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Deep brain stimulation (DBS), which uses an implantable device to modulate brain activity, is an adjunctive treatment for partial-onset seizures in patients with medically refractory epilepsy. Our objective was to perform an exploratory cost-utility analysis of DBS in conjunction with medical therapy, compared with medical therapy alone, using the latest clinical data and costs for the Australian healthcare system.
A deterministic five-state Markov model was used to project treatment response and outcomes over the patients’ lifetimes, based on 5-year data from the recent Stimulation of the Anterior Nucleus of the Thalamus for Epilepsy (SANTE) DBS trial and drug outcome data identified through a literature search. Costs were based on 2017 data for the Australian healthcare system, and response-specific utilities were derived from published literature. We estimated the lifetime discounted incremental cost-effectiveness ratio (ICER) in Australian dollars per quality-adjusted life-year (QALY) for patients 36 years of age, fifty-five percent of whom were men. Costs and effects were discounted at five percent per annum. The robustness of projections was evaluated through scenario and sensitivity analyses.
Under assumed continued treatment benefit, DBS was projected to add 3.48 QALYs over the patients’ lifetimes, at an increased cost of AUD 142,304 (USD 105,960), resulting in an ICER of AUD 40,951 (USD 30,492) per QALY gained. Reducing the analysis horizon to 20 years increased the ICER to AUD 49,803 (USD 37,083). Increasing the DBS generator life from 3 to 6 years decreased the ICER to AUD 23,956 (USD 17,838) per QALY. Longer follow-up periods and younger age at treatment were associated with greater cost effectiveness. Results were sensitive to assumptions about health state-specific utility estimates and long-term treatment effects.
Our exploratory findings suggest that DBS is a cost-effective treatment strategy in the Australian healthcare system for patients with medically refractory epilepsy. DBS therapy might meaningfully improve patient outcome at a health economic profile that compares favorably to other well accepted therapies. Consideration of indirect costs would further add to this value proposition.
Health Technology Assessment (HTA) considers the question of whether evaluated technologies are cost-effective in real world settings. As observed in HTA conducted by the Australian Medical Services Advisory Committee (MSAC), questions regarding the validity of data inputs to economic analyses that reflect real-world practice is a common reason for uncertainty on the cost effectiveness of new technologies. In addition to resource use and costs, there may be other uncertainties regarding the eligible patient population, patient management pathways and comparator selection. Our objective in this study was to present case studies from Australia where real world linked datasets could be better utilized to inform HTA conducted by the MSAC.
For selected therapy areas, assessment reports and public summary documents of HTA conducted by the MSAC published between January 2015 and November 2017 were reviewed. Our analysis identified HTAs where uncertainties around the inputs for health economic evaluations, as well as uncertainties in defining eligible patient numbers or current patient pathways of care were shown to exist. We then explored whether these uncertainties could have been addressed through real world linked datasets.
Our preliminary investigations identified two assessments: MSAC assessment of capsule endoscopy and transcatheter aortic valve implantation - where availability of real world linked data could have addressed uncertainties around the inputs required for the health economic evaluations.
Australia has a range of real world datasets with the potential to be used to inform HTA conducted by the MSAC. This can only be achieved if the datasets could be better linked and accessible for use by key stakeholders in the MSAC HTA process (e.g. industry, clinician, patient societies). Use of these data sets in HTA will enable timelier patient access to cost-effective technologies and more effective implementation and review of technologies after adoption into clinical practice.
As the pace of legal harmonization in developing East Asian states increases to comply with international trading treaties, a disjunction is forming between legislative expectations and everyday business practices. Evidence considered in this article suggests that Vietnam is no exception. State control over public discourse favors the interests of business elites, while small-scale entrepreneurs struggle to make their views known. Lawmakers exposed to this asymmetric discourse rarely adjust global legal rules to suit the transactional requirements of small-scale entrepreneurs. As a consequence, the largely imported commercial legislative framework is increasingly reflecting the interests of business elites. The article concludes that for the state to develop a more inclusive regulatory regime, it needs to relax its control over public deliberation and give small-scale entrepreneurs more opportunities to convey local precepts and practices to lawmakers.
Since China's reform and opening up started in 1978 and Vietnam's Doi Moi reforms were initiated in 1986, these two East Asian economies have adopted capitalistic models of development while retaining and reforming their socialist legal systems along the way. Tracking the trajectory of socialist laws and their legacy, this book offers a unique comparison of laws and institutional designs in China and Vietnam. Leading scholars from China, Vietnam, Australia and the United States analyze the history, development and impact of socialist law reforms in these two continuing socialist states. Readers are offered a varied insight into the complex quality and unique features of socialist law and why it should be taken seriously. This is a fresh theoretical approach to, and internal critique of, socialist laws which demonstrates how socialist law in China and Vietnam may shape the future of global legal development among developing countries.
The Darwin–Hatherton Glacial system (DHGS) connects the East Antarctic Ice Sheet (EAIS) with the Ross Ice Shelf and is a key area for understanding past variations in ice thickness of surrounding ice masses. Here we present the first detailed measurements of ice thickness and grounding zone characteristics of the DHGS as well as new measurements of ice velocity. The results illustrate the changes that occur in glacier geometry and ice flux as ice flows from the polar plateau and into the Ross Ice Shelf. The ice discharge and the mean basal ice shelf melt for the first 8.5 km downstream of the grounding line amount to 0.24 ± 0.05 km3 a−1 and 0.3 ± 0.1 m a−1, respectively. As the ice begins to float, ice thickness decreases rapidly and basal terraces develop. Constructed maps of glacier geometry suggest that ice drainage from the EAIS into the Darwin Glacier occurs primarily through a deep subglacial canyon. By contrast, ice thins to <200 m at the head of the much slower flowing Hatherton Glacier. The glaciological field study establishes an improved basis for the interpretation of glacial drift sheets at the link between the EAIS and the Ross Ice Sheet.