R WE ready for reimbursement? A round up of developments in real-world evidence relating to health technology assessment: part 15

In this latest update we discuss real-world evidence (RWE) guidance from the leading oncology professional societies, the American Society of Clinical Oncology and the European Society for Medical Oncology, and the PRINCIPLED practical guide on the design and analysis of causal RWE studies.

Access in all areas? a round up of developments in market access and health technology assessment: part 4

In this latest update, we look at recent developments in market access including the pricing agreement of Libmeldy® by the Beneluxa Initiative, the financial impact of managed entry agreements in Italy and the restructuring of Agenzia Italiana del Farmaco (AIFA). We also highlight the collaboration between FINOSE and the New Expensive Drug (NED) section of the Nordic Pharmaceutical Forum.

Access in all areas? A round up of developments in market access and health technology assessment: part 3

In this latest update, we explore some of the key updates in market access over recent months including the UK's voluntary scheme for branded medicines pricing, access and growth (VPAG), the first drugs funded by the Innovative Medicines Fund in the UK and the Direct Access Scheme in France, and, finally, the new Institute for Clinical and Economic Review (ICER) value assessment framework in the USA.

Is the price right? Paying for value today to get more value tomorrow

BACKGROUND

Contemporary debates about drug pricing feature several widely held misconceptions, including the relationship between incentives and innovation, the proportion of total healthcare spending on pharmaceuticals, and whether the economic evaluation of a medicine can be influenced by things other than clinical efficacy.

MAIN BODY

All citizens should have access to timely, equitable, and cost-effective care covered by public funds, private insurance, or a combination of both. Better managing the collective burden of diseases borne by today's and future generations depends in part on developing better technologies, including better medicines. As in any innovative industry, the expectation of adequate financial returns incentivizes innovators and their investors to develop new medicines. Estimating expected returns requires that they forecast revenues, based on the future price trajectory and volume of use over time. How market participants decide what price to set or accept can be complicated, and some observers and stakeholders want to confirm whether the net prices society pays for novel medicines, whether as a reward for past innovation or an incentive for future innovation, are commensurate with those medicines' incremental value. But we must also ask "value to whom?"; medicines not only bring immediate clinical benefits to patients treated today, but also can provide a broad spectrum of short- and long-term benefits to patients, their families, and society. Spending across all facets of healthcare has grown over the last 25 years, but both inpatient and outpatient spending has outpaced drug spending growth even as our drug armamentarium is constantly improving with safer and more effective medicines. In large part, this is because, unlike hospitals, drugs typically go generic, thus making room in our budgets for new and better ones, even as they often keep patients out of hospitals, driving further savings.

CONCLUSION

A thorough evaluation of drug spending and value can help to promote a better allocation of healthcare resources for both the healthy and the sick, both of whom must pay for healthcare. Taking a holistic approach to assessing drug value makes it clear that a branded drug's value to a patient is often only a small fraction of the drug's total value to society. Societal value merits consideration when determining whether and how to make a medicine affordable and accessible to patients: a drug that is worth its price to society should not be rendered inaccessible to ill patients by imposing high out-of-pocket costs or restricting coverage based on narrow health technology assessments (HTAs). Furthermore, recognizing the total societal cost of un- or undertreated conditions is crucial to gaining a thorough understanding of what guides the biomedical innovation ecosystem to create value for society. It would be unwise to discourage the development of new solutions without first appreciating the cost of leaving the problems unsolved.

R WE ready for reimbursement? A round up of developments in real-world evidence relating to health technology assessment: part 14

In this latest update we highlight: a publication from the US FDA regarding the definitions of real-world data (RWD) and real-world evidence (RWE); a publication from academic researchers on a demonstration project for target trial emulation; a publication from the National Institute of Health and Care Excellence (NICE) on the 1 year anniversary of their RWE framework; and a publication from NICE and Flatiron Health on the utility of US RWD for initial UK health technology assessment decision making.

Access in all areas? A round up of developments in market access and health technology assessment: part 2

In this latest update, we explore the Inflation Reduction Act (IRA) enacted by the US Congress in August 2022, with the Centers for Medicare and Medicaid Services (CMS) recently releasing the list of the first ten drugs it will negotiate prices on. We also cover the consequences of price controls and rigid value assessment in Germany which have led to the withdrawal of a number of medicines. It will be important to see how the IRA balances cost-saving with holistic value assessment, incentives for innovation and patient access to treatment.

