Economic evaluations of health technologies in Dutch healthcare decision-making: a qualitative study of the current and potential use, barriers, and facilitators

Recent updates in the therapeutic uses of Pembrolizumab: a brief narrative review

INTRODUCTION

Treatment of cancer has been improved with the discovery of biological drugs that act as immune checkpoint inhibitors. In 2017, FDA designated pembrolizumab, an immune checkpoint inhibitor employed in immunotherapy, as the first tissue-agnostic cancer treatment.

OBJECTIVES

To review pembrolizumab's use in oncology, gather and examine the latest discoveries regarding the effectiveness of pembrolizumab in cancer treatment.

METHODOLOGY

A literature review was conducted through PubMed(Medline) from January 2015 to December 2023 using "pembrolizumab", "cancer" and "treatment" as search terms.

RESULTS

Pembrolizumab demonstrated effectiveness as primary treatment for metastatic nonsmall cell lung cancer, unresectable esophageal cancer, head and neck squamous cell carcinoma and alternative treatment for notable triple-negative breast cancer, biliary, colorectal, endometrial, renal cell, cervical carcinoma, and high microsatellite instability or mismatch repair deficiencies tumors. Pediatric applications include treatment for refractory Hodgkin lymphoma.

CONCLUSION

Evolving research on pembrolizumab allows a deeper clinical understanding, despite challenges as variable patient responses. Pembrolizumab has emerged as a pivotal breakthrough in cancer treatment, improving patient outcomes and safety.

Clinical decision-making process and distributive justice: The mediating role of economic analysis. Empirical evidence from Italy

BACKGROUND

The COVID-19 pandemic has not only tested the resilience of public health systems but also underscored the criticality of allocative choices on health resources. These choices, however, are not confined to health emergencies but are integral to public health decisions, which inherently grapple with limited resources. In this context, physicians play a pivotal role as the architects of clinical actions in various scenarios. Therefore, doctors are called upon to make their decisions by considering not only the criteria of clinical appropriateness but also the ethical aspects linked, in particular, to the principle of justice. Indeed, the assessment of the effectiveness of a treatment for a particular patient must be balanced against criteria of equity and justice for the whole. To be fully applied, the principle of justice presupposes the use of economic evaluation techniques designed to drive the organisation decisions by effectiveness and efficiency.

METHODS

The present paper aims to empirically analyse whether and to what extent economic evaluation is known and used by doctors in healthcare decision-making and, therefore, what the most widespread approaches are used in such processes. In particular, this paper intends to present the results of an empirical study on a sample of doctors registered with the Order of Physicians in Lombardy (Italy), one of the areas most affected by the COVID-19 pandemic.

RESULTS

The research reveals a particular awareness of the criticality of allocation issues accompanied by a lack of knowledge of the economic evaluation techniques or, more broadly, by an almost total disuse of financial criteria. The main reasons are doctors' need for more knowledge of these tools and insufficient availability of economic information at the country system level.

CONCLUSION

In the conclusion, we propose some suggestions to facilitate the transition to more current decision-making models consistent with the characteristics of more advanced national healthcare contexts.

Assessing unConventional Evidence (ACE) tool: development and content of a tool to assess the strengths and limitations of 'unconventional' source materials

BACKGROUND

When deciding whether to implement an intervention, decision-makers typically have questions on feasibility and acceptability and on factors affecting implementation. Descriptions of programme implementation and of policies and systems are rich sources of information for these questions. However, this information is often not based on empirical data collected using explicit methods. To use the information in unconventional source materials in syntheses or other decision support products, we need methods of assessing their strengths and limitations. This paper describes the development and content of the Assessing unConventional Evidence (ACE) tool, a new tool to assess the strengths and limitations of these sources.

METHODS

We developed the ACE tool in four stages: first, we examined existing tools to identify potentially relevant assessment criteria. Second, we drew on these criteria and team discussions to create a first draft of the tool. Third, we obtained feedback on the draft from potential users and methodologists, and through piloting the tool in evidence syntheses. Finally, we used this feedback to iteratively refine the assessment criteria and to improve our guidance for undertaking the assessment.

