The use of the ‘linked evidence approach’ to guide policy on the reimbursement of personalized medicines

The Cost-Effectiveness of Primary Prevention Interventions for Skin Cancer: An Updated Systematic Review

OBJECTIVE

Preventing the onset of skin malignancies is feasible by reducing exposure to ultraviolet radiation. We reviewed published economic evaluations of primary prevention initiatives in the past decade, to support investment decisions for skin cancer prevention.

METHODS

We assessed cost-effectiveness, cost-utility and benefit-cost analyses published from 1 September 2013. Seven databases were searched on 18 July 2023 and updated on 15 November 2023. Studies must have reported outcomes in terms of monetary costs, life years, quality-adjusted life years or variant thereof. A narrative synthesis was undertaken and reporting quality was assessed by three reviewers using the Consolidated Health Economic Evaluation Reporting Standards checklist.

RESULTS

In total, 12 studies were included with five studies located in Australia; three in North America and the remaining four in Europe. Interventions included restricting the use of indoor tanning devices (7 studies), television advertising, multi-component sun safety campaigns, shade structures plus protective clothing provision for outdoor workers and provision of melanoma genomic risk information to individuals. Most studies constructed Markov cohort models and adopted a societal cost perspective. Overall, the reporting quality of the studies was high. Studies found highly favourable returns on investment ranging from US$0.35 for every $1 spent on prevention, up to €3.60 for every €1 spent. Other studies showed substantial skin cancers avoided, gains in life years, quality-adjusted survival, and societal cost savings.

CONCLUSIONS

From both population health and economic perspectives, allocating limited health care resources to primary prevention of skin cancer is highly favourable.

Financing and Reimbursement Models for Personalised Medicine: A Systematic Review to Identify Current Models and Future Options

BACKGROUND

The number of healthcare interventions described as 'personalised medicine' (PM) is increasing rapidly. As healthcare systems struggle to decide whether to fund PM innovations, it is unclear what models for financing and reimbursement are appropriate to apply in this context.

OBJECTIVE

To review financing and reimbursement models for PM, summarise their key characteristics, and describe whether they can influence the development and uptake of PM.

METHODS

A literature review was conducted in Medline, Embase, Web of Science, and Econlit to identify studies published in English between 2009 and 2021, and reviews published before 2009. Grey literature was identified through Google Scholar, Google and subject-specific webpages. Articles that described financing and reimbursement of PM, and financing of non-PM were included. Data were extracted and synthesised narratively to report on the models, as well as facilitators, incentives, barriers and disincentives that could influence PM development and uptake.

RESULTS

One hundred and fifty-three papers were included. Research and development of PM was financed through both public and private sources and reimbursed largely through traditional models such as single fees, Diagnosis-Related Groups, and bundled payments. Financial-based reimbursement, including rebates and price-volume agreements, was mainly applied to targeted therapies. Performance-based reimbursement was identified mainly for gene and targeted therapies, and some companion diagnostics. Gene therapy manufacturers offered outcome-based rebates for treatment failure for interventions including Luxturna®, Kymriah®, Yescarta®, Zynteglo®, Zolgensma® and Strimvelis®, and coverage with evidence development for Kymriah® and Yescarta®. Targeted testing with OncotypeDX® was granted value-based reimbursement through initial coverage with evidence development. The main barriers and disincentives to PM financing and reimbursement were the lack of strong links between stakeholders and the lack of demonstrable benefit and value of PM.

CONCLUSIONS

Public-private financing agreements and performance-based reimbursement models could help facilitate the development and uptake of PM interventions with proven clinical benefit.

