Niklas Lampenius

Burden of non-tuberculous mycobacterial pulmonary disease in Germany

The objective of this study was to estimate the burden of disease in incident patients with non-tuberculous mycobacterial pulmonary disease (NTM-PD). A sample of 7 073 357 anonymised persons covered by German public statutory health insurances was used to identify patients with NTM-PD. In total, 125 patients with newly diagnosed NTM-PD in 2010 and 2011 were matched with 1250 control patients by age, sex and Charlson Comorbidity Index, and followed for 39 months. The incidence rate for NTM-PD was 2.6 per 100 000 insured persons (95% CI 2.2–3.1). The mortality rate for patients with NTM-PD and the control group in the observational period was 22.4% and 6%, respectively (p<0.001). Mean direct expenditure per NTM-PD patient was €39 559.60 (95% CI 26 916.49–52 202.71), nearly 4-fold (3.95, 95% CI 3.73–4.19) that for a matched control (€10 006.71, 95% CI 8907.24–11 106.17). Hospitalisations were three times higher in the NTM-PD group and accounted for 63% of the total costs. Attributable annual direct costs and indirect work-loss costs in NTM-PD patients were €9093.20 and €1221.05 per control patient, respectively. Only 74% of NTM-PD patients received antibiotics and nearly 12% were prescribed macrolide monotherapy. Although NTM-PD is considered rare, the attributable mortality and financial burden in Germany are high. Efforts to heighten awareness of appropriate therapy are urgently needed. Newly diagnosed NTM-PD causes substantial healthcare costs and has high mortality http://ow.ly/Y0I03089UBc

Development and Validation of a Model and Measure of Financial Risk-Taking

This study presents a theoretical model and assessment tool that measures individual differences in risk-aversion in financial matters. Unlike other measures of financial risk-taking, this measure assumes no prior technical knowledge of finance. The assessment tool was developed using item response theory as well as classical test theory methods. The measure is tested for predictive validity through various procedures and proves to have those properties. In addition the measure is tested for construct validity using structural equation modeling and allows for the successful classification of individuals in one of four classifications: Non-Investor, Risk Managing Investor, Conservative Investor, and Speculator. We discuss potential applications of this measure.

Cost of multi drug resistance tuberculosis in Germany.

OBJECTIVES 4220 new cases of tuberculosis (TB) were reported in Germany in 2012; of those, 65 cases were multidrug-resistant TB (MDR-TB) or extensively multidrug-resistant TB (XDR-TB) cases. However, there is only limited information on the economic consequences of drug resistance patterns on the treatment costs of MDR-and XDR-TB patients. METHODS On the basis of drug susceptibility of the single MDR-TB/XDR-TB strains the direct medical costs of suitable therapies were calculated according to the current guidelines of the World Health Organization (WHO) and those of the German Central Committee against Tuberculosis. These costs were combined with hospital and outpatients monitoring costs and followed the most recent German invoicing system and health statistics. Total drug and monitoring costs and were determined by Monte-Carlo simulation comprising all different options. RESULTS According to this, the mean drug costs were €51,113.22 (range €19,586.14 to €94,767.90). The weighted costs for hospitalization were €26,000.76 per patient compared to only €2,192.13 for primary outpatients; the total treatment costs of MDR-TB amounted to €64,429.23. These are joined by the costs due to loss of productivity, varying between €17,721.60 and €44,304. From a societal perspective, the total cost per MDR-TB/XDR-TB case reach an amount between €82,150 and €108,733 per case, respectively. CONCLUSION Cost analyses based on strain resistance patterns allow more reliable estimates of the real costs of treating MDR-TB/XDR-TB than do methods that ignore this factor. Advantageously, they demonstrate the economic impact of drug-resistant TB in low-incidence countries. Costs of productivity loss is of new importance because of the length of MDR-XDR therapy, but its true share of total costs has still to be determined.

Cost Effectiveness of Preventive Treatment for Tuberculosis in Special High-Risk Populations

ObjectiveIn view of the goal of eliminating tuberculosis (TB) by 2050, economic evaluations of interventions against the development of TB are increasingly requested. Little research has been published on the incremental cost effectiveness of preventative therapy (PT) in groups at high risk for progression from latent TB infection (LTBI) with Mycobacterium TB (MTB) to active disease. A systematic review of studies with a primary focus on model-driving inputs and methodological differences was conducted.MethodsA search of MEDLINE, the Cochrane Library and EMBASE to July 2014 was undertaken, and reference lists of eligible articles and relevant reviews were examined.ResultsA total of 876 citations were retrieved, with a total of 24 studies being eligible for inclusion, addressing six high-risk groups other than contact persons. Results varied considerably between studies and countries, and also over time. Although the selected studies generally demonstrated cost effectiveness for PT in HIV-infected subjects and healthcare workers (HCWs), the outcome of these analyses can be questioned in light of recent epidemiologic data. For immigrants from high TB-burden countries, patients with end-stage renal disease, and the immunosuppressed, now defined as further vulnerable groups, no consistent recommendation can be taken from the literature with respect to cost effectiveness of screening and treating LTBI. When the concept of a fixed willingness-to-pay (WTP) threshold as a prerequisite for final categorization was used, the sums ranged between ‘no specification’ and US

Inflation and the Constant Growth Model: Reconciling the Literature

100,000 per quality-adjusted life-year.ConclusionsTo date, incremental cost-effectiveness analyses on PT in groups at high risk for TB progression, other than contacts, are surprisingly scarce. The variation found between studies likely reflects variations in the major epidemiologic factors, particularly in the estimates on the accuracy of the tuberculin skin test (TST) and interferon-gamma release assays (IGRA) as screening methods used before considering PT. Further research, including explicit evaluation of local epidemiological conditions, test accuracy, and methodology of WTP thresholds, is needed.

