Economic Evaluation of Adding Bevacizumab to Chemotherapy for Metastatic Colorectal Cancer (mCRC) Patients in Indonesia

Cost-Effectiveness Analysis of Bevacizumab Biosimilars Versus Originator Bevacizumab for Metastatic Colorectal Cancer: A Comparative Study Using Real-World Data

OBJECTIVES

MVASI (Amgen) and Zirabev (Pfizer) are 2 of the earliest bevacizumab biosimilars approved for the first-line treatment of metastatic colorectal cancer (mCRC). We aimed to confirm and quantify the real-world cost savings and cost-effectiveness of MVASI and Zirabev relative to originator bevacizumab for patients with mCRC.

METHODS

We conducted a population-based, retrospective cohort study in Ontario, Canada, where originator and biosimilar bevacizumab are universally publicly funded. All mCRC patients who received originator bevacizumab between January 2008 and August 2019 or biosimilar bevacizumab between August 2019 and March 2021 were propensity score matched (1:4) to adjust for baseline differences. Total 1-year patient-level costs (CAD) and effects (life years [LY] and quality-adjusted LYs) were calculated from the public health payer's perspective. Primary outcomes included incremental net monetary benefit and incremental net health benefit (INHB). Sensitivity analyses included a subgroup analysis by biosimilar type (MVASI/Zirabev) and a 2-year analysis.

RESULTS

The matched cohort included 747 biosimilar cases and 2945 comparators. Bevacizumab biosimilars were associated with an incremental cost of -$6379 (95%CI: -9417, -3537) (ie, cost saving) and incremental effect of 0.0 (95% CI: -0.02, 0.02) LY and -0.01 (95% CI: -0.03, 0) quality-adjusted LYs gained. Incremental net monetary benefit and INHB estimates were $6331 (95% CI: 6245, 6417) and 0.127 LY (95% CI: 0.125, 0.128), respectively, at a willingness-to-pay threshold of $50 000/life year gained, with all estimates indicating the cost-effectiveness of biosimilar bevacizumab. Cost-effectiveness remained consistent across biosimilar brand subgroups and 2-year sensitivity analyses.

CONCLUSION

Bevacizumab biosimilars demonstrated real-world cost savings while providing similar survival benefit as originator bevacizumab, confirming the initial expectations of their implementation and supporting health system sustainability.

Evolution of Health Technology Assessment in Indonesia: Supply Landscape, Implementation, and Future Directions

In 2014, Indonesia's Ministry of Health established the Indonesian Health Technology Assessment Committee (InaHTAC) to prioritize evidence-based health care technology for inclusion in the national health insurance benefits package. This commentary provides an overview of the current state of the health care technology supply landscape in Indonesia, as well as the impact of HTA studies on priority-setting decisions. Indonesia's decision-making process for health care technology approval and patient access involves multiple stakeholders and follows several evaluation principles. The licensing, inclusion, and evaluation of health care technology is complex and time consuming, however, requiring input from stakeholders with different roles and interests. Although efforts have been made to establish an HTA ecosystem by, for example, engaging in capacity-building activities and issuing guidelines, challenges remain, including a lack of infrastructure, financial resources, and technical capacity and inadequate stakeholder involvement. Additionally, the current position of the HTA unit, which is connected to the Ministry of Health (MOH), and political pressures from the pharmaceutical industry can result in delayed or ignored HTA recommendations. Therefore, the establishment of an independent and robust HTA body that can inform policy makers about health technology development, licensing, dissemination, and use, along with strong regulations to ensure harmonization and coordination among stakeholders, is necessary. This requires a step-by-step approach to address inadequate overall HTA resources.

Health economic evaluations for Indonesia: a systematic review assessing evidence quality and adherence to the Indonesian Health Technology Assessment (HTA) Guideline

Background

The Government of Indonesia implemented health technology assessment (HTA) to ensure quality and cost control in the National Health Insurance Program (Jaminan Kesehatan Nasional/JKN). The current aim of the study was to improve the usefulness of future economic evaluation for resource allocation by appraising current methodology, reporting, and source of evidence quality of studies.

Methods

The inclusion and exclusion criteria were applied to search for relevant studies using a systematic review. The methodology and reporting adherence were appraised according to Indonesia's HTA Guideline issued in 2017. The differences in adherence before and after the guideline dissemination were compared using Chi-square and Fisher's exact tests for methodology adherence wherever appropriate, and the Mann-Whitney test for reporting adherence. The source of evidence quality was assessed using evidence hierarchy. Two scenarios of the study start date and the guideline dissemination period were tested using sensitivity analyses.

Findings

Eighty-four studies were obtained from PubMed, Embase, Ovid, and two local journals. Only two articles cited the guideline. No statistically significant difference (P > 0.05) was found between the pre-dissemination and post-dissemination period with respect to methodology adherence, except for outcome choice. Studies during the post-dissemination period showed a higher score for reporting which was statistically significant (P = 0.01). However, the sensitivity analyses revealed no statistically significant difference (P > 0.05) in methodology (except for modelling type, P = 0.03) and reporting adherence between the two periods.

Interpretation

The guideline did not impact the methodology and reporting standard used in the included studies. Recommendations were provided to improve the usefulness of economic evaluations for Indonesia.

