Lifetime Benefits Research Articles

Cost-Effectiveness of Recombinant Activated Factor VII as Adjunctive Therapy for Bleeding Control in Severely Injured Trauma Patients in Germany.

The purpose of this study was to assess the cost-effectiveness of recombinant activated factor VII (rFVIIa) as adjunctive therapy for the control of bleeding in patients with severe blunt trauma injuries in Germany. The primary outcome measure was incremental cost per quality-adjusted life-year (QALY) gained. We developed a cost-effectiveness model based on patient-level data from a 30 day international, randomized, placebo-controlled phase II trial. The data were supplemented with secondary data from the German Trauma Register and German life tables to estimate lifetime costs and benefits. We assumed that the non-significant difference in mortality observed in the phase II trial of 5% in favor of rFVIIa could be verified in the ongoing, much larger follow-up trauma study. We adopted the perspective of third-party payers in Germany, and included all trauma-related healthcare costs. The incremental cost per QALY gained with rFVIIa relative to placebo was e29,451. The probability that this was below e30,000 and e40,000 was 51 and 58%, respectively. The estimates were sensitive to the differences observed in mortality and the applied discount rate. Based on preliminary evidence from a phase II trial, we conclude that, relative to placebo, rFVIIa may be a cost-effective therapy from the thirdparty payer perspective in Germany.

Welfare Returns and Temporary Time Limits: A Proportional Hazard Model

This study analyzes welfare returns for families who leave welfare for a period of 12 months in response to a temporary time limit requirement in Nevada. Findings reveal that relatively few families return for cash assistance after sitting and that the majority who do return soon after their sit-out period is complete. Results also reveal that families with young children, large families, and those with multiple spells before reaching their time limits are at greater risk of re-entry. The study demonstrates the critical role of the economy in shaping welfare re-entry. A simulation exercise estimates that if faced with a high unemployment rate of 14%, nearly 92% of those who leave because of temporary time limits would eventually return to welfare. KEY WORDS: economy and welfare returns; proportional hazard models; welfare temporary time-limits; welfare reform ********** One of the most conspicuous features of 'the 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA, EL. 104-193) was the imposition of time limits. This legislation replaced the federal entitlement program Aid to Families with Dependent Children with a block grant for Temporary Assistance for Needy Families (TANF). Presently, the federal government prohibits states from using federal TANF funds for most families for more than 60 cumulative months (Pavetti & Bloom, 2001). Nine states impose a permanent time limit of less than 60 months, and five states impose a temporary period of ineligibility following the receipt of cash benefits ranging from 18 to 36 months (Rowe & Roberts, 2002). Permanent or temporary welfare time limits represent a nonpermissive welfare system and extreme measures taken to curb welfare dependence. Nevada, where the present study took place, imposes a 60-month time limit and requires families to out for 12 months after receiving cash assistance for 24 months. This requirement creates a unique opportunity to examine how welfare returns play after recipients sit for 12 months. Using longitudinal monthly administrative data and a proportional hazard model, this study examined how the economy, welfare benefit levels, and recipients' personal characteristics or behaviors before reaching time limits shape patterns of return after sitting in Nevada. The issue of welfare recidivism takes on greater significance in the wake of welfare reform than it did before PRWORA, in part because welfare recipients are using more of their lifetime benefits after returning to welfare. Yet, only a few studies have examined welfare recidivism after the inception of PRWORA, and to our knowledge the present study is the first one to explain patterns of return to welfare after leaving because of mandatory temporary time limits. The results of this study are interesting not only for what they can tell us about welfare returns under a unique circumstance in a single state, but also because they may serve as a template for similar research in other states. The findings of this investigation have special value for states with temporary time-limited welfare or for states considering such a policy option. The findings have nationwide value and relevance because of general national concerns about longterm self-sufficiency and welfare re-entry. Our study determines the extent to which patterns of re-entry and the effect of explanatory factors on welfare returns resemble similar research conducted in states with no temporary time limits. State flexibility in designing welfare policies or programs in the wake of welfare reform means that researchers need to investigate state-specific programs and that Congress needs to consider state-specific research findings when debating future national welfare reforms. BACKGROUND Return Rates and Patterns Before welfare reform, returns to welfare ranged from 17% to 37% within one year after exit and between 35% and 45% within two years after exit (Bane & Ellwood, 1994; Harris, 1996; Hofferth, Stanhope,& Harris, 2005; Meyer & Cancian, 1996). …

