A structured methodology for essential medicines lists and health emergency stockpiles: Experience with the Emergency Medicines Buffer Stock in the United Kingdom.

INTRODUCTION: Formularies of essential medicines, such as Essential Medicines Lists (EMLs) and health emergency stockpiles, are intended to be always available, including in emergency situations, acting as important tools for access to medicines. The Emergency Medicines Buffer Stock (EMBS) in the United Kingdom (UK) was a stockpile of critical medicines managed by the UK Department of Health and Social Care (DHSC). We propose a new methodology for selecting and including medicines in EMLs and health emergency stockpiles and empirically apply it for selecting medicines in the case of the UK EMBS. METHODS: We used Multi-Attribute Value Theory and Portfolio Decision Analysis to develop a three-phase methodological framework for medicines selection, involving: (i) the decision context definition and selection of evaluation criteria, (ii) the therapeutic area prioritisation, and (iii) the medicines value-for-money evaluation and product selection. The EMBS application took place in 2018-2019 and focused on therapeutic area prioritisation, involving primary data collection through expert interviews (n = 4), a workshop with DHSC decision-makers (n = 13), and an online survey with National Clinical Directors and relevant experts (n = 24). A Monte Carlo simulation supported therapeutic area prioritisation using the British National Formulary (BNF) classification. FINDINGS: Two criteria sets were selected for i) therapeutic area prioritisation, reflecting the value concerns of population need and shortage severity, and ii) medicines evaluation, reflecting magnitude of clinical benefit and supply vulnerability, among others. Primary evidence was collected for "national need" and "shortage severity", based on which a "population health loss" index was developed. A total of 51 therapeutic areas were ranked using their index value while assessing the robustness of the ranking. The top ranked therapeutic area was antisecretory drugs and mucosal protectants, closely followed by diabetes drugs. CONCLUSIONS: The methodological application generated a ranking of therapeutic areas based on expected "population health loss" index, while addressing evidence uncertainty. The methodology can be adapted for other EMLs and emergency stockpile contexts to inform medicines selection.

Multiple Criteria Decision Analysis for HTA across four EU Member States: Piloting the Advance Value Framework.

Multiple Criteria Decision Analysis (MCDA) has emerged as a methodology for Health Technology Assessment (HTA). However, limited empirical evidence is available on its use by decision-makers; where available, it only comes from single-setting exercises, while cross-country comparative studies are unavailable. This study applies the Advance Value Framework (AVF), an MCDA methodology for HTA based on multi-attribute value theory, through a series of case studies with decision-makers in four countries, to explore its feasibility and compare decision-makers' value preferences and results. The AVF was applied in the evaluation of three drugs for metastatic, castrate resistant, prostate cancer (abiraterone, cabazitaxel and enzalutamide) in the post-chemotherapy indication. Decision conferences were organised in four European countries in collaboration with their HTA or health insurance organisations by involving relevant assessors and experts: Sweden (TLV), Andalusia/Spain (AETSA), Poland (AOTMiT) and Belgium (INAMI-RIZIV). Participants' value preferences, including performance scoring and criteria weighting, were elicited through a facilitated decision-analysis modelling approach using the MACBETH technique. Between 6 and 11 criteria were included in each jurisdiction's value model, allocated across four criteria domains; Therapeutic Benefit criteria consistently ranked first in relative importance across all countries. Consistent drug rankings were observed in all settings, with enzalutamide generating the highest overall weighted preference value (WPV) score, followed by abiraterone and cabazitaxel. Dividing drugs' overall WPV scores by their costs produced the lowest "cost per unit of value" for enzalutamide, followed by abiraterone and cabazitaxel. These results come in contrast with the actual country HTA recommendations and pricing decisions. Overall, although some differences in value preferences were observed between countries, drug rankings remained the same. The MCDA methodology employed could act as a decision support tool in HTA, due to the transparency in the construction of value preferences in a collaborative manner.

[Rapid improvement in vision and visual field after olfactory groove meningioma operation]. / Rasanter Visusanstieg und Gesichtsfeldverbesserung nach Olfaktoriusmeningeomoperation.

This article reports the case of a 46-year-old female patient with a large olfactory groove meningioma (56 × 60 × 52 mm). Postoperatively, the patient rapidly experienced a significant improvement in vision and visual field, which initially was greatly impaired (initial vision 0.2 and circular impairment of the visual field of the left eye). The meningioma was resected by a frontal, osteoplastic craniotomy. Even on the sixth postoperative day, the vision and the visual field had completely recovered. An operative approach is indicated in large meningiomas targeting a complete resection.