicines Consortium (SMC) in deciding whether to accept pharmaceutical technologies for use within the Scottish health care system.

METHODS

A database of SMC submissions between 2006 and 2013 was created, containing a range of clinical, economic, and other factors extracted from published health technology assessment reports. A binomial outcome variable was used, defined as the decision to "accept for use" or "not recommend" a technology. Univariate and multivariate analyses were conducted to assess the impact by means of odds ratios (ORs) of the submitted evidence on the recommendation decision.

RESULTS

Out of 463 applications, 265 were accepted for use (57%) and 198 (43%) were not recommended for use within National Health Service Scotland. Univariate analyses showed that 13 variables significantly affected the SMC decision. Of these 13 variables, 7 variables were shown to have a meaningful impact in the multivariate analysis. Four of these concerned the outcome of cost-effectiveness analyses; the fact that a submission was supported by a cost-minimization analysis was the strongest positive variable (OR = 10.30) and a submission showing a product not being cost-effective (i.e., incremental cost-effectiveness ratio above £30,000/quality-adjusted life-year gained) was the strongest negative predictor (OR = 0.47). The other variables concerned whether the submission was related to a product indicated for a nervous system disease (OR = 0.41), whether it was indicated for nonchronic use (OR = 1.66), and whether the submission was performed by a big company (OR = 2.83).

CONCLUSIONS

This study demonstrated that the outcome of cost-effectiveness analyses is an important factor affecting the SMC's reimbursement recommendation decision.

Reimbursement of orphan drugs in Belgium: what (else) matters?

Background

Most orphan drugs do not meet traditional standards of cost-effectiveness. Yet, most orphan drugs are reimbursed, which implies that other factors are taken into account at the time of reimbursement. To increase accountability of decision-makers, there is a need for more transparency in the factors that play a role in reimbursement decisions of orphan drugs. Therefore, the aim of this study is to use a combination of qualitative research methods to examine which official and non-official factors influence reimbursement decisions for orphan drugs in Belgium.

Methods

Six semi-structured interviews with past or present members of the Drug Reimbursement Committee (DRC) were performed with a view to obtaining an overview of the potential factors influencing reimbursement. Additionally, these presence of these factors was assessed in the reimbursement dossiers of all orphan drugs (n = 64) for which an application for reimbursement was submitted to the National Institute for Health and Disability Insurance in Belgium between January 2002 and July 2013.

Results

Different official (i.e. therapeutic value, budget impact, price and impact in clinical practice) and non-official factors (i.e. pricing and reimbursement in other countries, interference by patient organisations and experts, arguments related to quality of branded drug versus compounding, media attention, innovative character, economic importance, ethical arguments and the political climate) may have influenced past reimbursement decisions for orphan drugs in Belgium.

Discussion

The identification of factors influencing orphan drug reimbursement is a crucial step in the development of a transparent and consistent framework which will guide future decision-making for reimbursement of orphan drugs.

Electronic supplementary material

The online version of this article (doi:10.1186/s13023-014-0139-z) contains supplementary material, which is available to authorized users.

Public funding of pharmaceuticals in The Netherlands: investigating the effect of evidence, process and context on CVZ decision-making

The College Voor Zorgverzekeringen (CVZ) provides guidance to the Dutch healthcare system on funding and use of new pharmaceutical technologies. This study examined the impact of evidence, process and context factors on CVZ decisions in 2004-2009. A data set of CVZ decisions pertaining to pharmaceutical technologies was created, including 29 variables extracted from published information. A three-category outcome variable was used, defined as the decision to 'recommend', 'restrict' or 'not recommend' a technology. Technologies included in list 1A/1B or on the expensive drug list were considered recommended; those included in list 2 or for which patient co-payment is required were considered restricted; technologies not included on any reimbursement list were classified as 'not recommended'. Using multinomial logistic regression, the relative contribution of explanatory variables on CVZ decisions was assessed. In all, 244 technology appraisals (256 technologies) were analysed, with 51%, of technologies recommended, 33% restricted and 16% not recommended by CVZ for funding. The multinomial model showed significant associations (p ≤ 0.10) between CVZ outcome and several variables, including: (1) use of an active comparator and demonstration of statistical superiority of the primary endpoint in clinical trials, (2) pharmaceutical budget impact associated with introduction of the technology, (3) therapeutic indication and (4) prevalence of the target population. Results confirm the value of a comprehensive and multivariate approach to understanding CVZ decision-making.

Prioritising health service innovation investments using public preferences: a discrete choice experiment

BACKGROUND

Prioritising scarce resources for investment in innovation by publically funded health systems is unavoidable. Many healthcare systems wish to foster transparency and accountability in the decisions they make by incorporating the public in decision-making processes. This paper presents a unique conceptual approach exploring the public's preferences for health service innovations by viewing healthcare innovations as 'bundles' of characteristics. This decompositional approach allows policy-makers to compare numerous competing health service innovations without repeatedly administering surveys for specific innovation choices.

METHODS

A Discrete Choice Experiment (DCE) was used to elicit preferences. Individuals chose from presented innovation options that they believe the UK National Health Service (NHS) should invest the most in. Innovations differed according to: (i) target population; (ii) target age; (iii) implementation time; (iv) uncertainty associated with their likely effects; (v) potential health benefits; and, (vi) cost to a taxpayer. This approach fosters multidimensional decision-making, rather than imposing a single decision criterion (e.g., cost, target age) in prioritisation. Choice data was then analysed using scale-adjusted Latent Class models to investigate variability in preferences and scale and valuations amongst respondents.

RESULTS

Three latent classes with considerable heterogeneity in the preferences were present. Each latent class is composed of two consumer subgroups varying in the level of certainty in their choices. All groups preferred scientifically proven innovations, those with potential health benefits that cost less. There were, however, some important differences in their preferences for innovation investment choices: Class-1 (54%) prefers innovations benefitting adults and young people and does not prefer innovations targeting people with 'drug addiction' and 'obesity'. Class- 2 (34%) prefers innovations targeting 'cancer' patients only and has negative preferences for innovations targeting elderly, and Class-3 (12%) prefers spending on elderly and cancer patients the most.

CONCLUSIONS

DCE can help policy-makers incorporate public preferences for health service innovation investment choices into decision making. The findings provide useful information on the public's valuation and acceptability of potential health service innovations. Such information can be used to guide innovation prioritisation decisions by comparing competing innovation options. The approach in this paper makes, these often implicit and opaque decisions, more transparent and explicit.