Cost comparison of continued anticoagulation with rivaroxaban versus placebo based on the 1-year EINSTEIN-Extension trial efficacy and safety results

Aims: The EINSTEIN-Extension trial (EINSTEIN-EXT) found that continued treatment with rivaroxaban for an additional 6 or 12 months (vs placebo) after 6–12 months of initial anticoagulation significantly reduced the risk of recurrent venous thromboembolism (VTE) with a small non-significant increased risk of major bleeding (none fatal or in critical site). This study aimed to compare total healthcare cost between rivaroxaban and placebo, based on the EINSTEIN-EXT event rates.

Methods: Total healthcare cost was calculated as the sum of treatment and clinical event costs from a US managed care perspective. Treatment duration and event rates were obtained from the EINSTEIN-EXT study. Adjustment on treatment duration was made by assuming a 10% non-adherence rate. Drug costs were based on wholesale acquisition costs. Cost estimates for clinical events (i.e. recurrent deep vein thrombosis [DVT], recurrent pulmonary embolism, major bleeding, clinically relevant non-major bleeding) were determined from the literature. Results were examined over a ±20% range of each cost component and over 95% confidence intervals (CIs) of event rate differences in deterministic (one-way) and probabilistic sensitivity analyses (PSA).

Results: Total healthcare cost was $1,454 lower for rivaroxaban-treated (vs placebo-treated) patients in the base-case, with a lower clinical event cost fully offsetting drug cost. The cost savings of recurrent DVT alone (–$3,102) was greater than drug cost ($2,723). Total healthcare cost remained lower for rivaroxaban in the majority (73%) of PSA (cost difference [95% CI]?=?–$1,454 [–$2,396, $1,231]).

Limitations: This study was conducted over the 1-year observation period of the EINSTEIN-EXT trial, which limited “real-world” applicability and examination of long-term economic impact. Assumptions on drug and clinical event costs were US-based and, thus, not applicable to other healthcare systems.

Conclusions: Total healthcare costs were estimated to be lower for patients continuing rivaroxaban therapy compared to those receiving placebo in VTE patients who had completed 6–12 months of VTE treatment.     

UK Asian communities: A profitable market for nonprofits?

The ethnic minority communities in the UK are an increasingly powerful force. But UK charities have not had a great deal of experience in approaching this market, despite a readily acknowledged desire to increase their own levels of cultural diversity. How many want a better ethnic representation among their donor base? How many want greater cultural diversity among volunteers, let alone staff? This paper examines the Asian communities within the UK, and suggests that these are groupings with which UK charities should be engaging. The communities are identifiable, with strong philanthropic traditions, they have increasing economic power and they are accessible. The paper also looks briejly at a positive response generated by one organisation-the Aga Khan Foundation (UK) — to a non-denominational, intercommunal appeal for funds from the Asian Communities in the UK.     

Retesting Fair's (1978) model on infidelity

Modern econometrics stresses the diagnostic testing of estimated models as an important part of the model‐building process. In a survey article published in this journal (Pagan and Vella 1989 ), methods for testing the validity of the assumptions underlying the censored regression of the Tobit model were presented. This paper questions the numerical results presented there. Indeed, my results concerning the tests when applied to Fair's well‐known model for infidelity (1978) are the opposite of those presented in this journal. Copyright © 2003 John Wiley & Sons, Ltd.     

Economic Reform and Macroeconomic Policy in New Zealand

In 1984 the Labour government in New Zealand began a wide-ranging process of reform with the objective of achieving a sustainable improvement in economic performance. The breadth and rapidity with which deregulation, tax reform, and privatisation were implemented has attracted widespread interest. The expected improvement in macroeconomic performance, however, has not yet been realised.
This article describes some background to the policy shift, and focuses on macroeconomic aspects of the reforms. It argues that while many improvements in microeconomic resource allocation have been made, the interaction between monetary, fiscal and wages policies has contributed substantially to the present high cost of structural change in New Zealand.     

The Antecedents of Middle Managers' Strategic Contribution: The Case of a Professional Bureaucracy

abstract    Our study contributes towards a burgeoning literature that argues organizational performance is heavily influenced by what happens in the middle of the organization, rather than at the top. Examining the UK National Health Service, our study develops the work of Floyd and Wooldridge (1992 , 1994 , 1997 , 2000 ). It utilizes role theory to conceptualize changing experiences of middle managers in organizations as a role transition. Associated with this are problems of role conflict and role ambiguity ( Biddle, 1979 , 1986 ; Biddle and Thomas, 1966 ; Kahn et al., 1964 , 1966 ). Our study illustrates that there are limiting factors to a more strategic role for middle managers associated with the professional bureaucracy context. However, role conflict and ambiguity can be mediated by a socialization process, which values incoming identity and personal characteristics ( Van Maanen and Schein, 1979 ).     

Incentive Regulation of Prices When Costs are Sunk

We present a model featuring irreversible investment, economies of scale, uncertain future demand and capital prices, and a regulator who sets the firm’s output price according to the cost structure of a hypothetical replacement firm. We show that a replacement firm has a fundamental cost advantage over the regulated firm: it can better exploit the economies of scale because it has not had to confront the historical uncertainties faced by the regulated firm. We show that setting prices so low that a replacement firm is just willing to participate is insufficient to allow the regulated firm to expect to break even whenever it has to invest. Thus, unless the regulator is willing to incur costly monitoring to ensure the firm invests, revenue must be allowed in excess of that required for a replacement firm to participate. This contrasts with much of the existing literature, which argues that the market value of a regulated firm should equal the cost of replacing its existing assets. We also obtain a closed-form solution for the regulated firm’s output price when this price is set at discrete intervals. In contrast to rate of return regulation, we find that resetting the regulated price more frequently can increase the risk faced by the firm’s owners, and that this is reflected in a higher output price and a higher weighted-average cost of capital.