The Relative Importance of Clinical, Economic, Patient Values and Feasibility Criteria in Cancer Drug Reimbursement in Canada: A Revealed Preferences Analysis of Recommendations of the Pan-Canadian Oncology Drug Review 2011–2017

Abstract

BackgroundMost Canadian provinces and territories rely on the pan-Canadian Oncology Drug Review (pCODR) to provide recommendations regarding public reimbursement of cancer drugs. The pCODR review process considers four dimensions of value—clinical benefit, economic evaluation, patient-based values and adoption feasibility—but they do not define weights for individual decision criteria or an acceptable threshold for any of the criteria. Given this implicit review process, it is of interest to understand which factors appear to carry the most weight in pCODR recommendations using a revealed preferences approach.MethodsUsing publicly available decision summaries (n = 91) describing submissions and resulting recommendations 2011–2017, we extracted ten attributes that characterized each submission. Using logistic regression, we identified statistically significant attributes and estimated their relative impact in final recommendations.ResultsClinical aspects appear to carry the greatest weight in the decision to reject or not reject, along with aspects of patient value (treatments with no alternatives were less likely to be rejected). Cost effectiveness does not appear to play a role in the initial decision to reject or not reject but is critical in full versus conditional approvals. There is evidence of a maximum acceptable threshold of around $Can140,000 per quality-adjusted life-year (QALY) gained.ConclusionA set of factors driving pCODR recommendations is identifiable, supporting the consistency of the review process. However, the implicit nature of the review process and the difficulty of extracting and interpreting some of the attribute levels used in the analysis suggests that the process may still lack full transparency.Electronic supplementary materialThe online version of this article (10.1007/s40273-018-0610-0) contains supplementary material, which is available to authorized users.

New Cancer Drug Approvals From the Perspective of a Universal Healthcare System: Analyses of the Pan-Canadian Oncology Drug Review Recommendations

“…Again, setting an ICER threshold for approval based on indications may allow for a more transparent and homogeneous approval process. Although higher ICER was a predictor of negative pCODR recommendation, which is concordant with a previous analysis suggesting that clinical aspects (rather than cost) carries more weight in pCO-DR decisions, 7 it was interesting to note that neither of the effectiveness measures (HR-OS and HR-PFS) had significant association with a positive pCODR recommendation. Similarly, none of the other cost and/or effectiveness variables were associated statistically with pCODR decisions.…”

“…Previous studies have looked at methodological issues and consistencies in economic evaluations by pCODR. 6,7 Almost all services related to cancer treatment are publicly funded in Canada, and cancer drugs are actively price-negotiated. This poses unique challenges and opportunities, with drug approvals that could vary systematically from private healthcare systems.…”

Factors associated with positive and negative recommendations for cancer and non-cancer drugs for rare diseases in Canada

“…Third, the association between feasibility, one of the factors described in documents emerging from pCODR deliberations, and recommendation type was not evaluated, since similar information was not available for drugs reviewed by the CDR. Nonetheless, adoption feasibility takes into account budget impact, which may be an important consideration during pricing and reimbursement decision-making [30]. Fourth, biomarker and surrogate outcomes were included in the same category due to small sample size.…”

Economic Evaluation of Azacitidine in Elderly Patients with Acute Myeloid Leukemia with High Blast Counts

“…It is also quite sensitive to the cost of azacitidine and to the utilities in both the azacitidine and conventional care regimen. Legend: Prob Dying CCR probability of death when treated with CCR, Prob Dying AZA probability of death when treated with azacitidine, Cost AZA cost of treatment with azacitidine; Cost CCR: conventional care regimen reimbursement decisions for pharmaceuticals [18][19][20]. This study found that azacitidine has an ICER of $Can160,438 per QALY gained compared with CCR and, as such, is above the typically accepted willingness-to-pay threshold for a QALY in Canada.…”