There is a lack of Health-Technology-Assessment (HTA) tools in pharmacy practice and the collection of real-world-evidence (RWE) in community pharmacy to populate longer-term-disease-progression-modelling (1). This project is looking at the development and application of a novel Patient-Reported-Outcome- Measure (PROM) in community pharmacy that can enable: the evaluation of the quality of care delivered from the patient perspective in terms of economic impact, patient health outcomes and ‘utilities’; the collection of RWE and evaluate long-term effect of care; to provide different stakeholders with unique evidence-based information that help formulate health policies in community pharmacy that are safe, effective, patient-focused and cost-effective, balancing access to innovation and cost containment.

Evidence from the Italian-Medicine-Use-Review (I-MUR) trial (2) showed that the I-MUR intervention provided by community pharmacists to asthma patients is effective, cost-saving and cost-effective (3). The trial allowed to model a framework (I-MUR-HTA) that would enable to routinely deliver the intervention, but also collect and analyse PROM data on its clinical-effectiveness, quality-of-life and cost-effectiveness. I-MUR-HTA was discussed within three expert-panel discussions including policy-makers, commissioners, academics, healthcare-professionals and patient-representatives in Italy, United Kingdom and Europe. Current plan include testing the use of the tool in the real world environment.

Evidence collected from the panel discussions confirmed that I-MUR-HTA evidence-based information is relevant to meet current National-Health-Care-System plans and this is what is needed to support the evaluation of innovative effective and cost-effective health policies and promote their implementation across nations. Current Italian law on pharmacy services provides the appropriate institutional framework to regulate the introduction of I-MUR-HTA across the territory. Its implementation is underway and a real-world pilot is planned to take place in Italy.

I-MUR-HTA appears to be an innovative tool to promote active patient involvement into policy-decision-making and pharmacy-service.

Understanding the current landscape of patient engagement across value decision-making bodies internationally is a critical first step toward improving the patient centricity of Health Technology Assessment (HTA). This study assessed: (i) Terms and definitions used; (ii) Patient engagement opportunities; (iii) Evidence of patient engagement.

A sample of country-specific HTA's (HTA; n = 6), professional organizations (PO; n = 4), and collaborations/independent organizations (CO; n = 3) was selected for representativeness. Information was gathered through: (i) targeted web search and (ii) emailing organizations directly. Definitions, HTA methods documents, and the three most recent evaluations were identified, abstracted, and compared. Data were collected between September-October 2016.

Numerous terms are used to describe patient engagement: patient input (HTA = 1, PO = 1), patient-group submitted information (HTA = 1), cooperation with patients/users (HTA = 1), public consultation (HTA = 1), patient perspectives (HTA = 1, PO = 1), involvement of people affected (HTA = 1), patient involvement (HTA = 2), patient and public involvement (HTA = 1), lay involvement (HTA = 1), inclusion of patient representative (PO = 3), patient reports (PO = 1), patient preference (PO = 2), public consultation (CO = 1), stakeholder consultation (CO = 1), open input (CO = 1), stakeholder engagement (CO = 1), and patient participation (CO = 1). Opportunities for patient engagement were described as: patient questionnaire (HTA = 2); comment period (HTA = 1; CO = 1); committee participation (HTA = 3; PO = 3); propose topics (HTA = 1); draft guidance (HTA = 1); general stakeholder forum (CO = 1). While organizations outline opportunities for patient engagement, not all organizations have clear evidence the practices are used or have impact. Recent evaluations demonstrate clear evidence of engagement (HTA = 2); Unclear or mixed evidence (HTA = 1; PO = 1; CO = 2); No evidence (HTA = 3; PO = 3; CO = 1).

There is substantial heterogeneity in the terms used to describe patient engagement activities across organizations. While a variety of opportunities for patient engagement are described, lack of clear evidence to how patient engagement practices are consistently used may contribute to the perception that engagement by HTAs.

Rapid reviews are of increasing importance within Health Technology Assessment (HTA) due to the need for timely evidence to underpin the assessment of new technologies as well as financial constraints. There are many rapid review methods available (1) although there is little guidance as to the most suitable methods (2). A recent paper outlines issues to consider when selecting rapid review methods (3). The aim of this presentation is to present key aspects to consider when selecting rapid review methods.

