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Spagnolo M, Laudani C, Greco A, Giacoppo D, Capodanno D. Characteristics and Impact of Randomized Trials on Drugs or Devices in Cardiovascular Medicine. Am J Cardiovasc Drugs 2024:10.1007/s40256-024-00670-4. [PMID: 39088111 DOI: 10.1007/s40256-024-00670-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/22/2024] [Indexed: 08/02/2024]
Abstract
INTRODUCTION Clinical trials, essential for medical advancement, vary significantly in methodology and regulatory pathways depending on the type of therapeutic intervention (i.e., drugs or devices). This study aimed to determine whether the drug or device intervention types influence the impact of randomized trials in cardiovascular medicine. METHODS We analyzed late-breaking randomized controlled trials presented at major cardiology conferences from 2015 to 2021. The primary endpoint was the total number of citations obtained. Secondary endpoints included the number of citations at 1 and 2 years, number of total and 1-year mentions, and several metrics of study conduct and publication. Statistical analysis included tests for comparisons of continuous or categorical variables, based on their distribution, as appropriate. To adjust the results for potential confounders, univariable and multivariable regression models were utilized. Additionally, sensitivity analyses were conducted to explore both the effect of neutral or positive study outcomes on the comparative impact of drug versus device trials and the impact of the coronavirus disease 2019 (COVID-19) pandemic on the primary endpoint. RESULTS Of 382 eligible randomized trials, 227 (59.4%) were trials of drugs and 155 (40.6%) were trials of devices. Drug trials had a higher median number of total citations compared to device studies (93 [interquartile range {IQR} 48-137] vs. 82 [IQR 39-192]; p = 0.025). This difference was consistent at 1 and 2 years and was also observed in the number of total mentions and mentions at 1 year. All the metrics of study conduct and publication were similar, except for drug studies being more often stopped prematurely (8.8 vs. 1.9%; p = 0.006). After adjusting for multiple potential confounders, the difference in citations and mentions was no longer statistically significant. However, drug trials remained more likely to be stopped prematurely (adjusted odds ratio = 1.15; 95% confidence interval 1.03-1.28; p = 0.009). Positive study outcomes significantly influenced the number of citations and the likelihood of a trial being stopped prematurely. CONCLUSIONS Drug trials are often stopped early and receive more citations and mentions than device trials. However, these differences are mainly due to factors other than the treatment itself. Studies published simultaneously tend to get more attention, and drug trials with positive results are cited more often than those with neutral results.
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Affiliation(s)
- Marco Spagnolo
- Division of Cardiology, C.A.S.T., Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Via S. Sofia, 78, 95100, Catania, Italy
| | - Claudio Laudani
- Division of Cardiology, C.A.S.T., Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Via S. Sofia, 78, 95100, Catania, Italy
| | - Antonio Greco
- Division of Cardiology, C.A.S.T., Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Via S. Sofia, 78, 95100, Catania, Italy
| | - Daniele Giacoppo
- Division of Cardiology, C.A.S.T., Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Via S. Sofia, 78, 95100, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, C.A.S.T., Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico-San Marco", University of Catania, Via S. Sofia, 78, 95100, Catania, Italy.
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Siontis GCM, Frenk A, Windecker S. Randomized controlled trials remain underutilized. Eur Heart J 2024; 45:553-554. [PMID: 38087906 DOI: 10.1093/eurheartj/ehad806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2024] Open
Affiliation(s)
- George C M Siontis
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - André Frenk
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
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Lübbeke A, Barea C, Zingg M, Lauper N, Hannouche D, Garavaglia G. Radiographic signs and hip pain 5 years after THA with a cemented stem predict future revision for aseptic loosening: a prospective cohort study. Acta Orthop 2024; 95:32-38. [PMID: 38284749 PMCID: PMC10823869 DOI: 10.2340/17453674.2023.26190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 11/02/2023] [Indexed: 01/30/2024] Open
Abstract
BACKGROUND AND PURPOSE We aimed to evaluate the long-term predictive value of radiographic abnormality and/or hip pain assessed 5 years following primary total hip arthroplasty (THA) and the occurrence of revision for aseptic loosening between 5 and 25 years postoperatively. PATIENTS AND METHODS We included all primary THAs performed between 1996 and 2011 (same uncemented cup, polyethylene-ceramic bearing, 28 mm head, cemented stem) and prospectively enrolled in the institutional registry, for whom baseline and follow-up radiographs were available. At 5 years radiographically we assessed femoral osteolysis and/or stem migration. Pain was evaluated with the Harris Hip pain subscore. Kaplan-Meier survival and Cox regression analyses were performed. RESULTS 1,317 primary THAs were included. 25 THAs (2%) were revised for aseptic stem loosening. Any abnormal radiographic sign at 5 years was present in 191 THAs (14%). Occasional hip pain was reported by 20% and slight to severe pain by 12% of patients at 5 years. In patients < 60 years, 10 of the 12 later revised for aseptic stem loosening had abnormal radiographs at 5 years vs. 5 of the 13 later revised in those ≥ 60 years. Hazard ratios (HR) were 34 (95% confidence interval [CI] 7-155) in younger vs. 4 (CI 1-11) in the older group. HR for association of hip pain at 5 years with future revision was 3 (CI 1-5). CONCLUSION The presence of abnormal radiographic signs 5 years after THA was strongly associated with later revision for aseptic stem loosening, especially in patients < 60 years. The association between pain at 5 years and future revision was much weaker.
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Affiliation(s)
- Anne Lübbeke
- Division of Orthopaedics and Trauma Surgery, Geneva University Hospitals, University of Geneva, Faculty of Medicine, Geneva, Switzerland; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.
| | - Christophe Barea
- Division of Orthopaedics and Trauma Surgery, Geneva University Hospitals, University of Geneva, Faculty of Medicine, Geneva, Switzerland
| | - Matthieu Zingg
- Division of Orthopaedics and Trauma Surgery, Geneva University Hospitals, University of Geneva, Faculty of Medicine, Geneva, Switzerland
| | - Nicolas Lauper
- Division of Orthopaedics and Trauma Surgery, Geneva University Hospitals, University of Geneva, Faculty of Medicine, Geneva, Switzerland
| | - Didier Hannouche
- Division of Orthopaedics and Trauma Surgery, Geneva University Hospitals, University of Geneva, Faculty of Medicine, Geneva, Switzerland
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Siontis GCM, Coles B, Häner JD, McGovern L, Bartkowiak J, Coughlan JJ, Spirito A, Galea R, Haeberlin A, Praz F, Tomii D, Melvin T, Frenk A, Byrne RA, Fraser AG, Windecker S. Quality and transparency of evidence for implantable cardiovascular medical devices assessed by the CORE-MD consortium. Eur Heart J 2024; 45:161-177. [PMID: 37638967 DOI: 10.1093/eurheartj/ehad567] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/15/2023] [Accepted: 08/21/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND AND AIMS The European Union Medical Device Regulation 2017/745 challenges key stakeholders to follow transparent and rigorous approaches to the clinical evaluation of medical devices. The purpose of this study is a systematic evaluation of published clinical evidence underlying selected high-risk cardiovascular medical devices before and after market access in the European Union (CE-marking) between 2000 and 2021. METHODS Pre-specified strategies were applied to identify published studies of prospective design evaluating 71 high-risk cardiovascular devices in seven different classes (bioresorbable coronary scaffolds, left atrial appendage occlusion devices, transcatheter aortic valve implantation systems, transcatheter mitral valve repair/replacement systems, surgical aortic and mitral heart valves, leadless pacemakers, subcutaneous implantable cardioverter-defibrillator). The search time span covered 20 years (2000-21). Details of study design, patient population, intervention(s), and primary outcome(s) were summarized and assessed with respect to timing of the corresponding CE-mark approval. RESULTS At least one prospective clinical trial was identified for 70% (50/71) of the pre-specified devices. Overall, 473 reports of 308 prospectively designed studies (enrolling 97 886 individuals) were deemed eligible, including 81% (251/308) prospective non-randomized clinical trials (66 186 individuals) and 19% (57/308) randomized clinical trials (31 700 individuals). Pre-registration of the study protocol was available in 49% (150/308) studies, and 16% (48/308) had a peer-reviewed publicly available protocol. Device-related adverse events were evaluated in 82% (253/308) of studies. An outcome adjudication process was reported in 39% (120/308) of the studies. Sample size was larger for randomized in comparison to non-randomized trials (median of 304 vs. 100 individuals, P < .001). No randomized clinical trial published before CE-mark approval for any of the devices was identified. Non-randomized clinical trials were predominantly published after the corresponding CE-mark approval of the device under evaluation (89%, 224/251). Sample sizes were smaller for studies published before (median of 31 individuals) than after (median of 135 individuals) CE-mark approval (P < .001). Clinical trials with larger sample sizes (>50 individuals) and those with longer recruitment periods were more likely to be published after CE-mark approval, and were more frequent during the period 2016-21. CONCLUSIONS The quantity and quality of publicly available data from prospective clinical investigations across selected categories of cardiovascular devices, before and after CE approval during the period 2000-21, were deemed insufficient. The majority of studies was non-randomized, with increased risk of bias, and performed in small populations without provision of power calculations, and none of the reviewed devices had randomized trial results published prior to CE-mark certification.
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Affiliation(s)
- George C M Siontis
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Bernadette Coles
- Velindre University NHS Trust Library and Knowledge Service, Cardiff, UK
| | - Jonas D Häner
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Laurna McGovern
- Department of Cardiology and Cardiovascular Research Institute (CVRI) Dublin, Mater Private Network, Dublin, Ireland
| | - Joanna Bartkowiak
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - J J Coughlan
- Department of Cardiology and Cardiovascular Research Institute (CVRI) Dublin, Mater Private Network, Dublin, Ireland
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Alessandro Spirito
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Roberto Galea
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Andreas Haeberlin
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Fabien Praz
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Daijiro Tomii
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Tom Melvin
- School of Medicine, Trinity College Dublin, Ireland
| | - André Frenk
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Robert A Byrne
- Department of Cardiology and Cardiovascular Research Institute (CVRI) Dublin, Mater Private Network, Dublin, Ireland
| | - Alan G Fraser
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
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Harkin KR, Sorensen J, Thomas S. Lifecycle evaluation of medical devices: supporting or jeopardizing patient outcomes? A comparative analysis of evaluation models. Int J Technol Assess Health Care 2024; 40:e2. [PMID: 38179661 PMCID: PMC10859834 DOI: 10.1017/s026646232300274x] [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: 11/28/2022] [Revised: 10/16/2023] [Accepted: 11/14/2023] [Indexed: 01/06/2024]
Abstract
OBJECTIVES Lack of evidence regarding safety and effectiveness at market entry is driving the need to consider adopting a lifecycle approach to evaluating medical devices, but it is unclear what lifecycle evaluation means. This research sought to explore the tacit meanings of "lifecycle" and "lifecycle evaluation" as embodied within evaluation models/frameworks used for medical devices. METHODS Drawing on qualitative evidence synthesis methods and using an inductive approach, novel methods were developed to identify, appraise, analyze, and synthesize lifecycle evaluation models used for medical devices. Data was extracted (including purpose; audience; characterization; outputs; timing; and type of model) from key texts for coding, categorization, and comparison, exploring embodied meaning across four broad perspectives. RESULTS Fifty-two models were included in the synthesis. They demonstrated significant heterogeneity of meaning, form, scope, timing, and purpose. The "lifecycle" may represent a single stage, a series of stages, a cycle of innovation, or a system. "Lifecycle evaluation" focuses on the overarching goal of the stakeholder group, and may use a single or repeated evaluation to inform decision-making regarding the adoption of health technologies (Healthcare), resource allocation (Policymaking), investment in new product development or marketing (Trade and Industry), or market regulation (Regulation). The adoption of a lifecycle approach by regulators has resulted in the deferral of evidence generation to the post-market phase. CONCLUSIONS Using a "lifecycle evaluation" approach to inform reimbursement decision-making must not be allowed to further jeopardize evidence generation and patient safety by accepting inadequate evidence of safety and effectiveness for reimbursement decisions.
