Trust, regulatory processes and NICE decision-making: Appraising cost-effectiveness models through appraising people and systems

Assessing the credibility of a drug's effects: identification and judgment of uncertainty by the Dutch Medicines Evaluation Board

Medicine regulators need to judge whether a drug's favorable effects outweigh its unfavorable effects based on a dossier submitted by an applicant, such as a pharmaceutical company. Because scientific knowledge is inherently uncertain, regulators also need to judge the credibility of these effects by identifying and evaluating uncertainties. We performed an ethnographic study of assessment procedures at the Dutch Medicines Evaluation Board (MEB) and describe how regulators evaluate the credibility of an applicant's claims about the benefits and risks of a drug in practice. Our analysis shows that regulators use an investigative approach, which illustrates the effort required to identify uncertainties. Moreover, we show that regulators' expectations about the presentation, the design, and the results of studies can shape how they perceive a medicine's dossier. We highlight the importance of regulatory experience and expertise in the identification and evaluation of uncertainties. In light of our observations, we provide two recommendations to reduce avoidable uncertainty: less reliance on evidence generated by the applicant; and better communication about, and enforcement of, regulatory frameworks toward drug developers.

A qualitative study on the feasibility and acceptability of institutionalizing health technology assessment in Malawi

OBJECTIVE

The objective of this study was to assess the feasibility and acceptability of institutionalizing Health Technology Assessment (HTA) in Malawi.

METHODS

This study employed a document review and qualitative research methods, to understand the status of HTA in Malawi. This was complemented by a review of the status and nature of HTA institutionalization in selected countries.Qualitative research employed a Focus Group Discussion (FGD ) with 7 participants, and Key Informant Interviews (KIIs) with12 informants selected based on their knowledge and expertise in policy processes related to HTA in Malawi.Data extracted from the literature was organized in Microsoft Excel, categorized according to thematic areas and analyzed using a literature review framework. Qualitative data from KIIs and the FGD was analyzed using a thematic content analysis approach.

RESULTS

Some HTA processes exist and are executed through three structures namely: Ministry of Health Senior Management Team, Technical Working Groups, and Pharmacy and Medicines Regulatory Authority (PMRA) with varyingdegrees of effectiveness.The main limitations of current HTA mechanisms include limited evidence use, lack of a standardized framework for technology adoption, donor pressure, lack of resources for the HTA process and technology acquisition, laws and practices that undermine cost-effectiveness considerations. KII and FGD results showed overwhelming demand for strengthening HTA in Malawi, with a stronger preference for strengthening coordination and capacity of existing entities and structures.

CONCLUSION

The study has shown that HTA institutionalization is acceptable and feasible in Malawi. However, the current committee based processes are suboptimal to improve efficiency due to lack of a structured framework. A structured HTA framework has the potential to improve processes in pharmaceuticals and medical technologies decision-making.In the short to medium term, HTA capacity building should focus on generating demand and increasing capacity in cost-effectiveness assessments. Country-specific assessments should precede HTA institutionalization as well as recommendations for new technology adoptions.

Making particularity travel: Trust and citizen science data in Swedish environmental governance

This paper focuses on how particularities are performed and made to travel through the creation of trust. The Swedish Species Observation System (Artportalen) is one of the largest inscription and calculation centers for citizen data in the world, used extensively by public authorities in Sweden. Observations by members of the public become actionable through environmental governance laws in Sweden. These observations are made through networks of things and humans in which trust is created but unevenly distributed. Important for them to be trusted and to travel are such things as computer software to filter and map observations, red lists, GIS-tools to determine time and place, and validation committees. However, trust is more concentrated in a core set of actors, and there depends on interpersonal relations - though these relations are facilitated by other parts of the epistemic system.

Decision-making in the midst of uncertainty: appraising expensive medicines in England

Decisions need to be made about which services or technologies should be prioritized for provision in the NHS in England .The analysis focuses specifically on the National Institute for Health and Care Excellence (NICE), and on how they appraise expensive medicines. This analysis takes a sociological perspective on decision-making in relation to uncertainty and how uncertainties are managed, drawing on evidence from a scoping study and an ethnographic study. Uncertainties were central to these rationing decisions. Three types of layers of uncertainty -epistemic, procedural and interpersonal - were shown to be salient. Another form of uncertainty was associated with the complexity of the science and that included the level of technicality of the information provided. The analysis highlighted the salience of uncertainties associated with interpersonal relations and the relations between the committees and the drug industry, clinical and patient experts. A key element in these relationships was trust. Decision makers adopted a mixture of formal and informal, collective and individual strategies in making decisions and a need to exercise pragmatism within a more formal institutional framework. The paper concludes by considering more recent policy developments in relation to appraising expensive medicines.

