Length of stay and economic consequences with rivaroxaban vs enoxaparin/vitamin K antagonist in patients with DVT and PE: findings from the North American EINSTEIN clinical trial program

Objective:

Venous thromboembolism (VTE) (deep vein thrombosis [DVT] and pulmonary embolism [(PE]) represents a substantial economic burden to the healthcare system. Using data from the randomized EINSTEIN DVT and PE trials, this North American sub-group analysis investigated the potential of rivaroxaban to reduce the length of initial hospitalization in patients with acute symptomatic DVT or PE.

Methods:

A post-hoc analysis of hospitalization and length-of-stay (LOS) data was conducted in the North American sub-set of patients from the randomized, open-label EINSTEIN trial program. Patients received either rivaroxaban (15?mg twice daily for 3 weeks followed by 20?mg once daily; n?=?405) or dose-adjusted subcutaneous enoxaparin overlapping with (guideline-recommended ‘bridging’ therapy) and followed by a vitamin K antagonist (VKA) (international normalized ratio?=?2.0–3.0; n?=?401). The open-label study design allowed for the comparison of LOS between treatment arms under conditions reflecting normal clinical practice. LOS was evaluated using investigator records of dates of admission and discharge. Analyses were carried out in the intention-to-treat population using parametric tests. Costs were applied to the LOS based on weighted mean cost per day for DVT and PE diagnoses obtained from the Healthcare Cost and Utilization Project dataset.

Results:

Of 382 patients hospitalized, 321 (84%), had acute symptomatic PE; few DVT patients required hospitalization. Similar rates of VTE patients were hospitalized in the rivaroxaban and enoxaparin/VKA treatment groups, 189/405 (47%) and 193/401 (48%), respectively. In hospitalized VTE patients, rivaroxaban treatment produced a 1.6-day mean reduction in LOS (median?=?1 day) compared with enoxaparin/VKA (mean?=?4.5 vs 6.1; median?=?3 vs 4), translating to total costs that were $3419 lower in rivaroxaban-treated patients.

Conclusion:

In hospitalized North American patients with VTE, treatment with rivaroxaban produced a statistically significant reduction in LOS. When treating DVT and PE patients, clinicians should consider newer anti-coagulants with less complex treatment regimens.     

Externalities in the agricultural export sector and economic growth: a developing country perspective

For years economists have ignored the diversity in agriculture and its potential to increase long run growth rates by enhancing a country's knowledge base. Non-traditional agriculture requires significant investments in the infrastructure and knowledge; and therefore, has the potential to increase long run growth rates. Policy makers in developing countries have tended to enact macroeconomic policies designed to enhance the manufacturing sector at the expense of the agricultural sector. A theoretical model is developed to explain the dynamics between two non-traditional export sectors and the long run economic growth of the country. The model illustrates that growth in highly perishable agricultural exports, not domestic production of manufactured goods, can potentially lead to higher long run growth rates. The model is applied to the fruit and flower industries in Colombia to bring forth an example with real world relevance.     

Economic implications of proposed accounting for stock-based compensation

This article examines the market expectations of the proposed accounting changes for stock-based compensation in the exposure draft that preceded the Statement of Financial Accounting Standards No. 123. The exposure draft made recommendations that significantly differed from current practice. Affected firms expressed concern that the proposed changes would drastically reduce their reported earnings. This could lead to firms becoming less attractive to capital sources (resulting in higher costs of capital) and firms refraining from using stock options to attract talented managers and entrepreneurs. The market test shows that affected firms experienced negative security market prices contemporaneous with issuance of the exposure draft. Cross-sectional analyses indicate that the magnitude of price decline is associated with measures of high risk and less mature firms.     