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Affiliation(s)
- Kathleen R. Harkin
- Centre for Health Policy and Management, Trinity College Dublin (TCD), Dublin, Ireland
| | - Jan Sorensen
- RCSI Healthcare Outcomes Research Centre, School of Population Health, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - Steve Thomas
- Centre for Health Policy and Management, Trinity College Dublin (TCD), Dublin, Ireland
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Siu DHW, Lin FPY, Cho D, Lord SJ, Heller GZ, Simes RJ, Lee CK. Framework for the Use of External Controls to Evaluate Treatment Outcomes in Precision Oncology Trials. JCO Precis Oncol 2024; 8:e2300317. [PMID: 38190581 DOI: 10.1200/po.23.00317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 09/03/2023] [Accepted: 10/13/2023] [Indexed: 01/10/2024] Open
Abstract
Advances in genomics have enabled anticancer therapies to be tailored to target specific genomic alterations. Single-arm trials (SATs), including those incorporated within umbrella, basket, and platform trials, are widely adopted when it is not feasible to conduct randomized controlled trials in rare biomarker-defined subpopulations. External controls (ECs), defined as control arm data derived outside the clinical trial, have gained renewed interest as a strategy to supplement evidence generated from SATs to allow comparative analysis. There are increasing examples demonstrating the application of EC in precision oncology trials. The prospective application of EC in conducting comparative studies is associated with distinct methodological challenges, the specific considerations for EC use in biomarker-defined subpopulations have not been adequately discussed, and a formal framework is yet to be established. In this review, we present a framework for conducting a prospective comparative analysis using EC. Key steps are (1) defining the purpose of using EC to address the study question, (2) determining if the external data are fit for purpose, (3) developing a transparent study protocol and a statistical analysis plan, and (iv) interpreting results and drawing conclusions on the basis of a prespecified hypothesis. We specify the considerations required for the biomarker-defined subpopulations, which include (1) specifying the comparator and biomarker status of the comparator group, (2) defining lines of treatment, (3) assessment of the biomarker testing panels used, and (4) assessment of cohort stratification in tumor-agnostic studies. We further discuss novel clinical trial designs and statistical techniques leveraging EC to propose future directions to advance evidence generation and facilitate drug development in precision oncology.
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Affiliation(s)
- Derrick H W Siu
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, NSW, Australia
- Department of Medical Oncology, Illawarra Cancer Care Centre, Wollongong, NSW, Australia
| | - Frank P Y Lin
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, NSW, Australia
- Kinghorn Centre for Clinical Genomics, Garvan Institute of Medical Research, Darlinghurst, NSW, Australia
- School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Doah Cho
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, NSW, Australia
| | - Sarah J Lord
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, NSW, Australia
- School of Medicine, University of Notre Dame, Sydney, NSW, Australia
| | - Gillian Z Heller
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, NSW, Australia
- Mathematics and Statistics, Macquarie University, Macquarie Park, NSW, Australia
| | - R John Simes
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, NSW, Australia
| | - Chee Khoon Lee
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, NSW, Australia
- Cancer Care Centre, St George Hospital, Kogarah, NSW, Australia
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Marcus HJ, Ramirez PT, Khan DZ, Layard Horsfall H, Hanrahan JG, Williams SC, Beard DJ, Bhat R, Catchpole K, Cook A, Hutchison K, Martin J, Melvin T, Stoyanov D, Rovers M, Raison N, Dasgupta P, Noonan D, Stocken D, Sturt G, Vanhoestenberghe A, Vasey B, McCulloch P. The IDEAL framework for surgical robotics: development, comparative evaluation and long-term monitoring. Nat Med 2024; 30:61-75. [PMID: 38242979 DOI: 10.1038/s41591-023-02732-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 11/20/2023] [Indexed: 01/21/2024]
Abstract
The next generation of surgical robotics is poised to disrupt healthcare systems worldwide, requiring new frameworks for evaluation. However, evaluation during a surgical robot's development is challenging due to their complex evolving nature, potential for wider system disruption and integration with complementary technologies like artificial intelligence. Comparative clinical studies require attention to intervention context, learning curves and standardized outcomes. Long-term monitoring needs to transition toward collaborative, transparent and inclusive consortiums for real-world data collection. Here, the Idea, Development, Exploration, Assessment and Long-term monitoring (IDEAL) Robotics Colloquium proposes recommendations for evaluation during development, comparative study and clinical monitoring of surgical robots-providing practical recommendations for developers, clinicians, patients and healthcare systems. Multiple perspectives are considered, including economics, surgical training, human factors, ethics, patient perspectives and sustainability. Further work is needed on standardized metrics, health economic assessment models and global applicability of recommendations.
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Affiliation(s)
- Hani J Marcus
- Department of Neurosurgery, National Hospital of Neurology and Neurosurgery, London, UK.
- Wellcome/Engineering and Physical Sciences Research Council (EPSRC) Centre for Interventional and Surgical Sciences (WEISS), London, UK.
| | - Pedro T Ramirez
- Department of Obstetrics and Gynaecology, Houston Methodist Hospital Neal Cancer Center, Houston, TX, USA
| | - Danyal Z Khan
- Department of Neurosurgery, National Hospital of Neurology and Neurosurgery, London, UK
- Wellcome/Engineering and Physical Sciences Research Council (EPSRC) Centre for Interventional and Surgical Sciences (WEISS), London, UK
| | - Hugo Layard Horsfall
- Department of Neurosurgery, National Hospital of Neurology and Neurosurgery, London, UK
- Wellcome/Engineering and Physical Sciences Research Council (EPSRC) Centre for Interventional and Surgical Sciences (WEISS), London, UK
| | - John G Hanrahan
- Department of Neurosurgery, National Hospital of Neurology and Neurosurgery, London, UK
- Wellcome/Engineering and Physical Sciences Research Council (EPSRC) Centre for Interventional and Surgical Sciences (WEISS), London, UK
| | - Simon C Williams
- Department of Neurosurgery, National Hospital of Neurology and Neurosurgery, London, UK
- Wellcome/Engineering and Physical Sciences Research Council (EPSRC) Centre for Interventional and Surgical Sciences (WEISS), London, UK
| | - David J Beard
- RCS Surgical Interventional Trials Unit (SITU) & Robotic and Digital Surgery Initiative (RADAR), Nuffield Dept Orthopaedics, Rheumatology and Musculo-skeletal Sciences, University of Oxford, Oxford, UK
| | - Rani Bhat
- Department of Gynaecological Oncology, Apollo Hospital, Bengaluru, India
| | - Ken Catchpole
- Department of Anaesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Andrew Cook
- NIHR Coordinating Centre and Clinical Trials Unit, University of Southampton, Southampton, UK
| | | | - Janet Martin
- Department of Anesthesia & Perioperative Medicine, University of Western Ontario, Ontario, Canada
| | - Tom Melvin
- Department of Medical Gerontology, School of Medicine, Trinity College Dublin, Dublin, Republic of Ireland
| | - Danail Stoyanov
- Wellcome/Engineering and Physical Sciences Research Council (EPSRC) Centre for Interventional and Surgical Sciences (WEISS), London, UK
| | - Maroeska Rovers
- Department of Medical Imaging, Radboudumc, Nijmegen, the Netherlands
| | - Nicholas Raison
- Department of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Prokar Dasgupta
- King's Health Partners Academic Surgery, King's College London, London, UK
| | | | - Deborah Stocken
- RCSEng Surgical Trials Centre, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | | | - Anne Vanhoestenberghe
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | - Baptiste Vasey
- Department of Surgery, Geneva University Hospital, Geneva, Switzerland
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Peter McCulloch
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK.
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Ivama-Brummell AM, Marciniuk FL, Wagner AK, Osorio-de-Castro CG, Vogler S, Mossialos E, Tavares-de-Andrade CL, Naci H. Marketing authorisation and pricing of FDA-approved cancer drugs in Brazil: a retrospective analysis. LANCET REGIONAL HEALTH. AMERICAS 2023; 22:100506. [PMID: 37235087 PMCID: PMC10206192 DOI: 10.1016/j.lana.2023.100506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 04/21/2023] [Accepted: 04/25/2023] [Indexed: 05/28/2023]
Abstract
Background Most cancer drugs enter the US market first. US Food and Drug Administration (FDA) approvals of new cancer drugs may influence regulatory decisions in other settings. The study examined whether characteristics of available evidence at FDA approval influenced time-to-marketing authorisation (MA) in Brazil, and price differences between the two countries. Methods All new FDA-approved cancer drugs from 2010 to 2019 were matched to drugs with MA and prices approved in Brazil by December 2020. Characteristics of main studies, availability of randomised controlled trials (RCTs), overall survival (OS) benefit, added therapeutic benefit, and prices were compared. Findings Fifty-six FDA-approved cancer drugs with matching indications received a MA at the Brazilian Health Regulatory Agency (Anvisa) after a median of 522 days following US approval (IQR: 351-932). Earlier authorisation in Brazil was associated with availability of RCT (median: 506 vs 760 days, p = 0.031) and evidence of OS benefit (390 vs 543 days, p = 0.019) at FDA approval. At Brazilian marketing authorisation, a greater proportion of cancer drugs had main RCTs (75% vs 60.7%) and OS benefit (42.9% vs 21.4%) than that in the US. Twenty-eight (50%) drugs did not demonstrate added therapeutic benefit over drugs for the same indication in Brazil. Median approved prices of new cancer drugs were 12.9% lower in Brazil compared to the US (adjusted by Purchasing Power Parity). However, for drugs with added therapeutic benefit median prices were 5.9% higher in Brazil compared to the US, while 17.9% lower for those without added benefit. Interpretation High-quality clinical evidence accelerated the availability of cancer medicines in Brazil. The combination of marketing and pricing authorisation in Brazil may favour the approval of cancer drugs with better supporting evidence, and more meaningful clinical benefit albeit with variable degree of success in achieving lower prices compared to the US. Funding None.
