Societal perspective on access to publicly subsidised medicines: A cross sectional survey of 3080 adults in Australia

Comparative policy analysis of national rare disease funding policies in Australia, Singapore, South Korea, the United Kingdom and the United States: a scoping review

BACKGROUND

Rare diseases pose immense challenges for healthcare systems due to their low prevalence, associated disabilities, and attendant treatment costs. Advancements in gene therapy, such as treatments for Spinal Muscular Atrophy (SMA), have introduced novel therapeutic options, but the high costs, exemplified by Zolgensma® at US$2.1 million, present significant financial barriers. This scoping review aimed to compare the funding approaches for rare disease treatments across high-performing health systems in Australia, Singapore, South Korea, the United Kingdom (UK), and the United States (US), aiming to identify best practices and areas for future research.

METHODS

In accordance with the PRISMA-ScR guidelines and the methodological framework by Arksey and O'Malley and ensuing recommendations, a comprehensive search of electronic databases (Medline, EMBASE, and Cochrane) and grey literature from health department websites and leading national organizations dedicated to rare diseases in these countries was conducted. Countries selected for comparison were high-income countries with advanced economies and high-performing health systems: Australia, Singapore, South Korea, the UK, and the US. The inclusion criteria focused on studies detailing drug approval processes, reimbursement decisions and funding mechanisms, and published from 2010 to 2024.

RESULTS

Based on a thorough review of 18 published papers and grey literature, various strategies are employed by countries to balance budgetary constraints and access to rare disease treatments. Australia utilizes the Life Saving Drugs Program and risk-sharing agreements. Singapore depends on the Rare Disease Fund, which matches public donations. South Korea's National Health Insurance Service covers specific orphan drugs through risk-sharing agreements. The UK relies on the National Institute for Health and Care Excellence (NICE) to evaluate treatments for cost-effectiveness, supported by the Innovative Medicines Fund. In the US, a combination of federal and state programs, private insurance and non-profit support is used.

CONCLUSION

Outcome-based risk-sharing agreements present a practical solution for managing the financial strain of costly treatments. These agreements tie payment to actual treatment efficacy, thereby distributing financial risk and promoting ongoing data collection. Countries should consider adopting and expanding these agreements to balance immediate expenses with long-term benefits, ultimately ensuring equitable access to crucial treatments for patients afflicted by rare diseases.

Problems with NICE's severity weights

This essay examines the implications, plausibility, and justification of the severity weighting that NICE (The National Institute for Health and Care Excellence) has endorsed for technology assessments in the U.K. It argues that the assignment by NICE of additional weights to health conditions which involve a large absolute or proportional shortfall of future expected QALYs (Quality-Adjusted Life Years) as compared to those who do not have these health conditions is not well supported and has troubling implications. The literature concerned with attitudes toward prioritizing severity has found a variety of notions of severity, and it is questionable to what extent those studies bear on whether to assign greater weights to health states involving large absolute or proportional shortfalls. In addition, the severity weighting is not well supported by either egalitarian or prioritarian political philosophy, because it is concerned only with the future and focuses only on health rather than well-being in general.

Eliciting Societal Preferences for Non-health Outcomes: A Person Trade-Off Study in the Context of Genomics

PURPOSE

Economic evaluations of health technologies traditionally aim to maximize population health outcomes measured by using quality-adjusted life-years (QALYs). Non-health outcomes, however, may have high social value, and their exclusion has the potential to bias decisions regarding allocation of health care resources. This research positions Australian participants as societal decision-makers to explore their willingness to trade-off health gains in adults for non-health benefits in families with a child affected by a rare disease.

METHODS

To estimate the social value of the different health care interventions, a person trade-off (PTO) method was used. PTOs present participants with groups of beneficiaries that vary in terms of the number of individuals who will benefit, the individuals' characteristics, their expected benefits, or a combination, and ask which group should be prioritized. Each trade-off presented health gains from the treatment of moderate physical and mental health conditions described by the 3-level version of the EuroQol 5-Dimension (EQ-5D-3L) health states. The health gains in these groups were traded-off against non-health gains in families accessing diagnostic genomic testing, and equivalence values were calculated, using median and ratio of means methods, based on the ratio of the group sizes at the point of equivalence. Participants were recruited through Prolific and were stratified according to age, sex, and education. The impact of participant characteristics on equivalence values was assessed using Kruskal-Wallis H tests and ordinary least-squares log-linear regressions.

