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Callenbach MHE, Schoenmakers D, Vreman RA, Vijgen S, Timmers L, Hollak CEM, Mantel-Teeuwisse AK, Goettsch WG. Illustrating the Financial Consequences of Outcome-Based Payment Models From a Payers Perspective: The Case of Autologous Gene Therapy Atidarsagene Autotemcel (Libmeldy®). VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024; 27:1046-1057. [PMID: 38795960 DOI: 10.1016/j.jval.2024.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 04/12/2024] [Accepted: 05/04/2024] [Indexed: 05/28/2024]
Abstract
OBJECTIVES To illustrate the financial consequences of implementing different managed entry agreements (managed entry agreements for the Dutch healthcare system for autologous gene therapy atidarsagene autotemcel [Libmeldy]), while also providing a first systematic guidance on how to construct managed entry agreements to aid future reimbursement decision making and create patient access to high-cost, one-off potentially curative therapies. METHODS Three payment models were compared: (1) an arbitrary 60% price discount, (2) an outcome-based spread payment with discounts, and (3) an outcome-based spread payment linked to a willingness to pay model with discounts. Financial consequences were estimated for full responders (A), patients responding according to the predicted clinical pathway presented in health technology assessment reports (B), and unstable responders (C). The associated costs for an average patient during the time frame of the payment agreement, the total budget impact, and associated benefits expressed in quality-adjusted life-years of the patient population were calculated. RESULTS When patients responded according to the predicted clinical pathway presented in health technology assessment reports (scenario B), implementing outcome-based reimbursement models (models 2 and 3) had lower associated budget impacts while gaining similar benefits compared with the discount (scenario 1, €8.9 million to €6.6 million vs €9.2 million). In the case of unstable responders (scenario C), costs for payers are lower in the outcome-based scenarios (€4.1 million and €3.0 million, scenario 2C and 3C, respectively) compared with implementing the discount (€9.2 million, scenario 1C). CONCLUSIONS Outcome-based models can mitigate the financial risk of reimbursing atidarsagene autotemcel. This can be considerably beneficial over simple discounts when clinical performance was similar to or worse than predicted.
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Affiliation(s)
- Marcelien H E Callenbach
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
| | - Daphne Schoenmakers
- Department of Child Neurology, Expertise Center Amsterdam Leukodystrophy Center, including lead of MLDi registry, Emma's Children's Hospital, Amsterdam UMC, Amsterdam, The Netherlands; Medicine for Society, Platform at Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Rick A Vreman
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands; National Health Care Institute (ZIN), Diemen, The Netherlands
| | - Sylvia Vijgen
- National Health Care Institute (ZIN), Diemen, The Netherlands
| | - Lonneke Timmers
- National Health Care Institute (ZIN), Diemen, The Netherlands
| | - Carla E M Hollak
- Medicine for Society, Platform at Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands; Department of Endocrinology and Metabolism, Expertise Center for Inborn Errors of Metabolism, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Aukje K Mantel-Teeuwisse
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands
| | - Wim G Goettsch
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, The Netherlands; National Health Care Institute (ZIN), Diemen, The Netherlands.
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Wiedmann LA, Cairns JA, Nolte E. Evidence Quality and Health Technology Assessment Outcomes in Reappraisals of Drugs for Rare Diseases in Germany. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024:S1098-3015(24)02795-5. [PMID: 39094688 DOI: 10.1016/j.jval.2024.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 06/08/2024] [Accepted: 07/08/2024] [Indexed: 08/04/2024]
Abstract
OBJECTIVES Evidence on reappraisals of health technologies in Germany is limited, and for rare disease treatments (RDTs), the Federal Joint Committee follows different processes (limited or regular), depending on whether an annual revenue threshold has been exceeded. Our objective is to better understand (re)appraisal processes and their outcomes for RDTs in Germany. METHODS We analyzed appraisal documents of 55 RDT indications for which an initial appraisal and a reappraisal were conducted between 2011 and 2023. We extracted information for the type of evidence, the risk of bias, the availability of additional evidence, and the change in the maturity of survival data as proxies for evidence quality. Specifically, we reviewed the reasons for conducting reappraisals, examined how evidence quality and the clinical benefit rating (CBR) differed between initial appraisals and reappraisals, and explored the association between evidence quality and (1) the CBR and (2) the change in the CBR after reappraisal. RESULTS Most reappraisals were conducted because the annual revenue threshold was exceeded or the initial appraisal resolution was time limited. Almost all initial appraisals used the limited process, whereas the majority of reappraisals used the regular process. The CBR increased in only 9 and decreased in 21 of 55 reappraisals. There was some evidence that reappraisals with an accepted randomized controlled trial were significantly more likely to achieve a higher CBR. CONCLUSIONS Findings confirmed that reasons and processes for conducting reappraisals of RDTs in Germany differ. Further, high CBRs in reappraisals were not common and evidence quality in initial appraisals and reappraisals was limited.
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Affiliation(s)
- Lea A Wiedmann
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, England, UK.
| | - John A Cairns
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, England, UK
| | - Ellen Nolte
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, England, UK
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Lorenzoni V, Marinello D, Palla I, Mosca M, Turchetti G, Talarico R. A cost-of-illness study of Behçet syndrome in Italy. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2024; 25:411-422. [PMID: 37212892 PMCID: PMC10973046 DOI: 10.1007/s10198-023-01593-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 04/21/2023] [Indexed: 05/23/2023]
Abstract
OBJECTIVE This study aims at evaluating the cost-of-illness (COI) of patients diagnosed with Behcet's syndrome (BS) in Italy, trying to depict the impact of different costs' components to the overall economic burden and analysing the variability of costs according to years since diagnosis and age at first symptoms. METHODS With a cross-sectional evaluation, we surveyed a large sample of BS patients in Italy assessing several dimensions related to BS, also including fact related to the use of health resources utilization, formal and informal care, and productivity losses. Overall costs, direct health, direct non-health, and indirect costs were thus estimated per patient/year considering a Societal perspective and the impact of years since diagnosis, age at first symptoms on costs was evaluated using generalized linear model (GLM) and a two-part model, adjusting for age and distinguishing among employed and non-employed responders. RESULTS A total of 207 patients were considered in the present study. From the perspective of the Society, mean overall costs for BS patient were estimated to be 21,624 € (0;193,617) per patient/year. Direct non-health expenses were the main costs component accounting for 58% of the overall costs, followed direct health costs, 36%, while indirect costs because of productivity losses represented 6% of the overall costs. Being employed resulted in significantly lower overall costs (p = 0.006). Results from the multivariate regression analyses suggested that the probability of incurring in overall costs equal to zero decreased as time from BS diagnosis is 1 year or more as compared to newly diagnosed patients (p < 0.001); while among those incurring in expenses, costs decreased for those experiencing first symptoms between 21 and 30 years (p = 0.027) or later (p = 0.032) as compared to those having symptoms earlier. Similar findings emerged among the subgroups of patients declaring themselves as workers, while no impact of years since diagnosis or age of first symptoms was found among non-workers. CONCLUSIONS The present study offers a comprehensive overview of the economic consequences imposed by BS in a societal perspective, providing insights into the distribution of the different costs component related to BS, thus helping the development of targeted policies.
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Affiliation(s)
- Valentina Lorenzoni
- Institute of Management, Scuola Superiore Sant'Anna, Piazza Martiri Della Libertà n. 33, 56127, Pisa, Italy.
| | - Diana Marinello
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Ilaria Palla
- Institute of Management, Scuola Superiore Sant'Anna, Piazza Martiri Della Libertà n. 33, 56127, Pisa, Italy
| | - Marta Mosca
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Giuseppe Turchetti
- Institute of Management, Scuola Superiore Sant'Anna, Piazza Martiri Della Libertà n. 33, 56127, Pisa, Italy
| | - Rosaria Talarico
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
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Sarri G, Rizzo M, Upadhyaya S, Paly VF, Hernandez L. Navigating the unknown: how to best 'reflect' standard of care in indications without a dedicated treatment pathway in health technology assessment submissions. J Comp Eff Res 2024; 13:e230145. [PMID: 38226913 PMCID: PMC10842305 DOI: 10.57264/cer-2023-0145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 12/12/2023] [Indexed: 01/17/2024] Open
Abstract
There is an urgent need for expedited approval and access for new health technologies targeting rare and very rare diseases, some of which are associated with high unmet treatment needs. Once a new technology achieves regulatory approval, the technology needs to be assessed by health technology assessment (HTA) bodies to inform coverage and reimbursement decisions. This assessment quantitatively examines the clinical effectiveness, safety and/or economic impact of the new technology relative to standard of care (SoC) in a specific market. However, in rare and very rare diseases, the patient populations are small and there is often no established treatment pathway available to define 'SoC'. In these situations, several challenges arise to assess the added benefit of a new technology - both clinically and economically - due to lack of established SoC to guide an appropriate comparator selection. These challenges include: How should 'SoC' be defined and characterized in HTA submissions for new technologies aiming to establish new treatment standards? What is usual care without an established clinical pathway? How should the evidence for the comparator 'SoC' (i.e., usual care) arm be collected in situations with low patient representation and, sometimes, limited disease-specific clinical knowledge in certain geographies? This commentary outlines the evidence generation challenges in designing clinical comparative effectiveness for a new technology when there is a lack of established SoC. The commentary also proposes considerations to facilitate the reliable integration of real-world evidence into HTA and decision-making based on the collective experience of the authors.
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Affiliation(s)
| | | | | | | | - Luis Hernandez
- Takeda Pharmaceuticals America, Inc., Lexington, MA, USA
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5
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Wiedmann L, Blumenau J, Carroll O, Cairns J. Using automated text classification to explore uncertainty in NICE appraisals for drugs for rare diseases. Int J Technol Assess Health Care 2024; 40:e5. [PMID: 38178720 PMCID: PMC10859832 DOI: 10.1017/s0266462323002805] [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: 09/15/2023] [Revised: 11/28/2023] [Accepted: 12/02/2023] [Indexed: 01/06/2024]
Abstract
OBJECTIVE This study examined the application, feasibility, and validity of supervised learning models for text classification in appraisals for rare disease treatments (RDTs) in relation to uncertainty, and analyzed differences between appraisals based on the classification results. METHODS We analyzed appraisals for RDTs (n = 94) published by the National Institute for Health and Care Excellence (NICE) between January 2011 and May 2023. We used Naïve Bayes, Lasso, and Support Vector Machine models in a binary text classification task (classifying paragraphs as either referencing uncertainty in the evidence base or not). To illustrate the results, we tested hypotheses in relation to the appraisal guidance, advanced therapy medicinal product (ATMP) status, disease area, and age group. RESULTS The best performing (Lasso) model achieved 83.6 percent classification accuracy (sensitivity = 74.4 percent, specificity = 92.6 percent). Paragraphs classified as referencing uncertainty were significantly more likely to arise in highly specialized technology (HST) appraisals compared to appraisals from the technology appraisal (TA) guidance (adjusted odds ratio = 1.44, 95 percent CI 1.09, 1.90, p = 0.004). There was no significant association between paragraphs classified as referencing uncertainty and appraisals for ATMPs, non-oncology RDTs, and RDTs indicated for children only or adults and children. These results were robust to the threshold value used for classifying paragraphs but were sensitive to the choice of classification model. CONCLUSION Using supervised learning models for text classification in NICE appraisals for RDTs is feasible, but the results of downstream analyses may be sensitive to the choice of classification model.
