Historical clinical and economic consequences of anemia management in patients with end-stage renal disease on dialysis using erythropoietin stimulating agents versus routine blood transfusions: a retrospective cost-effectiveness analysis

Abstract

Objective:

To determine whether Medicare’s decision to cover routine administration of erythropoietin stimulating agents (ESAs) to treat anemia of end-stage renal disease (ESRD) has been a cost-effective policy relative to standard of care at the time.

Methods:

The authors used summary statistics from the actual cohort of ESRD patients receiving ESAs between 1995 and 2004 to create a simulated patient cohort, which was compared with a comparable simulated cohort assumed to rely solely on blood transfusions. Outcomes modeled from the Medicare perspective included estimated treatment costs, life-years gained, and quality-adjusted life-years (QALYs). Incremental cost-effectiveness ratio (ICER) was calculated relative to the hypothetical reference case of no ESA use in the transfusion cohort. Sensitivity of the results to model assumptions was tested using one-way and probabilistic sensitivity analyses.

Results:

Estimated total costs incurred by the ESRD population were $155.47B for the cohort receiving ESAs and $155.22B for the cohort receiving routine blood transfusions. Estimated QALYs were 2.56M and 2.29M, respectively, for the two groups. The ICER of ESAs compared to routine blood transfusions was estimated as $873 per QALY gained. The model was sensitive to a number of parameters according to one-way and probabilistic sensitivity analyses.

Limitations:

This model was counter-factual as the actual comparison group, whose anemia was managed via transfusion and iron supplements, rapidly disappeared following introduction of ESAs. In addition, a large number of model parameters were obtained from observational studies due to the lack of randomized trial evidence in the literature.

Conclusions:

This study indicates that Medicare’s coverage of ESAs appears to have been cost effective based on commonly accepted levels of willingness-to-pay. The ESRD population achieved substantial clinical benefit at a reasonable cost to society.     

Utilization and cost comparison of erythropoiesis-stimulating agents in inpatient and outpatient hospital settings

Abstract

Objective:

To compare utilization and associated costs of epoetin alfa (EPO) and darbepoetin alfa (DARB), two erythropoiesis-stimulating agents (ESAs), in patients with cancer undergoing chemotherapy and patients with chronic kidney disease (CKD) not on dialysis in inpatient and outpatient hospital settings.

Methods:

An analysis of medical claims recorded between January 2006 and December 2009 was conducted using the Premier Perspective Comparative Hospital database. Patients included were ≥18 years old with cancer and chemotherapy or with pre-dialysis CKD and with ≥1 claim for EPO or DARB during a hospital inpatient or outpatient treatment episode. Patients treated with both ESAs or who were receiving dialysis were excluded. Mean cumulative drug costs and dose ratios (units EPO: mcg DARB) were calculated using cumulative dose and April 2010 wholesale acquisition costs.

Results:

Cancer chemotherapy: 13,832 inpatient stays (EPO: 10,454; DARB: 3378) and 5590 outpatient treatment episodes (EPO: 2856; DARB: 2734) were identified. The inpatient and outpatient populations reported ESA dose ratios of 230:1 and 238:1 with DARB cost premiums of 42% (EPO: $948; DARB: $1348) and 38% (EPO: $3358; DARB: $4627), respectively. CKD: 148,746 hospital stays (EPO: 116,017; DARB: 32,729) and 11,012 outpatient treatment episodes (EPO: 6921; DARB 4091) were identified. The inpatient and outpatient populations reported ESA dose ratios of 251:1 and 257:1 with DARB cost premiums of 30% (EPO: $566; DARB: $738) and 27% (EPO: $2077; DARB: $2642), respectively.

Limitations:

The lack of randomization may have led to confounding by indication. In addition, statistical significance must be interpreted with caution in studies involving large samples.