FINDINGS

Participants (N = 434) positioned as societal decision-makers were generally willing to trade-off adult health gains with the familial non-health benefits of genomic testing, showing a preference for valuing both types of outcomes within public health policy. The aggregation of preferences generated 2 weightings for genomic testing against each health treatment, an unadjusted value and a reweighted value to match target demographic characteristics. Converted into QALY value per test, it was found that participants valued the non-health benefits of genomic testing between 0.730 and 0.756 QALY. A minority of participants always prioritized diagnostic genomic testing over the physical (6.0%) or mental (4.6%) health treatments, with a larger minority always prioritizing the physical (15.4%) or mental (14.8%) health treatments.

IMPLICATIONS

The findings indicate that participants perceived the non-health parental benefits in children experiencing rare disease to have comparable value to health gains in adults experiencing the moderate physical or mental health conditions described using EQ-5D-3L. These findings suggest that the benefits of genomic tests would be underestimated if only health benefits are included in economic evaluations.

Comparison of Rare and Common Diseases in the Setting of Healthcare Priorities: Evidence of Social Preferences Based on a Systematic Review

Background

In light of the limited availability of healthcare resources, providing universal access to healthcare is a challenging task. As a result, prioritizing healthcare services has emerged as a crucial issue. This study aims to explore the preferences of the public regarding healthcare prioritization for rare and common diseases. By examining public attitudes, this study seeks to inform government decisions concerning resource allocation and distribution within healthcare.

Methods

"Social preference" and "rare disease" were searched as MeSH terms in the electronic databases of Ovid Medline, Web of Science, Embase, and Econlit for articles published since their establishment, and the information on the characteristics of the articles and the results of social preferences for rare diseases were analyzed and summarized.

Results

The public held predominantly neutral views on the setting of healthcare priorities for rare and common diseases. The results of the included studies showed that with all else being equal, no social preference for rarity was found, but when the public considered the proportional advantage of rare diseases or when the respondents were young, a social preference for rarity existed. In addition, the public weighed attributes such as the health benefits of treatments, the effectiveness of treatment options, the safety of treatment, equity, unmet needs, and disease severity in the process of setting of treatment priorities for rare diseases. Furthermore, in consideration of equity, the public showed a willingness to pay for rare diseases in spite of the high medical costs.

Conclusion

International studies on social preferences provide some evidence for the setting of healthcare priorities for rare diseases, and health policymakers should consider social preferences in an integrated manner in order to set healthcare priorities appropriately.

The Challenge for Orphan Drugs Remains: Three Case Studies Demonstrating the Impact of Changes to NICE Methods and Processes and Alternative Mechanisms to Value Orphan Products

BACKGROUND

The National Institute for Health and Care Excellence (NICE) is responsible for ensuring that patients in England and Wales can access clinically and cost-effective treatments. However, NICE's processes pose significant reimbursement challenges for treatments for rare diseases. While some orphan medicines have been appraised via the highly specialised technology route, most are appraised via the single technology appraisal programme, a route that is expected to be increasingly used given new more restrictive highly specialised technology criteria. This often results in delays to access owing to differences in applicable thresholds and the single technology appraisal approach being ill-equipped to deal with the inevitable decision uncertainty. NICE recently published their updated methods and process manual, which includes a new severity-of-disease modifier and an instruction to be more flexible when considering uncertainty in rare diseases. However, as the threshold gap between the single technology appraisal and highly specialised technology programmes remains, it is unlikely that these changes alone will address the problem.

OBJECTIVE

We explored the potential impact of quality-adjusted life-year weights in decision making.

METHODS

We explored the impact of NICE's new severity-of-disease modifier weighting and two alternative methods (the use of alternative quality-adjusted life-year weights and the fair rate of return), using three recent single technology appraisals of orphan medicines (caplacizumab, teduglutide and pirfenidone for mild idiopathic pulmonary fibrosis).