R WE ready for reimbursement? A round up of developments in real-world evidence relating to health technology assessment: part 13

In this latest update we highlight a report from the European Medicines Agency on their use of real-world evidence (RWE) in decision making, RWE reporting guidance from the Canadian Agency for Drugs and Technologies in Health and highlight some new data demonstrating the value medicines for spinal muscular atrophy have brought patients.

Access in all areas? A round up of developments in market access and health technology assessment: part 1

In this new series reviewing recent developments in market access, we highlight publications investigating health technology assessment (HTA) guidance, review processes and outcomes across the world and discuss how forthcoming changes in the HTA and regulatory environment in the European Union may allow for more consistency in decision making.

R WE ready for reimbursement? A round up of developments in real-world evidence relating to health technology assessment: part 12

In this latest update we highlight the final results from the RCT-DUPLICATE initiative, the publication of guidance from Haute Autorité de Santé (HAS), the joint viewpoint from the Institute for Quality and Efficiency in HealthCare (IQWIG) and the Belgian HealthCare Knowledge Center, and a position from the European Organization for Research and Treatment of Cancer (EORTC). Finally, we discuss how the NICE RWE framework has been implemented to allow consideration of RWE external control arms.

R WE ready for reimbursement? A round up of developments in real-world evidence relating to health technology assessment: part 11

In this latest update we highlight a study from the REPEAT initiative that evaluates the reproducibility of real-world data studies, the publication of the HARPER Protocol Template developed by a joint ISPE/ISPOR taskforce, and discuss recent US FDA guidance on external control arms.

R WE ready for reimbursement? A round up of developments in real-world evidence relating to health technology assessment: part 10

In this latest update we discuss the transportability of comparative effectiveness evidence across countries. We highlight results of a survey indicating that European HTA agencies are reluctant to accept real-world data from other countries, review recent benefit assessments indicating a potential softening of a requirement for the use of local real-world data in Germany, and outline a recent review presenting approaches that can correct for a lack of transportability.

Transportability of Overall Survival Estimates From US to Canadian Patients With Advanced Non-Small Cell Lung Cancer With Implications for Regulatory and Health Technology Assessment

IMPORTANCE

The external validity of survival outcomes derived from clinical practice data from US patients with advanced non-small cell lung cancer (NSCLC) is not known and is of potential importance because it may be used to support regulatory decision-making and health technology assessment outside of the US.

OBJECTIVE

To evaluate whether overall survival (OS) estimates for a selected group of patients with advanced NSCLC from a large US clinical practice database are transportable to Canadian patients receiving the same systemic therapies.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective multicenter cohort study used transportability analysis to assess whether adjustment for pretreatment characteristics of eligible patient cohorts could reliably approximate OS estimated from US-based samples to Canadian populations. A total of 17 432 eligible adult patients who were diagnosed de novo with advanced NSCLC on or after January 1, 2011, were included in the analysis and followed up until September 30, 2020. Because data on race and ethnicity were available in the US database but not the Canadian database and because racial and ethnic distribution was likely to be similar between US and Canadian patients, these characteristics were not analyzed.

EXPOSURES

Initiation of platinum-doublet chemotherapy or pembrolizumab monotherapy as first-line systemic treatment for advanced NSCLC.

MAIN OUTCOMES AND MEASURES

OS measured from the time of initiation of the respective treatment regimen.

RESULTS

Among 17 432 eligible patients, 15 669 patients from the US and 1763 patients from Canada were included in the analysis. Of those, 11 863 patients (sample size-weighted estimates of mean [SD] age, 68.0 [9.3] years; 6606 [55.7%] male; 10 100 from the US and 1763 from Canada) were included in the subset of patients with complete data for baseline covariates. A total of 13 532 US patients received first-line chemotherapy, and 2137 received first-line pembrolizumab monotherapy. Of those, 8447 patients (62.4%) in the first-line chemotherapy group and 1653 patients (77.3%) in the first-line pembrolizumab group had complete data on baseline covariates for outcome model estimation. A total of 1476 Canadian patients who received first-line chemotherapy and 287 patients who received first-line pembrolizumab monotherapy were identified from the target population. After standardization to baseline patient covariates in the Canadian cohorts, transported OS estimates revealed a less than 5% mean absolute difference from the observed OS in the target population (0.56% over 60 months of follow-up in the first-line chemotherapy group and 4.54% over 30 months of follow-up in the first-line pembrolizumab group). Negative control analysis using a mismatched outcome model revealed a 6.64% discrepancy and an incompatible survival curve shape. The results were robust to assumptions of random missingness for baseline covariates, to unadjusted differences in baseline metastases and comorbidities, and to differences in the standard of care between the US and Canada related to administration of second-line anti-programmed cell death 1 ligand 1 immunotherapy for patients who initiated first-line chemotherapy.