A Pluralistic Perspective on Research in Psychotherapy: Harnessing Passion, Difference and Dialogue to Promote Justice and Relevance

The adoption of a pluralistic perspective on research design, processes of data collection and analysis and dissemination of findings, has the potential to enable psychotherapy research to make a more effective contribution to building a just society. A review of the key features of the concept of pluralism is followed by a historical analysis of the ways in which research in counselling, psychotherapy and related disciplines has moved in the direction of a pluralistic position around knowledge creation. Core principles of a pluralistic approach to research are identified and explored in the context of a critical case study of contemporary research into psychotherapy for depression, examples of pluralistically oriented research practices, and analysis of a pluralistic conceptualisation of the nature of evidence. Implications of a pluralistic perspective for research training and practice are discussed. Pluralistic inquiry that emphasises dialogue, collaboration, epistemic justice and the co-existence of multiple truths, creates opportunities for individuals, families and communities from a wide range of backgrounds to co-produce knowledge in ways that support their capacities for active citizenship and involvement in open democratic decision-making. To fulfil these possibilities, it is necessary for psychotherapy research to be oriented towards social goals that are sufficiently relevant to both researchers and co-participants to harness their passion and work together for a common good.

Valuing patient engagement: Reflexive learning in evidence generation practices for health technology assessment

Much attention in health technology assessment (HTA), a health system governance mechanism used for determining the value of health technologies, is being paid to improving the quality and patient-relevance of the evidence used in assessment pratices. Whilst the direct involvement of patient actors throughout HTA processes has become a more routine element of institutional practice, the 'impacts' of patient engagement (PE) initiatives have proven difficult to determine and enhance. In reflexive governance theories, reflexive learning is a critical mechanism of multi-stakeholder arrangements that better handles the complexities of technologies and how they are understood through governance practices. This paper explores how reflexive learning can be used to build a richer conceptualisation of PE in HTA, in order to generate suggestions for enhancing PE practices and their impact. We critically apply reflexive learning insights on qualitative data derived from the co-creation process of a PE evaluation framework, organised through an EU project focused on strengthening PE practices across medicines development (2018-2020), including 24 interactive case studies, 3 multi-stakeholder workshops, and our observations throughout the project. The findings characterise two dimensions of reflexive learning in PE: First, reflexive learning refers to the adaptive reorganisation of evidence generating practices, including the revision of medicines' evaluation criteria and the conditions under which evidence 'relevant' to HTA is constructed. Second, reflexive learning spotlights the sociopolitics which shape technology evaluation. Four themes affecting meaningful and sustained PE in medicines development were analysed: institutional boundaries due to established evaluation criteria; timing of engagements; network relations between institutional actors; and the politics of patient representation. Extending beyond discrete PE activities and their reported impacts, reflexive forms of learning are crucial to yielding more 'meaningful' PE for HTA and medicines development, facilitating a HTA practice that more meaningfully deals with the complexities of medicines evidence generation.

Personalized Medicine, Disruptive Innovation, and "Trailblazer" Guidelines: Case Study and Theorization of an Unsuccessful Change Effort

Policy Points For complex reasons, the promise of "precision medicine" based on molecular pathways remains unrealized for many conditions. Clinical practice guidelines (theoretically, at least) can act as "trailblazers" to introduce tests and treatments that reflect precision medicine discoveries. We describe a detailed case study from the United Kingdom in which such an attempt was (so far) unsuccessful and show how this case provides generalizable lessons. Policymakers should be wary of using clinical practice guidelines as the sole, or even the primary, lever for introducing precision medicine.

CONTEXT

Precision medicine, which addresses underlying molecular mechanisms of disease, depends on new technologies that measure specific biomarkers, leading (it is anticipated) to more accurate diagnosis, patient stratification, and tailored treatment. These technologies can be disruptive-that is, they make possible, and often require, radical changes to clinical practice and service organization-thereby improving quality, safety, or efficiency of care. Clinical practice guidelines may act as "trailblazers," introducing and legitimizing novel technologies and practices.

METHODS

We describe a case study of an attempt by academic researchers to radically change asthma management in the United Kingdom using a precision medicine biomarker (fractional exhaled nitric oxide, FeNO), measured using a portable breath device. We collected a wide-ranging data set that included more than 100 documents, 61 interviews, and 150 hours of ethnographic observation, and we analyzed it using technology-enhanced strong structuration theory (TESST).

FINDINGS

Our study describes a so-far unsuccessful attempt by academic respiratory medicine researchers to pave the way for a precision medicine approach to asthma using a government-endorsed national guideline. These researchers considered asthma management, especially in primary care, to be characterized by overdiagnosis and poor tailoring of treatment; engaged a national guideline development body in an effort to fix this problem; and ensured that the guideline required primary care clinicians to use FeNO technology for diagnosis and monitoring. However, clinicians working outside the tertiary referral centers did not accept, or agree to enact, the vision of precision medicine inscribed in the guideline-for multiple professional, operational, and economic reasons.

