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Messori A, Mamone D, Rivano M, Romeo MR, Vaiani M, Trippoli S. Pulsed-field ablation for paroxysmal atrial fibrillation: An indirect comparison of effectiveness among three proprietary devices conducted in the absence of randomized trials. Int J Cardiol 2024; 406:132025. [PMID: 38583595 DOI: 10.1016/j.ijcard.2024.132025] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 04/04/2024] [Indexed: 04/09/2024]
Abstract
INTRODUCTION In patients with paroxysmal atrial fibrillation, pulsed-field ablation has been developed as an alternative to thermal ablation. Three devices are currently available: Farawave by Boston, PulseSelect by Medtronic, and Varipulse by Johnson. In the present report, we studied the outcomes at 12 months of these three devices using indirect comparisons. METHODS A standard PubMed search was conducted that identified all studies evaluating these devices in patients with paroxysmal atrial fibrillation. The endpoint was freedom from arrhythmia recurrence. Kaplan-Meier curves were subjected to the IPDfromKM method that generated reconstructed patients. Standard time-to-event statistical testss (including heterogeneity assessment) were performed. RESULTS Our analysis included 9 studies (8 single-arm and 1 randomized trial based on Farawave for a total of 1916 patients). A significant heterogeneity was found across the trials using Farawave because the outcomes found in the single-arm trials were better than those found in the randomized trial. Farawave (according exclusively to the results of the randomized trial), PulseSelect, and Varipulse showed a similar time-course of their respective outcomes with no significant difference. The single-arm trials using Farawave showed better outcomes than the randomized trial using Farawave and the pivotal trials using PulseSelect and Varipulse. DISCUSSION Our study provided an updated overview of all the studies that have so far used pulsed-fileld ablation in patients with paroxysmal atrial fibrillation.
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Trippoli S, Fadda V, Messori A. In-hospital expenditure for medical devices: basic benchmarks for interpreting local data. Eur J Hosp Pharm 2024; 31:285-286. [PMID: 37369594 PMCID: PMC11042459 DOI: 10.1136/ejhpharm-2023-003885] [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] [Indexed: 06/29/2023] Open
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Messori A, Trippoli S, Marinai C. In-hospital expenditure for medical devices in relation to funds from diagnosis-related groups and ambulatory activity: temporal trend from 2019 to 2022. Eur J Hosp Pharm 2024; 31:179-180. [PMID: 36822845 PMCID: PMC10895170 DOI: 10.1136/ejhpharm-2023-003723] [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] [Indexed: 02/25/2023] Open
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Messori A, Romeo MR, Fadda V, Collini F, Trippoli S. Costs and benefits in patients with NYHA class III heart failure treated with CardioMEMS in Italy. Glob Reg Health Technol Assess 2024; 11:105-107. [PMID: 38706524 PMCID: PMC11067868 DOI: 10.33393/grhta.2024.3018] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 02/27/2024] [Indexed: 05/07/2024] Open
Abstract
Background CardioMEMS is a device suitable for telemedicine that is currently being evaluated by the Regional Health Technology Assessment (HTA) Committee of Tuscany. Two detailed HTA reports are available in the specialized literature, the results of which need to be transferred to our regional setting. These decisions in Tuscany are made by the so-called Centro Operativo HTA. Aim To validate, with local cost-effectiveness data, the decision on CardioMEMS that will be made in the Tuscany region. Methods Two detailed international HTA reports were rearranged and adapted to our regional setting to generate a simplified analysis that could form the basis of our decision. Two willingness-to-pay (WTP) thresholds of €20,000/quality-adjusted life year (QALY) and €50,000/QALY were considered. Results Based on epidemiological and regulatory information, the target population in Tuscany for this device is 166 cases. The value-based price of CardioMEMS is estimated to be €4,332 and €16,662 at WTP thresholds of 20,000/QALY and 50,000/QALY, respectively. Its current price in Italy is €12,000. Conclusion In our region, the introduction of CardioMEMS is likely to be gradual, around 50 patients/year (or €0.60 million/year at current price). This example highlights the need to adapt the information published in the international literature to the local context in which the approval decision is made. In this context, simplified analyses are easier to apply than complex Markov models.
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Affiliation(s)
| | - Maria Rita Romeo
- Centro Operativo HTA, Regione Toscana, Firenze - Italy
- Ospedale del Cuore, Fondazione Monasterio, Massa - Italy
| | - Valeria Fadda
- Centro Operativo HTA, Regione Toscana, Firenze - Italy
- Unità Farmaceutica, ESTAR Toscana, Firenze - Italy
| | - Francesca Collini
- Centro Operativo HTA, Regione Toscana, Firenze - Italy
- Agenzia Regionale di Sanità, Firenze - Italy; Centro Operativo HTA, Regione Toscana, Firenze - Italy
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Messori A, Fadda V, Romeo MR, Veneziano S, Trippoli S. A Comparison of Statistical Analysis Between "Real" Patients Reported in Kaplan-Meier Curves and "Reconstructed" Patients Estimated Through the IPDfromKM Method: Analysis of Eight Trials Evaluating Catheter Ablation of Ventricular Tachycardia. Cureus 2023; 15:e47891. [PMID: 37905162 PMCID: PMC10613324 DOI: 10.7759/cureus.47891] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2023] [Indexed: 11/02/2023] Open
Abstract
Time-to-event endpoints are most widely used in oncology and, to a lesser extent, in cardiology. Typical statistical parameters employed in this context include overall survival, progression-free survival, and recurrence-free survival. The graphical presentation of the results is based on the Kaplan-Meier plot. When Kaplan-Meier curves are included in a meta-analysis, the typical methodological approach is a simplified one because the results of each trial (as well as those of the meta-analysis itself) are expressed through a 2x2 contingency; the methodological simplification is that the follow-up is left out from the analysis and, consequently, the Kaplan-Meier curves are omitted as well. The IPDfromKM method, developed in 2021, is an artificial intelligence algorithm designed to be used in these situations. According to this method, to keep the Kaplan-Meier curves in the meta-analysis, each curve is converted into a database of individual patients (which are denoted as "reconstructed" individual patients). In this way, for the purposes of the meta-analysis, the statistical methods are based on individual patients (like those of clinical trials) so that the Kaplan-Meier curves must not be excluded, and the effect of the follow-up can, therefore, be investigated. This technical report describes the IPDfromKM method in all of its operational details. To present the method, a meta-analysis investigating the effects of catheter ablation to prevent ventricular tachyarrhythmia (VT) has been taken as an example. The original meta-analysis, which included nine controlled trials, was published in February 2023 and adopted the simplified approach based on 2x2 contingency tables. We have reanalyzed these trials by using the IPDfromKM method. Overall, both the standard binary meta-analysis and the IPDfromKM method showed that ablation significantly reduces VT recurrence (hazard ratio, 0.820 for binary meta-analysis vs 0.728 for the IPDfromKM method). By contrast, while no heterogeneity was found by the binary method, the IPDfromKM found significant heterogeneity, which was confirmed by visual inspection of the Kaplan-Meier curves. This suggests that the results of the IPDfromKM method are more accurate because they include the effect of the follow-up on patients' outcomes. In conclusion, our reanalysis confirms the significant benefit determined by ablation, but a more pronounced degree of between-trial heterogeneity has been found. Finally, it should be stressed that, outside the field of meta-analysis, the IPDfromKM method is also applicable to carry out an indirect comparison between treatments that have never been compared in real clinical trials. In this case, reconstructed patients are analyzed by conducting a simulated comparative trial.