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Affiliation(s)
- Lea Wiedmann
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, UK
| | - Jack Blumenau
- Department of Political Science, Faculty of Social & Historical Sciences, University College London, UK
| | - Orlagh Carroll
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, UK
| | - John Cairns
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, UK
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Sarri G, Forsythe A, Elvidge J, Dawoud D. Living health technology assessments: how close to living reality? BMJ Evid Based Med 2023; 28:369-371. [PMID: 36797052 DOI: 10.1136/bmjebm-2022-112152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/04/2023] [Indexed: 02/18/2023]
Affiliation(s)
- Grammati Sarri
- Real World and Advanced Analytics, Cytel Inc, London, UK
| | - Anna Forsythe
- Real World and Advanced Analytics, Cytel Inc, Miami, Florida, USA
| | - Jamie Elvidge
- Science, Evidence and Analytics Directorate, National Institute for Health and Care Excellence, London, UK
| | - Dalia Dawoud
- Science, Evidence and Analytics Directorate, National Institute for Health and Care Excellence, London, UK
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Geissler J, Makaroff LE, Söhlke B, Bokemeyer C. Precision oncology medicines and the need for real world evidence acceptance in health technology assessment: Importance of patient involvement in sustainable healthcare. Eur J Cancer 2023; 193:113323. [PMID: 37748397 DOI: 10.1016/j.ejca.2023.113323] [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: 07/03/2023] [Revised: 08/24/2023] [Accepted: 08/30/2023] [Indexed: 09/27/2023]
Abstract
Precision oncology has made remarkable strides in improving clinical outcomes, offering hope to patients with historically difficult-to-treat, as well as rare or neglected cancers. However, despite rapid advancement, precision oncology has reached a critical juncture, where patient access to these life-saving medicines may be hampered by strict requirements by Health Technology Assessment (HTA) bodies for randomised controlled trials (RCTs) for assessing new medicines against appropriate comparator. The very nature of precision oncology-matching a tumour's unique molecular alterations to targeted therapies predicted to elicit response-can make the use of RCTs very difficult, as only a very small number of patients might qualify for a given therapy within a traditional clinical trial setting. Real-world evidence (RWE) has been accepted for regulatory decision-making but has yet to reach widespread acceptance by HTA bodies. As the oncology treatment landscape has evolved towards favouring the concept of precision oncology, there is a growing need for flexibility in the way HTA bodies evaluate new medicines. We must acknowledge that current assessment methodologies can limit access to life-changing medicines for many patients who have no alternative options and that a growing number of precision oncology medicines with proven clinical benefits in rare tumours cannot be reasonably evaluated using traditional methodologies. The objectives of this paper are to advocate a change in mindset regarding best practices in drug assessment models and to propose alternative approaches when considering indications for which RWE is the most compelling data source available.
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Affiliation(s)
| | - Lydia E Makaroff
- World Bladder Cancer Patient Coalition, Brussels, Belgium; Fight Bladder Cancer, Oxfordshire, UK
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Gibson E, Ollendorf DA, Simoens S, Bloom DE, Martinón-Torres F, Salisbury D, Severens JL, Toumi M, Molnar D, Meszaros K, Sohn WY, Begum N. Rule of Prevention: a potential framework to evaluate preventive interventions for rare diseases. JOURNAL OF MARKET ACCESS & HEALTH POLICY 2023; 11:2239557. [PMID: 37583879 PMCID: PMC10424616 DOI: 10.1080/20016689.2023.2239557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/19/2023] [Accepted: 07/18/2023] [Indexed: 08/17/2023]
Abstract
Background: The benefits of preventive interventions lack comprehensive evaluation in standard health technology assessments (HTA), particularly for rare and transmissible diseases. Objective: To identify possible considerations for future HTA using analogies between the treatment and prevention of rare diseases. Study design: An Expert panel meeting assessed whether one HTA assessment framework can be applied to assess both rare disease treatments and preventive interventions. Experts also evaluated the range of value elements currently included in HTAs and their applicability to rare, transmissible, and/or preventable diseases. Results: A broad range of value should be considered when assessing rare, transmissible disease prevention. Although standard HTA can be applied to transmissible diseases, the risk of local outbreaks and the need for large-scale prevention programs suggest a modified assessment framework, capable of incorporating prevention-specific value elements in HTAs. A 'Rule of Prevention' framework was proposed to allow broader value considerations anchored to severity, equity, and prevention benefits in decision-making for preventive interventions for rare transmissible diseases. Conclusion: The proposed prevention framework introduces an explicit initial approach to consistently assess rare transmissible diseases, and to incorporate the broader value of preventive interventions compared with treatment.
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Affiliation(s)
| | - Daniel A. Ollendorf
- Institute for Clinical Research and Health Policy Studies (ICRHPS), Center for the Evaluation of Value and Risk in Health (CEVR), Tufts Medical Center, Boston, MA, USA
| | - Steven Simoens
- Clinical Pharmacology and Pharmacotherapy, KU Leuven, Leuven, Belgium
| | - David E Bloom
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Federico Martinón-Torres
- Department of Pediatrics, Translational Pediatrics and Infectious Diseases, Pediatrics Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
- Genetics, Vaccines and Infections Research Group (GENVIP), Instituto de Investigación Sanitaria de Santiago, University of Santiago, Santiago de Compostela, Spain
- Centro de Investigación Biomédica En Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España
| | - David Salisbury
- Royal Institute of International Affairs, Chatham House, London, UK
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Wiedmann L, Cairns J. Review of economic modeling evidence from NICE appraisals of rare disease treatments for spinal muscular atrophy. Expert Rev Pharmacoecon Outcomes Res 2023; 23:469-482. [PMID: 36947403 DOI: 10.1080/14737167.2023.2193690] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
INTRODUCTION The National Institute of Health and Care Excellence (NICE) in England has appraised three treatments for spinal muscular atrophy (SMA), namely, nusinersen, onasemnogene abeparvovec, and risdiplam. As rare disease treatments (RDTs) commonly face challenges in health technology assessment (HTA) processes due to their clinical and economic uncertainties, an in-depth review of these appraisals is useful to enable a deeper understanding of economic modelling considerations for SMA. AREAS COVERED This review is a detailed analysis of NICE appraisals for SMA and aims to compare the economic modelling evidence of the three RDTs. This is done by examining differences and similarities and by discussing critical outstanding issues across the economic evaluations of the appraisals. EXPERT OPINION This article aims to contribute to the development of evidence that can be used as guidance to inform resource allocation decisions for RDTs for SMA, but also to be a resource about approaches for the generation, analysis and interpretation of economic modelling evidence for RDTs more broadly.
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Affiliation(s)
- Lea Wiedmann
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, Address: 15-17 Tavistock Place London WC1H 9SH UK
| | - John Cairns
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, Address: 15-17 Tavistock Place London WC1H 9SH UK
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Wagner M, Goetghebeur MM, Ganache I, Demers-Payette O, Auclair Y, Olivier C, Arbour S, de Guise M. HTA challenges for appraising rare disease interventions viewed through the lens of an institutional multidimensional value framework. Expert Rev Pharmacoecon Outcomes Res 2023; 23:143-152. [PMID: 36542763 DOI: 10.1080/14737167.2023.2161513] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Evaluating rare disease interventions poses challenges for HTA agencies, including uncertainties and ethical issues and tensions. INESSS has recently adopted a Statement of Principles and Ethical Foundations which proposes a multidimensional approach to value appraisal as well as five principles to frame the evaluation process. AREAS COVERED Our aim was to identify and analyze HTA challenges for appraising interventions for rare diseases, using the Statement's approach to value appraisal as an analytical framework, and outline how the Statement's principles can help address these challenges. Challenges, covering a diversity of aspects, were identified by leveraging institutional experience in diverse domains of expertise and consolidated through narrative literature review. Challenges were categorized by value dimension (clinical, populational, economic, organizational, and sociocultural), which allowed to pinpoint how each challenge affects the ability to appraise the value of an intervention. Key ethical tensions across dimensions were also identified. Specific approaches to addressing these challenges - related to knowledge mobilization and integration, deliberation, and recommendation-making - were outlined on the basis of the principles promulgated in the Statement. EXPERT OPINION A multidimensional approach can be fruitful for analyzing challenges for appraising the value of rare disease interventions and help guide approaches to tackle them.
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Affiliation(s)
- Monika Wagner
- Bureau - Méthodologies et éthique, Institut national d'excellence en santé et en services sociaux (INESSS), 2021 Avenue Union, bureau 1200; Montréal H3A 2S9, Quebec, Canada
| | - Mireille M Goetghebeur
- Bureau - Méthodologies et éthique, Institut national d'excellence en santé et en services sociaux (INESSS), 2021 Avenue Union, bureau 1200; Montréal H3A 2S9, Quebec, Canada.,School of Public Health, Department of Management, Evaluation and Health Policy, Université de Montréal; 7101, avenue du Parc, 3e étage H3N 1X9 Montréal, Quebec, Canada
| | - Isabelle Ganache
- Bureau - Méthodologies et éthique, Institut national d'excellence en santé et en services sociaux (INESSS), 2021 Avenue Union, bureau 1200; Montréal H3A 2S9, Quebec, Canada.,School of Public Health, Department of Social and Preventive Medicine, Université de Montréal, 7101avenue du Parc, 3e étage H3N 1X9 Montréal, Quebec, Canada
| | - Olivier Demers-Payette
- Bureau - Méthodologies et éthique, Institut national d'excellence en santé et en services sociaux (INESSS), 2021 Avenue Union, bureau 1200; Montréal H3A 2S9, Quebec, Canada.,School of Public Health, Department of Management, Evaluation and Health Policy, Université de Montréal; 7101, avenue du Parc, 3e étage H3N 1X9 Montréal, Quebec, Canada
| | - Yannick Auclair
- Bureau - Méthodologies et éthique, Institut national d'excellence en santé et en services sociaux (INESSS), 2021 Avenue Union, bureau 1200; Montréal H3A 2S9, Quebec, Canada
| | - Catherine Olivier
- Bureau - Méthodologies et éthique, Institut national d'excellence en santé et en services sociaux (INESSS), 2021 Avenue Union, bureau 1200; Montréal H3A 2S9, Quebec, Canada.,School of Public Health, Department of Social and Preventive Medicine, Université de Montréal, 7101avenue du Parc, 3e étage H3N 1X9 Montréal, Quebec, Canada
| | - Sylvie Arbour
- Bureau - Méthodologies et éthique, Institut national d'excellence en santé et en services sociaux (INESSS), 2021 Avenue Union, bureau 1200; Montréal H3A 2S9, Quebec, Canada
| | - Michèle de Guise
- Bureau - Méthodologies et éthique, Institut national d'excellence en santé et en services sociaux (INESSS), 2021 Avenue Union, bureau 1200; Montréal H3A 2S9, Quebec, Canada.,Institut national d'excellence en santé et en services sociaux (INESSS), 2021 Avenue Union, bureau 1200; Montréal H3A 2S9, Québec, Canada
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Nicod E, Lloyd AJ, Morel T, Meregaglia M, Upadhyaya S, Whittal A, Facey K, Drummond M. Improving Interpretation of Evidence Relating to Quality of Life in Health Technology Assessments of Rare Disease Treatments. THE PATIENT 2023; 16:7-17. [PMID: 36217098 DOI: 10.1007/s40271-022-00598-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/28/2022] [Indexed: 11/05/2022]
Abstract
Rare diseases are often severe, debilitating, life-limiting conditions, many of which occur in childhood. These complex conditions have a wide range of clinical manifestations that have a substantial impact on the lives of patients, carers and families and often produce heterogeneous clinical outcomes. Therefore, the evaluation of quality-of-life (QoL) impacts is important. In health technology assessment (HTA), patient-reported outcome measures (PROMs) and/or health state utility values (HSUVs) are used to determine QoL impacts of new treatments, but their use in rare diseases is challenging due to small and heterogeneous populations and limited disease knowledge. This paper describes challenges associated with the use of patient-reported outcomes (PROs)/HSUVs to evaluate QoL in HTA of rare disease treatments (RDTs) and identifies five recommendations to ensure appropriate interpretation of QoL impacts. These were derived from mixed methods research (literature reviews, appraisal document analyses, appraisal committee observations and interviews) examining the use of PROs/HSUVs in HTA of RDTs. They highlight that HTAs of RDTs must (1) understand the QoL impacts of the disease and of treatments; (2) critically assess PRO data, recognising the nuances in development and administration of PROMs/HSUVs, considering what is feasible and what matters most to the patient population; (3) recognise that lack of significant effect on a PRO does not imply no QoL benefit; (4) use different forms of evidence to understand QoL impacts, such as patient input; and (5) provide methodological guidance to capture QoL impacts on patients/carers.
