Real-World Evidence in Healthcare Decision Making: Global Trends and Case Studies From Latin America

Real-world data: a comprehensive literature review on the barriers, challenges, and opportunities associated with their inclusion in the health technology assessment process

Objective: This review aimed to assess the current use and acceptance of real-world data (RWD) and real-world evidence (RWE) in health technology assessment (HTA) process. It additionally aimed to discern stakeholders' viewpoints concerning RWD and RWE in HTA and illuminate the obstacles, difficulties, prospects, and consequences associated with the incorporation of RWD and RWE into the realm of HTA. Methods: A comprehensive PRISMA-based systematic review was performed in July 2022 in PubMed/Medline, Scopus, IDEAS-RePEc, International HTA database, and Centre for Reviews and Dissemination with ad hoc supplementary search in Google Scholar and international organization websites. The review included pre-determined inclusion criteria while the selection of eligible studies, the data extraction process and quality assessment were carried out using standardized and transparent methods. Results: Twenty-nine (n = 29) studies were included in the review out of 2,115 studies identified by the search strategy. In various global contexts, disparities in RWD utilization were evident, with randomized controlled trials (RCTs) serving as the primary evidence source. RWD and RWE played pivotal roles, surpassing relative effectiveness assessments (REAs) and significantly influencing decision-making and cost-effectiveness analyses. Identified challenges impeding RWD integration into HTA encompassed limited local data access, complexities in non-randomized trial design, data quality, privacy, and fragmentation. Addressing these is imperative for optimal RWD utilization. Incorporating RWD/RWE in HTA yields multifaceted advantages, enhancing understanding of treatment efficacy, resource utilization, and cost analysis, particularly via patient registries. RWE complements assessments of advanced therapy medicinal products (ATMPs) and rare diseases. Local data utilization strengthens HTA, bridging gaps when RCT data is lacking. RWD aids medical device decision-making, cancer drug reassessment, and indirect treatment comparisons. Challenges include data availability, stakeholder acceptance, expertise, and privacy. However, standardization, training, collaboration, and guidance can surmount these barriers, fostering enhanced RWD utilization in HTA. Conclusion: This study highlights the intricate global landscape of RWD and RWE acceptance in HTA. Recognizing regional nuances, addressing methodological challenges, and promoting collaboration are pivotal, among others, for leveraging RWD and RWE effectively in healthcare decision-making.

Assessing unConventional Evidence (ACE) tool: development and content of a tool to assess the strengths and limitations of 'unconventional' source materials

BACKGROUND

When deciding whether to implement an intervention, decision-makers typically have questions on feasibility and acceptability and on factors affecting implementation. Descriptions of programme implementation and of policies and systems are rich sources of information for these questions. However, this information is often not based on empirical data collected using explicit methods. To use the information in unconventional source materials in syntheses or other decision support products, we need methods of assessing their strengths and limitations. This paper describes the development and content of the Assessing unConventional Evidence (ACE) tool, a new tool to assess the strengths and limitations of these sources.

METHODS

We developed the ACE tool in four stages: first, we examined existing tools to identify potentially relevant assessment criteria. Second, we drew on these criteria and team discussions to create a first draft of the tool. Third, we obtained feedback on the draft from potential users and methodologists, and through piloting the tool in evidence syntheses. Finally, we used this feedback to iteratively refine the assessment criteria and to improve our guidance for undertaking the assessment.

RESULTS

The tool is made up of 11 criteria including the purpose and context of the source; the completeness of the information presented; and the extent to which evidence is provided to support the findings made. Users are asked to indicate whether each of the criteria have been addressed. On the basis of their judgements for each criterion, users then make an overall assessment of the limitations of the source, ranging from no or very minor concerns to serious concerns. These assessments can then facilitate appropriate use of the evidence in decision support products.

CONCLUSIONS

Through focussing on unconventional source materials, the ACE tool fills an important gap in the range of tools for assessing the strengths and limitations of policy-relevant evidence and supporting evidence-informed decision-making.

Real-world evidence: experiences and challenges for decision making in Latin America

OBJECTIVE

The Health Technology Assessment (HTA) process aims to optimize health system funding of technologies. In recent years there has been an increase in what is known as Real-World Evidence (RWE) as a complement to clinical trials. The objective of Health Technology Assessment International's Latin American Policy Forum 2022 was to explore the utility of incorporating RWE into HTA and decision-making processes in the region.

METHODS

This article is based on a background document, survey, and the deliberative work of the country representatives who participated in the Forum.

RESULTS

There is a growing interest in the use of Real-World Data / Real-World Evidence in HTA processes in Latin America, although currently there are no specific local guidelines for RWE use by HTA agencies. At present, its use is limited to certain areas such as adding context to HTA reports, the evaluation of adverse events, or cost estimation.Potential future uses of RWE were identified, including the creation of risk-sharing agreements, the assessment of technology performance in routine practice, providing information on outcomes that are not so easily evaluated in clinical trials (e.g., the identification of specific subpopulations or quality of life), and the estimation of input parameters for economic evaluations.

CONCLUSIONS

The participants agreed that there are several areas presenting significant potential to expand the application of RWD/RWE and that the development of normative frameworks for its use could be helpful.

Real-World Evidence Studies in Oncology Therapeutics: Hope or Hype?

Randomized controlled trial (RCT) remains a gold standard in evidence-based medicine for assessing the efficacy and safety of cancer therapies. However, due to some inherent methodological limitations of RCT, such as stringent inclusion criteria, highly specific treatment, ethical and scientific compromise in rare cancer, and inability to adequately assess safety, real-world evidence (RWE) has been adjudged as a suitable option to complement data obtained from RCT. Moreover, in the context of cancer therapeutics, few notable merits pertain to developing a novel product for rare cancer subtypes, establishing new indications for already approved drugs, optimization of treatment regimen and sequence, a better description of long-term safety, and supporting the reimbursement-related decision. However, the implementation of RWE for the aforementioned purposes will be limited by various challenges, especially in the context of developing economies such as India. Special attention should be given to the availability of data, maintaining the quality standard, and establishing stringent regulations for privacy and security along with active regulatory engagement with relevant stakeholders. Such activities will be key to facilitating the use of RWE in cancer therapeutics.

Real-world evidence of neoadjuvant chemotherapy for breast cancer treatment in a Brazilian multicenter cohort: Correlation of pathological complete response with overall survival

OBJECTIVES

We aimed to evaluate the pCR rate in patients receiving NAC for the treatment of breast cancer (BC) in a multicenter cohort in Brazil. Additionally, we aimed to use RWD to assess the impact of pCR on OS and DFS.

