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Naudet F, Patel CJ, DeVito NJ, Le Goff G, Cristea IA, Braillon A, Hoffmann S. Improving the transparency and reliability of observational studies through registration. BMJ 2024; 384:e076123. [PMID: 38195116 DOI: 10.1136/bmj-2023-076123] [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: 01/11/2024]
Affiliation(s)
- Florian Naudet
- CHU Rennes, Inserm, Institut de Recherche en Santé, Environnement et Travail-UMR_S 1085, University of Rennes, Rennes, France
- Institut Universitaire de France, Paris, France
| | - Chirag J Patel
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA
| | - Nicholas J DeVito
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Ioana A Cristea
- Department of General Psychology, University of Padova, Padova, Italy
| | | | - Sabine Hoffmann
- Department of Statistics, Ludwig-Maximilians-Universität München, Munich, Germany
- Institute for Medical Information Processing, Biometry, and Epidemiology, Ludwig-Maximilians-Universität München, Munich, Germany
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Grupstra RJ, Goedecke T, Scheffers J, Strassmann V, Gardarsdottir H. Review of Studies Evaluating Effectiveness of Risk Minimization Measures Assessed by the European Medicines Agency Between 2016 and 2021. Clin Pharmacol Ther 2023; 114:1285-1292. [PMID: 37634124 DOI: 10.1002/cpt.3034] [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: 06/12/2023] [Accepted: 08/16/2023] [Indexed: 08/28/2023]
Abstract
The European Medicines Agency (EMA) supervises medicines' safe and effective use throughout the product's life cycle by, for example, monitoring the implementation of risk minimization measures (RMMs). Limited information is available on factors associated with effectiveness of RMMs. This study reviews post-authorization safety studies (PASS) evaluating the effectiveness of RMMs assessed by the Pharmacovigilance Risk Assessment Committee (PRAC) between 2016 and 2021. PASS assessment reports finalized by PRAC between January 1, 2016, and December 31, 2021, were compiled from non-public EMA databases and PASS characteristics were extracted. Of the 93 PASS included, 62.4% aimed to measure healthcare professionals' awareness, knowledge, and behavior regarding RMMs. There were 67.7% of the 93 PASS that used primary data, 24.7% used secondary data sources, and 7.5% used both. A cross-sectional study design was most frequently applied (77.4%), followed by a cohort study design (29.0%). Nearly 40% of the included PASS did not render a conclusion on RMM effectiveness. Of the 60% that did render a conclusion, 82.1% were deemed effective. Only minor differences in characteristics were found when stratified by outcome (i.e., effective RMM, ineffective RMM, and no conclusion on RMM effectiveness). To conclude, 4 out of 10 PASS assessing impact of RMMs did not render a conclusion on RMM effectiveness. No clear differences in PASS characteristics were found in relation to their outcomes, indicating that additional research is needed to understand better the underlying reasons for PASS being inconclusive.
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Affiliation(s)
- Renske J Grupstra
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | | | - Jet Scheffers
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
| | | | - Helga Gardarsdottir
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Utrecht, The Netherlands
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands
- Faculty of Pharmaceutical Sciences, University of Iceland, Reykjavik, Iceland
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Agustí A, Cereza G, de Abajo FJ, Maciá MA, Sacristán JA. Clinical pharmacology facing the real-world setting: Pharmacovigilance, pharmacoepidemiology and the economic evaluation of drugs. Pharmacol Res 2023; 197:106967. [PMID: 37865127 DOI: 10.1016/j.phrs.2023.106967] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/15/2023] [Accepted: 10/18/2023] [Indexed: 10/23/2023]
Abstract
Traditionally, clinical pharmacology has focused its activities on drug-organism interaction, from an individual or collective perspective. Drug efficacy assessment by performing randomized clinical trials and analysis of drug use in clinical practice by carrying out drug utilization studies have also been other areas of interest. From now on, Clinical pharmacology should move from the analysis of the drug-individual interaction to the analysis of the drug-individual-society interaction. It should also analyze the clinical and economic consequences of the use of drugs in the conditions of normal clinical practice, beyond clinical trials. The current exponential technological development that facilitates the analysis of real-life data offers us a golden opportunity to move to all these other areas of interest. This review describes the role that clinical pharmacology has played at the beginning and during the evolution of pharmacovigilance, pharmacoepidemiology and economic drug evaluations in Spain. In addition, the challenges that clinical pharmacology is going to face in the following years in these three areas are going to be outlined too.
