Willingness to pay for QALY: perspectives and contexts in Japan

Abstract

Objectives: Theoretically, willingness-to-pay (WTP) for quality-adjusted life years (QALY) can vary depending on social and personal preferences and on ex-ante and ex-post settings. However, empirical investigations into the theoretical differences are lacking. In Japan, setting the threshold has been controversial since a pilot project to implement health technology assessments (HTA) launched in 2016. The study aim is to estimate WTP values for one additional QALY from different perspectives, health statuses, and contexts to confirm the difficulty in setting a uniform price threshold using WTP.

Methods: More than 1,000 respondents representing a cross-section of the Japanese population answered each of nine questionnaire decks in an online panel. WTP values were estimated on three different perspectives (personal, social, and socially inclusive) and on two contexts (ex-ante and ex-post). This study primarily used the non-parametric spike model based on double-bounded dichotomous choice (DBDC) settings to obtain the conditional WTP values.

Results: WTP per QALY was higher in the severe health status than in the moderate health status from all perspectives. Respondents from the socially inclusive perspective estimated the highest WTP value for a new drug. Respondents were also asked about life-threatening diseases in ex-post and ex-ante. The WTP value in ex-ante was higher than in ex-post, and demographic factors affecting the WTP were different in both situations. The various WTP values were obtained from these surveys.

Limitations: The analysis was based on data collected from an internet panel, which could be biased. There is also a risk that respondents answered the questionnaire differently if asked in everyday situations.

Conclusion: Use of a uniform price threshold may not be appropriate in policy settings, because it may not reflect diverse preferences based on different situations, such as disease type and severity. Setting a price threshold as Japan institutes an HTA system requires further research.     

Cost-effectiveness achieved through changing the composition of renal replacement therapy in Japan

Abstract

Objective:

The cost-effectiveness of renal replacement therapy (RRT) is affected by the composition of treatment. This study aimed to estimate the costs and outcomes associated with changing the composition of RRT modality over time.

Methods:

By using clinical and cost data from a systematic review, a Markov model was developed to assess the costs and benefits of the four main treatments available for RRT in Japan. The model included direct health service costs and quality-adjusted life years (QALY). Sensitivity analyses were performed to assess the robustness of the results.

Results:

Over the 15-year period of the model, the current composition of RRT (i.e., the base composition of RRT) was $84,008/QALY. The most cost-effective treatment was when the likelihood of a living donor transplant was increased by 2.4-times ($70,581/QALY). Compared with the base composition of RRT, dominant treatments with respect to cost-effectiveness were when the likelihood of a deceased donor transplant was increased by 22-times and when the likelihood of a pre-emptive living donor transplant was increased by 2.4-times. Little difference was found between these two treatments. One-way sensitivity analysis did not change the cost effectiveness except for costs of chronic hemodialysis and a living donor transplant in subsequent years.

Limitations:

It is difficult to increase the rate of transplant overall in the shorter term nationally and internationally.

Conclusions:

Appropriate distribution of all transplant options and hemodialysis is necessary to achieve the most cost-effective solution.     

Brentuximab vedotin in relapsed/refractory Hodgkin lymphoma post-autologous stem cell transplant: a cost-effectiveness analysis in Scotland

Objective: To evaluate cost-effectiveness of brentuximab vedotin in patients with relapsed/refractory Hodgkin lymphoma who have received autologous stem cell transplantation, from a Scottish healthcare payer perspective.

Methods: A Microsoft Excel-based partitioned survival model comprising three health states (progression-free survival [PFS], post-progression survival, and death) was developed. Relevant comparators were chemotherapy with or without radiotherapy (C/R) and C/R with intent to allogeneic hematopoietic stem cell transplantation (alloSCT). Data were obtained from the pivotal phase II single-arm trial in 102 patients (SG035-0003; NCT00848926), a systematic literature review and clinical expert opinions (where empirical evidence was unavailable). PFS and overall survival for brentuximab vedotin were estimated using 5-year follow-up data from SG035-0003, and extrapolated using event rates observed for comparator treatments from published survival data. Resource use included drug acquisition and administration; alloSCT; treatment of adverse events; and long-term follow-up. Deterministic and probabilistic sensitivity analyses were conducted to evaluate the impact of uncertainty.