Cost-Effectiveness Analysis of Interventions for Tuberculosis Control: DALYs Versus QALYs

We formulate a generalized constant growth valuation model incorporating inflation and capital maintenance. We find that in general there are two sources of growth: growth due to capital maintenance and growth due to net new investments. The generalized version of the constant growth model allows the reconciliation of the existing literature, particularly the works of Gordon and Shapiro (1956), Lally (1988), and Bradley and Jarrell (2008), which all employ particular definitions of capital maintenance. Evaluating the practical relevance of either model we find that each model is best suited for a very particular company set-up, which does not necessarily correspond to the commonly observed business models. The generalized version of the constant growth valuation model, however, presents a flexible approach that is capable of capturing various conceptions of capital maintenance.

The Terminal Value and Inflation Controversy

The emergence of multi-drug-resistant tuberculosis (MDR-TB) in the European region and the high costs (nearly €536 million) generated by the nearly 72,000 notified TB cases in the EU are the factors driving the need for development and implementation of new tools against TB. In this context, cost-effectiveness analyses applying quality-adjusted life-years (QALYs) or disability-adjusted life-years (DALYs) as outcome measures for economic evaluation of improved approaches to TB control are increasingly important. While the methodology applied to derive the effectiveness data is commonly reported, less information is given regarding the derivation of utility weights in the calculation of QALYs for TB treatment. To date, despite the particular complexities of the disease, TB health effects have not been fully measured and there is no agreement on how disutility of TB disease should be accounted for. Consequently, disutility values in published studies vary considerably, and often appear to lack empirical evidence. As the need for a solid heath-economics rationale for investment in new tools against TB grows, adequate and comprehensive methods for assessing the impairments caused by different types of TB must be developed. Focusing on the assessment of DALYs as a measure of outcome in economic evaluation, we have built an exemplary model calculation applying the original TB data for Germany as reported to the Robert Koch Institute. Our work demonstrates that the use of standard equations provided in the scientific literature probably results in an underestimation of lost DALYs compared with probabilistic techniques. Providing distributions around epidemiological averages, coupled with Monte Carlo simulation to address uncertainty, may result in more realistic values. In line with a previous recommendation by the World Health Organization, it appears worthwhile to consider this more intricate approach to providing healthcare resource allocation decisions, particularly for TB.

Are Real Investment Decisions Based on Risk Adjusted Performance Measures Consistent with Maximizing Shareholder Value

This journal recently published what was effectively a debate between Gunther Friedl and Bernhard Schwetzler (hereafter “F&S”), on the one hand, and Michael Bradley and Gregg Jarrell (“B&J”). B&J initiated the first round of the debate by criticizing the constant growth valuation model, commonly known as the “Constant Growth Model” or “Gordon Growth Model.” The Gordon Growth Model was introduced by Myron Gordon and Eli Shapiro (“G&S”) in a 1956 paper and has long been widely used by corporate and investment practitioners. F&S responded to B&J with a defense of the original G&S formulation. In revisiting this debate, the authors find that the models B&J and F&S advocate are at bottom two different versions of the same G&S constant growth model, but with quite different assumptions about the effect of inflation on the amount of capital reinvestment required to sustain businesses over time. The authors resolve the dispute by showing that both models, when using a consistent set of assumptions about inflation and capital reinvestment, produce identical growth rates and estimates of value. At the same time, however, the authors recognize that the two models (the G&S/F&S model, on the one hand, and the B&J model on the other) are likely to be appropriate for very different kinds of companies, and each for only small subsets of companies.

How do Firms Manage their Foreign Exchange Exposure

We show that the usage of risk adjusted performance measures (RAPM), such as the RORAC or the RARORAC, as decision criterion for real investment decisions might favor projects that do not maximize shareholder value for project selection of mutually exclusive projects. We find that RAPM based on the CVaR are in general more consistent with the NPV-criterion than RAPM based on the VaR. In addition, measures that are based on the relative (C)VaR are more consistent with the NPV-criterion than measures based on the absolute (C)VaR. Overall we find that the RARORAC based on the relative (C)VaR outperforms all evaluated RAPM in this context.

Income Measurement and the Fisher Equation: Apples and Oranges when Converting from Nominal to Real Terms!

We examine how firms manage their foreign exchange (FX) exposure using publicly reported data on FX exposure before and after hedging with corresponding hedging instruments. Based on calculated firm-, year-, and currency-specific hedge ratios, we find that about 80 [20] percent of FX firm exposure are managed using risk-decreasing [risk-increasing/risk-constant] strategies. Further, we find that prior hedging outcomes affect the management of current FX exposure, where the exposure is reduced and management adjusts the hedge ratio closer to its benchmark average hedge ratio following prior benchmark losses. When separately evaluating risk-decreasing and risk-increasing positions, we find that prior benchmark losses are only relevant for risk-increasing but not for risk-decreasing positions, i.e., hedging decisions are independent of prior benchmark losses if the intention is to reduce FX exposure.