We searched the evidence base for guidance on the selection of rapid review methods. We also examined three recently completed systematic reviews to identify rapid review methods used, the reasons for selection and the strengths and weaknesses of each method. Finally we identified key aspects to consider when selecting rapid review methods.

The evidence on guidance identified for the selection of rapid review methods was very limited. The analysis of the three reviews found that each review had distinctly different challenges, such as large numbers of relevant trials and heterogeneity in terms of populations, interventions, comparators and outcomes. All reviews included at least ten randomized controlled trials and numerous outcome measures. Three different approaches to the rapid review of the evidence were used in the three reviews. Key themes to consider when selecting rapid review methods were identified. These include: the size and nature of the evidence base, the characteristics of included studies and the expectations of those commissioning the review.

Rapid review methods need to be chosen to fit the needs of the review, each of which may have different challenges. Collaboration between those producing rapid reviews and commissioners is crucial when choosing methods to ensure that the needs of commissioners are met and limitations associated with the chosen methods are understood.

The expanding range of disease modifying therapies (DMT) for relapsing-remitting multiple sclerosis (RRMS) has led to increased interest in the relative effects of different DMTs. Previous mixed treatment comparisons (MTCs) have used different methods to address similar questions highlighting the need for a consistent approach to the assessment of treatments in RRMS.

We compared the methodology of six published MTCs of DMTs for RRMS identified by a systematic search of the literature. We assessed sources of evidence, DMTs included, outcomes reported and methods of data synthesis.

All six MTCs were based on systematic reviews that included randomized controlled trials (RCTs). MS relapse was reported as the rate ratio based on annualised relapse rates (four MTCs) and as odds ratios or relative risk (one MTC each) based on the proportion with relapse. The analysis of relapse included between sixteen and twenty-seven RCTs and seven to twenty DMTs in different MTCs. One MTC reported both disability progression confirmed after three months (CDP3M) and disability progression confirmed after six months (CDP6M) as hazard ratios. One MTC combined CDP3M and CDP6M as a single outcome. One MTC reported only CDP3M based on hazard ratios. Two MTCs reported only CDP6M as either odds ratios or risk ratios (one MTC each). In one MTC the definition of disability progression was not reported. The analysis of disability included between seven and twenty-six RCTs and between six and nineteen DMTs in different MTCs. All six MTCs fitted a random effects MTC model using either Bayesian (four MTCs) or frequentist (two MTCs) methods.

There is substantial heterogeneity between published MTCs in RRMS with regard to inclusion criteria, outcome definitions, effect measures and statistical methods. There is a clear requirement for a consistent approach to health technology assessment of DMTs for RRMS.

Alzheimer's disease (AD) is the most common type of dementia. Plasmapheresis is a procedure consisting of removing the plasma, or specific elements which are considered to be involved in pathological processes. Plasmapheresis could reduce the A beta peptides load in the brain. The objective is to study the safety and efficacy of plasmapheresis for AD.

Systematic review, with all studies published before April 2016 reviewed. Selected studies included patients with AD treated with plasmapheresis. GRADE was used to assess quality. Efficacy outcomes include: (i) Cognitive, functional and behavior status, through Mini Mental State Examination, and Alzheimer Disease Assessment Scale-Cognitive test; (ii) Plasma and cerebrospinal fluid A beta levels; (iii) Brain-imaging and functional neuroimaging studies. Safety outcomes included side effects related to the treatment.

Two papers reporting results from three studies were selected: (i) pilot study (n = 10), (ii) its extended study (12 months more of follow-up) (n = 7), and (iii) clinical trial (n = 39). The quality of evidence was very low. About efficacy, the studies didn't report quantitative results and were inconclusive. The pilot study and its extended study reported (1): a tendency towards stabilization in cognitive status; the plasma levels of A beta peptides didn't show a clear pattern; and the brain-imaging assessment suggested a progressive volume increase in the hippocampus. The clinical trial reported in the experimental group vs control (2): a better score for the cognitive status; an increase of plasma A beta peptides; and did not find significant differences between groups for cerebrospinal fluid A beta peptides. The brain-imaging assessment showed a progressive loss of hippocampus volume in both groups. Regarding safety, the studies didn't report quantitative data. We didn't find economic evaluation studies.