CONCLUSIONS AND RELEVANCE

The results of this cohort study suggest that, under specific circumstances, OS estimates from US clinical practice data can be adjusted using baseline clinical characteristics to closely approximate OS in selected groups of Canadian patients with advanced NSCLC. These results may have implications for regulatory decision-making and health technology assessment in target populations outside of the US.

R WE ready for reimbursement? A round up of developments in real-world evidence relating to health technology assessment: part 9

In this latest update we highlight a recent International Society of Pharmacoeconomics and Outcomes Research Good Practice Report on machine learning (ML) for health economics and outcomes research. We specifically discuss use cases of ML that offer opportunities in the generation of evidence using real-world data, including improvements in the identification of study cohorts, confounder identification and adjustment and estimating treatment effect heterogeneity. Barriers to the wider adoption of ML methods are also discussed.

Addressing challenges with real-world synthetic control arms to demonstrate the comparative effectiveness of Pralsetinib in non-small cell lung cancer

As advanced non-small cell lung cancer (aNSCLC) is being increasingly divided into rare oncogene-driven subsets, conducting randomised trials becomes challenging. Using real-world data (RWD) to construct control arms for single-arm trials provides an option for comparative data. However, non-randomised treatment comparisons have the potential to be biased and cause concern for decision-makers. Using the example of pralsetinib from a RET fusion-positive aNSCLC single-arm trial (NCT03037385), we demonstrate a relative survival benefit when compared to pembrolizumab monotherapy and pembrolizumab with chemotherapy RWD cohorts. Quantitative bias analyses show that results for the RWD-trial comparisons are robust to data missingness, potential poorer outcomes in RWD and residual confounding. Overall, the study provides evidence in favour of pralsetinib as a first-line treatment for RET fusion-positive aNSCLC. The quantification of potential bias performed in this study can be used as a template for future studies of this nature.

Real-world data (RWD) based control arms provide an option to compare the effectiveness of single-arm trials. By performing multiple quantitative bias analyses to alleviate concerns about trial-RWD comparability, here the authors show that the RET inhibitor pralsetinib provides survival benefit in patients with RET fusion-positive non-small cell lung cancer from the ARROW single-arm trial, (NCT03037385) when compared to pembrolizumab monotherapy and pembrolizumab with chemotherapy RWD cohorts.

R WE ready for reimbursement? A round up of developments in real-world evidence relating to health technology assessment: part 8

In this latest update we highlight the publication of a draft real-world evidence framework by the UK National Institute for Health and Care Excellence, and describe a press release from Germany's Institute for Quality and Efficiency in HealthCare outlining how real-world evidence submissions are not following their guidelines. We also discuss whether the lack of adherence to guidelines is due to ignorance of these guidelines on the part of manufacturers, the difficulty in achieving best practices or a failure of guidelines to comprehensively describe best practices.

R WE ready for reimbursement? A round up of developments in real-world evidence relating to health technology assessment: part 7

This month we focus on papers that provide insights into the potential for target trial emulation to be used in health technology assessment, the role of real-world evidence (RWE) in informing additional elements of value and the importance of RWE to European joint clinical assessments.

Association Between Smoking History and Overall Survival in Patients Receiving Pembrolizumab for First-Line Treatment of Advanced Non-Small Cell Lung Cancer

IMPORTANCE

There is a need to tailor treatments to patients who are most likely to derive the greatest benefit from them to improve patient outcomes and enhance cost-effectiveness of cancer therapies.

OBJECTIVE

To compare overall survival (OS) between patients with a current or former history of smoking with patients who never smoked and initiated pembrolizumab monotherapy as first-line (1L) treatment for advanced non-small lung cancer (NSCLC).