Results: In the base case, the incremental cost-effectiveness ratio (ICER) for brentuximab vedotin was £38,769 per quality-adjusted life year (QALY) vs C/R, whereas C/R with intent to alloSCT was dominated by brentuximab vedotin. ICERs for brentuximab vedotin generated by the deterministic sensitivity analysis ranged between £32,000–£54,000 per QALY. Including productivity benefits reduced the ICER to £28,881 per QALY.

Limitations: Limitations include lack of comparative data from this single arm study and the heterogeneous population. Inconsistent baseline characteristic reporting across studies prevented complete assessment of heterogeneity and the extent of potential bias in clinical and cost-effectiveness estimates.

Conclusions: Although the base case ICER is above the threshold usually applied in Scotland, it is relatively low compared with other orphan drugs, and lower than the ICER generated using a previous data cut of SG035-0003 that informed a positive recommendation from the Scottish Medicines Consortium, under its decision-making framework for assessment of ultra-orphan medicines.     

碳足迹的概念和核算方法研究进展

碳足迹提供了分析人类活动对气候变化影响的新视角.从概念和核算方法两个方面对有关碳足迹的研究进行了分析:(1)概念上,碳足迹目前无统一的定义.在分析度量单位、温室气体种类及系统边界的基础上,文章提出了碳足迹的建议定义.(2)方法上,碳足迹目前无统一的核算方法.投入产出分析、生命周期评价及混合生命周期评价是三种主要的核算方法.文章对这三种方法的原理、适用范围、优缺点及应用情况进行了分析.最后,从方法、应用和不确定性三个方面对碳足迹研究作了展望.     

Score-driven Markov-switching EGARCH models: an application to systematic risk analysis

We introduce new Markov-switching (MS) dynamic conditional score (DCS) exponential generalized autoregressive conditional heteroscedasticity (EGARCH) models, to be used by practitioners for forecasting value-at-risk (VaR) and expected shortfall (ES) in systematic risk analysis. We use daily log-return data from the Standard & Poor’s 500 (S&P 500) index for the period 1950–2016. The analysis of the S&P 500 is useful, for example, for investors of (i) well-diversified US equity portfolios; (ii) S&P 500 futures and options traded at Chicago Mercantile Exchange Globex; (iii) exchange traded funds (ETFs) related to the S&P 500. The new MS DCS-EGARCH models are alternatives to of the recent MS Beta-t-EGARCH model that uses the symmetric Student’s t distribution for the error term. For the new models, we use more flexible asymmetric probability distributions for the error term: Skew-Gen-t (skewed generalized t), EGB2 (exponential generalized beta of the second kind) and NIG (normal-inverse Gaussian) distributions. For all MS DCS-EGARCH models, we identify high- and low-volatility periods for the S&P 500. We find that the statistical performance of the new MS DCS-EGARCH models is superior to that of the MS Beta-t-EGARCH model. As a practical application, we perform systematic risk analysis by forecasting VaR and ES.

Abbreviation Single regime (SR); Markov-switching (MS); dynamic conditional score (DCS); exponential generalized autoregressive conditional heteroscedasticity (EGARCH); value-at-risk (VaR); expected shortfall (ES); Standard & Poor's 500 (S&P 500); exchange traded funds (ETFs); Skew-Gen-t (skewed generalized t); EGB2 (exponential generalized beta of the second kind); NIG (normal-inverse Gaussian); log-likelihood (LL); standard deviation (SD); partial autocorrelation function (PACF); likelihood-ratio (LR); ordinary least squares (OLS); heteroscedasticity and autocorrelation consistent (HAC); Akaike information criterion (AIC); Bayesian information criterion (BIC); Hannan-Quinn criterion (HQC).     