Cost effectiveness of recombinant activated factor VII for the control of bleeding in patients with severe blunt trauma injuries in the United Kingdom

The aim of this study was to assess the lifetime cost effectiveness of recombinant activated factor VII vs placebo as adjunctive therapy for control of bleeding in patients with severe blunt trauma in the UK. We developed a cost-effectiveness model based on patient level data from a 30-day international, randomised, placebo-controlled Phase II trial. The data were supplemented with secondary data from UK sources to estimate lifetime costs and benefits. The model produced a baseline estimate of the incremental cost per life year gained with recombinant activated factor VII relative to placebo of 12 613 UK pounds. The incremental cost per quality adjusted life year gained was 18 825 UK pounds. These estimates are sensitive to the choice of discount rate and health state utility values used. Preliminary results suggest that relative to placebo, recombinant activated factor VII may be a cost-effective therapy to the UK National Health Service.

Optimal Design of Pension Rule with Flexible Retirement: The Two-Type Case

We study a model where the government offers two contracts: either low retirement age, low lifetime benefit or high retirement age, high lifetime benefit. Each worker privately knows whether he has a low or high life expectancy and chooses accordingly. The so-called ``actuarially fair'' system – calculated at an average life expectancy – is shown to be not fair: the expectedly shorter-lived subsidize the expectedly longer-lived. Considering optimal design, second-best contracts are separating. Under neutrality, the shorter-lived retire too early with too low a benefit. Under redistribution, the shorter-lived work long enough and receive a high enough benefit to enjoy a higher lifetime utility than under neutrality, although they subsidize the longer-lived.

AFDC to TANF: The Effects of Welfare Reform on Instrumental and Expressive Crimes

In 1996, Congress modified the Aid to Families with Dependent Children (AFDC) welfare program by passing The Personal Responsibility and Work Opportunity Reconciliation Act. This act limited lifetime benefits to eligible recipients and called for states to design and implement their own programming to shift the welfare‐receiving population to wage earners. Past studies have found a significant inverse relationship between welfare spending and index crimes. This study builds upon the existing research by examining spending in AFDC’s replacement program, Temporary Assistance to Needy Families (TANF), by focusing on the effects TANF spending has on crimes beyond index offenses.

Cost-effectiveness analyses and modelling the lifetime costs and benefits of health-behaviour interventions

Background: We describe an approach to estimating the cost-effectiveness of an intervention that changes health behaviour. The method captures the lifetime costs and benefits incurred by participants in an ongoing cluster-randomized controlled trial of an intervention that aims to change health behaviour. The existing literature only captures short-term economic and health outcomes. Methods: We develop a state-transition Markov model of how individuals move between different health behaviour states over time. We simulate hypothetical data to describe the costs and health benefits of the intervention, illustrate how the data collected in the ongoing randomized controlled trial can be used and demonstrate how incremental cost-effectiveness ratios are estimated. Results: On the basis of the simulated (i.e. hypothetical) data, we estimate the cost per quality-adjusted life year. The estimate reflects the lifetime health and economic consequences of the intervention. Discussion: The method used for the cost-effectiveness analysis described in this paper is appropriate for investigating whether interventions that change health behaviour in relation to chronic diseases represent good value for money as compared to alternative uses of scarce healthcare resources.