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Affiliation(s)
- Adriana M. Ivama-Brummell
- Department of Health Policy, London School of Economics and Political Science, Cowdray House, Houghton Street, London, WC2A 2AE, United Kingdom
- Office of Assessment of Safety and Efficacy, General Office of Medicines, Brazilian Health Regulatory Agency, SIA, Trecho 05, Área Especial 57, Brasília-DF CEP 71.205-050, Brazil
| | - Fernanda L. Marciniuk
- Executive Secretariat of the Drug Market Regulation Chamber, Brazilian Health Regulatory Agency, SIA, Trecho 05, Área Especial 57, Brasília-DF CEP 71.205-050, Brazil
| | - Anita K. Wagner
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, 401 Park Drive, Suite 401 East, Boston, MA, 02215, USA
| | - Claudia G.S. Osorio-de-Castro
- Department of Medicines Policy and Pharmaceutical Services, Sergio Arouca National School of Public Health, Oswaldo Cruz Foundation, Rua Leopoldo Bulhões, 1480, sala 632, Manguinhos, Rio de Janeiro, RJ, 21041-210, Brazil
| | - Sabine Vogler
- WHO Collaborating Centre for Pharmaceutical Pricing and Reimbursement Policies, Pharmacoeconomics Department, Austrian National Public Health Institute, Stubenring 6, Vienna, 1010, Austria
- Department of Health Care Management, Technical University of Berlin, Berlin, 10623, Germany
| | - Elias Mossialos
- Department of Health Policy, London School of Economics and Political Science, Cowdray House, Houghton Street, London, WC2A 2AE, United Kingdom
| | - Carla L. Tavares-de-Andrade
- Department of Health Administration and Planning, Sergio Arouca National School of Public Health, Oswaldo Cruz Foundation, Rua Leopoldo Bulhões, 1480, sala 727A, Manguinhos, Rio de Janeiro, RJ, 21041-210, Brazil
| | - Huseyin Naci
- Department of Health Policy, London School of Economics and Political Science, Cowdray House, Houghton Street, London, WC2A 2AE, United Kingdom
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Neyt M, Devos C, Thiry N, Silversmit G, De Gendt C, Van Damme N, Castanares-Zapatero D, Hulstaert F, Verleye L. Belgian observational survival data (incidence years 2004-2017) and expenditure for innovative oncology drugs in twelve cancer indications. Eur J Cancer 2023; 182:23-37. [PMID: 36731327 DOI: 10.1016/j.ejca.2022.12.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/19/2022] [Accepted: 12/28/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND The Food and Drug Administration and European Medicines Agency typically approve market access for cancer drugs based on surrogate end-points, which do not always translate into substantiated improvements in outcomes that matter the most to patients, i.e. survival and quality of life. These drugs often, also, have a high price tag. We assessed whether there was an increase in cancer drug expenditure for a broad selection of indications, and whether this correlates with increased overall survival. METHODS This cohort study used Belgian Cancer Registry data from 125,692 patients (12 cancer indications, incidence period 2004-2017), which was linked to reimbursement and survival data. This reliably represents the Belgian situation. One-to-five year observed survival probability, median survival time, oncology drug expenditure and mean oncology drug cost per patient were reviewed. FINDINGS In almost all indications, total expenditure and average treatment cost for oncology drugs increased over the years (2004-2017). In contrast, mixed findings are observed for the evolution in overall survival probability and median survival time. While an absolute improvement in the 3-year survival probability of about 10% is noticed in non-small-cell lung cancer and chronic myeloid leukaemia, improvements in about half of the other indications are limited or even absent. INTERPRETATION The Belgian observational data indicate that assuming 'innovative' oncology drugs always add value in terms of improved survival is often unjustified. The literature also highlights the problem of using surrogate end-points, and the lack of comparative evidence showing an added value of oncology drugs for both survival and quality of life at market approval or during the post-marketing phase. Comparative studies should be conducted in the pre-marketing phase that are suitable for registration purposes, aid reimbursement decisions and support physicians and patients when making treatment decisions.
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Affiliation(s)
- Mattias Neyt
- Belgian Health Care Knowledge Centre (KCE), Belgium.
| | - Carl Devos
- Belgian Health Care Knowledge Centre (KCE), Belgium
| | - Nancy Thiry
- Belgian Health Care Knowledge Centre (KCE), Belgium
| | | | | | | | | | | | - Leen Verleye
- Belgian Health Care Knowledge Centre (KCE), Belgium
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10
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Tang M, Pearson SA, Simes RJ, Chua BH. Harnessing Real-World Evidence to Advance Cancer Research. Curr Oncol 2023; 30:1844-1859. [PMID: 36826104 PMCID: PMC9955401 DOI: 10.3390/curroncol30020143] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/16/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023] Open
Abstract
Randomized controlled trials (RCTs) form a cornerstone of oncology research by generating evidence about the efficacy of therapies in selected patient populations. However, their implementation is often resource- and cost-intensive, and their generalisability to patients treated in routine practice may be limited. Real-world evidence leverages data collected about patients receiving clinical care in routine practice outside of clinical trial settings and provides opportunities to identify and address gaps in clinical trial evidence. This review outlines the strengths and limitations of real-world and RCT evidence and proposes a framework for the complementary use of the two bodies of evidence to advance cancer research. There are challenges to the implementation of real-world research in oncology, including heterogeneity of data sources, timely access to high-quality data, and concerns about the quality of methods leveraging real-world data, particularly causal inference. Improved understanding of the strengths and limitations of real-world data and ongoing efforts to optimise the conduct of real-world evidence research will improve its reliability, understanding and acceptance, and enable the full potential of real-world evidence to be realised in oncology practice.
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Affiliation(s)
- Monica Tang
- Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, Randwick 2031, Australia
- Correspondence:
| | | | - Robert J. Simes
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown 2050, Australia
| | - Boon H. Chua
- Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, Randwick 2031, Australia
- Faculty of Medicine and Health, UNSW Sydney, Sydney 2052, Australia
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11
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Cherla A, Mossialos E, Salcher-Konrad M, Kesselheim AS, Naci H. Post-Marketing Requirements for Cancer Drugs Approved by the European Medicines Agency, 2004-2014. Clin Pharmacol Ther 2022; 112:846-852. [PMID: 35662000 PMCID: PMC9540185 DOI: 10.1002/cpt.2679] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 05/25/2022] [Indexed: 12/01/2022]
Abstract
To address unresolved questions about drug safety and efficacy at the time of approval, the European Medicines Agency (EMA) may require that manufacturers conduct additional studies during the postmarketing period. As a growing proportion of new cancer drugs are approved on the basis of limited evidence of clinical benefit, timely completion of postmarketing requirements is important. We used publicly available regulatory documents to evaluate key characteristics of pivotal studies supporting EMA‐approved cancer drugs from 2004–2014 and assessed completion rates of postmarketing data collection requirements after a minimum of 5 years. From 2004–2014, 79% (45/57) of EMA‐approved cancer drugs had to fulfill postmarketing requirements. Pivotal trials supporting the approval of cancer drugs with postmarketing requirements were less likely to have randomized designs (41/61, 67% vs. 11/11, 100%), include an active comparator (20/61, 33% vs. 10/11, 91%), or measure overall survival as the primary study end point (18/61, 30% vs. 6/11, 55%) compared with pivotal trials for drugs without postmarketing requirements. Among 200 postmarketing requirements, almost half were designed to assess drug safety. After a minimum of 5 years, 60% (121/200) of requirements were completed, 10% (19/200) were ongoing, and 30% (60/200) were delayed. About half (40/75, 53%) of postmarketing requirements for new clinical studies were completed on time. Delays in the completion of postmarketing requirements often did not impact the likelihood of drugs receiving permanent marketing authorization (87%, 39/45) after 5 years. Our findings highlight the need for EMA to better enforce its authority to require timely completion of postmarketing requirements and studies.
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Affiliation(s)
- Avi Cherla
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Elias Mossialos
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Maximilian Salcher-Konrad
- Department of Health Policy, London School of Economics and Political Science, London, UK.,Austrian National Public Health Institute (Gesundheit Österreich GmbH/GÖG), Vienna, Austria
| | - Aaron S Kesselheim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Program on Regulation, Therapeutics, and Law (PORTAL), Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Huseyin Naci
- Department of Health Policy, London School of Economics and Political Science, London, UK
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12
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Naci H, Kyriopoulos I, Feldman WB, Hwang TJ, Kesselheim AS, Chandra A. Coverage of New Drugs in Medicare Part D. Milbank Q 2022; 100:562-588. [PMID: 35502786 DOI: 10.1111/1468-0009.12565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Policy Points Only a small minority of new drugs in "nonprotected" classes are widely covered by Part D plans nationwide in the year after US Food and Drug Administration (FDA) approval. Part D plans frequently apply utilization management restrictions such as prior authorizations to newly approved drugs in both protected and nonprotected classes. Drug price influences both formulary inclusion (in nonprotected classes) and coverage restrictions (in both protected and nonprotected classes), while other drug characteristics such as therapeutic benefits are not consistently associated with formulary design. Plans do not seem to favor the minority of drugs that are determined to offer added therapeutic benefit over existing alternatives. CONTEXT Medicare Part D is an outpatient prescription drug benefit for older Americans covering more than 46 million beneficiaries. Except for mandatory coverage for essentially all drugs in six protected classes, plans have substantial flexibility in how they design their formularies: which drugs are covered, which drugs are subject to restrictions, and what factors determine formulary placement. Our objective in this paper was to document the extent to which Part D plans limit coverage of newly approved drugs. METHODS We examined the formulary design of 4,582 Part D plans from 2014 through 2018 and measured (1) the decision to cover newly approved drugs in nonprotected classes, (2) use of utilization management tools in protected and nonprotected classes, and (3) the association between plan design and drug-level characteristics such as 30-day cost, therapeutic benefit, and the US Food and Drug Administration (FDA) expedited regulatory pathway. FINDINGS The FDA approved 109 new drugs predominantly used in outpatient settings between 2013 and 2017. Of these, 75 fell outside of the six protected drug classes. One-fifth of drugs in nonprotected classes (15 out of 75) were covered by more than half of plans during the first year after approval. Coverage was often conditional on utilization management strategies in both protected and nonprotected classes: only seven drugs (6%) were covered without prior authorization requirements in more than half of plans. Higher 30-day drug costs were associated with more widespread coverage in nonprotected classes: drugs that cost less than $150 for a 30-day course were covered by fewer than 20% of plans while those that cost more than $30,000 per 30 days were covered by more than 50% of plans. Plans were also more likely to implement utilization management tools on high-cost drugs in both protected and nonprotected classes. A higher proportion of plans implemented utilization management strategies on covered drugs with first-in-class status than drugs that were not first in class. Other drug characteristics, including availability of added therapeutic benefit and inclusion in FDA expedited regulatory approval, were not consistently associated with plan coverage or formulary restrictions. CONCLUSIONS Newly approved drugs are frequently subject to formulary exclusions and restrictions in Medicare Part D. Ensuring that formulary design in Part D is linked closely to the therapeutic value of newly approved drugs would improve patients' welfare.
