改善急诊科破伤风预防措施：一项前瞻性、双盲成本效益研究。
Improving tetanus prophylaxis in the emergency department: a prospective, double-blind cost-effectiveness study.
作者信息
Stubbe Muriel, Mortelmans Luc J M, Desruelles Didier, Swinnen Rohnny, Vranckx Marc, Brasseur Edmond, Lheureux Philippe E
机构信息
Department of Emergency Medicine, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium.
出版信息
Emerg Med J. 2007 Sep;24(9):648-53. doi: 10.1136/emj.2007.048520.
BACKGROUND
The choice of tetanus prophylaxis for patients with wounds depends on obtaining their vaccination history, which has been demonstrated to be unreliable. Use of a rapid immunoassay (Tétanos Quick Stick, the TQS), combined with knowledge of certain demographic characteristics, may improve the evaluation of tetanus immunity and thus help to avoid inadequate prophylactic measures and reduce costs.
OBJECTIVES
To evaluate the contribution of the TQS in the choice of tetanus prophylaxis and to perform a cost-effectiveness analysis. The final aim was to define the place of the TQS in a modified algorithm for assessment of tetanus immunity in the emergency department.
METHOD
In this Belgian prospective, double-blind, multicentre study, 611 adult patients with a wound were included; 498 (81.5%) records were valid. The TQS test was performed by a nurse before the vaccination history was taken and the choice of prophylaxis was made, using the official algorithm (Belgian Superior Health Council), by a doctor who was unaware of the TQS result.
RESULTS
The prevalence of protective anti-tetanus immunity was 74.1%. Immunity was lower in older patients and in female patients. The TQS was a cost-effective tool for patients presenting with a tetanus-prone wound and considered from the vaccination history to be unprotected. Use of the TQS would have improved management in 56.9% (95% CI 47.7% to 65.7%) of patients by avoiding unnecessary treatments, leading to a reduction in the mean cost per patient (10.58 euros/patient with the TQS versus 11.34 euros/patient without). The benefits of the TQS use were significantly greater in patients <61 years old: unnecessary treatment would have been avoided in 76.9% (95% CI 65.8% to 85.4%) of cases and the mean cost per patient reduced to 8.31 euros.
CONCLUSION
In selected patients, the TQS is a cost-effective tool to evaluate tetanus immunity. An algorithm is proposed for ED assessment of tetanus immunity integrating age and the TQS result.
背景
伤口患者破伤风预防措施的选择取决于了解其疫苗接种史，但事实证明这种方式并不可靠。采用快速免疫测定法（破伤风快速检测棒，即TQS），并结合某些人口统计学特征的信息，可能会改善对破伤风免疫力的评估，从而有助于避免预防措施不足并降低成本。
目的
评估TQS在破伤风预防措施选择中的作用，并进行成本效益分析。最终目的是确定TQS在急诊科评估破伤风免疫力的改良算法中的地位。
方法
在这项比利时前瞻性、双盲、多中心研究中，纳入了611例有伤口的成年患者；498份（81.5%）记录有效。TQS检测由护士在获取疫苗接种史和选择预防措施之前进行，预防措施的选择由一名不知道TQS结果的医生按照官方算法（比利时高级卫生委员会）进行。
结果
具有保护性抗破伤风免疫力的患病率为74.1%。老年患者和女性患者的免疫力较低。对于有破伤风易感伤口且根据疫苗接种史被认为无免疫力的患者，TQS是一种具有成本效益的工具。使用TQS可避免不必要的治疗，从而使56.9%（95%置信区间47.7%至65.7%）的患者得到更好的管理，导致每位患者的平均成本降低（使用TQS时为每位患者10.58欧元，未使用时为每位患者11.34欧元）。在年龄小于61岁的患者中，使用TQS的益处显著更大：76.9%（95%置信区间65.8%至85.4%）的病例可避免不必要的治疗，每位患者的平均成本降至8.31欧元。
结论
在特定患者中，TQS是评估破伤风免疫力的一种具有成本效益的工具。提出了一种将年龄和TQS结果纳入其中的急诊科破伤风免疫力评估算法。
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