METHODS

This was a retrospective, multicenter cohort study that included female patients over 18 years of age who were diagnosed with nonmetastatic breast cancer and received NAC. OS and DFS at five years were estimated by the Kaplan‒Meier method. Additionally, we conducted a multivariate analysis to identify factors that were significantly associated with pCR and OS.

RESULTS

From 2011 to 2020, 1891 patients were included in the study, and 421 (22,3%) achieved pCR (ypT0 ypN0). Considering the presence of residual DCIS, pCR was achieved in 467 patients (23,5%). The pCR rate varied between the subtypes: HER-2+ (p = 0,016) and clinical stage IIIA and IIIB (p < 0,001). Among HER-2+ patients, those who received trastuzumab had a significantly higher pCR rate than those who did not receive trastuzumab (p < 0.0001). Similarly, patients with TNBC who received treatment with platinum-based regimens also showed higher pCR rates (p < 0.0001). OS was grouped according to pCR status, and the OS rate was 88,3% in the pCR group and 58.1% in the non-pCR group (p < 0.0001). The five-year DFS was 92.2% in the pCR group and 64.3% in the non-pCR group (p < 0.0001).

CONCLUSION

The pCR rate and its prognostic value varied across BC subtypes. In our study, pCR could be used as a surrogate of favorable clinical outcome, as it was associated with higher OS and DFS rates.

Real-world treatment patterns of rheumatoid arthritis in Brazil: analysis of DATASUS national administrative claims data for pharmacoepidemiology studies (2010-2020)

Our study assessed DATASUS as a potential source for pharmacoepidemiologic studies in rheumatoid arthritis (RA) in the Brazilian population focusing on treatment patterns and determinants of initiating or switching to a novel therapy. This was a descriptive database study of RA patients with at least one claim of RA and ≥ 2 claims of disease-modifying anti-rheumatic drug (DMARD); conventional synthetic (cs), biologic (b) or targeted synthetic (ts) DMARD with more than 6 months of follow-up from 01-Jan-2010 to 31-Dec-2020. Analyses were stratified for SUS-exclusive and SUS+ private user cohorts. We identified 250,251 patients with RA in DATASUS: mean age of 58.4 years, majority female (83%) and white (58%). 62% were SUS-exclusive and 38% SUS+ private. Most common bDMARDs were adalimumab and etanercept. Age (adjusted odds ratio 1.78 [50+]; 95% CI 1.57-2.01), SUS exclusive status (0.53; 0.47-0.59), distance to clinic [160+ km] (0.57; 0.45-0.72), and pre-index csDMARD claims (1.23; 1.08-1.41) were independent predictors of initiating a novel oral tsDMARD. Switching from bDMARD to tsDMARD, associations were similar, except for the direction of associations for SUS exclusive status (adjusted hazard ratio 1.10; 1.03-1.18), distance to clinic (1.18; 1.03-1.35), and number of previous bDMARD (0.15; 0.14-0.16). DATASUS is a source suitable for treatment-related analyses in RA reflecting the public health system in Brazil.

A Case for Synthetic Data in Regulatory Decision-Making in Europe

Regulators are faced with many challenges surrounding health data usage, including privacy, fragmentation, validity, and generalizability, especially in the European Union, for which synthetic data may provide innovative solutions. Synthetic data, defined as data artificially generated rather than captured in the real world, are increasingly being used for healthcare research purposes as a proxy to real-world data (RWD). Currently, there are barriers particularly challenging in Europe, where sharing patient's data is strictly regulated, costly, and time-consuming, causing delays in evidence generation and regulatory approvals. Recent initiatives are encouraging the use of synthetic data in regulatory decision making and health technology assessment to overcome these challenges, but synthetic data have still to overcome realistic obstacles before their adoption by researchers and regulators in Europe. Thus, the emerging use of RWD and synthetic data by pharmaceutical and medical device industries calls regulatory bodies to provide a framework for proper evidence generation and informed regulatory decision making. As the provision of data becomes more ubiquitous in scientific research, so will innovations in artificial intelligence, machine learning, and generation of synthetic data, making the exploration and intricacies of this topic all the more important and timely. In this review, we discuss the potential merits and challenges of synthetic data in the context of decision making in the European regulatory environment. We explore the current uses of synthetic data and ongoing initiatives, the value of synthetic data for regulatory purposes, and realistic barriers to the adoption of synthetic data in healthcare.

Prevalence of neuromyelitis optica spectrum disorder in Colombia: Analysis of the official Ministry of Health administrative registry

BACKGROUND

Neuromyelitis optica spectrum disorder (NMOSD) is a rare entity with severe inflammatory demyelinating events of the central nervous system with debilitating sequelae. Its global prevalence ranges between 0.5 and 4/100,000 individuals, with variations by region and ethnicity. Latin America lacks epidemiological data on the disease, and Colombian prevalence is unknown.

OBJECTIVE

Prevalence of NMOSD in Colombia was estimated between 2017 and 2021 using the official Ministry of Health administrative database (SISPRO).

METHODS

This is an observational, cross-sectional retrospective study, using data between January 2017 and December 2021 in the SISPRO database using the International Classification of Disease code for NMOSD G36.0. Prevalence by gender, age and geographic distribution was estimated using official government statistics for 2019. World Health Organization (WHO) standard population was used to adjust using the direct method.

RESULTS

2,650 patients were diagnosed with NMOSD; the average age was 44.9 years with an overall unadjusted prevalence of 5.3/100,000 individuals, higher for females (7.8) than for males (2.8). No significant changes (from 5.3 to 5.4) were seen after adjusting to the WHO standard.

CONCLUSION

According to this study Colombia has one of the highest prevalence rates of NMOSD in Latin America, further studies are needed to elucidate the contributing factors.

Integration of real-world evidence from different data sources in health technology assessment

Real-world evidence (RWE) is being increasingly used by a wide range of stakeholders involved in the therapeutic product lifecycle but remains underutilized in the health technology assessment (HTA) process. RWE aims to fill the current evidence gaps, reduce the uncertainty around the benefits of medical technologies, and better understand the long-term impact of health technologies in real-world conditions. Despite the minimal use of RWE in some elements of HTA, there has been a larger push to further utilize RWE in the HTA processes. HTA bodies, as other stakeholders, work towards developing more robust means to leverage RWE from various data sources in the HTA processes. However, these agencies need to overcome important challenges before the broader incorporation of RWE into their routine practice. This paper aims to explore the extensive integration of RWE utilizing diverse sources of RWD. We discuss the utilization of RWE in HTA processes, considering aspects such as when, where, and how RWE can be effectively applied. Additionally, we seek the potential challenges and barriers associated with the utilization of different data sources.