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Affiliation(s)
- Andrea Messori
- Health Technology Assessment (HTA) Unit, Tuscany Regional Health Care System, Firenze, ITA
| | - Valeria Fadda
- Pharmacology and Therapeutics, Ente di Supporto Tecnico Amministrativo Regionale (ESTAR), Firenze, ITA
| | - Maria R Romeo
- Health Policy, Fondazione Toscana Gabriele Monasterio, Massa, ITA
| | | | - Sabrina Trippoli
- Health Technology Assessment (HTA) Unit, Tuscany Regional Health Care System, Firenze, ITA
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Hyeraci G, Trippoli S, Rivano M, Messori A. Estimation of Value-Based Price for 48 High-Technology Medical Devices. Cureus 2023; 15:e39934. [PMID: 37287820 PMCID: PMC10243399 DOI: 10.7759/cureus.39934] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2023] [Indexed: 06/09/2023] Open
Abstract
Value-based price is estimated quite frequently for medicines, but its application to medical devices is scarce. While some reports have been published in which this parameter has occasionally been determined for devices, no large-scale application has yet been reported. Our objective was to pursue a systematic analysis of the literature published on value-based prices of medical devices. Pertinent papers were selected upon the criterion that the value-based price was reported for the device examined. The real prices of the devices were compared with their values of value-based price and the ratios between real price versus value-based price were calculated. A total of 239 economic articles focused on high-technology medical devices were selected from a standard PubMed search. Among these, the proportion of analyses unsuitable for value-based price estimation was high (191/239; 80%), whereas adequate clinical and economic information for estimating this parameter was available in 48 cases (20%). Standard equations of cost-effectiveness were applied. The value-based price was determined according to a willingness-to-pay threshold of 60,000 € per quality-adjusted life year. Real prices of devices were compared with the corresponding estimates of value-based prices. From each analysis, we extracted also the value of incremental cost-effectiveness ratio (ICER). Our final dataset included 47 analyses because one was published twice. There were five analyses in which the ICER could be estimated for the treatment, but not for the device. In the dataset of 42 analyses with complete information, 36 out of 42 devices (86%) were found to have an ICER lower than the pre-specified threshold (favorable ICER). Three ICERs were borderline. A separate analysis was conducted on the other three devices that showed an ICER substantially greater than the threshold (unfavorable ICER). Regarding value-based prices, the values of real price were appreciably lower than the corresponding value-based price in 36 cases (86%). For three devices, the real price was substantially higher than the value-based price. In the remaining three cases, real prices and value-based prices were very similar. To our knowledge, this is the first experience in which a systematic analysis of the literature has been focused on the application of value-based pricing in the field of high-technology devices. Our results are encouraging and suggest a wider application of cost-effectiveness in this field.
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Affiliation(s)
- Giulia Hyeraci
- Health Sciences, Agenzia Regionale Toscana, Firenze, ITA
| | - Sabrina Trippoli
- Health Technology Assessment (HTA) Unit, Regione Toscana, Firenze, ITA
| | | | - Andrea Messori
- Health Technology Assessment (HTA) Unit, Regione Toscana, Firenze, ITA
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Messori A, Trippoli S, Fadda V, Romeo MR. Managing Tenders in the Procurement of Advanced Medical Devices: An Original Model Based on the Net Monetary Benefit Combined With Three Clinical Endpoints. Cureus 2023; 15:e39062. [PMID: 37220569 PMCID: PMC10200267 DOI: 10.7759/cureus.39062] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2023] [Indexed: 05/25/2023] Open
Abstract
In medical devices, recent studies have proposed original approaches for standardizing competitive tenders with the aim of promoting reproducibility, avoiding discretional decisions, and applying value-based principles. In the framework of tenders' standardization, the net monetary benefit (NMB) method has attracted much interest, but its mathematical complexity has prevented a wide application. In the present work, we developed a procurement model that simplifies clinical information management for high-technology devices purchased for our public hospitals. Our objective was to promote the application of NMB in competitive tenders, particularly at the final stage of the procurement process, where the tender scores are determined. Software to facilitate this task in everyday practice has been developed. This software is made available through the present technical report. We surveyed the most relevant literature about NMB to select the main models commonly used in the studies published thus far. Standard equations of cost-effectiveness were identified. A simplified computation model based on three clinical endpoints was developed to estimate the NMB with less mathematical complexity. This model is proposed as an alternative to the standard approach based on a full economic analysis. The model developed herein has been implemented in a web-based software freely available on the Internet. This software is accompanied by a detailed description of the equations by which the NMB is estimated. A detailed application example is reported; a real tender carried out in 2021 has been re-examined for this purpose. In this re-analysis, the new software has been used to calculate the NMB of three devices. To our knowledge, this is the first experience in which an institution of the Italian healthcare system has evaluated the NMB as a tool for determining tender scores. The model is designed to offer performance similar to a full economic analysis. Our preliminary results are encouraging and suggest a wider application of this method. This approach has important implications regarding cost-effectiveness and cost containment because a value-based procurement is known to maximize effectiveness without determining an increase in costs.
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Affiliation(s)
- Andrea Messori
- Health Technology Assessment (HTA) Unit, Regione Toscana, Firenze, ITA
| | - Sabrina Trippoli
- Health Technology Assessment (HTA) Unit, Regione Toscana, Firenze, ITA
| | | | - Maria Rita Romeo
- Biomedical Engineering, Fondazione Toscana Gabriele Monasterio, Pisa, ITA
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Affiliation(s)
| | - Sabrina Trippoli
- Pharmaceutical Sciences, Regione Toscana, Firenze, Toscana, Italy
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Messori A, Trippoli S. Estimation of Value-Based Price for Five High-Technology Medical Devices Approved by a Regional Health Technology Assessment Committee in Italy. Cureus 2022; 14:e24695. [PMID: 35663657 PMCID: PMC9162886 DOI: 10.7759/cureus.24695] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2022] [Indexed: 11/08/2022] Open
Abstract
Background and objectives Value-based pricing (VBP) is used quite frequently for medicines, but its application to medical devices is very limited. The objective of the present study was to conduct a pilot experience of systematic estimation of the value-based price of medical devices from the perspective of our national health system. Our experience was focused on high-technology devices (class IIb/III and active implantable). The objective was to evaluate the applicability of VBP in a real-world setting and to estimate the value-based price of devices in all cases where this estimation was feasible. Methods The dataset analysed in this work consists of 24 new devices approved consecutively in the Tuscany region over the period from January 2020 to December 2021. Since the calculation of value-based price requires the availability of a cost-effectiveness analysis, we searched for this information for each of these devices. The Cost-Effectiveness Analysis (CEA) Registry of Tufts Medical Center (US) and the health technology assessment (HTA) reports of our region were considered adequate sources of these data. Standard equations of cost-effectiveness were applied to determine the value-based price for these devices, and these prices were compared with the corresponding real prices charged in our region. Results We found adequate information for five devices (21%) out of the total of 24. In three of these cases, the published analysis taken as a reference was based on Markov modelling. The comparison between value-based prices and real prices generally showed an acceptable concordance, though with a couple of outliers. An important finding is that, in a large proportion of cases (79%), the information needed for this calculation was lacking. Conclusion To our knowledge, this is the first experience in which an institution of the healthcare system has tried a systematic application of VBP in the field of high-technology devices. Our results are encouraging and suggest a wider application of cost-effectiveness in this field.
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Messori A, Trippoli S. Current treatments for inoperable mesothelioma: indirect comparisons based on individual patient data reconstructed retrospectively from 4 trials. J Chemother 2022; 35:158-162. [PMID: 35411826 DOI: 10.1080/1120009x.2022.2061183] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
In inoperable pleural mesothelioma, pemetrexed + cisplatin as first line is considered the standard of care, but novel treatments have been recently proposed. Our objective was to comparatively examine the information on overall survival (OS) with these new agents. The Shiny technique was employed for reconstructing individual patient data. Cox statistics was run to estimate hazard ratios (HRs). After a standard literature search, four new treatments were identified (nivolumab + ipilimumab, bevacizumab + pemetrexed + cisplatin, pembrolizumab monotherapy, and durvalumab + pemetrexed + cisplatin). Pemetrexed + ciplatin was the treatment for controls. Nivolumab + ipilimumab and bevacizumab + pemetrexed + cisplatin showed a better OS compared with controls (HR, 0.79 and 0.79, respectively; p < 0.05). Pembrolizumab determined only a numerical improvement (p > 0.05). In contrast, OS worsened with durvalumab + pemetrexed + cisplatin. Our analysis indicates that the novel treatments for inoperable mesothelioma have similar efficacy and, in general, provide a small though significant survival benefit compared with standard of care. Further research is needed to identify agents determining a more substantial OS improvement.
