Cost-effectiveness of telaprevir in combination with pegylated interferon alpha and ribavirin in previously untreated chronic hepatitis C genotype 1 patients

Background:

Telaprevir (T, TVR) is a direct-acting antiviral (DAA) used for the treatment of genotype 1 chronic hepatitis C virus (HCV) infection. The sustained virological response (SVR) rates, i.e., undetectable HCV RNA levels 24 weeks after the end of treatment, is what differentiate treatments. This analysis evaluated the cost-effectiveness of TVR combined with pegylated interferon (Peg-IFN) alfa-2a plus ribavirin (RBV), with Peg-IFN and RBV (PR) alone or with boceprevir (B, BOC) plus Peg-IFN alfa-2b and RBV, in naïve patients.

Methods:

A Markov cohort model of chronic HCV disease progression reflected the pathway of naïve patients initiating anti-HCV therapy. SVR rates were derived from a mixed-treatment comparison including results from Phase II and III trials of TVR and BOC, and trials comparing both PR regimens. SVR has significant impact on survival, quality-of-life, and costs. Incremental cost per life year (LY) gained and quality-adjusted-life-year (QALY) gained were computed at lifetime, adopting the (National Health Service) NHS perspective. Cost and health outcomes were discounted at 3.5%. Uncertainty was assessed using deterministic and probabilistic sensitivity analyses. Sub-group analyses were also performed by interleukin (IL)-28B genotype and fibrosis stage.

Results:

Higher costs and improved outcomes were associated with T/PR relative to PR alone, resulting in an ICER of £12,733 per QALY gained. T/PR retained a significant SVR advantage over PR alone and was cost-effective regardless of IL-28B genotype and fibrosis stages. T/PR regimen ‘dominated’ B/PR, generating 0.2 additional QALYs and reducing lifetime cost by £2758. Sensitivity analyses consistently resulted in ICERs less than £30,000/QALY for the T/PR regimen over PR alone.

Limitations:

No head-to-head trial provides direct evidence of better efficacy of T/PR vs B/PR.

Conclusion:

The introduction of TVR-based therapy for genotype 1 HCV patients is cost-effective for naïve patients at the £30,000 willingness-to-pay threshold, regardless of IL-28B genotype or fibrosis stage.     

A Brief Outline of the Israel–Palestinian Conflict

Before we can explore the use of management science, game theory, cognitive science and artificial intelligence to attempt to resolve (or just manage) the Israel–Palestinian dispute, we need some sort of mutual understanding about the conflict. Given such a long and multi-faceted history rife with multiple conflicting claims, interpretations and emphases, all fraught with moral and political implications, it is unlikely that any account will be acceptable to all parties as authoritative. Nevertheless, we must search for some common ground. Our examination of history commences with the life of Abraham, the father of the three great monotheistic religions: Judaism, Christianity, and Islam and continues through to a discussion of Zionism and Arab nationalism. This leads to the creation of the State of Israel on May 14, 1948; celebrated as Yom Ha’atzmaut (Independence Day) and commemorated as ‘al-Nakhba (the catastrophe), according to one’s background. Whilst our discussion concludes with recent events, including the spring 2011 protests and demonstrations spread throughout the Middle East, there is no doubt that during the time between which this article is written and it appears in a journal, momentous events will have occurred.     

Virtual worlds

Games, role‐playing, and simulations as developmental tools have been used in education since the 1800s. An emerging form of collaborative game play is virtual worlds; however, the use of virtual worlds in leadership education has not been fully investigated. The purpose of this article is to (a) demonstrate how virtual worlds are a viable venue for leadership education, and (b) present a hierarchy of skills sets that can be developed in virtual world settings. In doing so, this article provides evidence that virtual worlds can be used as a new instructional delivery environment for leadership education as the appeal and intrinsic nature of virtual environments aligns well with the experiential framework of leadership education.