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Affiliation(s)
- Antonia Agustí
- Clinical Pharmacology Service, Vall Hebron University Hospital and Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain
| | - Gloria Cereza
- Catalan Centre of Pharmacovigilance. Directorate-General for Healthcare Planning and Regulation, Ministry of Health, Government of Catalonia, and Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain
| | - Francisco J de Abajo
- Department of Biomedical Sciences, University of Alcalá (IRYCIS) and Unit of Clinical Pharmacology, University Hospital Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Miguel A Maciá
- Division of Pharmacoepidemology and Pharmacovigilance, Spanish Agency for Medicines and Medical Devices, Spain
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Essink SCM, Zomerdijk IM, Straus SMJM, Gardarsdottir H, De Bruin ML. Duration of Effectiveness Evaluation of Additional Risk Minimisation Measures for Centrally Authorised Medicinal Products in the EU Between 2012 and 2021. Drug Saf 2023; 46:1007-1020. [PMID: 37658281 PMCID: PMC10584707 DOI: 10.1007/s40264-023-01341-0] [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] [Accepted: 07/26/2023] [Indexed: 09/03/2023]
Abstract
INTRODUCTION In studies evaluating the effectiveness of additional risk minimisation measures (aRMMs), the need for speed must be properly balanced with the quality of the study. We assessed the duration of aRMM effectiveness evaluations, using additional pharmacovigilance activities, for centrally authorised medicinal products in the European Union. METHODS We established a cohort of medicinal products with aRMMs at marketing authorisation (MA) that were centrally authorised from July 2012-December 2021 using the European Public Assessment Reports. Evaluation studies were identified from the Risk Management Plans at the time of MA. Subsequently, we retrieved protocols, final study reports, Pharmacovigilance Risk Assessment Committee (PRAC) assessment reports, and PRAC minutes. We calculated the probability of completing an effectiveness evaluation within 60 months after MA using time-to-event analyses. Besides, we compared the planned final report with the actual final report date. RESULTS We identified 134 medicinal products authorised with aRMMs, of which almost half (n = 63, 47.0%) had an effectiveness evaluation study. The probability of an evaluation for a medicinal product being completed within 60 months after MA was 20.7% (95% CI 6.8-32.6). Regarding study design, the probability of completing a study was higher for cross-sectional studies when compared to cohort studies (p = 0.002). Moreover, 81.0% of studies were delayed when compared to their planned final report date. CONCLUSION The probability of completing an aRMM effectiveness evaluation at time for renewal of the MA was only one in five. Furthermore, estimates of the duration of studies around MA are too optimistic, with the majority being delayed.
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Affiliation(s)
- Sharon C M Essink
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
- Department of Pharmacovigilance, Medicines Evaluation Board, Utrecht, The Netherlands
| | - Inge M Zomerdijk
- Department of Pharmacovigilance, Medicines Evaluation Board, Utrecht, The Netherlands
| | - Sabine M J M Straus
- Department of Pharmacovigilance, Medicines Evaluation Board, Utrecht, The Netherlands
- Department of Medical Informatics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Helga Gardarsdottir
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands
- Faculty of Pharmaceutical Sciences, University of Iceland, Reykjavik, Iceland
| | - Marie L De Bruin
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands.
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Sindahl P, Overgaard-Steensen C, Wallach-Kildemoes H, De Bruin ML, Kemp K, Gardarsdottir H. Impact of a Treatment Guide on Intravenous Fluids in Minimising the Risk of Hospital-Acquired Hyponatraemia in Denmark. J Clin Med 2023; 12:5105. [PMID: 37568506 PMCID: PMC10420267 DOI: 10.3390/jcm12155105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 07/14/2023] [Accepted: 07/18/2023] [Indexed: 08/13/2023] Open
Abstract
Hypotonic intravenous (IV) fluids are associated with an increased risk of hospital-acquired hyponatraemia, eventually leading to brain injury and death. We evaluated the effectiveness of a treatment guide to improve prescribing practices of IV fluids. We conducted a before-and-after cross-sectional survey among physicians working at Danish emergency departments. The primary outcome was prescribing practices of IV fluids. Participants were asked which IV fluid they would select in four clinical scenarios. We applied multivariate logistic regression models to estimate the odds ratio of selecting hypotonic fluids. Secondary outcomes included knowledge about IV fluids and hyponatraemia, and the receipt, reading, and usefulness of the treatment guide. After the intervention, about a third (47/154) reported that they would use hypotonic fluids in patients with increased intracranial pressure, and a quarter (39/154) would use hypotonic maintenance fluids in children, both of which are against guideline recommendations. A total of 46% selected the correct fluid, a 3% hypertonic saline solution for a patient with hyponatraemia and severe neurological symptoms. None of the knowledge questions met the predefined criteria of success of 80% correct answers. Of the respondents, 22% had received the treatment guide. Since the implementation failed, we recommend improving distribution by applying methods from implementation science.
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Affiliation(s)
- Per Sindahl
- Danish Medicines Agency, Division of Pharmacovigilance and Medical Devices, 2300 Copenhagen, Denmark;
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, 3584 CG Utrecht, The Netherlands; (M.L.D.B.); (H.G.)
- Copenhagen Centre for Regulatory Science, Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, 2100 Copenhagen, Denmark
| | | | - Helle Wallach-Kildemoes
- Section for Social and Clinical Pharmacy, Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, 2100 Copenhagen, Denmark;
| | - Marie Louise De Bruin
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, 3584 CG Utrecht, The Netherlands; (M.L.D.B.); (H.G.)
- Copenhagen Centre for Regulatory Science, Department of Pharmacy, Faculty of Health and Medical Sciences, University of Copenhagen, 2100 Copenhagen, Denmark
| | - Kaare Kemp
- Danish Medicines Agency, Division of Pharmacovigilance and Medical Devices, 2300 Copenhagen, Denmark;
| | - Helga Gardarsdottir
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, 3584 CG Utrecht, The Netherlands; (M.L.D.B.); (H.G.)