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study compared patients diagnosed with advanced NSCLC aged 18 or higher selected from a nationwide real-world database originating from more than 280 US cancer clinics. The study inclusion period was from January 1, 2011, to October 1, 2019.

EXPOSURES

Smoking status at the time of NSCLC diagnosis.

MAIN OUTCOMES AND MEASURES

OS measured from initiation of 1L pembrolizumab monotherapy.

RESULTS

In this retrospective cohort study, a total of 1166 patients (median [IQR] age, 72.9 [15.3] years; 581 [49.8%] men and 585 [50.2%] women) were assessed in the primary analysis, including 91 patients [7.8%] with no history of smoking (ie, never-smokers) and 1075 patients [92.2%] who currently or formerly smoked (ie, ever-smokers). Compared with ever-smokers, never-smokers were older (median age [IQR] of 78.2 [12.0] vs 72.7 [15.5] years), more likely to be female (61 [67.0%] vs 524 [48.7%]) and to have been diagnosed with nonsquamous tumor histology (70 [76.9%] vs 738 [68.7%]). After adjustment for baseline covariates, ever-smokers who initiated 1L pembrolizumab had significantly prolonged OS compared to never-smokers (median OS: 12.8 [10.9-14.6] vs 6.5 [3.3-13.8] months; hazard ratio (HR): 0.69 [95% CI, 0.50-0.95]). This trend was observed across all sensitivity analyses for the 1L pembrolizumab cohort, but not for initiators of 1L platinum chemotherapy, for which ever-smokers showed significantly shorter OS compared with never-smokers (HR, 1.2 [95% CI, 1.07-1.33]).

CONCLUSIONS AND RELEVANCE

In patients with advanced NSCLC who received 1L pembrolizumab monotherapy in routine clinical practices in the US, patients who reported a current or former history of smoking at the time of diagnosis had consistently longer OS than never-smokers. This finding suggests that in never-smoking advanced NSCLC, 1L pembrolizumab monotherapy may not be the optimal therapy selection, and genomic testing for potential genomically matched therapies should be prioritized over pembrolizumab in never-smokers.

R WE ready for reimbursement? A round up of developments in real-world evidence relating to health technology assessment: part 6

In this latest update we highlight recent publications from the US FDA and a Canadian Health Technology Assessment collaboration which provide insights into the future role of real-world evidence in market access in terms of health technology management.

R WE ready for reimbursement? A round up of developments in real-world evidence relating to HTA: part 5

In the latest update we focus on recent publications which have provided insights into the importance of focusing on the development and consideration of a body of real-world evidence, and an approach to evaluating the complex area of treatment sequencing.

R WE ready for reimbursement? A round up of developments in real-world evidence relating to health technology assessment: part 4

In this month's round up, we discuss a number of recent publications and guidelines addressing the use of real-world evidence to evaluate the clinical benefit of health technology assessments and what the publications mean practically for manufacturers.

Keeping it real: implications of real-world treatment outcomes for first-line immunotherapy in metastatic non-small-cell lung cancer

Tweetable abstract Recent RWD studies suggest that the performance of immunotherapy in NSCLC is not as good as that seen in RCTs. However, analyses using RWD (and their interpretation) require careful appraisal and quantification of possible sources of bias.

R WE ready for reimbursement? A round up of developments in real-world evidence relating to HTA: part 3

In this round up, we discuss a number of recent publications that have utilized real-world evidence to explore the value that innovative treatments have brought to patients.

R WE ready for reimbursement? A round up of developments in RWE relating to health technology assessment: part 2

In this round up, we cover how COVID-19 has been beneficial for improved access to real-world data, as well as how real-world data can be used to address health inequity, an area of increasing interest for health technology assessment.

Effect of Vitamin D Supplements on Relapse Rate and Expanded Disability Status Scale (EDSS) in Multiple Sclerosis (MS): A Systematic Review and Meta-Analysis

Background

Multiple sclerosis (MS) is an inflammatory disease while there are controversies regarding the role of vitamin D supplements in controlling relapse and disability improvement during treatment.

Objective

The goal of this systematic review and meta-analysis was to evaluate the effect of vitamin D supplements on MS-related relapse and the Expanded Disability Status Scale (EDSS).

