Harewood G C, Baron T H
Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota 55905, USA.
Am J Gastroenterol. 2002 May;97(5):1152-8. doi: 10.1111/j.1572-0241.2002.05682.x.
Palliation of patients with Klatskin tumors involving both hepatic ducts is usually performed with bilateral biliary stent placement. Magnetic resonance cholangiopancreatography (MRCP) offers the ability to visualize the hepatic ducts without injection of contrast, thereby reducing the patient's risk of developing postprocedure bacterial cholangitis. We used decision analysis techniques to quantitate the cost-effectiveness of MRCP before stent placement versus routine placement of bilateral biliary stents in the setting of inoperable malignant hilar obstruction. In addition to determining which strategy was most economical, we used sensitivity analysis to identify the critical factors defining relative costs.
A decision analysis model was designed comparing MRCP with subsequent unilateral biliary stent placement and double biliary stent placement approaches for palliation of jaundice in a patient with inoperable malignant hilar obstruction, as viewed from the societal perspective. Baseline probabilities, obtained from the published literature, were varied through plausible ranges using sensitivity analysis. Charges were based on Medicare professional plus facility fees or diagnosis-related group rates for out- and inpatients, respectively.
MRCP with subsequent directed unilateral stent placement was the least costly approach ($3806) compared with bilateral stent placement ($4275), provided the bilateral biliary stent complication rate was >3%. Bilateral stent placement needed to confer a survival advantage of at least 7 days over unilateral stent placement to become the more cost-effective approach.
The use of MRCP to guide biliary stent placement in a patient with inoperable hilar obstruction reduces the overall cost of treatment. The uncertainty of any survival advantage that bilateral biliary stent placement confers over unilateral stent placement makes cost-effectiveness difficult to assess.
对于累及双侧肝管的克氏壶腹肿瘤患者，通常通过双侧胆管支架置入术进行姑息治疗。磁共振胆胰管造影（MRCP）能够在不注射造影剂的情况下可视化肝管，从而降低患者术后发生细菌性胆管炎的风险。我们运用决策分析技术，对在无法手术的恶性肝门梗阻情况下，放置支架前进行MRCP与常规放置双侧胆管支架的成本效益进行量化。除了确定哪种策略最经济外，我们还使用敏感性分析来确定定义相对成本的关键因素。
设计了一个决策分析模型，从社会角度比较MRCP联合后续单侧胆管支架置入术和双侧胆管支架置入术在无法手术的恶性肝门梗阻患者中缓解黄疸的效果。从已发表的文献中获取基线概率，并通过敏感性分析在合理范围内进行变化。费用分别基于医疗保险专业人员加医疗机构费用或住院和门诊患者的诊断相关组费率。
如果双侧胆管支架并发症发生率>3%，与双侧支架置入术（4275美元）相比，MRCP联合后续定向单侧支架置入术是成本最低的方法（3806美元）。双侧支架置入术需要比单侧支架置入术至少多带来7天的生存优势，才能成为更具成本效益的方法。
在无法手术的肝门梗阻患者中使用MRCP指导胆管支架置入可降低总体治疗成本。双侧胆管支架置入术相对于单侧支架置入术在生存优势方面的不确定性使得成本效益难以评估。