- Department of Clinical Pharmacy, Division Laboratories, Pharmacy and Biomedical Genetics, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
- Department of Pharmaceutical Sciences, School of Health Sciences, University of Iceland, 102 Reykjavik, Iceland
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Schneiderova K, Bere N, Stenver DI, Straus SMJM. Patient Preferences for Rituximab Additional Risk Minimization Measures: Results From an International Online Survey. J Patient Saf 2022; 18:331-336. [PMID: 34608891 PMCID: PMC9162062 DOI: 10.1097/pts.0000000000000919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
OBJECTIVE Patients' opinions are essential in optimizing risk minimization measures (RMMs) because they bring their real-life experience of disease management and medicines' use into the regulatory assessments. The aim of the survey launched in 2018 by the European Medicines Agency, in collaboration with the Pharmacovigilance Risk Assessment Committee, was to consult targeted patient groups treated with rituximab for nononcology indications to evaluate their preferences on how to receive information on progressive multifocal leukoencephalopathy and (serious) infections. Additional RMMs such as educational materials for physicians and patients including a patient alert card (PAC) and a patient brochure (PB) are in place to minimize these risks. METHODS A question-based online survey in English created on the EU-Survey platform and disseminated primarily via relevant European patient organizations. RESULTS Most patients (47 of 61) had knowledge of these potential adverse effects. Mostly, they were informed by a healthcare professional. Both a PAC and a PB were supported as useful tools to raise awareness of these adverse effects and thus minimize the potential risks among patients. Where the participants had to choose only 1 of these educational materials, 43 of them preferred a PAC, a shorted description that is always held by the patient and reaches the relevant healthcare professional when needed. CONCLUSIONS Collecting patients' preferences supports periodic assessment of additional RMMs and increase transparency of regulatory processes. Considering the limitations of this initial survey, further investigation is needed to generalize the results into patients' safety outcomes.
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Affiliation(s)
| | - Nathalie Bere
- From the European Medicines Agency, Amsterdam, the Netherlands
| | - Doris Irene Stenver
- From the European Medicines Agency, Amsterdam, the Netherlands
- Danish Medicines Agency, Copenhagen, Denmark
| | - Sabine M. J. M. Straus
- From the European Medicines Agency, Amsterdam, the Netherlands
- College ter Beoordeling van Geneesmiddelen–Medicines Evaluation Board, Utrecht, the Netherlands
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de Vries E, Bakker E, Francisca RDC, Croonen S, Denig P, Mol PGM. Handling of New Drug Safety Information in the Dutch Hospital Setting: A Mixed Methods Approach. Drug Saf 2022; 45:369-378. [PMID: 35349127 PMCID: PMC9021088 DOI: 10.1007/s40264-022-01149-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION The implementation of new drug safety information and Direct Healthcare Professional Communications (DHPCs) in hospitals is important for patient safety. OBJECTIVES The aim of this study was to gain insight into which procedures and practices are in place to handle new drug safety information and particularly DHPCs in the Dutch hospital setting. METHODS We first conducted focus groups including medical specialists and hospital pharmacists, focusing on handling of drug safety information at the individual and organisational level. A survey was then developed and distributed among hospital pharmacists in all Dutch hospitals to quantify the existence of specific procedures and committees to handle drug safety information and DHPCs. RESULTS Eleven specialists and 14 pharmacists from six hospitals participated in focus groups. Drug safety information was usually considered before drugs were included in formularies or treatment protocols. Furthermore, drug safety information was consulted in response to patients experiencing adverse events. DHPCs were mostly dealt with by individual professionals. DHPCs could lead to actions but this was very uncommon. Completed surveys were received from 40 (53%) of the hospitals. In 32 (80%), the hospital pharmacy had procedures to deal with new drug safety information, whereas in 11 (28%) a hospital-wide procedure was in place. Drug safety was considered in committees concerning drug formulary decisions (69%) and antibiotic policies (63%). DHPCs were assessed by a hospital pharmacist in 50% of the hospitals. CONCLUSIONS Drug safety information was used for evaluation of new treatments and in response to adverse events. Assessment of whether a DHPC requires action was primarily an individual task.
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Affiliation(s)
- Esther de Vries
- Department Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Dutch Medicines Evaluation Board, Utrecht, The Netherlands
| | - Elisabeth Bakker
- Department Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Dutch Medicines Evaluation Board, Utrecht, The Netherlands
| | - Remy D C Francisca
- Dutch Medicines Evaluation Board, Utrecht, The Netherlands
- Department of Medical Informatics, Erasmus Medical Centre, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Stijn Croonen
- Dutch Medicines Evaluation Board, Utrecht, The Netherlands
- Utrecht Institute for Pharmaceutical Sciences, University of Utrecht, Utrecht, The Netherlands
| | - Petra Denig
- Department Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Peter G M Mol
- Department Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
- Dutch Medicines Evaluation Board, Utrecht, The Netherlands.