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Trippoli S, Messori A, Borselli G, Autieri F, Mamone D, Marinai C. Relationship Between Price and Diagnosis-Related Group Tariff for Medical Devices Assessed by a Regional Health Technology Assessment Committee. Cureus 2022; 14:e23092. [PMID: 35308183 PMCID: PMC8920792 DOI: 10.7759/cureus.23092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction Medical devices (MDs) make up an important share of total in-hospital expenditure. At the level of individual patients, this share is represented by the ratio of the cost of MD incurred by the patient vs. the total cost of in-hospital care for the same patient. If tariffs rather than costs are considered, the denominator of this ratio is given by the diagnosis-related group (DRG) and the ratio is the cost of MD over DRG tariff. The objective of this paper is to present a retrospective analysis comparing the ratio of price vs. DRG tariff for a group of devices belonging to risk class III or active implantable. These devices are those assessed in the years 2020 and 2021 by two committees of the Tuscany region in Italy. Materials and methods The information on price and DRG was taken from the health technology assessment (HTA) reports concerning MDs evaluated by the two above-mentioned regional committees in the years 2020 and 2021. In these reports, the information on the cost-effectiveness ratio was reported for a subset of MDs. In all cases, a preliminary qualitative assessment was carried out to determine the presence or absence of a healthcare impact in the post-discharge phase. In these preliminary analyses, the perspective of NHS was adopted. Results Our analysis was focused on 24 devices of either class III or active implantable. According to our results, a wide variability was found in the ratios between device price and DRG associated with its use. This ratio ranged from a minimum of about 3% in the case of the Hyalobarrier gel (Nordic Pharma GmbH, Zürich, Switzerland) for post-surgical adhesion to a maximum of 132% in the case of the Neovasc Reducer (EPS Vascular AB, Viken, Sweden), a device indicated in the narrowed coronary sinus. Three devices, i.e., PuraStat (3-D Matrix, Ltd., Tokyo, Japan), Ascyrus Medical Dissection Stent (AMDS, CryoLife, Inc., Kennesaw, GA), and Tendyne (Abbott Cardiovascular, Plymouth, MN), were found to be priced more than the reimbursement tariff (i.e., ratio > 100%). Ratios between 50% and 100% were found in about half of the devices. From our preliminary assessment on the presence of a post-discharge impact, 15 devices out of 24 (62%) were found to determine a substantial impact, while the remaining nine (38%) did not. In general, when costs and benefits of a device do not extend beyond the patients’ discharge, the presence of a ratio > 100% reliably suggests the conclusion that the device price needs to be reduced and/or the tariff needs to be increased. On the other hand, in cases where the device extends its impact beyond the patient’s hospital stay, the decision of reducing price or increasing tariff becomes more complex, and so these adjustments cannot be determined unless more information on some critical aspects is made available. Conclusions Until the above-mentioned improvements do not take place, rational interventions on DRG are virtually unfeasible owing to this lack of critical information. On the other hand, it is also difficult to intervene on device prices, again owing to the lack of critical information.
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Trippoli S, Di Spazio L, Chiumente M, Messori A. Medical Therapy, Radiofrequency Ablation, or Cryoballoon Ablation as First-Line Treatment for Paroxysmal Atrial Fibrillation: Interpreting Efficacy Through the Shiny Method. Cureus 2022; 14:e22645. [PMID: 35237496 PMCID: PMC8882246 DOI: 10.7759/cureus.22645] [Citation(s) in RCA: 2] [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] [Accepted: 02/27/2022] [Indexed: 01/22/2023] Open
Abstract
In patients with paroxysmal atrial fibrillation, cryoballoon ablation (CBA) and radiofrequency ablation (RFA) represent two therapeutic approaches supported by increasing literature. While both these ablation techniques play a role during different stages of the patient’s therapeutic pathway, their use as first-line is being increasingly recognized. This scoping review comparatively examined the evidence of effectiveness for these two ablation techniques. Our analysis was limited to the evaluation of the end-point of time to recurrence of atrial fibrillation (or other forms of atrial arrhythmias), which was the primary end-point in most clinical trials. The method used for pooling the information from clinical trials (Shiny method) is original and based on an artificial intelligence (AI) method that reconstructs individual patient data from published Kaplan-Meier time-to-event curves. Because a network meta-analysis has been published on this same clinical material, one objective of the present work was to compare the meta-analytic results with those generated by the Shiny method. A standard literature search was conducted on PubMed/Medline. Only randomized studies comparing CBA versus medical therapy, RFA versus medical therapy, or CBA versus RFA in previously untreated patients were eligible. Trials presenting a Kaplan-Meier curve to present the above-mentioned end-point were included. Patient-level data were reconstructed by application of the Shiny method. These individual patient data were then analyzed by standard statistical testing based on hazard ratio (HR) for risk of recurrence and medians of time to recurrence. Our analysis compared the two ablation treatments and medical therapy. A total of five trials were identified through our literature search. Information from these trials was pooled according to the three treatments (CBA: three trials, n = 365; RFA: two trials, n = 99; medical therapy: five trials, n = 457). CBA showed higher effectiveness than medical therapy (HR, 0.51; 95% confidence interval (CI): 0.38 to 0.67). In comparison with medical therapy, RFA showed a numerical trend that remained far from statistical significance (HR, 0.89; 95% CI: 0.62 to 1.27). Medians for time to recurrence were 14.1 months (95% CI: 10.0 to not reached) for RFA and 11.5 months (95% CI: 9.3 to 25.3) for medical therapy. This parameter was not reached for CBA. The current evidence from five randomized trials suggests that CBA ranks first in effectiveness, followed by RFA and medical therapy. In our comparison between the results generated by the Shiny method with those published in the previous meta-analysis, the Shiny method confirmed its ability to account for the length of follow-up in individual trials, whereas the meta-analytic approach confirmed its ability to account for the effects of randomizations performed in the trials.
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Affiliation(s)
- Sabrina Trippoli
- Health Technology Assessment Unit, Regione Toscana, Firenze, ITA
| | - Lorenzo Di Spazio
- Hospital Pharmacy Department, Santa Chiara Trento Hospital, Trento, ITA
| | - Marco Chiumente
- Scientific Direction, Società Italiana di Farmacia Clinica e Terapia (SIFaCT), Milano, ITA
| | - Andrea Messori
- Health Technology Assessment Unit, Regione Toscana, Firenze, ITA
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Messori A, Bartoli L, Ferracane E, Trippoli S. Medical therapy, radiofrequency ablation or cryoballoon ablation as first-line treatment for paroxysmal atrial fibrillation: interpreting efficacy through restricted mean survival time and network meta-analysis. Rev Cardiovasc Med 2021; 22:557-561. [PMID: 34565059 DOI: 10.31083/j.rcm2203067] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 08/17/2021] [Accepted: 08/25/2021] [Indexed: 11/06/2022] Open
Abstract
When multiple treatments are available, network meta-analysis can evaluate data to rank the relative effectiveness. We applied this approach to first-line treatments for paroxysmal atrial fibrillation (medical therapy, radiofrequency ablation or cryoballoon ablation). Individual trials were analysed based on the restricted mean survival time (RMST). Randomised controlled trials (RCT) assessing first-line treatments for paroxysmal atrial fibrillation were referenced from PubMed and the websites of regulatory agencies. The primary end-point was atrial fibrillation recurrence-free survival at 12 months. The treatments assessed for their relative effectiveness were medical therapy, radiofrequency ablation and cryoballoon ablation. Individual trials were examined based on RMST. A Bayesian network meta-analysis was conducted to comparatively evaluate these treatments. Five trials were included in the analysis: two compared radiofrequency with medical treatment and three cryoballoon ablation with medical treatment. The indirect comparison of radiofrequency ablation vs cryoballoon ablation was assessed in the absence of RCTs. Differences in RMST (with 95% credible intervals) were estimated for all binary comparisons (direct or indirect). Radiofrequency and cryoballoon ablation showed significantly increased effectiveness compared with medical treatment. In the indirect comparison, radiofrequency showed a non-significant advantage over cryoballoon ablation. The ranking of effectiveness was as follows: (1) radiofrequency; (2) cryoballoon ablation; (3) medical treatment. In conclusion, we found that radiofrequency was the most effective treatment for paroxysmal atrial fibrillation according to a Bayesian probabilistic model.
