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Vu M, Degeling K, Westerman D, IJzerman MJ. Scenario analysis and multi-criteria decision analysis to explore alternative reimbursement pathways for whole genome sequencing for blood cancer patients. J Cancer Policy 2024; 41:100501. [PMID: 39142605 DOI: 10.1016/j.jcpo.2024.100501] [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: 01/21/2024] [Revised: 08/07/2024] [Accepted: 08/11/2024] [Indexed: 08/16/2024]
Abstract
BACKGROUND Whole genome sequencing (WGS) has transformative potential for blood cancer management, but reimbursement is hindered by uncertain benefits relative to added costs. This study employed scenario planning and multi-criteria decision analysis (MCDA) to evaluate stakeholders' preferences for alternative reimbursement pathways, informing future health technology assessment (HTA) submission of WGS in blood cancer. METHODS Key factors influencing WGS reimbursement in blood cancers were identified through a literature search. Hypothetical scenarios describing various evidential characteristics of WGS for HTA were developed using the morphological approach. An online survey, incorporating MCDA weights, was designed to gather stakeholder preferences (consumers/patients, clinicians/health professionals, industry representatives, health economists, and HTA committee members) for these scenarios. The survey assessed participants' approval of WGS reimbursement for each scenario, and scenario preferences were determined using the geometric mean method, applying an algorithm to improve reliability and precision by addressing inconsistent responses. RESULTS Nineteen participants provided complete survey responses, primarily clinicians or health professionals (n = 6; 32 %), consumers/patients and industry representatives (both at n = 5; 26 %). "Clinical impact of WGS results on patient care" was the most critical criterion (criteria weight of 0.25), followed by "diagnostic accuracy of WGS" (0.21), "cost-effectiveness of WGS" (0.19), "availability of reimbursed treatment after WGS" (0.16), and "eligibility criteria for reimbursed treatment based on actionable WGS results" and "cost comparison of WGS" (both at 0.09). Participants preferred a scenario with substantial clinical evidence, high access to reimbursed targeted treatment, cost-effectiveness below $50,000 per quality-adjusted life year (QALY) gained, and affordability relative to standard molecular tests. Reimbursement was initially opposed until criteria such as equal cost to standard tests and better treatment accessibility were met. CONCLUSION Payers commonly emphasize acceptable cost-effectiveness, but strong clinical evidence for many variants and comparable costs to standard tests are likely to drive positive reimbursement decisions for WGS.
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Affiliation(s)
- Martin Vu
- Cancer Health Services Research, Centre for Cancer Research, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia; Cancer Health Services Research, Centre for Health Policy, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Koen Degeling
- Cancer Health Services Research, Centre for Cancer Research, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia; Cancer Health Services Research, Centre for Health Policy, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia
| | - David Westerman
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia; Clinical Haematology, Peter MacCallum Cancer Centre/Royal Melbourne Hospital, Melbourne, Australia
| | - Maarten J IJzerman
- Cancer Health Services Research, Centre for Cancer Research, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia; Cancer Health Services Research, Centre for Health Policy, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Australia; Erasmus School of Health Policy and Management, Rotterdam, the Netherlands.
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Pataky RE, Weymann D, Bosdet I, Yip S, Bryan S, Sadatsafavi M, Peacock S, Regier DA. Real-world cost-effectiveness of panel-based genomic testing to inform therapeutic decisions for metastatic colorectal cancer. J Cancer Policy 2024; 41:100496. [PMID: 39032558 DOI: 10.1016/j.jcpo.2024.100496] [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: 03/25/2024] [Revised: 06/26/2024] [Accepted: 07/12/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND Mutations in KRAS and NRAS are associated with a lack of response to cetuximab and panitumumab, two biologics used for third-line therapy of metastatic colorectal cancer (mCRC). In British Columbia, Canada, eligibility for cetuximab or panitumumab was first based on single-gene KRAS testing. OncoPanel, a multi-gene next-generation sequencing panel with both KRAS and NRAS, was introduced in 2016. Our objective was to estimate the real-world cost-effectiveness of OncoPanel versus to single-gene KRAS testing to inform eligibility for cetuximab or panitumumab in mCRC. METHODS Using population-based administrative health data, we identified a cohort of mCRC patients who had received a KRAS or OncoPanel test, and completed prior chemotherapy in 2010-2019. We matched KRAS- and OncoPanel-tested patients (1:1) using genetic matching to balance baseline covariates. Mean and incremental 3-year costs, survival, and quality-adjusted survival were estimated using inverse-probability-of-censoring weighting and bootstrapping. We conducted scenario-based sensitivity analysis for key costs and assumptions. FINDINGS All OncoPanel-tested cases (n=371) were matched to a KRAS-tested comparator. In the KRAS and OncoPanel groups, respectively, 55·8 % and 41·2 % of patients were potentially eligible for cetuximab or panitumumab based on mutation status. Incremental cost and effectiveness of OncoPanel were $72 (95 % CI: -6387, 6107), -0·004 life-years (95 % CI: -0·119, 0·113), and -0·011 quality-adjusted life-years (95 % CI: -0·094, 0·075). Reductions in systemic therapy costs were offset by increased costs in other resources. Results were moderately sensitive to time horizon and changes in testing or treatment cost. INTERPRETATION The use of OncoPanel resulted in more precise targeting of cetuximab and panitumumab, but there was no change in incremental cost or quality-adjusted survival. Understanding the balance of costs achieved in practice can provide insight into the effect of future changes in testing policy, test cost, treatment eligibility, or drug prices in this setting.
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Affiliation(s)
- Reka E Pataky
- Canadian Centre for Applied Research in Cancer Control, Canada; Cancer Control Research, BC Cancer, Vancouver, BC, Canada.
| | - Deirdre Weymann
- Canadian Centre for Applied Research in Cancer Control, Canada; Cancer Control Research, BC Cancer, Vancouver, BC, Canada
| | - Ian Bosdet
- Department of Pathology & Laboratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada; Cancer Genetics & Genomics Laboratory, BC Cancer, Vancouver, BC, Canada
| | - Stephen Yip
- Cancer Genetics & Genomics Laboratory, BC Cancer, Vancouver, BC, Canada; Department of Pathology, BC Cancer, Vancouver, BC, Canada
| | - Stirling Bryan
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada; Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Mohsen Sadatsafavi
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Stuart Peacock
- Canadian Centre for Applied Research in Cancer Control, Canada; Cancer Control Research, BC Cancer, Vancouver, BC, Canada; Faculty of Health Sciences, Simon Fraser University, Vancouver, BC, Canada
| | - Dean A Regier
- Canadian Centre for Applied Research in Cancer Control, Canada; Cancer Control Research, BC Cancer, Vancouver, BC, Canada; School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
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Ehman M, Punian J, Weymann D, Regier DA. Next-generation sequencing in oncology: challenges in economic evaluations. Expert Rev Pharmacoecon Outcomes Res 2024:1-18. [PMID: 39096135 DOI: 10.1080/14737167.2024.2388814] [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: 06/20/2024] [Revised: 07/19/2024] [Accepted: 08/01/2024] [Indexed: 08/04/2024]
Abstract
INTRODUCTION Next-generation sequencing (NGS) identifies genetic variants to inform personalized treatment plans. Insufficient evidence of cost-effectiveness impedes the integration of NGS into routine cancer care. The complexity of personalized treatment challenges conventional economic evaluation. Clearly delineating challenges informs future cost-effectiveness analyses to better value and contextualize health, preference-, and equity-based outcomes. AREAS COVERED We conducted a scoping review to characterize the applied methods and outcomes of economic evaluations of NGS in oncology and identify existing challenges. We included 27 articles published since 2016 from a search of PubMed, Embase, and Web of Science. Identified challenges included defining the evaluative scope, managing evidentiary limitations including lack of causal evidence, incorporating preference-based utility, and assessing distributional and equity-based impacts. These challenges reflect the difficulty of generating high-quality clinical effectiveness and real-world evidence (RWE) for NGS-guided interventions. EXPERT OPINION Adapting methodological approaches and developing life-cycle health technology assessment (HTA) guidance using RWE is crucial for implementing NGS in oncology. Healthcare systems, decision-makers, and HTA organizations are facing a pivotal opportunity to adapt to an evolving clinical paradigm and create innovative regulatory and reimbursement processes that will enable more sustainable, equitable, and patient-oriented healthcare.
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Affiliation(s)
- Morgan Ehman
- Cancer Control Research, BC Cancer, Vancouver, BC, Canada
| | - Jesman Punian
- Cancer Control Research, BC Cancer, Vancouver, BC, Canada
| | - Deirdre Weymann
- Cancer Control Research, BC Cancer, Vancouver, BC, Canada
- Faculty of Health Sciences, Simon Fraser University, Vancouver, BC, Canada
| | - Dean A Regier
- Cancer Control Research, BC Cancer, Vancouver, BC, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
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Salisbury A, Ciardi J, Norman R, Smit AK, Cust AE, Low C, Caruana M, Gordon L, Canfell K, Steinberg J, Pearce A. Public Preferences for Genetic and Genomic Risk-Informed Chronic Disease Screening and Early Detection: A Systematic Review of Discrete Choice Experiments. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2024:10.1007/s40258-024-00893-1. [PMID: 38916649 DOI: 10.1007/s40258-024-00893-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/15/2024] [Indexed: 06/26/2024]
Abstract
PURPOSE Genetic and genomic testing can provide valuable information on individuals' risk of chronic diseases, presenting an opportunity for risk-tailored disease screening to improve early detection and health outcomes. The acceptability, uptake and effectiveness of such programmes is dependent on public preferences for the programme features. This study aims to conduct a systematic review of discrete choice experiments assessing preferences for genetic/genomic risk-tailored chronic disease screening. METHODS PubMed, Embase, EconLit and Cochrane Library were searched in October 2023 for discrete choice experiment studies assessing preferences for genetic or genomic risk-tailored chronic disease screening. Eligible studies were double screened, extracted and synthesised through descriptive statistics and content analysis of themes. Bias was assessed using an existing quality checklist. RESULTS Twelve studies were included. Most studies focused on cancer screening (n = 10) and explored preferences for testing of rare, high-risk variants (n = 10), largely within a targeted population (e.g. subgroups with family history of disease). Two studies explored preferences for the use of polygenic risk scores (PRS) at a population level. Twenty-six programme attributes were identified, with most significantly impacting preferences. Survival, test accuracy and screening impact were most frequently reported as most important. Depending on the clinical context and programme attributes and levels, estimated uptake of hypothetical programmes varied from no participation to almost full participation (97%). CONCLUSION The uptake of potential programmes would strongly depend on specific programme features and the disease context. In particular, careful communication of potential survival benefits and likely genetic/genomic test accuracy might encourage uptake of genetic and genomic risk-tailored disease screening programmes. As the majority of the literature focused on high-risk variants and cancer screening, further research is required to understand preferences specific to PRS testing at a population level and targeted genomic testing for different disease contexts.
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Affiliation(s)
- Amber Salisbury
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia.
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia.
| | - Joshua Ciardi
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | | | - Amelia K Smit
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia
| | - Anne E Cust
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia
| | - Cynthia Low
- Lived Experience Expert, Adelaide, SA, Australia
| | - Michael Caruana
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia
| | - Louisa Gordon
- QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Karen Canfell
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia
| | - Julia Steinberg
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia
| | - Alison Pearce
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
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Marshall DA, Hua N, Buchanan J, Christensen KD, Frederix GWJ, Goranitis I, Ijzerman M, Jansen JP, Lavelle TA, Regier DA, Smith HS, Ungar WJ, Weymann D, Wordsworth S, Phillips KA. Paving the path for implementation of clinical genomic sequencing globally: Are we ready? HEALTH AFFAIRS SCHOLAR 2024; 2:qxae053. [PMID: 38783891 PMCID: PMC11115369 DOI: 10.1093/haschl/qxae053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/18/2024] [Accepted: 04/25/2024] [Indexed: 05/25/2024]
Abstract
Despite the emerging evidence in recent years, successful implementation of clinical genomic sequencing (CGS) remains limited and is challenged by a range of barriers. These include a lack of standardized practices, limited economic assessments for specific indications, limited meaningful patient engagement in health policy decision-making, and the associated costs and resource demand for implementation. Although CGS is gradually becoming more available and accessible worldwide, large variations and disparities remain, and reflections on the lessons learned for successful implementation are sparse. In this commentary, members of the Global Economics and Evaluation of Clinical Genomics Sequencing Working Group (GEECS) describe the global landscape of CGS in the context of health economics and policy and propose evidence-based solutions to address existing and future barriers to CGS implementation. The topics discussed are reflected as two overarching themes: (1) system readiness for CGS and (2) evidence, assessments, and approval processes. These themes highlight the need for health economics, public health, and infrastructure and operational considerations; a robust patient- and family-centered evidence base on CGS outcomes; and a comprehensive, collaborative, interdisciplinary approach.
