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Thavorn K, Thompson E, Kumar S, Heiskanen A, Agarwal A, Atkins H, Shorr R, Hawrysh T, Kar-Wing Chan K, Presseau J, Ollendorf DA, Graham ID, Grimshaw JM, Lalu MM, Nochaiwong S, Fergusson DA, Hutton B, Coyle D, Kekre N. Economic Evaluations of CAR-T Cell Therapies for Hematologic and Solid Malignancies: A Systematic Review. Value Health 2024:S1098-3015(24)02336-2. [PMID: 38641057 DOI: 10.1016/j.jval.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 03/22/2024] [Accepted: 04/02/2024] [Indexed: 04/21/2024]
Abstract
OBJECTIVES This study aims to systematically review evidence on the cost-effectiveness of chimeric antigen receptor (CAR)-T therapies for patients with cancer. METHODS Electronic databases were searched in October 2022 and updated in September 2023. Systematic reviews, health technology assessments and economic evaluations that compared costs and effects of CAR-T therapy in cancer patients were included. Two reviewers independently screened studies, extracted data, synthesized results, and critically appraised studies using the Philips checklist. Cost data were presented in 2022 US Dollars RESULTS: Our search yielded 1,809 records, 47 of which were included. The majority of included studies were cost-utility analysis, published between 2018 and 2023, and conducted in the United States. Tisagenlecleucel, axicabtagene ciloleucel, idecabtagene vicleucel, ciltacabtagene autoleucel, lisocabtagene maraleucel, brexucabtagene autoleucel, and relmacabtagene autoleucel were compared to various standard-of-care chemotherapies. The incremental cost-effective ratio (ICER) for CAR-T therapies ranged from $9,424 to $4,124,105 per QALY in adults and from $20,784 to $243,177 per QALY in pediatric patients. ICERs were found to improve over longer time horizons or when an earlier cure point was assumed. Most studies failed to meet the Philips checklist due to a lack of head-to-head comparisons and uncertainty surrounding CAR-T costs and curative effects. CONCLUSIONS CAR-T therapies were more expensive and generated more QALYs than comparators, but their cost-effectiveness were uncertain and dependent on patient population, cancer type, and model assumptions. This highlights the need for more nuanced economic evaluations and continued research to better understand the value of CAR-T therapies in diverse patient populations.
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Affiliation(s)
- Kednapa Thavorn
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, General Campus, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Pharmacoepidemiology and Statistics Research Center, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand.
| | - Emily Thompson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, General Campus, Ottawa, ON, Canada
| | - Srishti Kumar
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, General Campus, Ottawa, ON, Canada
| | - Aliisa Heiskanen
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, General Campus, Ottawa, ON, Canada
| | - Anubhav Agarwal
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, General Campus, Ottawa, ON, Canada
| | - Harold Atkins
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Transplant and Cell Therapy Program, The Ottawa Hospital, Ottawa, ON, Canada
| | - Risa Shorr
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, General Campus, Ottawa, ON, Canada
| | - Terry Hawrysh
- Patient Partner, Ottawa Hospital Research Institute, General Campus, Ottawa, ON, Canada
| | | | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, General Campus, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Daniel A Ollendorf
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA; Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Ian D Graham
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, General Campus, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, General Campus, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Manoj Mathew Lalu
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, General Campus, Ottawa, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Surapon Nochaiwong
- Pharmacoepidemiology and Statistics Research Center, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, General Campus, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Brian Hutton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, General Campus, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Doug Coyle
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Natasha Kekre
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, General Campus, Ottawa, ON, Canada; Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Ollendorf DA. Revival? Prospects for a return to comprehensive and coordinated health technology assessment in America. Expert Rev Pharmacoecon Outcomes Res 2024; 24:11-13. [PMID: 37925648 DOI: 10.1080/14737167.2023.2279725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 11/01/2023] [Indexed: 11/07/2023]
Affiliation(s)
- Daniel A Ollendorf
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research & Health Policy Studies, Tufts Medical Center, Boston, MA, USA
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Trowman R, Migliore A, Ollendorf DA. The value and impact of health technology assessment: discussions and recommendations from the 2023 Health Technology Assessment International Global Policy Forum. Int J Technol Assess Health Care 2023; 39:e75. [PMID: 38130164 DOI: 10.1017/s0266462323002763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Health technology assessment (HTA) programs inform decision making about the value and reimbursement of new and existing health technologies; however, they are under increasing pressure to demonstrate that they are a cost-effective use of finite healthcare resources themselves. The 2023 HTAi Global Policy Forum (GPF) discussed the value and impact of HTA, including how it is assessed and communicated, and how it could be enhanced in the future. This article summarizes the discussions held at the 2023 HTAi GPF, where the challenges and opportunities related to the value and impact of HTA were debated. Core themes and recommendations identified that defining the purpose of value and impact assessment is an essential first step prior to undertaking it, and that it can be done through the use and expansion of existing tools. Further work around aligning HTA programs with underlying societal values is needed to ensure the long-term value and impact of HTA. HTA could also have a role in assessing the efficiency of the wider health system by applying HTA methods or concepts to broader budgetary allocations and organizational aspects of health care. Stakeholders (particularly patients, industry, and clinicians but also payers, wider society, and the media) should ideally be actively engaged when undertaking the value and impact assessment of HTA. More concerted efforts in communicating the role and remit of HTA bodies would also help stakeholders to better understand the value and impact of HTA, which in turn could improve the implementation of HTA recommendations and application to future actions in the lifecycle of technologies.
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Affiliation(s)
| | - Antonio Migliore
- Health Technology Assessment International (HTAi), Edmonton, AB, Canada
| | - Daniel A Ollendorf
- Tufts Medical Center, Center for the Evaluation of Value and Risk in Health, Boston, MA, USA
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Voehler D, Koethe BC, Synnott PG, Ollendorf DA. The impact of external reference pricing on pharmaceutical costs and market dynamics. Health Policy OPEN 2023. [DOI: 10.1016/j.hpopen.2023.100093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023] Open
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Gibson E, Ollendorf DA, Simoens S, Bloom DE, Martinón-Torres F, Salisbury D, Severens JL, Toumi M, Molnar D, Meszaros K, Sohn WY, Begum N. Rule of Prevention: a potential framework to evaluate preventive interventions for rare diseases. J Mark Access Health Policy 2023; 11:2239557. [PMID: 37583879 PMCID: PMC10424616 DOI: 10.1080/20016689.2023.2239557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/19/2023] [Accepted: 07/18/2023] [Indexed: 08/17/2023]
Abstract
Background: The benefits of preventive interventions lack comprehensive evaluation in standard health technology assessments (HTA), particularly for rare and transmissible diseases. Objective: To identify possible considerations for future HTA using analogies between the treatment and prevention of rare diseases. Study design: An Expert panel meeting assessed whether one HTA assessment framework can be applied to assess both rare disease treatments and preventive interventions. Experts also evaluated the range of value elements currently included in HTAs and their applicability to rare, transmissible, and/or preventable diseases. Results: A broad range of value should be considered when assessing rare, transmissible disease prevention. Although standard HTA can be applied to transmissible diseases, the risk of local outbreaks and the need for large-scale prevention programs suggest a modified assessment framework, capable of incorporating prevention-specific value elements in HTAs. A 'Rule of Prevention' framework was proposed to allow broader value considerations anchored to severity, equity, and prevention benefits in decision-making for preventive interventions for rare transmissible diseases. Conclusion: The proposed prevention framework introduces an explicit initial approach to consistently assess rare transmissible diseases, and to incorporate the broader value of preventive interventions compared with treatment.
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Affiliation(s)
| | - Daniel A. Ollendorf
- Institute for Clinical Research and Health Policy Studies (ICRHPS), Center for the Evaluation of Value and Risk in Health (CEVR), Tufts Medical Center, Boston, MA, USA
| | - Steven Simoens
- Clinical Pharmacology and Pharmacotherapy, KU Leuven, Leuven, Belgium
| | - David E Bloom
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Federico Martinón-Torres
- Department of Pediatrics, Translational Pediatrics and Infectious Diseases, Pediatrics Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
- Genetics, Vaccines and Infections Research Group (GENVIP), Instituto de Investigación Sanitaria de Santiago, University of Santiago, Santiago de Compostela, Spain
- Centro de Investigación Biomédica En Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España
| | - David Salisbury
- Royal Institute of International Affairs, Chatham House, London, UK
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Synnott PG, Voehler D, Enright DE, Kowal S, Ollendorf DA. The Value of New: Consideration of Product Novelty in Health Technology Assessments of Pharmaceuticals. Appl Health Econ Health Policy 2023; 21:305-314. [PMID: 36529826 DOI: 10.1007/s40258-022-00779-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/27/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Efforts to understand how treatments affect patients and society have broadened the criteria that health technology assessment (HTA) organizations apply to value assessments. We examined whether HTA agencies in eight countries consider treatment novelty in methods and deliberations. METHODS We defined a novel pharmaceutical product to be one that offers a new approach to treatment (e.g., new mechanism of action), addresses an unmet need (e.g., targets a rare condition without effective treatments), or has a broader impact beyond what is typically measured in an HTA. We reviewed peer-reviewed publications and technical guidance materials from HTA organizations in Australia, Canada, England, France, The Netherlands, Norway, Sweden, and the United States (US). In addition, we explored how HTA organizations integrated novelty considerations into deliberations and recommendations related to two newer therapies-voretigene neparvovec for an inherited retinal disorder and ocrelizumab for multiple sclerosis. RESULTS None of the HTA organizations acknowledge treatment novelty as an explicit value criterion in their assessments of pharmaceutical products. However, drugs that have novel characteristics are given special consideration, particularly when they address an unmet need. Several organizations document a willingness to expend more resources and accept greater evidence uncertainty for such treatments. Qualitative deliberations about the additional unquantified potential benefits of treatment may also influence HTA recommendations. CONCLUSION Major HTA organizations do not recognize novelty as an explicit value criterion, although drugs with novel characteristics may receive special consideration. There is an opportunity for organizations to codify their approach to evaluating novelty in value assessment.
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Affiliation(s)
- Patricia G Synnott
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, 800 Washington Street, #063, Boston, MA, 02111, USA.
| | - Dominic Voehler
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, 800 Washington Street, #063, Boston, MA, 02111, USA
| | - Daniel E Enright
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, 800 Washington Street, #063, Boston, MA, 02111, USA
| | - Stacey Kowal
- Genentech, Inc, 1 DNA Way, South San Francisco, CA, 94080, USA
| | - Daniel A Ollendorf
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, 800 Washington Street, #063, Boston, MA, 02111, USA
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Chambers JD, Enright DE, Panzer AD, Cohen JT, Ollendorf DA, Neumann PJ. Examining US commercial health plans' use of The Institute for Clinical and Economic Review's reports in specialty drug coverage decisions. J Manag Care Spec Pharm 2023; 29:257-264. [PMID: 36840954 PMCID: PMC10387943 DOI: 10.18553/jmcp.2023.29.3.257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
BACKGROUND: The Institute for Clinical and Economic Review (ICER) has emerged in a visible role in US health care. However, it is unclear to what extent US commercial health plans use ICER value assessments in their specialty drug coverage decisions. OBJECTIVE: To evaluate the relationship between ICER's reported cost-effectiveness ratios (CERs) and coverage restrictiveness. Also, to examine the frequency with which plans have cited ICER in their coverage policies and to investigate how frequently health plans adjusted their drug coverage criteria in the 12 months after ICER's assessments. METHODS: We analyzed the Tufts Medical Center Specialty Drug Evidence and Coverage Database, which includes specialty drug coverage decisions issued by 17 large US commercial health plans. For ICER-assessed drugs, we recorded ICER's estimated CERs in the form of cost per quality-adjusted life-year (QALY) gained. First, we used multivariate logistic regression to examine the association between ICER's reported CERs and plan coverage restrictiveness, when controlling for other factors that were likely to affect decision-making. Next, we examined how often plans cited ICER's assessments in coverage decisions issued in years 2017-2020. Lastly, we examined whether plans added or removed coverage restrictions (eg, patient subgroup restrictions or step therapy protocols) in the 12 months following ICER's assessment. RESULTS: Plans tended to cover drugs with higher (less favorable) CERs more restrictively than drugs with CERs less than $100,000 per QALY: odds ratio (OR) = 4.48 if $100,000-$175,000 per QALY; OR = 2.00 if $175,000-$500,000 per QALY; and OR = 2.10 if $500,000 or more per QALY (all P < 0.01). Plans cited ICER in 0.8% (5/622) of coverage policies in 2017, 0.6% (5/833) in 2018, 1.7% (19/1,139) in 2019, and 2.4% (33/1,406) in 2020. For drugs with CERs less than $175,000 per QALY, plans adjusted coverage in 37% of cases: added restrictions in 20%, removed restrictions in 15%, and added one restriction but removed another in 2%. For drugs with CERs of $175,000 or more, plans changed coverage criteria in 29% of cases: added restrictions in 21%, removed restrictions in 5%, and added one restriction but removed another in 4%. CONCLUSIONS: We found that when controlling for other factors, health plans' specialty drug coverage decisions were associated with ICER's estimated CERs. Plans infrequently cited ICER value assessments. We did not observe a trend for plans more often narrowing coverage criteria for drugs with CERs $175,000 or more compared with drugs with CERs less than $175,000. DISCLOSURES: This research study was supported by a consortium of funders: Amgen, Genen-tech, Janssen Pharmaceuticals, Otsuka, and GSK.
