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Versteeg JW, Vreman R, Mantel-Teeuwisse A, Goettsch W. Uncertainty in Long-Term Relative Effectiveness of Medicines in Health Technology Assessment. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024; 27:1358-1366. [PMID: 38971220 DOI: 10.1016/j.jval.2024.05.023] [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: 12/18/2023] [Revised: 05/21/2024] [Accepted: 05/27/2024] [Indexed: 07/08/2024]
Abstract
OBJECTIVES Uncertainty regarding the long-term relative effectiveness is an important factor in health technology assessment (HTA) of medicines. This study investigated how different HTA bodies address this uncertainty in their assessments. METHODS A total of 49 HTA reports from 6 national HTA bodies, assessing 9 medicines for spinal muscular atrophy, cystic fibrosis, and hypercholesterolemia, were included. In these reports, 81 relative effectiveness assessments and 45 cost-effectiveness assessments were performed on an indication level. We collected information on included trials, assessment outcomes, uncertainty regarding the long-term effectiveness, proposed managed entry agreements, and reassessments. RESULTS Uncertainty regarding the long-term effectiveness was an important consideration in almost all cost-effectiveness assessments (91%) and three-quarters of relative effectiveness assessments (74%), despite differences in methodologies among HTA bodies. There were considerable differences in the amount and type of long-term effectiveness data included by HTA bodies due to timing and inclusion criteria. In total 23 managed entry agreements were proposed of which 14 were linked to uncertainty regarding the long-term effectiveness. In addition, 13 reassessments were performed of which 4 led to an increase in patient access because of more available long-term effectiveness data. CONCLUSIONS Uncertainty regarding the long-term effectiveness is an important challenge for HTA bodies. There are large differences in the acceptance of evidence among HTA bodies, which leads to heterogeneity in the inclusion of available long-term effectiveness data for decision making. In cases with large uncertainty regarding the long-term effectiveness, outcome-based agreements and reassessments are used by HTA bodies, but differently between HTA bodies and indications.
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Affiliation(s)
- Jan-Willem Versteeg
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Rick Vreman
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands; National Health Care Institute, Diemen, The Netherlands
| | - Aukje Mantel-Teeuwisse
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Wim Goettsch
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands; National Health Care Institute, Diemen, The Netherlands.
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Jakubowski S, Kawalec P, Holko P, Kowalska-Bobko I, Kamusheva M, Petrova G, Draganić P, Fuksa L, Männik A, Ispán F, Briedis V, Bianchi I, Paveliu MS, Tesar T. Clinical aspects of reimbursement policies for orphan drugs in Central and Eastern European countries. Front Pharmacol 2024; 15:1369178. [PMID: 38523639 PMCID: PMC10957562 DOI: 10.3389/fphar.2024.1369178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 02/16/2024] [Indexed: 03/26/2024] Open
Abstract
Objectives: The aim of this study was to characterize the reimbursement policy for orphan drugs (ODs) in Central and Eastern European (CEE) countries in relation to the availability and impact of clinical evidence, health technology assessment (HTA) procedure, selected economic indicators, and the drug type according to indications. Materials and methods: A list of authorized medicines with orphan designation and information about active substance, Anatomical Therapeutic Chemical (ATC) classification, and therapeutic area was extracted from the web-based register of the European Medicines Agency (EMA). A country-based questionnaire survey was performed between September 2021 and January 2022 in a group of selected experts from nine CEE countries (an invitation was sent to 11 countries). A descriptive and statistical analysis was conducted to determine statistical significance, correlations, between the drug or country characteristic and the positive recommendation or reimbursement of ODs. Results: The proportion of reimbursed orphan drugs differed between countries, ranging from 17.7% in Estonia to 49.6% in Hungary (p < 0.001). The odds that ODs were reimbursed were reduced in countries with a "strong" level of impact of drug safety and efficacy on reimbursement decisions (p=0.018), the presence of other additional specific clinical aspects (e.g., genomic data) considered in the reimbursement decision (p < 0.001) and mandatory (without exception) safety assessments (p=0.004). The probability that ODs were reimbursed was increased in countries with a "moderate" level of impact of drug safety and efficacy on reimbursement decisions (p=0.018), when reimbursement decisions are dependent on the EMA registration status and orphan drug designation (p < 0.001), the presence of the "positive HTA recommendation guarantees reimbursement" policy (p < 0.001), higher GDP per inhabitant (p=0.003), and higher healthcare expenditure (p < 0.001). Conclusion: We found that there are differences among CEE countries in the reimbursement of orphan drugs, and we identified aspects that may influence these differences. Safety, efficacy, and specific clinical aspect issues significantly influenced reimbursement decisions. Antineoplastic and immunomodulating agents drugs were the largest group of ODs and increased the chance of getting a positive recommendation. The higher GDP per inhabitant and healthcare expenditures per inhabitant were positively linked to the chance that an OD receives reimbursement.
