The cost-effectiveness of 5-FU-SA in the treatment of actinic keratoses of the face and scalp in the UK secondary care setting

Objective: The objective of this analysis was to estimate the relative cost-effectiveness of Actikerall¹ (5-FU-SA) vs cryotherapy in a secondary care setting in the UK, for lesion-directed treatment in patients with actinic keratoses (AK) of the face and scalp.

Methods: The model was a simple decision tree, with a 6-month time horizon. The perspective was that of the UK National Health Service (NHS). Modeled treatment effects included reported per-patient histological clearance and recurrence rates. Cost inputs comprised professional consultation time and cost of medication. Health-related utility estimation followed previously published methodology. Adverse events were not modeled. The key data and model structural assumptions followed expected UK practice. One-way and probabilistic sensitivity analyses were conducted to assess structural and parameter uncertainty.

Results: 5-FU-SA was found to be less costly (?£204) and more effective (+0.001 QALY) in base case and sensitivity analyses. In the probabilistic analysis there was 100% probability of being cost-effective over cryotherapy at £20,000 willingness to pay. Cost of professional time was a key driver of the model outcome. 5-FU-SA remained dominant across a range of scenario analyses, including exploration of assumptions around setting of care.

Limitations: The time horizon of the analysis was short and data were not extrapolated beyond the duration of the clinical trial; however, this approach is consistent with likely follow-up of an AK patient. The clinical outcomes observed in the trial were based on a large proportion of cryotherapy patients undergoing an additional cycle of treatment; this may not occur or be required in an experienced secondary care setting.

Conclusion: 5-FU-SA could be considered as a cost-effective choice for treatment of AK lesions of the face and scalp in secondary and mixed care settings in the UK. Use of 5-FU-SA in patients who would otherwise be managed with cryotherapy has the potential to result in cost savings.     

Reduced medical spending associated with increased use of a remote diabetes management program and lower mean blood glucose values

Abstract

Aims: Many new mobile technologies are available to assist people in managing chronic conditions, but data on the association between the use of these technologies and medical spending remains limited. As the available digital technology offerings to aid in diabetes management increase, it is important to understand their impact on medical spending. The aim of this study was to investigate the financial impact of a remote digital diabetes management program using medical claims and real-time blood glucose data.

Materials and methods: A retrospective analysis of multivariate difference-in-difference and instrumental variables regression modeling was performed using data collected from a remote digital diabetes management program. All employees with diabetes were invited, in a phased introduction, to join the program. Data included blood glucose (BG) values captured remotely from members via connected BG meters and medical spending claims. Participants included members (those who accepted the invitation, n?=?2,261) and non-members (n?=?8,741) who received health insurance benefits from three self-insured employers. Medical spending was compared between people with well-controlled (BG ≤ 154?mg/dL) and poorly controlled (BG > 154?mg/dL) diabetes.

Results: Program access was associated with a 21.9% (p?<?0.01) decrease in medical spending, which translates into a $88 saving per member per month at 1 year. Compared to non-members, members experienced a 10.7% (p?<?0.01) reduction in diabetes-related medical spending and a 24.6% (p?<?0.01) reduction in spending on office-based services. Well-controlled BG values were associated with 21.4% (p?=?0.03) lower medical spending.

Limitations and conclusions: Remote digital diabetes management is associated with decreased medical spending at 1 year. Reductions in spending increased with active utilization. It will be beneficial for future studies to analyze the long-term effects of the remote diabetes management program and assess impacts on patient health and well-being.     

Economic impact of onabotulinumtoxinA for overactive bladder with urinary incontinence in Europe

Background: Overactive bladder (OAB) is a common condition that has a significant impact on patients’ health-related quality-of-life and is associated with a substantial economic burden to healthcare systems. OnabotulinumtoxinA has a well-established efficacy and safety profile as a treatment for OAB; however, the economic impact of using onabotulinumtoxinA has not been well described.

