Oral Anticoagulants, Health Technology Assessment, and Health Policy

Abstract

I read with great interest a recent article on the reimbursement policy for direct oral anticoagulants and a call for advocacy in this domain.1Stone J.A. Earl K.M. O'Neill B.J. et al.Aligning health care policy with evidence-based medicine: the case for funding direct oral anticoagulants in atrial fibrillation.Can J Cardiol. 2014; 30: 1245-1248Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar I wonder whether the escalating prices of pharmaceuticals should also be scrutinized as a target for physician advocacy in cardiology, as an oncology panel of over 100 experts has done.2Experts in Chronic Myeloid LeukemiaThe price of drugs for chronic myeloid leukemia (CML) is a reflection of the unsustainable prices of cancer drugs: from the perspective of a large group of CML experts.Blood. 2013; 121: 4439-4442Crossref PubMed Scopus (484) Google Scholar Decision making at the population level rests not only at the intersection of clinical evidence and patient preference, but also cost—the finite resources available and the myriad health care needs necessitate a process of ranking competing technological innovations by reimbursement at a price commensurate with their demonstrated efficacy. This is especially important as we observe a decline in therapeutic advancement: of the 192 new active substances approved by the Patented Medicine Prices Review Board between 2001 and 2009, only 19 agents were classified as a product that provides breakthrough or substantial improvement.3Patented Medicine Prices Review Board. Annual Report 2009. Available at: http://www.pmprb-cepmb.gc.ca/CMFiles/Publications/Annual%20Reports/ar09-en-online.pdf. Accessed February 17, 2015.Google Scholar As noted by the authors, Canada has a long and rich history of health technology assessment—for over 25 years, the Canadian Agency for Drugs and Technologies in Health (CADTH) has filled an important role in the economic evaluation of pharmaceutical and medical device products and has seen an increasing level of stakeholder engagement. The lack of alignment between reimbursement and clinical care guidelines can perhaps be traced to the lack of agency integration between technology assessment and guideline production—in the United Kingdom, eg, the National Institute for Health and Care Excellence (NICE) produces both practice guidelines and reimbursement decisions for the National Health Service (NHS), thus eliminating conflicting recommendations. Both NICE and CADTH perform assessment from the perspective of the health care system rather than from a societal perspective; this is befitting, as noted in its methodology document: “NICE works in a specific context; in particular, it does not set the budget for the NHS. The objective of NICE is to offer guidance that represents an efficient use of available NHS … resources.”4National Institute for Health and Care Excellence. The guidelines manual appendix G: Methodology checklist: Economic evaluations. Available at: http://www.nice.org.uk/article/pmg6b/chapter/appendix-g-methodology-checklist-economic-evaluations. Accessed February 17, 2015.Google Scholar This statement is equally applicable in a Canadian context. Rigorous assessment of cost-effectiveness has been shown to lead to lower prices; this is especially important in Canada, which has seen unrivaled growth in pharmaceutical expenditure. We need to redouble our efforts to serve as advocates for fair sustainable pharmaceutical prices to fulfill our duties as responsible stewards of the health care system. The author has no conflicts of interest to disclose. Aligning Health Care Policy With Evidence-Based Medicine: The Case for Funding Direct Oral Anticoagulants in Atrial FibrillationCanadian Journal of CardiologyVol. 30Issue 10PreviewMisalignment between evidence-informed clinical care guideline recommendations and reimbursement policy has created care gaps that lead to suboptimal outcomes for patients denied access to guideline-based therapies. The purpose of this article is to make the case for addressing this growing access barrier to optimal care. Stroke prevention in atrial fibrillation (AF) is discussed as an example. Stroke is an extremely costly disease, imposing a significant human, societal, and economic burden. Stroke in the setting of AF carries an 80% probability of death or disability. Full-Text PDF Open AccessReply to Xu—Oral Anticoagulants, Health Technology Assessment, and Health PolicyCanadian Journal of CardiologyVol. 31Issue 8PreviewWe appreciate Mr. Xu's interest in our recent article discussing misalignment between reimbursement policy and clinical guidelines.1 We suggest a number of contemporary realities that transcend his observations. Full-Text PDF