Cost-effectiveness analyses and modelling the lifetime costs and benefits of health-behaviour interventions

We describe an approach to estimating the cost-effectiveness of an intervention that changes health behaviour. The method captures the lifetime costs and benefits incurred by participants in an ongoing cluster-randomized controlled trial of an intervention that aims to change health behaviour. The existing literature only captures short-term economic and health outcomes. We develop a state-transition Markov model of how individuals move between different health behaviour states over time. We simulate hypothetical data to describe the costs and health benefits of the intervention, illustrate how the data collected in the ongoing randomized controlled trial can be used and demonstrate how incremental cost-effectiveness ratios are estimated. On the basis of the simulated (i.e. hypothetical) data, we estimate the cost per quality-adjusted life year. The estimate reflects the lifetime health and economic consequences of the intervention. The method used for the cost-effectiveness analysis described in this paper is appropriate for investigating whether interventions that change health behaviour in relation to chronic diseases represent good value for money as compared to alternative uses of scarce healthcare resources.

73.1 Invited Paper: Performance of High Power Light Emitting Diodes in Projection Applications

High Power LEDs are potentially attractive light sources for projection because of color, lifetime, speed, and environmental benefits. An update and outlook of luminance performance of LEDs will be given, showing performance is getting to an entry level required for commercial projection applications.

Life-saving or life-prolonging? Interpreting trial data and survival curves for patients with congestive heart failure

Chronic heart failure is responsible for considerable suffering and mortality throughout the world. Clinical trials have consistently demonstrated the benefits of pharmacological therapies such as angiotensin-converting enzyme inhibitors and beta-adrenoceptor blockers. These drugs are often quoted as reducing mortality from heart failure, yet all patients with heart failure deteriorate and most will die because of their disease. Therapies in heart failure are not truly life saving; they modify the natural history of the disease and delay the time to deterioration. The time benefit in survival is not usually reported in clinical trials, which are conducted over fixed time points and report risk reductions during this period only. In this paper, we discuss the use of prolongation of life statistics as an outcome measure in clinical trials and review simple techniques for calculating the lifetime benefit of pharmacological intervention in heart failure using data from a number of major studies

Analysis of Costs and Benefits of the Gambian Eye Care Program

To estimate the net benefit of the Gambian Eye Care Program (GECP) using a limited definition of benefits from a societal perspective. The number of cases of blindness avoided was modeled using population projections, population-based blindness survey estimates from 1986 and 1996, and reported blindness-related mortality differences. Benefits were measured as lifetime productivity gains that resulted from the cases of blindness avoided between the surveys. Costs included all contributions to GECP between the surveys. In 1996, 1658 fewer individuals were blind than would have been without GECP. The present value of costs was 1.28 US million dollars (1995 dollars). Although the net benefit between the blindness surveys was negative, the net lifetime benefit was 1.01 US million dollars (1995 dollars), yielding an internal rate of return of 10%. In the primary sensitivity analysis, assuming similar benefits to Senegalese citizens, who accounted for 30% of patients, the internal rate of return was 19%. Upper bound sensitivity analyses result in internal rates of return higher than 20%. In one sub-Saharan African country with avoidable blindness due to cataract and eye infections, the internal rate of return of a national eye care program was substantial when using a limited definition of benefit.

Cost-effectiveness of photodynamic therapy for high-grade dysplasia in Barrett's esophagus

Photodynamic therapy appears to be effective in ablating high-grade dysplasia in Barrett's esophagus. Our aim was to identify the most effective and cost-effective strategy for managing high-grade dysplasia in Barrett's esophagus without associated endoscopically visible abnormalities. By using decision analysis, the lifetime costs and benefits of 4 strategies for which long-term data exist were estimated by us: esophagectomy, endoscopic surveillance, photodynamic therapy, followed by esophagectomy for residual high-grade dysplasia; and photodynamic therapy followed by endoscopic surveillance for residual high-grade dysplasia. It was assumed by us that there was a 30% prevalence of cancer in high-grade dysplasia patients and a 77% efficacy of photodynamic therapy for high-grade dysplasia and early cancer. Esophagectomy cost 24,045 dollars, with life expectancy of 11.82 quality-adjusted life years. In comparison, photodynamic therapy followed by surveillance for residual high-grade dysplasia was the most effective strategy, with a quality-adjusted life expectancy of 12.31 quality-adjusted life years, but it also incurred the greatest lifetime cost (47,310 dollars) for an incremental cost-effectiveness of 47,410 dollars/quality-adjusted life years. The results were sensitive to post-surgical quality of life and survival, and to cancer prevalence if photodynamic therapy efficacy for cancer was less than 50%. Photodynamic therapy followed by endoscopic surveillance for residual high-grade dysplasia appears to be cost effective compared with esophagectomy for patients diagnosed with high-grade dysplasia in Barrett's esophagus. Clinical trials directly comparing these strategies are warranted.

