What happens after a single surgical intervention for hidradenitis suppurativa? A retrospective claims-based analysis

Objective Hidradenitis suppurativa (HS) is often treated by surgery. The risk of recurrence after surgery is common and the consequences are substantial, but neither has been quantified using a claims database. This study aimed to estimate the burden associated with non-curative surgery in HS patients.

Methods A retrospective analysis was performed of health insurance claims data from Q1 1999 to Q2 2011 in a US claims database. The analysis included 2668 adults with ≥1 diagnosis of HS and ≥1 claim for skin surgery within 6 months after diagnosis. Healthcare resource utilization and medical costs were compared using multivariate regressions.

Results Overall, 46% of HS patients had ≥1 indicator of non-curative surgery. The incidences of inpatient, emergency department, and outpatient visits were 88%, 40%, and 30% higher, respectively, for patients with non-curative surgery vs patients without indicator of non-curative surgery (all p?<?0.001). Average medical costs were $11,858 and $6427 for patients with and without indicators of non-curative surgery, respectively. The difference of $4185 (p?<?0.001) was mainly driven by inpatient costs (difference = $2685; p?<?0.001).

Limitations Indicators of non-curative HS surgery were defined based on an empirical algorithm.

Conclusions Non-curative HS surgery occurred in almost half of all cases and represents a significant burden on patients and payers in terms of resource utilization and costs.     

Amino acid formula as a new strategy for diagnosing cow’s milk allergy in infants: is it cost-effective?

Aims: To estimate the cost-effectiveness of a new strategy that uses an amino acid formula in the elimination diet of infants with suspected cow’s milk allergy (CMA).

Materials and methods: This pharmacoeconomic study was developed from the perspective of the Brazilian Public Healthcare System. The new strategy proposes using an amino acid formula in the diagnostic elimination diet of infants (≤24 months) with suspected CMA. The rationale is that infants who do not respond to the amino acid formula do not suffer from CMA. Patients with a positive oral challenge test receive a therapeutic elimination diet based on Brazilian Food Allergy Guidelines. This approach was compared to the current recommendations of the Brazilian Food Allergy Guidelines. A decision model was constructed using TreeAge Pro 2012 software. Model inputs were based on a literature review and the opinions of a panel of experts. A univariate sensitivity analysis of incremental cost-effectiveness ratios was performed.

Results: The mean cost per patient of the new amino acid formula strategy was R$3,341.57, while the cost of the current Brazilian guidelines strategy was R$3,641.08. The mean number of symptom-free days per patient, which was used as an indicator of effectiveness, was 900.6 and 875.7 days, respectively. The new strategy is, therefore, dominant. In the sensitivity analysis, the dominance was maintained with parameter variation.

Limitations: In the absence of information in the literature, some premises were defined by a panel of specialists.

Conclusions: The new strategy, which uses an amino acid formula in the elimination diagnostic diet followed by an oral food challenge, is a dominant pharmacoeconomic approach that has a lower cost and results in an increased number of symptom-free days.     

Cost-effectiveness of droxidopa in patients with neurogenic orthostatic hypotension: post-hoc economic analysis of Phase 3 clinical trial data

Objective:

Falls are associated with neurogenic orthostatic hypotension (nOH) and are an economic burden on the US healthcare system. Droxidopa is approved by the US FDA to treat symptomatic nOH. This study estimates the cost-effectiveness of droxidopa vs standard of care from a US payer perspective.

Methods:

A Markov model was used to predict numbers of falls and treatment responses using data from a randomized, double-blind trial of patients with Parkinson’s disease and nOH who received optimized droxidopa therapy or placebo for 8 weeks. The severity of falls, utility values, and injury-related costs were derived from published studies. Model outcomes included number of falls, number of quality-adjusted life-years (QALYs), and direct costs. Incremental cost-effectiveness ratios (ICERs) were calculated. Outcomes were extrapolated over 12 months.

Results:

Patients receiving droxidopa had fewer falls compared with those receiving standard of care and gained 0.33 QALYs/patient. Estimated droxidopa costs were $30,112, with estimated cost savings resulting from fall avoidance of $14,574 over 12 months. Droxidopa was cost-effective vs standard of care, with ICERs of $47,001/QALY gained, $24,866 per avoided fall with moderate/major injury, and $1559 per avoided fall with no/minor injury. The main drivers were fall probabilities and fear of fall-related inputs.

Limitations:

A limitation of the current study is the reliance on falls data from a randomized controlled trial where the placebo group served as the proxy for standard of care. Data from a larger patient population, reflecting ‘real-life’ patient use and/or comparison with other agents used to treat nOH, would have been a useful complement, but these data were not available.

