Cost-effectiveness of percutaneous patent foramen ovale closure as secondary stroke prevention

Objective: Compared to medical therapy alone, percutaneous closure of patent foramen ovale (PFO) further reduces risk of recurrent ischemic strokes in carefully selected young to middle-aged patients with a recent cryptogenic ischemic stroke. The objective of this study was to evaluate the cost-effectiveness of this therapy in the context of the United Kingdom (UK) healthcare system.

Methods: A Markov cohort model consisting of four health states (Stable after index stroke, Post-Minor Recurrent Stroke, Post-Moderate Recurrent Stroke, and Death) was developed to simulate the economic outcomes of device-based PFO closure compared to medical therapy. Recurrent stroke event rates were extracted from a randomized clinical trial (RESPECT) with a median of 5.9-year follow-up. Health utilities and costs were obtained from published sources. One-way and probabilistic sensitivity analyses (PSA) were performed to assess robustness. The model was discounted at 3.5% and reported in 2016 Pounds Sterling.

Results: Compared with medical therapy alone and using a willingness-to-pay (WTP) threshold of £20,000, PFO closure reached cost-effectiveness at 4.2 years. Cost-effectiveness ratios (ICERs) at 4, 10, and 20 years were ?20,951, ?6,887, and ?2,158, respectively. PFO closure was cost-effective for 89% of PSA iterations at year 10. Sensitivity analyses showed that the model was robust.

Conclusions: Considering the UK healthcare system perspective, percutaneous PFO closure in cryptogenic ischemic stroke patients is a cost-effective stroke prevention strategy compared to medical therapy alone. Its cost-effectiveness was driven by substantial reduction in recurrent strokes and patients’ improved health-related quality-of-life.     

Reviews

Regenerating town centres. Evans, R. 1997: REGENERATING TOWN CENTRES. Manchester: Manchester University Press, £30.00 cased.

Privatised utilities. Marvin, S., Graham, S. and Guy, S. 1996: PRIVATISED UTILITIES AND REGIONAL MANAGEMENT. Harlow: SEEDS (South East Economic Development Strategy), £25.00 plus £3.50 postage and packing.

Women returners. Chisholm, L. (ed) 1997: GETTING IN, CLIMBING UP AND BREAKING THROUGH. London: The Policy Press, £15.25 paper.

Regionalism. John, P. and Whitehead, A. (eds) 1997: POLICY AND POLITICS VOL 25 NO. 1 SPECIAL ISSUE. REGIONALISM IN ENGLAND: CURRENT TRENDS AND FUTURE PROSPECTS. Policy Press.

Socially regulated labour markets. Peck, J. 1996: WORK-PLACE. THE SOCIAL REGULATION OF LABOUR MARKETS. New York and London: The Guilford Press, £16.99 paper £35.00 cased.

Private delivery — public goods. Arnold-Forster, J., Lee, M. and McLeod, J. 1997: HAND IN GLOVE: PRIVATE SECTOR DELIVERING PUBLIC GOODS. London: Fabian Society, supported by Generale des Eaux, £15.00 paper.

Bio-tech. Milhell, D., Kingham, D. and Stott, M. 1997: THE DEVELOPMENT OF THE BIOTECHNOLOGY SECTOR IN OXFORDSHIRE: IMPLICATIONS FOR PUBLIC POLICY. Oxford: Oxford Innovation Limited, £5.00 paper.     

Screening the impacts of municipal service policy changes

The planning of municipal service delivery systems requires accurate forecasts of demand, and particularly of the effects the quality of service delivery has on demand. A metholology for this problem should meet three criteria, if it is to be useful for municipal planning: it must be low-cost and use generally available data; it must be based on user behavior, so that the effects of policy changes can be correctly attributed; and it must allow testing of the transferability of the results, since this is required for general forecasting use. This paper develops such a methodology, based on econometric analysis of data from a number of service areas within a number of regions, forming a double cross-section. Empirical tests of the methodology were performed for two local government services where the effect of service quality on demand is important: sewer and highway construction, which have been hypothesized to affect the patterns of development within regions; and solid waste collection, where the level of service provided affects how much waste enters the collection system and how much is littered, burned or recycled. The two case studies and other analyses suggest that the methodology is a useful tool for testing whether policy changes have an effect on the demand for service, but not for accurate demand forecasting. Thus, these simple models are relevant for the role of screening the effect of policy changes, but more detailed and localized approaches are necessary for system design.     

