The association between the severity of chronic kidney disease and medical costs among patients with type 2 diabetes

Aims: Examine healthcare costs across chronic kidney disease (CKD) stages for US patients with type 2 diabetes (T2D).

Materials and methods: IQVIA Real World Data Adjudicated Claims linked electronic medical records and insurance claims from January 1, 2012 through March 31, 2017 were used for this retrospective study. Adults diagnosed with T2D and comorbid CKD were included. General linear models incorporating splines were constructed, and information from these regressions were used to inform the relationship between medical costs and CKD. Multivariable analyses controlled for patient characteristics, vital signs, general health, prior medication use, prior visit to specialists, index A1c, and year of index date.

Results: There were 6,645 individuals who met the study criteria. Results generally indicate sharp increases in annual total medical costs and non-drug medical costs in the 1?year post-period for patients with Stage 4 or 5 CKD (estimated glomerular filtration rate [eGFR]?≤?30?mL/min/1.73 m²) with each 1 point reduction in eGFR from 30 associated with an increase of $1,870 in all-cause total medical costs (p?<?0.0001) and $1,805 of all-cause non-drug medical costs (p?<?0.0001). Similarly, each point decline below 30?mL/min was associated annual cost increases of $1,701 for CKD-related total medical costs, $1,695 for CKD-related non-drug medical costs, $173 for diabetes-related medical costs, and $187 for diabetes-related non-drug medical costs (all p?<?0.0001).

Limitations: The investigation included only patients with medical insurance and laboratory test results, and results may not be generalizable to all T2D patients with CKD. The methodology allowed us to determine associations, not causation, and potential confounders, such as duration of diabetes, diet, exercise, or social support, could not be assessed.

Conclusions: Results indicate there are sharp and significant increases in medical costs among T2D patients with Stage 4 and 5 CKD compared to those with earlier stages of CKD.     

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.     

The influence of hospitable design and service on patient responses

ABSTRACT

A study of 216 respondents examined a medical center environment’s influence on patient responses. A stimulus–organism–response (S-O-R) model was adapted to the theory that more hospitable healthcare servicescape elements will affect patients’ overall satisfaction with healthcare experience, loyalty intentions, and willingness to pay out-of-pocket expenses for healthcare services. Servicescape elements included atmospherics of the healthcare environment, service delivery by healthcare staff, physical design of the healthcare environment, and wayfinding. Results of structural equation modeling confirmed that the four servicescape elements – had a significant impact on patients’ overall satisfaction with the healthcare experience. Furthermore, overall satisfaction with the healthcare experience predicted patients’ loyalty intentions and willingness to pay out-of-pocket expenses for healthcare services. The study makes a significant contribution to the empirical modeling of patients’ behavioral responses to hospitable healthcare environments.     

Private information for foreign investment in emerging economies

In previous studies it has been found that new foreign investment is significantly related to the stock of existing investment in the country/region. This paper's contribution is the finding that a Japanese firm's new investment in an emerging economy is positively correlated with its own previous investment in that economy and also with the current/planned investments by competitors. These two channels are primarily substitutes; that is, investment by competitors becomes less salient when the firm has experience in the market. The correlated behaviour is not explained by industrial agglomerations but appears to reflect the value of private information to investment in emerging economies.
Information privée et investissement étranger dans les économies en émergence. Des travaux antérieurs ont montré que les nouveaux investissements à l'étranger sont co-reliés de manière significative à la taille du stock d'investissement étranger dans le pays ou la région. La contribution de ce mémoire porte sur le fait qu'un nouvel investissement d'une entreprise japonaise dans une économie en émergence est co-relié positivement avec son propre niveau antérieur d'investissement dans cette économie mais aussi avec le niveau des investissements présents et anticipés de ses concurrents. Ces deux canaux d'information sont des substituts: le niveau d'investissement par les concurrents devient moins important à proportion que l'entreprise a acquis de l'expérience dans ce marché. Ce comportement co-relié n'est pas expliqué par les effets d'agglomération industrielle mais semble refléter la valeur de l'information privée quand on investit dans des économies en émergence.     

