Medium-term Costs Research Articles

Economic implications of novel regimens for tuberculosis treatment in three high-burden countries: a modelling analysis.

With numerous trials investigating novel drug combinations to treat tuberculosis, we aimed to evaluate the extent to which future improvements in tuberculosis treatment regimens could offset potential increases in drug costs. In this modelling analysis, we used an ingredients-based approach to estimate prices at which novel regimens for rifampin-susceptible and rifampin-resistant tuberculosis treatment would be cost-neutral or cost-effective compared with standards of care in India, the Philippines, and South Africa. We modelled regimens meeting targets set in the WHO's 2023 Target Regimen Profiles (TRPs). Our decision-analytical model tracked cohorts of adults initiating rifampin-susceptible or rifampin-resistant tuberculosis treatment, simulating their health outcomes and costs accumulated during and following treatment under standard-of-care and novel regimen scenarios. Price thresholds included short-term cost-neutrality (considering only savings accrued during treatment), medium-term cost-neutrality (additionally considering savings from averted retreatments and secondary cases), and cost-effectiveness (incorporating willingness-to-pay for improved health outcomes). Total medium-term costs per person treated using standard-of-care regimens were estimated at US$450 (95% uncertainty interval 310-630) in India, $560 (350-860) in the Philippines, and $730 (530-1090) in South Africa for rifampin-susceptible tuberculosis (current drug costs $46) and $2100 (1590-2810) in India, $2610 (2090-3280) in the Philippines, and $3790 (3090-4630) in South Africa for rifampin-resistant tuberculosis (current drug costs $432). A rifampin-susceptible tuberculosis regimen meeting the optimal targets defined in the TRPs could be cost-neutral in the short term at drug costs of $140 (90-210) per full course in India, $230 (130-380) in the Philippines, and $280 (180-460) in South Africa. For rifampin-resistant tuberculosis, short-term cost-neutral thresholds were higher with $930 (720-1230) in India, $1180 (980-1430) in the Philippines, and $1480 (1230-1780) in South Africa. Medium-term cost-neutral prices were approximately $50-100 higher than short-term cost-neutral prices for rifampin-susceptible tuberculosis and $250-550 higher for rifampin-resistant tuberculosis. Health system cost-neutral prices that excluded patient-borne costs were 45-70% lower (rifampin-susceptible regimens) and 15-50% lower (rifampin-resistant regimens) than the cost-neutral prices that included patient costs. Cost-effective prices were substantially higher. Shorter duration was the most important driver of medium-term savings with novel regimens, followed by ease of adherence. Improved tuberculosis regimens, particularly shorter regimens or those that facilitate better adherence, could reduce overall costs, potentially offsetting higher prices. WHO.

Short- and medium-term cost effects of non-indicated thyroid diagnostics: empirical evidence from German claims data

This paper contributes to the discussion of whether non-indicated ultrasound examinations of the thyroid gland contribute to overtreatment and excess health care expenditures. Using two sources of claims data from Germany, we analyzed data from patients who underwent a TSH blood test which is the initial diagnostic measure to check for possible presence of thyroid dysfunction. In a matching analysis, we compared health costs of two groups of patients. One consisted of patients who underwent an early thyroid ultrasound that according to medical guidelines—at this point—was probably not indicated. The other group consisted of patients, who underwent no ultrasound examination at all or later in the course of the disease, making probable a correct indication. Both groups were made comparable by the means of a matching procedure. Average thyroid-specific health costs were substantially higher for the first group in the quarter in which the ultrasound examination took place. Some deviation in these specific costs persisted over a substantial period of time, with drug expenditures exhibiting the biggest difference. If, however, total health costs were considered, difference in costs was only found in the initial quarter. We conclude that non-indicated ultrasound examination of the thyroid gland may have some moderate effects on thyroid-specific costs. Yet the data do not suggest that long-lasting overtreatment and excess health expenditures are initiated by non-indicated ultrasound in Germany.

HER2-positive MBC has high short- and medium-term costs

HER2-positive MBC has high short- and medium-term costs

The costs of the immune memory within generations.