RESULTS

Our results suggest NICE's severity-of-disease modifier would not have affected the recommendations. Using alternative methods, based upon achievement of an incremental cost-effectiveness ratio below standard thresholds, patients could have received access to caplacizumab approximately 5 months earlier, and the appraisals for teduglutide and pirfenidone would have resulted in a positive recommendation following appraisal consultation meeting 1 when neither of these products was available over 5 years from the initial submission.

CONCLUSION

Ultimately, moving from a restrictive end-of-life modifier to one based on disease severity is a more equitable approach likely to benefit many therapies, including orphan products. However, NICE's single technology appraisal updates are unlikely to result in faster reimbursement of orphan medicines, nor will they address concerns around market access for orphan medicines in the UK.

Public preferences regarding the priority setting criteria of health interventions for budget allocation: results of a survey of Iranian adults

Objectives

Priority setting in health directly impacts the general public as payers and final consumers, so the public preferences must be considered. The present study aimed to provide public preferences about health intervention allocation criteria for the optimal allocation of public health budget in Iran.

Methods

A choice-based survey method was used to assess the general public’s preferences regarding 8 critical criteria with a societal aspect. One thousand sixty-four adult citizens of Tehran, Iran, participated in the study. Participants were asked to allocate a hypothetical budget between the two groups with differences in allocation criteria. Public preferences were inferred from absolute majority responses i.e., more than 50% of participants’ allocation for a criterion. The Logistic Regression Model was used to investigate the factors affecting the preferences regarding the importance of allocation criteria.

Results

Based on expressed participants’ preferences, criteria of disease severity, age, daily care needs, Number of alternative interventions, individual’s economic status, and diseases with absence from work were important. Thus, 77, 69, 61, 57, 54, and 51% of participants preferred to allocate the hypothetical budget to the treatment of patients with poor economic status, treatment of patients with diseases leading to absence from work, treating patients with severe diseases, treatment of diseases in need of daily care and treatment of children’s diseases, respectively. Findings from the factors affecting participants’ preferences regarding allocation criteria also showed that people with different characteristics had different preferences.

Conclusions

Iranian general public pays special attention to the criteria of equitable allocation, including patients’ economic status, criteria with societal aspects such as absenteeism from work and the need for daily care, as well as criteria with medical aspects such as disease severity and access to alternative interventions which may sometimes be less considered in decision making.

No Time to Waste: An Appraisal of Value at the End of Life

OBJECTIVES

The use of economic evaluations of end-of-life interventions may be limited by an incomplete appreciation of how patients and society perceive value at end of life. The objective of this study was to evaluate how patients, caregivers, and society value gains in quantity of life and quality of life (QOL) at the end of life. The validity of the assumptions underlying the use of the quality-adjusted life-years (QALY) as a measure of preferences at end of life was also examined.

METHODS

MEDLINE, Embase, CINAHL, PsycINFO, and PubMed were searched from inception to February 22, 2021. Original research studies reporting empirical data on healthcare priority setting at end of life were included. There was no restriction on the use of either quantitative or qualitative methods. Two reviewers independently screened, selected, and extracted data from studies. Narrative synthesis was conducted for all included studies. The primary outcomes were the value of gains in quantity of life and the value of gains in QOL at end of life.

RESULTS

A total of 51 studies involving 53 981 participants reported that gains in QOL were generally preferred over quantity of life at the end of life across stakeholder groups. Several violations of the underlying assumptions of the QALY to measure preferences at the end of life were observed.

CONCLUSIONS

Most patients, caregivers, and members of the general public prioritize gains in QOL over marginal gains in life prolongation at the end of life. These findings suggest that policy evaluations of end-of-life interventions should favor those that improve QOL. QALYs may be an inadequate measure of preferences for end-of-life care thereby limiting their use in formal economic evaluations of end-of-life interventions.

