Can We Afford to Exclude Patients Throughout Health Technology Assessment?

Systematic review for the development of a core outcome set for monofocal intraocular lenses for cataract surgery

Introduction

The aim of the study was to define a core outcome set (COS) to be measured following cataract surgery for the postoperative evaluation of monofocal intraocular lenses (IOLs). Compared to current COSs, the present work provides updates considering the advances in the technology due to the development of new generation monofocal IOLs, which are characterized by a safety profile comparable to standard monofocal IOLs but with an extended range of intermediate vision.

Methods

Healthcare professionals (ophthalmologist surgeons) and patients were involved in the selection of outcomes to be included in the COS, starting from a list of indicators retrieved from a systematic literature search. The search considered observational studies with both a retrospective or prospective design, case studies and classic randomized controlled trials (RCTs). A mixed methodology integrating a Delphi-driven and an expert panel approach was adopted to reach an agreement among clinicians, while patients were involved in the completion of a questionnaire.

Results

The final COS included 15 outcomes. Eleven outcomes, all clinical, were considered for inclusion after a joint discussion among ophthalmologists; seven outcomes were linked to visual acuity, while the remaining to contrast sensitivity, refractive errors, aberrations and adverse events. Measurement metrics, method of aggregation and measurement time point of these outcomes were specified. The most important aspects for the patients were (1) quality of life after cataract surgery, (2) the capacity to perform activities requiring good near vision (e.g., reading), (3) spectacle independence, and (4) safety of movements without fear of getting hurt or falling (intermediate vision).

Discussion

In a context with limited healthcare resources, it is important to optimize their use considering also the preferences of end-users, namely patients. The proposed COS, developed involving both ophthalmologists and patients, provides an instrument for the postoperative evaluation of different technologies in the context of monofocal IOLs, which can be used not only in clinical trials but also in clinical practice to increase the body of real-world evidence.

The Psychological, Physiological, and Behavioral Responses of Patients to Magnetic Resonance Imaging (MRI): A Systematic Review and Meta-Analysis

BACKGROUND

MRI is generally well-tolerated although it may induce physiological stress responses and anxiety in patients.

PURPOSE

Investigate the psychological, physiological, and behavioral responses of patients to MRI, their evolution over time, and influencing factors.

STUDY TYPE

Systematic review with meta-analysis.

POPULATION

181,371 adult patients from 44 studies undergoing clinical MRI.

ASSESSMENT

Pubmed, PsycInfo, Web of Science, and Scopus were systematically searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Quality appraisal was conducted with the Joanna Briggs Institute critical appraisal tools. Meta-analysis was conducted via Meta-Essentials workbooks when five studies were available for an outcome. Psychological and behavioral outcomes could be analyzed. Psychological outcomes were anxiety (State-Trait-Anxiety Inventory, STAI-S; 37) and willingness to undergo MRI again. Behavioral outcomes included unexpected behaviors: No shows, sedation, failed scans, and motion artifacts. Year of publication, sex, age, and positioning were examined as moderators.

STATISTICAL TESTS

Meta-analysis, Hedge's g. A P value <0.05 was considered to indicate statistical significance.

RESULTS

Of 12,755 initial studies, 104 studies were included in methodological review and 44 (181,371 patients) in meta-analysis. Anxiety did not significantly reduce from pre- to post-MRI (Hedge's g = -0.20, P = 0.051). Pooled values of STAI-S (37) were 44.93 (pre-MRI) and 40.36 (post-MRI). Of all patients, 3.9% reported unwillingness to undergo MRI again. Pooled prevalence of unexpected patient behavior was 11.4%; rates for singular behaviors were: Failed scans, 2.1%; no-shows, 11.5%; sedation, 3.3%; motion artifacts, 12.2%. Year of publication was not a significant moderator (all P > 0.169); that is, the patients' response was not improved in recent vs. older studies. Meta-analysis of physiological responses was not feasible since preconditions were not met for any outcome.

DATA CONCLUSION

Advancements of MRI technology alone may not be sufficient to eliminate anxiety in patients undergoing MRI and related unexpected behaviors.

LEVEL OF EVIDENCE

1 TECHNICAL EFFICACY: Stage 5.

How to mobilise users' experiential knowledge in the evaluation of advanced technologies and practices in Quebec? The example of the permanent users' and relatives' panel

INTRODUCTION

With the purpose of supporting scientific professionals and helping them to better integrate the expertise of users in their work, a users' and relatives' panel (URP) was set up at the National Institute for Excellence in Health and Social Services in Quebec (INESSS), Canada for the social services and mental health directorate. URPs are advisory structures that mobilise the experiential knowledge of people affected by various issues.

OBJECTIVES

The objective of this study is to assess from a diverse stakeholders' perceptions: (1) the experience of developing and implementing the URP within the context of an Agencies for Health Technology Assessment and Assessment of Social Services (AHTAASS), (2) the contribution of such a URP, (3) the challenges encountered and (4) the perspectives of improvement for the following years.

