Application of Multi-Criteria Decision Analysis (MCDA) to Prioritize Real-World Evidence Studies for Health Technology Management: Outcomes and Lessons Learned by the Canadian Real-World Evidence for Value of Cancer Drugs (CanREValue) Collaboration

Multi-criteria decision analysis (MCDA) is a value assessment tool designed to help support complex decision-making by incorporating multiple factors and perspectives in a transparent, structured approach. We developed an MCDA rating tool, consisting of seven criteria evaluating the importance and feasibility of conducting potential real-world evidence (RWE) studies aimed at addressing uncertainties stemming from initial cancer drug funding recommendations. In collaboration with the Canadian Agency for Drugs and Technologies in Health's Provincial Advisory Group, a validation exercise was conducted to further evaluate the application of the rating tool using RWE proposals varying in complexity. Through this exercise, we aimed to gain insight into consensus building and deliberation processes and to identify efficiencies in the application of the rating tool. An experienced facilitator led a multidisciplinary committee, consisting of 11 Canadian experts, through consensus building, deliberation, and prioritization. A total of nine RWE proposals were evaluated and prioritized as low (n = 4), medium (n = 3), or high (n = 2) priority. Through an iterative process, efficiencies and recommendations to improve the rating tool and associated procedures were identified. The refined MCDA rating tool can help decision-makers prioritize important and feasible RWE studies for research and can enable the use of RWE for the life-cycle evaluation of cancer drugs.

Development of a Multi-Criteria Decision Analysis Rating Tool to Prioritize Real-World Evidence Questions for the Canadian Real-World Evidence for Value of Cancer Drugs (CanREValue) Collaboration

The Canadian Real-world Evidence for Value of Cancer Drugs (CanREValue) collaboration developed an MCDA rating tool to assess and prioritize potential post-market real-world evidence (RWE) questions/uncertainties emerging from public drug funding decisions in Canada. In collaboration with a group of multidisciplinary stakeholders from across Canada, the rating tool was developed following a three-step process: (1) selection of criteria to assess the importance and feasibility of an RWE question; (2) development of rating scales, application of weights and calculating aggregate scores; and (3) validation testing. An initial MCDA rating tool was developed, composed of seven criteria, divided into two groups. Group A criteria assess the importance of an RWE question by examining the (1) drug’s perceived clinical benefit, (2) magnitude of uncertainty identified, and (3) relevance of the uncertainty to decision-makers. Group B criteria assess the feasibility of conducting an RWE analysis including the (1) feasibility of identifying a comparator, (2) ability to identify cases, (3) availability of comprehensive data, and (4) availability of necessary expertise and methodology. Future directions include partnering with the Canadian Agency for Drugs and Technology in Health’s Provincial Advisory Group for further tool refinement and to gain insight into incorporating the tool into drug funding deliberations.

Building a National Reassessment Process for Oncology Drugs: Lessons Learned by the Canadian Real-World Evidence for Value of Cancer Drugs (CanREValue) Collaboration through a Simulated Reassessment Exercise

The CanREValue Collaboration established the Reassessment & Uptake Working Group to develop a preliminary process to reassess funded cancer drugs in Canada. A simulated exercise was conducted to evaluate the proposed reassessment process using a real-world case. We invited 32 attendees including representatives from Health Canada and Health Technology Assessment (HTA) agencies, along with payers, clinicians, academics, and patient representatives. A case was developed using a real-world study on a publicly funded cancer drug. In facilitated group sessions, participants were asked to deliberate upon the evidence presented in the case to issue reassessment recommendations. Several themes were identified through the deliberation discussions. While the generalizability of real-world evidence (RWE) is perceived as a strength, trust in the RWE depends largely on the source of the real-world data. The attendees suggested several improvements to the proposed reassessment process including evidence requirement for reassessment, recommendation categories, and a priori study protocols. This exercise generated important insights on the evidence required for conducting reassessment and considerations for improvements of the proposed reassessment process. Building upon lessons from this exercise, future work would continue to refine the reassessment process as part of the overall CanREValue framework.