The included studies had very high risk of bias and very low quality. We found no evidence on efficacy and safety of plasmapheresis treating AD. Plasmapheresis isn't a priority line in research of AD treatment.

A Health Technology Assessment (HTA) systematic review was undertaken in rheumatoid arthritis (RA) of treat-to-target (TTT) studies (n = 16) in which studies were grouped according to: TTT versus usual care, trials comparing different targets, or trials comparing different treatment protocols. To our knowledge, this was the first RA TTT review where studies were grouped in this way. We wanted to compare if our approach had been adopted in reviews of hypertension, hyperlipidemia or diabetes.

We searched MEDLINE for systematic reviews (SRs) of TTT studies in hypertension, hyperlipidaemia or diabetes.

Eleven SRs were included; eight were in diabetes, and four were in hypertension, while none were in hyperlipidaemia. The diabetes SRs evaluated different insulin regimens (n = 3), non-insulin medications (n = 1), any antidiabetic treatment (n = 2), metformin monotherapy versus combination therapy (n = 1), and tight versus conventional glucose control (n = 1). The metformin review grouped studies by outcome whereas all other diabetes SRs grouped studies by treatment. Two hypertension SRs evaluated the effects of any treatment on two blood pressure targets, whereas one evaluated two different treatment regimen effects on the same blood pressure target. No SR in hypertension or diabetes included a mix of TTT versus usual care, and/or same treatment protocol different targets, and/or different treatment protocols same target study designs.

In RA TTT does not refer to a single concept but a range of different approaches to the treatment of patients and the evidence reflects this. Whilst our approach to grouping RA TTT studies in a review was novel, this made it complex for us to synthesize evidence and draw general conclusions. We did not identify any TTT reviews in hypertension or diabetes including a mix of the TTT approaches we identified in RA. At present, a comparison of the strengths and limitations of our TTT review study grouping with reviews of hypertension, hyperlipidemia or diabetes cannot be made.

Knotless barbed sutures can eliminate knot tying when patients are undergoing cosmetic surgery (CS). Although benefits reported on clinical outcomes are obvious, many studies have failed to demonstrate the potential for barbed sutures to mitigate adverse events. Thus, this study aimed to determine the safety of knotless barbed suture in CS.

PubMed, EMBASE, Cochrane Register of Clinical Studies, and ClinicalTrials.gov were searched for randomized controlled trials (RCTs) and cohort studies comparing barbed sutures with conventional sutures in CS (until 30 June 2016). Quality assessment was conducted using Cochrane recommendations. Review Manager was applied to analyze the data, and we sequentially omitted each study to perform sensitivity analyses.

A total of five RCTs (low to moderate risk of bias) and six cohort studies (low to moderate risk of bias), proved eligible (3,481 patients). The CS included body contouring operations, breast reconstruction, lipoabdominoplasty, abdominoplasty and wound closure of cesarean delivery. Comparing to conventional sutures, pooling data showed that general adverse events of barbed sutures were not significantly different (Odds Ratio, OR = .6, 95 percent Confidence Interval, CI .24 to 1.52, P = .28), while the subgroup analysis showed that fewer adverse events occurred in cohort studies, though with high heterogeneity (I2 = 87 percent). Specifically, no significant differences were shown between barbed and traditional sutures in wound dehiscence (OR = .55, 95 percent CI .29 to 1.03, P = .06), incisional infection (OR = .56, 95 percent CI .22 to 1.48, P = .25), seroma (OR = .87, 95 percent CI .42 to 1.79, P = .70) and hematoma (OR = 1.52, 95 percent CI .29 to 7.99, P = .62).

No differences were found between knotless barbed sutures and conventional sutures generally, but the cohort studies suggested barbed sutures resulted in fewer adverse events with longer follow-up. Thus barbed sutures are considered a safe surgical technique in CS. More evidence with larger sample sizes and longer follow up are needed to confirm the advantages of this technique in the future.

