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1.
Artigo em Inglês | MEDLINE | ID: mdl-33806543

RESUMO

Many universal health care systems have increased the share of the price of medicines paid by the patient to reduce the cost pressure faced after the Great Recession. This paper assesses the impact of cost-sharing changes on the propensity to consume prescription and over-the-counter medicines in Catalonia, a Spanish autonomous community, affected by three new cost-sharing policies implemented in 2012. We applied a quasi-experimental difference-in-difference method using data from 2010 to 2014. These reforms were heterogeneous across different groups of individuals, so we define three intervention groups: (i) middle-income working population-co-insurance rate changed from 40% to 50%; (ii) low/middle-income pensioners-from free full coverage to 10% co-insurance rate; (iii) unemployed individuals without benefits-from 40% co-insurance rate to free full coverage. Our control group was the low-income working population whose co-insurance rate remained unchanged. We estimated the effects on the overall population as well as on the group with long-term care needs. We evaluated the effect of these changes on the propensity to consume prescription or over-the-counter medicines, and explored the heterogeneity effects across seven therapeutic groups of prescription medicines. Our findings showed that, on average, these changes did not significantly change the propensity to consume prescription or over-the-counter medicines. Nonetheless, we observed that the propensity to consume prescription medicines for mental disorders significantly increased among unemployed without benefits, while the consumption of prescribed mental disorders medicines for low/middle-income pensioners with long-term care needs decreased after becoming no longer free. We conclude that the propensity to consume medicines was not affected by the new cost-sharing policies, except for mental disorders. However, our results do not preclude potential changes in the quantity of medicines individuals consume.


Assuntos
Custo Compartilhado de Seguro , Medicamentos sob Prescrição , Custos de Medicamentos , Humanos , Prescrições , Espanha
2.
Pan Afr Med J ; 38: 84, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33889250

RESUMO

Methadone maintenance treatment is reported as cost-effective in treatment of opioid use disorder. Estimated cost of providing methadone varies widely in different regions but there is no data regarding cost of methadone treatment in Kenya. The aim of this study was to estimate the cost of methadone maintenance treatment at a methadone maintenance treatment clinic in Nairobi, Kenya from the perspective of the government, implementing partner and the clients. Data was collected for the period of February 2017 to September 2018 for 700 enrolled clients. The cost of providing methadone treatment was estimated as the sum of salaries, laboratory test, methadone and other commodities costs. The outcome was daily cost of methadone per client. The costs are given in Kenya Shillings (Ksh). The cost of treating one client is approximately Ksh. 149 (US$1.49) per day which amounts to Ksh 4500 (US$ 45) per month. This is from the estimated direct costs such as salaries which accounted for 86.4%, methadone 9.6%, tests and other consumables at 4%. The estimated average dose per patient per day is 60mg.This excludes indirect costs such as capital and set up cost, maintenance cost, training, drug import and distribution and other bills. The findings of this study show that the estimate cost of providing methadone at Nairobi, Kenya is comparable to that in other centers. This can help to inform policy makers on continued provision of methadone treatment in the country.


Assuntos
Custos de Cuidados de Saúde/estatística & dados numéricos , Metadona/economia , Tratamento de Substituição de Opiáceos/economia , Transtornos Relacionados ao Uso de Opioides/reabilitação , Instituições de Assistência Ambulatorial/economia , Análise Custo-Benefício , Custos de Medicamentos , Humanos , Quênia , Metadona/administração & dosagem , Tratamento de Substituição de Opiáceos/métodos , Transtornos Relacionados ao Uso de Opioides/economia , Salários e Benefícios/economia
3.
Pan Afr Med J ; 38: 41, 2021.
Artigo em Francês | MEDLINE | ID: mdl-33854670

