Current Knowledge and Attitudes Concerning Cost-Effectiveness in Glaucoma Pharmacotherapy: A Glaucoma Specialists Focus Group Study.

Background:Rising healthcare costs motivate continued cost-reduction efforts. To help lower costs associated with open-angle glaucoma (OAG), a prevalent, progressive disease with substantial direct and indirect costs, clinicians need to understand the cost-effectiveness of intraocular pressure (IOP)-lowering pharmacotherapies. There is little published information on clinicians' knowledge and attitudes about cost-effectiveness in glaucoma treatment. Purpose:This pilot focus group study aimed to explore clinician attitudes and perspectives around the costs and cost drivers of glaucoma therapy; the implementation of cost-effectiveness decisions; the clinical utility of cost-effectiveness studies; and the cost-effectiveness of available treatments. Methods:Six US glaucoma specialists participated in two separate teleconferencing sessions (three participants each), managed by an independent, skilled moderator (also a glaucoma specialist) using a discussion guide. Participants reviewed recent publications (n=25) on health economics outcomes research in glaucoma prior to the sessions. Results:Participants demonstrated a clear understanding of the economic burden of glaucoma therapy and identified medications, diagnostics, office visits, and treatment changes as key cost drivers. They considered cost-effectiveness an appropriate component of treatment decision-making but identified the need for additional data to inform these decisions. Participants indicated that there were only a few recent studies on health economics outcomes in glaucoma which evaluate parameters important to patient care, such as quality of life and medication adherence, and that longitudinal data were scant. In addition to efficacy, participants felt patient adherence and side-effect profile should be included in economic evaluations of glaucoma pharmacotherapy. Recently approved medications were evaluated in this context. Conclusion:Clinicians deem treatment decisions based on cost-effectiveness data as clinically appropriate. Newer IOP-lowering therapies with potentially greater efficacy and favorable side-effect and adherence profiles may help optimize cost-effectiveness. Future studies should include: clinicians' perspectives; lack of commercial bias; analysis of long-term outcomes/costs; more comprehensive parameters; real-world (including quality-of-life) data; and a robust Markov model

A Competitive Bidding Approach to Medicare Reform

Medicare reform is a critical issue for the public agenda. The most promising option for addressing Medicare reform is competitive bidding -- using health plans' bids to determine the government's contribution to a basic set of benefits in every market area. This paper begins with a review of the history of competitive bidding in Medicare. It then moves to a definition of terms, which is crucial in any discussion of competitive pricing because the often-heated public debate around these issues frequently distorts positions and confuses issues by conflating different terms and making some arguments appear other than they are. Following this terminological exercise, the report includes a series of sections discussing competitive bidding in Medicare, with special focus on the challenges to introducing it

State Higher Education Spending and the Tax Revolt

Public effort in support of higher education – measured as state funding per thousand dollars of personal income – has declined by thirty percent since the late 1970s. During this time period many states implemented Tax and Expenditure Limits and/or supermajority requirements for tax increases. We use a forty-eight state panel from 1961 to 2001 to evaluate the effect of these tax revolt institutions for state effort on behalf of higher education. These provisions have a statistically significant and economically large impact on the timing and magnitude of this decline in state effort. An understanding of the fiscal environment caused by these provisions is critical for the future of state-supported higher education.State higher education spending, tax revolt, Tax and Expenditure Limits

Pharmacokinetic and Pharmacodynamic Profiles of Ethinylestradiol/Norgestimate Combination or Norethindrone upon Coadministration with Elagolix 150 mg Once Daily in Healthy Premenopausal Women

Background: Two pharmacokinetic/pharmacodynamic studies were conducted to evaluate the potential drug-drug interaction between elagolix, an oral gonadotropin-releasing hormone receptor antagonist, and an oral contraceptive (ethinylestradiol [EE] 0.035 mg and norgestimate 0.18/0.215/0.25 mg) or progestin-only contraceptive (norethindrone 0.35 mg) in healthy premenopausal women. Methods: These phase I studies used a two-period, sequential design, where period 1 included treatment with oral contraceptives, followed by period 2 with contraceptives coadministered with elagolix 150 mg once daily. Results: In study 1, pharmacokinetic exposures for EE in period 2 increased by 30% and the norgestimate metabolites decreased by approximately 15% when coadministered with elagolix. Mean hormone exposure appeared lower for follicle-stimulating hormone (FSH; 31%), luteinizing hormone (LH; 38%), and estradiol (E2; 16%). The percentage of women with consecutive progesterone (P) concentrations above 5 nmol/L was similar in both periods. Norethindrone pharmacokinetic exposures were comparable in both periods. The hormone exposure for LH and FSH was similar, and mean E2 exposure was 32% lower in period 2. The percentage of subjects with consecutive ovulatory P concentrations was also similar in both periods (study 2). Safety and tolerability profiles were unremarkable in both studies. Conclusions: Coadministration of elagolix 150 mg once daily with oral contraceptives containing EE and norgestimate, or norethindrone, resulted in small pharmacokinetic changes in the oral contraceptive components. Similar or lower FSH, LH, and E2 exposures were observed during coadministration, with ovulatory P concentrations also comparable in both periods. The pharmacodynamic profiles of the oral contraceptives were maintained when coadministered with elagolix

Compiling knowledge-based systems from KEE to Ada

The dominant technology for developing AI applications is to work in a multi-mechanism, integrated, knowledge-based system (KBS) development environment. Unfortunately, systems developed in such environments are inappropriate for delivering many applications - most importantly, they carry the baggage of the entire Lisp environment and are not written in conventional languages. One resolution of this problem would be to compile applications from complex environments to conventional languages. Here the first efforts to develop a system for compiling KBS developed in KEE to Ada (trademark). This system is called KATYDID, for KEE/Ada Translation Yields Development Into Delivery. KATYDID includes early prototypes of a run-time KEE core (object-structure) library module for Ada, and translation mechanisms for knowledge structures, rules, and Lisp code to Ada. Using these tools, part of a simple expert system was compiled (not quite automatically) to run in a purely Ada environment. This experience has given us various insights on Ada as an artificial intelligence programming language, potential solutions of some of the engineering difficulties encountered in early work, and inspiration on future system development