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Affiliation(s)
- James D Chambers
- The Center for the Evaluation of Value and Risk in Health Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
| | - Daniel E Enright
- The Center for the Evaluation of Value and Risk in Health Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
| | - Ari D Panzer
- The Center for the Evaluation of Value and Risk in Health Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
| | - Josh T Cohen
- The Center for the Evaluation of Value and Risk in Health Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
| | - Daniel A Ollendorf
- The Center for the Evaluation of Value and Risk in Health Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
| | - Peter J Neumann
- The Center for the Evaluation of Value and Risk in Health Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA
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Wilson M, Thavorn K, Hawrysh T, Graham ID, Atkins H, Kekre N, Coyle D, Lalu MM, Fergusson DA, Chan KKW, Ollendorf DA, Presseau J. Engaging Patients and Caregivers in an Early Health Economic Evaluation: Discerning Treatment Value Based on Lived Experience. Pharmacoeconomics 2022; 40:1119-1130. [PMID: 36071263 DOI: 10.1007/s40273-022-01180-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/01/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Traditionally, economic evaluations have engaged clinicians and policymakers; however, patients and their caregivers have insight that can ensure that the economic evaluation process appropriately reflects disease consequences and adequately addresses their priorities related to treatment. OBJECTIVE We aimed to identify patient priorities to inform an early economic evaluation of chimeric antigen receptor T-cell therapy for adults with relapsed or refractory B-cell acute lymphoblastic leukemia. METHODS We conducted two online group discussions of four participants each, involving patients with experience of hematological cancer and a caregiver. We used an adapted version of the nominal group technique, a consensus-building discussion approach, to generate focused qualitative data. RESULTS Patients and a caregiver acknowledged both the costs directly related to clinical care, such as the out-of-pocket cost of drugs, and the indirect treatment costs, such as the cost of transport, accommodation, and food. The emotional and physical toll of treatment and the influence of treatment on employment and education were additional costs emphasized by participants. Treatment benefits prioritized by participants included the efficacy of treatment, manageable side effects, improved quality of life, accessibility of treatment, and short treatment duration. CONCLUSIONS Engaging patients and caregivers in an early economic evaluation could help identify additional costs and benefits of therapies that are not typically recognized in economic evaluations but have the potential to increase the commercial viability of novel therapies. This research also demonstrates how patients and caregivers can be engaged at different levels in the development of early economic evaluation models.
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Affiliation(s)
- Mackenzie Wilson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, General Campus, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
| | - Kednapa Thavorn
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, General Campus, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada.
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
| | | | - Ian D Graham
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, General Campus, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Harold Atkins
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Transplant and Cell Therapy Program, The Ottawa Hospital, Ottawa, ON, Canada
| | - Natasha Kekre
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, General Campus, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Doug Coyle
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Manoj M Lalu
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, General Campus, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, General Campus, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Kelvin K W Chan
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
- Canadian Centre for Applied Research in Cancer Control, Toronto, ON, Canada
| | - Daniel A Ollendorf
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, General Campus, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
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Breslau RM, Cohen JT, Ollendorf DA, Neumann PJ. Should Drug Companies Engage with ICER? An Empirical Analysis of How Often Manufacturers Engage with ICER and Whether Engagement May Influence ICER's Cost-Effectiveness Estimates. Pharmacoecon Open 2022; 6:893-895. [PMID: 35871128 PMCID: PMC9596652 DOI: 10.1007/s41669-022-00358-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 07/12/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Rachel Milstein Breslau
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St, #063, Boston, MA, 02111, USA
| | - Joshua T Cohen
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St, #063, Boston, MA, 02111, USA
- Department of Medicine, Tufts University School of Medicine, 145 Harrison Ave, Boston, MA, 02111, USA
| | - Daniel A Ollendorf
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St, #063, Boston, MA, 02111, USA
- Department of Medicine, Tufts University School of Medicine, 145 Harrison Ave, Boston, MA, 02111, USA
| | - Peter J Neumann
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St, #063, Boston, MA, 02111, USA.
- Department of Medicine, Tufts University School of Medicine, 145 Harrison Ave, Boston, MA, 02111, USA.
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Kim DD, Daly AT, Koethe BC, Fendrick AM, Ollendorf DA, Wong JB, Neumann PJ. Low-Value Prostate-Specific Antigen Test for Prostate Cancer Screening and Subsequent Health Care Utilization and Spending. JAMA Netw Open 2022; 5:e2243449. [PMID: 36413364 PMCID: PMC9682424 DOI: 10.1001/jamanetworkopen.2022.43449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
IMPORTANCE Delivering low-value care can lead to unnecessary follow-up services and associated costs, and such care cascades have not been well examined in common clinical scenarios. OBJECTIVE To evaluate the utilization and costs of care cascades of prostate-specific antigen (PSA) tests for prostate cancer screening, as the routine use of which among asymptomatic men aged 70 years and older is discouraged by multiple guidelines. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study included men aged 70 years and older without preexisting prostate conditions enrolled in a Medicare Advantage plan during January 2016 to December 2018 with at least 1 outpatient visit. Medical billing claims data from the deidentified OptumLabs Data Warehouse were used. Data analysis was conducted from September 2020 to August 2021. EXPOSURES At least 1 claim for low-value PSA tests for prostate cancer screening during the observation period. MAIN OUTCOMES AND MEASURES Utilization of and spending on low-value PSA cancer screening and associated care cascades and the difference in overall health care utilization and spending among individuals receiving low-value PSA cancer screening vs those who did not, adjusting for observed characteristics using inverse probability of treatment weighting. RESULTS Of 995 442 men (mean [SD] age, 78.0 [5.6] years) aged 70 years or older in a Medicare Advantage plan included in this study, 384 058 (38.6%) received a low-value PSA cancer screening. Utilization increased for each subsequent cohort from 2016 to 2018 (49 802 of 168 951 [29.4%] to 134 404 of 349 228 [38.5%] to 199 852 of 477 203 [41.9%]). Among those receiving initial low-value PSA cancer screening, 241 188 of 384 058 (62.8%) received at least 1 follow-up service. Repeated PSA testing was the most common, and 27 268 (7.1%) incurred high-cost follow-up services, such as imaging, radiation therapy, and prostatectomy. Utilization and spending associated with care cascades also increased from 2016 to 2018. For every $1 spent on a low-value PSA cancer screening, an additional $6 was spent on care cascades. Despite avoidable care cascades, individuals who received low-value PSA cancer screening were not associated with increased overall health care utilization and spending during the 1-year follow-up period compared with an unscreened population. CONCLUSIONS AND RELEVANCE In this cross-sectional study, low-value PSA tests for prostate cancer screening remained prevalent among Medicare Advantage plan enrollees and were associated with unnecessary expenditures due to avoidable care cascades. Innovative efforts from clinicians and policy makers, such as payment reforms, to reduce initial low-value care and avoidable care cascades are warranted to decrease harm, enhance equity, and improve health care efficiency.
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Affiliation(s)
- David D. Kim
- Center for the Evaluation of Value and Risk in Health (CEVR), Institute for Clinical Research and Health Policy Studies (ICRHPS), Department of Medicine, Tufts Medical Center, Boston, Massachusetts
- Tufts University School of Medicine, Boston, Massachusetts
| | - Allan T. Daly
- Center for the Evaluation of Value and Risk in Health (CEVR), Institute for Clinical Research and Health Policy Studies (ICRHPS), Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Benjamin C. Koethe
- Biostatistics, Epidemiology, and Research Design (BERD) Center, ICRHPS, Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - A. Mark Fendrick
- Department of Internal Medicine and Health Management and Policy, University of Michigan, Ann Arbor
| | - Daniel A. Ollendorf
- Center for the Evaluation of Value and Risk in Health (CEVR), Institute for Clinical Research and Health Policy Studies (ICRHPS), Department of Medicine, Tufts Medical Center, Boston, Massachusetts
- Tufts University School of Medicine, Boston, Massachusetts
| | - John B. Wong
- Tufts University School of Medicine, Boston, Massachusetts
- Division of Clinical Decision Making, Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Peter J. Neumann
- Center for the Evaluation of Value and Risk in Health (CEVR), Institute for Clinical Research and Health Policy Studies (ICRHPS), Department of Medicine, Tufts Medical Center, Boston, Massachusetts
- Tufts University School of Medicine, Boston, Massachusetts
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Do LA, Koethe BC, Daly AT, Chambers JD, Ollendorf DA, Wong JB, Fendrick AM, Neumann PJ, Kim DD. State-Level Variation In Low-Value Care For Commercially Insured And Medicare Advantage Populations. Health Aff (Millwood) 2022; 41:1281-1290. [PMID: 36067429 DOI: 10.1377/hlthaff.2022.00325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Low-value care is a major source of health care inefficiency in the US. Our analysis of 2009-19 administrative claims data from OptumLabs Data Warehouse found that low-value care and associated spending remain prevalent among commercially insured and Medicare Advantage enrollees. The aggregated prevalence of twenty-three low-value services was 1,920 per 100,000 eligible enrollees, which amounted to $3.7 billion in wasteful expenditures during the study period. State-level variation in spending was greater than variation in utilization, and much of the variation in spending was driven by differences in average procedure prices. If the average price for twenty-three low-value services among the top ten states in spending were set to the national average, their spending would decrease by 19.8 percent (from $735,000 to $590,000 per 100,000 eligible enrollees). State-level actions to improve the routine measurement and reporting of low-value care could identify sources of variation and help design state-specific policies that lead to better patient-centered outcomes, enhanced equity, and more efficient spending.
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Affiliation(s)
- Lauren A Do
- Lauren A. Do, Tufts Medical Center, Boston, Massachusetts
| | | | | | - James D Chambers
- James D. Chambers, Tufts Medical Center and Tufts University, Boston, Massachusetts
| | | | - John B Wong
- John B. Wong, Tufts Medical Center and Tufts University
| | - A Mark Fendrick
- A. Mark Fendrick, University of Michigan, Ann Arbor, Michigan
| | | | - David D Kim
- David D. Kim , Tufts Medical Center and Tufts University
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Ma S, Olchanski N, Cohen JT, Ollendorf DA, Neumann PJ, Kim DD. The Impact of Broader Value Elements on Cost-Effectiveness Analysis: Two Case Studies. Value Health 2022; 25:1336-1343. [PMID: 35315331 DOI: 10.1016/j.jval.2022.01.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 12/29/2021] [Accepted: 01/26/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES This study aimed to explore the impact of including broader value elements in cost-effectiveness analyses by presenting 2 case studies, one on human papillomavirus (HPV) infection and one on early-stage Hodgkin's lymphoma (ESHL). METHODS We identified broader value elements (eg, patient and caregiver time, spillover health effects, productivity) from the Second Panel's Impact Inventory and the ISPOR Special Task Force's value flower. We then evaluated the cost-effectiveness of HPV vaccination versus no vaccination (case 1) and combined modality therapy (CMT) versus chemotherapy alone for treatment of adult ESHL (case 2) using published simulation models. For each case study, we compared incremental cost-effectiveness ratios considering health sector impacts only (the "base-case" scenario) with incremental cost-effectiveness ratios incorporating broader value elements. RESULTS For vaccination of US girls against HPV before sexual debut versus no vaccination, the base-case result was $38 334 per disability-adjusted life-year averted. Including each broader value element made cost-effectiveness progressively more favorable, with HPV vaccination becoming cost-saving (ie, reducing costs and averting more disability-adjusted life-years) when the analysis incorporated productivity costs. For CMT versus chemotherapy alone in patients with ESHL, the base-case result indicated that CMT was cost-saving. Including all elements made this treatment's net monetary benefits (the sum of its averted resource costs and the net value of its health impacts) less favorable, even as the contribution from CMT's near-term health benefits grew. CONCLUSIONS Including broader value elements can substantially influence cost-effectiveness ratios, although the direction and the magnitude of their impact can differ across interventions and disease context.
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Affiliation(s)
- Siyu Ma
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA.
| | - Natalia Olchanski
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA; Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Joshua T Cohen
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA; Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Daniel A Ollendorf
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA; Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Peter J Neumann
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA; Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - David D Kim
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA; Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
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13
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Ma S, Lavelle TA, Ollendorf DA, Lin PJ. Herd Immunity Effects in Cost-Effectiveness Analyses among Low- and Middle-Income Countries. Appl Health Econ Health Policy 2022; 20:395-404. [PMID: 35001292 PMCID: PMC8743090 DOI: 10.1007/s40258-021-00711-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/05/2021] [Indexed: 05/06/2023]
Abstract
BACKGROUND Herd immunity (HI) is a key benefit of vaccination programs, but the effects are not routinely included in cost-effectiveness analyses (CEAs). OBJECTIVE This study investigated how the inclusion of HI in CEAs may influence the reported value of immunizations in low- and middle-income countries (LMICs) and illustrated the implications for COVID-19 immunization. METHODS We reviewed immunization CEAs published from 2000 to 2018 focusing on LMICs using data from the Tufts Medical Center CEA Registries. We investigated the proportion of studies that included HI, the methods used, and the incremental cost-effectiveness ratios (ICERs) reported. When possible, we evaluated how ICERs would change with and without HI. RESULTS Among the 243 immunization CEAs meeting inclusion criteria, 44 studies (18%) included HI. Of those studies, 11 (25%) used dynamic transmission models, whereas the remainder used static models. Sixteen studies allowed for ICER calculations with and without HI (n = 48 ratios). The inclusion of HI always resulted in more favorable ratios. In 20 cases (42%), adding HI decreased the ICERs enough to cross at least one or more common cost-effectiveness benchmarks for LMICs. Among pneumococcal vaccination studies, including HI in the analyses decreased seven of 24 ICERs enough to cross at least one cost-effectiveness benchmark. CONCLUSION The full value of immunization may be underestimated without considering a scenario in which HI is achieved. Given the evidence in pneumococcal CEAs, COVID-19 vaccine value assessments should aim to show ICERs with and without HI to inform decision-making in LMICs.
