Primary vs secondary prophylaxis with pegfilgrastim for the reduction of febrile neutropenia risk in patients receiving chemotherapy for non-Hodgkin’s lymphoma: cost-effectiveness analyses

Objective:

Evaluate the cost-effectiveness of primary vs secondary prophylaxis (PP vs SP) with pegfilgrastim to reduce the risk of febrile neutropenia (FN) in Non-Hodgkin’s Lymphoma (NHL) patients receiving myelosuppressive chemotherapy from a US payer perspective.

Methods:

A Markov model was used to compare PP vs SP with pegfilgrastim in a cohort of patients receiving six cycles of cyclophosphamide, vincristine, doxorubicin, and prednisone (CHOP) or CHOP plus rituximab (CHOP-R) chemotherapy. Model inputs, including efficacy of pegfilgrastim in reducing risk of FN and costs, were estimated from publicly available sources and peer-reviewed publications. Incremental cost-effectiveness was evaluated in terms of net cost per life-year saved (LYS), per quality-adjusted life-year (QALY) gained, and per FN event avoided over a lifetime horizon. Deterministic and probabilistic analyses were performed to assess sensitivity and robustness of results.

Results:

Lifetime costs for PP were $5000 greater than for SP; however, PP was associated with fewer FN events and more LYs and QALYs gained vs SP. Incremental cost-effectiveness ratios (ICERs) for PP vs SP for CHOP were $13,400 per FN event avoided, $29,500 per QALY gained, and $25,800 per LYS. CHOP-R results were similar ($15,000 per FN event avoided, $33,000 per QALY gained, and $28,900 per LYS). Results were most sensitive to baseline FN risk, cost per FN episode, and odds ratio for reduced relative dose intensity due to prior FN event. PP was cost-effective vs SP in 85% of simulations at a $50,000 per QALY threshold.

Limitations:

In the absence of NHL-specific data, estimates for pegfilgrastim efficacy and relative risk reduction of FN were based on available data for neoadjuvant TAC in patients with breast cancer. Baseline risks of FN for CHOP and CHOP-R were assumed to be equivalent.

Conclusions:

PP with pegfilgrastim is cost-effective compared to SP with pegfilgrastim in NHL patients receiving CHOP or CHOP-R.     

La transición de Tailandia en las esferas laboral y sanitaria

La economía de Tailandia ha cambiado rápidamente de la agricultura a la industria manufacturera y el sector de los servicios, pero el ordenamiento del mercado laboral y la representación de los trabajadores son mucho menos consistentes que en los países desarrollados, donde hubo una transición más lenta y gradual hace ya décadas. Los autores estudian el robustecimiento de las políticas y la legislación tailandesas en el ámbito de la seguridad y la salud en el trabajo, que obedece a las normas internacionales y a la nueva Constitución democrática. Por último, identifican los principales retos pendientes, entre ellos el cumplimiento de la ley y una medición mejor de los efectos del trabajo en la salud física y mental.     

Engineering,a civilising influence?

The global environment is increasingly under threat and we face a challenge with little time to respond. Are we prepared to change the actions and attitudes that have led to this parlous situation, and if we are, how do we do it? Is the world ready for a more ecologically benign, less economically driven, peaceful and spiritually oriented way of living? My challenge lies in higher education. How do you encourage such values in a tertiary education system which has spent many years applying and rewarding a ‘respond to the market’ discourse? My responses are grounded in transformative education research with large diverse cohorts of first year engineering students. This paper also uses a critical futures methodology, Causal Layered Analysis, to update my concerns about Australian engineering education and the profession, using two recent reports. The aim is to offer constructive insights that may be transferable to educators in other contexts.     

Summary of Results of Survey of Seminar Attendees

Abstract

The Society of Actuaries undertook a three-phase research project on mortality improvement in the three NAFTA countries: Canada, Mexico, and the U.S. Phase 1 consisted of a literature review of papers on projecting mortality levels in the future and a study of the trend in mortality improvement during this century. Phase 2 consisted of a discussion of different facets of modeling mortality rates at a seminar attended by 79 experts (actuaries, demographers, economists, and medical researchers) representing different countries. The last session of the seminar consisted of the completion of a survey by the attendees to obtain input for Phase 3, which would analyze the impact of mortality improvement on the social security system of each country. This paper summarizes the results of the survey.

The survey results illustrate the difficulty in forecasting mortality levels, because the effects of many factors that could have significant impact on mortality rates are unknown. This suggests the need for dynamic forecasting, which allows for the possibility of random shocks. A majority of the survey respondents believe that stochastic forecasting models, despite their complexity, have significant potential to add value. Respondents also believe that both historical data and cause-specific mortality forecasts are useful as input and also in validating forecasts of the aggregate levels of mortality. The challenge is to develop more sophisticated forecasting models to produce results that are relatively easy to interpret and to communicate these results to the desired audiences, including the public and policymakers.