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Sultana J, Crisafulli S, Almas M, Antonazzo IC, Baan E, Bartolini C, Bertuccio MP, Bonifazi F, Capuano A, Didio A, Ehrenstein V, Felisi M, Ferrajolo C, Fontana A, Francisca R, Fourrier-Reglat A, Fortuny J, Gini R, Hyeraci G, Hoeve C, Kontogiorgis C, Isgrò V, Lalagkas PN, L'Abbate L, Layton D, Landi A, Narduzzi S, Pereira LR, Poulentzas G, Rafaniello C, Roberto G, Scondotto G, Sportiello L, Toma M, Toussi M, Verhamme K, Volpe E, Trifirò G. Overview of the EU PAS register post-authorization studies performed in Europe from September 2010 to December 2018. Pharmacoepidemiol Drug Saf 2022; 31:689-705. [PMID: 35092329 PMCID: PMC9303697 DOI: 10.1002/pds.5413] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 12/09/2021] [Accepted: 01/24/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND The European post-authorisation study (EU PAS) register is a repository launched in 2010 by the European Medicines Agency (EMA). All EMA-requested PAS, commonly observational studies, must be recorded in this register. Multi-database studies (MDS) leveraging secondary data have become an important strategy to conduct PAS in recent years, as reflected by the type of studies registered in the EU PAS register. OBJECTIVES To analyse and describe PAS in the EU PAS register, with focus on MDS. METHODS Studies in the EU PAS register from inception to 31st December 2018 were described concerning transparency, regulatory obligations, scope, study type (e.g. observational study, clinical trial, survey, systematic review/meta-analysis), study design, type of data collection and target population. MDS were defined as studies conducted through secondary use of >1 data source not linked at patient-level. Data extraction was carried out independently by 14 centres with expertise in pharmacoepidemiology, using publicly available information in the EU PAS register including study protocol, whenever available, using a standardised data collection form. For validation purposes, a second revision of key fields for a 15% random sample of studies was carried out by a different centre. The inter-rater reliability (IRR) was then calculated. Finally, to identify predictors of primary data collection-based studies /vs those based on secondary use of healthcare databases) or MDS (vs. non-MDS), odds ratios (OR) and 95% confidence intervals (CI) were calculated fitting univariate logistic regression models. RESULTS Overall, 1,426 studies were identified. Clinical trials (N=30; 2%), systematic reviews/meta-analyses (N=16; 1%) and miscellaneous study designs (N=46; 3%) were much less common than observational studies (N=1,227; 86%). The protocol was available for 63% (N=360) of 572 observational studies requested by a competent authority. Overall, 36% (N=446) of observational studies were based fully or partially on primary data collection. Of 757 observational studies based on secondary use of data alone, 282 (37%) were MDS. Drug utilisation was significantly more common as a study scope in MDS compared to non-MDS studies. The overall percentage agreement among collaborating centres that collected the data concerning study variables was highest for study type (93.5%) and lowest for type of secondary data (67.8%). CONCLUSIONS Observational studies were the most common type of studies in the EU PAS register, but 30% used primary data, which is more resource-intensive. Almost half of observational studies using secondary data were MDS. Data recording in the EU PAS register may be improved further, including more widespread availability of study protocols to improve transparency.
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Affiliation(s)
- Janet Sultana
- Pharmacy Department, Mater Dei Hospital, Malta.,Exeter College of Medicine and Health, Exeter
| | - Salvatore Crisafulli
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Mariana Almas
- Real World Solutions Department, IQVIA, Lisbon, Portugal
| | - Ippazio Cosimo Antonazzo
- Research Centre on Public Health (CESP), University of Milan-Bicocca, Milan, Italy.,Agenzia Regionale di Sanità della Toscana, Florence, Italy
| | - Esme Baan
- Department of Medical Informatics, Erasmus Medical Centre, Rotterdam, The Netherlands
| | | | - Maria Paola Bertuccio
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Fedele Bonifazi
- TEDDY European Network of Excellence for Paediatric Clinical Research, Pavia, Italy.,Fondazione per la Ricerca Farmacologica Gianni Benzi Onlus, Bari, Italy
| | - Annalisa Capuano
- Department of Experimental Medicine, University of Campania "Vanvitelli", Naples, Italy.,Campania Regional Center of Pharmacovigilance and Pharmacoepidemiology, Naples, Italy
| | - Antonella Didio
- TEDDY European Network of Excellence for Paediatric Clinical Research, Pavia, Italy.,Fondazione per la Ricerca Farmacologica Gianni Benzi Onlus, Bari, Italy
| | - Vera Ehrenstein
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Mariagrazia Felisi
- TEDDY European Network of Excellence for Paediatric Clinical Research, Pavia, Italy.,CVBF Consorzio per Valutazioni Biologiche e Farmacologiche, Pavia, Italy
