Canada’s Drug Agency | Drugs, Health Technologies and Systems.

Major Depressive Disorder – Focused Critical Appraisal of a Network Meta-Analysis

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Major depressive disorder (MDD) is a common, debilitating, and recurrent mental health disorder. Over the past decades, multiple classes of antidepressant drugs have been developed to treat this condition. The relative effectiveness and safety of antidepressants are uncertain. This project will review a recently published network meta-analysis featuring broad comparisons of several oral antidepressants for MDD. Implications for decision-making will be discussed.

 

Last Updated : February 18, 2020

Appropriate Pharmacotherapy for Inflammatory Bowel Disease


(December 17, 2024)
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Background

Ulcerative colitis (UC) and Crohn disease (CD) are types of inflammatory bowel disease (IBD); the two are considered distinct from each other. According to Crohn’s and Colitis Canada, as of 2018 there were approximately 270,000 Canadians living with IBD. More than 10,200 new cases of IBD are diagnosed every year (5,700 with CD and 4,500 with UC) in the country — an incidence of 0.7%. Approximately 20% to 30% of people with IBD are diagnosed before the age of 20. Canada has one of the highest incidences and prevalences of IBD in the world.1

Criteria for conducting Environmental Assessments in CADTH HTAs

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Environmental considerations are increasingly being recognized by decision-makers and policy-makers. Initiatives to “green” the delivery of health care and health technologies are becoming more common to ensure that the sector is sustainable for future generations and that the impacts to the environment and to health are minimal.

Last Updated : June 5, 2019

Rural Breast Cancer Surgery Programs: A Rapid Qualitative Review

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Question(s)

  1. What are the experiences and perspectives of breast cancer patients, their caregivers and their health care providers with respect to breast cancer surgical care in rural areas? To ensure the relevance of the analysis to the objectives of the primary research question, a secondary set of research questions was explored during data extraction and analysis:
    1. How do people with breast cancer, and their families, experience travelling for breast cancer surgical care?
    2. What is the meaning and impact of receiving breast cancer surgical care close to home, from the perspective of patients and their families?
    3. How does the need to travel for breast cancer surgical care shape patients’, their families’ and their health care providers’ experiences and perceptions of breast cancer surgical care?

Key Message

Long distances, isolation, and transportation issues represented a great challenge and a source of additional stress among rural breast cancer patients and their caregivers. When patients lacked the support of partners, family, or their health professionals, they felt vulnerable and lonely both in rural and urban settings. Physical and logistical challenges, such as transportation barriers, travel expenses, and disruption of work and family commitments intensified patients’ and caregivers’ discomfort and distress. Such conditions often exacerbated patients’ and caregivers' experience of care leading patients to seek the less stressful [treatment] pathway or to deny cancer treatment in the case of advanced cancer stage, old age or lack of support. Health care providers expressed similar feelings of frustration due to distance and their patients needing to travel.In some instances, patients’ perceptions of rurality mitigated perceived barriers to surgical care. Some patients viewed travel and travel expenses as part of rural life, and rural values of self-sufficiency and endurance likewise permeated reported experiences. Rural culture can carry a commitment to self-reliance, leading patients to opt for a treatment pathway that limited work and life disruptions and avoided relying on others. For some patients this meant choosing mastectomy over breast conserving surgery, which allowed them to avoid radiation therapy and repeated trips to the cancer centre. Rural stoicism also emerged through a general reticence to seek care, which may contribute in part to the common phenomena of delayed diagnosis among rural breast cancer patients.Shortages of health care professionals and fragmented health care services were further disadvantages in rural settings, experienced through delayed diagnoses, more trips to urban centres, shorter consultations, and limited access to medical support. For health care professionals this also meant shifting roles and delegating responsibilities across specialties and patients. Poor communication and coordination among care providers left patients confused about care professionals’ roles and responsibilities as well as feeling lost in the cracks of the health care system. Overall, travel and distance alone do not affect the experience of breast cancer surgery care. Rather patients, caregivers, and health care professionals rationalize distance and travel differently in relation to additional factors, such as rural culture, access to support, age, cancer conditions, availability of health care professionals and coordination of care. Rural patients and caregivers generally expressed high levels of satisfaction with their treatment and care, especially when compared to their urban counterparts.

Last Updated : May 3, 2019

Buprenorphine for Opioid Use Disorders during Pregnancy: A Review of Comparative Clinical Effectiveness, Safety, Cost-Effectiveness, and Guidelines

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Question(s)

  1. What is the comparative clinical effectiveness of various buprenorphine or buprenorphine-naloxone formulations versus other buprenorphine formulations for the treatment of opioid use disorders during pregnancy?
  2. What is the clinical evidence regarding the safety of various buprenorphine or buprenorphine-naloxone formulations for the treatment of opioid use disorders during pregnancy?
  3. What is the cost-effectiveness of various buprenorphine or buprenorphine-naloxone formulations for the treatment of opioid use disorders during pregnancy?
  4. What are the evidence-based guidelines regarding the use of various buprenorphine or buprenorphine-naloxone formulations for the treatment of opioid use disorders during pregnancy?