Conclusion:

Using Markov modeling, droxidopa appears to be a cost-effective option compared with standard of care in US clinical practice for the treatment of nOH.     

The Development of Inequality and Poverty in Indonesia, 1932–2008

We estimate inequality in Indonesia between 1932 and 2008. Inequality increased at the start of this period but declined sharply from the 1960s onwards. The increase was due to a shift from domestic to export agriculture over the period up to the Great Depression. During the 1930s, as the price of export crops declined, the income of rich farmers suffered a blow. Yet this was counterbalanced by an increasing gap between expenditures in the urban and rural sectors, causing an overall rise in inequality. As for the second half of the century, we find that the employment shift towards manufacturing and services—combined with an increase in labour productivity in agriculture—accounts for inequality’s decline, which was halted in the 1990s. These inequality trends affected poverty as well, but prior to the 1940s the negative impact of the rise in inequality was offset by an increase in per capita GDP. Between 1950 and 1980 a decline in inequality, combined with increased per capita GDP, rapidly raised a large portion of the population above the poverty line.     

The Clean Development Mechanism in a world carbon market

This paper discusses the role of the Clean Development Mechanism (CDM) in the market for carbon quotas and countries' commitments to reduce their carbon emission levels. We show that the CDM contributes to an efficient funding of clean technology investments in least developed countries. However, the CDM is not neutral on the global level of carbon emissions as it entices countries to raise their emission caps. The CDM may also make inappropriate the inclusion of any country that takes no emission abatement commitment. It can even make inefficient a country's decision to commit to an emission target. The implications of the presence of non‐additional projects are also analyzed.     

An additional explanation for the variable Keynesian multiplier: The role of the propensity to import

This article analyzes the concept of the Keynesian multiplier from a new perspective. Several recent studies have shown that the fiscal multiplier is endogenous to the level of economic activity, increasing during recessions and decreasing during the boom. Here, we provide some evidence, explaining this variability over the business cycle, based on the overreaction of aggregate imports. Then, we apply the concept of endogenous propensity to import, varying with capacity utilization, to a neo-Kaleckian model of growth and distribution. We perform some simple simulations showing that the Keynesian multiplier increases during a recession, which logically does not advocate a reduction in public spending when the economy is in crisis.     

Do regional trade agreements really boost trade? Evidence from agricultural products

We evaluate the impact on trade of regional trade agreements (RTAs) using a panel data approach at the detailed product level which exploits exports to third destinations and imports from third origins as benchmarks. This method is robust to both endogeneity and heterogeneity across agreements and across products, and allows differentiation between the impacts of tariff provisions and non-tariff provisions. The analysis covers agricultural and food products for 74 country pairs linked by an agreement entered into force during the period 1998–2009. Our estimate of the mean elasticity of substitution across imports at product level is slightly below four. Counterfactual simulations suggest that RTAs have increased partners’ bilateral agricultural and food exports by 30–40 % on average, with marked heterogeneity across agreements. Also, RTAs are found to increase the probability of exporting a given product to a partner country although this impact is small. Finally, we found non-tariff provisions have no measurable trade impact.     

The Nordic Model on the Global Market of Ideas: The Welfare State as Scandinavia’s Best Brand

This article analyses the contemporary deployment of the Nordic welfare state model as a centrepiece of Nordic competitive identity and strategic communication on the global market of ideas. First, it looks at the interrelated phenomena of global competition, competitive identity and region branding. Second, it studies the interplay between Nordic transnational public diplomacy and national public diplomacy of individual Nordic countries, in particular Sweden, on the one hand and international media outlets’ reporting on the Nordic countries on the other. In analysing this cross-fertilizing genre, the article identifies how the welfare state is being repackaged for export along with a set of “progressive values” which are coded as specifically “Nordic.” The article discusses (1) the interaction between outer images and inner visions; (2) the place and significance of the Nordic model, progressive values and the welfare state in today’s Nordic branding; and (3) the possible function of outward competitive identity as a kind of “compensatory imagination” directed inward as well as outward.     

Persistence of Current‐account Disequilibria and Real Exchange‐rate Misalignments

This paper aims at studying whether the persistence of the gap between the observed current‐account position and its equilibrium value nonlinearly depends on real exchange‐rate misalignments. Estimating a panel smooth transition regression model on a sample of 22 industrialized countries, we find evidence for this hypothesis, showing that persistence of current‐account imbalances strongly depends on the deviation of the real exchange rate from its long‐term equilibrium. More specifically, while there is no persistence in cases of currency undervaluation or weak overvaluation, persistence tends to augment for overvaluations higher than 11%. In addition, whereas disequilibria are persistent even for very low overvaluations in the euro area, persistence is observed only for overvaluations higher than 14% for non‐eurozone members.