Health Technology Assessment and Its Use in Drug Policies in China

Psychometric Measurements of the Adherence to Refills and Medication Scales Among Patients With HIV/AIDS in Indonesia

OBJECTIVE

This study aimed to conduct a psychometric evaluation of the Adherence to Refills and Medications Scale (ARMS) among patients with HIV/AIDS in Indonesia.

METHODS

Psychometric analysis was conducted at 2 hospitals and 7 public health centers at the voluntary counseling and testing clinic. Content validity was measured by assessing the relevance and clarity of each ARMS item. Construct validity was also assessed. Reliability was evaluated using internal consistency and test-retest reliability.

RESULTS

This study involved 11 experts in the assessment of the content validity and 240 participants in the estimation of the construct validity. All ARMS items were generally considered easy to understand and relevant, with scale-level content validity index based on the average method (S-CVI/Ave) of 0.9 (>0.78) and item-level content validity index (I-CVI) in the range from 0.5 to 1 for the relevance level and S-CVI/Ave of 0.95 (>0.78) and I-CVI in the range from 0.8 to 1 for the clarity level. Two items (numbers 2 and 3) were revised based on experts' suggestions to enhance comprehension. Confirmatory factor analysis supported 2 subscales: adherence to taking medications and adherence to refilling prescriptions. Good reliability was supported by internal consistency (Cronbach's α 0.793) and test-retest reliability (intraclass correlation coefficient 0.722) for the overall adherence score.

CONCLUSIONS

The Indonesian version of ARMS is a valid and reliable medication adherence scale when used in Indonesian patients with HIV/AIDS.

Mapping of health technology assessment in China: a comparative study between 2016 and 2021

BACKGROUND

Health Technology Assessment (HTA) in China has recently expanded from purely academic research to include policy or decision-oriented practice, especially after HTA evidence was used to update the National Reimbursement Drug List for the first time in 2017. This study aims to identify the progress and challenges of HTA development from 2016 to 2021 and inform policies and decisions to promote further HTA development in China.

METHODS

We conducted a cross-sectional web-based survey with policy makers, researchers and industry-providers in China in 2016 and 2021 respectively. The 'Mapping of HTA Instrument', was utilized to assess the HTA development across eight domains: Institutionalization, Identification, Priority setting, Assessment, Appraisal, Reporting, Dissemination of findings and conclusions, and Implementation in policy and practice. To reduce the influence of confounders and compare the mapping outcomes between the 2016 and 2021 groups, we conducted 1:1 Propensity Score Matching (PSM). Univariate analysis was conducted to compare the differences between the two groups. The overall results were further compared with those of a mapping study that included ten countries.

RESULTS

In total, 212 and 255 respondents completed the survey in 2016 and 2021, respectively. The total score of the HTA development level in China in 2021 was higher than that in 2016 before PSM (89.38 versus 83.96). Following PSM, 183 respondents from the 2016 and 2021 groups were matched. Overall, the mean scores for most indicators in the Institutionalization domain and Dissemination domain in 2021 were higher than those in 2016 (P < 0.05). The Appraisal domain in 2021 was more explicit, transparent and replicable than that in 2016 (t = -3.279, P < 0.05). However, the mean scores of most indicators in the Assessment domain were higher in 2016 than those in 2021 (P < 0.05).

CONCLUSIONS

Our study suggest that the level of HTA development in China progressed significantly from 2016 to 2021. However, before engaging in HTA activities, further efforts are required to enhance the assessment process. For instance, it is important to establish a clear goal and scope for HTA; adapt standardized methodologies for evaluating the performance of systematic reviews or meta-analyses; and provide comprehensive descriptions of the safety, clinical effectiveness, cost, and cost-effectiveness of the assessed technologies, thus improving the development of HTA in China.

Evaluating the cost utility of estradiol plus dydrogesterone for the treatment of menopausal women in China

AIM

Evaluate the cost utility of menopausal hormone therapy for women in China.

MATERIALS AND METHODS

A bespoke Markov cost utility model was developed to evaluate a cohort of symptomatic perimenopausal women (>45 years) with intact uterus in China in accordance with China's Pharmacoeconomic guideline. Short (5-year) and long (10-year) treatment durations were evaluated over a lifetime model time horizon with 12-month cycle duration. Societal and healthcare payer perspectives were evaluated in the context of a primary care provider/prescriber, outpatient setting with inpatient care for patients with chronic conditions. Disease risk and mortality parameters were derived from focused literature searches, and China Diagnosis-related Group cost data was included. Comprehensive scenario, univariate and probabilistic sensitivity analysis were undertaken along with independent validation. This is the first model to include MHT-related disease risks.