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Affiliation(s)
- Siyu Ma
- The Center for the Evaluation of Value and Risk in Health (CEVR), The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington Street, Boston, MA, 02111, USA.
| | - Tara A Lavelle
- The Center for the Evaluation of Value and Risk in Health (CEVR), The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington Street, Boston, MA, 02111, USA
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Daniel A Ollendorf
- The Center for the Evaluation of Value and Risk in Health (CEVR), The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington Street, Boston, MA, 02111, USA
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Pei-Jung Lin
- The Center for the Evaluation of Value and Risk in Health (CEVR), The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington Street, Boston, MA, 02111, USA
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
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14
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Synnott PG, Lin PJ, Hickson SS, Glaetzer C, Ollendorf DA. Is Value Portable? An Examination of Contextual and Practical Considerations that Affect the Transferability of Value Assessments between Settings. Int J Technol Assess Health Care 2022; 38:1-26. [PMID: 35443906 DOI: 10.1017/s026646232200023x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Abstract
Objectives
The extent to which value assessments are uniquely deployed in any given geographic setting is variable. Increasingly, markets are seeking insights from external health technology assessments (HTAs) to assist with decisions surrounding the adoption of new technologies. We reviewed the environment, infrastructure, and practice of value assessment in six countries, with a focus on how these elements influence the transferability of value assessments between settings.
Methods
We reviewed the diverse settings in which six organizations conducting HTA operate, and explored how differences might affect the transferability of value assessment. We focused attention on Australia’s Pharmaceutical Benefits Advisory Committee, China’s National Center for Medicine and HTA, Germany’s Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen, Japan’s Center for Outcomes Research and Economic Evaluation for Health (Core 2 Health), the National Institute for Health and Care Excellence in England and Wales, and the Institute for Clinical and Economic Review in the United States.
Results
HTA is adopted to address unique objectives for a given health system and is tailored to support local standards and preferences. Some elements of a value assessment, such as evidence on clinical effectiveness, may be more transferable than others. It is challenging to appropriately adjust external assessments to the local context.
Conclusions
Contextual differences influence both the role and application of HTA. These differences limit the transferability of value assessments from one setting to another. De novo appraisals, customized to the local decision context, are the ideal approach to determinations about value.
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Neumann PJ, Podolsky MI, Basu A, Ollendorf DA, Cohen JT. Do Cost-Effectiveness Analyses Account for Drug Genericization? A Literature Review and Assessment of Implications. Value Health 2022; 25:59-68. [PMID: 35031100 DOI: 10.1016/j.jval.2021.06.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 06/18/2021] [Accepted: 06/23/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES We investigated how health technology assessment (HTA) organizations around the world have handled drug genericization (an allowance for future generic drug entry and subsequent drug price declines) in their guidelines for cost-effectiveness analyses (CEAs). We also analyzed a large sample of published CEAs to examine prevailing practices in the field. METHODS We reviewed 43 HTA guidelines to determine whether and how they addressed drug genericization in their CEAs. We also selected a sample of 270 US-based CEAs from the Tufts Medical Center's CEA Registry, restricting the sample to studies on pharmaceuticals published from 1991 to 2019 and to analyses taking a lifetime time horizon. We determined whether each CEA examined genericization (and if so, whether in base case or sensitivity analyses), and how inclusion of genericization influenced the estimated incremental cost-effectiveness ratios. RESULTS Fourteen (33%) of the 43 HTA guidelines mention genericization for CEAs and 4 (9%) recommend that base case analyses include assumptions about future drug price changes due to genericization. Most published CEAs (95%) do not include assumptions about future generic prices for intervention drugs. Only 2% include such assumptions about comparator drugs. Most studies (72%) conduct sensitivity analyses on drug prices unrelated to genericization. CONCLUSIONS The omission of assumptions about genericization means that CEAs may misrepresent the long run opportunity costs for drugs. The field needs clearer guidance for when CEAs should account for genericization, and for the inclusion of other price dynamics that might influence a drug's cost-effectiveness.
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Affiliation(s)
- Peter J Neumann
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA, USA.
| | - Meghan I Podolsky
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA, USA
| | - Anirban Basu
- The CHOICE Institute, University of Washington, Seattle, WA, USA
| | - Daniel A Ollendorf
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA, USA
| | - Joshua T Cohen
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA, USA
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16
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Voehler D, Neumann PJ, Ollendorf DA. Patient and Caregiver Views on Measures of the Value of Health Interventions. Patient Prefer Adherence 2022; 16:3383-3392. [PMID: 36573224 PMCID: PMC9789716 DOI: 10.2147/ppa.s390227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 11/30/2022] [Indexed: 12/24/2022] Open
Abstract
PURPOSE We aimed to investigate patient and caregiver views on the relative importance of traditional and nontraditional domains of value, and to determine if these views differed according to key demographic characteristics. PATIENTS AND METHODS We conducted a modified Delphi approach using a web-based survey of adult patients managing a chronic condition or caregivers of a patient with chronic illness who were recruited using purposive sampling focused on demographic and clinical characteristics. The first survey round asked participants to rate the 13 domains of value on a 5-point Likert scale and rank each domain that they rated as important or very important. In the second survey round, participants reconsidered their own and aggregated round 1 results. New questions were added, including "rescuing" domains, challenges faced in taking medication, and a free-text option to add domains not already captured. RESULTS Initial recruitment resulted in 79 participants. Sixty-three (79.7%) completed the first round, and 58 participants completed both rounds. Overall ratings and rankings were consistent between survey rounds, and respondents ranked most highly domains considered traditional domains of value (for example, survival, costs). Patient activists were about six times more likely to rate each domain as important or very important compared to general disease advocates. Significant factors associated with a higher odds of rating a domain as important or very important were age 35-54 and 55-64 compared to 18-34, while factors associated with a decreased odds were males and patients compared to caregivers. CONCLUSION Patients and caregivers place significant emphasis on traditional measures of value compared to nontraditional measures, and participants' prior beliefs impact what aspects of value they deem important.
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Affiliation(s)
- Dominic Voehler
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Peter J Neumann
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Daniel A Ollendorf
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
- Correspondence: Daniel A Ollendorf, Tufts Medical Center, 800 Washington St., #063, Boston, MA, 02111, USA, Tel +1 617 636 2581, Email
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17
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Neumann PJ, Ollendorf DA, Cohen JT. Value-based drug pricing in the Biden era: Opportunities and prospects. Health Serv Res 2021; 56:1093-1099. [PMID: 34085289 PMCID: PMC8586482 DOI: 10.1111/1475-6773.13686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 05/06/2021] [Accepted: 05/06/2021] [Indexed: 12/01/2022] Open
Affiliation(s)
- Peter J Neumann
- Center for the Evaluation of Value and Risk in Health, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Daniel A Ollendorf
- Center for the Evaluation of Value and Risk in Health, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Joshua T Cohen
- Center for the Evaluation of Value and Risk in Health, Tufts University School of Medicine, Boston, Massachusetts, USA
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18
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Affiliation(s)
- Peter J Neumann
- From the Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston
| | - Joshua T Cohen
- From the Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston
| | - Daniel A Ollendorf
- From the Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston
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19
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Silver MC, Neumann PJ, Ma S, Kim DD, Cohen JT, Nyaku M, Roberts C, Sinha A, Ollendorf DA. Frequency and impact of the inclusion of broader measures of value in economic evaluations of vaccines. Vaccine 2021; 39:6727-6734. [PMID: 34656380 DOI: 10.1016/j.vaccine.2021.09.070] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 08/25/2021] [Accepted: 09/24/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND The health and economic benefits of immunization may extend beyond the elements traditionally included in cost-effectiveness analyses (CEAs). This review investigated how broader impacts are considered in economic evaluations of vaccines and whether their inclusion would substantially change CEA findings. METHODS We reviewed CEAs of vaccines associated with the largest global health burden, published from 2014 to 2019 using the Tufts CEA Registry and Tufts Global Health CEA Registry. We supplemented this with a systematic review of published and grey literature. We conducted descriptive analyses to examine the frequency of inclusion of specific social factors and study characteristics associated with their inclusion. We also conducted a case study of the human papilloma virus (HPV) vaccine to illustrate the potential change in CEA findings from selected social impacts. RESULTS We identified 475 relevant health economic assessments. Overall, 40% of studies included at least one category of social impact. The most commonly included non-healthcare cost among cost-per-QALY studies was productivity (25%), while cost-per-DALY studies reported transportation costs most frequently (24%). Few studies examined the impact of vaccination on other sectors such as education and housing (<3%). Middle-income and North American settings were positively associated with social impact inclusion, while sub-Saharan African location was negatively associated. In the HPV case study, the addition of nonhealth costs improved cost-effectiveness by up to 90% or made the vaccine cost-saving, depending on geographic setting. The cost-saving scenario saved up to $30,000 in costs per case of cervical cancer averted. CONCLUSIONS A minority of vaccine CEAs include social impacts, particularly for nonhealth sectors. The omission of these impacts may result in a systematic undervaluation of vaccines from a societal perspective. Further efforts are required to document the full benefits of vaccination for policymaker consideration.
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Affiliation(s)
- Madison C Silver
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, USA.
| | - Peter J Neumann
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, USA
| | - Siyu Ma
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, USA
| | - David D Kim
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, USA
| | - Joshua T Cohen
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, USA
| | | | | | | | - Daniel A Ollendorf
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, USA
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20
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Kim DD, Do LA, Daly AT, Wong JB, Chambers JD, Ollendorf DA, Neumann PJ. An Evidence Review of Low-Value Care Recommendations: Inconsistency and Lack of Economic Evidence Considered. J Gen Intern Med 2021; 36:3448-3455. [PMID: 33620623 PMCID: PMC8606489 DOI: 10.1007/s11606-021-06639-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 12/11/2020] [Accepted: 01/25/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND Low-value care, typically defined as health services that provide little or no benefit, has potential to cause harm, incur unnecessary costs, and waste limited resources. Although evidence-based guidelines identifying low-value care have increased, the guidelines differ in the type of evidence they cite to support recommendations against its routine use. OBJECTIVE We examined the evidentiary rationale underlying recommendations against low-value interventions. DESIGN We identified 1167 "low-value care" recommendations across five US organizations: the US Preventive Services Task Force (USPSTF), the "Choosing Wisely" Initiative, American College of Physicians (ACP), American College of Cardiology/American Heart Association (ACC/AHA), and American Society of Clinical Oncology (ASCO). For each recommendation, we classified the reported evidentiary rationale into five groups: (1) low economic value; (2) no net clinical benefit; (3) little or no absolute clinical benefit; (4) insufficient evidence; (5) no reason mentioned. We further investigated whether any cited or otherwise available cost-effectiveness evidence was consistent with conventional low economic value benchmarks (e.g., exceeding $100,000 per quality-adjusted life-year). RESULTS Of the identified low-value care recommendations, Choosing Wisely contributed the most (N=582, 50%), followed by ACC/AHA (N=250, 21%). The services deemed "low value" differed substantially across organizations. "No net clinical benefit" (N=428, 37%) and "little or no clinical benefit" (N=296, 25%) were the most commonly reported reasons for classifying an intervention as low value. Consideration of economic value was less frequently reported (N=171, 15%). When relevant cost-effectiveness studies were available, their results were mostly consistent with low-value care recommendations. CONCLUSIONS Our study found that evidentiary rationales for low-value care vary substantially, with most recommendations relying on clinical evidence. Broadening the evidence base to incorporate cost-effectiveness evidence can help refine the definition of "low-value" care to reflect whether an intervention's costs are worth the benefits. Developing a consensus grading structure on the strength and evidentiary rationale may help improve de-implementation efforts for low-value care.
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Affiliation(s)
- David D Kim
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St., Box 063, Boston, MA, 02111, USA.
