Management and cost analysis of cancer patients treated with G-CSF: a cohort study based on the French national healthcare insurance database

Objectives: To describe the management and costs associated with G-CSF therapy in cancer patients in France.

Methods: This study analyzed a representative random population sample from the French national healthcare insurance database, focusing on 1,612 patients with hematological or solid malignancies who were reimbursed in 2013 or 2014 for at least one G-CSF treatment dispensed in a retail pharmacy. Patient characteristics and treatment costs were analyzed according to the type of cancer. Then the costs and characteristics of patients associated with the use of different G-CSF products were analyzed in the sub-set of breast cancer patients.

Results: The most frequent malignancies in the database population were breast cancer (23.3%), hematological malignancies (22.2%), and lung cancer (12.4%). The reimbursed G-CSF was pegfilgrastim in 34.1% of cases, lenograstim in 26.7%, and filgrastim in 17.9%. More than one G-CSF product was reimbursed to 21.3% of patients. The total annual reimbursed health expenses per patient, according to the type of G-CSF, were €27,001, €24,511, and €20,802 for patients treated with filgrastim, lenograstim, and pegfilgrastim, respectively. Ambulatory care accounted for, respectively, 35%, 38%, and 41% of those costs. In patients with breast cancer, ambulatory care cost was €7,915 with filgrastim, €7,750 with lenograstim, and €6,989 with pegfilgrastim, and the respective cost of G-CSF was €1,733, €1,559, and €3,668.

Conclusion: All available G-CSF products have been shown to be effective in cancer patients, and both daily G-CSFs and pegylated G-CSF are recommended in international guidelines. Nevertheless, this analysis of G-CSF reimbursement indicates that the choice of product can markedly affect the total cost of ambulatory care.     

Management of vaccinations in Italy: a national survey after healthcare regionalization

Abstract

Objectives:

The main aim of this study was to describe the effects of regional organization and performance in managing vaccinations, in the light of the institutional devolution recently introduced in Italy.

Methods:

We analysed (1) the general organization of regions for vaccination programmes, (2) the management of four vaccination programmes (combined measles-rubella-parotitis, varicella for children, influenza, and pneumococcal 23-valent for adults).

First, we conducted preliminary face-to-face interviews with 16 regional managers of the infective disease prevention departments. Subsequently, we sent them a standardized questionnaire to obtain comparable information on general organization and on the four specific vaccination programmes considered. In all, 14 regions were eventually included.

Results:

The survey showed a widespread lack of regional staff involved in the management of vaccinations and a geographical variation in the availability of computerized data collection. We recorded poor coverage for varicella and pneumococcal 23-valent vaccinations compared to MRP and influenza. Prices of the four vaccines varied widely among regions, with only a weak correlation between prices and volumes.

Limitations and conclusions:

The major limitation of the survey was the lack of information available at regional level. The piecemeal diffusion of computerized systems and the widespread lack of sufficient staff should mainly explain this.

Economic incentives could be offered to regions that achieve national targets. Such incentives should encourage collaboration between central and regional authorities consistent with institutional trends in regional devolution.     

Poverty as social deprivation: a survey

The concept of poverty is discussed using qualitative and quantitative measures as an indicator for social deprivation. Poverty can be absolute, relative, income based, consumption based, or entitlement based. The variation in the concept of poverty reveals its dimensionality. However, when closely examined, these dimensions are seen to be conceptually interrelated and complementary rather than substitutable. The concept used to define poverty determines the methods employed to measure it. Composite indicators can hide important policy messages inherent in their constituent variables.     

Lottery expenditures in Canada: a regional analysis of determinants and incidence

This article examines two issues; first, it evaluates the statistical significance of a number of socio-economic and demographic variables on the level of household lottery expenditures in the six regions of Canada. While some household characteristics vary in the extent to which they significantly affect the level of lottery expenditures across regions (wealth, age, occupation, mother tongue and urban location, for example), others are significant in every region. Regional consistency exists in the statistical significance of after tax household income, sex and education of the head of household – lottery expenditures increase as incomes increase; lottery expenditures are significantly lower for female heads of households than for their male counterparts; lottery expenditures decline as the education level of the head of household increases. Second, lottery expenditures are found to be regressive, although the degree of regressivity is less than for lotteries in the United States.     

Economic burden of chemotherapy-treated recurrent and/or metastatic squamous cell carcinoma of the head and neck in France: real-world data from the permanent sample of national health insurance beneficiaries

Aims: Overall survival (OS) of patients with recurrent or metastatic (R/M) squamous cell carcinoma of the head and neck (SCCHN) is extremely poor. New therapeutic options emerge but need to establish their economic value. The objective was to describe the direct and related costs of R/M SCCHN in France.