RESUMO

Introduction: hydroxyurea is the unique medication that has been proven to prevent complications in patients with sickle cell disease and is approved by the Food and Drug Administration. This medication requires a prescription to be dispensed, it must be available and at an affordable price. The purpose of this study was to determine the availability and market price of hydroxyurea in the Democratic Republic of the Congo and to make a comparison between these two aspects in a small city, such as Mbujimayi, and in a big city, such as Lubumbashi. Methods: we conducted a cross-sectional study in the context of a face-to-face survey involving 188 Congolese pharmacies from 1st April to 1st September 2017. Results: hydroxyurea was available at 41/188 (22%) participating pharmacies, but more frequently at those of a big city than at those of a small city (34/96 versus 7/92). Most patients got a prescription (36/41; 88%). The average price of hydroxyurea was $15 (from $10 to $35 a blister packs of 25 capsules), which was higher than the purchasing power of the majority of sickle cell patients. Hydroxyurea is still an imported product from Europe, the United States or Asia. Conclusions: hydroxyurea is one of the main treatments to slow down disease progression in sickle cell patients. Nevertheless, in the Democratic Republic of the Congo, its availability could be improved, in particular in small cities, and its price is still too high.


Assuntos
Anemia Falciforme/tratamento farmacológico , Antidrepanocíticos/provisão & distribução , Hidroxiureia/provisão & distribução , Assistência Farmacêutica/estatística & dados numéricos , Anemia Falciforme/economia , Antidrepanocíticos/economia , Estudos Transversais , República Democrática do Congo , Custos de Medicamentos/estatística & dados numéricos , Humanos , Hidroxiureia/economia , Assistência Farmacêutica/economia , Inquéritos e Questionários
4.
Curr Oncol ; 28(2): 1056-1066, 2021 02 26.
Artigo em Inglês | MEDLINE | ID: mdl-33652898

RESUMO

The COVID-19 pandemic has a significant impact on cancer patients and the delivery of cancer care. To allow clinicians to adapt treatment plans for patients, Ontario Health (Cancer Care Ontario) issued a series of interim funding measures for the province's New Drug Funding Program (NDFP), which covers the cost of most hospital-delivered cancer drugs. To assess the utility of the measures and the need for their continuation, we conducted an online survey of Ontario oncology clinicians. The survey was open 3-25 September 2020 and generated 105 responses. Between April and June 2020, 46% of respondents changed treatment plans for more than 25% of their cancer patients due to the pandemic. Clinicians report broad use of interim funding measures. The most frequently reported strategies used were treatment breaks for stable patients (62%), extending dosing intervals (59%), and deferring routine imaging (56%). Most clinicians anticipate continuing to use these interim funding measures in the coming months. The survey showed that adapting cancer drug funding policies has supported clinical care in Ontario during the pandemic.


Assuntos
Antineoplásicos/economia , Custos de Medicamentos , Neoplasias/tratamento farmacológico , Antineoplásicos/uso terapêutico , Atitude do Pessoal de Saúde , Coleta de Dados , Política de Saúde , Acesso aos Serviços de Saúde , Humanos , Oncologia/economia , Oncologia/organização & administração , Neoplasias/epidemiologia , Ontário/epidemiologia , Pandemias , Qualidade da Assistência à Saúde , Inquéritos e Questionários
5.
Milbank Q ; 99(1): 240-272, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33751664

RESUMO

Policy Points  Spending on prescription drugs is much higher per capita in the United States than in most other industrialized nations, including France.  Lower prescription drug spending in France is due to different approaches to managing drug prices, volume of prescribing, and global health budgets.  Linking a drug's price to value both at the launch of the drug and over its lifetime is key to controlling spending. Regulations on prescription volume and global spending complement the interventions on prices.  If the United States adopted the French approach to regulating drug pricing, Medicare could potentially save billions of dollars annually on prescription drug spending. CONTEXT: Prescription drug spending per capita in the United States is higher than in most other industrialized countries. Policymakers seeking to lower drug spending often suggest benchmarking prices against other countries, including France, which spends half as much as the United States per capita on prescription drugs. Because differences in drug prices may result from how markets are organized in each nation, we sought to directly compare drug prices and pricing regulations between the United States and France. METHODS: For the six brand-name drugs with the highest gross expenditures in Medicare Part D in 2017, we compared the price dynamics in France and the United States between 2010 and 2018 and analyzed associations between price changes in each country and key regulatory events. We also comprehensively reviewed US and French laws and regulations related to drug pricing. FINDINGS: Prices for the six drugs studied were higher in the United States than in France. In 2018, if Medicare had paid French prices for the brand-name drugs in our cohort, the agency would have saved $5.1 billion. We identified 12 factors that explain why the United States spends more than France on drugs, including variations in unit prices and the volume of prescriptions, driven by use of health technology assessment and value-based pricing in France. CONCLUSIONS: Key drivers of lower drug spending in France compared to the United States are that the French government regulates drug prices when products are launched and prohibits substantial price increases after launch. The regulation of prescription drugs in France is governed by rules that can inform discussions of US prescription drug policy and potential Medicare price negotiations.


