Economic modelling of costs associated with outcomes reported for type 2 diabetes mellitus (T2DM) patients in the CANVAS and EMPA-REG cardiovascular outcomes trials

Aims: To model direct medical costs associated with reductions in cardiovascular disease (CVD) events in T2DM patients reported in the CANVAS and EMPA-REG trials, which assessed the cardiovascular safety of canagliflozin and empagliflozin, respectively.

Materials and methods: Costs were modeled from a US managed care organization (MCO) perspective for the CVD outcomes included in both trials: three-point major adverse cardiovascular event (MACE) and its components (cardiovascular-related death, nonfatal myocardial infarction, nonfatal stroke), as well as heart failure requiring hospitalization. The rate of CVD events averted (difference between study drug and placebo) was projected to the portion of an MCO T2DM population matching the respective trial’s inclusion criteria. A targeted literature search for paid amounts directly associated with each CVD event provided the unit costs, which were applied to the projected number of events averted, to calculate costs avoided per member per year (PMPY). One-way sensitivity analyses were performed on events averted, unit costs, and percentages of trial-applicable patients.

Results: Based on three-point MACE events averted, costs avoided PMPY of $6.17 (range: $1.27–$10.94) for CANVAS and $2.75 ($0.19–$4.83) for EMPA-REG were estimated. Costs avoided for individual components of MACE ranged from $0.77 to $3.84 PMPY for CANVAS and from -$0.97 (additional costs) to $1.54 for EMPA-REG. PMPY costs avoided for heart failure were $2.72 for CANVAS and $1.32 for EMPA-REG.

Limitations and conclusions: Models assumed independent, non-recurrent outcomes and were restricted to medical costs directly associated with the trial-reported events. The reductions in CVD events in T2DM patients reported for both CANVAS and EMPA-REG project to a positive cost avoidance for these events in an MCO population. The analysis did not include an assessment of the impact on total cost, as the costs associated with adverse events, drug utilization or other clinical outcomes were not examined.     

Configurable e-negotiation systems for large scale and transparent decision making

Participatory democracy is one of several conceptions of democracy which strives to create opportunities for all members of a group to contribute to the decision making process. Recent developments in information technologies in general and Internet technologies in particular are affecting the existing democratic mechanisms, hence enabling citizens and organizations to participate widely, efficiently and transparently in the decision making process and, most importantly, to arrive at better decisions faster, through negotiation. E-negotiation systems rely on such technologies to implement protocols ranging from motion raising and voting to auctions, and to make them available on the web for general use. E-negotiation systems can be used for political and societal decision making as well as business dealings within e-government and B2B settings. In order for these systems to fulfill their promise of bringing decision making opportunities to all, we need a structured approach and a configurable framework for designing, implementing and deploying them. The resulting systems should be web-based, easy to use, affordable, traceable, reliable, secure, flexible, efficient, and open for integration with other systems. This paper starts by examining leading research initiatives to devise such a framework and discussing the motivations behind them. We then introduce several design requirements derived from the expectations of e-negotiation systems providers and users. We argue that meeting these requirements fosters a more democratic and efficient decision making process. We also present our approach and vision of a configurable framework for designing, implementing and deploying e-negotiation systems.     

Understanding before implementing: the context of Lean in public healthcare organizations

A three-year study of Lean implementation in public healthcare organizations in Québec identified poor understanding of the organizational context as a contributing factor to unsustainable Lean implementation. This paper presents a holistic perspective of the unique context of public healthcare organizations and discusses its implications with regards to Lean implementation.     

Adherence,persistence, and inpatient utilization among adult schizophrenia patients using once-monthly versus twice-monthly long-acting atypical antipsychotics

Aims: This study compared healthcare resource utilization (HRU), healthcare costs, adherence, and persistence among adult patients with schizophrenia using once-monthly (OM) vs twice-monthly (TM) atypical long-acting injectable (LAI) antipsychotic (AP) therapy.

Materials and methods: A longitudinal retrospective cohort study was conducted using Medicaid claims data from six states. Patients initiated on aripiprazole or paliperidone palmitate were assigned to the OM cohort; risperidone-treated patients were assigned to the TM cohort. HRU and healthcare costs were assessed during the first 12 months following stabilization on the medication. Adherence was measured using the proportion of days covered (PDC) during the first year of follow-up. Persistence to the index medication was measured during the first 2 years following the index date. Comparison between the cohorts was achieved using multivariable generalized linear models, adjusting for demographic and clinical characteristics.

