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.     

The barriers to effective global talent management: The example of corporate élites in MNEs

This paper focuses on talent management failure by multinational enterprises (MNEs). It examines barriers to corporate advancement of talents located in subsidiaries and more specifically on promotion of talent already employed by the MNE to be part of the upper echelon management team at its centre. Drawing on agency and bounded rationality theories, we discuss the underlying causes of talent management failure in MNEs. At the subsidiary level, we draw on agency theory to delineate self-serving mechanisms displayed by subsidiary managers that might hinder effective talent management systems throughout the MNE. At the headquarter level, we use bounded rationality to explain how decision-making processes, and information top management teams use to make decisions about talent management results in overlooking talents at subsidiary level.     

Community care in England,Scotland and Wales

How far does the writ of Whitehall and Westminster really run? An analysis of community care shows that a policy common to successive Governments has been interpreted in radically different ways in England, Scotland and Wales. Can this lack of uniformity be turned to advantage?     

Evaluating impacts of institutional reforms on port efficiency changes: Ownership,corporate structure,and total factor productivity changes of world container ports

This paper evaluates how port institutional reforms influenced efficiency gains between 1991 and 2004. We constructed a panel data for port ownership, corporate structure, and port inputs and outputs for 98 major world ports, and we implemented the Malmquist Productivity Index (MPI) model. The MPI provides efficiency measures for input combinations that allow for obtaining the outputs in the presence of institutional reforms, ownership changes, main agent problems, technological progress, efficient scale growth, and many other reasons for efficiency and the lack of it. The results illustrate that ownership restructuring contributed to total factor productivity gains. The restructuring induced optimized operation of container terminals, especially for large ports, as it allowed specialized private entities to concentrate on terminal operation and cargo handling services.     

A Development‐friendly Prioritisation of Doha Round Proposals

Agriculture looms large on the WTO's agenda. It was the first substantive item listed in the work programme of the Ministerial Declaration launching the Doha Round, and it was arguably at the centre of the failure at Cancun. Developing countries made it clear both before and during the Cancun meeting that progress on agriculture was their primary objective. Negotiations in other areas have received less attention and progressed more slowly. This paper considers that prioritisation, and suggests that the interests of developing countries in the current round of trade negotiations are much broader than is suggested by the narrow range of agricultural issues that have dominated negotiations. A true development round would require a significant reprioritisation of many areas of the WTO's current agenda.     

The Impact of Program Environment on Recall of Humorous Television Commercials

This study investigated the possible effect of television program types on the recall performance of humorous television commercials. An experimental design was developed to test the relative performance of the same humorous and non-humorous ads in three different contextual environments—situation comedy, action/adventure, and documentary. The findings indicate that the recall performance of commercials and of the product or service promoted are both affected by the program environment within which the ads appear.     

Dangers in the reduction in U.S. international net worth

The great concern exercised over the accuracy of estimates of the net direct investment position as a part of the U.S. international net worth is largely misplaced. By focusing on additions to the U.S. international net worth embodied in real assets owned in foreign countries, analysts divert attention from the large and growing volume of foreign-owned claims in private U.S. financial markets and the implications of those claims for instability in the foreign exchange market and for financial crisis.