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Affiliation(s)
- Andrea Messori
- Heath Technology Assessment TA Unit and Ente Supporto Tecnico Amministrativo, Regional Health Service, 50100 Firenze, Italy
| | - Laura Bartoli
- Heath Technology Assessment TA Unit and Ente Supporto Tecnico Amministrativo, Regional Health Service, 50100 Firenze, Italy
| | - Elisa Ferracane
- Heath Technology Assessment TA Unit and Ente Supporto Tecnico Amministrativo, Regional Health Service, 50100 Firenze, Italy
| | - Sabrina Trippoli
- Heath Technology Assessment TA Unit and Ente Supporto Tecnico Amministrativo, Regional Health Service, 50100 Firenze, Italy
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Messori A, Bartoli L, Ferracane E, Trippoli S. "Real-world" endovascular versus surgical arteriovenous fistula economic evaluation: Can clinical outcomes and use of resources be derived from different countries? J Vasc Access 2021; 24:515. [PMID: 34296647 DOI: 10.1177/11297298211029554] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Andrea Messori
- Regional Group for Evaluation of Medical Devices, Regional Health System, Regione Toscana, Firenze, Italy
| | - Laura Bartoli
- Regional Group for Evaluation of Medical Devices, Regional Health System, Regione Toscana, Firenze, Italy
| | - Elisa Ferracane
- Regional Group for Evaluation of Medical Devices, Regional Health System, Regione Toscana, Firenze, Italy
| | - Sabrina Trippoli
- Regional Group for Evaluation of Medical Devices, Regional Health System, Regione Toscana, Firenze, Italy
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Fadda V, Bartoli L, Ferracane E, Trippoli S, Messori A. Simplified figure to present direct and indirect comparisons: Revisiting the graph 10 years later. World J Methodol 2021; 11:228-230. [PMID: 34322372 PMCID: PMC8299911 DOI: 10.5662/wjm.v11.i4.228] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 05/09/2021] [Accepted: 05/27/2021] [Indexed: 02/06/2023] Open
Abstract
A “simplified” figure was proposed in 2011 to summarize the results of controlled trials that evaluate different treatments aimed at the same disease condition. The original criteria for classifying individual binary comparisons included superiority, inferiority and no significance difference; hence, they did not differentiate between no proof of difference vs proof of no difference. We updated the criteria employed in the original “simplified” figure in order to include this differentiation. A revised version of the simplified figure is proposed and described herein. An example of application is also presented. The example is focused on first-line treatments for paroxysmal atrial fibrillation. Three treatments (medical therapy, cryoballoon ablation, radiofrequency ablation) are compared with one another through direct and indirect comparisons.
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Messori A, Bartoli L, Chiumente M, Mengato D, Trippoli S. The Restricted Mean Survival Time as a Tool for Ranking Comparative Outcomes in a Narrative Review that Evaluates a Network of Randomized Trials: An Example Based on PCSK9 Inhibitors. Am J Cardiovasc Drugs 2021; 21:349-354. [PMID: 33030677 DOI: 10.1007/s40256-020-00444-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/22/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION On the basis of two randomized trials, evolocumab and alirocumab have been approved in patients with cardiovascular disease. The evidence on these two agents has been studied through different methods of analysis that span from narrative approaches to network meta-analysis. In the present study, we assessed the performance of a narrative approach combined with the application of the restricted mean survival time (RMST). METHODS We studied the two pivotal placebo-controlled trials focused on evolocumab and alirocumab. Our original framework of comparative assessment employed the RMST. Our objective was to show that in the context of a narrative review, the RMST can be an efficient although simple tool to make indirect comparisons. The endpoint was event-free survival, expressed in months. RESULTS For each cohort of patients (13,784 patients administered evolocumab, 9462 patients administered alirocumab, 23,242 controls), we determined the RMST values with 95% confidence intervals (CI) [evolocumab: 33.60 months, 95% CI 33.46-33.74; alirocumab: 34.07 months, 95% CI 33.92-34.22]. These results, along with those of the control groups, were analyzed and interpreted narratively. Univariate statistics were conducted, but no network meta-analysis was performed. CONCLUSION The experience presented herein indicates that a framework of evidence assessment focused on the RMST is a worthwhile option. Our study is in line with the growing literature that has recently emphasized the methodological advantages of the RMST.
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Messori A, Bartoli L, Trippoli S. The restricted mean survival time as a replacement for the hazard ratio and the number needed to treat in long-term studies. ESC Heart Fail 2021; 8:2345-2348. [PMID: 33733623 PMCID: PMC8120383 DOI: 10.1002/ehf2.13306] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 01/03/2021] [Accepted: 03/02/2021] [Indexed: 12/11/2022] Open
Abstract
Aims We applied the restricted mean survival time (RMST) to analyse the survival data reported in the PARADIGM‐HT trial in which sacubitril + valsartan was studied in comparison with enalapril in patients with heart failure. The estimates of this parameter were compared with the published values of hazard ratio (HR). Methods Two endpoints were evaluated: a composite of death or hospitalization and cardiovascular death. Our analyses were performed by considering the original follow‐up of 41.4 months and on the basis of a lifetime perspective. All statistical calculations were carried out using specific packages developed under the R‐platform. Results According to our RMST analysis, the results for the composite endpoint in the comparison of sacubitril + valsartan vs. enalapril showed an improvement from 32.9 to 34.2 months (gain of 1.25 months). This result is based on a time horizon of 41.4 months. The results for the cardiovascular mortality endpoint showed a RMST of 37.2 months for sacubitril + valsartan vs. 36.2 for enalapril (gain of 0.96 months). In the two lifetime analyses, the improvements were much more relevant and yielded a gain of 25.8 months for the composite endpoint and 27.6 months for survival free from cardiovascular death. Conclusions Using the data of the PARADIGM‐HT trial, our analysis confirmed that the RMST has documented advantages over the HR, particularly when the clinical study is characterized by a long follow‐up. The number needed to treat (NNT) has a more specific methodological role and cannot be replaced by the RMST.
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Affiliation(s)
- Andrea Messori
- HTA Unit, Toscana Region Health Service, Florence, Toscana Region, Italy
| | - Laura Bartoli
- HTA Unit, Toscana Region Health Service, Florence, Toscana Region, Italy
| | - Sabrina Trippoli
- HTA Unit, Toscana Region Health Service, Florence, Toscana Region, Italy
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Messori A, Angileri M, Chiumente M, Agnoletto L, Baldo P, Bartoli L, Cirino M, Damuzzo V, Ferracane E, Giron MC, Laudisio C, Mengato D, Palozzo AC, Trippoli S. SARS-COV-2 pandemic: establishing three risk levels for 19 Italian regions and two autonomous provinces. Eur J Hosp Pharm 2021; 29:e3. [PMID: 33558220 PMCID: PMC9047933 DOI: 10.1136/ejhpharm-2021-002692] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
| | - Manuela Angileri
- Hospital Pharmacy, Azienda Sanitaria di Firenze, Firenze, Toscana, Italy
| | | | - Laura Agnoletto
- Hospital Pharmacy, Azienda ULSS 5 Polesana, Rovigo, Veneto, Italy
| | - Paolo Baldo
- Hospital Pharmacy, Centro di Riferimento Oncologico, Aviano, Italy
| | | | - Mario Cirino
- Hospital Pharmacy, Azienda Sanitaria Universitaria Giuliano Isontina, Presidio Ospedale Maggiore, Trieste, Italy
| | - Vera Damuzzo
- Pharmaceutical Sciences, Universita degli Studi di Padova, Padova, Veneto, Italy
| | | | - M Cecilia Giron
- Department of Pharmaceutical Sciences, Universita degli Studi di Padova, Padova, Veneto, Italy
| | - Carolina Laudisio
- Pharmacy, Azienda Sanitaria Locale Salerno, Salerno, Campania, Italy
| | | | - Angelo Claudio Palozzo
- Presidency, SIFaCT President, Italian Society for Clinical Pharmacy and Therapy, Milano, Milano, Italy
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Messori A, Trippoli S, Marinai C. The role of medical devices in influencing in-hospital sustainability: an analysis of expenditure in 2019 vs DRG reimbursement according to major medical specialties in a region of middle Italy. Expert Rev Med Devices 2020; 17:1013-1016. [DOI: 10.1080/17434440.2020.1787828] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Messori A, Bartoli L, Trippoli S. Adjuvant treatments in biliary tract cancer: an analysis based on restricted mean survival time. Dig Liver Dis 2020; 52:1208-1209. [PMID: 32505564 DOI: 10.1016/j.dld.2020.05.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 05/14/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Andrea Messori
- HTA Unit, Toscana Region Health Service, Toscana Region, Florence, Italy.
