肘部尺神经病变的治疗：成本效益分析。
Treatment of ulnar neuropathy at the elbow: cost-utility analysis.
作者信息
Song Jae W, Chung Kevin C, Prosser Lisa A
机构信息
Section of Plastic Surgery, Department of Surgery, University of Michigan Health System; Ann Arbor, MI, USA.
出版信息
J Hand Surg Am. 2012 Aug;37(8):1617-1629.e3. doi: 10.1016/j.jhsa.2012.05.012.
PURPOSE
The choice of surgical treatment for ulnar neuropathy at the elbow (UNE) remains controversial. A cost-utility analysis was performed for 4 surgical UNE treatment options. We hypothesized that simple decompression would emerge as the most cost-effective strategy.
METHODS
A cost-utility analysis was performed from the societal perspective. A decision analytic model was designed comparing 4 strategies: (1) simple decompression followed by a salvage surgery (anterior submuscular transposition) for a poor outcome, (2) anterior subcutaneous transposition followed by a salvage surgery for a poor outcome, (3) medial epicondylectomy followed by a salvage surgery for a poor outcome, and (4) anterior submuscular transposition. A poor outcome when anterior submuscular transposition was the initial surgery was considered an end point in the model. Preference values for temporary health states for UNE, the surgical procedures, and the complications were obtained through a time trade-off survey administered to family members and friends who accompanied patients to physician visits. Probabilities of clinical outcomes were derived from a Cochrane Collaboration meta-analysis and a systematic MEDLINE and EMBASE search of the literature. Medical care costs (in 2009 U.S. dollars) were derived from Medicare reimbursement rates. The model estimated quality-adjusted life-years and costs for a 3-year time horizon. A 3% annual discount rate was applied to costs and quality-adjusted life-years. Incremental cost-effectiveness ratios were calculated, and sensitivity analyses performed.
RESULTS
Simple decompression as an initial procedure was the most cost-effective treatment strategy. A multi-way sensitivity analysis varying the preference values for the surgeries and a model structure sensitivity analysis varying the model assumptions did not change the conclusion. Under all evaluated scenarios, simple decompression yielded incremental cost-effectiveness ratios less than US$2,027 per quality-adjusted life-year.
CONCLUSIONS
Simple decompression as an initial treatment option is cost-effective for UNE according to commonly used cost-effectiveness thresholds.
TYPE OF STUDY/LEVEL OF EVIDENCE: Economic and Decision Analysis III.
目的
肘部尺神经病变（UNE）手术治疗方式的选择仍存在争议。对4种UNE手术治疗方案进行了成本效益分析。我们假设单纯减压将成为最具成本效益的策略。
方法
从社会角度进行成本效益分析。设计了一个决策分析模型，比较4种策略：（1）单纯减压，若效果不佳则进行挽救手术（前肌下转位）；（2）前皮下转位，若效果不佳则进行挽救手术；（3）内上髁切除术，若效果不佳则进行挽救手术；（4）前肌下转位。以前肌下转位作为初始手术时效果不佳被视为模型的终点。通过对陪同患者就诊的家属和朋友进行时间权衡调查，获得了UNE、手术操作及并发症的临时健康状态的偏好值。临床结局的概率来自Cochrane协作网的荟萃分析以及对MEDLINE和EMBASE文献的系统检索。医疗费用（以2009年美元计）来自医疗保险报销率。该模型估计了3年时间范围内的质量调整生命年和成本。对成本和质量调整生命年应用3%的年贴现率。计算了增量成本效益比并进行了敏感性分析。
结果
单纯减压作为初始手术是最具成本效益的治疗策略。改变手术偏好值的多因素敏感性分析以及改变模型假设的模型结构敏感性分析均未改变这一结论。在所有评估的情景下，单纯减压产生的增量成本效益比均低于每质量调整生命年2027美元。
结论
根据常用的成本效益阈值，单纯减压作为初始治疗方案对UNE具有成本效益。
研究类型/证据水平：经济与决策分析III级。
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