Marketing authorisations for unmet medical needs: a critical appraisal of regulatory pathways in the European Union

For unmet medical needs, the European Union has established fast-track regulatory pathways for ensuring patients' access to essential treatments. It is the case of Conditional Marketing Authorisation (CMA) and the Authorisation under "Exceptional Circumstances" (EXC), which can be granted even if the clinical part of a medicinal product's dossier is not yet complete. The article aims to discuss the peculiarity of such regulatory pathways and assess the impact of their application on products' market access and penetration. A review of the regulatory history of medicines authorised with EXC or CMA has been performed on European Institutional databases (e.g., EMA portal, Union Register). Excluding vaccines, 71 CMAs and 51 EXCs were granted in the EU from 2002 and 2006, respectively, to 2022. Most CMAs have been released for the treatment of different types of tumours, while most of EXCs for alimentary tract and metabolism diseases, especially in the paediatric population, addressing unmet medical needs. Therefore, both regulatory pathways are effective for placing on the market essential medicines, preserving the initial positive benefit-risk balance. However, on average, CMAs are converted into standard authorisations only after a time which is significantly longer than the provided one-year renewal period, suggesting that such a regulatory pathway is still far from optimized.

Adherence to Positive Airway Pressure Therapy in a Cohort of Colombian Patients with Obstructive Sleep Apnea Syndrome

Objective  To describe the adherence to the use of positive air pressure (PAP) devices in a cohort of patients with sleep apnea syndrome in Colombia. Material and Methods  Descriptive cross-sectional study of adult patients treated between January 2018 and December 2019 in the sleep clinic of a private insurer in Colombia. Results  The analysis included 12,538 patients (51.3% women) with a mean age of 61.3 years; 10,220 patients (81.5%) use CPAP and 1,550 (12.4%) BIPAP. Only 37% are adherent (> 70% of use for 4 hours or more), adherence rates were highest in the >65 years age groups. 2,305 patients (18.5%) were hospitalized, on average 3.2 times; 515 of these (21.3%) had one or more cardiovascular comorbidities. Conclusion  Adherence rates in this sample are lower than those reported elsewhere. They are similar in males and females and tend to improve with age.

Intestinal complications in patients with Crohn’s disease in the Brazilian public healthcare system between 2011 and 2020

BACKGROUND

This is a secondary database study using the Brazilian public healthcare system database.

AIM

To describe intestinal complications (ICs) of patients in the Brazilian public healthcare system with Crohn’s disease (CD) who initiated and either only received conventional therapy (CVT) or also initiated anti-tumor necrosis factor (anti-TNF) therapy between 2011 and 2020.

METHODS

This study included patients with CD [international classification of diseases – 10^th revision (ICD-10): K50.0, K50.1, or K50.8] (age: ≥ 18 years) with at least one claim of CVT (sulfasalazine, azathioprine, mesalazine, or methotrexate). IC was defined as a CD-related hospitalization, pre-defined procedure codes (from rectum or intestinal surgery groups), and/or associated disease (pre-defined ICD-10 codes), and overall (one or more type of ICs).

RESULTS

In the 16809 patients with CD that met the inclusion criteria, the mean follow-up duration was 4.44 (2.37) years. In total, 14697 claims of ICs were found from 4633 patients. Over the 1- and 5-year of follow-up, 8.3% and 8.2% of the patients with CD, respectively, presented at least one IC, of which fistula (31%) and fistulotomy (48%) were the most commonly reported. The overall incidence rate (95%CI) of ICs was 6.8 (6.5–7.04) per 100 patient years for patients using only-CVT, and 9.2 (8.8–9.6) for patients with evidence of anti-TNF therapy.

CONCLUSION

The outcomes highlighted an important and constant rate of ICs over time in all the CD populations assessed, especially in patients exposed to anti-TNF therapy. This outcome revealed insights into the real-world treatment and complications relevant to patients with CD and highlights that this disease remains a concern that may require additional treatment strategies in the Brazilian public healthcare system.

High cost drugs in Latin America: access and barriers

INTRODUCTION

Latin America comprises a large set of culturally diverse middle-income countries sharing an inequality gap and a rapidly ageing population. A better informed growing middle class adds to the pressure on fragmented health systems that strive to attain universal coverage. Cost containment becomes crucial for sustainability.

AREAS COVERED

Using "high cost" as free term, together with individual country names, a search was performed in Pubmed and Scopus databases for relevant documents centered on pharmaceutical products. References of selected articles were also reviewed.

EXPERT OPINION

In the region as elsewhere improving health information systems has been the starting point. Official health technology assessment agencies have been established in several countries, supporting decisions on best available evidence. A few centralized procurement and price regulation schemes using international reference pricing have been successful. Fast-track approval of generics and biosimilars, or establishing a separate funding source for high cost technologies are other options that, with varying degrees of success, have been. Since Latin America is characterized by its social, geographical and political diversity, each health system needs to recognize its individual priorities, learn from successful experiences elsewhere, and adapt possible alternative interventions to the different local contexts.

Guidance on using real-world evidence from Western Europe in Central and Eastern European health policy decision making

Aim: Real-world data and real-world evidence (RWE) are becoming more important for healthcare decision making and health technology assessment. We aimed to propose solutions to overcome barriers preventing Central and Eastern European (CEE) countries from using RWE generated in Western Europe. Materials & methods: To achieve this, following a scoping review and a webinar, the most important barriers were selected through a survey. A workshop was held with CEE experts to discuss proposed solutions. Results: Based on survey results, we selected the nine most important barriers. Multiple solutions were proposed, for example, the need for a European consensus, and building trust in using RWE. Conclusion: Through collaboration with regional stakeholders, we proposed a list of solutions to overcome barriers on transferring RWE from Western Europe to CEE countries.

Drug utilization research in Peru: Is real-world data available?