Assuntos
Redução de Custos , Regulamentação Governamental , Medicare Part D/economia , Medicamentos sob Prescrição/economia , Custos e Análise de Custo , Custos de Medicamentos/legislação & jurisprudência , França , Cobertura do Seguro , Legislação de Medicamentos , Estados Unidos
8.
Recenti Prog Med ; 112(3): 219-224, 2021 03.
Artigo em Italiano | MEDLINE | ID: mdl-33687361

RESUMO

The pandemic period has generated major problems in the pharmacies of hospitals and local health care companies regarding the distribution of drugs to patients undergoing treatment with chronic drugs. This is because the patient, during the lockdown, was forced to leave the house and go several miles away to reach the place where the drug was dispensed. Moreover, very often, the place was placed in covid-19 hospitals, like the one in Perugia, and was also a risk for the patient himself. The logistical organization allows, in addition to the advantages of traceability, efficiency and savings, with the arrival of the drug at home, a very high patient compliance that also translates into greater security in a pandemic period. To the Usl Umbria 1 of Perugia (Italy) has been centralized the activity of warehouse for all the South area that includes three hospitals and four sanitary districts. Such warehouse, through computerized procedure, guarantees the direct distribution with sending of the medicines directly to the district of belonging of the patient. In this way the patient was not forced to make long and risky trips to continue their chronic therapies. Moreover, this logistic warehouse has also allowed to cope with the correct management of many medicinal specialties that have been used against the SARS-CoV-2 virus avoiding their temporary deficiency for patients already on therapy according to the normal therapeutic indications (anti-inflammatory, antiretroviral and immunomodulatory). This paper aims to demonstrate how logistical organization is of vital importance for a National Health System that has to face increasing costs, ensure the traceability of all processes and, last but not least, survive a worldwide pandemic period.


Assuntos
Armazenamento de Medicamentos , Pandemias , Preparações Farmacêuticas/provisão & distribução , Anti-Infecciosos/provisão & distribução , Anti-Infecciosos/uso terapêutico , Anti-Inflamatórios/provisão & distribução , Anti-Inflamatórios/uso terapêutico , Anti-Hipertensivos/provisão & distribução , Anti-Hipertensivos/uso terapêutico , Antineoplásicos/provisão & distribução , Antineoplásicos/uso terapêutico , Antivirais/provisão & distribução , Antivirais/uso terapêutico , Área Programática de Saúde , Custos de Medicamentos/estatística & dados numéricos , Reposicionamento de Medicamentos , Armazenamento de Medicamentos/estatística & dados numéricos , Humanos , Fatores Imunológicos/provisão & distribução , Fatores Imunológicos/uso terapêutico , Itália , Organização e Administração , Preparações Farmacêuticas/economia , Serviço de Farmácia Hospitalar/organização & administração
9.
J Ment Health Policy Econ ; 24(1): 3-11, 2021 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-33739932