Methods

We searched databases to include randomized clinical trials (RCTs) which were published up to October 2018. We included RCTs, being single-blinded or double-blinded or open-label trials in which one of the main outcomes was EDSS and/or relapse after vitamin D supplementation. All statistical analyses were performed using RevMan 5.3. Odds ratios (OR) and 95% confidence intervals (CI) were calculated for relapse between treatment arms. The mean difference was calculated for EDSS comparisons.

Results

Nine articles were included for analysis. Of these nine studies, five compared vitamin D supplement groups with placebo (group 1 studies), and four compared high- and low-dose vitamin D groups. A total of 561 patients were analyzed. Being treated with vitamin D instead of placebo showed no effect on relapse rate (OR = 0.66, 95% CI = 0.28-1.54) as well as EDSS (mean difference = 0.06, 95%CI [-0.31, 0.42]). The results of studies comparing high- vs. low-dose vitamin D interventions showed no significant effect on relapse rate (OR = 1.08, 95%CI [0.29-4.08] as well as final EDSS (mean difference = 0.17, 95% CI = -0.73, 1.07).

Conclusions

Our findings show that vitamin D supplements (high or low dose) have no significant effect on relapse rate and disability during treatment in MS patients.

R WE ready for reimbursement? A round up of developments in real-world evidence relating to health technology assessment

Highlighting the latest developments in both real-world evidence as it relates to health technology assessment and acceptance of real-world evidence by health technology assessment agencies.

Association of Pertuzumab, Trastuzumab, and Docetaxel Combination Therapy With Overall Survival in Patients With Metastatic Breast Cancer

This cohort study compares the findings of combined pertuzumab, trastuzumab, and docetaxel therapy in women with metastatic breast cancer with those in the CLEOPATRA trial.

Comparative effectiveness of trastuzumab emtansine versus lapatinib plus chemotherapy for HER2+ metastatic breast cancer

Aim: To investigate the comparative effectiveness of trastuzumab emtansine (T-DM1) in a real-world population of HER2+ metastatic breast cancer (mBC) patients. Materials & methods: The Flatiron Health database was used to identify a cohort of HER2+ mBC patients who received first-line trastuzumab treatment and T-DM1 or lapatinib plus chemotherapy as second-line treatment. Overall survival was compared between the two groups. Results: A total of 278 patients with HER2+ mBC received second-line T-DM1 and 34 lapatinib plus chemotherapy. Overall survival was longer in patients treated with T-DM1 than those treated with lapatinib plus chemotherapy (adjusted hazard ratio: 0.56; 95% CI: 0.38-0.85). Conclusion: Real-world data supports the effectiveness of T-DM1 in the second-line treatment of HER2+ mBC patients.

Prevalence of Anti-JC Virus Antibody Seropositivity in Patients with Multiple Sclerosis: A Systematic Review and Meta-Analysis

BACKGROUND

The John Cunningham virus (JCV) is the causative agent of progressive multifocal leukoencephalopathy. Anti-JCV antibody seropositivity is an important consideration in patients with multiple sclerosis (MS). The reported prevalence of JCV in MS patients has been conflicting.

OBJECTIVE

We aimed to conduct a systematic review and meta-analysis to estimate the pooled prevalence of anti-JCV antibody seropositivity in cases with MS.

METHODS

We searched PubMed, Scopus, EMBASE, CINAHL, Web of Science, Ovid, ProQuest, Google Scholar, and gray literature including reference of included studies, and conference abstracts which were published up to April 2019. Two independent researchers independently assessed the articles.

RESULTS

The literature search found 181 articles. After eliminating duplicates, reviews, case reports, and trials, 15 articles remained. Finally, 8 articles were included for the final analysis (from Asia, Europe, the USA, and Canada). In total, 16,041 MS cases were analyzed. The prevalence of anti-JCV antibody seropositivity varied between 40 and 80%, and the pooled estimate was calculated as 60% (95% CI: 56-64%), though with significant heterogeneity (I2 = 95%, p = 0.01).

CONCLUSION

The prevalence of anti-JCV antibody seropositivity is variable among MS patients in different countries, and the pooled estimate showed that this is 60% overall.