Cost-effectiveness of ezetimibe coadministration in statin-treated patients not at cholesterol goal

Despite the growing use of statins, many hypercholesterolaemic patients fail to reach their lipid goal and remain at elevated risk of coronary heart disease (CHD). Alternative treatment strategies, such as ezetimibe coadministration and statin titration, can help patients achieve greater lipid control, and thereby lower their CHD risk. But is it cost effective to more aggressively lower cholesterol levels across a broad range of current statin users? Using a decision-analytic model based on epidemiological and clinical trials data, we project the lifetime benefit and cost of alternative lipid-lowering treatment strategies for CHD and non-CHD diabetic patients in Germany, Spain and Norway. It is projected that from 40% to 76% of these patients who have failed to reach their lipid goal with their current statin treatment will be able to reach their goal with ezetimibe coadministration; this represents a gain of up to an additional absolute 14% who will be able to reach their goal compared with a 'titrate to goal' strategy where patients are titrated in order to reach their lipid goal (up to the maximum approved dose). For CHD patients, the estimated incremental cost-effectiveness ratio for ezetimibe coadministration is under Euro 18 000 per life-year gained (Euro/LYG) and 26 000 Euro/LYG compared with strategies based on the observed titration rates and the aggressive 'titrate to goal' strategy, respectively; for non-CHD diabetic patients, these ratios are under 26 000 Euro/LYG and 48 000 Euro/LYG for ezetimibe coadministration compared with the two titration strategies. Compared with statin titration, ezetimibe coadministration is projected to be cost effective in the populations and countries studied.

Beta engineering and circuit styles for SEU hardening PD-SOI SRAM cells

SOI technologies have long been used for SEU-hardened SRAMs and other radiation-hard circuits. However, to maintain their advantages in the submicron regime, it is essential that the strength of the floating body effects (FBE) and the role of the parasitic bipolar transistor (PBJT) should be minimized. In this work these are achieved by reducing the gain β of the PBJT by controlling the carrier recombination lifetime of the SOI film. Two sets of devices (A and B) were fabricated on 0.35 μm PD SOI technology, where Device A underwent a lifetime “killing”-processing step to control the single event upset (SEU) vulnerability. These devices were experimentally characterized and simulated and the results verified the benefits of lifetime “killing”. Additional SEU control was achieved by optimizing the circuit design of the cell through the incorporation of suitable delay elements.

The Gender Impact of Pension Reform: And Which Policies Shape This Impact

Pension systems may have a different impact on the two genders because women are less likely than men to work in formal labor markets and earn lower wages when they do. Recent multi-pillar pension reforms tighten the link between payroll contributions and benefits, leading critics to argue that they will hurt women. In contrast, supporters of these reforms argue that women will be helped by the removal of distortions that favored men and the better targeted redistributions in the new systems. In order to test these conflicting claims and to analyze more generally the gender impact of alternative pension systems, this paper examines the differential impact of the new and old systems in three Latin American countries - Chile, Argentina and Mexico. Based on household survey data, we simulate the wage and employment histories of representative men and women, the pensions that these are likely to generate under the new and old rules, and the relative gains or losses of the two genders due to the reform. We find that women do indeed accumulate private annuities that are only 30-40% those of men in the new systems. However, this effect is mitigated by sharp targeting of the new public pillars toward low earners, many of whom are women, and by restrictions on payouts from the private pillars, particularly joint annuity requirements. As a result of these transfers, total lifetime retirement benefits for women reach 60-80% of those for men and for full career married women they equal or exceed benefits of men. Also as a result, women are the biggest gainers from the pension reform. For women who receive these transfers, female/male ratios of lifetime benefits in the new systems exceed those in the old systems in all three countries. Private intra-household transfers from husband to wife in the form of joint annuities play the largest role. Women who work no longer have to give up their own annuity to get this widows' benefit, as they did in some old systems.

