The clinical and economic burden of significant bleeding during lung resection surgery: A retrospective matched cohort analysis of real-world data

Objectives: The objective of this retrospective study was to quantify the clinical and economic burden of significant bleeding in lung resection surgery in the US.

Methods: This study utilized 2009–2012 data from the Premier Perspective Database^TM. Adult patients with primary pulmonary lobectomy or segmentectomy procedures were categorized by the surgical approach (VATS vs open) and primary diagnosis (primary or metastatic lung cancer vs non-lung cancer). Patients requiring ≥3 units of blood products with at least 1 unit of PRBCs: “significant bleeding” cohort; those requiring <3 units: “non-significant bleeding” cohort; and those not requiring blood products: “no bleeding” cohort. A matched cohort analysis was performed between the “significant bleeding” and the “no bleeding cohort” using matching variables: hospital, lung cancer diagnosis, year of surgery, APR-DRG severity score, procedure type and approach, age, and gender.

Results: The “All-patient” cohort comprised 21,429 patients: 213 “significant bleeding”; 2,780 “non-significant bleeding”; and 18,436 “no bleeding”. Overall incidence of significant chest bleeding was 0.99%. Patients from “significant bleeding” cohort and “non-significant bleeding” cohort had 2.5 days and 2 days (p?p?Conclusions: Although significant bleeding during lung resection surgery is rare, patients with such complication could stay longer at the hospital and cost an average of $13,103 more than those without.     

Religion and political economy in Saint-Simon

Abstract

The project of Henri Saint-Simon (1760–1825) was to complete the French Revolution by a social change in order to eliminate the so-called “feudal-military” system and to bring about a new society which he named “the industrial system”. Everything had to be changed, including religion and its relation to political economy. In this paper, I examine: (i) the recurring problem of religion, raised by Saint-Simon as early as his first text; (ii) the emergence of the economic problem of identifying production with politics; (iii) and finally, the metamorphosis of the Christian religion into a moral and industrial religion.     

Global hospital and operative costs associated with various ventral cavity procedures: a comprehensive literature review and analysis across regions

Abstract

Objectives: The aim of this literature review was to provide a comprehensive report on hospital costs, and cost components, for a range of ventral cavity surgical procedures across three regions of focus: (1) Americas, (2) Europe, Middle East and Africa (EMEA), and (3) Asia-Pacific.

Methods: A structured search was performed and utilized a combination of controlled vocabulary (e.g., “Hepatectomy”, “Colectomy”, “Costs and Cost Analysis”) and keywords (e.g. “liver resection”, “bowel removal”, “economics”). Studies were considered eligible for inclusion if they reported hospital-related costs associated with the procedures of interest. Cost outcomes included operating room (OR) time costs, total OR costs, ward stay costs, total admission costs, OR cost per minute and ward cost per day. All costs were converted to 2018 USD.

Results: Total admission costs were observed to be highest in the Americas, with an average cost of $15,791. The average OR time cost per minute was found to vary by region: $24.83 (Americas), $14.29 (Asia-Pacific), and $13.90 (EMEA). A cost-breakdown demonstrated that OR costs typically comprised close to 50%, or more, of hospital admission costs. This review also demonstrates that decreasing OR time by 30?min provides cost savings approximately equivalent to a 1-day reduction in ward time.

Conclusion: This literature review provided a comprehensive assessment of hospital costs across various surgical procedures, approaches, and geographical regions. Our findings indicate that novel processes and healthcare technologies that aim to reduce resources such as operating time and hospital stay, can potentially provide resource savings for hospital payers.     

Classical political economy: the subsistence wage,and job guarantee concerns

Abstract:

In the theoretical framework of classical political economy, including the revisions of Marx and the more recent work of Piero Sraffa and others, the concept of the subsistence wage figures prominently. Here, following a recounting of this concept and demonstrating its significance not only for classical theory but also for larger social concerns, I argue that the “base wage” (as it is sometimes termed) as articulated within a “Job Guarantee” program, is (or should be) comparable to the subsistence wage but requires modification to make it (roughly) equivalent. It will be demonstrated that adherents of the classical approach did not rest their wage theory on a quasi-neoclassical supply–demand approach (with some primitive marginal productivity notion lying behind a supposed demand for labor schedule), but understood wages as socially determined where institutional and historic forces established a normative standard around which market wages gravitated. Such an approach was shared by, among others, Thorstein Veblen and John Maynard Keynes.     

