血管再通策略治疗前循环大血管闭塞急性缺血性卒中的成本效果分析

目的评价静脉溶栓(IVT)、动脉溶栓(IAT)、静脉溶栓联合机械取栓(IVT+MT)和动静脉联合溶栓(IVT+IAT)4种血管再通策略治疗前循环大血管闭塞急性缺血性卒中的成本效果,为中国相关决策者选择治疗策略和制订相应政策提供参考。方法从中国医疗卫生系统的角度进行成本效果分析。运用决策树模型和Markov模型分别评价4种措施干预后短期(治疗后90 d)和长期(治疗后20年)的成本效果,并对模型中的参数进行确定敏感性分析和概率敏感性分析。该研究的时间周期设定为20年,用以模拟急性缺血性卒中患者的全生命周期,贴现率为3%。疾病状态分为功能独立[改良Rankin量表(mRS)评分0~2分]、残疾(mRS评分3~5分)和死亡(mRS评分6分)。4种治疗策略的效果指标为质量调整生命年(QALY);采用增量成本效果比(ICER)评价IAT、IVT+MT和IVT+IAT分别与IVT相比,每增加1个QALY所需要支付的成本。以2018年中国人均国内生产总值(GDP)65000元计算,ICER<195000元/QALY的意愿支付阈值认为某种血管再通策略具有成本效果。结果(1)对4种血管内治疗策略的治疗费由低到高为IVT(10062.46元)、IAT(25099.24元)、IVT+IAT(29730.92元)、IVT+MT(53330.99元)。(2)成本效果分析结果显示,术后第1年,IAT、IVT+IAT和IVT+MT与单独IVT相比均不具有成本效果;术后第3年,IVT+IAT和IAT仍不具有成本效果,而IVT+MT则略小于195000元/QALY元的意愿支付阈值;术后第20年,IVT+MT具有明显的成本效果,每增加1个QALY需要支付71102.03元。当模拟1000人研究队列,20年后,IVT+MT与IVT相比,能够增加18例术后功能独立,避免4例残疾和13例死亡。(3)确定敏感性分析和概率敏感性分析验证了该结果的稳定性。结论对于具有IVT适应证的前循环大血管闭塞急性缺血性卒中患者,采取IVT+MT策略具有长期成本效果。

Cost-effectiveness analysis of recanalization therapy for acute ischemic stroke caused by anterior circulation large vessel occlusion

Objective To evaluate the cost-effectiveness of four recanalization therapies including intravenous thrombolysis(IVT),intra-arterial thrombolysis(IAT),intravenous thrombolysis plus mechanical thrombectomy(IVT+MT),and intravenous thrombolysis plus intra-arterial thrombolysis(IVT+IAT)for acute ischemic stroke(AIS)due to anterior circulation large vessel occlusion,thus providing effective recommendation for selecting therapy and policymaking.Methods The cost-effectiveness analysis was performed from the perspective of the Chinese Medical Health System.The study used a decision tree model and Markov model to evaluate the short-term(90 days after treatment)and long-term(20 years after treatment)cost-effectiveness of the four interventions;the parameters in the model were subjected to deterministic sensitivity analysis and probabilistic sensitivity analysis.The cycle of Markov model was 20 years to simulate a lifelong time horizon of patient with AIS,and a discount rate was 3%.According to the score on modified Rankin Scale(mRS),health state was divided into independent state(mRS score 0-2),disable state(mRS score 3-5)and death(mRS score 6).The effect was quality-adjusted life-years(QALY).The incremental cost-effectiveness ratio(ICER),expressed as the cost per QALY gained,was use to evaluate the cost-effectiveness of IAT,IVT+MT,IVT+IAT compared with IVT respectively.According to a per capita gross domestic product(GDP)in 2018(￥65000),the intervention was considered cost-effective if the ICER was<￥195000/QALY.Results The cost calculation results showed that the cost of IVT was the lowest(￥10062.46),followed by IAT(￥25099.24),IVT+IAT(￥29730.92),and the highest cost was IVT+MT(￥53330.99).The cost-effectiveness analysis implied that IAT,IVT+IAT,and IVT+MT had no cost-effectiveness compared with IVT alone in the first year after the operation.IVT+IAT and IAT still had no cost-effectiveness,and IVT+MT was slightly less than￥195000/QALY in the third year,while in the 20 th year after the operation,IVT+MT had significant cost-effectiveness,the ICER was￥71102.03/QALY.When simulating a 1000-person study cohort,IVT+MT could increase 18 patients with functional independence compared with IVT,and avoid four patients from being disabled and 13 patients being died in 20 years.Deterministic sensitivity analysis and probabilistic sensitivity analysis verified the stability of the results.Conclusion IVT+MT appears to be cost-effectiveness for AIS caused by anterior circulation large vessel occlusion for eligible IVT patients.