Refined measurement of outcome for adjuvant breast carcinoma therapy.

Traditional nonparametric statistical methods do not provide a quantitative measure of the lifetime benefit from adjuvant therapy. This deficiency makes it difficult to determine the long-term difference in impact between the two treatment arms of a clinical trial. To assess the impact of breast carcinoma recurrence, parametric survival models were derived from two randomized, controlled clinical trials of adjuvant therapy for Stage II breast carcinoma. To assess time to death from causes other than breast carcinoma, actuarial models derived from 1980 Census data were used. These two models were then combined to estimate the mean time to event (MTE) as a function of patient age, with the event being either recurrence or death from other causes. The MTE was then used to measure the differential benefit between two arms of a clinical trial. In the first trial, differences in MTE between treatment groups varied from 2.7 years for 35-year-old patients to 1.4 years for 75-year-old patients. For this trial, the mechanism of survival benefit was an increase in time to recurrence. In the second trial, differences in MTE varied from 7.6 to 1.6 years over the same age ranges. For this trial, the mechanism of survival benefit was an increase in the likelihood of cure, i.e., an increase in the asymptote of the curve that represents proportion of patients without relapse. When applied to data from controlled clinical trials, MTE offers a quantitative measure of long-term outcome from adjuvant therapy. The greatest benefit is achieved when therapy that increases the likelihood of cure is provided to young patients.

Oxidation and lifetime of PYSZ and CeSZ coated Ni-base substrates with MCrAlY bond layers

IN100 blades and CMSX-4 samples with NiCoCrAlY bond coats manufactured via LPPS and EB-PVD were cyclically tested in a burner rig at 1120°C and a furnace at 1100°C. Two different TBC chemistries were deposited by EB-PVD techniques: PYSZ and CeSZ. In all cases the performance of the CeSZ coated variances was superior to the PYSZ coated counterparts. TGO growth kinetics were slightly slower for the CeSZ coated samples. The benefits in lifetime are mainly attributed to the mixed zone oxides that tolerate spinel phase formation due to their ability to “wet” each other. Pore formation in the mixed zone is hereby suppressed favoring crack blunting mechanisms.

Cost-effectiveness of gastric bypass for severe obesity

Purpose To estimate the cost-effectiveness of gastric bypass in the treatment of severe obesity. Subjects and methods We performed a cost-effectiveness analysis of gastric bypass versus no treatment from the payer perspective. We discounted quality-adjusted life-years (QALYs), life-years, and cost during the patient’s lifetime. Our target group comprised women and men aged 35 to 55 years with a body mass index between 40 and 50 kg/m 2, and who did not have cardiovascular disease and in whom conservative bariatric therapies had been unsuccessful. Results The base case cost-effectiveness ratios ranged from $5000 to $16,100 per QALY for women and from $10,000 to $35,600 per QALY for men, depending on age and initial body mass index. In a few subgroups of older, less obese men, variation in parameters such as loss of excess weight, obesity-related quality of life, complication rates, and perioperative mortality affected the cost-effectiveness ratios. Parameter variation did not result in meaningful changes in the remaining patients. Conclusion Gastric bypass is a cost-effective alternative to no treatment, providing substantial lifetime benefits in patients who are severely obese.

Esthetically objectionable fluorosis attributable to water fluoridation.