Materials and methods: We selected all adult patients treated with chemotherapy for R/M SCCHN between 1 January 2009 and 31 December 2014 from the permanent sample of the French national health insurance database (EGB). Data were analyzed from the index date (first chemotherapy) until patients’ death or 31 December 2015. “Treatment period” and “end-of-life” (EoL) (from last chemotherapy until death) were distinguished. Costs included all hospitalizations for SCCHN and ambulatory care. Costs of hospitalized and non-hospitalized adverse events (AEs) were estimated.

Results: Among 267 patients identified, 85% were men, 44% had metastases at the index date and the mean age was 62.0 years (±9.9). The most common tumor location was oropharynx (29%) but 39% of patients had multiple locations. Median OS was 9.3 (95% CI: 7.9–11.8) months for the overall population. The average total direct cost per patient was €49,954, broken down into €32,908 (95% CI: 29,525–36,290) for hospitalizations and €17,047 (14,941–19,152) for ambulatory care. Main cost drivers were drug acquisition and administration (€14,538) during the treatment period (209?days on average) and palliative care (€3,750) during the EoL period (125?days). Regarding related costs, around 12% of patients received disability pensions (€1,397 per patient [624–2,171]) and sick leave payments (€1,592 [888–2,297]). “Metabolism and nutrition disorders” and “Infections and infestations” were the most expensive hospitalized AEs (€1,513 and €1,180 per patient, respectively). Febrile neutropenia was the most expensive non-hospitalized AE (€766 per patient).

Conclusions: This analysis of real-world data confirms the poor prognosis of patients with R/M SCCHN and provides cost data for future economic evaluations.     

Small firms in Portugal: a selective survey of stylized facts,economic analysis,and policy implications

I survey a number of stylized facts pertaining to the dynamics of firm entry, growth, and exit in competitive industries. I focus particularly on data for Portugal, although I also consider, for comparison purposes, data from other countries. I then present a series of theoretical models that attempt to explain the stylized facts and evaluate the welfare impact of market distortions. Finally, I derive a number of policy implications, all centered around the notion of economic mobility.

The determinants of FDI location choice in China: a discrete-choice analysis

This study addresses two questions: What are the determinants of foreign direct investment (FDI) location choice in China? What are the factors that determine investors’ choice between ‘Economic zones’ in China on one hand, and ‘other cities’ of China on the other hand? This study shows that FDI location choice is sensitive both on the endowment conditions in different regions/cities/economic zones in China as well as on the country of origin of the FDI. Based on a data set of 1218 observations, the results of the binary logit regressions indicate that the protection of intellectual rights, agglomeration economies, investments in education and gross regional product affect the location choice of FDI in China. This choices, however, varies depending on the origin of the FDI. Policy makers can use these findings to channel FDI to targeted regions/ cities.     

Long-run determinants of pollution: A robustness analysis

This paper examines how robust economic, political, and demographic variables are related to water and air pollution. Employing Bayesian Averaging of Classical Estimates (BACE) for a cross section of 47 countries, 34 variables and 3 proxies for air and water pollution over a period from 1980 to 2000 we confirm the environmental Kuznets curve hypothesis and highlight the relevance of variables that are not directly related to production.     

The relationship between insurance and economic growth in Europe: a theoretical and empirical analysis

The role of insurance companies, although growing in importance in financial intermediation, has received less attention than bank and stock markets and if so, mainly as a provider of risk transfer in single country or very heterogeneous samples. We investigate both the impact of insurance investment and premiums on GDP growth in Europe. We conduct a cross-country panel data analysis from 1992 to 2005 for 29 European countries. We find a positive impact of life insurance on GDP growth in the EU-15 countries, Switzerland, Norway and Iceland. For the New EU Member States from Central and Eastern Europe, we find a larger impact for liability insurance. Furthermore our findings emphasise the impact of the real interest rate and the level of economic development on the insurance-growth nexus. We argue that the insurance sector needs to be paid more attention in financial sector analysis and macroeconomic policy.

Societal implications of medical insurance coverage for imatinib as first-line treatment of chronic myeloid leukemia in China: a cost-effectiveness analysis

Objectives: Imatinib (Glivec) and nilotinib (Tasigna) have been covered by critical disease insurance in Jiangsu province of China since 2013, which changed local treatment patterns and outcomes of patients with chronic myeloid leukemia (CML). This study evaluated the long-term cost-effectiveness of insurance coverage with imatinib as the first-line treatment for patients with CML in China from a societal perspective.

Methods: A decision-analytic model based on previously published and real-world evidence was applied to simulate and evaluate the lifetime clinical and economic outcomes associated with CML treatments before and after imatinib was covered by medical insurance. Incremental cost-effectiveness ratio (ICER) was calculated with both costs and quality-adjusted life years (QALYs) discounted at 3% annually. Different assumptions of treatment benefits and costs were taken to address uncertainties and were tested with sensitivity analyses.