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Affiliation(s)
- Elena Nicod
- Research Centre on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Milan, Italy. .,Dolon Ltd, London, UK.
| | - Andrew J Lloyd
- Acaster Lloyd Consulting Ltd, London, UK.,London School of Hygiene & Tropical Medicine, London, UK
| | - Thomas Morel
- UCB Pharma, Brussels, Belgium.,KU Leuven, Leuven, Belgium
| | - Michela Meregaglia
- Research Centre on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Milan, Italy
| | | | - Amanda Whittal
- Research Centre on Health and Social Care Management (CERGAS), SDA Bocconi School of Management, Milan, Italy
| | - Karen Facey
- Usher Institute, University of Edinburgh, Edinburgh, UK
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Abdallah K, Claes K, Huys I, Follon L, Calis C, Simoens S. Exploring alternative financing models and early access schemes for orphan drugs: a Belgian case study. Orphanet J Rare Dis 2022; 17:429. [PMID: 36494733 PMCID: PMC9733299 DOI: 10.1186/s13023-022-02571-8] [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: 03/15/2022] [Accepted: 11/20/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Although some jurisdictions have implemented particular adjustments to accommodate often-expensive orphan drugs in their healthcare systems, availability of these drugs remains complex. This study investigates alternative financing models and early access schemes for orphan drugs in the context of the Belgian healthcare system. METHODS Three focus group discussions were held with a panel of eleven experts from the Belgian Drug Reimbursement Committee, the Colleges for Orphan Drugs, the pharmaceutical industry, physicians, ethicists and pharmacists. Retrieved data were pseudonymised, analysed and coded according to the Qualitative Analysis Guide of Leuven. RESULTS Experts disfavoured the insulated fund as well as private insurance for financing orphan drugs, as, respectively, isolation of a separate budget and a mostly profit-driven mechanism would contradict the Belgian fundamental principle of solidarity. Moreover, an insulated fund could, albeit on a smaller scale, reproduce the same budgetary constraints as the general reimbursement system. As the Special Solidarity Fund is intended for urgent care and exclusively accommodates financial needs subject to eligibility criteria, its design would not allow general financing of orphan drugs. Overall, implementation of an alternative financing model was not endorsed, instead, improving the current reimbursement system was preferred. Suggestions mentioned were; increased collaboration and transparency, robust and quality real-world evidence but also digitalization of data. Alleviating administrative burden and simplifying the admission process of compassionate use program, medical need program and early treatment reimbursement should be prioritized to facilitate early access. Furthermore, a legal framework for off-label use could stimulate proper implementation. Efforts on collaboration of expertise centres and coordination of orphan drug databases across Europe could foster a robust data network to support orphan drug availability in individual countries. CONCLUSIONS This research reveals that reassessing current financing models and early access schemes by eliminating inadequacies, may be more conducive than establishing alternative systems to increase availability of orphan drugs in Belgium. Other jurisdictions may rely on this information to review their own models of early access and financing to cultivate a more sustainable delivery of orphan drugs.
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Affiliation(s)
- Khadidja Abdallah
- grid.5596.f0000 0001 0668 7884Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Onderwijs en Navorsing 2 Bus 521, Herestraat 49, 3000 Louvain, Belgium
| | - Kathleen Claes
- grid.5596.f0000 0001 0668 7884Nephrology and Renal Transplantation Research Group, Department of Microbiology, Immunology and Transplantation, KU Leuven, Louvain, Belgium ,grid.410569.f0000 0004 0626 3338Department of Nephrology and Renal Transplantation, UZ Leuven, Louvain, Belgium
| | - Isabelle Huys
- grid.5596.f0000 0001 0668 7884Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Onderwijs en Navorsing 2 Bus 521, Herestraat 49, 3000 Louvain, Belgium
| | - Lennert Follon
- grid.5596.f0000 0001 0668 7884Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Onderwijs en Navorsing 2 Bus 521, Herestraat 49, 3000 Louvain, Belgium
| | - Charlotte Calis
- grid.5596.f0000 0001 0668 7884Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Onderwijs en Navorsing 2 Bus 521, Herestraat 49, 3000 Louvain, Belgium
| | - Steven Simoens
- grid.5596.f0000 0001 0668 7884Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Onderwijs en Navorsing 2 Bus 521, Herestraat 49, 3000 Louvain, Belgium
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13
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Making Sure That Orphan Incentives Tip the Right Way in Europe. Healthcare (Basel) 2022; 10:healthcare10091600. [PMID: 36141212 PMCID: PMC9498781 DOI: 10.3390/healthcare10091600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/16/2022] [Accepted: 08/19/2022] [Indexed: 12/03/2022] Open
Abstract
The delicate balance of funding research and development of treatments for rare disease is only imperfectly achieved in Europe, and even the current provisional equilibrium is under a new threat from well-intentioned policy changes now in prospect that could—in addition to the intrinsic complexities of research—reduce the incentives on which commercial activity in this area is dependent. The European Union review of its pharmaceutical legislation, for which proposals are scheduled to appear before the end of 2022, envisages adjusting the decade-old incentives to meet objectives that are more precisely targeted. However, researchers, physicians, patients and industry have expressed concerns that ill-considered modifications could have unintended consequences in disrupting the current balance and could reduce rather than increase the flow of innovative treatments for rare diseases.
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Blonda A, Denier Y, Huys I, Kawalec P, Simoens S. How Can We Optimize the Value Assessment and Appraisal of Orphan Drugs for Reimbursement Purposes? A Qualitative Interview Study Across European Countries. Front Pharmacol 2022; 13:902150. [PMID: 35928274 PMCID: PMC9343828 DOI: 10.3389/fphar.2022.902150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 05/23/2022] [Indexed: 12/01/2022] Open
Abstract
Introduction: The expansion of orphan drug treatment at increasing prices, together with uncertainties regarding their (cost-)effectiveness raises difficulties for decision-makers to assess these drugs for reimbursement. The present qualitative study aims to gain better insight into current value assessment and appraisal frameworks for orphan drugs, and provides guidance for improvement. Methods: 22 European experts from 19 different countries were included in a qualitative survey, followed by in-depth semi-structured interviews. These experts were academics, members of reimbursement agencies or health authorities, or members of regulatory or health/social insurance institutions. Adopting a Grounded Theory approach, transcripts were analysed according to the QUAGOL method, supported by the qualitative data analysis software Nvivo. Results: Although participants indicated several good practices (e.g., the involvement of patients and the presence of structure and consistency), several barriers (e.g., the lack of transparency) lead to questions regarding the efficiency of the overall reimbursement process. In addition, the study identified a number of “contextual” determinants (e.g., bias, perverse effects of the orphan drug legislation, and an inadequate consideration of the opportunity cost), which may undermine the legitimacy of orphan drug reimbursement decisions. Conclusion: The present study provides guidance for decision-makers to improve the efficiency of orphan drug reimbursement. In particular, decision-makers can generate quick wins by limiting the impact of contextual determinants rather than improving the methods included in the HTA. When implemented into a framework that promotes “Accountability for Reasonableness” (A4R), this allows decision-makers to improve the legitimacy of reimbursement decisions concerning future orphan drugs.
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Affiliation(s)
- Alessandra Blonda
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
- *Correspondence: Alessandra Blonda,
| | - Yvonne Denier
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Isabelle Huys
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Pawel Kawalec
- Institute of Public Health, Faculty of Health Sciences, Jagiellonian University Medical College, Krakow, Poland
| | - Steven Simoens
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
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Kirwin E, Round J, Bond K, McCabe C. A Conceptual Framework for Life-Cycle Health Technology Assessment. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:1116-1123. [PMID: 35779939 DOI: 10.1016/j.jval.2021.11.1373] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 11/11/2021] [Accepted: 11/23/2021] [Indexed: 05/06/2023]
Abstract
OBJECTIVES Health technology assessment (HTA) uses evidence appraisal and synthesis with economic evaluation to inform adoption decisions. Standard HTA processes sometimes struggle to (1) support decisions that involve significant uncertainty and (2) encourage continued generation of and adaptation to new evidence. We propose the life-cycle (LC)-HTA framework, addressing these challenges by providing additional tools to decision makers and improving outcomes for all stakeholders. METHODS Under the LC-HTA framework, HTA processes align to LC management. LC-HTA introduces changes in HTA methods to minimize analytic time while optimizing decision certainty. Where decision uncertainty exists, we recommend risk-based pricing and research-oriented managed access (ROMA). Contractual procurement agreements define the terms of reassessment and provide additional decision options to HTA agencies. LC-HTA extends value-of-information methods to inform ROMA agreements, leveraging routine, administrative data, and registries to reduce uncertainty. RESULTS LC-HTA enables the adoption of high-value high-risk innovations while improving health system sustainability through risk-sharing and reducing uncertainty. Responsiveness to evolving evidence is improved through contractually embedded decision rules to simplify reassessment. ROMA allows conditional adoption to obtain additional information, with confidence that the net value of that adoption decision is positive. CONCLUSIONS The LC-HTA framework improves outcomes for patients, sponsors, and payers. Patients benefit through earlier access to new technologies. Payers increase the value of the technologies they invest in and gain mechanisms to review investments. Sponsors benefit through greater certainty in outcomes related to their investment, swifter access to markets, and greater opportunities to demonstrate value.
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Affiliation(s)
- Erin Kirwin
- Institute of Health Economics, Edmonton, AB, Canada; Health Organisation, Policy, and Economics, School of Health Sciences, University of Manchester, Manchester, England, UK.
| | - Jeff Round
- Institute of Health Economics, Edmonton, AB, Canada; Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Ken Bond
- Institute of Health Economics, Edmonton, AB, Canada
| | - Christopher McCabe
- Institute of Health Economics, Edmonton, AB, Canada; Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
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16
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Hogervorst MA, Vreman RA, Mantel-Teeuwisse AK, Goettsch WG. Reported Challenges in Health Technology Assessment of Complex Health Technologies. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:992-1001. [PMID: 35667787 DOI: 10.1016/j.jval.2021.11.1356] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/06/2021] [Accepted: 11/09/2021] [Indexed: 06/15/2023]
Abstract
OBJECTIVES With complex health technologies entering the market, methods for health technology assessment (HTA) may require changes. This study aimed to identify challenges in HTA of complex health technologies. METHODS A survey was sent to European HTA organizations participating in European Network for HTA (EUnetHTA). The survey contained open questions and used predefined potentially complex health technologies and 7 case studies to identify types of complex health technologies and challenges faced during HTA. The survey was validated, tested for reliability by an expert panel, and pilot tested before dissemination. RESULTS A total of 22 HTA organizations completed the survey (67%). Advanced therapeutic medicinal products (ATMPs) and histology-independent therapies were considered most challenging based on the predefined complex health technologies and case studies. For the case studies, more than half of the reported challenges were "methodological," equal in relative effectiveness assessments as in cost-effectiveness assessments. Through the open questions, we found that most of these challenges actually rooted in data unavailability. Data were reported as "absent," "insufficient," "immature," or "low quality" by 18 of 20 organizations (90%), in particular data on quality of life. Policy and organizational challenges and challenges because of societal or political pressure were reported by 8 (40%) and 4 organizations (20%), respectively. Modeling issues were reported least often (n = 2, 4%). CONCLUSIONS Most challenges in HTA of complex health technologies root in data insufficiencies rather than in the complexity of health technologies itself. As the number of complex technologies grows, the urgency for new methods and policies to guide HTA decision making increases.
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Affiliation(s)
- Milou A Hogervorst
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands; National Health Care Institute, Diemen, The Netherlands
| | - Rick A Vreman
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands; National Health Care Institute, Diemen, The Netherlands
| | - Aukje K Mantel-Teeuwisse
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Wim G Goettsch
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands; National Health Care Institute, Diemen, The Netherlands.
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17
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A systematic literature review of revealed preferences of decision-makers for recommendations of cancer drugs in health technology assessment. Int J Technol Assess Health Care 2022; 38:e36. [PMID: 35382919 DOI: 10.1017/s0266462322000216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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18
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O'Hara J, Neumann PJ. Health technology assessment for gene therapies in haemophilia. Haemophilia 2022; 28 Suppl 2:19-26. [DOI: 10.1111/hae.14413] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/15/2021] [Accepted: 08/31/2021] [Indexed: 12/20/2022]
Affiliation(s)
- Jamie O'Hara
- HCD Economics Daresbury UK
- University of Chester Chester UK
| | - Peter J. Neumann
- Center for the Evaluation of Value and Risk in Health Institute for Clinical Research and Health Policy Studies, Tufts Medical Centre Boston Massachusetts USA
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19
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Blonda A, Barcina Lacosta T, Toumi M, Simoens S. Assessing the Value of Nusinersen for Spinal Muscular Atrophy: A Comparative Analysis of Reimbursement Submission and Appraisal in European Countries. Front Pharmacol 2022; 12:750742. [PMID: 35126102 PMCID: PMC8814578 DOI: 10.3389/fphar.2021.750742] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 09/30/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Nusinersen is an orphan drug intended for the treatment of spinal muscular atrophy (SMA), a severe genetic neuromuscular disorder. Considering the very high costs of orphan drugs and the expected market entry of cell and gene therapies, there is increased interest in the use of health technology assessment (HTA) for orphan drugs. This study explores the role of the economic evaluation and budget impact analysis on the reimbursement of nusinersen. Methods: Appraisal reports for nusinersen were retrieved from reimbursement and HTA agencies in Belgium, Canada, France, England and Wales, Germany, Italy, Ireland, Scotland, Sweden, the Netherlands, and the United States. Detailed information was extracted on the economic evaluation, the budget impact, the overall reimbursement decision, and the managed entry agreement (MEA). Costs were adjusted for inflation and currency. Results: Overall, the reports included limited data on budget impact, excluding information on the sources of data for cost and patient estimates. Only three jurisdictions reported on total budget impact, estimated between 30 and 40 million euros per year. For early-onset SMA, the incremental cost-effectiveness threshold (ICER) ranged from €464,891 to €6,399,097 per quality-adjusted life year (QALY) gained for nusinersen versus standard of care. For later-onset SMA, the ICER varied from €493,756 to €10,611,936 per QALY. Although none of the jurisdictions found nusinersen to be cost-effective, reimbursement was granted in each jurisdiction. Remarkably, only four reports included arguments in favor of reimbursement. However, the majority of the jurisdictions set up an MEA, which may have promoted a positive reimbursement decision. Conclusion: There is a need for more transparency on the appraisal process and conditions included in the MEA. Additionally, by considering all relevant criteria explicitly during the appraisal process, decision-makers are in a better position to justify their allocation of funds among the rising number of orphan drugs that are coming to the market in the near future.