沈阳市再生水源热泵供暖技术的节能减排潜力

利用生命周期评价方法分析对比再生水源热泵和燃煤锅炉在原材料生产、机组生产、运输、热量生产及废弃物处理整生命周期过程的能源消耗及SO2、总悬浮颗粒物(TSP)排放。结果表明在生产1GJ热能的情况下,再生水源热泵比燃煤锅炉节能约1GJ,减排SO20.7kg,减排大气TSP 7.2kg。热量生产阶段是耗能及污染物排放的关键环节,超过99%的能源消耗和污染排放在这一环节产生。在供暖季节,如果沈阳市现有和规划污水处理厂的再生水应用再生水源热泵替代燃煤锅炉供暖,在每年的供暖期里可为沈阳市节能11×106GJ(折合标煤37.5×104t),减排SO275.9t,减排TSP 775.4t。     

基于DEA模型的中国主要轿车企业生产效率分析

文章利用数据包络分析法(DEA)对中国12家主要的轿车生产企业2001~2004年的生产经营效率进行总体分析与评价,并利用Malquist生产力指数对这些企业的效率变动进行了分析。研究结果表明,中国主要轿车企业的生产经营效率总体上呈现逐年提高之势;同时企业的股权结构、含有外资的企业的股本来源、企业的区域分布以及所属不同企业集团等因素都会使企业在技术效率、纯技术效率与规模效率方面存在差异;动态效率分析的结果表明中国轿车业总体上还处在依靠规模扩张的量的增长阶段,行业技术进步对效率提升的作用微弱。这表明,要从根本上提高中国轿车业的生产经营效率,必须推进行业技术进步,提高技术进步对全要素生产力改善的贡献率。     

The environmental effect of car-free housing: A case in Vienna

A case-control study of the car-free model housing project in Vienna was conducted to evaluate whether people living in this settlement have more ‘sustainable lifestyles’ than people living in comparable buildings in Vienna. Another aim was to identify the lifestyle characteristics and household activities which significantly influence the environmental impact of the residents of the car-free housing project and a control group. The control group, referred to as the reference settlement, was chosen from a nearby building complex, with similar characteristics, but without the car-free feature. Household consumption patterns were estimated based on interviews in combination with data from the Austrian consumer expenditure survey and the national accounts. The evaluation of household environmental impacts uses emissions estimates from the Austrian national accounting matrices including environmental accounts and data from life-cycle assessments. Households from the car-free settlement have substantially lower environmental impacts in the categories of ground transportation and energy use; their CO₂ emissions of these two categories are less than 50% of those living in the reference settlement. The households in the car-free settlement have somewhat higher emissions in the categories air transport, nutrition, and ‘other’ consumption, reflecting the higher income per-capita. As a result, the CO₂ emissions are only slightly lower than in the reference settlement, but the emissions intensity is 20% lower. Both household groups have significantly lower environmental impacts than the Austrian average reflecting less car use and cleaner heating energy in Vienna.     

A systemic comparative assessment of the multifunctional performance of alternative olive systems in Spain within an AHP-extended framework

The concept of sustainable agriculture is strongly related to the multifunctional role, either explicitly or implicitly, recognized to the primary sector. When assessing the performance and value to society of particular agricultural systems, the multifunctional nature of agriculture requires an approach based on multicriteria. Amongst others, these include economic, environmental, social, cultural and technical criteria. Like other complex multicriteria analyses, this evaluation of agricultural systems is characterized by the existence of not only many, but often conflicting criteria, multiple stakeholders and decision-makers who have competing interests, lack of information and a consideration of the high risks involved.The Analytic Hierarchy Process (AHP) is a methodology that deals with problems of this sort in a relatively easy, flexible and economical manner. Therefore it is a potentially useful tool for the practical resolution of complex problems, often an object of Ecological Economics. One such problem is the analysis of the sustainability of economic activities.This article has three aims. The first is to present AHP as a powerful methodology for assessing multifunctional performances of different agricultural systems in a comparative way. AHP can also be applied to other multifunctional economic activities. The second aim is to propose an extension of AHP for improving the decision-making processes when different groups of decision agents are involved. A final aim is to illustrate the AHP-extended methodology in a particular case study. This is done by using it to compare the multifunctional performance of alternative olive growing systems in Andalusia, a region located in the south of Spain, on the basis of the assessments of different groups of experts. This tests the hypothetically greater sustainability of organic and integrated farming over conventional farming systems in the medium/long term under average conditions for this region. Results for this case study show a greater global performance of organic and integrated agriculture despite differences in the ideological tendencies of the experts, thus providing a scientific basis for endorsing institutional and social support for the promotion and implementation of these farming techniques. Some conflictive issues, however, have been detected, especially in areas related to environmental performance. Further research on the controversial topics is desirable for clarification.     