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Affiliation(s)
- Deborah A Marshall
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta T2N 4Z6, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta T2N 4N1, Canada
| | - Nicolle Hua
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta T2N 4Z6, Canada
| | - James Buchanan
- Health Economics and Policy Research Unit, Centre for Evaluation and Methods, Wolfson Institute of Population Health, Queen Mary University of London, London E1 2AB, United Kingdom
| | - Kurt D Christensen
- PRecisiOn Medicine Translational Research (PROMoTeR) Center, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA 02215, United States
| | - Geert W J Frederix
- Epidemiology and Health Economics, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, 3584 CG Utrecht, The Netherlands
| | - Ilias Goranitis
- Health Economics Unit, Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria 3010, Australia
- Australian Genomics, Parkville, Victoria 3052, Australia
| | - Maarten Ijzerman
- University of Melbourne Centre for Cancer Research, University of Melbourne, Melbourne, Victoria 3000, Australia
- Erasmus School of Health Policy & Management, Eramus University Rotterdam, 3062 PA Rotterdam, The Netherlands
| | - Jeroen P Jansen
- Center for Translational and Policy Research on Precision Medicine (TRANSPERS), Department of Clinical Pharmacy, School of Pharmacy, University of California, San Francisco, San Francisco, CA 94158, United States
| | - Tara A Lavelle
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA 02111, United States
| | - Dean A Regier
- Canadian Centre for Applied Research in Cancer Control, Cancer Control Research, BC Cancer Research Institute, Vancouver, British Columbia V5Z 1L3, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia V6T 1Z3, Canada
| | - Hadley S Smith
- PRecisiOn Medicine Translational Research (PROMoTeR) Center, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA 02215, United States
| | - Wendy J Ungar
- Program of Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario M5G 0A4, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario M5T 3M6, Canada
| | - Deirdre Weymann
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia V6T 1Z3, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia V5A 1S6, Canada
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health and NIHR Biomedical Research Centre, University of Oxford, Oxford OX3 7LF, United Kingdom
| | - Kathryn A Phillips
- Center for Translational and Policy Research on Precision Medicine (TRANSPERS), Department of Clinical Pharmacy, School of Pharmacy, University of California, San Francisco, San Francisco, CA 94158, United States
- Health Affairs Scholar Emerging & Global Health Policy, Health Affairs, Washington, DC 20036, United States
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Regier DA, Loewen R, Chan B, Ehman M, Pollard S, Friedman JM, Stockler-Ipsiroglu S, van Karnebeek C, Race S, Elliott AM, Dragojlovic N, Lynd LD, Weymann D. Real-world diagnostic outcomes and cost-effectiveness of genome-wide sequencing for developmental and seizure disorders: Evidence from Canada. Genet Med 2024; 26:101069. [PMID: 38205742 DOI: 10.1016/j.gim.2024.101069] [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: 07/21/2023] [Revised: 01/03/2024] [Accepted: 01/04/2024] [Indexed: 01/12/2024] Open
Abstract
PURPOSE To determine real-world diagnostic rates, cost trajectories, and cost-effectiveness of exome sequencing (ES) and genome sequencing (GS) for children with developmental and/or seizure disorders in British Columbia, Canada. METHODS Based on medical records review, we estimated real-world costs and outcomes for 491 patients who underwent standard of care (SOC) diagnostic testing at British Columbia Children's Hospital. Results informed a state-transition Markov model examining cost-effectiveness of 3 competing diagnostic strategies: (1) SOC with last-tier access to ES, (2) streamlined ES access, and (3) first-tier GS. RESULTS Through SOC, 49.4% (95% CI: 40.6, 58.2) of patients were diagnosed at an average cost of C$11,683 per patient (95% CI: 9200, 14,166). Compared with SOC, earlier ES or GS access yielded similar or improved diagnostic rates and shorter times to genetic diagnosis, with 94% of simulations demonstrating cost savings for streamlined ES and 60% for first-tier GS. Net benefit from the perspective of the health care system was C$2956 (95% CI: -608, 6519) for streamlined ES compared with SOC. CONCLUSION Using real-world data, we found earlier access to ES may yield more rapid genetic diagnosis of childhood developmental and seizure disorders and cost savings compared with current practice in a Canadian health care system.
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Affiliation(s)
- Dean A Regier
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, Canada; Cancer Control Research, BC Cancer Research Institute, Vancouver, Canada
| | - Rosalie Loewen
- Cancer Control Research, BC Cancer Research Institute, Vancouver, Canada
| | - Brandon Chan
- Cancer Control Research, BC Cancer Research Institute, Vancouver, Canada
| | - Morgan Ehman
- Cancer Control Research, BC Cancer Research Institute, Vancouver, Canada
| | - Samantha Pollard
- Cancer Control Research, BC Cancer Research Institute, Vancouver, Canada
| | - Jan M Friedman
- Department of Medical Genetics, University of British Columbia, Vancouver, Canada; BC Children's Hospital Research Institute, Vancouver, Canada
| | - Sylvia Stockler-Ipsiroglu
- BC Children's Hospital Research Institute, Vancouver, Canada; Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, Canada; Division of Biochemical Genetics, BC Children's Hospital, Vancouver, Canada
| | - Clara van Karnebeek
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, Canada; Departments of Pediatrics and Human Genetics, Emma Center for Personalized Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Simone Race
- Division of Biochemical Genetics, BC Children's Hospital, Vancouver, Canada
| | - Alison M Elliott
- Department of Medical Genetics, University of British Columbia, Vancouver, Canada; BC Children's Hospital Research Institute, Vancouver, Canada
| | - Nick Dragojlovic
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
| | - Larry D Lynd
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada; Centre for Health Evaluation and Outcomes Sciences, Providence Health Research Institute, Vancouver, Canada
| | - Deirdre Weymann
- Cancer Control Research, BC Cancer Research Institute, Vancouver, Canada.
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Pan T, Wu Y, Buchanan J, Goranitis I. QALYs and rare diseases: exploring the responsiveness of SF-6D, EQ-5D-5L and AQoL-8D following genomic testing for childhood and adult-onset rare genetic conditions in Australia. Health Qual Life Outcomes 2023; 21:132. [PMID: 38087302 PMCID: PMC10717517 DOI: 10.1186/s12955-023-02216-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 12/02/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Genomic testing transforms the diagnosis and management of rare conditions. However, uncertainty exists on how to best measure genomic outcomes for informing healthcare priorities. Using the HTA-preferred method should be the starting point to improve the evidence-base. This study explores the responsiveness of SF-6D, EQ-5D-5L and AQoL-8D following genomic testing across childhood and adult-onset genetic conditions. METHOD Self-reported patient-reported outcomes (PRO) were obtained from: primary caregivers of children with suspected neurodevelopmental disorders (NDs) or genetic kidney diseases (GKDs) (carers' own PRO), adults with suspected GKDs using SF-12v2; adults with suspected complex neurological disorders (CNDs) using EQ-5D-5L; and adults with dilated cardiomyopathy (DCM) using AQol-8D. Responsiveness was assessed using the standardised response mean effect-size based on diagnostic (having a confirmed genomic diagnosis), personal (usefulness of genomic information to individuals or families), and clinical (clinical usefulness of genomic information) utility anchors. RESULTS In total, 254 people completed PRO measures before genomic testing and after receiving results. For diagnostic utility, a nearly moderate positive effect size was identified by the AQoL-8D in adult DCM patients. Declines in physical health domains masked any improvements in mental or psychosocial domains in parents of children affected by NDs and adult CNDs and DCM patients with confirmed diagnosis. However, the magnitude of the changes was small and we did not find statistically significant evidence of these changes. No other responsiveness evidence related to diagnostic, clinical, and personal utility of genomic testing was identified. CONCLUSION Generic PRO measures may lack responsiveness to the diagnostic, clinical and personal outcomes of genomics, but further research is needed to establish their measurement properties and relevant evaluative space in the context of rare conditions. Expected declines in the physical health of people experiencing rare conditions may further challenge the conventional application of quality of life assessments.
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Affiliation(s)
- Tianxin Pan
- Economics of Genomics and Precision Medicine Unit, Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
| | - You Wu
- Economics of Genomics and Precision Medicine Unit, Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
- Australian Genomics Health Alliance, Melbourne, Victoria, Australia
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - James Buchanan
- Health Economics Research Centre, University of Oxford, Oxford, United Kingdom
- Health Economics and Policy Research Unit, Queen Mary University of London, London, United Kingdom
| | - Ilias Goranitis
- Economics of Genomics and Precision Medicine Unit, Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia.
- Australian Genomics Health Alliance, Melbourne, Victoria, Australia.
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.
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Weymann D, Pollard S, Lam H, Krebs E, Regier DA. Toward Best Practices for Economic Evaluations of Tumor-Agnostic Therapies: A Review of Current Barriers and Solutions. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:1608-1617. [PMID: 37543205 DOI: 10.1016/j.jval.2023.07.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 06/28/2023] [Accepted: 07/26/2023] [Indexed: 08/07/2023]
Abstract
OBJECTIVES Cancer therapies targeting tumor-agnostic biomarkers are challenging traditional health technology assessment (HTA) frameworks. The high prevalence of nonrandomized single-arm trials, heterogeneity, and small benefiting populations are driving outcomes uncertainty, challenging healthcare decision making. We conducted a structured literature review to identify barriers and prioritize solutions to generating economic evidence for tumor-agnostic therapies. METHODS We searched MEDLINE and Embase for English-language studies conducting economic evaluations of tumor-agnostic treatments or exploring related challenges and solutions. We included studies published by December 2022 and supplemented our review with Canadian Agency for Drugs and Technologies in Health and National Institute for Health and Care Excellence technical reports for approved tumor-agnostic therapies. Three reviewers abstracted and summarized key methodological and empirical study characteristics. Challenges and solutions were identified through authors' statements and categorized using directed content analysis. RESULTS Twenty-six studies met our inclusion criteria. Studies spanned economic evaluations (n = 5), reimbursement reviews (n = 4), qualitative research (n = 1), methods validations (n = 3), and commentaries or literature reviews (n = 13). Challenges encountered related to (1) the treatment setting and clinical trial designs, (2) a lack of data or low-quality data on clinical and cost parameters, and (3) an inability to produce evidence that meets HTA guidelines. Although attempted solutions centered on analytic approaches for managing missing data, proposed solutions highlighted the need for real-world evidence combined with life-cycle HTA to reduce future evidentiary uncertainty. CONCLUSIONS Therapeutic innovation outpaces HTA evidence generation and the methods that support it. Existing HTA frameworks must be adapted for tumor-agnostic treatments to support future economic evaluations enabling timely patient access.
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Affiliation(s)
| | | | - Halina Lam
- Cancer Control Research, BC Cancer, Vancouver, Canada
| | - Emanuel Krebs
- Cancer Control Research, BC Cancer, Vancouver, Canada
| | - Dean A Regier
- Cancer Control Research, BC Cancer, Vancouver, Canada; School of Population and Public Health, University of British Columbia, Vancouver, Canada.
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Mallett A, Stark Z, Fehlberg Z, Best S, Goranitis I. Determining the utility of diagnostic genomics: a conceptual framework. Hum Genomics 2023; 17:75. [PMID: 37587497 PMCID: PMC10433656 DOI: 10.1186/s40246-023-00524-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 08/09/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND Diagnostic efficacy is now well established for diagnostic genomic testing in rare disease. Assessment of overall utility is emerging as a key next step, however ambiguity in the conceptualisation and measurement of utility has impeded its assessment in a comprehensive manner. We propose a conceptual framework to approach determining the broader utility of diagnostic genomics encompassing patients, families, clinicians, health services and health systems to assist future evidence generation and funding decisions. BODY: Building upon previous work, our framework posits that utility of diagnostic genomics consists of three dimensions: the domain or type and extent of utility (what), the relationship and perspective of utility (who), and the time horizon of utility (when). Across the description, assessment, and summation of these three proposed dimensions of utility, one could potentially triangulate a singular point of utility axes of type, relationship, and time. Collectively, the multiple different points of individual utility might be inferred to relate to a concept of aggregate utility. CONCLUSION This ontological framework requires retrospective and prospective application to enable refinement and validation. Moving forward our framework, and others which have preceded it, promote a better characterisation and description of genomic utility to inform decision-making and optimise the benefits of genomic diagnostic testing.
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Affiliation(s)
- Andrew Mallett
- Australian Genomics, Murdoch Children's Research Institute, Melbourne, VIC, Australia.
- College of Medicine and Dentistry, James Cook University, Douglas, QLD, Australia.
- Institute for Molecular Bioscience, The University of Queensland, St Lucia, QLD, Australia.
- Department of Renal Medicine, Townsville University Hospital, Douglas, QLD, 4029, Australia.
| | - Zornitza Stark
- Australian Genomics, Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Melbourne, VIC, Australia
- University of Melbourne, Melbourne, VIC, Australia
| | - Zoe Fehlberg
- Australian Genomics, Murdoch Children's Research Institute, Melbourne, VIC, Australia
- University of Melbourne, Melbourne, VIC, Australia
| | - Stephanie Best
- Australian Genomics, Murdoch Children's Research Institute, Melbourne, VIC, Australia
- University of Melbourne, Melbourne, VIC, Australia
- Department of Health Services Research, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Victorian Comprehensive Cancer Centre Alliance, Melbourne, VIC, Australia
| | - Ilias Goranitis
- Australian Genomics, Murdoch Children's Research Institute, Melbourne, VIC, Australia
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Melbourne, VIC, Australia
- University of Melbourne, Melbourne, VIC, Australia
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10
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Knott T, Creeden J, Horbach B, Rauch‐Zumbrägel M, Vat L, Harnik H, Maravic Z. Stakeholders' expectations of precision medicine: A qualitative study to identify areas of (mis)alignment. Health Sci Rep 2023; 6:e1428. [PMID: 37599652 PMCID: PMC10435831 DOI: 10.1002/hsr2.1428] [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: 12/21/2022] [Revised: 06/08/2023] [Accepted: 07/04/2023] [Indexed: 08/22/2023] Open
Abstract
Background and Aims To sustainably address challenges in implementing precision medicine (PM), coordinated efforts of different stakeholders are required. Understanding their expectations represents a first key step toward aligning on future actions and strategies. Here, we aimed to explore the expectations of different stakeholders from themselves and each other regarding PM. Methods This collaborative qualitative study was initiated by the global multistakeholder consortium From Testing to Targeted Treatments (FT3). Structured interviews were conducted with participants from five stakeholder groups: patients/patient advocates, healthcare providers (HCPs), researchers, policymakers/regulators/payers and industry representatives. A broad reach across geography, roles, experiences, and disease areas was sought. Results were analyzed by grounded theory methodology. Results All stakeholders stated that optimal implementation of PM can only be achieved through collaboration; industry representatives were the biggest promoters of collaboration. Stakeholders agreed that PM should be implemented focusing on the patient's best interest; HCPs were seen as important gatekeepers for PM by interacting directly with patients, and policymakers/payers were perceived as the most important drivers of access to PM. Areas of misalignment included the role of industry in clinical trial design and in access to PM (perceived as important by patients, HCPs and policymakers but not by industry representatives), and the stakeholders responsible for elaborating guidelines on PM use (patients indicated policymakers, while researchers indicated themselves). Priorities for optimal PM implementation and suggested actions included the need for enhancing high-level policy focus, improving genomic literacy, optimizing the health technology assessment for PM, advocating for equitable access, promoting collaboration between industry and other stakeholder groups and development of reliable research standards. Conclusion Stakeholder expectations revealed in this study suggested that no stakeholder group can drive change on its own; a global, multistakeholder collaborative approach that brings together current programs and best practices to support universal access to PM is needed.