Liberal Jansenists and interest-bearing loans in eighteenth-century France: a reappraisal

Abstract

This article is an attempt to prove that although the liberal Jansenists – Jansenism being the most powerful Christian protest movement of the seventeenth and eighteenth centuries – were not the first and the only ones to address the prohibition of interest-bearing loans, their writings on the issue shifted and fuelled the debate during the French Enlightenment, especially among the Encyclopédistes and the economists. By refuting the very logic of “extrinsic titles” of the Scholastics and their extension later on by the Jesuits, the liberals Jansenists redefined “interest” as the price to be paid for the use of money.     

Estimating the clinical effectiveness and value-based price range of erenumab for the prevention of migraine in patients with prior treatment failures: a US societal perspective

Background: Frequent migraine with four or more headache days per month is a common, disabling neurovascular disease. From a US societal perspective, this analysis models the clinical efficacy and estimates the value-based price (VBP) for erenumab, a fully human monoclonal antibody that inhibits the calcitonin gene-related peptide receptor.

Methods: A Markov health state transition model was developed to estimate the incremental costs, quality-adjusted life-years (QALYs), and value-based price range for erenumab in migraine prevention. The model comprises “on preventive treatment”, “off preventive treatment”, and “death” health states across a 10-year time horizon. The evaluation compared erenumab to no preventive treatment in episodic and chronic migraine patients that have failed at least one preventive therapy. Therapeutic benefits are based on estimated changes in monthly migraine days (MMD) from erenumab pivotal clinical trials and a network meta-analysis of migraine studies. Utilities were estimated using previously published mapping algorithms. A VBP analysis was performed to identify maximum erenumab annual prices at willingness-to-pay (WTP) thresholds of $100,000–$200,000 per QALY. Estimates of VBP under different scenarios such as choice of different comparators, assumptions around inclusion of placebo effect, and exclusion of work productivity losses were also generated.

Results: Erenumab resulted in incremental QALYs of 0.185 vs supportive care (SC) and estimated cost offsets due to reduced MMD of $8,482 over 10 years, with an average duration of treatment of 2.01 years. The estimated VBP at WTP thresholds of $100,000–$200,000 for erenumab compared to SC ranged from $14,238–$23,998. VBP estimates including the placebo effect and excluding work productivity ranged from $7,445–$13,809; increasing to $12,151–$18,589 with onabotulinumtoxinA as a comparator in chronic migraine.

Conclusion: Erenumab is predicted to reduce migraine-related direct and indirect costs, and increase QALYs compared to SC.     

Outcomes of tumor necrosis factor inhibitor cycling versus switching to a disease-modifying anti-rheumatic drug with a new mechanism of action among patients with rheumatoid arthritis

Objectives: To examine treatment patterns, treatment effectiveness, and treatment costs for 1 year after patients with rheumatoid arthritis switched from a tumor necrosis factor inhibitor (TNFi) (adalimumab, certolizumab pegol, etanercept, golimumab, or infliximab), either cycling to another TNFi (“TNFi cyclers”) or switching to a new mechanism of action (abatacept, tocilizumab, or tofacitinib) (“new MOA switchers”).

Methods: This retrospective cohort study used administrative claims data for a national insurer. Treatment persistence (without switching again, restarting, or discontinuing), treatment effectiveness (defined below), and costs were assessed for the 12-month post-switch period. Patients were “effectively treated” if they satisfied all six criteria for a treatment effectiveness algorithm (high adherence, no dose increase, no new conventional synthetic disease-modifying anti-rheumatic drug, no subsequent switch in therapy, no new/increased oral glucocorticoids, and <2 glucocorticoid injections). Multivariable logistic models were used to adjust for baseline factors.