Organisational Justice: A Senian Perspective

In this paper, we draw inferences from the Nobel laureate Amartya Sen’s book, The Idea of Justice to inform the organisational justice literature. The extant societal-level theories of justice tend to emphasise aspects that are analogous to either the procedural or distributive dimensions of organisational justice. The Senian idea of comprehensive justice is different in that it synthesises the procedural- and distributive-related dimensions at the societal-level. We theorise that the Senian notion could be applied at the organisational-level to facilitate outcomes that are actually valued by the workforce. Further, we contend that the emphasis on non-parochialism in the Senian notion of justice makes it particularly relevant to the ethics of multi-national corporations (MNCs) operating in alien cultures. To support our contention, we analyse the lean manufacturing practices of a Japanese MNC operating in India. Our case analysis demonstrates how Senian thinking helps one surface unjust outcomes that would otherwise go unacknowledged. Our analysis also offers tentative support to Senian claims about the capacity of human behaviour to undermine well-designed institutions. Concurring with the Senian view, which favours combating manifest injustice rather than fixating over designing perfectly just institutions, we derive some normative implications to advance the cause of striving for outcomes that are actually valued by the workforce.     

Evaluation of medical costs associated with use of new oral anticoagulants compared with standard therapy among venous thromboembolism patients

Objective:

This study evaluated differences in medical costs associated with clinical end-points from randomized clinical trials that compared the new oral anticoagulants (NOACs), dabigatran, rivaroxaban, apixaban, and edoxaban, to standard therapy for treatment of patients with venous thromboembolism (VTE).

Research design and methods:

Event rates of efficacy and safety end-points from the clinical trials (RE-COVER, RE-COVER II, EINSTEIN-Pooled, AMPLIFY, Hokusai-VTE trial) were obtained from published literature. Incremental annual medical costs among patients with clinical events from a US payer perspective were obtained from the literature or healthcare claims databases and inflation adjusted to 2013 costs. Differences in total medical costs associated with clinical end-points for the NOACs vs standard therapy were then estimated. One-way and Monte Carlo sensitivity analyses were carried out.

Results:

A lower rate of major bleedings was associated with use of any of the NOACs vs standard therapy. Except for dabigatran, use of NOACs was also associated with a lower rate of recurrent VTE/death. As a result of the reduction in clinical event rates, the overall medical cost differences were ?$146, ?$482, ?$918, and ?$344 for VTE patients treated with dabigatran, rivaroxaban, apixaban, and edoxaban, respectively, vs patients treated with standard therapy.

Conclusions:

When any of the four NOACs are used instead of standard therapy for acute VTE, treatment medical costs are reduced. Apixaban is associated with the greatest reduction in medical costs, which is driven by medical cost reductions associated with both efficacy and safety end-points. Further evaluation may be needed to validate these results in the real-world setting.     

Inter-firm learning and knowledge-sharing in multinational networks: An outsourced organization's perspective

This research provides insights into how learning and knowledge are exchanged multinationally between customer firms and their outsourced suppliers who provide non-core, yet essential, services. The paper seeks to understand: (1) how information is exchanged in these networks; (2) how cumulative knowledge adds value in these networks; and (3) how boundary-spanners assist in the dissemination of knowledge and learning within the network. Based on a pharmaceutical industry case, the results suggest that: (a) multinational firms operate more effectively and interact by sharing knowledge with outsourced firms which reflect the customers' structure and fit; (b) networked firms benefit from interactions through economies of scope, but knowledge is not necessarily shared equally among partners; (c) learning and knowledge-sharing interactions are tightly coupled at the product development stage; and (d) outsourced firms interact with external boundary-spanners as needed. The research provides insights for managers of multinational organizations and managers of firms from where essential services are outsourced.     

Stock markets, banks, and economic growth: Empirical evidence from the MENA region

Over the last four decades, a wide theoretical debate is concerned with the fundamental relationship between financial development and economic growth. Recent studies shed some light on the simultaneous effect of banks and financial system development on growth rather than a separate impact. The empirical study is conducted using an unbalanced panel data from 11 MENA region countries. Econometric issues will be based on estimation of a dynamic panel model with GMM estimators. Thus, peculiarities of MENA region countries will be detected. The empirical results reinforce the idea of no significant relationship between banking and stock market development, and growth. The association between bank development and economic growth is even negative after controlling for stock market development. This lack of relationship must be linked to underdeveloped financial systems in the MENA region that hamper economic growth. Then, more needs to be done to reinforce the institutional environment and improve the functioning of the banking sector in the MENA region. Based on these results, other regions at the same stage of financial development such as Africa, Eastern Europe or Latin America should improve the functioning of their financial system in order to prevent their economies from the negative impact of a shaky financial market.