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van Hezik-Wester V, de Groot S, Kanters T, Wagner L, Ardesch J, Brouwer W, Corro Ramos I, le Cessie S, Versteegh M, van Exel J. Effectiveness of Seizure Dogs for People With Severe Refractory Epilepsy: Results From the EPISODE Study. Neurology 2024; 102:e209178. [PMID: 38417090 PMCID: PMC11033982 DOI: 10.1212/wnl.0000000000209178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 12/04/2023] [Indexed: 03/01/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The aim of this study was to evaluate whether people living with severe medically refractory epilepsy (PSRE) benefit from a seizure dog. METHODS An individual-level stepped-wedge randomized controlled trial was conducted. The study was conducted in the Netherlands among adults with daily to weekly seizures. All participants were included simultaneously (on June 1, 2019) while receiving usual care. Then, during the 36-month follow-up, they received a seizure dog in a randomized sequence. Participants kept a seizure diary and completed 3-monthly surveys. Seizure frequency was the primary outcome. Secondary outcomes included seizure-free days, seizure severity, health-related quality of life (HRQoL), and well-being. Data were analyzed using generalized linear mixed modeling (GLMM). The models assumed a delayed intervention effect, starting when the seizure dog reached an advanced stage of training. Effects were calculated as changes per 28-day period with the intervention. RESULTS Data were collected from 25 participants, of whom 20 crossed over to the intervention condition. The median follow-up was 19 months with usual care and 12 months with the intervention. On average, participants experienced 115 (SD 164) seizures per 28-day period in the usual care condition and 73 (SD 131) seizures in the intervention condition. Seven participants achieved a reduction of 50% or more at the end of follow-up. GLMM indicated a 3.1% decrease in seizure frequency for each consecutive 28-day period with the intervention (0.969, 95% CI 0.960-0.977). Furthermore, an increase in the number of seizure-free days was observed (1.012, 95% CI 1.009, 1.015), but no effect on seizure severity measured with the NHS3. Generic HRQoL scores improved, as reflected in the decrease in EQ-5D-5L utility decrement (0.975, 95% CI 0.954-0.997). Smaller improvements were observed on overall self-rated HRQoL, epilepsy-specific HRQoL, and well-being, measured with the EQ VAS, QOLIE-31-P, and ICECAP-A, respectively. DISCUSSION Seizure dogs reduce seizure frequency, increase the number of seizure-free days, and improve the quality of life of PSRE. The magnitude of the effect on generic HRQoL indicates that seizure dogs benefit PSRE beyond the impact on seizure frequency alone. Early discontinuation of seizure dog partnerships suggests that this intervention is not suitable for all PSRE and requires further study. TRIAL REGISTRATION INFORMATION This study was registered in the Dutch Trial Register (NL6682) on November 28, 2017. Participants were enrolled on June 1, 2019. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that seizure dogs are associated with a decrease in seizure frequency in adult patients with medically refractory epilepsy.
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Affiliation(s)
- Valérie van Hezik-Wester
- From the Erasmus School of Health Policy & Management (ESHPM) (V.H.-W., S.G., T.K., W.B., I.C.R., M.V., J.E.), Institute for Medical Technology Assessment (iMTA) (V.H.-W., S.G., T.K., I.C.R., M.V.), and Erasmus Centre for Health Economics Rotterdam (EsCHER) (V.H.-W., S.G., T.K., W.B., I.C.R., M.V., J.E.), Erasmus University Rotterdam; Academic Center for Epileptology Kempenhaeghe (L.W.), Heeze; Stichting Epilepsie Instellingen Nederland (SEIN) (J.A.), Heemstede; Leiden University Medical Center (S.C.); Huygens & Versteegh (M.V.), Zwijndrecht, the Netherlands
| | - Saskia de Groot
- From the Erasmus School of Health Policy & Management (ESHPM) (V.H.-W., S.G., T.K., W.B., I.C.R., M.V., J.E.), Institute for Medical Technology Assessment (iMTA) (V.H.-W., S.G., T.K., I.C.R., M.V.), and Erasmus Centre for Health Economics Rotterdam (EsCHER) (V.H.-W., S.G., T.K., W.B., I.C.R., M.V., J.E.), Erasmus University Rotterdam; Academic Center for Epileptology Kempenhaeghe (L.W.), Heeze; Stichting Epilepsie Instellingen Nederland (SEIN) (J.A.), Heemstede; Leiden University Medical Center (S.C.); Huygens & Versteegh (M.V.), Zwijndrecht, the Netherlands
| | - Tim Kanters
- From the Erasmus School of Health Policy & Management (ESHPM) (V.H.-W., S.G., T.K., W.B., I.C.R., M.V., J.E.), Institute for Medical Technology Assessment (iMTA) (V.H.-W., S.G., T.K., I.C.R., M.V.), and Erasmus Centre for Health Economics Rotterdam (EsCHER) (V.H.-W., S.G., T.K., W.B., I.C.R., M.V., J.E.), Erasmus University Rotterdam; Academic Center for Epileptology Kempenhaeghe (L.W.), Heeze; Stichting Epilepsie Instellingen Nederland (SEIN) (J.A.), Heemstede; Leiden University Medical Center (S.C.); Huygens & Versteegh (M.V.), Zwijndrecht, the Netherlands
| | - Louis Wagner
- From the Erasmus School of Health Policy & Management (ESHPM) (V.H.-W., S.G., T.K., W.B., I.C.R., M.V., J.E.), Institute for Medical Technology Assessment (iMTA) (V.H.-W., S.G., T.K., I.C.R., M.V.), and Erasmus Centre for Health Economics Rotterdam (EsCHER) (V.H.-W., S.G., T.K., W.B., I.C.R., M.V., J.E.), Erasmus University Rotterdam; Academic Center for Epileptology Kempenhaeghe (L.W.), Heeze; Stichting Epilepsie Instellingen Nederland (SEIN) (J.A.), Heemstede; Leiden University Medical Center (S.C.); Huygens & Versteegh (M.V.), Zwijndrecht, the Netherlands
| | - Jacqueline Ardesch
- From the Erasmus School of Health Policy & Management (ESHPM) (V.H.-W., S.G., T.K., W.B., I.C.R., M.V., J.E.), Institute for Medical Technology Assessment (iMTA) (V.H.-W., S.G., T.K., I.C.R., M.V.), and Erasmus Centre for Health Economics Rotterdam (EsCHER) (V.H.-W., S.G., T.K., W.B., I.C.R., M.V., J.E.), Erasmus University Rotterdam; Academic Center for Epileptology Kempenhaeghe (L.W.), Heeze; Stichting Epilepsie Instellingen Nederland (SEIN) (J.A.), Heemstede; Leiden University Medical Center (S.C.); Huygens & Versteegh (M.V.), Zwijndrecht, the Netherlands
| | - Werner Brouwer
- From the Erasmus School of Health Policy & Management (ESHPM) (V.H.-W., S.G., T.K., W.B., I.C.R., M.V., J.E.), Institute for Medical Technology Assessment (iMTA) (V.H.-W., S.G., T.K., I.C.R., M.V.), and Erasmus Centre for Health Economics Rotterdam (EsCHER) (V.H.-W., S.G., T.K., W.B., I.C.R., M.V., J.E.), Erasmus University Rotterdam; Academic Center for Epileptology Kempenhaeghe (L.W.), Heeze; Stichting Epilepsie Instellingen Nederland (SEIN) (J.A.), Heemstede; Leiden University Medical Center (S.C.); Huygens & Versteegh (M.V.), Zwijndrecht, the Netherlands
| | - Isaac Corro Ramos