Considerations for Developing a Reassessment Process: Report from the Canadian Real-World Evidence for Value of Cancer Drugs (CanREValue) Collaboration's Reassessment and Uptake Working Group

The Canadian Real-world Evidence for Value in Cancer Drugs (CanREValue) Collaboration was established to develop a framework for generating and using real-world evidence (RWE) to inform the reassessment of cancer drugs following initial health technology assessment (HTA). The Reassessment and Uptake Working Group (RWG) is one of the five established CanREValue Working Groups. The RWG aims to develop considerations for incorporating RWE for HTA reassessment and strategies for using RWE to reassess drug funding decisions. Between February 2018 and December 2019, the RWG attended four teleconferences (with follow-up surveys) and two in-person meetings to discuss recommendations for the development of a reassessment process and potential barriers and facilitators. Modified Delphi methods were used to gather input. A draft report of recommendations (to December 2018) was shared for public consultation (December 2019 to January 2020). Initial considerations for developing a reassessment process were proposed. Specifically, reassessment can be initiated by diverse stakeholders, including decision makers from public drug plans or industry stakeholders. The reassessment process should be modelled after existing deliberation and recommendation frameworks used by HTA agencies. Proposed reassessment outcome categories include maintaining status quo, revisiting funding criteria, renegotiating price, or disinvesting. Overall, these initial considerations will serve as the basis for future advancements by the Collaboration.

Distance-limited walk tests post-stroke: A systematic review of measurement properties

BACKGROUND

Improving walking capacity is a key objective of post-stroke rehabilitation. Evidence describing the quality and protocols of standardized tools for assessing walking capacity can facilitate their implementation.

OBJECTIVE

To synthesize existing literature describing test protocols and measurement properties of distance-limited walk tests in people post-stroke.

METHODS

Electronic database searches were completed in 2017. Records were screened and appraised for quality.

RESULTS

Data were extracted from 43 eligible articles. Among the 12 walk tests identified, the 10-metre walk test (10mWT) at a comfortable pace was most commonly evaluated. Sixty-three unique protocols at comfortable and fast paces were identified. Walking pace and walkway surface, but not walkway length, influenced walking speed. Intraclass correlation coefficients for test-retest reliability ranged from 0.80-0.99 across walk tests. Measurement error values ranged from 0.04-0.40 and 0.06 to 0.20 for the 10mWT at comfortable and fast and paces, respectively. Across walk tests, performance was most frequently correlated with measures of strength, balance, and physical activity (r = 0.26-0.8, p < 0.05).

CONCLUSIONS

The 10mWT has the most evidence of reliability and validity. Findings indicate that studies that include people with severe walking deficits, in acute and subacute phases of recovery, with improved quality of reporting, are needed.

Malpositioning of central venous catheter from right to left subclavian vein: A rare complication

Invasive monitoring with central venous catheter (CVC) is a valuable tool now a day in Intensive Care Units and in postoperative hemodynamically unstable patients. It is often employed for administering medications and parenteral nutrition. In most of the instances, these catheters are inserted using proper topographical landmarks and ultrasonography-guided methods. Central venous cannulation is associated now and then with unexpected complications despite the use of all precautions and help of imaging techniques. There is a wide variety of complications related to the central venous cannulation including malpositioning. Malpositioning of the catheter into contralateral subclavian is an extremely unusual event. Here, we report a rare case of malpositioning of CVC from the right to the left subclavian vein also we outline how the misplacement was identified and effectively managed.

Considerations for the Selection of Time-Limited Walk Tests Poststroke: A Systematic Review of Test Protocols and Measurement Properties

BACKGROUND AND PURPOSE

Systematic reviews of research evidence describing the quality and methods for administering standardized outcome measures are essential to developing recommendations for their clinical application. The purpose of this systematic review was to synthesize the research literature describing test protocols and measurement properties of time-limited walk tests in people poststroke.

METHODS

Following an electronic search of 7 bibliographic data-bases, 2 authors independently screened titles and abstracts. One author identified eligible articles, and performed quality appraisal and data extraction.

RESULTS

Of 12 180 records identified, 43 articles were included. Among 5 walk tests described, the 6-minute walk test (6MWT) was most frequently evaluated (n = 36). Only 5 articles included participants in the acute phase (<1 month) poststroke. Within tests, protocols varied. Walkway length and walking aid, but not turning direction, influenced 6MWT performance. Intraclass correlation coefficients for reliability were 0.68 to 0.71 (12MWT) and 0.80 to 1.00 (2-, 3-, 5- and 6MWT). Minimal detectable change values at the 90% confidence level were 11.4 m (2MWT), 24.4 m (5MWT), and 27.7 to 52.1 m (6MWT; n = 6). Moderate-to-strong correlations (≥0.5) between 6MWT distance and balance, motor function, walking speed, mobility, and stair capacity were consistently observed (n = 33). Moderate-to-strong correlations between 5MWT performance and walking speed/independence (n = 1), and between 12MWT performance and balance, motor function, and walking speed (n = 1) were reported.