METHODOLOGY

We conducted a qualitative descriptive evaluation study. Nineteen interviews were conducted: six with URP members and 13 with staff representatives. The documents related to the creation of the panel, the URP minutes summarising the discussions and the reports published during that period were collected and analysed. Following a preliminary round of data analysis, a debriefing meeting was conducted with a few participants to validate the results.

RESULTS

The panel was set up as part of the INESSS' desire to better integrate experiential knowledge into its recommendations. Twelve projects were presented to the panel on various themes. The URP enabled health professionals to consider dimensions they had not identified, to better integrate the experiential data collected from users into their work and to develop recommendations that made more sense to users. Panel members and INESSS professionals learned to work together, moving the working methods from consultation to collaboration and even coconstruction. Based on the panel's significant contribution, the INESSS decided to maintain it and to strengthen its place in its system to better integrate the experiential knowledge of users into its work.

CONCLUSION

This research illustrates how AHTAASS can set up a URP composed exclusively of users, and how it can contribute and be evaluated. It shows that URPs are structures that value the sharing of experiential knowledge of its members, humanise decision-making and give meaning to the work done by scientific professionals.

PATIENT OR PUBLIC CONTRIBUTION

One patient-researcher has contributed to the preparation and writing of this manuscript.

Civil society and medical product access in Africa: Lessons from COVID-19

Understanding health as a human right creates a legal obligation on countries to ensure access to timely, acceptable, and affordable health care. We highlight the importance of a meaningful role for civil society in improving access to well-regulated quality medical products in Africa; to support and be part of a regional social contract approach following the access issues that have been particularly evident during the COVID-19 pandemic. We argue that African communities have a clear participatory role as important stakeholders in the regulatory lifecycle. Solidarity is important for a cohesive approach as formal government healthcare infrastructure may be minimal for some countries, with little training of communities available for disease management and insufficient money to fund people to organise and deliver health care. Some of the issues for civil society engagement with multi-stakeholders, and possible mitigating strategies, are tabulated to initiate discussion on facilitators and concerns of governments and other stakeholders for meaningful participation by patients, communities and civil society within a regional regulatory lifecycle approach. Solidarity is called for to address issues of equity, ethics and morality, stigmatisation and mutual empowerment - to sustainably support the region and national governments to develop greater self-sufficiency throughout the regulatory lifecycle. By creating a participatory space, patients, communities and civil society can be invited in with clear missions and supported by well-defined guidance to create a true sense of solidarity and social cohesion. Strong leadership coupled with the political will to share responsibilities in all aspects of this work is key.

Where National Medicines Policies Have Taken Us With Patient Involvement and Health Technology Assessment in Africa

The Covid-19 pandemic has highlighted global knowledge about, but lack of equitable access to, life-changing medicines, and other innovative medical products by populations in African low and middle income countries. The World Health Organization (WHO) and other international non-profit foundations and organizations are constantly striving to address inequity. In the 1970s, WHO initiated a regularly updated essential medicines list, together with the concept of national medicines policies (NMPs) to ensure access and availability, affordability, rational, and effective use of medicines which are considered essential in addressing predominant population health issues and disease burden. We studied the NMPs of Ghana, South Africa, Uganda and Zimbabwe to highlight some of the important issues that these countries experience in the safe and effective use of medical products. Thailand is an example of how health technology assessment (HTA) can provide a country with an internationally supported, clearly defined and transparent process to broaden access to medicines and services. These medical services can add considerable value in accordance with local values and priorities. Involvement of civil society adds democratic legitimacy to such processes. Community health workers and patient advocacy groups are important in raising awareness and knowledge of safety issues and the effective use of quality medicines. They can apply pressure for increased funding to improve access to healthcare. Medicines and services that contribute to supported self-care are of benefit in any setting. Joint efforts across African countries such as with the African Medicines Agency are important in addressing some of the major health issues.

Patient-centered health technology assessment: a perspective on engagement in health technology assessment by three patient organizations and a health technology assessment body

Patient engagement in health technology assessment (HTA) has become increasingly important over the past 20 years. Academic and practitioner literature has produced numerous case studies and best practice accounts of patient involvement practices around the world. This text analyzes the experience of being involved in an Institute for Clinical and Economic Review (ICER) HTA review in the United States. The analysis comes from the joint perspective of three patient organizations: Lupus and Allied Diseases Association, Inc.; Lupus Foundation of America; and Black Women’s Health Imperative, as well as ICER. We suggest that meaningful, patient-centered engagement, where patient communities are systematically integrated throughout the review, can be a way of returning to the discipline’s roots focusing on technologies’ societal and ethical impact. It is a process that requires robust commitment from all involved but produces assessments relevant to those directly affected by them.