Methods: An economic model was developed to assess the budget impact associated with OAB treatment in France, Germany, Italy, Spain and the UK, using onabotulinumtoxinA alongside best supportive care (BSC)—comprising incontinence pads and/or anticholinergic use and/or clean intermittent catheterisation (CIC)—vs BSC alone. The model time horizon spanned 5 years, and included direct costs associated with treatment, BSC, and adverse events.

Results: Per 100,000 patients in each country, the use of onabotulinumtoxinA resulted in estimated cost savings of €97,200 (Italy), €71,580 (Spain), and €19,710 (UK), and cost increases of €23,840 in France and €284,760 in Germany, largely due to day-case and inpatient administration, respectively. Projecting these results to the population of individuals aged 18 years and above gave national budget saving estimates of €9,924,790, €27,458,290, and €48,270,760, for the UK, Spain, and Italy, respectively, compared to cost increases of €12,160,020 and €196,086,530 for France and Germany, respectively. Anticholinergic treatment and incontinence pads were the largest contributors to overall spending on OAB management when onabotulinumtoxinA use was not increased, and remained so in four of five scenarios where onabotulinumtoxinA use was increased. This decreased resource use was equivalent to cost offsets ranging from €106,110 to €176,600 per 100,000 population.

Conclusions: In three of five countries investigated, the use of onabotulinumtoxinA, in addition to BSC, was shown to result in healthcare budget cost savings over 5 years. Scenario analyses showed increased costs in Germany and France were largely attributable to the treatment setting rather than onabotulinumtoxinA acquisition costs.     

New evidence on the firm-university linkages in Europe. The role of meritocratic management practices

ABSTRACT

This paper investigates the determinants of university-industry links in five European countries (France, Germany, Italy, Spain and the UK), using internationally comparable firm-level data for the period 2007–2009. Besides the usual firm-specific variables, it examines the role of meritocratic management practices in firms’ decisions to collaborate in R&D. Firm innovative efforts, the export status and the R&D government support are positively related to business-university links in almost all countries, human capital and firms’ size in two out of five countries under scrutiny, while belonging to science-based sectors does not seem to play a significant role in all countries but Italy. Importantly, we find that meritocratic managerial practices positively affect the firm-university nexus in Germany, France and the UK, while meritocracy does not appear to enhance businesses’ R&D collaboration in Italy and in Spain.     

The intertemporal relation between government revenue and expenditure in the United Kingdom, 1750 to 2004

We examine the intertemporal relation between government revenue and expenditure in the UK during 1750 to 2004. We pay particular attention to long run trends by applying a battery of unit root and cointegration techniques to the data, and we use a modified Granger causality test on data spans organized around structural breaks in the series. The results suggest that, allowing for structural breaks, UK real revenue and spending are I(1) series and cointegrated and that Granger causality runs from government spending to revenue. As such, the ‘spend-tax’ hypothesis appears to best characterize the long run intertemporal relation between government revenue and spending in the UK.     

Social motives in intergroup conflict: Group identity and perceived target of threat

We experimentally test the social motives behind individual participation in intergroup conflict by manipulating the perceived target of threat—groups or individuals—and the symmetry of conflict. We find that behavior in conflict depends on whether one is harmed by actions perpetrated by the out-group, but not on one׳s own influence on the outcome of the out-group. The perceived target of threat dramatically alters decisions to participate in conflict. When people perceive their group to be under threat, they are mobilized to do what is good for the group and contribute to the conflict. On the other hand, if people perceive to be personally under threat, they are driven to do what is good for themselves and withhold their contribution. The first phenomenon is attributed to group identity, possibly combined with a concern for social welfare. The second phenomenon is attributed to a novel victim effect. Another social motive—reciprocity—is ruled out by the data.     