Background: Drug utilization research (DUR) is used to provide evidence-based data to inform policies and make decisions. The aim of this study was to map and describe available data sources for drug utilization research in Peru. Methods: We performed a search of data sources providing information on medication use on the website of governmental organizations. We also conducted a literature review using PubMed, LILACs, and BVS. Independently, researchers screened eligible data sources. Data characterization included accessibility, coverage data provider, type of data sources, and setting. We performed a descriptive analysis. Results: We identified seven data sources, CENAFyT, ICI, IDI (SISMED), and ENSUSALUD from MINSA, and CRI-ESSALUD, SGSS/ESSI, and ENSSA from ESSALUD. These presented information on adverse drug reactions (n = 2), drug consumption, and distribution (n = 2), prescription and drug dispensing (n = 1), and surveys addressed to medication users (n = 2). ENSUSALUD was the only data source publicly available. VIGIFLOW and ENSUSALUD have a national granularity from the public and private sectors. The setting of the data sources was both hospital and ambulatory care. Two data sources have individual-level data on adverse drug reactions and one on prescriptions. Four studies on drug utilization research in Peru were derived from ENSUSALUD. Conclusion: In Peru, few data sources are available for drug utilization research. There is an increased need to monitor medications for decision-making purposes. Local and international initiatives and partnerships of the government with academic institutions and the private sector might be a good strategy to increase the transparency of health data and for supporting decision-making using drug utilization research.

Empowering quality data - the gordian knot of bringing real innovation into healthcare system

OBJECTIVES

The introduction of Personalised Medicine (PM) into healthcare systems could benefit from a clearer understanding of the distinct national and regional frameworks around the world. Recent engagement by international regulators on maximising the use of real-world evidence (RWE) has highlighted the scope for improving the exploitation of the treasure-trove of health data that is currently largely neglected in many countries. The European Alliance for Personalised Medicine (EAPM) led an international study aimed at identifying the current status of conditions.

METHODS

A literature review examined how far such frameworks exist, with a view to identifying conducive factors - and crucial gaps. This extensive review of key factors across 22 countries and 5 regions revealed a wide variety of attitudes, approaches, provisions and conditions, and permitted the construction of a comprehensive overview of the current status of PM. Based on seven key pillars identified from the literature review and expert panels, the data was quantified, and on the basis of further analysis, an index was developed to allow comparison country by country and region by region.

RESULTS

The results show that United States of America is leading according to overall outcome whereas Kenya scored the least in the overall outcome.

CONCLUSIONS

Still, common approaches exist that could help accelerate take-up of opportunities even in the less prosperous parts of the world.

Using real world evidence to generate cost-effectiveness analysis of fibrinolytic therapy in patients with ST-segment elevation myocardial infarction in Thailand

BACKGROUND

Due to limited access to primary percutaneous coronary intervention for the management of ST-segment elevation myocardial infarction (STEMI) in low-to-middle-income countries (LMICs), fibrinolysis serves as a vital alternative reperfusion therapy. Among fibrinolytic agents, the cost-effectiveness of tenecteplase (TNK) in LMICs as compared to streptokinase (SK) for STEMI management remains unknown.

METHODS

Cost-effectiveness was analyzed using a hybrid model consisting of short-term analysis (30-days decision tree model) and long-term analysis (Markov model). Both health care provider and societal perspectives over a lifetime horizon with 3% discount rate were considered. Input parameters were obtained from Thailand's national health database, a network meta-analysis and literature review. Outcome measure was an incremental cost-effectiveness ratio (ICER) determined by an incremental cost per quality-adjusted life years (QALY) gain. An ICER of less than $5,590 per QALY gain is considered cost-effective. Series of sensitivity analyses were also performed.

FINDINGS

From the societal perspective, TNK increases cost by $827 and increases QALY by 0·173. Thus, the ICER is $4,777 per QALY gained. Similarly, the ICER from health care provider perspective is $4,664 per QALY gained. In the probabilistic sensitivity analysis, using 5,590 USD per QALY as threshold, the probability of TNK being cost-effective was 83% from both perspectives. The most influential parameters were risk ratio of death for treatment with TNK compared to SK and drug cost of TNK.

INTERPRETATION

In a resource-limited country like Thailand, tenecteplase is a cost-effective fibrinolytic drug for treatment of STEMI compared to streptokinase.

FUNDING

None.

Real-World Evidence-Current Developments and Perspectives

Real-world evidence (RWE) is increasingly involved in the early benefit assessment of medicinal drugs. It is expected that RWE will help to speed up approval processes comparable to RWE developments in vaccine research during the COVID-19 pandemic. Definitions of RWE are diverse, marking the highly fluid status in this field. So far, RWE comprises information produced from data routinely collected on patient's health status and/or delivery of health care from various sources other than traditional clinical trials. These sources can include electronic health records, claims, patient-generated data including in home-use settings, data from mobile devices, as well as patient, product, and disease registries. The aim of the present update was to review current RWE developments and guidelines, mainly in the U.S. and Europe over the last decade. RWE has already been included in various approval procedures of regulatory authorities, reflecting its actual acceptance and growing importance in evaluating and accelerating new therapies. However, since RWE research is still in a transition process, and since a number of gaps in this field have been explored, more guidance and a consented definition are necessary to increase the implementation of real-world data.

Using real-world evidence in healthcare from Western to Central and Eastern Europe: a review of existing barriers

As part of the HTx (Next Generation Health Technology Assessment) project, this study was aimed at identifying the main barriers for application of real-world evidence (RWE) for the purposes of health technology assessment in the Central and Eastern European countries. A mixed methods approach was employed to identify the main barriers: a scoping review of the literature and a series of discussions with stakeholders. Based on the applied approaches, we attempted to summarize the main barriers and challenges related to transferability of RWE in five main groups: technical, regulatory, clinical, scientific and perceptional barriers. Further research should pursue the development of detailed, consensus-based guidelines to improve the harmonization and standardization of RWE.

Report from the Ready for the Next Round Thought-Leadership Roundtables on Building Resilience in Cancer Care and Control in Canada-Colorectal Cancer Canada; 2021

(1) Background: The COVID-19 pandemic illuminated vulnerabilities in the Canadian health care system and exposed gaps and challenges across the cancer care continuum. Canada is experiencing significant disruptions to cancer-related services, and the impact these disruptions (delays/deferrals/cancellations) have on the health care system and patients are yet to be determined. Given the potential adverse ramifications, how can Canada’s health care systems build resilience for future threats? (2) Methods: To answer this question, CCC facilitated a series of four thought-leadership roundtables, each representing the views of four different stakeholder groups: patients, physicians, health care system leaders, and researchers. (3) Results: Six themes of strength were identified to serve as a springboard for building resilience including, (1) advancing virtual care and digital health technologies to prevent future interruptions in cancer care delivery. (2) developing real-time data metrics, data sharing, and evidence-based decision-making. (3) enhancing public–private-non-profit partnerships to advance research and strengthen connections across the system. (4) advancing patient-centricity in cancer research to drive and encourage precision medicine approaches to care. (5) investing in training and hiring a robust supply of health care human resources. (6) implementing a national strategy and infrastructure to ensure inter-provincial collaborative data sharing (4). Conclusions: A resilient health care system that can respond to shocks and threats is not an emergency system; it is a robust everyday system that can respond to emergencies.