RESULTS

The tool is made up of 11 criteria including the purpose and context of the source; the completeness of the information presented; and the extent to which evidence is provided to support the findings made. Users are asked to indicate whether each of the criteria have been addressed. On the basis of their judgements for each criterion, users then make an overall assessment of the limitations of the source, ranging from no or very minor concerns to serious concerns. These assessments can then facilitate appropriate use of the evidence in decision support products.

CONCLUSIONS

Through focussing on unconventional source materials, the ACE tool fills an important gap in the range of tools for assessing the strengths and limitations of policy-relevant evidence and supporting evidence-informed decision-making.

Daring discourse: economics of neuromodulation for the treatment of persistent spinal pain syndrome and complex regional pain syndrome

The treatment options for patients with chronic pain conditions are impacted by recent research, patient needs, and insurance coverage. Although various factors affect the cost of healthcare, the economic burden on the patient and the healthcare system must be considered when choosing the appropriate treatments for each patient. This Daring Discourse aims to review and further clarify existing economic evaluations and thus examine cost-effectiveness with regards to neuromodulation for the treatment of persistent spinal pain syndrome and complex regional pain syndrome. Specific consideration is given to spinal cord stimulation, as it is a widely studied and implemented neuromodulation modality for the treatment of these debilitating conditions.

Interpretation of trial-based economic evaluations of musculoskeletal physical therapy interventions

BACKGROUND

As resources for healthcare are scarce, decision-makers increasingly rely on economic evaluations when making reimbursement decisions about new health technologies, such as drugs, procedures, devices, and equipment. Economic evaluations compare the costs and effects of two or more interventions. Musculoskeletal disorders have a high prevalence and result in high levels of disability and high costs worldwide. Because physical therapy interventions are usually the first line of treatment for musculoskeletal disorders, economic evaluations of such interventions are becoming increasingly important for stakeholders in the field of physical therapy, including physical therapists, decision-makers, and reseachers. However, economic evaluations are relatively difficult to interpret for the majority of stakeholders.

OBJECTIVE

To support physical therapists, decision-makers, and researchers in the field of physical therapy interpreting trial-based economic evaluations and translating the results of such studies to clinical practice.

METHODS

The design, analysis, and interpretation of economic evaluations performed alongside randomized controlled trials are discussed. To further illustrate and explain these concepts, we use a case study assessing the cost-effectiveness of exercise therapy compared to standard advice in patients with musculoskeletal disorders.

CONCLUSIONS

Economic evaluations are increasingly being used in healthcare decision-making. Therefore, it is of utmost importance that their design, conduct, and analysis are state-of-the-art and that their interpretation is adequate. This masterclass will help physical therapists, decision-makers, and researchers in the field of physical therapy to critically appraise the quality and results of trial-based economic evaluations and to apply the results of such studies to their own clinical practice and setting.

"Slow science" for 21st century healthcare: reinventing health service research that serves fast-paced, high-complexity care organisations

Purpose

The purpose of this paper is to argue for an improved conceptualisation of health service research, using Stengers' (2018) metaphor of “slow science” as a critical yardstick.

Design/methodology/approach

The paper is structured in three parts. It first reviews the field of health services research and the approaches that dominate it. It then considers the healthcare research approaches whose principles and methodologies are more aligned with “slow science” before presenting a description of a “slow science” project in which the authors are currently engaged.

Findings

Current approaches to health service research struggle to offer adequate resources for resolving frontline complexity, principally because they set more store by knowledge generalisation, disciplinary continuity and integrity and the consolidation of expertise, than by engaging with frontline complexity on its terms, negotiating issues with frontline staff and patients on their terms and framing findings and solutions in ways that key in to the in situ dynamics and complexities that define health service delivery.

Originality/value

There is a need to engage in a paradigm shift that engages health services as co-researchers, prioritising practical change and local involvement over knowledge production. Economics is a research field where the products are of natural appeal to powerful health service managers. A “slow science” approach adopted by the embedded Economist Program with its emphasis on pre-implementation, knowledge mobilisation and parallel site capacity development sets out how research can be flexibly produced to improve health services.