RESULTS

According to base case results, the total cost for MHT was 22,516$ (150,106¥) and total quality adjusted life years 12.32 versus total cost of no MHT 30,824$ (205,495¥) and total quality adjusted life years 11.16 resulting in a dominant incremental cost effectiveness ratio of -7,184$ (-47,898¥) per QALY. Results hold true over a range of univariate deterministic sensitivity and scenario analyses. Probabilistic analysis showed a 91% probability of being cost effective at a willingness to pay threshold of three times Gross Domestic Product per capita in China.

CONCLUSION

Contingent on the structure and assumptions of the model, combination of estradiol plus dydrogesterone MHT is potentially cost saving in symptomatic women over the age of 45 years in China.

The pan-Canadian Tiered Pricing Framework and Chinese National Volume-Based Procurement: A comparative study using Donabedian's structure-process-outcome framework

Background

Generic drugs have been seen as a potentially powerful way to alleviate the financial burden on patients and health care systems. Two strategies for achieving rational prices of generic drugs are tiered pricing framework and pooled purchasing power. We compare the pan-Canadian Tiered Pricing Framework (TPF) and the Chinese National Volume-Based Procurement (NVBP) as comparators to explore the similarities and differences between the two mechanisms and summarise lessons for other jurisdictions.

Methods

This comparative study applies Donabedian's structure-process-outcome framework to systematically analyse the macro contexts, procedures, and long- and short-term results of each pricing mechanism, and the interactions between them.

Results

Structure: TPF is an upstream initiative aimed at lowering the prices of generic drugs and increasing coverage and price consistency. NVBP is a downstream national initiative prioritised for reducing drug prices to achieve value-based purchasing. Process: By associating the number of manufacturers with price cuts, TPF leaves the choice to manufacturers to decide if they want to enter a specific market. In contrast, the Chinese government determines NVBP list and has the authority to choose manufacturer(s) with the lowest price(s). TPF provides clear price information to potential suppliers with unclear order quantity. The NVBP drug price is determined by tendering, while procurement volume is clear and massive. Outcome: The effectiveness of TPF and NVBP is similar, with both achieving a 53% price cut. Both TPF and NVBP experienced efficiency improvement since their establishment, with 98 and 86 drugs priced per year. By comparing 60 drugs covered by both programmes, the NVBP price is 57% of that of the TPF counterpart on average (1.1 to 301.6%), by purchase power parity.

Conclusions

The tiered pricing scheme is feasible in regions with a stable and mature pharmaceutical market, typically seen in high-income countries, while tendering is more workable in low- and middle-income countries where the pharmaceutical market is weak and unstable. Experience in the two countries shows that a coordinated pricing mechanism involves many piecemeal interactive problems, which a sophisticated system with a robust long-range plan may address better.

The quality of published health economic evaluations on screening programs in China: a systematic review and quantitative appraisal

BACKGROUND

This study seeks to assess the quality of HEEs reporting on screening programs over the last 20 years in China, to identify potential predictors of reporting quality.

METHODS

We performed a literature search of HEE studies published in PubMed, Embase, CNKI, and WANFANG from 2000 to 2021. The search terms included 'screening,' 'China,' 'CEA,' 'CBA,' 'CUA,' and all other names for health economic evaluation. Two reviewers independently extracted data and assessed the reporting quality using CHEERS checklist. A generalized linear regression analysis was used to identify the predictors of reporting quality.

RESULTS

133 of 1,281 identified studies was included. The reporting quality scores showed an increasing trend and the mean score was 0.56. Some items were underreported, such as study perspective, discount rate, measurement of effectiveness, analytical methods, uncertainty, heterogeneity etc. Five factors (year of publication, journal type, first author's affiliation, economic evaluation type, specialty journals or not) predicted a higher score of reporting quality in the regression analyses (P < 0.05).

CONCLUSIONS

Overall, the quality of HEEs on screening programs in China showed an improving trend. Given the significance of reporting quality, it is advisable to report HEE results following standard evaluation guidelines to improve their transparency.