Propensity score matching and inverse probability of treatment weighting to address confounding by indication in comparative effectiveness research of oral anticoagulants

After decades of warfarin being the only oral anticoagulant (OAC) widely available for stroke prevention in atrial fibrillation, four direct OACs (apixaban, dabigatran, edoxaban and rivaroxaban) were approved after demonstrating noninferior efficacy and safety versus warfarin in randomized controlled trials. Comparative effectiveness research of OACs based on real-world data provides complementary information to randomized controlled trials. Propensity score matching and inverse probability of treatment weighting are increasingly popular methods used to address confounding by indication potentially arising in comparative effectiveness research due to a lack of randomization in treatment assignment. This review describes the fundamentals of propensity score matching and inverse probability of treatment weighting, appraises differences between them and presents applied examples to elevate understanding of these methods within the atrial fibrillation field.

Consistency of recording of chemotherapy cycles in the National Cancer Registration and Analysis Service Systemic Anti-Cancer Therapy database and the Hospital Episode Statistics Admitted Patient Care database

Aim: We assessed the extent to which chemotherapy cycles recorded in Hospital Episode Statistics (HES) Admitted Patient Care (APC) were captured in National Cancer Registration & Analysis Service Systemic Anti-Cancer Therapy (SACT) for a cohort of lung cancer patients. Methods: All chemotherapy cycles recorded for linkage eligible lung cancer patients with a National Cancer Registration & Analysis Service diagnosis between 2012 and 2015 were identified in HES APC and SACT. Results: Among a population of 4070 lung cancer patients, 6076 chemotherapy cycles were observed in HES APC data. A total of 61% of cycles were recorded in SACT on the same day, 8% on a different day and 31% were not recorded in SACT. Conclusion: Our results suggest that SACT may not capture all chemotherapy cycles administered to a patient between 2012 and 2016; however, administrative changes mean data after this period may be more complete.

Risk of Schizophrenia and Bipolar Disorder in Patients With Multiple Sclerosis: Record-Linkage Studies

BACKGROUND

The epidemiology of psychiatric comorbidity in multiple sclerosis (MS) remains poorly understood.

OBJECTIVE

We aimed to determine the risk of schizophrenia and bipolar disorder in MS patients.

MATERIAL AND METHODS

Retrospective cohort analyses were performed using an all-England national linked Hospital Episode Statistics (HES) dataset (1999-2016) and to determine whether schizophrenia or bipolar disorder are more commonly diagnosed subsequently in people with MS (n=128,194), and whether MS is more commonly diagnosed subsequently in people with schizophrenia (n=384,188) or bipolar disorder (n=203,592), than would be expected when compared with a reference cohort (~15 million people) after adjusting for age and other factors. Adjusted hazard ratios (aHRs) were calculated using Cox proportional hazards models.

RESULTS

Findings were dependent on whether the index and subsequent diagnoses were selected as the primary reason for hospital admission or were taken from anywhere on the hospital record. When searching for diagnoses anywhere on the hospital record, there was a significantly elevated risk of subsequent schizophrenia (aHR 1.51, 95% confidence interval (CI) 1.40 to 1.60) and of bipolar disorder (aHR 1.14, 95% CI 1.04 to 1.24) in people with prior-recorded MS and of subsequent MS in people with prior-recorded schizophrenia (aHR 1.26, 1.15-1.37) or bipolar disorder (aHR 1.73, 1.57-1.91), but most of these associations were reduced to null when analyses were confined to diagnoses recorded as the primary reason for admission.

CONCLUSION

Further research is needed to investigate the potential association between MS and schizophrenia and/or bipolar disorder as it may shed light on underlying pathophysiology and help identify potential shared risk factors.

Age at menarche and risk of multiple sclerosis (MS): a systematic review and meta-analysis

BACKGROUND

Some studies have looked at the age at menarche and risk of Multiple Sclerosis (MS).We aimed to conduct a systematic review and meta-analysis to estimate a pooled odds ratio of developing MS by increasing age at menarche.

METHODS

We searched PubMed, Scopus, EMBASE, CINAHL, Web of Science, Ovid, google scholar and gray literature (references of references, congress abstracts) up to 10th April 2019.

RESULTS

The literature search found 312 articles. After eliminating duplicates, reviews, case reports and trials, 18 articles remained. Three articles were ultimately included in the final analysis. Two studies were from Iran, and one from Canada. The pooled odds ratio (OR) for increasing 1 year of age at menarche was 0.88 (95% CI:0.82-0.94), with no significant heterogeneity (I2 = 49%, p = 0.1). Mean age at menarche was significantly different between case and control groups (mean difference = - 0.22, 95% CI = -0.42,-0.02).

