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Castanon A, Sloan R, Arocha LS, Ramagopalan SV. EU HTA Joint Clinical Assessment: are patients with rare disease going to lose out? J Comp Eff Res 2024; 13:e240052. [PMID: 38696698 PMCID: PMC11145525 DOI: 10.57264/cer-2024-0052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 04/15/2024] [Indexed: 05/04/2024] Open
Affiliation(s)
| | | | | | - Sreeram V Ramagopalan
- Lane Clark & Peacock LLP, London, W1U 9DQ, UK
- Centre for Pharmaceutical Medicine Research, King's College London, London, SE1 9NH, UK
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2
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Fernandez J, Babin C, Thomassin C, Pelon F, Kelley S, Cochat P, Galbraith M, Berdaï D, Pariente A, Salvo F, Vanier A. Can requests for real-world evidence by the French HTA body be planned? An exhaustive retrospective case-control study of medicinal products appraisals from 2016 to 2021. Int J Technol Assess Health Care 2024; 40:e33. [PMID: 38757153 DOI: 10.1017/s0266462324000291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
OBJECTIVES In France, decisions for pricing and reimbursement for medicinal products are based on appraisals performed by the National authority for health (Haute Autorité de Santé (HAS)). During the appraisal process, additional real-world evidence can be requested as "Post-Registration Studies" (PRS) when there are uncertainties in evidence that could be resolved by additional data collection. To facilitate PRS planning, a retrospective exploratory analysis was conducted to identify the characteristics of medicinal products associated with a PRS request. METHODS This analysis encompassed all appraisals finalized between January 1, 2016 and December 31, 2021 and compared products for which the appraisal led to a PRS request with those that did not. RESULTS Six hundred positive opinions for reimbursement were identified, with a PRS request present in 17 percent (n = 103) of cases. The independent characteristics associated with a PRS request were a mild or moderate clinical benefit score, a major to moderate or minor clinical added value score, previous availability under an early access program, and certain therapeutic areas (neurology, pulmonology, and endocrinology). These findings suggest two different profiles of PRS requests: (i) products for which there is uncertainty in the size of the clinical benefit and (ii) innovative products for which a substantial benefit is expected but uncertainties persist. CONCLUSIONS These results will assist health technology developers to better anticipate data generation to promptly address uncertainties identified by HAS. It may also help HAS and other assessment agencies to work together to improve postlaunch evidence generation according to the characteristics of the medicinal products.
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Affiliation(s)
- Judith Fernandez
- HTA Department, Haute Autorité de Santé, La Plaine Saint-Denis, France
| | - Céleste Babin
- HTA Department, Haute Autorité de Santé, La Plaine Saint-Denis, France
| | - Camille Thomassin
- HTA Department, Haute Autorité de Santé, La Plaine Saint-Denis, France
| | - Floriane Pelon
- HTA Department, Haute Autorité de Santé, La Plaine Saint-Denis, France
| | - Sophie Kelley
- HTA Department, Haute Autorité de Santé, La Plaine Saint-Denis, France
| | - Pierre Cochat
- Scientific Board and Chairman of the Transparency Committee, Haute Autorité de Santé, La Plaine Saint-Denis, France
| | | | - Driss Berdaï
- CHU de Bordeaux, Pharmacoepidemiology and Appropriate use of Medicine Team, Public Health Department, Clinical Pharmacology Unit Bordeaux, Nouvelle-Aquitaine, France
| | - Antoine Pariente
- CHU de Bordeaux, Pharmacoepidemiology and Appropriate use of Medicine Team, Public Health Department, Clinical Pharmacology Unit Bordeaux, Nouvelle-Aquitaine, France
- University of Bordeaux, INSERM, BPH, U1219, Team AHeaD Talence, Aquitaine, France
| | - Francesco Salvo
- University of Bordeaux, INSERM, BPH, U1219, Team AHeaD Talence, Aquitaine, France
- CHU de Bordeaux, Regional center for pharmacovigilance Public Health Department, Clinical Pharmacology Unit Bordeaux, Nouvelle-Aquitaine, France
| | - Antoine Vanier
- HTA Department, Haute Autorité de Santé, La Plaine Saint-Denis, France
- Université de Tours, UMR U1246 Sphere, Inserm Tours, Centre-Val de Loire, France
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3
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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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4
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Bray BD, Ramagopalan SV. R WE ready for reimbursement? A round up of developments in real-world evidence relating to health technology assessment: part 14. J Comp Eff Res 2024; 13:e230189. [PMID: 38179957 PMCID: PMC10842288 DOI: 10.57264/cer-2023-0189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 12/19/2023] [Indexed: 01/06/2024] Open
Abstract
In this latest update we highlight: a publication from the US FDA regarding the definitions of real-world data (RWD) and real-world evidence (RWE); a publication from academic researchers on a demonstration project for target trial emulation; a publication from the National Institute of Health and Care Excellence (NICE) on the 1 year anniversary of their RWE framework; and a publication from NICE and Flatiron Health on the utility of US RWD for initial UK health technology assessment decision making.