RESUMO

BACKGROUND: SSRIs and SNRIs are antidepressants that have largely substituted old antidepressants like Monoamine Oxidase Inhibitors (MAOIs) and Tricyclic Antidepressants (TCAs). They have been widely used since 1987 when the FDA approved the first SSRI Fluoxetine and the first SNRI Venlafaxine in 1993. Since then, several new SSRIs and SNRIs have been approved and entered the market. Utilization, pricing, and spending trends of SSRIs and SNRIs have not been analyzed yet in Medicaid. AIM: To assess the trends of drug expenditure, utilization, and price of SSRI and SNRI antidepressants in the US Medicaid program, and to highlight the market share of SSRIs and SNRIs and the effect of generic drug entry on Medicaid drug expenditure. METHODS: A retrospective descriptive data analysis was conducted for this study. National pharmacy summary data for study brand and generic drugs were retrieved from the Medicaid State Outpatient Drug Utilization Data. These data were collected by the US Centers for Medicare and Medicaid Services (CMS). The study period was between 1991 and 2018. Study drugs include 12 different SSRI and SNRI brands and their generics available in the market, such as citalopram, escitalopram, paroxetine, fluoxetine, sertraline, venlafaxine, desvenlafaxine, duloxetine, and levomilnacipran. Data were analyzed annually and categorized by total prescriptions (utilization), total reimbursement (spending), and cost per prescription as the proxy of the price for each drug. RESULTS: From 1991 to 2018, total prescriptions of SSRI and SNRI drugs rose by 3001%. Total Medicaid spending on SSRIs and SNRIs increased from USD 64.5 million to USD 2 billion in 2004, then decreased steadily until it reached USD 755 million in 2018. The SSRIs average utilization market share was 87% compared to 13% of the SNRIs utilization market share. About 72% of total Medicaid spending on the two groups goes to SSRIs, while the remaining 28% goes to SNRIs. Brand SSRIs and SNRIs prices increased over time. On the contrary, generic drugs prices steadily decreased over time. DISCUSSION: An increase in utilization and spending for both SSRI and SNRI drugs was observed. After each generic drug entered the market, utilization shifted from the brand name to the respective generic due to their lower price. These generic substitutions demonstrate a meaningful cost-containment policy for Medicaid programs. IMPLICATIONS FOR HEALTH POLICIES: Our findings show the overall view of Medicaid expenditure on one of the most commonly prescribed drug classes in the US. They also provide an important insight toward the antidepressant market and the importance of monitoring different drugs and their alternatives.


Assuntos
Antidepressivos/economia , Antidepressivos/uso terapêutico , Custos de Medicamentos/tendências , Uso de Medicamentos/tendências , Medicaid/economia , Inibidores de Captação de Serotonina/economia , Inibidores de Captação de Serotonina/uso terapêutico , Inibidores da Recaptação de Serotonina e Norepinefrina/economia , Inibidores da Recaptação de Serotonina e Norepinefrina/uso terapêutico , Idoso , Gastos em Saúde , Humanos , Medicaid/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos
10.
An Bras Dermatol ; 96(2): 200-209, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33573869

RESUMO

The technological advancement of the pharmaceutical industry, resulting from the techniques of molecular biology and expansion of the knowledge of immunopathogenesis, has modified the therapeutic arsenal used in dermatology. Scientific research and regulatory standards cause drug costs to rise, thus making their use impossible in most public policies. In order to make high-cost drugs viable in the public health network, the Specialized Pharmaceutical Assistance Component was created. However, despite the frequent incorporation of medications, the constant requirement of drugs through lawsuits leads to exorbitant costs to the state budget. The present work analyzed through a descriptive observational study, the current situation of the Specialized Component and the involvement of medicines used in dermatology, through legal reviews, financial analyses, and medical articles, aiming at future incorporations for the specialty. When assessing the legal demands for dermatological drugs in the state of São Paulo, the specialty still has a low participation and psoriasis is the main disease involved in requiring drugs through the judicial system in the state. New methods of access to raw materials must be created to reduce legal issues. Cost-effectiveness and public planning studies are mandatory for incorporating new dermatological therapies.


Assuntos
Dermatologia , Preparações Farmacêuticas , Brasil , Custos de Medicamentos , Humanos , Fatores Socioeconômicos
11.
JAMA Netw Open ; 4(2): e2037880, 2021 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-33616665

