Stylopoulos N, Gazelle G S, Rattner D W
Massachusetts General Hospital, Boston, MA, USA.
Surg Endosc. 2003 Feb;17(2):180-9. doi: 10.1007/s00464-002-8849-z. Epub 2002 Nov 6.
The controversial issue of the cost-effectiveness of laparoscopic inguinal hernia repair is examined, employing a decision analytic method.
The NSAS, NHDS (National Center for Health Statistics), HCUP-NIS (Agency for Healthcare Research and Quality) databases and 51 randomized controlled trials were analyzed. The study group constituted of a total of 1,513,008 hernia repairs. Projection of the clinical, economic, and quality-of-life outcomes expected from the different treatment options was done by using a Markov Monte Carlo decision model. Two logistic regression models were used to predict the probability of hospital admission after an ambulatory procedure and the probability of death after inguinal hernia repair. Four treatment strategies were modeled: (1) laparoscopic repair (LR), (2) open mesh (OM), (3) open non-mesh (ONM), and (4) expectant management. Costs were expressed in US dollars and effectiveness in quality-adjusted life years (QALYs). The main outcome measures were the average and the incremental cost-effectiveness (ICER) ratios.
Compared to the expectant management, the incremental cost per QALY gained was 605 dollars (4086 dollars, 9.04 QALYs) for LR, 697 dollars (4290 dollars, 8.975 QALYs) for OM, and 1711 dollars (6200 dollars, 8.546 QALYs) for ONM. In sensitivity analysis the two major components that affect the cost-effectiveness ratio of the different types of repair were the ambulatory facility cost and the recurrence rate. At a LR ambulatory facility cost of 5526 dollars the ICER of LR compared to OM surpasses the threshold of 50,000 dollars/QALY.
On the basis of our assumptions this mathematical model shows that from a societal perspective laparoscopic approach can be a cost-effective treatment option for inguinal hernia repair.
采用决策分析方法研究腹腔镜腹股沟疝修补术成本效益这一颇具争议的问题。
分析了国家门诊医疗调查（NSAS）、国家卫生统计中心（NHDS）数据库、医疗保健研究与质量局的医疗成本和利用项目国家住院样本（HCUP-NIS）数据库以及51项随机对照试验。研究组共计1,513,008例疝修补术。采用马尔可夫蒙特卡洛决策模型预测不同治疗方案的临床、经济和生活质量结果。使用两个逻辑回归模型预测门诊手术后住院概率以及腹股沟疝修补术后死亡概率。模拟了四种治疗策略：（1）腹腔镜修补术（LR），（2）开放网片修补术（OM），（3）开放无网片修补术（ONM），（4）观察等待。成本以美元表示，效果以质量调整生命年（QALY）表示。主要结局指标为平均成本效益比和增量成本效益比（ICER）。
与观察等待相比，LR每获得一个QALY的增量成本为605美元（4086美元，9.04个QALY），OM为697美元（4290美元，8.975个QALY），ONM为1711美元（6200美元，8.546个QALY）。敏感性分析中，影响不同类型修补术成本效益比的两个主要因素是门诊设施成本和复发率。当LR门诊设施成本为5526美元时，LR与OM相比的ICER超过了50,000美元/QALY的阈值。
基于我们的假设，该数学模型表明，从社会角度来看，腹腔镜方法可能是腹股沟疝修补术具有成本效益优势的治疗选择。