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Affiliation(s)
- Benjamin D Bray
- Lane Clark & Peacock LLP, London, W1U 1DQ, UK
- Department of Population Health Sciences, King's College London, London, SE1 9NH, UK
| | - Sreeram V Ramagopalan
- Lane Clark & Peacock LLP, London, W1U 1DQ, UK
- Centre for Pharmaceutical Medicine Research, King's College London, London, SE1 1UL, UK
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5
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Van Remoortel H, van den Hurk K, Compernolle V, O'Leary P, Tiberghien P, Erikstrup C. Very-high frequency plasmapheresis and donor health-absence of evidence is not equal to evidence of absence. Transfusion 2023; 63:2358-2361. [PMID: 37982361 DOI: 10.1111/trf.17601] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 11/06/2023] [Indexed: 11/21/2023]
Affiliation(s)
- Hans Van Remoortel
- Centre for Evidence-Based Practice, Belgian Red Cross, Brussels, Belgium
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Katja van den Hurk
- Department of Donor Medicine Research, Donor Studies, Sanquin Research, Amsterdam, The Netherlands
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Veerle Compernolle
- Blood Services, Belgian Red Cross, Brussels, Belgium
- Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium
| | | | - Pierre Tiberghien
- European Blood Alliance, Brussels, Belgium
- Etablissement Français du Sang, La Plaine Saint-Denis, France
- EFS, INSERM, UMR Right, Université de Franche-Comté, Besançon, France
| | - Christian Erikstrup
- Department of Clinical Immunology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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6
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Leahy TP, Durand-Zaleski I, Sampietro-Colom L, Kent S, Zöllner Y, Coyle D, Casadei G. The role of quantitative bias analysis for nonrandomized comparisons in health technology assessment: recommendations from an expert workshop. Int J Technol Assess Health Care 2023; 39:e68. [PMID: 37981828 DOI: 10.1017/s0266462323002702] [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] [Indexed: 11/21/2023]
Abstract
The use of treatment effects derived from nonrandomized studies (NRS) in health technology assessment (HTA) is growing. NRS carry an inherently greater risk of bias than randomized controlled trials (RCTs). Although bias can be mitigated to some extent through appropriate approaches to study design and analysis, concerns around data availability and quality and the absence of randomization mean residual biases typically render the interpretation of NRS challenging. Quantitative bias analysis (QBA) methods are a range of methods that use additional, typically external, data to understand the potential impact that unmeasured confounding and other biases including selection bias and time biases can have on the results (i.e., treatment effects) from an NRS. QBA has the potential to support HTA bodies in using NRS to support decision-making by quantifying the magnitude, direction, and uncertainty of biases. However, there are a number of key aspects of the use of QBA in HTA which have received limited discussion. This paper presents recommendations for the use of QBA in HTA developed using a multi-stakeholder workshop of experts in HTA with a focus on QBA for unmeasured confounding.