New approaches are needed to safely reduce emergency admissions to hospital by targeting interventions effectively in primary care. A predictive risk stratification tool (PRISM) identifies each registered patient's risk of an emergency admission in the following year, allowing practitioners to identify and manage those at higher risk. We evaluated the introduction of PRISM in primary care in one area of the United Kingdom, assessing its impact on emergency admissions and other service use.

We conducted a randomized stepped wedge trial with cluster-defined control and intervention phases, and participant-level anonymized linked outcomes. PRISM was implemented in eleven primary care practice clusters (total thirty-two practices) over a year from March 2013. We analyzed routine linked data outcomes for 18 months.

We included outcomes for 230,099 registered patients, assigned to ranked risk groups.

Overall, the rate of emergency admissions was higher in the intervention phase than in the control phase: adjusted difference in number of emergency admissions per participant per year at risk, delta = .011 (95 percent Confidence Interval, CI .010, .013). Patients in the intervention phase spent more days in hospital per year: adjusted delta = .029 (95 percent CI .026, .031). Both effects were consistent across risk groups.

Primary care activity increased in the intervention phase overall delta = .011 (95 percent CI .007, .014), except for the two highest risk groups which showed a decrease in the number of days with recorded activity.

Introduction of a predictive risk model in primary care was associated with increased emergency episodes across the general practice population and at each risk level, in contrast to the intended purpose of the model. Future evaluation work could assess the impact of targeting of different services to patients across different levels of risk, rather than the current policy focus on those at highest risk.

This study examined the technical efficiency determinants of each Organisation for Economic Co-operation and Development (OECD) country's behavioral health system (BHS).

The technical efficiency of each OECD country's BHS was analyzed through data envelopment analysis with model combinations ranging from 1–11 models, with each model constructed with different BHS input and output variable combinations. A decision tree was generated from the efficiency scores of the model with the highest mean technical efficiency score as a predictor variable. Data was obtained from 2013 OECD and Eurostat statistics.

Different model combinations indicated that the model with the highest mean technical efficiency score (.9214) for OECD countries included (i) input variables for smoking, alcohol consumption, daily fruit consumption, the number of psychiatrists, the percentage of live births of young mothers first children, and the time devoted to leisure and personal care and (ii) output variables for death rate by mental and behavioral disorders, diabetes hospital admissions in adults, and suicide rates. Among all model combinations, >45 percent of OECD countries have an efficient BHS. The decision tree graph shows that daily fruit consumption, smoking, and suicide rates are predictor variables of the technical efficiency of an OECD country's BHS.

The study results offer important insights regarding the development of BHS in OECD countries. Health policymakers must develop collaborative activities and implement comprehensive policies promoting internationally-oriented BHS in order to improve the health status of people worldwide and reduce health inequality.

The Comprehensive Public Healthcare System of Catalonia (SISCAT) Atlases of Quality aim to evaluate the quality of care in relation to specific diseases or procedures in the Catalan territory with a focus on outcomes of care in order to promote best practices. The first Atlas of Quality aimed to assess the quality of integrated care for chronic patients.

Methodology was articulated in four stages:(i) Establishment of a conceptual framework of reference specific for each intervention/technology being assessed, (ii) Definition and consensus of the assessment indicators, and (iii) Implementation of indicators using the Basic Health Areas (ABS) of Catalonia as a unit of analysis, comparing ABS with vs without the intervention (such as integrated care for chronicity). Indicators were obtained from the SISCAT databases and implemented through risk adjustment models. For performance assessment, we calculated the observed and expected indicator rates for each ABS, and for the benchmarking analysis, these ratios were represented in funnel plots (Confidence Interval, CI 95 percent and 99.8 percent for exclusion zones). (iv) Evaluation of the intervention and identification of specific success factors.

For the assessment of integrated care interventions for chronicity, the defined framework in stage 1 was base on the Kaiser Pyramid (population distribution), and the Porter and the Donabedian's approaches (structure, processes, outcomes) (1). In stage 2 more than 500 experts, using several qualitative techniques, considered 18 indicators as relevants and feasibles for the assessment (2). Ten of them were implemented in stage 3 for congestive heart failure and pulmonary obstructive chronic disease. Significant values were found both in ABS with and without chronicity care programms (phase 3).

