Cost-effectiveness of pembrolizumab in combination with chemotherapy in the 1st line treatment of non-squamous NSCLC in the US

Abstract

Aims: To describe cost-effectiveness of pembrolizumab plus platinum and pemetrexed chemotherapy in metastatic, non-squamous, NSCLC patients in the US.

Materials and methods: A model is developed utilizing partitioned survival analysis to estimate the cost-effectiveness of KEYNOTE-189 trial comparators pembrolizumab?+?chemotherapy (carboplatin/cisplatin?+?pemetrexed) vs chemotherapy alone. Clinical efficacy, treatment utilization, health utility, and safety data are derived from the trial and projected over 20 years. For extrapolating survival beyond the trial, a novel SEER population-data approach is applied (primary analysis), with separate estimation via traditional parametric extrapolation methods. Costs for drugs and non-drug disease management are also incorporated. Based on an indirect treatment comparison, cost-effectiveness of pembrolizumab?+?chemotherapy vs pembrolizumab monotherapy is evaluated for patients with programmed death-ligand 1 (PD-L1)?≥?50%.

Results: In the full non-squamous population, pembrolizumab?+?chemotherapy is projected to increase life expectancy by 2.04 years vs chemotherapy (3.96 vs 1.92), for an approximate doubling of life years. Resultant incremental cost-effectiveness ratios (ICERs) are $104,823/QALY and $87,242/life year. In patients with PD-L1?≥?50% and 1–49%, life expectancy is more than doubled (4.53 vs 1.88 years) and (4.87 vs 2.01 years), with a 32% (2.60 vs 1.97 years) increase in PD-L1?<?1% patients. Corresponding incremental costs/quality-adjusted life year (QALY) are $103,402, $66,837, and $183,529 for PD-L1?≥?50%, 1–49%, and <1% groups, respectively. Versus pembrolizumab monotherapy in PD-L1?≥?50% patients, representing current standard of care, pembrolizumab?+?chemotherapy increases life expectancy by 65% (4.53 vs 2.74 years) at an ICER of $147,365/QALY.

Limitations and conclusions: The addition of pembrolizumab to chemotherapy is projected to extend life expectancy to a point not previously seen in previously untreated metastatic non-squamous NSCLC. Although ICERs vary by sub-group and comparator, results suggest pembrolizumab?+?chemotherapy yields ICERs near, or in most cases, well below a 3-times US per capita GDP threshold of $180,000/QALY, and may be a cost-effective first-line treatment for metastatic non-squamous NSCLC patients.     

A DYNAMIC MODEL OF HOUSING DEMAND: ESTIMATION AND POLICY IMPLICATIONS*

Using data from the PSID, we estimate a dynamic model of housing demand with nonconvex adjustment costs, credit constraints, and uncertainty about income and home prices. We simulate how consumer behavior responds to house price and income declines as well as tightening credit. In response to a negative home price shock, households early in the life cycle climb the housing ladder more quickly and invest more in housing assets due to the lower price. With a concurrent negative income shock, however, housing demand falls among young and middle aged households who stay in smaller homes rather than to trade up.     

Designing Effective Graphs

Abstract

Actuaries, like other business professionals, communicate quantitative ideas graphically. Because the process of reading, or decoding, graphs is more complex than reading text, graphs are vulnerable to abuse. To underscore this vulnerability, we give several examples of commonly encountered graphs that mislead and hide information. To help creators design more effective graphs and to help viewers recognize misleading graphs, this article summarizes guidelines for designing graphs that show important numerical information. When designing graphs, creators should:

• (1) Avoid chartjunk

• (2) Use small multiples to promote comparisons and assess change

• (3) Use complex graphs to portray complex patterns

• (4) Relate graph size to information content

• (5) Use graphical forms that promote comparisons

• (6) Integrate graphs and text

• (7) Demonstrate an important message

• (8) Know the audience.

Some of these guidelines for designing effective graphs, such as (6), (7) and (8), are drawn directly from principles for effective writing. Others, such as guidelines (3), (4) and (5), come from cognitive psychology, the science of perception. Guidelines (1) and (2) have roots both in effective writing and in graphical perception. For example, the writing principle of brevity demonstrates how eliminating pseudo three-dimensional perspectives and other forms of chartjunk improve graphs. As another example, the writing principle of parallel structure suggests using small multiple variations of a basic graphical form to visualize complex relationships across different groups and over time.

To underscore the scientific aspect of graphical perception, we examine the process of communicating with a graph, beginning with a sender’s interpretation of data and ending with a receiver’s interpretation of the graph. In keeping with scientific tradition, this article discusses several studies in the literature on the effectiveness of graphs.

We conclude that the actuarial profession has many opportunities to improve its practice, making communication more efficient and precise.     

Public policy dilemma—gender equality mainstreaming in UK policy formulation

The UK government has committed itself to improving the representation of women in public service and has introduced a number of legislative measures, policies and development programmes to do this. In 2006, the government enacted a regulatory duty, placed on public sector organizations, to mainstream gender equality in policy and service delivery. This article explores the extent to which this duty could promote gender equality and makes some recommendations for improving the representation of women.     

Implications of internal organization structure for firm boundaries

Knowledge issues are central to governance choice. Organization structure influences knowledge flows and costs of knowledge creation and exchange inside the firm. Yet the question of how a firm's internal structure affects its governance choice for new activities has received scant empirical attention. We examine the role of internal structure, specifically unit autonomy and lateral coordination, in a firm's governance decision for new, knowledge‐intensive activities. The findings show that internal structure is a ‘shift parameter’ that affects governance choice by moderating the relationship between task complexity and degree of integration. The empirical setting is the U.S. banking industry and its adoption of Internet banking. Copyright © 2013 John Wiley & Sons, Ltd.     

Is family leadership always beneficial?

There has been much debate concerning the performance of family firms and the drivers of their performance. Some scholars have argued that family management is to blame when family firms go wrong; others claim that family management removes costly agency problems and encourages stewardship. Our thesis is that these disagreements can only be resolved by distinguishing among different types of family firms. We argue that family CEOs will outperform in smaller firms with more concentrated ownership and underperform in larger firms with more dispersed ownership; they will do neither where firms are smaller and ownership is more dispersed or firms are larger and ownership is more concentrated. Copyright © 2012 John Wiley & Sons, Ltd.     

Financial System Development and Economic Growth in Transition Economies: New Empirical Evidence from the CEE and CIS Countries

We examine the role of financial development in economic growth in the former Communist countries of Central and Eastern Europe and the Commonwealth of Independent States during the first two decades since the beginning of transition. These countries, which had undeveloped financial systems under Communism, provide an interesting test of the relationship between financial development and growth. Our study is the broadest in terms of coverage and time period. We find that measures of financial market efficiency and competitiveness are more important than the size of the market in terms of promoting economic growth.     

Tertiary Performance, Field of Study and Graduate Starting Salaries

This paper analyses data from the University of Western Australia (UWA) Graduate Destination Survey linked to information from the University's Student Records System to explore the determinants of graduates' starting salaries over the years 2002 to 2004. While the details examined also include age, gender, language spoken at home, country of birth, disability status and high school attended, most emphasis is placed on the impact on starting salaries of students' academic performance and their field of study. The analyses show that the main determinant of graduates' starting salaries is the weighted average mark they achieve at university. The salary differentials associated with higher marks in the Australian labour market appear greater than those reported in similar studies of the US and the UK labour markets. Science graduates are shown to have relatively low starting salaries, casting a shadow over recent suggestions that the supply of this group be increased through lower fee regimes.