- From the Erasmus School of Health Policy & Management (ESHPM) (V.H.-W., S.G., T.K., W.B., I.C.R., M.V., J.E.), Institute for Medical Technology Assessment (iMTA) (V.H.-W., S.G., T.K., I.C.R., M.V.), and Erasmus Centre for Health Economics Rotterdam (EsCHER) (V.H.-W., S.G., T.K., W.B., I.C.R., M.V., J.E.), Erasmus University Rotterdam; Academic Center for Epileptology Kempenhaeghe (L.W.), Heeze; Stichting Epilepsie Instellingen Nederland (SEIN) (J.A.), Heemstede; Leiden University Medical Center (S.C.); Huygens & Versteegh (M.V.), Zwijndrecht, the Netherlands
| | - Saskia le Cessie
- From the Erasmus School of Health Policy & Management (ESHPM) (V.H.-W., S.G., T.K., W.B., I.C.R., M.V., J.E.), Institute for Medical Technology Assessment (iMTA) (V.H.-W., S.G., T.K., I.C.R., M.V.), and Erasmus Centre for Health Economics Rotterdam (EsCHER) (V.H.-W., S.G., T.K., W.B., I.C.R., M.V., J.E.), Erasmus University Rotterdam; Academic Center for Epileptology Kempenhaeghe (L.W.), Heeze; Stichting Epilepsie Instellingen Nederland (SEIN) (J.A.), Heemstede; Leiden University Medical Center (S.C.); Huygens & Versteegh (M.V.), Zwijndrecht, the Netherlands
| | - Matthijs Versteegh
- From the Erasmus School of Health Policy & Management (ESHPM) (V.H.-W., S.G., T.K., W.B., I.C.R., M.V., J.E.), Institute for Medical Technology Assessment (iMTA) (V.H.-W., S.G., T.K., I.C.R., M.V.), and Erasmus Centre for Health Economics Rotterdam (EsCHER) (V.H.-W., S.G., T.K., W.B., I.C.R., M.V., J.E.), Erasmus University Rotterdam; Academic Center for Epileptology Kempenhaeghe (L.W.), Heeze; Stichting Epilepsie Instellingen Nederland (SEIN) (J.A.), Heemstede; Leiden University Medical Center (S.C.); Huygens & Versteegh (M.V.), Zwijndrecht, the Netherlands
| | - Job van Exel
- From the Erasmus School of Health Policy & Management (ESHPM) (V.H.-W., S.G., T.K., W.B., I.C.R., M.V., J.E.), Institute for Medical Technology Assessment (iMTA) (V.H.-W., S.G., T.K., I.C.R., M.V.), and Erasmus Centre for Health Economics Rotterdam (EsCHER) (V.H.-W., S.G., T.K., W.B., I.C.R., M.V., J.E.), Erasmus University Rotterdam; Academic Center for Epileptology Kempenhaeghe (L.W.), Heeze; Stichting Epilepsie Instellingen Nederland (SEIN) (J.A.), Heemstede; Leiden University Medical Center (S.C.); Huygens & Versteegh (M.V.), Zwijndrecht, the Netherlands
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de Groot S, Santi I, Bakx P, Wouterse B, van Baal P. Informal Care Costs According to Age and Proximity to Death to Support Cost-Effectiveness Analyses. Pharmacoeconomics 2023; 41:1137-1149. [PMID: 36725787 PMCID: PMC10450016 DOI: 10.1007/s40273-022-01233-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/19/2022] [Indexed: 06/18/2023]
Abstract
BACKGROUND Costs of informal care are ignored in many cost-effectiveness analyses (CEAs) conducted from a societal perspective; however, these costs are relevant for lifesaving interventions targeted at the older population. In this study, we estimated informal care costs by age and proximity to death across European regions and showed how these estimates can be included in CEAs. METHODS We estimated informal care costs by age and proximity to death using generalised linear mixed-effects models. For this, we selected deceased singles from the Survey of Health, Ageing and Retirement, which we grouped by four European regions. We combined the estimates of informal care costs with life tables to illustrate the impact of including informal care costs on the incremental cost-effectiveness ratio (ICER) of a hypothetical intervention that prevents a death at different ages. RESULTS Informal care use, and hence informal care costs, increase when approaching death and with increasing age. The impact of including informal care costs on the ICER varies between €200 and €17,700 per quality-adjusted life-year gained. The impact increases with age and is stronger for women and in southern European countries. CONCLUSION Our estimates of informal care costs facilitate including informal care costs in CEAs of life-extending healthcare interventions. Including these costs may influence decisions as it leads to reranking of life-extending interventions compared with interventions improving quality of life.
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Affiliation(s)
- Saskia de Groot
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands.
| | - Irene Santi
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Pieter Bakx
- Department of Health Economics, Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Bram Wouterse
- Department of Health Economics, Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Pieter van Baal
- Department of Health Economics, Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
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van Hezik-Wester V, de Groot S, Kanters T, Versteegh M, Wagner L, Ardesch J, Brouwer W, van Exel J. Burden of illness in people with medically refractory epilepsy who suffer from daily to weekly seizures: 12-month follow-up of participants in the EPISODE study. Front Neurol 2022; 13:1012486. [PMID: 36388190 PMCID: PMC9650114 DOI: 10.3389/fneur.2022.1012486] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 09/28/2022] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND A small group of people with epilepsy suffers from frequent seizures despite the available pharmacological and non-pharmacological interventions. The impact of epilepsy on these people extends beyond health-related quality of life (HRQoL), impacting a person's broader well-being and ability to participate in society. This study describes the burden of medically refractory epilepsy in people who suffer from daily to weekly seizures, in terms of HRQoL, well-being, and societal costs. METHODS Data from the EPISODE study on (cost-) effectiveness of seizure dogs for adults with severe medically refractory epilepsy were used, collected in 25 patients during the first 12 months before they were partnered with a certified seizure dog. Data comprised seizure diaries covering 365 days and five three-monthly surveys, including the EQ-5D-5L, QOLIE-31-P, and ICECAP-A to measure HRQoL and well-being. A societal perspective was applied to estimate costs using the iMCQ and iPCQ questionnaires about healthcare use, informal care, and productivity losses. RESULTS Daily seizure frequency and survey data were collected in 25 patients. A minimum of 114 observations was available for each instrument included in the survey. A total of 80% of participants experienced seizures on three or more days per week, with a median ranging from 1 to 17 seizures per seizure day. The mean EQ-5D-5L utility score was 0.682 (SD 0.235), which is considerably lower than the age-adjusted general population average. The mean QOLIE-31-P and ICECAP-A scores were 55.8 (SD 14.0) and 0.746 (SD 0.172), respectively. The average annual total cost amounted to €39,956 (range €3,804-€132,64). Informal care accounted for the largest share of costs (50%); those who received informal care reported, on average, 26 h per week (SD 30). CONCLUSIONS Severe medically refractory epilepsy is associated with a considerable burden of illness at the patient and societal level. People with this condition have significantly reduced HRQoL and well-being and are limited in their ability to work while having substantial medical costs and a strong dependency on informal care.
