CAR-T therapy and historical trends in effectiveness and cost-effectiveness of oncology treatments.

Aim: This study examines how chimeric antigen receptor T-cell (CAR-T) therapy's incremental effectiveness and cost-effectiveness profile fits into the recent history of anticancer treatments. Materials & methods: We conducted graphical and multivariable analyses using data from the Cost-Effectiveness Analysis Registry of the Tufts Medical Center and the Institute for Clinical and Economic Review's analysis of CAR-T therapies. We collected additional information including the US FDA approval years for pharmacologic innovations. Results: CAR-T provided 5.03 (95% CI: 3.88-6.18) more incremental quality-adjusted life-years than the average pharmaceutical intervention and 4.61 (95% CI: 1.67-7.56) more than the average nonpharmaceutical intervention, while retaining similar cost-effectiveness. There was evidence of worsening cost-effectiveness by approval year for pharmaceutical interventions. Limitations: Analysis is limited to anticancer treatments studied in cost-utility analyses, estimated to cover approximately 60% of FDA-approved antineoplastic agents. Conclusion: CAR-T therapy breaks a pattern of stagnant efficacy growth in pharmaceutical innovation and demonstrates significantly greater incremental effectiveness and similar cost-effectiveness to prior innovations.

Inclusiveness in the health economic evaluation space.

This paper presents an overview of Gavin Mooney's contributions to broadening the evaluative space in health economics. It outlines how Mooney's ideas have encouraged many, including ourselves, to expand the conventional QALYs/health gain approach and look more broadly at what it is that is of value from health services. We reflect on Mooney's contributions to debates around cost-effectiveness analysis, Quality Adjusted Life Years (QALYs) and cost-utility analysis as well as his contribution to the development and application of contingent valuation and discrete choice experiments in health economics. We conclude by suggesting important avenues for future research to take forward Mooney's work.

Preventing the reintroduction of malaria in Mauritius: a programmatic and financial assessment.

Sustaining elimination of malaria in areas with high receptivity and vulnerability will require effective strategies to prevent reestablishment of local transmission, yet there is a dearth of evidence about this phase. Mauritius offers a uniquely informative history, with elimination of local transmission in 1969, re-emergence in 1975, and second elimination in 1998. Towards this end, Mauritius's elimination and prevention of reintroduction (POR) programs were analyzed via a comprehensive review of literature and government documents, supplemented by program observation and interviews with policy makers and program personnel. The impact of the country's most costly intervention, a passenger screening program, was assessed quantitatively using simulation modeling.On average, Mauritius spent $4.43 per capita per year (pcpy) during its second elimination campaign from 1982 to 1988. The country currently spends $2.06 pcpy on its POR program that includes robust surveillance, routine vector control, and prompt and effective treatment and response. Thirty-five percent of POR costs are for a passenger screening program. Modeling suggests that the estimated 14% of imported malaria infections identified by this program reduces the annual risk of indigenous transmission by approximately 2%. Of cases missed by the initial passenger screening program, 49% were estimated to be identified by passive or reactive case detection, leaving an estimated 3.1 unidentified imported infections per 100,000 inhabitants per year.The Mauritius experience indicates that ongoing intervention, strong leadership, and substantial predictable funding are critical to consistently prevent the reestablishment of malaria. Sustained vigilance is critical considering Mauritius's enabling conditions. Although the cost of POR is below that of elimination, annual per capita spending remains at levels that are likely infeasible for countries with lower overall health spending. Countries currently embarking on elimination should quantify and plan for potentially similar POR operations and costs.

Contested visions of American democracy: citizenship, public housing, and the international arena.

This essay reexamines the history of public housing and the controversy it generated from the Great Depression to the Cold War. By recasting that history in the global arena, it demonstrates that the debate over public housing versus homeownership was also a debate over the meaning of American citizenship and democracy, pointing up starkly divergent notions about what was and was not American. Through an examination of national conflicts and neglected local struggles, this article further shows that the fight over public housing was far more meaningful and volatile than traditionally assumed. Both critics and advocates of public housing drew from international experiences and imagery in positioning the home as a constitutive feature of citizenship in American democracy. Fears of Bolshevism, fascism, and communism served to internationalize issues of race, space, and housing and together shaped the decision of whether a decent home was an American right or privilege.