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Affiliation(s)
- Szczepan Jakubowski
- Department of Health Promotion and e-Health, Faculty of Health of Science, Jagiellonian University Medical College, Kraków, Poland
| | - Pawel Kawalec
- Department of Nutrition and Drug Research, Faculty of Health of Science, Jagiellonian University Medical College, Kraków, Poland
| | - Przemyslaw Holko
- Department of Nutrition and Drug Research, Faculty of Health of Science, Jagiellonian University Medical College, Kraków, Poland
| | - Iwona Kowalska-Bobko
- Health Policy and Management Department, Faculty of Health of Science, Jagiellonian University Medical College, Kraków, Poland
| | - Maria Kamusheva
- Department of Organization and Economics of Pharmacy, Faculty of Pharmacy, Medical University of Sofia, Sofia, Bulgaria
| | - Guenka Petrova
- Department of Organization and Economics of Pharmacy, Faculty of Pharmacy, Medical University of Sofia, Sofia, Bulgaria
| | - Pero Draganić
- Agency for Medicinal Products and Medical Devices of Croatia, Zagreb, Croatia
- Department of Biotechnology, University of Rijeka, Rijeka, Croatia
| | - Leos Fuksa
- Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Kralove, Charles University in Prague, Prague, Czechia
| | - Agnes Männik
- Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
| | - Fanni Ispán
- Department of Reimbursement, National Institute of Health Insurance Fund Management, Budapest, Hungary
| | - Vitalis Briedis
- Department of Clinical Pharmacy of Lithuanian, University of Health Sciences, Kaunas, Lithuania
| | - Ioana Bianchi
- The Romanian Association of International Medicine Manufacturers. ARPIM, Bucharest, Romania
| | | | - Tomas Tesar
- Department of Organisation and Management in Pharmacy, Faculty of Pharmacy, Comenius University in Bratislava, Bratislava, Slovakia
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Kudyar P, Konwar M, Khatri Z, Gogtay NJ, Thatte UM. Evaluation of clinical trials done for orphan drugs versus nonorphan drugs in infectious diseasesan eleven year analysis [2010-2020]. Perspect Clin Res 2023; 14:56-60. [PMID: 37325577 PMCID: PMC10267988 DOI: 10.4103/picr.picr_137_21] [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: 06/26/2021] [Revised: 08/09/2021] [Accepted: 01/20/2022] [Indexed: 11/04/2022] Open
Abstract
Background The 1983 US Orphan Drug Act provided impetus for the development of new therapies for rare diseases. Several studies focused on the number of orphan designations over time. However, very few focused on clinical trials that lead to their approval, particularly for infectious diseases. Materials and Methods All new drug approvals (orphan and non-orphan) by the US Food and Drug Administration (FDA) from January 2010 to December 31, 2020, were identified and details of approvals were taken from the US-FDA labels and summary reports for each drug. The pivotal trials for each were characterized based on their design. We tested the association of the type of drug approval with respect to the characteristics of trial using Chi-square test and generated crude odds ratios with 95% confidence intervals. Results From the total 1122 drugs approved, 84 were for infectious diseases, of which 18 were orphan drugs and 66 were nonorphan. A total of 35 pivotal trials supported 18 orphan drug approvals, while 115 pivotal trials supported 66 nonorphan drugs. The median number of participants enrolled/trial for orphan drugs was 89, while for nonorphan drugs, it was 452 (P < 0.0001). Blinding was done for 13/35 (37%) orphan drugs versus 69/115 (60%) nonorphan drugs (P = 0.029); randomization was done for 15/35 (42%) orphan drugs versus 100/115 (87%) nonorphan drugs (P < 0.0001) and 20/35 (57%) of the orphan drugs got approval in phase II versus 8/115 (6%) of nonorphan drugs (P < 0.00001). Conclusion A significant number of orphan drugs get approval based on early phase, nonrandomized, and unblinded with a smaller sample size as compared to nonorphan drugs.
