Barkun Alan N, Crott Ralph, Fallone Carlo A, Kennedy Wendy A, Lachaine Jean, Levinton Carey, Armstrong David, Chiba Naoki, Thomson Alan, Veldhuyzen van Zanten Sander, Sinclair Paul, Escobedo Sergio, Chakraborty Bijan, Smyth Sandra, White Robert, Kalra Helen, Nevin Krista
McGill University, Montréal, Quebec.
Can J Gastroenterol. 2010 Aug;24(8):489-98. doi: 10.1155/2010/379583.
The cost-effectiveness of initial strategies in managing Canadian patients with uninvestigated upper gastrointestinalsymptoms remains controversial.
To assess the cost-effectiveness of six management approaches to uninvestigated upper gastrointestinal symptoms in the Canadian setting.
The present study analyzed data from four randomized trials assessing homogeneous and complementary populations of Canadian patients with uninvestigated upper gastrointestinal symptoms with comparable outcomes. Symptom-free months, qualityadjusted life-years (QALYs) and direct costs in Canadian dollars of two management approaches based on the Canadian Dyspepsia Working Group (CanDys) Clinical Management Tool, and four additional strategies (two empirical antisecretory agents, and two prompt endoscopy) were examined and compared. Prevalence data, probabilities, utilities and costs were included in a Markov model, while sensitivity analysis used Monte Carlo simulations. Incremental cost-effectiveness ratios and cost-effectiveness acceptability curves were determined.
Empirical omeprazole cost $226 per QALY ($49 per symptom-free month) per patient. CanDys omeprazole and endoscopy approaches were more effective than empirical omeprazole, but more costly. Alternatives using H2-receptor antagonists were less effective than those using a proton pump inhibitor. No significant differences were found for most incremental cost-effectiveness ratios. As willingness to pay (WTP) thresholds rose from $226 to $24,000 per QALY, empirical antisecretory approaches were less likely to be the most costeffective choice, with CanDys omeprazole progressively becoming a more likely option. For WTP values ranging from $24,000 to $70,000 per QALY, the most clinically relevant range, CanDys omeprazole was the most cost-effective strategy (32% to 46% of the time), with prompt endoscopy-proton pump inhibitor favoured at higher WTP values.
Although no strategy was the indisputable cost effective option, CanDys omeprazole may be the strategy of choiceover a clinically relevant range of WTP assumptions in the initial management of Canadian patients with uninvestigated dyspepsia.
在加拿大，对患有未经检查的上消化道症状的患者进行初始治疗策略的成本效益仍存在争议。
评估在加拿大环境下，针对未经检查的上消化道症状的六种管理方法的成本效益。
本研究分析了四项随机试验的数据，这些试验评估了患有未经检查的上消化道症状、结局可比的加拿大患者的同质和互补人群。研究考察并比较了基于加拿大消化不良工作组（CanDys）临床管理工具的两种管理方法以及另外四种策略（两种经验性抗分泌药物和两种即时内镜检查）的无症状月数、质量调整生命年（QALY）和以加元计的直接成本。患病率数据、概率、效用和成本被纳入马尔可夫模型，同时敏感性分析采用蒙特卡罗模拟。确定了增量成本效益比和成本效益可接受性曲线。
经验性使用奥美拉唑每位患者每获得一个QALY的成本为226加元（每个无症状月49加元）。CanDys奥美拉唑和内镜检查方法比经验性使用奥美拉唑更有效，但成本更高。使用H2受体拮抗剂的替代方法比使用质子泵抑制剂的方法效果更差。大多数增量成本效益比没有显著差异。随着每QALY的支付意愿（WTP）阈值从226加元提高到24,000加元，经验性抗分泌方法不太可能是最具成本效益的选择，CanDys奥美拉唑逐渐成为更有可能的选择。对于每QALY支付意愿值在24,000加元至70,000加元之间（最具临床相关性的范围），CanDys奥美拉唑是最具成本效益的策略（占32%至46%的时间），在较高的WTP值时，即时内镜检查 - 质子泵抑制剂更受青睐。
尽管没有一种策略是无可争议的具有成本效益的选择，但在加拿大患有未经检查的消化不良的患者的初始管理中，在临床相关的WTP假设范围内，CanDys奥美拉唑可能是首选策略。