Perception of Medical Students on the Need for End-of-Life Care: A Q-Methodology Study

End-of-life care and the limitation of therapeutic effort are among the most controversial aspects of medical practice. Many subjective factors can influence decision-making regarding these issues. The Q methodology provides a scientific basis for the systematic study of subjectivity by identifying different thought patterns. This methodology was performed to find student profiles in 143 students at Cantabria University (Spain), who will soon deal with difficult situations related to this topic. A chi-square test was used to compare proportions. We obtained three profiles: the first seeks to ensure quality of life and attaches great importance to the patient’s wishes; the second prioritizes life extension above anything else; the third incorporates the economic perspective into medical decision-making. Those who had religious beliefs were mostly included in profile 2 (48.8% vs. 7.3% in profile 1 and 43.9% in profile 3), and those who considered that their beliefs did not influence their ethical principles, were mainly included in profile 3 (48.5% vs. 24.7% in profile 1 and 26.8% in profile 2). The different profiles on end-of-life care amongst medical students are influenced by personal factors. Increasing the clinical experience of students with terminally ill patients would contribute to the development of knowledge-based opinion profiles and would avoid reliance on personal experiences.

Use of the incremental cost-effectiveness ratio for decision-making policies-what is the problem? A perspective paper

INTRODUCTION

Drug reimbursement decisions that spark public controversy are potential signals that processes used to reach such decisions do not adequately reflect society's goals. Such controversial decisions appear to be a characteristic of Quality-Adjusted Life Year (QALY)-based Incremental Cost Effectiveness Ratio (ICER)-dominated decision-making systems. QALY-based ICER-heavy systems have several known weaknesses that lead to individual and societal preferences being either ignored or considered in an unsystematic and inconsistent manner.

AREAS COVERED

We reprise some of the key inadequacies of QALY-based ICER analyses and suggest that there are other means including multicriteria decision analysis (MCDA) and cost-benefit analysis based on willingness to pay (WTP) measures by which to partially mitigate these weaknesses.

EXPERT OPINION

For long, the inadequacies of QALY-based ICER-heavy decision-making systems have been rationalized with the answer: 'while the method is a second best, it is the best we currently have.' In light of the equally well-developed and widely utilized alternatives available, this resistance to improve assessment processes should not be accepted by policy makers. Health technology assessment bodies should consider and, with appropriate modifications, adopt these alternatives as they have the potential to result in more comprehensive, systematic, and accountable decision-making.

What Aspects of Illness Influence Public Preferences for Healthcare Priority Setting? A Discrete Choice Experiment in the UK

BACKGROUND

Decisions on funding new healthcare technologies assume that all health improvements are valued equally. However, public reaction to health technology assessment (HTA) decisions suggests there are health attributes that matter deeply to them but are not currently accounted for in the assessment process. We aimed to determine the relative importance of attributes of illness that influence the value placed on alleviating that illness.

METHOD

We conducted a discrete choice experiment survey that presented general public respondents with 15 funding decisions between hypothetical health conditions. The conditions were defined by five attributes that characterise serious illnesses, plus the health gain from treatment. Respondent preferences were modelled using conditional logistic regression and latent class analysis.

RESULTS

905 members of the UK public completed the survey in November 2017. Respondents generally preferred to provide treatments for conditions with 'better' characteristics. The exception was treatment availability, where respondents preferred to provide treatments for conditions where there is no current treatment, and were prepared to accept lower overall health gain to do so. A subgroup of respondents preferred to prioritise 'worse' health states.

CONCLUSION

This study suggests a preference among the UK public for treating an unmet need; however, it does not suggest a preference for prioritising other distressing aspects of health conditions, such as limited life expectancy, or where patients are reliant on care. Our results are not consistent with the features currently prioritised in UK HTA processes, and the preference heterogeneity we identify presents a major challenge for developing broadly acceptable policy.

Eliciting the public preferences for pharmaceutical subsidy in Iran: a discrete choice experiment study

BACKGROUND

Deciding on pharmaceutical subsidy is regarded as a challenging issue for healthcare policymakers in Iran in most times. Public preferences, rarely attended in Iran, could be invaluable for including a particular drug in the list of subsidized medications.

OBJECTIVES

The current study aims to elicit the public preferences to develop an evidence-based decision-making framework for entering a drug into the list of subsidies in Iran.

METHODS

Discrete Choice Experiment (DCE) was employed to elicit the public preferences. Around 34 attributes were identified based on the systematic review and interview with 51 experts. By holding an expert panel, 7 attributes were finalized, namely: the survival after treatment, quality of life after treatment (QoL), alternative treatment, age group of the target population, cost burden for the government, disease severity, and drug manufacturer country. Next, 1224 households were selected for the survey in the city of Tehran, using random cluster sampling. Data were analyzed using conditional logit model.