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Affiliation(s)
- Palvi Kudyar
- Department of Clinical Pharmacology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Mahanjit Konwar
- Department of Clinical Pharmacology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Zoya Khatri
- Department of Clinical Pharmacology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Nithya Jaideep Gogtay
- Department of Clinical Pharmacology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Urmila Mukund Thatte
- Department of Clinical Pharmacology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
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Skweres-Kuchta M, Czerska I, Szaruga E. Literature Review on Health Emigration in Rare Diseases-A Machine Learning Perspective. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2483. [PMID: 36767849 PMCID: PMC9915846 DOI: 10.3390/ijerph20032483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 01/15/2023] [Accepted: 01/28/2023] [Indexed: 06/18/2023]
Abstract
The article deals with one of the effects of health inequalities and gaps in access to treatments for rare diseases, namely health-driven emigration. The purpose of the paper is to systematize knowledge about the phenomenon of health emigration observed among families affected by rare diseases, for which reimbursed treatment is available, but only in selected countries. The topic proved to be niche; the issue of "health emigration in rare diseases" is an area for exploration. Therefore, the further analysis used text mining and machine learning methods based on a database selected based on keywords related to this issue. The results made it possible to systematize the guesses made by researchers in management and economic fields, to identify the most common keywords and thematic clusters around the perspective of the patient, drug manufacturer and treatment reimbursement decision-maker, and the perspective integrating all the others. Since the topic of health emigration was not directly addressed in the selected sources, the authors attempted to define the related concepts and discussed the importance of this phenomenon in managing the support system in rare diseases. Thus, they indicated directions for further research in this area.
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Affiliation(s)
- Małgorzata Skweres-Kuchta
- Department of Organization and Management, Institute of Management, University of Szczecin, Cukrowa 8 Street, 71-004 Szczecin, Poland
| | - Iwona Czerska
- Department of Marketing Research, Faculty of Management, Wroclaw University of Economics and Business, 118/120 Komandorska Str, 53-345 Wroclaw, Poland
| | - Elżbieta Szaruga
- Department of Transport Management, Institute of Management, University of Szczecin, Cukrowa 8 Street, 71-004 Szczecin, Poland
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Health technology assessment and reimbursement policy for oncology orphan drugs in Central and Eastern Europe. Orphanet J Rare Dis 2020; 15:277. [PMID: 33032634 PMCID: PMC7545889 DOI: 10.1186/s13023-020-01556-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 09/23/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The reimbursement of orphan drugs (OD) is an increasingly important for country policymakers, and still insufficiently understood, especially in Central and Eastern Europe. The aim of this research was to provide a comprehensive description of country-specific health technology assessment (HTA) policies as well as evaluate the percentage of HTA recommendations and reimbursement decisions for oncology OD. In addition, the study was designed to elucidate the impact of reimbursement of these drugs on the public budget and the agreement between HTA recommendations and reimbursement decisions in the analysed countries. A questionnaire survey was used to collect data on the reimbursement status, HTA recommendation, marketing authorisation, and public expenses on reimbursement in 2014, 2015, and 2016 for all oncology drugs with an orphan designation by the European Medicine Agency in 2017 in Bulgaria, Croatia, Czechia, Estonia, Hungary, Latvia, Lithuania, Poland, Romania, and Slovakia. The agreement between the HTA recommendation and reimbursement status was assessed using the kappa coefficient. The Pearson's correlation was used to analyse the relationship between gross domestic product (GDP) and GDP per capita and reimbursement expenses. RESULTS A total of 36 drugs were analysed (25% conditionally approved; 5.56% approved under exceptional circumstances). The share of reimbursed drugs ranged from 11.11% in Latvia to 41.67% in Poland. The highest share of positive recommendations was observed for Bulgaria and Estonia (36.11%), and the lowest, for Latvia (11.11%). The agreement varied from 0.4 for Poland to 1 for Latvia, Hungary, and Slovakia. Expenses were correlated with GDP (0.95 [0.81-0.99]), and not with GDP per capita (0.54 [- 0.136 to 0.873]). Expenses per capita were not correlated with GDP per capita (0.52 [- 0.15 to 0.87]). CONCLUSIONS In Hungary, Latvia, and Slovakia, a positive recommendation was associated with a reimbursement, and a negative one, with the lack of reimbursement. The reimbursement of oncology OD is associated with a growing burden for public budget, and the expenses are correlated with the total GDP. The highest share of drugs with any recommendation was observed in Poland, and the lowest, in Latvia and Romania. The share of reimbursed drugs was the lowest in Latvia and the highest in Poland.
