Cost-effectiveness of rivaroxaban compared with enoxaparin plus a vitamin K antagonist for the treatment of venous thromboembolism

Background:

Venous thromboembolism (VTE), comprised of deep vein thrombosis (DVT) and pulmonary embolism (PE), is commonly treated with a low-molecular-weight heparin such as enoxaparin plus a vitamin K antagonist (VKA) to prevent recurrence. Administration of enoxaparin?+?VKA is hampered by complexities of laboratory monitoring and frequent dose adjustments. Rivaroxaban, an orally administered anticoagulant, has been compared with enoxaparin?+?VKA in the EINSTEIN trials. The objective was to evaluate the cost-effectiveness of rivaroxaban compared with enoxaparin?+?VKA as anticoagulation treatment for acute, symptomatic, objectively-confirmed DVT or PE.

Methods:

A Markov model was built to evaluate the costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios associated with rivaroxaban compared to enoxaparin?+?VKA in adult patients treated for acute DVT or PE. All patients entered the model in the ‘on-treatment’ state upon commencement of oral rivaroxaban or enoxaparin?+?VKA for 3, 6, or 12 months. Transition probabilities were obtained from the EINSTEIN trials during treatment and published literature after treatment. A 3-month cycle length, US payer perspective ($2012), 5-year time horizon and a 3% annual discount rate were used.

Results:

Treatment with rivaroxaban cost $2,448 per-patient less and was associated with 0.0058 more QALYs compared with enoxaparin?+?VKA, making it a dominant economic strategy. Upon one-way sensitivity analysis, the model’s results were sensitive to the reduction in index VTE hospitalization length-of-stay associated with rivaroxaban compared with enoxaparin?+?VKA. At a willingness-to-pay threshold of $50,000/QALY, probabilistic sensitivity analysis showed rivaroxaban to be cost-effective compared with enoxaparin?+?VKA approximately 76% of the time.

Limitations:

The model did not account for the benefits associated with an oral and minimally invasive administration of rivaroxaban. ‘Real-world’ applicability is limited because data from the EINSTEIN trials were used in the model. Also, resource utilization and costs were based on the US healthcare system.

Conclusion:

Rivaroxaban is a cost-effective option for anticoagulation treatment of acute VTE patients.     

Technological experience and the technology adoption decisions in small manufacturing firms

This paper investigates changes in factors bearing on technology adoption decisions in small manufacturing firms. It is hypothesized that, as a firm's experience with technology increases and its technological capabilities grow, the decision process is gradually modified and puts more weight on those factors which are more closely related to the true potential of the technology. An empirical study shows the more innovative firms to have an outward orientation dominated by clients and suppliers, and to pay more attention to the added flexibility brought about by new technology. It is also shown that functional groups within the company play a more important role in the decision-making process.     

An alternative proof of the nonemptiness of the private core

Summary. We focus on the private core [19] of an economy with a finite number of agents with differential information, a continuum of states and an infinite number of commodities. We state a nonemptiness result for the private core and provide a proof based on a fixed-point argument. Received: October 4, 1999; revised version: June 7, 2000     

Determinants and impacts of environmental performance in SMEs

The paper analyzes empirical evidence from 368 environmentally responsive small and medium-sized enterprises (SMEs) operating in four industries. The results demonstrate that firms' environmental performance cannot be viewed as a one-dimensional concept and that determinants of firms' environmental performance depend on the dimension retained. The impacts of firms' environmental performance on their innovativeness and competitiveness vary according to the industry within which they operate. However, impacts on product and process innovations as well as on managerial innovations are positive and significant in all four industries.     

The content and focus of Canadian corporate codes of ethics

This paper primarily reports the findings of content analyses of seventy-five codes of ethics ofFinancial Post 500 corporations. The contents of each code were comprehensively evaluated along sixty-one criteria according to four levels. It was found that the focus of these codes was the protection of the firm. While some of them refer to issues of social responsibility, they are principally concerned with conduct against the firm.Maurica Lefebvre holds an Honours Bachelor of Arts Degree in Psychology from the University of Western Ontario and a Bachelor of Commerce degree and MBA from the University of Windsor. She is presently employed marketing consumer packaged goods.Jang B. Singh, B. A. (Toronto), M. A. (St. Thomas), M. A. (Toronto), M. B. A. (Windsor), Ph. D. (Toronto) is Associate Professor at the Faculty of Business Administration of the University of Windsor. His research focus is on ethical issues involved in the management process.     

Social Security and Early Retirement: The Relationship Between Workers,Firms and Governments

In this paper we survey a number of theoretical and empirical studies in order to propose explanations to the fall of labour force participation at older age. Starting from the largely studied effect of social security schemes on labour supply, we explore the employers behaviour and the role of governments in the development of early retirement schemes. We show that early retirement is the result of a global agreement between firms and government where workers have incentives to early exit the labour market due to generous non actuarial benefits. Firms have an advantage to separate older workers because they are costly compared to young workers and governments hope that by pushing elderly into early retirement they will solve the massive unemployment problem.     

Costs of hospital visits among patients with deep vein thrombosis treated with rivaroxaban and LMWH/warfarin

Background:

For many years, the standard of care for patients diagnosed with deep vein thrombosis (DVT) has been low-molecular-weight heparin (LMWH) bridging to an oral Vitamin-K antagonist (VKA). The availability of new non-VKA oral anticoagulants (NOAC) agents as monotherapy may reduce the likelihood of hospitalization for DVT patients.

Objective:

To compare hospital visit costs of DVT patients treated with rivaroxaban and LMWH/warfarin.

Methods:

A retrospective claim analysis was conducted using the MarketScan Hospital Drug Database for care provided between January 2011 and December 2013. Adult patients using rivaroxaban or LMWH/warfarin with a primary diagnosis of DVT during the first day of a hospital visit were identified (i.e., index hospital visit). Based on propensity-score methods, historical LMWH/warfarin patients (i.e., patients who received LMWH/warfarin before the approval of rivaroxaban) were matched 4:1 to rivaroxaban patients. The hospital-visit cost difference between these groups was evaluated for the index hospital visit, as well as for total hospital-visit costs (i.e., including index and subsequent hospital visit costs).

Results:

All rivaroxaban users (n?=?134) in the database were well-matched with four LMWH/warfarin users (n?=?536). The mean hospital-visit costs were $5257 for the rivaroxaban cohort and $6764 in the matched-cohort of patients using LMWH/warfarin. The $1508 cost difference was statistically significant between cohorts (95% CI?=?[?$2296; ?$580]; p-value?=?0.002). Total hospital-visit costs were lower for rivaroxaban compared to LMWH/warfarin users within 1, 2, 3, and 6 months after index visit (significantly lower within 1 and 3 months, p-values <0.05)

Limitations:

Limitations were inherent to administrative-claims data, completeness of baseline characteristics, adjustments restricted to observational factors, and lastly the sample size of the rivaroxaban cohort.

Conclusion:

The availability of rivaroxaban significantly reduced the costs of hospital visits in patients with DVT treated with rivaroxaban compared to LMWH/warfarin.     

A structural model for early exit of older men in Belgium

In this article, we propose a structural model of the retirement decision for older workers in Belgium. We model the exit paths available through the various available schemes. Our framework allows exploiting all information on possible exit paths and also better identifying preferences and constraints. Results based upon Belgian microsimulation data from 2001 for private sector workers fits rather well-observed behavior. Simulations of hypothetical reforms illustrate the potential effects of changing social security rules.