OBJECTIVES: To analyse the extent to which indirect treatment comparisons (ITCs) and network meta-analyses (NMAs) are analysed and considered in drug positioning reports (IPTs) published by the Spanish Medicines Agency (AEMPS) to support drug positioning, pricing and funding decisions in Spain.

METHODS: All IPTs published on the AEMPS website from June 2023 to May 2024 were reviewed to identify whether ITCs or NMAs were analysed, referenced and considered as evidence. Methodological information on these ITC or NMA was also extracted.

RESULTS: AEMPS published 152 IPT during this period. At least one IC/NMA was available, reviewed and included in 45 (29.6%) of the IPTs, in one case the IPT authors performed an unadjusted ITC. In these 45 IPTs, 98 ITC/NMA were analysed, with a median (range) of 2 (1-6) ITC/NMA per report. Most ITC/NMA were published in journals, only four were obtained from agency reports. 28 (28.5%) were ITC, 67 (68%) were NMA, 3 could not be confirmed. Of the NMA, 59 (88%) were based on trials, 3 were matched-adjusted indirect comparisons (MAIC), 1 was a simulated treatment comparison (STC), and 3 included observational data. For ITC, 6 were based on trials, 1 was unadjusted, 12 were MAIC, 2 were STC and 2 included observational data. In general, it was not clear whether ITC/NMA were considered in the conclusions. Caution due to lower confidence in indirect evidence was often highlighted. The main limitations of ITC/NMA were heterogeneity in study populations, designs, outcome variables, etc.

CONCLUSIONS: Published ITC and NMA are reviewed when preparing drug assessment reports for drug positioning, pricing and funding decisions, and report authors do not perform ITC. Tools for critical appraisal of ITC, NMA, MAIC, STC and indirect evidence based on observational data, with guidance on how to incorporate them into decision making, can be useful.