Garton Hugh J L, Kestle John R W, Cochrane D Douglas, Steinbok Paul
Department of Neurosurgery, University of Michigan Medical Center, Ann Arbor 48109-0338, USA.
Neurosurgery. 2002 Jul;51(1):69-77; discussion 77-8. doi: 10.1097/00006123-200207000-00012.
Endoscopic third ventriculostomy (ETV) is currently the principal alternative to cerebrospinal fluid shunt placement in the management of pediatric hydrocephalus. Cost-effectiveness analysis can help determine the optimal strategy for integrating these different approaches.
All patients (n = 28) who underwent ETV at British Columbia's Children's Hospital between 1989 and 1998 were matched for age, pathogenesis, and number of previous shunt procedures, with patients treated with cerebrospinal fluid shunts. To perform a cost-effectiveness analysis, hydrocephalus-related resource consumption and outcome (determined as the number of hydrocephalus treatment-free days during follow-up) were then retrospectively identified. Cost data were linked to resource use to provide a total cost for all resources used. Costs and outcomes were discounted annually at 5% by standard economic analysis methods.
Twenty-four of 28 ETV patients had obstructive hydrocephalus. Over equivalent follow-up periods (median, 35 mo), the ETV success rate (defined by need for reoperation) was 54%. One hydrocephalus-related death and one hemiparesis occurred in the ETV group. No permanent procedure-related morbidity or mortality was seen in the shunt group. The cost/effect ratios for the two groups were similar. The additional incremental resource use by the shunt group included six readmissions and eight reoperations. ETV mean costs per patient were $10,570 +/- $7628, versus $10,922 +/- $8722 for the shunt group (Canadian dollars for the year 2000). Costs accrued more quickly for the shunt group as time passed. The additional incremental outcome benefit to the endoscopy group was 86 treatment-free days (3.07 d per patient [95% confidence interval, -7.56 to 13.70 d]). Neither of these differences was statistically significant.
In this matched cohort, ETV was not significantly less costly or more effective over a median 35 months of follow-up, with a 54% initial ETV success rate, even before the additional morbidity and mortality encountered were taken into account. The time course for the accrued costs suggests that a larger cohort, longer follow-up, or higher success rates are needed to demonstrate the cost-effectiveness of this therapy.
内镜下第三脑室造瘘术（ETV）目前是小儿脑积水治疗中脑脊液分流术的主要替代方法。成本效益分析有助于确定整合这些不同方法的最佳策略。
1989年至1998年间在不列颠哥伦比亚省儿童医院接受ETV手术的所有患者（n = 28），根据年龄、发病机制和既往分流手术次数，与接受脑脊液分流术治疗的患者进行匹配。为了进行成本效益分析，随后回顾性确定了与脑积水相关的资源消耗和结果（确定为随访期间无脑积水治疗天数）。成本数据与资源使用情况相关联，以提供所有使用资源的总成本。根据标准经济分析方法，成本和结果每年按5%进行贴现。
28例ETV患者中有24例患有梗阻性脑积水。在同等随访期（中位数为35个月）内，ETV成功率（由再次手术需求定义）为54%。ETV组发生1例与脑积水相关的死亡和1例偏瘫。分流组未出现与手术相关的永久性发病率或死亡率。两组的成本/效果比相似。分流组额外增加的资源使用包括6次再次入院和8次再次手术。ETV每位患者的平均成本为10,570加元±7628加元，分流组为10,922加元±8722加元（2000年加元）。随着时间的推移，分流组的成本累积更快。内镜组额外增加的结果效益为86个无治疗天数（每位患者3.07天[95%置信区间，-7.56至13.70天]）。这些差异均无统计学意义。
在这个匹配队列中，即使不考虑额外的发病率和死亡率，在中位35个月的随访期内，ETV的成本并不显著降低，效果也不显著更好，ETV初始成功率为54%。成本累积的时间进程表明，需要更大的队列、更长的随访期或更高的成功率来证明这种治疗方法的成本效益。