Real-World Evidence for Regulatory Decision-Making: Guidance From Around the World

PURPOSE

Interest in leveraging real-world evidence (RWE) to support regulatory decision making for product effectiveness has been increasing globally as evident by the increasing number of regulatory frameworks and guidance documents. However, acceptance of RWE, especially before marketing for regulatory approval, differs across countries. In addition, guidance on the design and conduct of innovative clinical trials, such as randomized controlled registry studies, pragmatic trials, and other hybrid studies, is lacking.

METHODS

We assessed the global regulatory environment with regard to RWE based on regional availability of the following 3 key regulatory elements: (1) RWE regulatory framework, (2) data quality and standards guidance. and (3) study methods guidance.

FINDINGS

This article reviews the available frameworks and existing guidance from across the globe and discusses the observed gaps and opportunities for further development and harmonization.

IMPLICATIONS

Cross-country collaborations are encouraged to further shape and align RWE policies and help establish frameworks in countries without current policies with the goal of creating efficiencies when considering RWE to support regulatory decision-making globally.

Real World Data in Health Technology Assessment of Complex Health Technologies

The available evidence on relative effectiveness and risks of new health technologies is often limited at the time of health technology assessment (HTA). Additionally, a wide variety in real-world data (RWD) policies exist among HTA organizations. This study assessed which challenges, related to the increasingly complex nature of new health technologies, make the acceptance of RWD most likely. A questionnaire was disseminated among 33 EUnetHTA member HTA organizations. The questions focused on accepted data sources, circumstances that allowed for RWD acceptance and barriers to acceptance. The questionnaire was validated and tested for reliability by an expert panel, and pilot-tested before dissemination via LimeSurvey. Twenty-two HTA organizations completed the questionnaire (67%). All reported accepting randomized clinical trials. The most accepted RWD source were patient registries (19/22, 86%), the least accepted were editorials and expert opinions (8/22, 36%). With orphan treatments or companion diagnostics, organizations tended to be most likely to accept RWD sources, 4.3-3.2 on a 5-point Likert scale, respectively. Additional circumstances were reported to accept RWD (e.g., a high disease burden). The two most important barriers to accepting RWD were lacking necessary RWD sources and existing policy structures. European HTA organizations seem positive toward the (wider) use of RWD in HTA of complex therapies. Expanding the use of patient registries could be potentially useful, as a large share of the organizations already accepts this source. However, many barriers still exist to the widespread use of RWD. Our results can be used to prioritize circumstances in which RWD might be accepted.

Clinical and economic analysis of Gastrodin injection for dizziness or vertigo: a retrospective cohort study based on electronic health records in China

Background

Dizziness and vertigo are common clinical symptoms. Gastrodin injection has shown clinical effects on dizziness or vertigo. However, little is known about the effectiveness and costs of combining Gastrodin injection with conventional treatment on dizziness or vertigo in daily practice. This study aimed to analyze the clinical and economic effects of Gastrodin injection for patients with dizziness or vertigo in comparison to Extract of Ginkgo Biloba Leaves injection in real-world practice.

Methods

Data was collected from the Hospital Information System of 131 hospitals across China from January to December 2018. Patients whose primary discharge diagnosis was dizziness or vertigo according to ICD-10 diagnostic coding were included and divided into two samples: sample of dizziness or vertigo; sample of dizziness or vertigo, with the complication of cerebral infarction. Comparative analysis of the medical cost per hospitalization, hospitalization duration, effective rates, and cure rates between the group of Gastrodin injection and the group of Extract of Ginkgo Biloba Leaves injection was conducted. Propensity Score Matching was used to control potential confounding factors.

Results

In the sample of dizziness or vertigo, although there was no significant differences on hospitalization duration (P = 0.080), the group of Gastrodin injection was significantly better than the group of Extract of Ginkgo Biloba Leaves injection (P < 0.001) in terms of treatment effect and the per capita hospitalization cost. In the sample of dizziness or vertigo, with the complication of cerebral infarction, there was no significant difference (P = 0.371) in terms of hospitalization duration, but the group of Gastrodin injection was significantly better than the group of Extract of Ginkgo Biloba Leaves injection (P = 0.009) in terms of treatment effect, and significant difference regarding the per capita hospitalization cost (P < 0.001).

Conclusions

Gastrodin injection showed advantages for inpatients with dizziness or vertigo compared with Extract of Ginkgo Biloba Leaves injection. Future studies using prospective pragmatic controlled trials can test and explore more about the effects of Gastrodin injections on dizziness or vertigo.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13020-021-00561-9.

Data Sources for Drug Utilization Research in Latin American countries - a cross-national study: DASDUR-LATAM Study

PURPOSE

Drug utilization research (DUR) contributes to inform policymaking and to strengthen health systems. The availability of data sources is the first step for conducting DUR. However, documents that systematize these data sources in Latin American (LatAm) countries are not known. We compiled the potential data sources for DUR in the LatAm region.

METHODS

A network of DUR experts from nine LatAm countries was assembled and experts conducted: (i) a website search of the government, academic, and private health institutions; (ii) screening of eligible data sources, and (iii) liaising with national experts in pharmacoepidemiology (via an on-line survey). The data sources were characterized by accessibility, geographic granularity, setting, sector of the data, sources and type of the data. Descriptive analyses were performed.

RESULTS

We identified 125 data sources for DUR in nine LatAm countries. Thirty-eight (30%) of them were publicly and conveniently available; 89 (71%) were accessible with limitations, and 18 (14%) were not accessible or lacked clear rules for data access. From the 125 data sources, 76 (61%) were from the public sector only; 46 (37%) were from pharmacy records; 43 (34%) came from ambulatory settings and; 85 (68%) gave access to individual patient-level data.