| | - Carmen Ferrajolo
- Department of Experimental Medicine, University of Campania "Vanvitelli", Naples, Italy.,Campania Regional Center of Pharmacovigilance and Pharmacoepidemiology, Naples, Italy
| | - Andrea Fontana
- Unit of Biostatistics, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Remy Francisca
- Department of Medical Informatics, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Annie Fourrier-Reglat
- Univ. Bordeaux, INSERM, Bordeaux Population Health Research Center, Team of Pharmacoepidemiology, UMR 1219, Bordeaux, France
| | | | - Rosa Gini
- Agenzia Regionale di Sanità della Toscana, Florence, Italy
| | - Giulia Hyeraci
- Agenzia Regionale di Sanità della Toscana, Florence, Italy
| | - Christel Hoeve
- Department of Medical Informatics, Erasmus Medical Centre, Rotterdam, The Netherlands
| | | | - Valentina Isgrò
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | | | - Luca L'Abbate
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Deborah Layton
- Data Science Hub, Real World Solutions, IQVIA, London, United Kingdom
| | - Annalisa Landi
- TEDDY European Network of Excellence for Paediatric Clinical Research, Pavia, Italy.,Fondazione per la Ricerca Farmacologica Gianni Benzi Onlus, Bari, Italy
| | - Silvia Narduzzi
- Data Science Hub, Real World Solutions, IQVIA, London, United Kingdom
| | - Leonardo Roque Pereira
- University Medical Center Utrecht, Department of Datascience & Biostatistics, Utrecht, the Netherlands
| | | | - Concetta Rafaniello
- Department of Experimental Medicine, University of Campania "Vanvitelli", Naples, Italy.,Campania Regional Center of Pharmacovigilance and Pharmacoepidemiology, Naples, Italy
| | | | - Giulia Scondotto
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Liberata Sportiello
- Department of Experimental Medicine, University of Campania "Vanvitelli", Naples, Italy.,Campania Regional Center of Pharmacovigilance and Pharmacoepidemiology, Naples, Italy
| | - Maddalena Toma
- TEDDY European Network of Excellence for Paediatric Clinical Research, Pavia, Italy.,Fondazione per la Ricerca Farmacologica Gianni Benzi Onlus, Bari, Italy
| | - Massoud Toussi
- Data Science Hub, Real World Solutions, IQVIA, London, United Kingdom
| | - Katia Verhamme
- Department of Medical Informatics, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Elisabetta Volpe
- TEDDY European Network of Excellence for Paediatric Clinical Research, Pavia, Italy.,Fondazione per la Ricerca Farmacologica Gianni Benzi Onlus, Bari, Italy
| | - Gianluca Trifirò
- Department of Diagnostics and Public Health, University of Verona, Verona, Italy
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Jouaville LS, Paul T, Almas MF. A review of the sampling methodology used in studies evaluating the effectiveness of risk minimisation measures in Europe. Pharmacoepidemiol Drug Saf 2021; 30:1143-1152. [PMID: 34092001 PMCID: PMC8453956 DOI: 10.1002/pds.5301] [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: 08/04/2020] [Accepted: 05/27/2021] [Indexed: 12/02/2022]
Abstract
Purpose This review aims to describe the sampling methodology used in studies assessing effectiveness of risk minimisation measures (RMMs) in the European Union. Methods The European Union electronic Register of Post‐Authorization Studies (EU PAS Register) was searched to identify studies that assessed the effectiveness of RMMs and recruited a target population of healthcare professionals (HCPs), sites or patients. Studies with both protocol and report were included and data was extracted from these documents to describe study characteristics and variables involved in the sampling methodology. Results Out of 1092 studies finalised between June 2017 and May 2019, 17 studies were eligible for review. Thirteen were surveys, three chart reviews and one combined both methodologies. All the 17 studies recruited HCPs/sites and 8 of them also recruited patients. The most common rationale for country sampling was market uptake (10/17), while for HCP/site sampling, it was representativeness of the prescribing practices (14/17). Only a minority of the studies (4/17) provided supporting evidence to inform this theoretical framework. HCP/site sampling frames were mainly network of physicians (5/17) or HCP databases (5/17), with only one study providing a detailed description of the sampling frame. HCPs were selected mainly using probabilistic sampling (10/17) and patients using non‐probabilistic sampling (6/8). Only a few studies compared participating with non‐participating HCPs/sites (5/17) and patients (3/8). Eight studies reported that their results were generalisable. Conclusions Overall, the study documents provided insufficient details to understand the rationale behind the sampling decisions. More standardisation and guidance in reporting the sampling strategy and operational considerations applicable to these types of studies would support transparency and facilitate the evaluation of representativeness of the study results.