Barriers and facilitators to conducting economic evaluation studies of Gulf Cooperation Council (GCC) countries: a survey of researchers

Background

The number of published economic evaluations of Gulf Cooperation Council (GCC) countries is notably scarce. Limited local evidence could have a major impact on the implementation of economic evaluation recommendations in the decision-making process in GCC countries. Little is known about the factors affecting researchers who seek to conduct economic evaluations. Therefore, we aimed to assess researcher barriers and facilitators in conducting such studies of GCC countries.

Methods

A cross-sectional survey of health economic researchers working in GCC countries was conducted online between January and February 2020. The survey instrument collected researchers’ perceived barriers and facilitators and demographic information. For barriers, respondents rated their agreement on a 5-point Likert scale ranging from “strongly disagree” to “strongly agree”. For facilitators, respondents rated the importance of each facilitator on a six-point scale ranging from “extremely important” to “not very important”. Then, participants were asked to select the three most important barriers and facilitators from the lists. The data collected were examined using descriptive analysis.

Results

Fifty-one researchers completed the survey (37% response rate). The majority of participants (more than 80%) agreed that lack of quality of effectiveness data and restricted access to unit cost data are the main barriers to conducting economic research. Availability of relevant local data was reported as an important facilitator, followed by collaboration between health economic researchers, policy-makers and other stakeholders.

Conclusions

The results of this study provide an exploratory view of the issues faced by health economics researchers in GCC countries. Recommendations to GCC countries based on international experiences, such as to use real-world data in economic evaluation research, were provided.

Embedding an economist in regional and rural health services to add value and reduce waste by improving local-level decision-making: protocol for the 'embedded Economist' program and evaluation

Background

Systematic approaches to the inclusion of economic evaluation in national healthcare decision-making are usual. It is less common for economic evaluation to be routinely undertaken at the ‘local-level’ (e.g. in a health service or hospital) despite the largest proportion of health care expenditure being determined at this service level and recognition by local health service decision makers of the need for capacity building in economic evaluation skills. This paper describes a novel program – the embedded Economist (eE) Program. The eE Program aims to increase local health service staff awareness of, and develop their capacity to access and apply, economic evaluation principles in decision making. The eE program evaluation is also described. The aim of the evaluation is to capture the contextual, procedural and relational aspects that assist and detract from the eE program aims; as well as the outcomes and impact from the specific eE projects.

Methods

The eE Program consists of a embedding a health economist in six health services and the provision of supported education in applied economic evaluation, provided via a community of practice and a university course. The embedded approach is grounded in co-production, embedded researchers and ‘slow science’. The sites, participants, and program design are described. The program evaluation includes qualitative data collection via surveys, semi-structured interviews, observations and field diaries. In order to share interim findings, data are collected and analysed prior, during and after implementation of the eE program, at each of the six health service sites. The surveys will be analysed by calculating frequencies and descriptive statistics. A thematic analysis will be conducted on interview, observation and filed diary data. The Framework to Assess the Impact from Translational health research (FAIT) is utilised to assess the overall impact of the eE Program.

Discussion

This program and evaluation will contribute to knowledge about how best to build capacity and skills in economic evaluation amongst decision-makers working in local-level health services. It will examine the extent to which participants are able to improve their ability to utilise evidence to inform decisions, avoid waste and improve the value of care delivery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06181-1.

What do national pharmacoeconomic guidelines recommend regarding the statistical analysis of trial-based economic evaluations?