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Affiliation(s)
- Valérie van Hezik-Wester
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, Netherlands
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Saskia de Groot
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, Netherlands
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Tim Kanters
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, Netherlands
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Matthijs Versteegh
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, Netherlands
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Louis Wagner
- Kempenhaeghe and MUMC+, Academic Centre for Epileptology, Heeze, Netherlands
| | | | - Werner Brouwer
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, Netherlands
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Job van Exel
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, Netherlands
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Klein P, Blommestein H, Al M, Pongiglione B, Torbica A, de Groot S. Real-world evidence in health technology assessment of high-risk medical devices: Fit for purpose? Health Econ 2022; 31 Suppl 1:10-24. [PMID: 35989520 PMCID: PMC9541731 DOI: 10.1002/hec.4575] [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] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 06/30/2022] [Accepted: 07/01/2022] [Indexed: 06/15/2023]
Abstract
Health technology assessment (HTA) of medical devices (MDs) increasingly rely on real-world evidence (RWE). The aim of this study was to evaluate the type and the quality of the evidence used to assess the (cost-)effectiveness of high risk MDs (Class III) by HTA agencies in Europe (four European HTA agencies and EUnetHTA), with particular focus on RWE. Data were extracted from HTA reports on the type of evidence demonstrating (cost-)effectiveness, and the quality of observational studies of comparative effectiveness using the Good Research for Comparative Effectiveness principles. 25 HTA reports were included that incorporated 28 observational studies of comparative effectiveness. Half of the studies (46%) took important confounding and/or effect modifying variables into account in the design and/or analyses. The most common way of including confounders and/or effect modifiers was through multivariable regression analysis. Other methods, such as propensity score matching, were rarely employed. Furthermore, meaningful analyses to test key assumptions were largely omitted. Resulting recommendations from HTA agencies on MDs is therefore (partially) based on evidence which is riddled with uncertainty. Considering the increasing importance of RWE it is important that the quality of observational studies of comparative effectiveness are systematically assessed when used in decision-making.
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Affiliation(s)
- Philip Klein
- Institute for Medical Technology AssessmentErasmus University RotterdamRotterdamNetherlands
| | - Hedwig Blommestein
- Erasmus School of Health Policy & ManagementErasmus University RotterdamRotterdamNetherlands
| | - Maiwenn Al
- Erasmus School of Health Policy & ManagementErasmus University RotterdamRotterdamNetherlands
| | - Benedetta Pongiglione
- Centre for Research on Health and Social Care Management (CERGAS)Bocconi UniversityMilanItaly
| | - Aleksandra Torbica
- Centre for Research on Health and Social Care Management (CERGAS)Bocconi UniversityMilanItaly
| | - Saskia de Groot
- Institute for Medical Technology AssessmentErasmus University RotterdamRotterdamNetherlands
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Wester V, de Groot S, Versteegh M, Kanters T, Wagner L, Ardesch J, Brouwer W, van Exel J. Good Days and Bad Days: Measuring Health-Related Quality of Life in People With Epilepsy. Value Health 2021; 24:1470-1475. [PMID: 34593170 DOI: 10.1016/j.jval.2021.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 03/25/2021] [Accepted: 05/03/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES Cost-effectiveness analyses typically require measurement of health-related quality of life (HRQoL) to estimate quality-adjusted life-years. Challenges with measuring HRQoL arise in the context of episodic conditions if patients are less likely-or even unable-to complete surveys when having disease symptoms. This article explored whether HRQoL measured at regular time intervals adequately reflects the HRQoL of people with epilepsy (PWE). METHODS Follow-up data from the Epilepsy Support Dog Evaluation study on the (cost-)effectiveness of seizure dogs were used in which HRQoL is measured in 25 PWE with the EQ-5D at baseline and every 3 months thereafter. Seizure count is recorded daily using a seizure diary. Regression models were employed to explore whether PWE were more likely to complete the HRQoL survey on a good day (ie, when seizures are absent or low in frequency compared with other days) and to provide an estimate of the impact of reporting HRQoL on a good day on EQ-5D utility scores. RESULTS A total of 111 HRQoL measurements were included in the analyses. Regression analyses indicated that the day of reporting HRQoL was associated with a lower seizure count (P<.05) and that a lower seizure count was associated with a higher EQ-5D utility score (P<.05). CONCLUSIONS When HRQoL is measured at regular time intervals, PWE seem more likely to complete these surveys on good days. Consequently, HRQoL might be overestimated in this population. This could lead to underestimation of the effectiveness of treatment and to biased estimates of cost-effectiveness.
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Affiliation(s)
- Valérie Wester
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands; Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands.
| | - Saskia de Groot
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Matthijs Versteegh
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Tim Kanters
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Louis Wagner
- Kempenhaeghe and MUMC+, Academic Center for Epileptology, Heeze, The Netherlands
| | | | - Werner Brouwer
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands; Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Job van Exel
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
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Ciani O, Grigore B, Blommestein H, de Groot S, Möllenkamp M, Rabbe S, Daubner-Bendes R, Taylor RS. Validity of Surrogate Endpoints and Their Impact on Coverage Recommendations: A Retrospective Analysis across International Health Technology Assessment Agencies. Med Decis Making 2021; 41:439-452. [PMID: 33719711 PMCID: PMC8108112 DOI: 10.1177/0272989x21994553] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 01/21/2021] [Indexed: 12/03/2022]
Abstract
BACKGROUND Surrogate endpoints (i.e., intermediate endpoints intended to predict for patient-centered outcomes) are increasingly common. However, little is known about how surrogate evidence is handled in the context of health technology assessment (HTA). OBJECTIVES 1) To map methodologies for the validation of surrogate endpoints and 2) to determine their impact on acceptability of surrogates and coverage decisions made by HTA agencies. METHODS We sought HTA reports where evaluation relied on a surrogate from 8 HTA agencies. We extracted data on the methods applied for surrogate validation. We assessed the level of agreement between agencies and fitted mixed-effects logistic regression models to test the impact of validation approaches on the agency's acceptability of the surrogate endpoint and their coverage recommendation. RESULTS Of the 124 included reports, 61 (49%) discussed the level of evidence to support the relationship between the surrogate and the patient-centered endpoint, 27 (22%) reported a correlation coefficient/association measure, and 40 (32%) quantified the expected effect on the patient-centered outcome. Overall, the surrogate endpoint was deemed acceptable in 49 (40%) reports (k-coefficient 0.10, P = 0.004). Any consideration of the level of evidence was associated with accepting the surrogate endpoint as valid (odds ratio [OR], 4.60; 95% confidence interval [CI], 1.60-13.18, P = 0.005). However, we did not find strong evidence of an association between accepting the surrogate endpoint and agency coverage recommendation (OR, 0.71; 95% CI, 0.23-2.20; P = 0.55). CONCLUSIONS Handling of surrogate endpoint evidence in reports varied greatly across HTA agencies, with inconsistent consideration of the level of evidence and statistical validation. Our findings call for careful reconsideration of the issue of surrogacy and the need for harmonization of practices across international HTA agencies.
