Brentuximab vedotin in relapsed/refractory Hodgkin lymphoma post-autologous stem cell transplant: a cost-effectiveness analysis in Scotland

Objective: To evaluate cost-effectiveness of brentuximab vedotin in patients with relapsed/refractory Hodgkin lymphoma who have received autologous stem cell transplantation, from a Scottish healthcare payer perspective.

Methods: A Microsoft Excel-based partitioned survival model comprising three health states (progression-free survival [PFS], post-progression survival, and death) was developed. Relevant comparators were chemotherapy with or without radiotherapy (C/R) and C/R with intent to allogeneic hematopoietic stem cell transplantation (alloSCT). Data were obtained from the pivotal phase II single-arm trial in 102 patients (SG035-0003; NCT00848926), a systematic literature review and clinical expert opinions (where empirical evidence was unavailable). PFS and overall survival for brentuximab vedotin were estimated using 5-year follow-up data from SG035-0003, and extrapolated using event rates observed for comparator treatments from published survival data. Resource use included drug acquisition and administration; alloSCT; treatment of adverse events; and long-term follow-up. Deterministic and probabilistic sensitivity analyses were conducted to evaluate the impact of uncertainty.

Results: In the base case, the incremental cost-effectiveness ratio (ICER) for brentuximab vedotin was £38,769 per quality-adjusted life year (QALY) vs C/R, whereas C/R with intent to alloSCT was dominated by brentuximab vedotin. ICERs for brentuximab vedotin generated by the deterministic sensitivity analysis ranged between £32,000–£54,000 per QALY. Including productivity benefits reduced the ICER to £28,881 per QALY.

Limitations: Limitations include lack of comparative data from this single arm study and the heterogeneous population. Inconsistent baseline characteristic reporting across studies prevented complete assessment of heterogeneity and the extent of potential bias in clinical and cost-effectiveness estimates.

Conclusions: Although the base case ICER is above the threshold usually applied in Scotland, it is relatively low compared with other orphan drugs, and lower than the ICER generated using a previous data cut of SG035-0003 that informed a positive recommendation from the Scottish Medicines Consortium, under its decision-making framework for assessment of ultra-orphan medicines.     

Regulatory arbitrage and the FERC rate settlement process

We demonstrate that the Federal Energy Regulatory Commission’s (FERC) regulatory procedures for natural gas pipelines, specifically its rate-refund policy, induces regulatory arbitrage that leads to economic distortions. Specifically, we demonstrate that the rate refund policy causes pipelines effectively to “extort” ratepayers through the addition of economically inefficient capital investment, akin to “gold-plating” investments. We estimate the potential magnitude of this arbitrage impact on ratepayers to be between $400 and $700 million annually. Counterintuitively, however, we demonstrate that the presence of this arbitrage opportunity leads to underinvestment in pipeline capacity, thus negating one of the principal purposes of rate regulation. We further demonstrate that FERC could easily eliminate this regulatory arbitrage by setting the refund interest rate to the pipeline’s as-filed weighted average cost of capital.     

When haste makes sense: Cracking down on street markets for illicit drugs

This paper presents an analytical approach to the tactical question: ‘What level of enforcement over time allows one to eliminate a street market for illicit drugs while expanding the least possible total effort?’ The analysis is done in the context of Caulkins' model [6] which predicts the rate of change of dealers as a function of enforcement level and several market parameters. Our analysis suggests that the simple strategy of using the maximum available enforcement intensity until the market has been eliminated minimizes the total enforcement effort required.     

The (hidden) costs of political instability: Evidence from Kenya's 2007 election crisis

This paper studies the microeconomic impacts of the political crisis and civil conflict that immediately followed the December 2007 presidential election in Kenya. Income, expenditures, and consumption dramatically declined for a broad segment of the rural population for the duration of the conflict. To make up for the income shortfall, women who supply transactional sex engaged in higher risk sex both during and after the crisis. While this particular crisis was likely too short for these behavioral responses to seriously increase the risk of HIV or other STIs for these women, such responses could have long-term repercussions for health in countries with longer or more frequent crises. Overall, our results suggest that social unrest can be an important channel through which political instability can affect long-term outcomes such as health.     

An integrated tax-subsidy policy for carbon emission reduction

A carbon tax is often cited by economists as an effective instrument to mitigate greenhouse gas emissions, but there is little political interest in the United States. In light of this political unpopularity, we develop and examine a net-revenue constrained carbon tax and subsidy program. The optimal revenue constrained tax and subsidy schedule based on our utility maximization model taxes energy sources with high emissions to energy price ratio, and subsidizes sources with low emissions to energy price ratios. This approach may be more palatable than a traditional carbon tax because it can change the relative price of low and high emissions energy sources while providing a mechanism to limit net tax increases and energy price increases. We find that a constrained tax/subsidy program provides welfare gains relative to a no-tax scenario. Welfare gains are estimated to be 1% and 36% of the welfare gains from a Pigouvian tax for the motor fuels industry and electric power industry, respectively. In contrast, subsidies for low-emitting energy sources funded from general tax funds rather than from high-emission energy tax revenues lead to welfare decreases substantially below our proposed tax/subsidy policy approach.     

No End to the Racial Wage Hierarchy in South Africa?

The South African apartheid system formally ended with the election of the African National Congress at the first all-race elections held in 1994. As a result, racist policies such as color barring, that particularly hindered the advancement of black workers throughout the apartheid period, are no longer legal. Yet the legacy of apartheid may endure as a result of both the persistence of racial differences in human capital attributes and the possible continuation of discriminatory practices within employment. In this paper the authors examine the evolution of the racial wage hierarchy in the early post-apartheid era against the background of the long-term decline in racial wage disparities observed over the last years of the apartheid regime. They find evidence that the position of black workers between 1995 and 1997 actually deteriorated relative to the overall geometric mean wage, while that of colored, Asian, and white workers improved.     

Do stock market returns predict changes to output? Evidence from a nonlinear panel data model

Recent empirical work suggests a predictive relationship between stock returns and output growth. We employ quarterly data from a panel of 27 countries to test whether stock returns as useful in predicting growth. Unlike previous research, our approach allows for the possible non-linear effect of recessions on the growth-return relationship. There is strong evidence to suggest that a linear model would be misspecified and provide potentially misleading inference. Using a switching regression approach, we find evidence that returns are most useful in predicting growth when the economy is in recession.First version received: November 2002/Final version received: April 2003This paper benefited greatly from discussions with Kalvinder Shields, Mark Harris, Pete Summers, and Vance Martin. Two anonymous referees provided useful comments on an earlier version of the paper for which we are grateful. The usual disclaimer applies to any errors and omissions. Funding from The University of Melbourne greatly assisted in the completion of this paper.