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Affiliation(s)
| | - Tulika Paul
- IQVIA Real World Solutions, Gurugram, Haryana, India
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10
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Mayall S, Kahlon R, Al-Dakkak I, Shen SW. Evaluating the Effectiveness of Apixaban Additional Risk Minimisation Measures Using Surveys in Europe. Pharmaceut Med 2021; 35:123-135. [PMID: 33660230 PMCID: PMC7979585 DOI: 10.1007/s40290-021-00380-1] [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] [Accepted: 01/07/2021] [Indexed: 11/24/2022]
Abstract
Background Apixaban (ELIQUIS®) is a direct oral anticoagulant authorised for multiple indications in the European Economic Area (EEA). Additional risk minimisation measures (aRMMs) to address the risk of bleeding include educational materials comprising a Prescriber Guide and Patient Alert Card. Objectives This study evaluated effectiveness of the apixaban Prescriber Guide and Patient Alert Card in terms of healthcare professional (HCP) and patient knowledge of associated bleeding risk, as well as material distribution, utilisation and behaviour. Methods This non-interventional, cross-sectional study included online surveys in ten countries that represented a high proportion of apixaban usage in the EEA. The HCP source population was based on HCP lists used for communications about and distribution of the risk minimisation materials. Patient recruitment took place via HCPs. Study participants included HCPs involved in apixaban treatment and patients treated with apixaban (or their caregivers) for multiple indications. Data collection took place over an 18-month period between August 2015 and February 2017. Results Survey responses from 385 HCPs and 125 patients/caregivers were analysed. HCP knowledge of bleeding risk included early recognition of symptoms requiring immediate contact with an HCP (96.1%), appropriate dosing (83.6%), contraindications (76.1%) and subpopulations at increased risk of bleeding complications (ranging from 63.5 to 85.9%). Patient knowledge included abnormal bleeding as an important side effect (71.2%), communicating risk factors to HCPs (76.8%) and recognition of potential bleeding symptoms (‘high’ knowledge levels 22.4%, ‘moderate’ knowledge levels 49.6%). Of 226 (58.7%) HCPs who recalled receiving/obtaining the Prescriber Guide, 97.8% read at least part of it and 74.8% had used it to assist patient discussions. Of 74 (59.2%) patients who were aware of the Patient Alert Card, 89.2% recalled receiving/obtaining a copy. When received, 90.9% of patients read the card at least once and 93.9% kept it with them at least some of the time. Conclusions HCP and patient respondent knowledge of bleeding risk was satisfactory. Although not optimal, reach of the aRMMs was consistent with other studies. No modifications to aRMM content were required. To increase reach, the Prescriber Guide has been provided in an additional format as a web-based platform whilst the Patient Alert Card was included within product packaging. Supplementary Information The online version contains supplementary material available at 10.1007/s40290-021-00380-1.
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Affiliation(s)
- Steve Mayall
- Development Consulting, Pope Woodhead and Associates Ltd (now part of Axian Consulting Ltd, Cambridge, UK), St Ives, Cambridgeshire, UK.
| | - Randip Kahlon
- Worldwide Patient Safety, Bristol Myers Squibb, Uxbridge Business Park, Sanderson Road, Uxbridge, UB8 1DH, UK
| | - Imad Al-Dakkak
- Development Consulting, Pope Woodhead and Associates Ltd (now part of Axian Consulting Ltd, Cambridge, UK), St Ives, Cambridgeshire, UK
| | - Sophie W Shen
- Worldwide Patient Safety, Bristol Myers Squibb, Route 206 and Province Line Road, Princeton, NJ, 08540, USA
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Risk Minimisation Evaluation with Process Indicators and Behavioural or Health Outcomes in Europe: Systematic Review. Pharmaceut Med 2020; 34:387-400. [PMID: 33141411 DOI: 10.1007/s40290-020-00361-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND European Pharmacovigilance regulatory guidance recommends the evaluation of additional risk minimisation measures (aRMMs) with process indicators and outcomes. Evaluation of both measures within the same evaluation helps to establish the relationship between the implementation of aRMMs (across process indicators) and the impact on drug safety-related outcomes. The term risk minimisation evaluation (RMEv) was used to describe a study or group of studies that assesses the effectiveness of aRMMs for one specific product. OBJECTIVES The objective of this systematic review was to describe the characteristics and results of RMEv that include both process indicators and outcomes as well as those of studies that conform the RMEv in Europe. METHODS We conducted a systematic search in the European Union Register of Post-Authorization Studies, PubMed and grey literature (Google and abstracts of the International Conference on Pharmacoepidemiology and Therapeutic Risk Management) to identify studies that assessed the effectiveness of aRMMs including at least one European country, from 1 January, 2011 to 12 October, 2019. Identified studies linked to one product were considered part of the product RMEv. Only RMEv that included both process indicators and outcomes (behavioural and/or health/safety outcomes) were eligible. Data were abstracted from reports, manuscripts and abstracts. RESULTS Eighteen of 102 (18%) RMEv had both process indicators and outcomes, and were included in this review. Of the 18 RMEv, ten consisted of one study only, five of two studies, and three of three or more studies. A total of 30 studies were included within the 18 RMEv. The designs of the studies were: 19 (63%) cross-sectional surveys (47% targeted patients and 89% healthcare professionals), 17 (57%) retrospective studies (47% using pre/post approach) and 3 (10%) prospective studies. Nineteen studies included process indicators that were receipt (n = 14), use (n = 12), knowledge (n = 17) and self-reported behaviour (n = 15). Regarding outcomes, 67% of the 18 RMEv evaluated behavioural outcomes and 50% health/safety outcomes. Three of the 18 RMEv evaluated both behavioural and health/safety outcomes. For five RMEv, correlations between process indicators and outcomes were performed, two at the patient level. Results were available for 14 of the 18 RMEv. In healthcare professional surveys, the median percentage was 57% for receipt, 92% for reading, 80% for use, 77% for knowledge and 74% for behaviour. In patient surveys, the median percentage was 56% for receipt, 87% for reading, 65% for use, 47% for knowledge and 69% for behaviour. Knowledge was better in healthcare professionals than patients (p < 0.05). Of the three RMEv with a correlation analysis, only one found a positive trend for a lower occurrence of outcomes as process indicators improved, though this was not statistically significant. CONCLUSIONS A minority of RMEv assessed both process indicators and outcomes. More RMEv require approaches that correlate process indicators and outcomes at the patient level to evaluate more comprehensively the implementation of aRMMs.