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA.
| | - Lauren A Do
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St., Box 063, Boston, MA, 02111, USA
| | - Allan T Daly
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St., Box 063, Boston, MA, 02111, USA
| | - John B Wong
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
- Division of Clinical Decision Making, Tufts Medical Center, Boston, MA, USA
| | - James D Chambers
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St., Box 063, Boston, MA, 02111, USA
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Daniel A Ollendorf
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St., Box 063, Boston, MA, 02111, USA
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Peter J Neumann
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St., Box 063, Boston, MA, 02111, USA
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
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21
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Asukai Y, Briggs A, Garrison LP, Geisler BP, Neumann PJ, Ollendorf DA. Principles of Economic Evaluation in a Pandemic Setting: An Expert Panel Discussion on Value Assessment During the Coronavirus Disease 2019 Pandemic. Pharmacoeconomics 2021; 39:1201-1208. [PMID: 34557996 PMCID: PMC8460393 DOI: 10.1007/s40273-021-01088-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/02/2021] [Indexed: 05/15/2023]
Abstract
As the coronavirus disease 2019 (COVID-19) pandemic continues to generate significant morbidity and mortality as well as economic and societal impacts, the landscape of potential treatments has slowly begun to broaden. In the case of a novel disease with widespread consequences, society is more likely to place significant value on interventions that reduce the outsized economic burden of COVID-19. Treatments for severe disease will have a different value profile to that of large-scale vaccines because of their application in targeted and potentially small subsets of those with symptomatic disease vs broad deployment as a preventative measure. Where vaccines reduce transmissibility of COVID-19, use of therapeutics will target symptoms, up to and including death for infected individuals. This paper describes discussions from a virtual expert panel that met to attempt a consensus on how existing principles of economic evaluation should be applied to therapeutics that emerge in a pandemic setting, with specific focus on severe hospitalised cases of COVID-19. The panel concluded that the core principles of economic evaluation do not need to be drastically overhauled to meet the challenges of a pandemic, but that there are several additional elements of value such as equity, disease severity, insurance value, and scientific and family spillover effects that should be considered when presenting results to decision makers. The panel also highlighted the persistent challenges on how society should value novel therapies, such as the appropriate cost-effectiveness threshold to apply, which are particularly salient during a pandemic.
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Affiliation(s)
- Yumi Asukai
- Value Evidence and Outcomes, GSK, Brentford, England, UK.
| | - Andrew Briggs
- London School of Hygiene and Tropical Medicine, London, England, UK
| | - Louis P Garrison
- The Comparative Health Outcomes, Policy, and Economics Institute, University of Washington, Seattle, WA, USA
| | - Benjamin P Geisler
- Institute for Medical Information Processing, Biometry, and Epidemiology, Ludwig Maximilian University, Munich, Germany
- Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA
| | - Peter J Neumann
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA, USA
| | - Daniel A Ollendorf
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA, USA
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22
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Beinfeld M, Lee S, McQueen B, Fluetsch N, Pearson SD, Ollendorf DA. Anti B-cell maturation antigen CAR T-cell and antibody drug conjugate therapy for heavily pretreated relapsed and refractory multiple myeloma. J Manag Care Spec Pharm 2021; 27:1315-1320. [PMID: 34464215 PMCID: PMC10391002 DOI: 10.18553/jmcp.2021.27.9.1315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
DISCLOSURES: Funding for this summary was contributed by Arnold Ventures, California Health Care Foundation, The Donaghue Foundation, Harvard Pilgrim Health Care, and Kaiser Foundation Health Plan to the Institute for Clinical and Economic Review (ICER), an independent organization that evaluates the evidence on the value of health care interventions. ICER's annual policy summit is supported by dues from AbbVie, Aetna, America's Health Insurance Plans, Anthem, Alnylam, AstraZeneca, Biogen, Blue Shield of CA, Boehringer-Ingelheim, Cambia Health Services, CVS, Editas, Evolve Pharmacy, Express Scripts, Genentech/Roche, GlaxoSmithKline, Harvard Pilgrim, Health Care Service Corporation, HealthFirst, Health Partners, Humana, Johnson & Johnson (Janssen), Kaiser Permanente, LEO Pharma, Mallinckrodt, Merck, Novartis, National Pharmaceutical Council, Pfizer, Premera, Prime Therapeutics, Regeneron, Sanofi, Spark Therapeutics, uniQure, and United Healthcare. Beinfeld, Fluetsch, and Pearson are employed by ICER. Ollendorf received funding from ICER for work on this summary and reports consulting and other personal fees from EMD Serono, Amgen, Analysis Group, Aspen Institute/University of Southern California, GalbraithWight, Cytokinetics, Executive Insight, Sunovion, University of Colorado, World Health Organization, and Eli Lilly, unrelated to this work. Lee and McQueen received funding from ICER for work on this summary.
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Affiliation(s)
| | - Sei Lee
- University of California, San Francisco
| | - Brett McQueen
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora
| | | | | | - Daniel A Ollendorf
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA
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Wilson M, Thavorn K, Hawrysh T, Graham ID, Atkins H, Kekre N, Coyle D, Lalu MM, Fergusson DA, Chan KK, Ollendorf DA, Presseau J. Stakeholder engagement in economic evaluation: Protocol for using the nominal group technique to elicit patient, healthcare provider, and health system stakeholder input in the development of an early economic evaluation model of chimeric antigen receptor T-cell therapy. BMJ Open 2021; 11:e046707. [PMID: 34385243 PMCID: PMC8362692 DOI: 10.1136/bmjopen-2020-046707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 07/20/2021] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Chimeric antigen receptor T-cell (CAR-T) therapy is a class of immunotherapy. An economic evaluation conducted at an early stage of development of CAR-T therapy for treatment of adult relapsed or refractory acute lymphoblastic leukaemia could provide insight into factors contributing to the cost of treatment, the potential clinical benefits, and what the health system can afford. Traditionally, stakeholders are engaged in certain parts of health technology assessment processes, such as in the identification and selection of technologies, formulation of recommendations, and implementation of recommendations; however, little is known about processes for stakeholder engagement during the conduct of the assessment. This is especially the case for economic evaluations. Stakeholders, such as clinicians, policy-makers, patients, and their support networks, have insight into factors that can enhance the validity of an economic evaluation model. This research outlines a specific methodology for stakeholder engagement and represents an avenue to enhance health economic evaluations and support the use of these models to inform decision making for resource allocation. This protocol may inform a tailored framework for stakeholder engagement processes in future economic evaluation model development. METHODS AND ANALYSIS We will involve clinicians, healthcare researchers, payers, and policy-makers, as well as patients and their support networks in the conduct and verification of an early economic evaluation of a novel health technology to incorporate stakeholder-generated knowledge. Three stakeholder-specific focus groups will be conducted using an online adaptation of the nominal group technique to elicit considerations from each. This study will use CAR-T therapy for adults with relapsed or refractory B-cell acute lymphoblastic leukaemia as a basis for investigating broader stakeholder engagement processes. ETHICS AND DISSEMINATION This study received ethics approval from the Ottawa Hospital Research Institute Research Ethics Board (REB 20200320-01HT) and the results will be shared via conference presentations, peer-reviewed publications, and ongoing stakeholder engagement.
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Affiliation(s)
- Mackenzie Wilson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Kednapa Thavorn
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Ian D Graham
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Harold Atkins
- Cancer Therapeutics Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Blood and Marrow Transplant Program, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Natasha Kekre
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Doug Coyle
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Manoj M Lalu
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Kelvin Kw Chan
- Sunnybrook Odette Cancer Centre, University of Toronto, Toronto, Ontario, Canada
- Canadian Centre for Applied Research in Cancer Control, Toronto, Ontario, Canada
| | - Daniel A Ollendorf
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts, USA
- Department of Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
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Bloudek LM, Pandey R, Fazioli K, Ollendorf DA, Carlson JJ. Optimal treatment sequence for targeted immune modulators for the treatment of moderate to severe ulcerative colitis. J Manag Care Spec Pharm 2021; 27:1046-1055. [PMID: 34337994 PMCID: PMC10390993 DOI: 10.18553/jmcp.2021.27.8.1046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Ulcerative colitis is a chronic immune-mediated inflammatory condition of the large intestine and rectum. Several targeted immune modulators (TIMs) have demonstrated effectiveness for the treatment of moderate to severe ulcerative colitis and are approved by the FDA. Patients may try multiple TIMs, and currently there are no biomarkers or prognostic factors to guide choice of treatment sequence. In 2020, the Institute for Clinical and Economic Review (ICER) conducted a review of TIMs for the treatment of ulcerative colitis as individual agents relative to conventional treatment but did not address the relative ranking of various treatment sequences to each other. OBJECTIVE: To extend the ICER framework to identify the optimal treatment sequence as informed by metrics such as maximizing incremental net health benefit (NHB), minimizing incremental total cost, or maximizing incremental quality-adjusted life-years (QALYs). METHODS: The model was developed as a Markov model with 8-week cycles over a lifetime time horizon from a US payer perspective, including only direct health care costs. Health states consisted of active moderate to severe ulcerative colitis, clinical response without achieving remission, clinical remission, and death. Efficacy of TIMs were informed by the ICER-conducted network meta-analysis. Up to 3 treatments were modeled in a sequence that consisted of 2 different TIMs followed by conventional treatment. Sequences were ranked according to each objective. NHB was calculated using a threshold of $150,000 per QALY gained. Probabilistic sensitivity analysis (PSA) was undertaken to estimate the probability of each sequence having the highest NHB rank under each objective. RESULTS: 21 possible sequences were evaluated in the base case. Two attempts at conventional treatment represented the lowest cost option and, while yielding the fewest QALYs, resulted in the highest NHB. None of the sequences had an incremental cost per QALY below $150,000 relative to 2 attempts with conventional treatment, so the resulting NHB was negative for all sequences. The sequence with the highest NHB was infliximab-dyyb followed by tofacitinib (-0.116). This regimen also had the lowest incremental costs ($37,266). For orally and subcutaneously administered TIMs, the sequence of golimumab-tofacitinib had the highest NHB (-0.344). Ustekinumab-vedolizumab was the top-ranked sequence as measured by QALY maximization (0.172 incremental QALYs) but also had the highest total incremental cost ($166,094). Results of the PSA were consistent with deterministic rankings for the top-ranking sequences but also showed that the top 2 or 3 regimens were often close together. CONCLUSIONS: Based on the results of this analysis, the optimal sequence of TIMs as measured by NHB and cost minimization was infliximab or biosimilars as first-line treatment, then moving to tofacitinib, adalimumab, or vedolizumab. Sequences that generated the most QALYs began with ustekinumab, followed by vedolizumab, tofacitinib, and adalimumab. DISCLOSURES: This study was based on an evidence synthesis and economic evaluation sponsored by the Institute for Clinical and Economic Review (ICER). Pandey and Fazioli are employees of ICER. Bloudek reports grants from ICER during the conduct of the study and personal fees from Astellas, Akcea, Dermira, GlaxoSmithKline, Sunovion, Seattle Genetics, and TerSera Therapeutics, outside the submitted work. Pandey reports grants from California Healthcare Foundation, Harvard Pilgrim Healthcare, Kaiser Foundation Health Plan Inc., and the Donoghue Foundation, during the conduct of the study, and other support from Aetna, America's Health Insurance Plans, Anthem, AbbVie, Alnylam, AstraZeneca, Biogen, Genentech/Roche, GlaxoSmithSline, Harvard Pilgrim, Health Care Service Corporation, Health Partners, Johnson & Johnson (Janssen), Kaiser Permanente, LEO Pharma, Mallinckrodt, Merck, Novartis, National Pharmaceutical Council, Premera, Prime Therapeutics, Regeneron, Sanofi, Spark Therapeutics, United Healthcare, HealthFirst, Pfizer, Boehringer-Ingelheim, uniQure, Evolve Pharmacy Solutions, and Humana, outside the submitted work. Fazioli reports grants from Arnold Ventures, California Healthcare Foundation, Harvard Pilgrim Healthcare, Kaiser Foundation Health Plan Inc., and The Donaghue Foundation, during the conduct of the study, and other support from Aetna, America's Health Insurance Plans, Anthem, AbbVie, Alnylam, AstraZeneca, Biogen, Blue Shield of CA, Cambia Health Services, CVS, Editas, Express Scripts, Genentech/Roche, GlaxoSmithKline, Harvard Pilgrim, Health Care Service Corporation, Health Partners, Johnson & Johnson (Janssen), Kaiser Permanente, LEO Pharma, Mallinckrodt, Merck, Novartis, National Pharmaceutical Council, Premera, Prime Therapeutics, Regeneron, Sanofi, Spark Therapeutics, United Healthcare, HealthFirst, Pfizer, Boehringer-lngelheim, uniQure, Evolve Phamacy Solutions, and Humana, outside the submitted work. Ollendorf reports grants from ICER, during the conduct of the study, along with other support from CEA Registry sponsors and personal fees from EMD Serono, Amgen, Analysis Group, Aspen Institute/University of Southern California, GalbraithWight, Cytokinetics, Sunovion, University of Colorado, Center for Global Development, and Neurocrine, outside the submitted work. Carlson reports grants from ICER, during the conduct of the study, and personal fees from Allergan, outside the submitted work. The inputs and model framework that were leveraged for this analysis were presented as part of the ICER assessment of TIMs for the treatment of moderate to severe ulcerative colitis.
