Objective: Patients with relapsing-remitting multiple sclerosis (RRMS) treated with disease modifying therapies (DMTs) who continue to experience disease activity may be considered for escalation therapies such as fingolimod, or may be considered for alemtuzumab. Previous economic modeling used Markov models; applying one alternative technique, discrete event simulation (DES) modeling, allows re-treatment and long-term adverse events (AEs) to be included in the analysis.
Methods: A DES was adapted to model relapse-triggered re-treatment with alemtuzumab and the effect of including ongoing quality-adjusted life year (QALY) decrements for AEs that extend beyond previous 1-year Markov cycles. As the price to the NHS of fingolimod in the UK is unknown, due to a confidential patient access scheme (PAS), a variety of possible discounts were tested. The interaction of re-treatment assumptions for alemtuzumab with the possible discounts for fingolimod was tested to determine which DMT resulted in lower lifetime costs. The lifetime QALY results were derived from modeled treatment effect and short- and long-term AEs.
Results: Most permutations of fingolimod PAS discount and alemtuzumab re-treatment rate resulted in fingolimod being less costly than alemtuzumab. As the percentage of patients who are re-treated with alemtuzumab due to experiencing a relapse approaches 100% of those who relapse whilst on treatment, the discount required for fingolimod to be less costly drops below 5%. Consideration of treatment effect alone found alemtuzumab generated 0.2 more QALYs/patient; the inclusion of AEs up to a duration of 1 year reduced this advantage to only 0.14 QALYs/patient. Modeling AEs with a lifetime QALY decrement found that both DMTs generated very similar QALYs with the difference only 0.04 QALYs/patient.
Conclusions: When the model captured alemtuzumab re-treatment and long-term AE decrements, it was found that fingolimod is cost-effective compared to alemtuzumab, assuming application of only a modest level of confidential PAS discount. 相似文献
Automating routine organizational tasks, such as meeting scheduling, requires a careful balance between the individual (respecting his or her privacy and personal preferences) and the organization (making efficient use of time and other resources). We argue that meeting scheduling is an inherently distributed process, and that negotiating over meetings can be viewed as a distributed search process. Keeping the process tractable requires introducing heuristics to guide distributed schedulers' decisions about what information to exchange and whether or not to propose the same tentative time for several meetings. While we have intuitions about how such heuristics could affect scheduling performance and efficiency, verifying these intuitions requires a more formal model of the meeting schedule problem and process. We present our preliminary work toward this goal, as well as experimental results that validate some of the predictions of our formal model. We also investigate scheduling in overconstrained situations, namely, scheduling of high priority meetings at short notice, which requires cancellation and rescheduling of previously scheduled meetings. Our model provides a springboard into deeper investigations of important issues in distributed artificial intelligence as well, and we outline our ongoing work in this direction. 相似文献
The purpose of this study is to identify generational differences and similarities among hospitality employees and managers in order to develop leadership strategies and management styles that can be utilized to increase employee morale and productivity while enhancing recruitment and retention rates of highly qualified workers. Data for this study were collected through a series of in-depth focus group discussions. Findings indicated significant generational differences in world views, attitudes toward authority and perspectives on work. Findings suggested the Baby Boomers respect authority and hierarchy, while the Generation X-ers (Gen X-ers) rebel against authority. Findings also suggested while Baby Boomers live to work, Gen X-ers work to live. The Baby Boomers are willing to wait their turn for promotions and rewards, and are very loyal. On the other hand, Gen X-ers expect immediate recognition through title, praise, promotion, and pay. They also want a life outside of work—they are not likely to sacrifice theirs for the company. The Millennial Generation believes in collective action, with optimism of the future, and trust in centralized authority. They like teamwork, showing a strong will to get things done with a great spirit. 相似文献