Immune response is evolutionary costly, but it is not clear whether these costs affect energetic expenditure (short-term cost), growth (medium-term cost), or reproduction (long-term cost). We tested the costs of immune memory in Tenebrio molitor against Metarhizium brunneum. To do this, we used two groups of T. molitor larvae: (a) the control group, which was injected first with Tween solution and 10 days later with M. brunneum and (b) the memory group, which was first injected with M. brunneum and 10 days later with M. brunneum. Compared to controls, larvae of the memory group were more likely to survive, but they also had an increased metabolic rate (CO2 production), spent a long time before becoming pupae, and had a shorter time from pupae to adulthood. In the adult stage, control females preferred control males, but there was no significant difference in the preference of memory females. Finally, control and memory males preferred control females. These results confirm that immune memory has costs in terms of energetic expenditure, growth, and reproduction. To the best of our knowledge, this is the first experimental demonstration that immune memory in larvae is traded-off with adult sexual selection involving mate choice.

Debt That Costs Less Than Nothing: Greece's Unique Opportunity

A river of ink and controversy has been spent for the past seven years trying to ascertain and comprehend how the money loaned to Greece through the infamous Eurozone-IMF bailout programs has been used. Research pieces, live debates, and opinion articles aplenty have attempted to clarify things, not always reaching identical conclusions. A particular point of contention is exactly how much of the funds directly reached the pockets of ordinary Greeks (to put it in familiar terminology, how much “austerity” was enhanced or reduced because of the bailouts). Here I endorse a very simple way of appreciating what the bailouts delivered and shall continue to deliver: repayment for a very prolonged number of years of all outstanding debt obligations of the Greek government (at no medium-term cost to the sovereign, and without implying an increase in overall borrowing levels), plus a huge pile of money (to be used, for instance, to make a national investment that happens to save the domestic banking industry, and to pay many a government employee salary, state pension, and social benefit). Clearly, having someone else give you for a long time all the cash you need to avoid default plus a lot of extra cash to spend on nice things sounds like a definitely positive proposition, especially when the terms attached to the loans are incredibly generous and accommodative towards the bailed-out party. In essence, Greece’s liabilities would have been transformed into debt that costs less than nothing (don´t make any debt payment, get a ton of cash). The amounts of the rescue loans, €255 billion so far with €55 billion more in waiting, would be enough to meet all existing debt repayments during 2010-16 and, if all proceeds along, 2010-18 and still have many billions left for non-debt-related austerity-fighting government spending. A key concept here is the idea of “bailouts-enabled money”, which encompasses the very substantial sums of money accruing to Greece on top of the bailout loans that took place because, and only because, the bailouts took place first. That is, the real aid that reached and shall reach Greece since 2010 is larger than the already vast headline bailout figures. This is a side-effect that seems often ignored, and that adds extra fuel to the conclusion that the rescue programs, far from being a drag on Greece, have been a Godsend. A unique multiyear opportunity to get back on its feet and regain financial independence.

Does Early Life Exposure to Cigarette Smoke Permanently Harm Childhood Welfare? Evidence from Cigarette Tax Hikes

Evidence suggests that excise taxes on tobacco improve fetal health. However, it remains unknown if smoke exposure in early life causes lasting harm to children. I find that in utero exposure to a dollar increase in the state cigarette tax causes a 10 percent decrease in sick days from school and a 4.7 percent decrease in having two or more doctor visits. I present additional evidence for decreases in hospitalizations and asthma. This supports the hypothesis that exposure to cigarette smoke in utero and infancy carries significant medium-term costs, and that excise taxes can lead to lasting intergenerational improvements in well-being. (JEL H25, H71, I12, J13)

The oxidative debt of fasting: evidence for short- to medium-term costs of advanced fasting in adult king penguins.