Impact of 18F-FET PET/MR on clinical management of brain tumor patients

Multiparametric PET/MRI with the amino-acid analog O-(2-¹⁸F-fluoroethyl)-l-tyrosine (¹⁸F-FET) enables the simultaneous assessment of molecular, morphologic, and functional brain tumor characteristics. Although it is considered the most accurate noninvasive approach in brain tumors, its relevance for patient management is still under debate. Here, we report the diagnostic performance of ¹⁸F-FET PET/MRI and its impact on clinical management in a retrospective patient cohort. Methods: We retrospectively analyzed brain tumor patients who underwent ¹⁸F-FET PET/MRI between 2017 and 2018. ¹⁸F-FET PET/MRI examinations were indicated clinically because of equivocal standard imaging results or the clinical course. Histologic confirmation or clinical and standard imaging follow-up served as the reference standard. We evaluated ¹⁸F-FET PET/MRI accuracy in identifying malignancy in untreated suspected lesions (category, new diagnosis) and true progression during adjuvant treatment (category, detection of progression) in a clinical setting. Using multiple regression, we also estimated the contribution of single modalities to produce an optimal PET/MRI outcome. We assessed the recommended and applied therapies before and after ¹⁸F-FET PET/MRI and noted whether the treatment changed on the basis of the ¹⁸F-FET PET/MRI outcome. Results: We included 189 patients in the study. ¹⁸F-FET PET/MRI allowed the identification of malignancy at new diagnosis with an accuracy of 85% and identified true progression with an accuracy of 93%. Contrast enhancement, ¹⁸F-FET PET uptake, and tracer kinetics were the major contributors to an optimal PET/MRI outcome. In the previously equivocal patients, ¹⁸F-FET PET/MRI changed the clinical management in 33% of the untreated lesions and 53% of the cases of tumor progression. Conclusion: Our results suggest that ¹⁸F-FET PET/MRI helps clarify equivocal conditions and profoundly supports the clinical management of brain tumor patients. The optimal modality setting for ¹⁸F-FET PET/MRI and the clinical value of a simultaneous examination need further exploration. At a new diagnosis, multiparametric ¹⁸F-FET PET/MRI might help prevent unnecessary invasive procedures by ruling out malignancy; however, adding static ¹⁸F-FET PET to an already existing MRI examination seems to be of equal value. At detection of progression, multiparametric ¹⁸F-FET PET/MRI may increase therapy effectiveness by distinguishing between tumor progression and therapy-related imaging alterations.

Shedding Light on Reimbursement Policies of Companion Diagnostics in European Countries

OBJECTIVES

Ensuring access to precision medicine has been an issue because in some European countries, desynchronized reimbursement decision-making occurs between the medicine and the companion diagnostic (CDx). This has resulted in cases in which precision medicine is reimbursed but not the CDx. In overcoming this issue, an alignment of the decision-making process for reimbursement between the 2 entities should be considered. As pharmaceutical reimbursement procedures are meticulously covered in the literature, we set out to systematically map in vitro diagnostic (IVD) reimbursement procedures and identify policies for aligning these procedures with the pharmaceutical reimbursement procedures.

METHODS

We selected 8 European countries for this analysis. For each country, we characterized the national benefit basket entailing the IVD medical acts in outpatient care, evaluated the procedure for inclusion, and identified alternative reimbursement practices for CDx. Targeted searches, using publicly accessible sources, were conducted to identify relevant reimbursement policies and laws.

RESULTS

We systematically describe the reimbursement process in 8 European countries. Alternative procedures for CDx reimbursement were identified in Belgium and Germany. Alternative policies attributed to the practice of precision medicine were identified in England and Italy. In France, some CDx are included in the "coverage with evidence" development program. Specifically, the health technology assessment agencies of France and England commented on the assessment of companion diagnostics and their clinical utility.

CONCLUSION

CDx reimbursement procedures have recently been implemented in some countries. This was seemingly done primarily to ensure access to the precision medicine and only secondary to the value they would provide.

Toward Alignment in the Reporting of Economic Evaluations of Diagnostic Tests and Biomarkers: The AGREEDT Checklist

Objectives. General frameworks for conducting and reporting health economic evaluations are available but not specific enough to cover the intricacies of the evaluation of diagnostic tests and biomarkers. Such evaluations are typically complex and model-based because tests primarily affect health outcomes indirectly and real-world data on health outcomes are often lacking. Moreover, not all aspects relevant to the evaluation of a diagnostic test may be known and explicitly considered for inclusion in the evaluation, leading to a loss of transparency and replicability. To address this challenge, this study aims to develop a comprehensive reporting checklist. Methods. This study consisted of 3 main steps: 1) the development of an initial checklist based on a scoping review, 2) review and critical appraisal of the initial checklist by 4 independent experts, and 3) development of a final checklist. Each item from the checklist is illustrated using an example from previous research. Results. The scoping review followed by critical review by the 4 experts resulted in a checklist containing 44 items, which ideally should be considered for inclusion in a model-based health economic evaluation. The extent to which these items were included or discussed in the studies identified in the scoping review varied substantially, with 14 items not being mentioned in ≥47 (75%) of the included studies. Conclusions. The reporting checklist developed in this study may contribute to improved transparency and completeness of model-based health economic evaluations of diagnostic tests and biomarkers. Use of this checklist is therefore encouraged to enhance the interpretation, comparability, and—indirectly—the validity of the results of such evaluations.

Practice-based evidence for the clinical benefit of PET/CT-results of the first oncologic PET/CT registry in Germany

PURPOSE

The purpose of this study was to evaluate the impact of PET/CT on clinical management of cancer patients based on a prospective data registry. The study was developed to inform consultations with public health insurances on PET/CT coverage.

