This presentation discusses pharmacoeconomic assessment through different phases of drug development and approval. It provides an overview of different types of pharmacoeconomic analyses including cost-minimization analysis, cost-effectiveness analysis, cost-utility analysis, and budget impact modeling. It emphasizes the importance of real-world pharmacoeconomic assessment to demonstrate the true cost-effectiveness and safety of drugs based on real-world data rather than clinical trials alone. The presentation outlines considerations for planning and implementing real-world pharmacoeconomic assessments, including study design, data collection from multiple sources like electronic health records, and ongoing analysis of updated data streams.
2. Agenda for Today’s Presentation
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o Eat Lunch
o Try to Stay Awake!!!
o Overview of Pharmacoeconomic (PE) Assessment
o Planning PE Assessment
o Real World PE (RWPE) Assessment
o Implementing RWPE Assessment
o Working with Data
o Closing Considerations
o Questions
4. Types of PE Assessment to be Discussed
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o Cost-minimization analysis
o Cost-effectiveness analysis
o Cost-utility analysis
o Budget impact modeling
5. Cost-Minimization Analysis (CMA)
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o Compare costs of two or more drugs or therapies
to determine least costly option
Baseline costs include acquisition costs as well as
costs of preparation and administration
Additional costs depend on perspective of analysis
o Main benefit: cheaper and easier than cost-
effectiveness analysis
o Main drawback: assumption that two drugs or
therapies are used at equivalently effective doses
6. Cost-Effectiveness Analysis (CEA)
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o Considers both costs and effectiveness of two or
more drugs or therapies
Costs measured in monetary unit of interest (Eg, $)
Effectiveness generally measured using one or more
clinical outcome (Eg, years of life saved)
o Main outcome is incremental cost-effectiveness
ratio (ICER): (∆ Costs / ∆ Effectiveness)
Eg, incremental cost per life year saved
o ICER compared against willingness-to-pay (WTP)
thresholds to determine if cost-effective, cost-
saving, or cost-neutral
8. Cost-Utility Analysis (CUA)
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o CEA accounting for quality of time gained or lost
o Quality of life (QOL) measured using utility
Generally ranges from 0 (dead) to 1 (perfect QOL)
o Most common ICER assessed in CUA is cost per
quality-adjusted life year (QALY) gained
9. Budget Impact Modeling (BIM)
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o Generally designed for specific audiences,
particularly third party payers
o Measures net cumulative treatment cost with drug
or therapy of interest for specified number of
patients in particular population
o Impact of particular drug or therapy is assessed
as effect on cost per member per month (PMPM)
10. Perspective of PE Assessment
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o Who pays for treatment and who benefits?
o Potential perspectives include:
Healthcare provider
Third party payer
Society
o Different perspectives mean different considerations
13. PE Assessment at Different Phases
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o Phase II
o Earlier phase III
o Phase III piggyback studies
o Peri-authorization
o Post-authorization
o Contemporaneous with later Phase III is common
but can consider earlier Phase III or Phase II
o Collection of RWPE data?
14. Planning PE Assessment
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o Plan must consider:
Disease area
• Acute vs. chronic vs. oncology?
• Recurrence timeframe?
All relevant phases
Sponsor budget
• CEA for publication vs. BIM for use with payers?
16. Why RWPE?
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o Differentiation in costly yet lucrative landscape
$2.6 billion to bring new drug to market (Tufts CCSD)
o Development cycle does not end with approval
Real world research, including RWPE, can drive new
earlier phase research, in turn driving new real world
research
Sustain value across product lifecycle
o Collect extensive effectiveness and safety data
More relevant than literature-based models
More robust than earlier phase clinical data
o True cost-effectiveness rather than cost-efficacy
17. Are Payers the True Decision Makers?
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o Roles of FDA and payers, including Medicare and
Medicaid, are constantly evolving
Correcting Signals for Innovation in Healthcare
Medicaid expansion under Affordable Care Act
o Drug approval becoming “easier” (Forbes)?
2008: 50% of NMEs approved by FDA
2014: 88% of NMEs approved
o US District Court ruling re: Amarin’s Vascepa®
o Increased emphasis on generation and
dissemination of evidence aimed at payers
Real World Evidence/Outcomes liaisons
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o Three recommendations:
1. Replace tax exclusion for employer-provided health
insurance with tax credit
2. Strengthen Medicare coverage determination
process
3. Experiment with reference pricing for certain
therapies in Medicare
o RWPE can inform last two recommendations
19. Epidemiologic Study Designs
(by Traditional Strength of Evidence)
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1. Randomized controlled trial
2. Community trial
3. Prospective cohort study
4. Retrospective cohort study
5. Case-control study
6. Cross-sectional study
7. Ecologic study
8. Case report or case series
Observational
Interventional
Descriptive
Analytic
Strength of evidence: ability to establish causal link
20. Real World/Observational Epidemiology
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o Data gathered in naturalistic (real world) setting
o Variables of interest include:
Exposure
• Harmful (Eg, behavior) or protective (Eg, drug, vaccine)
Outcome
• Disease or health state
• Time to event
Potential confounders
o If treatment involved, prescribed in usual manner
Therapy assignment not decided in advance by protocol
No diagnostic or monitoring procedures other than those
ordinarily applied
21. RWPE Builds on Observational Epidemiology
o Registries are cohort studies
Specifically prospective and retrospective cohort studies
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24. RWPE Means Dynamic
Data Collection and Analysis
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o Specifically, continually updated data streams
allow for refinement of CEA and BIMs to reflect
most up-to-date data, providing consistently
refreshed ICER and PMPM cost estimates
o How is this implemented?