CONCLUSION

The result of this systematic review showed that the risk of MS decreases by increasing age at menarche.

Suspected cancer symptoms and blood test results in primary care before a diagnosis of lung cancer: a case-control study

Aim: To compare symptoms and blood test results prior to cancer diagnosis in individuals who developed lung cancer and those who did not. Patients & methods: Nested case-control study, lung cancer patients were matched to up four controls with no record of cancer. Differences in symptoms and blood test results were investigated in the 2-year period prior to diagnosis. Results: 26,379 lung cancer patients were matched to 92,125 controls. Elevated C-reactive protein (CRP) was independently predictive of lung cancer at every 2-month interval 12 months prior to diagnosis. Elevated CRP in conjunction with at least one symptom was associated with greater than fourfold higher odds of lung cancer. Conclusion: CRP may be a prediagnostic marker for lung cancer, and when present with other symptoms could facilitate the investigation of high-risk individuals.

Patient characteristics and stroke and bleeding events in nonvalvular atrial fibrillation patients treated with apixaban and vitamin K antagonists: a Spanish real-world study

Aim: To compare the risk of stroke, systemic thromboembolism and bleeding, in patients initiating apixaban or acenocoumarol for the treatment of nonvalvular atrial fibrillation. Methods: An observational, retrospective study was performed using medical records of patients who initiated apixaban or acenocoumarol between 2015 and 2017. Propensity score matching was used to match patients; stroke, systemic thromboembolism, major and minor bleeding events were compared between the matched patients. Results: Patients who were prescribed apixaban had a lower rate of systemic embolism/stroke (hazard ratio [HR] = 0.54; 95% CI: 0.38–0.78; p = 0.001), minor bleeding (HR = 0.64; 95% CI: 0.52–0.79; p < 0.001) and major bleeding (HR = 0.51; 95% CI: 0.37–0.72; p < 0.001). Conclusion: Patients prescribed apixaban for the treatment of nonvalvular atrial fibrillation had lower rates of thromboembolic events and minor/major bleeding than patients on acenocoumarol.

Incidence of seroconversion and sero-reversion in patients with multiple sclerosis (MS) who had been treated with natalizumab: A systematic review and meta-analysis

BACKGROUND

Natalizumab is a medication of choice for some patients with relapsing remitting (RR) form of multiple sclerosis (MS). John Cunningham virus (JCV) antibody status is important in cases who are treating with natalizumab. Different studies reported various rates of seroconversion and sero-reversion in patients who had been treated with natalizumab. As there is no systematic review reporting incidence of seroconversion and seroreversion in MS cases who were treated with natalizumab, we aimed to conduct this systematic review and meta-analysis to find pooled incidence of seroconversion and seroreversion in MS cases who were treated with natalizumab.

METHODS

PubMed, Scopus, EMBASE, CINAHL, Web of Science, Ovid, and google scholar were systematically searched. We also searched the gray literature including references from included studies, and conference abstracts which were published up to April 2019.

RESULTS

The incidence of seroconversion was reported between 6% and 41% and the incidence of seroreversion was reported between 1% and 11%. The pooled estimate of seroconversion incidence was 19% (95% CI: 13%-25%) (I² = 96.8%, P < 0.001) and the pooled estimate of seroreversion incidence was 5% (95% CI: 3%-8%) (I² = 72.2%, P < 0.001). Subgroup analysis by considering the country of the origin showed that the pooled incidence of seroconversion incidence during the studies was 6% in Asian countries and 21% in European/American countries. The incidence difference between subgroups was significant (p < 0.001).

CONCLUSION

Incidence of seroconversion in MS patients who had been treated with natalizumab is higher in European/American countries than Asian countries.

Automated extraction of treatment patterns from social media posts: an exploratory analysis in renal cell carcinoma

Aim: The use of health-related social media forums by patients is increasing and the size of these forums creates a rich record of patient opinions and experiences, including treatment histories. This study aimed to understand the possibility of extracting treatment patterns in an automated manner for patients with renal cell carcinoma, using natural language processing, rule-based decisions, and machine learning. Patients & methods: Obtained results were compared with those from published observational studies. Results: 42 comparisons across seven therapies, three lines of treatment, and two-time periods were made; 37 of the social media estimates fell within the variation seen across the published studies. Conclusion: This exploratory work shows that estimating treatment patterns from social media is possible and generates results within the variation seen in published studies, although further development and validation of the approach is needed.

