Cost-effectiveness of treatments for superficial venous refluxin patients with chronic venous ulceration.

Background Venous leg ulcers impair quality of life significantly, with substantial costs to health services. The aim of this study was to estimate the cost‐effectiveness of interventional procedures alongside compression therapy versus compression therapy alone for the treatment of chronic venous leg ulceration. Methods A Markov decision analytical model was developed. The main outcome measures were quality‐adjusted life‐years (QALYs) and lifetime costs per patient, from the perspective of the UK National Health Service at 2015 prices. Resource use included the initial procedures, compression therapy, primary care and outpatient consultations. The interventional procedures included superficial venous surgery, endothermal ablation and ultrasound‐guided foam sclerotherapy (UGFS). The study population was patients with a chronic venous ulcer who were eligible for either compression therapy or an interventional procedure. Data were obtained from systematic review and meta‐analysis of RCTs. Results Surgery gained 0·112 (95 per cent c.i. −0·011 to 0·213) QALYs compared with compression therapy alone, with a difference in lifetime costs of €−1330 (−3570 to 1262). Given the expected savings in community care, the procedure would pay for itself within 4 years. There was insufficient evidence regarding endothermal ablation and UGFS to draw conclusions. Discussion This modelling study found surgery to be more effective and less costly than compression therapy alone. Further RCT evidence is required for both endothermal ablation and UGFS

Leg Ulcer Outcomes

Background Venous disease is the most common cause of leg ulceration. Treatment of superficial venous reflux has been shown to reduce the rate of ulcer recurrence but the effect of early endovenous ablation of superficial venous reflux on ulcer healing remains unclear. It is generally accepted that there is considerable global variation in the management of leg ulcers. Objectives To determine: the clinical and cost-effectiveness of early endovenous treatment of superficialvenous reflux in addition to standard care compared to standard care alone in patients with venous ulceration; the current standards of global management of venous leg management and the impact on these following the results of the randomised controlled trial. Methods i. The Early Venous Reflux Ablation Trial (EVRA) multi-centre randomised clinical trial of 450 participants compared early versus deferred intervention at 12 months and at 3.5 years. ii. Health professionals treating patients with leg ulcers globally were surveyed before and after the publication of the RCT results to gain insight on the management of venous leg ulceration, and subsequent impact on practice. Results i. EVRA: i. time to ulcer healing was shorter in the early group at 12 months; no clear difference in time to first ulcer recurrence at 3.5 years; early intervention at 3 years is 91% likely to be cost-effective at £20,000/QALY. ii. Surveys: ⁃ Pre/post-EVRA UK primary care: 90/643 responses received; Pre/post-EVRA global clinicians: 799/644 responses were received. Conclusions The EVRA RCT showed that early intervention reduces the time to healing of venous leg ulcers, does not affect the time to recurrent ulceration but is highly likely to be cost-effective and therefore is beneficial for both patients and healthcare providers. The surveys demonstrated that the management of venous ulceration is disparate globally. It is likely that the EVRA RCT results influenced the timing of intervention worldwide.Open Acces

The Brand is the Bundle - Strategies for the Mobile Ecosystem

The current mobile ecosystem is best understood in terms of a monopolistic competition model characterised by heterogeneous producers providing a range of differentiated products for consumers with heterogeneous preferences. Product differentiation offers producers some market power ultimately constrained by imperfect substitutes from rivals and the threat of market entry. To achieve their goals consumers require a mixture of products from the network handset and application domains. Reduced search and other transaction costs are a demand-side benefit of product bundling. Producers in this market have high fixed costs and low marginal costs. High fixed costs discourage entry which increases the market power of producers. Low marginal costs and uncorrelated customer preferences across products for individual consumers encourage producers to expand their sales using supply-side bundling. Thus there are strong supply and demand side benefits from product bundling. We argue that producers will compete in terms of differentiated bundles combining network handset and application features with branding as the essential strategy for bundle differentiation. Successful business strategies will require direct access to customers and information about their specific preferences. For illustration we look at the currently apparent strategies of Google Apple and Nokia. The mobile ecosystem is complex but not unique. Strong parallels can be drawn between the mobile ecosystem and the television ecosystem. Google appears to be following a "free to air" strategy and Apple a "pay TV" strategy in bundle differentiation. Television manufacturers are largely undifferentiated and have little market power: this may be the fate of handset manufacturers and network operators who are comparatively powerless to withstand the evolutionary development of the mobile ecosystem.website for Communications & Strategies http://www.comstrat.org

Structural Separation and Prospects for Welfare-Enhancing Price Discrimination in a New 'Natural Monopoly' Network: comparing fibre broadband proposals in Australia and New Zealand

The Australian and New Zealand governments have both decided that substantial government investment is required to accelerate the deployment of new nationwide fibre-to-the-home (FTTH) networks. This paper examines the two proposals in light of the crucial role of price discrimination in enabling rapid and early uptake of a new technology with a natural monopoly cost structure given the assumptions that both networks will be subject to provisions that separate elements of network ownership from retail operations and both will face competition from other (vertically integrated) network technologies. Whilst price discrimination enables a monopolist to maximise profits by extracting surplus from consumers when the firm has a natural monopoly cost structure it also enables the firm to increase welfare by accessing scale economies (static efficiency gains) and to introduce the technology earlier than under the counterfactual of a single price (dynamic efficiency gains). However vertical separation of network and retail functions and regulated 'open access' and 'equivalence' requirements used as regulatory tools to increase retail competition and constrain price and non-price discrimination by monopoly network operators restricts the ability of a new network operator to use its price structure to introduce the technology in a timely manner and to gain access to welfare-enhancing scale economies. In a competitive environment when the new (frontier) network must build its customer base principally from the substitution of customers from the existing (legacy) natural monopoly networks (which may be vertically integrated and engaging in price discrimination themselves) the non-discriminatory provisions of structural separation impose substantial limitations upon the regulated firm's business case. Both the Australian and New Zealand FTTH proposal impose separation and non-discrimination requirements as a precondition for government financing although they differ in their approaches in respect of both the point at which the separation must be enforced and the extent of competition anticipated from existing network operators. Whilst neither proposal enables the full efficiency gains available from producing at maximum efficient scale to be realised the Australian proposal with integration of layer 1 and 2 operators and acquisition of the competing copper access networks appears to offer efficiency and substitution advantages over the New Zealand proposal which requires separation between layer 1 and 2 operators and provides no clear view of the competitive positioning of the FTTH network relative to the legacy copper access rival

UFBI 2.0: Revised separation boundaries may partially address pricing and uptake limitations in New Zealand fibre broadband model, but significant competition policy problems remain

On July 1 2010, the Minister of Communications Steven Joyce announced fundamental changes to the structure and regulation of the New Zealand Government's Ultra-Fast Broadband Initiative. The changes were deemed necessary in order to achieve uptake targets sufficient to underpin the business case for both government and private sector investment. Whilst the changes would appear to enable progress towards the ability to access productive scale efficiencies and competitive pricing structures that will induce some degree of substitution, lack of clarity about the future competitive environment still exposes investors in the sector to significant uncertainties and potential perverse outcomes. Consequently, overall sector investment will likely be inhibited, and the evolution of broadband sector institutions substantially constrained