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Affiliation(s)
- Alessandra Blonda
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | | | - Mondher Toumi
- Department of Public Health, Aix-Marseille Université, Marseille, France
| | - Steven Simoens
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
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20
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Goodman C, Berntorp E, Wong O. Alternative payment models for durable and potentially curative therapies: The case of gene therapy for haemophilia A. Haemophilia 2022; 28 Suppl 2:27-34. [DOI: 10.1111/hae.14425] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 08/25/2021] [Accepted: 09/17/2021] [Indexed: 12/28/2022]
Affiliation(s)
| | - Erik Berntorp
- Clinical Coagulation Research Department of Translational Medicine, Lund University Malmö Sweden
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21
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Ho C, Lim HJ, Regier DA. FDA Accelerated Approval for Malignant Hematology and Oncology Indications in the Canadian Environment. Curr Oncol 2022; 29:402-410. [PMID: 35200536 PMCID: PMC8870743 DOI: 10.3390/curroncol29020036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 01/07/2022] [Accepted: 01/12/2022] [Indexed: 11/16/2022] Open
Abstract
Accelerated approval (AA) by the FDA enables earlier access to promising new therapies. Health Canada has a similar process. Canada implemented a national health technology assessment (HTA) for reimbursement decisions in 2011. This study evaluated regulatory and funding timelines and decisions for FDA AA cancer therapies in Canada. The FDA’s AA of malignant hematology and oncology from January 2000–December 2019 was reviewed. Dates from Health Canada, HTA decisions and provincial listings were collected. There were 94 FDA AAs, two of which were subsequently withdrawn. Of the 92 AAs, 70 received full (46)/conditional (24) Health Canada approval, and 22 were not filed. Since the introduction of HTA, 31 out of 45 of Health Canada’s approved indications underwent HTA review: 18 received a positive recommendation conditional on cost-effectiveness, 8 were not recommended and 5 were withdrawn/suspended. The median time from the AA to any Health Canada approval is 9.4 months, from any Health Canada approval to HTA decision is 5.8 months and from HTA decision to the first formulary listing is 12.0 months. The access and timeline for the first formulary listing differences were observed between the USA and Canada due to the decision of pharmaceutical companies to submit (or not) to regulatory/HTA bodies, national procedural delays with different healthcare delivery models and submission timelines. This study demonstrates that there is delayed access to promising new therapies in Canada.
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Affiliation(s)
- Cheryl Ho
- Department of Medical Oncology, BC Cancer, Vancouver, BC V5Z 4E6, Canada;
- Department of Medicine, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
- Correspondence: ; Tel.: +1-604-877-6000 (ext. 2445); Fax: +1-604-877-0585
| | - Howard J. Lim
- Department of Medical Oncology, BC Cancer, Vancouver, BC V5Z 4E6, Canada;
- Department of Medicine, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
| | - Dean A. Regier
- Cancer Control Research, BC Cancer Research Institute, Vancouver, BC V5Z 1L3, Canada;
- School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z4, Canada
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22
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Moro D, Schlander M, Telser H, Sola-Morales O, Clark MD, Olaye A, Camp C, Jain M, Butt T, Bakshi S. Evaluating Discrete Choice Experiment Willingness to Pay [DCE-WTP] analysis, and Relative Social Willingness to Pay [RS-WTP] analysis in a Health Technology Assessment of a treatment for an ultra-rare childhood disease [CLN2]. Expert Rev Pharmacoecon Outcomes Res 2021; 22:581-598. [PMID: 34877915 DOI: 10.1080/14737167.2022.2014324] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND : Conventional cost-effectiveness analysis [CEA] using cost per QALY thresholds may counteract other incentives introduced to foster development of treatments for rare and ultra-rare diseases. Therefore, alternative economic evaluation methods were explored, namely Discrete Choice Experiment Willingness to Pay (DCE-WTP) and Relative Social Willingness to Pay (RS-WTP), to value interventions for an ultra-rare childhood disease, Neuronal Ceroid Lipofuscinosis type 2 (CLN2). RESEARCH DESIGN AND METHODS Treatment for CLN2 was valued from a citizen's ("social") perspective using DCE-WTP and RS-WTP in a survey of 4,009 United Kingdom [UK] adults. Three attributes (initial quality of life, treatment effect, and life expectancy) were used in both analyses. For DCE-WTP a cost attribute (marginal income tax increase) was also included. Optimal econometric models were identified. RESULTS DCE-WTP indicated that UK adults are willing to pay incremental increases through taxation for improvements in CLN2 attributes. RS-WTP identified a willingness to allocate >40% of a pre-assigned healthcare budget to prevent child mortality and approximately 15% for improved health status. CONCLUSIONS Both techniques illustrated substantive social WTP for CLN2 interventions, despite the small number of children benefitting. This highlights a gap between UK citizens' willingness to spend on rare disease interventions and current funding policies.
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Affiliation(s)
- Domenico Moro
- Department of Economics, University of Birmingham, UK.,Certara Evidence & Access, London, UK.,Apple Education Ltd, Birmingham, UK
| | - Michael Schlander
- Institute for Innovation & Valuation in Health Care (InnoValHC), Wiesbaden, Germany.,Division of Health Economics, German Cancer Research Center (DKFZ) & University of Heidelberg, Heidelberg, Germany
| | - Harry Telser
- Polynomics, Olten, Switzerland.,Center for Health, Policy and Economics, University of Lucerne, Switzerland
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Biglia LV, Mendes SJ, Lima TDM, Aguiar PM. Incorporation of drugs for rare diseases in Brazil: is it possible to have full access to these patients? CIENCIA & SAUDE COLETIVA 2021; 26:5547-5560. [PMID: 34852089 DOI: 10.1590/1413-812320212611.26722020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 07/27/2020] [Indexed: 11/22/2022] Open
Abstract
This study aims to describe the profile for the requested incorporation of rare disease drugs submitted to CONITEC and its recommendations, comparing the incorporation criteria employed by other HTA agencies globally. To this end, requests for the treatment of rare diseases submitted to CONITEC from July 2012 to June 2019 and its recommendations to the Brazilian Unified Health System (SUS) were included in this study. Subsequently, we compared the criteria used by CONITEC and other HTA agencies to incorporate these drugs. Sixty medicine incorporation requests to treat thirty rare diseases were submitted to CONITEC. Pharmaceutical companies made the most requests (66%). Budget impact analyses were presented in 85% of the requests and HT economic analyses in 68%. A total of 52% of the requests were incorporated into the SUS. CONITEC's justifications for the non-incorporation were the lack of quality clinical evidence, non-cost-effective technologies, and modest clinical benefits that do not justify the high prices. International HTA agencies (CAN, UK, FR, AUS) use different criteria for rare diseases assessments. The data indicate that most of the evaluated drugs were incorporated into the SUS, and adopting different criteria to assess the incorporation of rare diseases medicines will possibly strengthen decision-making.
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Affiliation(s)
- Luiza Vasconcelos Biglia
- Faculdade de Ciências Farmacêuticas, Universidade de São Paulo. Av. Prof. Lineu Prestes 580 Conj. das Químicas Bloco 13, Cidade Universitária, Butantã. 05508-900 São Paulo SP Brasil.
| | - Samara Jamile Mendes
- Faculdade de Ciências Farmacêuticas, Universidade de São Paulo. Av. Prof. Lineu Prestes 580 Conj. das Químicas Bloco 13, Cidade Universitária, Butantã. 05508-900 São Paulo SP Brasil.
| | - Tácio de Mendonça Lima
- Departamento de Ciências Farmacêuticas, Universidade Federal Rural do Rio de Janeiro. Seropédia RJ Brasil
| | - Patricia Melo Aguiar
- Faculdade de Ciências Farmacêuticas, Universidade de São Paulo. Av. Prof. Lineu Prestes 580 Conj. das Químicas Bloco 13, Cidade Universitária, Butantã. 05508-900 São Paulo SP Brasil.
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Vicente G, Cunico C, Leite SN. Transforming uncertainties into legitimate regulation? NICE and CONITEC agencies' decisions on rare diseases. CIENCIA & SAUDE COLETIVA 2021; 26:5533-5546. [PMID: 34852088 DOI: 10.1590/1413-812320212611.34542020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 02/28/2021] [Indexed: 11/22/2022] Open
Abstract
As a scientific and technological practice, the evaluation of health technologies (HTA) is, at the same time, a challenge to determine the value of the technologies to be incorporated. This study aimed to explore and compare the results and technical elements of the evaluations issued for rare diseases between the English (NICE) and the Brazilian agency (CONITEC). The first part of the study involved the systematic search for evaluations from 2013 to 2019. In the second stage, the reports were analyzed based on: (i) descriptive narrative review; and (ii) calculation of the absolute and relative frequency according to each domain and component (element) applied in the European HTA network model. Twenty-four medicines were distinctly assessed during the study period. Through 126 questions (elements) distributed among nine domains, the analysis revealed that 67 (53.2%) and 44 (35.0%) were described in the reports, 42 (33.3%) and 59 (47.0 %) were only considered partially, and 17 (13.5%) and 23 (18.0%) were not considered in the NICE and CONITEC reports, respectively. We identified a relatively low agreement between the Brazilian agency with the English agency in the reports issued for rare diseases. It remains to be seen whether the agencies are able to capture the various values of these medicines, as well as manage uncertainties in the evaluations.
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Affiliation(s)
- Geison Vicente
- Departamento de Ciências Farmacêuticas, Centro de Ciências da Saúde, Universidade Federal de Santa Catarina. R. Delfino Conti S/N Trindade, 88040-370 Florianópolis SC Brasil.
| | - Cássia Cunico
- Departamento de Ciências Farmacêuticas, Centro de Ciências da Saúde, Universidade Federal de Santa Catarina. R. Delfino Conti S/N Trindade, 88040-370 Florianópolis SC Brasil.
| | - Silvana Nair Leite
- Departamento de Ciências Farmacêuticas, Centro de Ciências da Saúde, Universidade Federal de Santa Catarina. R. Delfino Conti S/N Trindade, 88040-370 Florianópolis SC Brasil.
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Stevens B, Kenny T, Thomas S, Morrison A, Jarrett J, Jain M. Elosulfase alfa in the treatment of mucopolysaccharidosis type IVA: insights from the first managed access agreement. Orphanet J Rare Dis 2021; 16:394. [PMID: 34563214 PMCID: PMC8467187 DOI: 10.1186/s13023-021-01876-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 05/20/2021] [Indexed: 11/10/2022] Open
Abstract
Managed access agreements provide a crucial mechanism whereby real-world data can be collected systematically to reduce uncertainty around available clinical and economic data, whilst providing the opportunity to identify patient sub-populations who are most likely to benefit from a new treatment. This manuscript aims to share learnings from the first managed access agreement, which was initiated following positive conditional approval in 2015 from the National Institute for Health and Care Excellence (NICE) for elosulfase alfa, an enzyme replacement therapy for the treatment of mucopolysaccharidosis type IVA (MPS IVA). This managed access agreement enabled the collection of comprehensive real-world data for patients with MPS IVA, with results demonstrating that patients starting elosulfase alfa treatment showed gains similar to those seen in the pivotal trial for outcomes including endurance, respiratory and cardiac function, pain, quality of life measures and urinary keratan sulfate levels. In addition, former trial patients continued to see benefits in both clinical assessments and quality of life/activities of daily living nine years after beginning treatment. Key strengths of the process included recruitment of a high proportion of MPS IVA patients treated in England (72/89 known eligible patients) with a wide range of ages (2-58 years). Participation of a patient organisation (the MPS society) ensured that the patient voice was present throughout the process, whilst a contract research organisation (Rare Disease Research Partners) ensured that patients were represented when interpreting agreement criteria and during patient assessment meetings. Longer-term follow-up will be required for several MPS IVA outcomes (e.g. skeletal measures) to further reduce uncertainty, and continued follow-up of patients who had stopped treatment was found to be challenging. The burden associated with this managed access agreement was found to be high for patients, physicians, patient organisations, NHS England and the manufacturer, therefore costs and benefits of future agreements should be considered carefully before initiation. Through evaluation of the strengths and limitations of this process, it is hoped that learnings from this managed access agreement can be used to inform future agreements.