Results: The database included 581 new MOA switchers and 935 TNFi cyclers. New MOA switchers were 39% more likely than TNFi cyclers to persist after the switch (odds ratio [OR]?=?1.39; 95% confidence interval [CI]?=?1.12–1.74; p?=?.003) and 36% less likely to switch therapy again (OR?=?0.64; 95% CI?=?0.51–0.81; p?p?=?.006). New MOA switchers had 16% lower drug costs than TNFi cyclers (cost ratio?=?0.84; 95% CI?=?0.79–0.88; p?p?Limitations: Claims payments may not reflect rebates or other cost offsets. Medical and pharmacy claims do not include clinical end-points or reasons that lead to new MOA switching vs TNFi cycling.

Conclusions: These results support switching to a new MOA after a patient fails treatment with a TNFi, which is consistent with recent guidelines for the pharmacologic management of established rheumatoid arthritis.     

Toward Reasonable Capitalism: The Role of John R. Commons’s Price and Business Cycle Theories

Abstract

John R. Commons thought that prices should be stable and that the law of supply and demand should be controlled by the power of the state through patent law and by protecting bargaining equality. Commons also thought that prices should be stabilized by macro monetary policy. These means would allow the realization of a “reasonable price.” Commons called the objective and measurable value in money, which is determined by a court ruling, “reasonable value.” Analysis of Commons’s price and business cycle theories point toward the realization of both “reasonable price” and “reasonable value” and toward “reasonable capitalism” that can replace banker capitalism.     

Adding links,adding persons,and adding structures: Using Sen's frameworks

Abstract

This essay is a comment on “Sen on Freedom and Gender Justice,” by Mozaffar Qizilbash, which appeared in Feminist Economics Volume 11, Number 3, November 2005.

Building on the 2003 double special issue of Feminist Economics entitled “Amartya Sen's Work and Ideas,” this paper responds to the review essay by Mozaffar Qizilbash. It identifies and illustrates various possible evaluations of a theoretical system, including that it has acknowledged strengths, unrecognized strengths, remediable gaps or failings, or structural faults. The paper then looks at Sen's system as a theoretical basis for “human development”– in particular in relation to personhood, emotions, and psychological interdependence – and argues that it points in directions required for economic and social analysis, including towards theories of care, but is not itself a sufficient treatment. The paper suggests deepening Sen's system by connecting to other important languages of analysis concerning the structuring of attitudes, emotions, felt well-being, public reasoning, and politics.     

Relevance of barriers and facilitators in the use of health technology assessment in Colombia

Objectives: Several studies, mostly from developed countries, have identified barriers and facilitators with regard to the uptake of health technology assessment (HTA). This study elicited, using best-worst scaling (BWS), what HTA experts in Colombia consider to be the most important barriers and facilitators in the use of HTA, and makes a comparison to results from the Netherlands.

Methods: Two object case surveys (one for barriers, one for facilitators) were conducted among 18 experts (policymakers, health professionals, PhD students, senior HTA-researchers) from Colombia. Seven respondents were employees of the national HTA agency Instituto de Evaluación Tecnológica de Salud (IETS). In total, 22 barriers and 19 facilitators were included. In each choice task, participants were asked to choose the most and least important barrier/facilitator from a set of five. Hierarchical Bayes modeling was used to compute the mean relative importance scores (RIS) for each factor, and a subgroup analysis was conducted to assess differences between IETS and non-IETS respondents. The final ranking was further compared to the results from a similar study conducted in the Netherlands.

Results: The three most important barriers (RIS >6.00) were “Inadequate presentation format”, “Absence of policy networks”, and “Insufficient legal support”. The six most important facilitators (RIS >6.00) were “Appropriate timing”, “Clear presentation format”, “Improving longstanding relation”, “Appropriate incentives”, “Sufficient qualified human resources”, and “Availability to relevant HTA research”. The perceived relevance of the barriers and facilitators differed slightly between IETS and non-IETS employees, while the differences between the rankings in Colombia and the Netherlands were substantial.

Conclusion: The study suggests that barriers and facilitators related to technical aspects of processing HTA reports and to the contact and interaction between researchers and policymakers had the greatest importance in Colombia.     

