Prospective utility study of patients with multiple cardiovascular events

Objectives: The effects of acute coronary syndrome (ACS) events on health-related quality-of-life (HRQoL) and the time dependency of these effects are unknown. This study aimed to characterize health utilities in ACS patients to aid development of future economic models estimating the cost per quality-adjusted life-year impact of ACS events and potential treatments.

Methods: Multi-center, non-interventional, longitudinal evaluation of health utility in patients experiencing ACS or stroke events. EuroQol-5 dimension 3 level (EQ-5D-3L) surveys were sent to patients (≥18 years) from three UK centers, 1 month after hospital discharge for myocardial infarction (MI), unstable angina (UA), or stroke. Patient demographics, lifestyle, and baseline utility score were collected in the first survey. Follow-up surveys were sent at 6, 12, 18, and 24 months to prospectively capture utility and subsequent health events. Two methods of patient identification were adopted—prospective, where the patient’s qualifying events occurred after the study index date, and retrospective, where the patient’s qualifying event occurred prior to the study index date. General healthy population utility values were assumed for pre-event HRQoL.

Results: Between January 2011 and March 2014, 2,103 prospectively (n?=?1,350)/retrospectively (n?=?753) identified patients (mean age?=?68.3 years; 67.9% male) responded: MI?=?55.9% (n?=?1,176), UA?=?42.7% (n?=?898), stroke?=?1.4% (n?=?29); 24% had type 2 diabetes. Post-event utility values were lower than general healthy population values, although significant differences in utility between subsequent 6 (n?=?1,031, change?=?–0.002), 12 (n?=?1,096, change?=?–0.008), 18 (n?=?1,246, change?=?–0.007), and 24 (n?=?1,277, change?=?–0.004) month timepoints were not detected. Through multivariate regression analyses, wheelchair use, current smoking, and secondary mental and joint health events were associated with the greatest statistically significant utility decrements.

Conclusions: This study indicates that health utility decreases following a cardiovascular event and, although some improvement occurs over the subsequent 24 months, general healthy population utility is not necessarily attained.     

Towards an Epistemology for Radical Accounting: Beyond Objectivism and Relativism

This paper reviews some of the ontological and epistemological issues confronting writers who are currently pursuing a "radical" critique of "mainstream" accounting thought. This burgeoning heterodoxy has a common point of departure, that mainstream accounting relies upon the received wisdom that the veracity of competing theories may be adjudicated through criteria that appeal to the accuracy of their correspondence with the facts of a cognitively accessible external reality. This dualism between subject and object is both implicitly and explicitly challenged by the radical as they draw attention to, in a variety of ways, the projective role of the epistemic subject. But the maintenance of such a critique requires further epistemological self-reflection if incoherence and relativism are to be avoided. To contribute to the development of this heterodoxy, realism is explored as an epistemological haven from which this critique may be pursued and three key implications are explored through reference to the work of radical accountants.     

Trade union recognition and the recession in the UK

Against a background of falling union density and the increased presence of non-union plants and firms in the UK, this paper reviews union attempts to obtain recognition in recent years. Particular attention is paid to the use of conciliation for this purpose, with the evidence indicating a considerable decline in union success.     

Avoid the four perils of CRM

Customer relationship management is one of the hottest management tools today. But more than half of all CRM initiatives fail to produce the anticipated results. Why? And what can companies do to reverse that negative trend? The authors--three senior Bain consultants--have spent the past ten years analyzing customer-loyalty initiatives, both successful and unsuccessful, at more than 200 companies in a wide range of industries. They've found that CRM backfires in part because executives don't understand what they are implementing, let alone how much it will cost or how long it will take. The authors' research unveiled four common pitfalls that managers stumble into when trying to implement CRM. Each pitfall is a consequence of a single flawed assumption--that CRM is software that will automatically manage customer relationships. It isn't. Rather, CRM is the creation of customer strategies and processes to build customer loyalty, which are then supported by the technology. This article looks at best practices in CRM at several companies, including the New York Times Company, Square D, GE Capital, Grand Expeditions, and BMC Software. It provides an intellectual framework for any company that wants to start a CRM program or turn around a failing one.     

Formal versus informal knowledge networks in R&D: a case study using social network analysis

The existence of informal social networks within organizations has long been recognized as important and the unique working relationships among scientific and technical personnel have been well documented by both academics and practitioners. The growing interest in knowledge management practices has led to increased attention being paid to social network analysis as a tool for mapping the nature and membership of informal networks. However, despite the knowledge-intensive nature of research and development (R&D) activities, social network analyses of the R&D function remain relatively rare. This paper discusses the role of informal networks in the development, exchange and dissemination of knowledge within the R&D function. A case study using social network analysis is used to compare and contrast formal and informal knowledge networks within ICI. Marked differences between the informal organization and ICI's formal structures for knowledge exchange are revealed and a series of insights into the working habits of technical staff are presented. The implications for managers are clear: through a better understanding of the informal organization of R&D staff, they can more successfully capture and exploit new ideas; more efficiently disseminate information throughout the function; and more effectively understand the working habits and activities of employees.     