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Affiliation(s)
- Tanya Knott
- Sarah Jennifer Knott FoundationDublinIreland
- From Testing to Targeted Treatments (FT3) Board Member, The SynergistBrusselsBelgium
| | - James Creeden
- From Testing to Targeted Treatments (FT3) Board Member, The SynergistBrusselsBelgium
- Creeden ConsultingBaselSwitzerland
| | - Benjamin Horbach
- F. Hoffmann‐La Roche Ltd.BaselSwitzerland
- From Testing to Targeted Treatments (FT3) Member, The SynergistBrusselsBelgium
| | | | - Lidewij Vat
- From Testing to Targeted Treatments (FT3) Program Team, The SynergistBrusselsBelgium
| | - Helena Harnik
- From Testing to Targeted Treatments (FT3) Program Team, The SynergistBrusselsBelgium
| | - Zorana Maravic
- From Testing to Targeted Treatments (FT3) Member, The SynergistBrusselsBelgium
- Digestive Cancers EuropeBrusselsBelgium
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11
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Lavelle TA, Smith HS. Pediatric Genomic Medicine: Value, Implementation, and Access. Clin Ther 2023; 45:687-689. [PMID: 37563063 DOI: 10.1016/j.clinthera.2023.07.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 07/12/2023] [Indexed: 08/12/2023]
Affiliation(s)
- Tara A Lavelle
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts.
| | - Hadley Stevens Smith
- PRecisiOn Medicine Translational Research (PROMoTeR) Center, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
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12
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Smith HS, Bonkowski ES, Deloge RB, Gutierrez AM, Recinos AM, Lavelle TA, Veenstra DL, McGuire AL, Pereira S. Key drivers of family-level utility of pediatric genomic sequencing: a qualitative analysis to support preference research. Eur J Hum Genet 2023; 31:445-452. [PMID: 36434257 PMCID: PMC10133279 DOI: 10.1038/s41431-022-01245-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 10/16/2022] [Accepted: 11/14/2022] [Indexed: 11/26/2022] Open
Abstract
Given that pediatric genomic sequencing (GS) may have implications for the health and well-being of both the child and family, a clearer understanding of the key drivers of the utility of GS from the family perspective is needed. The purpose of this study is to explore what is important to caregivers of pediatric patients regarding clinical GS, with a focus on family-level considerations. We conducted semi-structured interviews with caregivers (n = 41) of pediatric patients who had been recommended for or completed GS that explored the scope of factors caregivers considered when deciding whether to pursue GS for their child. We analyzed the qualitative data in multiple rounds of coding using thematic analysis. Caregivers raised important family-level considerations, in addition to those specifically for their child, which included wanting the best chance at good quality of life for the family, the ability to learn about family health, the impact on the caregiver's well-being, privacy concerns among family members, and the cost of testing to the family. We developed a framework of key drivers of utility consisting of four domains that influenced caregivers' decision making: underlying values, perceived benefits, perceived risks, and other pragmatic considerations regarding GS. These findings can inform measurement approaches that better capture the utility of pediatric GS for families and improve assessments of the value of clinical GS.
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Affiliation(s)
- Hadley Stevens Smith
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA.
| | - Emily S Bonkowski
- Institute for Public Health Genetics, University of Washington School of Public Health, Seattle, WA, USA
| | | | - Amanda M Gutierrez
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Alva M Recinos
- Texas Children's Cancer Center, Texas Children's Hospital, Houston, TX, USA
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Tara A Lavelle
- Center for the Evaluation of Value and Risk in Health (CEVR), Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - David L Veenstra
- Comparative Health Outcomes, Policy & Economics (CHOICE) Institute, School of Pharmacy, University of Washington, Seattle, WA, USA
| | - Amy L McGuire
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Stacey Pereira
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
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13
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Turbitt E, Kohler JN, Angelo F, Miller IM, Lewis KL, Goddard KAB, Wilfond BS, Biesecker BB, Leo MC. The PrU: Development and validation of a measure to assess personal utility of genomic results. Genet Med 2023; 25:100356. [PMID: 36516964 DOI: 10.1016/j.gim.2022.12.003] [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] [Received: 09/13/2022] [Revised: 12/06/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022] Open
Abstract
PURPOSE People report experiencing value from learning genomic results even in the absence of clinically actionable information. Such personal utility has emerged as a key concept in genomic medicine. The lack of a validated patient-reported outcome measure of personal utility has impeded the ability to assess this concept among those receiving genomic results and evaluate the patient-perceived value of genomics. We aimed to construct and psychometrically evaluate a scale to measure personal utility of genomic results-the Personal Utility (PrU) scale. METHODS We used an evidence-based, operational definition of personal utility, with data from a systematic literature review and Delphi survey to build a novel scale. After piloting with 24 adults, the PrU was administered to healthy adults in a Clinical Sequencing Evidence-Generating Research Consortium study after receiving results. We investigated the responses using exploratory factor analysis. RESULTS The exploratory factor analysis (N = 841 participants) resulted in a 3-factor solution, accounting for 74% of the variance in items: (1) self-knowledge (α = 0.92), (2) reproductive planning (α = 0.89), and (3) practical benefits (α = 0.91). CONCLUSION Our findings support the use of the 3-factor PrU to assess personal utility of genomic results. Validation of the PrU in other samples will be important for more wide-spread application.
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Affiliation(s)
- Erin Turbitt
- Graduate School of Health, University of Technology Sydney, Ultimo, New South Wales, Australia.
| | - Jennefer N Kohler
- Stanford Center for Undiagnosed Diseases, Standard University, Stanford, CA
| | - Frank Angelo
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Ilana M Miller
- Rare Disease Institute, Children's National Hospital, Washington, DC
| | - Katie L Lewis
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD
| | | | - Benjamin S Wilfond
- Treuman Katz Center for Pediatric Bioethics, Seattle Children's Hospital, Seattle, WA
| | - Barbara B Biesecker
- Genomics, Ethics, and Translational Research Program, RTI International, Washington, DC
| | - Michael C Leo
- Center for Health Research, Kaiser Permanente Northwest, Portland, OR
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14
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Hayeems RZ, Bernier F, Boycott KM, Hartley T, Michaels-Igbokwe C, Marshall DA. Positioning whole exome sequencing in the diagnostic pathway for rare disease to optimise utility: a protocol for an observational cohort study and an economic evaluation. BMJ Open 2022; 12:e061468. [PMID: 36216418 PMCID: PMC9557316 DOI: 10.1136/bmjopen-2022-061468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Despite the superior diagnostic performance of exome and genome sequencing compared with conventional genetic tests, evidence gaps related to clinical utility and cost effectiveness have limited their availability in routine clinical practice in many jurisdictions. To inform adoption and reimbursement policy, this protocol provides a chain of evidence approach to determining the diagnostic utility, clinical utility and cost-effectiveness of whole exome sequencing (WES) from seven medical genetic centres in two Canadian provinces. METHODS AND ANALYSIS Using a multicentre observational cohort design, we will extract data specific to the pre-WES diagnostic pathway and 1-year post-WES medical management from electronic medical records for 650 patients with rare disease of suspected genetic aetiology who receive WES. The date from the clinical record will be linked to provincial administrative health database to capture healthcare resource use and estimate costs. Our analysis will: (1) define and describe diagnostic testing pathways that occur prior to WES among patients with rare disease, (2) determine the diagnostic utility of WES, characterised as the proportion of patients for whom causative DNA variants are identified, (3) determine the clinical utility of WES, characterised as a change in medical management triggered by WES results, (4) determine the pattern and cost of health service utilisation prior and 1 year following WES among patients who receive a diagnosis, do not receive a diagnosis, or receive an uncertain diagnosis and (5) estimate the cost-effectiveness of WES compared with conventional diagnostic testing pathways, measured by the incremental cost per additional patient diagnosed by WES using simulation modelling. ETHICS AND DISSEMINATION This protocol was approved by Clinical Trials Ontario (CTO-1577) and research ethics boards at the University of Calgary (REB18-0744 and REB20-1449) and University of Alberta (Pro0009156). Findings will be disseminated through academic publications and policy reports.
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Affiliation(s)
- Robin Z Hayeems
- Child Health Evaluative Sciences, Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Francois Bernier
- Department of Medical Genetics, Alberta Children's Hospital, Calgary, Alberta, Canada
- Cummings School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kym M Boycott
- Department of Genetics, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
- Department of Paediatrics, Facuty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Taila Hartley
- Department of Genetics, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Christine Michaels-Igbokwe
- Cummings School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Deborah A Marshall
- Cummings School of Medicine, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
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15
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Ferket BS, Baldwin Z, Murali P, Pai A, Mittendorf KF, Russell HV, Chen F, Lynch FL, Lich KH, Hindorff LA, Savich R, Slavotinek A, Smith HS, Gelb BD, Veenstra DL. Cost-effectiveness frameworks for comparing genome and exome sequencing versus conventional diagnostic pathways: A scoping review and recommended methods. Genet Med 2022; 24:2014-2027. [PMID: 35833928 PMCID: PMC9997042 DOI: 10.1016/j.gim.2022.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 06/13/2022] [Accepted: 06/15/2022] [Indexed: 01/21/2023] Open
Abstract
PURPOSE Methodological challenges have limited economic evaluations of genome sequencing (GS) and exome sequencing (ES). Our objective was to develop conceptual frameworks for model-based cost-effectiveness analyses (CEAs) of diagnostic GS/ES. METHODS We conducted a scoping review of economic analyses to develop and iterate with experts a set of conceptual CEA frameworks for GS/ES for prenatal testing, early diagnosis in pediatrics, diagnosis of delayed-onset disorders in pediatrics, genetic testing in cancer, screening of newborns, and general population screening. RESULTS Reflecting on 57 studies meeting inclusion criteria, we recommend the following considerations for each clinical scenario. For prenatal testing, performing comparative analyses of costs of ES strategies and postpartum care, as well as genetic diagnoses and pregnancy outcomes. For early diagnosis in pediatrics, modeling quality-adjusted life years (QALYs) and costs over ≥20 years for rapid turnaround GS/ES. For hereditary cancer syndrome testing, modeling cumulative costs and QALYs for the individual tested and first/second/third-degree relatives. For tumor profiling, not restricting to treatment uptake or response and including QALYs and costs of downstream outcomes. For screening, modeling lifetime costs and QALYs and considering consequences of low penetrance and GS/ES reanalysis. CONCLUSION Our frameworks can guide the design of model-based CEAs and ultimately foster robust evidence for the economic value of GS/ES.
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Affiliation(s)
- Bart S Ferket
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Zach Baldwin
- The Comparative Health Outcomes, Policy and Economics (CHOICE) Institute, School of Pharmacy, University of Washington, Seattle, WA
| | - Priyanka Murali
- Division of Medical Genetics, Department of Medicine, University of Washington Medical Center, University of Washington, Seattle, WA
| | - Akila Pai
- Institute for Healthcare Delivery Science, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Kathleen F Mittendorf
- Department of Translational and Applied Genomics (TAG), Kaiser Permanente Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon; Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN
| | - Heidi V Russell
- Texas Children's Cancer Center, Baylor College of Medicine, Houston, TX; Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX
| | - Flavia Chen
- Program in Bioethics, University of California San Francisco, San Francisco, CA; Institute for Human Genetics, University of California San Francisco, San Francisco, CA
| | | | - Kristen Hassmiller Lich
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Lucia A Hindorff
- Division of Genomic Medicine, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD
| | - Renate Savich
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS; Division of Neonatology, School of Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM
| | - Anne Slavotinek
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Hadley Stevens Smith
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX
| | - Bruce D Gelb
- Departments of Pediatrics and Genetics & Genomic Sciences, Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - David L Veenstra
- The Comparative Health Outcomes, Policy and Economics (CHOICE) Institute, School of Pharmacy, University of Washington, Seattle, WA
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16
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Abbott M, McKenzie L, Moran BVG, Heidenreich S, Hernández R, Hocking-Mennie L, Clark C, Gomes J, Lampe A, Baty D, McGowan R, Miedzybrodzka Z, Ryan M. Continuing the sequence? Towards an economic evaluation of whole genome sequencing for the diagnosis of rare diseases in Scotland. J Community Genet 2022; 13:487-501. [PMID: 34415556 PMCID: PMC9530076 DOI: 10.1007/s12687-021-00541-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 07/15/2021] [Indexed: 11/21/2022] Open
Abstract
Novel developments in genomic medicine may reduce the length of the diagnostic odyssey for patients with rare diseases. Health providers must thus decide whether to offer genome sequencing for the diagnosis of rare conditions in a routine clinical setting. We estimated the costs of singleton standard genetic testing and trio-based whole genome sequencing (WGS), in the context of the Scottish Genomes Partnership (SGP) study. We also explored what users value about genomic sequencing. Insights from the costing and value assessments will inform a subsequent economic evaluation of genomic medicine in Scotland. An average cost of £1,841 per singleton was estimated for the standard genetic testing pathway, with significant variability between phenotypes. WGS cost £6625 per family trio, but this estimate reflects the use of WGS during the SGP project and large cost savings may be realised if sequencing was scaled up. Patients and families valued (i) the chance of receiving a diagnosis (and the peace of mind and closure that brings); (ii) the information provided by WGS (including implications for family planning and secondary findings); and (iii) contributions to future research. Our costings will be updated to address limitations of the current study for incorporation in budget impact modelling and cost-effectiveness analysis (cost per diagnostic yield). Our insights into the benefits of WGS will guide the development of a discrete choice experiment valuation study. This will inform a user-perspective cost-benefit analysis of genome-wide sequencing, accounting for the broader non-health outcomes. Taken together, our research will inform the long-term strategic development of NHS Scotland clinical genetics testing services, and will be of benefit to others seeking to undertake similar evaluations in different contexts.
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Affiliation(s)
- Michael Abbott
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK.
| | - Lynda McKenzie
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Sebastian Heidenreich
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
- Evidera Inc., London, UK
| | - Rodolfo Hernández
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Caroline Clark
- Department of Medical Genetics, University of Aberdeen, Aberdeen, UK
- NHS Grampian Regional Genetics Service, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Joana Gomes
- NHS Grampian Regional Genetics Service, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Anne Lampe
- South East Scotland Clinical Genetics Service, Western General Hospital, Edinburgh, UK
| | - David Baty
- NHS Tayside Regional Genetics Service, Ninewells Hospital, Dundee, UK
| | - Ruth McGowan
- South East Scotland Clinical Genetics Service, Queen Elizabeth University Hospital, Glasgow, UK
| | | | - Mandy Ryan
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
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17
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White S, Turbitt E, Phillips JL, Jacobs C. Approaching discussions about genetics with palliative patients and their families: a qualitative exploration with genetic health professionals. Eur J Hum Genet 2022:10.1038/s41431-022-01179-7. [PMID: 36064787 PMCID: PMC9441822 DOI: 10.1038/s41431-022-01179-7] [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: 06/02/2022] [Revised: 07/19/2022] [Accepted: 08/15/2022] [Indexed: 11/09/2022] Open
Abstract
Genetic information can provide clinical benefits to families of palliative patients. However, integration of genetics into mainstream medicine has not focused on palliative populations. We explored the views and experiences of genetic health professionals in addressing genetics with palliative patients, and their families. We conducted an interpretive descriptive qualitative study with genetic counsellors and clinical geneticists using interviews and focus groups. Findings were generated using reflexive thematic analysis. Three themes were identified: (1) Focusing on the benefit to the family, (2) The discomfort of addressing genetics near end-of-life and (3) "It's always on the back-burner": Challenges to getting genetics on the palliative care agenda. Participants discussed the familial benefit of genetics in palliative care alongside the challenges when patients are near end-of-life. They perceived genetics as low priority for palliative care due to misunderstandings related to the value of genetic information. Acknowledging the challenges in the palliative care context, genetic health professionals want improved service leadership and awareness of the familial benefits of palliative genetic testing. Strong leadership to support genetic health professionals in addressing these barriers is needed for the benefits of genetic information to be realised.