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Malinowski KP, Kawalec P, Trąbka W, Czech M, Petrova G, Manova M, Savova A, Draganić P, Vostalová L, Slabý J, Männik A, Márky K, Rugaja Z, Gulbinovic J, Tesar T, Paveliu MS. Reimbursement Legislations and Decision Making for Orphan Drugs in Central and Eastern European Countries. Front Pharmacol 2019; 10:487. [PMID: 31139080 PMCID: PMC6518361 DOI: 10.3389/fphar.2019.00487] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 04/17/2019] [Indexed: 01/30/2023] Open
Abstract
Background Reimbursement policies influence access of patients to orphan drugs in the European countries. Objectives To provide a comprehensive description of orphan drug reimbursement policies and to assess reimbursement decision-making process in the EU-CEE countries as well as the impact of the type of approval and disease on reimbursement decisions. Methods For each drug, the information regarding conditional approval or approval under exceptional circumstances was obtained from the EMA website. The reimbursement status for analyzed drugs was collected in a questionnaire survey performed in a group of experts in reimbursement policy. The agreement between countries was assessed using the κ coefficient, nominal variables tests were compared using the χ2 test or the Fisher exact test. The impact of the EMA’s conditional approval and approval under exceptional circumstances was assessed using logistic regression and presented as an odds ratio (OR). Results The analysis revealed that most orphan drugs were authorized for the treatment of oncological or metabolic diseases [36 drugs (38%) and 22 drugs (23%), respectively]. The shares of reimbursed orphan drugs varied significantly (p = 0.0031) from 6.3% in Latvia to 27.4% in Poland. No correlation (r = 0.02; p = 0.9583) with GDP per capita was observed. The highest agreement in reimbursement decisions was observed between Estonia and Lithuania, and the lowest – between Estonia and Latvia, with kappa of 0.69 and 0.11, respectively. Significant impact of the type of approval and reimbursement status was observed for Czechia, Lithuania and Slovakia where conditional approval and exceptional circumstances negatively influenced reimbursement decision. Type of disease has significant influence on reimbursement decision in 4 out of 10 analyzed countries with significant outweigh of positive decisions for oncological diseases. Conclusion In considered countries specific regulations on reimbursement of orphan drugs are valid but in Lithuania and Romania no formal HTA process was employed; in case of some countries higher ICER values for orphans are used. The share of reimbursed orphan drugs varied significantly across the countries, but it was not associated with GDP per capita.
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Affiliation(s)
- Krzysztof Piotr Malinowski
- Institute of Public Health, Faculty of Health Sciences, Jagiellonian University Medical College, Kraków, Poland
| | - Paweł Kawalec
- Institute of Public Health, Faculty of Health Sciences, Jagiellonian University Medical College, Kraków, Poland
| | - Wojciech Trąbka
- Bioinformatics and Public Health Department, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, Kraków, Poland
| | - Marcin Czech
- Department of Pharmacoeconomics, Institute of Mother and Child, Warsaw, Poland
| | - Guenka Petrova
- Faculty of Pharmacy, Medical University of Sofia, Sofia, Bulgaria
| | - Manoela Manova
- Faculty of Pharmacy, Medical University of Sofia, Sofia, Bulgaria.,National Council on Prices and Reimbursement of Medicinal Products, Sofia, Bulgaria
| | - Alexandra Savova
- Faculty of Pharmacy, Medical University of Sofia, Sofia, Bulgaria.,National Council on Prices and Reimbursement of Medicinal Products, Sofia, Bulgaria
| | - Pero Draganić
- Agency for Medicinal Products and Medical Devices of Croatia, Zagreb, Croatia.,Department of Biotechnology, University of Rijeka, Rijeka, Croatia
| | - Lenka Vostalová
- Pricing and Reimbursement Regulation Branch, State Institute for Drug Control, Prague, Czechia
| | - Juraj Slabý
- Pricing and Reimbursement Regulation Branch, State Institute for Drug Control, Prague, Czechia
| | - Agnes Männik
- Institute of Family Medicine and Public Health, University of Tartu, Tartu, Estonia
| | - Kristóf Márky
- National Institute of Health Insurance Fund Management, Budapest, Hungary
| | | | - Jolanta Gulbinovic
- Department of Pathology, Forensic Medicine and Pharmacology, Institute of Biomedical Sciences, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Tomas Tesar
- Department of Organisation and Management in Pharmacy, Faculty of Pharmacy, Comenius University in Bratislava, Bratislava, Slovakia
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Morant AV, Jagalski V, Vestergaard HT. Characteristics of Single Pivotal Trials Supporting Regulatory Approvals of Novel Non-orphan, Non-oncology Drugs in the European Union and United States from 2012-2016. Clin Transl Sci 2019; 12:361-370. [PMID: 30681284 PMCID: PMC6662549 DOI: 10.1111/cts.12617] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 12/24/2018] [Indexed: 11/29/2022] Open
Abstract
For regulatory approval of a new medicine, the gold standard for demonstration of efficacy has traditionally been a minimum of two positive, adequate, and well‐controlled clinical trials. Nevertheless, drugs to treat cancer and rare diseases are usually approved based on a single and often uncontrolled pivotal trial. In contrast, little is known about single pivotal trial approvals for non‐orphan, non‐oncology drugs. Between 2012 and 2016, 23 novel therapeutic drugs were approved by the US Food and Drug Administration (FDA) and/or the European Medicines Agency (EMA) for 27 non‐orphan, non‐oncology indications each based on a single pivotal trial. Although there was considerable variation in the nature and strength of the efficacy evidence supporting these drug approvals, the majority (85%) of the pivotal trials were randomized and controlled. For all superiority trials, the primary outcome was met with a statistical significance of P ≤ 0.005. Most approvals were supported by additional efficacy data from nonpivotal studies.