Cost-effectiveness modeling for neuropathic pain treatments: investigating the relative importance of parameters using an open-source model

Aims: The study objective was to develop an open-source replicate of a cost-effectiveness model developed by National Institute for Health and Care (NICE), in order to explore uncertainties in health economic modeling of novel pharmacological neuropathic pain treatments.

Materials and methods: The NICE model, consisting of a decision tree with branches for discrete levels of pain relief and adverse event (AE) severities, was replicated using R, and used to compare a hypothetical neuropathic pain drug to pregabalin. Model parameters were sourced from NICE’s clinical guidelines and associated with probability distributions to account for underlying uncertainty. A simulation-based scenario analysis was conducted to assess how uncertainty in efficacy and AEs affected the net monetary benefit (NMB) for the hypothetical treatment at a cost-effectiveness threshold of £20,000 per QALY.

Results: Relative to pregabalin, an increase in efficacy was associated with greater NMB than an improvement in tolerability. A greater NMB was observed when efficacy was marginally higher than that of pregabalin, while maintaining the same level of AEs than when efficacy was equivalent to pregabalin, but with a more substantial reduction in AEs. In the latter scenario, the NMB was only positive at a low cost-effectiveness threshold.

Limitations: The replicate model shares the limitations described in the NICE guidelines. There is a lack of support in scientific literature for the assumption that increased efficacy is associated with a greater reduction in tolerability. The replicate model also included a single comparator, unlike the NICE model.

Conclusions: Pain relief is a stronger driver of NMB than tolerability, at a cost-effectiveness threshold of £20,000 per QALY. Health technology assessment decisions which are influenced by NICE’s model may reward efficacy gains, even if they are associated with more severe AEs. This contrasts with recommendations from clinical guidelines for neuropathic pain, which place more equal weighting on improvements in efficacy and tolerability as value drivers.     

Puerto Rico in the 1970s and 1980s: Crisis of the Development Model

In his institutional economic essay on "Taxation in Chicago and Philadelphia" (published in 1895) John R. Commons addresses property tax assessment. He demonstrates that the revenue is not just a question of the tax rate and the distribution of the tax burden but also one of constitutional requirements and how the taxes are assessed. His essay is reviewed with regard to his later work, subsequent Institutional Economics, and the social provisioning of the market for professional tax advice. The degree of liabilities is defining characteristics of the differences between the United States and Germany.     

The influence of CSR on firm value: an application of panel smooth transition regression on Taiwan

Previous studies on the relationship between corporate social responsibility (CSR) and firm value generally belong to one of the two opposing schools of thought: the social impact hypothesis and the shift of focus hypothesis. This study, however, proposes that the relationship between CSR and company value is non-linear and neither wholly positive nor negative. We employed the corporate social responsibility index (CRSI) to test this hypothesis. The panel smooth transition regression (PSTR) model was used to analyse listed Taiwanese firms from 2010 to 2012 and calculate the value transition threshold of CSR, using CSRI as the transition variable. We then applied PSTR to determine whether CSRI shows a two-regime, non-linear relationship, as inferred by our model. Empirical findings show that the threshold value of CSRI is 13.082, thus, we concluded that investment in CSR does not contribute to enhancing company value until it exceeds the value transition threshold.     

