Costs and effectiveness of fingolimod versus alemtuzumab in the treatment of highly active relapsing-remitting multiple sclerosis in the UK: re-treatment,discount, and disutility

Objective: Patients with relapsing-remitting multiple sclerosis (RRMS) treated with disease modifying therapies (DMTs) who continue to experience disease activity may be considered for escalation therapies such as fingolimod, or may be considered for alemtuzumab. Previous economic modeling used Markov models; applying one alternative technique, discrete event simulation (DES) modeling, allows re-treatment and long-term adverse events (AEs) to be included in the analysis.

Methods: A DES was adapted to model relapse-triggered re-treatment with alemtuzumab and the effect of including ongoing quality-adjusted life year (QALY) decrements for AEs that extend beyond previous 1-year Markov cycles. As the price to the NHS of fingolimod in the UK is unknown, due to a confidential patient access scheme (PAS), a variety of possible discounts were tested. The interaction of re-treatment assumptions for alemtuzumab with the possible discounts for fingolimod was tested to determine which DMT resulted in lower lifetime costs. The lifetime QALY results were derived from modeled treatment effect and short- and long-term AEs.

Results: Most permutations of fingolimod PAS discount and alemtuzumab re-treatment rate resulted in fingolimod being less costly than alemtuzumab. As the percentage of patients who are re-treated with alemtuzumab due to experiencing a relapse approaches 100% of those who relapse whilst on treatment, the discount required for fingolimod to be less costly drops below 5%. Consideration of treatment effect alone found alemtuzumab generated 0.2 more QALYs/patient; the inclusion of AEs up to a duration of 1 year reduced this advantage to only 0.14 QALYs/patient. Modeling AEs with a lifetime QALY decrement found that both DMTs generated very similar QALYs with the difference only 0.04 QALYs/patient.

Conclusions: When the model captured alemtuzumab re-treatment and long-term AE decrements, it was found that fingolimod is cost-effective compared to alemtuzumab, assuming application of only a modest level of confidential PAS discount.     

Bioenergy Crop Production in the United States: Potential Quantities, Land Use Changes, and Economic Impacts on the Agricultural Sector

The U.S. Departments of Agriculture and Energyjointly analyzed the economic potential for,and impacts of, large-scale bioenergy cropproduction in the United States. Anagricultural sector model (POLYSYS) wasmodified to include three potential bioenergycrops (switchgrass, hybrid poplar, and willow). At farmgate prices of US $2.44/GJ, anestimated 17 million hectares of bioenergycrops, annually yielding 171 million dry Mg ofbiomass, could potentially be produced at aprofit greater than existing agricultural usesfor the land. The estimate assumes highproductivity management practices are permittedon Conservation Reserve Program lands. Traditional crops prices are estimated toincrease 9 to 14 percent above baseline pricesand farm income increases annually by US $6.0billion above baseline.At farmgate prices of US $1.83/GJ, anestimated 7.9 million hectares of bioenergycrops, annually yielding 55 million dry Mg ofbiomass, could potentially be produced at aprofit greater than existing agricultural usesfor the land. The estimate assumes managementpractices intended to achieve highenvironmental benefits on Conservation ReserveProgram lands. Traditional crops prices areestimated to increase 4 to 9 percent abovebaseline prices and farm income increasesannually by US $2.8 billion above baseline.     

CUTTING CARBON EMISSIONS AT A PROFIT (PART II): IMPACTS ON U.S. COMPETITIVENESS AND JOBS

This article examines how an integrated least-cost implementation of the Kyoto Protocol in the United States would affect U.S. competitiveness and jobs. Drawing on previous work, the authors analyze integrated emission reduction strategies based on a $50/ton carbon tax (including border tax adjustments), a payroll tax cut, energy-productivity–oriented market reforms, and international flexibility mechanisms. This policy portfolios is compared to conventional approaches that omit market and fiscal reforms.
Input-output data are used to estimate the impact on export prices of goods and services produced in the United States. Similar data are used to translate changes in GDP and energy production into employment impacts in energy and nonenergy sectors. The costs of providing transitional assistance for workers in the coal industry are compared to the GDP benefits of a profitable Kyoto strategy.
The analysis shows that relative to purchasing international emission rights, productivity-raising domestic market, institutional, and fiscal reforms offer much broader advantages for tradE-exposed U.S. industries. Though allowance purchases alone increase export prices of U.S. manufactured goods and services, an integrated no-regrets strategy reduces export prices for the large majority of U.S. industries and limits the impact of climate protection policies on the few most energy-intensive basic materials industries to very small levels. Relative to the baseline, an integrated least-cost implementation of the Kyoto target increases economy-wide employment levels by several hundred thousand jobs in 2010.     