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Affiliation(s)
- Stephanie White
- Graduate School of Health, University of Technology Sydney, Sydney, NSW, Australia.
| | - Erin Turbitt
- Graduate School of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Jane L Phillips
- School of Nursing, Faculty of Health, Queensland University of Technology, Brisbane, QLD, Australia
| | - Chris Jacobs
- Graduate School of Health, University of Technology Sydney, Sydney, NSW, Australia
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18
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Pollard S, Weymann D, Chan B, Ehman M, Wordsworth S, Buchanan J, Hanna TP, Ho C, Lim HJ, Lorgelly PK, Raymakers AJN, McCabe C, Regier DA. Defining a Core Data Set for the Economic Evaluation of Precision Oncology. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:1371-1380. [PMID: 35216902 DOI: 10.1016/j.jval.2022.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 12/11/2021] [Accepted: 01/10/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Precision oncology is generating vast amounts of multiomic data to improve human health and accelerate research. Existing clinical study designs and attendant data are unable to provide comparative evidence for economic evaluations. This lack of evidence can cause inconsistent and inappropriate reimbursement. Our study defines a core data set to facilitate economic evaluations of precision oncology. METHODS We conducted a literature review of economic evaluations of next-generation sequencing technologies, a common application of precision oncology, published between 2005 and 2018 and indexed in PubMed (MEDLINE). Based on this review, we developed a preliminary core data set for informal expert feedback. We then used a modified-Delphi approach with individuals involved in implementation and evaluation of precision medicine, including 2 survey rounds followed by a final voting conference to refine the data set. RESULTS Two authors determined that variation in published data elements was reached after abstraction of 20 economic evaluations. Expert consultation refined the data set to 83 unique data elements, and a multidisciplinary sample of 46 experts participated in the modified-Delphi process. A total of 68 elements (81%) were selected as required, spanning demographics and clinical characteristics, genomic data, cancer treatment, health and quality of life outcomes, and resource use. CONCLUSIONS Cost-effectiveness analyses will fail to reflect the real-world impacts of precision oncology without data to accurately characterize patient care trajectories and outcomes. Data collection in accordance with the proposed core data set will promote standardization and enable the generation of decision-grade evidence to inform reimbursement.
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Affiliation(s)
- Samantha Pollard
- Canadian Centre for Applied Research in Cancer Control, Cancer Control Research, BC Cancer, Vancouver, Canada
| | - Deirdre Weymann
- Canadian Centre for Applied Research in Cancer Control, Cancer Control Research, BC Cancer, Vancouver, Canada
| | - Brandon Chan
- Canadian Centre for Applied Research in Cancer Control, Cancer Control Research, BC Cancer, Vancouver, Canada
| | - Morgan Ehman
- Canadian Centre for Applied Research in Cancer Control, Cancer Control Research, BC Cancer, Vancouver, Canada
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, England, UK; Oxford NIHR Biomedical Research Centre, Oxford, England, UK
| | - James Buchanan
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, England, UK; Oxford NIHR Biomedical Research Centre, Oxford, England, UK
| | - Timothy P Hanna
- Department of Oncology, Queen's University, Kingston, Canada
| | - Cheryl Ho
- Division of Medical Oncology, BC Cancer, Vancouver, Canada; Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Howard J Lim
- Division of Medical Oncology, BC Cancer, Vancouver, Canada; Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Paula K Lorgelly
- Department of Applied Health Research, University College London, London, England, UK
| | - Adam J N Raymakers
- Canadian Centre for Applied Research in Cancer Control, Cancer Control Research, BC Cancer, Vancouver, Canada
| | | | - Dean A Regier
- Canadian Centre for Applied Research in Cancer Control, Cancer Control Research, BC Cancer, Vancouver, Canada; School of Population and Public Health, University of British Columbia, Vancouver, Canada.
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19
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Chaudhari VS, Hole KC, Issa AM. Evaluating the quality of the economic evidence in colorectal cancer genomics studies. Per Med 2022; 19:361-375. [PMID: 35786999 DOI: 10.2217/pme-2021-0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The increase in the use of genome-based screening and diagnostic tests adds to the overall costs of oncologic care for colorectal cancer. This, in turn, has resulted in an increase in published economic analyses. Aim: To perform a systematic literature review of the available economic evidence evaluating the value of genomic testing for colorectal cancer and appraise the quality of the economic studies conducted to date. Methods: A systematic review of the literature for economic studies of colorectal cancer genomics from January 2006 through October 2020, and evaluation of study quality using the Quality of Health Economic Studies (QHES) instrument was conducted. The validated QHES was then applied to a final set of articles that met eligibility criteria. Results: Our search of the literature initially yielded 12,859 records. A final set of 49 articles met our inclusion criteria. The QHES score ranged from 24 to 100, with an average score of 82. Most of the studies (n = 40, 82%) scored above 75 and were considered of good quality. Conclusion: Our analysis revealed that most of the economic analyses of colorectal cancer genomic molecular diagnostics in the literature may be of good quality. There is, however, some variation in methodological rigor between the articles.
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Affiliation(s)
- Vivek S Chaudhari
- Personalized Precision Medicine & Targeted Therapeutics, Springfield, PA 19064, USA.,Health Policy, University of the Sciences, Philadelphia, PA 19104, USA
| | - Kanchan C Hole
- Personalized Precision Medicine & Targeted Therapeutics, Springfield, PA 19064, USA
| | - Amalia M Issa
- Personalized Precision Medicine & Targeted Therapeutics, Springfield, PA 19064, USA.,Health Policy, University of the Sciences, Philadelphia, PA 19104, USA.,Pharmaceutical Sciences, University of the Sciences, Philadelphia, PA 19104, USA.,Family Medicine, McGill University, Montreal, QC, H3S 1Z1, Canada
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20
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Challenges of conducting value assessment for Comprehensive Genomic Profiling. Int J Technol Assess Health Care 2022; 38:e57. [PMID: 35674123 DOI: 10.1017/s026646232200040x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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21
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Zischke J, White N, Gordon L. Accounting for Intergenerational Cascade Testing in Economic Evaluations of Clinical Genomics: A Scoping Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:944-953. [PMID: 35667782 DOI: 10.1016/j.jval.2021.11.1353] [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: 05/07/2021] [Revised: 10/25/2021] [Accepted: 11/03/2021] [Indexed: 06/15/2023]
Abstract
OBJECTIVES Clinical genomics is emerging as a diagnostic tool in the identification of blood relatives at risk of developing heritable diseases. Our objective was to identify how genetic cascade screening has been incorporated into health economic evaluations. METHODS A scoping review was conducted to identify how multiple generations of a family were included in economic evaluations of clinical genomic sequencing, how many and which relatives were included, and uptake rates. Databases were searched for full economic evaluations of genetic interventions that screened multiple generations of families and were in English language, and no restrictions were made for disease or publication type. Data were synthesized using a narrative approach. RESULTS Twenty-five studies were included covering a range of diseases in various countries. Markov cohort models were mostly used with hypothetical populations and unsupported by clinical evidence. Cascade testing was either the primary intervention or secondary to the index cases. The number and type of relatives were based on assumptions or identified through population or family records, clinical registry data, or clinical literature. Studies included only immediate family members and the uptake of testing ranged between 20% and 100%. All interventions were reported as cost-effective, and a higher number of relatives was a key driver. CONCLUSIONS Several economic evaluations have considered the impacts of cascade testing interventions within clinical genomics. Ideally, models supported with high-quality clinical data are needed and, in their absence, transparent and justifiable assumptions of uptake rates and choices about including relatives. Consideration of more appropriate modeling types is required.
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Affiliation(s)
- Jason Zischke
- Health Economics Group, QIMR Berghofer Medical Research Institute, Brisbane, Australia; School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia.
| | - Nicole White
- Centre for Healthcare Transformation, School of Public Health and Social Work and Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, Australia
| | - Louisa Gordon
- Health Economics Group, QIMR Berghofer Medical Research Institute, Brisbane, Australia; School of Nursing, Queensland University of Technology, Brisbane, Australia; School of Public Health, The University of Queensland, Brisbane, Australia
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22
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Goranitis I, Wu Y, Lunke S, White SM, Tan TY, Yeung A, Hunter MF, Martyn M, Gaff C, Stark Z. Is faster better? An economic evaluation of rapid and ultra-rapid genomic testing in critically ill infants and children. Genet Med 2022; 24:1037-1044. [PMID: 35181209 DOI: 10.1016/j.gim.2022.01.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 01/17/2022] [Accepted: 01/19/2022] [Indexed: 01/02/2023] Open
Abstract
PURPOSE To evaluate whether the additional cost of providing increasingly faster genomic results in pediatric critical care is outweighed by reductions in health care costs and increases in personal utility. METHODS Hospital costs and medical files from a cohort of 40 children were analyzed. The health economic impact of rapid and ultra-rapid genomic testing, with and without early initiation, relative to standard genomic testing was evaluated. RESULTS Shortening the time to results led to substantial economic and personal benefits. Early initiation of ultra-rapid genomic testing was the most cost-beneficial strategy, leading to a cost saving of AU$26,600 per child tested relative to standard genomic testing and a welfare gain of AU$12,000 per child tested. Implementation of early ultra-rapid testing of critically ill children is expected to lead to an annual cost saving of AU$7.3 million for the Australian health system and an aggregate welfare gain of AU$3.3 million, corresponding to a total net benefit of AU$10.6 million. CONCLUSION Early initiation of ultra-rapid genomic testing can offer substantial economic and personal benefits. Future implementation of rapid genomic testing programs should focus not only on optimizing the laboratory workflow to achieve a fast turnaround time but also on changing clinical practice to expedite test initiation.
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Affiliation(s)
- Ilias Goranitis
- Health Economics Unit, Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia; Australian Genomics Health Alliance, Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia.
| | - You Wu
- Health Economics Unit, Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia; Australian Genomics Health Alliance, Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Sebastian Lunke
- Australian Genomics Health Alliance, Melbourne, Victoria, Australia; Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Pediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Susan M White
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Pediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Tiong Y Tan
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Pediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Alison Yeung
- Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Pediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Matthew F Hunter
- Monash Genetics, Monash Health, Melbourne, Victoria, Australia; Department of Pediatrics, Monash University, Melbourne, Victoria, Australia
| | - Melissa Martyn
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Melbourne Genomics Health Alliance, Melbourne, Victoria, Australia
| | - Clara Gaff
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Pediatrics, University of Melbourne, Melbourne, Victoria, Australia; Melbourne Genomics Health Alliance, Melbourne, Victoria, Australia
| | - Zornitza Stark
- Australian Genomics Health Alliance, Melbourne, Victoria, Australia; Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Pediatrics, University of Melbourne, Melbourne, Victoria, Australia.
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23
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Buckell J, Vasavada V, Wordsworth S, Regier DA, Quaife M. Utility maximization versus regret minimization in health choice behavior: Evidence from four datasets. HEALTH ECONOMICS 2022; 31:363-381. [PMID: 34787942 DOI: 10.1002/hec.4455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 10/22/2021] [Accepted: 10/26/2021] [Indexed: 06/13/2023]
Abstract
Choice models in health are almost exclusively based on the neoclassical economic paradigm of utility maximization. Recently developed choice models have captured and shown empirical support for regret minimization as an alternative decision rule. In health economics, recent applications of RRM models indicate that individuals making health-based choices may exhibit regret minimization-type behavior. In this paper, we build on this research using a more flexible model that allows for heterogeneous decision rules, separately from preference heterogeneity, and comparing it to models that assume single decision rules. We use four datasets from diverse settings in which individuals make health choices: tobacco markets, genomic testing, and HIV prevention. We found that, if a one-size-fits-all rule is applied, then utility maximization was preferable to regret minimization for these datasets. However, we also find that individuals apply varying decision rules in similar proportions in these health settings, suggesting that models for heterogeneous decision rules were needed to capture these behaviors in these settings.
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Affiliation(s)
- John Buckell
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Vrinda Vasavada
- Department of Computer Science, Stanford University, Stanford, California, USA
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Dean A Regier
- Cancer Control Research, BC Cancer, School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, UK
| | - Matthew Quaife
- Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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24
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Meng Y, Clarke PM, Goranitis I. The Value of Genomic Testing: A Contingent Valuation Across Six Child- and Adult-Onset Genetic Conditions. PHARMACOECONOMICS 2022; 40:215-223. [PMID: 34671943 DOI: 10.1007/s40273-021-01103-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/07/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES The aim of this study was to elicit the willingness-to-pay (WTP) for genomic testing, using contingent valuation, among people with lived experience of genetic conditions in Australia. METHODS Parents of children with suspected mitochondrial disorders, epileptic encephalopathy, leukodystrophy, or malformations of cortical development completed a dynamic triple-bounded dichotomous choice (DC) contingent valuation. Adult patients or parents of children with suspected genetic kidney disease or complex neurological and neurodegenerative conditions completed a payment card (PC) contingent valuation. DC data were analyzed using a multilevel interval regression and a multilevel probit model. PC data were analyzed using a Heckman selection model. RESULTS In total, 360 individuals participated in the contingent valuation (CV), with 141 (39%) and 219 (61%) completing the DC and PC questions, respectively. The mean WTP for genomic testing was estimated at AU$2830 (95% confidence interval [CI] 2236-3424) based on the DC data and AU$1914 (95% CI 1532-2296) based on the PC data. The mean WTP across the six cohorts ranged from AU$1879 (genetic kidney disease) to AU$4554 (leukodystrophy). CONCLUSIONS Genomic testing is highly valued by people experiencing rare genetic conditions. Our findings can inform cost-benefit analyses and the prioritization of genomics into mainstream clinical care. While our WTP estimates for adult-onset genetic conditions aligned with estimates derived from discrete choice experiments (DCEs), for childhood-onset conditions our estimates were significantly lower. Research is urgently required to directly compare, and critically evaluate, the performance of CV and DCE methods.