Does Multinationality Affect the Propensity to Innovate? An Analysis of the Third UK Community Innovation Survey

The paper is developed at the interface between internationalization and innovation studies. It utilizes data on innovation from the UK Community Innovation Surveys 3 and 2 (CIS3 and CIS2) to assess whether multinationality affects the innovation propensity of surveyed enterprises. The indicators of innovation propensity—our dependent variables—are taken from the following CIS sets of variables: innovation outputs; innovation inputs; innovation outcomes (patent applications); innovation continuity/sustainability. The latter element is considered to be the ability of the enterprise to sustain innovation over a long period of time and the relevant variable is derived from both CIS3 and 2 data. This allows the paper to introduce dynamic elements into the analysis. Four hypotheses are developed and tested. Our main hypothesis states that multinationality per se (i.e. being part of a multinational company network) affects the propensity to innovate. We also test for three sub‐hypotheses related to characteristics of multinationality: belonging to a group vs being independent; degree of multinationality; being part of a foreign vs domestic multinational. The results show that all those CIS enterprises that belong to a multinational corporation—whether UK or foreign—are more likely to exhibit innovation propensity; they are also more likely to engage in innovation activities on a continuous basis.     

An asymmetric error correction model of UK consumer spending

This paper augments the Granger and Lee (Journal of Applied Econometrics, 4, 1989) non-symmetric error (equilibrium) correction model to assess the possibility that, in the aggregate, consumers respond differently to different types of disequilibrium error. This idea is illustrated using an Engle-Granger implementation of the Davidson, Hendry, Srba and Yeo (DHSY, Economic Journal, 80, 1978) model. The disequilibrium error is endogenously determined by the long-run, empirical model and a binary dummy variable captures two alternative states, above and below equilibrium spending. Interaction of the dummy variable with key variables in a short-run dynamic model of UK consumer spending augments the dynamics of the DHSY model. Income elasticities, inflation elasticities and speeds of adjustment are all seen to change significantly depending on whether the disequilibrium error is positive or negative, and is suggestive of asymmetric behaviour on the part of consumers. Moreover, the asymmetrically augmented model substantially outperforms a symmetric model with standard error improvements in excess of 50%.     

Barking up the right tree: Are small groups rational agents?

Both mainstream economics and its critics have focused on models of individual rational agents even though most important decisions are made by small groups. Little systematic work has been done to study the behavior of small groups as decision-making agents in markets and other strategic games. This may limit the relevance of both economics and its critics to the objective of developing an understanding of how most important decisions are made. In order to gain some insight into this issue, this paper compares group and individual economic behavior. The objective of the research is to learn whether there are systematic differences between decisions made by groups and individual agents in market environments characterized by risky outcomes. A quantitative measure of deviation from minimally-rational decisions is used to compare group and individual behavior in common value auctions. JEL Classification D44, C91, C92     

The temporary equilibrium method: Hicks against Hicks

Abstract

Hicks is renowned for having introduced the temporary equilibrium framework in his book Value and Capital. Subsequently, however, he partially recanted this framework by rejecting the market clearing idea while still keeping the week device. The aim of this paper is to assess whether this change was right. My answer will be broadly negative. To make my point, I will ponder on the meaning and implications of the week device, assess the validity of Hicks' claim that slow adjustment can cause market rationing, examine his claim that the possibility of market clearing depends on the prevailing market form and, finally, assess his twofold filiations towards Marshall and Walras.     

Deficits for the Rich: Inequality and Instability

Abstract

Deficit spending has long been understood as a stabilizing counter-cyclical force. The thesis presented herein is that over recent decades, the cumulative deficits of government and non-corporate entities have expanded the inequality of wealth and income, which, over the long haul, contributes to slow growth and potential instability. The thesis builds on the Kaleckian-Minsky insight that deficits create gross profits in excess of new investment expenditures (free cash). Since the 1980s, this free cash has been spilled in the stock market through mergers, dividends and stock buybacks—worsening inequality. As the upper classes have a larger range of discretionary spending options, this expanded inequality has made for more spending volatility and speculative endeavors. The authors call for expanded taxes on the rich to claim the deficit-generated free cash. Such taxes would be in the service of more stability and equity.     

