Cost-effectiveness analysis of oxycodone with naloxone versus oxycodone alone for the management of moderate-to-severe pain in patients with opioid-induced constipation in Canada

Background:

Approximately 20–30% of Canadians suffer from chronic pain. Guidelines for the management of chronic pain support the use of controlled-release (CR) opioids to treat chronic pain. Although effective in managing chronic pain, oxycodone is associated with high rates of opioid-induced constipation (OIC). The cost-effectiveness of a combination of oxycodone for the management of pain and naloxone for the relief of OIC has not previously been evaluated for Canada.

Methods:

A decision analytic model was developed to estimate the cost-utility of combination oxycodone/naloxone compared to oxycodone alone in four populations. Drug costs for managing pain and healthcare costs related to managing OIC were included in the analysis and the primary measure of effectiveness was quality adjusted life years (QALYs) derived from OIC rates observed in clinical trials. The analysis was conducted from a healthcare system perspective, used a 1-year time horizon, and results were expressed in 2015 Canadian dollars.

Results:

In all four patient populations, there was a trade-off between slightly higher total expected costs for Targin treated patients compared to oxycodone treated patients, but also improved clinical benefits in terms of reduced OIC, which resulted in higher QALYs for patients. Although analgesic costs were found to be slightly higher for Targin treated patients, Targin also resulted in cost offsets to the healthcare system in terms of less rescue laxative drug use and other resources required for the management of OIC. The resulting 1-year cost-utility of Targin compared to oxycodone ranged from $2178–$7732 per QALY gained in the base case analysis, and it was found that these cost-utility results remained robust and at low values throughout a series of one-way deterministic analyses of uncertainty.

Conclusion:

The clinical effectiveness of oxycodone/naloxone in managing pain and OIC compared to CR oxycodone alone resulted in low cost-utility estimates.     

Is property assessment really essential for taxation? Evaluating the performance of an ‘Alternative Assessment’ method

Many countries evade the formal valuation of real property for taxation purposes by using qualitative and spatial criteria in order to pursue an equitable distribution of burden. This paper evaluates the performance of a prototypical setup as such, by analyzing the relationship between property value, household income and the actual tax paid, in the exact framework of which the qualitative criteria are set to determine tax assessment. Drawing on detailed data from the Israeli Household Expenditure Surveys 1997–2005, the strong correlation between the three variables is evident. Yet, the limited differences in rates, compared with large variation in property value, make it regressive. Policy implications are relevant for many other countries using non-ad valorem taxation.     

Managerial Work in a Practice-Embodying Institution: The Role of Calling, The Virtue of Constancy

What can be learned from a small scale study of managerial work in a highly marginal and under-researched working community? This article uses the ‘goods–virtues–practices–institutions’ framework to examine the managerial work of owner–directors of traditional circuses. Inspired by MacIntyre’s arguments for the necessity of a narrative understanding of the virtues, interviews explored how British and Irish circus directors accounted for their working lives. A purposive sample was used to select subjects who had owned and managed traditional touring circuses for at least 15 years, a period in which the economic and reputational fortunes of traditional circuses have suffered badly. This sample enabled the research to examine the self-understanding of people who had, at least on the face of it, exhibited the virtue of constancy. The research contributes to our understanding of the role of the virtues in organizations by presenting evidence of an intimate relationship between the virtue of constancy and a ‘calling’ work orientation. This enhances our understanding of the virtues that are required if management is exercised as a domain-related practice.     

Preservation or Conversion? Valuation and Evaluation of a Mangrove forest in the Philippines

Mangrove ecosystems are rapidly declining in many parts of the world. This has resulted in the loss of important environmental and economic products and services including forest products, flood mitigation and nursery grounds for fish. The aquaculture industry was the single biggest threat to mangroves in the Philippines until 1981 when conversion of the remaining mangrove stands was prohibited by law. However, the decreasing yield from capture fisheries is putting pressure for the re-examination of this policy. To understand the importance of mangroves, insight is needed into the value of products and services provided is needed. This article compares the costs and benefits of mangrove preservation with those generated by alternative uses such as aquaculture and forestry. Equity and sustainability objectives are taken into account, in addition to economic efficiency and analyzed according to the perspectives of the different types of decision makers involved.     