Costs of gastrointestinal bleeding events in atrial fibrillation: a UK Clinical Practice Research Datalink study

Aim: To estimate the healthcare costs attributable to gastrointestinal (GI) bleeds in nonvalvular atrial fibrillation (NVAF) patients. Material & methods: A difference-in-differences approach was used in which NVAF patients suffering a (GI) bleed were propensity score matched to those not suffering a GI bleed, and the difference in healthcare costs in the year prior to the GI bleed and the subsequent 3 years was compared between the two groups. Results: The mean cost attributable to GI bleeds was £3989 (p < 0.0001) in the year of the bleed and £1816 (p = 0.001) in the subsequent year. Attributable costs arose primarily from inpatient visits. Conclusion: GI bleeds among NVAF patients are associated with significant healthcare costs up to 2 years following the bleed.

Commonly used definitions in real-world studies may underestimate the prevalence of renal disease among nonvalvular atrial fibrillation patients

Aim: To describe comorbidities among treated nonvalvular atrial fibrillation (NVAF) patients and assess the impact of using different time ('look back' windows) on the prevalence estimates. Patients & methods: We included all adult nonvalvular atrial fibrillation patients newly initiating treatment in the Clinical Practice Research Datalink. Comorbidities included in the Charlson Comorbidity Index were defined using an all available, 3- and 1-year look back window before the start of treatment. Results: The prevalence of comorbidities was high and increased when using longer look back windows; the largest difference was observed for renal disease (+15.6%). Conclusion: Our findings emphasize the importance of using all available data when characterizing chronic conditions and highlights the high comorbidity burden in this population.

Impact of atrial fibrillation awareness campaigns: interrupted time series using the Clinical Practice Research Datalink

Aim: This study investigated whether the rates of atrial fibrillation (AF) consultations changed following AF awareness campaigns in England. Materials & methods: Among adults in the Clinical Practice Research Datalink, Poisson regression was used to model weekly rates of AF-related consultations over time. The models were used to assess whether rates changed in the 8 weeks following World Heart Rhythm Week (WHRW) and Global AF aware week. Results: A higher incidence of pulse checks was observed following WHRW (IRR 1.16 [95% CI 1.08-1.24]). No difference in the incidence of AF diagnoses was noted following WHRW (IRR: 1.03 [95% CI: 0.97-1.09]) or Global AF aware week (IRR: 0.94 [95% CI: 0.88-1.00]). Conclusion: The results suggest AF campaigns may increase awareness but do not bring about short-term increases in the rates of AF diagnoses.

Renal function and oral anticoagulant treatment of incident non-valvular atrial fibrillation: a retrospective study

Aim: To describe the renal function of individuals newly diagnosed with non-valvular atrial fibrillation in England, and describe how oral anticoagulant (OAC) treatment varies according to renal function. Patients & methods: We identified a cohort of individuals with non-valvular atrial fibrillation (n = 18,419) and described their renal function at diagnosis and the prevalence of OAC treatment initiation by renal function. Results: 79% of individuals had some evidence of renal dysfunction with 12% having a glomerular filtration rate <30 ml/min/1.73 m². OAC treatment initiation in the 6 months following diagnosis was lower in individuals with severe renal dysfunction than in those with normal renal function. Conclusion: The high prevalence of renal dysfunction and low OAC treatment prevalence highlights the need for additional evidence regarding OACs in individuals with severe renal dysfunction.

The changing face of venous thromboembolism management in England

Aim: Venous thromboembolism (VTE), which comprises deep vein thrombosis and pulmonary embolism, poses a global disease burden. Vitamin K antagonists have traditionally been the mainstay of treatment; however, the non-vitamin K oral anticoagulants (NOACs) are emerging as an alternative. The relative use of these treatment classes in the real world is unknown. Patients & methods: We performed a retrospective study using data from the UK Clinical Practice Research Datalink to understand VTE treatment patterns. Results: NOACs have unseated vitamin K antagonist as the main form of VTE patient treatment in England. Conclusion: The data highlight how comfortable physicians have become in using NOACs to treat VTE in England and it is likely that the increasing use of NOACs will continue.