CONCLUSIONS

Although multiple sources for DUR are available in LatAm countries, the accessibility is a major challenge. The procedures for accessing DUR data should be transparent, feasible, affordable and protocol-driven. This inventory could permit a comparison of drug utilization between countries identifying potential medication-related problems that need further exploration.

Expectations for the Development of Health Technology Assessment in Brazil

The implementation of health technology assessment (HTA) in emerging countries depends on the characteristics of the health care system and the needs of public health care. The objective of this survey was to investigate experts' expectations for the development of HTA in Brazil and to derive measures to strengthen the impact of HTA in Brazil on health care decisions. Based on a scoping literature review, a questionnaire was developed proposing eight theses for seven domains of HTA: (i) capacity building, (ii) public involvement, (iii) role of cost-effectiveness analysis (CEA), (iv) institutional framework, (v) scope of HTA studies, (vi) methodology of HTA, and (vii) HTA as the basis for jurisdiction. Thirty experts responded in full to the survey and agreed to five of the eight theses proposed. Experts suggested several measures to promote HTA within the scope of each domain, thus addressing capacity building related to HTA, availability, and reliability of population data, and legal endowment of the HTA system. Finally, HTA processes in Brazil should also address public health issues (e.g., appraisal of interventions directed at chronic diseases).

Perspectives on emerging technologies, personalised medicine, and clinical research for cancer control in Latin America and the Caribbean

Challenges of health systems in Latin America and the Caribbean include accessibility, inequity, segmentation, and poverty. These challenges are similar in different countries of the region and transcend national borders. The increasing digital transformation of health care holds promise of more precise interventions, improved health outcomes, increased efficiency, and ultimately reduced health-care costs. In Latin America and the Caribbean, the adoption of digital health tools is in early stages and the quality of cancer registries, electronic health records, and structured databases are problematic. Cancer research and innovation in the region are limited due to inadequate academic resources and translational research is almost fully dependent on public funding. Regulatory complexity and extended timelines jeopardise the potential improvement in participation in international studies. Emerging technologies, artificial intelligence, big data, and cancer research represent an opportunity to address the health-care challenges in Latin America and the Caribbean collectively, by optimising national capacities, sharing and comparing best practices, and transferring scientific and technical capabilities.

Ocular toxoplasmosis in immunocompetent adults: current cost-effectiveness of four treatment regimens in Colombia

BACKGROUND

Ocular toxoplasmosis is an infection caused by Toxoplasma gondii. In South America, the clinical course of ocular toxoplasmosis is more severe than in Europe and North America because virulent strains of the parasite are present. Ocular toxoplasmosis is the leading cause of posterior uveitis and retinochoroiditis in Colombia, requiring timely and appropriate treatment. However, there is no standardized therapy protocol based on economic studies for the country.

PURPOSE

To compare the cost-effectiveness of four first-line treatment regimens for active ocular toxoplasmosis in immunocompetent adults in Colombia, using the number of averted therapeutic failures as the outcome.

METHODS

We performed an economic and cost-effectiveness analysis to compare four first-line treatment regimens for ocular toxoplasmosis from the perspective of a third-party payer (Colombian General System of Social Security in Health). A decision analysis tree was used over a 24-week time horizon, considering only direct costs. Additionally, we performed a discrete sensitivity analysis and a probabilistic sensitivity analysis with 10,000 iterations in the Monte Carlo simulation.

RESULTS

For the base case, trimethoprim/sulfamethoxazole showed 86% effectiveness at a cost of <57 United States Dollars, resulting in the most cost-effective first-line alternative. When performing the probabilistic sensitivity analysis and maintaining the willingness to pay 466.00 United States Dollars, the trimethoprim/sulfamethoxazole regimen remained the most cost-effective alternative.

CONCLUSION

Ocular toxoplasmosis is a public health issue in Latin America. Despite severe visual consequences for affected patients, there are no standardized treatment guidelines in countries such as Colombia. Our evidence supports the use of trimethoprim/sulfamethoxazole as first-line treatment in Colombia because of its availability and optimal cost-effectiveness performance; it reduces recurrences and complications, while averting therapeutic failure. Furthermore, our evidence can be generalized to other Latin American countries with similar frequencies and severities of Toxoplasma gondii ocular infection and health systems similar to the Colombian system.

Real-world outcomes associated with new cancer medicines approved by the Food and Drug Administration and European Medicines Agency: A retrospective cohort study

Purpose

Real-World Data (RWD) studies are increasingly used to support regulatory approvals, reimbursement decisions, and changes in clinical practice for novel cancer drugs. However, few studies have systematically appraised their quality or compared outcomes to pivotal trials.

Methods

All RWD studies (2010–2019) for drugs approved by the Food and Drug Administration (FDA) and European Medicines Agency (EMA) from 2010 to 2015 for solid organ tumours in the non-curative setting were identified. Quality assessment was undertaken using the Newcastle Ottawa Scale. Survival differences between each RWD study and the pivotal trial were determined using a related sample Wilcoxon signed-rank test.

Results

293 RWD studies for 45 of the 57 drug indications approved by the FDA/EMA were identified. The most common tumour types were prostate cancer (29%, n = 86) and melanoma (15%, n = 43). A quarter of the studies had industry funding. No high-quality studies were identified, and 78% were low quality. Comparative survival analysis between RWD and pivotal trials was possible for 224 studies (37 drug indications). Differences in median survival between the RWD studies and their corresponding trial ranged from −32 months to 21 months (IQR –4·2 months to 1·6 months). Low-quality studies were more likely to report superior survival outcomes (23%) compared to higher quality studies (8%) (p = 0.02).

Conclusion

RWD study quality for novel cancer drugs is low and of insufficient rigour to inform reimbursement decisions and clinical practice. RWD studies seeking publication should provide a completed quality assessment tool on submission. Greater investment in properly designed RWD studies is required.

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Study provides a systematic appraisal of FDA/EMA approved drugs in real-world practice.

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Most novel FDA/EMA cancer drugs have real-world data (RWD) studies, but the quality is low.

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Variability in survival outcomes exists, and findings should be applied cautiously.

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Most RWD studies reported inferior survival outcomes compared to the pivotal trial.

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Pre-publication critical appraisal checklists should be used for RWD studies.

Use of real-world evidence for oncology clinical decision making in emerging economies

Real-world evidence (RWE) can provide insights into patient profiles, disease detection, treatment choice, dosing strategies, treatment sequencing, adverse event management and financial toxicity associated with oncology treatment. However, the full potential of RWE is untapped in emerging economies due to structural and behavioral factors. Structural barriers include lack of regulatory engagement, real-world data availability, quality and integrity. Behavioral barriers include entrenched healthcare professional behaviors that impede rapid RWE understanding and adoption. These barriers can be addressed with close collaboration of healthcare stakeholders; of whom, regulators need to be at the forefront given their ability to facilitate use of RWE in healthcare policy and legislation.