CONCLUSIONS

"Trailblazer" guidelines, in which new technologies are recommended, may succeed as catalysts of change only in a limited way for interested individuals and groups. In the absence of a wider program of professionally led and adequately resourced change efforts, such guidelines will lack meaning, legitimacy, and authority among intended users and may be strongly resisted.

The Emerging Social Science Literature on Health Technology Assessment: A Narrative Review

BACKGROUND

Social scientists have paid increasing attention to health technology assessment (HTA). This paper provides an overview of existing social scientific literature on HTA, with a focus on sociology and political science and their subfields.

METHODS

Narrative review of key pieces in English.

RESULTS

Three broad themes recur in the emerging social science literature on HTA: the drivers of the establishment and concrete institutional designs of HTA bodies; the effects of institutionalized HTA on pricing and reimbursement systems and the broader society; and the social and political influences on HTA decisions.

CONCLUSION

Social scientists bring a focus on institutions and social actors involved in HTA, using primarily small-N research designs and qualitative methods. They provide valuable critical perspectives on HTA, at times challenging its otherwise unquestioned assumptions. However, they often leave aside questions important to the HTA practitioner community, including the role of culture and values. Closer collaboration could be beneficial to tackle new relevant questions pertaining to HTA.

The everyday risk work of Dutch child-healthcare professionals: inferring 'safe' and 'good' parenting through trust, as mediated by a lens of gender and class

Amidst intensifying policy concerns with children's wellbeing and development, healthcare professionals are required not only to assess risk of abuse and neglect, but to manage risk of 'poor parenting' more broadly. Drawing on 15 in-depth interviews and non-participant observations of 61 professional-family interactions, across four preventative public health services for children in the Netherlands, we explored how professionals accomplished such risk work amid intractable uncertainties. Building inferences from brief encounters with families, professionals gauged the extent to which they trusted parents to care 'appropriately'. This trust developed most readily with parents experienced as 'familiar' by the largely middle-class female professionals. Harnessing Schutzian phenomenology, we analyse the related manifestations of social structure within the interactional-dynamics and lifeworlds of risk assessment. We argue that social structures of gender, class and ethnicity can be seen as influential both through the differing potential for 'we-relationships' to be formed and via the generalising and stereotyped knowledge applied in their absence.

Decision making in NICE single technological appraisals: How does NICE incorporate patient perspectives?

CONTEXT

The National Institute for Health and Care Excellence (NICE) has an explicit mandate to include patient and public involvement in the appraisal of medicines to be available for funding on the NHS. NICE involves an appraisal committee who are required to take on board experiential evidence from patient experts alongside population-based evidence on clinical and cost-effectiveness when making a decision whether to fund a drug.

OBJECTIVE

This paper considers how NICE Single Technological Appraisal (STA) committees attempt to incorporate the views of patients in making decisions about funding medicines on the NHS.

METHODS

A prospective design was employed to follow three pharmaceutical products involving three different appraisal committees. Three data collection methods were used: analysis of documentary evidence sent by NICE, non-participant unstructured observations of the open and closed sessions of meetings and qualitative interviews.

SETTINGS AND PARTICIPANTS

Unstructured non-participant observations were carried out at nine STA meetings, and 41 semi-structured interviews were undertaken with committee members from NICE's STA committees, patient experts, analysts from NICE's project team and drug manufacturers.

RESULTS

Our analysis showed how the committees displayed a preference for an ideal-type of patient representative, disagreement among the committee when weighing-up patient statements in the STA process and more pre-preparation support for patient involvement.

CONCLUSIONS

Although NICE has attempted to adopt an approach flexible to patients and carers through formal decision-making arrangements that incorporate patient views, nonetheless, the processes of the STAs can in fact undermine the very evidence collected from patient representatives.

Still Elegantly Muddling Through? NICE and Uncertainty in Decision Making About the Rationing of Expensive Medicines in England

This article examines the "technological appraisals" carried out by the National Institute for Health and Care Excellence as it regulates the provision of expensive new drugs within the English National Health Service on cost-effectiveness grounds. Ostensibly this is a highly rational process by which the regulatory mechanisms absorb uncertainty, but in practice, decision making remains highly complex and uncertain. This article draws on ethnographic data-interviews with a range of stakeholders and decision makers (n = 41), observations of public and closed appraisal meetings, and documentary analysis-regarding the decision-making processes involving three pharmaceutical products. The study explores the various ways in which different forms of uncertainty are perceived and tackled within these Single Technology Appraisals. Difficulties of dealing with the various levels of uncertainty were manifest and often rendered straightforward decision making problematic. Uncertainties associated with epistemology, procedures, interpersonal relations, and technicality were particularly evident. The need to exercise discretion within a more formal institutional framework shaped a pragmatic combining of strategies tactics-explicit and informal, collective and individual-to navigate through the layers of complexity and uncertainty in making decisions.