In response to prolonged periods of fasting, animals have evolved metabolic adaptations helping to mobilize body reserves and/or reduce metabolic rate to ensure a longer usage of reserves. However, those metabolic changes can be associated with higher exposure to oxidative stress, raising the question of how species that naturally fast during their life cycle avoid an accumulation of oxidative damage over time. King penguins repeatedly cope with fasting periods of up to several weeks. Here, we investigated how adult male penguins deal with oxidative stress after an experimentally induced moderate fasting period (PII) or an advanced fasting period (PIII). After fasting in captivity, birds were released to forage at sea. We measured plasmatic oxidative stress on the same individuals at the start and end of the fasting period and when they returned from foraging at sea. We found an increase in activity of the antioxidant enzyme superoxide dismutase along with fasting. However, PIII individuals showed higher oxidative damage at the end of the fast compared with PII individuals. When they returned from re-feeding at sea, all birds had recovered their initial body mass and exhibited low levels of oxidative damage. Notably, levels of oxidative damage after the foraging trip were correlated to the rate of mass gain at sea in PIII individuals but not in PII individuals. Altogether, our results suggest that fasting induces a transitory exposure to oxidative stress and that effort to recover in body mass after an advanced fasting period may be a neglected carryover cost of fasting.

Wind Vision: A New Era for Wind Power in the United States

Despite near- to medium-term cost barriers, a future U.S. electricity system in which wind plays a major role is technically feasible; could result in enduring benefits globally, nationally, and locally; and could result in consumer and system cost savings in the long term.

Anti-Muslim Violence in Burma: Why Now?

Why does anti-Muslim violence take place in Burma now and with what costs? Three related arguments are made to answer the puzzle. Firstly, the pattern, nature, level, frequency, and impact of anti-Muslim violence during the quasi-civilian regime that took power in 2011have changed and been distinct from religious riots in the previous reign. Secondly, both �hardliners� and �reformists� of the transitional regime are complicit in ongoing communal violence in Burma and taking advantage out of it, in contrast to prevailing depiction of the violence as actions of �dark forces� and �hardliners� behind the scene. Thirdly, the paper investigates unprecedented trend, which is an emerging conflicts between Burmese Monastic Order and its lay adherents, that would lead to a societal transformation in the long-run while the immediate and medium-term costs of the religious violence remain to be very devastating.

Medium-term cost analysis of breast reconstructions in a single Dutch centre: A comparison of implants, implants preceded by tissue expansion, LD transpositions and DIEP flaps

Free flap breast reconstruction (BR) is generally believed to be more expensive than implant BR, but costs were previously shown to level out over time due to complications and re-operations. The aim of this study was to assess the economic implications of four BR techniques: silicone prosthesis (SP), implant preceded by tissue expansion (TE/SP), latissimus dorsi transposition with or without implant (LD ± SP) and deep inferior epigastric perforator (DIEP) flap. A prospective historic cohort study was performed to evaluate intramural medical costs in 427 patients, who had undergone BR between 2002 and 2009. Short- and medium-term complications were incorporated. In addition, 58 patients, who had recently undergone BR, participated in a questionnaire study to prospectively evaluate extramural medical and non-medical costs. Estimates of mean short- and medium-term costs are presented per patient. Intramural medical costs for BR and short-term complications for unilateral DIEP flaps (€ 12,848) and TE/SP reconstructions (€ 12,400) were significantly higher than those for LD ± SP reconstructions (€ 5804), which, in turn, were more expensive than SP reconstructions (€ 4731). In bilateral cases, costs of TE/SP (€ 12,723) and LD ± SP (€ 10,760) reconstructions were comparable, while DIEP flaps (€ 15,747) were significantly more expensive and SP reconstructions were significantly cheaper (€ 6784). Overall, the medium-term costs for complications and additional operations were not significantly different (€ 3017-€ 4503). Extramural medical costs and non-medical costs were approximately € 9300 per stage, regardless of technique. Differences in short-term costs between techniques did not level out during follow-up and SP reconstructions remained least expensive. Single-stage SP reconstructions, however, are not suitable for all patients due to high complication rates. Definite implant placement is therefore increasingly preceded by tissue expansion at more comparable costs to autologous BR. Incorporation of non-medical costs into the cost analysis would render two-stage procedures more costly than autologous BR. To achieve the optimal result, careful patient selection is critical. Only in select cases where two options are equally applicable, cost comparison becomes a valid argument for treatment selection.