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Affiliation(s)
- Bob Stevens
- The MPS Society, Amersham, Buckinghamshire, UK
| | - Tom Kenny
- Rare Disease Research Partners, Amersham, Buckinghamshire, UK
| | | | | | | | - Mohit Jain
- BioMarin Europe Ltd., 10 Bloomsbury Way, London, WC1A 2SL, UK.
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Facey KM, Espin J, Kent E, Link A, Nicod E, O'Leary A, Xoxi E, van de Vijver I, Zaremba A, Benisheva T, Vagoras A, Upadhyaya S. Implementing Outcomes-Based Managed Entry Agreements for Rare Disease Treatments: Nusinersen and Tisagenlecleucel. PHARMACOECONOMICS 2021; 39:1021-1044. [PMID: 34231135 PMCID: PMC8260322 DOI: 10.1007/s40273-021-01050-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/01/2021] [Indexed: 05/21/2023]
Abstract
BACKGROUND AND OBJECTIVE Enthusiasm for the use of outcomes-based managed entry agreements (OBMEAs) to manage uncertainties apparent at the time of appraisal/pricing and reimbursement of new medicines has waned over the past decade, as challenges in establishment, implementation and re-appraisal have been identified. With the recent advent of innovative treatments for rare diseases that have uncertainties in the clinical evidence base, but which could meet a high unmet need, there has been renewed interest in the potential of OBMEAs. The objective of this research was to review the implementation of OBMEAs for two case studies across countries in the European Union, Australia and Canada, to identify good practices that could inform development of tools to support implementation of OBMEAs. METHODS To investigate how OBMEAs are being implemented with rare disease treatments, we collected information from health technology assessment/payer experts in countries that had implemented OBMEAs for either nusinersen in spinal muscular atrophy or tisagenlecleucel in two cancer indications. Operational characteristics of the OBMEAs that were publicly available were documented. Then, the experts discussed issues in implementing these OBMEAs and specific approaches taken to overcome challenges. RESULTS The OBMEAs identified were based on individual outcomes to ensure appropriate use, manage continuation of treatment and in two cases linked to payment schedules, or they were population based, coverage with evidence development. For nusinersen, population-based OBMEAs are documented in Belgium, England and the Netherlands and individual-based schemes in Bulgaria, Ireland, Italy and Lithuania. For tisagenlecleucel, there were population-based schemes in Australia, Belgium, England and France and individual-based schemes in Italy and Spain. Comparison of the OBMEA constructs showed some clear published frameworks and clarity of the uncertainties to be addressed that were similar across countries. Agreements were generally made between the marketing authorisation holder and the payer with involvement of expert physicians. Only England and the Netherlands involved patients. Italy used its long-established, national, web-based, treatment-specific data collection system linked to reimbursement and Spain has just developed such a national treatment registry system. Other countries relied on a variety of data collection systems (including clinical registries) and administrative data. Durations of agreements varied for these treatments as did processes for interim reporting. The processes to ensure data quality, completeness and sufficiency for re-analysis after coverage with evidence development were not always clear, neither were analysis plans. CONCLUSIONS These case studies have shown that important information about the constructs of OBMEAs for rare disease treatments are publicly available, and for some jurisdictions, interim reports of progress. Outcomes-based managed entry agreements can play an important role not only in reimbursement, but also in treatment optimisation. However, they are complex to implement and should be the exception and not the rule. More recent OBMEAs have developed document covenants among stakeholders or electronic systems to provide assurances about data sufficiency. For coverage with evidence development, there is an opportunity for greater collaboration among jurisdictions to share processes, develop common data collection agreements, and share interim and final reports. The establishment of an international public portal to host such reports would be particularly valuable for rare disease treatments.
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Affiliation(s)
- Karen M Facey
- Usher Institute, University of Edinburgh, NINE Edinburgh Bioquarter, 9 Little France Road, Edinburgh, 16 4UX, EH, UK.
| | - Jaime Espin
- Andalusian School of Public Health/Escuela Andaluza de Salud Pública (EASP), Granada, Spain
- CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain
- Instituto de Investigación Biosanitaria ibs, Granada, Spain
| | - Emma Kent
- National Institute for Health and Care Excellence (NICE), London, UK
| | - Angèl Link
- Zorginstituut (ZIN) Nederland, Diemen, The Netherlands
| | - Elena Nicod
- Centre for Research on Health and Social Care Management (CERGAS), Bocconi University, Milan, Italy
| | - Aisling O'Leary
- National Centre for Pharmacoeconomics (NCPE), Trinity Centre for Health Sciences, St. James's Hospital, Dublin, Ireland
| | - Entela Xoxi
- Università Cattolica del Sacro Cuore, Rome, Italy
| | - Inneke van de Vijver
- National Institute for Health and Disability Insurance (INAMI), Brussels, Belgium
| | - Anna Zaremba
- Agency for Health Technology Assessment and Tariff System (AOTMiT), Warsaw, Poland
| | | | - Andrius Vagoras
- Pharmacy Center, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Sheela Upadhyaya
- National Institute for Health and Care Excellence (NICE), London, UK
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Simões MV, Fernandes F, Marcondes-Braga FG, Scheinberg P, Correia EDB, Rohde LEP, Bacal F, Alves SMM, Mangini S, Biolo A, Beck-da-Silva L, Szor RS, Marques W, Oliveira ASB, Cruz MW, Bueno BVK, Hajjar LA, Issa AFC, Ramires FJA, Coelho OR, Schmidt A, Pinto IMF, Rochitte CE, Vieira MLC, Mesquita CT, Ramos CD, Soares-Junior J, Romano MMD, Mathias W, Garcia MI, Montera MW, de Melo MDT, Silva SME, Garibaldi PMM, de Alencar AC, Lopes RD, de Ávila DX, Viana D, Saraiva JFK, Canesin MF, de Oliveira GMM, Mesquita ET. Position Statement on Diagnosis and Treatment of Cardiac Amyloidosis - 2021. Arq Bras Cardiol 2021; 117:561-598. [PMID: 34550244 PMCID: PMC8462947 DOI: 10.36660/abc.20210718] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- Marcus V. Simões
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoRibeirão PretoBrasilFaculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto – Brasil
| | - Fabio Fernandes
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
| | - Fabiana G. Marcondes-Braga
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
| | - Philip Scheinberg
- Hospital da Beneficência Portuguesa de São PauloSão PauloSPBrasilHospital da Beneficência Portuguesa de São Paulo, São Paulo, SP – Brasil
| | - Edileide de Barros Correia
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil
| | - Luis Eduardo P. Rohde
- Hospital de Clínicas de Porto AlegrePorto AlegreRSBrasilHospital de Clínicas de Porto Alegre, Porto Alegre, RS – Brasil
- Hospital Moinhos de VentoPorto AlegreRSBrasilHospital Moinhos de Vento, Porto Alegre, RS – Brasil
- Universidade Federal do Rio Grande do SulPorto AlegreRSBrasilUniversidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS – Brasil
| | - Fernando Bacal
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
| | - Silvia Marinho Martins Alves
- Pronto Socorro Cardiológico de PernambucoRecifePEBrasilPronto Socorro Cardiológico de Pernambuco (PROCAPE), Recife, PE – Brasil
- Universidade de PernambucoRecifePEBrasilUniversidade de Pernambuco (UPE), Recife, PE – Brasil
| | - Sandrigo Mangini
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
| | - Andréia Biolo
- Hospital de Clínicas de Porto AlegrePorto AlegreRSBrasilHospital de Clínicas de Porto Alegre, Porto Alegre, RS – Brasil
| | - Luis Beck-da-Silva
- Hospital de Clínicas de Porto AlegrePorto AlegreRSBrasilHospital de Clínicas de Porto Alegre, Porto Alegre, RS – Brasil
- Universidade Federal do Rio Grande do SulPorto AlegreRSBrasilUniversidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS – Brasil
| | - Roberta Shcolnik Szor
- Fundação Faculdade de MedicinaSão PauloSPBrasilFundação Faculdade de Medicina, São Paulo, SP – Brasil
- Universidade de São PauloSão PauloSPBrasilInstituto do Câncer do Estado de São Paulo da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP – Brasil
| | - Wilson Marques
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoRibeirão PretoBrasilFaculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto – Brasil
| | - Acary Souza Bulle Oliveira
- Universidade Federal de São PauloSão PauloSPBrasilUniversidade Federal de São Paulo, São Paulo, SP – Brasil
| | - Márcia Waddington Cruz
- Universidade Federal do Rio de JaneiroRio de JaneiroRJBrasilHospital Universitário Clementino Fraga Filho (HUCFF) da Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ – Brasil
| | - Bruno Vaz Kerges Bueno
- Faculdade de Ciências Médicas da Santa Casa de São PauloSão PauloSPBrasilFaculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, SP – Brasil
| | - Ludhmila Abrahão Hajjar
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
- Universidade de São PauloSão PauloSPBrasilInstituto do Câncer do Estado de São Paulo da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP – Brasil
| | - Aurora Felice Castro Issa
- Instituto Nacional de CardiologiaRio de JaneiroRJBrasilInstituto Nacional de Cardiologia, Rio de Janeiro, RJ – Brasil
| | - Felix José Alvarez Ramires
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
- Hospital Israelita Albert EinsteinSão PauloSPBrasilHospital Israelita Albert Einstein, São Paulo, SP – Brasil
| | - Otavio Rizzi Coelho
- Universidade Estadual de CampinasCampinasSPBrasilFaculdade de Ciências Médicas da Universidade Estadual de Campinas (UNICAMP), Campinas, SP – Brasil
| | - André Schmidt
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoRibeirão PretoBrasilFaculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto – Brasil
| | | | - Carlos Eduardo Rochitte
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
- Hospital do CoraçãoSão PauloSPBrasilHospital do Coração (HCor), São Paulo, SP – Brasil
- Hospital Pró-CardíacoRio de JaneiroRJBrasilHospital Pró-Cardíaco, Rio de Janeiro, RJ – Brasil
| | - Marcelo Luiz Campos Vieira
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
- Hospital Israelita Albert EinsteinSão PauloSPBrasilHospital Israelita Albert Einstein, São Paulo, SP – Brasil
| | - Cláudio Tinoco Mesquita
- Universidade Federal FluminenseRio de JaneiroRJBrasilUniversidade Federal Fluminense (UFF), Rio de Janeiro, RJ – Brasil
| | - Celso Dario Ramos
- Universidade Estadual de CampinasCampinasSPBrasilFaculdade de Ciências Médicas da Universidade Estadual de Campinas (UNICAMP), Campinas, SP – Brasil
| | - José Soares-Junior
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
| | - Minna Moreira Dias Romano
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoRibeirão PretoBrasilFaculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto – Brasil
| | - Wilson Mathias
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoRibeirão PretoBrasilFaculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto – Brasil
| | - Marcelo Iório Garcia
- Universidade Federal do Rio de JaneiroRio de JaneiroRJBrasilHospital Universitário Clementino Fraga Filho (HUCFF) da Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ – Brasil
| | | | | | | | - Pedro Manoel Marques Garibaldi
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoRibeirão PretoBrasilFaculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto – Brasil
| | - Aristóteles Comte de Alencar
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
| | | | - Diane Xavier de Ávila
- Hospital Pró-CardíacoRio de JaneiroRJBrasilHospital Pró-Cardíaco, Rio de Janeiro, RJ – Brasil
- Complexo Hospitalar de NiteróiRio de JaneiroRJBrasilComplexo Hospitalar de Niterói, Rio de Janeiro, RJ – Brasil
- Hospital e Maternidade Christóvão da GamaSanto AndréSPBrasilHospital e Maternidade Christóvão da Gama, Santo André, SP – Brasil
- Hospital Universitário Antônio PedroRio de JaneiroRJBrasilHospital Universitário Antônio Pedro (Huap), Rio de Janeiro, RJ – Brasil
| | - Denizar Viana
- Universidade do Estado do Rio de JaneiroRio de JaneiroRJBrasilUniversidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ – Brasil
| | - José Francisco Kerr Saraiva
- Sociedade Campineira de Educação e InstruçãoCampinasSPBrasilSociedade Campineira de Educação e Instrução, Campinas, SP – Brasil
| | - Manoel Fernandes Canesin
- Universidade Estadual de LondrinaLondrinaPRBrasilHospital Universitário da Universidade Estadual de Londrina, Londrina, PR – Brasil
| | - Glaucia Maria Moraes de Oliveira
- Universidade Federal do Rio de JaneiroRio de JaneiroRJBrasilUniversidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ – Brasil
| | - Evandro Tinoco Mesquita
- Universidade Federal FluminenseRio de JaneiroRJBrasilUniversidade Federal Fluminense (UFF), Rio de Janeiro, RJ – Brasil
- Centro de Ensino e Treinamento Edson de Godoy BuenoRio de JaneiroRJBrasilCentro de Ensino e Treinamento Edson de Godoy Bueno/UHG, Rio de Janeiro, RJ – Brasil
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Price and reimbursement for orphan medicines and managed entry agreements: does Italy need a framework? GLOBAL & REGIONAL HEALTH TECHNOLOGY ASSESSMENT 2021; 8:114-119. [PMID: 36627869 PMCID: PMC9616180 DOI: 10.33393/grhta.2021.2278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 07/27/2021] [Indexed: 01/13/2023] Open
Abstract
This article illustrates a consensus opinion of an expert panel on the need and usefulness of a framework for price and reimbursement (P&R) process and managed entry agreements (MEAs) for orphan medicines in Italy. This opinion was gathered in three rounds: an introductory document was sent to the panel and discussed during a recorded online meeting. A second document was sent to the panel for their review. In the third step the final document was validated. Members of the expert panel are the authors of the article. The panel agreed that Italy does not need a specific value framework for orphan medicines, driving the P&R process. Rather, a more structured value framework for all medicines tailored to the specific drugs can be useful. For orphan drugs, the panel advocated for a multidisciplinary approach and the contribution of different stakeholders to value assessment, and acknowledged the importance of addressing, more than for other drugs, unmet needs, equity issues and societal value. The panel raised the need of increasing the importance of patient-reported outcomes. Experts, acknowledging the growing criticisms in implementation of outcome-based agreements in Italy, expressed their position against their abandonment in favour of discounts only and supported orphan medicines as natural candidates for these agreements. Finally, the panel made some recommendations on the appraisal process for orphan medicines, including an early discussion on the uncertainty of the evidence generated and the adoption of a structured approach to identify the agreement, which better responds to the uncertainty.