International Trade in Nutmeg and Mace: Issues and Options for Indonesia

Indonesia produces more than three-quarters of the world's output of nutmeg and mace. In 1986 the government introduced export regulations that facilitated cartehsation of the market. This led to a dramatic rise in world prices. Problems such as accumulation of unsold stocks in Indonesia and smuggling of nutmeg and mace through Singapore led the government to abolish the regulations in 1990. World prices fell steeply, and since then have remained low. Indonesian nutmeg and mace exporters have called for the reregulation of the market. This paper assesses the case for reregulation, considering the costs and benefits to affected parties within Indonesia and the long-term sustainability of regulation.     

The Possibility of Inefficient Liberalization Through Tariffication*

A typical step in trade liberalization under the GATT is tariffication—the conversion of quantitative import restrictions to their ad valorem tariff equivalents. This paper shows that, if there is market power in the protected industry, tariffication may cause a global efficiency loss. In particular, in a small country, if the protected industry is a monopoly that is freely able to export but cannot profitably do so, then tariffication unambiguously imposes global efficiency costs. In a large country, the global efficiency effects are uncertain a priori. In both cases, however, tariffication unambiguously benefits the monopoly and lowers foreign welfare.     

Marketing Biotech Soybeans with Functional Health Attributes

This study investigates possible marketing strategies for biotechnology (biotech) functional foods in the U.S. market. Means‐end chain theory is used to translate consumer product knowledge into self‐knowledge, where knowledge is presumed to be organized in a hierarchy with concrete thoughts linked to more abstract thoughts in a sequence progressing from means to ends. A sample of 60 households was randomly drawn from the population of a Midwest town. The random sample was drawn from a population of females aged 20 to 50 with children and who regularly purchase yogurt products. Eight products with various attributes and production technologies were ranked by the participants prior to a hard laddering interview. The study found that biotech functional foods were generally acceptable to the participants. Functional attributes, such as higher protein, increased calcium, and lower cholesterol, were valued by the consumers. Soy was considered inferior on the basis of taste for some segments of consumers unfamiliar with soymilk. On the other hand, consumers already purchasing soymilk were more willing to purchase functional soy attributes and have more complex purchasing decisions (cognitive maps). These consumers associate soy with attaining values of “better health,”“taking care of family,”“happiness,” and “more choice.” La présente étude a examiné les stratégies de marketing possibles pour les aliments fonctionnels issus de la biotechnologie sur le marchéétatsunien. La méthode de la chaîne moyens‐fins a été utilisée pour traduire la connaissance du consommateur sur le produit en connaissance de soi, où la connaissance est présumée être structurée en hiérarchie d'idées concrètes liées à des idées plus abstraites dans un ordre progressant des moyens vers les fins. Nous avons formé un échantillon aléatoire de soixante ménages d'une ville du Midwest. L'échantillon aléatoire a été sélectionné parmi une population de femmes âgées de 20 à 50 ans qui avaient des enfants et qui achetaient régulièrement du yogourt. Huit produits renfermant des attributs variés et issus de technologies de production variées ont d'abord été classés par les participants avant de procéder aux entrevues effectuées selon la technique du laddering. Les résultats ont montré que les aliments fonctionnels issus de la biotechnologie convenaient généralement aux participants. Les attributs des aliments fonctionnels tels que plus élevé en protéines, les plus élevé en calcium et faible en cholestérol étaient valorisés par les consommateurs. Le soja est arrivé en dernier pour le goût chez certains consommateurs qui connaissaient mal le lait de soja. Par contre, consommateurs qui achetaient déjà du lait de soja étaient plus enclins à acheter les attributs fonctionnels du soja et avaient des décisions d'achats plus complexes (cartes cognitives). Ces consommateurs associaient le soja à des valeurs telles que ? meilleure santé?, ? s'occuper de la famille ?, ? bonheur ? et ? choix élargi ?.     

The Labor Market in the Aftermath of the Great Recession

The Great Recession took a large toll on the U.S. labor market, reducing jobs and raising unemployment across most sectors and among workers of all skill levels. Although conditions have improved over the last five years, by most metrics the labor market recovery remains incomplete. The slow progress of recovery has raised concerns that some of the damage done by the recession will be permanent, and that a return to prerecession conditions is unlikely. This paper argues that although the recession coincided with, and even accelerated ongoing structural changes in the economy, most of the disruptions were cyclical and will likely be repaired over time. Should things evolve otherwise, the impact on the potential output and future growth of the economy could be profound.