Cost effectiveness and impact on quality of life of abobotulinumtoxinA and onabotulinumtoxinA in the treatment of children with lower limb spasticity in Canada

Abstract

Background: Injectable botulinum neurotoxins are a mainstay of treatment for pediatric spasticity. AbobotulinumtoxinA and onabotulinumtoxinA are both injectable toxin therapies used to treat pediatric lower limb (PLL) spasticity in Canada. The objective of this study was to assess the cost-effectiveness of abobotulinumtoxinA vs. onabotulinumtoxinA in the treatment of PLL spasticity in Canada.

Methods: A probabilistic Markov cohort model with a 2-year time horizon was developed, with health states defined by response to therapy, as characterized by the goal attainment scale (GAS). Based on randomized controlled trial evidence, response to therapy was similar or higher for abobotulinumtoxinA relative to onabotulinumtoxinA; uncertainty was incorporated into model parameters, however, as the two therapies have not been compared head-to-head. Canadian resource use and cost data were incorporated.

Results: In the base case, abobotulinumtoxinA generated 1.48 quality-adjusted life years over the model time horizon, compared to 1.47 for onabotulinumtoxinA. AbobotulinumtoxinA was associated with cost savings of $123 CAD, reflecting lower costs in both medication acquisition and health services. The estimated improvement to quality of life and reduced costs result in an estimate of economic dominance for abobotulinumtoxinA over onabotulinumtoxinA. This dominant result persisted across probabilistic and scenario analyses.

• Key points for decision makers

• Based on a review of available clinical evidence, abobotulinumtoxinA was found to have significant and/or numerical efficacy benefits to onabotulinumtoxinA on functional outcomes (Goal Attainment Scale) and tone (Modified Ashworth Scale) and in the treatment of pediatric lower limb spasticity

• In this cost-effectiveness analysis, abobotulinumtoxinA was found to be associated with greater quality-adjusted life years and lower costs than onabotulinumtoxinA (economically dominant)

• A limitation of this analysis was the uncertainty around key parameters. Specifically, the lack of head-to-head comparison data for the two therapies, and variable data regarding likely onabotulinumtoxinA dosing in PLL in clinical practice. However, across a range of plausible scenarios, the economic dominant result remained.

     

Why have business cycle fluctuations become less volatile?

This paper shows that a standard Real Business Cycle model driven by productivity shocks can successfully account for the 50% decline in cyclical volatility of output, its components, and labor input that has occurred since 1983. The model is successful because the volatility of productivity shocks has also declined significantly over the same time period. We then investigate whether the decline in the volatility of the Solow Residual is due to changes in the volatility of some other shock operating through a channel that is absent in the standard model. We therefore develop a model with variable capacity and labor utilization. We investigate whether government spending shocks, shocks that affect the household’s first order condition for labor, and shocks that affect the household’s first order condition for saving can plausibly account for the change in TFP volatility and in the volatility of output, its components, and labor. We find that none of these shocks are able to do this. This suggests that successfully accounting for the post-1983 decline in business cycle volatility requires a change in the volatility of a productivity-like shock operating within a standard growth model. We thank Stephen Parente, Ed Prescott, John Taylor, and two anonymous referees for helpful comments and suggestions.     

Organizational Culture and Organizational Change: The Transformation of Savings Banks in Denmark, 1965-1990

In this article, I argue that organizations' historical narrativesare a basic and important component of their culture and identity,and that these narratives can be resources as well as constraints.I combine a narrative approach with Joanne Martin's three perspectivetheory of organizational culture, and using the transformationof Danish savings banks as a case, I demonstrate how a narrativeapproach can provide a new and better understanding of organizationalbehaviour and change than mainstream economics and the abundantfunctionalist organizational culture literature. I demonstratehow, when change was called for by external pressures, the savingsbanks choice set was constrained by a shared narrative abouttheir historical origins. This narrative, in turn, constitutedthe identity, image and organizational culture of savings banksand to a high degree restrained learning capabilities, createdorganizational inertia and delayed the adoption of a new strategy.     

Structural estimates of the intergenerational education correlation

Using a structural dynamic programming model, we investigate the relative importance of family background variables and individual specific abilities in explaining cross‐sectional differences in schooling attainments and wages. Each type of ability is the sum of one component correlated with family background variables and a residual (orthogonal) component which is purely individual specific. Household background variables (especially parents' education) account for 68% of the explained cross‐sectional variations in schooling attainments, while ability correlated with background variables accounts for 17% and pure individual specific ability accounts for 15%. Interestingly, individual differences in wages are mostly explained by pure individual specific abilities as they account for as much as 73% of the explained variations in wages. Family background variables account for only 19%, while ability endowments correlated with family background account for 8%. Copyright © 2003 John Wiley & Sons, Ltd.     

A multidimensional scale for measuring business ethics: A purification and refinement

Many researchers in the field of business ethics have attempted to develop methods to determine and evaluate the ethics of a variety of different classes of people, including students, professionals, and mixed samples of students and professionals. Unfortunately, most of these studies were disjunctive, simply adding confusion to an already unfocused area of research. However, Reidenbach and Robin (1988, 1990), have changed this trend by attempting to quantify the various ethical philosophies into a multi-dimensional scale of business ethics. This paper examines the background of the Reidenbach and Robin (1988, 1990) scale — including the authors' findings, empirically tests the scale, and concludes that the scale needs further refinement. A promising result is a model with four dimensions: a broadbased ethical judgment dimension, a deontological judgment dimension, a teleological judgment dimension, and a social contract dimension.Randall S. Hansen is ABD at Florida State University, where his major is marketing and his support area is strategic management. His research interests are directed toward the applied areas of managerial and consumer ethical decision-making as well as strategic issues in social responsibility. He has published in theProceedings of the Academy of Marketing Science, Proceedings of the Southern Marketing Association, andProceedings of the Southern Management Association.     

Endogenous schooling and the distribution of the gender wage gap

Previous studies on the gender wage gap have relied on OLS when estimating the wage equations. However, a number of recent studies, devoted to estimating the return to education, have shown that OLS may produce biased estimates for a number of reasons. As a consequence, previous results regarding the gender wage gap may also be biased. In this paper, we first estimate wage equations using a GMM procedure applied to panel data and then investigate the distribution of the gender wage gap. The results indicate that OLS may seriously overestimate the unexplained gender wage gap.First version received: October 2001/Final version accepted: July 2003     

The Rise in Danish Unemployment: Reallocation or Mismatch?*

The two main competing theories for the outward shift in the uv‐curve are investigated: increased separations from employment at a given employment level (reallocation) and decreased levels of hires, given unemployment and vacancies (mismatch). Shifts in the unemployment–vacancy (uv)‐curve and the hiring function are modelled by smooth transition functions, and the hypothesis of analogous shifts in the two curves is tested and accepted. This is interpreted as evidence in favour of the mismatch hypotheses.     

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Book reviews

     

Arab socialism in Egypt

The characteristic feature of ‘Arab socialism’, as practised in Egypt, is public ownership of the modern sectors, including finance and trade. Efficiency, in these sectors, and perhaps in agriculture, however, has suffered. Despite some improvement in distribution, following confiscation of larger businesses and rural estates, Egyptian society cannot be considered egalitarian. Egypt's system of agrarian co-operatives is perhaps the only feature of Arab socialism worth imitating.