The declining retirement prospects of immigrant men.

We compare the retirement prospects of immigrant men with their native-born counterparts. Using data from the Survey of Labour and Income Dynamics, we estimate a significant gap of 43 percent in private pension income and 30 percent in private pension contributions between immigrants and the native born. The gap in public pension incomes is negligible and reduces the overall pension gap, but only partially. Furthermore, the pension income and contribution gap is significantly larger for more recently arrived immigrant cohorts, consistent with evidence of weaker earnings for this group. We provide age profiles of pension income and contributions and discuss problems in interpreting the results without adjusting for age. Controlling for age and earnings differences, immigrants are still about 11 percent less likely to make contributions to a private pension program, but there is no difference in the contribution rates out of earnings of those who contribute. Recently arrived immigrants are significantly less likely to make contributions to a private pension program and appear to be neglecting private pension contribution opportunities more than earlier immigrants and the native born, which may have adverse implications for Canada's public retirement programs.

Comparing the capitalisation benefits of light-rail transit and overlay zoning for single-family houses and condos by neighbourhood type in metropolitan Phoenix, Arizona.

Light rail transit (LRT) is increasingly accompanied by overlay zoning which specifies the density and type of future development to encourage landscapes conducive to transit use. Neighbourhood type (based on land use mix) is used to partition data and investigate how pre-existing land use, treatment with a park-and-ride (PAR) versus walk-and-ride (WAR) station and overlay zoning interrelate. Hedonic models estimate capitalisation effects of LRT-related accessibility and overlay zoning on single-family houses and condos in different neighbourhoods for the system in metropolitan Phoenix, Arizona. Impacts differ by housing and neighbourhood type. Amenity-dominated mixed-use neighbourhoods-predominantly WAR communities-experience premiums of 6 per cent for single-family houses and over 20 per cent for condos, the latter boosted an additional 37 per cent by overlay zoning. Residential neighbourhoods-predominantly PAR communities-experience no capitalisation benefits for single-family houses and a discount for condos. The results suggest that land use mix is an important variable to select comparable neighbourhoods.

Historical lifetimes of drugs in England: application to value of information and cost-effectiveness analyses.

OBJECTIVES: The expected lifetime of a health technology is a critical parameter in value of information analysis and in two methodologies for cost-effectiveness analysis which have recently been suggested. The first method allows for the possibility that a superior technology will become available in the future. The second advocates modeling both the prevalent and all future incident patient cohorts. Unfortunately, for value of information analysis, the period of time over which information about the decision problem would be useful is very uncertain, and existing estimates are seemingly arbitrary. Furthermore, there is very little literature on the historical lifetimes of technologies. Here, I quantify and analyze the historical lifetimes of drugs in England. I then apply this information to inform the value of further research and the cost-effectiveness of health technologies. METHODS: A Weibull regression model was fitted to the historical drug lifetimes of 455 drugs. These represented all British National Formulary drugs in England which were launched from 1981 to 2007, and which did not have very low sales volumes. RESULTS: The mean drug lifetime was 57 years (95% confidence interval 39-79 years), and the median was 46 years (35-60 years). Drugs with low sales volumes tended to have shorter lifetimes. Under certain assumptions, the ratio of population level to per-year expected value of information is 21. Drug lifetimes are used to parameterize the two models of cost-effectiveness. CONCLUSIONS: The distribution function of the historical lifetimes of drugs can inform suitable time horizons for: 1) value of information; and 2) cost-effectiveness analyses related to drugs.

Valoración económica de la producción científica en salud en Colombia: 2000-2005 / Economic valuation of scientific production in health in Colombia: 2000 - 2005