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Affiliation(s)
- Oriana Ciani
- />Centre for Research on Health and Social Care Management, SDA Bocconi, Milan, Lombardia, Italy
- />Evidence Synthesis & Modelling for Health Improvement, University of Exeter Medical School, Exeter, Devon, UK
| | - Bogdan Grigore
- Evidence Synthesis & Modelling for Health Improvement, University of Exeter Medical School, Exeter, Devon, UK
| | - Hedwig Blommestein
- Institute for Medical Technology Assessment, Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Saskia de Groot
- Institute for Medical Technology Assessment, Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Meilin Möllenkamp
- Hamburg Center for Health Economics, Universität Hamburg, Hamburg, Germany
| | - Stefan Rabbe
- Hamburg Center for Health Economics, Universität Hamburg, Hamburg, Germany
| | - Rita Daubner-Bendes
- />Syreon Research Institute, Budapest, Hungary
- />MRC/CSO Social and Public Health Sciences Unit & Robertson Centre for Biostatistics, Institute of Health and Well Being, University of Glasgow, Glasgow, Scotland, UK
| | - Rod S. Taylor
- />Evidence Synthesis & Modelling for Health Improvement, University of Exeter Medical School, Exeter, Devon, UK
- />MRC/CSO Social and Public Health Sciences Unit & Robertson Centre for Biostatistics, Institute of Health and Well Being, University of Glasgow, Glasgow, Scotland, UK
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Grigore B, Ciani O, Dams F, Federici C, de Groot S, Möllenkamp M, Rabbe S, Shatrov K, Zemplenyi A, Taylor RS. Surrogate Endpoints in Health Technology Assessment: An International Review of Methodological Guidelines. Pharmacoeconomics 2020; 38:1055-1070. [PMID: 32572825 DOI: 10.1007/s40273-020-00935-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
In the drive towards faster patient access to treatments, health technology assessment (HTA) agencies are increasingly faced with reliance on evidence from surrogate endpoints, leading to increased decision uncertainty. This study undertook an updated survey of methodological guidance for using surrogate endpoints across international HTA agencies. We reviewed HTA and economic evaluation methods guidance from European, Australian and Canadian HTA agencies. We considered how guidelines addressed the methods for handling surrogate endpoints, including (1) level of evidence, (2) methods of validation, and (3) thresholds of acceptability. Across the 73 HTA agencies surveyed, 29 (40%) had methodological guidelines that made specific reference to consideration of surrogate outcomes. Of the 45 methods documents analysed, the majority [27 (60%)] were non-technology specific, 15 (33%) focused on pharmaceuticals and three (7%) on medical devices. The principles of the European network for Health Technology Assessment (EUnetHTA) guidelines published in 2015 on the handling of surrogate endpoints appear to have been adopted by many European HTA agencies, i.e. preference for final patient-relevant outcomes and reliance on surrogate endpoints with biological plausibility and epidemiological evidence of the association between the surrogate and final endpoint. Only a small number of HTA agencies (UK National Institute for Care and Excellence; the German Institute for Medical Documentation and Information and Institute for Quality and Efficiency in Health Care; the Australian Pharmaceutical Benefits Advisory Committee; and the Canadian Agency for Drugs and Technologies in Health) have developed more detailed prescriptive criteria for the acceptance of surrogate endpoints, e.g. meta-analyses of randomised controlled trials showing strong association between the treatment effect on the surrogate and final outcomes. As the decision uncertainty associated with reliance on surrogate endpoints carries a risk to patients and society, there is a need for HTA agencies to develop more detailed methodological guidance for consistent selection and evaluation of health technologies that lack definitive final patient-relevant outcome evidence at the time of the assessment.
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Affiliation(s)
- Bogdan Grigore
- Evidence Synthesis and Modelling for Health Improvement, College of Medicine and Health, Institute of Health Research, University of Exeter, Exeter, UK.
| | - Oriana Ciani
- Evidence Synthesis and Modelling for Health Improvement, College of Medicine and Health, Institute of Health Research, University of Exeter, Exeter, UK
- Center for Research on Health and Social Care Management, SDA Bocconi, Milan, Italy
| | - Florian Dams
- KPM Center for Public Management, University of Bern, Bern, Switzerland
| | - Carlo Federici
- Center for Research on Health and Social Care Management, SDA Bocconi, Milan, Italy
| | - Saskia de Groot
- Institute for Medical Technology Assessment, Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Meilin Möllenkamp
- Hamburg Center for Health Economics, Universität Hamburg, Hamburg, Germany
| | - Stefan Rabbe
- Hamburg Center for Health Economics, Universität Hamburg, Hamburg, Germany
| | - Kosta Shatrov
- KPM Center for Public Management, University of Bern, Bern, Switzerland
| | - Antal Zemplenyi
- Syreon Research Institute, Budapest, Hungary
- Division of Pharmacoeconomics, Faculty of Pharmacy, University of Pécs, Pécs, Hungary
| | - Rod S Taylor
- Evidence Synthesis and Modelling for Health Improvement, College of Medicine and Health, Institute of Health Research, University of Exeter, Exeter, UK
- MRC/CSO Social and Public Health Sciences Unit and Robertson Centre for Biostatistics, Institute of Health and Well Being, University of Glasgow, Glasgow, Scotland
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Wester V, de Groot S, Kanters T, Wagner L, Ardesch J, Corro Ramos I, Enders-Slegers MJ, de Ruiter M, le Cessie S, Los J, Papageorgiou G, van Exel J, Versteegh M. Evaluating the Effectiveness and Cost-Effectiveness of Seizure Dogs in Persons With Medically Refractory Epilepsy in the Netherlands: Study Protocol for a Stepped Wedge Randomized Controlled Trial (EPISODE). Front Neurol 2020; 11:3. [PMID: 32038471 PMCID: PMC6987301 DOI: 10.3389/fneur.2020.00003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 01/03/2020] [Indexed: 11/23/2022] Open
Abstract
Background: Epilepsy is associated with a high disease burden, impacting the lives of people with epilepsy and their caregivers and family. Persons with medically refractory epilepsy experience the greatest burden, suffering from profound physical, psychological, and social consequences. Anecdotal evidence suggests these persons may benefit from a seizure dog. As the training of a seizure dog is a substantial investment, their accessibility is limited in the absence of collective reimbursement as is seen in the Netherlands. Despite sustained interest in seizure dogs, scientific knowledge on their benefits and costs remains scarce. To substantiate reimbursement decisions stronger evidence is required. The EPISODE study aims to provide this evidence by evaluating the effectiveness and cost-effectiveness of seizure dogs in adults with medically refractory epilepsy. Methods: The study is designed as a stepped wedge randomized controlled trial that compares the use of seizure dogs in addition to usual care, with usual care alone. The study includes adults with epilepsy for whom current treatment options failed to achieve seizure freedom. Seizure frequency of participants should be at least two seizures per week, and the seizures should be associated with a high risk of injury or dysfunction. During the 3 year follow-up period, participants receive a seizure dog in a randomized order. Outcome measures are taken at multiple time points both before and after receiving the seizure dog. Seizure frequency is the primary outcome of the study and will be recorded continuously using a seizure diary. Questionnaires measuring seizure severity, quality of life, well-being, resource use, productivity, social participation, and caregiver burden will be completed at baseline and every 3 months thereafter. The study is designed to include a minimum of 25 participants. Discussion: This protocol describes the first randomized controlled trial on seizure dogs. The study will provide comprehensive data on the effectiveness and cost-effectiveness of seizure dogs in adults with medically refractory epilepsy. Broader benefits of seizure dogs for persons with epilepsy and their caregivers are taken into account, as well as the welfare of the dogs. The findings of the study can be used to inform decision-makers on the reimbursement of seizure dogs.