Economic burden of chemotherapy-treated recurrent and/or metastatic squamous cell carcinoma of the head and neck in France: real-world data from the permanent sample of national health insurance beneficiaries

Aims: Overall survival (OS) of patients with recurrent or metastatic (R/M) squamous cell carcinoma of the head and neck (SCCHN) is extremely poor. New therapeutic options emerge but need to establish their economic value. The objective was to describe the direct and related costs of R/M SCCHN in France.

Materials and methods: We selected all adult patients treated with chemotherapy for R/M SCCHN between 1 January 2009 and 31 December 2014 from the permanent sample of the French national health insurance database (EGB). Data were analyzed from the index date (first chemotherapy) until patients’ death or 31 December 2015. “Treatment period” and “end-of-life” (EoL) (from last chemotherapy until death) were distinguished. Costs included all hospitalizations for SCCHN and ambulatory care. Costs of hospitalized and non-hospitalized adverse events (AEs) were estimated.

Results: Among 267 patients identified, 85% were men, 44% had metastases at the index date and the mean age was 62.0 years (±9.9). The most common tumor location was oropharynx (29%) but 39% of patients had multiple locations. Median OS was 9.3 (95% CI: 7.9–11.8) months for the overall population. The average total direct cost per patient was €49,954, broken down into €32,908 (95% CI: 29,525–36,290) for hospitalizations and €17,047 (14,941–19,152) for ambulatory care. Main cost drivers were drug acquisition and administration (€14,538) during the treatment period (209?days on average) and palliative care (€3,750) during the EoL period (125?days). Regarding related costs, around 12% of patients received disability pensions (€1,397 per patient [624–2,171]) and sick leave payments (€1,592 [888–2,297]). “Metabolism and nutrition disorders” and “Infections and infestations” were the most expensive hospitalized AEs (€1,513 and €1,180 per patient, respectively). Febrile neutropenia was the most expensive non-hospitalized AE (€766 per patient).

Conclusions: This analysis of real-world data confirms the poor prognosis of patients with R/M SCCHN and provides cost data for future economic evaluations.     

A best–worst scaling in Colombian patients to rank the characteristics of HIV/AIDS treatment

Aim: To elicit patients’ preferences for HIV/AIDS treatment characteristics in Colombia.

Materials and methods: A best–worst scaling case was used to provide a ranking of 26 HIV/AIDS treatment characteristics that were similar to a previous study conducted in Germany. In each choice task, participants were asked to choose the most important and the least important treatment characteristics from a set of five from the master list. Using the Hierarchical Bayes method, relative importance scores were calculated. Sub-group analyses were conducted according to sex, education, source of infection, symptoms, and age.

Results: A total of 195 patients fully completed the questionnaire. The three most important characteristics were “drug has very high efficacy” (relative importance score [RIS]?=?10.1), “maximum prolongation of life expectancy” (RIS?=?9.7), and “long duration of efficacy” (RIS?=?7.4). Sub-group analysis showed only three significant (but minor) differences between older and younger people.

Conclusion: This study suggests that treatment characteristics regarding efficacy and prolongation of life are particularly important for patients in Colombia. Further investigation on how patients make trade-offs between these important characteristics and incorporating this information in clinical and policy decision-making would be needed to improve adherence with HIV/AIDS medication.     

A health economic model to assess the cost-effectiveness of OPTIFAST for the treatment of obesity in the United States

Objectives: Obesity is associated with high direct medical costs and indirect costs resulting from productivity loss. The high prevalence of obesity generates a justified need to identify cost-effective weight loss approaches from a payer’s perspective. Within the variety of weight management techniques, OPTIFAST is a clinically recognized and scientifically proven total meal replacement Low Calorie Diet that provides meaningful results in terms of weight loss and reduction in comorbidities. The objective of this study is assess potential cost-savings of the OPTIFAST program in the US, as compared to “no intervention” and pharmacotherapy.

Methods: An event-driven decision analytic model was used to estimate payer’s cost-savings from reimbursement of the 1-year OPTIFAST program over 3 years in the US. The analysis was performed for the broad population of obese persons (BMI >30?kg/m²) undergoing the OPTIFAST program vs liraglutide 3?mg, naltrexone/bupropion and vs “no intervention”. The model included the risk of complications related to increased BMI. Data sources included published literature, clinical trials, official US price/tariff lists, and national population statistics. The primary perspective was that of a US payer; costs were provided in 2016?US dollars.