| | - Laura Bartoli
- HTA Unit, Toscana Region Health Service, Toscana Region, Florence, Italy
| | - Sabrina Trippoli
- HTA Unit, Toscana Region Health Service, Toscana Region, Florence, Italy
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Messori A, Bartoli L, Trippoli S. Outcomes at 5 years in patients with severe aortic stenosis: reviewing current information using the restricted mean survival time. Am J Cardiovasc Dis 2020; 10:136-141. [PMID: 32923094 PMCID: PMC7486527] [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] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 08/01/2020] [Indexed: 06/11/2023]
Abstract
The information about outcomes at 5 years in patients receiving transcatheter aortic valve replacement (TAVR) has grown. We interpreted the information on this topic using the restricted mean survival time (RMST). The purpose of our study was to summarise the current evidence using an original outcome measure with potential methodological advantages. Four cohorts of patients, previously published in the literature, met our criterion of 5 years of follow-up after the implant; another cohort was identified from a group of controls subjected to surgical replacement of the valve. The estimated values of RMST at 5 years for the 5 patient cohorts were the following (N = number of patients, all time values in years): a) real-world high surgical risk cohort: N = 114, RMST = 3.80; b) real-world cohort treated with Corevalve: N = 309, RMST = 3.79; c) a real-world cohort treated with Sapien: N = 180, RMST = 3.61; d) TAVR arm of a randomized trial in intermediate risk patients: N = 1,011; RMST = 3.73; e) surgical replacement arm of the same trial: N = 1,021, RMST = 3.72. The main result of our analysis based on the RMST is represented by the extreme homogeneity of the outcomes (RMSTs ranging from 3.61 to 3.80 years per patient) that remained virtually constant irrespective of the baseline risk of the patients (intermediate or high risk) and regardless of whether the intervention was transcatheter or by surgical replacement. Last but not least, our analysis showed the good methodological performance of the RMST in this disease condition.
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Affiliation(s)
- Andrea Messori
- HTA Unit, Toscana Region Health Service Toscana Region, Florence, Italy
| | - Laura Bartoli
- HTA Unit, Toscana Region Health Service Toscana Region, Florence, Italy
| | - Sabrina Trippoli
- HTA Unit, Toscana Region Health Service Toscana Region, Florence, Italy
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Messori A, Trippoli S, Caccese E, Marinai C. Tenders for the Procurement of Medical Devices: Adapting Cost-Effectiveness Rules to the Requirements of the European Public Procurement Directive. Ther Innov Regul Sci 2020; 54:226-231. [PMID: 32008234 DOI: 10.1007/s43441-019-00049-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 08/29/2018] [Accepted: 12/26/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND In evaluating 3 or more comparators, pharmacoeconomic analyses can be improved by using the methodology of net monetary benefit (NMB) as opposed to incremental cost-effectiveness ratio (ICER). NMB is particularly suitable for managing competitive tenders that evaluate 3 or more devices in the same lot. For scientific purposes, the methodology of NMB is perfectly adequate. However, when tenders are managed in European countries, the Public Procurement Directive states that the tender score for price should be kept separate from that of clinical benefits. As a result, the traditional mathematical approach of NMB must be rearranged to comply with this administrative requirement. METHODS In this report, we describe how the classic equations of NMB should be modified to achieve this purpose. The mathematical principle of proportionality, which is typical of the ICER, must be replaced by the principle of mathematical additivity, which is typical of NMB. Furthermore, to rearrange the scale of benefits according to the NMB, an estimate is needed of the minimum acceptable benefit converted into monetary units, which is associated with 0 in the benefit scale. RESULTS A detailed example is presented to explain the practical application of these mathematical equations. These equations are widely applicable in the field of implantable devices. CONCLUSION Since the expenditure for medical devices in European hospitals is close to that of hospital medicines, tenders for the in-hospital procurement of devices may represent a decisive tool to manage sustainability and ensure access to innovation. In this context, the methodology for managing clinical outcomes through tenders requires a specific mathematical approach that we have described in the present article.
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Affiliation(s)
- Andrea Messori
- HTA Unit, ESTAR and University of Florence, Regional Health System, Via di San Salvi 12, 50100, Florence, Italy.
| | - Sabrina Trippoli
- HTA Unit, ESTAR and University of Florence, Regional Health System, Via di San Salvi 12, 50100, Florence, Italy
| | - Erminia Caccese
- HTA Unit, ESTAR and University of Florence, Regional Health System, Via di San Salvi 12, 50100, Florence, Italy
| | - Claudio Marinai
- HTA Unit, ESTAR and University of Florence, Regional Health System, Via di San Salvi 12, 50100, Florence, Italy
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Messori A, Attanasio F, Trippoli S, Banfi R. Orphan drugs. Lancet 2019; 393:1595. [PMID: 31007198 DOI: 10.1016/s0140-6736(19)30015-7] [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] [Received: 07/23/2018] [Accepted: 12/17/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Andrea Messori
- Sector of Pharmaceutics, Regional Health Service, Regione Toscana, 50135 Firenze, Italy.
| | - Francesco Attanasio
- Sector of Pharmaceutics, Regional Health Service, Regione Toscana, 50135 Firenze, Italy
| | - Sabrina Trippoli
- Sector of Pharmaceutics, Regional Health Service, Regione Toscana, 50135 Firenze, Italy
| | - Roberto Banfi
- Sector of Pharmaceutics, Regional Health Service, Regione Toscana, 50135 Firenze, Italy
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Messori A, Trippoli S, Caccese E, Marinai C. Tenders for the Procurement of Medical Devices: Adapting Cost-Effectiveness Rules to the Requirements of the European Public Procurement Directive. Ther Innov Regul Sci 2019. [DOI: 10.1177/2168479018825131] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Andrea Messori
- HTA Unit, ESTAR and University of Florence, Florence, Italy
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Messori A, Trippoli S. Incremental Cost-Effectiveness Ratio and Net Monetary Benefit: Promoting the Application of Value-Based Pricing to Medical Devices-A European Perspective. Ther Innov Regul Sci 2018; 52:755-756. [PMID: 29714590 DOI: 10.1177/2168479018769300] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Andrea Messori
- 1 HTA Unit, ESTAR, University of Florence, Regional Health System, Firenze, Italy
| | - Sabrina Trippoli
- 1 HTA Unit, ESTAR, University of Florence, Regional Health System, Firenze, Italy
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Trippoli S, Caccese E, Tulli G, Ipponi P, Marinai C, Messori A. Biological meshes for abdominal hernia: Lack of evidence-based recommendations for clinical use. Int J Surg 2018; 52:278-284. [DOI: 10.1016/j.ijsu.2018.02.046] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 02/13/2018] [Accepted: 02/17/2018] [Indexed: 11/28/2022]
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Messori A, Peyvandi F, Trippoli S, Palla R, Rosendaal FR, Mannucci PM. High-titre inhibitors in previously untreated patients with severe haemophilia A receiving recombinant or plasma-derived factor VIII: a budget-impact analysis. Blood Transfus 2018; 16:215-220. [PMID: 28686156 PMCID: PMC5839620 DOI: 10.2450/2017.0352-16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Accepted: 03/29/2017] [Indexed: 11/21/2022]
Affiliation(s)
- Andrea Messori
- HTA Unit, ESTAR, Regional Health Service, Florence, Italy
| | - Flora Peyvandi
- ”A. Bianchi Bonomi” Haemophilia and Thrombosis Centre, “Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico”, Milan, Italy
- ”Luigi Villa” Foundation, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | | | - Roberta Palla
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Frits R. Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Pier Mannuccio Mannucci
- ”A. Bianchi Bonomi” Haemophilia and Thrombosis Centre, “Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico”, Milan, Italy
- ”Luigi Villa” Foundation, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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Messori A, Trippoli S, Marinai C. Handling the procurement of prostheses for total hip replacement: description of an original value based approach and application to a real-life dataset reported in the UK. BMJ Open 2017; 7:e018603. [PMID: 29259062 PMCID: PMC5778279 DOI: 10.1136/bmjopen-2017-018603] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES In most European countries, innovative medical devices are not managed according to cost-utility methods, the reason being that national agencies do not generally evaluate these products. The objective of our study was to investigate the cost-utility profile of prostheses for hip replacement and to calculate a value-based score to be used in the process of procurement and tendering for these devices. METHODS The first phase of our study was aimed at retrieving the studies reporting the values of QALYs, direct cost, and net monetary benefit (NMB) from patients undergoing total hip arthroplasty (THA) with different brands of hip prosthesis. The second phase was aimed at calculating, on the basis of the results of cost-utility analysis, a tender score for each device (defined according to standard tendering equations and adapted to a 0-100 scale). This allowed us to determine the ranking of each device in the simulated tender. RESULTS We identified a single study as the source of information for our analysis. Nine device brands (cemented, cementless, or hybrid) were evaluated. The cemented prosthesis Exeter V40/Elite Plus Ogee, the cementless device Taperloc/Exceed, and the hybrid device Exeter V40/Trident had the highest NMB (£152 877, £156 356, and £156 210, respectively) and the best value-based tender score. CONCLUSIONS The incorporation of value-based criteria in the procurement process can contribute to optimising the value for money for THA devices. According to the approach described herein, the acquisition of these devices does not necessarily converge on the product with the lowest cost; in fact, more costly devices should be preferred when their increased cost is offset by the monetary value of the increased clinical benefit.