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Affiliation(s)
| | - Isabelle Durand-Zaleski
- AP-HP, Health Economics Research Unit, Department of Public Health, Henri Mondor Hospital, Paris, France
- Methods, UMRS 1153, French National Institute of Health and Medical Research, Paris, France
- Faculty of Medicine, Université Paris Est Creteil, Creteil, France
| | - Laura Sampietro-Colom
- Health Technology Assessment (HTA) Unit, Hospital Clinic of Barcelona, Barcelona, Spain
| | | | - York Zöllner
- Department of Health Sciences, HAW Hamburg, Hamburg, Germany
| | - Doug Coyle
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Gianluigi Casadei
- Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
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7
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Foy R, Ivers NM, Grimshaw JM, Wilson PM. What is the role of randomised trials in implementation science? Trials 2023; 24:537. [PMID: 37587521 PMCID: PMC10428627 DOI: 10.1186/s13063-023-07578-5] [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: 05/08/2023] [Accepted: 08/04/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND There is a consistent demand for implementation science to inform global efforts to close the gap between evidence and practice. Key evaluation questions for any given implementation strategy concern the assessment and understanding of effects. Randomised trials are generally accepted as offering the most trustworthy design for establishing effectiveness but may be underused in implementation science. MAIN BODY There is a continuing debate about the primacy of the place of randomised trials in evaluating implementation strategies, especially given the evolution of more rigorous quasi-experimental designs. Further critiques of trials for implementation science highlight that they cannot provide 'real world' evidence, address urgent and important questions, explain complex interventions nor understand contextual influences. We respond to these critiques of trials and highlight opportunities to enhance their timeliness and relevance through innovative designs, embedding within large-scale improvement programmes and harnessing routine data. Our suggestions for optimising the conditions for randomised trials of implementation strategies include strengthening partnerships with policy-makers and clinical leaders to realise the long-term value of rigorous evaluation and accelerating ethical approvals and decluttering governance procedures for lower risk studies. CONCLUSION Policy-makers and researchers should avoid prematurely discarding trial designs when evaluating implementation strategies and work to enhance the conditions for their conduct.
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Affiliation(s)
- Robbie Foy
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.
| | - Noah M Ivers
- Women's College Hospital, Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | | | - Paul M Wilson
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
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Hulstaert F, Pouppez C, Primus-de Jong C, Harkin K, Neyt M. Gaps in the evidence underpinning high-risk medical devices in Europe at market entry, and potential solutions. Orphanet J Rare Dis 2023; 18:212. [PMID: 37491269 PMCID: PMC10369713 DOI: 10.1186/s13023-023-02801-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 07/05/2023] [Indexed: 07/27/2023] Open
Abstract
AIM To determine the level of evidence for innovative high-risk medical devices at market entry. METHODS We reviewed all Belgian healthcare payer (RIZIV-INAMI) assessor reports on novel implants or invasive medical devices (n = 18, Class IIb-III) available between 2018 to mid-2019 on applications submitted for inclusion on their reimbursement list. We also conducted a review of the literature on evidence gaps and an analysis of relevant legal and ethical frameworks within the European context. FINDINGS Conformity assessment of medical devices is based on performance, safety, and an acceptable risk-benefit balance. Information submitted for obtaining CE marking is confidential and legally protected, limiting access to clinical evidence. Seven out of the 18 RIZIV-INAMI assessor reports (39%) included a randomized controlled trial (RCT) using the novel device, whilst 2 applications (11%) referred to an RCT that used a different device. The population included was inappropriate or unclear for 3 devices (17%). Only half of the applications presented evidence on quality of life or functioning and 2 (11%) presented overall survival data. Four applications (22%) included no data beyond twelve months. The findings from the literature demonstrated similar problems with the study design and the clinical evidence. DISCUSSION AND CONCLUSIONS CE marking does not indicate that a device is effective, only that it complies with the law. The lack of transparency hampers evidence-based decision making. Despite greater emphasis on clinical benefit for the patient, the provisions of the European Medical Device Regulation (MDR) are not yet fully aligned with international ethical standards for clinical research. The MDR fails to address key issues, such as the lack of access to data submitted for CE marking and a failure to require evidence of clinical effectiveness. Indeed, a first report shows no improvement in the clinical evidence for implantable devices generated under the MDR. Thus, patients may continue to be exposed to ineffective or unsafe novel devices. The Health Technology Assessment Regulation plans for Joint Scientific Consultations for specific high-risk devices before companies begin their pivotal clinical investigations. The demanded comparative evidence should facilitate payer decisions. Nevertheless, there is also a need for legislation requiring comparative RCTs assessing patient-relevant outcomes for high-risk devices to ensure implementation, including development and implementation of common specifications for study designs.
