Health horizons: Future trends and technologies from the European Medicines Agency's horizon scanning collaborations

In medicines development, the progress in science and technology is accelerating. Awareness of these developments and their associated challenges and opportunities is essential for medicines regulators and others to translate them into benefits for society. In this context, the European Medicines Agency uses horizon scanning to shine a light on early signals of relevant innovation and technological trends with impact on medicinal products. This article provides the results of systematic horizon scanning exercises conducted by the Agency, in collaboration with the World Health Organization (WHO) and the European Commission's Joint Research Centre's (DG JRC). These collaborative exercises aim to inform policy-makers of new trends and increase preparedness in responding to them. A subset of 25 technological trends, divided into three clusters were selected and reviewed from the perspective of medicines regulators. For each of these trends, the expected impact and challenges for their adoption are discussed, along with recommendations for developers, regulators and policy makers.

Strengthening the Interface of Evidence-Based Decision Making Across European Regulators and Health Technology Assessment Bodies

OBJECTIVES

Access to medicines in Europe depends on a benefit-risk decision taken by regulators and a relative effectiveness assessment performed by health technology assessment bodies (HTABs) to inform, as one element, a reimbursement decision. Although various similarities in evidence needs exist, understanding of their needs is currently suboptimal and therefore the evidence generated does not always meet their needs. Subsequently, delays in decision making can be expected, negatively affecting access. To overcome this, this study reviewed the evidentiary needs of European regulators and HTABs at European level and analyzed how their collaboration can further facilitate optimal evidence generation plans, evidence use, and evidence presentation.

METHODS

Through systematic literature review, expert interviews, and pairwise comparison of assessment reports by the European Medicines Agency and European network for health technology assessment, respective clinical evidence requirements and impact of product-specific collaboration between European Medicines Agency and HTABs were established.

RESULTS

Clinical evidence needs are quite similar but differences exist in comparator choice, preferred efficacy endpoints, and target population. Results of the impact of collaboration to date were mixed: preapproval joint advice procedures were successful and highly valued by all stakeholders; information exchange at the time of regulatory decision is coming together, yet the European Public Assessment Report can be further optimized; and collaboration on postlicensing evidence generation requirements shows potential but needs solidifying.

CONCLUSIONS

These findings demonstrate the potential to further improve the evidence utilization across stakeholders to avoid duplication and streamline decision making, to ultimately improve access to medicines for European patients.

Biomarker and Companion Diagnostics-A Review of Medicinal Products Approved by the European Medicines Agency

Background: An increasing number of medicines authorised in Europe recommend or require biomarker-based patient selection. For some of these the use of a companion diagnostic (CDx), a subset of in vitro diagnostics (IVDs), to identify patient populations eligible for a specific medicinal product may be required. The information and recommendations of use of a medicinal product for which a CDx is required is particularly important to healthcare professionals for correct patient identification.

Methods: We reviewed the existing information in SmPCs and European Public Assessment Reports (EPARs) of EU medicinal products approved via the centralised procedure at EMA where reference was made to biomarker testing, including by CDx, for patient selection.

Results: The results show that varying levels of detail are provided for the biomarker and the diagnostic test, including variability in where the information was presented. The overall results demonstrate transparent but sometimes heterogeneous reporting of CDx in the SmPC and EPAR.

Conclusions: With the introduction of the new Regulation (EU) 2017/746 on in vitro diagnostic medical devices, medicines regulatory authorities' will be required to be consulted during the review of CDx conformity assessment and so, there is opportunity for more consistent and transparent information on CDx to be provided in the SmPC and EPAR.

Regulatory Science and Innovation Programme for Europe (ReScIPE): A proposed model

Regulatory science underpins the objective evaluation of medicinal products. It is therefore imperative that regulatory science and expertise remain at the cutting edge so that innovations of ever-increasing complexity are translated safely and swiftly into effective, high-quality therapies. We undertook a comprehensive examination of the evolution of science and technology impacting on medicinal product evaluation over the next 5-10 years and this horizon-scanning activity was complemented by extensive stakeholder interviews, resulting in a number of significant recommendations. Highlighted in particular was the need for expertise and regulatory science research to fill knowledge gaps in both more fundamental, longer-term research, with respect to technological and product-specific challenges. A model is proposed to realise these objectives in Europe, comprising a synergistic relationship between the European Medicines Agency, the European Medicines Regulatory Network and academic research centres to establish a novel regulatory science and innovation platform.

Regulatory Science to 2025: An Analysis of Stakeholder Responses to the European Medicines Agency's Strategy

The pace of innovation is accelerating, and so medicines regulators need to actively innovate regulatory science to protect human and animal health. This requires consideration and consultation across all stakeholder groups. To this end, the European Medicines Agency worked with stakeholders to draft its Regulatory Science Strategy to 2025 and launched it for public consultation. The responses to this consultation were analyzed qualitatively, using framework analysis and quantitatively, to derive stakeholders' aggregate scores for the proposed recommendations. This paper provides a comprehensive resource of stakeholder positions on key regulatory science topics of the coming 5 years. These stakeholder positions have implications for the development and regulatory approval of both human and veterinary medicines.