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Kent S, Salcher-Konrad M, Boccia S, Bouvy JC, Waure CD, Espin J, Facey K, Nguyen M, Rejon-Parrilla JC, Jonsson P. The use of nonrandomized evidence to estimate treatment effects in health technology assessment. J Comp Eff Res 2021; 10:1035-1043. [PMID: 34279114 DOI: 10.2217/cer-2021-0108] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Health technology assessment (HTA) is increasingly informed by nonrandomized studies, but there is limited guidance from HTA bodies on expectations around evidence quality and study conduct. We developed recommendations to support the appropriate use of such evidence based on a pragmatic literature review and a workshop involving 16 experts from eight countries as part of the EU's Horizon-2020 IMPACT-HTA program (work package six). To ensure HTA processes remain rigorous and robust, HTA bodies should demand clear, extensive and structured reporting of nonrandomized studies, including an in-depth assessment of the risk of bias. In recognition of the additional uncertainty imparted by nonrandomized designs in estimates of treatment effects, HTA bodies should strengthen early scientific advice and engage in collaborative efforts to improve use of real-world data.
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Affiliation(s)
- Seamus Kent
- National Institute for Health & Care Excellence, Manchester, M1 4BT, UK
| | - Maximilian Salcher-Konrad
- Care Policy & Evaluation Center (CPEC), London School of Economics & Political Science, London, WC2A 2AE, UK.,LSE Health, London School of Economics & Political Science, London, WC2A 2AE, UK
| | - Stefania Boccia
- Section of Hygiene, University Department of Life Sciences & Public Health, Università Cattolica del Sacro Cuore, Rome, 20123, Italy.,Department of Woman & Child Health & Public Health - Public Health Area, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome RM, 00168, Italy
| | - Jacoline C Bouvy
- National Institute for Health & Care Excellence, Manchester, M1 4BT, UK
| | - Chiara de Waure
- Department of Medicine & Surgery, University of Perugia, Perugia, 06123, Italy
| | - Jaime Espin
- Andalusian School of Public Health/Escuela Andaluza de Salud Pública (EASP), Granada, 18011, Spain.,CIBER en Epidemiología y Salud Pública (CIBERESP), Spain / CIBER of Epidemiology & Public Health (CIBERESP), Planta 0, Madrid, 28029 Spain.,Instituto de Investigación Biosanitaria ibs, Granada, 18012, Spain
| | - Karen Facey
- Usher Institute, University of Edinburgh, Nine Bioquarter, 9 Little France Road, Edinburgh, EH16 4UX, UK
| | - Mary Nguyen
- LSE Health, London School of Economics & Political Science, London, WC2A 2AE, UK
| | | | - Pall Jonsson
- National Institute for Health & Care Excellence, Manchester, M1 4BT, UK
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Zimmermann BM, Eichinger J, Baumgartner MR. A systematic review of moral reasons on orphan drug reimbursement. Orphanet J Rare Dis 2021; 16:292. [PMID: 34193232 PMCID: PMC8247078 DOI: 10.1186/s13023-021-01925-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 06/20/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The number of market approvals of orphan medicinal products (OMPs) has been increasing steadily in the last 3 decades. While OMPs can offer a unique chance for patients suffering from rare diseases, they are usually very expensive. The growing number of approved OMPs increases their budget impact despite their low prevalence, making it pressing to find solutions to ethical challenges on how to fairly allocate scarce healthcare resources under this context. One potential solution could be to grant OMPs special status when considering them for reimbursement, meaning that they are subject to different, and less stringent criteria than other drugs. This study aims to provide a systematic analysis of moral reasons for and against such a special status for the reimbursement of OMPs in publicly funded healthcare systems from a multidisciplinary perspective. RESULTS With a systematic review of reasons, we identified 39 reasons represented in 243 articles (scientific and grey literature) for and against special status for the reimbursement of OMPs, then categorized them into nine topics. Taking a multidisciplinary perspective, we found that most articles came from health policy (n = 103) and health economics (n = 49). More articles took the position for a special status of OMPs (n = 97) than those against it (n = 31) and there was a larger number of reasons identified in favour (29 reasons) than against (10 reasons) this special status. CONCLUSION Results suggest that OMP reimbursement issues should be assessed and analysed from a multidisciplinary perspective. Despite the higher occurrence of reasons and articles in favour of a special status, there is no clear-cut solution for this ethical challenge. The binary perspective of whether or not OMPs should be granted special status oversimplifies the issue: both OMPs and rare diseases are too heterogeneous in their characteristics for such a binary perspective. Thus, the scientific debate should focus less on the question of disease prevalence but rather on how the important variability of different OMPs concerning e.g. target population, cost-effectiveness, level of evidence or mechanism of action could be meaningfully addressed and implemented in Health Technology Assessments.
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Affiliation(s)
- Bettina M Zimmermann
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland.
- Institute for History and Ethics in Medicine, Technical University of Munich School of Medicine, Technical University of Munich, Munich, Germany.
| | - Johanna Eichinger
- Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056, Basel, Switzerland
- Institute for History and Ethics in Medicine, Technical University of Munich School of Medicine, Technical University of Munich, Munich, Germany
| | - Matthias R Baumgartner
- Division of Metabolism and Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
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Examining the impact of different country processes for appraising rare disease treatments: a case study analysis. Int J Technol Assess Health Care 2021; 37:e65. [PMID: 34044899 DOI: 10.1017/s0266462321000337] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Conventional appraisal and reimbursement processes are being challenged by the increasing number of rare disease treatments (RDTs) with a small evidence base and often a high price. Processes to appraise RDTs vary across countries; some use standard processes, others have separate processes or adapted processes that explicitly deal with rare disease specificities. The objective of this study was to examine the impacts of different appraisal processes for two RDTs. METHODS A case study analysis was conducted using countries with different forms of appraisal processes for RDTs for which public health technology assessment (HTA) reports were available. Two contrasting RDTs were chosen according to the criteria: rare versus ultra-rare treatment, affecting child versus adult, life-threatening versus disabling. Information from public HTA reports for each country's RDT appraisal was extracted into templates, allowing a systematic comparison of the appraisals across countries and identification of the impact of the different processes in practice. RESULTS Reports from Belgium, England, France, Germany, Italy, Netherlands, Norway, Scotland, Sweden, and the USA were selected for nusinersen (for spinal muscular atrophy) and voretigene neparvovec (for inherited retinal disorders). Countries with separate or adapted processes had more consistent approaches for managing RDT-related issues during appraisal, such as stakeholder involvement and criteria to address the specificities of RDTs, creating more transparency in decision-making. CONCLUSIONS Findings suggest that separate or adapted approaches for RDT appraisal may facilitate more structured, consistent decision-making and better management of RDT specificities.
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Clarke S, Ellis M, Brownrigg J. The impact of rarity in NICE's health technology appraisals. Orphanet J Rare Dis 2021; 16:218. [PMID: 33985575 PMCID: PMC8117316 DOI: 10.1186/s13023-021-01845-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In the absence of a framework designed to evaluate medicines for rare diseases in the UK, most orphan medicines are appraised by the National Institute for Health and Care Excellence (NICE) through the Single Technology Appraisal (STA) process. RESULTS An analysis of STA appraisals of orphan and non-orphan medicines revealed that orphan medicines were subject to a significantly longer mean time in the NICE process than non-orphan medicines [370 days (n = 44) vs. 277 days (n = 118), p = < 0.0001]. A higher proportion of orphan STAs required more than one Appraisal Committee Meeting (ACM) versus non-orphan STAs, and orphan STAs were disadvantaged by worse outcomes with respect to positive recommendations than those orphan medicines assessed by Highly Specialised Technology evaluation (HST). CONCLUSIONS The uncertainties inherent to developing orphan medicines may contribute to these disadvantages. Improved understanding of the challenges in drug development for orphan medicines and clearer guidance for decision makers on navigating uncertainty in the HTA process may promote greater equity in access to medicines across rare and common conditions.
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Affiliation(s)
- Sophie Clarke
- Pfizer Ltd, Walton Oaks, Dorking Road, Tadworth, Surrey, KT20 7NS, UK.
| | - Michelle Ellis
- Pfizer Ltd, Walton Oaks, Dorking Road, Tadworth, Surrey, KT20 7NS, UK
| | - Jack Brownrigg
- Pfizer Ltd, Walton Oaks, Dorking Road, Tadworth, Surrey, KT20 7NS, UK
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Blonda A, Denier Y, Huys I, Simoens S. How to Value Orphan Drugs? A Review of European Value Assessment Frameworks. Front Pharmacol 2021; 12:631527. [PMID: 34054519 PMCID: PMC8150002 DOI: 10.3389/fphar.2021.631527] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 03/16/2021] [Indexed: 11/22/2022] Open
Abstract
Background: Decision-makers have implemented a variety of value assessment frameworks (VAFs) for orphan drugs in European jurisdictions, which has contributed to variations in access for rare disease patients. This review provides an overview of the strengths and limitations of VAFs for the reimbursement of orphan drugs in Europe, and may serve as a guide for decision-makers. Methods: A narrative literature review was conducted using the databases Pubmed, Scopus and Web of Science. Only publications in English were included. Publications known to the authors were added, as well as conference or research papers, or information published on the website of reimbursement and health technology assessment (HTA) agencies. Additionally, publications were included through snowballing or focused searches. Results: Although a VAF that applies a standard economic evaluation treats both orphan drugs and non-orphan drugs equally, its focus on cost-effectiveness discards the impact of disease rarity on data uncertainty, which influences an accurate estimation of an orphan drug’s health benefit in terms of quality-adjusted life-years (QALYs). A VAF that weighs QALYs or applies a variable incremental cost-effectiveness (ICER) threshold, allows the inclusion of value factors beyond the QALY, although their methodologies are flawed. Multi-criteria decision analysis (MCDA) incorporates a flexible set of value factors and involves multiple stakeholders’ perspectives. Nevertheless, its successful implementation relies on decision-makers’ openness toward transparency and a pragmatic approach, while allowing the flexibility for continuous improvement. Conclusion: The frameworks listed above each have multiple strengths and weaknesses. We advocate that decision-makers apply the concept of accountability for reasonableness (A4R) to justify their choice for a specific VAF for orphan drugs and to strive for maximum transparency concerning the decision-making process. Also, in order to manage uncertainty and feasibility of funding, decision-makers may consider using managed-entry agreements rather than implementing a separate VAF for orphan drugs.