Key Message

This report identified a lack of evidence regarding the comparative effectiveness, safety, and cost-effectiveness of various buprenorphine or buprenorphine-naloxone formulations for the treatment of opioid use disorders during pregnancy. Three relevant evidence-based guidelines were identified. Two of three guidelines contained relevant recommendations that reflected this lack of high-quality comparative evidence. These two guidelines recommended buprenorphine treatment in preference to the buprenorphine-naloxone formulation for opioid use disorders during pregnancy. One other Canadian guideline cited the same evidence to support the use of buprenorphine-naloxone as a safe and effective alternative to buprenorphine alone during pregnancy. No additional recommendations for various buprenorphine or buprenorphine-naloxone formulations during pregnancy were identified. Evidence-based treatment of pregnant patients with opioid use disorders requires further well-controlled studies for various buprenorphine and buprenorphine-naloxone formulation treatment options.

Last Updated : May 9, 2019

Prescription Drug Monitoring Programs: A Rapid Qualitative Review

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Question(s)

  1. How do healthcare providers (prescribers and dispensers) who prescribe monitored drugs use prescription drug monitoring programs?
  2. What are their perspectives on and preferences for prescription drug monitoring programs, including specific design and administrative features?

Key Message

Health care providers found prescription drug monitoring programs (PDMPs) useful for their practice in most instances however not routinely. PDMP use was either subjective, prompted by a concerning interaction with a patient about controlled substances; or systematic, mandated by institutional policy. PDMP use appeared to vary based on the provider’s personal preconceptions, institutional circumstances and professional judgement in terms of who genuinely requires treatment, or who may be doctor shopping. PDMP use helped determine barriers that were experienced and enablers that were most relevant to providers. Use was delineated into three broad functions including an information function, a patient safety function, and an engagement function. While several benefits to PDMPs were raised, challenges were also noted. These challenges included anticipated negative patient response to learning their providers accessed PDMP information; finding time and dedicated space in a busy pharmacy or medical practice to appropriately engage in discussion with patients; challenges in accessing the system, either due to lack of time or challenges with the interface (e.g., losing passwords, finding the website, entering patient data, a need for in-person authentication); and timely updates of the PDMP system which may lead to incomplete or inaccurate information. Suggestions for increased adoption and sustained PDMP use included better integrating PDMPs into clinical workflows, integrating PDMPs into existing electronic health record systems or developing a national linked system. Suggestions for specific design features include real time updating of prescription information; stronger user-friendly display to ensure the most relevant information is available for efficient prescribing decisions, a streamlined login process and automatic enrollment. Training was also identified as important and thought to include guidance on how to interpret information, strategies to incorporate PDMPs into clinical workflow, and how to approach patients for engagement discussions based on PDMP information.

Last Updated : April 30, 2019

Engaging with History Taking for Adverse Childhood Experiences in Care: A Rapid Qualitative Review

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Question(s)

  1. How have individuals experienced engaging with history taking for adverse childhood experiences (ACEs) or childhood trauma as part of their care, and how have those engagements varied, for example, among: a. Individuals within typically marginalized populations (e.g., refugees, Indigenous peoples, active substance users)b. Individuals having experienced different forms of trauma (e.g., sexual abuse, residential school)

Key Message

Participants in the five included primary studies and the one included literature synthesis noted a general acceptance of history taking for childhood trauma or adverse experiences in primary care. That being said, there was a dearth of literature exploring the perspectives and experiences of individuals within typically marginalized populations. While one included study focused specifically on refugees living in the United States,9 the remainder engaged with a broader North American population who had experienced childhood trauma or adverse experiences. As such, though the findings within this report do offer space for reflection regarding any clinical encounter, particular emphasis on typically marginalized populations is largely absent. Furthermore, participant acceptance of history taking while generally accepted by those represented in this review, was not without bounds. The following descriptive themes emerged from the included studies as the form these bounds may take. The importance of developing and demonstrating clarity regarding the purpose of history taking was spoken to across all six studies. A need for clarity was articulated in terms of a perceived need for provider awareness of the context surrounding conversations of childhood trauma or adverse experiences. Clinical languages of abuse and trauma may not always be understood or perceived as appropriate and dependent upon the purpose of the clinical visit (e.g., a prenatal obstetrics visit), emphasis could be placed on different forms of childhood trauma (e.g., perhaps a particular focus on sexual abuse). Assurance that the conversation was not standing in for any ulterior motives and that it would be completely confidential were also important to study participants particularly among expectant or recent parents and members of the military. The importance of developing and demonstrating commitment to building a trusting patient-provider relationship was also noted. Rather than treating history taking as a singular performance or rapid exercise, patients expressed that they need their health care providers to foster a safe and trusting environment for the conversation. While some participants noted this was a temporal issue, where each visit added to the strength of the relationship, trust could also be built through the intensity and patience of a singular clinical interaction. Similar to an expressed need for clarity, the importance of taking action or providing resources, if required, once the conversation had taken place was noted across studies. This could take the form of referring patients onto professional or peer support groups, but it could also be done by the provider themselves. Knowing how to hold and work with the traumatic pasts of their patients, from the patient perspective, comes hand-in-hand with asking about those pasts.

