The cost-effectiveness and budget impact of stepwise addition of bolus insulin in the treatment of type 2 diabetes: evaluation of the FullSTEP trial

Background and aims:

Intensification of basal insulin-only therapy in type 2 diabetes is often achieved through addition of bolus insulin 3-times daily. The FullSTEP trial demonstrated that stepwise addition (SWA) of bolus insulin aspart was non-inferior to full basal-bolus (FBB) therapy and reduced the rate of hypoglycemia. Here the cost-effectiveness and budget impact of SWA is evaluated.

Methods:

Cost-effectiveness and budget impact models were developed to assess the cost and quality-of-life (QoL) implications of intensification using SWA compared with FBB in the US setting. At assessment, SWA patients added one bolus dose to their current regimen if the HbA1c target was not met. SWA patients reaching three bolus doses used FBB event rates. Outcomes were evaluated at trial end and projected annually up to 5 years. Models captured hypoglycemic events, the proportion meeting HbA1c target, and self-measured blood glucose. Event rates and QoL utilities were taken from trial data and published literature. Costs were evaluated from a healthcare-payer perspective, reported in 2013 USD, and discounted (like clinical outcomes) at 3.5% annually. This analysis applies to patients with HbA1c 7.0–9.0% and body mass index <40?kg/m².

Results:

SWA was associated with improved QoL and reduced costs compared with FBB. Improvement in QoL and cost reduction were driven by lower rates of hypoglycemia. Sensitivity analyses showed that outcomes were most influenced by the cost of bolus insulin and QoL impact of symptomatic hypoglycemia. Budget impact analysis estimated that, by moving from FBB to SWA, a health plan with 77,000 patients with type 2 diabetes, of whom 7.8% annually intensified to basal-bolus therapy, would save USD 1304 per intensifying patient over the trial period.

Conclusions:

SWA of bolus insulin should be considered a beneficial and cost-saving alternative to FBB therapy for the intensification of treatment in type 2 diabetes.     

Twenty-Five Years of Counting for Nothing: Waring's Critique of National Accounts

Marilyn Waring’s If Women Counted (1988) shows how national income accounting became infused with the patriarchal values dominant during its post–World War II development. This article revisits Waring’s analysis in the light of continued support of gross domestic product as a useful statistic. It explains the historical and personal context for her analysis, emphasizing postwar patriarchal values as well as Waring’s experience as a Member of the New Zealand Parliament (1975–84) and her active engagement with women in developed and developing countries. It illustrates the support If Women Counted gives to reformers and recognizes that change has occurred, including provision for satellite accounts in the United Nations System of National Accounts (UNSNA). Nevertheless, the paper concludes that Waring’s profound challenge to the central framework of UNSNA will continue as long as the system excludes unpaid household work and impacts on the natural environment from its core statistics.     

The economic costs of weeds on productive land in New Zealand

Here we review published research on the costs of weeds to New Zealand’s pastoral, arable and forestry sectors, and propose an alternative dynamic approach for future research. The studies reviewed had little in common methodologically, often contained guesswork, or were outdated. Their aggregation resulted in a conservative estimate of the cost of weeds to New Zealand’s agricultural economy of $1658 million (2014 NZD). To address deficiencies in previously used methodologies, a dynamic approach is developed and applied to a case study on giant buttercup in dairy pastures. This approach accounts for probable temporal changes in both the geographic extent of the weed and in producer prices and indicates annuitized costs (over the period 2012–2030) of $166 million, $259 million and $592 million for rates of spread of 144, 60 and 20 years for giant buttercup to invade all dairy regions in New Zealand. Comparing the aggregate cost of all weeds to the three productive sectors estimated from the historical data with these ‘dynamic’ estimates for the one species in dairy pasture, indicates that the historical data provide a substantial underestimate of the true aggregate cost of weeds to New Zealand’s agricultural economy.     

Financial architecture, systemic risk, and universal banking

Consolidation has been a fact of life in the wholesale financial services sector, resulting in fundamental change in the financial architecture and public exposure to systemic risk. The underlying drivers include advances in transactions and information technologies, regulatory changes, geographic shifts in growth opportunities, and the rapid evolution of client requirements, which in combination have obliged financial firms to rethink their roles as intermediaries. Moreover, financial sector reconfiguration has accelerated as a result of the global market turbulence that began in 2007, with governments either forcing or encouraging combinations of stronger and weaker financial firms in an effort to stem the crisis and improve systemic robustness. In the process, financial firms that are “systemic” in nature and had a major role in creating the crisis have come out of it with even larger market shares and greater systemic importance. Given the episodic socialization of risk in the form of widespread use of public guarantees to firms judged too big or too interconnected to be allowed to fail, the role of systemically important financial institutions (SIFIs) is central to the financial architecture and the public interest going forward. This survey paper considers the sources of systemic gains, losses and risks associated with SIFIs in historical context, in the theoretical and empirical literature, and in public policy discussions—i.e., what is gained and what is lost as a result of the available policy options to deal the dominant role of SIFIs in the financial architecture?     

The application of marketing to British politics

This article looks at some very basic questions concerning Marketing's application to British politics. Firstly it identifies the degree of influence which marketing has in this area. Secondly it discusses the efficacy of marketing activity in politics to date and in the future. Next it links voting behaviour with buyer behaviour and market segmentation to highlight areas where gaps exist and marketing expertise could be usefully transferred. A practical example is then provided as Cluster Analysis is used on relevant attitudinal data to produce a novel way of segmenting the electorate. From this some of the implications for political parties are discussed and the future research possibilities considered.