The subsequent analysis (phase 4) will allow identification of practices of each ABS that best explain these results. Some limitations must be considered such as the availability of the consensued indicators in the SISCAT databases.

Ceroid lipofuscinosis neuronal 2 (CLN2) disease, a form of Batten disease, is a rare, degenerative neurometabolic disorder. Disease onset around 2–4 years is followed by rapid decline in motor and neurologic function and mortality in early teenage years (1). Disease burden is best captured using observer-reported outcomes. However, validation is challenging in ultra-orphan diseases, requiring flexible methods and reasonable acceptance of limitations related to participant access.

The study aim was to assess content validation of clinical trial measures (i) CLN2 Disease Based Quality of Life Assessment (Sponsor-developed), (ii) EQ-5D-5L, (iii) Pediatric Quality of Life Inventory (PedsQL); and (iv) PedsQL Family Impact Module.

The Batten Disease Family Association recruited United Kingdom caregivers of a child with CLN2 disease (aged 3–7 years, non-participants in any CLN2 trial), to:

1. 1. Focus groups with symptom elicitation

2. 2. Cognitive interviews to assess measures.

The Focus group comprised eleven caregivers (eight female, three male) from six families. Three families were current caregivers and remainders bereaved. Symptom and disease impact elicited showed the majority of measures domains were relevant.

The interview sample comprised sixteen current caregivers (twelve female, four male) from ten families (caring for eleven children). Overall measures were relevant, easy to understand and answer. However several items were difficult to apply to children with advanced disease (for example, Euroqol, EQ-5D-5L “overall health”), when ability is lost (for example, PedsQL walking), with misinterpretation of “no difficulties” with eating where child feeds using gastrostomy (CLN2 QoL). Caregivers found it difficult to know how their uncommunicative child was feeling (PedsQL worrying, EQ-5D-5L depression). Some symptoms and impacts were missing (for example, constipation, working life).

The mixed-methods approach enabled content validity assessment of multiple measures. While these measures were largely relevant, adjustments could strengthen these for use in this fatal pediatric condition population and increase their acceptance within health technology assessment (HTA).

Anti-tumor necrosis factor drugs (anti-TNF) are the last line of treatment for psoriatic arthritis (PsA) in the guideline of Brazilian Public Health System (SUS). Data of effectiveness of these drugs are scarce in the Latin American population. This study evaluated the effectiveness of the anti-TNF on a cohort of patients with PA in the SUS.

PsA patients treated with anti-TNF, were included in an open prospective cohort study. The Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Clinical Disease Activity Index (CDAI) were used to assess the effectiveness at six months of follow-up. The anti-TNF was considered effective when the patient achieves scores of four or less measured for BASDAI or scores of ten or less for CDAI. Frequency distributions were compiled for the sociodemographic variables and mean and standard deviation (SD) was used for clinical variables. The paired Student t-test was established to evaluate the differences between baseline and 6 months evaluated for BASDAI and CDAI.

Fifty-four patients with PsA completed six months of follow-up. The mean age of patients was 54.03 years (10.44) and the mean disease duration was 8.00 years (7.49). Furthermore, 50 percent of the patients were female, 61.1 percent white and 59.6 percent married. The most used anti-TNF was adalimumab (63.0 percent), followed by etanercept (20.4 percent) and infliximab (16.7 percent). The anti-TNF reduced disease activity measured by BASDAI and CDAI at six months of follow-up (p<.001). The percentage of patients achieving the effectiveness with anti-TNF was 61.1 percent measured by BASDAI and 53.7 percent by CDAI.

Anti-TNF drugs demonstrated to be effective in more than half of patients at six months. This result highlighted the importance of the treatment with the anti-TNF drugs in the Brazilian population. Long-term data are needed to confirm these results.

Older people with cancer are less likely to receive radical treatment for cancer. We conducted a series of systematic reviews to explore the effectiveness and tolerability of systemic anti-cancer therapy for older people with cancer. The reviews were conducted on behalf of the National Cancer Equality Initiative to establish an understanding of the current body of research and to enable the development of more personalized treatment protocols for elderly patients that take into account fitness and personal choice.