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Affiliation(s)
- Huseyin Naci
- London School of Economics and Political Science
| | | | - William B Feldman
- Program on Regulation, Therapeutics, and Law (PORTAL), Brigham and Women's Hospital and Harvard Medical School
| | - Thomas J Hwang
- Program on Regulation, Therapeutics, and Law (PORTAL), Brigham and Women's Hospital and Harvard Medical School
| | - Aaron S Kesselheim
- Program on Regulation, Therapeutics, and Law (PORTAL), Brigham and Women's Hospital and Harvard Medical School
| | - Amitabh Chandra
- John F. Kennedy School of Government and Harvard Business School
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13
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Affiliation(s)
- Paul S Myles
- From the Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
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14
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Flynn A, Rogers A, McConnachie L, Barr R, Flynn RWV, Mackenzie IS, MacDonald TM, Doney ASF. Evaluating Diuretics in Normal Care (EVIDENCE): a feasibility report of a pilot cluster randomised trial of prescribing policy in primary care to compare the effectiveness of thiazide-type diuretics in hypertension. Pilot Feasibility Stud 2022; 8:62. [PMID: 35277204 PMCID: PMC8914438 DOI: 10.1186/s40814-022-01016-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 02/25/2022] [Indexed: 11/10/2022] Open
Abstract
Background Obtaining evidence on comparative effectiveness and safety of widely prescribed drugs in a timely and cost-effective way is a major challenge for healthcare systems. Here, we describe the feasibility of the Evaluating Diuretics in Normal Care (EVIDENCE) study that compares a thiazide and thiazide-like diuretics for hypertension as an exemplar of a more general framework for efficient generation of such evidence. In 2011, the UK NICE hypertension guideline included a recommendation that thiazide-like diuretics (such as indapamide) be used in preference to thiazide diuretics (such as bendroflumethiazide) for hypertension. There is sparse evidence backing this recommendation, and bendroflumethiazide remains widely used in the UK. Methods Patients prescribed indapamide or bendroflumethiazide regularly for hypertension were identified in participating general practices. Allocation of a prescribing policy favouring one of these drugs was then randomly applied to the practice and, where required to comply with the policy, repeat prescriptions switched by pharmacy staff. Patients were informed of the potential switch by letter and given the opportunity to opt out. Practice adherence to the randomised policy was assessed by measuring the amount of policy drug prescribed as a proportion of total combined indapamide and bendroflumethiazide. Routinely collected hospitalisation and death data in the NHS will be used to compare cardiovascular event rates between the two policies. Results This pilot recruited 30 primary care practices in five Scottish National Health Service (NHS) Boards. Fifteen practices were randomised to indapamide (2682 patients) and 15 to bendroflumethiazide (3437 patients), a study population of 6119 patients. Prior to randomisation, bendroflumethiazide was prescribed to 78% of patients prescribed either of these drugs. Only 1.6% of patients opted out of the proposed medication switch. Conclusion The pilot and subsequent recruitment confirms the methodology is scalable within NHS Scotland for a fully powered larger study; currently, 102 GP practices (> 12,700 patients) are participating in this study. It has the potential to efficiently produce externally valid comparative effectiveness data with minimal disruption to practice staff or patients. Streamlining this pragmatic trial approach has demonstrated the feasibility of a random prescribing policy design framework that can be adapted to other therapeutic areas. Trial registration ISRCTN Registry, ISRCTN46635087. Registered on 11 August 2017
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Affiliation(s)
- Angela Flynn
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, DD1 9SY, UK.
| | - Amy Rogers
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, DD1 9SY, UK
| | - Lewis McConnachie
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, DD1 9SY, UK
| | - Rebecca Barr
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, DD1 9SY, UK
| | - Robert W V Flynn
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, DD1 9SY, UK
| | - Isla S Mackenzie
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, DD1 9SY, UK
| | - Thomas M MacDonald
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, DD1 9SY, UK
| | - Alexander S F Doney
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, DD1 9SY, UK
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15
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Madrid RE, Ashur Ramallo F, Barraza DE, Chaile RE. Smartphone-Based Biosensor Devices for Healthcare: Technologies, Trends, and Adoption by End-Users. Bioengineering (Basel) 2022; 9:bioengineering9030101. [PMID: 35324790 PMCID: PMC8945789 DOI: 10.3390/bioengineering9030101] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 02/15/2022] [Accepted: 02/24/2022] [Indexed: 12/15/2022] Open
Abstract
Smart biosensors are becoming an important support for modern healthcare, even more so in the current context. Numerous smartphone-based biosensor developments were published in recent years, some highly effective and sensitive. However, when patents and patent applications related to smart biosensors for healthcare applications are analyzed, it is surprising to note that, after significant growth in the first half of the decade, the number of applications filed has decreased considerably in recent years. There can be many causes of this effect. In this review, we present the state of the art of different types of smartphone-based biosensors, considering their stages of development. In the second part, a critical analysis of the possible reasons why many technologies do not reach the market is presented. Both technical and end-user adoption limitations were addressed. It was observed that smart biosensors on the commercial stage are still scarce despite the great evolution that these technologies have experienced, which shows the need to strengthen the stages of transfer, application, and adoption of technologies by end-users.
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16
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Taipale H, Schneider-Thoma J, Pinzón-Espinosa J, Radua J, Efthimiou O, Vinkers CH, Mittendorfer-Rutz E, Cardoner N, Pintor L, Tanskanen A, Tomlinson A, Fusar-Poli P, Cipriani A, Vieta E, Leucht S, Tiihonen J, Luykx JJ. Representation and Outcomes of Individuals With Schizophrenia Seen in Everyday Practice Who Are Ineligible for Randomized Clinical Trials. JAMA Psychiatry 2022; 79:210-218. [PMID: 35080618 PMCID: PMC8792792 DOI: 10.1001/jamapsychiatry.2021.3990] [Citation(s) in RCA: 51] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Most evidence about efficacy and safety of antipsychotics in schizophrenia spectrum disorders relies on randomized clinical trials (RCTs). However, owing to their strict eligibility criteria, RCTs represent only a part of the real-world population (ie, unselected patients seen in everyday clinical practice), which may result in an efficacy-effectiveness gap. OBJECTIVE To quantify the proportion of real-world individuals with schizophrenia spectrum disorders who would be ineligible for participation in RCTs, and to explore whether clinical outcomes differ between eligible and ineligible individuals. DESIGN, SETTING, AND PARTICIPANTS This study applied eligibility criteria typically used in RCTs for relapse prevention in schizophrenia spectrum disorders to real-world populations. Individuals with diagnoses of schizophrenia spectrum disorders recorded in national patient registries in Finland and Sweden were identified. Individuals who had used antipsychotics continuously for 12 weeks in outpatient care were selected. Individuals were followed up for up to 1 year while they were receiving maintenance treatment with any second-generation antipsychotic (excluding clozapine). Follow-up was censored at treatment discontinuation, initiation of add-on antipsychotics, death, and end of database linkage. MAIN OUTCOMES AND MEASURES Proportions of RCT-ineligible individuals with schizophrenia spectrum disorders owing to any and specific RCT exclusion criteria. The risk of hospitalization due to psychosis within 1-year follow-up in ineligible vs eligible persons were compared using hazard ratios (HR) and corresponding 95% CIs. RESULTS The mean (SD) age in the Finnish cohort (n = 17 801) was 47.5 (13.8) years and 8972 (50.4%) were women; the mean (SD) age in the Swedish cohort (n = 7458) was 44.8 (12.5) years and 3344 (44.8%) were women. A total of 20 060 individuals (79%) with schizophrenia spectrum disorders would be ineligible for RCTs (Finnish cohort: 14 221 of 17 801 [79.9%]; Swedish cohort: 5839 of 7458 [78.3%]). Most frequent reasons for ineligibility were serious somatic comorbidities and concomitant antidepressant/mood stabilizer use. Risks of hospitalization due to psychosis was higher among ineligible than eligible individuals (Finnish cohort: 18.4% vs 17.2%; HR, 1.14 [95% CI, 1.04-1.24]; Swedish cohort: 20.1% vs 14.8%; HR, 1.47 [95% CI, 1.28-1.92]). The largest risks of hospitalization due to psychosis were observed in individuals ineligible owing to treatment resistance, tardive dyskinesia, and history of suicide attempts. Finally, with more ineligibility criteria met, larger risks of hospitalization due to psychosis were observed in both countries. CONCLUSIONS AND RELEVANCE RCTs may represent only about a fifth of real-world individuals with schizophrenia spectrum disorders. Underrepresented (ineligible) patients with schizophrenia spectrum disorders have moderately higher risks of admission due to psychosis while receiving maintenance treatment than RCT-eligible patients. These findings set the stage for future studies targeting real-world populations currently not represented by RCTs.
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Affiliation(s)
- Heidi Taipale
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland,Divisions of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden,School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | - Johannes Schneider-Thoma
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Justo Pinzón-Espinosa
- Department of Mental Health, Parc Tauli University Hospital, Sabadell, Barcelona, Spain,Department of Medicine, University of Barcelona School of Medicine, Barcelona, Spain,Department of Clinical Psychiatry, University of Panama School of Medicine, Panama City, Panama
| | - Joaquim Radua
- Divisions of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden,Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBERSAM, Barcelona, Spain,Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King’s College London, London, United Kingdom
| | - Orestis Efthimiou
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland,Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | - Christiaan H. Vinkers
- Department of Psychiatry, Amsterdam Neuroscience, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ellenor Mittendorfer-Rutz
- Divisions of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Narcís Cardoner
- Department of Mental Health, Parc Tauli University Hospital, Sabadell, Barcelona, Spain,Institut d’Investigació I Innovació Parc Tauli (I3PT), CIBERSAM, Sabadell, Barcelona, Spain,Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Luis Pintor
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBERSAM, Barcelona, Spain,Department of Psychiatry and Psychology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Antti Tanskanen
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland,Divisions of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Anneka Tomlinson
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom,Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, United Kingdom
| | - Paolo Fusar-Poli
- Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Department of Psychosis Studies, Institute of Psychiatry, Psychology, and Neuroscience, King’s College London, London, United Kingdom,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy,OASIS Service, South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Andrea Cipriani
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom,Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, United Kingdom
| | - Eduard Vieta
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBERSAM, Barcelona, Spain,Department of Psychiatry and Psychology, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Jari Tiihonen
- Department of Forensic Psychiatry, Niuvanniemi Hospital, University of Eastern Finland, Kuopio, Finland,Divisions of Insurance Medicine, Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden,Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden
| | - Jurjen J. Luykx
- Department of Psychiatry, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands,Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, the Netherlands,Outpatient second opinion clinic, GGNet Mental Health, Warnsveld, the Netherlands
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17
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Schnog JJB, Samson MJ, Gans ROB, Duits AJ. An urgent call to raise the bar in oncology. Br J Cancer 2021; 125:1477-1485. [PMID: 34400802 PMCID: PMC8365561 DOI: 10.1038/s41416-021-01495-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 06/09/2021] [Accepted: 07/09/2021] [Indexed: 02/07/2023] Open
Abstract
Important breakthroughs in medical treatments have improved outcomes for patients suffering from several types of cancer. However, many oncological treatments approved by regulatory agencies are of low value and do not contribute significantly to cancer mortality reduction, but lead to unrealistic patient expectations and push even affluent societies to unsustainable health care costs. Several factors that contribute to approvals of low-value oncology treatments are addressed, including issues with clinical trials, bias in reporting, regulatory agency shortcomings and drug pricing. With the COVID-19 pandemic enforcing the elimination of low-value interventions in all fields of medicine, efforts should urgently be made by all involved in cancer care to select only high-value and sustainable interventions. Transformation of medical education, improvement in clinical trial design, quality, conduct and reporting, strict adherence to scientific norms by regulatory agencies and use of value-based scales can all contribute to raising the bar for oncology drug approvals and influence drug pricing and availability.