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Affiliation(s)
- Lisa M Bloudek
- Comparative Health Outcomes, Policy & Economics (CHOICE) Institute, University of Washington School of Pharmacy, Seattle
| | | | | | - Daniel A Ollendorf
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA
| | - Josh J Carlson
- Comparative Health Outcomes, Policy & Economics (CHOICE) Institute, University of Washington School of Pharmacy, Seattle
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Do LA, Synnott PG, Ma S, Ollendorf DA. Bridging the gap: aligning economic research with disease burden. BMJ Glob Health 2021; 6:bmjgh-2021-005673. [PMID: 34099483 PMCID: PMC8186754 DOI: 10.1136/bmjgh-2021-005673] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/16/2021] [Indexed: 01/16/2023] Open
Abstract
Introduction Cost-effectiveness analysis (CEA) is critical for identifying high-value interventions that address significant unmet need. This study examines whether CEA study volume is proportionate to the burden associated with 21 major disease categories. Methods We searched the Tufts Medical Center CEA and Global Health CEA Registries for studies published between 2010 and 2019 that measured cost per quality-adjusted life-year or cost per disability-adjusted life-year (DALY). Stratified by geographical region and country income level, the relationship between literature volume and disease burden (as measured by 2019 Global Burden of Disease estimates of population DALYs) was analysed using ordinary least squares linear regression. Additionally, the number of CEAs per intervention deemed ‘essential’ for universal health coverage by the Disease Control Priorities Network was assessed to evaluate how many interventions are supported by cost-effectiveness evidence. Results The results located below the regression line but with relatively high burden suggested disease areas that were ‘understudied’ compared with expected study volume. Understudied disease areas varied by region. Higher-income and upper-middle-income country (HUMIC) CEA volume for non-communicable diseases (eg, mental/behavioural disorders) was 100-fold higher than that in low-income and lower-middle-income countries (LLMICs). LLMIC study volume remained concentrated in HIV/AIDS as well as other communicable and neglected tropical diseases. Across 60 essential interventions, only 33 had any supporting CEA evidence, and only 21 had a decision context involving a low-income or middle-income country. With the exception of one intervention, available CEA evidence revealed the 21 interventions to be cost-effective, with base-case findings less than three times the GDP per capita. Conclusion Our analysis highlights disease areas that require significant policy attention. Research gaps for highly prevalent, lethal or disabling diseases, as well as essential interventions may be stifling potential efficiency gains. Large research disparities between HUMICs and LLMICs suggest funding opportunities for improving allocative efficiency in LLMIC health systems.
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Affiliation(s)
- Lauren A Do
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, Massachusetts, USA
| | - Patricia G Synnott
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, Massachusetts, USA
| | - Siyu Ma
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, Massachusetts, USA.,HEOR, GlaxoSmithKline, Philadelphia, Pennsylvania, USA
| | - Daniel A Ollendorf
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, Massachusetts, USA.,Tufts University School of Medicine, Boston, Massachusetts, USA
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Pandey R, Ollendorf DA, Fazioli K, Bloudek L, Carlson JJ, Pearson SD. The effectiveness and value of targeted immune modulators for moderate to severe ulcerative colitis. J Manag Care Spec Pharm 2021; 27:405-410. [PMID: 33645245 PMCID: PMC10391273 DOI: 10.18553/jmcp.2021.27.3.405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
DISCLOSURES: Funding for this summary was contributed by Arnold Ventures, California Health Care Foundation, The Donaghue Foundation, Harvard Pilgrim Health Care, and Kaiser Foundation Health Plan to the Institute for Clinical and Economic Review (ICER), an independent organization that evaluates the evidence on the value of health care interventions. ICER's annual policy summit is supported by dues from AbbVie, Aetna, America's Health Insurance Plans, Anthem, Alnylam, AstraZeneca, Biogen, Blue Shield of CA, Boehringer-Ingelheim, Cambia Health Services, CVS, Editas, Evolve Pharmacy, Express Scripts, Genentech/Roche, GlaxoSmithKline, Harvard Pilgrim, Health Care Service Corporation, HealthFirst, Health Partners, Humana, Johnson & Johnson (Janssen), Kaiser Permanente, LEO Pharma, Mallinckrodt, Merck, Novartis, National Pharmaceutical Council, Pfizer, Premera, Prime Therapeutics, Regeneron, Sanofi, Spark Therapeutics, uniQure, and United Healthcare. Pandey, Fazioli, and Pearson are employed by ICER. Ollendorf reports grants from ICER related to this study and reports other support from the CEA Registry Sponsors and consulting and advisory board fees from EMD Serono, Amgen, Analysis Group, Aspen Institute/University of Southern California, GalbraithWight, Cytokinetics, Sunovion, University of Colorado, the Center for Global Development, and Neurocrine, unrelated to this work. Bloudek reports grants from ICER related to this work and reports fees from AbbVie, Astellas, Akcea, Dermira, GlaxoSmithKline, Sunovion, Seattle Genetics, TerSera Therapeutics, and Incyte, unrelated to this work. Carlson reports grants from ICER related to this work.
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Affiliation(s)
| | - Daniel A Ollendorf
- Center for the Evaluation of Value and Risk in Health, Tufts University Medical Center, Boston, MA
| | | | - Lisa Bloudek
- Department of Pharmacy, University of Washington, Seattle
| | - Josh J Carlson
- Department of Pharmacy, University of Washington, Seattle
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Diener HC, Ashina M, Durand-Zaleski I, Kurth T, Lantéri-Minet M, Lipton RB, Ollendorf DA, Pozo-Rosich P, Tassorelli C, Terwindt G. Health technology assessment for the acute and preventive treatment of migraine: A position statement of the International Headache Society. Cephalalgia 2021; 41:279-293. [PMID: 33472427 PMCID: PMC7961634 DOI: 10.1177/0333102421989247] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The Clinical Trials Subcommittee of the International Headache Society presents the first Health Technology Assessment for the Acute Treatment of Migraine Attacks and Prevention of Migraine. Health technology assessments are systematic evaluations of the properties, effects, and consequences of healthcare technologies; this position statement is designed to inform decision makers about access to and reimbursement for medications and devices for the acute and preventive treatment of migraine. This position statement extends beyond the already available guidelines on randomized controlled trials for migraine to incorporate real-world evidence and a synthetic approach for considering multiple data sources and modelling methods when assessing the value of migraine treatments.
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Affiliation(s)
- Hans Christoph Diener
- Institute for Medical Informatics, Biometry and Epidemiology, University Duisburg-Essen, Essen, Berlin, Germany
| | - Messoud Ashina
- Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health and Medical Sciences, University of Copenhagen, Glostrup, Denmark
| | - Isabelle Durand-Zaleski
- Université de Paris, CRESS, INSERM, INRA, URCEco, AP-HP, Hôpital de l'Hôtel Dieu, Paris, France.,Santé Publique Hôpital Henri Mondor, Créteil, France
| | - Tobias Kurth
- Institute of Public Health, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Michel Lantéri-Minet
- Départment d'Evaluation et Traitement de la Douleur, CHU de Nice, FHU InovPain, Universite Cete Azur, Nice, France
| | | | - Daniel A Ollendorf
- Value Measurement and Global Health Initiatives, Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, 1867Tufts Medical Center, Boston, MA, USA
| | - Patricia Pozo-Rosich
- Headache Unit, Neurology Department, Vall d'Hebron University Hospital, Barcelona, Spain.,Headache Research Group, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Cristina Tassorelli
- Headache Science Center, IRCCS Mondino Foundation, Pavia, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
| | - Gisela Terwindt
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
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Neumann PJ, Cohen JT, Kim DD, Ollendorf DA. Consideration Of Value-Based Pricing For Treatments And Vaccines Is Important, Even In The COVID-19 Pandemic. Health Aff (Millwood) 2021; 40:53-61. [DOI: 10.1377/hlthaff.2020.01548] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Peter J. Neumann
- Peter J. Neumann is a professor and director of the Center for the Evaluation of Value and Risk in Health at the Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, in Boston, Massachusetts
| | - Joshua T. Cohen
- Joshua T. Cohen is a research associate professor at the Center for Evaluation of Value and Risk in Health, Tufts Medical Center
| | - David D. Kim
- David D. Kim is an assistant professor in the Center for Evaluation of Value and Risk in Health, Tufts Medical Center
| | - Daniel A. Ollendorf
- Daniel A. Ollendorf is director of value measurement and global health initiatives, Center for Evaluation of Value and Risk in Health, Tufts Medical Center
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Kim DD, Silver MC, Kunst N, Cohen JT, Ollendorf DA, Neumann PJ. Correction to: Perspective and Costing in Cost‑Effectiveness Analysis, 1974-2018. Pharmacoeconomics 2020; 38:1377. [PMID: 33089479 PMCID: PMC7661411 DOI: 10.1007/s40273-020-00968-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The article Perspective and Costing in Cost-Effectiveness Analysis.
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Affiliation(s)
- David D Kim
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St, Box 063, Boston, MA, 02111, USA.
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA.
| | - Madison C Silver
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St, Box 063, Boston, MA, 02111, USA
| | - Natalia Kunst
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale University School of Medicine, New Haven, CT, USA
- LINK Medical Research, Oslo, Norway
| | - Joshua T Cohen
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St, Box 063, Boston, MA, 02111, USA
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Daniel A Ollendorf
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St, Box 063, Boston, MA, 02111, USA
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Peter J Neumann
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St, Box 063, Boston, MA, 02111, USA
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
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Abstract
OBJECTIVE Our objective was to examine perspective and costing approaches used in cost-effectiveness analyses (CEAs) and the distribution of reported incremental cost-effectiveness ratios (ICERs). METHODS We analyzed the Tufts Medical Center's CEA and Global Health CEA registries, containing 6907 cost-per-quality-adjusted-life-year (QALY) and 698 cost-per-disability-adjusted-life-year (DALY) studies published through 2018. We examined how often published CEAs included non-health consequences and their impact on ICERs. We also reviewed 45 country-specific guidelines to examine recommended analytic perspectives. RESULTS Study authors often mis-specified or did not clearly state the perspective used. After re-classification by registry reviewers, a healthcare sector or payer perspective was most prevalent (74%). CEAs rarely included unrelated medical costs and impacts on non-healthcare sectors. The most common non-health consequence included was productivity loss in the cost-per-QALY studies (12%) and patient transportation in the cost-per-DALY studies (21%). Of 19,946 cost-per-QALY ratios, the median ICER was $US26,000/QALY (interquartile range [IQR] 2900-110,000), and 18% were cost saving and QALY increasing. Of 5572 cost-per-DALY ratios, the median ICER was $US430/DALY (IQR 67-3400), and 8% were cost saving and DALY averting. Based on 16 cost-per-QALY studies (2017-2018) reporting 68 ICERs from both the healthcare sector and societal perspectives, the median ICER from a societal perspective ($US22,710/QALY [IQR 11,991-49,603]) was more favorable than from a healthcare sector perspective ($US30,402/QALY [IQR 10,486-77,179]). Most governmental guidelines (67%) recommended either a healthcare sector or a payer perspective. CONCLUSION Researchers should justify and be transparent about their choice of perspective and costing approaches. The use of the impact inventory and reporting of disaggregate outcomes can reduce inconsistencies and confusion.
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Affiliation(s)
- David D Kim
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St, Box 063, Boston, MA, 02111, USA.
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA.
| | - Madison C Silver
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St, Box 063, Boston, MA, 02111, USA
| | - Natalia Kunst
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
- Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale University School of Medicine, New Haven, CT, USA
- LINK Medical Research, Oslo, Norway
| | - Joshua T Cohen
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St, Box 063, Boston, MA, 02111, USA
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Daniel A Ollendorf
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St, Box 063, Boston, MA, 02111, USA
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Peter J Neumann
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, 800 Washington St, Box 063, Boston, MA, 02111, USA
- Department of Medicine, Tufts University School of Medicine, Boston, MA, USA
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Kim DD, Ollendorf DA, Neumann PJ, Fendrick AM. Crisis into opportunity: can COVID-19 help set a path to improved health care efficiency? Am J Manag Care 2020; 26:369-370. [PMID: 32930548 DOI: 10.37765/ajmc.2020.88412] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
With a "new normal" level of care going forward post coronavirus disease 2019 (COVID-19), the key will be to invest in high-value services while deterring a resurgence of low-value care.
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Affiliation(s)
- David D Kim
- Tufts Medical Center, 800 Washington St, Box 063, Boston, MA 02111.
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Abstract
Deliberative processes are a well-established part of health technology assessment (HTA) programs in a number of high- and middle-income countries, and serve to combine complex sets of evidence, perspectives, and values to support open, transparent, and accountable decision making. Nevertheless, there is little documentation and research to inform the development of effective and efficient deliberative processes, and to evaluate their quality. This article summarizes the 2020 HTAi Global Policy Forum (GPF) discussion on deliberative processes in HTA.Through a combination of small and large group discussion and successive rounds of polling, the GPF members reached strong agreement on three core principles for deliberative processes in HTA: transparency, inclusivity, and impartiality. In addition, discussions revealed other important principles, such as respect, reviewability, consistency, and reasonableness, that may supplement the core set. A number of associated supporting actions for each of the principles are also described in order to make each principle realizable in a given HTA setting. The relative importance of the principles and actions are context-sensitive and must be considered in light of the political, legislative, and operational factors that may influence the functioning of any particular HTA environment within which the deliberative process is situated. The paper ends with suggested concrete next steps that HTA agencies, researchers, and stakeholders might take to move the field forward. The proposed principles and actions, and the next steps, provide a springboard for further research and better documentation of important aspects of deliberation that have historically been infrequently studied.
