早期筛查老年人群糖尿病视网膜病变的卫生经济学分析

目的从社会角度和卫生系统角度探讨中国50岁以上人群行糖尿病视网膜病变(DR)筛查的经济学效益。方法检索中国知网、万方数据库、PubMed及Medline等数据库,检索日期为自建库之始至2020年12月,搜集中国50岁以上人群DR的患病率、转归率、筛查依从性、治疗依从性、筛查敏感性、筛查特异性、DR不同分期的效用值及死亡率等指标。按照国际分级系统将DR分为不威胁视力DR、威胁视力DR,糖尿病性黄斑水肿及DR致盲等4个阶段。筛查项目、转诊检查及治疗费用来源于邯郸眼病研究和2020年首都医科大学附属北京同仁医院住院系统。使用TreeAge Pro软件构建DR筛查的马尔可夫模型,以社区筛查、远程筛查及人工智能(AI)辅助筛查为研究策略,以无筛查为对照策略,以我国农村和城市50岁以上人群为队列人群,比较不同策略的成本效益,并比较1~5年筛查间隔的成本效益。2020年中国农村和城市人均生产总值(GDP)分别为49000元和84000元。经济学效益以增量成本-效用比(ICUR)和增量成本-效果比(ICER)表示。成本效益阈值按照世界卫生组织规定的ICER或ICUR<3倍人均GDP为具有成本效益,<1倍人均GDP为具有高成本效益,>3倍人均GDP则不具备经济性。通过敏感性分析评价模型的稳健性。结果农村和城市人群的成本效益阈值分别为147000元和252000元。从社会角度看,对农村50岁以上人群进行社区、远程及AI辅助筛查的ICUR分别为4214元、2772元及3206元;每避免1个致盲年导致的ICER分别为216524元、152726元及164745元;对城市人群筛查的ICUR分别为7133元、5061元及5894元;每避免1个致盲年导致的ICER分别为57792元、37632元及55839元。与无筛查人群相比,农村和城市的ICUR以及城市人群的ICER均<1倍人均GDP;3种筛查方式对农村50岁以上人群的ICER均略高于成本效益阈值。从卫生系统角度看,3种筛查方式对农村和城市老年人群的ICUR和ICER均低于成本效益阈值。社区或AI辅助筛查对城市老年人群间隔2年以上具有成本效益,远程筛查间隔1年以上已具有成本效益;而对农村人群各筛查间隔均不具有成本效益。经概率敏感性分析,当成本效益阈值为3倍人均GDP时,农村老年人群社区、远程及AI辅助筛查成本效益概率分别为87.34%、87.56%及87.54%;城市老年人群筛查的成本效益概率分别为89.19%、89.48%及89.61%。当成本效益阈值为1倍人均GDP时,3种筛查方式对农村老年人群筛查有成本效益的概率分别为86.03%、86.84%及86.55%;城市老年人群的成本效益概率分别为87.83%、88.55%及88.62%。说明构建马尔可夫模型的设计和结果稳健,对参数的浮动不敏感。结论对我国50岁以上老年人群进行DR筛查具有成本效益,因农村和城市的经济发展水平和疾病负担不同,应制定适宜当地的DR筛查模式。

Health economic analysis of early screening for diabetic retinopathy in the elderly

ObjectiveTo explore the cost-effectiveness of screening for diabetic retinopathy (DR) among people over 50 years old in China from social and health system perspectives. MethodsCNKI, Wanfang Database, PubMed and Medline from the beginning of self-built database to December 2020 were searched, and parameters such as prevalence, transition rate, screening and treatment compliance, screening sensitivity and specificity, utility value and mortality rate of DR among people over 50 years old in China were collected. According to the international classification system, DR was be divided into four stages: non-sight-threatening DR, sight-threatening DR, diabetic macular edema and blindness caused by DR. The cost of screening program, referral examination and treatment was based on the Handan Eye Study and inpatients system of Beijing Tongren Hospital affiliated with Capital Medical University in 2020. TreeAgePro software was used to build a Markov model of DR screening, in which the research strategies were community screening, telescreening and artificial intelligence (AI)-based screening, the control strategy was no-screening, and the cohort population were people over 50 years old in rural and urban areas of China. The cost-effectiveness of different strategies was compared, and the cost-effectiveness of 1 to 5 years screening interval was compared. In 2020, China′s rural and urban per capita GDP was ￥49 000 and ￥84 000, respectively. Economic benefits were expressed in terms of incremental cost-effectiveness ratio (ICUR) and incremental cost-effectiveness ratio (ICER). The WHO defined interventions that cost between one to three times the per capita gross domestic product (GDP) was defined as cost-effective, and interventions that cost less than the per capita GDP as highly cost-effective, and interventions that cost more than three times the per capita GDP as not cost-effective. The sensitivity analysis was used to evaluate the robustness of the model. ResultsFrom the societal perspective, the ICUR of community, telemedicine and AI-based screening for people over 50 years old for rural elderly were ￥4217, ￥2772 and ￥3206, respectively. The ICER was ￥216 524, ￥152 726 and ￥164 745, respectively. The ICUR for urban elderly was ￥7133, ￥5061 and ￥5894, respectively. The ICER was ￥57 792, ￥37 632 and ￥55 839, respectively. Com-pared with elderly without screening , ICUR for rural and urban elderly and ICER for urban elderly were less than the per capita GDP. However, the ICER of 3 screening methods for over 50 years rural elderly was slightly higher than the cost-effectiveness threshold. From health system perspective, ICUR and ICER of 3 screening methods for rural and urban elderly were lower than the cost-effectiveness threshold. Community and AI-assisted screening were cost-effective for urban elderly at intervals of more than 2 years, while telescreening at intervals of more than 1 year was cost-effective; however, it was not cost-effective to screen rural residents frequently. The sensitivity analysis showed that when the cost-effectiveness threshold was 3 times per capita GDP, the cost-effectiveness probabilities of community, telemedicine and AI-assisted screening for rural population were 87.34%, 87.56% and 87.54%, and the probability of urban population 89.19%, 89.48% and 89.61%, respectively. When the cost-effectiveness threshold was 1 time per capita GDP, the cost-effectiveness probability of 3 screening methods for rural eldly was 86.03%, 86.84% and 86.55%, and the cost-effectiveness probability of urban elderly population 87.83%, 88.55% and 88.62%, respectively. It showed that the design and results of Markov model were robust and insensitive to the fluctuation of parameters. ConclusionsDR screening for the elderly over 50 years old in China is cost-effective. Due to the different levels of economic development and disease burdens in rural and urban areas, appropriate DR screening models should be developed according to local conditions.