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8
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Hurdles in gene therapy regulatory approval: a retrospective analysis of European Marketing Authorization Applications. Drug Discov Today 2019; 24:823-828. [DOI: 10.1016/j.drudis.2018.12.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 12/02/2018] [Accepted: 12/18/2018] [Indexed: 02/06/2023]
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9
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Malinowski KP, Kawalec P, Trabka W, Sowada C, Pilc A. Reimbursement of Orphan Drugs in Europe in Relation to the Type of Authorization by the European Medicines Agency and the Decision Making Based on Health Technology Assessment. Front Pharmacol 2018; 9:1263. [PMID: 30483124 PMCID: PMC6240661 DOI: 10.3389/fphar.2018.01263] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 10/16/2018] [Indexed: 11/13/2022] Open
Abstract
Objective: To assess shares of reimbursed orphan drugs and agreement in reimbursement decision-making in different European Union member states as well as to define odds for reimbursement influenced by the presence of conditional approval or exceptional circumstances granted by the European Medicines Agency (EMA) or by type of the disease. Methods: The list of authorized drugs with current orphan designations was collected from the website of the EMA. For each drug, the information regarding conditional approval or approval under exceptional circumstances was collected. The reimbursement statuses were available on national reimbursement or HTA agencies websites. The agreement for reimbursement decisions between selected countries was assessed using the κ coefficient for the measurement of agreement. The impact of the EMA's conditional approval as well as approval under exceptional circumstances was assessed using the logistic regression and presented as odds ratio. Results: The percentage of reimbursed orphan drugs varied significantly from 27% in Poland to 88% in Denmark, with an average value of 51% (p < 0.0001). Regarding the reimbursement status, the highest, substantial agreement was observed between Spain and Italy, and the lowest agreement was observed between Germany and England, with κ of 0.64 and 0.01, respectively. Conditional approval status significantly decreased the chance for reimbursement in France, Italy, and Spain by 77-80%; however, approval granted under exceptional circumstances had significant impact only in Germany with 85% decrease in chances for reimbursement. The type of the disease (oncology or metabolic) was significantly associated with both conditional approval (p of 0.03-oncology drugs were more likely to be conditionally approved then the rest of analyzed drugs) and exceptional circumstances (p of 0.02-drugs for metabolic diseases were more likely to be approved under exceptional circumstances). Conclusions: Access to reimbursed orphan drugs varies significantly across EU countries. The highest, substantial agreement in reimbursement decisions was observed between Italy and Spain and the lowest between Germany and England. Conditional approval and approval under exceptional circumstances were significant negative predictors of reimbursement in some countries and they were significantly associated with the type of the disease (oncology or metabolic).
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Affiliation(s)
- Krzysztof Piotr Malinowski
- Faculty of Health Sciences, Institute of Public Health, Jagiellonian University Medical College, Krakow, Poland
| | - Paweł Kawalec
- Faculty of Health Sciences, Institute of Public Health, Jagiellonian University Medical College, Krakow, Poland
| | - Wojciech Trabka
- Bioinformatics and Public Health Department, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Krakow University, Krakow, Poland
| | - Christoph Sowada
- Faculty of Health Sciences, Institute of Public Health, Jagiellonian University Medical College, Krakow, Poland
| | - Andrzej Pilc
- Faculty of Health Sciences, Institute of Public Health, Jagiellonian University Medical College, Krakow, Poland.,Institute of Pharmacology, Polish Academy of Sciences, Krakow, Poland
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10
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Ladanie A, Speich B, Naudet F, Agarwal A, Pereira TV, Sclafani F, Martin-Liberal J, Schmid T, Ewald H, Ioannidis JPA, Bucher HC, Kasenda B, Hemkens LG. The Comparative Effectiveness of Innovative Treatments for Cancer (CEIT-Cancer) project: Rationale and design of the database and the collection of evidence available at approval of novel drugs. Trials 2018; 19:505. [PMID: 30231912 PMCID: PMC6146631 DOI: 10.1186/s13063-018-2877-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 08/24/2018] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND The available evidence on the benefits and harms of novel drugs and therapeutic biologics at the time of approval is reported in publicly available documents provided by the US Food and Drug Administration (FDA). We aimed to create a comprehensive database providing the relevant information required to systematically analyze and assess this early evidence in meta-epidemiological research. METHODS We designed a modular and flexible database of systematically collected data. We identified all novel cancer drugs and therapeutic biologics approved by the FDA between 2000 and 2016, recorded regulatory characteristics, acquired the corresponding FDA approval documents, identified all clinical trials reported therein, and extracted trial design characteristics and treatment effects. Herein, we describe the rationale and design of the data collection process, particularly the organization of the data capture, the identification and eligibility assessment of clinical trials, and the data extraction activities. DISCUSSION We established a comprehensive database on the comparative effects of drugs and therapeutic biologics approved by the FDA over a time period of 17 years for the treatment of cancer (solid tumors and hematological malignancies). The database provides information on the clinical trial evidence available at the time of approval of novel cancer treatments. The modular nature and structure of the database and the data collection processes allow updates, expansions, and adaption for a continuous meta-epidemiological analysis of novel drugs. The database allows us to systematically evaluate benefits and harms of novel drugs and therapeutic biologics. It provides a useful basis for meta-epidemiological research on the comparative effects of innovative cancer treatments and continuous evaluations of regulatory developments.
