Guest Julian F, Candy David C A, Clegg John P, Edwards Di, Helter Marianne T, Dale Anne K, Fell John, Cosgrove Michael, Debelle Geoffrey
Catalyst Health Economics Consultants, Northwood, Middlesex, UK.
Curr Med Res Opin. 2007 Sep;23(9):2213-25. doi: 10.1185/030079907X210462.
To estimate the clinical and economic impact of using macrogol 3350 plus electrolytes (macrogol 3350; Movicol; Movicol Paediatric Plain) in an outpatient setting compared to enemas and suppositories and manual evacuation to treat paediatric faecal impaction.
A chart review was undertaken to extract clinical outcomes and resource use from the case notes of a cohort of children aged 2-11 years with faecal impaction who initially received either macrogol 3350 (in an outpatient setting) or enemas and suppositories or manual evacuation for initial disimpaction. Five centres across England and Wales participated in the study. These data were used to inform a decision model which depicted the management of children during the disimpaction phase and for a period of 12 weeks following initial disimpaction. Unit resource costs at 2005/2006 prices were applied to the resource utilisation estimates within the model, enabling the incremental costs and consequences of using macrogol 3350 in an outpatient setting, compared to the other treatments, to be estimated.
112 patients treated with macrogol 3350, 101 who received enemas and suppositories and 11 who underwent a manual evacuation were eligible for analysis. Ninety-seven per cent of children treated with macrogol 3350 were successfully disimpacted within 5 days, compared to 73% of those who received enemas and suppositories and 89% of those who underwent a manual evacuation (p < 0.001). There were no significant differences in reported adverse events between the different treatments for disimpaction, with the exception of vomiting which was significantly higher among those who underwent a manual evacuation (18% versus 2% with the other treatments; p < 0.01). There were no significant differences in the number of clinician outpatient visits between treatments. However, macrogol 3350-treated patients had significantly fewer hospital admissions than those who received the other interventions (0.1 versus 1.4 and 1.0 for enemas and suppositories and manual evacuation respectively; p < 0.05) and occupied fewer bed days. The total NHS cost of disimpaction and subsequent maintenance of children initially treated with macrogol 3350 was estimated to be 694 pounds sterling (95% CI: 496 pounds sterling; 892 pounds sterling). This compared with 2759 pounds sterling (95% CI: 1266 pounds sterling; 4252 pounds sterling) and 2333 pounds sterling (95% CI: 1609 pounds sterling; 3058 pounds sterling) for those who initially received enemas and suppositories or underwent a manual evacuation, respectively. Hence, using macrogol 3350 instead of enemas and suppositories and manual evacuation to disimpact the whole annual cohort of faecally impacted children aged 2-11 years in England could potentially reduce annual NHS expenditure on this condition by 59% (5 million pounds sterling) and reduce the annual number of paediatric hospital admissions for this condition by 92% (4330).
Within the limitations of our model, macrogol 3350 affords the NHS a clinically effective and cost-effective treatment for the disimpaction of children suffering from faecal impaction compared to enemas and suppositories or a manual evacuation, and has the potential to release healthcare resources for alternative use within the system.
评估在门诊环境中使用聚乙二醇3350加电解质（聚乙二醇3350；Movicol；小儿Movicol原味制剂）与灌肠剂、栓剂及手工排便法相比，治疗小儿粪便嵌塞的临床和经济影响。
进行一项病历回顾，从2至11岁粪便嵌塞患儿的病历中提取临床结局和资源使用情况，这些患儿最初接受聚乙二醇3350（在门诊环境中）或灌肠剂、栓剂或手工排便法进行初次解除嵌塞。英格兰和威尔士的五个中心参与了该研究。这些数据被用于构建一个决策模型，该模型描述了患儿在解除嵌塞阶段及初次解除嵌塞后的12周内的管理情况。将2005/2006年价格的单位资源成本应用于模型中的资源利用估计值，从而能够估计在门诊环境中使用聚乙二醇3350与其他治疗方法相比的增量成本和结果。
112例接受聚乙二醇3350治疗的患者、101例接受灌肠剂和栓剂治疗的患者以及11例接受手工排便法治疗的患者符合分析条件。97%接受聚乙二醇3350治疗的患儿在5天内成功解除嵌塞，相比之下，接受灌肠剂和栓剂治疗的患儿为73%，接受手工排便法治疗的患儿为89%（p<0.001）。不同解除嵌塞治疗方法之间报告的不良事件无显著差异，但手工排便法组的呕吐发生率显著更高（18%，而其他治疗方法为2%；p<0.01）。不同治疗方法之间临床医生门诊就诊次数无显著差异。然而，接受聚乙二醇3350治疗的患者住院次数显著少于接受其他干预措施的患者（分别为0.1次，而灌肠剂和栓剂治疗组及手工排便法治疗组分别为1.4次和1.0次；p<0.05），且占用的床日数更少。最初接受聚乙二醇3350治疗的患儿解除嵌塞及后续维持治疗的英国国家医疗服务体系（NHS）总费用估计为694英镑（95%置信区间：496英镑；892英镑）。相比之下，最初接受灌肠剂和栓剂治疗或手工排便法治疗的患儿分别为2759英镑（95%置信区间：1266英镑；4252英镑）和2333英镑（95%置信区间：1609英镑；3058英镑）。因此，在英格兰，使用聚乙二醇3350而非灌肠剂、栓剂及手工排便法来解除2至11岁粪便嵌塞患儿的全年队列嵌塞，可能会使NHS在这种疾病上的年度支出减少59%（500万英镑），并使该疾病的儿科住院年度数量减少92%（4330例）。
在我们模型的局限性范围内，与灌肠剂、栓剂或手工排便法相比，聚乙二醇3350为NHS提供了一种治疗粪便嵌塞患儿解除嵌塞的临床有效且具有成本效益的方法，并且有可能释放医疗资源以供系统内其他用途使用。