RESULTS

The survival after treatment (β = 1.245; SE = 0.053) and disease severity (β =- 0.143; SE = 0.043) had the highest and lowest priority, respectively, in the preferences for allocating subsidy to a drug. In developed region, unlike the other two regions, the level of domestic drug production (β =- 0.302; SE = 0.073) was inversely associated with preferences toward allocating subsidy to a drug. In contrast to other districts, those living in district number one (β = 2.053; SE = 0.138) gave the highest value to promoting the QoL after treatment.

CONCLUSIONS

It is suggested that policymakers pay more attention to attributes such as effectiveness and alternative treatment when developing an evidence-based framework for entering a drug into the list of subsidies. This study highlighted the public belief in the government's subsidy for medicines, provided that, this results in an increased survival and QoL.

A systematic review of moral reasons on orphan drug reimbursement

BACKGROUND

The number of market approvals of orphan medicinal products (OMPs) has been increasing steadily in the last 3 decades. While OMPs can offer a unique chance for patients suffering from rare diseases, they are usually very expensive. The growing number of approved OMPs increases their budget impact despite their low prevalence, making it pressing to find solutions to ethical challenges on how to fairly allocate scarce healthcare resources under this context. One potential solution could be to grant OMPs special status when considering them for reimbursement, meaning that they are subject to different, and less stringent criteria than other drugs. This study aims to provide a systematic analysis of moral reasons for and against such a special status for the reimbursement of OMPs in publicly funded healthcare systems from a multidisciplinary perspective.

RESULTS

With a systematic review of reasons, we identified 39 reasons represented in 243 articles (scientific and grey literature) for and against special status for the reimbursement of OMPs, then categorized them into nine topics. Taking a multidisciplinary perspective, we found that most articles came from health policy (n = 103) and health economics (n = 49). More articles took the position for a special status of OMPs (n = 97) than those against it (n = 31) and there was a larger number of reasons identified in favour (29 reasons) than against (10 reasons) this special status.

CONCLUSION

Results suggest that OMP reimbursement issues should be assessed and analysed from a multidisciplinary perspective. Despite the higher occurrence of reasons and articles in favour of a special status, there is no clear-cut solution for this ethical challenge. The binary perspective of whether or not OMPs should be granted special status oversimplifies the issue: both OMPs and rare diseases are too heterogeneous in their characteristics for such a binary perspective. Thus, the scientific debate should focus less on the question of disease prevalence but rather on how the important variability of different OMPs concerning e.g. target population, cost-effectiveness, level of evidence or mechanism of action could be meaningfully addressed and implemented in Health Technology Assessments.

Consumer perspectives of accelerated access to medicines: a qualitative study

PURPOSE

In this study, the authors aimed to explore consumer perspectives on accelerated access to medicines. The authors were particularly interested in how they balance competing considerations of safety, efficacy, equity and access; whether and how their views change when there are different levels of uncertainty surrounding the safety and efficacy of new medicines; and the procedures that they think should be used to make decisions about accelerated access to new medicines.

DESIGN/METHODOLOGY/APPROACH

This was an exploratory qualitative study. Thirteen semi-structured interviews with patient advocates and two focus groups with patients were conducted and analysed thematically. Interviews and focus groups were audio recorded and transcribed verbatim. Data were analysed through inductive thematic analysis.

FINDINGS

Participants outlined a range of justifications for accelerated access, including addressing unmet medical needs and encouraging further research and development. However, they were also cognisant of the potential risks and viewed ongoing data collection, disinvestment and market withdrawal as ways to address these. They also emphasised the importance of transparent decisions being made by people with relevant expertise, based on a thorough consideration of scientific evidence and stakeholder perspectives.

ORIGINALITY/VALUE

This is the first study to comprehensively explore Australian consumers' views of accelerated access to medicines. The results suggest that consumers want timely access to new medicines, but not at the expense of safety, efficacy, equity and sustainability. While accelerated access programs are likely to be welcomed by consumers, they must be fully informed of their conditions and limitations, and robust post-market data surveillance must be implemented and enforced to protect the interests of both individual patients and the broader community.