We conducted six systematic reviews that considered the effectiveness and tolerability of treatment for older people with cancer (breast, colorectal, lung, renal cell, chronic myeloid leukaemia and non-Hodgkin's lymphoma). Four electronic databases were searched from 2010 to 2013. Data were extracted on a range of outcomes from published studies (randomised controlled trials, subgroup analyses, pooled analyses, cohort studies and retrospective studies).

We found a large quantity of published research from a wide range of study types. We included a total of 490 studies (64 randomized controlled trials, 30 subgroup analyses, 24 pooled analyses, 255 cohort studies, and 117 retrospective studies).

Most of the randomized controlled trials enrolled fitter and healthier patients than those seen in routine clinical practice. The evidence indicates that older patients with good performance status can, and do, respond well to chemotherapy, frequently achieving similar survival benefit to younger patients.

We found no consistent definitions of ‘old’ or ‘elderly’ and these varied from 50 years to 85 years across studies.

The study results demonstrate that comprehensive geriatric assessment has not been routinely conducted in clinical cancer studies and that readily available assessment tools were not used by study investigators.

Age should not be a barrier to treatment for the older population. Research is needed to determine which treatment regimens offer the appropriate balance of clinical effect and likelihood of adverse events within older populations. Future randomized controlled trials could be designed to include either higher proportions of older people, or only older people.

Drug prices are mainly determined by production costs, commercial circulation and use in medical institutions. In 2015, total sales of the Chinese drug distribution industry was CNY1,613.3 billion (USD248.6 billion at 31 December 2015 exchange rate), with CNY28.3 billion (USD4.4 billion) profit and an average cost rate of 5.4 percent due to high logistics costs (1). Under Multi-invoice Systems in China, drugs are delivered through national, provincial, local agents, with invoiced and prices going up each time (2). The Two-invoice System, which comes up in April 2016, is China's first drug distribution policy aiming to compress circulation, and reduce unrealistically high prices. There will be only two invoices, one from production enterprises to distributors, the other from distributors to medical institutions. The objective of this study is to evaluate the effect of the Two-invoice System on drug distribution and price in China.

We conducted a literature review of relevant articles and policies in five provinces on China National Knowledge Infrastructure (CNKI), Wanfang, PubMed and government websites. We conducted in-depth individual interviews for qualitative research on policy mechanisms with two government officials and four drug production and distribution enterprise managers. The quantitative study on policy effect measured indicators, namely, number of distributors, concentration ratio index (CR), net sales ratio, and ex-factory price. We compared the pilot province before and after the policy, with national level and other provinces. We considered related drug policies to eliminate confounding. Focus group discussion on conclusions and suggestions will be conducted.

There are no peer review articles, only news media on this topic. In Fujian Province, the number of distributors droped from 246 to 62. In 2015, the Top 3 drug wholesalers reached a market share of 36 percent (CR3), and Top 10 for 86 percent (CR10). Compared to the whole country, CR3 is 26 percent and CR100 is 86 percent. Net sales in the drug wholesale market in Fujian accounted for 75.6 percent, with an increase of 4.3 percent. While at the national level, it is only 57.2 percent with an increase of 0.3 percent (3).

The Two-invoice System in China reduces intermediate circulation, and increases industrial concentration. Net sales directly to hospitals are encouraged, whichaffects distribution and production areas. Production enterprises tend to invoice with higher prices instead of offering reserve prices to agents.

Health Technology Assessment (HTA) processes have become a fundamental part in the lifecycle of new medicines. However, their deep relation with national legislation creates ambiguous and controversial results between the European countries. Can they be standardized across Europe?

Sources of national differences have been identified in timelines, documents, methods, data interpretation, and conclusions. In order to harmonize and standardize HTA cooperation across Europe the European Network for HTA (EUnetHTA) was established. We analyzed guidelines, requirements, and output of EUnetHTA and noted the differences between those guidelines and the German G-BA (Federal Joint Committee, Gemeinsamer Bundesausschuss) standard and IQWiG (Institute for Quality and Efficiency in Health Care, Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen) methods.