DISCUSSION AND CONCLUSIONS

Strong evidence of the reliability and construct validity of using the 6MWT poststroke exists; studies in the acute phase are lacking. Because protocol variations influence performance, a standardized 6MWT protocol poststroke for use across the care continuum is needed.Video Abstract available for more insights from the authors (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A150).

GEANT4 simulation of cyclotron radioisotope production in a solid target

The use of radioisotopes in nuclear medicine is essential for diagnosing and treating cancer. The optimization of their production is a key factor in maximizing the production yield and minimizing the associated costs. An efficient approach to this problem is the use of Monte Carlo simulations prior to experimentation. By predicting isotopes yields, one can study the isotope of interest expected activity for different energy ranges. One can also study the target contamination with other radioisotopes, especially undesired radioisotopes of the wanted chemical element which are difficult to separate from the irradiated target and might result in increasing the dose when delivering the radiopharmaceutical product to the patient. The aim of this work is to build and validate a Monte Carlo simulation platform using the GEANT4 toolkit to model the solid target system of the South Australian Health and Medical Research Institute (SAHMRI) GE Healthcare PETtrace cyclotron. It includes a GEANT4 Graphical User Interface (GUI) where the user can modify simulation parameters such as the energy, shape and current of the proton beam, the target geometry and material, the foil geometry and material and the time of irradiation. The paper describes the simulation and presents a comparison of simulated and experimental/theoretical yields for various nuclear reactions on an enriched nickel 64 target using the GEANT4 physics model QGSP_BIC_AllHP, a model recently developed to evaluate with high precision the interaction of protons with energies below 200MeV available in Geant4 version 10.1. The simulation yield of the (64)Ni(p,n)(64)Cu reaction was found to be 7.67±0.074 mCi·μA(-1) for a target energy range of 9-12MeV. Szelecsenyi et al. (1993) gives a theoretical yield of 6.71mCi·μA(-1) and an experimental yield of 6.38mCi·μA(-1). The (64)Ni(p,n)(64)Cu cross section obtained with the simulation was also verified against the yield predicted from the nuclear database TENDL and compared to experimental yield obtained from literature.

Reference values for standardized tests of walking speed and distance: a systematic review

OBJECTIVE

To provide an overview of the reference values and methodology used to obtain them for time- and distance-limited walk tests.

METHODS

We performed a systematic review and searched PubMed, MEDLINE (Ovid), EMBASE, CINAHL, Scopus, PEDro, and The Cochrane Library from 1946 to May 2013. Full-text peer-reviewed articles written in English, French or Spanish were considered eligible. Two authors independently screened titles and abstracts. One author determined eligibility of full-text articles, appraised methodological quality, and extracted data. A second author independently verified the accuracy of extracted data.

RESULTS

Of the 41 eligible studies reviewed, 25 failed to describe the method used to select participants and 10 had an inadequate sample size. Twenty-five studies provided reference values for one time-limited walk test (6-min walk test (6 MWT)) and 18 studies provided reference values for 15 distance-limited walk tests. Across studies, walk test distances ranged from 3m to 40m. Descriptive values and reference equations for the 6 MWT were reported in 15 and 20 studies, respectively. Across 43 regression equations (median R(2)=0.46), age (98%) and sex (91%) were most frequently included. The equation yielding the maximum R(2) value (0.78) included age, height, weight and percentage of predicted maximum heart rate. Among six unique regression equations for distance-limited walk tests (median R(2)=0.17), sex (83%), age (67%) and weight (67%) were most frequently included. The equation yielding the maximum R(2) value (0.25) included age and sex.

CONCLUSIONS

Reference values reported for these tests provide a basis for classifying walking capacity as within normal limits, determining the magnitude of deficit, educating clients, setting rehabilitation goals, and planning studies.

Speed and distance requirements for community ambulation: a systematic review

OBJECTIVE

To provide an overview of the research literature on distance and speed requirements for adults to walk outside the home.

DATA SOURCES

We conducted a systematic review and searched PubMed, MEDLINE (Ovid), EMBASE, CINAHL, Scopus, PEDro, and The Cochrane Library from 1948 to May 2012, and other sources. Search terms included communities, walk, ambulation, and neighborhood.

STUDY SELECTION

Full-text peer-reviewed articles written in English, French, or Spanish reporting distance and/or speed requirements for individuals walking outside the home were considered eligible. Two authors independently screened titles and abstracts. One author reviewed full-text articles to determine inclusion. Of the 3191 titles and abstracts screened, 15 studies (.47%) were selected for detailed review. One author appraised methodological quality. Inadequate description of the reliability of the measurement methods and the population of the town/city assessed was noted.

DATA EXTRACTION

One author extracted data from included studies. A second reviewer independently verified extracted data for accuracy.

