American politics, especially at the national level, has become dysfunctional; citizens are deeply frustrated with their political leaders and feel that political institutions are unresponsive and corrupted by entrenched power and money. Government leaders must bear the brunt of this anger and distrust, and subsequently feel a sense of disconnection between themselves and those whom they serve. Ironically, at the same time as the ability of local government to solve problems is severely hindered due to this ‘disconnect,' devolution at the federal and state level is forcing local government to take more and more responsibility for resolving local challenges. This essay argues that the solution to this impasse lies in re-inventing the way communities operate—we need to make a shift from government to governance. The dominant model of local politics, which fit the political landscape of the 1940s–1970s, vested decision making authority solely with governmental leadership; citizens voted and governors governed. This essay describes a new mode of operation, one where non-governmental actors are ‘granted a seat at the table.' In this model the goal of political struggles is no longer to defeat your enemy, but to reach collaborative, consensus-based decisions; government, business, community groups and citizens work together; and leaders share power, working to enable others to decide issues. 相似文献
AbstractObjective: The standard of care for cancer-related venous thromboembolism (VTE) has been low molecular weight heparin (LMWH), but oral anticoagulants are also widely prescribed. This study compared VTE-related healthcare resource utilization and costs of cancer patients treated with anticoagulants.Methods: Claims data from Humana Database (January 1, 2013–May 31, 2015) were analyzed. Based on the first anticoagulant received, patients were classified into LMWH, warfarin, or rivaroxaban cohorts. Characteristics were evaluated during the 6 months pre-index date (i.e. the first VTE); VTE-related resource utilization and costs were evaluated during follow-up. Cohorts were compared using rate ratios, and p-values and 95% confidence intervals were calculated. Healthcare costs were evaluated per-patient-per-year (PPPY) and compared using mean cost differences.Results: A total of 2,428 patients (LMWH: n?=?660; warfarin: n?=?1,061; rivaroxaban: n?=?707) were included. Compared to patients treated with LMWH, patients treated with rivaroxaban had significantly fewer VTE-related hospitalizations, hospitalization days, and emergency room and outpatient visits, resulting in an increase of $12,000 VTE-related healthcare costs PPPY with LMWH vs rivaroxaban. Patients treated with rivaroxaban had significantly lower VTE-related resource utilization compared to patients treated with warfarin; however, VTE-related costs were similar between cohorts. The higher drug costs ($1,519) were offset by significantly lower outpatient (?$1,039) and hospitalization costs (?$522) in rivaroxaban relative to the warfarin cohort.Conclusions: Healthcare resource use and costs associated with VTE treatment in cancer patients are highest with LMWH relative to warfarin and rivaroxaban. 相似文献
Aims: Broad molecular profiling of patients with advanced non-small cell lung cancer (NSCLC) is strongly advised to optimize genomic matching with available targeted treatment options or investigational agents. Unlike conventional molecular diagnostic testing, or smaller hotspot panels, comprehensive genomic profiling (CGP) identifies genomic alterations across hundreds of clinically relevant cancer genes from a single tissue specimen. The present study sought to estimate the budget impact of increased use of CGP using a 324-gene panel (FoundationOne) vs non-CGP (represented by a mix of conventional molecular diagnostic testing and smaller NGS hotspot panels) and the number needed to test with CGP to gain 1 life year.
Materials and methods: A decision analytic model was developed to assess the budget impact of increased CGP in advanced NSCLC from a US private payer perspective. Model inputs were based on published literature (epidemiology and treatment outcomes), real-world data (testing and rates, medical service costs), list prices for CGP and anti-cancer drugs, and assumptions for clinical trial participation.
Results: Among 2 million covered lives, 532 had advanced NSCLC; 266 underwent molecular diagnostic testing. An increase in CGP among those tested, from 2% to 10%, was associated with $0.02 per member per month budget impact, of which $0.013 was attributable to costs of prolonged drug treatment and survival and $0.005 to testing cost. Approximately 12 patients would need to be tested with CGP to add 1 life year.
Limitations: The model incorporated certain assumptions to account for inputs with a limited evidence profile and simplify the possible post-CGP treatments.
Conclusions: An increase in CGP utilization from 2% to 10% among patients with advanced NSCLC undergoing molecular diagnostic testing was associated with a modest budget impact, most of which was attributable to increased use of more effective treatments and prolonged survival. 相似文献