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Affiliation(s)
- Valérie Wester
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, Netherlands.,Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Saskia de Groot
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Tim Kanters
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Louis Wagner
- Kempenhaeghe & MUMC+, Academic Centre for Epileptology, Heeze, Netherlands
| | | | - Isaac Corro Ramos
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Marie-Jose Enders-Slegers
- Faculty of Psychology, Open University, Heerlen, Netherlands.,Institute for Anthrozoology, Ammerzoden, Netherlands
| | | | - Saskia le Cessie
- Department of Clinical Epidemiology and Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, Netherlands
| | - Jeanine Los
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, Netherlands
| | | | - Job van Exel
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Matthijs Versteegh
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, Netherlands
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Büyükkaramikli NC, de Groot S, Riemsma R, Fayter D, Armstrong N, Portegijs P, Duffy S, Kleijnen J, Al MJ. Ribociclib with an Aromatase Inhibitor for Previously Untreated, HR-Positive, HER2-Negative, Locally Advanced or Metastatic Breast Cancer: An Evidence Review Group Perspective of a NICE Single Technology Appraisal. Pharmacoeconomics 2019; 37:141-153. [PMID: 30194622 PMCID: PMC6386053 DOI: 10.1007/s40273-018-0708-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
The National Institute for Health and Care Excellence, as part of the institute's single technology appraisal process, invited the manufacturer of ribociclib (Kisqali®, Novartis) to submit evidence regarding the clinical and cost effectiveness of the drug in combination with an aromatase inhibitor for the treatment of previously untreated, hormone receptor-positive, human epidermal growth factor receptor 2-negative, locally advanced or metastatic breast cancer. Kleijnen Systematic Reviews Ltd and Erasmus University Rotterdam were commissioned as the Evidence Review Group for this submission. The Evidence Review Group reviewed the evidence submitted by the manufacturer, corrected and validated the manufacturer's decision analytic model, and conducted exploratory analyses to assess the robustness and validity of the presented clinical and cost-effectiveness results. This article describes the company submission, the Evidence Review Group assessment and National Institute for Health and Care Excellence subsequent decisions. The main clinical effectiveness evidence was obtained from the MONALEESA-2 trial, a randomised controlled trial comparing ribociclib plus letrozole with placebo plus letrozole. Progression-free survival was significantly longer in the ribociclib group (95% confidence interval, 19.3-not reached) vs. 14.7 months (95% confidence interval 13.0-16.5) in the placebo group. To assess the cost effectiveness of ribociclib in combination with an aromatase inhibitor, the company developed an individual patient-level model using a discrete-event simulation approach in Microsoft® Excel. In the model, simulated patients move through a series of three health states until death, i.e. first-line progression-free survival, second-line progression-free survival and progressive disease. The length of progression-free survival during the first line was informed by the MONALEESA-2 trial. The benefit in progression-free survival in the first line was transferred to a benefit in overall survival assuming full progression-free survival to overall survival surrogacy (because of the immaturity of overall survival data from the MONALEESA-2 trial). Patient-level data from the BOLERO-2 trial, evaluating the addition of everolimus to exemestane in the second-line treatment of postmenopausal HR-positive advanced breast cancer, were used to inform the length of progression-free survival during the second line. Costs included in the model were treatment costs (e.g. technology acquisition costs of first, second, third and/or later line treatments), drug administration costs, monitoring costs and health state costs (including terminal care). Additionally, the costs of adverse events associated with the first-line treatment were incorporated. The Evidence Review Group recalculated the incremental cost-effectiveness ratio using data from a different data cut-off date from the MONALEESA-2 trial and by changing some assumptions (e.g. progression-free survival to overall survival surrogacy approach and post-progression third and/or later line treatment-related costs). After two appraisal committee meetings and a revised base case submitted by the company (including a second enhanced patient access scheme discount), the committee concluded that taking into account the uncertainties in the calculation of the cost effectiveness, there were plausible cost-effectiveness estimates broadly in the range that could be considered as a cost-effective use of National Health Service resources. Therefore, ribociclib was recommended as a treatment option for the first-line treatment of hormone receptor-positive, human epidermal growth factor receptor 2-negative breast cancer, contingent on the company providing ribociclib with the discount agreed in the second enhanced patient access scheme.
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Affiliation(s)
- Nasuh C Büyükkaramikli
- Institute for Medical Technology Assessment (iMTA), Erasmus School of Health Policy & Management (ESHPM), Erasmus University Rotterdam, P.O. Box 1738, 3000 DR, Rotterdam, The Netherlands.
| | - Saskia de Groot
- Institute for Medical Technology Assessment (iMTA), Erasmus School of Health Policy & Management (ESHPM), Erasmus University Rotterdam, P.O. Box 1738, 3000 DR, Rotterdam, The Netherlands
| | | | | | | | - Piet Portegijs
- Department of Family Medicine, School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | | | - Jos Kleijnen
- Kleijnen Systematic Reviews Ltd, York, UK
- Department of Family Medicine, School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Maiwenn J Al
- Institute for Medical Technology Assessment (iMTA), Erasmus School of Health Policy & Management (ESHPM), Erasmus University Rotterdam, P.O. Box 1738, 3000 DR, Rotterdam, The Netherlands
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Abstract
OBJECTIVES Patients with diabetes mellitus are at a risk for hypoglycaemia. Besides the burden of hypoglycaemia for patients, hypoglycaemia poses an economic burden to society. The aim of this study was to calculate the per patient societal costs of hypoglycaemia among patients with type1 diabetes (T1DM) and type 2 diabetes (T2DM) on insulin therapy in the Netherlands. METHODS To calculate the costs of hypoglycaemia, data from the Global Hypoglycaemia Assessment Tool (HAT) study were used. Dutch patients were selected from the HAT study database and data regarding healthcare resource use, informal care use and productivity losses were combined with Dutch unit costs to calculate the per patient 4-week costs of patients experiencing hypoglycaemia. Besides these 4-week costs, costs per hypoglycaemic event were calculated by dividing the study population total 4-week costs by the total number of events in this period. RESULTS Mean 4-week total costs of hypoglycaemia amounted to €163 (SD, €870) in T1DM and €134 (SD, €364) in T2DM. While productivity costs were the most important cost driver of hypoglycaemia in patients with T1DM (accounting for 72% of the total costs), costs of hypoglycaemia in patients with T2DM were almost entirely driven by costs within the healthcare sector (accounting for 98% of the total costs). Mean costs of a severe hypoglycaemic event were €828 and €508 in T1DM and T2DM, respectively, whereas mean costs of a non-severe event were almost zero. CONCLUSIONS This study showed that the economic burden of severe hypoglycaemia is substantial. The prevention of hypoglycaemia could therefore not only reduce the burden for patients, but also the economic burden to society.
