Recent Trends in Oncology Appraisal Decisions: NICE vs. SMC
England’s NICE and Scotland’s SMC are responsible for issuing appraisal guidance for reimbursement of new health technologies in their respective countries. Xcenda wanted to understand the similarities and differences in approaches to oncology decision making between NICE and SMC.
HTA QUARTERLY | SPRING 2018
Recent Trends in Oncology Appraisal Decisions: A Comparison Between the National Institute for Health and Care Excellence (NICE) and the Scottish Medicines Consortium (SMC)
As part of the appraisal process, both NICE and SMC consider the economic value of drugs in terms of cost-effectiveness as measured by the ICER. Based on publicly available information, the ICER submitted by the manufacturer to SMC and the ICER calculated by the Evidence Review Group (ERG) for the NICE committee were analyzed. Comparing the cost-effectiveness of these evaluations, all 18 NICE decisions with reported ICERs from the ERG of less than £30,000 received favorable guidance; however, the guidance from SMC was more varied. For the 28 SMC decisions with a reported ICER of less than £30,000, 46% (13) were favorable, 43% (12) were mixed, and 11% (3) were unfavorable (Table 1).
Pairs of decisions between NICE and SMC were compared when both agencies evaluated a single drug for the same indication. These decision pairs were classified into 3 categories based on their level of agreement between the appraisal result: matched (ie, both decisions were the same), similar (ie, one agency’s decision was favorable and the other agency’s decision was mixed), or discordant (ie, one agency’s decision was unfavorable and the other’s was favorable/mixed). Between agencies, 53 pairs of decisions matched across 14 tumor types and indications; of those, 33 (62.3%) matched exactly, 7 (13.2%) were similar, and 13 (24.5%) were discordant (Figure 2).
Upon analyzing the decisions by tumor type, the most common NICE and SMC oncology decisions were for non-small cell lung cancer (NSCLC) with 10 decision pairs, followed by melanoma with 9 decision pairs (Table 2).
The analysis of NICE and SMC oncology appraisals provides useful insights, but there are a few important limitations to recognize. First, the ICERs utilized in this analysis were from publicly available sources, and manufacturers often provide confidential discounts to NICE and SMC as part of a patient access scheme (PAS). As a result, the final ICER accepted by the HTA agency is often unknown and likely is lower than reported publicly. Secondly, NICE and SMC guidance may designate specific subpopulations or include other access restrictions that should be considered when comparing the agencies’ decisions. Lastly, the time between NICE and SMC decision pairs varied and may reflect different clinical and economic evidence if new data were generated between submissions.
Overall, NICE and SMC are largely aligned when considering appraisals across tumor types, with the majority (75.5%) of oncology HTA decisions being the same or similar. However, compared to NICE, there appears to be less association between the reported ICERs and SMC appraisal decision results. This observed difference may result from NICE having both the manufacturer-submitted ICER and the ICER proposed by the ERG, whereas SMC has only the manufacturer-submitted ICER for consideration. Compared to previous research on rare-disease decisions, the recommendation rate (favorable or mixed) observed in oncology compared to rare diseases was lower for NICE (68.1% vs 76%, respectively) but higher for SMC (67.3% vs 60%, respectively). While this analysis demonstrates the concordance between NICE and SMC oncology HTA decisions that have been observed in other therapeutic areas and previous research, this study found the agencies still disagreed on approximately 25% of decisions. These findings highlight the need for manufacturers seeking access in the UK to develop a comprehensive strategy that addresses each country’s market-specific evidentiary requirements.
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