Can the Consideration of Societal Costs Change the Recommendation of Economic Evaluations in the Field of Rare Diseases? An Empirical Analysis

OBJECTIVES

To analyze whether the adoption of a societal perspective would alter the results and conclusions of economic evaluations for rare disease-related healthcare technologies.

METHODS

A search strategy involving all the active substances considered as orphan drugs by the European Medicines Agency plus a list of 76 rare diseases combined with economic-related terms was conducted on Medline and the Cost-Effectiveness Registry from the beginning of 2000 until November 2018. We included studies that considered quality-adjusted life years as an outcome, were published in a scientific journal, were written in English, included informal care costs or productivity losses, and separated the results according to the applied perspective.

RESULTS

We found 14 articles that fulfilled the inclusion criteria. Productivity losses were considered in 12 studies, the human capital approach being the method most frequently used. Exclusively, informal care was considered in 2 articles, being valued through the opportunity cost method. The 14 articles selected resulted in 26 economic evaluation estimations, from which incremental cost-utility ratio values changed from cost-effective to dominant in 3 estimates, but the consideration of societal costs only modified the authors' conclusion in 1 study.

CONCLUSIONS

The presence of societal costs in the economic evaluation of rare diseases did not affect the conclusions of the studies except in a single specific case. In those studies where the societal perspective was considered, we did not find significant changes in the economic evaluation results due to the higher costs of treatments and the low quality-adjusted life-years gained.

Who should be given priority for public funding?

BACKGROUND

This study explored if Koreans consider the type of disease, rarity, and availability of alternative treatments as priority criteria in limited healthcare resource allocation.

MATERIALS AND METHODS

A web-based survey was conducted with a representative sample of 3,482 Korean adults. Participants were divided into six cohorts, differing in terms of the disease being compared and the cost and benefits of the treatments. Each cohort was asked two questions: 1) How to allocate a fixed budget into each of the two groups (cancer vs non-cancer, rare vs common, no other treatments available vs several treatments available), all else being equal; 2) allocation choices when conditions of two groups differed. The McNemar test was used to assess changes in responses between the two questions.

RESULTS

Under the control condition, the majority chose to treat an even number of patients with cancer and non-cancer diseases, and preferred to treat common diseases and those with no alternative treatments. However, when the treatment effects or costs of two comparison groups changed, choice shifted toward more effective or less costly treatment.

CONCLUSIONS

While Koreans generally support the principle of health maximization, they also believe that priority should be given to diseases that previously did not have any treatments. However, no priority was given to cancer or rare diseases.

Does Consumer Engagement in Health Technology Assessment Enhance or Undermine Equity?

Consumer engagement in decisions about the funding of medicines is often framed as a good in and of itself and as an activity that should be universally encouraged. A common justification for calls for consumer engagement is that it enhances equity. In this paper we systematically critique this assumption. We show that consumer engagement may undermine equity as well as enhance it and show that a simple relationship cannot be assumed but must be justified and demonstrated. In concluding, we present a number of challenges that need to be overcome in order for consumer engagement to contribute to health technology assessment in a morally and politically sound manner.

Physicians' attitudes towards accelerated access to medicines

In recent years, a variety of 'accelerated access' schemes have been introduced by pharmaceutical regulators and funders globally. These schemes aim to overcome perceived regulatory and reimbursement barriers to accessing medicines - particularly for patients with limited time or therapeutic options. However, patient access to approved medicines is mediated by a number of third parties including regulators and payers, and physicians who act both as gatekeepers and guides to prescribed medications. It is therefore essential to know how physicians think about accelerated access as they are responsible for advising patients on and prescribing medicines made available via these pathways. We conducted semi-structured interviews with 18 Australian physicians focusing on their attitudes towards accelerated access. We identified three 'archetypes' of physicians: 'confident accelerators', 'cautious accelerators', and 'decelerators'. Although all acknowledged the potential risks and benefits of accelerated access, they disagreed on their magnitude and extent and how they should be balanced in both policy formation and clinical practice. Overall, our results illustrate the diversity of clinical opinions in this area and the importance of monitoring both the prescribing and clinical outcomes that result from accelerated access programmes to ensure that these are both clinically and morally acceptable.