The determinants of tendering periods for PPP procurement in the UK: an empirical analysis

The procurement of infrastructure projects via public–private partnerships (PPPs) is rising globally. PPPs are, however, often characterized by lengthy tendering periods, defined as the difference between contract notice and financial close. Tendering periods are important because they account for a significant proportion of overall project delivery time. Slow tendering deters bidders and thus reduces competition for contracts. We source data on 670 PPP projects in the United Kingdom and use a duration analysis model to empirically examine factors that impact tendering period duration. Our results reveal significant sectoral variation with projects in the health and housing sectors taking significantly longer to reach financial close. We also show that, after controlling for other factors, projects with higher capital values and projects that overlap with the timing of general elections are associated with significantly longer tendering periods. We further examine the impact of the competitive dialogue procurement method and find evidence that tendering periods have increased since 2006; the year competitive dialogue was introduced. We do, however, observe a significant reduction in the time between appointment of preferred bidder and financial close post-2006. This suggests that competitive dialogue is effective in reducing the scope for negotiations by preferred bidders holding quasi-monopoly advantages.     

Payments for environmental services as an alternative to logging under weak property rights: The case of Indonesia

Decentralization reforms in Indonesia have led to local communities negotiating logging agreements with timber companies for relatively low financial payoffs and at high environmental cost. This paper analyzes the potential of payments for environmental services (PES) to provide an alternative to logging for these communities and to induce forest conservation. We apply a game-theoretical model of community-firm interactions that explicitly considers two stylized conditions present in the Indonesian context: (i) community rights to the forest remain weak even after decentralization, and (ii) the presence of logging companies interested in the commercial exploitation of the forest. Intuition may suggest that PES design should focus on those communities with the lowest expected payments from logging deals. However, we show that these communities may not be able to enforce a PES agreement, i.e., they may not be able to prevent logging activities by timber companies. Moreover, some communities would conserve the forest anyway; in these cases PES would not lead to additional environmental gains. Most important, the introduction of PES may increase a community's expected payoff from a logging agreement. A failure to consider this endogeneity in expected payoffs could lead to communities opting for logging agreements despite PES, simply allowing communities to negotiate better logging deals. Our results indicate that PES design is a complex task, and that the costs of an effective PES system could potentially be much higher than expected from observing current logging fees. Using data collected in Indonesia on actual logging fees received by communities, we illustrate how the theoretical results could be used in empirical analysis to guide PES design. Our results are likely to be useful in other cases where local people make resource use decisions but have weak property rights over these resources, and where external commercial forces are present. The results highlight the importance of understanding the details of the local context in order to design PES programs appropriately.     

The impact of different scenarios for intermittent bladder catheterization on health state utilities: results from an internet-based time trade-off survey

Aims: Intermittent catheterization (IC) is the gold standard for bladder management in patients with chronic urinary retention. Despite its medical benefits, IC users experience a negative impact on their quality of life (QoL). For health economics based decision making, this impact is normally measured using generic QoL measures (such as EQ-5D) that estimate a single utility score which can be used to calculate quality-adjusted life years (QALYs). But these generic measures may not be sensitive to all relevant aspects of QoL affected by intermittent catheters. This study used alternative methods to estimate the health state utilities associated with different scenarios: using a multiple-use catheter, one-time-use catheter, pre-lubricated one-time-use catheter and pre-lubricated one-time-use catheter with one less urinary tract infection (UTI) per year.

Methods: Health state utilities were elicited through an internet-based time trade-off (TTO) survey in adult volunteers representing the general population in Canada and the UK. Health states were developed to represent the catheters based on the following four attributes: steps and time needed for IC process, pain and the frequency of UTIs.

Results: The survey was completed by 956 respondents. One-time-use catheters, pre-lubricated one-time-use catheters and ready-to-use catheters were preferred to multiple-use catheters. The utility gains were associated with the following features: one time use (Canada: +0.013, UK: +0.021), ready to use (all: +0.017) and one less UTI/year (all: +0.011).

Limitations: Internet-based survey responders may have valued health states differently from the rest of the population: this might be a source of bias.

Conclusion: Steps and time needed for the IC process, pain related to IC and the frequency of UTIs have a significant impact on IC related utilities. These values could be incorporated into a cost utility analysis.     