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Affiliation(s)
- Saskia de Groot
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Catherine F Enters-Weijnen
- Julius Clinical, Zeist, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Tim A Kanters
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
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11
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Büyükkaramikli NC, de Groot S, Fayter D, Wolff R, Armstrong N, Stirk L, Worthy G, Albuquerque de Almeida F, Kleijnen J, Al MJ. Pomalidomide with Dexamethasone for Treating Relapsed and Refractory Multiple Myeloma Previously Treated with Lenalidomide and Bortezomib: An Evidence Review Group Perspective of an NICE Single Technology Appraisal. Pharmacoeconomics 2018; 36:145-159. [PMID: 29086363 PMCID: PMC5805808 DOI: 10.1007/s40273-017-0581-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
The National Institute for Health and Care Excellence (NICE), as part of the institute's single technology appraisal (STA) process, invited the manufacturer of pomalidomide (POM; Imnovid®, Celgene) to submit evidence regarding the clinical and cost effectiveness of the drug in combination with dexamethasone (POM + LoDEX) for the treatment of relapsed and refractory multiple myeloma (RRMM) after at least two regimens including lenalidomide (LEN) and bortezomib (BOR). Kleijnen Systematic Reviews Ltd (KSR) and Erasmus University Rotterdam were commissioned as the Evidence Review Group (ERG) for this submission. The ERG reviewed the evidence submitted by the manufacturer, validated the manufacturer's decision analytic model, and conducted exploratory analyses in order to assess the robustness and validity of the presented clinical and cost-effectiveness results. This paper describes the company submission, the ERG assessment, and NICE's subsequent decisions. The company conducted a systematic review to identify studies comparing POM with comparators outlined in the NICE scope: panobinostat with bortezomib and dexamethasone (PANO + BOR + DEX), bendamustine with thalidomide and dexamethasone (BTD) and conventional chemotherapy (CC). The main clinical effectiveness evidence was obtained from MM-003, a randomized controlled trial (RCT) comparing POM + LoDEX with high-dose dexamethasone (HiDEX; used as a proxy for CC). Additional data from other studies were also used as nonrandomized observational data sources for the indirect treatment comparison of POM + LoDEX with BTD and PANO + BOR + DEX. Covariate or treatment switching adjustment methods were used for each comparison. The model developed in Microsoft® Excel 2010 using a semi-Markov partitioned survival structure, submitted in the original submission to NICE for TA338, was adapted for the present assessment of the cost effectiveness of POM + LoDEX. Updated evidence from the clinical-effectiveness part was used for the survival modelling of progression-free survival and overall survival. For POM + LoDEX, the patient access scheme (PAS) discount was applied to the POM price. Three separate comparisons were conducted for each comparator, each comparison using a different dataset and adjustment methods. The ERG identified and corrected some errors, and the corrected incremental cost-effectiveness ratios (ICERs) for POM + LoDEX versus each comparator were presented: approximately £45,000 per quality-adjusted life-year (QALY) gained versus BTD, savings of approximately £143,000 per QALY lost versus PANO + BOR + DEX, and approximately £49,000 per QALY gained versus CC. The ERG also conducted full incremental analyses, which revealed that CC, POM + LoDEX and PANO + BOR + DEX were on the cost-effectiveness frontier. The committee's decision on the technology under analysis deemed that POM + LoDEX should be recommended as an option for treating multiple myeloma in adults at third or subsequent relapse of treatments including both LEN and BOR, contingent on the company providing POM with the discount agreed in the PAS.
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Affiliation(s)
- Nasuh C Büyükkaramikli
- Institute for Medical Technology Assessment (iMTA), Institute of Health Policy and Management (iBMG), Erasmus University Rotterdam, Rotterdam, The Netherlands.
| | - Saskia de Groot
- Institute for Medical Technology Assessment (iMTA), Institute of Health Policy and Management (iBMG), Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | | | | | - Lisa Stirk
- Kleijnen Systematic Reviews Ltd, York, UK
| | | | - Fernando Albuquerque de Almeida
- Institute for Medical Technology Assessment (iMTA), Institute of Health Policy and Management (iBMG), Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Jos Kleijnen
- Kleijnen Systematic Reviews Ltd, York, UK
- Department of Family Medicine, School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Maiwenn J Al
- Institute for Medical Technology Assessment (iMTA), Institute of Health Policy and Management (iBMG), Erasmus University Rotterdam, Rotterdam, The Netherlands
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de Groot S, van der Linden N, Franken MG, Blommestein HM, Leeneman B, van Rooijen E, Koos van der Hoeven JJM, Wouters MW, Westgeest HM, Uyl-de Groot CA. Balancing the Optimal and the Feasible: A Practical Guide for Setting Up Patient Registries for the Collection of Real-World Data for Health Care Decision Making Based on Dutch Experiences. Value Health 2017; 20:627-636. [PMID: 28408005 DOI: 10.1016/j.jval.2016.02.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 02/05/2016] [Accepted: 02/09/2016] [Indexed: 06/07/2023]
Abstract
OBJECTIVES The aim of this article was to provide practical guidance in setting up patient registries to facilitate real-world data collection for health care decision making. METHODS This guidance was based on our experiences and involvement in setting up patient registries in oncology in the Netherlands. All aspects were structured according to 1) mission and goals ("the Why"), 2) stakeholders and funding ("the Who"), 3) type and content ("the What"), and 4) identification and recruitment of patients, data handling, and pharmacovigilance ("the How"). RESULTS The mission of most patient registries is improving patient health by improving the quality of patient care; monitoring and evaluating patient care is often the primary goal ("the Why"). It is important to align the objectives of the registry and agree on a clear and functional governance structure with all stakeholders ("the Who"). There is often a trade off between reliability, validity, and specificity of data elements and feasibility of data collection ("the What"). Patient privacy should be carefully protected, and address (inter-)national and local regulations. Patient registries can reveal unique safety information, but it can be challenging to comply with pharmacovigilance guidelines ("the How"). CONCLUSIONS It is crucial to set up an efficient patient registry that serves its aims by collecting the right data of the right patient in the right way. It can be expected that patient registries will become the new standard alongside randomized controlled trials due to their unique value.
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Affiliation(s)
- Saskia de Groot
- Institute of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands; Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands.
| | - Naomi van der Linden
- Institute of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Margreet G Franken
- Institute of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands; Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Hedwig M Blommestein
- Institute of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands; Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - Brenda Leeneman
- Institute of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Ellen van Rooijen
- Institute of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | - Michel W Wouters
- Dutch Institute for Clinical Auditing (DICA), Leiden, The Netherlands; Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Hans M Westgeest
- Institute of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands; Department of Oncology, Amphia Hospital, Breda, The Netherlands
| | - Carin A Uyl-de Groot
- Institute of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands; Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands; Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
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13
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Blommestein HM, de Groot S, Aarts MJ, Vemer P, de Vries R, van Abeelen AF, Posthuma EW, Uyl-de Groot CA. Cost-effectiveness of obinutuzumab for chronic lymphocytic leukaemia in The Netherlands. Leuk Res 2016; 50:37-45. [DOI: 10.1016/j.leukres.2016.09.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 08/02/2016] [Accepted: 09/01/2016] [Indexed: 10/21/2022]
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de Groot S, Redekop WK, Sleijfer S, Oosterwijk E, Bex A, Kiemeney LALM, Uyl-de Groot CA. Survival in Patients With Primary Metastatic Renal Cell Carcinoma Treated With Sunitinib With or Without Previous Cytoreductive Nephrectomy: Results From a Population-based Registry. Urology 2016; 95:121-7. [PMID: 27179773 DOI: 10.1016/j.urology.2016.04.042] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 04/02/2016] [Accepted: 04/05/2016] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To evaluate the effect of cytoreductive nephrectomy (CN) on overall survival (OS) in primary metastatic renal cell carcinoma (mRCC) patients treated with first-line sunitinib. PATIENTS AND METHODS Patients with primary mRCC treated with first-line sunitinib were selected from a Dutch population-based registry. A propensity score was calculated reflecting the probability of a patient undergoing CN prior to sunitinib using a set of known covariates, such as the Memorial Sloan Kettering Cancer Center and International mRCC Database Consortium risk factors. After propensity score matching, differences in OS were analyzed using the Kaplan-Meier method and a multivariable Cox proportional hazards model was used to evaluate the effect of CN on OS. RESULTS A total of 227 patients met the selection criteria; 74 patients (33%) underwent CN prior to sunitinib. In the matched population, the median OS of patients who underwent CN was 17.9 months compared to 8.8 months for patients treated with sunitinib only. Multivariable analysis showed that CN was an independent predictor of OS (hazard ratio 0.61, 95% confidence interval: 0.41-0.92). A subgroup analysis of patients with a time to targeted therapy of <1 year showed a median OS of 12.7 months for patients treated with CN compared to 8.0 months for patients treated with sunitinib only. The corresponding hazard ratio was 0.67 (95% confidence interval: 0.46-0.98). CONCLUSION This study suggests that CN may be effective. However, the benefit was modest when correcting for time from diagnosis to sunitinib. One important limitation is the use of a registry (with retrospectively collected data), which made it impossible to correct for unmeasured characteristics that could be associated with treatment choices or survival.