Conclusions:

This study of 19,422 patients with cancer receiving chemotherapy and 159,758 patients with pre-dialysis CKD reported ESA dose ratios ranging from 230:1–257:1 (units EPO: mcg DARB) and associated cost premiums of 27–42% for DARB.     

图书馆的环境污染与防治

健康权利是人最基本的权利,对图书馆工作环境污染的现实,从多方面阐述了图书馆职业面临的各种危害因素,呼吁重视图书馆馆员的职业健康,加强职业防护意识,采取有力措施改善工作环境已刻不容缓。     

浅述沥青混凝土路面病害的预防措施

近几年,沥青混凝土路面越来越多地被应用到高等级公路建设中,但是产生的如开裂、泛油、剥落、车辙等病害现象却不容忽视,直接影响了车辆的运行。本文较系统地对沥青混凝土路面几种常见病害产生的原因进行分析,并提出相应的预防与治理措施。     

Dutch Disease in Tourism Economies: Evidence from the Balearics and the Canary Islands

Considerable attention has been given in the economic literature to Dutch disease, with symptoms of the disease being extensively described in many different contexts. Dutch disease is a condition which describes the reaction of an economy, subject to rapid change, on finding new export uses for natural resources. None of the studies, however, has focused on the tourist industry as a source of increased wealth through the exploitation of natural resources, such as beaches or natural areas, using typical mass models of tourism development. By examining two different Spanish regions, this paper provides evidence that the Balearics and the Canary Islands, whose economies are heavily orientated towards tourism, both show signs of Dutch disease and that, as a result, their economic growth might be compromised in coming years.     

Economic impact of using inhaled corticosteroids without prior exacerbation among elderly patients with chronic obstructive pulmonary disorder

Abstract

Objective:

To assess the economic impact of initiating inhaled corticosteroids (ICS) without evidence of prior exacerbation among elderly patients with chronic obstructive pulmonary disease (COPD) in the US.

Methods:

This retrospective study used administrative claims to identify newly diagnosed COPD patients between 1/1/2005 and 6/30/2006 who were dispensed ICS. The dispense date of the first ICS was set as the index date. Patients with prior diagnoses for asthma, cystic fibrosis, or lung cancer were excluded. Cohorts were constructed based on whether ICS therapy was concordant with recommended guidelines of having prior COPD exacerbation. Each COPD patient with prior exacerbation was matched to four patients without exacerbation based on age, gender, Charlson Comorbidity Index, and whether COPD diagnosis code was not elsewhere specified (i.e., 496). Multivariate regressions were estimated to assess the association between use of ICS therapy without prior exacerbation and total healthcare costs, controlling for demographics and clinical characteristics.

Results:

The study included 3650 patients: 730 with prior exacerbation and 2920 without prior exacerbation. Patients were 76 years of age and 54% were male. Those with prior exacerbation were more likely to have inpatient stays both prior to (74.4 vs. 44.1%, p?<?0.05) and following (37.0 vs. 33.1%, p?<?0.05) the index date. Controlling for patient characteristics, patients who were dispensed ICS without prior exacerbation had $1859 higher in total costs (p?<?0.05) compared to patients with prior exacerbation during the 12 months following ICS initiation.

Limitations:

The retrospective design of this study limits the interpretation of findings as association and not causality. This study is subject to selection bias due to unobservable confounders.

Conclusions:

Among COPD patients, initiation of ICS without prior exacerbation appears to be associated with increased healthcare costs. These findings suggest that ICS initiation without evidence of exacerbation as consistent with guidelines is associated with adverse economic consequences.     

Adherence,persistence, healthcare utilization,and cost benefits of guideline-recommended hepatitis B pharmacotherapy

Abstract

Objective:

To compare pharmacotherapy adherence, persistence, and healthcare utilization/costs among US patients with chronic hepatitis B (CHB) initiated on an oral antiviral monotherapy recommended as first-line treatment by current national (US) guidelines vs an oral antiviral not recommended as first-line monotherapy.