Objetivo. Valorar económicamente la investigación en salud en Colombia, financiada parcialmente por Colciencias a partir de la gestión del Fondo para la Investigación en Salud (FIS) 2001 – 2005. Materiales y métodos. Se realizó una valoración económica desde la perspectiva de la sociedad y el Estado teniendo en cuenta resultados intermedios, para los que se adoptaron dos escenarios (máximo y mínimo). Resultados. Se revisaron 338 proyectos (48.7% financiado por Conciencias). El costo medio de los proyectos fue 287 millones. El crecimiento de recursos por proyecto aportados por el FIS fue del 75% en términos reales y la razón de financiación Colciencias/contrapartida, pasó de 0.8 en 2001 a 1.1 en 2005. Antioquia fue el departamento con mayor participación (30.2%). A 2005 habían finalizado 57 (16.8%) con un costo de 8.889 millones (9.7%). Como productos se destacan 30 artículos sometidos en revistas nacionales y 35 en internacionales, 69 participaciones en congresos y la formación de 4 doctores y 24 magísteres. La formación de talento humano representa más del 95% por ciento de los beneficios. La razón beneficio/costo oscila entre 4.72 y 6.34 (por cada peso invertido en investigación en salud se generan, para la sociedad, más de seis veces dicha inversión). Conclusiones. La valoración económica destaca la importancia que en la ejecución de los proyectos de investigación se formen investigadores, frente a los altos retornos que ello implica. Por ello, debe consolidarse, por parte de Colciencias, como criterio de valoración positiva de un proyecto de investigación, el hecho de proponer la formación de investigadores.

Housing policy, aging, and life course construction in a Canadian Inuit community.

The provisioning and administration of social housing has been a continuous problem in the Canadian North since the 1960s, when the Canadian government began taking an active role in the welfare of Inuit. Some of these problems are quite basic and include high costs for construction and maintenance of units. An examination of the development and evolution of Canadian housing policy in the North demonstrates that changes to the administration of social housing programs and, since the mid-1980s, development of formal privatization schemes have steadily shifted housing costs onto local residents. These shifting costs, however, are borne unequally, with Inuit born and raised in the context of permanent communities (the Settlement Generation) facing the greatest burdens.

Unfinished symphony: a tribute to the life and career of Bernie O'Brien (1959-2004).

The death of Bernie O'Brien in February 2004 brought a premature end to one of the most productive and influential careers in the area of health technology assessment and economic evaluation. A long-term member of the Society for Medical Decision Making, Bernie will be remembered for his research contributions in areas including outcome valuation, decision modeling, statistical methods in economic evaluation, and applied cost-effectiveness studies. He was also an excellent communicator and teacher and, above all, a fun guy to work with. In this article, the authors provide a review of Bernie's academic contributions.

The strange career of managed competition: from military failure to medical success?

Managed competition remains untested as the basis of a national health program. However, key principles of managed competition first emerged in the military. For this study, published works on systems analysis and the planning-programming-budgeting system (PPBS), developed by Alain Enthoven and colleagues at the US Department of Defense during the 1960s, were compared with published presentations of managed competition. The influence of PPBS waned after it generated controversy and opposition. PPBS and managed competition represent similar managerial strategies of policy reform. Although the origin of managed competition in failed military policy does not ensure failure in the medical arena, this history also does not augur success.

Joseph Hersey Pratt's cost-effective class method and its contemporary application: some problems in biopsychosocial innovation.

Problems reflecting the stress of illness and the illness of stress account for 20-50% of medical visits and an unquantified but substantial portion of the billions of dollars spent annually on tests and procedures (Stoeckle et al. 1964). The "high-tech" form of practice, favored so powerfully by American medicine and supported so lavishly by financial incentives, produces limited benefits in this domain of suffering and medical care. In an era of increasing panic about the runaway cost of health care, medicine desperately needs cost-effective forms of "low-tech" treatment for patients with psychosomatic conditions and the emotional dimensions of chronic and recurrent illness. Between 1905 and 1955 Joseph Hersey Pratt (1872-1956), an eminent Boston internist and professor of medicine, developed what appears to have been a highly efficient, class-based method for treating such patients in an empathic and biotechnically sound manner. Pratt pioneered his technique in the Emmanuel Church Tuberculosis Class between 1905 and 1923, the work for which he is best known. Seven years later he adapted the method for treatment of patients with chronic psychosomatic conditions, and from 1930 to 1955 he again appears to have achieved considerable success in a highly efficient manner in what was called the Thought Control Class at the Boston Dispensary. Although the treatment of tuberculosis has of course been totally transformed by antibiotics, psychosomatic conditions and the emotional dimensions of chronic illnesses like tuberculosis form an ever larger component of the suffering seen in general medical practices. For this reason, a historical study of Pratt's techniques, theories, and the fate of his innovations may provide practical guidance for contemporary health care practice.