Last Updated : November 19, 2018

Gene Expression Profiling Tests for Breast Cancer: A Rapid Qualitative Review

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Question(s)

  1. What are patients’ and clinicians’ expectations of gene expression profiling tests for breast cancer?
  2. How do patients and clinicians understand, communicate, and make decisions to undergo gene expression profiling testing for breast cancer?
  3. How do patients and clinicians understand, communicate and make decisions based on the results?
  4. How does the option, or not, of gene expression profile testing help to shape patients’, and clinicians’ experiences and perceptions of breast cancer and its treatment?

Key Message

Gene expression profiling testing is seen by patients and oncologists as a valuable aid in making decisions about whether or not to undergo chemotherapy. Many patients and oncologists rely heavily on the results (i.e., recurrence risk score) for treatment decision making. Patients expect tests to provide valid, personalized, individualized and authoritative results that determine the most appropriate course of treatment. While low and high risk results may meet these expectations, intermediate results defy them. Instead, people identified with intermediate risk face further confusion and anxiety in what is an already emotionally-laden decision. Oncologists use gene expression profiling testing for a range of purposes from communicating to patients, to reducing uncertainty and helping them feel more confident in their decisions for clinically indicated disease and beyond. Some oncologists expressed concern around overreliance on the results of gene expression profiling testing in treatment decision making, with inadequate consideration of other relevant clinical and pathological characteristics.Patients’ preferences for chemotherapy were viewed as critical to determining whether or not to proceed with gene expression profiling testing, as the value of testing is seen as contingent on its ability to be used in treatment decision making. While understanding patients’ preferences for and willingness to undergo chemotherapy were identified as critical to guide testing decisions, patients’ preferences were not used consistently by oncologists in deciding whether to order testing. Some patients did not understand the nature of testing and the possibility of it being fallible. Instead its certainty and validity was assumed through notions of testing being of a personalized and individual nature. Because of the need to communicate complex information about the nature and purpose of the test, elicit patients’ preferences for treatment, and make decisions based on the results, implementation of gene expression profiling testing would likely require additional time in terms of length and number of consultations with oncologists. Ordering the test at the appropriate time in care is important so as to avoid delays in testing and subsequent delays in treatment or by initiating unnecessary treatment.

Last Updated : April 18, 2019

Buprenorphine for Opioid Use Disorder: A Review of Comparative Clinical Effectiveness, Safety, Cost-Effectiveness, and Guidelines

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Question(s)

  1. What is the comparative clinical effectiveness of various buprenorphine or buprenorphine-naloxone (BUP-NAL) formulations versus other buprenorphine formulations for the treatment of opioid use disorder (OUD)?
  2. What is the clinical evidence regarding the safety of various buprenorphine or BUP-NAL formulations for the treatment of OUD?
  3. What is the cost-effectiveness of various buprenorphine or BUP-NAL formulations for the treatment of OUD?
  4. What are the evidence-based guidelines regarding the use of various buprenorphine or BUP-NAL formulations for the treatment of OUD?

Key Message

Two relevant systematic reviews, three randomized controlled trials (in four publications), six non-randomized studies, and two economic evaluations were identified regarding the clinical effectiveness, safety, and cost-effectiveness of various buprenorphine formulations for the treatment of OUD.Though there were some instances where specific formulations of buprenorphine demonstrated statistically significant improvements in outcomes of interest compared to other formulations, no clear patterns emerged regarding the comparative clinical effectiveness of buprenorphine for the treatment of OUD. The economic evaluation concluded that buprenorphine implant did not provide cost-effective benefit over generic sublingual buprenorphine-naloxone (BUP-NAL). The second economic evaluation reported that implantable buprenorphine was cost-effective compared to sublingual buprenorphine. It remains uncertain whether the findings of the reviewed literature are generalizable to the Canadian population as all of the included studies were conducted outside of Canada.Two evidence-based guidelines were identified regarding the use of various buprenorphine formulations for the treatment of OUD. One guideline recommends BUP-NAL as a first-line therapy for individuals who require opioid agonist treatment (strong recommendation based on high quality evidence). The second guideline recommends offering either BUP-NAL or methadone, while considering patient preferences, for individuals with OUD (strong recommendation). The limitations of the included studies, such as several with lack of blinding to treatment or few studies from Canadian settings, and of this report should be considered when interpreting the results.

Last Updated : April 24, 2019

Environmental Scan on Health Technology Reassessment Processes

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The objective of this Environmental Scan was to identify the processes at national and international health technology assessment agencies to conduct the reassessment of existing or currently funded health technologies, including single and multiple technologies, drugs, and medical devices. Process elements of interest include:

Last Updated : March 22, 2019