Comprehensive Evaluation of Clinical Application of Balanced Compound Amino Acid Injection

Background

To provide a reference for hospital drug selection and rational clinical drug selection based on the evaluation of the safety, nutritional quality, and economy of 27 manufacturers of five varieties (18AA, 18AA-I, 18AA-II, 18AA-IV, 18AA-V) of balanced compound amino acids for injection and (18AA-II_{original research}).

Methods

The safety of compound amino acids for injection was evaluated by comparing the antioxidant sulfite contents. Based on the amino acid scoring standard mode and the whole egg protein mode as proposed by the Food and Agriculture Organization of the United Nations/World Health Organization (FAO/WHO) in 1973, we compared the formula. The first limiting amino acid content and the comprehensive quality of the total essential amino acid (EAA) contents of the six formulations were studied. The price/content ratio was used to evaluate their economy.

Results

Similar variety produced by different manufacturers have the same formula and contents of balanced compound amino acids for injection. Safety: 18AA-II_{original research} and 18AA-II had the lowest sulfite content. Compared with 18AA-II_{original research}, the sulfite content of 18AA-I, 18AA, 18AA-V, and 18AA-IV were higher (10 times, 16.67 times, 16.67 times, and 33.33 times, respectively). The lower the sulfite content, the safer the product. Nutritional quality: The proportions of amino acids in the five varieties of compound amino acid injection were all suitable. The order of the first limiting amino acids for the formulations was 18AA-II_{original research} = 18AA-II>18AA >18AA-I = 18AA-IV>18AA-V. The order of the EAA values for the formulations was 18AA-II_{original research} = 18AA-II>18AA>18AA-I > 18AA-IV > 18AA-V. The overall effectiveness order was 18AA-II_{original research} = 18AA-II>18AA > 18AA-I>18AA-IV>18AA-V. Economy: Among the 27 manufacturers, 12 manufacturers had a price/content ratio higher than that of 18AA-II original research manufacturers, and 15 manufacturers had a price/content ratio lower than original research manufacturers.

Conclusion

Through its security, effectiveness, and economy of the comprehensive research, we recommended 18AA-II and 18AA-IIoriginal research with high safety, efficacy, and reasonable price as the first choice. 18AA and 18AA-I with better safety and reasonable price, secondary recommendation. 18AA-IV or 18AA-V with poor safety, efficacy, and economy are not recommended.

Estimation of the cost-effective threshold of a quality-adjusted life year in China based on the value of statistical life

Cost-effective threshold (CET) is essential for health technology assessment and decision-making based on health economic evaluations. Recently, it has been argued that the commonly used once and three times of gross domestic product (GDP) per capita CETs of a quality-adjusted life year (QALY) are not necessarily empirically supported in all countries. Therefore, we aimed to estimate the CET of a QALY as times of GDP per capita in China, of which the reimbursement coverage decisions are increasingly engaging economic evaluations. Estimates on the value of statistical life (VSL) in China were identified from several studies in the literature and converted to times of GDP per capita, the weighted average of which was used for subsequent calculation. By pooling data on population mortality, health utility, and age distribution, we estimated the value of a statistical QALY (VSQ) from VSL using an established mathematical process, which represented the theoretical upper bound of CET. The corresponding point estimate and theoretical lower bound were obtained using their numerical relationships with the upper bound. Scenarios analyses were also conducted. The estimated CET, its upper bound, and its lower bound were 1.45, 2.90, and 1.16 times of GDP per capita in China, respectively. In different scenarios, the estimated CET varied but was greater than once GDP per capita in most cases. As such, the CET of a QALY in China is close to 1.5 times of GDP per capita, which should be benchmarked for future ICER-based coverage decisions.

Health Economics in the Field of Prosthetics and Orthotics: A Global Perspective

The rapid advancement of prosthetic and orthotic (P&O) technology raises the question how the industry can ensure that patients have access to the benefits and providers get paid properly and fairly by healthcare payers. This is a challenge that not only P&O but all areas of health technology face. In many areas of medicine and health products, such as drugs and medical devices, health-technology assessments (HTA) have become a standard procedure in the coverage and reimbursement process. In most countries, P&O is lagging behind that development, although some countries have already formalized HTA for prosthetic and orthotic products and may even use cost-effectiveness analyses to determine pricing and payment amounts. This article gives an overview on the coverage and reimbursement processes in the United States, Canada, Germany, France, Sweden, the United Kingdom, Poland, Japan, and China. This selection reflects the variety and diversity of coverage and reimbursement processes that the P&O industry faces globally. The paper continues with an overview on the necessary research and investment efforts that manufacturers will have to make in the future, and contemplates the likely consequences for the manufacturer community in the market place. Health economics may help support the transition from price-based to value-based coverage and reimbursement but will come at considerable costs to the industry.