RESUMO

Importance: Ten percent of the Medicare Part B budget is spent on aflibercept, used to treat a myriad of ocular neovascular diseases. A substantial portion of these costs can be attributed to a few hundred ophthalmologists, raising concerns regarding the influence of pharmaceutical companies on the choice of medication by a relatively small group of clinicians. One approach to protect patients' health care interests is to include them in deliberations on the choice of therapy for their eye disease. Objective: To examine factors associated with patients' choice between an effective and less expensive off-label drug or a more effective, but also more expensive, US Food and Drug Administration (FDA)-approved drug. Design, Setting, and Participants: This retrospective cohort analysis used data from the satellite office of a tertiary referral center from August 2, 2013, to April 9, 2018. Insured patients initiating treatment with anti-vascular endothelial growth factor were included in the analysis. Data were analyzed from March 26, 2018, to June 10, 2020. Interventions: Patients were asked to choose between bevacizumab (approximately $100 per dose), a chemotherapy that is effective, but not FDA approved, for the treatment of ocular vascular disease, or aflibercept (approximately $2000 per dose), an FDA-approved drug for ocular vascular disease that may be more effective than bevacizumab in some patients. Independent of this choice, patients were separately asked by a study coordinator to participate in an invasive clinical study for which they would not be compensated, there was a small risk for an adverse event, and they would not personally benefit from participating (a surrogate marker for altruism). Main Outcomes and Measures: Factors associated with patients' choice of medication, including age, sex, ocular disease, race, and participation in an invasive clinical study. Results: A total of 189 patients were included in the analysis (106 women [56%]; mean [SEM] age, 74.6 [0.8] years). Despite being told that it may not be as effective as aflibercept, 100 patients (53%) selected bevacizumab for their own eye care. An act of altruism (ie, participation in an invasive clinical study) when the patient was making a choice between the 2 drugs was associated with a patient's choice of bevacizumab (odds ratio [OR], 7.03; 95% CI, 2.27-21.80; P < .001); the OR for selecting bevacizumab for patients who never agreed to participate in the clinical study was 0.45 (95% CI, 0.25-0.83; P = .001). Age (OR, 1.00; 95% CI, 0.97-1.03; P = .86), race (OR, 0.70; 95% CI, 0.41-1.22; P = .21), sex (OR, 0.72; 95% CI, 0.39-1.35; P = .31), presence of diabetes (OR, 1.52; 95% CI, 0.59-3.93; P = .39), and type of eye disease (OR, 0.56; 95% CI, 0.30-1.04; P = .07) were not associated with choice of therapy. Conclusions and Relevance: These findings suggest that clinicians must consider the ethical implications of the influence of altruism when patients participate in the decision between cost-effective vs the most effective medicines for their own health care.


Assuntos
Altruísmo , Inibidores da Angiogênese/economia , Bevacizumab/economia , Comportamento de Escolha , Tomada de Decisões , Oftalmopatias/tratamento farmacológico , Participação do Paciente , Proteínas Recombinantes de Fusão/economia , Afro-Americanos , Idoso , Inibidores da Angiogênese/uso terapêutico , Americanos Asiáticos , Bevacizumab/uso terapêutico , Estudos de Coortes , Análise Custo-Benefício , Retinopatia Diabética/tratamento farmacológico , Custos de Medicamentos , Grupo com Ancestrais do Continente Europeu , Feminino , Humanos , Degeneração Macular/tratamento farmacológico , Masculino , Pessoa de Meia-Idade , Neovascularização Patológica/tratamento farmacológico , Razão de Chances , Uso Off-Label , Receptores de Fatores de Crescimento do Endotélio Vascular/uso terapêutico , Proteínas Recombinantes de Fusão/uso terapêutico , Oclusão da Veia Retiniana/tratamento farmacológico , Estudos Retrospectivos , Resultado do Tratamento , Acuidade Visual
12.
JAMA Netw Open ; 4(2): e210037, 2021 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-33625508