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Affiliation(s)
- Yan Meng
- Health Economics Unit, Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, 207-221 Bouverie St., Parkville, Melbourne, VIC, 3010, Australia
- Australian Genomics Health Alliance, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Philip M Clarke
- Health Economics Unit, Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, 207-221 Bouverie St., Parkville, Melbourne, VIC, 3010, Australia
- Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Headington, UK
| | - Ilias Goranitis
- Health Economics Unit, Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, 207-221 Bouverie St., Parkville, Melbourne, VIC, 3010, Australia.
- Australian Genomics Health Alliance, Melbourne, VIC, Australia.
- Murdoch Children's Research Institute, Melbourne, VIC, Australia.
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25
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Horgan D, Curigliano G, Rieß O, Hofman P, Büttner R, Conte P, Cufer T, Gallagher WM, Georges N, Kerr K, Penault-Llorca F, Mastris K, Pinto C, Van Meerbeeck J, Munzone E, Thomas M, Ujupan S, Vainer GW, Velthaus JL, André F. Identifying the Steps Required to Effectively Implement Next-Generation Sequencing in Oncology at a National Level in Europe. J Pers Med 2022; 12:72. [PMID: 35055387 PMCID: PMC8780351 DOI: 10.3390/jpm12010072] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 12/16/2021] [Accepted: 12/29/2021] [Indexed: 02/07/2023] Open
Abstract
Next-generation sequencing (NGS) may enable more focused and highly personalized cancer treatment, with the National Comprehensive Cancer Network and European Society for Medical Oncology guidelines now recommending NGS for daily clinical practice for several tumor types. However, NGS implementation, and therefore patient access, varies across Europe; a multi-stakeholder collaboration is needed to establish the conditions required to improve this discrepancy. In that regard, we set up European Alliance for Personalised Medicine (EAPM)-led expert panels during the first half of 2021, including key stakeholders from across 10 European countries covering medical, economic, patient, industry, and governmental expertise. We describe the outcomes of these panels in order to define and explore the necessary conditions for NGS implementation into routine clinical care to enable patient access, identify specific challenges in achieving them, and make short- and long-term recommendations. The main challenges identified relate to the demand for NGS tests (governance, clinical standardization, and awareness and education) and supply of tests (equitable reimbursement, infrastructure for conducting and validating tests, and testing access driven by evidence generation). Recommendations made to resolve each of these challenges should aid multi-stakeholder collaboration between national and European initiatives, to complement, support, and mutually reinforce efforts to improve patient care.
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Affiliation(s)
- Denis Horgan
- European Alliance for Personalised Medicine, Avenue de l’Armee/Legerlaan 10, 1040 Brussels, Belgium
| | - Giuseppe Curigliano
- European Institute of Oncology, IRCCS, Via Giuseppe Ripamonti, 435, 20141 Milan, Italy; (G.C.); (E.M.)
- Department of Oncology and Hemato-Oncology, University of Milan, Via Festa del Perdono, 7, 20122 Milan, Italy
| | - Olaf Rieß
- Institute of Medical Genetics and Applied Genomics, University of Tuebingen, Calwerstrasse 7, 72070 Tuebingen, Germany;
| | - Paul Hofman
- Laboratory of Clinical and Experimental Pathology, University of Côte d’Azur, FHU OncoAge, Biobank BB-0033-00025, Pasteur Hospital, 30 Avenue de la voie Romaine, CEDEX 01, 06001 Nice, France;
| | - Reinhard Büttner
- Institute for Pathology, University Hospital Cologne, Kerpener Str. 62, 50937 Cologne, Germany;
| | - Pierfranco Conte
- The Veneto Institute of Oncology, IRCCS, Via Gattamelata, 64, 35128 Padua, Italy;
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Via Giustiniani, 2, 35124 Padua, Italy
| | - Tanja Cufer
- Medical Faculty, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia;
| | - William M. Gallagher
- School of Biomolecular and Biomedical Science, University College Dublin, Belfield, D04 V1W8 Dublin, Ireland;
| | - Nadia Georges
- Exact Sciences, Quai du Seujet 10, 1201 Geneva, Switzerland;
| | - Keith Kerr
- School of Medicine and Dentistry, University of Aberdeen, Foresterhill, Aberdeen AB25 2ZD, UK;
| | - Frédérique Penault-Llorca
- Centre Jean Perrin, 58, Rue Montalembert, CEDEX 01, 63011 Clermont-Ferrand, France;
- Department of Pathology, University of Clermont Auvergne, INSERM U1240, 49 bd François Mitterrand, CS 60032, 63001 Clermont-Ferrand, France
| | - Ken Mastris
- Europa Uomo, Leopoldstraat 34, 2000 Antwerp, Belgium;
| | - Carla Pinto
- AstraZeneca, Rua Humberto Madeira 7, 1800 Oeiras, Portugal;
| | - Jan Van Meerbeeck
- Antwerp University Hospital, University of Antwerp, Wijlrijkstraat 10, 2650 Edegem, Belgium;
| | - Elisabetta Munzone
- European Institute of Oncology, IRCCS, Via Giuseppe Ripamonti, 435, 20141 Milan, Italy; (G.C.); (E.M.)
| | - Marlene Thomas
- F. Hoffmann-La Roche Ltd., Grenzacherstrasse 124, 4070 Basel, Switzerland;
| | - Sonia Ujupan
- Eli Lilly and Company, Rue du Marquis 1, Markiesstraat, 1000 Brussels, Belgium;
| | - Gilad W. Vainer
- Department of Pathology, Hadassah Hebrew-University Medical Center, Hebrew University of Jerusalem, Kalman Ya’akov Man St, Jerusalem 91905, Israel;
| | - Janna-Lisa Velthaus
- University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251 Hamburg, Germany;
| | - Fabrice André
- Institut Gustave Roussy, 114 Rue Edouard Vaillant, 94805 Villejuif, France;
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26
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Economic evaluation of genomic/genetic tests: a review and future directions. Int J Technol Assess Health Care 2022; 38:e67. [DOI: 10.1017/s0266462322000484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
It has been suggested that health economists need to improve their methods in order to meet the challenges of evaluating genomic/genetic tests. In this article, we set out twelve challenges identified from a rapid review of the literature and suggest solutions to the challenges identified. Two challenges were common to all economic evaluations: choice of perspective and time-horizon. Five challenges were relevant for all diagnostic technologies: complexity of analysis; range of costs; under-developed evidence base; behavioral aspects; and choice of outcome metrics. The final five challenges were pertinent for genomic tests and only these may require methodological development: heterogeneity of tests and platforms, increasing stratification, capturing personal utility; incidental findings; and spillover effects. Current methods of economic evaluation are generally able to cope with genomic/genetic tests, although a renewed focus on specific decision-makers’ needs and a willingness to move away from cost-utility analysis may be required. Certain analysts may be constrained by reference cases developed primarily for the assessment of pharmaceuticals. The combined impact of multiple challenges may require analysts to be particularly careful in setting the scope of their analysis in order to ensure that feasibility is balanced with usefulness to the decision maker. A key issue is the under-developed evidence-base and it may be necessary to rethink translation processes to ensure sufficient, relevant evidence is available to support economic evaluation and adoption of genomic/genetic tests.
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Pollard S, Dunne J, Costa S, Regier DA. Stakeholder Perspectives on Navigating Evidentiary and Decision Uncertainty in Precision Oncology. J Pers Med 2022; 12:22. [PMID: 35055337 PMCID: PMC8778253 DOI: 10.3390/jpm12010022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 12/18/2021] [Accepted: 12/21/2021] [Indexed: 12/11/2022] Open
Abstract
(1) Background: Precision oncology has the potential to improve patient health and wellbeing through targeted prevention and treatment. Owing to uncertain clinical and economic outcomes, reimbursement has been limited. The objective of this pan-Canadian qualitative study was to investigate barriers to precision oncology implementation from the perspectives of health system stakeholders. (2) Methods: We conducted 32 semi-structured interviews with health technology decision makers (n = 14) and clinicians (n = 18) experienced with precision oncology. Participants were recruited using a purposive sampling technique. Interviews were analyzed using thematic analysis. Recruitment continued until two qualitative analysts reached agreement that thematic saturation was reached. (3) Results: While cautiously optimistic about the potential for enhanced therapeutic alignment, participants identified multiple decisional challenges under conditions of evidentiary uncertainty. Decision makers voiced concern over resource requirements alongside small benefitting patient populations and limited evidence supporting patient and health system impacts. Clinicians were comparatively tolerant of evidentiary uncertainty guiding clinical decision-making practices. Clinicians applied a broader definition of patient benefit, focusing on the ability to assist patients making informed clinical decisions. (4) Conclusions: Sustainable precision oncology must balance demand with evidence demonstrating benefit. We show that clinicians and decision makers vary in their tolerance for evolving knowledge, suggesting a need to establish evidentiary standards supporting precision oncology reimbursement decisions.
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Affiliation(s)
- Samantha Pollard
- Cancer Control Research, BC Cancer, Vancouver, BC V5Z 4C2, Canada; (S.P.); (J.D.); (S.C.)
| | - Jessica Dunne
- Cancer Control Research, BC Cancer, Vancouver, BC V5Z 4C2, Canada; (S.P.); (J.D.); (S.C.)
| | - Sarah Costa
- Cancer Control Research, BC Cancer, Vancouver, BC V5Z 4C2, Canada; (S.P.); (J.D.); (S.C.)
| | - Dean A. Regier
- Cancer Control Research, BC Cancer, Vancouver, BC V5Z 4C2, Canada; (S.P.); (J.D.); (S.C.)
- School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
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The complexity of diagnosing rare disease: An organizing framework for outcomes research and health economics based on real-world evidence. Genet Med 2021; 24:694-702. [PMID: 34906497 DOI: 10.1016/j.gim.2021.11.005] [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] [Received: 05/14/2021] [Accepted: 11/05/2021] [Indexed: 11/23/2022] Open
Abstract
PURPOSE To facilitate robust economic analyses of clinical exome and genome sequencing, this study was taken up with the objective of establishing a framework for organizing diagnostic testing trajectories for patients with rare disease. METHODS We collected diagnostic investigations-related data before exome sequencing from the medical records of 228 cases. Medical geneticist experts participated in a consensus building process to develop the SOLVE Framework for organizing the complex range of observed tests. Experts categorized tests as indicator or nonindicator tests on the basis of their specificity for diagnosing rare diseases. Face validity was assessed using case vignettes. RESULTS Most cases had symptom onset at birth (42.5%) or during childhood (43.4%) and had intellectual disability (73.3%). On average, the time spent seeking a diagnosis before sequencing was 1989 days (SD = 2137) and included 16 tests (SD = 14). Agreement across experts on test categories ranged from 83% to 96%. The SOLVE Framework comprised observed tests, including 186 indicator and 39 nonindicator tests across cytogenetic/molecular, biochemical, imaging, electrical, and pathology test categories. CONCLUSION Real-world diagnostic testing data can be ascertained and organized to reflect the complexity of the journey of the patients with rare diseases. SOLVE Framework will improve the accuracy and certainty associated with value-based assessments of genomic sequencing.
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The Clinician-reported Genetic testing Utility InDEx (C-GUIDE): Preliminary evidence of validity and reliability. Genet Med 2021; 24:430-438. [PMID: 34906486 DOI: 10.1016/j.gim.2021.10.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 08/25/2021] [Accepted: 10/06/2021] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Demonstrating the clinical utility of genetic testing is fundamental to clinical adoption and reimbursement, but standardized definitions and measurement strategies for this construct do not exist. The Clinician-reported Genetic testing Utility InDEx (C-GUIDE) offers a novel measure to fill this gap. This study assessed its validity and inter-rater reliability. METHODS Genetics professionals completed C-GUIDE after disclosure of test results to patients. Construct validity was assessed using regression analysis to measure associations between C-GUIDE and global item scores as well as potentially explanatory variables. Inter-rater reliability was assessed by administering a vignette-based survey to genetics professionals and calculating Krippendorff's α. RESULTS On average, a 1-point increase in the global item score was associated with an increase of 3.0 in the C-GUIDE score (P < .001). Compared with diagnostic results, partially/potentially diagnostic and nondiagnostic results were associated with a reduction in C-GUIDE score of 9.5 (P < .001) and 10.2 (P < .001), respectively. Across 19 vignettes, Krippendorff's α was 0.68 (95% CI: 0.63-0.72). CONCLUSION C-GUIDE showed acceptable validity and inter-rater reliability. Although further evaluation is required, C-GUIDE version 1.2 can be useful as a standardized approach to assess the clinical utility of genetic testing.
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Abstract
Prior to integration into clinical care, a novel medical innovation is typically assessed in terms of its balance of benefits and risks, often referred to as utility. Members of multidisciplinary research teams may conceptualize and assess utility in different ways, which has implications within the translational genomics community and for the evidence base upon which clinical guidelines groups and healthcare payers make decisions. Ambiguity in the conceptualization of utility in translational genomics research can lead to communication challenges within research teams and to study designs that do not meet stakeholder needs. We seek to address the ambiguity challenge by describing the conceptual understanding of utility and use of the term by scholars in the fields of philosophy, medicine, and the social sciences of decision psychology and health economics. We illustrate applications of each field's orientation to translational genomics research by using examples from the Clinical Sequencing Evidence-Generating Research (CSER) consortium, and we provide recommendations for increasing clarity and cohesion in future research. Given that different understandings of utility will align to a greater or lesser degree with important stakeholders' views, more precise use of the term can help researchers to better integrate multidisciplinary investigations and communicate with stakeholders.
