Yelin Edward
Rosalind Russell Medical Research Center for Arthritis, University of California, San Francisco, California 94143-0920, USA.
J Rheumatol Suppl. 2005 Jan;72:36-8.
Historically, the largest components of costs associated with rheumatoid arthritis (RA), the most common inflammatory rheumatic disease, were hospitalizations, principally for joint replacement surgery, and work loss. Thus, for expensive interventions such as biological agents to be "worthwhile," they must reduce the prevalence of joint replacement and assist persons with RA in maintaining employment. However, joint replacement surgery and work losses tend to occur at least several years after onset of disease, even in severe cases. Assessing the cost-effectiveness of expenditures becomes computationally and politically difficult when the expenditure and the outcome are separated in time. The computational issue concerns the translation of future benefits--surgeries avoided and jobs held onto years from now--into present monetary values. The computational issue may be even more complex when the benefits are less tangible than surgery and wages; for example, when measured by quality-adjusted life-years. The political issue concerns the disjuncture between the agents making the expenditures--provincial health insurance in Canada or an employer's health plan in the US--and the agents reaping the benefits, a private disability insurance company or provincial or state workers' compensation fund. In addition, there is an ethical dilemma. In the US, many of the advances in the care for RA such as the biological agents derive, at least in part, from federal research expenditures. Such expenditures are financed by increasingly regressive taxes. Yet the individuals bearing an increasing share of the tax burden find themselves relegated to more restrictive health insurance plans less likely to provide access to those agents. Thus, whether expenditures for early interventions are worthwhile may turn on such issues as how long the expenditure and the benefits are separated in time, how well the interests of the agent making the expenditure and the agent reaping the rewards are aligned, and how equitable the financing of the benefit and the access to it.
从历史上看，类风湿性关节炎（RA）是最常见的炎性风湿性疾病，与之相关的成本中最大的组成部分是住院费用，主要用于关节置换手术，以及工作损失。因此，对于生物制剂等昂贵的干预措施要“物有所值”，它们必须降低关节置换的发生率，并帮助类风湿性关节炎患者维持就业。然而，即使在严重的情况下，关节置换手术和工作损失往往在疾病发作至少几年后才会出现。当支出和结果在时间上分开时，评估支出的成本效益在计算和政治上都变得困难。计算问题涉及将未来的收益——避免的手术和从现在起几年内保住的工作——转化为当前的货币价值。当收益比手术和工资更难以捉摸时，计算问题可能会更加复杂；例如，当用质量调整生命年衡量时。政治问题涉及支出的主体——加拿大的省级医疗保险或美国雇主的健康计划——与受益的主体，一家私人残疾保险公司或省级或州工人赔偿基金之间的脱节。此外，还存在一个伦理困境。在美国，类风湿性关节炎护理方面的许多进展，如生物制剂，至少部分源自联邦研究支出。这些支出由累进性越来越强的税收提供资金。然而，承担越来越多税收负担的个人发现自己只能参加限制更多的健康保险计划，这些计划提供使用这些药物的可能性较小。因此，早期干预的支出是否值得可能取决于诸如支出和收益在时间上分开多久、支出主体和受益主体的利益契合程度以及收益的融资和获取的公平性等问题。