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Affiliation(s)
- Aviv Ladanie
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital and University of Basel, Spitalstrasse 12, 4031, Basel, Switzerland.,Swiss Tropical and Public Health Institute (Swiss TPH), Socinstrasse 57, Basel, 4002, Switzerland
| | - Benjamin Speich
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital and University of Basel, Spitalstrasse 12, 4031, Basel, Switzerland
| | - Florian Naudet
- Univ Rennes, CHU Rennes, Inserm, CIC 1414 [(Centre d'Investigation Clinique de Rennes)], 22 rue Henri Le Guilloux, 35000, Rennes, France
| | - Arnav Agarwal
- Department of Medicine, University of Toronto, 1 King's College Circle, Toronto, M5S 1A8, ON, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, Hamilton, L8S 4K1, ON, Canada
| | - Tiago V Pereira
- Health Technology Assessment Unit, Institute of Education and Health Sciences, Oswaldo Cruz German Hospital, Rua João Julião, 245 1º andar, Bloco D, São Paulo, 01323-040, Brazil
| | - Francesco Sclafani
- Department of Medicine, The Royal Marsden NHS Foundation Trust, Downs Road, Sutton, SM2 5PT, Surrey, UK
| | - Juan Martin-Liberal
- Catalan Institute of Oncology (ICO) Hospitalet, Melanoma, Sarcoma and GU Tumors Unit, Av Gran Via de L'Hospitalet 199-203, Barcelona, 08908, Spain.,Vall d'Hebron Institute of Oncology (VHIO), Early Drug Development Unit (UITM), Pg Vall d'Hebron, 119-129, Barcelona, 08035, Spain
| | - Thomas Schmid
- St. Clara Hospital, Kleinriehenstrasse 30, Basel, 4058, Switzerland
| | - Hannah Ewald
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital and University of Basel, Spitalstrasse 12, 4031, Basel, Switzerland.,Swiss Tropical and Public Health Institute (Swiss TPH), Socinstrasse 57, Basel, 4002, Switzerland.,University Medical Library, University of Basel, Schönbeinstrasse 18-20, Basel, 4056, Switzerland
| | - John P A Ioannidis
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, 1265 Welch Road, Stanford, 94305, CA, USA.,Department of Medicine, Stanford University School of Medicine, 1265 Welch Road, Stanford, 94305, CA, USA.,Department of Health Research and Policy, Stanford University School of Medicine, 1265 Welch Road, Stanford, 94305, CA, USA.,Department of Biomedical Data Science, Stanford University School of Medicine, 1265 Welch Road, Stanford, 94305, CA, USA.,Department of Statistics, Stanford University School of Humanities and Sciences, 1265 Welch Road, Stanford, 94305, CA, USA
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital and University of Basel, Spitalstrasse 12, 4031, Basel, Switzerland
| | - Benjamin Kasenda
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital and University of Basel, Spitalstrasse 12, 4031, Basel, Switzerland.,Medical Oncology, University Hospital and University of Basel, Petersgraben 4, Basel, 4031, Switzerland
| | - Lars G Hemkens
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital and University of Basel, Spitalstrasse 12, 4031, Basel, Switzerland.