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Francisca RDC, Baba E, Hoeve CE, Zomerdijk IM, Sturkenboom MCJM, Straus SMJM. Introduction or Discontinuation of Additional Risk Minimisation Measures During the Life Cycle of Medicines in Europe. Drug Saf 2020; 44:63-72. [PMID: 33000427 PMCID: PMC7813721 DOI: 10.1007/s40264-020-00993-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Introduction Additional risk minimisation measures (aRMMs) may be required to minimise important risks of medicines. aRMMs may be required at the time of authorisation, but may also be introduced or discontinued during the product life cycle as new safety information arises. The aim of this study is to describe post-authorisation introductions of new aRMMs and discontinuations of existing aRMMs for medicines authorised in the European Union (EU). Methods We performed a retrospective cohort study that included all new active substances authorised through the EU centralised procedure between January 1st 2006 and December 31st 2017. Data was extracted from European Public Assessment Reports available on the website of the European Medicines Agency (ema.europa.eu). Medicines were followed up from the date of marketing authorisation (MA) until first introduction or discontinuation of aRMMs, excluding Direct Healthcare Professional Communications (DHPCs), withdrawal/suspension/revocation of the MA, or July 1st 2018, when data extraction took place. Descriptive statistics were used to analyse frequency data, and survival analysis was used to calculate 5- and 10-year probability of introduction or discontinuation of aRMMs. Results A total of 476 medicines were authorised during the study period. The probability of getting aRMMs after authorisation for products authorised without aRMMs was 3.5% [95% confidence interval (CI) 1.2–5.7] within 5 years after authorisation and 6.9% (95% CI 2.6–11) within 10 years after authorisation. For products authorised with aRMMs, the probability of discontinuation of aRMMs was 0.9% (95% CI 0–2.6) within 5 years and 8.3% (95% CI 0–16.1) within 10 years after authorisation. Conclusions We found low probabilities of introduction and discontinuation of aRMMs (excluding DHPCs) during the product life cycle for medicines authorised between 2006 and 2017. The low rate of discontinuation may potentially be due to a lack of robust data on effectiveness of aRMMs. Further research is needed to get more insight into the dynamics of aRMMs during the medicine life cycle.
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Affiliation(s)
- Reynold D C Francisca
- Erasmus Medical Centre, Department of Medical Informatics, Rotterdam, The Netherlands.
- Medicines Evaluation Board, Department of Pharmacovigilance, Utrecht, The Netherlands.
| | - Emna Baba
- Medicines Evaluation Board, Department of Pharmacovigilance, Utrecht, The Netherlands
| | - Christina E Hoeve
- Erasmus Medical Centre, Department of Medical Informatics, Rotterdam, The Netherlands
- Medicines Evaluation Board, Department of Pharmacovigilance, Utrecht, The Netherlands
| | - Inge M Zomerdijk
- Erasmus Medical Centre, Department of Medical Informatics, Rotterdam, The Netherlands
- Medicines Evaluation Board, Department of Pharmacovigilance, Utrecht, The Netherlands
| | | | - Sabine M J M Straus
- Erasmus Medical Centre, Department of Medical Informatics, Rotterdam, The Netherlands
- Medicines Evaluation Board, Department of Pharmacovigilance, Utrecht, The Netherlands
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Farcas A, Balcescu T, Anghel L, Bucsa C, Mogoșan C. A description of medicines-related safety issues evaluated through a referral procedure at the EU level after 2012. Expert Opin Drug Saf 2020; 19:755-762. [PMID: 32186202 DOI: 10.1080/14740338.2020.1744561] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Important drug safety issues are evaluated through a referral procedure in the EU by the Pharmacovigilance Risk Assessment Committee (PRAC) within the European Medicines Agency. We aim to describe all safety-related referrals assessed by the PRAC by June 2019. METHODS Publicly available data on safety issues assessed through referral procedures that reached a final decision during July 2012-June 2019 were identified, analyzed and classified according to predefined criteria. RESULTS Fifty-one safety issues were assessed by PRAC for 45 medicines/combinations/therapeutic classes during this timeframe. Referrals were initiated mostly by the European Commission (16) and France (8). Nine medicines were authorized in the last five years, the rest being well-established drugs. In four cases (flupirtine, hydroxyethyl-starch, valproate, codeine) PRAC re-assessed the same risks as previous recommendations have not been effective. Post-referral recommendations consisted of updates of the summary of product characteristics and package leaflet (42), Direct Healthcare Professional Communication (32), and other additional risk minimization measures (RMMs). Withdrawal was recommended for seven active substances. CONCLUSIONS PRAC recommended routine or additional RMMs for most referrals. Complete withdrawal of a drug or withdrawal of certain pharmaceutical forms or concentrations was advised only when the risk could not be managed by RMMs.