We compared estimates of fluorosis prevalence and risk attributable to fluoridation using an index applied to the entire dentition and to the maxillary anterior teeth. We also estimated the prevalence of perceived esthetic problems attributable to current fluoridation policy (Attributable Burden). Fluorosis prevalence estimates were obtained from the National Survey of Oral Health in US School Children (1986-87) for the 1839 survey children aged 12 -14 years who were scored for fluorosis, had never received fluoride drops or tablets, and had lived in only one home. For each child we calculated Dean's fluorosis index, and an anterior fluorosis index (value of the highest scored maxillary anterior tooth). We used each index to calculate risk of fluorosis attributable to fluoridation by subtracting at each level of severity the prevalence of fluorosis among those living in low fluoride areas (F <or= 0.3 ppm) from the prevalence among those living in optimally fluoridated areas (0.7 ppm F <or=1.2 ppm). Findings from five published studies were used to calculate risk of perceived esthetic problem attributable to fluorosis, by severity, i.e. the difference in the mean percentage of respondents who were satisfied with the appearance of their teeth with and without fluorosis. Finally, Attributable Burden was estimated by summing the products of risk of perceived esthetic problems attributable to fluorosis and risk of fluorosis attributable to fluoridation for each level of fluorosis severity. Prevalence of fluorosis, very mild or greater, was 26% with Dean's Index, which was significantly higher than the 18% figure calculated with the anterior index. Using the anterior index, fluoridation was a risk factor for very mild (attributable risk = 15%) and mild fluorosis (attributable risk = 3%). Risk of fluorosis (very mild or greater) attributable to fluoridation was significantly higher when calculated from prevalence estimates using Dean's Index than estimates calculated with the anterior index (24% versus 18%). The mean values of risk of perceived esthetic problems attributable to very mild and mild fluorosis were 9% and 33%, respectively. We found that approximately 2% of US schoolchildren may experience perceived esthetic problems which could be attributed to the currently recommended levels of fluoride in drinking water. The findings further suggest that both estimates of fluorosis prevalence and risk of fluorosis attributable to fluoridation will be higher when calculated with an index applied to the entire dentition. Data were unavailable for fluoridated toothpaste and diluted formula consumption, thus the risk of fluorosis attributable to fluoridation may be overestimated if consumption was higher in fluoridated areas. The risk of perceived esthetic problems attributable to fluoridation must be weighed against its lifetime benefits and the associated costs of alternative solutions such as educating parents about appropriate toothpaste use and lowering the fluoride content of children's toothpaste.

Actuarial Nonequivalence in Early and Delayed Social Security Benefit Claims

Age-related adjustments to Social Security benefits are intended to be actuarially equivalent, on average, rendering lifetime benefits invariant to the timing of first receipt. This article analyzes actuarial equivalence with respect to early and delayed Social Security benefit claims using a large sample of current and former retired-worker beneficiaries. We find substantial deviations from actuarial equivalence that have resulted in “actuarial premiums” for males, particularly low-income males, and “actuarial losses” for females who accept benefits early. Gender-neutral actuarial adjustments partially offset the female life expectancy advantage in Social Security. For delayed claims, the 8% credit scheduled in current law is too low for actuarial equivalence. The patterns of actuarial nonequivalence should be considered in analyses of claiming behavior or in simulations of Social Security reform proposals that may affect claiming behavior.

PDB7: COSTS AND EFFECTIVENESS OF INTENSIVE INSULIN THERAPY FOR TYPE 2 DIABETES

OBJECTIVE: To estimate the lifetime benefits and costs of intensive insulin therapy for type 2 diabetes mellitus (2DM), cost-effectiveness analysis was carried out. METHODS: Cost-effectiveness analysis (CEA) and cost-utility analysis (CUA) were carried out to estimate the lifetime benefits and costs of intensive insulin therapy (IIT) for 2DM. A Markov model base on a randomized controlled trial (Kumamoto Study) was developed. As a comparator, conventional therapy (CV) was used. A societal viewpoint was adopted for the estimation of costs, and both direct and indirect costs were evaluated. A Monte Carlo simulation was done to evaluate a confidence interval of cost-effective or cost-utility ratio. Quality of life (utility) was measured by a time-trade off method among 2DM patients. RESULTS: At lifetime follow-up among 40 years of men, expected life years (28.7 years) for IIT were longer than those (26.5 years) for CT. On the other hand, expected costs ($106,500) for ITT were higher than those ($95,600). The incremental cost per life-year gained for IIT was $3,020 (discount rate of cost and effectiveness: 5%). The incremental cost per QALY gained was $3,270. Sensitivity analysis for age, costs, and health outcomes confirmed robustness of these results. CONCLUSION: Over lifetime, IIT for 2DM not only reduces complications, but also improves QOL and increases length of life. From a societal perspective, efficiency of IIT is considerably high.