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Tingley K, Coyle D, Graham ID, Sikora L, Chakraborty P, Wilson K, Mitchell JJ, Stockler-Ipsiroglu S, Potter BK. Using a meta-narrative literature review and focus groups with key stakeholders to identify perceived challenges and solutions for generating robust evidence on the effectiveness of treatments for rare diseases. Orphanet J Rare Dis 2018; 13:104. [PMID: 29954425 PMCID: PMC6022712 DOI: 10.1186/s13023-018-0851-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 06/20/2018] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION For many rare diseases, strong analytic study designs for evaluating the efficacy and effectiveness of interventions are challenging to implement because of small, geographically dispersed patient populations and underlying clinical heterogeneity. The objective of this study was to integrate perspectives from published literature and key rare disease stakeholders to better understand the perceived challenges and proposed methodological approaches to research on clinical interventions for rare diseases. METHODS We used a meta-narrative literature review and focus group interviews with key rare disease stakeholders to better understand the perceived challenges in generating and synthesizing treatment effectiveness evidence, and to describe various research methods for mitigating these identified challenges. Data from both components of this study were synthesized narratively according to research paradigms that emerged from our data. RESULTS Results from our meta-narrative literature review and focus group interviews revealed three fundamental challenges in generating robust treatment effectiveness evidence for rare diseases: i) limitations in recruiting a sufficient sample size to achieve planned statistical power; ii) inability to account for clinical heterogeneity and assess treatment effects across a clinical spectrum; and iii) reliance on short-term, surrogate outcomes whose clinical relevance is often unclear. We mapped these challenges and associated solutions to three interrelated research paradigms: i) explanatory evidence generation; ii) comparative effectiveness/pragmatic evidence generation; and iii) patient-oriented evidence generation. Within each research paradigm, numerous criticisms and potential solutions have been described with respect to overcoming these challenges from a research study design perspective. CONCLUSIONS Over time, discussions about clinical research for interventions for rare diseases have moved beyond methodological approaches to overcome challenges related to explanatory evidence generation, with increased recognition of the importance of pragmatic and patient-oriented evidence. Future directions for our work include developing a framework to expand current evidence synthesis practices to take into consideration many of the concepts discussed in this paper.
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Affiliation(s)
- Kylie Tingley
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON K1G 5Z3 Canada
| | - Doug Coyle
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON K1G 5Z3 Canada
| | - Ian D. Graham
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON K1G 5Z3 Canada
- Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Lindsey Sikora
- Health Sciences Library, University of Ottawa, Ottawa, ON Canada
| | - Pranesh Chakraborty
- Metabolics and Newborn Screening, Department of Pediatrics, Children’s Hospital of Eastern Ontario, Ottawa, ON Canada
- Department of Pediatrics, University of Ottawa, Ottawa, ON Canada
- Newborn Screening Ontario, Ottawa, ON Canada
| | - Kumanan Wilson
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON K1G 5Z3 Canada
- Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - John J. Mitchell
- Department of Pediatrics and Department of Medical Genetics, McGill University Health Centre, Montreal, QC, Canada
| | - Sylvia Stockler-Ipsiroglu
- Division of Biochemical Diseases, BC Children’s Hospital, Vancouver, BC Canada
- Department of Pediatrics, University of British Columbia, Vancouver, BC Canada
| | - Beth K. Potter
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON K1G 5Z3 Canada
| | - in collaboration with the Canadian Inherited Metabolic Diseases Research Network
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON K1G 5Z3 Canada
- Ottawa Hospital Research Institute, Ottawa, ON Canada
- Health Sciences Library, University of Ottawa, Ottawa, ON Canada
- Metabolics and Newborn Screening, Department of Pediatrics, Children’s Hospital of Eastern Ontario, Ottawa, ON Canada
- Department of Pediatrics, University of Ottawa, Ottawa, ON Canada
- Newborn Screening Ontario, Ottawa, ON Canada
- Department of Pediatrics and Department of Medical Genetics, McGill University Health Centre, Montreal, QC, Canada
- Division of Biochemical Diseases, BC Children’s Hospital, Vancouver, BC Canada
- Department of Pediatrics, University of British Columbia, Vancouver, BC Canada
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12
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Logviss K, Krievins D, Purvina S. Characteristics of clinical trials in rare vs. common diseases: A register-based Latvian study. PLoS One 2018; 13:e0194494. [PMID: 29614103 PMCID: PMC5882124 DOI: 10.1371/journal.pone.0194494] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 02/22/2018] [Indexed: 11/19/2022] Open
Abstract
Background Conducting clinical studies in small populations may be very challenging; therefore quality of clinical evidence may differ between rare and non-rare disease therapies. Objective This register-based study aims to evaluate the characteristics of clinical trials in rare diseases conducted in Latvia and compare them with clinical trials in more common conditions. Methods The EU Clinical Trials Register (clinicaltrialsregister.eu) was used to identify interventional clinical trials related to rare diseases (n = 51) and to compose a control group of clinical trials in non-rare diseases (n = 102) for further comparison of the trial characteristics. Results We found no significant difference in the use of overall survival as a primary endpoint in clinical trials between rare and non-rare diseases (9.8% vs. 13.7%, respectively). However, clinical trials in rare diseases were less likely to be randomized controlled trials (62.7% vs. 83.3%). Rare and non-rare disease clinical trials varied in masking, with rare disease trials less likely to be double blind (45.1% vs. 63.7%). Active comparators were less frequently used in rare disease trials (36.4% vs. 58.8% of controlled trials). Clinical trials in rare diseases enrolled fewer participants than those in non-rare diseases: in Latvia (mean 18.3 vs. 40.2 subjects, respectively), in the European Economic Area (mean 181.0 vs. 626.9 subjects), and in the whole clinical trial (mean 335.8 vs. 1406.3 subjects). Although, we found no significant difference in trial duration between the groups (mean 38.3 vs. 36.4 months). Conclusions The current study confirms that clinical trials in rare diseases vary from those in non-rare conditions, with notable differences in enrollment, randomization, masking, and the use of active comparators. However, we found no significant difference in trial duration and the use of overall survival as a primary endpoint.