METHODS

We evaluated a prospective patient cohort having a clinically indicated PET/CT at a single German University Center from April 2013 to August 2016. The registry collected questionnaire data from requesting physicians on intended patient management before and after PET/CT. A total of 4,504 patients with 5,939 PET/CT examinations were enrolled in the registry, resulting in evaluable data from 3,724 patients receiving 4,754 scans. The impact of PET/CT on patient management was assessed across 22 tumor types, for different indications (diagnosis, staging, suspected recurrence) and different categories of management including treatment (curative or palliative) and non-treatment (watchful waiting, additional imaging, invasive tests).

RESULTS

The most frequent PET/CT indication was tumor staging (59.7%). Melanoma, lung cancer, lymphoma, neuroendocrine tumor and prostate cancer accounted for 70% of cases. Overall, the use of PET/CT resulted in a 37.1% change of clinical management (95% CI, 35.7-38.5), most frequently (30.6%) from an intended non-treatment strategy before PET/CT to active treatment after PET/CT. The frequency of changes ranged from 28.3% for head and neck cancers up to 46.0% for melanomas. The impact of PET/CT was greatest in reducing demands for additional imaging which decreased from 66.1% before PET/CT to 6.1% after PET/CT. Pre-PET/CT planned invasive tests could be avoided in 72.7% of cases. The treatment goal changed after PET/CT in 21.7% of cases, in twice as many cases from curative to palliative therapy than vice versa.

CONCLUSIONS

The data of this large prospective registry confirm that physicians often change their intended management on the basis of PET/CT by initiating treatment and reducing additional imaging as well as invasive tests. This applies to various cancer types and indications.

Impact of the "Linked Evidence Approach" Method on Policies to Publicly Fund Diagnostic, Staging, and Screening Medical Tests

Background: The linked evidence approach (LEA) is used in health technology assessment (HTA) to evaluate the clinical utility of new medical tests in the absence of direct trial evidence. Objective: To determine whether use of LEA affects decisions to publicly fund medical tests. Methods: Australian HTAs that evaluated medical tests before and after LEA was mandated (in 2005) were screened for eligibility. Data were extracted and the impact of LEA and other possible clinical predictors (selected a priori) on funding decisions was modelled. Regression diagnostics were performed to estimate model fit, model specification, and to inform model selection. The unit of analysis was per clinical indication for each new test, so analyses were adjusted for clustering. Results: 83 HTAs (for 173 clinical indications) were eligible from the 259 screened. When health policy was compared before and after 2005, there was an 11% reduction in overall positive funding decisions, including a 25% decrease in “interim” (coverage with evidence development) funding decisions. The odds of obtaining interim funding reduced by 98% (odds ratio = 0.02, 95% confidence interval = 0.0005, 0.17), but there was no change in the direction of funding decisions (odds ratio = 1.36, 95% confidence interval = 0.62, 3.01). Across both time periods, when LEA was used there was a very strong likelihood that the medical test would not receive interim funding (χ² = 12.63, df = 1, P = 0.001). For positive funding decisions, the strongest predictors were whether or not the new test would replace an existing test and whether the available evidence was limited. Conclusions: The use of LEA did not predict the direction of funding decisions. Application of the method did predict that a “coverage with evidence development” decision was unlikely. This suggests that LEA may reduce decision-maker uncertainty.

Setting analytical performance specifications based on outcome studies - is it possible?

The 1st Strategic Conference of the European Federation of Clinical Chemistry and Laboratory Medicine proposed a simplified hierarchy for setting analytical performance specifications (APS). The top two levels of the 1999 Stockholm hierarchy, i.e., evaluation of the effect of analytical performance on clinical outcomes and clinical decisions have been proposed to be replaced by one outcome-based model. This model can be supported by: (1a) direct outcome studies; and (1b) indirect outcome studies investigating the impact of analytical performance of the test on clinical classifications or decisions and thereby on the probability of patient relevant clinical outcomes. This paper reviews the need for outcome-based specifications, the most relevant types of outcomes to be considered, and the challenges and limitations faced when setting outcome-based APS. The methods of Model 1a and b are discussed and examples are provided for how outcome data can be translated to APS using the linked evidence and simulation or decision analytic techniques. Outcome-based APS should primarily reflect the clinical needs of patients; should be tailored to the purpose, role and significance of the test in a well defined clinical pathway; and should be defined at a level that achieves net health benefit for patients at reasonable costs. Whilst it is acknowledged that direct evaluations are difficult and may not be possible for all measurands, all other forms of setting APS should be weighed against that standard, and regarded as approximations. Better definition of the relationship between the analytical performance of tests and health outcomes can be used to set analytical performance criteria that aim to improve the clinical and cost-effectiveness of laboratory tests.