Beyond cost-effectiveness: A five-step framework for appraising the value of health technologies in Asia-Pacific

Given resource constraints and the potential for increasingly high-cost, cost-effective medicines to become available, policymakers require strategies that go beyond cost-effectiveness when making resource allocation decisions. This manuscript presents a five-step framework that complements traditional health technology assessment (HTA) guidance documents that policymakers in Asia-Pacific and elsewhere may consider when setting up HTA guidelines and/or evaluating whether or not to subsidize a medicine or other health innovations. The framework recommends that subsidy decisions be based on five criteria: the relative burden of the condition as compared with other conditions (step 1), comparative and cost-effectiveness of the medicine (steps 2 and 3), the short-term impact on the budget (step 4), and other considerations including patient and societal preferences (step 5). Our approach, which is a complement to traditional HTA guidance documents, is not prescriptive but provides an evidence-based framework that HTA agencies in Asia-Pacific can follow as they aim to deliver value-based medicines to their constituents.

Improving Patient Access to New Drugs in South Korea: Evaluation of the National Drug Formulary System

This study reviews and evaluates the national drug formulary system used to improve patient access to new drugs by making reimbursement decisions for new drugs as part of the South Korean national health insurance system. The national health insurance utilizes three methods for improving patient access to costly drugs: risk-sharing agreements, designation of essential drugs, and a waiver of cost-effectiveness analysis. Patients want reimbursement for new drugs to be processed quickly to improve their access to these drugs, whereas payers are careful about listing them given the associated financial burden and the uncertainty in cost-effectiveness. However, pharmaceutical companies are advocating for drug prices above certain thresholds to maintain global pricing strategies, cover the costs of drug development, and fund future investments into research and development. The South Korean government is expected to develop policies that will improve patient access to drugs with unmet needs for broadening health insurance coverage. Simultaneously, the designing of post-listing management methods is warranted for effectively managing the financial resources of the national health insurance system.

O acesso a medicamentos em sistemas universais de saúde – perspectivas e desafios

RESUMO Este estudo objetivou analisar os desafios do acesso a medicamentos em quatro sistemas universais de saúde da Austrália, do Brasil, do Canadá e do Reino Unido. Estudo qualitativo crítico-reflexivo por meio de revisão integrativa da literatura. Um dos grandes desafios dos sistemas estudados é o da incorporação de medicamentos de alto custo, via análises de custo-efetividade para cumprir a difícil tarefa de conciliar a justiça social e a equidade no acesso com sustentabilidade econômica. Particularmente o Canadá, mesmo sendo um país desenvolvido, ainda vive o dilema de como financiar um sistema de saúde no qual o acesso a medicamentos também seja universal. O Brasil convive com duas realidades problemáticas: primeiro, dar acesso a medicamentos, já padronizados pelo Sistema Único de Saúde (SUS), diante de um financiamento diminuto, segundo, de maneira semelhante aos sistemas australiano, canadense e inglês, vive o dilema de como incorporar novos medicamentos eficazes e com viabilidade econômica, além da questão da judicialização da saúde, um fenômeno complexo resultante da fragilidade pública na organização, financiamento, consolidação do SUS.

Research Designs and Methodologies Related to Pharmacy Practice

The need for evidence to inform policy and practice in pharmacy is becoming increasingly important. In parallel, clinical pharmacy and practice research is evolving. Research evidence should be used to identify new areas for improved health service delivery and rigorously evaluate new services in pharmacy. The generation of such evidence through practice-based research should be predicated on appropriate use of robust and rigorous methodologies. In addition to the quantitative and qualitative approaches used in pharmacy practice research, mixed methods and other novel approaches are increasingly being applied in pharmacy practice research. Approaches such as discrete choice experiments, Delphi techniques, and simulated client technique are now commonly used in pharmacy practice research. Therefore, pharmacy practice researchers need to be competent in the selection, application, and interpretation of these methodological and analytical approaches. This chapter focuses on introducing traditional and novel study designs and methodologies that are particularly pertinent to contemporary clinical pharmacy and practice research. This chapter will introduce the fundamentals and structures of these methodologies, but more details regarding the different approaches may be found within the Encyclopedia.

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Discuss the value of pharmacy practice research to evidence-based practice and policy.