Ideological Divide within the Cabinet and Public Spending

A budget, i.e., spending by category, is prepared by the cabinet of (three key) ministers. The finance minister wants to minimize total spending, while the rest have single‐peaked preferences over budgets and each views his own spending as relatively more important. The goal is to understand effects of polarization in spending priorities,—or divergence of the ideal points,—on the budget under two typical budgeting procedures. If the procedure is “fragmented,” i.e., the finance minister just passively compiles spending requests, then the divergence of the ideal budgets increases total spending. If the procedure is more centralized, i.e., challenging the initial proposal of the finance minister is costly, and it also requires support of another minister, then polarization may lead to a tighter budget, as it enlarges the set of the unchallenged proposals, provided the ideals of the spending ministers are sufficiently far apart.     

A study of regional variation in the inpatient cost of lower extremity amputation among patients with diabetes in the United States

Abstract

Objective:

Understanding of the effects of providers’ cost on regional variation in healthcare spending is still very limited. The objective of this study is to assess cross-state and cross-region variations in inpatient cost of lower extremity amputation among diabetic patients (DLEA) in relation to patient, hospital, and state factors.

Methods:

Patient and hospital level data were obtained from the 2007 US Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project (HCUP). State level data were obtained from the US Census Bureau and the Kaiser Family Foundation websites. Regression models were implemented to analyze the association between in-patient cost and variables at patient, hospital, and state levels.

Results:

This study analyzed data on 9066 DLEA hospitalizations from 39 states. The mean cost per in-patient stay was $17,103. Four out of the five most costly states were located on the East and West coasts (NY and NJ, CA and OR). Age, race, length of stay, level of amputation, in-patient mortality, primary payer, co-morbidities, and type of hospital were significantly correlated with in-patient costs and explained 55.3% of the cost variance. Based on the means of costs unexplained by those factors, the three West coast states had the highest costs, followed by five Midwestern states, and four Southern states, and Kansas were the least costly.

Conclusions:

Over 40% of the variations in DLEA hospital costs could not be explained by major patient-, hospital-, and state-level variables. Further research is needed to examine whether similar patterns exist for other costly surgical procedures among diabetic patients.     

Cost-effectiveness analysis of solifenacin versus oxybutynin immediate-release in the treatment of patients with overactive bladder in the United Kingdom

Abstract

Objective:

To carry out a cost-utility analysis comparing initial treatment with solifenacin 5?mg/day vs oxybutynin immediate-release (IR) 15?mg/day for the treatment of patients with overactive bladder (OAB) from the perspective of the UK National Health Service (NHS).

Methods:

A Markov model with six health states was developed to follow a cohort of OAB patients treated with either solifenacin or oxybutynin during a 1-year period. Costs and utilities were accumulated as patients transited through the health states in the model and a drop-out state. Some of the solifenacin patients were titrated from 5?mg to 10?mg/day at 8 weeks. A proportion of drop-out patients were assumed to continue treatment with tolterodine ER. Utility values were obtained from a Swedish study and pad use was based on a multinational clinical trial. Adherence rates for individual treatments were derived from a UK database study. For pad use and utility values, the drop-out state was split between those patients who were no longer receiving treatment and those on second-line therapy. Patients on second-line therapy who drop-out were referred for a specialist visit. Results were expressed in terms of incremental cost-utility ratios.

Results:

Total annual costs for solifenacin and oxybutynin were £504.30 and £364.19, respectively. First-line drug use represents 49% and 4% of costs and pad use represent 23% and 40% of costs for solifenacin and oxybutynin, respectively. Differences between cumulative utilities were small but were greater for solifenacin (0.7020 vs 0.6907). The baseline incremental cost-effectiveness ratio was £12,309/QALY.