Data transparency for building a stronger healthcare system: A case study from Argentinean administrative drug utilization data sources

In order to compile an inventory of national data sources for drug utilization research (DUR) in Argentina and to verify publicly available data sources, we performed a cross-sectional study that sought to identify national and provincial databases of drug use. In July 2020, we searched the websites of government institutions, carried out a systematic query of bibliographic databases for "drug utilization research" conducted in Argentina, and conducted a survey with local experts. Data collected included: the institution responsible for the database, population covered, accessibility, source of the data, healthcare setting, geographic information, and whether data were individual or aggregated. Descriptive analyses were then performed. We identified 31 data sources for DUR; only one was publicly and conveniently accessible. Five published aggregated data and provide more detailed access by formal request. Only seven sources (23%) reported national data, and most (n=29) included only data from the public healthcare sector. Although data sources for DUR have been found in Argentina, limited access by researchers and policymakers is still an significant obstacle. Increasing health data transparency by making data sources publicly available for the purpose of analyzing public health information is crucial for building a stronger health system.

Improving Collection of Real-World Data: The Experience of the Joven & Fuerte Prospective Cohort for Mexican Young Women With Breast Cancer

The prospective collection of clinical data can generate detailed information on heterogeneous populations. This article reviews the strengths and limitations of the collection of real-world data and provides insight into the feasibility of routine collection of high-quality evidence even in a resource-constrained setting. The acquisition of high-quality data to assess the clinical and psychosocial needs of young Mexican patients with breast cancer has been enhanced through the use of preplanned, standardized data definitions and instrumentation to provide internally and externally comparable results, optimization of data collection with web-based surveys, engagement of participants to minimize missing data, and routine review for data consistency. A similar approach by other research groups could improve the quality of real-world data and accomplish enhanced inference of information.

Hospital incidence, in-hospital mortality and medical costs of pneumococcal disease in Spain (2008-2017): a retrospective multicentre study

OBJECTIVE

The aim of this study was to analyze the characteristics of the patients attended with a pneumococcal disease in Spanish hospitals, to evaluate trends in hospital incidence and in-hospital mortality and to quantify patients' use of resources and medical costs.

METHODS

Medical admission records of patients admitted due to pneumococcal disease between 1 January 2008 and 31 December 2017 were obtained from a Spanish hospital discharge database. Records were identified with the International Statistical Classification of Diseases and Related Health Problems, 9th and 10th version codes corresponding to pneumococcal pneumonia, bacteraemia, pyogenic arthritis, endocarditis, meningitis, peritonitis and unspecified pneumococcal infections.

RESULTS

Admissions of 168,074 patients were analyzed, with a mean age of 63.5 years (median = 72; interquartile range = 28). Pneumococcal pneumonia was responsible for 64.1% of all admissions, with a hospital incidence of 31.1 per 10,000 patients that decreased significantly over the study period (p = .002). Hospital incidence of meningitis also displayed a decreasing trend over the study period (p = .003), whereas incidence of bacteraemia and pyogenic arthritis increased significantly (p = .001; p = .004). Mean Charlson Comorbidity Index was 3.3 (standard deviation = 2.2). In-hospital mortality was 7.0% over the study period, being the highest in patients admitted with endocarditis (17.2%). Sepsis, acute renal failure, disorders of fluid electrolyte and acid-base balance, heart failure and acute respiratory failure were strongly associated with in-hospital mortality. Mean length of hospital stay was of 11.1 days (median = 22; interquartile range = 26) and there was a majority of urgent admissions (95.0%); the most extended stays were registered in patients with endocarditis, meningitis and pyogenic arthritis. The mean hospital admission cost was €5676, €104.2 million annually for all registered patients; 50.3% of all costs were associated with pneumonia, whereas the highest admission costs were registered in patients with endocarditis (€15,991) and meningitis (€11,934). Mean admission costs increased significantly over the study period for pneumonia and bacteraemia and decreased for endocarditis.

CONCLUSIONS

The incidence of pneumococcal pneumonia and meningitis decreased over the study period after the introduction of vaccination in Spain. The advanced age of patients and presence of chronic comorbid conditions that are associated to in-hospital mortality must be taken into account when improving care protocols and upcoming vaccination plans.

Hospital incidence, management and direct cost of osteogenesis imperfecta in Spain: a retrospective database analysis

OBJECTIVE

The objective of this study was to analyse hospital incidence of osteogenesis imperfecta (OI) in Spanish hospitals and the associated medical costs from a healthcare system perspective.

METHODS

To this aim, a retrospective multicentre study was designed analysing admission records from patients admitted with OI in specialized care settings in Spain between 2000 and 2017. Direct medical costs were calculated based on the diagnosis-related group-based hospital payment systems, determined by the Spanish Ministry of Health.

RESULTS

Overall, 3,747 admissions were reviewed, corresponding to 998 patients, 48.20% of which were males and 51.80% females. Hospital incidence was 5.64 per 100,000 patients (95% CI, 4.80-6.60) over the study period, whereas incidence at birth was 10.14 per 100,000 (95% CI, 8.16-12.05). In-hospital mortality appeared primarily associated to neonatal conditions and acute respiratory failure. Mean length of hospital stay was 2.83 days, decreasing significantly during the study period (p < 0.0001). Readmission rate was significantly higher in younger patients (p = 0.0110). In most hospital admissions other disorders of bone and cartilage (osteoporosis and pathologic fractures) were registered, together with delayed growth and hypocalcaemia. The mean annual direct medical cost per hospital admission was €2,571, increasing significantly over the study period (p < 0.0001).

CONCLUSIONS

Overall, this study provides data that should be taken into account for the development of improved and more efficient treatment protocols, and in reducing the burden of OI at the healthcare system level.

Analysis of hospital incidence and direct medical costs of intrahepatic cholangiocarcinoma in Spain (2000-2018)

INTRODUCTION

Intrahepatic cholangiocarcinomas (iCCA) are aggressive tumors, often diagnosed in advanced stages and with limited curative treatment options. Their incidence has raised in the past years, increasing their associated economic burden. This study aimed to measure hospital incidence and mortality of iCCA and to evaluate direct medical costs.

