Ehrlich Jacqueline E, Demopoulos Byron P, Daniel Kenneth R, Ricarte M Christina, Glied Sherry
Joan and Sanford Weill Medical College of Cornell University, New York, NY, USA.
Prev Med. 2002 Sep;35(3):250-7. doi: 10.1006/pmed.2002.1062.
We set out to examine which treatment option available in the United States was most cost-effective in treating children with endemic group A streptococcal pharyngitis to prevent rheumatic heart disease.
Cost-effectiveness was calculated from the societal perspective and expressed in cases of rheumatic heart disease prevented annually in the U.S. pediatric population aged 5 to 17 based on U.S. Census data. We used a decision-analysis model to assess the cost-effectiveness of five treatment options for patients with pharyngitis: (1) "treat all," (2) "treat none," (3) "rapid test," where only patients with a positive rapid antigen test are treated, (4) "culture," where only patients with a positive throat culture are treated, and (5) "rapid test with culture" or (RTCX), where confirmatory cultures are used on patients with negative rapid tests. Cost data were gathered from existing empirical data or estimated. We performed sensitivity analyses of the antigen test sensitivity and antibiotic effectiveness and examined whether changes in these variables would alter our outcome.
The "rapid test" was the most cost-effective option. Using "rapid tests" prevented 85 cases of rheumatic heart disease annually and cost society $727,000 per case prevented. Performing throat cultures instead of "rapid tests" would pick up an additional 11 cases of rheumatic heart disease but would cost $13.7 million for each of these additional cases prevented. The current standard of using throat cultures as a confirmatory test on patients with a negative "rapid" test would detect an additional 21 cases of rheumatic heart disease but cost society an additional $8 million per case prevented.
To reduce the incidence of rheumatic heart disease cost-effectively, the management of pediatric pharyngitis may best be accomplished by using antigen testing. The added costs associated with the remaining treatment options may not be justified, especially, as the sensitivity of the antigen tests continues to improve and closely approaches the sensitivity of the practice standard, throat culture.
我们着手研究在美国可获得的哪种治疗方案在治疗地方性A组链球菌性咽炎患儿以预防风湿性心脏病方面最具成本效益。
从社会角度计算成本效益，并根据美国人口普查数据，以美国5至17岁儿科人群每年预防的风湿性心脏病病例数来表示。我们使用决策分析模型评估咽炎患者的五种治疗方案的成本效益：（1）“全部治疗”，（2）“不治疗”，（3）“快速检测”，即仅治疗快速抗原检测呈阳性的患者，（4）“培养检测”，即仅治疗咽培养呈阳性的患者，以及（5）“快速检测加培养检测”（RTCX），即对快速检测呈阴性的患者进行确诊培养。成本数据从现有经验数据收集或估算得出。我们对抗原检测敏感性和抗生素有效性进行了敏感性分析，并研究这些变量的变化是否会改变我们的结果。
“快速检测”是最具成本效益的方案。使用“快速检测”每年可预防85例风湿性心脏病，每预防一例病例社会成本为72.7万美元。进行咽培养而非“快速检测”可多发现11例风湿性心脏病病例，但每预防一例这些额外病例的成本为1370万美元。目前对“快速”检测呈阴性的患者使用咽培养作为确诊检测的标准做法可多发现21例风湿性心脏病病例，但每预防一例病例社会成本额外增加800万美元。
为了以具有成本效益的方式降低风湿性心脏病的发病率，儿科咽炎的管理最好通过使用抗原检测来完成。与其余治疗方案相关的额外成本可能不合理，特别是随着抗原检测的敏感性持续提高并接近实践标准咽培养的敏感性。