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Describe the classifications and types of study designs commonly used in pharmacy practice research.

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Discuss the concepts and structure of common study designs used in pharmacy practice research including experimental, quasi-experimental, observational, qualitative, and mixed method designs.

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Discuss the important considerations for conducting pharmacy practice research in terms of study design, data collection, data analyses, and ethical considerations.

Societal Preferences for Funding Orphan Drugs in the United Kingdom: An Application of Person Trade-Off and Discrete Choice Experiment Methods

BACKGROUND

It is unclear whether UK National Health Service (NHS) policies for orphan drugs, which permit funding of non-cost-effective treatments, reflect societal preferences.

METHODS

We conducted person trade-off (PTO) and discrete choice experiment (DCE) among 3950 adults selected to be representative of the UK general population. Experimental design was informed by surveys of patients affected by rare diseases, their caregivers, health care staff, and policymakers. Societal preferences were estimated in relation to treating a common disease, increases in waiting lists, or filling of vacant NHS posts. Results of the DCE were applied to recently licensed orphan drugs.

RESULTS

On the basis of equal cost, the majority of respondents to the PTO (54%; 95% confidence interval [CI] 50-59) chose to allocate funds equally between patients treated for rare diseases and those treated for common diseases, with 32% (95% CI 28-36) favoring treating rare diseases over treating common diseases (14%; 95% CI 11-17), which this reduced to 23% (95% CI 20-27) when rare disease treatments were 10 times more expensive. When framed differently, more respondents prioritized not increasing waiting list size (43%; 95% CI 39-48) than to treat rare disease patients (34%; 95% CI 30-38).

DISCUSSION

The DCE indicated a greater preference for treating a common disease over a rare disease. Respondents agreed with five of 12 positive appraisal recommendations for orphan drugs, even if their list price was higher, but preferred the NHS not to fund the remainder.

CONCLUSIONS

The general public does not value rarity as a sufficient reason to justify special consideration for additional NHS funding of orphan drugs. This has implications regarding the appropriateness of operating higher thresholds of cost-effectiveness.

Rare disease prevention and treatment: the need for a level playing field

Pharmacogenetic tests are being used increasingly to prevent rare and potentially life-threatening adverse drug reactions. For many tests, however, cost-effectiveness is hard to demonstrate, and with the exception of a few cases, widespread implementation remains a distant prospect. Many orphan drugs for rare diseases are also not cost effective but are nonetheless normally reimbursed. In this article, we argue that the health technology assessment of pharmacogenetic tests aimed to prevent rare but severe adverse drug reactions should be on a level playing field with orphan drugs. This is supported by a number of arguments, concerning the severity, rarity and iatrogenic nature of adverse drug reactions, the distribution of benefits and costs and societal preference towards prevention over treatment.

Does the Public Prefer Health Gain for Cancer Patients? A Systematic Review of Public Views on Cancer and its Characteristics

BACKGROUND

Policies such as the Cancer Drugs Fund in England assumed a societal preference to fund cancer care relative to other conditions, even if that resulted in lower health gain for the population overall.

OBJECTIVE

The aim of this study was to investigate the evidence for such a preference among the UK public.

METHODS

The MEDLINE, PubMed and Econlit electronic databases were searched for studies relating to preferences for prioritising cancer treatment, as well as studies relating to preferences for the characteristics of cancer (severity of disease, end-of-life). The searches were run in November 2015 and updated in March 2017. Empirical preference studies, studies of public views, and studies in English were included.

RESULTS

We identified 24 studies relating to cancer preferences. Two directly addressed health trade-offs in the UK-one showed a preference for health gain in cancer, while the other found no such preference but provided results consistent with population health maximisation. Other studies mostly showed support for cancer but did not require a direct health trade-off. Severity and end-of-life searches identified 12 and 6 papers, respectively, which were additional to existing reviews. There is consistent evidence that people give priority to severe illness, while results for end-of-life are mixed.

CONCLUSION

We did not find consistent support for a preference for health gains to cancer patients in the context of health maximisation. The evidence base is small and the results are highly sensitive to study design. There remains a contradiction between these findings and the popular view of cancer, and further work is required to determine the features of cancer which contribute to that view.