Results: OPTIFAST leads over a period of 3 years to cost-savings of USD 9,285 per class I and II obese patient (BMI 30–39.9?kg/m²) as compared to liraglutide and USD 685 as compared to naltrexone/bupropion. In the same time perspective, the OPTIFAST program leads to a reduction of cost of obesity complications of USD 1,951 as compared to “no intervention”, with the incremental cost-effectiveness ratio of USD 6,475 per QALY. Scenario analyses also show substantial cost-savings in patients with class III obesity (BMI?≥?40.0?kg/m²) and patients with obesity (BMI?=?30–39.9?kg/m²) and type 2 diabetes vs all three previous comparators and bariatric surgery.

Conclusions: Reimbursing OPTIFAST leads to meaningful cost-savings for US payers as compared with “no intervention” and liraglutide and naltrexone/bupropion in obese patients. Similar results can be expected in matching healthcare settings of other countries. Moreover, OPTIFAST has additional clinical and economic advantages through very low complication and adverse events rates.     

A Monte Carlo simulation estimating US hospital cost reductions associated with hypotension control in septic ICU patients

Objective: This economic analysis extends upon a recent epidemiological study to estimate the association between hypotension control and hospital costs for septic patients in US intensive care units (ICUs).

Methods: A Monte Carlo simulation decision analytic model was developed that accounted for the probability of complications—acute kidney injury and mortality—in septic ICU patients and the cost of each health outcome from the hospital perspective. Probabilities of complications were calculated based on observational data from 110?US hospitals for septic ICU patients (n?=?8,782) with various levels of hypotension exposure as measured by mean arterial pressure (MAP, units: mmHg). Costs for acute kidney injury (AKI) and mortality were derived from published literature. Each simulation calculated mean hospital cost reduction and 95% confidence intervals based on 10,000 trials.

Results: In the base-case analysis hospital costs for a hypothetical “control” cohort (MAP of 65?mmHg) were $699 less per hospitalization (95% CI: $342–$1,116) relative to a “case” cohort (MAP of 60?mmHg). In the most extreme case considered (45?mmHg vs 65?mmHg), the associated cost reduction was $4,450 (95% CI: $2,020–$7,581). More than 99% of the simulated trials resulted in cost reductions. A conservative institution-level analysis for a hypothetical hospital (which assumes no benefit for increasing MAP above 65?mmHg) estimated a cost decline of $417 for a 5?mmHg increase in MAP per ICU septic patient. These results are applicable to the US only.

Conclusions: Hypotension control (via MAP increases) for patients with sepsis in the ICU is associated with lower hospitalization cost.     

Pleasure and belief in Hume's Decision Process

Abstract

The purpose of this paper is to introduce explicitly pleasure and belief in what aims at being a Humean theory of decision, like the one developed in Diaye and Lapidus (2005a). Although we support the idea that Hume was in some way a hedonist – evidently different from Bentham's or Jevons' way – we lay emphasis less on continuity than on the specific kind of hedonism encountered in Hume's writings (chiefly the Treatise, the second Enquiry, the Dissertation, or some of his Essays). Such hedonism clearly contrasts to its standard modern inheritance, expressed by the relation between preferences and utility.

The reason for such a difference with the usual approach lies in the mental process that Hume puts to the fore in order to explain the way pleasure determines desires and volition. Whereas pleasure is primarily, in Hume's words, an impression of sensation, it takes place in the birth of passions as reflecting an idea of pleasure, whose “force and vivacity” is precisely a “belief”, transferred to the direct passions of desire or volition that come immediately before action. As a result, from a Humean point of view, “belief” deals with decision under risk or uncertainty, as well as with intertemporal decision and indiscrimination problems.

The latter are explored within a formal framework, and it is shown that the relation of pleasure is transformed by belief into a non-empty class of relations of desire, among which at least one is a preorder.     