Results: In base case analysis, both cost and effectiveness of CML treatments increased after imatinib was covered by the medical insurance; on average, the incremental QALY and cost were 5.5 and ¥277,030 per patient in lifetime, respectively. The ICER of insurance coverage with imatinib was ¥50,641, which is less than the GDP per capita of China. Monte Carlo simulation resulted in the estimate of 100% probability that the insurance coverage of imatinib is cost-effective. Total cost was substantially saved at 5 years after patients initiated imatinib treatment with insurance coverage compared to no insurance coverage, the saved cost at 5 years was ¥99,565, which included the cost savings from both direct (e.g. cost of bone marrow or stem cell transplant) and indirect costs (e.g. productivity loss of patients and care-givers).

Conclusions: The insurance coverage of imatinib is very cost-effective in China, according to the local cost and clinical data in Jiangsu province. More importantly, the insurance coverage of imatinib and nilotinib have changed the treatment patterns of CML patients, thus dramatically increasing life expectancy and quality-of-life (QoL) saving on productivity losses for both CML patients and their caregivers.     

Adverse selection and statistical discrimination: An analysis of Canadian automobile insurance

Statistical discrimination occurs when a characteristic, such as sex, is used as an indicator of the risk group of an individual. The theory of adverse selection is used to explain the occurrence of statistical discrimination. A model of the market for collision insurance, which is based on the theory of adverse selection, is estimated on Canadian data. The results suggest that adverse selection occurs in this market. Simulations of the effect of prohibiting sexual discrimination in the 21–24 age group indicate that the premiums for single females would increase substantially and that a significant proportion would no longer purchase collision insurance.     

Institutional obstacles to African economic development: State, ethnicity, and custom

To account for the African growth tragedy and, in particular, for its causes rooted in governance problems, the institutional legacy that African countries inherited from pre-colonial and colonial times must be considered. Three aspects are examined here. First, the relationship between ethnicity and state performance is bi-directional: if strong ethno-regional identities prevent the emergence of modern citizenship, they themselves constitute an endogenous outcome of continuous state failures. Second, the persistence of informal rules and social norms causes legal dualism, which undermines the credibility of modern statutory law. Third, social customs and norms that hinder socio-economic differentiation and individual capital accumulation lower the performance of indigenous enterprises.     

Medical interventions among pregnant women in fee-for-service and managed care insurance: a propensity score analysis

This paper extends earlier research on the effect of managed care on the receipt of four medical interventions for pregnant women: ultrasound, induction/stimulation of birth, electronic fetal monitor, and Caesarean delivery. Propensity score methods are used to account for sample selection issues regarding insurance choice. Managed care enrollees are more likely to receive an ultrasound, which may be indicative of receiving better prenatal care. Managed care plans reduce the rate of Caesarean deliveries, but such limitations may be beneficial given the substantial medical evidence that Caesarean deliveries are over-utilized. The results indicate that insurance coverage does influence treatment intensity, but that utilization controls and provider financial incentives do not adversely affect care for pregnant women.     

Nominal and real volatility as determinants of FDI

This article examines the role of country-specific sources of output and interest rate or exchange rate volatility in driving Foreign Direct Investment (FDI) activities. Building on a dataset with bilateral FDI flows among 24 Organization for Economic Co-operation and Development (OECD) economies over the period 1985–2007, we find that nominal and real volatility strongly deter foreign investments. Output and exchange rate volatility matter in particular for the decision whether to invest in a foreign country in the first place. Interest rate volatility mainly influences the amount of foreign investments.     

Economic determinants of the consumption of alcoholic beverages in Canada: a panel data analysis

In this article, the economic determinants of the demand for three alcoholic beverages (wine, spirits, and beer) are investigated with a focus on the price, income and unemployment effects. The investigation is conducted within the fixed effects panel regression framework using a balanced panel for ten Canadian provinces spanning the years 1981–2004. The estimated own price elasticities indicate that increased government taxation is an effective tool for curtailing the consumption of spirits (at the expense of lower government tax revenue), but it is less effective for curtailing the consumption of wine or beer. The cross-price elasticity estimates reveal that taxing beer or spirits may not be an effective tool for encouraging consumption switch from these alcoholic beverages to wine in light of wine’s greater health benefits. Income emerges as an important determinant of the consumption of both wine and spirits but not of beer, whereas unemployment emerges as an important determinant of the consumption of beer but not of wine or spirits. With respect to unemployment, we find no support for the addiction hypothesis in the case of wine and spirits and strong support for the severe budget constraint hypothesis in the case of beer.