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31
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Jayasinghe K, Wu Y, Stark Z, Kerr PG, Mallett AJ, Gaff C, Martyn M, Goranitis I, Quinlan C. Cost-Effectiveness of Targeted Exome Analysis as a Diagnostic Test in Glomerular Diseases. Kidney Int Rep 2021; 6:2850-2861. [PMID: 34805637 PMCID: PMC8589690 DOI: 10.1016/j.ekir.2021.08.028] [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: 06/01/2021] [Revised: 08/12/2021] [Accepted: 08/30/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Despite the emergence of diagnostic and clinical utility evidence in nephrology, publicly funded access to genomic testing is restricted in most health care systems. To establish genomic sequencing as a clinical test, an evaluation of cost-effectiveness is urgently required. METHODS An economic evaluation, informed by a primary clinical study and available clinical evidence and guidelines in nephrology, was performed to evaluate the cost-effectiveness and optimal timing of exome sequencing (ES) in adults and children with suspected monogenic glomerular diseases compared with nongenomic investigations (NGIs). Six diagnostic strategies reflecting current practice and recommended models of care in Australia were modeled: (i) NGIs, (ii) late gene panel followed by ES, (iii) late ES, (iv) early gene panel, (v) early gene panel followed by ES, and (vi) early ES. RESULTS ES with targeted analysis achieved a diagnosis in 23 of 63 (36.5%) adults and 10 of 24 (41.6%) children. NGIs were estimated to diagnose 4.0% of children, with an average estimated cost of AU$6120 per child. Integrating ES as a first-line test in children was cost saving, with an incremental cost saving of AU$3230 per additional diagnosis compared with NGIs. In adults, NGIs was estimated to diagnose 8% of patients, with an average estimated cost of AU$1830 per person. In adults, integrating ES early resulted in an incremental cost per additional diagnosis of AU$5460 relative to NGIs. CONCLUSIONS Early ES with targeted analysis was effective for diagnosing monogenic kidney disease, with substantial cost savings in children.
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Affiliation(s)
- Kushani Jayasinghe
- Department of Nephrology, Monash Medical Centre, Melbourne, Australia
- Monash University, Melbourne, Australia
- Murdoch Children’s Research Institute, Melbourne, Australia
- The KidGen Collaborative, Australian Genomics Health Alliance, Melbourne, Australia
| | - You Wu
- Centre for Health Policy, University of Melbourne, Melbourne, VIC, Australia
- Australian Genomics Health Alliance, Melbourne, VIC, Australia
| | - Zornitza Stark
- Murdoch Children’s Research Institute, Melbourne, Australia
- The KidGen Collaborative, Australian Genomics Health Alliance, Melbourne, Australia
- Department of Pediatrics, University of Melbourne, Australia
- Victorian Clinical Genetics Services, Melbourne, Australia
| | - Peter G. Kerr
- Department of Nephrology, Monash Medical Centre, Melbourne, Australia
- Monash University, Melbourne, Australia
| | - Andrew J. Mallett
- The KidGen Collaborative, Australian Genomics Health Alliance, Melbourne, Australia
- Department of Renal Medicine, Townsville University Hospital, Townsville, QLD, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, QLD, Australia
| | - Clara Gaff
- Department of Pediatrics, University of Melbourne, Australia
- Melbourne Genomics Health Alliance, Melbourne, Australia
| | - Melissa Martyn
- Murdoch Children’s Research Institute, Melbourne, Australia
- Melbourne Genomics Health Alliance, Melbourne, Australia
| | - Ilias Goranitis
- Centre for Health Policy, University of Melbourne, Melbourne, VIC, Australia
- Australian Genomics Health Alliance, Melbourne, VIC, Australia
| | - Catherine Quinlan
- Murdoch Children’s Research Institute, Melbourne, Australia
- The KidGen Collaborative, Australian Genomics Health Alliance, Melbourne, Australia
- Department of Pediatrics, University of Melbourne, Australia
- Department of Pediatric Nephrology, Royal Children’s Hospital, Melbourne, Australia
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Pollard S, Weymann D, Dunne J, Mayanloo F, Buckell J, Buchanan J, Wordsworth S, Friedman JM, Stockler-Ipsiroglu S, Dragojlovic N, Elliott AM, Harrison M, Lynd LD, Regier DA. Toward the diagnosis of rare childhood genetic diseases: what do parents value most? Eur J Hum Genet 2021; 29:1491-1501. [PMID: 33903739 PMCID: PMC8484431 DOI: 10.1038/s41431-021-00882-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 01/18/2021] [Accepted: 03/23/2021] [Indexed: 02/07/2023] Open
Abstract
Genomic testing is becoming routine for diagnosing rare childhood genetic disease. Evidence underlying sustainable implementation is limited, focusing on short-term endpoints such as diagnostic yield, unable to fully characterize patient and family valued outcomes. Although genomic testing is becoming widely available, evidentiary and outcomes uncertainty persist as key challenges for implementation. We examine whether the current evidence base reflects public tolerance for uncertainty for genomics to diagnose rare childhood genetic disease. We conducted focus groups with general population parents in Vancouver, Canada, and Oxford, United Kingdom, to discuss expectations and concerns related to genomic testing to diagnose rare childhood genetic disease. Applying a purposive sampling technique, recruitment continued until thematic saturation was reached. Transcripts were analysed using thematic analysis. Thirty-three parents participated across four focus groups. Participants valued causal diagnoses alongside management strategies to improve patient health and wellbeing. Further, participants valued expanding the evidence base to reduce evidentiary uncertainty while ensuring security of information. Willingness to pay out of pocket for testing reflected perceived familial health benefit. Diagnostic yield fails to fully capture valued outcomes, and efforts to resolve uncertainty better reflect public priorities. Evaluations of genomic testing that fully integrate valued endpoints are necessary to ensure consistency with best practices and public willingness to accept the uncertain familial benefit.
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Affiliation(s)
- Samantha Pollard
- Canadian Centre for Applied Research in Cancer Control, BC Cancer, Vancouver, Canada
| | - Deirdre Weymann
- Canadian Centre for Applied Research in Cancer Control, BC Cancer, Vancouver, Canada
| | - Jessica Dunne
- Canadian Centre for Applied Research in Cancer Control, BC Cancer, Vancouver, Canada
| | - Fatemeh Mayanloo
- Canadian Centre for Applied Research in Cancer Control, BC Cancer, Vancouver, Canada
| | - John Buckell
- grid.4991.50000 0004 1936 8948Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Oxford, UK
| | - James Buchanan
- grid.4991.50000 0004 1936 8948Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Oxford, UK
| | - Sarah Wordsworth
- grid.4991.50000 0004 1936 8948Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Oxford, UK
| | - Jan M. Friedman
- grid.17091.3e0000 0001 2288 9830Department of Medical Genetics, University of British Columbia, Vancouver, Canada ,grid.414137.40000 0001 0684 7788BC Children’s Hospital Research Institute, Vancouver, Canada
| | - Sylvia Stockler-Ipsiroglu
- grid.414137.40000 0001 0684 7788BC Children’s Hospital Research Institute, Vancouver, Canada ,grid.17091.3e0000 0001 2288 9830Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, Canada ,grid.414137.40000 0001 0684 7788Division of Biochemical Genetics, BC Children’s Hospital, Vancouver, Canada
| | - Nick Dragojlovic
- grid.17091.3e0000 0001 2288 9830Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
| | - Alison M. Elliott
- grid.17091.3e0000 0001 2288 9830Department of Medical Genetics, University of British Columbia, Vancouver, Canada ,grid.414137.40000 0001 0684 7788BC Children’s Hospital Research Institute, Vancouver, Canada
| | - Mark Harrison
- grid.17091.3e0000 0001 2288 9830Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada ,Centre for Health Evaluation and Outcomes Sciences, Providence Health Research Institute, Vancouver, Canada
| | - Larry D. Lynd
- grid.17091.3e0000 0001 2288 9830Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada ,Centre for Health Evaluation and Outcomes Sciences, Providence Health Research Institute, Vancouver, Canada
| | - Dean A. Regier
- Canadian Centre for Applied Research in Cancer Control, BC Cancer, Vancouver, Canada ,grid.17091.3e0000 0001 2288 9830School of Population and Public Health, University of British Columbia, Vancouver, Canada
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Norris S, Belcher A, Howard K, Ward RL. Evaluating genetic and genomic tests for heritable conditions in Australia: lessons learnt from health technology assessments. J Community Genet 2021; 13:503-522. [PMID: 34570356 PMCID: PMC9530105 DOI: 10.1007/s12687-021-00551-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 09/15/2021] [Indexed: 11/28/2022] Open
Abstract
The Medical Services Advisory Committee (MSAC) is an independent non-statutory committee established by the Australian government to provide recommendations on public reimbursement of technologies and services, other than pharmaceuticals. MSAC has established approaches for undertaking health technology assessment (HTA) of investigative services and codependent technologies. In 2016, MSAC published its clinical utility card (CUC) Proforma, an additional tool to guide assessments of genetic testing for heritable conditions. We undertook a review and narrative synthesis of information extracted from all MSAC assessments of genetic testing for heritable conditions completed since 2016, regardless of the HTA approach taken. Ten assessments met our inclusion criteria, covering a range of testing methods (from gene panels to whole-exome sequencing) and purposes (including molecular diagnosis, genetic risk assessment, identification of congenital anomaly syndromes, and carrier screening). This analysis identified a range of methodological and policy challenges such as how to incorporate patient and societal preferences for the health and non-health outcomes of genomic testing, how best to capture the concept of co-production of utility, and how to engage clinicians as referrers for genomics tests whilst at the same time ensuring equity of access to a geographically dispersed population. A further challenge related to how qualitative assessments of patient and community needs influenced the evidence thresholds against which decisions were made. These concepts should be considered for incorporation within the value assessment frameworks used by HTA agencies around the world.
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Affiliation(s)
- Sarah Norris
- Menzies Centre for Health Policy and Economics and School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.
| | - Andrea Belcher
- Australian Genomics, Melbourne, VIC, 3052, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, QLD, 4072, Australia
| | - Kirsten Howard
- Menzies Centre for Health Policy and Economics and School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Robyn L Ward
- University of Queensland, Brisbane, QLD, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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Vellekoop H, Huygens S, Versteegh M, Szilberhorn L, Zelei T, Nagy B, Koleva-Kolarova R, Tsiachristas A, Wordsworth S, Rutten-van Mölken M. Guidance for the Harmonisation and Improvement of Economic Evaluations of Personalised Medicine. PHARMACOECONOMICS 2021; 39:771-788. [PMID: 33860928 PMCID: PMC8200346 DOI: 10.1007/s40273-021-01010-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/15/2021] [Indexed: 05/02/2023]
Abstract
OBJECTIVE The objective of this study was to develop guidance contributing to improved consistency and quality in economic evaluations of personalised medicine (PM), given current ambiguity about how to measure the value of PM as well as considerable variation in the methodology and reporting in economic evaluations of PM. METHODS A targeted literature review of methodological papers was performed for an overview of modelling challenges in PM. Expert interviews were held to discuss best modelling practice. A systematic literature review of economic evaluations of PM was conducted to gain insight into current modelling practice. The findings were synthesised and used to develop a set of draft recommendations. The draft recommendations were discussed at a stakeholder workshop and subsequently finalised. RESULTS Twenty-two methodological papers were identified. Some argued that the challenges in modelling PM can be addressed within existing methodological frameworks, others disagreed. Eighteen experts were interviewed. They believed large uncertainty to be a key concern. Out of 195 economic evaluations of PM identified, 56% addressed none of the identified modelling challenges. A set of 23 recommendations was developed. Eight recommendations focus on the modelling of test-treatment pathways. The use of non-randomised controlled trial data is discouraged but several recommendations are provided in case randomised controlled trial data are unavailable. The parameterisation of structural uncertainty is recommended. Other recommendations consider perspective and discounting; premature survival data; additional value elements; patient and clinician compliance; and managed entry agreements. CONCLUSIONS This study provides a comprehensive list of recommendations to modellers of PM and to evaluators and reviewers of PM models.
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Affiliation(s)
- Heleen Vellekoop
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR, Rotterdam, The Netherlands.
| | - Simone Huygens
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR, Rotterdam, The Netherlands
| | - Matthijs Versteegh
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR, Rotterdam, The Netherlands
| | | | - Tamás Zelei
- Syreon Research Institute, Budapest, Hungary
| | - Balázs Nagy
- Syreon Research Institute, Budapest, Hungary
| | | | | | - Sarah Wordsworth
- Health Economics Research Centre, University of Oxford, Oxford, UK
| | - Maureen Rutten-van Mölken
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR, Rotterdam, The Netherlands
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
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Wu Y, Balasubramaniam S, Rius R, Thorburn DR, Christodoulou J, Goranitis I. Genomic sequencing for the diagnosis of childhood mitochondrial disorders: a health economic evaluation. Eur J Hum Genet 2021; 30:577-586. [PMID: 34099885 PMCID: PMC9090793 DOI: 10.1038/s41431-021-00916-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 05/19/2021] [Accepted: 05/26/2021] [Indexed: 12/25/2022] Open
Abstract
The diagnostic and clinical benefits of genomic sequencing are being increasingly demonstrated across multiple rare genetic conditions. Despite the expanding clinical literature, there is a significant paucity of health economics evidence to inform the prioritization and implementation of genomic sequencing. This study aims to evaluate whether genomic sequencing for pediatric-onset mitochondrial disorders (MDs) is cost-effective and cost-beneficial relative to conventional care from an Australian healthcare system perspective. Two independent and complementary health economic modeling approaches were used. Approach 1 used a decision tree to model the costs and outcomes associated with genomic sequencing and conventional care. Approach 2 used a discrete-event simulation to incorporate heterogeneity in the condition and clinical practice. Deterministic and probabilistic sensitivity analyses were performed. Genomic sequencing was less costly and more effective compared with conventional care, saving AU$1997 (Approach 1) to AU$8823 (Approach 2) per child tested, while leading to an additional 11 (Approach 1) to 14 (Approach 2) definitive diagnoses per 100 children tested. The mean monetary value of the incremental benefits of genomic sequencing was estimated at AU$5890 (95% CI: AU$5730-$6046). Implementation of genomic sequencing for MDs in Australia could translate to an annual cost-saving of up to AU$0.7 million. Genomic sequencing is cost-saving relative to traditional investigative approaches, while enabling more diagnoses to be made in a timely manner, offering substantial personal benefits to children and their families. Our findings support the prioritization of genomic sequencing for children with MDs.
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Affiliation(s)
- You Wu
- Health Economics Unit, Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia.,Australian Genomics Health Alliance, Melbourne, VIC, Australia.,Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Shanti Balasubramaniam
- Genetic Metabolic Disorders Service, The Children's Hospital at Westmead, Sydney, NSW, Australia.,Discipline of Genetic Medicine, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Rocio Rius
- Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - David R Thorburn
- Australian Genomics Health Alliance, Melbourne, VIC, Australia.,Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia.,Victorian Clinical Genetics Services, Royal Children's Hospital, Melbourne, VIC, Australia
| | - John Christodoulou
- Australian Genomics Health Alliance, Melbourne, VIC, Australia. .,Murdoch Children's Research Institute, Melbourne, VIC, Australia. .,Discipline of Genetic Medicine, Sydney Medical School, University of Sydney, Sydney, NSW, Australia. .,Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia.
| | - Ilias Goranitis
- Health Economics Unit, Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia. .,Australian Genomics Health Alliance, Melbourne, VIC, Australia. .,Murdoch Children's Research Institute, Melbourne, VIC, Australia.