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Affiliation(s)
| | | | - Daniel A Ollendorf
- Value Measurement and Global Health Initiatives, Center for the Evaluation of Value and Risk in Health, Tufts University, Boston, USA
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Panzer AD, Emerson JG, D'Cruz B, Patel A, Dabak S, Isaranuwatchai W, Teerawattananon Y, Ollendorf DA, Neumann PJ, Kim DD. Growth and capacity for cost-effectiveness analysis in Africa. Health Econ 2020; 29:945-954. [PMID: 32412153 PMCID: PMC7383734 DOI: 10.1002/hec.4029] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 03/11/2020] [Accepted: 04/14/2020] [Indexed: 05/07/2023]
Abstract
As economic evaluation becomes increasingly essential to support universal health coverage (UHC), we aim to understand the growth, characteristics, and quality of cost-effectiveness analyses (CEA) conducted for Africa and to assess institutional capacity and relationship patterns among authors. We searched the Tufts Medical Center CEA Registries and four databases to identify CEAs for Africa. After extracting relevant information, we examined study characteristics, cost-effectiveness ratios, individual and institutional contribution to the literature, and network dyads at the author, institution, and country levels. The 358 identified CEAs for Africa primarily focused on sub-Saharan Africa (96%) and interventions for communicable diseases (77%). Of 2,121 intervention-specific ratios, 8% were deemed cost-saving, and most evaluated immunizations strategies. As 64% of studies included at least one African author, we observed widespread collaboration among international researchers and institutions. However, only 23% of first authors were affiliated with African institutions. The top producers of CEAs among African institutions are more adherent to methodological and reporting guidelines. Although economic evidence in Africa has grown substantially, the capacity for generating such evidence remains limited. Increasing the ability of regional institutions to produce high-quality evidence and facilitate knowledge transfer among African institutions has the potential to inform prioritization decisions for designing UHC.
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Affiliation(s)
- Ari D. Panzer
- Center for the Evaluation of Value and Risk in HealthTufts Medical CenterBostonMassachusettsUSA
| | - Joanna G. Emerson
- Center for the Evaluation of Value and Risk in HealthTufts Medical CenterBostonMassachusettsUSA
| | - Brittany D'Cruz
- Center for the Evaluation of Value and Risk in HealthTufts Medical CenterBostonMassachusettsUSA
| | - Avnee Patel
- Health Intervention and Technology Assessment Program (HITAP)Ministry of Public HealthNonthaburiThailand
| | - Saudamini Dabak
- Health Intervention and Technology Assessment Program (HITAP)Ministry of Public HealthNonthaburiThailand
| | - Wanrudee Isaranuwatchai
- Health Intervention and Technology Assessment Program (HITAP)Ministry of Public HealthNonthaburiThailand
- Institute of Health Policy, Management and EvaluationUniversity of TorontoTorontoOntarioCanada
| | - Yot Teerawattananon
- Health Intervention and Technology Assessment Program (HITAP)Ministry of Public HealthNonthaburiThailand
- The Saw Swee Hock School of Public HealthNational University of SingaporeSingapore
| | - Daniel A. Ollendorf
- Center for the Evaluation of Value and Risk in HealthTufts Medical CenterBostonMassachusettsUSA
| | - Peter J. Neumann
- Center for the Evaluation of Value and Risk in HealthTufts Medical CenterBostonMassachusettsUSA
| | - David D. Kim
- Center for the Evaluation of Value and Risk in HealthTufts Medical CenterBostonMassachusettsUSA
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Synnott PG, McQueen RB, Ollendorf DA, Campbell JD, Pearson SD. The Effectiveness and Value of Rivaroxaban and Icosapent Ethyl as Additive Therapies for Cardiovascular Disease. J Manag Care Spec Pharm 2020; 26:782-785. [PMID: 32463783 PMCID: PMC10390898 DOI: 10.18553/jmcp.2020.26.6.782] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
DISCLOSURES Funding for this summary was contributed by Arnold Ventures, Commonwealth Fund, California Health Care Foundation, National Institute for Health Care Management (NIHCM), New England States Consortium Systems Organization, Blue Cross Blue Shield of Massachusetts, Harvard Pilgrim Health Care, Kaiser Foundation Health Plan, and Partners HealthCare to the Institute for Clinical and Economic Review (ICER), an independent organization that evaluates the evidence on the value of health care interventions. ICER's annual policy summit is supported by dues from Aetna, America's Health Insurance Plans, Anthem, Allergan, Alnylam, AstraZeneca, Biogen, Blue Shield of CA, Cambia Health Services, CVS, Editas, Express Scripts, Genentech/Roche, GlaxoSmithKline, Harvard Pilgrim, Health Care Service Corporation, Health Partners, Johnson & Johnson (Janssen), Kaiser Permanente, LEO Pharma, Mallinckrodt, Merck, Novartis, National Pharmaceutical Council, Premera, Prime Therapeutics, Regeneron, Sanofi, Spark Therapeutics, and United Healthcare. Pearson is employed by ICER; Synnott was employed by ICER at the time of this report. Ollendorf, Campbell, and McQueen received grants from ICER for work on this review. Ollendorf also reports advisory board, consulting, and other fees from Sarepta Therapeutics, DBV Technologies, EMD Serono, Gerson Lehman Group, The CEA Registry Sponsors, Autolus, Analysis Group, Amgen, AbbVie, Cytokinetics, Aspen Institute/University of Southern California, and University of Colorado, unrelated to this review.
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Affiliation(s)
| | - R Brett McQueen
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora
| | - Daniel A Ollendorf
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, Massachusetts
| | - Jonathan D Campbell
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora
| | - Steven D Pearson
- Institute for Clinical and Economic Review, Boston, Massachusetts
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Ollendorf DA, Kim E, Bridger N, Naci H. The Supercar Stays in the Garage: Factors Preventing Indirect Comparisons of Novel Medicines Targeting the Same Condition. J Manag Care Spec Pharm 2020; 26:333-334. [PMID: 32105173 PMCID: PMC10391154 DOI: 10.18553/jmcp.2020.26.3.333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
DISCLOSURES No outside funding supported the writing of this letter. Ollendorf reports advisory board and consulting fees from DBV Technologies, EMD Serano, Gerson Lehman Group, and Sarepta Therapeutics, unrelated to the content of this research letter. Naci reports a grant from the Commonwealth Fund, unrelated to the content of this letter. The other authors have nothing to disclose.
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Affiliation(s)
- Daniel A Ollendorf
- Center for the Evaluation of Value and Risk in Health Tufts Medical Center
| | - Eunice Kim
- School of Pharmacy University of Washington
| | - Naomi Bridger
- O'Neill School of Public and Environmental Affairs Indiana University
| | - Huseyin Naci
- Department of Health Policy London School of Economics and Political Science
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Ollendorf DA. Histology independent cancer drugs: the drug makers' responsibility. BMJ 2020; 368:m350. [PMID: 32014852 DOI: 10.1136/bmj.m350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Cohen JT, Silver MC, Ollendorf DA, Neumann PJ. Does the Institute for Clinical and Economic Review Revise Its Findings in Response to Industry Comments? Value Health 2019; 22:1396-1401. [PMID: 31806196 DOI: 10.1016/j.jval.2019.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 08/07/2019] [Accepted: 08/12/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND The Institute for Clinical and Economic Review (ICER) has gained prominance through its work conducting health technology assessments of pharmaceuticals in the United States. OBJECTIVE To understand the influence of industry comments on pharmaceutical value assessments conducted by ICER. METHODS We reviewed 15 ICER reports issued from 2017 through 2019. We quantified ICER's revisions to its cost-effectiveness analysis (CEA) estimates between release of its draft and revised evidence reports and whether ratios shifted across ICER-specified categories of high, intermediate, or low value. We also reviewed industry-submitted comments recommending revision to ICER's CEAs, noting ICER's response as no change, text revised, assumption(s) revised, or conclusion revised. We evaluated each comment in terms of clarity, whether it offered an alternative to ICER's approach, and whether it characterized the expected impact of revision on ICER's analysis. RESULTS We identified 53 ICER-reported ratios. Of these, 45 (84.9%) changed between the draft and revised report, but 26 changes (57.8%) were small (<10%). Six ratios shifted across value categories. We identified 256 industry comments recommending that ICER revise its CEA. Of these, 159 (62%) lacked clarity, 145 (57%) offered no alternative, and 243 (95%) did not characterize their impact on ICER's estimated ratio. Ninety-one comments (35.5%) caused ICER to revise its assumptions, but only 5 (2.0%) caused ICER to revise its conclusions. Four of these 5 comments characterized their impact on ICER's findings. CONCLUSIONS Changes in ICER's estimates of cost-effectiveness between its draft and revised evidence reports are generally modest. Greater precision in industry comments could increase the influence of industry critiques, thus enhancing the dialogue around pharmaceutical value.
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Affiliation(s)
- Joshua T Cohen
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA.
| | - Madison C Silver
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Daniel A Ollendorf
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Peter J Neumann
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
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Carlson JJ, Walton SM, Basu A, Chapman RH, Campbell JD, McQueen RB, Pearson SD, Touchette DR, Veenstra D, Whittington MD, Ollendorf DA. Achieving Appropriate Model Transparency: Challenges and Potential Solutions for Making Value-Based Decisions in the United States. Pharmacoeconomics 2019; 37:1321-1327. [PMID: 31485925 PMCID: PMC6860462 DOI: 10.1007/s40273-019-00832-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Transparency in decision modeling remains a topic of rigorous debate among healthcare stakeholders, given tensions between the potential benefits of external access during model development and the need to protect intellectual property and reward research investments. Strategies to increase decision model transparency by allowing direct external access to a model's structure, source code, and data can take on many forms but are bounded between the status quo and free publicly available open-source models. Importantly, some level of transparency already exists in terms of methods and other technical specifications for published models. The purpose of this paper is to delineate pertinent issues surrounding efforts to increase transparency via direct access to models and to offer key considerations for the field of health economics and outcomes research moving forward from a US academic perspective. Given the current environment faced by modelers in academic settings, expected benefits and challenges of allowing direct model access are discussed. The paper also includes suggestions for pathways toward increased transparency as well as an illustrative real-world example used in work with the Institute for Clinical and Economic Review to support assessments of the value of new health interventions. Potential options to increase transparency via direct model access during model development include adequate funding to support the additional effort required and mechanisms to maintain security of the underlying intellectual property. Ultimately, the appropriate level of transparency requires balancing the interests of several groups but, if done right, has the potential to improve models and better integrate them into healthcare priority setting and decision making in the US context.
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Affiliation(s)
- Josh J Carlson
- Department of Pharmacy, Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, WA, USA
| | - Surrey M Walton
- Department of Pharmacy Systems, Outcomes, and Policy, University of Illinois-Chicago, Chicago, IL, USA
| | - Anirban Basu
- Department of Pharmacy, Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, WA, USA
| | | | | | | | - Steven D Pearson
- Institute for Clinical and Economic Review (ICER), Boston, MA, USA
| | - Daniel R Touchette
- Department of Pharmacy Systems, Outcomes, and Policy, University of Illinois-Chicago, Chicago, IL, USA
| | - David Veenstra
- University of Washington, Box 357630, H375 Health Science Building, Seattle, WA, USA
| | | | - Daniel A Ollendorf
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, 800 Washington Street, Box 63, Boston, MA, 02111, USA.
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Whittington MD, Ollendorf DA, Campbell JD. Accounting for All Costs in the Total Cost of Chimeric Antigen Receptor T-Cell Immunotherapy. JAMA Oncol 2019; 4:1784-1785. [PMID: 30325984 DOI: 10.1001/jamaoncol.2018.4625] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Pearson SD, Ollendorf DA, Chapman RH. New Cost-Effectiveness Methods to Determine Value-Based Prices for Potential Cures: What Are the Options? Value Health 2019; 22:656-660. [PMID: 31198182 DOI: 10.1016/j.jval.2019.01.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 01/10/2019] [Accepted: 01/31/2019] [Indexed: 06/09/2023]
Abstract
Evaluating different approaches to assessing the clinical effectiveness and value of potential cures will be essential to arm the policymaker, payer, and manufacturer communities with a platform that can reward innovation while supporting a sustainable health insurance system. Potential cures will accentuate concerns about substantial uncertainty in long-term outcomes. They will also focus attention on whether broader elements of value need to be incorporated and whether specific social values have a special place in evaluations of potential cures. In addition, the large magnitudes of potential health gain and cost offsets may require new methods before translation into value-based price recommendations. This article analyzes the challenges and presents several options to modify the conduct and presentation of cost-effectiveness analyses to ensure they provide policy-relevant assessments of the value of potential cures.
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Affiliation(s)
- Steven D Pearson
- The Institute for Clinical and Economic Review, Boston, MA, USA.