The comparison between German and European HTAs highlights that although both procedures follow the rules of Evidence-Based Medicine, differences in Body of Evidence, Comparator, Surrogate Endpoints, Subgroups, and Evidence Synthesis may lead to diverging HTA outcomes. The European HTA framework facilitates the appropriate depiction of clinical reality through comprehensive inclusion of the existing evidence with context specific statistical methods. It might become a worldwide platform for HTA evaluation and discussion.

Only the involvement of both, pharmaceutical companies and HTA bodies within a unified European framework can lead to a mature and transparent procedure with a reliable outcome independent of legal requirements.

There has been a growing interest in international collaboration among Health Technology Assessment (HTA) organizations on macro, meso, and micro policy-making levels. Global member-driven professional HTA societies make contributions to scientific improvement and enhance interactions in the HTA ecosystem. However, little is known about collaboration between HTA organizations at the global level. This study intends to examine the main drivers of network relationships of HTA organizations.

Social network analysis was used to ascertain the relationships between HTA organizations and to visualize the main drivers of collaboration. The total number of memberships of the HTA organizations of the International Society For Pharmacoeconomics and Outcomes Research (ISPOR), Health Technology Assessment International (HTAi), International Netowork of Agencies for HTA (INAHTA), EuroScan, European Network for HTA (EUnetHTA), HTAsiaLink, Red de Evaluación de Tecnologías en Salud de las Américas (RedETSA) were considered to create the network. Ten different types of HTA organizations were considered in the analysis including the Ministry of Health (MoH), university, for-profit, and hospitals. The Fruchterman-Reingold algorithm was used to perform network analysis; average clustering coefficient and average path length were examined to measure collaborative performance.

A network graph of the HTA ecosystem shows the highest collaborative frequency in terms of HTA organizations, occurred with members of the Ministry of Health, government agencies, universities, and non-profit organizations. The average path length was 2.21 and the average clustering coefficient was 36.576 which indicates an obvious clustering effect.

These study results highlight that the network throughout the HTA ecosystem is driven by government organizations. Integrating the private sector into the system, creating common information and data sharing strategies, and improving the number of internationally experienced HTA professionals are essential strategies to foster collaboration in HTA organizations. As HTA is shaped by local dynamics and there is no gold standard for HTA implementation, encouragement of collaborative efforts is the only way to prevent duplication of effort and to make health technologies available for everyone.

A novel, sensor-based, factory-calibrated Flash Monitoring System (FMS) has recently proved to be an effective alternative to conventional self-monitoring of blood glucose (SMBG) in patients affected by type 1 and type 2 diabetes. The 14-days adhesive sensor, that continuously measures glucose levels in the interstitial fluid, can transfer glucose levels data to a handheld reader or a smartphone equipped with a specific medical app. The uptake of the new technology has been limited so far, because of its high costs. A cost analysis has been conducted to identify the optimal target population of introducing FSM in Veneto.

The model was designed with a 1-year time horizon for patients with diabetes using intensive insulin in Veneto region. The costs of the new technology was estimated using inputs from the two main randomized controlled trials (the IMPACT study and the REPLACE study) published in the international literature, Regional evidence-based guidelines and administrative database. Resource utilization included strips, lancets, needles, sensors, distribution and patients training. Regional unit costs were adopted.

FSM has not shown so far relevant and statically significant benefits in terms of severe adverse events’ reduction. Estimated yearly costs for a FSM user included glucose monitoring, technology training and distribution costs, for a total of EUR1277 per patient. The new technology has been shown to be affordable in diabetic patients with i) 4years<age<18years, ii) continuous subcutaneous insulin infusion and iii) ≥5 blood glucose monitoring per day.

The Veneto Region should carefully consider prescribing extension to other diabetic patients categories, since the high cost of the new technology. A strict prescribing monitoring is strongly recommended with the aim of ensuring appropriateness and avoiding overspending.

Following a first field evaluation conducted in 2013, we found that hemolysis can be induced by infusion pumps during blood transfusion. Actually, limited data is available on the risk of hemolysis associated with the most used infusion pumps in Quebec hospitals: InfusomatSpace (peristaltic), Plum A+TM (piston) and ColleagueCXE (shuttle).