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Abstract
Cost-effectiveness evaluations concerning devices for total knee arthroplasty (TKA) have little impact on real-life management of these devices. This study explored how pharmacoeconomic models can inform the procurement of TKA devices to improve their value for money. Our study included three phases: i) literature search for data of outcome, cost, and device type in TKA; ii) development of a Markov model predicting costs, QALYs, and net monetary benefit (NMB); iii) simulation of tenders aimed at value-based device procurement. Phases 1 and 2 were managed by selecting a single study as the source of data for our analysis. In Phase 3, each TKA device was associated with its values of NMB, and the tender scores were estimated. Finally, the ranking of each device in the simulated tender was determined. We identified a study published in 2016 as our source of data. Five devices were evaluated. For these devices, QALYs were 7.3952, 7.2939, 7.4952, 7.1919, 7.2930; NMB: £142,005, £140,653, £144,184, £138,040, £140,261; tender scores: 64.53, 42.53, 100, 0, 36.15, respectively. We showed that incorporating the principles of cost-effectiveness into the tendering process is feasible for TKA devices. This can maximize the value for money for these devices.
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Affiliation(s)
- Andrea Messori
- HTA Section, ESTAR Toscana, Regional Health Service, Firenze, Italy
| | - Sabrina Trippoli
- HTA Section, ESTAR Toscana, Regional Health Service, Firenze, Italy
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Abstract
The field of medical devices is characterized by a paucity of cost-effectiveness data that support their use. In this context, we have proposed a project based on the calculation of net monetary benefit (NMB) for each product subjected to procurement through tenders. This project consists of two steps: 1) calculation of NMB; 2) calculation of a value-based score to be used in the process of procurement and tendering. The NMB is defined as follows: NMB per patient= (monetary threshold of WTP) x (QALYs per patient) - (treatment cost per patient); WTP= willingness to pay]. Its main advantage is represented by the linear relation between NMB and unit price as opposed to the non-linear relationship that links the ICER to the unit price of the device. For all devices included in the same tender lot, our procedure firstly determines the valus of NMB and converts the NMB into a tender score determined on a 0-to-100 scale. The device with the worst pharmacoeconomic profile is assigned a tender score of 0 while the one with the best pharmacoeconomic profile is assigned a tender score of 100.
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Affiliation(s)
- Sabrina Trippoli
- Coordinamento HTA, Ente per i Servizi Tecnici Amministrativi della Regione Toscana, Firenze
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Trippoli S, Chiumente M, Messori A. Promoting the use of Markovian simulation models to study outcomes of thrombectomy after acute ischemic stroke. J Cardiovasc Med (Hagerstown) 2017; 18:777-779. [PMID: 28858948 DOI: 10.2459/jcm.0000000000000532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Sabrina Trippoli
- aHTA Unit, ESTAR, Regional Health Service, FlorencebItalian Society for Clinical Pharmacy and Therapeutics, Milan, Italy
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Trippoli S. Incremental cost-effectiveness ratio and net monetary benefit: Current use in pharmacoeconomics and future perspectives. Eur J Intern Med 2017; 43:e36. [PMID: 28552463 DOI: 10.1016/j.ejim.2017.05.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [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] [Received: 05/08/2017] [Accepted: 05/12/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Sabrina Trippoli
- HTA Section, ESTAR Toscana, Regional Health Service, Firenze, Italy.
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Messori A, Trippoli S, Marinai C. Effectiveness of interventions based on implantable devices: meta-analyses or systematic reviews that fail to indicate which device brands were used. ACTA ACUST UNITED AC 2017; 22:195. [PMID: 28851753 DOI: 10.1136/ebmed-2017-110802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Messori A, Trippoli S, Marinai C. Appraisal of Innovative Anticancer Agents: Do the Scores of European Society for Medical Oncology–Magnitude of Clinical Benefit Scale and American Society of Clinical Oncology Task Force Correlate With Survival Gains? J Clin Oncol 2017; 35:1132-1133. [DOI: 10.1200/jco.2016.69.2731] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Andrea Messori
- Andrea Messori, Sabrina Trippoli, and Claudio Marinai, Ente di Supporto Tecnico Amministrativo Regionale, Regional Health Service, Firenze, Italy
| | - Sabrina Trippoli
- Andrea Messori, Sabrina Trippoli, and Claudio Marinai, Ente di Supporto Tecnico Amministrativo Regionale, Regional Health Service, Firenze, Italy
| | - Claudio Marinai
- Andrea Messori, Sabrina Trippoli, and Claudio Marinai, Ente di Supporto Tecnico Amministrativo Regionale, Regional Health Service, Firenze, Italy
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Tulli G, Messori A, Trippoli S, Marinai C. Non-inferiority of colistin compared with standard care for the treatment of ventilator-associated pneumonia. Int J Antimicrob Agents 2017; 49:638-641. [PMID: 28365431 DOI: 10.1016/j.ijantimicag.2017.01.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [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: 06/04/2016] [Revised: 11/15/2016] [Accepted: 01/14/2017] [Indexed: 11/25/2022]
Abstract
This study examined the literature on the treatment of ventilator-associated pneumonia (VAP) using colistin or standard care (SC). Based on this clinical material, a meta-analysis was conducted and a non-inferiority test was performed. Studies were selected for inclusion based on the following criteria: (a) patients with VAP; (b) experimental arm based on intravenous or aerosolized colistin; and (c) control arm based on SC. The meta-analysis employed a fixed-effect model, and the endpoint was the rate of clinical response. No pre-specified non-inferiority threshold for the upper boundary of the 95% confidence interval was adopted; instead, the intention was to perform a retrospective evaluation of whether the threshold suggested by the results was acceptable on clinical grounds. In total, eight controlled studies were included. The pooled risk ratio was 1.019 for colistin compared with SC (95% confidence interval 0.895-1.16); this result corresponds to a non-significant 1.9% increase in cure rate with colistin compared with SC (range +16% to -10.5%). Heterogeneity was minimal (0%). The post-hoc non-inferiority threshold for colistin compared with SC was -10.5% in terms of relative cure rate (pooled risk ratio = 0.895). This margin was considered to be acceptable on clinical grounds. This analysis found that colistin can play a role in the treatment of VAP, particularly when given as a combination of aerosolized and intravenous drug.
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Affiliation(s)
- Giorgio Tulli
- Agenzia Sanitaria Toscana, Regional Health Service, Firenze, Italy
| | - Andrea Messori
- HTA Unit, ESTAR, Regional Health Service, Firenze, Italy.