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Affiliation(s)
- Saskia de Groot
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - William K Redekop
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Stefan Sleijfer
- Department of Medical Oncology and Cancer Genomics Netherlands, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Egbert Oosterwijk
- Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Department of Urology, Nijmegen, The Netherlands
| | - Axel Bex
- Department of Urology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Lambertus A L M Kiemeney
- Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Department of Urology, Nijmegen, The Netherlands; Radboud Institute for Health Sciences, Radboud University Medical Center, Department for Health Evidence, Nijmegen, The Netherlands
| | - Carin A Uyl-de Groot
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.
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de Groot S, Rijnsburger AJ, Versteegh MM, Heymans JM, Kleijnen S, Redekop WK, Verstijnen IM. Which factors may determine the necessary and feasible type of effectiveness evidence? A mixed methods approach to develop an instrument to help coverage decision-makers. BMJ Open 2015. [PMID: 26220869 PMCID: PMC4521513 DOI: 10.1136/bmjopen-2014-007241] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVES Reimbursement decisions require evidence of effectiveness and, in general, a blinded randomised controlled trial (RCT) is the preferred study design to provide it. However, there are situations where a cohort study, or even patient series, can be deemed acceptable. The aim of this study was to develop an instrument that first examines which study characteristics of a blinded RCT are necessary, and then, if particular characteristics are considered necessary, examines whether these characteristics are feasible. DESIGN We retrospectively studied 22 interventions from 20 reimbursement reports concerning medical specialist care made by the Dutch National Health Care Institute (ZIN) to identify any factors that influenced the necessity and feasibility of blinded RCTs, and their constituent study characteristics, that is, blinding, randomisation and a control group. A literature review was performed to identify additional factors. Additional expertise was included by interviewing eight experts in epidemiology, medicine and ethics. The resulting instrument was called the FIT instrument (Feasible Information Trajectory), and was prospectively validated using three consecutive reimbursement reports. RESULTS (Blinded) RCT evidence was lacking in 5 of 11 positive reimbursement decisions and 3 of 11 negative decisions. In the reimbursement reports, we found no empirical evidence supporting situations where a blinded RCT is unnecessary. The literature also revealed few arguments against the necessity of a blinded RCT. In contrast, many factors influencing the feasibility of randomisation, a control group and blinding, were found in the reimbursement reports and the literature; for example, when a patient population is too small or when an intervention is common practice, randomisation will be hindered. CONCLUSIONS Policy regarding the necessity and feasibility of different types of evidence of effectiveness would benefit from systematic guidance. The FIT instrument has the potential to support transparent, reproducible and well-founded decisions on appropriate evidence of effectiveness in medical specialist care.
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Affiliation(s)
- Saskia de Groot
- Department of Health Policy and Management, Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Adriana J Rijnsburger
- Department of Health Policy and Management, Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Matthijs M Versteegh
- Department of Health Policy and Management, Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Juanita M Heymans
- Dutch National Health Care Institute (ZIN) (formerly named CVZ), Diemen, The Netherlands
| | - Sarah Kleijnen
- Dutch National Health Care Institute (ZIN) (formerly named CVZ), Diemen, The Netherlands
| | - W Ken Redekop
- Department of Health Policy and Management, Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Ilse M Verstijnen
- Dutch National Health Care Institute (ZIN) (formerly named CVZ), Diemen, The Netherlands
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Blommestein HM, Verelst SGR, de Groot S, Huijgens PC, Sonneveld P, Uyl-de Groot CA. A cost-effectiveness analysis of real-world treatment for elderly patients with multiple myeloma using a full disease model. Eur J Haematol 2015; 96:198-208. [DOI: 10.1111/ejh.12571] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2015] [Indexed: 01/05/2023]
Affiliation(s)
- Hedwig M. Blommestein
- Department of Health Policy & Management/institute for Medical Technology Assessment; Erasmus University; Rotterdam The Netherlands
- Comprehensive Cancer Organisation; Utrecht The Netherlands
| | | | - Saskia de Groot
- Department of Health Policy & Management/institute for Medical Technology Assessment; Erasmus University; Rotterdam The Netherlands
| | - Peter C. Huijgens
- Comprehensive Cancer Organisation; Utrecht The Netherlands
- VU Medical Center Amsterdam; Amsterdam The Netherlands
| | | | - Carin A. Uyl-de Groot
- Department of Health Policy & Management/institute for Medical Technology Assessment; Erasmus University; Rotterdam The Netherlands
- Comprehensive Cancer Organisation; Utrecht The Netherlands
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van Gils CWM, de Groot S, Redekop WK, Koopman M, Punt CJA, Uyl-de Groot CA. Real-world cost-effectiveness of oxaliplatin in stage III colon cancer: a synthesis of clinical trial and daily practice evidence. Pharmacoeconomics 2013; 31:703-718. [PMID: 23657918 DOI: 10.1007/s40273-013-0061-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVES Previous cost-effectiveness analyses of oxaliplatin have been based on randomised trials whereas current Dutch policy requires evidence from daily practice. The objective of this study was to examine the real-world cost-effectiveness of oxaliplatin plus fluoropyrimidines (FL) versus FL-only as adjuvant treatment of stage III colon cancer. METHODS A Markov model was developed to estimate lifetime cost and quality-adjusted life-years from a hospital perspective. The effectiveness of the oxaliplatin arm was modelled by combining published efficacy data from the pivotal clinical registration trial (MOSAIC trial) with real-world (RW) data from a Dutch population-based observational study. RW patients were categorised into "eligible" or "ineligible", depending on whether the patients fulfilled the MOSAIC trial eligibility criteria. Ineligible RW patients (18 %) had a poorer prognosis than eligible RW patients (82 %) and MOSAIC trial patients. The effectiveness of the comparator was modelled using MOSAIC trial results. All cost inputs were based on RW patients and reported in Euro 2012. Cost-effectiveness analyses were performed for four different scenarios: (1) cost-effectiveness analyses based on MOSAIC trial patients; (2) cost-effectiveness analyses using MOSAIC and eligible RW patients; (3) cost-effectiveness analyses using MOSAIC and both eligible and ineligible RW patients, assuming oxaliplatin had an equal effect in ineligible and eligible patients; (4) cost-effectiveness analyses using MOSAIC and both eligible and ineligible RW patients, assuming oxaliplatin had no effect amongst ineligibles. For each scenario, univariate and probabilistic sensitivity analyses were undertaken. RESULTS MOSAIC trial patients and eligible RW patients treated with oxaliplatin had comparable 2-year disease-free survivals (79.5 vs. 78.4 %). Oxaliplatin showed an incremental QALY gain of 1.02, 1.13, 1.17 and 0.93 and incremental cost of <euro>9,961, <euro>11,055, <euro>9,814 and <euro>11,854 in scenarios 1-4, respectively. The corresponding incremental cost-effectiveness ratios (ICERs) were <euro>9,766, <euro>9,783, <euro>8,388 and <euro>12,746 in scenarios 1-4, respectively. In all scenarios, univariate and probabilistic sensitivity analyses indicated that the ICERs are acceptable and robust under a wide range of model assumptions. CONCLUSIONS The ICERs of the different scenarios that resulted from combining MOSAIC trial data with data from Dutch daily practice all suggest that FL + oxaliplatin is cost-effective versus FL alone in the adjuvant treatment of colon cancer. This article illustrates how one could design and implement a real-world cost-effectiveness study to yield internally valid results that could also be generalisable.