Funding

The Access and Delivery Partnership (ADP) hosted by the United Nations Development Programme (UNDP) and the Health Systems Research Institute (HSRI).

How Least Developed to Lower-Middle Income Countries Use Health Technology Assessment: A Scoping Review

Health Technology Assessment (HTA) is a multidisciplinary tool to inform healthcare decision-making. HTA has been implemented in high-income countries (HIC) for several decades but has only recently seen a growing investment in low- and middle-income countries. A scoping review was undertaken to define and compare the role of HTA in least developed and lower middle-income countries (LLMIC). MEDLINE and EMBASE databases were searched from January 2015 to August 2021. A matrix comprising categories on HTA objectives, methods, geographies, and partnerships was used for data extraction and synthesis to present our findings. The review identified 50 relevant articles. The matrix was populated and sub-divided into further categories as appropriate. We highlight topical aspects of HTA, including initiatives to overcome well-documented challenges around data and capacity development, and identify gaps in the research for consideration. Those areas we found to be under-studied or under-utilized included disinvestment, early HTA/implementation, system-level interventions, and cross-sectoral partnerships. We consider broad practical implications for decision-makers and researchers aiming to achieve greater interconnectedness between HTA and health systems and generate recommendations that LLMIC can use for HTA implementation. Whilst HIC may have led the way, LLMIC are increasingly beginning to develop HTA processes to assist in their healthcare decision-making. This review provides a forward-looking model that LLMIC can point to as a reference for their own implementation. We hope this can be seen as timely and useful contributions to optimize the impact of HTA in an era of investment and expansion and to encourage debate and implementation.

Effectiveness and Cost-Utility Analysis of Different Doses of Irinotecan Plus Bevacizumab in Patients With Metastatic Colorectal Cancer: A Long-Term and Prospective Cohort Study

Objective

Patients with metastatic colorectal cancer (mCRC) had oncological benefits with irinotecan dose escalation of FOLFIRI regimen combined with bevacizumab according to UGT1A1 genotypes in our previous study. In the current study, we performed a quality of life (QOL) outcome evaluation and cost-utility analysis of different irinotecan dose regimens in patients with mCRC.

Materials and Methods

With inverse probability-of-treatment weighting (IPTW) matching on all covariates, 75 patients with dose escalation of irinotecan (study group) and 121 patients with the recommended dose of irinotecan (control group) were recruited between October 2015 and December 2019. The QOL outcome measures were Functional Assessment of Cancer Therapy-Colorectal, Beck Anxiety Inventory, Beck Depression Inventory, and SF-36; cost-utility outcome measures were medical direct costs, quality-adjusted life-years (QALYs), and incremental cost-utility ratios (ICURs).

Results

All mCRC patients exhibited a significant decrease in both emotional wellbeing and depression from pretherapeutic period to posttherapeutic 6th month (P < 0.05); however, from the posttherapeutic 1st year to the 2nd year, improvement in most QOL measures was significantly better in the study group than in the control group (P < 0.05). Over a 2-year time period, the study group had higher total medical direct costs than the control group (US$ 54,742 ± 14,013 vs. US$ 54,608 ± 9,673) and higher average QALYs gained (1.88 vs. 1.65), with an ICUR of US$ 583 per QALY gained.

Conclusion

For patients with mCRC, irinotecan dose escalation appeared cost-effective with considerable QOL improvements during the study period. Further randomized, multi-institutional controlled trials are warranted to corroborate these results.

Cost Effectiveness of Bevacizumab Plus Chemotherapy for the Treatment of Advanced and Metastatic Cervical Cancer in India-A Model-Based Economic Analysis

PURPOSE

Patients with advanced and metastatic cervical cancer have a poor prognosis with a 1-year survival rate of 10%-15%. Recently, an antiangiogenic humanized monoclonal antibody bevacizumab has shown to improve the survival of these patients. This study was designed to assess the cost effectiveness of incorporating bevacizumab with standard chemotherapy for the treatment of patients with advanced and metastatic cervical cancer in India.

METHODS

Using a disaggregated societal perspective and lifetime horizon, a Markov model was developed for estimating the costs and health outcomes in a hypothetical cohort of 1,000 patients with advanced and metastatic cervical cancer treated with either standard chemotherapy alone or in combination with bevacizumab. Effectiveness data for each of the treatment regimen were assessed using estimates from Gynecologic Oncology Group 240 trial. Data on disease-specific mortality in metastatic cervical cancer, health system cost, and out-of-pocket expenditure were derived from Indian literature. Multivariable probabilistic sensitivity analysis was undertaken to account for parameter uncertainty.

RESULTS

Over the lifetime of one patient with advanced and metastatic cervical cancer, bevacizumab along with standard chemotherapy results in a gain of 0.275 (0.052-0.469) life-years (LY) and 0.129 (0.032-0.218) quality-adjusted life-years (QALY), at an additional cost of $3,816 US dollars (USD; 2,513-5,571) compared with standard chemotherapy alone. This resulted in an incremental cost of $19,080 USD (7,230-52,434) per LY gained and $34,744 USD (15,782-94,914) per QALY gained with the use of bevacizumab plus standard chemotherapy.

CONCLUSION

Addition of bevacizumab to the standard chemotherapy is not cost effective for the treatment of advanced and metastatic cervical cancer in India at a threshold of 1-time per-capita gross domestic product.