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Affiliation(s)
- Alessandra Blonda
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Yvonne Denier
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Isabelle Huys
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Steven Simoens
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
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Rozenbaum MH, Garcia A, Grima D, Tran D, Bhambri R, Stewart M, Li B, Heeg B, Postma M, Masri A. Health impact of tafamidis in transthyretin amyloid cardiomyopathy patients: an analysis from the Tafamidis in Transthyretin Cardiomyopathy Clinical Trial (ATTR-ACT) and the open-label long-term extension studies. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 8:529-538. [PMID: 33895806 PMCID: PMC9382662 DOI: 10.1093/ehjqcco/qcab031] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 04/16/2021] [Accepted: 04/21/2021] [Indexed: 12/29/2022]
Abstract
AIM The Tafamidis in Transthyretin Cardiomyopathy Clinical Trial (ATTR-ACT) showed that tafamidis reduced all-cause mortality and cardiovascular-related hospitalizations in patients with transthyretin amyloid cardiomyopathy (ATTR-CM). This study aimed to estimate the impact of tafamidis on survival and quality-adjusted life-years (QALYs). METHODS AND RESULTS A multi-state, cohort, Markov model was developed to simulate the disease course of ATTR-CM throughout a lifetime. For survival extrapolation, survival curves were fitted by treatment arm and New York Heart Association (NYHA) Class I/II (68% of patients) and NYHA Class III (32% of patients) cohorts using the individual patient-level data from both the ATTR-ACT and the corresponding long-term extension study. Univariate and multivariate sensitivity analyses were conducted. The predicted mean survival for the total population (NYHA Class I/II + III) was 6.73 years for tafamidis and 2.85 years for the standard of care (SoC), resulting in an incremental mean survival of 3.88 years [95% confidence interval (CI) 1.32-5.66]. Of the 6.73 life-years, patients on tafamidis spend, on average, 4.82 years in NYHA Class I/II, while patients on SoC spend an average of 1.60 life-years in these classes. The combination of longer survival in lower NYHA classes produced a QALY gain of 5.39 for tafamidis and 2.11 for SoC, resulting in 3.29 incremental QALYs (95% CI 1.21-4.74) in favour of tafamidis. CONCLUSION Based on the disease simulation model results, tafamidis is expected to more than double the life expectancy and QALYs of ATTR-CM patients compared to SoC. Longer-term follow-up data from the ATTR-ACT extension study will further inform these findings. CLINICAL TRIALS.GOV IDENTIFIER NCT01994889 (date of registration: 26 November 2013).
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Affiliation(s)
| | - Andrea Garcia
- Ingress-health, Weena 316-318 3012 NJ, Rotterdam, The Netherlands
| | - Daniel Grima
- Eversana Life Science Services, 204-3228 South Service Road, Burlington L7N 3H8 ON, Canada
| | - Diana Tran
- Eversana Life Science Services, 204-3228 South Service Road, Burlington L7N 3H8 ON, Canada
| | | | | | - Benjamin Li
- Pfizer Inc., 235 E 42nd St, New York, NY, USA
| | - Bart Heeg
- Ingress-health, Weena 316-318 3012 NJ, Rotterdam, The Netherlands
| | - Maarten Postma
- Unit of PharmacoEpidemiology & PharmacoEconomics, Department of Pharmacy, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands,Unit of Economics, Econometrics & Finance, Faculty of Economics & Business, University of Groningen, Nettelbosje 2, 9747 AE, Groningen, The Netherlands,Department of Health Sciences, University of Groningen, University Medical Center Groningen, Antonius Deusinglaan 1, 9713 AV Groningen NL, The Netherlands
| | - Ahmad Masri
- The Amyloidosis Center, Knight Cardiovascular Institute, Oregon Health & Science University, 3303 S Bond Ave Building 1, 9th Floor, Portland, OR 97239, USA
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Abdallah K, Huys I, Claes K, Simoens S. Methodological Quality Assessment of Budget Impact Analyses for Orphan Drugs: A Systematic Review. Front Pharmacol 2021; 12:630949. [PMID: 33967766 PMCID: PMC8098807 DOI: 10.3389/fphar.2021.630949] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 01/25/2021] [Indexed: 11/16/2022] Open
Abstract
Objectives: This research aims to evaluate the methodological quality of budget impact analyses for orphan drugs and to provide suggestions for future analyses. Methods: Conference abstracts and peer-reviewed literature on budget impact analyses were collected through searches of Pubmed and Embase. ISPOR good practice guidelines were used as a methodological standard for budget impact analyses. Examined parameters encompassed: perspective, target population, data sources, intervention and comparator(s), time horizon, scope of costs, discounting, validation, assumptions and sensitivity analysis. Results: Seventy studies on individual orphan drugs and 21 studies on a combination of orphan drugs analyzing budget impact were identified. Overall, analyses considered a third-party payer perspective, reported periodic budget impacts over a one-to-five-year time horizon, and did not apply discounting. A dynamically fluctuating population and costs beyond drug costs were accounted for in 18.7% and 51.7% of studies, respectively. Input data were retrieved from published literature, clinical trials, registries, claims databases, expert opinions, historical data and market research. Assumptions were mostly made about population size and intervention/comparator(s) market uptake, but these assumptions were rarely justified and their impact was insufficiently explored through sensitivity analyses. Budget impact results were rarely validated. Conclusion: Existing budget impact analyses for orphan drugs are concise, vary greatly and are of substandard methodological quality. To eliminate possible bias in future budget impact analyses, future studies should adhere to national or ISPOR good practice guidelines on budget impact analysis.
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Affiliation(s)
- Khadidja Abdallah
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Isabelle Huys
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Kathleen Claes
- Department of Microbiology, Immunology and Transplantation, UZ Leuven, Leuven, Belgium
| | - Steven Simoens
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
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Koçkaya G, Atalay S, Oğuzhan G, Kurnaz M, Ökçün S, Sar Gedik Ç, Şaylan M, Şencan N. Analysis of patient access to orphan drugs in Turkey. Orphanet J Rare Dis 2021; 16:68. [PMID: 33549137 PMCID: PMC7868010 DOI: 10.1186/s13023-021-01718-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 01/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Rare diseases are life-threatening, serious, and chronic conditions that require complex care and have a low prevalence. An estimated one in 15 people worldwide are affected by rare diseases. This study aims to analyze the accessibility, reimbursement status, licensed status, and Anatomical Therapeutic Chemical (ATC) codes of drugs that the European Medicines Agency (EMA) in Turkey considers to be "orphan" pharmaceuticals. METHODS The drugs included in this analysis were obtained from the list of orphan drugs published by the EMA. Orphan drugs' accessibility and licensing status in Turkey were obtained from the Health Implementation Communiqué published by the Social Security Institution (SGK) and the List of Abroad Active Substance and List of Licensed Products published by the Turkey Pharmaceuticals and Medical Devices Agency (TİTCK). Descriptive analysis was applied to determine the accessibility status of orphan drugs identified by the EMA in Turkey. RESULTS Based on the EMA, 105 pharmaceuticals were approved with "orphan drug" status except for drugs that have lost orphan drug status, decommissioned in the European Union and withdrawn from the European Community Register by January 2020. Of the 105 rare drugs on the EMA list, 34 were inaccessible in Turkey. Of the 71 available drugs, 23 (32%) were licensed and 48 (68%) were unlicensed in Turkey. 17 (74%) of licensed products and 17 (35%) of unlicensed products were covered by reimbursement. When orphan drugs' ATC codes were examined, the most common ATC group was found to be "L-Antineoplastic and Immunomodulatory" agents. CONCLUSION An orphan drug incentive policy is very important to ensure early access to the drugs used to treat rare diseases. Considering the capacity and prices for orphan drugs in Turkey, it can be said that many patients with rare diseases have difficulty in their treatment. It is obvious that such a policy must prepare for the regulation of orphan drugs in Turkey.
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Affiliation(s)
- Güvenç Koçkaya
- Econix Research, Analysis and Consulting Inc., İstanbul, Turkey.
| | - Sibel Atalay
- Gen Pharmaceuticals and Health Products Inc., İstanbul, Turkey
| | | | - Mustafa Kurnaz
- Econix Research, Analysis and Consulting Inc., İstanbul, Turkey
| | - Selin Ökçün
- Econix Research, Analysis and Consulting Inc., İstanbul, Turkey
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Nicod E, Whittal A, Drummond M, Facey K. Are supplemental appraisal/reimbursement processes needed for rare disease treatments? An international comparison of country approaches. Orphanet J Rare Dis 2020; 15:189. [PMID: 32690107 PMCID: PMC7370450 DOI: 10.1186/s13023-020-01462-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 07/07/2020] [Indexed: 12/22/2022] Open
Abstract
Background There is increasing recognition that conventional appraisal approaches may be unsuitable for assessing the value rare disease treatments (RDTs). This research examines what supplemental appraisal/reimbursement processes for RDTs are used internationally and how they can be characterised. A qualitative research design was used that included (1) documentation of country appraisal/reimbursement processes for RDTs via questionnaires, desk research and iterative interactions with country experts to produce country vignettes, and (2) a cross-country analysis of these processes to identify and characterise features in supplemental processes for RDTs, and compare them to countries without supplemental processes. Results Thirty-two of the 37 invited countries participated in this research. Forty-one percent (13/32) use supplemental processes for RDTs. Their level of integration within standard processes ranged from low to high, characterised by whether they are separate or partially separate from the standard process, adapted or accelerated standard processes, or standard processes that may be applied to RDTs. They are characterised by features implemented throughout the appraisal process. These features are mechanisms that allow application of different standards to assess the value of the medicine, support to the appraisal/decision-making process, overcome the issues of lack of cost-effectiveness, or exempt from part of/the full appraisal/reimbursement process. They increase the likelihood of reimbursement by adjusting and/or foregoing part of the assessment process, or accepting to pay more for the same added benefit as for common conditions. A large proportion of countries with standard processes include one or more of these features (formally or informally) or are discussing potential changes in their systems. Conclusions Results suggest revealed preferences to treat RDTs differently than conventional medicines. Some of the challenges around uncertainty and high price remain, but supplemental process features can support decision-making that is more flexible and consistent. Many of these processes are new and countries continue to adjust as they gain experience.
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Affiliation(s)
- Elena Nicod
- Research Centre on Health and Social Care Management (CERGAS), Bocconi University, Via Roentgen 1, 20136, Milan, Italy.
| | - Amanda Whittal
- Research Centre on Health and Social Care Management (CERGAS), Bocconi University, Via Roentgen 1, 20136, Milan, Italy
| | - Michael Drummond
- Centre for Health Economics, University of York, York, YO10 5DD, UK
| | - Karen Facey
- Usher Institute, University of Edinburgh, NINE Edinburgh BioQuarter, 9 Little France Road, Edinburgh, EH16 4UX, UK
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Vreman RA, de Ruijter AS, Zawada A, Tafuri G, Stoyanova-Beninska V, O'Connor D, Naumann-Winter F, Wolter F, Mantel-Teeuwisse AK, Leufkens HGM, Sidiropoulos I, Larsson K, Goettsch WG. Assessment of significant benefit for orphan medicinal products by European regulators may support subsequent relative effectiveness assessments by health technology assessment organizations. Drug Discov Today 2020; 25:1223-1231. [PMID: 32344040 DOI: 10.1016/j.drudis.2020.04.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/08/2020] [Accepted: 04/15/2020] [Indexed: 11/26/2022]
Abstract
To maintain orphan drug status at the time of market authorization, orphan medicinal products (OMPs) need to be assessed for all criteria, including significant benefit, by the Committee for Orphan Medicinal Products (COMP) of the European Medicines Agency (EMA). Subsequently, health technology assessment (HTA) organizations evaluate the same OMPs in their relative effectiveness assessments (REAs). This review investigates the similarities and differences between the two frameworks for six HTA organizations, including the European Network for HTA. We discuss differences between both assessment frameworks within five domains (clinical evidence used, patient population, intervention, comparators, and outcome measures) for all drugs. Five illustrative cases studies were selected for a qualitative review.