Conclusion:

Under the baseline assumptions, solifenacin would appear to be cost-effective with an incremental cost-utility of less than £20,000/QALY. However, small differences in utility between the alternatives and the large number of drop-outs means that the results are sensitive to small adjustments in the values of utilities assigned to the drop-out state.     

The foundations of Chinese attitudes towards advocating luxury spending

Abstract

In China, some scholars have argued that luxury spending is socially beneficial to equalise wealth, under the assumption that the total endowment of resources is a fixed amount. This argument is not only consistent with Confucianism but also might point to another lesser known side of Confucianism that the luxury spending of the rich can be regarded as a wealth-transferring mechanism. Furthermore, luxury spending was encouraged for purposes of enjoyment; it did not involve the consideration of power and protection. This is in sharp contrast to the extravagance of the European nobility; their intention was to maintain a hierarchical structure.     

Perceiving Urban Transformation from the Perspective of Evolutionary Economics: Renewal of Houses in Bağdat Street,Istanbul

Abstract:

In this article, we analyze urban transformation in Istanbul using the concepts of evolutionary economics and show that it is a process driven by people’s desire to climb the social hierarchy through “costly signaling,” or conspicuous consumption, rather than by a desire to improve the functional quality of their living spaces. To understand the main motivation behind people’s demand for urban transformation, we conducted in-depth interviews with residents and observed that they endorse the process because it generates extensive costs, waste, and a decrease in the quality of life that can only be afforded by the wealthy, who thereby differentiate themselves from the less well-off. We argue that this is different from consumption decisions motivated solely by benefit maximization¬—a concept that is independent from the social context¬—and therefore can only be understood via evolutionary economics.     

Can social spending cushion the inequality effect of globalization?

This paper examines whether social spending cushions the effect of globalization on within‐country inequality. Using information on disposable and market income inequality and data on overall social spending, and health and education spending from the ILO and the World Bank/WHO, we analyze whether social spending moderates the association between economic globalization and inequality. The results confirm that economic globalization—especially economic flows—associates with higher income inequality, an effect driven by non‐OECD countries. Health spending is strongly associated with lower inequality, but we find no robust evidence that any kind of social spending negatively moderates the association between economic globalization and inequality.     

Cost-utility analyses of targeted immunomodulators in rheumatoid arthritis: systematic review

Abstract

Aims: Cost-utility (CU) modeling is a common technique used to determine whether new treatments represent good value for money. As with any modeling exercise, findings are a direct result of methodology choices, which may vary widely. Several targeted immuno-modulators have been launched in recent years to treat moderate-to-severe rheumatoid arthritis (RA) which have been evaluated using CU methods. Our objectives were to identify common and innovative modeling choices in moderate-to-severe RA and to highlight their implications for future models in RA.

Materials and methods: A systematic literature search was conducted to identify CU models in moderate-to-severe RA published from January 2013 to June 2019. Studies must have included an active comparator and used quality-adjusted life-years (QALYs) as the common measure of effectiveness. Modeling methods were characterized by stakeholder perspective, simulation type, mapping between parameters, and data sources.

Results: Thirty-one published modeling studies were reviewed spanning 13 countries and 9 drugs, with common methodological choices and innovations observed among them. Over the evaluated time period, we observed common methods and assumptions that are becoming more prominent in the RA CU modeling landscape, including patient-level simulations, two-stage models combining trial results and real-world evidence, real-world treatment durations, long-term health consequences, and Health Assessment Questionnaire (HAQ)-related hospitalization costs. Models that consider the societal perspective are increasingly being developed as well.

Limitations: This review did not consider studies that did not report QALYs as a utility measure, models published only as conference abstracts, or cost-consequence models that did not report an incremental CU ratio.

Conclusions: CU modeling for RA increasingly reflects real-world conditions and patient experiences which are anticipated to provide better information in the assessment of health technologies. Future CU models in RA should consider applying the observed advances in modeling choices to optimize their CU predictions and simulation of real-world outcomes.