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Preferences and values for rapid genomic testing in critically ill infants and children: a discrete choice experiment. Eur J Hum Genet 2021; 29:1645-1653. [PMID: 33811253 DOI: 10.1038/s41431-021-00874-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 03/09/2021] [Accepted: 03/16/2021] [Indexed: 12/23/2022] Open
Abstract
Healthcare systems are increasingly considering widespread implementation of rapid genomic testing of critically ill children, but evidence on the value of the benefits generated is lacking. This information is key for an optimal implementation into healthcare systems. A discrete choice experiment survey was designed to elicit preferences and values for rapid genomic testing in critically ill children. The survey was administered to members of the Australian public and families with lived experience of rapid genomic testing. A Bayesian D-efficient explicit partial profiles design was used, and data were analysed using a panel error component mixed logit model. Preference heterogeneity was explored using a latent class model and fractional logistic regressions. The public (n = 522) and families with lived experiences (n = 25) demonstrated strong preferences for higher diagnostic yield and clinical utility, faster result turnaround times, and lower cost. Society on average would be willing to pay an additional AU$9510 (US$6657) for rapid (2 weeks results turnaround time) and AU$11,000 (US$7700) for ultra-rapid genomic testing (2 days turnaround time) relative to standard diagnostic care. Corresponding estimates among those with lived experiences were AU$10,225 (US$7158) and AU$11,500 (US$8050), respectively. Our work provides further evidence that rapid genomic testing for critically ill children with rare conditions generates substantial utility. The findings can be used to inform cost-benefit analyses as part of broader healthcare system implementation.
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Smith HS, McGuire AL, Wittenberg E, Lavelle TA. Family-level impact of genetic testing: integrating health economics and ethical, legal, and social implications. Per Med 2021; 18:209-212. [PMID: 33728981 DOI: 10.2217/pme-2021-0016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Tweetable abstract Health economics and ELSI can be better integrated to consider the family impacts of genetic and genomic testing.
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Affiliation(s)
- Hadley Stevens Smith
- Center for Medical Ethics & Health Policy, Baylor College of Medicine, Houston, TX 77030, USA
| | - Amy L McGuire
- Center for Medical Ethics & Health Policy, Baylor College of Medicine, Houston, TX 77030, USA
| | - Eve Wittenberg
- Center for Health Decision Science, Harvard TH Chan School of Public Health, Boston, MA 02115, USA
| | - Tara A Lavelle
- Center for the Evaluation of Value & Risk in Health (CEVR), Institute for Clinical Research & Health Policy Studies, Tufts Medical Center, Boston, MA 02111, USA
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Koldehoff A, Danner M, Civello D, Rhiem K, Stock S, Müller D. Cost-Effectiveness of Targeted Genetic Testing for Breast and Ovarian Cancer: A Systematic Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:303-312. [PMID: 33518037 DOI: 10.1016/j.jval.2020.09.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 08/25/2020] [Accepted: 09/21/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND Targeted genetic testing is a tool to identify women at increased risk of gynaecological cancer. OBJECTIVE This systematic review evaluates the results and quality of cost-effectiveness modeling studies that assessed targeted genetic-based screen-and-treat strategies to prevent breast and ovarian cancer. METHODS Using MEDLINE and databases of the Centre for Reviews and Dissemination, we searched for health economic modeling evaluations of targeted genetic-based screen-and-treat strategies to prevent inheritable breast and ovarian cancer (until August 2020). The incremental cost-effectiveness ratios (ICERs) were compared. Methodological variations were addressed by evaluating the model conceptualizations, the modeling techniques, parameter estimation and uncertainty, and transparency and validation of the models. Additionally, the reporting quality of each study was assessed. RESULTS Eighteen studies met our inclusion criteria. From a payer perspective, the ICERs of (1) BRCA screening for high-risk women without cancer ranged from dominating the no test strategy to an ICER of $21 700/quality-adjusted life years (QALY). In studies that evaluated (2) BRCA cascade screening (ie, screening of women with cancer plus their unaffected relatives) compared with no test, the ICERs were between $6500/QALY and $50 200/QALY. Compared with BRCA alone, (3) multigene testing in women without cancer had an ICER of $51 800/QALY (one study), while for (4) multigene-cascade screening the ICERs were $15 600/QALY, $56.500/QALY, and $69 600/QALY for women in the United Kingdom, Norway, and the United States, respectively (2 studies). More recently published studies showed a higher methodological and reporting quality. CONCLUSIONS Targeted BRCA or multiple gene screening is likely to be cost-effective. Methodological variations could be decreased by the development of a reference model, which may serve as a tool for validation of present and future cost-effectiveness models.
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Affiliation(s)
- Andreas Koldehoff
- Department of Anaesthesiology, Ruhr-Universität Bochum (RUB), Bochum, Germany
| | - Marion Danner
- University Hospital Schleswig-Holstein, SHARE TO CARE Team, Department of General Pediatrics, Kiel, Germany
| | - Daniele Civello
- Cologne Institute for Health Economics and Clinical Epidemiology, University Hospital of Cologne (AöR), Cologne, Germany
| | - Kerstin Rhiem
- Center for Familial Breast and Ovarian Cancer, Center for Integrated Oncology (CIO), Faculty of Medicine and University Hospital Cologne (AöR), Cologne, Germany
| | - Stephanie Stock
- Cologne Institute for Health Economics and Clinical Epidemiology, University Hospital of Cologne (AöR), Cologne, Germany
| | - Dirk Müller
- Cologne Institute for Health Economics and Clinical Epidemiology, University Hospital of Cologne (AöR), Cologne, Germany.
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Hayeems RZ, Dimmock D, Bick D, Belmont JW, Green RC, Lanpher B, Jobanputra V, Mendoza R, Kulkarni S, Grove ME, Taylor SL, Ashley E. Clinical utility of genomic sequencing: a measurement toolkit. NPJ Genom Med 2020; 5:56. [PMID: 33319814 PMCID: PMC7738524 DOI: 10.1038/s41525-020-00164-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 11/12/2020] [Indexed: 12/21/2022] Open
Abstract
Whole-genome sequencing (WGS) is positioned to become one of the most robust strategies for achieving timely diagnosis of rare genomic diseases. Despite its favorable diagnostic performance compared to conventional testing strategies, routine use and reimbursement of WGS are hampered by inconsistencies in the definition and measurement of clinical utility. For example, what constitutes clinical utility for WGS varies by stakeholder's perspective (physicians, patients, families, insurance companies, health-care organizations, and society), clinical context (prenatal, pediatric, critical care, adult medicine), and test purpose (diagnosis, screening, treatment selection). A rapidly evolving technology landscape and challenges associated with robust comparative study design in the context of rare disease further impede progress in this area of empiric research. To address this challenge, an expert working group of the Medical Genome Initiative was formed. Following a consensus-based process, we align with a broad definition of clinical utility and propose a conceptually-grounded and empirically-guided measurement toolkit focused on four domains of utility: diagnostic thinking efficacy, therapeutic efficacy, patient outcome efficacy, and societal efficacy. For each domain of utility, we offer specific indicators and measurement strategies. While we focus on diagnostic applications of WGS for rare germline diseases, this toolkit offers a flexible framework for best practices around measuring clinical utility for a range of WGS applications. While we expect this toolkit to evolve over time, it provides a resource for laboratories, clinicians, and researchers looking to characterize the value of WGS beyond the laboratory.
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Affiliation(s)
- Robin Z Hayeems
- Program in Child Health Evaluative Sciences, The Hospital for Sick Children and the Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada.
| | - David Dimmock
- Rady Children's Hospital Institute for Genomic Medicine, San Diego, CA, USA
| | - David Bick
- HudsonAlpha Institute for Biotechnology, Huntsville, AL, USA
| | | | - Robert C Green
- Brigham and Women's Hospital Broad Institute and Harvard Medical School, Boston, MA, USA
| | | | - Vaidehi Jobanputra
- New York Genome Center, New York, NY, USA
- Department of Pathology and Cell Biology Columbia University Medical Center, New York, NY, USA
| | - Roberto Mendoza
- The Division of Clinical and Metabolic Genetics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Shashi Kulkarni
- Baylor Genetics and Baylor College of Medicine, Houston, TX, USA
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
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Costa S, Regier DA, Raymakers AJN, Pollard S. Genomic Testing for Relapsed and Refractory Lymphoid Cancers: Understanding Patient Values. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2020; 14:187-196. [PMID: 32875479 PMCID: PMC7884583 DOI: 10.1007/s40271-020-00448-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND New clinical genomic assays for lymphoid cancers allow for improved disease stratification and prognostication. At present, clinical implementation has been appropriately limited, owing to a paucity of evidence to support clinical and cost effectiveness. Understanding patients' values for precision oncology under conditions of uncertainty can be used to inform priority-setting decisions. OBJECTIVES Our objective was to ascertain patients' qualitative preferences and attitudes for prognostic-based genomic testing. METHODS Individuals who were diagnosed with lymphoid cancer between 2000 and 2018 in British Columbia, Canada, were recruited to participate in one of three focus groups. A maximum variation sampling technique was used to capture a diversity of perspectives. A patient partner was involved in the development of the focus group topic guide and presentation materials. All sessions were audio recorded and analyzed using NVivo qualitative analysis software, version 12. RESULTS In total, 26 participants took part in focus groups held between November 2018 and February 2019. Results illustrate qualitative preference heterogeneity for situations under which individuals would be willing to undergo genomic testing for relapsed lymphoid cancers. Preferences were highly contextualized within personal experiences with disease and treatment protocols. Hypothetical willingness to pay for testing was contingent on invasiveness, the potential for treatment de-escalation, and personal health benefit. CONCLUSIONS Patients are supportive and accepting of evidentiary uncertainty up until the point at which they are required to trade-off the potential for improved quality and length of life. Demand for precision medicine is contingent on expectations for benefit alongside an acknowledgment of the opportunity cost required for implementation. The clinical implementation of precision medicine will be required to address evidentiary uncertainty surrounding personal benefit while ensuring equitable access to emerging innovations.
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Affiliation(s)
- Sarah Costa
- Canadian Centre for Applied Research in Cancer Control, BC Cancer, Vancouver, BC, Canada
| | - Dean A Regier
- Canadian Centre for Applied Research in Cancer Control, BC Cancer, Vancouver, BC, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Adam J N Raymakers
- Canadian Centre for Applied Research in Cancer Control, BC Cancer, Vancouver, BC, Canada
- Faculty of Health Sciences, Simon Fraser University, Vancouver, BC, Canada
| | - Samantha Pollard
- Canadian Centre for Applied Research in Cancer Control, BC Cancer, Vancouver, BC, Canada.
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The value of genomic sequencing in complex pediatric neurological disorders: a discrete choice experiment. Genet Med 2020; 23:155-162. [DOI: 10.1038/s41436-020-00949-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 08/12/2020] [Accepted: 08/12/2020] [Indexed: 12/31/2022] Open
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The personal utility and uptake of genomic sequencing in pediatric and adult conditions: eliciting societal preferences with three discrete choice experiments. Genet Med 2020; 22:1311-1319. [PMID: 32371919 PMCID: PMC7394876 DOI: 10.1038/s41436-020-0809-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 04/01/2020] [Accepted: 04/02/2020] [Indexed: 11/09/2022] Open
Abstract
Purpose To estimate the personal utility and uptake of genomic sequencing (GS) across pediatric and adult-onset genetic conditions. Methods Three discrete choice experiment (DCE) surveys were designed and administered to separate representative samples of the Australian public. Bayesian D-efficient explicit partial profile designs were used. Choice data were analyzed using a panel error component random parameter logit model. Results Overall, 1913 participants completed the pediatric (n = 533), symptomatic adult (n = 700) and at-risk adult (n = 680) surveys. The willingness-to-pay for GS information in pediatric conditions was estimated at $5470–$15,250 (US$3830–$10,675) depending on the benefits of genomic information. Uptake ranged between 60% and 81%. For symptomatic adults, the value of GS was estimated at $1573–$8102 (US$1100–$5671) and uptake at 34–82%. For at-risk adults, GS was valued at $2036–$5004 (US$1425–$3503) and uptake was predicted at 35–61%. Conclusion There is substantial personal utility in GS, particularly for pediatric conditions. Personal utility increased as the perceived benefits of genomic information increased. The clinical and regulatory context, and individuals’ sociodemographic and attitudinal characteristics influenced the value and uptake of GS. Society values highly the diagnostic, clinical, and nonclinical benefits of GS. The personal utility of GS should be considered in health-care decision-making.
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Marshall DA, Grazziotin LR, Regier DA, Wordsworth S, Buchanan J, Phillips K, Ijzerman M. Addressing Challenges of Economic Evaluation in Precision Medicine Using Dynamic Simulation Modeling. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:566-573. [PMID: 32389221 PMCID: PMC7218800 DOI: 10.1016/j.jval.2020.01.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 01/08/2020] [Accepted: 01/26/2020] [Indexed: 05/17/2023]
Abstract
OBJECTIVES The objective of this article is to describe the unique challenges and present potential solutions and approaches for economic evaluations of precision medicine (PM) interventions using simulation modeling methods. METHODS Given the large and growing number of PM interventions and applications, methods are needed for economic evaluation of PM that can handle the complexity of cascading decisions and patient-specific heterogeneity reflected in the myriad testing and treatment pathways. Traditional approaches (eg, Markov models) have limitations, and other modeling techniques may be required to overcome these challenges. Dynamic simulation models, such as discrete event simulation and agent-based models, are used to design and develop mathematical representations of complex systems and intervention scenarios to evaluate the consequence of interventions over time from a systems perspective. RESULTS Some of the methodological challenges of modeling PM can be addressed using dynamic simulation models. For example, issues regarding companion diagnostics, combining and sequencing of tests, and diagnostic performance of tests can be addressed by capturing patient-specific pathways in the context of care delivery. Issues regarding patient heterogeneity can be addressed by using patient-level simulation models. CONCLUSION The economic evaluation of PM interventions poses unique methodological challenges that might require new solutions. Simulation models are well suited for economic evaluation in PM because they enable patient-level analyses and can capture the dynamics of interventions in complex systems specific to the context of healthcare service delivery.
