Cost-effectiveness of rivaroxaban compared with enoxaparin plus a vitamin K antagonist for the treatment of venous thromboembolism

Background:

Venous thromboembolism (VTE), comprised of deep vein thrombosis (DVT) and pulmonary embolism (PE), is commonly treated with a low-molecular-weight heparin such as enoxaparin plus a vitamin K antagonist (VKA) to prevent recurrence. Administration of enoxaparin?+?VKA is hampered by complexities of laboratory monitoring and frequent dose adjustments. Rivaroxaban, an orally administered anticoagulant, has been compared with enoxaparin?+?VKA in the EINSTEIN trials. The objective was to evaluate the cost-effectiveness of rivaroxaban compared with enoxaparin?+?VKA as anticoagulation treatment for acute, symptomatic, objectively-confirmed DVT or PE.

Methods:

A Markov model was built to evaluate the costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios associated with rivaroxaban compared to enoxaparin?+?VKA in adult patients treated for acute DVT or PE. All patients entered the model in the ‘on-treatment’ state upon commencement of oral rivaroxaban or enoxaparin?+?VKA for 3, 6, or 12 months. Transition probabilities were obtained from the EINSTEIN trials during treatment and published literature after treatment. A 3-month cycle length, US payer perspective ($2012), 5-year time horizon and a 3% annual discount rate were used.

Results:

Treatment with rivaroxaban cost $2,448 per-patient less and was associated with 0.0058 more QALYs compared with enoxaparin?+?VKA, making it a dominant economic strategy. Upon one-way sensitivity analysis, the model’s results were sensitive to the reduction in index VTE hospitalization length-of-stay associated with rivaroxaban compared with enoxaparin?+?VKA. At a willingness-to-pay threshold of $50,000/QALY, probabilistic sensitivity analysis showed rivaroxaban to be cost-effective compared with enoxaparin?+?VKA approximately 76% of the time.

Limitations:

The model did not account for the benefits associated with an oral and minimally invasive administration of rivaroxaban. ‘Real-world’ applicability is limited because data from the EINSTEIN trials were used in the model. Also, resource utilization and costs were based on the US healthcare system.

Conclusion:

Rivaroxaban is a cost-effective option for anticoagulation treatment of acute VTE patients.     

Length of stay and economic consequences with rivaroxaban vs enoxaparin/vitamin K antagonist in patients with DVT and PE: findings from the North American EINSTEIN clinical trial program

Objective:

Venous thromboembolism (VTE) (deep vein thrombosis [DVT] and pulmonary embolism [(PE]) represents a substantial economic burden to the healthcare system. Using data from the randomized EINSTEIN DVT and PE trials, this North American sub-group analysis investigated the potential of rivaroxaban to reduce the length of initial hospitalization in patients with acute symptomatic DVT or PE.

Methods:

A post-hoc analysis of hospitalization and length-of-stay (LOS) data was conducted in the North American sub-set of patients from the randomized, open-label EINSTEIN trial program. Patients received either rivaroxaban (15?mg twice daily for 3 weeks followed by 20?mg once daily; n?=?405) or dose-adjusted subcutaneous enoxaparin overlapping with (guideline-recommended ‘bridging’ therapy) and followed by a vitamin K antagonist (VKA) (international normalized ratio?=?2.0–3.0; n?=?401). The open-label study design allowed for the comparison of LOS between treatment arms under conditions reflecting normal clinical practice. LOS was evaluated using investigator records of dates of admission and discharge. Analyses were carried out in the intention-to-treat population using parametric tests. Costs were applied to the LOS based on weighted mean cost per day for DVT and PE diagnoses obtained from the Healthcare Cost and Utilization Project dataset.

Results:

Of 382 patients hospitalized, 321 (84%), had acute symptomatic PE; few DVT patients required hospitalization. Similar rates of VTE patients were hospitalized in the rivaroxaban and enoxaparin/VKA treatment groups, 189/405 (47%) and 193/401 (48%), respectively. In hospitalized VTE patients, rivaroxaban treatment produced a 1.6-day mean reduction in LOS (median?=?1 day) compared with enoxaparin/VKA (mean?=?4.5 vs 6.1; median?=?3 vs 4), translating to total costs that were $3419 lower in rivaroxaban-treated patients.