METHODS

Records of admissions due to iCCA between 1 January 2000 and 31 December 2018 were obtained from a Spanish National discharge database. Hospital incidence and mortality were measured within the hospitalized population and medical costs were assessed for specialized healthcare.

RESULTS

Admission files corresponded to 23,315 patients, with a median age of 73 years (IQR = 17) and 55.9% of males. Cholangiocarcinoma presented a hospital incidence of 6.9 per 10,000 persons in 2018, increasing significantly over the study period. In-hospital mortality was 31.5% in the year 2018 and remained stable over the study period. The mean annual direct medical cost of secondary care was €9417 per patient in the year 2017, and increased significantly between 2000 and 2008, stabilizing after 2009.

CONCLUSION

The incidence of iCCA in Spain increased over the past years. The medical costs of iCCA per patient stabilized after 2008 but total costs are expected to increase if incidence continues to raise.

Availability of secondary healthcare data for conducting pharmacoepidemiology studies in Colombia: A systematic review

Real-world evidence (RWE) is emerging as a fundamental component of the post-marketing evaluation of medicinal products. Even though the focus on RWE studies has increased in Colombia, the availability of secondary data sources to perform this type of research is not well documented. Thus, we aimed at identifying and characterizing secondary data sources available in Colombia. We performed a systematic literature review on PubMed, EMBASE, and VHL using a combination of controlled vocabulary and keywords for the concepts of electronic health records, epidemiologic studies and Colombia. A total of 323 publications were included. These comprised 123 identified secondary data sources including pharmacy dispensing databases, government datasets, disease registries, insurance databases, and electronic heath records, among others. These data sources were mostly used for cross-sectional studies focused on disease epidemiology in a specific population. Almost all databases (95%) contained demographic information, followed by pharmacological treatment (44%) and diagnostic tests (39%). Even though the database owner was identifiable in 94%, access information was only available in 44% of the articles. Only a pharmacy-dispensing database, local cancer registries, and government databases included a description regarding the quality of the information available. The diversity of databases identified shows that Colombia has a high potential to continue enhancing its RWE strategy. Greater efforts are required to improve data quality and accessibility. The linkage between databases will expand data pooling and integration to boost the translational potential of RWE.

Atopic dermatitis in specialized centers in Spain: a retrospective analysis of incidence and costs (2000-2017)

BACKGROUND

Atopic dermatitis is a chronic inflammatory skin disease that has substantial effects on patients' quality of life, with a prevalence between 2.2% and 17.6% worldwide. This study aimed to evaluate the use of specialized care resources generated by children and adults with atopic dermatitis, and the associated direct medical costs.

METHODS

Admission details from patients admitted in specialized healthcare centers (inpatient and outpatient care) in Spain between 1 January 2000 and 31 December 2017 were analyzed in a retrospective multicentre study.

RESULTS

Records corresponded to 3036 patients, 1266 aged 5 years or younger. Comorbid conditions corresponded to skin infections and respiratory difficulties (asthma, bronchiectasis). Hospital incidence of atopic dermatitis was 5.8 per 100,000 persons, stable over the study period, and 30.0 per 100,000 in those aged 5 years and younger. Mean annual direct medical cost per patient was €2469. Overall, direct medical costs per patient increased significantly over the study period (p < 0.0001).

CONCLUSION

Hospital incidence of atopic dermatitis remained stable over the study period, which is in contrast with the increasing incidence reported by the Spanish government in primary care centers. The increase in direct medical costs of specialized care responded to the increase in treatment costs.

Current status of lung cancer in Spain: a retrospective analysis of patient characteristics, use of healthcare resources and in-hospital mortality

Objective: This study aimed to describe the current status of lung cancer in Spain, including patient characteristics and in-hospital mortality, and to revise disease management and the direct medical costs of secondary care.Methods: A retrospective observational study was set to analyse anonymized primary and secondary care records of patients admitted with lung cancer in Spain between 2011 and 2016. Data were obtained from the Primary Care Dataset and the Centralised Hospital Discharge Database.Results: Admissions files from 12,119 primary care and 113,574 secondary care patients were analyzed. Only 21% of all patients were females, yet the number of female patients presented an increasing trend over the study period. Non-small-cell lung carcinoma represented 85.29% of all lung malignant neoplasms; metastatic or secondary malignant neoplasms were diagnosed in 76.66% of admissions. Other relevant comorbid conditions registered at the hospital level were hypertension, disorders of lipoid metabolism, diabetes mellitus and a history of tobacco use. In-hospital mortality was 22% over the study period and was associated with respiratory failure. Mean hospitalization time was 9.57 days and most admissions were due to emergencies. The mean cost of secondary care per patient was €8475, increasing significantly over the study period. Cost per patient was higher in those diagnosed with a squamous cell carcinoma.Conclusions: Preventive and early detection measures are recommended, continuing to focus on females. In parallel, a multidisciplinary approach could optimize patient journey considering the presence of disease comorbidities, although its role in lung cancer mortality should be further explored.

Analysis of the management and costs of headache disorders in Spain during the period 2011-2016: a retrospective multicentre observational study

OBJECTIVES

To investigate the number and characteristics of the Spanish population affected by headache disorders and the direct medical cost that these patients represent for the healthcare system.

DESIGN

A retrospective multicentre observational study.

SETTING

Records from all patients admitted with headache in primary and secondary care centres in Spain between 2011 and 2016 that were registered in a Spanish claims database were included in the analysis. Direct medical costs were calculated using the standardised average expenses of medical procedures determined by the Spanish Ministry of Health.

RESULTS

Data extraction claimed primary care records from 636 722 patients and secondary care records from 30 077 patients. Women represented 63% and 65% of all patients with headache in primary and secondary care respectively, with the exception of cluster headaches, a group with 60% of male patients. No large shifts were observed over time in patients' profile; contrarily, the number of cases per 10 000 patients attended in primary care increased 2-folds between 2011 and 2016 for migraine and 1.85-folds for other headaches. Migraine was the cause for 28% of primary care consultations and 50% of secondary care admissions, and it was responsible for the largest portion of healthcare costs in 2016, a total amount of € 7 302 718. The estimated annual direct medical cost of headache disorders was € 10 716 086.

CONCLUSIONS

Migraine was responsible for half of the secondary care admissions linked to headache disorders. The raise detected in the number of cases registered in primary care is likely to impact the direct medical costs associated to these disorders causing an increase in the total burden they represent for the Spanish National Healthcare System.