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Affiliation(s)
| | - Dainis Krievins
- Department of Education and Science, Pauls Stradins Clinical University Hospital, Riga, Latvia
- University of Latvia, Riga, Latvia
| | - Santa Purvina
- Department of Pharmacology, Riga Stradins University, Riga, Latvia
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Hofer MP, Hedman H, Mavris M, Koenig F, Vetter T, Posch M, Vamvakas S, Regnstrom J, Aarum S. Marketing authorisation of orphan medicines in Europe from 2000 to 2013. Drug Discov Today 2018; 23:424-433. [DOI: 10.1016/j.drudis.2017.10.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 09/28/2017] [Accepted: 10/13/2017] [Indexed: 01/12/2023]
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Kawalec P, Sagan A, Pilc A. The correlation between HTA recommendations and reimbursement status of orphan drugs in Europe. Orphanet J Rare Dis 2016; 11:122. [PMID: 27600717 PMCID: PMC5012088 DOI: 10.1186/s13023-016-0501-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Accepted: 08/09/2016] [Indexed: 11/18/2022] Open
Abstract
Background The aim of this study was to review and compare types of reimbursement recommendations for orphan drugs issued by eight European health technology assessment (HTA) agencies and the reimbursement status of these drugs in the corresponding countries. Separate calculations were also performed for three sub-groups: ultra-orphan drugs, oncology orphan drugs and other (non-ultra, non-oncology) orphan drugs. Results We reviewed drugs authorized by the European Medicine Agency (EMA) between 1 November 2002 and 30 September 2015. Among these, we identified 101 orphan drugs. Seventy-nine of them were assessed by eight European HTA agencies. The average rates of positive, conditional and negative reimbursement recommendations issued by these agencies were 55.7 %, 15.3 % and 29.0 %, respectively. On average, 21.2 % of EMA-authorized orphan drugs were reimbursed in the eight European countries studied: 49.0 % of those with positive, 53.6 % of those with conditional, and 16.0 % of those with negative reimbursement recommendations. In addition, 5.4 % of orphan drugs that had not been assessed by any of the eight HTA agencies were also reimbursed. The shares of oncology, ultra, and other orphan drugs that were assessed by HTA agencies were similar, with the lowest share observed in ultra-orphan drugs (72 %) and the highest in other orphan drugs (80 %). In terms of reimbursement, 20 % of oncology orphan drugs, 25 % of ultra-orphan drugs and 21 % of other orphan drugs were reimbursed. Conclusions Reimbursement of orphan drugs does not always correspond to the type of HTA recommendation. While the highest rate of reimbursement is observed (unsurprisingly) among drugs with positive or conditional recommendation, a high rate of reimbursement (11 %) is also observed among ultra-orphan drugs that had never been assessed by any HTA agency.
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Affiliation(s)
- Paweł Kawalec
- Drug Management Department, Institute of Public Health, Faculty of Health Sciences, Jagiellonian University Medical College, ul. Grzegórzecka 20, 31-531, Kraków, Poland.
| | - Anna Sagan
- European Observatory on Health Systems and Policies, London, United Kingdom.,London School of Economics, Health and Social Care, London, United Kingdom
| | - Andrzej Pilc
- Institute of Pharmacology Polish Academy of Sciences, Kraków, Poland
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