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Affiliation(s)
- John-John B. Schnog
- Department of Hematology-Medical Oncology, Curaçao Medical Center, Willemstad, Curaçao ,Curaçao Biomedical and Health Research Institute, Willemstad, Curaçao
| | - Michael J. Samson
- Department of Radiation Oncology, Curaçao Medical Center, Willemstad, Curaçao
| | - Rijk O. B. Gans
- grid.4494.d0000 0000 9558 4598Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ashley J. Duits
- Curaçao Biomedical and Health Research Institute, Willemstad, Curaçao ,grid.4494.d0000 0000 9558 4598Institute for Medical Education, University Medical Center Groningen, Groningen, The Netherlands ,Red Cross Blood Bank Foundation, Willemstad, Curaçao
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18
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Rogers A, Flynn A, Mackenzie IS, McConnachie L, Barr R, Flynn RWV, Morant S, MacDonald TM, Doney A. Evaluating Diuretics in Normal Care (EVIDENCE): protocol of a cluster randomised controlled equivalence trial of prescribing policy to compare the effectiveness of thiazide-type diuretics in hypertension. Trials 2021; 22:814. [PMID: 34789314 PMCID: PMC8596935 DOI: 10.1186/s13063-021-05782-9] [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: 01/13/2021] [Accepted: 11/01/2021] [Indexed: 01/19/2023] Open
Abstract
INTRODUCTION Healthcare systems must use treatments that are effective and safe. Regulators licensed many currently used older medications before introducing the stringent evidential requirements imposed on modern treatments. Also, there has been little encouragement to carry out within-class, head-to-head comparisons of licensed medicines. For commonly prescribed drugs, even small differences in effectiveness or safety could have significant public health implications. However, conventional clinical trials that randomise individual subjects are costly and unwieldy. Such trials are also often criticised as having low external validity. We describe an approach to rapidly generate externally valid evidence of comparative safety and effectiveness using the example of two widely used diuretics for the management of hypertension. METHODS AND ANALYSIS The EVIDENCE (Evaluating Diuretics in Normal Care) study has a prospective, cluster-randomised, open-label, blinded end-point design. By randomising prescribing policy in primary care practices, the study compares the safety and effectiveness of commonly used diuretics in treating hypertension. Participating practices are randomised 1:1 to a policy of prescribing either indapamide or bendroflumethiazide when clinically indicated. Suitable patients who are not already taking the policy diuretic are switched accordingly. All patients taking the study medications are written to explaining the rationale for changing the prescribing policy and notifying them they can opt-out of any switch. The prescribing policies' effectiveness and safety will be compared using rates of major adverse cardiovascular events (hospitalisation with myocardial infarction, heart failure or stroke or cardiovascular death), routinely collected in national healthcare administrative datasets. The study will seek to recruit 250 practices to provide a study population of approximately 50,000 individuals with a mean follow-up time of two years. A primary intention-to-treat time-to-event analysis will be used to estimate the relative effect of the two policies. ETHICS AND DISSEMINATION EVIDENCE has been approved by the East of Scotland Research Ethics Service (17/ES/0016, current approved protocol version 5, 26 August 2021). The results will be disseminated widely in peer reviewed journals, guideline committees, National Health Service (NHS) organisations and patient groups. TRIAL REGISTRATION ISRCTN 46635087 . Registered on 11 August 2017 (pre-recruitment).
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Affiliation(s)
- Amy Rogers
- MEMO Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK.
| | - Angela Flynn
- MEMO Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
| | - Isla S Mackenzie
- MEMO Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
| | - Lewis McConnachie
- MEMO Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
| | - Rebecca Barr
- MEMO Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
| | - Robert W V Flynn
- MEMO Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
| | - Steve Morant
- MEMO Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
| | - Thomas M MacDonald
- MEMO Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
| | - Alexander Doney
- MEMO Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, DD1 9SY, UK
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Dean RL, Marquardt T, Hurducas C, Spyridi S, Barnes A, Smith R, Cowen PJ, McShane R, Hawton K, Malhi GS, Geddes J, Cipriani A. Ketamine and other glutamate receptor modulators for depression in adults with bipolar disorder. Cochrane Database Syst Rev 2021; 10:CD011611. [PMID: 34623633 PMCID: PMC8499740 DOI: 10.1002/14651858.cd011611.pub3] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Glutamergic system dysfunction has been implicated in the pathophysiology of bipolar depression. This is an update of the 2015 Cochrane Review for the use of glutamate receptor modulators for depression in bipolar disorder. OBJECTIVES 1. To assess the effects of ketamine and other glutamate receptor modulators in alleviating the acute symptoms of depression in people with bipolar disorder. 2. To review the acceptability of ketamine and other glutamate receptor modulators in people with bipolar disorder who are experiencing depressive symptoms. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Embase and PsycINFO all years to July 2020. We did not apply any restrictions to date, language or publication status. SELECTION CRITERIA RCTs comparing ketamine or other glutamate receptor modulators with other active psychotropic drugs or saline placebo in adults with bipolar depression. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion, assessed trial quality and extracted data. Primary outcomes were response rate and adverse events. Secondary outcomes included remission rate, depression severity change scores, suicidality, cognition, quality of life, and dropout rate. The GRADE framework was used to assess the certainty of the evidence. MAIN RESULTS Ten studies (647 participants) were included in this review (an additional five studies compared to the 2015 review). There were no additional studies added to the comparisons identified in the 2015 Cochrane review on ketamine, memantine and cytidine versus placebo. However, three new comparisons were found: ketamine versus midazolam, N-acetylcysteine versus placebo, and riluzole versus placebo. The glutamate receptor modulators studied were ketamine (three trials), memantine (two), cytidine (one), N-acetylcysteine (three), and riluzole (one). Eight of these studies were placebo-controlled and two-armed. In seven trials the glutamate receptor modulators had been used as add-on drugs to mood stabilisers. Only one trial compared ketamine with an active comparator, midazolam. The treatment period ranged from a single intravenous administration (all ketamine studies), to repeated administration for riluzole, memantine, cytidine, and N-acetylcysteine (with a follow-up of eight weeks, 8 to 12 weeks, 12 weeks, and 16 to 20 weeks, respectively). Six of the studies included sites in the USA, one in Taiwan, one in Denmark, one in Australia, and in one study the location was unclear. All participants had a primary diagnosis of bipolar disorder and were experiencing an acute bipolar depressive episode, diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders fourth edition (IV) or fourth edition text revision (IV-TR). Among all glutamate receptor modulators included in this review, only ketamine appeared to be more efficacious than placebo 24 hours after infusion for response rate (odds ratio (OR) 11.61, 95% confidence interval (CI) 1.25 to 107.74; P = 0.03; participants = 33; studies = 2; I² = 0%, low-certainty evidence). Ketamine seemed to be more effective in reducing depression rating scale scores (MD -11.81, 95% CI -20.01 to -3.61; P = 0.005; participants = 32; studies = 2; I2 = 0%, very low-certainty evidence). There was no evidence of ketamine's efficacy in producing remission over placebo at 24 hours (OR 5.16, 95% CI 0.51 to 52.30; P = 0.72; participants = 33; studies = 2; I2 = 0%, very low-certainty evidence). Evidence on response, remission or depression rating scale scores between ketamine and midazolam was uncertain at 24 hours due to very low-certainty evidence (OR 3.20, 95% CI 0.23 to 45.19). In the one trial assessing ketamine and midazolam, there were no dropouts due to adverse effects or for any reason (very low-certainty evidence). Placebo may have been more effective than N-acetylcysteine in reducing depression rating scale scores at three months, although this was based on very low-certainty evidence (MD 1.28, 95% CI 0.24 to 2.31; participants = 58; studies = 2). Very uncertain evidence found no difference in response at three months (OR 0.82, 95% CI 0.32 to 2.14; participants = 69; studies = 2; very low-certainty evidence). No data were available for remission or acceptability. Extremely limited data were available for riluzole vs placebo, finding only very-low certainty evidence of no difference in dropout rates (OR 2.00, 95% CI 0.31 to 12.84; P = 0.46; participants = 19; studies = 1; I2 = 0%). AUTHORS' CONCLUSIONS It is difficult to draw reliable conclusions from this review due to the certainty of the evidence being low to very low, and the relatively small amount of data usable for analysis in bipolar disorder, which is considerably less than the information available for unipolar depression. Nevertheless, we found uncertain evidence in favour of a single intravenous dose of ketamine (as add-on therapy to mood stabilisers) over placebo in terms of response rate up to 24 hours, however ketamine did not show any better efficacy for remission in bipolar depression. Even though ketamine has the potential to have a rapid and transient antidepressant effect, the efficacy of a single intravenous dose may be limited. We did not find conclusive evidence on adverse events with ketamine, and there was insufficient evidence to draw meaningful conclusions for the remaining glutamate receptor modulators. However, ketamine's psychotomimetic effects (such as delusions or delirium) may have compromised study blinding in some studies, and so we cannot rule out the potential bias introduced by inadequate blinding procedures. To draw more robust conclusions, further methodologically sound RCTs (with adequate blinding) are needed to explore different modes of administration of ketamine, and to study different methods of sustaining antidepressant response, such as repeated administrations.