Perception of What the Ethical Climate is and What it Should be: The Role of Gender, Academic Status, and Ethical Education

This study examined ethical attitudes and perceptions of 691 undergraduate seniors and freshmen in a college of business. Gender was found to be correlated to perceptions of "what the ethical climate should be" with female subjects showing significantly more favorable attitude towards ethical behaviors than males. Further, Seniors had a more cynical view of the current ethical climate than freshmen. Freshmen were significantly more likely than seniors to believe that good business ethics is positively related to successful business outcomes. Ethical education was significantly correlated to both perceptions of "current ethical climate" as well as "what the ethical climate should be". Students who had been exposed to ethical issues in a course were more likely to believe both, that ethical behavior is, and should be, positively associated with successful business outcomes.     

(Noisy) communication

Communication is central to many settings in marketing and economics. A focal attribute of communication is miscommunication. We model this key characteristic as a noise in the messages communicated, so that the sender of a message is uncertain about its perception by the receiver, and then identify the strategic consequences of miscommunication. We study a model where competing senders (of different types) can invest in improving the precision of the informative but noisy message they send to a receiver, and find that there exists a separating equilibrium where senders’ types are completely revealed. Thus, although communication is noisy it delivers perfect results in equilibrium. This result stems from the fact that a sender’s willingness to invest in improving the precision of their messages can itself serve as a signal. Interestingly, the content of the messages is ignored by the receiver in such a signaling equilibrium, but plays a central role by shaping her beliefs off the equilibrium path (and thus, enables separation between the types). This result also illustrates the uniqueness of the signaling model presented here. Unlike other signaling models, the suggested model does not require that the costs and benefits of the senders will be correlated with their types to achieve separation. The model’s results have implications for various marketing communication tools such as advertising and sales forces.

Unintended Consequence of Centralized Public School Funding in Michigan Education

As part of the movement to create greater spending equity among school districts, states have centralized funding for public education and instituted funding formulas where high-spending districts are often constrained in their operational expenditures. However, these school districts often maintain local discretion over capital expenditures financed by the sale of bonds. In this study, we find that Michigan's high-spending school districts have a greater probability of issuing bonds after centralizing public school funding, indicating that debt financing of capital expenditures may have become a mechanism to allow these school districts to circumvent the policy's intent for greater spending equity.     

Price Effects of Dutch Hospital Mergers: An Ex-post Assessment of Hip Surgery

This study analyses price effects of six mergers in the Dutch healthcare industry. We investigate whether the merging hospitals raised their prices for hip surgery after the merger and, if so, how patients react to this higher price. For seven of the twelve hospitals involved, we found a statistically significant price increase for hip surgery, for three hospitals we found a significant price decrease. There is no clear relationship between price changes of hip surgery and changes in travelling behaviour of patients post merger.     

Measuring the Economic Effects of Competition Law Enforcement

Summary  Together with a move from a rules-based legal approach to a more economic approach in competition cases, the economic effects of competition law enforcement have received increasing attention. Measuring these effects is important for external accountability of the Competition Authority, for quality control of its decisions and for evaluating the effectiveness of the competition law. This raises many issues in measurement, including the choice of counterfactual, the choice of effects to be measured, and the proper use of available data. The papers in this Special Issue of De Economist discuss these and related issues, based on a broad range of experience in competition law enforcement.      

Shareholder Wealth Effects of the Private Securities Litigation Reform Act of 1995

This paper investigates the reaction ofstock prices to enactment of the Private Securities LitigationReform Act of 1995 (PSLRA). Based on a sample of 489 high-technologyfirms, we find that the PSLRA was wealth-increasing, on average,and that the market reaction is more positive for firms at greatestrisk of being sued in a securities class action. However, wealso show that the PSLRA was less beneficial for firms likelyto be the subject of a meritorious lawsuit. Collectively, ourevidence implies that shareholders generally benefit from restrictionson private securities litigation, although these benefits aremitigated when other mechanisms for curbing fraudulent activityare inadequate.