Healthcare resource use and costs of privately insured patients who switch,discontinue, or persist on anti-muscarinic therapy for overactive bladder

Objectives:

To compare the healthcare costs of patients with overactive bladder (OAB) who switch vs persist on anti-muscarinic agents (AMs), describe resource use and costs among OAB patients who discontinue AMs, and assess factors associated with persisting vs switching or discontinuing.

Methods:

OAB patients initiating an AM between January 1, 2007 and March 31, 2012 were identified from a claims database of US privately insured beneficiaries (n?≈?16 million) and required to have no AM claims in the 12 months before AM initiation (baseline period). Patients were classified as persisters, switchers, or discontinuers, and assigned a study index date based on their AM use in the 6 months following initiation. Baseline characteristics, resource use, and costs were compared between persisters and the other groups. Resource use and costs in the 1 month before and 6 months after the study index date (for switchers, the date of index AM switching; for persisters, a randomly assigned date to reflect the distribution of the time from AM initiation to switching among switchers) were also compared between persisters and switchers in unadjusted and adjusted analyses. Factors associated with persisting vs switching or discontinuing were assessed.

Results:

After controlling for baseline characteristics and costs, persisters vs switchers had significantly lower all-cause and OAB-related costs in both the month before (all-cause $1222 vs $1759, OAB-related $142 vs $170) and 6 months after the study index date (all-cause $7017 vs $8806, OAB-related $642 vs $797). Factors associated with switching or discontinuing vs persisting included index AM, younger age, and history of UTI.

Conclusion:

A large proportion of OAB patients discontinue or switch AMs shortly after initiation, and switching is associated with higher costs.     

Decomposing the effects of financial liberalization: Crises vs. growth

We present a new empirical decomposition of the effects of financial liberalization on economic growth and on the incidence of crises. Our empirical estimates show that the direct effect of financial liberalization on growth by far outweighs the indirect effect via a higher propensity to crisis. We also discuss several models of financial liberalization and growth whose predictions are consistent with our empirical findings.     

Programme Evaluation with Multiple Treatments

Abstract.  This paper reviews the main identification and estimation strategies for microeconometric policy evaluation. Particular emphasis is laid on evaluating policies consisting of multiple programmes, which is of high relevance in practice. For example, active labour market policies may consist of different training programmes, employment programmes and wage subsidies. Similarly, sickness rehabilitation policies often offer different vocational as well as non‐vocational rehabilitation measures. First, the main identification strategies (control‐for‐confounding‐variables, difference‐in‐difference, instrumental‐variable, and regression‐discontinuity identification) are discussed in the multiple‐programme setting. Thereafter, the different nonparametric matching and weighting estimators of the average treatment effects and their properties are examined.     

Analysis of treatment response data from eligibility designs

In this paper, we develop and compare two alternative approaches for calculating the effect of the actual intake when treatments are randomized, but compliance with the assignment in the treatment arm is less than perfect for reasons that are correlated with the outcome. The approaches are based on different identification assumptions about these unobserved confounders. In the first approach, which stems from [Sommer, A., Zeger, S., 1991. On estimating efficacy in clinical trials. Statistics in Medicine 10, 45–52], the unobserved confounders are modeled by a discrete indicator variable that represents subject-type, defined in terms of the potential intake in the face of each possible assignment. In the second approach, confounding is modeled without reference to subject-type in the spirit of the Roy model. Because the two models are non-nested, and model comparison and assessment of the approaches in a real data setting is one of our central goals, we formulate the discussion from a Bayesian perspective, comparing the two models in terms of marginal likelihoods and Bayes factors, and in terms of inferences about the treatment effects. The latter we calculate from a predictive perspective in a way that is different from that in the literature, where typically only a point summary of that effect is calculated. Our real data analysis focuses on the JOBS II eligibility trial that was implemented to test the effectiveness of a job search seminar in decreasing the negative mental health effects commonly associated with job loss. We provide a comparative analysis of the data from the two approaches with prior distributions that are both reasonable in the context of the data and comparable across the model specifications. We show that the approaches can lead to different evaluations of the treatment.     

健康冲击、社会资本与农户经济脆弱性——基于“CHIP2013”数据的实证分析

健康人力资本在农村经济中发挥着重要作用,农户健康受损时,会通过"劳动效应"、"挤占效应"和"情感效应"影响其经济脆弱性,而社会资本作为一种非正式机制,在血缘、地缘与业缘关系的连接下,通过及时获取信息与资源等对农户经济产生影响。文章利用"中国家庭收入调查2013"数据实证分析了健康冲击和社会资本对农户经济脆弱性的影响及作用机制。通过倾向得分匹配（PSM）和处理效应模型解决内生偏误问题、建立中介效应模型后,回归结果显示：健康冲击会通过挤占效应和情感效应两条渠道机制对农户经济产生负向影响,社会资本分项指标则通过信任渠道机制对农户经济产生正向影响;男性户主更易因遭受健康冲击而陷入经济脆弱困境,处于劳动年龄的户主在利用社会资本缓解经济脆弱性方面更具优势;而社会资本在缓解健康冲击对农户经济脆弱性中的作用并不显著,一个可能的原因是在农村社会中,社会资本等非正式机制逐渐被正式医疗保障机制所替代。在稳健性检验中,构造基于预期贫困定义的贫困脆弱性指标（VEP）进行替换变量回归,进一步证实所得结论。文章的政策涵义在于,应加强对于农户健康风险的管理,并重新挖掘社会资本在农村经济发展中的作用,从而缓解经济脆弱性,阻断贫困。     

Treatment persistence in attention deficit/hyperactivity disorder: a retrospective analysis of patients initiated on lisdexamfetamine vs other medications

Abstract

Objective:

To compare treatment persistence in attention-deficit/hyperactivity disorder (ADHD) of patients initiated on lisdexamfetamine (LDX) vs other ADHD medications.