DATA SYNTHESIS

Seven studies examining 24 community sites and crosswalks in the United States, Australia, and Singapore were included. Three sites with the largest mean distance requirements for adults to walk were club warehouses (677m), superstores (183-607m), and hardware stores (566m). Three sites with the lowest mean distance requirements were walking at the front (16m) and back (19m) of the house, and at cemeteries (18m). The average speed required to cross the street in the time of a walk signal varied from .44 to 1.32m/s.

CONCLUSIONS

Distance and speed requirements for adults to walk in the community environment vary widely. Findings are relevant to judging capacity for community ambulation to carry out essential activities of daily living, educating patients, and setting rehabilitation goals.

Local receptor revision and class switching to IgE in chronic rhinosinusitis with nasal polyps

BACKGROUND

Chronic rhinosinusitis with nasal polyps (NP) and allergic rhinitis (AR) is characterized by local Th2 inflammation and up-regulation of IgE; however, IgE in NP is 'polyclonal' and allergen specific, whereas IgE in AR is 'oligoclonal' and allergen specific. Germinal center (GC) reactions occur in AR, while only the formation of GC-like structures in NP is described. The aim of this study was to investigate the involvement of local IgE production, class switch recombination, and receptor revision in NP.

METHODS

We compared the levels of local IgE, germline gene transcripts, and mature Ig mRNA expression, recombination activating gene (RAG1 and RAG2), key markers of Th2 inflammation, and GC reactions in NP tissue vs AR and control tissue. Nasal mucosa was immunostained for the co-expression of RAG1 and RAG2 in B cells, plasma cells, and T cells, using dual or triple immunofluorescence (IF).

RESULTS

In NP, local IgE level and key markers of local class switching are increased compared with AR and normal controls (NC). In NP, switch circle transcripts reveal ongoing local class switch recombination to IgE. Up to 30% of B cells, plasma cells, and T cells in nasal polyps re-express both RAG1 and RAG2, required for receptor revision. RAG1 and RAG2 mRNA concentrations are increased in NP and correlated with the magnitude of inflammation and the presence of S. aureus enterotoxin (superantigen)-specific IgE in the nasal polyp mucosa.

CONCLUSION

Our results provide the first evidence of local receptor revision and class switching to IgE, and B-cell differentiation into IgE-secreting plasma cells in NP.

Abstract 262: Speed and Distance Requirements for Community Ambulation: A Systematic Review

Introduction: People with chronic conditions, such as stroke, commonly experience walking limitations and require rehabilitation services to optimize ability. Speed and distance requirements for walking around common community sites would help patients and health care professionals gauge readiness for community ambulation and set realistic goals relevant to activities patients wish to perform.

Objective: To synthesize the research literature on speed and distance requirements for adults walking outside the home.

Methods: A systematic review was conducted to identify full text peer-reviewed articles written in English, French or Spanish reporting distance and/or speed requirements for walking outside the home. Eight electronic databases (PubMed, MEDLINE, EMBASE, CINAHL, Scopus, PEDro, ProQuest® digital dissertations and The Cochrane Library ) were searched until August 2011. The principal investigator’s library and reference lists of included studies were also reviewed. Two authors independently reviewed titles and abstracts. One reviewer determined inclusion and extracted data. A second reviewer independently verified data accuracy. Stakeholders and decision-makers from the physical therapy community were consulted throughout the course of the review to guide the team with respect to the review question, interpretation of results and message creation.

Results: Six English-language studies (5 in the United States and 1 in Singapore) were included. In the American studies, community sites were measured in 26 cities/towns. Across all studies, 27 unique community sites were investigated. Sites most frequently examined include: banks, supermarkets, department stores, drugstores, post offices and physican’s offices. Superstores and club warehouses required the greatest average walking distance of 606.6 metres (m) and 676.8 m, respectively. In four studies that examined common sites using the same protocol, the average walking distance was highest for supermarkets, department stores and drugstores (Range 129-380 m) and lowest for banks, physican’s offices and post offices (Range 38-98 m). Walking distance requirements appeared to substantially increase with population size for some sites (supermarkets, department stores, drugstores and post offices) but not others (banks, physican’s offices). The median speed required to cross the street was lowest in rural areas (0.74 metres/second (m/s)) and highest in cities (1.06 m/s).

Conclusions: In conclusion, our findings suggest that retail sites have the highest walking distance requirements and that site distances increase with population size. Walking speed requirements for crosswalks also appear to increase with population size. Clients and health professionals may use findings to help establish practical rehabilitation goals and to determine readiness for community ambulation.