Results: Patients in the OM LAI cohort had lower inpatient HRU and medical costs when compared with patients in the TM cohort. Higher medical costs in the TM LAI cohort offset the higher pharmacy costs in the OM LAI cohort. Mean PDC during the first 12 months of follow-up was higher in the OM cohort than in the TM cohort (0.56 vs 0.50, p?<?.01). Median persistence was longer in the OM cohort than in the TM cohort (7.5 months vs 5.5 months), as was the hazard of discontinuing the index medication (hazard ratio?=?0.83, p?=?.01). Kaplan-Meier rates of persistence at 1 year were higher for OM patients than for TM patients (37.6% vs 29.6%, p?<?.01).

Limitations: This was a Medicaid sample with few aripiprazole LAI patients (5.4% of OM cohort). Medication use was inferred from pharmacy claims.

Conclusions: Among Medicaid patients in these six states, OM AP treatment was associated with lower HRU, better adherence and persistence, and similar total costs compared to patients on TM treatment.     

Social mix policies in Paris: discourses, policies and social effects

Since the 1980s, the issue of social mix has become a public policy category in France. Enshrined in legislation, yet remaining controversial, it represents a major premise on which housing policies have been reconfigured. The concept of social mix is essentially based on who lives where, but it is also evoked in the context of urban renewal schemes for social housing estates, as well as in relation to new-build developments. A study of the bases of social mix policies conducted in Paris since 2001 in the context of the embourgeoisement of the capital shows the fundamental role of social housing stock. The City Council has become involved in policy decisions about both the location and the allocation of social housing. Particular attention has been paid to the middle classes in the name of the principle of ‘balancing the population’. In order to measure the effects of the policy, this article relies on an analysis of two City of Paris schemes that have the stated intent of creating social mix. One of these schemes consists of redeveloping a working-class neighbourhood, Goutte d'Or, while the other involves the new acquisition of social housing in various more affluent neighbourhoods in the capital. This comparative study of the population shows that, whether in a neighbourhood poised for gentrification or in a more affluent neighbourhood, this policy has major effects on forms of local social cohesion, setting in motion individual trajectories and reshaping social and/or ethnic identities.     

Subaltern Urbanization: Indian Insights for Urban Theory

The concept of subaltern urbanization is about vibrant smaller settlements—outside the metropolitan shadow—sustainably supporting a dispersed pattern of urbanization. We propose a theoretical framework which draws on an empirical research collective using both large statistical and land-use data sets and detailed case studies in non-metropolitan Indian geographies. Anchored in postcolonial urban studies, it looks beyond the logic of agglomeration and questions our understanding of settlement hierarchies and the location of social and economic innovation processes, opening up an alternative reading of urbanization that could be valuable for other regions. Local agency is core to this concept, transporting the arguments of the ordinary and the subaltern beyond large cities. Our findings, apart from emphasizing the agency of smaller settlements, highlight their multiple local and translocal flows, shaping an autonomous external engagement that could exist independently of relationships with large cities. Further, even though the rural and the urban seep into each other, they do so organically, unlike the process in planetary urbanization. Additionally, the rural-urban dichotomy remains performative, in that governance regimes influence the urbanization process. Appreciation of these dynamics can provide insights towards a better understanding of the system of human settlements, which is our goal in advancing this framework.     

What if subordinates took care of managers’ mental health at work?

Managers’ mental health is increasingly a subject of concern. However, organizational interventions to reduce stress and promote mental health do not target managers, but rather employees. Numerous studies report a link between supervisory behaviors and subordinates’ mental health at work, and suggest that developing managers’ behavior is a promising avenue in enhancing subordinates’ mental health at work. Nonetheless, the literature has neglected the role and behaviors of subordinates in the prevention of their managers’ mental health problems. This article presents the results of a qualitative research study that inventories 38 specific work practices (observable behaviors) of subordinates, grouped into 12 competencies. Managers and subordinates identified these work practices as affecting work environmental stressors and promoting managers’ mental health at work. The results also point to a major gap between the specific working practices cited by managers and those cited by subordinates, who generally report practices in a passive way. The theoretical and practical repercussions and implications for organizational intervention and human resource management are discussed.     

One size may not fit all: Financial fragmentation and European monetary policies

This article investigates the impact of European Central Bank policies on credits considering financial and banking fragmentation. Using European data from the past decade, we estimate SVAR models to analyze the regional impact of conventional and unconventional measures on price and volume indicators of fragmentation. The risk-taking channel is studied using GVAR models to document the national consequences of this fragmentation. We find that unconventional measures increase credit in peripheral countries. Monetary policies alleviate fragmentation, but mostly in terms of price dispersion rather than credit volume. Finally, unconventional measures imply a rebalancing of European bank assets in favor of foreign currency denominated-assets.