The Macroeconomic Loss due to Violence Against Women: The Case of Vietnam

Violence against women (VAW) is now acknowledged as a global problem with substantial economic costs. However, the current estimates of costs in the literature provide the aggregate loss of income, but not the macroeconomic loss in terms of output and demand insofar as they fail to consider the structural interlinkages of the economy. Focusing on Vietnam, this study proposes an approach based on the social accounting matrix (SAM) to estimate the macroeconomic loss due to violence. Using Vietnam’s 2011 SAM, the study estimates the income and multiplier loss due to VAW. From a policy point of view, the study argues that the macroeconomic loss due to VAW renders a permanent invisible leakage to the circular flow that can potentially destabilize, weaken, or neutralize the positive gains from government expenditure on welfare programs.     

Driving forces for research and development strategies: an empirical analysis based on firm-level panel data

This paper investigates empirically different ways to organize research and development (R&D) within Swiss firms. Based on a longitudinal data set comprising three cross-sections (1999, 2002, and 2005) of the Swiss Innovation Survey, four different types of R&D strategies could have been separated; firms combine in-house R&D with R&D co-operations (coop) or in-house R&D with external R&D (buy), or they conduct in-house R&D, external R&D, and R&D co-operations (mixed), or they exclusively rely on in-house R&D (make). It is the aim of this paper to understand what drive firms to go for different strategies. Based on econometric estimations controlling for correlations between the dependent variables and endogeneity among the independent variables, it was found that concepts related to the absorptive capacity, incoming spillovers, and appropriability, the importance of different knowledge sources, the competitive environment, costs, and skill aspects as well as technological uncertainty are essential factors to determine a firm's decision to choose a specific way to organize R&D.     

From Libertinism to Marital Commitment: The Economics of Marital Search with Heterogeneous Agents

Synopsis The actual characteristics and desires of candidates or marriage cannot be clearly identified without careful examination (Anderson & Hamori 2000). Accordingly, the classified advertisement system looks like a market or lemons (Akerlof 1970), which sharply contrasts with the matchmaking agency system. The continued existence of classified advertisement system just proves it furthers the goals of certain singles—namely, libertine females and libertine males. The present paper uses two databases: the first database consists of a sample of personal advertisements extracted from a specialized publication; the second database is the customer file of a matchmaking agency. This paper predicts which variables will determine the commitment level desired by individuals and why matchmaking agencies customers are more sincere than advertisers.     

Measurement of Quality of Life and Well‐Being in France: The Drivers of Subjective Well‐Being

Ever since the publication of the Stiglitz Report, France has been heavily involved in the measurement of well‐being. The French Statistical Institute (INSEE) has expanded the scope of its existing surveys. It has also launched an innovative experimental survey which, drawing upon a single statistical source, aims for the first time to explore the different dimensions of both objective and subjective quality of life, as highlighted in the Stiglitz Report. It allows us to study, at the individual level, correlations between these dimensions and the accumulation of deprivations. It has enabled us to better understand the links between determinants generally referred to as objective dimensions of quality of life (such as health or education) and subjective well‐being. This information is of paramount importance for policy makers who cannot act directly on the level of people's satisfaction but can only act upon the levers of objective dimensions. This paper presents the main findings of the experimental survey.     

民国遗产税制度思想之演进*--从分遗产税制到总遗产税制

发端于清末的中国遗产税制度思想,历经北洋政府时期、国民政府前期和国民政府后期的发展,具有明显的阶段性特征,并最终促成了遗产税制度在中国的实施。文章将思想界的活动与政府决策综合起来考虑,系统地梳理了民国遗产税制度思想的发展历程及其特征。研究发现：（1）民国时期思想界对遗产税制度建设的讨论遵循了三个原则,即公平原则、国情原则和可行性原则。（2）民国遗产税制度思想的演进过程,实为国人从本国国情出发,对税制公平性和可行性的权衡过程。（3）20世纪30年代中期以前,思想界在遗产税制度模式的选择上明显倾向于分遗产税制;而到了国民政府后期,总遗产税制最终得到了大多数人的认可。因此,民国时期的遗产税制度思想演进过程,是一个从注重公平性向注重可行性的转变过程。这是民国遗产税制度思想臻于成熟的表现。文章不仅是对近代中国财政思想研究的拓展和深化,还能为我国当前的遗产税制度建设提供有益的借鉴。