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Messori A, Trippoli S, Marinai C. Network meta-analysis as a tool for improving the effectiveness assessment of biosimilars based on both direct and indirect evidence: application to infliximab in rheumatoid arthritis. Eur J Clin Pharmacol 2016; 73:513-514. [PMID: 27966035 DOI: 10.1007/s00228-016-2177-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 12/06/2016] [Indexed: 11/25/2022]
Affiliation(s)
- Andrea Messori
- HTA Unit, ESTAR Toscana, Regional Health Service, Via San Salvi 12, 50100, Florence, Italy.
| | - Sabrina Trippoli
- HTA Unit, ESTAR Toscana, Regional Health Service, Via San Salvi 12, 50100, Florence, Italy
| | - Claudio Marinai
- HTA Unit, ESTAR Toscana, Regional Health Service, Via San Salvi 12, 50100, Florence, Italy
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Maratea D, Fadda V, Trippoli S, Messori A. Economic analysis of not running tenders for recombinant Factor VIII procurement: a simplified analysis to estimate an otherwise unknown pharmacoeconomic index. Eur J Hosp Pharm 2016; 23:219-223. [PMID: 31156852 DOI: 10.1136/ejhpharm-2015-000728] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 11/17/2015] [Accepted: 11/23/2015] [Indexed: 11/04/2022] Open
Abstract
Background Two approaches to the procurement of recombinant Factor VIII products are used by health systems: (A) the most common approach where acquisition tenders are not carried out; (B) the approach tested in the UK in which procurement is based on tenders. The respective cost-effectiveness is not known. Objective To estimate the incremental cost-effectiveness ratio (ICER) for the comparison A vs B. Methods The analysis evaluated: (i) Factor VIII cost with/without tenders; (ii) inhibitor development caused by switching between products; (iii) clinical and economic consequences of inhibitors. Information on these items was obtained from a literature search. Because of the scarce evidence available on some items, our analysis considered the 'most favourable' scenario-that is, some extreme though reasonable assumptions were adopted that were intentionally biased towards improving the ICER of the no-tender option. Results and discussion We estimated an ICER for A vs B of £486 409 (€657 139; £1=€1.351) per quality-adjusted life year (QALY). Since pharmacoeconomic thresholds are ∼£30 000 per QALY, our results indicate that the cost-effectiveness of acquisition strategies that avoid tenders is prohibitive. Because of the simplified nature of our analysis, this estimate is preliminary. Conclusions The 'true' ICER of A vs B remains unknown, but its value is likely to be even worse than the unfavourable ICER of £486 409 (€657 139) per QALY.
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Affiliation(s)
- Dario Maratea
- HTA Unit, ESTAV Toscana Centro, Regional Health Service, Firenze, Italy
| | - Valeria Fadda
- HTA Unit, ESTAV Toscana Centro, Regional Health Service, Firenze, Italy
| | - Sabrina Trippoli
- HTA Unit, ESTAV Toscana Centro, Regional Health Service, Firenze, Italy
| | - Andrea Messori
- HTA Unit, ESTAV Toscana Centro, Regional Health Service, Firenze, Italy
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Messori A, Trippoli S, Fadda V, Maratea D. Producing evidence in support of disinvestment: The experience of the Tuscany region in Italy. Eur J Intern Med 2016; 28:e18-9. [PMID: 26563936 DOI: 10.1016/j.ejim.2015.10.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 10/23/2015] [Accepted: 10/27/2015] [Indexed: 11/17/2022]
Affiliation(s)
| | | | - Valeria Fadda
- HTA Unit, Regional Health System, 50135 Firenze, Italy
| | - Dario Maratea
- HTA Unit, Regional Health System, 50135 Firenze, Italy
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Chiumente M, Trippoli S, Messori A. Differences in Effectiveness among Devices for Endovascular Thrombectomy in Patients with Acute Ischemic Stroke. J Stroke 2016; 18:230-2. [PMID: 26915502 PMCID: PMC4901945 DOI: 10.5853/jos.2015.01662] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 12/25/2015] [Accepted: 01/06/2016] [Indexed: 12/05/2022] Open
Affiliation(s)
- Marco Chiumente
- Italian Society for Clinical Pharmacy and Therapeutics, Milano, Italy
| | - Sabrina Trippoli
- HTA Unit, ESTAV Toscana Centro, Regional Health Service, Firenze, Italy
| | - Andrea Messori
- HTA Unit, ESTAV Toscana Centro, Regional Health Service, Firenze, Italy
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Messori A, Trippoli S. Left Atrial Appendage Occlusion Devices Versus Pharmacological Agents for Stroke Prevention in Atrial Fibrillation. J Am Coll Cardiol 2015; 66:2056-2058. [DOI: 10.1016/j.jacc.2015.07.080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 07/07/2015] [Accepted: 07/13/2015] [Indexed: 10/22/2022]
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Messori A, Fadda V, Maratea D, Trippoli S. Comparative effectiveness of treatments for newly diagnosed follicular non-Hodgkin lymphoma. Leuk Lymphoma 2015; 56:2728-30. [DOI: 10.3109/10428194.2015.1006219] [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: 11/13/2022]
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Messori A, Trippoli S. Infections in Patients Receiving Subcutaneous Biological Treatments for Moderate to Severe Psoriasis. Drugs Real World Outcomes 2015; 2:319-321. [PMID: 27747575 PMCID: PMC4883222 DOI: 10.1007/s40801-015-0040-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Trippoli S, Fadda V, Maratea D, Messori A. Bayesian network meta-analysis to evaluate interferon-free treatments in naive patients with genotype 1 hepatitis C virus infection. Eur J Gastroenterol Hepatol 2015; 27:983-4. [PMID: 26114910 DOI: 10.1097/meg.0000000000000389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 12/10/2022]
Affiliation(s)
- Sabrina Trippoli
- HTA Unit, ESTAV Toscana Centro, Regional Health Service, Firenze, Italy
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Messori A, Fadda V, Maratea D, Trippoli S, Marinai C. Biological drugs for inducing remission in patients with Crohn's disease: determining statistical equivalence according to evidence-based methods. Arch Med Sci 2015; 11:458-60. [PMID: 25995767 PMCID: PMC4424265 DOI: 10.5114/aoms.2015.50980] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Revised: 03/03/2014] [Accepted: 03/31/2014] [Indexed: 11/17/2022] Open
Affiliation(s)
| | - Valeria Fadda
- Regional Health System, ESTAV, HTA Unit, Firenze, Italy
| | - Dario Maratea
- Regional Health System, ESTAV, HTA Unit, Firenze, Italy
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Messori A, Fadda V, Maratea D, Trippoli S. First-line treatments for chronic lymphocytic leukaemia: interpreting efficacy data by network meta-analysis. Ann Hematol 2015; 94:1003-9. [PMID: 25677267 DOI: 10.1007/s00277-015-2310-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 01/27/2015] [Indexed: 10/24/2022]
Abstract
When multiple treatments are available, network meta-analysis can synthesize evidence and rank relative effectiveness. We applied this approach to current treatments for previously untreated chronic lymphocytic leukaemia. Data search was conducted in PubMed and websites of regulatory agencies (year 2000 through present time). Our analysis included randomized controlled trials assessing treatments for previously untreated chronic lymphocytic leukaemia. The endpoint of the analysis was the rate of progression-free survival at 3 years. At least two reviewers abstracted study data and outcomes. Agents examined for their relative effectiveness included four monotherapies (chlorambucil, fludarabine, bendamustine, alemtuzumab) and four combination treatments (cyclophosphamide + fludarabine, cyclophosphamide + cladribine, cyclophosphamide + fludarabine + rituximab, cyclophosphamide + fludarabine + alemtuzumab). A Bayesian network meta-analysis was conducted to comparatively evaluate these treatments. Nine trials (3620 patients) were included in the analysis. Odds ratio (with 95 % credible intervals) was estimated for all direct and indirect comparisons. Combinations treatments were found to be significantly more effective than single-agent treatments. Ranking in effectiveness was as follows: (1) cyclophosphamide + fludarabine + rituximab, (2) alemtuzumab, (3) cyclophosphamide + fludarabine + alemtuzumab, (4) cyclophosphamide + fludarabine and (at same ranking) cyclophosphamide + cladribine, (6) fludarabine, (7) bendamustine and (8) chlorambucil. Bendamustine fared worse in our analysis than in its pivotal trial. Overall, the estimated rankings appeared to be robust according to probabilistic analysis. Numerous indirect comparisons were assessed in the absence of RCTs. In conclusion, we generated an updated synthesis of the effectiveness of these treatments and we ranked them according to a Bayesian probabilistic model. In our probabilistic analysis, cyclophosphamide + fludarabine + rituximab ranked first in the base case while the worst-case scenario of this analysis placed this treatment at a remarkable second place.