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Affiliation(s)
| | | | | | - Styliani Spyridi
- Department of Rehabilitation Sciences, Faculty of Health Sciences, Cyprus University of Technology, Lemesos, Cyprus
| | | | | | - Philip J Cowen
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Rupert McShane
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Keith Hawton
- Centre for Suicide Research, University Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - Gin S Malhi
- Discipline of Psychiatry, Northern Clinical School, University of Sydney, Sydney, Australia
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Dean RL, Hurducas C, Hawton K, Spyridi S, Cowen PJ, Hollingsworth S, Marquardt T, Barnes A, Smith R, McShane R, Turner EH, Cipriani A. Ketamine and other glutamate receptor modulators for depression in adults with unipolar major depressive disorder. Cochrane Database Syst Rev 2021; 9:CD011612. [PMID: 34510411 PMCID: PMC8434915 DOI: 10.1002/14651858.cd011612.pub3] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Many studies have recently been conducted to assess the antidepressant efficacy of glutamate modification in mood disorders. This is an update of a review first published in 2015 focusing on the use of glutamate receptor modulators in unipolar depression. OBJECTIVES To assess the effects - and review the acceptability and tolerability - of ketamine and other glutamate receptor modulators in alleviating the acute symptoms of depression in people with unipolar major depressive disorder. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Embase and PsycINFO all years to July 2020. We did not apply any restrictions to date, language or publication status. SELECTION CRITERIA Double- or single-blinded randomised controlled trials (RCTs) comparing ketamine, memantine, esketamine or other glutamate receptor modulators with placebo (pill or saline infusion), other active psychotropic drugs, or electroconvulsive therapy (ECT) in adults with unipolar major depression. DATA COLLECTION AND ANALYSIS Three review authors independently identified studies, assessed trial quality and extracted data. The primary outcomes were response rate (50% reduction on a standardised rating scale) and adverse events. We decided a priori to measure the efficacy outcomes at different time points and run sensitivity/subgroup analyses. Risk of bias was assessed using the Cochrane tool, and certainty of the evidence was assessed using GRADE. MAIN RESULTS Thirty-one new studies were identified for inclusion in this updated review. Overall, we included 64 studies (5299 participants) on ketamine (31 trials), esketamine (9), memantine (5), lanicemine (4), D-cycloserine (2), Org26576 (2), riluzole (2), atomoxetine (1), basimglurant (1), citicoline (1), CP-101,606 (1), decoglurant (1), MK-0657 (1), N-acetylcysteine (1), rapastinel (1), and sarcosine (1). Forty-eight studies were placebo-controlled, and 48 were two-arm studies. The majority of trials defined an inclusion criterion for the severity of depressive symptoms at baseline: 29 at least moderate depression; 17 severe depression; and five mild-to-moderate depression. Nineteen studies recruited only patients with treatment-resistant depression, defined as inadequate response to at least two antidepressants. The majority of studies investigating ketamine administered as a single dose, whilst all of the included esketamine studies used a multiple dose regimen (most frequently twice a week for four weeks). Most studies looking at ketamine used intravenous administration, whilst the majority of esketamine trials used intranasal routes. The evidence suggests that ketamine may result in an increase in response and remission compared with placebo at 24 hours odds ratio (OR) 3.94, 95% confidence interval (CI) 1.54 to 10.10; n = 185, studies = 7, very low-certainty evidence). Ketamine may reduce depression rating scale scores over placebo at 24 hours, but the evidence is very uncertain (standardised mean difference (SMD) -0.87, 95% CI -1.26 to -0.48; n = 231, studies = 8, very low-certainty evidence). There was no difference in the number of participants assigned to ketamine or placebo who dropped out for any reason (OR 1.25, 95% CI 0.19 to 8.28; n = 201, studies = 6, very low-certainty evidence). When compared with midazolam, the evidence showed that ketamine increases remission rates at 24 hours (OR 2.21, 95% CI 0.67 to 7.32; n = 122,studies = 2, low-certainty evidence). The evidence is very uncertain about the response efficacy of ketamine at 24 hours in comparison with midazolam, and its ability to reduce depression rating scale scores at the same time point (OR 2.48, 95% CI 1.00 to 6.18; n = 296, studies = 4,very low-certainty evidence). There was no difference in the number of participants who dropped out of studies for any reason between ketamine and placebo (OR 0.33, 95% CI 0.05 to 2.09; n = 72, studies = 1, low-certainty evidence). Esketamine treatment likely results in a large increase in participants achieving remission at 24 hours compared with placebo (OR 2.74, 95% CI 1.71 to 4.40; n = 894, studies = 5, moderate-certainty evidence). Esketamine probably results in decreases in depression rating scale scores at 24 hours compared with placebo (SMD -0.31, 95% CI -0.45 to -0.17; n = 824, studies = 4, moderate-certainty evidence). Our findings show that esketamine increased response rates, although this evidence is uncertain (OR 2.11, 95% CI 1.20 to 3.68; n = 1071, studies = 5, low-certainty evidence). There was no evidence that participants assigned to esketamine treatment dropped out of trials more frequently than those assigned to placebo for any reason (OR 1.58, 95% CI 0.92 to 2.73; n = 773, studies = 4,moderate-certainty evidence). We found very little evidence for the remaining glutamate receptor modulators. We rated the risk of bias as low or unclear for most domains, though lack of detail regarding masking of treatment in the studies reduced our certainty in the effect for all outcomes. AUTHORS' CONCLUSIONS Our findings show that ketamine and esketamine may be more efficacious than placebo at 24 hours. How these findings translate into clinical practice, however, is not entirely clear. The evidence for use of the remaining glutamate receptor modulators is limited as very few trials were included in the meta-analyses for each comparison and the majority of comparisons included only one study. Long term non-inferiority RCTs comparing repeated ketamine and esketamine, and rigorous real-world monitoring are needed to establish comprehensive data on safety and efficacy.
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Affiliation(s)
| | | | - Keith Hawton
- Centre for Suicide Research, Department of Psychiatry, University of Oxford, Oxford, UK
| | - Styliani Spyridi
- Department of Rehabilitation Sciences, Faculty of Health Sciences, Cyprus University of Technology, Lemesos, Cyprus
| | - Philip J Cowen
- Department of Psychiatry, University of Oxford, Oxford, UK
| | | | | | | | | | - Rupert McShane
- Oxford Health NHS Foundation Trust, Oxford, UK
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Erick H Turner
- Portland Veterans Affairs Medical Center, P3MHDC, Portland, USA
- Department of Psychiatry, Oregon Health & Science University, Portland, Oregon, USA
| | - Andrea Cipriani
- Oxford Health NHS Foundation Trust, Oxford, UK
- Department of Psychiatry, University of Oxford, Oxford, UK
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21
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Iessa N, Macolic Sarinic V, Ghazaryan L, Romanova N, Alemu A, Rungapiromnan W, Jiamsuchon P, Pokhagul P, Castro JL, Macias Saint-Gerons D, Ghukasyan G, Teferi M, Gupta M, Pal SN. Smart Safety Surveillance (3S): Multi-Country Experience of Implementing the 3S Concepts and Principles. Drug Saf 2021; 44:1085-1098. [PMID: 34331675 PMCID: PMC8325038 DOI: 10.1007/s40264-021-01100-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2021] [Indexed: 11/29/2022]
Abstract
Introduction The Smart Safety Surveillance (3S) concept is based on the understanding that, when faced with competing pharmacovigilance priorities, countries will have to invest judiciously, by focusing on new priority products, sharing work and resources with other countries when possible and building national competence for those activities that cannot be delegated. Method The 3S principles were applied to Armenia, Brazil, Ethiopia, India, Peru and Thailand using three priority products: bedaquiline, rotavirus vaccine and tafenoquine. A baseline assessment of pharmacovigilance preparedness was used to identify gaps and establish a work plan. The impact was measured by comparing pre and post 3S-intervention outcomes, which included the number and quality of reports (completeness scores) in the WHO global database of Individual Case Safety Reports, VigiBase, and number of structural indicators met. The implementation period was 9–18 months, ranging from March 2018 (earliest started) until May 2020 (latest). Result An increase in adverse drug reaction (ADR) reporting was demonstrated in Armenia (bedaquiline), Brazil (TB and malaria medicines), India (rotavirus vaccine) and Ethiopia (TB medicines). Completeness scores were above 0.5 at baseline in all countries, and reports improved in quality for Brazil (TB), Peru (malaria), Thailand (malaria) and India (immunization). The number of structural indicators met increased by more than double for Ethiopia. Ethiopia and India demonstrated an increased capacity for signal detection and signal evaluation. Armenia, Brazil, Peru and Thailand showed increased capacity to assess risk management plans following the implementation of 3S principles. Conclusion The 3S concept has demonstrated success in different ways across the six countries. Activities focused on three products for a proof of concept of the 3S principles, with the expectation that the project impact will be sustained through strengthened systems, to guide pharmacovigilance activities of other products in the future. It is important to continue monitoring the countries to understand if the gains and successes of the current 3S project are sustainable. Supplementary Information The online version contains supplementary material available at 10.1007/s40264-021-01100-z.
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Affiliation(s)
- Noha Iessa
- World Health Organization Headquarters, Geneva, Switzerland
| | | | - Lilit Ghazaryan
- Scientific Centre of Drug and Medical Technology Expertise of MoH, Yerevan, Armenia
| | - Naira Romanova
- Scientific Centre of Drug and Medical Technology Expertise of MoH, Yerevan, Armenia
| | - Asnakech Alemu
- Ethiopian Food and Drug Administration, Addis Ababa, Ethiopia
| | | | - Porntip Jiamsuchon
- Ministry of Public Health, Thai Food and Drug Administration, Nonthaburi, Thailand
| | - Pattreya Pokhagul
- Ministry of Public Health, Thai Food and Drug Administration, Nonthaburi, Thailand
| | | | | | | | | | | | - Shanthi Narayan Pal
- World Health Organization Headquarters, 20 Avenue Appia, 1202, Geneva, Switzerland.
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22
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Cipriani A, Cortese S, Furukawa TA. IF. EVIDENCE-BASED MENTAL HEALTH 2021; 24:ebmental-2021-300301. [PMID: 34285107 PMCID: PMC10231515 DOI: 10.1136/ebmental-2021-300301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 07/14/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Andrea Cipriani
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
- Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK
| | - Samuele Cortese
- Centre for Innovation in Mental Health, School of Psychology, Faculty of Environmental and Life Sciences, Clinical and Experimental Sciences (CNS and Psychiatry), Faculty of Medicine, University of Southampton, Southampton, UK
- Solent NHS Trust, Southampton, UK
- Department of Child and Adolescent Psychiatry, Hassenfeld Children's Hospital at NYU Langone, New York, New York, USA
- Division of Psychiatry and Applied Psychology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Toshi A Furukawa
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine / School of Public Health, Kyoto, Japan
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23
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Criteria-based curation of a therapy-focused compendium to support treatment recommendations in precision oncology. NPJ Precis Oncol 2021; 5:58. [PMID: 34162978 PMCID: PMC8222322 DOI: 10.1038/s41698-021-00194-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 05/26/2021] [Indexed: 11/09/2022] Open
Abstract
While several resources exist that interpret therapeutic significance of genomic alterations in cancer, many regional real-world issues limit access to drugs. There is a need for a pragmatic, evidence-based, context-adapted tool to guide clinical management based on molecular biomarkers. To this end, we have structured a compendium of approved and experimental therapies with associated biomarkers following a survey of drug regulatory databases, existing knowledge bases, and published literature. Each biomarker-disease-therapy triplet was categorised using a tiering system reflective of key therapeutic considerations: approved and reimbursed therapies with respect to a jurisdiction (Tier 1), evidence of efficacy or approval in another jurisdiction (Tier 2), evidence of antitumour activity (Tier 3), and plausible biological rationale (Tier 4). Two resistance categories were defined: lack of efficacy (Tier R1) or antitumor activity (Tier R2). Based on this framework, we curated a digital resource focused on drugs relevant in the Australian healthcare system (TOPOGRAPH: Therapy Oriented Precision Oncology Guidelines for Recommending Anticancer Pharmaceuticals). As of November 2020, TOPOGRAPH comprised 2810 biomarker-disease-therapy triplets in 989 expert-appraised entries, including 373 therapies, 199 biomarkers, and 106 cancer types. In the 345 therapies catalogued, 84 (24%) and 65 (19%) were designated Tiers 1 and 2, respectively, while 271 (79%) therapies were supported by preclinical studies, early clinical trials, retrospective studies, or case series (Tiers 3 and 4). A companion algorithm was also developed to support rational, context-appropriate treatment selection informed by molecular biomarkers. This framework can be readily adapted to build similar resources in other jurisdictions to support therapeutic decision-making.