Conclusion:

In hospitalized North American patients with VTE, treatment with rivaroxaban produced a statistically significant reduction in LOS. When treating DVT and PE patients, clinicians should consider newer anti-coagulants with less complex treatment regimens.     

Effect of perceived conflict among multiple performance goals and goal difficulty on task performance

Contemporary performance measurement systems, such as the balanced scorecard, often advocate the use of an array of financial and non‐financial measures. Despite many claimed advantages for these systems, recent research shows that the inclusion of multiple performance measures sometimes has undesirable effects. The present study examines one of the potential problems of implementing these systems; namely, the impact of perceived goal conflict on task performance. Using survey data from employees working in multiple call centres in a telecommunication company, we find that perceived goal difficulty increases perceived goal conflict. Additionally, perceived goal difficulty also has a negative, indirect effect of task performance, through the mediating role of perceived goal conflict. Our results have important implications for both the research literature and the designers of performance measurement systems.     

Economic implications of proposed accounting for stock-based compensation

This article examines the market expectations of the proposed accounting changes for stock-based compensation in the exposure draft that preceded the Statement of Financial Accounting Standards No. 123. The exposure draft made recommendations that significantly differed from current practice. Affected firms expressed concern that the proposed changes would drastically reduce their reported earnings. This could lead to firms becoming less attractive to capital sources (resulting in higher costs of capital) and firms refraining from using stock options to attract talented managers and entrepreneurs. The market test shows that affected firms experienced negative security market prices contemporaneous with issuance of the exposure draft. Cross-sectional analyses indicate that the magnitude of price decline is associated with measures of high risk and less mature firms.     

Organisational Justice: A Senian Perspective

In this paper, we draw inferences from the Nobel laureate Amartya Sen’s book, The Idea of Justice to inform the organisational justice literature. The extant societal-level theories of justice tend to emphasise aspects that are analogous to either the procedural or distributive dimensions of organisational justice. The Senian idea of comprehensive justice is different in that it synthesises the procedural- and distributive-related dimensions at the societal-level. We theorise that the Senian notion could be applied at the organisational-level to facilitate outcomes that are actually valued by the workforce. Further, we contend that the emphasis on non-parochialism in the Senian notion of justice makes it particularly relevant to the ethics of multi-national corporations (MNCs) operating in alien cultures. To support our contention, we analyse the lean manufacturing practices of a Japanese MNC operating in India. Our case analysis demonstrates how Senian thinking helps one surface unjust outcomes that would otherwise go unacknowledged. Our analysis also offers tentative support to Senian claims about the capacity of human behaviour to undermine well-designed institutions. Concurring with the Senian view, which favours combating manifest injustice rather than fixating over designing perfectly just institutions, we derive some normative implications to advance the cause of striving for outcomes that are actually valued by the workforce.     

Inter-firm learning and knowledge-sharing in multinational networks: An outsourced organization's perspective

This research provides insights into how learning and knowledge are exchanged multinationally between customer firms and their outsourced suppliers who provide non-core, yet essential, services. The paper seeks to understand: (1) how information is exchanged in these networks; (2) how cumulative knowledge adds value in these networks; and (3) how boundary-spanners assist in the dissemination of knowledge and learning within the network. Based on a pharmaceutical industry case, the results suggest that: (a) multinational firms operate more effectively and interact by sharing knowledge with outsourced firms which reflect the customers' structure and fit; (b) networked firms benefit from interactions through economies of scope, but knowledge is not necessarily shared equally among partners; (c) learning and knowledge-sharing interactions are tightly coupled at the product development stage; and (d) outsourced firms interact with external boundary-spanners as needed. The research provides insights for managers of multinational organizations and managers of firms from where essential services are outsourced.