Lipid reserves, fasting capability and the evolution of nestling obesity in procellariiform seabirds

Several alternative explanations have been proposed to account for the evolution of nestling obesity in a variety of avian groups. These predict quite different patterns of fat accumulation, storage and use by chicks of different ages. Yet surprisingly few studies have measured changes in body composition during chick development. We tested the applicability of these hypotheses for fulmars, Fulmarus glacialis , by direct measurement of changes in water, lipid and lean dry mass in growing chicks. Lipid and lean dry mass increased until ca. 70% of the way through chick rearing, but then levelled off. Total body water also increased until the same stage, but gradually declined thereafter, and it was this change rather than fat metabolism that resulted in mass recession. The observed pattern of a continued increase in stored lipid, and most importantly, its maintenance all the way through the mass–recession phase until chicks reach fledging, is incompatible with many of the proposed hypotheses. We suggest that the most likely ultimate explanation for large fat deposits is to fuel chicks during the initial critical period away from the nest site while they learn to forage

Evaluating public expenditure management systems: An experimental methodology with an application to the Australia and New Zealand reforms

This article examines how institutional arrangements affect the size, allocation, and use of public expenditures. It identifies a set of arrangements that can address underlying problems and affect three levels of expenditure outcomes - aggregate fiscal discipline, strategic prioritization, and technical efficiency in the use of resources. A diagnostic questionnaire is constructed which produces index values for each arrangement. This methodology is used to analyze the radical reforms introduced by New Zealand and Australia. The results show that New Zealand sought to achieve aggregate fiscal discipline and enhance technical efficiency through formal mechanisms for transparency and accountability. The Australian reforms sought to improve strategic prioritization through transparency of the medium-term costs of competing policies, and the devolution of detailed program decisions to line ministries within hard budgets.

Business process re-engineering and strategic change

This article draws upon a programme of work commissioned and funded by the Commission of the European Communities. It was undertaken as an element of the COBRA (constraints and opportunities in business restructuring—an analysis) project which has involved a pan-European study of business process re-engineering (BPR) experience and practice. It presents some summary findings relating to the extent to which BPR is being used as a vehicle of strategic change. Most of the BPR exercises examined by members of the COBRA team were of a process ‘simplification’ rather than ‘re-engineering’ variety and were being undertaken to achieve medium-term cost and time savings rather than longer term and strategic benefits. The approaches to BPR adopted by many organizations will not necessarily lead to BPR methodologies being applied to areas and activities of strategic significance. Many of the methodologies appear designed to secure incremental improvements in existing processes rather than achieve fundamental change.

Constructing CO 2 reduction cost curves The case of Denmark

The paper summarizes phase two of the Danish contribution to the UNEP Greenhouse Gas Abatement Study, which has the main purpose of developing a common methodology for undertaking a cost assessment of greenhouse gas abatement, and using this methodology to carry out a number of country studies. The methodological possibilities for constructing cost curves — showing the marginal cost of the CO 2 reducing options and the related quantity of CO 2 reduced — are described. Three main cost-curve approaches are then identified: the partial, retrospective and integrated approaches. Following the development of a baseline scenario, two main reduction scenarios are constructed using the integrated approach. Based on these two reduction scenarios, the medium-term cost curve for 2005 and long-term cost curve for 2030 for CO 2 reduction are established, and the economically most attractive and most efficient options with regard to CO 2 reduction are each discussed. The main conclusion to be drawn is that it seems possible for Denmark to reduce CO 2 emissions substantially compared to the baseline without imposing heavy economic burdens on Danish society.

Transmission of the Effects of the Fiscal Deficit in Industrial Countries to the Fiscal Deficit of the Developing Countries

The paper shows that an increase in the aggregate fiscal deficit of the industrial countries may worsen the economic growth and fiscal balance of the developing countries that are burdened with external debt and facing current account constraints. The discussion is based on theoretical analysis and simulation exercises highlighting the relevant transmission mechanisms involved. Simulations show that higher fiscal deficits and interest rates in the industrial countries can explain some of the fiscal deterioration in the developing countries during the early 1980s, and the medium-term costs to the developing countries may be partly mitigated through flexible domestic economic policies.