MitraClip therapy in mitral regurgitation: a Markov model for the cost-effectiveness of a new therapeutic option

Introduction Mitral regurgitation is a heart condition resulting from blood flowing from the left ventricle towards the left atrium, increasing the risk of heart failure and mortality. While surgery can greatly reduce these risks, some patients are not eligible, resulting in medication being their only therapeutic alternative. The MitraClip (Abbot Vascular) is a medical device that is percutaneously implanted and designed to eliminate leaking of the mitral valve.

Methods The efficacy of the MitraClip strategy vs medical management was assessed using a 4-state Markov model based on the mitral regurgitation grade (mitral regurgitation grade 0, I/II, and III/IV, and death). At each 1-month cycle, patients were or were not hospitalized. The model analyzed a fictional population of 1000 patients over a 5-year period from a national Health Insurance perspective. The primary end-point was the number of deaths avoided. Data from the EVEREST II High Risk Study patients were used along with a literature review.

Results At 5 years, among the 1000 patients, 276 deaths were found to be avoidable with the MitraClip strategy. The incremental cost-effectiveness ratio (ICER) was €93,363 per death avoided. The annual ICER was calculated to take into consideration excess costs resulting from the MitraClip over the first year (€29,984 vs €8557 for the reference strategy) and the reduction of costs in following years (€3122 for MitraClip vs €8557 for reference strategy). Thus, the mean ICER was calculated to be €20,720 per death avoided.

Conclusion The MitraClip is a novel alternative therapy for mitral insufficiency in patients ineligible for surgery that may offer a medico-economic advantage.     

Capital Structure and Debt Priority

We study a defaultable firm's debt priority structure in a simple structural model where the firm issues senior and junior bonds and is subject to both liquidity and solvency risks. Assuming that the absolute priority rule prevails and that liquidation is immediate upon default, we determine the firm's interior optimal priority structure along with its optimal capital structure. We also obtain closed‐form solutions for the market values of the firm's debt and equity. We find that the magnitude of the spread differential between junior and senior bond yields is positively, but not linearly related to the total debt level and the riskiness of assets. Finally, we provide an in‐depth analysis of probabilities of default and the term structure of credit spreads.     

Optimum consumption and portfolio rules with money as an asset

This article generalizes Merton's optimum consumption and portfolio rules in continuous time by introducing money as a capital asset and allowing for uncertain inflation. Assuming that prices are log-normally distributed, a three-funds theorem is derived and the introduction of money is shown not to change the form of the standard inflation-adjusted CAPM but to change the market price of risk. The individual's consumption-portfolio problem is completely solved under uncertain inflation if his utility function is iso-elastic in its arguments. Comparative statics are used to assess the influence of changes in exogenous parameters on the individual's optimal rules.     

From boycott to buycott: is activism from the North good for the South?

Review of World Economics - This article provides an original theoretical exploration of the potential effects of northern activism on labor conditions and welfare in the South using a duopoly...     

Front-line responses to customer orientation programmes: a theoretical and empirical analysis

Programmes designed to strengthen customer orientation among front-line service workers represent one of the most common forms of culture change initiatives within service organizations. Despite their importance to contemporary management theory and practice, we know relatively little about how employees react to interventions of this kind, and why they react as they do. The paper aims to address this gap in the literature. It does this through an analysis of front line reactions to a major customer care initiative in one of the largest supermarket chains in the UK. Using data from a large-scale employee survey carried out in seven stores, we first propose a general typology of employee responses to customer care programmes. We then examine some typical employee profiles associated with the main types of response. The analysis is placed within a wider theoretical context consisting of a critical overview of the main theories which might help explain the nature of general and individual reactions to culture change programmes. To this end, we address and draw upon a variety of literatures and debates linked to various aspects of organization and management, industrial psychology, training and development and critical discourse analysis.