Marx and Kalecki on aggregate instability and class struggle

Abstract

Michal Kalecki developed his original model of the business cycle in the early 1930s. Several versions referred as versions I, II and III have been developed until the late 1960s from which Kalecki draw three central propositions on instability and class struggle: (1) the capitalist system “cannot break the impasse of fluctuations around a static position” unless it is shocked by “semi-exogenous factors”, (2) the dynamics of the profit rate and investment – as in version I and II – may be disconnected from “class struggle” and (3) when class struggle impacts the dynamics of the economy – as in version III – this is happening in a context in which expected profitability of new investment projects is negatively related to the profit share. In this article, we want to show that each of these three proposals represents key differences with Marx.     

Dualistic Discourse and Immigration Policy

Abstract:

The central question in immigration policy is whether to support less immigration through more “restrictive” laws and procedures or whether to support more immigration through a “relaxation” of existing laws. Recently, however, a second debate has arisen on one side of this debate regarding the appropriate types of arguments that may be used to support “restrictive” immigration. Ross Douthat refers to this dispute as the “race versus economics” question: using “race-based” arguments is not legitimate; while an “economic” or a “fact-based” argument is regarded as legitimate. We argue that this distinction in anti-immigration rhetoric is more apparent than real. Using the two most common historical “tropes” in immigration policy, “criminal” and “worker,” we find that racist, anti-ethnic, and classist assumptions pervade U.S. immigration law and policy and have been far more influential in formulating actual policy than either economic or “fact-based” analysis. The central problem with restrictive immigration policy is that its primary purpose is to determine who is eligible to be an American, and who is not; in other words, immigration policy is, by its fundamental intent, invidious. The question is whether it is possible to exclude individuals on these “legitimate” grounds without relying on “illegitimate” invidious distinctions?     

The effect of major adverse renal cardiovascular event (MARCE) incidence,procedure volume,and unit cost on the hospital savings resulting from contrast media use in inpatient angioplasty

Objective: To determine the net economic impact of switching from low-osmolar contrast media (LOCM) to iso-osmolar contrast media (IOCM; iodixanol) in patients undergoing inpatient coronary or peripheral angioplasty in the United States (US).

Methods: A budget impact model (BIM) was developed from a hospital perspective. Nationally representative procedural and contrast media prevalence rates, along with MARCE (major adverse renal cardiovascular event) incidence and episode-related cost data were derived from Premier Hospital Data (October 2014 to September 2015). A previously estimated relative risk reduction in MARCE associated with IOCM usage (9.3%) was applied. The higher cost of IOCM was included when calculating the net impact estimates at the aggregate, hospital type, and per hospital levels. One-way (±25%) and probabilistic sensitivity analyses identified the model’s most important inputs.

Results: Based on weighted analysis, 513,882?US inpatient angioplasties and 35,610 MARCE cases were estimated annually. Switching to an “IOCM only” strategy from a “LOCM only” strategy increases contrast media cost, but prevents 2,900 MARCE events. The annual budget impact was an estimated saving of $30.71 million, aggregated across all US hospitals, $6,316 per hospital, or $60 per procedure. Net savings were maintained across all univariate sensitivity analyses. While MARCE/event-free cost differential was the most important factor driving total net savings for hospitals in the Northeast and West, procedural volume was important in the Midwest and rural locations.

Conclusions: Switching to an “IOCM only” strategy from a “LOCM only” approach yields substantial net global savings to hospitals, both at the national level and within hospital sub-groups. Hospital administrators should maintain awareness of the factors that are likely to be more influential for their hospital and recognize that purchasing on the basis of lower contrast media cost may result in higher overall costs for patients undergoing inpatient angioplasty.     

Nicolas Baudeau,an anti-physiocrat? Éphémérides du citoyen prior to “conversion” (1765–1766)

Abstract

Éphémérides du citoyen is often considered to be an anti-physiocratic periodical, up until Baudeau's adherence to Quesnay's theories in 1766. An analysis of the journal's main economic themes between 1765 and 1766 however shows that this interpretation is inaccurate. It is true that the theme of rurality, the issue of the colonies and Baudeau's needs analyses indicate an original line of thinking, in which the public powers played the role of primary investor via a “land clearing company” or a “threefold royal messengers service”. However, these contain no radical opposition to the liberal ideas developed by Quesnay.