Research design and methods:

In this retrospective cohort study, patients aged 18–64 with medical claims for CHB who initiated an oral antiviral monotherapy for CHB between 07/01/05 and 01/31/10 were identified from a large US commercial health insurance claims database. Patients were continuously enrolled for a 6-month baseline period and ≥ 90 days follow-up. They were assigned to ‘currently recommended first-line therapy’ (RT: entecavir or tenofovir) or ‘not currently recommended first-line therapy’ (NRT: lamivudine, telbivudine, or adefovir) cohorts.

Main outcome measures:

Multivariate analyses were conducted to compare treatment adherence, persistence, healthcare utilization, and costs for RT vs NRT cohorts.

Results:

Baseline characteristics were similar between RT (n?=?825) and NRT (n?=?916) cohorts. In multivariate analyses, RT patients were twice as likely as NRT patients to be adherent (OR?=?2.09; p?<?0.01) and persistent (mean: RT?=?361 days, NRT?=?298 days; p?<?0.01) and half as likely to have an inpatient stay (OR?=?0.527; p?<?0.01). Between the two oral antivirals recommended as first-line treatment, even though pharmacy cost was higher for entecavir, mean total healthcare costs for entecavir and tenofovir were similar ($1214 and $1332 per patient per month, respectively). Similar results were also observed with regard to adherence, persistence, and healthcare use for entecavir and tenofovir.

Conclusions:

A limitation associated with analysis of administrative claims data is that coding errors can be mitigated but are typically not fully eradicated by careful study design. Nevertheless, the current findings clearly indicate the benefits of initiating CHB treatment with an oral antiviral monotherapy recommended as first-line treatment by current guidelines.     

The Baumol Diseases and the Korean Economy

ABSTRACT

This article examines the Baumol effect and the consequences of unbalanced growth across Korean industries. The results demonstrate that the Baumol effect exists, but it is qualitatively different from existing literature. Although Baumol’s cost disease is significant, it is weak. Certain attributes of the Korean economy such as heavy reliance on exports and compressed growth seem to be responsible. Weak cost disease leads to a weak growth disease: the aggregate productivity growth does not monotonically decline over time. Productivity growth has led to the deindustrialization of employment. The value holds effective after controlling the growth of international trade.     

商洛地区核桃主要病害发生特点及防治策略

通过调查,笔者发现影响商洛地区核桃生产的主要病害有3种:核桃黑斑病、核桃枝枯病、核桃腐烂病。分别对每种病害的危害症状、病原特点、发病规律进行了总结。结合生产实践,提出了以上3种主要病害的相应的防治策略。     

Science vs. fear: the Ebola quarantine debate as a case study that reveals how the public perceives risk

This study focuses on newspaper coverage of the Hickox quarantine incident, using it as a case study to examine how the media characterized the spread of disease in an ongoing crisis situation characterized by uncertainty. The study builds on Slovic et al.’s research, who argue that risk perception is comprised of both emotional and analytical aspects. We employed a qualitative approach, first examining articles on Hickox’s story in The New York Times and New York Daily News between October 25 and 31, 2014; and second, readers’ comments in response to these articles. The findings from the newspaper articles show that in their treatment of the quarantine debate, the media did not address the issue of uncertainty, and thus continued the health authorities’ neglect of this issue. Although the media gave expression to various sides of the debate, it emphasized those who objected to the quarantine policy, thus raising the claim that the conflict was between ‘science’ and the public’s ‘irrational fears,’ and that the governors decided on quarantine in response to the public’s panic and fears. From our analysis of readers’ comments, it appears that these claims are unjustified. First, we found that the public did not speak in a single unified voice, but rather, was divided into supporters and opponents of quarantine. Both sides used scientific arguments and resorted to similar terminology, and tended to cite and present studies backing their arguments. As for irrational fears, although quarantine supporters expressed emotions, they indicated mainly concerns, not panic or hysteria.