The Impact of the Berlin Accord and European Enlargement on Dairy Markets

Journal paper No. J-18684 of the Iowa Agriculture and Home Economics Experiment Station, Ames, Iowa, Project No. 3566, and supported by Hatch Act and State of Iowa funds. Using a world agricultural model, we analyze the impact on dairy markets of the Berlin Accord on the European Union (EU) Common Agricultural Policy (CAP) Reforms. We also investigate the consequences of enlargement of the EU to include the Czech Republic, Hungary and Poland for the same markets. We produce a market outlook up to 2010 for these two scenarios. The Berlin Accord induces lower EU milk and dairy prices. A change in relative prices between cheese and butter-skim milk powder (SMP) occurs after 2005 and induces an expansion of cheese production, consumption and exports at the expense of the butter–SMP sector. Accession of the three central and eastern European countries (CEECs) leads to a permanent but moderate decrease in EU prices of milk and dairy products. For the three acceding CEECs, domestic prices increase dramatically. Their final consumption of milk decreases and dairy product consumption drops considerably. The derived demand of milk in dairy production increases, however, because of the higher prices for dairy products, benefiting dairy producers in these CEECs. Dairy exports of the three acceding countries to the EU–15 increase by one to three orders of magnitude, despite building large inventories. The impact of accession on world markets is small. À l'aide d'un modèle agricole à l'échelle mondiale, nous analysons l'impact des accords de Berlin sur la réforme de la Politique agricole commune (PAC) de l'Union Européenne, en ce qui touche les marchés laitiers. Nous examinons aussi les conséquences éventuelles de l'élargissement de l'Union Européenne à la République Tchèque, à la Hongrie et à la Pologne. Ces deux scénarios nous ont servi de base d‘élaboration de perspectives du marché jusqu'en 2010. Les accords de Berlin déclenchent une hausse duprix du lait et desproduits laitiers dans l'UE. Selon nos prédictions, on assiste après 2005 à un changement du prix relatif du fromage par rapport à celui de la poudre de lait écremé (PLE). II s‘ensuit une expansion de la production et de la consommation et des exportations defromage aux dépens du segment de la PLE. L'entrée des trois pays de l'Europe, du centre et de l'est (PECE) conduit à une baisse permanente, encore que modeste, des prix du lait et des produits laitiers dans l'UE. Chez les trois nouveaux arrivés, les prix intérieurs grimpent de façon spectaculaire, ce qui entraîne une chute de la consommation du lait particulièrement de celle des produits laitiers transformés. En revanche, la demande de lait industriel augmente à cause des prix plus élevés des produits dérivés, ce qui profite aux producteurs laitiers des trois pays. Les exportations laitières de ces pays augmentent de 1 à 3 ordres de grandeur, ce qui n'empèche pas la constitution de stocks importants. L'impact de l'accession sur leur marchés mondiaux devrait être de peu d'importance.     

Cohort versus patient level simulation for the economic evaluation of single versus combination immuno-oncology therapies in metastatic melanoma

Abstract

Background: Model structure, despite being a key source of uncertainty in economic evaluations, is often not treated as a priority for model development. In oncology, partitioned survival models (PSMs) and Markov models, both types of cohort model, are commonly used, but patient responses to newer immuno-oncology (I-O) agents suggest that more innovative model frameworks should be explored.

Objective: A discussion of the theoretical pros and cons of cohort level vs patient level simulation (PLS) models provides the background for an illustrative comparison of I-O therapies, namely nivolumab/ipilimumab combination and ipilimumab alone using patient level data from the CheckMate 067 trial in metastatic melanoma. PSM, Markov, and PLS models were compared on the basis of coherence with short-term clinical trial endpoints and long-term cost per QALY outcomes reported.

Methods: The PSM was based on Kaplan-Meier curves from CheckMate 067 with 3-year data on progression free survival (PFS) and overall survival (OS). The Markov model used time independent transition probabilities based on the average trajectory of PFS and OS over the trial period. The PLS model was developed based on baseline characteristics hypothesized to be associated with disease as well as significant mortality and disease progression risk factors identified through a proportional hazards model.

Results: The short-term Markov model outputs matched the 1–3?year clinical trial results approximately as well as the PSMs for OS but not PFS. The fixed (average) cohort PLS results corresponded as well as the PSMs for OS in the combination therapy arm and PFS in the monotherapy arm. Over the lifetime horizon, the PLS produced an additional 5.95 quality adjusted life years (QALYs) associated with combination therapy relative to ipilimumab alone, resulting in an incremental cost-effectiveness ratio (ICER) of £6,474 per QALY, compared with £14,194 for the PSMs which gave an incremental benefit of between 2.2 and 2.4 QALYs. The Markov model was an outlier (～ £49,000 per QALY in the base case).

Conclusions: The 4- and 5-state versions of the PSM cohort model estimated in this study deviate from the standard 3-state approach to better capture I-O response patterns. Markov and PLS approaches, by modeling state transitions explicitly, could be more informative in understanding I-O immune response, the PLS particularly so by reflecting heterogeneity in treatment response. However, both require a number of assumptions to capture the immune response effectively. Better I-O representation with surrogate endpoints in future clinical trials could yield greater model validity across all models.