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Affiliation(s)
- Deborah A Marshall
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Alberta, Canada.
| | - Luiza R Grazziotin
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Alberta, Canada
| | - Dean A Regier
- Alberta Cancer Control Research, BC Cancer, School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, England, UK; National Institute for Health Research Oxford Biomedical Research Centre, Oxford, England, UK
| | - James Buchanan
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, England, UK; National Institute for Health Research Oxford Biomedical Research Centre, Oxford, England, UK
| | - Kathryn Phillips
- Center for Translational & Policy Research on Personalized Medicine, Department of Clinical Pharmacy, University of California San Francisco, San Francisco, CA, USA; Philip R. Lee Institute for Health Policy, San Francisco, CA, USA; Helen Diller Family Comprehensive Cancer Center, University of California at San Franciso, San Francisco, CA, USA
| | - Maarten Ijzerman
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, The Netherlands; Cancer Health Services Research, University of Melbourne Centre for Cancer Research, School of Population and Global Health, Melbourne, Australia
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Smith HS, Swint JM, Lalani SR, de Oliveira Otto MC, Yamal JM, Russell HV, Lee BH. Exome sequencing compared with standard genetic tests for critically ill infants with suspected genetic conditions. Genet Med 2020; 22:1303-1310. [PMID: 32336750 DOI: 10.1038/s41436-020-0798-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 03/26/2020] [Accepted: 03/27/2020] [Indexed: 02/04/2023] Open
Abstract
PURPOSE As exome sequencing (ES) is increasingly used as a diagnostic tool, we aimed to compare ES with status quo genetic diagnostic workup for infants with suspected genetic disorders in terms of identifying diagnoses, survival, and cost of care. METHODS We studied newborns and infants admitted to intensive care with a suspected genetic etiology within the first year of life at a US quaternary-referral children's hospital over 5 years. In this propensity-matched cohort study using electronic medical record data, we compared patients who received ES as part of a diagnostic workup (ES cohort, n = 368) with clinically similar patients who did not receive ES (No-ES cohort, n = 368). RESULTS Diagnostic yield (27.4% ES, 25.8% No-ES; p = 0.62) and 1-year survival (80.2% ES, 84.8% No-ES; p = 0.10) were no different between cohorts. ES cohort patients had higher cost of admission, diagnostic investigation, and genetic testing (all p < 0.01). CONCLUSION ES did not differ from status quo genetic testing collectively in terms of diagnostic yield or patient survival; however, it had high yield as a single test, led to complementary classes of diagnoses, and was associated with higher costs. Further work is needed to define the most efficient use of diagnostic ES for critically ill newborns and infants.
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Affiliation(s)
- Hadley Stevens Smith
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA.
| | - John M Swint
- The University of Texas Health Science Center at Houston, School of Public Health, Houston, TX, USA
| | - Seema R Lalani
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA.,Texas Children's Hospital, Houston, TX, USA
| | | | - Jose-Miguel Yamal
- The University of Texas Health Science Center at Houston, School of Public Health, Houston, TX, USA
| | - Heidi V Russell
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA.,Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Brendan H Lee
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX, USA
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Dhanda DS, Veenstra DL, Regier DA, Basu A, Carlson JJ. Payer Preferences and Willingness to Pay for Genomic Precision Medicine: A Discrete Choice Experiment. J Manag Care Spec Pharm 2020; 26:529-537. [PMID: 32223606 PMCID: PMC10390910 DOI: 10.18553/jmcp.2020.26.4.529] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Although precision medicine using genetic information offers significant promise, its uptake and eventual clinical and economic impacts are uncertain. Health care payers will play an important role in evaluating evidence and costs to develop coverage and reimbursement policies. OBJECTIVE To elicit U.S. health care payer preference for genomic precision medicine to better understand trade-offs among clinical benefits, uncertainty, and cost. METHODS Using key informant interviewer discussions (N = 6 payers), we identified 6 key attributes of genetic tests important to payers: type of information the test provides (screening vs. treatment prediction), probability that the member has an informative genetic marker, expert agreement on changing medical care based on the marker, quality-of-life gains, life expectancy gains (with statistical uncertainty), and cost to the plan. We designed a stated preference discrete choice experiment using these attributes and administered a web survey to a sample of U.S. health care payers. We used effects coding and analyzed the data using an error component mixed logit modeling approach. RESULTS The survey response rate was 58% (150 participants completed the survey). Approximately 53% of respondents had previous experience evaluating genetic tests for reimbursement, and 85% had more than 5 years of health care decision-making experience. Payers valued improvements in quality of life the most (marginal willingness to pay [mWTP] of $1,513-$6,076), followed by medical expert agreement on the treatment change (mWTP of $2,881-$3,489). Payers placed a relatively lower value for genetic tests with lower marker probability (mWTP of $2,776 for highest marker probability to $423 for lowest marker probability). Payers mWTP was lowest for resolving uncertainty in quality of life (mWTP of $1,513-$2,031) and life expectancy gains ($536-$1,537). CONCLUSIONS Payers exhibited a strong preference for genetic tests that improved quality of life, had high expert agreement on changing medical care, and increased life expectancy. These findings suggest that payers will need evidence of clinical utility to support coverage and reimbursement of genomic precision medicine. DISCLOSURES This study was supported by a grant from the NIH Common Fund and NIA (1U01AG047109-01) via the Personalized Medicine Economics Research (PriMER) project. Unrelated to this study, Veenstra reports consulting fees from Bayer and Halozyme; Basu reports consulting fees from Salutis Consulting; and Reiger reports consulting fees from Roche. Carlson reports grants from Institute for Clinical and Economic Review, during the conduct of this study, and consulting fees from Bayer, Adaptive Biotechnologies, Allergan, Galderma, and Vifor Pharma, unrelated to this study.
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Affiliation(s)
- Devender S. Dhanda
- The Comparative Health Outcomes, Policy & Economics (CHOICE) Institute, University of Washington School of Pharmacy, Seattle
| | - David L. Veenstra
- The Comparative Health Outcomes, Policy & Economics (CHOICE) Institute, University of Washington School of Pharmacy, Seattle
| | - Dean A. Regier
- School of Population and Public Health, University of British Columbia, and Canadian Centre for Applied Research in Cancer Control (ARCC), BC Cancer, Vancouver, BC, Canada
| | - Anirban Basu
- The Comparative Health Outcomes, Policy & Economics (CHOICE) Institute, University of Washington School of Pharmacy, Seattle
| | - Josh J. Carlson
- The Comparative Health Outcomes, Policy & Economics (CHOICE) Institute, University of Washington School of Pharmacy, Seattle
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Best S, Stark Z, Phillips P, Wu Y, Long JC, Taylor N, Braithwaite J, Christodoulou J, Goranitis I. Clinical genomic testing: what matters to key stakeholders? Eur J Hum Genet 2020; 28:866-873. [PMID: 32024983 DOI: 10.1038/s41431-020-0576-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 01/02/2020] [Accepted: 01/14/2020] [Indexed: 11/09/2022] Open
Abstract
Beyond a narrow focus on cost and outcomes, robust evidence of what is valued in genomic medicine is scarce. We gathered views on value from key stakeholders (clinical genomic staff, operational genomic staff and community representatives) in relation to three testing contexts (General Healthcare, Acute Care and Neurodevelopmental Conditions). We conducted an iterative focus group in three stages over a week using a multiphase mixed methods study, i.e. quantitative ratings and qualitative discussion. For each testing context, the characteristics of genomic testing were generated and ranked by the group using a co-productive approach. Up to 17 characteristics were identified in one scenario with several characteristics featuring in all three testing contexts. The likelihood of getting an answer was consistently reported as most highly valued, followed by the potential for the test to impact on clinical management (or wellbeing/health for Neurodevelopmental Conditions). Risk of discrimination did not feature highly across the different settings (and not at all in Acute Care). While cost was an issue in the general health setting, it was one of the least-valued characteristics in the other two testing contexts. In conclusion, co-producing an understanding of what is valued in different testing contexts, and identifying the areas of differences or commonalities, is important to maximise value provision and inform future policy to ensure that clinical genomic services meet the needs of the community and service providers.
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Affiliation(s)
- Stephanie Best
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia. .,Australian Genomics, Murdoch Childrens Research Institute, Melbourne, VIC, Australia.
| | - Zornitza Stark
- Australian Genomics, Murdoch Childrens Research Institute, Melbourne, VIC, Australia.,Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,University of Melbourne, Melbourne, VIC, Australia
| | - Peta Phillips
- Australian Genomics, Murdoch Childrens Research Institute, Melbourne, VIC, Australia
| | - You Wu
- Health Economics Unit, Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - Janet C Long
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | - Natalie Taylor
- Cancer Council NSW, Woolloomooloo, Sydney, NSW, Australia.,Faculty of Health Science, University of Sydney, Sydney, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | - John Christodoulou
- University of Melbourne, Melbourne, VIC, Australia.,Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Ilias Goranitis
- Australian Genomics, Murdoch Childrens Research Institute, Melbourne, VIC, Australia.,Health Economics Unit, Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
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Regier DA, Veenstra DL, Basu A, Carlson JJ. Demand for Precision Medicine: A Discrete-Choice Experiment and External Validation Study. PHARMACOECONOMICS 2020; 38:57-68. [PMID: 31489595 DOI: 10.1007/s40273-019-00834-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND A limited evidence base and lack of clear clinical guidelines challenge healthcare systems' adoption of precision medicine. The effect of these conditions on demand is not understood. OBJECTIVE This research estimated the public's preferences and demand for precision medicine outcomes. METHODS A discrete-choice experiment survey was conducted with an online sample of the US public who had recent healthcare experience. Statistical analysis was undertaken using an error components mixed logit model. The responsiveness of demand in the context of a changing evidence base was estimated through the price elasticity of demand. External validation was examined using real-world demand for the 21-gene recurrence score assay for breast cancer. RESULTS In total, 1124 (of 1849) individuals completed the web-based survey. The most important outcomes were survival gains with statistical uncertainty, cost of testing, and medical expert agreement on changing care based on test results. The value ($US, year 2017 values) for a test where most (vs. few) experts agreed to changing treatment based on test results was $US1100 (95% confidence interval [CI] 916-1286). Respondents were willing to pay $US265 (95% CI 46-486) for a test that could result in greater certainty around life-expectancy gains. The predicted demand of the assay was 9% in 2005 and 66% in 2014, compared with real-world uptake of 7% and 71% (root-mean-square prediction error 0.11). Demand was sensitive to price (1% increase in price resulted in > 1% change in demand) when first introduced and insensitive to price (1% increase in price resulted in < 0.1% change in demand) as the evidence base became established. CONCLUSIONS Evidence of external validity was found. Demand was weak and responsive to price in the near term because of uncertainty and an immature evidence base. Clear communication of precision medicine outcomes and uncertainty is crucial in allowing healthcare to align with individual preferences.
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Affiliation(s)
- Dean A Regier
- Cancer Control Research - Canadian Centre for Applied Research in Cancer Control (ARCC), BC Cancer, 675 West 10th Avenue, Vancouver, British Columbia, V5Z 1L3, Canada.
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
| | - David L Veenstra
- The Comparative Health Outcomes, Policy and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Anirban Basu
- The Comparative Health Outcomes, Policy and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Seattle, Washington, USA
| | - Josh J Carlson
- The Comparative Health Outcomes, Policy and Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Seattle, Washington, USA
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Using the Delphi method to identify clinicians’ perceived importance of pediatric exome sequencing results. Genet Med 2019; 22:69-76. [DOI: 10.1038/s41436-019-0601-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Accepted: 06/19/2019] [Indexed: 01/14/2023] Open
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Allocating healthcare resources to genomic testing in Canada: latest evidence and current challenges. J Community Genet 2019; 13:467-476. [PMID: 31273679 DOI: 10.1007/s12687-019-00428-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 06/14/2019] [Indexed: 12/30/2022] Open
Abstract
Precision medicine (PM) informed by next-generation sequencing (NGS) poses challenges for health technology assessment (HTA). To date, there has been limited reimbursement of genomic testing with NGS in Canada, particularly for whole-genome and whole-exome sequencing (WGS/WES). Through a structured literature review, we examine Canadian economic evidence and evidentiary challenges for the adoption of genomic testing. We searched Medline (PubMed) for published Canadian studies generating economic evidence for PM informed by NGS. Our search focused on studies examining the costs and/or value of NGS. We reviewed included studies and summarized results according to evaluation type, clinical context, NGS technology, and test strategy. We then grouped HTA challenges encountered by authors when evaluating NGS. Our review included twenty-five studies. To determine the economic impacts of NGS-informed PM in Canada, studies applied cost-effectiveness analysis (52%, n = 13), stated preference analysis (20%, n = 5), cost-consequence analysis (16%, n = 4), and healthcare resource utilization or costing analysis (12%, n = 3). NGS panels were the most common technology evaluated (n = 13), followed by WGS and/or WES (n = 8). The included studies highlighted multiple challenges when generating economic evidence, many of which remain unaddressed. Challenges were broadly related to (1) accounting for all NGS outcomes; (2) addressing uncertainty; and (3) improving consistency of economic approaches. Canadian studies are beginning to produce estimates of the economic impacts of NGS-informed PM, yet challenges for HTA remain. While solutions and real-world evidence are generated, lifecycle health technology management methods can be designed to better support resource allocation decisions for genomic testing in Canada.
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The value of diagnostic testing for parents of children with rare genetic diseases. Genet Med 2019; 21:2798-2806. [PMID: 31239560 DOI: 10.1038/s41436-019-0583-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 06/01/2019] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Exome sequencing (ES) can rapidly identify disease-causing variants responsible for rare, single-gene diseases, and potentially reduce the duration of the diagnostic odyssey. Our study examines how parents and families value ES. METHODS We developed a discrete choice experiment (DCE) survey that was administered to parents of children with rare diseases. The DCE included 14 choice tasks with 6 attributes and 3 alternatives. A valuation-space model was used to estimate willingness to pay, willingness to wait for test results, and minimum acceptable chance of a diagnosis for changes in each attribute. RESULTS There were n = 319 respondents of whom 89% reported their child had genetic testing, and 66% reported their child had a diagnosis. Twenty-six percent reported that their child had been offered ES. Parents were willing to pay CAD$6590 (US$4943), wait 5.2 years to obtain diagnostic test results, and accept a reduction of 3.1% in the chance of a diagnosis for ES compared with operative procedures. CONCLUSION Timely access to ES could reduce the diagnostic odyssey and associated costs. Before ES is incorporated routinely into care for patients with rare diseases in Canada and more broadly, there must be a clear understanding of its value to patients and families.
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