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Affiliation(s)
- Frank Hulstaert
- Administrative Centre Botanique, Belgian Health Care Knowledge Centre (KCE), Doorbuilding (10th floor), Boulevard du Jardin Botanique 55, Brussels, B-1000, Belgium.
| | - Céline Pouppez
- Administrative Centre Botanique, Belgian Health Care Knowledge Centre (KCE), Doorbuilding (10th floor), Boulevard du Jardin Botanique 55, Brussels, B-1000, Belgium
| | - Célia Primus-de Jong
- Administrative Centre Botanique, Belgian Health Care Knowledge Centre (KCE), Doorbuilding (10th floor), Boulevard du Jardin Botanique 55, Brussels, B-1000, Belgium
| | - Kathleen Harkin
- Centre for Health Policy and Management, Trinity College Dublin, 3-4 Foster Place, Room 0.18, Dublin, Ireland
| | - Mattias Neyt
- Administrative Centre Botanique, Belgian Health Care Knowledge Centre (KCE), Doorbuilding (10th floor), Boulevard du Jardin Botanique 55, Brussels, B-1000, Belgium
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9
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Bray B, Ramagopalan SV. R WE ready for reimbursement? A round up of developments in real-world evidence relating to health technology assessment: part 12. J Comp Eff Res 2023; 12:e230092. [PMID: 37345541 PMCID: PMC10508304 DOI: 10.57264/cer-2023-0092] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 05/26/2023] [Indexed: 06/23/2023] Open
Abstract
In this latest update we highlight the final results from the RCT-DUPLICATE initiative, the publication of guidance from Haute Autorité de Santé (HAS), the joint viewpoint from the Institute for Quality and Efficiency in HealthCare (IQWIG) and the Belgian HealthCare Knowledge Center, and a position from the European Organization for Research and Treatment of Cancer (EORTC). Finally, we discuss how the NICE RWE framework has been implemented to allow consideration of RWE external control arms.
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Affiliation(s)
- Ben Bray
- Lane Clark & Peacock, London, W1U 1DQ, UK
- Department of Population Health Sciences, King’s College London, London, SE1 3QD, UK
| | - Sreeram V Ramagopalan
- Lane Clark & Peacock, London, W1U 1DQ, UK
- Center for Pharmaceutical Medicine Research, King’s College London, London, SE1 9NH, UK
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10
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Schillinger G. [Genetic tumour diagnostics and personalised medicine from a systems perspective]. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2023; 179:91-94. [PMID: 37183116 DOI: 10.1016/j.zefq.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 04/03/2023] [Indexed: 05/16/2023]
Abstract
High-quality studies are necessary and feasible in personalised medicine in order to evaluate the benefits across the entire treatment chain of biomarker tests and resulting treatments in regard to patient-relevant endpoints. With the introduction of genome sequencing in oncology, a considerable number of new treatment concepts with mostly low-quality evidence can be expected. High quality requirements, interdisciplinary cooperation structures, knowledge-generating care and the connection of patient care at the expense of the statutory health insurance funds, with research at the expense of the manufacturers or public funding, are necessary.
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11
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Affiliation(s)
- Daniel R Morales
- European Medicines Agency, Domenico Scarlattilaan 6, 1083 HS Amsterdam, Netherlands
| | - Peter Arlett
- European Medicines Agency, Domenico Scarlattilaan 6, 1083 HS Amsterdam, Netherlands
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12
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Wieseler B, Neyt M, Kaiser T, Hulstaert F, Windeler J. Authors' reply to Morales and Arlett. BMJ 2023; 381:740. [PMID: 37011919 DOI: 10.1136/bmj.p740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Affiliation(s)
- Beate Wieseler
- Institute for Quality and Efficiency in Health Care (IQWiG), Cologne, Germany
| | - Mattias Neyt
- Belgian Health Care Knowledge Centre (KCE), Brussels, Belgium
| | - Thomas Kaiser
- Institute for Quality and Efficiency in Health Care (IQWiG), Cologne, Germany
| | - Frank Hulstaert
- Belgian Health Care Knowledge Centre (KCE), Brussels, Belgium
| | - Jürgen Windeler
- Institute for Quality and Efficiency in Health Care (IQWiG), Cologne, Germany
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