Methods:

A large US administrative claims database was used to select ADHD patients who initiated an ADHD medication (index treatment) during/after 2007. Patients were classified, based on age and previous treatment status, as treatment-naïve or previously treated children and adolescents (6–17 years) and treatment-naïve or previously treated adults (18 years and older). Furthermore, patients were classified into seven mutually exclusive treatment groups, based on their index treatment: LDX, atomoxetine (ATX), osmotic-release methylphenidate hydrochloride long-acting (OROS MPH), other methylphenidate/dexmethylphenidate short-acting (MPH SA) and long-acting (MPH LA), and amphetamine/dextroamphetamine short acting (AMPH SA) and long-acting (AMPH LA). Treatment persistence, analyzed through discontinuation (interruption of the index treatment for ≥30 consecutive days), was compared between treatment groups using multivariate Cox proportional hazards. Patients were followed until first treatment discontinuation or up to 12 months after the initiation of the index treatment, whichever occurred first.

Results:

Among children and adolescents, LDX patients had a significantly lower discontinuation rate compared to other treatment groups (range hazard ratios [HRs]; 1.04–2.26; all p?<?0.05), except when compared to treatment-naïve patients on ATX and OROS MPH, where no statistically significant differences were found and where LDX had a higher risk of discontinuation, respectively. Among adults, LDX patients had a significantly lower discontinuation rate compared to patients in other treatment groups (range HR; 1.14–1.86; all p?<?0.05), except for the comparison with AMPH LA patients, where differences were not statistically significant.

Limitations:

This study did not control for ADHD severity.

Conclusion:

LDX-treated patients were associated with higher persistence compared to patients initiated on other ADHD medications, except for the comparisons with OROS MPH and ATX treated patients in treatment-naïve children and adolescents and AMPH LA-treated patients in adults.     

Radiation therapy remains the key cost driver of oncology inpatient treatment

Abstract

Objective:

Current radiation therapy capacities in Serbia and most of Eastern Europe are heavily lagging behind population needs. The primary study aim was assessment of direct costs of cancer medical care for patients suffering from cancer with assigned radiotherapy-based treatment protocols. Identification of key cost drivers and trends during 2010–2013 comparing brachytherapy and teleradiotherapy was a secondary objective of the study.

Methods:

Retrospective, bottom-up database analysis was conducted on electronic discharge invoices. Payer’s perspective has been adopted with a 1-year long time horizon. Total sample size was 2544 patients during a 4-years long observation period (2010–2013). The sample consisted of all patients with confirmed malignancy disorder receiving inpatient radiation therapy in a large university hospital.

Results:

Diagnostics and treatment cost of cancer in the largest Western Balkans market of Serbia were heavily dominated by radiation therapy related direct medical costs. Total costs of care as well as mean cost per patient were steadily decreasing due to budget cuts caused by global recession. The paradox is that at the same time the budget share of radiotherapy increased for almost 15% and in value-based terms for €109 per patient (in total €109,330). Second ranked cost drivers were nursing care and imaging diagnostics. Costs of high-tech visualizing examinations were heavily dominated by nuclear medicine tests.

Conclusion:

The budget impact of radiation oncology to the large tertiary care university clinics of the Balkans is likely to remain significant in the future. Brachytherapy exhibited a slow growth pattern, while teleradiotherapy remained stable in terms of value-based turnover of medical services. Upcoming heavy investment into the national network of radiotherapy facilities will emphasize the unsatisfied needs. Huge contemporary budget share of radiotherapy coupled with rising cancer prevalence brings this issue into the hot spot of the ongoing cost containment efforts by local governments.     

基层保险机构“跟人走”现象剖析与治理

跟人走是人才流动的非正常形式,目前在保险行业内部较为突出。其表现形式多样,具有整体性、附随性、牵连性和趋利性特点。其产生的直接原因是当事各方追求短期利益,深层原因是人际信任高于人司信任、机制缺陷与管理粗放。跟人走现象容易导致公司文化对抗、诱发违规行为、干扰人才正常流动等经营管理风险。治理跟人走现象首先要解决治理界限、行为认定、强制依据等先决问题,并从市场主体、从业者及监管部门三个方面入手,实施全方位综合治理。     

高填土路基下沉的预防与处治

根据不同的填料选用不同的施工方法。在高等级公路填方路堤中,由于其土方量大,土源多又分散,因此土质也比较复杂,若都采用一种施工方法,施工效果很不理想。     

Estimating impact of cassava research for development approach on productivity,uptake and food security in Malawi

Cassava in Malawi is the second most important staple food crop after maize. This paper assesses the impact of agricultural research for development approach in Malawi on cassava yields, per capita area planted to cassava and household calorie intake from cassava and maize. Given the growing interest over the past decade in agricultural research for development as an innovation systems approach for improving the delivery of research-derived benefits to smallholder farmers and having impact in Africa, this paper provides empirical evidence as to the effects of this framework. The paper concludes that Malawi’s cassava research for development has contributed to measurable gains in area planted to cassava, cassava yields and household caloric intake.