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24
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Hoffmann F, Kaiser T, Apfelbacher C, Benz S, Bierbaum T, Dreinhöfer K, Hauptmann M, Heidecke CD, Koller M, Kostuj T, Ortmann O, Schmitt J, Schünemann H, Veit C, Hoffmann W, Klinkhammer-Schalke M. [Routine Practice Data for Evaluating Intervention Effects: Part 2 of the Manual]. DAS GESUNDHEITSWESEN 2021; 83:470-480. [PMID: 34020493 DOI: 10.1055/a-1484-7235] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The evaluation of intervention effects is an important domain of health services research. The ad hoc commission for the use of routine practice data of the German Network for Health Services Research (DNVF) therefore provides this second part of its manual focusing on the use of routine practice data for the evaluation of intervention effects. First, we discuss definition issues and the importance of contextual factors. Subsequently, general requirements for planning, data collection and analysis as well as concrete examples for the evaluation of intervention effects for the 3 fields of application regarding pharmacotherapy, nonpharmaceutical interventions as well as complex interventions are elaborated. We consider scenarios in which no information from randomized controlled trials (RCTs) comparing the two groups directly is yet available or in which RCTs are already available but an extension of the research question is required. In all examples either with or without randomization, the first and foremost question is always whether the data source is suitable for the specific research question. Most of the examples chosen are from oncology trials, because the necessary data are already available for Germany, at least in some form. Finally, the manual discusses possible challenges for future use of these data.
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Affiliation(s)
- Falk Hoffmann
- Department für Versorgungsforschung, Carl von Ossietzky Universität Oldenburg, Oldenburg
| | - Thomas Kaiser
- Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen (IQWiG), Köln
| | - Christian Apfelbacher
- Institut für Sozialmedizin und Gesundheitssystemforschung, Otto von Guericke Universität Magdeburg, Magdeburg
| | - Stefan Benz
- Kliniken Böblingen, Klinikverbund Südwest GmbH, Sindelfingen.,Arbeitsgemeinschaft Deutscher Tumorzentren, Berlin
| | | | - Karsten Dreinhöfer
- Klinik für Orthopädie und Unfallchirurgie, Medical Park Berlin Humboldtmühle.,Centrum für Muskuloskeletale Chirurgie (CMSC), Charité Universitätsmedizin Berlin
| | - Michael Hauptmann
- Institut für Biometrie und Registerforschung, Fakultät für Gesundheitswissenschaften, Medizinische Hochschule Brandenburg Theodor Fontane, Neuruppin
| | | | - Michael Koller
- Zentrum für Klinische Studien, Universitätsklinikum Regensburg, Regensburg
| | - Tanja Kostuj
- Orthopädisch-Traumatologische Zentrum, St. Marien-Hospitals Hamm, Hamm
| | - Olaf Ortmann
- Klinik für Frauenheilkunde und Geburtshilfe, Universität Regensburg Fakultät für Medizin, Regensburg
| | - Jochen Schmitt
- Zentrum für Evidenzbasierte Gesundheitsversorgung, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden
| | - Holger Schünemann
- Cochrane Canada and Mc Master GRADE Centre, WHO Collaborating Centre for Infectious Diseases, Research and Methods, Hamilton, Canada
| | - Christof Veit
- BQS Institut für Qualität & Patientensicherheit GmbH, Hamburg
| | | | - Monika Klinkhammer-Schalke
- Deutsches Netzwerk Versorgungsforschung e.V., Berlin.,Tumorzentrum Regensburg, Institut für Qualitätssicherung und Versorgungsforschung, Universität Regensburg, Regensburg
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De Crescenzo F, Amato L, Cruciani F, Moynihan LP, D'Alò GL, Vecchi S, Saulle R, Mitrova Z, Di Franco V, Addis A, Davoli M. Comparative Effectiveness of Pharmacological Interventions for Covid-19: A Systematic Review and Network Meta-Analysis. Front Pharmacol 2021; 12:649472. [PMID: 34012398 PMCID: PMC8126885 DOI: 10.3389/fphar.2021.649472] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 04/16/2021] [Indexed: 12/15/2022] Open
Abstract
Background: Several pharmacological interventions are now under investigation for the treatment of Covid-19, and the evidence is evolving rapidly. Our aim is to assess the comparative efficacy and safety of these drugs. Methods and Findings: We performed a systematic review and network meta-analysis searching Medline, Pubmed, Embase, Cochrane Covid-19 register, international trial registers, medRxiv, bioRxiv, and arXiv up to December 10, 2020. We included all randomised controlled trials (RCTs) comparing any pharmacological intervention for Covid-19 against any drugs, placebo or standard care (SC). Data extracted from published reports were assessed for risk of bias in accordance with the Cochrane tool, and using the GRADE framework. Primary outcomes were all-cause mortality, adverse events (AEs) and serious adverse events (SAEs). We estimated summary risk ratio (RR) using pairwise and network meta-analysis with random effects (Prospero, number CRD42020176914). We performed a systematic review and network meta-analysis searching Medline, Pubmed, Embase, Cochrane Covid-19 register, international trial registers, medRxiv, bioRxiv, and arXiv up to December 10, 2020. We included all randomised controlled trials (RCTs) comparing any pharmacological intervention for Covid-19 against any drugs, placebo or standard care (SC). Data extracted from published reports were assessed for risk of bias in accordance with the Cochrane tool, and using the GRADE framework. Primary outcomes were all-cause mortality, adverse events (AEs) and serious adverse events (SAEs). We estimated summary risk ratio (RR) using pairwise and network meta-analysis with random effects (Prospero, number CRD42020176914). We included 96 RCTs, comprising of 34,501 patients. The network meta-analysis showed in terms of all-cause mortality, when compared to SC or placebo, only corticosteroids significantly reduced the mortality rate (RR 0.90, 95%CI 0.83, 0.97; moderate certainty of evidence). Corticosteroids significantly reduced the mortality rate also when compared to hydroxychloroquine (RR 0.83, 95%CI 0.74, 0.94; moderate certainty of evidence). Remdesivir proved to be better in terms of SAEs when compared to SC or placebo (RR 0.75, 95%CI 0.63, 0.89; high certainty of evidence) and plasma (RR 0.57, 95%CI 0.34, 0.94; high certainty of evidence). The combination of lopinavir and ritonavir proved to reduce SAEs when compared to plasma (RR 0.49, 95%CI 0.25, 0.95; high certainty of evidence). Most of the RCTs were at unclear risk of bias (42 of 96), one third were at high risk of bias (34 of 96) and 20 were at low risk of bias. Certainty of evidence ranged from high to very low. Conclusion: At present, corticosteroids reduced all-cause mortality in patients with Covid-19, with a moderate certainty of evidence. Remdesivir appeared to be a safer option than SC or placebo, while plasma was associated with safety concerns. These preliminary evidence-based observations should guide clinical practice until more data are made public.
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Affiliation(s)
- Franco De Crescenzo
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom.,Department of Epidemiology of the Regional Health Service Lazio, Rome, Italy.,Paediatric University Hospital-Department (DPUO), Bambino Gesù Children's Hospital, Rome, Italy
| | - Laura Amato
- Department of Epidemiology of the Regional Health Service Lazio, Rome, Italy
| | - Fabio Cruciani
- Department of Epidemiology of the Regional Health Service Lazio, Rome, Italy
| | - Luke P Moynihan
- Department of Acute Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Gian Loreto D'Alò
- Department of Epidemiology of the Regional Health Service Lazio, Rome, Italy
| | - Simona Vecchi
- Department of Epidemiology of the Regional Health Service Lazio, Rome, Italy
| | - Rosella Saulle
- Department of Epidemiology of the Regional Health Service Lazio, Rome, Italy
| | - Zuzana Mitrova
- Department of Epidemiology of the Regional Health Service Lazio, Rome, Italy
| | - Valeria Di Franco
- Department of Anaesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Antonio Addis
- Department of Epidemiology of the Regional Health Service Lazio, Rome, Italy
| | - Marina Davoli
- Department of Epidemiology of the Regional Health Service Lazio, Rome, Italy
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The Potential Benefit of Expedited Development and Approval Programs in Precision Medicine. J Pers Med 2021; 11:jpm11010045. [PMID: 33466644 PMCID: PMC7828670 DOI: 10.3390/jpm11010045] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/07/2021] [Accepted: 01/11/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Increased understanding of the molecular causes of disease has begun to fulfill the promise of precision medicine with the development of targeted drugs, particularly for serious diseases with unmet needs. The drug approval regulatory process is a critical component to the continued growth of precision medicine drugs and devices. To facilitate the development and approval process of drugs for serious unmet needs, four expedited approval programs have been developed in the US: priority review, accelerated approval, fast track, and breakthrough therapy programs. METHODS To determine if expedited approval programs are fulfilling the intended goals, we reviewed drug approvals by the US Food and Drug Administration (FDA) between 2011 and 2017 for new molecular entities (NMEs). RESULTS From 2011 through 2017, the FDA approved 250 NMEs, ranging from 27 approvals in 2013 to 46 in 2017. The NME approvals spanned 22 different disease classes; almost one-third of all NMEs were for oncology treatments. CONCLUSIONS As these pathways are utilized more, additional legislative changes may be needed to re-align incentives to promote continued development of innovative drugs for serious unmet needs in a safe, efficacious, and affordable manner.
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Tarricone R, Ciani O, Torbica A, Brouwer W, Chaloutsos G, Drummond MF, Martelli N, Persson U, Leidl R, Levin L, Sampietro-Colom L, Taylor RS. Lifecycle evidence requirements for high-risk implantable medical devices: a European perspective. Expert Rev Med Devices 2020; 17:993-1006. [PMID: 32975149 DOI: 10.1080/17434440.2020.1825074] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION The new European Union (EU) Regulations on medical devices and on in vitro diagnostics provide manufacturers and Notified Bodies with new tools to improve pre-market and post-market clinical evidence generation especially for high-risk products but fail to indicate what type of clinical evidence is appropriate at each stage of the whole lifecycle of medical devices. In this paper we address: i) the appropriate level and timing of clinical evidence throughout the lifecycle of high-risk implantable medical devices; and ii) how the clinical evidence generation ecosystem could be adapted to optimize patient access. AREAS COVERED The European regulatory and health technology assessment (HTA) contexts are reviewed, in relation to the lifecycle of high-risk medical devices and clinical evidence generation recommended by international network or endorsed by regulatory and HTA agencies in different jurisdictions. EXPERT OPINION Four stages are relevant for clinical evidence generation: i) pre-clinical, pre-market; ii) clinical, pre-market; iii) diffusion, post-market; and iv) obsolescence & replacement, post-market. Each stage has its own evaluation needs and specific studies are recommended to generate the appropriate evidence. Effective lifecycle planning requires anticipation of what evidence will be needed at each stage.