RESUMO

Importance: Treatment with atezolizumab plus bevacizumab may prolong overall survival among patients with unresectable hepatocellular carcinoma. However, to our knowledge, the cost-effectiveness of using this high-priced therapy for this indication is currently unknown. Objective: To evaluate the cost-effectiveness of atezolizumab plus bevacizumab to treat unresectable hepatocellular carcinoma from the US payer perspective. Design, Setting, and Participants: This economic evaluation used a partitioned survival model consisting of 3 discrete health states to assess the cost-effectiveness of treatment of hepatocellular carcinoma with atezolizumab plus bevacizumab vs sorafenib. The characteristics of patients in the model were similar to patients in a phase 3, open-label randomized clinical trial (IMbrave150) who had unresectable hepatocellular carcinoma and had not previously received systemic treatment. Key clinical data were generated from the IMbrave150 trial conducted between March 15, 2018, and January 30, 2019, and cost and health preference data were collected from the literature. Main Outcomes and Measures: Costs, quality-adjusted life-years (QALYs), incremental cost-utility ratios, incremental net health benefits, and incremental net monetary benefits were calculated for the 2 treatment strategies. Subgroup, 1-way sensitivity, and probabilistic sensitivity analyses were performed. Results: Treatment of hepatocellular carcinoma with atezolizumab plus bevacizumab added 0.530 QALYs and resulted in an incremental cost of $89 807 compared with sorafenib therapy, which had an incremental cost-utility ratio of $169 223 per QALY gained. The incremental net health benefit was -0.068 QALYs, and the incremental net monetary benefit was -$10 202 at a willingness-to-pay threshold of $150 000/QALY. The probabilistic sensitivity analysis indicated that treatment with atezolizumab plus bevacizumab achieved a 35% probability of cost-effectiveness at a threshold of $150 000/QALY. One-way sensitivity analysis revealed that the results were most sensitive to the hazard ratio of overall survival. The subgroup analysis found that treatment with atezolizumab plus bevacizumab was associated with preferred incremental net health benefits in several subgroups, including patients with hepatitis B and C. Conclusions and Relevance: Atezolizumab plus bevacizumab treatment is unlikely to be a cost-effective option compared with sorafenib for patients with unresectable hepatocellular carcinoma. Reducing the prices of atezolizumab and bevacizumab may improve cost-effectiveness. The economic outcomes also may be improved by tailoring treatments based on individual patient factors.


Assuntos
Antineoplásicos/uso terapêutico , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Carcinoma Hepatocelular/tratamento farmacológico , Neoplasias Hepáticas/tratamento farmacológico , Sorafenibe/uso terapêutico , Idoso , Anticorpos Monoclonais Humanizados/administração & dosagem , Antineoplásicos/economia , Protocolos de Quimioterapia Combinada Antineoplásica/economia , Bevacizumab/administração & dosagem , Carcinoma Hepatocelular/patologia , Análise Custo-Benefício , Árvores de Decisões , Progressão da Doença , Custos de Medicamentos , Feminino , Humanos , Neoplasias Hepáticas/patologia , Masculino , Pessoa de Meia-Idade , Mortalidade , Intervalo Livre de Progressão , Modelos de Riscos Proporcionais , Anos de Vida Ajustados por Qualidade de Vida , Sorafenibe/economia , Resultado do Tratamento
19.
Artigo em Inglês | MEDLINE | ID: mdl-33466893

RESUMO

BACKGROUND: The demand for implementing a new listing scheme to expedite patient access to novel oncology drugs has increased in South Korea. This study was conducted to compare the prices of anticancer drugs between eight countries and to explore the feasibility of a 'pre-listing and post-evaluation' scheme to expedite patient access to oncology drugs. METHODS: This study included 34 anticancer drugs, which were reimbursed between 1 January 2007 and 31 December 2017. The unit price and sales volume of the study drugs were collected from eight countries and IQVIA data, respectively. The prices were adjusted to estimate the ex-factory prices using the discount/rebate rate suggested by the Health Insurance Review Agency (HIRA). The four price indices of Laspeyres, Paasche, Fisher, and the unweighted index were calculated using the price in each country, the average price, and lowest price among the study countries. Each currency was converted using the currency exchange rate and purchasing power parity (PPP). The budget impact of implementing the proposed pre-listing and post-evaluation scheme on payers was calculated. RESULTS: Based on the currency exchange rate, anticancer drug prices were higher in other countries (index range: 1.05-2.78) compared to Korea. The prices in Korea were similar to countries with the lowest prices. When the PPP was applied, prices were higher in the US, Germany, Italy, and Japan than in Korea (range: 1.10-2.13); however, the prices were lower in the UK, France, and Switzerland than in Korea (range: 0.72-0.99). The financial burden of implementing the pre-listing and post-evaluation scheme was calculated at 0.83% of the total anticancer drug sales value in Korea from 2013-2017. CONCLUSIONS: The prices of anticancer drugs in Korea were similar to the lowest prices among the seven other study countries. A pre-listing and post-evaluation scheme should be considered to improve patient access to novel anticancer drugs by reducing the reimbursement review time and uncertainties.


Assuntos
Antineoplásicos , Custos de Medicamentos , França , Alemanha , Humanos , Itália , Japão , República da Coreia , Suíça
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