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Affiliation(s)
- Chantal W M van Gils
- Department of Health Policy and Management, Institute for Medical Technology Assessment, Erasmus University, Burgemeester Oudlaan 50, P.O. Box 1738, 3000 DR, Rotterdam, The Netherlands.
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Uyl-de Groot CA, de Groot S, Steenhoek A. The economics of improved cancer survival rates: better outcomes, higher costs. Expert Rev Pharmacoecon Outcomes Res 2010; 10:283-92. [PMID: 20545593 DOI: 10.1586/erp.10.27] [Citation(s) in RCA: 5] [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] [Indexed: 11/08/2022]
Abstract
In 2006, over three million new cases of cancer were diagnosed in Europe. This number will increase in the coming years as a result of an aging population and population growth. Advances in the diagnosis and treatment of cancer have resulted in increased survival rates. Simultaneously, increasing costs of screening, diagnosis and the treatment of cancer could threaten the ability to ensure high-quality care and provide access to care for all patients. New genetic tests and biomarkers may help to identify those subtypes of patients that would be most likely to benefit from new cancer drugs. In our opinion, there is still much to gain in cancer diagnosis and treatment but these gains should be worth the costs.
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Affiliation(s)
- Carin A Uyl-de Groot
- Institute for Medical Technology Assessment, Institute of Health Policy & Management, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands.
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de Groot S, Mailund T, Lunter G, Hein J. Investigating selection on viruses: a statistical alignment approach. BMC Bioinformatics 2008; 9:304. [PMID: 18616801 PMCID: PMC2478691 DOI: 10.1186/1471-2105-9-304] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [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] [Received: 12/10/2007] [Accepted: 07/10/2008] [Indexed: 01/14/2023] Open
Abstract
Background Two problems complicate the study of selection in viral genomes: Firstly, the presence of genes in overlapping reading frames implies that selection in one reading frame can bias our estimates of neutral mutation rates in another reading frame. Secondly, the high mutation rates we are likely to encounter complicate the inference of a reliable alignment of genomes. To address these issues, we develop a model that explicitly models selection in overlapping reading frames. We then integrate this model into a statistical alignment framework, enabling us to estimate selection while explicitly dealing with the uncertainty of individual alignments. We show that in this way we obtain un-biased selection parameters for different genomic regions of interest, and can improve in accuracy compared to using a fixed alignment. Results We run a series of simulation studies to gauge how well we do in selection estimation, especially in comparison to the use of a fixed alignment. We show that the standard practice of using a ClustalW alignment can lead to considerable biases and that estimation accuracy increases substantially when explicitly integrating over the uncertainty in inferred alignments. We even manage to compete favourably for general evolutionary distances with an alignment produced by GenAl. We subsequently run our method on HIV2 and Hepatitis B sequences. Conclusion We propose that marginalizing over all alignments, as opposed to using a fixed one, should be considered in any parametric inference from divergent sequence data for which the alignments are not known with certainty. Moreover, we discover in HIV2 that double coding regions appear to be under less stringent selection than single coding ones. Additionally, there appears to be evidence for differential selection, where one overlapping reading frame is under positive and the other under negative selection.
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Affiliation(s)
- Saskia de Groot
- Department of Statistics, University of Oxford, 1 South Parks Road, OX1 3TG, UK.
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Abstract
MOTIVATION Viral genomes tend to code in overlapping reading frames to maximize informational content. This may result in atypical codon bias and particular evolutionary constraints. Due to the fast mutation rate of viruses, there is additional strong evidence for varying selection between intra- and intergenomic regions. The presence of multiple coding regions complicates the concept of K(a)/K(s) ratio, and thus begs for an alternative approach when investigating selection strengths. Building on the paper by McCauley and Hein, we develop a method for annotating a viral genome coding in overlapping reading frames. We introduce an evolutionary model capable of accounting for varying levels of selection along the genome, and incorporate it into our prior single sequence HMM methodology, extending it now to a phylogenetic HMM. Given an alignment of several homologous viruses to a reference sequence, we may thus achieve an annotation both of coding regions as well as selection strengths, allowing us to investigate different selection patterns and hypotheses. RESULTS We illustrate our method by applying it to a multiple alignment of four HIV2 sequences, as well as of three Hepatitis B sequences. We obtain an annotation of the coding regions, as well as a posterior probability for each site of the strength of selection acting on it. From this we may deduce the average posterior selection acting on the different genes. Whilst we are encouraged to see in HIV2, that the known to be conserved genes gag and pol are indeed annotated as such, we also discover several sites of less stringent negative selection within the env gene. To the best of our knowledge, we are the first to subsequently provide a full selection annotation of the Hepatitis B genome by explicitly modelling the evolution within overlapping reading frames, and not relying on simple K(a)/K(s) ratios.
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Affiliation(s)
- Stephen McCauley
- Department of Statistics, University of Oxford, 1 South Parks Road, OX1 3TG, UK
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Abstract
MOTIVATION Detecting genes in viral genomes is a complex task. Due to the biological necessity of them being constrained in length, RNA viruses in particular tend to code in overlapping reading frames. Since one amino acid is encoded by a triplet of nucleic acids, up to three genes may be coded for simultaneously in one direction. Conventional hidden Markov model (HMM)-based gene-finding algorithms may typically find it difficult to identify multiple coding regions, since in general their topologies do not allow for the presence of overlapping or nested genes. Comparative methods have therefore been restricted to likelihood ratio tests on potential regions as to being double or single coding, using the fact that the constrictions forced upon multiple-coding nucleotides will result in atypical sequence evolution. Exploiting these same constraints, we present an HMM based gene-finding program, which allows for coding in unidirectional nested and overlapping reading frames, to annotate two homologous aligned viral genomes. Our method does not insist on conserved gene structure between the two sequences, thus making it applicable for the pairwise comparison of more distantly related sequences. RESULTS We apply our method to 15 pairwise alignments of six different HIV2 genomes. Given sufficient evolutionary distance between the two sequences, we achieve sensitivity of approximately 84-89% and specificity of approximately 97-99.9%. We additionally annotate three pairwise alignments of the more distantly related HIV1 and HIV2, as well as of two different hepatitis viruses, attaining results of approximately 87% sensitivity and approximately 98.5% specificity. We subsequently incorporate prior knowledge by 'knowing' the gene structure of one sequence and annotating the other conditional on it. Boosting accuracy close to perfect we demonstrate that conservation of gene structure on top of nucleotide sequence is a valuable source of information, especially in distantly related genomes. AVAILABILITY The Java code is available from the authors.
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