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Affiliation(s)
- Rosanna Tarricone
- Department of Social and Political Science, Bocconi University , Milan, Italy.,SDA Bocconi School of Management , Milan, Italy.,SDA Bocconi School of Management, Centre for Research on Health and Social Care Management (CERGAS) , Milan, Italy
| | - Oriana Ciani
- SDA Bocconi School of Management, Centre for Research on Health and Social Care Management (CERGAS) , Milan, Italy.,Institute of College and Medicine, University of Exeter, South Cloisters, St Luke's Campus , Exeter, UK
| | - Aleksandra Torbica
- Department of Social and Political Science, Bocconi University , Milan, Italy.,SDA Bocconi School of Management , Milan, Italy
| | - Werner Brouwer
- Erasmus School of Health Policy & Management (ESHPM), Erasmus University Rotterdam , Rotterdam, PA, The Netherlands
| | - Georges Chaloutsos
- Biomedical Engineering Department, Onassis Cardiac Surgery Centre & Director , Athens, Greece
| | - Michael F Drummond
- Professor of Health Economics, Centre for Health Economics, University of York , York, UK
| | - Nicolas Martelli
- Associate Clinical Professor, Hôpital Européen Georges Pompidou , Paris, France
| | - Ulf Persson
- IHE, Swedish Institute for Health Economics , Lund, Sweden
| | - Reiner Leidl
- Institute of Health Economics and Healthcare Management, Helmholtz Zentrum München - German Research Center for Environmental Health (Gmbh) , Neuherberg, Germany
| | - Les Levin
- Chief Executive Officer & Scientific Officer, EXCITE International , Canada
| | - Laura Sampietro-Colom
- Deputy Director of Innovation, Head of Health Technology Assessment Unit at Hospital Clinic Barcelona , Spain
| | - Rod S Taylor
- Institute of Health and Wellbeing, University of Glasgow , Glasgow, UK
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28
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Naci H, Kesselheim AS, Røttingen JA, Salanti G, Vandvik PO, Cipriani A. Producing and using timely comparative evidence on drugs: lessons from clinical trials for covid-19. BMJ 2020; 371:m3869. [PMID: 33067179 DOI: 10.1136/bmj.m3869] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Huseyin Naci
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Aaron S Kesselheim
- Program On Regulation, Therapeutics, And Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - John-Arne Røttingen
- Research Council of Norway, Oslo, Norway
- Blavatnik School of Government, University of Oxford, Oxford, UK
| | - Georgia Salanti
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Per O Vandvik
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Andrea Cipriani
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
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29
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Vreman RA, Leufkens HGM, Kesselheim AS. Getting the Right Evidence After Drug Approval. Front Pharmacol 2020; 11:569535. [PMID: 33013409 PMCID: PMC7509198 DOI: 10.3389/fphar.2020.569535] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 08/14/2020] [Indexed: 11/21/2022] Open
Abstract
To generate comparative evidence in a timely fashion for drugs without restricting or delaying access, value-based pricing and reimbursement could be conditioned on a prospective, post-approval evidence generation plan.
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Affiliation(s)
- Rick A Vreman
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands.,National Health Care Institute (ZIN), Diemen, Netherlands
| | - Hubert G M Leufkens
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands
| | - Aaron S Kesselheim
- Program on Regulation, Therapeutics and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, MA, United States
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30
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Macias Saint-Gerons D, Solà Arnau I, De Mucio B, Arévalo-Rodríguez I, Alemán A, Castro JL, Ropero Álvarez AM. Adverse events associated with the use of recommended vaccines during pregnancy: An overview of systematic reviews. Vaccine 2020; 39 Suppl 2:B12-B26. [PMID: 32972737 DOI: 10.1016/j.vaccine.2020.07.048] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 06/02/2020] [Accepted: 07/22/2020] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Maternal immunization is aimed at reducing morbidity and mortality in pregnant women and their newborns. Updated evidence synthesis of maternal-fetal outcomes is constantly needed to ensure that the risk-benefit of vaccination during pregnancy remains positive. METHODS An overview of systematic reviews (OoSRs) was performed. We searched The Cochrane Library, MEDLINE and EMBASE for SRs including recommended vaccines for maternal immunization reporting the following: abortion, stillbirth, chorioamnionitis, congenital anomalies, microcephaly, neonatal death, neonatal infection, preterm birth (PTB), low birth weight (LBW), maternal death and small for gestational age (SGA) from 2010 to April 2019. Quality and overlap of SRs was assessed. RESULTS Seventeen SRs were identified, eight of them included meta-analysis; quality was high in three SRs, moderate in six SRs, low in two SRs, and critically low in six SRs. Stillbirth and PTB were the most frequently reported outcomes by 15 and 13 SRs, respectively, followed by abortion (9 SRs), congenital anomalies (9 SRs), SGA (8 SRs), neonatal death (8 SRs), LBW (4 SRs), chorioamnionitis (3 SRs), maternal death (1 SR). SRs included mainly observational evidence for influenza and Tdap vaccines (11 SRs and 4 SRs, respectively); limited evidence was found for hepatitis (1 SR), yellow fever (1 SR), and meningococcal (1 SR) vaccines. Most of the SRs found no effect. Eight SRs found benefit/protection of influenza vaccine (for stillbirth, neonatal death, preterm birth, LBW), or Tdap vaccine (for preterm birth and SGA); one found a probable risk (chorioamnionitis/Tdap). The SRs for Hepatitis B, meningococcal and yellow fever vaccines were inconclusive. CONCLUSIONS Definite risks were not identified for any vaccine and outcome; however better evidence is needed for all outcomes and vaccines. The available evidence in the SRs to support vaccine safety was based mainly on observational data. More RCTs with adequate reporting of maternal-fetal outcomes and larger high-quality observational studies are needed.
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Affiliation(s)
- Diego Macias Saint-Gerons
- Department of Medicine, University of Valencia/INCLIVA Health Research Institute and CIBERSAM, Valencia, Spain; Department of Health Systems and Services (HSS)/Unit of Medicines and Health Technologies (MT), Pan American Health Organization PAHO/WHO, Washington DC, USA
| | - Iván Solà Arnau
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), CIBER of Epidemiology and Public Health, Spain
| | - Bremen De Mucio
- Department of Preventive Medicine, School of Medicine, University of the Republic, Montevideo, Uruguay
| | - Ingrid Arévalo-Rodríguez
- Clinical Biostatistics Unit, Hospital Universitario Ramón y Cajal, IRYCIS, CIBER of Epidemiology and Public Health, Madrid, Spain
| | - Alicia Alemán
- Department of Preventive Medicine, School of Medicine, University of the Republic, Montevideo, Uruguay
| | - José Luis Castro
- Department of Health Systems and Services (HSS)/Unit of Medicines and Health Technologies (MT), Pan American Health Organization PAHO/WHO, Washington DC, USA
| | - Alba María Ropero Álvarez
- Department of Family, Gender and Life Course, Immunization Unit, Pan American Health Organization PAHO/WHO, Washington DC, USA.
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31
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Percival MEM, Estey EH. Truth or consequences: under-reporting of post-accrual changes in clinical trial design. Leuk Lymphoma 2020; 61:2034-2035. [PMID: 32568607 DOI: 10.1080/10428194.2020.1779262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Mary-Elizabeth M Percival
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Elihu H Estey
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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32
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Buyse M, Trotta L, Saad ED, Sakamoto J. Central statistical monitoring of investigator-led clinical trials in oncology. Int J Clin Oncol 2020; 25:1207-1214. [PMID: 32577951 PMCID: PMC7308734 DOI: 10.1007/s10147-020-01726-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 06/14/2020] [Indexed: 01/17/2023]
Abstract
Investigator-led clinical trials are pragmatic trials that aim to investigate the benefits and harms of treatments in routine clinical practice. These much-needed trials represent the majority of all trials currently conducted. They are however threatened by the rising costs of clinical research, which are in part due to extensive trial monitoring processes that focus on unimportant details. Risk-based quality management focuses, instead, on “things that really matter”. We discuss the role of central statistical monitoring as part of risk-based quality management. We describe the principles of central statistical monitoring, provide examples of its use, and argue that it could help drive down the cost of randomized clinical trials, especially investigator-led trials, whilst improving their quality.
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Affiliation(s)
- Marc Buyse
- International Drug Development Institute (IDDI), San Francisco, CA, USA. .,Interuniversity Institute for Biostatistics and Statistical Bioinformatics (I-BioStat), Hasselt University, Hasselt, Belgium. .,CluePoints, Louvain-la-Neuve, Belgium.
| | | | - Everardo D Saad
- International Drug Development Institute (IDDI), 30 avenue provinciale, 1340, Ottignies-Louvain-la-Neuve, Belgium
| | - Junichi Sakamoto
- Tokai Central Hospital, Kakamigahara, Japan.,Epidemiological and Clinical Research Information Network (ECRIN), Kyoto, Japan
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33
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Rogers A, Craig G, Flynn A, Mackenzie I, MacDonald T, Doney A. Cluster randomised trials of prescribing policy: an ethical approach to generating drug safety evidence? A discussion of the ethical application of a new research method. Trials 2020; 21:477. [PMID: 32498697 PMCID: PMC7273660 DOI: 10.1186/s13063-020-04357-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 04/28/2020] [Indexed: 11/10/2022] Open
Abstract
For most chronic medical conditions, multiple medications are available and prescribers often have limited evidence about which therapy is likely to be the most effective and safe for an individual patient. As many patients are exposed every day to medicines that may be less effective than available alternatives, this is of public health importance. Cluster randomised trials of prescribing policy offer an opportunity to rapidly obtain evidence of comparative effectiveness and safety. These trials can pose a low risk to patients and cause minimal disruption to usual care. Despite the potential scientific value of this approach, there remain valid concerns about consent, medication switching and the use of routinely collected data in research. We discuss these concerns with reference to an ongoing pilot study (Evaluating Diuretics in Normal Care (EVIDENCE) - a cluster randomised evaluation of hypertension prescribing policy, ISRCTN 46635087, registered 11 August 2017).
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Affiliation(s)
- Amy Rogers
- MEMO Research, School of Medicine, University of Dundee, Ninewells Hospital, Dundee, DD1 9SY, UK.
| | - Gillian Craig
- Health and Clinical Services, School of Medicine, University of Dundee, Ninewells Hospital, Dundee, DD1 9SY, UK
- Department of Physics, University of Strathclyde, 107 Rottenrow East, Glasgow, G4 0NG, UK
| | - Angela Flynn
- MEMO Research, School of Medicine, University of Dundee, Ninewells Hospital, Dundee, DD1 9SY, UK
| | - Isla Mackenzie
- MEMO Research, School of Medicine, University of Dundee, Ninewells Hospital, Dundee, DD1 9SY, UK
| | - Thomas MacDonald
- MEMO Research, School of Medicine, University of Dundee, Ninewells Hospital, Dundee, DD1 9SY, UK
| | - Alexander Doney
- MEMO Research, School of Medicine, University of Dundee, Ninewells Hospital, Dundee, DD1 9SY, UK
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34
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Singh I, Naci H, Miller J, Caplan A, Cipriani A. Ethical implications of poor comparative effectiveness evidence: obligations in industry-research partnerships. Lancet 2020; 395:926-928. [PMID: 32199476 DOI: 10.1016/s0140-6736(20)30413-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 12/23/2019] [Accepted: 02/14/2020] [Indexed: 12/23/2022]
Affiliation(s)
- Ilina Singh
- Department of Psychiatry, University of Oxford, Oxford OX3 7JX, UK; Wellcome Centre for Ethics and Humanities, Big Data Institute, University of Oxford, Oxford, UK.
| | - Huseyin Naci
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Jennifer Miller
- Yale School of Medicine, Yale University, New Haven, CT, USA
| | - Arthur Caplan
- Division of Medical Ethics, New York University, Grossman School of Medicine New York, NY, USA
| | - Andrea Cipriani
- Department of Psychiatry, University of Oxford, Oxford OX3 7JX, UK; Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
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