Smartphone and web-based independent consultation and feedback for joint replacement surgeries: a randomized control trial protocol

Background

Cost control and usage regulation of medical materials (MMs) are the practical issues that the government pays close attention to. Although it is well established that there is great potential to mobilize doctors and patients in participating MMs-related clinical decisions, few interventions adopt effective measures against specific behavioral deficiencies. This study aims at developing and validating an independent consultation and feedback system (ICFS) for optimizing clinical decisions on the use of MMs for inpatients needing joint replacement surgeries.

Methods

Development of the research protocol is based on a problem or deficiency list derived on a trans-theoretical framework which incorporates including mainly soft systems-thinking, information asymmetry, crisis-coping, dual delegation and planned behavior. The intervention consists of two main components targeting at patients and doctors respectively. Each of the intervention ingredients is designed to tackle the doctor and patient-side problems with MMs using in joint replacement surgeries. The intervention arm receives 18 months' ICFS intervention program on the basis of the routine medical services; while the control arm, only the routine medical services. Implementation of the intervention is supported by an online platform established and maintained by the Quality Assurance Center for Medical Care in Anhui Province, a smartphone-based application program (APP) and a web-based clinical support system.

Discussion

The implementation of this study is expected to significantly reduce the deficiencies and moral hazards in decision-making of MMs using through the output of economic, efficient, sustainable and easy-to-promote cooperative intervention programs, thus greatly reducing medical costs and standardizing medical behaviors.

Trial registration number

ISRCTN10152297.

Driving factors and mode transformation regarding health technology assessment (HTA) in China: Problems and recommendations

As the reform of Chinese medical and health undertakings has advanced (since 2015), the admission, pricing and payment policies regarding the new health technologies of China have undergone significant changes, and health technology assessment (HTA) has gradually become one of the current reform and research hotspots in China. Based on the perspective of HTA driving factors and the development mode, this paper proposes a two-stage mode of HTA development in China, namely, the mode driven by the management of new heath technology admission and another one driven by new health technology pricing and medical insurance payment. In addition, the paper also proposes the challenges that HTA faces in China under the current mode, including the development system, process standard, data mechanism, and policy application. Besides, recommendations are provided for the further development of HTA construction in China, including strengthening the development system of regional HTA centers, formulating HTA process guidance, building a database, improving evaluation quality and intensifying policy integration.

Strengthening health technology assessment systems in the global south: a comparative analysis of the HTA journeys of China, India and South Africa

BACKGROUND

Resource allocation in health is universally challenging, but especially so in resource-constrained contexts in the Global South. Pursuing a strategy of evidence-based decision-making and using tools such as Health Technology Assessment (HTA), can help address issues relating to both affordability and equity when allocating resources. Three BRICS and Global South countries, China, India and South Africa have committed to strengthening HTA capacity and developing their domestic HTA systems, with the goal of getting evidence translated into policy. Through assessing and comparing the HTA journey of each country it may be possible to identify common problems and shareable insights.

OBJECTIVES

This collaborative paper aimed to share knowledge on strengthening HTA systems to enable enhanced evidence-based decision-making in the Global South by: Identifying common barriers and enablers in three BRICS countries in the Global South; and Exploring how South-South collaboration can strengthen HTA capacity and utilisation for better healthcare decision-making.

METHODS

A descriptive and explorative comparative analysis was conducted comprising a Within-Case analysis to produce a narrative of the HTA journey in each country and an Across-Case analysis to explore both knowledge that could be shared and any potential knowledge gaps.

RESULTS

Analyses revealed that China, India and South Africa share many barriers to strengthening and developing HTA systems such as: (1) Minimal HTA expertise; (2) Weak health data infrastructure; (3) Rising healthcare costs; (4) Fragmented healthcare systems; and (5) Significant growth in non-communicable diseases. Stakeholder engagement and institutionalisation of HTA were identified as two conducive factors for strengthening HTA systems.

CONCLUSION

China, India and South Africa have all committed to establishing robust HTA systems to inform evidence-based priority setting and have experienced similar challenges. Engagement among countries of the Global South can provide a supportive platform to share knowledge that is more applicable and pragmatic.