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Affiliation(s)
- Andreea Farcas
- Drug Information Research Center, "Iuliu Hatieganu" University of Medicine and Pharmacy , Cluj-Napoca, Romania
| | - Teodora Balcescu
- Drug Information Research Center, "Iuliu Hatieganu" University of Medicine and Pharmacy , Cluj-Napoca, Romania
| | - Laura Anghel
- Drug Information Research Center, "Iuliu Hatieganu" University of Medicine and Pharmacy , Cluj-Napoca, Romania
| | - Camelia Bucsa
- Drug Information Research Center, "Iuliu Hatieganu" University of Medicine and Pharmacy , Cluj-Napoca, Romania
| | - Cristina Mogoșan
- Drug Information Research Center, "Iuliu Hatieganu" University of Medicine and Pharmacy , Cluj-Napoca, Romania
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Salem L, Malouvier A, Blatchford J, Rivero-Ferrer E, Deltour N, Jacquot E. Ivabradine drug utilization study in five European countries: A multinational, retrospective, observational study to assess effectiveness of risk-minimization measures. Pharmacoepidemiol Drug Saf 2019; 28:1470-1479. [PMID: 31486198 PMCID: PMC6899761 DOI: 10.1002/pds.4880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 06/18/2019] [Accepted: 07/05/2019] [Indexed: 11/10/2022]
Abstract
Purpose This drug utilization study of ivabradine evaluated prescriber compliance with the new risk minimization measures (RMMs), communicated starting 2014 following preliminary results from the SIGNIFY study. Methods This was a multinational (five European countries) chart review study with two study periods: pre‐RMM and post‐RMM. Patients initiating ivabradine for chronic stable angina pectoris in routine clinical practice were identified across general practitioners and specialists. The primary outcome analysis evaluated the compliance with the new RMMs, ie, use in patients with a heart rate greater than or equal to 70 bpm at initiation, no doses higher than those recommended in the summary of product characteristics (SmPC) at initiation and during 6 months of follow‐up, and no concomitant use of verapamil or diltiazem. Results Overall, 711 and 506 eligible patients were included in the pre‐RMM and post‐RMM periods, respectively. The percentage of patients prescribed ivabradine according to the new RMMs increased significantly in the post‐RMM period (70.6% and 78.4% in the pre‐ and post‐RMM periods respectively; P value = .0035). The compliance to RMMs increased for all the criteria assessed independently: the proportions of patients with (a) heart rate ≥ 70 bpm at initiation (79.4% and 85.2%, respectively; P value = .0141), (b) no dose higher than the SmPC doses at initiation and during follow‐up (92.8% and 94.1%, respectively; P value = .3957), and (c) no concomitance with verapamil or diltiazem (96.1% and 99.2%, respectively; P value = .0007). Conclusions The RMMs for ivabradine were well implemented across the five participating European countries confirming a favorable benefit‐risk balance of ivabradine in chronic stable angina pectoris.
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Affiliation(s)
- Linda Salem
- Department of Pharmacoepidemiology and Real World Evidence, Les Laboratoires Servier, CEDEX, France
| | | | | | | | - Nicolas Deltour
- Department of Pharmacoepidemiology and Real World Evidence, Les Laboratoires Servier, CEDEX, France
| | - Emmanuelle Jacquot
- Department of Pharmacoepidemiology and Real World Evidence, Les Laboratoires Servier, CEDEX, France
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Farcas A, Huruba M, Mogosan C. Study design, process and outcome indicators of post-authorization studies aimed at evaluating the effectiveness of risk minimization measures in the EU PAS Register. Br J Clin Pharmacol 2018; 85:476-491. [PMID: 30497102 DOI: 10.1111/bcp.13824] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 11/09/2018] [Accepted: 11/23/2018] [Indexed: 11/29/2022] Open
Abstract
Risk minimization measures (RMMs) represent an essential tool for preventing the occurrence of safety-related outcomes. The evaluation of RMMs effectiveness is essential to prove their success and ensure protection of public health. The aim of this qualitative review was to assess the design, process and outcome indicators used for attesting successful implementation of RMMs. We searched the EU Post-Authorization Studies Register up to 30 June 2018 for studies having the scope defined as 'effectiveness evaluation'. Study titles and objectives were screened to select the ones evaluating the effectiveness of RMMs. We described and assessed the extent to which these studies aligned with Good Pharmacovigilance Practices guidelines recommendations. Out of 360 registered studies, we identified 35 studies on evaluation of RMMs effectiveness, 29 being eligible for review. Twenty-six studies evaluated additional RMMs, employed in case routine interventions are considered insufficient. All studies assessed process indicators, five also assessing outcome indicators, thus using a dual-evidence approach as recommended by the guidelines. However, none of the latter used a pre-post design, comparing the frequency of the adverse outcome before and after the implementation of RMMs. Behaviour and knowledge were the most often assessed process indicators. Outcome indicators included occurrence of adverse reactions, pregnancy, off-label use and medication errors. Only four studies had an established threshold, all for process indicators. Stricter adherence to existing recommendations would allow for a more robust design for reaching established endpoints for RMM effectiveness evaluation. It would also infer harmonization, facilitate review and further more detailed guidance on conducting these studies.
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Affiliation(s)
- Andreea Farcas
- Drug Information Research Center, 'Iuliu Haţieganu' University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Madalina Huruba
- Drug Information Research Center, 'Iuliu Haţieganu' University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Cristina Mogosan
- Drug Information Research Center, 'Iuliu Haţieganu' University of Medicine and Pharmacy, Cluj-Napoca, Romania
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