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Ollendorf DA, Kamal-Bahl S, Gleason PP, Schrandt S, McElwee N. Practical Next Steps in Improving Value Measurement and Use. Value Health 2019; 22:S29-S31. [PMID: 31200804 DOI: 10.1016/j.jval.2019.04.1913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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Kumar VM, Agboola F, Synnott PG, Segel C, Webb M, Ollendorf DA, Banken R, Chapman RH. Impact of Abuse Deterrent Formulations of Opioids in Patients With Chronic Pain in the United States: A Cost-Effectiveness Model. Value Health 2019; 22:416-422. [PMID: 30975392 DOI: 10.1016/j.jval.2018.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 11/29/2018] [Accepted: 12/09/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Opioid abuse is a significant public health problem in the United States. We evaluate the clinical effectiveness and economic impact of abuse-deterrent formulations (ADF) of opioids relative to non-ADF opioids in preventing abuse. METHODS We developed a cost-effectiveness model simulating 2 cohorts of 100 000 noncancer, chronic-pain patients newly prescribed either ADF or non-ADF extended-release (ER) opioids and followed them over 5 years, tracking new events of opioid abuse and opioid-related overdose deaths in addition to tracking 5-year cumulative costs of therapeutic use and abuse of ADF and non-ADF opioids. Patients in each cohort entered the model for therapeutic opioid use from where they could continue in that pathway, discontinue opioid use, or abuse opioids or die of opioid overdose-related or unrelated causes. In addition, one-way sensitivity and scenario analysis were conducted. RESULTS Over a 5-year time period, using ADF opioids prevented an additional 2300 new cases of opioid abuse at an additional cost of approximately $535 million to the healthcare sector. Threshold analyses showed that a 40% decrease in ADF opioid costs was required to attain cost neutrality between the 2 cohorts, whereas a 100% effectiveness in abuse reduction still did not result in cost neutrality. A 43% decrease in diversion with ADFs relative to non-ADFs was required to attain cost neutrality. Including a societal perspective produced results directionally similar to the base-case analysis findings. CONCLUSION ADF opioids have the potential to prevent new cases of opioid abuse, but at substantially higher costs to the health system.
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Affiliation(s)
- Varun M Kumar
- Institute for Clinical and Economic Review, Boston, MA, USA.
| | - Foluso Agboola
- Institute for Clinical and Economic Review, Boston, MA, USA
| | | | - Celia Segel
- Institute for Clinical and Economic Review, Boston, MA, USA
| | - Maggie Webb
- Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Roslindale, MA, USA
| | - Daniel A Ollendorf
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA, USA
| | - Reiner Banken
- Direction de santé publique, CISSS de Laval, Laval, QC, Canada
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Whittington MD, McQueen RB, Ollendorf DA, Kumar VM, Chapman RH, Tice JA, Pearson SD, Campbell JD. Long-term Survival and Cost-effectiveness Associated With Axicabtagene Ciloleucel vs Chemotherapy for Treatment of B-Cell Lymphoma. JAMA Netw Open 2019; 2:e190035. [PMID: 30794298 PMCID: PMC6484589 DOI: 10.1001/jamanetworkopen.2019.0035] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
IMPORTANCE Axicabtagene ciloleucel, a chimeric antigen receptor T-cell therapy, represents a new and potentially curative treatment option for B-cell lymphoma. It is expected to have long-term survival benefits; however, long-term survival data are limited. OBJECTIVE To estimate the long-term survival and cost-effectiveness of axicabtagene ciloleucel for treatment of relapsed or refractory B-cell lymphoma. DESIGN, SETTING, AND PARTICIPANTS Economic evaluation study using a survival analysis that digitized and extrapolated survival curves published in the ZUMA-1 trial (Safety and Efficacy of KTE-C19 in Adults With Refractory Aggressive Non-Hodgkin Lymphoma), which enrolled patients between November 2015 and September 2016 and had a maximum follow-up of 24 months. Five different survival models (standard parametric, flexible parametric, 2 mixture cure models, and a flexible parametric mixture model) were used to extrapolate the survival curves to a lifetime horizon from January through June 2018. A cost-effectiveness analysis, from both a trial-based and lifetime horizon, was also conducted to inform the value of this novel therapy. The model was based on data from 111 patients with B-cell lymphoma who were enrolled in the ZUMA-1 trial. INTERVENTIONS One-time administration of axicabtagene ciloleucel compared with chemotherapy. MAIN OUTCOMES AND MEASURES Undiscounted and discounted life-years (LYs) and quality-adjusted life-years (QALYs), total costs, and incremental costs per LY and QALY gained. RESULTS The modeled cohort of 111 patients started at 58 years of age. At the end of the trial, treatment with axicabtagene ciloleucel resulted in 0.48 more LYs and 0.34 more QALYs than chemotherapy, producing a cost-effectiveness estimate of $896 600 per QALY for public payers and $1 615 000 per QALY for commercial payers. Extrapolated long-term survival for patients treated with axicabtagene ciloleucel ranged from 2.83 to 9.19 discounted LYs and from 2.07 to 7.62 discounted QALYs. Incrementally, treatment with axicabtagene ciloleucel was associated with 1.89 to 5.82 discounted LYs and 1.52 to 4.90 discounted QALYs vs chemotherapy. With the use of these incremental estimates of survival, cost-effectiveness estimates ranged from $82 400 to $230 900 per QALY gained for public payers and from $100 400 to $289 000 per QALY gained for commercial payers. CONCLUSIONS AND RELEVANCE Treatment with axicabtagene ciloleucel appears to be associated with incremental gains in survival over chemotherapy. The range in projected long-term survival was wide and reflected uncertainty owing to limited follow-up data. Cost-effectiveness is associated with long-term survival, with further evidence needed to reduce uncertainty.
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Affiliation(s)
- Melanie D. Whittington
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora
| | - R. Brett McQueen
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora
| | | | - Varun M. Kumar
- Institute for Clinical and Economic Review, Boston, Massachusetts
| | | | - Jeffrey A. Tice
- Department of Medicine, University of California, San Francisco
| | | | - Jonathan D. Campbell
- Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora
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Whittington MD, McQueen RB, Ollendorf DA, Chapman RH, Kumar VM, Synnott PG, Agboola F, Campbell JD. Assessing the Value of Sarilumab Monotherapy for Adults with Moderately to Severely Active Rheumatoid Arthritis: A Cost-Effectiveness Analysis. J Manag Care Spec Pharm 2019; 25:80-87. [PMID: 30589626 PMCID: PMC10402693 DOI: 10.18553/jmcp.2019.25.1.080] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Rheumatoid arthritis is associated with a societal burden greater than $39 billion annually. Novel treatments, known as targeted immune modulators (TIMs), are expensive but effective, producing improvements in response rates compared with conventional disease-modifying antirheumatic drugs (cDMARDs). Sarilumab, a TIM approved in 2017, shows superior improvements compared with cDMARDs and produced significantly greater likelihood of achieving response and improvement in the Health Assessment Questionnaire Disability Index than adalimumab monotherapy. Although sarilumab monotherapy has shown improvements over cDMARDs and the TIM market leader adalimumab, treatment with sarilumab is costly, with an annual wholesale acquisition cost of $39,000. OBJECTIVE To estimate the lifetime cost-effectiveness of starting treatment with sarilumab monotherapy for adult patients with moderately to severely active rheumatoid arthritis who have had an inadequate response to cDMARDs. METHODS A sequential treatment cohort model followed a hypothetical cohort from initiation of sarilumab monotherapy until death. The model allowed patients to switch therapies up to 3 times due to effectiveness or adverse events. The first switch was to a TIM within the same treatment category; the second switch was to a TIM within a different treatment category; and the third switch was to a cDMARD. Sarilumab monotherapy was compared with a cDMARD (methotrexate) and the TIM market leader (adalimumab monotherapy). Key risk and benefit evidence came from clinical studies and network meta-analyses of data on radiographic progression and response. We used a lifetime time horizon and the U.S. health sector payer perspective assuming therapy net pricing. We also incorporated loss of productivity to reflect a restricted societal perspective. RESULTS Over a lifetime time horizon, a treatment pathway starting with sarilumab resulted in 17.16 life-years and 13.66 quality-adjusted life-years (QALYs). Treatment pathways starting with the cDMARD resulted in 16.54 life-years and 11.77 QALYs; treatment pathways starting with adalimumab resulted in 17.05 life-years and 13.35 QALYs. Total costs for sarilumab ($492,000 for payer perspective, $634,000 for societal perspective) were less than total costs for adalimumab ($536,000 for payer perspective, $689,000 for societal perspective) but higher than total costs for the cDMARD ($63,000 for payer perspective, $272,000 for societal perspective). When compared with cDMARD therapy, sarilumab resulted in a cost-effectiveness estimate of $227,000 per QALY gained from the payer perspective and $191,000 per QALYs gained from the societal perspective. When compared with adalimumab, sarilumab was dominant from both perspectives. CONCLUSIONS Sarilumab resulted in better health outcomes than conventional therapy alone. However, its additional cost with assumed class-level net prices led to cost-effectiveness estimates above commonly cited thresholds. When compared with the market leader, sarilumab achieved favorable value. This evaluation informs stakeholders of the value of sarilumab and its alternatives to promote high value practices in health care. DISCLOSURES Funding for this research was contributed by the Institute for Clinical and Economic Review (ICER). Ollendorf, Chapman, Kumar, Synnott, and Agboola are employees of ICER, an independent organization that evaluates the evidence on the value of health care interventions, which is funded by grants from the Laura and John Arnold Foundation, Blue Shield of California Foundation, and the California HealthCare Foundation. The organization's annual policy summit is supported by dues from Aetna, AHIP, Anthem, Blue Shield of California, CVS Caremark, Express Scripts, Harvard Pilgrim Health Care, Omeda Rx, United Healthcare, Kaiser Permanente, Premera Blue Cross, AstraZeneca, Genentech, GlaxoSmithKline, Johnson & Johnson, Merck, National Pharmaceutical Council, Takeda, Pfizer, Novartis, Lilly, and Humana. This work is an extension of an analysis presented at the New England Comparative Effectiveness Public Advisory Council on March 24, 2017, where the authors received public feedback on the analysis, results, and effect of a value assessment for targeted immune modulators. At the time of presentation, sarilumab was still an investigational product; therefore, a price was not known, so cost-effectiveness estimates were not generated. Since the presentation of that material, additional evidence for sarilumab has become available. The additional evidence has been incorporated into this analysis to present cost-effectiveness estimates for sarilumab.
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MESH Headings
- Antibodies, Monoclonal, Humanized/economics
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antirheumatic Agents/economics
- Antirheumatic Agents/therapeutic use
- Arthritis, Rheumatoid/complications
- Arthritis, Rheumatoid/drug therapy
- Arthritis, Rheumatoid/economics
- Arthritis, Rheumatoid/immunology
- Cost of Illness
- Cost-Benefit Analysis
- Drug Therapy, Combination
- Female
- Humans
- Male
- Middle Aged
- Models, Economic
- Quality-Adjusted Life Years
- Receptors, Interleukin-6/antagonists & inhibitors
- Receptors, Interleukin-6/immunology
- Treatment Outcome
- United States
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Affiliation(s)
| | - R. Brett McQueen
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora
| | | | | | - Varun M. Kumar
- Institute for Clinical and Economic Review, Boston, Massachusetts
| | | | - Foluso Agboola
- Institute for Clinical and Economic Review, Boston, Massachusetts
| | - Jonathan D. Campbell
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora
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Kristensen FB, Husereau D, Huić M, Drummond M, Berger ML, Bond K, Augustovski F, Booth A, Bridges JFP, Grimshaw J, IJzerman MJ, Jonsson E, Ollendorf DA, Rüther A, Siebert U, Sharma J, Wailoo A. Identifying the Need for Good Practices in Health Technology Assessment: Summary of the ISPOR HTA Council Working Group Report on Good Practices in HTA. Value Health 2019; 22:13-20. [PMID: 30661627 DOI: 10.1016/j.jval.2018.08.010] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 08/10/2018] [Accepted: 08/14/2018] [Indexed: 05/11/2023]
Abstract
The systematic use of evidence to inform healthcare decisions, particularly health technology assessment (HTA), has gained increased recognition. HTA has become a standard policy tool for informing decision makers who must manage the entry and use of pharmaceuticals, medical devices, and other technologies (including complex interventions) within health systems, for example, through reimbursement and pricing. Despite increasing attention to HTA activities, there has been no attempt to comprehensively synthesize good practices or emerging good practices to support population-based decision-making in recent years. After the identification of some good practices through the release of the ISPOR Guidelines Index in 2013, the ISPOR HTA Council identified a need to more thoroughly review existing guidance. The purpose of this effort was to create a basis for capacity building, education, and improved consistency in approaches to HTA-informed decision-making. Our findings suggest that although many good practices have been developed in areas of assessment and some other key aspects of defining HTA processes, there are also many areas where good practices are lacking. This includes good practices in defining the organizational aspects of HTA, the use of deliberative processes, and measuring the impact of HTA. The extent to which these good practices are used and applied by HTA bodies is beyond the scope of this report, but may be of interest to future researchers.