The survey results suggest that the aggregate effect of lifestyle changes, medical advances, diseases, catastrophe, and physical environmental changes is an increase in life span. However, there is much uncertainty about the future. Respondents expect that beyond the year 2020 the mean annual rate of reduction in mortality for males age 65 and over will average about 0.58% for Canada, 0.76% for Mexico, and 0.67% for the U.S. The results for the female age 65 and over population are 0.64%, 0.83%, and 0.70%, respectively. The age 65 and over population is expected to see larger percentage reductions in mortality than the 0–14 and 15–64 populations. The reductions in male and female mortality will be ultimately the same, and the mortality levels in the three countries will ultimately converge, although differences may persist for decades.     

The Impact of the Inpatient Prospective Payment System and Diagnosis-Related Groups

Abstract

The outpatient prospective payment system for the Medicare program became effective Aug. 1, 2000, as mandated by the Balanced Budget Act of 1997. This outpatient program complements Medicare’s inpatient prospective payment system, which was introduced in 1983. A survey of the literature over the past 20 years is undertaken to review the effects of the inpatient prospective payment system and diagnosis-related groups (DRGs) on inpatient hospital utilization, expenditures, and outcomes. The level of the DRG payment has been questioned, as well as the process of adjusting the payment levels from one year to the next. In addition, past research has speculated that the DRG classification may not be sensitive to severity and is subject to coding ambiguities. These conclusions can be used as input to future research on the new outpatient program, as well as updating research on the inpatient program.     

Poor relief in Elizabethan English communities: an analysis of Collectors' accounts

This article analyses 30 accounts of income and expenditure left by Collectors for the Poor in Elizabethan England, before the period known as the old poor law. Collectors were appointed by parishes and incorporated boroughs in accordance with the poor laws of 1552 and 1563, but few of their fragile records survive. The accounts examined here document early use of compulsory rates to provide income, but several features of the distribution of relief differ from patterns common in the seventeenth and eighteenth centuries. Adult male recipients outnumbered women in many of the parishes; children were frequently helped directly; and cities and towns assisted a smaller fraction of their total populations than did villages but awarded larger per capita payments. Accounts from the 10 villages and small towns analysed most fully show that Elizabethan Collectors were moving away from the late medieval practice of providing only occasional aid; increasingly they awarded regular payments to a selected subset of the local poor. Comparison with the early seventeenth century suggests that the poor laws of 1598 and 1601 contributed to a transition that was already underway but did not create a new system of relief.     

Are serial Condorcet rules strategy-proof?

Abstract. This paper explores the extent to which majority rule is invulnerable to manipulation by individuals and coalitions, even when majority rule is used to select more than one alternative. The resulting rule may or may not be strategy-proof, depending on the size of the coalitions that can form, and on the nature of the individual preferences over sets of alternatives. No individual can manipulate with respect to a wide family of preferences over sets. The only restriction on the domain of true and revealed individual preferences is that the selection rule is always well defined. Received: 1 November 1999 / Accepted: 7 May 2001 We thank two anonymous referees for suggestions that have significantly improved the paper. We are also grateful to l'Université de Caen for sponsoring a Workshop on Social Choice Theory, where a first draft of this paper was presented in May, 1999, and to the workshop participants for helpful observations. Work on the final version of the paper was done while one of the authors was a guest of the Project on Intergenerational Equity supported by the Ministry of Education, Science, and Technology of Japan. We are grateful to the Ministry and to the project leader, Professor Kotaro Suzumura, for their support.     

Two estimators for the apt model when factors are measured

Non-linear SUR and ITSUR techniques are proposed for the estimation of the APT and the CAPM when the factors are observed. These techniques estimate all of the parameters of the model simultaneously and directly impose the model's non-linear parameter restrictions.     

Predicting corporate financial distress: Reflections on choice-based sample bias

Financial distress precedes bankruptcy. Most financial distress models actually rely on bankruptcy data, which is easier to obtain. We obtained a dataset of financially distressed but not yet bankrupt companies supplying a major auto manufacturer. An early warning model successfully discriminated between these distressed companies and a second group of similar but healthy companies. Previous researchers argue the matched-sample design, on which some earlier models were built, causes bias. To test for bias, the dataset was partitioned into smaller samples that approach equal groupings. We statistically confirm the presence of a bias and describe its impact on estimated classification rates.