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Affiliation(s)
- Andrea Messori
- HTA Unit, ESTAV Toscana Centro, Regional Health Service, 50100, Firenze, Italy,
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Fadda V, Maratea D, Trippoli S, Messori A. Gastrointestinal and renal side effects of bisphosphonates: differentiating between no proof of difference and proof of no difference. J Endocrinol Invest 2015; 38:189-92. [PMID: 25412945 DOI: 10.1007/s40618-014-0211-5] [Citation(s) in RCA: 5] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 11/10/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND This study was aimed at comparing the safety of bisphosphonates in women with osteoporosis by application of equivalence testing. METHODS Gastrointestinal and renal side effects were evaluated based on information published in randomized controlled trials. RESULTS The data on gastrointestinal side effects (47 trials) indicated that alendronate, risedronate etidronate, and zolendronate have similar rates of the adverse effects; application of Bayesian network meta-analysis showed that equivalence was demonstrated according to margins around ±10%. The data on renal safety were more sparse and suffered from the use of different outcome measures; hence, a single trial could be evaluated. This trial showed a similar effect of alendronate and risedronate on renal function at 12 months; equivalence was based on differences between the two agents in renal function with margins of less than ±10.4 ml/min. CONCLUSION Our study provided quantitative information to determine to what extent bisphosphonates can be considered equivalent in terms of gastrointestinal and renal side effects.
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Affiliation(s)
- V Fadda
- HTA unit, Area Vasta Centro Toscana, Regional Health System, Via San Salvi 12, 50100, Florence, Italy
| | - D Maratea
- HTA unit, Area Vasta Centro Toscana, Regional Health System, Via San Salvi 12, 50100, Florence, Italy
| | - S Trippoli
- HTA unit, Area Vasta Centro Toscana, Regional Health System, Via San Salvi 12, 50100, Florence, Italy
| | - A Messori
- HTA unit, Area Vasta Centro Toscana, Regional Health System, Via San Salvi 12, 50100, Florence, Italy.
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Messori A, Trippoli S, Fadda V, Maratea D, Marinai C. Subcutaneous Biological Treatments for Moderate to Severe Psoriasis: Interpreting Safety Data by Network Meta-Analysis. Drugs Real World Outcomes 2015; 2:23-27. [PMID: 27747609 PMCID: PMC4883196 DOI: 10.1007/s40801-014-0006-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND When multiple treatments are available, network meta-analysis can synthesize evidence and rank their relative profile in terms of effectiveness and/or safety. We applied this approach to the safety of subcutaneous biologicals used in the treatment of moderate to severe psoriasis. METHODS Our literature search covered the articles published from January 2000 to September 2014 and was restricted to randomized controlled trials. The agents eligible for our analysis were subcutaneous biological drugs used in patients with moderate to severe psoriasis. A network meta-analysis was conducted using the Bayesian model. The analysis was aimed to compare the safety of these treatments based on 95 % credible intervals and to consequently generate a ranking in safety across the treatments. Two safety end-points were considered: any serious adverse events (AE) and any infectious AE. Risk difference was the outcome measure. The analysis estimated 95 % credible intervals for all direct and indirect comparisons as well as the ranking histogram across the treatments which was determined according to model-based probabilistic analysis. RESULTS Our literature search selected a total of 13 randomized controlled trials of which three evaluated adalimumab, five ustekinumab (45 and 90 mg), four etanercept (both high-dose and low-dose) and one high-dose etanercept and ustekinumab (45 and 90 mg). For both end-points of any serious AE and any infectious AE, the Bayesian analysis showed no significant difference in all indirect head-to-head comparisons between active agents. For the end-point of any serious AE, the ranking was ustekinumab 45 mg and ustekinumab 90 mg (at the same rank), followed by placebo and by adalimumab and high-dose etanercept (at the same rank). For any infectious AE, the ranking was: low-dose etanercept, placebo, ustekinumab 45 mg and ustekinumab 90 mg, adalimumab and high-dose etanercept. CONCLUSION Our analysis synthesized the current evidence on the safety of subcutaneous biological treatments for patients with moderate to severe psoriasis and was successful in defining their respective rankings.
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Affiliation(s)
- Andrea Messori
- HTA Unit, ESTAV Toscana Centro, Regional Health Service, 50100, Florence, Italy. .,HTA Unit, ESTAV Centro, Area Vasta Centro Toscana, Regional Health System, Via Guimaraes 9-11, 59100, Prato, Italy.
| | - Sabrina Trippoli
- HTA Unit, ESTAV Toscana Centro, Regional Health Service, 50100, Florence, Italy
| | - Valeria Fadda
- HTA Unit, ESTAV Toscana Centro, Regional Health Service, 50100, Florence, Italy
| | - Dario Maratea
- HTA Unit, ESTAV Toscana Centro, Regional Health Service, 50100, Florence, Italy
| | - Claudio Marinai
- HTA Unit, ESTAV Toscana Centro, Regional Health Service, 50100, Florence, Italy
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Messori A, Fadda V, Maratea D, Trippoli S, Gatto R, De Rosa M, Marinai C. Biological drugs for the treatment of rheumatoid arthritis by the subcutaneous route: interpreting efficacy data to assess statistical equivalence. Ther Adv Musculoskelet Dis 2014; 6:207-16. [PMID: 25435923 DOI: 10.1177/1759720x14554792] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND No equivalence analysis has yet been conducted on the effectiveness of biologics in rheumatoid arthritis. Equivalence testing has a specific scientific interest, but can also be useful for deciding whether acquisition tenders are feasible for the pharmacological agents being compared. METHODS Our search covered the literature up to August 2014. Our methodology was a combination of standard pairwise meta-analysis, Bayesian network meta-analysis and equivalence testing. The agents examined for their potential equivalence were etanercept, adalimumab, golimumab, certolizumab, and tocilizumab, each in combination with methotrexate (MTX). The reference treatment was MTX monotherapy. The endpoint was ACR50 achievement at 12 months. Odds ratio was the outcome measure. The equivalence margins were established by analyzing the statistical power data of the trials. RESULTS Our search identified seven randomized controlled trials (2846 patients). No study was retrieved for tocilizumab, and so only four biologics were evaluable. The equivalence range was set at odds ratio from 0.56 to 1.78. There were 10 head-to-head comparisons (4 direct, 6 indirect). Bayesian network meta-analysis estimated the odds ratio (with 90% credible intervals) for each of these comparisons. Between-trial heterogeneity was marked. According to our results, all credible intervals of the 10 comparisons were wide and none of them satisfied the equivalence criterion. A superiority finding was confirmed for the treatment with MTX plus adalimumab or certolizumab in comparison with MTX monotherapy, but not for the other two biologics. CONCLUSION Our results indicate that these four biologics improved the rates of ACR50 achievement, but there was an evident between-study heterogeneity. The head-to-head indirect comparisons between individual biologics showed no significant difference, but failed to demonstrate the proof of no difference (i.e. equivalence). This body of evidence presently precludes any option of undertaking competitive tenderings for the procurement of these agents.
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Affiliation(s)
- Andrea Messori
- HTA Unit, Area Vasta Centro Toscana, Regional Health System, Via San Salvi 12, 50100 Firenze, Italy
| | - Valeria Fadda
- HTA Unit, ESTAV Toscana Centro, Regional Health Service, Firenze, Italy
| | - Dario Maratea
- HTA Unit, ESTAV Toscana Centro, Regional Health Service, Firenze, Italy
| | - Sabrina Trippoli
- HTA Unit, ESTAV Toscana Centro, Regional Health Service, Firenze, Italy
| | - Roberta Gatto
- HTA Unit, ESTAV Toscana Centro, Regional Health Service, Firenze, Italy
| | - Mauro De Rosa
- President, SIFACT, Italian Society for Clinical Pharmacy and Therapeutics, Milano, Italy
| | - Claudio Marinai
- Department of Pharmaceutical Logistics, ESTAV Toscana Centro, Regional Health Service, Firenze, Italy
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