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Affiliation(s)
| | - Don Husereau
- School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, ON, Canada; Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University of Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria.
| | - Mirjana Huić
- Agency for Quality and Accreditation in Health Care and Social Welfare, Zagreb, Croatia
| | | | | | - Kenneth Bond
- Patient Engagement, Ethics and International Affairs, Canadian Agency for Drugs and Technologies in Health (CADTH), Ottawa, ON, Canada
| | - Federico Augustovski
- Economic Evaluations and HTA Department, Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Andrew Booth
- ScHARR, The University of Sheffield, Sheffield, UK
| | - John F P Bridges
- Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Jeremy Grimshaw
- Cochrane Canada and Professor of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Maarten J IJzerman
- School of Population and Global Health, University of Melbourne, Melbourne, Australia; Department of Health Technology & Services Research, University of Twente, Enschede, The Netherlands
| | - Egon Jonsson
- Institute of Health Economics, Edmonton, AB, Canada
| | - Daniel A Ollendorf
- Center for the Evaluation of Value and Risk in Health (CEVR), Tufts University, Boston, MA, USA
| | - Alric Rüther
- International Affairs, Institute for Quality and Efficiency in Health Care (IQWiG), Cologne, Germany
| | - Uwe Siebert
- Department of Public Health, Health Services Research and Health Technology Assessment, UMIT - University of Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria; Division of Health Technology Assessment, ONCOTYROL - Center for Personalized Cancer Medicine, Innsbruck, Austria; Institute for Technology Assessment, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, and Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Jitendar Sharma
- AP MedTech Zone & Advisor (Health), Department of Health & Family Welfare, Andhra Pradesh, India
| | - Allan Wailoo
- ScHARR, The University of Sheffield, Sheffield, UK; NICE Decision Support Unit, Sheffield, UK
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Whittington MD, McQueen RB, Ollendorf DA, Kumar VM, Chapman RH, Tice JA, Pearson SD, Campbell JD. Long-term Survival and Value of Chimeric Antigen Receptor T-Cell Therapy for Pediatric Patients With Relapsed or Refractory Leukemia. JAMA Pediatr 2018; 172:1161-1168. [PMID: 30304407 PMCID: PMC6583018 DOI: 10.1001/jamapediatrics.2018.2530] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Among children and young adults with relapsed or refractory B-cell acute lymphoblastic leukemia, the rate of 5-year disease-free survival is 10% to 20%. Approval of tisagenlecleucel, a chimeric antigen receptor T-cell therapy, represents a new and potentially curative treatment option. However, tisagenlecleucel is expensive, with a current list price of $475 000 per one-time administration. OBJECTIVE To estimate the long-term survival and value of tisagenlecleucel for children and young adults with B-cell acute lymphoblastic leukemia. DESIGN, SETTING, AND PARTICIPANTS In this cost-effectiveness analysis, a decision analytic model was designed to extrapolate trial evidence to a patient lifetime horizon. The survival evidence for the model was extracted from 3 studies: B2202 (enrolled patients from April 8, 2015, to November 23, 2016), B2205J (enrolled patients from August 14, 2014, to February 1, 2016), and B2101J (enrolled patients from March 15, 2012, to November 30, 2015). Long-term survival and outcomes of patients younger than 25 years with B-cell acute lymphoblastic leukemia that is refractory or in second or later relapse were derived using flexible parametric modeling from the direct extrapolation of event-free survival and overall survival curves. The published Kaplan-Meier curves were digitized from November 1, 2017, to November 30, 2017, using an algorithm to impute patient-level time-to-event data. Sensitivity and scenario analyses assessed uncertainty in the evidence and model assumptions to further bound the range of cost-effectiveness. Data were analyzed from December 1, 2017, to March 31, 2018. INTERVENTIONS The primary intervention of interest was tisagenlecleucel. The comparator of interest was the chemoimmunotherapeutic agent clofarabine. MAIN OUTCOMES AND MEASURES Model outcomes included life-years gained, quality-adjusted life-years (QALYs) gained, and incremental costs per life-year and QALY gained. RESULTS Forty percent of patients initiating treatment with tisagenlecleucel are expected to be long-term survivors, or alive and responding to treatment after 5 years. Tisagenlecleucel had a total discounted cost of $667 000, with discounted life-years gained of 10.34 years and 9.28 QALYs gained. The clofarabine comparator had a total discounted cost of approximately $337 000, with discounted life-years gained of 2.43 years and 2.10 QALYs gained. This difference resulted in an incremental cost-effectiveness ratio of approximately $42 000 per life-year gained and approximately $46 000 per QALY gained for tisagenlecleucel vs clofarabine. These results were robust to probabilistic sensitivity analyses. Across scenario analyses that included more conservative assumptions regarding long-term relapse and survival, the incremental cost-effectiveness ratio ranged from $37 000 to $78 000 per QALY gained. CONCLUSIONS AND RELEVANCE Tisagenlecleucel likely provides gains in survival and seems to be priced in alignment with these benefits. This study suggests that payers and innovators should develop novel payment models that reduce the risk and uncertainty around long-term value and provide safeguards to ensure high-value care.
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Affiliation(s)
| | - R. Brett McQueen
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora
| | | | - Varun M. Kumar
- The Institute for Clinical and Economic Review, Boston, Massachusetts
| | | | - Jeffrey A. Tice
- Department of Medicine, University of California, San Francisco
| | - Steven D. Pearson
- The Institute for Clinical and Economic Review, Boston, Massachusetts
| | - Jonathan D. Campbell
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora
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Hendrix N, Ollendorf DA, Chapman RH, Loos A, Liu S, Kumar V, Linder JA, Pearson SD, Veenstra DL. Cost-Effectiveness of Targeted Pharmacotherapy for Moderate to Severe Plaque Psoriasis. J Manag Care Spec Pharm 2018; 24:1210-1217. [PMID: 30479197 PMCID: PMC10398188 DOI: 10.18553/jmcp.2018.24.12.1210] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Newer classes of targeted drugs for moderate to severe plaque psoriasis are more effective and more expensive than older classes, posing a difficult and potentially costly decision about whether to use them as initial targeted treatments. OBJECTIVE To estimate the clinical and economic outcomes of initial targeted treatment for the following drugs: adalimumab, etanercept, and infliximab (TNFα inhibitors); apremilast (PDE4 inhibitor); ustekinumab (IL-12/23 inhibitor); and ixekizumab, secukinumab, and brodalumab (IL-17 inhibitors). METHODS We developed a Markov model to simulate patient outcomes as measured by quality-adjusted life-years (QALYs) and health care costs over a 10-year period. We assumed that patients who fail initial targeted treatment either proceed to subsequent therapy or discontinue targeted treatment. Effectiveness estimates for initial treatment were defined as improvement in Psoriasis Area and Severity Index (PASI) from baseline and derived from a 2018 network meta-analysis. Wholesale acquisition drug costs were discounted by a class-specific, empirically derived rebate percentage off of 2016 costs. We conducted one-way and probabilistic sensitivity analyses to assess uncertainty in results. RESULTS The incremental benefits compared with no targeted treatment were, in descending order: ixekizumab 1.68 QALYs (95% credible range [CR] = 1.11-2.02), brodalumab 1.64 QALYs (95% CR = 1.08-1.98), secukinumab 1.51 QALYs (95% CR = 1.00-1.83), ustekinumab 1.43 QALYs (95% CR=0.94-1.74), infliximab 1.27 QALYs (95% CR = 0.89-1.55), adalimumab 1.15 QALYs (95% CR = 0.76-1.44), etanercept 0.97 QALYs (95% CR = 0.61-1.25), and apremilast 0.87 QALYs (95% CR = 0.52-1.17). Costs of care without targeted treatment totaled $66,451, and costs of targeted treatment ranged from $137,080 (apremilast) to $255,422 (ustekinumab). Probabilistic sensitivity analysis results indicated that infliximab and apremilast are likely to be the most cost-effective initial treatments at willingness-to-pay thresholds around $100,000 per QALY, while IL-17 drugs are more likely to be cost-effective at thresholds approaching $150,000 per QALY. Acquisition cost of the initial targeted drug and utility of clinical response were the most influential parameters. CONCLUSIONS Our findings suggest that initial targeted treatment with IL-17 inhibitors is the most effective treatment strategy for plaque psoriasis patients who have failed methotrexate and phototherapy. Apremilast, brodalumab, infliximab, ixekizumab, and secukinumab are cost-effective at different willingness-to-pay thresholds. Additional research is needed on whether the effectiveness of targeted agents changes when used after previously targeted agents. DISCLOSURES Funding for this study was contributed by the Institute for Clinical and Economic Review (ICER). Ollendorf, Chapman, Pearson, and Kumar are current employees, and Loos and Liu are former employees, of ICER, an independent organization that evaluates the evidence on the value of health care interventions, which is funded by grants from the Laura and John Arnold Foundation, Blue Shield of California Foundation, and the California HealthCare Foundation. ICER's annual policy summit is supported by dues from Aetna, AHIP, Anthem, Alnylam, AstraZeneca, Blue Shield of California, Cambia Health Solutions and MedSavvy, CVS Caremark, Editas, Express Scripts, Genentech, GlaxoSmithKline, Harvard Pilgrim Health Care, Health Care Service Corporation, OmedaRx, United Healthcare, Johnson & Johnson, Kaiser Permanente, Premera Blue Cross, Merck, National Pharmaceutical Council, Takeda, Pfizer, Novartis, Lilly, Humana, Prime Therapeutics, Sanofi, and Spark Therapeutics. Linder owns stock in Amgen, Biogen, and Eli Lilly; has contingent value rights in Sanofi Genzyme (related to alemtuzumab for multiple sclerosis); has received grant support from Astellas Pharma not related to this study and Clintrex, which was supported by AstraZeneca on an unrelated topic; and has received an honorarium from the Society of Healthcare Epidemiology of America (SHEA) as part of the SHEA Antimicrobial Stewardship Research Workshop Planning Committee, an educational activity supported by Merck. No other authors have potential conflicts of interest.
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Affiliation(s)
- Nathaniel Hendrix
- Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle
| | | | | | - Anne Loos
- Institute for Clinical and Economic Review, Boston, Massachusetts
| | - Shanshan Liu
- Institute for Clinical and Economic Review, Boston, Massachusetts
| | - Varun Kumar
- Institute for Clinical and Economic Review, Boston, Massachusetts
| | - Jeffrey A. Linder
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - David L. Veenstra
- Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle
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Carlson JJ, Guzauskas GF, Chapman RH, Synnott PG, Liu S, Russo ET, Pearson SD, Brouwer ED, Ollendorf DA. The Authors Respond. J Manag Care Spec Pharm 2018; 24:712-713. [PMID: 29952702 PMCID: PMC10397929 DOI: 10.18553/jmcp.2018.24.7.712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
DISCLOSURES Funding for the Carlson et al. study was provided in part by the Institute for Clinical and Economic Review. Ollendorf, Synnott, Chapman, and Pearson disclosed grants from Blue Shield of California Foundation, California Health Care Foundation, Laura and John Arnold Foundation, Aetna, AHIP, Anthem, Blue Shield of California, CVS Caremark, Express Scripts, Harvard Pilgrim Health Care, OmedaRx, United Healthcare, Kaiser Permanente, Premera, AstraZeneca, Genentech, GlaxoSmithKline, Johnson & Johnson, Merck, National Pharmaceutical Council, Takeda, Pfizer, Novartis, Lilly, Spark Therapeutics, Sanofi, Prime Therapeutics, and Health Care Service Corporation. Carlson disclosed grants from the Institute for Clinical and Economic Review and personal fees from Seattle Genetics, Genentech, and Pfizer. Russo, Guzauskas, Liu, and Brouwer have nothing to disclose.
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Affiliation(s)
- Josh J. Carlson
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle
| | - Gregory F. Guzauskas
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle
| | | | | | - Shanshan Liu
- Institute for Clinical and Economic Review, Boston, Massachusetts
| | | | | | - Elizabeth D. Brouwer
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle
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Kazi DS, Penko J, Ollendorf DA, Coxson PG, Bibbins-Domingo K. Effect of Money-Back Guarantees on the Cost-Effectiveness of Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitors. Ann Intern Med 2018; 168:896-898. [PMID: 29610832 DOI: 10.7326/m17-3367] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Dhruv S Kazi
- University of California, San Francisco, San Francisco, California (D.S.K., J.P., P.G.C., K.B.)
| | - Joanne Penko
- University of California, San Francisco, San Francisco, California (D.S.K., J.P., P.G.C., K.B.)
| | - Daniel A Ollendorf
- Institute for Clinical and Economic Review, Boston, Massachusetts (D.A.O.)
| | - Pamela G Coxson
- University of California, San Francisco, San Francisco, California (D.S.K., J.P., P.G.C., K.B.)
| | - Kirsten Bibbins-Domingo
- University of California, San Francisco, San Francisco, California (D.S.K., J.P., P.G.C., K.B.)
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Ollendorf DA, Chapman RH, Pearson SD. Evaluating and Valuing Drugs for Rare Conditions: No Easy Answers. Value Health 2018; 21:547-552. [PMID: 29753351 DOI: 10.1016/j.jval.2018.01.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 12/19/2017] [Accepted: 01/16/2018] [Indexed: 06/08/2023]
Abstract
We find ourselves in an era of unprecedented growth in the development and use of so-called "orphan" drugs to treat rare diseases, which are poised to represent more than one-fifth of pharmaceutical expenditures by 2022. This widespread use has been facilitated by legislative and regulatory incentives in both the United States and abroad, yet US payers and health systems have not yet made a concerted effort to understand whether and how rare diseases require special considerations on their part and how to adapt traditional methods of health technology assessment and economic evaluation to accommodate these situations. In this article, we explore the general ethical dilemmas that rare diseases present, steps taken by health technology assessment bodies worldwide to define the level of rarity that would necessitate special measures and the modifications to their assessment and valuation processes needed, and the contextual components for rare-disease evaluation that lie outside of the assessment framework as a guide to US decision makers on constructing a formal and relevant process stateside.
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