Introduction: The statistical quality of many trial-based economic evaluations is poor. When conducting trial-based economic evaluations, researchers often turn to national pharmacoeconomic guidelines for guidance. Therefore, this study reviewed which recommendations are currently given by national pharmacoeconomic guidelines on the statistical analysis of trial-based economic evaluations.Areas covered: 40 national pharmacoeconomic guidelines were identified. Data were extracted on the guidelines' recommendations on how to deal with baseline imbalances, skewed costs, correlated costs and effects, clustering of data, longitudinal data, and missing data in trial-based economic evaluations. Four guidelines (10%) were found to include recommendations on how to deal with baseline imbalances, five (13%) on how to deal with skewed costs, and seven (18%) on how to deal with missing data. Recommendations were very general in nature and recommendations on dealing with correlated costs and effects, clustering of data, and longitudinal data were lacking.Expert opinion: Current national pharmacoeconomic guidelines provide little to no guidance on how to deal with the statistical challenges to trial-based economic evaluations. Since the use of suboptimal statistical methods may lead to biased results, and, therefore, possibly to a waste of scarce resources, national agencies are advised to include more statistical guidance in their pharmacoeconomic guidelines.

Long-term effectiveness and cost-effectiveness of an 18-week supervised exercise program in patients treated with autologous stem cell transplantation: results from the EXIST study

Purpose

To evaluate the long-term effectiveness and cost-effectiveness of a supervised 18-week high-intensity exercise program compared with usual care in patients treated with autologous stem cell transplantation.

Methods

One hundred nine patients were randomly assigned to the exercise intervention (n = 54) or the usual care control group (n = 55). Data on cardiorespiratory fitness (VO₂peak), handgrip strength, general fatigue, and health-related quality of life (quality-adjusted life years [QALYs]) were collected at baseline (T0), after completion of the exercise intervention or at a similar time point in the control group (T1) and 12 months later (T2). Cost questionnaires were used to assess societal costs. Long-term effectiveness (at T2) was evaluated using linear mixed model analyses. For the economic evaluation, missing data were imputed using multiple imputation, and data were analyzed using linear mixed models.

Results

At T2, no statistically significant differences were found between the intervention and control group for VO₂peak (0.12; 95%CI − 1.89; 2.14 ml/min/kg), handgrip strength (− 1.08; 95%CI− 2.47; 2.31), and general fatigue (− 0.69; 95%CI − 2.52; 1.14). During 12-months follow-up, no significant between-group differences in QALYs and societal costs were found (QALYs − 0.07; 95%CI − 0.17; 0.04; costs 529; 95%CI − 3205;4452). Intervention costs were €1340 per patient. For all outcomes, the probability of the intervention being cost-effective was low at reasonable values of willingness-to-pay.

Conclusion

We found no evidence for the exercise intervention being effective on physical fitness and fatigue, nor cost-effective from a societal perspective.

Trial registration

The study was prospectively registered on 27 May 2010 at the Netherlands Trial Register (NTR2341).

Implications for Cancer Survivors

The current exercise intervention should not be recommended to patients recently treated with autologous stem cell transplantation.

Health economic evidence gaps and methodological constraints in low back pain and neck pain: Results of the Research Agenda for Health Economic Evaluation (RAHEE) project

Despite the increased interest in economic evaluations, there are difficulties in applying the results of such studies in practice. Therefore, the "Research Agenda for Health Economic Evaluation" (RAHEE) project was initiated, which aimed to improve the use of health economic evidence in practice for the 10 highest burden conditions in the European Union (including low back pain [LBP] and neck pain [NP]). This was done by undertaking literature mapping and convening an Expert Panel meeting, during which the literature mapping results were discussed and evidence gaps and methodological constraints were identified. The current paper is a part of the RAHEE project and aimed to identify economic evidence gaps and methodological constraints in the LBP and NP literature, in particular. The literature mapping revealed that economic evidence was unavailable for various commonly used LBP and NP treatments (e.g., injections, traction, and discography). Even if economic evidence was available, many treatments were only evaluated in a single study or studies for the same intervention were highly heterogeneous in terms of their patient population, control condition, follow-up duration, setting, and/or economic perspective. Up until now, this has prevented economic evaluation results from being statistically pooled in the LBP and NP literature, and strong conclusions about the cost-effectiveness of LBP and NP treatments can therefore not be made. The Expert Panel identified the need for further high-quality economic evaluations, especially on surgery versus conservative care and competing treatment options for chronic LBP. Handling of uncertainty and reporting quality were considered the most important methodological challenges.