Your employment brand: is it working for or against you?

The ability to attract and retain hard-to-find professionals is vitally connected to the perceptions of your organization both internally and externally. Many organizations confuse their employment brand with branding and all too often put considerable effort and often scarce resources against ineffective initiatives. Most health care organizations do not consistently allocate the necessary resources needed to build and sustain a strong employer brand. The relationship between employers and employees to and among each other and the values you strive for collectively are the cornerstones of your employment brand. It is imperative for nurse leaders to create and sustain an environment where employees are inherently positive and connected to their organization.     

Shrinking the state or the Big Society? Public service employment relations in an era of austerity

The Big Society is an integral part of the coalition's plans for public service retrenchment, but it is premature to dismiss it as exclusively concerned with expenditure cuts and privatisation. The Big Society signals the government's ambition to transform public services and it is the rubric that is being used to shrink the state and undermine long‐standing systems of public service employment relations. This article considers the origins and meaning of the Big Society and then assesses its consequences for public service provision and the workforce. The Big Society is integrally connected to deficit reduction with the voluntary sector and an increased emphasis on volunteering promoted as a more user‐centred and cost‐effective way of delivering public services in tough times. For the workforce, more competition between diverse providers in conjunction with budget cuts is placing downward pressure on terms and conditions and encouraging employers to question the continuation of national pay determination in many parts of the public sector.     

A true simulation study of three estimators at equal protection of respondents in randomized response sampling

In this study, three different estimators for estimating the proportion of a sensitive attribute in survey sampling are compared at equal protection of the respondents. The three estimators considered are due to Odumade and Singh (2009, Comm. Statist. Theory Methods) , Singh and Sedory (2011, Sociological Methods and Research) and a new estimator obtained by minimizing a chi‐squared distance. A SAS Macro is developed to compare these three estimators using a simulation study at equal protection of the respondents. A set of data from a real face‐to‐face interview was collected using two decks of cards and has been analyzed. The results are discussed.     

Prototypicality advantages for pioneers over me-too brands: the role of evolving product designs

Prior empirical research suggests that consumers perceive pioneers as more prototypical (i.e., representative) of their product categories than me-too followers. This prototypicality advantage is believed to contribute to an enduring marketplace advantage for the pioneer. We extend research into pioneering prototypicality advantages by considering the ramifications of simultaneous product design (i.e., product attribute) evolutions. We hypothesize that the simultaneous evolution of product designs of both the pioneer and me-too will diminish the pioneer’s prototypicality advantage over the me-too, even though the me-too does not initiate the change. To test our hypotheses, we create an experimental environment consisting of four cells, each corresponding to a different marketplace scenario: a no-change condition; a simultaneous-evolution condition; a pioneer-updates-first condition; and a leapfrogging (i.e., me-too updates first) condition. The results suggest that simultaneous design evolutions can diminish the pioneer’s prototypicality advantage. As a result, me-too entry may be a more attractive strategy in the long-run than currently believed in product categories characterized by substantial design evolution.

Public–private partnerships: Task interdependence and contractibility

We examine the proper scope of public–private partnerships in the context of a project consisting of two tasks, building and operation of a facility. We investigate the optimal arrangement regarding bundling versus unbundling and private ownership versus public ownership. Like Bennett and Iossa (2006), we assume that the innovative activity in the building stage has impacts on, among other things, the subsequent operational cost. We relax the nature of task interdependence and study different contractual frameworks. The general insight is that given limitations in contractibility, contrary to common sense, complementarity between tasks favors unbundling over bundling.