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Affiliation(s)
- Rick A Vreman
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Universiteitsweg 99, 3584 CG Utrecht, The Netherlands; The National Health Care Institute (ZIN), Willem Dudokhof 1, 1112 ZA Diemen, The Netherlands
| | - Angela S de Ruijter
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Universiteitsweg 99, 3584 CG Utrecht, The Netherlands
| | - Anna Zawada
- Medical University of Warsaw, Zwirki i Wigury St. 61, 02-091 Warsaw, Poland
| | - Giovanni Tafuri
- The National Health Care Institute (ZIN), Willem Dudokhof 1, 1112 ZA Diemen, The Netherlands
| | - Violeta Stoyanova-Beninska
- Committee for Orphan Medicinal Products, European Medicines Agency, Domenico Scarlattilaan 6, 1083 HS, Amsterdam, The Netherlands; College ter Beoordeling van Geneesmiddelen/Medicines Evaluation Board (CBG-MEB), Graadt van Roggenweg 500, 3531 AH, Utrecht, The Netherlands
| | - Daniel O'Connor
- Committee for Orphan Medicinal Products, European Medicines Agency, Domenico Scarlattilaan 6, 1083 HS, Amsterdam, The Netherlands; Medicines and Healthcare products Regulatory Agency (MHRA), 10 SC, Canary Wharf, London, UK
| | - Frauke Naumann-Winter
- Committee for Orphan Medicinal Products, European Medicines Agency, Domenico Scarlattilaan 6, 1083 HS, Amsterdam, The Netherlands; Bundesinstitut für Arzneimittel und Medizinprodukte, Kurt-Georg-Kiesinger-Allee 3, 53175, Bonn, Germany
| | - Franziska Wolter
- Bundesinstitut für Arzneimittel und Medizinprodukte, Kurt-Georg-Kiesinger-Allee 3, 53175, Bonn, Germany
| | - Aukje K Mantel-Teeuwisse
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Universiteitsweg 99, 3584 CG Utrecht, The Netherlands
| | - Hubert G M Leufkens
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Universiteitsweg 99, 3584 CG Utrecht, The Netherlands
| | - Iordanis Sidiropoulos
- Committee for Orphan Medicinal Products, European Medicines Agency, Domenico Scarlattilaan 6, 1083 HS, Amsterdam, The Netherlands
| | - Kristina Larsson
- Committee for Orphan Medicinal Products, European Medicines Agency, Domenico Scarlattilaan 6, 1083 HS, Amsterdam, The Netherlands
| | - Wim G Goettsch
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Universiteitsweg 99, 3584 CG Utrecht, The Netherlands; The National Health Care Institute (ZIN), Willem Dudokhof 1, 1112 ZA Diemen, The Netherlands.
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Czech M, Baran-Kooiker A, Atikeler K, Demirtshyan M, Gaitova K, Holownia-Voloskova M, Turcu-Stiolica A, Kooiker C, Piniazhko O, Konstandyan N, Zalis'ka O, Sykut-Cegielska J. A Review of Rare Disease Policies and Orphan Drug Reimbursement Systems in 12 Eurasian Countries. Front Public Health 2020; 7:416. [PMID: 32117845 PMCID: PMC6997877 DOI: 10.3389/fpubh.2019.00416] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 12/24/2019] [Indexed: 12/22/2022] Open
Abstract
Background: Despite international initiatives on collaboration within the field of rare diseases, patient access to orphan medicinal products (OMPs) and healthcare services differ greatly between countries. This study aimed to create a comprehensive and in-depth overview of rare diseases policies and reimbursement of OMPs in a selection of 12 countries in the Western Eurasian region: Armenia, France, Germany, Kazakhstan, Latvia, The Netherlands, Poland, Romania, Russia, Turkey, Ukraine, and the United Kingdom. Methods: A systematic literature review was performed and an analysis of publicly available legislative and rare disease health policy data was undertaken in five focus areas: rare disease definition, newborn screening, registries, national plans, access to/reimbursement of OMPs. Results: Screening programs are broadly implemented but the number of screened diseases differs significantly (2-35 diseases), either between EU and non-EU countries, between EU member states and sometimes even within a single country. In most countries rare disease registries are operating with regional, national, European or worldwide coverage. The number of rare disease registries is growing, as a result of the National Plans (EU) and increased international scientific cooperation. France, Russia, and Poland have a centrally acting registry. National plans are present in all EU countries but implementation varies and is ongoing. The number of reimbursed OMPs in the selected countries ranges from nearly all available OMPs in the Netherlands, Germany, and France to zero in Armenia. Reimbursement rules differ considerably regionally and a trend is observed of reimbursement conditions getting stricter for expensive (orphan) drugs. Discussion: Inequality in patient access to new OMPs still exists due to variations in national policies, healthcare budgets, health insurance, and reimbursement systems. The observed differences are challenging for rare disease patients, health authorities and manufacturers alike. Progress can be seen, however, and international cooperation and harmonization is slowly but steadily expanding in the rare disease arena.
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Affiliation(s)
- Marcin Czech
- Department of Pharmacoeconomics, The Institute of Mother and Child, Warsaw, Poland
| | - Aleksandra Baran-Kooiker
- Department of Pharmacoeconomics, Faculty of Pharmacy, Medical University of Warsaw, Warsaw, Poland
| | - Kagan Atikeler
- Division of Pharmacoepidemiology and Clinical Pharmacology, Faculty of Science, Utrecht Institute for Pharmaceutical Sciences, Utrecht, Netherlands
- Unit of Health Technology Assessments, Turkish Ministry of Health, Turkish Medicines and Medical Devices Agency, Ankara, Turkey
| | - Maria Demirtshyan
- Ascent Global Market Solutions (Non-profit), Walnut Creek, CA, United States
| | - Kamilla Gaitova
- Center for Economics and Health Technology Assessment, Republican Center for Health Development, Ministry of Health, Nur-Sultan, Kazakhstan
| | - Malwina Holownia-Voloskova
- State Budgetary Institution Research Institute for Healthcare Organization and Medical Management of Moscow Healthcare Department, Moscow, Russia
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Warsaw, Poland
| | - Adina Turcu-Stiolica
- Department of Pharmacoeconomics, Faculty of Pharmacy, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | | | - Oresta Piniazhko
- Department of Management and Economy of Pharmacy, Medicine Technology and Pharmacoeconomics, Postgraduate Faculty, Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
| | - Natella Konstandyan
- Republican Center of Medical Genetics, Yerevan State Medical University, Yerevan, Armenia
| | - Olha Zalis'ka
- Department of Management and Economy of Pharmacy, Medicine Technology and Pharmacoeconomics, Postgraduate Faculty, Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
| | - Jolanta Sykut-Cegielska
- Department of Inborn Errors of Metabolism and Paediatrics, The Institute of Mother and Child, Warsaw, Poland
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Terpos E, Jamotte A, Christodoulopoulou A, Campioni M, Bhowmik D, Kennedy L, Willenbacher W. A cost-effectiveness analysis of denosumab for the prevention of skeletal-related events in patients with multiple myeloma in four European countries: Austria, Belgium, Greece, and Italy. J Med Econ 2019; 22:766-776. [PMID: 30969797 DOI: 10.1080/13696998.2019.1606002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Aim: The approved indication for denosumab (120 mg) was expanded in 2018 to include skeletal-related event (SRE) prevention in patients with multiple myeloma (MM). Therefore, a cost-effectiveness analysis was conducted comparing denosumab with zoledronic acid (ZA) for SRE prevention in patients with MM from the national healthcare system perspective in a representative sample of European countries: Austria, Belgium, Greece, and Italy. Methods: The XGEVA global economic model for patients with MM was used to calculate incremental cost-effectiveness ratios (ICERs) for denosumab vs ZA over a lifetime horizon. Clinical inputs were derived from the denosumab vs ZA randomized, phase 3 study ("20090482") in patients newly-diagnosed with MM, and comprised real-world adjusted SRE rates, serious adverse event (SAE) rates, treatment duration, dose intensity, progression-free survival (PFS), and overall survival (OS). Economic inputs comprised country-specific denosumab and ZA acquisition and administration costs, SRE and SAE management costs, and discount rates. Health utility decrements associated with MM disease progression, SRE and SAE occurrence, and route of administration were included. Results: Estimated ICERs (cost per quality-adjusted life-year [QALY] gained) for denosumab vs ZA in Austria, Belgium, Greece, and Italy were €26,294, €17,737, €6,982, and €27,228, respectively. Using 1-3 times gross domestic product (GDP) per capita per QALY as willingness to pay thresholds, denosumab was 69-94%, 84-96%, 79-96%, and 50-92% likely to be cost-effective vs ZA, respectively. Limitations: Economic inputs were derived from various sources, and time to event inputs were extrapolated from 20090482 study data. Conclusions: Denosumab is cost-effective vs ZA for SRE prevention in patients with MM in Austria, Belgium, Greece, and Italy, based on often-adopted World Health Organization thresholds. This conclusion is robust to changes in model parameters and assumptions. Cost-effectiveness estimates varied across the four countries, reflecting differences in healthcare costs and national economic evaluation guidelines.
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Affiliation(s)
- Evangelos Terpos
- a Department of Clinical Therapeutics, School of Medicine , National and Kapodistrian University of Athens , Athens , Greece
| | - Aurelien Jamotte
- b Global Health Economics , Amgen (Europe) GmbH , Rotkreuz , Switzerland
| | | | - Marco Campioni
- b Global Health Economics , Amgen (Europe) GmbH , Rotkreuz , Switzerland
| | | | | | - Wolfgang Willenbacher
- e Department of Internal Medicine V , Innsbruck University Hospital & Oncotyrol, Center for Personalized Cancer Medicine , Innsbruck , Austria
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Health technology assessment at age 25—Squaring the circle of strong methodology and context-dependency? Health Policy 2019; 123:115-117. [DOI: 10.1016/j.healthpol.2019.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Cannizzo S, Lorenzoni V, Palla I, Pirri S, Trieste L, Triulzi I, Turchetti G. Rare diseases under different levels of economic analysis: current activities, challenges and perspectives. RMD Open 2018; 4:e000794. [PMID: 30488003 PMCID: PMC6241967 DOI: 10.1136/rmdopen-2018-000794] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 10/08/2018] [Accepted: 10/08/2018] [Indexed: 01/08/2023] Open
Abstract
Rare diseases imply clinical and economic burden as well as a significant challenge for health systems. One relevant objective of the activities planned within the European Reference Network on Rare and Complex Connective Tissue and Musculoskeletal Diseases (ERN ReCONNET) is to address the economic dimensions of rare diseases to identify, develop and suggest strategies to improve research and patients' access to orphan drugs (ODs) and highly specialised health technologies. This paper presents a preliminary review of the existing policies on rare diseases in the countries of the Network members. It also introduces and discusses the theme of how to perform health economic evaluations of rare diseases and of existing or new treatments for rare diseases. To obtain a preliminary overview aiming at defining the state of the art of rare diseases policies and initiatives in ERN ReCONNET countries, we collected and analysed the rare diseases national plans of all the eight countries of the ERN ReCONNET participants. The preliminary overview that has been performed showed that in all the ERN ReCONNET countries are in place national plans for rare diseases; however, heterogeneity exists in the reimbursement of ODs, direct provision by the healthcare system, involvement of patients' associations in decision making and implementation of clinical practice guidelines.
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Affiliation(s)
- Sara Cannizzo
- Institute of Management, Scuola Superiore Sant’Anna, Pisa, Italy
| | | | - Ilaria Palla
- Institute of Management, Scuola Superiore Sant’Anna, Pisa, Italy
| | - Salvatore Pirri
- Institute of Management, Scuola Superiore Sant’Anna, Pisa, Italy
| | - Leopoldo Trieste
- Institute of Management, Scuola Superiore Sant’Anna, Pisa, Italy
| | - Isotta Triulzi
- Institute of Management, Scuola Superiore Sant’Anna, Pisa, Italy
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43
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Öffentliche Lenkung und Preisbegrenzung für Orphan-Drugs. Monatsschr Kinderheilkd 2018. [DOI: 10.1007/s00112-018-0518-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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44
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Cannizzo S, Lorenzoni V, Palla I, Pirri S, Trieste L, Triulzi I, Turchetti G. Rare diseases under different levels of economic analysis: current activities, challenges and perspectives. RMD Open 2018. [PMID: 30488003 DOI: 10.1136/rmdopen-2018-000794.pmid:30488003;pmcid:pmc6241967] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2023] Open
Abstract
Rare diseases imply clinical and economic burden as well as a significant challenge for health systems. One relevant objective of the activities planned within the European Reference Network on Rare and Complex Connective Tissue and Musculoskeletal Diseases (ERN ReCONNET) is to address the economic dimensions of rare diseases to identify, develop and suggest strategies to improve research and patients' access to orphan drugs (ODs) and highly specialised health technologies. This paper presents a preliminary review of the existing policies on rare diseases in the countries of the Network members. It also introduces and discusses the theme of how to perform health economic evaluations of rare diseases and of existing or new treatments for rare diseases. To obtain a preliminary overview aiming at defining the state of the art of rare diseases policies and initiatives in ERN ReCONNET countries, we collected and analysed the rare diseases national plans of all the eight countries of the ERN ReCONNET participants. The preliminary overview that has been performed showed that in all the ERN ReCONNET countries are in place national plans for rare diseases; however, heterogeneity exists in the reimbursement of ODs, direct provision by the healthcare system, involvement of patients' associations in decision making and implementation of clinical practice guidelines.
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Affiliation(s)
- Sara Cannizzo
- Institute of Management, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | - Ilaria Palla
- Institute of Management, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Salvatore Pirri
- Institute of Management, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Leopoldo Trieste
- Institute of Management, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Isotta Triulzi
- Institute of Management, Scuola Superiore Sant'Anna, Pisa, Italy
| | | |
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