Dedicated processes
25. Dedicated Processes for RWPE
o Protocol must describe study challenges and
methods for resolution, while addressing (Giezen
et al. 2009, Kiri 2012):
Ecological validity
Achievable study objectives
Tailored operational processes
Study Design and Protocol
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26. Dedicated Processes for RWPE
o Ensure straightforward navigation for electronic
case report forms (eCRFs)
o Provide guidance for online queries
o Design database to be flexible and easy to use
o Include all stakeholders in design as well as any
changes
Sites
Analysts
Submissions team (if relevant)
eCRF Design and Development
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27. Dedicated Processes for RWPE
o Obtain permissions and licenses
o Validate per FDA guidance
o Address HIPAA and security concerns
o Plan for incorporating PRO data into PE
assessment
Ie, primary EQ-5D scores are preferred source of
utility data for NICE
Patient Reported Outcomes (PROs)
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28. Dedicated Processes for RWPE
o Incorporate alerts into analysis dataset programs
o Use templates designed for repeated delivery
o Design output programs with locked, validated
modules as well as modules that are intended to
evolve and change
o Structure eCRF rules to promote easy updates
o Normalize dataset design and use of metadata to
support multiple data cuts
Programming and Data Governance
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30. Merging Data from Multiple Sources
o RWPE involves coordination with healthcare
providers and payers to collect regularly
refreshed, relevant data such as electronic health
records (EHR), PROs, and costs/reimbursements
o Timing and costs of implementation are concerns
o Therefore, data collection must be as efficient as
possible
Efficiency derives from well-designed and well-
integrated electronic data capture (EDC) system
The Crux of the Matter for RWPE
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31. Cost/Reimbursement Data Sources
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o Patient records at doctor’s office
CMS 1450 (UB04 Uniform Bill)
o Claims databases
Medicare and private
o Coding
CPT, other codes
o RED BOOK
o Published literature
o Government reports
32. o Real world effectiveness study
Prospective cohort
Retrospective cohort
o Claims data
Standalone
Link with study data
Data Sources: Effectiveness and Claims
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=
Payer
Study
Payer Study
33. Merging Data from Multiple Sources
CDISC Healthcare Link Initiative
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34. Merging Data from Multiple Sources
FDA EHR Demonstration Project
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35. Merging Data from Multiple Sources
National Claims Database?
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36. Merging Data from Multiple Sources
o Standardize any coding as well as definitions of events
and outcomes (Abbing et al. 2010, Blake et al. 2012,
Andrews et al. 2012)
o Foster harmonization across multiple sources by using
common data model (Coloma et al. 2011)
Standardized input files can be created from each
database, linked via patient ID, and managed locally
o Develop storage system making individual databases
accessible from common platform as anonymized data
at appropriate level
Based on common data model in compliance with
guidelines relevant for each database (Trifirò et al. 2014)
Process should involve stakeholders for each database
Some Thoughts
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37. Target Data for Hybrid EHR Sourcing
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Problem data for
EHR systems
Stop dates
Scaled data
Surveys/PROs
Costs
Better data for
EHR systems
Coded for payments
Already transactional
(lab systems,
pharmacy)
Most problematic
data for sites
High volume
Complex
Query-prone
Research vs.
Healthcare
Labs
Meds
39. Recruitment and Retention
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o Well-integrated EDC, EHR, and ePRO will
enhance retention of sites and patients
o Recruitment populations for RWPE studies differ
from populations for interventional trials
o RWPE studies tend to be longer
Direct impact on site motivation
o Gauging and developing site experience and
motivation are essential in optimizing enrollment
Establishing study expectations from outset
Capacity for integration with EDC?
Training?
40. Too Much of a Good Thing?
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41. In Other Words…
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o … is RWPE worth the hassle?
o Blommenstein et al. conclude…
o In short, YES, if done properly and efficiently
42. Future Considerations
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o Product development cycle does not end with
approval
o PE assessment in earlier and later phases,
including RWPE, is essential to demonstrating
product value
o Real world research, including RWPE, can drive
innovation
o RWPE demonstrates market leadership
o Flexibility is essential