Choice of Cost-Effectiveness Measure in the Economic Evaluation of Cholesterol-Modifying Pharmacotherapy: An Illustrative Example Focusing on the Primary Prevention of Coronary Heart Disease in Canada

Objective: To evaluate the effect of using different cost-effectiveness measures in the economic evaluation of cholesterol-modifying pharmacotherapy. Design and setting: An economic model was used to examine the extent to which the relative cost effectiveness of cholesterol-modifying agents varies depending upon the cost-effectiveness measure used. The perspective taken was that of the Canadian public healthcare system. Patients: Individuals without coronary heart disease (CHD) with low-density lipoprotein cholesterol (LDL-C) levels in excess of 190 mg/dl. Interventions: Cholesterol-modifying pharmacotherapies available in Canada. Main outcome measures and results: Cost per 1% reduction in LDL-C level; incremental cost per life-year gained; least-cost agent achieving the LDL-C reduction required to meet the target level of 160 mg/dl; incremental cost per life-year gained of agents reaching the target LDL-C level of 160 mg/dl relative to no therapy; incremental cost per life-year gained of agents achieving the target LDL-C level of 160 mg/dl relative to the least-cost agent reaching the target. Each cost-effectiveness measure had a different informational content to decision-makers, both in terms of the usefulness of the information they provided, and in terms of the extent to which they showed one agent to be more cost effective than another. The most cost-effective treatment regimens were fluvastatin 20mg per day, fluvastatin 40mg per day, atorvastatin 10mg per day and atorvastatin 20mg per day, depending on the pretreatment LDL-C level and the cost-effectiveness measure used. Conclusions: We recommend that the cost effectiveness of cholesterol-modifying pharmacotherapy be measured using incremental cost per life-year gained in reaching a predefined target LDL-C level.Pharmacoeconomics, Coronary-disorders, Antihyperlipidaemics, Cost-effectiveness, Hyperlipidaemia

Donor investment choices in developing countries: a methodology and some illustrative results based on Public-Private partnerships for product development (PD PPPs)

Background: Public-Private Partnerships for product development (PD PPPs) have been developed as a major initiative to increase the number of innovative interventions for diseases mainly affecting populations in developing countries. Their development and funding have been supported by a number of donors, who are also interested in evaluating the cost-effectiveness of PD PPs in comparison with other uses of donor expenditure such as increased support for existing programmes. Methods: Evaluating the cost-effectiveness of PD PPPs raises a number of methodological and empirical problems. First, the costs and likely product outcomes of the PD PPP process must be simulated by drug or vaccine and by disease area. Second, an efficiency frontier of existing therapies must be constructed, to estimate the potential yield of shifting that frontier via PD PPP investment versus moving up the existing frontier. Third, the cost-effectiveness of PD PPP investment depends in part on the likely demand for products of the PD PPP process, based on the expected quality of PD PPP products, willingness to pay for health gain, budget constraints and disease burden. Ideally a cost-effectiveness frontier can be constructed empirically by collecting evidence on the total costs and effects of a full set of existing interventions, and we demonstrate this for one restrictive budget scenario. However, for two other scenarios we consider, such information is not readily available, and we have to use a simplifying assumption.We show that it is possible to make a simplifying assumption about the cost-effectiveness of the intervention(s) that will be displaced from other disease budgets to fund the new technology - that is, the "opportunity cost" of funding the new technology. The assumption we adopt is that the cost per DALY averted of the healthcare programmes being displaced will on average have a slope equivalent to a straight line at the midpoint between the cost-effectiveness of the new technology and the maximum willingness to pay for health gain: the maximum willingness to pay will signal the cost-effectiveness of the last acceptable intervention within the budget constraint if resources were all allocated using cost-effectiveness criteria. Results: Using our model we estimate the cost per DALY averted for a range of HIV, TB and Malaria drugs and vaccines in the PD PPP programme. In gneeral these compare favourably with existing interventions but some are subject to significant uncertainty, particularly relating to the underlying R&D; process for vaccines compared to drugs. Conclusions: This study offers a framework to assess the cost-effectiveness of providing additional resources to tackle major health problems in developing countries, using the example of investment in R&D; via PD PPP mechanisms compared with investment in existing interventions. The results suggest that trying to shift the cost-effectiveness frontier may be a cost-effective use of resources. The methods used to reach this results should be generalisable to other interventions

Reimag [in] ing the village as a portrait of a nation-state in Uganda:

In this article I reexamine the ways in which certain contemporary artists based in Uganda problematize the narrative that the ruling National Resistance Movement (the NRM) party is the party of the rural poor (Cheeseman, Lynch, and Willis 2016) in their work while using it as a metaphor to inform their visual expression. I focus on the contest between tradition (imagined as a village) and modernity (imagined as a modern state), as well as the dilemma such a contest causes for a contemporary artist. Cornelius Adepegba (1995) argues that this dilemma influenced the African novel. Agreeing with Adepegba, Freeborn Odiboh (2009) observes that the same dilemma has shaped African visual artists, such as Abayomi Barber, and formal art education institutions like the Barber School in Nigeria; Odiboh then assesses the historical context in which this dilemma evolved as African nationalists struggled to forge postcolonial states based on a national consciousness amid competing ethnic, religious, and ideological interests

Isotope ratios of H, C, and O in CO2 and H2O of the Martian atmosphere

Stable isotope ratios of H, C, and O are powerful indicators of a wide variety of planetary geophysical processes, and for Mars they reveal the record of loss of its atmosphere and subsequent interactions with its surface such as carbonate formation. We report in situ measurements of the isotopic ratios of D/H and O-18/O-16 in water and C-13/C-12, O-18/O-16, O-17/O-16, and (CO)-C-13-O-18/(CO)-C-12-O-16 in carbon dioxide, made in the martian atmosphere at Gale Crater from the Curiosity rover using the Sample Analysis at Mars (SAM)'s tunable laser spectrometer (TLS). Comparison between our measurements in the modern atmosphere and those of martian meteorites such as ALH 84001 implies that the martian reservoirs of CO2 and H2O were largely established similar to 4 billion years ago, but that atmospheric loss or surface interaction may be still ongoing