How the Subprime Crisis went global: Evidence from bank credit default swap spreads

How did the Subprime Crisis, a problem in a small corner of U.S. financial markets, affect the entire global banking system? To shed light on this question we use principal components analysis to identify common factors in the movement of banks' credit default swap spreads. We find that fortunes of international banks rise and fall together even in normal times along with short-term global economic prospects. But the importance of common factors rose steadily to exceptional levels from the outbreak of the Subprime Crisis to past the rescue of Bear Stearns, reflecting a diffuse sense that funding and credit risk was increasing. Following the failure of Lehman Brothers, the interdependencies briefly increased to a new high, before they fell back to the pre-Lehman elevated levels – but now they more clearly reflected heightened funding and counterparty risk. After Lehman's failure, the prospect of global recession became imminent, auguring the further deterioration of banks' loan portfolios. At this point the entire global financial system had become infected.     

Environmental Regulation and Development: A Cross-country Empirical Analysis

This paper develops comparative indices of environmental policy and performance for 31 countries, using a quantified analysis of reports prepared for the United Nations Conference on Environment and Development (UNCED). In cross-country regressions, we find a very strong, positive association between our indicators and the level of economic development, particularly when the latter is adjusted for purchasing power parity. Our results suggest a characteristic progression in the development process, from protection of natural resources to regulation of water pollution and, finally, air pollution control. They also highlight the importance of institutional development, with significant roles for degree of private property protection, effectiveness of the legal/judicial system and efficiency of public administration. Controlling for these variables, "Green" sector indices should be positively correlated with: (1) rural population density; and (2) agricultural and forest production share of national output. "Brown" sector indices should be positively correlated with: (1) particular focus on public health, indexed by life expectancy; (2) urban share of total population; (3) urban population density; and (4) manufacturing share of national output. Our analysis of overall regulatory performance reveals strong cross-country associations with income per capita, security of property rights, and general development of the legal and regulatory system. Surprisingly, however, we find only insignificant or perverse associations with degree of popular representation and freedom of information. For both the Green and Brown indices, performance is again strongly associated with income per capita, freedom of property and (in small samples) measures of regulatory efficiency. The two specifically rural sector variables (population density; proportion of GDP in agriculture and forestry) are only weakly associated with the Green index. The fit is much better for the Brown index: degree of urbanization, population density and manufacturing share in GDP all have the expected signs and relatively high significance. Life expectancy as a proxy for public health priority has no independent effect. In summary, our findings suggest that a detailed, quantified analysis of the UNCED reports can yield comparable and plausible indices of environmental policy performance across countries. Cross-country variations in our environmental index are explained well by variations in income per capita, degree of urbanization and industrialization, security of property rights and general administrative efficiency.     

The Global Disconnect: The Role of Transactional Distance and Scale Economies in Gravity Equations

Recent empirical analyses show that asset flows can be modelled by the same 'gravity' equations that trade economists have used so successfully for the past few decades. This is something of a surprise. Trade economists do not yet have a unified theory of why gravity models should work‐and the situation is worse for asset flows. Reasonable theories would predict that greater distance between countries should generate more asset flows rather than less as the econometric results seem to consistently show. In this paper we discuss how host and source country GDPs, language, and distance the core explanatory variables in the traditional gravity models‐fare in trade and asset flows estimations. While the 'distance puzzle' is not resolved, it is considerably reduced by going beyond consideration of physical distance to concepts of transactional distance and scale economies.     

Financial integration, capital mobility, and income convergence

Recent studies have found that capital moves 'uphill' from poor to rich countries, and brings little or no growth dividend when it does flow into poor economies. We show that Europe does not conform to this paradigm. In the European experience of financial integration, capital has flown from rich to poor countries, and such inflows have been associated with significant acceleration of income convergence. Analysing broader samples of countries, we find that 'downhill' capital flows tend to be observed above certain thresholds in institutional quality and financial integration. But Europe remains different even when allowing for such threshold effects, and its experience is similar to that of interstate flows within the United States. Our findings are consistent with the notion that financial diversification reduces countries' incentives to save in order to self-insure against specific shocks.
— Abdul Abiad, Daniel Leigh and Ashoka Mody