Using benchmarking to identify standards for restructuring

Benchmarking is a process of comparing an organization's performance to that of a selected standard. Because the standard is one selected from other organizations for their "best" performance, benchmarking establishes a vision or goal for restructuring. This author, who is experienced in helping organizations restructure using the benchmarking process describes the steps and how to use it to guide an organization to successful restructuring.

Streamlining documentation: an opportunity to reduce costs and increase nurse clinicians' time with patients

Clinical documentation can take up to 25 percent of a nurse's time in an acute care setting, not to mention the time spent by other clinicians and ancillary caregivers on documentation. Institutions can reduce documentation time by systematically determining what information is crucial to the provision of patient care across all disciplines and then using a redesign process that mirrors work redesign. By following a structured process that challenges the philosophy and function of the documentation system, a hospital's multidisciplinary staff members can use their expertise to design alternatives that achieve documentation's original intent-to document diagnoses and treatment accurately-in a more efficient and useful way.

Work restructuring: the process of redefining roles of patient caregivers

Redefining roles of patient caregivers as an element of work restructuring is essential to maintain and/or enhance an organization's efficiency in this competitive health care environment. This process works best when all levels and disciplines within the organization are involved and when meshed with senior management's leadership and vision.

Failure of serology in diagnosing chlamydial infections of the female genital tract

Chlamydia trachomatis was recoved from 20% (36/180) of women attending a venereal disease clinic. All infected women had chlamydial antibodies in their serum and cervical secretions. However, the background rates of chlamydial antibody in chlamydia-negative women were very high. Measurement of antibodies in serum (complement fixation or immunoglobulin G [IgG] and IgM by microimmunofluorescence) or cervical secretion (IgG, IgM, IgA or secretory IgA classes) did not result in predictive values of greater than 32%. It is concluded that the detection of chlamydial antibodies in serum or cervical secretions cannot be substituted for agent isolation in diagnosing these infections.

Haemophilus vaginalis (Corynebacterium vaginale) vaginitis in women attending public health clinics: response to treatment with ampicillin

Haemophilus vaginalis (Corynebacterium vaginale) was isolated from genital specimens from 150 women who came to a public health venereal disease clinic. Forty-six patients returned to the clinic for at least one follow-up examination. Of the returnees, 22 of 24 who initially had received adequate therapy (14 g ampicillin in seven days) were cured, compared with three of 22 who did not received adequate therapy (X2 = 25.11; P less than 0.00005). These data included significant cure rates with adequate therapy among the 46 returnees, of whom 25 had vaginitis due to H. vaginalis only (X2 = 16.67; P less than 0.00005) and 21 had vaginitis caused by a mixture of pathogens (X2 = 5.86; P less than 0.0156). Specimens obtained from 24 of the 46 returnees were cultured for H. vaginalis on the second visit; 19 were negative, and only five were positive. Clinical responses of the patients correlated closely with the results of culture in both treated and untreated groups (X2 = 14.23; P less than 0.00016).

Comparisons between direct microscopic and cultural methods for recognition of Corynebacterium vaginale in women with vaginitis

The frequency with which clue cells could be detected in Gram-stained vaginal smears and/or cervical Papanicolaou (Pap) smears was compared with the frequency of Corynebacterium vaginale (Haemophilus vaginalis) isolation in a group of 236 female patients, of whom 221 had vaginitis. Vaginal clue cells were found most often in women from whom C. vaginale was isolated (P = 0.00006) whereas, conversely, clue cells in cervical Pap smears were reported more frequently in women with negative cultures for this organism (P = 0.006). C. vaginale isolations were made more frequently from women with both vaginal and cervical clue cells reported (P = 0.000088). However, the combined false positive-false negative vaginal clue cell rate in the patients studied was 36.5%. Neither the detection of vaginal clue cells nor the isolation of C. vaginale was significantly affected by whether or not patients had trichomoniasis (P = 0.25). Trichomonas vaginalis detection in cervical Pap smears and vaginal isolation were related (P = 0.00005), whereas the same relationship was not significant for fungi (P = greater than 0.05).

The etiology of nongonococcal urethritis in men attending a venereal disease clinic

Nongonococcal urethritis was identified as a major reason that men attended our Venereal Disease Clinic. The prevalence of several agents that might cause nongonococcal urethritis was determined. Attempts were made to isolate gonococci; chlamydiae, Ureaplasms urealyticum, trichmonads, Candida sp., and Corynebacterium vaginale from urethral swabs from 307 men. Chlamydiae were recovered from 31% of the 67 men with nongonococcal urethritis compared to only 4% of 86 asymptomatic men without pyuria. Unexpectedly, cultures from only 4% of the 99 men with gonorrhea also yielded chlamydiae. Ureaplasma urealyticum was recovered from 9 of 27 asymptomatic men (33%), 16 of 30 men with nongonococcal urethritis (53%) and 16 of 68 men with gonorrhea (42%). These differences were not statistically significant. However, when chlamydiae-positive men were excluded from the analysis urethritis. Twelve of 18 (76%) men with nononchlamdial nongonococcal urethritis yielded the organism compared to 8 of 26 (31%) men without urethritis. The other organisms sought were recovered infrequently and could not be associated with nongonococcal urethritis.