A cost analysis of SIR-Spheres yttrium-90 resin microspheres versus tyrosine kinase inhibitors in the treatment of unresectable hepatocellular carcinoma in France,Italy, Spain and the UK

Abstract

Background and aims: A wide range of treatment options are available for hepatocellular carcinoma (HCC), including systemic treatment with tyrosine kinase inhibitors (TKIs) such as sorafenib and lenvatinib, immunotherapies, locoregional therapies such as selective internal radiation therapy (SIRT) and treatments with curative intent such as resection, radiofrequency ablation and liver transplantation. Given the substantial economic burden associated with HCC treatment, the aim of the present analysis was to establish the cost of using SIRT with SIR-Spheres yttrium-90 (Y-90) resin microspheres versus TKIs from healthcare payer perspectives in France, Italy, Spain and the United Kingdom (UK).

Methods: A cost model was developed to capture the costs of initial systemic treatment with sorafenib (95%) or lenvatinib (5%) versus SIRT in patients with HCC in Barcelona Clinic Liver Cancer (BCLC) stages B and C. A nested Markov model was utilized to model transitions between progression-free survival (PFS), progression and death, in addition to transitions between subsequent treatment lines. Cost and resource use data were identified from published sources in each of the four countries.

Results: Relative to TKIs, SIRT with SIR-Spheres Y-90 resin microspheres were found to be cost saving in all four country settings, with the additional costs of the microspheres and the SIRT procedure being more than offset by reductions in drug and drug administration costs, and treatment of adverse events. Across the four country settings, total cost savings with SIR-Spheres Y-90 resin microspheres fell within the range 5.4–24.9% and SIRT resulted in more patients ultimately receiving treatments with curative intent (4.6 vs. 1.4% of eligible patients).

Conclusion: SIR-Spheres Y-90 resin microspheres resulted in cost savings relative to TKIs in the treatment of unresectable HCC in all four country settings, while increasing the proportion of patients who become eligible for treatments with curative intent.     

On Teasing Out Sociology from Economics

A bstract .   Of the many interesting pieces of information that can be found in Parsons's March 10, 1973 seminar at Brown University, one concerns his relationship to Schumpeter, and it is to this that this brief note is devoted. Parsons and Schumpeter knew each other for some 20 years, and one of the many things that Schumpeter taught Parsons was that one can read the texts of economists for the sociological insights that they contain. In Parsons's formulation from the seminar: "economists must have some sociological ideas."     

Doing the right thing in the workplace: Responsibility in the face of accountability

Changing trends and the nature of the work force dictate increased personal responsibility by employees and expanded use of self-management practices. Nevertheless, organizations also feel the need to maintain external control. We propose a progressive view of accountability theory which can resolve the dilemma of how internal and external control can effectively coexist. Success of accountability forces is determined primarily by the relationship between the principal (party to whom one is accountable) and the agent (employee). The agent’s felt responsibility is enhanced to the extent that accountability leads to the structuring of expectations, the agent’s perceptions of the task or activity as significant, and the agent’s perception of control over the situation. Propositions that may be used to guide future research are offered throughout the article.     

Air pollution-mortality models: A demonstration of the effects of random measurement error

Errors of measurement have long been recognized as a chronic problem in statistical analysis. Although there is a vast statistical literature of multiple regression models estimating the air pollution-mortality relationship, this problem has been largely ignored. It is well known that pollution measures contain error, but the consequences of this error for regression estimates is not known. We use Lave and Seskin's air pollution model to demonstrate the consequences of random measurement error. We assume a range of 0% to 50% of the variance of the pollution measures is due to error. We find large differences in the estimated effects on mortality of the pollution variables as well as the other explanatory variables once this measurement error is taken into account. These results cast doubt on the usual regression estimates of the mortality effects of air pollution. More generally our results demonstrate the consequences of random measurement error in the explanatory variable of a multiple regression analysis and the misleading conclusions that may result in policy research if this error is ignored.     

Structural instability of the core

Let σ be a q-rule, where any coalition of size q, from the society of size n, is decisive. Let w(n,q)= 2q-n+1 and let W be a smooth ‘policy space’ of dimension w. Let U(W)^N be the space of all smooth profiles on W, endowed with the Whitney topology. It is shown that there exists an ‘instability dimension’ w^*(σ) with 2w^*(σ)w(n,q) such that:

1. (i) if ww^*(σ), and W has no boundary, then the core of σ is empty for a dense set of profiles in U(W)^N (i.e., almost always),

2. (ii) if ww^*(σ)+1, and W has a boundary, then the core of σ is empty, almost always,

3. (iii) if ww^*(σ)+1 then the cycle set is dense in W, almost always,

4. (iv) if ww^*(σ)+2 then the cycle set is also path connected, almost always.

The method of proof is first of all to show that if a point belongs to the core, then certain generalized symmetry conditions in terms of ‘pivotal’ coalitions of size 2q−n must be satisfied. Secondly, it is shown that these symmetry conditions can almost never be satisfied when either W has empty boundary and is of dimension w(n,q) or when W has non-empty boundary and is of dimension w(n,q)+1.     

PROPRIETORIAL CONTROL IN FAMILY FIRMS: SOME FUNCTIONS OF 'QUASI-ORGANIC' MANAGEMENT SYSTEMS

The purpose of this paper is to investigate the strategies of managerial control which are used by the proprietors of family-owned business enterprises. Interviews with the proprietors and senior managers of businesses in the building industry illustrate the ‘quasi-organic’ nature of management structures. These grant some autonomy to senior managers without threatening proprietorial decision-making prerogatives. Although the family firm has certain distinctive features, similar control strategies designed to ensure that delegated decisions are ‘reliable’ and ‘responsible’ are evident in various types of business enterprise. There is, then, scope for further comparative research within a conceptual framework which does not entirely divorce the family firm from other business organizations.     

Income Inequality and Macroeconomic Volatility: An Empirical Investigation

We explore the impact of macroeconomic volatility on the distribution of income. Using a cross‐section of developed and developing countries, we find that greater output volatility, defined as the standard deviation of the rate of output growth, is associated with a higher Gini coefficient and income share of the top quintile. The coefficients suggest that a strong effect on inequality resulting from a reduction in volatility: the Gini coefficient of a country like Chile would fall by 6 points if it were to reduce its volatility to the same level as Sweden or Norway. Our results seem not to be driven by the high‐inequality/high‐volatility Latin American countries.     

Learning for Innovation and the Skill Premium

The computer revolution took very long to pay off in productivity growth in the computer-using sectors. The relative wage of skilled workers, however, has risen sharply from the early days of the computer revolution onward. As skilled workers wages reflect their productivity, the two observations together pose a puzzle.This paper provides a micro-based explanation for the long diffusion period of the computer revolution. The general equilibrium model of growth zooms in on the research process and provides an explanation for sluggish growth with booming relative wages of the skilled. Technological progress in firms is driven by research aimed at improving the production technology (innovation) and by assimilation of ideas or principles present outside the firm (learning). A new General Purpose Technology (GPT) like the computer revolution generates an initial slowdown in economic growth and an increase in the skill premium.Acknowledgement I am indebted to Theo van de Klundert for suggestions and encouragement. Suggestions by Jan Boone, Bas Jacobs, Patrick Francois, Henri de Groot, Lex Meijdam, Niek Nahuis Sjak Smulders, Harald Uhlig and anonymous referees have contributed to the paper.