Staff from the blood bank and the Health Technology Assessment (HTA) unit in our hospital collaborated in 2016 to assess the hemolysis and potassium level (that is, a blood test sensitive to hemolysis) induced by the use of the three infusion pumps mentioned above. Measurements were taken for each pump at five flow rates, from 30 to 450 ml/hour, and were compared with measurements taken before using the pumps. Tests were conducted with 135 red blood cell (RBC) units. RBC units were aged from 10 to 28 days.

The shuttle- and piston-type pumps resulted in low hemolysis levels. The peristaltic-type pump produced significantly more hemolysis. However, the absolute value of hemolysis remained within the range recommended by the regulatory agencies in North America and Europe. Potassium levels did not increase with the use of the pumps.

The collaboration between the blood bank and the HTA unit led to the conclusion that modern infusion pumps widely used in Quebec hospitals produce non-threatening levels of hemolysis during blood transfusion. This finding is important to ensure safe practices.

In order to support service planning of the youth program of the East of Montreal Health and Social Services Board, and potentially of the other twenty-five programs across the Quebec province, our hospital-based Health Technology Assessment (HTA) unit was asked to bring evidence of the effective interventions for five most common mental disorders in children and young populations, namely anxio-depressive disorders, attention deficit and hyperactivity disorder, oppositional and conduct disorders, substance abuse disorders, and suicide attempts.

A review of reviews was conducted for the five disorders in young populations aged 6 to 25 years. This was based exclusively on systematic reviews and meta-analysis of a minimum two randomized-controlled trials. The review was completed with examples of Quebec's good practices in youth mental health gathered from personal research experience of clinical researchers involved in the project. The project involved collaboration with three other hospital units and provincial HTA agencies.

No review supporting screening and early detection for the five disorders was identified. Prevention, however, was better covered in the literature, and a clear distinction was made between universal, targeted and indicated interventions. In general, targeted and indicated prevention interventions were effective in the case of anxio-depressive (1) and substance use disorders, while universal prevention strategies seemed to reduce suicide attempts and suicide ideation (2). Effective treatments also exist for these mental disorders. In general, psychotherapies dominated for anxio-depressive and substance use disorders; parental skills dominated in oppositional disorders, whilst pharmacological treatment dominated in attention deficit and hyperactivity disorder (3). Evidence was limited for suicide attempts. The overview of Quebec's good practices allowed identification of interventions or practices already in use in the province.

The review summarized effective interventions for five most common mental disorders in young populations. It also permitted to identify several research gaps, and therefore research recommendations were formulated for the province's health research agency.

Despite numerous medical, pharmacological and surgical approaches for chronic low back pain (LBP), many patients continue to complain of severe disabling pain. Peripheral nerve field stimulation (PNfS), alone or combined with spinal cord stimulation, is a neuromodulation procedure that have been recently developed and implemented in our hospital. We conducted a Health Technology Assessment (HTA) to determine if PNfS may be considered as a standard of practice in the management of intractable LBP and failed back surgery syndrome (FBSS).

An interdisciplinary group of experts was involved in the project. A systematic review (SR) was performed in several databases and grey literature to identify clinical practice guidelines, SR and observational studies published through September 2016. A survey was conducted among other chronic pain centers in Canada to document PNfS use in LBP and FBSS treatment.

Data on effectiveness and safety of PNfS in chronic LBP treatment were scarce. Short-term results (3-12 months) from small sample and low quality studies suggest that PNfS, alone or combined with spinal cord stimulation, is associated with pain intensity and opioid use reductions. Effects on functional status and quality of life remain undetermined. Most frequent adverse events reported with PNfS devices are lead migrations, discomfort or pain and surgical site infections. No other Canadian pain centers were found to use PNfS in chronic LBP or FBSS.

PNfS is potentially a beneficial treatment option for patients with chronic low back pain or FBSS. However, the value of this innovative treatment remains unknown. Among factors to be clarified are target population (any chronic low back pain or FBSS), use of PNfS alone or combined with spinal cord stimulation, long-term effects, and comparison with conventional medical management. PNfS use in chronic LBP has to be assessed through a rigorous framework before its introduction as a standard medical practice.